Abstract by Marlene Walden, PhD, RNC, NNP
The American Academy of Pediatrics (AAP) recently issued a new circumcision policy statement which states that the medical benefits of male newborn circumcision are not sufficiently significant to recommend it as a routine procedure. This policy statement reverses its earlier 1989 policy statement which concluded that, while the circumcision procedure had associated risks, newborn male circumcision did provide certain potential medical benefits including reduction of urinary tract infections and sexually transmitted diseases, particularly acquired human immunodeficiency virus (HIV) infection. The reversal in position follows an ongoing debate by a number of medical societies in the developed world as well as new research findings which led the AAP to undertake a closer scrutiny of 40 years of available medical research on circumcision.
The AAP conducted extensive analysis on the association between circumcision status and the risk of urinary tract infections, penile cancer, and sexually transmitted diseases. In examining the association between circumcision status and the risk of developing a urinary tract infection (UTI), studies show an increased risk of UTI in uncircumcised males, with the greatest risk in infants younger than 1 year of age. While the estimated relative risk of UTI in uncircumcised male infants may be increased to as much as 10-fold during the first year of life, the absolute risk of a male uncircumcised infant developing a UTI is extremely low (at most, ~1%). Studies were also examined which explored the relationship between penile cancer and circumcision status. While uncircumcised males have more than a three-fold increase in penile cancer compared to circumcised males, the overall risk of developing penile cancer in an uncircumcised male in the United States remains quite low. In regards to circumcision status and sexually transmitted diseases, some research suggests that circumcised men may be at less risk for acquiring syphilis and HIV infection. The AAP policy concluded that behavioral factors might be more significant in determining a person's actual risk for acquiring sexually transmitted diseases than circumcision status.
The AAP policy statement also examined the incidence of complications associated with the circumcision procedure. The two most common, but rarely occurring complications, are minor bleeding and infection. While the true incidence of these complications is unknown, the absolute risk of a male infant developing one of these two complications following a newborn circumcision is at most ~ 0.1%.
The AAP recommendation for circumcision states that if circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy. In determining the appropriateness of a circumcision procedure when the procedure is not essential to the child's current well-being, the AAP policy statement emphasizes parental autonomy to determine what is in the best interest of their male newborn infant. The policy further obligates the physician to ensure that parents have been given accurate and unbiased information about the risks, benefits, and alternatives prior to making an informed choice and that they understand that circumcision is an elective procedure. The policy statement further expounds on the legitimacy of the parents using cultural, religious, and ethnic decisions in addition to the medical factors when determining the appropriateness of the procedure for their individual child.
In addition to examining the medical benefits of male newborn circumcision, the AAP for the first time in their circumcision policy history recommended that if parents decide to have their male infant circumcised, procedural analgesia should be provided. While subcutaneous ring block appears to provide superior analgesia, the AAP policy statement also endorses the use of dorsal penile nerve blocks and eutectic mixture of local anesthetics (EMLA Cream) for pain associated with the circumcision procedure. The statement also advocates for the use of more physiologic positioning of the newborn to decrease the distress associated with circumcision. A sucrose pacifier during the procedure and acetaminophen in the immediate postoperative period may be used to supplement analgesic approaches.
This policy statement has direct implications for nursing and medical staff caring for newborns and their families. First, because nurses are in a unique position to help educate parents regarding the care of their newborns, they must take responsibility for ensuring that each parent has accurate and unbiased information by which to make an informed decision regarding the appropriateness of the circumcision procedure for their newborn. To help answer common questions parents may have about the new guidelines on circumcision, the AAP has also developed a patient education brochure. Copies of the brochure, "Circumcision: Information for Parents" can be purchased from the AAP at the following address or printed from their database:
The second important implication concerns ensuring adequacy of analgesia for newborn circumcisions. Despite adequate scientific evidence that newborns feel and respond to pain, circumcisions are still being performed in many nurserys around the country with either insufficient analgesia or no analgesia at all. Nurses can use this policy statement to advocate more effectively for the use of optimal pain relief for circumcision procedures. A previous barrier to the use of one analgesic method has been removed with the recent approval by the U.S. Food and Drug Administration (FDA) to expand the pediatric indication for EMLA Cream to birth with a gestational age of 37 weeks or greater. Previously, EMLA Cream was contraindicated for use in infants less than one month of age due to the potential risk of methemoglobinemia. Now EMLA Cream can be safely considered as an alternative to analgesic management of newborn circumcisions when other more effective regional methods of analgesia cannot be employed.
In summary, ongoing scholarly dialogue between health care professionals, new research findings, and systematic reviews of the literature often stimulate clinical inquiry of traditional care practices and lead the way to the development of new recommendations for practice. The AAP policy statement is an excellent example of how an evidence-based approach to clinical practice can improve the quality of care delivered to all newborns and their families.
Task Force on Circumcision of the American Academy of Pediatrics: Circumcision policy statement. Pediatrics, 103(3), 686-693. 1999.
See Chapter 8 in Essentials of Pediatric Nursing, 5th edition.
See Chapter 8 in Nursing Care of Infants and Children, 6th edition.
March 15, 2002
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