Last updated January 14, 2022

Recommendations for Preprocedural Fasting for the Breastfed Infant

Recommendations

Minor painless procedures or procedures requiring local anesthesia for pain control that do not require sedation or fasting. Minor procedures such as circumcision with a local block, diagnostic examinations, placement of peripheral intravenous lines, and drawing blood can be performed without sedation or general anesthesia. A procedure that is considered minor should cause minimal physical trauma and psychological impact, therefore not requiring sedation. Without sedation, the infant can protect his or her airway with an intact cough/gag reflex, and thus fasting is not required. (Iundefined)
The need for sedation should be decided upon at the physician’s discretion based on the intensity and duration of the procedure as well as the infant’s medical history.1 If sedation is not necessary, the need for oral analgesics or other means for comfort should be determined by the practitioner.
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If it is a minor procedure not requiring sedation or general anesthesia, then feed normally. Infants are more likely to tolerate minor procedures when the usual feeding pattern is maintained. They will be more comfortable when they have eaten in a normal routine. Without anesthesia, even if the patient is sleeping during the procedure, the upper airway reflexes are intact, and infants will be able to naturally protect their airways. (I, )
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If possible, consider breastfeeding for comfort during the minor procedure without sedation. Breastfeeding while receiving a heel stick, intravenous placement, or drawing blood has been shown to be an effective means of pain relief and should be an option made available to mothers and infants. (III, )
Please refer to the Academy of Breastfeeding Medicine Clinical Protocol #23 for more information.
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Exceptions for the active patient. The child who is unable to follow instructions or cooperate because of age or level of development may require sedation for minor procedures after efforts to perform the procedure without it have failed. Under these circumstances, the procedure may need to be postponed so that the patient can follow strict fasting guidelines. (, )
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Diagnostic examinations or invasive procedures requiring pharmacologic immobilization or sedation. Procedures that are more painful or stressful, such as bone marrow biopsies or lumbar puncture with intrathecal chemotherapy administration, require sedation. (III, )
Other procedures may require a motionless patient, such as central line placement or magnetic resonance imaging/ computed tomography exams. In these situations, a licensed anesthesia provider may need to perform a general anesthetic, but these procedures can possibly be performed under sedation if a strict sedation protocol is followed and the provider is well trained.
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When should the infant fast? When an infant undergoes a surgery or diagnostic examination under anesthesia, the mother must withhold breastfeeding for at least 4 hours prior to anesthesia. (III, )
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Conditions such as gastroesophageal reflux disease have not been shown to change the gastric emptying times versus controls, so recommendations for these patients do not differ. (I, )
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If the infant needs to fast, provide clear instructions to the caregiver. The physician providing or supervising the sedation or anesthesia at the hospital, clinic, or surgery center must provide strict fasting instructions to minimize adverse outcomes such as pulmonary aspiration, hypoglycemia, and volume depletion (I, )
These instructions are often provided in a preprocedure office visit and/or by phone the day before the scheduled procedure. The mother can be reassured that adherence to fasting guidelines is for the safety of her child.
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Consider the infant’s daily medications. Vital prescriptions such as antiepileptics, reflux, and cardiac medications should be taken as scheduled. If the prescription in the form of a clear sugar-based syrup, then the volume of the medication and its rapid absorption make the risk of aspiration of the medication lower than the risk of missing the needed prescription drug. (I, )
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This is also true of oral liquid acetaminophen/paracetamol, which may be given to the child prior to the procedure for analgesia. When possible, the dose can be timed a little earlier or a little later to separate the ingestion from the time of anesthesia. Whenever possible, nonprescription medications, multivitamins, or any medications that are opaque or alkaline should be avoided for 8 hours before a procedure because they are considered equivalent to solids. (III, )
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It is best to finish breastfeeding at 4 hours prior to fasting and anesthesia. Per ASA guidelines, the mother (or other caretaker) should be advised to finish breastfeeding or providing breastmilk to the infant approximately 4 hours prior to the scheduled surgery time, even if the infant needs to be awakened. Waking the child to feed 4 hours prior to the scheduled procedure decreases the risk for hypoglycemia and hemodynamic instability, especially in children less than 3 months old. (II-1, )
This optimizes the infant’s glycogen stores and volume status because the infant might otherwise sleep through the night and not receive optimal nutrition or hydration prior to the scheduled surgery or procedure.
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Continue clear liquids until 2 hours prior to anesthesia. Ad libitum clear liquids up to 2 hours prior to anesthesia or sedation are recommended. (III, )
