THE CIRCUMCISION REFERENCE LIBRARY
The AAP made statements about circumcision in 1971, 1975, 1977, 1989, and 1997. Here they are:
The AAP issued a new statement in March 1999, which is in a different file.
[CIRP note: All AAP policy statements in this file have been superseded by the new policy statement that was issued on March 1, 1999.]
American Academy of Pediatrics, Committee on Fetus and Newborn. Standards and Recommendation for Hospital Care of Newborn infants. 5th ed. Evanston, IL: American Academy of Pediatrics: 1971.
Extract of text on circumcision:
There are no valid medical indications for circumcision in the neonatal period.4
4. Preston, E. N.: Whither the foreskin? A consideration of routine neonatal circumcision. J.A.M.A. 213:1853, 1970.
[CIRP note: All AAP policy statements in this file have been superseded by a new policy statement issued on March 1, 1999.]
Thompson HC, King LR, Knox E, et al. Report of the ad hoc task force on circumcision, Pediatrics, Vol. 56 No. 4: Pages 610-611, October 1975.
The Committee on Fetus and Newborn of the American Academy of Pediatrics stated in 1971 that there are no valid medical indications for circumcision in the neonatal period. The present committee has undertaken a review of data to support arguments "pro" and "con" circumcision of the newborn, and finds no basis for changing this statement.
Nevertheless, traditional, cultural, and religious factors play a role in the decision made by parents, pediatrician, obstetrician, or family practitioner on behalf of a son. It is the responsibility of the physician to provide parents with factual and informative medical options regarding circumcision. The final decision is theirs, and should be based on true informed consent. It is advantageous for discussion to take place well in advance of delivery, when the capacity for clear response is more likely.
The followup is a summary of factors relating to neonatal circumcision which may be presented to parents for their consideration before deciding on the procedure.
A diagnosis of phimosis cannot be made with assurance in the newborn period because the cleavage plane between the glans and the deep preputial layer of the penis is not well developed at birth. There is a real need for research which will improve diagnostic accuracy in this area. It therefore follows that "phimosis of the newborn" is not a valid medical indication for circumcision. Circumcision performed later in life in the approximately in the 2% to 10% of male with true phimosis has the disadvantage of anesthetic risk and increased cost. Circumcision done after the newborn period should be performed when trauma to the genitalia is least likely to induce psychologic problems. (e. g., before the boy starts school)
Circumcision, properly performed, eliminates much of the need for careful penile hygiene. If circumcision is not elected, the necessity for lifelong penile hygiene should be discussed with the parents, preferably before birth of the infant. Factors such as climate, the social and emotional reaction of prospective parents to penile cleansing, and the ability to understand and facilitate good hygiene, etc. should be taken into account when recommending whether circumcision should be performed.
There is evidence that carcinoma of the penis can be prevented by neonatal circumcision. There is also much evidence that optimal hygiene confers as much, or nearly as much protection. Although circumcision is an effective method of method of preventing penile carcinoma, a great deal of unnecessary surgery, with attendant complications would have to be done if circumcision were to be used as prophylaxis against this disease. Promulgation of the principles of adequate hygiene is an alternative prophylactic measure.
There is presently no convincing scientific evidence to substantiate the assertion that circumcision reduces the eventual incidence of cancer of the prostate.
A review of existing literature indicates that noncircumcision is not of itself of primary etiologic significance in the development of cervical cancer in women.
Balanitis, infection of the foreskin, is painful and occurs only in uncircumcised males. If this occurs, staged surgical corrections may be necessary - first a dorsal slit to allow inflammation to subside, and then a secondary circumcision. [CIRP note: This is inaccurate. Balanitis is infection of the glans. Posthitis is infection of the foreskin. Balanoposthitis is infection of both the glans and the foreskin. Circumcision leaves a foreskin remnant, which may partially cover the glans. Thus, any of these conditions may occur also in circumcised males.]
Adequate studies to determine the relationship between circumcision and the incidence of venereal disease have not been performed.
Circumcision is a surgical procedure that requires careful aseptic technique, systemized postoperative observation, and evaluation after discharge from the hospital.
