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===Pain's injury to the infant nervous system===Anand & Hickey [[Paul Emil Flechsig]] (19851847-1929) conclusively demonstrated was an eminent nineteenth-century German neuroanatomist, psychiatrist and neuropathologist. He suggested in 1872 that infants could not feel pain and feel it more intensely than adults. Pain researcher Maria Fitzgerald (1998) reported the sensitivity of the infant nervous system to extreme pain:<blockquote>We and others have established that the developing nervous system is even more vulnerable to injury than in adults and that changes to the pathways induced shortly after birth can become permanent. This is because newborn nerve damage their nerves are not only results in the death of sensory nerve cells, but causes other sensory nerve terminals to sprout extensively and occupy areas normally exclusively devoted to the damaged nervecompletely myelinated.<refname="cope1998">{{REFjournal |last=Fitzgerald |first=Cope |init=MDK
|etal=no |title=The Birth Neonatal pain: the evolution of Pain |trans-title= |language=an idea. |journal=MRC News |location=The American Association of Anesthesiologists Newsletter |date=1998 |season=Summer-09
</blockquote>
Fitzgerald & Walker * Emde et al. (20031971) argued that extreme pain (such as showed that the "stress" of circumcision caused by circumcision) may alter developing nervous tissue an increase in the very youngamount of non-REM sleep.<refname="emde1971">{{REFbookREFjournal |last=FitzgeraldEmde |firstinit=MariaRN |initfirst=MRobert N
Tye * Richards, Bernal & Sardi advised:<blockquote>Thus, while there is literature that addresses the ways in which pain experienced by neonates not only has negative short- and long term psychological consequences, policy making documents on neonatal circumcision do not address the fact that such pain is not adequately nor regularly controlled for during the procedure, Brackbill (1976) reported behavioral differences between American boys (circumcised) and that failure to control for pain can have lasting effects on the child, possibly into adulthoodBritish boys (genitally intact).<ref name="tye2022richards1976">{{REFjournal |last=Tye |first=Richards |init=NCMPM
</blockquote>
===History=======Investigating pain of circumcision==== [[Paul Emil Flechsig]] * Luther, Kraybill & Potter (1847-19291976) was an eminent nineteenth-century German neuroanatomist, psychiatrist compared the level of cortisol in infants before and neuropathologistafter circumcision. He suggested They found a substantial rise in the cortisol levels in 1872 that the infants could not feel pain because their nerves are not completely myelinated, which they said was due to the "stress" of circumcision.<ref name="cope1998">{{REFjournal |last=CopeTalbert |init=DKLM |first=Luther M.
As a result* Rawlings, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions and even open heart surgery. Open heart surgery was performed with curare to paralyze the infant but without any anesthesia. Flechsig's bizarre opinion was not questioned until the 1970s. Several lines of empirical research carried out in the 1970s suggested that infants can in fact feel intense pain.<ref name="vanhowe2008" /> * Anders et al. Miller & Engel (19701980) showed that measurement as the pain of serum cortisol is a useful indicator circumcision increased, oxygenation of pain for psychological investigation in infancythe [[skin]] decreased.<ref name="anders1970rawlings1980">{{REFjournal |last=AndersRawlings |init=TFDJ |first=Thomas FDavid J. |author-link= |last2=SacharMiller |init2=EJPA |first2=Edward J.Patricia Anne
|last4=Roffwarg
|init4=HP
|first4=Howard P.
|author4-link=
|last5=Hellman
|init5=L
|first5=Leon
|author5-link=
* LutherPorter, Kraybill Miller & Potter Marshall (19761986) compared studied the level nature of cortisol in infants before and after pain cries during unanesthetized, non-therapeutic circumcision. They the cries during circumcision were found a substantial rise in to shorter, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; and greater variability of the cortisol levels in the infants, which they said was due fundamental. Adult listeners judged these cries to the "stress" have an unusual degree of circumcisionurgency.<refname="porter1986">{{REFjournal |last=TalbertPorter |initfirst=LMFran Lang |firstinit=Luther M.FL
* RawlingsSurgical operation on infants without anesthesia continued for well over a century, Miller & Engel (1980) showed that as the pain of circumcision increasedat least until 1987, oxygenation of when the [[skinAmerican Academy of Pediatrics]] decreasedwas forced to issue a CYA statement that called for the use of anesthesia.<ref name="rawlings1980poland1987">{{REFjournal |last=RawlingsPoland |initfirst=DJRonald L. |firstinit=David J.RL
* Gunnar et al. Anand & Hickey (19811987) recorded serum cortisol published a paper in the ''New England Journal of Medicine'' that totally demolished Flechsig's ridiculous claims and behavior state throughout the unanesthetizedconclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress were found to be closely relatedno doubt about pain sensation in infants remained. The authors article stated:
}}
So great Although by 1989 it was Flechsig's influencetotally clear that infants can feel intense pain, the authors were still unwilling to use 1989 American Academy of Pediatrics Circumcision Task Force, under the word ''pain'' and substituted leadership of the word ''stress''infamous [[Edgar J.<ref name="Gunnar et al 1981"/> * Marshall et al. (1982) studied motherSchoen]], {{MD}}, declined to recommend the use of analgesics for non-child interaction with regard to feeding behavior after circumcision without anesthesia. They found that therapeutic neonatal [[circumcisedcircumcision]] , thereby condemning millions of newborn baby boys had more interruptions of feeding in the 24-hour period of observationto a painful, stressful' traumatizing circumcision.<ref name="marshall1982">{{REFjournal |last=MarshallSchoen |initfirst=REEdgar J. |firstinit=Richard E.EJ |author-link=Edgar J. Schoen |last2=PorterAnderson |init2first2=FLGlen |first2init2=Fran L.G
