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Are You Having a Boy?
Easing the Pain of Circumcision

What are your options?

The decision of whether or not to circumcise your male newborn is a personal one. It is often influenced by religious, cultural or individual beliefs. Circumcision does however offer numerous health benefits including a decrease in the incidence of local foreskin problems, urinary tract infections, kidney problems, bacteremia, penile cancer, sexually transmitted diseases and HIV. If you opt for the procedure, you may also be wondering about the pain it might cause him.

Until a few years ago, the commonly held belief has been that the circumcision procedure is so brief that the baby will not remember the pain, that the babies' neurologic systems necessary for pain transmission and perception are not well developed and as such the newborn does not feel pain, or that the procedure will be over within a few seconds.

However, that belief is changing, in large part because of the results of a study which showed that a local anesthetic helped to lessen babies' pain.

In 1997, the New England Journal of Medicine published a study of 68 infants, 38 of whom were treated with an anesthetic cream called EMLA prior to the circumcision, 30 of whom received a placebo. The study evaluated babies' facial expression, crying, and heart rate (all indicators of distress).

Researchers found that those in the EMLA group had a 12-49% reduction in perceived pain; thus, the pain pathways and neurologic systems necessary for pain transmission and perception are developed and functional in the newborn infant. Even in light of this research, not all practitioners agree that anesthesia is essential.

Many hospitals that offer pain relief have policies in place so that parents may not be able to choose a specific anesthetic. However if you have the choice, it may be important to you to know the options that may be employed to decrease any discomfort caused by the procedure. Anesthetics are medications used to block pain impulses. The anesthetic may be applied topically, locally or regionally.

Topical application of an anesthetic is accomplished with the use of EMLA cream. The cream is applied to the tip of the baby's penis and the penis is covered with an occlusive dressing. The cream itself is painless. In order for EMLA to be effective, the application of the cream must be coordinated with the procedure, allowing the appropriate amount of time (approx. one hour) for the cream to work prior to the circumcision. The EMLA cream, removed just before the procedure is performed, anesthetizes the penis for approximately two to four hours after its removal.

A ring block refers to the infiltration of local anesthetic to the loose skin around the penis. The medication (lidocaine or Bupivacaine) numbs the foreskin where the circumcision incision is made for approximately one to four hours.

A third option for pain control during circumcision is a penile nerve block. This procedure involves the injection of local anesthetic in two locations at the base of the penis. Similar to the ring block, it is infiltrated just prior to the circumcision procedure. This method works by numbing the nerves, thereby blocking the transmission of pain.

While these pain relief methods are valid, the anesthetic procedure used to ease circumcision pain may create technical difficulties in performing the circumcision itself. It is difficult to determine the absolute efficacy of any of the above interventions. The baby may still experience some discomfort, whether it is from the application of the anesthetic or the procedure itself. If you choose to have your baby circumcised, it is helpful to discuss pain control options with your healthcare team and decide on the method best suited for you and your baby.

Editor's Note: On March 1st, the American Academy of Pediatrics issued a new policy stating for the first time that circumcision should not be done routinely on all newborn boys but, if parents do decide to circumcise, they should make sure their son is given some kind of pain relief during the procedure. 

Wendy Mackey R.N., MSN is a mother of 2 and resides in Guilford. She is a Clinical Nurse Specialist in Pediatric Surgery and Pediatrics at Yale-New Haven Children's Hospital, and is chair of the Pediatric Painless Resource Group, a special interest group focusing on pediatric pain management.

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