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.

When Baby is Cranky - Is Tylenol a Solution?

The impetus for this posting comes from two incidents which took place in the last few weeks.


1. Tylenol, and other OTC baby pain medications had some kind of recall (the details did not concern me personally as my children don't use any of the items in question, and I never recommend any of them as a mohel)


2. Someone I know, who lives in New York, had his son circumcised by a local NY mohel, and called me that evening, after his baby had an unusually difficult day, to confirm that what his mohel had told him was "normal" in the post-op care of the baby. Details to follow.


I will not address the Tylenol recall directly, as it is not my area of expertise. But the issue which is raised often enough is whether there is room to give the baby tylenol if he seems cranky after the bris?


My answer is twofold. Firstly, let your pediatrician recommend tylenol or something to ease your baby's discomfort. Most mohels I know are not physicians, and while they can offer advice, they are not in charge of your baby's long-term care. Even if the mohel IS a physician, if he (or she - there are female Dr. physicians who are mohelets) is not your baby's physician, the questions about medications should be directed to the primary long-term caregiver.


Secondly, and this leads into the second impetus as mentioned above, your baby should not feel discomfort after the bris.


You may ask, how could a baby not feel discomfort after going through this surgery? I don't know the answer to this question, but I can report on what I've observed.


Post-bris, most babies who have a bandage placed on comfortably, who have their needs met (clean diaper and full belly), sleep nicely, eat nicely, wet their diapers consistently, etc. They cry under the same conditions they cried for before the bris: dirty diaper, hungry, tired... The main difference will be that baby might wince when he urinates - which would be directly impacted by the bris.


So what causes a baby to be cranky after the bris?

The number one item that causes a baby discomfort is an uncomfortable bandage. It could be the material does not agree with him. The bandage may also be on too tight, constricting what should otherwise be an easy urine-flow.


In my personal experience, when I fiddle (as necessary, after the bris) to get a new bandage on, the baby will usually cry as I am reapplying a gauze pad. Once I am finished and leave the baby alone, he is usually calm and comfortable, the crying stops, and he either eats or goes right to sleep.


Solutions


And so I asked the father of the baby three questions:

1. Is it bleeding? (usually indicative of either a case that requires attention or a bandage that fell off prematurely)

2. Has the baby urinated? (if not, there is too much constriction on account of the bandage, and it needs to either be loosened, removed, or replaced with a looser and softer bandage)

3. Will your mohel come and check it?


If the bandage is on too tightly - guess what - Tylenol or Motrin ain't gonna do a thing.

*************************



I mentioned in a different posting that it is normal to see swelling after the bris, particularly on the ventral side of the penis. In this case, that was not as much of a concern from my perspective (though the father did see swelling and was concerned about it).


In the end, the mohel did come and check, he removed the bandage (or loosened it) and baby was able to urinate more readily, easily and comfortably.


The point of this story is not to knock another mohel. It is to encourage you to avoid jumping to conclusions, to avoid worrying, and to realize there may be a very simple solution.


I have taken steps to avoid this problem. The bandage I leave on the baby is a softer one, which usually comes off on its own a few hours after the bris. I remind parents from the get-go that they need to report to me if the baby has not urinated a few hours after the bris. I consciously put the bandage on tight enough to constrict the bleeding, but not so tight to be uncomfortable for baby.

With the exception of babies who are extremely hungry after the bris, most babies I care for are calm when I finally leave them alone, and may even sleep comfortably for a few multi-hour stretches, waking up for feedings and diaper changes.


And I tell the baby's mother, "You see how he is now? That is how he should be throughout the rest of the day, except when he is telling you he is hungry or needs to be changed (which is when he normally cries anyway)."


Instead of Tylenol being the solution, let us return to appropriate TLC which will undoubtedly help ease the pain and make the ordeal so much easier for parents and baby.

Putting Parents At Ease - More Considerations

Over the weekend, I attended a presentation/discussion in which one person mentioned her impression that bris turns some people off from Judaism. Almost as an aside she said "They think it is barbaric."

It wasn't my forum, so I kept quiet. I have a lot to say on the subject, but it's for a different place. My blog, for example.

Firstly, I don't believe the bris turns people off from Judaism. It's a big world out there. People who are unhappy with Judaism will find any excuse they want.

As far as circumcision being barbaric, that statement is a hard sell in the United States when over 60% of the newborn male population is circumcised - either routinely with a clamp (with or without a local anesthetic), in the O.R. under general anesthesia, or as part of a religious or holistic ceremony - and until relatively recently, over 90% of the newborn male population of this country was circumcised.

The American Choice

In American culture, people have all kinds of reasons for circumcising their sons. I learned about this recently when our son was born, when my wife and I were handed a pamphlet about circumcision which boiled the choices down to two: "to circumcise or not to circumcise; that is the question."

They have a number of reasons why people may opt to circumcise.
* Medical suggestions that urinary tract infections, penile cancer, and other penile illnesses (including STDs) are less common and the penis is less susceptible when circumcised.
* It is easier to clean.
* Family - father and brothers are circumcised
* Cultural - everyone else does it
* Aesthetics - You like the circumcised "look" better than not.
* And, of course, religious reasons.

