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.

Introduction

According to the World Health Organization (1), cleft lip and palate are among the most common congenital developmental malformations in the oral and maxillofacial regions. The highest incidence of cleft lip and palate occurred in Asia (1.57‰), North America (1.56‰), and Europe (1.55‰), whereas Africa showed the lowest prevalence (0.57‰). Among ethnic groups, American Indians exhibit the highest incidence (2.62‰), which is significantly greater than that in the Japanese (1.73‰) and Chinese (1.56‰) populations (2). Cleft lip and palate repair surgery is a crucial step in the treatment process, and it is recommended to be completed during infancy and early childhood (3). For cleft lip repair, it is recommended that children undergo surgery at 3–6 months of age. Cleft palate repair is recommended to be completed at 8–12 months of age (4). Pediatric cleft lip and palate patients face more complex perioperative stress situations. Since the surgical incision is located on the lip, nose, or palate, children often cry during the postoperative recovery period because of localized swelling and pain, which not only pulls on the surgical wound and exacerbates the painful irritation but can also lead to complications such as incision bleeding, cracking, and infection (5). In cleft care, perioperative practices such as tympanometry and hearing screening, postoperative antibiotics, feeding protocols, and inpatient stay duration lack standardization and exhibit significant inter-center variation (6). Therefore, the perioperative rehabilitation of children with cleft lip and palate cannot be ignored.

Traditional management models require prolonged preoperative fasting, delayed postoperative feeding, and reliance on a single opioid for analgesia. Prolonged fasting can lead to adverse reactions such as hunger, thirst, and dehydration (7). Delayed feeding and opioid-related side effects such as nausea and respiratory depression can prolong postoperative recovery (8). The core concept of enhanced recovery after surgery (ERAS) is to reduce perioperative stress response by regulating perioperative nursing to promote postoperative rehabilitation of patients (9). Research shows that under the ERAS concept, consuming sugar-containing liquids 2 hours before surgery can alleviate thirst and hunger in children and reduce the incidence of postoperative insulin resistance (7). Multimodal analgesia can effectively reduce postoperative complications, such as nausea and vomiting, and early postoperative feeding helps with recovery and shortens hospital stay (10). The results of existing research have shown that the introduction of the ERAS program during the perioperative period in children with cleft lip and palate can effectively reduce postoperative discomfort and opioid use, and shorten hospitalization time (11,12). One study found that children in the ERAS group used 49% less opioids after surgery and started eating again 45% faster compared to previous patients (13). Similarly, meta-analyses indicate that ERAS may shorten hospital length of stay by approximately 1 day (14). Therefore, the objective of this study was to assess the extant literature on ERAS in pediatric patients with cleft lip and palate and to synthesize the most robust evidence for clinical application. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-318/rc).

Methods

Problem establishment

The PIPOST model (15) was used to construct evidence-based questions: P (target population): children with cleft lip and palate during the perioperative period; I (intervention): perioperative nursing practice of cleft lip and palate under the concept of accelerated rehabilitation surgical nursing; P (application to evidence professionals): clinical nurses, physicians, or anesthesiologists; O (outcome): the incidence of postoperative complications, hospitalization time, etc.; S (Setting): evidence application site; T (type): clinical practice guidelines, evidence summary, systematic review, expert consensus and randomized controlled trial (RCT).

Evidence retrieval

The top-down retrieval principle was adopted according to the ‘6S’ model of evidence resources (16). The network of guidelines retrieved in this study included The British Medical Journal (BMJ), UpToDate, The Cochrane Library, Guidelines International Network (GIN), Scottish Intercollegiate Guidelines Network (SIGN), Joanna Briggs Institute (JBI), Medlive. The websites of the relevant professional associations including American Cleft Palate-Craniofacial Association (ACPA), Enhanced Recovery After Surgery Society, Chinese Stomatological Association (CSA). The retrieved databases included PubMed, Web of Science, Embase, Scopus, SinoMed, CNKI, Wanfang, and China Science and Technology Journal (VIP). The search terms included “cleft lip/cleft palate/cleft lip and palate”, “Enhanced Recovery After Surgery OR Enhanced Postsurgical Recovery/Perioperative Nursing/Psychological Care/Wound Care/Pain Management/Feeding/Health Education”, “practice guideline/consensus/evidence summary/randomized controlled trial*/best practice*/ OR systematic review/meta-analysis”. Detailed search strategies for English-language databases (with PubMed as an example) are provided in Table S1. The retrieval period was from the establishment of the database to December 2024. The research methods utilized in this review are detailed in Table 1.

