EMLA and Paracetamol: My Approach to Pain Relief During Infant Circumcision

What I tell parents about topical anaesthesia, paracetamol and pain relief

By Dr Martin Harris BPharm Hons, MB BS, LRCP MRCS FRCGP RCPathME
Circumcision London

Pain relief is an important part of my approach to infant circumcision.

Parents understandably want to know what I do to minimise discomfort for their baby during the procedure and as the local anaesthetic wears off afterwards.

In my practice, I use a combination of topical local anaesthesia and oral analgesia as part of my approach to pain relief.

The topical anaesthetic I use is EMLA cream, which contains two local anaesthetic medicines, lidocaine and prilocaine.

In my personal clinical experience, I have found EMLA useful as part of the preparation for circumcision.

I want to make one point particularly clear to parents:

I apply the EMLA cream myself.

I do not ask parents to apply EMLA to their baby’s penis before coming to the procedure, and I do not expect parents or another person accompanying the baby to decide where, how much or for how long it should be applied.

The application forms part of my medical preparation for the procedure.

EMLA is only one part of my pain-relief approach

I do not regard topical anaesthesia as the whole of the analgesic plan.

At the same time as I prepare the baby for the circumcision, I also administer the appropriate dose of oral paracetamol for that individual baby.

This means that my approach combines two different forms of pain relief:

• EMLA provides topical local anaesthesia as part of the preparation for the procedure.
• Paracetamol provides systemic analgesia.

I consider the baby’s age, weight, maturity and clinical circumstances when deciding what is appropriate.

The purpose is not simply to give medicines because a procedure is taking place.

The purpose is to plan pain relief carefully for the individual baby.

Why I administer the paracetamol myself

I prefer to administer the oral paracetamol myself at the time of preparation rather than asking parents to give a dose before they arrive.

There are several reasons for this approach.

It allows me to confirm which baby is receiving the medicine, what preparation is being used and what dose is being administered.

It also means that I know exactly when the dose was given.

This is particularly important with medicines in young infants, where dosing needs to be considered carefully and parents should not have to make calculations or decisions immediately before a surgical procedure.

My experience with EMLA

I have used EMLA as part of my preparation for circumcision for many years.

My view is based on my own clinical experience of caring for babies undergoing the procedure.

I have found that, when I use EMLA appropriately as part of my overall analgesic approach, it is useful in preparing the baby for circumcision.

I do not present this as a claim that EMLA alone eliminates pain.

It does not.

Nor do I believe that any single measure should be regarded as the entire answer to pain management during an infant procedure.

My approach is to use appropriate measures together and to monitor the baby throughout.

Parents should not apply EMLA themselves

This is an important practical point.

Because EMLA is a medicine, I do not ask parents to apply it themselves to their baby’s genital area.

I apply it personally as part of the clinical preparation for the circumcision.

The UK product information for EMLA contains specific precautions concerning its use in infants, including restrictions relating to prematurity, age, dosing and the risk of methaemoglobinaemia.

It also contains important information concerning its use on genital skin in children.

These are important considerations when deciding whether and how EMLA should be used.

My use of EMLA in my clinical practice should therefore not be interpreted as a recommendation for parents to purchase the cream and reproduce my technique at home.

The circumstances in which I use it, the amount, the application and the timing are part of my clinical management of the baby.

Why I combine EMLA with paracetamol

I think it is useful for parents to understand that these medicines have different roles.

EMLA is a topical local anaesthetic. Its active ingredients, lidocaine and prilocaine, act locally to produce anaesthesia in the skin.

Paracetamol is an analgesic medicine that acts differently.

For me, therefore, the two are not simply interchangeable medicines.

I use them as complementary components of my pain-relief approach.

The paracetamol is administered orally at the time I prepare the baby for circumcision, using the appropriate dose for that individual baby.

The EMLA is applied by me as part of the preparation for the procedure.

This is deliberate rather than incidental.

My approach is individualised

I do not believe in a generic instruction such as:

“Give the baby this medicine and apply this cream.”

A young baby is not simply a smaller adult.

Age, weight, maturity, medical history, gestational age and the particular circumstances of the procedure all need to be considered.

This is also why I do not encourage parents to copy a dosing or application schedule from an internet article.

My role is to assess the baby and take responsibility for the clinical decisions involved in the procedure.

Parents’ role is to understand what I am doing, know what to expect and tell me if there is anything about their baby’s health or circumstances that I need to know.

My final message to parents

Pain relief is an important part of my approach to infant circumcision.

In my practice, I use EMLA as part of the preparation for the procedure and I apply it myself.

At the same time, I administer the appropriate oral paracetamol dose for the individual baby.

I consider these measures together as part of a planned approach to analgesia rather than relying on one medicine alone.

My experience is that EMLA has a useful role in my clinical practice.

However, I would not want parents to interpret that statement as an instruction to apply EMLA themselves or to use it without medical supervision.

The product information for EMLA contains important age-related and safety information, particularly concerning very young infants, and should always be considered when the medicine is used.

My approach is simple:

I assess the baby.

I apply the EMLA myself.

I administer the appropriate paracetamol myself.

I perform the procedure.

And I remain responsible for the baby’s care throughout.

That is how I believe pain relief should be approached: carefully, deliberately and individually for the baby in front of me.

Medical Information Disclaimer

The information in this article is provided for general educational and informational purposes and reflects my personal clinical experience.

It is not intended to replace an individual medical assessment, diagnosis or treatment plan.

Parents should not purchase, apply or administer EMLA or alter medication doses for their baby on the basis of this article.

The use of medicines in young infants requires appropriate clinical judgement and consideration of the current product information.

If you have any concerns about your baby’s health, medication or recovery following circumcision, seek appropriate medical advice.

References and Further Reading

• Electronic Medicines Compendium (EMC) — EMLA Cream: Summary of Product Characteristics.
• Electronic Medicines Compendium (EMC) — EMLA Cream: Patient Information Leaflet.
• NHS — Medicines for children and information about paracetamol.