CAEC Reg. I.D. No.

1318 Sheffield Children’s (NHS) Foundation Trust

Preoperative Starvation Guidelines

Guideline for Preoperative

Starvation of Elective and
Emergency Patients
Reference: 1318v3
Written by: Dr Judith A Short, Consultant Paediatric Anaesthetist
Peer reviewer: Dr Teresa Dorman, Consultant Paediatric Anaesthetist
Approved: January 2017
Review Due: March 2020

Purpose
To optimise comfort of patients waiting for surgery, while minimising the risk of
pulmonary aspiration.

Intended Audience
This guideline is for use by all health professionals in SC(NHS)FT when preparing
patients for operative procedures.

Author: Dr Judith A Short, Consultant Paediatric Anaesthetist Review date: March 2020
© SC(NHS)FT 2016. Not for use outside the Trust. Page 1 of 5
CAEC Reg. I.D. No. 1318 Sheffield Children’s (NHS) Foundation Trust
Preoperative Starvation Guidelines

Table of Contents
1. Introduction
2. Intended Audience
3. Guideline Content
4. References

1. Introduction
The purpose of guidelines on fasting times prior to general anaesthesia is to reduce
the potentially fatal risk of pulmonary aspiration of gastric contents, but also to avoid
the discomfort and morbidity of prolonged starvation. Small children may be
particularly at risk of dehydration and hypoglycaemia, and all children dislike the
feelings of hunger and thirst. The following guidelines are designed to minimise
prolonged fasting times, while concurring with national and international
recommendations [see below, 1-6]:

2. Intended audience
This guideline is for use by all health professionals in SC(NHS)FT when preparing
patients for operative procedures.

3. Guideline content
Oral intake should be restricted prior to general anaesthesia as follows:

ELECTIVE SURGERY

Infants up to 12 months of age

Solid food Formula feed Breast milk Clear fluids
(if weaned)
Morning list Fast from Please feed at Please feed at
2.30am 5am then fast until 6am then fast
theatre until theatre Allow sips until
Afternoon list Fast from Please feed at Please feed at called to theatre
7.30am 9.30am then fast 10.30am then fast
until theatre until theatre

Older Children (over 12 months)

Food, milk, formula, Breast milk Clear fluids
sweets, fizzy drinks
Morning list Fast from 2.30am Please feed at 6am
then fast until theatre Allow sips until
Afternoon list Fast from 7.30am Please feed at 10.30am called to theatre
then fast until theatre

Author: Dr Judith A Short, Consultant Paediatric Anaesthetist Review date: March 2020
© SC(NHS)FT 2016. Not for use outside the Trust. Page 2 of 5
CAEC Reg. I.D. No. 1318 Sheffield Children’s (NHS) Foundation Trust
Preoperative Starvation Guidelines

EMERGENCY SURGERY

Infants up to 12 months of age:

Unrestricted clear fluid before anaesthesia unless instructed otherwise
Breast milk up to 3 hours before anaesthesia
Formula feed up to 4 hours before anaesthesia
Solid food up to 6 hours before anaesthesia

Children over 12 months:

Unrestricted clear fluid before anaesthesia unless instructed otherwise
Breast milk up to 3 hours before anaesthesia
Cow’s milk / formula up to 6 hours before anaesthesia
Solid food up to 6 hours before anaesthesia

NOTES:

General information:
Children should be actively encouraged to drink unrestricted clear fluids
before the start of elective operating lists. Selected ice lollies may also be
allowed.
Clear fluids are water, diluted squash and fruit juice without pulp. Glucose
polymer solutions (e.g. Polycal) are allowed where required for glycaemic
control. Fizzy drinks, juice with pulp and drinks containing milk are excluded.
Chewing gum and boiled sweets are considered food and not
recommended. However, we would not postpone an operation based on use
of chewing gum alone.
Some patients may need IV fluids starting to cover the period of starvation.
Examples would be neonates starved for longer than 4-6 hours, some
metabolic conditions, sickle cell anaemia, and diabetes.
Continuous nasogastric or gastrostomy tube feeding should usually be
discontinued a minimum of 4 hours (<12 month babies) or 6 hours (children
>12 months) prior to anaesthesia. This should be determined individually with
the anaesthetist.
Oral contrast prior to abdominal CT scanning should be given a minimum of
2 hours prior to anaesthesia, or by nasogastric tube after anaesthetic
induction.
Bowel prep should be completed 6 hours prior to anaesthesia as it is
thickened liquid. Clear fluids should be encouraged prior to anaesthesia to
avoid dehydration.

