This open-access article is distributed under

Creative Commons licence CC-BY-NC 4.0. RESEARCH

A prospective study of paediatric preoperative

fasting times at Red Cross War Memorial Children’s
Hospital, Cape Town, South Africa
A J Kouvarellis,1 MB ChB, DA (SA); K van der Spuy,1 BSc Hons (Physiotherapy), MB ChB, FCA (SA), MMed (Anaesth);
B M Biccard,1 MB ChB, FFARCSI, FCA (SA), MMed (Anaesth), PhD; G Wilson,2 MB ChB, FCA (SA)

1
Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
2
D
 ivision of Paediatric Anaesthesia, Department of Anaesthesia and Perioperative Medicine, Red Cross War Memorial Children’s Hospital and
Faculty of Health Sciences, University of Cape Town, South Africa

Corresponding author: A J Kouvarellis (akouvarellis@gmail.com)

Background. Fasting for liquids and solids is recommended prior to procedures requiring anaesthesia, to reduce the risk of pulmonary
aspiration. Children often experience excessive fasting, which is associated with negative physiological and behavioural consequences, and
patient discomfort. The duration of preoperative fasting in children in South Africa (SA) is unknown.
Objectives. To determine compliance with fasting guidelines and fasting times of children prior to elective procedures performed under
anaesthesia at a paediatric hospital in Cape Town, SA. The primary focus was fasting for clear liquid. We also intended to identify the most
common reasons for prolonged clear liquid fasting.
Methods. Over a 7-week period, we prospectively captured fasting times of consecutive patients undergoing elective surgical, medical
and radiological procedures at Red Cross War Memorial Children’s Hospital. Measurement outcomes were defined as the period from the
last clear liquid, milk or solid feed to the start of anaesthesia. For analysis of compliance with preoperative fasting guidelines, institutional
preoperative fasting target limits were established based on the standard 6-4-2-hour guideline.
Results. The study included 721 elective paediatric cases. The mean (standard deviation (SD)) fasting time for clear liquids (n=585) was
8.0 (4.8) hours, with an adherence rate of 25.5% (95% confidence interval 22 - 29) to the institutional target of 2 - 4 hours. The mean (SD)
fasting times for breastmilk (n=92), formula milk (n=116) and solid feeds (n=560) were 7.1 (2.8), 8.8 (2.8) and 13.9 (3.6) hours, respectively.
The factors associated with clear liquid fasting >4 hours were inadequate fasting instructions, poor adherence to fasting orders, procedural
delays and fasting to promote theatre flexibility.
Conclusions. This study demonstrates that children in an SA hospital experience excessive fasting times prior to elective procedures.
To reduce fasting durations and improve the quality of perioperative care, quality improvement interventions are required to create an
adaptable fasting system that allows individualised fasting. Improving preoperative fasting times in children is the responsibility of all
healthcare professionals in the multidisciplinary management team.

S Afr Med J 2020;110(10):1026-1031. https://doi.org/10.7196/SAMJ.2020.v110i10.14814

The routine application of preoperative fasting, first introduced in In healthy paediatric patients, the risk of aspiration is low and
1883, is intended to reduce the morbidity of anaesthesia-related complications from clear liquid aspiration are rare.[17-21] Reducing
regurgitation and pulmonary aspiration.[1] The current American preoperative clear liquid fasting times improves patient comfort and
Society of Anesthesiologists (ASA) preoperative fasting guidelines quality of care without theatre disruption.[11,22]
recommend the following fasting periods: 6 hours for solids and
non-human milk, 4 hours for breastmilk, and 2 hours for clear Objectives
liquid.[2] These guidelines apply to patients with oral and nasogastric Preoperative fasting of children in South Africa (SA) has not been
tube (NGT) intake preparing for elective procedures requiring investigated. Clinical observation would suggest that fasting times
monitored anaesthetic care.[2] Nasojejunal tube (NJT) feeds should be parallel the international trend. This study aimed to elucidate current
discontinued 2 hours prior to anaesthesia.[2] fasting practices of children before anaesthesia for elective procedures
International paediatric literature has highlighted that preoperative at Red Cross War Memorial Children’s Hospital (RCWMCH), a
fasting durations frequently exceed the minimum durations tertiary paediatric hospital, as the first step to improving quality of
recommended by these guidelines, with average fasting times for care. The primary objective was to determine the mean duration of
clear liquid of 6.3 - 12.61 hours,[3-8] breastmilk 6.27 - 9.82 hours,[3,8] preoperative fasting for clear liquid and the percentage of children
formula milk 9.9 hours[8] and solids 10.0 - 14.08 hours.[3-8] Extended fasted for 2 - 4 hours, in compliance with institutional fasting
fasting confers no advantages, but rather incites significant standards for clear liquids. The secondary objectives included mean
physiological, psychological and behavioural perturbations including fasting times for breastmilk, formula milk and solids, and the
hypoglycaemia, ketoacidosis, hypotension at induction of anaesthesia, percentage compliance with their respective preoperative fasting
hunger, thirst, sadness, irritability and anxiety.[3,5,8-14] Children aged standards. Reasons for prolonged clear liquid fasting and the
<36 months are most vulnerable to these complications.[15,16] incidence of regurgitation and aspiration were reviewed.

