Canadian Medical Association Journal

Neonatal circumcision revisited

Canadian Medical Association Journal Vol. 154, no. 6 (March 15, 1996): pp. 769-780.

Reaffirmed February 2001.

Paper reprints of the full text may be obtained from: Fetus and Newborn Committee, Canadian Paediatric Society, 401 Smyth Rd., Ottawa ON K1H 8L1; phone: (613) 526-9397; fax: (613) 526-3332.


Objective: To assist physicians in providing guidance to parents regarding neonatal circumcision.

Options: Whether to recommend the routine circumcision of newborn male infants.

Outcomes: Costs and complications of neonatal circumcision, the incidence of urinary tract infections, sexually transmitted diseases and cancer of the penis in circumcised and uncircumcised males, and of cervical cancer in their partners, and the costs of treating these diseases.

Evidence: The literature on circumcision was reviewed by the Fetus and Newborn Committee of the Canadian Paediatric Society. During extensive discussion at meetings of the committee over a 24-month period, the strength of the evidence was carefully weighed and the perspective of the committee developed.

Values: The literature was assessed to determine whether neonatal circumcision improves the health of boys and men and is a cost-effective approach to preventing penile problems and associated urinary tract conditions. Religious and personal values were not included in the assessment.

Benefits, harms and costs: The effect of neonatal circumcision on the incidence of urinary tract infection, sexually transmitted diseases, cancer of the penis, cervical cancer and penile problems; the complications of circumcision; and estimates of the costs of neonatal circumcision and of the treatment of later penile conditions, urinary tract infections and complications of circumcision.

Recommendation: Circumcision of newborns should not be routinely performed.

Validation: This recommendation is in keeping with previous statements on neonatal circumcision by the Canadian Paediatric Society and the American Academy of Pediatrics. The statement was reviewed by the Infectious Disease Committee of the Canadian Paediatric Society. The Board of Directors of the Canadian Paediatric Society has reviewed its content and approved it for publication.

Sponsor: This is an official statement of the Canadian Paediatric Society. No external financial support has been received by the Canadian Paediatric Society, or its members, for any portion of the statement's preparation.

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Circumcision is one of the procedures performed most often on males. It was estimated in 1970 that 69% to 97% of all boys and men in the United States had been circumcised, in comparison with 70% of those in Australia, 48% of those in Canada and 24% of those in the United Kingdom.1 The procedure is uncommon in northern European countries, Central and South America and Asia.1

In 1971 and 1975 the American Academy of Pediatrics (AAP) took a stand against the routine circumcision of newborns on the basis that there are no valid medical indications for circumcision in the neonatal period.2,3 In 1975 the Fetus and Newborn Committee of the Canadian Paediatric Society (CPS) reviewed the literature available at that time and reached the same conclusion.4 In 1983 this position was reiterated by the AAP and the American College of Obstetricians and Gynecologists in their joint publication Guidelines for Perinatal Care.5 The CPS Fetus and Newborn Committee re-examined the issue in 1982, in response to an article on the benefits and risks of circumcision,6 and saw no reason to modify its 1975 statement.7

In 1989 a multidisciplinary Task Force on Circumcision established by the AAP summarized the evidence for and against the routine circumcision of newborns but did not make a specific recommendation.8 The evidence the task force reviewed on the status of circumcision of newborns and the question of routine neonatal circumcision was subsequently discussed in commentaries by the chairman of the task force and by one of its members.9,10 Considerable discussion followed in the letters to the editor of the two journals in which these appeared.11-17

There have continued to be articles published presenting arguments supporting and opposing routine neonatal circumcision.18-26 Detailed estimates of the financial and medical advantages and disadvantages have been made.27,28 Groups opposed to neonatal circumcision have been formed and have become visible lobbyists (for example, the National Organization to Halt the Abuse and Routine Mutilation of Males, San Francisco, and the National Organization of Circumcision Information Resource Centers based in San Anselmo, Calif., with branches across the United States and in Canada and other countries).29 It therefore seemed appropriate for the Fetus and Newborn Committee of the CPS to revisit the subject.

Articles on circumcision published between 1982 and 1992 were identified from Index Medicus, and articles published from 1988 to 1994 were found through MEDLINE searches. Relevant articles were also identified from the bibliographies of the AAP task force statement,8 the subsequent commentaries and other review articles. The reference lists of identified articles were searched for additional publications. A total of 671 published articles on circumcision were identified. Case reports, case-control studies, cohort studies, randomized controlled trials and two meta-analyses were identified and included. No randomized controlled trials of circumcision per se were identified; the only randomized controlled trials found involved the use of analgesia or anesthetic agents during circumcision. Of the articles identified, 61 concerned urinary tract infections (UTIs) and circumcision, 23 involved the relation between male circumcision and HIV status and 25 discussed the pain caused by circumcision and the use of analgesia. Articles reviewed were restricted to those in English, except for one article in Spanish.

We asked the following questions. What is the effect of routine circumcision of newborn male infants on the rate of UTI, sexually transmitted diseases, cancer of the penis, cervical carcinoma and penile problems? What is its effect on health care costs? Is the balance of evidence sufficient to warrant a change in the position taken by the CPS in 1982?7

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What is the prepuce?

The prepuce is described anatomically as a simple fold of skin.30 Its function has been assumed to be protection of the glans. There are unwritten assumptions in the literature discussing circumcision. However, a recent report has described numerous oval, rounded or elongated nerve corpuscles in the inner mucosal surface of the prepuce.31 These are similar to nerve endings seen, although less frequently, in the glans and the frenulum. Their function is unknown. The author of the report speculated that this specialized sensory tissue may perform different functions at different times of life and may be involved in sexual responses in adults. The presence of these nerve endings also emphasizes the need for pain control when circumcision is performed.

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Urinary tract infection

An association between an increased incidence of UTI and uncircumcised status has been reported. In 1982 Ginsburg and McCracken32 reported a case series of 109 infants in whom UTI developed between 5 days and 8 months of age. Male infants predominated in their series; of these, 95% were uncircumcised.

