{"paper_id":"4b9f3a84-e6b3-46e0-9d23-4aaf3db7e2d0","body_text":"Consensus-Based Eligibility Criteria and Component Definitions for Neonatal and Infant Enhanced Recovery Pathway: A Multidisciplinary Delphi Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Consensus-Based Eligibility Criteria and Component Definitions for Neonatal and Infant Enhanced Recovery Pathway: A Multidisciplinary Delphi Study Willemijn Schäfer, Johanna Borst, Mehul Raval, Mallory Perez, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9452775/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objective The 2020 Enhanced Recovery After Surgery (ERAS®) guidelines for neonatal intestinal surgery have not been widely implemented due to unclear eligibility criteria and poorly defined components. We sought to establish consensus-based eligibility criteria and definitions for a revised enhanced recovery pathway (ERP). Study Design We conducted two modified Delphi processes to establish eligibility criteria and define the components by engaging stakeholders including surgeons, anesthesiologists, neonatologists, nurses, dietitians, quality improvement specialists, and parents/caregivers at six pediatric hospitals. Eligibility criteria were established through two survey rounds; components were defined through two survey rounds and one focus group. Results Forty-five stakeholders participated (82% response). Consensus supported inclusion of infants born ≥ 32 weeks’ gestation or ≥ 1.5 kg undergoing elective/semi-urgent gastrointestinal surgery and defined 19 components with 10 initially accepted and 9 revised. Conclusions The consensus-based Delphi process established eligibility and defined the components to facilitate implementation and adoption of an ERP for neonates and infants undergoing gastrointestinal surgery. Health sciences/Health care/Paediatrics Scientific community and society/Scientific community Health sciences/Medical research/Outcomes research Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Enhanced recovery pathways (ERPs) are multidisciplinary, evidence-based perioperative care pathways designed to mitigate surgical stress, accelerate recovery, and improve outcomes. 1 Common components include reduced preoperative fasting, minimally invasive surgical approaches, early postoperative feeding, and multimodal, opioid-sparing analgesia. Initially developed in adult colorectal surgery, these ERPs have since been adopted across a wide range of specialties and age groups, consistently demonstrating benefits such as fewer complications, reduced opioid use, and shorter hospital stays. 2 – 4 In 2020, the Enhanced Recovery After Surgery (ERAS®) Society published the first guidelines for neonatal intestinal surgery. 5 Neonates represent a high-risk surgical population given their limited physiologic reserve and immature metabolic and thermoregulatory systems, which contribute to prolonged recovery and elevated postoperative morbidity. 5 , 6 These same factors also make them strong candidates to benefit from a standardized, evidence-based ERP. Yet, adoption in the neonatal population has been limited. The ERAS® Neonatal Guidelines introduced 17 evidence- and expert-informed recommendations tailored to perioperative management within the neonatal intensive care unit (NICU) emphasizing multidisciplinary collaboration among surgeons, neonatologists, anesthesiologists, and nursing teams. 5 Early implementation results, while encouraging, revealed major challenges in translating a neonatal ERP into clinical practice. In a single-center pilot of 10 infants undergoing intestinal resection, partial adoption was associated with reduced opioid exposure, but there was high variation in adherence to ERAS® components, such as maintenance of normothermia (0%), preoperative acetaminophen (10%), and early enteral feeding within 48 hours of surgery (40%). Furthermore, adherence to other components (e.g., fluid management, lingual sucrose, and parental readiness for discharge) could not be reliably assessed due to inconsistent or absent documentation. 7 A larger retrospective study of 186 neonates and infants undergoing ostomy takedown found median adherence of only 6 of 13 components, with poor adherence to hypothermia prevention (14.5%), opioid limitation (9.1%) and early enteral feeding (24.7%). 8 These studies underscore the challenges of implementing the ERAS® Neonatal Guidelines clinical practice. To investigate barriers to implementation and adoption, we conducted focus groups with clinicians and parents at six children’s hospitals, which identified uncertainty about patient eligibility criteria, inconsistent or unclear component definitions, and concerns about acceptability and flexibility of select components. 9 Across sites, adoption of the neonatal ERAS guidelines was variable and overall limited, with no center reporting use of a comprehensive ERP. This aligns with prior literature demonstrating that issues related to eligibility criteria and component definitions hinder implementation, reduce adherence, and diminish overall effectiveness. 10 , 11 Clear, standardized eligibility criteria and components are essential to increase adoption, standardize reach, and allow for meaningful assessment of clinical outcomes. 12 We used the ERAS® Neonatal Guidelines as the foundation of this study to reach consensus on eligibility criteria and definitions of components of a neonatal and infant ERP by engaging a multidisciplinary panel of clinicians and parent representatives from six U.S. hospitals in a modified Delphi process to refine consensus-based, implementable definitions of eligibility criteria and pathway components. These consensus definitions will serve as the foundation for a multicenter implementation trial evaluating feasibility, adherence, and patient outcomes. METHODS Framework We conducted two consecutive modified Delphi processes to establish eligibility criteria and to further define the components of the neonatal and infant ERP. Two survey rounds were needed to reach consensus and establish the eligibility criteria and two survey rounds and one focus group were needed to reach consensus on definitions of the components. The Delphi approach was selected to enable structured, iterative, consensus-building of the geographically distributed, multidisciplinary stakeholders while minimizing the influence of hierarchical dynamics. The study procedures were approved by the Ann & Robert H. Lurie Children’s Hospital Institutional Review Board (Approval date/number: 4/24/2024; IRB 2023–6422). All participants provided informed consent. This study was conducted in accordance with the principles of the Declaration of Helsinki. This study is being reported following the Delphi Studies in Social and Health Sciences Recommendations for Interdisciplinary Standardized Reporting (DELPHISTAR) checklist. 13 Panel Recruitment Six hospitals across diverse US regions with neonatal intensive care units (NICUs) and neonatal surgery teams with high procedural volumes for intestinal surgery were identified through the Pediatric Health Information System® (PHIS) database. A pediatric surgeon at each site was contacted and invited to participate by a study investigator (MR). During an initial virtual meeting, study objectives were reviewed, and site surgeons were asked to nominate additional stakeholders involved in neonatal perioperative care at their institution’s NICU. These included neonatologists, pediatric anesthesiologists, nursing staff, advanced practice providers, nurse leaders and educators, allied health professionals such as dietitians and lactation consultants, quality improvement personnel, and parent or caregiver representatives. Individuals without direct involvement in neonatal perioperative care were excluded. Parent or caregiver participants (hereafter: parents) were eligible if they cared for a neonate who had undergone intestinal surgery within the preceding two years; parents of infants who were deceased or still hospitalized were excluded. 9 Invitations to participate in the surveys were distributed electronically, with up to three reminders, and a modest remuneration was provided. Response rates were calculated by counting each eligible opportunity to respond to a survey round as a single unit, and summing responses across all rounds, both overall and by stakeholder group. For participants no longer affiliated with a site at a later survey round, the denominators were adjusted accordingly. No new participants were added. Consensus Definition Consensus was defined a priori as ≥ 70% agreement for an inclusion eligibility criteria, consistent with thresholds commonly applied in Delphi guideline development. 