Vol. 165, No. 6 December 2014 of tracheostomy placement for chronic ventilation. However, the bigger questions pertain to which interventions best optimize long-term neurodevelopmental outcomes in this population. Jason Gien, MD Steven H. Abman, MD Christopher D. Baker, MD Department of Pediatrics University of Colorado Aurora, Colorado http://dx.doi.org/10.1016/j.jpeds.2014.08.031
References 1. DeMauro SB, D’Agostino JA, Bann C, Bernbaum J, Gerdes M, Bell EF, et al. Developmental outcomes of very preterm infants with tracheostomies. J Pediatr 2014;164:1303-10.e2. 2. Mammel MC. The mixed blessing: neonatal tracheostomy. J Pediatr 2014; 164:1255-6. 3. Allen J, Zwerdling R, Ehrenkranz R, Gaultier C, Geggel R, Greenough A, et al. Statement on the care of the child with chronic lung disease of infancy and childhood. Am J Repir Crit Care Med 2003;168:356-96. 4. Abman SH, Nelin LD. Management of the infant with severe BPD. In: Banalari ED, ed. The newborn lung: Neonatology questions and controversies. Philadelphia: Elsevier; 2012. p. 21.1-21.19.
Reply To the Editor: We thank Gien et al for their comments on our report. We wholeheartedly agree that infants with tracheostomies deserve highly coordinated multidisciplinary care, both during the inpatient hospitalization and throughout long-term follow-up. In ventilator-dependent infants, such care often is safest when offered to the infant post-tracheostomy, at which time the focus shifts from rapid weaning of the ventilator to optimization of longer-term medical and developmental outcomes. For example, parent handling can likely only be maximized with a tracheostomy. This shift in approach is one potential explanation for our finding that earlier tracheostomy is associated with fewer adverse developmental outcomes at 18-21 months. Further studies are urgently needed to improve our understanding of how both timing and developmental interventions impact outcomes in this highly vulnerable group of infants.
Sara B. DeMauro, MD, MSCE Haresh Kirpalani, MD, MSc Division of Neonatology Department of Pediatrics The Children’s Hospital of Philadelphia University of Pennsylvania Philadelphia, Pennsylvania http://dx.doi.org/10.1016/j.jpeds.2014.08.035
Standardized nomenclature needed for epidemiologic accuracy To the Editor: A retrospective observational case-control study identified gestational age (GA) as an independent risk factor for subsequent development of asthma in the offspring, with a significantly higher risk in infants born before 32 weeks (aOR 3.9).1 The authors also report a novel finding of almost double the risk in late preterm infants with an aOR of 1.7 compared with term infants (reference group 39-40 weeks or >40 weeks). In the study methods, however, the authors categorized late preterm infants as 33-36 weeks of gestation, which is an inaccurate definition. The National Institute of Child Health and Human Development of the National Institutes of Health recommended using the terminology, late preterm, for infants born between 34 and 37 completed weeks GA (340/7-366/7 weeks GA)2 and moderately preterm for infants 320/7-336/7 weeks GA.2 It would be important for the authors to exclude infants 330/7-386/7 GA from the late preterm group as these are moderately preterm infants. In addition, they also conclude that delivery after 41 weeks might have a protective effect against asthma compared with delivery at term. ‘Term’ gestation is defined by the World Health Organization as delivery between 37 and 42 completed weeks of gestation, and this includes ‘early’ term (370/7-386/7 weeks) and ‘late’ term (410/7-416/7 weeks).3 It is important to be specific when using the terminology ‘term’ gestation as in this study, the reference group was 390/7-406/7 weeks, which is ‘full’ term; therefore, applying the results to ‘term’ delivery in general is not ideal. Also, delivery after 41 weeks includes the infants from 410/7-416/7 weeks (late term), which is in fact a subset of ‘term’ gestation. Because of the need for ongoing studies evaluating the burden of prematurity, use of globally accepted standardized nomenclature is critical for epidemiologic accuracy. Shilpi Chabra, MD Division of Neonatology Department of Pediatrics University of Washington Seattle, Washington http://dx.doi.org/10.1016/j.jpeds.2014.09.002
References 1. Harju M, Keski-Nisula L, Georgiadis L, Raisanen S, Gissler M, Heinonen S, et al. The burden of childhood asthma and late preterm and early term births. J Pediatr 2014;164:295-9. 2. Raju TN. Epidemiology of late preterm (near-term) births. Clin Perinatol 2006;33:751-63. 3. ACOG Committee Opinion No 579: Definition of term pregnancy. Obstet Gynecol 2013;122:1139-40.
