Transplants are performed for organs such as kidney, liver, heart, intestine, pancreas, heart-lung, and kidney-pancreas. However, the kidney, liver, and heart are the most commonly transplanted organs. In 2000, doctors performed 13,333 kidney, 4,950 liver, and 2,197 heart transplants. Of these, children made up 617 of the kidney recipients, 569 of the liver recipients, and 274 of the heart recipients. Organ transplants were performed at 261 centers, which had one or more specific organ transplant programs, in 1998. Some of these centers accept both adults and children, and others are for children only. In 1998, pediatric kidney transplants were performed at 129 of the 241 centers that performed kidney transplants; pediatric liver transplants were performed at 77 of the 116 centers that transplanted livers; and pediatric heart transplants were performed at 54 of the 134 centers that transplanted hearts. In 1984, Congress enacted the National Organ Transplant Act (P.L. 98-507), which requires HHS to establish the OPTN. In 1986, HHS awarded the OPTN contract to UNOS, which operates the network under HRSA’s oversight. The OPTN develops national transplantation policy, maintains the list of patients waiting for transplants, and fosters efforts to increase the nation’s organ supply. OPTN members include all transplant centers, organ procurement organizations, and tissue-typing laboratories. Only a small fraction of those who die are considered for organ donation. Most cadaveric organs derive from donors who have been pronounced brain-dead as a result of a motor vehicle collision, stroke, violence, suicide, or severe head injury. When an organ becomes available, staff from the local organ procurement organization typically identify potential recipients from the OPTN computerized waiting list. Patients are ranked on the OPTN waiting list according to points assigned on the basis of time waiting, medical urgency, organ size, and the quality of the tissue-type match between the donor and the potential recipient, as determined by antigen matching. The criteria that determine the order of candidates on the list are applied or defined differently for each type of organ and for pediatric versus adult patients. With certain limitations, organs from pediatric donors can be transplanted into adults, and vice versa. The UNOS computer matches each patient in the OPTN database against a donor’s characteristics and then generates a different ranked list of potential recipients for each transplantable organ from the donor. Organs are generally allocated first to patients waiting in the local organ procurement organization’s service area, with priority based on a patient’s severity of illness. If a matching recipient is not found locally, the organ is offered regionally and then nationally. Organ allocation policies are revised from time to time to reflect advancements in medical science and technology. Title XXI of the Children’s Health Act of 2000 (P.L. 106-310, October 17, 2000) requires the OPTN to recognize the differences in organ transplantation needs between children and adults and adopt criteria, policies, and procedures that address the unique health care needs of children. In addition, the OPTN is to carry out studies and demonstration projects for improving procedures for organ procurement and allocation, including projects to examine and to increase transplantation among populations with special needs, such as children and racial or ethnic minority groups. Finally, the act requires the Secretary of HHS to conduct a study and make recommendations regarding the (1) special growth and developmental issues that children have before and after transplant; (2) extent of denials by medical examiners and coroners to allow donation of organs; (3) other special health and transplantation needs of children; and (4) costs of the immunosuppressive drugs that children must take after receiving a transplant and the extent of their coverage by health plans and insurers. (For a discussion of children’s access to these necessary medications, see app. I.) The Secretary must report to the Congress by December 31, 2001. Pediatric patients in need of an organ transplant continue to face a shortage of donated organs. From 1991 through 2000, the number of pediatric organ donors each year has remained relatively constant, even though the number of potential pediatric donors decreased. The number of adult donors has increased significantly during the same period, in large part because donor eligibility criteria have been expanded to include older donors and donors with certain diseases that were not accepted in the past. Simultaneously, the demand for organs for pediatric patients has grown substantially, with the number of children on waiting lists for organ transplants more than doubling. However, compared to adults, children account for a small number of transplant candidates. Several factors can prevent the recovery of organs from a potential donor. Refusal by the family to give consent for donation is the primary reason for nonrecovery of an organ, but failure by health professionals to identify potential donors or approach families and refusal by medical examiners and coroners to release the body also account for significant losses of transplantable organs. Nonetheless, organs are recovered from a higher proportion of potential pediatric donors than potential adult donors. The