Circumcision: The Effect of Information on Parental Decision Making

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PEDIATRICS Vol. 71 No. 3 March 1 983 453

EXPERIENCE

AND

REASON--Briefly

Recorded

.‘In Medicine one must pay attention not to plausible theorizing but to experience and reason

together. . . .Iagree 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.)

Circumcision:

The

Effect

of

Information

on Parental

Decision

Making

Circumcision, a surgical procedure of debatable

medical value, is performed on more than 80% of

male infants in the United States.’3 Although there

are numerous documented complications of the

sur-geny,4 parents are rarely informed adequately about

the operation or its risks.5’6 We speculated that if

parents were given more complete and objective

information about the procedure, some might elect

not to have their sons circumcised. This study was

designed to test this hypothesis.

METHODS

During a 3-month period, 104 mothers seen in

our prenatal clinic at 30 to 34 weeks of gestation

were randomly assigned to receive, or not to receive,

written information about circumcision. This

infor-mation, occupying 2#{189}double-spaced pages,

con-sisted of a detailed description of the circumcision

procedure, the discomforts and risks, and the

po-tential benefits of circumcision. The information

was based upon the report of the Committee on

Fetus and Newborn of the American Academy of

Pediatrics.’ It contained the conclusion reached in

this report; viz, that there are no valid medical

indications for circumcision in the newborn period,

and that personal hygiene can provide benefits

sim-ilar to routine circumcision without the attendant

surgical risk. The mothers were invited to read the

information and discuss it with the fathers. In the

group that did not receive written information,

in-formation regarding circumcision, when provided,

was given by the obstetric resident or attending

physician caring for the mother, or the pediatric

resident or attending physician caring for the infant.

A structured questionnaire, previously field

tested, was administered to the parents of male

infants in the immediate postpartum period, prior

to hospital discharge. If the child was circumcised,

this questionnaire was administered after the

cir-cumcision was performed. The data were analyzed

using the nonpained t test,

x2

with Yates correction,

on the Fisher exact test when the expected value for

any cell was <5.

RESULTS

Fifty-one male infants were born to the 104

moth-ers: 23/51 mothers had received the written

infor-mation and 28 had not. Sociologic information and

the response to the questionnaires are provided in

the Table: 21/23 infants (91%) in the information

group and 27/28 (96%) in the no-information group

were circumcised. There were no significant

differ-ences between the two groups with regard to

paren-tal age, education, and occupation, understanding

of the circumcision procedure and its benefits and

risks, reasons for wanting circumcision, or

satisfac-tion with the amount of information received. Six

(26%) of the women who received the written

infor-mation did not know what circumcision was (v 25%

in the no-information group); 14 (61%) women said

that the information provided did not lead to any

further discussion and played no part in their

deci-sion to circumcise, or not to circumcise, their sons.

The only significant difference found between the

two groups was in the timing of the decision. In the

information group, 74% had made their decision

regarding circumcision before birth, whereas only

33% of the other parents did so (P = .001). The

provision of written information did not appear to

have any significant effect on the understanding of

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for, or against, newborn circumcision. It is possible,

however, that the design of the study contributed

Received Did Not P to this conclusion. In order to avoid physician bias

Informa- Rece,ve In- and its potential effect on the parents’ decision, the

tion formation . .

n = 23 n = 28 information was provided as a handout, by a nurse,

21 27 NS at the beginning of the clinic visit. The provision of

49.3 48 NS written mformation once, without purposeful verbal

or written reinforcement, might not be adequate for

25.9 27 NS decision making. However, 83% of women in the

i

information group said they had received enough

information on which to base a decision and only

four (17%) said they would have liked more

infor-mation. In our desire for objectivity, we might not

17 (74%) 9 (33%) have given sufficient emphasis to the view (disputed

6 (26%) 18 (67%) by some3) that circumcision is a procedure that is

17 (74%) 19 (70%) NS not medically necessary. Finally, the content itself

may not have been universally understandable.

6 (26%) 8 (30%) NS These concerns are pertinent to many studies that

0 0 NS test learning.

