Metzitzah B’peh (Direct Oral Suctioning)

When a baby is circumcised, some ritual Jewish circumcisers (mohelim) do a practice called metzitzah b’peh. Metzitzah b’peh is when the mohel uses their mouth to suck blood away from the baby’s circumcision wound as part of the circumcision ritual. After metzitzah b’peh, some babies can get an infection.

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How Metzitzah B’peh (Direct Oral Suctioning) Can Cause Infection

Public health experts have found that metzitzah b’peh can put babies at risk of getting a harmful virus called herpes simplex virus type 1 or HSV-1. 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, though there are options to reduce the risk.

Many adults carry HSV-1 in their bodies. They may have no symptoms or only mild symptoms, such as cold sores. Unlike adults, babies are too young to fight the virus. When a baby gets the virus, they could have brain damage, develop a lifelong disability or, in some cases, die.

A baby can get the virus when the mohel's saliva gets on the baby's skin and circumcision wound. If a mohel does metzitzah b’peh, even for just a moment, there is no way to avoid this risk. Even if the mohel has no symptoms or obvious signs of HSV-1, such as cold sores near their mouth, they could still have the virus and not know it.

As a baby’s immune system is not mature enough to fight infection, HSV-1 is a 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 babies could even die from the infection.

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

Avoiding metzitzah b’peh during circumcision eliminates the risk of herpes transmission during the bris.

If metzitzah b’peh is still performed despite this guidance, one can reduce — but not eliminate — the risk of HSV-1 infection associated with direct oral suctioning, by ensuring that mohelim rinse their mouth with alcohol-containing mouthwash (specifically, Listerine Original Gold, with 26.9% alcohol) for at least 30 seconds immediately before performing direct oral suctioning.

To protect the health of New York City’s infants, the Commissioner of Health has ordered mohelim identified as having infected a baby with HSV-1 through metzitzah b’peh to not perform this practice during the circumcision ritual.

Before the Bris, Talk to the Mohel and Your Doctor

Before you hire a mohel, ask if they do metzitzah b’peh. If you don't want metzitzah b’peh, tell the mohel not to do it. They are required to respect your wishes.

If you decide to include metzitzah b’peh during your baby's bris, take the following steps:

  • Talk with your baby’s doctor about metzitzah b’peh.

  • Before you hire a mohel for the bris, ask if they have tested positive for herpes, or if they have received an order from the Commissioner of Health to not perform metzizah b’peh. If a mohel answers "yes" to either of those questions, you should not hire that mohel.

  • Talk to the mohel to make sure they rinse their mouth with mouthwash (Listerine Original Gold, with 26.9% alcohol) for at least 30 seconds immediately before performing metzitzah b’peh.

Taking Care of Your Baby During and After 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.

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