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.