Research

JAMA Ophthalmology | Original Investigation

Spontaneous Resolution and Timing of Intervention

in Congenital Nasolacrimal Duct Obstruction
Saraniya Sathiamoorthi, MD; Ryan D. Frank, MS; Brian G. Mohney, MD

Invited Commentary
IMPORTANCE Although the overall rate of spontaneous resolution in congenital nasolacrimal page 1286
duct obstruction (CNLDO) and efficacy of probing have been documented in the literature, Supplemental content and
the optimal timing of intervention has not been established. Journal Club Slides

CME Quiz at
OBJECTIVE To report new findings regarding spontaneous resolution in a large cohort of jamanetwork.com/learning
children with CNLDO.

DESIGN, SETTING, AND PARTICIPANTS The medical records of 1998 consecutive infants
diagnosed with CNLDO from January 1, 1995, through December 31, 2004, while residing in
Olmsted County, Minnesota, were retrospectively reviewed. Data were analyzed between
January 1, 2015, and January 2017.

MAIN OUTCOMES AND MEASURES Rate of spontaneous resolution over time and by sex.

RESULTS The cohort, diagnosed at a median age of 1.2 months (interquartile range, 0.4-3.6),
was 48% girls (n = 959) and 89% white (n = 1626; 173 were unreported). Among the 1998
cases, 1669 (83.5%) spontaneously resolved, 289 (14.5%) underwent treatment, and the
remaining 40 (2.0%) were lost to follow-up. Of the 1958 infants followed up, CNLDO in 925
(47.3%) spontaneously resolved by age 3 months, in 1300 (66.4%) by 6 months, in 1472
(75.7%) by 9 months, and in 1516 (78.4%) by 12 months. The rate of resolution was 35%
faster (95% CI, 23%-47%; P < .001) at less than 1 month vs 3 months, 43% faster (95% CI,
27%-64%; P < .001) at 3 months vs 6 months, 39% faster (95% CI, 16%-64%; P < .001) at
6 months vs 9 months, and 1% slower at 9 months vs 12 months (hazard ratio, 0.99; 95% CI,
0.80-1.22; P = .78). Congenital nasolacrimal duct obstruction resolved in boys 0.5 months
(95% CI, 0.2-0.8; P < .001) faster than girls (median, 2.9 vs 3.4 months), and unilateral
obstructions resolved 0.2 months (95% CI, 0.1-0.4; P = .002) faster than bilateral (median,
3.1 vs 3.3 months) ones. Children probed at 15 months or older had decreased odds of
resolution after probing (odds ratio, 0.11; 95% CI, 0.01-0.89; P = .04) compared with children
probed at age 12 to 14 months.

CONCLUSIONS AND RELEVANCE Based on this large cohort of children with CNLDO, probing
between age 9 and 15 months may be reasonable given that the rate of spontaneous
resolution plateaued after 9 months and initial probing success declined after 15 months. This
time frame supports both an earlier and narrower range of ages for intervention compared
with the current practice of probing after age 1 year.

Author Affiliations: Mayo Clinic

School of Medicine, Rochester,
Minnesota (Sathiamoorthi);
Department of Biomedical Statistics
and Informatics, Mayo Clinic,
Rochester, Minnesota (Frank);
Department of Ophthalmology,
Mayo Clinic, Rochester, Minnesota
(Mohney).
Corresponding Author: Brian G.
Mohney, MD, Department of
Ophthalmology, Mayo Clinic,
JAMA Ophthalmol. 2018;136(11):1281-1286. doi:10.1001/jamaophthalmol.2018.3841 200 First St SW, Rochester, MN
Published online August 30, 2018. 55905 (mohney@mayo.edu).

