Circumcision in the Newborn Period

1975 Statement by the Canadian Paediatric Society

Note:

This file contains the original 1975 policy statement of the Canadian Paediatric Society regarding male neonatal circumcision and two supplements which were issued in 1982 and 1989. These policy statements have been superseded by the 1996 policy statement,  Neonatal Circumcision Revisited. These statements, however, are retained as reference material.

Statement

1. It may be expected that local customs will influence any decision for or against routine circumcision of male infants during the first few days of life, For instance. this is rarely done in Britain, whereas in parts of California it is quite common, perhaps as an index of social status or virtually as universal policy in some large hospitals.
2. Nevertheless, there is no medical indication for circumcision during the neonatal period.
    [ Note: Standards and Recommendations for the Care of the Newborn Infant in Hospital. American Academy of Pediatrics 1972, Evanston, Illinois.] 
3. Any claim for the presence of phimosis as a reason for circumcision during the first four years fails to acknowledge the natural history of tissue differentiation in the region destined to develop the cleavage between the prepuce on the outside and the glans deep to it, or of the range of variation in the rate of atrophy or redundant foreskin within that age group.
4. Any assertion that a policy against routine circumcision has predisposed infants to phimosis or paraphimosis cannot be valid without first ruling out the possibility that the infants in question had experienced the common practice of forceful retraction of the prepuce just after birth, using the fingers alone or aided by a probe to break down the adhesions—really the undifferentiated tissue, and perhaps a haemostat to stretch the preputial orifice. The scarring effects of such a manipulation, usually an unrecorded procedure, are more hazardous than either circumcision itself or unmolested non-circumcision.
5. Such unrecorded manipulations and subsequent fibrosis have not been exonerated as the initiating cause of troublesome collections of smegma which are sometimes found in children considered prone to the complications of neglected personal hygiene.
6. The more immediate hazards of circumcision include infection which may be minor, or which could lead to gangrene or general sepsis, severe haemorrhage, mutilative deformity of the penis, or rarely, a procedural misadventure requiring partial amputation of the penis.
7. Later complications include the excoriation of the exposed edges of the glans from a diaper dermatitis, or a similar lesion at the urethral meatus, resulting in stenosis in some cases. The narrowed passage may produce obstructive uropathy and its more serious consequences.
8. There seems to be little basis for prescribing routine circumcision because of a fear of cancer of the uncircumcised prepuce developing in a septuagenarian. It is an infrequently encountered lesion, easy to detect and unlikely to spread. This remote possibility of a curable condition of very old age stands in sharp contrast to the established hazards of neonatal circumcision.
9. There is no foundation to the belief that in adult life, circumcision adds or reduces tactile sensation in the adult penis during intercourse.
    [ Note: This statement has been disproved. See  The Ridged Band: Specialized Sexual Tissue.] 
10. The claim that circumcision is associated with a reduced prevalence of venereal diseases in the adult male, or a decreased frequency of cervical carcinoma in the sexual partner, has not been established as a cause-and-effect relationship.
11. Although the desire for conformity has sometimes influenced a parent's or doctor's decision, intended to ensure that the newborn infant in question will grow up to have genital resemblance with his father and brothers, any important conformity must now be considered in relation with the peer group in a society with a rapidly diminishing demand for circumcision.
12. Because a decision to circumcise in the newborn period must be ascribed to social rather than medical reasons, it would be even more inappropriate in an infant who is destined for adoption or other placement to impose the operation before the transition into the new family setting has been completed. A natural parent giving up a child for such placement should not be empowered to authorize circumcision, nor should a social agency be responsible for such a decision on behalf of the infant. Such an agency would be overstepping any mandate provided by its Provincial Protection of Children Act.
13. Certainly,  no circumcision should be performed on an infant with a hypospadias, or any other genital abnormality no matter how slight, until a careful diagnosis has been made, together with an assignment of sex if necessary, and a detailed plan of management has been developed.
14. Although there is some unresolved contention about the propriety of performing circumcision during the first few days of life, there is no disagreement in condemning the practice of carrying out this procedure while the infant is still in the delivery room. During his first few hours, he must be protected against the stress of pain and the possible exposure to cold, each of which may interfere with the success of the cardiovascular and pulmonary adjustments necessary for adequate respiratory function after birth. Also, so soon after birth, there is a greater chance of inadequate awareness, should there be a familial bleeding tendency that would have been a positive contra-indication for circumcision.
15. If circumcision is to be carried out later during the first few days, it should be performed by the person most adept at the procedure, and most readily available and capable to deal with any early complications. If paediatricians are showing leadership in curtailing the numbers of mutilative operations of questionable benefit, it is likely that uninformed parents may turn to their family physician or obstetrician to perpetuate such an obsolete operation. Therefore, discussion of this subject should be encouraged among all who may deal with parents, both among the medical and nursing professions.
16. The actual technique of circumcision, whether by the classical method with scalpel and sutures, or using the Gomco clamp, seems less important than the individual choice according to the individual operator's skill and preference. Care should be taken, however, to ensure that the bell in socket of the clamp has not worn to such a degree as to allow less than total crushing force evenly distributed along the circumference of the prepuce. The reported misadventure in the literature, and the lack of any impressive review, should make one reluctant to recommend the disposable Plastibell device for this operation.
17. Although the neonatal infant is given only a sugar ball to suck on as a soother against the pain, no one would perform a circumcision on a two-month old infant without first administering anaesthesia. This seems incongruous in the absence of any known neurophysiological difference between these two age groups that would justify such a discrepancy in approach. If there is validity in this consideration, the alternatives would have to be an acceptance of the added risk of anaesthesia for each newborn infant undergoing circumcision, or else the conclusion that such a risk or the vagal and psychological consequences of withholding pain relief should remove any remaining defence of the circumcision routine.
18. The appropriate time in which to enlighten prospective parents about contemporary concepts of circumcision is during prenatal care. Therefore, family physicians. obstetricians and nurses should be invited to consider these facts and opinions.
19. In the search for ways in which to stem the rising cost of health care, the removal of such an unnecessary procedure as a routine practice can be calculated as a major saving in terms of direct charges - professional fees, nursing and other hospital services and supplies, and sometimes the length of hospital stay - and secondary costs resulting from any recognized clinical complications.
20. Adoption of the foregoing concepts should result in a sharper decrease in the percentage of infants circumcised, and thus a reason to convert a hospital circumcision room to a more useful function, e.g. a parents' room for privacy with their baby, a breast feeding room for the mother discharged before the infant, or if in an appropriate area, a laboratory supporting foetal and neonatal intensive care. The greatly reduced numbers of circumcisions may be performed in facilities used for other procedures requiring aseptic control, e.g. exchange transfusion and lumbar puncture in the infant. Facilities in a maternity unit should not be expected to serve the requirements of an infant already sent home from his place of birth.
21. Ritual circumcisions are performed for religious reasons and are therefore outside the category of medical or social indications. Because these ritual rites are performed on the eight day, beyond the usual length of newborn infant stay, it seems unlikely that any special facility will be required for this purpose in any new construction of maternity facilities.

