nutrition for children and adolescents with chronic kidney disease
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Nutrition for Children and Adolescents Nutrition for Children and Adolescents
with Chronic Kidney Diseaswith Chronic Kidney Diseasee
Dr. Doaa HamedDr. Doaa Hamed Lecture of Clinical NutritionLecture of Clinical Nutrition
National Nutrition InstituteNational Nutrition Institute Cairo Cairo (Egypt(Egypt((
1. Integrated renal care .
2. Importance of renal diet .
3. Nutritional counseling
4. Nutrition Care Process
5. Nutritional needs(Diet planning )
Estimation of GFR in Estimation of GFR in childrenchildren
GFR (mL/min/1.73 m2) = (0.413 × height
[cm])/Serum creatinine (mg/dL)
The normalnormal GFR in children is
90-13090-130 ml/min/1.73m2ml/min/1.73m2
Staging of CKD in childrenStaging of CKD in children
No No symptomssymptoms
AnemiaAnemiaFatigue, Fatigue, Anemia, Anemia, EdemaEdema
Prepare Pt. for Prepare Pt. for RRTRRT
(HD or PD or (HD or PD or TX)TX)
Start RRT Start RRT
A psychotherapist / motivation speaker
A diabetes educator
A renal specialist dietitian
A combination of:- Nephrologist Nurse pharmacist Social Worker Caregiver
لللللللل للللللللللل
Trained & experienced in Renal nutrition
Implementation of many guidelines concerning nutritional
assessment
Anthropometry, SGA, dietary interviews
Plan for nutritional management & therapy
Counseling the patient & the family
Educational activities
Nutritional care for childrenNutritional care for children
GoalsGoals:
Maintenance of an optimal nutritional status Maintenance of an optimal nutritional status (ie, achievement of a normal pattern of growth and body composition by intake of appropriate amounts and types of nutrients).
AvoidanceAvoidance of uremic toxicity, metabolic abnormalities , and malnutrition.
ReductionReduction of the risk of chronic morbiditiesmorbidities and mortalitymortality in adulthood.
Causes of (PEW) in Children with CKDCauses of (PEW) in Children with CKD
Inadequate food intake secondary toInadequate food intake secondary to: anorexia
altered taste sensation
nausea/vomiting
emotional distress
inter current illness
unpalatable prescribed diets
imposed dietary restriction
impaired ability to procure food because of socioeconomic situation
Causes of (PEW) in Children with CKDCauses of (PEW) in Children with CKD
• • Chronic inflammatory state Chronic inflammatory state
• • Catabolic response to superimposed illnesses Catabolic response to superimposed illnesses
• • Possible accumulation of endogenously formed Possible accumulation of endogenously formed uremic toxins and/ or the ingestion of exogenous toxins
•• Removal of nutrients during dialysis procedure Removal of nutrients during dialysis procedure
•• Endocrine causes sEndocrine causes such as: •• resistance to the actions of insulin and IGF-I
•• hyperglucagonemia
• • hyperparathyroidism
PEDIATRIC PEDIATRIC
NUTRITION ASSESSMENTNUTRITION ASSESSMENT
AssessmentAssessment
Medical History MedicationDietary Interview
ل Actual intakeل RDA
ل Physical eating skills
ل Psychosocial status
ل Consumptions of special or unusual food
NKF, Kidney Disease Outcomes Quality Initiative, 2009).
Recommended assessment components includeRecommended assessment components include:-:-
ل Dietary intake Dietary intake ل (3-day food record or three 24-h recalls dietary recalls)
Growth ParametersGrowth Parameters◦Height- or length-for-age percentile or standard deviation
score (SDS); ◦Height or length velocity-for-age percentile or SDS; ◦Estimated dry weight and weight-for-age percentile or SDS; ◦Head circumference until age 3◦Change in SD (0.5 SD in ht)
NKF, Kidney Disease Outcomes Quality Initiative, 2009).
More evaluationMore evaluation
◦ normalized protein catabolic rate (nPCR).◦ Abnormal labs◦ Specific signs of vitamin deficiency ◦ Dry weight loss◦ Repeated intra dialysis Wt. gain◦ Decrease oral intake ◦ Change in GIT function ◦ Complication with recommendation
NKF, Kidney Disease Outcomes Quality Initiative, 2009).
