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RESEARCH
Research and Practice Innovations
How to Perform Subjective Global Nutritional
Assessment in Children
Donna J. Secker, PhD, RD, FDC; Khursheed N. Jeejeebhoy, PhD, MBBS, FRCPC
ARTICLE INFORMATION
ABSTRACT
Article history:
Subjective Global Assessment (SGA) is a method for evaluating nutritional status based on a practitioner’s
clinical judgment rather than objective, quantitative measurements. Encompassing historical, symptomatic, and physical parameters, SGA aims to identify an individual’s initial nutrition state and consider the
interplay of factors inﬂuencing the progression or regression of nutrition abnormalities. SGA has been
widely used for more than 25 years to assess the nutritional status of adults in both clinical and research
settings. Perceiving multiple beneﬁts of its use in children, we recently adapted and validated the SGA
tool for use in a pediatric population, demonstrating its ability to identify the nutritional status of children
undergoing surgery and their risk of developing nutrition-associated complications postoperatively. Objective measures of nutritional status, on the other hand, showed no association with outcomes. The
purpose of this article is to describe in detail the methods used in conducting nutrition-focused physical
examinations and the medical history components of a pediatric Subjective Global Nutritional Assessment tool. Guidelines are given for performing and interpreting physical examinations that look for
evidence of loss of subcutaneous fat, muscle wasting, and/or edema in children of different ages. Agerelated 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, the
associated rating form is provided, along with direction for how to consider all components of a physical
exam 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 professionals
will be able to perform Subjective Global Nutritional Assessment to determine a global rating of nutritional status for infants, children, and adolescents, and use this rating to guide decision making about
what nutrition-related attention is necessary. Dietetics practitioners and other clinicians are encouraged
to incorporate physical examination for signs of protein-energy depletion when assessing the nutritional
status of children.
J Acad Nutr Diet. 2012;112:424-431.
Accepted 20 August 2011
Keywords:
Malnutrition
Pediatric nutritional assessment
Subjective Global Assessment (SGA)
Physical examination
Copyright © 2012 by the Academy of Nutrition
and Dietetics.
2212-2672/$36.00
doi: 10.1016/j.jada.2011.08.039
D
IETETICS PRACTITIONERS AND CLINICIANS ASSESSING
the nutritional status of children are trying to identify
malnourished individuals in whom nutrition-associated
morbidities are likely to occur and for whom nutrition
intervention should reduce occurrence. Common
objective measures of nutritional status have a number of weaknesses
that hamper their use in clinical practice. Anthropometric measurements are often interpreted using classiﬁcation criteria developed 30 to
50 years ago to identify pediatric malnutrition in developing countries
(1-5), where the cause of undernutrition differs from in developed nations. Commonly used biochemical surrogates of nutritional status (ie,
albumin, prealbumin, and transferrin) are affected signiﬁcantly by factors other than nutrition, and many now agree that they are more indicative of inﬂammation and morbidity than of nutritional status (6,7).
As well, many anthropometric and laboratory measurements have
wide conﬁdence limits or normal ranges, making them less sensitive
and nonspeciﬁc in individual, sick, hospitalized children (8). In the absence of a gold standard measure, a combination of measures is recommended when assessing nutritional status (9).
SUBJECTIVE GLOBAL ASSESSMENT (SGA)
SGA is a comprehensive approach to nutrition assessment that
uses clinical judgment to aggregate ﬁndings of a nutrition-focused medical history and physical examination. For the past
28 years, SGA has been shown to be a valid and reliable tool for
identifying malnourished adults (10,11) and it is used around
the world for clinical, epidemiologic, and research purposes in
a wide variety of adult populations (12-19). In contrast with
objective measures, SGA has been shown capable of predicting
development of nutrition-associated morbidities (20-25).
