Regional anesthesia during newborn circumcision. Effect on infant pain response

A controlled, double-blind investigation was undertaken to determine whether regional anesthesia by dorsal penile nerve block (DPNB) could effectively minimize the pain and behavioral disruptions usually associated with newborn circumcision. Fifteen infants had DPNB with lidocaine, eight control infants had DPNB with saline, and eight additional control infants were circumcised without undergoing DPNB. Newborn distress was gauged by subjective observation, measurement of heart rate, and the percent of time spent crying in six sequential timed intervals during circumcision. Ninety-three percent of subjects who received lidocaine were observed to have a decrease in agitation after anesthetic administration. The mean increase in heart rate during circumcision was at least 50 percent less in the lidocaine injected group than in either control group (p less than 0.01). Infants who had DPNB with lidocaine cried 50 percent less during circumcision compared to combined controls (p less than 0.01). DPNB was easily administered, and there were no significant complications. Physicians who circumcise newborns have good reason to employ the technique of dorsal penile nerve block with lidocaine to minimize infant pain and distress.     

Is neonatal circumcision judicious?

BACKGROUND: Circumcision is the most frequently performed procedure in male children. AIM: The aim of the study was to compare the outcome of circumcision performed in the early neonatal period and circumcision performed at 5 months of age. Setting of the study was the King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia. METHODS: The study was performed as a prospective cohort study. RESULTS: A total of 350 infants were enrolled. 250 neonates were circumcised at the age of 1 to 4 days (early group) and 100 infants underwent circumcision at the age of 5 months (late group). A bone cutter was used for 50 neonates, a Gomco clamp in another 50 neonates, and a Plastibell in the remaining 250 cases (150 in the early group and 100 in the late group). Complications including meatal deformities, meatal stenosis, adhesions and infection were more frequent and more significant in the neonatal circumcision group. CONCLUSIONS: From our study, circumcision at 5 months results in significantly fewer serious complications than circumcision in the neonatal period, irrespective of the method used. Therefore, neonatal circumcision should not be recommended.     

Dorsal penile nerve block vs topical placebo for circumcision in low-birth-weight neonates.

OBJECTIVE: To investigate the efficacy and safety of dorsal penile nerve block (DPNB) and eutectic mixture of lidocaine (EMLA) for palliation of pain associated with circumcision in low-birth-weight infants. DESIGN: Randomized, blinded, controlled trial. SETTING: Intensive care nursery (step down unit) at Georgetown University Medical Center, Washington, DC. PARTICIPANTS: Fifty neonates with weights of 1600 to 2500 g at the time of circumcision who were discharged from the hospital between May 1994 and June 1995 were randomly assigned to the DPNB, EMLA, or control group. Twenty-five infants who were otherwise eligible were excluded because of parental refusal of consent to participate. INTERVENTIONS: Infants in the DPNB and EMLA groups received anesthesia with subcutaneous injection of 1% lidocaine hydrochloride or topical EMLA, respectively. The control group received sham anesthesia with topical placebo (acid mantle cream). MAIN OUTCOME MEASURES: Changes in physiologic variables (heart rate, blood pressure, oxygen saturation, and respiratory rate) and behavioral score 20 minutes before, during, and 5 and 20 minutes after circumcision between DPNB and control groups. Surgical complications and adverse effects were also monitored. RESULTS: Fifty infants were enrolled in the study: 19 randomized to the DPNB group, 19 to the control group, and 12 to the EMLA group. Enrollment into the EMLA group was suspended early because of redness and blistering of the foreskin in 2 infants, and this entire group was excluded from further analysis. The clinical course was similar in all groups of infants. All circumcisions were performed without complication or technical difficulty. Statistically significant differences were noted in heart rate, respiratory rate, and behavioral score when comparing the DPNB group with controls during and after circumcision. CONCLUSION: Dorsal penile nerve block is safe and effective in controlling pain associated with circumcision in low-birth-weight infants.     

