Purpose of review: To highlight the current trends in immunosuppression and their application to paediatric transplantation informed by the systematic reviews and randomized controlled trials: new induction agents, steroid avoidance, calcineurin minimization and desensitization protocols. Recent findings: Newer induction agents, belatacept and alemtuzumab, are associated with serious side-effects, and interleukin-2 receptor antagonists remain the preferred agents in children. Steroid-free regimens may improve growth and, compared with steroid-containing regimens, have similar short to medium term graft survival, although long-term outcomes are uncertain. Mammalian target of rapamycin inhibitors, sirolimus and everolimus, when used in recipients as primary immunosuppression to avoid calcineurin exposure, results in poorer graft survival. Although desensitization is being performed more frequently, the relative benefits and harms of regimens used are uncertain. Summary: There is growing evidence for the use of steroid-free immunosuppression regimens in children to maximize growth. Further trials with a focus on long-term graft survival are needed to establish the role of desensitization protocols in organ transplantation in children.