BJA Education, 20(7): 235e241 (2020)
doi: 10.1016/j.bjae.2020.03.004
Matrix codes: 1A02,
2A03, 3A03
Enhanced recovery after surgery in paediatrics: a
review of the literature
K. Roberts1,2, M. Brindle2,3 and D. McLuckie2,3,*
1
Foothills Medical Centre, Calgary, Alberta, Canada, 2Alberta Children’s Hospital, Calgary, Alberta, Canada
and 3University of Calgary, Calgary, Alberta, Canada
*Corresponding author. duncan.mcluckie@albertahealthservices.ca
Learning objectives
By reading this article you should be able to:

Compare the differences between enhanced re-
covery after surgery (ERAS), perioperative surgical
home and fast-track surgery.

Explain the various components of an ERAS pro-
tocol in paediatrics.

Describe the limited evidence for common ERAS
interventions in paediatric practice.

Propose future directions for multidisciplinary
paediatric standardised care protocols.
Katrina Roberts BSc is a resident anaesthesiologist completing her
training at the University of Calgary. Her interests include quality
improvement and patient safety.
Duncan McLuckie DA FRCPC is an attending paediatric anaes-
thesiologist at the Alberta Children’s Hospital and a clinical assis-
tant professor at the University of Calgary. His interests include the
development of protocols and care bundles for paediatric patients
undergoing common surgeries.
Mary Brindle MPH FRCSC is a paediatric surgeon at the Alberta
Children’s Hospital, Associate Department Head and Health systems
researcher at the University of Calgary. She has done extensive work
in surgical quality and safety care pathways, both in research and in
clinical practice. Dr Brindle has helped to spearhead the development
of an international paediatric ERAS collaborative, and is the first lead
of an ERAS Society sponsored guideline addressing neonatal pa-
tients. She has written and presented on her work and co-chairs the
guidelines and standards group for ERAS.
Accepted: 9 March 2020
© 2020 Published by Elsevier Ltd on behalf of British Journal of Anaesthesia.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 6 May 2020
Key points

The concept of ERAS is that multiple, evidence-
based best practice interventions combined into
a protocol will contribute synergistically to
improved outcomes.

The success of adult ERAS protocols has led to
interest in creating paediatric ERAS pathways.

Key ERAS principles include preoperative educa-
tion, reduced preoperative fasting, minimally
invasive surgical techniques, multimodal opioid-
sparing analgesia including regional anaes-
thesia, minimising the use of surgical drains and
early postoperative feeding and mobilisation.

Although robust, high-quality evidence is lacking,
the available literature demonstrates reduced
length of stay, use of opioids and intraoperative
fluids, and time to restarting a regular diet with
paediatric ERAS protocols.
Background: history of enhanced recovery
after surgery
In the era of modern surgery, it is vitally important to provide
high-quality, resource-conscious, patient-centred care.
Enhanced recovery after surgery (ERAS) is a concept devel-
oped to meet these goals. Enhanced recovery after surgery
utilises a patient-centred, multidisciplinary approach through
the perioperative period. Key ERAS concepts include preop-
erative education for patients and families, reduction of pre-
operative fasting, using minimally invasive surgical
techniques, multimodal opioid-sparing analgesia and
regional anaesthesia, minimising tubes and drains and early
postoperative feeding and mobilisation.1 The concept of ERAS
is that multiple, evidence-based best practice interventions
can be combined into a protocol; when applied together, the
235
Enhanced recovery after surgery in paediatrics

