Medical Guidelines for Mohel

Cleaning of hands and the baby

A Mohel’s hands should be as clean as possible when handling the baby. Bacteria and viruses can be transmitted to the baby and this risk must be avoided and reduced.

The gold standard of hand cleansing would be a thorough washing with handsoap that is antibacterial and approved for surgical scrubbing. This soap is usually a chlorhexidine gluconate soap. It is available from Pharmacies (and others). The most commonly used brand is DISMED. Iodine hand-soap would also be acceptable.

All the skin of the hands should be scrubbed, ensuring to get in-between the fingers and the web spaces. The lower forearms should also be included in the scrubbing procedure. All the scrubbing should be performed in a ‘distal to proximal’ direction (or finger to elbows direction). After a complete scrubbing (approx. 45 seconds), the hands and arms should be rinsed with the water flowing in the distal to proximal direction again. The whole process should be repeated approximately 3 times. Scrubbing takes approximately 3 – 5 minutes. Some prefer to use a sterile sponge, but this is not necessary and personal preference should prevail.

There is evidence in medical literature [ 2] that pouring chlorhexidine in alcohol over the hands as a once off (without scrubbing) can have equal, if not better, cleansing of the hands for surgical purposes. Whilst this is true, alcohol cannot clean the hands if there are pieces of dirt on them. It would therefore be prudent to wash the hands free of dirt particles before applying the alcohol. Certainly, a combination of hand scrubbing and alcohol would be ideal. Some practitioners that do many procedures a day complain that frequent application of alcohol to the hands causes the skin to dry out, and this should be considered if the Mohel is doing frequent procedures. Surgical alcohol is also available from DISMED as Chlorhexidine in alcohol. Note that this alcohol is a surgical preparation and contains 70% alcohol. [ 3]

The skin of the baby should be cleaned with an iodine or chlorhexidine containing solution. (DISMED or others). Some have used an alcohol solution to clean the area. In this case, the alcohol should not be applied too liberally and allowed to evaporate and dry off completely before starting the procedure (the bacteria are killed on evaporation of the alcohol.) The entire penis as well as surrounding scrotum and pubic area should be included in the skin cleaning.

Analgesia (pain control)

Newborn babies do feel pain! The misconception that the nerves of a neonate are underdeveloped and do not conduct pain signals has long since been disproven [ 4]. Medical science uses different scoring systems to determine pain felt by infants. Having said this, small babies do very well with quite simple analgesic techniques. Breastfeeding the baby shortly before the procedure will calm the baby down. Sucrose 24% actually has quite powerful analgesic effects in the young child [ 5][ 6]. The sweet wine that is used during a Brit Milah can be applied to a piece of gauze, and the baby allowed to suck on it. This has the effect of the sucrose analgesia. The alcohol may have an analgesic effect too!

Oral Paracetamol (Panado) can also be given to help with pain before or after the Brit Milah. There are mixed views in the medical literature as to how well this works [ 7], but it can certainly be given as long as there are no contra-indications. Parents are usually happier if their child is getting a medicinal form of analgesic. The oral dose of paracetamol is 10 mg/kg/dose given every 6 to 8 hours. If giving rectal, the dose can be increased to 15 mg/kg/dose.

As an example ….

• A child weighs 3.0 kg. His oral dose would be 10 x 3.0 per dose, so he can get 30mg per dose every 6 to 8 hours.
• The oral form usually comes as 120mg per 5ml. (NB formulations do differ, so you must check this concentration on the label before assuming the above). 30 divided by 120 equals 0.25.
• So the dose would be 0.25 of the 5 ml which is 1.25ml of paracetamol syrup as the single dose. This dose can be given every 6 to 8 hours.

Note. According to South African law, a person (like a Mohel) without a medical qualification cannot prescribe any medication, even paracetamol. However, since the medicine is not scheduled and is an ‘over the counter’ medication, the parents are allowed to use it of their own volition. As such, the Mohel should not ‘prescribe’ the paracetamol, but merely suggest to the parents that it is available, and if they want to they can get it and use it. It sounds silly and technical, but it is important to follow in order to keep legal.

A Word on EMLA Cream

The standard Brit Milah would not involve the use of a local anaesthetic. However, in some cases, a parent may insist on a type of local anaesthetic being used. Injectable local anesthesia requires training and a medical license to use. A simpler alternative would be the use of a cream called “EMLA” (Eutetic Mixture of Local Aneasthetics). If EMLA is correctly applied, it may provide aneasthesia that is equivalent to an injectable local anaesthesia ( 8 ) [REF 4].

EMLA cream is a mixture of local anaesthetics containing Lignocaine and Prilocaine. It needs to be applied ‘as a blob’ of cream on the area to be cut. This ‘blob’ must NOT be rubbed in, but kept in place and covered with a plastic adhesive dressing (e.g. Tegaderm/Opsite) so it does not accidentally become wiped off.  It must be applied approximately 60 minutes before the procedure.