Porter, Miller & Marshall (1986) studied the nature of pain cries during unanesthetized, ====Finding an ethical way to do painful non-therapeutic circumcision. the cries during ==== The financially and psychologically vested circumcision were industry suddenly found to shorter, with more more frequent vocalizations; higher peak fundamental frequencies; fewer harmonics; itself in a predicament. It was now suddenly proven beyond any shadow of a doubt that newborn baby boys can feel intense pain. Medical ethics and greater variability the standard of the fundamentalcare now necessitated pain relief, however it is dangerous to give general anesthesia to neonates. Adult listeners judged these cries to have an unusual degree [[Edward Wallerstein]] (1985) had proposed that [[Routine Infant Circumcision| routine]] (non-therapeutic) circumcision of urgency.baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="porter1986wallerstein1985">{{REFjournal |last=PorterWallerstein |first=Fran LangEdward |init=FLE |author-link= |last2=Miller |first2=Richard H. |init2=RH |author2-link= |last3=Marshal |first3=Richard E |init3=RE |author3-link=Edward Wallerstein
|pubmedID= |pubmedCID= |DOI= |accessdate=2020-11-12}}</ref><ref name="vanhowe2008" />
Anand & Hickey (1987) published a paper in the ''New England Journal of Medicine'' that totally demolished Flechsig's ridiculous claims and conclusively proved that newborn infants are capable of feeling intense pain. After publication of this paper, no doubt about pain sensation in infants remained. The article stated:{{Citation |Text=Numerous lines of evidence suggest that even in the human * [[fetusDorsal penile nerve block| Dorsal Penile Nerve Block]], pain pathways as well (DPNB) as cortical and subcortical centers necessary for pain perception are well developed late in gestation, and the neurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, and cardiorespiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns. |Author=Anand proposed by Kirya & Hickey (1987) |ref=<ref name="anand1987"/><ref name="vanhowe2008"/>}} Gunnar et al. Werthman (19881978) examined the association between behavioral distress and adrenocortical activity. It was found that differences in behavioral distress did not reliably the level of adrenocortical activity. Moreover, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus of circumcision pain.<ref name="gunnar1988kirya1978">{{REFjournal |last=GunnarKirya |first=MeganChristopher |init=MC
|last3=Isensee |first3=Jill |init3=J |author3-link= |last4=Wall |first4=Lee |init4=L |author4-link= |etal=yesno |title=Adrenocortical activity Neonatal circumcision and behavioral distress in human newbornspenile dorsal nerve block—a painless procedure. |trans-title= |language=English |journal=Dev PsychobiolJ Pediatr
Although by 1989 it was totally clear that infants can feel intense pain, the 1989 American Academy of Pediatrics Circumcision Task Force, under the leadership of the infamous * [[Edgar J. SchoenRing block| Ring Block]], {{MD}}, declined to recommend the use of analgesics . Broadman et al. (1987) proposed ring block for neonatal non-therapeutic neonatal [[circumcision]], thereby condemning millions of newborn baby boys to a painful, stressful' traumatizing circumcision.<refname="broadman1987">{{REFjournal |last=Schoen |first=Edgar J.Broadman |init=EJLM |author-link=Edgar J. Schoen |last2=Anderson |first2=GlenHannallah |init2=GRS
* The pain that infant boys experience would not be acceptable in older boys and adults. It is not clear why infant boys are still subjected to a lesser standard of care with regard to pain than older boys and adults. ==Attitudes and practices regarding analgesia for newborn circumcision== ===Historic attitudes and practices=== Wellington & Rieder (1993) conducted a survey of physicians in London, Ontario. They found that only 4 percent used [[Ring dorsal penile nerve block| Ring BlockDPNB]]. Broadman et alThey concluded:{{Citation |Text=Despite evidence that neonates perceive pain and that there is a physiologic stress response to circumcision which can be reduced if analgesia is employed, the vast majority of physicians performing newborn circumcisions either do not employ analgesics or employ analgesics of questionable efficacy. (1987) proposed ring Lack of familiarity with the use of analgesics among neonates and with dorsal penile block in particular are the most common reasons cited for neonatal non-therapeutic lack of analgesic use. Educational efforts and research into less invasive techniques of analgesia for newborn circumcisionare urgently required. |Author=Wellington & Rieder (1993) |ref=<ref name="broadman1987">{{REFjournal |last=BroadmanWellington |first=Nancy |init=LMN
|last3=Condon |first3=Lawrence M |init3=LM |author3-link= |last4=Conroy |first4=Mary Margaret |init4=MM |author4-link= |last5=Liebo |first5=Rhoda |init5=R |author5-link= |last6=Brodersen |first6=Laurie |init6=L |author6-link= |last7=Gunnar |first7=Megan R. |init7=MR |author7-link= |etal=no |title=Beyond dorsal penile nerve block: A more humane Changing attitudes and practices regarding local analgesia for newborn circumcision. |trans-title= |language=English |journal=PediatricsPedatrics
The pain that infant boys experience would not be acceptable in older boys and adults. It is not clear why infant boys are still subjected to a lesser standard of care with regard to pain than older boys and adults. ==Attitudes and practices regarding analgesia for newborn circumcision== ===Historic attitudes and practices=== Wellington & Rieder Kraft (19932003) conducted a survey of physicians in London, Ontario. They found reported that only 4 percent used [[dorsal penile nerve block| DPNB]]. They concluded:{{Citation |Text=Despite evidence that neonates perceive pain and that there is a physiologic stress response to circumcision which can be reduced if analgesia is employed, "many health care practitioners routinely perform this procedure without the vast majority use of physicians performing newborn circumcisions either do not employ analgesics any or employ analgesics of questionable efficacy. Lack of familiarity with the use of analgesics among neonates inadequate or ineffective analgesia and with dorsal penile block in particular are the most common reasons cited for lack of analgesic useanesthesia. Educational efforts and research into less invasive techniques of analgesia for newborn circumcision are urgently required. |Author=Wellington & Rieder (1993) |"<refname=<ref"kraft2003">{{REFjournal |last=WellingtonKraft |firstinit=NancyNL |initfirst=NNancy L
|last2=Rieder
|first2=Michael J.
