We appreciate the careful review of our article.1  We agree with the authors that other studies also support the low incidence of aspiration in pediatric sedation. While the study by Walker2  of 118,371 pediatric patients is also large, only information on the 24 cases of aspiration was collected. Our study collected data on all patients, allowing us to evaluate risk factors for aspiration using major complications. We agree that our definition of nil per os (NPO) is not based on current American Society of Anesthesiologists guidelines from 2011 because the data were collected from 2007 to 2011.

The vast majority of our data come from elective sedations provided by sedation services, so they do not speak to the issue of emergency sedation provision. Of the 135,860 patients for whom emergency status was known, 134,539 (99%) procedures were routine and all 10 aspirations occurred in this group. One would imagine that emergency sedation could have more risk; however, the current literature does not reflect that.

Given the limitations of the study, we do not suggest that our data argue for a complete overhaul of the NPO guidelines, but rather point out that clinicians should be aware that a rigid focus on adhering to the guidelines does not offer complete protection to patients. It confirms the previous aspiration investigations that indicate aspiration in a pediatric population is more likely to track with a patient’s pathology than NPO status, and issues such as underlying illness and bowel pathology are of paramount importance when considering aspiration risk.

There is a growing literature regarding enhanced recovery of surgical patients, which suggests that our current model of prolonged starvation of patients may not lead to ideal recovery outcomes. It seems appropriate for our specialty to recognize that the current guidelines, while they have likely served patients and professionals well over the course of several decades, are based on consensus and a reasoned interpretation of data from animals and gastric emptying studies. They are not, strictly speaking, evidence based. Consideration should be given to supporting studies of very large data sets with detailed intake history to further clarify risk versus benefit with regard to NPO status.

The authors declare no competing interests.

Major adverse events and relationship to nil per os status in pediatric sedation/anesthesia outside the operating room: A report of the Pediatric Sedation Research Consortium.
Pulmonary aspiration in pediatric anesthetic practice in the UK: A prospective survey of specialist pediatric centers over a one-year period.
Paediatr Anaesth