(Reprinted) 1281
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 Research Original Investigation
C
ongenital nasolacrimal duct obstruction (CNLDO) oc-
curs in 1 in 9 newborns1 and is characterized by per-
sistent tearing and intermittent mucopurulent dis-
charge from 1 or both eyes. Standard early treatment
includes hydrostatic nasolacrimal massage and topical anti-
biotics. While the obstruction will spontaneously resolve
in most infants, it does not in up to 25% of affected
children.2-8 Mechanical probing of the nasolacrimal duct
has been accepted as a first-line treatment for persistent
CNLDO; however, a consensus on the optimal timing for this
intervention has not been established. To capitalize on the
condition’s high frequency of spontaneous resolution,3-7
some authors propose waiting until the child is aged 12 or
13 months to probe. Others contend that delaying probing
can increase the risk of inflammation and fibrosis, which
may decrease the success rates of subsequent probings.8-10
The purpose of this study is to describe the natural course of
spontaneous resolution in a cohort of 1998 infants diag-
nosed as having CNLDO and to suggest a reasonable time
frame for surgical intervention.
Methods
The medical records of 1998 consecutive patients younger
than 5 years diagnosed as having CNLDO while residing in
Olmsted County, Minnesota, from January 1, 1995, through
December 31, 2004, were retrospectively reviewed. The
inclusion criteria and demographic data of the 1998 patients
have been previously reported.1 Institutional review board
approval was obtained from Mayo Clinic and Olmsted Medi-
cal Group, and written informed consent was obtained from
the patients’ families. The population of Olmsted County is
relatively isolated from other urban areas and virtually all
medical care is provided to its residents by Mayo Clinic,
Olmsted Medical Group, and their affiliated hospitals. All
patient-physician encounters in the county, including sum-
mary information on demographics, clinical examinations,
diagnoses, and surgical interventions, are collected through
the Rochester Epidemiology Project (REP), a computerized
medical record linkage system used in this study.11
Data regarding sex, laterality, natural history, and treat-
ment were recorded for each patient. The date on which the
symptoms of dacryostenosis resolved was established by
parental history. If the date was not documented, resolution
was calculated to occur between the last documentation of
CNLDO and the subsequent infant evaluation negative for
the condition. For example, if a child, when examined at age
2 months, was found to have dacryostenosis that was
absent at the examination at age 4 months, the calculated
date of resolution was the midpoint between the 2 examina-
tions, or at 3 months of age. Most infants had well-child
examinations at age 2 days, 2 weeks, 1 month, 2 months,
4 months, 6 months, 9 months, and 12 months. Any addi-
tional sick child visits provided increased surveillance dur-
ing relatively short intervals of time. Multiple examinations
over the years, in both primary and subspecialty care, were
reviewed to confirm full resolution of symptoms.
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Timing of Intervention in Congenital Nasolacrimal Duct Obstruction
Key Points
Question What are the trends for spontaneous resolution in
congenital nasolacrimal duct obstruction, and when is an
appropriate time to intervene?
Findings In this large population-based study of 1998 infants with
congenital nasolacrimal duct obstruction, the rate of spontaneous
resolution of congenital nasolacrimal duct obstruction plateaued
after age 9 months, and the success rate of the initial probing
declined after age 15 months.
Meaning These findings suggest that surgical intervention may be
appropriate during a new time frame, between 9 and 15 months,
capitalizing on the condition’s changing rate of resolution as well
as the declining success rate of the initial probing.
Categorical and continuous variables were descriptively
summarized using frequencies and percentages and medi-
ans and ranges, respectively. The rates of spontaneous reso-
lution, beginning at age 12 months vs 9 months, were com-
pared by first left-truncating follow-up for all patients
still being followed up at age 9 months and 12 months (ie,
b e g i n n i n g f o l l o w- u p a t 9 m o n t h s a n d 1 2 m o n t h s ,
respectively). A marginal Cox regression model clustered on
each patient was then used to estimate the relative risk of
spontaneous resolution beginning at 12 months compared
with 9 months.12 Similar methods were used to compare
3 months and 0 months, 6 months and 3 months, and
9 months and 6 months. Kaplan-Meier curves were used to
summarize overall unresolved over time for the entire
cohort and to compare time with resolution by sex and lat-
erality. Distribution of variables across the need for surgical
treatment were compared using χ2/Fisher exact tests (where
appropriate) for categorical variables and 2-sample t tests
for continuous variables. Associations between successful
probing intervention and probing age were examined using
multivariable logistic regression. A successful probing was
defined as the absence of epiphora postoperatively, whether
the condition was unilateral or bilateral preoperatively.
Other variables included in the model were diagnosis age
(categorized as <1 month, 1-2 months, 3-5 months, and 6
months or older), sex, and presence of bilateral CNLDO. All
analyses were performed using SAS, version 9.4 (SAS Insti-
tute Inc). All tests were 2-sided.
Results
Among the 1998 infants who received a diagnosis during the
10-year period, CNLDO in 1669 (83.5%) spontaneously
resolved, 289 (14.5%) required surgical treatment, and 40
(2.0%) were lost to follow-up. The principal cohort of this
study is the 1958 infants followed up, which includes the
1669 whose obstruction spontaneously resolved and the
289 who required surgical intervention. The 1669 whose
obstruction spontaneously resolved were diagnosed at a
median age of 1.0 months compared with 6.0 months for
jamaophthalmology.com
 Timing of Intervention in Congenital Nasolacrimal Duct Obstruction Original Investigation Research

