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PubMed1998

Paediatric resuscitation--by phone.

OBJECTIVE: To ascertain the training and knowledge of paediatric resuscitation amongst all paediatric residents in New Zealand. METHOD: A validated national telephone survey. RESULTS: Interviews were conducted with 96 out of a possible 109 paediatric residents. Most had been qualified less than 5 years and a third had received some training in paediatric resuscitation in the last year. The initial dose of intravenous adrenaline was known by 61% but only 10% knew the recommended ten-fold increase in subsequent doses. Recognition of the importance of cervical spine management in trauma was poor. Correct resuscitation fluids and volumes were selected by 90%, though infusion rates were frequently too slow. Residents with paediatric qualifications and greater experience scored significantly higher. CONCLUSION: Many junior paediatric staff are inadequately prepared for resuscitating children. We believe improved regular training is required and that the introduction of a nation-wide Advanced Paediatric Life Support course, subsequent to the completion of this survey, will lead to improved standards. Its effectiveness needs to be audited.

Child↗

PubMed2003

A survey of obstetric complications and pregnancy outcomes in paediatric and nonpaediatric anaesthesiologists.

BACKGROUND: Obstetric complications such as spontaneous abortion, preterm labour, preterm delivery, low birth weight and congenital anomalies may be associated with exposure to anaesthetic gases. We hypothesized that female anaesthesiologists practicing primarily paediatric anaesthesia, with increased exposure to trace anaesthetic agents, experience a greater prevalence of obstetric complications than female anaesthesiologists performing primarily adult anaesthesia. METHODS: Questionnaires were sent to all female Society for Pediatric Anesthesia (SPA) members and to an equal number of randomly selected female American Society of Anesthesiologists (ASA) members. Subjects were asked to answer questions regarding their pregnancy outcomes, work history and personal habits. Parametric data were analysed by unpaired t-tests. Nonparametric data were analysed by chi-square, Fisher's exact test and Mann-Whitney U-test as appropriate. RESULTS: Paediatric anaesthesiologists were defined as those having >75% paediatric practice. Paediatric anaesthesiologists were older and had greater operating room exposure during their pregnancies than nonpaediatric anaesthesiologists. There was a significantly higher prevalence of spontaneous abortion among paediatric anaesthesiologists than nonpaediatric anaesthesiologists. In an exploratory analysis, the following factors were found to be significantly associated with the development of spontaneous abortion: age >35 years, gravida >1, exercise during pregnancy, percentage of inhalational anaesthetics >75% and paediatric anaesthesia practice >75%. Independent risk factors for spontaneous abortion among anaesthesiologists included exercise (>1 time/week) and age. CONCLUSION: Our results suggest a higher prevalence of spontaneous abortion in anaesthesiologists whose practice is >75% paediatrics.

Abortion, Spontaneous↗

PubMed2002

European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.11 Paediatrics (specific problems).

GUIDELINES: A. Kidney transplantation should be the treatment of choice for end-stage renal disease (ESRD) in children (up to 16 years of age). Because the incidence rate of ESRD is very low, approximately 1-2 children per million general population or 4-6 children per million childhood population, kidney transplantation in children should be performed in specialized paediatric centres with multidisciplinary experts, i.e. transplant surgeons, anaesthetists and paediatric nephrologists, and optimally should be supported by psychologists, paediatric nurses and social workers. B. Due to the urgent need for transplantation, children should have priority in the allocation systems. In addition, pre-emptive transplantation from either live or cadaveric donors should be offered to all paediatric transplant candidates whenever possible. These protocols will reduce the time on dialysis, thus limiting the retardation of growth and development. C. Absolute contra-indications to renal transplantation in children are extremely rare but should be respected: uncontrollable malignancy, ABO incompatibility, the presence of a current positive cross-match or multi-organ failure. There are few relative or transient contra-indications: history of cancer (Wilms tumour), viral infection (HIV, HBV, EBV), very young age (<6 months), severe mental retardation and/or additional disabilities. D. In contrast to adult patients, primary renal diseases responsible for ESRD in children are mostly congenital and hereditary disorders (60%). Children with massive vesico-ureteric reflux or permanent urinary infection should undergo nephroureterectomy to avoid the development of sepsis. In children with ESRD not due to any urinary tract malformation, pre-transplant bilateral nephrectomy of the native kidney should be considered in the case of severe arterial hypertension, heavy proteinuria or risk of renal cancer. E. Psychosocial evaluation of future transplant recipients and their parents is necessary in assessing compliance with management of dialysis and after transplantation. Poor compliance worsens the outcome of paediatric renal transplantation. F. Routine childhood vaccination should be completed whenever possible prior to transplantation, in addition to vaccination against hepatitis B and varicella. G. The pharmacokinetics of immunosuppressive drugs often differ between adult and paediatric recipients. Therefore, drug monitoring is mandatory in order to find the correct drug dosage. H. Today the actuarial probability of graft survival at 1 year should exceed 90% in unselected renal transplant children, and the acute rejection rate should be lower than 30%. I. Special attention should be paid to specific risk factors in paediatric transplantation, such as thrombotic complications, EBV and CMV infections, post-transplant lymphoproliferative disease (PTLD) and recurrence of original renal disease, mainly in patients with focal segmental glomerulosclerosis (FSGS) or atypical haemolytic-uraemic syndrome (HUS).

