Notat om omskæring af drenge - Sundhedsstyrelsen

FROM THE AMERICAN ACADEMY OF PEDIATRICSTABLE 4 Assessment of Research Design and MethodsComponent ofStudy andRatingExcellent Good Fair Poor UnsatisfactoryDesign andMethodsHighly appropriatesample or model,randomized, propercontrols ANDoutstanding accuracy,precision, and datacollection in its classHighly appropriatesample or model,randomized, propercontrols ORoutstanding accuracy,precision, and datacollection in its classAdequate design butpossibly biased ORadequate under thecircumstancesSmall or clearly biasedpopulation or modelOR weakly defensiblein its class, limiteddata or measuresAnecdotal, no controls, offtarget end points OR notdefensible in its class,insufficient data ormeasurescurriculum item in childbirth classes.Information to assist in parental decision-makingshould be made availableas early as possible. For thisreason, obstetrician-gynecologists andfamily physicians who manage prenatalcare probably have a more pivotal rolein this decision than do pediatricians.Bright Futures: Guidelines for HealthSupervision of Infants, Children, andAdolescents, Third Edition, supportsprenatal pediatric visits, at which timepediatricians can provide counselingabout male circumcision (http://brightfutures.aap.org). Medical benefitsand risks need to be presented accuratelyand in a nonbiased fashion sofamilies can make a decision in light oftheir own cultural, religious, and personalpreferences.There is fair evidence that there arefinancial barriers to the circumcisiondecision in the United States; whenthe procedure is not covered by insurance,parents are less likely tochoose to have their child circumcised.21 This finding does not seem tobe true in Canada, where the prevalenceof circumcision did not changeafter circumcision for ritual, religious,cultural, or cosmetic reasonswas delisted from insurance benefitsin 1994. 17,23Care of the Circumcised VersusUncircumcised Penis Task Force Recommendations:8 Parents of newborn boysshould be instructed in thecare of the penis at the timeof discharge from the newbornhospital stay, regardless ofwhether the newborn has beencircumcised or not.This review found no systematicstudies in infants and children on thecare of the uncircumcised versuscircumcised penis.Parents of newborn boys should beinstructed in the care of the penisat the time of discharge from thenewborn hospital stay, regardless ofwhether they choose circumcision ornot. The circumcised penis should bewashed gently without any aggressivepulling back of the skin. 24 The noncircumcisedpenis should be washedwith soap and water. Most adhesionspresent at birth spontaneously resolvebyage2to4months,andtheforeskin should not be forcibly retracted.When these adhesions disappearphysiologically (which occursat an individual pace), the foreskincan be easily retracted, and thewhole penis washed with soap andwater. 25Circumcision reduces the bacteriathat accumulate under the prepucewhich can cause UTIs and, in the adultmale, can be a reservoir for bacteriathat cause STIs. In an internallycontrolled study with fair evidence,researchers cultured the periurethraland glandular sulcus of 50children aged 1 to 12 weeks beforeand 4 weeks after circumcisionand found the pathogenic bacterialargely disappeared after circumcision(33 children had pathogenicbacteria before circumcision and4 had pathogenic bacteria aftercircumcision). 26In adults and children, there is fairevidence that periurethral flora containsfewer pathogens after circumcisionthan before circumcision. 26,27Because these studies looked at cultures1 time (4 weeks after the circumcision),the long-term significanceof the findings is unclear.Penile wetness (defined as the observationof a diffuse homogeneousfilm of moisture on the surface of theglans and coronal sulcus) is considereda marker for poor penile hygieneand is more prevalent in uncircumcisedthan in circumcised men. 28Penile wetness has been associatedwith HIV infection in 1 cross-sectionalstudy, although the temporal relationshipis unclear and the evidencelevel is fair. 29 A related study with fairevidence assessed the frequency ofwashing the whole penis (includingretracting the foreskin for uncircumcisedmen) and found that notalways washing the whole penis wasapproximately 10 times more commonin uncircumcised than in circumcisedmen. 30 The relationshipbetween penile wetness and thoroughwashing of the penis is unclearand, because the studies were conductedin STI clinics, the findingsmay not be generalizable to thepopulation at large.PEDIATRICS Volume 130, Number 3, September 2012Downloaded from pediatrics.aappublications.org by guest on June 19, 2013e763