Liberal vs. conventional pre-operative clear fluid fasting policies in children: a systematic review and meta-analysis of randomised and non-randomised studies.

Summary

This systematic review and meta-analysis included 33 studies involving 580,197 children. Pulmonary aspiration occurred at a pooled incidence of 0.03% under both conventional and liberal clear-fluid fasting policies, with no significant difference in risk ratio, although the certainty of evidence was very low.

Key Findings

• The review included 33 studies and 580,197 pediatric patients.
• Pooled pulmonary aspiration incidence was 0.03% with both conventional and liberal clear-fluid fasting policies.
• Risk of aspiration did not differ significantly between policies (risk ratio 0.77, 95% confidence interval 0.40-1.47).
• Vomiting rates were also similar, but certainty of evidence was very low.

Clinical Implications

Selected children may be allowed clear fluids closer to anesthesia than two hours before induction, potentially reducing thirst, discomfort, dehydration, and unnecessary cancellations. Local protocols should be updated cautiously, with attention to aspiration risk factors and the very low certainty of evidence.

Limitations

• The certainty of evidence was very low for both aspiration and vomiting outcomes.
• Aspiration was rare, and most included evidence was observational or otherwise vulnerable to confounding and imprecision.

Future Directions

Prospective multicenter surveillance and pragmatic trials should evaluate liberal fasting protocols in defined pediatric risk groups, including emergency procedures and children with delayed gastric emptying, while monitoring aspiration, comfort, cancellations, and recovery outcomes.