Surgery through the spectrum: Behavioral and analgesic outcomes in children with autism

Children with autism spectrum disorder (ASD) may experience communication differences and sensory sensitivities relevant to perioperative care. Evidence comparing perioperative outcomes and opioid prescribing practices in this population is limited. We evaluated the perioperative course and discharge opioid prescribing patterns in children with ASD versus matched neurotypical peers undergoing ambulatory surgery.

We conducted a retrospective matched cohort study (June 1, 2015-June 1, 2025) of children <18 years undergoing ambulatory surgery at a tertiary pediatric hospital. ASD patients were matched 1:2 with neurotypical controls by age, sex, American Society of Anesthesiologists (ASA) classification, and procedure type. Communication and behavioral characteristics reflected documented history; controls were selected to exclude neurodevelopmental diagnoses. Outcomes included perioperative agitation, recovery time, unplanned admission, and discharge opioid prescribing. Opioid doses were converted to morphine milligram equivalents (MME). Group comparisons used chi-square/Fisher exact and Wilcoxon rank-sum tests.

Forty-five ASD patients and 90 controls were included. Preoperative agitation (11.1 % vs 1.1 %) and benzodiazepine use (11.1 % vs 1.1 %) were more common in the ASD group (p = 0.016). Pain scores, recovery duration, and postoperative analgesic use were similar. Unplanned admission occurred only in the ASD group (6.7 % vs 0 %, p = 0.02), exclusively for agitation. ASD patients were less likely to receive an opioid prescription (13.3 % vs 31.1 %, p = 0.03), with comparable MME among those prescribed (p = 0.82).

Children with ASD undergoing ambulatory surgery demonstrate similar postoperative pain outcomes and comparable opioid doses when prescribed. Higher perioperative agitation and unplanned admissions support individualized preparation and sensory-aware strategies to promote equitable recovery.