As you know, ASA task forces use several approaches when developing a position statement. The first approach is evidence based conclusions using the available literature and the second is the opinion of its expert consultants. A thorough search of the literature did not reveal any papers that clearly defined from a scientific standpoint what period of fasting results in an empty stomach from milk, formula, and solids when related to age.

In recent years our practice as pediatric anesthesiologists has been to make children 0-6 months NPO milk (breast milk), formula and solids for 4 hours and two hours for clear liquids. Older children (7-36 months) NPO milk and solids for 6 hours and clear fluids 2-3 hours whereas older patients were generally fasted from milk and solids for 8 hours and clear liquids for 2-3 hours.

There is no scientific evidence that somehow gastric emptying of milk and solids changes when a child is 5 months and 30 days compared with 6 months and 1 day. Likewise, there is no evidence that there is a difference when a child is 35 months 30 days and 36 months and 1 day old. Therefore the committee polled its members regarding a 2-4 hour fast or an 8 hour fast; the flaw in the questionnaire was that no one asked about 4 hours or 6 hours. This then resulted in a flawed answer by the panel of experts and thus recommendations for an 8 hour fast.

When this became evident to the community of pediatric anesthesiologists, representatives of the Society for Pediatric Anesthesia, the Section on Anesthesiology of the American Academy of Pediatrics, and the ASA Subcommittee on Pediatric Anesthesia, as well as a number of individual pediatric anesthesiologists raised concerns that if passed as written, the task force guideline would set back our current approach to fasting for children and perhaps create a medical/legal issue which previously did not exist.

When this was discussed at reference committee, it was wisely decided to table the proposal pending further modification and input from the pediatric anesthesia community. My guess is that many pediatric anesthesiologists (including myself) are grateful for the opportunity to work with the task force to reach some common ground.

The second important issue for children was a meeting of the Anesthesia Subcommittee of the United States Pharmacopoeia Drug Index. Several years ago, the USPDI, with input from pediatric practitioners, recognized that the labeling of drugs for children was severely deficient. Approximately 80% of current drugs lack pediatric labeling or have a disclaimer, e.g. for bupivacaine, "Until further experience is gained in children younger than 12 years, administration of MARCAINE in this age group is not recommended."

Such disclaimers have not hindered our use of appropriate medications in children, but it could potentially create an unnecessary medical/legal situation should a problem arise, leaving the practitioner who only occasionally used certain drugs without a resource to guide dosing. This then left the practitioner in the awkward position of using new drugs without the benefit of full FDA approved studies, which examined pharmacokinetics and pharmacodynamics for children of various ages. Since the Physicians Desk Reference (up until the last two years) could only include data from drug-company sponsored studies, the labeling remained deficient.

The USPDI asked for input from pediatricians and pediatric anesthesiologists to help them revise all drug monographs to include prescribing information based on current use and to provide pediatric references when available. The enormity of this task was underestimated and it soon became evident that these changes would be enormously expensive and time consuming.

A subcommittee of pediatric anesthesiologists from the Section on Anesthesiology of the American Academy of Pediatrics provided revised labeling suggestions on several hundred medications. The bad news was that nothing happened with this information for the past two years, the good news is that the USPDI is now prepared to move forward and will begin the revision process. This is another victory for equal rights for children when it comes to access to pharmaceuticals.