RESEARCH ARTICLE
Neonatal Circumcision: Is Feeding
Behavior Altered?
abstract
BACKGROUND: The effect of circumcision on feeding behavior in the newborn
period is unknown. We hypothesized that circumcision would not have a
significant effect on newborn feeding.
METHODS: This prospective study analyzed the effect of circumcision on
neonatal feeding behavior. Inclusion criteria were healthy male infants WHO
were exclusively bottle-fed and underwent a circumcision before discharge
from the newborn nursery. We collected data (N = 42) on gestational age, birth
weight, Apgar scores, maternal age, gravid status, anesthesia used during
delivery, analgesia used after circumcision, time of circumcision, and volume and
frequency of feeding before and after circumcision. Data were analyzed by using
paired t tests, multivariable regression analysis, and analysis of variance (with
SPSS version 18). Significance was P < .05 (2-tailed α).
RESULTS: Descriptive statistics for the entire group (N = 42) are as follows:
mean ± SD gestational age: 38.7 ± 1.2 weeks; mean birth weight: 3.3 ± 0.4 kg;
maternal age: 26.7 ± 6.3 years; baseline feeding (mean of first 2 feedings before
circumcision): 24.5 ± 9.9 mL; mean first feeding after circumcision: 21.7 ± 11.9
mL; and mean second feeding: 26.7 ± 13.5 mL. Forty-eight percent of patients
increased their feeding volume after circumcision compared with baseline,
and 52% of patients decreased their feeding volume, which persisted with the
second feeding. There was no statistical difference between the baseline and
first feeding (P = .11) or second feeding (P = .22).
CONCLUSIONS: Our data suggest that circumcision does not alter feeding
after circumcision. This information will be useful in counseling families
regarding circumcision in the newborn period.
AUTHORS
Theresa B. Gattari,1 Andrea R. Bedway, 2 Robert
Drongowski, MA, 3 Kristin Wright,1 Patricia
Keefer, MD,1 Kerry P. Mychaliska, MD1
1
Department of Pediatrics and Communicable
Diseases, and
3
Division of Pediatric Surgery, Department of
Surgery, The University of Michigan Medical
School, CS Mott Children’s Hospital, Ann Arbor,
Michigan; and
2
Department of Physiology, Wayne State University
School of Medicine, Detroit, Michigan
KEY WORDS
circumcision, neonatal feeding, newborn
ABBREVIATION
EMR: electronic medical record
www.hospitalpediatrics.org
doi:10.1542/hpeds.2012-0082
Address correspondence to Kerry P. Mychaliska,
MD, The University of Michigan Health System,
CS Mott Children’s Hospital, 1540 E Medical
Center Dr, Ann Arbor, MI 48109.
E-mail: [email protected]
HOSPITAL PEDIATRICS (ISSN Numbers: Print,
2154 - 1663; Online, 2154 - 1671).
Copyright © 2013 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURE: The authors have
indicated they have no financial relationships
relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The
authors have indicated they have no potential
conflicts of interest to disclose.
Literature exists that addresses both the positive and negative effects of circumcision. However, few studies have examined the specific effect of circumcision
on neonatal feeding behavior. In the current literature, some evidence suggests
that male circumcision has many health benefits, including protection against
HIV, urinary tract infections, and penile cancer.1–7 Macke,8 however, reported that
circumcision in the newborn period causes severe and persistent pain, often
requiring analgesia for circumcision to prevent negative effects on mother–infant
interaction. Anecdotal evidence suggests that circumcision before breastfeeding
is associated with difficulty breastfeeding.9 Marshall et al10 studied 59 bottle-fed
infants and found that the feeding behavior of the experimental group (circumcised on day 2) differed slightly from the control group (circumcised on day 3).
However, the findings from this observational study were neither statistically
362 |
VOLUME 3 • ISSUE 4
www.hospitalpediatrics.org
HOSPITAL Pediatrics ®
significant (Wilcoxon P < .09) nor did
they evaluate volumetric data.
Thus, there is a paucity of literature
that measures the effect of circumcision on neonatal feeding behavior, and
we are unaware of any literature that
evaluates the feeding behavior on a
volume-based scale. The purpose of
our study was to evaluate the effects of
male circumcision on neonatal feeding
behavior by using volumetric data.
METHODS
This was a prospective study that collected feeding data on healthy, bottlefed males that were circumcised before
discharge from the newborn nursery at CS Mott Children’s Hospital
in Ann Arbor, Michigan, from June
2010 to April 2011. We elected to study
newborns who were bottle-fed for
the purposes of more accurate feeding volumes. Feeding volumes precircumcision and postcircumcision were
compared. Exclusion criteria included
breastfed male infants, female infants,
uncircumcised male infants, infants
with abnormal vital signs in the first
24 hours of life, and infants admitted
to the NICU. This study was approved
by the institutional review board at the
University of Michigan Medical School
(HUM00036627).