Adolescent↗

PubMed2006

Superior long-term graft function and better growth of grafts in children receiving kidneys from paediatric compared with adult donors.

BACKGROUND: Organs from paediatric donors are often not accepted for paediatric recipients because previous reports suggested inferior graft function for small kidneys transplanted in children. On the other hand, studies have shown that kidneys of adult donors transplanted into children down-regulate filtration after transplantation and may not increase their function to the need of the growing child. METHODS: We assessed 64 male and 35 female (total n = 99) white children aged <10 years (male: mean 5.1 years, SD 2.8; female: mean 5.8 years, SD 3.4) who had received cadaveric kidney transplants at our centre between 1990 and 2005. Mean observation time was 5.9 years, SD 4.0. The children were divided into two groups depending on the kidney donor age: 63 children (mean age 5.0 years, SD 2.9) received an organ of an adult, and 39 (mean age 6.4 years, SD 3.4) of a paediatric donor. Immunosuppression was performed with prednisolone, cyclosporin A microemulsion+/-mycophenolate mofetil. RESULTS: Three to five years after transplantation the calculated glomerular filtration rate corrected to body surface was significantly higher in recipients of paediatric organs. The size of paediatric grafts doubled in the first years after transplantation while adult grafts had a stable size. Graft survival was comparable in both groups during observation time. CONCLUSIONS: We conclude that paediatric donor kidneys should be given preferentially to paediatric recipients due to better long-term function.

Adolescent↗

PubMed2006

Complications in paediatric anaesthesia.

PURPOSE OF REVIEW: This review identifies the most serious complications likely to be encountered in the current practice of paediatric anaesthesia. RECENT FINDINGS: The findings of the ASA Closed Claims Project, published in 1993, showed a higher proportion of closed paediatric malpractice claims related to respiratory events than to cardiovascular events. The Pediatric Perioperative Cardiac Arrest Registry--an offshoot of the American Society of Anesthesiologists Closed Claims Project--reviewed cardiac arrest data collected between 1994 and 1997, revealing a shift in the aetiology of cardiac arrest during paediatric anaesthesia over the past 20 years. The study found that reported cardiac arrests were now more prevalent from cardiovascular causes than respiratory causes, unlike the findings in the previous Closed Claims Project. Follow-up data collected by both the Pediatric Perioperative Cardiac Arrest Registry and the American Society of Anesthesiologists Closed Claims Project confirm this trend. SUMMARY: Outcomes for paediatric patients undergoing anaesthesia have improved over the years as a result of advances in monitoring and equipment, safer and more easily titratable anaesthetic agents, and possibly the practice of subspecialization. Preventable complications still, however, occur. An awareness of frequently encountered complications during paediatric anaesthesia may lead to the earlier detection and treatment of perioperative problems, leading to better outcomes.

Anesthesia↗

PubMed2004

Training in paediatric clinical pharmacology in the UK.

AIMS: To produce a training programme in paediatric clinical pharmacology. METHODS: A working group, consisting of clinical pharmacologists (paediatric and adult), general paediatricians and the pharmaceutical industry was established to produce the training programme. RESULTS: Following a two year training programme in general paediatrics, a three year training programme in clinical pharmacology has been established. This includes one year of research in clinical pharmacology (paediatric or adult). The other two years involve training in different aspects of paediatric clinical pharmacology and general paediatrics. CONCLUSION: The existence of a formal training programme should result in a significant increase in the number of paediatric clinical pharmacologists.

