GUIDELINE
PAEDIATRICS

Neonatal Circumcision

Background

Circumcision of the male neonate is a common procedure in our society, usually for religious or cultural reasons. Male neonatal circumcision is not an innocuous procedure. Consideration should be given to factors which may affect the outcome. For the purposes of this guideline, "neonatal" is defined as the first month of life.

Contraindications

• Congenital penile abnormalities, eg. hypospadias, chordae, prominent dorsal preputial hood with lack of ventral foreskin, micropenis, buried penis, penis with severe penoscrotal webbing. Neonates with such problems should be referred to a Urological Specialist.
• Known bleeding diathesis.
• Premature infant or an infant with medical complications.
• Family history of gross keloid formation.

Indications

Specific medical indications for the performance of circumcision in the neonate are rare. There may be benefits to circumcision in the prevention of phimosis, the prevention of urinary tract infection, reduction in the spread of the papillovirus, and the protection of men from infection with the Human Immunodeficiency Virus (HIV). The degree of benefit is small, however, and does not support a recommendation to circumcise neonates.

The Following Conditions Are Not An Indication For Circumcision:

• Single urinary tract infection
• Difficulty retracting the foreskin (the foreskin is not normally retractable in the neonate)
• Prevention of balanitis

Precautions

• The neonate who has a urinary tract infection (UTI) should be assessed by a specialist before the circumcision is recommended. Vesicoureteric reflux and/or urinary tract obstruction must be ruled out before circumcision would be contemplated. The foreskin may act as a reservoir for bacteria under such circumstances.
• The circumcision of neonates or infants with documented vesicoureteric reflux, in order to prevent recurrent infections, is still a controversial issue.
• Electro-cautery should not be used in newborn circumcision.

Informed Consent

Parental consent must be obtained prior to the performance of circumcision. It is recommended that such discussions occur as part of prenatal care rather than hastily after the birth of the baby as has been the common practice. Complaints by parents are usually related to their expectations not being achieved.

Timing Of Circumcision

When performed, it is preferable that circumcision be done within the first month of life. If the procedure is not performed within the first month, most urologists advise that the procedure should be delayed until well after the neonatal period, unless a specific medical indication arises. In children above the age of three months, a free hand circumcision is preferable to a clamp or bell technique.

Anaesthesia/Analgesia

Infants do experience pain with neonatal circumcision, manifested by crying, elevation of the heart rate, and a measurable increase in serum cortisol levels. Evidence suggests that the use of approved topical analgesia or local infiltration (e.g. Dorsal penile nerve block) containing adrenaline free local anaesthetic are effective methods to block the pain of neonatal circumcision. Studies demonstrate that these techniques are simple and safe with little risk of complication to the newborn provided it is performed by a physician who is experienced in such procedures. It is imperative to ensure that injection is not intravascular or intracorporeal.

Training Standards

In order to be granted privileges in neonatal circumcision, the Physician must:

• Be registered and a licensed member of the College of Physicians and Surgeons of Manitoba.
• Demonstrate competence in the performance of 10 procedures proctored by a physician who has neonatal circumcision privileges and who agrees to provide documentation attesting to the competency of the other physician.

References

1. American Academy of Family Physicians. Fact Sheet For Physicians Regarding Neonatal Circumcision. American Family Physician 1995;52(2):523-6.
2. Anand KJS, Hickey MD. Pain And Its Effects In The Human Neonate And Fetus. The New England J Of Medicine 1987;317(21):1321-29.
3. Chessare JB. Circumcision: Is The Risk Of Urinary Tract Infection Really The Pivotal Issue? Clinical Pediatrics 1992;Feb:100-4.
4. Fetus And Newborn Committee, Canadian Paediatric Society. Neonatal Circumcision Revisited. Canadian Medical Association J 1996;154(6):769-80.
5. Fletcher AB. Pain In The Neonate. The New England J of Medicine 1987;317(21):1347-48.
6. Ganiats TG, Humphrey JBC et al. Routine Neonatal Circumcision: A Cost-Utility Analysis. Medical Decision Making 1991;11(4):282-293.
7. Lawler FH, Bisonni RS, Holtgrave DR. Circumcision: A Decision Analysis Of Its Medical Value. Family Medicine 1991;23(8):587-93.
8. Masciello A. Anesthesia For Neonatal Circumcision: Local Anesthesia Is Better Than Dorsal Penile Nerve Block. Obstetrics And Gynaecology 1990;75(5):834-38.
9. Maxwell LG, Yaster M et al. Penile Nerve Block For Newborn Circumcision. Obstetrics And Gynaecology 1987;70(3):415-18.
10. Niku SD, Stock JA, Kaplan GW. Neonatal Circumcision. Urologic Clinics Of North America 1995;22(1):57-65.
11. Poland RL. The Question Of Routine Neonatal Circumcision. New England J Of Medicine 1990;322(18):1312-15.
12. Schoen EJ. Sounding Board: The Status Of Circumcision Of Newborns. The New England J Of Medicine 1990;322(18):1308-11.
13. Stang HJ, Gunnar MR et al. Local Anesthesia For Neonatal Circumcision: Effects On Distress And Cortisol Response. J Of American Medical Association 1988;259(10):1507-11.
14. Spach DH, Stapleton AE, Stamm WE. Lack of Circumcision Increases The Risk Of Urinary Tract Infection In Young Men. J Of American Medical Association 1992;267(5):679-81.
15. Task Force on Circumcision, American Academy of Pediatrics. Report of the Task Force on Circumcision. Pediatrics 1989;84:388-91.
16. Williamson PS, Williamson ML. Physiologic Stress Reduction by a Local Anesthetic During Newborn Circumcision. Pediatrics 1983;71(1):36-40.

First Print PDRC/02-94
Revision PMWC/06-97

A Guideline is practice generally recommended.

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