Cho E, Song J, Huh J, Kang IS, Kim HJ, Youn IY, Lee H, Kwak JH. Evaluation of Modified Fasting Protocols to Shorten Fasting Time Before Sedation in Children: A Prospective Randomized Noninferiority Trial. Paediatr Anaesth. 2025 Sep;35(9):753-760. doi: 10.1111/pan.15142. Epub 2025 Jun 18. PMID: 40530767; PMCID: PMC12340336.

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Abstract
Backgrounds: Guidelines for fasting before procedural sedation aim to prevent pulmonary aspiration and are primarily targeted for deep sedation. Our study explored whether a shortened fasting protocol is noninferior to the standard protocol by comparing gastric contents evaluated by ultrasound.

Methods: Pediatric patients aged < 3 years, scheduled for elective transthoracic echocardiography under sedation, were randomly allocated to a standard group (4-h fasting) or a modified group (4-h fasting for solid and 1-h fasting for water). Gastric ultrasound was performed to evaluate cross-sectional area (CSA) in supine and right lateral decubitus positions (RLDP), with the upper body elevated at 45°. The primary outcome was the CSA-RLDP (CSARLDP 45). A noninferiority test was performed applying the delta (Δ) of 2.1.

Results: The noninferiority test showed that the modified fasting protocol was noninferior to the standard fasting protocol in terms of CSARLDP 45, with a mean difference (95% confidence interval) of 0.16 (-0.55 to 0.87) within the noninferiority range of delta.

Conclusion: The modified fasting protocol was noninferior to the standard in pediatric patients undergoing sedation for transthoracic echocardiography, as assessed by gastric ultrasound.

Trial registration: ClinicalTrials.gov identifier: NCT05810532.

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Glenski TA, Wu M, Taylor C, Weisberg E, Doyle N. Clear Liquid Fasting Guidelines for Pediatric Patients: A Survey of the Society for Pediatric Anesthesia. Paediatr Anaesth. 2025 Sep;35(9):761-767. doi: 10.1111/pan.15140. Epub 2025 Jun 6. PMID: 40476655.

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Abstract
Introduction: Recently, several international anesthesia societies have updated their guidelines by shortening the NPO clear liquid time from 2 to 1 h in children. When the American Society of Anesthesiologists (ASA) released their interim update to the preoperative fasting guidelines, they maintained the 2-h clear liquid fasting recommendation, while advising the use of clinical judgment for cases involving PO intake within 2 h. Given international support for decreased NPO times, we aimed to evaluate the current practice and opinions of the Society for Pediatric Anesthesia (SPA) members regarding clear liquid NPO times.

Methods: A 17-question survey was developed by members of Children’s Mercy Kansas City Department of Anesthesiology and submitted to the SPA Research Committee for review. After approval, a survey link and QR code were distributed to all SPA members.

Results: A total of 430 surveys (9.85%) were completed. Seventy-three percent indicated that their department follows a 2-h NPO policy for clear liquids, while 24% reported a 1-h policy. Overall, 71% of respondents felt that 1-h is the ideal NPO time for clear liquids. Of the respondents whose department follows a 2-h policy, 86% believe their NPO policy would be shortened if ASA guidelines were updated to 1-h. Forty-nine percent of respondents reported that NPO instructions to patients are congruent with departmental policies, while 33% reported that NPO instructions differ from departmental NPO policies.

Discussion: The results demonstrate that although only a small number of respondents practice a 1-h policy, most respondents believe that a 1-h policy is ideal. This discrepancy is potentially due to adherence to ASA practice guidelines/recommendations, as 86% of respondents who have an NPO policy of 2 or more hours indicated that their departments would switch to 1-h if the ASA were to revise their guideline.

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Dalal PG, Malviya S, Cravero J, Fehr J; Society for Pediatric Anesthesia, Quality and Safety Committee “Nil per Os” Task Force. Reviewing “Nil Per Os” Guidance for Clear Fluids in Children Before Anesthesia: Survey of the Pediatric Anesthesia Leadership Council. Anesth Analg. 2025 Mar 1;140(3):507-514. doi: 10.1213/ANE.0000000000007219. Epub 2024 Nov 19. PMID: 39773771; PMCID: PMC11842216.

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Abstract
Background: Several international pediatric anesthesia societies have endorsed a change in the traditional nil per os (NPO) cutoff of clear fluids (CF) from 2 hours to 1 hour. These recommendations were compiled from large-scale outcomes, gastric ultrasound, and quality improvement studies. The American Society of Anesthesiologists (ASA) recently published their updated guidelines. Despite the lack of prospective randomized studies with conclusive outcomes, several major children’s health systems in North America have already implemented or are modifying their institutional guidelines for CF. The objectives of this survey were to evaluate the current practices, changing trends, perceived benefits, and barriers in reducing the NPO times for CF in children presenting for anesthesia.

Methods: After approval from the Penn State University Institutional Review Board, an electronic survey of the Pediatric Anesthesia Leadership Council (PALC, consortium of Pediatric Anesthesiology Chairs and Division Chiefs across the United States) members was conducted by the Society for Pediatric Anesthesia Quality and Safety Committee (SPA-QS) NPO Clears Task Force between June 2023 and October 2023. Inclusion criteria were PALC membership and single response from each institution.

Results: A total of 88 member institutions were represented by the PALC group. The final response rate was 75 of 88 (85.2%) from across 33 states. Eighty-eight percent of the respondents belonged to a tertiary pediatric center, and 94.7% belonged to an academic setting. At the time of the survey, 8 out of 75 (10.6%) responding institutions followed 1-hour CF cutoff, 7 (9.3%) were in the process of changing to 1-hour and 60 (80%) followed a 2-hour cutoff. 55(73%) respondents actively encouraged CF up to the time they had to be NPO. 46.7% of the respondents reported significant issues (hypoglycemia, dehydration, difficulty in establishing intravenous access, patient and parental dissatisfaction) with prolonged fasting in children. The survey responses included multiple comments in favor of changing guidelines to 1 hour for CF in healthy young children. The overarching concern for implementation of 1-hour cutoff for CF was the potential medicolegal ramification of a policy change in the absence of an official statement from national professional societies.

Conclusions: The survey demonstrates growing trends toward implementing the reduced NPO time for CF to 1 hour nationally. Based on the current ASA guidelines, the SPA-QS committee recommends close attention to NPO times and strongly encourages CF consumption up to the recommended cutoff time. It appears reasonable to follow a 1-hour cutoff for CF as deemed appropriate by the attending anesthesiologist or the institution.