Internal/External Monitoring Show Equal Rates of Fetal Distress, C-Section

By Danelle Frisbie © 2010
newborn baby bruised/scratched by internal monitor

The New England Journal of Medicine recently published a study that looked at labor (contraction) monitoring and different birth outcomes in hospitals. The study was conducted in the Netherlands (where rates of neonatal and maternal health and well-being are much better than in the United States). 734 women were assigned to internal monitoring (tocodynamometry) and 722 to external monitoring.

The purpose of the study was primarily to determine if there is a form of monitoring (internal or external) that leads to less unnecessary interventions, and therefore less fetal distress, better regulation of pitocin or other augmenting drugs, and less resulting c-section surgeries.

Continuous contraction monitoring is performed to (theoretically) monitor and artificially regulate contraction frequency, duration and magnitude. Because so many U.S. women today have their labors artificially started or augmented in some way via artificial oxytocin (pitocin), it has become necessary to monitor uterine contractions or face potential severe consequences to baby and/or mom such as uterine hyperstimulation and fetal hypoxia (lack of oxygen), which continues to take place anyway. [See video clip below for more on how this domino effect plays out.]

There had been speculation by some within obstetrics that internal monitoring (tocodynamometry) would lead to more effective 'feedback' and less intervention than the more commonly used external monitor (the belt).

Contraction and fetal monitoring is notorious for increasing unnecessary interventions and leading to cesarean section birth. It is hypothesized that this (along with the ubiquitously high use of pitocin and labor augmentation) in the United States is one reason we see our c-section rates souring while our neonatal and maternal morbidity and mortality rates worsen.

Typically, when an internal contraction monitor (tocodynamometry) is used, an internal fetal monitor is also placed (screwed into baby's scalp) or has already been in use prior to the tocodynamometry.

The results of this NEJM study conclude that there is no significant difference in outcome between internal or external monitoring. Both lead to unnecessary intervention and consequences equally as often including such things as:
-an intrauterine pressure catheter being inserted at some point during labor (whether or not this was the instrument used initially)
-amount of pitocin given to the birthing mother
-increased time to delivery
-adverse neonatal health at birth.

Both internal and external monitoring end in distress to baby, hypoxia, and consequential c-section to the same rate.

Moral of the study?

Do not believe (or allow it) if you are told you need to have an internal monitor during labor to monitor your contractions OR the baby's heartbeat (internal fetal monitor). This monitoring, whether for contractions or fetal heartbeat, does nothing more than the external (belt) monitor, and in no way improves your likelihood of a safe and healthy birth experience, or your baby's outcome.

Internal monitoring does, however, increase your risk of placental or fetal vessel damage, infection, and anaphylactic reaction. Previous studies have demonstrated that as much as 38% of the time an internal monitor is used, it is misplaced during insertion (hitting the placenta, the baby, or being passed between the membranes and uterine wall). This occurs no matter the skill or experience of the practitioner doing the insertion. For all of these reasons, authors of this study have made the recommendation that internal monitoring not be performed.

Above: correct placement of an internal (contraction) monitor
(in amniotic fluid next to baby)

Above & Below: incorrect placement of internal (contraction) monitor

BOTH forms of monitoring (internal and external) increase your chance of unnecessary interventions, the domino effect of hospital birth, distress to your baby, and the likelihood of having birth end in c-section.

Best thing? Ditch the monitoring altogether and find a birth attendant who believes in birth and is willing to do periodic (not continuous) checks on you and your baby.

If you'd like a gentle, normal, natural, peaceful birth that is as mother/baby-friendly as possible, the best thing to do may just be, as perinatologist, Dr. Marsden Wagner, so plainly put it - "get the hell out of the hospital!"

Related Reading:

Born in the USA


Gentle Birth, Gentle Mothering

Gentle Birth Choices

Your Best Birth

The Thinking Woman's Guide to a Better Birth

Ina May's Guide to Childbirth

Related Videos:

Pregnant in America

Birth As We Know It

Orgasmic Birth

The Business of Being Born

Born in the U.S.A.

[End Note: I 100% agree with Rosemary Romberg when she states that it is utterly hypocritical to have a gentle birth (for mom and/or baby) only to cut up this newborn after s/he enters the world. Gentle birth does not end at baby's initial entrance into the world. This is only the beginning and the entire process -- being protected, cared for, loved, nursed, and mothered from the first second earthside -- matters a great deal! Genital cutting ('circumcision') has absolutely NO place in or around birth.]

Outcomes after Internal versus External Tocodynamometry for Monitoring Labor
Jannet J.H. Bakker, M.Sc., Corine J.M. Verhoeven, M.Sc., Petra F. Janssen, M.D., Jan M. van Lith, M.D., Ph.D., Elisabeth D. van Oudgaarden, M.D., Kitty W.M. Bloemenkamp, M.D., Ph.D., Dimitri N.M. Papatsonis, M.D., Ph.D., Ben Willem J. Mol, M.D., Ph.D., and Joris A.M. van der Post, M.D., Ph.D.


Background: It has been hypothesized that internal tocodynamometry, as compared with external monitoring, may provide a more accurate assessment of contractions and thus improve the ability to adjust the dose of oxytocin effectively, resulting in fewer operative deliveries and less fetal distress. However, few data are available to test this hypothesis.

Methods: We performed a randomized, controlled trial in six hospitals in the Netherlands to compare internal tocodynamometry with external monitoring of uterine activity in women for whom induced or augmented labor was required. The primary outcome was the rate of operative deliveries, including both cesarean sections and instrumented vaginal deliveries. Secondary outcomes included the use of antibiotics during labor, time from randomization to delivery, and adverse neonatal outcomes (defined as any of the following: an Apgar score at 5 minutes of less than 7, umbilical-artery pH of less than 7.05, and neonatal hospital stay of longer than 48 hours).