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References 1. DeMauro SB, D’Agostino JA, Bann C, Bernbaum J, Gerdes M, Bell EF, et al. Developmental outcomes of very preterm infants with tracheostomies. J Pediatr 2014;164:1303-10.e2. 2. Mammel MC. The mixed blessing: neonatal tracheostomy. J Pediatr 2014; 164:1255-6. 3. Allen J, Zwerdling R, Ehrenkranz R, Gaultier C, Geggel R, Greenough A, et al. Statement on the care of the child with chronic lung disease of infancy and childhood. Am J Repir Crit Care Med 2003;168:356-96. 4. Abman SH, Nelin LD. Management of the infant with severe BPD. In: Banalari ED, ed. The newborn lung: Neonatology questions and controversies. Philadelphia: Elsevier; 2012. p. 21.1-21.19.
Reply To the Editor: We thank Gien et al for their comments on our report. We wholeheartedly agree that infants with tracheostomies deserve highly coordinated multidisciplinary care, both during the inpatient hospitalization and throughout long-term follow-up. In ventilator-dependent infants, such care often is safest when offered to the infant post-tracheostomy, at which time the focus shifts from rapid weaning of the ventilator to optimization of longer-term medical and developmental outcomes. For example, parent handling can likely only be maximized with a tracheostomy. This shift in approach is one potential explanation for our finding that earlier tracheostomy is associated with fewer adverse developmental outcomes at 18-21 months. Further studies are urgently needed to improve our understanding of how both timing and developmental interventions impact outcomes in this highly vulnerable group of infants.
Sara B. DeMauro, MD, MSCE Haresh Kirpalani, MD, MSc Division of Neonatology Department of Pediatrics The Children’s Hospital of Philadelphia University of Pennsylvania Philadelphia, Pennsylvania http://dx.doi.org/10.1016/j.jpeds.2014.08.035
Standardized nomenclature needed for epidemiologic accuracy To the Editor: A retrospective observational case-control study identified gestational age (GA) as an independent risk factor for subsequent development of asthma in the offspring, with a significantly higher risk in infants born before 32 weeks (aOR 3.9).1 The authors also report a novel finding of almost double the risk in late preterm infants with an aOR of 1.7 compared with term infants (reference group 39-40 weeks or >40 weeks). In the study methods, however, the authors categorized late preterm infants as 33-36 weeks of gestation, which is an inaccurate definition. The National Institute of Child Health and Human Development of the National Institutes of Health recommended using the terminology, late preterm, for infants born between 34 and 37 completed weeks GA (340/7-366/7 weeks GA)2 and moderately preterm for infants 320/7-336/7 weeks GA.2 It would be important for the authors to exclude infants 330/7-386/7 GA from the late preterm group as these are moderately preterm infants. In addition, they also conclude that delivery after 41 weeks might have a protective effect against asthma compared with delivery at term. ‘Term’ gestation is defined by the World Health Organization as delivery between 37 and 42 completed weeks of gestation, and this includes ‘early’ term (370/7-386/7 weeks) and ‘late’ term (410/7-416/7 weeks).3 It is important to be specific when using the terminology ‘term’ gestation as in this study, the reference group was 390/7-406/7 weeks, which is ‘full’ term; therefore, applying the results to ‘term’ delivery in general is not ideal. Also, delivery after 41 weeks includes the infants from 410/7-416/7 weeks (late term), which is in fact a subset of ‘term’ gestation. Because of the need for ongoing studies evaluating the burden of prematurity, use of globally accepted standardized nomenclature is critical for epidemiologic accuracy. Shilpi Chabra, MD Division of Neonatology Department of Pediatrics University of Washington Seattle, Washington http://dx.doi.org/10.1016/j.jpeds.2014.09.002
References 1. Harju M, Keski-Nisula L, Georgiadis L, Raisanen S, Gissler M, Heinonen S, et al. The burden of childhood asthma and late preterm and early term births. J Pediatr 2014;164:295-9. 2. Raju TN. Epidemiology of late preterm (near-term) births. Clin Perinatol 2006;33:751-63. 3. ACOG Committee Opinion No 579: Definition of term pregnancy. Obstet Gynecol 2013;122:1139-40.
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