Circumcision practice patterns in the United States

Growth in Newborn Circumcisions Performed by Pediatric Urologists and Advanced Practice Providers Between 2010 and 2021 in the United States

OBJECTIVE

To characterize changes in the proportion of newborn circumcisions performed by pediatric urologists and advanced practiced providers (APPs) in the United States over the last decade.

METHODS

The Merative MarketScan Commercial Database was queried for newborn circumcision private health insurance claims (Common Procedural Terminology 54150) between 2010 and 2021. Setting (inpatient/outpatient), US Census Bureau region, clinician specialty, and patient age (days) were determined for the full study time period, and by study year. Simple linear regression assessed growth in proportion of newborn circumcisions performed by pediatric urologists and APPs (nurse practitioner/physician assistant/midwife), over time.

RESULTS

In total, 1,006,748 newborn circumcisions (59% inpatient) were identified; while most were performed by obstetricians (45%) or pediatricians (33%); APPs performed 0.9%, and pediatric urologists performed 0.7%. From 2010-2021, the proportion of newborn circumcisions performed by pediatric urologists increased from 0.3% to 2.0% and by APPs in from 0.5% to 2.9% (P < .001 for both). Growth for both pediatric urologists and APPs occurred APPs predominantly from 2016 to 2021. Trends in proportion of newborn circumcision performed by pediatricians was stable [31.5% (2010) and 32.5% (2021)], but decreased for obstetricians [48.8% (2014) and 38.1% (2021)].

CONCLUSION

The proportion of newborn circumcisions performed by pediatric urologists and APPs increased more than 6-fold between 2010 and 2021, though both specialties still perform a minority of newborn circumcisions. These data provide important baseline information for newborn circumcision workforce planning, including evaluating collaborative care models where pediatric urologists train APPs to perform circumcision.

Critical evaluation of contrasting evidence on whether male circumcision has adverse psychological effects: A systematic review

OBJECTIVE

To conduct the first systematic review critically examining evidence on whether early male circumcision has short- and long-term adverse psychological effects.

METHODS

We searched PubMed, EMBASE, SCOPUS, Cochrane Library, and Google Scholar.

RESULTS

Twenty-four studies with original data met the inclusion criteria. These comprised 11,173 total males, 4340 circumcised in infancy and 6908 uncircumcised. Nineteen were rated 1+, 2++ or 2+, and 5 were rated 2- by SIGN criteria. Neonatal circumcision, particularly without anesthetic, increased vaccination pain response, but had little effect on breastfeeding or cognitive ability. Studies reporting associations with sudden infant death syndrome, autism, alexithymia and impaired sexual function and pleasure had design flaws and were rated 2-. Sexual arousal, touch, pain, and warmth thresholds measured by quantitative sensory testing were not diminished in neonatally circumcised men. Neonatal circumcision was not associated with empathy in men, contradicting the hypothesis that procedural pain causes central nervous system changes. After correcting all associations with socioaffective processing parameters for multiple testing only higher sociosexual desire, dyadic sexual libido/drive, and stress remained significant. The relatively greater sexual activity found in circumcised men might reflect reduced sexual activity in uncircumcised men overall owing to pain and psychological aversion in those with foreskin-related medical conditions (reverse causality). Most studies employed case-control designs with limited follow-up. Studies beyond childhood were prone to confounding.

CONCLUSION

The highest quality evidence suggest that neonatal and later circumcision has limited or no short-term or long-term adverse psychological effects.

Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study

BACKGROUND

The American Academy of Pediatrics (AAP) Task Force on Circumcision has called for the development of standards of trainee proficiency in regards to evaluation and technique for neonatal clamp circumcision (NCC). At the present time, there is no standardized or general consensus on patient selection for NCC. An improved method to evaluate newborns for NCC is an important first step in this process. Therefore, the authors collaborated to identify criteria useful in the evaluation of newborns for suitability for NCC, and for assessment of success after NCC and have named it "Checklist Assessment for Neonatal Clamp Circumcision Suitability."

METHODS

A national multi-institutional collaboration was created to obtain consensus on objective criteria for use in determining patient suitability for NCC, and for assessing post-circumcision success outcomes. Criteria included elements from detailed medical history, bedside physical examination, and post-circumcision follow-up. Patients desiring NCC were enrolled consecutively and prospectively. The Checklist was followed to determine which newborns were suited to NCC, and NCC was done in those cases. The patients' caretakers were given post-circumcision care instructions and a follow-up appointment. Post circumcision, the Checklist was followed to determine if the procedure resulted in a successful circumcision or if there were complications.