Table 1. The search strategy summary.

Items	Specification
Date of search	30 December 2024
Databases and other sources searched	The British Medical Journal (BMJ), UpToDate, The Cochrane Library, Guidelines International Network (GIN), Scottish Intercollegiate Guidelines Network (SIGN), Joanna Briggs Institute (JBI), Medlive; the websites of the relevant professional associations include American Cleft Palate-Craniofacial Association (ACPA), Enhanced Recovery After Surgery Society, Chinese Stomatological Association (CSA); the retrieved databases included PubMed, Web of Science, Embase, Scopus, SinoMed, China National Knowledge Infrastructure (CNKI), Wanfang, China Science and Technology Journal (VIP)
Search terms used	“Cleft lip”, “cleft palate”, “cleft lip and palate”, “Enhanced Recovery After Surgery”, “Enhanced Postsurgical Recovery”, “Perioperative Nursing”, “Psychological Care”, “Wound Care”, “Pain Management”, “Feeding”, “Health Education”, “practice guideline”, “consensus”, “evidence summary”, “randomized controlled trial”, “best practice”, “systematic review/meta-analysis”
Timeframe	The retrieval period was from the establishment of the database to December 2024
Inclusion and exclusion criteria	Inclusion criteria: (I) children with congenital cleft lip and palate diagnosed according to the diagnostic criteria of cleft lip and palate who underwent surgical treatment, aged ≤18 years; (II) accept perioperative enhanced recovery after surgery nursing measures, including at least one of the following contents: psychological nursing, feeding/diet/nutrition nursing, pain management, etc.; (III) outcome indicators included pain and incidence of postoperative complications; (IV) evidence type: clinical guidelines, evidence summary, systematic review, expert consensus, RCT
	Exclusion criteria: (I) non-Chinese and non-English literature; (II) incomplete methodological details or low-quality appraisal ratings; (III) unavailable data for both intervention protocols and outcome measures
Selection process	Two reviewers independently screened articles for inclusion; discrepancies were adjudicated by a third reviewer

RCT, randomized controlled trial.

Inclusion and exclusion criteria of evidences

The inclusion criteria of this study were as follows: (I) children with congenital cleft lip and palate diagnosed according to the diagnostic criteria of cleft lip and palate in ‘Oral and Maxillofacial Surgery’ (17), who underwent surgical treatment, aged ≤18 years; (II) research content: accept perioperative ERAS nursing measures, including at least one of the following contents: psychological nursing, feeding/diet/nutrition nursing, pain management, etc.; (III) outcome indicators included pain and incidence of postoperative complications; (IV) evidence type: clinical guidelines, evidence summary, systematic review, expert consensus, RCT.

The exclusion criteria were as follows: (I) non-Chinese and non-English literature; (II) incomplete methodological details or low-quality appraisal ratings [excluded if scoring <50% in any single domain of the Clinical Guidelines Research and Evaluation System (AGREE II) tool, or randomized trials rated ‘high risk’ in ≥2 key domains per Cochrane Risk of Bias Tool]; (III) unavailable data for both intervention protocols and outcome measures.

Literature screening

All identified studies were imported into EndNote (Clarivate, Philadelphia, PA, USA), and duplicates were removed. Two researchers, trained in evidence-based medicine, independently screened the titles, abstracts, and keywords of the retrieved articles. Full-text articles were then obtained and further screened for eligibility, with any disagreements resolved by a third reviewer—an evidence-based care specialist—to determine the final inclusion of studies.

Quality evaluation of the literature

The guidelines were assessed using AGREE II (18). The evaluation criteria encompassed 23 items distributed across six domains, including the scope, purpose, and involvement of stakeholders. On the AGREE II scale, a rating of 1 signifies strong disagreement, whereas a score of 7 indicates strong concurrence with each item’s evaluation. The standardized score for each domain was computed using the following formula: (actual score − minimum possible score)/(maximum possible score − minimum possible score) ×100%. Based on these scores, the recommended level A guidelines were classified into three tiers: (I) level A, where all six domains of the guideline attained a score of ≥60%, meriting direct endorsement without alterations; (II) level B, indicating that at least three domains achieved a score of ≥30%, yet with domains scoring <60%, necessitating variable degrees of revision and enhancement; and (III) level C, where at least three domains achieved scores <30%, resulting in exclusion from consideration.

