How often are circumcisions performed without proper anesthesia?

[Freud]

Has anyone come across this statistic? I'd like to find this so that I can give it to someone who believes that infants experience no pain during circ.

[MyBoysBlue]

First you have to define what proper anesthesia is. There are many different methods.

[Freud]

I guess I would define proper anesthesia as whatever is currently the standard of care. But any studies that show that infants still experience pain with the current standard of care, if that is the case, would also be helpful.

[glongley]

Sorry for the length: This is what I have collected on the two points you asked about. Gillian

EVIDENCE THAT ANESTHESIA DOES NOT ELIMINATE THE PAIN:

Taeusch HW et al. Pain during Mogen or Plastibell circumcision. J PErinatology. 2002 Apr-May;22(3):214-8.

My summary of the study: 59 circs on term infants, also using dorsal penile nerve block (DPNB), performed by interns or residents at San Francisco General Hospital 1997-8. Pain was assessed by measuring duration of the procedure and by a simple behavioral score done sequentially.

RESULTS: DPNB was judged to be fully effective in over 70% of cases. Neither Mogen nor Plastibell was associated with greater pain per 3-minute time period, but the Plastibell technique on average took nearly twice as long as the Mogen procedure (20 vs. 12 minutes). We judged that 60% of the infants had pain or discomfort associated with the procedure that was excessive.


Brady-Fryer B et al. Pain Relief for neonatal circumcision. Cochrane Database of Systematic Reviews 2004, Issue 3.

From the Abstract: Based on 35 clinical trails involving 1997, it can be concluded that DPNB and EMLA do not eliminate circumcision pain, but are both more effective than placebo or no treatment in diminishing it. Compared head to head, DPNB is substantially mmore effective than EMLA cream. Ring block and lidocaine creasm other than EMLA also reduced pain but did not eliminate it.
Not effective: oral acetaminophen, sugar solutions, pacifiers, music, and other environmental modifications

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WHY PAIN RELIEF METHODS DO NOT ELIMINATE THE PAIN:

DPNB:
Operator skill is one factor – i.e. getting the correct placement of needle
Also, Length of wait time for the anesthetic to take effect …
Some sources say 10-15 min required, others say at least 5 minutes.
However, doctors will rarely even wait that long
Besides these, the most important reason is:
Besides the dorsal nerve, there are other nerve branches of the perineal nerve, which serve the ventral (or under) side of the penis in a significant proportion of males.
DPNB does not numb these.
Explains why the ring block which numbs the penis in a circle, is generally more effective

EMLA cream:
This is a topical cream that is placed directly on the penis
The length of wait time after the application is an issue
It is limited to a maximum of 1 hour because of the risks of the medication
Because of this limitation, may not always get optimal length of application
Most important reason EMLA not effective has to due with inadequate depth of penetration of the anesthetic…
Because there are multiple layers of skin, muscle, and mucosa all the way down to the surface of the glans that are cut through or otherwise damaged with circumcision.


EVIDENCE THAT NOT ALL DOCTORS USE ANESTHESIA:

Obstetricians less likely than other docs [25% vs. 45% - 85% using DPNB] to use anesthesia than pediatricians [Stang 1998]

Most circumcisions still performed with inadequate anesthesia and little if any post-surgical pain relief.
Multiple studies report scant anesthesia rates and over-reliance on inadequate methods [See below]


Analgesia Underused for Management of Circumcision Pain
AAP 2004 National Conference & Exhibition: Abstract 44. Presented Oct. 9, 2004. http://www.medscape.com/viewarticle/491035

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Circumcision Practice Patterns in the United States
Pediatrics 1998;101(6). URL: http://www.pediatrics.org/cgi/content/full/101/6/e5

Howard J. Stang, MD, and Leonard W. Snellman, MD
Survey of 3000+ physicians.

From the Abstract: Of the physicians performing circumcisions, 45% use anesthesia (71% of PEDs; 56% of FPs; 25% of OBs). Of physicians using anesthesia, 85% use dorsal penile nerve block. ... Recently trained PEDs and FPs were more likely to use anesthetics than were their older colleagues... Physicians in the western states were significantly more likely to use anesthesia than were other physicians from the rest of the United States.


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Yawman D et al. Pain relief for neonatal circumcision: a follow-up of residency training practices. Ambulatory Pediatrics. July 2006;6(4):210-214.

My Summary: Survey of FP, OB, PED residency programs in US, 2003. 82% taught circumcision. Of those programs, 97% taught administration of an anesthetic either locally or topically [EMLA?]. (Compare to 71% in 1998 Stang survey). However, of these same programs that taught circumcision, the anesthetic techniques were used by attendings "frequently or always" only 84% of the time. (This result may not generalize to populations of physicians who practice outside of university medical center settings, or who were not recently trained.)

[Freud]

Wow. Thank you so much.

What horrible statistics. I didn't expect them to be so horrifying.

[Minarai]

From what I've read, there's a heightened bleeding risk associated with analgesic use during circumcision, so doctors often are reluctant to use it.
Also, Dr. Kellogg DID say explicitly that the procedure was to be carried out without anesthetic.

[MCatLvrMom2A&X]

A note on EMLA it is contraindicated for use on the genitals and the insert clearly states that it should never be used during a circ and never on infants younger than 6 months. Why dr's keep using it I will never know

[*Erin*]

so freaking nauseating, those stats. how on earth it is in any way, shape, or form -common and acceptable medical practice- to mutilate a newborn baby's GENITALS WITHOUT ANESTHETIC...i just cannot wrap my brain around it. can you imagine if one of these peds or obs that carry this out needed some penile surgery, what they would say if you just patted them and told them they didn't need any anesthetic?
im sure it happens all the time to babies.
i remember when my dd was a babe, my cousin had a little ds, and i presented all the info to her, and begged her to leave him intact. i even cornered her OB in her room, and asked him about what type of anesthetic they would use, and he replied, with a chilling smile, that they used "none, because it doesn't work anyway, and he won't feel anything but a pinch."
*shudder*
i asked my cousin if she was ok with that, and she just shrugged. (she's got issues, huge ones, way beyond this incident...)
sick sick sick.