MonitoringMonitoring
It is suggested that It is suggested that
The frequency of monitoring nutritional and growth parameters in all children with CKD stages 2 to5and 5D bebe based on the child’s age and stage of CKD based on the child’s age and stage of CKD . (C) (C)
Performed at least twicetwice as frequently as they would be performed in a healthy child of the same age. (C)(C)
Infants and children with polyuria, evidence of growth delay, decreasing or low BMI, comorbidities influencing growth or nutrient intake, or recent acute changes in medical status or dietary intake may warrant more frequent more frequent evaluation.(C)evaluation.(C)
GrowthGrowth
Identification and treatment of existing nutritional deficiencies and metabolic abnormalities
should be aggressively pursued in children with CKD stages 2 to 5 and 5D, short stature short stature (height SDS < 1.88 or height-for-age < 3rd percentile), and potential for linear growth.(A)
Serum bicarbonate level should be corrected to at least the lower limit of normal (22 mmol/L) in children with CKD stages 2to5and5D.(B)
GrowthGrowth
Recombinant human growth hormone (rhGHrhGH) therapy should
be considered in children with CKD stages 2 to 5 and 5D,
short stature short stature (heightheight SDS < 1.88 or SDS < 1.88 or height-for-ageheight-for-age < 3rd percentile < 3rd percentile), and
potential for linear growth if growth failurepotential for linear growth if growth failure (height velocity-for-height velocity-for-
age SDS age SDS < 1.88 or < 1.88 or height velocity-for-ageheight velocity-for-age < 3rd percentile < 3rd percentile) persists beyond 3
months despite treatment of nutritional deficiencies and
metabolic abnormalities. (B)
NutritionalNutritional Management & Counseling Management & Counseling
NutritionNutrition counselingcounseling, based on based on an individualized individualized assessment assessment and plan of careplan of care, should be considered for children with CKD stages 2 to 5 and 5D and their caregivers.(B)
Nutritional intervention Nutritional intervention that is individualizedindividualized according to results of the nutritional assessment nutritional assessment and with consideration of the child’s agechild’s age, developmentdevelopment, food food preferencespreferences, cultural beliefscultural beliefs, and psychosocial status psychosocial status should be considered for children with CKD stages 2 to 5 and 5D.(B)
Frequent reevaluation and modification 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 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 impacton nutritional status.(C)
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 nutritional management be a
collaborative effort collaborative effort involving the childchild, caregivercaregiver, dietitiandietitian,
and other members of the multidisciplinary pediatric multidisciplinary pediatric
nephrology team nephrology team (ie, nurses, social workers, therapists, and nurses, social workers, therapists, and
nephrologists)nephrologists).(C)
AKIAKI
The aim of dietary treatment is:- The aim of dietary treatment is:-
1. To provideprovide adequate proteinprotein and energyenergy where possible
2. ControlControl of dietary potassiumpotassium
3. ControlControl of dietary sodiumsodium
4. ControlControl of dietary phosphatephosphate
5. To tailortailor fluidfluid intakeintake to maintain fluid balance
With respect to calorie
Provision, it is generally agreed that critically ill children, like adults, should receive 100-130% of the basal energy expenditure , which can be estimated with acceptable precision and accuracy by the Caldwell-Kenndy equation
resting energy expenditure
22 + 31.05 x weight(kg) + 1.16 x age (yr.)
AKIAKI
In children with AKI, Physiological macronutrient requirements
are age-dependent, reflecting the developmental dynamic of
growth and metabolism. Research exploring nutritional
requirements in children with critical illness and AKI is limited
to observational studies
Protein intake Protein intake 2.4 , 1.9 and 1.3 g/Kg/d in children aged < 1 -
1,13 , and > 13 years , respectively
Although not validated by outcome studies, these figures provide
an orientation for the macronutrient supply typically achieved in
and tolerated by children with AKI receiving RT
Chronic Kidney Disease Chronic Kidney Disease
(CKD(CKD((
Dietary RecommendationsDietary Recommendations
Food Groups Kcal CHO g. PRO g. FAT g. Na mg. K+ mg. PO4 mg.
Milk ( ½ c.) 85 6 4 5 80 185 110
Meat 65 0 7 4 25 100 65
Starch 80 15 2 1 80 35 35
Vegetable 25 5 1 0 15 150 20
Fruit 60 15 0.5 0 5 150 15
Fat (1TB.) 100 0 0 11 150 0 5
Calorie Boosters 60 15 0 0 15 20 5
Beverages:Coffee (1c.) tea (1 bag) wine (4 oz.) beer (12
oz.)
