Comprehensive Child and Adolescent Nursing

ISSN: 2469-4193 (Print) 2469-4207 (Online) Journal homepage: http://www.tandfonline.com/loi/icpn21

The Pediatric Yorkhill Malnutrition Score Is a

Reliable Malnutrition Screening Tool

Nur Eni Lestari, Nani Nurhaeni & Dessie Wanda

To cite this article: Nur Eni Lestari, Nani Nurhaeni & Dessie Wanda (2017) The Pediatric Yorkhill
Malnutrition Score Is a Reliable Malnutrition Screening Tool, Comprehensive Child and Adolescent
Nursing, 40:sup1, 62-68, DOI: 10.1080/24694193.2017.1386972

To link to this article: https://doi.org/10.1080/24694193.2017.1386972

Published online: 22 Nov 2017.

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COMPREHENSIVE CHILD AND ADOLESCENT NURSING
2017, VOL. 40, NO. S1, 62–68
https://doi.org/10.1080/24694193.2017.1386972

The Pediatric Yorkhill Malnutrition Score Is a Reliable

Malnutrition Screening Tool
Nur Eni Lestari, Nani Nurhaeni, and Dessie Wanda
Faculty of Nursing, Universitas Indonesia, Jalan Bahder Djohan Campus, Depok, Indonesia

ABSTRACT KEYWORDS
Children often experience malnutrition while they are hospita- Malnutrition; screening;
Pediatric Yorkhill
lized. Therefore, the prevention of malnutrition and nutritional Malnutrition Score; PYMS
management need to be done properly using malnutrition
screening tools. This study aimed to determine the sensitivity
and specificity of the Pediatric Yorkhill Malnutrition Score
(PYMS) and the Screening Tool for the Risk of Impaired
Nutritional Status and Growth (STRONGkids) when compared
to the Subjective Global Nutritional Assessment for Children
(SGNA). This study involved 81 pediatric patients with ages
ranging from 1 to 16 years old. The two screening tools and
the SGNA were examined in each subject. The results of this
study determined that the sensitivity and specificity of the
PYMS were 95.7% and 66.7%, respectively, while in the
STRONGkids they were 52.2% and 41.7%, respectively. This
indicates that the PYMS is the most appropriate malnutrition
screening tool to be used for a malnutrition screening policy.

Introduction
Malnutrition, especially nutritional deficiency, occurs commonly in hospita-
lized patients, especially pediatric patients. A lack of nutrients can have a
significant impact on the physical, social and economic status of a patient.
Malnutrition can increase mortality, disability, the length of the hospital stay,
and health care costs. It can also affect a patient’s quality of life. Therefore, a
patient’s nutrition status is very important, and should be identified as soon
as the patient is admitted into the ward so that appropriate action can be
taken to improve the patient’s prognosis (Mahdavi, Ostadrahimi, & Safaiyan,
2010; Rocha, Rocha, & Martins, 2006).
An inadequate nutritional status can cause negative impacts affecting the
health and development of a child. Childhood malnutrition is a pathological
condition associated with immune system susceptibility, an increased risk of
infection, postoperative complications, wound healing disorders, and
increased morbidity and mortality (Mehta et al., 2013). The worldwide
malnutrition rate is approximately one-third of the 8.8 million deaths per

CONTACT Dessie Wanda dessie@ui.ac.id Faculty of Nursing, Universitas Indonesia, Jalan Bahder Djohan
Campus, Depok,16424, Indonesia
© 2017 Taylor & Francis
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 63

year (Nhampossa et al., 2013). In Indonesia, the prevalence of malnutrition

among children under 5 years of age is 5.7%, or about 1.3 million per year
(Kemenkes, 2013). Globally, the number of malnourished children who are
hospitalized is between 19% and 45.6% per year, with a rate of 20–50% per
year in Indonesia (Hulst, Zwart, Hop., & Joosten, 2010; Sarni, Carvalho,
Albuquerque, Monte, & Sousa, 2009).
While they are hospitalized, children may experience malnutrition, so
early detection is important, not only for those patients who are already
malnourished, but also for those patients at risk of malnutrition. The early
detection of malnutrition is very important because it can prevent children
from suffering from malnutrition while they are hospitalized (Hartman,
Shamir, & Hecht, 2012). A malnutrition screening tool can show the current
nutritional status, and specifically, help identify the nutritional care that the
patient needs. It can also be useful in detecting changes in a child’s nutri-
tional status while they are hospitalized (Mahdavi, Ostadrahimi, & Safaiyan,
2010). Proper nutritional management can improve the body’s resistance and
reduce the risk of complications, making an early assessment of the nutri-
tional status and monitoring the nutritional changes all the more important
(Marginean, Pitea, Voidazan, & Marginean, 2014).
Nutritional screening can identify those patients at risk of malnutrition, those
not at risk, and those with special conditions. These special conditions can include
metabolic abnormalities, hemodialysis, geriatrics, chemotherapy or radiation,
burn injuries, immunodeficiency, and critical illness. An accurate nutritional
screening can result in an accurate nutritional intervention to prevent malnutri-
tion in the hospital, thus accelerating the healing process. The European Society
for Parenteral and Enteral Nutrition (ESPEN) recommends that screening should
be done in the initial 24 hours of admission in order to identify those patients at
risk for malnutrition (Hulst et al., 2010; Sarni et al., 2009).
The Subjective Global Nutritional Assessment for Children (SGNA) is a
customized tool for assessing the nutritional status of children and identify-
ing those who are at a high risk of malnutrition and prolonged hospitaliza-
tion. However, the SGNA can take a long time and is very complex (Lochs
et al., 2006; Secker & Jeejeebhoy, 2007); therefore, a short and accurate
malnutrition screening tool is required.
In adult patients, several malnutrition screening tools have been validated
in the hospital setting. However, appropriate pediatric malnutrition screen-
ing tools remain scarce, with no agreement on the best malnutrition screen-
ing tool to assess the risk of malnutrition in children (Hulst et al., 2010).
Despite the recommendations of several studies conducted to identify the
risks of malnutrition in pediatric patients, there is still a lack of a simple and
validated screening tool. Malnutrition screening tools for children must meet
the following qualifications: simple, fast, accurate, good sensitivity, and good
specificity (Hartman et al., 2012; White et al., 2014).
64 N. E. LESTARI ET AL.