RESULTS

A total of 193 cases were enrolled prospectively and consecutively from January 2014 through October 2014. The mean age was 15 days (1-30 days). Of those 193 patients, 129 (67%) were deemed suitable for circumcision and underwent NCC. Post-circumcision assessment showed a 100% success rate with no complications. A total of 64 (23%) cases were deemed unsuitable for NCC because at least one checklist criterion was not satisfied, most commonly: penile torsion (n = 25), chordee (n = 19), and penoscrotal webbing (n = 19).

DISCUSSION

Use of the Checklist in the present study has demonstrated a method of patient screening resulting in a 100% success rate with no complications. A high proportion of patients (33%) was identified as unsuited for NCC; however, the patient population consisted of newborn males referred to pediatric urology, and thus does not represent the general population, which is expected to have a lower proportion of unsuited patients. Regardless, the Checklist has the potential to enhance the decision-making process for both urologic and non-urologic care providers.

CONCLUSIONS

The use of the "Checklist Assessment for Neonatal Clamp Circumcision Suitability" assessment tool improves identification of patients unsuited for NCC and thereby potentially decreases the likelihood of circumcision-related complications.

Medical risks and benefits of newborn male circumcision in the United States: physician perspectives

INTRODUCTION

In 2012, the American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) published recommendations that physicians should discuss with parents the benefits and risks of newborn male circumcision. Our objective was to assess physicians' perspectives of newborn male circumcision.

METHODS

A self-administered, cross-sectional electronic survey of US physicians was conducted in 2008 (N = 1500).

RESULTS

Approximately one-third (33.2%) of the respondents reported that their current perspective was that the medical benefits outweigh the risks associated with newborn male circumcision and less than one-third (31.1%) reported they would recommend the procedure when counseling parents.

CONCLUSIONS

In 2008, only about one-third of the physicians surveyed thought that the benefits of male circumcision outweighed the risks and recommended it to parents of newborn sons. These attitudes may be relevant to the declining circumcision rates in the United States. Repeat surveys may be useful, given the new AAP and ACOG recommendations.

Routine neonatal circumcision: opportunities for improving residency training

OBJECTIVES

Primary care physicians are the routine providers of neonatal circumcision, yet urologists commonly manage the complications. We previously identified a need for improved formalized training in neonatal circumcisions among ob-gyn residents. Here we extend the needs assessment to urology residents.

METHODS

From Nov 2008 to Nov 2009, ob-gyn and urology residents at our institution were given an online survey to assess comfort, education, and proficiency in pre-operative evaluation and performance of circumcisions.

RESULTS

26/35 (74%) ob-gyn and 12/17 (65%) urology residents responded to the survey. 62% of ob-gyn and 33% of urology residents intended to perform neonatal circumcisions in practice. Both groups described having little formal training in neonatal circumcision. Ob-gyn residents felt more comfortable than urology residents in performing neonatal circumcisions [mean 5.9 vs. 4.3, p = 0.001; 1 (very uncomfortable) - 7 (very comfortable)], though urology residents' comfort level increased with resident year. Ob-gyn residents felt less comfortable than urology residents (mean 3.9 vs. 5.1, p = 0.031) evaluating if a newborn penis may undergo circumcision safely. Urology residents performed better than ob-gyn residents at identifying contraindications to routine circumcision from 10 scenarios (mean 63% vs. 42% p < 0.001). Both felt that an online module was a good alternative to practical experience.

CONCLUSIONS

At our institution, ob-gyn and urology residents have little formalized training in neonatal circumcision. While ob-gyn residents are comfortable performing circumcisions, they feel less comfortable evaluating the newborn penis and correctly managed fewer scenarios than did urology residents. This highlights the need for further curriculum development and formalized training.

Male circumcision: pain, trauma and psychosexual sequelae

Infant male circumcision continues despite growing questions about its medical justification. As usually performed without analgesia or anaesthetic, circumcision is observably painful. It is likely that genital cutting has physical, sexual and psychological consequences too. Some studies link involuntary male circumcision with a range of negative emotions and even post-traumatic stress disorder (PTSD). Some circumcised men have described their current feelings in the language of violation, torture, mutilation and sexual assault. In view of the acute as well as long-term risks from circumcision and the legal liabilities that might arise, it is timely for health professionals and scientists to re-examine the evidence on this issue and participate in the debate about the advisability of this surgical procedure on unconsenting minors.

