There are special challenges associated with the use of transvenous pacemakers in children. For example, a child's chest cavity or vascular dimensions could be too small to host the generator and leads available or required. If leads are implanted, they may stretch as the child grows. This increases the risk that the leads will later dislodge or fracture. Moreover, children requiring pacemakers often have coexisting congenital heart defects and the structural abnormalities of those could hinder easy placement of the pacing system. This article will first review the indications for permanent pacing in children and will then describe the unique challenges associated with such use.