All newborn male patients were identified on the newborn daily patient
census by using OB Tracevue, the
electronic medical record (EMR) system for the newborn service. The newborns were identified by the resident
assistant, who determined if the infant
was bottle-fed or breastfed and subsequently e-mailed the study team
with the names and medical record
numbers of the newborn males who
were bottle-fed. A study team member then determined eligibility of the
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
patients based on the aforementioned
formal exclusion criteria. During the
11-month study, ∼1880 male infants on
the nursery census were screened for
eligibility, and 1838 male infants were
excluded due to breastfeeding. Written
informed consent was obtained from
the patient’s mother by a study team
member. After obtaining consent, the
newborn was entered (via name and
medical record number) into our
data collection file in Microsoft Excel
(Microsoft Corporation, Redmond,
Washington) and enrolled in the study.
The following predictor variables were
collected from the EMR: time of birth,
birth weight, Apgar scores, gestational
age, maternal age, delivery method, and
record of any anesthesia given during
delivery. After circumcision completion, we collected the date and time of
circumcision, dose of 0.1% lidocaine
(without epinephrine) administered
for circumferential block, dose of acetaminophen administered, whether the
patient received sucrose, type of clamp
used, and description of any complications of the circumcision procedure.
Date and time of patient discharge
were also obtained from the EMR.
We determined that the average hours
of life that males are circumcised at
CS Mott Hospital is ∼19 hours, necessitating 36 to 48 hours of feeding data
for most patients. Staff nurses record
all newborn feedings each shift in the
patient’s EMR; therefore, this source
was used to retrieve feeding data on
each newborn precircumcision and
postcircumcision.
The means and frequencies of the
predictor variables were determined.
The primary outcome of this study
was the difference in feeding volume
measured before and after circumcision. The baseline was determined to
be the average of the first 2 feedings
before circumcision to reduce the variability of the baseline value. Baseline
was compared with both the first and
second feeding volumes after circumcision. The primary outcome was
determined by using the paired t test.
Mean feeding volume postcircumcision was categorized according to
patients who increased or decreased
feeding volumes postcircumcision.
Lastly, a multivariable regression analysis was performed to analyze these
2 trends. The significance was P < .05
(2-tailed α).
RESULTS
We enrolled 39 full-term infants and
3 preterm infants; we did not exclude
infants whose gestational age was
between 35 and 37 weeks due to the
limited availability of bottle-fed subjects. Therefore, 42 male infants who
met the inclusion criteria were studied.
Table 1 presents a description of the
study group.
The baseline was determined as the
average of the first and second feeding volumes before circumcision (24.5
± 9.9 mL). The first and second feeding volumes after circumcision were
compared with the baseline control.
The first feeding volume was 21.7 ±
11.9 mL. The second feeding volume
was 26.7 ± 13.5 (Fig 1). There was no
FIGURE 1 Volume of infant feedings
postcircumcision.
| 363
HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
significant difference between the first
feeding volume and baseline (P = .11)
or second feeding volume and baseline (P = .22). Paired t tests revealed
that, compared with baseline, 48% of
patients showed an increase in feeding
volume for the first feeding after circumcision, persisting with the second
feeding. Furthermore, 52% of patients
showed a decrease in feeding volume
for the first feeding after circumcision,
with a slight increase in the second
feeding (Fig 2).
A multivariable analysis was performed
on all the variables listed in Table 1 to
determine if any of the predictor variables influenced the volume of infant
feedings postcircumcision. Variables
categorized as dichotomous included
maternal anesthesia, whether the patient received sucrose, and Gomco clamp
use. Variables categorized as continuous included gestational age, birth
weight, maternal age, Apgar scores,
previous children, age at circumcision,
dose of lidocaine, and dose of acetaminophen. No statistically significant
relationship was found between these
2 trends.
TABLE 1 Demographic Characteristics of the Study Population
Characteristic
Frequency
38.9 ± 1.3
3.30 ± 0.38
Mean gestational age, wk
Mean birth weight, kg
Apgar score
Median 1 min
Median 5 min
Mean maternal age, y
Mean previous children
Multiparous mothers
Primiparous mothers
Delivery
Vaginal
Cesarean
Maternal anesthesia
Spinal
Epidural
Local
Mean age at circumcision, h
Mean dose of lidocaine, mL
Mean dose of acetaminophen, mg (n = 39)
Sucrose use
Gomco clamp use
8 (range: 3–9)
9 (range: 8–10)
26.5 ± 6.2
1.7 ± 1.8
33 (78.6%)
9 (21.4%)
33 (78.6%)
9 (21.4%)
11 (27.5%)
27 (67.5%)
4 (9.5%)
19.2 ± 7.8
0.90 ± 0.1
44.21 ± 7.53
42 (100%)
42 (100%)
Unless otherwise noted, data are presented as mean ± SD or n (%).