14 – 16 For all analyses, the denominator comprised only participants who selected a response other than “don’t know.” Study Objectives The study focused on two primary objectives: (1) to establish inclusion and exclusion criteria for the neonatal and infant surgical population and (2) to further define the ERP components. Objective 1: Establishing Eligibility Criteria The process for establishing the eligible population is depicted in Fig. 1 . Initial inclusion and exclusion criteria were informed by the Neonatal ERAS® guidelines, published literature, and multidisciplinary discussion. Two survey rounds were administered using Qualtrics (Provo, UT). In round 1, participants rated proposed inclusion and exclusion criteria using four response options: “include,” “possibly include,” “exclude,” or “don’t know.” Candidate criteria were organized by procedure type (elective, semi-urgent, emergent), specific gastrointestinal procedures (e.g., bowel resection with or without ostomy, ostomy creation or reversal), concurrent subspecialty procedures, comorbidities, and categories for gestational age, age at surgery, and weight at surgery. Criteria were determined as “established” if ≥ 70% of respondents selected “include” and removed if > 30% selected “exclude.” Items without consensus (i.e., < 70% selected include, and ≤ 30% selected exclude), or those prompting substantive free-text comments, were refined by the study team for the round 2 survey. In the round 2 survey, participants received a summary of the round 1 survey results and then rated proposed inclusion and exclusion criteria using 3 options “include,” “exclude” and “don’t know,” with “don’t know” responses being excluded from any denominator calculation. The same thresholds for established and not established were used for round 2. Round 2 established criteria were then combined with round 1 established criteria to finalize the established eligibility criteria. Objective 2: Defining Components A round 1 survey, round 2 focus groups, and a round 3 survey are depicted in Fig. 2 . The components were drawn from the 2020 ERAS® Neonatal Guidelines, supplemented by recent literature and prior focus group findings. 9 Nineteen components were included, three of which were designated as “exploratory” secondary to limited evidence. The round 1 survey included all 19 components with descriptions and supporting literature. Survey items were tailored to participants’ clinical expertise (e.g., clinicians rated all components, dietitians only rated diet- and team-related components, parents only rated parent- and team-related items). Each item was rated as “include,” “include but revise,” “exclude,” or “don’t know,” with option to provide free-text comments. “Don’t know” responses were not included in the denominators. Components that reached consensus (> 70% “include”) without substantive free-text comments were accepted as proposed. When the free-text comments were consistent, a component was revised accordingly. When the comments were disparate, the component was then discussed in a virtual focus group of 5–9 relevant participants (e.g., clinicians only for a clinical component). Semi-structured prompts explored participants’ perspectives, clinical examples, and barriers or facilitators to feasibility and acceptability. The round 2 focus group sessions were recorded, transcribed, and summarized and reviewed by the study team to inform component revisions. Round 3 survey presented revised components (either based on free-text comments or focus groups discussion). Revised components were rated, using the same four response options. Consensus was again determined by > 70% “include”. Data Analysis Quantitative data from the Delphi surveys were summarized as frequencies and proportions of participants selecting each response option. Consensus determinations were based on the predefined thresholds for inclusion and exclusion for the eligibility criteria and threshold for inclusion for the component definition. Free-text comments and focus group transcripts were summarized by component and discussed by the study team, which included a surgeon, a neonatologist, an anesthesiologist and qualitative researchers. Summaries of the survey comments and focus group transcripts were also provided to all participants with the round 2 surveys. RESULTS Across all rounds for both Delphi processes, the response rate was 79.4% (139 of 175 total response opportunities), with consistently high participation by stakeholder groups, ranging from 67.9% of nurses and advanced practice providers to 93.8% of neonatologists. Objective 1: Defining Eligibility Criteria Round 1 Survey Thirty-five of 44 stakeholders participated (80% response rate, with respondents including 5/8 surgeons, 5/6 anesthesiologists, 7/8 neonatologists, 6/7 nurses or advanced practice providers, 6/7 dietitians, 2/3 parents, 4/5 quality improvement leaders. Consensus (≥ 70% “include”) was reached for inclusion of patients born at 32–37 weeks’ gestation (81.2%) and ≥ 38 weeks’ gestation (90.6%), patients aged ≥ 4 weeks old at surgery (90.6%), and patients weighing 1.5–2.5 kg (71.9%) or ≥ 2.5 kg (81.3%). Consensus was also reached for inclusion of elective (88.2%) and semi-urgent procedures (70.6%). Consensus was reached for inclusion of diverting ileostomy (76.5%), diverting or leveling colostomy (84.8%), small bowel resection with or without ostomy (82.4%), and ostomy reversal (88.2%). Items with ≥ 30% “exclude” were exclusion criteria. Exclusion criteria were birth at 28–32 weeks’ gestation (40%), weight < 1.0 kg (48.4%), extracorporeal membrane oxygenation requirement (75%), severe neurologic or metabolic disorders (33.3%), severe coagulopathies (35.7%), or sickle cell anemia (32%). Round 2 Survey Round 2 evaluated criteria that lacked consensus in Round 1 and additional criteria identified through free-text feedback, including comorbidities and surgical pathologies (e.g., renal agenesis, Hirschsprung disease), timing of surgery (within the first week of life), and concurrent subspecialty procedures (e.g., orthopedic surgery). Thirty-three stakeholders completed the survey (75% response rate). Participants included 4 of 6 anesthesiologists, 8 of 8 neonatologists, 5 of 7 nurses or advanced practice providers, 5 of 7 dietitians, 2 of 3 parent or caregiver representatives, 3 of 5 quality improvement representatives, and 6 of 8 surgeons. Consensus for inclusion was achieved for procedures occurring within the first week of life (100%), lower-risk cardiac conditions (92.6%), Risk Adjustment for Congenital Heart Surgery (RACHS) category 1 (95.5%), chromosomal abnormalities (77.8%), Hirschsprung disease (81.5%), anorectal malformation (88.9%), and neonatal respiratory distress requiring intubation (72.0%). Items designated as exclusion criteria due to ≥ 30% “exclude” votes included preterm infants between 28–32 weeks’ gestation (37.9%), infants weighing 1.0–1.5 kg (40.7%), bladder or cloacal exstrophy (65.4%), complicated gastroschisis (79.2%), higher-risk cardiac disease (e.g., RACHS ≥ 2) (42.9%), congenital diaphragmatic hernia (72.0%), renal agenesis (68.0%), tracheoesophageal fistula or esophageal atresia (60.0%), giant omphalocele (68.0%), short-gut syndrome (70.4%), and tracheomalacia or bronchopulmonary dysplasia (42.3%). Responses from round 2 were combined with the round 1 responses to establish final eligibility criteria (Fig. 3 ). Objective 2: Defining Components Round 1 Survey Of the 44 invited stakeholders, 36 participated (82% response rate). Participants included 7/8 surgeons, 4/6 anesthesiologists, 7/8 neonatologists, 6/7 nurses or advanced practice providers, 5/7 dietitians, 3/3 parents, and 5/5 quality improvement leaders. In the round 1 survey, 4 of 19 ERP components did not reach consensus (> 70% “include”), and an additional 5 components received substantive free-text feedback, resulting in revisions to 9 components (Fig. 4 ). Five of the nine components had consistent free-text comments that resulted in minor revisions focused on improving clarity, enhancing clinical applicability, and alignment with current literature. For transfusion parameters , “significant O₂ requirement” was explicitly defined, gestational age (< 37 weeks) was incorporated as a criterion for higher transfusion thresholds with more restrictive practice permitted. For preoperative fasting , solids and formula were given different fasting intervals and shorter intervals were permitted. For antimicrobial prophylaxis , procedure-specific antibiotic recommendations were removed. For mucus fistula re-feeding and perioperative glucose control , language was clarified. The four remaining components had disparate comments and were brought to round 2 focus groups: enteral feeds (78% “include,” 22% “revise”), perioperative