Introduction: In the United States (US), more than 105,000 people are waiting for a needed organ transplant including more than 2200 children. A significant gap remains between organ donors, organs recovered and transplanted. Children are a small percentage of all organ donors. Improved surgical and medical therapies, and refinement of pediatric critical care teams have resulted in fewer deaths. Evolution of organ preservation technologies allow increased organ availability for transplantation. A retrospective study was performed to evaluate changes in pediatric donation and transplantation over a 29-year period.
Methods: Data was obtained from the Organ Procurement and Transplantation Network (OPTN) and reviewed from 1995-2024. Pediatric patients birth to 18 years of age were reviewed. Data included annual deceased pediatric organ donors, donors by age, mode of death, number and type of organ transplants, and waiting list deaths. 
Results: There were 25150 pediatric brain-dead (BD) donors, mean 838.3 (range 621-1169), and 2912 donation after circulatory death (DCD) donors, mean 97 (range 6-264). There were 27922 pediatric donors, mean 930.7 (range 773-1198). 54584 pediatric transplants were performed, mean 1819.5 (range 1596-2017). 22721 renal transplants, mean 757.4 (range 629-892), 16710 liver transplants, mean 557 (range 506-613), 11060 cardiac transplants, mean 368.7 (range 251-507), 1361 lung transplants, mean 45.3 (range 18-67), 147 heart lung transplants, mean 4.9 (range 1-12). Waitlist deaths totaled 4695, mean 156.5 (range 76-281). 1597 children became to sick to transplant and and died.      
Comparing time periods between 1995-2009 and 2010-2024, mean pediatric donors were 978.7 and 882.8 respectively. BD donors were 947.6 and 729.1 and DCD donors were 33.8 and 166.6.  Pediatric transplant mean 1784 and 1854.8. Renal transplant mean 762.4 and 752.3, liver transplant mean 570.9 and 540, cardiac transplant mean 294.3 and 443, lung transplant 52.5 and 38.3, heart lung transplant 6.9 and 2.9. Mean waitlist deaths 214.4 and 98.6 respectively. 
Conclusions: Pediatric donors have remained relatively stable over a 29-year period with a trend towards fewer total organ donors in the past 14 years. There has been a significant increase in DCD donors for all ages compared to BD donors that have decreased for all ages. The majority of children are waiting for a kidney transplant. Pediatric transplants have steadily increased with the greatest growth in cardiac transplants. Renal transplants have remained stable with a slight decrease in liver transplants. Relatively few lung and heart lung transplants occur in children and have decreased. Waitlist deaths have significant decreased however children removed from the waitlist has increased. Despite children being a small percentage of all organ donors in the US, a robust pediatric donation and transplantation system exists with a significant number of pediatric donors and increasing transplantation rates.