Assessment of nutritional status in children with kidney diseases-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Assessment and management of magnesium and trace element status in children with CKD stages 2-5, on dialysis and post-transplantation: Clinical practice points from the Pediatric Renal Nutrition Taskforce

Children and young people with chronic kidney disease (CKD) are at risk for deficiency or excess of magnesium and trace elements. Kidney function, dialysis, medication, and dietary and supplemental intake can affect their biochemical status. There is much uncertainty about the requirements of magnesium and trace elements in CKD, which leads to variation in practice. The Pediatric Renal Nutrition Taskforce is an international team of pediatric kidney dietitians and pediatric nephrologists, formed to develop evidence-based clinical practice points to improve the nutritional care of children with CKD. PICO (patient, intervention, comparator, and outcomes) questions led the literature searches, which were conducted to ascertain current biochemical status, dietary intake, and factors leading to requirements differing from healthy peers, and to guide nutritional care of children with CKD stages 2-5, on dialysis, and post-transplantation. We address the assessment and intervention of magnesium and the trace elements chromium, copper, fluoride, iodine, manganese, selenium, and zinc. We suggest routine biochemical assessment of magnesium. Trace element assessment is based on clinical suspicion of deficiency or excess and their risk factors, including accumulation, losses, medications, nutrient interactions, and comorbidities. In particular, we suggest assessing magnesium, copper, iodine, and zinc when growth is poor, and evaluating magnesium, copper, selenium, and zinc in the presence of proteinuria. A structured approach to magnesium and trace element management, including biochemical, physical, and dietary assessment, is beneficial in the paucity of evidence. Research recommendations are suggested.

Home Enteral Tube Feeding in Children and Young People: A Review of Current Literature on Optimum Frequency and Mode of Dietetic Assessment and Monitoring in the Community Setting

INTRODUCTION

Home enteral nutrition (HEN) is the provision of nutrition support administered via feeding tube designed to support growth and development when oral feeding is not possible. Post-hospital discharge, patients are provided with all necessary enteral feed and equipment for continued nutrition support in the community. Specialist HEN dietitians, typically undertake assessment and monitoring of growth, tolerance and correct administration of HEN within the community. However, national clinical guidelines specific to the assessment and monitoring of children in receipt of HEN do not exist.

AIM

This review sought to identify current evidence on (1) optimum frequency of HEN dietetic reviews and (2) ideal mode of review, including explicit criteria on how this might alter based on the child's age, nutritional parameters and clinical condition.

METHODS

Two electronic databases, CINAHL and Medline were screened to identify relevant articles published between February 2006 and June 2022 that met the inclusion criteria, using a PEO (population, exposure, outcome) search strategy. The search yielded 1677 articles, these were screened by title, abstract and full text for suitability for inclusion within the final review. A total of 1674 articles were excluded, yielding three articles considered suitable for this review.

RESULTS

Recommendations on frequency and mode of assessment and monitoring of this patient group varied between the three articles. There was a lack of consensus on 'ideal' dietetic care, and explicit guidance on how this may alter based on clinical presentation was not provided.

CONCLUSIONS

There is a paucity of evidence on the most effective and efficient assessment and monitoring of children in receipt of HEN. Evidence-based and person-centred clinical guidelines are needed to inform commissioners and healthcare professionals on the optimum monitoring of this patient group. Future research should explore children, family and clinician expectations and needs, with pertinence to patient age and primary diagnosis, type and adequacy of feed used, feed tolerance, tube-related complications and treatment, hydration status, biochemical monitoring, the use of telehealth platforms, obtaining anthropometric measurements and the effects of drug/nutrient interactions.

Malnutrition management in children with chronic kidney disease

Chronic kidney disease (CKD) encompasses diverse conditions such as congenital anomalies, glomerulonephritis, and hereditary nephropathies, necessitating individualized nutritional interventions. Early detection is pivotal due to the heightened risk of adverse outcomes, including compromised growth and increased healthcare costs. The nutritional assessment in pediatric CKD employs a comprehensive, multidisciplinary approach, considering disease-specific factors, growth metrics, and dietary habits. The prevalence of malnutrition, as identified through diverse tools and guidelines, underscores the necessity for regular and vigilant monitoring. Nutritional management strategies seek equilibrium in calorie intake, protein requirements, and electrolyte considerations. Maintaining a well-balanced nutritional intake is crucial for preventing systemic complications and preserving the remaining kidney function. The nuanced landscape of enteral nutrition, inclusive of gastrostomy placement, warrants consideration in scenarios requiring prolonged support, with an emphasis on minimizing risks for optimized outcomes. In conclusion, the ongoing challenge of managing nutrition in pediatric CKD necessitates continuous assessment and adaptation. This review underscores the significance of tailored dietary approaches, not only to foster growth and prevent complications but also to enhance the overall quality of life for children grappling with CKD.

