Providers' frequently asked questions about fasting guidelines for children

What about oral contrast?

Oral contrast is a mixture of Gastrografin® 50 cc, Black Cherry Drink Mix, and water to form a solution which looks and tastes like Kool-Aid®, containing a Ph of about 6.0 to 7.6. When patients are not going to have anesthesia, an adult is required to drink between 800 cc and a liter of oral contrast. Children are asked to drink a certain volume of oral contrast based on age and the type of anesthesia for the procedure (general anesthesia or sedation). Risk and benefit for patient safety regarding the urgency of the procedure following oral contrast consumption versus the risk of aspiration must be discussed among the patient and medical specialists involved in the patient’s care.

Who came up with these guidelines?

The durations for fasting are based on analysis of the current medical literature and expert opinion. The American Society of Anesthesiologists and the European Society of Anesthesiologists appointed separate task forces to develop guidelines. Faculty in the Department of Anesthesia at the University of Iowa adapted these guidelines for the University of Iowa Hospitals & Clinics.

If the patient takes food in through an enteral or nasogastric tube (e.g., gastric/stomach tube, enteral/jejunostomy tube, etc.) should I observe the same fasting intervals?

Yes. The patient should fast for six hours from formula/non-human milk feeds, regardless of whether the feed is via the gastric route or post-pyloric. Patients on feeding tubes should fast for four hours from breast milk feeds and for two hours from clear fluids.

What about perioperative enteral feeding in burned patients?

Burned patients have special metabolic requirements because of increased caloric needs and nutritional support.

Critically Ill and Burn Elective Adult Procedures WITHOUT a cuffed endotracheal tube or cuffed tracheostomy tube in place:

• 8 hours after all solid foods, of any volume
• 4 hours after any non-clear beverage OR artificial enteral nutrition OR non-human milk, of any volume, and regardless if fed via gastric route or post-pyloric
  • Non-clear beverages include orange juice (with or without pulp) or other fruit juices with pulp; smoothies; milk, cream, or creamer added to coffee or tea; and include “tube feeds” such as Promote®, Impact®, Nepro®, etc
• 4 hours after breast milk
• 2 hours after clear fluids*, of any volume
  • Clear fluids are limited to water, apple or white grape juice, black coffee or tea (WITHOUT added milk, cream or creamer), Gatorade®, infant electrolyte solutions (Pedialyte®), carbonated beverages (Coke®, 7-Up®, etc.), plain Jello® or other gelatins without added fruits or other solids, clear, fat-free and non-turbid broth (bouillon or consommé), non-turbid clear protein beverages (Ensure Clear®, Premier Protein® Fizzique®, etc.), but do not include alcohol.
  • The defining feature of a “clear fluid” is the ability to “see through it” and clearly read text
• NO DELAY after chewing gum, hard candy, chewing tobacco, or any other substance that is not swallowed
  • Swallowing any of these items counts as ingesting a "solid food," and may require a delay of 8 hours

A small volume (30mL / 1 ounce) of clear fluids may be utilized to take prescribed medications within 2 hours prior to the procedure. Crushed medications may be administered with up to 2 tablespoons of plain apple jelly (not apple sauce or yogurt).

Critically Ill and Burn Adult Elective Procedures WITH a cuffed endotracheal tube or cuffed tracheostomy tube in place:

• 4 hours after artificial enteral nutrition for the following patients, regardless if fed via gastric route or post-pyloric
  • Those who will be positioned PRONE
  • Those whose cuffed endotracheal tube or cuffed tracheostomy tube will NOT remain in place for the entire duration of the procedure (such as scheduled airway surgery, or patients for whom “attempted extubation” is planned in the operating room at the completion of the procedure)
• NO DELAY after enteral feeds, of any formula or volume, for other case types, regardless if fed via gastric route or post-pyloric.

Fasting guidelines are specifically designed for elective procedures; what is an “elective procedure”?

The University of Iowa Hospitals & Clinics operate using a Triage Schema. Triage priority is based upon patient’s condition. The triage priorities are defined as follows:

Elective case

A patient/case that does not meet the urgency/emergency criteria of the triage emergency prioritization system as noted below.

Emergency classifications

Class A

Life, limb, and/or sight threatening condition requiring immediate surgery, and takes precedence over any other case.

Class B

Life, limb, and/or sight threatening requiring immediate surgery within four hours.

Class C

A non-life threatening condition that may lead to severe complications if surgery is not performed within eight hours of classification.

Class D

A non-life threatening condition but requiring surgery within 24 hours or severe complications will occur.

Class U

Urgent – inpatient referrals or patients admitted who require surgical intervention within 48 to 72 hours; these cases may be worked into the existing schedule.

Preoperative should be considered synonymous with periprocedural, as the latter term is often used to describe procedures that are not considered operations, like MRI scans.

A patient’s doctor wants to cleanse the bowel before surgery, “bowel prep.” The doctor has prescribed GoLYTELY® (polyethylene glycol electrolyte solution (PEG). What is the fasting period between ingestion of the GoLYTELY® and when the patient can receive regional, general or monitored anesthesia care?

Please follow GoLYTELY or MiraLAX instructions from the GI clinic and complete ingestion the day prior to the procedure. Clear liquids are allowed up to two hours before the procedure.