1 0 NS A question is whether this type of information

14 (61%) 15 (55%) NS should be unbiased, ie, should obstetricians and

1 0 NS pediatricians become active opponents of a

proce-0 3 (11%) NS dune that, apparently, has no medical basis? We are

0 1 NS reluctant to assume a role of active advocacy (one

(30%) (21%) way or the other) because our experience suggests

19 (83%) 17 (63%) NS that the decision is not usually a medical one.

Rather, it is based on the parents’ perceptions of

4 (15%) 10 (37%) NS hygiene, their lack of understanding of the surgical

risks, on their desire to conform to the pattern

established by the infant’s father and their own

societal structure. If circumcision practices are ever

to be changed, such changes will likely result from

organized advocacy of lay groups (as has happened

7 (30%) 7 (26%) in breast-feeding and family-centered care) rather

1 NS than from the efforts of the medical profession.

Whatever the view of the physician concerned, we

accept an obligation to provide appropriate

infor-0 1 mation to the parents, prior to delivery of the infant,

2 4 (15%) NS for the purpose of obtaining proper informed

con-21 (91%) 22 (81%) sent. Both our experience (37% of the

noninfonma-tion group) and that of others4’5 indicate that the

latter requirement is frequently not met.

the parents with regard to the risks and benefits of

circumcision.

Of the three women whose infants were not

cir-cumcised, two (one in each group) chose this course

because their husbands were not circumcised. One

mother in the information group said the decision

was the result of the information provided. On the

other hand, one mother whose son was circumcised

said that the information provided actually

rein-forced her (and her husband’s) previous decision in

favor of circumcision.

DISCUSSION

This study suggests that providing written

infor-mation to mothers in the third trimester of

preg-nancy has little role in the decision-making process

M. JEFFREY MAISELS, MB, BCH

Department of Pediatrics

BARBARA HAYES, RN, MSN

SARAH CONRAD, RNC

RONALD A. CHEZ, MD

Department of Obstetrics and Gynecology

The Milton S. Hershey Medical Center

Hershey, Pennsylvania

REFERENCES

1. Committee on Fetus and Newborn: Report of the ad hoc task force on circumcision. Pediatrics 1975;56:610-611

454 PEDIATRICS Vol. 71 No. 3 March 1983

TABLE. Parental Information and Response to Ques-tionnaires in Groups Studied

Infant circumcised

Combined parental age

(yr)

Combined education (yr)

Father circumcised

Understand meaning of

circumcision

Decision about

circumci-sion Before birth After birth Risks of circumcision

Not serious or don’t know

Could be serious

Very serious Benefits of circumcision:

None Hygiene Tradition Appearance Future sex life

Later problems

Don’t know

Received enough

informa-tion to make decision

Would have liked more

information

Information about

cir-cumcision (other

than written)

re-ceived from obstetri-cian

Before birth After birth None

Information received from pediatrician

Before birth After birth None

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Reprint requests to (L.C.) Children’s Orthopedic Hospital, P0 Box C-5371, Seattle, WA 98105.

American Academy of Pediatrics.

EXPERIENCE AND REASON 455

2. Wallerstein E: Circumcision: An American Health Fallacy.

New York, Springer Publishing Co, 1980

3. Warner E, Strashin E: Benefits and risks of circumcision.

Can Med Assoc J 1981;125:967-992

4. Kaplan GW: Circumcision: An overview. Curr Prob Pediatr

1977;7

5. Grimes DA: Routine circumcision of the newborn infant: A reappraisal. Am J Obstet Gynecol 1978;130:125-129

6. Herrera AJ, Trouern-Trend JBG: Routine neonatal circum-cisions. Am J Dis Child 1979;133:1069-1070

Disseminated

Neonatal

Herpes

Simplex

Virus

Type

1 from

a Maternal

Breast

Lesion

Most cases of neonatal herpes simplex virus

(HSV) result from contact with infected secretions

from the maternal genital tract.’ Postnatal

acqui-sition of neonatal HSV infections, a subject recently

reviewed by Light,2 is uncommon. We report a case

of fatal neonatal HSV-1 infection acquired by

con-tact with a maternal breast lesion. Restriction

en-donuclease “fingerprinting” revealed a similar

pat-tern in the viruses isolated from the maternal breast

lesion and the infant’s skin lesion. The purpose of

this report is to alert physicians of this potential

route of transmission, especially in women

experi-encing primary mucocutaneous HSV infection at or

near term.