Nutritional management of the child with chronic kidney disease and on dialysis

While it is widely accepted that the nutritional management of the infant with chronic kidney disease (CKD) is paramount to achieve normal growth and development, nutritional management is also of importance beyond 1 year of age, particularly in toddlers, to support the delayed infantile stage of growth that may extend to 2-3 years of age. Puberty is also a vulnerable period when nutritional needs are higher to support the expected growth spurt. Inadequate nutritional intake throughout childhood can result in failure to achieve full adult height potential, and there is an increased risk for abnormal neurodevelopment. Conversely, the rising prevalence of overweight and obesity among children with CKD underscores the necessity for effective nutritional strategies to mitigate the risk of metabolic syndrome that is not confined to the post-transplant population. Nutritional management is of primary importance in improving metabolic equilibrium and reducing CKD-related imbalances, particularly as the range of foods eaten by the child widens as they get older (including increased consumption of processed foods), and as CKD progresses. The aim of this review is to integrate the Pediatric Renal Nutrition Taskforce (PRNT) clinical practice recommendations (CPRs) for children (1-18 years) with CKD stages 2-5 and on dialysis (CKD2-5D). We provide a holistic approach to the overall nutritional management of the toddler, child, and young person. Collaboration between physicians and pediatric kidney dietitians is strongly advised to ensure comprehensive and tailored nutritional care for children with CKD, ultimately optimizing their growth and development.

Comparison of the Efficacy of Indwelling Gastric Tubes in Preoperative and Postoperative Patients With Oral and Maxillofacial Malignancies

PURPOSE

To explore the optimal plan for the timing of indwelling gastric tube placement in oral and maxillofacial malignant tumor patients.

DESIGN

A prospective randomized controlled trial.

METHODS

80 patients with oral and maxillofacial tumor were selected, and 40 patients were Pre-operative group. The remaining 40 patients were the control group, called Postoperative group. The body weight and hospital stay of the two groups were observed before and after surgery. Blood samples were taken before surgery and 1, 3 and 7 days after surgery to detect hemoglobin and plasma albumin.

FINDINGS

The number of postoperative hospitalization days in the pre-operative group was significantly lower than that in the post-operative group; postoperative hemoglobin and plasma albumins were lower in both groups compared with the preoperative level.

CONCLUSIONS

Preoperative nasogastric tube ensured early postoperative administration of gastrointestinal nutrition, promoted postoperative plasma albumin recovery, and shortened the days of hospitalization.

Supporting Infants with Multicystic Dysplastic Kidney Disease: A Comprehensive Approach

Multicystic dysplastic kidney (MCDK) is a congenital renal disease characterized by variable-sized noncommunicative cysts, impeding parenchymal development and functionality. Renal capabilities are relative to the functionality of the contralateral kidney and response to management. Unilateral and isolated cases are often asymptomatic with more positive outcomes, while severe bilateral derangements have a high mortality rate. We present a case of left-sided MCDK and right-sided renal dysplasia diagnosed at a nontertiary center. In addition, we offer a review of the epidemiology, epigenetics, and pathophysiology of MCDK. A concise discussion of prenatal, intrapartum, and postnatal renal function surveillance methods is presented to assist neonatal healthcare providers in collaborating with pediatric nephrology and urology specialists.

