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 studies17-20 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.
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:
- Health Policy Unit. Breastfeeding. Sydney: Royal Australasian College of Physicians, 2001.
- Anonymous. Breastfeeding. Ottawa: Canadian Paediatric Society, 1998.
- Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100(6):1035-39.
- Horwood J, Fergusson DM. Breastfeeding and Later Cognitive and Academic Outcomes. Pediatrics 1998;101(1):e9.
- Angelsen NK, Vik T, Jacobsen G, Bakke L S. Breast feeding and cognitive development at age 1 and 5 years. Arch Dis Child 2001;85:183-188.
- Prescott JW. Brain nutrients in brain development for human love and peace. Touch the Future Newsletter, Spring 1997.
- Oddy WH, Holt PG, Sly PD, et al. Association between breast feeding and asthma in 6 year old children: findings of a prospective birth cohort study. BMJ 1999;319:815-819.
- Betrán AP, de Onís M, Lauer JA, Villar J. Ecological study of effect of breast feeding on infant mortality in Latin America. BMJ 2001;323:303.
- Clemens J, Elyazeed RA, Rao M, et al. Early Initiation of Breastfeeding and the Risk of Infant Diarrhea in Rural Egypt. Pediatrics 1999;104(1):e3.
- Duffy LC, Faden H, Wasielewski R, et al. Exclusive Breastfeeding Protects Against Bacterial Colonization and Day Care Exposure to Otitis Media. Pediatrics 1997;100(4):e7.
- Groer MR, Davis MW, Hemphill J. Postpartum stress: Current concepts and the possible protective role of breastfeeding. JOGNN 2002:31;411-417.
- Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985, 75: 901-903.
- Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infection in circumcised male infants. Pediatrics 1986;78:96-99.
- Altschul MS. The circumcision controversy (editorial). Am Fam Physician 1990;41:817-820.
- Littlewood JM. 66 infants with urinary tract infection in first month of life Arch Dis Child 1972;47(252):218-2.
- McCracken G. Options in antimicrobial management of urinary tract infections in infants and children. Pediatr Infect Dis J 1989;8(8):552-555.
- Coppa GV, Gabrielli O, Giorgi P, et al. Preliminary study of breastfeeding and bacterial adhesion to uroepithelial cells. Lancet 1990; 335:569-571.
- Pisacane A, Graziano L, Zona G. Breastfeeding and urinary-tract infection (Letter). Lancet 1990;336:50.
- Maarild S, Jodal U, Hansen AL. Breastfeeding and urinary tract infection. Lancet 1990;336:942.
- Pisacane A, Graziano L, Mazzarella G, et al. Breast-feeding and urinary tract infection. J Pediatr 1992;120:87-89.
- To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet 1998;352(9143):1813-16.
- Outerbridge EW. Decreasing the risk of urinary tract infections (Letter). Paediatr Child Health 1998; 3(1):19.
- Anand KJS, Hickey PR, Pain and its effects in the human neonate and fetus. New Engl J Med 1987; 317 (21):1321-9.
- Lander J, Brady-Freyer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997; 278:2158-62.
- Emde RN, Harmon RJ, Metcalf D, et al. Stress and neonatal sleep. Psychosom Med 1971;33(6):491-7.
- Gunnar MR, Fisch RO, Korsvik S, Donhowe JM. The effects of circumcision on serum cortisol and behavior. Psychoneuroendocrinology 1981; 6(3)269-275.
- Anders TF, Chalemian RJ. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med 1974;36(2):174-179.
- Marshall RE, Porter FL, Rogers AG, et al. Circumcision: II effects upon mother-infant interaction. Early Hum Dev 1982; 7(4):367-374.
- Howard CR, Howard FM, and Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994;93(4):641-646.
- Anonymous. Elective Surgery for You or Baby. In: The Womanly Art of Breastfeeding, 3rd ed. Franklin Park, IL: La Leche League International, 1981: 92-93. (ISBN 0-912500-10-7)
- Lee N. Circumcision and Breastfeeding [Letter]. J Hum Lact 2000;16(4):295.
- Caplan L. Circumcision and breastfeeding: a response to Nikki Lee's letter [Letter]. J Hum Lact 2001;17(1):7.
- Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. (CPS) Can Med Assoc J 1996; 154(6): 769-780.
- Council on Scientific Affairs, American Medical Association. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999.
- AAFP Commission on Clinical Policies and Research. Position Paper on Neonatal Circumcision. Leawood, Kansas: American Academy of Family Physicians, 2002.
- Williams N, Kapila L. Complications of circumcision. Brit J Surg 1993; 80: 1231-1236.
- Baker RL. Newborn male circumcision: needless and dangerous. Sexual Medicine Today 1979;3(11):35-36.
- Fergusson DM, Lawton JM, Shannon FT. Neonatal circumcision and penile problems: an 8-year longitudinal study. Pediatrics 1988;81(4):537-541.
- Van Howe RS. Variability in penile appearance and penile findings: a prospective study. Brit J Urol 1997;80:776-782.
- Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychology 2002;7(3):329-43.
- Chessare JB. Circumcision: Is the risk of urinary tract infection really the pivotal issue? Clinical Pediatrics 1992;31(2):100-4.
- American Academy of Pediatrics. Committee on Fetus and Newborn, Committee on Drugs, Section on Anesthesiology, Section on Surgery. Prevention and Management of Pain and Stress in the Neonate. Pediatrics 2000;105(2):454-461.
- Anand KJS, International Evidence-Based Group for Neonatal Pain. Consensus statement for the prevention and management of pain in the newborn. Arch Pediatr Adolesc Med 2001;155:173-180.
- Kendel DA. Caution Against Routine Circumcision of Newborn Male Infants (Memorandum to physicians and surgeons of Saskatchewan). Saskatoon: College of Physicians and Surgeons of Saskatchewan, February 20, 2002. Photocopy.
- Boyle GJ, Goldman R, Svoboda JS, Fernandez E. Male circumcision: pain, trauma and psychosexual sequelae. J Health Psychology 2002;7(3):329-43.
- Section on Urology, American Academy of Pediatrics. Timing of Elective Surgery on the Genitalia of Male Children With Particular Reference to the Risks, Benefits, and Psychological Effects of Surgery and Anesthesia (RE9610). Pediatrics 1996;97(4):590-4.
- J. Fred Leditsche. Guidelines for Circumcision. Australasian Association of Paediatric Surgeons. Herston, QLD: 1996
- Geyer J, Ellbury D, Kleiber C, et al. An Evidence-Based Multidisciplinary Protocol for Neonatal Circumcision Pain Management. JOGNN 2002 31, 403-410.
- Hill G. Informed consent for circumcision. South Med J 2002;95(8):946.
- La Leche League. [Breastfeeding problems after circumcision]. Leaven 1994; September-October:78.