Circumstantial: An Evaluation of Circumcision, Breastfeeding, and Overall Dyad Success

Male circumcision is a common practice in the United States¹  and one of the most common newborn procedures in the world.²  Male circumcision decreases the risk of urinary tract infections,³  sexually transmitted infections, and penile and cervical cancers. The American Academy of Pediatrics Circumcision Policy Statement from 2012 asserts that the preventive benefits of neonatal circumcision outweigh the risk of the procedure.^2,4  Additionally, the circumcision procedure itself is considered safest in the neonatal period^5–7  because of the use of local anesthesia alone, absence of the need for suture use or removal, minimal procedural costs, good cosmetic outcomes, and fast healing. Despite these reported benefits, male circumcision remains a polarizing procedure.⁸  Controversy around whether to perform male circumcision can even exist within a medical team or family unit. Broadly, the risks of circumcisions include bleeding, decreased feeding that can be associated with hyperbilirubinemia,^9,10  procedural complications requiring the need for increased medical resource utilization, and a need for circumcision revisions. Meanwhile, breastfeeding parents, lactation consultants, and clinicians attempting to provide family-centered care often worry about the pain associated with circumcision and its impact on an infant’s next feeds, maternal milk supply, a family’s ability to bond, and overall familial stress.

Numerous studies and many physicians attempt to identify male circumcision as a negative factor that might impact breastfeeding success. Because circumcisions often take place during the pivotal first days of newborn life as breastfeeding is being established, it is reasonable to question whether circumcision might affect breastfeeding success. The study by Mondzelewski et al¹¹  in this month’s Hospital Pediatrics sought to answer this conundrum. Using a randomized control trial study design, the authors randomly assigned 148 maternal–infant dyads into an early circumcision group (<24 hours), intermediate circumcision group (24–72 hours and before hospital discharge), or late circumcision group (1–3 weeks after birth as an outpatient). The authors assessed exclusive breastfeeding duration at discharge, 2 weeks, and at 2, 4, and 6 months. They found that infants randomly assigned to the intermediate group were at a statistically significant increased risk of not being exclusively breastfed at 6 months compared with the early and late groups. These are interesting findings and advance the field by using a more rigorous randomized control trial study design to answer a clinically relevant question.

Although circumcision may influence breastfeeding success, care should be exercised when interpreting these findings. From a statistical perspective, it is important to consider if there were demographic characteristics associated with the loss of follow-up between the groups that might influence the outcome. Given the unblinded assessment of the outcome, there is a concern for measurement bias (as the authors discuss) as well as a desire for social desirability among study participants potentially leading to higher reports of breastfeeding prevalence. Mechanistically, there is not a clear link to the timing of circumcision with the most frequent reasons for breastfeeding cessation being “perceived inadequate milk supply” and “maternal choice”. There are many complex drivers of breastfeeding success that are difficult to fully account for in any study. Despite a rigorous study design, accounting for all of these complexities and potential confounders is challenging and we cannot help but continue to question what role circumcision really plays in breastfeeding success.

“Successful” breastfeeding is also a difficult construct to define and is complicated by the many factors that influence it. Breastfeeding success has been defined as effective and exclusive milk transfer from mother to infant without the use of artificial milk substitutes.¹²  Yet, successful breastfeeding often means something different to each breastfeeding mother, newborn, and family. Success can be defined as infant weight gain, minimal supplementation, breastfeeding for the infant’s first year of life, financial savings, maternal wellness, or immunity transfer. Some, and certainly not all, of the factors that influence breastfeeding success include maternal anatomy, mode of delivery, maternal baseline health conditions, maternal mental health, maternal familial and partner support, maternal desire, maternal confidence in breastfeeding ability, infant gestational age, infant anatomy, infant oral coordination, infant health and interventions for conditions such as neonatal hypoglycemia or hyperbilirubinemia, maternity leave policies, work responsibilities and employer expectations, access to medical care, and availability of certified lactation consultants.

We appreciate Mondzelewski and colleagues’ work in this area, including their previous observational study¹³  and this prospective randomized trial to examine if the age at which a newborn is circumcised impacts breastfeeding outcomes. The authors appropriately acknowledge that there are multiple factors that contribute to breastfeeding success and recognized that their inability to account for all of them was a limitation. However, with many unmeasured confounders impacting the association between circumcision and breastfeeding, more studies are needed to better account for confounders. Additionally, the relevant clinical utilization of the statistically significant findings from the most recent Mondzelewski et al¹¹  study is challenging. Despite the finding that infants circumcised in the 24- to 72-hour group have a statistically significant increased risk of not exclusively breastfeeding at 6 months compared with those circumcised at <24 hours or at 1 to 3 weeks, we do not foresee recommending that parents of infants who are unable to be circumcised in the first 24 hours of life (due to workflow limitations or parental preference) return for an outpatient circumcision at 1 to 3 weeks. This is neither convenient nor family- or infant-friendly. As was noted in the study, some of the families randomly assigned to the 1 to 3 weeks group opted out. Intentional delay of circumcision to 1 to 3 weeks after delivery would likely lead to missed or late (>1 year) circumcisions that have downstream effects related to increased health care utilization and unnecessary anesthesia for these children.

Although the researchers studied an important question asked by many newborn clinicians, we recommend expanding the focus to include the impact of culturally competent care, shared medical decision making, the availability of interpretation services for non-English speaking families, adequate education and anticipatory guidance related to the newborn period, and maternal, familial and societal support structures. Although these elements of newborn care are challenging to study, they are instrumental in facilitating a therapeutic postpartum experience that enhances dyad bonding so that the health care system can better support families to initiate and maintain breastfeeding success.

The decision to breastfeed, much like the decision to circumcise, is deeply personal and is impacted by a complex interplay of medical, familial, and societal factors. We recommend interpreting the results of this recent study with caution given the multifactorial drivers that influence breastfeeding and urge researchers to examine measures and policies that target a more holistic approach to breastfeeding success.