March 8, 2013
Another circumcision death
An 11-day-old boy has died died at UC Davis Children's Hospital in Sacramento, California, two days after being circumcised in the nearby town of Lodi.
According to his grandfather, Brayden Tyler Frazier had been taken to the doctor when he was a week old because he had been sleeping constantly and not eating. His parents had also noticed that his neonatal sticks and pricks had not healed quickly, and had to stay bandaged for two days or more.
The doctor in Lodi sent them home with instructions to monitor his condition and after two days, he was circumcised. It was later discovered that the wound had continued to bleed. He was taken back to the doctor, then to Urgent Care, then to the ER, and then transferred to UC Davis Medical.
He had "generalized bleeding" and an unidentified infection.
Over the two days after his circumcision, he went into seizures and a coma, and died.
It was claimed online that the baby should have been tested for haemophilia, but a paediatric haematologist/oncologist comments
Coagulation studies are not routinely done before many types of surgeries,
including circumcisions. ... Also, coagulation
studies are not a part of routine newborn screening tests.
Coagulation is complex, and involves the platelet cell and a couple dozen
chemicals / proteins, to clot when needed but also not to clot in
inappropriate locations, or excessively, and to additionally reabsorb clots
after they have done their jobs.
Plus hemophilia isn't a single disorder; there are two main types of
"hemophilia" (deficiency of Factor 8 or Factor 9 ). But there are many
other reasons to bleed excessively. However, a combination of several
functional tests can narrow down the list of specific aspects of the
coagulation system that need testing, in a given individual whose
screening functional tests are abnormal, in order to identify what needs
to be done to treat that individual's bleeding/risk.
However it is more complicated in newborns:
1) Of the couple dozen chemicals, many are in different levels in
newborns. For several reasons, some aspects of the newborn's system are
hypo-coagulable [blood won't clot] while others are hyper-coagulable [blood clots very easily] and it generally balances out. So there are different normal ranges for results in
2) Most tests of the coagulation system involve drawing blood from a vein
or artery and simultaneously mixing it with anticoagulants (different
anticoagulants for different tests). These tests also involve a relatively
large amount of blood.
Additionally the tissue factors, that trigger the initiation of the
clotting system in injuries, are released from a heel stick and affect
3) It is however easy to do extensive or specific coagulation tests in
When planned, the blood is correctly drawn at delivery from the umbilical
cord, taking the blood otherwise left in the placenta... This
can be planned when a family history [of haemophila] is present or there are other reasons
Surgeries / procedures that have no medical necessity, [such as] circumcision,
should not be done.
Dustin Evans Jr. - death from anaesthetic
Dustin Evans Jr was born in Cleveland, Ohio in October 1998. He was circumcised by a Dr Russell soon after, who took so much shaft skin that the scar healed as a wideband stricture (a tight "collar") around his penis, preventing him
from urinating. When he was given sevoflourane, an anaesthetic, in order to "revise" his circumcision, he immediately died of cardiopulmonary arrest.
His father said, "You think, 'What could go wrong with a circumcision?' The
next thing I know, he's dead."
Oddly, the report of Cuyahoga County Coroner, Elizabeth Balraj MD, says
|IDENTIFYING MARKS AND SCARS: None|
EVIDENCE OF RECENT THERAPY: [does not mention his circumcision]
EVIDENCE OF RECENT INJURY: None
Jamaal Coleson, dead from anaesthetic (?) at less than two years old in Manhattan, May 3, 2011
Chinonso Onyenekwu died after circumcision from complications associated with anaesthetic at the Lister Poly Clinic in Johannesburg in January 2009
Death via septicaemia
Contemporary OB/GYN® Archive
By Richard Ballad
Septicemia secondary to circumcision
A child was born without incident in a West Virginia hospital and was circumcised before discharge. Two days later, the baby boy was brought to a health center where the doctor did a follow-up examination. Four days after that, the child was rushed to a hospital emergency room after developing a fever and undergoing seizures. The ER physician telephoned the doctor who had performed the circumcision and decided not to admit the child. The next morning, the mother brought the infant back to the ER where he suffered more seizures and was noted to have a greenish cast to the penis. That afternoon the child was transferred to a medical center, where he died 4 hours later.
The cause of death was found to be septicemia derived from an infection secondary to the circumcision. Both physicians were sued for negligence for failure to admit the child to the hospital on the first visit to the ER. After 6 months, a settlement of $150,000 was reached.
9 July 1994
Death from painkiller overdose
A FAMILY doctor who killed a nine-year-old boy by giving him a massive
overdose of a pain-killing drug during a circumcision operation, was given a one-year suspended jail sentence yesterday. Dr. Mahbubul Alam, 59, of Handsworth Wood, Birmingham, admitted the manslaughter in July 1991 of Raju Miah, of Smethwick, who died in hospital six days after being given diamorphine (heroin).
