Feature
Preoperatíve Fasting Times for Dental Sedations
in Pédiatrie Dentistry.
authored by - Abimbola 0 Adewumi, BDS, FD5RCS, - Flavio M Soares, DDS and - Enrique Bimstein, CD
Abimbola O Adewumi
BDS, FDSRCS (Eng) MPed DentRCS (Eng)
Assistant Professor, Department of
Pédiatrie Dentistry, University of Florida,
Gainesville, Florida
Flavio M Soares, DDS, MS
Assistant Professor, Department of
Pédiatrie Dentistry, University of Florida,
Gainesville, Florida
Enrique Bimstein, CD
Professor, Department of Pédiatrie
Dentistry, University of Florida,
Gainesville, Florida
Corresponding address:
Dr Abi Adewumi
Department of Pédiatrie Dentistry,
College of Dentistry, University of Florida,
Gainesville, FL 32610, United States.
E-mail: aadewumi@dental.ufl.edu
Abstract
OÍ3/ecf/ve:ToexaminepreoperatÍve fasting times
in children undergoing dental sedation.
Methods: Structured interviews were conducted
with parents of 110 children undergoing dental
sedation. The interview asked parents about
specific fasting times (FTs) from solids and
liquids and about instructions received prior to
sedation. Children's behavior during sedation
was also recorded and compared with fasting
times.
Results: The mean solid fasting time (SFT) was
12 hours and the mean liquid fasting time (LFT)
was 10 hours. Patients sedated in the morning
fasted from solids for an average of 12.7 hours
and those sedated in the afternoon fasted
from solids for 10.7 hours. No associations were
observed between FTs and the behavior of
children undergoing dental sedations. Despite
standard written instructions, there were
variations between written and oral instructions
given to parents provided by different staff
members.
Conclusion: This study suggests that in spite
14 The Journal of Pédiatrie Dental Care - Vol. 15, No 1, 2010
of prolonged fasting times, it may not affect
the behavior of children undergoing dental
sedations. As a part of a eareful appraisal of
fasting protoeols for pédiatrie sedations, health
professionals and their staff must endeavor
to provide a eonsensus of verbal and written
preoperative instruetions in order to prevent
misinformation.
Introduction
Ttie application of NPO [nil per os, Latin for
'nothing by mouth') guidelines from midnight
prior to surgery was suggested by Mendelson
and has guided the practice of sedation or
general anesthesia sinee the mid-1940s'. In 1999,
the American Society of Anesthesiologists (ASA)
published preoperativefastingguidelineslnorder
to ensure the safe delivery of anesthesia'. These
guidelines serve as a resource for healthcare
providers who advise and care for patients that
receive anesthesia eare during procedures. In
spite of these guidelines, there remains some
concern about the lack of consensus regarding
pre-surgieal fasting instructions. This ambiguity
can result in unnecessarily prolonged fasting
periods with resultant morbidity. While failure
to adhere to stringent fasting requirements
ean result in costly rescheduling of procedures,
prolonged fasting can increase the risk of
dehydration or hypoglycemia.
Sedation is an integral aspect of the clinieal
praetiee of pédiatrie dentistry in the United
States and according to the American Academy
of Pédiatrie Dentistry, patients with ASA classes
I and II are frequently considered appropriate
eandidates for minimal, moderate, or deep
sedationlThe main purpose of dental sedation
in children is to eontrol their behavior while
allowing the safe completion of a procedure. The
ASA guidelines for preoperative fasting periods
for infants and children are shown in Figure I,
These guidelines, which have been extended to
sedation/analgesia, are somewhat arbitrary and
based largely upon consensus. A study by Haas
et ar on the current praetiee of pre-medieation
and preoperative fasting in ehildren showed
that preoperative fasting guidelines still vary,
Emerson and his eolleagues'^ surveyed pédiatrie
anesthesiology residents in the United Kingdom
Figure I: The ASA guidelines for mini-
m u m fasting periods for infants and
ehildren
*Clear fluids: = 2 hours
Clear liquids include, but are not limited to;
water, fruit juices without pulp, carbonated
beverages, clear tea and black coffee. The vol-
ume of liquid ingested is less important than
the type of liquid ingested.