|init2=MJ
|author2-link=
}}
Ryan & Finer (1994) carried out a training program for physicians ===Contemporary attitudes and practices===Little is known about current attitudes and practices regarding the use of analgesia in circumcision of the newborn nurseries . Application of the Womens' Pavilionanalgesia prior to neonatal nontherapeutic circumcision takes additional physician time, so there may be a tendency to skip it. ==Standard of care==It is now clear that boys are born with a healthy [[https://wwwforeskin]] without evidence of disease.albertahealthservices.ca/rah/rah.aspx Royal Alexandra HospitalTherefore there are no indications for infant [[circumcision]], Edmonton, Alberta, Canada. After which is a training program, they found that 66 percent of physicians who perform non-therapeutic neonatal circumcisions had started to use analgesia during the procedure. This applies to one hospital in [[Canada]]and medically-unnecessary surgical operation.<ref name="ryan1994cps1996">{{REFjournal |last=RyanEugene |first=C. AnthonyOuterbridge |init=CA
|last2=Finer |first2=Neil N. |init2=NN |author2-link= |etal=no |title=Changing attitudes and practices regarding local analgesia for newborn Neonatal circumcision.revisited
}}</blockquote> The practice of non-therapeutic circumcision of boys has nearly died out in [[Australia]].== Pain's injury to the infant nervous system ==Anand & Hickey (1985) conclusively demonstrated that infants feel pain and feel it more intensely than adults.<ref name="anand1987"/>
The [[American Academy of Pediatrics]] convened a new task force on circumcision under Pain researcher Maria Fitzgerald (1998) reported the chair sensitivity of Carole M. Lannon, {{MD}}. That task force reversed the position previously taken under [[Edgar J. Schoen]]. It clearly stated infant nervous system to extreme pain:<blockquote>We and others have established that non-therapeutic infant circumcision the developing nervous system is "not essential even more vulnerable to injury than in adults and that changes to the child’s current well-beingpathways induced shortly after birth can become permanent." It provided an extensive discussion This is because newborn nerve damage not only results in the death of procedural analgesia sensory nerve cells, but causes other sensory nerve terminals to sprout extensively and said, quite strongly, that, if a circumcision is done, procedural analgesia should be providedoccupy areas normally exclusively devoted to the damaged nerve.<ref name="aap1999">{{REFjournal |last=LannonFitzgerald |first=Carole M. |init=M
Kraft Fitzgerald & Walker (2003) reported argued that "many health care practitioners routinely perform this procedure without extreme pain (such as that caused by circumcision) may alter developing nervous tissue in the use of any or with inadequate or ineffective analgesia and anesthesiavery young."<ref name="kraft2003">{{REFjournalREFbook |last=KraftFitzgerald |initfirst=NLMaria |firstinit=Nancy LM
===Contemporary attitudes and practices===Tye & Sardi advised:<blockquote>Little Thus, while there is known about current attitudes and practices regarding literature that addresses the use of analgesia ways in which pain experienced by neonates not only has negative short- and long term psychological consequences, policy making documents on neonatal circumcision of do not address the fact that such pain is not adequately nor regularly controlled for during the newborn. Application of analgesia prior to neonatal nontherapeutic circumcision takes additional physician timeprocedure, so there may be a tendency and that failure to skip it. ==Standard of care==It is now clear that boys are born with a healthy [[foreskin]] without evidence of disease. Therefore there are no indications control for infant [[circumcision]]pain can have lasting effects on the child, which is a non-therapeutic and medically-unnecessary surgical operationpossibly into adulthood.<ref name="cps1996tye2022">{{REFjournal |last=EugeneTye |first=Outerbridge |init=NC
The practice of non-therapeutic circumcision of boys has nearly died out in [[Australia]].
Pain
,Relocate section.
}}</ref>
}}
==Infant circumcision==
|accessdate=2020-11-11
}}</ref>
===History===
====Investigating pain of circumcision====
|author-link=
|volume=
|issue=
|pages= |url= |accessdate=2020-11-12}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="vanhowe2008">{{REFjournal |last=Van Howe |first=Robert S. |init=RS |author-link=Robert S. Van Howe |last2=Svoboda |first2=J. Steven |init2=JS |author2-link=J. Steven Svoboda |etal=no |title=Neonatal pain relief and the Helsinki Declaration |journal=Journal of Law, Medicine, and Ethics |location= |date=2008-12 |volume=36 |issue=4 |article=
|page=
|pages=20803-23 |url=https://www.cirpacademia.orgedu/librarydownload/pain/fitzgerald33981944/27_Van_Howe.pdf
|archived=
|quote=
|pubmedID=19094008 |pubmedCID= |DOI=10.1111/j.1748-720X.2008.00339.x |accessdate=20242021-0110-31
}}</ref>
As a result, medical doctors performed all manners of invasive, painful procedures on neonates without anesthesia or analgesia, including millions upon millions of painful circumcisions and even open heart surgery. Open heart surgery was performed with curare to paralyze the infant but without any anesthesia. Flechsig's bizarre opinion was not questioned until the 1970s. Several later researchers lines of empirical research carried out in the 1970s suggested that extreme infants can in fact feel intense pain in the newborn could cause neurological injury. [[Kanwaljeet J<ref name="vanhowe2008" /> * Anders et al. Singh Anand| Anand]] & Scalzo (20001970) concluded:{{Citation |Text=The public health importance showed that measurement of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health policies and public education campaigns must disseminate this message, it serum cortisol is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies useful indicator of pain for the growing children and adolescents who were exposed to abnormal conditions during the neonatal periodpsychological investigation in infancy. |Author=Anand & Scalzo (2000) |ref=<ref name="anand2000anders1970">{{REFjournal |last=AnandAnders |firstinit=TF |initfirst=KJSThomas F. |author-link=Kanwaljeet J. Singh Anand |last2=ScalzoSachar |first2init2=EJ |init2first2=FMEdward J.
|author2-link=
|last3=Kream
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|last4=Roffwarg
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|first5=Leon
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|title=Can adverse neonatal experiences alter brain development Behavioral state and subsequent behavior? |trans-title= |language=plasma cortisol response in the human neonate |journal=Biol NeonatePediatrics
|location=
|date=20001970-0210 |volume=7746 |issue=2 |article= |page=4 |pages=69532-827 |url=http://www.cirp.org/library/pain/anand4anders1/
|archived=
|quote=
|pubmedID=106576824323242
|pubmedCID=
|DOI=10.1159/000014197 |accessdate=20212020-0811-0913}}</ref>}}
|author-link=
|last2=WalkerHarmon |first2init2=SuellenRJ |init2first2=SRobert J.
|author2-link=
|yearlast3=2003Metcalf |titleinit3=D |first3=David |author3-link= |last4=Koenig |init4=The role of activity in developing pain pathwaysKL |urlfirst4=http://wwwKenneth L.cirp.org/library/pain/fitzgerald2/ |workauthor4-link= |last5=Wagonfeld |init5=S |first5=Samuel |author5-link= |etal=no |title=Stress and neonatal sleep |journal=Proceedings of the 10th World Congress on PainPsychosom Med |editorlocation=Dostovsky JO, Carr DB, Koltzenburg M (eds) |editiondate=1971 |volume=2433 |chapterissue=6 |pages=185491-967 |locationurl=http://www.cirp.org/library/birth/emde/ |archived=Seattle |publisherquote=ASP Press |isbnpubmedID= |quotepubmedCID=In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent. Evidence from both animal and human studies shows that alterations in the patterns of sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the somatosensory system. While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear. |accessdateDOI=2020-11-18 |noteaccessdate=
}}</ref>
|author-link=
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|last3=Brackbill
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|etal=no
|title=Psychological, psychosocial, and psychosexual aspects ofpenile Early behavioral differences: gender or circumcision |trans-title= |language=? |journal=Int J Impot ResDev Psychobiol
|location=
|date=20221976-03-2801 |volume=9 |issue= |article= |page=1 |pages=89-95 |url=httpshttp://www.naturecirp.comorg/library/psych/articlesbrackbill/s41443-022-00553-9
|archived=
|quote=
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|DOI=10.1038/s41443-022-00553-9 |accessdate=20222020-0411-2913
}}</ref>
|author-link=
|titlelast2=Neonatal pain: the evolution of an idea.Kraybill |journalinit2=The American Association of Anesthesiologists NewsletterEN |date=1998-09 |volume= |issue= |pages= |url= |accessdate=2020-11-12}}</ref> Incredible as it may seem today, his idea was accepted without question and without being tested.<ref name="vanhowe2008">{{REFjournal |last=Van Howe |firstfirst2=Robert SErnest N. |init=RS |authorauthor2-link=Robert S. Van Howe |last2last3=SvobodaPotter |first2init3=J. StevenHD |init2=JS |author2author3-link=J. Steven Svoboda
|etal=no
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* Emde Gunnar et al. (19711981) showed that recorded serum cortisol and behavior state throughout the "stress" of unanesthetized, non-therapeutic circumcision process. Serum cortisol levels and behavioral distress were found to be closely related. The authors stated:{{Citation |Text=Neonatal circumcision caused an increase in is performed without anesthesia and it is clearly stressful for the amount of non-REM sleepinfant. |Author=Gunnar et al.(1981) |ref=<ref name="emde1971Gunnar et al 1981">{{REFjournal |last=EmdeGunnar |init=RNMR |first=Robert NMegan R.
|author-link=
|last2=HarmonFisch |init2=RJRO |first2=Robert JO.
