Sara, the below is from my files. The information is from 2000.
I'm sorry that it is so long.
Pat Gima, IBCLC
Milwaukee, Wisconsin
> Thanks for writing... there actually is a consensus Practice Guideline
> issued by the American Society of Anesthesiologists. It was recently
> updated based on new studies. Here is the relevant quote:
>
> "The ASA Practice Guidelines for Preoperative Fasting suggests that
patients undergoing elective surgery may be allowed to drink limited
quantities of clear liquids up to two hours before surgery with permission
from their physicians. Clear liquids include water, fruit juices without
pulp, carbonated beverages, clear tea and black coffee. These liquids
should not include alcohol.
>
> Studies show that there are significant benefits to allowing patients to
drink clear liquids up to two hours before surgery. Patients, especially
children, are less anxious, better hydrated and may have fewer headaches
and nausea after surgery. The developers of the guidelines have concluded
that clear liquids are digested quickly, so the amount of liquid a patient
drinks before anesthesia is not as important as what the patient drinks.
>
> The guidelines are more strict when it comes to breast milk, nonhuman
milk and solid food. Breast milk is more easily digested than nonhuman milk
but should not be given to babies less than four hours before surgery. The
guidelines state that surgical patients should avoid solid food, nonhuman
milk and infant formula for at least eight hours before surgery."
>From the ASA guidelines:
> III. Preoperative fasting status (breast milk)
>
> There is insufficient published evidence to evaluate the relationship of
the timing of breast milk intake before procedures to the incidence of
emesis/reflux or pulmonary aspiration. The Consultants and Task Force
support a fasting period for breast milk of 4 hours for both neonates
and infants.
>
> Recommendations:
> It is appropriate to fast from intake of breast milk for 4 or more hours
before procedures requiring general anesthesia, regional anesthesia, or
sedation/analgesia (i.e., monitored anesthesia care)
>
> Unfortunately the web version of the guidelines do not have the
bibliography included. The bottom of the page just says to contact the ASA
if you are interested in the data and statistical methods used to come up
with these recommendations. So - I can't give you the specifics... but
you'll note that they said there is "insufficient published evidence".
>
> Basically they treat breast milk as in-between clear liquids (2 hours)
and non-human mild (6 hours)... which at least one study does support.
>
Pre-op NPO Status for infants and Children
especially Breastfed Children
Below is the evidence that supports changing routine management of pediatric
patients preoperatively--especially breastfed infants. As you will see from
the below information there is plenty of documentation to support a change in
practice, thereby improving the quality of care we provide our pediatric
patients. Changing pre-op fasting guidelines will improve quality of care
based on the studies which demonstrate that there are significant benefits to
allowing patients to drink clear liquids up to two hours before surgery.
Patients, especially children, are less anxious, better hydrated and may have
fewer headaches and nausea after surgery.
First and foremost are the recent consensus practice guidelines issued by the
American Society of Anesthesiologists. It was recently updated based on new
studies. Basically they treat breast milk as in-between clear liquids (2
hours) and non-human milk (6 hours).
Here are the relevant guidelines summarized in a table:
Table 1. Summary of Fasting Recommendations toReduce the Risk of Pulmonary
Aspiration 1
Ingested Material Minimum Fasting Period 2
Clear liquids 3 2 h
Breast milk 4 h
Infant formula 6 h
Non-human milk 4 6h
Light meal 5 6h
1 These recommendations apply to health patients who are undergoing elective
procedures. They are not intended for women in labor. Following the
guidelines does not guarantee a complete gastric emptying has
occurred.
2 The fasting periods noted above apply to all ages.
3 Examples of clear liquids include water, fruit juices without pulp,
carbonated beverages, clear tea, and black coffee.
4 Since non-human milk is similar to solids in gastric emptying time, the
amount ingested must be considered when determining an appropriate fasting
period.
5 A light meal typically consists of toast and clear liquids. Meals that
include fried or fatty foods or meat may prolong gastric emptying time. Both
the amount and type of foods ingested must be considered when determining an
appropriate fasting period.
These guidelines and the above table can be viewed in their entirety at this
web site address: http://www.asahq.org/practice/NPO/NPOguide.html . You may
also find this statement at:
Preoperative Fasting ANESTHESIOLOGY 1999; 90:896-905.
Additional supportive evidence can be found in the results of a survey
regarding NPO requirements for breastfed infants in this article:
Lynne R. Ferrari, M.D.*; Fiona M. Rooney†; Mark A. Rockoff, M.D.‡
Preoperative Fasting Practices in Pediatrics
This article is featured in "This Month in Anesthesiology."
ANESTHESIOLOGY 1999; 90:978-980
Some institutions (36%) consider the composition of breast milk to be
equivalent to that of a clear fluid, others (34%) equivalent to a solid, and
the remaining institutions consider it "something else." This is likely due
to the paucity of data examining absorption of breast milk in healthy
infants. Most institutions (77%) consider at least a 4 hour fast for breast
milk to be sufficient; only 23% allowed breast milk to be ingested less than
4 hour before induction.
According to Jack Newman, MD, FRCPC, "Philadelphia Children's and Boston
Children's have 3 hour NPO periods for nursing infants." Here are a few
references, which support and suggest up to three hours:
Litman RS, Wu CL, Quinlivan JK. Gastric volume and pH in infants fed clear
liquids and breastmilk prior to surgery. Anesth Analg 1994;79:482-5
Schreiner MS. Preoperative and postoperative fasting in children.
Pediatric
Clinics of North America 1994;41:111-20
Nicolson SC, Schreiner MS. Feed the babies. (editorial) Anesth Analg
1994;79:407-9
In fact, at Boston Children's Hospital they consider breastmilk a clear
fluid, and it is listed right there in the printed-information guidelines,
alongside juice and water, as something the child CAN have up to 3 hours
pre-op. Formula is listed as somthing the child CANNOT have. As I am sure you
are aware, this is widely considered to be among the best anaesthesia
departments in the county.
Some final supportive references are:
Spear R. Anesthesia for premature and term infants: peri-operative
implications. J Pediatr 1992; 120:165-75
Emerson BM (1999). Pre-operative fasting for paediatric anaesthesia. A
survey of current practice. Anaesthesia 53(4) 326-330.
Anesth Analg 1998 Jul;87(1):57-61
In summary, there are many studies, a few reputable institutions and a
report by the American Society of Anesthesiologist that all provide clear
evidence to warrant a change in how we practice.
Here are a few more references to support the brief period of NPO prior to
surgery kindly given to me by Dr. Gartner:
Litman R et al. Gastric volume and pH in infants fed clear liquids and
breastmilk prior to surgery. Anesth Analg 1994; 79:482-85
Schreiner M. Preoperative and postoperative fasting in children. Ped
Clin N.A. 1994; 41:111-120
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