Does initial low energy permissive underfeeding reduce overall mortality in comparison to full energy enteral feeding in patients with acute lung injury? – An Update

Objective: To test whether selection bias has affected the reported effect estimate for initial low energy permissive underfeeding in comparison to full energy enteral feeding (RD 0.00. 95%CI: -0.06 to 0.06), concerning overall mortality in patients with acute lung injury. Method: Trial adjusted, simulated comparator trial (SCT) based I2 test for single randomised controlled trials, using revised I2 threshold limits. Result: A baseline covariate imbalance, either due to chance or due to selection bias was established, being equivalent to selection bias level = B% 0-30 (Bias category = 1). This level suggests that 0-30% of (0 – 286 of the total 951) subjects were non-randomly allocated in favour of one treatment group above the other. Conclusion: The effect estimate reported by the tested trial suggests a zero % higher overall mortality in the initial low energy permissive underfeeding intervention group. The selection bias level, estimated by use of the trial adjusted, simulated comparator trial (SCT) based I2 test for single RCTs, B% = 0-30%, appears to be not high enough in order to have affected the reported estimate. In line with new findings, this report updates previous report to the same RCT: EBSM Volume 2, Issue 2, 2026 Pages 43-46, DOI: 10.5281/zenodo.18457070.