GUIDELINES BY AN AD HOC EUROPEAN COMMITTEE ON THE ASSESSMENT OF GROWTH AND NUTRITIONAL STATUS IN CHILDREN ON CHRONIC PERITONEAL DIALYSIS

Janet E Coleman; Paediatric Renal Dietitian, Nottingham Alberto Edefonti; Paediatric Nephrologist, Clinica Pediatrica C and D de Marchi, University of Milan Milan Alan R Watson; Paediatric Nephrologist, Nottingham

On behalf of the European Paediatric Peritoneal Dialysis Working Group†

Correspondence to:

    Dr Alan R Watson
    Children & Young People's Kidney Unit
    Nottingham City Hospital
    Hucknall Road
    Nottingham NG5 1PB
    UK

    Tel: +44 115 962 7961
    Fax: +44 115 962 7759
    E-Mail:     watpaed@aol.com

†C Schroder, Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands
G Klaus, University of Marburg, Marburg, Germany
E Simkova, University Hospital Motol, Prague, Czech Republic
K Ronnholm, University of Helsinki, Helsinki, Finland
A Zurowska, Medical University of Gdansk, Gdansk, Poland
V Strazdins, University Hospital, Riga, Latvia
M Fischbach, Hopital de Hautepierre, Strasbourg, France
D Stefanidis, A&P Kyriakou Childrens Hospital, Athens, Greece

Key Words: guidelines; pediatric; peritoneal dialysis; nutrition; growth

Running Title: guidelines on nutrition in pediatric peritoneal dialysis

Abstract

If children are to thrive and grow on chronic peritoneal dialysis (CPD) they require close attention to their nutritional needs with dietetic support being an essential part of the multidisciplinary team approach. This paper offers a practical approach to the assessment of growth and nutritional status in children on CPD with a combined medical and dietetic strategy.

The nutritional status of each child should be evaluated prior to commencing CPD and at regular intervals thereafter. Anthropometric measurements, particularly weight, length and head circumference should be measured and plotted so that growth velocity can be calculated. Clinical assessment of children should be combined with regular dietary assessments which can be with 3 day dietary diaries or by dietary recall in clinic by an experienced dietitian. Nutrient intakes should be computer analysed and reference made to national guidelines. The nutritional prescription will also consider the dialysis prescription along with biochemical and haematological data as well as relevant medications (phosphate binders, iron and micronutrient supplements and diuretics).

Each child will have individualised nutritional requirements and these should be given by the oral route whenever possible. Failure to meet nutritional intakes or maintain an adequate growth velocity may necessitate the early introduction of enteral feeding via the gastrostomy or nasogastric route. The family and team members must be fully engaged in such decisions with age-related normal weaning, feeding and eating skills being encouraged in infants. Nutritional supplements in use are listed.

Evidence is accumulating that intensive nutritional support and adequate dialysis clearances in pre-pubertal CPD patients promote normal and even enhanced growth without the need for recombinant human growth hormone. Adequate dietetic time is essential to provide this support.

Nutritional assessment and dietetic support is an essential part of the multidisciplinary team approach for children and families on chronic peritoneal dialysis (CPD). This is especially true during infancy where nutritional support via an enteral feeding route is often required1.

Children on CPD require frequent nutritional assessment and dietary prescription alongside the prescription of dialysis and medications. Such advice should meet individualised nutritional requirements to maintain nutritional status and promote growth, prevent the build-up of waste products and metabolic abnormalities in accordance with biochemical parameters and should satisfy individual psychosocial needs2,3. Assessment by a paediatric renal dietitian is crucial for the close and frequent supervision that is required to monitor and maintain qualitative standards of care for each child because of the changing needs for growth and development4.

The European Paediatric Peritoneal Working Group was established in 1999 by paediatric nephrologists with a major interest in peritoneal dialysis5. These guidelines were initiated and discussed at meetings of the group and developed through seven drafts by e-mail discussion with the principle authors, one of whom is a senior paediatric renal dietitian (JC). The guidelines are evidence and opinion-based incorporating the cumulative clinical experience of the group members and relevant literature. They are intended as a practical approach to the assessment of growth and nutritional status in children on CPD with a combined medical and dietetic strategy.