The Pediatric Yorkhill Malnutrition Score (PYMS) was developed and is

used at the Royal Hospital for Sick Children at Yorkhill in Glasgow. This
screening tool was based on the European Society for Clinical Nutrition and
Metabolism nutritional screening guidelines. The PYMS has four parameters
that can assess and predict the symptoms of malnutrition: (1) The body mass
index, (2) history of unintentional weight loss over a short period of time, (3)
changes in food intake, and (4) the predictive effect of the disease diagnosis
on the nutritional status. Each parameter is scored separately and the total
score of all of the parameters shows the child’s malnutrition risk level
(Gerasimidis et al., 2010).
There was one previous study that described the PYMS, the Screening
Tool for the Risk of Impaired Nutritional Status and Growth (STRONGkids)
and the Screening Tool for the Assessment of Malnutrition in Pediatrics
(STAMP). The sensitivity and specificity of the PYMS were 95.32% and
76.92%, while they were 100% and 7.7% for the STRONGkids and 100%
and 11.54% for the STAMP. Therefore, the PYMS is the most appropriate
and reliable nutritional screening tool (Wonoputri, Julistio, & Rosalina,
2014). A similar study described the PYMS as a practical screening tool
that only takes a short time to detect the nutritional status of children
(Gerasimidis et al., 2012). In line with this, another study stated that the
PYMS was feasible for use as an efficient malnutrition screening tool for
children (Gerasimidis et al., 2011).
Based on observations during clinical practice in an infectious diseases
ward, most nurses have performed malnutrition screenings for hospitalized
pediatric patients by using screening tools adapted from the STRONGkids.
However, there are some STRONGkids screening results that do not match
the nutritional conditions of the patients. Another study has explained that
the PYMS has better sensitivity and specificity (Wonoputri et al., 2014).
Based on the abovementioned background information, this study aimed to
explore the extent of the sensitivity and specificity of the PYMS.

Methods
This study was conducted in March and April of 2017 at the pediatric
inpatient ward of the top referral hospital in Indonesia. The inclusion criteria
for this research were children aged 1–16 years old who were undergoing
treatment in the pediatric ward (building A, floor 1, zone A) and who were
newly admitted patients in their initial 24 hours. The demographic charac-
teristics of the children included their sex, age, weight, and height or body
length. The data were collected by the researcher.
The two malnutrition screening tools (PYMS and STRONGkids) and the
SGNA were performed with each subject as the gold standard benchmark.
The PYMS and STRONGkids each consist of 4 parameters that are scored
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 65

separately, with the total score divided into 3 categories: low, medium, and
high malnutrition risks. The SGNA assessment has 3 categories: good nutri-
tion, moderate nutrition, and poor nutrition. A statistical analysis was used
to determine the sensitivity and specificity by using crosstabs. A total of 81
patients participated, and the study was approved by the ethics committee of
the Faculty of Nursing of the Universitas Indonesia and hospital.

Results
The characteristics identified included the gender and age of each subject,
with a higher number of male participants (64.2%). With regard to age, 63%
(n = 51) of the children were between 1 and 5 years old. The weight based on
age was determined by using the World Health Organization (WHO)
z-scores chart, and ranged from 0 to –2 standard deviations (SD), while the
height based on age ranged from –2 SD to –3 SD. Most of the children had a
high risk of malnutrition based on all three measurement instruments
(PYMS, STRONGkids, and SGNA), with scores of 86.4%, 53.1%, and
85.2%, respectively.
The sensitivity and specificity test results of the PYMS and STRONGkids
compared to the SGNA can be seen in Table 1. It describes the greater
sensitivity and specificity of the PYMS screening tool (95.7% and 66.7%,
respectively) when compared to the STRONGkids. In addition to the sensi-
tivity and specificity testing, the feasibility of using the PYMS screening tool
was assessed with three nurses in the children’s infectious diseases ward of
the hospital. The highest educational degrees of these three nurses were
associate’s degree with 1 year and 3 years of experience working in the
pediatric ward. Two of the nurses said that the PYMS screening tool was
more difficult because calculations were required for the BMI parameter.
When the nurses used the STRONGkids, they found it easier since there were
no calculations. One nurse said that the PYMS was a practical malnutrition
screening tool that could be applied in the children’s infectious diseases ward.
All three of the nurses said that the PYMS screening tool added a little to
their workloads.