Results: We randomly assigned 1456 women to either internal tocodynamometry (734) or external monitoring (722). The operative-delivery rate was 31.3% in the internal-tocodynamometry group and 29.6% in the external-monitoring group (relative risk with internal monitoring, 1.1; 95% confidence interval [CI], 0.91 to 1.2). Secondary outcomes did not differ significantly between the two groups. The rate of adverse neonatal outcomes was 14.3% with internal monitoring and 15.0% with external monitoring (relative risk, 0.95; 95% CI, 0.74 to 1.2). No serious adverse events associated with use of the intrauterine pressure catheter were reported.

Conclusions: Internal tocodynamometry during induced or augmented labor, as compared with external monitoring, did not significantly reduce the rate of operative deliveries or of adverse neonatal outcomes. (Current Controlled Trials number, ISRCTN13667534 [] ; Netherlands Trial number, NTR285.)

Full Text at the New England Journal of Medicine

Taking Down Babywise: A Hero

I am so frequently impressed by the way that many of you reach out and make the world a better place for babies and their mothers, for families, and for society in general. Occasionally, I am forced to pause in silent awe of your strength and wisdom to handle situations with gentle grace, but urgent demand for change.

As Laurel Thatcher Ulrich said, "Well behaved women rarely make history." And here's to YOU for stirring the pot just a bit when our stagnant ways start to stink.

Today my hero is Laura Bilbo.

Laura with her two youngest boys

Mother to three boys, one who is all grown up and recently enlisted in the Navy, Laura is a stellar example of a woman of strength, courage, compassion, and honesty.

She will openly tell her story of how her first sons were circumcised before she dug into the research on the matter. After self-educating and seeking out the information that is rarely provided to parents making this choice, Laura kept her 3rd son intact. She speaks about the situation from a foundation that is steadily making a difference for those around her. Today, she is an intactivist, working in her own way to save babies and empower others with accurate information.

Laura also takes steps toward making the world a baby-friendly place in other situations as they present themselves. Always aware. Always on the lookout. Always keen and quick on the draw - Laura is changing lives.

Today, she took her two youngest boys to a half-price bookstore near her home in Texas. As the boys indulged in their latest fictional discoveries, Laura scanned the shelves to check for any copies of Babywise.

I'm sure she was half-hoping not to find any. After all, when they are there glaring you in the face you are presented with the bigger dilemma - what to do about them? When I recently walked into our local Babies R Us store to find the shelves lined with nothing but Babywise, I stumbled into my own catastrophe of sorts.

As I've mentioned before, I am not a fan of censorship, or book burning. That is, in virtually all cases but this one. The Ezzos and their Babywise books have damaged more infants and caused more problems than is even comprehensible. You would think that if the AAP (who tends to be rather conservative on most subjects) issues a statement regarding the damaging effects of Babywise methods, that parents would hear about it and the failure-to-thrive incidents would end.

Unfortunately, as I type there are still "I Love Babywise" groups in various locations online with hundreds of members and mothers asking, "What do I do if my 10 week old is crying for 5 hours a night?" "How should I handle my 3 month old who screams in between his every-4-hour-feedings?" "Why is my milk decreasing in volume?" "How can I get my newborn on MY schedule?!" get the picture.

So there Laura stood, scanning the books, and was a bit taken aback to find 2 copies of the yellow book glaring at her from their place on the shelf.

And now the problem presents itself.

Should she buy the books to toss - ensuring another unknowing mother seeking advice doesn't accidentally stumble upon them and reek havoc on herself and her little ones in the process?

Or should she use the money for her sons' books - her original intent on coming into the book store in the first place.

She could hide them. That is what many women have admitted to doing in libraries and bookstores across the country. Only in this small store, they would easily be found and placed back on the shelf for purchase. Plus, there are cameras, and hiding books isn't exactly a social norm that mothers need to be caught breaking in front of their kids.

So instead, Laura went to the store manager. "Now don't think I'm crazy..." she started her explanation, "but I thought you should know that The American Academy of Pediatrics has issued a statement against this book for health reasons." The manager was intrigued as Laura quickly pulled up the AAP's statement on Babywise on her iPhone and let the manager look it over.

The manager was genuinely concerned and took the books from the shelves with Laura's request that they be removed from the store. It may be too much to hope that the books will not make their way back up to the "Baby" section of this second hand book store. But the manager did assure Laura she would at least make sure each book had a disclaimer warning parents who may buy the book.

And with that small feat, Laura has changed the world in her South Central Texas town. At least for someone, somewhere.

Cheers, Laura!! Now if I had that personal jet of mine, I'd fly over and give you a big ol' hug. But just know, I am cheering you on from D.C. with happy tears in my eyes and a smile in my heart for all the ways you made life a better one to live. Thank you for inspiring others to do the same.

...and now, too, I guess I will have to admit to my husband that there is at least one useful reason for him to have that iPhone always on hand. ;)


For more on Babywise, the Ezzos and Growing Kids God's Way methods see:

American Academy of Pediatrics (AAP) Statement on Babywise

The Case for Cue Feeding (rather than PDF - "parent directed feeding")

Parents Against Babywise (Facebook page)

Moms Against Babywise (Facebook group)

Info cards (front/back) available to share. 
Suggested Donation (includes shipping):
$3 = set of 25
$6 = set of 50
$10 = set of 100

Or write to

Painful Urination During Prepuce Separation

By Jennifer Coias, M.D. © 2010

Photo Credit: © Darren Melrose

I've received several questions from parents regarding painful urination.

Frequently a mother will arrive describing a painful experience her son is having when he urinates. 97% of the time this is just normal separation of the prepuce (foreskin) from the glans (head) of the penis, and will not typically last more than 24-72 hours. Especially if there are no other symptoms of urinary tract infection (UTI) present such as frequent urination, fever, etc.

The experience of pain or sting during urination will be more intense when the foreskin separates suddenly, as was the case for my son. Often, there will be some swelling (edema) and/or ballooning that occurs as well. The foreskin might separate all at once on one side and then slowly detach as the pressure from the urine knocks the connections loose. This means that the pain can go on for a couple days. For my son the entire foreskin took about 24 hours to knock loose, then the glans took about 3 days to smooth over, and for him to not experience any pain when urinating.

