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How to Perform Subjective Global NutritionalAssessment in ChildrenDonna J. Secker, PhD, RD, FDC; Khursheed N. Jeejeebhoy, PhD, MBBS, FRCPC

ABSTRACTSubjectiveGlobalAssessment (SGA) is amethod forevaluatingnutritional statusbasedonapractitioner’sclinical judgment rather thanobjective, quantitativemeasurements. Encompassinghistorical, symptom-atic, and physical parameters, SGA aims to identify an individual’s initial nutrition state and consider theinterplay of factors influencing the progression or regression of nutrition abnormalities. SGA has beenwidely used formore than 25 years to assess the nutritional status of adults in both clinical and researchsettings. Perceiving multiple benefits of its use in children, we recently adapted and validated the SGAtool foruse inapediatricpopulation,demonstrating itsability to identify thenutritional statusof childrenundergoing surgery and their risk of developing nutrition-associated complications postoperatively. Ob-jective measures of nutritional status, on the other hand, showed no association with outcomes. Thepurpose of this article is to describe in detail themethods used in conducting nutrition-focused physicalexaminations and the medical history components of a pediatric Subjective Global Nutritional Assess-ment tool. Guidelines are given for performing and interpreting physical examinations that look forevidence of loss of subcutaneous fat, muscle wasting, and/or edema in children of different ages. Age-related questionnaires are offered to guide history taking and the rating of growth, weight changes,dietary intake, gastrointestinal symptoms, functional capacity, and any metabolic stress. Finally, theassociated rating form is provided, alongwith direction for how to consider all components of a physicalexam and history in the context of each other, to assign an overall rating of normal/well nourished,moderate malnutrition, or severe malnutrition. With this information, interested health professionalswill be able to perform Subjective Global Nutritional Assessment to determine a global rating of nutri-tional status for infants, children, and adolescents, and use this rating to guide decision making aboutwhat nutrition-related attention is necessary. Dietetics practitioners andother clinicians are encouragedto incorporatephysical examination for signsof protein-energydepletionwhenassessing thenutritionalstatus of children.

ARTICLE INFORMATION

Article history:Accepted 20 August 2011

Keywords:MalnutritionPediatric nutritional assessmentSubjective Global Assessment (SGA)Physical examination

Copyright © 2012 by the Academy of Nutritionand Dietetics.2212-2672/$36.00doi: 10.1016/j.jada.2011.08.039

J Acad Nutr Diet. 2012;112:424-431.

DIETETICS PRACTITIONERS AND CLINICIANS ASSESSINGthe nutritional status of children are trying to identifymalnourished individuals in whom nutrition-associatedmorbidities are likely to occur and for whom nutritionintervention should reduce occurrence. Common

objectivemeasures of nutritional status have a number ofweaknessesthat hamper their use in clinical practice. Anthropometric measure-mentsareofteninterpretedusingclassificationcriteriadeveloped30to50 years ago to identify pediatricmalnutrition in developing countries(1-5), where the cause of undernutrition differs from in developed na-tions. Commonly used biochemical surrogates of nutritional status (ie,albumin, prealbumin, and transferrin) are affected significantly by fac-tors other than nutrition, andmany now agree that they are more in-dicative of inflammation andmorbidity thanof nutritional status (6,7).As well, many anthropometric and laboratory measurements havewide confidence limits or normal ranges, making them less sensitiveand nonspecific in individual, sick, hospitalized children (8). In the ab-sence of a gold standardmeasure, a combination ofmeasures is rec-ommendedwhen assessing nutritional status (9).

SUBJECTIVE GLOBAL ASSESSMENT (SGA)SGA is a comprehensive approach to nutrition assessment thatuses clinical judgment to aggregate findings of a nutrition-fo-cused medical history and physical examination. For the past28 years, SGA has been shown to be a valid and reliable tool foridentifying malnourished adults (10,11) and it is used aroundthe world for clinical, epidemiologic, and research purposes ina wide variety of adult populations (12-19). In contrast withobjective measures, SGA has been shown capable of predicting
development of nutrition-associated morbidities (20-25).
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Pediatric Subjective Global Nutritional Assessment(SGNA)We adapted the SGA for use in a pediatric population, and renamed itSGNA because in the field of pediatrics the abbreviation SGA refers toinfantsbornsmall forgestationalage. Inaprospectivecohortstudy(26),wedemonstratedthereliabilityandvalidityofSGNAinidentifyingmal-nutrition and the risk of occurrence of postoperative nutrition-associ-ated outcomes in pediatric surgery patients, something that objectivenutrition parameterswere unable to do. Subsequent studies have alsoreported its ability to identifymalnourished children (27,28) and thoseat risk for longer hospital stay (27).Inresponsetonumerousrequestsfor instructionsonhowtoperform

