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Before the Bris

How to Protect Your Baby Against Infection

A practice called metzitzah b’peh (direct oral suctioning) is performed during some religious circumcisions (bris). Direct oral suctioning has been associated with infections and deaths of babies caused by herpes simplex type 1 virus (HSV-1), the virus that causes cold sores of the mouth.

Direct oral suctioning is performed by some mohelim, or religious circumcisers, in the Jewish community. With this practice, the mohel’s mouth and lips come into direct contact with the baby’s circumcision wound during the bris. The New York State Department of Health and New York City Department of Health and Mental Hygiene have documented a number of cases of HSV-1 infection on or around the genitals in male babies after circumcisions that included direct oral suctioning. Some of these babies became seriously ill. Some developed brain damage, and others have died. There is no proven way to eliminate the risk of HSV-1 infection from direct oral suctioning.

How Metzitzah B’peh (Direct Oral Suctioning) Can Cause Infection
More than half of adults have oral HSV-1 infection. This infection may cause cold sores in the mouth, but most people with oral HSV-1 do not have cold sores and do not know they are infected. People can spread the virus to others even when they don’t have any cold sores. Even though HSV-1 causes cold sores in most people, newborn babies are at risk for severe infection if they are exposed to the virus. This is because their immune systems are still not mature enough to fight off infection. With direct oral suctioning, the mohel places his mouth and lips directly on the baby’s circumcision wound to draw blood away from the cut. HSV-1 infection spreads through saliva. This is especially true when saliva touches a cut or a break in the skin, such as occurs with direct oral suctioning. If the mohel has HSV-1 infection, he may not know it, and he may transmit HSV-1 to the baby.
Alternatives to Direct Oral Suctioning
Some religious authorities consider direct oral suctioning the only acceptable way to draw blood away from the circumcision cut. But other religious authorities within the Jewish faith approve different means. For example, sometimes a glass tube or a glass tube attached to a rubber bulb is used to suction blood in a way that does not include contact between the mohel’s mouth and the baby’s cut. Others use a sponge or a sterile gauze pad to suction blood. In contrast to direct oral suctioning, there is no evidence that any of these other practices cause HSV-1 infection.
Reducing the Risk
While mohelim may rinse their mouths with alcohol-containing mouthwash or even take antiviral medications, there is no proof that these strategies reduce the risk of HSV-1 infection associated with direct oral suctioning.

Because a baby’s immune system is not mature enough to fight infection, HSV-1 is a very serious risk for babies. If infected, babies will need to be hospitalized for at least two weeks of intravenous medicine to fight the infection. Even with treatment, the infection could result in lifelong disability, and your baby could even die from the infection.

Ask About Metzitzah B’peh (Direct Oral Suctioning) In Advance
Some parents whose babies had direct oral suctioning say they did not know beforehand that the mohel would perform direct oral suctioning during the bris. The Department of Health and Mental Hygiene is very concerned about the risk of infection and strongly advises that parents not have metzizah b’peh (direct oral suctioning) performed during the bris. To help you protect your baby, you should ask about direct oral suctioning before the bris, while there is time to explore all options.  

Signed Parental Consent is Required for Metzitzah B'peh

The New York City Health Code (Section 181.21) now requires written parental consent before direct oral suction can be performed as part of circumcision.  The consent must include the name of the mohel and the signature of at least one parent.  One copy of the signed consent must be given to the parents, and the mohel must retain another copy for one year.
Consent form (PDF).
Other languages: [Yiddish] [Русский][Hebrew]

Taking Care of Your Baby During and After the Circumcision
Circumcision involves cutting off skin and leaving an open wound. To protect the wound from infection, the circumcision should always be done under sterile conditions. The circumciser’s hands should be thoroughly washed and surgical gloves worn. The foreskin should be swabbed with an antiseptic solution. Sterile instruments should be used to cut the foreskin. Sterile gauze can be used to absorb bleeding, and a sterile dressing should be used to cover the incision site.

Regardless of how circumcision is performed, it is important to take good care of the circumcision wound until your baby fully heals. To prevent all types of infection, parents and other caregivers should apply a fresh gauze pad, dabbed with petroleum jelly or other ointment, on the penis during each diaper change. It is also important that parents and other caregivers frequently wash their hands with soap and water, especially before and after changing diapers or dressings for the wound.

More Information

For more information about the risk of HSV-1 infection in your baby, talk to your family doctor or pediatrician.

For more information about the risk of HSV-1 infection in your baby,
to your family doctor or pediatrician.