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Copyright (c) 2026 Ekta Rai, Yunita Widyastuti, Teddy Suratos Fabila, Zehra Serpil Ustalar Ozgen, Norifumi Kuratani, Ina Ismiarti Shariffuddin
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Abstract
Preoperative fasting guidelines have evolved substantially over three decades, moving from rigid nil-per-os-after-midnight directives to evidence-based regimens permitting clear fluids within one to two hours of induction. However, most supporting evidence originates from Western high-income settings, raising concerns about its applicability to Asian paediatric populations. This narrative review examines the evidence base for preoperative fasting in Asian children, the contextual factors that shape its practice across the region, and the path toward region-specific guidance. Four integrated lenses are applied: the physiology of gastric emptying and aspiration risk; the evolution of major international fasting guidelines; the persistent problem of prolonged fasting in clinical practice; and the cultural, dietary, and climate considerations that render the Asian context distinctly different from the settings in which current guidelines were conceived. Pulmonary aspiration during elective paediatric anaesthesia is exceedingly rare, fewer than three to four events per 10,000 cases, yet actual clear fluid fasting durations of eight to twelve hours remain common across Asian centres. Three evidence gaps of particular regional significance are identified: uncharacterised gastric emptying profiles of rice-based staple meals in children; nutritional vulnerability of paediatric patients in lower-middle-income Asian settings; and the potential interaction between prolonged fasting and climate-driven heat exposure across South and Southeast Asia. Although current international fasting principles remain physiologically sound, their implementation in Asia requires dedicated research on regional diets, consensus guidelines developed by Asian anaesthesiology societies, and institutional strategies to reduce unnecessary fasting. A multinational survey currently underway aims to support a future Delphi-based regional consensus.
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