Is Infant Circumcision Incompatible With Breastfeeding?

Is circumcision the ‘Voldemort’ in a conversation about early breastfeeding difficulties? Though it’s a studied certainty that infant circumcision can have ruinous effects upon breastfeeding, it seems only the rare or high-profile breastfeeding expert dares to mention this risk by name, much less maintain an official protocol for assistance if challenges arise.

When I was pregnant with my oldest baby, I knew I wanted to breastfeed. It’s the recommended form of infant feeding by all national medical organizations, it’s healthy, it’s cost-effective, it’s a biologically normal extension of the childbearing process, and many would argue, it’s vital.

I pledged to know as much as I could about breastfeeding before that first latch. And I discovered a lot — I mean, my head was so jammed full of breastfeeding tips and factoids you’d have thought my brain was engorged with milk, too. I was without the courage to admit it aloud, but I badly longed for breastfeeding to work.

Early on I found out my baby’s sex: a boy. I thought about which name he would like. It was an important decision to make after all, and I obsessed over lists of boy names. Then I realized there was one another decision I needed to make based on his sex: would I opt to have his foreskin surgically removed? Suddenly the issue of his name was mere child’s play. He could always change his name if he disagreed with my choice, but what would happen if he disagreed with my choice in the matter of his foreskin’s fate?

In my continuing quest for breastfeeding knowledge, I noticed something peculiar. I must have read a mountain’s worth of breastfeeding books and articles about situations that are incompatible with breastfeeding, but so far not one of them had directly mentioned circumcision.

Apparently different foods, medications, pacifiers, even things like nipple piercings can influence breastfeeding. Separating a mother and baby after birth can influence breastfeeding. Birth trauma and early adverse events can influence breastfeeding. Prolonged newborn sleep periods can influence breastfeeding.

So what about circumcision?

What about when a baby is removed from his mother shortly after birth, often hungry or tiring (as newborns cycle through these needs for food and sleep very quickly)? When he is taken to the surgery room, restrained to a cold board, and experiences what can only be accurately described as an adverse event: his genitals are manipulated, probed, torn, and cut, often without any anesthesia or otherwise with pain relief that is proven to be inadequate for amputative surgery, especially for newborns who feel pain more acutely than adults?

What about when he is returned to his mother so exhausted or shocked by what just transpired, he can’t help but fall into a prolonged period of sleep that his mother is reassured is “normal”? And when he attempts to recall or learn the mechanics of eating while a fresh genital wound painfully chafes and burns inside his diaper?

What about when circumcision is incompatible with breastfeeding?

What Studies Say

Since 1982, studies have corroborated the link between breastfeeding difficulties and circumcision. A breastfeeding relationship thrives on mutual comfort, minimal stress, and low interference (and sometimes suffers a fatal hit with just a single incidence of interference, if the resulting troubles cannot be swiftly  overcome). Circumcision, like any early adverse event, is an interference upon the biologically normal birth and postpartum experience.

Effects On Bonding

In this study, it was found that four hours after circumcision surgery, 90% of the observed babies “reacted to stimuli differently than they had pre-operatively. Approximately half of the infants became more active, agitated and fussy following circumcision, and half more subdued, drowsy or sleepy.”

The follow-up study focused on how circumcision might affect breastfeeding. Commentary included “infants eyes were typically closed (71%), had neutral facial expressions (91%), did little vocalizing (8%), clinging (13%), or even feeding (40%).”

Researchers observed “immediately following circumcision there were differences in the feeding patterns between the two groups.” Alas, “circumcision has brief and transitory effects on mother-infant interactions observed during hospital feeding sessions, the only time mothers who are not rooming in have to be with their infants.”

Incidence of Bottle Supplementation

In twenty years’ worth of research, it was found that babies who are kept whole are less likely to be supplemented with formula. This is significant when we consider the documented negative consequences of early supplementation for breastfeeding success.

Babies who were given bottles in the previous study were described as “suck[ing] on the bottles harder, faster and more concertedly” and “seemed to `tune out’ external distractions.” Supplementing with bottles is not an uncommon practice after circumcision because nursing on the breast requires more of a baby’s physical effort than bottle-feeding, thus may be easier for him to quickly fill his belly when already in a state of combined hunger and stress.

According to this study authored by Cynthia R. Howard, MD; Fred M. Howard, MD;
and Michael L. Weitzman, MD:

“Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration.”

