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Editorial
Nutrition Nutrition as a neglected domain of post-intensive care syndrome in children
Acute and Critical Care 2026;41(3):708-710.
DOI: https://doi.org/10.4266/acc.009724
Published online: August 31, 2026

Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, Korea

Corresponding author: Hwa Jin Cho Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea Tel: +82-62-220-6646 Fax: +82-62-222-6103 E-mail: chhj98@gmail.com
• Received: August 11, 2026   • Revised: August 20, 2026   • Accepted: August 20, 2026

© 2026 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Survival alone is no longer an adequate endpoint in pediatric critical care. As mortality in the pediatric intensive care unit (PICU) has declined, attention has increasingly turned to the morbidities survivors carry after discharge—the physical, cognitive, emotional, and social impairments now conceptualized as post-intensive care syndrome in pediatrics (PICS-p) [1]. Within this framework, nutrition has remained unexpectedly peripheral. During the PICU stay, nutritional status is measured meticulously; after discharge, it is often no longer systematically assessed. Yet nutritional recovery involves more than weight restoration. It intersects with growth, muscle mass, physical function, neurodevelopment, feeding ability, and, ultimately, a child’s capacity to resume everyday life.
The study by Wannaphahoon and Chaiyakulsil [2] in this issue of Acute and Critical Care examines what happens after routine nutritional assessment ends. In a retrospective cohort of 129 children followed in a dedicated post-intensive care clinic, malnutrition was present in 35.6% of patients at 1 month and in 22.5% at 1 year after discharge. Baseline malnutrition was by far the strongest predictor at both time points, with adjusted odds ratios of 31.42 at 1 month and 5.69 at 1 year. Longer ventilator duration and prolonged PICU stay were associated with any malnutrition; inotropic support and extracorporeal membrane oxygenation were associated with wasting; and any malnutrition at 1 year was associated with at least moderate dysfunction on the Pediatric Cerebral Performance Category (PCPC).
Three features make this report particularly noteworthy. First is the follow-up horizon. The most frequently cited pediatric study on this question, by Hulst et al. [3], suggested nearly complete nutritional recovery by 6 months, but that cohort was predominantly neonatal. Valla et al. [4] subsequently documented nutritional deterioration during the PICU stay itself. What has remained unclear is the trajectory beyond the first few months in a broader PICU population. The persistence of malnutrition in approximately one in five children a full year after discharge is therefore a meaningful contribution, and it is not the outcome a clinician reassured by the earlier literature might expect. Second, the authors treat malnutrition as bidirectional. They analyze wasting and overweight as parallel subgroups rather than collapsing nutritional status into undernutrition alone. This approach is consistent with the World Health Organization growth reference thresholds applied in the study and, for undernutrition, with the etiology-based definitions advocated by the American Society for Parenteral and Enteral Nutrition [5]; it also reflects the double burden of malnutrition now seen across much of Asia. The persistence of both directions of malnutrition, together with the finding that only wasting was associated with functional impairment, offers a useful signal for post-discharge nutritional follow-up. These findings also caution against treating “malnutrition” as a single biological phenotype. Wasting and overweight may fall under the same broad classification, but they are unlikely to represent the same post-critical illness trajectory or to carry the same functional implications. Third, and most practically, the strongest predictor is available at admission. Baseline nutritional status requires no new technology, no additional cost, and no delay. If it identifies children who remain malnourished a year later, it can immediately serve as a trigger for structured nutritional follow-up. This is an actionable message, and it deserves emphasis precisely because much of the PICS-p literature identifies risk factors only in retrospect.
Several caveats limit how far these findings can be extended. The most important is temporality. Nutritional status and PCPC were assessed at the same clinic visits. The authors are appropriately candid about this limitation, but the point deserves emphasis: a cross-sectional association at 1 year cannot distinguish malnutrition that contributes to functional decline from functional impairment—through dysphagia, feeding difficulty, immobility, or caregiver dependence—that contributes to malnutrition. Most likely, malnutrition and functional impairment reinforce one another. Separating these pathways would require measurement at different time points, which this study design does not allow.
The measurement of nutritional status is also limited. It relies largely on weight-for-height or age-specific body mass index. Mid-upper arm circumference, triceps skinfold thickness, bioimpedance-derived phase angle, and ultrasound-measured muscle thickness were unavailable—a limitation the authors acknowledge and one that matters disproportionately in critical illness, where acute skeletal muscle wasting can occur despite preserved or even increasing body weight [6]. A child with normal weight but substantial muscle loss could therefore be classified as having normal anthropometric status in these data. In children, moreover, a single anthropometric snapshot may miss deviation from the pre-illness growth trajectory, making longitudinal changes in weight, height, and age-adjusted z-scores particularly relevant.
The outcome measure also imposes important limits. PCPC was designed to capture global cerebral performance [7], and it is relatively insensitive to the domains most likely to reflect nutritional status or its consequences: motor function, endurance, feeding independence, and growth. Instruments such as the Functional Status Scale [8] or domain-specific measures of physical function would be better aligned with the study hypothesis. The fact that an association emerged despite this mismatch is arguably the more striking observation; however, it also means that the effect size reported here should not be interpreted as a calibrated estimate.
Finally, of 177 eligible children, 48 were excluded because of missing anthropometry, loss to follow-up, or death before the 1-year visit. Whether the children who did not return were healthier and therefore disengaged from care, or sicker and therefore lost to other systems of care, is unknowable; these possibilities could bias the findings in opposite directions. The wide confidence intervals across the multivariable models—several of which span an order of magnitude—reflect the imprecision associated with the relatively small single-center sample.
These limitations narrow the clinical message but do not erase it. The 2025 Global Leadership Initiative on Malnutrition guidance recommends reassessing nutritional status in critically ill adults before intensive care unit discharge and during post-discharge visits [9]. No equivalent pediatric recommendation exists. This study does not, by itself, justify such a recommendation, but it makes the absence of one more difficult to defend. A reasonable interim position is that children with malnutrition at PICU admission, prolonged mechanical ventilation, or extracorporeal support should undergo formal nutritional reassessment at post-discharge follow-up rather than being assessed only at the discretion of the reviewing clinician. Importantly, identifying malnutrition as a marker of poor recovery does not establish that nutritional intervention will improve long-term functional outcomes. Nevertheless, it identifies a potentially modifiable domain that warrants systematic assessment rather than passive observation.
The field’s next steps are relatively clear: multicenter prospective cohorts with standardized body-composition assessment, longitudinal growth measures, nutritional and functional outcomes measured at separate time points, and functional instruments selected for sensitivity to the physical domain. Agreement on a core outcome set for pediatric post-intensive care nutrition would accelerate this work. Studies such as this one make it possible to design larger investigations, and the authors deserve credit for following their patients beyond the PICU door and for a full year after discharge. The next step is to ensure that nutrition follows them as well—not as an isolated measure of weight, but as an integral component of recovery from critical illness.

CONFLICT OF INTEREST

Hwa Jin Cho is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: WKK. Writing – original draft: IC. Writing – review & editing: HJC. All authors read and agreed to the published version of the manuscript.

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        Nutrition as a neglected domain of post-intensive care syndrome in children
        Acute Crit Care. 2026;41(3):708-710.   Published online August 31, 2026
        DOI: https://doi.org/10.4266/acc.009724
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