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Research Article

Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study

  • Agnes Binagwaho mail,

    abinagwaho@gmail.com

    Affiliation: Ministry of Health, Kigali, Rwanda

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  • Elisabetta Pegurri,

    Affiliation: UNAIDS, Kigali, Rwanda

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  • Jane Muita,

    Affiliation: UNICEF, Kigali, Rwanda

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  • Stefano Bertozzi

    Affiliation: Centro de Investigación Evaluación y Encuestas, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, Mexico

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  • Published: January 19, 2010
  • DOI: 10.1371/journal.pmed.1000211

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Neonatal Circumcision and Vitamin K

Posted by DSokal on 27 Jan 2010 at 22:41 GMT

Neither of two articles published January 19th that discussed neonatal circumcision (Binagwaho et al and Kalichman) mentioned the potential usefulness of perinatal administration of vitamin K to prevent bleeding after circumcisions of newborns. Vitamin K is inexpensive and is routinely given in developed countries to prevent vitamin K deficiency bleeding (VKDB) of the newborn (previously known as hemorrhagic disease of the newborn). VKDB most commonly presents on days 2 to 3 of life. Vitamin K may be given as 1 mg intramuscularly or 2 mg orally. Classical VKDB is defined as bleeding occurring between days 1 and 7 of life, and is more common in breast-fed infants (Shearer, 2009). VKDB generally does not occur on day 1 because some maternal vitamin K is still present, and virtually disappears after day 6, when the infant’s own production of vitamin K becomes adequate.

Data from two randomized controlled trials demonstrated that an important benefit of vitamin K is that it greatly reduces bleeding complications from neonatal circumcisions performed within a few days after birth (Vietti, 1960; Sutherland, 1967). In the Vietti study, 6.1% of babies that did not get vitamin K required suturing to control bleeding compared to 0.4% of babies that received vitamin K. In the Sutherland study, 1% and 0.7% of babies that didn't get vitamin K, had moderate or severe bleeding respectively. With vitamin K, 0.35% of babies had moderate bleeding and none had severe bleeding. Circumcisions in these studies were apparently done mostly on days 2 to 4, probably a worst case-scenario for classic vitamin K deficiency bleeding.

For more information on vitamin K administration to newborns, see the American Academy of Pediatrics’ policy (AAP, 2003), the Cochrane review of this subject (Puckett, 2000) and a more recent and more comprehensive review (Shearer, 2009). While it may be the policy in some low-resource countries to give vitamin K to newborns, the World Health Organization and UNICEF have not yet addressed this issue from a programmatic perspective, and a much smaller proportion of infants in low-resource countries receive vitamin K than in developed countries.

Serious bleeding events from vitamin K deficiency are generally thought to be rare compared to other threats to babies’ lives in low-resource settings. However, if circumcisions are done during the first few days of life without vitamin K administration, then bleeding complications might become an issue.

David C. Sokal, MD
Family Health International, Durham, NC, USA

References:

Shearer, M. J. (2009). "Vitamin K deficiency bleeding (VKDB) in early infancy." Blood Rev 23(2): 49-59.

Vietti, T. J., T. P. Murphy, et al. (1960). "Observations on the prophylactic use of vitamin Kin the newborn infant." J Pediatr 56: 343-6.

Sutherland, J. M., H. I. Glueck, et al. (1967). "Hemorrhagic disease of the newborn. Breast feeding as a necessary factor in the pathogenesis." Am J Dis Child 113(5): 524-33.

Puckett, R. M. and M. Offringa (2000). "Prophylactic vitamin K for vitamin K deficiency bleeding in neonates." Cochrane Database Syst Rev(4): CD002776. Available at: http://www.nichd.nih.gov/...

AAP (2003). "Controversies concerning vitamin K and the newborn. American Academy of Pediatrics Committee on Fetus and Newborn." Pediatrics 112(1 Pt 1): 191-2. Available at: http://aappolicy.aappubli...

Competing interests declared: Actually, I don't think so, but being paranoid... I suppose that I could potentially apply for a research grant to look at this issue. Would that be considered a competing interest?