It is customary for a Brit to be performed on the 8th day, yet there are some situations where the Halacha prohibits the bris from being performed on the eighth day. In such cases the bris is postponed to a later date.
The most common reason for postponing the Brit is a condition called Jaundice. According to Jewish law, when the child’s health is questionable, as with Jaundice, the Brit must be postponed .Maimonides explains that a bris can always be done on a later date, but we can never return a life. The Lubavitcher Rebbe also emphasized that whenever there is a doubt, or even if there are opposing opinions by a Rabbi, a Mohel or a Physician as to the child’s health, the Rebbe writes that the proper thing to do is to postpone the bris for the above mentioned reason.
A common condition in newborns, jaundice refers to the yellow color of the skin and whites of the eyes caused by excess bilirubin in the blood. Bilirubin is produced by the normal breakdown of red blood cells.
Normally bilirubin passes through the liver and is excreted as bile through the intestines. Jaundice occurs when bilirubin builds up faster than a newborn's liver can break it down and pass it from the body. Reasons for this include:
• A newborn baby's still-developing liver may not yet be able to remove adequate bilirubin from the blood.
• More bilirubin is being made than the infant's liver can handle.
• Too large an amount of bilirubin is reabsorbed from the intestines before the baby gets rid of it in the stool.
Jaundice affects as many as 60% of all newborn babies.
Types of Jaundice
There are several types of jaundice in newborns. The following are the most common:
Physiological (normal) jaundice:
occurring in more than 50% of newborns, this jaundice is due to immature development of the baby's liver, which leads to a slow processing of bilirubin. It generally appears at 2 to 4 days of age and disappears by 1 to 2 weeks of age.
Jaundice of prematurity:
this occurs frequently in premature babies since they take longer to adjust to excreting bilirubin effectively.
Breast milk jaundice: in 1% to 2% of breastfed babies, jaundice can be caused by substances produced in their mother's breast milk that can cause the bilirubin level to rise above 20 mg. These substances can prevent the excretion of bilirubin through the intestines. It starts at 4 to 7 days and normally lasts from 3 to 10 weeks.
Blood group incompatibility (Rh or ABO problems): if a baby has a different blood type than the mother, the mother might produce antibodies that destroy the infant's red blood cells. This creates a sudden buildup of bilirubin in the baby's blood. Incompatibility jaundice usually begins during the first day of life. Rh problems once caused the most severe form of jaundice. To prevent the mother from forming antibodies that might endanger subsequent babies, an injection of Rh immune globulin is given to the mother within 72 hours after delivery.
In mild or moderate levels of jaundice, the baby will take care of the excess bilirubin on its own within 5-7 days after birth. If high levels of jaundice do not clear up, phototherapy may be prescribed. This type of treatment uses a specific type of light to help rid the body of the bilirubin by altering it or making it easier for your baby's liver to get rid of it.
More frequent feedings of breast milk or formula to help infants pass the bilirubin in their stools may also be recommended. In rare cases, a blood exchange may be required to give a baby fresh blood and remove the bilirubin.
If your baby develops jaundice that lasts more than a week, your doctor may ask you to temporarily stop breastfeeding. During this time, you can pump your breasts so you can keep producing breast milk and start nursing again once the condition has cleared.
If the amount of bilirubin is high, your baby may be readmitted to the hospital for treatment. Once the bilirubin level drops, however, it is unlikely it will increase again.
Jaundice as a reason to postpone the Bris
Because jaundice is a symptom of some type of abnormality in the body - an indication of an increased level of bilirubin in the blood - all conditions of Jaundice should be closely monitored. Conditions will vary from minimal or slight risk to dangerously high and life threatening. One should always consult a Mohel or a physician when jaundice is detected. You may find the Mohel to be more stringent, often postponing the bris even though the doctor permits the circumcision.
The severity of jaundice and its effect on the timing of a bris can be divided into three categories.
• The first level is a slight jaundice that has already peeked and is now decreasing. This condition, in itself, is of no concern. A Bilirubin count of 10mg/dL or less in an otherwise healthy full term infant will generally not postpone an eighth-day bris.
• The next level of jaundice is a slightly stronger yellow appearance. Here, the bilirubin count is anywhere from 11mg/dL to 15mg/dL. At this level there are two medical opinions regarding circumcision. One says that it still is considered within the normal range and will probably clear by itself, thereby allowing circumcision to be performed. The other will not permit circumcision, requiring the jaundice to clear, as all non-critical surgeries are postponed with any signs of abnormality. Jaundice may be a sign of low oxygen level in the blood. Oxygen in the blood is an importing agent in the healing process. At this level of jaundice, or whenever the infant’s health is in doubt, we postpone the bris until the day after the condition clears.
• The third level of jaundice is when the bilirubin toxin reaches extremely high levels. Level of 15mg/dL and higher can cause brain damage to the child if not controlled. In most such cases, the child is sent back to the hospital for phototherapy. This condition is considered a general illness requiring that the Brit be postponed until seven full days after the bilirubin level has dropped to about 10mg/dL or less.
One should always consult a Mohel prior to setting a Brit date. In different countries there may be different levels of tolerance. However, in the U.S. the above mentioned levels are generally accepted by most Mohalim.