Postneonatal Circumcision: Population Profile

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METHODS

Chart reviews were done at Primary Children’s

Medical Center and Cottonwood Hospital in Salt

Lake City, Utah, to identify all postneonatal

dir-cumcisions performed between January 1, 1985, and

January 1, 1987. Postneonatal circumcisions were

Postneonatal

Circumcision:

Population

Profile

Gordon

L. Larsen,

BS, and Scott

D. Williams,

MD

From the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah

ABSTRACT. Because postneonatal circumcision includes the risk of general anesthesia and costs more than elective

neonatal circumcision, a retrospective study was

per-formed to describe the population currently undergoing

postneonatal circumcision and to identify the factors

influencing decisions that lead to this procedure. A chart

review and follow.up telephone survey were done to

gather information concerning patients admitted for postneonatal circumcision to two Salt Lake City hospitals

during a 2-year period. From the 135 patients eligible for analysis, two distinct groups emerged: the “sick” group (n = 52)-those who had neonatal complications, and the

“well” group (n = 83)-those with no neonatal

compli-cations. The median age at circumcision was 5.5 months for the boys in the sick group and 35 months for the boys in the well group (P < .001, Student’s t test). During the

neonatal period, 32% of families in the well group

re-ceived anticircumcision advice from their primary care physician. The decision in favor ofcircumcision was made by two thirds of the families of sick infants before their sons were 6 weeks of age. Other surgery was performed

concurrent with the circumcision in 44% of patients in

the sick group and 24% of patients in the well group (P

< .0001, x’). Balanitis, phimosis, or a physician’s rec-ommendation were listed as the primary reason for post-neonatal circumcision by 50% of patents in the well group. Phimosis was listed by the surgeon as an indication

for postneonatal circumcision in 65% of all patients’

charts, although only 13% of parents listed phimosis as

an indication for their children’s circumcision. According to this profile of two distinct populations of postneonatal circumcision patients, pediatricians may be able to reduce

the incidence of this procedure by providing support of

individual preferences and objective information regard-ing circumcision to families of healthy infants during the neonatal period; by anticipating and facilitating the de-cisions surrounding neonatal circumcision for families of sick infants; and by educating families of uncircumcised boys about foreskin care and development during regular

well-child visits. Pediatrics 1990;85:808-812;

circumci-sion, newborn, phimosis.

In 1975, after reviewing the available data on the

proposed risks and benefits of neonatal

circumci-sion, the American Academy of Pediatrics

con-cluded that “there is no absolute medical indication

for routine circumcision of the newborn.”6”

Re-cently, the Academy published a revised position

concluding with the following, less definitive

state-ment: “Newborn circumcision has potential medical

benefits and advantages as well as disadvantages

and nisks.”28 Despite the controversies and

nec-ommendations, 70% to 90% of families in the

United States request that circumcision be

pen-formed on their newborn sons.3’4 Moreover, some

boys undergo circumcision after the neonatal

period. We found no published reports describing

the boys who undergo later circumcision or the

influences on their parents’ decisions leading to

this procedure.

The purpose of our study was as follows: (1) to

describe the population undergoing postneonatal

circumcision; (2) to identify factors influencing

par-ents’ decisions to have their sons circumcised in the

postneonatal period; (3) to determine whether

pni-many care physicians play an important role in the

parents’ decision not to have their son circumcised

in the neonatal period; and (4) to determine

whether boys likely to undergo postneonatal

cm-cumcision could be identified in the neonatal

period. Received for publication Jun 15, 1989; accepted Jul 26, 1989.

Presented, in part, at the annual meeting of the Ambulatory Pediatric Association Regions 9 and 10, Carmel, CA, February 6, 1989.

Reprint requests to (S.D.W.) 50 N Medical Dr, Dept of Pediat-rics, University of Utah Medical Center, Salt Lake City, UT

84132.

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defined as those circumcisions performed in the

operating suite on children older than 1 month of

age and younger than 18 years of age. Patients who

were undergoing circumcision revision or

circum-cision concurrent with hypospadias repair were

ex-cluded from the study. Families of the eligible

pa-tients were then contacted by telephone and asked

several questions concerning the influences,

atti-tudes, and decisions leading to their son’s

post-neonatal circumcision.

For statistical analysis, the population was

strat-ified into those children who experienced medical

complications during the neonatal period (the

“sick” group) and those who had an uncomplicated

neonatal course (the “well” group). Children were

assigned to the sick group if they were described by

their parents or surgeon as premature or requiring

newborn intensive care. Children not meeting these

criteria were assigned to the well group. Statistical

comparisons of the sick and well groups were

per-formed using the

x2

and Student’s t test. Statistical significance was defined as P < .05.

