The 6-4-0 regime for paediatric pre-operative fasting

Andersson et al. Paediatr Anaesth. 2018 Jan;28(1):46-52. doi: 10.1111/pan.13282. Epub 2017 Nov 23

The times, they are a-changing – Bob Dylan


  • Site of project: Uppsala University Hospital, Uppsala, Sweden
  • The most widely practiced regimen for fasting in children: 6-4-2 (in hours for solids and milk- breast milk-clear fluids respectively), but does it actually translate into 6-4-2 in practice – especially for clear fluids?
  • What are the reasons for poor compliance?
  • The main operating theatres in Uppsala have been running 6-4-0 since the year 2000
  • A separate operating unit (ENT, plastics, oral surgery) wanted to trial the 6-4-0 regime

Materials and Methods:

  • All patients 16 years of age and younger, having elective procedures were included
  • Nurse and parents were questioned in the anaesthetic room
  • 6-4-0 regimen: Patients were allowed clear fluids till the time of being called for theatre
  • Individual assessments to avoid 6-4-0 rule as deemed necessary
  • The study included 203 patients in total, divided into three groups:
    • ENT6-4-2: patients having their operation in the ENT unit with the 6-4-2 rule, before the introduction of 6-4-0 (66 children)
    • ENT6-4-0: patients having their operation in the ENT after the introduction of 6-4-0 (64 children)
    • MP6-4-0: patients having their operation in main theatres, which has been running 6-4-0 since the year 2000 (70 children)
  • Outcome measures: Actual total fluid fasting times
  • Information about fasting times was provided by Preassessment nurse, Paediatric anaesthetists and/or Surgeons, based on Medical records and sometimes given over the phone.




  • There was a significant improvement in fasting times after introduction of the 6-4-0 regimen
  • The MP6-4-0 median fasting time was longer than ENT6-4-0
    • This could be due to different type of patients, different surgical or medical complexity and different proportions of inpatients (MP 50% vs ENT 80%)
  • The identified reasons for failure were:
    • Tradition, Rearrangements of surgery list schedules among others.
  • Why are younger children suffering more?
    • Breast milk fed (4 hour starvation), over-zealous parents/carers, first on the list.
  • Safety:
    • Fear of risk of pulmonary aspiration: incidence of 1 to 10 in 10,000 was not increased with 6-4-0
    • Gastric volume and pH is unaffected by fluid ingestion 1-2 hours prior
    • The half-time for gastric emptying of clear fluids is 10-27 min
    • There was no pulmonary aspiration in this study but it’s not powered to detect this
    • Individual assessment is advised


Summary by Dr Prakash Krishnan

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