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Bris - Circumcision and Anesthesia

Although the proper technique used by myself and other traditional mohalim takes approximately 10-30 seconds to perform, and there is "no crushing of tissue" involved (as compared with a hospital circumcision or one performed by a doctor/mohel that can take anywhere from 10-40 minutes), the pain is not as severe as techniques used by doctors [Shechet et al., 1998]. 

 

  • The actual incision is so quick and precise that subjecting the baby to the nerve block is more painful than the bris itself. 

  • The potential for side effects or extreme reactions--especially in newborns--is substantial.

  • Injections of anesthesia are unnecessary and tend to increase the level of discomfort of the baby. 

 

"It is, moreover, acknowledged that for Jews the traditional bris might be less traumatic than common institutional approaches [Lander et al., 1998]. Jewish Mohelim take 10 seconds, with 1 second for excision, and 60 seconds on average for crying; "  [​More here]

 

In a hospital it is required to give the baby a nerve block (two injections into the base of the penis) because of the length of the procedure that can take anywhere from 10-40 minutes. But regarding a bris, if done with proper technique the actual incision is so quick and precise that subjecting the baby to the nerve block is more painful than the bris itself.

 

Understandably, parents are still concerned about their baby's discomfort during a bris and wonder what can be done to minimize it.

 

Using a numbing cream (topical anesthetic) before the bris.

 

As a mohel who has successfully been performing circumcisions for over 27 years without such methods, I am deeply concerned that many parents have opted to use some of these products without doing the necessary research to determine if they are safe, effective, etc.

 

Parents should be aware of the following warnings and  information regarding using topical anesthetics: 

 

  1. In term newborn infants, infants and children, Topical creams should only be used on intact skin They are not to be applied to damaged skin or open wounds.  [More here]

  2. Possible side effects include: Redness, swelling, tingling/burning, or lightening of the skin may occur. [More here]

  3. Remove the cream and get medical help right away if any of these rare but very serious side effects occur: slow/shallow breathing, pale/bluish skin around the mouth/lips, dizziness, fainting, fast/slow/irregular heartbeat, mental/mood changes (e.g., confusion, nervousness), seizures, severe drowsiness. [More here]

  4. Reports of significant methemoglobinemia (20% to 30%) in infants and children following excessive applications of the cream.  [More here]

  5. EMLA  may be of little or no use in reducing the pain of heel pricks or venepuncture in newborn infants up to 3 months [More here]

  6. There are insufficient data to support the use of these products for circumcision in newborn infants at this time. There are no studies that adequately address safety or efficacy. The most extreme reaction to a topical anesthetic cream resulted in the death of an adult. [More here]

 

Mohalim personal experiences in performing brisses or circumcisions where the parents have decided to use topical anesthetic creams has shown:

 

  1. There is always much more bleeding after the bris and sometimes causes high blood pressure when a topical cream was used.

  2. Brissim had to be postponed because the circumcision site was severely distorted by swelling caused by the cream.

  3. The baby cries equally whether a topical anesthetic has been used or not. He cries when his diaper is removed and he is exposed to the cold air, and he also cries when his legs are briefly held or restrained. No anesthetic will prevent that.

  4. Topical creams need to be applied about 1 hour prior to the bris. Practically speaking, the mohel generally arrives between 15-20 minutes before the beginning of the ceremony, which means the family has to apply the topical anesthetic ahead of time, and they may be unsure how to do it correctly.

  5. If a family does choose to use an anesthetic cream, the mohel has to make sure it is completely removed from the circumcision area immediately before he performs the bris. Otherwise, the area is too slippery and may affect the mohel's ability to grasp the skin properly.

  6. Anesthesia is used in only 45% of circumcisions; the type of anesthetic varies. The most  common type used, a topical creme, does almost nothing to reduce the discomfort. The head of the Anesthesiology Department of a major New York hospital stopped the neonatology unit from using the topical cream before circumcisions. The reason she gave, and I quote, "It is dangerous and inappropriate."

Truthfully, the use of an anesthetic is more for the psychological advantage of the parents to relieve some of their anxiety in relation to the baby's discomfort. 

 

What about Infant Tylenol?

 

Tylenol can mask a fever. While fever after a bris is very rare, the one thing parents need to know about their infant at any time is if he has a fever so I do not recommend the use of Tylenol. In my observation, giving the baby Tylenol does not have that much affect on pain relief at all.