to current ERAS concepts, including early postoperative

Table 1 Key components of paediatric ERAS pathways14 feeding and mobilisation, use of minimally invasive surgery
and avoiding tubes and catheters where possible. The term
Intervention APSA colorectal ‘enhanced recovery after surgery’ puts more emphasis on a
care pathway
holistic approach to recovery with a broader focus on out-
Preoperative comes that are important for the patient.
Provide preoperative information and Yes An enhanced recovery protocol (ERP) is the implementation
education strategy used to institute an ERAS guideline. The goal of ERP is
Optimise underlying medical Yes to ensure that an evidence-based and standardised approach
conditions is applied to all patients undergoing surgery. ERPs involve all
Minimise the use of mechanical bowel No
multidisciplinary team members and engage the patient and
preparation
Avoid prolonged fasting Yes their family in their care. An effective ERP uses an ERAS
Administer non-opioid preoperative Yes guideline to improve the quality and efficiency of surgical care
analgesic medications while reducing costs.
Intraoperative The success of adult enhanced recovery strategies has led to
Use thromboembolism prophylaxis Yes interest in creating ERAS pathways in children. Previous litera-
Use preoperative antibiotic prophylaxis Yes
ture reviews on paediatric ERAS have identified a lack of pro-
and skin preparation
Use a standard anaesthetic protocol, Yes spective and randomised control trials in this area, and have
including regional anaesthesia when acknowledged that the creation and implementation of paedi-
possible atric ERAS pathways (Table 1) has been slower than in adults.4
Apply a multimodal approach to Yes A recent review identified one retrospective and four pro-
preventing PONV if >2 risk factors spective cohort studies evaluating children undergoing
Utilise laparoscopic surgery Yes
gastrointestinal (GI), urological and thoracic surgery.1 The
Avoid routine nasogastric tubes Yes
Use standardised protocol for Yes intervention bundles in the studies included six or fewer in-
hypothermia prevention terventions, substantially less than the more than 20 recom-
Postoperative mended interventions in most adult guidelines. Despite this,
Avoid routine peritoneal cavity Yes the studies did suggest that ERPs may be associated with
drainage after colonic anastomosis benefits such as decreased LOS and decreased use of opioids,
Use goal directed fluid therapy or zero Yes
without an increase in complications in appropriate groups of
fluid balance model to guide
postoperative fluid management children undergoing surgery.
Avoid urinary catheter placement or Yes In September 2016, a scoping review identified the extent
early removal on postoperative day 1 to which ERAS has been used in paediatric surgery.1 The au-
or 2 thors identified nine studies from 2003 to 2014 including 1269
Use interventions to minimise Yes patients. Interventions within these protocols were restricted
postoperative ileus
in number and included early postoperative feeding and
Minimise use of opioids Yes
Use insulin to control severe No mobilisation protocols, morphine-sparing analgesia and
hyperglycaemia in the ICU reduced use of nasogastric (NG) tubes and urinary catheters.
Provide nutritional care, including Yes These relatively limited ‘fast-track’ programmes significantly
screening for nutritional status reduced LOS, time to oral feeding and time to first stool.
Begin early scheduled mobilisation on Yes More extensive strategies to introduce ERAS in paediatrics
postoperative days 0e1
have been undertaken. In 2017, at an American Academy of
Collect information on protocol Yes
compliance and outcomes Paediatrics symposium, paediatric surgeons assessed an
existing ERAS Society guideline in adults for use in adoles-
cents undergoing colorectal surgery. The initial consensus
agreement was to adopt 14 of the 21 key elements. After
interventions contribute synergistically to improved out- reviewing the evidence for the elements excluded, group
comes for patients.2 In adults, ERAS protocols reduce consensus resulted in the final inclusion of 19 of the 21 ele-
morbidity and increase patients’ satisfaction while reducing ments. Experience with this paediatric-specific ERP was
overall costs. Clearly defined, standardised elements applied recently published: outcomes from 43 patients undergoing
in a consistent manner can optimise care. The earliest uptake surgery before the ERP were compared with those from 36
of ERAS Society guidelines was for adults undergoing colo- patients after introduction of ERP. In the period before ERP, the
rectal surgery. As growing evidence demonstrated benefits median number of ERAS interventions per patient was five; in
such as reduced length of stay (LOS) and decreased costs, the period after ERP, the median number of interventions was
ERAS was expanded into other adult surgical specialties, 11. Key results included a statistically significant difference in
including gynaecological, orthopaedic and cardiac surgery. the median LOS from 5 to 3 days with the ERP. The times to
This was accompanied by increasing evidence that proto- restarting a regular diet, use of opioids and volumes of fluids
colised care improves morbidity and mortality.3 given during surgery were all reduced.5
The term ‘fast-track surgery’ is often used interchangeably
with ERAS. ‘Fast track’ was the term initially applied to the
approach developed by Kehlet in the 1990s that has subse-
Paediatric evidence for common ERAS
quently become ERAS. The early goal of fast-track surgery was
earlier discharge from hospital after surgery through a
interventions
comprehensive programme to optimise perioperative care. Children pose unique physical and psychosocial challenges to
Many of the original elements of fast-track surgery are similar the anaesthetist. The surgical stress response is complicated