Child↗

PubMed2006

Specialist services and transitional care in paediatric endocrinology in the UK and Ireland.

OBJECTIVE: To assess current provision of specialist and transitional paediatric endocrine services in the UK and Ireland. DESIGN: A questionnaire was sent to paediatric endocrinologists requesting details of patients receiving GH and also details of specialist and transitional services. RESULTS: Of 72 questionnaires received, 56 [21 from historical growth centres (group 1), 10 from other teaching hospitals (group 2) and 25 from district general hospitals (DGHs) (group 3)] were analysed. A total of 4758 children [3709 (78%) in group 1] currently receive GH in the UK. Fifty-six per cent of units (90% in groups 1 and 2) provide transfer clinics: transition (N = 27), adolescent (10), young adult (11) and adult (3). In 90% of the paediatric units, the paediatric and adult endocrinologist sit together, and 58% of clinics are held in the paediatric unit. Clinic entry is based on final height (33%), age (51%), both (14%), and other (2%). Fifty-five per cent of units transfer all GH-treated patients, the remainder transfer only those non-GH-deficient on retesting. Eighty per cent retest prior to transfer using the insulin tolerance test (ITT) [N = 27 (including three DGHs)], glucagon (22), arginine (4), clonidine (2) and other (5). Apart from intersex clinics (13), there are few specialist clinics for other paediatric endocrine patients, including only three for Turner syndrome (TS). Adult TS transfer is to multidisciplinary clinics (N = 11), adult endocrinology (27), gynaecology (14), cardiology (5) and general practitioner (GP) (1). CONCLUSIONS: We have confirmed more GH-treated patients than before; many remain within historic growth centres. Although in the UK and Ireland transition services are established in many larger units, current guidelines are not always adhered to. Provision of specialist paediatric endocrine clinics for all groups remains variable.

Adolescent↗

PubMed2006

A survey of specialist paediatric dental services in Sweden: results from 2003, and trends since 1983.

UNLABELLED: The child population in Sweden has changed dramatically during the last 20 years. Changes have also occurred within the Public Dental Service (PDS), regarding the provision of dental care to children and adolescents. All these changes may affect the referral pattern and provision of specialist dental care for children and adolescents. OBJECTIVES: The primary aim of this study was to survey the services provided by specialists in paediatric dentistry in Sweden during 2003. A secondary aim was to compare the results with previous surveys. METHODS: A Web-based survey was sent to all 34 specialist paediatric dentistry clinics and was answered by all clinics. Data were compared with results from the surveys performed in 1983, 1989, and 1996. RESULTS: The number of paediatric dentists had been relatively constant over the last 20 years, whereas the number of children referred to paediatric dentists had increased by 28% since 1983. It was estimated that 1.3% of all children in Sweden are treated at a specialist paediatric dental clinic in 2003. Dental treatment need in combination with behaviour management problems (BMP) was the main reason for referral and occurred in 37% of all referrals. The proportion of medically compromised children/children with disabilities had increased from 6% in 1983 to 22% in 2003. The number of patients treated using sedation and general anaesthesia had increased since 1983, and particularly since 1996. CONCLUSIONS: Despite improvements in dental health among children and adolescents in Sweden during the last 20 years, an increasing number of children are referred for specialist paediatric dental treatment. There is an urgent need to increase the number of specialist paediatric dentists in Sweden in order to ensure the continuation of high quality of dental care for children and adolescents.

Adolescent↗

PubMed1989

Residents' evaluation of behavioural paediatrics instruction.

This study sought to explore the following questions: (1) Do residents perceive training focused on infancy and early childhood care issues as more clinically applicable than training focused on care of older children and adolescents? (2) Do residents at different training levels differ in their evaluation of behavioural paediatrics instruction? (3) What is the strength of the association between instructional style and clinical impact dimensions? and (4) Compared to the instruction provided by instructors from other medical and academic disciplines, do paediatric residents perceive differences in the teaching efficacy and clinical relevance of instruction provided by paediatricians? Data were drawn from 1341 residents' evaluations of 116 required behavioural paediatrics sessions over 3 years. The data demonstrated that house officers recognize the value of acquiring knowledge in behavioural paediatrics, regardless of the level of the house officers' training, or whether the focus concerned infants or older children. However, residents were more likely to perceive the presentations provided by paediatricians as providing instruction that was slightly more applicable to their practice needs than instruction that other faculty presented. The study results further demonstrated that the clarity and organization of instruction influences, but does not supercede, the residents' perception of the merit of instruction. The findings suggest that international recommendations for greater inclusion and acceptance of behavioural paediatric instruction can be achieved in programmes that, by requiring participation, confer equal status to behavioural paediatrics and traditional residency training. The results support residents' acceptance of a health team approach to behavioural paediatric instruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗

PubMed1988

Postgraduate training in paediatrics: analysis of deficiencies as perceived by paediatricians.

