Raising bar on bris practices — Your Health 2-13-09



By Rabbi Avi Billet

Issue of Feb. 13, 2009 / 19 Shevat 5769

Relative to other surgeries, bris milah is a simple procedure, with a surprisingly low risk rate. At the same time, an incision, an open wound and the removal of skin tissue necessitate precautions which will minimize danger to the child. The parents and the mohel must be on the same page on this latter point.

In an operating room, a surgeon takes many precautions to minimize the chance of bacterial infection reaching the patient. Mohels should be held to these same standards when operating on infant boys. It is understood, of course, that the public nature of the ceremony makes complete sterility an impossibility. Nonetheless, we are a far cry from where standards should be.

The sterility litmus test can be broken down to five components: how instruments are sterilized, how they are laid out for bris use, how the mohel cleans his hands, whether sterile gloves are worn when dealing with the open wound and how metzitzah is done.

Surgeons sterilize packaged instruments in a machine at 273° Fahrenheit, and avoid opening the “sterility guaranteed” package until surgery time. Mohels should do the same. Cold sterilization in a solution or in rubbing alcohol is less than ideal, and the five minute soaking some mohels employ before the bris is substandard. It may produce a nice alcohol aroma, but real cold sterilization requires hours of soaking to be completely effective.

Instruments laid out on a freshly laundered diaper cloth may be quite comfortable, but they have lost any claim of sterility. A pre-packaged sterile drape is easily accessible and should be standard for every mohel to use.

A mohel who washes his hands and is careful not to shake others’ hands should be commended. But when he adjusts his pants, head-covering, lab coat or tallis, not to mention his instrument bag or a bottle of wine while laying out instruments, he has negated any previous hand washing.

Some mohels will operate with bare hands “sterilized” by alcohol or Purell. Nice as this is, touching the pillow, baby, sandak, and baby’s diaper make previous efforts meaningless. Additionally, it is virtually impossible to completely clean under the fingernails, unless (with a big ‘perhaps’) the mohel soaks in a chlorinated pool for 20 minutes immediately before the bris. This is an uncommon practice.

Mohels should be required to wear sterile gloves, donned immediately before touching sterile instruments and the sterile field of the bris. If it is time consuming, he can wear two pairs, removing the outer pair immediately prior to beginning. Non-sterile gloves are a step up from “no gloves,” but they are still less than ideal.

“Metzitzah” is defined as drawing “deeper” blood from the circumcision spot, which some view as a medical necessity while others view it, based on modern medical knowledge, as a ritualistic remnant of what may have once been deemed a medical requirement (Shabbat 133a-b).

Over time the idea of doing metzitzah with the power of the mouth was introduced, which is defined in two ways: either put a mouth directly on the wound, or use the power of the mouth through a sterile pipette. The latter avoids direct contact and the sharing of body fluids between mohel and baby.

Both are halachically sanctioned, while only one meets the approval of any unbiased modern medical sensibility. Arguments such as “saliva heals” and “one’s first instinct is to suck a cut on your finger” are irrelevant to the case of a mohel’s mouth touching a fresh wound in a newborn.

Any parent who insists that metzitzah be done with direct oral contact should do the metzitzah himself.

Maimonides writes, “It is impossible to restore the lost life of a Jewish child” (Milah 1:18). While he says this to allow delaying a bris on a child who is not physically ready, certainly the same dictum should be followed when circumcising a child: no step in the bris procedure should allow the slightest possibility that its inclusion can open the door to giving the baby an infection.

It is our responsibility and right to demand the best for our children. For the sake of the health of our children, let us begin with insistence that the bris maintains the highest standards of sterility.

High standards of sterility for a bris

When the following precautions are taken, the possibility of infection is reduced to the smallest percentage.

  • All instruments, drapes and bandages are completely sterile
  • The sandak, who holds the baby during the bris, does not touch the baby directly. Baby’s legs are covered with a blanket or wrapped with a conform bandage.
  • Mohel wears sterile gloves for the bris and every time he touches the baby’s open wound thereafter
  • When metzitzah is done, there is no direct bodily contact between mohel and baby
  • No one who is ill participates in the bris ceremony
  • Those who care for the wound after the bris wash hands with soap and water before opening the diaper
  • After bandage is removed, anti-infection ointment, such as bacitracin, is applied to the healing wound for a few days

Rabbi Avi Billet has been a mohel for 10 years.