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|last4=KoenigDonhowe |init4=KLJM |first4=Kenneth LJohn M.
|author4-link=
|last5etal=Wagonfeld no |init5title=SThe effects of circumcision on serum cortisol and behavior. |first5=Samuel |author5trans-linktitle= |etal=no |titlelanguage=Stress and neonatal sleepEnglish |journal=Psychosom Med Psychoneuroendocrinology
|location=
|date=19711981 |volume=336 |issue=63 |pages=491260-775 |url=http://www.cirp.org/library/birthpain/emdegunnar/
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|quote=
|pubmedID=7291435
|pubmedCID=
|DOI=10.1016/0306-4530(81)90037-8 |accessdate=2020-11-13
}}</ref>
}}
So great was Flechsig's influence, the authors were still unwilling to use the word ''pain'' and substituted the word ''stress''.<ref name="Gunnar et al 1981"/>
* Richards, Bernal & Brackbill Marshall et al. (19761982) reported behavioral differences between American boys (studied mother-child interaction with regard to feeding behavior after circumcision without anesthesia. They found that [[circumcised) and British ]] boys (genitally intact)had more interruptions of feeding in the 24-hour period of observation.<ref name="richards1976marshall1982">{{REFjournal |last=RichardsMarshall |init=MPMRE |first=Richard E.
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|DOI=10.1001/archpedi.1980.02130190044011 |accessdate=2020-11-1312}}</ref><ref name="vanhowe2008" />
{{Citation
|Text=Neonatal circumcision is performed without anesthesia Numerous lines of evidence suggest that even in the human [[fetus]], pain pathways as well as cortical and it is clearly stressful subcortical centers necessary for pain perception are well developed late in gestation, and the infantneurochemical systems now known to be associated with pain transmission and modulation are intact and functional. Physiologic responses to painful stimuli have been well documented in neonates of various gestational ages and are reflected in hormonal, metabolic, and cardiorespiratory changes similar to but greater than those observed in adult subjects. Other responses in newborn infants are suggestive of integrated emotional and behavioral responses to pain and are retained in memory long enough to modify subsequent behavior patterns. |Author=Gunnar et al. Anand & Hickey (19811987) |ref=<ref name="anand1987"/><ref name="vanhowe2008"/>}} Gunnar et al 1981. (1988) examined the association between behavioral distress and adrenocortical activity. It was found that differences in behavioral distress did not reliably the level of adrenocortical activity. Moreover, it was found that while non-nutritive sucking reduces crying it did not reduce the adrenocortical response to the stressful stimulus of circumcision pain.<ref name="gunnar1988">{{REFjournal
|last=Gunnar
|initfirst=MRMegan |firstinit=Megan R.M
|author-link=
|last2=FischConnors |init2first2=ROJoan |first2init2=Robert O.J
|author2-link=
|last3=KorsvickIsensee |init3first3=SJill |first3init3=SherryJ
|author3-link=
|last4=DonhoweWall |init4first4=JMLee |first4init4=John M.L
|author4-link=
|etal=noyes |title=The effects of circumcision on serum cortisol Adrenocortical activity and behavior.behavioral distress in human newborns
|trans-title=
|language=English
|journal=PsychoneuroendocrinologyDev Psychobiol
|location=
|date=19811988-05 |volume=621 |issue=34 |pages=260297-75310 |url=http://www.cirp.org/library/pain/gunnargunnar1988/
|archived=
|quote=
|pubmedID=72914353378676
|pubmedCID=
|DOI=10.10161002/0306-4530(81)90037-8dev.420210402 |accessdate=2020-11-1315
}}</ref>
|author2-link=
|last3=RogersBohon |init3first3=AGConstance |first3init3=Ann G.C
|author3-link=
|last4=MooreHinman Jr |init4first4=JFrank |first4init4=JoAnnF
|author4-link=
|last5=AndersonPoland |init5first5=BRonald L. |first5init5=BarbaraRL
|author5-link=
|last6=BoxermanWakeman |first6=Stuart B.Maurice |init6=SBME
|author6-link=
|etal=no
|title=Report of the Task Force of Circumcision: II: Effects upon mother-infant interaction
|trans-title=
|language=English
|journal=Early Hum DevPediatrics
|location=
|date=19821989-10 |volume=789
|issue=4
|pages=367388-7491 |url=http://www.cirp.org/library/birthstatements/marshall2aap/#a1989
|archived=
|quote=
|pubmedID=71690322664697
|pubmedCID=
|DOI=10.1016/0378-3782(82)90038-x |accessdate=2020-11-1418
}}</ref>
|etal=no
|title=Neonatal pain criesCircumcision: effect of circumcision on acoustic features and perceived urgencythe uniquely American medical enigma
|trans-title=
|language=English
|journal=Child DevUrol Clin North Am
|location=
|date=1986-061985 |volume=5712 |issue=31 |pages=790123-80232 |url=httpshttp://www.jstorcirp.org/stablelibrary/general/wallerstein/1130355?seq=1
|archived=
|quote=
|pubmedID= 37204043883617
|pubmedCID=
|DOI=10.2307/1130355
|accessdate=2020-11-15
}}</ref> Surgical operation on infants without anesthesia continued however this clearly would not do for well over a century, at least until 1987, when the avid pro-circumcision lobby. No circumcision equals no fee for surgery. The financial gain from discontinuing non-therapeutic circumcision is just too high to discard. [[American Academy of PediatricsDan Bollinger]] was forced to issue a CYA statement (2012) estimated that called for the use total annual cost of anesthesianon-therapeutic circumcision to Americans is $3,647,000,000.<ref name="poland1987">{{REFjournalREFweb |lasturl=Poland https://www.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |firstarchived=Ronald L. |inittitle=RLHigh cost of circumcision |authortrans-linktitle= |last2language=Roberts English |first2last=Ronald JBollinger |init2first=RJDan |author2author-link=Dan Bollinger |last3publisher=Gutierrez-MazorraAcademia |first3website=Juan F. |init3date=JF2012 |author3accessdate=2020-11-link=15 |last4format=FonkalsrudPDF |first4quote=Eric W}}</ref> The avaricious American [[circumcision industry]] is simply not willing to give that lucrative income up, so a way to make non-therapeutic circumcisions in infancy acceptable had to be found. Three methods were proposed: * Application of [[EMLA]] Cream topical anesthetic. [[EMLA]] is a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%. [[EMLA]] Cream (lidocaine 2.5% and prilocaine 2.5%), applied to intact [[skin]] under occlusive dressing, provides dermal analgesia by the release of lidocaine and prilocaine from the cream into the epidermal and dermal layers of the [[skin]] and by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings.<ref>{{REFweb |init4url=EW |author4https://www.drugs.com/pro/emla.html#s-34069-link=5 |etalarchived=no |title=Neonatal anesthesiaEMLA
