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[Canadian Paediatric Society, fetus and newborn committee:
Circumcision in the newborn period. CPS News Bull Suppl 1975; 8(2)]
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CIRCUMCISION IN THE NEWBORN PERIOD
STATEMENT BY THE CANADIAN PAEDIATRIC
SOCIETY
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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.*
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 septuagenerian. 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.
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, nut-sing 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. Pare
Dr. E. Rees
Dr. S. Segal - Editor
Dr. J. C. Sinclair
* Standards and Recommendations for the Care of the Newborn
Infant in Hospital. American Academy of Pediatrics 1972,
Evanston, Illinois.
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Courtesy of:
Canadian Paediatric Society
c/o Children's Hospital of Eastern Ontario
Smythe Road
Ottawa, Ontario
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