Acetaminophen Analgesia in Neonatal Circumcision: The Effect on Pain

Cynthia R. Howard, MD*; Fred M. Howard, MDX; and Michael L. Weitzman, MD*

ABSTRACT. Objective. Recognizing the concerns shown to provide anesthesia and analgesia,9”12 but it
about the use of local anesthesia in neonatal circumcision, is not widely used due to concerns of sufficient
a painful procedure usually performed without analgesia safety,4’1#{176}the additional time required to perform the
or anesthesia, we undertook a study of acetaminophen for block, and the continued belief that the pain of neo-
pain management of this procedure.
natal circumcision is insignificant. The American
Design. A prospective, randomized, double-blind,
Academy of Pediatrics supports the use of anesthetics
placebo-controlled, clinical trial of acetaminophen anal-
gesia in 44 healthy full-term neonates undergoing circum- and analgesics in neonates and in its statement on
cision was conducted. Beginning 2 hours before Gomco neonatal anesthesia recommends that “the decision to
circumcision, neonates received either acetaminophen (15 withhold such medication should be based on the
mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 same medical criteria used for older patients.”3
mL/kg per dose) every 6 hours for 24 hours. Neonates were Recognizing the concerns about the use of local an-
monitored intraoperatively for changes in heart rate, res- esthesia in neonatal circumcision, we undertook a
piratory rate, and crying time. Postoperative pain was as- study of acetaminophen for pain management of this
sessed at 30, 60, 90, 120, 360 minutes, and 24 hours using procedure. Acetaminophen is used extensively for re-
a standardized postoperative comfort scoring system.
lief of mild to moderate pain after minor surgery, has
Feeding behavior was also assessed before and after cir-
a broad margin of safety in infancy,’4 and is metabo-
cumcision by nursing observation.
Results. Neonates in both groups showed significant lized and excreted efficiently by newborns.’5-17 To test
increases in heart rate, respiratory rate, and crying during the hypothesis that acetaminophen alleviates intra-
circumcision with no clinically significant differences ob- operative and postoperative pain in neonatal circum-
served between the groups. Postoperative comfort scores cision, a prospective, randomized, double-blind,
showed no significant differences between the groups un- placebo-controlled, clinical trial of acetaminophen an-
til the 360-minute postoperative assessment, at which algesia in healthy full-term neonates undergoing cir-
time the acetaminophen group had significantly im- cumcision was conducted.
proved scores (P < .05). Feeding behavior deteriorated in
breast- and bottle-fed neonates in both groups, and acet- MATERIALS AND METHODS
aminophen did not seem to influence this deterioration.
Patient Population
Conclusions. This study confirms that circumcision of
the newborn causes severe and persistent pain. Acet- All male neonates who met the study criteria defined below
aminophen was not found to ameliorate either the intra- and who were delivered by the staff obstetrical service of Roch-
ester Ceneral Hospital from July 1992 to April 1993 were poten-
operative or the immediate postoperative pain of circum-
tially eligible to participate in the study. Rochester Ceneral Hos-
cision, although it seems that it may provide some benefit
pital is a 526-bed community hospital affiliated with the
after the immediate postoperative period. Pediatrics University of Rochester School of Medicine and Dentistry with
1994;93:641-646; neonatal circumcision, acetaminophen. approximately 2500 deliveries per year. Parents requesting cir-
cumcision of healthy, appropriate for gestational age, full-term
male newborns were asked to participate, and informed consent
Neonatal circumcision is the most common surgical was obtained for study participation. Full-term was defined as 37
procedure performed on males in the United States.1’2 to 42 weeks gestation. Further eligibility criteria were: (1) Apgar
As many as 86% of male neonates undergo this op- scores >7 at I and 5 minutes; (2) absence of any chronic or infec-
tious disease process; (3) no history of maternal illicit drug or
eration.3 It is unlikely that the frequency of this pro-
alcohol use; (4) absence of any other contraindication to circum-
cedure will decrease in the near future as the Amen- cision, such as hypospadias, epispadias, or cordee of the penis;
can Academy of Pediatrics has acknowledged that it and (5) no family history of a bleeding disorder. The study pro-
has possible medical benefits.4 Although there is clear tocol and consent form were approved by the hospital’s Clinical
neurophysiologic and clinical evidence that neonates Investigation Committee.

