Translated by David Fink, Ph.D.

The issue of circumcising jaundiced babies is still current in halachic literature. Cases arise daily. Around one hundred thousand Jewish babies are born every year in Israel and slightly more than half are boys who undergo circumcision. Many of them experience a period of jaundice that can be evaluated by a blood test measuring their bilirubin level.

There are three basic categories associated with jaundice in babies:

Category 1: Jaundice that has the status of an “illness of the whole body” requiring a full seven-day waiting period between the moment of recovery and the act of circumcision (sources: Shmuel in Tract. Shabbat 137a; Y.D. 262:2).

Category 2: Jaundice that, although not considered an illness, does make the baby appear yarok (tinged with yellowish color) requiring a delay of the act of circumcision until the color reverts to normal (sources: Tract. Shabbat 134a; Y.D. 263:1). According to the Yoreh De'ah the seven-day waiting period is not required in this case.

Category 3: Mild physiological jaundice, which is not considered an illness and is not sufficiently pronounced that the baby is considered "tinged with yellowish color." In the absence of any other medical counter indication, this case calls for prompt circumcision.

How is the Baby's Status Determined?

The principle problem is determining to which of the three categories a specific baby belongs. Is skin tone or etiology definitive?

It should be clear that we are speaking only about cases where in medical opinion there is no danger associated with circumcision. If in the opinion of a physician the procedure would be dangerous, it is of course prohibited to circumcise the baby even in the absence of any visible symptoms. Any condition which is considered to be life threatening clearly has the status of an "illness of the whole body" requiring a full seven-day waiting period between the moment of recovery and the circumcision. We therefore shall limit our discussion to cases that are medically defined as "physiological jaundice."

It is prohibited to circumcise a jaundiced baby even when a pediatrician determines that the procedure is safe. We accept the opinion of our Sages as codified in the Shulchan Aruch: “A jaundiced child... is not to be circumcised until his blood is restored and his appearance reverts to that of other children”. Such jaundice is clearly in category 2.

The difference between jaundice that requires waiting until it passes (category 2) and mild jaundice that does not call for any delay is explained in the Nishmat Avraham (Vol. 2, Y.D. 263:1 s.v. tinok ha-tzahov). According to R. Sh.Z. Auerbach, the mohel must make the diagnosis. The baby is to be circumcised as soon as “it appears to the mohel that he is no longer jaundiced”.

Distinguishing Category 1 from Category 2

There is some lack of clarity regarding the difference between categories 1 and 2. We have already discussed the clear-cut cases. Any case that a physician considers medically significant or life threatening is surely in category 1. Therefore, any case which requires blood transfusion because of anemia combined with an elevated bilirubin level is universally considered an "illness of the whole body" requiring a full seven-day waiting period. Further, such a case is life threatening (Nishmat Avraham, Vol. 2, Y.D., ibid.). In the fourth volume of Nishmat Avraham, the author added, in the name of R. Sh.Z. Auerbach, that a bilirubin level of 18mg% or higher constitutes an "illness of the whole body.”

We still must determine when to begin counting the seven full days: from the moment that the bilirubin level falls below 18mg% or from the moment that “it appears to the mohel that he is no longer jaundiced”?

R. Y.Y. Neuwirth decided in favor of the first option (counting seven full days from the moment that the bilirubin level falls below 18mg%). But R. Sh.Z. Auerbach tended to begin the count from the moment that the baby no longer appears jaundiced. R. Sh.Z.

Auerbach’s doubt in this matter clearly requires us to take a strict stance since this is a potentially life-threatening situation. It follows that the seven-day count should begin at whichever is later: the fall of the bilirubin level or the improvement in the baby’s appearance.

The Decision of Rabbi Yisrael Zeev Gustman

In the mid eighties, I had the pleasure of discussing this matter with Rabbi Yisrael Zeev Gustman, a former member of the Rabbinical Court of R. Chaim Ozer in Vilna and the Dean of the Netzach Yisrael Rabbinical Academy in New York and Jerusalem. Rabbi Gustman was quite definite in his opinion that one must wait seven full days from the moment that the baby looses its jaundiced appearance.

Rabbi A. Farbstein, the Dean of the Hevron Rabbinical Academy in Givat Mordechai, Jerusalem, held the same opinion.

Hemolytic Jaundice due to ABO Incompatibility

This is the background: My son, Eliezer, was born with his father’s type A blood. Due to incompatibility between his blood type and his mother’s (type O), he developed jaundice on the first day after his birth. His bilirubin level rose to around 15.5mg%. The baby was treated with photo therapy in order to slow the rising bilirubin level. The rise in level was arrested, and the level began to fall slowly.

From a medical point of view, there was no counter indication to circumcision, and some physicians characterized his condition as “physiological jaundice”. This characterization, although well meant, was imprecise. Physiological jaundice develops a few days after birth as a result of the natural process of disintegration of fetal red blood cells in the slowly maturing liver.

Eliezer had, in addition to the normal physiological reason for jaundice in the newborn, a second, pathological reason: hemolysis resulting from the effect of maternal antibodies on fetal blood cells. The damage was, thank God, not great.

It is known that incompatibility of the main blood types does not generally cause great damage, unlike incompatibility of Rh types, which causes severe, life-threatening damage. Nonetheless, it is clear that this was not a normal case. It was rather a mild hemolytic disorder, caused by the effect of maternal antibodies on the newborn.

It follows that hemolytic jaundice is a systemic illness involving the whole body. It therefore requires delaying the circumcision for seven full days after recovery.

In consultation with great rabbis, as described above, his circumcision was delayed until Friday, when seven full days had passed from the moment that he no longer appeared jaundiced to the eye of the mohel.

Source: Medicine & Halacha (Hebrew), May 2006, pp. 336-338.