G e o r g e H i l l 1323 North River Road Port Allen, LA 70767-3303 E-mail: DYKS96A@prodigy.com Tel: 504-383-8067 Fax: 504-381-8200 8 December 1997 Carole Marie Lannon, MD, MPH Chair, Task Force on Circumcision c/o Mr. Edward P. Zimmerman, Director Division of Physician Payment Systems American Academy of Pediatrics P. O. Box 927 Elk Grove Village, IL 60009-0927 Re: AAP Work Group on Breastfeeding Statement. Dear Dr. Lannon: As you know, the AAP Work Group on Breastfeeding has issued its official policy statement, Breastfeeding and the Use of Human Milk, in the December 1997 Pediatrics. This new statement highlights the importance of breastfeeding in promoting general child health. The statement contains two matters of interest in relation to circumcision. I would like to call your attention to these. Urinary Tract Infection We have known for seven years that breastfeeding causes a significant drop in the rate of UTI. The acceptance of this data by the Work Group on Breastfeeding underscores this information. The various retrospective studies by Thomas E. Wiswell in the 1980s failed to control for this confounding factor.[3,4] If there was any lingering doubt that these and other studies that fail to control for breastfeeding are invalid, it should be removed by this new policy statement. To the extent that circumcision contributes to breastfeeding failure, it is likely to increase the incidence of UTI and other diseases such as otitis media as described in the policy statement. Breastfeeding provides a proven non-surgical, risk-free method of reducing incidence of UTI and is thus much to be preferred to circumcision. Interference with Breastfeeding The Work Group on Breastfeeding states: Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized. Neonatal circumcision is the most obvious and frequently performed procedure that fits this description. Marshall et al., in a prospective study, observed that "a stressful, painful event such as circumcision, however still appears to affect the feeding patterns and general state behavior of infants who have recently undergone circumcision. Howard et al., in a prospective study, found that the "severe and persistent pain" of circumcision interferes with the initiation of breastfeeding. Howard reported, "Infants feed less frequently and are less available for interaction after circumcision. Furthermore, some neonates in the study required formula supplementation "because of maternal frustration with attempts at breastfeeding or because the neonate was judged unable to breastfeed postoperatively." (emphasis added) Taddio et al., in a prospective study, found that circumcision induces "an infant analogue of post traumatic stress disorder." Taddio describes circumcision a s a "traumatic and painful event." Circumcision is most frequently performed 12 to 48 hours after birth and in the same time frame that parents are attempting to intiate and establish breastfeeding. Failure to establish breastfeeding compromises the overall health of the child. Thus, it is appropriate to say, based upon the new policy statement of the AAP Work Group on Breastfeeding and the findings of Marshall, Howard, and Taddio: Circumcision is contraindicated because the pain and trauma of circumcision interferes with successful breastfeeding. Conclusion The AAP policy statement, Breastfeeding and the Use of Human Milk, shows that breastfeeding is of foremost importance in insuring overall child health. Breastfeeding is documented as providing a wide range of benefits to child health that far exceed the wildest claims that the most ardent advocates make for neonatal circumcision. Circumcision should not be allowed to interfere with the successful establishment of breastfeeding. Cordially yours, George Hill References 1. AAP Workgroup on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100: 1035-39. 2. Pisacane A, Graziano L, Zona G. Breastfeeding and urinary tract infection. Lancet 1990; 33:50. 3. Pisacane A, Graziano L, Mazarella G, et al. Breastfeeding and urinary tract infection. J Pediatrics 1992; 120:87-9. 3. Wiswell TE, Smith FR, Bass JW. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1985; 75:901-3. 4. Wiswell TE, Roscelli JD. Corroborative evidence for decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1986; 78:96-9. 5. Marshall, RE, Porter FL, Rogers AG, et al. Circumcision: II. effects on mother child interaction. Early Human Development 1982; 7: 367-374. 6. Howard, CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision. Pediatrics 1994; 93:641-645. 7. Taddio A, Katz J, Ilersich AL, et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997; 349:599-603.
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