are capable of mature pain perception, even at rela-

Protocol and Data Collection
tively immature gestational ages,5 neonatal circum-
Using a computer-generated random number list, neonates
cision is usually performed without analgesia or
were randomized to either an acetaminophen or placebo group.
anesthesia.1 Dorsal penile nerve block has been Twenty-one infants were randomized to the placebo group, and 23
to the acetaminophen group. The acetaminophen group received
acetaminophen infant drops (Tylenol infant drops, McNeil Con-
The Departments of *pediatrics and $Qbstetrics and Gynecology, Rochester sumer Products), 15 mg/kg per dose (0.15 mL/kg per dose) every
General Hospital, The University of Rochester School of Medicine and 6 hours for 24 hours (or until the neonate was discharged if this
Dentistry, Rochester, NY. occurred before 24 hours), starting 2 hours preoperatively. Neo-
Received for publication Aug 4, 1993; accepted Oct 8, 1993. nates in the placebo group were treated by an identical protocol,
Reprint requests to (C.R.H.) Dept of Pediatrics, Rochester General Hospital, but received 0.15 mL/kg per dose of a placebo solution, colored
1425 Portland Aye, Rochester, NY 14621. and saccharin-sweetened to resemble the acetaminophen drops.
PEDIATRICS (ISSN 0031 4005). Copyright © 1994 by the American Acad- Five single doses of either placebo or acetaminophen were dis-
emy of Pediatrics. pensed to the hospital’s mother-baby unit for each infant. Medi-

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PEDIATRICS Vol. 93 No. 4 April 1994 641
cations were dispensed in nursing bottles containing individual, at 30, 60, 90, 120, and 360 minutes. Those neonates who were
prediluted doses ready for administration to the infant. Study hospitalized long enough to allow for additional postoperative
medications for both groups were prediluted by pharmacy per- scoring at 24 and 48 hours were also assessed at these times. All
sonnel with 4 mL of sterile water. After administration of the comfort scores were obtained by the same physician (C.R.H.).
acetaminophen or placebo, 4 mL of sterile water were placed into Before scoring, the state of the neonate (quiet/awake, fussy, or
the nursing bottle, swirled to dissolve any residual medication, sleeping) was recorded. The amount of time since the neonate was
and given to the neonate. All nurses and physicians involved in last fed and any blood drawing or other painful procedure (eg,
the study were blinded to the group assignments. immunization) that had occurred within the last 30 minutes were
All circumcisions were performed in a quiet room specifically also recorded.
designated for circumcision procedures. All neonates were treated Two of the authors (C.R.H. and F.M.H.), both blinded to in-
identically to the fullest possible extent. Circumcisions were per- fants’ circumcision status, performed a pilot test of the Postopera-
formed between 6:30 AM and 8:00 AM to allow one investigator to tive Comfort Score in a group of 55 well, full-term newborns, 15 of
do all postoperative assessments and to guarantee relatively uni- whom were postcircumcision. lntraobserver reliability for this in-
form routine care experiences for the neonates before evaluation. strument was r = .90, and interobserver reliability was r = .85. A
Neonates had received nothing by mouth for a minimum of 2 comfort score of <16 from <1 hour to 70 hours postcircumcision
hours before circumcision, and no neonates went longer than 3 identified neonates who had undergone circumcision with a posi-
hours without feeding before the procedure. All neonates had tive predictive value of 85%, a sensitivity of 73%, and of
specificity
uneventful newborn nursery courses and were at least 24 hours 96%. In the subgroup of circumcised neonates, a score of <16
old at the time of circumcision. predicted with 85% sensitivity and 100% specificity those neonates
Intraoperatively, pain was assessed using crying time, heart who were <24 hours postcircumcision. Interobserver reliability
rate changes, and respiratory rate changes. Heart rate was counted was reverified (r > .90) in the later half of the current study in a
by a nurse via cardiac auscultation. Respiratory rate was deter- subgroup of 13 neonates.
mined by visual observation by a second nurse. Heart rates and Feeding behavior was evaluated before and after circumcision.
respiratory rates were assessed every 30 seconds beginning with In accord with standard nursing protocol at this hospital, nurses
the 3-minute preoperative observation and extending through the record breast-feeding behavior or formula intake each time an
3-minute postoperative observation. Crying time was assessed by neonate feeds. For the purposes of this
feeding study, preoperative
the same investigator (C.R.H.) for all neonates and was deter- behavior was defined as follows for breast-fed neonates: (1 ) breast-
mined using stopwatch measurement of crying vocalizations dur- feeding satisfactory, if by nursing observation the neonate was
mg each stage of the procedure. Pacifiers were offered to all neo- judged to have breast-fed well for the two feedings before circum-
nates during the procedures. cision; and (2) breast-feeding unsatisfactory, if by nursing obser-
Neonates were restrained on a circumcision board for 3 mm- vation the neonate was judged to have fed poorly on either of two
utes before the surgical procedure to assess baseline measure- breast-feedings before circumcision.
ments of crying times, heart rate, and respiratory rate. All circum- All neonates were taken to their mothers for feeding immedi-
cisions were performed by the same physician (F.M.H.) using the ately after circumcision. If, in postoperative feedings, a neonate
same Comco clamp technique in all neonates. For purposes of data who was in the satisfactory category was judged to have fed
interpretation, the operation was divided into the following poorly in two breast-feeding attempts or if the neonate refused to
stages: (1) 3 minutes baseline with limbs restrained; (2) cleansing be breast-fed on two attempts, then breast-feeding behavior was
of genital area; (3) dissection and lysis of adhesions; (4) Comco judged to have deteriorated postoperatively. If after two attempts
clamp placement; (5) foreskin excision; (6) Comco clamp removal at breast-feeding the neonate required formula supplementation
and dressing placement; and (7) 3-minute postoperative period on (eg, the neonate was symptomatic with a blood glucose <50) or the
circumcision board without restraint. Mean heart rates and respi- mother chose to feed the infant formula, breast-feeding was also
ratory rates were calculated for each of these stages, as were judged to have deteriorated. If a neonate who had breast-fed
percents of time spent in crying. poorly preoperatively fed well in postoperative feedings, breast-
The Postoperative Comfort Score described by Attia et al’8 feeding behavior was judged to have improved.
(Table 1), which has previously been used in the assessment of Formula intakes of bottle-fed neonates for the two feedings
postoperative pain in infancy,’9 was utilized to assess postopera- before circumcision were averaged. This average was recorded
tive pain. This score assesses 10 infant behaviors, each of which is as the baseline formula intake for the neonate. If on the first post-
scored 0, 1, or 2, resulting in possible scores from 0 to 20. The lower operative feeding the neonate consumed <50% of the preopera-
the score, the more uncomfortable the infant. Each neonate was tive volume of formula, feeding behavior was judged to have
scored in the immediate preoperative period, and postoperatively worsened.

