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Neonatal Male Circumcision and Breastfeeding: Does Timing Matter?

MMMM d, yyyy

Elective circumcision in male infants is a fairly hot topic in newborn medicine and despite being a very common procedure, many individuals and groups still question its purpose. The main drivers for most parents who choose to circumcise their male infant are familial, cultural, and ultimately, personal. Neonatal circumcision in the US is most often performed in the well-newborn unit prior to hospital discharge. In fewer male infants, the procedure is completed as an outpatient in the first couple of weeks of life. A major part of the relatively short birth hospitalization following an uncomplicated delivery, is establishing feeding between the mother-infant dyad. Anecdotally, many newborn hospitalists, myself included, note a decreased interest in feeding and more sleepiness after a circumcision and have wondered if the timing of the procedure affects breastfeeding.

Mondzelewski et al attempt to answer this very question in this month’s Hospital Pediatrics (10.1542/hpeds.2021-006400). Investigators conducted a randomized clinical trial (RCT) across 3 sites. Male otherwise healthy newborns undergoing circumcision were randomized into 3 groups depending on the timing of circumcision: “early” (between 6-24 hours of life), “intermediate” (>24 and <72 hours of life and before hospital discharge) and “late” (between 1-3 weeks of life). Outcomes studied were exclusive breastfeeding at various time points. As expected, exclusive breastfeeding rates at 6 months declined in all 3 groups but the rate of decline was lowest in the “early” group. The authors concluded that infants circumcised at <24 hours of life were more likely to be exclusively breastfed from 2 weeks through 6 months of age (compared with infants circumcised at 24-72 hours of life), and delaying the procedure after 1 week did not greatly improve exclusive breastfeeding rates. Intrigued? I strongly suggest reading the paper for more details.

In an accompanying commentary, Weinberg et al recommend caution when interpretating the study findings (10.1542/hpeds.2022-006614). Breastfeeding is a complex endeavor with many individual and system-level confounders and biases that are difficult to fully control for despite an RCT study design. The authors of the commentary point out an important consideration to how “successful” breastfeeding is defined and highlight numerous additional maternal, child, resource, cultural, and access factors that can influence breastfeeding success.

I have no doubt that newborn hospitalists will read Mondzelewski et al’s study with great interest. Although Weinberg et al do not foresee an immediate shift in recommending circumcisions to be performed in the first 24 hours of life as a result of this study, we now have more information than before and perhaps, more questions.

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