Oral sucrose compares favourably with lidocaine-prilocaine cream for pain relief during venepuncture in neonates

To compare the relative efficacy of oral sucrose versus EMLA cream for pain relief during venepuncture, 51 full-term newborns (38M, 13F; postnatal age <4 d) in a stable condition were randomly allocated to one of four treatment groups: placebo (2 ml spring water); 2 ml sucrose 24% w/v; 1 g lidocaine-prilocaine 5% cream (EMLA); or EMLA plus sucrose. Water or a single dose of sucrose solution was administered orally 2 min before venepuncture. EMLA cream was applied in the antecubital fossa 45-60 min before venepuncture and covered by a Tegaderm dressing. A pacifier was given before skin puncture, but it was not actively held or replaced during the procedure or observation periods. In total, 55 venepunctures were performed blindly, always for clinical reasons. As indicators of pain, the total crying time was recorded and heart rate, respiratory rate and arterial oxygen saturation were measured blindly at baseline, immediately post-venepuncture, and 2 and 4 min afterwards. The main effects observed were: (i) time spent crying decreased significantly in the sucrose alone (p = 0.001) and EMLA plus sucrose (p = 0.008) groups; (ii) the above treatments attenuated significantly (p < 0.05) the immediate heart rate response to pain; and (iii) the concomitant use of EMLA did not increase further the analgesic efficacy of sucrose. Conclusion: This study shows that a 24% oral sucrose solution compares favourably with EMLA cream as a safe and cheap analgesic procedure to decrease pain responses to venepuncture in newborns.     

Sucrose as an analgesic for newborn infants

The effectiveness of sucrose as an analgesic agent for newborn infants was assessed during two standard painful hospital procedures: blood collection via heel lance and circumcision. Infants who drank 2 mL of a 12% sucrose solution prior to blood collection cried 50% less during the blood collection procedure than did control infants who had received 2 mL of sterile water. Crying of infants who ingested sucrose returned to baseline levels within 30 to 60 seconds after blood collection whereas control infants required 2.5 to 3.0 minutes to return to baseline. Like findings were obtained for infants who received sucrose on a pacifier prior to and during circumcision. Specifically, control infants who underwent a standard circumcision procedure without intervention cried 67% of the time. A water-moistened pacifier reduced crying to 49% (P less than .01). Crying was reduced further to 31% (P less than .05) by providing infants with a sucrose-flavored pacifier to suck. These findings, which parallel results obtained in studies of pain in infant rats, provide a potent yet simple, benign intervention to help alleviate stress and pain routinely experienced by human infants.     

Optimal time for neonatal circumcision: An observation-based study

ObjectiveA detailed observation-based study to determine the ideal age for neonatal circumcision.Patients and methodsA prospective study of 583 neonatal circumcisions was carried out over a 3-year period (December 2005–December 2008). First a penile ring block was performed with 1% lignocaine solution, injected with a 26G needle. Formula milk, expressed breast milk or 20% sucrose solution was given to the child ad libitum as a further soothing agent. Circumcision was performed utilizing the Gomco sutureless clamp technique. Neonatal/Infant Pain Scale (NIPS) was used to score the severity of pain. NIPS ≥2 was taken to imply a painful procedure.ResultsOnly 6.5% of neonates under 1 week of age scored NIPS ≥2 during the procedure, but this reached 100% by the 4th week of life. There were 2 minor complications in this cohort.ConclusionDespite current controversy over whether it is ethical for parents to consent to a non-therapeutic neonatal circumcision, it remains a widely practiced procedure. Therefore it is important for pediatric surgeons/urologists to perform circumcision safely with minimal trauma to the neonate. This study shows that painless circumcision is possible in almost all newborns if it is performed during the first week after birth.     

Male circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.     

Neonatal circumcision reduces the incidence of asymptomatic urinary tract infection: a large prospective study with long-term follow up using Plastibell

ObjectiveTo evaluate the preventive effect of neonatal circumcision on urinary tract infection and the incidence of complications following neonatal circumcision using Plastibell.Materials and methodsA prospective study was carried out between 2004 and 2008. During this period, there were 3000 neonatal circumcisions. All of the cases were examined for any complications 1 week later, and occurrence of meatal stenosis was followed up to 15 months of age. In this group, urine analysis and culture was successfully performed four times for 2000 circumcised infants at 1.5, 3, 9 and 15 months. In the control group of 3000 uncircumcised infants, 1000 cases accomplished urine analysis and culture at the same designated intervals.ResultsA positive urine culture was observed in none of the circumcised cases and in 20 (2%) uncircumcised cases after obtaining a suprapubic bladder aspiration sample. The latter 20 infants were circumcised and follow-up cultures were negative in 17 cases. The overall complication rate in the circumcised group was 1.6%. The difference in frequency of urinary tract infection between the two groups was statistically significant (P < 0.0001).ConclusionNeonatal circumcision has few complications and reduces the incidence of asymptomatic urinary infection. It may be considered as a preventative health measure.     

