Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials

Yunita Widyastuti; Djayanti Sari; Anisa Fadhila Farid; Amar Rayhan

doi:10.12688/f1000research.156172.3

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Systematic Review

Revised

Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials

[version 3; peer review: 1 approved, 2 approved with reservations]

Yunita Widyastuti ¹, Djayanti Sari¹, Anisa Fadhila Farid¹, Amar Rayhan¹

PUBLISHED 23 Dec 2024

Author details Author details

¹ Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Dr. Sardjito General Hospital, Gadjah Mada University, Yogyakarta, Special Region of Yogyakarta, Indonesia

Yunita Widyastuti
Roles: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Djayanti Sari
Roles: Conceptualization, Methodology, Validation, Visualization, Writing – Review & Editing

Anisa Fadhila Farid
Roles: Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Amar Rayhan
Roles: Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Introduction

Preoperative carbohydrate loading (PCL), part of Enhanced Recovery After Surgery (ERAS) protocols, involves giving carbohydrate-rich liquids before surgery instead of traditional fasting. It improves glucose control, reduces insulin resistance, and enhances patient comfort.

Methods

A comprehensive scoping review was conducted using databases such as PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, and Web of Science, focusing on studies from 2017 to 2024. Primary, English-language clinical trial involving pediatric patients were included without restrictions on surgical procedure, or outcomes. Data extraction was focused on sample sizes, PCL types, and perioperative outcomes.

Results

The scoping review examined 11 studies on PCL in pediatric surgery, covering various procedures with sample sizes ranging from 18 to 1200 participants. Most studies indicated metabolic benefits, with 7 out of 11 showing stabilized blood glucose and reduced hypoglycemia risk. Additionally, 5 studies associated PCL with reduced preoperative anxiety, agitation, and discomfort, including thirst and hunger. For stomach content, 5 studies showed PCL reduced gastric residual volume and improved pH. Postoperative findings were mixed: 4 studies found no significant difference in nausea and vomiting, while 2 suggested benefits. Length of hospital stay from 3 studies showed no clinical difference results.

Conclusions

PCL in pediatric surgery shows potential to stabilize blood glucose, reduce metabolic risks, and improve recovery. However, the evidence regarding outcomes such as length of hospital stay and postoperative complications remains inconsistent, indicating the need for further investigation.

Keywords

Preoperative Carbohydrate Loading, Pediatric Surgery, Preoperative Fasting, Perioperative Care

Corresponding author: Yunita Widyastuti

Competing interests: No competing interests were disclosed.

Grant information: This author is supported by the Damas Community Fund Grant Hibah DAMAS (Dana Masyakarat) FK-KMK UGM” with grant number “3030/UNI/FKKMK 1.3/PPKE/PT/2024
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Widyastuti Y et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Widyastuti Y, Sari D, Fadhila Farid A and Rayhan A. Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials [version 3; peer review: 1 approved, 2 approved with reservations]. F1000Research 2024, 13:1089 (https://doi.org/10.12688/f1000research.156172.3) First published: 24 Sep 2024, 13:1089 (https://doi.org/10.12688/f1000research.156172.1) Latest published: 23 Dec 2024, 13:1089 (https://doi.org/10.12688/f1000research.156172.3)

Revised Amendments from Version 2

In this minor revision, we addressed all remaining reviewer comments to improve clarity and quality. The abstract now explicitly mentions the knowledge gap in preoperative carbohydrate loading (PCL) in children that the review aims to address. The final line of the introduction was revised to clarify the purpose of the scoping review. In the search strategy, "Databases to be searched include" was updated to "Databases searched included." The results section was corrected by removing redundant phrases and replacing placeholders with the actual number of excluded records.

See the authors' detailed response to the review by Vibhavari Naik and Abhijit Sukumaran Nair

1. Introduction

Preoperative carbohydrate loading (PCL) has emerged as a key component in optimizing surgical outcomes, particularly within the framework of Enhanced Recovery After Surgery (ERAS) protocols. The practice involves administering carbohydrate-rich clear liquids to patients in the hours leading up to surgery, which contrasts with the traditional approach of fasting from midnight. This approach has shown benefits, including improving perioperative glucose control, reducing insulin resistance, and enhancing patient comfort. Additionally, preoperative carbohydrate therapy offers physiological advantages, such as reducing the stress response associated with surgery and contributing to better recovery. While the evidence supporting PCL continues to grow, these studies underline the need for further research to establish standardized protocols and maximize patient outcomes across diverse surgical populations.¹^–³

PCL has gained support for its potential benefits in surgery, particularly for its role in reducing insulin resistance (IR), inflammation, and length of hospital stay, without increasing gastric volume. While much of the existing evidence focuses on adult populations, including elderly patients undergoing major procedures like colorectal surgery, the application of PCL in pediatric surgery is less established.³^–⁶ In pediatric patients, while research is more limited, similar benefits have been observed, including less nausea and reduced gastric contents with no increased aspiration risk during procedures. Further studies are needed to determine the optimal use of carbohydrate loading in various pediatric age groups and conditions.⁷ This scoping review aims to systematically examine the effects and safety of PCL in pediatric patients reported from recent clinical trials, focusing on perioperative benefits.

2. Methods

2.1 Research quesition

The scoping review main question is “What is the current evidence on the effects and safety of PCL in pediatric surgery?”.

2.2 Search strategy

To conduct a comprehensive scoping review on PCL in pediatric surgery, we used a multi-database approach. The databases searched include PubMed (MEDLINE), CINAHL, EMBASE, Cochrane Library, Scopus, and Web of Science. The searchemployed a range of terms such as (“Preoperative Carbohydrate Loading” OR “Preoperative Carbohydrate Supplementation” OR “Preoperative Carbohydrate Administration”) AND (“Pediatric Surgery” OR “Child Surgery” OR “Pediatric Surgical Procedures” OR “Children Surgery”).

2.3 Eligiblity criteria

Primary original English articles examining PCL clinical trial in pediatric patients published from 2017 to 2024 were included from scholarly journals. There were no limitation in surgical procedure and study outcome. Exclusion criteria filtered out articles not related to pediatric populations or those focused exclusively on adult populations or unrelated to PCL. The PRISMA flow chart provides a detailed summary of the study selection process, documenting the number of articles that advanced through each stage of screening.

2.4 Data selection and extraction

The selection process involve screening titles and abstracts to select relevant studies based on inclusion criteria. Full-text articles were reviewed to confirm relevance and quality. Two reviewers ensured accuracy and consistency, resolving discrepancies through discussion or a third reviewer if needed. For each article, data were extracted concerning type of pediatric surgery, sample sizes, type of PCL and control group used, and outcomes measured and results. The outcome results were reported from each article individually, presenting the available information in accordance with the data provided, such as mean, standard deviation (SD), median, interquartile range (IQR), sample size (n), percentage (%), and p-values.

2.5 Risk of bias

The authors independently reviewed the methodological quality of the studies using the ‘Risk of bias’ tool, which has undergone modifications and improvements, with an updated version Risk of Bias (RoB) Assessment 2.0 Tools. They evaluated key aspects such as the randomization process, deviations from the intended intervention, missing outcome data, outcome measurement, and selection of reported outcomes. Each study was classified as having low, some concerns, or high risk of bias for each domain. Studies were rated as “low risk” if the information was clear and complete, “high risk” if certain details were missing or suggested a clear risk of bias, and “some concerns” if the data were incomplete.

3. Results

Two independent reviewers conducted a comprehensive literature search across databases and registers, yielding a total of 1471 records. After removing duplicates, 1125 unique records remained. These records were screened based on titles and abstracts, resulting in the exclusion of 397 studies that did not meet the inclusion criteria. 332 full-text articles could not be retrieved for detailed review. Subsequently, 396 full-text articles were assessed for eligibility, of which 385 were excluded due to ineligible research articles, review articles, books, case reports, and other articles. The scoping review identified a total of 11 studies that investigated the effects of PCL in pediatric surgery ( Figure 1 and Table 1).

The studies included a diverse range of surgical procedures, with most focusing on elective operations such as abdominal, orthopedic, and cardiac surgeries. Sample sizes varied across the studies, ranging from 18 to 1200 participants. Interventions typically involved administering a carbohydrate-rich drink 2-3 hours before surgery, with comparison groups following traditional fasting protocols. The outcomes reported included stomach content, metabolic indicators, incidence of preoperative anxiety and agitation, postoperative complications including nausea and vomiting and length of hospital stay. Additionally, we assessed the risk of bias and found that 4 studies had a low risk, 5 studies had some concerns, and 1 study had a high risk ( Figures 2 and 3).

Figure 1. PRISMA flow diagram.

Table 1. Study Characteristics.

