Surgery and eating restrictions?

[moongazer]

Does anyone know why the eating restrictions before surgery are so vastly different for LOs over and under a year? Ds had surgery at 11 months and he could have BM up until 4 hours before surgery. Now at 14 months, they want no BM after midnight which would be 9 hours before surgery (if they are actually on time)!

I asked the pre-admission nurse and she said that older kids can go longer without eating. But 9 hours? That seems crazy to me. She said he could have apple juice, water or pedialyte until 4 hours before.

Any experiences with this??
Thanks
Becky

[MotherWhimsey]

The longer it has been since they have eaten, the less the risk of aspiriation under GA. So if it is reasonable for them to go 12 hours without eating, it is worth the PIA factor because it's much better to decrease the risk of potential aspiration. So it's a pain in the butt, but it's really for a good reason.

Smaller babies can't always tolerate going from midnight on NPO. Their blood sugar may be too much of a problem to deal with at home (with no IV access).

[moongazer]

I guess I am wondering if the risk of aspiration goes up after they turn 1, or is it just because they figure they can go longer without food and be OK?

[2boyzmama]

Breastmilk is breastmilk is breastmilk, no matter what the age.

It's ridiculous to say he can have apple juice or pedialyte 4 hours before but not breastmilk. Besides, if he was going to aspirate, I'd rather it be breastmilk, not apple juice.

Breastmilk is a clear fluid at 4 weeks, 4 months, and 4 years.

Go ahead and breast feed him 4 hours before. I always have breastfed 3 hours before (the studies on the American Academy of Anesthesiologists say clear fluids 2-4 hours before, some hospitals say 2, some say 4, some say 3). I don't always *tell* them this though!

[MotherWhimsey]

Please do not lie about when you last gave your child breast milk. That is incredibly irresponsible and very unfair to the anesthesiologist that is assuming responsibility for your child's life based on the understanding that their protocols have been followed.

Since they ARE assuming a risk in being your child's anesthesiologist, they have a right to law down what rules have to be followed to minimize the risk they are taking. If you can't play by their rules, then find someone else. Those guidelines are in place for a reason.

If you want to call and argue with them about it, that's fine. It at least gives the anesthesiologist to shoot it down and tell you why. And maybe they'll say it's not a problem. But it's just not right to do it without asking. If they say no, then play by their rules. 9 hours without breast milk is probably not going to kill either of you. Sometimes you just gotta do what you have to.

[MotherWhimsey]

And breast milk grows stuff too. It's still got sugars and fatty lipids and a lot of good growth medium for bacteria. It might be good stuff, but it doesn't have magic powers to prevent bacterial growth. If you leave it out in a bottle, it still gets nasty. And you're actually only allowed to hang it in a feed bag for 4 hours unrefrigerated whereas you can hang formula for 8-12. It does tend to spoil faster. Maybe the bacteria find it just as easy to break down as the baby does.

[2boyzmama]

Obviously you have to do what you're comfortable with. I wasn't comfortable with it until I read the research myself. I did ask the intake nurse why the rules changed at a year, her first answer was "most kids aren't breastfeeding past a year", which is fine and dandy, but what about those that are? She said "well, I don't know if it's still a clear fluid." I asked if some property in the breastmilk is thought to change at a year, or if something in the baby's gut changes to slow down the rate it digests, she said she wasn't aware.

Then I called around to other hospitals to get their policies. *Most* will still list clear fluids past a year, some don't.

Then I called several lactation consultants, who all said it is always a clear fluid.

I know that breastmilk has properties in it that can be dangerous if aspirated, but so does apple juice or pedialyte, and I'd rather it be breastmilk if I have the choice.

Obviously not aspirating is preferred, it's yet another risk/benefit analysis every parent has to weigh for themselves. But in our case, when we were faced with a procedure at the one children's hospital near us that for some reason had different rules about breastmilk than most of the others, after I did the research, I felt perfectly confident in feeding him 3 hours before.

[2boyzmama]

http://www.pedsanesthesia.org/newsle...erpoint.iphtml

This is specific to formula, but does include information on breast milk.

[MotherWhimsey]

Originally Posted by 2boyzmama

I know that breastmilk has properties in it that can be dangerous if aspirated, but so does apple juice or pedialyte, and I'd rather it be breastmilk if I have the choice.

I take the apple juice over breast milk. Apple juice has no fatty lipids.

I wasn't saying if breast milk was or was not a clear fluid, but that you shouldn't give it to your child without telling someone. The parents would be in a bad place legally if something happened to the child and they had lied about when they last fed them.

I personally think that 6 hours is totally reasonable in most cases that young, but it depends a whole lot on all the factors involved. We put Linden on an IV the night before and he's fed into his intestine with his stomach always draining. For us it's just much riskier to have him potentially back something up during the procedure. All those drugs make him pukey. So there are a lot of factors involved.

