Nutrition Therapy for Intensive Care Patients

Posted on August 4, 2026 by gutsandgrowth

JJ Patel, SA McClave. NEJM 2026; 395: 162-174. Nutrition Therapy in Critically Ill Adults

Key points: (for adults)

Early enteral nutrition preserves gut integrity and supports the microbiome, so it is the preferred approach, although contemporary randomized, controlled trials show that early short-term parenteral nutrition is safe when enteral nutrition is contraindicated.
Providing full-dose nutrition early may lead to more metabolic and gastrointestinal complications than restrictive or trophic feeding.
High-dose protein (>2.0 g per kilogram of body weight per day) offers no outcome benefit over standard dosing (≤1.2 g per kilogram per day) and may be harmful in patients with acute kidney injury.
Adverse events with enteral feeding (often called enteral feeding intolerance) are common during critical illness, and the safe delivery of nutrition requires gradual advancement, strategies for prevention of refeeding syndrome, glycemic control (glucose level, <180 mg per deciliter), and avoidance of routine gastric residual volume monitoring.

TIMING, ROUTE AND DOSE OF NUTRITION:

“The receipt of nothing by mouth…impairs gut health by reducing epithelial-cell proliferation, increasing apoptosis, and disrupting mucosal integrity, enteral nutrition supports gut function by enhancing tight-junction protein expression, reducing enterocyte apoptosis, preserving villous and crypt architecture, maintaining Paneth-cell function, supporting gut-associated lymphoid tissue, and helping to sustain commensal microbiota.^11,12 The collective evidence from 21 randomized, controlled trials has shown that early enteral nutrition, initiated within the first 24 to 36 hours after ICU admission, leads to better outcomes than delayed delivery or no provision of enteral nutrition.¹³” [if no contraindications]
“The CALORIES and NUTRIREA-2 trials randomly assigned critically ill adults to receive early enteral nutrition or early short-term parenteral nutrition, and the results showed no between-group differences in 30-day and 28-day mortality, respectively”
“Thirteen randomized, controlled trials questioned the practice of providing full-dose nutrition during the acute phase of critical illness and compared restrictive strategies — such as hypocaloric feeding, permissive underfeeding, and trophic feeding (Table 2) — with full-dose regimens.^{18–22,36–43} Nine trials showed no significant between-group differences in mortality.^{18,19,21,37–41,43} Four trials showed that restrictive-dose enteral nutrition led to better outcomes, including reductions in mortality and duration of mechanical ventilation and earlier time-to-readiness for ICU discharge, than full-dose nutrition.^20,22,36,42 …Early aggressive full-dose nutrition may cause net harm by increasing the risk of bowel ischemia, refeeding syndrome, overfeeding (exogenous nutrients combined with hepatic gluconeogenesis), suppression of autophagy, increased demand on dysfunctional mitochondria, delivery of excessive fluid volume, and gastrointestinal adverse effects.²⁸“

HIGH PROTEIN NUTRITION:

Several large well-designed studies have looked at higher protein dosing, including the EFFORT Protein Trial, the PRECISE trial and the TARGET Protein trial. Even in patients with preexisting malnutrition which was assciated wiht higher mortality, provision of high protein did not modify this outcome. “These findings were supported by two meta-analyses that showed that a high dose of protein did not lead to better outcomes in critically ill adults than a lower dose.^56,57 Moreover, a high dose of protein may be harmful in patients with severe illness and acute kidney injury.”

GASTRIC RESIDUALS:

” A meta-analysis of seven trials (involving 1240 patients) indicated that not monitoring gastric residual volume reduced unnecessary feeding interruptions and showed no between-group differences in the incidence of ventilator-associated pneumonia, the length of ICU stay, or mortality.⁶⁷ Current evidence does not support the use of gastric residual volume monitoring to reduce the risk of aspiration or pneumonia in ICU patients. Gastric residual volume monitoring may hinder enteral nutrition delivery… Routine monitoring of gastric residual volume — as a marker of adverse events with enteral feeding — should be strongly discouraged.”

Figure 2. Conceptual model of evolution of physiological responses and nutrition strategy across phases of critical illness.

Long Term Outcomes:

“Over the past four decades, survival from critical illness has improved but is marred by substantial loss of lean body mass, which is a major long-term consequence for survivors.⁴ Loss of lean body mass contributes to acquired muscle weakness and functional disability, which can persist for up to 5 years after the initial ICU admission.⁷⁴ In healthy persons, resistance exercise combined with protein supplementation has been shown to elicit a greater anabolic response than protein supplementation alone.⁷⁵“

My take: While this article is geared towards adult patients, my expectation is that the recommendations are largely applicable to pediatric patients. However, there is much more data in adults and pediatric care needs to be adjusted based on size.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

The Politicization of Science and Outcomes for Health Care

Posted on August 3, 2026 by gutsandgrowth

Yesterday’s blog post highlighted how the current policies are leading to a brain drain, undermining economic advangages and harming our ability to improve outcomes for patients.