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Methods Sample size

This was a single-centre prospective observational study conducted Acceptable compliance with the institutional target fasting time for
from 4 October to 23 November 2018 at RCWMCH, Cape Town, SA. clear liquids was set at 90%. If the proportion of patients fasted for
The protocol, data collection sheet and consent poster were approved clear liquid <2 hours and >4 hours was found to be >10%, with a 95%
by the Human Research Ethics Committee of the Faculty of Health confidence interval (CI) that did not include 10%, RCWMCH would
Sciences of the University of Cape Town (ref. no. 410/2018) and be considered non-compliant for clear liquid fasting. A calculated
the RCWMCH Research Committee (ref. no. RXH: RCC: 15). The sample size of 484 cases with enteral clear liquid intake data was
conduct of the study upheld patient privacy and confidentiality. required to prove non-compliance, with a two-sided 95% CI of 6%.[24]
We aimed to recruit an additional 20% (97 cases) to compensate for
Participants incomplete data.
Inpatients and outpatients undergoing general anaesthesia or
sedation for elective medical, surgical or radiological procedures at Data analysis
RCWMCH were eligible for recruitment. This included patients aged All captured data were de-identified, entered into an Excel chart
<18 years of all ASA physical status classifications, receiving enteral (Microsoft Excel for Mac version 16.40; Microsoft, USA), and
nutrition via oral, NGT, percutaneous endoscopic gastrostomy (PEG) analysed using SPSS software, version 25 (IBM, USA). Descriptive
or NJT. Unscheduled and/or emergency cases and patients receiving analyses were conducted and results appropriately represented as
total parenteral nutrition (TPN) were excluded. Patients prescribed mean and standard deviation (SD) or median and interquartile
‘bowel preparation’ were excluded from all but the clear liquid range (IQR). Frequencies of patients with fasting times consistent
analysis. Patients whose procedures were postponed or cancelled with compliance were expressed as percentages derived using the
were excluded owing to time and resource constraints. total number of times available for that fasting category. Bivariate
analyses were performed using parametric or non-parametric
Outcome measures tests as appropriate. Subgroup analysis of clear liquid fasting time
Measurement outcomes were fasting times, defined as the period was performed according to the age of the children: <12 months,
from the last liquid, milk or solid feed time to the start time of 12 - 36 months, and >36 months. The relationship between
anaesthesia.[4] For analysis of compliance with preoperative fasting age and mean clear liquid fasting time was assessed using the
guidelines, institutional preoperative fasting target limits were Kruskal-Wallis test. A χ2 test of independence was performed to
established using the standard 6-4-2 guideline, plus 2 hours for examine the relationship between age and compliance with clear
each category.[4,23] This provided a clinically feasible goal without liquid fasting time. To investigate for confounding variables,
significant negative physiological impact. Acceptable time limits for an independent-samples t-test was performed, comparing mean
fasting are defined in Table 1. Non-compliance was defined as fasting clear liquid fasting time in patients with and without preoperative
times outside these ranges. intravenous (IV) maintenance fluids. To identify possible selection
Anaesthesiologists recruited consecutive patients and obtained bias, characteristics of captured and non-captured cases were
data, including last intake time for clear liquid, milk and/or solids, assessed as follows: age (two-tailed t-test), sex (Fisher’s exact test),
via in-person interviews with parents immediately preoperatively. weight (Mann-Whitney U-test), ASA classes (χ2 test) and admission
A standardised case report form (CRF), based on previous studies,[7,8] status (Fisher’s exact test).
was used. Parents or guardians provided verbal consent, and opt-out
posters were clearly displayed. Translation from English was available Results
and performed as required. The CRF included a checklist of reasons The study cohort included 721 patients, of whom 585 were eligible for
for prolonged clear liquid fasting and an area for additional reasons analysis of the primary outcome (Fig. 1). The 100 patients excluded
and/or comments. owing to missing data did not differ significantly from recruited
Missing data, unrelated to fasting times, were retrospectively patients, with the exception of ASA and inpatient status. The time
acquired from patient records. CRFs with no recorded fasting times of last intake of clear liquid was not captured in 136 recruited cases
were excluded. Patients with NGT and PEG intake were included (18.9%), for the following reasons: 2 patients had an ‘unknown
in the oral intake group, since the same guidelines for preoperative time’ of last liquid intake, 23 were exclusively breastfed, 16 were
fasting apply. For children receiving breastmilk and formula milk, exclusively formula fed, 17 received IV preoperative fluids, and 78
the fasting time for the primary feed was analysed. Similarly, the most had no oral or IV liquid intake captured preoperatively. This study
recent infant formula milk or solid feed was analysed as an additional included 411 ward inpatients, 13 intensive care unit patients and
combined ‘last feed’ category. Distinguishing between formula milk 297 outpatients from a wide range of surgical specialities. Clinical and
and solids is of little clinical importance and may be a source of surgical patient characteristics are summarised in Table 2.
confounding because a mother giving formula milk might omit solid The mean (SD) clear liquid fasting time was 8.0 (4.8) hours
food, giving the impression of prolonged fasting for solids. (Table 3). The compliance of clear liquid intake with the institu­
tional target was 25.5% (n=149; 95% CI 22 - 29). Clear liquid
Table 1. Institutional targets for preoperative fasting fasting >4 hours occurred in 73% of cases (n=426; 95% CI 69 - 77),
durations and affected all age groups. Details of clear liquid fasting in age
Target preoperative subgroups are shown in Table 4. Age <12 months was significantly
Fasting category fasting duration (hours) associated with improved clear liquid compliance (χ2(2) = 16.06;
Clear liquids 2-4 p<0.01) and reduced mean fasting duration (p<0.001). There was
Breastmilk 4-6 no difference in the mean (SD) clear liquid fasting times of children
Infant formula milk 6-8 with and without preoperative IV maintenance fluids (9.0 (5.3) v. 7.9
Solids and semi-solids 6-8 (4.8) hours, respectively; p=0.20).
Nasojejunal tube 2-4 The compliance and mean fasting times for breastmilk, formula
milk, solids and semi-solids, and NJT feeds, are shown in Table 3.