number of pediatric donors has held relatively steady despite a drop in the number of potential donors. Our analysis of 1989 through 1997 mortality data for children showed a 20-percent decline in deaths of the kinds that are most likely to result in organ donation, such as those resulting from head trauma, motor vehicle collisions, and violence. (See app. II for a complete list of these causes of death.) Mortality for potential donors up to age 19 years declined from 24,069 deaths in 1989 to 19,327 in 1997, the latest data available at the time of our analysis (see table 1). OPTN data show that from 1991 through 2000, while the number of pediatric donors remained relatively constant, the number of adult donors increased 45 percent (see fig. 1). The large increase in the number of adult donors is primarily due to changes in the criteria for accepting organs from a donor. At one time, organs were accepted only from someone who had been declared brain-dead and was relatively young and free from diseases that could affect organ quality. However, because of the continuing shortage of transplantable organs, transplant professionals have gradually expanded the criteria for acceptable organs. Older individuals and persons with certain medical conditions who previously would have been excluded from donating organs can now be donors.From 1991 through 2000, the number of cadaveric donors aged 50 to 64 increased 108 percent, and the number of cadaveric donors aged 65 or older increased 272 percent. The number of children waiting for a transplant has increased over time, but not as much as for adults (see fig. 2). OPTN data show that the number of pediatric patients awaiting transplants increased from 1,010 in 1991 to 2,299 in 2000, a 128-percent increase. The number of adults on the waiting list has increased even faster, from 23,709 in 1991 to 77,047 in 2000, a 225- percent increase. These increases have been spurred by advances in medical science and technology, which have made transplantation a more acceptable medical procedure; improvements in immunosuppressive medications, which have increased survival rates; and an increase in the incidence of certain diseases that lead to end stage organ failure. Despite these increases, the proportion of patients awaiting transplant who are children has remained fairly constant from 1991 through 2000, at between 3 and 4 percent overall. Several factors can prevent the recovery of organs from potential pediatric and adult donors and thus contribute to the continuing shortage of transplantable organs for both children and adults. For example, for many potential donors, families refuse to give consent for organ donation. For others, health care professionals may fail to offer the families the opportunity to donate. Further, some medical examiners and coroners believe that the need to preserve forensic evidence in certain types of cases, such as suspected child abuse and sudden infant death syndrome, makes it impossible for them to allow organ donation to proceed. The Association of Organ Procurement Organizations (AOPO) recently conducted a study at 31 organ procurement organizations on the reasons why potential adult and pediatric donors do not become organ donors. The study found that consent was not given for 39 percent of potential donors and only 41 percent of suitable individuals actually become organ donors. AOPO provided us with the survey data from the referral, request, and organ recovery processes for the pediatric patients. As our analysis shows in table 2, of the 2,420 potential pediatric donors, organs were recovered in 1,230 cases, or about 51 percent of pediatric cases, a rate higher than the overall donation rate. Family refusal (25 percent) was the most common obstacle to organ recovery, but this occurred less frequently for potential pediatric donors than for the entire group of potential donors. Most pediatric organs are transplanted into adults because adults make up the vast majority of patients waiting for an organ transplant and therefore are more likely to be at a higher status on local organ waiting lists than children. However, the degree to which pediatric organs are transplanted into adults varies by organ. In particular, adult patients receive more pediatric kidneys than pediatric patients do, partly because of the importance of tissue-type matching criteria in the allocation of kidneys.While most pediatric kidneys are transplanted into adults, adult kidneys are sometimes transplanted into children. The situation is different for livers and hearts, where organ size is an important determinant of suitability. Livers and hearts from children under 10 are usually transplanted into pediatric patients, whereas those from children aged 11 to 17 are usually transplanted into adults. Figure 3 shows the distribution of pediatric kidneys, livers, and hearts to pediatric and adult recipients. (See app. III for a detailed listing of the distribution of kidneys, livers, and hearts by age of donor and recipient.) Pediatric livers and hearts that are given to adults have sometimes been refused beforehand for a pediatric patient by the patient’s physician for various medical or logistical reasons. Adult organs are also transplanted into children, but in much smaller numbers. Although the majority of pediatric kidneys are transplanted into adults, some adult kidneys are transplanted into children.