Preoperative fasting is a balance between patient safety and patient comfort. Prolonged fasting is harmful — maintaining hydration improves safety, comfort, and perioperative stability.

Recent large scale studies have demonstrated that liberal clear fluid regimes do not increase aspiration risk in children.

Children should fast 6 hours for solids, 4 hours for formula, 3 hours for breast milk, and may have clear fluids up to transfer to theatre (‘Sip til Send’) unless contraindicated.

These recommendations apply to all paediatric patient groups undergoing elective or emergency operations under general anaesthesia and sedation.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Pre-operative fasting in low-risk children1 undergoing surgery

• 6 hours for solids, including cows milk and thickened feeds

• 4 hours for formula feeds and non-clear fluids

• 3 hours for breastmilk

• Clear fluids sips until transfer to theatre ‘Sip till Send’

Post-operative resumption of oral intake in healthy children

Oral fluids can be offered to healthy children when they are fully awake following anaesthesia unless prohibited by specific post-operative instructions from the surgeon or anaesthetist. There is no requirement to drink as part of the discharge criteria.

Patients who have received topical anaesthesia to the airway must wait one hour from the time of administration until resumption of oral fluids or solids, after the return of oral sensation and protective swallowing reflexes.

1.1 The aim of this Guideline is to standardise preoperative fasting and drug administration and the postoperative resumption of oral intake for paediatric patients.

1.2 Patients:

• should be subject to fasting (for example before an operation or procedure) for the minimum possible period, and the service will ensure they have adequate hydration as soon as possible afterwards.

• can be confident that consideration is given to the duration of fasting for each child prior to the scheduling of operations or procedures.

• are given nutrition as soon as possible after procedures requiring fasting are cancelled.

This Guideline applies to all children undergoing elective and emergency operations under general anaesthesia. Patients undergoing procedures that require conscious sedation should also be fasted according to this Guideline unless the responsible consultant anaesthetist has specifically indicated and recorded in the patient notes that fasting is not necessary. This guideline applies to both clinical and non-clinical staff, as the latter may be responsible for providing pre-operative fasting instructions.

For postoperative fasting, patients undergoing surgery involving the gastrointestinal tract or major abdominal surgery are not covered by this Guideline. These patients should have specific post operative instructions that should be followed.

Recommendations for patients with impaired swallowing are not covered by this Guideline.

Clear fluid – as defined by ‘allowed’ in the table

The pre-operative period – the six hours prior to the planned induction of anaesthesia time.

The post-operative period - the first few hours after surgery is finished.

The peri-operative period – the time period describing the duration of a patient's surgical procedure; this commonly includes ward admission, anaesthesia, surgery and recovery.

Excessive fasting can cause significant stress for children and their carers. The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) issued a consensus statement in 2018 stating that, unless contraindicated, all children able to take clear fluids should be encouraged to have them up to one hour before elective general anaesthesia (1). This position was reinforced by European (ESPA/ESAIC) guidelines in 2022 (2). More recently the Centre for Peri-op Care/Royal College of Anaesthetists advocate for a policy of “sip to send” in both adults and children (3). This policy is supported by a best practice guideline endorsed by our regional Surgery in Children operational delivery network (4).

Excessive fasting has measurable harms: irritability, agitation, dehydration and metabolic stress, with children more prone than adults to ketosis and hypoglycaemia (5). Intravenous access is more challenging in dehydrated children and haemodynamic instability more likely. Importantly, fasting does not render the stomach “empty,” as gastric secretions continue regardless.

Recent evidence supports a shorter clear-fluid fast. The 2025 EUROFAST study, a prospective observational trial of over 300,000 paediatric anaesthetics across Europe, demonstrated that clear fluid fasting of ≤1 h(“sip to send”) is non-inferior to longer fasting times in terms of pulmonary aspiration risk, with an overall aspiration incidence that remained extremely low (6). Earlier physiological and clinical studies confirm that >80% of ingested clear fluids empty from the stomach within 1 h (7), and that inclusion of glucose in drinks can accelerate gastric emptying (8).

The policy should be for all patients. There are some clinical situations where an individual anaesthetist may prefer to use the traditional 2-hour clear fluid fasting period including:

• Gastro-oesophageal reflux disease – either on treatment (such as lansoprazole, domperidone or omeprazole), or under investigation

• Enteropathies – problems with digestion or absorption

• Documented history of gastric immobility e.g. autonomic dysfunction related to diabetes

• Admission for gastrointestinal surgery where the patient has a known obstructing lesion

• Patients who have a bowel obstruction or ileus

• Patients having procedures on their oesophagus or stomach, such as a gastroscopy or oesophageal dilatation.

• Achalasia

• Renal failure

5.1 Pre-operative intake of solids

Solid food, including sweets and all feeds given via nasogastric, gastrostomy or jejunal routes, must be avoided for 6 hours prior to elective surgery.

For patients admitted for morning lists, this means no food from 02.00 on the day of surgery. For patients admitted for afternoon lists, a light breakfast before 08.00 can be consumed.

Breast fed children can receive breast milk up to 3 hours before elective surgery, i.e. all feeds must be finished by 05.00 for morning lists, and 11.00 for afternoon lists.

