Pain of circumcision and pain control

This page indexes material on the pain of neonatal male circumcision, its effects, and attempts to control circumcision pain.

Introduction

Baby in pain.

Before the late nineteenth century, medical doctors understood that infants feel pain.1 Then, in 1872, Paul Emil Flechsig advanced the idea that infants could not feel pain because their nerves are not completely myelinated.1 Incredibly, this idea caught on, and all sorts of operations---including open heart surgery---were carried out on infants without anesthesia for many years.1

The scientific study of neonatal pain, appearing in the literature from circa 1970, began to say that newborns experienced stress from neonatal circumcision.2-5 Until then, however, the medical orthodoxy (amazingly) seemingly still did not believe that newborns could actually feel pain.

Talbert et al demonstrated a rise in serum cortisol during circumcision surgery in 1976.6 This was confirmed by Gunnar et al. in 1981.8 Cortisol is a stress hormone. It is an accepted marker for pain. This was clear proof that infants feel the pain of circumcision.

Surgeons continued to perform open-heart surgery without anesthetic, using curare only to paralyze the newborn, until 1987.55 A public outcry finally forced surgeons to stop this practice.

The definitive study of the human neonatal pain sensory mechanism was published by Anand and Hickey in the New England Journal of Medicine in November 1987.17 They wrote:

Numerous lines of evidence suggest that even in the human fetus, pain pathways as well as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission are intact and functional....Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns....[I]n decisions about the use of these techniques, current knowledge suggests that humane considerations should apply as forcefully to the care of neonates and young nonverbal infants as they do to children and adults in similar painful and stressful situations.

The evidence that neonates feel pain and suffer as much or more than do older children and adults is conclusive and generally accepted today.17

The American Academy of Pediatrics released its statement on neonatal pain control in September 1987.87 The AAP stated clearly that local or systemic pharmacologic agents now available permit relatively safe administration of anesthesia or analgesia to neonates undergoing surgical procedures and that such administration is indicated according to the usual guidelines for the administration of anesthesia to high-risk, potentially unstable patients.87 External link The Canadian Paediatric Society states that the evidence of the need for pain control is strong... The Australasian Association of Paediatric Surgeons condemns neonatal circumcision but states that if it is to be carried out,

...the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional, or local anaesthesia...

Even with this information, the practice of unanesthetised neonatal circumcision continued. This allowed doctors to conduct experiments into the parameters of extreme pain during the 1980s and 1990's on human babies that would have been prohibited in laboratory animals.

All studies on the subject to date compare the pain experienced under anesthesia to the pain of unanesthetized circumcision. None compare the pain under anesthesia to the lack of pain experienced by the non-circumcised infant. In other words, they lacked a control group of children who were subjected to no surgery. This violates the scientific method and hurts children needlessly, because circumcision always causes some pain. No method of pain control for neonatal circumcision exists that is 100 percent effective. All circumcised infants suffer during the procedure and afterwards.

Wallerstein suggested that the best way to avoid the stress of circumcision is to abandon the practice.12

Behavioral changes. Taddio et al reported in 1997 that baby boys who are circumcised with inadequate anesthesia exhibit behavior changes at six months of age that are suggestive of an infant analogue of post traumatic stress disorder.27 External link Porter et al. report increasingly strong behavioral and physiologic responses as the invasiveness of the procedure increases.30 Circumcision is classified as a highly invasive procedure.

Neurological effects. The study of permanent changes in the brain and other neurological structures is not complete. Fitzgerald reports on the neurological changes found in her research.45,47 Fitzgerald reports that excessive activity (pain sensations) in the developing and still plastic neural pathways of the newborn are likely to cause permanent changes in structure.

EMLA (Eutectic Mixture of Local Anesthetics): This topical anesthetic cream from Astra Pharma is much touted for relief of circumcision pain, but studies show that it is only slightly effective for that purpose.68 Not only have Benini et al found that EMLA only relieves pain during approximately 1/3 of the procedure66, but EMLA simply does not penetrate deeply enough to be 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. EMLA simply cannot control the extreme deep pain of such physical trauma to human tissue.

WARNING: EMLA cream is not approved for use in the first thirty days of life due to the threat of methemoglobinemia, a blood disease. The package insert from the manufacturer states that EMLA should not be used on mucosal tissue (which would rule out its use for circumcision), and in any case should not be used on children under 12 months of age, because of the risks of its use. Furthermore, it is not a sterile preparation and should not be used on open wounds.

