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THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, Volume 299, Number 15, Pages 1169-1171,
April 15, 1998.


Local Anesthesia For Infants Undergoing Circumcision

To the Editor.--Dr. Lander and colleagues[1] have shown once again the
value and safety of anesthesia for neonatal circumcision.  In this
study, local infiltration ring block or dorsal penile nerve block
resulted in less heart rate elevation and less crying during the cir-
cumcision procedure.  Outcome measures said to have been investigated
included heart rate, respiratory rate, oxygen saturation, palmar
sweat, sleep-wake state, crying, motor responses, and methemoglobin
level.  Only heart rate, crying, and methemoglobin levels were re-
ported, and the reader assumes that no significant changes were found
in the remaining parameters.

  A larger prospective, controlled study of the effectiveness of
penile nerve block by Arnett et al[2] showed not only significantly
less heart rate elevation and less crying in the anesthetized infant,
but also demonstrated significant decrease in oxygen saturation when
circumcision was done without anesthesia.  Although Lander et al
followed the procedure of Kirya and Werthman[3] for penile nerve
block, using 0.4 mL of 1% lidocaine in each of two injection sites,
the 14 nerve blocks under study were performed by 4 physicians and 3
assistants.  In the study by Arnett et al,[2] 85% of the 44 in-
jections and 51 circumcisions were performed by a single investigator,
and only 0.2 mL per injection site provided effective anesthesia.

  We applaud the efforts of Lander et al to encourage the use of
anesthesia for neonatal circumcision.  However, we have observed that
many physicians resist using such anesthesia in their practices,
likely related to the erroneous belief that it adds much time to the
circumcision procedure.  Nontheless, as more parents become aware of
its availability and effectiveness, more physicians become proponents
of its value and expert in its use.  All evidence indicates that such
anesthesia does decrease the pain and stress on the infant.

                              E. O. Horger III, MD
                              Columbia, SC

                              Robert M. Arnett, MD
                              Spartanburg, SC

                              J. Stephen Jones, MD
                              Greenville, SC

1. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S.
   Comparison of ring block, dorsal penile nerve block, and topical
   anesthesia for neonatal circumcision. JAMA. 1997;278:1074-1080.

2. Arnett RM, Jones JS, Horger EO III, Effectiveness of 1% lidocaine
   dorsal penile nerve block in infant circumcision. Am J Obstet
   Gynecol. 1990; 163:1074-1090.

3. Kirya C, Werthmann M. Neonatal circumcision and penile dorsal nerve
   block: a painless procedure. J Pediatr. 1978;92:998-1000.

To the Editor.--Dr. Lander and colleagues have corroborated earlier
work documenting that significant pain is experienced during neonatal
circumcision, especially when performed without anesthetic, and they
are to be commended for recognizing that this pain should be con-
sidered.  In recommending that anesthetic should be administered
during the neonatal period, the authors have failed, however, to note
that the pain of circumcision would be more effectively addressed if
the operation were postponed to a later age.

   Historically, the neonatal period has been preferred for elective
circumcisions in large part because of the perceived danger of ad-
ministering anesthetic at a later age.[2]  This logic was based on
the unfortunate presumption that neonatal pain should be ignored.  In
view of the ongoing improvements in local anesthetics and the authors'
argument that the pain of neonatal circumcision should be addressed, a
more complete analysis of the available options is indicated.  Two re-
levant medical concerns are mentioned: sexually transmitted diseases
(STDs) and urinary tract infections.  The objective of reducing uri-
nary tract infection may represent a rationale for performing the
procedure on neonates, but the cited authors do not recommend neonatal
circumcision as a medically necessary procedure to address this risk.
Methodological problems involve, for example, the reported counsel to
retract the foreskin in the uncircumcised cohort.  Other, less drastic
strategies have been suggested.[3]

   On the other hand, the prevention of STDs represents a far more
important issue, and in this case, the need for more information
argues for postponing the procedure.  Although the cited studies have
favored circumcision as a means of reducing the tranmission of STDs,
more recent work has found a negligible association in most cases as
well as evidence indicating that chlamydia infections occurs more
often in men with circumcisions.[4]  But it is not the prevalence or
transmission of STDs today that is primarily at issue.  Rather of
relevance to the neonate is the possible role of the foreskin in the
transmission or prevention of future STDs decades hence, and this is
both unknown and unknowable at birth.

