Wednesday, December 23, 2009

Why Can't the Baby Eat Before the Bris?

I generally recommend that the last pre-bris feeding take place 90 minutes before the bris.

For babies who drink formula, this usually does not present a problem, as they are usually on a schedule.

But for babies who nurse (I am happy to report that the number of nursing moms is on the rise), this presents a bit of a problem. My wife likes to call herself "Mommy's 24-hour open bar," so I understand very well how nursing moms like to provide when baby asks. And this is a wonderful thing. One might argue that the only downside of nursing is that babies love it! and don't want to give mommy a break.

Before a bris, however, the problem is twofold.
A: Nursing during the bris is impossible - for obvious reasons.
B: The baby's system needs to be cleaned out in anticipation of the bris.

I assume I don't have to explain the first reason, so here is the explanation for reason "B."

The baby will be crying in a way he might not be consolable while the bris or bandage change is taking place, and if he happens to have recent food in his system, there is a good chance he'll spit it up. "Spitting up baby + crying and can't be moved due to position he is in when caring for his circumcision wound" is not an equation we want to deal with.

The best I can recommend if the 90 minute window does not work for you is to try to estimate how much time he can handle, so he'll be ready for a good feeding (nice and hungry) 15 minutes after the bris is scheduled to begin.

After the bris he can eat all he wants.

But it is not worth risking a spit up during the bris or when I am checking his bandage right after the bris. Choking baby is much worse than crying baby.

I hope you will agree.

Tuesday, December 22, 2009

Prioritizing our questions

I've received a number of calls in the last couple of weeks, from people who are doing their research before baby arrives. I mean this with all sincerity - kudos to you! It it so important to do proper research before the baby arrives.

The question I hear most often is about the "cost." Let me assure you this is not an issue - I graciously accept whatever you offer. [Note from 1/2/11 - here is a new posting on the subject] [And yet another posting on why Costs should not be a determining factor - August 2011]

While it is most understandable that this is a top question, at the same time, I feel that other questions which should be at the top are not asked at all.

Are there ever complications?
What is the healing process like?
What are your methods for maintaining sterility? (See the second half of the link)
How will you treat our baby and how will you treat us?

More examples of Important questions can be found here and here (this second one is the same as the link above, but the questions in it focus more on things you ought to be asking yourself - to help you decide what you want out of the bris experience).

Let's talk!

Thursday, December 17, 2009

What is a "Kvatter"?

The role of the "kvatter" is to bring the baby from the mom to the dad at the start of the bris ceremony.

The term is Yiddish, and probably comes from the term "K'fater" which means "like the father." Those of Germanic descent might pronounce the word "g'fotter" with an "umlaut" over the "e" (the "e" should be pronounced like the "e" in "yes," as opposed to rolled over as it is in "fodder").

[Update 11/2014 - In the book "Minhagei Worms" (customs of the city of Worms), the author notes a custom that the woman who would take the baby from the mother (who is called the "Sandeket") would give the mother a gift called the "גיפאטר שאפט" (Gifater Shoft) in order to distract the mother from the pain her child is about to go through as she enjoys her new gift. I don't know what the literal translation of the term is (though "שאפט/shoft" seems to mean "community"), but clearly "G'fater" relates to our word in question.]

The word may also come from a diminutive or derivative of "Godfather."

There are different customs related to who is honored to play this role, particularly as pertains to what is called a "segulah" - a special merit to achieve a certain result.

This is not the place to discuss the general benefits of "segulah"s - but there is a nice list of segulahs at the "In the Pink" blog - you can read it here. [I don't recommend the last one for "getting pregnant" - and I happen to think it is a mistake. There is no way that anyone "really" ever did that. At least I hope I am correct]

The major "segulah" of this role is for people who are not yet parents to merit to become parents. Just as they are participating in the bris, just as the woman and man are "like" the mother and father of the baby in the way they are bringing him to his bris, they should merit to have a child, and if he's a boy, to bring him to his bris.

Brief History

Before the age of the mega-mom and the DIY ladies of today, whom we admire very much, by the way, women would not attend a bris in the way they do now. The mother might be in a different room or building, possibly being forced to rest by all her relatives or attendants after having given birth, and the baby would be brought to his bris.

Who would bring the baby? A woman who is trustworthy to the mother.
Who would she give the baby to? The baby's father, surely, except that it was considered immodest for a woman to hand something to a man, who is not her husband, in a public ceremony. So she would give the baby to her husband, who would bring the baby to his (baby's) father.

Present Day

I have not yet met a mother who chose to hide in a room somewhere while the bris takes place elsewhere. So why do we still have the kvatter? Let the mother bring her son to his bris!

There are a few reasons why the kvatter is still used, and other thoughts to consider when choosing a kvatter.

1. Married couples who observe the laws of "niddah" are not supposed to pass things to each other, on account of rules which limit certain practices between husband and wife during the niddah period. While "niddah" status is usually a private affair, a woman who has given birth is known to be in the status of "niddah" on account of her having given birth, so in a public Jewish ceremony, we help them follow the rules by having the "kvatter" couple as their go-between.

