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.
"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. |
A 2005 study in Australia indicates that babies feel pain more than adults.
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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 |
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.)
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JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION,
Comparison of Ring Block, Dorsal Penile 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.
Taddio et al. found the effects of the pain of circumcision could be detected months later:
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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) |
Porter et al. guessed that circumcision would be painful, and surprise! It was.
Procedural Pain in Newborn Infants: The Influence of Intensity and Development
"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." |
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
Regional anaesthetic techniques for neonatal
surgery: indications and selection of techniques
CIRCUMCISION
Penile block
Caudal or spinal anaesthesia
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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.
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Pediatrics |
Volume 105, Number 2 |
February 2000, pp 454-461 | |
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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:
[...] Studies indicate a lack of awareness among health care professionals of pain perception, assessment, and management in neonates. [...] [...] 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 [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:
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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 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. 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:
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
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Ruda et al show that pain in neonates causes changes in pain-sensitivity in adulthood.
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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!] |
In 2006 a baby died after his circumcision, and in response to a complaint the doctor gave reasons he still does not use anaesthesia.
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."
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