I would appreciate any comments that you all would care to give me on the
following letter, which I am sending out to all the pediatricians and
family practice physicians in my area.  The impetus for this letter was a
"dressing down" I received on Saturday (from a doctor, but through a
nursery nurse) for counseling a couple to delay circumcision due to
problems getting their son started breastfeeding.  The letter is not nearly
as strong as I would like to make it, but it is a foot in the door.  Let me
know if there are changes you would suggest.  I did quote Ann Eglash, from
one of her contributions to our list, since our comments are public.  But
I've sent a private email to her to ask her permission, as well.  I think
the letter would be fine without the quote also.  Arly Helm

15 May 1995

Re:  Timing of Circumcisions


Dear Dr. ---------:

As you may already be aware, Logan Regional Hospital now has a lactation
clinic providing in-patient assistance in breastfeeding, out-patient
consultations, a telephone "Warm Line," and in-services for physicians and
nurses.  I work in the Lactation Clinic; my credentials include a master's
in nutrition (research in breastfeeding; thesis on hospital practices
affecting breastfeeding), Certified Lactation Educator, and Internationally
Board Certified Lactation Consultant.  I am a member of IHC's Breastfeeding
Project Team at the corporate level, meeting with other lactation
consultants, physicians, and administrators bi-weekly at Primary Children's
Medical Center.  In addition, I keep in contact with other lactation
consultants worldwide through daily discussions on a lactation specialists'
group on the Internet.  One of my goals is to work with patients,
physicians, nurses, and administrators to make Logan Regional Hospital a
center of breastfeeding excellence.

My own observation and that of other Cache Valley lactation consultants,
which has been corroborated by our colleagues on the Internet, is that the
timing of circumcisions can be problematical in the establishment of early
breastfeeding.  It has been our experience that most babies become quite
sleepy and many are difficult or impossible to rouse for breastfeeding for
several hours post circumcision.

This becomes a problem when the baby has not eaten well prior to the
surgery.  It is commonplace for our infants to have an alert phase after
birth, lasting 1 1/2 to 2 hours, followed by a sleepy phase of
approximately 8 hours' duration.  We will be working toward developing
hospital policies to support early breastfeeding during the first two hours
after birth.

We are anxious to get the baby breastfeeding well as soon as we possibly
can.  When the mother has inverted, semi-inverted, or flat nipples, or any
other of several nipple or breast structures which alone or in combination
present a challenge to the neonate we are particularly concerned about
getting breastfeeding off to a good start.  Because breastfeeding,
well-managed, corrects most inversions, most of those who present with
difficult nipples are also mothers with no previous breastfeeding
experience.

In these days of increasingly early discharge, our "window of opportunity"
for establishing breastfeeding is correspondingly diminished.  The
challenge to our lactation consultants is to ensure that each breastfeeding
dyad will, through our patient education, hands-on teaching methods, and
careful observation, assessment, and appropriate intervention, maintain
optimal health in this area.  A mother-infant pair who leave the hospital
prior to initiating breastfeeding or not yet having appropriate
breastfeeding skills may present at subsequent check-ups with excessive
weight loss, failure to stool or urinate, excessively high bilirubin, a
progressively sleepiness, or failure to thrive in the infant, and cracked,
bleeding or damaged nipples or mastitis in the mother.

As a general rule, the population of breastfed infants is healthier than
the population of artificially-fed infants, and thus breastfeeding is
endorsed by professional medical groups; higher rates of breastfeeding in
this country is one of the goals of the United States' "Healthy People
2000."  Breastfed infants are at lower risk for a wide spectrum of
illnesses and poor outcomes of various types. Yet breastfeeding often does
not proceed smoothly until the mother has acquired some knowledge in this
area.  It is a learned activity on both the mother's and infant's part.

Good nutrition is critical in the neonatal period.  As a lactation
consultant and nutritionist, I believe that it is more imperative that
those infants who have not yet become proficient at nursing receive
adequate breastfeedings, concurrent with teaching the mother and baby how
to feed, than to undergo an elective surgery at that time.

Unfortunately, the option of artificially feeding the infant while in the
hospital has been shown to decrease breastfeeding rates; with regard to
early discharge, it can usurp our only chance to teach breastfeeding before
the mother and baby leave the hospital.

The lactation consultants at Logan Regional Hospital (and the Budge Clinic)
would be happy to work with you in determining which babies are not good
candidates for early circumcision, based on their level of success of early
breastfeeding.  We would be willing to flag any babies who need more
breastfeedings and more time to get breastfeeding established before taking
the long break from feedings that circumcision generally entails.
Alternatively, we would be available to work with you in developing a
protocol for identifying babies who would benefit from delaying
circumcision.

This will likely result in more, though by no means all, babies being
circumcised in your office.  There may be some costs associated with this,
however, the costs associated with doing every circumcision soon after
birth I have already elucidated.  Some pediatricians who are routinely
doing circumcisions in the office have found benefits in it:

I am suspicious about early circumcision interfering with successful early
latch-on and nursing. So, when a family comes to me as a consult for me to
be the pediatrician, I often discuss (if they want a circ) timing of circs.
I have done the majority of circs in my office, at 3-8 days of age. I try
to encourage parents to at least wait until the baby is nursing well and
the milk is in...One other note is that doing a circ in the office is
calmer for me, and the room is quieter.  I have my own nurse who is
nurturing and not in a hurry, and the parents can go take a walk or go get
ice cream or whatever for 20 minutes.
Anne Eglash, MD

I hope that we can work together to find a way to support those babies who
need more time to get breastfeeding well underway.  I and all the other
lactation consultants in Cache Valley hope to be a valuable resource to
you, as you guide your patients through their first years of
parenthood/life.

Sincerely,



Arly Helm, MS, CLE, IBCLC
Lactation Clinic
Logan Regional Hospital
1400 N 500 East
Logan UT 84321

Lactation Clinic  750-5413
Women's Health Center  750-5376  (patient rounds, Mon-Sat, 9 AM-noon)
Pager  750-8117
email <[log in to unmask]>

[log in to unmask] (Arly Helm, LC)