No	Author (year)	Study design	Number of patients	Carbohydrate intervention group (n)	Comparison group (n)	Outcome	Outcome results
1	Akgun (2024)¹⁴	RCT	90	11 g/100 mL apple juice without fat or protein with 5 mL/kg dose 1 hour before surgery (Group C, n = 30)	5 mL/kg Water 1 hour before surgery (Group W, n =30) and 6 hour fasting group (Group F, n = 30)	m-YPAS, GRV, gastric antral CSA, 20th minute of surgery blood glucose	1. m-YPAS 1 hour after surgery (Mean±SD; Median [Q1 – Q3]) - Group F = 63.3±16.0; 65 [50–72.0] - Group W = 47.0±17.1; 48.3 [32.9–59.6] - Group C = 31.6±8.5; 28.3 [23.3–37.0] - p value = <0.001 2. GRV, mL (Mean±SD; Median [Q1 – Q3]) - Group F = 18.5±8.2; 16.7 [13.1–20.6] - Group W = 12.9±5.0; 11.8 [9.5–16.5] - Group C = 12.7±6.2; 11.4 [7.7–18.0] - p value = <0.001 3. Antral CSA, ${cm}^{2}$ (Mean±SD; Median [Q1 – Q3]) - Group F = 4.0±1.9; 3.8 [2.9–4.7] - Group W = 2.7±1.0; 2.5 [2.0–3.4] - Group C = 2.3±1.2; 2.0 [1.5–2.5] - p value = <0.001 4. blood glucose (Mean±SD; Median [Q1 – Q3]) - Group F = 112.8±23.3; 109.0 [102.3–118.5] - Group W = 101.7±14.6; 97.5 [92.0–113.0] - Group C = 90.9±12.8; 90.0 [82.0–102.3] - p value = <0.001
2	Karami (2020)¹³	RCT	120	5 ml/kg of 20% dextrose solution 2 hours before surgery (Intervention Group, n = 60)	5 ml distilled water (Control Group, n = 60)	Perioperative agitation	1. Perioperative agitation (n [%]) - Intervention Group = 6 [10] - Control Group = 33 [55] - p value = 0.001
3	Laird (2023)⁸	RCT	119	sugar-free cordial drink containing a carbohydrate load (Polyjoule® 24%, 90kcal/100 ml) 2 hours before surgery (Group A, n = 60)	sugar-free cordial and water drink (Group B, n = 59)	Incidence of postoperative nausea, vomiting, pain, and irritability, LOS and preoperative before induction metabolic state (blood glucose, ketone and gases)	1. Postoperative nausea (n [%]) - Group A = 17 [28.3] - Group B = 15 [25.4] - p value = 0.9 2. Postoperative vomiting (n [%]) - Group A = 7 [11.7] - Group B = 9 [15.3] - p value = 0.8 3. Postoperative pain (n [%]) - Group A = 25 [41.7] - Group B = 27 [45.7] - p value = 0.7 4. Postoperative Irritability (n [%]) - Group A = 20 [33.3] - Group B = 14 [23.7] - p value = 0.3 5. Postoperative LOS, minute (Median [Q1 – Q3]) - Group A = 135 [85-235] - Group B = 161 [90-354] - p value = 0.02 6. blood glucose levels, mmol/L (Median [Q1 – Q3]) - Group A = 5.4 [3.3-9.4] - Group B = 4.9 [3.6-6.5] - p value = 0.01 7. blood ketone levels (Median [Q1 – Q3]) - Group A = 0.2 [0-1.4] - Group B = 0.3 [0-1.6] - p value = 0.0003 8. venous blood pH (Median [Q1 – Q3]) - Group A = 7.36 [7.24-7.44] - Group B = 7.37 [7.25-7.44] - p value ≥ 0.9 9. venous blood lactate, mmol/L (Mean [95 % CI]) - Group A = 1.3 [1.25, 1.51] - Group B = 1.0 [0.96, 1.15] - p value ≤ 0.0001
4	Drobjewski (2018)¹⁶	RCT	120	5 ml/kg of a lemon-flavoured 0.126 g carbohydrat or 0.5 kcal or 2.15 kJ beverage (PreOp™) 2 hours before endoscopy (Carbohydrate group, n = 60)	Standart fasting, 6 h for solid foods, 4 h for breast milk adn 2 h for clear fluids (Fasting group, n = 60).	Volume and pH of each patient’s stomach content, preoperative thirst and hunger, postoperative nausea and vomiting, and perioperative discomfort ratings	1. Mean volume of gastric content (Mean [SD]), ml/kg 0.01 - Carbohydrate Group = 0.41 [0.28] - Fasting Group = 0.28 [0.27] - p value = 0.01 2. pH of gastric content (Mean [SD]) - Carbohydrate Group = 1.9 [0.5] - Fasting Group = 2.0 [0.6] - p value = not significant 3. Preoperative thirst (n [%]) - Group A = 20 [32] - Group B = 14 [30] - p value = not significant 4. Preoperative hunger (n [%]) - Group A = 18 [30] - Group B = 20 [33] - p value = not significant 5. Postoperative nausea (n [%]) - Group A = 24 [25] - Group B = 6 [10] - p value = 0.028 6. Postoperative vomiting (n [%]) - Group A = 3 [5] - Group B = 1 [2] - p value = not significant
5	Jiang (2018)⁹	prospective, multi-center, randomized study	1200	10% carbohydrate solution 2 h before anesthesia. (Group B 5 mL/kg, n = 300; Group C 10 mL/kg, n = 300; Group D 15 mL/kg, n = 300)	preoperative fasting at 6 hours before anaesthesia (Group A, n = 300)	Blood glucose, gastric residual, crying ratio perioperatively, hospital stay	1. The blood glucose = significant higher in groups B, C, and D than group A at the time of anesthesia. 2. The gastric residual = no residue in groups A, B, and C. 15 infants in group D had a gastric residual volume. 3. The crying ratio was significantly higher in group A. 4. The length of hospital = not significant different between the groups.
6	Zhang (2020)¹⁷	Randomized crossover study	18	5 ml/kg 5% glucose solution or carbohydrate-rich drink (CHO Group, n = 18)	Fasting (GS Group, n = 18)	gastric emptying time (antral CSA and gastric fluid volume), thirst and hunger	1. gastric emptying time, ${cm}^{2}$ (Mean [95% CI, P Value]) - CHO Group = significantly increased compared to baseline at 10 minutes 2.4 [1.5-3.4, 0.02], 30 minutes 1.1 [0.2-2.1, 0.02], and 60 minutes 1.5 [0.6-2.4, <0.001]. - GS Group = significantly increased compared to baseline at 10 minutes 1.3 [0.6-2.0, 0.02]. 2. gastric fluid volume, ml (Mean Difference [95% CI]) - CHO Group = significantly increased compared to baseline at 10 minutes −0.71 [−1.08 to −0.34], 30 minutes −0.38 [−0.71 to −0.05], and 60 minutes −0.43 [−0.86 to 0.01]. - GS Group = significantly increased compared to baseline at 10 minutes −0.38 [−0.64 to −0.13]. 3. thirst (median [IQR; range]) - CHO Group = significantly increased compared to baseline at 10 minutes 1.5 [0-4.0; 0-10], 30 minutes 2.0 [2.0-4.8; 0-8], and 60 minutes 3.0 [2.0-6.0; 0-8]. - GS Group = significantly increased compared to baseline at 10 minutes 0 [0-0; 0-3], 30 minutes 1.0 [0-2.8; 0-5], and 60 minutes 1.5 [0-3.5; 0-6]. - p value 10 minutes 0.01, 30 minutes 0.02, and 60 minutes 0.01 4. hunger (median [IQR; range]) - CHO Group = significantly increased compared to baseline at 10 minutes 2 [0.3-3.0; 0-5], - GS Group = significantly increased compared to baseline at 10 minutes 4 [3.3-5.0; 0-6] - p value = not significant
7	Huang (2020)¹⁵	RCT	351	oral glucose water (10 g of glucose in 100 ml of warm water, 5 ml/kg). 2 hour group (174) vs 1 hour group (170)		Volume of gastric content, preoperative blood glucose, Distribution of gastric volume and pH Pre- and intraoperative adverse reactions	1. Volume of gastric content, ml/kg body weight (Mean ± SD [95% CI, p Value] - 1-h fast group = 0.34±0.35 [0.29–0.39] - 2-h fast group = 0.43±0.33 [0.38–0.48] - p value = 0.011 2. Blood glucose, mmol/L (Mean ± SD [95% CI]) - 1-h fast group = 5.59±1.11 [5.43, 5.76] - 2-h fast group = 6.21±0.78 [6.09, 6.33] - p value = < 0.001 3. Volume of gastric content >0.4 ml/kg of body weight (n [%]) - 1-h fast group = 18 [10.6] - 2-h fast group = 35 [20.1] - p value = 0.014 4. pH of gastric content <2.5 (n [%]) - 1-h fast group = 88 [51.8] - 2-h fast group = 92 [52.9] - p value = not significant 5. Pre- and intraoperative adverse reactions (n [%]) - 1-h fast group = Crying, 68 [40]; Thirst, 35 [20.6]; Hypoxia, 9 [5.3]; Vomiting, 7 [4.1]; Pulmonary Aspiration, 3 [1.8]; Heart Failure, 2 [1.2]. - 2-h fast group = Crying, 90 [51.7]; Thirst, 58 [33.3]; Hypoxia, 20 [11.5]; Vomiting, 6 [3.4]; Pulmonary Aspiration, 3 [1.7]; Heart Failure, 3 [1.7]. - p value = Crying, 0.029; Thirst, 0.008; Hypoxia, 0.039; Vomiting, 0.745; Pulmonary Aspiration, 0.647; Heart Failure, 0.511.
8	Carvalho (2020)¹⁰	RCT	40	12.5% maltodextrin diluted in 150 mL of water (CHO Group, n = 19)	Fasting (Fasting Group, n = 21)	Albumin, IL-6, blood glucose, insulin, CRP, Insulin resistance with HOMA-IR Index	1. Albumin (Mean±SD) - Fasting Group = preoperative, 4.08±0.39; postoperative, 3.82 ± 0.48 - CHO Group = preoperative, 4.12 ± 0.29; postoperative, 3.77 ± 0.29 - p value = preoperative, 0.94; postoperative, 0.53 2. IL-6 - Fasting Group = preoperative, 1.5 ± 2.6; postoperative, 3.82 ± 0.48 - CHO Group = preoperative, 2.0 ± 2.3; postoperative, 1.5 ± 2.0 -p value = preoperative, 0.98; postoperative, 0.41 3. blood glucose - Fasting Group = preoperative, 88 ± 16; postoperative, 91 ± 34 -CHO Group = preoperative, 86 ± 9; postoperative, 93 ± 24 - p value = preoperative, 0.32; postoperative, 0.60 4. insulin - Fasting Group = preoperative, 3.09 ± 6.34; postoperative, 91 ± 34 - CHO Group = preoperative, 4.90 ± 4.52; postoperative, 4.55 ± 3.43 - p value = preoperative, 0.69; postoperative, 0.78 5. CRP - Fasting Group = preoperative, 3.60 ± 7.60; postoperative, 3.53 ± 7.75 - CHO Group = preoperative, 0.53 ± 0.59; postoperative, 0.49 ± 0.53 - p value = preoperative, 0.05; postoperative, 0.02 6. HOMA IR - Fasting Group = preoperative, 0.86 ± 2.05; postoperative, 91 ± 34 - CHO Group = preoperative, 1.57 ± 1.86; postoperative, 1.13 ± 1.05 - p value = preoperative, 0.49; postoperative, 0.37 7. PCR/albumin - Fasting Group = preoperative, 0.89 ± 1.86; postoperative, 0.91 ± 1.97 - CHO Group = preoperative, 0.13 ± 0.15; postoperative, 0.13 ± 0.15 - p value = preoperative, 0.03; postoperative, 0.08 8. Preoperative Hyperglicemia - Fasting Group = 4 (21%) - CHO Group = 0 - ± 0.15 - p value = 0.04
9	Bharadwaj (2021)¹¹	RCT	101	5 mL/kg Body Weight (BW) of pulp-free clear apple juice (Tropicana (100 mL pack)-containing 12% sugar, Tropicana Products, Inc., division of PepsiCo, Inc., Chicago, USA), 2 hours prior to induction of anaesthesia (Study Group, n = 50)	Standard ASA fasting guidelines (6-4-2 regimen) (Control Group, n = 51)	Preoperative and postoperative of UMSS and behavior score. child parent separation score and mask acceptance score. Time to attain MAS, to ask for oral intake and time for attaining the discharge criteria. Random blood sugar with 2 minutes interval in 51 minute	1. Time to attain MAS of >9, minutes (Mean±SD [Range]) - Study Group = 18.70±10.19 [5-40] - Control Group = 16.86±6.85 [0-30] - p value = 0.007 2. Time to ask for oral intake, minutes (Mean±SD [Range]) - Study Group = 49.40±31.8 [10-120] - Control Group = 25.88±16.93 (5-90] - p value = 0.0001 3. Time for attaining the discharge criteria, minutes (Mean±SD [Range]) - Study Group = 35.5±14.11 [15-6] - Control Group = 38.04±13.71 [20-60] - p value = 0.841 4. Preoperative UMSS (Median [Range]) - Study Group = 0 (0-2) - Control Group = 1 (0-3) - p value = 0.001 5. Postoperative UMSS (Median [Range]) - Study Group = 2 [0-3] - Control Group = 2 [0-3] - p value = 0.305 6. Preoperative behaviour score (Median [Range]) - Study Group = 3 [1-4] - Control Group = 3 [1-4] - p value = 0.667 7. Postoperative behaviour score (Median [Range]) - Study Group = 3.5 [1-4] - Control Group = 3 [1-4] - p value = 0.412 8. Child-parent separation score (Median [Range]) - Study Group = 2 (1-3) - Control Group = 2 (1-3) - p value = 0.96 9. Mask acceptance score (Median [Range]) - Study Group = 3 (1-4) - Control Group = 3 (1-4) - p value = 0.659 10. Random blood sugar, mg/dL (Median [IQR]) - Study Group = 70 [60-79] - Control Group = 90 [85-98] - p value = 0.005
10	Balasubramaniam (2018)¹²	RCT	120	2 ml per kg of body weight of 10% Dextrose water as oral feeds half hour before the expected time of start of anaesthesia (Group B, n = 60)	fasting according to ASA guidelines preoperatively (Group A, n = 60)	Preoperative blood sugar, hypoglycemia	1. Preoperative blood glucose concentrations (Mean±SD [Range]) - Group A = 64.08 ± 25.37 - Group Group B = 102.5 ± 16.97 - p value ≤ 0.0001 2. Hypoglycemia (n [%]) - Group A = 39 (65) - Group Group B = 14 (23)
11	Bauer (2024)¹⁸	RCT	62	10 fluid ounces, 50 g carbohydrate, 0 g protein, 0 g fat, 200 total calories (Ensure Pre-Surgery®) 2 h before surgery	standard eight hours NPO	LOS, time to first bowel movement, emesis event, Suppository/enema administration, flatus return at 12 h, nausea at 24 h, other perioperative complications	1. LOS, days (Mean) - CHO drink = 2.9 - Control = 3.1 - p value = 0.3 2. Time to first bowel movement (Mean) - CHO drink = 5.1 - Control = 5.2 - p value = 0.99 3. Emesis events (n) - CHO drink = 0.9 - Control = 1.2 - p value = 0.3 4. Suppository/enema administration, % (Mean) - CHO drink = 75 - Control = 91 - p value = 0.16 5. Flatus return at 12 h (n) - CHO drink = 5 - Control = 1 - p value = 0.08 5. nausea at 24 h, 1–100 scale (Mean) - CHO drink = 8 - Control = 22 - p value = 0.068 7. aspiration, abdominal pain, anxiety, back pain, hunger, thirst, nausea = insignificant difference.

