Premarket Assessment of Pediatric 
Medical Devices  
Guidance for Industry and Food 
and Drug Administration Staff  
 
 
Document issued on: March 24, 2014  
 
This document supersedes Guidance for Industry and FDA Staff: 
Premarket Assessment  of Pediatric Medical  Devices dated May 
14, 2004. 
 
 
For questions regarding this document contact Hina Pinto at 301-796-6351 or 
hina.pinto@fda.hhs.gov or the Premarket Approval Section Staff at 301-796-5640.  
 
For questions about this document concerning products regulated by CBER, contact the 
Office of Communication, Outreach and Development (OCOD) by calling 1-800-835-
4709 or 301-827-1800.  
 
 
 
 
 
U.S. Department of Health and Human Services 
Food and Drug Administration 
Center for Devices and Radiological Health 
Office of Device Evaluation 
Center for Biologics Evaluation Research   Contains Nonbinding Recommendations 
 
Preface 
 
 
Public Comment 
 
You may submit electronic comments and suggestions at any time for Agency consideration to 
http://www.regulations.gov. Submit written comments to the Division of Dockets 
Management, Food and Drug Administration, 5630 Fishers Lane, Room 1061, (HFA-305), 
Rockville, MD 20852.  Identify all comments with Docket No. 2003D-0319. Comments may 
not be acted upon by the Agency until the document is next revised or updated.  
 
 
Additional Copies 
 
Additional copies are available from the Internet.  You may also send an e-mail 
request to CDRH-Guidance@fda.hhs.gov to receive an electronic copy.  Please use 
the document number 1220 to identify the guidance you are requesting. Contains Nonbinding Recommendations 
 
 
Table of Contents 
 
1.  Introduction .......................................................................................................................... 1 
II.  Stakeholder Input .............................................................................................................. 2 
III.   Objectives ...................................................................................................................... 3 
IV.   Pediatric Population and Use ...................................................................................... 3 
A. Definition of Pediatric Population Subgroups .............................................................. 3 
B. Definition of Pediatric Use ............................................................................................. 4 
V.  General Principles  in Medical Device Evaluation .......................................................... 5 
VI.   Pre-clinical  Studies ....................................................................................................... 5 
VII.  Clinical Studies ............................................................................................................... 6 
VIII.  Unique Host Characteristics ....................................................................................... 8 
IX.   Labeling ....................................................................................................................... 11 
A. Basic Elements of Labeling .......................................................................................... 11 
B. Pediatric Information ................................................................................................... 13 
C. Special Considerations ................................................................................................. 13 
X.    Protections for Pediatric Populations in Clinical Trials ......................................... 13 
A. Relevant  Definitions ..................................................................................................... 14 
B. Study Design Considerations ....................................................................................... 15 
C. The Role of the Institutional Review Board (IRB) .................................................... 16 
D. Consent and Assent ...................................................................................................... 17 
XI. Other Resources ................................................................................................................ 18 
  Contains Nonbinding Recommendations 
 
 
Premarket Assessment of Pediatric Medical 
Devices  
Guidance for Industry and Food and Drug 
Administration Staff  
 
This guidance represents the Food and Drug Administration's (FDA's) current thinking 
on this topic.  It does not create or confer any rights for or on any person and does not 
operate to bind FDA or the public.  You can use an alternative approach if the approach 
satisfies the requirements of the applicable statutes and regulations.  If you want to discuss 
an alternative approach, contact the FDA staff responsible for implementing this 
guidance.  If you cannot identify the appropriate FDA staff, call the appropriate number 
listed on the title page of this guidance.  
 
1.  Introduction 
FDA reviews pediatric devices through all of its premarket pathways, including 
premarket notification (510(k)), premarket approval (PMA), biological license 
application (BLA), and humanitarian device exemption (HDE). A manufacturer may 
show substantial equivalence to a predicate device, or may seek marketing approval by 
demonstrating with reasonable assurance that the device is safe and effective for its 
intended use. Clinical evaluation may be needed to support marketing of a device 
indicated for pediatric use. If such studies are needed, they should be conducted in 
accordance with the investigational device exemptions (IDE) regulation (21 CFR Part 
812). FDA has jurisdiction over significant risk studies, whereas Institutional Review 
Boards (IRBs) have oversight responsibility for non-significant risk studies. 
 
On October 26, 2002, the Medical Device User Fee and Modernization Act of 2002 
(MDUFMA) was signed into law. Among other things, MDUFMA amends the Federal, 
Food, Drug, and Cosmetic Act (the Act) by adding several new provisions intended to 
promote the development of safe and effective pediatric devices and to protect this vulnerable 
patient population during the course of clinical trials involving such products. This guidance, 
as well as a collateral guidance on procedures for ensuring that pediatric expertise is available 
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  Contains Nonbinding Recommendations 
 
to FDA Advisory Panels when appropriate,1 will help the agency achieve the intent of the 
pediatric provisions of MDUFMA. 
 
This guidance should be used in conjunction with other device-specific guidances to help 
ensure that medical devices intended for use in the pediatric population provide reasonable 
assurance of safety and effectiveness. 
 
