"T" wrote in message
et...
I am having sons circumcision tomorrow. I had one other question.
They do not use pain killer because of swelling, is there something that
the
doc can use that will not swell. I heard of a cream that they can put on
to
minimize pain.

From the AAP's most recent policy statement on infant circumcision:

"
ANALGESIA

There is considerable evidence that newborns who are circumcised without
analgesia experience pain and physiologic stress. Neonatal physiologic
responses to circumcision pain include changes in heart rate, blood
pressure, oxygen saturation, and cortisol levels.36-39 One report has noted
that circumcised infants exhibit a stronger pain response to subsequent
routine immunization than do uncircumcised infants.40 Several methods to
provide analgesia for circumcision have been evaluated.

Eutectic Mixture of Local Anesthetics (EMLA Cream)

EMLA cream, containing 2.5% lidocaine and 2.5% prilocaine, attenuates the
pain response to circumcision when applied 60 to 90 minutes before the
procedure. Compared with placebo groups, neonates who had EMLA cream applied
spend less time crying and have smaller increases in heart rate during
circumcisions.41-43 The analgesic effect is limited during the phases
associated with extensive tissue trauma such as during lysis of adhesions
and tightening of the clamp.42,43

Ideally, 1 to 2 g of EMLA cream is applied to the distal half of the penis,
which then is wrapped in an occlusive dressing. There is a theoretic concern
about the potential for neonates to develop methemoglobinemia after the
application of EMLA cream, because a metabolite of prilocaine can oxidize
hemoglobin to methemoglobin. When measured, blood levels of methemoglobin in
neonates after the application of 1 g of EMLA cream have been well below
toxic levels.42-46 Two cases of methemoglobinemia in infants occurred after
3 g of EMLA cream was applied; in 1 of these cases, the infant also was
receiving sulfamethoxazole.47,48 EMLA cream should not be used in neonates
who are receiving other drugs known to induce methemoglobinemia.

Dorsal Penile Nerve Block (DPNB)

DPNB is very effective in reducing the behavioral and physiologic indicators
of pain caused by circumcision. Compared with control subjects who received
no analgesia, neonates with DPNB cry 45% to 76% less,39,49-51 have 34% to
50% smaller increases in heart rate,50,52 and have smaller decreases in
oxygen saturation during the procedure.39,52 Additionally, DPNB lidocaine
attenuates the adrenocortical stress response compared with control subjects
who received no injections or injections of saline.49 The technique of Kirya
and Werthmann is used most commonly to perform the block.53 A 27-gauge
needle is used to inject the 0.4 mL of 1% lidocaine, to be administered at
both the 10- and 2- o'clock positions at the base of the penis. The needle
is directed posteromedially 3 to 5 mm on each side until Buck's fascia is
entered. After aspiration, the local anesthetic is injected. Systemic
lidocaine levels obtained with use of this technique demonstrated peak
concentrations at 60 minutes, well below toxic ranges.52 Several studies
evaluating the efficacy of DPNB reported bruising as the most frequent
complication.49,50,54,55 Hematomas were rarely seen and caused no long-term
injury.50,56 A single report of penile necrosis may have been secondary to
the surgical technique rather than to the DPNB.57

Subcutaneous Ring Block

A subcutaneous circumferential ring of 0.8 mL of 1% lidocaine without
epinephrine at the midshaft of the penis was found to be more effective than
EMLA cream or DPNB in a recent study.43 Although all treatment groups
experienced an attenuated pain response, the ring block appeared to prevent
crying and increases in heart rate more consistently than did EMLA cream or
DPNB throughout all stages of circumcision. In another study, after a
subcutaneous injection of lidocaine had been given at the level of the
corona, it was noted that fewer infants cried during the dissection of the
foreskin, placement of the bell, and clamping of the Gomco, compared with
those infants with a DPNB.58 Additionally, the cortisol response was
diminished in the subcutaneous group compared with the DPNB group.58 No
complications of this simple and highly effective technique have been
reported.

Others

Sucrose on a pacifier has been demonstrated to be more effective than water
for decreasing cries during circumcision.59 Acetaminophen may provide
analgesia after the immediate postoperative period.60 Neither technique is
sufficient for the operative pain and cannot be recommended as the sole
method of analgesia. A more physiologic positioning of the infant in a
padded environment also may decrease distress during the procedure.61

In summary, analgesia is safe and effective in reducing the procedural pain
associated with circumcision and, therefore, adequate analgesia should be
provided if neonatal circumcision is performed. EMLA cream, DPNB, and a
subcutaneous ring block are options, although the subcutaneous ring block
may provide the most effective analgesia."

You can read the whole thing at http://www.aap.org/policy/re9850.html. And
if your son's surgeon is unwilling to do what the AAP recommends with regard
to analgesia during circumcision (which is to use it), you should
*certainly* find another surgeon who *will* do the surgery according to best
established practice.

Also, why is it best practice to NOT do circumcision. I figure since my
first son is circ. I should have 2nd son also.

This is about the weakest justification I can imagine for doing something
which you now know is not the best practice. For heaven's sake! If your
first child was born before the Back to Sleep campaign to prevent SIDS came
into existence, would you insist on putting your next baby to sleep on his
belly to be "fair"? Do you feel you have to make every parenting mistake
with your second child that you made with your first in the interest of
equality?

The best practices in child care and medicine are always changing as more
information is gained. If you *know* that circumcision is no longer
recommended by medical professionals, why would you do it again?

My first boy is circumcised because, at the time he was born, my husband
felt it was best and I didn't have a strong enough opinion on the matter to
disagree. My second boy is intact because neither my husband or I thought it
was the right thing to do any more. I wouldn't have *considered* having my
youngest son's penis altered just to make them "match," any more than I'd
consider having the youngest's hair dyed so it would be the same color as
his brother's.
--
Be well, Barbara
(Julian [6], Aurora [4], and Vernon's [a quarter to 2] mom)

This week's special at the English Language Butcher Shop:
"Custom fabracation" -- Auto body shop sign

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Aurora: No, I'm up with my dolls!

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