Today’s post summarizes a recent editorial by the NEJM editors (NEJM 2026; 395: 187-188. The OMB and the Politicization of Science) that drills down on three specific proposals by the OMD to change research policy.

An excerpt:

“For decades, the Soviet Union promoted the unorthodox views of Trofim Lysenko, an agronomist who used his close ties to the political leadership to spread misinformation denying Mendelian genetics. What followed was a disaster: many years of poor harvests based on unsupported science and suppression of the teaching and practice of modern genetics throughout the Soviet bloc. A similar threat now hangs over U.S. science…

The rule changes that the White House Office of Management and Budget (OMB) recently proposed to the Health and Human Services (HHS) grant process would drastically change this process. There are too many objectionable aspects of these proposals to discuss here. But three are particularly striking. Political appointees would be able to make funding decisions and could ignore the advice of independent scientists. They could also stop funding midway through the promised grant period. And they would institute new rules, including rules severely limiting foreign interactions…

Expert, independent peer review of grant applications is essential for directing NIH dollars to research that has the greatest potential for advancing science and improving health. Selecting the most promising research is an enormously complex and challenging undertaking…

The OMB proposal to permit political appointees to discontinue funding of ongoing grants at any time, without cause, would have serious adverse consequences for the research enterprise and for patients…the gold standard of evidence is the randomized, controlled trial (RCT). The RCT’s methods minimize the influence of bias and preconceived notions. However, this type of trial often takes years to conduct…If a decision to stop funding the trial occurred at year 4 for political rather than scientific reasons, what would happen to patients who were enrolled in the study at that time? How would longer-term safety and efficacy observations be made?…Can physician–investigators ethically enroll a patient in a trial if ongoing funding for the trial is uncertain?

There would be substantial adverse effects on researchers as well as patients. Why would a basic science investigator start a line of investigation that might take years to complete if the funding for it could be cut at any moment, without cause?…A corrosive consequence of such an arbitrary funding process would be the diminishment of the U.S. workforce of clinical and basic science investigators — and it would ultimately harm biomedical innovation and cutting-edge patient care…

The proposed rules would also severely limit foreign research partnerships, requiring political approval of international collaborations…Broad global collaboration has led to…studies [which] can be completed years earlier than they would be otherwise, at a fraction of the cost, bringing earlier and greater benefits to all affected people, including people in the United States. Aren’t we better off addressing Ebola, tuberculosis, or screwworm before they spread to additional communities?”

My take: Allowing politicians to arbitrarily choose which research to fund rather than those with the greatest merit will lead to a poor harvest of scientific advances for all of us. This would, however, enable a select few to benefit from their corrupt connections to steer more money into their greedy pockets.

Scientific Excellence Leaving U.S.

Posted on August 2, 2026 by gutsandgrowth

Numerous articles have documented the abrupt changes to research funding by this administration.

WJ Broad. NY Times, 7/09/26. Nobel-Winning U.S. Chemist Will Move to China to Lead A.I. Institute
M Kozlov et al. Nature, 1/20/26. US science after a year of Trump
M Krass, A Gawert. Brennan Center, 5/14/26. The Cost of the Trump Administration’s Attacks on Research Funding
K Riddle. NPR, 5/21/26. Researchers say the Trump administration is finding new ways to punish science

I will focus on the first article but the others provide additional insight into this issue.

An excerpt:

Omar Yaghi, an immigrant to the United States who shared last year’s Nobel Prize in Chemistry, has left his faculty post at the University of California, Berkeley, for one in China, where he will lead an institute using artificial intelligence to accelerate the discovery of new materials…

Last year, three of America’s six winners of science Nobels were born outside the country. In this century, overall, the émigré fraction for U.S. Nobels in physics, chemistry and medicine now stands at 40 percent…

Last year, before flying to Stockholm to receive his Nobel Prize, Dr. Yaghi in an interview with The New York Times voiced concern about Mr. Trump’s immigration policies, saying that they endanger the nation’s system of universities, companies and governments that promote scientific excellence…

My take: The arbitrary cuts and policy shifts have undermined an engine for American prosperity, stalled the development of medications for numerous disorders, imperiled thousands of patients enrolled in clinical trials. and resulted inthe loss of enormous scientific/medical talent.