SGNA inchildrenofdifferent ages,wedescribeherehowtoconduct itsnutrition-focused medical history and physical examination and thenhowtosubjectivelyconsiderthemtogethertoassignanoverallratingofnormal/well nourished, moderately malnourished, or severely mal-nourished.Whileattempting todescribe the interpretationofeach fea-ture of SGNA in detail, practitioners are reminded that the subjectivenature of clinical judgment and the assignment of ratings in the SGNArating toolmake it difficult to provide stringent guidelines in the sameway that objectivemeasurements and their recommended cutoffs do.Although these precise, black-and-white objective measurements areoften favored, subjective impressions are equally important andmoreinformative in determining nutritional status and identifying causes ofmalnutrition.

PERFORMING SGNAMore in-depth than a nutrition-screening tool, SGNA is used to as-sess the nutritional status of children whomay be at risk of malnu-
trition (eg, children living in poverty, those who are hospitalized, or
© 2012 by the Academy of Nutrition and Dietetics.

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thosewithneurocognitivedisabilities or chronic illness/disease). Al-though effective in evaluating baseline nutritional status, it was notdesigned to be a responsive assessment tool (ie, one that measuresacute change). SGNA’s slowly changing parameters are an insensi-tive measure of acute nutritional manipulation, and after 7 to 10days of optimal nutrition support an SGNA rating would not be ex-pected to change.SGNA considers seven specific features of a nutrition-focused

medical history and three features of a nutrition-focused physicalexamination for signs of inadequate energy and/or protein intake.An age-specific questionnaire (Figures 1 and 2, available online atwww.andjrnl.org) can be used to guide the medical-nutrition inter-viewof children and/or caregivers. Historicalmeasurements of length/heightandweightareobtainedfrommedical recordsand/orcaregiversandplottedonage-andsex-appropriategrowthcharts. Finally, anutri-tion-focusedphysical examination is performed. Considering thepres-ence or absence of the historical features and physical signs associatedwithmalnutrition, a child’s nutritional status is assignedaglobal ratingof normal/well nourished,moderatelymalnourished, or severelymal-nourished according to guidelines provided on the SGNA rating form(see Figure 3).

Nutrition-Focused Medical HistoryLinearGrowth.Aratingofnormal,moderate,or severe isassigned forthe child’s height-for-age percentile, appropriateness of the child’sheightrelativetotheirmid-parentalheight*(29),andserialgrowth.Weconsiderlengthorheightjustbelowthethirdpercentileassuspiciousofabnormalgrowthandrate it asmoderate,whereasmeasures farbelowthe third percentile are rated severe. Direction of serialmeasurementson the growth curves is also important; a rapid or sharp downwardmovementonthecurvesisconsideredseverewhereasagradualmove-ment downward is rated moderate. With the exception of the first 2years of life, andduringpuberty,when shifting of percentiles is normal(30), crossingpercentilesorchannelsdownward isconsideredapoten-tial sign of a nutrition-related growth disturbance. It is normal forhealthy infants to shift one to two major centiles for both length andweight, especiallyduring thefirst6monthsof life. Theseshifts typicallyoccurtoward, ratherthanawayfrom,the50thpercentile (ie, regressiontoward the mean); a rapid or sharp decline or a growth pattern thatremains flat suggests a problem.

Weight Relative to Length/Height. After plotting length/heightand weight on the growth chart a child’s ideal body weight (IBW)†andpercent of idealweight (% IBW)‡ are calculated. % IBW is rated as�90% IBW�normal/well nourished, 75% to 90% IBW�moderatemalnutrition, and �75% IBW�severemalnutrition (31).

*To determine mid-parental height for girls, subtract 13cm from the father’s height and average with the mother’sheight. To determine mid-parental height for boys, add 13cm to the mother’s height and average with the father’sheight. Thirteen centimeters is the average difference inheight between women and men. For both girls and boys,8.5 cm on either side of this calculated value (target height)represents the 3rd to 97th percentiles for anticipated adultheight (29).†Ideal body weight refers to the weight that is at the same

percentile for age as the child’s length/height. For childrenwhose length/height is less than the third percentile, deter-mine ideal body weight by first estimating height age (ageat which their height would be at the 50th percentile) andthen identifying the weight at the 50th percentile for thatheight-age.‡Percent of ideal body weight is determined by the equa-