Figure 1. Overall Percentage Without Spontaneous Resolution Over Time Using Kaplan-Meier Methods in 1958 Infants

100

80

Overall Unresolved, %
60

40

20

0
0 1 3 6 9 12 15 18 21 24
Patient Age, mo
No. at risk 1958 1027 647 426 328 214 179 142 121
No. of obstructions that
spontaneously resolved 0 925 1300 1472 1516 1581 1590 1600 1610

Figure 2. Percentage of Children Whose Obstruction Eventually Spontaneously Resolved at Any Time After Specified Age

100
Patients Whose Obstruction Will

80
Spontaneously Resolve, %

60

40

20

0
0 2 4 6 8 10 12 14 16 18 20 22 24 26
Age, mo
No. at risk 1958 1170 783 647 481 381 328 244 206 179 154 131 121
No. of obstructions that
spontaneously resolved 1669 884 501 369 234 177 153 102 85 79 73 65 59

the 289 who required treatment (P < .001). Figure 1 illus- resolved 0.2 months faster (95% CI, 0.1-0.4; P = .002) than
trates graphically the number and percentage of the 1958 bilateral (median, 3.1 vs 3.3 months) ones (eFigure 2 in
observed infants whose obstruction had not yet spontane- the Supplement).
ously resolved by age in months. The median age at resolu- Two hundred seventy-two (94.1%) of the 289 surgically
tion was 2.4 months (interquartile range, 1.3-5.3 months; treated patients eventually underwent a probing, of which
range, 0-87 months) for the 1669 whose obstruction sponta- 242 (89%) had obstruction resolve without additional treat-
neously resolved, while the 289 surgically treated patients ment. After adjusting for the effects of age at diagnosis, sex,
u n d e r we nt t h e i r f i r s t p r o c e d u r e at m e d i a n a ge o f and laterality, children probed at 15 months or older had
14.0 months (interquartile range, 9.5-21.1 months; range, decreased odds of resolution after probing (OR, 0.11; 95%
1-248 months). CI, 0.01-0.89; P = .04) relative to children probed at age
The rate of spontaneous resolution was highest in the 12 to 14 months (Table). When patients younger than
first few months of life, declining until age 9 months, when 9 months (OR, 0.16; 95% CI, 0.02-1.35; P = .09) and aged
the rate flattened thereafter as shown in Figure 2. The rate 9 to 11 months (OR, 0.41; 95% CI, 0.04-4.10; P = .45) were
of resolution was 35% faster (95% CI, 23%-47%; P < .001) at compared with probed patients aged 12 to 14 months, there
younger than 1 month vs 3 months; 43% faster (95% CI, was no difference in their success rates. The success rate of
27%-64%; P < .001) at 3 months vs 6 months; 39% faster probing was 89.5% (n = 68 of 76) in children younger than 9
(95% CI, 16%-64%; P < .001) at 6 months vs 9 months; and months, 94.5% (n = 52 of 55) in children aged 9 to 11
1% slower at 9 vs 12 months (HR, 0.99; 95% CI, 0.80-1.22; months, 97.8% (n = 45 of 46) in children aged 12 to 14
P = .78). Boys’ obstruction resolved 0.5 months faster (95% months, and 81.1% (n = 77 of 95) in children months or
CI, 0.2-0.8; P < .001) than girls’ (median, 2.9 vs 3.4 months) older. When segregated by 6-month age groups, a successful
(eFigure 1 in the Supplement), and unilateral obstructions initial surgical intervention was 90.2%, 83.1%, 71.4%, and