It is unclear why some boys experience this separation symptom more suddenly than others. For my son I believe that the cause was some early manipulation of his foreskin by a doctor (forced retraction). This is just another reason that doctors should not manipulate the foreskin for any reason. For other boys, it could be that they are a little hard on themselves during self-exploration which starts the ball rolling sooner.

One of the remedies we have for painful urination during separation, is to have the child pee with his penis in a cup of water. However, this does not often work for young boys. If the foreskin opening is still very narrow, the water will not be able to mix with the urine and dilute it so that it does not sting. For these boys, they will just have to weather the experience, and it will be over as quickly as it started.

In addition, the foreskin may not separate all at once, causing painful urination to come and go until complete separation has occurred.

The sting may be worse during times of the day when the urine is more concentrated. Have you son drink LOTS OF WATER (or breastmilk if he is nursing). For my son, the discomfort was bad all day. It can be very painful. Sometimes a boy will be reluctant to pee to try to avoid the pain.

The objective of this brief article is to ensure that parents know painful urination, even when it sounds very painful, is most likely to be normal separation. Especially if there are no other symptoms of UTI. Swelling is also a good indication that it is separation, but may or may not be present. Other symptoms that can be present are smegma discharge, ballooning, and a small amount of blood.

Comfort your babe and wait and watch. It may be a rough few days, but a lifetime of normal, optimal functioning is worth it! Unless you see other symptoms that could indicate UTI, I would not run to the doctor. Most (in the U.S.) are not familiar with the normal development of the intact boy and often do more harm than good.

Good solutions for red or irritated foreskin or inflammation of the genitals (on girls or boys). 

Additional intact information at:
How to Care for Your Intact Son

 Proper Intact Care Basics

Also by Dr. Jennifer Coias:

For additional information and resources on the prepuce, intact care and circumcision, see The Pros and Cons of Infant Circumcision: Are You Fully Informed? 


Basic Care of the Intact Child

By Jennifer Coias, M.D. © 2009
See also: Intact Care Resource Page

This is important care information for all intact children. It might seem silly that I am giving basic directions about proper care of the genitals, but I see parents receiving improper information on a daily basis.


In both boys and girls the genitals are not fully developed at birth. Yes, all the parts are there, but those parts are not sexually developed. Both boys and girls are born with the prepuce (foreskin) that is fused to the underlying sex organ. On a girl it is fused to the clitoris and on boys it is fused to the glans (head) of the penis. The genitals are like a rose that will bloom will age and sexual maturity. There should NEVER be an attempt to try to pull at the foreskin of a girl or boy. In general we don't try to do this to girls but many people do not understand the importance of leaving a boy's foreskin alone. Trying to retract a foreskin causes tearing, scaring, bleeding, introduces infection, and other more serious complications.

The foreskin is fused for a reason, to protect the underlying sex organ from urine, feces and other pathogens. With girls you never have to worry about a care provider or doctor trying to retract, but with boys it is a real danger. Stay with your newborn son at all times at the hospital. If they ask to take your son to the nursery, send a member of the family with him. Clearly address that your son's foreskin should NOT be manipulated in any way, shape, or form on your birth plan and consider buying a onsie that says "Please do NOT manipulate my foreskin". When you take your baby to your baby-well-checks always remind the doctor that he is NOT to manipulate your son's foreskin for any reason. Have this discussion before he removes your son's diaper.

This might seem redundant but I find that doctors have a general curiosity to see what is "underneath". There is absolutely nothing for the doctor to see and there is no reason for him to try to manipulate your son's foreskin. Print off the following pamphlets and give them to your doctor if they ever try to challenge you. If the doctor continues to challenge you, take your son and leave. Do not put your son at risk to be forcibly retracted.

Answers to your questions about your intact son

Dangers of Forcible Retraction

Medical Professionals for Genital Autonomy

AAP Care for Intact Boy Guidelines

Avoiding Circumcision after the Neonatal Period


If your son is intact, do not retract. Only clean what is seen. Wipe his penis, base to tip, like a finger. That's it! A quick wipe, or dip in the tub or sink with warm water is all that is ever needed for 'cleaning' of your son.

If this is so easy, why is there so much information today on intact care? The answer to this is simply that we have yet to start teaching proper intact care or development in medical and nursing schools in the United States. As a result, improper information (and myths) get passed onto our patients, and parents are lead to believe they must 'clean' or retract to care for their baby boy. Currently, forced retraction is the leading cause of problems with intact children.

Intact Care Basics


• The foreskin is fused to the glans (head) of a child's penis like your fingernail to your finger.
• This may not loosen until puberty, and that is normal and okay.
• The only one who should ever retract a child's foreskin is the child himself.
• Never push back the foreskin in an attempt to 'clean inside' the foreskin - this is called forced retraction.
• To clean: wipe the outside of the penis only with a wipe, or have your baby splash in a warm water bath.
• Forced retraction is something all parents should be well versed on -- it can cause pain, bleeding, scarring, infections and future complications.
• Ensure anyone who will be changing your son's diaper knows proper intact care.
Catheters can be safely inserted without retraction on intact boys - by feel alone - when necessary.


If poop gets on the penis you can wipe like a finger, from base to tip. For a girl wipe from front to back. For really messy diapers you should shower your child off or take a bath with clean, warm water. You DO NOT need to wipe after urination. This is totally unnecessary and could disturb the natural flora of the genitals. As children learn to wipe themselves teach them the importance of wiping from front to back and washing their hands after they finish.

In the bath, just swish genitals gently in the water. With both boys and girls you want to avoid bubble baths and soaking in soapy water daily. This can irritate genitals and cause flora imbalance (causing yeast). I always apply the baby wash to my son LAST after he has finished playing in the water and then rinse him immediately. Never apply soaps directly to your child's genitals or try to 'scrub' them. Warm water is enough. For kids who enjoy bubble baths, opt for a natural bubble, and limit to once a week, or skip them if irritation arises.