Emergency surgery:
The recommendations are sometimes slightly different for patients listed for
emergency surgery, as trauma and acute illness delay gastric emptying.
Sometimes arrangements might be made to fast a child so that they can be
done if there is spare theatre space. This might lead to some children being

Author: Dr Judith A Short, Consultant Paediatric Anaesthetist Review date: March 2020
© SC(NHS)FT 2016. Not for use outside the Trust. Page 3 of 5
CAEC Reg. I.D. No. 1318 Sheffield Children’s (NHS) Foundation Trust
Preoperative Starvation Guidelines

starved for longer than necessary, but gives us the flexibility to proceed if we
can. Establish the strategy with the anaesthetist who is doing the case.
Slightly prolonged fasting times are unlikely to cause clinically significant
problems in most patients and allowing unrestricted clear fluids should
alleviate thirst. Discuss with theatres or the on-call anaesthetist if uncertain
(bleep 525).
Normal policy may be ignored in life or limb threatening cases. Not all patients
are the same: ultimately the starvation strategy will be up to the anaesthetist
concerned.

Medication while fasting:

Regular medication taken orally should be continued while fasting (ideally
given at least 2 hours preoperatively, to allow absorbtion) unless there is
advice to the contrary. This includes oral analgesia and antibiotics prescribed
for children awaiting emergency surgery. Children may be allowed a cup of
water to help them take their medication.
Oral premedication, e.g. midazolam may be given less than 1 hour prior to
anaesthesia.

Explanation to parents:
We do our best to keep starvation times down to a minimum, but we cannot always
predict when an operation is going to proceed. We actively encourage parents of
babies under 6 months to wake the baby and give a feed during the night before a
planned morning operation, to ensure the fasting time is kept to a minimum.
Out of hours, the order in which patients come to theatre is always under review and
patients may be moved further down the list by cases that are more urgent. This
may even mean that cases that are planned for the evening are postponed until the
next day, at short notice. Our priority is the safety of the patient, as patients who
have full stomachs could regurgitate whilst anaesthetised and inhale their stomach
contents. The consequences can be life threatening.

Postoperative resumption of oral intake in healthy infants and children:

Oral fluids can be offered to healthy infants and children when they are fully
awake following anaesthesia, providing there are no medical, surgical or
nursing contraindications – check the operation notes or with the surgeon if
unsure.
Clear fluids or breast milk should be offered before introducing other oral
intake.
Infants and children undergoing day surgery should not be required to drink as
part of the discharge criteria [3]. Encouraging children to drink before they are
ready increases the incidence of post-operative nausea and vomiting.

Author: Dr Judith A Short, Consultant Paediatric Anaesthetist Review date: March 2020
© SC(NHS)FT 2016. Not for use outside the Trust. Page 4 of 5
CAEC Reg. I.D. No. 1318 Sheffield Children’s (NHS) Foundation Trust
Preoperative Starvation Guidelines

4. References

1. Brady M, Kinn S, O’Rourke K, Randhawa N, Stuart P. Preoperative fasting for

preventing perioperative complications in children (Review). Cochrane
Database of Systemic Reviews
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005285/p
df_fs.html
2. Perioperative fasting in adults and children – An RCN guideline for the
multidisciplinary team. RCN publications, November 2005
http://www.rcn.org.uk/publications/pdf/guidelines/perioperative_fasting_adults_
children_full.pdf
3. Warner MA et al, Practice Guidelines for preoperative fasting and the use of
pharmacologic agents to reduce the risk of pulmonary aspiration: Application
to healthy patients undergoing elective procedures: A report by the American
Society of Anesthesiologists Task Force on Preoperative Fasting.
Anesthesiology 1999; 90 (3): 896-905
4. Cook-Sather SD and Litman RS. Modern fasting guidelines in children. Best
Practice and Research Clinical Anaesthesiology 2006; 20(3): 471-481
5. Ragg P. Let them drink! Pediatric Anesthesia 2015; 25(8): 762-3
6. Anderson H, Zaren B, Frykholm P. Low incidence of pulmonary aspiration in
children allowed intake of clear fluids until called to the operating
theatre. Pediatric Anesthesia 2015; 25: 770–777

Author: Dr Judith A Short, Consultant Paediatric Anaesthetist Review date: March 2020
© SC(NHS)FT 2016. Not for use outside the Trust. Page 5 of 5