236 BJA Education - Volume 20, Number 7, 2020


by physiological considerations based on a child’s develop-
mental stage. Given the unique biopsychosocial factors in
paediatrics, individual ERAS principles may not be universally
translatable to children, despite demonstrated evidence in
adults. Adolescent ERAS guidelines may resemble adult ERAS
guidelines; however, neonates will require considerably
different guidelines. The paediatric evidence supporting the
recommendations commonly used in adult ERAS protocols
are described below.4
Preoperative patient/family education
Engagement and education of patients is a major component
of adult ERAS protocols. In paediatrics, information should be
provided to families to reduce the child’s and parents’ anxiety
surrounding surgery. Education must be provided at an age-
appropriate level before surgery. Educating families has a
substantial impact on overall satisfaction with the surgical
process and reduces anxiety. Involving older children and
adolescents in the preoperative planning process can promote
engagement and understanding and establish expectations,
which has been shown to improve the quality of their care and
aid their postoperative recovery.6
Minimisation of fasting and administration of a
preoperative carbohydrate load
A recent joint consensus statement by the Association of
Paediatric Anaesthetists of Great Britain and Ireland, the Eu-
ropean Society for Paediatric Anaesthesiology and L’Associa-
tion Des Anesthesistes-Renamateurs Paediatriques
d’Expression Francaise agreed that based on the current
literature and in the absence of a contraindication, children
should be encouraged and allowed to consume clear liquids
up to 1 h before elective general anaesthesia, up to a recom-
mended maximum volume of 3 ml kge1.7 This is in contrast to
other society guidelines, such as the ASA, which continue to
recommend 2 h fasting from clear liquids before surgery.8
With a 2 h clear liquids fasting policy, the literature suggests
that patients actually fast for 6e7 h, with several studies
demonstrating fasts of up to 15 h. The liberalised policy on
clear fluid fasting is based on evidence that water empties
from the stomach within 30 min, and other clear fluids are
almost gone within an hour. There is evidence from rando-
mised control studies demonstrating no significant difference
in gastric volume or pH if children are fasted for clear fluids for
1 compared with 2 h.9 Prolonged fasting primes metabolic and
immune responses which induce a catabolic state, increase
insulin resistance and potentially reduce intravascular vol-
ume. Giving an oral carbohydrate liquid drink 2e3 h before
surgery in adults has been shown to modify this response by
reducing insulin resistance, maintaining glycogen reserves,
minimising protein breakdown, improving overall muscle
strength and possibly contributing to earlier return of bowel
function and decreased LOS, without increasing complication
rates.4
Avoidance of preoperative hyperosmotic mechanical
bowel preparation
Mechanical bowel preparation (MBP) was once a mainstay in
adult colorectal practice, but its utility and potential harms
have recently been questioned. The goal of MBP is to reduce
complications associated with stool bacterial contamination
Enhanced recovery after surgery in paediatrics
including anastomotic dehiscence, wound infection and
sepsis. In adults, evidence suggests that hyperosmotic MBP
may increase risk of surgical site infection (SSI), increase
bowel wall oedema and increase risks of bowel leak and
anastomotic dehiscence; however, the data are conflicting. In
the largest study to date, 32,359 adult patients who underwent
elective colorectal resections in the American College of Sur-
geons national surgery quality improvement programme
database were analysed retrospectively.10 MBP alone was
ineffective at reducing the risk of SSI when compared with no
bowel preparation. However, oral antibiotics (OA) alone and
OA plus MBP were associated with decreased risk of SSI,
anastomotic leak, postoperative ileus, readmission and
shorter LOS. In a similar retrospective analysis of 27,804 adult
surgical patients undergoing elective colorectal resections,
combined MBP/antibiotic bowel preparation (ABP) resulted in
significantly lower rates of SSI, organ space infection, wound
dehiscence and anastomotic leak than no preparation; and a
lower rate of SSI than ABP alone.11 Thus, future adult ERAS
recommendations may recommend that patients undergoing
elective colorectal resection should have both mechanical
agents and OA when feasible.
In children, MBP carries increased morbidity, often