2. Some situations and circumstances do not make the mother's entrance possible, such as in certain synagogues or smaller rooms which have limited space. As such, the male half of the kvatter is in the room anyway and he'll take the baby from his wife to bring him to the ceremony.

3. The segulah to have a child is something that some people put a lot of stock in. Why not give them the opportunity, if it would be meaningful to them?

4. In a ceremony with limited participation - most of the honors consist of holding the baby briefly - it provides an opportunity to have more people hold the baby. Many people like to get additional "kvatter people" involved to give additional grandmothers, great aunts, friends and the like the opportunity to participate. It also provides more opportunities for photographs.

My rule in this respect (#4) is simple. Let the women pass the baby first, and the last woman gives the baby to her husband before other men pick up the hand-offs.

What if I don't have any childless married friends? Do I need to find such a couple? (Or - Who else could serve as kvatter?)

No. The couple should ideally be married to one another. Some people give it to the baby's aunt and uncle, or a great-aunt and great-uncle, or even the baby's grandparents. In the case that a married couple is not available, or they are being utilized for something else, the honor can also be given to a male-female team whose contact with one another would not be considered "immodest" in a public Jewish ceremony: for example, a mother/son or a father/daughter team. I guess a brother/sister team could also work.

What if the couple I want to include as kvatter are expecting - in other words, the wife is currently pregnant?

It really depends. Technically they don't have a baby yet, so the "segulah" could still apply. Some who are superstitious might view their being kvatter as a curse on their unborn baby (I believe this to be nonsense). Some feel that an expectant couple don't "need" to play this role.
May they be kvatters? Yes. Is it commonly done? No.

What if there is a couple with no kids that have been kvatter many times?

If they do believe in the segulah and want to play the role again, it is appropriate to give it to them as many times as possible.

BUT... be sensitive!

If they seem to be remorseful, or if it seems to be embarrassing to them because "everyone" knows they are "always" the kvatter couple, and "everyone" sees every time that they "still don't have kids" - which, of course, is nobody's business, then give the honor to somebody else.

Bottom Line

Follow the rules of a couple or appropriate tag-team, and give the honor to someone you care about and/or love.

p.s. Afterthought question

For those who follow the laws of niddah, what happens if the kvatter couple themselves are in a state of niddah?

There are two approaches:

1. This is nobody's business, and as it is a public ceremony, it does not matter. You should not be asking them, and they certainly should not be offering such information.

2. In some circles and some communities, the wife bring the baby in on two pillows, and the husband takes the baby and only the top pillow. In this way, the possibility of the wife handing the husband the baby is taken away. And as "everyone" does it this way, it removes any uncomfortable situations or needs for explaining.

Tuesday, December 15, 2009

Methods of Circumcision

Most parents looking to have their son circumcised just want it to be done as efficiently as possible, as speedily as possible, with minimal pain to the baby.

Of course they'd prefer the circumcision be aesthetically pleasing, and that the circumcision heals sooner than later with no complications.

When doing research about ANY mohel, the end results are important. (I've written elsewhere about the demeanor and the ceremony and the need for things to be done at your speed.) And most people leave the method to achieving those end results up to the mohel, and how he feels most comfortable getting there.

However, there is not "only" one way to circumcise. And if it is important to you, it is important to ask about methods, and to inquire if the mohel can accomodate your desires.

There are some methods which are questionable according to some (in some cases, many) rabbinic opinions. There are others which are standard - even if the "innovation" in them is "only" hundreds of years old. And there is old-school, bare bones (literally), which is advocated by few.

Sadly, those who advocate the latter method often knock everyone else, even going so far as to declare other circumcisions "unkosher" and requiring hatafat dam brit - a ceremonial drawing of blood from the circumcision scar that would "kosherize" the bris. This is not only a form of lashon hara and rechilut (talebearing), but is a lie, a form of fear-mongering, and does nothing but increase hatred amongst Jews.

Hmmmmm. That last paragraph was a mouthful. Take a deep breath and let's move on to methods:

INTRODUCTION

Bris Milah has three steps:
1. Milah - the removal of the foreskin
2. Priah - the removal of the membrane that is found between the foreskin and the glans
3. Metzitzah - drawing of "distant" blood

The foreskin is drawn forward and removed. The membrane is often removed with the foreskin. If it is not completely removed, then it is torn and folded back beyond the glans. Finally, blood is drawn from the wound.

In the interest of space, the methods described will not include metzitzah, which will be the subject of different posts.

And I will leave the issue of whether the mohel is wearing gloves up to you, the parents, as well. I've addressed this in a number of posts already. [Search "sterility" in the keywords]

Method #1. Clamp





The foreskin and membrane are grasped with a hemostat and a clamp is applied to the foreskin. There are two kinds of clamps that have been utilized by mohels over the last sixty years. The first is the Gomco (on the right in the photo), which is often the method of choice for doctors in hospitals, but is not largely used by mohels. The second is the Mogen or Bronstein clamp (on the left), which is the method of choice for many mohels in the US (though most Orthodox mohels, including me, do NOT use it). The foreskin and membrane are then removed together in one incision, with a scalpel or bris knife.

