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Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations
  1. Nergis Nina Suleiman1,
  2. Markus M Luedi2,3,
  3. Girish Joshi4,
  4. Geertrui Dewinter5,
  5. Christopher L Wu6 and
  6. Axel R Sauter7
  7. on behalf of the PROSPECT Working Group
    1. 1Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway
    2. 2Department of Anaesthesiology and Pain Medicine, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
    3. 3Department of Anaesthesiology, Cantonal Hospital of St Gallen, St Gallen, Switzerland
    4. 4Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
    5. 5Department of Cardiovascular Sciences, Section Anesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium
    6. 6Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
    7. 7Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
    1. Correspondence to Dr Axel R Sauter, Department of Anaesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway; axsa{at}


    Background/importance Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery.

    Objectives The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology.

    Evidence review MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023.

    Findings Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown.

    Conclusion The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients.

    PROSPERO registration number CRD42022364788.

    • analgesia
    • Pain, Postoperative
    • Pain Management
    • Acute Pain

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    • Collaborators PROSPECT Working Group: M Van de Velde, E Albrecht, H Beloeil, M P Bonnet, G Dewinter, S M Freys, G Joshi, H Kehlet, P Lavand’homme, D N Lobo, E M Pogatzki-Zahn, J Raeder, N Rawal, A R Sauter, T Volk, C L Wu.

    • Contributors NNS, MML, and ARS conducted the literature search. NNS, MML, GS, and ARS analyzed the retrieved data and wrote the manuscript. GD and CLW helped establish the guidelines based on the data presented by NNS, MML, and ARS and helped improve the manuscript. Final approval of completed article and guarantor: ARS.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests GJ has received honoraria for consultation from Merck.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.