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

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.2,3,4,5 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 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 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 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 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

