NKF KDOQI GUIDELINES
Malnutrition, growth delay, and nutrition-related metabolic abnormalities are common in children with CKD and are associated with a greater risk of morbidity and mortality. Numerous studies of infants and young children have documented energy intakes less than 80% of recommendations9,151,152 with reversal of both weight loss and poor growth when nutritional therapy is provided to meet recommendations. Although other factors are involved, nutritional care and therapy are essential to prevent or correct these disturbances and are vital components of the multidisciplinary management of children with CKD. Individualized nutrition care plans require frequent modification according to changes in the child's age, development, residual kidney function, and mode of kidney replacement therapy.
3.1 Nutrition counseling, based on an individualized assessment and plan of care, should be considered for children with CKD stages 2 to 5 and 5D and their caregivers. (B)
3.2 Nutritional intervention that is individualized according to results of the nutritional assessment and with consideration of the child's age, development, food preferences, cultural beliefs, and psychosocial status should be considered for children with CKD stages 2 to 5 and 5D. (B)
3.3 Frequent reevaluation and modification of the nutrition plan of care is suggested for children with CKD stages 2 to 5 and 5D. (C) More frequent review is indicated for infants and children with advanced stages of CKD, relevant comorbidities influencing growth or nutrient intake, evidence of inadequate intake or malnutrition, or if acute illness or adverse events occur that may negatively impact on nutritional status. (C)
3.4 Nutritional management, coordinated by a dietitian who ideally has expertise in pediatric and renal nutrition, is suggested for children with CKD stages 2 to 5 and 5D. (C) It is suggested that nutritional management be a collaborative effort involving the child, caregiver, dietitian, and other members of the multidisciplinary pediatric nephrology team (ie, nurses, social workers, therapists, and nephrologists). (C)
3.1: Nutrition counseling based on an individualized assessment and plan of care should be considered for children with CKD stages 2 to 5 and 5D and their caregivers. (B)
Children with CKD frequently have poor appetites and require modification of dietary nutrient intake to maintain optimal nutrition, growth, and development. Studies have shown that the caloric intake of infants and young children with CKD is frequently less than 80% of recommended intake,9,151,152 and that low intakes and decreased rates of weight gain and growth may occur early in those with CKD and worsen with increasing severity of CKD.9,28,153 Correction of nutritional deficits through enhanced nutrition in the form of oral supplements and/or tube feeding achieves catch-up weight gain for all and catch-up linear growth for infants and young children.17,18,111,150,154-156 Alterations to fluid or dietary intake of protein, carbohydrate and/or fat, phosphorus, sodium, potassium, or calcium may be required. Vitamin, mineral, or trace element supplements also may be needed.
Nutrition counseling is performed based on the nutritional assessment and nutrition prescription and is recommended on a frequent basis because of the dynamic nature of a child's growth, food preferences, development, medical condition, and level of independence. Intensive counseling should occur at the time of initial presentation; when undesirable changes in appetite, weight gain, linear growth, blood work, blood pressure, or fluid balance occur; or when the method of kidney replacement therapy is altered. Dietary counseling should be positive in nature, providing information about foods the child can eat to replace foods that they must limit or avoid. Family members and primary caregivers should be involved in the education process to be sure the child has appropriate foods available and to provide consistent support for recommended food and fluid modifications, as well as encouragement for nutrient consumption. Counseling must be targeted at the appropriate education level of the child and family member.
Evidence from studies using dietary intervention indicates that frequent nutrition counseling results in adherence and improved outcomes in the general pediatric population157-159; however, there are limited studies of the CKD population. A randomized controlled trial of individualized nutritional counseling and frequent follow-up in adults with CKD stages 4 or 5 showed positive changes in energy intake, nutritional status according to SGA, and body cell mass in the intervention group compared with the control group.160
3.2: Nutritional intervention that is individualized according to results of the nutritional assessment and with consideration of the child's age development, food preferences, cultural beliefs, and psychosocial status should be considered for children with CKD stages 2 to 5 and 5D. (B)
Indications for nutritional intervention include:
Neonates should also be considered at nutritional risk if they are preterm or have:
In addition to providing fuel for the body to function, food and beverages have an important role in family and social life and induce feelings of satisfaction, pleasure, and comfort. Promoting quality of life and patient satisfaction is a critical component of effective health care; therefore, diet and fluid restrictions should be individualized and imposed only when clearly needed. They should be kept as liberal as possible to achieve recommended energy and protein intakes and optimal weight gain and growth. Restrictions can be adjusted based on responses in relevant parameters. Children who are polyuric, have residual kidney function, or are on daily dialysis therapy149 typically require less stringent restrictions.
Promoting satisfaction with a prescribed diet is an important component of effective nutrition intervention. Many factors are involved in satisfaction with and adherence to prescribed diets, including the complexity of the diets and differences between the patient's typical eating pattern and the prescribed one. An eating pattern that incorporates personal, ethnic, and cultural food preferences and gives satisfaction and pleasure while meeting prescribed medical recommendations is likely to support long-term maintenance of dietary changes.161 The Modification of Diet in Renal Disease (MDRD) Study of adults with CKD measured patient satisfaction with modified protein and phosphorus eating patterns and the relationship of satisfaction to adherence.162 Results showed that satisfaction decreased as the magnitude of diet changes increased, and that patient adherence to diet modification was related to their satisfaction with diet. In a study of adult Hispanic patients on HD therapy, knowledge of the renal diet, food-frequency consumption, socioeconomic status, family support, and attitudes toward the renal diet were identified as factors that influenced dietary adherence.163 Patient education provided in the patient's native language also was an important element promoting adherence.