In 1985 Wiswell, Smith and Bass33 reviewed a cohort of 5261 infants born at an army hospital and found a higher incidence rate of UTI among the uncircumcised male infants (4.12%) than among those who were circumcised (0.21%). A subsequent review of the records of 427 698 infants (219 755 of whom were boys) born in US Armed Forces hospitals from 1975 to 1979 supported these findings, showing a 10-fold higher incidence rate of UTI among uncircumcised boys (1.03%) than among circumcised boys (0.10%).34 By comparison, the incidence rate among the female infants was 0.52%. In addition, the investigators reported a temporal association between a decrease in the circumcision rate and an increase in the UTI rate among boys in the early 1980s. There was no concurrent change in the incidence among girls, and the ratio of the incidence of UTI among boys to that among girls during early infancy shifted toward a predominance among boys.34

A later review of UTI among 209 399 infants born between 1985 and 1990 in US Army hospitals worldwide found that 1046 infants, of which 496 were boys, had been admitted to hospital for UTI in the first year of life.35 There was a 10-fold greater incidence of infection among the uncircumcised than among the circumcised boys. Among the uncircumcised boys younger than 3 months of age, the incidence rate of concomitant bacteremia caused by the same organism that caused the UTI was 23%. The diagnosis of UTI in all of these studies was made on the basis of culture of urine samples obtained by bladder tap or by catheter. These studies are retrospective, and therefore some caution must be exercised in their interpretation. A potential bias in these studies is that patients were admitted to hospital because of the infections; since infections not requiring hospital treatment were excluded, the true incidence may have been underreported.

Herzog,36 in an evaluation of febrile infants seen in an outpatient clinic, also showed a higher incidence of UTI among uncircumcised boys than among those circumcised. The authors of two review articles each concluded that the circumcision of newborns reduced the incidence of UTI.37,38 Despite the impressive magnitude of the decrease in the incidence of UTI (10-fold or more) associated with circumcision, when one recognizes the low overall incidence rate of UTI among infant boys (1% to 2%), several questions arise. Is universal circumcision warranted for the prevention of UTI? What are the risks and the costs of this approach? Are there any alternative strategies for the prevention of UTI that should be evaluated?

There is a plausible explanation for the association of UTI with uncircumcised status. The explanation involves colonization of the prepuce with bacteria in infancy and childhood. Several bacteria, including fimbriated strains of Proteus mirabilis, nonfimbriated Pseudomonas, Klebsiella and Serratia species39-41 and pyelonephritogenic fimbriated Escherichia coli,39,41,42 have been shown to bind closely to the mucosal surface of the foreskin within the first few days of life. It has been suggested that circumcision protects male infants from UTI by preventing the bacterial colonization of the prepuce and subsequent ascending infection.37

In natural settings, infants are often subject to colonization at birth with the aerobic and anaerobic flora of their mothers; they also receive specific immunoglobulin across the placenta before delivery and, later, through ingestion of breast milk. In contrast, babies born and cared for in hospital tend to be colonized by E. coli acquired from the environment.43,44 The virulence of E. coli strains isolated in cases of UTI is correlated with the ability of the strain to adhere to uroepithelial cells.45 This ability has been shown to be associated with the presence on the bacteria of proteinaceous, filamentous organelles called fimbria, which appear to recognize and bind to specific receptors on the epithelial cells.45 Kallenius and associates46 reported that 94% of the cases of infantile pyelonephritis they reviewed were due specifically to P-fimbriated E. coli.

On the basis of these observations, Winberg and collaborators47 suggested two alternative preventive strategies: deliberate colonization with nonpathogenic bacterial flora during the newborn period or the promotion of rooming-in to facilitate close contact between newborns and their mothers. The first strategy is analogous to the active colonization of the umbilicus and nasal mucosa undertaken in the past to arrest epidemics of infection with Staphylococcus aureus.48

These two strategies need to be evaluated further. One would expect both to have a low risk of complications. The second is in keeping with recent trends in maternal and infant care and could also have a low cost. If either strategy is successful, it may prove to be a more cost-effective way to prevent UTI among male infants than circumcision. Such an approach could also be applied to the prevention of UTI in female infants, since adherence of bacteria to epithelial cells also plays a role in the development of UTI in girls.45

There has been one report of a case-control study of breast-feeding and UTI among infants.49 In the study, 47% of 62 infants presenting with a UTI had been breast-fed, whereas 82% of 62 control infants seen at a well-baby clinic and 87% of 62 control infants admitted to hospital because of fever had been breast-fed, and none of the control infants had a UTI (p < 0.001). No information was given about alterations in the bacterial flora of the infants in the study.

A meta-analysis has been made of six articles containing original patient data on circumcision and UTI.50 In a sample of 221 799 patients the odds ratio (OR) of UTI among uncircumcised male infants compared with circumcised male infants was 13.1 (95% confidence interval [CI] 10.9 to 15.7). A second meta-analysis of nine studies of the circumcision status of boys with UTI, which included the six articles covered by the first meta-analysis, reported an OR of 12.0 (95% CI 10.6 to 13.6).35

However, the risk of UTI among the uncircumcised boys during the first year of life was low enough that the first set of authors felt that routine neonatal circumcision was not justified.50 The authors of the second analysis emphasized the importance of discussing the association between UTI and uncircumcised status while counselling parents about neonatal circumcision to obtain their informed consent.35

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Effect of timing of circumcision

An epidemiological study of UTI during the first year of life involving 169 children born in Israel found that 48% (27/56) of the male infants presented with UTI within 12 days after ritual circumcision.51 The incidence of UTI among male infants was significantly higher just after circumcision (from 9 to 20 days of life) than during the rest of the first month of life and significantly higher in the first month of life than during the rest of the year. After the immediate postcircumcision period, the incidence rate of UTI dropped to a level comparable to that reported among circumcised male infants in the United States. Among the 113 female infants, the episodes of infection were evenly distributed throughout the first year of life, except that the incidence was lower during the first month. This study suggests that the method and the timing of circumcision also may be important factors to consider.

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Circumcision and UTI among young adults

In a retrospective case-control study, 26 men with symptomatic UTI confirmed by microbiological analysis were compared with 52 men who had urinary symptoms but negative results of cultures from urine specimens.52 The groups were similar with respect to age, race and sexual activity. Of the men with a UTI, 31% (8/26) were uncircumcised, whereas 12% (6/52) of the men without a UTI were uncircumcised (p = 0.037, OR 5.6, 95% CI 1.6 to 19.4).

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Identification of urinary tract abnormalities

In the case-control study by Herzog,36 in 8 of the 31 patients who underwent radiographic investigation, abnormalities were found. Four of the patients had grade II reflux, two had grade IV reflux, one had posterior urethral valves with hydronephrosis, and one had ureteropelvic junction obstruction with hydronephrosis. Amir, Varsano and Mimouni53 found anomalies of the urinary tracts of three out of eight patients who had a UTI after ritual circumcision. It has been suggested that not circumcising male infants is, therefore, advantageous because it allows early identification of infants who have structural abnormalities that require surgical intervention or close medical follow-up.54,55 Whether the reflux found in the patients in the case-control study was acquired or was a result of a congenital lesion, as suggested by Rockney and Caldamone,54 is unknown.