Breast milk: = 4 hours
Non-human milk, infant formula = 6
hours
*Solids, Light meal = 6 hours
"The recommendations for solid food were
reportedly made with insufficient published
data. A typical light meal includes toast and
clear fluids. Fried and Fatty foods may prolong
gastric emptying. The amount and type of
foods must be considered.
and Ireland on their eonsensus on preoperative
fasting times in children. The recommendations
for children were 2 hours for clear fluids and 6
hours for milk and solids. On the other hand,
Ferrari et al^ surveyed 51 institutions (47 in the
United States, 4 in Canada) that performed
pédiatrie anesthesia to determine current
practice patterns for preoperative fasting at
major pédiatrie hospitals. Despite agreement
amongst most institutions regarding ingestion of
clear fluids 2-3 hours prior to general anesthesia,
there vwas no consensus regarding fasting times
for solids in ehildren. It appears many hospitals
are still restricting solid intake from midnight
onward. The authors felt that this was neither
the optimal nor safe praetiee for pédiatrie
anesthesia.
Since dentistry has taken its eue from the
mediealeommunity regarding fastingguidelines,
it is eonceivable that general misapprehensions
of preoperative fasting practices have been
inherited. Despite available information on
fasting times for medieal proeedures, no studies
have examined fasting times for dental sedations
in ehildren. Coulthard deseribed a eonseious
sedation guidanee dcx:ument for the Dundee-
5eottish Dental Clinieal Effeetiveness Program
and recommended that areas of future research
should include, among others, fasting before
sedation and conscious sedation of pédiatrie
dental patients'.
 Therefore, the main purpose of this study
^vas to examine preoperative fasting times in
children undergoing sedation for routine dental
treatment. The main outcome measures were: ¡)
to determine the duration of fasting from solids
j n d liquids and ii) to evaluate the relationship
l)etween fasting times and the child's behavior
before and after undergoing dental sedations.
Materials and Methods
Ihis study was approved by the University of
i-lorida Institutional Review Board. Ail subjects
-ittended a new patient or recall appointment at
Ihe University Pédiatrie Dental Clinic. Following
j n evaluation of the child's age, medical
liistory, behavior and extent of treatment by
the pédiatrie resident, a treatment plan was
devised and patients were considered under
ihree main treatment categories: i) No sedation;
ii) Sedation; iii) General anesthesia. For patients
in the'sedation'treatment category, the sedation
protocol was discussed and parents were
provided with written preoperative and NPO
instructions prior to discharge and a separate
-lppointment was scheduled for the dental
sedation. In situations where parents had to
reschedule the sedation appointment, the office
receptionist reminded parents of preoperative
instructions over the telephone.
On the day of the sedation appointment,
the treating dentist, a pédiatrie resident verified
'he patient's medical history and performed
•he usual preoperative evaluations including
measurements of baseline vital signs. They also
. onfirmed compliance with NPO instructions
.ind obtained informed consent from the parent
'ir legal guardian for the procedure. Sedation
was not performed on the appointed day if
Ihe pédiatrie resident, in consultation with the
.ittendingfacultymember.consideredthe patient
unsuitable due to health reasons, or if there was
violation of preoperative instructions such as
inadequacy of adult escort or non-adherence
to fasting instructions. Despite attempts to
maintain continuity of care, on occasion the
initial consultation and dental sedation was
not performed by the same resident. As was
the usual practice in the department, patients
leceived either oral or intranasal sedation, The
treating dentist administered the appropriate
sedative regime based on his/her clinical
judgment of the child's behavior and the extent
of treatment required. Once adequate time was
.illowed for the desired effect of the drug, the
child was carefully separated from the parent
.^nd taken into the sedation room by the dentist
,ind the dental assistant.