If using EMLA, one must be very aware of the dangers of Methaemaglobinaemia. This occurs when the haemaglobin (the protein in the red blood cells that carries oxygen) is changed in form (ferric form instead of the usual ferrous from). As a result, the blood cannot carry oxygen to the tissues. Methaemaglobinaemia occurs if too much EMLA is applied. Pre-term infants are particularly susceptible. If using EMLA, one must use as little as is absolutely necessary. One must also prevent accidentally getting it on any other areas of the baby’s skin. As such, have someone hold the arms and legs away from the area of application until it is covered with occlusive dressing to prevent transfer onto the limbs. The maximum dose of EMLA in a neonate is 1g, and the maximum application area should be 10 cm².

EMLA may cause temporary skin reactions like blanching, redness or swelling. Some Mohelim are concerned that the swelling may distort the anatomy that is required to feel during the Brit Milah. [ 9]

The legalities of a Mohel, without a healthcare qualification using EMLA still need to be investigated by the Regulatory Board

A Word on Haemophilia

A family history of haemophilia should prompt medical and genetic testing to ascertain if the baby has haemophilia. This should obviously be done before this Brit Milah.

If the tests come out positive, the Mohel should consider the risks of doing the Brit Milah. Surprisingly, not all haemophiliacs have a contra-indication to having a Brit Milah, but this should be discussed with the medical professional involved. There have been many reports in the medical literature of circumcisions being done on haemophiliac babies. Most of the time, the circumcision is done at an older age and clotting factor replacement will be required (an intravenous infusion). There are also reports in the literature of diathermy knives being used and fibrin being used to ensure a safer circumcision and reduce the need for Factor replacement. [ 10]

Needless to say, all these options should be discussed with the medical professional involved before making any decisions

Dressing the wound & bleeding

There is strong evidence that covering a surgical wound for 24 to 48 hours can help prevent a surgical site infection. [ 11], [ 12] [ 13]

The most important elements of the bandage are to protect the wound, help control bleeding and oedema, allow for monitoring of bleeding, and allow the passage of urine. The dressing also ensures that the Or Hapriah lies flat on the shaft and does not lie too distal, over the glans, where it may form an adhesion, and does not lie too far away from the shaft skin to minimise denuded area.

If bleeding occurs after immediate application of the bandage, compression of the area for 5 minutes can be applied and then released to observe for on-going bleeding. This pressure can be repeated for 10 minutes as above. With any on-going bleeding, consider an underlying haematological problem. In select cases, a suture may need to be applied, especially when there is frenular bleeding. These are general principles and it is understood that each Mohel has their own learnt dressing.

Some texts suggest that bleeding can be controlled by application of lignocaine with adrenalin. Topical application of this is safe, but injecting this solution is not.

There are commercially available topical haemostatic agents that work in various different ways …

Fibrin glue or Thrombin products.

• These work the best and have the actual clotting agents inside them that the body would normally produce. They are, however, extremely expensive and not practical for routine use.

Dehydrating agents (polysaccharides)

• These word by literally drawing the water out of blood. This leaves behind all the non-water elements of blood (cells, platelets, clotting proteins) in a highly concentrated form which allows for clotting. Examples are Perclot, Vereset, etc. A product named Arista works in this manner, is made of natural ingredients, and is not too expensive. It is a powder that can be applied.

Clotting process activators

• These speed up the normal process of blood clotting. An example is Quicklot.

Physical products

• These products allow a scaffold onto which clot can form. An example of this is Surgicell. Gelfoam and Kaltostat work in slightly different ways by absorbing excess fluid and blood.

Vitamin K deficiency is present in most newborns due to low liver stores of Vitamin K. It is most prevalent in the first week of life, and can occur up to 2-6 months of life. Breast milk does not contain enough to replenish these stores. [ 14] As a result, it is standard practice in South African Hospitals to inject every newborn with Vitamin K. Parents sign consent to this in the standard forms that they get during the birth. It can be assumed that a hospital born child has received Vitamin K (an injection). For home births, the Mohel should ensure to confirm with the midwife that Vitamin K was given before performing the Brit Milah. This is important as life threatening bleeding has been reported with Vitamin K deficiency. [ 15]

A lubricant (e.g. Vaseline) or ointment of sorts should be utilised on the wound and the glans. This is to ensure the wound does not adhere to the nappy, but more importantly prevents complications like post-circumcision adhesions to the glans, skin bridges or meatal stenosis [ 16]. Chloromycetin is an antibiotic and it comes in an ointment form. As such, it acts as the required lubricant but with the additional advantage of having antibiotic properties. One should be aware though, that it tends to dry up quicker than Vaseline and should only be used for a few days.

Infectious diseases

Transmission of diseases is a reality in medical practice. It is important to ensure that neither the Mohel infects the baby, nor should the baby infect the Mohel.

