Enhanced Recovery After Surgery for Pediatrics Gains Ground

In late 2018, a handful of pediatric specialists with an interest in the nascent field of enhanced recovery after surgery, more commonly known as ERAS, gathered in Richmond, Virginia. It was the first meeting of its kind and a notable step forward in the quest to standardize low- to no-opioid perioperative pain management in pediatrics.

The following spring, a review article titled, “Embracing change: the era for pediatric ERAS is here,” appeared in Pediatric Surgery International.

“We were really just trying to will it into existence,” laughed Kyle Rove, MD, in an interview. Rove is an associate professor of urologic surgery at the University of Colorado Anschutz Medical Campus in Denver and is a pediatric urologist at Colorado Children’s Hospital on the campus.

Since then, the group has attracted a growing number of pediatric specialists who, frustrated by the lack of evidence for opioid-based pain management in pediatric surgery, have been developing their own best practices. In the process, they are delivering better patient outcomes, achieving shorter lengths of stay, and saving their health systems money. In addition, they are helping ease the national opioid burden.

ERAS Core Features

“What we’re doing is evidence-based, patient-centered, and multimodal,” said Andrew Franklin, MD, MBA, an associate professor of pediatric anesthesiology and director of Pediatric Acute Pain Services at Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center (VUMC), Nashville, Tennessee.

The central tenets of ERAS in pediatrics include early patient and family education and engagement, perioperative hydration and nutrition with limited fasting, early mobility after surgery, minimally invasive surgical approaches, and reduced opioid use, typically in favor of nonsteroidal pain medications dosed regularly to keep ahead of the pain and to prevent nausea and vomiting.

“Under the auspices of enhancing recovery, the fasting times at many pediatric hospitals have been abbreviated to allow clear liquids such as apple juice until 1-2 hours before the surgery start times,” Mehul Raval, MD, head of the Division of Pediatric Surgery at Ann and Robert H. Lurie Children’s Hospital in Chicago, said. “This means that patients are less dehydrated, hungry, and have normal blood sugar levels going into their surgery.”

Other strategies include the use of local and regional nerve blocks, heat or ice packs, as well as deep breathing or mindfulness exercises.

Opioids are sometimes used, according to Rove, such as when nonsteroidal anti-inflammatory drugs are contraindicated, but another of ERAS’s goals is to minimize exposure to complications from opioid comorbidities, including respiratory depression and gastrointestinal distress, but also opioid use disorder.

“Multimodal pain management strategies actually target the specific pain our patients face while decreasing the negatives of opioids such as constipation and sleepiness,” Raval told Medscape Medical News. “By using a multimodal approach, opioid use can be dramatically reduced or eliminated for some cases.”

Updates and Recommendations

Rove, Franklin, and Raval are three of several pediatric specialists who met in 2018. They were among those who initially formed the ERAS Society Pediatrics, an arm of the international ERAS Society, a Europe-based international organization borne out of a study group that convened in the late 1990s and early 2000s to further explore the multimodal surgical recovery techniques in adults pioneered by colorectal surgeon, Professor Henrik Kehlet at the University of Copenhagen in Copenhagen, Denmark.

ERAS in adults is now well-described, with the ERAS Society issuing evidence-based ERAS guidelines across several surgical specialties. In pediatrics, the field is still coming into its own as the number of updates and recommendations begin to multiply.

For instance, Franklin, who is also an associate professor of anesthesiology at VUMC, and his colleagues published core pediatric ERAS protocols in 2024 in an update on advances in the field, published in Journal of Pediatric Surgery.

Raval, who is also a professor of surgery and pediatrics at Northwestern’s Feinberg School of Medicine, Chicago, is a co-author with Franklin and others on ERAS consensus recommendations to minimize opioid use in perioperative neonatal pain management, published online in 2024, in JAMA Surgery.

Standardizing Protocols

Although few clinical data exist on opioid use in pediatric surgery, clinical data on the efficacy of ERAS compared with historic approaches to pain management increasingly are being published across a range of surgical specialties, helping to standardize the ERAS framework.

“Physicians have tremendous understanding of medicines, but we overestimate our ability to understand if something might work better in one patient over another — leading to variability,” Rove said.

The lack of standards meant that how pain was treated in the pediatric setting prior to 1999, when opioid analgesics began to flood the market after the US Food and Drug Administration approved oxycontin in 1995 for noncancer pain, was not necessarily optimal either, according to Rove. “It wasn’t based on any objective measure,” he said.

Now, taking an integrated approach to care means a single surgeon is not the arbiter of best practices in pain management. Instead, there are multiple voices, according to Rove.

“There is an entire team — students, residents, advanced practice providers, and more — and each might have a slightly different view of ‘what works,’” said Rove. “Without ERAS, ‘what works’ is all over the place. When well implemented, ERAS minimizes variability and narrows the spectrum of outcomes in pain control, recovery time, complications, and even cost.”