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Twenty-eight captured cases were fasted for a time period shorter

Table 2. Demographic, surgical and anaesthetic information
than the fasting guidelines. Inadequate fasting times were found in
(N=721)
10 patients (1.7%) receiving clear liquid, 9 (9.8%) breastmilk, 7 (6%)
Patient demographic information
formula milk, and 2 (0.4%) solids. All these fasting times were within
Age (months), mean (SD) 53.1 (44.6)
1 hour of the recommended fasting times. No regurgitation events
Weight (kg), median (IQR) 14.4 (10.0 - 20.7)
were recorded in this group.
Female, n (%) 311 (43.1)
A reason for prolonged clear liquid fasting was identified in 278
ASA physical status class, n (%)
of the 426 cases with clear liquid fasting periods >4 hours. The key
themes identified were: (i) inadequate preoperative preparation I 369 (51.2)
and provision of fasting instructions; (ii) poor adherence to fasting II 224 (31.1)
instructions in the immediate preoperative period; (iii) delays at the III 121 (16.8)
time of the procedure; and (iv) provisional fasting to permit theatre list IV 7 (1.0)
flexibility (Table 5). Inadequate preparation for preoperative fasting Surgical information
Preoperative location, n (%)
Same-day admission 297 (41.2)
Elective procedures Inpatient 411 (57.0)
booked,
Intensive care unit 13 (1.8)
N=990
Timing of list, n (%)
Morning 334 (46.3)
Cancelled procedures,
n=167 Afternoon 123 (17.1)
Full day 264 (36.6)
Type of procedure or surgery, n (%)
Elective procedures
performed,
Burns 55 (7.6)
n=823 Cardiothoracic 44 (6.1)
Cardiology (cath lab) 26 (3.6)
Missing data: Dental 24 (3.3)
No information captured, n=81
No fasting information, n=19 Ear, nose and throat 118 (16.4)
General 140 (19.4)
Initially recruited Medical specialties* 20 (2.8)
in the study, Neurosurgery 25 (3.5)
n=723
Ophthalmology 63 (7.7)
Orthopaedic surgery 9 (1.2)
Excluded cases:
TPN, n=2
Plastic 75 (10.4)
Radiology 80 (11.1)
Urology 42 (5.8)
Final recruited cases, Anaesthetic information
n=721
Anaesthesia technique, n (%)
General anaesthesia 643 (89.2)
Sedation 78 (10.8)
Preoperative IV fluid infusion, n (%)
IV maintenance fluid infusion 67 (9.3)
Primary outcome: No IV maintenance fluid infusion 640 (88.8)
Clear fluid Unknown 14 (1.9)
fasting times, n=585
SD = standard deviation; IQR = interquartile range; ASA = American Society of
Anesthesiologists; IV = intravenous.
Fig. 1. STROBE (Strengthening the Reporting of Observational Studies in *Gastroenterology, pulmonology, rheumatology.

