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Circumcision and Pain

 

Baby being circumcised, screaming his head off

 

Contents

Anecdotes

Studies

Babies feel pain...

...more than adults ...

... even with anaesthetic ...

...(sugar is no good)...

And the pain may resume after the circumcision is over. "It was nothing like his cries when he got his shots. Nothing like when he came out of the womb. Nothing like anything he'd done yet. It was a deep cry - totally from pain. It was evident through his entire body." Blog of a father whose baby had extreme post-operative pain.

... and it has long-term effects.

Other

 

Dr S lays Sarah's baby on the bench. "You're not going to faint, are you?" he asks me. "That's the main injury risk round here." He straps Bobby to a rack, known as a Circumstraint. Bobby rails a little as Dr S swabs his pubis with Betadine. "This will hurt a bit," says the doctor, injecting anaesthetic into the base of the penis. Bobby spits his dummy and starts wailing while Dr S loosely ties a silk thread around the tiny penile shaft. The foreskin is attached to the glans and has to be forcibly freed before it is clamped, stretched and slit. This widens the aperture to accommodate the "Plastibell", basically a notched thimble which fits over the head of the penis.

Bobby's wails are getting louder, and Dr S looks slightly uncomfortable. "They don't all cry like this," he says. He manoeuvres the thread over the Plastibell notch and gives a sharp, hard tug. The crying stops. Bobby's limbs go rigid, his eyes bulge, his mouth gapes and his fingers snap straight. Then his body goes limp and all is quiet.

Dr S looks mildly dismayed. "About one in two jump like that." He waits a few minutes before slicing off the strangled foreskin and breaking off the Plastibell handle. "The ring will fall off in about five days. Really, it's no more risky or difficult than doing sheep's tails." With that, he buttons Bobby into his babysuit. The entire operation has taken eight minutes.

"How was he?" Sarah asks the doctor when we return to the waiting room. "Fine," he says. "Give him a feed and he'll be right."

- from "Losing It" by John van Tiggelen
the Sydney Morning Herald / The Age (Melbourne)
26 August, 2000

 

For generations, millions upon millions of babies were routinely circumcised without anaesthetic, in the comforting belief that "babies can't feel pain" - and in spite of those babies turning blue in the face trying to tell us they can.

 

Once [the Gomco™ clamp] was carefully and correctly in place, I started turning the clamp handle. I had been told that newborns didn't feel pain which I scarcely believed, when all of a sudden came screams which loosened the paint on the wall.

What an eye-opening, eardrum damaging event. I had heard and seen battle injured soldiers before but this screaming raised the hair on my neck.

- Dr. Phillip Leveque

 

I am an American white female age 56, and I worked in many family practice doctor's offices over the years. Part of my job was to assist with circumcisions. I quit my job over that very duty. It was barbaric. I watched babies pass out, turn blue, scream in a guttural scream that turned my blood cold. Parents should be forced to watch a doctor cut off the tip of their son's penis, hear him scream, see his skin mottle white and blue, watch his head roll back and forth in agony while strapped down, unable to move. Babies have no voice in the decision other than vomiting all over themselves during the "procedure". If parents want that for their son, they should be forced to participate in the torture.

Zuzu on Chron.com, May 19, 2011

 

Noah was circumcised yesterday (no bashing please, this was our choice) and it was very traumatic, probably more for me than for him. [She wishes.] I did stay in the room with him while they did it and did my best to comfort him and give him his sugar binky. They kept telling me that usually the babies will sleep through the procedure. Noah didn't, he SCREAMED the entire time. I was brought to tears, I hate seeing my son so upset. Now he is screaming each time I change his diaper. There's minimal bleeding, but his penis is pretty swollen. I've been giving him ibuprofen every 6 hours, but he still seems to be in quite a bit of pain with each diaper change. It is so hard for me to change him, and get his penis cleaned while he is screaming like that (I am doing it, I just don't like it). I don't know what else I can do to comfort him. ...

- athiede on Cafemom, December 15, 2011

reply by mommy2brandon11: ... I give you a lot of credit for being in the room while they did the procedure I was not and I do not think that I could have been either.

reply by mommyal060911: Me too! That is very brave. I refused. My husband was in the room with our first son, but he said he couldn't handle going in there again with our second son.

[Raising the question, if they couldn't bear to stay there, why did their babies have to?]

 

(offsite) Dawn tells what happened after the doctor told her "he wouldn't feel a thing", with photographs, in Everything Birth, April 27, 2013

 

Babies feel pain...

"Infants have the same capacity for pain as adults. ...By 20 weeks' gestation, ascending fibers, neurotransmitters, and the cerebral cortex are developed and function to the extent that the fetus is capable of feeling pain. ...However, inhibitory neurotransmitters are in insufficient supply until birth at full term.

Preverbal [not yet speaking] infants are at high risk for undertreatment of pain because of persistent myths and beliefs that infants do not remember pain. Therefore the preterm infant is rendered more sensitive to painful stimuli. ...New research indicates that repetitive and poorly controlled pain in infants can result in lifelong adverse consequences such a neurodevelopmental problems, poor weight gain, learning disabilities, psychiatric disorders and alcoholism (Anand, 2000)" (Jarvis, 2004, p. 211).

Jarvis, C. (2004). Physical examination & health assessment (4th ed.). St. Louis, MO: Elsevier. Anand, KJS: Effects of perinatal pain and stress, Prog Brain Res 122:117-119, 2000. Anand, KJS: The applied physiology of pain. In Anand KJS, McGrath, RJ, editors: Pain in neonates, Amsterdan, 1993, Elsevier.

