Pediatric preoperative fasting guidelines
Libby (Elizabeth) Elliott, MD and Rebecca Isserman, MD
Disclaimer: Both authors of this PAAD contributed to the guidelines from the ESAIC to be published January 2022. CHOP has ascribed to 1 hour clear fasting time since November 2017, and 3 hour fasting time for breast milk since at least 1999 (according to Mark Schreiner and the late great Ron Litman).
‘Twas a day before solstice and children were drinking,
For ESAIC wrote guidelines that got us all thinking!
Through COVID we worked with our eyes on the data(r),
With the goal that our patients could drink a bit later.
Frykholm P, Disma N, Andersson H, et al. Preoperative fasting in children: guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4–25.
Frykholm P, Disma N, Kranke P, Afshari A. The rationale for the recommendations of the European Paediatric Fasting Guideline. Improving paediatric anaesthesia and perioperative medicine. Eur J Anaesthesiol 2022; 39:1-3
Two weeks ago, a small group of us from the Society for Pediatric Anesthesia task force on NPO times met to determine how best to decrease fasting times for children in the U.S. presenting for anesthesia and sedation. Our societies (SPA, ASA) are requesting data that decreasing NPO time is safe before any change to the guidelines and recommendations is made. Given the rarity of aspiration events, estimates for necessary recruitment range from 50,000 to 100,000.
Several large children’s hospitals in the US (Children’s Hospital of Philadelphia, Texas Children’s Hospital, Children’s Healthcare of Atlanta, St. Jude Children’s Research Hospital, etc.) have adopted shorter fasting times for clear liquids without an increase in aspiration events. Thousands of patients at these hospitals and surgery centers have benefited from decreased fasting times. Numerous studies have been published recently, mostly from Europe, with burgeoning evidence of the safety of decreasing fasting times for children.1,2
The first issue of the European Journal of Anesthesiology for the year 2022 features updated fasting guidelines for children and a commentary by the lead authors. These guidelines are an update to the European Society of Anaesthesiology’s initial fasting guidelines published in 2011, which were similar to the ASA guidelines published in 1999 and updated in 2017. We are excited to report that these updated fasting guidelines from the European Society of Anaesthesiogy and Intensive Care (ESAIC, name updated in 2020) are pediatric focused and reduce the minimum fasting times for formula, breast milk and clear liquids.3,4
Six fundamental questions formed the basis of a wide query to determine safe and tolerated fasting times in children (paraphrased): 1) What are risks and benefits to more liberal fasting regimens? 2) How is gastric emptying affected by different volumes and types of food and liquids? 3) What patient factors, comorbidities, and medications should determine fasting times? 4 and 5) What is the utility of Gastric Ultrasound (GUS) in clinical decision making regarding the risk of pulmonary aspiration? And can GUS be validated to assess gastric emptying? 6) “What are the risks and benefits of early postoperative feeding in terms of patient comfort vs. the risk of adverse effects?”3
With the help of a professional librarian, several members from the European Society of Pediatric Anaesthesiology, Canadian Pediatric Anesthesia Society and the Society for Pediatric Anesthesia in the U.S. screened 28,000 titles, yielding 1,200 abstracts for further review, and ultimately found 125 relevant articles for further analysis. 6 groups organized by PICO question (as above) extracted the data, which was presented to the group at large in the form of recommendations. Through a three step Delphi process, recommendations and suggestions were made and quality of evidence was defined.3
The new guidelines modify the old and worn (8)-6-4-2 fasting guidelines in favor of a 6-4-3-1 regimen. The updated recommendations are 4 hours for infant formula, 3 hours for breast milk, and 1 hour for clear fluids. These recommendations come with at least 1C level of evidence except 4-hour fast for infant formula. Recent work by Jennifer Lee, et al5, published after the conclusion of the ESAIC work lends further credence to a reduced fasting time for infant formula, and would serve to increase the body of evidence that shorter fasting times are safe and well tolerated. Furthermore, the authors conclude that solid food may be consumed 6 hours prior to anesthesia induction and a “light breakfast” or non-clear fluid may be allowed 4 hours prior to anesthesia induction.3
Among the other questions investigated for the guidelines were specific patient comorbidity effect on gastric emptying, and the utility of ultrasound to determine gastric contents and clearance. The evidence for various comorbidities causing delayed gastric emptying does not exist, and fasting instructions needn’t be modified for patients with obesity, GERD, congenital heart disease, esophageal atresia +/- tracheoesophageal fistula (without evidence of esophageal stricture or delayed gastric emptying), and type 1 diabetes. The utility of ultrasound as a diagnostic modality for gastric clearance lies in the ability of a trained provider to make a qualitative assessment regarding the presence of solids, and volume of content.3
We would like to conclude this PAAD with an acknowledgment of the legions of data produced by our European counterparts on behalf of thirsty children everywhere. We invite the ASA and SPA to critically consider these updated guidelines in light of the current literature and reevaluate their recommendations on fasting times for children in the United States. We are happy to provide references.
1. Andersson H, Hellström PM, Frykholm P. Introducing the 6-4-0 fasting regimen and the incidence of prolonged preoperative fasting in children. Paediatr Anaesth. 2018 Jan;28(1):46-52.
2. Beck CE et al. Impact of clear fluid fasting on pulmonary aspiration in children undergoing general anesthesia. Results of the German Prospective multicenter observational (NiKs) study. Pediatric Anesthesia 2020; 30(8): 892-899
3. Frykholm P, Disma N, Andersson H, et al. Preoperative fasting in children: guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4–25.
4. Frykholm P, Disma N, Kranke P, Afshari A. The rationale for the recommendations of the European Paediatric Fasting Guideline. Improving paediatric anaesthesia and perioperative medicine. Eur J Anaesthesiol 2022; 39:1-3
5. Lee J, Price JC, et al. Ultrasound evaluation of gastric emptying time in healthy term neonates after formula feeding. Anesthesiology 2021; 134: 845-51