Epidemiology) flow diagram.

Table 3. Fasting mean times and compliance with preoperative fasting time targets
Fasting category Fasting time (hours), mean (SD) Fasting compliance, n (%; 95% CI)
Primary outcome
Clear liquid (N=585) 8.0 (4.8) 149 (25.5; 21.9 - 29.0)
Secondary outcomes
Breastmilk (N=92) 7.1 (2.8) 35 (38.0; 28.1 - 48.0)
Formula milk (N=116) 8.8 (2.8) 53 (45.7; 36.6 - 54.8)
Solid feed (N=560) 13.9 (3.6) 49 (8.8; 6.4 - 11.1)
Last feed (N=639) 12.9 (4.0) 102 (16.0; 13.1 - 18.8)
Nasojejunal tube (N=5) 6.7 (3.3) 1 (0)

SD = standard deviation; CI = confidence interval.

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Table 4. Clear liquid fasting in age categories

Age category (months) Fasting duration (hours), mean (SD) or median (IQR) Fasting compliance, n (%; 95% CI)
<12 (N=84) 4.3 (3.0 - 6.9)* 36 (42.8; 32.3 - 53.4)
12 - 36 (N=138) 7.7 (4.6) 34 (24.6; 17.4 - 31.8)
>36 (N=363) 8.7 (5.0) 79 (21.8; 17.5 - 26.0)
p<0.001 p<0.001
CI = confidence interval; IQR = interquartile range; SD = standard deviation.
*Non-normally distributed.