0 0 0 0 0 100 0
RENAL EXCHANGES FOR MEAL PLANNING
Energy RequirementsEnergy Requirements
Adequate intake of calories is important not only not only for weight gain and growth but also to avoid but also to avoid gluconeogenesis
Energy needs for children with CKD are likely similarsimilar to those of healthy children
Children with PEW/ cachexia may have higher kcal needs
Energy requirements for children with CKD stages 2 to 5 and 5D should be considered to be 100% of the EER 100% of the EER for chronological ageage, individuallyindividually adjusted for PALPAL and body size body size (ie, BMI). (B) (B)
Further adjustment to energy intake is suggested based upon the response in rate of weight gain or loss.(B).(B)
To increase the To increase the energyenergy content of meals content of meals::
Add extra oil to rice, noodles, breads, crackers, and cooked vegetables.
Add extra salad dressing.Non-protein calorie (NPC) supplement can be
added
(J Ren Nutr. Nov. 2012 )
Glucose absorption from peritoneal dialysis solutions provides approximately 9 kcal/kg daily for children on PDPD
◦number of cycles for patients receiving automated PD,
◦dwell time,
◦ body surface area,
◦peritoneal membrane transport capacity
KDOQI clinical practice guideline for nutrition in children with CKD: 2008 update. Am J Kidney Dis. 2009;53 Suppl 2:S1–124
Energy RequirementsEnergy Requirements
EEREER
PALPAL
Supplemental nutritional support Supplemental nutritional support should be
considered when the usual intake of a child with CKD
stages 2 to 5 or 5D fails to meet his or her energy
requirements andand the child is not achieving expected
rates of weight gain and/or growth for age.(B)
Energy RequirementsEnergy Requirements
Oral intake of an energy-dense diet and commercial
nutritional supplements should be considered the preferred
route for supplemental nutritional support for children with
CKD stages 2 to 5 and 5D. (B)
When energy requirements can not be met with oral
supplementation, tube feeding should be considered.(B)
Energy RequirementsEnergy Requirements
A trial of intra dialytic parenteral nutrition (IDPN) to
augment in adequate nutritional intake is suggested for
malnourished children malnourished children (BMI-for-height-age < 5th
percentile)receiving maintenance HD who are unable to meet
their nutritional requirements through oral and tube feeding.
(C)
Energy RequirementsEnergy Requirements
A balance of calories from carbohydratcarbohydratee and unsaturatedunsaturated
fatsfats with in the physiological ranges recommended as the
AMDR of the DRI is suggested when prescribing oraloral,
enteralenteral, or parenteralparenteral energyenergy supplementationsupplementation to children
with CKD stages 2 to5 and5D.(C)
Energy RequirementsEnergy Requirements
Overweight or ObeseOverweight or Obese
DietaryDietary and lifestylelifestyle changes are suggested to achieve weight weight control control in over weight or obese children with CKD stages 2 to 5and 5D.(C)
DIETARY PROTEINDIETARY PROTEIN
ProteinProtein
Essential for ❖ building muscles repairing tissue❖ ❖ fighting infection ❖Keeping fluid balance in the blood
There are two kinds of proteins
◦ (HBV) oror animal protein-meat, fish, poultry, eggs and dairy
◦ (LBV) oror plant protein – breads, grains, vegetables, dried beans and peas and fruits
50 -70% should be of HBV.
A well balanced diet for kidney patients should include both kinds of proteins every day.
Dietary protein and progressive CKDDietary protein and progressive CKD
◦ Dietary protein intake to RDA / optimize nutritional status.
◦ No association between protein restriction and CKD progression in small studies
◦ Low protein diet leads to decrease in ions :- Hyperkalemia Metabolic acidosis Hyperphosphatemia
◦ Obese use ABW
It is suggested to maintain dietary protein intake at 100% to 100% to 140% 140% of the DRI for ideal body weight in children with CKD stage 3stage 3 and at 100% to 120% 100% to 120% of the DRI in children with CKD stages 4 to 5stages 4 to 5.(C)
In children with CKD stage 5Dstage 5D, it is suggested to maintain dietary protein intake at 100% of the DRI for ideal body weight plusplus an allowance for dialytic protein and amino acid lossesdialytic protein and amino acid losses.(C)
The use of protein supplementssupplements to augment inadequate oral and/or enteral protein intake should be considered when children with CKD stages 2 to 5 and 5D are unable to meet their protein unable to meet their protein requirements requirements through food and fluids alone.(B)
protein and phosphorus intake, which determines a frequent association of high protein in the diet with hyperphosphatemia.
Whereas hyperphosphatemia is a powerful independent predictor of mortality on dialysis therapy,
Evidence for any benefit from high-protein diets is lacking. Hence, it appears mandatory to limit protein intake to the safe levels known to ensure adequate growth and nutrition in healthy children.