DPNB. Dorsal penile nerve block (DPNB) was first described by Kirya and Werthmann in 1978.49 Prior to that time anesthesia was almost never used for neonatal circumcision. DPNB 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.69

Dangerous Complications. Lander's study67 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 injury41, pneumothorax42 and gastric rupture43.

Post-operative analgesia. Very few children receive analgesia for the post-operative pain of circumcision. Howard et al studied the post-operative pain of circumcision for a period of 24 hours.23 Howard reports that circumcision pain is severe and persistent and continues beyond the 24 hour period of the study. Acetominophen (paracetamol) may be helpful in relieving post-circumcision pain.23,82

Attitudes and Practices. The medical community has by now extensively researched the need for pain control in infants, as evidenced by the large number of articles indexed below. The standard of care now requires anesthesia for surgical procedures on neonates,87-90 and failure to provide pain control in accordance with current standards is now considered an unethical practice.91,92 Nonetheless, a recent survey by Garry and published in OBG Management found that only 14 percent of US obstetricians who are circumcisers use any form of anesthesia for the surgery.80 A similar study by External link 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.83 Howard et al. reported in 1998 that 26 percent of circumcision training programs do not train doctors to use anesthesia/analgesia.82 The American Medical Association encourages training programs for pediatricians, obstetricians, and family physicians to incorporate information on the use of local pain control techniques for neonatal circumcision.93

New Recommendations: The American Academy of Pediatrics released its now aging External link circumcision policy statement on March 1, 1999. The AAP withdrew its previous recommendation for neonatal circumcision but stated that, if a circumcision is to be done, analgesia should be used. The AAP says the ring block method is the most effective. Furthermore the AAP states that all methods reduce but do not eliminate pain. CIRP has more information about the last AAP statement. The Council on Scientific Affairs of the American Medical Association calls for parents to be given very full information on non-circumcision, circumcision, and especially about pain and pain control so that parents may make informed choices about circumcision and the use of pain control if a boy is to be circumcised.93

Standard of Care: In light of the fact that many health care professionals are still failing to provide needed pain medication to newborn children, the AAP has issued a policy statement89 (2000) containing additional detailed guidelines for the control of pain and stress in the neonate. The statement calls for pain to be avoided rather than controlled whenever possible. It states:

Pain is managed most effectively by preventing, limiting, or avoiding noxious stimuli and providing analgesia. ...Unnecessary noxious stimuli (acoustic, visual, tactile, vestibular) of neonates should be avoided.

The emphasis is on preventing pain by eliminating, avoiding, and limiting painful procedures whenever possible and on using anaesthesia when pain cannot be avoided.90

Circumcision is the most stressful surgical procedure commonly performed on newborns. Avoidance of circumcision is also consistent with principles four and five of the internationally recognized Charter for Children in Hospital. This principle was also suggested by Wallerstein in 1984.

Trauma. The pain and stress of the circumcision experience is intensely traumatic. Taddio et al. have documented behavior suggestive of post-circumcision traumatic stress disorder in infants at the age of six months.24,27 Rhinehart has documented PTSD from neonatal circumcision in middle-aged men.31 Anand and Scalzo suggest that early adverse experiences may result in stress disorders, hyperactivity, and self-destructive behavior.32

For more information on the long-lasting effects of the psycho-trauma of circumcision see Psychological Impacts of Circumcision.

George Hill
December, 2004

References

History

  1. Cope DK. External link Neonatal Pain: The Evolution of an Idea. The American Association of Anesthesiologists Newsletter, September 1998. [Offsite link]