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They are considered safe up to 2 hours prior because they empty from the stomach much more rapidly than HBM. They can prevent volume depletion, improve glycogen stores, and maximize hemodynamics by hydrating the infant. The most common clear liquids provided to breastfeeding patients are apple juice, water, sucrose-based solutions, clear broth (nonfat commercially prepared only—homemade will have fat in it), and electrolyte solutions. Water is least preferred because of the absence of a glucose source. If the mother prefers to avoid the bottle, the clear liquid can be offered via a small cup, syringe, or spoon. (III, )
Clear liquids can help to soothe an anxious infant while fasting and separated from the mother’s breast. This can help to maximize satisfaction of the patient and parent and allow for a more pleasant perioperative experience.
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Do not give formula and other HBM supplements for at least 6 hours prior to the anesthesia. Enriched feedings include additives or supplements to expressed HBM,37 like formula, protein powder, vitamins, or minerals. These empty more slowly from the stomach and worsen the lung injury if aspirated. Some fortifications to HBM may not change the gastric emptying, (II-1, )
but to avoid confusion, HBM given to an infant 4 hours prior to surgery must be ‘‘non-enriched.’’
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Do not give non-human milk for 6–8 hours prior to the anesthesia. Gastric emptying times of soy, rice, or cow’s milk vary, and volume ingested must be considered. Thus, it is safest to recommend that all nonhuman milk be held for 6–8 hours. (III, )
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Solid food must be avoided for at least 8 hours prior to the anesthesia. An 8-hour fast is recommended for fatty or proteinaceous solids such as meat or any fried food. (III, )
This is suggested for children who are at the stage of development when they are concurrently eating solid foods and breastfeeding. To avoid confusion, most physicians recommend a fast from all heavy solid meals, which would include most foods fed to babies, for an 8-hour period.
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Postpone sedation or anesthesia if fasting requirements are not met. If an infant has breastfed within 4 hours prior to an elective sedation or anesthetic, the risk of aspiration of acidic contents or particulate matter is greatly increased. (III, )
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Attempts to allow ‘‘non-nutritive’’ suckling of the breast for infant comfort within the 4 hours prior to anesthesia may increase gastric contents and should not occur. (III, )
Also, if clear liquids have been ingested in the 2 hours prior to sedation, the patient can have residual gastric contents. Thus, if the procedure is not an emergency, the case should be cancelled or postponed until the minimum fasting period is met.
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Comfort for the infant and mother during a fast. Infant comfort during the fasting period can be addressed with a pacifier (dummy) or other measures such as swaddling, rocking, and holding by caregivers or nursing staff. The mother holding the infant may send signals consistent with an impending meal; thus some mothers find that the infant may need to be held by another adult during the fasting period. (, )
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Use of a pacifier (dummy) in the NPO period. Non-nutritive sucking on a pacifier (or a gloved clean finger) has been shown to reduce crying spells and can be considered a temporary measure in the preoperative NPO period prior to the start of sedation or induction of anesthesia. Sucrose should be treated as a clear liquid if used with the pacifier for comfort. Therefore the use of sucrose should cease 2 hours prior to sedation per ASA guidelines. (III, )
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Introducing a pacifier for the first time, with or without sucrose, may prove to be unrealistic in infants accustomed to breastfeeding. Also, mothers may try to avoid pacifiers (dummies) to prevent premature weaning. Studies on this have mixed results. (Iundefined)
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If accepted by the infant and allowed by the mother, pacifiers (dummies) are an inexpensive and temporary way to relieve anxiety and improve the infant’s comfort and physiologic status. (Iundefined)
Please refer to the Academy of Breastfeeding Medicine Clinical Protocol #23 for further information on comforting an infant with a pacifier and sucrose.
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If possible, express and store breastmilk during the NPO period. Until the time the mother can breastfeed again, she should be encouraged to express and store HBM for her own comfort and to avoid feedback inhibition of milk synthesis. Mothers should be advised of lactation rooms or other private spaces to express milk. (, )
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Breastfeed immediately after the procedure. After a minor procedure under anesthesia, if her child is stable, otherwise healthy, and the type of surgery does not prevent oral intake, a mother can immediately begin to breastfeed her infant as soon as he or she is awake. (II-3, )
This increases comfort, reduces pain in the child, and is widely practiced and evidence-based, even following cleft lip and palate repairs.
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Recommendation Grading

Overview

Title

Recommendations for Preprocedural Fasting for the Breastfed Infant

Authoring Organization

Publication Month/Year

July 17, 2012

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The purpose of this document is to define the minimum fasting requirements for breastfed infants and provide suggestions to avoid unnecessary fasts while improving the infant’s safety and comfort during the required fasting periods.

Inclusion Criteria

Female, Male, Infant

Health Care Settings

Ambulatory, Emergency care, Hospital, Medical transportation, Operating and recovery room

Intended Users

Medical assistant, dietician nutritionist

Scope

Counseling, Management

Diseases/Conditions (MeSH)

D007224 - Infant Care, D007225 - Infant Food, D007186 - Incubators, Infant, D013513 - Obstetric Surgical Procedures

Keywords

Breastfeeding, NPO Infant, Fasting Infant, Pre-surgical Infant

Source Citation

The Academy of Breastfeeding Medicine.Breastfeeding Medicine.Jun 2012.197-202.http://doi.org/10.1089/bfm.2012.9988