FDA's guidance documents, including this guidance, do not establish legally enforceable 
responsibilities.  Instead, guidances describe the Agency's current thinking on a topic and 
should be viewed only as recommendations, unless specific regulatory or statutory 
requirements are cited.  The use of the word should in Agency guidances means that 
something is suggested or recommended, but not required.  
 
II.  Stakeholder Input 
In developing the draft and final versions of this guidance, FDA considered comments from 
its stakeholders. On February 4, 2003, FDA published a Federal Register (FR) notice 
entitled, Medical Device User Fee and Modernization Act of 2003, Establishment of a 
Public Docket (68 FR 5643) (hereinafter referred to as the MDUFMA Docket). In this FR 
notice, the agency identified several statutory provisions for which FDA was particularly 
interested in receiving stakeholder input, and this pediatric provision2 was one of them. 
While no comments were submitted to the MDUFMA Docket on this topic, three comments 
were submitted in response to the draft of this guidance. 
 
One comment questioned why the guidance did not reference the least burdensome provisions 
of the Act (Sections 513(a)(1)(D) and 513(a)(3)(D)(ii)) or encourage the use of early 
collaboration meetings to help ensure that the least burdensome approach is followed in 
determining safety and effectiveness for pediatric devices. For more information on the least 
burdensome provisions of the Act, please refer to FDAs guidance The Least Burdensome 
Provisions of the FDA Modernization Act of 1997: Concept and Principles ; Final Guidance 
for FDA and Industry 
(http://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm0
85994.htm). For more information on the pre-submission program and meetings with FDA 
staff, please refer to FDAs guidance Requests for Feedback on Medical Device 
Submissions: The Pre-Submission Program and Meetings with Food and Drug 
Administration Staff 
(http://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm3
10375.htm).  
Another comment asked how devices that are already legally marketed for pediatrics with an 
upper age limit of 18 would be affected by the guidance since this document extends the 
                                                           
1 See FDA guidance on Pediatric Expertise for Advisory Panels which is available at 
http://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm082
185.htm. 
2 Section 213 of MDUFMA. 
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definition through age 21. As stated in the guidance, the Agency recognizes that the age 
descriptions presented here are somewhat arbitrary and that other factors, such as the 
subjects weight, body size, and physiological and neurological development may be more 
appropriate indicators than chronological age. The intent of this guidance is to identify those 
issues that should be considered by sponsors conducting clinical trials involving pediatrics to 
ensure that the studies are appropriately designed and that measures are taken to protect this 
vulnerable patient population. Similarly, the Agency hopes this guidance will help 
manufacturers develop clear labeling for their products and take into account the above 
physiological and neurological factors, when appropriate. 
 
Finally, two comments sought clarification of how State and Federal law pertaining to the 
age of consent relates to the clinical definition of the pediatric population put forth in the 
guidance. The draft guidance was revised to clarify this distinction. 
 
III.   Objectives 
 
 
1.   To help define the pediatric population and pediatric use for medical devices. 
 
2.   To help identify the types of information needed to provide reasonable assurance of 
the safety and effectiveness of medical devices intended for use in the pediatric 
population. 
 
3.   To help define the guiding principles and protections sponsors should consider for 
pediatric subjects in device clinical trials. 
 
 
IV.   Pediatric Population and Use 
A. Definition of Pediatric Population Subgroups 
For purposes of this guidance, we are proposing the following ranges of pediatric 
subpopulations to be used as a guide for manufacturers in developing medical 
devices: 
 
Table 1.  Age Ranges of Pediatric Subgroups 
 
   
Pediatric Subgroup  Approximate Age Range 
Newborn (neonate)  from birth to 1 month of age 
Infant  greater than 1 month to 2 years of age 
Child  greater than 2 to 12 years of age 
Adolescent  greater than 12 through 21 years of age 
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Although the upper age limit used to define the pediatric population varies among 
experts, including adolescents up through the age of 21 is consistent with the 
definition found in several sources.3, 4  FDA interprets pediatrics as individuals who 
are 21 years of age or younger (that is, from birth through the 21st year of life, up to 
but not including the 22nd birthday).5  Given the scope of medical devices and the 
impact that a device could have on a growing adolescent, as well as the effect growth 
could have on the device, we believe that including the upper age limit identified 
above may be useful for some devices and device clinical trials. The agency 
recognizes, however, that the descriptions are somewhat arbitrary and that, in fact, the 
subjects weight, body size, physiological development, neurological development, 
and neuromuscular coordination may often be more appropriate indicators than 
chronological age. 
 
Additional pediatric subpopulations include: 
 
-  low birth weight describes newborns less than 2.5 Kg 
-  very low birth weight describes newborns less than 1.5 Kg 
-  preadolescent age group typically ranges from 11 to 13 years. 
 