Table 5. Reasons for clear liquid fasting >4 hours (N=278) Our study is in keeping with the international published literature,
Themes and reasons n (%) which demonstrates that following a 2-hour clear liquid fasting
Issues with fasting instructions guideline consistently translates into actual clear liquid fasting times
Non-individualised fasting instructions 34 (12.2) of 6.3 - 10.85 hours, with marginal improvements achieved with
No fasting information or education 3 (1.1) quality improvement (QI) interventions.[3-8,15,16]
Poor adherence to fasting instructions The four major drivers of prolonged clear liquid fasting identified
Instructions to give clear liquid not followed 77 (27.7) at RCWMCH are inadequate fasting instructions provided, poor
Child asleep 29 (10.4)
adherence to fasting instructions, delays in procedural starting time,
and provisional fasting to promote theatre list flexibility. These
Child refused clear liquid 22 (7.9)
barriers to improving clear liquid fasting compliance seem to be
Lack of flexibility in liquid fasting time
largely similar to those experienced in well-resourced settings.[6,25-27]
No liquid offered while waiting 83 (29.9)
Service delivery issues, including hospital operational factors and
Delays
resource limitations, and patient-related factors, such as language
Delay in start of procedure 30 (10.8)
barriers, cultural beliefs and psychosocial circumstances, may be
compounding influences in SA.[28]
This study presents an opportunity to improve the perioperative
included no fasting education or instructions being provided to experience for staff, patients and parents.[29] Reducing the duration
outpatients, fasting instructions not being documented for inpatients, of clear liquid fasting confers considerable benefits, mitigating the
universal fasting times prescribed regardless of the anticipated negative emotional, behavioural, biochemical and haemodynamic
starting time, and single fasting times ordered for liquids and solids. effects of fasting, and improving pain scores.[12,15,30-32] To optimise
Parents reported not being informed that clear liquid was allowed on compliance with preoperative fasting guidelines, the areas of failure
the morning of surgery. In the immediate preoperative period, ward identified should be systematically addressed using QI methodology
nurses and parents did not follow fasting instructions or ward fasting with context-appropriate interventions and ongoing monitoring
guidelines. In some cases this may not have been preventable owing using plan-do-study-act cycles. A successful QI intervention relies
to the child being asleep or refusing the clear liquid offered. Further on a systems approach, driven by a strong guiding team with
reasons for non-adherence to fasting orders were not investigated. commitment from all key stakeholders and role players from
Delays in the starting time of the procedure were reportedly due to ministerial to community level.
problems with surgical consent and other paperwork, the preceding Greater adaptability in the fasting system is required to
case being of longer duration than anticipated, changes in the order accommodate the changeable nature of theatre lists. Establishing
of the list, and emergency cases interrupting the list. Provisional efficient communication and regular updates between theatre
fasting to permit theatre list flexibility was considered responsible staff and ward nurses facilitates appropriate adjustment of fasting
when the patient was not offered a drink during the day to promote times, to reduce liquid fasting times. [33,34] In 2018 the Association
list adaptability and avoid delays or postponements in the case of list of Paediatric Anaesthetists of Great Britain and Ireland and the
changes. European Society for Paediatric Anaesthesiology released a joint
Regurgitations were recorded in 7 patients receiving general consensus statement,[35] subsequently endorsed by other international
anaesthesia, with no aspirations. All preoperative fasting times for paediatric anaesthesia societies,[36-38] recommending that children
these patients met the minimum times recommended by the ASA. receive clear liquid up to 1 hour before elective general anaesthesia.
A 1-hour clear liquid fasting protocol enhances theatre flexibility
Discussion and assists in individualising fasting times,[39,40] thus addressing
The principal finding of our study was that compliance with the a major obstacle to improved fasting compliance at RCWMCH.
prespecified clear liquid fasting time target of 2 - 4 hours was Two paediatric centres[23,41] that adopted this policy demonstrated a
25.5%, which is considerably lower than the acceptable institutional 43% and 53% absolute risk reduction in the proportion of patients
compliance rate of 90%. The mean duration of clear liquid fasting fasted of clear liquids for >4 hours. Based on the 1-hour fasting
was almost 8 hours. This extended to the majority of children aged recommendation and the two studies with a number needed to treat
<36 months, who are most susceptible to the adverse metabolic of two to three, we would expect to improve compliance from 25.5%
effects of prolonged fasting.[11,12,15,16] The subgroup analysis of children to between 58.8% and 75.5% (25.5% + (33.3% to 50%)). Liberal liquid
aged <12 months suggested better compliance with fasting times, fasting policies have not been shown to increase risk of aspiration or
which may indicate awareness that younger children are at increased theatre interruption, and as such promise a safe and practical strategy
risk of the adverse effects of prolonged fasting, although the fasting to reduce fasting times.[19,23,29,35-37,40-44]
times were still unimpressive, since all age groups showed inadequate Outdated and widely variable fasting instructions provided by
compliance and average fasting times >4 hours. medical staff, and non-adherence to fasting instructions by parents

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and ward nurses, were major contributors to prolonged fasting in this manuscript was written by AJK and revised by KvdS and BMB. All authors
study. Compliance relies greatly on the quality of fasting instructions participated in critical review of the manuscript.
provided, but is also influenced by personal beliefs, staff availability Funding. None.
and parental threat perception, anxiety levels, health literacy, Conflicts of interest. None.
language barriers and recall.[23,25,45,46] Anaesthesiology departments
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Readily available up-to-date preoperative fasting guidelines and pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients
educational campaigns for staff can be used to advance knowledge undergoing elective procedures: An updated report by the American Society of Anesthesiologists Task
Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary
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pan.13282 Accepted 17 June 2020.

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