Clinical Nutrition 30 (2011) 430e435

Contents lists available at ScienceDirect

Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Original Article

Performance of the novel Paediatric Yorkhill Malnutrition Score (PYMS)

in hospital practiceq
Konstantinos Gerasimidis a, b, *, Isobel Macleod a, Anne Maclean a, Elaine Buchanan a, Paraic McGrogan a,
Isabel Swinbank a, Mary McAuley c, Charlotte M. Wright b, Diana M. Flynn a
a
Women and Children Directorate, NHS Greater Glasgow and Clyde, Glasgow, UK
b
Human Nutrition Section, Division of Developmental Medicine, University of Glasgow, Royal Hospital for Sick Children, Glasgow G3 8SJ, UK
c
Children and Young Combined Health, NHS Grampian, Aberdeen, UK

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Nutritional screening in paediatric inpatients is important. However, there is a lack of
Received 21 July 2010 validated screening tools for this population. In this study the development of a nurse administered
Accepted 31 January 2011 paediatric malnutrition screening tool is described and its performance evaluated.
Methods: The Paediatric Yorkhill Malnutrition Score (PYMS) rate BMI, weight loss, dietary intake and
Keywords: predicted effect of the current condition on nutritional status, with a score of 0e2 for each element.
Nutritional screening tool
Patients with total score of 2 or more are referred for dietetic review. A four month pilot phase was
Malnutrition
conducted in three medical and one surgical wards of a tertiary hospital and the general paediatric ward
of a district general hospital. Performance of the tool was assessed by auditing completion rates, yield,
impact on dietetic workload, and by evaluating dietitians’ feedback.
Results: 1571 patients (72% of admissions) were screened of whom 158 (10%) scored at high risk. Non-
screened children were younger and had a shorter length of hospital stay. Of the 125 patients who scored
at high risk, between the 2nd and 4th month of the pilot, 66 (53%) were assessed by a dietitian of whom
86% were judged to be at true risk of malnutrition and 50% of these were new to the dietetic service.
Dietetic workload did not increase significantly during the pilot phase although the proportion of
referrals from the acute receiving wards increased. Dietitians’ feedback was positive, with recognition
that PYMS identified patients at risk of malnutrition who may not have otherwise been referred.
Conclusions: Nutrition screening by nurses using the new PYMS score is feasible for paediatric inpatients,
identifies children at risk of malnutrition and uses available resources efficiently.
! 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Introduction with significant potential impact on patient’s health4,5,6,7 and

health expenditure.8 Thus identification of children at risk of
While disease associated malnutrition is a common problem in malnutrition should be an important part of any program for
paediatric hospitals, it often remains undetected and untreated1,2,3 providing optimal hospital care. This has been highlighted in recent
national guidelines which state that all patients should be screened
for risk of malnutrition on admission and periodically during
Abbreviations: PYMS, Paediatric Yorkhill Malnutrition Score; SGNA, Subjective
Global Nutritional Assessment; STAMP, Screening Tool for the Assessment of hospital stay.9
Malnutrition in Paediatrics; TPH, Tertiary Paediatric Hospital; DGH, District General Anthropometry and growth charts have traditionally been used
Hospital. to assess growth and to screen for chronic undernutrition, but this
q Conference Presentation: Part of the data has already been presented at the
will not identify children in the early stages of malnutrition or those
BSPGHAN (British Society of Paediatric Gastroenterology, Hepatology and Nutri-
at risk of deterioration as a result of an acute medical condition. In
tion) Annual Winter Meeting 2009 in Sheffield, UK in the 43rd conference of the
European Society of Paediatric Gastroenterology, Hepatology and Nutrition addition, plotting data is time consuming for nurses and requires
(ESPGHAN 2009) in Budapest, Hungary and at the winter meeting of the British training. It has been proposed that nutritional screening tools may
Association of Parenteral and Enteral Nutrition (BAPEN 2009), Cardiff, UK. be more appropriate to identify nutritional risk and could be uti-
* Corresponding author. Human Nutrition Section, Division of Developmental
lised by ward nursing staff.10 These are usually presented as
Medicine, University of Glasgow, Royal Hospital for Sick Children, Glasgow G3 8SJ,
UK. Tel.: þ44 141 201 6969; fax: þ44 141 201 9275.
a questionnaire proforma outlining factors that put patients at high
E-mail address: [email protected] (K. Gerasimidis). malnutrition risk, and a number of such screening tools have been