Figure 2. RoB 2.0 traffic light plot.

Figure 3. RoB 2.0 summary plot.

3.1 Metabolic effects

The research on PCL demonstrates its significant impact on stabilizing blood glucose levels and enhancing metabolic control before pediatric surgery. In studies comparing carbohydrate-loaded patients with those in control or fasting groups, those who received carbohydrates generally had higher, yet stable, blood glucose levels. For example, patients in the carbohydrate group showed a median blood glucose level of 5.4 mmol/L, which was slightly higher than that of the placebo group. This suggests that PCL helps maintain energy reserves during the perioperative period, reducing the risk of hypoglycemia and providing metabolic benefits.⁸ Additionally, carbohydrate-loaded patients exhibited fewer abnormal ketone levels, indicating better overall metabolic stability, although a slight increase in lactate levels was noted. These findings underscore the potential of PCL to enhance patient outcomes by ensuring more consistent blood glucose levels before surgery.⁹

Further research supports these benefits by showing that PCL not only stabilizes blood glucose levels but also reduces the likelihood of hyperglycemia and hypoglycemia. In one study, fasting patients were more prone to hyperglycemia, with 21% exceeding 99 mg/dL, while none of the patients in the carbohydrate group experienced hyperglycemia. Both groups had similar insulin levels and Homeostatic Model Assessment for IR (HOMA-IR) Index data before and after the operation, indicating that carbohydrate loading helps prevent hyperglycemia without affecting insulin resistance.¹⁰ Another study found significantly lower random blood sugar levels in the carbohydrate group compared to the control group, where higher glucose levels were trending. This suggests that carbohydrate loading effectively prevents the sharp fluctuations in blood glucose that can pose risks during surgery.¹¹ Moreover, the fasting group was found to experience more frequent signs of hypoglycemia, such as excessive crying, sweating, and irritability, highlighting the discomfort and potential risks associated with fasting.¹² Overall, the evidence points to PCL as a valuable strategy for improving preoperative care by maintaining blood glucose stability, reducing metabolic risks, and enhancing patient comfort.

3.2 Preoperative anxiety and agitation

The studies collectively highlight the positive impact of PCL and varying fasting durations on reducing perioperative anxiety, agitation, and crying in pediatric patients. One study found that children who received PCL were significantly calmer, with 90% being quiet and relaxed compared to only 11.7% in a control group, indicating a notable decrease in postoperative agitation.¹³ Another investigation showed that preoperative anxiety levels were markedly lower in children who consumed carbohydrate fluids, as measured by the modified Yale Preoperative Anxiety Scale (m-YPAS), compared to those who fasted.¹⁴ While one randomized clinical trial found no significant differences in behavior scores, separation anxiety, or mask acceptance between PCL and fasting groups, other research demonstrated that PCL significantly reduced preoperative crying, likely due to its ability to alleviate thirst and hunger. This reduction in crying not only conserves energy but also prevents gastrointestinal flatulence, which can interfere with surgical procedures.⁹^,¹¹ Additionally, a comparison of fasting durations revealed that a 1-hour fasting period resulted in fewer instances of crying than a 2-hour fast, supporting the effectiveness of shorter fasting intervals combined with PCL.¹⁵ Overall, the studies emphasize the benefits of PCL in minimizing anxiety, agitation, and crying, thereby improving the preoperative experience for pediatric patients.

3.3 Stomach content

The studies provide a comprehensive analysis of how PCL and different fasting durations impact gastric content, gastric emptying, and the associated risks of pulmonary aspiration. Significant differences were observed in antral cross-sectional area (CSA) and gastric residual volume (GRV) between groups, with both PCL and water intake leading to reduced gastric content compared to fasting.¹⁴ This reduction is further emphasized by findings that PCL led to a 68% decrease in gastric content compared to fasting, highlighting its effectiveness in minimizing gastric volume.¹⁶ Temporal changes in antral CSA indicate that PCL causes a significant increase within the first 10 minutes post-ingestion, which then returns to baseline by 90 minutes, underscoring the importance of timing in PCL administration.¹⁷

In terms of safety, administering PCL at doses up to 10 mL/kg does not increase gastric residuals in adults, children, or infants, thereby reducing the risk of regurgitation and aspiration. The absence of significant gastric residuals across these groups suggests that PCL is well-tolerated and does not compromise gastric emptying.⁹ Additionally, a comparison of fasting durations reveals that a 1-hour fast results in lower gastric content volume than a 2-hour fast, without increasing the risk of low gastric pH or the simultaneous presence of large gastric volumes and low pH, which are key factors in pulmonary aspiration risk.¹⁵ Collectively, these studies underscore the efficacy and safety of PCL in reducing gastric content and improving patient outcomes by lowering the risk of aspiration during surgery.

3.4 Postoperative complications

PCL indicate that it generally does not lead to significant postoperative complications compared to fasting or placebo groups. For instance, the incidence of nausea, vomiting, and pain were similar between groups, with no significant differences observed in postoperative anti-emetic use or pain severity. In one study, children who received carbohydrates were more likely to experience severe nausea in the first postoperative hour, but this difference did not persist beyond that time. Additionally, there was no difference in the time taken to meet discharge criteria between those who received carbohydrates and those who did not.⁸^,¹¹^,¹²^,¹⁸

Other studies reported no complications during the study period, and PCL was associated with reduced incidences of crying, thirst, and hypoxia compared to longer fasting durations. Moreover, no adverse reactions such as pulmonary aspirations, heart failure, or severe hunger were observed in the groups receiving carbohydrates.¹⁵^,¹⁷ These findings suggest that PCL is generally safe and does not increase the risk of postoperative complications, while it may offer some benefits in reducing discomfort after surgery.

3.5 Length of hospital stay

The study results indicate that PCL has a potential impact on the length of stay (LOS) in a hospital setting. One study found a significant reduction in the median LOS for children in the carbohydrate group (135 minutes) compared to the placebo group (161 minutes), suggesting that carbohydrate loading may enhance postoperative recovery and reduce hospital stay. However, the clinical relevance of this 26-minute reduction is debatable, and the study suggests that maintaining adequate hydration alone, regardless of carbohydrate intake, could improve postoperative recovery. It was also noted that the effect was more pronounced in morning surgeries, potentially influencing future clinical guidelines for preoperative hydration.⁸ Another study, however, found no significant difference in the length of hospital stay between groups receiving PCL and those who did not.⁹^,¹⁸ The studies consistently show no clinically meaningful difference in the LOS between groups receiving PCL and those who did not, highlighting the need for further research to better understand the factors influencing LOS and the role of PCL in pediatric surgical recovery.

4. Discussion

The American Society of Anaesthesiology (ASA) guideline emphasizes the importance of adhering to recommended fasting durations to avoid adverse patient and clinical outcomes. Prolonged fasting, whether due to unclear or extended fasting policies, can increase preoperative thirst, hunger, anxiety, and discomfort, as well as lead to dehydration and hypotension during anesthesia induction. Although recent European and Canadian guidelines suggest reducing clear liquid fasting to 1 hour in children, the ASA task force refrains from making a strong recommendation due to limited and low-quality evidence.¹⁹^–²²

In this context, PCL appears to be a promising intervention to address certain challenges in pediatric populations. The findings from this scoping review suggest that PCL may offer several benefits, such as reducing metabolic risks and improving perioperative outcomes. However, the impact of PCL on blood glucose levels is inconsistent. While some studies showed that PCL helps maintain stable blood glucose levels and reduces the risk of hypoglycemia during the perioperative period, others reported lower glucose levels in children receiving PCL. This metabolic stability, when achieved, is crucial for pediatric patients, helping to preserve energy reserves and potentially supporting better recovery outcomes.

However, the review also highlighted variability in outcomes such as LOS and the incidence of postoperative complications. While some studies reported a significant reduction in LOS for patients receiving PCL, others found no significant differences between the PCL and control groups. This inconsistency suggests that the effectiveness of PCL may be influenced by factors like the timing of surgery, the type of surgical procedure, and individual patient characteristics.

Moreover, although PCL generally did not increase the risk of postoperative complications, the extent of its benefits varied across different studies. Some studies reported reductions in postoperative complications such as nausea, vomiting, and pain, while others did not. These mixed results highlight the need for further research to better understand the specific conditions under which PCL provides the most benefit.

In evaluating the risk of bias among the included studies, we found that four studies had a low risk, five studies had some concerns, and one study had a high risk. This variability in study quality may partially explain the inconsistent findings related to PCL outcomes, such as the LOS and the incidence of postoperative complications. While some studies reported significant benefits from PCL, others did not, indicating that the effectiveness of PCL might be influenced by factors like surgical timing, procedure type, and patient characteristics.

A recent meta-analysis of nine randomized controlled trials involving 1,279 pediatric patients found that PCL significantly reduced postoperative nausea and vomiting and improved intraoperative sedation scores. However, no significant differences were observed in postoperative blood glucose levels or residual gastric volume, suggesting variability in the clinical benefits of PCL. These inconsistencies likely stem from differences in study design, patient characteristics, and intervention protocols. Limitations such as small sample sizes, inconsistent CHO administration times and doses, variations in surgery types, and inadequate blinding also raise concerns about the reliability of the pooled results. The overall methodological quality of the studies, with several showing moderate to high risk of bias, underscores the need for caution when interpreting these findings.²³

This scoping review has limitations, including potential language bias, as only articles published in English were considered. The search strategy may have missed relevant studies due to variations in terminology or publication practices. Data extraction could be subject to reviewer bias, and the reporting of outcomes might vary across studies, leading to inconsistencies. Additionally, publication bias may exist, as studies with positive findings are more likely to be published than those with negative or inconclusive results. Lastly, selection bias could affect the generalizability of the findings, as included studies may not represent the broader pediatric population undergoing surgery.

Future research should prioritize optimizing PCL protocols and evaluating its effects across a wider range of surgical procedures, particularly in pediatric populations where evidence is limited. Identifying the optimal timing, dosage, and composition of PCL is crucial to maximize its benefits. Additionally, advanced metabolic indicators such as insulin levels, HOMA-IR, blood analysis, and inflammatory biomarkers like IL-6 have been inadequately explored in current studies. Addressing these gaps will help refine preoperative care and improve patient outcomes by reducing the adverse effects of prolonged fasting. High-quality, well-powered randomized controlled trials (RCTs) with standardized protocols, consistent outcome measures, and rigorous blinding are essential to produce reliable conclusions. A comprehensive, registered systematic review process with a broader search strategy and standardized inclusion criteria will also enhance the evidence base. Until these gaps are addressed, conducting a high-quality systematic review and meta-analysis may be premature, as the current evidence lacks the rigor necessary for definitive conclusions.

5. Conclusions

PCL in pediatric surgery may stabilize blood glucose, reduce metabolic risks, improve recovery, and minimize postoperative complications. However, evidence on safety and outcomes, such as hospital stay length and postoperative complications, remains inconsistent, highlighting the need for further research to refine PCL protocols for pediatric care.

Ethics and consent

Ethical approval and consent were not required.

Data availability

Underlying data

No underlying data are associated with this article.

Extended data

Open Science Framework: Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Evidence, DOI: https://doi.org/10.17605/OSF.IO/KPNV5.²⁴

This project contains the following extended data: truncated search results from various databases and a full electronic search strategy for at least one database including any limits used.

