Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Critical Care Medicine www.ccmjournal.org 1 Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation. Data Sources: We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational stud- ies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. In- cluded articles were subjected to manual searching. Study Selection: Studies in mechanically ventilated children that compared early with late tracheostomy were included. Data Extraction: Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). Data Synthesis: Data were meta-analyzed using an inverse vari- ance, random effects model. Continuous outcomes were calculated as mean differences with 95% CIs, and dichotomous outcomes were calculated as Mantel-Haenszel risk ratios with 95% CIs. We included eight studies (10 study arms). These studies were all ret- rospective cohort studies. Early tracheostomy was associated with significant reductions in mortality, days on mechanical ventilation, and length of intensive care and total hospital stay, although the lack of randomized, controlled trials limits the validity of these findings. Although variance was imputed for some studies, these conclusions did not change after removing these studies from the analysis. Conclusions: In children on mechanical ventilation, early trache- ostomy may improve important medical outcomes. However, our data demonstrate the urgent need for high-quality, randomized controlled trials in the pediatric population. (Crit Care Med 2019; XX:00–00) Key Words: critical care; early tracheostomy; late tracheostomy; pediatric; ventilation T racheostomy is a frequent clinical procedure performed in critically ill adult patients. It is especially advanta- geous in improving patient comfort, speech, and oral intake, compared with endotracheal intubation. Tracheostomy 1 Department of Anesthesia, Pain Management and Surgical Intensive Care, Beni-Suef University Hospital and Faculty of Medicine, Beni Suef University, Beni Suef, Egypt. 2 Department of Anaesthesia, Birmingham Children’s Hospital, Bir- mingham, United Kingdom. 3 Department of Anaesthesia, Cambridge University Hospitals, Cam- bridge, United Kingdom. 4 School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia. 5 Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt. 6 Department of Anesthesia, Ain Shams University Hospital and Faculty of Medicine, Ain Shams University, Cairo, Egypt. 7 The Department of Cardiothoracic Anaesthesia and Intensive Care, Essex Cardiothoracic Center, Basildon and Thurrock University Hospi- tals NHS Foundation Trust, Basildon, United Kingdom. 8 Department of Anesthesia, Faculty of Medicine and Fayoum University Hospital, Fayoum University, Faiyum, Egypt. 9 Department of Anesthesia, National Cancer Institute, Cairo University, Cairo, Egypt. 10 Medical Research Librarian, United Kingdom. 11 Department of Science and Technology, University of Canberra, Can- berra, ACT, Australia. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Reeves received funding from Ahmed Mahmoud. The remaining authors have disclosed that they do not have any potential conflicts of interest. ORCID ID: 0000-0002-0473-9764. For information regarding this article, E-mail: carnitin7@yahoo.com; dr. ahmedabdelaalmahmoud@gmail.com; ahmed.alkhatip@nhs.net Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000004114 Timing of Tracheostomy in Pediatric Patients: A Systematic Review and Meta-Analysis Ahmed Abdelaal Ahmed Mahmoud M. Alkhatip, MD, EDAIC, FCAI 1,2 ; Mohamed Younis, EDAIC, FCAI 3 ; Negar Jamshidi, BSc(Hons), BDSc 4 ; Hazem A Hussein, MSc, MD 1 ; Ehab Farag, MD, EDAIC, FCAI 1 ; Mohamed K. Hamza, MD, EDAIC 5 ; Mahmoud H. Bahr, MSc, MD 1 ; Ahmed Goda Ahmed, MSc, MD 1 ; Amr M. Sallam, MD, EDAIC, FCAI 6 ; Hassan Mohamed, MD, EDAIC, FCAI 5 ; Mohamed Elayashy, MD, EDAIC, FCAI 5 ; Hisham Hosny, MD, DESA 5,7 ; Hany M. Yassin, MSc, MD 8 ; Mohamed Abdelhaq, MSc, MD 5 ; Mohamed A. Elramely, MD, EDAIC, FCAI 9 ; David Reeves, BSc AFHEA 10 ; Kerry E. Mills, PhD 11 ; Ahmed M. Kamal, MD 5 ; Dina Zakaria, MD 5