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 Research Original Investigation Timing of Intervention in Congenital Nasolacrimal Duct Obstruction

Table. Associations Between Probing Age and CNLDO Resolution Using Multivariable Logistic Regression
Total No. CNLDO Resolution Without Additional Odds Ratio (95%
Characteristic (N = 272) Treatment, No. (%) (n = 242) CI)a P Value
Probing age, mo
<9 76 68 (89.5) 0.16 (0.02-1.35) .09
9-11 55 52 (94.5) 0.41 (0.04-4.10) .45
12-14 46 45 (97.8) 1 [Reference] NA
≥15 95 77 (81.1) 0.11 (0.01-0.89) .04
Age at diagnosis, mo
<1 51 47 (92.2) 1 [Reference] NA
1-2 43 41 (95.3) 1.91 (0.33-11.24) .47
3-5 42 38 (90.5) 0.85 (0.19-3.73) .83
≥6 136 116 (85.3) 0.59 (0.18-1.96) .39 Abbreviations: CNLDO, congenital
Sex nasolacrimal duct obstruction;
NA, not applicable.
Male 121 110 (90.9) 1.38 (0.61-3.11) .43
a
An odds ratio significantly less than
Female 151 132 (87.4) 1 [Reference] NA
1.0 can be interpreted as a
Bilateral decreased odds of successful
No 181 164 (90.6) 1 [Reference] NA CNLDO resolution without further
intervention relative to the referent
Yes 91 78 (85.7) 0.80 (0.36-1.81) .60
group.

64.7% at ages 6 to 12 months, 12 to 18 months, 18 to 24
months, and older than 24 months, respectively.
Discussion
In this population-based cohort of 1958 followed-up infants,
complete resolution of CNLDO with nonsurgical treatment was
achieved in 1516 patients (78.4%) by the first year of life. The
rate of resolution was highest in the first months of life, de-
creasing until 9 months of age, after which the rate changed
minimally. The obstruction resolved faster in boys than girls
and in unilateral disease compared with bilateral disease. Pa-
tients probed at 15 months or older had lower odds of resolu-
tion without additional treatment compared with those probed
at age 12 to 14 months, with no difference in the success
rates between patients younger than 9 months and aged
9 to 11 months.
Spontaneous resolution has been reported to occur in more
than 90% of infants treated conservatively by several clinical
studies.2-4,7,13 However, most of these studies were of se-
lected populations, with less than 200 patients. Their small
sample sizes and associated biases may have provided impre-
cise and unrepresentative estimates. While our study corrobo-
rates the tendency of CNLDO to resolve without surgical treat-
ment as suggested in the literature, it does so with a relatively
lower 1-year resolution rate. In this cohort diagnosed over a
10-year period, 78.4% of the observed infants spontaneously
resolved by 12 months, and among the 1669 who never re-
quired surgical treatment, 1516 (90.8%) had resolved by the
first year of life.
The rate of resolution decreases with increasing age, as ob-
served by other investigators3,6 and confirmed in this cohort.
Beginning at soon after birth, the spontaneous resolution rate
declines by approximately 30% every 3 months until age
9 months, at which time the rate plateaus. Although the rate
of resolution is no better at age 9 months compared with
12 months, there are fewer patients at age 1 year who have the
potential to resolve. In this study, nearly 9 of 10 patients whose
obstruction spontaneously resolved did so by age 9 months.
The condition resolved faster in boys than in girls, which,
to our knowledge, has not been previously demonstrated. Al-
though the rate of resolution between the sexes was small and
is likely to be clinically irrelevant, any differences could be ow-
ing, at least in part, to the observation that the nasolacrimal
canal and fossa of girls is a mean of 0.35 mm smaller than
boys. 1 4 Resolution of CNLDO also occurred faster in
unilateral disease than bilateral disease, consistent with
prior reports.15-17
Several studies have described an age-dependent de-
crease in success rates of initial probings from greater than 90%
when done before age 12 months to 50% to 70% of those done
after.13-16,18 One group noted a similar decline when compar-
ing the success of probings before age 6 months with those be-
tween age 6 months and 12 months.19 However, the Pediatric
Eye Disease Investigator Group, reporting on a prospective co-
hort of 718 children, did not find an association between age
at surgery and surgical success up to age 36 months.17 The find-
ings of this cohort confirm a negative association between in-
creasing age after 15 months and a successful initial surgical
intervention. The poorer results in older children have been
attributed to the development of more complicated obstruc-
tions from chronic infections and scarring.20 Moreover, be-
cause the median age at CNLDO diagnosis was 6.0 months in
the group who received surgical treatment compared with 1.0
months in those who spontaneously resolved, the decreasing
success of probings in older children is likely owing to natural
selection. Presumably, later-presenting children may have more
complicated obstructions that reduce successful outcomes.
The optimal timing of the first probing remains contro-
versial. A number of studies advocate delaying surgical pro-
cedures until after the first year of life, citing CNLDO’s high rate
of spontaneous resolution.3-7 However, others favor early prob-
ing, citing the decline in favorable outcomes with increasing