   Therefore, postponement of circumcision preserves options and
allows for the decision to be informed by future developments.  Post-
ponement also has other advantages.  For example, performing the
operation at a later age increases the likelihood that the foreskin
will have separated from the glans, and, as noted elsewhere, the risk
of complications may be substantially reduced.[5]

   The authors refer to the controversy surrounding the decision to
circumcise, but the question at issue is more narrowly whether to
circumcise at birth.  Urgency in the choice of the neonatal period
should be argued in the context of a presumption of preference that
the decision to circumcise be informed by the patient's own advice.[6]
It is not enough for the authors to claim that their method represents
an improvement over current practice.  In light of their pointed ap-
preciation of the problems of both pain and pain management during the
neonatal period, it should be noted that postponement is an alterna-
tive worth considering.

                              Carl Anderson, Ph.D.
                              University of Wisconsin
                              Madison, Wisconsin

1. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S.
   Comparison of ring block, dorsal penile nerve block, and topical
   anesthesia for neonatal circumcision. JAMA. 1997;278:1074-1080.

2. Warner E, Strashin E. Benefits and risks of circumcision. Can Med
   Assoc J. 1981;125:967-976.

3. Winberg, J, Bollgren I. Gothefors L, et al. The prepuce: a mistake
   of nature? Lancet 1989;1:598-599.

4. Laumann, E, Masi C, Zuckerman E. Circumcision in the United States:
   prevalence, prophylactic effects and sexual practices. JAMA 1997;

5. Storms, M. AAFP fact sheet on neonatal circumcision: a need for
   updating. Am Fam Physician. 1996; 54:1216-1218.

6. Lepiege A, Hunt S. The problem of quality of life in medicine. JAMA

To the Editor.--Dr. Lander and colleagues[1] studied pain relief
options for neonatal circumcision that differ greatly from those
offered to adults for the same surgery.  If these methods are inef-
fective in adults, why would they be considered efficacious in newborn
who have a lower pain threshold?  The Australian Association of
Paediatric Surgeons recommends deferring circumcision until adequate
anesthesia can be administered.[2]

   To anyone familiar with the anatomy of the penis, these findings
should not be surprising.  In a study by Taddio et al, the eutectic
mixture of local anesthetics cream (EMLA) was more effective than
placebo during only 31% of the stages of neonatal circumcision.[3]  To
be effective, the EMLA cream would have to penetrate the outer epi-
dermis, dermis, dartos muscle, mucosal lamina propria, the fused inner
prepuce mucosa/glans penis mucosa, and the glans lamina propria to
anesthetize the free nerve endings of the glans penis.  Clearly it
does not.  With higher doses, however, life-threatening consequences
have been reported.[4]

   Dorsal penile nerve block is inadequate because the ventral surface
of the penis is also innervated by the perineal branch of the pudendal
nerve.[5]  The frenulum, which has the highest concentration of nerve
endings in the penis,[6] is the prominent ventral structure and may
not be affected by blocking the dorsal penile nerve.

   There is currently little experience with ring block in neonates.
Since Lander had 50% bruising with the ring block and little patient
follow-up, it is impossible to predict its safety in newborns.  While
ring block was superior to no treatment, heart rates increased
significantly above baseline, suggesting that the surgery was still
painful with anesthetic use.

   The apnea and choking noted in 18% of controls meet the criteria
for apparent life threatening events.  Reporting this as a "new"
finding reflects how little study the most commonly performed surgery
has received and howe the complications following circumcision have
been ignored.  While non-treatment of pain is clearly unethical in a
research setting, we may have to debunk the "pain is good for boys"
myth before anesthetized circumcisions are abandoned in clinical

   Although some men may prefer a scar on their penis, and some men
may prefer to have an unanesthetized circumcision for personal rea-
sons, ultimately, the decision is theirs, not their parents'.  Instead
of searching for the optimal anesthetic, the most prudent course may
be to abandon ritual newborn circumcision.

                              Robert S. Van Howe, MD
                              Marshfield Clinic
                              Lakeland Center
                              Minocqua, Wis

                              Christopher Cold, MD
                              Marshfield Clinic
                              Marshfield, Wis

1. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S.
   Comparison of ring block, dorsal penile nerve block, and topical
   anesthesia for neonatal circumcision. JAMA 1997;278:1074-1080.

2. Australasian Association of Paediatric Surgeons. Guidelines for
   Circumcision. Hersion, Queenland, Australia; April 1996.