Although these pediatric subpopulations are not included in Table 1, device labeling 
and clinical studies should address, as applicable, any issues that pertain to these or 
other pediatric subpopulations, such as low birth weight newborns. 
It is important to note the distinction between the clinical age limit of 21 described in this 
guidance and the legal age for consent. For the purposes of informed consent, 
manufacturers must comply with all federal and state regulations governing age and 
mental capacity.6  A detailed discussion of informed consent issues as they pertain to the 
pediatric population is presented in Section X. 
B. Definition of Pediatric Use 
For purposes of this guidance, FDA will consider a pediatric use to be any use of a 
medical device in a pediatric population, as defined above, in which there is a 
primary pediatric indication. General indications, where considerable pediatric 
application is anticipated, are also included in this definition. 
                                                           
3 21 U.S.C.  360j(m)(6)(E)(i) and (ii) (Section 520m(6)E of the FD&C Act) defines pediatric 
patients as age 21 years or younger at the time of diagnosis or treatment and specifies 
categories of pediatric subpopulations. 
4 21 U.S.C.  360e-1(a) (Section 515A of the FD&C Act), which requires sponsors of PMA 
and HDE applications and supplements to submit information on pediatric subpopulations 
and pediatric patients, uses the same definition of pediatric subpopulations. 
5 21 CFR 814.3 (s) Definitions. 
6 See 21 CFR 50.55 Requirements for permission by parents or guardians and for assent by 
children. 
4 
  Contains Nonbinding Recommendations 
 
 
V.  General Principles  in Medical Device Evaluation 
In general, FDA assesses safety and effectiveness of devices in the pediatric population 
using the same regulatory bases, scientific approaches, and processes used to assess all 
devices. Device considerations that are also germane to pediatric devices include, but are 
not limited to, the following pre-clinical and clinical testing as well as other regulatory 
controls: 
 
-  biocompatibility, including toxicity and carcinogenicity 
-  sterility and infection control 
-  environmental factors related to location of use, such as electromagnetic fields 
and radiation 
-  design controls and good manufacturing practices (GMP) 
 
Because the pediatric population represents a particularly vulnerable group, specific 
measures are needed to protect the safety of pediatric study subjects. Adult devices may be 
inappropriate for use in pediatric subjects for a variety of reasons, or may require specific 
design changes and/or specific labeling to accommodate their use in pediatric subjects. We 
recommend that you consider the following when you develop devices or plan a clinical 
trial for devices intended for pediatric subjects: 
 
-  height 
-  weight 
-  growth and development 
-  disease or condition 
-  hormonal influences 
-  anatomical and physiological differences from the adult population 
-  activity and maturity level 
-  immune status. 
 
 
VI.   Pre-clinical  Studies 
Given the wide spectrum of devices, the necessary pre-clinical testing may vary 
considerably. FDA may request bench or animal data depending on the type of device, the 
target population, and the extent of existing knowledge about the device. In many cases, 
FDA has developed device-specific guidance documents that will provide information on 
the types of pre-clinical testing that should be completed either to support marketing or to 
support initiation of a clinical trial. We recommend that you contact the reviewing division 
or visit the CDRH or CBER websites for a complete listing of relevant guidances.
 
 
 
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  Contains Nonbinding Recommendations 
 
VII.  Clinical Studies 
As is true for medical devices in general, FDA does not believe that clinical data will be 
necessary to demonstrate safety and effectiveness for all devices intended for pediatric 
populations. The agency recognizes that the amount and type of evidence required will 
depend on a number of factors, including the nature of the device, what is already known 
about the product in the adult population (if relevant), what is known or can be 
extrapolated about the device to the pediatric population, and the underlying disease or 
condition being treated. In some cases, well-designed bench and animal testing will be 
sufficient to evaluate the device. In others, clinical data may be needed to evaluate the 
safety and effectiveness of the device. 
 
FDA is committed to following the least burdensome principles as described in the 
guidance document entitled, The Least Burdensome Provisions of the FDA Modernization 
Act of 1997: Concept and Principles.  This commitment applies equally to pediatric 
devices. We recommend that sponsors of pediatric device clinical trials take advantage of 
the pre-submission program to obtain feedback on their investigational protocol before 
initiating the trial and to discuss the least burdensome regulatory path. 
 
If it is determined that clinical data are needed, it may be that the course of the disease and 
the device's effects are similar in adult and pediatric patients. In such a situation, the 
pediatric indication may be supported by the adult data with limited additional safety data 
in the pediatric population. In other cases, the prognosis, severity, or symptoms of the 
disease in the adult population may be significantly different than in the pediatric 
population, the device's effects may not be well understood, or there may be risks specific 
to the pediatric population necessitating clinical data in this population. 
 
In some situations, devices that are already approved and indicated for adult populations are 
modified for pediatric uses.  To support the modifications, the manufacturer should conduct 
a risk analysis of the changes and develop methods to adequately address or mitigate the 
identified risks.  This may require verification testing alone, or validation testing may be 
needed in the intended pediatric population. 
 
Finally, because weight, body size, and physiological and neurological development all 
vary among pediatric subpopulations and change as the child grows, clinical data may be 
needed to assess safety and effectiveness in the various subgroups.  In other cases, it may 
be possible to extrapolate from one group to another, thus limiting or obviating the need 
for clinical data. When clinical trials in a pediatric population are necessary to support a 
marketing application, these trials should follow existing scientific approaches and 
methods to ensure the safety of subjects. 
In summary, FDA believes clinical data are appropriate when any of the 
following circumstances apply: 
 
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-  supporting information from sources, such as pre-clinical bench or animal testing, 
literature, or adult clinical trials, are inadequate to establish safety and 
effectiveness for the pediatric indication 
-  adult data are inadequate to predict pediatric risks and adverse events 
-  pediatric data are needed for validation of design modifications 
-  pediatric data are needed to develop an age-appropriate treatment regimen. 
 