0261-5614/$ e see front matter ! 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2011.01.015
 K. Gerasimidis et al. / Clinical Nutrition 30 (2011) 430e435 431

developed for adults.7,11,12 However these tools are inappropriate malnutrition risk and to raise awareness of malnutrition risk. The
for children and validated paediatric screening tools are scarce. scoring system was further revised after assessment of the diag-
In paediatrics four validated tools have been developed to date: nostic validity of the tool at different scoring levels/combinations.17
The first of these, the Subjective Global Nutritional Assessment The tool was not to be used before the age of 1 year as we felt that
(SGNA) for children, as proposed by Secker and Jeejeebhoy,13 is a generic tool would probably not be valid during the first year of
a comprehensive nutritional assessment method rather than life. However further work is planned to develop and testing
a rapid screening tool. The other two are shorter screening tools; a related tool for use in infancy.
one assesses pain, disease condition and food intake in the hospital
and has been validated in a tertiary hospital in France.14 The other, 2.2. Introduction of the PYMS in clinical practice
the Screening Tool for the Assessment of Malnutrition in Paediatrics
(STAMP) has been developed in the UK for use by the nursing staff, Following the development of the tool, the PYMS was piloted in 4
although detailed validation data is as yet not available and it has so paediatric wards (3 general medical, 1 general surgical) of a Tertiary
far only been described in abstract form.15 STAMP uses a compar- Paediatric Hospital (TPH) and the general paediatric ward of
ison of weight and height centiles, recent changes in nutritional a District General Hospital (DGH) with high patient turnover, to
intake, and the impact of disease diagnosis on nutritional status. evaluate its performance. All patients (1e16 years) admitted to these
A recent Dutch tool which combines subjective clinical assessment, wards over a 4 month period were eligible for screening within 24 h
high risk disease, nutritional intake and weight loss was developed of admission. Patients from other specialist wards (cardiology, renal,
for use by paediatricians and therefore may not be suitable for orthopaedic), critical care and those seen only in the day assessment
nursing use.16 unit were not included in the TPH. Prior to the launch of the project,
While seeking a tool for use by nursing staff in our tertiary nursing staff (nw180) attended a 1 h awareness session by a nutri-
children’s hospital we considered STAMP and the French tool which tion nurse specialist and received training on anthropometric
were available at the time, but while the STAMP tool was attractive, measurements of weight and height by a research dietitian and the
none appeared to fully meet the needs of our hospital population, hospital auxologist. Infants’ weight were measured with Grade 3
leading us to develop our own: the Paediatric Yorkhill Malnutrition electronic baby scales with accuracy down to 20 g. Older children
Score (PYMS). We have demonstrated elsewhere that PYMS has were measured on Grade 3 electronic standing scales with accuracy
acceptable levels of sensitivity and specificity compared to full down to 50 g. Babies were measured nude and children with
dietetic assessment and to have a more useful profile than other minimal clothing. In children aged 1e2 years length was measured
screening tools already in use.17 In this paper we describe the with a supine infantometer, and older children with wall mounted or
process of developing the tool and how it functioned as performed portable standiometers, all without shoes. Measurements were
by nursing staff in day to day practice. recorded to the nearest millimetre. Each ward had its own equip-
ment and maintenance and calibration of the equipment was carried
2. Patients and methods out regularly by the department of biophysics. Non weight-bearing
children were measured either with sitting or sling scales. For chil-
2.1. Development of the Paediatric Yorkhill Malnutrition Score dren unable to stand or in those where measurements are imprac-
tical (e.g. major trauma/operations) or unfeasible (e.g. cerebral palsy,
A multidisciplinary health professional team (medical, dietetic, muscular dystrophy, chronically ventilated) measurements of height
nursing, academic, practice development staff) developed were not carried out. In these cases the first PYMS step (BMI) was
a screening tool that would fulfil the following criteria: replaced by weight and the cut offs defined as being below the 2nd
centile on the UK 1990 growth chart.
a. To identify the majority of children ("1 years) at the highest In the first month, nurses completed PYMS but did not utilise
risk of malnutrition (sensitive) whilst not misclassifying too these to initiate dietetic referrals, but in months 2e4 they were
many patients at low risk. asked to refer all children with scores of 2 or more to the dietetic
b. To be quick and easy to use at ward level using information service. On-site support by the research team was available the first
regularly collected on admission by nursing staff. 3 months of the project at the TPH, with only limited support
c. To be feasible to integrate in regular hospital admission available at the DGH.
procedure without significantly increasing nursing and dietetic
workload or staffing levels. 2.3. Performance of PYMS in clinical practice
d. To lead to a simple explicit action plan.
This was evaluated in four ways:
The tool (Paediatric Yorkhill Malnutrition Score-PYMS) was
developed based on nutritional screening guidelines of the Euro- 2.3.1. Audit of completion rates
pean Society of Clinical Nutrition and Metabolism (ESPEN).18 It The rate of PYMS completion was audited as the percentage of
assesses 4 elements which are all recognised predictors/symptoms eligible admissions (all admitted patients "1 year) that were
of malnutrition risk: STEP 1: Body Mass Index (BMI) below the 2nd screened successfully by ward nursing staff. On a daily basis the
centile (#2 SD) on UK 1990 growth chart; STEP 2: history of recent patient discharge list was retrieved from the hospital internal
weight loss; STEP 3: recent change in nutritional intake for at least network and the proportion off discharged patients who had
the past week; STEP 4: the likely effect of the current medical a PYMS form fully completed was audited. Self carbonated forms
condition on the nutritional status of the patient for at least the were introduced to facilitate the auditing process. Differences in
next week (Fig. 1). Each step bears a score of 0e2 and the total score demographics (e.g. gender age), and disease characteristics (length
reflects the degree of the nutrition risk of the patient. A score of of hospital stay) were assessed between screened patients and
0 indicates a patient at low risk of malnutrition, a score of one those who were not. Serological markers of disease activity (e.g.
moderate risk, and a score of two or above high risk (Fig. 1). The serum albumin, C-reactive protein, haemoglobin) were retrieved
scoring system was the consensus of a multidisciplinary health from the hospital internal network for those patients who had
profession group in accordance with ESPEN guidelines17 and was appropriate blood tests carried out during their hospital stay in
devised to reflect the clinical significance of factors associated with the TPH.
432 K. Gerasimidis et al. / Clinical Nutrition 30 (2011) 430e435

