The goal of nutrition support is to provide the substrates required to match the bioenergetic needs of the patient and promote the net synthesis of macromolecules required for the preservation of lean mass, organ function, and immunity. Contemporary observational studies have exposed the pervasive undernutrition of critically ill patients and its association with adverse clinical outcomes. The intuitive hypothesis is that optimization of nutrition delivery should improve ICU clinical outcomes. It is therefore surprising that multiple large randomized controlled trials have failed to demonstrate the clinical benefit of restoring or maximizing nutrient intake. This may be in part due to the absence of biological markers that identify patients who are most likely to benefit from nutrition interventions and that monitor the effects of nutrition support. Here, we discuss the need for practical risk stratification tools in critical care nutrition, a proposed rationale for targeted biomarker development, and potential approaches that can be adopted for biomarker identification and validation in the field.

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INTRODUCTION:Congenital diaphragmatic hernia (CDH) is a critical congenital defect with significant potential morbidity. There are limited studies describing long-term functional outcomes in CDH survivors. We aimed to examine clinical characteristics and serial change in functional status scale (FSS) after hospital discharge in CDH survivors. METHODS:Single-center retrospective cohort study of infants with CDH admitted to the PICU. Baseline demographics and disease-specific variables were collected. We extracted medical record data to calculate FSS scores at 4 timepoints: hospital discharge, 0-6-months, 6-12-months, and >12-months after discharge. We excluded patients that died before discharge. We assessed inter-rater reliability of FSS calculations. We recorded the change in median composite and domain-related FSS scores up to 1 year after discharge.RESULTS: FSS data was analyzed for a random sample of 135 newborns (60% male, average birth weight 3.03 kg) in the PICU from Jan 2009 to Dec 2019. CDH was left-sided in 74%. Defect sizes were A (20%), B (34%), C (34%), and D (3%). Median CDH risk score was 2.00 [1.75, 3.00]. 23 (17%) patients died before discharge. Median [IQR] FSS score at hospital discharge was 8.0 [7.0, 9.0] with 32 (30.5%) patients having at least moderate impairment (FSS >9). Median [IQR] FSS at 0-6-months (n=104), 6-12-months (n=104), and at >12-months (n=103) followup visits were 7.