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JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
Pediatric Subjective Global Nutritional Assessment
(SGNA)
We adapted the SGA for use in a pediatric population, and renamed it
SGNA because in the ﬁeld of pediatrics the abbreviation SGA refers to
infants born small for gestational age. In a prospective cohort study (26),
we demonstrated the reliability and validity of SGNA in identifying malnutrition and the risk of occurrence of postoperative nutrition-associated outcomes in pediatric surgery patients, something that objective
nutrition parameters were unable to do. Subsequent studies have also
reported its ability to identify malnourished children (27,28) and those
at risk for longer hospital stay (27).
In response to numerous requests for instructions on how to perform
SGNA in children of different ages, we describe here how to conduct its
nutrition-focused medical history and physical examination and then
how to subjectively consider them together to assign an overall rating of
normal/well nourished, moderately malnourished, or severely malnourished. While attempting to describe the interpretation of each feature of SGNA in detail, practitioners are reminded that the subjective
nature of clinical judgment and the assignment of ratings in the SGNA
rating tool make it difﬁcult to provide stringent guidelines in the same
way that objective measurements and their recommended cutoffs do.
Although these precise, black-and-white objective measurements are
often favored, subjective impressions are equally important and more
informative in determining nutritional status and identifying causes of
malnutrition.
PERFORMING SGNA
More in-depth than a nutrition-screening tool, SGNA is used to assess the nutritional status of children who may be at risk of malnutrition (eg, children living in poverty, those who are hospitalized, or
© 2012 by the Academy of Nutrition and Dietetics.
RESEARCH
those with neurocognitive disabilities or chronic illness/disease). Although effective in evaluating baseline nutritional status, it was not
designed to be a responsive assessment tool (ie, one that measures
acute change). SGNA’s slowly changing parameters are an insensitive measure of acute nutritional manipulation, and after 7 to 10
days of optimal nutrition support an SGNA rating would not be expected to change.
SGNA considers seven speciﬁc features of a nutrition-focused
medical history and three features of a nutrition-focused physical
examination for signs of inadequate energy and/or protein intake.
An age-speciﬁc questionnaire (Figures 1 and 2, available online at
www.andjrnl.org) can be used to guide the medical-nutrition interview of children and/or caregivers. Historical measurements of length/
height and weight are obtained from medical records and/or caregivers
and plotted on age- and sex-appropriate growth charts. Finally, a nutrition-focused physical examination is performed. Considering the presence or absence of the historical features and physical signs associated
with malnutrition, a child’s nutritional status is assigned a global rating
of normal/well nourished, moderately malnourished, or severely malnourished according to guidelines provided on the SGNA rating form
(see Figure 3).
Nutrition-Focused Medical History
Linear Growth. A rating of normal, moderate, or severe is assigned for
the child’s height-for-age percentile, appropriateness of the child’s
height relative to their mid-parental height* (29), and serial growth. We
consider length or height just below the third percentile as suspicious of
abnormal growth and rate it as moderate, whereas measures far below
the third percentile are rated severe. Direction of serial measurements
on the growth curves is also important; a rapid or sharp downward
movement on the curves is considered severe whereas a gradual movement downward is rated moderate. With the exception of the ﬁrst 2
years of life, and during puberty, when shifting of percentiles is normal
(30), crossing percentiles or channels downward is considered a potential sign of a nutrition-related growth disturbance. It is normal for
healthy infants to shift one to two major centiles for both length and
weight, especially during the ﬁrst 6 months of life. These shifts typically
occur toward, rather than away from, the 50th percentile (ie, regression
toward the mean); a rapid or sharp decline or a growth pattern that
remains ﬂat suggests a problem.
Weight Relative to Length/Height. After plotting length/height
and weight on the growth chart a child’s ideal body weight (IBW)†
and percent of ideal weight (% IBW)‡ are calculated. % IBW is rated as
⬎90% IBW⫽normal/well nourished, 75% to 90% IBW⫽moderate
malnutrition, and ⬍75% IBW⫽severe malnutrition (31).
*To determine mid-parental height for girls, subtract 13
cm from the father’s height and average with the mother’s
height. To determine mid-parental height for boys, add 13
cm to the mother’s height and average with the father’s
height. Thirteen centimeters is the average difference in
height 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 adult
height (29).
