Dr. B's Baby Buzz

To "circ" or not to "circ"

One of the most frequent questions I have been asked by parents is whether their newborn son should be circumcised.  The issue of circumcision has been debated for years and even has been the subject of lawsuits by grown children.  My traditional stance is that parents should do their due diligence about the pros and cons of this procedure before making this decision. The information I provide here isn’t meant to sway opinion one way or the other, rather to help present some information to assist parents in their decision-making.

Early References to Circumcision

The practice of male circumcision is historically documented across many cultures.  Perhaps the earliest known reference to circumcision originates in Egypt in tomb artwork from the Sixth Dynasty (2345 - 2181 BC).  Many who read this are no doubt familiar with references to circumcision of infant males in the Old Testament originating with convenent between Abraham and God in Genesis.  In fact, many cultures over the centuries have accepted circumcision as a practice, citing beliefs that have cultural, religious and medical origins.

Circumcision in the United States

In more recent times there have been broad swings in public opinion regarding perceived advantages or disadvantages of circumcision. In the United States an initial shift in the cultural norm favoring newborn circumcision occurred around the onset of the 20^th century.  As a result the United States continues to have a wider sphere of acceptance of this practice than in other parts of the world. The reason for that initial shift in practice seems to stem from a number of factors.  These include emerging knowledge of germ theory and the accompanying belief that circumcision promotes hygiene, belief that there would be less risk for syphilis, and, in a period of time that saw the emergence of temperance, belief that circumcision would promote chastity and prevent masturbation. Additionally, the increase in births occuring in hospitals rather than at home in the mid-20th century, correlates with an increase in rate of circumcision at that time.

Table 1: International circumcision rates
Country	Year	Neonatal circumcisions (%)
United States	2003	55.9%
Canada	2003	< 14%
Australia	2004	10%-20%
New Zealand	1995	0-5%
**Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer. There are significant ethinc and regional differences in circumcision practices within the United States.  In general, circumcision is more likely to be performed on non-Hispanic white male infants, whereas Hispanic infants have the lowest rate of circumcision. Statements by the medical community, in particular by the American Academy of Pediatrics in 1971, 1989, and 1999, as well as a reaffiramation statement in 2005, have historically taken the position that circumcision is not medically indicated, and in the past several decades more parents opted not to have the procedure performed on their newborn sons. Emerging Medical Data

Although major medical societies in the US as well as in the United Kingdom, Australia, and Canada have formally stated that circumcision is not medically necessary, a series of recent studies have strongly indicated that circumcised males benefit from decreased risk of a number of health problems:

1. Urinary tract infection. There appears to be a significant decreased risk of urinary tract infection in circumcised males. The compilation of data from numerous studies indicates that incidence of urinary tract infections in uncircumcised males is about 1:1000 versus about 1:100 in circumcised males.
2. Cancer of the penis.  In general, this is a relatively rare condition occurring in about 1:100,000 men annually in the United States.The majority of those cases occur in uncircumcised men, and invasive penile cancer, the most severe form, occurs almost exclusively in uncircumcised males.  Of note, cancer of the penis is almost unheard of in Israel, where almost all males are circumcised.
3. Sexually transmitted disease.  Numerous studies have shown decreased transmission of STDs such as syphilis, Chlamydia, human papilloma virus, and herpes not only to circumcised males, but also from males to their female partners. Given the association of HPV with cervical cancer in women, there has been evolving opinion that circumcision is a women's health issue as well. More recently a series of studies in Africa has shown a 60% reduction in the rate of transmission of HIV to males that have been circumcised versus those who are uncircumcised. This is significantly better than the 30% reduction of risk that was target goal of a future AIDS vaccine.

This last point, reduction in transmission of STDs and HIV, has fanned the embers of the circumcision debate.  There have been some strong voices of dissent to the AAP statement calling for a reevaluation of circumcision as an effective means to stem the tide of HIV, particualrly in developing nations.

Surgical Procedure

Circumcision is a surgical procedure, and as such, has associated risks.   In general, the risk of a complication from circumcision is very low (~1/500,000).  These risks include, but are not limited to, bleeding, infection, scarring, incomplete resection of foreskin, and partial amputation of the penis.  In the not too distant past circumcision was performed without anesthesia owing to an ill-conceived notion that infants do not experience pain.  Thankfully, we have come along way, and the current practice of circumcision involves a local anesthetic. The most commonly performed in-patient newborn circumcision methods are done with either a clamp (Gomco or Mogan) or with a Plastibell.  The results can vary depending on the method used and the skill of the person performing the circumcision.  Just as with any surgery, the method and procedure should be explained clearly to you by the person performing the surgery.

As mentioned previously, post-operative complication rate is extremely low and your baby's medical care provider will review how to care for the baby after the procedure.  There are certain infants who should not be circumcised in the neonatal period.  These would include ill newborns, premature infants, infants born with congenital anomalies of the penis ( e.g. hypospadius)  or infants who have a bleeding disorder such as hemophilia.

