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                              2 h
Breast milk                             4 h
Infant formula                          6 h
Non-human milk                          6h
Light meal                             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.


Mailto:[log in to unmask]

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html