TABLE 1. Postoperative Comfort Score

Assessment Score

0 2

Sleep during preceding None Short naps between 5 and Longer naps, >10 mm
hour 10 mm each each
Facial expression of pain Marked, constant Less marked, intermittent Calm, relaxed
Quality of cry Screaming, painful, high Modulated, can be dis- No cry
pitched tracted by normal sound
Consolability None after 2 mm Quiet after I mm of effort Calm before I mm of
effort
Sociability, eye contact, Absent Difficult to obtain Easy and prolonged
response to voice, smile,
real interest in face
Sucking Absence or disorganized Intermittent suck (3 or 4) Strong, rhythmic
suck and stops with crying pacifying effect
Spontaneous excitability Tremulous, clonic move- Excessive reactivity (to any Normal
and responsiveness to ments, spontaneous moro stimulation)
ambient stimulation reflexes
Spontaneous motor Thrashing around, incessant Moderate agitation Normal
activity agitation
Constant and excessive Very pronounced, marked, Less marked, intermittent Absent
flexion of fingers and toes and constant
Clobal evaluation of tone Strong hypertonicity Moderate hypertonicity Normal for age

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642 ACETAMINOPHEN ANALGESIA IN NEONATAL CIRCUMCISION
TABLE 2. Intraoperative Heart Rates, Respiratory Rates, and Crying Times DuringNeonatal Circumcision

Baseline Sterile Dissection Clamp On Excision Clamp Off Recovery

Preparation

Heart rate (beats/mm)

Acetarninophen 132.4 ± 14.5 138.3 ± 14.4 155.3 ± 20.5 162.0 ± 21.8 141.8 ± 15.7 149.4 ± 19.6 141.0 ± 20.2
Placebo 138.9 ± 21.0 141.0 ± 23.0 156.8 ± 20.0 161.1 ± 21.9 139.9 ± 17.4 140.0 ± 22.1 135.7 ± 17.6
Respiratory rate (breaths/mm)
Acetaminophen 48.9 ± 10.4 43.1 ± 13.4 48.5 ± 12.5 55.1 ± 10.5 59.9 ± 13.3 53.6 ± 16.9 61.6 ± 12.8
Placebo 55.2 ± 14.2 51.0 ± 22.5 53.4 ± 14.8 57.5 ± 15.7 67.8 ± 19.3 53.3 ± 19.4 67.6 ± 16.9
Crying time (% time)
Acetaminophen 0.15 ± 0.27 0.56 ± 0.30 0.83 ± 0.15 0.79 ± 0.27 0.16 ± 0.20* 0.63 ± 0.21 0.32 ± 0.27
Placebo 0.32 ± 0.35 0.66 ± 0.27 0.85 ± 0.12 0.80 ± 0.24 0.35 ± 0.29* 0.68 ± 0.30 0.39 ± 0.34
* P value <.05.

