Hi, Elaine
As you know from a few CRS tickets (
), the Norwegian NRC recently worked on revising nutrition-related translations and discovered some underlying issues. Some of the concepts are on this list, and we welcome this review.
Some terms should be coordinated across the hierarchy:
- Malnutrition/undernutrition
- We suggest adopting the WHO definitions, where “malnutrition” is an umbrella concept for overnutrition, undernutrition and nutritional deficiencies.
- Protein-energy malnutrition / protein-calorie malnutrition / protein-energy undernutrition / protein-calorie undernutrition
- We suggest “protein-energy undernutrition” in the FSNs.
We have submitted a CRS ticket on the term “malnutrition” in general, suggesting a review of all FSNs under 2492009 |Nutritional disorder (disorder)| containing the term “malnutrition” in the narrower meaning of “undernutrition”.
Some input on specific concepts on the list:
238107002 |Deficiency of macronutrients (disorder)|
The meaning of the FSN is clear and it makes an appropriate sibling concept to 238111008 |Deficiency of micronutrients (disorder)|. I am not confident that “Protein-energy undernutrition” and the similar synonyms are truly synonymous, or if “protein-energy undernutrition” should rather be a child concept.
For example, essential fatty acid deficiency (EFAD) could be considered a macronutrient deficiency, but not necessarily a protein-energy undernutrition. However, I note that 238114000 |Essential fatty acid deficiency (disorder)| is a child of 238111008 |Deficiency of micronutrients (disorder)|. Is that correct? The WHO defines micronutrients as “vitamins and minerals needed by the body in very small amounts”.
419261006 |Malnutrition due to child maltreatment (disorder)|
The FSN should be clearer (how old is the patient today?). I also suspect that wording is a little outdated, maybe NRCs using English can provide some more input here. The attribute concept (from 2002) uses “nutritional maltreatment” (213004004 |Nutritional maltreatment of child (event)|), but newer concept use the phrase “nutritional neglect” (231421000119102 |Child victim of nutritional neglect (finding)|, 432262005 |Nutritional neglect of adult (event)|), which sounds more up-to-date.
My suggestion: “Undernutrition of child due to nutritional neglect (disorder)”.
272588001 |Malnutrition (calorie) (disorder)|
The FSN should be reworded without the use of parenthesis, preferably with the term “undernutrition”: “Energy undernutrition” (or “Calorie undernutrition”, depending on editorial choice of “protein-energy” or “protein-calorie”).
238109004 |Marasmic kwashiorkor (disorder)|
This concept should have 29740003 |Nutritional marasmus (disorder)| as a parent in addition to 58262005 |Kwashiorkor (disorder)|, as it is a combination of the two conditions.
58262005 |Kwashiorkor (disorder)|
We believe some of the synonyms are not true synonyms. We agree that the synonym “Protein malnutrition” is inappropriate, and a new concept of “Protein undernutrition” should be created as a child of 238107002 |Deficiency of macronutrients (disorder)| and sibling of 272588001 |Malnutrition (calorie) (disorder)|.
The synonym “Nutritional edema with dyspigmentation of skin AND/OR hair” could be inactivated and replaced by a definition. Different sources include different symptoms in their definition of kwashiorkor, and I suspect it would be difficult to formulate a precise definition. ICD-10 had the code E40 Kwashiorkor with the text “Severe malnutrition with nutritional oedema with dyspigmentation of skin and hair”. In ICD-11, kwashiorkor is an index term under 5B52 Acute malnutrition in infants, children or adolescents, without further explanation.
29740003 |Nutritional marasmus (disorder)|
We believe some of the synonyms are not truly synonymous. Especially, “Severe malnutrition” should be inactivated, and a new concept of “Severe protein-energy undernutrition” could be created as a child of a concept representing “protein-energy undernutrition” (currently a synonym f 238107002 |Deficiency of macronutrients (disorder)|). See below for input on the grading in mild, moderate and severe.