Fig. 1. The Paediatric Yorkhill Malnutrition Score (PYMS).

2.3.2. Assessment of yield 2.4. Statistical analysis and ethics

This was defined as the proportion of the patients with PYMS
score " 2 who on review by dietitians were rated as being at true Differences between two groups were assessed with the
risk or to require dietetic intervention (positive predictive value). ManneWhitney test and between categories with chi-square test.
The gold standard of malnutrition risk in this study was the global Data analysis was conducted with Minitab 15 (Minitab Ltd,
clinical judgement of the dietetic staff, on the principle that what is Coventry, UK).
needed is a tool that identifies the majority of the patients which This study was conducted according to the guidelines laid down
need dietetic referral for malnutrition issues in a clinical setting. in the Declaration of Helsinki. Ethical permission to conduct the
The 6 dietitians in this study were registered senior specialist study was not required as this was a clinical audit not involving
dietitians and none of them had been involved in the development active patient participation.19
of the PYMS.
3. Results
2.3.3. Impact on dietetic service
The impact of introducing PYMS on the dietetic service was 3.1. Audit of completion rates
audited one month before and during the last month of PYMS
launch. The number of dietetic referrals, means of referral (i.e. Between 23rd June and 28th October 2008, 2174 children were
established hospital electronic system, verbal, phone) and whether admitted to the 5 pilot wards (Table 1). Of these patients 1571
these were appropriate or not were recorded daily by the hospital (72.3%) were screened, with a higher proportion screened in the
dietitians using audit sheets. TPH [TPH n ¼ 1208 (73.7%) vs. DGH n ¼ 363 (68%), p ¼ 0.011].
Screened patients came from a variety of medical and surgical
2.3.4. Dietetic feedback on PYMS performance specialties (Table 2). In the TPH only, those children who were not
Dietitians’ feedback on the performance of the tool was assessed screened were significantly younger and had a shorter length of
semi-anonymously using a predefined questionnaire at the end of hospital stay than those who were screened (Table 1). However
the pilot. This assessed the impact of PYMS introduction on work- during the last month of the pilot these differences were no longer
load, its ability to identify patients at risk of malnutrition, its significant. There was no difference in gender or serological
feasibility/functionality within clinical practice and within current markers (TPH patients only) between patients who were screened
resources. (Questionnaire available on request). for malnutrition and those were not (Table 1).
 K. Gerasimidis et al. / Clinical Nutrition 30 (2011) 430e435 433

