Kids Fast Too Long: Why Are Guidelines Ignored?

Most children fast from clear liquids twice as long as guidelines allow, risking dehydration and blood sugar imbalance.

A large review of data from over 70,000 pediatric surgeries found that most children — including nearly 80% of infants — abstain from clear liquids for more than twice the recommended fasting duration before anesthesia ().

Current guidelines from the American Society of Anesthesiologists advise that healthy infants and children may safely consume clear fluids such as water, pulp-free fruit juice, or carbohydrate drinks up to two hours before anesthesia.

Extending fasting beyond this period can be detrimental, potentially leading to dehydration and abnormal fluctuations in blood sugar and other metabolic markers.

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Prolonged Fasting Increases Discomfort and Surgical Stress

“Prolonged fasting from clear liquids of four hours or longer can be uncomfortable and increase thirst, anxiety, pain, nausea and vomiting,” said Alexander Nagrebetsky, M.D., M.Sc., senior author of the study and an anesthesiologist and intensivist at Massachusetts General Hospital, Boston and assistant professor at Harvard Medical School, Cambridge, Massachusetts.

“It can be harmful too. Children and infants are especially vulnerable to dehydration and calorie loss, which may heighten stress and slow recovery from surgery.”

Researchers reviewed records from 71,835 children, aged 17 or younger (3,771 of whom were infants younger than 1 year old), who had elective surgery at one of 12 U.S. hospitals between 2016 and 2024.

In the study, prolonged fasting was defined as fasting from clear liquids for four hours (or longer) before surgery, which is two times longer (or more) than guidelines recommend.

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Trends in Fasting Duration Among Children and Infants

Overall, the proportion of children who fasted from clear liquids for at least two times longer than recommended before surgery decreased from 84.3% in 2016 to 70.2% in 2024, but increased in infants, from 75.9% in 2016 to 79.6% in 2024.

The median length of time all children fasted from clear liquids decreased overall from 10.9 hours in 2016 to 8.7 hours in 2024.

However, there was no significant improvement in infants, who fasted a median of 6.7 hours in 2016 and 6.3 hours in 2024. In 2024 alone, the median duration of clear liquid fasting was three times longer than the recommendation in infants and four times longer in all children.

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Prolonged Fasting Persists Despite Guidelines

While the study didn’t address why parents and health care professionals withheld clear liquids from children for longer than recommended, there are likely several reasons: parents and physicians may be following outdated practices of prolonged fasting (e.g., nothing to drink after midnight); lack of awareness of ASA fasting guidelines that note “efforts should be made to allow clear liquids in healthy children as close to two hours before the procedure as possible;” and a lack of understanding that prolonged fasting can increase complications and negatively impact recovery.

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Encouraging Better Preoperative Hydration Practices

Perioperative team members should encourage patients to drink water and liquids with sugar for up to two hours before the procedure when appropriate, said Dr. Nagrebetsky. Parents should advocate for their children and ask their anesthesiologist about current recommendations for clear liquids before the procedure, he said.

Widespread Non-Adherence to Guidelines

“The study confirmed our hypothesis that non-adherence to ASA fasting guidelines is common in the U.S.,” said Ethan Lowder, B.A., lead study author and a student at Harvard Medical School.

“Drinking sugar-containing clear liquids such as juices or those with electrolytes provides water and calories that children’s bodies need for normal functioning, including dealing with the stress of surgery and recovery.”

Reference:

Children Fast From Clear Liquids Much Longer Before Surgery Than Guidelines Recommend, Large Study Shows - (https://www.asahq.org/about-asa/newsroom/news-releases/2025/10/children-fast-from-clear-liquids-much-longer-before-surgery-than-guidelines-recommend)

Source-American Society of Anesthesiologists