Upon return to the waiting area, parents were
approached and invited for participation in this
study by one of three research assistants, using
a parental information letter designed for the distribution of categorical parameters by other
study and consent for study participation was categorical parameters. Pair-wise correlation
obtained. The parents were interviewed in a analyses were utilized to test for associations
separate privatearea using thequestionnaire,and between variables.
those who declined participation were excluded
from the study. We decided to conduct parental
interviews during the sedation procedure when Results
the parent and child were separated In order to
gain the full attention of the parent during the Parents or guardians of 110 children who
interview process. Once dental treatment was received conscious sedation for routine dental
completed, the patient was reunited with their treatment were interviewed for the study The
parent and subsequently discharged home age range of the patients was from 2 to 12 years
following an uneventful recovery. with a mean of 5 years (SD=2.1) and 55% were
males. Sixty-four percent of the children were
Questionnaire Caucasians, 27% were African-Americans, 7%
The interview questionnaire used in this study were Hispanics, and 2% were 'other.'Ali patients
was a modiñed version of the one previously belonged to ASA I category (89%) and II (11%).
developed by Crenshaw and Wlnslow^. Solid Eighty-five children (77%) were accompanied
fasting time (SFT) was defined as the time by their mother, 4% by their father, 11 % by both
between the last meal by mouth and the dental parents, and 8% came with a legal guardian.
appointment and liquid fasting time (LFT) was With respect to the educational background of
the time between last intake of any oral fluids these adults, 60 (55%) had up to high school
and the appointment time. Data colleaion education or its equivalent, 25% had some
included demographics of patients, time of college and 20% had completed college
sedation (i.e. morning vs. afternoon), type of education. The range of travel time to the clinic
sedation (oral vs. nasal route), time taken to travel was from 30 to 180 minutes with a mean time
to the dental clinic, information on which adult of 63 minutes (SD^38). Eighty-eight children
(parent or legal guardian) brought the child to (80%) were sedated due to age and behavioral
the appointment including their educational challenges. In 90% of the children, midazolam
background. The behavior of the child before was the single sedative agent used. For 57% of
and after sedation as determined by the dentist the children, this was their first dental sedation
was also recorded using the FrankI Behavioral experience and 63 (58%) were sedated in the
Scale". The questionnaire asked parents about morning.
their children's fasting times from both solids The structured interview revealed that 56
and liquids, instructions they received prior (89%) of parents of morning patients stated
to the sedation appointment, who they felt that the NPO instructions from both solids and
provided the instructions and how instructions liquids were from midnight. With respect to the
were provided. afternoon patients, 28 (61%) reported instructed
fasting times from solids and liquid ranging from
Statistical analysis 7 a.m. to 9 a.m, 6 (13%) reported being asked to
For the statistical analysis, a standard statistical fast their children from solids and liquids from
software program (JMP
6*, Statistical Discovery™, Figure II: Who provided preoperative instructions?
from SAS" Institute Inc.,
Cary, NC, USA, 2006)
was utilized. Differences 40%
in distribution within
the various parameters 35%
were used to obtain the
30%
values for the descriptive
statistics. Analysis of
25%
Variance (ANOVA) was
utilized to evaluate the 20%
statistical significance of
15%
the differences between
numerical parameters by
10%
a categorical parameter
(this includes t-Test). 5%
Chi-square analysis was
utilized to evaluate the
statistical significance
of the differences in
www.pdciDiirniiI.com The Journal of Pédiatrie Dentai Care 15
 Feature

Figure III; Solid and liquid fasting times by morning and there was no statistically fluids in the morning to prevent dehydration.