When the above circumstances exist, clinical data from pediatric subjects help ensure 
that manufacturers: 
 
-  design the device properly for the intended population 
-  perform accurate risk assessments 
-  provide clear instructions for use. 
 
 
Compared to drugs, devices present additional challenges due to the range of technology 
they incorporate and their varying applications. It is difficult to outline a prescriptive 
approach that would be appropriate for evaluating all devices. For example, some devices 
are relatively simple in terms of design and use, such as blood pressure cuffs and 
bilirubinometers. FDA generally recommends only pre-clinical testing to support adult and 
pediatric use of these types of products. Other devices may present additional risks, e.g., 
intraosseous access devices. For devices of this kind, the supporting information included 
performance studies in animals and cadavers, clinical experience in the adult population, 
and a clinical trial in a pediatric population. The study design addressed issues relating to 
differences in bone density and depth of penetration requirements in children of various 
ages and between children and adults. The study also addressed issues related to the growth 
plate and epiphyseal closure in children. 
 
If clinical data are needed, other sources of data, such as published studies and reports and 
actual use information, may help reduce the burden. FDA advises sponsors to consider 
these alternative sources of information when designing their clinical trial. Sponsors 
should also consider if adequate data may be gathered by including pediatric patients as 
well as adults in the original studies conducted on the device. Finally, the type and extent 
of the studies needed, especially in different age groups, is often best decided on a case-by-
case basis.  FDA encourages you to discuss your clinical trial plan with the reviewing 
division. 
 
FDA recommends that when developing medical devices for pediatric use, you consider 
the following: 
 
Risk Assessment and Mitigation 
Because the risk posed by the device may vary depending on the particular pediatric 
subgroup, you should determine the types of risk for each targeted pediatric subgroup 
by conducting a risk assessment. When assessing risk, you should consider the 
following critical factors: 
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  Contains Nonbinding Recommendations 
 
 
  age and degree of physiological maturity of the child 
  nature and natural history of the clinical condition to be treated 
  presence of complicating clinical conditions 
  safety and effectiveness of the device that may have been demonstrated in 
older patients, or that is expected on the basis of other clinical or preclinical 
investigations 
  likely duration of device use and its impact on the growth and development of 
the child. 
 
Using the results of the risk analysis, you should develop methods to address or 
mitigate the identified risks.  In many cases, well-designed bench and animal studies 
may accomplish this. In others, clinical data will be necessary. 
 
Pediatric Subgroups 
 
If clinical data are needed to support a pediatric indication, you should make every 
effort to gather data that adequately addresses each targeted pediatric subgroup.  In 
some cases, the expected benefit and safety can be determined without separate studies 
in each subgroup.  That is, it may be extrapolated from one age group to another. In 
other cases, such as with neonates, clinical data gathered specifically in that subgroup 
will likely be needed. You should be prepared to provide data for each targeted 
subpopulation or a justification as to why it is either not needed or can be extrapolated. 
 
 
VIII.  Unique Host Characteristics 
We recommend that you specify relevant subsets of the pediatric population in your 
intended use and indications rather than pooling them all into a single pediatric population. 
You should address the factors discussed below with respect to your device design, clinical 
study design, and labeling for each population. We recommend that you address these 
factors in devices specific to pediatrics and in general use devices with pediatric 
indications, where there may be unique issues when used in the pediatric population. 
 
Age 
 
As discussed in Section IV, the identification of specific age limits for pediatric 
subpopulations is somewhat arbitrary. Characteristics such as the subjects weight, 
body size, physiological and neurological development, and neuromuscular 
coordination may be more appropriate when deciding upon the appropriate 
subpopulation for a device. For example, the use of cochlear implants in certain 
pediatric subgroups may not be advisable due to the size of the implant or may be 
inappropriate due to the stage of the neurological development of the child. Therefore, 
when designing the clinical trial or the device labeling, age may be used as a 
preliminary approximator, but other factors should be considered to further define the 
appropriate population. 
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Size 
 
We recommend that you determine if design modifications are necessary based 
on subject size (e.g., weight, height, body mass, or surface area). 
 
Growth and Development 
 
We recommend that you consider the following: 
 
-  impact of growth on the device and vice versa 
-  if the child will outgrow the device, and if so, at what rate 
-  if adjustments to the device will be necessary 
-  if further intervention may be needed 
-  impact of technological advances in the device (e.g., will the device be 
easily upgraded?) 
 
Body Habitus 
 
We recommend that you consider the following: 
 
-  normal as well as abnormal variations in the targeted pediatric group 
-  normal anatomic landmarks for each subgroup and anticipated deviations 
based on the targeted population 
-  impact of anomalies, particularly congenital anomalies. 
 
Developmental Milestones 
 
We recommend that you consider the following: 
 
-  impact of the device on the child 
-  activity level of the child 
-  ambulatory status of the child 
-  maturity level of the child 
-  stage of puberty (for example, in the pre-adolescent and adolescent, breast 
bud development may influence device placement). 
 