Power calculations based on the results of the pilot test of the was born to a mother with pregnancy-induced hy-
Postoperative Comfort Score indicated that a group size of 18
pertension, whereas there were no obstetric compli-
neonates in each of the two test groups would allow detection of
a 50% improvement in Postoperative Comfort Scores with 80%
cations in the group receiving placebo. In all cases,
power and an a of .05 in a one-tailed analysis. neonates were asymptomatic at birth with normal
growth parameters and uneventful newborn courses.
Data Analysis There were no statistically significant differences in
Data analysis was performed using EPI Info, Version 5 (Centers unadjusted heart rate or respiratory rate (Table 2) be-
for Disease Control Shareware) and SPSS-PC statistical programs. tween the acetaminophen and placebo groups at any
Statistical comparisons were performed using the Student’s t-test
for normally distributed continuous data, and the Wilcoxon two-
stage of the circumcision procedure. Neonates in the
sample test for nonnormally distributed data. Categorical van- placebo group cried significantly more than those in
ables were tested for differences by x statistics, and 95% confi- the acetaminophen group during foreskin removal
dence intervals for proportions were calculated to examine the (Table 2, P < .05). These differences, however, were
variance of the point estimates. Fisher’s exact tests were used
not evident when crying times were adjusted for base-
whenever a cell size was <5. Differences between groups for Post-
operative Comfort Scores were analyzed using the Student’s t-test line crying time (Table 3). The analysis of adjusted
and analysis of variance techniques. Analysis of variance tech- mean heart rates showed that the acetaminophen
niques tested for differences between the groups with the preced- group had significantly greater changes in heart rate
ing comfort scores treated as a covaniate.
Comparisons between groups were also performed for all out-
during the clamp removal and recovery periods of the
come measures accounting for rates obtained in preoperative ob- procedure (P < .05 for each of these stages).
servations. Preoperative values were subtracted from subsequent There were no significant differences between the
measures of a particular pain measure to produce adjusted values.
groups at any designated postoperative pain assess-
Appropriate statistical analysis was then performed on these ad-
justed values.
ment for the behavioral state of the neonates before
scoring, time since last feeding, or for the numbers of
RESULTS painful procedures (eg, blood drawing or immuni-
There were no significant differences between the zation) which occurred within 30 minutes of a com-
study groups for birth weight, race, maternal age, ges- fort score. Significant differences occurred between
tational age, maternal smoking during pregnancy, preoperative scores and the 30-, 60-, 90-, 120-minute,
method of delivery, maternal use of intravenous or and 6-hour postoperative comfort scores in both
intramuscular analgesics during labor, maternal use groups. When preoperative and postoperative corn-
of local or epidural anesthesia during labor, Apgar fort scores were compared, significant changes oc-
scores at I and 5 minutes, method of infant feeding, curred in 9 of 10 and 8 of 10 components of the
age at circumcision, or time required for the proce- comfort score in the acetaminophen and placebo
dure. Only the incidence of obstetric complications groups, respectively.
differed between the groups. Two neonates in the ac- The t-test comparisons of comfort scores, adjusted
etaminophen group were born to mothers with ges- and unadjusted for preoperative values, revealed no
tational diabetes (non-insulin-dependent), and one significant differences between the groups at any of

TABLE 3. Changes in Intraoperative Heart Rates, Respiratory Rates, and Crying Times During Neonatal Circumcision Adjusted for
Baseline Values

Sterile Dissection Clamp On Excision Clamp Off Recovery

Preparation

Heart rate (beats/mm)