ventilation (46% “include,” 38% “revise,” 17% “exclude”), optimal surgical technique (50% “include,” 50% “revise”), and urine electrolyte monitoring (67% “include,” 22% “revise,” 11% “exclude.”) Round 2 Focus Groups For enteral feeds , “when appropriate” was clarified as < 20 mL/kg/day, with advancement specified based on tolerance criteria. For perioperative ventilation , focus group participants recommended removing prescriptive strategies such as “lung-protective ventilation” and the routine use of cuffed endotracheal tubes, citing limited neonatal evidence. For optimal surgical technique , laparoscopic duodenal atresia repair was excluded due to its technical complexity and uncertainty regarding comparative benefit, which may limit consistent adoption across centers. The (exploratory) urine electrolyte monitoring component was refined to recommend selective monitoring in neonates and infants with high stoma output (> 20 mL/kg/day) or inadequate weight gain (< 10 g/day), with a target urinary sodium > 20 mmol/L and greater than urinary potassium. These four revised components were then included in round 3 survey. Round 3 Survey The round 3 survey was comprised of the five round 1 components that had minor revisions based on free-text comments and four components discussed during the focus groups. Thirty-five of the 43 stakeholders responded (81, including 7/8 surgeons, 5/6 anesthesiologists, 8/8 neonatologists, 2/7 nurses or advanced practice providers, 5/6 dietitians, 3/3 parents, and 4/4 quality improvement leaders. All remaining components achieved consensus for inclusion: transfusion parameters (75%), urine electrolyte monitoring (80%), enteral feeds (81%), mucous fistula re-feeding (85%), perioperative glucose control (92%), perioperative ventilation (88%), preoperative fasting (95%), antimicrobial prophylaxis (96%), optimal surgical technique (100%) (Fig. 5 ). Final consensus component definitions were synthesized and organized for clarity and clinical application (Supplementary Fig. 1). DISCUSSION Although ERPs are increasingly used in adults and some pediatric populations, adoption in neonates and infants remains limited despite the 2020 ERAS® Neonatal Guidelines and their 2024 expansion. In prior work, we identified substantive barriers to implementation and adoption, including lack of clear eligibility criteria and precise component definitions. 9 Building on this foundation, we applied a rigorous, multidisciplinary Delphi process to establish consensus on eligibility criteria and component definitions for a Neonatal and Infant ERP. A key strength of this work was the iterative engagement of a broad, multidisciplinary group of stakeholders, including surgeons, anesthesiologists, neonatologists, nurses, dietitians, quality improvement experts, and parents, reflecting the team-based nature of NICU care and prioritizing patient- and family-centeredness. While the ERAS® Society’s 2020 and 2024 neonatal guidelines similarly incorporated multidisciplinary input and parent perspectives during development, the depth and structure of stakeholder engagement in those processes are not fully detailed, whereas our approach deliberately emphasized iterative, consensus-driven input to enhance acceptability and facilitate future implementation. 5 , 17 The explicitly defined eligibility criteria, established through consensus, represent a key strength of the study given the limited and low-to-moderate quality evidence base and absence of robust neonatal-specific trial data. While the expanded 2024 ERAS® Neonatal Guidelines sought to move beyond procedure-specific to broader perioperative guidance, the guidelines lack specificity about age, comorbidities, physiologic stability, and procedure types. Such lack of specificity contributed to reduced adoption by clinicians because of concerns of inappropriate use. 17 Consensus-based eligibility criteria about gestational age, weight, comorbid conditions, and procedure types, by providing greater clarity supports implementation and adoption into neonatal surgical practice. The iterative refinement of component definitions is another strength of the study, optimizing clarity, enhancing clinical feasibility, and incorporating the best available evidence. For example, the removal of prescriptive ventilation strategies and cuffed endotracheal tube recommendations reflected recognition of limited evidence in neonates and the need to preserve flexibility. 17 , 18 Participants strongly advocated for clear, explicit definitions for feeding-related components, including when to initiate feeds, intolerance criteria, and advancement parameters. The transfusion and electrolyte monitoring components were revised to incorporate objective thresholds while allowing for some variation in practice. Collectively, consensus was reached when definitions were specific, evidence-informed, clinically feasible, and generalizable. Our findings build on and extend the ERAS® Neonatal Guidelines, which, despite providing a critical foundation, have been inconsistently adhered to, incompletely adopted, and difficult to measure accurately. 9 Several components, such as normothermia and preoperative acetaminophen, demonstrated particularly low adherence, and others could not be reliably assessed within existing electronic health records. 7 , 8 Our Delphi process directly addressed these challenges and enhanced the practical feasibility of several components. A prospective trial with robust implementation and evaluation is needed to assess the effectiveness of the neonatal and infant ERP, as the evidence supporting several components remains sparse and there have been no multicenter trials evaluating the combined implementation of these components. Establishing clear and feasible definitions through this consensus process lays the groundwork for such a trial by ensuring that each component can be implemented consistently and evaluated reliably across centers. Finally, this work advances implementation science by positioning consensus-building not only as a preliminary step, but as a strategy to improve ERP implementation. Established frameworks identify stakeholder engagement, leadership alignment, and multidisciplinary culture as central to uptake, and our Delphi process operationalized these principles by embedding frontline clinicians and caregivers directly into co-development. 19 , 20 This reframes ERP development as shared ownership rather than top-down dissemination. Evidence suggests that participation is associated with increased adoption. Delphi-based ERPs have achieved high uptake, with participants reporting greater willingness to implement recommendations they helped develop. 21 Structured collaborative engagement may further build problem-solving capacity and shared accountability. 19 Consistent with the Guidelines International Network–McMaster framework, our approach emphasized early and meaningful stakeholder involvement to enhance acceptability, feasibility, and implementability. 20 In this context, consensus-building functions not only as a component of ERP design but also as a mechanism to support ERP implementation. By aligning stakeholders around clear, feasible, and context-specific practices, this approach directly addresses limitations of prior neonatal ERPs, including ambiguous eligibility criteria and poorly defined components that may hinder adoption. 9 , 22 , 23 These findings position stakeholder-engaged consensus as an implementation-focused approach to ERP development, improving the clarity and actionability required for real-world uptake. This study has limitations. The ≥ 70% consensus threshold, though consistent with prior Delphi studies, is inherently arbitrary. Additionally, focus group discussions may have been influenced by dominant voices despite semi-structured facilitation. Although participation was robust across disciplines, representation varied, with relatively limited parent participation (n = 4) and lower participation among nurses and advanced practice providers compared to other stakeholder groups. The panel was also limited to six hospitals within one consortium and may not capture all perspectives. Finally, while the consensus definitions enhance clarity and feasibility, they may require further refinement when applied in diverse settings. CONCLUSION Through a rigorous, multi-disciplinary Delphi process, we established consensus-based eligibility criteria and component definitions for an ERP for neonates and infants undergoing gastrointestinal surgery. This work addresses previously identified barriers to implementation and adoption by providing a clinically feasible, clearly specified ERP that is more likely to be adopted, thereby laying the foundation for future multicenter