The immediate hazards of circumcision of the newborn include local infection which may progress to septicemia, significant hemorrhage, and mutilation. Incomplete removal of the prepuce may result in phimosis.
Neonatal circumcision predisposes to meatitis, which may lead to meatal stenosis. The incidence of this complication is unknown, since the diagnosis of "meatal stenosis is seldom made on objective grounds. Meatal stenosis is seldom, if ever, associated with hydronephrosis or other objective evidence of urinary tract obstruction, such as a diminished urinary flow rate. Meatitis undoubtedly results in painful urination, but "meatal stenosis appears benign except in rare instances.
Prematurity, neonatal illness, any congenital anomaly (especially hypospadias), or bleeding problems are absolute contraindications to neonatal circumcision. The procedure is also contraindicated in the immediate neonatal period or until complete neonatal physical adaption has occurred (usually 12 to 24 hours). The avoidance of circumcision in the delivery room is particularly important because neonatal disease is not always apparent at birth. In addition, it entails protracted exposure of infants to significant cold stress.
There is no absolute medical indication for routine circumcision of the newborn. The physician should provide parents with information pertaining to the long-term medical effects of circumcision and non-circumcision, so they may make a thoughtful decision. It is recommended that this discussion take place before the birth of the infant, so the parental consent to the surgical procedure, if given, will be truly informed.
A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk. Therefore, circumcision of the newborn cannot be considered an essential component of adequate total health care.
AD HOC TASK FORCE ON CIRCUMCISION
HUGH C. THOMPSON, M. D., Chairman
LOWELL R. KING, M. D.
ERIC KNOX, M. D.
SHELDON B. KORONES, M. D.
1977 STATEMENT OF THE AAP
[CIRP note: All AAP policy statements in this file have been superseded by a new policy statement issued on March 1, 1999.]
Committee on Fetus and Newborn: Standards and Recommendations for Hospital Care of Newborn Infants. Sixth Edition. American Academy of Pediatrics; Evanston, IL 60204.
Extracts related to circumcision:
THE PRENATAL PERIOD
Parents should seek consultation with their pediatrician prior to their infant's birth and participate in parent education classes. Members of the medical and nursing staffs who communicate effectively a nd are aware of the needs and anxieties of expectant mothers and fathers should plan and conduct the education program. Classes and other educational material should be informal and include both demonstrations and an opportunity for personal participation. This is the time to discuss infant feeding, circumcision, the possible effect the pregnancy or new infant might have on an older sibling, and other concerns about the infant, the pregnancy or other aspects of family life.
CARE IN THE NORMAL NEWBORN INFANT CARE AREA
There are no medical indications for routine circumcisions, and the procedure cannot be considered an essential components of health care.7 If an infant is circumcised, the procedure must be delayed until the infant is at least 24 hours old and stable, without bleeding tendency or any other illness. Circumcision must never be done at time of delivery.
Reference:7. Committee on Fetus and Newborn: Report of the Ad Hoc Task Force on Circumcision. Pediatrics, 56:610, 1975.
THE INFANTS-- THEIR CARE AND SURVEILLANCE
Skin Care of the Newly Born Infant
The skin is a protective organ, and any break in its integrity affords an opportunity for initiation of infection. In addition, it is clear that protection against invading pathogenic organisms is afforded by skin secretions or contents and, in older infants by the normal skin biota. At birth the infant does not have protective skin flora, has at least one and, later, possibly two open surgical wounds (the umbilicus and the circumcision site), and is exposed to fomites and personnel that harbor a variety of infectious agents.
[CIRP note: All AAP policy statements in this file have been superseded by a new policy statement issued on March 1, 1999.]
[CIRP Note: This now replaced 1989 report has received unceasing and severe criticism from many sources. Comments include its failure to recommend anesthesia for neonatal circumcision and its citation of very old papers to support the practice of non-therapeutic neonatal circumcision. For one such comment see Circumcision and the American Academy of Pediatrics: Should Scientific Misconduct Result in Trade Association Liability?]
