Neonatal circumcisions and parental refusal of intramuscular vitamin K: A review of the literature and current guidelines.

Introduction: Parental refusal of intramuscular (IM) vitamin K in newborns poses challenges, particularly for pediatric urologists assessing the safety of neonatal circumcision. Vitamin K deficiency bleeding (VKDB) is a known risk, with lack of prophylaxis increasing bleeding complications. This study evaluates the safety of neonatal circumcision without IM vitamin K, reviews guidelines, and explores alternative prophylaxis options.

Objective: To assess if neonatal circumcision can be safely performed on infants lacking IM vitamin K and to identify both optimal timing and alternative prophylactic approaches.

Methods: We conducted a literature review using PubMed and Google Scholar to gather data on neonatal circumcision and VKDB in the context of IM vitamin K refusal. Additionally, we searched for relevant guidelines from the American Urological Association (AUA), American Academy of Pediatrics (AAP), and other organizations. Our study included analysis of ten recent cases of neonatal circumcision without IM vitamin K, focusing on safety outcomes and timing.

Results: IM vitamin K is the most effective prophylaxis against VKDB, significantly reducing bleeding risk up to sixfold in neonatal circumcision. Oral vitamin K, sometimes used as an alternative in Europe, shows variable effectiveness and lacks standardization in the U.S. Newborn prothrombin (PT) levels fluctuate significantly in the first week: PT levels are high at birth, drop within 24 h, reach a nadir at 24-72 h, then rebound. Circumcisions performed at 14 days on ten patients without IM vitamin K showed no bleeding complications, suggesting that timing circumcisions after PT stabilization may be safer.

Conclusions: IM vitamin K prophylaxis should remain standard care. In cases of refusal, alternative prophylaxis and timing circumcision after the PT nadir may improve safety. This study underscores the need for updated guidelines from professional organizations, including the AUA, to address the growing trend of IM vitamin K refusal and its implications for neonatal circumcision.