 

Porter et al. guessed that circumcision would be painful, and surprise! It was.

Procedural Pain in Newborn Infants: The Influence of Intensity and Development
Fran Lang Porter, PhD, Cynthia M. Wolf, PhD, and J. Philip Miller, AB

"We had hypothesized that circumcision would be at the most invasive end of the spectrum, and this procedure did elicit the most vigorous physiologic and behavioral reactions of those we studied. Similarly, clinicians rated circumcision as the most painful of 12 clinical procedures. Thus, there was convergence in a hypothetical gradient of pain, a survey-based gradient of pain, and the infants' actual responses to one procedure, circumcision."

PEDIATRICS Vol. 104 No. 1 July 1999, p. e13.

 

 

That circumcision is acutely painful was scientifically demonstrated in 1994:

ACETAMINOPHEN ANALGESIA IN NEONATAL CIRCUMCISION: THE EFFECT ON PAIN

Cynthia R. Howard, MD; Fred M. Howard, MD; and Michael L. Weitzman, MD, Pediatrics, April 1994

Objective. Recognizing the concerns about the use of local anesthesia in neonatal circumcision, a painful procedure usually performed without analgesia or anesthesia, we undertook a study of acetaminophen for pain management of this procedure.

Design. A prospective, randomized, double blind, placebo-controlled, clinical trial of acetaminophen analgesia in 44 healthy full term neonates undergoing circumcision was conducted. Beginning two hours before Gomco circumcision, neonates received either acetaminophen (15 mg/kg per dose, 0.15 mL/kg per dose) or placebo (0.15 mL/kg per dose) every six hours for 24 hours. [There was no control group left intact, who would of course have experienced no pain.] Neonates were monitored intraoperatively for changes in heart rate, respiratory rate, and crying time. Postoperative pain was assessed at 30, 60, 90, 120, 360 minutes and 24 hours using a standardized postoperative comfort scoring system. Feeding behavior was also assessed before and after circumcision by nursing observation.

Results. Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences between the groups. Postoperative comfort scores showed no significant differences between the groups until the 360-minute postoperative assessment, at which time the acetaminophen group had significantly improved scores. (P<.05). Feeding behavior deteriorated in breast- and bottle-fed infants in both groups, and acetaminophen did not seem to influence this deterioration.

Conclusions. This study confirms that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the postoperative period. Pediatrics 1994;93:641-646; neonatal circumcision, acetaminophen.

... In summary, this study confirmed that circumcision of the newborn causes severe and persistent pain. Acetaminophen was not found to ameliorate the the intraoperative or the immediate postoperative pain of circumcision, although it may provide some benefit after the immediate postoperative period. Given the large numbers of newborns who undergo this painful surgical procedure [This is not a given. Parents could stop asking for circumcision. Doctors could refuse to circumcise. Pain is one of many reasons.], it is imperative that safe and easily administered methods of anesthesia be found and utilized.


Studies like these raise serious ethical issues. Experimentation on children is normally governed by rigorous rules. Painful experimentation is especially restricted. Only when it involves circumcision, it seems, may doctors inflict major pain on neonates with impunity.

Now the authorities are moving to "recommend" that anaesthetics be used - but without ever admitting they were wrong to circumcise all those babies without anaesthetic, and without ever doubting the wisdom of circumcising at all.

Lander et al. found the pain of circumcising without anaesthetic to be severe. The circumcising of a control group without anaesthetic seems to have been called off for ethical reasons. (There was no control group of babies left intact.)

JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION,
Volume 278 No. 24,
Pages 2157-2162,
December 24/31, 1997.

Comparison of Ring Block, Dorsal Penile
Nerve Block, and Topical Anesthesia
for Neonatal Circumcision

A Randomized Controlled Trial

Janice Lander, PhD; Barbara Brady-Freyer, MN; James B. Metcalfe, MD, FRCSC; Shermin Nazerali, MPharm; Sarah Muttit, MD, FRCPC.

Abstract

Context. - Beliefs about the safety and effectiveness of current anesthetics have resulted in many newborns being circumcised without the benefit of anesthesia.

Objective. - To compare ring block, dorsal penile nerve block, a topical eutectic mixture of local anesthetics (EMLA), and topical placebo when used for neonatal circumcision. The placebo represented current practice, with no anesthetic for neonatal circumcision.

Design. - A randomized controlled trial.

Setting. - Antenatal units in 2 tertiary care hospitals in Edmonton, Alberta.

Participants. [Participants participate voluntarily. Those who do not are called "subjects" or "victims".]. - A consecutive sample of 52 healthy, full-term male newborns, aged 1 to 3 days.

Interventions. - Physiological and behavioral monitoring occurred in a series of trials: baseline, drug application, preparation, circumcision, and postcircumcision. Surgical procedures defined the following 4 stages of the circumcision: cleansing, separation, clamp on, and clamp off. Methemoglobin level was assessed 6 hours after surgery.

Main Outcome Measures. - Heart rate, cry, and methemoglobin level.

