THE CIRCUMCISION REFERENCE LIBRARY
GEORGE R. SPENCE, MD,+ Silver Spring, Md
The author has shown that the delay of holding a newborn in the delivery room for circumcision before his removal to the nursery results in chilling. He recommends postponement of the operation to later in the neonatal period.
FOR SOME YEARS in this community, it increasingly has become customary to perform routine circumcision in the delivery room immediately after birth and before sending the infant to the nursery.
Because it was noted that some circumcised infants were arriving in the nursersy with rather low temperatures, a study was carried out at Holy Cross Hospital to determine whether circumcision in the delivery room increased the likelyhood of chilling infants.
This statistical study of 1047 newborn infants in 1968, indicates that the percentage of chilled infants in the circumcised group was significantly greater than in the uncircumcised group.
The following is the routine care given to infants in the delivery room: An infant who is born in this hospital is received from the delivery table by a nurse who carries him, wrapped in a dry towel, to the resuscitation unit where he is wrapped in a warmed cotton blanket and resuscitated. Infants who are to be circumcised remain in the resuscitation unit until the obstetrician finishes with the mother; the infant then is placed on the circumcision table, still covered except for the genital region, and is circumcised. He is then carried to the nursery. There is a warmer beneath the infant in the resuscitation unit but none on the circumcision table.
On arrival at the nursery the infant's rectal temperature is taken immediately and recorded.
In this study, to exclude other major factors affecting temperature, it was thought desirable to exclude infants whose condition had been compromised or who were at risk of other reasons. Therefore no infant was accepted into the study who had been admitted to either the premature or observation nurseries. The period of study included 8 months in 1968. No similar study of this type has been found in the literature.
The infants were divided into two main groups. Group I included the infants who were circumcised in the delivery room immediately following birth; Group II consisted of the male infants not circumcised at that time and the female infants. The groups were then further subdivided by setting arbitrary ranges and placing each baby into its division, depending on the rectal temperature recorded on admission to the regular nursery. These temperature ranges were:
Temperatures above 37.2 C (99.0 F)
Temperatures from 36.7 - 37.2 C (98 - 98.9 F)
Temperatures from 36.1 - 36.6 C (97 - 97.9 F}
Temperatures from 35.5 - 36.1 C (96 - 96.9 F)
Temperatures from 35.0 - 35.5 C (95 - 95.9 F)
Temperatures below 35.0 (95.0 F)
By this procedure it was possible to obtain percentage differences between the circumcised and the uncircumcised infants (Fig.1). The time elapsed from birth of an infant until arrival in the newborn nursery was recorded, and averaged for each group (Table 1).
The differences in time that elapsed from the moment of delivery until arrival in the nursery averaged 8.7 minutes longer in the circumcised group. This increased time in the delivery room probably contributed to the heat loss and was due to the extra time for the obstetrician to complete his attention to the mother and to perform the circumcision.
If we classify infants as chilled, those whose temperatures were below 35.5 C (96.0 F), we find that 7.0% of the uncircumcised are chilled, compared with 12.8% of the circumcised. By using the chi-square calculation on the 2 by 2 contingency table, P<.01. This is a highly significant difference. It would appear that to escape chilling at the time of birth, it would be safer to be in the uncircumcised group of infants.
Is excessive heat loss at the time of birth a handicap to the newly born infant? The answer must be yes. At this very early period of life, immediately following delivery, infants are less able to conserve body heat than later in the neonatal period.[1-4]
Silverman and his associates[1,5,6] have shown that infants have a decreased morbidity and mortality if they are kept in a neutral thermal environment. Bruck, in 1961, wrote that a fall in body temperature increased the oxygen requirements of neonates.
Gandy and co-workers showed that cooling in the delivery room caused a distinctly stressful situation in newborn infants. In the presence of normal Po2 (plasma oxygent content), cooling caused a compensated acidosis and with a low Po2 it caused, frequently, an uncompensated acidosis and a lowering of the pH of the blood.
Miller and Oliver demonstrated that chilled infants took a longer time to reach body temperatures than did infants kept warm after birth.
In this series of infants there was a statistical increase in the number of chilled babies who arrived in the regular nursery at our hospital after having been circumcised in the delivery room, when compared with babies who arrived there under similar circumstances but not circumcised. Circumcision was probably responsible for the delayed arrival time of Group I.
Because there is convincing proof in the recent literature that chilling puts the newborn infants under handicap in several ways, it would be better, perhaps to defer circumcision until a later time in the neonatal period when an infant's temperature regulated mechanism is better stablized.
Acknowledgements. I wish to thank Leonard Chiazzc, Jr., ScD, of the Division of Bio-statistics and Epidemiology, Georgetown University School of Medicine, for aid with the statistics. I also thank Mrs. Lorraine Nickerson, RN, former nursery supervisor at Holy Cross Hospital, and her staff for help in collecting the data on temperatures of the infants.1515 Highland Way
+From the Department of Pediatrics, Holy Cross Hospital, Silver Spring, Md.
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