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Purpose: Over the last decade, ultrasonography has taken on an increasingly important role in the daily management of critically patients and has recently been suggested for measuring muscle volume and architecture. The aims of this study were to assess the accuracy of ultrasound for measuring quadriceps femoris muscle thickness in mechanically ventilated pediatric patients and examine if demographic and clinical factors impact muscle loss in critically unwell children. Methods: Prospective, observational, single-center study. All the children admitted to our Pediatric Intensive Care Unit requiring mechanical ven­tilation for more than 48 hours were included. Two trained clinicians measured the thickness of the quadriceps using a 12 MHz linear ultrasound transducer. Results: In the entire cohort, quadriceps femoris muscle thickness decreased 4.67% (-13.4 to -0.59) between the first two assessments and 13% when considering the final measurement performed (-24% to -0.5%) or 1.57%/day (p < 0.001). Approximately half of all the children (23/41; 56%) experienced muscle atrophy (defined a priori as a >10% decrease in thickness). Bivariate analyses revealed that increasing age, being a child (vs. infant), cumulative energy and protein deficit, highest C-reactive protein value, exposure to neuromuscular blockers , and a longer stay in the Pediatric Intensive Care Unit predicted a greater decrease in thickness. In a multivariate linear regression, exposure to NMB was linked with greater muscle loss. Conclusions: In mechanically ventilated children, point-of-care ultrasonography can identify skeletal muscle atrophy. Limb muscle loss is strongly associated with the use of neuromuscular blockers. Ultrasound-based evaluation of the quadriceps femoris is a clinically useful tool for assessing muscle mass and it can serve as a surrogate for nutritional status and guide rehabilitation

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