New York – Anesthesia For A B’ris?

New York – Neonatal circumcision (the operation used in a b’ris milah) is one of the oldest and most frequently performed surgical procedures in the United States. Most parents elect to circumcise their sons for religious or cultural reasons. In light of the growing evidence that newborns experience pain, many practitioners, including traditional mohalim, are making use of anesthetics that are available today to minimize the child’s pain during the circumcision.

Prior to the mid-1980s, anesthesia was not used, because the medical community denied that the infant felt any pain. That belief has changed among many physicians, because recent studies have found that in instances where anesthesia was used, the babies were found to cry less, maintain a more normal heart rate during the procedure, and be less irritable afterwards.

In recent years, the use of anesthetics has increased. It has become so commonplace that in a recent medical article on the subject, the writers described circumcision without pain relief as “barbaric.” Another physician wrote that subjecting an adult to the same practice would be “unfathomable.”

The use of anesthesia during circumcision is beneficial in two ways. The obvious and primary advantage is indeed to minimize the levels of pain to the child undergoing the procedure. Another equally important purpose is to reduce the stress levels and anxiety of the parents.

As a practicing mohel, I must admit that caring for the baby is the easy part. A much more involved and difficult task is to contend with some of the really nervous parents. I spend a great deal of time (and gladly so) in playing the role of psychiatrist to many young first-time parents. I patiently listen to their concerns and do my best to assure them that their child will be well taken care of.

To relieve some of their anxiety, I jokingly tell them about the mohel who had the perfect solution for treating the baby’s pain: both the mother and the father should drink a full glass of vodka before the b’ris, and the baby would not feel any pain at all.

The use of an anesthetic is a great psychological advantage for the parents. The mere knowledge that the baby will be “treated” to minimize his discomfort can help put the stressed parents at ease. That in itself is a valid and justifiable reason for its use.

Various factors contribute to the negative reaction of the baby to the b’ris, including the technique and the instruments used by the mohel. Parents should make sure that the mohel they choose does not use any clamping devices for the circumcision. Clamps (Mogen, Gomco) are torturous devices designed to assist the operator such as the doctor or mohel (many who are inexperienced) in performing the circumcision. In fact, they were originally invented to be used by inexperienced doctors and were designed to minimize the amount of postoperative bleeding. Unfortunately, they are used by many practitioners today. Additionally, its use has been forbidden according to halachah.

There are a few types of anesthetics typically used for circumcision. Some are topical, meaning that it is applied only onto the surface of the skin; it is not injected into the body. This is certainly the least invasive method of anesthesia, and it is the one that I use.

Another method, called “local anesthesia” or “ring block,” is far more invasive—and completely unnecessary. It is administered by injecting the anesthesia with a needle deep into the skin, close to where the incision will be made. I believe that giving the injection to the child involves much more pain and trauma than the actual b’ris itself.

General anesthesia, which is putting the baby to sleep for the b’ris, is simply not done, because virtually all practitioners would agree that it is not worth taking the greater risk of general anesthesia for such a simple procedure. In addition, there are halachic issues regarding a b’ris performed under general anesthesia.

A common objection to the use of anesthetics is the concern for safety. However, over the years many studies have been conducted, and the accepted conclusion reported in medical literature is that topical anesthetics for circumcision are safe. Parents can feel comfortable with the knowledge that it is only used as a temporary means to alleviate pain and does not have any long-term negative effects on the child.

In a study (“The Safety of Topical Anesthetics for Neonatal Circumcision”) conducted by a group of doctors from the University of Kansas Children’s Center and published in the Journal of American Academy of Pediatrics, the doctors concluded that the topical application of a 30 percent Lidocaine cream may be a safe and effective anesthetic for circumcision. In addition, there was no reported significance of absorption of the Lidocaine as measured in the serum.

As a mohel, my personal preference is to prep the baby before the b’ris with a topical anesthetic gel (20 percent Benzocaine) to numb the area. Because the actual b’ris takes place a few minutes later, the anesthesia has sufficient time to take its desired effect prior to the circumcision procedure. As an additional step to assure long-lasting effects of the anesthesia, at the b’ris I also apply a bandage dressing to the wound that is treated with a mild 5 percent Lidocaine topical anesthetic. In my experience, this method results in a calm baby and, yes, calm parents.

Rabbi Moshe Chaim Friedman is a certified and expert mohel based in Brooklyn, NY you can visit his web site at visit his website at www.NYmohel.com