afternoon patients significant correlation Despite the rare incidence of aspirations,
observed between attempts to shift from the standard 'nil-by-
14 providers of preoperative mouth from midnight' fasting policy to more
• SFTILFT fasting instructions and relaxed regimes have been met with resistance
12 SFTs (P=.75) and LFTs from some healthcare professionals, resulting in
(P=.26). Despite this, there extended fasting times. Murphy et al" observed
was a trend showing there was mistrust from practitioners about
10 extended SFTs (12,8 hours) patients' understanding and compliance with
and LFTs (13 hours) when fasting policy. Providers felt that patients might
preoperative instructions consume solid foods if they are allowed to ingest
were provided by multiple clear fluids, Patients'lack of knowledge regarding
persons. No statisticaily the rationale for preoperative fasting may also
significant differences were account for prolonged fasting. Chapman'-'
observed between the found that 31% of surgical patients were
behavior of the children unaware of the reason for preoperative fasting;
treated in the morning 50% thought fasting reduced vomiting and
and those sedated in the only 18% associated vomiting with aspiration
afternoon. Age correiated of gastric contents. Another study" found that
with SFTs (P=.O4) and older even though 28% of patients reported being
children had longer SFTs, told why it was important to fast, 35% thought it
Mornini After noon " There were no associations was to prevent nausea and vomiting. Our study
revealed that while majority (64%) felt it was to
between FTs and the
midnight, and 13 (26%) reported being given prevent nausea and vomiting and 9% said it was
FrankI behavioral ratings of
different fasting times for solids than liquids. (Chi to prevent aspiration, 27% remained uncertain
the child before or after sedation. (Table I)
Square, P<0,001), about tbe rationaie for fasting. Another major
Parents felt that for the most part, instructions contributing factor to prolonged fasting may
were provided by the office receptionist (Figure Discussion be related to the policies of healthcare facilities
on fasting. The general policy in this university-
II) in verbal and written forms (Figure i). Eighty-
nine (81%) reported that they were informed based dental clinic was that the clinician
The issue of prolonged preoperative fasting
why it was necessary to avoid food or fluids provided both oral and written NPO instructions
times to reduce aspiration during surgery have
prior to their child's sedation. Of these parents, at the initial consultation for treatment planning
been widely published since the advent of the
64% felt it was to prevent nausea and vomiting, though some of parents were given preoperative
universally accepted ASA guidelines2,8,10,l 1
9% said it was to prevent aspiration and the instructions over the telephone by the office
Madsen et ai 10 investigated 50 adult male
remainder were unclear. When asked about receptionist. Results from this study revealed
patients undergoing elective 5urgical procedures
fasting times, the parental report showed that that 39% of parents reported that they were
and found that patients were without fluids for
overall solid fasting times ranged from 6-21 given NPO instructions by the office receptionist
almost 14 hours and without food for more than
hours with a mean SFT of 12 hours and mean alone and the remainder of the time, parents
14 hours. Crenshaw and Winsiov^ investigated
LFT of 10 hours (Figure III), There was a positive felt others such as the dentist and/or dental
fasting times and associated discomforts in
pair-wise correlation observed between SFT and assistant provided instructions. These results
women undergoing caesarean birth. They found
LFT (r=.39; P<0,001). Using OneWay ANOVA, are comparable with the study by Crenshaw
that patients were fasting from liquids and solids
and Winslow'^ where 32% of the patients were
for an average of 11-13 hours
provided instructions by a nurse alone.
respectively and most patients
Table I: Comparison of Solid Fasting Times (SFTs) and
were stiil instructed to be NPO The inadequate knowledge of staff members
Liquid Fasting Times (LFTs) after midnight whether the may also affect fasting outcome and it is possible
scheduled surgery was in the that healthcare personnel may either have a
SFTs LFTs morning or afternoon. Some reduced awareness or a misinterpretation of
patients fasted from liquids the ASA guidelines. For instance, Ramirez-IMora
Age *P=.OA ^»=.92 for up to 20 hours and from et all4 surveyed Mexican anesthesiologists on
solids for up to 37 hours. These their attitudes towards preoperative fasting
FrankI behavioral ratings studies are comparable to guidelines. They found that 40% had not read
our findings which showed
he fore seJaiion P=50 P=.%1 the ASA guidelines on fasting. Some however
children fasting from liquids for considered only water as a dear fluid, more than
afler sedation P=,25 P=.35 up to 18 hours and from solids half ofthem considered naturalfruitjuicesasdear
Ethnicity P^.29 for up to 21 hours. Our study fluids and only a small proportion of respondents
also showed that children considered industrialized clear juices and black
Parental education P=,28 P=.59 sedated in the morning had coffee as clear fluids. The authors concluded that
longer fasting times than due to poor definition of clear fluids by some
those sedated in the afternoon anesthesiologists, several patients went without
Distance of travel P=.32 P=.3O
and we suspect that parents oral clear fluids for prolonged periods. Our study
whose children were treated results revealed a trend towards prolonged
"Chi-squared test in the afternoon gave them fasting times of approximately 13 hours when

16 The Journal of Pédiatrie Dental Care - Vol, 15, No. 20]Q

multiple persons were involved in providing
preoperative instructions. It is therefore probable
that the varied knowledge of the ASA guidelines
among staff members providing instructions
to parents may have accounted for extended
fasting times. We agree with Crenshaw and
Winslow" that physicians and other health
providers give patients standardized written
and oral instructions about the rationales for
preoperative fasting and recommend that
written instructions be precise and simply
constructed at the appropriate reading level.