A. Nutritional Assessment (Table 1)

  1. Clinical staff will assess the nutritional status of individual children with an initial evaluation prior to commencing CPD.
  2. Further evaluations should take place at clinic visits
    1. minimum of monthly for infants and children <5 yrs
    2. minimum 2-monthly for older children.
  3. Re-evaluation during ward admissions, particularly during peritonitis episodes
  4. Telephone contact at home should be available for each family in between ward and clinic visits.4
  5. A visit to home and school/nursery with other team members is beneficial to evaluate the practicalities of treatment.
B. Anthropometry

  1. The reliable assessment of growth requires staff who have received training in the use of appropriate measuring techniques and equipment. Measurements should be plotted on reference growth charts for healthy children at baseline and clinic visits thereafter.
  2. Weight* -
      Infants should be weighed in the nude (monthly)
      Older children should be weighed in light clothing without shoes
  3. Supine Length* -
      Recommended up to the age of 2-3 years on a flat surface (Note that change in height difference between recumbent length and standing height is ~ 2.5cm)
  4. Standing Height -
      Taken without shoes, with the child standing with heels and back in contact with an upright wall using a height stadiometer
  5. Head circumference -
      Measured using a non-stretchable measuring tape for children up to 2 years of age
  6. Mid-arm circumference
      Ensure measurement in same arm (non-dominant) with a non-stretchable measuring tape. (Record to nearest 0.1cm)3,6
  7. Skin-fold thickness -
      Not popular with children and has poor reproducibility in routine clinical usage.
  8. Height velocity -
      Calculated and plotted over a yearly period
  9. Body Mass Index -
      Wt (kg)/Ht (m2)7
  10. Bone age -
      Checked annually usually using single AP film of hand and wrist
Standard deviation scores (SDS) relative to age or height (in case of severe growth retardation) must be used when calculating BMI, height, weight, height velocity, mid-arm circumference and skinfold thicknesses.

SDS = [patients actual value] - value of 50th percentile for controls / Standard deviation of control subjects

Computer packages are available or reference can be made to appropriate tables3,6.

* For premature infants - correct for gestational age, up to 2 years of age, on growth chart

C. Clinical/Physical Examination

The clinical and physical examination combined with the nutritional assessment and monitoring techniques all form part of a paediatric assessment which encompasses many of the following parameters.

  1. Clinical observations:
    1. Change in appetite
    2. Gastrointestinal problems such as nausea, vomiting, diarrhoea, constipation
    3. In infants: gagging, swallowing difficulties and inability to chew solids
    4. Energy levels and activity

  2. Physical observations:
    1. Condition of hair, teeth, tongue, skin, nails, breath
    2. Impression of the preservation or wasting of fat or protein mass
    3. Oedema
    4. Blood pressure

  3. Measurements of:
    1. Urine output for residual renal function
    2. Fluid balance
    3. Estimated dry weight without oedema
D. Dietary Assessment

  1. Diet recall should be routinely discussed in clinic. A 3 day dietary diary should be completed for analysis at baseline and ideally within 3-4 months of commencing dialysis, and 6 monthly thereafter. In infants more frequent adjustments will be required.
  2. All nutrients should be computer analysed (qualitatively/quantitatively) whenever possible and compared with recommended intakes for children of the same sex and chronological age:
    1. If the child is within the normal percentile ranges for height (>2nd percentile), energy and micronutrient requirements can be based upon the recommendations for children of the same chronological age (DRV 1991)8
    2. If the child falls below the normal percentile ranges for height (<2nd percentile), the child's height age may be used to determine acceptable baseline energy and micronutrient requirements when compared with recommended intakes (DRV 1991)8 and adjusted accordingly thereafter.
  3. The results should be discussed with the child and family.
  4. A written report for the nephrologist and responsible renal nurse is advised.
  5. The dietary analysis should include data on:
    1. Energy, protein, fat, carbohydrate
    2. Vitamins, minerals, trace minerals
    3. Fluid and electrolytes
      Analysis should include the prescribed nutritional and micronutrient supplements
  6. In the UK, the dietary reference values (DRV 1991, UK)8 for food, energy and nutrients is used as the reference source. For other countries national reference guidelines may be available and can be used as baseline requirements for the majority of nutrients. However, protein, phosphate, sodium, potassium and the vitamins folic acid, C and B6 will require individualised prescription, depending upon dialysis losses and biochemical parameters.9 Protein losses into the peritoneal fluid need to be considered and these are reported to be greater in infants.10
E. Biochemical/Haematological Parameters