A listing of all general paediatricians in the country was obtained from the directory of members of the Australian College of Paediatrics. Each of the 287 paediatricians identified was sent a questionnaire requesting information about morbidity patterns of patients seen in their practices and their views regarding paediatric training. The response rate was 80.9%. Half the respondents had been in practice for 10 years or less, while two-thirds practised in a capital city. Respondents rated their training in each of 10 organic specialty areas, on average, as having been appropriate. However, when given a listing of nine areas related to child development and behaviour, chronic disease and counselling, 70% rated training in these areas as having been inadequate; this figure was even higher for recent graduates. Less than one-third had formal training in developmental, behavioural and community paediatrics; the remaining two-thirds of respondents acquired their knowledge by clinical experience, books or journals, professional contacts or meetings. This was despite the fact that almost 80% of respondents felt that practical experience was not an adequate substitute for formal training in developmental and behavioural paediatrics. There was an encouraging trend for paediatricians who had been in practice for 10 years or less to have had training in these areas, although the number was still less than half. Almost 90% of respondents felt that changes were needed in paediatric training to equip trainees for general paediatric practice, while 62% of respondents were of the opinion that the present FRACP training system mitigated against appropriate training for general paediatrics.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care↗

PubMedDate not supplied

The organisation of paediatric renal care in different European countries: results of the PAC project.

The Paediatric Access Care (PAC) project, organised by the Research Board of EDTNA/ERCA, aimed to study the organisation of paediatric renal care in Europe and to investigate the practice of access care for both haemodialysis (HD) and peritoneal dialysis (PD) paediatric patients. This paper reports on the organisation of paediatric renal care. The majority of paediatric renal care units were located in specific paediatric units of university hospitals. Most of the centres had offered HD, PD and transplantation (Tx) for more than 20 years. Half of nursing staff had qualifications in paediatric and renal nursing. Most of the centres offered an extended multidisciplinary team approach with the family actively involved in the care of the patient. PD and HD were equally used. Automatic Peritoneal Dialysis (APD) was offered as the standard PD treatment in 2 out of 3 centres. The HD schedule mostly utilised was 3 x 4 hours a week. Half of the patients were on the Tx waiting list and one third of registered patients were transplanted in 2004.

Adolescent↗

PubMed1989

General practitioner training in paediatrics in the Trent region.

A total of 259 postal questionnaires were sent to all final year vocational trainees and new principals in general practice in the Trent region to find out how much training in paediatrics they had had. Questionnaires were returned by 105 trainees and 139 principals (244; 94%). Overall 72% (175) had taken up a hospital post in paediatrics during training, but among the 138 doctors who were on or had completed a three year vocational training scheme the proportion was slightly higher (82%; 115) (p = 0.01). Among the 175 who had had a post in paediatrics 108 (62%) had been given teaching sessions every week, and for half of these doctors the sessions lasted over one hour a week. Seventy five (54%) of the 139 principals reported that in their training in a general practice they had received no teaching about child health and a fifth said that they had not attended a clinic for children; 47 (34%) had received no training on procedures for dealing with cases of child abuse. The doctors who had held posts as senior house officers in paediatrics were more likely to report that they had adequate skills in paediatrics than those who had not, but overall only 62 (44%) reported that they could run a preschool child health surveillance programme. Extra paediatric posts in hospital are needed, but in the mean time improvements can be made to the teaching content in hospital and in the general practice attachment and postgraduate training in paediatrics provided for all general practitioners.

Child↗

PubMed1995

Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team.