The 1971 edition of Standards and Recommendations of Hospital Care of Newborn Infants by the Committee on the Fetus and Newborn of the American Academy of Pediatrics (AAP) stated that "there are no valid medical indications for circumcision in the neonatal period."1(p110) In 1975, an Ad Hoc Task Force of the same committee reviewed this statement and concluded that "there is no absolute medical indication for routine circumcision of the newborn."2 The 1975 recommendation was reiterated in 1983 by both the AAP and the American College of Obstetrics and Gynecology in the jointly published Guidelines to Perinatal Care.3
Large scale studies of US hospitals indicate that most male infants born in this country are circumcised in the newborn period,4 although the circumcision rate recently appears to be decreasing.5 Since the 1975 report, new evidence has suggested possible medical benefits from newborn circumcision. Preliminary data suggest the incidence of urinary tract infection in male infants may be reduced when this procedure is performed during the newbornperiod. There is also additional published information5 concerning the relationship of circumcision to sexually transmitted diseases and, in turn, the relationship of viral sexually transmitted diseases to cancer of the penis and cervix.
The penis consists of a cylindrical shaft with a rounded tip (the glans). The shaft and glans are separated by a groove called the coronal sulcus. The foreskin, or prepuce, is the fold of skin covering the glans. At birth, the prepuce is still developing histologically, and its separation from the glans is usually incomplete. Only about 4% of boys have a retractable foreskin at birth, 15% at 6 months, and 50% at l year; by 3 years, the foreskin can be retracted in 80% to 90% of uncircumcised boys.6[CIRP note: the previous statement is based on inaccurate information. See Normal for the correct values.] Phimosis is stenosis of the preputial ring with resultant inability to retract a fully differentiated foreskin. Paraphimosis is retention of the preputial ring proximal to the coronal sulcus, creating a tension greater than Iymphatic pressure resulting in subsequent edema of the prepuce and glans distal to the ring. Balanitis is inflammation of the glans, and posthitis is inflammation of the prepuce; these conditions usually occur together (balanoposthitis). Meatitis is inflammation of the external urethral meatus.
Newborn circumcision consists of removal of the foreskin to near the coronal sulcus performed in early infancy (before age 2 months). The procedure prevents phimosis, paraphimosis, and balanoposthitis. Meatitis is more common in circumcised boys. There is no evidence that meatitis leads to stenosis of the urethral meatus.
It is particularly important that uncircumcised boys be taught careful penile cleansing. As the boy grows, cleansing of the distal portion of the penis is facilitated by gently, never forcibly, retracting the foreskin only to the point where resistance is met. Full retraction may not be achieved until age 3 years or older.
A small percentage of boys who are not circumcised as newborns will later require the procedure for treatment of phimosis, paraphimosis, or balanoposthitis. When performed after the newborn period, circumcision may be a more complicated procedure.7
The overall annual incidence of cancer of the penis in US men has been estimated to be 0.7 to 0.9 per 100,000 men and the mortality rate is as high as 25%.8-11 This condition occurs almost exclusively in uncircumcised men.12-14 In five major reported series since 1932, not one man had been circumcised neonatally.11, 15-19 The predicted lifetime risk of cancer of the penis developing in an uncircumcised man has been estimated at 1 in 600 men in the United States20; in Denmark, the estimate is 1 in 909 men.21 in developed countries where neonatal circumcision is not routinely performed, the incidence of penile cancer is reported to range from 0.3 to 1.1 per 100,000 men per year 4. This low incidence is about half that found in uncircumcised US men, but greater than that in circumcised US men.
Factors other than circumcision are important in the etiology of penile cancer. The incidence of penile cancer is related to hygiene. In developing nations with low standards of hygiene, the incidence of cancer of the penis in uncircumcised men is 3 to 6 per 100,000 men per year22. The decision not to circumcise a male infant must be accompanied by a lifetime commitment to genital hygiene to minimize the risk of penile cancer developing. Recently, human papillomavirus types 16 and 18 DNA sequences have been found in 31 of 53 cases of penile cancer, suggesting the importance of these viruses in the development of this condition.23 Poor hygiene, lack of circumcision, and certain sexually transmitted diseases all correlate with the incidence of penile carcinoma.
