Circumcision after vitamin K refusal: Clinical guidance for providers

Intramuscular (IM) vitamin K at birth remains the standard and most reliable protection against vitamin K deficiency bleeding (VKDB) and should be recommended for every newborn.¹ When parents decline IM vitamin K but still desire circumcision, clinicians face a more difficult question: Does refusal of prophylactic IM vitamin K necessarily preclude infant circumcision?

Current evidence does not establish IM vitamin K refusal as an absolute contraindication in every infant. In 2025, Dr. David Tomlinson and colleagues specifically addressed this clinical situation and concluded:

“When appropriately counseled and with contingency protocols in place, circumcision may be safely performed in select infants without prophylactic IM vitamin K.”²

Circumcision in this setting, however, should not be approached as routine newborn circumcision. Additional counseling, patient selection, and preparation for bleeding are warranted.²

From Dr. Tomlinson: A clinical experience that shaped our approach

While working in Botswana, I had the privilege of working with Dr. Rebeca Plank, who was conducting clinical research on early infant male circumcision and evaluating the AccuCirc® device. During our work, one infant developed persistent bleeding following circumcision. When we evaluated the newborn, we learned that he had not received prophylactic vitamin K at birth because of a local stock-out or supply shortage. We were able to obtain and administer vitamin K, and the bleeding subsequently stopped. Dr. Plank and colleagues later published this clinical experience.⁴

That experience has stayed with me and has directly informed how we think about caring for newborns whose families decline prophylactic IM vitamin K. It reinforced both the importance of recommending vitamin K at birth and the need for a clear contingency plan when circumcision is performed without it. Providers should know before beginning the procedure how significant bleeding will be managed, have IM vitamin K readily available, and establish in advance whether the family will consent to its emergency use.²

Why vitamin K matters

Newborns have physiologically limited vitamin K stores. Vitamin K is required for normal activation of coagulation factors II, VII, IX, and X, and deficiency can result in VKDB.¹

VKDB may occur during the first days of life or later in infancy. Bleeding can involve the circumcision site, gastrointestinal tract, skin or mucous membranes, or central nervous system. Intracranial hemorrhage is among its most serious manifestations.¹˒²

Circumcision-specific evidence also supports the importance of prophylaxis. Historical studies demonstrated substantially greater post-circumcision bleeding among infants who had not received vitamin K prophylaxis.²˒³˒⁷

When IM vitamin K is declined

Declining IM vitamin K does not necessarily mean declining all prophylaxis.

Multidose oral vitamin K regimens are used internationally when parents decline IM administration. Oral prophylaxis reduces the risk of VKDB compared with no prophylaxis, but it should not be considered equivalent to IM prophylaxis in all circumstances. Oral administration requires adherence to a multidose regimen, absorption is less predictable, and effectiveness may be reduced in infants with unrecognized cholestasis or impaired intestinal absorption.¹˒⁵˒⁶

When IM vitamin K is declined, clinicians should discuss an appropriate oral regimen, including its benefits and limitations.¹˒⁵

If parents decline all vitamin K prophylaxis, the infant should be assessed individually for additional factors that may increase bleeding risk, including birth history, clinical stability, feeding, jaundice or possible cholestasis, maternal medications affecting vitamin K metabolism, family history of bleeding disorders, and abnormal bleeding or bruising.¹˒²

If the history or examination raises concern for increased bleeding risk, elective circumcision should be deferred and appropriate evaluation pursued.²

The decision belongs with the family

IM vitamin K should be recommended to every family. At the same time, recommending a treatment and respecting a family’s authority to make medical decisions for their child are not contradictory principles.

As a matter of ethics and law in the United States, parents have broad authority to make medical decisions for their children, including declining recommended beneficial care. That authority is not unlimited; clinicians may need to seek judicial intervention when a parental decision places a child at sufficiently serious risk of harm.² Tomlinson and colleagues reviewed this issue specifically in the context of prophylactic IM vitamin K and concluded that declining IM vitamin K is not considered one of those circumstances.²

For clinicians, the appropriate response is therefore to recommend IM vitamin K clearly, explain the risks and alternatives accurately, respect informed parental decision-making, and determine whether circumcision can be offered responsibly within a defined clinical and emergency-response protocol.

Emergency IM vitamin K: Establish the plan before circumcision

An important distinction is between declining prophylactic IM vitamin K and declining IM vitamin K if it becomes medically indicated to treat significant bleeding.

Tomlinson and colleagues recommend that caregivers who decline prophylactic IM vitamin K be asked before circumcision whether they would consent to IM vitamin K in the event of post-circumcision bleeding.²

They identify four conditions for considering circumcision without prophylactic IM vitamin K:

1. Caregivers are counseled about the increased risk of VKDB.

2. IM vitamin K is readily available.

3. The provider is experienced in treating post-circumcision bleeding.

4. Caregivers consent to IM vitamin K if post-circumcision bleeding occurs.²

Consent to emergency IM vitamin K should therefore be obtained and documented before the procedure.²

The rationale is clinically important. Plank and colleagues reported an infant who had not received prophylactic vitamin K and developed persistent bleeding after circumcision. Bleeding continued for approximately 90 minutes despite direct pressure and was controlled approximately 30 minutes after IM vitamin K administration.⁴

Providers undertaking circumcision without prophylactic IM vitamin K should have vitamin K readily available and a defined pathway for treating and escalating significant bleeding.²

When emergency IM vitamin K Is declined

The published pathway also addresses families who will not consent to emergency IM vitamin K.

