Time to Rethink NPO? The Shift Toward 1-Hour Clear Fluid Fasting in Children

A recent Anesthesia & Analgesia (March 2025) study by the Society for Pediatric Anesthesia Quality and Safety Committee (SPA-QS), led by Dr. Priti G. Dalal, surveyed pediatric anesthesiology leaders across the U.S. The results suggest growing support for reducing clear fluid (CF) fasting from 2 hours to 1 hour in healthy children undergoing anesthesia.

Key findings 

Growing support for a 1-hour clear fluid fasting rule:

• Of the 75 surveyed institutions, 8 (10.6%) had already adopted a 1-hour NPO rule for clear fluids.
• 7 (9.3%) were in the process of transitioning from a 2-hour to a 1-hour rule.
• 60 (80%) continued to follow the traditional 2-hour fasting period.

Potential benefits of reducing fasting times:

• Improved patient comfort: Reduced hunger and thirst and decreased incidence of dehydration and hypoglycemia.
• Fewer difficulties with IV access and higher parental satisfaction.

Challenges to implementation:

• Legal concerns: 73% of respondents cited medicolegal risks as a barrier to reducing fasting times.
• Lack of official endorsement: Institutions hesitated to change policies without updated guidance from national professional societies.
• Concerns about patient safety: Some institutions worry about aspiration risks despite evidence suggesting otherwise.

Why the change? 

Studies show clear fluids empty from the stomach in 30–60 minutes, with no significant increase in aspiration risk between 1-hour and 2-hour fasting groups. Prolonged fasting can lead to dehydration, hypoglycemia, and stress in children. International societies like ESAIC and the Canadian Pediatric Anesthesia Society endorse the 1-hour rule, but ASA has not yet updated its guidelines.

Current practices in the U.S.

Institutions that have adopted the 1-hour NPO rule:

• No increase in aspiration or extended hospital stays.
• Improved parental satisfaction.
• Over 650,000 pediatric anesthesia cases performed under the rule without major adverse events.

Strategies used to encourage clear fluid intake:

73% of institutions use pre-op reminders, phone calls, and nursing staff to ensure hydration up to the cutoff time.

What’s next? 

The SPA-QS Committee recommends actively encouraging clear fluid intake up to the fasting limit. While ASA guidelines remain unchanged, more hospitals are expected to transition to the 1-hour rule.

What can parents do?

• Ask your child’s doctor about the latest fasting guidelines at your hospital.
• Encourage your child to drink clear fluids (water, apple juice, electrolyte drinks) up until the approved cutoff time.
• Advocate for shorter fasting periods to reduce unnecessary discomfort.

With increasing evidence and international support, the shift to 1-hour clear fluid fasting is gaining momentum in pediatric anesthesia.

Want more updates like this? Subscribe and download the Anesthesia Updates App (AA) to access the latest in Anesthesiology and Pain medicine Updates. With AA, you will have access to step-by-step management algorithms, the latest research, and peer-reviewed insights—all in one place. Download the Anesthesia Assistant App today and experience the future of anesthesia education and decision-making.

Reference: Dalal PG. Anesth Analg. 2025;140(3):507-514.