What you Need to Know about Anesthesia & Pain from Circumcision by Mary G. Ray ©1997,  All Rights Reserved

       Many parents believe their child can be protected against the pain of circumcision through the use of anesthesia, but there is no pain control method that is 100 percent effective. All infants suffer during and after the procedure.  There are risks from anesthesia and there are risks if anesthesia is not used.  If a baby is left intact, he is not subjected to any of these risks.

DPNB - Dorsal Penile Nerve Block is more effective than EMLA but DPNB does not block the ventral nerve pain pathways so it is only partially effective. The infant still feels pain when DPNB is used. Lander et al reported that ring block is more effective than either EMLA or DPNB for control of circumcision pain. Excerpt from Pain of Circumcision and Pain Control by George Hill        The shot itself can be very painful and the injection of local anesthesia into the penis can cause permanent vascular and nerve damage.

EMLA is a topical anesthetic cream.  Many parents are told it eliminates the pain of circumcision. Studies show it's only slightly effective. "Not only have Benini et al  found that EMLA only relieves pain during approximately 1/3 of the procedure, but EMLA simply does not penetrate deeply enough to be very effective: During circumcision, the membranes are torn from the glans, the inner and outer layers are clamped, and the foreskin is cut away with a scalpel."  Excerpt from Pain of Circumcision and Pain Control by George Hill EMLA is not recommended for infants under six months of age. Read the WARNING as well.

WARNING  In August 1994 a Canadian hospital issued a strong warning against the use of Prilocaine and EMLA cream upon newborns. Their hospital experienced a case where a few hours after his circumcision, a baby developed significant Methaemo-globinaemia [which can cause brain damage and death in small infants]. Two other cases of Methaemo-globinaemia due to Prilocaine have occurred in British Columbia. [Canadian] Lidocaine has been know to cause the same results. 

Additionally, a recent survey by Garry and published inOBG Management found that only 14 percent of US obstetricians who perform circumcision use any form of anesthesia for the surgery. A similar study by Stang (et al.) in 1998 found that only 25 percent of OBs, 56 percent of family practitioners, and 71 percent of pediatricians surveyed use anesthesia. Howard (et al.) reported in 1998 that 26 percent of circumcision training programs do not train doctors to use anesthesia/analgesia. 

        Quoting from the CNN article, Circumcision Study Halted Due to Trauma, "Up to 96% of babies in the U.S. and Canada receive no anesthesia when they are circumcised. ...It has also been argued that injecting anesthesia can be as painful as the circumcision itself."

Dangerous Complications. Lander's study was terminated after several infants circumcised without anesthesia experienced apparent life threatening breathing difficulties, including choking and apnea. The shock of circumcision without anesthesia and extremely vigorous crying can produce additional dangerous complications including heart injury, pneumothorax and gastric rupture. Excerpt from Pain of Circumcision and Pain Control by George Hill

       Just as the fingernail is fused to the finger, “at birth the foreskin is fused to the glans.” [Fleiss] In order to remove it, the foreskin is pulled, torn, crushed and cut. We now know that babies actually feel pain more intensely than adults. [Anand] Most babies scream wildly. Blood pressure and heart rate increases markedly. Some go into severe shock, and lapse into a semi-comatose state. This is often misunderstood by medical professionals who later insist that the baby experienced no pain because they laid there without moving or crying. Babies continue to feel pain after the surgery.

       Events that cause stress and pain appear to affect a baby’s feeding patterns. [*Marshall] Breastfeeding failure occurs at a higher rate among circumcised babies. [Marshall] Newborns are acutely aware of their mothers. When an infant suffers overwhelming pain, he cannot formulate the idea that this invasion was well intended. He can only assume that his mother was somehow responsible. A common opinion is that the trauma of circumcision impairs maternal bonding and can cause psychological damage. [Laibow]

CHICAGO (AP) and AP-NY-12-24-97 “Circumcision causes newborns a lot of pain, and they should always receive anesthesia for it, researchers say. Suffering caused by the procedure was so clear in a new study of anesthetics that researchers stopped enrollment early because they decided it was unethical to circumcise any more newborns without an anesthetic.” “The debate over whether circumcision should be performed at all has overshadowed the problem of how often it is done without anesthesia . . .” “Some doctors remain unconvinced that anesthesia is safe and effective for the procedure, despite studies indicating it is, the researchers said. And some physicians believe that circumcision causes minimal pain, that newborns do not remember pain or that an efficient circumcision causes less pain than injecting an anesthetic.” “Two of 11 newborns who received no anesthetic had potentially dangerous episodes within minutes of the procedure. One newborn lost muscle tone, stopped breathing several times and vomited. The other choked and stopped breathing briefly, the researchers said.” “The most effective technique for pain relief tested among the 52 healthy newborns in hospitals in Edmonton, Alberta, was a ring block. That procedure involves injecting anesthesia at points forming a ring around the shaft of the penis.” Rabbi Gerald Chirnomas of Boonton, N.J., who estimates that he has done more than 11,000 circumcisions without anesthesia or complications, disagreed. He says he discussed the issue with many urologists and never met one who favored injecting anesthetic into the penis. He thinks it’s very dangerous.

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References:

Anand, K.J.S., Hickey, PR, “Pain and its Effects in the Human Neonate and Fetus,” The New England Journal of Medicine, Vol. 317:21, November 19, 1987, pp. 1321-9.

Canadian Nurse, August 1994, pp. 5-6.

Fleiss, M.D. Paul M. and Frederick Hodges, The Foreskin is Necessary, in the Townsend Letter for Doctors and Patients, April 1996.

Laibow, R. Circumcision: Relationship Attachment Impairment. NOCIRC International Symposium on Circumcision, San Francisco, April, 1991:14.

*Marshall, RE, Stratton WC, Moore JA, Boxerman SB, Circumcision I: effects upon newborn behavior. Infant Behavior Dev. 1980;3:1-14

Marshall RE, Porter FL, Rogers AG, Moore J, Anderson B, Boxerman SB, Circumcision II: effects upon mother-infant interaction. Early Human Development 1982;7:367-374