Myelodysplastic syndromes (MDS) in childhood comprise a heterogeneous group of disorders, many of which respond poorly to intensive chemotherapy; the only curative treatment for these is bone marrow transplant (BMT). There are, however, some types of paediatric MDS with a slower, more indolent course, and it is important to differentiate these and tailor treatment accordingly. The prognosis for children with MDS who have a matched sibling BMT is improving and, as experience of unrelated donor BMT is gained, this treatment modality is likely to become available for the majority of the remainder.