Pathophysiology 
We recommend that you determine the impact of the disease/condition on the 
pediatric patient and take into account the following: 
 
-  maturity or immaturity of various organ systems, including the immune system 
-  impact of materials, chemicals, electromagnetic radiation, electrical 
stimulation, and other agents 
-  hormonal influences, for example, effects of puberty in the preadolescent 
and adolescent population 
-  short-term and long-term effects of device use. 
 
Behavioral  factors 
 
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We recommend that you consider the behavior expected in the targeted pediatric 
subgroup and anticipate the potential impact of the device. For example, an 
adolescent with a learning disorder may not be able to interface very well with certain 
devices and may require additional help or an alternative therapy. 
 
Psychosocial factors 
 
We recommend that you consider the psychosocial factors of the pediatric subgroups. 
For some pediatric devices or device trials, the family structure and environment, 
including how supportive the various family members are and who the primary 
caregiver will be, are important factors to consider. 
 
Human  Factors 
 
Each pediatric subgroup will have different needs; therefore, you should consider these 
in the design and use of the device. We recommend that you consider the following for 
each targeted subgroup: 
 
-  invasiveness of the device 
-  optimal size of the device 
-  manual dexterity and strength required 
-  resistance to damage from wear and tear 
-  portability 
-  clarity of the labeling 
-  ease of use 
-  level of interaction required for the proper functioning and use of the device 
-  age-appropriate usability of the user interface 
-  age and maturity level needed to safely and effectively operate the device, 
particularly in adolescents and especially with regard to placement, 
compliance, and use of the device. 
 
 
Surgical Factors for Implantable Devices 
For each targeted pediatric subgroup, we recommend that you assess: 
 
-  the surgical site and anatomical landmarks 
-  surgical technique and level of expertise needed 
-  short-term and long-term effects of the surgery and the device 
-  immune status and update immunizations, if indicated 
-  special issues pertaining to combination products, such as the possibility 
of drug/device interactions 
-  the need for antibiotic prophylaxis. 
 
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IX.   Labeling 
Labeling requirements for medical devices are defined by regulation.7  In general, the 
goal of medical device labeling is to provide the user with the following information: 
-  What the device is 
-  What the device does 
-  When the device should and should not be used 
-  How the device should be used to achieve maximum benefit and minimal risk. 
 
To this end, we recommend that labeling for devices intended for use in pediatric 
subgroups incorporate the information discussed below. 
A. Basic Elements of Labeling 
The following list identifies some of the basic elements of labeling and discusses ways 
to address these elements for pediatric populations. 
 
Device Description 
 
Many devices and device accessories come in different models, sizes, shapes, 
and materials, as well as different modes of operation and different levels of 
sophistication requiring varying degrees of user interface. The labeling should 
describe various options recommended for use in pediatric subgroups and, when 
feasible, present these options in tabular form by age, weight, or other 
appropriate criteria. 
 
Indications for Use 
If your device is intended for use in a pediatric population, you should clearly 
define the indication(s) as well as the target population in the labeling. The 
indication may be general (e.g., cut, coagulate, ablate), or specific (e.g., treatment 
of vesicoureteral reflux). The target population may be broad (e.g., children and 
adults of all ages) or narrow (e.g., infants between the ages of 6-9 months). You 
should be prepared to explain and, when necessary, support the indication and 
targeted population(s) with appropriate data.  
 
Contraindications, Warnings, and Precautions 
 
Contraindications, warnings, and precautions, respectively, alert the potential user 
to situations where the device should absolutely not be used; data suggest that 
there is increased risk associated with use of the device; or data are lacking to 
define risk/benefit for a particular aspect of use or in a particular subgroup.  Given 
the vulnerability of the pediatric population and specific host concerns described 
                                                           
7 For premarket notification submissions, see 21 CFR 807.87(e). For PMAs and HDEs, see 
21 CFR 814.20(b)(10) and 21 CFR 814.104(b)(4)(ii). 
 
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above, it is especially important that the contraindications, warnings, and 
precautions in labeling provide clear descriptions and well-defined actions and 
consequences. Contraindications, warnings, and precautions for devices intended 
for pediatric use should clearly address the risks associated with age, size, and 
maturity of the pediatric subject and alert the user to specific hazards associated 
with the use of the device in the target population. 
 
Adverse Events 
 
Another key element of labeling is a discussion of device-related adverse events 
that have been reported from clinical investigations or literature pertaining to the 
use of medical devices. Device-related adverse events could be captured in many 
different ways: by severity, frequency, indication, gender, etc. If your device is 
intended for use in pediatrics, you should make a concerted effort to obtain and 
report the frequency of device-related adverse events according to the various 
pediatric subgroups in which the device will be used.  This information will assist 
health care providers in assessing age-specific risk profiles and may be useful in 
mitigating the risks. 
 
Clinical Studies 
 
As discussed above, gathering clinical information directly on the targeted pediatric 
subgroup may be necessary. The importance of summarizing that information in 
labeling warrants special attention. Your labeling should present information in a 
way that is clear, objective, and meaningful. You should report study results in a 
format that allows the user to recognize easily substantive differences in 
performance between children and adults and between various pediatric subgroups.  
Labeling should summarize these data using appropriate qualitative or quantitative 
analyses, recognizing that subgroups may be too small to show statistical 
significance using standard tests. 
 
