Preoperative fasting in children.

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Children undergo a preoperative fast in an attempt to minimize the fluid and solid food component of gastric contents. The importance of a preoperative fast was acknowledged early in the evolution of anesthesia as a discipline of medicine. In response to concerns about the aspiration of gastric contents, a prolonged fast presumably came into vogue. With this practice, it was not unusual to have hungry, irritable children who were prone to hypoglycemia after fasts of 8 ‐12 h or even longer. The purpose of this article is to provide the reader with a narrative review of the literature pertaining to preoperative fasting in children. This article is primarily focused on randomized controlled trials (RCTs), but when not available, literature of lesser intensity was used. We present the physiology of gastric emptying with an emphasis on studies focusing on children in the perioperative period. These studies of gastric emptying were, when possible, divided into studies involving solid food and those involving clear fluids. We then present preoperative fasting of children, which was subdivided by age (neonates, infants, toddlers, and adolescents) and by health (elective versus emergent surgery and healthy versus medically compromised patients). In the concluding portions of this review, we present recommendations for the management of perioperative fasting and recommendations with respect to the need for more research, as more questions remain unanswered than those that have been answered. During preparation of this article, we accepted several links. The linkage between gastric fluid volume and aspiration pneumonia for healthy patients has recently been examined by an ASA taskforce, which concluded that the available data were insufficient to confirm or deny a relationship. Although this means that gastric fluid volume is a surrogate end point for aspiration pneumonia, virtually all studies examining preoperative feeding practices have gastric residual volume as their primary end point. For the purpose of this review, we focus on the end point of gastric residual volume, which is the almost exclusive choice of numerous peer-reviewed investigations. Furthermore, in the practice of anesthesia, patients undergoing emergency surgery have increased gastric contents and are at increased risk of aspiration pneumonia. This is an established link, and if we were to refute it, we would deny the need for rapid-sequence induction plus appropriate airway management during general anesthesia for emergency surgery. Although increased gastric contents increase the risk of aspiration pneumonia, there is no known gastric fluid volume that places a particular patient at clinically relevant risk or eliminates all risk.