To the Editor,
The Canadian Pediatric Anesthesia Society (CPAS) Fasting Guidelines Working Group was tasked by the CPAS board of directors to review contemporary fasting guidelines and the relevant perioperative fasting literature. A review of the literature by our group concluded that the current Canadian Anesthesiologists’ Society’s (CAS) fasting guidelines (that recommend a minimum two hours of clear fluid fasting prior to elective procedures) are similar to most fasting guidelines published by other anesthesiology Societies.1 In addition, we found that the scientific basis for the CAS fasting guidelines is largely rooted in expert opinion with little compelling evidence to support improved outcomes in pediatric patients by following these (or other similar anesthesiology Society’s) fasting guidelines. Furthermore, two recent reports involving large numbers of children failed to show an increase in adverse events when fasting times for clear fluids were shorter than the CAS guidelines recommend.2,3 We also found reports of deleterious effects of prolonged fasting (i.e., those in accordance with the CAS fasting guidelines), including patient distress, increased hemodynamic instability, and ketoacidiosis.4,5
Accordingly, the CPAS supports (in a statement ratified by the membership at its 2018 annual meeting) fasting guidelines for pediatric patients as follows:
Pediatric patients should be encouraged and allowed to ingest clear fluids up to one hour before elective anesthesia or sedation.
The CPAS Fasting Guidelines Working Group has also agreed to support the ongoing review and generation of comprehensive fasting guidelines. Nevertheless, until further evidence becomes available, and is reviewed and discussed, the decision was made to alter fasting guidelines pertaining to clear fluids only.
A similar fasting guideline is now supported (in jointly published statements6 by other pediatric anesthesia societies including the Association of Paediatric Anaesthetists of Great Britain and Ireland, The European Society of Pediatric Anesthetists, and L’Association Des Anesthésistes-Réanimateurs Pédiatriques d’Expression Française, who similarly endorsed the guidelines of the Society for Paediatric Anaesthesia in New Zealand and Australia.7 We recommend that anesthesia groups caring for pediatric patients review their own institutional fasting guidelines and develop policies and provide education which encourages clear fluid intake closer to the time of anesthesia or sedation.
Dobson G, Chow L, Flexman A, et al. Guidelines to the practice of anesthesia – revised edition 2019. Can J Anesth 2019; 66: 75-108.
Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major adverse events and relationship to nil per os status in pediatric sedation/anesthesia outside the operating room: a report of the Pediatric Sedation Research Consortium. Anesthesiology 2016; 124: 80-8.
Andersson H, Zarén B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Pediatr Anesth 2015; 25: 770-7.
Engelhardt T, Wilson G, Horne L, Weiss M, Schmitz A. Are you hungry? Are you thirsty? – fasting times in elective outpatient pediatric patients. Pediatr Anesth 2011; 21: 964-8.
Dennhardt N, Beck C, Huber D, et al. Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study. Pediatr Anesth 2016; 26: 838-43.
Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Pediatr Anesth 2018; 28: 411-4.
Linscott D. SPANZA endorses 1-hour clear fluid fasting consensus statement. Pediatr Anesth 2019; 29: 292.
We gratefully acknowledge the assistance of the members of Canadian Pediatric Anesthesia Society Fasting Guidelines Working Group.
Conflict of interest
Commercial or non-commercial affiliations that are or may be perceived to be a conflict of interest with the work of each author; and any other associations, such as consultancies: No author has any commercial or other affiliations that are, or may be perceived to be, a conflict of interest.
This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.
Funding was derived from academic stipends of the authors’ institutions.
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Rosen, D., Gamble, J. & Matava, C. Canadian Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia. Can J Anesth/J Can Anesth 66, 991–992 (2019). https://doi.org/10.1007/s12630-019-01382-z