Shorter clear fluid fasts in children showed no rise in aspiration

Design

Systematic review and meta-analysis of randomised and non-randomised studies

Population

About 580,000 children under 18 having general anaesthesia or sedation

Primary outcome

Pulmonary aspiration

Effect

0.03% with both policies; RR 0.77 (95% CI 0.40–1.47); very low certainty

This meta-analysis included 33 randomised and non-randomised studies of about 580,000 children under 18 having general anaesthesia or sedation, comparing liberal clear fluid fasting (under 2 hours) with conventional fasting (2 hours or more).

Pulmonary aspiration was rare under both: 0.03% (95% CI 0.01 to 0.09%) with each policy, about 3 in 10,000. In the 14 studies giving risk ratios (475,399 children), there was no difference (RR 0.77, 0.40 to 1.47). Vomiting without aspiration was also similar (about 1.0% vs 0.8%). Certainty of evidence was very low, because most data are observational and aspiration is too rare for any trial to be powered for it.

That low certainty is unavoidable for an outcome this rare, and the size of the dataset is the reassurance. Prolonged fasting in children causes thirst, distress, hypoglycaemia risk and haemodynamic instability at induction. Several European paediatric anaesthesia societies already advise one hour for clear fluids; this analysis supports that direction. Units still using two hours, or the much longer fasts that happen in practice when lists move, have good grounds to review their policy.

• Consider allowing clear fluids until 1 hour before anaesthesia in healthy children.
• Audit actual fasting times — children often fast far longer than the written policy.
• Give families a clear 'drink until' time rather than a vague 'nothing after midnight'.
• Keep longer fasts for children with known delayed gastric emptying or obstruction.
• Follow your national or institutional guideline until it is updated.

Why it matters

Long fasts harm children every day, while the aspiration risk they guard against did not change.

Don't overread it

Very low certainty evidence, mostly observational — it cannot rule out a small increase in a very rare event.

The statistics, in plain English

An RR of 0.77 with an interval from 0.40 to 1.47 means the data are consistent with anything from about 60% less to about 50% more aspiration — but on a baseline of 3 per 10,000, even the upper end is a very small absolute risk. 'Very low certainty' reflects study design, not a signal of harm.

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