BACKGROUND: Patients undergoing primary palatoplasty generally rely on narcotic medication for pain control. However, there are concerns with over-medication, sedation, respiratory depression, sensitization to pain, and physical dependency with the use of narcotics. Enhanced Recovery after Surgery (ERAS) protocols using multi-modal therapy for pain control have seen adoption in numerous surgical sub-specialties since their inception in the 1990s. Recent publications have demonstrated decreased narcotic usage and hospital length of stay after palatoplasty with the use of ERAS protocols. This study aims to assess clinical outcomes before and after ERAS implementation to evaluate for a differential effect among Veau Classifications and identify significant predictors of narcotic medication prescription at discharge. METHODS: A single center study of patients undergoing primary palatoplasty examined two cohorts: a retrospective review (2014–2016) of patients treated prior to ERAS implementation and a prospective trial (2016–2018) in which palatoplasty patients were managed with an ERAS protocol. Data regarding postoperative pain scores, oral intake, morphine milligram equivalents (MMEs) administered, narcotic medication prescription at discharge, and length of stay for retrospective and prospective cohorts were compiled (Excel, Microsoft Corporation). Pain scores were measured using the Faces, Legs, Activity, Cry, and Consolability scale. All data were analyzed using R Software (R Foundation for Statistical Computing, Vienna, Austria). RESULTS: A total of 113 patients (56 Pre-ERAS, 57 ERAS) were included in this study. ERAS patients were found to have significantly longer operative times when compared with Pre-ERAS [167min (121–191) versus 131min (114.75–157)] as well as a significantly higher rate of Furlow repair (63.2% versus 33.9%, P = 0.002). The ERAS group was found to have a significant decrease in total MMEs administered when compared with Pre-ERAS (5.29 ± 4.61 versus 11.83 ± 7.13, P < 0.001). Comparison of clinical outcomes within Veau classifications by their respective cohorts yielded no significant differences. Comparison of clinical outcomes among Veau classification between cohorts revealed significant decreases in the ERAS group for total MMEs administered in Veau class II (8.87 ± 5.97 versus 4.38 ± 3.43, p =0.015), III (12.42 ± 7.05 versus 6.25 ± 5.39, P = 0.001), and IV (16.54 ± 6.39 versus 4.54 ± 4.45, P = 0.003). A multivariate generalized linear model using significant univariate variables as well as Cohort and Veau Classification data demonstrated that total MMEs administered was a significant predictor with a P value of 0.041 and an odds ratio of 1.10 (CI 1.01–1.21). CONCLUSIONS: Our ERAS protocol for primary palatoplasty led to decreased pain scores and improved oral intake. Significant reductions in total MMEs administered to patients with Veau II–IV cleft palates were observed, which was associated with 10% increased odds for discharge narcotics per MME administered. There was variability in outcomes based on Veau classification, though larger studies may demonstrate a more reproducible effect. Our results illustrate the potential benefit that standardized ERAS protocols may have in this patient population, and merit further study.