Article Data

  • Views 3236
  • Dowloads 418


Open Access Special Issue

Fasting in pediatric anesthesia: the art of making simple things complex

  • Nadia Veigaard1,2
  • Nicole Brahe1,2
  • Tom G. Hansen1,2
  • Nicola G. Clausen1,2

1Department of Anesthesiology and Intensive Care, University Hospital Odense, DK-5000 Odense, Denmark

2Department of Clinical Research, University of Southern Denmark, DK-5000 Odense, Denmark

DOI: 10.22514/sv.2021.139 Vol.17,Issue 5,September 2021 pp.11-17

Submitted: 12 April 2021 Accepted: 08 July 2021

Published: 08 September 2021

(This article belongs to the Special Issue Anaesthesia in Paediatrics: Take Good Care of the Children)

*Corresponding Author(s): Nicola G. Clausen E-mail:


Prolonged preoperative fasting times for children scheduled for general anesthesia and surgery continue to be reported despite a plethora of recent studies suggesting that fasting for clear fluids can be shortened without increasing the risk of pulmonary aspiration. The aim of this narrative review was to summarize knowledge about the known benefits and potential consequences of prolonged fasting in pediatric anesthesia and to discuss the difficult implementation of reduced fasting times in clinical practice. This narrative review is based on fifteen studies published in the databases PubMed, EMBASE and Cinahl from October 2009 to June 2020. Outcome measures assessed were divided into 4 overall domains: metabolism and hemodynamics (1), patient comfort and patient/parent satisfaction (2), gastric volume and/or emptying time (3) and risk of pulmonary aspiration (4). While incidences of pulmonary aspiration remain low after implementation of less restrictive recommendations, the duration of fasting times relates to negative outcomes (low post-induction blood pressure, increase of blood ketones, poor patient/parent satisfaction). Preoperative fasting times must balance the risk of aspiration during anesthesia against children’s wellbeing and metabolic homeostasis. Based on the current evidence on preoperative fasting in children, liberal fasting times with nil-per-mouth for solids and formulas, breast milk and clear fluids corresponding to 6, 4 and 1 hours respectively, are safe. However, a reduction in real fasting times is pending and requires a multifactorial approach.


Children; Preoperative fasting; General anesthesia

Cite and Share

Nadia Veigaard,Nicole Brahe,Tom G. Hansen,Nicola G. Clausen. Fasting in pediatric anesthesia: the art of making simple things complex. Signa Vitae. 2021. 17(5);11-17.


[1] Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respiratory Medicine. 2017; 5: 412–425.

[2] Pfaff KE, Tumin D, Miller R, Beltran RJ, Tobias JD, Uffman JC. Perioperative aspiration events in children: a report from the Wake up Safe Collaborative. Pediatric Anesthesia. 2020; 30: 660–666.

[3] Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia. Pediatric Anesthesia. 2018; 28: 411–414.

[4] Andersson H, Zarén B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Paediatric Anaesthesia. 2015; 25: 770–777.

[5] Isserman R, Elliott E, Subramanyam R, Kraus B, Sutherland T, Madu C, et al. Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia. Pediatric Anesthesia. 2019; 29: 698–704.

[6] Okabe T, Terashima H, Sakamoto A. Determinants of liquid gastric emptying: comparisons between milk and isocalorically adjusted clear fluids. British Journal of Anaesthesia. 2015; 114: 77–82.

[7] Schmidt AR, Buehler P, Seglias L, Stark T, Brotschi B, Renner T, et al. Gastric pH and residual volume after 1 and 2 h fasting time for clear fluids in children. British Journal of Anaesthesia. 2015; 114: 477–482.

[8] Dennhardt N, Beck C, Huber D, Sander B, Boehne M, Boethig 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. Pediatric Anesthesia. 2016; 26: 838–843.

[9] Simpao AF, Wu L, Nelson O, Gálvez JA, Tan JM, Wasey JO, et al. Preoperative Fluid Fasting Times and Postinduction Low Blood Pressure in Children: A Retrospective Analysis. Anesthesiology. 2020; 133: 523–533.