Instructions for use 
 
Understanding how to use a medical device correctly can be as important as the 
design, manufacturing, and testing of the device. Instructions may be provided 
for the health care practitioner, as is the case with prescription products, or the 
patient, as is the case with over-the-counter products, or both. Labeling provided 
for the healthcare practitioner or caregiver should be written to provide the user 
with instructions for safe and effective use.  This includes addressing anatomic, 
developmental, educational, and other age-related factors in this section of the 
labeling to help ensure proper use of the device and prevent avoidable device-
related adverse events. Any instructions provided specifically for the pediatric 
patient should be age-appropriate with respect to written language and other 
visual and auditory tools. 
 
 
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B. Pediatric Information 
You should submit appropriate information and summarize it adequately to ensure that 
labeling is satisfactory for all pediatric subgroups or specific pediatric subgroups 
(e.g., all pediatric subgroups except neonates) targeted in your intended use. 
 
If you did not include a particular subgroup, or did not include sufficient numbers in 
that subgroup in your clinical trials, and there is reason to expect that there may be 
differences in safety and effectiveness among subgroups, your labeling should indicate 
that the device was not tested in the particular subgroup or that there is insufficient 
information to establish safety and effectiveness for that subgroup. 
 
We recommend that you describe the specific age ranges rather than using pediatric 
in a broad sense.  Please see Table 1. Age Ranges of Pediatric Subgroups. 
C. Special Considerations 
We recommend that you ensure the instructions for use are clear, take into 
consideration different pediatric subgroups, and address any special issues, where 
appropriate. For example, including a precaution to consider future breast bud 
development in female pediatric subjects when selecting a site on the chest for 
placement of a port or catheter may be appropriate. Another example may be including 
a precaution that provides advice on the appropriate activity level for the child, 
especially with respect to participation in certain sports. 
 
X.    Protections for Pediatric Populations in Clinical 
Trials  
The pediatric population represents a vulnerable subgroup of research subjects. Therefore, 
it is important that special measures be taken to protect the rights, safety, and welfare of the 
pediatric study participant. Every effort should be made to ensure that adequate protections 
are provided to these subjects during the conduct of clinical trials. The roles and 
responsibilities of the clinical investigator, sponsor, and the Institutional Review Board are 
crucial in protecting the rights and welfare of the pediatric subject. 
 
FDA regulations governing IRBs identify children as subjects who may be vulnerable and 
subject to coercion. In such cases, IRBs must determine that additional safeguards are in 
place to protect their rights and welfare (21 CFR 56.111(b)).  FDAs guidance document 
entitled, Guidance for Institutional Review Boards and Clinical Investigators, 
http://www.fda.gov/oc/ohrt/irbs/default.htm addresses issues regarding informed consent 
and the assent of children. The basic requirements of 21 CFR 50.20 regarding informed 
consent apply to the pediatric population. See also the guidance entitled, E11 Clinical 
Investigation of Medicinal Products in the Pediatric Population,  
http://www.fda.gov/downloads/RegulatoryInformation/Guidances/ucm129477.pdf . We 
recommend that you consult 21 CFR Part 50 - Subpart D  Additional Safeguards for 
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Children in Clinical Investigations (discussed below) and other referenced resources 
dealing with informed consent, assent, permission, financial remuneration, direct benefit, 
and minimal risk. 
A. Relevant  Definitions 
The following terms are defined in FDAs and the Department of Health and Human 
Services human subject protection regulations and guidance: 
 
Assent means a childs affirmative agreement to participate in a clinical 
investigation. Mere failure to object may not be construed as assent. 21 CFR 
50.3(n). 
 
Children means persons who have not attained the legal age for consent to treatments 
or procedures involved in the clinical investigations, under the applicable law of the 
jurisdiction in which the clinical investigation will be conducted. 21 CFR 50.3(o). 
 
Emancipated Minor: A legal status conferred upon persons who have not yet attained 
the age of legal competency as defined by state law, but who are entitled to treatment as 
if they had by virtue of assuming adult responsibilities, such as self-support, marriage, 
or procreation.8 
 
Family member means any one of the following legally competent persons: Spouse; 
parents; children (including adopted children); brothers, sisters, and spouses of 
brothers and sisters; and any individual related by blood or affinity whose close 
association with the subject is the equivalent of a family relationship. 21 CFR 
50.3(m). 
 
Guardian means an individual who is authorized under applicable state or local law to 
consent on behalf of a child to general medical care when general medical care 
includes participation in research. For purposes of subpart D of 21 CFR Part 50, a 
guardian also means an individual who is authorized to consent on behalf of a child to 
participate in research. 21 CFR 50.3(s). 
 
Legally authorized representative means an individual or judicial or other body 
authorized under applicable law to consent on behalf of a prospective subject to 
the subjects participation in the procedure(s) involved in the research. 21 CFR 
50.3(l). 
 
Mature Minor:  Persons who have not reached adulthood (as defined by state law) but 
who may be treated as an adult for certain purposes (e.g., consenting to medical care). 
Note that a mature minor is not necessarily an emancipated minor. 11 
                                                           
8 IRB Guidebook: Chapter VI Special Classes of Subjects, 
http://www.hhs.gov/ohrp/archive/irb/irb_chapter6.htm.  
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  Contains Nonbinding Recommendations 
 
Minimal risk means that the probability and magnitude of harm or discomfort 
anticipated in the research are not greater in and of themselves than those ordinarily 
encountered in daily life or during the performance of routine physical or psychological 
examinations or tests. 21 CFR 50.3(k). 
 