studies to robustly evaluate its effectiveness. Declarations MEETING PRESENTATION Portions of this work were presented at the 2025 American Academy of Pediatrics (AAP) National Conference & Exhibition and have been submitted for presentation at the 2026 AAP National Conference & Exhibition. CONFLICT OF INTEREST: There are no conflicts of interest regarding these data. INTENDED JOURNALS Journal of Perinatology FUNDING: This work was supported by a Visionary Award from the Stanley Manne Children’s Research Institute Internal Grant Award program (Award Number AWD001929). The authors acknowledge the support of the Steven J. Stryker, MD, Gastrointestinal Surgery Research and Education Endowment AUTHOR CONTRIBUTION: J.M.B. contributed to data collection, data analysis, and manuscript drafting. M.V.R. contributed to study conception and design, supervision, and critical revision of the manuscript. M.N.P., G.H.F., and N.E.B. contributed to study design and interpretation of data. J.L.H. and W.L.A.S. contributed to study design, data interpretation, and critical revision of the manuscript. All authors reviewed and approved the final manuscript. AVAILABILITY OF DATA: The datasets generated and analyzed during the current study are not publicly available due to the inclusion of potentially identifiable participant information from survey responses and focus group transcripts but are available from the corresponding author on reasonable request. References Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg . Feb 2014;101(3):172–88. doi: 10.1002/bjs.9394 Ljungqvist O, de Boer HD, Balfour A, et al. Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review. JAMA Surg . Aug 1 2021;156(8):775–784. doi: 10.1001/jamasurg.2021.0586 Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg . Mar 1 2017;152(3):292–298. doi: 10.1001/jamasurg.2016.4952 Ljungqvist O, Young-Fadok T, Demartines N. The History of Enhanced Recovery After Surgery and the ERAS Society. 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The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature. J Clin Epidemiol . Oct 2023;162:169–181. doi: 10.1016/j.jclinepi.2023.08.017 Wang T, Tan JB, Liu XL, Zhao I. Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews. BMJ Open . Jan 6 2023;13(1):e062158. doi: 10.1136/bmjopen-2022-062158 Additional Declarations There is NO conflict of interest to disclose. Supplementary Files ComponentFigure.docx Supplementary Figure 1 Cite Share Download PDF Status: Under Review Version 1 posted Reviewer # 1 agreed at journal 01 May, 2026 Reviewers invited by journal 27 Apr, 2026 Submission checks completed at journal 22 Apr, 2026 First submitted to journal 21 Apr, 2026 Unknown event 21 Apr, 2026 Editor assigned by journal 17 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9452775\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":630554753,\"identity\":\"c5513072-6bab-4a97-9fe4-f6fa46514ebe\",\"order_by\":0,\"name\":\"Willemijn Schäfer\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Northwestern University Feinberg School of Medicine\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Willemijn\",\"middleName\":\"\",\"lastName\":\"Schäfer\",\"suffix\":\"\"},{\"id\":630554754,\"identity\":\"3d4006ea-c69c-4756-89a5-82580bbccbe6\",\"order_by\":1,\"name\":\"Johanna Borst\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0002-1838-0852\",\"institution\":\"Northwestern University Feinberg School of Medicine\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Johanna\",\"middleName\":\"\",\"lastName\":\"Borst\",\"suffix\":\"\"},{\"id\":630554755,\"identity\":\"1354c1d7-625c-449e-83dc-b19bfc7524c0\",\"order_by\":2,\"name\":\"Mehul Raval\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0002-1527-2661\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mehul\",\"middleName\":\"\",\"lastName\":\"Raval\",\"suffix\":\"\"},{\"id\":630554756,\"identity\":\"1cbccafe-ef5f-4bb5-8856-6403f41b6cda\",\"order_by\":3,\"name\":\"Mallory Perez\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Northwestern University Feinberg School of Medicine\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mallory\",\"middleName\":\"\",\"lastName\":\"Perez\",\"suffix\":\"\"},{\"id\":630554757,\"identity\":\"88d55682-5021-4d39-96a3-4b15afdb20f1\",\"order_by\":4,\"name\":\"Gustave Falciglia\",\"email\":\"\",\"orcid\":\"https://orcid.org/0000-0002-2702-776X\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Gustave\",\"middleName\":\"\",\"lastName\":\"Falciglia\",\"suffix\":\"\"},{\"id\":630554758,\"identity\":\"f30870c4-947d-43eb-bc37-346ee01195cd\",\"order_by\":5,\"name\":\"Nicholas Burjek\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Ann \\u0026 Robert H. Lurie Children's Hospital of Chicago\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Nicholas\",\"middleName\":\"\",\"lastName\":\"Burjek\",\"suffix\":\"\"},{\"id\":630554759,\"identity\":\"0347f130-ffca-4854-acca-a89f2d273515\",\"order_by\":6,\"name\":\"Jane Holl\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Chicago\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jane\",\"middleName\":\"\",\"lastName\":\"Holl\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-04-17 21:30:15\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9452775/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9452775/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":108631350,\"identity\":\"ccb18234-0334-4af6-8ce5-1d8b53168acf\",\"added_by\":\"auto\",\"created_at\":\"2026-05-06 16:42:20\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 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16:05:10\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":441955,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9452775/v1/bb2094d7-f134-4a7e-97ef-508c95b39015.pdf\"},{\"id\":108805022,\"identity\":\"8d0a9a5c-3e75-48ed-a3f3-dbb622934dbf\",\"added_by\":\"auto\",\"created_at\":\"2026-05-08 15:24:32\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":31701,\"visible\":true,\"origin\":\"\",\"legend\":\"Supplementary Figure 1\",\"description\":\"\",\"filename\":\"ComponentFigure.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9452775/v1/489dfd2e5005415904df9c75.docx\"}],\"financialInterests\":\"There is \\u003cb\\u003eNO\\u003c/b\\u003e conflict of interest to disclose.\",\"formattedTitle\":\"Consensus-Based Eligibility Criteria and Component Definitions for Neonatal and Infant Enhanced Recovery Pathway: A Multidisciplinary Delphi Study\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eEnhanced recovery pathways (ERPs) are multidisciplinary, evidence-based perioperative care pathways designed to mitigate surgical stress, accelerate recovery, and improve outcomes.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e Common components include reduced preoperative fasting, minimally invasive surgical approaches, early postoperative feeding, and multimodal, opioid-sparing analgesia. Initially developed in adult colorectal surgery, these ERPs have since been adopted across a wide range of specialties and age groups, consistently demonstrating benefits such as fewer complications, reduced opioid use, and shorter hospital stays.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR3\\\" citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e In 2020, the Enhanced Recovery After Surgery (ERAS\\u0026reg;) Society published the first guidelines for neonatal intestinal surgery.\\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e Neonates represent a high-risk surgical population given their limited physiologic reserve and immature metabolic and thermoregulatory systems, which contribute to prolonged recovery and elevated postoperative morbidity.\\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e These same factors also make them strong candidates to benefit from a standardized, evidence-based ERP. Yet, adoption in the neonatal population has been limited.\\u003c/p\\u003e \\u003cp\\u003eThe ERAS\\u0026reg; Neonatal Guidelines introduced 17 evidence- and expert-informed recommendations tailored to perioperative management within the neonatal intensive care unit (NICU) emphasizing multidisciplinary collaboration among surgeons, neonatologists, anesthesiologists, and nursing teams.\\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e Early implementation results, while encouraging, revealed major challenges in translating a neonatal ERP into clinical practice. In a single-center pilot of 10 infants undergoing intestinal resection, partial adoption was associated with reduced opioid exposure, but there was high variation in adherence to ERAS\\u0026reg; components, such as maintenance of normothermia (0%), preoperative acetaminophen (10%), and early enteral feeding within 48 hours of surgery (40%). Furthermore, adherence to other components (e.g., fluid management, lingual sucrose, and parental readiness for discharge) could not be reliably assessed due to inconsistent or absent documentation.