†Ideal body weight refers to the weight that is at the same
percentile for age as the child’s length/height. For children
whose length/height is less than the third percentile, determine ideal body weight by ﬁrst estimating height age (age
at which their height would be at the 50th percentile) and
then identifying the weight at the 50th percentile for that
height-age.
‡Percent of ideal body weight is determined by the equation (actual body weight divided by ideal body
weight)⫻100%.
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Changes in Body Weight. Unintentional weight loss is a good
prognosticator of clinical outcome. In pediatrics, failure to gain
weight is also a concern. Serial weight measurements are rated
normal if they are following the growth curves, moderate if they
are low but moving upward on the curves, and severe if shifting
downward on the curves. Acute weight loss in children is often
due to changes in hydration status or onset of acute illness. Therefore, the pattern of weight change (eg, amount, speed, and duration) is also important (11). A large, rapid weight loss (eg, ⱖ5% in
less than 1 month is more concerning than a small, steady loss (eg,
2% across 3 months). Percent weight loss§ between 5% and 10% is
considered moderate and sustained loss ⬎10% is considered severe. A separate rating is also made based on any change during
the past 2 weeks (continued loss, stable weight, or weight gain).
The normal/well-nourished rating or an upgraded rating could be
based on improvement in status (32). Accumulation or loss of
ﬂuid is not regarded as real change in body mass.
Adequacy of Dietary Intake. During assessment, ask about the
child’s appetite, frequency of intake, foods eaten, and feeding/
eating problems, or dietary restrictions that interfere with the
ability to meet nutrition requirements. Subjectively compare
the child’s dietary intake to recommended intakes for age and
level of activity. Rate inadequate intake as hypocaloric (moderate) or starvation (severe). Assign a rating for any changes in
food intake compared to the child’s usual intake (eg, decreasing, same, or improving), as well as the duration of the change
(eg, days, weeks, or months) (32). Low intakes lasting for more
than 2 weeks and that are continuing or worsening place a
child at higher risk of malnutrition. Low, but improving, intakes could be rated as moderate.
Persistent Gastrointestinal (GI) Symptoms. This feature helps
clarify the degree to which a child’s ability to take and tolerate a
normal diet is restricted. Inquire about the presence, severity, and
duration of GI symptoms such as anorexia, nausea, abdominal
pain, vomiting/gastroesophageal reﬂux, diarrhea, and constipation. The more severe the symptoms, the poorer the SGNA rating.
GI symptoms are considered severe if they have been present on
an almost daily basis for at least 2 weeks. Short-term or intermittent 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 nutrition changes and of complication risk in sick persons (33,34).
Functional impairment helps clarify whether a child is simply a
normally thin individual with lots of energy, or whether there are
signs that recent weight loss due to low energy intake is affecting
his or her ability to perform. The magnitude of the effect of malnutrition is greater for an individual who has lost weight and
become less ambulatory (11). Consider whether decreased food
intake has been severe enough to lead to compromised physical
function and altered daily activities. View this information compared to energy and activity levels that are usual for that child, not
similar-aged children in general. Give separate ratings to severity
of the dysfunction, and any change during the past 2 weeks. If the
impairment is worsening, assign the severe category. Rate no
change as moderate, 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’s
underlying illness and any acute stresses that may alter those
metabolic demands and increase energy and/or protein requirements. Examples of severe- and moderate-stress conditions are
shown 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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Figure 3. Pediatric Subjective Global Nutritional Assessment (SGNA) rating form. (continued)
Nutrition-Focused Physical Examination
A physical exam helps corroborate information obtained in the
medical-nutrition history by providing supportive evidence of
weight loss or decreased functional capacity. Look for signs of
loss of fat stores, muscle wasting, and edema (Figure 5) (35),
following a logical and sequential process using a head-to-toe
approach. Because it is difﬁcult to determine fat vs muscle loss
during the early years of life, physical examination in infants
and toddlers assesses fat and muscle stores together as general
wasting.