Newborn circumcision outcomes: Are parents satisfied with the results?

Background/purpose

Although physician-reported complications following circumcision are very low, parental satisfaction is not well documented. This study examined parental opinions and compared these with those of the medical professional.

Methods

Physicians independently assessed complications and cosmetic outcome following the circumcision. Six weeks post-circumcision, parental report of complications, cosmetic outcome, and overall satisfaction were assessed.

Results

Newborn infants (n = 710) were prospectively recruited and underwent either a Gomco [n = 552 (78 %)] or Plastibell^® [n = 158 (22 %)] circumcision. Physician assessed complication rates were equivalent (Gomco 4.3 % versus Plastibell 5.1 %; p = 0.67), however, parental assessment found a much lower complication rate for Gomco 5.6 % versus Plastibell 12.0 % (p < 0.001). There was no difference between who performed the procedure nor between the techniques in regards to parental rating of overall satisfaction (excellent/good: Gomco 96.9 % versus Plastibell 95.6 %, p = 0.45). However, perceived post-operative pain as scored by parents was significantly higher in patients undergoing Plastibell procedure (6.4 % too much pain) versus Gomco (2.7 %; p = 0.05). Gomco accounted for 72.7 % of parental cosmetically unsatisfactory cases.

Conclusions

Clinicians and parents differed considerably in terms of opinion of cosmetic outcome and occurrence of post-operative complications. This study emphasizes the need for clinicians to better understand and address parental concerns before and after circumcision.     

Randomised controlled trial of swaddling versus massage in the management of excessive crying in infants with cerebral injuries

Background: Infants with neonatal cerebral insults are susceptible to excessive crying as a result of difficulties with self-regulation. Aims: To compare the effectiveness of swaddling versus massage therapy in the management of excessive crying of infants with cerebral insults. Methods: Randomised three-week parallel comparison of the efficacy of two intervention methods. Infants with symptoms of troublesome crying and their parents were randomly assigned to a swaddling intervention group (n = 13) or a massage intervention group (n = 12). Results: The amount of total daily crying decreased significantly in the swaddling group, but did not decrease significantly in the massage group. Infant behavioural profiles and maternal anxiety levels improved significantly in the swaddling group post-intervention. Parents in the swaddling group were more satisfied with the effectiveness of the intervention in reducing crying than parents in the massage group. Conclusion: Results indicate that swaddling may be more effective than massage intervention in reducing crying in infants with cerebral injuries.     

Randomised controlled trial of swaddling versus massage in the management of excessive crying in infants with cerebral injuries.

BACKGROUND: Infants with neonatal cerebral insults are susceptible to excessive crying as a result of difficulties with self-regulation. AIMS: To compare the effectiveness of swaddling versus massage therapy in the management of excessive crying of infants with cerebral insults. METHODS: Randomised three-week parallel comparison of the efficacy of two intervention methods. Infants with symptoms of troublesome crying and their parents were randomly assigned to a swaddling intervention group (n = 13) or a massage intervention group (n = 12). RESULTS: The amount of total daily crying decreased significantly in the swaddling group, but did not decrease significantly in the massage group. Infant behavioural profiles and maternal anxiety levels improved significantly in the swaddling group post-intervention. Parents in the swaddling group were more satisfied with the effectiveness of the intervention in reducing crying than parents in the massage group. CONCLUSION: Results indicate that swaddling may be more effective than massage intervention in reducing crying in infants with cerebral injuries.     

Knowledge of and attitude towards circumcision of adult Korean males by age

AIM: Circumcision is widely practised in Korea, but little is known regarding the public's attitude towards circumcision. This study was designed to evaluate the knowledge and the general opinion of Korean adult males towards circumcision. METHODS: Fifteen hundred self-completion questionnaires were distributed to adult males in five decadal age groups ranging from 10 to 59 y old. Questions concerning opinions regarding the necessity, reasons, potential benefits and disadvantages of circumcision, as well as the role of peer pressure upon the decision to circumcise were included. Completed questionnaires were collected and analysed statistically. RESULTS: The achieved response rate was 62.7%. 73.1% believed that circumcision is necessary, while 7.1% believed it is not necessary. The principal reason for circumcision was to improve penile hygiene (77.9%). 68.7% did not prefer neonatal circumcision regardless of the respondent's age. The major reason was fear of pain (36.9%). Peer pressure was one of the most influential factors when deciding upon circumcision: 60.8% believed that they might be ridiculed by their peer group unless circumcised, and the younger the age of the respondent, the more frequently this opinion was held (p < 0.05). 62.7% thought that circumcision would prevent genital tract infection of the sexual partner. Respondents with older age tended to emphasize improved sexual potency (p < 0.05). CONCLUSIONS: This study indicates that common beliefs of adult males about circumcision in Korea are relatively homogeneous. Tailored education about circumcision is needed.     

