Bris | Imamother

cassandra

Fri, May 22 2009, 9:50 am

I found this interesting (re: using Emla for a bris). I'm guessing if you come from a community that will not even budge on the way you do metzitzah this isn't going to fly for you. I had a very knowledgeable MO mohel and we did not use Emla either.

Quote:

As most of you already know, my son Shlomo David N"Y had a
bris on Shabbos Parshas R'ei.

One of the things we thought about doing, and discussed with
several people, was the possibility of using EMLA, a topical
anesthetic cream that is commonly used before giving shots,
drawing blood, etc., before the Bris. Please note that, although the
Bris took place on Shabbos, I don't propose to raise Hilchos
Shabbos issues in this post. Those can be saved for another time.
What I would like to address are the issues involved in using EMLA
for a Bris in general, and see if people's views have changed since
this list last discussed the use of local (albeit apparently not
topical except for one poster) anesthetics for a Bris in 1994 (see
Vol. 14, Numbers 48, 53 and 55 - there may be others that I
missed).

For those who are not familiar with it, EMLA is an anesthetic
cream. In its ordinary use, it is placed on the skin surface from
which one intends to draw blood approximately 30 minutes ahead
of time. It can be effective in as little as 15 minutes; in our
experience (we have used it regularly for the last eighteen months
for Baruch Yosef) if you leave it for 90 minutes or more you are
running a risk of skin irritations (at least). Shortly before you give
the injection or draw the blood, you wipe off the EMLA, and you are
left with a numbed skin surface underneath. (Note - this is very
much a layman's explanation, but I think I have the basics correct).

We discussed the question of using EMLA with Shlomo David's
sandak (who is a recognized posek) and mohel, both of whom were
opposed. They also indicated that at least two gdolim in Eretz
Yisrael have come out very strongly against the use of EMLA, one
of whom apparently plans to publish a tshuva about it in the future.
Among the reasons they gave me were that the baby is supposed
to feel pain, that brissin have always been done in a certain way
and we can't vary from how they were always done in the past, and
that the use of EMLA would make the orla (foreskin) slippery and
more difficult to remove.

However, we heard through the grapevine that there is at least one
recognized posek in the States who not only permits the use of
EMLA, but actually encourages it. He holds (according to what his
daughter told Adina) that there is enough pain to the baby even
with the use of EMLA, that to make the baby suffer when there is
no need to do so is tzaar baalei chaim (generally used to mean
making an animal suffer pain without reason - all the more so a
child), and that since EMLA does not require an injection, there are
none of the hatofas dam bris (drawing blood for the bris) concerns
that were raised in the list's last discussion of this issue five years
ago.

I also discussed it with one of my e-pals, who is a medical student,
who made a bris about two and a half weeks before we did. She
told me that she and her husband considered using EMLA but
decided not to use it. She raised several medical concerns. First,
she assured me that, contrary to what I thought before, the baby
feels real pain despite the fact that the nerve endings are not fully
developed. As proof, she mentioned how much a baby cries when
its heel is pricked for a blood test, something I remember well from
one of my own children. She cited medical studies of *physician*
circumcisions, in which several indicia of pain showed that there
was a real difference between boys who had received EMLA and
boys who had not.

Second, she said that there is some small risk of blood pressure
dropping as a result of EMLA use, without any prior indications.
When I pointed out that we had been using EMLA without a
physician present to prepare one of our children for medical
procedures for the last year and a half, she reminded me that
*proportionate to a newborn's size* one would have to use EMLA
on a larger amount of body space than would be the case for an
older child.

Third, since a bris is not one of EMLA's official uses, the doctors
she talked to were not really sure exactly how to use it for a bris -
where to put it on, when (how long before the bris) and for how long
to leave it on (it may take less time for a baby than the times I
cited above).

Another concern is scheduling. Especially here in Israel where
many brissin do not take place immediately after Shachris (unlike
what seemed to be the case with every bris in the States), and it
often happens here that a bris does not start on time or even close
to on time. If you've applied EMLA, you cannot leave it on for too
long, yet you cannot take it off too long before the bris or it will not
help. Come to think of it, my first son's bris started over an hour
late in the States (it was Rosh HaShanna and the baal Shachris
went overtime), so I guess that could be an issue outside of Israel
too.

Finally, in the discussion about this topic on this list five years ago,
the one post that seemed to be dealing with a topical anesthetic
(and it may not have been EMLA specifically - I don't think EMLA
has been around for very long) raised the issue that the anesthetic
could inhibit healing of the wound after the bris. I have not
researched the medical literature on EMLA sufficiently to comment
intelligently on this issue.

In the end we decided not to use EMLA, since neither our sandak
nor our mohel approved of its use. But, it bothered me enough that
I have been planning for a couple of weeks now to write this post
and see what collective knowledge this list has about the subject.
Specifically:

1. Does anyone have a source in halacha for the idea that the baby
is supposed to feel pain as part of the bris? I was told that when
the baby is crying is the best time to make Mi Sheberach's for
people, but is there a requirement that the baby actually cry from
pain (as opposed to discomfort)? Is there a halachic requirement
that the baby cry at all?

2. Is there anything in the use of EMLA that would render the bris
b'dieved or worse? I understood the problem with giving an injection
that was discussed five years ago, but it seems to me that EMLA
takes away that problem by eliminating the issue of a false hatofas
dam bris.

3. Is there really an issue of us having to perform the bris in a
specific manner? I know that, for example, nearly all poskim
oppose the use of clamps to reduce bleeding, require that the pria
(pulling back the foreskin) be done with a fingernail, etc. I know that
some poskim have sanctioned the use of a pipette for metzitza
(sucking the blood). But to what extent are we halachically
permitted to make changes in the mechanics of performing a bris?
How would applying a cream and then wiping it off before the bris
change the manner in which the bris is performed? Is there
something the mohel would do differently because of the EMLA? If
so, what? (I'm hoping we have at least one mohel on the list who
can discuss these issues...). Is slippage really an issue?

4. What about the medical issues raised? Are any of them serious
concerns? Would any of them make it unwise to use EMLA for a
bris without a doctor being present? How significant are the risks
involved, and are they greater than numerous other risks to which
we subject ourselves and our children? How do those risks weigh
against the benefit of the lesser pain the boy would feel during the
bris?

I should add that my e-pal tells me that this entire issue is to be
addressed in an upcoming issue of Assia (the fruhm medical
journal published here in Israel), so if anyone can give a sneak
preview, please pipe up!

Carl M. Sherer