Loss of Subcutaneous Fat. Fat content in the body alters with
age, increasing rapidly after birth from 14% to 15% of body weight
to 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 age
7 years in boys and 16% at age 6 years in girls, followed by an
increase to 14% in boys and 19% in girls around the age of 10 years
(36). Infants are therefore physiologically fat compared to chilMarch 2012 Volume 112 Number 3
dren and adolescents, and they have a higher proportion of protein in viscera than somatic tissue.
Examine the child’s face, arms, chest, and buttocks for loss of
subcutaneous fat. Look for clearly deﬁned, bony, or muscular outlines because the outline of muscles is easily observed when there
is loss of fat. Hollow facial cheeks, little space between the ﬁngers
when pinching fat stores over the biceps and triceps, depressions
between the ribs, and ﬂat or baggy buttocks are signs of loss of
subcutaneous fat. Evaluation is not meant to be an exact measurement, but to provide a subjective impression of fat stores and
losses that may have resulted from inadequate nutrition (11).
Muscle Wasting. Muscle wasting is deﬁned as loss of bulk and
tone. Examine the child’s temple, clavicle, shoulder, scapula,
thigh, knee, and calf for signs of muscle wasting. Prominent or
protruding bone structure at the clavicle, shoulder, scapula, and
knee sites, and ﬂat or hollow areas in the upper or lower legs,
suggest muscle wasting. Ask whether this is the usual amount of
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
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Figure 4. Examples of moderate or severe metabolic stress conditions that should be considered when using the Subjective Global
Nutrition Assessment tool for pediatric populations.
muscle mass for the child or whether there has been a recent
change. Consider if low muscle mass is due to neuropathy or myopathy rather than nutritional restriction.
Edema. Test for dependent edema by applying ﬁrm pressure with
the thumb into the skin over the bony surface of the distal anterior
surface of the foot, or over the sacrum (for infants and bedridden
children) for 5 seconds and observing the depth of the depression
and whether it persists after lifting the thumb. Edema known to
be related to a child’s illness (eg, oligoanuria, nephrotic syndrome,
liver disease, or congestive heart failure) should not be rated as
potential malnutrition. If observed, assess weight change and
edema together to determine whether tissue wasting is hidden by
ﬂuid retention.
Assigning the Overall SGNA Rating
Determine a child’s nutritional status by ﬁrst rating each of the
components of the seven features of the medical-nutrition history as well as the physical examination as normal, moderate, or
severe using the SGNA Rating Form (Figure 3). The overall SGNA
rating is subjective and is not based on a numerical scoring system. Examine the rating form to obtain a general feel for the
child’s status. More checkmarks on the right-hand side of the
form suggest the child is likely to be malnourished. If most of the
checkmarks are on the left-hand side, the child is likely to be
normal/well nourished. It is inappropriate to simply add the
number of normal, moderate, or severe ratings to arrive at the
overall classiﬁcation. Give the most consideration to unintentional changes in body weight and serial growth, adequacy of
dietary intake, and physical signs of loss of fat or muscle mass.
Use the other components to conﬁrm the child’s or caregiver’s
self-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 that
restoration of food intake to optimal levels can rapidly reduce the
risks associated with malnutrition (37,38), even though an individual is still wasted and underweight. Therefore, if the child has
recently gained weight, and other indicators such as appetite
show improvement, the child may be assigned the normal/well
nourished rating despite previous loss of fat and muscle that remains physically noticeable. On the other hand, children with
obesity could be moderately or severely malnourished based
upon 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 medical history suggestive of risk (eg, continuing weight loss ⬎10%
and a decline in dietary intake, with or without poor linear
growth) (32). GI symptoms and functional impairments usually
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exist in these children. Severely malnourished children rank in
the moderate to severe category in most features on the SGNA
form, and show little or no sign of improvement during the previous 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 intake
and mild or no loss of subcutaneous fat or muscle (32). These
children may or may not have functional impairments or GI
symptoms. The child may be experiencing a downward trend but
started with reasonably good nutritional status and has the potential to progress to a severely malnourished state. The moderate rating is expected to be the most ambiguous of all SGNA classiﬁcations. These children may have rankings in all three
categories.