[2boyzmama]

Practice Guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: A report by the American Society of Anesthesi- ologist Task Force on Preoperative Fasting. ANESTHESIOLOGY 1999; 90:896–905

Summary of American Society of Anesthesiologists Preprocedure Fasting Guidelines2*
Anesthesiology, V 96, No 4, Apr 2002
Ingested Material
Clear liquids‡ 2h
Breast milk 4h
Infant formula 6h
Nonhuman milk§ 6h
Light meal

[MotherWhimsey]

It's more just the ethical and legal issues that are the big thing for me.

And if you judge what is or isn't okay to aspirate based on how one kid responds, then the list is really really long. Linden has aspirated all kinds of things, like confirmed aspiration, and he's never gotten aspiration pneumonia. So by that logic, applesauce, milk, water, yogurt, candy, suckers, soda, bread, rice cereal, formula, and heaven knows how many other things Linden has sucked down his lungs and come out on top. It still doesn't mean it's good.

Ironically, he did have 3 bouts of pneumonitis in the 3 months he was exclusively breast fed before the tube. And that on top of chronic bronchitis.

[Momily]

One of the really nice things about a feeding tube, is you get a really good sense of how your child's stomach empties.

My son never got any breastmilk, but I can tell you there was a huge difference between the way that formula, or milk, or diluted babyfood emptied out of his stomach, and the way clear liquids emptied out of his stomach. I could bolus him water or apple juice and his stomach would be completely empty 1/2 an hour later. Give him the same amount of something not "clear" and he'd still be full hours later. I would imagine that breastmilk is somewhere in the middle, but I don't really know. So from that point of view, clear liquids are simply less likely to be vomited in the first place.

As far as breastmilk as a "better" substance to be aspirated -- my understanding from the pulmnologist, was that breastmilk is by far and away the safest form of fat to aspirate, but that fat is always very risky. So, if you're going to feed a child completely by mouth, then breastmilk makes perfect sense because you need a fat source (and of course breastmilk makes sense for lots of other reasons), but breastmilk is still less safe than other non-fat things like apple juice, or water. But if you're feeding breastmilk and water by tube and want to try one by mouth then water's the best choice, followed by juice if your child won't drink the water.

[moongazer]

Thanks for your input Mommas. You have given me a lot to think about and some good resources to check.
Becky

[DoulaVallere]

Originally Posted by MotherWhimsey

And breast milk grows stuff too. It's still got sugars and fatty lipids and a lot of good growth medium for bacteria. It might be good stuff, but it doesn't have magic powers to prevent bacterial growth. If you leave it out in a bottle, it still gets nasty. And you're actually only allowed to hang it in a feed bag for 4 hours unrefrigerated whereas you can hang formula for 8-12. It does tend to spoil faster. Maybe the bacteria find it just as easy to break down as the baby does.

Actually, that's not completely true. Breastmilk naturally contains (magic powers) antibacterial and antifungal properties and spoils MUCH more slowly than formula. I would expect that the reason you can hang bag it less time is because it seperates due to not being homogenized, not because it spoils.

According to La Leche League, here are the storage suggestions for breastmilk:

•at room temperature (66-78°F, 19-26°C) for 4 hours (ideal), up to 6 hours (acceptable) (Some sources use 8 hours)
•in a refrigerator (<39°F, <4°C) for 72 hours (ideal); up to 8 days (acceptable)
•in a freezer (-0.4 to -4°F, -18 to -20°C) for 6 months (ideal) up to 12 months (acceptable)

Prepared formula companies say to discard after sitting at room temp for 1 hour, or after being in the fridge for 24 hours. Of course, in a hospital, formula is probably made with sterile water, so the time might go longer than what you mix up at home, but still - breastmilk IS safe at room temp for a number of hours.

For the OP, I would call and ask to speak to the anesthesiologist, point out that the AAA says that breastmilk is ok to have 4 hours before surgery, and ask if he's cool with you following their recomendations.

[MotherWhimsey]

Originally Posted by DoulaVallere

Actually, that's not completely true. Breastmilk naturally contains (magic powers) antibacterial and antifungal properties and spoils MUCH more slowly than formula. I would expect that the reason you can hang bag it less time is because it seperates due to not being homogenized, not because it spoils.

Well, my kid has gotten lung issues from exclusively breast milk. Maybe mine wasn't magical enough.

And really the issue is not so much what is better to aspirate, but that it's better to be NPO for the time they say and just not aspirate at all.

It also has a lot to do with what surgery is being done. If they're doing a bronch, then it's not as big as a deal. If they're doing an endoscopy, it counts as a non clear liquid because the camera can't see through it. If it was a gut surgery, it would matter more as well. So really, no one can give appropriate advice (aside from do what the anesthesiologist recommends) without even knowing what surgery is being done.

She may have said somewhere else, but I didn't see it here.

[vbactivist]

Originally Posted by 2boyzmama

Breastmilk is breastmilk is breastmilk, no matter what the age.