Prolonged exposure to urine saturated diapers can cause redness or irritation/rash to the genitals of children.

YEAST 411:

For both boys and girls yeast infections can happen during the diaper wearing years or after a round of antibiotics. Yeast is easily treated with an anti-fungal ointment (prescription or otc). To avoid yeast infections you should always have give your child probiotics during and for one week after a round of antibiotics. You can get probiotic supplements from the pediatrician or from a health food store. They have some especially formulated for infants and babies. Probiotics are healthy bacteria. Also, if you choose to cloth diaper you will want to strip your diapers with vinegar and hang them to dry in the sunlight if you ever get diaper yeast (thrush). Yeast can be quite hard to remove from cloth diapers. You will want to use disposables until the yeast on your baby is treated and all the diapers have been thoroughly stripped.


During childhood/adolescence your son will go through a normal separation process as the foreskin separates from the glans. As I said before, the foreskin is fused during childhood to protect the developing penis from feces and other pathogens. Separation is different for each boy and happens at a different age for each boy. During this time he might experience some irritation, itching, stinging, minor redness, minor swelling, ballooning, spraying, smegma pearls, uneven retraction, etc. These are all totally NORMAL and resolve by themselves.

I get many concerned parents asking about their son's irritated, red, or slightly inflamed penis. 97% of the time it is just normal separation occurring. Some boys don't experience any of this but most boys have 1 of these symptoms at some point especially around ages 2-5 when boys really begin to explore their genitals with their hands. During self-discovery is a prime time for separation trauma to appear. UNLESS it gets increasingly worse, extremely inflamed, he has fever, or you suspect yeast infection there is nothing to worry about. (Bacterial infections are VERY RARE and usually only occur only after forcible retraction or a wound to the penis.) Usually the symptoms of normal separation resolve themselves within 48 hours. Due to the fact that U.S. doctors know very little about the development of the intact boy, it is wise to wait it out and let this resolve on its own. Since boys tend to be more "hands on" with their genitals and their genitals are not as internal these symptoms appear more frequently than with girls. You may want to remind your son to be gentle with his privates as he begins to self-explore.

Important Article--- Protect Your Intact Son, Expert Medical Advice

Here is a helpful article about separation

Remember that just because the foreskin has separated from the glans does NOT mean that anyone should try to retract your son. The opening of the foreskin remains very narrow and widens with sexual maturity. A foreskin only becomes retractable after the foreskin has separated and the opening has widened. Hormones play a big role in the widening process. These hormones replace the fiberous tissue with a more elasticy tissue. Through self-discovery your son will learn when he is retractable. Only 50% of boys are retractable by age 10. It is normal for a boy to not become retractable until after puberty. The only person to retract a boy should be the boy himself. Once a boy/man is retractable he can retract his foreskin, rinse with water only, and replace the foreskin back over the glans during his showers. Easy as that!

If your son becomes retractable at an early age you will notice that his glans and inner foreskin is very red and moist. This is NORMAL. The intact boy's glans are an internal organ, unlike a circumcised boy. Circumcised boys develop extra layers of skin over their glans, this puts the blood flow further from the surface than with the intact boy. Because the foreskin is protecting the glans the intact boy's blood-flow is very close to the surface which gives it a red appearance. The foreskin is also very vascular (like the lips) so this also gives it a more red appearance. The normal appearance of the intact boy is red and moist. If your son becomes retractable at a young age, remind him that he should always replace his foreskin over the glans after retraction.

Additional Resources on Intact Care and Forced Retraction can be found at How To Care for Your Intact Son.

Dr. Adrienne Carmack, American Urologist, is the author of the excellent booklet, The Good Mommy's Guide to Her Little Boy's Penis. You do not need a book to care for your son, but if you wish to have a urologist's thoughts on the topic, this is it!

Also by Jennifer Coias:

Circumcision: Already Illegal?

For additional information and resources on the prepuce, intact care and circumcision, see Are You Fully Informed? The pros and cons of infant circumcision

Intact Care information at: How to Care for Your Intact Son

Medical Professionals for Genital Autonomy

STOP! Do not retract! No, not even 'just a little.' 

Circumcision Care - Intact Care

Intact Care - Circumcision Care

Intact Care Diaper Tab Reminder Stickers
Do Not Retract - Available at Etsy

Questions Regarding Normal Separation of the Prepuce

MCatLvrMom2A&X at Mothering
notes used with author's permission
Photos © 2010 Danelle Day, Ph.D. and Jennifer Quesada

The following information is to help answer some of the questions we see most often in regards to the normal separation of the prepuce (foreskin) from the glans (head) of the intact boy. In the course of the normal development of the intact penis some things might happen that may be alarming to those who have never been around an intact boy/man before. Many boys will have none of these things happen, and some will have one or more of them.

The following information has been compiled through many sources, along with personal experiences from myself and others.

When babies are born the prepuce is fused to the head of the penis much like the fingernail is to the nail bed. As a child grows, the process of separation starts (prepuce separating from the clitoris or penis glans). This process can start shortly after birth, or it may not be until the teenage years, and in some cases even into adulthood. (Some men and women go their entire lives without their prepuce (foreskin) retracting with no problems at all). There is no set age on when the foreskin will become or should be retractable just as they are is no set age when a girl will reach menarche. It appears that 2.5-3 years old is a time when a lot of the following separation questions arise. However, they can occur at any age.

The separation process in general does not happen all at once. It happens over a period of time from weeks to months, and in many cases even years. It can appear to happen overnight for some boys. The foreskin will often have spots that are still attached even after the rest of the foreskin has released from the glans. This is not cause for concern, when the time is right the spot will release just like the rest of the foreskin has. Unless trauma (such as forcible retraction) has occurred, in which case a skin bridge may form that may or may not need to be fixed. Generally, when the hormones of puberty hit, these attachments will release on their own. This can cause soreness in the spot that will usually resolve within 24-48 hours.

healthy, intact penis of 2 year old
(prepuce has just started to open to begin separation process at the very end)

When the separation process starts there are some things you may, or may not see. These things include: ballooning, soreness, swelling and possibly some discharge.


