Nesiritide (B-type natriuretic peptide) is one of the newest therapies available in the treatment of adults with decompensated congestive heart failure (CHF). It rapidly improves hemodynamics and induces diuresis in adult patients with moderate to severe CHF. This report details our experience with nesiritide in 4 pediatric cases in 3 subjects with chronic CHF of various causes. As described in adults, our patients generally diuresed and had symptomatic improvement in response to the infusion with only dose-related hypotension and asymptomatic hyponatremia as recognized side effects. Given the number of pediatric patients who progress to CHF as a result of myocarditis, cardiomyopathy, or failed palliation for complex congenital heart disease, we believe nesiritide has a role in managing acutely decompensated CHF in the pediatric population.