RESULTS

Charts were available for all 135 patients

identi-fled as eligible for the study; of these patients, 52

met the criteria for the sick group and 83, the well

group. The families of 111 (82%) patients were

contacted by telephone and all agreed to answer the

questionnaire. Within the sick and well groups,

telephone surveys were completed for 48 (92%) and

63 (76%) patients, respectively. rfhe patients came

from a pool of uncircumcised boys who were born

throughout a 17-year period and were residing

within indistinct referral areas for one of the two

hospitals at some point during the 2-year period of

our study. Therefore, the denominator for our

pop-ulation could not be determined and incidence rates

for postneonatal circumcision were not calculated.

The racial distribution of the study population

did not significantly differ from 1980 census data

for Salt Lake County.5 There was a statistically

significant difference between the racial

distnibu-tion of the sick and well groups (the percentage of

white boys was 96% and 66% in the sick and in the

well groups, respectively) (P < .001, x2). For all

reported data the statistically significant

differ-ences between the sick and well groups persisted

when we controlled for race.

In Table 1 are responses to three survey questions

concerning factors surrounding parents’ decisions

not to circumcise their sons in the neonatal period.

Parents’ reasons for deciding against neonatal din-cunlcision and the influences on their decisions

differed markedly between the groups. Parents in

the sick group were almost exclusively motivated

TABLE 1. Attitudes and Influences Surrounding

Par-ents’ Decisions not to Circumcise Their Sons During the Neonatal Period

Survey Item and Patient Group % of Patients

Parents’ reason for not circumcising child during the neonatal period

Well

Mother’s choice 22

Child adopted 22

Father’s choice 20

Advice of primary care physician 19

Sick

Prematurity 62

x2).

In Table 2 are responses to three survey questions

concerning factors surrounding parents’ decisions

to later circumcise their sons. When we categorized

the children’s ages when the parents first

consid-ered circumcision as “younger” (birth to 6 months

of age) and “olden” (greater than 6 months of age),

parents in the well group were shown to have first

considered circumcision much later than parents in

the sick group (P < .0001,

x2).

The mean ages of

the boys when the circumcision was actually

(3)

TABLE 2. Conditions Surrounding Parents’ Decisions

to Have Their Sons Circumcised After the Neonatal

Period

Child’s age when parents considered circumcision

Well 0-6 wk 6 wk-6 mo 6 mo-3 yr 3-5 y 5-12y >12 y Sick

0-6 wk 6 wk-6 mo 6 mo-3 y 3-5 y 5-12y >12 y 8 14 38 25 10 5 67 25 4 2 2 0 18 18 13 13 10 23 17 17 12 2 77 24 22 17 16 4

Survey Item and Patient Group % of Children

Parents’ indication for circumcision Well Phimosis Balanitis Social reasons Hygiene Father’s choice Sick Hygiene Father’s choice Social reasons Mother’s choice Phimosis

Surgeon’s indications for circumci-sion4 Well Phimosis Other surgery Other Parent’s desire Infection Patient’s desire Sick Other surgery Prematurity Phimosis Parent’s desire Other 69 50 46 28 8

4As many as three indications were recorded from each

medical chart, resulting in percentage totals for this item that exceed 100%.

age in the sick and well groups, respectively (P <

.0001, Student’s t test).

When parents’ reasons for having their sons

undergo postneonatal circumcision were

catego-nized as medical or nonmedical, parents in the well

group gave medical reasons more often than those

in the sick group (P < .001,

x2).

Children from the

sick group were more likely to undergo circumcision

concurrent with another surgery (P < .0001,

x2).

The median age of the children described by either

parent on surgeon as having phimosis was 28

months.

All but 2 of the 135 patients in our study

popu-lation received general anesthesia for their surgery,

and 76% of the patients underwent endotnacheal

intubation. Of those patients who did not have their

circumcision performed concurrently with another

surgical procedure, 63% underwent endotracheal

intubation.

In our review of changes in Salt Lake County, we

learned that an uncomplicated neonatal

circumci-sion performed in the hospital nursery on in th8

physician’s office cost approximately $100. Based

on four cases in our study, we determined that an

uncomplicated, postneonatal circumcision

per-formed in the operating room cost approximately

$1000.

DISCUSSION

There are no reports or guidelines that indicate

the optimal age or weight when circumcision should

be performed on a premature infant or the upper

age on weight limit when standard neonatal

cincum-cising techniques can no longer be used. Therefore,

the decision as to when and where to circumcise

premature infants, sick full-term infants, on healthy

infants whose parents request circumcision after

hospital discharge varies with individual practice

patterns.