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 Timing of Intervention in Congenital Nasolacrimal Duct Obstruction Original Investigation Research

age as well as the previous reports of morbidities associated Limitations

with persistent CNLDO.8-10 Conflicting conclusions based on
underpowered studies, case series, and expert opinions pro-
mote the ongoing controversy. Given that the overall resolu-
tion rate changes minimally after age 9 months, it may be rea-
sonable to consider intervening earlier than the current practice
of probing at 12 months or older. However, probing beyond 12
months, as demonstrated by this study and others, appears to
be less successful than when performed before age 1 year.
While probing with general anesthesia is recommended for
better procedural control and completion, studies in the past
several years on the association of childhood anesthesia and
the development of cognitive impairment have questioned
whether some procedures, including probings under anesthe-
sia, is worth the risk. However, these studies suggest that mul-
tiple, not single, exposures to anesthetics and cumulative ex-
posure greater than 120 minutes were associated with
increased learning disabilities.20 Neurotoxicity risk stratified
by being younger than 18 months is nonexistent in the litera-
ture; that is, there is no calculated difference in anesthesia risk
for a 9-month-old child compared with a 1-year-old child. Find-
ings from the landmark Pediatric Anesthesia Neurodevelop-
ment Assessment study also demonstrated that 1 brief anes-
thetic, of a duration less than 80 minutes, was not associated
with cognitive or behavioral abnormalities in exposed chil-
dren when compared with their unexposed sibling.21 A prob-
ing typically involves less than 20 minutes of anesthetic ex-
posure, and 80% to 90% of children require only one
procedure.17 An argument for earlier probing, other than a
higher success rate, is that by delaying procedures, older chil-
dren could develop more complicated obstructions and ulti-
mately require additional surgical procedures and increased
exposure to general anesthesia.
There are a number of limitations to the findings in this study.
Its retrospective design is limited by nonstandardized and in-
complete documentation. Accurately determining the age at
resolution, for example, was problematic. Although most in-
fants experienced 8 to 9 well-child examinations by age
18 months, both parental observation and the calculated date
of resolution could have been calculated imprecisely if they
were not. However, underestimations of the age at resolution
would be expected to be balanced by overestimations with no
systemic bias and no effect on the observations regarding sex,
laterality, and the total number of resolutions. Although the
REP system is uniquely designed to capture all of a patient’s
medical visits in Olmsted County, some residents may have
sought care outside of the county, leading to an overestima-
tion of spontaneous resolution rate in this population. Fi-
nally, our ability to generalize these findings to other popula-
tions is limited by the demographics of Olmsted County, a
relatively homogeneous semiurban white population.
Conclusions
Given that the rate of spontaneous resolution appears to pla-
teau after age 9 months and a successful probing outcome de-
clines beyond age 15 months, surgical intervention between
these time intervals appears to be a reasonable treatment strat-
egy for infants with nasolacrimal duct obstruction. This time
frame establishes both an earlier and narrower range of ages
for intervention compared with the current general practice
of probing after age 1 year. Further prospective investigation
is needed to definitively determine the most appropriate age
for surgical intervention in children with CNLDO.

