Letter. Rebuttal of Edgar J. Schoen

The editor has asked Dr. Ingela Bollgren, Sachs' Children's Hospital and Prof. Jan Winberg, Karolinska Hospital to comment on Dr. Schoen's letter.

Routine neonatal circumcision has been a matter of controversy in the United States during the last decade, reflected by the fact that not even the Task Force on Circumcision was able to give definite recommendations but concluded that circumcision has advantages as well as disadvantages. Dr. Schoen, being the chairman of the Task Force, has recently presented a broad survey in the New England Journal of Medicine, advocating general and unanaesthetized circumcision of newborns¹. However in the same issue of NEJM another member of the task force, took an opposite view, i.e. circumcision is unwarranted². Asked by the editors of Acta Paediatrica we want to make the following comments to Dr. Schoen's letter.

We think that the discussion of routine neonatal circumcision should focus on the prevention of childhood diseases. With regard to prevention of diseases in adult men, it is in our opinion more fair to postpone a decision till the young man may make a choice of his own.

Balanoposthitis is reduced in circumcised small boys, but even a proportion of circumcised boys have penile problems³. The pyelonephritis preventing effect of neonatal circumcision, explained by the decrease in periurethral colonization with potentially uropathogenic bacteria seems well documented^4,5. However, we think that circumcision is an unphysiologic way to solve this problem and we have recently discussed these aspects⁶. It is unprecedented in medical history that a common and potentially lethal disease can be prevented by extirpation of a piece of healthy tissue of universal occurrence in males. we suggested that the effects of one unphysiological intervention, e.g. circumcision counterbalance those of another, e.g. colonization of the baby's gastrointestinal tract and genitals in maternity units by Escherichia coli strains of non-maternal origin, to which the baby has no passive immunity. We suggest that aspects of preputial bacterial colonization should be better studied before advice is given about the routine circumcision.

The situation is different in babies at high risk for infections and severe renal damage, e.g. those with urethral valves or uterocele where the obstructions should be eliminated immediately, or with grade IV-V vesicouteric reflux, especially when associated with intrarenal reflux. These conditions are now often diagnosed immediately postnatally as a consequence of antenatal sound examinations. In this selected group of patients preputial colonization might constitute a seizable [sic] risk, where extirpation of the prepuce breaks an important link in the chain of events leading to UTI. We feel that circumcision in these instances should be considered as an alternative to long-term antibiotic prophylaxis.

There are also two ethical aspects which should be considered before routine circumcision is recommended. Firstly, it it justifiable to operate on 100 babies to prevent infection in one, or to operate on 1 000 babies to prevent renal scarring in one or two (assuming that 1/5 or 1/10 of those infected will attract a scar)? Secondly, when mass circumcision in applied, caution or even reluctance against anaesthesia is advocated - the risks (and costs?) would be too high¹. In the debate on circumcision in NEJM, provoked by the papers by Dr. Schoen and Dr. Poland, it was pointed out that an Ethics Committee on Experimental Animals would not accept a procedure such as circumcision on laboratory animals without adequate anaesthesia⁹. If circumcision is used in only a few selected cases, as suggested above, appropriate pain relief can be given. Thus the human rights not to be subjected to unnecessary pain will be recognized and defended also in the newborn, who as a matter of a fact reacts more intensely to painful stimuli than other age groups do^7,8.

References

Schoen EJ. Sounding Board. The status of circumcision of newborns. N Engl J Med 1990; 322:1308-12.
Poland RL. The question of routine neonatal circumcision. N Engl J Med 1990; 322:1312-15.
Fergusson DM, Lawton JW, Shannon FT. Neonatal circumcision and penile problems: an eight year longitudinal study. Pediatrics 1988: 81: 537-41.
Wiswell TE, Miller GM, Gelston HM, Jones SK. Clemmings AF. Effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatrics 1988; 113:442-46.
Fussell EN, Kaack B, Cherry R, Roberts JA. Adherence of bacteria to human foreskins. J Urol 1988; 140:997-1001.
Winberg J, Bollgren I, Gothefors L. Herthenius M. Tullus K. The prepuce: a mistake of nature? Lancet 1989: i:598-99.
Fitzgerald M. Millard C. McIntosh N. Cutaneous hypersensitivity following peripheral tissue damage is newborn infants and its reversal with topical anaesthesia. Pain 1989: 39:31-36.
Fitzgerald M. McIntosh N. Pain and analgesia in the newborn. Arch Dis Child. 1989; 64:441-43.
Rieder MJ. Letter to the Editor. N Engl J Med1990:323:1205.

Citation:

Bollgren I, Winberg J. Letter. Rebuttal of Edgar J. Schoen. Acta Paediatrica Scand. 1991;80:575-7.

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