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Sexually transmitted diseases

A higher risk of nongonococcal urethritis among circumcised men than among uncircumcised men has been described.56 A recent cross-sectional study of 300 consecutive heterosexual male patients attending a sexually transmitted diseases (STD) clinic showed that circumcision had no significant effect on the incidence of common STDs.57 However, a significantly greater incidence of STDs -- including genital herpes, candidiasis, gonorrhea and syphilis -- among men who were not circumcised than among those who were circumcised has been previously reported.58 Uncircumcised status and diseases causing genital ulceration have been reported to be risk factors in the transmission of HIV to heterosexual men.59,60 A recent review of the literature on the association between circumcision status and the risk of HIV infection included 30 epidemiological studies, of which 15 were published articles and 15 were abstracts presented at conferences.61 Twenty-six of these studies were cross-sectional, two were prospective and two ecological in design. One of the latter estimated the seroprevalence of HIV in the general population of 37 African capital cities and correlated these data with the estimated national proportions of uncircumcised males. The other related data on HIV seroprevalence from 140 discrete geographic locations in Africa to the usual male circumcision practices in those areas. Both showed positive associations. Eighteen of the cross-sectional studies reported a statistically significant association, determined through univariate or multivariate analysis, between the presence of the foreskin and the risk of HIV infection. Four other such studies showed a trend toward an association, and four showed no association. The two prospective studies showed positive associations. The ORs or relative risks (RRs) calculated in the studies that showed statistically significant associations ranged from 1.5 to 8.4. However, an editorial review of 26 studies on this subject (including 23 of the previously reviewed studies) commented on the lack of a distinction between susceptibility and infectivity, the use of inadequate controls for confounding variables, potential selection biases and misclassifications of exposure or inappropriate choices of comparison groups, each of which may lead to an incorrect estimation of the association.62 The authors of this review also commented that the use of an OR rather than RR in several of the studies may have led to an overestimation of the association, which would incorrectly suggest a causal relation. They judged that further studies were required to ascertain the RR associated with the lack of circumcision before considering interventional studies.

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Cancer of the penis

The incidence rate of cancer of the penis is 0.3 to 1.1 per 100 000 men per year in developed countries and 3 to 6 per 100 000 men per year in developing nations.63,64 In the United States the incidence rate is less than 1 per 100 000 per year. This is similar to the rates in Norway and Sweden, where circumcision is rarely performed.64-67 Among uncircumcised men in the United States, the incidence rate is 2.2 per 100 000 per year.68 Only a few cases have been reported among men who were circumcised as newborns.69-72 In two reported studies, human papillomavirus (HPV) types 16 and 18 were found in 58% (31/53) and 49% (33/67) of cases of penile cancer, respectively, which suggests that this virus plays a causal role in penile cancer.73,74

A recent population-based case-control study involved 110 men with penile cancer who were available and consented to participate, from a total of 219 men diagnosed with this condition, and 355 controls who were successfully interviewed, from a total of 481 eligible men. The controls were matched with the case subjects in a 2:1 ratio by 5-year age groups and the year of diagnosis.74 The authors found that the RR of penile cancer was 3.2 for uncircumcised men compared with circumcised men (95% CI 1.8 to 5.7). However, other factors were also found to be associated with an increased risk of penile cancer. The RR was 2.8 (95% CI 1.4 to 5.5) among men who currently smoked compared with men who had never smoked. In addition, the RRs associated with a history of genital warts, penile rash or penile tear were 5.9 (95% CI 2.1 to 17.6), 9.4 (95% CI 3.8 to 23.9) and 3.9 (95% CI 1.9 to 7.7), respectively. Furthermore, the men with penile cancer reported more sexual partners than those without cancer, and the men with tumours associated with HPV also reported more sexual partners than those whose tumours had a negative result of a test for HPV. In a case-control study conducted in Hunan province in China, where a high rate of death from penile cancer has been documented and early circumcision is not practised, the RR of penile cancer was 32.9 (95% CI 4.3 to 253.8) among subjects who had been circumcised compared with those who had not.75 An elevated risk persisted when the analysis was restricted to men who were circumcised more than 5 years before penile cancer was diagnosed (RR 14.9, 95% CI 1.8 to 121). Among those who had never been circumcised, those who failed to retract their foreskin while bathing were at elevated risk (RR 1.49), although this risk was not statistically significant (95% CI 0.8 to 2.8). Smoking was not identified as a risk factor. More case than control subjects reported previous STDs. Reported premarital or extramarital affairs were associated with an elevated risk. Although the number of subjects was small, making it difficult to ascertain the significance of this finding, the investigators found a greater number of genital warts, many in the same area as the tumours, during physical examination of the case subjects. The researchers did not test the subjects for HPV. Although circumcision was not routinely practised in Hunan, among the men who had been circumcised the most common reason for circumcision was the presence of a redundant prepuce or phimosis; both of these conditions were also identified as risk factors for penile cancer. These studies support the need for further evaluation of the causal role of hygiene and STDs in penile cancer.

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Cervical carcinoma

HPV types 16 and 18 are the viruses most commonly associated with cancer of the cervix.76-79 Herpes simplex virus type 2 has also been shown to be a causal agent in cervical cancer.78,80 A higher-than-average risk of cervical cancer has been reported among the wives of men who had been previously married to women with cervical cancer.81 As well, epidemiological studies have shown that starting sexual activity at an early age and having multiple sexual partners predispose women to cervical cancer.82,83 Overall, no specific cause-and-effect relation between exposure to uncircumcised sexual partners and cervical cancer has been established.80

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Complications of circumcision

Circumcision may lead to complications, which range from minor to severe. They include easily controllable bleeding,84,85 amputation of the glans,84-86 acute renal failure,87 life-threatening sepsis and, rarely, death.84,85 The exact incidence of postoperative complications is unknown.84 The rates of complications reported in several large case series are low, from 0.2% to 0.6%.8 However, published rates range as widely as 0.06%88 to 55%.89 Williams and Kapila90 have suggested that a realistic rate is between 2% and 10%.