If the Mohel has a fresh wound on his hand, it would be prudent to either wear gloves, or if this is not acceptable, to cover the wound with a plastic occlusive dressing (e.g. Tegaderm/Opsite).

The Mohel should be adequately vaccinated against Hepatitis B. This vaccination consists of 3 separate injections given immediately, then a month later and then 6 months after the first injection. It is prudent to have a blood test after the full course of injections to ensure that one has ‘seroconverted’ which basically means that the vaccination worked. If not, you may need a booster vaccination immediately. A booster dose is not required in otherwise healthy people [ 17]. The results of the serology should be submitted to the Regulatory Board.

Herpes virus transmission may be of concern with Metzitza b’Peh. If a Mohel has mouth ulcers or a rash around the mouth, it would be wise to seek medical advice as to the safety of doing Metzitza b’peh.

There is no vaccine for HIV. Being that a Mohel generally works without gloves, he should be tested on an annual basis for HIV and submit his results to the board.

Jaundice

Jaundice is a topic well known to Mohelim. The inability to do a Brit Milah with jaundice is mostly halachic and not specifically medical and the halachic aspects will not be discussed here.

There are 2 types of jaundice – Physiological and Pathological.

Physiological jaundice occurs in many babies – more than 50%. It is due to the breakdown of Foetal Haemoglobin after birth. The ‘waste product’ of the breakdown of these cells is ultimately bilirubin and a high bilirubin content in the blood causes jaundice. Normally, bilirubin should be cleared from the blood by the liver. The neonatal liver is immature and cannot remove this bilirubin quickly enough, and jaundice results. Because it is due to this breakdown of cells (which takes a few hours to occur after birth), the jaundice is not present at birth, but appears approximately 24 hours later. This ‘delayed’ presentation is also because any haemoglobin breakdown prior to birth is removed by the mother’s liver, and the build-up will thus only occur after birth. Breast milk can also cause jaundice. The reason for this is not entirely clear. ‘Breast Milk Jaundice’ is mild and certainly should not be a reason for the mother to stop breastfeeding the child. The advantages of breast-feeding far outweigh the innocuous jaundice that it causes.

The important issue medically is for the Mohel to recognise when a jaundice may be pathological and not simply physiological. As mentioned, a physiological jaundice usually does not start within the first 24 hours. Any jaundice that is present within 24 hours of birth should be referred for workup by a doctor. Another feature of pathological jaundice is that it is usually a much deeper jaundice than the physiological one.

Other factors that may delay the Brit Milah

The baby must be a ‘well’ baby before embarking on the Brit Milah. To this extent, the following conditions may necessitate the delay of the Brit Milah [ 18]. If they are present, or in doubt, discuss the matter with the GP or paediatrician.

Low weight

• Generally we do not do the Brit Milah if the weight is less than 2.5kg. Between 2.5 and 3.0 kg is a grey zone and should depend on other factors like developmental maturation, weight gain since birth and whether the child is thriving.

Persistent vomiting and poor feeding

• Refer for medical workup and decide with the doctor about the Brit Milah.

Eye infections

Thrush (oral or peri-anal)

• This should be treated before doing the Brit Milah

Rash in the nappy area – at the Mohel’s discretion

Finger infections (paronychia)

• These are small pus filled areas next to the nail. It may necessitate delaying of the Brit Milah.

Complications

The following complications [ 1] [ 19] may be associated with the surgical procedure of the Brit Milah. Fortunately complications are extremely rare and an Israeli study quoted the complication rate as low as 0.34% [ 20] he most common of these, bleeding, is usually of little consequence, and well handled by the Mohel. In the event that the Mohel feels that the bleeding is excessive or uncontrollable, he should seek medical advice. The complications are as follows.

• Bleeding, including the risk associated with a blood transfusion in the extremely rare case of life-threatening bleeding, most often associated with an underlying bleeding disorder.
• Infection, including the risk of systemic spread and the need for intravenous antibiotics.
• Injury to the penis and surrounding structures, including the urethra, glans and scrotum.
• Poor cosmetic outcomes, i.e. general dissatisfaction with the appearance of the wound, adhesions, buried/concealed penis, removing an excess or an insufficient amount of foreskin, preputial-glandular fusion, and skin bridges.

It must be re-iterated that the above complications are rare indeed, especially the serious ones. The vast majority of Brit Milahs occur without incident.

The Mohel is required to register any complications, even minor ones, on the website. The reason for this is to protect the Mohel from legal implications later on should they arise. Whilst it is assumed that the Mohel would have taken the appropriate action should there be a complication, there is always a need to document everything that is done. This section of the website will allow for such documentation, and ensure that the Mohel can never be accused of not dealing with a complication

In addition, the Mohel is also required to contact the Medical Officer of The Regulatory Board in all cases of a serious complication. A serious complication is one that requires referral to a general practitioner, hospital casualty or specialist.