Babies should receive anesthesia or analgesia for circumcision, and every major medical authority recommends it. In practice, though, not every infant gets adequate pain relief. Survey data from the late 1990s found that only about 45% of U.S. physicians performing circumcisions used any form of anesthesia, and while rates have improved since then, the gap between guidelines and bedside practice has not fully closed. The story behind that gap involves outdated beliefs about infant pain, multiple competing pain-relief techniques with different strengths, and a slow-moving shift in clinical culture.
The Long History of Ignoring Infant Pain
For most of the twentieth century, mainstream medicine held that newborns did not truly experience pain. Infant surgeries, including circumcision, were routinely performed with minimal or no anesthesia well into the 1980s. Researchers tested infants’ responses to pinpricks and even electric shocks, and when babies clearly reacted, the reactions were dismissed as mere reflexes rather than evidence of suffering. The assumption was that immature brains could not process pain the way older children or adults could.1PubMed. The infancy of infant pain research: the experimental origins of infant pain denial
That view has been thoroughly overturned. Brain-imaging research on healthy full-term newborns shows that they process at least some aspects of pain in ways similar to adults.2PubMed Central. How do babies feel pain? Babies cannot verbalize what they feel, but their physiological and behavioral responses to painful stimuli are unmistakable: spiking heart rates, elevated stress hormones, distinctive high-pitched cries, and drops in vagal tone, a measure of the nervous system’s response to stress.3PubMed. Newborn pain cries and vagal tone: parallel changes in response to circumcision In controlled studies of unanesthetized circumcision, these indicators reliably shoot up during the procedure and take time to return to baseline afterward.
What Happens Without Pain Relief
Studies that include an unanesthetized control group paint a stark picture. Babies circumcised without any form of pain management show sharp increases in heart rate, prolonged crying, and measurable surges in cortisol, the body’s primary stress hormone. One double-blind trial comparing lidocaine nerve blocks to saline injections to no injection at all found that the nerve block safely and effectively reduced both behavioral distress and the cortisol stress response, while infants in the other two groups experienced significantly more of both.4PubMed. Local anesthesia for neonatal circumcision. Effects on distress and cortisol response
Pain scores in unmedicated infants consistently register in the severe range on standardized scales. In one trial comparing topical cream, nerve block, and no treatment, the babies who received no anesthesia scored significantly higher on the Neonatal Infant Pain Scale than either treatment group.5PubMed. Analgesia for neonatal circumcision: a randomized controlled trial of EMLA cream versus dorsal penile nerve block These aren’t subtle differences. The heart rate increase during circumcision in babies receiving only topical cream was roughly 49 beats per minute above baseline, compared with about 9 beats per minute in the nerve-block group.
Types of Pain Relief Available
There is no single “anesthesia for circumcision” method. Practitioners choose from several techniques, each with distinct advantages and limitations.
- Dorsal penile nerve block (DPNB): A small injection of local anesthetic (usually lidocaine) at the base of the penis, numbing the main nerve supplying the foreskin. This is the most widely used injection-based technique. It works well for much of the procedure but has been shown to be less effective during the initial foreskin-separation and incision stages.
- Ring block: An injection that encircles the base of the penis, blocking nerves on all sides. Trials have found that ring block provides more consistent pain control throughout every stage of circumcision, including separation and incision, compared with DPNB or topical cream alone.6PubMed. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial
- Topical anesthetics: Creams like EMLA (a mix of lidocaine and prilocaine) or concentrated lidocaine cream applied to the foreskin before the procedure. These reduce pain compared with no treatment but are generally less effective than nerve blocks, especially during the most painful steps. A trial using 30% lidocaine cream found it safely reduced stress behaviors and prevented the rise in stress hormones seen in the placebo group.7Pediatrics. Safety and Efficacy of a Topical Anesthetic for Neonatal Circumcision
- Sucrose pacifiers: A pacifier dipped in concentrated sugar water, given to the infant to suck during the procedure. This provides real, measurable comfort but is considered an adjunct, not a standalone method.
