I received the following information when a client's baby had to have
surgery last fall.

Pat Gima, IBCLC
Milwaukee, Wisconsin


>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
>      Spear R. Anesthesia for premature and term infants: pelriperkative
>implications. J Pediatr 1992; 120:165-75
____________________________________________________________
>References for Dorothy Rae Collier regarding length of time for breastfed
>infants to be NPO before surgery:
>
>Litman RS, Wu CL, Quinlivan JK. Gastric volume and pH in infants fed clear
>liquids and breast milk prior to surgery. Anesth Analg 1994; 79:482-5.
>
>In a prospective, blinded study, 24 breastfed infants nursed as usual 2
>hours prior to surgery (feeding ended by 1 1/2 hours before anesthesia
>induction). After induction of general anesthesia and tracheal intubation,
>gastric fluid samples were aspirated and volume and pH were measured.
>Sufficient gastric fluid for analysis was obtained from 8 (33 %) of the
>infants.
>The volumes were great enough that the authors do not recommend
>breastfeeding less than 3 hours before surgery.  The majority of the
>infants had residual gastric contents which were alkaline.  Animal studies
>suggest that this higher pH may confer an advantage in case of pumonary
>aspiration. The formula fed infants in the study were safely able to
>receive 2 - 8 ounces of clear liquids up to 2 hours prior to surgery.
>
>Schreiner MS.  preoperative and postoperative fasting in children.
>Pediatric Clinics of North America 1994; 41(1):111-119.
>
>"Until early 1990 perioperative oral fluid management for children could be
>summarized as 'Starve Preop: Feed Postop.'  Recent advances have reversed
>the conventional wisdom and now allow children to drink clear liquids up
>until 2 hours prior to surgery and to fast after surgery until they want to
>eat.  The pattern of gastric emptying of milk, formula and breast milk
>needs further investigation..."  The author's recommendations are for clear
>liquids to be stopped 2-3 hours before arrival at the hospital for day
>surgery anesthesia, and breast milk 3 hours before.  He refers to a 1987
>study by Tomomosa (Gastroduodenal motility in neonates: response to human
>milk compared with cow's milk formula. Pediatrics 1987; 80:434) that showed
>that 3 hours after a test meal, 75% of breastfed infants but only 17% of
>formula fed infants had entered a fasting state.  "Breast milk clearly
>empties faster than formula but slower than clear liquids."
>
>Dr. Schreiner is with the Dept. of Anesthesia at Children's Hospital of
>Philadelphia, with a very high volume of patients.
>
>Both of these articles are worth getting to show those who are still
>advocating prolonged fasting for infants and young children. Also see
>Correspondence columns in the British Journal of Anesthesia for March 1995
>Vol. 74 (no 3) p. 349 and September 1995 Vol 75 (no 3) p. 375 for more
>support for the 2 hour clear liquid timing (no mention there of breast
>milk).
____________________________

>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.

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