The normal/well nourished category is assigned if the child has
few or no physical signs of malnutrition, weight loss or growth
failure, dietary difﬁculties, nutrition-related functional impairments, or persistent GI symptoms that might predispose to malnutrition.
Limitations
SGNA was designed to identify undernourished children and, as
such, it does not differentiate children with adiposity from wellnourished children. Children with overweight or obesity could be
moderately or severely malnourished based on a current poor medical history and signs of muscle loss. Physical detection of loss of fat
and muscle mass in these children is difﬁcult. Although the usefulness of body mass index in identifying pediatric overweight and obesity is well established, accurate body mass index cutoffs for determining undernutrition that is associated with adverse outcomes
have not been well established. When that occurs, research to determine whether body mass index better replaces percent ideal body
weight in SGNA will be warranted. Most of the older children and
adolescents declined assessment of the fat mass in their buttocks.
For future use, we suggest that this site be used only for infants and
toddlers. In our original study (26), moderate edema was identiﬁed
in only 11 out of 175 (6%) children and severe edema not at all,
numbers too small to assess the importance of this variable in the
overall SGNA rating. Given limitations of serum proteins as markers
of nutritional status, we suggest that inclusion of edema in physical
exams be considered exclusively for populations where its frequency is high in association with their underlying illness. We also
suggest that it be used solely to evaluate whether a child’s measured
weight is a true “dry” or euvolemic weight, rather than using it as a
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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parison of clinical judgment and objective measurements. N Engl J
Med. 1982;306(16):969-972.
CONCLUSIONS
SGNA is a comprehensive, organized representation of the thought
process a clinician should use in assessing a child’s nutritional status.
Its simple, noninvasive nature moves an assessor away from a ﬁxation on objective measures and numerical precision and back to the
child. It allows one to capture the dynamic nature of malnutrition
through consideration of subtle patterns of change in variables, such
as the direction and duration of weight changes rather than absolute
amounts. Many children are thin or have lost weight, and this in
itself does not constitute malnutrition. Objective measurements are
unable to discern the difference. SGNA outperforms objective measures and has advantages over them that merit its use.
Practitioners who work with pediatric populations should incorporate clinical judgment into their nutrition assessments and rely
less on black-and-white objective measures. Further development
and testing of SGNA and its ability to portray adverse events in other
pediatric populations, including those with overnutrition, is warranted.
Physical examination as a component of pediatric nutrition assessment is rarely utilized; however, it can be quite revealing.
Physical signs of wasting were one of the variables that had the
highest correlation with the overall SGNA rating for children of all
ages in our original study. This is consistent with studies of SGA in
adults (11,39,40). Dialog during a physical exam can provide additional information on physical activity and functional capacity
not revealed while taking a medical-nutrition history. Another
important beneﬁt is the opportunity to assess a child without
bulky clothes that can effectively hide under- or overnutrition.
Some children have a deceptively normal or mildly low weightfor-height, but on examination have visible severe wasting in the
presence 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 skinfold measurement 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, therefore, less prepared to get a complete picture of the patient (41).
We strongly advocate for inclusion of a nutrition-focused physical
examination in pediatric nutrition assessments performed by dietetics practitioners as well as physicians and nurses. We also
recommend that physical examination skills be incorporated into
the core curriculum of dietetics students to facilitate this clinical
practice.
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AUTHOR INFORMATION
At the time of the study, D. J. Secker was an academic and clinical specialist dietitian, Department of Clinical Dietetics and Division of
Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada. K. N. Jeejeebhoy is a gastroenterologist, Division of Gastroenterology, St
Michael’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 provided
by the Canadian Institutes of Health Research Doctoral Research Award, the Canadian Institutes of Health Research Clinician Scientist Training
Program in Clinical Nutrition, and The Hospital for Sick Children Research Institute Research Training Centre (Restracomp).
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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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Figure 2. (Continued)
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Figure 2. (Continued)
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