THE CIRCUMCISION REFERENCE LIBRARY
At the 1997 meeting of the Canadian Paediatric Society (CPS) I listened with interest to a presentation entitled "A cohort study on male neonatal circumcision and the subsequent risk of urinary tract infection" by Doctors To, Agha, Dick and Feldman . The data presented supported the previous reports in the literature of a decreased risk of urinary tract infection (UTI) among circumcised boys compared with circumcised ones, in addition they estimated that 625 boys would have to be circumcised to prevent one hospitalization for UTI in the first five years of life. This perspective indeed lends support to the position of the CPS that circumcision of newborns should not be routinely performed.
While these authors did not look at the incidence of UTI in girls, those investigators who have done so have reported the incidence of UTIs in girls to be intermediate between that observed in circumcised and uncircumcised boys. Wiswell and colleagues when they reviewed the records of 427,698 infants (219,755) boys born in the United States armed forces hospitals between 1975 and 1979 found an incidence of UTI that was 10-fold higher for uncircumcised boys (1.03%) than for circumcised boys (0.1%). Mentioned for comparison purposes only and without other comment was the rate of 0.52% among girls. However, if we are concerned about prevention, should we also not be concerned about the incidence of UTI in girls?
I am writing to express my concern that in focusing on the role of circumcision, we have failed to evaluate other potentially important suggestions that have been made regarding the prevention of UTIs in infancy, suggestions that are not sex specific! It is known that the virulence of Escherichia coli strains isolated in cases of UTI correlates with the ability of the strain to bind to uroepithelial cells . For example in one series, 94% of infantile pyelonephritis was reported to be due to P-fimbriated E Coli. Based on these observations Winberg and colleagues have suggested two alternative measures for UTI prevention in infancy. The first is the deliberate colonization of infants with nonpathogenic bacteria from their mothers; the second is the promotion of rooming-in to facilitate colonization by nonpathogenic bacteria from their mothers. The first measure is analogous to the deliberate colonization of the umbilicus and nasal mucosa, which was undertaken to arrest epidemics of Staphyloccus aureus in the past. The second is in keeping with current trends in maternal and infant care and, if effective, might prove to be a preventative program that actually has no added cost!
Neither of these measures has ever been fully evaluated. One case control study  has looked at breast-feeding and UTI. In that report only 47% of 62 infants presenting with a UTI had been breastfed, while 82% of 62 control infants from a well baby clinic and 87% of 62 control infants admitted to a hospital because of fever had been breastfed. None of the control infants had a UTI (P<0.001). Winberg and colleagues' suggestions have not otherwise been tested. The CPS statement "Neonatal circumcision revisited" has as one of its conclusions "Evaluation of alternative measures of preventing UTI in infancy is required". If we are truly concerned about prevention this needs to be done.
EW Outerbridge, MD FRCPC
Newborn Medicine Service
The Montreal Children's Hospital,
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