Ballooning is a normal developmental stage and is not a cause for concern and does not require treatment, it is actually a sign that nature is doing it's job. Ballooning occurs when separation of the foreskin from the glans has started but the sphincter at the tip of the foreskin is still tight causing urine to pool under the foreskin. This is not harmful but it can be disconcerting to see it as the foreskin can balloon up quiet dramatically. It can last a short time or can come and go for months or years.

A child temporarily may report some discomfort or pain while urinating during this period. This occurs because the ballooning may tear at any residual connection to the glans. The discomfort will stop when separation is complete. The foreskin may still not be retractable at this point because the opening of the foreskin, sphincter, is still narrow. With increased growth and maturity, the ballooning will end when opening of the foreskin widens.  See More: Ballooning

Pain, Swelling, Redness

Pain, swelling and redness can also go along with the ballooning or it can be seen without it. If either case 9 times out of 10 the pain and redness will resolve within 24-48 hours. If anything lasts longer than that the odds are higher that there is a infection present. It is important to note that if the problems last longer than the above mentioned time frame or you feel something is really wrong a trip to the Dr. is warranted since long term untreated infections can lead to scaring of the glans resulting in loss of sensation in those area's. Sometimes you may see small amounts of blood but it should not be much and it shouldn't last very long.

The most common infections are yeast or bacterial. The treatment for these is not at all difficult. Depending which is present treatment will either be anti fungal, OTC yeast medications like Monistat 7 day treatment (not the 3 day kind) and for bacterial infections OTC Bacitracin (a safer less reactive cream than Neosporin) can be used. Sometimes a prescription of oral antibiotics is required as well. If you do go the antibiotic route make sure to finish the whole prescription even if you son's penis looks healed in just a few days.

Neosporin is not recommended as some people react badly to it [and microflora is altered]. It is important to figure out if you are dealing with yeast or bacterial since the treatment for bacterial infection can make yeast worse. So a swab culture is essential to figure out exactly what you are dealing with.

If you do take your child to the doctor make sure that his foreskin is not pushed back on at all (See the Warning For Parents Of Intact Sons for more information as well as The Definition Of Retraction & Why it is BAD) If there is infection present this will make it easier to spread and cause more pain and trauma. To check to see exactly what pathogen is present a swab culture should be done. This is done with the long q-tip and a gentle rub of the very tip of the foreskin will pick anything up that is present without pushing on the foreskin at all.

Helpful tips for dealing with pain

Some things you can do to help if your son is in pain is letting him urinate in a cup of water or the bath tub this will dilute the urine so that wont sting. If your son is old enough you can tell him to retract just enough that the urinary opening is exposed so the urine doesn't go back under the foreskin. Long soaks in the bath with baking soda or a very small amount of Tea Tree Oil can also help sooth the pain.

[Editor's Update: If breastfeeding do not apply human milk to the genitals as this feeds yeast. Instead, opt for Calmoseptine which is an ointment that aids in healing without interfering with normal pH and healthy microflora. For more see: Yeast, Rash and Redness: Breastmilk feeds yeast, Neosporin alters microflora - what to do instead]. Diaper free time and stripping your diapers if you use cloth can be very helpful as well. Especially if dealing with yeast.

The things to watch for that would indicate more than separation injury is going on are: severe swelling that keeps getting worse, fever, discharge with a foul smell or dark green in color, unusual redness accompanied by any of the things mentioned above. If your son is having trouble urinating he needs immediate medical help.

The reason the foreskin reacts so strongly sometimes when separation is happening is because it is a very vascular organ and much like the lips even a small bump can cause swelling and pain.

The normal appearance of the glans and inner foreskin is usually a bright red/purple color. This is often disconcerting to parents who see it for the first time and they think that it is irritated, when in fact it is how it should look. The washed out color of the glans on a circumcised boy/man is caused from the drying out and keritinization of the skin caused by being exposed and rubbed against the clothing.

Smegma Pearl (Picture) Note: The penis in this picture is being partially retracted something that should NOT be done. The pearl is on the right side near the base of the glans it is the very large whitish area.

Something you may also see is called a smegma pearl. This is a whitish lump that can range in size from very tiny to pea size or larger. Smegma (the Greek word for soap) is a substance that consists of dead skin cells, body oil and other debris that clumps together forming a ball. It is not damaging and will work its way out once separation is sufficient for it to do so. It is not recommended that you try to massage it out or mess with it since this could cause tearing between the foreskin and the glans and result in pain and possible infection.

The time that smegma pearls are seen is when separation has started. It may make the glans under the foreskin appear like it is crooked. When touched it may feel hard but slightly squishy. It may also look like a blister under the foreskin. If there is any pain in that area odds are that it is being caused by separation and not the pearl, since Smegma is not a irritating substance in itself, unless there is a foreign body in there like lint, that can cause a bit of irritation. For the most part nothing will get under the foreskin but sometimes it happens, especially if separation is well underway.

You may also see a milky whitish discharge. This is smegma mixed with urine and is no cause for alarm. On occasion you may see a very large amount come out or it may just be a small amount.

Smegma can be the consistency of cottage cheese or it can be like liquid. It comes in many colors, pure white, yellowish, greenish, tan or a combination, it is often confused with pus. But the main thing between pus and smegma is that pus will have a really bad odor like an infection. While smegma may smell strong like unwashed genitals depending on how long it has been under the foreskin but not have a odor you would associate with sickness.

Preputial Cyst (Picture) Note: The penis in this picture is fully retracted something that should NOT be done.

There is also something called a Preputial Cyst that occurs on occasion. Sometimes known as a Keratin Pearl caused by dead skin cells accumulating under the top layer of skin on the glans. The appearance of swelling may occur sporadically as preputial cysts break through adhesions (push up against them) to allow separation of the prepuce, foreskin, from the glans. These whitish cysts are sometimes mistaken for pus due to infection, but they merely represent sterile collections of dead skin. It is a lot like a Smegma pearl but is not between the glans and foreskin but under the skin of the glans. In either case nothing special needs to be done.

