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Letters to LLLI:
Circumcision and Breastfeeding

From: LEAVEN, Vol. 36 No. 5, October-November 2000, pp. 94-95

We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.

Dear LLLI,

As the mother of two intact sons, I am aware of my bias on the issue of circumcision. I am careful not to discuss this and other "off-topic" items during LLL meetings. However, I would like to cite LLLI sources when I am asked to provide information to mothers.

I located a copy of LEAVEN (Sept-Oct 1994, p. 78) which indicates that we should "avoid a protracted discussion" of circumcision during a meeting but that we can mention the potential effects on breastfeeding. Although circumcision is discussed in the 1981 edition of THE WOMANLY ART OF BREASTFEEDING, the section does not appear in any subsequent editions. Why? What other resources does LLLI have relating to circumcision? Do we have the latest research that addresses its effect on breastfeeding? How can Leaders respond to questions on this issue? Does LLLI have a policy statement on circumcision?

I am a very dedicated supporter of La Leche League International and have been extremely proud of my association with such a bold and accurate organization. Thank you for considering this issue.

Sincerely,
Linda Frank
Stillwater, Oklahoma, USA

Dear Linda,

Thank you for your letter regarding infant circumcision. It is a topic that is of interest to many mothers - and one of many issues that can have an impact on the breastfeeding relationship.

When a mother questions how anything might affect her ability to nurse, or might have the potential to change the course of her breastfeeding experience, it is logical she would bring it up at a meeting. The Leader responds without giving medical advice. She is aware of the LLL resources she can share and how to respond to the mother in light of the cultural and religious perspectives that are present in an international organization such as LLLI. Finally, she knows how to facilitate the informal discussion that takes place at Series Meetings.

Circumcision, in and of itself, is not directly related to breastfeeding. However, like other elective surgeries, this procedure can affect the early days of breastfeeding. If a mother contacts LLL with questions, we can share general information from such La Leche League resources as THE WOMANLY ART OF BREASTFEEDING (see "surgery") and the BREASTFEEDING ANSWER BOOK which have information on how any surgical procedure can affect breastfeeding. The most recent LLLI publications on this subject are Babies and Children in the Hospital (No. 527-24) and The Hospitalized Nursing Baby - Meeting the Needs of Mothers, Babies, and Families in Health Care Settings (No. 388-19). With any question about studies related to breastfeeding, a Leader can check with the Professional Liaison Department. In addition, the LLLI Center for Breastfeeding Information database, with an index of over 15,000 bibliographic entries, is now linked to the LLLI web site and can be accessed by anyone wanting research information on breastfeeding.

It would not be appropriate for the Leader to get into the pros and cons of an actual procedure because such a discussion is outside our roles as Leaders and can be construed as LLL endorsing or criticizing a particular medical choice or procedure. Instead, Leaders refer mothers to their health care provider who can explain the possible risks and benefits of the procedure as well as answer questions relating to recovery time, pain medications and so on. We need to keep our focus on what we do best-sharing information about breastfeeding. We do that all the time whether the surgery is a circumcision or tumor removal or broken clavicle (collarbone).

The mother may have questions as to whether or not the separation such a procedure requires will interfere with establishing her milk supply. There can be the issue of trauma to the baby which may result in difficulty comforting the baby enough to get him to nurse. The mother may become anxious, resulting in problems with let-down or the baby picking up on her anxiety. But those are issues that may arise in many situations and those are what we as Leaders help the mother with, not the circumcision per se.

As with so many parenting choices, there are good reasons for Leaders to avoid sharing personal information because new mothers may take that as the definitive answer to their questions. In this situation, as with childbirth, an informed mother makes the best possible decisions for herself and her family. These choices will be based on a mother's beliefs, religion, or customs.

Although some people may not consider circumcision a religious issue, the fact remains that for some parents, it is. As a nonsectarian organization, La Leche League endeavors to avoid religious references, with or without disclaimers, that might make some parents feel unwelcome or uncomfortable. As stated in the American Academy of Pediatrics Policy Statement on Circumcision, "The percentage of male infants circumcised varies by geographic location, by religious affiliation, and, to some extent, by socioeconomic classification. Circumcision is uncommon in Asia, South America, Central America, and most of Europe. In Canada, 48% of males are circumcised. Some groups such as followers of the Jewish and Islamic faiths practice circumcision for religious and cultural reasons." Devorah Schesch-Wernick, a Leader in Israel, writes, "Jewish circumcision is performed by expert practitioners, on the eighth day after birth, or later if there are medical complications. At this age, breastfeeding is normally well established. In my personal experience of breastfeeding two sons, and in the experience of other Israeli Leaders, Jewish circumcision has no effect on breastfeeding."

In the 1981 edition of THE WOMANLY ART OF BREASTFEEDING under a section called "Elective Surgery for You or Your Baby," there was mention of circumcision as well as tubal ligation. However, it was omitted in all subsequent editions because these issues were considered mixing causes. We consider circumcision to be outside the realm of our expertise in La Leche League. Other organizations can do a better job of educating parents about circumcision than LLL. (See reference list below.) Because it is not, in and of itself, a breastfeeding issue, LLLI does not take any position on it, nor does the Board of Directors plan to issue any sort of policy statement about it. We see a distinction between making published statements in LLLI publications distributed worldwide and responding to mothers' concerns in the context of informal discussions at Series Meetings.