\\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e A larger retrospective study of 186 neonates and infants undergoing ostomy takedown found median adherence of only 6 of 13 components, with poor adherence to hypothermia prevention (14.5%), opioid limitation (9.1%) and early enteral feeding (24.7%).\\u003csup\\u003e8\\u003c/sup\\u003e These studies underscore the challenges of implementing the ERAS\\u0026reg; Neonatal Guidelines clinical practice.\\u003c/p\\u003e \\u003cp\\u003eTo investigate barriers to implementation and adoption, we conducted focus groups with clinicians and parents at six children\\u0026rsquo;s hospitals, which identified uncertainty about patient eligibility criteria, inconsistent or unclear component definitions, and concerns about acceptability and flexibility of select components.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e Across sites, adoption of the neonatal ERAS guidelines was variable and overall limited, with no center reporting use of a comprehensive ERP. This aligns with prior literature demonstrating that issues related to eligibility criteria and component definitions hinder implementation, reduce adherence, and diminish overall effectiveness.\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e Clear, standardized eligibility criteria and components are essential to increase adoption, standardize reach, and allow for meaningful assessment of clinical outcomes.\\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e We used the ERAS\\u0026reg; Neonatal Guidelines as the foundation of this study to reach consensus on eligibility criteria and definitions of components of a neonatal and infant ERP by engaging a multidisciplinary panel of clinicians and parent representatives from six U.S. hospitals in a modified Delphi process to refine consensus-based, implementable definitions of eligibility criteria and pathway components. These consensus definitions will serve as the foundation for a multicenter implementation trial evaluating feasibility, adherence, and patient outcomes.\\u003c/p\\u003e\"},{\"header\":\"METHODS\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFramework\\u003c/h2\\u003e \\u003cp\\u003eWe conducted two consecutive modified Delphi processes to establish eligibility criteria and to further define the components of the neonatal and infant ERP. Two survey rounds were needed to reach consensus and establish the eligibility criteria and two survey rounds and one focus group were needed to reach consensus on definitions of the components. The Delphi approach was selected to enable structured, iterative, consensus-building of the geographically distributed, multidisciplinary stakeholders while minimizing the influence of hierarchical dynamics. The study procedures were approved by the Ann \\u0026amp; Robert H. Lurie Children\\u0026rsquo;s Hospital Institutional Review Board (Approval date/number: 4/24/2024; IRB 2023\\u0026ndash;6422). All participants provided informed consent. This study was conducted in accordance with the principles of the Declaration of Helsinki. This study is being reported following the Delphi Studies in Social and Health Sciences Recommendations for Interdisciplinary Standardized Reporting (DELPHISTAR) checklist.\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003ePanel Recruitment\\u003c/h3\\u003e\\n\\u003cp\\u003eSix hospitals across diverse US regions with neonatal intensive care units (NICUs) and neonatal surgery teams with high procedural volumes for intestinal surgery were identified through the Pediatric Health Information System\\u0026reg; (PHIS) database. A pediatric surgeon at each site was contacted and invited to participate by a study investigator (MR). During an initial virtual meeting, study objectives were reviewed, and site surgeons were asked to nominate additional stakeholders involved in neonatal perioperative care at their institution\\u0026rsquo;s NICU. These included neonatologists, pediatric anesthesiologists, nursing staff, advanced practice providers, nurse leaders and educators, allied health professionals such as dietitians and lactation consultants, quality improvement personnel, and parent or caregiver representatives. Individuals without direct involvement in neonatal perioperative care were excluded. Parent or caregiver participants (hereafter: parents) were eligible if they cared for a neonate who had undergone intestinal surgery within the preceding two years; parents of infants who were deceased or still hospitalized were excluded.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e Invitations to participate in the surveys were distributed electronically, with up to three reminders, and a modest remuneration was provided. Response rates were calculated by counting each eligible opportunity to respond to a survey round as a single unit, and summing responses across all rounds, both overall and by stakeholder group. For participants no longer affiliated with a site at a later survey round, the denominators were adjusted accordingly. No new participants were added.\\u003c/p\\u003e\\n\\u003ch3\\u003eConsensus Definition\\u003c/h3\\u003e\\n\\u003cp\\u003eConsensus was defined a priori as \\u0026ge;\\u0026thinsp;70% agreement for an inclusion eligibility criteria, consistent with thresholds commonly applied in Delphi guideline development.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR15\\\" citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e For all analyses, the denominator comprised only participants who selected a response other than \\u0026ldquo;don\\u0026rsquo;t know.\\u0026rdquo;\\u003c/p\\u003e\\n\\u003ch3\\u003eStudy Objectives\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study focused on two primary objectives: (1) to establish inclusion and exclusion criteria for the neonatal and infant surgical population and (2) to further define the ERP components.\\u003c/p\\u003e\\n\\u003ch3\\u003eObjective 1: Establishing Eligibility Criteria\\u003c/h3\\u003e\\n\\u003cp\\u003eThe process for establishing the eligible population is depicted in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. Initial inclusion and exclusion criteria were informed by the Neonatal ERAS\\u0026reg; guidelines, published literature, and multidisciplinary discussion. Two survey rounds were administered using Qualtrics (Provo, UT). In round 1, participants rated proposed inclusion and exclusion criteria using four response options: \\u0026ldquo;include,\\u0026rdquo; \\u0026ldquo;possibly include,\\u0026rdquo; \\u0026ldquo;exclude,\\u0026rdquo; or \\u0026ldquo;don\\u0026rsquo;t know.\\u0026rdquo; Candidate criteria were organized by procedure type (elective, semi-urgent, emergent), specific gastrointestinal procedures (e.g., bowel resection with or without ostomy, ostomy creation or reversal), concurrent subspecialty procedures, comorbidities, and categories for gestational age, age at surgery, and weight at surgery. Criteria were determined as \\u0026ldquo;established\\u0026rdquo; if\\u0026thinsp;\\u0026ge;\\u0026thinsp;70% of respondents selected \\u0026ldquo;include\\u0026rdquo; and removed if\\u0026thinsp;\\u0026gt;\\u0026thinsp;30% selected \\u0026ldquo;exclude.\\u0026rdquo; Items without consensus (i.e., \\u0026lt;\\u0026thinsp;70% selected include, and \\u0026le;\\u0026thinsp;30% selected exclude), or those prompting substantive free-text comments, were refined by the study team for the round 2 survey. In the round 2 survey, participants received a summary of the round 1 survey results and then rated proposed inclusion and exclusion criteria using 3 options \\u0026ldquo;include,\\u0026rdquo; \\u0026ldquo;exclude\\u0026rdquo; and \\u0026ldquo;don\\u0026rsquo;t know,\\u0026rdquo; with \\u0026ldquo;don\\u0026rsquo;t know\\u0026rdquo; responses being excluded from any denominator calculation. The same thresholds for established and not established were used for round 2. Round 2 established criteria were then combined with round 1 established criteria to finalize the established eligibility criteria.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eObjective 2: Defining Components\\u003c/h2\\u003e \\u003cp\\u003eA round 1 survey, round 2 focus groups, and a round 3 survey are depicted in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. The components were drawn from the 2020 ERAS\\u0026reg; Neonatal Guidelines, supplemented by recent literature and prior focus group findings.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e Nineteen components were included, three of which were designated as \\u0026ldquo;exploratory\\u0026rdquo; secondary to limited evidence.