Foreskin was retracting now it is not? (From Dr. Paul Fliess)

Sometimes a previously retractable foreskin will become resistant to retraction for reasons that are unrelated to impending puberty. In these cases, the opening of the foreskin may look chapped and sting when your son urinates. This is not an indication for surgery any more than chapped lips. This is just the foreskin doing its job. If the foreskin were not there, the glans and urinary opening would be chapped instead. Chapping is most often caused by overly chlorinated swimming pools, harsh soap, bubble baths, or a diet that is too high in sugar, all of which destroy the natural balance of skin bacteria and should be avoided if chapping occurs. The foreskin becomes resistant to retraction until a natural and healthy bacterial balance is reestablished.

You can aid healing by having your son apply a little barrier cream or some ointment to the opening of the foreskin. Acidophilus culture (which can be purchased from a health food store) can be taken internally and also applied to the foreskin several times a day to assist healing, and should be given any time a child is taking antibiotics.

Spraying While Urinating

Some boys will spray at one time or another during the process of penile growth. If your son has entered a spraying phase, simply instruct him to retract his foreskin enough to expose the meatus when he urinates (if he can do so himself and without pain of course). This is a phase and won't last that long. But it might come and go several times during the separation process. There is no difference in the amount of spraying between intact or circumcised boys - this has much more to do with a child's aim and the development of his urethra than whether or not he is intact.


A question we see here a lot as well is if the toddler/child is retractable should the parent retract the foreskin to clean. The answer to this is no, if the boy is not old enough to do it himself then the penis should continue to be cleaned by washing like a finger from base to tip, outside only, with warm water (no soap). Once the boy is old enough to retract on his own foreskin, he can retract, rinse with pure water, and replace - do not use soap on the exposed glans of the penis as this can cause pain, irritation and/or infection.

Paraphimosis (very rare, but good information to have)

Once your son is retracting on his own (for some boys this will not occur until their teenage years) be sure to let your son know to replace the foreskin over the glans any time he has retracted, so that it does not become trapped behind the glans. If this happens, it is known as paraphimosis and needs immediate attention. There are a few simple things that work most of the time to get it back in the proper position.

(Actual medical pictures of reduction, genitals shown)
Here are two great article on reducing paraphimosis:
British Journal of Urology 1999
Circumstitions Paraphimosis

How the foreskin works animated pictures:
NOHARMM Anatomy & Functions
Circumstitions Functions & Mobility of the Foreskin

Related Reading: 

Painful Urination During Prepuce Separation

Ballooning in the Intact Child

How to Care for Your Intact Son (resource list of articles)

Basic Care of an Intact Child

Q&A For Intact Men

Protect Your Intact Son

For more information on the prepuce, intact care and circumcision see resources on this page.

Breastfeeding Protects Against Rotavirus Diarrhea MORE Than Vaccination

By Dr. Linda Palmer
posted with author's permission

Exclusive breastfeeding reduces Rotavirus diarrhea in Brazil by 90%
a 40% reduction in Rotavirus diarrhea by vaccination in Mexico.

“Rotavirus vaccine cuts deaths of Mexican babies from diarrhoea by 40%," states a January, 2010, British Medical Journal headline summarizing two studies.(1) Yet, a study of Brazilian children finds that exclusive breastfeeding cuts diarrhea cases in this similarly developing nation by a whopping 90% (1 / 9.41), versus a diet of formula and/or other foods.(2)

A study on the cost of breastfeeding promotion programs for Brazil and Mexico accounted a 30 to 40 cent cost per birth for breastfeeding promotion programs.(3) The vaccine costs $190 for a series of 3 oral Rotovirus doses. The vaccine also leads to a substantial increase in cases of intussusception, a dangerous intestinal condition where part of the intestine folds in, inside itself. Treatment costs and lives lost from this side effect of the vaccine should be considered as well.

For more on the many ways breastfeeding acts as the ultimate 'vaccine' against all of infant (and later life) maladies, see Palmer's excellent book, The Baby Bond.


1 A. Gutland, “Rotavirus vaccine cuts deaths of Mexican babies from diarrhoea by 40%,” BMJ 2010 Jan 28, doi:10.1136/bmj.c511.

2. H.S. Maranhão, et al., “The epidemiological and clinical characteristics and nutritional development of infants with acute diarrhoea, in north-eastern Brazil,” Ann Trop Med Parasitol, 2008 Jun;102(4):357-65.

3. S. Horton, et al., “Breastfeeding promotion and priority setting in health,” Health Policy Plan, 1996 Jun;11(2):156-68.

Circumcision Deserves Circumspection

By Elizabeth Reis, Ph.D.
Read more by Reis

Banner image courtesy of Sweet Little Bundles Birth Services

Twenty-one years ago I agreed to have my son circumcised. Today I signed a petition urging the American Academy of Pediatrics NOT to recommend circumcision to parents of newborn baby boys.

Why the change of heart? Nothing traumatic happened to my own son; in fact, he’s sick and tired of my apologies regarding his circumcision and wishes I would never mention it again. I began to change my mind when I actually saw the procedure done, and as I’ve researched the reasons for genital surgery and the ethics of informed consent over the years, I’ve become more and more convinced that neonatal infant surgery is ethically wrong.

I signed the petition because I do not want the supreme authority on children’s health, the American Academy of Pediatrics, to issue a statement that will affect thousands of pediatricians’ judgments around the country and potentially sway the decisions of the parents of baby boys.

Circumcision has a long and disturbing history in this country. In the nineteenth century doctors touted it as a cure for masturbation primarily, but also paralysis, syphilis, eczema, gangrene, tuberculosis, impotence, general nervousness, and convulsions, among other ills. By the 1920s, some 50 percent of the urban male population was circumcised; by World War II, it was pretty clear that circumcision didn’t prevent masturbation, but the threat of sexually transmitted diseases loomed large. Doctors convinced the public that circumcision prevented STDs, and so by the 1970s, 85 percent of men were circumcised. As it happens, these assertions were misguided; today the United States has the highest rate of STDs of any developed nation, the highest rate of heterosexually transmitted HIV infection, and also the highest rate of circumcision. Go figure.