Results. - Newborns in the untreated placebo group [that is, the unanaesthetised, circumcised group. There was no untreated control group] exhibited homogeneous responses that consisted of sustained elevation of heart rate and high pitched cry throughout the circumcision and following. Two newborns in the placebo group became ill following circumcision (choking and apnea [i.e.they stopped breathing]). The 3 treatment groups all had significantly less crying and lower heart rates during and following circumcision compared with the treated group. The ring block was equally effective through all stages of the circumcision, whereas the dorsal penile nerve block and EMLA were not effective during foreskin separation and incision. Methemoglobin levels were highest in the EMLA group, although no newborn required treatment.

Conclusions. - The most effective anesthetic is the ring block; EMLA is the least effective. It is our recommendation that an anesthetic should be administered to newborns prior to undergoing circumcision.

[Not only would an uncircumcised control group have demonstrated no pain reactions, it would have provided valuable baseline data. It seems the option of leaving any babies uncircumcised was deliberately avoided. Why?]

JAMA 1997; 278: 2157-2161

Part of the main text:

RESULTS

Part way through the trial, physicians and members of the research team remarked that there were obvious differences in behavior of newborns in either infiltration group compared with those in both topical groups. This led us to reexamine our estimation of effect size as well as the ethical matters related to sample size. [This has commonly been interpreted to mean the experiment was called off, but it may mean only that one baby was withdrawn.]

[...]

Adverse Outcomes

A serious postsurgery incident was observed in 1 newborn in the placebo group. There was nothing remarkable about this newborn's history prior to the circumcision. His 1- and 5-minute Apgar scores were 9 and 10. He was last fed 3 hours before circumcision. During and following circumcision, the newborn reacted much the same as others who received a placebo (continuously elevated heart rate and high-pitched cry). About 2.5 minutes after the conclusion of surgery, the new-born had an episode that included abnormal posture (lack of tone in limbs), several periods of apnea [not breathing] (one lasting more than 25 seconds), and projectile vomiting. No physiological data were recorded during the episode, since the computer had lost contact with the monitor immediately prior to its onset. The newborn recovered following the episode.

Another newborn in the placebo group had a choking episode with apnea after surgery. This began about 3.5 minutes after the circumcision and lasted less than 30 seconds.

[That's two serious adverse outcomes out of only 12 babies circumcised without anaesthetic, or 52 babies in the whole experiment.]

This study was videotaped, and the videotapes of the unanaesthetised control group were extensively analysed. This analysis is on another page.

 

In 2006 a baby died after his circumcision, and in response to a complaint the doctor gave reasons he still does not use anaesthesia.

Williamson and Evans found that, contrary to a common claim, circumcision hurts much more than a heelstick, and local anaesthetic is ineffective.

Clinical Pediatrics August 1986 vol. 25 no. 8 412-415

Neonatal Cortisol Response to Circumcision with Anesthesia

Paul S. Williamson, Nolan Donovan Evans
[Paul Williamson was a co-author of the much-cited Iowa study that claimed to show women prefer circumcised men. One of its subjects has since written how it was skewed.]

Abstract

Eleven male newborns were circumcised with a local dorsal penile nerve block, and 13 controls were circumcised without anesthetic. [How was this ethical, even in 1986?] Matched pairs of pre- and postcircumcision cortisol levels in the two groups were compared. The adrenal cortisol response to surgery was not significantly reduced by the administration of lidocaine. Blood sampling and anesthetic injection of venipuncture alone did not evoke the adrenal response in uncircumcised control infants. Cortical input or secondary epinephrine elevation may be producing the cortisol elevation in infants despite regional blockage of the afferent nerve pathways.

 

Slater et al. found that sugar-water is ineffective in pain relief.

The Lancet, Early Online Publication, 1 September 2010

Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial

Dr Rebeccah Slater PhD, Laura Cornelissen MSci, Lorenzo Fabrizi PhD, Debbie Patten BSc, Jan Yoxen BSc, Alan Worley MSc, Stewart Boyd MD, Judith Meek MBBS, Prof Maria Fitzgerald PhD

Summary
Background
Many infants admitted to hospital undergo repeated invasive procedures. Oral sucrose is frequently given to relieve procedural pain in neonates on the basis of its effect on behavioural and physiological pain scores. [It is also commonly given to babies undergoing ritual circumcision, and sometimes to babies undergoing "medical" circumcison.] We assessed whether sucrose administration reduces pain-specific brain and spinal cord activity after an acute noxious procedure in newborn infants.

Methods
In this double-blind, randomised controlled trial, 59 newborn infants at University College Hospital (London, UK) were randomly assigned to receive 0·5 mL 24% sucrose solution or 0·5 mL sterile water 2 min before undergoing a clinically required heel lance. Randomisation was by a computer-generated randomisation code, and researchers, clinicians, participants, and parents were masked to the identity of the solutions. The primary outcome was pain-specific brain activity evoked by one time-locked heel lance, recorded with electroencephalography and identified by principal component analysis. Secondary measures were baseline behavioural and physiological measures, observational pain scores (PIPP), and spinal nociceptive reflex withdrawal activity. Data were analysed per protocol. This study is registered, number ISRCTN78390996.

Findings
29 infants were assigned to receive sucrose and 30 to sterilised water; 20 and 24 infants, respectively, were included in the analysis of the primary outcome measure. Nociceptive [indicative of pain] brain activity after the noxious heel lance did not differ significantly between infants who received sucrose and those who received sterile water (sucrose: mean 0·10, 95% CI 0·04—0·16; sterile water: mean 0·08, 0·04—0·12; p=0·46). No significant difference was recorded between the sucrose and sterile water groups in the magnitude or latency of the spinal nociceptive reflex withdrawal recorded from the biceps femoris of the stimulated leg. The PIPP score was significantly lower in infants given sucrose than in those given sterile water (mean 5·8, 95% CI 3·7—7·8 vs 8·5, 7·3—9·8; p=0·02) and significantly more infants had no change in facial expression after sucrose administration (seven of 20 [35%] vs none of 24; p<0·0001).

