Influence of Parental Awareness Drive on Preoperative Fasting Compliance in Pediatric Day Care Surgery.

Context: Optimum preoperative fasting is imperative for the prevention of aspiration in pediatric patients. The current guidelines advocate 2-4-6 rule for the same. However, direct supervision is lacking in large volume centers. Aims: Thus, we aimed to determine the fasting compliance of children preoperatively and to ascertain whether parents understood the significance and purpose of optimum fasting. Materials and
Methods: Design - A prospective questionnaire-based study regarding preoperative fasting was performed in pediatric patients aged 1-10 years scheduled for "day care surgery" or "same day admission surgery" over 12 weeks. Thereafter, parental awareness drive was carried out, and a re-audit was performed with a questionnaire in the next cohort of patients.
Results: The number of patients in the pre and postcounseling groups were 98 and 99. Thirteen percent of the patients were optimally fasted for solids initially. Re-audit confirmed compliance increased to 46%. Patients fasting adequately (2-3 h) for clear fluids increased from 22.4% to 51.5% postcounseling. The number for optimally breast-fed children increased postaudit (23.1%-39.1%). Consequent to the drive, parental awareness increased and 49.5% parents knew that only plain water was permitted during fasting. Number of parents considering preoperative fasting important increased from 39.8% to 79.7%. Initially, 27.6% of the parents did not know the reason for fasting, which reduced to 3% postaudit.
Conclusion: Parents are misinformed and ignorant about optimum preoperative fasting. Adequate education and awareness to improve their knowledge was associated with increased compliance for optimal fasting. Copyright:

INTRODUCTION

P reoperative fasting guidelines permit clear fluids up to 2 h, breast milk up to 4 h, and solid food (and other liquids like coffee with milk) up to 6 h preoperatively.[123] However, in clinical practice, it is challenging to adhere to these guidelines.[4] This is owing to unpredictable sequence of OT lists, poor communication between parents and health-care staff, and poor understanding of parents resulting in both intentional and unintentional noncompliance.

Thus, we conducted an audit aiming to study the preoperative fasting compliance of children and to ascertain whether parents understood the meaning and purpose of optimum fasting. We hypothesized that pediatric patients are incorrectly fasted preoperatively.

Our ultimate aim was to improve communication with parents about fasting, increasing the likelihood of a child being fasted appropriately.

MATERIALS AND METHODS

The procedures followed were in accordance with the ethical standards of our institutional committee and with the Helsinki Declaration of 1975, as revised in 2000. A prospective questionnaire-based study was conducted over 12 weeks, from October 2019 to December 2019 after seeking a waiver from our local institutional committee. The grounds for seeking waiver were in conjunction with ICMR guidelines 2017.

All American Society of Anesthesiologists 1 and 2 patients aged 1–10 years of either gender, posted for day care surgery and same-day admission surgery, were included after a detailed explanation and consent from their parents.

Children under the age of one were excluded because of inability of direct comparisons with rest of the participants. Children with complex nutritional requirements, for example, feeding through a gastrostomy tube, were also excluded.

Day care surgery comprised of patients who were admitted on the morning of surgery and were expected to be discharged the Same day like patients undergoing inguinal hernia, hydroceles etc. The same-day admission surgery included patients who are admitted on the same day of surgery but were required to spend one night in the hospital after surgery.

With α, margin of error as 5%, power of study as 90%, and confidence interval of 90%, the sample size was calculated to be 197.

Detailed preanesthetic check-up (PAC) and investigations were done. Written informed consent was sought from parents. They were explained in detail about the purpose of the study. They were asked to take a survey in their vernacular language (English, Hindi) and were assured that the survey would remain confidential, and the answers would not affect patient management and surgery. The first 98 parents were asked to complete questionnaire as depicted in Table 1.

Table 1

Observations: Questionnaire

Understanding of fasting
Has your child undergone surgery before?
Yes
No
Were you aware your child had to fast?
Yes
No
If yes, who informed you?
Surgeon
Anesthetist
Both
None
What do you think is the purpose of fasting?
Avoid vomiting
For requirement of surgery
To avoid urination
Avoid urine and bowel movement during surgery
Don’t know
How long did you keep your child fasting for solids? (h)
<6
6-8
8-12
>12
How long did you keep your child fasting for liquids?
Clear fluids
Breast milk
Other liquids (formula milk, juice, tea, coffee etc.)
Which of the following foods are exempted while fasting?
Coffee or tea
Soft drinks
Plain water
Sweets
How is important is fasting?
Very important
Important
Somewhat important
Not important

Following this, an awareness drive was initiated. Parents were explained in detail regarding preoperative fasting and their fears were allayed. They were explained why and how it is imperative, ensuring they would not resort to lying to evade cancellation/postponement of surgery. A separate resident doctor was assigned the job of reiterating fasting instructions to patients coming to PAC clinic. Parents were asked by the resident to repeat what was taught to them to confirm satisfactory comprehension. The parents who could not repeat the guidelines had the information reiterated to them through visual medium. They were shown images of foods permitted and not permitted during fasting. The pediatric surgery residents were also counseled and encouraged to provide clear orders regarding the time and foods allowed in fasting in pediatric surgery outpatient department. Consequently, the next 99 parents were interviewed and asked to complete the questionnaire.