Male circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.

Need for physician education on the benefits and risks of male circumcision in the United States

Physicians may be called upon to counsel male patients or parents of newborn males regarding their decision to circumcise their newborn sons. The purpose of the present study was to describe physicians who do not understand the benefits and risks associated with male circumcision well enough to counsel parents of newborn male infants and adult men. A self-administered, cross-sectional electronic survey of physicians was conducted in 2008. We analyzed responses from 1,500 physicians (510 family practitioners, 490 internists, 250 pediatricians, and 250 obstetricians/gynecologists). Nearly 22% (n = 327/1500) reported they did not understand the risks and benefits of newborn male circumcision well enough to counsel parents and 40.3% (n = 504/1250) reported not understanding the risks and benefits well enough to counsel adult men. A substantial minority of physicians may need additional training and/or information about current male circumcision research to feel comfortable counseling parents of newborn male infants or adult men.

Residency training in neonatal circumcision: a pilot study and needs assessment

PURPOSE

Routine neonatal circumcision is one of the most commonly performed procedures in a neonate. Residents are expected to acquire the skills to properly evaluate the neonate and gain proficiency in performing circumcision despite significant variability in training. We performed a needs assessment to evaluate obstetric-gynecology residency training in neonatal circumcision.

MATERIALS AND METHODS

We performed an online self-assessment survey of obstetric-gynecology residents at Prentice Hospital, Chicago, from November 2008 to February 2009. Using images of uncircumcised penises residents were asked to identify which patients were candidates for routine neonatal circumcision.

RESULTS

Of 36 obstetric-gynecology residents 27 responded to the survey. Most respondents planned to perform neonatal circumcision when in practice, 44% had no formal training in circumcision and most were comfortable performing routine neonatal circumcision. Overall respondents were less comfortable evaluating whether the a newborn penis could undergo circumcision safely. When presented with 10 pictures of penises and asked to determine whether the neonate should undergo circumcision, 0% of respondents correctly identified all contraindications to neonatal circumcision with an average of 42% of contraindications identified correctly. Of the respondents 77% listed practical experience as the first choice to learn a procedure with an online module preferred by 55% as the second choice.

CONCLUSIONS

Although most residents feel competent to technically perform the procedure, they are not confident in their ability to judge the appropriate contraindications to neonatal circumcision. This needs assessment highlights the necessity for further curriculum development and formalized training in this domain.

Psychosocial factors influence parental decision for circumcision in pediatric males of African American descent

BACKGROUND

The most recent policy statement by the American Academy of Pediatrics suggests there are insufficient data to recommend routine newborn circumcision. Nevertheless, circumcision rates have not declined in the United States. Some studies suggest that African Americans are less likely to be circumcised. In blacks that choose to circumcise their males, we sought to examine the factors that drive parents to favor circumcision.

METHODS

The Parental Attitudes on Circumcision questionnaire was utilized to obtain demographic information and attitudinal responses to circumcision during urology clinic sessions at Howard University Hospital, a major teaching hospital located in an urban setting. Parents and caregivers of male children aged 3 months to 7 years participated. Valid responses from 146 participants were collected.

RESULTS

Ninety-six percent of our respondents believe that circumcision is healthy. Forty-one percent indicated health reasons as the most important influencing factor for choosing to circumcise their child, while 25% selected maternal preference. Eighty-one percent of all respondents indicated that 1 or more health care providers asked about their decision to circumcise their child. The mother was 12 times more likely than the father to make the final decision for circumcision, especially when her personal preference played a role. Eighty-eight percent of respondents felt that circumcision is painful, but 87% considered the procedure safe, and another 72% believe that it is a necessary procedure.

CONCLUSION

African American parents strongly believe that circumcision is essential for a healthy state and are willing to opt for the procedure despite the belief that it may be painful for the child. The mother primarily made the final decision to circumcise her child, largely based on the perceived health and hygiene benefits. In blacks, the mother yields considerable influence in the decision to circumcise the child, with maternal preference as the main reason for seeking circumcision in as much as a quarter of cases.

