Pediatric Group Dismisses Need for Circumcision

After years of taking a neutral stand on whether circumcision should be performed on male newborns, the American Academy of Pediatrics on Monday issued a strong statement saying there are too few medical benefits to justify recommending the procedure.

The academy said its review of medical data suggests that circumcision is not necessary, but added that families should continue to follow personal preferences, including religious traditions. The statement, published in the journal Pediatrics, should help parents who base their decision about circumcision strictly on health criteria.

“Circumcision is not essential to a child’s well-being at birth, even though it does have some potential medical benefits,” said Dr. Carole Lannon, chairwoman of the academy’s task force on circumcision. “These benefits are not compelling enough to warrant the AAP to recommend routine newborn circumcision.”

The academy also departed from previous statements by recommending that all newborns undergoing circumcision receive pain relief. The decision to use analgesics during circumcision varies widely nationwide.

The task force based its summary on a review of 40 years of studies, many of which show that the procedure offers some health advantages. Compared to uncircumcised boys, circumcised babies are less likely to develop a urinary tract infection during the first year of life. In addition, the rate of penile cancer is three times lower in circumcised men.

But the academy noted that both penile cancer and infant urinary tract infections have become so rare that parents should not feel it necessary to reduce their child’s risk through circumcision.

“It’s three- to tenfold more likely for someone uncircumcised to have a urinary tract infection in the first year of life. But it’s still rare,” said Dr. Alan R. Fleischman, a task force member and senior vice president of the New York Academy of Medicine.

“The benefit is small enough that families shouldn’t be criticized for not circumcising their little boy.”

The risk of penile cancer also is rare: Only about 10 cases per 1 million men are diagnosed each year in the United States.

The task force addressed concerns that uncircumcised men may be at greater risk for sexually transmitted diseases. It concluded that behavioral factors, such as using condoms, are far more important in determining a person’s risk.

Parents should be advised, however, that circumcision helps keep the penis clean, said Dr. Bernard Churchill, chief of the Clark Morrison Children’s Urological Center at UCLA.

“If the infant is not circumcised, then parents should be taught how to retract the foreskin and clean it,” he said. “I don’t quite agree with statements on penile cancer that [the task force] makes. It’s virtually 100% a disease of uncircumcised males who do not clean themselves out for many years.”

Children who have urinary disorders or other ailments that might prevent them from practicing good hygiene should be considered for circumcision, even if it is later in childhood, he said.

About 64% of male infants are circumcised in the United States. The procedure carries few risks; about 1 in 200 to 1 in 500 infants have complications such as mild bleeding or local infection.

While the new statement may influence the rate of circumcisions in the United States, it is not expected to--and should not--alter religious, familial or cultural customs that favor circumcision, Fleischman said. “I think most families take into account cultural, religious and family practices, such as whether the father has been circumcised,” he said. “That plays a major role.”

However, families should be encouraged to consider pain relief, the task force said.

“The academy is calling for pain management for every circumcision procedure. That is a serious recommendation,” Fleischman said. “For a newborn circumcision, it has been unusual to have any kind of pain management. But we expect that this will change.”

The use of pain medication, usually a locally administered anesthetic, has been debated because of doubts that infants feel pain and a controversy over whether the injection of anesthesia is just as painful, or worse, than the circumcision.

The task force reviewed extensive data that should end both controversies, Fleischman said.

“There is no question that newborns do feel pain,” he said. “It makes good sense to provide pain management.”

Studies show that infants who receive anesthesia cry less, have a lower heart rate and release less stress hormones during the circumcision.

Pain relief can be given through an injection or with use of an anesthetic cream, called EMLA cream, applied to the skin about 40 minutes before the circumcision.