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Reporting guidelines

Open Science Framework: Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Evidence, DOI: https://doi.org/10.17605/OSF.IO/KPNV5.²⁴

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

References

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2. Nygren J, Thorell A, Ljungqvist O: Preoperative oral carbohydrate therapy. Curr. Opin. Anaesthesiol. 2015 Jun; 28(3): 364–369. Publisher Full Text
3. Rafeeqi T, Pearson EG: Enhanced recovery after surgery in children. Transl. Gastroenterol. Hepatol. 2021; 6: 46. PubMed Abstract | Publisher Full Text | Free Full Text
4. Chen L, Wang N, Xie G, et al.: The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial. BMC Anesthesiol. 2024; 24(1): 1–10. Publisher Full Text
5. Kumar SM, Anandhi A, Sureshkumar S, et al.: Effect of preoperative oral carbohydrate loading on postoperative insulin resistance, patient-perceived well-being, and surgical outcomes in elective colorectal surgery: a randomized controlled trial. J. Gastrointest. Surg. 2024 Oct; 28(10): 1654–1660. PubMed Abstract | Publisher Full Text Reference Source
6. Wang X, Zhuang J, Cheng J, et al.: Effect of preoperative oral carbohydrates on insulin resistance in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial. Langenbeck’s Arch. Surg. 2024; 409(1): 77–79. PubMed Abstract | Publisher Full Text | Free Full Text
7. Raval MV, Brockel MA, Kolaček S, et al.: Key Strategies for Optimizing Pediatric Perioperative Nutrition-Insight from a Multidisciplinary Expert Panel. Nutrients. 2023 Mar; 15(5). PubMed Abstract | Publisher Full Text | Free Full Text
8. Laird A, Bramley L, Barnes R, et al.: Effects of a Preoperative Carbohydrate Load on Postoperative Recovery in Children: A Randomised, Double-Blind, Placebo-Controlled Trial. J. Pediatr. Surg. 2023; 58(9): 1824–1831. PubMed Abstract | Publisher Full Text
9. Jiang W, Liu X, Liu F, et al.: Safety and benefit of pre-operative oral carbohydrate in infants: A multi-center study in China. Asia Pac. J. Clin. Nutr. 2018; 27(5): 975–979. PubMed Abstract | Publisher Full Text
10. Carvalho CAL d B, de Carvalho AA , Preza AD, et al.: Metabolic and inflammatory benefits of reducing preoperative fasting time in pediatric surgery. Rev. Col. Bras. Cir. 2020; 47(1): 1–10.
11. Bharadwaj AA, Bhukal I, Mathew PJ: Effect of Oral 12% Carbohydrate Containing Clear Fluid in Children on Post-anaesthesia Recovery Profile- A Randomised Clinical Trial. J. Clin. Diagn. Res. 2021; 10–13. Publisher Full Text
12. Balasubramaniam U, Kiran U, Hasija S, et al.: Randomized Study Comparing Pre-Operative Glycemic Profile in Pediatric Cardiac Surgical Patients Administered Oral Carbohydrate Solution Preoperatively versus Those Kept Fasting. World J. Cardiovasc. Dis. 2018; 08(06): 298–306. Publisher Full Text
13. Karami T, Karami N, Hoshyar H, et al.: Evaluation of Effect of Preoperative Oral Carbohydrate on the Perioperative Agitation in Pediatrics Undergoing Elective Herniorrhaphy; A Doubl-Blind Randomized Clinical Trial. Int. J. Pediatr. 2021; 9(1): 12815–12823. Reference Source
14. Bozoglu Akgun B, Hatipoglu Z, Gulec E, et al.: The Effect of Oral Fluid Administration 1 Hour before Surgery on Preoperative Anxiety and Gastric Volume in Pediatric Patients. Eur. Surg. Res. 2024; 65(1): 54–59. PubMed Abstract | Publisher Full Text
15. Huang X, Zhang H, Lin Y, et al.: Effect of oral glucose water administration 1 hour preoperatively in children with cyanotic congenital heart disease: A randomized controlled trial. Med. Sci. Monit. 2020; 26: 1–6.
16. Tudor-Drobjewski BA, Marhofer P, Kimberger O, et al.: Randomised controlled trial comparing preoperative carbohydrate loading with standard fasting in paediatric anaesthesia. Br. J. Anaesth. 2018; 121(3): 656–661. PubMed Abstract | Publisher Full Text
17. Zhang YL, Li H, Zeng H, et al.: Ultrasonographic evaluation of gastric emptying after ingesting carbohydrate-rich drink in young children: A randomized crossover study. Paediatr. Anaesth. 2020; 30(5): 599–606. PubMed Abstract | Publisher Full Text
18. Bauer JM, Trask M, Coughlin G, et al.: Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform [Internet]. 2024; 12(5):1283–1287. PubMed Abstract | Publisher Full Text
19. Frykholm P, Disma N, Andersson H, et al.: Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur. J. Anaesthesiol. 2022 Jan; 39(1): 4–25. PubMed Abstract | Publisher Full Text
20. Joshi GP, Abdelmalak BB, Weigel WA, et al.: 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration - A Modular Update of the 2017 American Society of Anesthes. Anesthesiology. 2023; 138(2): 132–151. PubMed Abstract | Publisher Full Text
21. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Ta. Anesthesiology. 2017 Mar; 126(3): 376–393. PubMed Abstract | Publisher Full Text
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Version 3

VERSION 3 PUBLISHED 24 Sep 2024

Author details Author details

Yunita Widyastuti
Roles: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Djayanti Sari
Roles: Conceptualization, Methodology, Validation, Visualization, Writing – Review & Editing

Anisa Fadhila Farid
Roles: Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Amar Rayhan
Roles: Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This author is supported by the Damas Community Fund Grant Hibah DAMAS (Dana Masyakarat) FK-KMK UGM” with grant number “3030/UNI/FKKMK 1.3/PPKE/PT/2024
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (3)

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© 2024 Widyastuti Y et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Widyastuti Y, Sari D, Fadhila Farid A and Rayhan A. Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials [version 3; peer review: 1 approved, 2 approved with reservations]. F1000Research 2024, 13:1089 (https://doi.org/10.12688/f1000research.156172.3)

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Key to Reviewer Statuses VIEW HIDE

ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 3

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Reviewer Report 12 Feb 2025

Kalyani Patil, Bharati Vidyapeeth (Deemed to be) University Medical College, Pune, India; Anaesthesia and Pain Medicine., Bharati Hospital, Pune, Maharashtra, India

Approved with Reservations

https://doi.org/10.5256/f1000research.176192.r361303

Major:

The search strategy is well described and includes all important databases.

However there are no details of how the results of all studies were statistically analysed for the common outcomes.

The results only mention the number of studies having a particular finding.

There is no detailed mention of a comprehensive quantitative analysis of a particular outcome.

Forest plot can be included for common and important outcomes as it would make the article more relevant and the findings more objective.

The limitation mentions "publication bias" may exist. I suggest that the authors analyse the publication bias using a funnel plot. It would definitely add more value to the article.

Minor:
The article is relevant and has attempted well to answer the research gap on a topic that is so pertinent in paediatric anaesthesia and would bring a positive change in management and patient outcome.

The objective is clearly stated.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

No
Are the conclusions drawn adequately supported by the results presented in the review?

Yes
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Ultrasound guided Regional Anaesthesia; Perioperative Care, Simulation, Obstetric anaesthesia.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 13 Jan 2025

Maliwan Oofuvong, Prince of Songkla University, Songkhla, Thailand

Approved with Reservations

https://doi.org/10.5256/f1000research.176192.r357029

It is useful systemic review for application of fasting time with carbohydrate drink in pediatric surgery.
The result can be applied for clinical practice if the clearer methodology could be addressed.

1. What is the definition of preoperative carbohydrate loading? It sounds to have various of PCL intervention in the review:
Oral vs intravenous and carbohydrate vs dextrose in the intervention group (In Table 1 for 11 paper reviews). How many papers that intravenous intervention were given? Should the intervention confine only carbohydrate oral drink according to the title?

2. What was the age range included? The age range should be included in the Method section.

3. Result in page 13, #3 mentioned that "The studies included a diverse range of surgical procedures, with most focusing on elective operations such as abdominal, orthopedic, and cardiac surgeries". Why the authors included cardiac surgery in the systemic review since cardiac surgery encountered with hemodynamic instability, potential higher blood sugar and increase metabolic risk from cardiopulmonary bypass. It may induce the bias of result among intervention and control if different types of cardiac surgery were performed among groups and result from cardiac surgery may be incomparable with non cardiac surgery. How many studies of cardiac surgery had been included in the review?

4. # 3.5 Length of hospital stay (LOS)
Only the study of Laird (ref 8) reported the difference of LOS 26 min (135 vs 161 min) in day case surgery. Should the review separate between day case surgery or inpatient surgery? How many papers of day case surgery and inpatient surgery?

Minor comments
1. Figure 1 PRISMA flow diagram, at the screening process, reports assessed for eligibility of 396, reports excluded in total 249 papers, so reports should be remained for review 147, how come only 11 studies were included in the review.

2. According to paper 7, Huang (2020), study design of RCT, there was no information in the column of comparison group.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Yes
Are the conclusions drawn adequately supported by the results presented in the review?

Partly
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Pediatric and cardiac anesthesia.

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Reviewer Report 31 Dec 2024

Vibhavari Naik, Department of Oncoanaesthesia, Pain and Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India

Abhijit Sukumaran Nair, Ibra Hospital, Ibra, Ash Sharqiyah North Governorate, Oman

Approved

https://doi.org/10.5256/f1000research.176192.r351979

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Version 2

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PUBLISHED 26 Nov 2024

Revised

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Reviewer Report 12 Dec 2024

Vibhavari Naik, Department of Oncoanaesthesia, Pain and Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India

Abhijit Sukumaran Nair, Ibra Hospital, Ibra, Ash Sharqiyah North Governorate, Oman

Approved with Reservations

https://doi.org/10.5256/f1000research.173793.r343632

We thank authors for considering the suggestions and making changes to the draft. We have a few unaddressed concerns and would request the authors to consider them to improve the clarity and quality of the article.

1. The introduction part of abstract can be specific to mention the knowledge gap of 'preoperative carbohydrate loading in children' that the authors intend to address or why they have considered to conduct this topic for review.
2. The last line of Introduction section of the main article ‘Further studies are needed….’ is inappropriate for Introduction section. Introduction should end with authors mentioning why they conducted this scoping review or what this scoping review aims to address.
3. In Search strategy, ‘Databases to be searched include’ can be replaced by ‘Databases searched included’
4. In results section, ‘An additional’ needs to be removed. And {number of excluded records]’ should be replaced by the actual number. ‘The scoping review……in paediatric surgery’ is duplicated.
5. Table legends should include the short forms used in the tables.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Vibhavari Naik - oncoanaesthesia, paediatric anaesthesia, vascular access; Abhijit Nair - statistics and research methodology, systematic reviews

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

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Reviewer Report 18 Oct 2024

Vibhavari Naik, Department of Oncoanaesthesia, Pain and Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India

Abhijit Sukumaran Nair, Ibra Hospital, Ibra, Ash Sharqiyah North Governorate, Oman

Approved with Reservations

https://doi.org/10.5256/f1000research.171447.r327893

Overall – The authors have selected a pertinent topic for a scoping review. Although the concept and components of ERAS have been adopted from adult practice, evidence needs to be established to justify its role in paediatric care. In this article, the authors have evaluated the evidence regarding the use of preoperative carbohydrate loading as a component of ERAS in children.

The authors mention this as a scoping review but the methodology has overlapped with a systematic review. The inclusion of a risk of bias assessment in this study suggests a more rigorous approach typically used with systematic reviews. This being a scoping review authors should intend to provide an overview of the existing evidence including gaps in literature and determine if systematic review is required. Literature review for a scoping review apart from RCTs, should also include case reports, case series, observational studies, guidelines, blogs, etc. Alternatively, since most of the included studies are RCTs, authors could choose to perform a qualitative systematic review and a possible quantitative meta-analysis. But this would require following the stringent PRISMA methodology including study registration.

