American Academy Of Pediatrics Releases New Circumcision Policy

"Circumcision is not essential to a child's well-being at birth, even though it does have some potential medical benefits," said task force chair Dr. Carole Lannon.

"These benefits are not compelling enough to warrant the AAP to recommend routine newborn circumcision," said Lannon, clinical associate professor of pediatrics and internal medicine at the University of North Carolina at Chapel Hill School of Medicine. "We encourage parents to discuss the benefits and risks of circumcision with their pediatrician and then make an informed decision about what is in the best interest of their child."

The policy concluded, however, that it is legitimate for parents to take into account cultural, religious and ethnic traditions, in addition to medical factors, when making this decision. It states that to make an informed choice, parents of all male infants should be given accurate information and be provided the opportunity to discuss this decision with their pediatrician.

For the first time in AAP circumcision policy history, the new recommendations also indicate that if parents decide to circumcise their infant, it is essential that pain relief be provided. To assist parents in making the decision of whether or not to circumcise their sons, the AAP policy outlines the potential medical benefits and risks and discusses the use of analgesia.

Beginning in its 1971 manual, Standards and Recommendations of Hospital Care of Newborn Infants, and reiterated in the 1975 and 1985 revisions, the Academy concluded that there was no absolute medical indication for routine circumcision.

In 1989, due to new research exploring links between circumcision status and both urinary tract infections and sexually transmitted diseases, particularly AIDS, the Academy concluded that newborn male circumcision did have potential medical benefits and advantages, as well as risks.

In light of continued debate over the last decade regarding those benefits and risks, as well as the publication of new research, the Academy chose to reevaluate its 1989 policy. The new policy recommendations released today are based on analysis of all available medical literature on circumcision currently available, including new studies published in the last 10 years.

Although studies show the relative risk of developing a urinary tract infection (UTI) in the first year of life is higher for baby boys who are uncircumcised, the AAP policy concludes that their absolute risk of developing one is low - at most approximately 1 percent. Research indicates that during the first year of life an uncircumcised male infant has at most about a 1 in 100 chance of developing a UTI, while a circumcised male has about a 1 in 1000 chance.

Studies conclude that the risk of an uncircumcised man developing penile cancer is more than three-fold that of a circumcised man. However, the AAP policy notes that in the United States only 9 to 10 cases of this rare disease are diagnosed per year per 1 million men, indicating that while the risk is higher for uncircumcised men, their overall risk is extremely low.

Some research suggests that circumcised men may be at a reduced risk for developing syphilis and HIV infections. However, the AAP policy states that behavioral factors continue to be far more important in determining a person's risk of contracting sexually transmitted diseases than circumcision status.

Considerable new evidence shows that newborns circumcised without analgesia experience pain and stress measured by changes in heart rate, blood pressure, oxygen saturation and cortisol levels. Other studies suggest that the circumcision experience may cause infants to respond more strongly to pain of future immunization than those who are uncircumcised.

In response to this data, the AAP policy states that analgesia has been found to be safe and effective in reducing the pain associated with circumcision and should be provided if the procedure is performed. Analgesic methods include EMLA cream (a topical mixture of local anesthetics), the dorsal penile nerve block and the subcutaneous ring block.

Circumcision is generally a safe procedure, research suggests. Complications occur in 1 in 200 to 1 in 500 circumcised newborn males and are most often minor. The two most common are mild bleeding and local infection.

Helping develop the academy's new policy was a "significant amount of work" over a year and a half made easier by the congeniality and dedication of task force members, Lannon said. Such statements are helpful to both parents and physicians alike because they take into account the latest research on clinical practice.

"That two members of seven-member task force were from UNC-Chapel Hill reflects the high esteem in which the university is held by the medical community and the academy," she said.