As a physician who does circumcisions, I have some comments.  When I was
trained by a neonatologist to do this procedure in 1988, I was instructed to
use a dorsal penile nerve block.  I have never done a circumcision without
one, I can't imagine doing one without a block, and it infuriates me to
think they are being done without blocks.  I do the exact same procedure on
every baby, and some fall asleep, some cry intermittently, and some cry the
whole time.  I think this is because the pain threshold is established from
birth, and everyone reacts differently to different levels of pain.  I wait
at least 12 and preferably 24 hours to do this procedure, and I definitely
prefer to do it in the nursery, because the older they get, the fussier they
are, the more wide awake they are, and the more stressed out I get listening
to this.  These are babies that I give IM demerol to as well.  I always
prescribe 10mg/kg body weight of Tylenol every 4 hours after the procedure
if the baby needs it.  As far as parental consent is concerned, these are my
thoughts: this is an elective procedure.  There is no absolute medical
indication, there is still alot of argument about this.  I'd say that about
15% of the time when I tell a parent there is no indication, they choose not
to do it.  On the other hand, I have had parents tell me they want their
child circumcised and they really don't want to talk about it, but they are
relieved when I tell them I use a block.  Ultimately, it is their child and
their choice, so I never talk anyone into or out of a circ.
I don't know if it's because I use a block or not, but I don't recall having
a baby have trouble nursing because of a circ only.  In fact, I get that
baby right out to mom and have them go to the breast.  I have never had a
mom or dad call me from home saying that the circ is so painful, the baby
won't eat.  So, either I'm biased or the block really makes a big
difference.  As far as lidocaine having risks, they are minimal.  I have
never had a complication so far, and am in fact doing a study on the short
term effects of lidocaine.
Speaking of the Jewish procedure of ritual circumcision  known as the bris,
this is truly a fascinating topic.  A Jewish friend of mine leant me a book
entitled "Bris Milah" about the bris.  When I first asked her why jewish
boys are circed she said, "because it is written."  The foreskin symbolizes
the sin of mankind (in the garden of Eden) because Adam was created
circumcised.  Apparently it grew back when he sinned.  All Hebrew letters
have numerical values, and the word "knife" in Hebrew adds up to 8.  Also,
the Sabbath is the Queen, and you have to have greeted the Queen before
being circumcised, so that is a minimum of 8 days.  Most interesting to me,
is the fact that coagulation factors peak on the 8th day in newborns.  I'd
be happy to hear any comments from anyone.  Terry Dise


Terry Lynn Dise, MD
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