Preoperative fasting in children: review of existing guidelines and recent developments

Abstract

The current guidelines for preoperative fasting recommend intervals of 6, 4, and 2 h (6-4-2) of fasting for solids, breast milk, and clear fluids, respectively. The objective is to minimize the risk of pulmonary aspiration of gastric contents, but also to prevent unnecessarily long fasting intervals. Pulmonary aspiration is rare and associated with nearly no mortality in paediatric anaesthesia. The incidence may have decreased during the last decades, judging from several audits published recently. However, several reports of very long fasting intervals have also been published, in spite of the implementation of the 6-4-2 fasting regimens. In this review, we examine the physiological basis for various fasting recommendations, the temporal relationship between fluid intake and residual gastric content, and the pathophysiological effects of preoperative fasting, and review recent publications of various attempts to reduce the incidence of prolonged fasting in children. The pros and cons of the current guidelines will be addressed, and possible strategies for a future revision will be suggested.

Duration of preoperative clear fluid fasting and peripheral intravenous catheterization in children: A single‐center observational cohort study of 9693 patients

“…We also observed that fasting time was longer than the recommended guidelines of 2 hours in a large proportion of our patients (median 6.4 hours, IQR: 4.4–12.6 hours, Table ). These findings are consistent with previous reports that despite recommendations for clear liquid fasting time of 2 hours, children actually have longer fasting times . The European Society for Paediatric Anaesthesiology recently published a consensus statement advocating for clear liquid fasting time of 1 hour prior to elective general anesthesia…”

“…findings are consistent with previous reports that despite recommendations for clear liquid fasting time of 2 hours, children actually have longer fasting times 3,18. The European Society for PaediatricAnaesthesiology recently published a consensus statement advocating for clear liquid fasting time of 1 hour prior to elective general anesthesia.…”

“…Fasting time prior to administration of sedation or anesthesia in pediatrics has been a topic of active debate with recent evidence supporting shorter fasting durations. [1][2][3][4] Children undergoing an elective procedure under general anesthesia are required to fast to avoid the presence of solid gastric contents and lower the risks of regurgitation and pulmonary aspiration. A prolonged fasting time for clear fluids can have adverse effects, such as hunger, discomfort, headache, dehydration, hypovolemia, and hypoglycemia, and as a result, some pediatric hospitals have engaged in projects to reduce their preoperative fasting times for clear liquids.…”

“Full Stomach” Despite the Wait: Point‐of‐care Gastric Ultrasound at the Time of Procedural Sedation in the Pediatric Emergency Department

“…Moreover, fasting periods of 6 or more hours did not ensure an empty stomach. As summarized in Table , the majority of our patients had recently eaten fried/fatty food or meat, and the majority reported severe pain and received opioid analgesia, all of which can slow gastric emptying . Our findings mirror those of Bouvet and colleagues, who demonstrated that 56% of adults undergoing emergency surgical procedures had a full stomach at the time of anesthesia despite a mean fasting duration of 18 hours.…”

“…Unlike patients fasting prior to elective sedation, PED patients awaiting procedural sedation often have painful injuries, are frequently treated with opioids, and may have eaten large fatty meals immediately preceding injury, all of which can slow gastric emptying . Large, multicenter studies are necessary to estimate the risk of pulmonary aspiration in any setting .…”