Circumcision 6 "S" Comfort Care

Purpose for the program:

It is well documented that infants experience pain when undergoing circumcision. Infants’ nerve pathways are developed enough to allow them to feel pain, but not mature enough to interpret noxious stimuli and react. Pain scales help caregivers infer what the infant may be experiencing but most still feel the newborn has some degree of discomfort. Efforts have been made to minimize the pain felt during circumcision by using injected or topical lidocaine anesthetic and allowing the infant to suck sucrose on a pacifier or gloved finger during the procedure. The amount of 'wait time' from injection to circumcision many times is at the discretion of the physician. The purpose of this project was to develop a means to decrease the discomfort of circumcision. A review of the literature revealed additional interventions nurses could do to improve the care given to infants during the procedure.

Proposed change:

It seems that combining several modalities of comfort, thus using the sensory saturation theory is the best practice to address procedural pain in the term infant.  Merging current care practices with a few additional measures found in the literature resulted in the Circumcision 6 ”S” Comfort Care program.  The six measures were each given a word that begins with an “S”.  A poster was displayed in the circumcision area as a visual reminder of the steps and the order of implementation for maximum benefit.

Implementation, outcomes and evaluation:

The six “S” measures are: Swaddle - facilitated tucking promotes body self-regulation and assists in modulating physical response. Shade – the infant’s cap is used to shade his eyes from bright light. Sucrose – produces analgesia through endogenous opioid and non-opiod pathways. Sucking – synergistic effect with sucrose provides soothing. Syringe – dorsal nerve penile block or ring block blunt behavioral and physiological pain response. Stop – a timer is set for 3-5 minutes ‘wait time’ so all participants are aware of elapsed time after lidocaine injection. At the conclusion of the project, 58% of the circumcised infants displayed crying, either during the procedure, after or both. This compares to 68% of the infants crying prior to initiating the program. The thirty minute post-procedure mean NIPS (newborn infant pain scale) score went from 1.3 before the project to .85.

Implications for nursing practice:

Now nurses, assisting with circumcisions, feel they play a pivotal role in consistently helping infants manage pain. 

Keywords: infant procedural pain, pain management