3. Taddio, A, Stevens B. Craig K, et al. Efficacy and safety of
   lidocaine-prilocaine cream for pain during circumcision. N Engl J
   Med. 1997;336:1197-1201.

4. Kumar AR, Dunn N, Naqvi M. Methemoglobinemia associated with
   prilocaine-lidocaine cream. Clin Pediatr Phila 1997;96:239-240.

5. Kaneko S, Bradley WE. Penile electrodiagnosis: penile peripheral
   innervation. Urology. 1987;30:210-212.

6. Taylor JR. Lockwood Ap, Taylor M. The prepuce: specialized mucosa
   of the penis and its loss to circumcision. Br J Urol. 1996;

To the Editor.--Despite the several interesting points raised by Dr.
Lander and colleagues,[1] some issues remain unresolved.  As noted in
previous studies,[2,3] EMLA cream has the risk of methemoglibinemia
and only partly minimizes pain.

   The main outcome measure is the analysis of variance of heartrate
and the cry of babies undergoing the procedure contrasted with relaxed
babies.  To have a better perspective, the analysis of variance be-
tween babies crying for a diaper change or crying to be fed should be
studied in contrast to that for relaxed babies, also.

   The average length of time reported for a dorsal penile nerve block
is 25 seconds and for a ring block is 48 seconds.  Add 92 seconds
(1.53 minutes), the average time the newborns cried after the block,
and the total distress time becomes 117 seconds (1.95 minutes) for
dorsal penile nerve block and 140 seconds (2.33 minutes) for ring
block.  Add 210 seconds (3.5 minutes), the listed average circumcision
time (the newborns were not completely relaxed during their circum-
cisions), and the total distress time becomes 327 seconds (5.45
minutes) for dorsal penile nerve block and 350 seconds (5.83 minutes)
for ring block.

   Holman et al[4] recommend that "[t]he clamp should remain secure
for a total of five minutes to allow the crush effect to be com-
plete ... to reduce the incidence of bleeding after the clamp is re-
moved."  Add this 300 seconds (5 minutes) so the total distress time
is really 627 seconds (10.45 minutes) for dorsal penile nerve block
and 650 seconds (10.83 minutes) for ring block.

   Furthermore, the Gomco and Mogen clamps precrush the proposed
excision site.[4]  The inventor of the Mogen clamp stated: "You get
the same results by using a greater crushing pressure for a shorter
period of time as by using a lesser crushing pressure for a longer
period of time" (Rabbi H. Bronstein, oral communication, August 6,

   The Gomco clamp crushes the excision site with 1.35 kg (3 lb) of
pressure and requires 8 to 10 minutes to complete the procedure.[4]
The Mogen clamp crushes the excision site with 5.4 kg (12 lb) of
pressure and needs 1 to 2 minutes for the procedure to be com-
pleted.[4]  For crushing techniques, local anesthesia might be indi-

   However, the authentic traditional Jewish technique of newborn
bris[5] does not crush any tissue.  Circumcision clamps and dorsal
hemostats are not allowed.  Excising time is about 1 second, the
entire procedure takes approximately 10 seconds.  Healing is by
secondary intention (natural healing), and complications are rare.
Most babies who are properly fed stop crying within a half a minute to
a minute after the bris (without sedation or intoxication).  Add 10
seconds of procedure and 60 seconds of postoperative crying for a
total of seventy seconds.  Furthermore, since there is no crushing of
tissue, the pain is not as severe as with the other techniques.
Therefore, with the authentic traditional Jewish technique, it is
actually more humane to not subject the infant to local anesthesia.

   Jewish patients interested in this technique should be referred to
a mohel (ritual circumciser) who is adept at doing authentic
traditional bris.

                              Rabbi Jacob Shechet
                              Los Angeles, Calif

                              Stanley M. Fried, MD
                              Kaiser Permanente
                              Downer, Calif

                              Barton Tanenbaum, MD
                              Beverly Hills, Calif.

   Rabbi Shechet practices as a mohel.

1. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt S.
   Comparison of ring block, dorsal penile nerve block, and topical
   anesthesia for neonatal circumcision. JAMA. 1997;278:1074-1080.

2. Benini F, Johnston C, Faucher D, Aranda J. Topical anesthesia
   during circumcision in newborn infants. JAMA. 1993;270:850-853.