Circumcision rates rise and fall, based on prevailing social, rather than strictly medical, trends. In 1999 the American Academy of Pediatrics ruled that, in fact, there was no compelling reason to circumcise boys, other than religious and/or cultural ones. Absent any clear medical reason for the surgery, parents could make their own informed decisions, the AAP advised. Now, with recent discussion about circumcision preventing HIV infection in Africa, we’re back to the disease justification again, and the AAP might determine next week that baby boys should be circumcised for this public health reason.

I would hope parents would actually heed the “informed” part of their consent, but if they’re like me, they will likely make the decision based on other factors: some want the baby to look like the dad (who probably will be circumcised based on the rates in recent history); some choose the surgery because “it looks right.” But think about it: why should surgical alteration of a baby’s penis make it “look right?” There’s something wrong with this rationalization.

Others, like me, do it for religious reasons, without evaluating the necessity of the procedure. I’m not even religious. I don’t observe any of the other Jewish laws; why this one? If anyone had told me that my son could still be Jewish (just because his mother is Jewish), even if he wasn’t circumcised, I would not have gone through with it. But no one mentioned that possibility to me because circumcision is an enduring and undebated ritual in Judaism. And in American culture more broadly, it is sadly a choice that gets made without a whole lot of thought.

Even in the world of medical ethics, circumcision is a subject that is largely ignored. Several of the major medical ethics textbooks don’t even include it in their indexes. And this is what I object to. I think that circumcision needs to be recognized as most parents’ first ethical decision that they make about and for their child. Parents should be informed of what the procedure actually entails. Remember that video of the birth process that many of us had to watch in prenatal classes? Why not see a video of a circumcision? I am convinced that most people do not know what they are consenting to, and if they did, they would avoid the procedure like the plague.

Not to get too personal, but I had never even seen an intact penis until my son was born. So when people assured me that it was not a big deal -- “just a snip of skin” -- I naively believed them. I didn’t know how sensitive the foreskin is, what its purpose is, how protective it is, how many nerves it contains and are cut off. A 2007 study of circumcised and uncircumcised men suggests that penile sensitivity of circumcised men is lessened, and why not? The most responsive part of the penis has been excised. [Women are also impacted as a result of male circumcision.]

Even if all the studies on the spread of HIV in Africa were valid and we all agreed that circumcision prevents HIV, I think there are solutions other than surgery that would work to decrease the spread of the disease. Condoms prevent HIV, and in fact, they’re still necessary to avoid the virus even if men are circumcised. Fewer sexual partners would also help. Babies circumcised now won’t be having sex for several years, when we hope to have new and more effective strategies for preventing HIV. Avoiding HIV in adults simply isn’t a good enough reason to recommend cutting off a perfectly healthy, useful, and pleasurable part of infants’ bodies.

If men want to make this decision for themselves, for public health or personal reasons, then let them. The American Academy of Pediatrics should elevate the principle of autonomy and encourage parents to let their male children make the choice about circumcision when they’re all grown up.

Elizabeth Reis is Associate Professor of Women’s and Gender studies at the University of Oregon and the author of Bodies in Doubt: An American History of Intersex. (Johns Hopkins University Press, 2009).

Reasons NOT to Send Formula or Breastmilk to Haiti or other Disaster Locations

Letter from Dr. Carlos González Rodríguez, Pediatrician, Barcelona, Spain
Founder of the Asociación Catalana Pro Lactancia Materna.

Member of the La Leche League International
Advisory Board
Evaluator for the UNICEF Baby Friendly Hospital Initiative
Since 1992, Dr. Carlos González Rodríguez has taught more than 100 breastfeeding courses to health care providers.
This English translation is provided by Jeanette Panchula, IBCLC in CA

Despite the turmoil around, Renante Taris breastfeeds her son, Erikson, comforting him in this gentle mothering manner like nothing else can. Renante and her toddler are at a hospital in Port-au-Prince, Haiti.
Photo by Jae C. Hong.

The donations of formula for bottle feeding in times of catastrophe such as war, earthquake and floods, are very dangerous. In fact, they are not donations, but instead free samples - it is the means by which formula companies compete to create new markets. If you pay attention to the news, you will frequently hear how an airplane has departed loaded with FORMULA - rarely will you hear of a plane loaded with beans or noodles. That is because the companies that sell noodles and beans, unless they have an especially generous director, have no commercial interest in making donations. While the country in question is in ruins, it is unable to pay for food; when they overcome the catastrophe they will eat their own beans grown in their own country, or their own noodles made in by local enterprises.

On the other hand, if in a third world country you can take over lactation, you get millions of women to abandon breastfeeding and millions of doctors and nurses will learn the "advantages" of bottle feeding, which without a doubt is wonderful because Non-Governmental Organization (NGO) “X” gave it to us as a gift, then you have a captive market that will be worth millions because that milk is not manufactured in the country and it must be imported, and if used to brand Z, they will probably continue to buy brand Z.

Years ago a request was made that donations be given with just a white label stating "milk for babies" with no brand, but of course the manufacturers refused. In addition, the manufacturer saves on transport by giving the free samples to an NGO – serious NGOs no longer accept them, but at times one will - or a government accepts them and THEY pay for the transport. And the real market, let us not fool ourselves, is in the third world. In Spain only 500,000 babies are born a year. In Indonesia, more than 5 million and in India 25 million. There are many more clients, although some will die on the way, and will only buy their milk for a week, and dilute it so that it will last...

Some years ago, at the end of the war in Sarajevo, I met a Bosnian pediatrician in a meeting. He had suffered real hunger and was very thin, and during the meals he would pick up the smallest piece of bread that would fall on the tablecloth and eat it. He explained to us how at the beginning of the war, infant mortality rose horribly, as they were flooded with free samples.

