NPO Guidelines for Infants and Children

Introduction

• The goal of preoperative fasting recommendations is to reduce the risk of aspiration and the severity of pulmonary complications should aspiration occur.
• Most national guidelines recommend a “6-4-2” rule for preoperative fasting, meaning a minimum of 6-hour fast for solid food or formula, 4 hours for breast milk, and 2 hours for clear fluids.^1,2
• In infants and children, these recommendations often result in actual fasting times that far exceed the safety margin and may result in hunger, thirst, and patient and caregiver distress.³
• There has been a shift in focus to minimal safe fasting times and encouraging intake up until that time.

Solids and Nonhuman Milk

• The American Society of Anesthesiologists (ASA) practice guidelines on preoperative fasting1, as well as the European Society of Anaesthesiology and Intensive Care (ESA-IC) preoperative fasting guidelines in children,² recommend that solid food can be ingested until 6 hours before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.
• A meal of fried food, fatty food, or meat may require additional fasting times (e.g., 8 hours or more).
• While there is some evidence that 4 hours of fasting after a light meal is safe and well-tolerated in healthy children, there are no large studies confirming the lack of increase in aspiration rates, and the definition of a light meal may be a challenge to deliver and evaluate consistently.²

Breast Milk and Formula

• The ASA practice guidelines recommend a 4-hour fasting period for breast milk and a 6-hour fasting period for formula before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.¹
• The ESA-IC fasting guidelines recommend that breast feeding be encouraged until 3 hours prior to anesthesia.² This was based on 9 observational studies on gastric emptying after breast milk feeds in infants and young children. Their recommendations are the same (i.e., 3 hours) even for fortified breast milk.
• The ESA-IC fasting guidelines suggest that for infants, formula may be given safely up until 4 hours prior to anesthesia; however, larger studies are necessary to be confident of the safety in regard to aspiration.²

Clear Fluids

• The ASA recommends that clear fluids may be ingested for up to 2 hours before elective procedures requiring general anesthesia, regional anesthesia, or procedureal sedation and analgesia.¹
• Institutions that have been using shorter clear fluid fast times of 1 hour, or even 0 hours, have shown no increased risk of aspiration with this more liberal clear fluid fasting times and have shown a marked decrease in actual fasting times.^4,5
• This evidence has been shifting international consensus from a 2-hour to a more liberal 1-hour clear fluid fasting policy, which was proposed in a joint statement by the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Pediatric Anesthesiology, and the Association of French Speaking Paediatric Anaesthetists (ADARPEF).⁶
• This policy has seen been endorsed by the European Society of Anaesthesiology,² the Canadian Pediatric Anesthesia Society, and the Society for Pediatric Anaesthesia of New Zealand and Australia.