Wiswell and Geschke,91 in a survey of 136 086 boys, reported a rate of complications of circumcision and other genitourinary problems of 0.19% among circumcised infants during the first month of life and a rate of genitourinary problems of 0.24% among uncircumcised boys. Among the circumcised boys, hemorrhage, local infection, surgical trauma, UTI and bacteremia were identified. Among those not circumcised, the problems were all related to UTIs. Three of these children also had meningitis, two had renal failure, and two died. The incidence of urinary-tract abnormalities was not reported. The incidence of UTI and bacteremia was lower among the circumcised boys, at a statistically significant level, although the overall rates of complications and other problems between the two groups were not significantly different.

Therefore, the incidence of complications of circumcision, according to some reports, approaches or exceeds the incidence of UTI among uncircumcised male infants. Although some of the complications are less severe than a UTI, the incidence and cost of complications need to be included in any assessment of the cost-effectiveness of routine circumcision.

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Penile problems during childhood

The incidence of bleeding, erosion of the glans and stenosis of the ureteral meatus has been reported to be higher in male infants who have been circumcised than in those who have not been circumcised.84 Meatitis and meatal ulcers occur almost exclusively in circumcised boys.84 However, a retrospective survey of boys 4 months to 12 years of age showed a significantly greater frequency of penile problems (14% v. 6%, p = 0.001) and of medical visits for penile problems (10% v. 5%, p = 0.05) among uncircumcised boys than among those circumcised.92 Most of the problems were minor. Another study of boys in their first 8 years of life reported that the relation between the risk of penile problems and circumcision status varied with the child's age.93 During infancy, the circumcised children had a statistically significantly higher risk of problems than the uncircumcised boys, but among the older children the uncircumcised boys had a significantly higher rate of penile problems, which included penile inflammation and phimosis.

These studies did not assess the possible effect of the forcible retraction of the prepuce, before it had separated naturally from the glans, on the later incidence of phimosis, penile inflammation or UTI. Is this an important factor? How common is this practice? There are articles published describing this procedure.94,95 The development of adhesions, bleeding and phimosis are among its reported complications.84,95 In general, there is inadequate recognition of the long period before the natural separation of the prepuce and glans is complete.96 Some authors still refer to the presence of "adhesions," when, in fact, separation has not yet taken place; similarly, a nonretractile foreskin is still sometimes incorrectly diagnosed as phimosis.97

In a study by Rickwood and Walker98 involving 420 boys referred to their unit for possible circumcision, only 116 (28%) required the procedure. They found no true phimosis in boys younger than 5 years of age. Most of the patients had developmental nonretractability of the prepuce, and their preputial orifice, although somewhat narrow, was supple and unscarred. The authors compared this finding with data from the Mersey region of England, where phimosis was the most common indication for circumcision, accounting for 87% of the procedures, and where 390 of the 950 patients circumcised were younger than 5 years of age. They estimated that approximately two thirds of these circumcisions performed in the Mersey area were probably unnecessary.

An evaluation of hygienic practices among uncircumcised patients showed that those who retracted the foreskin while bathing were less likely to have inflammation, phimosis or adhesions than those who did not.99 The authors of this evaluation stated that these findings supported the 1975 recommendation of the AAP3 that good hygiene can offer many of the advantages of circumcision. There is an urgent need for appropriate studies of the effectiveness of simple hygienic interventions among circumcised and uncircumcised boys and men.

Pain control during circumcision

Newborn infants exhibit physiological, autonomic and behavioural responses to noxious stimuli. These responses suggest that they experience pain, and there is evidence that preventing pain in newborns can be important.100 Newborns who undergo circumcision without an anesthetic have greater increases in heart rate, cry longer and have greater decreases in transcutaneous oxygen tension than those who undergo the procedure after administration of a dorsal penile nerve block with lidocaine.101 Behavioural differences have also been reported. Infants circumcised without an anesthetic were reported to show decreases in reponsiveness and in optimal motor performance in comparison with those who received a dorsal penile nerve block.102 These differences were still evident a day after the procedure. Furthermore, a recent report has described significantly longer crying bouts and pain scores among circumcised boys than among uncircumcised boys during routine vaccination at 4 to 6 months of age.103

Dorsal penile nerve block has been shown to reduce the behavioural and physiological changes during circumcision104,105 but may have serious consequences, including skin sloughs.106,107 Topical anesthetic agents show promise108-110 but do not take effect until 45 to 60 minutes after application. Furthermore, these agents may produce methemoglobinemia.111 A prospective, randomized, double-blind, placebo-controlled trial involving 47 patients showed that acetaminophen did not alleviate the intraoperative or the immediate postoperative physiological and behavioural changes indicating pain.112 However, it may have provided some benefit after the immediate postcircumcision period.

The use of sucrose for pain relief has also been tested. In a controlled trial, 30 normal term infants undergoing circumcision were randomly assigned to receive no intervention, a nipple dipped in water or a nipple dipped in a solution of 24% sucrose.113 The bottles of sterile water and of sucrose solution were prepared and marked so as to ensure that neither the investigator nor the physician knew their contents. The use of a pacifier dipped in sterile water reduced the percentage of time spent crying after circumcision from 67% to 49% (p < 0.01), and the use of sucrose on the pacifier further reduced the percentage of time spent crying to a mean of 31% (p < 0.05).

The evidence of the need for pain control is strong, and there is evidence of the increasing use of agents to achieve this.114 However, the most effective and least risky type of anesthesia or analgesia remains to be determined.115 Further studies are required to determine the most appropriate agents and the timing of their use.

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Cost-benefit analyses

Prevention of UTI

Chessare116 developed a model for decisions concerning circumcision of newborn male infants to prevent UTIs. In the model, the probability of having a UTI in the first year of life was considered to be 4.1% for an uncircumcised boy and 0.2% for a circumcised boy,33 and the likelihood of renal scarring as a result of a UTI was considered to be 7.5%.47 The probability of minor complications was set at 21.8%, which is a much higher incidence rate than the rate of 0.19% reported by Wiswell and Geschke91 or of 2% to 10% estimated by the authors of a recent review.90 Chessare stated that the rate of minor complications has no effect on the preferred choice. Major complications were not included because they are relatively rare. All possible outcomes were ranked from worst (e.g., circumcision followed by renal disease) to best (e.g., no circumcision and no later UTI) on a scale of 0 to 1. For the set of values assigned to the possible outcomes, the highest expected benefit was obtained from the choice not to circumcise. The choice would remain not to circumcise even if none of the infants circumcised had complications as a result of the procedure and would change only if the probability of a UTI in the first year of life was 29% or greater. The possible reductions in the risk of penile carcinoma and of HIV infection were not considered in this model.