Table 1
Demographics, anthropometry, length of hospital stay and serological markers of disease severity between patients screened and those not screened in a TPH and DGH.

Setting TPH DGH

Screened Not screened Total Screened Not screened Total

N (%) 1208 (74%) 432 (26%) 1640 363 (68%) 171 (32%) 534
N (%) male 706 (58%) 265 (61%) 971 (59%) 181 (50%) 94 (55%) 275 (51%)

N Median (IQR) N Median (IQR) N Median (IQR) N Median (IQR) N Median (IQR) N Median (IQR)
Age (years) 1208 6.3 (7.8) 432 4.7 (7.8)a 1640 6.0 (7.9) 357 7.6 (7.8) 171 5.7 (10) 528 7.2 (8.6)
BMI z-score (SD) 1095 0.0 (2.1) N/A 1095 0.0 (2.1) 270 0.2 (1.8) N/A 270 0.2 (1.8)
BMI % #2 SD N (%) 88/1095 8% N/A 88/1095 8% 14/270 5.2% N/A 14/270 5.2%
Albumin (g/L) 293 39 (7.0) 88 38 (6.0) 381 38 (7.0) N/A N/A N/A
CRP (mg/L) 495 8.0 (24) 145 7.0 (23) 640 7.0 (24) N/A N/A N/A
Haemoglobin (g/dL) 533 12.6 (2.0) 172 12.4 (2.5) 705 12.6 (2.1) N/A N/A N/A
Length of stay (days) 1202 1.0 (2.0) 432 1.0 (2.0)a 1624 1.0 (2.0) 340 1.0 (2.0) 162 1.0 (1.0) 502 1.0 (2.0)
Length of stay " 1 day N (%) 1022 85% 320 74%a 1342 82% 246 72% 119 73% 365 73%

N/A: not available; TPH: Tertiary Paediatric Hospital; DGH: District General Hospital; IQR: Inter-quartile range.
a
p < 0.001 from screened in the same hospital for ManneWhitney test or chi-squared test where appropriate.

