DIETETICS PRACTITIONERS AND CLINICIANS ASSESSING. How to Perform Subjective Global Nutritional Assessment in Children

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1 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 Article history: Accepted 20 August 2011 Keywords: Malnutrition Pediatric nutritional assessment Subjective Global Assessment (SGA) Physical examination Copyright 2012 by the Academy of Nutrition and Dietetics /$36.00 doi: /j.jada ABSTRACT 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: DIETETICS 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). 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 howtosubjectivelyconsiderthemtogethertoassignanoverallratingof 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 424 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 2012 by the Academy of Nutrition and Dietetics.

2 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 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%. 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, 5% 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. March 2012 Volume 112 Number 3 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 425

3 Figure 3. Pediatric Subjective Global Nutritional Assessment (SGNA) rating form. (continued on next page) 426 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2012 Volume 112 Number 3

4 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 children 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 March 2012 Volume 112 Number 3 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 427

5 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 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. 428 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2012 Volume 112 Number 3

6 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). March 2012 Volume 112 Number 3 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 429

7 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. References 1. Gomez F, Galvan RR, Cravioto J, Frenk S. Malnutrition in infancy and childhood, with special reference to kwashiorkor. Adv Pediatr. 1955; 7: Jelliffe D. The Assessment of the Nutrition Status of the Community (with Special Reference to Field Surveys in Developing Regions of the World). Geneva, Switzerland: World Health Organization; Monograph Waterlow JC. Classification and definition of protein-calorie malnutrition. BMJ. 1972;3(5826): Waterlow JC. Note on the assessment and classification of proteinenergy malnutrition in children. Lancet. 1973;2(7820): McLaren DS, Read WWC. Classification of nutritional status in early childhood. Lancet. 1972;2(7769): Fuhrman M, Charney P, Mueller C. Hepatic proteins and nutrition assessment. J Am Diet Assoc. 2004;104(8): Banh L. Serum proteins as markers of nutrition: What are we treating? Pract Gastroenterol. 2006;Series 43: Tonglet R, Lembo E, Zihindula P, Wodon A, Dramix M, Hennart P. How useful are anthropometric, clinical and dietary measurements of nutritional status as predictors of morbidity of young children in central Africa? Trop Med Int Health. 1999;4(2): American Society for Parenteral and Enteral Nutrition Board of Directors and Clinical Practice Committee. Definition of terms, style, and conventions used in A.S.P.E.N. Board of Directors approved documents. Accessed April 13, Baker JP, Detsky AS, Wesson DE, et al. Nutritional assessment: A comparison of clinical judgment and objective measurements. N Engl J Med. 1982;306(16): Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987; 11(1): Gupta D, Lammersfeld C, Vashi P, Burrows J, Lis C, Grutsch J. Prognostic significance of Subjective Global Assessment (SGA) in advanced colorectal cancer. Eur J Clin Nutr. 2005;59(1): Shirodkar M, Mohandas K. Subjective global assessment: A simple and reliable screening tool for malnutrition among Indians. Indian J Gastroenterol. 2005;24(6): Pham N, Cox-Reijven P, Greve J, Soeters P. Application of subjective global assessment as a screening tool for malnutrition in surgical patients in Vietnam. Clin Nutr. 2006;25(1): Steiber A, Leon JB, Secker D, et al. Multicenter study of the validity and reliability of Subjective Global Assessment in the hemodialysis population. J Ren Nutr. 2007;17(5): Bauer J, Capra S, Ferguson M. Use of the scored patient-generated subjective global assessment (PG-SGA) as a nutrition assessment tool in patients with cancer. Eur J Clin Nutr. 2002;56(8): Waitzberg D, Caiaffa W, Correia I. Hospital malnutrition: The Brazilian National Survey (IBRANUTRI): A study of 4000 patients. Nutrition. 2001;17(7/8): Makhija S, Baker J. The Subjective Global Assessment: A review of its use in clinical practice. Nutr Clin Pract. 2008;23(4): Sheean P, Peterson S, Gurka D, Braunschweig C. Nutrition assessment: the reproducibility of subjective global assessment in patients requiring mechanical ventilation. 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Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients. Clin Nutr. 2005;24(6): Secker D, Jeejeebhoy K. Subjective Global Nutritional Assessment for children. Am J Clin Nutr.2007;85(4): Mahdavi AM, Safaiyan A, Ostadrahimi A. Subjective vs objective nutritional assessment study in children: A cross-sectional study in the northwest of Iran. Nutr Res. 2009;29(4): Gerasimidis K, Keane O, Macleod I, Flynn DM, Wright CM. A fourstage evaluation of the Paediatric Yorkhill Malnutrition Score in a tertiary paediatric hospital and a district general hospital. Br J Nutr. 2010;104(5): Tanner JM, Goldstein H, Whitehouse RH. Standards for children s height at ages 2-9 years allowing for height of parents. Arch Dis Child. 1970;45(244): Mei Z, Grummer-Strawn L, Thompson D, Dietz W. Shifts in percentiles of growth during early childhood: Analysis of longitudinal data from the California Child Health and Development Study. Pediatrics. 2004; 113(6):e617-e McLaren D, Read W. Weight/length classification of nutrition status. Lancet. 1975;2(7927): Detsky AS, Smalley PS, Chang J. Is this patient malnourished? JAMA. 1994;271(1): Lopes JM, Russell DM, Whitwell J, Jeejeebhoy KN. Skeletal muscle function in malnutrition. Am J Clin Nutr. 1982;36(4): Jeejeebhoy KN. Muscle function and nutritional status. Am J Clin Nutr. 1987;46(3): JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2012 Volume 112 Number 3

8 35. McCann L. Subjective global assessment as it pertains to the nutritional status of dialysis patients. Dial Transplant. 1996;25(4): Puig M. Body composition and growth. In: Walker W, Watkins J, eds. Nutrition in Pediatrics. 2nd ed. Hamilton, Ontario, Canada: BC Decker; 1996: Norman K, Kirchner H, Freudenreich M, Ockenga J, Lochs H, Pirlich M. Three month intervention with protein and energy rich supplements improve muscle function and quality of life in malnourished patients with non-neoplastic gastrointestinal disease A randomized controlled trial. Clin Nutr. 2008;27(1): Bourdel-Marchasson I, Joseph PA. Dehail P, et al. Functional and metabolic early changes in calf muscle occurring during nutritional repletion in malnourished elderly patients. Am J Clin Nutr. 2001;73(4): Hirsch S, de Obaldia N, Petermann M, et al. Subjective global assessment of nutritional status: Further validation. Nutrition. 1991;7(1): Nursal T, Noyan T, Atalay B, Koz N, Karakayali H. Simple two-part tool for screening of malnutrition. Nutrition. 2005;21(6): Hammond KA. The nutritional dimension of physical assessment. Nutrition. 1999;15(5): 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. [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). March 2012 Volume 112 Number 3 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 431

9 Figure 1. Questionnaire for obtaining nutrition-focused medical history from caregivers of infants and toddlers. 431.e1 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2012 Volume 112 Number 3

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12 Figure 2. Questionnaire for obtaining nutrition-focused medical history from children/teenagers and/or their caregivers. March 2012 Volume 112 Number 3 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 431.e4

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14 Figure 2. (Continued) March 2012 Volume 112 Number 3 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 431.e6