Perioperative Nutritional Optimization in Complex Pediatric Hip and Spine Surgery: A Systematic Review

Introduction: Pediatric orthopaedic surgeries for complex hip and spine conditions, particularly in children with cerebral palsy, are associated with high complication rates. Malnutrition, common in this population, contributes to poor wound healing, infections, and prolonged recovery. Despite its impact, definitions and assessments of malnutrition remain inconsistent. Posterior spinal fusion and hip reconstruction carry complication rates over 50%. While interest in nutritional optimization is growing, no standardized approach exists, especially in pediatric orthopaedic populations. The purpose of this study was to evaluate the existing literature on perioperative nutritional assessment and optimization of pediatric patients undergoing complex hip and spine surgery. Methods: We conducted a PRISMA-compliant systematic review of MEDLINE, Embase, and Cochrane databases in April 2025. Inclusion criteria were studies on patients 21 years or younger undergoing hip or spine surgery that reported perioperative nutritional status or interventions alongside clinical outcomes. Eligible study designs included RCTs, cohort studies, and case series (>10 patients). Data were independently extracted and study quality assessed using the Newcastle-Ottawa Scale (NOS). Results: Out of 371 studies, 23 met the inclusion criteria. Eighteen were retrospective cohorts, 1 prospective cohort, 2 cross-sectional, and 2 case-control studies. Fifteen were high quality (NOS ≥7). Thirteen studies (57%) examined laboratory-based markers; 10 (43%) assessed nutritional interventions or classifications. Common outcomes included wound complications (48%), respiratory complications (26%), LOS/readmissions (26%), and patient-reported outcomes (17%). Laboratory findings were inconsistent, though transferrin <200 mg/dL was linked to respiratory risk. BMI-based metrics better predicted complications, especially in those who were underweight or experiencing >10% weight loss. Enhanced recovery after surgery (ERAS) protocols improved LOS, pain, and IL-6 levels, while routine nutrition assessments showed no clear benefit. Conclusion: While isolated laboratory values are inconsistent predictors, underweight status and weight loss are more reliable indicators of risk. ERAS protocols incorporating nutritional strategies may improve outcomes, although more pediatric-focused data are needed. The lack of standardized malnutrition definitions across studies limits comparability. Future research should establish uniform nutritional screening practices and evaluate specific interventions in high-risk pediatric orthopaedic populations. Despite limitations in study heterogeneity and small sample sizes, this review supports integrating structured perioperative nutrition into care pathways.