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

Summary Introduction Pre‐operative clear fluid fasting in children aims to reduce the risk of pulmonary aspiration. Recent studies have shown the safety of shorter clear fluid fasting durations. However, because pulmonary aspiration is rare, it remains uncertain whether the incidence differs between the liberal (< 2 h) and conventional (≥ 2 h) clear fluid fasting policies. Methods We conducted a systematic review and meta‐analysis, performing comprehensive searches across five databases. We included studies with patients aged < 18 y who underwent general anaesthesia or sedation for surgery or procedures. Primary outcome was pulmonary aspiration and secondary outcome was vomiting without pulmonary aspiration. We performed meta‐analyses to estimate pooled incidences according to fasting policy (< 2 h vs. ≥ 2 h). Results We included 33 studies involving 580,197 patients. Twenty‐nine studies (579,737 patients) reported pulmonary aspiration. The pooled incidence of pulmonary aspiration was 0.03% (95%CI 0.01–0.09%) with conventional fasting policies and 0.03% (95%CI 0.01–0.09%) with liberal policies. Risk ratios were available from 14 studies (475,399 patients) and showed no difference in pulmonary aspiration between policies (risk ratio 0.77, 95%CI 0.40–1.47). Seventeen studies (344,653 patients) reported vomiting; the pooled incidence was 0.99% (95%CI 0.27–3.51%) with conventional policies and 0.76% (95%CI 0.18–3.14%) with liberal policies. The certainty of evidence was very low for both outcomes. Discussion Pulmonary aspiration is rare in children, and similar incidences of aspiration and vomiting were observed under liberal and conventional clear fluid fasting policies. The results should be interpreted cautiously due to the very low certainty of evidence.