In the US, The American Academy of Pediatrics, The American College of Obstetrics and Gynecology, and The Pediatric Urologists Association all say the circumcision of infant children is unnecessary. The present medical policy in the United States and some other English-speaking nations is to offer and perform elective non-therapeutic circumcision of infant males at the request of the parents. The Canadian Pediatric Society reported that there is no medical indication for circumcision during the neonatal period. They repeat the information from a publication, “Standards and Recommendations for the Care of the Newborn Infant in Hospital.” American Academy of Pediatrics 1972, Evanston, Illinois. That recommendation was made 36 years ago. Circumcisions are rarely done in Britain. The more immediate hazards of circumcision include infection which may be minor, or which could lead to gangrene or general sepsis, severe hemorrhage, mutilate deformity of the penis, or rarely, a procedural misadventure requiring partial amputation of the penis.
The 2004, highly publicized, death by hypovolemic shock of a healthy Canadian boy caused by hemorrhage from his circumcision wound has forced a reexamination of the risks occurred from bleeding. The prepuce is highly vascularized, so it is likely to hemorrhage when cut, and severing the frenular artery is very common. Infants can tolerate only about a 20 percent blood loss before hypovolemia, hypovolemic shock, and death. The quantity of blood loss that might kill an infant is easily concealed in today’s highly absorbent disposable diaper. Many newborns, and especially premature infants, weigh much less and a smaller amount of blood loss would be sufficient to trigger hypovolemic shock in those infants.
The March 2004 edition of Archives of Disease in Childhood (London) reports a substantial increase in bacteremia (viable bacteria circulating in the blood) caused by Methcillin Resistant Staphyloccus aureus (MRSA) in children. The article (Archives of Disease in Childhood 2004; 89:378-379) reported that MRSA bacteria is associated with a higher mortality rate, longer hospital stays and is a significant independent risk factor for death. St. Catherine’s Hospital on Long Island experienced an outbreak of MRSA infection among circumcised boys in the newborn nursery in 2003; Arlington Hospital in Arlington, VA had a similar outbreak in 1995; and the naval hospital in North Carolina had an outbreak of non-resistant S. aureus in 1998. Later complications include the excoriation of the exposed edges of the glans from 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.
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.
Additional problems arise when circumcisions are done for religious reasons. Ritual circumcisions are performed for religious reasons and are therefore outside the category of medical or social indications. Because these ritual rites are performed beyond the usual length of newborn infant stay, it seems unlikely that any medical facility will be required for this purpose. The boys are risking infection and mutilation by inexperienced and bogus circumcision practitioners. Problems arise when the procedure is carried out in an unsterile environment, such as the boy’s home. This can leave the boys open to infection. A bigger problem is the “community practitioners”, people who have no medical training, who carry out the circumcisions themselves. No one should perform a circumcision on a two-month old infant or older baby without first administering anesthesia. Only medically trained individuals should be administering anesthesia. Circumcision should be performed by the person most adept at the procedure, and most readily available and capable to deal with any early complications. Before allowing anyone outside the medical profession to perform a circumcision check credentials and references.
Although there is some unresolved contention about the aptness 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. 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.
If pediatricians are showing leadership in curtailing the numbers of mutilate operations of questionable benefit, it is likely that uninformed parents may turn to their family physician or obstetrician to perpetuate such an obsolete operation. Discussion of this subject should be encouraged among all who may deal with parents, both among the medical and nursing professions.