|trans-title=
|language=English
|journallast=Pediatrics |locationfirst= |dateauthor-link=1987-09 |volumepublisher=80Drugs.com |issuewebsite=3 |pagesdate=4462020-04-21 |urlaccessdate=https://pediatrics.aappublications.org/content/80/3/4462020-11-21 |archivedformat=
|quote=
|author-link=
|last2=Connors Werthman Jr |first2=JoanMilton W. |init2=JMW
|author2-link=
|location=
|date=19881978-0506 |volume=2192 |issue=46 |pages=297998-3101000 |url=http://www.cirp.org/library/pain/gunnar1988kirya1/
|archived=
|quote=
|pubmedID=3378676660375
|pubmedCID=
|DOI=10.10021016/dev.420210402s0022-3476(78)80386-2 |accessdate=2020-11-1516
}}</ref>
|author2-link=
|last3=Bohon |first3=ConstanceBelman |init3=CAB
|author3-link=
|last4=Hinman Jr |first4=FrankElder |init4=FPT
|author4-link=
|last5=Poland |first5=Ronald L.Ruttiman |init5=RLU
|author5-link=
|last6=Wakeman |first6=MauriceEpstein |init6=MEBS
|author6-link=
|etal=no
|title=Report Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the Task Force of Circumcision |trans-title= |language=Englishpenis |journal=PediatricsAnesthesiology
|location=
|date=19891987-1008-31 |volume=8967 |issue=43 |pages=388399-91402 |url=http://www.cirp.org/library/statements/aap/#a1989
|archived=
|quote=
|pubmedID=26646973307533
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019
|accessdate=2020-11-18
}}</ref> ====Finding an ethical way to do painful Ring block is considered the most effective analgesic procedure for neonatal non-therapeutic circumcision==== The financially and psychologically vested circumcision industry suddenly found itself in a predicament. It was now suddenly proven beyond any shadow of a doubt that newborn baby Infant boys can feel intense less pain. Medical ethics and suffer less trauma than with the standard of care now necessitated other two pain relief, however it is dangerous to give general anesthesia to neonatesreduction procedures. [[Edward Wallerstein]] (1985) had proposed that [[Routine Infant Circumcision| routine]] (non-therapeutic) circumcision of baby boys be eliminated just as routine tonsillectomy and adenoidectomy previously had been eliminated,<ref name="wallerstein1985lander1997"/><ref name="stang1997">{{REFjournal |last=WallersteinStang |first=EdwardHoward J. |init=EHJ |author-link=Edward Wallerstein |last2=Snellman |first2=Leonard W. |init2=LW |author2-link= |last3=Condon |first3=Lawrence M |init3=LM |author3-link= |last4=Conroy |first4=Mary Margaret |init4=MM |author4-link= |last5=Liebo |first5=Rhoda |init5=R |author5-link= |last6=Brodersen |first6=Laurie |init6=L |author6-link= |last7=Gunnar |first7=Megan R. |init7=MR |author7-link= |etal=no |title=CircumcisionBeyond dorsal penile nerve block: the uniquely American medical enigmaA more humane circumcision
|trans-title=
|language=English |journal=Urol Clin North AmPediatrics
|location=
|date=19851997-08 |volume=12100 |issue=12 |pages=123-32e3 |url=httphttps://wwwpediatrics.cirpaappublications.org/librarycontent/general100/wallerstein2/e3
|archived=
|quote=
|pubmedID=3883617 9233974
|pubmedCID=
|DOI=10.1542/peds.100.2.e3 |accessdate=2020-11-1518}}</ref> however this clearly would not do for {{Box|Boxtext=<big><b>However, none of the avid pro-circumcision lobbyabove three procedures totally eliminate pain. No circumcision equals no fee for surgeryA baby boy will still experience some pain and [[trauma]] despite any of those analgesic procedures. The financial gain <ref name="bellini2022 /> Prevention of pain requires protecting a boy from discontinuing elective neonatal non-therapeutic circumcision is just too high to discard. Only boys who are protected from the medically unnecessary circumcision surgery experience no pain or [[Dan Bollingertrauma]] .</b></big>}} Wallerstein (20121985) estimated that the total annual cost of non-therapeutic circumcision to Americans is $3,647,000,000.<ref>{{REFwebREFjournal |url=https://www.academia.edu/6442587/High_Cost_of_Circumcision_3_6_Billion_Annually |archivedlast=Wallerstein |title=High cost of circumcision |trans-title= |language=English |lastfirst=BollingerEdward |firstinit=Dan |author-link=Dan BollingerEdward Wallerstein |publisheretal=Academiano |websitetitle= |date=2012 |accessdate=2020Is non-11-15 |format=PDF |quote=}}</ref> The avaricious American [[religious circumcision industry]] is simply not willing to give that lucrative income up, so a way to make non-therapeutic circumcisions in infancy acceptable had to be found. Three methods were proposed: * Application of [[EMLA]] Cream topical anesthetic. [[EMLA]] is a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%. [[EMLA]] Cream (lidocaine 2.5% and prilocaine 2.5%), applied to intact [[skin]] under occlusive dressing, provides dermal analgesia by the release of lidocaine and prilocaine from the cream into the epidermal and dermal layers of the [[skin]] and by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings.<ref>{{REFweb |url=https://www.drugs.com/pro/emla.html#s-34069-5 |archived= |title=EMLAnecessary?