The "No Circ" Viewpoint

There are strong voices of opposition to circumcision.  The core points are well outlined be the National Organization of Circumcision Information Resource Center (www.norcirc.org). As stated in their website:

No national or international medical association recommends routine circumcision.

Only the USA circumcises the majority of newborn boys without medical or religious reason.

Medicalized circumcision began during the 1800s to prevent masturbation, which was believed to cause disease.

Today's parents are learning that the foreskin is a normal, protective, functioning organ.

Today's parents realize circumcision harms and has unneccesary risks.

Circumcision denies a male's right to genital integrity and choice for his own body.

With regards to the recent studies regarding circumcision and decreased HIV transmission, they strongly advocate more funds being shifted to education on HIV and safe sex. For those who want more information regarding the counter-argument regarding circumcision as a means to reduce the spread of HIV, read the statement from Doctors Opposing Circumcision.

Ultimately, the decision for circumcision is a personal one.  Educate yourselves and make an informed decision for your baby.

Sudden Infant Death Syndrome

The death of an infant is a tragedy unimaginable to most of us, yet for every 100,000 births in the

United States

more than 50 seemingly healthy infants will succumb to Sudden Infant Death Syndrome (SIDS). Another 20 infants per 100,000 will die unexpectedly from causes such as accidental suffocation. Since the “Back to Sleep” campaign was initiated by the

American

Academy

of Pediatrics in 1994 promoting placing infants on their backs rather than their stomachs to sleep, we have seen the rate of SIDS decrease by about half, but there has been no significant decline in SIDS rate for several years. Additionally we have seen an increase in other causes of unexpected infant death.  This may be in part due to better classification of SIDS such that we are no longer grouping accidental suffocation into the same category as SIDS.  However, it does illustrate that, in addition to true SIDS, accidental death also is a significant threat to the newborn.

Sudden Infant Death Syndrome is defined as the death of an infant less than one year of age that remains unexplained after thorough examination event including autopsy, examination of the death scene and assessment of the infant’s medical history.  There appears to be a moderately higher incidence of SIDS in male infants.  There are also ethnic differences in incidence, with SIDS occurring more than twice as often in African-American and Native American infants as compared to white, Hispanic and Asian infants.

There does not appear to be a single cause of SIDS.  A more recent hypothesis is the “triple risk model” which states that SIDS can occur when the following three conditions exist:  a vulnerable infant, a critical period of development in that infant, and an exogenous stressor.

What makes an infant vulnerable to SIDS? Unfortunately, we are not able to identify every vulnerable infant in advance since they appear healthy prior to succumbing to SIDS. However, we do know that some infants with certain prenatal conditions have increased risk. For example, infants born to mothers who smoke and/or consume alcohol during their pregnancy are at increased risk for SIDS. It has been suggested by some scientists studying SIDS that there may a neurodevelopmental effect of these substances on the fetus that ultimately makes them more vulnerable.  Additionally, preterm infants are a vulnerable population having a SIDS rate more than double that of term infants.

The most common time for SIDS to occur in term infants is between 2 and 4 months of age, and about 90% of SIDS cases occur before 6 months of age.  In preterm infants, the peak incidence of SIDS is several weeks later than in term infants.  For the many infants this time period defines a critical period of development, which, when combined with other factors, may increase likelihood of SIDS.

There have been many outside influences, or exogenous stressors, that have been strongly associated with increased risk for SIDS. We already are well aware of the association of SIDS risk with placing an infant on his or her stomach to sleep. Even placing an infant on the side rather than the back increases the risk of SIDS. Other things associated with increased risk include overheating the infant by overdressing, maternal smoking, having an infant share a bed with a caregiver who is overtired or under the influence of drugs, medications or alcohol, and multiple persons sharing a bed with an infant.

With our increased knowledge of SIDS and SIDS risk, we now know that there are strategies we can adopt to further reduce an infant’s chance of dying unexpectedly.  While the “Back to Sleep Program” addressed the important risk factor of sleep position and, as a result, has no doubt saved many infant lives, we can expand our efforts to further reduce risk.  At

Anna

Jaques

Hospital

we have adopted a “Safe Sleep” Campaign which focuses on addressing a number of risk factors and interventions important for SIDS prevention.  Our teaching points spell out the word “SLEEP”:

Safest place is in a crib with no loose bedding

Lay baby to sleep on the back – ALWAYS!

Eliminate cigarettes and alcohol

Educate secondary caregivers

Pacifiers reduce risk

We also strongly promote breastfeeding, which in addition to the many well known benefits to mother and baby, also has been shown to reduce risk of SIDS.  Use of a pacifier has been shown to have a strong protective effect in SIDS prevention in multiple studies, but the

American

Academy

of Pediatrics recommends that if choosing to use a pacifier it should not be introduced until after one month of age in breastfeeding mothers.

We all hope to see further progress in the area of SIDS prevention.  Taking the time to learn these important facts and interventions could save a baby’s life.