Why circumcision is a biomedical imperative for the 21(st) century

Circumcision of males represents a surgical "vaccine" against a wide variety of infections, adverse medical conditions and potentially fatal diseases over their lifetime, and also protects their sexual partners. In experienced hands, this common, inexpensive procedure is very safe, can be pain-free and can be performed at any age. The benefits vastly outweigh risks. The enormous public health benefits include protection from urinary tract infections, sexually transmitted HIV, HPV, syphilis and chancroid, penile and prostate cancer, phimosis, thrush, and inflammatory dermatoses. In women circumcision of the male partner provides substantial protection from cervical cancer and chlamydia. Circumcision has socio-sexual benefits and reduces sexual problems with age. It has no adverse effect on penile sensitivity, function, or sensation during sexual arousal. Most women prefer the circumcised penis for appearance, hygiene and sex. Given the convincing epidemiological evidence and biological support, routine circumcision should be highly recommended by all health professionals.

Declining rates in male circumcision amidst increasing evidence of its public health benefit

Background

Recent experimental evidence has demonstrated the benefits of male circumcision for the prevention of human immunodeficiency virus (HIV) infection. Studies have also shown that male circumcision is cost-effective and reduces the risk for certain ulcerative sexually transmitted diseases (STDs). The epidemiology of male circumcision in the United States is poorly studied and most prior reports were limited by self-reported measures. The study objective was to describe male circumcision trends among men attending the San Francisco municipal STD clinic, and to correlate the findings with HIV, syphilis and sexual orientation.

Methods and Findings

A cross sectional study was performed by reviewing all electronic records of males attending the San Francisco municipal STD clinic between 1996 and 2005. The prevalence of circumcision over time and by subpopulation such as race/ethnicity and sexual orientation were measured. The findings were further correlated with the presence of syphilis and HIV infection. Circumcision status was determined by physical examination and disease status by clinical evaluation with laboratory confirmation. Among 58,598 male patients, 32,613 (55.7%, 95% Confidence Interval (CI) 55.2–56.1) were circumcised. Male circumcision varied significantly by decade of birth (increasing between 1920 and 1950 and declining overall since the 1960's), race/ethnicity (Black: 62.2%, 95% CI 61.2–63.2, White: 60.0%, 95% CI 59.46–60.5, Asian Pacific Islander: 48.2%, 46.9–49.5 95% CI, and Hispanic: 42.2%, 95% CI 41.3–43.1), and sexual orientation (gay/bisexual: 73.0%, 95% CI 72.6–73.4; heterosexual: 66.0%, 65.5–66.5). Male circumcision may have been modestly protective against syphilis in HIV-uninfected heterosexual men (PR 0.92, 95% C.I. 0.83–1.02, P = 0.06).

Conclusions

Male circumcision was common among men seeking STD services in San Francisco but has declined substantially in recent decades. Male circumcision rates differed by race/ethnicity and sexual orientation. Given recent studies suggesting the public health benefits of male circumcision, a reconsideration of national male circumcision policy is needed to respond to current trends.

Pain relief for neonatal circumcision: a follow-up of residency training practices

OBJECTIVE

To assess current training practices regarding the provision of effective analgesia for routine newborn circumcision.

METHODS

All family practice (FP), obstetric and gynecologic (OB/GYN), and pediatric (PED) residency program directors in the United States received a mailed survey in 2003 (N = 940).

RESULTS

Survey responses were received from 86% (811/940) of the programs (FP 88%, OB/GYN 82%, and PED 87%). Eighty-two percent (669/811) of all programs surveyed taught circumcision (FP 95%, OB/GYN 89%, and PED 49%). Of programs that taught circumcision, 97% (648/669) taught the administration of an anesthetic, either locally or topically. This proportion is significantly higher than that reported in 1998 (71%, 374/527; P < .001). However, of these same programs that taught circumcision, the anesthetic techniques were used frequently or always in only 84%.

CONCLUSIONS

The percentage of training programs that teach effective analgesia for neonatal circumcision increased dramatically since the time of the previous data collection. Despite this improvement in teaching practices, some training programs may not consistently use effective analgesia for neonatal circumcision.

Analgesia and local anesthesia during invasive procedures in the neonate

BACKGROUND

Preterm and full-term neonates admitted to the neonatal intensive care unit or elsewhere in the hospital are routinely subjected to invasive procedures that can cause acute pain. Despite published data on the complex behavioral, physiologic, and biochemical responses of these neonates and the detrimental short- and long-term clinical outcomes of exposure to repetitive pain, clinical use of pain-control measures in neonates undergoing invasive procedures remains sporadic and suboptimal. As part of the Newborn Drug Development Initiative, the US Food and Drug Administration and the National Institute of Child Health and Human Development invited a group of international experts to form the Neonatal Pain Control Group to review the therapeutic options for pain management associated with the most commonly performed invasive procedures in neonates and to identify research priorities in this area.

