Is early starvation beneficial for the critically ill patient?

Abstract

Anorexia is a preserved evolutionally response that may be beneficial during acute illness. Yet current clinical practice guidelines recommend early and targeted enteral nutritional support. However, the optimal timing of the initiation of enteral nutrition and the caloric and protein requirements of critically ill patients is controversial. Starvation promotes autophagy and this may play a key role in promoting host defenses and the immune response to intracellular pathogens. Because of the perceived benefits of early enteral nutrition and the lack of clinical equipoise, randomized controlled trials comparing short-term starvation to targeted normocaloric enteral nutrition have until recently not been performed. The results of the recently reported PYTHON trial (Pancreatitis, Very Early Compared with Selective Delayed Start of Enteral Feeding) dispel the notion that short-term starvation is harmful. Furthermore, six recent randomized controlled trials that compared trophic and permissive underfeeding to normocaloric goals, failed to demonstrate any outcome benefit from the more aggressive approach. In addition, recent evidence suggests that intermittent enteral nutation may be preferable to continuous tube feeding. Limiting nutrient intake during the first 48-72 h of acute illness may be beneficial; in those patients who are unable to resume an oral diet after this time period intermittent enteral nutrition targeting 20-25 cal/kg/day is recommended.