Assessment and management of vitamin status in children with CKD stages 2-5, on dialysis and post-transplantation: clinical practice points from the Pediatric Renal Nutrition Taskforce

Children with chronic kidney disease (CKD) are at risk for vitamin deficiency or excess. Vitamin status can be affected by diet, supplements, kidney function, medications, and dialysis. Little is known about vitamin requirements in CKD, leading to practice variation.The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric kidney dietitians and pediatric nephrologists, was established to develop evidence-based clinical practice points (CPPs) to address challenges and to serve as a resource for nutritional care. Questions were formulated using PICO (Patient, Intervention, Comparator, Outcomes), and literature searches undertaken to explore clinical practice from assessment to management of vitamin status in children with CKD stages 2-5, on dialysis and post-transplantation (CKD2-5D&T). The CPPs were developed and finalized using a Delphi consensus approach. We present six CPPs for vitamin management for children with CKD2-5D&T. We address assessment, intervention, and monitoring. We recommend avoiding supplementation of vitamin A and suggest water-soluble vitamin supplementation for those on dialysis. In the absence of evidence, a consistent structured approach to vitamin management that considers assessment and monitoring from dietary, physical, and biochemical viewpoints is needed. Careful consideration of the impact of accumulation, losses, comorbidities, and medications needs to be explored for the individual child and vitamin before supplementation can be considered. When supplementing, care needs to be taken not to over-prescribe. Research recommendations are suggested.

Clearance and nutrition in neonatal continuous kidney replacement therapy using the Carpediem™ system

BACKGROUND

Infants with kidney failure (KF) demonstrate poor growth partly due to obligate fluid and protein restrictions. Delivery of liberalized nutrition on continuous kidney replacement therapy (CKRT) is impacted by clinical instability, technical dialysis challenges, solute clearance, and nitrogen balance. We analyzed delivered nutrition and growth in infants receiving CKRT with the Cardio-Renal, Pediatric Dialysis Emergency Machine (Carpediem™).

METHODS

Single-center observational study of infants receiving CKRT with the Carpediem™ between June 1 and December 31, 2021. We collected prospective circuit characteristics, delivered nutrition, anthropometric measurements, and illness severity Score for Neonatal Acute Physiology-II. As a surrogate to normalized protein catabolic rate in maintenance hemodialysis, we calculated normalized protein nitrogen appearance (nPNA) using the Randerson II continuous dialysis model. Descriptive statistics, Spearman correlation coefficient, Mann Whitney, Wilcoxon signed rank, receiver operating characteristic curves, and Kruskal-Wallis analysis were performed using SAS version 9.4.

RESULTS

Eight infants received 31.9 (22.0, 49.7) days of CKRT using mostly (90%) regional citrate anticoagulation. Delivered nutritional volume, protein, total calories, enteral calories, nPNA, and nitrogen balance increased on CKRT. Using parenteral nutrition, 90 ml/kg/day should meet caloric and protein needs. Following initial weight loss of likely fluid overload, exploratory sensitivity analysis suggests weight gain occurred after 14 days of CKRT. Despite adequate nutritional delivery, goal weight (z-score = 0) and growth velocity were not achieved until 6 months after CKRT start. Most (5 infants, 62.5%) survived and transitioned to peritoneal dialysis (PD).

CONCLUSIONS

Carpediem™ is a safe and efficacious bridge to PD in neonatal KF. Growth velocity of infants on CKRT appears delayed despite delivery of adequate calories and protein.

Optimizing Nutrition in Neonates with Kidney Dysfunction

The nutritional management of neonates with kidney disease is complex. There may be significant differences in nutritional needs based on the duration and cause of kidney dysfunction, including acute kidney injury (AKI) and chronic kidney disease (CKD). Furthermore, the treatment modality, including acute (continuous renal replacement therapy and peritoneal dialysis [PD]) and chronic (intermittent hemodialysis and PD) approaches may differentially affect nutritional losses and dietary needs. In this review, we discuss the pathophysiology of compromised nutrition in neonates with AKI and CKD. We also summarize the existing data and consensus recommendations on the provision of nutrition to neonates with AKI and CKD. We highlight the paucity of data on micronutrient losses and the need for future prospective studies to enhance nutritional supplementation to hopefully improve outcomes in these patients.

Malnutrition and protein energy wasting are associated with severity and progression of pediatric chronic kidney disease

BACKGROUND

Protein energy wasting (PEW), a state of deficient protein storage, is not well understood in children and adolescents with chronic kidney disease (CKD). We aimed to re-define PEW using pediatric malnutrition guidelines from the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN), and to describe the relationship between PEW, malnutrition, and kidney function.

METHODS

This was a retrospective review of outpatients ≤ 20 years old with a diagnosis of CKD from January 1, 2013, to August 31, 2018. Malnutrition was diagnosed by a licensed dietitian, and PEW was diagnosed using an updated definition incorporating AND/ASPEN malnutrition guidelines. Logistic regression and linear mixed effects modeling were performed on the relationship of malnutrition and PEW to estimated glomerular filtration rate (eGFR).

