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Am Fam Physician. 1999;59(2):433-434

Frenotomy Can Be Performed Safely in Outpatient Settings

(50th Annual Scientific Assembly of the American Academy of Family Physicians) A case report of an infant born with ankyloglossia indicates that a frenotomy can be performed safely and effectively in an outpatient setting with excellent results in infants born with ankyloglossia characterized by poor feeding and an inability to extend the tongue. In the illustrative case, a newborn male infant weighing 3,465 gm (7 lb 10 oz) was having difficulty with feeding. At discharge, the infant had lost 9 percent of his birth weight. The parents and a lactation nurse identified the infant as a “noisy” feeder with poor breast- and bottle-latch ability and a tight lingual frenulum. By day four, the infant had lost more weight. Physical examination showed an indentation of the tip of the tongue and a tight lingual frenulum. A frenotomy was performed in an outpatient clinic, and the procedure improved tongue movement. At two weeks of age, the infant was feeding normally and weighed 3,978 gm (8 lb 12 oz). The investigator believes that the clinical presentation of the illustrative case will alert family physicians to examine newborns for tight lingual frenulums that may result in poor feeding or failure-to-thrive. The most common clinical presentations of an infant with ankyloglossia include a history of failure to regain birth weight by the two-week check-up, a noisy eater, damage to the mother's nipples and poor latching ability. Physical findings include notching of the tongue tip, inability to see the tongue touching the top of the maxillary ridge, restriction of lateral movement or inability to protrude the tongue past the lower gum.—richard w. emerine, m.d., m.p.h., Family Practice Residency, Naval Hospital, Camp Pendleton, Calif.

Time for Newborn's Withdrawal from Methadone Can Be Decreased

(American Academy of Family Physicians) Infants with neonatal abstinence syndrome secondary to maternal methadone treatment during pregnancy for opiate addiction must have withdrawal treatment which often results in a lengthy hospital stay. Results of a retrospective case study to determine if there are modifiable factors that influence the length of hospital stay of such infants indicate that receiving doses of neonatal opiate solution every three to four hours instead of every six hours may shorten hospital stays for the infants. Forty-one infants born between January 1991 and December 1996 to mothers who were receiving methadone treatment for opiate addiction at time of delivery were included in the study. The factors that were analyzed to see if they were associated with a longer hospital stay were maternal methadone dose, Finnegan score at initiation of therapy, number of Finnegan scores over 8 prior to initiation of therapy, day of life when therapy was initiated, initial dose of neonatal opiate solution and peak dose of neonatal opiate solution. Peak dose of neonatal opiate solution and dosing interval were found to be significantly related to length of hospital stay. The investigator believes that more frequent dosing of neonatal opiate solution may shorten hospital stays for these infants.—heidi chumley, m.d., San Antonio, Texas.

Use of Budesonide Nebulizing Suspension in Children Is Effective

(American Academy of Family Physicians) Budesonide nebulizing suspension administered in any one of four different dosing regimens (0.25 mg once daily, 0.25 mg twice daily, 0.5 mg twice daily and 1.0 mg once daily) is an effective and well-tolerated treatment for young children ages six months to eight years who have persistent asthma, according to results of a multicenter, randomized double-blind, placebo controlled trial. The study included 481 children who had a diagnosis of persistent asthma. The children were randomized to receive one of the four treatment regimens or a placebo. A total of 471 children were evaluated for efficacy of budesonide. The primary efficacy variables that were evaluated were mean changes from baseline in nighttime and daytime asthma symptom scores over a 12-week treatment period. A total of 480 children were evaluated for safety of budesonide. The safety variables that were assessed included reported adverse events; morning basal and post-adrenocorticotropic hormone-stimulation effects on plasma cortisol levels in a subset of patients; and changes in physical examinations, vital signs and clinical laboratory results. All four groups of subjects receiving budesonide treatment showed improvements in nighttime and daytime symptoms and morning peek expiratory flow, compared with the children who received placebo. The subjects in all four treatment groups showed statistically significant reductions from baseline in the number of days a breakthrough medication was needed. There were no clinically significant differences noted in the evaluation of safety variables in the children who received treatment, compared with the children who received placebo.—martha v. white, m.d., et al., Institute for Asthma and Allergy at Washington Hospital Center, Washington, D.C.

Simulator Training Improves Performance of Flexible Sigmoidoscopy

(American Academy of Family Physicians) Training on a virtual reality simulator for flexible sigmoidoscopy improves the performance of family physician residents on subsequent flexible sigmoidoscopies in patients, according to a prospective randomized study in which 10 residents who had no experience in performing flexible sigmoidoscopies were randomized to either a control or experimental group. The residents in the experimental group were trained on a virtual reality sigmoidoscopy simulator prior to the performance of sigmoidoscopy on a patient. The residents in the control group received no training. After both groups of residents performed their first patient sigmoidoscopies, the control group and the experimental group both received training on the simulator to evaluate pre- and post-simulator training effects on performance and for comparison between the groups at different levels of simulator training. After six to 10 hours of training on the simulator, the experimental group had faster insertion times to 30 cm, to 40 cm and a shorter mean length of examination, compared with the control group prior to any simulator training for the control group. A significant improvement was also noted in hand-eye skill measures of the residents in the experimental group in directional errors, percent of colon visualized and viewing quality of examination, compared with the initial performance of the control group on patients. Residents in the control group also had significant improvement in performance times after training on the simulator following their first real patient examinations.—michael tuggy, m.d., Seattle, Washington.

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