The adverse impact of hyperphosphatemia on cardiovascular, bone, and endocrine function in children with CKD mandates the preferential selection of protein sources that are relatively low in phosphorus.
The lowest amount of phosphorus in proportion to the quantity and quality of protein comes from animal-flesh proteins (average, 11 mg of phosphorus per 1 g of protein),
LIPIDSLIPIDS
LipidsLipids
Patients considered at highest risk for cardiovascular disease
Nutrition therapy for Dyslipidemia is based on pt’s metabolic profile
and individualized treatment goals
requirement of fat requirement of fat
( 30 % total cal ) Minimize the ↑ in TG & Cholesterol
< 10% of calories → SFAc Ratio of USFAc to SFAc l fats = 2 : 1
8% SFAc l :10 % PUSFAc : 12% , MUFAc
250–300 mg cholesterol/day
Omega 3 fatty acid ↓ TG & Chol. as well as phospholipids may be tried
lipid profile usually characterized by ↑↑ TG ↑ cholesterol ↑ LDL ↓ HDL Abnormal apolipoprotein
In children with ESRD This inversely related to age
If TG is increased CHO ↓ 35-50% of total k.cal Mostly complex CHO
PUFA : SFA > 2:1
DyslipidemiaDyslipidemia
Tips to Implement AHA Pediatric Dietary Guidelines for Tips to Implement AHA Pediatric Dietary Guidelines for Prevention or Treatment of Dyslipidemia and CVD in Prevention or Treatment of Dyslipidemia and CVD in Prepubertal ChildrenPrepubertal Children
ReduceReduce addedadded sugarssugars, including sugar-sweetened drinks and juices. Use canola, soybean, corn, or safflower oils, or other unsaturated oils, in place of solid fats during food preparation.
UseUse fresh, frozen, and canned vegetables and fruits, and serve at every meal; bebe carefulcareful with added saucessauces and sugarsugar.
IntroduceIntroduce and regularlyregularly serve fish as an entrée. RemoveRemove the skin from poultry before eating. UseUse only leanlean cutscuts of meat and reduced-fat meat products. Limit high-calorie sauces such
as Alfredo, cream sauces, cheese sauces, and hollandaise. EatEat whole-grainwhole-grain breads and cereals ratherrather than refinedrefined productsproducts. Eat more Eat more legumes
(beans) and tofu in place of meat for some entrees. ReadRead foodfood labels—especiallylabels—especially for breads, breakfast cereals, and prepared foods—for
content, and choose high-fiber, lowsalt/low-sugar alternatives.
FiberFiber The AI 1 year and older is 14 g/1,000kcal/d14 g/1,000kcal/d.
To normalize cholesterol levels and reduce the risk of cardiovascular heart disease, an increase in soluble fiber intake is recommended as an addition to reductions in saturated fatty acid and cholesterol intake .
reduce energy intake and the risk of over weight.
Dietary fiber is found inDietary fiber is found in most fruits, vegetables, legumes, and whole grains, which are foods restricted in low-potassium and/or low-phosphorus.
CalciumCalcium
In children with CKD stages 2 to 5 and5D,it is suggested that the total oral and/or enteral calcium intake from nutritional sources and phosphate binders be in the range of 100% to 200% of the DRI for calcium for age.(C)
Intake of 100% of the DRI for calcium is a reasonable starting point for children with CKD. Although the safe limit of dietary calcium intake in children of different ages has not been defined by study evidence, it appears logical to scale maximal calcium intake relative to the age-specific DRI.
The safe UL of dietary calcium intake in healthy individuals older older than 1 year is 2,500 mg/dthan 1 year is 2,500 mg/d.
For adults and children 9 years and older , this is approximately 2 times the DRI.
Control = Control = BindersBinders + + DietDiet + + AdequateAdequate dialysisdialysis
PhosphorusPhosphorus
Phosphorus TypesPhosphorus Types
OrganicOrganic phosphorusphosphorus
4040 – – 6060% absorbed % absorbed Phytates Phytates ↓↓ absorption absorption
Dairy products Meat, poultry, fishSoy (soy milk, tofu)Nuts and seedsDried beans and peas Whole grains
InInorganicorganic phosphorusphosphorus
> > 9090% absorbed% absorbed
absorbed easily
Food additivesDietary supplementsCalcium fortification
Kalantar-Zadeh et al. Clin J Am Soc Nephrol 2010; 5(3):519-530
READ THE INGREDENTS LABEL!!READ THE INGREDENTS LABEL!!
