To the Editor: I read with interest the article by Morton et al, summarising their impressive results of lung transplantation in adolescents treated in an adult hospital.1 The authors state they “do not have an exclusion policy for patients suitable for LTx [lung transplantation] based on age or size criteria alone”, and refer small or very young children to overseas units. The accompanying editorial by Snell et al comments that a paediatric transplant unit would have too low a caseload (four to eight transplants per year) to ensure they deliver good results.2 I agree that large-volume units are desirable, yet of the 158 centres reporting adult lung transplantation to the International Society for Heart and Lung Transplantation, 59% averaged fewer than 10 lung transplants a year.3

While a Surgical Fellow at St Louis Children’s Hospital, Mo, USA (1996–97), I was part of the surgical team undertaking a transplantation operation on a 13-month-old ventilator-dependent infant referred from Sydney. He had an uncomplicated postoperative course, leading to early hospital discharge and early return to Australia. Over the ensuing 5 years, while I was in touch with the family, they travelled regularly to St Louis for follow-up, as local expertise in managing young lung transplant recipients was lacking. Referring families to overseas units may be a good, albeit extremely expensive, short-term solution, yet developing local expertise in the follow-up of these patients has to be part of this package, to ensure optimal management, referrals and dialogue with overseas transplantation centres.

Such local expertise could provide the backbone of a future paediatric lung transplantation unit, preventing unnecessary deaths in this population. Although paediatric lung transplantation is challenging, results for isolated operations in children are similar to those in older age groups,3 so the “perception that the risk of undertaking LTx in children and adolescents does not warrant the reward”2 needs to be challenged. From 1990 to 2002, 190 children received transplants at St Louis Children’s Hospital (45% of them younger than 10 years), 30 of whom underwent living-related lung transplantation (generally reserved for patients too ill to wait for cadaveric lung transplants); although they were a higher-risk group, their survival statistics exceeded those of adult lung transplant patients.4

After all, a low case workload does not stop any of the four paediatric cardiac surgery units in this country from offering arterial switch operations. A local paediatric lung transplant follow-up service, perhaps attached to an adult unit, would be instrumental in optimising paediatric lung transplantation outcomes and could inform the debate on the pros and cons of setting up local paediatric lung transplantation services.

In reply: We were interested to read about Robotin’s insights gained from her experience at St Louis Children’s Hospital, which has one of the largest and most successful paediatric lung transplantation units in the world. We agree that development of local expertise in paediatric lung transplantation would be a cost-efficient means of offering optimum care to young Australians. Because the experience in lung transplants at St Vincent’s Hospital, Sydney, has grown, we would like to provide this service for younger recipients, but our centre lacks specific expertise and facilities for ongoing paediatric care.

A dedicated paediatric ward with experienced nursing staff in a family-friendly environment is essential to meet world’s best practice in this area. There are many complications of the underlying conditions that might benefit from paediatric specialty expertise.

Our experience emphasises that a close working relationship with the patient and his or her family is crucial, and that distance from the location of care delivery and ease of access to the primary treating team are important factors. Given the tyranny of distance, a single Australian centre would be inefficient. However, analysis of outcomes in adult centres shows superior results with increasing transplantation volume, so the concept of small stand-alone centres is not supported by evidence.2

Logistics dictate that linking paediatric services to existing adult services in Australia should improve long-term outcomes. Our data show that performing adolescent lung transplantation in a centre with proven expertise in adult procedures produces excellent results.

We advocate provision of adequate funding and resources in all Australian transplantation centres to achieve optimum service delivery in paediatric lung transplantation.

In reply: We thank Robotin for her positive comments. We agree that the current successful lung transplantation outcomes for adolescents in Australia should be able to be extended to the whole paediatric population in due course.,2 The appropriate timing of the operation and peritransplantation management of young children with advanced lung diseases requires further consideration and debate.3 This should involve the existing lung transplantation services and specific committed paediatric institutions.

However, we disagree that a very low caseload, with procedures performed in a number of institutions, is acceptable. On the basis of cost, training, staffing and political support, it is appropriate to concentrate the expertise. A solid case can be made for a national approach, supported by the Australian Government, with Nationally Funded Centre status. In time, this would provide solid paediatric expertise and access to lung transplantation, either in Australia, or even overseas, as appropriate, during the early evolution of such a program. The objective would be improved survival in children with severe lung disease while minimising the disruption and cost associated with young Australians and their families travelling internationally for lung transplantation care.