Neonatal circumcision: associated factors and length of hospital stay (letter)

Letters to the Editor

Re: Mansfield CJ, Hueston WJ, Rudy M. Neonatal circumcision: associated factors and length of hospital stay. J Fam Pract 1995; 41: 370-6.

To the Editor:

Prolonged hospital stays resulting from infant male circumcision¹ may only increase as perinatal hospitalizations continue to shorten. A recent case at our institution exemplifies this.

A boy born vaginally at 37 weeks gestation to a 31 year old Gravida 3 Para 3 mother with Apgars of 8 and 9 and a birth weight of 2890 grams developed grunting, flaring, and intercostal retractions at 5 hours of age. A chest x-ray confirmed transient tachypnea of the newborn, and he was placed on oxygen. He was weaned to room air by 10 hours of age. At 20 hours of age he was circumcised by the obstetrician. Following the procedure the baby had difficulty nursing resulting in a weight loss to 2595 grams (89% of birth weight). By the fourth day the baby began to nurse well and was discharged. Newborn males respond to circumcision with a marked reduction in oxygenation during the procedure,² and a cortisol surge,³ decreased wakefulness,⁴ increased vagal tone,⁵ and less interactions with their environment⁶ following the procedure. All of these hinder the maternal-infant bonding process that makes breastfeeding possible. With shortened perinatal hospitalizations, there is a rush to have boys circumcised within 24 hour hours of age to facilitate timely discharge. The health of the boy is often secondary as demonstrated by the short time from weaning to room air and the procedure being performed. The degree to which circumcision adversely affected this baby's ability to nurse is not clear, but it may be partially or completely responsible for the prolonged stay.

Not too long ago, male infants were routinely circumcised in the delivery room. This practice was discontinued only after the adverse effects were published.⁷ With shortened perinatal hospitalizations, will we regress toward delivery room circumcisions? In 1989 the American Academy of Pediatrics stated that, Circumcision is contraindicated in an unstable or sick infant… . Infants who have demonstrated an uncomplicated transition to extrauterine life are considered stable. Signs of stability include normal feeding and elimination and maintenance of normal body temperature without an incubator or radiant warmer. A period of observation may allow for recognition of abnormalities or illnesses (e.g., hyperbilirubinemia, infection, or manifest bleeding disorder) that should he addressed before elective surgery.⁸ If one follows this standard in an era of 24 hour perinatal hospital stays, are inpatient neonatal circumcisions possible?

Robert S. Van Howe, M.D.
Marshfield Clinic - Lakeland Center
Minocqua, Wisconsin

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