Circumcision in neonates: evidence-based nursing guidance for informed parental decision-making

Circumcision

The Benefits and Risks of Circumcision in Neonates

Maternal Child Nursing Evidenced-Based Practice Paper Guidelines

Current viewpoints on whether to circumcise male children is a topic of debate among health care providers and parents. This practice is common in the United States, but not as common in other parts of the world. In the United States circumcision is a common practice based on information that suggests that it prevents certain diseases from developing later on in life. However, recent evidence presents the issue as a cultural issue, rather than one of medical need. This evidence-based practice guideline suggests that a nurse should play a neutral role in the decision of parents on whether to circumcise or not, and that they should provide information to support the decision. The information provided should be balanced and based on current medical evidence.

Introduction

Statement of Problem

Currently, information is not provided in many hospitals of that support either side of the issue. In many cases, hospitals support circumcision and consider it standard procedure. The parents get little choice in the matter, or are made to feel as if they do not. The purpose of this evidence-based guideline is to support the position that nurses need to provide information to patients that will allow them to understand the medical issues involved in the practice of circumcision. The issue of concern is that not enough information is provided to parents that will allow them to make their own informed decision on the issue of circumcision. Nurses can play a key role in helping parents to explore the issue and to make the right decision for their needs.

Currently, nurses do not provide sufficient support for the parent that decides not to circumcise and parents do not receive instruction on how to care for the foreskin and penis properly to avoid infection. This can lead to the need for a circumcision later due to infection that could have been prevented with proper education. Currently, practice in the United States dictates that medical professionals perform circumcisions on a majority of males, even though there is evidence to support a lack of medical need for the procedure. Providing parents with evidence-based information about care of the foreskin and penis, as well as evidence to support both sides of the issues will play a significant role in increasing the parents of decision-making role about their child from the early days of their life. It will also help parents to avoid infections in children that they choose not to circumcise.

A Summary of the literature

The debate on whether to circumcise or not to circumcise is supported by valid evidence on both sides of the issue. The following will present information on both sides of the issue that will relate it to current nursing practice. In order to resolve this issue more studies need to be conducted. The following summary of current literature on the subject of will present both sides of the issue as it currently stands.

Circumcisions in the United States are typically performed based on information that the surgery will prevent urinary tract infections, phimosis, paraphimosis, and sexually transmitted disease, including HIV (Fortier, 2009). According to Fortier, there are some statistics that support some of these claims, but many of those cited in his research are up to interpretation. Nurses that care for neonates often report that breastfeeding is more difficult when babies are circumcised, and that the trauma of the surgery is difficult for the newborn (Fortier, 2009). The rate of urinary tract infections in uncircumcised boys is only 1% to 2% and these are typically easily treated with cheap antibiotics (Sprunger, 2009). This is the current standpoint taken by those who are against circumcision.

Phimosis is the condition that most often leads to the decision to circumcise. Males with this condition have a foreskin that will not retract due to adhesions to the penis. When this occurs circumcision is the recommendation that is most often prescribed (Steadman & Ellsworth, 2006). However, according to the authors, physicians who are not familiar with normal neonate foreskin retraction and its development in the first three years often misdiagnose the condition and recommend surgery when in fact the foreskin retracts normally for the infant's age. The authors recognize that in cases where the child experiences recurrent urinary tract infections, that circumcision is often the best course of action in these cases. They also recognize that in cases of paraphimosis where the foreskin is retracted behind the head and cannot be replaced or when the child must undergo the frequent catheterization, that circumcision is also necessary. The conclusions drawn by Stearman & Ellsworth are supported by valid empirical studies.

Despite a growing body of empirical evidence that concludes that circumcision is not necessary, except in certain rare cases, a number of doctors claim that circumcision still has many medical benefits that are being ignored by those that do not support circumcision as standard practice. A number of empirical studies support an increased risk of urologic disorders in men who were not circumcised (Schoen, 2006). Dickerman (2007) feels that recent studies in Africa indicate that circumcision results in a protective factor against HIV in nearly 60% of the subjects studied. The author cites many other studies that support circumcision as a preventative measure against other STDs as well.

The current body of literature on circumcision contains valid empirical evidence to support both those who are for circumcision and those who are against it. The studies found during this literature review represent valid empirical studies, and therefore it is difficult to discredit one or the other. The only clear need that was found is that more research needs to be conducted before the issue of which is better health can be decided. Conflicting evidence regarding whether to circumcise or not to circumcise makes it difficult for nurses as they attempt to provide patients with the most accurate and up-to-date information that is available. These research disparities and gaps support the stance that at the current time, nurses need to provide credible empirical research on both sides in order to help parents make the most informed decision about what is best for their child. As new research becomes available, it can be added to that which is provided to parents.

Evidence-Based Practice

At the current time, it is difficult to draw any definitive conclusions as to whether circumcision is necessary, or whether it is unnecessary for the newborn. In the United States many do not realize that they even have a choice in the matter, as circumcision is often considered to be a routine procedure. Parents do not doubt that the procedure is necessary and often do not question whether it should be done or not due to prevailing cultural norms. However, several studies support the opinion that the procedure is not necessary at all. The key problem in resolving the issue is that valid studies exist on both sides of the issue and it is difficult to favor one side over the other at the present time.

It is difficult to make a decision based on the empirical evidence that exists on the topic of whether to circumcise or not. Regardless of one's personal opinion on the issue, it is difficult to determine which is the best course of action regarding nursing practices and the development of evidence-based guidelines for nursing practice. Unfortunately, in an issue where support exists for both sides, the nurse must often make a difficult decision as to how to present information on the decision of whether to circumcise or not to circumcise to the parents. The current body of information provided to patients, if any information is provided at all, does not present a balanced view of the issue, the rather reflects the cultural opinions of physicians of in the United States.

Recommended Actions

It is not the role of the nurse to make cultural decisions for patients. Yet, the nurses have an obligation to help of patients make informed medical decisions about the care of their newborn. Therefore, it is recommended that nurses implement plans to help provide parents with valid information on both the for and against side of the circumcision issue. The information should include empirical evidence that supports both sides of the issue.

This recommendation suggests that the hospitals prepare informational packets for parents that include evidence to support both sides the issue, at least until sufficient evidence is found to definitively support one side or the other. Hospitals need to develop a stance that is neutral and that is culturally sensitive. Hospitals that present a one-sided approach to the circumcision issue are not demonstrating that they are culturally diverse, but rather that they are reflecting the views of the dominant society.

Unlike research found during this literature review, it is recommended that evidence-based policy guidelines be developed that do not take a stance on the circumcision issue, but rather that present information on both sides. A hospital needs to develop policy guidelines that are based on solid evidence, rather than personal opinion. This guideline recommends that hospitals develop information that can be provided to parents that reflects the most current views on circumcision. According to the literature found during this exploration of the topic, the information contained in these materials should be neutral and present evidence on both sides of the issue. Only in rare medical cases, does the information favor circumcision.

Nurses might have their own personal opinion on the topic of circumcision, but it is not their place to make decisions for the parents of newborns. However, it is their place to provide parents with sufficient information and a balanced approach to the topic so that parents can make their own decisions based on research and their own cultural preferences. Many nurses, currently disagree that circumcision is the best choice for newborns. The stance of the AAP on the issue is based on research that suggests that the practice of circumcision is not necessary and that it has no medical basis. However, new research is beginning to come into light that suggests that prophylactic circumcision can have a positive effect on preventing certain serious diseases such as HIV and other sexually transmitted diseases. For parents who choose not to circumcise, nurses need to be prepared to provide the information on how to care for the foreskin and penis so that UTIs do not occur in the future.