OBJECTIVE

The goal of this article was to review and synthesize the published clinical evidence for the management of pain caused by invasive procedures in preterm and full-term neonates.

METHODS

Clinical studies examining various therapies for procedural pain in neonates were identified by searches of MEDLINE (1980-2004), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2004), the reference lists of review articles, and personal files. The search terms included specific drug names, infant-newborn, infant-preterm, and pain, using the explode function for each key word. The English-language literature was reviewed, and case reports and small case series were discarded.

RESULTS

The most commonly performed invasive procedures in neonates included heel lancing, venipuncture, IV or arterial cannulation, chest tube placement, tracheal intubation or suctioning, lumbar puncture, circumcision, and SC or IM injection. Various drug classes were examined critically, including opioid analgesics, sedative/hypnotic drugs, nonsteroidal anti-inflammatory drugs and acetaminophen, injectable and topical local anesthetics, and sucrose. Research considerations related to each drug category were identified, potential obstacles to the systematic study of these drugs were discussed, and current gaps in knowledge were enumerated to define future research needs. Discussions relating to the optimal design for and ethical constraints on the study of neonatal pain will be published separately. Well-designed clinical trials investigating currently available and new therapies for acute pain in neonates will provide the scientific framework for effective pain management in neonates undergoing invasive procedures.

THE INCREASING INCIDENCE OF NEWBORN CIRCUMCISION: DATA FROM THE NATIONWIDE INPATIENT SAMPLE

PURPOSE

Newborn circumcision is the most common surgical procedure in the United States, yet there are few contemporary data regarding circumcision rates or the factors that affect these rates. The goal of this study was to determine trends in the national rate of newborn circumcision between 1988 and 2000, and to evaluate patient and hospital factors associated with newborn circumcision.

MATERIALS AND METHODS

The Nationwide Inpatient Sample provides information on 5 million to 7 million inpatient stays per year. Newborn male hospitalizations were selected, and those newborns who underwent circumcision were identified using International Classification of Disease-9 procedure codes. Weighted national estimates of circumcision rates were calculated, and patient and hospital characteristics were examined to identify factors associated with newborn circumcision.

RESULTS

We identified 4,657,402 newborn male hospitalizations during a 13-year period. Circumcision rates increased significantly with time-48.3% of newborn males underwent circumcision in 1988 to 1991 vs 61.1% in 1997 to 2000 (p <0.0001). In multivariate regression analysis the odds of circumcision increased by 6.8% per year during the study period (p <0.0001). Patient characteristics associated with increased odds of circumcision in the multivariate model included private insurance (p <0.0001), higher socioeconomic status (p <0.0001), fewer co-morbid diagnoses (p <0.0001) and black race (p <0.0001). Hospital factors associated with increased odds of circumcision included Northeast or Midwest geographic region and rural location.

CONCLUSIONS

There was a significant increase in the rate of newborn circumcision between 1988 and 2000. The increase may be related to increased recognition of the potential medical benefits of circumcision. However, the increase may also result in a higher incidence of surgical complications of circumcision.

Pain relief for neonatal circumcision

BACKGROUND

Circumcision is a painful procedure that many newborn males undergo in the first few days after birth. Interventions are available to reduce pain at circumcision; however, many newborns are circumcised without pain management.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of interventions for reducing pain at neonatal circumcision.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), MEDLINE (1966 - April 2004), EMBASE (1988 - 2004 week 19), CINAHL (1982 - May week 1 2004), Dissertation Abstracts (1986 - May 2004), Proceedings of the World Congress on Pain (1993 - 1999), and reference lists of articles. Language restrictions were not imposed.

SELECTION CRITERIA

Randomised controlled trials comparing pain interventions with placebo or no treatment or comparing two active pain interventions in male term or preterm infants undergoing circumcision.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed trial quality and extracted data. Ten authors were contacted for additional information. Adverse effects information was obtained from the trial reports. For meta-analysis, data on a continuous scale were reported as weighted mean difference (WMD) or, when the units were not compatible, as standardized mean difference.