Interpretation
Our data suggest that oral sucrose does not significantly affect activity in neonatal brain or spinal cord nociceptive [pain-receptive] circuits, and therefore might not be an effective analgesic drug. The ability of sucrose to reduce clinical observational scores after noxious events in newborn infants should not be interpreted as pain relief.

 

"It's over in a few seconds..." "...when performed by an experience operator..."

Tauesch found that even with anaesthetic, pain was "excessive" in three babies out of ten, and that the most experienced operators could severely damage the penis.

Journal of Perinatology, April/May 2002, Volume 22, Number 3, Pages 214-218

Pain During Mogen or PlastiBell Circumcision

H William Taeusch MD, Alma M Martinez MD, J Colin Partridge MD, Susan Sniderman MD, Jennifer Armstrong-Wells MD and Elena Fuentes-Afflick MD

... This study was catalyzed by our hospital's obstetric service choice not to carry out circumcisions because of their belief that it was medically unjustified.8 Pediatric staff decided to continue to provide circumcisions gratis (MediCal does not reimburse physicians for routine neonatal circumcisions) for those parents who requested it, because we assumed that the inconvenience, costs, and discomfort would be greater if the procedure were carried out after the newborn period.

... Although circumcision is usually a rapid procedure in the hands of skilled operators,13 no studies have compared the amount of time required by trainees to perform different techniques.

METHODS

The sample included term male infants born at San Francisco General Hospital.

... The infants' responses to the application of the first foreskin clamp were graded by cry, with 0 to 1 indicating no or minimal response, 4 indicating a lusty bellow of rage, and 2 and 3 indicating midrange responses. This response was used to judge the adequacy of the dorsal nerve block. Thereafter, infant behaviors were graded using a scale of 1 to 7 that was adapted and simplified from other neonatal pain scores.18 A single grade, representing the average behavior, was assigned for each 3-minute period. Grade 1 was deep sleep indicated by regular breathing, eyes closed, and no eye or extremity movements. Grade 2 was rapid eye movement sleep defined by rapid eyelid movements, irregular respirations, and frequent limb movements or twitches. Grade 3, a drowsy state, was characterized by eyes mostly open and sparse body movements with some sucking. An infant who was awake and alert, with eyes occasionally fixing on objects, arms and legs moving, no cry, some sucking movements, was assigned grade 4. Grade 5 was defined by the infant being fussy with infrequent soft vocalizations, purposeful extremity movements against restraints, active head motion, and a facial expression of discontent. Grade 6 was scored for mild or moderate crying. Grade 7 was defined by continuous loud crying indicative of rage. The beginning of the circumcision was recorded as the time the first clamp was placed on the foreskin. The end of the procedure was recorded when sterile drapes were removed.

...

RESULTS

Sixty-one infants were enrolled in this study over a 2-year period from 1997 to 1998. Two were eliminated, one for insufficient data and one for unclear identification of the procedure, leaving 30 in the Mogen group and 29 in the PlastiBell group included in the analysis. The time from dorsal nerve block to placing the first clamp on the foreskin was 6 minutes for the group assigned to Mogen and 5 minutes for the group assigned to PlastiBell (p>>0.05). No difference in the response to placement of the first clamp was found between the two groups (an average score of 1 for each group). The efficacy of the dorsal nerve block for all infants in the study is shown in Figure 1, with approximately 65% of the infants having a minimal (or no) response.

Figure 2 indicates that distribution of the duration for the two techniques differs. Average duration for the PlastiBell technique was 20±1.7 minutes (mean±SEM), and average duration for the Mogen technique was 12±0.9 (p<0.001). Average pain scores over 3-minute periods were identical in the two groups. They averaged between 4 and 6 (Figure 3). Overall pain was also scored for the entire procedure. Sixty one percent of the entire sample had overall pain scores of >4 with no differences between groups. We did not assess postoperative pain in this study.

We assessed the duration of the circumcision by level of training of the operator. ... On nine occasions for the Mogen and seven for the PlastiBell, the procedure was the first circumcision performed by the trainee.

No major complications were encountered by either method during the course of the study (see Discussion section for a complication incurred after the study). In three instances, only the outer epidermal layer of the foreskin was removed by the Mogen, leaving the inner foreskin layer adherent to the glans. In these cases, the inner foreskin layer was removed from the glans and the time involved was included for the duration of the original procedure. Informal reports from our follow-up clinic indicated that mothers occasionally complained that their infant did not appear as if they had been circumcised (Mogen technique), and two of these infants had a repeat circumcision. We also received occasional complaints from the outpatient clinic regarding the PlastiBell technique. Issues included partial separation of the plastic ring from the penis, irregular foreskin removal, or swelling of the shaft of the penis.

