Neonatal Circumcision: When Can Infants Reliably Be Expected to Void?

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EXPERIENCE AND REASON—Briefly Recorded

‘‘In Medicine one must pay attention not to plausible theorizing but to experience and reason together. . . . I agree that theorizing is to be approved, provided that it is based on facts, and systematically makes its deductions from what is observed. . . . But conclusions drawn from unaided reason can hardly be serviceable; only those drawn from observed fact.’’ Hippocrates: Precepts. (Short communications of factual material are published here. Comments and criticisms appear as letters to the Editor.)

Neonatal Circumcision: When Can

Infants Reliably Be Expected to

Void?

ABSTRACT. Objective. Analysis of factors influenc-ing voidinfluenc-ing after neonatal circumcision.

Design. Prospective study of the following factors in 200 circumcised infants: birth weight, gestational and postnatal age, type and timing of feeding before the procedure, and timing of last voiding before circumci-sion.

Results. There was no significant difference in the age when circumcision was performed between breast-fed infants (6 and 60 hours) and in those formula-breast-fed (8 and 130 hours). All infants voided after circumcision, with 75% of breastfed infants and 100% of formula-fed infants voiding within 8 hours of the procedure. Breast-fed infants voided up to 8 hours after the procedure, compared with up to 6 hours in formula-fed infants, but without a significant difference.

The interval between last feed before the procedure and the time of voiding after circumcision was signifi-cantly shorter in formula-fed infants (1 to 9 hours) than in breastfed infants (2 to 21 hours). The interval between precircumcision and postcircumcision voiding was also significantly shorter in formula-fed infants (3 to 12 hours) than in breastfed infants (1 to 23 hours). Ninety percent of formula-fed and 64% of breastfed infants voided within 10 hours of the last voiding before circum-cision.

No infants aspirated during the procedure, regardless of the time of the last feed. No hemorrhagic, infectious, or surgical complications of circumcision were observed.

Conclusion. Postoperative voiding time is predict-able. Healthy infants who undergo an uncomplicated circumcision can be discharged before voiding occurs.

Pediatrics 1998;102:150 –152; neonatal circumcision, neo-natal feeding, voiding.

C

ircumcision is routinely offered to male in-fants in our institution. It is the most common surgical procedure carried out on infants and is a safe procedure when performed by experienced physicians on stable and healthy infants.1_Although

rare, complications have been reported, with a fre-quency of 0.2% to 0.6%.2– 6

Our current policy is to withhold infant discharge until voiding has been observed after the procedure.

Recent data advocate discharging the infant before voiding, in keeping with early discharge.7_However,

as uncertainties remain concerning the expected time of voiding after the procedure and whether this is affected by factors such as the type of feeding and the timing of the last feed before surgery, we undertook a prospective study to look into these potential fac-tors.

METHODS

A prospective, nonblinded study of all consecutive infants who underwent circumcision in our institution in March and April 1996 was carried out.

The procedure was performed on healthy infants before dis-charge, in the absence of contraindications, and after written pa-rental consent. The procedure was carried out by obstetricians in the nursery at 3 different times during the day (8:30am, 12:30pm, and 4 pm). No circumcision was performed outside these time periods. Immediately after offering the infant 2 mL of 50% sucrose orally to decrease pain response, the procedure was carried out with the Gomco clamp (Gomco Division of Allied Health Care Products, Inc, St Louis, MO). No local anesthesia was used and the infants were fed on demand, regardless of the time of circumci-sion. A gauze impregnated with petroleum jelly was lightly wrapped around the wound site and the infant diapered. The infants were discharged only after voiding had been documented. Nursing staff documented the time of circumcision (beginning of the procedure), the type of feeding (breast or formula), the precise time of the beginning of the last feed before the procedure, the time of observed voiding or of noted last wet diaper before circumcision and of noted first wet diaper after the procedure, and the exact time of discharge from hospital. Other data we reviewed included maternal parity, mode of delivery, birth weight, gesta-tional age, neonatal disorders and any complications related to the procedure.