Pain, Stress, and Trauma of Unanesthetised Circumcision and its Effects

  1. Anders T, Sachar E, Kream J et al. Behavioral state and plasma cortisol response in the human neonate. Pediatrics 1970; 46(4):532-537.
  2. Emde RN, Harmon RJ et al. Stress and neonatal sleep. Psychosomatic Medicine, Vol 33, No. 6 (November-December 1971), Pages 491-497.
  3. Tennes K, Carter D. Plasma cortisol levels and behavioral states in early infancy. Psychosom Med 1973; 35:121-128.
  4. Anders TF, Chalemian RJ. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med 1974; 36:174-9.
  5. Talbert LM. et al. Adrenal cortical response to circumcision in the neonate. Obstet Gynecol 48:208-210, Aug. 1976.
  6. Rawlings DJ, Miller PA, Engel RR. The effect of circumcision on transcutaneous PO₂ in term infants. Am J Dis Child 1980; 134: 676-8.
  7. Gunnar MR, Fisch RO, Korsvik S, Donhowe JM. The effects of circumcision on serum cortisol and behavior. Psychoneuroendocrinology 1981; 6: 269-75.
  8. Marshall RE, Porter FL, Rogers AG, Moore J, Anderson B, Boxerman SB. Circumcision: II. Effects upon mother-infant interaction. Early Hum Dev 1982;7: 367-74.
  9. Holve RL, Bromberger PJ, Groveman HD, et al. Regional anesthesia during newborn circumcision. Effect on infant pain response. Clin Pediatr Phila 1983; 22: 813-8.
  10. Gunnar MR, Fisch RO, Malone S. The effects of a pacifying stimulus on behavioral and adrenocortical responses to circumcision in the newborn. J Am Acad Child Psychiatry 1984; 23: 34-8.
  11. Wallerstein E. Is Non Religious circumcision necessary? J Am Acad Child Psychiatry 1985; 24(3):364-365.
  12. Dixon S. Snyder J. Holve R. Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Peds 1984; 5: 246-250.
  13. Gunnar MR, Malone S, Vance G, Fisch RO. Coping with aversive stimulation in the neonatal period: quiet sleep and plasma cortisol levels during recovery from circumcision. Child Dev 1985; 56: 824-34.
  14. Malone SM, Gunnar MR, Fisch RO. Adrenocortical and behavioral responses to limb restraint in human neonates. Dev Psychobiol 1985; 18: 435-46.
  15. Porter FL, Miller RH, Marshall RE. Neonatal pain cries: effect of circumcision on acoustic features and perceived urgency. Child Dev 1986; 57:790-802.
  16. Anand, KJS, Hickey PR. Pain and its Effects on the Human Neonate and Fetus. New Engl J Med 1987;317:1321-1329.
  17. Gunnar MR, Connors J, Isensee J, Wall L. Adrenocortical activity and behavioral distress in human newborns. Dev Psychobiol 1988; 21: 297-310.
  18. Porter FL, Porges SW, Marshall RE. Newborn pain cries and vagal tone: parallel changes in response to circumcision. Child Dev 1988; 59: 495-505.
  19. Marshall RE. Neonatal pain associated with caregiving procedures. Pediatr Clin North Am 1989; 36: 885-903.
  20. Anand KJS, Carr DB. The Neuroanatomy, Neurphysiology, and Neurochemistry of Pain, Stress, and Analgesia in Newborns and Children. Pediatric Clinics of North America 1989;36(4):795-822.
  21. Schoen EJ, Fischell AA. Pain in neonatal circumcision. Clin Pediatr (Phila) 1991; 30: 429-32.
  22. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641-6.
  23. Taddio A, Koren G et al. Effect of neonatal circumcision on pain responses at vaccination in boys. The Lancet 345: Pages 291-292 (February 4, 1995).
  24. Fleiss P. Letter. The Lancet, Vol 345, P. 927, 8 April 1995.
  25. Warren J. Letter. The Lancet, Vol 345, P. 927, 8 April 1995.
  26. Taddio A, Koren G et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet, Vol. 349: Pages 599-603 (March 1, 1997).
  27. Weisman SJ, Berstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med 1998; 152:147-9.
  28. Taddio A, Shah V, Gilbert-MacLeod C, Katz J. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA 2002;288(7):857-61.

Psychological Considerations

  1. Porter FL, Wolf CM, Miller JP. External link Procedural pain in newborn infants: the influence of intensity and development. Pediatrics. 1999;104:e13. (link to www.pediatrics.org)
  2. Rhinehart J. Neonatal circumcision reconsidered. Transactional Analysis Journal 1999; 29(3):215-221.
  3. Anand KJ, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior? Biol Neonate 2000 Feb;77(2):69-82.
  4. Chamberlain D. Babies Remember Pain. Pre- and Perinatal Psychology Journal, Summer 1989. (courtesy of the External link Primal Psychotherapy Page)

