G e o r g e   H i l l
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                           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.[2]  The acceptance of this data[3] 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.[5]  Howard et al., in a prospective study, found that
the "severe and persistent pain" of circumcision interferes with the
initiation of breastfeeding.[6]  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)[6]  Taddio et al., in a prospective
study, found that circumcision induces "an infant analogue of post
traumatic stress disorder."[7] Taddio describes circumcision a
s a "traumatic and painful event."[7]

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.