Published in the January issue, the article "Pediatric Tracheostomy Wound Healing: A Retrospective Cohort Study" by Odom et al addresses the pediatric population, which is truly a vulnerable population in regard to pressure injuries. However, we question the authors' use of albumin as a nutrition assessment marker.

Historically, hepatic proteins such as albumin, prealbumin, and transferrin have been linked to nutrition status. However, recent published research, review articles, and editorials show that serum levels of these hepatic proteins correlate with morbidity and mortality rather than nutrition status. As of 2012, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) do not recommend using hepatic protein levels for malnutrition diagnosis. The current ASPEN and Society for Critical Care Medicine Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient uphold this concept, stating: "In the critical care setting, the traditional serum protein markers (albumin, prealbumin, transferrin, retinol-binding protein) are a reflection of the acute phase response and do not accurately represent nutrition status in the ICU setting."1 This concept holds true for general hospitalized patients.2,3

Further, the authors state that prealbumin would have been a preferred nutrition marker, although not available during their study. They further relay that prealbumin is widely used in wound care nutrition measurements because it is less expensive and not affected by hydration or renal issues. This is an incorrect statement; in the critical care patient, prealbumin may be as affected as albumin by these issues. Prealbumin levels may increase in the presence of renal failure because of impaired degradation of the kidney and therefore are also not an accurate nutrition marker.4,5 Aside from clinical considerations, the statement made by the authors that prealbumin is less expensive than albumin may be false in many institutions. Prealbumin actually may be more costly, especially in cases where laboratory tests must be sent off-site to be processed.

Given advances in nutrition science, the following parameters to assess nutrition status are suggested instead: involuntary weight loss, muscle mass loss, subcutaneous fat loss, insufficient energy intake, fluid accumulation, and reduced handgrip strength.6 Correction of any nutrition deficits should be promptly addressed especially when preventing or healing pressure injuries.

We invite all clinicians to consider the Academy of Nutrition and Dietetics, ASPEN, and the Society for Critical Care Medicine nutrition guidelines when designing future research and assessing nutrition.

-Andy S. Chu, MS, RD, CD N, CNSC, FAND

Food and Nutrition Services, NYU Langone Health, New York, NY

-Barbara Delmore, PhD, RN, CWCN, MAPWCA, IIWCC-NYU

Center for Innovations in the Advancement of Care, NYU Langone Health, New York, NY

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