The care and evaluation of pediatric heart transplant recipients is similar to that of adults, with a few special considerations. Rejection surveillance in infants and small children is done primarily with serial echocardiograms. Difficulties with vascular access and the need for anesthesia make serial endomyocardial biopsy procedures impractical. Acute rejection is more frequently heralded by symptoms in children than in adults. Children will present with a low-grade fever, fussiness, and poor feeding. Echocardiography will demonstrate decreased ventricular contractility, thickening of the posterior wall of the left ventricle, cardiac enlargement, and mitral and tricuspid valve insufficiency. Because the signs of rejection may be subtle and difficult to quantify, serial echocardiographic studies are required throughout the postoperative period in order to establish each patient's baseline echocardiographic characteristics.
Immunosuppression for children is based on standard triple therapy. Because of the more rapid metabolism of cyclosporine and tacrolimus, higher doses and more frequent (thrice daily) dosing is often needed in children. Steroids are withdrawn whenever possible to avoid their deleterious effects on somatic growth.
Childhood infections are frequently encountered and should be treated according to routine practice. Vaccinations with live attenuated virus are avoided. Exposure to chickenpox (varicella) is avoided if possible. If exposure does occur in a recipient without a history of previous infection, treatment with varicellazoster immune globulin (VZIG) is indicated. Recipients who develop chickenpox are treated with intravenous acyclovir (Zovirax).
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