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From the Physicians' Lounge #2

June 23, 2017

From the Physicians' Lounge

Circumcision without anesthesia is painful. There is no doubt about it! Some of us older physicians cringe when we remember the days of neonatal circumcision without any numbing. All babies cried. Most cried very loudly. That said, most also had short procedures, then went back and fed with mom -- with a very low complication rate. Still, it was wrong!

We physicians, even pediatricians like me, screwed up when we assumed the risks of medications used for local and topical analgesia (numbing procedures) were a higher concern than worries about the pain of the procedure. It wasn't that we were unsympathetic to the pain and suffering of infants or pediatric patients in general! It's just that we knew circumcisions are not major procedures and we had all been trained to be very cautious with medications in the first days of life. We were wary of medications used commonly at later ages like Tylenol and lidocaine. We had a healthy concern about medications that were applied topically in the diaper area due to the risk of absorption into the newborn's body. We were afraid of the tiny injectable dose of anesthesia having unwanted systemic effects. We also knew there was always a risk of a medication error. Still, we were wrong!

Physicians make mistakes. Pediatricians make mistakes too even though it really falls on us to make sure they don't happen in newborn and infant medical care. Our profession has not been perfect over its history, but there is good news. In general, we learn from our mistakes. I can honestly say that I know of no newborn circumcision performed without local or topical analgesia in the last 20+ years! (The change started happening in the mid to late 1990s.) If you know a physician still doing circumcision without pain control, then they are not practicing within the American standard of care. They should have changed their practice a long time ago! It would be unthinkable for a new physician to come to town and try to perform circumcisions without numbing the foreskin -- hospitals, clinics, and parents would not allow it. If you have seen these procedures done over and over with good analgesia you would never, ever want to see it done the old way again!

Not all of us perform the same type of numbing procedure for newborn circumcision. Some docs perform shots of numbing medication (penile or ring blocks) and some docs use a topical numbing cream (EMLA/Ela-Max). Since recognizing the importance of analgesia, we have also added the comfort measure of giving some sugar water to suck on during circumcisions. It really helps since there can be some breakthrough pain, and since not all the fuss some babies make with circumcision is cured by a numb foreskin. Personally, I think good analgesia can be obtained with these methods in the first few weeks of life, after that more substantial pain management is usually needed (which is generally still safe but has significantly more risk for adverse reactions with the stronger analgesia, anesthesia, and/or sedation medications required).

Why am I writing this for It's because we want to be honest about the past while we fight the nonsense that is spread about medical circumcision in the present: whether it's the persistent anti-circumcision activist claim that numbing medication still isn't used in the U.S.; that pain control methods are universally not effective for circumcision pain; or, more laughably, that babies who receive pain control don't cry because they're in 'neurogenic shock;" or, taking a page from the anti-vaccination activists, that newborn circumcision pain leads to later-life autism, depression, anger, violence, sexual dysfunction, etc., etc. We don't want any babies to be in pain unnecessarily but medical procedures often do have some associated pain. For this reason, procedures need to show some benefit to justify the pain. I'm not here today to talk about those benefits, but we agree with the American Academy of Pediatrics and their statement that the risks of circumcision are low enough that the benefits outweigh them. Like the AAP, we also do not promote universal infant circumcision, however, we do strongly believe every parent should get the facts on circumcision, not misinformation from crusading intactivists, prior to making an informed decision about their son's medical care!


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