Complications of Anesthesia

  1. Sara CA, Lowry CJ. A complication of circumcision and dorsal nerve block of the penis. Anaesth Intensive Care 1985; 13: 79-82.
  2. Berens R, Pontus SP Jr A complication associated with dorsal penile nerve block. Reg Anesth 1990; 15: 309-10.
  3. Snellman LW, Stang HJ. Prospective evaluation of complications of dorsal penile nerve block for neonatal circumcision. Pediatrics 1995; 95: 705-708.
  4. Tse S, Barrington K. Methemoglobinemia associated with prilocaine use in neonatal circumcision. Am J Perinatol 1995; 12: 331.
  5. Arda IS, Ozbek N, Akpek NE and Ersoy ET. Toxic Neonatal Methaemoglobinaemia after Prilocaine Administration for Circumcision. BJU International 2000, 85 (9), 1-1.
  6. Couper RTL. Methaemoglobinaemia secondary to topical lignocaine/prilocaine in a circumcised neonate. J Paediatr Child Health 2000;36(4):406-407.
  7. Odemis E, Sonmez FM, Aslan Y. Toxic methemoglobinemia due to prilocaine injection after circumcision. Int Pediatr 2004;19(2):96-7.

Complications of Lack of Anesthesia

  1. Ruff ML, Clarke TA, Harris JP, Bartels EK, Rosenzweig M. Myocardial injury following immediate postnatal circumcision. Am J Obstet Gynecol 1978; 144:850-51.
  2. Auerbach MR, Scanlon JW. Recurrence of pneumothorax as a possible complication of circumcision. Am J Obstet Gynecol 1978; 132: 583.
  3. Connelly KP, Shropshire LC, Salzberg A. Gastric rupture associated with prolonged crying in a newborn undergoing circumcision. Clin Pediatr 1992;31:560-61.
  4. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278:2158-2162.

Neurological Effects

  1. Fitzgerald M. The birth of pain. MRC News 1998; Summer:20-23.
  2. Porter FL, Grunau RE, Anand KJ. Long-term effects of pain in infants. J Dev Behav Pediatr 1999;20(4):253-61.
  3. Fitzgerald M, Walker S. The role of activity in developing pain pathways. In: Dostovsky JO, Carr DB, Koltzenburg M (eds). Proceedings of the 10th World Congress on Pain. Progress in Pain Research and Management, Vol. 24. Seattle: IASP Press, 2003, pp 185-96.

Anesthesia and Analgesia

  1. Weiss C. Does circumcision of the newborn require an anesthetic? Clin Pediatr (PHILA) 1968; 7: 128-9.
  2. Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve block--a painless procedure. J Pediatr 1978; 92: 998-1000.
  3. Poma PA. Painless neonatal circumcision. Int J Gynaecol Obstet 1980; 18: 308-9.
  4. Williamson PS, Williamson ML. Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983; 71: 36-40.
  5. Holve RL, Bromberger PJ, Groveman HD, et al. Regional anesthesia during newborn circumcision. Effect on infant pain response. Clin Pediatr Phila 1983; 22: 813-8.
  6. Dixon S. Snyder J. Holve R. Bromberger P. Behavioral effects of circumcision with and without anesthesia. J Dev Behav Peds 1984; 5: 246-250.
  7. Williamson PS, Evans ND. Neonatal cortisol response to circumcision with anesthesia. Clin Pediatr (Phila) 1986; 25: 412-5.
  8. Anand KJ, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery: effects on the stress response. The Lancet 1987;1(8524):62-6.
  9. Maxwell LG, Yaster M, Wetzel RC, Niebyl JR. Penile nerve block for newborn circumcision. Obstet Gynecol 1987; 70: 415-9.
  10. Stang HJ, Gunnar MR, Snellman L, Condon LM, Kestenbaum R. Local anesthesia for neonatal circumcision. Effects on distress and cortisol response. JAMA 1988; 259: 1507-11.
  11. Marchette L, Main R, Redick E. Pain reduction during neonatal circumcision. Pediatr Nurs 1989; 15: 207-8, 210.
  12. Mudge D, Younger JB. The effects of topical lidocaine on infant response to circumcision. J Nurse Midwifery 1989; 34: 335-40.
  13. Toffler WL, Sinclair AE, White KA. Dorsal penile nerve block during newborn circumcision: underutilization of a proven technique? J Am Board Fam Pract 1990; 3: 171-4.
  14. Arnett RM, Jones JS, Horger EO. Effectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision. Am J Obstet Gynecol 1990; 163: 1074-80.
  15. Masciello AL. Anesthesia for neonatal circumcision: local anesthesia is better than dorsal penile nerve block. Obstet Gynecol 1990; 75: 834-8.
  16. Blass EM, Hoffmeyer LB. Sucrose as an analgesic for newborn infants. Pediatrics 1991; 87: 215-8.
  17. Marchette L, Main R, Redick E, Bagg A, Leatherland J. Pain reduction interventions during neonatal circumcision. Nurs Res 1991; 40: 241-4.
  18. Spencer DM, Miller KA, OQuin M, Tomsovic JP, Anderson B, Wong D, Williams WE. Dorsal penile nerve block in neonatal circumcision: chloroprocaine versus lidocaine. Am J Perinatol 1992; 9: 214-8.
  19. Benini F, Johnston CC, Faucher D, Aranda JV. Topical anesthesia during circumcision in newborn infants. JAMA 1993; 270: 850-3.
  20. Weatherstone KB, Rasmussen LB, Erenberg A, Jackson EM, Claflin KS, Leff RD. Safety and efficacy of a topical anesthetic for neonatal circumcision. Pediatrics 1993; 92: 710-14.
  21. Fontaine P, Dittberner D, Scheltema KE. The safety of dorsal penile nerve block for neonatal circumcision. J Fam Pract 1994; 39: 243-8.
  22. Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278:2158-2162.
  23. Van Howe RS. Anesthesia for neonatal circumcision: who benefits? J Pre Perinatal Psychol Health 1997; 12(1): 3-18.
  24. Van Howe RS, Cold CJ. Local anesthesia for infants undergoing circumcision. JAMA 1998; 279: 1170.
  25. Hardwick-Smith S, Mastrobattista JM, Wallace PA, Ritchey ML. Ring block for neonatal circumcision. Obstet Gynecol 1998;91(6):930-4.
  26. External link Technique of DPNB and Ringblock Illustrated (Link to units.ox.ac.uk)
  27. Taddio A, Pollock N, Gilbert-MacLeod C, et al. Combined analgesia and local anesthesia to minimize pain during circumcision. Arch Pediatr Adolesc Med 2000;154(6):620-3.
  28. Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics; Task Force on Pain in Infants, Children, and Adolescents, American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001;108(3):793-7.

