Frailty in Children From the Perioperative Management to the Multidisciplinary Approach

The Oxford Dictionary defines the noun “frailty” as “weakness or poor health” and the adjective “frail” as “physically weak and thin” or “easily damaged or broken.” Surgeons deal every day with frail individuals either because the surgical disease itself is endangering their health status and/or (more often) because, in addition to the current disease, they may have comorbidities. An aging patient with intestinal obstruction has a serious problem, but if this happens in association with diabetes, coronary insufficiency, and emphysema, the problem becomes very serious. Except in emergency situations, elective surgery is delayed until the comorbidities are more or less under control, and this is why pre-operative tests and anesthetic consultations are mandatory. Pediatric surgeons are not different from adult surgeons in this respect, and they have also to deal with similar situations although the age and the nature of comorbidities are usually different. In the core of the specialty the complexity of the situation may be extreme while performing surgery for newborns: A 900 g baby with respiratory distress syndrome, an open ductus, and stage 3 necrotizing enterocolitis is a very “frail” patient. The skin barrier is weak, immunity is developing, the g.i. tract is in the process of establishing a symbiotic flora, the lung is immature, and so are the clotting mechanisms and the brain. But prematurity is not the only dangerous comorbidity. A 3000 g term baby with left CDH, associated congenital heart disease, pulmonary insufficiency, and hypertension requiring ECMO may have more mature functions than a premature but shares the same extreme frailty. This could be extended to other surgical situations beyond the neonatal period. In addition, in a number of these clinical conditions there is no chance for “elective” surgery. If I look back at my career as a pediatric surgeon extended along more than 50 years, I realize that these issues have become more and more complicated with the passage of time. When I was a trainee, almost half the patients with esophageal atresia died and so did the majority of babies with congenital diaphragmatic hernia or Wilms’ tumor. Ventilation in newborns was at its beginnings, total parenteral nutrition was not yet available, and many of the supporting drugs currently used were not in the market. Survival of newborns below 1000 or even 1500 g was rare and our “frail” patients were the tip of the iceberg. Rapid progress made the iceberg emerge and it grew more and more until producing many of these cases that nowadays constitute a large results but, frankly, at the expense of a much more complex specialty. This is why this book on frailty is timely and appealing. Moreover, the editors, Mario Lima and Maria Cristina Mondardini, authors of a number of acknowledged books on various aspects of our specialty, planned a comprehensive coverage of the subject and recruited a set of first-class authors for different chapters. The book is structured in five parts: After an introduction, the frailty of the newborn is covered extensively. The next parts analyze the multiple comorbidities that may cause additional frailty, the various actions pointed to improving therapeutic actions in this context, and the need for social support, continuity of care, and transition to adult care of these individuals that may require follow-up and support for life. I predict that this volume will have great success and that many of us will be illuminated by this comprehensive view of the growing intricacies of our surgical activity.