The Effects of Circumcision on Breastfeeding

Review of research between The National Organization of Circumcision Information Resource Centers and La Leache League International

It is the human right of every baby
to have the opportunity to be breast or breastmilk fed.
~ Australian Breastfeeding Association

Advantages of Breastfeeding

Medical societies in Australia,¹ Canada,² and the United States³ concur that breastmilk is the optimum food for infants. The National Organization of Circumcision Information Resource Centers agrees with this conclusion. Breastfeeding provides nutritional, emotional, developmental, immunological, and economic benefits that are not equaled by any substitute.³ Studies show that breastfed babies exhibit improved neurodevelopment and greater cognitive ability.^1,4-6 Breastfeeding may contribute to improved mother-infant bonding and to lessened tendency for violence in adult life.⁶ One study finds that breastfeeding protects against childhood asthma.⁷ Another study finds that breastfeeding reduces infant mortality.⁸ Early initiation of breastfeeding reduces the incidence of diarrhea.^3,9 Breastfeeding protects against otitis media (middle ear infection)^3,10 and urinary tract infection (see below).

Breastfeeding also improves the mother's health because it provides increased levels of oxytocin with several important benefits, including reduced post-partum bleeding, more rapid return to pre-pregnant weight, improved bone remineralization with fewer hip fractures, and reduced risk of ovarian and breast cancer.³ Moreover, a recent study suggests that breastfeeding protects mothers from postpartum stress.¹¹ Only mothers who breastfeed enjoy these benefits.

How Breastfeeding Replaces Circumcision as a Prophylactic Measure Against UTI

Breastfeeding now is documented to dramatically reduce the incidence of urinary tract infection (UTI).

In the early 1980s, Thomas E. Wiswell, M.D., a vociferous advocate for routine circumcision, opined that lack of male circumcision might be the cause of UTI, and he set out to prove it with two retrospective studies that were published in 1985 and 1986.^12,13 The studies, carried out by searching through old medical records maintained by the United States Army on children of Army personnel, failed to examine an existing clinical population. The study purported to show that the incidence of UTI in circumcised and intact infants were 1.4 and 0.14, respectively. The difference of 1.26 percent is not clinically significant. Wiswell's studies suffered severe methodological flaws, including lack of control for confounding factors,¹⁴ such as maternal infection, perinatal anoxia, low or high birthweight,¹⁵ breastfeeding, socio-economic status, urogenital deformities, and the nature of infant hygienic care.

Escherichia coli, bacteria present in feces, is the most frequent etiologic agent of acute uncomplicated urinary tract infection (UTI) in infants and children, accounting for 85 to 90% of all pathogens recovered from urine cultures.¹⁶

After Wiswell's studies were published, Coppa et al. discovered that human milk contains oligosaccharides that are excreted in infant urine and inhibit the adhesion of E. coli to the tissue of the urinary tract.¹⁷ This protective effect was quickly confirmed in a preliminary report in 1990 by another group of Italian scientists, headed by Pisacane,¹⁸ and further confirmed by Swedish researchers.¹⁹ The Pisacane group then produced a prospective case-control study, published in 1992,²⁰ that found breastfed infants have only 38% as many UTIs as non-breastfed infants.²⁰

A recent study that tried to correct for some of the deficiencies in Wiswell's studies found that 195 circumcisions would be necessary to prevent one hospitalization for UTI.²¹

Wiswell could not have known about the significant effect of breastfeeding protection against UTI because these studies^17-20 had not been published at the time he conducted his studies,^12,13 which do not control for breastfeeding. The number of breastfed infants in his studies is unknown. Consequently, his data is inconclusive and inaccurate.

Even if one were to accept Wiswell's data, breastfeeding has an additional advantage that male circumcision could never provide: breastfeeding reduces UTI in both male and female infants.^3,22 Females have a four times greater incidence of UTI than males,¹⁶ which may be because females lack the protective effect of the preputial sphincter (see box). Breastfeeding actually delivers the protection against UTI infection that has been touted for circumcision.^3,18,19,20 Circumcision is an inappropriate and ineffective way to reduce the risk of UTI in infants.

Postoperative Pain, Stress, and Exhaustion

Human milk is the best food for babies.^1,3 Babies who are breastfed are more likely to experience optimum health and well-being throughout life than babies who are given a substitute for mother's milk. It is imperative, therefore, that nothing be done that would interfere with successful initiation and completion of breastfeeding during, at least, the first year of life. Mothers need full information, well in advance of birth, so that they may avoid the pitfalls and snares that prevent success in breastfeeding.

We now know that newborn babies are born with fully functioning pain pathways.²³ Infants exhibit greater physiologic responses to pain than do adult subjects.²³ Male neonatal circumcision has been documented to be an extremely painful, distressing, traumatic, and exhausting experience for a newborn male infant.^24-28 Circumcision disrupts the baby's normal sleep patterns.^25,27 Post-operatively, the circumcised infant is in pain and is in an exhausted, weakened, and debilitated condition.²⁸ Most importantly, the circumcision procedure frequently causes the newborn to withdraw from his environment,²⁵ thus interfering with his process of bonding and breastfeeding.²⁸

La Leche League International (LLLI) first reported problems with breastfeeding by circumcised male infants in 1981.³⁰ Circumcision has long-lasting postoperative pain that continues for days after the surgical event.²⁹ Howard et al. found that some male babies are unable to suckle the mother's breast after circumcision,²⁹ thus confirming the LLLI report.³⁰