Thompson21 interpreted the published data by considering a hypothetical cohort of 2000 newborn male infants, half of whom were circumcised and half of whom were not. Given an incidence of UTI of 0.1% in the circumcised boys and of 1.0% in the uncircumcised ones during the first year of life, he calculated that there would be nine more UTIs for every 1000 newborns who were not circumcised. Thus, 99.9% of the circumcised infants would not experience a UTI, whereas 99.0% of the uncircumcised group would not have a UTI. Given a complication rate of 0.2%,91 Thompson estimated that, whereas 9 boys out of 1000 circumcised would benefit from circumcision, 12 would have moderately severe complications. At a complication rate of 4.0%, 41 boys would have moderately severe or worse complications. He concluded that the potential benefit to 9 in 1000 boys would be more than offset by the rate of moderately severe or worse complications, even if this rate was as low as 0.2%.

Prevention of penile cancer

There have been two assessments of the cost-benefit ratio of routine neonatal circumcision to prevent penile cancer.6,117 However, neither assessment included the incidence and cost of the complications of circumcision, and both assumed that neonatal circumcision was completely protective. Since circumcision does not provide complete protection from penile cancer, and other factors appear to be involved in the causation of penile cancer, this assumption is an oversimplification. Cadman, Gafni and McNamee,117 on the basis of an incidence rate of penile carcinoma of two cases per 100 000 men annually and of the fact that the condition almost never presents before 50 years of age, calculated that the cost of circumcising 100 000 male infants is $3.8 million and that this manoeuvre would prevent only two cases of cancer of the penis. Cadman and colleagues then compared their estimate with Hartunian, Smart and Thompson's118 estimate of $103 000 as the cost of treatment and the lost earnings of a man 50 years of age with cancer. They conceptualized the cost of circumcision as a long-term investment, which, invested at 4% for 50 years, would have a value of $27.2 million. Hence, they estimated that the cost of prevention would be 100 times the cost of treatment.117 Not all factors concerning neonatal circumcision were considered, and the restriction of the analysis to purely economic factors is a significant limitation.

Overall assessments

Lawler, Bisonni and Holtgrave27 used a decision tree to illustrate the consequences of the choice to circumcise or not to circumcise male infants. With the use of the Markov process,119 they simulated the natural history of uncircumcised patients in whom penile cancer develops later in life. They assumed there was no risk of penile cancer after circumcision.

They included in the analysis the risks of death from the surgical procedure, of surgical complications, of UTI, of death from UTI and of penile problems. For the uncircumcised patients, the analysis included the risks of penile problems (e.g., balanitis, phimosis and paraphimosis), of death from the surgical procedure when performed at a later age, of surgical complications, of UTI, of death from UTI and of penile cancer. The incidence of these events was taken from the literature. However, this incidence information varies widely, and reliable data on the incidence of phimosis and the need for circumcision later in life are lacking as a result of differences in diagnostic criteria.97

Given an 85-year life expectancy, these investigators calculated that the expected lifetime cost of routine neonatal circumcision was $164.61 per patient, and the quality-adjusted survival was 84.999 years. For those not circumcised, the expected mean lifetime cost was $139.26 per patient and the quality-adjusted survival was 84.71 years. The investigators therefore concluded there was no medical indication for circumcision or contraindication against it. According to their sensitivity analyses, if the rate of surgical complications of neonatal circumcision fell below the threshold value of 0.6%, then circumcision would be preferred, both in terms of its cost and its favourable effect on lifespan. Similarly, if the risk of penile problems among uncircumcised males rose to 17% from the baseline value of 14%, then circumcision would be preferred from a cost perspective. The authors recognized and emphasized the need for epidemiologically sound data on the surgical complications of circumcision and on the incidence and outcome of therapy for balanitis, phimosis and other penile problems, in order to better assess the risks and benefits.

Ganiats and coworkers28 performed a cost-utility analysis of two hypothetical groups of 1000 neonates, one circumcised and the other uncircumcised. Their analysis included the reported differences in incidence of UTIs and of penile cancer, the estimated costs of treating these diseases, the incidence and cost of later therapeutic circumcision and the costs of neonatal circumcision and its complications. The net discounted lifetime cost of routine circumcision was $102 per man, and the net discounted lifetime cost to health of no circumcision was 14 hours per man. The results suggested that the financial and medical advantages and disadvantages of routine neonatal circumcision cancel each other out, and that personal cultural or religious views, rather than cost or health outcomes, should be the basis for decision making.

Poland10 commented that relatively few medical procedures are routinely recommended for the care of infants and children, and that a good general principle is to withhold the routine application of procedures to large groups unless the benefits clearly far outweigh the risks and costs. Our review of the literature leads us to conclude that, for routine neonatal circumcision, the benefits have not been shown to clearly outweigh the risks and costs.

When information on the medical advantages and disadvantages of neonatal circumcision is presented to parents before they make a decision concerning neonatal circumcision, it results in little change in their decisions.120,121 There is evidence that parents' decision making is based mainly on social, rather than medical, concerns.122 The strongest factor associated with the decision about whether to circumcise a male infant is whether his father was circumcised, and concerns about the attitude of peers and the boy's self-concept are also prominent influencing factors.122 These concerns also need to be discussed during physician counselling of parents. Further information that addresses these concerns is required.

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We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following.

  • There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%.
  • The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision.
  • Evaluation of alternative methods of preventing UTI in infancy is required.
  • More information on the effect of simple hygienic interventions is needed.
  • Information is required on the incidence of circumcision that is truly needed in later childhood.
  • There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases.
  • When circumcision is performed, appropriate attention needs to be paid to pain relief.
  • The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed.
  • When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.

