Hygienic Care in Uncircumcised Infants

The merits of circumcision have been widely debated in the literature.^1-4 As studies have failed to show benefits from the procedure, the value of routine circumcision has been questioned.^5-6 In 1975, the American Academy of Pediatrics Ad Hoc Committee on Circumcision stated that a program of education leading to continuing good personal hygiene would offer all of the advantages of routine circumcision without the attendant surgical risk.⁷ No such educational program was outlined by the committee, and a review of the pediatric literature revealed no information concerning what constituted good hygiene, nor what advice mothers of uncircumcised infants should be given.

The purpose of the study was to determine what advice pediatricians give and how mothers interpret that advice.

METHODOLOGY

A brief questionnaire was mailed to all 146 members of the local pediatric society, excluding house-staff. Multiple choice questions were asked concerning the respondents opinion about the incidence of circumcision, the incidence of infections in uncircumcised children, and when the foreskin could first be easily retracted. A written response was required to a single question concerning the respondents advice about the careof uncircumcised infants.

A telephone survey of new mothers was conducted. Contacts were made by reviewing the birth announcements of Salt Lake Citys two newspapers. The names of parents of infants born six months prior to the study were then matched with the numbers in the local telephone directory. The announcements of consecutive days were reviewed. Calls were made both during the day and evening hours until 108 mothers were surveyed. An additional 100 calls were made attempting to survey more mothers of uncircumcised infants. When this procedure still failed to yield an adequate number of uncircumcised infants, the records of a local hospital were reviewed. The parents of infants with no record of circumcision were contacted when a telephone number was available.

RESULTS

Of the 146 questionnaires mailed to pediatricians, 90 were returned, giving a response rate of 62%. Sixty-two percent of the respondents stated they counseled routinely about circumcision; 38% did not. Several wrote unsolicited comments indicating that the obstetrician had already circumcised the infants before they had an opportunity to speak with the mother. When asked to estimate the incidence of uncircumcised males in their practice, most said fewer than 5% were uncircumcised (Table 1). Sixty-one percent felt the incidence of circumcision over the past five years had remained the same; 4% felt it had increased. Seven percent did not respond. Most shared the opinion that the incidence of infection in uncircumcised males was low (Table 2). In response to the question, At what age should the foreskin retract easily in most children? 47% responded that this would occur by the age of 6 months, while an additional 20% said this would occur by the age of 1 year (Table 3).

TABLE 1. Incidence of Noncircumcision as Estimated by Pediatricians.

    No. of Respondents        Estimated Incidence

        55 (61%)                     <5%
        17 (19%)                      5%-10%
        18 (20%                      >10%
Total   90

TABLE 2. Incidence of Balanitis in Uncircumcised Infants as Estimated by Pediatricians

    No. of Respondents         Estimated Incidence
 
        41 (45%)                      0%
        41 (45%)                      1%-10%
         0                            
         8 (10%)                      No response
Total   90

The advice given for hygienic care varied greatly. Some (10%) felt it was necessary to manipulate the foreskin while the child was in the newborn nursery. Others (3%) claimed that the foreskin should never be retracted. Most stated that they instructed the mothers to retract the foreskin and clean the child each time he was bathed, but our data showed that few knew when this could readily be accomplished. (Table 4).

In the phone survey, 108 mothers were contacted. Of these infants 105 were circumcised; three were not. Ninety-two (85%) of the mothers of circumcised infants stated that they had been given instructions for hygienic care. Of those receiving advice, 80% had been told specifically to retract the foreskin from the glands and clear underneath. The remaining 20% had been instructedsimply to bathe the penis daily.

The difficulty in locating uncircumcised infants was surprising. Fifteen mothers of uncircumcised infants were eventually contacted. The incidence of circumcision in the state of Utah is about 87% (T. J. Metcalf et al, unpublished observation, 1979), yet only three uncircumcised infants were found in more than 200 telephone contacts. No telephone numbers were listed for approximately 75% of the parents whose children had no hospital record of circumcision. People with either unlisted telephone numbers or no telephone numbers tend to be middle-income, young, or transient.^-9 The correlation between noncircumcision and the lack of a telephone number suggests a corresponding distribution of parents who do not have their infants circumcised.

