CPS: Circumcision in the newborn period

[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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