tion (actual body weight divided by ideal body
weight)�100%.
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Changes in Body Weight. Unintentional weight loss is a goodprognosticator of clinical outcome. In pediatrics, failure to gainweight is also a concern. Serial weight measurements are ratednormal if they are following the growth curves, moderate if theyare low but moving upward on the curves, and severe if shiftingdownward on the curves. Acute weight loss in children is oftendue to changes in hydration status or onset of acute illness. There-fore, the pattern of weight change (eg, amount, speed, and dura-tion) is also important (11). A large, rapid weight loss (eg, �5% inless than 1month ismore concerning than a small, steady loss (eg,2% across 3 months). Percent weight loss§ between 5% and 10% isconsidered moderate and sustained loss �10% is considered se-vere. A separate rating is also made based on any change duringthe past 2 weeks (continued loss, stable weight, or weight gain).The normal/well-nourished rating or an upgraded rating could bebased on improvement in status (32). Accumulation or loss offluid is not regarded as real change in body mass.

Adequacy of Dietary Intake. During assessment, ask about thechild’s appetite, frequency of intake, foods eaten, and feeding/eating problems, or dietary restrictions that interfere with theability to meet nutrition requirements. Subjectively comparethe child’s dietary intake to recommended intakes for age andlevel of activity. Rate inadequate intake as hypocaloric (mod-erate) or starvation (severe). Assign a rating for any changes infood intake compared to the child’s usual intake (eg, decreas-ing, same, or improving), as well as the duration of the change(eg, days, weeks, or months) (32). Low intakes lasting for morethan 2 weeks and that are continuing or worsening place achild at higher risk of malnutrition. Low, but improving, in-takes could be rated as moderate.

Persistent Gastrointestinal (GI) Symptoms. This feature helpsclarify the degree to which a child’s ability to take and tolerate anormal diet is restricted. Inquire about the presence, severity, andduration of GI symptoms such as anorexia, nausea, abdominalpain, vomiting/gastroesophageal reflux, diarrhea, and constipa-tion. The more severe the symptoms, the poorer the SGNA rating.GI symptoms are considered severe if they have been present onan almost daily basis for at least 2 weeks. Short-term or intermit-tent symptoms, such as diarrhea or loss of appetite for 2 to 3 days,are considered less significant.

Functional Impairment.Muscle function is an early index of nu-trition changes and of complication risk in sick persons (33,34).Functional impairment helps clarify whether a child is simply anormally thin individual with lots of energy, or whether there aresigns that recent weight loss due to low energy intake is affectinghis or her ability to perform. The magnitude of the effect of mal-nutrition is greater for an individual who has lost weight andbecome less ambulatory (11). Consider whether decreased foodintake has been severe enough to lead to compromised physicalfunction and altered daily activities. View this information com-pared to energy and activity levels that are usual for that child, notsimilar-aged children in general. Give separate ratings to severityof the dysfunction, and any change during the past 2 weeks. If theimpairment is worsening, assign the severe category. Rate nochange asmoderate, and improvement as normal/well nourished.Only note changes in function related to nutritional status (11).

Metabolic Stress. Evaluate the metabolic demands of a child’sunderlying illness and any acute stresses that may alter thosemetabolic demands and increase energy and/or protein require-ments. Examples of severe- and moderate-stress conditions areshown in Figure 4.

§Percent weight loss is determined by the equation (usual
weight�current weight)/usual weight.
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Figure 3. Pediatric Subjective Global Nutritional Assessment (SGNA) rating form. (continued on next page)

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Nutrition-Focused Physical ExaminationA physical exam helps corroborate information obtained in themedical-nutrition history by providing supportive evidence ofweight loss or decreased functional capacity. Look for signs ofloss of fat stores, muscle wasting, and edema (Figure 5) (35),following a logical and sequential process using a head-to-toeapproach. Because it is difficult to determine fat vs muscle lossduring the early years of life, physical examination in infantsand toddlers assesses fat and muscle stores together as generalwasting.

Loss of Subcutaneous Fat. Fat content in the body alters withage, increasing rapidly after birth from 14% to 15% of bodyweightto a peak of 25% to 26% by age 6 months (36). After age 6 months,fat content begins to decrease, reaching a minimum of 13% at age7 years in boys and 16% at age 6 years in girls, followed by anincrease to 14% in boys and 19% in girls around the age of 10 years

Figure 3. Pediatric Subjective Global Nutritional Assessment (

(36). Infants are therefore physiologically fat compared to chil-


dren and adolescents, and they have a higher proportion of pro-tein in viscera than somatic tissue.Examine the child’s face, arms, chest, and buttocks for loss of

subcutaneous fat. Look for clearly defined, bony, ormuscular out-lines because the outline ofmuscles is easily observedwhen thereis loss of fat. Hollow facial cheeks, little space between the fingerswhen pinching fat stores over the biceps and triceps, depressionsbetween the ribs, and flat or baggy buttocks are signs of loss ofsubcutaneous fat. Evaluation is notmeant to be an exactmeasure-ment, but to provide a subjective impression of fat stores andlosses that may have resulted from inadequate nutrition (11).

