Summary of best evidence for enhanced recovery after surgery for perioperative management of pediatric cleft lip and palate surgery: a narrative review.

Abstract

Background and objective: Children with cleft lip and palate face more complex stressful situations in the perioperative period due to their underdeveloped systems and relatively weaker resistance to various injurious stimuli. The concept of enhanced recovery after surgery (ERAS) offers a novel perspective on the perioperative management of pediatric patients with cleft lip and palate. This narrative review aimed to search, evaluate, and summarize the best evidence for ERAS in children with cleft lip and palate, and provide reference for clinical perioperative nursing practice.

Methods: We searched the databases of The British Medical Journal (BMJ), UpToDate, The Cochrane Library, Guidelines International Network (GIN), Scottish Intercollegiate Guidelines Network (SIGN), Joanna Briggs Institute (JBI), Medlive, American Cleft Palate-Craniofacial Association (ACPA), Enhanced Recovery After Surgery Society, Chinese Stomatological Association (CSA), PubMed, Web of Science, Embase, Scopus, SinoMed, China National Knowledge Infrastructure (CNKI), Wanfang, and China Science and Technology Journal (VIP). The search covered the period from the database's inception to December 2024. This study included children undergoing congenital cleft lip and palate surgery who received perioperative ERAS interventions with evidence derived from guidelines, evidence summary, expert consensus, systematic reviews, or randomized controlled trials (RCTs), while excluding non-English/Chinese literature, incomplete methodological details or low-quality appraisal ratings, and studies with unavailable data. Quality was assessed using Clinical Guidelines Research and Evaluation System for guidelines, Critical Appraisal for Summaries of Evidence for evidence summaries, the JBI Critical Appraisal Tool for Systematic Reviews, the JBI Critical Appraisal Checklists for expert consensus, and the Cochrane Risk of Bias Tool for randomized trials. Evidence synthesis was performed using the JBI Evidence Pre-grading System (2014) to classify evidence levels (1-5), followed by recommendation grading (grade A/B).

Key content and findings: A total of 14 articles were included, including four guidelines, one technical report, two expert consensus articles, three systematic reviews, and four RCTs (covering 342 patients). The publication or update dates of these studies spanned 2019-2024, with their sources predominantly originating from the United States and China, and they covered the entire perioperative period. Through a comprehensive analysis of these studies, 17 themes and 34 recommendations were identified in total. These recommendations cover preoperative preparation (health education, nutrition, fasting), intraoperative care (anesthesia, temperature), postoperative management (pain, feeding, wound care), and discharge follow-up.

Conclusions: This study synthesizes 34 key evidence-based recommendations for perioperative ERAS management in pediatric cleft lip and palate surgery, providing structured guidance to accelerate postoperative recovery and standardize clinical practice. Since these findings originated from several nations, institution-specific factors must be assessed prior to adoption of ERAS protocols. These factors include resource availability, local healthcare policies, multidisciplinary team engagement, and existing clinical workflows.