|trans-title=
|language=English |lastjournal=J Am Acad Child Psychiatr |firstlocation= |authordate=1985-link05 |volume=24 |issue=3 |publisherarticle=Drugs.com |websitepage= |datepages=2020-04364-215 |accessdateurl=2020-11-21http://www.cirp.org/library/pain/gunnar1984/#wallerstein |formatarchived=
|quote=
|pubmedID= |pubmedCID= |DOI= |accessdate=2021-07-0}}</ref> * and [[Dorsal penile nerve blockRobert S. Van Howe| Dorsal Penile Nerve BlockVan Howe]] (DPNB) as proposed by Kirya & Werthman Cold (19781998).<ref name="kirya1978">{{REFjournal |last=KiryaVan Howe |first=ChristopherRobert S. |init=CRS |author-link=Robert S. Van Howe |last2=Werthman JrCold |first2=Milton WChristopher J. |init2=MWCJ |author2-link=Christopher J. Cold
|etal=no
|title= Neonatal circumcision and penile dorsal nerve block—a painless procedure. |trans-title= |language=EnglishLocal Anesthesia For Infants Undergoing Circumcision |journal=J PediatrJAMA
|location=
|date=19781998-0604-15 |volume=92299 |issue=615 |article= |page= |pages=9981169-100071 |url=http://www.cirp.org/library/pain/kirya1lander/letters.html
|archived=
|quote=
|pubmedID=660375
|pubmedCID=
|DOI=10.1016 |accessdate=2021-07-08}}</s0022ref> have suggested that it would be better to abandon the practice of non-3476therapeutic infant circumcision because of the pain associated with it. The ''Daily Mail'' (782021)80386reported the pain stress of non-2 therapeutic neonatal circumcision increases the risk of [[SIDS]], and that the incidence of Sudden Infant Death Syndrome (SIDS) is lower where baby boys are not [[circumcised]].<ref name="thompson2021">{{REFnews |title=Circumcising newborn boys increases their risk of cot death due to the stress of the procedure - and could explain why it is more common in boys than girls, study finds |url=https://www.dailymail.co.uk/health/article-5998771/Circumcising-newborn-boys-increases-risk-cot-death-stress-procedure.html |last=Thompson |first=Alexandra |coauthors= |publisher=Daily Mail |website= |date=2021-07-27 |accessdate=20202021-1108-1602 |quote=
}}</ref>
|author-link=
|last2=HannallahRieder |first2=Michael J. |init2=RSMJ
|author2-link=
|last3etal=Belmanno |init3title=ABAttitudes and practices regarding analgesia for newborn circumcision |author3trans-link= |last4title=Elder |init4language=PT |author4-link= |last5=Ruttiman |init5=U |author5-link= |last6=Epstein |init6=BS |author6-link= |etal=no |title=Post-circumcision analgesia—a prospective evaluation of subcutaneous ring block of the penisEnglish |journal=AnesthesiologyPediatrics
|location=
|date=19871993-08-3110 |volume=6792 |issue=34 |pages=399541-4023 |url=https://pediatrics.aappublications.org/content/92/4/541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
|archived=
|quote=
|pubmedID=33075338414824
|pubmedCID=
|DOI=10.1097/00000542-198709000-00019
|accessdate=2020-11-18
}}</ref> Ring block is considered }} Ryan & Finer (1994) carried out a training program for physicians in the most effective analgesic procedure for neonatal newborn nurseries of the Womens' Pavilion, [https://www.albertahealthservices.ca/rah/rah.aspx Royal Alexandra Hospital], Edmonton, Alberta, Canada. After a training program, they found that 66 percent of physicians who perform non-therapeutic circumcisionneonatal circumcisions had started to use analgesia during the procedure. Infant boys feel less pain and suffer less trauma than with the other two pain reduction proceduresThis applies to one hospital in [[Canada]].<ref name="lander1997"/><ref name="stang1997ryan1994">{{REFjournal |last=StangRyan |first=Howard JC.Anthony |init=HJCA
|author-link=
|last2=SnellmanFiner |first2=Leonard WNeil N. |init2=LWNN
|author2-link=
|location=
|date=19971994-08 |volume=10094
|issue=2
|pages=e3230-3 |url=https://pediatrics.aappublications.org/content/10094/2/e3230
|archived=
|quote=
|pubmedID=92339748036079
|pubmedCID=
|DOI=10.1542/peds.100.2.e3 |accessdate=2020-11-1819}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019">[[James Loewen]] (2019). Personal communication.</ref>
Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying:{{BoxCitation |BoxtextText=<big><b>HoweverDESPITE THE DEBATE that continues over the benefits and risks of nonritual neonatal circumcision, it remains a commonly performed surgical procedure in the United States. To the best of our knowledge, none it is the only surgical procedure that is routinely performed without first administering analgesia or anesthesia. This unconscionable state of affairs exists, despite the above three procedures totally eliminate overwhelming evidence that newborns, even those born prematurely, are capable of experiencing pain. A baby boy Indeed, anyone present during a circumcision realizes that the newborn feels and responds to pain and will still experience some attempt to withdraw if unrestrained. In addition, this pain has physiologic correlates: elevated heart rate and [[trauma]] despite any blood pressure, lowered arterial oxygen saturation, and elevated levels of those analgesic proceduresadrenocortical hormones.<ref name="bellini2022 /> Prevention During the past 15 years, results of a multitude of studies have demonstrated that effective analgesia can prevent this pain requires protecting a boy from elective neonatal non-therapeutic circumcisionand ameliorate the associated stress response. Only boys who are protected from Furthermore, the medically unnecessary circumcision surgery experience no pain failure to provide anesthesia or [[trauma]]analgesia has been shown to cause not only short-term physiologic perturbations but also longer-term behavioral changes.</b></big>}} Wallerstein |Author=Maxwell & Yaster (19851999) |ref=<ref>{{REFjournal |last=Wallerstein |first=EdwardMaxwell
|init=
|first= |author-link=Edward Wallerstein |last2=Yaster |init2= |first2= |author2-link=
|etal=no
|title=Is non-religious circumcision necessary?Analgesia for neonatal circumcisionː No more studies, just do tt
|trans-title=
|language=English |journal=J Am Acad Child PsychiatrArch Pediatr Adolesc Med
|location=
|date=19851999-05 |volume=24153 |issue=3 |article= |page=5 |pages=364444-5 |url=httphttps://www.cirpjamanetwork.orgcom/libraryjournals/painjamapediatrics/gunnar1984article-abstract/#wallerstein346832
|archived=
|quote=
|pubmedID=10323622
|pubmedCID=
|DOI=10.1001/archpedi.153.5.444 |accessdate=20212020-0711-021}}</ref> and }} The [[American Academy of Pediatrics]] convened a new task force on circumcision under the chair of Carole M. Lannon, {{MD}}. That task force reversed the position previously taken under [[Robert SEdgar J. Van Howe|Van HoweSchoen]] & Cold (1998). It clearly stated that non-therapeutic infant circumcision is "not essential to the child’s current well-being." It provided an extensive discussion of procedural analgesia and said, quite strongly, that, if a circumcision is done, procedural analgesia should be provided.<refname="aap1999">{{REFjournal |last=Van HoweLannon |first=Robert SCarole M. |init=RS |author-link=Robert S. Van Howe |last2=Cold |first2=Christopher J. |init2=CJ |author2-link=Christopher J. Cold |etallast3= |first3= |init3=no |titleauthor3-link=Local Anesthesia For Infants Undergoing Circumcision |journallast4=JAMA |locationfirst4= |dateinit4=1998 |author4-04-15link= |last5= |first5= |volumeinit5=299 |issueauthor5-link=15 |articlelast6= |pagefirst6= |pagesinit6=1169 |author6-71link= |urllast7=http://www.cirp.org/library/pain/lander/letters.html |archivedfirst7= |quoteinit7= |pubmedIDauthor7-link= |pubmedCIDlast8= |DOIfirst8= |accessdateinit8=2021 |author8-07-08link= |last9=}}</ref> have suggested that it would be better to abandon the practice of non-therapeutic infant circumcision because of the pain associated with it. |first9= |init9=The ''Daily Mail'' (2021) reported the pain stress of non |author9-therapeutic neonatal circumcision increases the risk of [[SIDS]], and that the incidence of Sudden Infant Death Syndrome (SIDS) is lower where baby boys are not [[circumcised]].<ref namelink= |etal="thompson2021">{{REFnewsyes |title=Circumcising newborn boys increases their risk of cot death due to the stress of the procedure Circumcision policy statement |trans- and could explain why it is more common in boys than girls, study findstitle= |language= |journal=Pediatrics |location= |urldate=https://www.dailymail.co.uk/health/article-5998771/Circumcising-newborn-boys1999-increases-risk-cot-death-stress-procedure.html03 |lastvolume=Thompson103 |firstissue=Alexandra3 |coauthorsarticle= |publisherpage=Daily Mail |websitepages=686-93 |dateurl=2021-07-27https://pediatrics.aappublications.org/content/103/3/686 |accessdatearchived=2021-08-02
