Revisiting Pediatric NPO Guidelines: a 5-Year Update and Practice Considerations

Abstract

Purpose of Review

From 2018 to 2019, several international pediatric anesthesia societies challenged the current fasting guidelines, moving to decrease the fasting increment for clear liquids to 1 hour (h). Both the American Society of Anesthesiologists (ASA) and the Society for Pediatric Anesthesia (SPA) have hesitated to change, citing insufficient support. We sought to better understand the evidence related to fasting in children.

Recent Findings

We reviewed the literature from the past 5 years and conducted an informal survey of 51 United States (US) pediatric medical centers. Some medical institutions in the US caring for children have implemented policies to mirror the international guidelines. Our search revealed many patient, family, and system reasons to move to a shorter clear fluid fasting period. However, some medical conditions create increased risk of aspiration.

Summary

Available evidence supports a shorter fasting period, but individual patient factors should be considered.

Appendices

Appendix

WELI NPO Survey

• 1. I understand and fully accept the terms in the attached cover letter

• 2. I agree to participate in this survey in which information from my responses will be collected and potentially used in future publication

• 3. Do you currently allow children to drink clear liquids up to 1 h prior to the induction of anesthesia?

• 4. If you responded no, what factors prohibit you/your group from making the change?

  • Medico-legal concerns?

  • Lack of support of American anesthesia societies?

  • Safety?

  • Other

• 5. If you had medico-legal concerns, have you spoken to your risk department? What concerns did they have regarding changing your practice?

• 6. If you responded no, does the lack of support by societies such as ASA or SPA influence your decision? If either of those organizations offered support, would you change your practice?

• 7. Do you have any concerns regarding the safety of reducing clear liquid fasting guidelines?

• 8. Would institutional reluctance to invest in changing patient communication (time/money) pose a barrier to implementing practice change?

WELI NPO Survey Results

34 Respondents/51 Total Surveyed

• 1. I understand and fully accept the terms in the attached cover letter: 100%

• 2. I agree to participate in this survey in which information from my responses will be collected and potentially used in future publication: 100%

• 3. Do you currently allow children to drink clear liquids up to 1 h prior to the induction of anesthesia? 5 (14.7%) YES; 29 (85.3%) NO

• 4. If you responded YES, can you comment on barriers you faced and how you were able to achieve the change at your respective institution?

  • a. I allow for clear liquids 1 h before anesthesia, and so do about 2/3 of my partners. Our official instructions to parents/patients are 2 h NPO. Our group has reviewed the literature and discussed changing our institutional guidelines. Some more conservative members of the group are concerned about going against the published ASA guidelines for NPO and the fact that SPA does not have a guideline stating 1 h for clears. They have said that they will not try to stop us if we go ahead at 1 h with our own patients, but that they will not personally go until 2 h with their patients. The differences in limits among our group does not cause much problem, and we expect that we will change to 1-h NPO in the not too distant future

  • b. Leadership buy-in 2. Legal/risk support 3. Change to surgical patient communications

  • c. As the chair, I have left it to the independent practice of my team depending on clinical circumstances. Our policy states 2 h for clears, however can be moved to 1 h pending on anesthesiologist approval

  • d. Our institutional policy is still 2 h—in line with ASA's general policy. I personally do not delay anesthesia if children present in the > 60 min but < 120 min time frame after consuming clears. Some of my colleagues also use a 1 h cut-off but it rarely comes up as the institution still uses 2 h as cut-off in the instructions. The obvious barrier is that it creates inconsistency within our team, so I emphasize to surgeons and families that this is outside our normal institutional policy, but in line with international recs etc.

  • e. We had full support from our leadership which helped to remove many barriers. We made this change in conjunction with a QI project to decrease the overall fasting times for clear fluids. We had an average of about 9 h prior to our project and we were all in agreement that this was way too long. We also had the European data showing no increased adverse events with 1 h or even zero hour fasting times for clears. I am also currently working on a task force out of the ESA-IC to revise all fasting guidelines in children, which I hope might help break down barriers.

• 5. If you responded NO, what factor(s) inhibit you/your group from making the change? (please check all that apply)

  • a. Medico-legal 23 (71.9%)

  • b. Lack of support from ASA/SPA 26 (81.3%)

  • c. Safety 7 (21.9%)

  • d. Reluctance or concerns from surgeons/proceduralists 4 (12.5%)

  • e. Resistance from hospital/administration/nursing to implementing changes 10 (31.3%)

  • f. Other

• 6. For those who selected Other in the previous question or wish to add further commentary, please respond below

  • a. Establishing consistency between providers to avoid confusion

  • b. Concerns by anesthesia providers and reluctance to change

  • c. Unaware that this was a new standard

  • d. Concerns that different guidelines for pediatric versus adult patients will lead to confusion among both staff giving instructions and families receiving instructions. (We have a small integrated children's hospital within the adult hospital, so many periop staff cover both adult and pediatric patients)

  • e. On an individualized delay a case for a 1 h clear liquid but we do not have this written in any policies.

