Guidelines for the Nutritional Management of Children With Renal Disease pot

NUTRITIONAL REQUIREMENTS IN CHRONIC RENAL FAILURE Energy kcal/kg/day Protein g/kg/day Predialysis Peritoneal Dialysis Males Females Haemodialysis Males Females... If a vitamin / min

Guidelines for the Nutritional Management of Children With Renal Disease

Dietetics Department Royal Hospital For Sick Children Women & Children’s Directorate

Contents Page Number(s)

1 INTRODUCTION

This guideline has been developed for dietitians and medical staff to assist in the nutritional management of infants and children with renal disease within Yorkhill Division

Specifically these guidelines detail nutritional requirements in:

• Chronic Renal Failure in infants and children

• Acute Renal Failure in infants and children

• Nephrotic Syndrome

• Renal Transplantation

2 NUTRITIONAL REQUIREMENTS IN CHRONIC RENAL FAILURE

Energy (kcal/kg/day) Protein (g/kg/day) Predialysis

Peritoneal Dialysis

Males

Females

Haemodialysis

Males

Females

2.1 Chronic Renal Failure in Infants 0-1.5yrs

Breast milk is the most suitable choice for infants with chronic renal failure However, problems occur in determining the actual amount of feed and therefore fluid consumed

Expressed breast milk can be fortified with energy and may be mixed with another formula if insufficient amounts are available

Farley's First has the lowest potassium and phosphate and should be the preferred choice of formula

Medical staff prescribe the fluid allowance which is based on urine output and insensible losses

The feed should provide the infants protein requirement The concentration of feed may need to be increased if the infant requires a strict fluid restriction The amount of formula may require to be reduced to provide the minimum protein requirement (if urea increases to above 20mmol/l) and energy supplements have been added

to meet requirement

Energy intake should initially be calculated to meet estimated requirement Maxijul / Duocal powders are preferable to liquids

If a vitamin / mineral supplement is required, Renal Paediatric Seravit can be used as it is free from sodium, potassium, calcium and phosphate

Infants with significantly elevated plasma potassium and/or phosphate levels - (phosphate >2mmol/l, potassium

>5.5mmol/l) should be given Kindergen This may only be required for a short duration

Infants who require Kindergen should be prescribed a supplement of Calcium Sandoz to provide a similar calcium intake to that provided from a whey based infant formula This will be reviewed if hypercalcaemia develops

Formula – Analysis per 100mls Energy (kcal) Protein (g) (mmol) Na (mmol) K (mmol) Ca (mmol) P

Casein formula i.e Milumil 68 1.9 1.2 2.5 2.2 1.8

2.1.2 Weaning

Weaning should commence between 4-6 months of age and normal weaning recommendations apply Usually no other dietary restrictions are applied to mixed feeding unless the plasma phosphate is ≥ 2mmol/l, potassium is ≥ 5mmol/l or urea is ≥ 20mmol/l In each individual case recommendations will vary

Rather than change to cow’s milk around the age of 1 year, it is usually best to continue with the infant formula, modifying it to take account of growth and changes in plasma biochemistry

2.2 Children and Adolescents 1.5yrs +

2.2.1 Protein

Protein intake should be adequate to promote growth, however excess dietary protein is harmful If necessary, first class protein foods should be measured using 6g protein exchanges - 2g protein exchanges are not recommended as these foods mainly supply energy Low protein proprietary foods such as bread, pasta and biscuits may be offered but are generally unpopular

The aim is to maintain the plasma urea below 20mmol, however it is important to note that there are other reasons why the plasma urea may be elevated i.e illness, dehydration, inadequate energy intake

2.2.2 Phosphate

Aim for plasma phosphate 1.4 - 1.8mmol/l Phosphate is always restricted in chronic renal failure but will automatically be reduced if protein foods are restricted as meat and dairy products provide the main source of dietary phosphate

<20kg 13-19mmol/day PO4 (400-600mg)

Children

>20kg <26mmol/day PO4 (<800mg)

Restrict cow’s milk to 200mls-300mls/day Loprofin and Snopro are low phosphate milk substitutes are available on prescription and can be used Alternatively a mixture of 50% Calogen and water can be used and may be preferred if a high energy intake is required Cheese and other dairy products should be restricted Fortijuice, Fortisip and Paediasure are suitable low phosphate supplements