  1. Patient plasma values compared with normal age specific reference ranges will identify abnormalities requiring adjustment in dietary, medications and/or dialysis prescriptions.
  2. The following indices should be measured at baseline and monthly thereafter:
    1. Urea, creatinine, sodium, potassium, bicarbonate, albumin*, calcium, phosphate, alkaline phosphatase
    2. Haemoglobin (Hb)
    3. Parathyroid hormone (PTH) especially if on Vitamin D metabolites. Intact PTH molecules should be assayed as this more accurately reflects parathyroid activity.
  3. At baseline and 3 monthly thereafter:
    1. Glucose
    2. % Hypochromic cells and ferritin or serum iron, ferritin and total iron binding capacity (% transferrin saturation TSAT)

    Cholesterol and triglycerides can be assessed at baseline but there is no firm agreement on frequency of monitoring or treatment for elevated levels.

*Serum albumin levels can be affected by many factors and must be interpreted on an individual basis together with the nutritional and clinical assessment 11.

F. Medications

  1. Children and their families should be advised on the correct administration and timing of medications to ensure compliance, optimise absorption and minimise potential side effects. Ongoing discussion with education and information about each medication should be routine within each dietetic interview with regular feedback to the medical, nursing staff and pharmacists. Adjustments of particular medications and dosages may be necessary.
  2. Medications requiring particular monitoring:
    1. Phosphate Binders
      Calcium Carbonate should be chewed or crushed to a fine powder or in solution, and taken with food at meal times usually three times daily.
      Calcium Acetate should be swallowed and not chewed. Sevelamer hydrochloride may be indicated when hypercalcaemia is a problem.
      Aluminium hydroxide binders should be avoided.
      (Oral iron supplements should not be taken with phosphate binders)
    2. Oral Iron Supplements 12
      A dosage of 2-3mg/kg body wt/day is recommended and administered in 2-3 divided doses either one hour before or 2 hours after food. They should not be added to infant formulas or nutritional supplements. If possible they should be prescribed with vitamin C to enhance absorption. (It is important not to over-supplement with vitamin C for risk of increased oxalate formation).
      Iron supplements should ideally not be taken with phytate (cereals and legumes), tannins (tea, cocoa, chocolate) and dairy products which interfere with absorption.
    3. Diuretics and Antihypertensives
      Can alter balance of minerals
    4. Antibiotics
      May cause diarrhoea (sometimes confused with nutritional supplements/tube feeding) and some can interfere with vitamin metabolism
    5. Micronutrient Supplements
        Should be prescribed only following individualised dietary assessment and should account for the potential CPD losses of folic acid and vitamins C and B6 as shown in adult studies12. Recommended intakes are based on the reference nutrient intake (RNI, DRV 19915) and from the few paediatric studies available13,14,15,16 would suggest intakes of:
      1. vitamin C 25 (infants)-60mg/day
      2. vitamin B6 0.2 (infants)-1.5mg/day
      3. folate 60 (infants)-400µg/day
        All other vitamins and trace minerals should meet with 100% of the reference nutrient intake (DRV, RNI 1991) with the exception of vitamin A, which should not exceed 100% of the RNI and should not be present in prescribed micronutrient preparations.3,14,17
G. Dialysis Prescription

Dialysis prescriptions (dose of dialysis, dialysis cycle times, dialysis solution(s), ultrafiltration, urine output) should be monitored on a monthly basis in clinic by the nephrologist, renal nurse and dietitian. Ongoing monitoring should take place on a weekly basis by the renal nurse(s) by telephone with discussion at team meetings.