|quote=
|pubmedID=10049981
|pubmedCID=
|DOI=https://doi.org/10.1542/peds.103.3.686
|accessdate=2021-07-12
}}</ref>
|author-link=
|etal=no
|title=Attitudes A pictorial and practices regarding analgesia for newborn video guide to circumcision |trans-title= |language=Englishwithout pain |journal=PediatricsAdv Neonatal Care
|location=
|date=19932003-1004 |volume=923 |issue=42 |pages=54150-362 |url=https://pediatricsjournals.aappublicationslww.orgcom/advancesinneonatalcare/contentAbstract/922003/404000/541?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+tokenA_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.aspx
|archived=
|quote=
|pubmedID=841482412881947
|pubmedCID=
|DOI=10.1053/adnc.2003.50015.
|accessdate=2020-11-18
}}</ref>
|author-link=
|trans-title=
|language=English |journal=PedatricsCMAJ
|location=
|date=19941996-0803-15 |volume=94154 |issue=26 |article= |page= |pages=230769-380 |url=https://pediatricswww.ncbi.aappublicationsnlm.orgnih.gov/contentpmc/94articles/2PMC1487803/230pdf/cmaj00090-0027.pdf
|archived=
|quote=
|pubmedID=80360798634956 |pubmedCID=1487803
|DOI=
|accessdate=20202021-07-11-19}}</ref> (Non-therapeutic neonatal circumcisions are no longer performed in most Canadian hospitals.)<ref name="jamesloewen2019racp2010">[[James Loewen]] (2019). Personal communication.</ref> Maxwell & Yaster (1999) called on physicians to use analgesia during neonatal non-therapeutic circumcision surgery, saying:{{CitationREFdocument |Texttitle=DESPITE THE DEBATE that continues over the benefits and risks Circumcision of nonritual neonatal circumcision, it remains a commonly performed surgical procedure in the United StatesInfant Males |url=https://www. To the best of our knowledge, it is the only surgical procedure that is routinely performed without first administering analgesia or anesthesiaracp. This unconscionable state of affairs exists, despite the overwhelming evidence that newborns, even those born prematurely, are capable of experiencing painedu. Indeed, anyone present during a au//docs/default-source/advocacy-library/circumcision realizes that the newborn feels and responds to pain and will attempt to withdraw if unrestrained. In addition, this pain has physiologic correlates: elevated heart rate and blood pressure, lowered arterial oxygen saturation, and elevated levels -of adrenocortical hormones. During the past 15 years, results of a multitude of studies have demonstrated that effective analgesia can prevent this pain and ameliorate the associated stress response. Furthermore, the failure to provide anesthesia or analgesia has been shown to cause not only short-term physiologic perturbations but also longerinfant-term behavioral changesmales. |Authorpdf?sfvrsn=Maxwell & Yaster (1999)eaa32f1a_10 |refcontribution=<ref>{{REFjournal |last=Maxwell |init=
|first=
|author-linkpublisher=[[Royal Australasian College of Physicians]] |last2format=YasterPDF |init2date=2010-09-01 |first2accessdate=2021-07-11}}</ref><ref>{{REFdocument |author2title=Non-link=therapeutic circumcision of male minors |etalurl=nohttps://pool.intactiwiki.org/images/KNMG-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.pdf |titlecontribution=Analgesia for neonatal circumcisionː No more studies, just do tt |trans-titlelast= |languagefirst=English |journalpublisher=Arch Pediatr Adolesc MedRoyal Dutch Medical Association (KNMG) |locationformat=PDF |date=19992010-05-27 |volumeaccessdate=1532021-07-11}}</ref> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, and sexual functions,<ref name="cold1999">{{ColdCJ TaylorJR 1999}}</ref> so it is an irreversible, lasting injury. Bellini (2022) considered that the pain of neonatal circumcision "can have long term consequences for the developing child."<ref name="bellini2022 /> Non-therapeutic circumcision of male minors is ''not'' the standard of care. Nevertheless, some non-therapeutic circumcisions of boys will continue to be performed for religious reasons, ethnic reasons, and the[[Adamant father syndrome|issueemotional needs of parents]]. When a [[circumcision]] is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of pain and trauma.<ref name="poland1987"/><ref name="cps1996"/><ref name="lander1997"/><ref name=5"aap1999"/> (Total anesthesia cannot be used with infants.) The Australian Association of Paediatric Surgeons (AAPS) (1996) opposed the practice of infant circumcision, but recognized that it would be performed for religious, cultural, or family reasons, in which case, the non-therapeutic [[circumcision]] should be deferred for six months, so that general anesthesia may be used. The AAPS stated:<blockquote>In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.<ref>{{REFdocument |pagestitle=444-5Guidelines for Circumcision |url=https://jamanetworkwww.cirp.comorg/journalslibrary/jamapediatricsstatements/article-abstractaaps/346832 |archivedcontribution= |last=Leditshke |first=JF |quotepublisher=Australasian Association of Paediatric Surgeons |pubmedIDlocation=10323622Herston, QLD, Australia |pubmedCIDformat= |DOIdate=10.1001/archpedi.153.5.4441996-04 |accessdate=20202024-1101-2122
}}</ref>
|author-link=
|last2etal=no |first2title=The Birth of Pain |init2trans-title= |author2-linklanguage= |last3journal=MRC News |first3location= |init3date=1998 |author3-linkseason=Summer |last4volume= |first4issue= |init4article= |author4-linkpage= |last5pages=20-23 |first5url=https://www.cirp.org/library/pain/fitzgerald/ |init5archived= |author5-linkquote= |last6accessdate=2024-01-31}}</ref></blockquote> |first6= Several later researchers suggested that extreme pain in the newborn could cause neurological injury. [[Kanwaljeet J. Singh Anand|init6=Anand]] & Scalzo (2000) concluded: |author6-link={{Citation |last7Text=The public health importance of abnormal stimulation during the neonatal period cannot be overemphasized. While programs for formulating appropriate health policies and public education campaigns must disseminate this message, it is also important for these effects to be investigated, particularly with a view to developing effective therapeutic strategies for the growing children and adolescents who were exposed to abnormal conditions during the neonatal period. |first7Author=Anand & Scalzo (2000) |init7ref= |author7-link<ref name="anand2000">{{REFjournal |last8last=Anand |first8first= |init8init=KJS |author8author-link=Kanwaljeet J. Singh Anand |last9last2=Scalzo |first9first2= |init9init2=FM |author9author2-link= |etal=yesno |title=Circumcision policy statementCan adverse neonatal experiences alter brain development and subsequent behavior?