DISCUSSION

Circumcisions using the Mogen procedure were carried out in about 60% of the time required for PlastiBell circumcisions and because our measure of pain per time period was similar for the two procedures, we assume the overall pain of the Mogen procedure was less. Probably because of our use of dorsal nerve blocks in both groups, we found no difference in degree of pain between procedures in the first 15 minutes, that is to say, pain was related only to the efficacy of the dorsal nerve block and to the duration of the procedure. Total pain, however, is the product of amount of pain times duration and more than half of the study group had what we considered excessive pain/discomfort over the course of the entire procedure. We agree with those who attribute much of the evident discomfort (when dorsal nerve block is used effectively) to the spread-eagled restraint of extremities in extension on an unforgiving surface. ...

Two circumcisions were repeated after discharge of the infant from the nursery, both after Mogen procedures, and the amount of pain incurred in the second circumcision is in addition to that of the first. Removal of too small amount of foreskin such that the infant looks uncircumcised was due to the fear of amputation of the glans if more was removed. In fact after completion of this study, approximately 10% of the glans of a newborn was amputated (it was reattached surgically) during a Mogen circumcision carried out by two of our most experienced physicians. The cause was a small adhesion near the meatus that was not lysed so that the glans was partially pulled through the Mogen clamp and removed with the foreskin. We have since modified the Mogen procedure, still in use in our nursery, by carrying out a dorsal slit of the foreskin and retracting it fully to ascertain that no adhesions remain before pulling it into the Mogen clamp for removal. This modification has also been associated with no further need for repeat circumcisions in over 200 Mogen procedures done since the modification was put in place.

Limitations of this study are several. Obviously the study was not double-blind. ... Behavioral testing for the assessment of pain, the use of pain scores, has been cogently critiqued.20 ... We did not assess the esthetics of the results of the procedure or parent satisfaction. [Or, of course, patient satisfaction, when he grows up.] Our sample was too small to assess the relative safety of these techniques.

Advocates of circumcision and those against this procedure both mount cogent arguments to support their respective viewpoints.21,22,23 We believe more studies of the risk and benefits of circumcision are needed. Outcome measures should include acute and long-term adverse effects like cosmesis, parent satisfaction, safety, complications, long-term medical outcomes, and ultimately an assessment of the feelings of the circumcised or uncircumcised boy/adult, and possibly his sexual partner(s).24,25,26 Sample sizes in the thousands would be necessary and the cost of the study would be high. However, current annual costs of routine neonatal circumcision are ca. $150,000,000, (est. 1,000,000 males in U.S. circumcised at $150 hospital+physician costs). Problems associated with the uncircumcised state (increased risk of urinary tract infections, sexually transmitted infections, and phimosis, for example) are more difficult to estimate, but may not be insignificant.1,21 Complications of circumcision are probably underreported....

 

A 2005 study in Australia indicates that babies feel pain more than adults.

 

So did a 2009 study in London:

 

Wellcome Trust
2 April, 2009

Feature: The pains of youth

By Mun-Keat Looi

As recently as the late 1980s, clinicians mistakenly believed that newborn babies did not feel pain. We are now beginning to understand just how different pain processing is in infants, progress that promises tremendous clinical benefits for those in intensive care.

... "Largely it was based on ignorance - a rather simplistic view that if you can't remember something then that means that you don't process it," says Maria Fitzgerald, Professor of Developmental Neurobiology at University College London.

... Our pain pathways undergo extensive structural and functional change after we are born. At first, the nervous system is not fine-tuned, with nerve cells underdeveloped and connections and circuits still raw.

"In very young babies there is a very strong, exaggerated, behavioural response to pain, much stronger than you would see in an older child or adult," says Professor Fitzgerald.

Her latest research, funded by the Wellcome Trust, has revealed a fundamental difference between infant and adult pain pathways.

As adults, when we detect a painful stimulus, the sensory nervous system in the spinal cord suppresses the signal to a certain extent, reducing the intensity of the pain and helping us to detect exactly where it is in the body. Also, when the brain receives the pain signal, it sends inhibitory information back to the spinal cord.

But in newborn babies, this system has the opposite effect.

"The brain actually enhances the pain inputs rather than suppressing them. It's a complete reverse of what happens in an adult," says Professor Fitzgerald.

... Children that have undergone a lot of intensive care when young seem to be less sensitive to things such as touch and temperature. But they are more sensitive to new pain stimuli. "It's quite an odd and complicated picture, almost like a contrast. The child is relatively less sensitive in its body but hypersensitive, it seems, to a new pain," says Professor Fitzgerald.

... "There's something about having an injury very early in life that does seem to produce a very long-lasting sensitivity in that injured area."

...

 

Taddio et al. found the effects of the pain of circumcision could be detected months later:

Abstracts - March 18, 1997 LANCET

Effect of Neonatal Circumcision on Pain Response During Subsequent Routine Vaccination

Background: Preliminary studies suggested that pain experienced by infants in the neonatal period may have long-lasting effects on future infant behaviour. The objectives of this study were to find out whether neonatal circumcision altered pain response at 4-month or 6-month vaccination compared with the response in uncircumcised infants, and whether pretreatment of circumcision pain with lidocaine-prilocaine cream (Emla) affects the subsequent vaccination response.

Methods: We used a prospective cohort design to study 87 infants. The infants formed three groups - uncircumcised infants, and infants who had been randomly assigned Emla or placebo in a previous clinical trial to assess the efficacy of Emla cream as pretreatment for pain in neonatal circumcision. Infants were videotaped during vaccination done at the primary care physician's clinic. Videotapes were scored without knowledge of circumcision or treatment status by a research assistant who had been trained to measure infant facial action, cry duration, and visual analogue scale pain scores.

