My Baby is Having Surgery

Surgical Procedures With AnesthesiaBefore Surgery During and After Surgery Minor Surgical Procedures Without Anesthesia Fasting Time Guidelines Around the World References When babies have major surgery, a general anesthetic is given to ensure they are unconscious and free from pain during the operation. Anesthetists administer the anesthesia and closely observe the child during surgery. They prescribe pain relief if needed after surgery. Before receiving a general anesthetic, your baby will not be allowed anything to eat or drink for a prescribed amount of time. The medical community refers to this time of fasting as NPO (nil per os) which means “nothing by mouth.” Why? Anesthesia stops their body’s normal reflexes working temporarily. If your baby’s stomach has food or drink in it, there is a risk of vomiting, and regurgitation (bringing up food into their throat). If this happens, the regurgitated food could spill into your baby’s lungs (aspiration) and affect their breathing. Human milk is digested more quickly than formula so many breastfed babies will be allowed shorter recommended fasting times prior to having a general anesthetic. Different hospitals and country guidelines put human milk into different categories, which affects the length of time they recommend restricting breastfeeding. Parents may wish to share the ABM Clinical Guideline #25: Recommendations for Preprocedural Fasting for the Breastfed Infant: “NPO” Guidelines with baby’s healthcare providers. Access to this guideline is listed at the end of this article. This document is available in English, Chinese, German, Japanese, Korean and Spanish. Requiring a breastfeeding baby to fast is stressful for both the baby and the parents. It is important to discuss the safest fasting time for your baby with your baby’s healthcare professionals. Before surgery, speak to your baby’s anesthetist, since they will make the decision about how long your baby should fast before the surgery. They may not realize that babies fed exclusively on human milk have empty stomachs in only two to four hours after a feeding due to the easy digestibility of human milk. Worldwide, most organizations recommend a fasting period of four hours although some recommend three hours. This means finishing breastfeeding by three to four hours before anesthesia will be administered. Discuss the recommendation in your area with your providers before surgery. Formula or breastmilk with added supplements should not be fed to a baby for six hours before anesthesia, as these feedings take longer to digest. Some organizations allow small amounts of clear liquids up to two hours before surgery. Clear liquids are fluids that are see-through and digest quickly without forming curds in the baby’s stomach. (Liddle, 2022) Ask your healthcare providers which clear liquids they recommend. Breastmilk is not considered a clear liquid. You may find it helpful to schedule surgery so that you can take advantage of a time when your baby or toddler is fairly content without nursing. For example, if the fasting period is four hours, your baby might nurse through the night until 6 a.m., and then be distracted with other activities until the scheduled surgery time of 10 a.m. It may be easier to skip breakfast and to distract a child from nursing in the morning than it would be to keep the child from nursing through the night. You will know what will work best for your own child. You might find these ideas to distract your baby from breastfeeding useful: If your breasts start to feel uncomfortably full during the fasting period you may want to express your milk. Ask for a safe, comfortable place to express that is not a bathroom. The nurses should be able to assist you. Depending on how long you and your baby will be separated, you may choose to continue to express your milk while your baby is having surgery to avoid engorgement and to maintain your normal milk production. Unless your healthcare team tells you otherwise, you will be able to breastfeed as soon as your baby is wide awake and ready to feed by mouth after surgery. Breastfeeding is soothing, pain relieving and comforting for the baby. If your baby has tubes, drains or lines after surgery, you can ask for assistance to help you position safely and comfortably while breastfeeding.. Many hospitals have professional lactation support on staff who are available to help. Breastfeeding will continue to be a source of comfort, pain reduction and healing for little ones after surgery. Babies need extra snuggling and small comforting feeds if this is possible. In any case, babies and parents being together contributes to more rapid healing and helps normalize a difficult time for both baby and parents. For minor painful surgical procedures when baby is not receiving general anesthesia, fasting may not be required. (ABM, 2012). In some cases of minor procedures, wide awake babies may be able to nurse throughout the procedure for comfort. “Effective and safe pain treatment strategies during procedures for sick and healthy newborns and infants include breastfeeding, skin-to-skin care, and sweet solutions.” (Harrison and Bueno) Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care.  Eur J Anaesthesiol 2022; 39:4–25. https://www.esaic.org/uploads/2022/01/pre_operative_fasting_in_children__a_guidelin.pdf UK and Ireland: Preoperative fasting of patients for theatre, Royal Hospital for Children. (2022). NHAGGC Guidelines. https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/anaesthetics/preoperative-fasting-of-elective-patients-royal-hospital-for-children/ USA: The Academy of Breastfeeding Medicine (ABM) states that babies may have breastmilk up to four hours before surgery. This recommendation is listed in their protocol #25. Breastfeeding Medicine Volume 7, Number 3, 2012, Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2012.9988. https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/25-preprocedural-fasting-protocol-english.pdf. Another useful protocol is ABM Protocol #35, Supporting Breastfeeding During Maternal or Child Hospitalization.   Breastfeeding Medicine Volume 16, Number 9, 2021Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2021.29190.mba.https://www.bfmed.org/assets/ABM%20protocol%2035%20Nov%202021.pdfAmerican College of Anesthesia: Isserman, R. and Elliott, E.  (2023) . https://www.openanesthesia.org/keywords/npo-guidelines-for-infants-and-children/ Canada: The CA2020 Fasting Guidelines. https://anesthesiology.queensu.ca/sites/anesthesiology/files/inline-files/CAS%202020%20Fasting%20Guidelines.pdf lists a fasting time of four hours for breastmilk. India: Indian J Anaesth. 2020 Jul; 64(7): 556–584. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413358/ Israel: The Sha’aray Tzeddek hospital website (one of the biggest hospitals in Jerusalem) lists a fasting time for breastmilk of four hours .https://www.szmc.org.il/departments/surgery/cherurgya-klalit/tzom-lifney-nituch-leyalaim/ Spain: Torrent, Ana Abad.Curso Edaic Intensivo.(2024) refers to a number of resources and states a fasting time of four hours for breastmilk should be used. https://anestesiar.org/2011/guias-practicas-2011-para-el-ayuno-preoperatorio-y-utilizacion-de-farmacos-para-reducir-el-riesgo-de-broncoaspiracion/ New Zealand and Australia: Australian and New Zealand College of Anaesthetists (ANZCA)  say: Harrison, Denise and Bueno, Mariana. Translating evidence:pain treatment in newborns, infants, and toddlers during needle related procedures. Pain Rep. (2023 Mar-Apr; 8)(2): e1064. Published online 2023 Feb 16. doi: 10.1097/PR9.0000000000001064 Liddle, C. (2022) Preoperative fasting: exploring guidelines and evidence to ensure consistent, high-quality care. Nursing Standard.doi: 10.7748/ns.2022.e12033 Published 2018, revised July 2024.