Congenital pulmonary airway malformation, abbreviated CPAM, is a rare developmental anomaly of the lung in which parts of the bronchial tree fail to mature normally and instead form cystic, maldeveloped airspaces. Many affected children are asymptomatic, with the lesion discovered incidentally on chest imaging, yet the malformation carries risks of recurrent infection, pneumothorax and, over the long term, malignant transformation, so surgical resection is often recommended. Thoracoscopic resection, performed through small incisions with camera-assisted instruments, has become the standard approach, sparing children the large incisions of open thoracotomy.

The traditional midnight fasting rule was designed to reduce the risk of pulmonary aspiration, in which gastric contents regurgitate under anesthesia and are inhaled into the lungs. But prolonged fasting, particularly in young children, carries its own physiological costs: hypoglycemia, dehydration, irritability, hunger distress and metabolic stress that can complicate the perioperative course. Enhanced recovery protocols in adult surgery have largely abandoned prolonged fasting in favor of clear carbohydrate drinks up to two hours before anesthesia, on the principle that clear liquids empty rapidly from the stomach and that a modest carbohydrate load improves insulin sensitivity and patient comfort. Translating that principle to pediatric thoracic surgery, however, requires evidence that children will actually drink the prescribed solution and that doing so is safe.

The West China team enrolled 110 consecutive pediatric patients diagnosed with CPAM who received a standardized preoperative oral carbohydrate protocol as part of routine clinical practice. Because the supplementation protocol was already embedded in standard care and no additional intervention was assigned, the study was conducted as an observational analysis rather than a randomized trial, and it was not registered as a clinical trial. The researchers calculated adherence using a straightforward formula: the actual consumed volume divided by the prescribed volume, multiplied by 100 percent. This metric allowed them to quantify, for each child, how much of the intended carbohydrate load actually made it into the stomach before the fasting window closed.

The headline finding was one of good tolerance and reasonable but imperfect adherence. Carbohydrate-associated adverse events were documented in only 3.6 percent of enrolled patients, four of the 110 children, indicating that the clear carbohydrate solution was well tolerated across the cohort. The median adherence rate reached 80 percent, meaning that most children consumed most of the prescribed volume. Yet when the team applied a predefined exploratory cutoff of adherence at or above 80 percent, only about half of the participants met that threshold. In other words, the protocol was feasible and safe, but a substantial fraction of children fell short of the intended carbohydrate load, and understanding why became the central analytical question of the study.

To identify the drivers of adherence, the researchers applied multivariable linear regression models, a statistical technique that screens multiple candidate variables simultaneously while adjusting for the influence of the others. Three independent positive predictors emerged. Children whose operations were scheduled later in the surgical sequence adhered better, a finding that makes intuitive sense: a later start time gives families more hours in the morning to complete the drinking protocol without rushing, whereas an early first case compresses the entire supplementation window into the pre-dawn hours when both children and parents are least cooperative. Children with a low nutritional risk screening score also adhered better; the team used the Screening Tool for the Assessment of Malnutrition in Pediatrics, known as STAMP, and children at elevated nutritional risk presumably faced greater difficulty tolerating or completing the oral load. And active parental care was the third independent predictor, underscoring that the protocol’s success depends not on the child alone but on the engagement of the caregiver administering the drink.

The second analytical phase tested whether adherence levels correlated with short-term postoperative outcomes. Using Spearman’s rank correlation and multiple linear regression, the team found that higher adherence presented a positive linear correlation with elevated caregiver satisfaction scores and with fewer episodes of postoperative hunger-induced crying. These outcomes are not the dramatic endpoints of adult enhanced recovery literature, such as length of stay or complication rates, but they are the outcomes that matter most to families in the immediate postoperative period. A child who is less hungry and less distressed is a child who recovers more comfortably, and a caregiver who observes that comfort reports higher satisfaction with the entire perioperative experience.

The authors conclude that preoperative oral carbohydrate supplementation may optimize the perioperative experience for pediatric patients with CPAM and showed acceptable feasibility within this study cohort. The practical implications are concrete. Adjusting surgical schedules to arrange operations at later time points would give families the morning hours needed to complete the protocol without the pressure of an early first case. Implementing targeted interventions for patients at elevated nutritional risk, identified through tools such as STAMP, would direct support to the children least likely to complete the oral load on their own. And strengthening parent-guided care strategies, including structured education and engagement of caregivers in the supplementation process, would address the third independent predictor directly.

The study carries the hallmarks of careful observational methodology. Written informed consent was obtained from all surveyed caregivers, and the research was reviewed and approved by the Biomedical Ethics Review Committee of West China Hospital, Sichuan University. The authors declare no competing interests and received no specific funding for the work. Because the supplementation protocol was part of routine clinical practice, the findings reflect real-world implementation rather than the idealized conditions of a controlled trial, which strengthens their external validity but also means that adherence rates could differ in centers with different protocols, patient populations or surgical scheduling practices.

For the broader pediatric surgery community, the study adds to a growing body of evidence that the midnight fasting rule, long treated as inviolable, deserves to be replaced by evidence-based clear liquid and carbohydrate protocols tailored to children. The finding that only about half of children reached the exploratory adherence cutoff is a reminder that protocols on paper are not protocols in practice, and that the determinants of adherence, surgical timing, nutritional risk and parental engagement, are as important as the biochemical rationale for the drink itself. As enhanced recovery principles continue to spread from adult to pediatric thoracic surgery, studies like this one provide the granular, real-world data needed to design protocols that children will actually follow and that families will actually benefit from.

Subject of Research: Health

Article Title: Determinants of adherence to preoperative oral carbohydrates and short-term outcomes in pediatric congenital pulmonary airway malformation

Article References: Hou, S., Liu, J., An, T., Feng, L., Yuan, M., & Gong, Y. (2026). Determinants of adherence to preoperative oral carbohydrates and short-term outcomes in pediatric congenital pulmonary airway malformation. Scientific Reports. https://doi.org/10.1038/s41598-026-69477-4

Image Credits: AI Generated

DOI: 10.1038/s41598-026-69477-4

Keywords: pediatrics, preoperative carbohydrate supplementation, CPAM, fasting, treatment adherence, anesthesia, enhanced recovery, caregiver satisfaction, Determinants, adherence, preoperative, oral