DISCUSSION
Male neonatal circumcision is a common procedure, with limited research
on all the risks and benefits. Our study
results suggest that circumcision does
not have a significant effect on neonatal feeding behavior. Our prospective
study design is unique because we
incorporated volume measurements
of feedings before and after circumcision. There was no significant difference between baseline and the first
or second feeding after circumcision
(Fig 1). Furthermore, some infants had
an increase in feeding after circumcision and others had a decrease. None
of the collected variables correlated to
either trend.
We did not exclude the 3 infants who
were not given acetaminophen for
pain management after circumcision
due to sample size availability. Acetaminophen use was a variable we collected and included in the multivariable
regression analysis, and it did not seem
to affect whether a newborn initially
had an increase or decrease in the volume of feeding postcircumcision.
FIGURE 2 The baseline for each subgroup was the average of the first 2 feeding volumes
before circumcision. Feeding 1 and feeding 2 reflect the feeding patterns postcircumcision
of the separate subgroups.
364 |
VOLUME 3 • ISSUE 4
www.hospitalpediatrics.org
The current study addresses a novel
clinical question and provides a platform for future research, although it
does have limitations. The first limitation is its small sample size due to the
limited number of newborns bottle-fed
HOSPITAL Pediatrics ®
at the time of hospital discharge.
Although the overall rate of successful
breastfeeding in the state of Michigan
is low at 3, 6, 9, and 12 months of age,
the vast majority of newborns evaluated
for our study were being breastfeed at
the time of discharge. According to the
number of male infants excluded due to
breastfeeding, the breastfeeding rate
at our hospital was ∼98%. Therefore,
the number of eligible patients for our
study was limited to 42. Secondly, we
are assuming that our results are generalizable to the bottle-fed population.
Lastly, an a priori power analysis was
not performed. A post hoc power analysis suggests that an n value of 17
will detect a 5-mL change in feeding
volume at the 0.05 level (2-tailed test)
with 80% power. The means used for
the post hoc power analysis were estimated by using previously observed
feeding volumes.
CONCLUSIONS
Our study suggests that male circumcision performed before discharge
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
had no significant effect on neonatal
feeding behavior among bottle-fed male
infants. Further research is required
to study the volumetric effect among
breastfed male infants and to continue expanding our knowledge in this
area.
REFERENCES
1. Weiss HA, Quigley MA, Hayes RJ. Male
circumcision and risk of HIV infection
in sub-Saharan Africa: a systematic
review and meta-analysis. AIDS. 2000;
14(15):2361–2370.
2. Baeten JM, Richardson BA, Lavreys L,
et al. Female-to-male infectivity of
HIV-1 among circumcised and uncircumcised Kenyan men. J Infect Dis. 2005;
191(4):546–553.
3. Siegfried N, Muller M, Deeks J, et al.
HIV and male circumcision—a systematic review with assessment of the
quality of studies. Lancet Infect Dis.
2005;5(3):165–173.
4. Singh-Grewal D, Macdessi J, Craig J.
Circumcision for the prevention of urinary tract infection in boys: a systematic
review of randomised trials and observational studies. Arch Dis Child. 2005;
90(8):853–858.
5. Schoen EJ. Circumcision for preventing
urinary tract infections in boys: North
American view. Arch Dis Child. 2005;
90(8):772–773.
6. Auvert B, Taljaard D, Lagarde E,
Sobngwi-Tambekou J, Sitta R, Puren
A. Randomized, controlled intervention
trial of male circumcision for reduction
of HIV infection risk: the ANRS 1265
Trial. PLoS Med. 2005;2(11):e298.
7. Larke NL, Thomas SL, dos Santos Silva
I, Weiss HA. Male circumcision and
penile cancer: a systematic review and
meta-analysis. Cancer Causes Control.
2011;22(8):1097–1110.
8. Macke JK. Analgesia for circumcision:
effects on newborn behavior and mother/
infant interaction. J Obstet Gynecol Neonatal Nurs. 2001;30(5):507–514.
9. Lee N. Circumcision and breastfeeding.
J Hum Lact. 2000;16(4):295.
10. Marshall RE, Porter FL, Rogers AG,
Moore J, Anderson B, Boxerman SB.
Circumcision: II. Effects upon motherinfant interaction. Early Hum Dev. 1982;
7(4):367–374.
11. Fergusson DM, Boden JM, Horwood
LJ. Neonatal circumcision: effects on
breastfeeding and outcomes associated
with breastfeeding. J Paediatr Child
Health. 2008;44(1–2):44–49.
| 365