Findings: Birth characteristics and infant characteristics at the time of vaccination, including age and temperament scores, did not differ significantly among groups. [...] infants circumcised with placebo had higher difference scores than uncircumcised infants for percentage facial action (136.9 vs 77.5%), percentage cry duration (53.8 vs 24.7%), and visual analogue scale pain scores (5.1 vs 3.1 cm). There was a significant linear trend on all outcome measures, showing increasing pain scores from uncircumcised infants, to those circumcised with Emla, to those circumcised with placebo.

[So anaesthesia does not eliminate pain.]

Interpretation: Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. [No good long-term studies have been done, but it seems reasonable to conclude that some physiological effects of circumcision may in fact be life-long.] Among the circumcised group, preoperative treatment with Emla attenuated the pain response to vaccination. We recommend treatment to prevent neonatal circumcision pain.

[But the paper has just demonstrated that it doesn't prevent it. Not circumcising would.]

(Lancet. 1997;349:599-603)

In 2002, Taddio et al. found by comparing 21 babies of diabetic mothers (who underwent repeated heelstick blood sampling) with 21 controls, that babies learn to anticipate a painful stimulus by crying and grimacing. In other words, they experience pain as pain, consciously, not just as some kind of reflex.

Best Practice & Research Clinical Anaesthesiology
Vol. 18, No. 2, pp. 357–375, 2004
available online at http://www.sciencedirect.com

Regional anaesthetic techniques for neonatal surgery: indications and selection of techniques
Martin Jöhr MD Thomas M. Berger MD

CIRCUMCISION
Clinical relevance

In some societies circumcision is performed in virtually all boys at a very early age for traditional or religious reasons. Other societies perform this type of surgery only for medical indications, such as phimosis or recurrent infections. In the past, circumcision for traditional or religious reasons has often been done in awake neonates with minimal or even no pain relief at all. [And in the US, it still is.] Forceful immobilisation, e.g. on a circumcision board, and performance of the procedure in a crying patient has been an accepted practice until recently. Today, some type of procedural pain relief appears to be mandatory for most practitioners.39 In Western Europe, where circumcisions are largely performed for medical indications, a major regional block with a completely comfortable patient or a general anaesthetic is mandatory. Performing surgery on a crying patient would not be an acceptable standard. These two completely different attitudes might explain why for some colleagues topical anaesthesia40 – 42 or oral sucrose alone43,44 seem to be useful for procedural analgesia during circumcision,45 whereas for others, these techniques are clearly insufficient.

Penile block
Dorsal nerve penile block had already been proposed for neonatal circumcision by the late 1970s.46 Penile block, in Europe often combined with a general anaesthetic, provides prolonged pain relief for up to 6–24 h after penile surgery, much longer than a caudal block [but not nearly as long as the duration of pain from urine in the wound, which takes at least a week to heal.]. Two paramedian injections of 0.1 ml/kg ... Penile block has a good safety record: in a series of 3909 penile blocks no permanent damage occurred52, while inadvertent injection of the wrong solution and urethral puncture during ring block were the important and clearly avoidable complications.

Caudal or spinal anaesthesia
Single shot caudal anaesthesia can be used for neonatal circumcision. In our practice, 3 ml of a mixture at equal parts of lidocaine 1% with bupivacaine 0.25% with epinephrine were clinically effective in virtually all cases and had, apparently, the advantages of relatively rapid onset and prolonged pain relief. Nevertheless, the role of neuraxial anaesthesia for this type of intervention has to be questioned.

 

In February 2000, the American Academy of Pediatrics and the Candian Paediatric Society issued a joint report on neonatal pain. Eight of the references in this report have "circumcision" in their titles, yet the report itself mentions circumcision only once, and the pain of the actual operation - surely the commonest and most severe pain experienced by neonates in the US today - not at all.

Pediatrics

Volume 105, Number 2

February 2000, pp 454-461

Prevention and Management of Pain and Stress in the Neonate (RE9945)

AMERICAN ACADEMY OF PEDIATRICS

Committee on Fetus and Newborn

Committee on Drugs

Section on Anesthesiology

Section on Surgery

CANADIAN PAEDIATRIC SOCIETY

Fetus and Newborn Committee

ABSTRACT. This statement is intended for health care professionals caring for neonates (preterm to 1 month of age). The objectives of this statement are to:

  1. Increase awareness that neonates experience pain;
  2. [...]

  3. Make recommendations for reduced exposure of the neonate to noxious stimuli and to minimize associated adverse outcomes[...]

Studies indicate a lack of awareness among health care professionals of pain perception, assessment, and management in neonates.

[...]

  • Exposure to prolonged or severe pain may increase neonatal morbidity.
  • Infants who have experienced pain during the neonatal period respond differently to subsequent painful events.
  • [...]

  • Neonates are not easily comforted when analgesia is needed.
  • A lack of behavioral responses (including crying and movement) does not necessarily indicate a lack of pain.
  • GENERAL PRINCIPLES

    [...]

    Some studies suggest that pain experienced early in life by term infants may exaggerate affective and behavioral responses during subsequent painful events.

    [...]

    Pain is managed most effectively by preventing, limiting, or avoiding noxious stimuli [such as...] and providing analgesia.13

    [...]

    PREVENTION OF ACUTE PAIN DURING OR AFTER SURGERY OR A PAINFUL PROCEDURE

    [...]

