477 tency” which is defined as “being positive, com fortable, and flexible with eating, as well as matter of fact and reliable about getting enough to eat of enjoyable and nourishing food” [146] Depen[.]
26 Nutritional Assessment and Prescription for Children Receiving Maintenance Dialysis tency” which is defined as “being positive, comfortable, and flexible with eating, as well as matter-of-fact and reliable about getting enough to eat of enjoyable and nourishing food” [146] Dependence on supportive gastrostomy feedings and altered taste perceptions, together with diet and fluid restrictions, prevents children from gaining independence and eating competency in the same way that their healthy peers Members of the healthcare team (e.g., dietitian, social worker, psychologist) can support the child with special feeding needs by collaborating closely with schools to develop and provide consistent supportive strategies [145] Adolescents and Young Adults The adolescent poses unique challenges for the clinician Energy needs may decline once the pubertal growth spurt occurs and growth is completed Emerging independence and psychosocial challenges are major considerations for this population Adolescence is a time of growth driven primarily by the sex hormones, as opposed to nutrition as seen in early childhood High calorie needs, especially in teen males or athletes, increase the risk of inadequate calorie intake or protein energy wasting (PEW) [147] Puberty is often delayed in children with CKD, and linear growth may be delayed compared to healthy children [148] Adequate nutrition is essential for achieving full height potential [148] Overweight and obesity are prevalent in children and adolescents with CKD [149] Those consuming an oral diet, especially one high in processed and fast foods, are likely to take in excess calories, fat, and sugar [92] Tube feeding and enteral supplements are not commonly used in adolescents When the growth spurt ends and needs are decreased, teens may not transition from the high-energy diet to which they are accustomed resulting in unwanted weight gain from excess calories The latter is especially prevalent in females for whom this growth ends sooner [3, 148] 477 The social dynamics of adolescents are also an important consideration Teenagers, more than children in any other age group, prefer to spend time with peers in social situations involving food More school and social activities are enjoyed away from home, increasing the possibility of nonideal food consumption [150] To complicate matters, children with CKD have, on average, lower IQs than healthy peers and demonstrate poorer executive functioning and higher impulsivity Decision-making skills, including those regarding health, are often impaired [151] Even in healthy individuals, development of the brain’s frontal lobe, the center that controls cognitive skills like problem-solving and judgment, is not complete until approximately 25 years of age This has important implications and may lead to increased risks as a result of poor decision-making in this population [152] Nonetheless, adolescents often resent juvenilization and will reject patronizing discussions pertaining to medical or nutritional needs The healthcare professional must find new ways to first present and then reinforce information frequently to optimize learning while at the same time maintaining the independence and individuality of the teenage patient Nutrition Considerations for Preparation of Transfer to Adult- Focused Facilities The newly transferred young adult may feel as though they have limited support after moving from the pediatric unit where high clinician-to- patient ratios are common In view of this, the pediatric dialysis team has an obligation to appropriately prepare the pediatric patient for the transition and transfer process [153] Acquiring and demonstrating nutrition knowledge and skills is an integral aspect of the transition process Patients must understand how dietary intake affects health and health risks Some of the many skills that patients need for successful transfer are understanding the importance of nutrition- related medications, such as phosphorus binders and vitamin supplements; having the ability to manage and track intake of fluids and other nutrients such as sodium, phosphorus, and potassium; C L Nelms et al 478 Table 26.8 Nutritional challenges and priorities by age group Infants and young children Adequate intake and growth Establishing healthy eating behaviors Gastrointestinal issues (reflux, delayed gastric emptying) Special nutrition needs associated with prematurity and catch-up growth Weaning from breast milk, tolerating formulas, and enteral feeds Progression of oral diet and physiologic skill development School-aged children Picky eating Establishing healthy eating behaviors Early participation in self-care School issues including school lunch Promoting oral diet Balancing oral intake with dependence on supplemental tube feeding Adolescents and young adults Increasing independence Maintaining healthy eating behaviors Prioritization of social needs over healthcare needs Developmental disabilities affecting ability to provide self-care Multiple approaches for nutrition education Transition to adult care Parental barriers (multiple