Dr. Greene, I'm having a baby boy, and we have decided to have him circumcised. I've read in magazines that a local anesthetic is a good idea. My OB says it doesn't hurt much, in fact babies cry as much from being strapped down as they do from the actual circumcision. She also says that sticking a needle into the penis is painful and not without complications, so it is better to do it quick and easy, like it has always been done. What do you think?

What a preposterous idea that little boys don't feel pain when part of the penis is first ripped from the underlying tissue, crushed with a clamp, and then amputated! This procedure is performed on more than 1 million babies each year in the United States alone, and many of them receive nothing to prevent or treat the pain.

We have a long history of underestimating the abilities of babies. Not long ago, we doctors were taught that babies couldn't see. Doctors waved brightly colored toys in front of babies, and the infants did not respond. Doctors flicked their fingers in front of babies' eyes, and the infants did not blink. Mothers, of course, reported that their babies gazed into their eyes, but this was attributed to wishful thinking.

It was not babies' eyes that were the problem, but doctors' tests! When faces or targets (nipple shapes) were held in front of babies, they were fascinated. We now know that newborns see quite well -- albeit primarily in black and white. Their interests, though, in that precious newborn stage are highly focused on connecting with their parents and on feeding. We also know that their excellent senses of smell, taste, and hearing are even more sensitive than ours are. They can distinguish their mother's nursing pads from those of other nursing women by smell alone!

We would like to believe that babies don't feel pain and that their genitals are not sensitive to pain or pleasure. But this is simply not true. Both baby boys and girls have sensitive genitals. A mountain of evidence forces us to conclude that newborns who are circumcised without an anesthetic experience true pain accompanied by increased blood pressure, increased heart rate, decreased oxygen in the blood, and a surge of stress hormones (Pediatrics, 1983; 71:36-40). Their screams are cries of surgical pain without anesthesia.

Thankfully, babies recover from this trauma fairly quickly. Following the circumcision, most boys have a prolonged period of sleep and then are largely unavailable for bonding or social interaction for up to 24 hours afterward. But after 24 hours, their behavior is indistinguishable from their uncircumcised counterparts (Developmental and Behavioral Pediatrics, 1984; 5:246).

Mostly.

Recent evidence suggests that boys who were circumcised without any anesthetic experience more trauma (pain and fear) with each of their numerous routine childhood immunizations Lancet, 1997; 349:599-603). As if shots weren't intrusive enough! Most kids with cancer dislike the pokes more than the disease.

Good news for the millions of boys who will be circumcised in the future! Thankfully, if the choice is made to circumcise, several excellent, safe alternatives are now available to provide pain relief: EMLA cream is easy to use. When spread onto half the length of the penis 60 to 90 minutes prior to the procedure, this topical anesthetic provides moderate pain relief (New England Journal of Medicine, 1997; 336:1197-1201).

Dorsal penile nerve block (DNPB) involves two deep injections of lidocaine at the base of the penis. Despite the shots, this technique greatly reduces overall pain (Journal of Pediatrics, 1978; 92:998-1000).