Acetaminophen 5,9 ± 13.9 22.9 ± 18.5 29.6 ± 21.8 9.4 ± 18.8 17.0 ± 21,4* 8.6 ± 20,4*
Placebo 2.0 ± 14.4 17.8 ± 14.9 22.3 ± 19.4 1.0 ± 17.9 1.2 ± 23,2* -3.2 ± 18.5*
Respiratory rate (breaths/mm)
Acetaminophen -5.8 ± 14.0 -0.4 ± 13.1 6.2 ± 10.3 11.0 ± 8.2 4.7 ± 13.8 12.7 ± 10.2
Placebo -4.2 ± 18.4 -1.7 ± 13.0 2.0 ± 10.3 12.5 ± 16.1 -2.0 ± 15.2 12.7 ± 10.2
Crying time (% time)
Acetaminophen 0.42 ± 0.30 0.68 ± 0.27 0.64 ± 0.34 0.03 ± 0.26 0.49 ± 0.29 0.18 ± 0.25
Placebo 0.34 ± 0.26 0.52 ± 0.33 0.49 ± 0.46 0.03 ± 0.28 0.35 ± 0.31 0.08 ± 0.21
* P value <.05.

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ARTICLES 643
 -1

C
0
U
U)
-2
Figure. Mean adjusted postop-
erative comfort scores after neona- E
0
tal circumcision: a comparison of 0
.
acetaminophen (n = 23) and pla- -3
C
cebo (n = 21) analgesia.

.4
. 30 Minutes

#{149}6
a acetaminophen
. placebo

the determinations (Figure and Table 4). Reanalysis of crease crying time.24 In the current study the observed
the data, however, via analysis of variance, with the changes in intraoperative heart rate, respiratory rate,
previous comfort score treated as a covariate, dem- and crying times were consistent with severe intra-
onstrated that the acetaminophen group was signifi- operative pain, and no clinically relevant differences
cantly more comfortable than the placebo group at the between the study groups for any of the intraopera-
6-hour postoperative score (P < .05). The 6-hour score tive pain measures were observed. Although differ-
occurred 2 hours after a dose of acetaminophen and ences were observed between groups for adjusted
at the time of maximal effect for the analgesic.’5’16 mean heart rates in the final two stages of the cir-
There were no significant differences between the cumcision procedure, they were unexpected because
groups for comfort scores at any other postoperative they occurred during the least invasive portions of the
time using this method of analysis. procedure, contrasted to all other outcome measures,
Preoperatively, all neonates fed well. Neonate feed- were not believed to be clinically relevant, and may
ing behavior after circumcision deteriorated in neo- have been the result of analysis of multiple measures.
nates in both groups. Of those breast-fed, 2 of 1 1 (18%) Acetaminophen, an analgesic of only mild to mod-
in the acetaminophen group and 3 of 8 (37%) in the erate potency, thus seems to be an ineffective anal-
placebo group either were judged to have breast-fed gesic for the management of the intraoperative pain
poorly or required formula feedings after circumci- associated with circumcision in the newborn.
sion. Of neonates who were formula-fed, 4 of 12(33%) Both groups of neonates showed significant dete-
in the acetaminophen group and 2 of 13 (15%) in the rioration in their comfort scores at all postoperative
placebo group fed poorly after circumcision. Acet- assessments. Although the number of neonates re-
aminophen did not significantly influence feeding maining in the hospital for the 24-hour assessment
changes for either breast-fed or formula-fed neonates. was small, postoperative scores in both groups at this
time had not returned to preoperative values. Other
DISCUSSION studies have documented changes in the Brazelton
Numerous studies have shown that circumcision Neonatal Behavioral Assessment secondary to cir-
causes severe intraoperative pain as measured by cumcision that have persisted for at least 24 hours.6’1’
changes in crying,8 heart rate, respiratory rate, tran- The overall deterioration in comfort scores observed
scutaneous Po2,’2’2#{176}
and cortiso! levels.9 Adequate an- in this study is consistent with these observations.
esthesia such as that provided by local anesthesia The results of this study also suggest that acet-
with lidocaine or dorsal penile nerve block has been aminophen is ineffective for pain management in the
shown to ameliorate changes in each of these immediate postoperative period (ie, the first 2 hours
parameters.9”2’2123 Additionally, simple interventions postcircumcision). Clinical experience with circumci-
like sucrose-flavored pacifiers have been shown to de- sion pain in older children validates this conclusion as

