Local anesthetic techniques for analgesia in neonatal circumcision: a network meta-analysis

OBJECTIVE: Neonatal circumcision is often performed without adequate analgesia despite significant harm related to acute pain. We compared local anesthetic techniques using network meta-analysis based on intraoperative physiological responses. STUDY DESIGN: Frequentist network meta-analysis of randomized controlled trials comparing nerve blocks (dorsal penile nerve block, DPNB; ring block, RB), topical anesthetics (eutectic mixture of local anesthetics, EMLA; topical lidocaine, TL), combination techniques, and control. OUTCOMES: intraoperative heart rate, oxygen saturation, their variation, respiratory rate, and hematoma. Risk of bias and certainty of evidence were assessed. RESULTS: Eighteen trials (1 035 neonates) were included. Nerve blocks reduced pain-related responses versus control and TL. DPNB outperformed EMLA, with increased hematoma risk. Meta-regression suggests smaller effect size in recent studies. CONCLUSIONS: Evidence supports local anesthetic techniques for neonatal circumcision, with nerve blocks providing greater benefit than topical anesthetics. However, given the small sample sizes and low certainty of evidence, higher-quality trials are needed.