Table 1. Sensitivity and specificity of the Pediatric Yorkhill Malnutrition Score (PYMS) and the
Screening Tool for the Risk of Impaired Nutritional Status and Growth (STRONGkids) measuring
instruments compared to the Subjective Global Nutritional Assessment for Children (SGNA) in the
children’s infectious diseases ward of the top referral hospital in Indonesia from March through
April of 2017 (n = 81).
Measurement tool Sensitivity (%) Specificity (%)
PYMS 95.7 66.7
STRONGkids 52.2 41.7
66 N. E. LESTARI ET AL.

Discussion
The characteristics of the participants in this study included the gender, age,
body weight, and height. According to one previous study, male children are
at a greater risk of morbidity and mortality since one of the characteristics of
boys is that they are more aggressive (Hockenberry & Wilson, 2009).
Children under 5 years old are more susceptible to infections than older
children, which is in line with one study reporting that children who are
hospitalized due to infection are most often under 5 years of age. This is
because they have more vulnerable immune systems than older children
(Schaible & Kaufmann, 2007).
This study determined that the PYMS had higher sensitivity and speci-
ficity values than the STRONGkids, which is supported by one previous
PYMS study reporting a sensitivity level of 95.32% and a specificity level of
76.92%. Therefore, the PYMS is the most appropriate and reliable malnu-
trition screening tool (Wonoputri et al., 2014). One study conducted in the
UK also reported that the PYMS had a higher specificity value than the
other screening tools, and that it was an acceptable screening tool for
identifying those pediatric patients at risk of malnutrition (Gerasimidis
et al., 2010).
The malnutrition screening tool should include four key principles based
on the ESPEN: recent history of the nutritional status, history of uninten-
tional weight loss over a short period of time, decreased food intake, and the
predictive effect of the disease diagnosis on the nutritional status (Kondrup,
Allison, Elia, Vellas, & Plauth, 2003; Wonoputri et al., 2014). The PYMS
consists of four parameters: BMI, history of unintentional weight loss over a
short period of time, history of food intake over the past week, and predictive
effect of the disease diagnosis on the nutritional status. While the
STRONGkids parameter is a subjective assessment of whether the patient
appears lean, the history of weight loss over the past month, the history of
decreased food intake, and the predictive effect of the disease diagnosis on
the nutritional status are not. The PYMS and STRONGkids have the four
main principles according to the ESPEN; however, in the history of the
nutritional status, the PYMS results are more accurate because they are
based on the calculation of the BMI, whereas the STRONGkids is only
based on one person’s subjective judgment.
Another study described the PYMS as an efficient malnutrition screening
tool for children (Gerasimidis et al., 2011). An assessment of the nutritional
status of children is very important and should be done precisely to deter-
mine the follow-up in the nutritional management during a child’s period of
hospitalization. If the child’s nutritional status is poor, it will affect the length
of the hospital stay and health care costs, which may worsen the condition
(Marginean et al., 2014).
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 67

One PYMS study was designed to obtain feedback from the nurses in a
clinical setting, and involved 160 nurses in the intensive care unit. The
questionnaires were distributed to and filled in by the nurses in order to
collect information and explore the nurses’ feedback and perceived impact of
using the PYMS screening tool. The conclusion of that study was that the
PYMS was a practical screening tool requiring only a short time to detect the
nutritional status of children (Gerasimidis et al., 2012).
The PYMS can be applied more practically and specifically when screening
for malnutrition. If the malnutrition screening is performed correctly, then
proper nutritional management can improve the quality of the nursing care.
The PYMS only requires a short amount of time and has a more accurate
value, so it can be applied in the ward. One limitation of the PYMS’s
feasibility is the ward nurses’ already high workload. Students must find
time to invite the nurses to perform malnutrition screening using a new
PYMS format. Therefore, this researcher could only invite three nurses and
ask their opinions on the application of the PYMS. The nurses felt that the
PYMS was more difficult because of the BMI calculation, but the researcher
did create a BMI table to facilitate the calculation of the BMI.

Conclusion
The sensitivity and specificity values of the PYMS were higher when com-
pared to the STRONGkids (95.7% and 66.7%, respectively). The results of
this study suggest that the PYMS can be considered as a new screening tool,
and can be used for the standard operating procedures in hospitals perform-
ing malnutrition screenings for children.

Acknowledgments
The researchers to thank the study subjects and their parents, and the clinical supervisor and
the head of the children’s infectious diseases ward of the top referral hospital in Indonesia.

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