The Workgroup on Breastfeeding of the American Academy of Pediatrics (AAP) recommends that stressful procedures that interfere with breastfeeding be avoided.³

Breastfeeding problems among circumcised male infants have been verified by lactation consultants.^31,32 Parents may avoid creating this problem simply by refusing to consent to the circumcision of their baby boy. In doing so, they would also be adopting the recommendations of the AAP and LLLI to avoid stressful procedures.^3,30 Mothers who protect their new baby from circumcision are more likely, therefore, to be successful in breastfeeding and less likely to have to resort to providing breast milk substitute.^3,29,30

The Relative Value of Breastfeeding and Circumcision

When it comes time for parents to make decisions about circumcision and breastfeeding, the choice is clear. Medical societies agree that no medical benefit from circumcision exists and "potential [alleged] benefits" cannot be proven. The Canadian Paediatric Society says that male neonatal circumcision should not routinely (i.e., in the absence of medical indication) be performed.³³ The American Medical Association calls male neonatal circumcision a non-therapeutic procedure.³⁴ The American Academy of Family Physicians equates male neonatal circumcision to a "cosmetic procedure."³⁵ Male neonatal circumcision now is regarded as a non-therapeutic procedure that is totally unnecessary for a child's health and well-being. Furthermore, male neonatal non-therapeutic circumcision has significant risks and complications.³⁶ Circumcision increases infant mortality because some babies die from complications of circumcision.³⁷ Studies show that intact boys have better penile health during the first three years of life.^39,40 Other drawbacks and disadvantages include psychological and sexual problems in adult life.⁴⁰ Non-therapeutic circumcision, therefore, provides no discernible health benefit to the child, while there are numerous documented significant risks, complications, and adverse sexual and psychological sequellae. Chessare found that non-circumcision produced the highest "utility" (or, in other words, the highest state of health).⁴¹

Pain in young babies presently is believed to permanently affect development of the immature nervous system.⁴⁰ The AAP and the Evidence Based Group for Neonatal Pain now emphasize prevention of pain by avoidance of painful procedures in infancy in preference to the use of anesthesia.^42,43 Neonatal circumcision is the most common painful procedure to which young children are subjected. Neonatal circumcision, therefore, should be avoided.

Breastfeeding, on the other hand, offers all of the benefits described above without any significant risk, complication, disadvantage, or drawback. Certainly, responsible parents will favor breastfeeding over circumcision for male infants. If parents are adamantly insistent on a circumcision of their male infant, the circumcision should be deferred until after breastfeeding is well established.

Breastfeeding, like non-circumcision or "intactness," is natural and healthy. Bottlefeeding, like circumcision, is unnatural and unhealthy. Male neonatal circumcision should never be allowed to compromise the successful initiation of breastfeeding.

Conclusion

Breastfeeding contributes significantly to the health and well-being of both baby and mother. We recommend that babies be breastfed, except in those few rare circumstances when a particular mother may have a medical condition that contraindicates breastfeeding.^1-3

Studies have proven that circumcision impairs the health and well-being of the child.^24,33,36-41 Doctors and parents should protect children from the complications, risks, and unavoidable surgical trauma inherent in circumcision.⁴⁴

Psychological studies show that some circumcised fathers adamantly insist on having a child circumcised in opposition to current informed medical opinion.⁴⁵ In that case, it is the mother’s job to protect the baby. When she does so. she is teaching her husband to protect the child, not to wound him. In any event, the operation should be deferred until breastfeeding is well established. Furthermore, the Section on Urology of the AAP recommends that no genital surgery should be performed during the first six weeks of life while the bonding process is occuring.⁴⁶ The Australasian Association of Paediatric Surgeons recommends, if a circumcision is to be performed, then it should be deferred until the child is at least six months of age when general anesthesia may be used.⁴⁷ If a circumcision is performed, it should be carried out by a skillful surgeon in a setting that provides all necessary emergency equipment to handle possible complications and emergencies. Ring block anesthesia (the most effective available type of local anesthesia for infant circumcision²⁴) should be used to reduce the pain. No local anesthesia can totally protect an infant from the pain of circumcision. While more dangerous, after six months, general anesthesia can be used. Circumcised babies should be given post-operative analgesia for the post-operative pain for seven to ten days.^33,48 ”

The information provided to parents prior to obtaining permission for circumcision must include all material and relevant information about circumcision, the known risks, and the benefits of non-circumcision necessary for a parent to make an informed decision.⁴⁹ Breastfeeding failure is a known and documented risk of circumcision. Doctors who perform circumcision, therefore, have a responsibility and a legal obligation to inform parents about the adverse effects of circumcision and the beneficial effects of non-circumcision upon breastfeeding.

Breastfeeding educational material for mothers should include information about the adverse effects of male circumcision on breastfeeding. Mothers need to learn "how the choices parents make about the birth experience can affect breastfeeding in the early days."⁵⁰ Organizations that promote breastfeeding have an ethical and moral responsibility to provide this information to parents well in advance of delivery so that they can make a truly informed decision about circumcision.^1,3

For more information on circumcision and breastfeeding see:

Circumcision Increases Breastfeeding Complications

Circumcision & Breastfeeding

The impacts of Circumcision & Breastfeeding on UTI (urinary tract infection)

References

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