A new international effort to make surgery safer for newborns and infants is proposing a common language for “enhanced recovery” care, a field traditionally associated with adult operations but now expanding into some of medicine’s most vulnerable patients. Published in the Journal of Perinatology, the multidisciplinary Delphi study by Borst, Raval, Perez and colleagues addresses a deceptively difficult question: which neonates and infants should be included in an enhanced recovery pathway, and what should that pathway actually contain? The researchers developed consensus-based eligibility criteria and definitions intended to help hospitals design, compare and evaluate programs for babies undergoing major surgical care. The work could become a foundation for a more consistent approach to perioperative medicine in early life, when even small changes in temperature, blood glucose, fluid balance or respiratory support can have profound consequences.
Enhanced recovery pathways are structured, evidence-informed systems that organize care before, during and after an operation. In adults, these programs may include preoperative counseling, limited fasting, multimodal pain relief, early feeding and prompt mobilization. The underlying principle is not simply to make patients leave the hospital sooner. Instead, enhanced recovery aims to reduce the physiological stress of surgery, prevent avoidable complications and help the body return to normal function as quickly and safely as possible. Translating that model to neonates and infants requires a major rethink. A newborn cannot provide informed consent, describe pain, follow breathing exercises or walk after surgery. Their organs are still developing, their reserves are limited and their clinical condition may change rapidly. A pathway for this population must therefore be built around developmental physiology, parental participation and continuous monitoring rather than adult-style milestones.
The study uses the Delphi method, a research approach designed to gather expert agreement when evidence is incomplete, practices vary or clinical questions are too complex for a single trial to answer. In a Delphi process, specialists respond to a series of structured questionnaires, usually without knowing the identities or individual opinions of the other participants. Researchers summarize the group’s responses and return the results for further rounds, allowing participants to reconsider their judgments in light of emerging consensus. This process can reduce the influence of hierarchy or the loudest voice in a meeting. For neonatal and infant surgery, where pathways may involve neonatologists, pediatric surgeons, anesthesiologists, nurses, dietitians, pharmacists, respiratory specialists and families, a multidisciplinary model is especially important. Each profession sees different risks, and safe recovery depends on how those risks interact.
One of the central contributions of the paper is its focus on eligibility criteria. Before a hospital can measure whether an enhanced recovery pathway works, it must define which patients the pathway is intended to serve. Neonates and infants are not a uniform group: a premature baby, a term newborn with congenital disease and an older infant undergoing a planned procedure may have very different nutritional, respiratory and neurological needs. The operation itself also matters, as does urgency, the presence of infection, the need for intensive care and the child’s ability to tolerate feeding. Clear eligibility definitions can help researchers avoid comparing fundamentally different populations. They can also help clinical teams identify when a standardized pathway is appropriate and when an individualized plan is safer because a baby’s condition is unstable or unusually complex.
The proposed framework is likely to be most valuable when it connects eligibility with clearly defined components of care. In neonatal surgery, enhanced recovery is not one intervention but a coordinated sequence of decisions. Before surgery, clinicians may need to assess nutrition, anemia, infection risk, respiratory status and the family’s understanding of the procedure. During anesthesia, teams must manage temperature, ventilation, blood pressure, glucose and fluid administration with extreme precision. After surgery, pain control must be effective without unnecessarily suppressing breathing or delaying neurological assessment. Feeding plans require particular care because the intestine may be recovering from manipulation, and premature advancement can be dangerous while excessive delay can worsen nutritional deficits. By defining these elements, a pathway can turn broad aspirations into steps that are visible, teachable and auditable.
The technical challenge is that the biology of a neonate changes rapidly. Premature infants have immature lungs and limited respiratory muscle strength, making them vulnerable to prolonged ventilation and oxygen-related injury. Their kidneys handle fluids and medications differently from those of older children, while their liver may metabolize drugs less predictably. Their ability to generate and retain heat is limited because of a high surface-area-to-volume ratio and low insulating fat stores. Even fasting, routine in surgical practice, can produce clinically important dehydration or hypoglycemia in a very small infant. These factors mean that recovery cannot be judged by a single endpoint such as hospital discharge. A credible pathway may need to track a range of outcomes, including time to extubation, return to enteral feeding, pain and sedation exposure, infection, readmission, length of stay, growth and the family’s experience of care.
The emphasis on consensus does not mean that every proposed element has already been proven by randomized clinical trials. Rather, the study offers a structured agreement about how the field should define and organize its work while stronger evidence develops. That distinction matters. A consensus pathway can standardize practice and make future research more meaningful, but it cannot replace rigorous evaluation. Hospitals adopting such programs will still need to monitor whether changes improve outcomes across different diagnoses, gestational ages and levels of illness. They must also watch for unintended effects. For example, a push toward earlier feeding or earlier discharge could be beneficial for selected patients but hazardous if applied without adequate assessment. Safety thresholds, escalation procedures and exceptions are therefore as important as recovery targets.
The human dimension is equally significant. Parents are not visitors in neonatal care; they are essential members of the care team, often helping with comfort, feeding, observation and decisions. A well-designed pathway can provide families with a clearer explanation of what to expect before surgery and what signs should trigger concern afterward. It may also reduce conflicting instructions when multiple specialties are involved. For clinicians, common definitions can make handoffs more reliable and allow hospitals to compare performance without confusing differences in terminology with differences in quality. For researchers, the framework may support multicenter studies by ensuring that participating institutions are enrolling similar patients and measuring comparable outcomes. The ultimate test will be whether these definitions lead to safer, more equitable care rather than simply more uniform paperwork.
The Delphi study arrives as pediatric and neonatal medicine increasingly recognizes that recovery begins before an operation and continues well beyond the operating room. By establishing consensus-based eligibility criteria and component definitions, Borst and colleagues are helping create the infrastructure needed to test enhanced recovery pathways in the youngest surgical patients. The approach is ambitious because it must balance standardization with the extraordinary diversity of neonatal illness. If validated in clinical practice, it could allow teams to identify preventable delays, reduce unnecessary physiological stress and tailor care more precisely to developmental needs. For now, the paper’s most important message is methodological: before the field can prove that enhanced recovery improves outcomes for babies, it must first agree on who qualifies, what care is being delivered and how success will be measured. That common foundation could turn a promising concept into a measurable advance in neonatal surgery.
Subject of Research: Consensus-based eligibility criteria and component definitions for enhanced recovery pathways in neonatal and infant surgery
Article Title: Consensus-based eligibility criteria and component definitions for neonatal and infant enhanced recovery pathway: a multidisciplinary delphi study
Article References: Borst, J.M., Raval, M.V., Perez, M.N. et al. Consensus-based eligibility criteria and component definitions for neonatal and infant enhanced recovery pathway: a multidisciplinary delphi study. J Perinatol (2026). https://doi.org/10.1038/s41372-026-02881-w
Image Credits: AI Generated
DOI: https://doi.org/10.1038/s41372-026-02881-w
Keywords: neonatal surgery, infant surgery, enhanced recovery, Delphi study, perioperative care, pediatric surgery, multidisciplinary care, surgical recovery