Dialysis adequacy assessments and peritoneal equilibrium tests are discussed in another guideline.

H. More Detailed Assessments to Assess Body Composition

  1. Dual Energy Xray Absorptiometry (DEXA) is a non-invasive method to estimate bone mineral content, fat and lean body mass. It is not widely available and requires expertise in use and patient co-operation. Estimates may be confounded by variations in hydration states in PD patients. Moreover the cost of DEXA makes it feasible no more than annually.18
  2. Bioelectrical Impedance (BI) allows the measurement of fat free mass in healthy children, but it is not widely available. However, it is fast, easily applied, repeatable and relatively inexpensive. It should be noted that results in PD patients may be confounded by variations in hydration states. It is debatable whether direct measures (resistance, reactance, phase angle, distance) or indirect (that is, equation derived) measures should be used in clinical practice. BI should only be used in combination with anthropometric/clinical assessments.18
Both DEXA and BI are not essential parameters to be included within the nutritional assessment process and will depend on individual unit protocol.

I. Psychosocial Assessment

  1. As part of the overall nutritional assessment it is essential for the dietitian, as a key member of the multidisciplinary team, to become familiar with each child's psychosocial environment which includes:
    1. Family/extended family dynamics
    2. Lifestyle, activities, exercise patterns
    3. Friends, hobbies
    4. Nursery/school attendance
    5. Eating patterns in/out of home
  2. A home visit made by the dietitian with the renal nurse or social worker prior to, or at the initiation of, a child onto a CPD programme is recommended. Further "update" visits at 6-12 months should be considered in children on combined enteral nutritional support and dialysis.19
J. Formulate Nutritional Prescription

  1. The dietitian having considered all of the nutritional assessment parameters will calculate individual nutritional requirements (Table 2).1 These goals will be discussed with the child, family and nephrologist to formulate the nutritional prescription.
  2. The oral route should always be considered. However, the early initiation of enteral nutrition support with use of nutritional supplements given orally or via an enteral tube feeding route (gastrostomy or nasogastric tube)20,21 should be considered when:
    1. the child's oral intake fails to meet recommended nutritional intakes and/or
    2. the child fails to maintain adequate growth velocity (for example, when weight, height and/or head circumference measurements begin to fall from percentiles and height velocity is consistently below the 25th percentile) and
    3. other non-nutritional causes are excluded.
  3. All children, but particularly infants and children < 5 years of age should be considered for the combined initiation of dialysis and overnight enteral nutritional support via a gastrostomy button or nasogastric tube21. If enteral nutritional support via a tube feeding route is considered, it is essential for all team members to ensure a common philosophy with understanding of the ongoing support which will be required for this treatment to be successful.

    Team discussion followed by counselling of each child and family with the use of booklets, children's stories and videos is recommended. Meeting another child/family undergoing or having undergone such management is recommended.

  4. Nutritional supplements suitable for paediatric use are shown in Table 3.1 These are the supplements commonly in use in the UK and can be compared to those available in other countries.
  5. Age related normal weaning, feeding and eating skills should be encouraged.

K. Recombinant Human Growth Hormone (rhGH)

Recombinant hGH would be considered in PD patients with growth potential only after nutritional parameters have been corrected along with acidosis, hyperphosphataemia and secondary hyperparathyroidism3. Evidence is accumulating that intensive nutritional support and adequate clearances in prepubertal patients promote normal and enhanced growth without rhGH22,23.