MAIN RESULTS

Thirty-five trials involving 1,984 newborns were included. Thirty-three trials enrolled healthy, full term neonates, and two enrolled infants born preterm. Fourteen trials involving 592 newborns compared dorsal penile nerve block (DPNB) with placebo or no treatment. Compared to placebo/no treatment, DPNB demonstrated significantly lower heart rate [WMD -35 bpm, 95% CI -41 to -30], decreased time crying [WMD -54 %, 95% CI -64 to -44], and increased oxygen saturation [WMD 3.2 %, 95% CI 2.7 to 3.7]. Six trials involving 190 newborns compared eutectic mixture of analgesics (EMLA) with placebo. EMLA demonstrated significantly lower facial action scores [WMD -46.5, 95% CI -80.4 to -12.6], decreased time crying [WMD - 15.8 %, 95% CI -20.8 to -6.8] and lower heart rate [WMD -15 bpm, 95% CI -19 to -10]. DPNB, compared with EMLA in four trials involving 164 newborns, demonstrated significantly lower heart rate [WMD -17 bpm, 95% CI -23 to -11] and pain scores. When compared with sucrose in two trials involving 126 newborns, DPNB demonstrated less time crying [MD -166 s, 95% CI -211 to -121], and lower heart rate [WMD -27 bpm, 95% CI -33 to -20]. Results obtained for trials comparing oral sucrose and oral analgesics to placebo, and trials of environmental modification were either inconsistent or were not significantly different. Adverse effects included gagging, choking, and emesis in placebo/untreated groups. Minor bleeding, swelling and hematoma were reported with DPNB. Erythema and mild skin pallor were observed with the use of EMLA. Methaemoglobin levels were evaluated in two trials of EMLA, and results were within normal limits.

REVIEWERS' CONCLUSIONS

DPNB was the most frequently studied intervention and was the most effective for circumcision pain. Compared to placebo, EMLA was also effective, but was not as effective as DPNB. Both interventions appear to be safe for use in newborns. None of the studied interventions completely eliminated the pain response to circumcision.

Male neonatal circumcision: indications, controversies and complications

The debate about whether to circumcise infants in the neonatal period likely will continue. As the medical and ethical issues are discussed and studied, however, economic factors are beginning to limit the practice in the United States. As the shift in reimbursement occurs, parents who believe that circumcision is a medically necessary practice will need to be reassured that their child may lead a healthy life with an intact foreskin.

Neonatal Circumcision: A Review of the World’s Oldest and Most Controversial Operation

Untimely old, circumcision has elicited more controversy and war of words than any surgical procedure in history. Although previous claims of benefits like curing masturbation, gout, epilepsy, and even insanity were no doubt absurd, important research has shed light on real medical benefits of circumcision. In particular, the procedure has consistently shown to result in the decreased risk of debilitating and costly diseases such as HIV, cervical cancer, and infantile urinary tract infection. Because of advances in the understanding of the anatomy of the foreskin and pain conditioning in infants, prevailing attitudes have changed about anesthesia and analgesia during the procedure. This article objectively summarizes the bulk of significant medical literature over the last century to provide an accurate statement about what we know and what we do not know about neonatal circumcision, including its history, epidemiology, medical benefits, complications, contraindications, techniques, management for pain, and current controversies.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the evolution of circumcision, to list the potential benefits of circumcision, to outline the various neonatal circumcision techniques, and to summarize the data on the use of analgesia for circumcision.

Attitudes and practices regarding circumcision in Turkey

BACKGROUND

In Turkey, circumcision is a necessity for boys to gain a masculine identity. In contrast to Western societies, where circumcision is performed in the neonatal period, it is performed at older ages in our population, and the timing may affect the psychosocial well-being of males. The person who performs the operation, a physician or a traditional circumciser, may affect their health as well.

OBJECTIVE

To provide some information about the practice of circumcision in Turkey, such as timing, by whom and why it is performed in our country, and relation of their fathers' past emotions about their own circumcision to this current practice.

METHODS

Questionnaires were filled out in face-to-face interviews with parents of 1235 male children under 16 years of age who attended well-child clinics of Gazi University Hospital and 10 different primary health care centres throughout Ankara, Turkey.