Statistical analysis

Data were compiled, tabulated, and analyzed using SPSS (IBM Corp. IBM SPSS Statistics for Windows, version 20.0, Armonk, NY, USA) version 20.0. Probability values <0.05 were considered significant. With margin of error 5% and confidence interval of 90%, sample size was calculated to be 197.

RESULTS

There was no statistically significant difference between the patient's age and gender in both groups. There was no statistically significant difference in educational status of parents belonging to both groups.

Thirteen percent of the patients were optimally fasted for solids initially. Reaudit confirmed compliance increased to 46% [Table 2]. This was statistically significant. Patients fasting adequately (2–3 h) for clear fluids (clear water, coconut water) increased from 22.4% to 51.5% postaudit as depicted in Table 3. Patients adequately fasting for other liquids (formula milk, tea, juice, and coffee) increased from 23% to 35%. This was statistically insignificant and is depicted in the same table. The number for optimally (4–6 h) breast-fed children increased postaudit (23.1%–39.1%). However, it was found to be statistically insignificant. This is represented in Table 4. Consequent to the drive, 49.5% parents knew that only plain water was permitted during fasting, which was statistically significant [Table 5]. Before the awareness drive, 27.6% of the parents did not know the reason for fasting. This was reduced to 3% after they were educated [Table 6]. Furthermore, precounseling 39.8% parents regarded optimum fasting as important prerequisite. Following the awareness drive, 79.7% parents considered fasting important as illustrated in Table 7.

Table 2

Fasting for solid food

How long did your child fast for solid food? (h)	Control, n (%)	Intervention, n (%)	P
<6	30 (30.6)	24 (24.2)	<0.001
6-8	13 (13.3)	46 (46.5)
8-12	31 (31.6)	28 (28.3)
>12	24 (24.5)	1 (1.0)
Total	98 (100.0)	99 (100.0)

Table 3

Fasting for clear fluids and other liquids

	Control, n (%)	Intervention, n (%)	P
How long did your child fast for clear fluids? (h)
<2	3 (3.06)	0	<0.001
2-3	22 (22.4)	51 (51.5)
3-4	28 (8.5)	27 (27.3)
4-12	22 (22.4)	12 (12.1)
>12	23 (23.5)	9 (9.1)
Total	98 (100.0)	99 (100.0)
How long did your child fast for other liquids? (h)
<6	20 (33.9)	10 (18.9)	0.150
6-8	14 (23.7)	19 (35.8)
>8	25 (42.4)	24 (45.3)
Total	59 (100.0)	53 (100.0)

Table 4

Fasting for breast milk

How long did your child fast for breast milk? (h)	Control, n (%)	Intervention, n (%)	P
<4	14 (35.9)	7 (15.2)	0.065
4-6	9 (23.1)	18 (39.1)
>6	16 (41.0)	21 (45.7)
Total	39 (100.0)	46 (100.0)

Table 5

Food exempted from fasting, as perceived by parents

Foods exempted	Control, n (%)	Intervention, n (%)	P
Coffee/tea	29 (29.6)	24 (24.2)	<0.001
Soft drinks	21 (21.4)	18 (18.2)
Plain water	17 (17.3)	49 (49.5)
Sweets	31 (31.6)	8 (8.1)
Total	98 (100.0)	99 (100.0)

Table 6

Purpose of fasting

Purpose of fasting	Control, n (%)	Intervention, n (%)	P
Avoid vomiting	6 (6.1)	45 (45.5)	<0.001
Required for surgery	33 (33.7)	32 (32.3)
Avoid passing urine	17 (17.3)	13 (13.1)
Avoid bowel movement	15 (15.3)	6 (6.1)
Don’t know	27 (27.6)	3 (3.0)
Total	98 (100.0)	99 (100.0)

Table 7

Importance of fasting

Importance of fasting	Control, n (%)	Intervention, n (%)	P
Very important	16 (16.3)	40 (40.4)	<0.001
Important	23 (23.5)	33 (33.3)
Somewhat important	16 (16.3)	16 (16.2)
Not important	43 (43.9)	10 (10.1)
Total	98 (100.0)	99 (100.0)

Percentage of patients receiving fasting instructions from surgeons increased from 31.63% to 43.43% and is statistically significant (P < 0.001). This suggests that awareness drive has positively influenced surgeons, who have a key role of instructing parents regarding fasting in pediatric day care cases.

DISCUSSION

Appropriate fasting remains the cornerstone for the prevention of aspiration in anesthesia.[5] Pediatric population is highly susceptible to intraoperative hypovolemia and Electrolyte imbalance due to excess starvation.[678910] On the contrary, inadequate fasting predisposes to the risk of aspiration. Thus, optimum preoperative fasting is vital. Preoperative fasting status is routinely confirmed by enquiring from the parents. The accuracy of this method is questionable as the parents’ answers may be unreliable. This may be attributed to the parents’ inability to comprehend the meaning and importance of fasting or the parent choosing to mislead the anesthetist, to avoid delay of surgery.[11]

Our results show a direct positive correlation between parental counseling and adequacy of optimal fasting for pediatric surgical day care cases. Number of patients optimally fasted for solids increased from 13.3% to 46.5%. While 24.5% patients had prolonged fasting (>12 h) initially, this was brought down to only 1% postdrive. The overall fasting for solids witnessed a statistically significant difference pre and postaudit.

