Pediatric SGNA rating form | ||||
Consider severity and duration of changes, as well as recent progression when rating each item. | ||||
Nutrition-focused medical history | SGNA score | |||
Normal | Moderate | Severe | ||
Appropriateness of current height for age (stunting) | ||||
| ≥3rd centile Just below 3rd centile Far below 3rd centile | |||
| Yes No | |||
| Following centiles Moving upwards on centiles Moving downwards on centiles (gradually or quickly) | |||
Appropriateness of current weight for age (wasting) | ||||
Ideal body weight = _____ kg | ||||
Percent ideal body weight: ___ ___ ___ % | >90% 75-90% <75% | |||
Unintentional changes in body weight | ||||
| Following centiles Crossed ≥1 centile upwards Crossed ≥1 centile downwards | |||
| <5% usual body weight 5-10% usual body weight >10% usual body weight | |||
| No change Increased Decreased | |||
Adequacy of dietary intake | ||||
| Adequate Inadequate - hypocaloric Inadequate - starvation (ie, taking little of anything) | |||
| No change Increased Decreased | |||
| <2 weeks ≥2 weeks | |||
Gastrointestinal symptoms | ||||
| No symptoms One or more symptoms; not daily Some or all symptoms; daily | |||
| <2 weeks ≥2 weeks | |||
Functional capacity (nutritionally related) | ||||
| No impairment, energetic, able to perform age-appropriate activity Restricted in physically strenuous activity, but able to perform play and/or school activities in a light or sedentary nature; less energy; tired more often Little to no play activities, confined to bed or chair >50% of waking time; no energy; sleeps often | |||
| No change Increased Decreased | |||
Metabolic stress of disease | ||||
No stress Moderate stressΔ Severe stress◊ | ||||
Physical exam | SGNA score | |||
Normal | Moderate | Severe | ||
Loss of subcutaneous fat | ||||
No loss in most or all areas Loss in some but not all areas Severe loss in most or all areas | ||||
Muscle wasting | ||||
No wasting in most or all areas Wasting in some but not all areas Severe wasting in most or all areas | ||||
Edema (nutrition-related) | ||||
No edema Moderate Severe | ||||
Normal | Moderate | Severe | ||
Overall SGNA ranking |
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