Unlike feeding, procedure and discharge times, the voiding time was not exact but estimated from the time of observed wet diaper. The resulting time intervals calculated are, therefore, not exact times but estimates. Therefore, the Mann-Whitney U test was used to compare these nonparametric intervals. Continuous variables were compared with the Student’sttest.

RESULTS

A total of 200 male infants underwent circumcision during the study period—185 were full-term and 15 were preterm (35–37 weeks gestation). The average birth weight was 3595 6 2310 g (mean 6 SD), ma-ternal parity was 562, and gestational age was 396 1.2 weeks.

One hundred seventy-nine infants were sively breastfed, 11 supplemented, and 10 exclu-sively formula-fed. For data analysis, we only com-pared exclusively breastfed infants and those entirely formula-fed. There was no significant differ-ence in maternal parity (P5.3), gestational age (P5

.7), or birth weight (P5.5) between the two groups. Circumcision was performed between 6 and 60

Received for publication Jun 25, 1997; accepted Dec 23, 1997.

Reprint requests to (H.N.) Al Hasa Specialty Services Division, Saudi Aramco–Al Hasa Health Center, Box 6030, Mubarraz 31311, Kingdom of Saudi Arabia.

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hours of age in breastfed infants and between 8 and 130 hours in those formula-fed (Table 1), without a significant difference (P 5 .71). Circumcision was delayed in 13 infants because of medical problems (7 patients required phototherapy, 5 had respiratory symptoms, and 1 was hypoglycemic), 9 of whom were exclusively breastfed.

All infants voided after circumcision, with 75% of breastfed infants and 100% of formula-fed infants voiding within 8 hours of the procedure. Breastfed infants voided up to 8 hours after the procedure, compared with up to 6 hours in formula-fed infants (Table 2), but without a significant difference (P 5

.75). When breastfed infants were studied separately, there was no significant difference in time of voiding after the procedure between 14 infants of

primipa-rous mothers and the other 165 infants of multipa-rous mothers (P5.15).

As shown in Table 3, the interval between last feed before the procedure and the time of voiding after circumcision was significantly shorter in formula-fed infants (1 to 9 hours) than in breastfed infants (2 to 21 hours) (P 5.03). The interval between precircumci-sion and postcircumciprecircumci-sion voiding was also signifi-cantly shorter in formula-fed infants (3 to 12 hours) than in breastfed infants (1 to 23 hours) (P 5 .01). Ninety percent of formula-fed and 64% of breastfed infants voided within 10 hours of the last voiding before circumcision.

No infants aspirated during the procedure, regard-less of the time of the last feed. No hemorrhagic, infectious, or surgical complications of circumcision were observed.

DISCUSSION

In our series, all infants (100%) voided after cir-cumcision—95% of them within 6 hours after the procedure, regardless of their gestational age. These results are comparable to previous studies.7

Ninety percent of formula-fed and 64% of breast-fed infants voided within 10 hours of the last voiding before circumcision. Although the interval separat-ing the time of voidseparat-ing before and after the proce-dure was significantly shorter in formula-fed than in breastfed infants, it was ,15 hours in 90% of all infants. Although a higher milk intake in formula-fed infants is a possible explanation for this observed difference, this remains speculative as our study did not measure the total amount of enteral intake or changes in body weight.