requiring an additional hospital day, NG tube placement for
administration of the preparation and additional laboratory
tests and i.v. fluids to ensure adequate fluid and electrolyte
balance during the preparation. A small randomised control
pilot study identified no significant difference in rates of
anastomotic leak, intra-abdominal infection or wound infec-
tion between children who received MBP and those who did
not.12 A retrospective, multicentre review of 272 children who
underwent reversal of colostomy found that using MBP was
associated with an increased risk of wound infection,
increased LOS and no reduction in any other complications.
LOS in the MBP group was longer, primarily because these
patients were admitted before their surgery for bowel prepa-
ration. These results suggest that omitting MBP in children is
safe, and may reduce cost and discomfort.13
Whether or not MBP is a beneficial element of paediatric
ERAS protocols remains to be determined. Avoidance of MBP
was one of only two elements that the American Paediatric
Surgical Association (APSA) ultimately excluded from their
recommendations for an adolescent colorectal ERAS protocol
(the other excluded element being glucose monitoring).14
Conflicting literature and lack of definitive evidence were
among the reasons for excluding avoiding MBP in the
recommendation.
Judicious use of fluids
A major component of adult ERAS protocols is rational and
judicious fluid therapy. However, there is less evidence that
children are as vulnerable to volume shifts as adults.
Aggressive use of i.v. fluids has been associated with worse
outcome in paediatric patients undergoing cardiac surgery,
but this trend has only recently been demonstrated in other
specialties such as colorectal surgery. A recent retrospective
cohort study of paediatric patients undergoing colonic resec-
tion identified an association between high volume intra-
operative fluid administration and worsened postoperative
outcomes. Specifically, giving fluids greater than 90th
percentile overall was associated with LOS >6 days (odds ratio
[OR], 8.14; 95% confidence interval [CI], 1.75e37.8; p¼0.007),
time to first meal >4 days (OR, 5.91; 95% CI, 1.30e27.17; p¼0.02)
BJA Education - Volume 20, Number 7, 2020 237
Enhanced recovery after surgery in paediatrics
and supplemental oxygen requirement >24 h (adjusted OR
[AOR], 3.60; 95% CI, 1.25e10.39; p¼0.02), after adjusting for ASA
status, blood loss, transfusion and open surgery.15 The
American Society for Enhanced Recovery makes several rec-
ommendations for adult colorectal surgery that may apply to
paediatric patients, including avoidance of fluid administra-
tion for intraoperative oliguria (but not anuria), administering
fluid to address specific clinical problems and avoiding fluid
administration for treatment of an isolated abnormal hae-
modynamic value.16 ERAS principles such as reduced fasting
and avoiding MBP have decreased the intravascular volume
deficits, and fluid needs and administration must be adjusted
accordingly.
New technologies can help assess a patient’s fluid
responsiveness (oesophageal Doppler, non-invasive cardiac
output monitoring, plethysmography variability index, aortic
peak blood flow velocity). The goal of these technologies is to
provide a metric to classify patients in whom fluid adminis-
tration will improve cardiac output and optimise tissue
perfusion, and in whom preload therapy is unnecessary and
will result in fluid overload. In mechanically ventilated adults,
dynamic indices of preload that rely on respiratory variation
in stroke volume are better able to predict fluid responsive-
ness than static variables. Further investigations in children
are required to guide fluid administration, assessment and
optimal maintenance of euvolaemia.
Regional anaesthesia
The adjunctive use of regional anaesthesia during procedures
requiring general anaesthesia has many potential advantages.
Although most commonly thought of as an effective means of
postoperative analgesia, regional anaesthesia may decrease
intraoperative requirements for intravenous and volatile
anaesthetic agents, thereby providing a more rapid awak-
ening and earlier extubation. Regional anaesthesia can also
attenuate or potentially ablate the harmful effects of the
surgical stress response. Afferent neural blockade attenuates
pro-inflammatory and metabolic responses to stress and re-
duces insulin resistance. High-quality evidence in adults
suggests additional benefits of neuraxial analgesia include
accelerated return of GI transit (decreased time to first flatus
and first stool) after abdominal surgery. In open surgeries, an
