Tongue tie or ankyloglossia has been the subject of much controversy. As defined in this review, tongue tie occurs when a common minor embryologic tissue remnantpersistence of midline sublingual tissue that usually undergoes apoptosis during embryonic development-causes restriction of normal tongue movement. Effective breastfeeding requires newborns to fine-tune their tongue movements to adapt to their mothers' particular nipple and breast anatomy and physiology. In the presence of tongue tie, two categories of signs/symptoms arise: those related to nipple trauma and those related to ineffective breast emptying and low infant intake. Untreated tongue tie can lead to untimely weaning and its attendant health risks. Frenotomy is a safe and effective procedure to release tongue tie and improve tongue function and breastfeeding outcomes.Objectives After completing this article, readers should be able to:1. Recognize the existence of tongue tie as a condition that can potentially cause clinical dysfunction. 2. Understand the pathophysiologic mechanisms of clinical signs and symptoms of tongue tie in a breastfeeding dyad. 3. Determine when to refer a breastfeeding infant for frenotomy.

ABSTRACT. Phototherapy results in the conversion of native bilirubin to more water-soluble configurational and structural isomers. The serum half-life for the configurational isomer, the principal photoproduct in vivo, was determined by high pressure liquid chromatography in six premature infants following cessation of phototherapy. The mean half-life for this isomer was 15 h. The excretion of this isomer, calculated from the measured half-life, is less than half of daily bilirubin production, and therefore cannot account for the total bilirubin elimination observed during phototherapy. The serum concentration of the structural isomer, lumirubin, is lower than that of the configurational isomer; however, excretion is more rapid (serum half-life < 2 h). Because of its rapid excretion, lumirubin may be an important pathway for bilirubin elimination during phototherapy. (Pediatr Res 19: 205-208, 1985) Abbreviation HPLC, high pressure liquid chromatography Despite the widespread use of phototherapy in the treatment of neonatal hyperbilirubinemia (l), the detailed mechanism by which visible light affects bilirubin metabolism in jaundiced newborns is not known. The purpose of this study was to measure the rate of elimination of the principal bilirubin photoproduct, 4Z,15E-bilirubin, and to determine whether this is sufficient to Received June 22, 1984; accepted October 3, 1984. Address account for the decline in plasma bilirubin observed during phototherapy.Bilirubin, derived from the degradation of heme, is a potentially toxic, highly lipophylic molecule. In mammals this pigment is ravidlv cleared from the circulation and excreted as a ducuronide~onju~ate, primarily in the bile (2). Newborn i n f a k commonly develop hyperbilirubinemia due in part to a decreased ability to conjugate bilirubin and an increased pigment load. During vhototheravy, the most commonlv used treatment for unconj~~ated&~~dilirubinemia, bilirubin undergoes several reactions (3-7). All of these reactions yield photoproducts which are more polar and therefore presumably more easily excreted than native bilirubin. The fastest photochemical reaction is a Z to E isomerization reaction (5, 8) which in human infants yields primarily the 4Z,15E-bilirubin isomer (6). This reaction is readily reversible and up to 20% of the total bilirubin can be converted to this isomer during phototherapy (9-12).Since the quantum yield of the configurational isomerization reaction is at least 40 times greater than that for any other photochemical reaction of bilirubin (8), it has been assumed that the elimination of bilirubin during phototherapy is the result of formation and excretion of this photoproduct. We have used a rapid, quantitative HPLC method (5) to measure the half-life of the configurational isomer in serum of preterm infants undergoing phototherapy. We have found that the rate of elimination of the 4Z,15E-bilirubin isomer is much slower than previously reported (13) and cannot account for the decline in serum bilirubin observed in infants treated wit...

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Results provide preliminary support for scale reliability and construct validity. As residencies seek to meet expectations of the Accreditation Council for Graduate Medical Education's Outcome Project, rCBS could prove useful in program evaluation, residents' self-assessment, and assessment by serving as a means to explore how residents learn, how residency programs affect learning behavior, and how clinically strong and weak residents differ in learning behaviors.

Lumirubin, a water-soluble photoproduct of bilirubin formed in vivo during phototherapy, is excreted in the urine. In premature infants with little or no bilirubin conjugating activity, lumirubin is the principal yellow pigment found in the urine during phototherapy. The clearance rate of lumirubin in nine premature infants varied from 0.05 to 0.65 ml/min and increased with postconceptional age in parallel with increased creatinine clearance rate. The amount of lumirubin excreted per 24 h was estimated to be from 0.2 to 9.4 mg with a mean of 3.2 mg. The urinary excretion of lumirubin is a significant pathway for pigment elimination during phototherapy.

Insulin may be an important regulator of growth in late fetal life. To assess the importance of endogenous insulin release in regulation of normal fetal growth, eight fetal lamb pairs were given either an intravenous injection of streptozocin (STZ), a nitrosourea that selectively damages pancreatic beta-cells, or buffer infusion (controls). In six preparations, twins were used, and in two cases, triplets, thus allowing for comparison between treated and control fetuses residing in the same intrauterine environment. Fetal STZ injection was associated with relative fetal hyperglycemia, hypoinsulinemia, and a decrease in the fetal plasma insulin-glucose ratio. Fetal lambs exposed to STZ also developed a mild nonprogressive metabolic acidosis compared with controls. Fetal body weight was depressed by 21% overall, the magnitude of reduction related to length of time in utero after STZ injection. Similar reductions in organ weights (liver, heart, and kidney) were also observed in STZ-administered fetuses compared with controls. Protein accretion in carcass, liver, and kidney after STZ was also depressed, but no significant changes in fetal lipid accretion were observed. Skeletal growth, as measured by tail and tibial lengths, was also depressed after STZ but to a lesser extent than body weight or protein accretion. Thus, in a stable maternal environment, isolated fetal insulin deficiency is associated with significant retardation of somatic and skeletal growth and protein deposition.

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