Bridging the Developmental Gap: Pediatric Considerations for the ISHLT Consensus Statement on Frailty in Lung Transplantation.

The recent International Society for Heart and Lung Transplantation consensus statement on frailty provides a crucial framework for operationalizing objective frailty metrics and prehabilitation in adult lung transplant candidates. However, translating adult frailty constructs to pediatric candidates with end-stage lung disease presents unique physiological and developmental challenges, as measures of physical performance must account for ongoing linear growth, somatic maturation, and neurodevelopmental trajectories. These complexities are heightened in critically ill pediatric patients, particularly those bridged to transplantation via mechanical ventilation or extracorporeal membrane oxygenation (ECMO), where distinguishing acute illness-attributable neuromuscular deconditioning from systemic, irreversible frailty remains an obstacle. The creation and incorporation of developmentally appropriate frailty measures into pediatric transplant evaluation will be essential to refine candidate selection, optimize pre-transplant functional capacity, and improve post-transplant outcomes. Accomplishing this task will require multidisciplinary collaboration involving critical care, lung transplant, nutritional support, rehabilitation, and behavioral health team members. Key priorities include validating pediatric-specific functional tools, establishing longitudinal tracking of sarcopenia and growth, implementing age-appropriate, play-based prehabilitation paired with nutritional support, and standardizing assessment across the transplant trajectory, including for patients bridged to transplant with inpatient mechanical support such as ECMO or lung assist devices, as well as those managed in the outpatient setting with chronic mechanical respiratory support.