Related blog posts:

Confusing Guidance and “Conditional” Recommendations for Probiotic Use in Pediatric Irritable Bowel Syndrome and Functional Abdominal Pain

Posted on July 31, 2026 by gutsandgrowth

R Francavilla et al. J Pediatr Gastroenterol Nutr. 2026;83:3–6. Open Access! From evidence to advice: How uncertainty shapes probiotic guidance in pediatric irritable bowel syndrome

Key points:

“Recent guidance documents of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) on probiotic use in pediatric irritable bowel syndrome (IBS) do not simply converge toward a shared recommendation.^1–3 Rather, they illustrate an evolution in how scientific uncertainty is operationalized in clinical advice. “
“The ESPGHAN Position Paper Probiotics for the Management of Pediatric Gastrointestinal Disorders represents the most structured approach among the three documents, treating probiotics as strain-specific interventions evaluated against predefined clinical outcomes.¹ In functional abdominal pain disorders, healthcare professionals may recommend Limosilactobacillus reuteri DSM 17938 to reduce pain intensity, while in pediatric IBS Lactobacillus rhamnosus GG may be recommended to reduce pain frequency and intensity. These recommendations are accompanied by explicit dosing ranges, defined clinical targets, and formal appraisal of evidence certainty (moderate) and strength of recommendation (weak).”
“The joint ESPGHAN/NASPGHAN guideline on treatment of IBS and functional abdominal pain—not otherwise specified in children aged 4–18 years represents a shift in emphasis.² L. rhamnosus GG is conditionally suggested as a therapeutic option for pediatric IBS, supported by moderate overall certainty of evidence and a small, reported effect size. Multistrain probiotics and synbiotics are likewise framed as options that may be suggested, but with low certainty of evidence. In contrast to earlier ESPGHAN position papers, the guideline does not specify detailed dosing regimens, treatment duration, or stopping rules.”
“This reframing extends further in the European and North American guidance addressing IBS and functional abdominal pain in childhood.³ …Within this framework, probiotics are positioned less as therapies to be prescribed and more as adjunctive measures to be discussed with families, including in primary care settings.”

Conclusions from authors: “At a policy level, conditional recommendations do not operate in a neutral context…Probiotics are widely available, variably regulated, and commonly perceived as harmless. In pediatric IBS, where symptoms are chronic, placebo responsiveness is high, and pharmacological options are limited, conditional guidance may be interpreted as tacit approval for routine use, regardless of modest effect sizes…their use may drift from deliberate intervention toward habitual supplementation.”

My take: I rarely recommend probiotics for pediatric IBS. Even simple dietary changes are much more likley to be beneficial. In addition, there is a concern about the lack of quality control in the production of probiotics.

Related blog posts:

Treatment Guidelines for Pediatric Irritable Bowel Syndrome
AGA Guidelines for Pharmacologic Therapy of IBS-D and IBS-C
AGA Practice Guidelines: Probiotics NOT Helpful for Most GI Conditions (2020). The report recommends NOT using probiotics outside of clinical trials for irritable bowel syndrome
Our Food is Killing Too Many of Us
Those Probiotics May Actually Be Hurting Your ‘Gut Health’ The key is simply to focus on eating a diverse, whole-food, plant-centered, high-fiber diet

Guidelines for Hirschsprung’s Disease

Posted on July 30, 2026 by gutsandgrowth

D Rossi et al. J Pediatr Gastroenterol Nutr. 2026;83:185–207. Open Access! Updated European Reference Network for rare Inherited and Congenital Digestive and Gastrointestinal Anomalies guidelines for the management of rectosigmoid Hirschsprung’s disease 2025

These guidelines cover recommendations for diagnosis, pre- and postoperative care, poor functional outcomes, long-term follow-up, and Hirschsprung’s-associated enterocolitis.

Some specific recommendations:

Diagnosis:

Preoperative Care:

Routine screening for all patients with rectosigmoid Hirschsprung’s disease (HSCR))with ultrasound for congenital anomalies of kidney and urinary tract (CAKUT) and systematic assessment of nutritional status.

Operative Care:

Hirschsprung’s-Associated Enterocolitis:

Table 9 provides extensive advice for bowel management strategies/evaluation in children with fecal incontinence.
Table 11 discussed genetic testing, noting that RET gene should be considered. Genetic counseling is recommended in those patients with a family history of Hirschsprung’s disease.

My take: This article provides good advice for optimizing care for patients with Hirschsprung’s disease.