The rate of PYMS completion increased during the first three assessed by dietetic staff (Table 3). A higher proportion was seen by
months in both hospitals but showed a slight decline in the last the ward dietitians in the TPH than in the DGH (TPH: 57% vs. DGH:
month (Fig. 2). The completion rates were slightly higher in the 29%; 0.009). No formal information was collected on why patients
acute receiving wards than in the specialist wards (acute receiving were not assessed. Informal discussion with dietetic and nursing
wards vs. specialist wards: 75% vs. 70%, p ¼ 0.05) in the TPH. staff suggested that this mainly related to patients passing though
the wards at weekends when no dietetic support was available or
3.2. Malnutrition risk exceptionally busy periods. However there were no differences in
demographic characteristics, length of hospital stay, serological
One hundred and fifty eight patients (9% in DGH vs. 10.5% in markers of disease severity (serum albumin, haemoglobin, CRP)
TPH) were scored as at high risk and 147 (10.4% in DGH vs. 9% in between patients who had been reviewed by the dietitians and
TPH) at medium risk of malnutrition. High risk of malnutrition was those who had not. More than 50% of these patients were new cases
more prevalent in the specialist wards compared with the acute to the dietetic service (Table 3).
receiving wards of the TPH (18% in specialist vs. 8.3% in acute The ward dietitians judged 49 (86%) of the patients seen in the
receiving). The majority of the patients at high risk of malnutrition TPH and 8 (89%) of the patients in the DGH to be at true risk of
were scored as at risk on two or more of the steps, with only 27% malnutrition (Table 3). In the TPH both the majority of the new true
scoring at high risk on the basis of a single step of the tool. Seventy cases identified by PYMS as at high risk and all of the patients
three (46%) of those children who scored at high risk of malnutri- judged to be inappropriate referrals, had been admitted to the acute
tion had a normal BMI and 64 (41%) had a low BMI. Of those with receiving medical and surgical wards (Table 3). All of the patients
a low BMI 30 (19% of all high scorers) scored zero on all other steps. admitted to the specialist wards and screened at high risk of
For 21 patients (13%) at high risk of malnutrition anthropometric malnutrition were judged to be at true risk of malnutrition, but the
measurements could not be obtained, so step 1 (i.e. BMI) could not majority of them were already under dietetic care. Of those judged
be computed, but these patients scored high on the basis of others to be at true risk of malnutrition 21% (12/57) did not report recent
steps. weight loss and did not have a low BMI (Step 1; Fig. 1). Of the
patients rated high risk because of decreased dietary intake and/or
due to the effect of the current condition 71% (12/17) were judged
3.3. Yield of PYMS at true risk by the dietitians, but the 5 rated false positives made up
over half of all those judged to be inappropriate referrals.
Screened children at high risk of malnutrition were only
referred to dieticians in months 2e4 of the pilot. Of the 125 patients
scored as high risk (PYMS " 2) during those months, 66 (53%) were 3.4. Impact on dietetic service

Table 2 During the one month audit period there was no increase in the
Number and percent of all admitted patients screened for malnutrition risk in each percentage of total admissions referred to the dietetic service,
specialty at the TPH.

Specialty Number and percent Total admitted

of patients screened patients

N (%) N
General medical 376 (75%) 502
Respiratory 127 (73%) 174
Diabetes and endocrinology 28 (74%) 38
Gastroenterology 57 (90%) 63
Haematology/Oncology 38 (64%) 59
Neurology 41 (64%) 64
Dermatology 15 (79%) 19
General surgical 457 (73%) 627
Plastics/Burns 19 (70%) 27
Ear/Nose/Throat 9 (60%) 15
Others 35 (74%) 47
Fig. 2. Percent of total admitted patients screened for malnutrition with the PYMS
TPH: Tertiary paediatric hospital. during the four month of the pilot.
434 K. Gerasimidis et al. / Clinical Nutrition 30 (2011) 430e435