According to a section on normal breastfeeding patterns in The Breastfeeding Answer Book by Nancy Mohrbacher, IBCLC and Julie Stock, MA, IBCLC:

“When a baby undergoes a painful medical procedure, such as a heel stick, injection, spinal tap, or circumcision, he may shut down and be unreceptive to feedings until he is feeling better. Vigorous suctioning of a baby’s mouth can also cause a sore throat and injured vocal cords, which can cause a baby to reject anything by mouth for a time.”

Pain Management Is Ineffective

This study on acetominophen analgesia as infant circumcision pain management warrants interest as well. Babies were given either acetominophen or a placebo before Gomco circumcision and in regular intervals for 24 hours afterward.

“Neonates in both groups showed significant increases in heart rate, respiratory rate, and crying during circumcision with no clinically significant differences between the groups.[…] Feeding behavior deteriorated in breast- and bottle-fed infants in both groups, and acetaminophen did not seem to influence this deterioration.

“Infants feed less frequently and are less available for interaction after circumcision. Subdued, less interactive behavior has been documented frequently. …Because most hospital discharges occurred 7 to 10 hours after circumcision, the data are inadequate to assess the duration of the effects on feeding. Neonatal circumcision are often performed on the day of discharge with many neonates leaving the hospital 3 to 6 hours postoperatively. Thus the observed deterioration in ability to breast-feed may potentially contribute to breast feeding failure.” – Cynthia R. Howard, MD; Fred M. Howard, MD; and Michael L. Weitzman, MD

Effects On Sleep

Further research shows sleep patterns are disrupted by circumcision with prolonged periods of non-REM sleep. What does sleep have to do with breastfeeding? When a baby sleeps excessively (‘recovery sleep’ after the energetic and emotional depletion of undergoing surgery) or poorly (unable to sleep due to pain), he’s afforded little to no opportunity for actively learning how to latch, or for socializing and bonding with his mother, both of which are paramount for the normal hormonal processes that enable ample milk production and a responsive milk ejection reflex.

Many babies reportedly leave the circumcision surgery room in a weakened state, unable to latch as well as they had before. Or they’re in such pain that they seek persistent comfort at the breast, nursing constantly enough to interfere with the mother’s own birth recovery. During this time, babies are observed in withdrawal from the world when they need to bond with and gain trust in their caregivers.

Effects on UTI Risk

It’s interesting how exclusive breastfeeding is shown to protect babies of both sexes against urinary tract infections (UTI), and how the presence of foreskin likewise has been shown to harbor the same UTI-defense properties. Why is breastfeeding touted for this protective factor yet no such thanks is customarily granted to the same function of foreskin?

One frequently cited study did show a statistically insignificant increase in UTI risk for intact male babies under one year of age. However, this statistic can be lowered if no forcible retractions occur and if the genital area isn’t vigorously or invasively cleaned. Exclusive breastfeeding for the first six months of life can reduce this already small risk of UTI for all boys, another reason why getting off to a good start with breastfeeding is ideal.

After this age the relative risk is virtually the same for both circumcised and intact male children. Females have a much higher lifetime risk of UTI (9.22% compared to 1.29% for intact males and 1.27% for circumcised males), but the standard protocol is to treat their cases with antibiotics, and for prevention we turn to exclusive breastfeeding and conservative cleaning practices instead of amputation.

 

What Experts Say

In a letter to Journal of Human Lactation entitled “Breastfeeding must be given priority over circumcision,” George Hill expressed concern over the minimal attention given to circumcision’s deleterious influence upon many breastfeeding dyads.

One lactation consultant confided to me that she feels saddened to witness this harm cast upon breastfeeding relationships but feels intensely terrified to bring it up with her clients. It is too taboo, too controversial, so enmeshed in cultural conscience that she worries she could risk her position by overstepping a boundary, for appearing judgmental or shaming.

Her observations echo those of others in the same field, such as a registered nurse and IBCLC who wrote this letter about noticing that boys who were circumcised before breastfeeding establishment “have more problems with breastfeeding” than their intact peers — even after traumatic births.

Thankfully some individuals who work closely with mothers and babies in the birth community do speak up. Written by a nurse with 19 years of experience with nursing mothers:

“Breastfeeding is often irreparably damaged by circumcision. At the time of most circumcisions, many mothers and babies are barely getting the hang of breast feeding and the baby is sometimes literally torn off the breast for his journey to the circ room. When he comes back, he is often in shock, in a deep sleep, and unarousable, or so irritable that he is inconsolable and will not take the breast, making the offer of a bottle by a healthcare professional more likely to be accepted. The main thing with getting breastfeeding going is uninterrupted exposure of baby to mother. They are one. Anything not crucial to sustaining life should be avoided. This is a huge concern in the pro-breastfeeding community.”