A 1982 series of infants with urinary tract infections noted that males preponderated, contrary to the female preponderance later in life, and that 95% of the infected boys were uncircumcised.24 Beginning in 1985, studies conducted at US Army hospitals involving more than 200,000 men showed a greater than tenfold increase in urinary tract infections in uncircumcised compared with circumcised male infants; moreover, as the rate of circumcision declined throughout the years, the incidence of urinary tract infection increased.5,25 In another army hospital study, infants were examined in the first month of life and it was concluded that the high incidence of urinary tract infection in uncircumcised boys was accompanied by a similarly increased incidence of other significant infection, including bacteremia and meningitis26; however, the authors of that study did not distinguish between bacteriuria secondary to septicemia and primary urinary tract infection. Still another recent army hospital study lends support to a 1986 hypothesis that circumcision prevents preputial bacterial colonization and thus protects male infants against urinary tract infection.27,28 It should be noted that these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study population may have been influenced by selection bias.
Evidence regarding the relationship of circumcision to sexually transmitted diseases is conflicting. Early series indicated a higher risk of gonococcal and nonspecific urethritis in uncircumcised men,29,30 whereas one recent study shows no difference in the incidence of gonorrhea and a higher incidence of nonspecific urethritis in circumcised men.31 Although published reports suggest that chancroid, syphilis, human papillomavirus, and herpes simplex virus type 2 infection are more frequent in uncircumcised men, methodologic problems render these reports inconclusive.29,30,32-34
There appears to be a strong correlation between squamous cell carcinoma of the cervix and sexually transmitted diseases. Human papillomavirus types 16 and 18 are the viruses most commonly associated with cancer of the cervix 35-38; Herpes simplex virus type 2 has also been linked with cervical cancer.36, 39 Although human papillomavirus types 16 and 18 are also associated with cancer of the penis,23,37 evidence linking uncircumcised men to cervical carcinoma is inconclusive. The strongest predisposing factors in cervical cancer are a history of intercourse at an early age and multiple sexual partners. The disease is virtually unknown in nuns and virgins.
Infants undergoing circumcision without anesthesia demonstrate physiologic responses suggesting that they are experiencing pain.40 The observed responses include behavioral, cardiovascular, and hormonal changes. Pain pathways as well as the cortical and subcortical centers necessary for pain perception are well developed by the third trimester. Responses to painful stimuli have been documented in neonates of all viable gestational ages. Behavioral changes include a cry pattern indicating distress during the circumcision procedure and changes in activity (irritability, varying sleep patterns) and in infant maternal interaction for the first few hours after circumcision.4l-43 These behavioral changes are transient and disappear within 24 hours after surgery.43
Circumcision is a safe surgical procedure if performed carefully by a trained, experienced operator using strict aseptic technique. The procedure should be performed only on a healthy, stable infant. Clamp techniques (eg, Gomco or Mogen clamps) or a Plastibell give equally good results.44 Techniques that may reduce postoperative complications include (1) using a surgical marking pen to mark the location of the coronal sulcus on the shaft skin preoperatively; (2) identifying the urethral meatus; (3) bluntly freeing the foreskin from the glans with a flexible probe; (4) completely retracting the foreskin; and (5) identifying the coronal sulcus, all before applying the clamp or Plastibell and before excising any foreskin.45 Electrocautery should not be used in conjunction with metal clamps. At the initial health supervision visit following hospital discharge, the penis should be carefully examined and the parents given instructions concerning ongoing care.
Dorsal penile nerve block using no more than 1cc lidocaine (without epinephrine) in appropriate doses (3 to 4 mg/kg) may reduce the pain and stress of newborn circumcision.41,46-49 However, reported experience with local anesthesia in newborn circumcision is limited, and the procedure is not without risk (see "Complications").
