Friday, 15 February 2013

Red wine as painkiller... In babies?!

A couple of years ago, I was working a locum shift in a supermarket pharmacy. It was quite late at night, and a man came up to the counter to ask me if I did circumcisions. I assumed I had heard incorrectly, but no. "I thought you would be able to do circumcisions, since you can do healthcare services and you have a private room" he said, pointing at the extremely small and flimsy consulting "room" and the end of the counter. I couldn't help but notice the small boy cowering behind him as I politely explained that no, circumcision certainly wasn't a pharmacy service.

At the time, I remember being amazed that it would occur to someone to take their child to a supermarket for what is a surgical procedure. Whilst it may be considered minor surgery, I'm sure to the young boy himself it didn't seem all that minor, and I'm pretty sure he wouldn't be wanting a pharmacist to do it in the middle of a supermarket with only some thin plastic walls between him and the vegetable aisle.

Anyway, I shall leave aside the ethics of circumcision for now, and consider a tweet I saw this morning by Andy Lewis. One particular Doctor, on his website, is advising pain relief options for babies who are about to be circumcised. He advises loading the child up on red wine as a preferred option. Now hold on here, this is a GMC registered Dr advising on giving babies alcohol. Whilst he doesn't give any information about how much wine to give, i'm assuming it would have to be enough to get the child at least slightly intoxicated to have any painkilling effect. A quick google search suggests the 8th day after birth is a usual time for the circumcision to take place.

"1. To give the baby sweet, red wine prior to the procedure. (Kiddush wine is ideal). This is very effective in calming the baby. Ideally it is given about 15 minutes before the circumcision and I will give it on arrival if you wish. You will need to provide the wine."

At this point, let us consult, the database of the National Poisons Information Service (NPIS). They advise that any children under the age of 10 who are symptomatic due to an alcohol ingestion (i.e. intoxicated) are taken into hospital for medical assessment.

Why is it dangerous to advise wine as a painkiller in a child of this age? Well, alcohol in children can be very nasty. It can cause hypoglycaemia, particularly in children, and a seemingly well child can sometimes suddenly and quickly go downhill fast- that's why NPIS recommend that they are observed in hospital.

Such advice, coming from a trusted Doctor, is very concerning indeed. It appears from the website that he expects the baby to be "prepared" prior to his arrival, so he is expecting the parents to administer and provide the wine (whilst he says he can give it "if they wish", to me this implies that its more usual for the parents to give it). He also recommends Emla cream, which he says the parents can buy from a pharmacy. This is an off-label use that he is openly promoting.

I have emailled the GMC to ask what their stance on such advice is:

"To whom it may concern,

I have happened upon the following website, which promotes the work of a GMC registered doctor, Dr Howard Cohen GMC number 3057256, and wish to clarify with yourselves whether I would be able to make a complaint against the advice he gives on his website:

I am particularly concerned about the advice regarding pain relief that Dr Cohen is giving. He recommends giving babies "sweet red wine prior to the procedure". It is my understanding that children should not be given alcohol, particularly on the advice of a healthcare professional. I regularly use Toxbase in my daily work and note that children who have ingested notable amounts of alcohol should be observed in hospital due to the risk of hypoglycaemia and other issues. A Dr recommending that a child is given presumably enough wine to be intoxicated as pain relief is highly dangerous advice.

He also advises purchasing Emla cream from a pharmacy for use prior to circumcision. It is my understanding that, although Emla cream is licensed in children, its use on the skin of male genital organs is only licensed in adults. Dr Cohen is therefore promoting off-label use of a drug on his website, without giving sufficient dosing advice or guidance.

I look forward to hearing from yourselves if this would be grounds for a complaint, or if promoting such advice is reasonable from your point of view.

Kind regards,"

Let's hope I get a decisive reply back. 


Update: As of 25th Feb I still haven't heard back from the GMC.