Related blog posts:

Diagrams of 3 common pull-through operations for Hirschsprung disease.
From left to right: full-thickness rectosigmoid dissection (Swenson), a recto-rectal pouch procedure (Duhamel), and an endorectal dissection (Soave). JPGN 2023; 76(4):533-546.

Impact of 5‐Aminosalicylic Acid Discontinuation in Children with Ulcerative Colitis Receiving Biologic Therapy

Posted on July 29, 2026 by gutsandgrowth

G D’Arcangelo et al. J Pediatr Gastroenterol Nutr 2026; 83: 96-107. Open Access! Impact of 5-Aminosalicylic acid discontinuation in children with ulcerative colitis on biologic therapy: A propensity score-matched study

Background: Several adult-based studies have found that discontinuing 5-ASA at the initiation of anti-TNF therapy is not associated with worse clinical outcomes. “Ungaro et al. analyzed data from over 3500 patients in the United States and Denmark and found no increased risk of adverse outcomes following mesalamine discontinuation after the initiation of anti-TNF therapy.¹⁸ Based on this evidence, the American Gastroenterological Association recommends discontinuing mesalamine in patients with moderate-to-severe UC who are starting biologics or small molecules and achieve remission.¹⁹ However, this recommendation is based on low-quality evidence, and pediatric guidelines do not offer a similar directive.²“

Methods: Retrospective, multicenter, case–control study which included 227 pediatric patients in the final analysis after matching (85 [37.5%] cases and 142 [62.5%] controls].

Key findings:

Children who discontinued 5-ASA were at higher risk of courses of steroids (Log-Rank p = 0.003) and hospitalization (p = 0.08). This finding persisted with multivariate Cox regression analysis.
“Fixed timepoint analyses showed a statistically significant increase in the odds of adverse outcomes at the 6-month follow-up (including hospitalizations and acute severe colitis), with no significant differences detected at 12, 18, or 24 months, and only a non-significant trend toward higher hospitalization risk over time.”

My take: This is an intriguing study with a small sample size of pediatric IBD patients. Given the findings in adults, it is customary to stop 5-ASA at the time of initiation of biologic therapy. However, this study indicates that pediatric patients—who often present with more extensive and severe disease—may have some benefit from overlapping these therapies, especially during the first six months. A prospective pediatric study would be helpful.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Elevated Amylase is Common in Pediatric Patients with Inflammatory Bowel Disease

Posted on July 28, 2026 by gutsandgrowth

F Vázquez López et al. J Pediatr Gastroenterol Nutr. 2026;83:79–86. Hyperamylasaemia in paediatric inflammatory bowel disease: Aetiology, outcomes and genetic determinants

Methods: This was a retrospective study with 334 pediatric patients, followed for ≥2 years (study duration was 7 years). Elevated amylase was considered to be above the laboratory’s reference range (102 U/L).

Key findings:

Hyperamylasaemia was found in 62/334 patients (18.6%), with 29% of these presenting at diagnosis
Hyperamylasaemia resolved in 77% of patients; in the majority (85%), spontaneously and in the remainder after medication withdrawal
One patient developed acute pancreatitis and one had recurrent pancreatitis

My take: It is best to avoid routinely checking an amylase if pancreatitis is not suspected; it could lead to ‘a wild goose chase.’ Most cases of elevated amylase are benign and self-limiting.

Related blog posts:

A deer in the middle of the Chattahoochee at Island Ford

Sheila McBrayer: Swallow Dysfunction and Swallow Evaluation in Infants

Posted on July 27, 2026 by gutsandgrowth

Recently, Sheila McBrayer SLP gave our group a terrific update on swallow dysfunction and swallow studies in infants. She is a nationally-certified speech-language pathologist with more than 20 years of experience at Children’s Healthcare of Atlanta. She has led initiatives in advanced swallowing assessment, worked to standardize instrumental swallowing assessments across the hospital campuses, and presented at regional and national conferences on NICU feeding topics. My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

Key points:

Video fluoroscopic swallow study )VFSS) is preferred nomenclature over modified barium swallow (MBS) or oral pharyngeal motility study (OPMS)

Study duration is important. Watch swallow for 2:30 minutes if feasible (KE McGrattan, et al Ped Radiology 2020; 50: 199-206)

Clinical evaluation accurately identifies aspiration in 56.7% in one study (may be better in a lower risk population). Thus, if concerned about aspiration, an objective study (e.g. VFSS) is needed
Analysis of sounds during feeding may provide insight into risk of aspiration

Ongoing efforts to standardize evaluation protocol. BaByVFSSimP tool (for bottle feeding)

