Nutrition for children and adolescents with chronic kidney disease

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)


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


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


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)


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)


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)


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)


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)


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)


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

Nutrition for children and adolescents with chronic kidney disease

Health & Medicine

Transcript of Nutrition for children and adolescents with chronic kidney disease