Based on the ‘6S evidence model’, clinical decision-making, technical reports, and evidence summaries all belong to the thematic evidence summary (16), which has a similar formulation process. Therefore, Critical Appraisal for Summaries of Evidence (CASE) is used to evaluate the quality of clinical decision-making, technical reports, and evidence summaries (19). The expert consensus used the JBI evidence-based healthcare center (20) to evaluate the authenticity evaluation tools of opinions and consensus articles. Systematic review and meta-analyses were performed using the literature quality evaluation tool of the evidence-based health care center of the JBI in Australia (20). The Cochrane bias risk assessment tool was used to evaluate the quality of RCTs (21).

Two researchers with experience in evidence-based nursing evaluated and graded the literature. When consensus could not be reached, a third researcher was invited to participate in the discussion to reach a consensus.

Evidence description

The researcher extracted and integrated evidence from the included literature and followed certain principles to prioritize evidence-based evidence, high-quality evidence, and recently published authoritative literature when the sources of evidence were inconsistent. This study used the evidence pre-classification system of the Evidence-based Healthcare Center of the JBI in Australia (2014 Edition) (22) to grade the original research, with 1–5 grades, of which grade 1 is the highest level and grade 5 is the lowest level. Combined with the JBI 2014 version of the evidence recommendation level, the recommendation strength of the evidence was finally determined, including A-level recommendation (strong recommendation) and B-level recommendation (weak recommendation).

Results

Search results

A total of 2,408 records were identified through database searching and supplementary sources for initial screening, and 14 articles were included after the screening, including four guidelines (4,23-25), one technical report (26), two expert consensuses (27,28), three systematic reviews and meta-analyses (14,29,30), and four RCT (7,31-33). Figure 1 illustrates the screening process of the literature, whereas Table 2 displays the general data characteristics of the included literature.

Figure 1.

Flow chart of literature screening. ACPA, American Cleft Palate-Craniofacial Association; CNKI, China National Knowledge Infrastructure; CSA, Chinese Stomatological Association; GIN, Guidelines International Network; JBI, Joanna Briggs Institute; SIGN, Scottish Intercollegiate Guidelines Network; VIP, China Science and Technology Journal.

Table 2. General characteristics of the included literatures.

Included literature	Year of publication	Literature reference	The literature theme	Type of literature	Country
Cleft Lip and Palate Committee of the Chinese Stomatological Association (4)	2024	Medlive	Guideline for cleft lip and palate team approach management	Guideline	China
Chinese Stomatological Association (24)	2024	CSA	Guidelines for unilateral cleft lip repair	Guideline	China
Oh et al. (23)	2022	Scopus	The role of enhanced recovery after surgery protocols in cleft and craniofacial surgery	Guideline	United States
Boyce et al. (25)	2019	Medlive	Guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate	Guideline	Australia
Melhem et al. (26)	2023	PubMed	Enhanced recovery after cleft lip repair: Protocol development and implementation in outreach settings	Technical reports	United States
Pediatric surgery Branch of Chinese Medical Association (27)	2021	Wanfang	Expert consensus on perioperative management of children under the guidance of enhanced recovery after surgery	Expert consensus	China
Shi et al. (28)	2017	CNKI	Application of team approach and key techniques of cleft lip and palate	Expert consensus	China
Suleiman et al. (29)	2024	Embase	Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations	Systematic review	Norway
Asadourian et al. (30)	2023	PubMed	A systematic review and meta-analysis of enhanced recovery after surgery protocols in primary cleft palate repair	Systematic review	United States
Shin et al. (14)	2022	Web of Science	Enhanced recovery after surgery for pediatric cleft repair: a systematic review and meta-analysis	Systematic review	United States
He et al. (31)	2023	CNKI	Accelerated rehabilitation in pediatric cleft lip and palate surgery nursing	RCT	China
Wang et al. (32)	2022	VIP	Application of fast-track rehabilitation in perioperative period of cleft lip repair in children	RCT	China
Zheng et al. (7)	2021	CNKI	Application of enhanced recovery after surgery in the repair of cleft lip and palate in infants	RCT	China
Huang et al. (33)	2020	CNKI	Effect of rapid rehabilitation nursing in perioperative period of children with cleft palate	RCT	China

CNKI, China National Knowledge Infrastructure; CSA, Chinese Stomatological Association; RCT, randomized controlled trial; VIP, China Science and Technology Journal.