ARTICLE INFORMATION
Accepted for Publication: July 12, 2018.
Published Online: August 30, 2018.
doi:10.1001/jamaophthalmol.2018.3841
Author Contributions: Drs Sathiamoorthi and
Mohney had full access to all the data in the study
and take responsibility for the integrity of the data
and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: Sathiamoorthi, Mohney.
Statistical analysis: Sathiamoorthi, Frank.
Obtained funding: Mohney.
Administrative, technical, or material support:
Sathiamoorthi, Mohney.
Supervision: Mohney.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Funding/Support: The study was supported by
Research to Prevent Blindness Inc and the
Rochester Epidemiology Project (grant R01-
AG034676 from the National Institute of Arthritis
and Musculoskeletal and Skin Diseases).
Role of the Funder/Sponsor: The funding sources
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
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Invited Commentary

Timing of Simple Probing for Congenital Nasolacrimal

Duct Obstruction
Not So Simple
Michael X. Repka, MD, MBA

The treatment of congenital nasolacrimal duct obstruction
(CLNDO) has long been a subject of debate, especially about
the optimum age to intervene. This debate has centered on
3 issues: (1) the spontaneous resolution rate and when it de-
clines, (2) the success of ini-
Related article page 1281
tial nasolacrimal duct prob-
ing and how it is affected
by age, and (3) the preferred site of service. In this issue of JAMA
Ophthalmology, Sathiamoorthi et al address the first 2 issues.1
When the spontaneous resolution rate is high, fewer children
need probing. However, the tradeoff for the chance of
avoiding surgery and in many cases general anesthesia is
additional months of CNLDO symptoms while awaiting
resolution. Concern has been voiced by some clinicians that
the delay in probing, with more months of symptoms, may be
associated with scarring of the nasolacrimal duct and could
be in part cause for lower success following simple probing in
older children.
In this study, the authors retrospectively evaluated medi-
cal record data from the Rochester Epidemiology Project (REP)
for 1998 children diagnosed as having CNLDO symptoms early
in the first year of life.1 These data are drawn from a population-
based sample rather than a clinic-based sample. The advan-
tage of this design is that the description and outcomes of the
disease better reflect the disease as seen in that community,
rather than a more limited set of patients seen at a particular
clinic. Therefore, the findings well represent outcomes for in-
fants with CNLDO living in portions of Minnesota and Wis-
consin included in the REP, but may not be generalizable to
patients from other regions or of other races/ethnicities. In ad-
dition, data were not collected in an organized fashion spe-
cifically to study CNLDO. Thus, the authors had to retrospec-
tively determine whether there was spontaneous resolution
or success of a probing based on their medical records review
of whether symptoms were present in subsequent records. In
addition, resolution was considered by the authors to have oc-
curred even when there was no follow-up because it was
assumed nearly all patients in the region would have been seen
somewhere and thus their records included in the database.
This decision, as the authors acknowledge, does bias their find-
ings slightly toward increased rates of spontaneous resolu-
tion and surgical success.
Overall, the authors found an overall spontaneous reso-
lution rate of 83.5%,1 comparable with other reports support-
ing the clinical decision to wait to perform surgery.2-5 As would
be expected, the rate of resolution was highest among the
younger children, declining with age, but remaining at just less
than 50% for children between ages 12 and 24 months. The
Pediatric Eye Disease Investigator Groups (PEDIG) conducted
a prospective randomized treatment study enrolling children
between ages 6 and 9 months and found the rate of sponta-
neous resolution to be 66% (95% CI, 54% to 76%).5 The over-
all spontaneous resolution rate in this Olmstead County proj-
ect was likely higher for at least 2 reasons. The most important
reason would be because they included infants from birth to
age 6 months, who they noted have a very high spontaneous
resolution rate. In addition, unlike the PEDIG trial, which had
masked outcome assessments, there was no specific
required outcome examination, so mild symptoms could have
been ignored in the medical records and the patient termed a
success. Lastly, their decision on how to account for no
follow-up differed from the PEDIG trial, as resolution
noted earlier.
The overall surgical success rate for simple probing was
89% (242 of 272),1 performed at a median age of 14.0 months.
This rate is similar to other reports.3,5-8 Success was high for
children up to age 14 months (93.2%) but declined to 81.1% in
the group 15 months and older. While this difference was sta-
tistically significant, it is a fairly small decline. More impor-
tantly, I do not believe the data suggest that the significant
change actually occurs at age 15 months and thus indicate the
time to perform surgery. In fact, when reviewing the data, 25%
of the children having probing (and comprising most of this
≥15 months age group) were older than 21 months (range, up

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