Pre-operative fasting in children

Abstract

Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a ‘light breakfast’ may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.

Ultrasound Assessment of Gastric Fluid Volume in Children Scheduled for Elective Surgery After Clear Fluid Fasting for 1 Versus 2 Hours: A Randomized Controlled Trial

“…28 The 3-point antral grading score had been proposed as a simple qualitative measure for risk of pulmonary aspiration, and it has been suggested by the ESAIC to be preferred in differentiating the safe and at-risk stomach over calculating the antral CSA. 11,29 It is strongly correlated with GFV in both children and adults but with relatively smaller GFV in relation to the corresponding antral grade in children than in adults. 19,20,29,30 This could explain why none of our participants had a GFV >1.5 mL kg -1 despite the incidence of grade 2 antrum in the 1-hour group was 56.9%.…”

“…11 Moreover, qualitative ultrasound can accurately detect increased gastric residual volumes, which potentially places patients at risk for pulmonary aspiration. 11,[15][16][17][18] This is the first randomized controlled study that we are aware of to use gastric ultrasound to assess the GFV in pediatric population having clear fluid fasting for 1 versus 2 hours before elective surgery. We hypothesized that clear fluids fasting for 1 hour will increase GFV compared to 2 hours fasting for children scheduled for elective surgery under general anesthesia.…”

“…However, this recommendation is not supported by strong evidence yet and is largely based on previous studies using orogastric aspiration, which might underestimate the gastric fluid volume (GFV). 11 Furthermore, the liberal clear fluid intake still questioned 12,13 and is not supported yet by the American Society of Anesthesiologists (ASA), which still recommends 2-hour fasting for clear fluids in children. 14 Therefore, there is a need for more pediatric-focused studies to determine the most appropriate duration for fasting before surgery.…”

Recent advances in paediatric anaesthesia

“…[ 1 ] Recent international consensus has shifted from conservative long durations of fasting toward a more liberal policy of 1 hour for clear fluids and is endorsed by several national societies. [ 2 ] Gastric ultrasound has played a major role in establishing the safety for children while moving toward liberal feeding practices. [ 3 ] Hospitalisation and surgery can provoke significant stress and anxiety in children with adverse outcomes.…”

Paediatric Post-Operative Nausea and Vomiting

“…A recent review recommends early and liberal resumption of oral fluid intake postoperatively as it is associated with reduced POV. 8…”