18 months after transplant most children can be switched to alternate day steroids. Children receiving primary therapy with tacrolimus may tolerate steroid withdrawal six months after transplant. Unfortunately, it is nearly impossible to predict which children will tolerate complete withdrawal of all immunosuppression. We have treated children who were taken off all immunosuppression for serious complications who did not develop graft rejection, even in long-term follow-up. These children are a minority. Once the immunosuppressive regimen has been decreased somewhat, children can resume a routine schedule of immunizations, see Table 12C.2. The intramuscular polio vaccine preparation should be substituted for the live attenuated vaccine. The approach to immunization with measles vaccine and varicella vaccine can be more liberal. Even though a poor response rate to these two vaccines has been noted in this population, serious consequences of immunization even in children on standard levels of immunosuppression have not been reported. In addition, most liver transplant recipients receive hepatitis B vaccine and yearly influenza vaccine as determined by their local physician. Obviously, children who have a history of asplenia or splenectomy are also immunized with Pneumovax.

One of the most important aspects of long-term follow-up care is monitoring growth and development. Poor linear growth is not uncommon in the first six months after transplant. The onset of catch-up growth is usually between 6 and 24 months after the transplant and can be improved with early withdrawal of corticosteroids. Developmental delay is common in infants in the first year following liver transplant, but steadily improves as children reach school age. Most pediatric liver transplant recipients do have normal school performance once they have rehabilitated from the transplant.

Outpatient management also focuses on patient education, and monitoring compliance. Addressing patient concerns about the cosmetic side-affects of their medication are important issues as well. The final objective of the outpatient visit is to evaluate chronic medical disabilities secondary to the transplant. Most children have minimal medical complaints. A few children are plagued with chronic minor infections. Occasionally, persistence of these infections will warrant a decrease in their immunosuppression to clear the pathogen naturally.

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