Abstract

The aim of this review is to present an integrated overview of pediatric perioperative anesthesia care by focusing on its fundamental components—preoperative evaluation, fasting management, prevention of postoperative nausea and vomiting (PONV), and postoperative pain control—based on current guidelines and evidence. The aim is to emphasize the need for individualized, risk-based approaches in pediatric patients.

This study is designed as a narrative review based on current international guidelines and relevant literature on pediatric perioperative anesthesia. Key domains including preoperative assessment, fasting protocols, PONV prophylaxis, and postoperative pain management were evaluated within a comprehensive and integrated clinical framework. Emphasis was placed on risk stratification strategies, avoidance of unnecessary routine investigations, and the implementation of multimodal and age-appropriate approaches.

Current evidence indicates that pediatric perioperative care differs significantly from adult practice due to limited physiological reserves, developmental variability, and age-related pharmacokinetic and pharmacodynamic differences. Risk-adapted strategies improve patient safety and outcomes. Specifically, shortened and evidence-based fasting protocols reduce metabolic stress; opioid-sparing multimodal analgesia minimizes adverse effects; risk-based antiemetic prophylaxis decreases the incidence of PONV; and age-appropriate pain assessment tools enhance postoperative pain management. Avoiding unnecessary routine tests further contributes to efficient and patient-centered care.

Pediatric perioperative anesthesia care should be based on an integrated, individualized, and risk-oriented approach. The effective combination of optimized preoperative evaluation, evidence-based fasting strategies, tailored PONV prevention, and multimodal pain management improves safety and clinical outcomes. Current evidence strongly supports a shift from routine, standardized practices toward patient-specific, guideline-driven perioperative management in children.