In addition we recommend that healthcare
facilities consider designating a single person to
provide preoperative instructions to minimize
confusion. Whereas this might present a
challenge in larger centers, it is incumbent upon
health professionals to prevent misinformation
by providing regular staff updates with careful
review of preoperative fasting protocols.
The mechanism of aspiration in healthy
patients usually occurs by an increase in
residual gastric volume, a decrease in pH, and
a reduction in the esophageal sphincter tone.
There is no evidence that any of these reasons
are a consequence of unrestricted fluid intake
until 2 hours preoperatively'^ Brady et al'*
searched the Cochrane register to identify
preoperative fasting regimes for children; of
the 43 randomized controlled trials involving
2350 children considered to be at 'normal risk'
of régurgitation or aspiration during anesthesia,
only one incidence of aspiration was reported.
They found that children permitted fluids up to
120 minutes preoperatively did not experience
higher gastric volumes or lower gastric pH than
those who fasted. They therefore concluded
that there is no evidence that children who are
not permitted oral fluids for more than 6 hours
benefited over those permitted unlimited fluids
up to 2 hours preoperativeiy. ingebo et al'^
also investigated the relationship between the
time children fasted prior to sedation and their
gastric volume and pH at time of surgery. They
also concluded that there was no advantage to
fasting longer than 2 hours in children before
sedation or anesthesia.
Prolonged fasting can induce a metabolic
rate that is unfavorable in patients'**, lead to
increased discomfort''' and in children, result
in an increase in failed sedation'". Converseiy
reducing preoperative fasting time results in
less postoperative nausea and vomiting^" and a
more comfortable experience'*.
This study confirms what we know from other
studies that patients still remain without food
or drink for lengthy periods prior to surgery. It
is therefore noteworthy that when considering
sedation, the likelihood of prolonged abstinence
generally outweighs the incidence of aspiration.
Despite the implications of cancellations or
delays to surgery, the provision of safe and
optimal care to patients must always be based
on a foundation of flexibility and trust.
Conclusion
This study suggests that
1. Prolonged fasting times exist with pédiatrie
dental sedations.
2. it may not affect the behavior of the
children before or after sedation.
There remains a crucial need for careful review
of fasting protocols for pédiatrie sedations to
prevent the morbidities related to prolonged
abstinence.
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Dr Abimbola 0 Adewumi
Dr Adewumi was born in London, England. She
graduated with a Bachelor of Dental Surgery (BDS)
degree from the University of Ibadan, Nigeria in 1991,
She subsequently moved back to the UK where she
undertook postgraduate training In Orai Surgery and
obtained her Fellowship in Dental Surgery (FDS) from
the Royal Coliege of Surgeons of England in 1996.
Dr Adewumi obtained a Masters degree in Pédiatrie
Dentistry from the University of London in 1999, She
completed her specialist training in Pédiatrie Dentistry
at King's College Dentai Institute and St George's
Hospital also in London. She was awarded a Diploma of
Member in Pédiatrie Dentistry from the Royal College
of Surgeons of England in 2003 and is a Board-certified
Pédiatrie Dentist in the United Kingdom,
Dr Adewumi moved to the US in 2004 and has
been a faculty member in Pédiatrie Dentistry at the
University of Florida College of Dentistry since 2005,
She became a Diplomate of the American Board
of Pédiatrie Dentistry in 2008 following her success
in the two-pan certification process. Her research
interest is in the area of Behavioral Sciences relating
to Pédiatrie Dentistry, Other areas of interest include
the management of children with special heaith care
needs inciuding those with Craniofacial Anomalies.
17
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