Emergency department sedation offers considerable savings, compared with theatre-based management for children who require short painful procedures.

The use of routine endomyocardial biopsies post-heart transplant in children remains controversial. It is generally accepted as the gold standard for detecting rejection, but details of the surveillance protocol, such as number and timing of biopsies, remain uncertain, with suggestions that recent advances in immunosuppressant therapy have obviated the need to perform surveillance biopsies. We retrospectively analysed results of endomyocardial biopsies performed in our unit since the introduction of a policy of three routine biopsies in the first six months post-transplantation. We specifically examined only routine surveillance biopsies in order to determine whether clinically unsuspected cases of rejection were identified. Between January 2002 and April 2006, 63 children completed three biopsies in the first six months post-transplant. Of 189 surveillance endomyocardial biopsies, 19 (10%) patients showed significant, grade III or above, rejection. One patient had two episodes of rejection. In only one case the child was haemodynamically unstable, four cases were mildly unwell, and 14 of 19 (74%) cases demonstrated no cardiac symptoms. Four of eight cases treated with sirolimus for some part of their post-transplant course had an episode of rejection and of 54 tacrolimus-treated patients, 13 had an episode of asymptomatic rejection detected. One of the seven infants had significant episode of rejection. Asymptomatic, clinically significant rejection is detected in about 10% of biopsies overall using a three-biopsy protocol in the first six months after paediatric heart transplantation, and occurs in 24% of tacrolimus-treated patients. More frequent surveillance appears needed in children treated with sirolimus, but less frequent surveillance may be possible in infants.

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''amenities'' (quality of refreshments, toys, toilet and disabled facilities), ''consultant care'' (privacy, listening, use of plain language and involvement in decision making) and ''clinic care'' (cleanliness, courtesy and understanding the child's needs). Seventy nine of the 149 (53%) questionnaires were returned. Of the 79 children, 37 (47%) were male, 42 (53%) were female and 50 (63%) were less than 2 years of age. Satisfaction with clinical care was high (satisfaction score 4.6). Comments by parents suggested that teamwork and having sufficient time to discuss immunisation were important factors. In England lack of time to discuss immunisation with a health care professional is one of the commonest causes of dissatisfaction with the immunisation visit. 2 The ''amenities'' domain was the lowest scoring (satisfaction score 3.9). Important factors included lack of refreshments (the clinic is located some distance from the canteen) and problems with car parking. Car parking is important for parents with young children and this problem has been reported previously. 3 We suspect that it is an important issue in many paediatric outpatient departments. Similar surveys 4-6 have identified high levels of satisfaction with clinical care. This survey highlighted to us that non-clinical factors are important for patient experience and that small changes within the clinic can lead to perceptible improvements for patients.