NPO Guidelines for Infants and Children
Last updated: 04/04/2023
- Pediatric preoperative fasting guidelines were developed to reduce the risk of pulmonary aspiration and the severity of pulmonary complications should aspiration occur.
- 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.
- Recently updated recommendations encourage shorter actual fasting times while still allowing sufficient fasting times for safety.
- 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
- 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.
- Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2017; 126(3):376-93. PubMed
- Frykholm P, Disma N, Andersson H, et al. Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2022; 39:4. PubMed
- Engelhardt T, Wilson G, Horne L, Weiss. Are you hungry? Are you thirsty? Fasting times in elective outpatient pediatric patients. Paediatr Anaesth. 2011; 21:964–968. PubMed
- Andersson H, Zaren B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Paediatr Anaesth. 2015; 25:770–777. PubMed
- Newton RJG, Stuart GM, Willdridge DJ, et ak. Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward. Paediatr Anaesth. 2017; 27:793–800. PubMed
- Thomas M, Morrison C, Newton R, et al. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Paediatr Anaesth. 2018; 28:411–4. PubMed
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