A trip down memory lane in the history of breastfeeding advocacy brings us to one of the first published warnings about circumcision as a source of nursing complications. La Leche League International (LLLI) cautioned in the 1981 third edition of The Womanly Art of Breastfeeding:

“[C]ircumcision is elective surgery and you have a choice of whether or not to have your baby circumcised.[…] Circumcision is as painful a procedure to a newborn as it is to an adult.[…] The most important reason for deciding against elective surgery following childbirth is that it interferes with a mother and her new baby being together and getting to know each other.”

In attempt to rescue a failing breastfeeding relationship, Leaders are encouraged to inquire about circumcision status in situations wherein a young male infant is having otherwise unexplained breastfeeding difficulties. An excerpt from Leaven, a publication for educational training of Leaders:

“Unquestionably, many babies are circumcised and go on to breastfeed without difficulty. But for some, the pain after circumcision may cause just enough disruption to interfere with the breastfeeding relationship. When a Leader is contacted by a mother whose male infant is having difficulties with breastfeeding, it may be appropriate to ask about circumcision.”

One Leader penned a letter to Leaven hoping to learn why circumcision isn’t covered in greater detail in current LLLI materials. The response does concede to the potential for injuriousness:

“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.“

Yet still, it is further explained that the earlier warning about circumcision was removed from subsequent editions of The Womanly Art of Breastfeeding because “these issues were considered mixing causes.” Alas, as further evidence of the popular proclivity to handle this topic with kid-gloves, a “protracted discussion” about circumcision between Leaders and mothers is now discouraged.

What Parents Say

If too many experts in the pediatric and breastfeeding communities hesitate to openly advise about this, who will?

As my nursing journey continued I visited breastfeeding support forums with increased frequency, and this is where parents’ tragic personal accounts emerged from the woodwork. I saw informal yet emphatic advice from birth workers and seasoned parents warning new mothers about the wrench that may be thrown into their nursing efforts by this unnecessary procedure, older counsel that had suspiciously quieted as the circumcision rate rose alongside the controversy associated with questioning it.

Several of the mothers interviewed in the article “18 Times Parents Wished They Hadn’t Circumcised Their Baby” insist circumcision interfered with their ability to breastfeed. For one of the mothers, a nursing strike after circumcision led to struggling with a nipple shield for the next three months. For another, her baby’s “latch was impaired when trying to breastfeed” due to pain that would unfortunately become his norm for the coming months.

Then a woman referred to as “The Nurse Who Couldn’t Nurse” shared how her son “struggled to breastfeed [after circumcision], and she remembers him being inconsolable and wailing during diaper changes. To this day, she blames circumcision for why their breastfeeding journey was cut short and she wasn’t able to share that bond with her baby.”

In a letter to NOCIRC of North Carolina, a mother wrote:

“I took my newborn son home and listened to him scream in pain for five days until his throat was hoarse. I struggled to comfort him and to encourage him to nurse. If I had not hired a Lactation Consultant five days a week for two weeks, I doubt I would have succeeded in breastfeeding my son.”

Of course, perhaps just as many mothers assert they went on to breastfeed their babies just fine after circumcision. While in many cases certainly possible (no two birth and postpartum experiences are equal), we cannot discount the validity of accounts by those who undoubtedly did relate their feeding troubles to the impact of circumcision.

It also stands to reason that the blurry, highly emotional days post-birth are not best for serving parental memory. Some who claim an unaffected baby may not recall the full picture as it were, especially in hindsight; likewise, they may have failed to connect the dots between fussiness, attributing it to ‘normal newborn behavior’ instead of pain, or explaining later-term agitation during the recovery period as baby’s communication of another less likely need. The overzealous nursing of some recently circumcised babies may be dismissed by their parents as simply very hungry babies instead of an abnormal desperation for more comfort.

JESSICA’S STORY

“Day one was perfect. He was latching, he was sleeping, he was everything I imagined my firstborn would be. Perfect in every way. The next morning, they came and took him for his circumcision. I knew just briefly what it meant — they would take some skin off the tip of his penis. But it didn’t feel right in my stomach. And I should have listened to that feeling. He came back sleeping. He did wonderful, they announced! They said it was a perfect procedure, he did great, he was already over it.