Parent means a childs biological or adoptive parent. 21 CFR 50.3(p). 
 
Permission means the agreement of parent(s) or guardian to the participation of their 
child or ward in a clinical investigation. Permission must be obtained in compliance 
with subpart B of 21 CFR Part 50 and must include the elements of informed consent 
described in 50.25.  21 CFR 50.3(r). 
B. Study Design Considerations 
As discussed above, FDA recommends that sponsors identify the subgroup(s) in which 
to evaluate the device, unless the device is intended for the entire pediatric population. 
When deciding whether a clinical trial is needed for a particular pediatric population, 
the following points are important to consider: 
 
  Does the research have an identifiable prospect of direct benefit to the 
individual child participant? Can that benefit be achieved through alternative 
means? 
  Does the research have an identifiable prospect of risk to the individual child 
participant? What safeguards are proposed to minimize these risks?  When 
procedures involving greater than minimal risk to children are anticipated, 
are convincing scientific and ethical justifications given? 
 
It is important when designing the study that every attempt is made to anticipate and 
reduce possible study hazards. Investigators should be knowledgeable of all relevant 
pre- clinical data and be properly trained and experienced in the pediatric population and 
medical procedures used for this population. 
 
We recommend that you ensure appropriate pediatric expertise is reasonably available 
during the entire trial. We also recommend all clinical sites have staff and equipment 
appropriate for pediatric care. Your clinical sites should also have pediatric-specific 
emergency measures, such as properly sized oxygen, suction, and resuscitation devices 
as well as medications to treat severe anaphylaxis and adverse reactions.  
 
Because many procedures used during clinical trials are often new to the child, every 
effort should be made to ensure the participants experiences in the study are positive 
and to minimize discomfort and distress.  Additionally, before studies are undertaken, an 
evaluation should be made to determine if the needed information can be obtained from 
less vulnerable populations. When studies are conducted in the pediatric population, 
every attempt should be made to include individuals representing the demographics of 
15 
  Contains Nonbinding Recommendations 
 
the region and the disease being studied. Studies in handicapped or institutionalized 
pediatric subjects should be limited to diseases or conditions found principally in 
these populations. 
 
To be of benefit to those participating in a clinical study, the study should be properly 
designed and conducted to ensure that quality data are obtained. Following Good 
Clinical Practice (GCP) is crucial to obtaining quality and reliable data from the 
study. 
C. The Role of the Institutional Review Board (IRB) 
The principal role of the IRB is to protect the rights and welfare of human research 
subjects; this is especially true when studies involve children as subjects. To safeguard 
the childs interests and to protect children from harm, special ethical and regulatory 
considerations are in place for reviewing research involving children. The regulations 
at 21 CFR Part 50 Subpart D Additional Protections for Children Involved as Subjects 
of Research describe these considerations. 
 
IRBs reviewing research involving children as subjects should consider the benefits, 
risks and discomforts inherent in the proposed research and assess their justification in 
light of the expected benefits to the child subject or to society as a whole. The IRB 
should weigh the circumstance of the subject under study, the magnitude of risks that 
may accrue for the research procedures, and the potential benefits the research may 
provide to the subjects. 
 
The regulations require IRBs to classify research involving children into one of 
four categories and to document their discussions of the risks and benefits of the 
research study. The four categories are: 
 
  Clinical investigations not involving greater than minimal risk (21 CFR 50.51) 
 
  Clinical investigations involving greater than minimal risk but presenting 
the prospect of direct benefit to individual subjects. (21 CFR 50.52) 
 
  Clinical investigations involving greater than minimal risk and no prospect of 
direct benefit to individual subjects, but likely to yield generalizable 
knowledge about the subjects disorder or condition. (21 CFR 50.53) 
 
  Clinical investigations not otherwise approvable that present an opportunity to 
understand, prevent, or alleviate a serious problem affecting the health or 
welfare of children. (21 CFR 50.54) 
 
In all cases, IRBs must determine that adequate provisions have been made for 
soliciting the assent of children and the permission of their parents or guardians. (21 
CFR 50.55) 
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  Contains Nonbinding Recommendations 
 
D. Consent and Assent 
We  recommend that  you  ensure that  the  informed consent document is  clearly 
written and that the risks and benefits are thoroughly explained.  FDA recognizes 
that consent depends on a number of factors, including: 
 
-  age 
-  maturity level 
-  legal status of the subject (emancipated or mature minor) 
-  applicable law of the jurisdiction in which the research is conducted and which 
in turn determines legal age of consent 
-  comprehension level of the pediatric research participant, parents, guardians, 
and legally authorized representative. 
 
We also recommend that you consider: 
 
-  prognosis and life expectancy of patients with certain diseases or disorders 
-  mental capacity, intellectual quotient, and level of functioning 
-  differing ages and maturity level 
-  direct benefits and risks of the pediatric participants research involvement 
(research versus therapeutic treatment) 
-  ethical issues 
-  proper monitoring (data and safety monitoring). 
 
