Friday, February 3, 2012

Numbing

I once addressed the "numbing" question in a posting that covered a few topics.

Since it comes up every now and then, here are a few thoughts to consider.

Concerned parents have different attitudes about numbing the foreskin before the circumcision. Here are a few examples of things that have been shared either with me or between parents who discuss this in my presence:
  • Babies have been circumcised for thousands of years without numbing. He'll be fine without it.
  • If you can do anything which will ease his discomfort, we'd appreciate it.
  • Babies nerve endings aren't developed as much. He doesn't feel it so much anyway.
  • He feels something, but he cries every time we open his diaper.
The feelings run the gamut, but they are also tainted by a little bit of misinformation.

#1. BABIES FEEL PAIN. The "nerve endings aren't developed" argument is a load of hooey. To suggest that a baby doesn't feel pain is to assume that a baby only cries when hungry or when needing a diaper change. Give a baby a blood test and you'll hear cries of "bloody murder."

#2. ALL STUDIES OF THE PAIN BABIES FEEL DURING CIRCUMCISION ARE IN HOSPITAL PROCEDURES (with either 0 or local anesthesia) WHICH CAN TAKE BETWEEN 10 AND 45 MINUTES. A BRIS, ON THE OTHER HAND, TAKES A FEW SECONDS. In other words, while there is pain at a bris, the amount of pain is directly correlated to the amount of time the procedure takes place. Since the bris is done using a different method than the hospital procedure, the painful part is minimal, in comparison to the rest of the time which I define as "discomfort" (ie. let go of me, stop putting pressure on my circumcision wound, close my diaper, let me eat, etc.)

#3. INJECTIONS ARE MORE PAINFUL THAN THE BRIS. We know injections are sometimes important. But that doesn't mean that they are painless. Even if we can withstand the needle, there are some shots that hurt hours after adminstered. Typically injections for a circumcision are done in three places, around the circumference of the dorsal (belly) side of the penis, to create what is called a "penile block." It makes the baby relatively calm during the circumcision, but at the cost of three painful injections.

#4. TOPICAL ANALGESICS WORK FOR THE MOMENT OF THE BRIS, BUT DO NOTHING ONCE THE FORESKIN IS GONE. Essentially, the shaft of the penis will not have sensation, and the baby can be quiet in the moment the foreskin is excised. But when pressure is applied to the now-open wound, all bets are off. The baby will likely cry even if the area was numbed beforehand, simply because he is uncomfortable (see the end of #2 above).

MY PERSONAL FEELINGS

I think injections are good for the doctor in a hospital setting (assuming he is working with a newborn and is not using general anesthesia), because a hospital procedure - or any procedure that includes a clamp utilized for more than a few seconds - is long, arduous, and painful to the baby if the area is not numbed. But I don't believe injections are beneficial to anyone in the event a mohel is circumcising using a more traditional circumcision method/procedure.

I have no personal problem or objection to the use of a topical analgesic/numbing agent, as long as I know what it is and it has a decent track record. There are debates about EMLA cream, for example. A doctor I know recommended I introduce people to "ELAMAX," which can be obtained OTC at a drugstore (just ask for it). I used to carry a 30% lidocaine cream that I had made by a compounder, as per a prescription given to me by a doctor (email me if you'd like to see the article that introduced me to this idea - I can send you the pdf). But it became complicated to get to people or if I only saw the baby a few minutes before the bris it was not enough time to put it on, so it wasn't worth the hassle.

There are other issues to consider as well (if you really care, see Phil Sherman's discussion of this in Q14 on his FAQ page), so I don't raise the issue unless people ask.

Simply put, I have found that the "pain concern" is more of an issue for parents than it is for the baby. When the bris is over - more accurately, when I close the diaper and get the baby dressed - he is usually fine. When I am done, the discomfort is over. The "pain" is over as soon as the foreskin is removed. Some babies still need to eat, but some go right to sleep. A little bit of Manischevitz does wonders.

To quote one of my teachers, there are two mitzvahs for which God said "You will feel pain." One of them is Bris Milah (the other is fasting on Yom Kippur). But, he argues, we do not need to maximize the baby's pain. He is therefore an advocate for using the numbing cream. Which is why I won't object to the proper cream being used. I will add, however, that the speed in which we operate is its own form of anesthetic. The method we use is far less painful than a "clamp method." All told, the traditional Jewish method minimizes the baby's pain as much as possible by its quick and simple design.

I mentioned above that the pain concern is more of a parental one. One of my colleagues is fond of saying that the person who feels the most pain at the bris is the... baby's mother. Sometimes the father too. The best anesthetic, therefore, is to pour two shots of whisky. Give one to Mommy, one to Daddy, and the baby will be fine.

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