[BlessedMommy2006]

Originally Posted by MCatLvrMom2A&X

A note on EMLA it is contraindicated for use on the genitals and the insert clearly states that it should never be used during a circ and never on infants younger than 6 months. Why dr's keep using it I will never know

What are the complications associated with using it on genitals and infants?

[MCatLvrMom2A&X]

From the physicians desk reference back in 96' http://www.cirp.org/library/complications/EMLA/

"EMLA Cream is not recommended for use prior to circumcision in pediatric patients."

The biggest and most serious is:

Methaemoglobinaemia [reaction with the blood] -snip- Methaemoglobinaemia can cause brain damage and death in small infants.

The U.S. Food and Drug Administration lists the current EMLA documentation (updated February 4,1998):
"Due to the risk of methemoglobinuria and the lack of proven efficacy EMLA Cream is not recommended for use prior to circumcision in pediatric patients."

[glongley]

Originally Posted by BlessedMommy2006

What are the complications associated with using it on genitals and infants?

Here is the package insert for EMLA cream from 2005

http://www.astrazeneca.co.za/_mshost...LA_5_Cream.pdf

The Cochrane review mentioned above says this about EMLA risks:

"EMLA and other lidocaine creams can cause skin color changes or local skin irritation. There is a rare risk with lidocaine creams of causing methaemoglobinaemia (blue-baby syndrome, where the baby's blood lacks sufficient oxygen). However, two trials of EMLA for circumcision pain relief measured methaemoglobin levels and found them normal. "

Apparently, it is the dosing that is the key concern (amount applied, length of application). This letter from Swedish and British physicians claims that proper/safe dosing parameters have been established. http://bja.oxfordjournals.org/cgi/content/full/92/3/450

Of course, whether proper dosing recommendations are carried out is another question, and EMLA is in any case not very effective in reducing pain in and of itself because of the reasons given in my post above.

[PuppyFluffer]

I have an aquaintance who used to work for a urologist at a hospital. Apparently he did infant circs. She told me that they would administer the injectable anesthetic and then the doctor would say "Let's get this over with" and start - never giving the medication time to numb the tissue. So, the baby gets the pain of the medication being injected (lidocaine stings!) then gets cut, with no benefit of the anesthetic. My friend loathes circumcision. She is now working in a labor/delivery unit in a hospital. I have no idea if she participated with circumcisions but the rate is high here.

[kxsiven]

And these stats are only about USA. The fact is that worldwide most circumcisions are done without anykind of pain relief - even when done to older boys/teenagers.

[DocsNemesis]

*wave* Hi kxsiven! Long time no see!

Anywho, from what I've seen, its VERY common to not recieve pain relief and as someone else said, its also rather common for them to not let the pain relief actually work. Why wait 15 minutes for it to take full effect when they could be almost done by then??

I really wish they made it so a parent HAD to be in the room. It just allows everyone to ignore the pain issue and to remain ignorant on purpose. Parents who don't research it have no idea-I thought it was just a little snip of skin too and didn't think it hurt much. I don't think I even thought about pain relief. I guess I assumed that if a doctor was doing it and it hurt, they'd be given something. I know a lot of parents who, if they actually saw it being done, wouldn't do it again. But no, instead we hear things like my former friend said: "They didn't even cry!" When asked if she was there in the room she replied "oh, no, I couldn't watch but the nurse told me they didn't cry." Come on, what nurse is going to hand a baby back and say "he screamed so loud and was in so much pain, poor thing..." Riiiiight.

Btw, the doc that did her son's circ's (she had twins) also told her they had "oral anesthesia." It was purple. IT WAS FREAKING TYLENOL. The fact that he straight out lies to ignorant people makes me so mad.

[Night_Nurse]

Originally Posted by DocsNemesis

Btw, the doc that did her son's circ's (she had twins) also told her they had "oral anesthesia." It was purple. IT WAS FREAKING TYLENOL. The fact that he straight out lies to ignorant people makes me so mad.

Or, sometimes they give the baby the sugar water/sugar pacifier and say they gave the baby "something for pain".

[QueenOfTheMeadow]

I have removed a post from this thread due to copyright violations. Please keep these guidelines in mind when posting about studies.

[Fyrestorm]

And really...I bet a needle to the penis feels REALLY great! Then to have the burning from the lidocane...best time of the baby's life so far I would guess!

Just like being licked by kittens

[NewDirections]

Originally Posted by DocsNemesis

I really wish they made it so a parent HAD to be in the room. It just allows everyone to ignore the pain issue and to remain ignorant on purpose. Parents who don't research it have no idea

You're so right. If parents could see how circ makes their baby boys suffer, they'd be much less likely to circ any future babiess they may have and they'd probably tell their friends how awful the procedure is. It's really sad that circ is so common, but most parents don't even think about how their sweet baby will be in pain

[Oubliette8]

Originally Posted by Fyrestorm

And really...I bet a needle to the penis feels REALLY great! Then to have the burning from the lidocane...best time of the baby's life so far I would guess!

Just like being licked by kittens

Am I the only person that thinks having ones genitals licked by kittens sounds excruciatingly painful? Cats tongues are like sandpaper- ouch!

[Fyrestorm]

Originally Posted by Oubliette8

Am I the only person that thinks having ones genitals licked by kittens sounds excruciatingly painful? Cats tongues are like sandpaper- ouch!

I guess it's still better than a scalpel and a clamp though