Later that evening, he seemed so fussy. He wouldn’t latch. He didn’t want to be at the breast or held. Nurses came in and announced that he had lost too much weight and [we] needed to supplement. He wasn’t latching anyways and I didn’t want them to admit him another night. So, the bottle was given. And he never looked back. I got home with my baby and quickly became engorged. I never attributed him refusing the breast all of a sudden as part of the pain he was experiencing with the circumcision. I figured I was ‘broken.’ After a week of pain that we both experienced, his wounds healed and my milk dried up.[…]

[I]t became quickly clear that I had made a choice I couldn’t take back. And it became even clearer that the reason he didn’t latch following his circumcision was more than likely not my fault. […] Then, regret set in. What had we done? The best we could and all we knew. That’s what.[…]

My second son [who was not circumcised] is just shy of 15 months old, and still a boobie monster. He has never had a single issue nursing (nor has he had any issues being left intact). Don’t fix what’s not broken is my rule of thumb!!” – Jessica Mace

MICHELLE’S STORY

“I don’t remember much from that day except that my baby was very unhappy. He did not latch well (if at all) after being cut, but breastfeeding was one of the things I was very adamant on. My baby boy seemed to not know what to do and when he did latch on, he would frantically suck until I began to bleed. It was awful. I would beg the nurses to help me latch him on correctly every hour, and they all said he was latching fine. They got very annoyed with me after a couple hours of this. I cried and cried, telling them I know something was wrong. Looking back, I have NO idea how I did not connect the dots. My baby boy was in pain!

When my son turned 3 weeks old, it was the first time I was able to finally latch him on properly. Up until then, I was pumping around the clock. Our first three weeks as a mother/child dyad were spent pumping, bottle feeding, and being very stressed out. All I wanted in the world was to cuddle and nurse my precious baby boy. My son was clearly upset most of the day and night post-circumcision, and still, I did not understand why.” – Michelle Merritt (read her full story here)

Prevention of Circumcision-Related Breastfeeding Problems

Studies have shown that when circumcision surgery is delayed until after breastfeeding has been well-established, the negative effects upon feeding are lessened. That said, the American Academy of Pediatrics (AAP) warns that painful or stressful procedures should be avoided whenever possible as they can interfere with breastfeeding initiation. Avoided — not delayed.

In this policy statement, the AAP states:

“Some common painful minor procedures, such as circumcision, do not always receive the warranted attention to comfort issues. Available research indicates that newborn circumcisions are a significant source of pain during the procedure and are associated with irritability and feeding disturbances during the days afterward.”

National health organizations around the world acknowledge circumcision to be a cosmetic, medically unnecessary procedure. Did you know that none of them recommend routine infant circumcision, yet all recommend breastfeeding as a health imperative?

“Prospective parents should be warned in advance of circumcision’s interference with breastfeeding. While current informed medical opinion does not support the practice, some parents, however, still have their baby circumcised. In this case, the circumcision should be avoided at least until breastfeeding is well established. Such a recommendation should be a part of all printed material regarding breastfeeding that is provided to expectant mothers in advance of delivery and should be volunteered by lactation consultants in every pre-partum counseling session.” – George Hill

So what are the entirely foolproof ways to evade the trap of circumcision-related breastfeeding complications? There is only one way: opting out of the elective surgery.

READ MORE:

• “Acetaminophen analgesia in neonatal circumcision: the effect on pain” – from Pediatrics
• “Breastfeeding & Circumcision” – DrMomma.org
• [Breastfeeding Problems After Circumcision] – from Leaven: La Leche League Journal For Leaders
• “Circumcision and Breastfeeding (Resources)” – KellyMom
• “Circumcision & Breast-feeding” – Circumstitions
• “Circumcision: effects upon newborn behaviour. A controlled blind observational study” – from Pediatric Research
• “Circumcision I: effects upon newborn behavior” – from Infant Behavior and Development
• “Circumcision II: effects upon mother-infant interaction” – from Early Human Development
• “Circumcision vs. Child Health, Breastfeeding and Maternal Bonding” – CIRP
• “Elective Surgery for You or Baby” – from The Womanly Art of Breastfeeding, 3rd ed.
• “How the Foreskin Protects Against UTI (urinary tract infection)” – DrMomma.org
• “Letters to LLLI: Circumcision and Breastfeeding” – from Leaven: La Leche League Journal For Leaders
• “The Assessment and Management of Acute Pain in Infants, Children, and Adolescents” – Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics; Task Force on Pain in Infants, Children, and Adolescents, American Pain Society
• “The Effects of Circumcision on Breastfeeding” – DrMomma.org