Quality evaluation results of the included literature

Quality evaluation results of guidelines

Four guidelines were included in this study (4,23-25), and their overall quality was high. The results of the quality evaluation are presented in Table 3. One of the four guidelines was from the United States (23), one from Australia (25), and two from China (4,24).

Table 3. Quality evaluation results of clinical guidelines (n=4).

Guidance	Standardized scores in various domains (%)						≥60%	≥30%	Quality evaluation
	Scope and purpose	Participant	Rigor	Clarity	Application	Independence
Guidelines for the sequential treatment of cleft lip and palate (4)	94.4	88.9	79.2	97.2	52.1	87.5	5	6	B
Oh et al. (23)	91.6	80.6	65.6	80.5	66.7	83.3	6	6	A
Chinese Stomatological Association (24)	100	94.4	86.5	91.6	64.6	62.5	6	6	A
Boyce et al. (25)	97.2	80.6	72.9	80.5	56.3	54.2	4	6	B

Quality evaluation results of technical report

A technical report has also been included (26). The evaluation results for item 3 [Are the reviewer(s)/editor(s) of the summary transparent?] were ‘Not completely’, whereas items 4 (Are the search methods transparent and comprehensive?) and 5 (Is the evidence grading system transparent and translatable?) both received ‘no’. All other items were rated as ‘yes’.

Quality evaluation results of expert consensus

Two expert consensuses were included (27,28), with all evaluation entries marked as ‘yes’. Consequently, both expert consensus statements were deemed to be of high quality and were included in the study.

Quality evaluation results of systematic reviews

Among the three systematic reviews included in this study (14,29,30), all the items in the studies of Suleiman et al. (29) and Shin et al. (14) were evaluated as “yes”, and the studies were approved for inclusion because of their complete design and high overall quality. In the study by Asadourian et al. (30), all the entries were rated as “yes” except for item 9, “Whether to assess the possibility of publication bias”, which was rated as ‘unclear’.

Quality evaluation results of RCTs

Four RCTs were included in this study (7,31-33). The evaluation results for items 2 (generation of randomization scheme), 3 (blinding of subjects and interveners), and 4 (blinding of outcome evaluators) were ‘unclear’. The remaining items were evaluated as ‘low risk’.

Summary of evidence

This study extracted the best evidence, covering four aspects: preoperative, intraoperative, postoperative, and discharge and follow-up, initially forming 17 themes and 34 recommendations, as shown in Table 4. The 2014 version of the JBI was used to study the pre-classification criteria for evidence. The results of the JBI 2014 version of the evidence recommendation level were used to uniformly determine the level of evidence included in the study.

Table 4. Best evidence summary and evidence grade classification.