Title - is clear and informative and includes the mention of scoping review

Abstract - is structured and conveys the gist of the review. The introduction part of the abstract could end with the objective of the review. In the methods section of abstract, future tense phrases like ‘would be used’ and ‘would focus’ could be changed to past tense like ‘was used’ and ‘was focused’. The authors mention ‘recent’ articles but have not explained what recent means.

Introduction – Authors could write introduction more crisply by avoiding repetition of enhancing patient comfort and improving outcomes; and reducing the content on adult population. It broadly could include what is available in literature about paediatric preoperative carbohydrate loading and end with what this review aims to achieve.

Methods – The PRISMA-ScR reporting guidelines could be accessed at Open Science Framework platform. But the authors have not mentioned if the protocol for the review exists, registration of the protocol and the link to the same.

A formal risk of bias assessment may not be necessary for scoping reviews.

Future tense of methodology needs to be changed to past tense throughout the methods section. Ex. The selection process will involved, Full-text articles would be reviewed, etc.

Eligibility criteria – includes the word ‘recent’ the time duration of which has not been explained.

The authors must provide truncations of the search results from various databases in a supplementary file. They could present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. Authors could include the date of database search.

Figure 1 PRISMA flow diagram mentions - Records excluded** Authors could mention what two asterisks stand for in the footnote of the figure mentioning the reason for exclusion. Authors mention ‘Reports not retrieved’ but have not mentioned the reason for non-retrieval. Authors mention 240 reports excluded after assessing for eligibility from 365 reports. However only 10 articles are included in review. Authors need to mention the reasons for excluding 115 articles.

Clarity on how many reviewers contributed to data charting will be useful instead of mentioning ‘multiple’.

Results – Table 1 legends should include expansion of short forms used in the table.

Length of stay – though authors mention inconsistency in results, the results appear to be consistent in studies not demonstrating clinically relevant difference amongst the groups. This could be restructured.

Carvalho in their abstract mention - Four patients (21%) in the fasting group but none in the CHO group were hyperglycemic before surgery (p = 0.04). This has been missed while compiling this review.

We have found a few relevant studies which were not included in this review. Could authors provide an explanation for the same?

Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report. Anaesthesiol Intensive Ther. 2014 Apr-Jun;46(2):61-4.
Bauer JM, Trask M, Coughlin G, Gopalan M, Gupta A, Yaszay B, Yang S, Grigg E. Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform. 2024 Sep;12(5):1283-1287.

Discussion – Authors mention that - Studies consistently demonstrated that PCL helps maintain higher yet stable blood glucose levels. However, Bharadwaj et al show lower glucose levels in children receiving PCL. The effect of PCL on glucose levels could be rewritten as inconsistent. Authors could highlight and explore the inconsistency in glucose levels after PCL and identify if any factors like duration of fasting affected it.

In Laird et al. difference of ketones by 0.1 and lactates by 0.3 mmol/L with overlapping ranges though may be statistically significant, the clinical relevance of such small differences may not be relevant. Authors could highlight such trivial ‘statistically significant’ results across all the articles included and explore the clinical relevance in the discussion of this review.

Authors could include a mention of recently published meta-analysis on the topic and compare results - Li Y, Chen L, Su Y, Zhang X. Preoperative Oral Carbohydrates for Children: A Meta-Analysis and Systematic Review. Biol Res Nurs. 2024 Oct;26(4):624-635.

Scoping reviews can have the following biases: language, search, data extraction, reporting, reviewer, publication, and selection bias. Authors need to mention these in the limitations including steps taken to mitigate them.

Few areas of spelling mistakes and improvement of grammar would be required.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Partly
Are the conclusions drawn adequately supported by the results presented in the review?

No
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

References

1. Carvalho CALB, Carvalho AA, Preza ADG, Nogueira PLB, et al.: Metabolic and Inflammatory Benefits of Reducing Preoperative Fasting Time in Pediatric Surgery.Rev Col Bras Cir. 2020; 47: e20202353 PubMed Abstract | Publisher Full Text
2. Gawecka A, Mierzewska-Schmidt M: Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report.Anaesthesiol Intensive Ther. 2014; 46 (2): 61-4 PubMed Abstract | Publisher Full Text
3. Li Y, Chen L, Su Y, Zhang X: Preoperative Oral Carbohydrates for Children: A Meta-Analysis and Systematic Review.Biol Res Nurs. 2024; 26 (4): 624-635 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Vibhavari Naik - oncoanaesthesia, paediatric anaesthesia, vascular access; Abhijit Nair - statistics and research methodology, systematic reviews

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Author Response 26 Nov 2024

Amar Rayhan, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Dr. Sardjito General Hospital, Gadjah Mada University, Yogyakarta, Indonesia

26 Nov 2024

Author Response
Thank you for your insightful feedback and constructive comments on our manuscript. We appreciate the opportunity to improve our work and have made significant revisions based on your suggestions. In ... Continue reading
Thank you for your insightful feedback and constructive comments on our manuscript. We appreciate the opportunity to improve our work and have made significant revisions based on your suggestions. In response, we have made the following adjustments:

Overall
Comment from reviewer :
The authors have selected a pertinent topic for a scoping review. Although the concept and components of ERAS have been adopted from adult practice, evidence needs to be established to justify its role in paediatric care. In this article, the authors have evaluated the evidence regarding the use of preoperative carbohydrate loading as a component of ERAS in children
Respond:
We already added the narrative review about ERAS in pediatric including Preoperative Carbohydrat loading as part of ERAS in pediatric

Comment from reviewer :
The authors mention this as a scoping review but the methodology has overlapped with a systematic review. The inclusion of a risk of bias assessment in this study suggests a more rigorous approach typically used with systematic reviews. This being a scoping review authors should intend to provide an overview of the existing evidence including gaps in literature and determine if systematic review is required. Literature review for a scoping review apart from RCTs, should also include case reports, case series, observational studies, guidelines, blogs, etc. Alternatively, since most of the included studies are RCTs, authors could choose to perform a qualitative systematic review and a possible quantitative meta-analysis. But this would require following the stringent PRISMA methodology including study registration
Respond:
Thank you for your feedback, according the scope and methodology we have revised some parts:

The title and eligibility criteria have been revised to "Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials" to clarify the focus and methodology of the study. This adjustment emphasizes our intent to provide an overview of existing evidence while addressing gaps in the literature surrounding the topic.

Our scoping review now specifies clinical trials research, prompting us to revise the methodology. The RoB (Risk of Bias) tool from Cochrane was chosen to evaluate the critical appraisal of included clinical studies.

Title
Comment from reviewer :
- is clear and informative and includes the mention of scoping review
Respond:
Thank you very much

Abstract
Comment from reviewer :
is structured and conveys the gist of the review. The introduction part of the abstract could end with the objective of the review. In the methods section of abstract, future tense phrases like ‘would be used’ and ‘would focus’ could be changed to past tense like ‘was used’ and ‘was focused’. The authors mention ‘recent’ articles but have not explained what recent means
Respond:
Thank you for your comment, we have adjusted some parts :

The objective has been repositioned in the introduction.

We have improved the methods section.

The term ‘recent’ has been changed to “2017-2024.”

Grammatical errors have been fixed in the method section

Introduction
Comment from reviewer :
Authors could write introduction more crisply by avoiding repetition of enhancing patient comfort and improving outcomes; and reducing the content on adult population. It broadly could include what is available in literature about paediatric preoperative carbohydrate loading and end with what this review aims to achieve.
Respond:

We reduced content related to the adult population and add more pediatric content

Methods
Comment from reviewer;

The PRISMA-ScR reporting guidelines could be accessed at Open Science Framework platform. But the authors have not mentioned if the protocol for the review exists, registration of the protocol and the link to the same.

A formal risk of bias assessment may not be necessary for scoping reviews.

Future tense of methodology needs to be changed to past tense throughout the methods section. Ex. The selection process will involved, Full-text articles would be reviewed, etc.

Eligibility criteria – includes the word ‘recent’ the time duration of which has not been explained.

The authors must provide truncations of the search results from various databases in a supplementary file. They could present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. Authors could include the date of database search.

Figure 1 PRISMA flow diagram mentions - Records excluded** Authors could mention what two asterisks stand for in the footnote of the figure mentioning the reason for exclusion. Authors mention ‘Reports not retrieved’ but have not mentioned the reason for non-retrieval. Authors mention 240 reports excluded after assessing for eligibility from 365 reports. However only 10 articles are included in review. Authors need to mention the reasons for excluding 115 articles.

Clarity on how many reviewers contributed to data charting will be useful instead of mentioning ‘multiple’.

Respond:
Thank you for your detailed feedback;

We have already included study protocol at OSF. Actually, we had added it prior submitting the manuscript but the editor asked us to remove the protocol file.

Thank you for your feedback. We agree that a formal risk of bias assessment may not be required for a scoping review. However, PRISMA-ScR guidelines recommend including a section for critical appraisal of the evidence. Although using RoB 2.0 is a formal approach, we believe it provides a thorough and reliable overview of study quality. Employing a trusted tool like RoB 2.0 allows us to gauge the clinical study quality in a structured way, enhancing the overall insight into the evidence included in our review.

Grammatical errors have been fixed.

The terms ‘recent’ and ‘multiple’ have been edited.

We have provided truncations of the search results from various databases in a supplementary file, including the full electronic search strategy for at least one database with specified limits and the date of the database search.

The PRISMA flowchart was revised to clarify the reasons for exclusion, noting that the asterisks in the footnote referred to a format picture that had not been deleted. Additionally, we included the reasons for excluding 385 articles from the initial assessment of 395 full-text articles.

The terms ‘recent’ and ‘multiple’ have been edited.

Results
Comment from reviewer;

Table 1 legends should include expansion of short forms used in the table.

Length of stay – though authors mention inconsistency in results, the results appear to be consistent in studies not demonstrating clinically relevant difference amongst the groups. This could be restructured.

Carvalho in their abstract mention - Four patients (21%) in the fasting group but none in the CHO group were hyperglycemic before surgery (p = 0.04). This has been missed while compiling this review.

We have found a few relevant studies which were not included in this review. Could authors provide an explanation for the same?

Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report. Anaesthesiol Intensive Ther. 2014 Apr-Jun;46(2):61-4.
Bauer JM, Trask M, Coughlin G, Gopalan M, Gupta A, Yaszay B, Yang S, Grigg E. Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform. 2024 Sep;12(5):1283-1287.

Respond:
Thank you for your thorough feedback;

We have added the expansions of all abbreviations and short forms used in Table 1 to the table legend, as suggested.

Regarding Length of Stay (LOS), we acknowledged the inconsistency in previous reports and agreed that the results should be restructured. The studies consistently showed no clinically meaningful difference in the length of hospital stay.

Preoperative hyperglycemia was added to the study characteristics table.

We excluded the study by Gawecka A et al. (2014) from our scoping review due to its publication year and added the study by Bauer JM et al. (2024).

Discussion
Comment from reviewer;

Authors mention that - Studies consistently demonstrated that PCL helps maintain higher yet stable blood glucose levels. However, Bharadwaj et al show lower glucose levels in children receiving PCL. The effect of PCL on glucose levels could be rewritten as inconsistent. Authors could highlight and explore the inconsistency in glucose levels after PCL and identify if any factors like duration of fasting affected it.

In Laird et al. difference of ketones by 0.1 and lactates by 0.3 mmol/L with overlapping ranges though may be statistically significant, the clinical relevance of such small differences may not be relevant. Authors could highlight such trivial ‘statistically significant’ results across all the articles included and explore the clinical relevance in the discussion of this review.

Authors could include a mention of recently published meta-analysis on the topic and compare results - Li Y, Chen L, Su Y, Zhang X. Preoperative Oral Carbohydrates for Children: A Meta-Analysis and Systematic Review. Biol Res Nurs. 2024 Oct;26(4):624-635.

Scoping reviews can have the following biases: language, search, data extraction, reporting, reviewer, publication, and selection bias. Authors need to mention these in the limitations including steps taken to mitigate them.