Tomlinson and colleagues recommend deferring circumcision until later in life when vitamin K deficiency bleeding is no longer a concern.² This distinction is important. Refusal of prophylactic IM vitamin K does not necessarily preclude circumcision within the proposed framework. However, refusal of both prophylactic vitamin K and emergency IM vitamin K removes an important component of the contingency plan and should prompt consideration of delaying the elective procedure.

Procedure and bleeding preparedness

When circumcision is undertaken without prophylactic IM vitamin K, meticulous surgical technique and hemostasis are particularly important.² The objective should be to minimize unnecessary tissue trauma, identify bleeding promptly, and confirm complete hemostasis before discharge.

Parents should also be taught how to recognize active bleeding, apply direct pressure to the circumcision site, and seek immediate medical attention when bleeding cannot be controlled.²

Providers should have a defined pathway for post-circumcision bleeding that includes direct assessment, local hemostatic measures, consideration of VKDB, ready access to IM vitamin K, and escalation for further evaluation and treatment when necessary.²

A published clinical pathway

Tomlinson and colleagues proposed a clinical pathway specifically for infant circumcision following prophylactic IM vitamin K refusal.²

The pathway begins by offering IM vitamin K to every newborn. If it is declined, parents are counseled about VKDB and offered oral vitamin K. Before circumcision, the provider determines whether caregivers would consent to IM vitamin K for serious post-circumcision bleeding.²

If they consent, circumcision may be considered with appropriate education, preparation, and bleeding-management capability. If they do not consent, the risks and benefits should be reviewed again and deferral considered.²

Practical guidance for providers

When considering circumcision after IM vitamin K refusal:

1. Recommend IM vitamin K. It remains the preferred and most reliable prophylaxis against VKDB.¹

2. Discuss oral prophylaxis if IM vitamin K is declined. Explain its benefits, limitations, and the importance of completing the regimen.¹˒⁵˒⁶

3. Assess the infant individually. Identify additional factors that may increase bleeding risk.¹˒²

4. Establish emergency consent before proceeding. Determine and document whether caregivers consent to emergency IM vitamin K for significant post-circumcision bleeding.²

5. Prepare for bleeding. Verify hemostasis before discharge, have vitamin K readily available, educate parents about bleeding, and establish a clear pathway for escalation.²

6. Consider deferral if emergency vitamin K is refused. Revisit the risks and benefits and consider delaying circumcision until VKDB is no longer a concern.²

Clinical summary

IM vitamin K remains the preferred and most reliable prophylaxis against VKDB and should be recommended for every newborn.¹ When IM prophylaxis is declined, oral prophylaxis should be discussed.¹˒⁵˒⁶

Circumcision without prophylactic IM vitamin K should not be considered routine, but current evidence does not establish refusal as an absolute contraindication in every infant. A selective approach may be considered in appropriately counseled families and carefully selected infants when the provider is prepared to manage bleeding and IM vitamin K is readily available.²

A central component of this framework is obtaining caregiver consent before circumcision for emergency IM vitamin K should significant post-circumcision bleeding occur. If caregivers will not provide that consent, deferral should be considered.²

References

1. Hand I, Noble L, Abrams SA. Vitamin K and the Newborn Infant. Pediatrics. 2022;149(3). doi:10.1542/peds.2021-056036.

2. Tomlinson A, Wu H-Y, Wolf LE, Plank R. Post-Circumcision Bleeding in Male Infants Who Do Not Receive Prophylactic IM Vitamin K. Urology. 2025;205:160-164. doi:10.1016/j.urology.2025.06.050.

3. Sankar MJ, Chandrasekaran A, Kumar P, et al. Vitamin K prophylaxis for prevention of vitamin K deficiency bleeding: a systematic review. J Perinatol. 2016;36(Suppl 1). doi:10.1038/jp.2016.30.

4. Plank RM, Steinmetz T, Sokal DC, et al. Vitamin K Deficiency Bleeding and Early Infant Male Circumcision in Africa. Obstet Gynecol. 2013;122(2 Pt 2):503-505. doi:10.1097/AOG.0b013e31828b2f5c.

5. Ng E, Loewy AD. Guidelines for vitamin K prophylaxis in newborns. Paediatr Child Health. 2018;23(6):394-397.

6. Mihatsch WA, Braegger C, Bronsky J, et al. Prevention of Vitamin K Deficiency Bleeding in Newborn Infants: A Position Paper by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2016;63(1):123-129. doi:10.1097/MPG.0000000000001232.

7. Vietti TJ, Murphy TP, James JA, Pritchard JA. Observations on the prophylactic use of vitamin K in the newborn infant. J Pediatr. 1960;56:343-346.