Clear fluids fasting for elective paediatric anaesthesia

Guidelines for the management of pre-operative paediatric clear fluid fasting historically recommend a minimum of 2 h. In particular, the published guideline from European Society of Anaesthesiology (ESA) in 2011, dedicated a section to peri-operative fasting in children and infants.¹ This guideline stated that: ‘Children should be encouraged to drink clear fluids (including water, pulp-free juice and tea or coffee without milk) up to 2 h before elective surgery’, with an evidence level 1++ and a recommendation grade A.

Similarly, the American Society of Anaesthesiology (ASA) published their updated guidelines in 2017.² ASA guidelines stated that ‘clear fluids may be ingested for up to 2 h before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia’, with category A1-E evidence on gastric volume and category A2-B evidence demonstrating children are more thirsty and hungry when fasted in excess of 4 h.

These recommendations, as others, were based on published reviews and meta-analyses of randomised controlled trials, primarily aimed at minimising the risk of pulmonary aspiration of gastric contents. However, pulmonary aspiration is a very rare event (less than 3 to 4/10 000),^3,4 and harm resulting from clear fluid aspiration in children is rarer still.⁴ It is also known that the stomach of a healthy child empties clear fluids within 30 min after intake (or even faster if fluids contain glucose), that gastric pH does not change 1 h after water intake, and that age does not affect the speed of gastric emptying.