\\u003c/p\\u003e \\u003cp\\u003eThe round 1 survey included all 19 components with descriptions and supporting literature. Survey items were tailored to participants\\u0026rsquo; clinical expertise (e.g., clinicians rated all components, dietitians only rated diet- and team-related components, parents only rated parent- and team-related items). Each item was rated as \\u0026ldquo;include,\\u0026rdquo; \\u0026ldquo;include but revise,\\u0026rdquo; \\u0026ldquo;exclude,\\u0026rdquo; or \\u0026ldquo;don\\u0026rsquo;t know,\\u0026rdquo; with option to provide free-text comments. \\u0026ldquo;Don\\u0026rsquo;t know\\u0026rdquo; responses were not included in the denominators.\\u003c/p\\u003e \\u003cp\\u003eComponents that reached consensus (\\u0026gt;\\u0026thinsp;70% \\u0026ldquo;include\\u0026rdquo;) without substantive free-text comments were accepted as proposed. When the free-text comments were consistent, a component was revised accordingly. When the comments were disparate, the component was then discussed in a virtual focus group of 5\\u0026ndash;9 relevant participants (e.g., clinicians only for a clinical component). Semi-structured prompts explored participants\\u0026rsquo; perspectives, clinical examples, and barriers or facilitators to feasibility and acceptability. The round 2 focus group sessions were recorded, transcribed, and summarized and reviewed by the study team to inform component revisions. Round 3 survey presented revised components (either based on free-text comments or focus groups discussion). Revised components were rated, using the same four response options. Consensus was again determined by \\u0026gt;\\u0026thinsp;70% \\u0026ldquo;include\\u0026rdquo;.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData Analysis\\u003c/h2\\u003e \\u003cp\\u003eQuantitative data from the Delphi surveys were summarized as frequencies and proportions of participants selecting each response option. Consensus determinations were based on the predefined thresholds for inclusion and exclusion for the eligibility criteria and threshold for inclusion for the component definition. Free-text comments and focus group transcripts were summarized by component and discussed by the study team, which included a surgeon, a neonatologist, an anesthesiologist and qualitative researchers. Summaries of the survey comments and focus group transcripts were also provided to all participants with the round 2 surveys.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eAcross all rounds for both Delphi processes, the response rate was 79.4% (139 of 175 total response opportunities), with consistently high participation by stakeholder groups, ranging from 67.9% of nurses and advanced practice providers to 93.8% of neonatologists.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eObjective 1: Defining Eligibility Criteria\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eRound 1 Survey\\u003c/h2\\u003e \\u003cp\\u003eThirty-five of 44 stakeholders participated (80% response rate, with respondents including 5/8 surgeons, 5/6 anesthesiologists, 7/8 neonatologists, 6/7 nurses or advanced practice providers, 6/7 dietitians, 2/3 parents, 4/5 quality improvement leaders. Consensus (\\u0026ge;\\u0026thinsp;70% \\u0026ldquo;include\\u0026rdquo;) was reached for inclusion of patients born at 32\\u0026ndash;37 weeks\\u0026rsquo; gestation (81.2%) and \\u0026ge;\\u0026thinsp;38 weeks\\u0026rsquo; gestation (90.6%), patients aged\\u0026thinsp;\\u0026ge;\\u0026thinsp;4 weeks old at surgery (90.6%), and patients weighing 1.5\\u0026ndash;2.5 kg (71.9%) or \\u0026ge;\\u0026thinsp;2.5 kg (81.3%). Consensus was also reached for inclusion of elective (88.2%) and semi-urgent procedures (70.6%). Consensus was reached for inclusion of diverting ileostomy (76.5%), diverting or leveling colostomy (84.8%), small bowel resection with or without ostomy (82.4%), and ostomy reversal (88.2%).\\u003c/p\\u003e \\u003cp\\u003eItems with \\u0026ge;\\u0026thinsp;30% \\u0026ldquo;exclude\\u0026rdquo; were exclusion criteria. Exclusion criteria were birth at 28\\u0026ndash;32 weeks\\u0026rsquo; gestation (40%), weight\\u0026thinsp;\\u0026lt;\\u0026thinsp;1.0 kg (48.4%), extracorporeal membrane oxygenation requirement (75%), severe neurologic or metabolic disorders (33.3%), severe coagulopathies (35.7%), or sickle cell anemia (32%).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eRound 2 Survey\\u003c/h2\\u003e \\u003cp\\u003eRound 2 evaluated criteria that lacked consensus in Round 1 and additional criteria identified through free-text feedback, including comorbidities and surgical pathologies (e.g., renal agenesis, Hirschsprung disease), timing of surgery (within the first week of life), and concurrent subspecialty procedures (e.g., orthopedic surgery). Thirty-three stakeholders completed the survey (75% response rate). Participants included 4 of 6 anesthesiologists, 8 of 8 neonatologists, 5 of 7 nurses or advanced practice providers, 5 of 7 dietitians, 2 of 3 parent or caregiver representatives, 3 of 5 quality improvement representatives, and 6 of 8 surgeons. Consensus for inclusion was achieved for procedures occurring within the first week of life (100%), lower-risk cardiac conditions (92.6%), Risk Adjustment for Congenital Heart Surgery (RACHS) category 1 (95.5%), chromosomal abnormalities (77.8%), Hirschsprung disease (81.5%), anorectal malformation (88.9%), and neonatal respiratory distress requiring intubation (72.0%).\\u003c/p\\u003e \\u003cp\\u003eItems designated as exclusion criteria due to \\u0026ge;\\u0026thinsp;30% \\u0026ldquo;exclude\\u0026rdquo; votes included preterm infants between 28\\u0026ndash;32 weeks\\u0026rsquo; gestation (37.9%), infants weighing 1.0\\u0026ndash;1.5 kg (40.7%), bladder or cloacal exstrophy (65.4%), complicated gastroschisis (79.2%), higher-risk cardiac disease (e.g., RACHS\\u0026thinsp;\\u0026ge;\\u0026thinsp;2) (42.9%), congenital diaphragmatic hernia (72.0%), renal agenesis (68.0%), tracheoesophageal fistula or esophageal atresia (60.0%), giant omphalocele (68.0%), short-gut syndrome (70.4%), and tracheomalacia or bronchopulmonary dysplasia (42.3%).\\u003c/p\\u003e \\u003cp\\u003eResponses from round 2 were combined with the round 1 responses to establish final eligibility criteria (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eObjective 2: Defining Components\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eRound 1 Survey\\u003c/h2\\u003e \\u003cp\\u003eOf the 44 invited stakeholders, 36 participated (82% response rate). Participants included 7/8 surgeons, 4/6 anesthesiologists, 7/8 neonatologists, 6/7 nurses or advanced practice providers, 5/7 dietitians, 3/3 parents, and 5/5 quality improvement leaders. In the round 1 survey, 4 of 19 ERP components did not reach consensus (\\u0026gt;\\u0026thinsp;70% \\u0026ldquo;include\\u0026rdquo;), and an additional 5 components received substantive free-text feedback, resulting in revisions to 9 components (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFive of the nine components had consistent free-text comments that resulted in minor revisions focused on improving clarity, enhancing clinical applicability, and alignment with current literature. For \\u003cem\\u003etransfusion parameters\\u003c/em\\u003e, \\u0026ldquo;significant O₂ requirement\\u0026rdquo; was explicitly defined, gestational age (\\u0026lt;\\u0026thinsp;37 weeks) was incorporated as a criterion for higher transfusion thresholds with more restrictive practice permitted. For \\u003cem\\u003epreoperative fasting\\u003c/em\\u003e, solids and formula were given different fasting intervals and shorter intervals were permitted. For \\u003cem\\u003eantimicrobial prophylaxis\\u003c/em\\u003e, procedure-specific antibiotic recommendations were removed. For \\u003cem\\u003emucus fistula re-feeding\\u003c/em\\u003e and \\u003cem\\u003eperioperative glucose control\\u003c/em\\u003e, language was clarified. The four remaining components had disparate comments and were brought to round 2 focus groups: \\u003cem\\u003eenteral feeds\\u003c/em\\u003e (78% \\u0026ldquo;include,\\u0026rdquo; 22% \\u0026ldquo;revise\\u0026rdquo;), \\u003cem\\u003eperioperative ventilation\\u003c/em\\u003e (46% \\u0026ldquo;include,\\u0026rdquo; 38% \\u0026ldquo;revise,\\u0026rdquo; 17% \\u0026ldquo;exclude\\u0026rdquo;), \\u003cem\\u003eoptimal surgical technique\\u003c/em\\u003e (50% \\u0026ldquo;include,\\u0026rdquo; 50% \\u0026ldquo;revise\\u0026rdquo;), \\u003cem\\u003eand urine electrolyte monitoring\\u003c/em\\u003e (67% \\u0026ldquo;include,\\u0026rdquo; 22% \\u0026ldquo;revise,\\u0026rdquo; 11% \\u0026ldquo;exclude.