Phosphate binders may be prescribed if plasma phosphate concentrations remain persistently high in spite of dietary phosphate restriction

Phosphate Binders

• Calcium Acetate - Phosex

• Non-calcium binder - Sevelamer

• Calcium carbonate

2.2.3 Potassium

Aim for plasma potassium 3.0 - 5.0mmol/l

Reasons for high plasma potassium

1 Excessive intake of high potassium-content food

2 Inadequate energy intake – catabolism

3 Infection

4 Constipation

5 Secondary to antihypertensive drugs e.g Captopril

6 Secondary to immune suppressants e.g Cycolsporin, Tacrolimus

Foods commonly eaten which are rich sources of potassium include

• Chips

• Fruits and vegetable

• Potato crisps

• Chocolate

• Fresh fruit juices

2.2.4 Vitamins / Minerals

Fat soluble vitamins are not usually prescribed as Vitamin A levels may be elevated in renal disease and toxicity can occur, however vitamin D is required in its active form Vitamin D is normally activated in the kidney and is prescribed by medical staff as 1 alpha cholecalciferol or 1.25 dihydroxycholecalciferol Water soluble vitamins are prescribed if necessary, either when the diet is poor or restricted in potassium, or if the child receives dialysis when these vitamins are given routinely - usually 3 x ketovite tablets are given daily

2.2.5 Enteral Feeds

A range of enteral feeds can be used – see “Formula used in Renal Disease” Normal enteral feeds may be considered if blood biochemistry and fluid allows, but protein, phosphate and potassium should be individually assess prior to use The amount of fluid allowed will generally be prescribed by the medical staff Often this is fairly restricted, but feeds containing 2 – 2.5kcal/ml can be well tolerated Current feed intake, plasma,

biochemistry and social factors should be considered when determining which feed to prescribe and be

discussed with the Renal Team

Refer to Formulae & Feeds used in Renal Conditions

2.3 Dialysis

Haemodialysis and Automated Peritoneal Dialysis (APD) are used Peritoneal Dialysis is usually preferred, particularly in the infant and young child

Haemodialysis

Usually sessions of 3-6 hours x 3 times/week

Sessions usually take place overnight Protein is usually lost in the dialysate effluent so more generous intakes can be given However, care should be taken with energy intake as glucose is absorbed from the dialysis fluid and could contribute significantly to intake

Fluid allowances are usually more generous as excess fluid can be removed by using a more concentrated dialysate

Vitamins and minerals are lost in the dialysate but only water soluble vitamins are prescribed - Ketovite tablets

x 3 daily However, these are usually not necessary when feeds such as Nepro and/or Suplena are used, as these are fortified with high levels of water soluble vitamins

2.4 Electrolyte Supplements

Calcium Calcium Sandoz Syrup - 1.85mmol Ca/ml

*Calcium should not be added to a feed with phosphate supplements as precipitation will occur

Sodium Sodium Bicarbonate 8.4% - 1mmol sodium/ml (frequently used to correct acidosis but

will also provide sodium)

Sodium Chloride 30% - 5.0mmol sodium/ml Sodium Chloride 15% - 2.5mmol sodium/ml Potassium Kay Cee L (potassium chloride – 1mmol potassium/ml)

In RHSC and QMH, electrolytes are no longer added to feeds in the Feeds Unit These should be prescribed on the Drug Kardex and added to feeds at ward level

3 ACUTE RENAL FAILURE

The aim of dietary treatment is:-

1 To provide adequate protein and energy where possible

2 Control of dietary potassium

3 Control of dietary sodium

4 Control of dietary phosphate

5 To tailor fluid intake to maintain fluid balance

Acute peritoneal dialysis (PD) is the preferred choice for infants but if complications occur with PD, then haemodialysis may be necessary In patients with multi-organ failure, haemofiltration is used

Protein kcal/kg/ideal body weight Energy kcal/kg/ideal body weight Conservative Management

3.1 Infants 0-1.5yrs

Farley's First has the lowest potassium and phosphate and should be the preferred choice of formula if the mother is not breastfeeding Expressed breast milk should be used wherever possible Additional energy will usually be required in the feed Fluid allowance will be prescribed by the medical staff and is reviewed daily Kindergen should be used if hyperkalaemia, hypercalcaemia or hyperphosphataemia are present

