Is it painful? That's a question many parents ask as they consider whether to have their newborn son circumcised. Circumcision - the removal of the sheath of skin (foreskin) covering the end of the penis - is still performed on the majority of boys born in the United States. Until recently, parents' concerns about pain were usually answered with these responses:

* Babies don't seem to feel pain or remember it the way older children and adults do, so pain relief for circumcision isn't necessary.

* Since circumcision is such a brief procedure, it's not justifiable to expose a baby to even minor risks inherent in using anesthetics or other pain medications.

* If you use an injection to anesthetize the penis, the injection itself will cause discomfort; therefore, is it really justifiable? Research of pain in newborns has led to a reassessment of these beliefs. Improved techniques for anesthesia and pain relief, initially used for operations on babies, are now being used for procedures such as circumcision.

Managing circumcision pain "If a baby is having a circumcision, there are options available to reduce pain," says Robert V. Johnson, M.D., a neonatologist at Mayo Clinic, Rochester, Minn., and editor-in-chief of "Mayo Clinic Complete Book of Pregnancy & Baby's First Year." Currently, local anesthetics offer the most effective pain management for circumcision, according to Dr. Johnson. These include:

* Dorsal nerve block - The anesthetic lidocaine is injected at the base of the penis, numbing pain impulses traveling from the circumcision site to the brain. "Though the injection itself causes some discomfort, it makes the circumcision less painful," Johnson says. Dorsal nerve block is commonly used for circumcisions performed at Mayo Clinic.

* Topical anesthetics - Lidocaine-prilocaine (EMLA) skin cream is similar to the medication injected in the dorsal nerve block. EMLA cream can be applied to the foreskin an hour before the procedure, numbing the area to be circumcised. Although the cream isn't in widespread use for circumcision, it appears to have potential. A study published in the April 24, 1997, issue of the New England Journal of Medicine reported that the cream reduced the pain of circumcision as measured by facial activity, the duration of crying and heart-rate changes. "EMLA cream is better than no pain relief, but it seems less effective than the dorsal nerve block," Johnson says.

* Combination - A third option is to apply EMLA cream one hour before the circumcision, followed by a dorsal nerve block just prior to the procedure. One simple but apparently effective way to reduce pain during circumcision (or other brief, painful procedures) is to give the baby a pacifier that has been dipped in sugar water. "We're not sure why this helps," Johnson says. "Perhaps it distracts the baby's attention from the pain." Analgesics (pain relievers) like acetaminophen have also been used, but there is not yet proof they are effective.

Does a baby remember pain?

"We still don't really know the answer to the question," Dr. Johnson says. However, he refers to a study published in the March 1, 1997, issue of the British medical journal Lancet. Researchers observed infant responses to injection for childhood vaccinations at 4 or 6 months of age. Infants who had been circumcised without pain management showed a stronger response to later injections than uncircumcised infants or infants who had received pain relief during circumcision. Parents should ask The use of pain management for newborn circumcision isn't universal, according to Dr. Johnson. "If parents request circumcision for their son, I would recommend that they also request analgesia for the procedure." For more information [PARA]* The Third Trimester - Decisions to Make [PARA]* Editor's Notes - Strongly held opinions!

Robert V. Johnson, M.D. O@sis Associate Medical Editor Dr. Robert V. Johnson is a board-certified neonatologist--a pediatrician who specializes in the care of newborns. In his day-to-day work at Mayo Clinic in Rochester, Minn., he is part of a large team of physicians, nurses, respiratory therapists and others who care for high-risk newborns. As head of the section of Neonatology he has a particular interest in the use of computerized data collection as an important tool in improving the outcomes of babies who require newborn intensive care. He is actively involved in teaching newborn care to resident physicians at Mayo and has served as director of the Pediatric Residency Program. Dr. Johnson is editor-in-chief of Mayo Clinic Complete Book of Pregnancy & Baby's First Year. This book was guided by the views of expectant and new parents from the planning stages through writing and final editing. Dr. Johnson worked with a group of more than 100 colleagues at Mayo Clinic in creating this book. Dr. Johnson is associate medical editor for Mayo Health O@sis and heads the section of pediatric health information. Dr. Johnson says, "An important part of our work is helping parents and children understand the medical concerns they are dealing with. It was a wonderful opportunity to do this through our book. Now we have another exciting challenge--to do this in an online format."

- "Editor's Notes - Strongly Held Opinions" Strongly held opinions! Dear Reader, Some health-related topics generate strong emotional responses from patients and physicians. These topics may have some common characteristics. * A degree of medical uncertainty - health-care professionals don't agree on what the best recommendation should be. * Issues involving deeply held feelings of what's right and what's wrong - for example, contraception decisions; abortion. * There may be a conflict between the individual and society - when should medical decisions be a private matter between individuals and their physicians and when should they be determined by public policy? For example: testing for and reporting of certain infectious diseases such as HIV or tuberculosis; euthanasia. One topic that generates strong opinions is whether newborn males should be circumcised. In 1994, I served as editor-in-chief of "Mayo Clinic Complete Book of Pregnancy and Baby's First Year." Following publication, I received a number of thoughtful letters from individuals and organizations who felt that certain views expressed in our book should be modified in future editions. The issue of circumcision generated more correspondence than any other. Many writers strongly expressed the view that circumcision is an elective and unnecessary procedure. They felt that infant circumcision is morally wrong - that it should only be done on adults who can make an informed personal choice, and that parents should not make this decision on behalf of their child. Others expressed strongly held views that circumcision is a decision that should be made by parents because they know best the personal and religious considerations of their family. Doctors should explain the medical aspects of circumcision and the techniques used, but the decision should left to the parents. On this week's Newsstand is an article entitled "Pain management for circumcision - An update." We welcome your comments. Send them to Talkback and we'll publish some of your responses. [PARA]Robert V. Johnson, M.D.[NL]Associate Medical Editor, Mayo Health O@sis