Sir,

We thank Mokashi et al1 for their interest in our review article2 and for sharing their outcomes of awake suture adjustment in older children aged 8–15 years. Their outcomes seem comparable to ours,3 though they do not specify whether any of their procedures were performed on vertical muscles. We agree that suitable patient selection and preoperative counselling help determine the success of awake adjustment in older children. We informally identify children who will not cooperate in suture adjustment using the ‘teddy bear sign’: older children who arrive at the preoperative holding area clinging to a teddy bear (or other soft toy) are probably going to require a sedated adjustment. It is important to reassure children (and adults) beforehand that if adjustment is required, they may feel some pulling but will not feel sharp pain. It is also helpful to communicate continuously during the adjustment procedure to reassure them that all is well and to inform them in advance what is going to happen next.

While patient selection may be important for awake suture adjustment in children, in our practice we offer adjustable sutures to patients of any age, regardless of whether they might be able to cooperate in adjustment. All paediatric adjustable suture patients are kept NPO until the postoperative assessment. A significant advantage of the short tag noose technique is that patients who have satisfactory alignment may be discharged home without need for any postoperative suture manipulation. If adjustment is required and sedation is needed, our anaesthesia and nursing staff in the post-anaesthesia care unit are capable of sedating the child at the bedside to allow for suture adjustment without the need for return to the operating room, which enormously simplifies the logistics. In this manner we are able to use the adjustable suture technique in appropriate candidates of any age, understanding that the youngest children (and older children with a positive teddy bear sign) will need a second stage of anaesthesia at the bedside, but only if postoperative adjustment is required.