When children or minors are involved in research, the regulations require the assent of 
the child or minor and the permission of the parent(s) in place of the consent of the 
subjects.  21 CFR 50.55.  While children may be legally incapable of giving informed 
consent, they may possess the ability to assent to or dissent from participation. The 
regulations do not require that assent be sought from children starting at a specific age, 
but that their assent should be sought when the children are capable of providing their 
assent. Therefore, children should be asked whether or not they wish to participate in 
the research particularly if the research: (1) does not involve interventions likely to be 
of benefit to the subjects and (2) the children can comprehend and appreciate what it 
means to be a volunteer for the benefit of others. 
 
Researchers may seek assent of children of various ages. Older children may be well 
acquainted with signing documents through prior experience with testing, licensing, 
and other procedures normally encountered in their lives. Signing a form to give their 
assent for research would not be perceived as unusual and would be reasonable. 
Younger children, however, may never have had the experience of signing a document. 
For these children, requiring a signature may not be appropriate, and some other 
technique to verify assent could be used.  For example, a third party may verify, by 
signature, that the assent of the child was obtained. 
 
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  Contains Nonbinding Recommendations 
 
Although there is no requirement that the informed consent document contain a space 
for assent by children, many investigators and IRBs consider it standard practice to 
obtain the agreement of older children who can understand the circumstances before 
enrolling them in research. The basic requirement of 21 CFR 50.20 applies, i.e., the 
legally effective informed consent of the subject or the subject's legally authorized 
representative must be obtained before enrollment. Parents, legal guardians and/or 
others may have the ability to give permission to enroll children in research, depending 
on applicable state and local law of the jurisdiction in which the research is conducted. 
(Note: permission to enroll in research is not the same as permission to provide medical 
treatment.) IRBs generally require investigators to obtain the permission of one or both 
of the parents or guardian (as appropriate) and the assent of children who possess the 
intellectual and emotional ability to comprehend the concepts involved. Some IRBs 
require two documents, a fully detailed explanation for parents and older children to 
read and sign, and a shorter, simpler one for younger children. 
 
For some research activities, IRBs may require that either an IRB member or an 
advocate for the child be present during the assent and permission procedures to verify 
the child understands and to support the childs preferences. The IRB may also require 
that the parent(s) or a close family member be present during the research, especially if 
a young child will be exposed to significant discomfort or inconvenience, or if the child 
will be required to spend time in an unfamiliar place (i.e., study site). 
 
In all cases where assent is required, the proposed research should be explained to the 
child in language that is appropriate to the childs age, experience, maturity, and 
condition.  This explanation should include a discussion of any discomfort and 
inconveniences the child may expect to experience if he or she agrees to participate. 
The subject should also be made aware of his or her rights to decline to participate or to 
withdraw from the study at any time. Additionally, the safety of the subject is always 
an overriding factor in the continuation of a subject in any study. If a subject wishes to 
withdraw from a study and, in the opinion of the investigator and the IRB, the safety 
and welfare of the pediatric subject would be jeopardized by his/her removal from the 
study, continued parental or legal guardian consent should be sufficient to allow 
participation in the study. 
 
A useful reference on informed consent for children participating in research can be found in 
the guidance entitled, Children Involved as Subjects in Research: Guidance on the HHS 45 
CFR 46.407 ("407") Review Process 
(http://www.hhs.gov/ohrp/policy/populations/guidance_407process.html). 
 
XI. Other Resources 
FDA Regulations 
 
Protection of Human Subjects 21 CFR Part 50 (see especially Subpart D Additional 
Safeguards for Children in Clinical Investigations)  
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  Contains Nonbinding Recommendations 
 
Institutional Review Boards 21 CFR Part 56 
Additional Safeguards for Children in Clinical Investigations of FDA-Regulated 
Products; Final Rule 78 FR 12933, February 26, 2013. 
 
Guidance 
 
Guidance on Medical Device Patient Labeling; Final Guidance for Industry and 
FDA Reviewers 
http://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocume
nts/ucm070782.htm 
 
Medical Device Use Safety: Incorporating Human Factors Engineering into Risk 
Management 
http://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm0
94460.htm 
 
Recognition and Use of Consensus Standards; Guidance for Industry and FDA, 
http://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm0
77274.htm and CDRH standards database FDA Recognized Consensus Standards, 
http://www.fda.gov/medicaldevices/deviceregulationandguidance/standards/default.htm 
 
International Conference on Harmonisation (ICH) Guidance for Industry: E11 
Clinical Investigation of Medicinal Products in the Pediatric Population 
http://www.fda.gov/regulatoryinformation/guidances/ucm129476.htm 
 
Guidance for Institutional Review Boards and Clinical Investigators, 1998 
Update http://www.fda.gov/oc/ohrt/irbs/default.htm 
 
Additional References 
 
IRB Guidebook: Chapter VI Special Classes of Subjects, 
http://www.hhs.gov/ohrp/archive/irb/irb_chapter6.htm 
 
International Organization for Standardization (ISO) 10993-6: 2007  Biological Evaluation 
of Medical Devices http://www.iso.org/iso/catalogue_detail.htm?csnumber=44789 
 
CDRH Standards Program webpage 
http://www.fda.gov/medicaldevices/deviceregulationandguidance/standards/default.htm 
 
 
 
 
 
 
 
 
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