Management of pain from heel lance with lidocaine-prilocaine (EMLA) cream: is it safe and efficacious in preterm infants?

Hospitalized preterm infants undergo multiple painful heel lances. A two-phase, randomized, controlled trial was undertaken to determine the safety and efficacy of lidocaine-prilocaine 5% cream (EMLA, Astra Pharmaceuticals, L.P, Westborough, MA) for relieving pain from heel lance. One hundred twenty infants were randomly assigned to receive 0.5 g of EMLA or placebo cream for 30 minutes (Phase 1) or 60 minutes (Phase 2) before a routine heel lance. Efficacy was assessed using the Premature Infant Pain Profile (PIPP). Safety was determined by methemoglobin concentration 8 hours after EMLA application and by clinical signs of methemoglobinemia. No significant differences existed on PIPP scores between EMLA and placebo groups in Phase 1 (p < .480) or Phase 2 (p < .831). No infant had any clinical signs of methemoglobinemia. The mean methemoglobin concentration was 1.19% (.47). Approximately 10% of infants had minor skin reactions, and approximately 20% of EMLA-treated infants had blanching at the application site. The authors conclude that EMLA is safe but not efficacious for relieving pain from heel lance in preterm infants.     

Neonatal behavioural profile and crying in premature infants at term age

Aim : To analyse behavioural characteristics of infants who cried more versus those who cried less, in a sample of low-risk premature infants. Methods : Participants were 63 low-risk healthy premature infants. At term age, the Neonatal Behavioral Assessment Scale (NBAS) was administered, and a 1-d diary for crying was recorded starting on the following day. Infants were categorized into two groups: those with "high level of crying" (≥75th percentile) and those with "less crying" (<75th percentile), based on the total amount of crying time. Results : Some individual NBAS scores and "habituation" and "regulation of state" cluster scores were lower in the high-level-of-crying group. Infants in the group with a high level of crying had lower thresholds for response in the "peak of excitement", "rapidity of build-up", "irritability" and "general irritability" items. Logistic regression analysis revealed that lower "habituation" and "regulation of state" cluster scores were significantly associated with lower thresholds for crying.
Conclusion : These results suggest that neonatal behavioural characteristics, such as hyperresponsivity and poor state regulation, are associated with high levels of crying. Clinical assessments based on the NBAS may help parents elucidate their infant's level of tolerance for stimuli, and identify strategies to minimize their crying.     

Oral sweet solution reduces pain-related behaviour in preterm infants

To evaluate the effectiveness of oral sucrose in the prevention of pain-induced crying in preterm infants, a sample of 28 healthy neonates (15M, 13F; gestational age at procedure less than 37 weeks) who were having routine blood drawn by arm venipuncture was studied. Infants were randomly allocated to receive by mouth, using a syringe, 2 ml of one of three solutions: spring water (group W) and sucrose 12 and 24% w/v (groups S12 and S24, respectively), all in water vehicle. After 2 min, while awake, arm venipuncture was performed and duration of crying was measured. The time spent crying was reduced in the group treated with the sweetest solution (S24, n = 8, mean =19.1 s). No difference was observed between the S12 group ( n = 8, mean = 63.1 s) and W group ( n = 12, mean = 72.9 s). Physiological measurements were recorded at different time points to evaluate excessive basal and procedural distress.     

Is the Gomco clamp hazardous to the neonate?

