Commentary on “The effects of coffee versus gum chewing after cesarean on bowel functions”

Dear Editor, We read with interest the systematic review and network meta-analysis by Gao et al, who compared coffee intake with gum chewing for postoperative bowel recovery after cesarean section[1]. By pooling 20 randomized trials, they provide quantitative estimates for time to first defecation, flatus and bowel sounds, as well as length of stay and complications. This synthesis is timely and supports the broader implementation of Enhanced Recovery After Surgery (ERAS) pathways in obstetric care. This correspondence adheres to the TITAN Guidelines 2025 for the declaration and use of artificial intelligence in scholarly manuscripts[2]. First, interpretation of the network meta-analysis should be considered in the context of heterogeneous perioperative care. Across the included trials, anesthetic techniques, as well as the dose, timing, and formulation of coffee and chewing gum, varied substantially, and postoperative feeding strategies also differed in some studies. Analgesic regimens, early mobilization, and other ERAS-related components were only sparsely reported in the original article and are likewise likely to represent important sources of heterogeneity. These co-interventions may modify the effect of sham feeding and could challenge the transitivity assumption underlying indirect comparisons between coffee and gum chewing. Although within-comparison heterogeneity was quantified using I2, further assessment of network consistency and, where feasible, stratified analyses or meta-regression according to key co-interventions might clarify whether the observed benefit of gum chewing over usual care can be generalized to contemporary ERAS settings[3–5]. Second, the statistically significant differences in time-based gastrointestinal endpoints should be interpreted alongside outcomes that matter directly to women and their families. For many patients, a reduction of several hours in time to first flatus or defecation may not fully reflect overall recovery, readiness for discharge or the ability to engage in early maternal–infant bonding. Incorporating standardized patient-reported outcome measures, such as global quality-of-recovery scores, fatigue, capacity to care for the newborn and breastfeeding success, alongside objective gastrointestinal metrics, could help clinicians judge whether coffee or gum chewing leads to a clinically meaningful improvement in postpartum recovery[4,6]. Future pragmatic trials might also prospectively collect safety outcomes that are seldom reported, including sleep disturbance, anxiety, and neonatal effects related to caffeine exposure. In conclusion, Gao et al highlight that low-cost, well-tolerated interventions such as coffee and gum chewing may facilitate gastrointestinal recovery after cesarean section[1]. Building on their important work, future studies could embed these interventions within standardized ERAS protocols, formally evaluate network assumptions and place greater emphasis on patient-centered and safety outcomes, to better define the role of coffee and gum chewing in modern postoperative care.