Pediatric Transplantation. 2019;23:e13537. wileyonlinelibrary.com/journal/petr | 1 of 8 https://doi.org/10.1111/petr.13537 © 2019 Wiley Periodicals, Inc. Received: 11 April 2019 | Revised: 3 June 2019 | Accepted: 11 June 2019 DOI: 10.1111/petr.13537 COMMENTARY Barriers to ideal outcomes after pediatric liver transplantation Vicky Lee Ng 1 | George V. Mazariegos 2 | Beau Kelly 3 | Simon Horslen 4 | Sue V. McDiarmid 5 | John C. Magee 6 | Kathleen M. Loomes 7 | Ryan T. Fischer 8 | Shikha S. Sundaram 9 | Jennifer C. Lai 10 | Helen S. Te 11 | John C. Bucuvalas 12 1 Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada 2 Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 3 Division of Surgery, DCI Donor Services, Sacramento, California 4 Department of Pediatrics, University of Washington, Seattle, Washington 5 David Geffen School of Medicine, University of California, Los Angeles, California, USA 6 Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan 7 Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 8 Division of Gastroenterology, Hepatology and Nutrition, Children’s Mercy Hospital, University of Missouri‐Kansas City School of Medicine, Kansas City, Missouri 9 Pediatrics, Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado 10 Division of Gastroenterology/Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California 11 Adult Liver Transplant Program, University of Chicago Medicine, Chicago, Illinois 12 Mount Sinai Kravis Childrens Hospital and Recanati/Miller Transplant Institute, New York City, New York Abbreviations: AASLD, American Association for the Study of Liver Diseases; AST, American Society of Transplantation; DDLT, deceased donor liver transplantation; FTR, failure to rescue; HRQOL, Health related Quality of Life; LDLT, living donor liver transplantation; LICOP, liver and intestinal community of practice; LT, liver transplantation; MLVI, Medication Level Variability Index; NASPGHAN, North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition; NSER, non‐standard exception requests; PCOP, pediatric community of practice; PELD, pediatric end‐stage liver disease; PeLTQL, pediatric liver transplant quality of life; PICU, pediatric intensive care unit; PRO, patient‐reported outcomes; PROM, Patient Reported Outcome Measure; PTLD, post‐transplant lymphoproliferative disease; SNEPT, Starzl Network for Excellence in Pediatric Transplantation; SPLIT, Society of Pediatric Liver Transplant; SRTR, Scientific Registry of Transplant Recipients. Correspondence Vicky Lee Ng, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada. Email: vicky.ng@sickkids.ca Funding information This study was funded in part by NIH K23AG048337 (Lai), NIH R01AG059183 (Lai). These funding agencies played no role in the analysis of the data or the preparation of this manuscript. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Abstract Long‐term survival for children who undergo LT is now the rule rather than the ex‐ ception. However, a focus on the outcome of patient or graft survival rates alone pro‐ vides an incomplete and limited view of life for patients who undergo LT as an infant, child, or teen. The paradigm has now appropriately shifted to opportunities focused on our overarching goals of “surviving and thriving” with long‐term allograft health, freedom of complications from long‐term immunosuppression, self‐reported well‐ being, and global functional health. Experts within the liver transplant community highlight clinical gaps and potential barriers at each of the pretransplant, intra‐op‐ erative, early‐, medium‐, and long‐term post‐transplant stages toward these broader mandates. Strategies including clinical research, innovation, and quality improvement targeting both traditional as well as PRO are outlined and, if successfully leveraged and conducted, would improve outcomes for recipients of pediatric LT.