References

  1. Sbaraglia F, Cuomo C, Della Sala F, et al. State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time. J Pers Med. 2024;14(2):182. https://doi.org/10.3390/jpm14020182
  2. Saatçi ŞG, Altun GT. Çocuk Hastada Preoperatif Değerlendirme, TARD Hasta ve Çalışan Güvenliği Bilimsel Kurulu, Şubat 2025.
  3. Fletke KJ, Kaysin A, Jones S. Preoperative Evaluation in Children. Am Fam Physician. 2022;105(6):640-9.
  4. Lewis H, Norrington A. Paediatric preoperative assessment. BJA Educ. 2023;23(6):238-44. https://doi.org/10.1016/j.bjae.2023.01.009
  5. American Society of Anesthesiologists Statement on ASA Physical Status Classification System. Anesthesiology Open 1(1): p e0002, January 2026. https://doi.org/10.1097/ao9.0000000000000002
  6. Bancalari E, Claure N, Sosenko IR. Bronchopulmonary dysplasia: changes in pathogenesis, epidemiology and definition. Semin Neonatol. 2003;8(1):63-71. https://doi.org/10.1016/S1084-2756(02)00192-6
  7. Michel F, Vacher T, Julien-Marsollier F, Dadure C, Aubineau JV, Lejus C, Sabourdin N, Woodey E, Orliaguet G, Brasher C, Dahmani S. Peri-operative respiratory adverse events in children with upper respiratory tract infections allowed to proceed with anaesthesia: A French national cohort study. Eur J Anaesthesiol. 2018;35(12):919-28. https://doi.org/10.1097/EJA.0000000000000875
  8. Hii J, Templeton TW, Sommerfield D, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia-Part 1 patient and surgical factors. Paediatr Anaesth. 2022;32(2):209-16. https://doi.org/10.1111/pan.14377
  9. Lee BJ, August DA. COLDS: A heuristic preanesthetic risk score for children with upper respiratory tract infection. Paediatr Anaesth. 2014 ;24(3):349-50. https://doi.org/10.1111/pan.12337
  10. Macrae J, Ng E, Whyte H. Anaesthesia for premature infants. BJA Educ. 2021;21(9):355-63. https://doi.org/10.1016/j.bjae.2021.03.007
  11. Hopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, McGrady E. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2021;76(5):655-64. https://doi.org/10.1111/anae.15317
  12. Zhang E, Hauser N, Sommerfield A, Sommerfield D, von Ungern-Sternberg BS. A review of pediatric fasting guidelines and strategies to help children manage preoperative fasting. Paediatr Anaesth. 2023;33(12):1012-9. https://doi.org/10.1111/pan.14738
  13. Aycan İÖ, Karaoğlan Lİ. TARD Pediyatrik Hastalarda Preoperatif Açlık Kilavuzu, Şubat 2025
  14. Frykholm P, Disma N, Andersson H et al. Pre -operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022:39(1): 4-25. https://doi.org/10.1097/EJA.0000000000001599
  15. Joshi GP, Abdelmalak BB, Weigel WA et al. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology 2023:138(2): 132-51. https://doi.org/10.1097/ALN.0000000000004381
  16. Ricci Z, Colosimo D, Saccarelli L, et al. Preoperative clear fluids fasting times in children: retrospective analysis of actual times and complications after the implementation of 1-h clear fasting. J Anesth Analg Crit Care. 2024;4(1):12. https://doi.org/10.1186/s44158-024-00149-3
  17. da Mata AMB, do Carmo Tomaz AG, Andrade da Cunha GC, Zamberlan P, Bonfim MAC. Influence of Shortened Fasting Time on Perioperative Outcomes in Pediatric Patients: A Systematic Review. J Pediatr Surg. 2024;59(10):161607. https://doi.org/10.1016/j.jpedsurg.2024.06.016
  18. Song IK, Kim HJ, Lee JH, Kim EH, Kim JT, Kim HS. Ultrasound assessment of gastric volume in children after drinking carbohydrate-containing fluids. Br J Anaesth. 2016;116(4):513-7. https://doi.org/10.1093/bja/aew031
  19. Bozoglu Akgun B, Hatipoglu Z, Gulec E, Turktan M, Ozcengiz D. The Effect of Oral Fluid Administration 1 Hour before Surgery on Preoperative Anxiety and Gastric Volume in Pediatric Patients. Eur Surg Res. 2024;65(1):54-9. https://doi.org/10.1159/000538842
  20. Das D, Trikha A, Kaur M, et al. Comparison of gastric emptying time between breast-fed and formula milk-fed infants less than 6 months old, using gastric ultrasound-An observational study. Paediatr Anaesth. 2024;34(5):430-7. https://doi.org/10.1111/pan.14841
  21. Gan TJ, Jin Z, Ayad S, et al. Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: Executive Summary. Anesth Analg. 2025 Nov 14. https://doi.org/10.1213/ANE.0000000000007816
  22. Emanuel O, Greenslade K, Lechner M, Eynon-Lewis N. Mindfulness for patients undergoing surgery: a cost-effective and potentially underrated tool for improving outcomes. Br J Anaesth. 2021;127(1): e22-e24. https://doi.org/10.1016/j.bja.2021.03.038
  23. Hung TY, Bai GH, Tsai MC, Lin YC. Analgesic effects of regional analgesic techniques in pediatric inguinal surgeries: a systematic review and network meta-analysis of randomized controlled trials. Anesth Analg. 2024;138:108-22. https://doi.org/10.1213/ANE.0000000000006341
  24. Demidovich T, Perez-Franco O, Silvestrini-Suarez M, Yue P. Aggressive prophylactic treatments for postoperative nausea and vomiting improve outcomes in pediatric adenotonsillectomy procedure. J Pediat Pharmacol Therap. 2020; 25:303-8.https://doi.org/10.5863/1551-6776-25.4.303
  25. Liu J, Li H, Zhang J, et al. Dexamethasone or combined with others for postoperative nausea and vomiting in children: A systematic review. Asian J Surg. 2020;43(9):873-9. https://doi.org/10.1016/j.asjsur.2019.11.012
  26. Zieliński J, Morawska-Kochman M, Zatoński T. Pain assessment and management in children in the postoperative period: A review of the most commonly used postoperative pain assessment tools, new diagnostic methods and the latest guidelines for postoperative pain therapy in children. Adv Clin Exp Med. 2020;29(3):365-74.https://doi.org/10.17219/acem/112600
  27. İnan N, Takmaz SA, Bilir A, et al. TARD Postoperatif Ağrı Tedavisi Kılavuzu, Ocak 2025
  28. Allegaert K, van de Velde M, van den Anker J. Neonatal clinical pharmacology. Paediatr Anaesth. 2014;24(1):30-8. https://doi.org/10.1111/pan.12176
  29. Cettler M, Zielińska M, Rosada-Kurasińska J, Kubica-Cielińska A, Jarosz K, Bartkowska-Śniatkowska A. Guidelines for treatment of acute pain in children - the consensus statement of the Section of Paediatric Anaesthesiology and Intensive Therapy of the Polish Society of Anaesthesiology and Intensive Therapy. Anaesthesiol Intensive Ther. 2022;54(3):197-218. https://doi.org/10.5114/ait.2022.118972
  30. Yaster M. Multimodal analgesia in children. Eur J Anaesthesiol. 2010;27(10):851-7. https://doi.org/10.1097/EJA.0b013e328338c4af
  31. Vittinghoff M, Lönnqvist PA, Mossetti V, et al. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth. 2018;28(6):493-506. https://doi.org/10.1111/pan.13373
  32. Vittinghoff M, Lönnqvist PA, Mossetti V, et al. Postoperative Pain Management in children: guidance from the Pain Committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative) Part II. Anaesth Crit Care Pain Med. 2024;43(6):101427. https://doi.org/10.1016/j.accpm.2024.101427
  33. Suresh S, De Oliveira GS Jr. Local anaesthetic dosage of peripheral nerve blocks in children: analysis of 40121 blocks from the Pediatric Regional Anesthesia Network database. Br J Anaesth. 2018;120(2):317-22. https://doi.org/10.1016/j.bja.2017.10.019
  34. Pillai Riddell RR, Racine NM, Turcotte K, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2011;(10):CD006275. https://doi.org/10.1002/14651858.CD006275.pub2

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Copyright © 2026 The Author(s). This is an open access article distributed under the Creative Commons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.

How to cite

1.
Ergen V, Horasanlı E. Pediatric perioperative management: An integrated review of preoperative evaluation, fasting protocols, postoperative nausea and vomiting, and postoperative pain in light of current guidelines. Turk J Pediatr Dis. 2026;20(4):302-308. https://doi.org/10.12956/TJPD.2026.1356