Inappropriate fasting may be a consequence of incorrect instructions given by health-care personnel, who themselves might have insufficient knowledge about the same. The parents might not be intellectually competent enough to understand the meaning of fasting and may misinterpret the orders given to them. They might assume that few foods are exempted from fasting and feed their children with them. Extreme anxiety too takes a toll on parents and inspite of proper comprehension of fasting instructions; they get distressed by the child crying excessively and feed them. These parents might end up lying about the fasting status, when asked preoperatively to avoid delay or cancellation of surgery. Moreover, at times, it is not feasible to wake up the child and feed them late night or early morning. Occasionally, inadvertent changes in the list sequence might result in children with inadequate fasting to be taken up for surgery or prolonged fasting of the others.

Medical personnel, who provided fasting instructions and parents, both were educated ensuring strengthening of communication between parents and caregivers.

Proportion of patients fasting adequately (2–3 h) for clear fluids (clear water and coconut water) increased from 22.4% to 51.5% postaudit. Whereas 23.5% patients were excessively fasted (>12 h) for clear fluids initially, this number reduced to 9.1% post the awareness drive. Fasting for clear fluids witnessed a positive statistically significant influence through the awareness drive.

Although the number for optimally (4–6 h) breast-fed children increased postaudit (23.1%–39.1%), it was found to be statistically insignificant. The general notion that coffee/tea and soft drinks were exempted from fasting also changed consequent to the drive, and almost half the parents (49.5%) knew that only plain water was permitted during fasting. This was found to be statistically significant.

Since it was difficult for parents to understand about aspiration, it was explained to them that the patient might vomit under anesthesia if not fasting and the vomitus might enter the lungs. Thus, in the questionnaire, for the purpose of ease, the option of avoiding vomiting was regarded as the correct answer for the reason to fast. Forty-five percent parents could successfully answer it after education as opposed to only 6.1% initially, which was statistically significant.

Before the awareness drive, 39.8% considered preoperative fasting to be important, whereas 73.7% parents realized its importance later. It was quantified on the basis of how easily they will give in (or not) to the demands of their child despite knowing and understanding the perils of inadequate fasting.

To the best of our knowledge, ours is the only study to incorporate plan-do-study-action cycle and assess most accurately the preoperative fasting compliance in pediatric patients.

In a study by Arun and Korula, the authors evaluated preoperative fasting times, which ranged between 4–18.75 h and 2–18.75 h for food (solids and milk) and water, respectively, in the initial audit.[12] We felt that a better and more accurate representation of this data could be analyzing patients using percentage of patients fasted adequately or inadequately. The authors chose to study all patients below 15 years. Analysis of such a study is difficult as patients <6 months would be exclusively breast-fed and results in a different impact on different population age groups. Thus, we in contrast chose patients between 1 and 10 years of age. Moreover, all elective cases might not be day care surgeries and thus in our study, we aimed to survey exclusively day care patients where role of parents is paramount.

The aforesaid was the only study except ours where an intervention in the form of education of parents was performed. The other studies discussed below, although mirrored the results of our initial audit, conducted only a baseline analysis of preoperative fasting compliance. Cantellow et al. evaluated 120 children of age 1–15 years through a questionnaire assessing their fasting compliance preoperatively and parents’ understanding of the same.[11] They concluded that 13.5% patients were not fasted. Fasting times of solids and fluids were recorded as 3–40 h (median 9.5) and 0.5–24 h (median 5), respectively. This again was not an accurate representation of adequately fasted patients and defaulters. Our precounseling audit showed similar results, which subsequently improved with proper education.

In another study performed in 2014, Lim et al. surveyed 130 adults regarding preoperative fasting compliance and understanding its importance.[13] Although the results suggested good compliance (98.4%), the understanding of patients was poor (44.6%). The root of the problem in both the studies was poor understanding, which was not just identified but also addressed in our study.

In 2002, a study by Crenshaw and Winslow highlighted prolonged preoperative fasting as a major issue with mean preoperative fasting times as 12 and 14 h for liquids and solids, respectively.[14] A follow-up study conducted at the same institution 4 years later still showed prolonged preoperative fasting time for clear liquids of 11 h and for over 14 h for solids.[15] This reiterates the fact that persistent efforts need to be instituted for implementation of optimum preoperative fasting compliance. Although patients were educated and several steps for awareness for the same were taken in 2002, none were followed up. This is one of the limitations of our study too. We should advocate future studies, which follow-up the measures taken by us.

CONCLUSION

Education of parents and medical personnel positively influenced the understanding and importance of fasting. Persistent efforts from health practitioners dealing with patients and their parents to explain and guide them properly regarding preoperative fasting are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.