  • f. Our group is divided on the 1 h vs 2 h and we would like to have a unanimous decision before moving forward in the updating of our NPO guidelines.

  • g. Only change my practice if my institution's policy changed to accept it

• 7. If either American Society of Anesthesiologists (ASA) or Society for Pediatric Anesthesiologists (SPA) supported a change to 1 h for clear liquid fasting times in pediatric patients, would you change your practice? YES (96.9%); NO (3.1%)

• 8. Would institutional reluctance to invest in changing patient communication (time/money) pose a barrier to implementing practice change? YES (37.5%); NO (62.5%)

Table 3 Evidence for shortened clears fasting in children

Evidence for shortened clears fasting in children
Reference (Country)	Study Design	Fasting Guideline	# Anesthetics (n)	Aspiration incidence (%) with notes
Pfaff 2020 (USA) [33••]	Retrospective Multicenter Database study	6–4-2, no subgroup analysis of < 2 h fasting times	2,440,810	135 (0.006%) *, 11% of these involved NPO violation
Beck 2020 (Germany) [37••]	Prospective Multicenter observational	Clears fasting of 1 h did not affect the incidence of adverse events	12,093	4 confirmed (0.03%) 10 suspected (0.08%) 31 (0.26%) regurgitation
Habre 2017 (Pan-European [8]	Prospective Multicenter	6–4-2, no subgroup analysis of < 2 h fasting times	31,131	29 (0.1%)
Beach 2016 (USA) [11••]	Retrospective database analysis	6–4-2	139,142	10 (0.007%), 0.01% in children appropriately NPO and 0.008% in those who were not NPO Status is not an independent predictor of aspiration or related major complications
Tan and Lee 2016 (Singapore) [4]	Retrospective cohort	6–4-2	102,425	22 (0.02%)
Andersson 2018 (Sweden) [39••]	Prospective	6–4-2 vs 6–4-0	2-h clears (n = 66) 0-h clears (n = 64)	None, median actual clears fasting time of 4 h for 6–4-2 group and 1 h for 6–4-0 group

*Of the 135 cases, 51 (38%) resulted in patient harm, including 2 deaths (1.5%)

Table 4 Categorical Summary

Categorical Summary
Major Society Guidelines recommending One Hour Clear Liquid Fasting	o Association of Paediatric Anaesthetists of Great Britain and Ireland [27] o European Society for Paediatric Anaesthesiology [27] o L’Association Des Anesthésistes-Réanimateurs Pédiatriques d’Expression Française [27] o The European Society of Anaesthesiology [56] o Canadian Pediatric Anesthesia Society [16] o The Society for Paediatric Anaesthesia of New Zealand and Australia [17]
Concerns with Current Fasting Time Recommendations	o Fasting times typically far exceed recommended 2 h clears fasting [10, 35, 38, 72] o Low post-induction blood pressures with current 6–4-2 guidelines [42•] o Increased metabolic stress and insulin resistance [12, 36, 73] o Increased thirst, irritability [73], and emergence delirium [65] o Places children with undiagnosed metabolic conditions at risk (e.g. medium-chain acyl-CoA dehydrogenase deficiency patients) [74]
POCUS Evidence	o Gastric emptying time of clear fluids, as assessed by POCUS, was < 1 h in children age 4-17y/o [75] o Gastric emptying time, as assessed by POCUS, is < 4 h after a light breakfast [75] and for all liquids [76] o Allowing clear carbohydrate drink until premedication is associated with decreased actual fasting times and no change in gastric pH. Increased gastric volume is seen more often in patients with 30 min or shorter fasting times. [19••]
Survey of Institutional Practice	o # US Hospitals surveyed: 51 o % Rate of response: 65.4% o Institutions with < 1 h clear liquid fasting requirement: 5/34 o Barriers to shortening clear liquid fasting requirement: Medicolegal, lack of support from national specialty societies, resistance from hospital/administration/nursing
Recommendations	o Use of clinical judgment in patients with increased risk factors for aspiration: Gastrointestinal comorbid conditions, emergency surgery, higher ASA status (3-4), anticipated blood or secretions in airway following or during procedure, age 1–3 y/o [33••, 50] o Consider limiting volume of clears between 1–2 h to 3-5 ml/kg [27, 37••] o Use of risk stratification methods in guiding NPO recommendations for sedation procedures [30] o Institutional QI processes/interventions to address issues with adherence to NPO regulation (whether fasting less than or more than advised times). QI considerations include: interpreter services, separate written instructions for solids and liquids, [72] use of visual aids in instructions to ensure patients understand aspiration concerns, [46] institutional efforts to decrease procedural delays, and operating room schedule optimization