epidural infusion containing local anaesthetic may decrease
the length of hospital stay (equivalent to 1 day).17
In neonates major abdominal surgery includes intestinal
resection surgery, congenital diaphragmatic hernia, gastro-
schisis and omphalocele. One means of reducing exposure to
drugs that may cause neuronal apoptosis is to use neuraxial
anaesthesia as an adjunct to general anaesthesia.
Various researchers have also demonstrated several po-
tential advantages of peripheral nerve block techniques in
paediatric patients for improving postoperative analgesia and
reducing adverse effects related to opioids. Examples on these
include transversus abdominal plane, erector spinae plane,
paravertebral, rectus sheath and quadratus lumborum blocks.
The paediatric regional anaesthesia network (PRAN) is a
multi-institutional centralised database that collects pro-
spective data on all regional anaesthetics given at partici-
pating centres, to study the incidence of complications of
paediatric regional anaesthesia. Data on 14,917 regional
blocks were gathered between 2007 and 2010, and all intra-
and postoperative complications were tracked until resolu-
tion. No deaths or complications with sequelae lasting more
238 BJA Education - Volume 20, Number 7, 2020
than 3 months occurred.18 As such, regional anaesthesia, and
specifically epidural or combined spinaleepidural (CSE), is
safe and may have physiological benefits in ERAS protocols.
Multimodal, opioid-sparing analgesia
Options for multimodal analgesia to reduce opioid re-
quirements in children include paracetamol, midazolam,
gabapentin, dexamethasone, clonidine, dexmedetomidine
and NSAIDs. Reduction in parenteral opioid requirements
potentially contributes to faster return of gut motility. Adjunct
therapies can be administered i.v., orally, rectally or as com-
ponents in regional blockade to prolong postoperative anal-
gesia. One study showed that addition of intravenous
dexamethasone 0.1 mg kg1 in paediatric patients undergoing
caudal analgesia with ropivicaine reduced pain scores for up
to 48 h and decreased the number of oral analgesics required
after orchidopexy.19 I.V. paracetamol can significantly reduce
postoperative care unit LOS, oversedation and total opioid
consumption.20
Avoidance or early removal of surgical drains and
tubes
Nasogastric tube placement post laparotomy is intended to
protect patients from abdominal distension and subsequent
postoperative nausea and vomiting, aspiration, anastomotic
leaks and wound complications. This concept has been chal-
lenged in adult patients, and robust level 1 evidence exists to
support the avoidance of routine postoperative gastric
drainage in adults after colorectal surgery. A systematic re-
view and meta-analysis of NG decompression from seven
adult studies with a total of 1416 patients after elective colon
and rectum surgery revealed no difference in time to return of
GI function and increased morbidity of pharyngolaryngitis
and respiratory infection with NG decompression. Routine NG
tube decompression was therefore not recommended after
elective colon and rectum surgery.21 Nasogastric tubes were
assumed to be required as children swallow large amounts of
air when distressed and crying, but evidence exists for
avoidance of routine NG tubes in paediatrics. One study found
that there was no difference in postoperative complications
after laparotomy for a variety of upper and lower GI surgeries
regardless of whether or not an NG tube was placed.22 A sig-
nificant decrease in time to first feed, first stool and discharge
was found in patients without NG tubes. However, children
who did not have postoperative NG decompression did have a
higher incidence of postoperative vomiting (22% vs 11%).
Historically, the postoperative ileus that frequently accom-
panies appendicitis and other complicated surgeries was
frequently cited as an indication for NG tube placement.
Current literature challenges this concept. One study suggests
that children with perforated appendicitis have reduced time
to first oral intake (3.8 vs 2.2 days), and reduced LOS (6.0 vs 5.6
days) if an NG tube is not inserted.23 As such, routine NG
drainage in paediatric patients is not recommended.
The utility of peritoneal drainage has also been challenged.
Peritoneal drainage was routine for many surgeries with sig-
nificant intra-abdominal contamination, in addition to
pancreatic and biliary surgeries. The rationale for drain
placement after biliary surgery is to facilitate early identifi-
cation of biliary leaks or haemorrhage and potentially obviate
the need for a radiologically placed drain.