RESULTS

Median age of circumcision was found to be 6 years. Only 14.8% of children were circumcised before 1 year of age. The main reasons for circumcision were religious and traditional. The medical benefits of the procedure outweighed the traditional reasons for only 15.2% of the families. The operation was carried out by a traditional circumciser in 13.3% of the children. Most of the fathers who could remember their own emotions about circumcision confessed that they had been frightened. They remembered the procedure as painful. Indeed, the mean age of their sons' circumcision was close to their own circumcision age.

CONCLUSIONS

Traditions still play an important role in the timing of circumcision and by whom and why it is performed in Turkey. Changing times and educational levels do not seem to affect the traditional approach to circumcision.

A pictorial and video guide to circumcision without pain

3 Despite the 1999 American Academy of Pediatrics (AAP) policy statement indicating that routine neonatal circumcision is not medically necessary, circumcision continues to be the most frequently performed surgical procedure in the newborn period in the United States. Further, many health care practitioners routinely perform this procedure without the use of any or with inadequate or ineffective analgesia and anesthesia. Multiple studies have evaluated the safety and efficacy of specific pharmacologic and nonpharmacologic interventions to relieve circumcision pain and discomfort. Penile nerve blocks, local anesthetics, various operative instruments, acetaminophen, sweet oral solutions, pacifiers, a physiologic restraining device, intrauterine sounds, and music all have been evaluated. This article synthesizes these studies and highlights their significance for current clinical practice. The article provides a detailed pictorial and video guide to circumcision with an emphasis on the use of multimodal strategies to ensure adequate anesthesia, analgesia, and infant comfort before, during, and after the procedure.

Office pediatric urologic procedures from a parental perspective

OBJECTIVES

To determine the parent perception of discomfort (PPD) in children receiving local anesthesia for the lysis of labial adhesions, meatotomy, and newborn circumcision; the parents' perceived outcome of these procedures; and the overall satisfaction of parents when these procedures are performed in the office.

METHODS

A confidential phone survey was given to 99 parent participants whose children had received local anesthesia for the lysis of labial adhesions (n = 14), meatotomy (n = 28), or newborn circumcision (n = 57). Parents in the labial adhesion and meatal stenosis groups were asked to rate their child's level of discomfort (PPD) during the procedure as mild (1), moderate (2), or severe (3), and those in the circumcision group were asked to use the same scale to rate their child's discomfort after the procedure. Parents were also asked whether they thought the procedure was successful and whether they were satisfied with their decision to have it done in the office using local anesthesia.

RESULTS

Among the labial adhesion, meatotomy, and circumcision groups, the mean PPD +/- SD was 1.64 +/- 0.75, 1.54 +/- 0.69, and 1.21 +/- 0.53, respectively. The observed procedures, lysis of labial adhesions and meatotomy, had a significantly higher PPD score (P = 0.005) than the unobserved procedure (circumcision). Parents reported good outcomes in 94 (94.9%) of 99 children, with 4 girls experiencing recurrent labial adhesions and 1 boy experiencing recurrent meatal stenosis. Overall, 95 (96.0%) of 99 parents stated that they were satisfied with their decision to have the procedure done in the office with local anesthesia. Of the remaining 4 parents, 3 parents in the circumcision group stated they would have preferred general anesthesia, and 1 parent in the labial adhesion group was undecided.

CONCLUSIONS

The PPD is greater if the parent observes their child's procedure. However, office procedures using local anesthesia for the lysis of labial adhesions, meatotomy, and newborn circumcision are well accepted among the parent population.

A randomized, controlled trial of a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) versus penile nerve block for pain relief during circumcision

OBJECTIVE

We set out to compare a eutectic mixture of local anesthetic cream (lidocaine and prilocaine) to dorsal penile nerve block with lidocaine for anesthesia during circumcision.

STUDY DESIGN

In a double-blind study, term newborns were randomized to local anesthetic cream and sodium chloride solution dorsal penile nerve block (n = 31) or to placebo cream and lidocaine dorsal penile nerve block (n = 29). Pain was assessed by determination of heart rate, respiratory rate, and behavioral distress scoring. Group differences were evaluated with repeat-measures analyses of variance.

RESULTS

Distress scores and heart rates were significantly higher in the eutectic mixture group than in the lidocaine group. Respiratory rates were higher in the eutectic mixture group but did not reach statistical significance.

CONCLUSIONS

Distress scores and heart rates were significantly higher in infants treated with the anesthetic mixture than in infants treated with lidocaine. Dorsal penile nerve block with lidocaine is a more efficacious means of providing anesthesia for neonatal circumcision than the mixture of local anesthetics.