Method #2. Shield


The foreskin and membrane are grasped either with a hemostat (as in method #1) or skillfully with the fingers. A metal plate with a thin slit is applied to the foreskin, leaving the foreskin resting above the plate, with the glans safely shielded below. A scalpel or bris knife is used to excise the foreskin.

If the membrane is removed along with the foreskin, metzitzah follows.
If the membrane is not completely removed along with the foreskin, it will either be cut with scissors, or the mohel will tear it with his sharpened thumbnails - in both cases to reveal the entire glans.

Method #3. Free hand


Without using any device other than a blade, the mohel will estimate the length of the foreskin, grasp it with the thumb and forefinger of one hand and excise the foreskin with the knife in his other hand.

Membrane removal will follow that of method #2. Metzitzah will follow.

PROS AND CONS OF THE METHODS

Obviously, the "con" of the baby having skin tissue removed and being subject to the pain of circumcision, and any bleeding are a given. If you are having your baby circumcised, it is assumed you understand that this is the down side (if you even view it as a downside) of the spiritual, national and Jewish significance attached to this procedure - which is the fulfillment of a commandment.

The pro: Baby bears the mark of the covenant established between God and Abraham, and all of the Jewish people, which established God as our only God, and we, the Jewish people, as His firstborn, the chosen people who have a mission on this earth to spread monotheism and ethics to as many people as we can.

Pros and Cons of #1 (Clamp)

Benefits include:
* Usually a bloodless circumcision.
* The mohel may not even need to use a bandage.
* If applied correctly, the glans is protected.

Cons:
* Usually a bloodless circumcision. (Blood is an essential element of the bris)
* Estimating the end of the foreskin along the shaft is inexact
* The FDA has issued severe warnings about the use of the clamp, as it could grasp and amputate the glans or the tip of the glans.
* The pain of the crushing of the foreskin is immense
* Once the clamping mechanism is applied, the estimation of the foreskin is irreversible. Even if one were to remove the clamp and then reapply it correctly before excising the skin, the skin tissue that remains would be dead, and would liekly either become the equivalent of a growth or fall off on its own.
* In order to achieve its desired effect, the clamp usually needs to be on for a significant amount of time - from 30 seconds to five or ten minutes. This is significantly longer than the next methods which take 3-4 seconds.
* Rabbinic approval is scant.

While Reform and Conservative mohels will often use this device, Orthodox mohels who use it usually do not have rabbinic dispensation to do so. Many will use it out of their own convenience (in other words, not because they have the baby's best interests in mind) so they need not come back and check the baby. This is not nice - every baby should be checked after the bris. No matter the method used.
Those who use it usually swear by it. I think they feel this way because of the lack of necessity to follow-up. But I may be wrong.

Pros and Cons of #2 (Shield)

Pros:
Quick procedure
* There is blood (necessary component of the bris)
* No chance of anything happening to the glans
* Until the actual incision is made, nothing is irreversible

Cons:
* Estimating the end of the foreskin along the shaft is inexact
* While the foreskin is not crushed, it is squeezed tightly for a few seconds.

The shield is an innovation which dates back at least four hundred years. It's purpose was (and remains) to protect the glans which is at great risk of being cut or amputated when a bris is done by anyone other than an extremely skilled operator. Like in the previous method, once the shield is in place, the actual removal of the foreskin - cutting along the shield, is the easiest part of the job.

Pros and Cons of #3 (Free-hand)

Pros:
* Quickest procedure
* Relatively painless

Cons:
* Estimating the end of the foreskin along the shaft is inexact
* There is no chance to second guess because the mohel never gives himself a chance to double check before excising the foreskin
* The possibility exists that the blade might cut the glans
* If done by anyone other than a skilled operator, the outcomes could be disastrous

The only people who still do brisses this way are some Chassidic Jews. While each person is entitled to have an opinion, those who do it this way are the most outspoken about - and against - any other form of circumcision.

THEREFORE

You may have noticed that the con that reads "Estimating the end of the foreskin along the shaft is inexact" was on every "con list." This is because many mohels were never taught to use a surgical pen to mark the edge of the foreskin before beginning the procedure. If the mohel's initial estimation is marked with a pen or marker, the "con" is removed from each list, as long as the mohel makes sure to cut along the mark.

I wrote about pain in the last few sections of this post. In simple terms, I think it is important to numb the area before the bris, but I think injections are not the way to go about doing it. There are topical methods out there that do just as good a job, and don't cause the baby pain from three "shots."

My Method

In addition to marking the end of the foreskin, I use Method #2 for a host of reasons. While I personally do not agree with methods #1 and #3, I believe that the bris is kosher if the operator is fit to be a mohel. I also think that parents should know what they are getting in to when hiring a mohel, and that the method which best suits your needs should be employed for your son.

When I circumcise, I aim to remove the foreskin and membrane at the same time, to minimize pain to the baby and the need to bother him too much. I always check the baby later, either a few hours after, the evening after, or the day after the bris. I wear gloves. I package all my instruments and bandages and sterilize everything in an autoclave machine - unless it is sterile in its packaging, e.g. gloves and drapes.

I hope this has been helpful to you. As always, feel free to contact me by email with any questions, or call me