    Nonsteroidal Anti-inflammatory Drugs

    Generally, this category of medications is used to treat less intense pain and as an adjunct to reduce the total dose of more potent analgesics, such as opioids. Limited data are available on the pharmacokinetics of acetaminophen (paracetamol) in newborns. Acetaminophen does not reduce the response to pain due to heel-lance procedures but may provide some reduction in pain after circumcision.

    [Paracetamol! And this is the only mention of circumcision in the whole paper. If paracetamol doesn't reduce the pain of heel-stick, why should it reduce the much greater pain of circumcision?]

    [...]

    RECOMMENDATIONS

  • Health care professionals should use appropriate environmental, nonpharmacological (behavioral), and pharmacological interventions to prevent, reduce, or eliminate the stress and pain of neonates.

    [And the most appropriate nonpharmacological, non-surgical (behavioural) "intervention" to prevent, reduce, and (with total certainty) eliminate the stress and pain of circumcision is of course, not circumcising.]

  •  

    Taddio et al. have published another pain study, with an extraordinarily basic flaw:

    Arch Pediatr Adolesc Med 2000 Jun;154(6):620-3

    Combined analgesia and local anesthesia to minimize pain during circumcision.

    Taddio A, Pollock N, Gilbert-MacLeod C, Ohlsson K, Koren G
    Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada. anna.taddio@sickkids.on.ca [Medline record in process]

    BACKGROUND: Pain of circumcision is only partially relieved by single modalities, such as penile nerve block, lidocaine-prilocaine cream, and sucrose pacifiers.

    OBJECTIVE: To assess the effectiveness of a combination of interventions on the pain response of infants undergoing circumcision.

    METHODS: Cohort study.
    Group 1 included infants circumcised using the Mogen clamp and combined analgesics (lidocaine dorsal penile nerve block, lidocaine-prilocaine, acetaminophen, and sugar-coated gauze dipped in grape juice).
    Group 2 included infants circumcised using the Gomco clamp and lidocaine-prilocaine. Infants were videotaped during circumcision, and pain was assessed using facial activity scores and percentage of time spent crying.

    RESULTS: There were 57 infants in group 1 and 29 infants in group 2. Birth characteristics did not differ between groups. Infants in group 1 were older than infants in group 2 (17 days vs 2 days) (P < .001). The mean duration of the procedure was 55 seconds and 577 seconds for infants in group 1 and 2, respectively (P < .001). Facial action scores and percentage of time spent crying were significantly lower during circumcision for infants in group 1 (P < .001). The percentage of time spent crying was 18% and 40% for infants in groups 1 and 2, respectively. No adverse effects were observed in infants in group 1; 1 infant in group 2 had a local skin infection.

    CONCLUSIONS: Infants circumcised with the Mogen clamp and combined analgesia have substantially less pain than those circumcised with the Gomco clamp and lidocaine-prilocaine cream. Because of the immense pain during circumcision, combined local anesthesia and analgesia using the Mogen clamp should be considered.

    [The conclusion patently does not follow from the experiment:

    • One group was much older than the other
    • One group was circumcised by a different method from the other, and of those
      • One method took 10 times as long as the other
    • One group was given different anaesthesia/analgesia from the other
    Any of these factors could be responsible for the differing pain suffered by the two groups.

    Predictibly, the two groups were not contrasted with a control group of babies left intact. It is, of course, safe to predict that such a group would experience no pain at all, but it is as though these scientists don't want to consider the option of leaving babies alone.

    The method they recommend, the Mogen clamp (a slicing rather than crushing method), carries a greater risk of trapping and slicing the glans because it is a "blind" method, as Varney's Midwifery points out.

    Prilocaine - used in both kinds of circumcision - is implicated in methaemoglobinaemia, according to the British Journal of Urology: Toxic neonatal methaemoglobinaemia after prilocaine administration for circumcision ]

    PMID: 10850512, UI: 20306685 http://archpedi.ama-assn.org/issues/v154n6/full/poa90426.html

     

    Ruda et al show that pain in neonates causes changes in pain-sensitivity in adulthood.

    From Science, July 2000

    Once Bitten, Twice Sensitive

    Advances in operation techniques and other medical treatments have improved the survival chances of immature or otherwise medically compromised neonates. Do such tissue damage and painful interventions early in life have adverse long-term effects? Ruda et al. ... show that hindlimb inflammation in rat pups triggers exuberant growth of small-diameter, pain-transmitting axons in the dorsal horn of the spinal cord. These changes are coupled with an increase in the sensitivity of the paw after inflammation in the adult. These results show that painful stimuli in early development can cause long-term alterations in the neuronal circuitry.

    Ruda MA, Ling Q, Hohmann AG, et al. Altered Nociceptive Neuronal Circuits After Neonatal Peripheral Inflammation. Science 2000; July 28 :

     

    From New Scientist
    5 August 2000, p25

    IN BRIEF

    Painful Start

    OPERATING on fetuses and newborns might make them more senstitive to pain later in life, say researchers at the National Institutes of Health, near Washington DC.

    Mary Ann Ruda and colleagues simulated surgery on newborn rats by injecting an inflammatory agent into a hind paw. When the rats reached adulthood, they withdrew the test paw from a hot bulb much faster than rats that had been injected with saline as newborns (Science, vol 289, p628). They also had more nerves in the region.

    Until the 1980s, anaesthesia was rarely given to newborns because their nervous system was considered immature. Even today, anaesthetics given to the mother during fetal surgery do not reach the fetus, Ruda says. "Now is a good time to find people who had procedures as infants and test for differences in their pain sensitivity."