Of the15 mothers whose infants were not circumcised, eight were given no advice concerning hygienic care. The remaining seven mothers were told to retract the foreskin daily while bathing the baby. None was told when the foreskin should retract easily. Physicians freed adhesions and retracted the foreskin in seven infants, one during the newborn period and an additional six prior to the age of 6 months. Six (40%) of the mothers were dissatisfied with the outcome. They felt hygienic care was difficult, and would choose to have their next male infant circumcised.

DISCUSSION

The recommendations of the American Academy of Pediatrics have made little impact on the incidence of circumcision in the state of Utah; over the past five years the number of uncircumcised males has remained relatively small (T. J. Metcalf et al, unpublished observations, 1979). Thus pediatricians are not often faced with the need for giving advice to mothers of uncircumcised infants. This study reveals that pediatricians routinely give excellent advice to mothers of circumcised infants, and that mothers seemed to follow that advice. Few mothers of uncircumcised infants, however were given adequate information.

Most pediatricians in our study did not know when the foreskin should retract easily. A study by Gairdner¹⁰ in 1949 showed that the foreskin was retractable in 25% of 6-month-old infants, 50% of 1-year-old infants, 80% of 2-year-old children, and 90% of 4-year-old children. A study by Oster¹¹ supports Gairdner's findings, indicating that a tight prepuce or phimosis was rare in Danish boys between the ages of 6 and 17. As can be seen in Table 4, the percentage of pediatricians correctly estimating the age when the foreskin can be retracted increased with the number of years in practice, an indication that this knowledge was learned empirically rather than during pediatric training.

TABLE 3. Pediatricians Opinion of Age When Foreskin Should Retract Easily in Most Children

Estimated Age When                Years in Practice                Total
Foreskin Retractable        <5         5-10         >10

Newborn                      2          4            3              9 (10%)
4-6 wk                       0          2            0              2 (2%) 
6 mo                         6          5           20             31 (35%)
12 mo                        3          6            9             18 (20%)   
18 mo                        1          0            2              3 (3%)
2 yr or older                0          5           15             20 (22%)
Never                        1          1            1              3 (%3)
No response                  3          0            1              4 (5%)
Total                       16 (18%)   23 (26%)     51 (56%)       90

TABLE 4. Pediatricians Correctly Estimating Age When Foreskin Should Retract Easily in Most Children

No. of Pediatricians Giving               Years in Practice
       Correct Estimate
       0/16 (0%)                                <5
       5/23 (21%)                               5-10
      15/51 (29%)                               >10
Total 20/90 (22%)

The seven mothers whose infants foreskins were retracted by the physicians expressed concern and distress over the practice. In two infants this procedure was repeated. These parents stated that even after the foreskin had been retracted in the office, it had again adhered to the glans despite efforts to clean the infant daily. Gairdner's data indicate that this practice is unnecessary. The discomfort of the above described procedure and the anxiety of providing care without instructions caused 40% of these parents to state that they would have the nextmale infant circumcised.

The only written information the authors could find concerning hygienic care of uncircumcised infants was this statement found in The Parenting Advisor: …retract the foreskin gently and return the foreskin to its normal position to prevent constriction and swelling.¹²

As demonstrated in this study, the need for recommendations concerning hygienic care of uncircumcised children is indicated by the pediatricians lack of knowledge concerning uncircumcised children, parental dissatisfaction stemming from the difficulty of caring for their infants without adequate advice, and the lack of written information about hygienic care in the uncircumcised infant.

RECOMMENDATIONS

The authors make the following recommendations for hygienic care in uncircumcised infants:

1. The foreskin should not be manipulated in the newborn nursery.
2. Parents should be given the above quoted advice found in The Parenting Advisor.
3. When the child is 4 years old, the mother should show the child how to retract the foreskin and wash. The child can then be expected to care for himself after a period of adult supervision.
4. The office practice of freeing adhesions and subsequent retraction of the foreskin is unnecessary.

Received for publication May 19, 1980; accepted July 23, 1980.
Reprint requests to (L.M.O.) Department of Pediatrics, UCLA Medical Center, 10833 Le Conte Ave, Los Angeles CA 90024.

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