In this study the reasons infants were not

cincum-cised during the neonatal period varied widely

be-tween the sick and well groups and within the well

group itself. In the sick group, as expected, the

neonatologist and other medical staff were nearly

always cited as the most influential in the decision

not to circumcise in the neonatal period. The

nea-sons for pursuing postneonatal circumcision given

by parents of sick infants were similar to those

leading to neonatal circumcision elicited from

par-ents of healthy full-term infants in a previous study

conducted in Salt Lake County.3

According to the data from our study, most of

the families of sick infants made a decision in favor

of circumcision during the neonatal period, but

deferred the circumcision based on the

recommen-dation of a neonatologist or other medical

person-nel. The health status of a few sick infants is likely

too fragile, even at hospital discharge, for them to

be considered good candidates for neonatal

circum-cision. In many cases, however, the issue of

circum-cision may not be discussed with the parents while

their child is hospitalized, resulting in delay of

circumcision until it is too late to use simpler

neo-natal techniques. When other surgery is anticipated

for infants with medical complications, it is

custom-any to postpone circumcision until the time of

sur-gery. This may or may not be appropriate,

(4)

complex-ity of the anticipated procedure, and the degree of certainty that the surgery will be performed.

In the well group, one out of three families were

advised against circumcision in the neonatal period

by their primary cane physician and one of five

cited this advice as the most influential factor in

their decision against neonatal circumcision. We

speculate that this may have occurred as an indirect

result of the 1975 statement on circumcision by the

American Academy of Pediatrics and question

whether the Academy’s revised position on

circum-cision will affect this behavior. Those physicians

who give such advice may not realize that by

im-posing their philosophy on families they may be

responsible for the child’s being subjected to a

potentially more risky and more expensive

proce-dune later in childhood.

In the well subpopulation, many parents changed

their minds about circumcision for nonmedical

nea-sons. An equal number of boys in this group were

eventually circumcised because of the parents’

per-ception that there had been medical complications

affecting the foreskin that indicated the need for

circumcision. This occurred more often in the well

group, but this may be due to the greaten number

of olden children in this group, thus allowing more

time for the patients to develop true medical

com-plications on for such parental perceptions to

evolve. Although medical conditions such as

bal-anitis do occur in uncircumcised males, they are

not necessarily an indication for circumcision. This

parental perception of important medical

compli-cations may be reinforced by the frequent diagnosis

of phimosis made by the physicians evaluating

these children.

Phimosis is a constriction of the prepuce

result-ing in an inability to retract the foreskin back over

the glans. In 1949, Gaindner6 reported that in 10%

of uncircumcised 3-year-old boys the foreskin

can-not be fully retracted, but that nearly all will

be-come fully retractable by the onset of puberty.

According to our data, many boys younger than 3

years of age were diagnosed as having phimosis

prior to undergoing postneonatal circumcision, and

this was the most common indication listed by the

surgeon in the patients’ charts. The accuracy of

this diagnosis is suspect because pathologic

phi-mosis is considered to be rare in boys of preschool

age. In one consecutive series7 of pediatric patients

diagnosed with phimosis, no boys younger than 4

years of age were identified. The discrepancy

be-tween the surgeons’ and parents’ reporting of

phi-mosis further supports the suspicion that this

di-agnosis was incorrectly made in many of our

pa-tients.

The frequent diagnosis of phimosis as an

mdi-cation for circumcision in our study may be due to

the fact that, when performed for a supposed

med-ical indication, this procedure is more readily

neim-bused by insurance companies. Another

explana-tion could be that many physicians remain largely

unaware of the natural history of foreskin

devel-opment in the uncircumcised male. Likewise, some

parents of uncircumcised males may not be aware

of normal foreskin development and may

subse-quently seek circumcision to allow access to the

glans. A previous study 8 conducted in Salt Lake

City indicated that few mothers of uncircumcised

infants are given adequate information regarding

foreskin cane. Since that time a pamphlet

instruct-ing parents in the care of the uncircumcised infant

has been published by the American Academy of

Pediatrics, but data concerning the use and

effec-tiveness of this and other techniques for educating

families about foreskin care have not been reported.

The adoption of an uncircumcised boy was the

primary indication for postneonatal circumcision

given by the family in 20% of cases in the well

group. This seems to represent an inordinately large

proportion of children from a relatively small

pop-ulation of adopted infants. The well group also

contained a significantly higher percentage of

non-white children. This may reflect strong cultural

influences on a family’s decision not to circumcise

at birth and the eventual desire of some of these

families to conform to the practice of the dominant

culture.

