Expanding ERAS Pathways in Pediatric Cleft and Craniofacial Surgery

Enhanced Recovery After Surgery (ERAS) protocols are evidence-based perioperative care pathways designed to optimize recovery by addressing factors across the preoperative, intraoperative and postoperative continuum. In adult surgical populations, ERAS pathways have demonstrated improvements in outcomes, reductions in morbidity and lower health care costs. In pediatric surgery, however, published data remain limited, particularly for children undergoing cleft and craniofacial procedures.

Building on prior quality improvement work, we expanded ERAS principles to pediatric cleft and craniofacial surgery at Children’s Wisconsin. Our earlier initiative focused on cranial vault remodeling and demonstrated meaningful benefits, including improved pain control, reduced opioid use and decreased need for blood transfusions. Encouraged by these results, we extended ERAS pathways to primary cleft lip and palate repair as well as alveolar bone grafting.

Applying ERAS Principles to Cleft Care

Cleft lip and cleft palate represent some of the most common congenital anomalies, occurring in approximately 1 in 600 to 700 births. At Children’s Wisconsin, we perform more than 60 primary cleft lip and palate procedures and over 30 alveolar bone grafts each year. Given this volume, even incremental improvements in recovery can have a meaningful impact on patient experience and outcomes.

A central focus of our ERAS protocol is minimizing opioid exposure. Opioid-related side effects such as nausea, vomiting, ileus, pruritus, urinary retention and respiratory depression can delay recovery and complicate postoperative care. Reducing reliance on narcotics supports earlier feeding, improved comfort and shorter hospital stays.

Early Impact and Future Direction

Key components of our pathway include the use of regional nerve blocks in combination with scheduled nonopioid medications. Early initiation of acetaminophen and ibuprofen has become a cornerstone of postoperative pain management. Together, these strategies provide effective analgesia while limiting opioid requirements. We have observed lower FLACC pain scores and improved tolerance of the first oral feeding in patients managed with this approach.

Since implementing the expanded ERAS protocol, we have maintained opioid prescription rates at discharge well below the national average and continue to pursue further reductions. By standardizing perioperative care and emphasizing multimodal analgesia, we have improved recovery for children undergoing cleft procedures while maintaining safety and comfort.