|trans-title=
|language=
|journal=PediatricsBiol Neonate
|location=
|date=19992000-0302 |volume=10377 |issue=32
|article=
|page=
|pages=68669-9382 |url=httpshttp://pediatricswww.aappublicationscirp.org/contentlibrary/103pain/3anand4/686
|archived=
|quote=
|pubmedID=1004998110657682
|pubmedCID=
|DOI=https://doi.org/10.15421159/peds.103.3.686000014197 |accessdate=2021-0708-1209
}}</ref>
}}
|author-link=
|etallast2=noWalker |titlefirst2=A pictorial and video guide to circumcision without pain Suellen |journalinit2=Adv Neonatal CareS |locationauthor2-link= |dateyear=2003-04 |volumetitle=3 |issue=2 |pages=50-62The role of activity in developing pain pathways |url=httpshttp://journalswww.lwwcirp.comorg/advancesinneonatalcarelibrary/Abstractpain/2003fitzgerald2/04000/A_PICTORIAL_AND_VIDEO_GUIDE_TO_CIRCUMCISION.2.aspx |archivedwork=Proceedings of the 10th World Congress on Pain |editor=Dostovsky JO, Carr DB, Koltzenburg M (eds) |edition= |volume=24 |chapter= |pages=185-96 |quotelocation=Seattle |pubmedIDpublisher=12881947ASP Press |pubmedCIDisbn= |DOIquote=10In common with other areas of the central nervous system, synaptic development of spinal sensory connections is experience or activity dependent.1053/adncEvidence from both animal and human studies shows that alterations in the patterns of sensory activity that can arise from tissue injury and pain in early life may disrupt normal synaptic organization within the somatosensory system.2003.50015While these studies are incomplete and more investigation is needed in this area, the potential clinical importance of neonatal plasticity in pain development is clear.
|accessdate=2020-11-18
|note=
}}</ref>
|author-link=
|last2=Sardi
|first2=
|init2=LM
|author2-link=
|etal=no
|title=Neonatal Psychological, psychosocial, and psychosexual aspects ofpenile circumcision revisited
|trans-title=
|language=
|journal=CMAJInt J Impot Res
|location=
|date=19962022-03-1528 |volume=154 |issue=6
|article=
|page=
|pages=769-80 |url=https://www.ncbinature.nlm.nih.gov/pmccom/articles/PMC1487803/pdf/cmaj00090s41443-022-00553-0027.pdf9
|archived=
|quote=
|pubmedID=863495635347302 |pubmedCID=1487803 |DOI= |accessdate=2021-07-11}}</ref><ref name="racp2010">{{REFdocument |title=Circumcision of Infant Males |url=https://www.racp.edu.au//docs/default-source/advocacy-library/circumcision-of-infant-males.pdf?sfvrsn=eaa32f1a_10 |contribution= |last= |first= |publisher=[[Royal Australasian College of Physicians]] |format=PDF |date=2010-09-01 |accessdate=2021-07-11}}</ref><ref>{{REFdocument |title=Non-therapeutic circumcision of male minors |url=https://pool10.intactiwiki.org1038/images/KNMGs41443-viewpoint-Non-therapeutic-circumcision-of-male-minors-27-05-2010-v2.pdf |contribution= |last= |first= |publisher=Royal Dutch Medical Association (KNMG) |format=PDF |date=2010022-0500553-279 |accessdate=2021-07-11}}</ref> Circumcision excises the highly functional foreskin, which provides numerous protective, immunological, sensory, and sexual functions,<ref name="cold1999">{{ColdCJ TaylorJR 1999}}</ref> so it is an irreversible, lasting injury. Bellini (2022) considered that the pain of neonatal circumcision "can have long term consequences for the developing child."<ref name="bellini2022 /> Non-therapeutic circumcision of male minors is ''not'' the standard of care. Nevertheless, some non-therapeutic circumcisions of boys will continue to be performed for religious reasons, ethnic reasons, and the[[Adamant father syndrome| emotional needs of parents]]. When a [[circumcision]] is to be performed, the standard of care requires that analgesia be provided to reduce the extreme level of pain and trauma.<ref name="poland1987"/><ref name="cps1996"/><ref name="lander1997"/><ref name="aap1999"/> (Total anesthesia cannot be used with infants.) The Australian Association of Paediatric Surgeons (AAPS) (1996) opposed the practice of infant circumcision, but recognized that it would be performed for religious, cultural, or family reasons, in which case, the non-therapeutic [[circumcision]] should be deferred for six months, so that general anesthesia may be used. The AAPS stated:<blockquote>In this event the procedure should be performed electively after six months of age. When performed, it should be carried out by a surgeon performing circumcisions on children on a regular basis with an anaesthetist using appropriate techniques. This would imply that the anaesthetist is fully trained in the art of paediatric anaesthesia, including the ability to perform caudal and penile regional or local anaesthesia. The operation should be carried out in a paediatrically orientated environment, designed to reduce the risk to the child and providing support to the parents or caregivers.<ref>{{REFdocument |title=Guidelines for Circumcision |url=https://www.cirp.org/library/statements/aaps/ |contribution= |last=Leditshke |first=JF |publisher=Australasian Association of Paediatric Surgeons |location=Herston, QLD, Australia |format= |date=1996-04 |accessdate=2024-01-2229
}}</ref>
</blockquote>
==Videos==