Timothy Barnes QC, for the prosecution, told Stafford Crown Court that the
boy was taken for the operation by his grandfather. Dr. Alam, who had performed four circumcisions that day, administered 10mg of diamorphine, "five to six times the appropriate dose."
Mr. Barnes said: "Raju was given 10mg of diamorphine, which sedates the
brain and also tends to depress breathing. After the operation the boy was still
unconscious and when he was driven back to the family home, Dr. Alam tried to arouse him by sprinkling water on his face and lightly smacking his face." He said shortly after the doctor left, the boy's condition worsened and he was taken by ambulance to hospital. After six days, he was certified brain dead and the life-support machine was switched off.
Mr. Barnes said the cause of death was narcotic poisoning. "The choice of drug was wholly inappropriate and on a boy of his age was grossly negligent," he said. Mr. Justice Buckley said: "I only hope Raju's family can find it in their hearts that sending Dr. Alam to prison...would serve no public interest and do nothing good for the memory of Raju."
Urethra blocked by a circumcision ring
Paediatr Child Health Vol 12 No 4 April 2007
Circumcision: A minor procedure?
Paediatric Death Review Committee: Office of the Chief Coroner of Ontario
A male infant at 37 weeks' gestation was born ... weighing 3.9 kg, with Apgar scores of seven at 1 min and nine at 5 min, Prenatally mild bilateral dilation of renal pelvises and ureters was noted on ultrasound. A urology consultation at 36 weeks' gestation suggested a possible normal variant ...
The baby was bottle-fed and was reported to he doing well when he was circumcised using a PlastiBell ring (Hollister, USA) at 10:00 on the seventh day of life (Figure 1).
Figure 1. (Click to enlarge)
Local anaesthetic was not used. Some slight oozing was noted during the procedure but it was not a problem at discharge.
Five hours later, the parents returned to their family doctor with the infant, reporting that he was very irritable and had blue discolouration below the umbilicus [navel] when he cried. The doctor confirmed this observation and noted that the penis was slightly swollen. ... He had several loose stools, and it could not be determined with certainty whether he had voided [emptied his bladder]. ...The baby was subsequently discharged home.
The infant was brought to a different hospital 14 h after the circumcision. He was now noted to be extremely irritable, with marked swelling of the penis and with marked swelling and cyanosis [blueness] of the scrotum and perineum [region behind the scrotum]. He had grunting respirations and was cyanotic below the umbilicus ... He was transferred to a tertiary care centre, where the bladder was identified as being distended to the level of the umbilicus, The PlastiBell ring was removed 16 h after the circumcision and a catheter was passed. The bladder was drained and the bluish coloration below the umbilicus subsided. Urine volume was not recorded. Over the next few hours, the infant went into septic shock with purpura fulminans, and went on to develop multiorgan failure and disseminated intravascular coagulopathy [a state of increased propensity for blood-clot formation] ... He died seven days after his circumcision from hypoxic-ischemic encephalopathy [damage to cells in the brain and spinal cord from getting too little oxygen]. ...
Complications of meatal obstruction [blockage of the urinary opening of the glans] with the PlastiBell technique have been previously described in the literature (1,2). Necrotizing fasciitis as a complication of circumcision is rare, and all cases reported seem to be associated with the PlastiBell technique (2,3) The finding of cyanosis below the umbilicus after circumcision due to meatal obstruction caused by a misplaced PlastiBell ring resulting in bladder distension and obstruction of venous return has also recently been described (1). A review of circumcision complications suggest that these may occur mote frequently than is conventionally believed (2,4)
The members of the Paediatric Death Review Committee of the Office of the Chief Coroner of Ontario were collectively aware of complications from their own institutions, including two children with necrosis of the glans, two infants requiring transfusion, one infant with a buried penis secondary to circumcision, numerous cases of retention of a PlastiBell ring, one infant with a slipped PlastiBell ring causing a penile tourniquet, and one infant with meatal obstruction due to a misplaced PlastiBell ring (Figures 2A and 2B).
Figure 2. (Click to enlarge)
None of these complications were reported in the medical literature and are therefore not available in a retrospective literature review. It is concerning that none of the initial three physicians who saw this infant, including the physician who performed the procedure, identified this problem as a meatal obstruction, although they were all concerned about, a possible link with the recent circumcision.
