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Women and Children’s Directorate

‘PYMS’Paediatric Yorkhill Malnutrition

Score

© Nutrition Tool Steering Group, Women and Children’s Directorate, NHS Greater Glasgow and Clyde, 2009


Malnutrition

A problem in Africa….

…and in our NHShospitals!


Malnutrition – What’s the problem?

• 25-35% in-patients suffer from malnutrition (Kondrupt et al 2002)

• Malnutrition is a state in which there is an imbalance of energy,protein or other nutrients that leads to detrimental effects ontissue/body function (Elia et al 2005)

• Screening tools detect the under-nutrition of protein/energy(Kondrupt et al 2002)

• Malnutrition estimated to cost £13 billion/year in UK (BAPEN 2009).


Complications of Malnutrition• Increased susceptibility to infections

• Impaired wound healing

• Delayed growth

• Impaired brain development

• Life-long health implications (i.e. bone health)

• Increased mortality/morbidity

• Reduced quality of life

• Increased hospital stay.

(Lucas et al 1998; Correia et al 2003)


Health Care Responsibilities

• Promote and protect health and well-being of patients (NMC 2008)

• The NPSA identify in their “10 key characteristics of goodnutritional care in hospitals” that all patients should be screenedon admission and re-screened weekly for risk of malnutrition(NPSA 2009)

• Hospital Nutrition Policy (specific to local Health Boards)

• Screen all patients for risk of under-nutrition with a validated toolappropriate to the patient population (NHS QIS 2003)


About PYMS…

• Created in Glasgow during 2008, in response to nationalstandards set that identified the importance of screening formalnutrition

• This is a means of identifying children who are at risk ofmalnutrition in order to aid dietetic referral

• ‘PYMS’ designed to detect energy/protein under-nutrition inpatients over 1 year of age

• 5 step process

• Quick and easy to use

• Part of admission and ongoing assessment


The ‘PYMS’ Form


BMI Calculation Wheel

• Alignweight &height

• Red ArrowindicatesBMI.

1. Weight inkilograms (kg) onOUTER wheel.

2. Height/Lengthin centimetres (cm)on INNER wheel

3. BMI valuemarked by redarrow.

Throughout this PowerPoint, commercially available products and services have been referred to which are not under the control of Greater Glasgow HealthBoard. We have no control over the nature, content and availability of those services or products. Reference to these services or products does not necessarilyimply a recommendation or endorsement. Therefore, we cannot be held responsible for any consequence of using said products or services.


Step 1: BMI Score• BMI alters withage and gender

• Don’t round upage

• If unable to obtainheight – weightmust be plotted ongrowth chart.Score 2 if below2nd centile

• Please fill in nursecomments section ifthis is the case•Re-do weight each time, ht/length monthly for

infants and 3 monthly otherwise


Step 2 : Weight Loss

•Recent weight loss may indicate nutritional risk•Look at recent records if available•Under 2’s is there concern about a lack of weight gain


Step 3: Assess recent change indiet/nutritional support

• Decrease intake for more than a week can place thechild at nutritional risk

• Ask about last week’s food intake. If on artificial feedsany change in amount tolerated?


Step 4: AcuteAdmission/Condition Effect

•Risk of being undernourished during hospital admission due to decreased intake, increased gut losses and increased energy requirements


Step 5: PYMS Score andAction Plan

•A score of 2 or more reflects significant nutritional risk•Score 2 = a dietetic review must be made•Score 1 = the child must be on a fluid balance chart and intake carefully observed. Score again in 3 days•Score 0 = Repeat score weekly


‘PYMS’ Exclusions & Summary

• Exclusions:• Patients < 1year old• End stage palliative care

• Local Protocols remain in place

• PYMS should be completed within 24hrs ofadmission

• Dietetic request must have PYMS Score

• Repeat ‘PYMS’ weekly or after 3 days if score 1


Important!• Local Policies and clinical judgement are not replaced by this scoring system

• Medical staff should still be plotting heights and weightson growth charts

• Any additional nutritional concerns should be discussedwith the medical/surgical team

• Requests to dietetics can still be made in the normal wayif scoring 0 (e.g. food allergies, special diets)


What are Sarah and John’s PYMS?• Sarah Athens is a 7 year old asthmatic admitted via A&E

following an acute exacerbation. She has been suffering from acold for the past few days. Her parents do not report any notedweight loss or change in eating habits. Following back to backnebulisers she appears to be much better and is looking forwardto the dinner trolley arriving. Sarah weighs 22.5Kg and is122.5cms tall.

• John McBlack is just 4 years old and has been admittedfollowing an RTA. He has sustained extensive facial trauma,with multiple mandible and facial fractures which are to beexplored and plated/pinned tomorrow in theatre. He weighs15kg and is 109.5cms tall. According to his Mum he is a ‘healthywee boy who eats well and loves football.


References1. Kondrupt J, Allison SP, Elia M, Vellas B and Plauth M.(2003) ESPEN Guidelines for Nutrition Screening 2002. Clinical Nutrition 22 415-421.

2. Elia M, Ljungqvist O and Dowsett J (2005) Principal of Clinical Nutrition: Contrasting the Practice of Nutrition in Health and Disease. Oxford, BlackwellScience Ltd

3. Bapen (2009) Combating Malnutrition Recommendations for Action. Executive summary. Redditch, British Association of Parenteral and Enteral Nutrition(BAPEN) [online] http://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf Accessed 15th July 2009

4. Correia MI and Waitzberg DL. (2003) The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariatemodel analysis. Clinical Nutrition 22 235-9.

5. Lucas A, Morley R and Cole TJ (1998) Randomised trial of early diet in preterm babies and later intelligence quotient. British Medical Journal 317 1481-1487.

6. Nursing and Midwifery Council (NMC) (2008) The Code. Standards of Conduct, Performance and Ethics for Nurses and Midwives. London, Nursing andMidwifery Council.

7. National Patient Safety Agency (NPSA) (2009) 10 Key Characteristics of Good Nutritional Care in Hospitals. [online]http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865. Accessed 20th October 2009

8. NHS Quality Improvement Scotland (QIS) (2003) Food, fluid and nutritional care in hospitals. Edinburgh, NHS QIS

9. Gerasimidis K, Macleod I, McGrogan P, Maclean A, Buchanan E, McAuley M, Stewart G, Wright C and Flynn D (2009) Development and Performance of aNew Paediatric Nutritional Screening Tool in a Tertiary and District General Hospital. The PYMS Project. British Society of Paediatric Gastroenterology,Hepatology and Nutrition (BSPGHAN) winter meeting (Sheffield), oral presentation.

10. Gerasimidis K, Keane O, Macleod I, Buchanan E, Maclean A, McGrogan P, Stewart G, McAuley M, Flynn D and Wright C (2009) Criterion validity andinter-rater reliability of the Paediatric Yorkhill Malnutrition Score. Journal of Pediatric Gastroenterology and Nutrition 48:E1–E149 # 2009 by EuropeanSociety for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutritio. E76.PN 1-10

11. Macleod I, Gerasimidis K, Purcell O, Mohammed T, Swinbank I, Wright C, Flynn D and McAuley M (2009) Implementing a novel paediatric nutritionalscreening tool (Paediatirc Yorkhill Malnutrition Score) in nursing practice. Challenges and impact in paediatric nursing practice. Journal of PediatricGastroenterology and Nutrition 48:E1–E149 # 2009 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North AmericanSociety for Pediatric Gastroenterology, Hepatology, and Nutritio. E149.AHP- 08

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