Subjects	Content of evidence	Level	Recommendation level
Preoperative management
Health education	1. Before surgery, the children and their guardians should be educated and communicated with in multiple ways and forms, and the surgical process and related preoperative optimization and postoperative recovery should be explained to the family members of the children (26,27)	5	A
Preparation and evaluation	2. The bodily state of the children should be fully evaluated before surgery, body function should be optimized by pre-rehabilitation and other measures, and a reasonable operation and anesthesia plan should be formulated (27)	5	B
	3. Review the patient’s history for conditions such as upper respiratory infections, diarrhea, fever, convulsions, and dyspnea; conduct a comprehensive assessment for any systemic diseases (e.g., congenital heart disease, hernia, epilepsy, etc.); and perform a physical and growth development evaluation, screening for issues such as delayed development, short neck, and excessive obesity (4)	5	A
	4. Following the rule of 10s for the timing of cleft lip repair surgery, surgical candidates were required to weigh at least 10 pounds and be at least 10 weeks old (26)	3	B
	5. It is recommended that newborn hearing screening and specialty examination records be completed prior to cleft palate repair (4)	5	A
Nutrition guidance and development monitoring	6. Normal nutritional development is the basic condition for children to undergo initial repair treatment. Appropriate feeding is the best way to ensure and promote nutritional development in children (24)	1	A
	7. Breastfeeding is recommended. Breast-milk/bottle mixed feeding or bottle feeding can be selected for mothers with insufficient or no breast milk. Children with severe feeding difficulties can be fed nasogastrically (24)	1	A
	8. Key indicators of infant nutrition and development include weight, height, head circumference, and chest circumference, with weight change being the most accessible. Regular monitoring and assessment of infant nutrition and development are crucial for timely nutrition adjustment (24)	1	A
Preoperative fasting	9. Preoperative fasting solid food ≥8 h, milk (formula) ≥6 h, breast milk ≥4 h, preoperative 2 h oral clear liquid, drinking ≤5 mL/kg (27,33)	1	A
Use of prophylactic antimicrobials	10. Children should receive intravenous preoperative prophylactic antimicrobial medications 30–60 min before surgery; preference should be given to first- and second-generation cephalosporins; aminoglycosides, quinolones, and tetracyclines are not advised (26,27)	5	A
Intraoperative management
Prepare for surgery	11. A restoration plan is created, anatomical markers are established, the table is turned 90 degrees, and the oral cannula is positioned in the midline position (23)	1	A
Anesthesia methods	12. Children’s general anesthesia attempts to choose short- and medium-acting anesthetic drugs and encourages general anesthesia combined with regional block (26,27)	5	A
	13. Anesthesia induction: intravenous propofol, fentanyl, and atracurium, intermittent positive pressure ventilation after tracheal intubation. Maintenance of anesthesia: remifentanil and propofol were pumped and stopped 5 min before the end of surgery (7)	1	B
	14. Local anesthetic infiltration: local infiltration with plain 0.2% ropivacaine at the end of the surgical procedure (23)	1	B
Temperature management	15. Routinely monitor body temperature and implement appropriate warming measures, such as maintaining the operating room at a temperature of not less than 24 ℃, using warming devices, etc., and maintaining a central body temperature of not less than 36 ℃ (27)	5	A
Postoperative management
Monitoring of vital signs	16. Electrocardiogram (ECG) monitoring was performed on the day after the operation, and the patient’s consciousness, respiration, heart rate, blood pressure, and oxygen saturation were closely observed (4,24)	1	A
Position management	17. Encourage the family to clean the secretion on a regular basis while helping the child lie flat with the head tilted sideways and a gentle cloth on the lip and palate (31)	1	B
Pain management	18. Dynamically assess pediatric pain, using non-pharmacological treatments for mild pain and multimodal analgesia with analgesics for moderate-to-severe pain to reduce adverse reactions from opioids (14,27)	5	A
	19. The main non-pharmacological therapies are massage, video watching, gaming, and music listening (27)	5	A
	20. Analgesic regimens should include acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2-specific inhibitors (14,29,30)	1	A
PONV	21. Measures to prevent PONV include multimodal analgesia, reduction in the use of perioperative opioids, combined local anesthesia, regional block anesthesia to reduce the use of general anesthetics, appropriate fluid therapy, and shortening the duration of fasting (27)	5	A
	22. Drugs commonly used to prevent PONV include 5-HT receptor antagonists (e.g., ondansetron) and dexamethasone, a combination of which further reduces the risk of nausea and vomiting (27)	5	A
	23. When nausea and vomiting still occur after prophylactic medication, antiemetic agents such as metoclopramide should be administered, and measures such as acupuncture or massage of acupoints should be taken (27)	5	A
Early eating and feeding guidelines	24. Trial feeding after 2 h of full consciousness and recovery of swallowing function from general anesthesia. Breastfeeding, or bottle-feeding is recommended after surgery, and the feeding method may not be changed after cleft lip operation. Patients with cleft palate should be fed with fluid on the day of the operation, semi-fluid or soft food within 2 weeks after surgery, and general food after 2 weeks (4,7)	1	A
	25. Breastfeeding posture: (I) infants with cleft lip: the front of the cleft lip should be held toward the top of the breast, such as the right side of the cleft lip with a cross cradle to hold the right side of the breast, the body shoulder higher than the torso, the and bilateral cleft lip with a “face-to-face” cross-legged position (25); (II) infants with cleft palate and cleft lip and palate: adopt a semi-sitting position to minimize nasal reflux and breastmilk entering the eustachian tube (25)	4	A
	26. If breastfeeding is not feasible, the promotion of breast milk feeding (by cup, spoon, bottle, syringe, etc.) should take precedence over artificial breast milk substitutes (25)	5	B
Incision management	27. Standardized wound care is recommended to keep wounds clean, free of scabs, and moisturized. The use of hand restraints and prophylactic antibiotics can be used as a non-routine tool depending on the experience of the physician (24)	1	A
	28. After cleft lip surgery, wash the wound twice a day with saline and apply moisturizing products; after cleft palate surgery, take care to keep the mouth clean. Use saline swabs to clean carefully, in order from both nostrils, the middle of the mouth, the upper lip, and the inner side of the upper lip (32)	1	A
Discharge education and follow-up
Scar care instructions	29. Early decompression of the wound, local application of silicone products, and moderate massage can help to reduce scarring (24)	1	A
	30. Wash hands thoroughly and trim nails before massaging to avoid scratching the baby’s skin. Don’t rub or apply too much pressure to the sutures. The strength of your fingers should be somewhat white in a circle. The pressure was applied for 10 s (32)	1	A
	31. It is recommended that about 3 weeks after the removal of stitches, at first press 8 s, 8 times a day, slowly extended, from the number of 10 s, 1 min to 2–3 min, and gradually controlled at 5–6 times/day (32)	1	A
Nasal molds care instructions	32. Postoperative use of nasal molds is recommended to shape the nasal vault as well as the symmetry of the nostril axis (24)	2	B
	33. Remove and clean every 4 h before suture removal, rest for 30 min, and apply an anti-inflammatory ointment before wearing. After removing the stitches, remove it 2–3 times a day. Wear it for approximately one year, during which time it will be reviewed every 2–3 months and sizes will be changed (32)	1	B
Discharge follow-up	34. Establish a comprehensive follow-up system and platform for doctor-patient communication, strengthen follow-up and health guidance for patients after discharge, and closely monitor their recovery progress and condition dynamics (27,32)	5	A