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  1. Leitch IOW: Circumcision: a continuing enigma Aust Paediatr J 1970; 6: 59-65
  2. Committee on the Fetus and Newborn, American Academy of Pediatrics: Standards and Recommendations for Hospital Care of Newborn Infants, 5th ed, American Academy of Pediatrics, Evanston, Ill, 1971: 110
  3. Thompson HC, King LR, Knox E et al: Report of the ad hoc Task Force on Circumcision. Pediatrics 1975; 56: 610-611
  4. Fetus and Newborn Committee, Canadian Paediatric Society: Circumcision in the newborn period. CPS News Bull 1975; 8 (2): 1-4
  5. Committee on the Fetus and Newborn, American Academy of Pediatrics, and Committtee on Obstetrics, Maternal and Fetal Medicine, American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, American Academy of Pediatrics and American College of Obstetricians and Gynecologists, Washington, 1983: 87
  6. Warner E, Strashin E: Benefits and risks of circumcision. Can Med Assoc J 1981; 125: 967-976,992
  7. Fetus and Newborn Committee, Canadian Paediatric Society: Benefits and risks of circumcision: another view. Can Med Assoc J 1982; 126: 1399
  8. Task Force on Circumcision, American Academy of Pediatrics: Report of the Task Force on Circumcision. Pediatrics 1989; 84: 388-391
  9. Schoen EJ: The status of circumcision of newborns. N Engl J Med 1990; 322: 1308-1311
  10. Poland RL: The question of routine neonatal circumcision. N Engl J Med 1990; 322: 1312-1315
  11. Wiswell TE: Circumcision. [letter] Pediatrics 1990; 85: 888-889
  12. Schoen EJ: Circumcision. [letter] Pediatrics 1990; 85: 889
  13. Lee PA: Neonatal circumcision. [letter] N Engl J Med 1990; 323: 1204-1205
  14. Kallen RJ: Neonatal circumcision. [letter] N Engl J Med 1990; 323: 1206
  15. Soper MR: Neonatal circumcision. [letter] N Engl J Med 1990; 323: 1206-1207
  16. Schoen EJ: Neonatal circumcision. [letter] N Engl J Med 1990; 323: 1207
  17. Poland RL: Neonatal circumcision. [letter] N Engl J Med 1990; 323: 1207
  18. Altshul MS: The circumcision controversy. [editorial] Am Fam Physician 1990; 41: 817-820
  19. Dozor R: Routine neonatal circumcision: boundary of ritual and science. [editorial] Am Fam Physician 1990; 41: 820-822
  20. Wiswell TE: Routine neonatal circumcision: a reappraisal. Am Fam Physician 1990; 41: 859-863
  21. Thompson RS: Is routine circumcision indicated in the newborn? An opposing view. J Fam Practice 1990; 31: 189-197
  22. Schoen EJ: Is it time for Europe to reconsider newborn circumcision? Acta Paediatr Scand 1991; 80: 573-575
  23. Bollgren I, Winberg J: In reply to: Is it time for Europe to reconsider newborn circumcision? Acta Paediatr Scand 1991; 80: 575-577
  24. Gordon A, Collin J: Save the normal foreskin. BMJ 1993; 306: 1-2
  25. Robson WL, Leung AK: The circumcision question. Postgrad Med 1992; 91: 237-242,244
  26. Schoen EJ: Circumcision updated - indicated? Pediatrics 1993; 92: 860-861
  27. Lawler FH, Bisonni RS, Holtgrave DR: Circumcision: a decision analysis of its medical value. Fam Med 1991; 23: 587-593
  28. Ganiats TG, Humphrey JBC, Taras HL et al: Routine neonatal circumcision: a cost-utility analysis. Med Decis Making 1991; 11: 282-293
  29. Hammond T (ed): Awakenings: a Preliminary Poll of Circumcised Men. National Organization to Halt the Abuse and Routine Mutilation of Males, San Francisco, 1994
  30. Williams PL, Warwick R, Dyson M et al (eds): Gray's Anatomy, 37th ed, Churchill Livingstone, New York, 1989: 1432
  31. Taylor J: The prepuce: What, exactly, is removed by circumcision? A preliminary report. In Milos M, Richter L and Hodges F (eds): Proceedings from the Second International Symposium on Circumcision, National Organization of Circumcision Resource Centers, San Anselmo, Calif, 1994: 21-27
  32. Ginsburg CM, McCracken GH Jr: Urinary tract infections in young infants. Pediatrics 1982; 69: 409-412
  33. Wiswell TE, Smith FR, Bass JW: Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75: 901-903
  34. Wiswell TE, Enzenauer RW, Holton ME et al: Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics 1987; 79: 338-403
  35. Wiswell TE, Hachey WE: Urinary tract infections and the uncircumcised state: an update. Clin Pediatr (Phila) 1993; 32: 130-134
  36. Herzog LW: Urinary tract infections and circumcision: a case-control study. Am J Dis Child 1989; 143: 348-350
  37. Roberts JA: Does circumcision prevent urinary tract infection? J Urol 1986; 135: 991-992
  38. Lohr JA: The foreskin and urinary tract infections. J Pediatr 1989; 114: 502-504
  39. Wiswell TE, Miller GM, Gelston HM Jr et al: Effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatr 1988; 113: 442-446
  40. Glennon J, Ryan PJ, Keane CT et al: Circumcision and periurethral carriage of Proteus mirabilis in boys. Arch Dis Child 1988; 63: 556-557
  41. Fussell EN, Kaack BM, Cherry R et al: Adherence of bacteria to human foreskins. J Urol 1988; 140: 997-1001
  42. Kallenius G, Svenson S, Mollby R et al: Structure of carbohydrate part of receptor on human uroepithelial cells for pyelonephritogenic Escherichia coli. Lancet 1981; 2: 604-606
  43. Gareau FE, Mackel DC, Boring III Jr et al: The acquisition of fecal flora by infants from their mothers during birth.
  44. J Pediatr 1959; 54: 313-318
  45. Gothefors L, Carlsson B, Ahlstedt S et al: Influence of maternal gut flora and colostral and cord serum antibodies on presence of Escherichia coli in faeces of the newborn infant. Acta Pediatr Scand 1976; 65: 225-232
  46. Winberg J, Bollgren I, Kallenius G et al: Clinical pyelonephritis and focal renal scarring. A selected review of pathogenesis, prevention, and prognosis. Pediatr Clin North Am 1982; 29: 801-814
  47. Kallenius G, Mollby R, Svenson SB et al: Occurrence of P-fimbriated Escherichia coli in urinary tract infections. Lancet 1981; 2: 1369-1372
  48. Winberg J, Bollgren I, Gothefors L et al: The prepuce: a mistake of nature? Lancet 1989; 1: 598-599
  49. Dubos R: Staphylococci and infection immunity. [editorial] Am J Dis Child 1966; 105: 643-645
  50. Pisacane A, Graziano L, Zona G: Breast feeding and urinary tract infection. [letter] Lancet 1990; 336: 50
  51. Amato D, Garduno-Espinosa J: Circumcision in the newborn boy and the risk of urinary tract infection during the first year of life. A meta-analysis. Bol Med Hosp Infant Mex 1992; 49: 652-658
  52. Cohen HA, Drucker MM, Vainer S et al: Postcircumcision urinary tract infection. Clin Pediatr (Phila) 1992; 31: 322-324
  53. Spach DH, Stapleton AE, Stamm WE: Lack of circumcision increases the risk of urinary tract infection in young men. JAMA 1992; 267: 679-681
  54. Amir J, Varsano I, Mimouni M: Circumcision and urinary tract infection in infants. [letter] Am J Dis Child 1986; 140: 1092
  55. Rockney RM, Caldamone AA: Circumcision and urinary tract abnormalities. [letter] Am J Dis Child 1989; 143: 1261-1262
  56. Hopp L: Circumcision and urinary tract abnormalities. [letter] Am J Dis Child 1989; 143: 1262
  57. Smith GL, Greenup R, Takafuji ET: Circumcision as a risk factor for urethritis in racial groups. Am J Public Health 1987; 77: 452-454
  58. Donovan B, Bassett I, Bodsworth NJ: Male circumcision and common sexually transmissible diseases in a developed nation. Genitourin Med 1994; 70: 317-320
  59. Parker SW, Stewart AJ, Wren MN et al: Circumcision and sexually transmissible disease. Med J Aust 1983; 2: 288-290
  60. Simonsen JN, Cameron DW, Gakinya MN et al: Human immunodeficiency virus infection among men with sexually transmitted disease: experience from a center in Africa. N Engl J Med 1988; 260: 1943-1944
  61. Cameron DW, Simonsen JN, D'Costa LJ et al: Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet 1989; 2: 403-407
