Can EMLA cream be used for pain relief during circumcision?

I read an article about the use of EMLA for pain relief during circumcision. When I asked our moyel about it, he claimed that it is a bad idea because it can cause swelling. He just lops without any anesthesia at all. Is EMLA safe and effective? Should I shop around until I find a moyel who will use it?

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

The medical article to which you refer was published in the "New England Journal of Medicine."

EMLA cream is a topical anesthetic. It is very effective in numbing the skin and the tissues just underneath the skin. However, the depth of the skin which becomes numb is dependent upon how long the cream is left on. The maximum depth it can go is about six to seven millimeters, about one-third inch, after the cream has been left on two hours.

This medication has been successfully used for a number of painful procedures including putting in IVs, doing spinal taps and skin-prick testing for allergies. Therefore, it seems only natural to find out if EMLA could be used for circumcision. Prior to formally studying this question, most physicians have felt confident that this cream would indeed be effective. The concern has been whether it would be safe to use in newborns. This concern was stemmed from previous observations that EMLA use may have caused mild forms methemoglobinemia in newborns.

Hemoglobin is the protein in red blood cells that is responsible for carrying oxygen. The body also makes a different form of this hemoglobin called methemoglobin. Methemoglobin is unable to carry oxygen. Normally, the body keeps the levels of methemoglobin very low. However, certain chemicals and medications can have the side effect of causing more methemoglobin to be made. This, in turn, makes it difficult for the red blood cells to get enough oxygen to the body. With this potential side effect, you can see why physicians have been cautious in using EMLA in newborn babies.

Eventually, experience with this medication showed that the potential problems with methemoglobinemia were probably not significant. Therefore, researchers began looking into the possibility of using EMLA in circumcision. The latest study was published last month. They concluded the following:

  1. EMLA cream is effective at decreasing the pain associated with circumcision although it was not felt to be as effective as using the dorsal penile nerve block technique.
  2. The use of EMLA cream in circumcision does not put the infant at increased risk of developing methemoglobinemia.

Ayelet, to summarize, EMLA cream appears to be safe and effective. However, the use of this medication for circumcision is not very widespread, so I anticipate you will have trouble finding anyone that uses it at this time. Applying the medication evenly is the key to having it be effective, and this may be difficult for those physicians with less expertise in this technique. In addition, EMLA is a prescription medication, so unless your moyel is a physician, he probably will not be able to obtain it. As for the EMLA cream itself, it generally does not cause any swelling, although it can occur. It may cause some transient pallor (or loss of color) of the skin.

It is clear that circumcision causes intense pain when no form of pain control is done. My view is that some form of pain control should always be used during this procedure, and using the EMLA cream seems to be a safe and effective option.

I hope this helps.

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