Reasons not to circumcise include:
* It is healthy tissue which guards a very sensitive area of the body
* No medical benefits if the child is taught how to clean under the foreskin
* Why subject a child to such surgery, which may be unnecessary?

The "barbaric" nature of circumcision is not raised, even if people may personally feel it to be such.

Why Jews Circumcise Their Sons

While the religious reason is most obvious, the best verbal explanation I have heard of late was in the documentary "Partly Private" - a film made by a secular Israeli woman living in NY, who was researching whether or not to circumcise her as-yet-unborn son (they had circumcised his older brother, but were displeased with the experience).

When a number of her Israeli friends gathered to be a sounding board for her deliberations, one of her friends who had become observant said, "If you are deliberating circumcision because you think it is 'barbaric' - you are right. Don't circumcise. But if you have faith in God and understand that this is what God asked of the Jewish people, as this is a mark of the covenant He forged with Abraham, then this is not barbaric. This is an act of love: for your child, for your people, for your God."

He is so right. The reason we circumcise is FAITH.

But it's still BARBARIC, Right?

It really depends on your perspective.

Most medical authorities who deal strictly from a medical perspective (in other words, who do not have an agenda), will argue the benefits versus the risks, the pros versus the cons. Very few will call it a barbaric procedure.

Most people who call it barbaric have an agenda, have an obsession, and find it hard to not think about how life (read "sex") would be different if the parents had not chosen to "make the cut" on them.

And they'll usually show a picture of a red, screaming baby to show the kind of pain a baby feels when undergoing a circumcision.

Before we continue, it is important to understand that there are different kinds of circumcision procedures, and all kinds of situations that can make a baby cry and scream bloody murder.

Setting the record straight

Babies cry. They scream. They can be in all kinds of discomfort. And sometimes there is not much we can do to ease their pain.

Babies who have blood tests, shots, raw diaper rashes, or sometimes just have colic may very well be inconsolable. Would you not have your baby have the necessary blood test or innoculation just so your baby won't ever cry?

Sometimes benefits outweigh the downsides. And sometimes not.

There are some who will argue that babies nerve endings are underdeveloped and so they don't feel the circumcision.

This is a lie.

Babies absolutely feel pain. But they only feel the pain to which they are subjected - and that, only if nothing is done to numb them from the pain. Which brings us to two points worthy of consideration when considering the difference between what is known as "routine circumcision" and a bris (A circ in an O.R. is a completely different story, because once the baby is under general anasthesia, all bets of pain and discomfort are off.)

SPEED OF PROCEDURE and NUMBING

Click this line to read the article in which it appears: "A mohel does not usually use anesthetic, because his anesthetic is the speed with which he does the circumcision. "

Most routine circumcisions are done elaborately, painstakingly, with a clamp that crushes the skin in order to achieve hemostasis. Since the skin is essentially dead when it is excised, there is usually no bleeding by the time the last skin is removed. Kudos.

Meanwhile, the baby has been in excruciating pain throughout the procedure (which usually takes between 5 and 20 minutes), unless the circumciser has used a penile block (3 injections around the circumference of the penis, along the lower base of the abdomen), to numb the area during the procedure.

3 injections = 3 shots. If your kid screams during one shot, imagine THREE, even if their outcome is a numbing. The shots themselves are painful!

A good mohel is usually done with the procedure, start to finish, in between 5 and 10 seconds. That's less time than it takes to administer the injections. Yes, there is usually a little more blood at a bris (only a little), but the drawing of blood is (like it or not) a necessity for the procedure according to Jewish law. The covenant was forged over blood. (If you like movies, you can see how a covenant is forged over blood in Kevin Costner's "Robin Hood" when he swears to avenge his father's murder in the first quarter of the film - I used to have a link to youtube here, but the video was taken down.)

NUMBING [See this posting - in which I revised what I wrote below - AB, 2012]

I happen to be a fan of numbing the foreskin, but not with injections. I prefer a topical analgesic with a dose of 30% lidocaine + 70% acid mantel cream base, to be applied to the penis at least a half hour before the bris. It doesn't hurt the baby at all in its application, and it does the same thing for the small amount of time it is helpful. Most of the discomfort at the bris comes from being handled, not from the pain of the bris (proof is that the baby usually stops crying once he is no longer being touched).

And even without it, the bris speed is, as mentioned above, its own form of anesthesia.

In Conclusion

If I were not Jewish, would I circumcise my son? Knowing what I know about circumcision, I probably would. My wife would probably not, just because she would not want to subject the baby to a painful experience - even a fleeting one.

As we are Jewish, we agree that we do it because the Torah commands it of us.

I don't think it is a barbaric custom, and I think those who do it properly have a tremendous sense of satisfaction that the baby is well and that the chapter of bris is behind them.

Consider the method and you have your answer. (Clamps, injections, drawn out, hospital v home, physician, resident, mohel, surgery v bris)

And hopefully, if you call me, you'll find what you're looking for in a mohel and you'll uncover the answers to more questions through our conversations.