Post-Operative Analgesia

  1. Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641-6.

Attitudes and Practices

  1. Fontaine P. Local anesthesia for neonatal circumcisions: are family practice residents likely to use it? Fam Med 1990; 22: 371-5.
  2. Wellington N, Rieder MJ. Attitudes and practices regarding analgesia for newborn circumcision. Pediatrics 1993; 92: 541-3.
  3. Ryan CA, Finer NN. Changing attitudes and practices regarding local analgesia for newborn circumcision. Pediatrics 1994; 94: 230-3.
  4. Garry T. Circumcision: a survey of fees and practices. OBG Management 1994. (October): 34-6.
  5. Holton ME. Comparison of newborn circumcision pain to calcaneal heel puncture pain: Is newborn circumcision pain control clinically warranted? JAOA 1996; 96: 31-3.
  6. Howard CR, Howard FM, Garfunkel LC, de Blieck EA, Weitzman M. Neonatal circumcision and pain relief: current training practices. Pediatrics 1998; 101:423-428.
  7. Stang HJ, Snellman LW. External link Circumcision practice patterns in the United States. Pediatrics 1998; 101: e5. Link to AAP website
  8. Robert S. Van Howe, Megan Butler-O'Hara, Christine LeMoine, and Ronnie Guillet. External link Pain Relief for Neonatal Circumcision: Serious Design Flaws? Pediatrics 1999;103:196.
  9. Sinno SHP, van Dijk M, Anand KS, et al. External link Do We Still Hurt Newborn Babies? A Prospective Study of Procedural Pain and Analgesia in Neonates. Arch Pediatr Adolesc Med 2003;157:1058-64.
  10. Howard RF. External link Current Status of Pain Management in Children. JAMA 2003;290(18):2464-9.

Standard of Care

  1. American Academy of Pediatrics. Neonatal anesthesia. Pediatrics 1987;80(3):446.
  2. Fletcher AB. Pain in the neonate. (Editorial) N Engl J Med 1987;317(21):1347-1348.
  3. American Academy of Pediatrics. Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery. Prevention and Management of Pain and Stress in the Neonate. Pediatrics 2000;105(2):454-461.
  4. Anand KJS, International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med 2001;155:173-180.

Ethics

  1. Walco GA, Cassidy RC, Schechter NL. Pain, Hurt and Harm: The ethics of pain control in infants and children. N Engl J Med 331(8), Aug 25 1994, 541-544.
  2. Dollberg S, Stolik-Dollberg O. [Prevention and pain management in term and preterm infants] Harefuah 2004;143(1):54-9, 84.

Informed Consent

  1. Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.

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