TABLE 4. Mean Preoperative an d Postoperative Comfort Scores

Preoperative 30 mm 60 mm 90 mm 120 mm 6 h 24 h

Acetaminophen 18.4 ± 1.3 14.9 ± 2.0 15.5 ± 2.6 15.0 ± 1.8 15.9 ± 2.0 17.1 ± 1.6* 16.7 ± 3.Ot
Placebo 18.4 ± 1.5 14.7 ± 2.5 15.0 ± 3.0 15.5 ± 2.0 15.8 ± 2.2 16.3 ± 2.3* 17.0 ± 1.9t
Adjusted for preoperative value
Acetaminophen -3.5 ± 2.2 -2.9 ± 3.1 -3.0 ± 2.1 -2.5 ± 2.5 -1.2 ± 2.0*
Placebo -3.7 ± 2.6 -3.4 ± 2.8 -2.7 ± 2.0 -2.6 ± 2.5 -2.0 ± 2,8*
* value <.05.
t Acetaminophen, n = 6; placebo, n = 5.

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644 ACETAMINOPHEN ANALGESIA IN NEONATAL CIRCUMCISION
regional anesthesia, potent nonsteroidal drugs, and maternal frustration with attempts at breast-feeding
narcotic analgesics are often used for postoperative or because the neonate was judged unable to breast-
pain control for circumcision outside the neonatal feed postoperatively. This finding is disconcerting be-
period?-5-27 cause early formula supplementation is associated
There was significant improvement, however, in with decreased breast-feeding duration.3”32 Because
the group of neonates who received acetaminophen 6 the vast majority of male infants in the United States
hours postoperatively. It thus seems that acetamino- undergo unanesthetized circumcision, this prelimi-
phen may provide some analgesia in circumcised nary observation deserves further study.
neonates after the immediate postoperative period. In summary, this study confirmed that circumci-
Due to the early discharge of neonates, the number of sion of the newborn causes severe and persistent pain.
postoperative comfort scores at 24 hours were insuf- Acetaminophen was not found to ameliorate either
ficient for statistical analysis, and we were unable to the intraoperative or the immediate postoperative
evaluate acetaminophen effects after 6 hours. pain of circumcision, although it may provide some
One probable explanation for the observed failure benefit after the immediate postoperative period.
of acetaminophen to control pain in the immediate Given the large numbers of newborns who undergo
postoperative period is that the pain of circumcision this painful surgical procedure, it is imperative that
is too severe to be controlled by a mild analgesic like safe and easily administered methods of anesthesia
acetaminophen. Thus, even though acetaminophen is and analgesia be found and utilized.
simple and safe to administer to newborns, it may not
be indicated for the treatment of pain of circumcision ACKNOWLEDGMENTS
in the immediate postoperative period. This work was supported in part, by grant 1D28PE50008-01
from the Bureau of Health Professions.
Subtherapeutic levels of acetaminophen might also
The authors would like to thank Klaus Roghmann, PhD, for his
explain inadequate postoperative analgesia, as acet- thoughtful comments, Neil Schecter, MD, for his help in selecting
aminophen levels were not monitored. Pharmaco- a method of assessing postoperative pain, and Marilyn Richards,
kinetic studies have been conducted in neonates, RNC, and Marifran Cooper, RNC, MSN, for their assistance dur-
ing the study.
however, and dosages similar to those used in older
children are recommended for use in neonates. These
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ARTICLES 645
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IS THERE A “RIGHT” OF PARENTHOOD?

A woman was enraged (recently) because her health insurance company, after
paying for two unsuccessful attempts at in vitro fertilization, had refused to reim-
burse her for further infertility treatments. “They’re depriving me of my right to
become a mother,” she said, “and I’m going to sue them.”
But where is it written that our society owes everyone the “right” to become a
parent, regardless of the financial or ethical cost? ...

Almost no one has questioned the notion of parenthood as a right and infertility
as a disaster that must be fought with all the high-tech tools of modern medi-
cine . . . but when infertility is viewed simply as one misfortune on a scale of
sorrows-less horrible, say, than mind destroying diseases or mass starvation-the
ethical balance looks quite different.

Jacoby S. Entitled to the embryo? New York Times. November 2, 1993.

Submitted by Student

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646 ACETAMINOPHEN ANALGESIA IN NEONATAL CIRCUMCISION
 Acetaminophen Analgesia in Neonatal Circumcision: The Effect on Pain
Cynthia R. Howard, Michael L. Weitzman and Fred M. Howard
Pediatrics 1994;93;641

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 Acetaminophen Analgesia in Neonatal Circumcision: The Effect on Pain
Cynthia R. Howard, Michael L. Weitzman and Fred M. Howard
Pediatrics 1994;93;641

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/93/4/641

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since 1948. Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1994 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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