OBJECTIVE: To evaluate the morbidity and severity of illness during interhospital transfer of critically ill children by a specialised paediatric retrieval team. DESIGN: Prospective, descriptive study. SETTING: Hospitals without paediatric intensive care facilities in and around the London area, and a paediatric intensive care unit at a tertiary centre. SUBJECTS: 51 critically ill children transferred to the paediatric intensive care unit. MAIN OUTCOME MEASURES: Adverse events related to equipment and physiological deterioration during transfer. Paediatric risk of mortality score before and after retrieval. Therapeutic intervention score before and after arrival of retrieval team. RESULTS: Two (4%) patients had preventable physiological deterioration during transport. There were no adverse events related to equipment. Severity of illness decreased during stabilisation and transport by the retrieval team, suggested by the difference between risk of mortality scores before and after retrieval (P < 0.001). The median (range) difference between the two scores was 3.0 (-6 to 17). Interventions during stabilisation by the retrieval team increased, demonstrated by the difference between intervention scores before and after retrieval, median (range) difference between the two scores being 6 (-8 to 38) (P < 0.001). CONCLUSIONS: Our study indicates that a specialised paediatric retrieval team can rapidly deliver intensive care to critically ill children awaiting transfer. Such children can be transferred to a paediatric intensive care unit with minimal morbidity and mortality related to transport. There was no deterioration in the clinical condition of most patients during transfer.

Child↗

PubMed1995

Paediatric perfusion practice in North America: an update.

In August 1994, an updated survey questionnaire was mailed to each paediatric open-heart surgery programme in North America as a follow-up to the 1989 paediatric survey. The survey requested demographic data, equipment selection criteria and specific perfusion techniques for paediatric patients. The earlier survey revealed a wide range of clinical practice. Data from the recent survey were compared with the 1989 survey to identify current programme demographics and trends in equipment use and techniques. Responses were received from 125 hospitals (110 active programmes and 15 programmes that do not perform paediatric open-heart surgery) for a response rate of 74%. Of the 110 active centres, 77 perform both adult and paediatric cardiac surgery, and 33 perform paediatric surgery exclusively. Forty-three centres reported that they perform paediatric cardiac transplantation, an increase from 35 centres in 1989. Total caseload increased by more than 8% per year from 1988 to 1994. In 1994, 18% of the patients were operated upon during the first month of life (versus 15% in 1989), and 46% were operated on during the first year of life (versus 45% in 1989). While the 1989 survey was characterized by a high degree of heterogeneity in equipment and techniques, the recent survey reveals a trend toward homogeneity among respondents. The use of membrane oxygenation and arterial line filtration has become universal, and there was an increase in the use of all types of safety devices in the cardiopulmonary bypass circuit.

Adolescent↗

PubMed1999

Comparison of adult and paediatric spine and whole body software for the Lunar dual energy X-ray absorptiometer.

Simple phantoms were devised to compare the performance of adult (software 3.64) and paediatric (software 3.8 g) spine and whole body software developed for the Lunar dual energy X-ray absorptiometer. Rectangular slabs of aluminium with high (1.18 g cm-2) and low (0.57 g cm-2) density were used to represent bone mineral. For spine measurements, the phantoms were scanned in water at depths of 5-20 cm. For whole body measurements, the phantoms were scanned with known amounts of oil and water to represent fat and lean tissue. This simulated tissue depths of 5.5-19.7 cm and body composition ranging from 14-29% fat. There were systematic differences in spine and whole body bone mineral content (BMC), bone area (BA) and bone mineral density (BMD) measurements and also between adult and paediatric software versions. The magnitude and direction of these differences were dependent on BMD of the phantom and tissue depth. Similar systematic differences were observed in vivo when volunteers were scanned using adult and paediatric software. Paediatric software enabled measurements to be made at low tissue depths. The weights of fat, lean and total soft tissue measured by the adult and paediatric whole body software were similar to the values calculated from the known composition of the phantom. Precision estimates for all softwares were excellent. In conclusion, paediatric software should improve bone mineral measurements of children but the discrepancies between adult and paediatric softwares may cause problems in longitudinal studies of skeletal growth and when compiling reference data from infancy through to adulthood.

Absorptiometry, Photon↗

PubMed2003

Paediatric medicines research in the UK: how to move forward?

