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Foreskin retraction: Not so age-specific

I write on behalf of Doctors Opposing Circumcision (DOC). Our organization applauds actions to improve care of the normal intact penis by educating the medical community and the public. The authors of "Caring for the uncircumcised penis: What parents (and you) need to know" (November 2002) have made a commendable effort in that direction. However, they have repeated the medical myth that the foreskin should retract by 5 years of age.

This myth is derived from data published in 1949 by Gairdner, who reported that 92% of 5-year-olds have a fully retractable prepuce. To achieve this figure, Gairdner first passed a blunt probe under the foreskin to break normal developmental attachments (a practice not recommended). This produced a falsely high rate of retractibility (Gairdner D: Br Med J 1949;1:1433). Subsequent research has demonstrated that the age of full retraction typically is much later (Oster J: Arch Dis Child 1968; 43:200; Kayaba H et al: J Urol 1996;156:1813; Morales Concepcion JC et al: Arch Esp Urol 2002;55:807). Approximately 40% of boys have a completely retractable prepuce at age 8 to 10 years; about 70%, at age 11 to 15 (Kayaba H et al); and about 99%, at age 18 (Oster J). In the 5- to 7-year-old group, Kayaba found that approximately 23% have a fully retractable prepuce, as compared with Gairdner's report of 92%. The nonretractile prepuce is, therefore, well within the normal range before age 18.

The notion that a 5-year-old should have a fully retractable foreskin should be buried. The new rule of thumb is that 50% of boys should have a retractable prepuce by puberty and puberty takes care of the rest.

Dr. Gairdner's inaccurate information, which, regrettably, has found its way into many medical texts, undoubtedly contributes to physician misunderstanding and many false diagnoses of phimosis, and, consequently, unnecessary postneonatal circumcision (Rickwood AMK et al: Ann R Coll Surg Engl 1989;71:275; Griffiths D et al: J R Soc Med 1992;85:324; Williams N et al: BMJ 1993;306:28). Increased use of evidence-based medicine and resulting better physician education has substantially reduced the misdiagnosis of phimosis and the incidence of unnecessary circumcision in England in recent years (Rickwood AMK et al: BMJ 2000;321:792). It is, therefore, important to discard erroneous information about the normal development of the prepuce so that the high rate of unnecessary postneonatal circumcision in North America can be reduced.

The first person to retract the prepuce should be the child himself. Only the child will know when the foreskin can be retracted without pain or trauma. Physicians should avoid retraction of the prepuce because it is painful and traumatic; may tear the synechial membrane that fuses the foreskin to the glans; may cause infection, iatrogenic adhesions, phimosis, and paraphimosis; and could result in medicolegal issues.

George Hill
Executive Secretary
Doctors Opposing Circumcision
Seattle, Wash.

Levalbuterol: Attractive for bronchiolitis?

Thank you for the nice review on bronchiolitis ("Bronchiolitis dilemma: A happy wheezer and his unhappy parent," November 2002). The problems with selective ß 2-adrenergic agonists, presumably albuterol, are increased oxygen consumption, tachycardia, potential worsening of lung ventilation/ perfusion, and short duration of symptom relief. Levalbuterol, a newly developed bronchodilator, is a version of albuterol that causes significantly less tachycardia, oxygen consumption, and irritability in asthma patients compared to racemic albuterol, while providing a longer period of bronchodilation. This improved side effect profile makes it sound much more useful for bronchiolitis. Has this medication been studied in bronchiolitis patients?

Brian W. Donnelly, MD
Pittsburgh, Pa.  

The author replies: I am unaware of any studies that have examined the effect of levalbuterol among infants with bronchiolitis. While the potential for an improved side effect profile is inviting, the lack of efficacy of albuterol for the treatment of bronchiolitis diminishes the likelihood that the related bronchodilator will be effective. The only way to answer this question, however, is with a placebo-controlled clinical trial.

Anne Gadomski, MD, MPH

When to refer a facial laceration to a plastic surgeon

Drs. Nowak and Slayton ("Trauma to primary teeth: Setting a steady management course for the office," November 2002) have performed a significant service with their review of the management of oral trauma, specifically as it pertains to primary teeth and the impact of trauma on the development of secondary teeth. One point made in the article, however, deserves further comment. In stating that "a facial laceration in a highly visible area that requires suturing . . . should be attended to by a plastic surgeon," the authors perpetuate a popular myth that is not borne out by clinical experience and that sets unrealistic and unnecessary expectations for parents.

Although it is essential for the emergency provider to have expertise in wound assessment and management (as well as in pediatric distraction or sedation, or both), the development of such skill is part of general and pediatric emergency medicine training. Unusually complex lacerations (large or jagged dog bites, for example) may require the services of a plastic or oromaxillofacial surgeon, but the great majority of facial wounds need only simple closure.

Reminding families that lacerations heal, by definition, through scar formation is important. Teaching them the importance of moisturizer and sunblock will promote an optimal final result. However, pediatric emergency medicine subspecialists and board-certified emergency medicine physicians should be viewed as adept at, and capable of, managing the majority of facial lacerations.

John C. Brancato, MD
Hartford, Conn.  

The authors reply: In communities that may not have ready access to an oral or plastic surgeon, we agree with Dr. Brancato's recommendations. We did review "The model of the clinical practice of emergency medicine" (Hockberger RS et al: Ann Emerg Med 2001;37:745) to determine procedures and skills integral to the practice of emergency medicine. We noted that, in the section "Other Techniques," wound closure techniques and wound management are included. A further review of the literature did not report any outcome measures comparing results from plastic surgeons and emergency medicine physicians when managing facial lacerations in highly visible areas.

Arthur J. Nowak, DMD
Rebecca L. Slayton, DDS, PhD


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