Of course, not all the professionals are knowledgeable about breastfeeding, as happens here. Many began to recommend "a little help" thinking the mothers, "stressed" by the war, would have NO milk, or wanted to help the poorly-nourished mothers by reducing the "load" of having to breastfeed. With no drinking water nor gas to boil it (as occurs also in Gaza today), when the explosions destroyed the water system and feces floods the lower floors, the death rate was enormous.

It fell upon the more knowledgeable pediatricians who went to UNICEF and called a meeting of the NGO's in the area, getting them to agree to not distribute any more free donations, and also provided their personnel with education on breastfeeding in emergencies...[which is available on-line from UNICEF now] in a few months, while the war continued, they were able to have a higher rate of breastfeeding and a lower infant mortality than prior to the war.

Of course some children need artificial milk in times of war; but for these few formula can be found without enormous loads of free samples. And those children, in those conditions, have such a high death rate that we can no longer think "the mother is free to decide if she wants to breastfeed or formula-feed."

In these conditions we must do everything we can to promote relactation even if it has been months since the mother breastfed, or find a wet-nurse. And sadly, it is not difficult to find them - because babies are weaker than adults - and in any catastrophe there are more mothers without babies than there are babies without mothers.

Emma Kwasnica, lactivist and breastfeeding supporter reminds those wishing to help Haitian babies and toddlers: "Sending donated artificial milk (and even donated breastmilk) to Haitian babies ultimately prevents them from getting breastmilk at their own mothers' breast, the impact of which is NOT benign. Breastfeeding is the single most effective way to ensure the health and survival of babies in any disaster zone. Please don't send milk. Send your money to an aid agency with experience in supporting lactation/re-lactation/cross-nursing on the ground (AFASS-type relief efforts)."

Dr. Carlos González Rodríguez' original letter en Español:

Las donaciones de leche para el biberón en casos de catástrofe (guerra, terremoto, inundación...) son sumamente peligrosas. En realidad no son donaciones, sino muestras gratuitas: es el medio por el que las empresas lácteas compiten para hacerse con nuevos mercados. Si estás atento a las noticias, muchas veces habrás oído cómo ha salido un avión cargado de leche... raramente oirás de un avión cargado de macarrones o lentejas.

Porque las empresas que venden macarrones o lentejas, fuera de que alguna en concreto tenga un director especialmente generoso o solidario, no tienen un interés comercial en hacer una donación. Mientras el país en cuestión esté en ruinas, no pagarán por la comida; cuando superen la catástrofe, se comerán sus propias lentejas cultivadas en su país, o sus propios macarrones
fabricados por empresas locales. En cambio, si en un país del tercer mundo consigues cargarte la lactancia, consigues que millones de madres abandonen la lactancia y millones de médicos y enfermeras aprendan las ventajas del biberón, que sin duda es buenísimo porque la asociación X nos lo regalaba para ayudarnos, luego tendrás un mercado cautivo que valdrá millones, porque esa leche no se fabrica en el país y la tendrán que importar, y acostumbrados a la marca Z probablemente seguirán comprando la marca Z.

Hace años pidieron que los donativos fueran con una etiqueta blanca, "leche para bebés", sin marca, y los fabricantes, claro, no quisieron. Además, muchas veces la empresa fabricante se ahorra el transporte: se limita a entregarle las muestras gratuitas a una ONG (por suerte las ONG serias ya no las aceptan, pero a veces encuentras a un primo), o a un gobierno, y estos pagan los portes. Y el mercado de la lactancia, no nos engañemos, está en el tercer mundo. En España sólo nacen menos de 500.000 niños al año; en Indonesia más de 5 millones, en la India más de 25 millones... Son muchos más clientes, aunque algunos se mueran por el camino, aunque sólo se compren una lata de leche por semana y la diluyan para que dure...

Hace unos años, acababa de terminar la guerra de Sarajevo, conocí a unpediatra bosnio en un congreso. Había pasado hambre, estaba delgadísimo, y en las comidas recogía hasta la más minúscula miga de pan que cayera en el mantel y se la comía. Nos explicó como al principio de la guerra la mortalidad infantil aumentó espectacularmente, porque fueron inundados con muestras gratuitas. Claro, no todos los profesionales tienen buena formación sobre lactancia, igual que pasa aquí. Muchos empezaron a recomendar "ayuditas", pensaban que las madres, "estresadas" por la guerra, no tendrían leche, o que al quitarle a una madre mal alimentada la pesada "carga" de tener que dar el pecho le hacías un favor. Sin agua potable ni gas para hervirla (lo mismo que ocurre ahora en Gaza), cuando las explosiones destruyen las alcantarillas y la mierda inunda las plantas bajas... la mortalidad fue enorme. Tuvieron que ser los pediatras más concienciados los que fueran a quejarse a UNICEF, que convocó una reunión de todas las ONG sobre el terreno, acordaron no distribuir más donaciones, realizaron cursos para el personal... en pocos meses, mientras la guerra continuaba, habían conseguido tasas de lactancia materna más altas y una mortalidad infantil más baja que antes de la guerra.

Por supuesto algunos niños necesitan leche artificial en las guerras; pero para esos pocos ya se consigue leche sin necesidad de espectaculares cargamentos de muestras. Y esos niños, en esas condiciones, tienen un riesgo de muerte tan alto que ya no vale aquello de "la madre es libre para
decidir, y si ha elegido la lactancia artificial...".En esas condiciones hay que hacer todo lo posible para que la madre relacte, aunque lleve meses sin dar el pecho, o para encontrar una nodriza. Y tristemente eso no es muy difícil, porque los bebés son más frágiles que los adultos: en cualquier catástrofe hay más madres sin bebé que bebés sin madre.

• Mi niño no me come (1999)
• Bésame mucho, cómo criar a tus hijos con amor (2003)
• Manual práctico de lactancia materna (2004)
• Un regalo para toda la vida, guía de la lactancia materna (2006)


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