Table 3 ideal tool identifies the majority of children at risk of malnutrition

Characteristics of patients at high risk of malnutrition who were reviewed by the and does not misclassify those at low risk, assessment of its
clinical dietitians. Values are % (N) unless otherwise specified.
performance in a clinical setting is essential before introducing it
TPH (n ¼ 57) DGH (n ¼ 9) for routine use. In a previous study we have reported the results of
Boys 51% (29) 55% (5) assessing the diagnostic validity of the PYMS, which demonstrated
Age (years) mean (SD) 7.3 (5.1) 7.8 (5.7) its usefulness as a screening tool. It was found to have acceptable
New identified patients 52% (29) 56% (5)
levels of sensitivity and specificity which were better in compar-
Patients at true risk 86% (49) 89% (8)
Acute receiving wards 78% (28) N/A ison with other similar tools.17 This study complements our
Specialist wards 100% (21) N/A previous work and assessed the performance, feasibility, and
New cases at true risk 76% (22) 80% (4) impact on dietetic workload of PYMS in a real life clinical setting.
Acute receiving wards 73% (19) N/A Introducing PYMS in a TPH and DGH over a 4 month pilot phase
Specialist wards 100% (3) N/A
achieved high completion rates, indicative of its feasibility for
N/A: not applicable; TPH: Tertiary paediatric hospital; DGH: District general routine clinical use within the current resources and without
hospital.
necessitating extra staff. An increase in dietetic workload had been
anticipated, but there was no objective evidence from the acute
receiving wards that this was the case. However one ward dietitian,
compared to before PYMS began (Period 1: 15% vs. during last from the acute receiving ward, felt that PYMS had impacted on her
month of PYMS-Period 2: 11%). In fact there were fewer patients workload. Interestingly there has been a decrease in referrals from
referred from the two specialist wards in the TPH during the PYMS the specialist wards, the reasons for which are not clear.
audit period, while there was no difference in the number and PYMS completion rates were good overall, but those most
proportion of patients referred from the acute receiving wards commonly not screened had shorter stays, were younger, and
(Table 4). Before PYMS introduction 66% of the dietetic referrals tended to come from the acute receiving wars. These may be
were made electronically (hospital established dietetic referral associated with the difficulty in applying the anthropometric
pathway) which increased to 87% during PYMS period. Four (5%) of measurements (both weight and height) in infants and some
the referrals in the survey period before PYMS were inappropriate patients in the specialist wards (severe cerebral palsy, long term
compared to 7 (11%) while PYMS was operating, although only 3 of ventilated patients). Also as many of these patients are already
these came through PYMS screening (Table 4). under regular dietetic care, screening for malnutrition risk in these
patients may have been seen by the nurses as less important.
3.5. Dietetic feedback However PYMS completion rates decreased in the last month, as on
site support was withdrawn suggesting that successful imple-
All 6 dietitians completed and returned the PYMS feedback mentation requires ongoing support and supervision.
questionnaire. All agreed that PYMS identified patients at risk of A weakness of this study is that approximately half of the
malnutrition, but two of them felt that PYMS overestimated risk in patients who were screened at high risk of malnutrition were never
some patients. Both of these dietitians were from the acute assessed by the hospital dietitians. Although specific reasons why
receiving wards in the TPH and DGH. All dietitians agreed that these patients were not assessed by the dietitians were not
PYMS identified patients at risk of malnutrition who may not have collected as part of this study it is believed that some of these
otherwise been referred and improved patient care, and only one patients were admitted and discharged during times where dietetic
(the dietitian from the acute medical and surgical wards) felt that it support was not available (night shifts, weekends). Thus if all of
increased dietetic workload significantly. Half felt the general these patients had been referred this implies that the actual dietetic
introduction of PYMS was feasible within current resources. All the workload could have doubled. Considering an average prevalence
dietitians in the TPH found the PYMS action plan appropriate. of malnutrition risk of 9e11% and an admission number of
approximately 100 patients per week in the TPH and 38 in the DGH
4. Discussion this would result in 10 additional patients per week referred to the
dietetic service in the TPH and 3 in the DGH in the pilot wards
Screening for malnutrition risk on hospital admission is rec- alone. Since approximately 50% of these patients are likely to be
ommended as an integral part of patient’s standard care. While an already under dietetic care, this would mean a net increase of 5
patients per week in the four pilot wards of the TPH and by 1.5
patients per week in the DGH. PYMS has now been in routine
Table 4
clinical use in every ward of the TPH and DGH for 2 years with
Number and percentage of dietetic referrals one month before and during the last
one month of the Paediatric Yorkhill Malnutrition Score pilot phase. a compliance of more than 75% and thus far there has been no
major issue regarding a significant increment in workload. Another
Before During last month of p-valuec
PYMS PYMS
limitation of this study is that the performance of the PYMS was not
evaluated in cardiology, renal, orthopaedic specialties and critical
N % N %
care. However the majority of the patients in these specialist wards
Patient admissions 586 559 are already under dietetic care, in line with the clinical manage-
Acute receiving wards 419 433 0.021
Specialist wards 167 126
ment pathways and malnutrition screening may actually have little
Dietetic referrals importance in such settings.
Acute receiving wards 48 11%a 47 11% There is no universally established definition or method to
Specialist wards 39 23%a 14 11% 0.004 determine nutritional status so our pragmatic benchmark was the
Total 87 61
dietitians’ assessment of whether the referral was appropriate. This
(14 through PYMS)
Inappropriate-false positives 4 5%b 7 11% 0.116 ensures that the tool is relevant for clinical use and would thereby
utilise resources appropriately. PYMS appears to be quite specific in
PYMS: Paediatric Yorkhill Malnutrition Score.
a
Of all ward admissions.
identifying patients whom dietitians then judge to be risk of
b
Of all dietetic referrals. malnutrition. However it is possible that there were more false
c
For difference between “Before PYMS” and “During last month of PYMS”. positives cases in the group who were not referred to dietitians at all.
 K. Gerasimidis et al. / Clinical Nutrition 30 (2011) 430e435 435

