Abstract and Keywords:

Keywords: Preoperative, Fasting, Adherence, Paediatrics, Guidelines

Background: Fasting is a preoperative requirement in children to reduce the
incidence of complications such as regurgitaion and aspiration, but prolonged fasting
can lead to dehydration, hypotension, metabolic disturbances, and hypohylcaemia.
Aims: This study aims in assessing the adherence to the fasting orders as given by the
anaesthetist and also the incidence of prolonged fasting for solids, breast milk and
water for these children undergoing surgery. It will also assess the behaviour of the
children pre-operatively and post-operatively.
Methods: A prospective study was conducted in a tertiary care institute in Tamil
Nadu, India. A total of 50 patients were assessed and included in the study. Data
analysis was done using Microsoft excel. The results were presented in tables, charts
and graphs. Paediatric age group between 2months to 16 years of ASA I and ASA II
who were planning to undergo surgery in our institute electively were included in the
study.
Results: A total of 50 patients were recruited for this study. The guidelines were
followed by 98 % of the study population.
The preoperative fasting time for solids varied from 4 hrs to 14.3 hrs, with a mean of
9.37 hrs (±2.47), breast milk was 4 hrs to 9.5 hrs, with a mean of 5.38hrs (±1.89), and
water and clear fluids was from 1 hrs to 14.3 hrs, with a mean of 4.59hrs (±2.89).
There was a delay of more than 2 hours to start the induction of anaesthesia in 14 % of
the cases. 10% of all the children showed abnormal behaviour in the recovery room
post-operatively. 38 % of all children were over-fasted.
Conclusion: 98 % was the adherence to the fasting orders and it was shown that
children who had followed the fasting orders more closely and had less duration of
prolonged fasting had lesser preoperative and post-operative abnormal behaviour.

Introduction: Paediatric patients that are posted for elective cases need to have
adequate fasting to avoid complications such as aspiration and regurgitation, however
on the opposite spectrum there is complications of irritability, hunger, dehydration,
anxiety etc. when the child is made to fast for prolonged periods. The American
Society of Anaesthesiologists have recommended that the standard guidelines for
preoperative fasting for children is 2 hours for water and clear fluids, 4 hours for
breast mild and 6 hours for solids. (1-3)
Aims and objectives:
Primary objective: To assess the compliance to The American Society of
Anaesthesiologists (ASA) guidelines for fasting in children in a tertiary hospital in
Tamilnadu between March 2020 to April 2020.
Secondary objective: To determine the reasons for which there was deviation in the
guidelines recommended for fasting and also the effect that the fasting has on the
child’s preoperative and postoperative behaviour.

Review of literature:
Preoperative fasting is a prescribed time prior to a procedure or a surgery during
which patients are restricted from oral intake of liquids and solids. This is to ensure
that the volume and the acidity of the stomach is decreased to safe levels to avoid the
complications that can come with under-fasting such as aspiration and regurgitation.
The general consensus that is present between anaesthesiologists is that the required
duration for fasting for clear liquids and water is 2 hours, 4 hours for breast milk, 6
hours for solids and food that contains fatty or fried items require 8 or more hours. All
patients should be encouraged to drink oral clear fluids that contain some
carbohydrates up to a period of 2 hours as they have reduced rates of hunger, thirst,
dehydration, and better haemodynamic stability. (3,4)
Prolonged fasting results in rapid dehydration and the requirement for fluid
administration intraoperatively increases. This also results in increased blood loss
during surgery. (5)
Some of the reasons that parents have given for not being able to adhere to the fasting
orders that are given by the anaesthetist are that “the child needs to eat well prior to
the surgery to keep up their strength”, The child also cries inconsolably due to hunger
and thirst and the parents out of desperation give oral fluids/food to relieve those
symptoms. (3)
Materials and methods:
Ethical committee approval was obtained to followup the details of 50 children in the
age group of 2 months to 14 years in the department of Anesthesia. All 50 children
were posted for elective surgery and the observations were noted by the
anaesthesiologists who were also responsible for writing the fasting orders one night
prior to the day of the surgery, taking into consideration the time of the surgery.
The observations that were noted were the delay in the starting of the surgery, the real
starvation duration, and disobedience in following the fasting orders, preoperative and
postoperative behaviour, requirement of post-operative analgesia, recovery time, and
post-operative feeding details.
Apart from the above any deviation in the time noted as per the schedule and the time
of induction of anaesthesia was also noted. Fasting order on water, clear juice, breast
milk, and solids was collected from the parents. Any reasons that the parents gave to
initiate feeds was also noted. If the child was fasted for more than 2 hours than the
recommendations provided by the ASA guidelines then it was considered that the
child was over-fasted.
Results: The data of 50 patients was collected. Of which 68 % were males and 32 %
were females. The age group of the study population ranged from 2 months to 14
years. The mean age was 4.92 years (±4.05). The mean weight was 16.88kg (±11.79).
The preoperative fasting time for solids varied from 4 hrs to 14.3 hrs, with a mean of
9.37 hrs (±2.47), breast milk was 4 hrs to 9.5 hrs, with a mean of 5.38hrs (±1.89), and
water and clear fluids was from 1 hrs to 14.3 hrs, with a mean of 4.59hrs (±2.89).
The difference between the posted time and the anaesthesia time was also noted. A
difference of more than 2 hours was considered to be a significant delay. Of the 50
patients, 3 cases were excluded due to incomplete data, 8 cases was able to start prior
to the scheduled time. 33 cases started without any significant delay. 7 cases had a
significant delay.
1 child had received feeds within the fasting orders despite providing proper
instructions as they gave soup thinking it to be similar to water/clear fluids. The
operation was done after the adequate duration of fasting.
40% of all children were over-fasted, which means that there was more than 2 hours
extra fasting duration as compared to the recommendations for solid, breast milk and
water/clear fluids.
The children’s behaviour was also assessed in the holding bay and 5 children (10%)
showed abnormal behaviour in the holding bay e.g. crying, irritability, anxiety due to
hunger and thirst. Of which 4 (8%) children were over-fasted.
12 (24%) were crying the recovery in the post-operative period and of those crying, 4
of them were over-fasted and 8 were adequately fasted. 3 children (6%) required
analgesics. 5 children (8%) also required feeds in the recovery room itself.
Mean recovery time was also 25.58 mins (±3.46) for all the children, it was 24.06
minutes for children who were not over-fasted and 24.78 mins who were adequately
fasted.