Last year, Raval and his colleagues concluded the ENRICH-US trial, one of the largest studies in pediatric ERAS to date, a $3.5 million, National Institutes of Health (NIH)–sponsored, multisite prospective study of the effectiveness of a multimodal pain management protocol in pediatric gastrointestinal surgery. Early analysis shows that clinical outcomes including lengths of stay were improved in the ERAS cohort, Raval said.

“The study was conducted at 18 hospitals from across the United States and enrolled nearly 600 patients ages 10-18 years old undergoing elective gastrointestinal surgery,” Raval told Medscape Medical News. “The final results will be presented at the American Pediatric Surgery Association [meeting] this May in Montreal.”

Cost Saving

Franklin recalls when 7 years ago, he told the pectus excavatum surgical team at Carell he wanted to bring their patients’ postoperative recovery time down from 5 to 3 days.

“They were skeptical. But I said, ‘Let’s do it.’ Three months later, everyone was going home on postoperative day 3,” said Franklin.

“Now we’re down to 1 or 2 days — some patients even go home the next morning. Think of the cost savings of that,” Franklin added.

To demonstrate the impact ERAS was having on patient outcomes and administrative costs, Franklin and his colleagues conducted a study of outcomes in complex reconstructive hip surgery in 85 adolescents treated with ERAS at Carell between 2015 and 2018 and compared them with retrospective outcomes data on 110 patients treated with historic protocols.

Franklin and his colleagues found that in the ERAS cohort, there were savings per case of about $118. Lengths of stay in that group were reduced by 0.79 days, and the number of unplanned readmissions was halved. The results are published in Anesthesia and Analgesia.

“We’re a very busy hospital. So if we’re able to vacate one patient sooner, we’re able to bring another patient into the hospital sooner. That helps with the overall health of our system,” Franklin said.

Now, there are nine surgical teams at Carell that routinely practice ERAS, according to Franklin. One of his goals is to standardize his hospital’s perioperative pain management approach while also allowing surgical teams the flexibility they need to meet individual patient needs.

Rove, meanwhile, is leading a multisite clinical trial of 85 patients to compare ERAS in adolescents and young adults undergoing urologic reconstructive surgery with historic control patients. In addition to investigating whether the ERAS cohort required additional pain control, Rove expects the study outcomes will add to the literature on postsurgical pain improvement rates and patient lengths of stay. Results are due later this year.

Reducing Pill Burden

A secondary outcome of using ERAS is that it helps lessen the national opioid pill burden. The most recent federal data on opioids are that in the United States, 125 million prescriptions — not pills — were written in 2023. That means surgeons, when they prescribe opioids, are among the top mediators of the opioid crisis, as they are gateways to opioid use.

The most recent data from the Monitoring the Future survey indicated that 37.37% of 29,220 adolescents in the United States who reported nonmedical use of opioids had been prescribed the drug first.

Franklin was among those who conducted an internal audit of opioid-prescribing practices at the VUMC overall. A study published about the findings in the pediatric setting at VUMC’s Carell indicated that 53% of parents kept the leftover prescription opioids, and 68% of those kept the pills in an unlocked location. In response, the VUMC partnered with a company that makes pill destruction packets with a pill-dissolving powder inside and began distributing them to all patients and their families.

“You just pour the leftover pills into the packet, and then add some warm water, and they just turn into a gel. Then you just toss it in the trash,” Franklin said.

If ERAS Is so Good…

Despite there being so much evidence in support of multimodal pain management in the pediatric setting, why are there so few institutions implementing it?

“It takes time for much of the dogma in medicine to be challenged and for practices to change,” suggested Raval. “Most physicians are data driven, and therefore, more evidence in pediatric populations is needed. This is why we embarked upon the ENRICH-US trial. We needed to better understand the clinical outcomes and the optimal drivers of implementing complex interventions like an enhanced recovery protocol.”

Rove added that dogma tends to be specific to certain eras in medicine.

“Change in medicine typically comes with generational learning and explains why such changes take decades to enter general practice,” he said. “We have also experienced skepticism around spending money and resources on ERAS within healthcare systems. It takes bright, enthusiastic people to evangelize ERAS with hospital leadership and make the case that return on investment can be quite substantial.”
 

Franklin, who has an MBA and said he used the implementation of ERAS at VUMC as his capstone project, encouraged others who might want to implement multimodal pain management at their institution to start small. For example, adding postoperative oral acetaminophen or ibuprofen every 6 hours will reduce the need for opioids by a third. “We know that,” Franklin said. “It’s true across the board, in all pediatric patients. So, start there.”

Franklin said a business degree isn’t necessary, but commitment is. “The problem is that when you hit a snag, things fall apart very quickly. Just keep track of your data.”

Rove reported being a site primary investigator for Sumitomo Pharma study of vibegron (unrelated to ERAS and not used in any of our protocols). Raval received funding from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development. Franklin reported no conflicts of interest.