LLLI: Circumcision and Breastfeeding

Note:

A plain-English translation: In this statement, LLLI representatives Sherar and Minam, in effect, advise LLLI Leaders that they are not to disclose information about the effect of circumcision on breastfeeding initiation unless pressed to do so. They say that this LLLI policy has been adopted for political reasons. Although LLLI is well aware that the pain, stress, and trauma that result from male neonatal non-therapeutic circumcision does cause difficulty in the initiation of breastfeeding of many circumcised baby boys, LLLI Leaders are instructed to not disclose this very relevant information unless pushed by a mother to do so.

It seems, therefore, that the average mother who asks for information from LLLI is unlikely to receive this necessary information about the problems that may be caused by male non-therapeutic circumcision unless she asks the exact, very specific questions that will draw out the information. LLLI ignores the AAP statement Breastfeeding and the use of Human Milk which pointedly states Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized.

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 LLI 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 the 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.

Thank you for your letter regarding infant circumcision. It is a topic that is of interest to many mothers—and one of many issues [ Note: The authors here euphemistically misuse the word issue to refer to an intentional surgical injury to a newborn baby that causes pain, stress and trauma.] that can have an impact onthe 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 effect 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 publication 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 in for the Professional Liason 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 website and can now 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 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 a tumor removal or broken clavicle (collarbone).

The mother may have questions as to whether 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 letdown or the baby picking up on her anxiety. But these 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 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 decision possible for herself and her family. These choices will be based on a mothers 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 non-sectarian organization, La Leche League endeavors to avoid 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 infants are circumcised. Some groups such as followers of the Jewish and Islam faiths practice circumcision for religious and cultural reasons. Devorah Schesch-Wernick, a Leader in Israel writes, Jewish circumcision is performed 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 expertise in La Leche League. Other organizations do a better job of educating parents about circumcision than LLL. (See references below.)

Because it is not, in and of itself, a breastfeeding issue, LLLI does not take a 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 mother's 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 mind and hearts. We want parents to be able to hear our message 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.

Judy Minami
Western United States Division
Professional Liason 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.

References

American Academy of Pediatrics: Circumcision: Information for Parents www.aap.org/family/circ.html
American Academy of Pediatrics: Circumcision Policy Statement Pediatrics March 1999; 103: 3, 689-93. 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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LLLI: Circumcision and Breastfeeding

Letters to LLLI

References