3.3: Frequent reevaluation and modification of the nutrition plan of care is suggested for children with CKD stages 2 to 5 and 5D. (C) More frequent review is indicated for infants and children with advanced stages of CKD, relevant comorbidities influencing growth or nutrient intake, evidence of inadequate intake or malnutrition, or if acute illness or adverse events occur that may negatively impact on the nutritional status. (C)
The nutrition plan of care synthesizes information obtained from the nutritional assessment to determine short- and long-term goals from which the nutrition prescription and plan for individualized nutritional therapy is developed. The plan of care is developed in collaboration with the child and caregivers and shared with the multidisciplinary team. The nutrition care plan should be reviewed often with the child and all caregivers to keep them informed and improve adherence. Conditions that dictate more frequent evaluation of the nutrition plan of care include young age; unfavorable changes in anthropometric measures, oral intake, gastrointestinal function, nutrient-related laboratory values, or fluid or blood pressure status; indication of nonadherence with recommendations; prolonged or large doses of glucocorticosteroids; change in psychosocial situation; or when placement of an enteral feeding tube is under consideration. In these cases, updates to the care plan monthly or more often may be necessary.
Studies reporting stabilization or improvement in growth parameters with nutritional care and therapy have involved a multidisciplinary approach with frequent assessments and counseling by pediatric renal dietitians, many of which occurred at least monthly.17,18,149,150,156,164,165 In a prospective longitudinal study to estimate the amount of dietetic care necessary to support and achieve adequate nutritional intake for growth in children (n = 13; age, 0.2 to 8.5 years) on long-term PD therapy with or without tube feeding, all direct and indirect contacts by the dietitian were recorded over a 3-year period.164 During this time, mean weight SDS and BMI SDS improved (weight SDS, −1.32 to −0.73; BMI SDS, −0.91 to 0.17; P = 0.03). The mean number of dietetic contacts per patient per month was greater for children younger than 5 years (n = 5; 5.9 ± 1.9) compared with the older children (n = 8; 3.1 ± 1.6). The majority of all contacts (82%) were with children with feeding tubes (n = 8).
In the MDRD Study,166 a variety of counseling strategies and sustained monthly support from dietitians helped prevent relapse and stimulated study participants' ability to improve their application of skills over time.167 This was demonstrated in the follow-up period by the ability of the patients on the low-protein and very-low-protein diets to adhere to modifications and decrease their protein intake further over time.
3.4: Nutritional management coordinated by a dietitian who ideally has expertise in pediatric and renal nutrition is suggested for children with CKD stages 2 to 5 and 5D. (C) It is suggested that nutritional management be a collaborative effort involving the child, caregiver, dietitian, and other members of the multidisciplinary pediatric nephrology team (ie, nurses, social workers, therapists, and nephrologists). (C)
A registered dietitian should be a central and integral part of dietary management. Registered dietitians are proficient in the assessment and ongoing evaluation of the patient's nutrition status and development of the diet prescription and nutrition care plan. The pediatric population requires a registered dietitian skilled in the evaluation of growth and the physical, developmental, educational, and social needs of children. At a minimum, registered dietitians should be responsible for assessing the child's nutritional status; developing the nutrition plan of care; providing culturally sensitive education and counseling at the appropriate age level for patients, family members, and/or caregivers; making recommendations for implementing and adjusting oral, enteral, and parenteral nutrition; monitoring the patient's progress, including adherence to the nutrition prescription and documentation of these services.
Early involvement of occupational or speech therapists and pediatric psychologists or psychiatrists who specialize in feeding problems is invaluable for managing chewing/swallowing/food-refusal issues in toddlers, avoiding oral hypersensitivity in tube-fed infants, and enabling the smooth transition from tube feeding to complete oral feeds after transplantation.17,154,168,169
Nonadherence to dietary modifications is a recurring problem for children, especially in children lacking family support or adolescents rebelling against parental supervision. However, there has been limited study of dietary compliance in this population. In 2 prospective studies, adherence to a low-sodium diet was poor165 and a decrease in use of nutritional supplements was observed during a 2-year period despite intensive counseling to continue their use.156 A program for the maintenance of special diets based on a token system of reinforcement was successful in effecting improved dietary behaviors related to intradialytic weight gain and excessive dietary protein and potassium intake in 4 children (aged 11 to 18 years) on HD therapy with longstanding compliance issues.170 Social workers, child life therapists, and nurses can provide additional coping strategies to children and families to help them deal with the frustrations and burdens around feeding problems, diet restrictions, and nutritional support and improve their ability to adhere to new regimens. Pharmacists can work with children and families to find the most acceptable liquid or solid form of such medications as phosphate binders, iron supplements, renal multivitamins, and gastrointestinal motility agents and help them develop medication schedules that fit their feeding schedule and lifestyle and result in optimal drug effectiveness.
The financial burden of dietary manipulation and nutritional supplementation can be excessive for some families, and social workers can identify sources of funding and facilitate funding applications for eligible families. As examples, the daily cost to a family of providing an additional 250 calories through commercial carbohydrate modules (glucose polymers) is approximately $2.00, and the cost of providing 100% of nutritional needs to a 3-year-old child through G-tube feeding using a commercial adult renal feeding product is about $14.30.
Collaboration and good communication among all members of a family-centered team best suit the needs of the child and family and work toward achieving the ideal outcomes for the child.156,165,171
Whereas it is assumed that consistent promotion of the benefits of dietary modification and provision of practical information and emotional support to children and their families can positively influence adherence and clinical outcomes and minimize stress around nutritional issues, there have been no high-quality studies to demonstrate such results in children with CKD.
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