Respond:

We revised our analysis to emphasize the inconsistencies in blood glucose levels following preoperative carbohydrate loading (PCL), highlighting factors such as fasting duration. Additionally, we addressed trivial statistically significant findings, such as the small differences in blood ketones and lactates reported by Laird et al., to explore their clinical relevance.

The current meta-analysis was added and discussed.

We already included Chen et al. study

We explained the limitations of the study
Thank you for your insightful feedback and constructive comments on our manuscript. We appreciate the opportunity to improve our work and have made significant revisions based on your suggestions. In response, we have made the following adjustments:

Overall
Comment from reviewer :
The authors have selected a pertinent topic for a scoping review. Although the concept and components of ERAS have been adopted from adult practice, evidence needs to be established to justify its role in paediatric care. In this article, the authors have evaluated the evidence regarding the use of preoperative carbohydrate loading as a component of ERAS in children
Respond:
We already added the narrative review about ERAS in pediatric including Preoperative Carbohydrat loading as part of ERAS in pediatric

Comment from reviewer :
The authors mention this as a scoping review but the methodology has overlapped with a systematic review. The inclusion of a risk of bias assessment in this study suggests a more rigorous approach typically used with systematic reviews. This being a scoping review authors should intend to provide an overview of the existing evidence including gaps in literature and determine if systematic review is required. Literature review for a scoping review apart from RCTs, should also include case reports, case series, observational studies, guidelines, blogs, etc. Alternatively, since most of the included studies are RCTs, authors could choose to perform a qualitative systematic review and a possible quantitative meta-analysis. But this would require following the stringent PRISMA methodology including study registration
Respond:
Thank you for your feedback, according the scope and methodology we have revised some parts:

The title and eligibility criteria have been revised to "Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials" to clarify the focus and methodology of the study. This adjustment emphasizes our intent to provide an overview of existing evidence while addressing gaps in the literature surrounding the topic.

Our scoping review now specifies clinical trials research, prompting us to revise the methodology. The RoB (Risk of Bias) tool from Cochrane was chosen to evaluate the critical appraisal of included clinical studies.

Title
Comment from reviewer :
- is clear and informative and includes the mention of scoping review
Respond:
Thank you very much

Abstract
Comment from reviewer :
is structured and conveys the gist of the review. The introduction part of the abstract could end with the objective of the review. In the methods section of abstract, future tense phrases like ‘would be used’ and ‘would focus’ could be changed to past tense like ‘was used’ and ‘was focused’. The authors mention ‘recent’ articles but have not explained what recent means
Respond:
Thank you for your comment, we have adjusted some parts :

The objective has been repositioned in the introduction.

We have improved the methods section.

The term ‘recent’ has been changed to “2017-2024.”

Grammatical errors have been fixed in the method section

Introduction
Comment from reviewer :
Authors could write introduction more crisply by avoiding repetition of enhancing patient comfort and improving outcomes; and reducing the content on adult population. It broadly could include what is available in literature about paediatric preoperative carbohydrate loading and end with what this review aims to achieve.
Respond:

We reduced content related to the adult population and add more pediatric content

Methods
Comment from reviewer;

The PRISMA-ScR reporting guidelines could be accessed at Open Science Framework platform. But the authors have not mentioned if the protocol for the review exists, registration of the protocol and the link to the same.

A formal risk of bias assessment may not be necessary for scoping reviews.

Future tense of methodology needs to be changed to past tense throughout the methods section. Ex. The selection process will involved, Full-text articles would be reviewed, etc.

Eligibility criteria – includes the word ‘recent’ the time duration of which has not been explained.

The authors must provide truncations of the search results from various databases in a supplementary file. They could present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. Authors could include the date of database search.

Figure 1 PRISMA flow diagram mentions - Records excluded** Authors could mention what two asterisks stand for in the footnote of the figure mentioning the reason for exclusion. Authors mention ‘Reports not retrieved’ but have not mentioned the reason for non-retrieval. Authors mention 240 reports excluded after assessing for eligibility from 365 reports. However only 10 articles are included in review. Authors need to mention the reasons for excluding 115 articles.

Clarity on how many reviewers contributed to data charting will be useful instead of mentioning ‘multiple’.

Respond:
Thank you for your detailed feedback;

We have already included study protocol at OSF. Actually, we had added it prior submitting the manuscript but the editor asked us to remove the protocol file.

Thank you for your feedback. We agree that a formal risk of bias assessment may not be required for a scoping review. However, PRISMA-ScR guidelines recommend including a section for critical appraisal of the evidence. Although using RoB 2.0 is a formal approach, we believe it provides a thorough and reliable overview of study quality. Employing a trusted tool like RoB 2.0 allows us to gauge the clinical study quality in a structured way, enhancing the overall insight into the evidence included in our review.

Grammatical errors have been fixed.

The terms ‘recent’ and ‘multiple’ have been edited.

We have provided truncations of the search results from various databases in a supplementary file, including the full electronic search strategy for at least one database with specified limits and the date of the database search.

The PRISMA flowchart was revised to clarify the reasons for exclusion, noting that the asterisks in the footnote referred to a format picture that had not been deleted. Additionally, we included the reasons for excluding 385 articles from the initial assessment of 395 full-text articles.

The terms ‘recent’ and ‘multiple’ have been edited.

Results
Comment from reviewer;

Table 1 legends should include expansion of short forms used in the table.

Length of stay – though authors mention inconsistency in results, the results appear to be consistent in studies not demonstrating clinically relevant difference amongst the groups. This could be restructured.

Carvalho in their abstract mention - Four patients (21%) in the fasting group but none in the CHO group were hyperglycemic before surgery (p = 0.04). This has been missed while compiling this review.

We have found a few relevant studies which were not included in this review. Could authors provide an explanation for the same?

Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report. Anaesthesiol Intensive Ther. 2014 Apr-Jun;46(2):61-4.
Bauer JM, Trask M, Coughlin G, Gopalan M, Gupta A, Yaszay B, Yang S, Grigg E. Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform. 2024 Sep;12(5):1283-1287.

Respond:
Thank you for your thorough feedback;

We have added the expansions of all abbreviations and short forms used in Table 1 to the table legend, as suggested.

Regarding Length of Stay (LOS), we acknowledged the inconsistency in previous reports and agreed that the results should be restructured. The studies consistently showed no clinically meaningful difference in the length of hospital stay.

Preoperative hyperglycemia was added to the study characteristics table.

We excluded the study by Gawecka A et al. (2014) from our scoping review due to its publication year and added the study by Bauer JM et al. (2024).

Discussion
Comment from reviewer;

Authors mention that - Studies consistently demonstrated that PCL helps maintain higher yet stable blood glucose levels. However, Bharadwaj et al show lower glucose levels in children receiving PCL. The effect of PCL on glucose levels could be rewritten as inconsistent. Authors could highlight and explore the inconsistency in glucose levels after PCL and identify if any factors like duration of fasting affected it.

In Laird et al. difference of ketones by 0.1 and lactates by 0.3 mmol/L with overlapping ranges though may be statistically significant, the clinical relevance of such small differences may not be relevant. Authors could highlight such trivial ‘statistically significant’ results across all the articles included and explore the clinical relevance in the discussion of this review.

Authors could include a mention of recently published meta-analysis on the topic and compare results - Li Y, Chen L, Su Y, Zhang X. Preoperative Oral Carbohydrates for Children: A Meta-Analysis and Systematic Review. Biol Res Nurs. 2024 Oct;26(4):624-635.

Scoping reviews can have the following biases: language, search, data extraction, reporting, reviewer, publication, and selection bias. Authors need to mention these in the limitations including steps taken to mitigate them.

Respond:

We revised our analysis to emphasize the inconsistencies in blood glucose levels following preoperative carbohydrate loading (PCL), highlighting factors such as fasting duration. Additionally, we addressed trivial statistically significant findings, such as the small differences in blood ketones and lactates reported by Laird et al., to explore their clinical relevance.

The current meta-analysis was added and discussed.

We already included Chen et al. study

We explained the limitations of the study
Competing Interests: We declare that we have no competing interests that could be perceived as influencing our assessment of the article's validity or the significance of the peer review report. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 26 Nov 2024

Amar Rayhan, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Dr. Sardjito General Hospital, Gadjah Mada University, Yogyakarta, Indonesia

26 Nov 2024

Author Response
Thank you for your insightful feedback and constructive comments on our manuscript. We appreciate the opportunity to improve our work and have made significant revisions based on your suggestions. In ... Continue reading
Thank you for your insightful feedback and constructive comments on our manuscript. We appreciate the opportunity to improve our work and have made significant revisions based on your suggestions. In response, we have made the following adjustments:

Overall
Comment from reviewer :
The authors have selected a pertinent topic for a scoping review. Although the concept and components of ERAS have been adopted from adult practice, evidence needs to be established to justify its role in paediatric care. In this article, the authors have evaluated the evidence regarding the use of preoperative carbohydrate loading as a component of ERAS in children
Respond:
We already added the narrative review about ERAS in pediatric including Preoperative Carbohydrat loading as part of ERAS in pediatric

Comment from reviewer :
The authors mention this as a scoping review but the methodology has overlapped with a systematic review. The inclusion of a risk of bias assessment in this study suggests a more rigorous approach typically used with systematic reviews. This being a scoping review authors should intend to provide an overview of the existing evidence including gaps in literature and determine if systematic review is required. Literature review for a scoping review apart from RCTs, should also include case reports, case series, observational studies, guidelines, blogs, etc. Alternatively, since most of the included studies are RCTs, authors could choose to perform a qualitative systematic review and a possible quantitative meta-analysis. But this would require following the stringent PRISMA methodology including study registration
Respond:
Thank you for your feedback, according the scope and methodology we have revised some parts:

The title and eligibility criteria have been revised to "Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials" to clarify the focus and methodology of the study. This adjustment emphasizes our intent to provide an overview of existing evidence while addressing gaps in the literature surrounding the topic.

Our scoping review now specifies clinical trials research, prompting us to revise the methodology. The RoB (Risk of Bias) tool from Cochrane was chosen to evaluate the critical appraisal of included clinical studies.

Title
Comment from reviewer :
- is clear and informative and includes the mention of scoping review
Respond:
Thank you very much

Abstract
Comment from reviewer :
is structured and conveys the gist of the review. The introduction part of the abstract could end with the objective of the review. In the methods section of abstract, future tense phrases like ‘would be used’ and ‘would focus’ could be changed to past tense like ‘was used’ and ‘was focused’. The authors mention ‘recent’ articles but have not explained what recent means
Respond:
Thank you for your comment, we have adjusted some parts :

The objective has been repositioned in the introduction.

We have improved the methods section.

The term ‘recent’ has been changed to “2017-2024.”

Grammatical errors have been fixed in the method section

Introduction
Comment from reviewer :
Authors could write introduction more crisply by avoiding repetition of enhancing patient comfort and improving outcomes; and reducing the content on adult population. It broadly could include what is available in literature about paediatric preoperative carbohydrate loading and end with what this review aims to achieve.
Respond:

We reduced content related to the adult population and add more pediatric content

Methods
Comment from reviewer;

The PRISMA-ScR reporting guidelines could be accessed at Open Science Framework platform. But the authors have not mentioned if the protocol for the review exists, registration of the protocol and the link to the same.

A formal risk of bias assessment may not be necessary for scoping reviews.

Future tense of methodology needs to be changed to past tense throughout the methods section. Ex. The selection process will involved, Full-text articles would be reviewed, etc.

Eligibility criteria – includes the word ‘recent’ the time duration of which has not been explained.

The authors must provide truncations of the search results from various databases in a supplementary file. They could present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. Authors could include the date of database search.

Figure 1 PRISMA flow diagram mentions - Records excluded** Authors could mention what two asterisks stand for in the footnote of the figure mentioning the reason for exclusion. Authors mention ‘Reports not retrieved’ but have not mentioned the reason for non-retrieval. Authors mention 240 reports excluded after assessing for eligibility from 365 reports. However only 10 articles are included in review. Authors need to mention the reasons for excluding 115 articles.

