How ERAS Protocols Are Revolutionizing Newborn Surgery
A quiet revolution is unfolding in neonatal intensive care units, where evidence-based care is yielding extraordinary results for our most vulnerable surgical patients.
Imagine a newborn, just hours old, facing major surgery. For decades, this scenario meant overwhelming stress for the infant's developing systems — from prolonged fasting that challenged fragile metabolism to potent opioids that risked brain development. Today, a transformative approach known as Enhanced Recovery After Surgery (ERAS) is reshaping this narrative through standardized, evidence-based protocols specifically designed for neonates. These tiny patients, once considered too delicate for standardized pathways, are now experiencing better outcomes, fewer complications, and stronger foundations for healthy development through carefully tailored perioperative care.
Enhanced Recovery After Surgery represents a fundamental shift in surgical care. Originally developed for adults, these protocols bundle multiple evidence-informed practices throughout the preoperative, intraoperative, and postoperative periods to optimize recovery. The approach has demonstrated significant benefits in adult populations, including reduced complications, shorter hospital stays, and decreased opioid usage .
The translation of ERAS principles to neonatal care required acknowledging the unique physiological challenges of this population. Neonates, especially preterm infants, face particular risks including:
Leading to rapid heat loss in vulnerable newborns.
Due to higher total body water content.
With limited energy reserves.
Including heightened sensitivity to opioids.
The first official ERAS guidelines for neonatal intestinal resection were published in 2020, marking a significant milestone in pediatric surgery . This groundbreaking work recognized that despite varied surgical pathologies, neonates share many perioperative priorities that allow for unit-wide ERAS recommendations independent of the specific procedure 5 .
The development of neonatal ERAS recommendations followed a rigorous methodological process guided by the ERAS Society standards. An international guideline development committee was assembled, comprising pediatric surgeons, anesthesiologists, neonatologists, neonatal nurses, and ERAS methodology experts 5 . This multidisciplinary approach ensured that all aspects of neonatal surgical care were represented.
The committee employed a modified Delphi consensus technique to define the scope and topics for inclusion 2 . This systematic approach involved:
To define target population and conditions for guideline development.
Rated on a nine-point scale for inclusion agreement among experts.
For topics scoring between 4-6 to reach expert agreement.
With quality assessment of relevant studies to inform recommendations.
The final population was defined as neonates (first 28 days of life) undergoing major noncardiac surgical intervention while admitted to a NICU 5 . Through this process, 21 topic areas were selected for guideline development, culminating in 16 specific recommendations across 11 topic areas 5 .
One of the most critical components of neonatal ERAS protocols involves pain management strategies that minimize opioid exposure while ensuring adequate comfort. A dedicated working group focused specifically on analgesia-related recommendations through systematic review and consensus methods.
The pain management guideline development followed a structured approach:
Abstracts screened for non-opioid analgesia
Abstracts screened for locoregional analgesia
Full-text articles reviewed
The analysis yielded two significant recommendations with moderate quality evidence:
Use regular acetaminophen to minimize opioid requirements.
Consider locoregional analgesia techniques when appropriate 1 .
The evidence demonstrated that neonates who received IV acetaminophen required 49% lower cumulative morphine doses while maintaining equivalent pain scores compared to those receiving continuous morphine infusion alone 1 . This finding is particularly significant given the known risks of opioid administration in neonates, including potential apneic events and concerns about long-term neurodevelopmental effects 1 .
| Intervention | Evidence Quality | Recommendation Strength | Clinical Application |
|---|---|---|---|
| Sweet-tasting solutions (sucrose/dextrose) | High | Strong | Heel lance, venipuncture, tube insertion |
| Non-nutritive sucking | High | Strong | Minor painful procedures when combined with other comfort measures |
| Skin-to-skin care | Moderate | Strong | Most effective when feasible and safe |
| Music therapy | Low | Weak | Multimodal approach for minor procedures |
Additionally, a separate consensus developed recommendations for non-pharmacological interventions, resulting in four key strategies for managing minor procedural pain frequently associated with surgical care 3 . These approaches are particularly valuable as they empower parents and bedside nurses to actively participate in comfort measures while avoiding medication side effects.
The development and implementation of neonatal ERAS protocols rely on specific methodological tools and approaches that ensure scientific rigor and clinical applicability.
| Tool/Resource | Function | Application in Neonatal ERAS |
|---|---|---|
| Modified Delphi Method | Structured communication technique to reach consensus | Determining scope, topics, and recommendations through expert panel input 2 |
| GRADE Methodology | Systematic approach to assessing quality of evidence and strength of recommendations | Evaluating literature and wording recommendations based on evidence strength 1 |
| JBI Critical Appraisal Tools | Standardized checklists to evaluate study quality | Assessing relevance and quality of full-text studies during literature review 1 |
| PARIHS Framework | Conceptual model for implementing research into practice | Guiding implementation strategies based on evidence, context, and facilitation |
The transition from published guidelines to actual clinical practice represents one of the most challenging aspects of any evidence-based protocol. A pilot implementation study conducted from 2021-2022 demonstrated that introducing ERAS protocols in a NICU setting was feasible and beneficial despite the complexities of the clinical environment .
This implementation study revealed several critical success factors:
Essential for promoting guideline adoption across specialties.
Improved compliance across team members through consistent messaging.
Reinforced the value of protocols and encouraged ongoing adherence 7 .
Healthcare providers reported that the implementation of ERAS protocols led to stronger team buy-in and engagement, improved communication, increased job satisfaction, and enhanced quality of care 7 . Perhaps most importantly, the structured approach increased meaningful parental involvement in their newborn's care journey.
| Outcome Measure | Implementation Results | Significance |
|---|---|---|
| Guideline Element Compliance | 64% overall adherence | Demonstrated feasibility of measuring and implementing recommendations |
| Postoperative Opioid Use | 70% of patients avoided opioids entirely | Significant reduction in opioid exposure and associated risks |
| Postoperative Complication Rate | 20% of patients experienced complications | Within expected range, demonstrating safety of the protocol |
| Feeding Outcomes | 90% reached full enteral feeds during admission | Appropriate nutritional outcomes maintained |
The development and implementation of ERAS protocols for neonatal patients represents a paradigm shift in how we approach the most vulnerable surgical population. By focusing on standardized, evidence-based practices while acknowledging the unique physiological needs of newborns, these guidelines have established a new standard for perioperative care.
To encompass more surgical conditions and patient populations.
In pain management adjuncts and other therapeutic areas.
Developing strategies for consistent application across diverse settings.
As one healthcare professional involved in the implementation study noted, the structured approach of ERAS protocols creates an environment where every team member — from surgeons to nurses to parents — is empowered to contribute to the infant's recovery 7 . This collaborative model, grounded in the best available evidence, promises to continue transforming outcomes for newborns facing the profound challenge of surgery during their first days of life.
The journey through neonatal surgery will always be fraught with challenges, but through the meticulous work of the ERAS Society and dedicated clinicians worldwide, this path is becoming increasingly guided by evidence, compassion, and the shared goal of giving every newborn the healthiest possible start.