caregivers, complex feeding plans) Polyuria, salt wasting, potassium retention References [3, 16, 61, 93, 124–153] and being able to demonstrate appropriate food choices, decision-making in meal planning, restaurant choices, and navigating meals with friends Skill demonstration may involve food preparation, verbalizing plans for obtaining and scheduling nutrition-related medications, and menu planning [153–155] (Table 26.8) Special Considerations Prematurity ESKD in the NICU remains relatively rare [156] However, renal conditions diagnosed in utero or in the NICU often progress quickly to ESKD. Renal- specific diet principles need to be layered upon the fundamental nutrition needs of prematurity when the premature infant receives chronic dialysis [156, 157] In general, nutrient needs are higher for premature compared to term infants and nutrition goals focused on providing nutrients in quantities that meet the needs based on the infant’s gestational age The use of concentrated feeds and fluid restrictions may be required to address respiratory needs; semi-elemental and elemental formulas along with TPN may be prescribed to address higher caloric and protein needs when gut injury occurs Calcium and phosphorus content of standard infant formulas may not meet the needs of the premature infant, and low serum phosphorus and high alkaline phosphatase levels can be associated with the development of osteopenia [156] Nutrition care of the newborn with ESKD should address sodium and fluid levels, as well as BUN [158] Term and premature infants undergo a 10–20% loss of extracellular fluid immediately after birth, which is accompanied by sodium loss In premature infants, sodium losses may be greater and more prolonged With renal failure, sodium supplementation needs may be higher, especially if the renal tubules are affected Maintenance fluids are approximately 100 ml/kg/ day, with additional requirements as caloric intake increases Fluid restriction, necessitating concentration of formula and TPN, is indicated for infants who are oliguric or anuric (60–80 ml/ kg/day), while fluid needs may be increased for the infant with polyuria (up to 200 ml/kg/day) In case of hyponatremia, fluid restriction or sodium supplementation is indicated and can be achieved through TPN alterations or supplemental sodium chloride added to formula Hyperkalemia is common and its content in formula or TPN should be adjusted Interpretation of BUN levels should consider hydration status, amino acid oxidation, renal function, energy intake, and degree of illness [158] In the absence of adequate guidelines for the needs of the preterm infant with CKD, the nutrition plan should provide adequate protein for age and degree of renal function, with careful monitoring of intake [159] 26 Nutritional Assessment and Prescription for Children Receiving Maintenance Dialysis Accommodation must be made for the physiologic higher serum phosphorus range in infants However, if hyperphosphatemia occurs and persists, the use of lower phosphorus formula or breast milk may be indicated Liquid calcium carbonate can also be added to formula to bind phosphorus If serum phosphorus levels decrease when dialysis is initiated, a reduction of calcium carbonate as a binder or the addition of supplemental phosphorus may be required [156] Protein Energy Wasting/Uremic Failure to Thrive PEW is defined by the International Society of Renal Nutrition and Metabolism (ISRNM) as “the loss of body protein mass and fuel reserves” The diagnosis of PEW in adults requires the presence of three criteria: reduced muscle mass, reduced body mass with reduced intake, and depressed albumin, transthyretin, or cholesterol PEW is also highly associated with inflammation [160] PEW in pediatrics, also termed uremic failure to thrive, alludes to the complexity that growth adds to underlying malnutrition in this population [161] The link between inflammation and malnutrition has not been well defined in the pediatric population [162] The only pediatric data on PEW comes from the pediatric CKD population [163] Using a modified definition, which included poor linear growth, 7–20% of children with CKD exhibited PEW. As CKD progresses to dialysis, appetite decreases, weight loss is common, and uremia increases; it is in turn likely that PEW is more common in the dialysis population than in children with CKD [164, 165] PEW creates a hormonal milieu in which the body is unable to utilize adipose stores and instead breaks down lean mass [166] Mak [166] notes that relative obesity may result from an overly aggressive nutrition plan that ultimately does not reverse the abnormalities in body composition Even when they are not meeting the true definition of PEW, children who are overweight or obese may present with a PEW-like picture [166] The greater the number of diagnostic criteria for PEW met, the greater is the risk of malnutri- 479 tion Two of the three biochemical markers used to identify PEW in adults, reduced transthyretin and cholesterol levels, have not be seen in pediatric CKD [163] It is unknown if children on dialysis have altered levels of the biochemical markers associated with PEW. In addition to adult biochemical values, an elevated CRP is included in pediatric diagnostic criteria Reduced body mass is defined as