Permissive underfeeding or standard enteral feeding in critically ill adults
Open accessAbstract
BACKGROUND: The appropriate caloric goal for critically ill adults is unclear. We evaluated the effect of restriction of nonprotein calories (permissive underfeeding), as compared with standard enteral feeding, on 90-day mortality among critically ill adults, with maintenance of the full recommended amount of protein in both groups. METHODS: At seven centers, we randomly assigned 894 critically ill adults with a medical, surgical, or trauma admission category to permissive underfeeding (40 to 60% of calculated caloric requirements) or standard enteral feeding (70 to 100%) for up to 14 days while maintaining a similar protein intake in the two groups. The primary outcome was 90-day mortality. RESULTS: Baseline characteristics were similar in the two groups; 96.8% of the patients were receiving mechanical ventilation. During the intervention period, the permissive-underfeeding group received fewer mean (±SD) calories than did the standard-feeding group (835±297 kcal per day vs. 1299±467 kcal per day, P<0.001; 46±14% vs. 71±22% of caloric requirements, P<0.001). Protein intake was similar in the two groups (57±24 g per day and 59±25 g per day, respectively; P=0.29). The 90-day mortality was similar: 121 of 445 patients (27.2%) in the permissive-underfeeding group and 127 of 440 patients (28.9%) in the standard-feeding group died (relative risk with permissive underfeeding, 0.94; 95% confidence interval [CI], 0.76 to 1.16; P=0.58). No serious adverse events were reported; there were no significant between-group differences with respect to feeding intolerance, diarrhea, infections acquired in the intensive care unit (ICU), or ICU or hospital length of stay. CONCLUSIONS: Enteral feeding to deliver a moderate amount of nonprotein calories to critically ill adults was not associated with lower mortality than that associated with planned delivery of a full amount of nonprotein calories. (Funded by the King Abdullah International Medical Research Center; PermiT Current Controlled Trials number, ISRCTN68144998.).
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Intentionally supplying fewer calories than recommended, even down to 400 kcal per day (trophic feeding), did not adversely affect patient outcomes.
“Intentionally supplying fewer calories than recommended, even down to 400 kcal per day (trophic feeding), did not adversely affect patient outcomes.16,17”
From Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3). (2023) · cites this paper as [16]
The Results (p. 2399) report similar mortality and other measured outcomes with permissive underfeeding, but that group received an average of 835 kcal/day, not 400. The Discussion describes separate trophic-feeding trials with similar findings at 15–25% of caloric requirements; it does not establish an outcome finding specifically at 400 kcal/day. (LLM, conf=0.89)
Experimental — accuracy not yet measuredThe non-significantly lower all-cause mortality in the low group is in keeping with previous studies.
“All-cause mortality was non-significantly lower in the low versus the standard group, in keeping with previous studies.10,16-18”
The association between calorie deficiency and infections was not replicated in randomised trials of permissive or trophic underfeeding.
“Observational ICU studies suggested an association between calorie deficiency and infections,4 but this finding was not replicated in randomised trials of permissive or trophic underfeeding.16,17”
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- Authors
- Arabi, Y. M., Aldawood, A. S., Haddad, S. H., Al-Dorzi, H. M., Tamim, H. M., Jones, G., Mehta, S., McIntyre, L., Solaiman, O., Sakkijha, M. H., Sadat, M., & Afesh, L.
- Affiliations
- University of Ottawa (CA)
- King Saud bin Abdulaziz University for Health Sciences (SA)
- Mount Sinai Hospital (CA)
- King Faisal Specialist Hospital & Research Centre (SA)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2015-06-18
- Volume
- 372
- Issue
- 25
- Pages
- 2398-2408
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W4251465341
- Semantic Scholar
- 1f7c8c9cde97df25b6047caa01dfd5cd47d0a4b0
- Cited by
- 614
- References
- 37
- Citations by year
- 2026: 35 · 2025: 50 · 2024: 60 · 2023: 48 · 2022: 44 · 2021: 47 · 2020: 73 · 2019: 61 · 2018: 62 · 2017: 57 · 2016: 57 · 2015: 18
- FWCI
- 62.44
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
- Health Sciences › Medicine › Epidemiology › Sepsis Diagnosis and Treatment
- Keywords
- permissive underfeeding, enteral nutrition, critically ill adults, 90-day mortality, protein intake, mechanical ventilation, intensive care unit, feeding intolerance, length of hospital stay
- MeSH terms
- Adult, Aged, Energy Intake, Enteral Nutrition, Female, Humans, Intensive Care Units, Length of Stay, Lipids, Male, Middle Aged, Nutritional Requirements, Proteins, Respiration, Artificial, Critical Illness, Caloric Restriction, Kaplan-Meier Estimate
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