There have been numerous studies to show that many of the medicines used in children are used off-label or are unlicensed for use in children. When children are prescribed unlicensed and off-label medications, some people may see them as unknowing participants in informal and uncontrolled experiments. However, the licensing status of a drug can be seen as a by-product of the real issues: the safety, efficacy and quality of these medicines in the current licensing system. It is important to conduct research in order to provide high quality data regarding safety and efficacy to support evidence-based paediatric prescribing. Clinical trials will always be an invaluable means of acquiring vital information about a drug; but when it comes to children, we may find that these trials are not always practical for technical, ethical and financial reasons; therefore, it is important to explore other methodologies in paediatric medicines research. Pharmacoepidemiological and prospective cohort studies could provide vital safety and efficacy data on paediatric medicines; however, resources need to be invested in the methodological research. Paediatric drug formulation research is under-resourced and under-valued, and, unfortunately, fatal and serious adverse reactions due to inappropriate formulations have been reported in many instances. Paediatric medication is a complex problem; we need to use all available tools for research on safety, efficacy and formulation. The reason for lack of progress in paediatric drug research is most likely due to lack of resources and research capacity. The industry and government should work together and invest more money in paediatric drug research. Finally, regulatory authorities, healthcare professionals and academics need to rethink the research strategy in order to provide better medicines for children.

Child↗

PubMed1994

Paediatric labelling requirements. Implications for pharmacokinetic studies.

The US Food and Drug Administration (FDA) has proposed new labelling regulations that describe alternative approaches for providing additional information to support labelling a drug, already approved for use in adults, for use in children. Therefore, the study of drugs in paediatric populations may now be encouraged. Paediatric pharmacokinetic studies are an important part of these trials. This action by the FDA may help resolve the ethical and technological concerns about the performance of clinical trials in children, and may render paediatric clinical trials more feasible. Most investigations in children are opportunistic in nature and their design is often constrained by a requisite noninvasive approach. Appropriately applied population-based techniques for both pharmacokinetic and pharmacodynamic data analysis may represent the most robust approach for generating a sufficiently large and accurate database for the use of new or old drugs in paediatric patients. Accordingly, this information, which is crucial for paediatric labelling of any drug product, must be obtained in infants and children if we are to truly individualize therapy for paediatric patients. The funding of 6 Pediatric Pharmacology Research Units by the US National Institutes of Health, and guidelines for application of pharmacokinetic methods to children may further contribute to the performance of paediatric clinical trials.

Aging↗

PubMed2002

Immunosuppressive therapy for paediatric transplant patients: pharmacokinetic considerations.

Immunosuppressive therapy in paediatric transplant recipients is changing as a consequence of the increasing number of available immunosuppressive agents. Generic and other new formulations are now emerging onto the market, clinical experience is growing, and it is expected that clinicians should tailor immunosuppressive protocols to individual patients by optimising dosages and drugs according to the maturation and clinical status of the child. Most information about the clinical pharmacokinetics of immunosuppressive drugs in paediatrics is centred on cyclosporin, tacrolimus and mycophenolate mofetil in renal and liver transplant recipients; data regarding other immunosuppressants and transplant types are limited. Although the clinical pharmacokinetics of these drugs in paediatric transplant recipients are still under investigation, it is evident that the pharmacokinetic parameters observed in adults may not be applicable to children, especially in younger age groups. In general, patients younger than 5 years old show higher clearance rates irrespective of the organ transplanted or drug used. Another important factor that frequently affects clearance in this patient population is the post-transplant time. In accordance with these findings, and in contrast with the usual under-dosage in children, the need for higher dosages in younger recipients and during the early post-transplant period seems evident. To achieve the best compromise between prevention of rejection and toxicity, dosage individualisation is required and this can be achieved through therapeutic drug monitoring (TDM). This approach is particularly useful to ensure the cost-effective management of paediatric transplant recipients in whom the pharmacokinetic behaviour, target concentrations for clinical use and optimal dosage strategies of a particular drug may not yet be well defined. Although TDM may be a tool for improving immunosuppressive therapy, there is little information concerning its positive contribution to clinical events, including outcomes, for paediatric patients. Substantial information to support the use of TDM exists for cyclosporin and, to a lesser extent, for tacrolimus, but a diversity of options affects their implementation in the clinical setting. The role of TDM in therapy with mycophenolate mofetil and sirolimus has yet to be defined regarding both methods and clinical indications. Pharmacodynamic monitoring appears more suited to other immunosuppressants such as azathioprine, corticosteroids and monoclonal or polyclonal antibodies. If coupled with pharmacokinetic measurements, such monitoring would allow earlier and more precise optimisation of therapy. Very few population pharmacokinetic studies have been carried out in paediatric transplant patients. This type of study is needed so that techniques such as Bayesian forecasting can be applied to optimise immunosuppressive therapy in paediatric transplant patients.

Area Under Curve↗