There are few indications in the contemporary era for
routine drain placement. There is no evidence supporting the
placement of drains at the time of removal of a perforated
appendix. Even in complex biliary and pancreatic re-
constructions, leaks are rare and interventional drain place-
ment, when required, is usually sufficient to manage these
uncommon complications. Moreover, the drains themselves,
aside from being frequently unnecessary, can also be harmful.
A surgical drain may be a source of infection and may oppose
the goals of minimally invasive surgery, such as reduction in
postoperative pain. A randomised study of 100 children un-
dergoing laparoscopic choledochal cyst excision Roux-en-Y
hepatojejunostomy (RYHJ) demonstrated that the group
treated without drainage had shorter time to resumption of
normal activity, LOS and decreased pain scores. No patients in
either group developed biliary, pancreatic or intestinal leaks
in the 12 month postoperative follow-up period.24 Drain
placement is required to manage rare biliary and pancreatic
leaks. With the increased availability of interventional radi-
ology support, the need to place these drains at the time of
surgery has decreased substantially. A review in 2018
assessed the benefits and harms of routine abdominal
drainage after pancreatic surgery in adults, and concluded
that it was unclear whether routine abdominal drainage had
an effect on mortality at 30 days or postoperative complica-
tions after pancreatic surgery. Routine abdominal drainage
may slightly reduce mortality at 90 days. The evidence for this
conclusion was moderate in quality.21
In summary, the available literature on peritoneal drainage
suggests that routine drainage is often unnecessary in chil-
dren. However, the quality of evidence is low and there are
situations where operative drainage is warranted or even life-
saving. In these cases, early drain removal is recommended if
feasible.
Prophylaxis for postoperative nausea and vomiting
ERPs best address postoperative nausea and vomiting (PONV)
through a multimodal approach. This approach includes
preoperative oral hydration, minimal use of volatile anaes-
thetics and opioids, prophylactic use of antiemetics and
tailored PONV therapy. Prevention of PONV begins in the
preoperative period. Strategies to reduce baseline risk of
PONV in children include avoidance of volatile anaesthetics
and nitrous oxide by utilisation of propofol for induction and
maintenance, regional anaesthesia to avoid general anaes-
thesia, multimodal analgesia to minimise intra- and post-
operative opioids, and adequate hydration. Risk scores for
PONV, such as the paediatric specific Eberhart risk score,
should be used to help tailor antiemetic therapy to each spe-
cific patient. The 4-point Eberhart scale assigns one point for
each of: surgery longer than 30 min, age older than 3 yr,
strabismus surgery and history of PONV in relatives. When
none, one, two, three or four independent predictors are
present, the risk for PONV is approximately 10%, 30%, 50% or
70%, respectively. 5-Hydroxytrytamine type 3 (5-HT3) receptor
antagonists, specifically ondansetron 0.1 mg kg1, are
commonly used antiemetics for both prophylaxis and rescue
treatment of PONV. Other first-line prophylactic antiemetics
include dexamethasone 0.15e0.3 mg kg1 and aprepitant 40
or 80 mg. Aprepitant is a neurokinin-1 receptor antagonist
with a half-life of approximately 9 h. This potent antiemetic is
optimally given 30e60 min before induction of anaesthesia.
The safety and antiemetic efficacy of aprepitant has been well
Enhanced recovery after surgery in paediatrics
established in the paediatric oncology population. There is
evidence for antiemetic prophylaxis with aprepitant in high-
risk adult surgical populations.25
Early feeding
The first ERAS protocols in adults challenged the initial dogma
of delayed feeding after intestinal surgery to allow anasto-
moses to heal and reduce nausea and vomiting. Despite initial
concerns, early feeding protocols in patients after GI surgery
have consistently demonstrated decreased length of hospital
stay and decreased rates of infection. The same benefits of
early feeding have been demonstrated in paediatric patients
although general practice has yet to catch up. There are ben-
efits to early feeding that are of particular importance for the
paediatric patient. Nutrition in an infant must support growth
and development in addition to anastomotic and wound
healing. A prospective, randomised trial published in 2013 of
150 infants randomised to ad libitum vs protocol feeds found
that ad libitum feeding after pyloromyotomy allowed infants to
reach goal feeds sooner than the protocol group.26 A meta-