 

To conclude, I don't apply topical creams or use other means of pharmaceutical anesthetics when I perform brisses, and I generally advise against their use in the circumcision of newborns. As an Orthodox traditional Jewish mohel, I am religiously obligated not to cause harm in performing the mitzvah (commandment) of circumcision, and I employ an ancient and time-honored technique that has been used successfully for thousands of years.

 

However, if parents feel strongly that they do want to use a topical anesthetic, they may need a prescription from their doctor (although some of these topical creams are now available over the counter). Application instructions should be followed exactly, and parents should definitely inform the mohel before the circumcision takes place that they have used it.

 

So finally, what form of pain relief do I recommend?

 

Studies suggest that an infant sucking on an oral sucrose solution may provide as much comfort as topical creams. That is why hospitals routinely have the infant suck on a pacifier or gauze sponges soaked with sugar solution. At a brit (ritual circumcision) most people think the baby becomes drunk sucking wine. However, kosher wine has low alcohol content and a high sugar content. It is best to dilute the alcohol. The wine itself is a potent pain relief medicine for the children. Read the article here for information corroborating what mohalim always knew.

 

Before the bris, let the baby suck on a gauze pad soaked in concentrated sugar water. After the bris (during the "naming" portion of the ceremony), let the baby suck on a second gauze pad dipped in sweet kosher wine or grape juice. In my opinion, this is the safest and most effective approach to pain relief in a newborn both before and after the bris.

 

Most of all, be sure to use a Certified Mohel who will perform a circumcision in 20-30 seconds without the use of any tourturus clamping devices  ( e.g. Mogen, Gomco, Plastibell etc.). Parents will then be assured of a proper bris experience that will significantly minimize any pain for their son. 

 

 

 

 

 

 

Note: It is important for parents to investigate the use of topical anesthetics or other pain relief options. Many parents have opted to use some of these products without doing the necessary research to determine if they are safe, effective, etc. That is a decision for the parents in consultation with their pediatrician.

 

If you do decide to use a topical anesthetic, kindly inform me prior to the Brit Milah.

Poskim (Jewish legal authorities) have debated for more than a century the Halachic viability of general and local anesthesia for Brit Milah. Recently, Poskim have actively debated the use of a topical anesthetic at a Brit.  [More here]

 

In Summary

 

  • An injection of a local anesthetic is administered at almost all circumcisions of adults.

  • General anesthetic is used for an adult born Jew only in case of great need.

  • Poskim do not permit general anesthesia for an adult convert in virtually all cases. 

  • Rav Moshe Feinstein permits only a local anesthetic for an adult convert, but forbids a general anesthetic for an adult convert. 

 

Topical Anesthetics

 

There has been a mixed reaction by Poskim regarding its use at a Brit.

 

  • Rav Eliezer Waldenberg (Teshuvot Tzitz Eliezer 20:73) forbids its use (based on the Teshuvot Imrei Yosher 2:40). 

  • Rav Wosner of Bnei Brak (Teshuvot Shevet Halevi 5:147:2) also forbids the use of a local anesthetic on a baby except in case of great need.

 

Rav Wosner believes that absent great need one should not tamper with the traditional character of Brit Milah, which includes experiencing pain. He cites the Gemara (Gittin 57b) that explains the Pasuk (Tehillim 44:23) "For Your sake we are killed all of the day", to be referring to Brit Milah, as proof for his assertion.

 

On the other hand, Dr. Abraham S. Abraham (Nishmat Avraham 5:83-84) reports: 

 

  • Rav Yaakov Hillel, a Rosh Yeshiva of a prestigious Yeshiva for Kabala studies, investigated the matter and found no source in the Zohar and other Kabalistic works.

  • Rav Shlomo Zalman Auerbach and Rav Yosef Shalom Eliashiv told him that if there is no medical problem associated with the use of a topical anesthesia, it can be used.

 

Rav Moshe Feinstein (Teshuvot Igrot Moshe Y.D. 4:40) writes that we do not use anesthetics at a Brit because of the danger associated with anesthetics. His concern might apply to the topical anesthetic creams.

The Halachic View  On Anesthesia

Mazel Tov on the birth of your new child! May you merit bringing him into the covenant of Abraham.

 

Many people contact the Mohel well before the baby is born in order to become familiar with the many details involved in a Jewish circumcision (Bris Milah) and ceremony.

 

  1. Please submit the information form [here]

  2. Upon receipt of your information you will receive a "Bris-Milah package" which includes: Bris-Milah Parent Guide, forms to fill out and checklist of items that you will need to prepare for the Bris Milah .

  3. Upon the birth your child please contact Rabbi Markovits to finalize plans.