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ABM Clinical Protocol #25: Recommendations for Preprocedural Fasting for the Breastfed Infant: ‘‘NPO’’ Guidelines
Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding .
Purpose
This protocol will help 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. When providing guidance for breastfeeding mothers of nil per os (NPO) infants in the preprocedure period, the main goals are to:
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Prevent pulmonary aspiration of gastric contents during anesthesia or sedation
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Prevent hypoglycemia intraoperatively and during the NPO period
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Prevent volume depletion and maximize hemodynamics Minimize stress or anxiety in the NPO infant
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Support optimal breastfeeding of the dyad before and after the procedure
Both general anesthesia and moderate sedation require adherence to the same fasting guidelines that will be discussed in this protocol. For further information about sedation please refer to the guidelines created by the American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia by Non-Anesthesiologists. As defined by these guidelines, “sedation and analgesia comprise a continuum of states ranging from minimal sedation (anxiolysis) through general anesthesia.” For the purposes of discussing fasting guidelines in this protocol, the term anesthesia is used to encompass the continuum of moderate sedation to general anesthesia.
Background
Requiring a breastfed infant to fast for any period of time can be stressful for both the infant and the mother. Hence, it is appropriate to minimize unnecessary fasting while maximizing the safety of diagnostic examinations, surgeries, and procedures with the patient under anesthesia.
Consequences of feeding prior to sedation or general anesthesia
The most serious sequela of noncompliance with fasting guidelines is pulmonary aspiration. Regurgitation and aspiration have been documented concerns of physicians providing sedation since the early 19th and 20th centuries and a leading cause of death under anesthesia in both adults and children. When this was established, all patients had to be NPO or nothing by mouth after midnight to avoid pulmonary aspiration syndrome. The fasting guidelines have developed through the years to be more reasonable for breastfeeding infants and are still evolving. Although potentially uncomfortable for the infant, the safest practice and most effective prevention of pulmonary aspiration is adherence to current fasting guidelines.
Mechanism
Upon initiation of sedation or induction of anesthesia, the gag and cough reflexes are inhibited; therefore, any remaining stomach contents can regurgitate and trickle into the open larynx that would have otherwise closed upon contact with acidic gastric fluid. This can cause aspiration of solid food particulates and acidic gastric juices into the unprotected airway, which can then lead to pneumonitis or pneumonia. While the incidence of aspiration is low with proper fasting (anywhere from 3 to 10 out of every 10,000 anesthetics performed on children), the consequences of pulmonary aspiration of residual gastric contents can be serious. Aspiration pneumonitis may necessitate mechanical ventilation and/or a prolonged hospital course.
Infants with multiple co-morbidities are placed in a higher risk stratification by the ASA, and they have a higher incidence of aspiration.
Animal models
Animal models of pulmonary aspiration of gastric contents containing human breastmilk (HBM) are characterized by airway irritability from inflammatory mediators, increased alveolar-to-arterial oxygen gradients, and decreased dynamic compliance. This leads to poor oxygenation and difficulty with ventilation and is especially evident when HBM is acidified. Death is more likely with gastric contents that have a pH of less than 2.5, with other studies showing increased death and severity with decreasing pH and increasing volume. Assuming that aspiration of HBM in an infant would have similar consequences as compared with animal studies, this could potentially affect adequate ventilation and oxygenation in the infant. Aspiration of larger volumes or concentrated particulate matter from HBM mixed with gastric juices further increases the severity of lung injury, including respiratory distress syndrome, alveolitis, atelectasis, and/or post-obstructive pneumonia.
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