Changes

}}</ref> Although ''E. coli'' is one of the most common bacteria on the surface of human [[skin]], strains found in hospitals tend to be particularly virulent. ''E. coli'' that live in the intestinal tract cause urinary tract infections when allowed to get into the sterile urinary tract. Whether [[intact ]] or [[circumcised]], baby boys sitting in poopy diapers allows ''E. coli'' an opportunity to enter the urinary tract. And, of course, fiddling with the [[foreskin]] and introducing bacteria foreign to the baby's body or his urinary tract can also cause UTI. The tight [[foreskin ]] of the infant boy acts as a sphincter to allow [[urine]] to flow out, but prevents contaminants and pathogens from coming in.<ref name="Fleiss 1998">{{FleissP HodgesF VanHoweRS 1998}}</ref>

}}</ref> Two interventions that put the male infant at immediate risk for UTIs are [[circumcision]], which removes the protection of the [[foreskin]], and [[forced retraction]] of the foreskin. These interventions tear away the synechia which binds the [[foreskin ]] to the [[glans]] in male infants, thereby creating entry points for ''E. coli'' bacteria,<ref name="Winberg 1989">{{REFjournal

}}</ref> Outerbridge (1998) pointed out that [[breastfeeding ]] is very effective in reducing incidence of UTI in both boys and girls.<ref name="Outerbridge 1998">{{REFjournal

Doctors and parents should refrain from touching a child's genitals as much as possible, as this could introduce E. coli into the urinary tract. When changing a child's diaper/nappy, parents should make sure their hands are sanitized, and be careful not to touch the area near the meatus (urinary opening) in either boys or girls. The insertion of parents' fingers into the [[foreskin]], or even the handling of a baby's penis, could introduce bacteria into the [[preputial sac| preputial space ]] of [[intact ]] infants.

Parents should be careful not to [[Forced retraction|forcibly retract]] the [[foreskin]] of a baby's [[penis]], and to instruct the child's doctor and/or caretaker likewise. The act of forced retraction involves forcible separation that destroys a structural defense mechanism; the [[synechia]] which binds the foreskin to the glans is torn away, which allows E. coli to invade where it could not before.<ref name="Winberg 1989"/>

As [[circumcision]] necessitates [[forced retraction]] of the [[foreskin]], additionally creating an open wound that is vulnerable to additional infection, parents are advised against circumcision.<ref name="Outerbridge 1998"/> These functions suggest that the [[intact]] prepuce may offer protection against UTI if undisturbed. The [[foreskin]] provides two physical lines of defense in the [[intact ]] male child, which are removed in [[circumcision]]: the preputial sphincter, which closes when a boy is not urinating, and a protected meatus (urinary opening), which is often inflamed and open in [[circumcised ]] boys.<ref name="Cunningham 1986"/> Recently, Fleiss et al. (1998) reviewed the immunological functions of the prepuce. In addition, the sub-preputial moisture contains lysosyme, which has an anti-bacterial action.<ref name="Fleiss 1998"/> Oligosaccharides excreted in the [[urine]] of breastfed babies prevent adhesion of pathogens to uroepithelial tissue.<ref name="Marild 1990"/>

}}</ref> Based on their observations of these old charts, they reported that [[intact]] boys had a slightly higher rate of bacteriuria (bacteria in the [[urine]]) than [[circumcised ]] boys during their first year of life, leading to the sensational statistic that [[circumcision]] resulted in a "ten to hundred times decrease in urinary tract infections in circumcised boys."

Wiswell's findings generated a great deal of controversy at the time. The prepuce (foreskin) is a protective organ, and one would not normally expect the removal of a healthy organ to reduce the risk of infections.<ref name="Cunningham 1986"/> Nevertheless, the apparent correlation of intact foreskin to bacteriuria (and hence UTI) prompted the [[American Academy of Pediatrics ]] (AAP) to review the evidence available in 1989.

}}</ref> so the majority of its young male client population would have necessarily remained [[intact]]. The observation that 95% of the boys were not circumcised, therefore, indicated nothing more than that the majority of male infant patients at Parkland Hospital were not circumcised.

* Breastfeeding is a major confounding factor in any study of the role of [[circumcision ]] in UTI. The Wiswell studies and all other studies in the literature fail to control for the effects of breastfeeding. The AAP observes that "breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status."<<ref name="Sreenarasimhaiah 1998"/>

Wiswell's sensational statistic, that [[circumcision]] resulted in a "ten to hundred times decrease in urinary tract infections in circumcised boys," has often been quoted; however, it is misleading. In fact, UTIs are so rare in either case that,even giving Wiswell's data the benefit of the doubt, 50 to 100 healthy boys would have to be [[circumcised ]] in order to prevent a UTI from developing in only one patient. Using more recent data from a better-controlled study, the number of unnecessary operations needed to prevent one hospital admission for UTI would jump to 195.<ref>{{REFjournal

}}</ref> In a prospective study, Kayaba et al. found a zero incidence of UTI in 603 [[intact ]] boys, over a range of ages.<ref>{{REFjournal

The American Academy of Pediatrics (AAP) formed a 1989 task force under the chairmanship of the late [[Edgar J. Schoen]] to reconsider its 1975 policy statement. This task force issued a statement in 1989 which cited the UTI papers of circumcision promoter [[Thomas E. Wiswell]] as a reason that one might circumcise a child., but it included a disclaimer. The report stated:

The [[American Academy of Pediatrics ]] (AAP) has issued two statements which, when read together, constitute a substantial change in AAP policy toward the prevention of UTI in infants. First, in 1997, the AAP Workgroup on Breastfeeding recommended [[breastfeeding ]] as highly beneficial in preventing a wide range of infections including UTI.<ref name="AAP 1997">{{REFjournal

The 1999 AAP Task Force on Circumcision did, however, declare that breastfeeding produces a three fold reduction in UTI in infants. Two separate panels of the AAP, the Work Group on Breastfeeding and the 1999 Task Force on Circumcision, now recommend [[breastfeeding ]] to reduce incidence of UTI.<<ref name="AAP 1997"/><ref name="AAP 1999"/>