5.2 Pre-operative intake of oral fluids

Intake of clear fluids up to one hour before induction of anaesthesia for elective surgery is safe in healthy children and improves wellbeing. All children should be encouraged to drink clear fluids freely up until their arrival time i.e. 07.00hr for morning lists and 13.00hr for afternoon lists.

The volume of administered fluids does not appear to have an impact on patients’ residual gastric volume and gastric pH, when compared to a standard fasting regimen. Therefore, patients may have unlimited amounts of clear fluid prior to their arrival in hospital.

Once in hospital they can sip at a rate of drinking of up to 3ml/kg/hr if weight is known, or otherwise:

• Age 1 – 5 years – 60 ml

• Age 6 - 11 years – 140 ml

• Age 12 - 16 years – A full cup.

5.3.1 Morning operating lists

These commence at 08.00. All patients arriving at or before 07.00 (except those excluded in paragraph 4) should be offered a drink of clear fluid immediately.

5.3.2 Staggered admission all day operating lists

For all day lists with staggered admission, all children who arrive at or before their scheduled time, except those excluded in paragraph 4, should be offered a drink on arrival.

5.3.3 Afternoon operating lists

These commence at 13.30. All patients arriving at or before 13.00 (except those excluded in paragraph 4), should be offered a drink of clear fluid immediately.

Starving requirements for each child will be discussed at each theatre WHO (World Health Organisation) meeting and relayed to the ward.

5.4 Chewing gum and sweets during preoperative fasting

Sweets (including lollipops) are solid food. Patients must refrain from eating sweets within six hours of anaesthesia⁷.

Chewing gum does not cause an increase in gastric volumes or acidity⁸. Chewing gum within the six hour starvation period will not result in surgery being delayed unless the gum has been swallowed.

5.5 Oral medication

Regular medication taken orally should be continued pre-operatively unless there is advice to the contrary. Refer to Appendix

A small volume of water may be given orally to help patients take their medication throughout the whole fasting period.

5.6 Pre-medication

Pre-meds prescribed by the anaesthetist can and should be given irrespective of fasting status.

5.7 Post-operative resumption of oral intake

When ready to drink, patients should be encouraged to do so, providing there are no medical, surgical or nursing contraindications.

The fasting guideline is the same for both elective and emergency cases, noting the possible exclusions in outlined in paragraph 4.

7.1 Information on the fasting regimen will be given by a healthcare professional who has received suitable training.

7.2 Clear signage will be visible at the patient’s bed space indicating the fasting regimen that is being followed.

7.3 The fasting regimen will be recorded in the patient’s notes.

Either pharmacists or anaesthetists should complete a clinical audit of this practice once a year. This will be added to the audit plan for all care groups where surgery is performed under general anaesthetic. It is recommended that this appendix is laminated and attached to ward drug trolleys for quick reference.

When a patient is admitted for surgery all their normal medication should be written up on their electronic drug chart. On the day of surgery certain drugs should be omitted as detailed below. This medication should have the administration boxes for the day of surgery marked 6 (=clinical reason) and initialled by the nurse or doctor making that decision. Surgical nurses trained in the use of this guide can make that decision. If you are unsure as to the class of a medication, you should look in the current edition of the BNF.

Most ‘significant’ drugs should be given on the day of surgery. A few exceptions are listed below. Drugs may be taken with a small amount of water at any time during the peri-operative fasting period.

PLEASE GIVE:

• All “cardiac” or blood pressure drugs - except ACE inhibitors, angiotensin-II receptor antagonists and diuretics (see below)

• All antibiotics (including oral)

• All epilepsy drugs

• All asthma drugs or inhalers

• All tablets which reduce gastric acid (e.g. omeprazole, lansoprazole, ranitidine)

• All thyroid drugs

• All hypnotics, anxiolytics, barbiturates, antipsychotic and antidepressant medications taken regularly at home

• All steroids taken regularly, including inhalers

• All immunosuppressants and cancer drugs

• All analgesics can be given before surgery - EXCEPT NSAIDs (see below)

OMIT (do not give):

• ACE inhibitors and angiotensin-II receptor antagonists - these drugs may drop the blood pressure during an anaesthetic. Some anaesthetists may request that these drugs are given before surgery, but this will be requested on an individual basis.

• All diuretics - the anaesthetist may request that these are given – this will be on an individual basis.

• Diabetic treatment - The patient must be written up for alternative diabetic treatment by the surgical or diabetic team.

• Aspirin, clopidogrel, dipyridamole, warfarin. You must seek advice from your surgical and cardiology teams where appropriate.

• Drugs which are not essential in the short term e.g. vitamins, iron, laxatives, liquid antacid medicines (e.g. Gaviscon), antihistamines, herbal remedies or homeopathic medicines.

• Non-steroidal anti-inflammatory drugs (e.g. diclofenac (voltarol), ibuprofen, indomethacin, naproxen), UNLESS prescribed by an anaesthetist as a pre-med.

But what about an empty stomach before anaesthesia?

It is a mistake to think that the stomach is empty just because the patient has starved. Gastric secretions are always present. We aim to keep the volume of gastric secretions low, but small amounts of water and a few tablets will not make a significant difference. Meanwhile the patient may have adverse effects from missing important medication.