analysis of 14 studies published in 2015 comparing ad libitum
feeding to structured feeding after pyloromyotomy demon-
strated that ad libitum feeding is associated with shorter LOS
(mean difference, 4.66 days). Although emesis was more likely
in infants on a rapid than a gradual feeding regime, emesis
was not found to have a negative effect on overall patient
outcome.27 Even for neonatal patients after intestinal resec-
tion, early feeding has been associated with a shorter LOS and
decreased time until first stool. Early postoperative feeding
may not be appropriate for all patients; for example infants
who have undergone post bowel resection for volvulus or
necrotising enterocolitis with ischaemic bowel may require a
different approach.
Strategies for implementation and future
directions for paediatric ERAS
Few ERAS guidelines have been applied to children, and very
few have been designed for children. Surrogate evidence from
adults has been used to guide paediatric ERAS in areas in
which paediatric evidence is lacking. Many elements in adult
ERAS protocols lack high-quality RCT evidence for use in
children (duration and timing of perioperative antibiotics, use
of postoperative Foley catheters and use of MBP).2 At the same
time, there may be a lack of the equipoise required to perform
paediatric RCTs, as strong but indirect data support the ben-
efits of individual ERAS elements (e.g. timing of perioperative
antibiotics).4
Implementation of ERAS protocols can be challenging as
there are numerous barriers to their effective use. Many fea-
tures of ERAS protocols are not intuitive. Routine periopera-
tive practices and the perception of best care can vary widely
within an institution and often lag behind latest evidence.
Enhanced recovery after surgery implementation requires a
team of motivated health professionals that catalyse the ed-
ucation of surgeons, anaesthetists, nurses, patients and their
families in order to influence culture and advance the imple-
mentation of new, impactful protocols.
Complete adoption may not be required to achieve many of
the benefits of ERAS. The application of even a few elements
can increase patients’ comfort and parental satisfaction and
reduce LOS. For example in one study, minimally invasive
techniques could not be applied in 48% of thoracic procedures,
BJA Education - Volume 20, Number 7, 2020 239
Enhanced recovery after surgery in paediatrics
but these paediatric patients could still benefit from other
ERAS elements, including early postoperative mobilisation
and nutrition.28 Exploring the relevance of adult ERAS pro-
tocols for an expanded range of paediatric conditions and
developing new, paediatric-focused ERAS elements will in-
crease the benefits of ERAS for children. It is notable that most
elective paediatric surgeries are performed on ASA 1 and 2
patients who are discharged on the same day as surgery.
Simple ERAS initiatives, such as encouraging clear fluids to be
taken by mouth up until 1 h before surgery and administering
regularly scheduled paracetamol and ibuprofen after opera-
tion, can have a significant impact on patient comfort and
morbidity. These practices could be easily adopted across
large surgical systems that care for children.
The interest in ERAS in paediatric surgery is rapidly
expanding. Teams of international perioperative experts have
begun to implement ERAS protocols in children based on
available evidence and consensus recommendations.14
Neonatal ERAS protocols will look dramatically different
than protocols in adults and adolescents. A neonatal guideline
for intestinal resection surgery contains elements specific to
the needs of neonates including early introduction of breast
milk, rational antibiotic administration, urinary sodium
monitoring and mucous fistula feeding for patients with
stomas.6 Specific recommendations related to anaesthetic
management include multimodal analgesia and the use of
anaesthetic protocols to maintain homeostasis. The first
World Congress for Paediatric ERAS was held in November
2018 in Virginia, USA, and an international working group for
Paediatric ERAS Surgery within the ERAS Society has been
established.
ERAS requires education and engagement from numerous
multidisciplinary teams throughout the perioperative periods.
Paediatric ERAS protocols will continue to develop in
numerous surgical areas of relevance to children. Anaesthe-
tists have an essential role in the creation and dissemination
of paediatric ERAS.
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) are
accessible at www.bjaed.org/cme/home for subscribers to BJA
Education.
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