    [She won't have to look far!]

     

    Murphy et al. found that early pain changes the brain

    Science Daily

    Pain in Infancy Alters Response to Stress, Anxiety Later in Life

    Oct. 30, 2013 — Early life pain alters neural circuits in the brain that regulate stress, suggesting pain experienced by infants who often do not receive analgesics while undergoing tests and treatment in neonatal intensive care may permanently alter future responses to anxiety, stress and pain in adulthood, a research team led by Dr. Anne Murphy, associate director of the Neuroscience Institute at Georgia State University, has discovered.

    An estimated 12 percent of live births in the U.S. are considered premature, researchers said. These infants often spend an average of 25 days in neonatal intensive care, where they endure 10-to-18 painful and inflammatory procedures each day, including insertion of feeding tubes and intravenous lines, intubation and repeated heel lance. Despite evidence that pain and stress circuitry in the brain are established and functional in preterm infants, about 65 percent of these procedures are performed without benefit of analgesia. Some clinical studies suggest early life pain has an immediate and long-term impact on responses to stress- and anxiety-provoking events.

    The Georgia State study examined whether a single painful inflammatory procedure performed on male and female rat pups on the day of birth alters specific brain receptors that affect behavioral sensitivity to stress, anxiety and pain in adulthood. The findings demonstrated that such an experience is associated with site-specific changes in the brain that regulate how the pups responded to stressful situations. Alterations in how these receptors function have also been associated with mood disorders.

    The study findings mirror what is now being reported clinically. Children who experienced unresolved pain following birth show reduced responsiveness to pain and stress.

    "While a dampened response to painful and stressful situations may seem advantageous at first, the ability to respond appropriately to a potentially harmful stimulus is necessary in the long term," Dr. Murphy said.

    "The fact that less than 35 percent of infants undergoing painful and invasive procedures receive any sort of pre- or post-operative pain relief needs to be re-evaluated in order to reduce physical and mental health complications associated with preterm birth."

    The research team included scientists at Georgia State's Center for Behavioral Neuroscience and Yerkes National Primate Center. Results of the study were published in the most recent edition of the journal Psychoneuroendocrinology. The peer-reviewed journal article summarizes research led by Murphy and graduate student Nicole Victoria from Dr. Murphy's lab. Also involved were Dr. Larry Young (Yerkes Division of Behavioral Neuroscience & Psychiatric Disorders and the Center for Translational Social Neuroscience) and postdoctoral fellow Dr. Kiyoshi Inoue from the Young lab.

    The paper is:
    Nicole C. Victoria, Kiyoshi Inoue, Larry J. Young, Anne Z. Murphy
    Long-term dysregulation of brain corticotrophin and glucocorticoid receptors and stress reactivity by single early-life pain experience in male and female rats.
    Psychoneuroendocrinology, 2013; DOI: 10.1016/j.psyneuen.2013.08.013

     

    It has long been the speculation of these pages that circumcision causes the nervous system to reinterpret the signals from the pain-receptors of the glans in terms of pleasure, using the genital pleasure centres of the brain left unemployed by the removal of the foreskin. These experiments indicate a complicating factor to that supposition. In any case, they throw another spanner in the works of the idea that "babies can't feel pain, or if they can, they soon forget it."

     

    Persistent pain after adult circumcision

    Q: Since a circumcision eight months ago I suffer constant pain which is eased a bit by Pregabalin tablets. My GP says my nerve ends may never heal, but is there any other effective treatment of any kind?

    A: Any surgical scar has the potential to cause persistent pain but it is a rare complication and the causes are poorly understood. It is postulated that the scar or the surgery interferes with the normal function of the nerves that supply the area. Those nerves would normally register normal sensations of touch, temperature, pressure and pain. For some reason the pain-sensing nerves behave abnormally and constantly register pain for which there is no apparent cause. It often has an unusual quality and is referred to as “neuropathic pain”. Standard painkillers are usually ineffective but a group of drugs which alter nerve function can ameliorate the pain to some degree. Pregabalin is one of these and it is worth trying others in the group as individuals can react differently to specific drugs. I have several patients in whom the intensity of the pain has slowly faded over a long period of time when medication can then be withdrawn, others are not so fortunate. So your pain may settle yet.

    - Dr David Roche answering a query on Saga, March 29, 2012

     

    Pain synaesthesia

    An unusual condition, but a striking illustration:

    New Scientist
    17 April 2010

    Empathy excess

    From Jaques de Boys

    Helen Thompson writes that all documented pain synaesthetes suffered traumatic pain before developing the condition: Many are amputees, and their phantom limb is the site of the pain the feel when faced with another's distress (13 March, p42)

    All my life - I am now 64 - whenever I heard about someone being sliced by a sharp object I felt a sharp pain in my circumcision scar. Now I know why. My case may expand the understanding of this phenomenon: unlike most amputees, I was only a week old when I was circumised and have no conscious memory of it.

    It was a routine circumcision performed by a competent doctor, but late in 1945 newborns being circumcised in the UK probably did not receive any anaesthetic.

    Address supplied, Canada

     

    Animals protected

    Anesthesia is required by U.S. federal law for any painful procedure on a veterinary or lab animal. See:  7 USC 54 Sec. 2143, which dates to the 1960’s. (A researcher was dismissed from the University of Washington a few years ago for operating on mice without it.)

    No such law exists to protect children.

     

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