\\u0026rdquo;)\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eRound 2 Focus Groups\\u003c/h2\\u003e \\u003cp\\u003eFor \\u003cem\\u003eenteral feeds\\u003c/em\\u003e, \\u0026ldquo;when appropriate\\u0026rdquo; was clarified as \\u0026lt;\\u0026thinsp;20 mL/kg/day, with advancement specified based on tolerance criteria. For \\u003cem\\u003eperioperative ventilation\\u003c/em\\u003e, focus group participants recommended removing prescriptive strategies such as \\u0026ldquo;lung-protective ventilation\\u0026rdquo; and the routine use of cuffed endotracheal tubes, citing limited neonatal evidence. For \\u003cem\\u003eoptimal surgical technique\\u003c/em\\u003e, laparoscopic duodenal atresia repair was excluded due to its technical complexity and uncertainty regarding comparative benefit, which may limit consistent adoption across centers. The (exploratory) \\u003cem\\u003eurine electrolyte monitoring\\u003c/em\\u003e component was refined to recommend selective monitoring in neonates and infants with high stoma output (\\u0026gt;\\u0026thinsp;20 mL/kg/day) or inadequate weight gain (\\u0026lt;\\u0026thinsp;10 g/day), with a target urinary sodium\\u0026thinsp;\\u0026gt;\\u0026thinsp;20 mmol/L and greater than urinary potassium. These four revised components were then included in round 3 survey.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eRound 3 Survey\\u003c/h2\\u003e \\u003cp\\u003eThe round 3 survey was comprised of the five round 1 components that had minor revisions based on free-text comments and four components discussed during the focus groups. Thirty-five of the 43 stakeholders responded (81, including 7/8 surgeons, 5/6 anesthesiologists, 8/8 neonatologists, 2/7 nurses or advanced practice providers, 5/6 dietitians, 3/3 parents, and 4/4 quality improvement leaders. All remaining components achieved consensus for inclusion: transfusion parameters (75%), urine electrolyte monitoring (80%), enteral feeds (81%), mucous fistula re-feeding (85%), perioperative glucose control (92%), perioperative ventilation (88%), preoperative fasting (95%), antimicrobial prophylaxis (96%), optimal surgical technique (100%) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eFinal consensus component definitions were synthesized and organized for clarity and clinical application (Supplementary Fig.\\u0026nbsp;1).\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eAlthough ERPs are increasingly used in adults and some pediatric populations, adoption in neonates and infants remains limited despite the 2020 ERAS\\u0026reg; Neonatal Guidelines and their 2024 expansion. In prior work, we identified substantive barriers to implementation and adoption, including lack of clear eligibility criteria and precise component definitions.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e Building on this foundation, we applied a rigorous, multidisciplinary Delphi process to establish consensus on eligibility criteria and component definitions for a Neonatal and Infant ERP.\\u003c/p\\u003e \\u003cp\\u003eA key strength of this work was the iterative engagement of a broad, multidisciplinary group of stakeholders, including surgeons, anesthesiologists, neonatologists, nurses, dietitians, quality improvement experts, and parents, reflecting the team-based nature of NICU care and prioritizing patient- and family-centeredness. While the ERAS\\u0026reg; Society\\u0026rsquo;s 2020 and 2024 neonatal guidelines similarly incorporated multidisciplinary input and parent perspectives during development, the depth and structure of stakeholder engagement in those processes are not fully detailed, whereas our approach deliberately emphasized iterative, consensus-driven input to enhance acceptability and facilitate future implementation.\\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eThe explicitly defined eligibility criteria, established through consensus, represent a key strength of the study given the limited and low-to-moderate quality evidence base and absence of robust neonatal-specific trial data. While the expanded 2024 ERAS\\u0026reg; Neonatal Guidelines sought to move beyond procedure-specific to broader perioperative guidance, the guidelines lack specificity about age, comorbidities, physiologic stability, and procedure types. Such lack of specificity contributed to reduced adoption by clinicians because of concerns of inappropriate use.\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e Consensus-based eligibility criteria about gestational age, weight, comorbid conditions, and procedure types, by providing greater clarity supports implementation and adoption into neonatal surgical practice.\\u003c/p\\u003e \\u003cp\\u003eThe iterative refinement of component definitions is another strength of the study, optimizing clarity, enhancing clinical feasibility, and incorporating the best available evidence. For example, the removal of prescriptive ventilation strategies and cuffed endotracheal tube recommendations reflected recognition of limited evidence in neonates and the need to preserve flexibility.\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e Participants strongly advocated for clear, explicit definitions for feeding-related components, including when to initiate feeds, intolerance criteria, and advancement parameters. The transfusion and electrolyte monitoring components were revised to incorporate \\u003cem\\u003eobjective\\u003c/em\\u003e thresholds while allowing for some variation in practice. Collectively, consensus was reached when definitions were specific, evidence-informed, clinically feasible, and generalizable.\\u003c/p\\u003e \\u003cp\\u003eOur findings build on and extend the ERAS\\u0026reg; Neonatal Guidelines, which, despite providing a critical foundation, have been inconsistently adhered to, incompletely adopted, and difficult to measure accurately.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e Several components, such as normothermia and preoperative acetaminophen, demonstrated particularly low adherence, and others could not be reliably assessed within existing electronic health records.\\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e Our Delphi process directly addressed these challenges and enhanced the practical feasibility of several components.\\u003c/p\\u003e \\u003cp\\u003eA prospective trial with robust implementation and evaluation is needed to assess the effectiveness of the neonatal and infant ERP, as the evidence supporting several components remains sparse and there have been no multicenter trials evaluating the combined implementation of these components. Establishing clear and feasible definitions through this consensus process lays the groundwork for such a trial by ensuring that each component can be implemented consistently and evaluated reliably across centers.\\u003c/p\\u003e \\u003cp\\u003eFinally, this work advances implementation science by positioning consensus-building not only as a preliminary step, but as a strategy to improve ERP implementation. Established frameworks identify stakeholder engagement, leadership alignment, and multidisciplinary culture as central to uptake, and our Delphi process operationalized these principles by embedding frontline clinicians and caregivers directly into co-development.\\u003csup\\u003e\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u003c/sup\\u003e This reframes ERP development as shared ownership rather than top-down dissemination. Evidence suggests that participation is associated with increased adoption. Delphi-based ERPs have achieved high uptake, with participants reporting greater willingness to implement recommendations they helped develop.\\u003csup\\u003e\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e\\u003c/sup\\u003e Structured collaborative engagement may further build problem-solving capacity and shared accountability.\\u003csup\\u003e\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e Consistent with the Guidelines International Network\\u0026ndash;McMaster framework, our approach emphasized early and meaningful stakeholder involvement to enhance acceptability, feasibility, and implementability.\\u003csup\\u003e\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eIn this context, consensus-building functions not only as a component of ERP design but also as a mechanism to support ERP implementation. By aligning stakeholders around clear, feasible, and context-specific practices, this approach directly addresses limitations of prior neonatal ERPs, including ambiguous eligibility criteria and poorly defined components that may hinder adoption.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u003c/sup\\u003e These findings position stakeholder-engaged consensus as an implementation-focused approach to ERP development, improving the clarity and actionability required for real-world uptake.