International consensus recommendations for identifying malnutrition in children with neurological impairment

Children with neurological impairment (CNI) are at increased risk of malnutrition because of functional, medical, and socioeconomic challenges. However, difficulties in obtaining reliable anthropometric measurements and differences in body composition limit the usefulness of conventional nutritional indicators. We convened an international multidisciplinary panel named the Promoting International Collaboration for Nutrition in Neurological Impairment in Children (PICNNIC) workgroup. Our aim was to review the literature and develop criteria for identifying malnutrition in CNI. A structured literature review (2012-2025) was conducted across multiple databases, which identified 177 articles for inclusion. Evidence was synthesized by domain experts and recommendations were developed using a modified Delphi process, with predefined thresholds for agreement (median score at least 7 and at least 80% consensus). All (n = 18) authors, except the medical librarian, voted and all recommendations reached consensus in the initial round. The 28 recommendations, with the accompanying algorithm, offer pediatricians and nutrition care professionals a structured, multimodal approach to identifying malnutrition in CNI.