References

  1. Coleman JE. The kidney. In: Shaw V, Lawson M, eds. (2nd ed) Clinical Paediatric Dietetics Boston: Blackwell (in press)
  2. Secker D, Pencharz MB. Nutritional therapy for children on CAPD/CCPD: Theory and practice. In: Fine RN, Alexander SR, Warady BA eds. CAPD/CCPD Children (2nd edition). Boston: Kluwer Academic 1998:567-603
  3. K/DOQITM clinical practice guidelines for nutrition in chronic renal failure II. Pediatric guidelines. Am J Kid Dis 2000;35(Suppl 2):S105-S136
  4. Coleman JE, Norman LJ, Watson AR. Provision of dietetic care in children on chronic peritoneal dialysis J Renal Nut 1999;9:145-148
  5. Watson AR, Gartland G on behalf of the European Paediatric Peritoneal Working Group. Guidelines by an ad hoc European committee on elective peritoneal dialysis in pediatric patients. Perit Dial Int (in press).
  6. Frizancho AR. New norms of upper limb fat and muscle areas for assessment by nutritional status. Am J Clin Nutr 1981;34:2540-2545
  7. Cole TJ, Freeman UV, Preece MA. Body mass index reference curves for the UK 1990. Arch Dis Child 1995;73:25-29
  8. Department of Health Report on Health and Social Subjects No 41. Dietary Reference Values for Food, Energy and Nutrients for the United Kingdom. London:HMSO, 1991
  9. Edefonti A, Picca M, Damioni B, Loi S, Chio L, Giani M, Consaluo G, Grassi MR. Dietary prescription based on estimated nitrogen balance during peritoneal dialysis. Pediatr Nephrol 1999;13:253-258
  10. Quan A, Baum M. Protein losses in children on continuous cyclic peritoneal dialysis. Pediatr Nephrol 1996;10:728-731
  11. Yeun JY, Kaysen GA. Factors influencing serum albumin in dialysis patients. Am J Kidney Dis 1998;32 (Suppl 4):S118-125.
  12. Anonymous. European best practice guidelines for the management of anaemia in patients with chronic renal failure. Working Party for European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure. Nephrol Dial Transpl 1999;14 (suppl 5):1-50
  13. Makoff R, Dwyer J, Rocco MV. Folic acid, pyridoxine, cobalamin and homocysteine and their relationship to cardiovascular disease in end-stage renal disease. J Ren Nutr 1996;6:2-11
  14. Coleman JE. Micronutrient supplements for children. Br J Ren Med 1998;3:21-23.
  15. Warady BA, Kriley M, Uri SA et al. Vitamin status of infants receiving long term peritoneal dialysis. Paediatr Nephrol 1994;8:354-356
  16. Kriley M, Warady BA. Vitamin status of pediatric patients receiving long term peritoneal dialysis. Am J Clin Nutr 1991;53:1476-1479
  17. Norman LJ, Coleman JE, Watson AR et al Nutritional supplements and elevated serum vitamin A levels in children on chronic dialysis J Hum Nut Diet 1996, 9 25-262
  18. Schaefer F. Adequacy of peritoneal dialysis in children. In: Fine RN, Alexander SR, Warady BA, eds CAPD/CCPD in Children (2nd edition), Boston: Kluwer Academic Publishers, 1998:99-118.
  19. Wright E, Gartland CE, Watson AR. An update programme for children on home peritoneal dialysis. EDTNA/ERCA 1995;3:25-27.
  20. Watson AR, Coleman JE, Warady BA. When and how to use nasogastric and gastrostomy feeding for nutritional support in infants and children on CAPD/CCPD, in Fine RN, Alexander SR, Warady BA et al eds. CAPD/CCPD Children (2nd edition). Boston: Kluwer Academic 1998;281-301
  21. Coleman JE, Watson AR, Rance CH, Moore E. Gastrostomy buttons for nutritional support on chronic dialysis. Nephrol Dial Transplant 1998;13:2041-2046.
  22. Tom A, McCauley L, Bell L, Rodd C, Espinosa P, Yu G, Yu J, Girardin C, Sharma A. Growth during maintenance hemodialysis: Impact of enhanced nutrition and clearance. J Pediatr 1999;134:464-471.
  23. Holtta T, Ronnholm K, Jalanko H, Holmberg C. Clinical outcome of pediatric patients on peritoneal dialysis under adequacy control. Pediatr Nephrol 2000 ;14 :889-897.
ADDENDUM
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