Fasting for surgery is a routine step in the preoperative preparation for surgery. There have however been increasing concerns with regard to the high incidence of prolonged fasting in children, and the subsequent psycho‐social distress and physiological consequences that this poses. Additionally, the past few years have yielded new research that has shown significant inter‐individual variation in gastric emptying regardless of the length of the fast, with some patients still having residual gastric contents even after prolonged fasts. Additionally, multiple large‐scale studies have shown no long‐term sequalae from clear fluid aspiration, although two deaths from aspiration have been reported within the large Wake Up Safe cohort. This has led to a change in the recommended clear fluid fasting times in multiple international pediatric societies; similarly, many societies continue to recommend traditional fasting times. Multiple fasting strategies exist in the literature, though these have mostly been studied and implemented in the adult population. This review hopes to summarize the recent updates in fasting guidelines, discuss the issues surrounding prolonged fasting, and explore potential tolerance strategies for children.

Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer‐centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri‐procedural anxiety.

Background: Anaesthesia related mortality in paediatrics is rare. There are limited data describing paediatric anaesthesia related mortality. This study determined the anaesthesia related mortality at a Tertiary Paediatric Hospital in Western Australia. Methods: A retrospective cohort study of children under-18 years of age, that died within 30-days of undergoing anaesthesia at Princess Margaret Hospital (PMH), between 01 January 2001 and 31 March 2015. A senior panel of clinicians reviewed each death to determine whether the death was (i) due wholly to the provision of anaesthesia (ii) due partly to the provision of anaesthesia or (iii) if death was related to the underlying pathology of the patient and anaesthesia was not contributory. Anaesthesia related mortality, 24-h and 30-day mortality as well as predictors of mortality were determined. Results: A total of 154,538 anaesthetic events were recorded. There were 198 deaths within 30-days of anaesthesia. Anaesthesia attributable mortality was 0.19/10,000 with all anaesthesia deaths occuring in patients undergoing cardiothoracic surgery. The 24-h and 30-day all-cause mortality rate was 3.43/10,000 (95% CI 2.57-4.49) and 9.38/10,000 (95% CI 7.92-11.04), respectively. Overall mortality was 12.34/10,000 (95% CI 11.09-14.73) Age less than 1-year, cardiac surgery, emergency surgery and higher ASA score were all significant predictors of mortality. Conclusion: Paediatric anaesthesia related mortality as reflected in this retrospective cohort study is uncommon. Significant risk factors were determined as predictors of mortality.

Summary: Introduction: Tonsillectomy, a common childhood surgery, is associated with difficult postoperative recovery. Previous reviews provided low‐grade evidence that honey may improve recovery. The BEE PAIN FREE study investigated whether honey alongside multimodal analgesia improved the recovery trajectory in children following tonsillectomy. Methods: A prospective randomised controlled trial was conducted across three centres in Western Australia. Children undergoing extracapsular tonsillectomy by coblation were allocated randomly to one of four postoperative treatment groups: standard treatment alone; Marri honey (from Western Australia); Manuka honey (from Western Australia); or placebo. The intervention groups took 5 ml of honey or placebo, six times a day, for at least 7 days, in addition to usual discharge analgesia (standard treatment). Data for daily pain scores, Parents' Postoperative Pain Measure scores, medications and unplanned re‐presentations were collected. Results: A total of 400 children were recruited; 20% were lost to follow‐up or withdrew. The mean number of honey doses taken varied between 2 and 3 doses per day over 7 days. Treatment with honey at this frequency did not impact postoperative pain scores significantly, with all groups showing similar trajectories. These findings did not alter with as‐treated analysis or using imputed models for missing data. Most children experienced significant pain until around postoperative day 8. Children allocated to the honey and placebo groups showed some improved oral tolerance around day 6 but had increased vomiting during earlier days. There were no clinically significant differences in medical re‐presentations, simple analgesia or oxycodone usage between groups. Discussion: Two to three doses daily of oral honey/placebo in children post‐extracapsular tonsillectomy for 7 days, in addition to regular paracetamol, ibuprofen and as required oxycodone did not result in a clinical improvement in pain or recovery over a 14‐day follow‐up period.