Key findings summary

This key findings summary highlights the key aspects of perioperative care that impact the recovery of children with cleft lip and palate. Among preoperative measures, health education and preoperative fasting emerge as the most universally implemented components. Similarly, preoperative preparation and evaluation are widely adopted, emphasizing the critical importance of identifying potential risks. In terms of intraoperative and postoperative management, multimodal analgesia is an important approach that includes different methods such as peripheral nerve blocks, intravenous analgesia, local infiltration, and oral administration, as well as non-drug therapies. Early eating and discharge follow-up have consistently been highlighted as key considerations.

Discussion

Preoperative assessment and preparation

Adequate preoperative preparation ensures a seamless and uneventful surgical procedure. Children with cleft lip and palate and comorbid congenital anomalies exhibit significantly increased surgical risks (34). For instance, concomitant cardiac disease impairs cardiopulmonary function and reduces tolerance to anesthesia and surgery. Specifically, cyanotic heart disease predisposes patients to metabolic acidosis, whereas low body weight elevates intraoperative risks of adverse respiratory events (35,36). Therefore, children with cleft lip and palate need sufficient preoperative preparation and evaluation before surgery to provide the maximum time for facial growth without affecting speech development. In addition, ensuring that children with cleft lip and palate receive sufficient nutrition to achieve normal development is important for successful implementation of the operation. According to the evidence reviewed, nurses should encourage parents to breastfeed and provide breast milk whenever possible (25). Previous studies have shown that, compared with children with cleft lip and palate who are breastfed, the incidence of malnutrition in children receiving artificial feeding or mixed feeding is higher (37). Long-term fasting may not only lead to the occurrence of insulin resistance, but also increase nausea and vomiting and reduce the comfort of children. Children have faster gastric emptying of clear liquids, most of which can be emptied within half an hour (38). The Cleft Lip and Palate Professional Committee of the CSA recommends that units with sufficient conditions should advocate for rapid recovery methods, including postponing the fasting from drinking until 2 hours before surgery (4). Gu et al. (39) also found that it is safe for children with obstructive sleep apnea-hypopnea syndrome to orally take 5 mL/kg of carbohydrates 2 hours before surgery, and this can, to a certain extent, improve postoperative insulin resistance. Surgical site infection is a complication of oral and maxillofacial surgery with potentially significant morbidity and mortality. Several studies have demonstrated that the preoperative use of antimicrobial agents significantly reduces the rate of postoperative infections, especially in surgeries involving the oral and nasal cavities (40). When antibiotic prophylaxis is indicated, the selection of the antibiotic type is specifically tailored to the surgical procedure and the likely population of organisms involved (40). Existing systematic review evidence supports the use of preoperative antibiotics for cleft palate repair, yet the clinical benefits of extending postoperative medication remain unclear (41).