Clarity on how many reviewers contributed to data charting will be useful instead of mentioning ‘multiple’.

Respond:
Thank you for your detailed feedback;

We have already included study protocol at OSF. Actually, we had added it prior submitting the manuscript but the editor asked us to remove the protocol file.

Thank you for your feedback. We agree that a formal risk of bias assessment may not be required for a scoping review. However, PRISMA-ScR guidelines recommend including a section for critical appraisal of the evidence. Although using RoB 2.0 is a formal approach, we believe it provides a thorough and reliable overview of study quality. Employing a trusted tool like RoB 2.0 allows us to gauge the clinical study quality in a structured way, enhancing the overall insight into the evidence included in our review.

Grammatical errors have been fixed.

The terms ‘recent’ and ‘multiple’ have been edited.

We have provided truncations of the search results from various databases in a supplementary file, including the full electronic search strategy for at least one database with specified limits and the date of the database search.

The PRISMA flowchart was revised to clarify the reasons for exclusion, noting that the asterisks in the footnote referred to a format picture that had not been deleted. Additionally, we included the reasons for excluding 385 articles from the initial assessment of 395 full-text articles.

The terms ‘recent’ and ‘multiple’ have been edited.

Results
Comment from reviewer;

Table 1 legends should include expansion of short forms used in the table.

Length of stay – though authors mention inconsistency in results, the results appear to be consistent in studies not demonstrating clinically relevant difference amongst the groups. This could be restructured.

Carvalho in their abstract mention - Four patients (21%) in the fasting group but none in the CHO group were hyperglycemic before surgery (p = 0.04). This has been missed while compiling this review.

We have found a few relevant studies which were not included in this review. Could authors provide an explanation for the same?

Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report. Anaesthesiol Intensive Ther. 2014 Apr-Jun;46(2):61-4.
Bauer JM, Trask M, Coughlin G, Gopalan M, Gupta A, Yaszay B, Yang S, Grigg E. Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform. 2024 Sep;12(5):1283-1287.

Respond:
Thank you for your thorough feedback;

We have added the expansions of all abbreviations and short forms used in Table 1 to the table legend, as suggested.

Regarding Length of Stay (LOS), we acknowledged the inconsistency in previous reports and agreed that the results should be restructured. The studies consistently showed no clinically meaningful difference in the length of hospital stay.

Preoperative hyperglycemia was added to the study characteristics table.

We excluded the study by Gawecka A et al. (2014) from our scoping review due to its publication year and added the study by Bauer JM et al. (2024).

Discussion
Comment from reviewer;

Authors mention that - Studies consistently demonstrated that PCL helps maintain higher yet stable blood glucose levels. However, Bharadwaj et al show lower glucose levels in children receiving PCL. The effect of PCL on glucose levels could be rewritten as inconsistent. Authors could highlight and explore the inconsistency in glucose levels after PCL and identify if any factors like duration of fasting affected it.

In Laird et al. difference of ketones by 0.1 and lactates by 0.3 mmol/L with overlapping ranges though may be statistically significant, the clinical relevance of such small differences may not be relevant. Authors could highlight such trivial ‘statistically significant’ results across all the articles included and explore the clinical relevance in the discussion of this review.

Authors could include a mention of recently published meta-analysis on the topic and compare results - Li Y, Chen L, Su Y, Zhang X. Preoperative Oral Carbohydrates for Children: A Meta-Analysis and Systematic Review. Biol Res Nurs. 2024 Oct;26(4):624-635.

Scoping reviews can have the following biases: language, search, data extraction, reporting, reviewer, publication, and selection bias. Authors need to mention these in the limitations including steps taken to mitigate them.

Respond:

We revised our analysis to emphasize the inconsistencies in blood glucose levels following preoperative carbohydrate loading (PCL), highlighting factors such as fasting duration. Additionally, we addressed trivial statistically significant findings, such as the small differences in blood ketones and lactates reported by Laird et al., to explore their clinical relevance.

The current meta-analysis was added and discussed.

We already included Chen et al. study

We explained the limitations of the study
Thank you for your insightful feedback and constructive comments on our manuscript. We appreciate the opportunity to improve our work and have made significant revisions based on your suggestions. In response, we have made the following adjustments:

Overall
Comment from reviewer :
The authors have selected a pertinent topic for a scoping review. Although the concept and components of ERAS have been adopted from adult practice, evidence needs to be established to justify its role in paediatric care. In this article, the authors have evaluated the evidence regarding the use of preoperative carbohydrate loading as a component of ERAS in children
Respond:
We already added the narrative review about ERAS in pediatric including Preoperative Carbohydrat loading as part of ERAS in pediatric

Comment from reviewer :
The authors mention this as a scoping review but the methodology has overlapped with a systematic review. The inclusion of a risk of bias assessment in this study suggests a more rigorous approach typically used with systematic reviews. This being a scoping review authors should intend to provide an overview of the existing evidence including gaps in literature and determine if systematic review is required. Literature review for a scoping review apart from RCTs, should also include case reports, case series, observational studies, guidelines, blogs, etc. Alternatively, since most of the included studies are RCTs, authors could choose to perform a qualitative systematic review and a possible quantitative meta-analysis. But this would require following the stringent PRISMA methodology including study registration
Respond:
Thank you for your feedback, according the scope and methodology we have revised some parts:

The title and eligibility criteria have been revised to "Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials" to clarify the focus and methodology of the study. This adjustment emphasizes our intent to provide an overview of existing evidence while addressing gaps in the literature surrounding the topic.

Our scoping review now specifies clinical trials research, prompting us to revise the methodology. The RoB (Risk of Bias) tool from Cochrane was chosen to evaluate the critical appraisal of included clinical studies.

Title
Comment from reviewer :
- is clear and informative and includes the mention of scoping review
Respond:
Thank you very much

Abstract
Comment from reviewer :
is structured and conveys the gist of the review. The introduction part of the abstract could end with the objective of the review. In the methods section of abstract, future tense phrases like ‘would be used’ and ‘would focus’ could be changed to past tense like ‘was used’ and ‘was focused’. The authors mention ‘recent’ articles but have not explained what recent means
Respond:
Thank you for your comment, we have adjusted some parts :

The objective has been repositioned in the introduction.

We have improved the methods section.

The term ‘recent’ has been changed to “2017-2024.”

Grammatical errors have been fixed in the method section

Introduction
Comment from reviewer :
Authors could write introduction more crisply by avoiding repetition of enhancing patient comfort and improving outcomes; and reducing the content on adult population. It broadly could include what is available in literature about paediatric preoperative carbohydrate loading and end with what this review aims to achieve.
Respond:

We reduced content related to the adult population and add more pediatric content

Methods
Comment from reviewer;

The PRISMA-ScR reporting guidelines could be accessed at Open Science Framework platform. But the authors have not mentioned if the protocol for the review exists, registration of the protocol and the link to the same.

A formal risk of bias assessment may not be necessary for scoping reviews.

Future tense of methodology needs to be changed to past tense throughout the methods section. Ex. The selection process will involved, Full-text articles would be reviewed, etc.

Eligibility criteria – includes the word ‘recent’ the time duration of which has not been explained.

The authors must provide truncations of the search results from various databases in a supplementary file. They could present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. Authors could include the date of database search.

Figure 1 PRISMA flow diagram mentions - Records excluded** Authors could mention what two asterisks stand for in the footnote of the figure mentioning the reason for exclusion. Authors mention ‘Reports not retrieved’ but have not mentioned the reason for non-retrieval. Authors mention 240 reports excluded after assessing for eligibility from 365 reports. However only 10 articles are included in review. Authors need to mention the reasons for excluding 115 articles.

Clarity on how many reviewers contributed to data charting will be useful instead of mentioning ‘multiple’.

Respond:
Thank you for your detailed feedback;

We have already included study protocol at OSF. Actually, we had added it prior submitting the manuscript but the editor asked us to remove the protocol file.

Thank you for your feedback. We agree that a formal risk of bias assessment may not be required for a scoping review. However, PRISMA-ScR guidelines recommend including a section for critical appraisal of the evidence. Although using RoB 2.0 is a formal approach, we believe it provides a thorough and reliable overview of study quality. Employing a trusted tool like RoB 2.0 allows us to gauge the clinical study quality in a structured way, enhancing the overall insight into the evidence included in our review.

Grammatical errors have been fixed.

The terms ‘recent’ and ‘multiple’ have been edited.

We have provided truncations of the search results from various databases in a supplementary file, including the full electronic search strategy for at least one database with specified limits and the date of the database search.

The PRISMA flowchart was revised to clarify the reasons for exclusion, noting that the asterisks in the footnote referred to a format picture that had not been deleted. Additionally, we included the reasons for excluding 385 articles from the initial assessment of 395 full-text articles.

The terms ‘recent’ and ‘multiple’ have been edited.

Results
Comment from reviewer;

Table 1 legends should include expansion of short forms used in the table.

Length of stay – though authors mention inconsistency in results, the results appear to be consistent in studies not demonstrating clinically relevant difference amongst the groups. This could be restructured.

Carvalho in their abstract mention - Four patients (21%) in the fasting group but none in the CHO group were hyperglycemic before surgery (p = 0.04). This has been missed while compiling this review.

We have found a few relevant studies which were not included in this review. Could authors provide an explanation for the same?

Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report. Anaesthesiol Intensive Ther. 2014 Apr-Jun;46(2):61-4.
Bauer JM, Trask M, Coughlin G, Gopalan M, Gupta A, Yaszay B, Yang S, Grigg E. Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform. 2024 Sep;12(5):1283-1287.

Respond:
Thank you for your thorough feedback;

We have added the expansions of all abbreviations and short forms used in Table 1 to the table legend, as suggested.

Regarding Length of Stay (LOS), we acknowledged the inconsistency in previous reports and agreed that the results should be restructured. The studies consistently showed no clinically meaningful difference in the length of hospital stay.

Preoperative hyperglycemia was added to the study characteristics table.

We excluded the study by Gawecka A et al. (2014) from our scoping review due to its publication year and added the study by Bauer JM et al. (2024).

Discussion
Comment from reviewer;

Authors mention that - Studies consistently demonstrated that PCL helps maintain higher yet stable blood glucose levels. However, Bharadwaj et al show lower glucose levels in children receiving PCL. The effect of PCL on glucose levels could be rewritten as inconsistent. Authors could highlight and explore the inconsistency in glucose levels after PCL and identify if any factors like duration of fasting affected it.

In Laird et al. difference of ketones by 0.1 and lactates by 0.3 mmol/L with overlapping ranges though may be statistically significant, the clinical relevance of such small differences may not be relevant. Authors could highlight such trivial ‘statistically significant’ results across all the articles included and explore the clinical relevance in the discussion of this review.

Authors could include a mention of recently published meta-analysis on the topic and compare results - Li Y, Chen L, Su Y, Zhang X. Preoperative Oral Carbohydrates for Children: A Meta-Analysis and Systematic Review. Biol Res Nurs. 2024 Oct;26(4):624-635.

Scoping reviews can have the following biases: language, search, data extraction, reporting, reviewer, publication, and selection bias. Authors need to mention these in the limitations including steps taken to mitigate them.

Respond:

We revised our analysis to emphasize the inconsistencies in blood glucose levels following preoperative carbohydrate loading (PCL), highlighting factors such as fasting duration. Additionally, we addressed trivial statistically significant findings, such as the small differences in blood ketones and lactates reported by Laird et al., to explore their clinical relevance.

The current meta-analysis was added and discussed.