The Gomco clamp is widely used for circumcision. The fact that it can be sterilized and reused causes wear and tear which may in turn lead to malfunction. Three sites where problems may arise and means of detecting them are reported. Awareness may enable the operator to prevent complications from occurring. Offprint requests to: American University of Beirut, 850 Third Avenue, New York, NY 10022 USA     

Circumcised hypospadias

Purpose  Patients with circumcised hypospadias have been of significant concern over many decades due to the belief that prior circumcision might negatively affect the results of hypospadias’ repair. We evaluated outcomes in consecutive males with anterior, distal penile, and the megameatus with intact prepuce variant of hypospadias (MIP). Methods  After IRB approval a retrospective of 48 consecutive males with circumcised hypospadias was reviewed. In all cases the urethroplasty was accomplished with either urethral plate tubularization or a MAGPI procedure. No skin flaps were used. Results  A total of 48 patients with circumcised hypospadias (anterior, MIP variant, and distal penile) underwent operative reconstruction by one of us (RVP). All patients were followed for at least 8 months. Conclusions  Prior circumcision did not negatively affect the results of subsequent urethroplasty in patients with anterior, distal penile, and the MIP variant of hypospadias. The use of the tubularized incised plate urethroplasty (TIP) has virtually eliminated the need for skin flaps in anterior hypospadias repair.     

Late complications of circumcision in Iran

Today, circumcision is the most commonly performed surgical procedure worldwide. Early and late complications may occur due to circumcision. To find the prevalence of late complications of circumcision, we studied 3,205 elementary-school boys aged 6–12 years in 2002. All of them were Iranian and Muslim. Nearly 3,125 of the boys have been circumcised. Most of the boys (2,214 boys) had been circumcised after 2 years of age. Moreover, most of them were operated by traditional circumcisers (43.49%). Late complications (7.39%) were reported in 231 boys. Excessive residual foreskin was seen in 113 children (3.6%). Excessive removal of skin was detected in 42 boys (1.3%), meatal stenosis in 29 boys (0.9%), granoloma in 22 boys (0.7%), penile rotation in 17 boys (0.5%), and 8 boys had secondary chordee (0.2%). The complication rate was not different between the neonatal circumcision and older groups. We suggested that circumcision should only be performed in medical institutions by suitably trained specialists.     

Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy

The results of an investigation examining the circumcision frequency rate and its effect on the incidence of urinary tract infections in a large, widely dispersed population base during the 10-year period since the 1975 report of the American Academy of Pediatrics Ad Hoc Task Force on Circumcision are reported. Our study population included the 427,698 infants born in all United States Army hospitals, worldwide, from Jan 1, 1975, through Dec 31, 1984. There was an initial plateau in the circumcision frequency rate at approximately 85% during the first 4 years of the study period. In the subsequent 6 years there was a steady, significant decrease (P less than .001) of 1.4% to 4.0% per year through 1984, when the circumcision frequency rate reached its nadir of 70.5%. There was a concomitant increase in the total number of urinary tract infections among male infants (P less than .02) as the circumcision rate declined. This increase was due to the increase in the overall number of uncircumcised boys (who had a greater than 11-fold increased infection rate compared with circumcised boys). During the first half of the study period, there was a female predominance for urinary tract infections from birth onward. As the number of circumcised boys decreased (with a resultant increase in the total number of boys with infection), the male to female ratio of urinary tract infections during the first 3 months of life reversed, reflecting a movement toward a male predominance for infection in early infancy. This is the first, well-documented report of a decreasing rate of circumcisions performed on the American male population.(ABSTRACT TRUNCATED AT 250 WORDS)     

Feeding and oral glucose--additive effects on pain reduction in newborns

AIMS: The aims of this study were to compare the pain reducing effect of oral glucose with that of being breast-fed shortly before venipuncture in newborns, and also the pain score and crying time with parents' assessment. DESIGN: Randomised, controlled trial. SUBJECTS: 120 full term newborns undergoing venipuncture randomly assigned to on of four groups: I, Breast-fed and 1-ml placebo; II, Breast-fed and 1-ml 30% glucose; III, Fasting and 1-ml placebo; and IV, Fasting and 1-ml 30% glucose. OUTCOME MEASURES: Pain during venipuncture was measured with the Premature Infant Pain Profile (PIPP). Crying time was recorded. The parents assessed their babies' pain on a Visual Analogue Scale (VAS). RESULTS: The PIPP score was significantly lower in the infants receiving glucose, than in those not given glucose (p=0.004). There was no significant difference in PIPP score between the infants who were fed and the fasting infants. The PIPP score was lower in group II (median 7) than in group I (md 10). There was a similar difference between group IV (md 9) and group III (md 11). The median crying times during the first 3 min in groups I, II, III, and IV were 63, 18, 142 and 93 s, respectively. There was low agreement between the parents' assessment of pain and the PIPP score and crying time. CONCLUSION: Breast-feeding shortly before venipuncture has no major impact on the pain score but on crying time. The combination of oral glucose and breast-feeding shows the lowest pain score and significantly shorter duration of crying.