Circumcision is contraindicated in an unstable or sick infant. Infants with genital anomalies, including hypospadias, should not be circumcised because the foreskin may later be needed for surgical correction of the anomalies. Appropriate laboratory studies should be performed when there is a family history of bleeding disorders. Infants who have demonstrated an uncomplicated transition to extrauterine life are considered stable. Signs of stability include normal feeding and elimination and maintenance of normal body temperature without an incubator or radiant warmer. A period of observation may allow for recognition of abnormalities or illnesses (eg, hyperbilirubinemia, infection, or manifest bleeding disorder) that should be addressed before elective surgery. It is prudent to wait until a premature infant meets criteria for discharge before performing circumcision.
The exact incidence of postoperative complications is unknown,50 but large series indicate that the rate is low, approximately 0.2% to 0 6%.44,45,51,52 The most common complications are local infection and bleeding. Deaths attributable to newborn circumcision are rare; there were no deaths in 500,000 circumcisions in New York City52 or in 175,000 circumcisions in US Army hospitals.51 A communication published in 1979 reported one death in the United States due to circumcision in 1973, and the authors' review of the literature during the previous 25 years documented two previous deaths due to this procedure.53
Complications due to local anesthesia are rare and consist mainly of hematomas and local skin necrosis.41,46-49,54 However, even a small dose of lidocaine can result in blood levels high enough to produce measurable systemic responses in neonates.55,56 Local anesthesia adds an element of risk and data regarding its use have not been reported in large numbers of cases. Circumferential anesthesia may be hazardous. It would be prudent to obtain more data from large controlled series before advocating local anesthesia as an integral part of newborn circumcision.
When considering circumcision of their infant son, parents should be fully informed of the possible benefits and potential risks of newborn circumcision, both with and without local anesthesia. In addition to the medical aspects, other factors will affect the parents' decisions, including esthetics, religion, cultural attitudes, social pressures, and tradition.
Properly performed newborn circumcision prevents phimosis, paraphimosis, and balanoposthitis and has been shown to decrease the incidence of cancer of the penis among US men. It may result in a decreased incidence of urinary tract infection. However, in the absence of well-designed prospective studies. conclusions regarding the relationship of urinary tract infection to circumcision are tentative. An increased incidence of cancer of the cervix has been found in sexual partners of uncircumcised men infected with human papillomavirus. Evidence concerning the association of sexually transmitted diseases and circumcision is conflicting.
Newborns circumcision is a rapid and generally safe procedure when performed by an experienced operator. It is an elective procedure to be performed only if an infant is stable and healthy. Infants respond to the procedure with transient behavioral and physiologic changes.
Local anesthesia (dorsal penile nerve block) may reduce the observed physiologic response to newborn circumcision. It also has its own inherent risks. However, reports of extensive experience or followup with the technique in newborns are lacking.
Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.
AAP TASK FORCE ON CIRCUMCISION
Edgar J. Schoen, MD, Chairman
Glen Anderson, MD
Constance Bohon, MD
Frank Hinman, Jr, MD
Ronald L. Poland, MD
E. Maurice Wakeman, MD
Policy statement RE9148, Report of the Task Force on Circumcision
Under the heading of "Urinary Tract Infections" (line 6, page 389), "men" should be changed to "infant boys." The complete statement should now read:
Beginning in 1985, studies conducted at US Army hospitals involving more than 200,000 infant boys showed a greater than ten-fold increase in urinary tract infections in uncircumcised compared with circumcised male infants; moreover, as the rate of circumcision declined throughout the years, the incidence of urinary tract infection increased."
The Task Force on Circumcision would also like to acknowledge the following for their provision of expert advice:
David T. Mininberg, MD, FAAP, Section Liaison
Jerome O. Klein, MD, FAAP
Edward A. Mortimer, Jr, MD, FAAP
William Oh and Gerald Merenstein. Fourth Edition of the Guidelines for Perinatal Care: Summary of Changes. Pediatrics 1997 100(6): 1021-1027. December 1997.
It is emphasized that newborn circumcision is an elective procedure to be performed at the request of the parents when the infant is physiologically and clinically stable. Because of the lack of hard scientific data, a firm recommendation for appropriate method of pain control was not provided. The AAP has recently convened a task force to review new information available since the writing of the Guidelines with the goal of making specific recommendations on this issue.
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