We already included Chen et al. study

We explained the limitations of the study
Competing Interests: We declare that we have no competing interests that could be perceived as influencing our assessment of the article's validity or the significance of the peer review report. Close
Report a concern

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Version 3

VERSION 3 PUBLISHED 24 Sep 2024

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2	3
Version 3 (revision) 23 Dec 24	read	read	read
Version 2 (revision) 26 Nov 24	read
Version 1 24 Sep 24	read

Vibhavari Naik, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India

Abhijit Sukumaran Nair, Ibra Hospital, Ibra, Oman
Maliwan Oofuvong, Prince of Songkla University, Songkhla, Thailand
Kalyani Patil, Bharati Vidyapeeth (Deemed to be) University Medical College, Pune, India; Bharati Hospital, Pune, India

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Reviewer Report

3 Views

12 Feb 2025 | for Version 3

Kalyani Patil, Bharati Vidyapeeth (Deemed to be) University Medical College, Pune, India; Anaesthesia and Pain Medicine., Bharati Hospital, Pune, Maharashtra, India

3 Views Cite this report Responses(0)

Approved With Reservations

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

No
Are the conclusions drawn adequately supported by the results presented in the review?

Yes
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Ultrasound guided Regional Anaesthesia; Perioperative Care, Simulation, Obstetric anaesthesia.

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5 Views

13 Jan 2025 | for Version 3

Maliwan Oofuvong, Prince of Songkla University, Songkhla, Thailand

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Approved With Reservations

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Yes
Are the conclusions drawn adequately supported by the results presented in the review?

Partly
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Pediatric and cardiac anesthesia.

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6 Views

31 Dec 2024 | for Version 3

Vibhavari Naik, Department of Oncoanaesthesia, Pain and Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India

Abhijit Sukumaran Nair, Ibra Hospital, Ibra, Ash Sharqiyah North Governorate, Oman

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Approved

We are happy that authors have considered our suggestions and corrections. We commend the authors for undertaking a review on such a relevant and impactful topic. This review's primary strength lies in its comprehensive exploration of the effects of preoperative carbohydrate loading on metabolic parameters, gastric volume, and psychological comfort. The authors have clearly articulated the study's limitations and proposed valuable directions for future research. We recommend the acceptance of this article for indexing.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Vibhavari Naik - oncoanaesthesia, paediatric anaesthesia, vascular access; Abhijit Nair - statistics and research methodology, systematic reviews

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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9 Views

12 Dec 2024 | for Version 2

Vibhavari Naik, Department of Oncoanaesthesia, Pain and Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India

Abhijit Sukumaran Nair, Ibra Hospital, Ibra, Ash Sharqiyah North Governorate, Oman

9 Views Cite this report Responses(0)

Approved With Reservations

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Vibhavari Naik - oncoanaesthesia, paediatric anaesthesia, vascular access; Abhijit Nair - statistics and research methodology, systematic reviews

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Reviewer Report

41 Views

18 Oct 2024 | for Version 1

Vibhavari Naik, Department of Oncoanaesthesia, Pain and Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, India

Abhijit Sukumaran Nair, Ibra Hospital, Ibra, Ash Sharqiyah North Governorate, Oman

41 Views Cite this report Responses(1)

Approved With Reservations

Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report. Anaesthesiol Intensive Ther. 2014 Apr-Jun;46(2):61-4.
Bauer JM, Trask M, Coughlin G, Gopalan M, Gupta A, Yaszay B, Yang S, Grigg E. Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform. 2024 Sep;12(5):1283-1287.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Partly
Are the conclusions drawn adequately supported by the results presented in the review?

No
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Vibhavari Naik - oncoanaesthesia, paediatric anaesthesia, vascular access; Abhijit Nair - statistics and research methodology, systematic reviews

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Author Response

26 Nov 2024

Amar Rayhan, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Public Health and Nursing, Dr. Sardjito General Hospital, Gadjah Mada University, Yogyakarta, Indonesia

Thank you for your insightful feedback and constructive comments on our manuscript. We appreciate the opportunity to improve our work and have made significant revisions based on your suggestions. In response, we have made the following adjustments:

Overall
Comment from reviewer :
The authors have selected a pertinent topic for a scoping review. Although the concept and components of ERAS have been adopted from adult practice, evidence needs to be established to justify its role in paediatric care. In this article, the authors have evaluated the evidence regarding the use of preoperative carbohydrate loading as a component of ERAS in children
Respond:
We already added the narrative review about ERAS in pediatric including Preoperative Carbohydrat loading as part of ERAS in pediatric

Comment from reviewer :
The authors mention this as a scoping review but the methodology has overlapped with a systematic review. The inclusion of a risk of bias assessment in this study suggests a more rigorous approach typically used with systematic reviews. This being a scoping review authors should intend to provide an overview of the existing evidence including gaps in literature and determine if systematic review is required. Literature review for a scoping review apart from RCTs, should also include case reports, case series, observational studies, guidelines, blogs, etc. Alternatively, since most of the included studies are RCTs, authors could choose to perform a qualitative systematic review and a possible quantitative meta-analysis. But this would require following the stringent PRISMA methodology including study registration
Respond:
Thank you for your feedback, according the scope and methodology we have revised some parts:

The title and eligibility criteria have been revised to "Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials" to clarify the focus and methodology of the study. This adjustment emphasizes our intent to provide an overview of existing evidence while addressing gaps in the literature surrounding the topic.
Our scoping review now specifies clinical trials research, prompting us to revise the methodology. The RoB (Risk of Bias) tool from Cochrane was chosen to evaluate the critical appraisal of included clinical studies.

Title
Comment from reviewer :
- is clear and informative and includes the mention of scoping review
Respond:
Thank you very much

Abstract
Comment from reviewer :
is structured and conveys the gist of the review. The introduction part of the abstract could end with the objective of the review. In the methods section of abstract, future tense phrases like ‘would be used’ and ‘would focus’ could be changed to past tense like ‘was used’ and ‘was focused’. The authors mention ‘recent’ articles but have not explained what recent means
Respond:
Thank you for your comment, we have adjusted some parts :

The objective has been repositioned in the introduction.
We have improved the methods section.
The term ‘recent’ has been changed to “2017-2024.”
Grammatical errors have been fixed in the method section

Introduction
Comment from reviewer :
Authors could write introduction more crisply by avoiding repetition of enhancing patient comfort and improving outcomes; and reducing the content on adult population. It broadly could include what is available in literature about paediatric preoperative carbohydrate loading and end with what this review aims to achieve.
Respond:

We reduced content related to the adult population and add more pediatric content

Methods
Comment from reviewer;

The PRISMA-ScR reporting guidelines could be accessed at Open Science Framework platform. But the authors have not mentioned if the protocol for the review exists, registration of the protocol and the link to the same.
A formal risk of bias assessment may not be necessary for scoping reviews.
Future tense of methodology needs to be changed to past tense throughout the methods section. Ex. The selection process will involved, Full-text articles would be reviewed, etc.
Eligibility criteria – includes the word ‘recent’ the time duration of which has not been explained.
The authors must provide truncations of the search results from various databases in a supplementary file. They could present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. Authors could include the date of database search.
Figure 1 PRISMA flow diagram mentions - Records excluded** Authors could mention what two asterisks stand for in the footnote of the figure mentioning the reason for exclusion. Authors mention ‘Reports not retrieved’ but have not mentioned the reason for non-retrieval. Authors mention 240 reports excluded after assessing for eligibility from 365 reports. However only 10 articles are included in review. Authors need to mention the reasons for excluding 115 articles.
Clarity on how many reviewers contributed to data charting will be useful instead of mentioning ‘multiple’.

Respond:
Thank you for your detailed feedback;

We have already included study protocol at OSF. Actually, we had added it prior submitting the manuscript but the editor asked us to remove the protocol file.
Thank you for your feedback. We agree that a formal risk of bias assessment may not be required for a scoping review. However, PRISMA-ScR guidelines recommend including a section for critical appraisal of the evidence. Although using RoB 2.0 is a formal approach, we believe it provides a thorough and reliable overview of study quality. Employing a trusted tool like RoB 2.0 allows us to gauge the clinical study quality in a structured way, enhancing the overall insight into the evidence included in our review.
Grammatical errors have been fixed.
The terms ‘recent’ and ‘multiple’ have been edited.
We have provided truncations of the search results from various databases in a supplementary file, including the full electronic search strategy for at least one database with specified limits and the date of the database search.
The PRISMA flowchart was revised to clarify the reasons for exclusion, noting that the asterisks in the footnote referred to a format picture that had not been deleted. Additionally, we included the reasons for excluding 385 articles from the initial assessment of 395 full-text articles.
The terms ‘recent’ and ‘multiple’ have been edited.

Results
Comment from reviewer;

Table 1 legends should include expansion of short forms used in the table.
Length of stay – though authors mention inconsistency in results, the results appear to be consistent in studies not demonstrating clinically relevant difference amongst the groups. This could be restructured.
Carvalho in their abstract mention - Four patients (21%) in the fasting group but none in the CHO group were hyperglycemic before surgery (p = 0.04). This has been missed while compiling this review.
We have found a few relevant studies which were not included in this review. Could authors provide an explanation for the same?

Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report. Anaesthesiol Intensive Ther. 2014 Apr-Jun;46(2):61-4.
Bauer JM, Trask M, Coughlin G, Gopalan M, Gupta A, Yaszay B, Yang S, Grigg E. Pre-operative carbohydrate drink in pediatric spine fusion: randomized control trial. Spine Deform. 2024 Sep;12(5):1283-1287.

Respond:
Thank you for your thorough feedback;

We have added the expansions of all abbreviations and short forms used in Table 1 to the table legend, as suggested.
Regarding Length of Stay (LOS), we acknowledged the inconsistency in previous reports and agreed that the results should be restructured. The studies consistently showed no clinically meaningful difference in the length of hospital stay.
Preoperative hyperglycemia was added to the study characteristics table.
We excluded the study by Gawecka A et al. (2014) from our scoping review due to its publication year and added the study by Bauer JM et al. (2024).

Discussion
Comment from reviewer;

Authors mention that - Studies consistently demonstrated that PCL helps maintain higher yet stable blood glucose levels. However, Bharadwaj et al show lower glucose levels in children receiving PCL. The effect of PCL on glucose levels could be rewritten as inconsistent. Authors could highlight and explore the inconsistency in glucose levels after PCL and identify if any factors like duration of fasting affected it.
In Laird et al. difference of ketones by 0.1 and lactates by 0.3 mmol/L with overlapping ranges though may be statistically significant, the clinical relevance of such small differences may not be relevant. Authors could highlight such trivial ‘statistically significant’ results across all the articles included and explore the clinical relevance in the discussion of this review.
Authors could include a mention of recently published meta-analysis on the topic and compare results - Li Y, Chen L, Su Y, Zhang X. Preoperative Oral Carbohydrates for Children: A Meta-Analysis and Systematic Review. Biol Res Nurs. 2024 Oct;26(4):624-635.
Scoping reviews can have the following biases: language, search, data extraction, reporting, reviewer, publication, and selection bias. Authors need to mention these in the limitations including steps taken to mitigate them.

Respond:

We revised our analysis to emphasize the inconsistencies in blood glucose levels following preoperative carbohydrate loading (PCL), highlighting factors such as fasting duration. Additionally, we addressed trivial statistically significant findings, such as the small differences in blood ketones and lactates reported by Laird et al., to explore their clinical relevance.
The current meta-analysis was added and discussed.
We already included Chen et al. study
We explained the limitations of the study

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Competing Interests

We declare that we have no competing interests that could be perceived as influencing our assessment of the article's validity or the significance of the peer review report.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Preoperative Carbohydrate Loading in Pediatric Surgery: A Scoping Review of Current Clinical Trials

Abstract

Abstract

Introduction

Methods

Results

Conclusions

Keywords

Revised Amendments from Version 2

1. Introduction

2. Methods

2.1 Research quesition

2.2 Search strategy

2.3 Eligiblity criteria

2.4 Data selection and extraction

2.5 Risk of bias

3. Results

Figure 1. PRISMA flow diagram.

Table 1. Study Characteristics.

Figure 2. RoB 2.0 traffic light plot.

Figure 3. RoB 2.0 summary plot.

3.1 Metabolic effects

3.2 Preoperative anxiety and agitation

3.3 Stomach content

3.4 Postoperative complications

3.5 Length of hospital stay

4. Discussion

5. Conclusions

Ethics and consent

Data availability

Underlying data

Extended data

Reporting guidelines

References

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