Phosphorus binders ineffective
PhosphorusPhosphorusIn children with CKD stages3to5 and 5D, reducing dietary
phosphorus intake to 100% of the DRI 100% of the DRI for age is suggested when the serum PTH concentration is above the target serum PTH concentration is above the target range for CKD stage and the serum phosphorus serum phosphorus concentration is within within the normal reference range for age. (C) the normal reference range for age. (C)
After initiation of dietary phosphorus restriction, it is suggested that serum phosphorus concentration be monitored at least every every 3 months3 months in children with CKD stages 3 to 4 and monthly in children with CKD stage 5 and 5D. (C)
In all CKD stages, it is suggested to avoid serum phosphorus concentrations both above and below the normal reference range for age.(C)
PhosphorusPhosphorusIn children with CKD stages3to5 and 5D, reducing dietary
phosphorus intake to 80% of the DRI 80% of the DRI for age is suggested when the serum PTH concentration is above the target range serum PTH concentration is above the target range for CKD stage and the serum phosphorus concentration exceeds the exceeds the normal reference range normal reference range for age. (C)
PhosphorusPhosphorus
After initiation of dietary phosphorus restriction, it is suggested that serum phosphorus concentration be monitored at least every 3 months in children every 3 months in children with CKD stages 3 to 4 and monthly in children with CKD stage 5 and 5D. (C)
In all CKD stages, it is suggested to avoid serum phosphorus concentrations both above and below the normal reference range for age.(C)
Phosphate BindersPhosphate Binders
◦Calcium Acetate - Phosex ◦Non-calcium binder - Sevelamer ◦Calcium carbonate
o Calcium 500 (soluble)
o Calcichew
These are only effective if taken with meals, feeds or
snacks.
Conversion factor for calcium and ionized calcium:mg/dL & 0.25#mmol/L. Conversion factor for phosphorus: mg/dL & 0.323 # mmol/L.
PotassiumPotassium
Aim for plasma potassium 3.0 - 5.0mmol/l. Foods commonly eaten which are rich sources of potassium include
• Chips • Fruits and vegetable • Potato crisps • Chocolate • Fresh fruit juices
Potassium intake should be limitedshould be limited for children with CKD stages 2 to 5 and 5D who have or are at risk of hyperkalemia. (A)
Onion
Spanish Fruits & Vegetables Low:Low: 20-150 mg MediumMedium: 150-250 mg HighHigh: 250-550 mg
Portion size is essential Avoid Salt Substitutes Dairy
1 cup 1 cup 380-400 mg High phosphorus foods
How to leach vegetables?How to leach vegetables?
ForFor PotatoesPotatoes, , Sweet PotatoesSweet Potatoes, , CarrotsCarrots,, Beets Beets , and, and Rutabagas Rutabagas::
1. Peel and place the vegetable in cold water so they won’t darken.
2. Slice vegetable 1/8 inch thick.
3. Rinse in warm water for a few seconds.
4. Soak for a minimum of two hours in warm water. Use ten times the amount of water to the amount of vegetables. If soaking longer, change the water every four hours.
5. Rinse under warm water again for a few seconds.
6. Cook vegetable with five times the amount of water to the amount of vegetable.
SodiumSodium
Plays vital role in regulation of fluid balance and blood pressure
In CKD& HDMay result in :- high blood pressure, fluid retention/swelling (edema) lead to shortness of breath
Excessive thirstCHF
Serum Sodium (nl 133-145 mEq/Lnl 133-145 mEq/L)
SourcesSources of Dietary Sodium of Dietary Sodium
Sodium & FluidsSodium & Fluids
Restriction of sodium intake should be considered for children with CKD stages 2 to 5 and 5D who have hypertensionhypertension (systolic and/or diastolic blood pressure > 95th
percentile) or prehypertensionprehypertension (systolic and/or diastolic blood
pressure > 90th percentile and < 95th percentile). (B)
Sodium & FluidsSodium & Fluids
Supplemental free water and sodiumSupplemental free water and sodium supplements should be considered for children with CKD stages 2 to 5 and 5D and polyuria to avoid chronic intravascular depletion and to promote optimal growth. (B)
Sodium supplements Sodium supplements should be considered for all infants with CKD stage 5D on PD therapy.(B)
Sodium & FluidsSodium & Fluids
Fluid intake Fluid intake should be restricted in children with CKD stages 3 to 5 and 5D who are oligoanuricoligoanuric to prevent the complications of fluid overload.(A)
Increase Kcal density up to 60 kcal/ml This done graduallygradually
20 kcal/oz and increase 2-4 kcal/oz
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