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)