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1997 AAP Guidelines for Prevention of Early-onset Group B Streptococcal Disease

We appreciate Dr Van Howe’s interest in our study; however, we must take issue with some of his comments. We do not endorse unanesthetized surgery. Unanesthetized surgery was not part of the study design and would certainly not be condoned by our Institutional Review Board. We specifically stated that we did not feel it was ethical to include such a group as part of our study, but rather quantified the reactions of the infants whose circumcisions were performed by physicians who do not routinely use local anesthesia. We are neither endorsing nor condemning the circumcision procedure itself. We are advocating the use of the most effective means of pain control available that is safest for the infant. Dr Van Howe seems to be suggesting that circumcision is an unnecessary procedure that has no benefit to the patient (a point being actively debated, but not the subject of our article). However, he also seems to be advocating general anesthesia for the procedure, a method that is surely not without significant risks. Now most surgeons seem to be doing more and more procedures using local rather than general anesthesia in both children and adults. To “properly” study the pain or stress response, Dr Van Howe advocates both noninvasive and invasive measurements. We evaluated the infants noninvasively—including virtually all of the parameters suggested. We chose the NIPS tool as it includes norms for no pain—thus obviating the need for a control group of infants that were not circumcised. We did not feel justified in evaluating the corticosteroid response as that would require an additional needlestick. We would like to emphasize again that when parents choose to have their sons circumcized, the procedure should be performed using the most effective and safe means of pain control available— which in our hands is the dorsal penile nerve block.