  62. Moses S, Plummer FA, Bradley JE et al: The association between lack of male circumcision and risk for HIV infection: a review of the epidemiological data. Sex Transm Dis 1994; 21: 201-210
  63. De Vincenzi I, Mertens T: Male circumcision: a role in HIV prevention? [editorial] AIDS 1994; 8: 153-160
  64. Wallerstein E: Circumcision: the uniquely American medical enigma. Urol Clin North Am 1985; 12: 123-132
  65. Garfinkel L: Circumcision and penile cancer. [letter] CA Cancer J Clin 1983; 33: 320
  66. Cutler SJ, Young JL (eds): Third National Cancer Survey: Incidence Data [monograph 41], National Cancer Institute, Washington, 1975
  67. Young JL, Percy CL, Asire AJ (eds): Surveillance, Epidemiology, and End Results: Incidence and Mortality Data, 1973-1977 [monograph 57], National Cancer Institute, Washington, 1981
  68. Persky L, deKernion J: Carcinoma of the penis. CA Cancer J Clin 1986; 36: 258-273
  69. Kochen M, McCurdy S: Circumcision and the risk of cancer of the penis: a life-table analysis. Am J Dis Child 1980; 134: 484-486
  70. Leiter E, Lefkovits AM: Circumcision and penile carcinoma. N Y State J Med 1975; 75: 1520-1522
  71. Boczko S, Freed S: Penile carcinoma in circumcised males. N Y State J Med 1979; 79: 1903-1904
  72. Rogus BJ: Squamous cell carcinoma in a young circumcised man. J Urol 1987; 138: 861-862
  73. Wolbarst AL: Circumcision and penile cancer. Lancet 1932; 1: 150-153
  74. McCance DJ, Kalache A, Ashdown K et al: Human papillomavirus types 16 and 18 in carcinomas of the penis from Brazil. Int J Cancer 1986; 37: 55-59
  75. Maden C, Sherman KJ, Beckmann AM et al: History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993; 85: 19-24
  76. Brinton LA, Jun-Yao L, Shou-De R et al: Risk factors for penile cancer: results from a case-control study in China. Int J Cancer 1991; 47: 504-509
  77. McCance DJ: Human papillomaviruses and cancer. Biochim Biophys Acta 1986; 823: 195-205
  78. Baird PJ: The causation of cervical cancer. Part II: the role of human papilloma and other viruses. Clin Obstet Gynecol 1985; 12: 19-32
  79. Kaufman RH, Adam E: Herpes simplex virus and human papilloma virus in the development of cervical carcinoma. Clin Obstet Gynecol 1986; 3: 678-692
  80. Zur Hausen H: Genital papillomavirus infections. Prog Med Virol 1985; 32: 15-21
  81. Kessler II: Etiological concepts in cervical carcinogenesis. Gynecol Oncol 1981; 12 (suppl 2): S7-S24
  82. Martinez I: Relationship of squamous cell carcinoma of the cervix uteri to squamous cell carcinoma of the penis among Puerto Rican women married to men with penile carcinoma. Cancer 1969; 24: 777-780
  83. Rotkin ID: Adolescent coitus and cervical cancer: associations of related events with increased risk. Cancer Res 1967: 27: 603-617
  84. Deeley TJ: Cancer of the cervix uteri - an epidemiological survey. Clin Radiol 1976; 27: 43-51
  85. Kaplan GW: Complications of circumcision. Urol Clin North Am 1983; 10: 543-549
  86. Kaplan GW: Circumcision: an overview. Curr Probl Pediatr 1977; 7 (5): 1-33
  87. Gluckman GR, Stoller ML, Jacobs MM et al: Newborn penile glans amputation during circumcision and successful reattachment. J Urol 1995; 153: 778-779
  88. Eason JD, McDonell M, Clark G: Male ritual circumcision resulting in acute renal failure. BMJ 1994; 309: 660-661
  89. Speert H: Circumcision of the newborn: an appraisal of the present status. Obstet Gynecol 1953; 2: 154-172
  90. Patel H: The problem of routine circumcision. Can Med Assoc J 1966; 95: 576-581
  91. Williams N, Kapila L: Complications of circumcision. Br J Surg 1993; 80: 1231-1236
  92. Wiswell TE, Geschke DW: Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989; 83: 1011-1015
  93. Herzog LW, Alvarez SR: The frequency of foreskin problems in uncircumcised children. Am J Dis Child 1986; 140: 254-256
  94. Fergusson DM, Lawton JW, Shannon FT: Neonatal circumcision and penile problems: an 8 year longitudinal study. Pediatrics 1988; 81: 537-541
  95. Cooper GG, Thomson GJ, Raine PA: Therapeutic retraction of the foreskin in childhood. BMJ 1983; 286: 168-167
  96. MacKinlay GA: Save the prepuce: painless separation of preputial adhesions in the outpatient clinic. BMJ 1988; 297: 590-591
  97. Oster J: Further fate of the foreskin: incidence of preputial adhesions, phimosis and smegma among Danish boys. Arch Dis Child 1968; 43: 200-203
  98. Williams N, Chell J, Kapila L: Why are children referred for circumcision? BMJ 1993; 306: 28
  99. Rickwood AM, Walker J: Is phimosis overdiagnosed in boys and are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989; 71: 275-277
  100. Krueger H, Osborn L: Effects of hygiene among the uncircumcised. J Fam Practice 1986; 22: 353-356
  101. Anand KJS, Hickey PR: Pain and its effects in the human neonate and fetus. N Engl J Med 1987; 317: 1321-1329
  102. Williamson PS, Williamson ML: Physiologic stress reduction by a local anesthetic during newborn circumcision. Pediatrics 1983; 71: 36-40
  103. Dixon S, Snyder J, Holve R et al: Behavioural effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984; 5: 246-250
  104. Taddio A, Goldbach M, Ipp M et al: Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345: 291-292
  105. Holve RL, Bromberger PJ, Groveman HD et al: Regional anesthesia during newborn circumcision: effect on infant pain response. Clin Pediatr (Phila) 1983; 22: 813-818
  106. Maxwell LG, Yaster M, Wetzell RC et al: Penile nerve block for newborn circumcision. Obstet Gynecol 1987; 70: 415-419
  107. Sara CA, Lowery CJ: A complication of circumcision and dorsal nerve block of the penis. Anaesth Intensive Care 1984; 13: 79-82
  108. Diaz M, Graff M, Hiatt M et al: Prenatal lidocaine and the auditory evoked responses in term infants. Am J Dis Child 1988; 142: 460-161
  109. Juhlin L, Evers H: EMLA: a new topical anesthetic. Adv Dermatol 1990; 5: 75-92
  110. Benini F, Nagourney B, Johnston C et al: Efficacy of topical anesthetics (EMLA) for pain control in neonatal circumcision. JAMA 1993; 270: 850-853
  111. Weatherstone KB, Rasmussen LB, Erenberg A et al: Safety and efficiency of a topical anesthetic for neonatal circumcision. Pediatrics 1993; 92: 710-714
  112. Engberg G, Danielson K, Henneberg S et al: Plasma concentrations of prilocaine and lidocaine and methaemoglobin formation in infants after epicutaneous application of a 5% lidocaine-prilocaine cream (EMLA). Acta Anaesthesiol Scand 1985; 31: 624-628
  113. Howard CR, Howard FM, and Weitzman ML: Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641-646
  114. Blass EM, Hoffmeyer LB: Sucrose as an analgesic for newborn infants. Pediatrics 1991; 87: 215-218
  115. Ryan CA, Finer NN: Changing attitudes and practices regarding local analgesia for newborn circumcision. Pediatrics 1994; 94: 130-133
  116. Wellington N and Rieder MJ: Analgesia for newborn circumcision. Pediatrics 1993; 92: 541-543
  117. Chessare J: Circumcision: Is the risk of urinary tract infection really the pivotal issue? Clin Pediatr (Phila) 1992; 31: 100-104
  118. Cadman D, Gafni A, McNamee J: Newborn circumcision: an economic perspective. Can Med Assoc J 1984; 131: 1353-1355
  119. Hartunian NS, Smart CN, Thompson MS: The incidence and economic costs of cancer, motor vehicle injuries, coronary heart disease and stroke: a comparative analysis. Am J Public Health 1980; 70: 1249-1260
  120. Beck JR, Pauker SG: The Markov process in medical prognosis. Med Decis Making 1983; 3: 419-458
  121. Herrera AJ, Cochran B, Herrera A et al: Parental information and circumcision in highly motivated couples with higher education. Pediatrics 1983; 71: 233-234
  122. Maisels MJ, Hayes B, Conrad S et al: Circumcision: the effect of information on parental decision making. Pediatrics 1983; 71: 453-455
  123. Brown MS, Brown CA: Circumcision decision: prominence of social concerns. Pediatrics 1987; 80: 215-219

