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# Nutrition and hydration in the ICU - Haygood Health

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### [Nutrition and hydration in the ICU](/c/nutrition-withheld)

MechanismPLAUSIBLEOutcomeC

Claimed

Withholding or delaying nutrition and fluids in hospitalized COVID-19 patients worsened outcomes.

What holds up

Critical illness drives catabolism and rapid muscle wasting, and observational data link cumulative energy and protein deficits to infections and longer stays, but the causal link is confounded and unproven by RCTs. Major guidelines agree on early feeding: ESPEN 2019 recommends early enteral nutrition within 48 hours when oral intake is impossible, preferring enteral over parenteral routes; ASPEN/SCCM 2016 similarly recommends enteral nutrition within 24 to 48 hours; ESPEN's 2020 COVID-specific guidance recommends early nutritional support for infected patients. Prospective cohorts (e.g., Villet et al.) associate cumulative energy and protein deficits with more infections, longer stays, and higher mortality.

What it does not show

Support for the claim rests on uncontrolled cohort associations only, while RCTs of feeding timing and intensity show no mortality difference and in one large trial favored delaying parenteral nutrition. No RCT ever tested deliberate withholding of nutrition or fluids during COVID specifically, so the claim as stated about COVID protocols was never directly tested. EPaNIC, a 4,640-patient RCT, showed that delaying parenteral nutrition to day 8 (with early enteral nutrition in both arms) produced faster recovery and fewer infections with no mortality difference, directly contradicting the strong version of the claim. PermiT showed moderate underfeeding did not change 90-day mortality. Cohort associations are confounded because sicker patients are harder to feed.

Evidence for

Singer P et al., Clin Nutr 2019;38:48-79 (ESPEN ICU guideline), McClave SA et al., JPEN J Parenter Enteral Nutr 2016;40:159-211 (ASPEN/SCCM guideline), Barazzoni R et al., Clin Nutr 2020, DOI 10.1016/j.clnu.2020.03.022 (ESPEN COVID guidance), Villet S et al., Clin Nutr 2005;24:502-509 (cohort, energy deficit and complications)

Sources

VERIFIED Casaer MP et al., N Engl J Med 2011;365(6):506-517, PMID 21714640. PENDING Singer P et al., Clin Nutr 2019;38:48-79 (ESPEN ICU guideline). PENDING McClave SA et al., JPEN J Parenter Enteral Nutr 2016;40:159-211 (ASPEN/SCCM guideline). PENDING Barazzoni R et al., Clin Nutr 2020, DOI 10.1016/j.clnu.2020.03.022 (ESPEN COVID guidance). PENDING Arabi YM et al., N Engl J Med 2015;372:2398-2408, DOI 10.1056/NEJMoa1502826 (PermiT trial). PENDING Villet S et al., Clin Nutr 2005;24:502-509 (cohort, energy deficit and complications).

## Grade history (append-only)

Every grade change is kept, never overwritten, so the current grade and every prior one stay visible.

Mechanism gradeJustificationGraded byStateGraded at

PLAUSIBLECritical illness drives catabolism and rapid muscle wasting, and observational data link cumulative energy and protein deficits to infections and longer stays, but the causal link is confounded and unproven by RCTs. Major guidelines agree on early feeding: ESPEN 2019 recommends early enteral nutrition within 48 hours when oral intake is impossible, preferring enteral over parenteral routes; ASPEN/SCCM 2016 similarly recommends enteral nutrition within 24 to 48 hours; ESPEN's 2020 COVID-specific guidance recommends early nutritional support for infected patients. Prospective cohorts (e.g., Villet et al.) associate cumulative energy and protein deficits with more infections, longer stays, and higher mortality.admindisplayed2026-10-08T23:52:30.446Z

Outcome gradeJustificationGraded byStateGraded at

CSupport for the claim rests on uncontrolled cohort associations only, while RCTs of feeding timing and intensity show no mortality difference and in one large trial favored delaying parenteral nutrition. No RCT ever tested deliberate withholding of nutrition or fluids during COVID specifically, so the claim as stated about COVID protocols was never directly tested. EPaNIC, a 4,640-patient RCT, showed that delaying parenteral nutrition to day 8 (with early enteral nutrition in both arms) produced faster recovery and fewer infections with no mortality difference, directly contradicting the strong version of the claim. PermiT showed moderate underfeeding did not change 90-day mortality. Cohort associations are confounded because sicker patients are harder to feed.admindisplayed2026-10-08T23:52:30.446Z

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