I have dealt with pediatric solid organ transplantation quite a bit over the years, both from the perspective of caring for children who receive transplants and for those unfortunate children whose parents choose for them to become organ donors. By solid organs I mean primarily kidney, liver, heart, and lung transplants–bone marrow transplants are somewhat different. Children comprise a small but significant subgroup of organ transplant patients: in a recent survey they accounted for 7% of transplant recipients, a number which had changed little in the previous decade.

Although children accounted for 7% of the recipients, they comprised twice that number of donors–14% of them. Some transplanted organs may come from a living donor; for example, about half of kidney transplants use an organ donated by someone, usually a close relative. (This is possible because we have two kidneys and can live quite normally with only one of them.) Children, however, are not living donors. This means all of those children who donated organs died, and their families made the choice for their child’s organs to live on and give life to another person. And that person was often an adult, because the number of children who donate organs far exceeds the number who receive them as transplants. We do try to match donated organs from children first with another child, particularly if size is important, as it often is for the very small children. But if no child is a match, and size is not an issue (it often is not if the donor is an older child), the organs are given to adult patients.

I have many times been in the position of asking grieving parents to consider donating their beloved child’s organs to another person. I could not find any national statistics about this, but in my personal experience, two-thirds at least of parents I ask make the choice to donate life. I do know the donation rate for adults is far, far lower than that. Children on the whole have healthier organs, and this is reflected by the fact that children who donate are more likely than adults to be able to donate several organs, often three or more. But this is not the reason children represent such a relatively large proportion of organ donors; the reason is their parents, however devastated by the loss of their child, choose this for them. We adults should be so generous with our own bodies.

If you are interested in learning more about transplantation in general, this is a good site with useful links to other authoritative sites. If you want to know more of the technical specifics of children’s transplant statistics over the past decade, you can read about it here.

I have a donor’s heart logo on my driver’s license. I encourage everyone to think deeply about doing that, too, as well as telling your family that, should tragedy strike unexpectedly, you wish your organs to live on in someone else.

It is unclear what will happen after the president’s veto of the bill reauthorizing the State Children’s Health Insurance Program (SCHIP) and the inability of Congress to override his veto. John Iglehart, the highly-respected national correspondent for the New England Journal of Medicine, reviews the episode here. It is brief, understandable, and to the point. Whatever you think of the issue, it is clear opponents of the program misrepresented what it was.

But there is a deeper issue — quality, as well as quantity, matters. In a way, the SCHIP debate is about quantityof healthcare because it concerns access to care; children and adolescents are disproportionately more likely than adults to be poor, something SCHIP was designed to address. Another recent New England Journal article shows how qualityof healthcare for children is also a major problem.

This observation goes against the common wisdom, which has been that problems in quality of healthcare are not such a problem for children as they are for adults. The unspoken assumption has been that children’s conditions are somehow easier to diagnose and less complicated to treat than those adults get. So if the child could get to the doctor, then we presumed the child usually got the correct care. This is not true; deficiency rates in the quality of care for children were similar to those noted in adults.

What is the solution? We need to assume children are just as complicated as adults in their healthcare needs.

Doctors do a lot of x-rays on children. Is there a risk to that, or are x-rays completely safe? The answer, for chest, bone, and abdominal x-rays, is that they are very, very, very safe, but not totally risk-free. All of us are constantly exposed to radiation similar to x-rays. It comes primarily from naturally-occurring radioactive things around us, such as radon gas seeping up through the ground, or from outer space in the form of cosmic rays. People living at higher altitudes receive higher doses of such background radiation, amounting to about half again as much for someone living on the Colorado plateau compared with someone at sea level. To put things in perspective, the radiation dose in a single chest x-ray, on average, is similar to the background radiation most of us receive during a ten day time span living our normal lives.

There are several important things to remember about radiation risks. High radiation doses definitely cause death and disease (primarily cancer); the atomic bomb and the disaster at Chernobyl clearly showed this. A second key point is that radiation risk is cumulative over a lifetime. This is an important consideration for children, since they have most of their life ahead of them. Children are also more sensitive to the effects of x-rays than are adults. Still, it is logical to think of routine chest, arm and leg, and abdominal x-rays as being virtually without risk unless the child has already gotten for some reason a large radiation dose in the past.

Computed tomographic scans, CT scans, are another form of x-rays. We most commonly use CT scans to look at a child’s head, chest, or abdomen. The technology produces good images of the organs inside those body regions, and CT scanning has revolutionized how medicine and surgery are practiced. But CT must be used judiciously, particularly in children, because it subjects the child to much more radiation than does a simple chest or abdomen x-ray–200 to 300 times more, depending upon the particular technique used. So if a chest x-ray is the equivalent of ten days of background radiation exposure, a child getting a CT scan receives the same radiation dose as anywhere from five to ten years of normal living. I’ve written more about CT scan risk here.

The future cancer risk to a child from a single CT scan is still vanishingly small, and the benefits of getting the information the CT provides nearly always outweigh this tiny risk. However, this may not be the case for children who get many CT scans or have been exposed to other radiation in the past. Fortunately, this represents a relatively small number of children. There are ways of using reduced radiation doses in children, compared to the doses adults receive for CT. If you are concerned about this issue, ask your child’s doctor about it, or you can read more about it here.

I’ve also posted here about what medical risk means.