A randomized trial that directly compared ring block and DPNB in terms of parental satisfaction found both techniques performed similarly, with parents reporting comparable satisfaction with pain control and overall anesthesia.8PubMed. Comparison of the effects of ring block and dorsal penile nerve block on parental satisfaction for circumcision operation in children: randomized controlled trial For low-birth-weight infants specifically, DPNB has been shown to be safe and effective, which matters because topical creams can cause more skin irritation in smaller babies.9JAMA Pediatrics. Dorsal Penile Nerve Block vs Topical Placebo for Circumcision in Low-Birth-Weight Neonates
Why Combining Methods Works Better
No single technique eliminates pain entirely. Nerve blocks do not always cover every stage of the procedure, and topical creams alone leave meaningful pain unaddressed. The evidence increasingly supports using multiple methods together. Research on combined approaches has shown clear benefits when two or more techniques are used simultaneously, such as a nerve block alongside a sucrose pacifier.10PubMed. Pain management for neonatal circumcision
A randomized controlled trial tested this directly by comparing EMLA cream plus sucrose alone against EMLA plus sucrose plus DPNB, and against EMLA plus sucrose plus ring block. All three multimodal combinations outperformed the control group substantially. But the triple combination of ring block, EMLA, and sucrose produced the lowest pain scores overall and was significantly more effective than the other two combinations.11PubMed. Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial The takeaway is that stacking methods addresses the gaps that any single method leaves, particularly during the most painful moments of foreskin separation and clamping.
What the Guidelines Actually Say
The American Academy of Pediatrics’ 2012 policy statement on circumcision is explicit: adequate analgesia should be provided whenever newborn circumcision is performed. The AAP states that non-pharmacologic methods like positioning and sucrose pacifiers alone are not sufficient to prevent procedural pain and should be used only as add-ons to pharmacologic pain relief, not as the sole method. For low-birth-weight infants, the AAP specifically recommends penile nerve block techniques over topical creams because of the higher risk of skin irritation with creams in that population.12AAP Publications. Male Circumcision
This position is echoed broadly. A review of policies from medical and religious authorities worldwide found agreement that anesthesia should be administered for neonatal circumcision. Even religious authorities whose traditions prescribe circumcision have not found reasons to oppose the use of pain relief during the procedure.13PubMed. Anesthesia for ritual circumcision in neonates
The Gap Between Recommendation and Practice
Guidelines and reality do not always match. A large U.S. survey published in 1998 found that only 45% of physicians performing circumcisions used any anesthesia at all. The rates varied strikingly by specialty: 71% of pediatricians used it, compared with 56% of family practitioners and just 25% of obstetricians.14PubMed. Circumcision practice patterns in the United States Among those who did use anesthesia, 85% chose DPNB. Physicians who skipped pain relief most commonly cited concern about adverse drug effects (54%) or a belief that the procedure simply did not warrant anesthesia (44%).
That survey is now over two decades old, and training programs have since put more emphasis on pain management. Recently trained pediatricians and family practitioners in that same survey were already more likely to use anesthetics than their older colleagues. Still, the picture outside hospital settings and outside wealthy countries remains uneven. Data from a more recent parental satisfaction study found that around 17% of circumcisions in their sample were performed by untrained practitioners without any anesthesia.15PubMed Central. Factors Affecting Parental Satisfaction after Male Circumcision The logistical barrier is real, too: providing local anesthesia for circumcision requires specific skills, and in many settings there are not enough trained pediatric providers to meet demand, especially when families request the procedure on a particular day for religious reasons.13PubMed. Anesthesia for ritual circumcision in neonates
What Parents Can Do
If you are considering circumcision for your baby, the single most important question to ask the practitioner is what specific pain management they plan to use. “We give them something” is not a sufficient answer. You want to hear the names of actual techniques: a nerve block (DPNB or ring block), a topical anesthetic, and ideally both alongside a sucrose pacifier. If the practitioner says they rely only on a sugar pacifier, or only on swaddling, that does not meet current guidelines.
You should also ask about the practitioner’s volume and training. Nerve blocks require a brief injection, and like any injection-based technique, they carry minor risks. Small bruises at the injection site are common and harmless. Serious complications from local anesthesia for circumcision are rare. A series of over 500 consecutive circumcisions performed under local anesthesia in infants under six months found no infections, no re-operations for bleeding, and only one case of a complication requiring a follow-up procedure.16PubMed Central. Avoidance of general anesthesia for circumcision in infants under 6 months of age using a modified Plastibell technique
General anesthesia, the kind that puts you completely under, is not typically used for newborn circumcision. It carries higher risks in very young infants, and the procedure is short enough that local methods work well. General anesthesia is sometimes used for older infants or toddlers who need circumcision for medical reasons, but that is a different clinical scenario handled by a surgical team.