Although we had asked the nursing staff to refer any patient who Acknowledgements
screened at high risk of malnutrition, it is possible that nurses chose
not to refer patients where they believed them not, in fact, to be at The authors of the study would like to acknowledge the
risk. Similarly we cannot know whether the reduced rate of referrals contribution of Mr Toby Mohammed, Dr Graham Stewart, Ms
in the specialist wards resulted in true cases being missed. As the Christina McGuckin on the development of the PYMS and the
dietitians did not assess patients who scored at low risk of malnu- hospital auxologist Ms Wendy Paterson for providing training to
trition on PYMS, this study cannot evaluate the sensitivity of the the nursing staff. They are particularly grateful to the nursing and
score, but this has been addressed in a linked study which compared dietetic departments at the Royal Hospital for Sick Children, York-
PYMS to a complete research dietetic assessment17 and we showed hill, Glasgow, and the Royal Alexandra Hospital, Paisley. The project
that PYMS identifies 59% of children at risk of malnutrition without was funded by the National Health Service Greater Glasgow &
misclassifying patients’ malnutrition risk (negative predictive value: Clyde, Food Fluid & Nutritional Care Planning Implementation
92% & specificity: 95%). Approximately half of the patients rated as Group, Women and Children Directorate, Glasgow, UK. A small
high risk had a normal BMI z-score, which indicates that although grant was provided generously by the Yorkhill Children Foundation
the use of anthropometric cut offs is important, it does not identify to cover consumable expenses. No conflict of interest to declare.
all patients at risk of future disease associated malnutrition. Indeed
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All authors have made substantial contributions to all of the 13. Secker DJ, Jeejeebhoy KN. Subjective global nutritional assessment for children.
following: (1) the conception and design of the study, or acquisition Am J Clin Nutr 2007;85:1083e9.
14. Sermet-Gaudelus I, Poisson-Salomon AS, Colomb V, Brusset MC, Mosser F,
of data, or analysis and interpretation of data, (2) drafting the article Berrier F, et al. Simple pediatric nutritional risk score to identify children at risk
or revising it critically for important intellectual content, (3) final of malnutrition. Am J Clin Nutr 2000;72:64e70.
approval of the version to be submitted. KG designed the study, 15. McCarthy H, McNulty H, Dixon M, Eaton-Evans MJ. Screening for nutrition risk
in children: the validation of a new tool. J Hum Nutr Diet 2008;21:395e6.
undertook the main research activities, conducted data analysis,
16. Hulst JM, Zwart H, Hop WC, Joosten KF. Dutch national survey to test the
drafted the manuscript; IM contributed to the research activities STRONG(kids) nutritional risk screening tool in hospitalized children. Clin Nutr
and revised the manuscript; AM, EB, PM, IS, MM, CMW, DMF 2009;29:106e11.
17. Gerasimidis K, Keane O, Macleod I, Flynn DM, Wright CM. A four stage eval-
contributed to the study design, coordinated the project and
uation of the Paediatric Yorkhill Malnutrition Score in a tertiary paediatric and
revised the manuscript. district general hospital 2010. Br J Nutr 2010;104:751e6.
18. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition
Conflicts of interest screening 2002. Clin Nutr 2003;22:415e21.
19. NRES. Defining research. National Research Ethics Service, http://www.nres.
npsa.nhs.uk/applications/apply/is-your-project-research/?locale¼en; 2009
None to declare. [accessed 07. 10. 10].