Intraoperative management

The choice of anesthesia is an important part of ERAS management. To minimize stress, ERAS advocates combined anesthesia, that is, general anesthesia combined with local or regional anesthesia, including intrathecal anesthesia, nerve blocks, and local incision anesthetic drug infiltration (7). Combined regional block based on general anesthesia according to the surgical site reduces intraoperative opioid dosage, postoperative pain, postoperative agitation, nausea and vomiting, and other adverse effects (42). Perioperative hypothermia was one of the first reported side effects of general anesthesia and is associated with a variety of complications and adverse outcomes, with infants and children being at the highest risk (43). Maintenance of normothermia is a core aspect of perioperative management of ERAS (44). Maintaining the patient’s body temperature by means of a warm environment at a constant temperature, heated blankets, heated fluids, and heated flushes can be effective in reducing the initial drop in the core temperature after induction of anesthesia (43).

Postoperative care and management

On account of the different mechanisms of pathophysiological damage caused by diseases and surgical procedures, ERAS programs should be tailored to their content (45). The surgical incision for cleft lip and palate repair is positioned on the lip, nose, or palate. During the postoperative recovery phase, local tissue swelling and pain can provoke crying in children. This crying motion may exacerbate surgical wounds, leading to further pain stimulation (7). The risk factors for opioid-induced respiratory depression are mostly concentrated within the first 24 hours post-surgery, particularly in airway-related surgeries and in patients under one year old (40). The goal of ERAS is to reduce the amount of opioids used, prevent related complications, and manage perioperative pain using multimodal analgesia. Thawanyarat et al. (46) showed that implementing the ERAS protocol in cleft lip and palate and craniofacial surgeries significantly reduced postoperative opioid use and increased nonsteroidal anti-inflammatory drugs utilization, but did not lead to an increase in related complications. This finding agrees with the study by Phillips et al., which showed that for children with inflammatory bowel disease, using ERAS protocols that include multimodal and regional analgesia can greatly lower the need for opioid analgesics (47). A study involving 180 patients undergoing oral and maxillofacial surgery indicated that allowing ERAS group patients to consume water 2 hours after waking can safely reduce discomfort, stabilize hemodynamics, and minimize stress responses (48). Infants with smaller clefts, particularly those with isolated cleft lip, often have the ability to breastfeed successfully by generating suction and negative pressure, whereas those with larger clefts, especially involving the soft and/or hard palate, may struggle to do so (49). The guidelines recommend resuming feeding as soon as possible after surgery, maintaining previous feeding methods, and adjusting the correct breastfeeding posture to optimize feeding effectiveness (4,25).

Discharge education and follow-up

The ERAS protocol emphasizes patient education before discharge, information transfer, and follow-up support after discharge, all of which help improve patient satisfaction and recovery quality (50). Postoperative scar formation is a common cause of patient dissatisfaction. Abdurrazaq et al. (51) reported that hypertrophic scarring is the second most common complication after cleft lip repair, comprising 13.7% of all complications. Research has confirmed that silicone products, including silicone gel and scar patches, can effectively reduce scar formation during the early stages of cleft lip repair (52). The main complication of silicone sheets is the risk of accidental ingestion by infants. It is recommended that infants use silicone gel to avoid the risk of ingestion (53). Under the ERAS pathway, patients can usually be discharged earlier, but it requires the medical team to provide comprehensive discharge instructions and complication management guidance. Follow-up appointments are also necessary to track the patient’s progress toward recovery and quickly address any problems.

This study has several limitations. Different studies use varied intervention protocols, measurement tools, and sample criteria, hindering result comparison and synthesis. Potential publication bias may overrepresent positive outcomes, leading to inaccurate intervention effectiveness conclusions. Some studies have methodological flaws, such as small samples or a lack of blinding, undermining the reliability of the results.

Conclusions

In this study, through rigorous and scientific literature search, screening, and literature quality evaluation, the best evidence summary of perioperative accelerated rehabilitation nursing for children with cleft lip and palate was obtained. To put the study’s findings into practice, organizations should first assess their local needs and challenges, including policy limitations and available resources. Then, they should develop a clear plan that details ERAS actions, communication strategies for different groups, and the use of resources. They should also obtain stakeholder approval and set up a system to monitor and make necessary adjustments.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.