CASE REPORT

A 3,693-g male infant was born to a 21-year-old white

primigravida after an uneventful term pregnancy.

Am-niotic membranes had been ruptured antifically 6#{189}hours

before delivery. The mother did not have any visible

external or internal genital lesions. Vaginal delivery was

vacuum assisted because of a difficult 10#{189}-hour labor.

Apgar scores were 6 at one minute and 8 at five minutes.

The infant was breast-fed from the day of birth, had an

uneventful nursery course, and was discharged from the

hospital on the second day of life. During her postnatal

hospitalization, the mother developed a “skin sore” on

the areola of her left breast.

On the fourth day of life, “pustules” appeared in the

right corner of the infant’s mouth and on his chin.

Smaller, but similar, pustules were noted in the diaper

area. The infant became lethargic, refused feedings, and

was admitted to the hospital at 5 days of age.

In addition to the skin lesions, physical examination

revealed a temperature of 37.9#{176}C,jaundice, poor cry, and

decreased activity. Peripheral WBC count was 15,300/FL

with a differential cell count of 38% polymorphonuclear

leukocytes, 21% band forms, 36% lymphocytes, 3%

mon-ocytes, and 2% eosinophils. The hemoglobin was 18.7 mgI

dL; hematocnt was 55%. Total bilirubin concentration

was 15.1 mg/dL; conjugated bilirubin, 1.3 mg/dL. CSF

analysis revealed: monocytes 5/jzL, protein 56 mg/dL,

and glucose 52 mg/dL. No organisms were seen on Gram

stain, and routine bacterial cultures revealed no growth.

The Gram stain of a penioral pustule showed 4+ WBC

and 4+ Gram-positive cocci in clumps. A culture of the

left eye subsequently grew coagulase-positive

staphylo-cocci. Treatment was begun with intravenous methicillin

and gentamicin for presumed staphylococcal sepsis.

On the following day, multiple oral, buccal, and lingual

ulcers measuring 3 mm or less in diameter developed. An infectious disease consultation suggested the diagnosis of

neonatal HSV infection. Scrapings from the mucosal

le-sions of the infant and the breast lesion of the mother

revealed multinucleated giant cells. Intravenous

vidara-bine was administered at a dose of 15 mg/kg/d. Over the

next five days, the infant’s condition continued to

dete-riorate. Increasing numbers of peripheral skin lesions, increasing seizure activity not controlled by conventional

antiseizure medications, frequent episodes of apnea and

bradycardia, an increase in serum aspartate

aminotrans-ferase to greater than 4,000 IU/mL and a decrease in the

platelet count to 39,0004iL developed. The infant died at

age 1 1 days. The parents declined consent for an autopsy.

Herpes simplex virus was isolated from the mouth of

the infant on days 6 and 7 of life, and on day 7 from the

breast lesions of the mother. Cultures of the vulva and cervix of the mother on day 7 of the infant’s life did not reveal herpes simplex virus. Immunoperoxidase typing of

the isolates from the infant and the mother showed them

to be HSV-1.3 Restriction endonuclease analysis of the

DNA of the HSV isolates from the infant’s mouth and

the mother’s lesion were performed by a modification of

the technique of Lonsdale.4 The Figure reveals the

re-striction endonuclease digestion using enzymes Barn H-i and Kpn 1. The HSV-1 isolates from the mother and the

infant had banding patterns identical with these enzymes

as well as the enzyme HpA-1. Antibodies to HSV in the

mother, infant, and father were determined by

microneu-tralization.5 Both mother and infant had titers of less

than 1:4 against HSV-1 and HSV-2. The father had

neutralizing antibody titers of 1:16 and 1:8 against

HSV-1 and HSV-2, respectively.

DISCUSSION

The clinical, epidemiologic, and restriction

en-donuclease analysis of the DNA from the HSV

isolated from the infant and mother indicate that

the source of HSV infection for this infant was from

oral mucosal contact with the mother’s HSV-1

breast lesion. The lack of neutralizing antibody to

HSV in maternal serum taken seven days after the

(4)

1983;71;453

Pediatrics

CHEZ

M. JEFFREY MAISELS, BARBARA HAYES, SARAH CONRAD and RONALD A.