\\u003c/p\\u003e \\u003cp\\u003eThis study has limitations. The \\u0026ge;\\u0026thinsp;70% consensus threshold, though consistent with prior Delphi studies, is inherently arbitrary. Additionally, focus group discussions may have been influenced by dominant voices despite semi-structured facilitation. Although participation was robust across disciplines, representation varied, with relatively limited parent participation (n\\u0026thinsp;=\\u0026thinsp;4) and lower participation among nurses and advanced practice providers compared to other stakeholder groups. The panel was also limited to six hospitals within one consortium and may not capture all perspectives. Finally, while the consensus definitions enhance clarity and feasibility, they may require further refinement when applied in diverse settings.\\u003c/p\\u003e\"},{\"header\":\"CONCLUSION\",\"content\":\"\\u003cp\\u003eThrough a rigorous, multi-disciplinary Delphi process, we established consensus-based eligibility criteria and component definitions for an ERP for neonates and infants undergoing gastrointestinal surgery. This work addresses previously identified barriers to implementation and adoption by providing a clinically feasible, clearly specified ERP that is more likely to be adopted, thereby laying the foundation for future multicenter studies to robustly evaluate its effectiveness.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003ch2\\u003eMEETING PRESENTATION\\u003c/h2\\u003e \\u003cp\\u003ePortions of this work were presented at the 2025 American Academy of Pediatrics (AAP) National Conference \\u0026amp; Exhibition and have been submitted for presentation at the 2026 AAP National Conference \\u0026amp; Exhibition.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eCONFLICT OF INTEREST:\\u003c/strong\\u003e \\u003cp\\u003eThere are no conflicts of interest regarding these data.\\u003c/p\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cstrong\\u003eINTENDED JOURNALS\\u003c/strong\\u003e \\u003cp\\u003eJournal of Perinatology\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFUNDING:\\u003c/h2\\u003e \\u003cp\\u003eThis work was supported by a Visionary Award from the Stanley Manne Children\\u0026rsquo;s Research Institute Internal Grant Award program (Award Number AWD001929). The authors acknowledge the support of the Steven J. Stryker, MD, Gastrointestinal Surgery Research and Education Endowment\\u003c/p\\u003e\\u003ch2\\u003eAUTHOR CONTRIBUTION:\\u003c/h2\\u003e \\u003cp\\u003eJ.M.B. contributed to data collection, data analysis, and manuscript drafting. M.V.R. contributed to study conception and design, supervision, and critical revision of the manuscript. M.N.P., G.H.F., and N.E.B. contributed to study design and interpretation of data. J.L.H. and W.L.A.S. contributed to study design, data interpretation, and critical revision of the manuscript. All authors reviewed and approved the final manuscript.\\u003c/p\\u003e\\u003ch2\\u003eAVAILABILITY OF DATA:\\u003c/h2\\u003e \\u003cp\\u003eThe datasets generated and analyzed during the current study are not publicly available due to the inclusion of potentially identifiable participant information from survey responses and focus group transcripts but are available from the corresponding author on reasonable request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eNicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. \\u003cem\\u003eBr J Surg\\u003c/em\\u003e. 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Achieving 90% Adoption of Clinical Practice Guidelines Using the Delphi Consensus Method in a Large Orthopedic Group. \\u003cem\\u003eJ Arthroplasty\\u003c/em\\u003e. Nov 2016;31(11):2380\\u0026ndash;2384. doi:\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.arth.2015.12.050\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.arth.2015.12.050\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhou P, Chen L, Wu Z, et al. The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature. \\u003cem\\u003eJ Clin Epidemiol\\u003c/em\\u003e. 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Jan 6 2023;13(1):e062158. doi:\\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1136/bmjopen-2022-062158\\u003c/span\\u003e\\u003cspan address=\\\"10.1136/bmjopen-2022-062158\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-perinatology\",\"isNatureJournal\":false,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"jp\",\"sideBox\":\"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)\",\"snPcode\":\"41372\",\"submissionUrl\":\"https://mts-jper.nature.com/cgi-bin/main.plex\",\"title\":\"Journal of Perinatology\",\"twitterHandle\":\"@jperinatology\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"Nature AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9452775/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9452775/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eObjective\\u003c/h2\\u003e \\u003cp\\u003eThe 2020 Enhanced Recovery After Surgery (ERAS\\u0026reg;) guidelines for neonatal intestinal surgery have not been widely implemented due to unclear eligibility criteria and poorly defined components. We sought to establish consensus-based eligibility criteria and definitions for a revised enhanced recovery pathway (ERP).\\u003c/p\\u003e\\u003ch2\\u003eStudy Design\\u003c/h2\\u003e \\u003cp\\u003eWe conducted two modified Delphi processes to establish eligibility criteria and define the components by engaging stakeholders including surgeons, anesthesiologists, neonatologists, nurses, dietitians, quality improvement specialists, and parents/caregivers at six pediatric hospitals. Eligibility criteria were established through two survey rounds; components were defined through two survey rounds and one focus group.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eForty-five stakeholders participated (82% response). Consensus supported inclusion of infants born\\u0026thinsp;\\u0026ge;\\u0026thinsp;32 weeks\\u0026rsquo; gestation or \\u0026ge;\\u0026thinsp;1.5 kg undergoing elective/semi-urgent gastrointestinal surgery and defined 19 components with 10 initially accepted and 9 revised.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eThe consensus-based Delphi process established eligibility and defined the components to facilitate implementation and adoption of an ERP for neonates and infants undergoing gastrointestinal surgery.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Consensus-Based Eligibility Criteria and Component Definitions for Neonatal and Infant Enhanced Recovery Pathway: A Multidisciplinary Delphi Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-06 16:42:16\",\"doi\":\"10.21203/rs.3.rs-9452775/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"This content is not available.\",\"date\":\"2026-05-01T12:22:17+00:00\",\"index\":1,\"fulltext\":\"This content is not available.\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-27T18:34:53+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-04-22T09:14:01+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Journal of Perinatology\",\"date\":\"2026-04-21T16:07:18+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksFailed\",\"content\":\"\",\"date\":\"2026-04-21T15:02:25+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-04-17T21:29:24+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-perinatology\",\"isNatureJournal\":false,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"jp\",\"sideBox\":\"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)\",\"snPcode\":\"41372\",\"submissionUrl\":\"https://mts-jper.nature.com/cgi-bin/main.plex\",\"title\":\"Journal of Perinatology\",\"twitterHandle\":\"@jperinatology\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"Nature AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"e0881f1d-cfce-4ba2-8ad7-0d8e451b6729\",\"owner\":[],\"postedDate\":\"May 6th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"reviewerAgreed\",\"content\":\"This content is not available.\",\"date\":\"2026-05-01T12:22:17+00:00\",\"index\":1,\"fulltext\":\"This content is not available.\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[{\"id\":67113222,\"name\":\"Health sciences/Health care/Paediatrics\"},{\"id\":67113223,\"name\":\"Scientific community and society/Scientific community\"},{\"id\":67113224,\"name\":\"Health sciences/Medical research/Outcomes research\"}],\"tags\":[],\"updatedAt\":\"2026-05-06T16:42:16+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-06 16:42:16\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9452775\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9452775\",\"identity\":\"rs-9452775\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}