Common impairments: increased sucking prior to bolus movement, disorganized lingual motion, late/incomplete laryngeal closure, disorganized or decreased pharyngeal transport, esophageal retention, and suck-swallow ratio variability

If unilateral cord dysfunction, feed infant with position to allow the better functioning vocal cord to be lower
When to care about penetration: deeper (e.g. touching vocal folds) and more frequent penetration. Deeper penetration should be considered as similar risk as aspiration on swallow study

Review article is a useful reference: R Kamity et al. Children (Basel). 2021 Dec 8;8(12):1158. DOI: 10.3390/children8121158. Open Access! Feeding Problems and Long-Term Outcomes in Preterm Infants-A Systematic Approach to Evaluation and Management
Thickeners: Gelmix, cereal and purees. Gelmix is suitable to mix with breastmilk. Rice cereal is generally more consistent as a thickener compared to oatmeal cereal

Thickening feeds can be difficult

Related blog posts:

“Businesses Race to Cash in on Peptide Craze”

Posted on July 26, 2026 by gutsandgrowth

SA O’Brien. WSJ 6/23/26: Businesses Are Taking Risks to Cash In on the Peptide Gold Rush

An excerpt:

Doctors, telehealth companies, med spas and venture capitalists are racing to get in on the craze for injectable drugs…

Demand for restricted peptides has fueled an online gray market for injections promising youth, beauty and strength. American businesses are racing—and taking risks—to get in on the craze…

These drugs, which advocate a D.I.Y. approach to health and longevity, are largely unapproved by the Food and Drug Association, meaning they can’t be marketed or sold for human consumption in the U.S. But with the support of Health Secretary Robert F. Kennedy Jr., several popular peptides will soon be up for reclassification, paving the way for a multibillion-dollar wellness gold rush.

Telehealth companies are already building infrastructure for a future where compounding pharmacies can safely provide experimental peptides…

Some longevity doctors and medical clinics are selling peptides directly to patients, obtaining substances both domestically and from abroad. Alabama’s Board of Medical Examiners released a statement in May underscoring its stance against doctors “recommending, supplying, prescribing or administering these substances.”

Wilson Hunter, the board’s general counsel, said the statement was prompted by unapproved peptides popping up in audits and investigations, via consumer complaints and as physicians inquire about guidance. “We’re not anti-peptide, we’re just anti people hurting themselves because they’re getting products that aren’t vetted or verified,” Hunter said.

In late July, the FDA’s Pharmacy Compounding Advisory Committee is set to discuss whether to greenlight seven unapproved peptides… could represent a $2.2 billion telehealth market opportunity next year…

Bill Holtz, a life sciences and U.S. Food and Drug Administration regulatory and policy strategist at Foley & Lardner LLP, said the compounding pharmacies producing the previously restricted peptides are doing so without explicit permission from FDA…

My take: Some peptides, like insulin, can be life sustaining. However, peptides that are being marketed for skin care, muscle strength and wellness are unproven and carry potential risks. In addition, like many other poorly-regulated products, there may be issues with product quality and contaminants. Long-term effects and even proper dosing are unknown.

Related blog posts:

Interplay of Genetics and Pediatric Pancreatitis

Posted on July 24, 2026 by gutsandgrowth

M Abu-El-Haija et al. Clinical Gastroenterology and Hepatology, 2026. (Article in print). DOI: 10.1016/j.cgh.2026.06.004. Open Access! Pancreatitis Risk Genes Play a Major Role in Pediatric Pancreatitis: Insights From INSPPIRE

Methods: A cross-sectional study involving 944 pediatric ARP or CP subjects was conducted. CASR, CEL, CFTR, CLDN2, CPA1, CTRC, GGT1, PRSS1, PRSS2, PRSS3, SBDS, SLC26A9, SPINK1, and UBR1 were sequenced.

Key findings:

A total of 120 variants, including 79 never previously reported to be associated with pancreatitis.
38 focused variants found in CFTR (10 variants), PRSS1 (6), CTRC (6), SPINK1 (5), PRSS3 (3), GGT1 (3), CASR (2), CPA1 (2), and PRSS2 (1).
Seventy-four percent of children with acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) carried at least one genetic risk variant.
In CP, CTRC (p=0.012) and PRSS1 (p<0.001) variants were most common. The presence of any genetic risk variant was associated with faster disease progression from AP to CP compared to none (p=0.014).

My take: This study shows the essential role that genetic mutations have in increasing the risk of ARP or CP. It reinforces the need for genettic testing in children with more than one episode of acute pancreatitis.

Related blog posts: