Question: How long must you wait before performing a bris milah on a child with neonatal jaundice?
Short Answer: There is no short answer to this complex medical halachah question. A competent poseik, with knowledge of the medical issues, or access to medical advice, should be consulted.
I. Disclaimer and Medical Background
While one should never rely on the discussion in this article without speaking with a rav, this issue is particularly dependent on medical knowledge and thus this article merely attempts to equip the reader with the background knowledge necessary to properly pose questions to the rav. Additionally, this article was reviewed by my father, Rabbi Dr. Aaron Glatt shlita (before coronavirus), who confirmed its accuracy.
An article by Rabbi David Brofsky on Yeshiva Har Etzion’s website, https://www.etzion.org.il/en/delaying-brit-mila-1-sick-child-and-jaundice, provides some pertinent medical information necessary to understand this topic: “Neonatal jaundice, a yellow discoloration of the infant’s skin, is caused by the presence of excess bilirubin in the blood. Bilirubin is a yellow bile pigment produced during the natural breakdown of blood cells (hemoglobin), which circulates in the plasma. During gestation, a baby excretes excess bilirubin through the mother’s placenta. However, after birth, the infant’s liver must begin to conjugate bilirubin, i.e., convert the bilirubin into a liquid that can be excreted through urine. During the first few days after birth, until the liver begins to function, the infant builds up unconjugated bilirubin, leading to hyper-bilirubinemia, usually leading to jaundice. A baby with jaundice will often have a yellowish appearance.”
Further, “up to 60% of newborns have clinical jaundice in their first week of life; few have a significant underlying disease. Neonatal jaundice is usually physiological and not pathological (i.e., indicative of a more serious problem), and the infant is considered to be healthy. However, very high levels of bilirubin can be due to other factors, such as an enzyme deficiency, liver problems, or an abnormality of the baby’s red blood cells. At times, a physician may recommend phototherapy, and in more extreme cases, exchange transfusions and intravenous immunoglobulin. The severity of neonatal jaundice is often indicated by the bilirubin level, measured by 10 mgs per 100 dL of blood. The serum bilirubin level usually peaks at 5-6 on the third to fourth day after birth, and then declines. At times, it reaches up to 12 mg per dL, and even higher.”
Thus, whether a bris miilah must be delayed due to jaundice is largely dependent on the bilirubin level of the child as explained herein.
II. Sickness vs. Ailment
The Shulchan Aruch (Yoreh Dei’ah 262:2), based on the Gemara in Shabbos (137a) and Y’vamos (71a), rules that we delay a bris milah where the baby is sick. However, there is an important distinction. Where the baby has a sickness that engulfs “the entire body” such as “chaltzaso chamah” – i.e., loosely translated as a bad fever – we delay the milah seven full days after the baby is declared fully healthy. On the other hand, where the baby merely has an ailment “in one limb” such as an ailment in his eye, we perform the milah immediately after the baby becomes fully healthy, and there is no need to wait seven additional days.
Practically speaking, the Nishmas Avraham (Vol. 2, p. 330) rules that any pathological jaundice requires delaying the milah for seven days after the baby becomes fully healthy. In this situation, the baby is engulfed by a sickness throughout his entire body. The trickier question is: When can a milah be performed for physiological jaundice? Often, it becomes a numbers game as explained herein.
III. Physiological Jaundice
The Shulchan Aruch (Yoreh Dei’ah 263:1) codifies a different Gemara in Shabbos (134a) where Abaye states that one should delay the milah of a baby who is green or red, as these are signs of abnormalities in the baby’s blood. Similarly, the Gemara relates two stories with Rabbi Nasan, who advised a mother whose baby was green and a mother whose baby was red to delay the milah of their children until the baby was healthy.
Practically speaking, it should be noted that the Nishmas Avraham (ibid) cites both Rav S. Z. Auerbach zt”l and the Minchas Yitzchak who require not only low bilirubin numbers to perform the milah, but also that the mohel determines that the baby is no longer “yellow” in appearance.
With respect to the bilirubin numbers: The sefer P’sakim U’T’shuvos (263:2) lists the various opinions as to what number the bilirubin must be under in order to perform the milah: (i) under 13 (Milas Shlomo in the name of Rav S. Z. Auerbach), (ii) under 12 (Minchas Yitzchak), (iii) under 10 (Sheivet HaLevi), (iv) under 8 (Kinyan Torah). The Nishmas Avraham (ibid), however, concludes his discussion on this topic by suggesting that Rav S. Z. Auerbach allowed the milah even where the bilirubin was a 14.
IV. Waiting Seven Days
The Aruch HaShulchan (Yoreh Dei’ah 263:1) cites the Yad K’tanah who understands the Shulchan Aruch as requiring a wait-period of seven days after the baby regains a natural and healthy color, as this is comparable to a sickness that engulfs the entire body. The Aruch HaShulchan himself disagrees. Since the Gemara implies that Abaye and Rabbi Nasan advised the parents to perform the milah immediately after the child became healthy, there is no need to wait an additional seven days. The Aruch HaShulchan elaborates that even though this jaundice engulfs the entire body of the baby, it is not necessary to wait seven days, because it is not the sign of sickness but rather is a normal and healthy occurrence for a baby to be born with jaundice.
However, is there ever any situation of physiological bilirubin where the milah must be delayed seven days after the child becomes healthy?
The Sefer P’sakim U’T’shuvos (263:2) lists the various opinions what number the bilirubin must reach before the milah to necessitate waiting seven days after the baby is back to normal in order to perform the milah: (i) reaches 13 (Minchas Yitzchak, but possibly would switch his opinion based on medical advice nowadays), (ii) reaches 15 (Sheivet HaLevi; see also Milas Shlomo in the name of Rav Yitzchok Zilberstein shlita), (iii) reaches 16 (T’shuvos V’Hanhagos, but would possibly require it to go a bit higher depending on circumstances), (iv) reaches 18/19 (Rav Y. S. Elyashiv zt”l), (v) reaches 19 (Rav S. Z. Auerbach).
VI. When To Start Counting
The final issue to address is: At what point do you begin counting the seven days where the bilirubin has risen to a level that requires waiting seven days? Do you start counting from the time that the bilirubin number dips below the level requiring waiting seven days (i.e., below 19 according to Rav S. Z. Auerbach above), or must you wait to start counting the seven days until the bilirubin drops below the level that you can perform the milah (i.e., below 14 according to Rav S. Z. Auerbach above)?
The sefer Milas Shlomo (p. 411-412) cites Rav Elyashiv zt”l and others who appear to rule that the counting begins only when the bilirubin is down to a level that the milah could be performed. However, the Nishmas Avraham (ibid) cites Rav Y. Y. Neuwirth zt”l who ruled that the counting may begin as long as the bilirubin level goes down to a level that does not require waiting seven days.
NEXT WEEK’S TOPIC: Must a baal t’shuvah perform hatafas dam bris (drawing of new blood) where his initial milah was performed by a mohel who was not shomer Torah u’mitzvos?