New version expands on recommendations to ensure adequate dietary intake among children with CKD.
The recently published National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update (Am J Kidney Dis. 2009:53[suppl2]:S1-S124) expands on the previous dialysis-specific guidelines to provide recommendations encompassing CKD stages 2-5 and transplant patients.
Recognizing the importance of addressing the individual health needs of each child, including quality of life, the KDOQI recommendations for nutrition in children with CKD (birth through age 18) cover a number of topics.
Promoting normal growth and development is key to better outcomes for children with CKD. The guideline recommends assessing this patient population on average about twice as often as non-CKD children by examining usual dietary intake, anthropometric comparisons for age (length or height, weight or estimated dry weight, BMI, infant/toddler head circumference), and normalized protein catabolic rate for adolescents on dialysis.
The importance of correcting nutritional and/or metabolic deficiencies (i.e., inadequate protein/energy intake, metabolic acidosis, disordered bone mineral metabolism) associated with poor growth in children with CKD, as well as indications for treatment with growth hormone (rhGH), is addressed.
With respect to rhGH, the Work Group notes that “whereas children receiving dialysis experience an increase in growth with rhGH therapy, the response is less than that of patients with earlier stages of CKD, thus emphasizing the need to initiate rhGH therapy at a young age and/or early in the evolution of CKD to maximize the achievement of growth potential.”
Management and counseling
Nutritional care planning and diet education should be conducted by a dietitian with expertise in pediatric and renal nutrition in coordination with caregivers and other members of the health-care team. The need for frequent diet review according to CKD stage, nutritional status, age development, and comorbidities is emphasized, along with the importance of considering food preferences in meal planning.
“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,” according to the guideline.
The guideline provides direction for early intervention to achieve adequate calorie intake for children with CKD, via either oral or tube feedings, while acknowledging that excessive calorie intake may be an issue for a subset of patients. Equations to estimate energy requirements for children of healthy weight (ages 0-18) and those who are overweight (ages 3 -18) are provided, along with coefficients to adjust calories according to physical activity level. A discussion of the pros and cons of intradialytic parenteral nutrition and recommendations to incorporate “heart-healthy” food choices are also included.
Ensuring adequate protein intake while preventing hyperphosphatemia, a risk factor for cardiovascular disease (CVD), is the balance the guideline aims to achieve. The recommended protein intake is 100%-140% of the dietary reference intake (DRI) for ideal body weight in children with stage 3 CKD, 100%-120% DRI for CKD stage 4, and 100% DRI for stage 5D (dialysis) plus additional protein to replace losses due to dialysis: approximately 0.1 g/kg/day for hemodialysis patients and 0.15-0.3 g/kg/day for peritoneal dialysis patients.
Vitamin and trace elements
The need for adequate vitamin and mineral intake for normal growth and development is reaffirmed, with recommendations for supplementation as needed to achieve 100% of the DRI based on age for CKD stages 2-5. For stage 5D, supplemental water-soluble vitamins are suggested.