Discussion: We were able to find out that children who were over-fasted were had on
an average 1.3 minutes less recovery time but it was not statistically significant
(p>0.05). On multivariate analysis taking into consideration whether the child was
crying in the recovery, required analgesia, required feeding in the recovery room,
children who were over-fasted were 1.2 times more likely to show abnormal
behaviour in the holding bay, however i.t was not statistically significant (p>0.05).
Conclusion:
We were able to mostly adhere to the ASA guidelines of fasting in a majority of the
cases. However a small proportion of the cases we were not able to adhere to the
timings as there was non-availability of the surgeon, or other technical problems.
Younger children should always be given priority while deciding the order of an
operation list. Occasionally the parents of the child will not follow the orders given by
the anaesthetist as there may be anxiety on the side of the parents, language barrier,
and miscommunication by the staff etc.
Children who are over-fasted are more likely to show abnormal behaviour in the
perioperative period. Hence it is beneficial to fast the children for correct period for
water/clear fluids, breast milk and solids. This helps in a smoother induction and
discharge from the recovery and an overall less traumatic experience for the child as
well as the parents.
References:
1) American Society of Anesthesiologists Committee, Practice Guidelines for
Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of
Pulmonary Aspiration : Application to Healthy Patients, vol. 114, 2017, p. 495, 3.
2) I. Smith, P. Kranke, I. Murat, A. Smith, G.O. Sullivan, E. Søreide, et al.,
Perioperative fasting in adults and children : guidelines from the, Eur. Soc.
Anaesthesiol. 28 (8) (2011) 556–569.
3) Yimer AH, Haddis L, Abrar M, Seid AM. Adherence to pre-operative fasting
guidelines and associated factors among pediatric surgical patients in selected public
referral hospitals, Addis Ababa, Ethiopia: Cross sectional study. Ann Med Surg
(Lond). 2022 May 21;78:103813. doi: 10.1016/j.amsu.2022.103813. PMID:
35734657; PMCID: PMC9207049.
4) E. Søreide, L.I. Eriksson, G. Hirlekar, H. Eriksson, S.W. Henneberg, R.R.J. Sandin,
Pre-operative fasting guidelines: an update, Acta Anaesthesiol. Scand. 49 (20) (2005)
1041–1047.
5)  Y. Li, R. He, X. Ying, R.G. Hahn, Dehydration, Hemodynamics and fluid volume
optimization after induction of general anesthesia, Clinics 69 (12) (2014) 809–816.
Tables:

Abnormal behaviour in children in various locations

40 38 38

35

30

25
Number

20

15 12
10
5
5

0
Holding bay Recovery room
Place

N=50
Abnormal behaviour Normal behaviour

Gender

16

N=50

34

Males Females

Fasting

20

N=50

30