3.2 Children and Adolescents 1.5yrs +

Complete nutritional supplements should be offered, preferably those with a low phosphate and potassium and

at least 1kcal/ml, i.e Paediasure, Fortijuice, Fortisip These will be included in the prescribed fluid allowance Energy supplements i.e Maxijul, can be added to drinks Advice should be given to encourage a high energy diet

Potassium/sodium/phosphate restrictions should be advised depending on the individual case

3.2.1 Enteral Feeding

Enteral feeding is usually required and the prescribed feed should be low in potassium and provide protein and energy with an aim to meet requirement

The choice of feed will depend on age and weight of child, fluid allowance, plasma biochemistry and presence

of vomiting or diarrhoea

Feeds should be introduced continuously via feeding pump, either overnight or over a 24 hour period

3.2.2 Vitamins & Minerals

Vitamins and minerals are only prescribed if the recovery phase is of long duration

Dietary restrictions are discontinued when plasma biochemistry returns to normal For a few children energy supplementation may require to be continued for a short period

4 NEPHROTIC SYNDROME

A dietary assessment indicating protein, energy and sodium intake is required Patients with this condition have heavy proteinuria, low plasma albumin and fluid retention A well balanced "healthy" diet containing the

recommended dietary reference value for protein is recommended with a "no added salt" regimen If the child's appetite remains poor, a complete nutritional and energy supplement is necessary Any liquid supplements are included in the prescribed fluid allowance

Prescribed steroids can cause a huge increase in appetite so the 'steroids and your diet' leaflet should be given

Most patients have elevated cholesterol and triglyceride levels

General healthy eating advice with the inclusion of mono and/or polyunsaturated dietary fats should be advised

4.1 Initial Dietary Management

• Dietary assessment indicating protein, energy and sodium intake is required

• A well balanced ‘healthy diet’ containing the dietary reference value for protein is recommended

• ‘No added salt’ restriction

• Fluid restriction as prescribed by medical staff

Note: Neither high protein or low protein diets are recommended for nephrotic syndrome If the child’s appetite

remains poor, complete nutritional supplements may be recommended until appetite returns

4.2 Ongoing Management

• Prescribed corticosteroids can cause a huge increase in appetite with subsequent weight gain

Cholesterol and triglyceride levels may be elevated

• Healthy eating advice with mono/polyunsaturated fat as an alternative to saturated fat in the diet should be advised

Weight reducing advice may be necessary

5 RENAL TRANSPLANTATION

5.1 Initial Management

Children who experience acute tubular necrosis following renal transplantation may require conservative management or dialysis These children should therefore be treated according to this protocol

Children who have been tube fed prior to transplant should have their tube feeds ceased wherever possible after a successful renal transplant, to encourage appetite

However, children who have been exclusively tube fed from an early age may not undergo the transition from tube to oral feeding easily These children should be offered as much support as possible to encourage eating, i.e speech therapy, psychology

Plasma levels of phosphate, magnesium and potassium often fall below ideal levels in the initial stages after successful renal transplantation Supplements tend to be given to correct this, however dietary advice is sometimes requested When advice is given it is important to encourage foods and drinks which conform to healthy eating guidelines, e.g to increase phosphate, encourage semi-skimmed milk and diet yoghurts rather

5.2 General Management

1 Steroid therapy and adequate renal function lead to a renewed appetite and often excessive weight gain Transplanted children are also at greater risk of developing coronary heart disease in later life Healthy eating principles should be discussed prior to discharge or during early outpatient consultation

2 Children with renal transplants require immunosuppressive therapy and advice should therefore be given to

take care with food hygiene and avoid foods which carry a high risk of food poisoning (Bug Busting Guide)

3 For children who have problems with hypertension, a ‘no added salt’ diet can be incorporated as part of healthy eating advice

4 An adequate calcium intake should be encouraged, as these children will require long term steroid therapy

5 Children are required to consume large amounts of fluids after transplantation This can prove difficult for children who have previously been fluid restricted

Children should be encouraged to have suitable drinks to promote dental health and to avoid excessive weight gain, i.e water, semi-skimmed milk, sugar free juice, fruit juice are preferential to sweetened fizzy drinks and whole milk

6 Future Guideline Development

Should any aspect of this guideline change before the next planned review in October 2008, then the guideline should be updated accordingly

7 References:

1 National Kidney Foundation – Dialysis Outcome Quality Initiatives (NKF – DOQI)

2 Clinical Paediatric Dietetics 2nd Edition – The Kidney, page 158 – 182