infections in infant boys and reduced HIV infections

Male circumcision

Complications of circumcision in male neonates, infants and children: a systematic review.

Approximately one in three men are circumcised globally, but there are relatively few data on the safety of the procedure. The aim of this paper is to summarize the literature on frequency of adverse events following paediatric circumcision, with a focus on developing countries. PubMed and other databases were searched with keywords and MeSH terms including infant/newborn/paediatric/child, circumcision, complications, and adverse events. Searches included all available years and were conducted on November 6th 2007 and updated on February 14th 2009. Additional searches of the Arabic literature included searches of relevant databases and University libraries for research theses on male circumcision. Studies were included if they contained data to estimate frequency of adverse events following neonatal, infant and child circumcision. There was no language restriction. A total of 1349 published papers were identified, of which 52 studies from 21 countries met the inclusion criteria. The Arabic literature searches identified 46 potentially relevant papers, of which six were included. Sixteen prospective studies evaluated complications following neonatal and infant circumcision. Most studies reported no severe adverse events (SAE), but two studies reported severe adverse event frequency of 2%. The median frequency of any complication was 1.5% (range 0-16%). Child circumcision by medical providers tended to be associated with more complications (median frequency 6%; range 2-14%) than for neonates and infants. Traditional circumcision as a rite of passage is associated with substantially greater risks, more severe complications than medical circumcision or traditional circumcision among neonates. Studies report few severe complications following circumcision. However, mild or moderate complications are seen, especially when circumcision was undertaken at older ages, by inexperienced providers or in non-sterile conditions. Paediatric circumcision will continue to be practiced for cultural, medical and as a long-term HIV/sexually transmitted infection prevention strategy. Risk-reduction strategies including improved training of providers, and provision of appropriate sterile equipment, are urgently needed.

Editors’ note: Circumcision of neonates and infant boys is cheaper than adult male circumcision, does not generally require suturing, and healing occurs much faster than in older boys, adolescents, and men. As this review of 16 prospective studies reveals, complication rates are low with bleeding and infection being the most common adverse events for methods using the Plastibell, Gomco clamp, freehand circumcision, or a combination of methods. Freehand circumcision had the highest complication rate (27%) and midwives (19%) had higher rates than doctors (7%). But different levels of training and supervision among doctors resulted in complication rates of 1.6% in a public teaching hospital versus 20% at private hospitals. WHO and UNAIDS recommend that high HIV prevalence countries consider neonatal circumcision in addition to adult male circumcision as a longer-term HIV prevention strategy and several African countries are planning to implement pilot projects for neonatal and infant circumcision, having assessed acceptability. Modelling shows that the effects of introducing neonatal circumcision now will take up to 20 years to show epidemic impact but in the grand scheme of things this investment could pay off over the short to medium term in improved hygiene and reduced urinary tract infections in infant boys and reduced HIV infections and genital ulcer diseases in young men down the line.