Foetus and Newborn Committee Members:

Dr. P. R. Swyer - Chairman
Dr. R. W. Boston
Dr. A. Murdock
Dr. C. Paré
Dr. E. Rees
Dr. S. Segal - Editor
Dr. J. C. Sinclair

Courtesy of:  Canadian Paediatric Society c/o Children's Hospital of Eastern Ontario, Smythe Road, Ottawa, Ontario

• Foetus and Newborn Committee. FN 75-01 Circumcision in the Newborn Period. CPS News Bull Suppl 1975; 8(2):1-2.

1982 Supplemental Statement by the CPS.

CANADIAN MEDICAL ASSOCIATION JOURNAL, Volume 126: Page 1399,
15 June 1982.

BENEFITS AND RISKS OF CIRCUMCISION: ANOTHER VIEW

Platform of the Fetus and Newborn Committee of the Canadian Paediatric Society

The review by Warner and Strashin¹ clearly presented the arguments for and against circumcision and the contraindications. However, the most important reason for favouring circumcision - that is, preventing carcinoma of the penis - is not completely established. In addition, Warner and Strashin overly minimized the risks of circumcision. They also did not include the cost of complications of neonatal circumcision in their cost benefit analysis.

While the literature suggests that circumcision may protect against carcinoma of the penis, the case is not entirely proven. There are, for example, wide differences in the incidence of penile carcinoma among African tribes that do not practise circumcision.² In Sweden, where circumcision is rare, the incidence of penile carcinoma is low.³ It is possible that there are genetic or environmental factors that influence the incidence of this carcinoma and, by coincidence, are associated with circumcision. Warner and Strashin do recognize that the protective role of circumcision is not completely established. In their conclusions they stated that cancer of the penis may be prevented by circumcision, but in the abstract of the article the crucial word may isomitted.

Warner and erated.

McKim's editorial on circumcision also minimized the risks of this operation in the newborn period.⁷ The risks should indeed be minimal; however, because circumcision is not always carried out by experienced, skilful surgeons, surgical complications are regularly seen and are not extremely rare, as McKim stated.

Certainly the good teaching and supervision of neonatal circumcision McKim pleaded for are vital.

In the past we made many errors when therapeutic approaches were developed in the absence of adequate proof of efficacy.⁸ Silverman⁸ has emphasized our need not only to learn from past experiences but also to ensure that we use the correct methods to evaluate our interventions.

Several years ago the fetus and newborn committee of the Canadian Paediatric Society carefully reviewed the pros and cons of circumcision; the conclusions were published in a statement in 1975.⁹ The intentions of this statement was to reduce the number of unnecessary circumcisions and the complications that might result. (Incidentally, Warner and Strashin did not refer to this review.) The present fetus and newborn committee sees no reason for modifying the statement of the previous committee and is concerned that a completely balanced view be available to the physician asked to decide upon the necessity for circumcision.

Courtesy of: Canadian Paediatric Society c/o Children's Hospital of Eastern Ontario, Smythe Road, Ottawa, Ontario

• Benefits and risks of circumcision: another view. Can Med Assoc J 1982;126:1399.

1989 Supplemental Statement by the CPS

ROUTINE CIRCUMCISION

In 1975, the CPS Foetus and Newborn Committee carefully reviewed the pros and cons of circumcision and published the conclusion that routine circumcisionwas not necessary.

In 1982, the Committee saw no reason to modify the previous statement. However, they advocated that a completely balanced view be available from the physician in order to make a decision regarding the necessity for circumcision.

In 1988, a growing concern arose due to a report by T.E. Wiswell (see 1 and 2 below) which showed a decreased incidence of urinary tract infections in circumcised male infants. Due to these concerns the Board asked the Foetus and Newborn and the Infectious Diseases and Immunization Committees to study the report.

As the present information available concerning the risks of urinary tract infections and transmission of sexually transmitted diseases in relation to circumcision are not sufficiently compelling to justify a change in policy, the Committees maintain that no change should be made to the CPS recommendations concerning routine circumcision.

We will continue to monitor the situation.

1. Wiswell TE, Smith FR, Bass JW: Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985;75:901-903.
2. Wiswell TE:  Further evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1986;78:96-99.

Courtesy of: Canadian Paediatric Society c/o Children's Hospital of Eastern Ontario, Smythe Road, Ottawa, Ontario

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