To the Editor.
—Although it is laudable that Dr Als and colleagues1 have evaluated a difficult issue such as developmental care in very low-birth-weight infants in a randomized controlled trial, we would like to point out certain methodological concerns. First, considering the large size of the unit, the 43 subjects enrolled over a 21-month period may represent a small and highly select group of the overall admissions, thus diminishing the generalizability of the study. Further concern of a possible selection bias stems from the surprising lack of any reported exclusions because of death or other causes following randomization at age 3 hours. Second, we find it difficult to imagine how 91 behaviors could be collected every 2 minutes for 20 minutes each, before, during, and after a clinical maneuver, even if some of these are automated. We wonder if such complexity is warranted if the intention of the investigators