3. Taddio A, Stevens B, Craig K, et al. Efficacy and safety of
   lidocaine-prilocaine cream for pain during circumcision. N Engl J
   Med. 1997;336:1197-1201.

4. Holman JR, Lewis E, Ringler R. Neonatal circumcision techniques. Am
   Fam Physician. 1995; 52:511-518.

5. Shechet RJ, Fried SM. Traditional Jewish circumcision technique of
   bris. Am Fam Physician. 1996;53:1070-1072.

In Reply.--Our study compared 3 anesthetic inventions to detect their
relative effectiveness for neonatal circumcision, thus providing evi-
dence to address a recently identified question.[1,2]  We evaluated
the authenticity of several beliefs about circumcision, neonates, and
pain.  We had the opportunity to observe and record apparent life-
threatening events by neonates who did or did not have an anesthetic.
THe opportunity for systematic observation is not often available in
clinical practice, and life-threatening events have often gone un-

   Many agree that clinicians should provide anesthetics for neonates
having circumcision.  Dr. Horger and colleagues thank that physicians
may not use anesthetic because of the belief that it lengthens the
procedure.  We have faith that few physicians would consider the 5 to
10 minutes needed to provide an anesthetic as more important than a
duty to protect the infant from preventable harm associated with pain.

   Dr. Anderson has suggested that delaying circumcision presumably
until adulthood, would eliminate several problems associated with
neonatal circumcision.  He did not elaborate on the risks that he
thinks are related to neonatal circumcision.  Anderson also suggested
that we ought not to assume that all males will have a lifestyle that
ncreases risks for STDs.  He stopped short of suggesting that there is
no medical indication for circumcision.  This was the position of Drs
Van Howe and Cold and one that is supported by the Fetus and Newborn
Committee of the Canadian Pediatric (sic) Society.[1]

   In our study, we followed the procedure first described by Kirya
and Werthmann.[3]  Horger et al may be correct that a smaller dose
than 0.4 mL of 1% lidocaine in each injection site is effective but we
know of no studies comparing dosages.

   Rabbi Shechet and colleagues described an unusual approach to
compare various circumcision techniques.  They seemed to view overall
time for the circumcision procedure as the important factor.  This is
not unlike the argument for performing circumcision without a
block[4]--that a quick and efficient circumcision negates the need
for a block.  Our results show that pain from the infiltration is
short lived and significantly less than the pain from unanesthetized
circumcision.  We know of no studies that have compared neonatal
distress associated with the various circumcision clamps or techniques
described by Shechet et al.  We have heard others suggest that the
traditional bris is less traumatic than common institutional
approaches.  This is a matter that is worthy of investigation.

   Horger et al asked about our analysis of other physiological
measures.  Oxygen saturation data duplicate the results obtained with
heart rate.  Respiration is a poor measure of neonatal distress since
it both rose and fell with invasive events in our study.

   Van Howe and Cold suggest that neonates in our study who had ring
blocks also experienced pain because their heart rates increased from
baseline.  In fact, this increase in heart rate reflects an alerting
response to the activity around them.  Neonates in all groups had
similar increases in heart rates as the draping and cleansing stage of
the circumcision commenced.  When the invasive part of the circum-
cision began, heart rates of infants in all groups, except ring block,
increased significantly.

   Whether or not to circumcise a newborn is an emotional issue.  We
advocate listening to the parents.  If they wish to proceed with the
circumcision, we believe that our study documents the benefits of
local anesthetics.  Like Van Howe and Cold, we also hope that our
study leads to a change in clinical practice.  It is a change that is
long past due.

                              Janice Lander, Ph.D.
                              James B. Metcalfe, MD, FRCSC
                              Sarah Muttit, MD, FRCSC
                              University of Alberta

                              Barbara Brady-Fryer, MN
                              University of Alberta Hospitals
                              Edmonton, Alberta

1. Fetus and Newborn Committee, Canadian Pediatrics Society, Neonatal
   circumcision revisited. Can Med Assoc J. 1996.

2. Wiswell T. Circumcision Circumspection. N Engl J Med. 1997;336:

3. Kirya C, Werthmann M. Neonatal circumcision and penile dorsal nerve
   block: a painless procedure. J Pediatr. 1978;92:998-1000.

4. Wellington N, Rieder M. Attitudes and practices regarding analgesia
   for newborn circumcision. Pediatrics. 1993;92:541-543.

(File revised 17 October 2006)