Muscle Wasting. Muscle wasting is defined as loss of bulk andtone. Examine the child’s temple, clavicle, shoulder, scapula,thigh, knee, and calf for signs of muscle wasting. Prominent orprotruding bone structure at the clavicle, shoulder, scapula, andknee sites, and flat or hollow areas in the upper or lower legs,

) rating form. (continued)

suggest muscle wasting. Ask whether this is the usual amount of


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muscle mass for the child or whether there has been a recentchange. Consider if lowmuscle mass is due to neuropathy or my-opathy rather than nutritional restriction.

Edema. Test for dependent edemaby applying firmpressurewiththe thumb into the skin over the bony surface of thedistal anteriorsurface of the foot, or over the sacrum (for infants and bedriddenchildren) for 5 seconds and observing the depth of the depressionand whether it persists after lifting the thumb. Edema known tobe related to a child’s illness (eg, oligoanuria, nephrotic syndrome,liver disease, or congestive heart failure) should not be rated aspotential malnutrition. If observed, assess weight change andedema together to determinewhether tissuewasting is hiddenbyfluid retention.

Assigning the Overall SGNA RatingDetermine a child’s nutritional status by first rating each of thecomponents of the seven features of the medical-nutrition his-tory as well as the physical examination as normal, moderate, orsevere using the SGNA Rating Form (Figure 3). The overall SGNArating is subjective and is not based on a numerical scoring sys-tem. Examine the rating form to obtain a general feel for thechild’s status. More checkmarks on the right-hand side of theform suggest the child is likely to be malnourished. If most of thecheckmarks are on the left-hand side, the child is likely to benormal/well nourished. It is inappropriate to simply add thenumber of normal, moderate, or severe ratings to arrive at theoverall classification. Give the most consideration to uninten-tional changes in body weight and serial growth, adequacy ofdietary intake, and physical signs of loss of fat or muscle mass.Use the other components to confirm the child’s or caregiver’sself-reports and support or strengthen these ratings.Consider also the progression of the child’s nutritional status in

relation to his or her usual. SGNA is based on the hypothesis thatrestoration of food intake to optimal levels can rapidly reduce therisks associated with malnutrition (37,38), even though an indi-vidual is still wasted and underweight. Therefore, if the child hasrecently gained weight, and other indicators such as appetiteshow improvement, the child may be assigned the normal/wellnourished rating despite previous loss of fat and muscle that re-mains physically noticeable. On the other hand, children withobesity could be moderately or severely malnourished basedupon a poor medical history and signs of muscle loss.The severely malnourished rating is generally given when a

child has physical signs of malnutrition in the presence of a med-ical history suggestive of risk (eg, continuing weight loss �10%and a decline in dietary intake, with or without poor linear

Figure 4. Examples of moderate or severe metabolic stress conNutrition Assessment tool for pediatric populations.

growth) (32). GI symptoms and functional impairments usually


exist in these children. Severely malnourished children rank inthe moderate to severe category in most features on the SGNAform, and show little or no sign of improvement during the pre-vious month.A child is assigned the moderately malnourished rating when

recent weight loss is �10% (eg, 5% in 1 month; 7.5% in 3 months)with no subsequent gain and there is a reduction in dietary intakeand mild or no loss of subcutaneous fat or muscle (32). Thesechildren may or may not have functional impairments or GIsymptoms. The child may be experiencing a downward trend butstarted with reasonably good nutritional status and has the po-tential to progress to a severely malnourished state. The moder-ate rating is expected to be the most ambiguous of all SGNA clas-sifications. These children may have rankings in all threecategories.The normal/well nourished category is assigned if the child has

few or no physical signs of malnutrition, weight loss or growthfailure, dietary difficulties, nutrition-related functional impair-ments, or persistent GI symptoms that might predispose to mal-nutrition.