[10] Schmidt AR, Buehler KP, Both C, Wiener R, Klaghofer R, Hersberger M, et al. Liberal fluid fasting: impact on gastric pH and residual volume in healthy children undergoing general anaesthesia for elective surgery. British Journal of Anaesthesia. 2018; 121: 647–655.

[11] Engelhardt T, Wilson G, Horne L, Weiss M, Schmitz A. Are you hungry?are you thirsty?–Fasting times in elective outpatient pediatric patients. Paediatric Anaesthesia. 2011; 21: 964–968.

[12] Brady M, Kinn S, Ness V, O’Rourke K, Randhawa N, Stuart P. Preoper-ative fasting for preventing perioperative complications in children. the Cochrane Database of Systematic Reviews. 2009; CD005285.

[13] Andersson H, Frykholm P. Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia: a prospective observational study. Pediatric Anesthesia. 2019; 29: 1173–1178.

[14] Beck CE, Witt L, Albrecht L, Dennhardt N, Böthig D, Sümpelmann R. Ultrasound assessment of gastric emptying time after a standardised light breakfast in healthy children: a prospective observational study. European Journal of Anaesthesiology. 2018; 35: 937–941.

[15] Beck CE, Chandrakumar T, Sümpelmann R, Nickel K, Keil O, Heiderich S, et al. Ultrasound assessment of gastric emptying time after intake of clear fluids in children scheduled for general anesthesia—a prospective observational study. Pediatric Anesthesia. 2020; 30: 1384–1389.

[16] Sümpelmann AE, Sümpelmann R, Lorenz M, Eberwien I, Dennhardt N, Boethig D, et al. Ultrasound assessment of gastric emptying after breakfast in healthy preschool children. Paediatric Anaesthesia. 2017; 27: 816–820.

[17] Beck CE, Witt L, Albrecht L, Winstroth A, Lange M, Dennhardt N, et al. Ultrasound assessment of gastric emptying time in preterm infants: a prospective observational study. European Journal of Anaesthesiology. 2019; 36: 406–410.

[18] Bonner JJ, Vajjah P, Abduljalil K, Jamei M, Rostami-Hodjegan A, Tucker GT, et al. Does age affect gastric emptying time? A model-based meta-analysis of data from premature neonates through to adults. Biopharmaceutics & Drug Disposition. 2015; 36: 245–257.

[19] Beck CE, Rudolp D, Becke‐Jakob K, Schindler E, Etspüler A, Trapp A, et al. Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study. Pediatric Anesthesia. 2019; 29: 1040–1045.

[20] Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. British Journal of Anaesthesia. 2014; 113: 12–22.

[21] Andersson H, Frykholm P. Gastric content assessed with gastric ultrasound in paediatric patients prescribed a light breakfast prior to general anaesthesia: a prospective observational study. Pediatric Anesthesia. 2019; 29: 1173–1178.

[22] Rostas JW, Mai TT, Richards WO. Gastric motility physiology and surgical intervention. Surgical Clinics of North America. 2011; 91: 983–999.

[23] Bouvet L, Desgranges F, Aubergy C, Boselli E, Dupont G, Allaouchiche B, et al. Prevalence and factors predictive of full stomach in elective and emergency surgical patients: a prospective cohort study. British Journal of Anaesthesia. 2017; 118: 372–379.

[24] Islam S. Gastroparesis in children. Current Opinion in Pediatrics. 2015; 27: 377–382.

[25] Hryhorczuk A, Lee EY, Eisenberg RL. Bowel obstructions in older children. American Journal of Roentgenology. 2013; 201: W1–W8.

[26] Sauer CG, Kugathasan S. Pediatric inflammatory bowel disease: high-lighting pediatric differences in IBD. Gastroenterology Clinics of North America. 2009; 38: 611–628.

[27] Newton RJG, Stuart GM, Willdridge DJ, Thomas M. Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward. Paediatric Anaesthesia. 2017; 27: 793–800.

[28] Hansen TG, Engelhardt T. Pre-operative fasting for clear fluids in children: Is 1 hour the answer? Acta Anaesthesiologica Scandinavica. 2021. (in press)

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.0 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time