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Fetus and Newborn Committee, Canadian Paediatric Society

Members: Drs. Wayne Andrews, Department of Pediatrics, Charles Janeway Hospital, St. John's, Nfld.; Douglas McMillan (chairman), Department of Pediatrics, Foothills Hospital, Calgary, Alta.; Arne Ohlsson, Department of Newborn and Developmental Pediatrics, Women's College Hospital, Toronto, Ont.; Thérèse Perreault, Department of Pediatrics, Montreal Children's Hospital, Montreal, Que.; Michael Vincer, Department of Neonatal Pediatrics, Grace Maternity Hospital, Halifax, NS; C. Robin Walker, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ont.; and John Watts, Department of Pediatrics, Chedoke-McMaster Hospitals, Hamilton, Ont. Consultants: Drs. Alexander Allen (former chairman), Department of Neonatal Pediatrics, Grace Maternity Hospital, Halifax, NS; Eugene Outerbridge (principal author), Department of Pediatrics, Montreal Children's Hospital, Montreal, Que.; and Saroj Saigal, director, Growth and Development Clinic, Neonatal Follow-Up, Chedoke-McMaster Hospitals, Hamilton, Ont. Liaisons: Ms. Debbie Fraser Askin, Neonatal Nursing Consultant, Clinical Nurse Specialist, St. Boniface Hospital, Winnipeg, Man.; Drs. Robert Liston, Maternal-Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada, Grace Hospital, Halifax, NS; Gerald Merenstein, Committee on Fetus and Newborn, American Academy of Pediatrics, Department of Pediatrics, University of Colorado, Children's Hospital, Denver, Colo.; Renato Natale, Maternal-Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada, chairman, Department of Obstetrics and Gynecology, St. Joseph's Health Centre, London, Ont.; William Oh, Committee on Fetus and Newborn, American Academy of Pediatrics, Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI; Apostolos Papageorgiou, Neonatal-Perinatal Medicine Section, Canadian Paediatric Society, Department of Pediatrics, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Que.; and Ms. Janet Pinelli, Neonatal Nursing Consultant, School of Nursing, McMaster University and Chedoke-McMaster Hospitals, Hamilton, Ont.


This guideline is for reference and education only and is not intended to be a substitute for the advice of an appropriate health care professional or for independent research and judgement. The CMA relies on the source of the CPG to provide updates and to notify us if the guideline becomes outdated. The CMA assumes no responsibility or liability arising from any outdated information or from any error in or omission from the guideline or from the use of any information contained in it.

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