Does the Circumcision Device Matter for Pain?
Three devices dominate newborn circumcision in the United States: the Mogen clamp, the Gomco clamp, and the Plastibell device. Each works differently and takes a different amount of time. A comparative analysis found statistically significant differences in subjective pain reports across the three methods, though complication rates and emergency visits were similar regardless of device.17PubMed. Comparative Analysis of Postoperative Outcomes Following Various Neonatal Circumcision Techniques: Mogen Clamp, Gomco Clamp, and Plastibell Device The Mogen clamp is generally the fastest technique, which means less total time the infant is experiencing the procedure, while the Plastibell involves a ring that stays on for several days and falls off on its own. Parents sometimes have a preference, but the choice of device is less important for pain management than the choice of anesthesia method applied alongside it.
Can Circumcision Pain Affect Babies Later?
One of the more striking findings in this area is that the pain of circumcision may leave a measurable imprint on how babies respond to pain months afterward. A study tracked boys at their four-to-six-month vaccinations and found that circumcised infants showed stronger pain responses to the needle than uncircumcised boys. Circumcised babies who had received no anesthesia during their circumcision cried longer and had higher pain scores during vaccination than uncircumcised infants. Circumcised babies who had received EMLA cream during the procedure fell somewhere in between, suggesting the topical anesthetic partially blunted whatever sensitization occurred.18PubMed. Effect of neonatal circumcision on pain response during subsequent routine vaccination
An earlier study using a smaller sample reached a similar finding: circumcised boys had higher observer-rated pain scores and cried longer after vaccination injections than uncircumcised boys.19PubMed. Effect of neonatal circumcision on pain responses during vaccination in boys These results do not mean circumcision causes permanent pain sensitivity, and the long-term significance beyond infancy is not established. But they do reinforce the argument that untreated neonatal pain is not a trivial event that the baby simply forgets. The researchers behind the vaccination studies explicitly recommended treating circumcision pain to help prevent this kind of altered response.
The Sucrose Pacifier Question
Parents sometimes hear that a sugar pacifier is all a baby needs, and it is worth understanding what sucrose actually does and does not accomplish. A randomized trial comparing sucrose pacifiers, DPNB, and no treatment found that sucrose provided real pain relief compared with nothing, particularly in the early stages of circumcision. Heart rates were about 10 beats per minute lower in the sucrose group than in the untreated group, and babies given sucrose lost less monitoring data to thrashing. But DPNB was substantially more effective, with a heart-rate advantage of about 27 beats per minute over the untreated group.20Archives of Pediatrics & Adolescent Medicine. Neonatal Circumcision: Randomized Trial of a Sucrose Pacifier for Pain Control
Sucrose works as a comfort measure, probably by triggering endogenous opioid release in the baby’s brain, but it does not numb tissue. It takes the edge off distress without blocking the pain signal itself. That is why the AAP classifies it as an adjunct rather than a primary analgesic. A sucrose pacifier on top of a nerve block is a good combination. A sucrose pacifier instead of a nerve block is not meeting the standard of care.
Ritual and Religious Circumcision
A significant share of circumcisions worldwide are performed for religious or cultural reasons outside hospital settings. Jewish brit milah ceremonies traditionally take place on the eighth day of life and are performed by a mohel, while Islamic khitan varies by community and timing. The question of anesthesia in these contexts has generated debate, but the medical and religious consensus has largely converged. Reviews of the topic have found that religious authorities across traditions have not identified any religious prohibition against using anesthesia during circumcision.13PubMed. Anesthesia for ritual circumcision in neonates The practical obstacle is that many traditional circumcisers are not trained to administer nerve blocks, and the scheduling demands of ritual circumcision do not always align with the availability of medical professionals who are. Some communities have addressed this by training mohels in local anesthesia techniques or having a physician provide the nerve block before the mohel performs the procedure.