Background: Children are starved before surgery following international preoperative guidelines. Extreme fasting is still reported, but data for Africa are scarce. Starving in hot climates leads to challenges arising from dehydration, hypotension, metabolic disturbances, and complications during induction of anesthesia. The purpose of this study was to evaluate the scope of the problem, identify possible reasons for this, and propose realistic solutions. Methods: We performed eleven prospective audits between 2008 and 2013 in Malawi to improve our preoperative fasting times. In total, 631 children (aged 3 days to 13 years) were monitored. Training was provided, and the results were measured using a visual analog scale. Conclusion:Excessive preoperative fasting is an underaddressed problem in Africa. Reduction is difficult, so it has to be accepted as an ongoing task.