Here is some input on the Gomez concepts and other graded concepts:
Other graded concepts
The CRG should consider if it would be useful to have separate concepts for mild, moderate and severe protein-energy undernutriton, perhaps also concepts for mild, moderate and severe undernutrition. These can then be grouper concepts for concepts representing Gomez gradings and future concepts with other grading scales/methods should that be relevant.
Norwegian national guidelines on prevention and treatment of undernutrition mention moderate and severe undernutrition. The guidelines mention different criteria for coding “moderate undernutrition”, for example: “unintentional weight loss >10% last 3–6 months or >5% last 2 months” or “Scored Patient-Generated Subjective Global Assessment grade B”. This illustrates the need for general grouper concepts of “moderate undernutrition” and “severe undernutrition” without mention of specific criteria or scales. I assume “mild undernutrition” will also be relevant for other countries.
Mild
190603003 |Mild protein-calorie malnutrition (weight for age 75-89 percent of standard) (disorder)| and 77702009 |Malnutrition of mild degree (Gomez: 75 percent to less than 90 percent of standard weight) (disorder)| are very similar. The CRG should consider if there is need for both. They are children of 272588001 |Malnutrition (calorie) (disorder)| but should rather be children of a concept representing protein-energy undernutrition.
There is no separate concept for “mild undernutrition” or “mild protein-energy undernutrition”, but this could be added as parallel to 190606006 |Moderate protein energy malnutrition (disorder)|.
Moderate
190602008 |Moderate protein-calorie malnutrition (weight for age 60-74 percent of standard) (disorder)| sounds like a direct parallel to 77091003 |Malnutrition of moderate degree (Gomez: 60 percent to less than 75 percent of standard weight) (disorder)|. Both are child concepts of 272588001 |Malnutrition (calorie) (disorder)| but should be children of “protein-energy malnutrition”, which is a synonym of 238107002 |Deficiency of macronutrients (disorder)|.
190606006 |Moderate protein energy malnutrition (disorder)| exists as a separate concept, but as a direct child of 238107002 |Deficiency of macronutrients (disorder)|. There is no concept for “moderate undernutrition”.
The CRG should evaluate if there really is a need for all three of these concepts.
Severe
360549009 |Severe protein-calorie malnutrition (Gomez: less than 60 percent of standard weight) (disorder)| has the synonym “Severe protein calorie malnutrition”. That synonym is broader and should be inactivated. “Severe protein-energy undernutrition” should be added as a separate concept.
“Severe malnutrition” is a synonym of 29740003 |Nutritional marasmus (disorder)|, which is a broader concept. “Severe undernutrition” could be added as a separate concept.
The wording of the Gomez concepts
- 77702009 |Malnutrition of mild degree (Gomez: 75 percent to less than 90 percent of standard weight) (disorder)|
- 77091003 |Malnutrition of moderate degree (Gomez: 60 percent to less than 75 percent of standard weight) (disorder)|
- 360549009 |Severe protein-calorie malnutrition (Gomez: less than 60 percent of standard weight) (disorder)|
These FSNs are not consistent (“… of mild degree”, “Severe …”) and include some superfluous information. However, all these should be considered in light of the Editorial Guide section on proprietary names and works: Proprietary Names and Works | Specifications SNOMED CT Editorial Guide | SNOMED International Documents If they are to be included in full, the FSNs should be reworded. I’m not sure what the best solution would be, as disorder concepts with similar use of scales and gradings are formulated quite differently.
The Gomez classification is older and uses the term “malnutrition” to grade undernutrition. As there is no risk of confusion, we have no objection to the use of “malnutrition” here.
I find no section of the Editorial Guide on how to formulate FSNs like these, but we should at least avoid parenthesis with additional information. Maybe something like this could be useful:
- Malnutrition with Gomez classification grade mild
- Malnutrition with Gomez classification grade moderate
- Malnutrition with Gomez classification grade severe
The percentages could then be specified in definitions and not as part of the FSN.