This is an important point to bring out at Series Meetings if mothers voice strong opinions on the matter. There are no specific rules about what to say or avoid about circumcision at an LLL Series Meeting. It is natural that this topic might come up as part of a discussion about childbirth decisions and the early days after birth. La Leche League welcomes all mothers who want to breastfeed, regardless of decisions about circumcision - and we rely on Leaders to present material and facilitate discussions with this idea in their minds and hearts. We want parents to be able to hear our message about breastfeeding without being sensitized by other issues. Each Leader knows the sensitivities of the mothers in her Group best. We rely on the Leader to bring the discussion back to the issue of breastfeeding and helping the mother decide what is best for her family.

Sincerely,
Cynthia Sherar
LLLI Board of Directors
Mahtomedi, Minnesota, USA

Judy Minami Western
United States Division,
Professional Liaison Editorial Advisor
Portland, Oregon, USA


Here are some questions that mothers might ask regarding circumcision and ideas about how Leaders might respond. Thanks to Leaders Ann Calandro, Waxhaw, North Carolina USA; Brandel Falk, Jerusalem, Israel; Devorah Schesch-Wernick, Efraim, Israel; and Karen Zeretzke, Baton Rouge, Louisiana USA, for providing suggested responses.

  1. I feel really strongly that children should not be circumcised and I've brought some information with me tonight that I think all of you should be aware of regarding this issue.

    [Name], it's evident that this issue is very important to you. Since LLL has no policy on circumcision - we focus only on breastfeeding - perhaps those who would be interested in your information could see you after the meeting?

  2. Why doesn't LLL have more information on circumcision? When I look in THE WOMANLY ART OF BREASTFEEDING, there isn't anything mentioned on this topic.

    Because La Leche League focuses solely on breastfeeding, there are many issues on which there is little or no LLL information. There are organizations whose function is to educate prospective parents about circumcision.

  3. You're worried about offending mothers who choose to circumcise? Well, this is one mother who chose not to circumcise who is deeply offended! My fourth baby and I stopped attending meetings, and I do not promote LLL the way I used to. Now you'll have to start worrying about the women you are offending by your silence on this matter.

    I am very sorry that you feel LLL let you down over the circumcision issue. We are a single-purpose organization whose focus is breastfeeding and don't feel that it is prudent for LLLI to take a position on this matter!

  4. What advice can you give me - we are planning to circumcise my son and I want to know how to minimize its effect on him?

    The majority of babies are sleepy at least twenty-four hours after birth. If they are already sleepy, and have not nursed well or often, the circumcision being performed early in the hospitalization may cause breastfeeding problems. As a mother and a patient, it is your choice to ask the physician to wait until the last hospital day to perform the surgery, or to ask if it could be done later. Also, you may request that the baby be brought back to you immediately if there is no prolonged bleeding. He will feel safer and more comforted in your arms and at your breast than he would in a hospital nursery. You can assure the nurses that you will check his bandage frequently and let them know if you see bright red bleeding. If you feel your baby is in pain, ask about pain medication in the early hours after the surgery.

  5. Who can you recommend to me? I need to find a doctor to perform my son's circumcision and want to find one who is supportive of breastfeeding.

    This would fall into the same category as recommending a doctor for any reason, which LLL does not do.

  6. I do not want my son circumcised and my husband does. My husband and all of his male family members are circumcised. They insist that our son also be circumcised, but I do not want to give in to their pressure tactics. I just cannot do this to my precious baby. This is causing me a lot of stress. I'm wondering if other mothers have run into this and how they dealt with it?

    Communication is the best tool to resolve differences. When strong opinions don't agree, sometimes a good place to begin is by reviewing what you both have in common: love for your son and the desire to make a decision you both can tolerate! You might also inquire on what basis the decision was made to circumcise those who are circumcised in your husband's family, and discuss together if those reasons are still valid.

  7. My son was circumcised yesterday and now I cannot get him to nurse. Things were going just fine before this was done. What do I do to get him to take the breast?

    It sounds like your baby is hurting. You might want to talk to your son's health care provider about pain relief while he is healing. Has he fed at all? It is very important that newborns are fed frequently and that you are maintaining your milk supply by hand expressing or pumping. Some mothers find that they can feed their babies who are unwilling to nurse their own expressed milk using a cup or a spoon. You could spend lots of time snuggling with your baby up against your bare breast, reminding him what he is missing. Once his discomfort decreases, it is likely he will again breastfeed well.

  8. Our son was not circumcised at birth, but now - at age four - his foreskin has still not retracted fully. He has not had an infection, but he does get sore occasionally. Our pediatrician says that he will eventually get an infection, and then the surgery will be even harder on him. Is it really necessary to put him through this now?

    La Leche League Leaders are trained and qualified breastfeeding counselors. This question is beyond the scope of the expertise of a Leader. If you are uncomfortable with information you have received from a medical practitioner, you may wish to consider getting a second opinion.

Abstract from the Circumcision Policy Statement (RE9850), March, 1999, American Academy of Pediatrics Task Force on Circumcision.

"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided."


References:

American Academy of Pediatrics: "Circumcision: Information for Parents" http://www.aap.org/family/circ.htm

American Academy of Pediatrics, "Circumcision Policy Statement." Pediatrics March,1999; 103: 3, 686-93. http://www.aap.org/policy/re9850.html

Popper, B. Babies and Children in the Hospital LLLI, 1998. Publication No. 527-24.

Popper, B. The Hospitalized Nursing Baby-Meeting the Needs of Mothers, Babies, and Families in Health Care Settings LLLI, 1998. Publication No. 388-19.

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