SPECULATION AND RELEVANCE

It is suggested by this profile of postneonatal

circumcision patients that physicians are

influen-tial in some families’ decisions regarding

circumci-sion for both sick and well newborns. In addition,

misinformation regarding both the medical

indica-tions for postneonatal circumcision and the natural

history of foreskin development may support many

parents’ decisions to have this procedure performed

on their sons.

We suggest that the primary care physician take

an active role in advising and educating new parents

on the issue of circumcision, keeping in mind that

the goal of this effort is to help the family make a

decision that will be acceptable to them as the child

develops. In light of our data, we believe that this

can best be accomplished for sick infants by

antic-ipating the decisions surrounding circumcision with

families of infants experiencing medical

complica-tions. The neonatologist on primary care physician

of sick infants should initiate discussions with the

family about circumcision prior to the child’s

(5)

deci-sion is understood. Further data are needed to help

establish the upper and lower limits of weight and

age when circumcision can be safely accomplished

using current neonatal circumcision techniques.

Families of healthy infants should receive

ade-quate education regarding circumcision and support

for their decisions. We question the wisdom of

actively discouraging parents who seem in favor of

circumcision or even those who are ambivalent. On

the other hand, maintaining neutrality while

pre-senting medically unsophisticated parents with

dir-cumcision data that continues to confuse

physi-cians also seems unhelpful. We advocate an

ap-proach in which the primary care physician

en-courages the parents to consider the known risks

and benefits of circumcision as well as the

short-and long-term consequences of their decision and

helps them to identify concerns that may cause

them to change their decision as the child gets olden.

For those who elect not to have their sons

circum-cised on who adopt uncircumcised boys, normal

foreskin development and cane should be

inconpo-rated into the educational component of well-child

cane. A review of the family’s decision should occur

at the routine 2-week-old and 2-month-old

well-child care visits when circumcision may still be

accomplished more easily if the parents have

changed their minds.

SUMMARY

We conclude that the need for general anesthesia and operating room services results in an increased

risk and cost for patients undergoing postneonatal

circumcision. Three of four of these procedures are

performed in the preschool years, suggesting the

possibility of reducing the incidence of postneonatal

circumcision through adequate parent education

during the neonatal and early childhood period.

There exist two distinct subpopulations of children

undergoing postneonatal circumcision: those whose

parents defer circumcision during the neonatal

period because of medical complications and those

whose parents initially decide against circumcision

and then later change their minds. Educating

par-ents and physicians about circumcision and normal

foreskin development may help families avoid the

increased costs and risks of postneonatal

circum-cision.

REFERENCES

1. American Academy of Pediatrics, Committee on Fetus and Newborn. Report of the Ad Hoc Task Force on Circumci-sion. Pediatrics. 1975;56:610-61 1

2. American Academy of Pediatrics Task Force on Circumci-sion. Report of the Task Force on Circumcision. AAP News.

March 1989;5:7-8

3. MetcalfTJ, Osborn LM, Moriani EM. Circumcision: a study of current practices. Clin Pediatr. 1983;22:575-579

4. Wiswell TE, Enzenauer RW, Holton ME, et al. Declining frequency of circumcision: Implications for change in the absolute incidence and male to female sex ratio of urinary

tract infections in early infancy. Pediatrics. 1987;79:338-341 5. U.S. Bureau of the Census. 1980 Census of Population:

Characteristics of the Population, General Population Char-acteristics, Utah. PC8O-1-B46. Washington, DC: US Gov-ernment Printing Office; May 1982

6. Gairdner D. The fate ofthe foreskin: a study of circumcision. Br Med J. 1949;2:1433

7. Rickwood AMK, Hemalatha V, Batcup G, et al. Phimosis in boys. Br J Urol. 1980;52:147-150

8. Osborn LM, Metcalf TJ, Mariani EM. Hygienic care in uncircumcised infants. Pediatrics. 1981;67:365-367

THE NEW BABY BOOM

The number of births in the United States fell in 1986, but rose sharply in

1987 and 1988. In 1988, the National Center for Health Statistics recorded 3.91

million births and the figures have been going up steadily. . .Experts agree that

the phenomenon of delayed childbirth is the main factor in the current surge.

Predictions of high rates of childlessness have not been proved.

Barringer F. Waiting is over: Births near 50’s level. The New York Times. October 31, 1989.

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1990;85;808

Pediatrics

Gordon L. Larsen and Scott D. Williams