In this infant, there was no description of the glans by the physician removing the PlastiBeil ring. If the foreskin is pulled too tight, then there will be considerable tension pulling the ring against the glans, thus compressing the urethra and making urination difficult or impossible. This is the mechanism described in the case report by Ly and Sankaran (I) We propose the mechanism shown in Figure 2B, given the rapid onset of symptoms, suggesting a complete obstruction. These coukl be differentiated clinically. In Figure 2A, the meatus would be visible in the middle of the ring and a catheter would be difficult or impossible to pass. In Figure 2B, the meatus would not be visible. The management of both complications would be the immediate removal of the PlastiBell ring. Perhaps a prospective surveillance study by the Canadian Paediatric Society of the complications of circumcision is warranted. Such a study would provide more accurate information for the ethical requirement of informed consent.
[Perhaps a ban on non-therautic neonatal circumcisions by members of the Canadian Paediatric Society is warranted. As the headline implies, this is not a minor procedure.]
In reply to a complaint, the College of Physicians and Surgeons of Ontario completely exonerated the doctor. In fact so excellent did they make his work seem, you would think the baby was still alive.
...The Paediatric Death Review Committee felt that Baby A had a urethral meatal obstruction secondary to the Plastibell ring, which it noted was not a common complication. They questioned whether the family physician who performed the circumcision was aware of this potential complication....
...Dr. X ... did not believe there was anything he/she could have done differently. When he/she examined the infant when the parents returned later in the day, there was no meatal obstruction.
[This will all be of interest to parents who assume that circumcision is made painless nowadays.]
- he/she had tried using local anaesthetic over the years but found that the infant appeard to be in just as much pain, if not more
- the needle to inject the anaesthetic is very painful, as is the local anaesthetic itself
- there is a concern about the increased chance of infection with the injecting of local anaesthetic, as the puncture holes from the needle would be in the diaper area surrounded by urine and faeces, below the area of the circumcision [...which raises questions about the risk of infection at the much bigger circumcision wound itself...]
- there is a concern regarding potential allergic reaction to the anaesthetic
- local anaesthetic tends to distort the site of the circumcision and make it more difficult to perform
- the period of restraint for the infant in the cirucmsion board is prolonged when using local anaesthetic, and the restraint causes the infant distress
- in the community, local anaesthetic is not used, and not the standard of care
...it is not possible to determine with any certainty how the urethral meatus became obstructed by the Plastibell device. ...
Committee's final comments
The Committee has the utmost sympathy for the parents of Baby A, given the very tragic outcome in this case. However, we are satisfied that the care provided by Dr. X in this case was conscientious and appropriate, and in compliance with the relevant legal and ethical standards in place at the time the circumcision was performed.
... no further action will be taken with respect to this matter.
A comprehensive Brazilian study:
Einstein (Sao Paulo) 2012 Sep;10(3):342-346.
Circumcisions for medical reasons in the Brazilian public health system: epidemiology and trends.
Korkes F, Silva Ii JL Pompeo AC
To evaluate the epidemiological factors associated to medical circumcision,
based on data from the Brazilian public health system.
Using the Unified Health System public database between 1984 and 2010,
hospital admissions associated with surgical treatment of phimosis were
searched. A total of 668,818 men admitted to public hospitals who underwent
circumcision were identified and included in the present study.
A mean±standard deviation of 47.8±13.4 circumcisions/100,000 men/year was
performed through the Unified Health System for medical reasons. During the
27-year period evaluated, 1.3% of the male population required circumcision
for medical reasons. [So 98.7% of routine circumcisions are wasted on boys and men who will never need it.] Total number of circumcisions and circumcision rate
increased in childhood, declined progressively after 5 years of age and rose
again progressively after the sixth decade of life. In the regions of the
country with better access to healthcare, 5.8% of boys aged 1 to 9 years old
required circumcisions. [Or were circumcised whether they needed it or not.] From 1992 to 2010 there were 63 deaths associated
with circumcisions (mortality rate of 0.013%).
[That's one death in 7692 circumcisions. In this USA, that would amount to 156 circumcision deaths per year.]
In conclusion, yearly circumcision rates could be estimated in Brazil, and a
very low mortality rate was associated with this procedures. Circumcision is
mostly performed in children in the first decade of life and a second peak
of incidence of penile foreskin diseases occurs after the sixth decade of
life, when circumcision is progressively performed again.
[This study was circulated by Prof. Brian Morris, who presumably thinks this is an "acceptable" death rate.]
Death by circumcision, in South Africa a regular event
Male circumcision morbidity and mortality statistics
Eastern Cape, South Africa, 2001-5
|Total||1748 ||107 ||177
|Average per annum||388 ||24 ||39
|The number of deaths has risen sharply since.|
source: Department of
Health, Eastern Cape
A list of named males dead from circumcision.
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