It's ridiculous to say he can have apple juice or pedialyte 4 hours before but not breastmilk. Besides, if he was going to aspirate, I'd rather it be breastmilk, not apple juice.

Breastmilk is a clear fluid at 4 weeks, 4 months, and 4 years.

Go ahead and breast feed him 4 hours before. I always have breastfed 3 hours before (the studies on the American Academy of Anesthesiologists say clear fluids 2-4 hours before, some hospitals say 2, some say 4, some say 3). I don't always *tell* them this though!

this.

[TiredX2]

I really think you need to be able to be honest with your health care team!

Have you asked about their recommendations. When DP was having surgery their recommendations were widely outside of what the ASA (American Society of Anesthesiologists) recommend and we asked why. Their basic answer--- "Saying don't eat past midnight is easy to remember and we get more people who actually follow the rule." DP ended up having his surgery put off by HOURS and if he had been an infant instead of a 33 year old it could have been horrible.

The standards are not new and considered very conservative:
http://www.asahq.org/publicationsAndServices/NPO.pdf

Clear fluids 2h
Bmilk 4h
Other milk 6h
Formula 6h
Light meal 6h

I would also encourage you to ask when he is checking in VERSUS when he is scheduled for going under. It can make a big difference as well. For me, I would ask the doctor why s/he is choosing to deviate from the ASA recommendation and make my decision from there. If it is a, "Well, we say midnight because lots of people don't listen and..." it would be different then if s/he said, "I have noticed with this specific surgery in children from ___-___ there is a higher asperation rate when they have _______"

You might also want to make it clear that your child regulary nurses during the night (if this is true). Many doctors seem to assume that the child will go to bed around 8 and wake up around 7 and don't want you to wake them up to eat. It might be a different matter if they understand your child will be screaming from 2-5 if not allowed to eat.

Good luck!

[MotherWhimsey]

Aspiration pneumonitis carries a 30-percent mortality rate and accounts for up to 20 percent of all deaths attributable to anesthesia .

The most important thing to know about aspiration pneumonitis is this: Aspiration pneumonitis can be prevented ! Careful monitoring during anesthesia, proper airway management and absolutely careful precautions before surgery can minimize or eliminate risk. When aspiration pneumonitis takes place during surgery, it is almost always a result of incompetent pre-surgical intake or improper management during surgery.

Aspiration of gastric contents can cause a broad range of damage, from very mild to severe, including adult respiratory distress syndrome (ARDS) that has a high degree of morbidity and mortality. Aspiration pneumonitis also predisposes its victims to subsequent bacterial pulmonary infection. One-third of patients will experience secondary complications. Twenty percent of deaths attributable to anesthesia are due to aspiration pneumonitis.

Because aspiration pneumonitis can be prevented, when aspiration pneumonitis takes place during surgery, it is almost always a result of some form of medical negligence or medical malpractice, including incompetent pre-surgical intake or errors in airway management and anesthesia during surgery.

From some points of view, there is really no excuse for aspiration pneumonitis and its complications to occur. Enforcement of pre-surgical fasting protocols (which are different for children and adults); re-scheduling surgery if protocols were not strictly followed, careful monitoring of the airways during unconsciousness, and proper intake and precautions during surgery can minimize or eliminate risk of aspiration pneumonitis during anesthesia. Even in patients who must undergo unplanned surgery, prophylactic measures can minimize risk. Both the volume and acidity of gastric contents can be reduced with appropriate drugs and stomach contents can be emptied.

.

[vbactivist]

I am going to throw this out there, it is just my experience/feelings. But I was not willing to let my daughter be horribly unhappy/crying hysterically before she had her second open heart surgery. I felt like, what if she died? Would I really want her last moments/hours with me to be her frantically wanting to nurse and me not letting her? Thankfully, our anesthesiologist said 3 hours for breastmilk, and she was very clear that we would be checking in long before surgery so I really did nurse her three hours until then. My family was all at the hospital, too, and so they were helpful in distracting her. But honestly? If I thought it would help to nurse my 14 month old a couple of hours before surgery, I would. And I would not tell. But that is me. We all have our own mother's intuition for a reason.

OP_

Good luck with the upcoming surgery. It's hard.

[MotherWhimsey]

to each their own, I think my mother's nightmare is that my kid would aspirate and spend the last hours of his life struggling for life on a vent from an issue that I could have prevented. Would you like to see what the results of aspiration (and not during the surgery but afterwards from vomit due to the anesthesia) looks like? It's not terribly pretty. http://s49.photobucket.com/albums/f2...spdistress.flv

He had a supraglottoplasty and we were not aware of how severe his aspiration became once his airway was fixed. So he was puking due to anesthesia complecations and aspirating the vomit (all exclusively breast milk by the way). And so, two weeks in the hospital, 14 days on high dose dexamethasone, and he was over the hill. But really, if they had told me I could have prevented that mess by just not feeding him after the surgery, I so would have been all over it.