LimitationsSGNA was designed to identify undernourished children and, assuch, it does not differentiate children with adiposity from well-nourished children. Children with overweight or obesity could bemoderately or severelymalnourished based on a current poormed-ical history and signs of muscle loss. Physical detection of loss of fatand muscle mass in these children is difficult. Although the useful-nessofbodymass index in identifyingpediatricoverweightandobe-sity is well established, accurate body mass index cutoffs for deter-mining undernutrition that is associated with adverse outcomeshavenot beenwell established.When that occurs, research todeter-mine whether body mass index better replaces percent ideal bodyweight in SGNA will be warranted. Most of the older children andadolescents declined assessment of the fat mass in their buttocks.For future use, we suggest that this site be used only for infants andtoddlers. In our original study (26), moderate edemawas identifiedin only 11 out of 175 (6%) children and severe edema not at all,numbers too small to assess the importance of this variable in theoverall SGNA rating. Given limitations of serumproteins asmarkersof nutritional status, we suggest that inclusion of edema in physicalexams be considered exclusively for populations where its fre-quency is high in association with their underlying illness. We alsosuggest that it beused solely to evaluatewhether a child’smeasuredweight is a true “dry” or euvolemic weight, rather than using it as a

s that should be considered when using the Subjective Global
dition
sign of inadequate intake.

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Figure 5. Physical examination findings: What to look for when applying Subjective Global Nutritional Assessment in a pediatric
population. Adapted with permission from reference (35).
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CONCLUSIONSSGNA is a comprehensive, organized representation of the thoughtprocess a clinician shoulduse inassessingachild’snutritional status.Its simple, noninvasive nature moves an assessor away from a fixa-tion on objectivemeasures and numerical precision and back to thechild. It allows one to capture the dynamic nature of malnutritionthrough considerationof subtle patterns of change in variables, suchas thedirectionanddurationofweight changes rather thanabsoluteamounts. Many children are thin or have lost weight, and this initself does not constitutemalnutrition. Objectivemeasurements areunable to discern the difference. SGNA outperforms objective mea-sures and has advantages over them that merit its use.Practitioners who work with pediatric populations should incor-

porate clinical judgment into their nutrition assessments and relyless on black-and-white objective measures. Further developmentand testing of SGNAand its ability to portray adverse events in otherpediatric populations, including those with overnutrition, is war-ranted.Physical examination as a component of pediatric nutrition as-

sessment is rarely utilized; however, it can be quite revealing.Physical signs of wasting were one of the variables that had thehighest correlationwith the overall SGNA rating for children of allages in our original study. This is consistentwith studies of SGA inadults (11,39,40). Dialog during a physical exam can provide ad-ditional information on physical activity and functional capacitynot revealed while taking a medical-nutrition history. Anotherimportant benefit is the opportunity to assess a child withoutbulky clothes that can effectively hide under- or overnutrition.Some children have a deceptively normal or mildly low weight-for-height, but on examination have visible severe wasting in thepresence of organomegaly or edema. In situations such as these,dimensionless assessment can be more useful than exact weight.Using a critical eye and feel is as informative as skinfoldmeasure-ment when assessing fat and muscle mass in children.Dietetics practitioners are less familiar than physicians and

nurses with this physical, hands-on aspect of care and are, there-fore, less prepared to get a complete picture of the patient (41).We strongly advocate for inclusion of a nutrition-focusedphysicalexamination in pediatric nutrition assessments performed by di-etetics practitioners as well as physicians and nurses. We alsorecommend that physical examination skills be incorporated intothe core curriculum of dietetics students to facilitate this clinicalpractice.

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AUTHOR INFORMATIONAt the time of the study, D. J. Secker was an academic and clinical specialist dietitian, Department of Clinical Dietetics and Division ofNephrology, The Hospital for Sick Children, Toronto, Ontario, Canada. K. N. Jeejeebhoy is a gastroenterologist, Division of Gastroenterology, StMichael’s Hospital, Toronto, Ontario, Canada, and a professor, Institute of Medical Sciences, Departments of Nutritional Sciences and Physiology,University of Toronto, Toronto, Ontario, Canada.Address correspondence to: Donna J. Secker, PhD, RD, FDC. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTEREST:No potential conflict of interest was reported by the authors.

FUNDING/SUPPORT:Funding for this research was provided by The Canadian Foundation for Dietetic Research. Doctoral fellowships for Dr Secker were providedby the Canadian Institutes of Health Research Doctoral Research Award, the Canadian Institutes of Health Research Clinician Scientist TrainingProgram in Clinical Nutrition, and The Hospital for Sick Children Research Institute Research Training Centre (Restracomp).


mailto:[email protected]

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Figure 1. Questionnaire for obtaining nutrition-focused medical history from caregivers of infants and toddlers.

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Figure 1. (Continued)

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Figure 2. Questionnaire for obtaining nutrition-focused medical history from children/teenagers and/or their caregivers.


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