Our data confirm that healthy breastfed or formula-fed infants who undergo an uncomplicated circum-cision can be discharged before postoperative void-ing if hemostasis is ensured and no bleedvoid-ing is ob-served after the procedure. The family should be instructed to observe the infant for bleeding at home and to reliably expect 75% of breastfed infants and 100% of formula-fed infants to void within 8 hours of the procedure. Significant deviation from the above warrants reporting to the medical or nursing staff. These guidelines will encourage early discharge home of the mother and her infant, providing they are both in a clinically stable condition and the fam-ily is reliable and well-instructed in the care of the infant. They will also help decrease any parental

TABLE 1. Neonatal Circumcision: Age at Circumcision and Interval Between Procedure and Discharge

Hours Number of Infants

Age at Circumcision Discharge After Circumcision Breastfed Formula-fed Breastfed Formula-fed

,12 17 1 84 2

12–24 91 5 49 1

24–48 69 2 38 3

.48 2 2 8 4

Total 179 10 179 10

Range 6–60 8–130 1–164 1–162

Pvalue* .71 .015

* Mann-WhitneyUtest.

TABLE 2. Neonatal Circumcision: Preprocedure Feeding and Postprocedure Feeding Intervals

Last Feed Before Procedure

First Void After Procedure Breastfed Formula-fed Breastfed Formula-fed

,2 47 2 33 1

2–4 96 3 61 5

2–6 32 5 64 2

6–8 4 0 21 2

Total 179 10 179 10

Range 0–7 0–4 0–8 0–6

Pvalue* .3 .75

TABLE 3. Neonatal Circumcision: Details of Preprocedure and Postprocedure Voiding Intervals

First Voiding After Circumcision

Preprocedure and Postprocedure Voiding Interval

Preprocedure Feed and Postprocedure Voiding

Interval

Breastfed Formula-fed Breastfed Formula-fed Breastfed Formula-fed

,5 69 8 15 3 18 3

5–10 76 2 77 5 90 7

10–15 24 0 66 2 54 0

.15 10 0 21 0 17 0

Total 179 10 179 10 179 10

Range 0–19 1–8 1–23 3–12 2–21 1–9

Pvalue* .007 .012 .039

EXPERIENCE AND REASON 151

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anxiety when it comes to the expected time of void-ing after circumcision.

Hassib Narchi, MD, FRCP, FRCPCH Naji Kulaylat, MD, MRCP, FRCPCH

Al Hasa Specialty Services Division Saudi Aramco–Al Hasa Health Center Mubarraz 31311, Kingdom of Saudi Arabia

ACKNOWLEDGMENTS

We thank Maggie Roach, RGN, and her nursing staff for par-ticipation in the data collection and Saudi Aramco Medical Ser-vices Organization for the use of their facilities, which supplied the data and study that resulted in this paper. The authors were employed by Saudi Aramco during the time the study was con-ducted and when the paper was written.

REFERENCES

1. Schoen EJ, Anderson G, Bohon D, Hinman F Jr, Poland RL, Wakeman EM. Report of the AAP Task Force on Circumcision.Pediatrics.1989;84: 388 –391

2. Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys.Pediatrics. 1989;83:1011–1015

3. Gee WF, Anslee JS. Neonatal circumcision: a 10-year overview with comparison of the Gomco clamp and the Plastibell device.Pediatrics. 1976;58:824 – 827

4. Woodside JR. Necrotizing fasciitis after neonatal circumcision.Am J Dis Child.1980;134:301–302

5. Feinberg AN, Blaczek MA. Mechanical complications of a circumcision with a Gomco clamp.Am J Dis Child.1988;142:813– 814

6. Kaplan GW. Complications of circumcision.Urol Clin North Am.1983; 10:543–549

7. Perlmutter DF, Lawrence JM, Krauss AN, Auld PAM. Voiding after neonatal circumcision.Pediatrics.1995;96:1111–1112

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DOI: 10.1542/peds.102.1.150

1998;102;150

Pediatrics

Hassib Narchi and Naji Kulaylat

Neonatal Circumcision: When Can Infants Reliably Be Expected to Void?

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DOI: 10.1542/peds.102.1.150

1998;102;150

Pediatrics

Hassib Narchi and Naji Kulaylat

Neonatal Circumcision: When Can Infants Reliably Be Expected to Void?

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