RESULTS

The 142 patients included in this analysis had a median age of 11.1 years and median eGFR of 57 ml/min/1.73 m2 at initial visit. Malnutrition was diagnosed in 50% of patients in at least one visit, and 17.6% met ≥ 2 PEW criteria. Patients with eGFR < 30 ml/min/1.73 m2 had significantly increased risk of malnutrition [OR 2.5, 95% CI 2.0-3.3] (p < 0.001) and PEW [OR 4.9, 95% CI 3.0-8.0] (p < 0.001). A diagnosis of malnutrition or PEW was associated with worse eGFR by logistic regression (p = 0.01 and p = 0.001, respectively) and more rapid eGFR decline by linear mixed effects model (p = 0.002 and p < 0.001, respectively) compared to those without these diagnoses.

CONCLUSIONS

Malnutrition and PEW are prevalent in pediatric CKD and are associated with significantly lower eGFR and more rapid decline in eGFR, emphasizing the need to address nutritional status. A higher resolution version of the Graphical abstract is available as Supplementary information.

Estimating Total Energy Expenditure to Determine Energy Requirements in Free-Living Children With Stage 3 Chronic Kidney Disease: Can a Structured Approach Help Improve Clinical Care?

OBJECTIVE

Malnutrition and obesity are complex burdensome challenges in pediatric chronic kidney disease (CKD) management that can adversely affect growth, disease progression, wellbeing, and response to treatment. Total energy expenditure (TEE) and energy requirements in children are essential for growth outcomes but are poorly defined, leaving clinical practice varied and insecure. The aims of this study were to explore a practical approach to guide prescribed nutritional interventions, using measurements of TEE, physical activity energy expenditure (PAEE), and their relationship to kidney function.

DESIGN AND METHODS

In a cross-sectional prospective age-matched and sex-matched controlled study, 18 children with CKD (6-17 years, mean stage 3) and 20 healthy, age-matched, and gender-matched controls were studied. TEE and PAEE were measured using basal metabolic rate (BMR), activity diaries and doubly labeled water (healthy subjects). Results were related to estimated glomerular filtration rate (eGFR). The main outcome measure was TEE measured by different methods (factorial, doubly labeled water, and a novel device).

RESULTS

Total energy expenditure and PAEE with or without adjustments for age, gender, weight, and height did not differ between the groups and was not related to eGFR. TEE ranged from 1927 ± 91 to 2330 ± 73 kcal/d; 95 ± 5 to 109 ± 5% estimated average requirement (EAR), physical activity level (PAL) 1.52 ± 0.01 to 1.71 ± 0.17, and PAEE 24 to 34% EAR. Comparisons between DLW and alternative methods in healthy children did not differ significantly, except for 2 (factorial methods and a fixed PAL; and the novel device).

CONCLUSION

In clinical practice, structured approaches using supportive evidence (weight, height, BMI sds), predictive BMR or TEE values and simple questions on activity, are sufficient for most children with CKD as a starting energy prescription.

Nutritional management of children with acute kidney injury-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

The nutritional management of children with acute kidney injury (AKI) is complex. The dynamic nature of AKI necessitates frequent nutritional assessments and adjustments in management. Dietitians providing medical nutrition therapies to this patient population must consider the interaction of medical treatments and AKI status to effectively support both the nutrition status of patients with AKI as well as limit adverse metabolic derangements associated with inappropriately prescribed nutrition support. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPR) for the nutritional management of children with AKI. We address the need for intensive collaboration between dietitians and physicians so that nutritional management is optimized in line with AKI medical treatments. We focus on key challenges faced by dietitians regarding nutrition assessment. Furthermore, we address how nutrition support should be provided to children with AKI while taking into account the effect of various medical treatment modalities of AKI on nutritional needs. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. CPRs will be regularly audited and updated by the PRNT.

Nutrition in Children With Chronic Kidney Disease: How to Thrive?

The nutritional status and management of children with chronic kidney disease (CKD) are complex and require a combined pediatric nephrology team work approach with physicians, nutritionists, nurses, and physical/occupational therapists. Prospective observational studies such as Children with CKD in the US, the 4C study in Europe and the International Pediatric Peritoneal Dialysis Network have advanced the field. However, most recommendations and guidelines from international task forces such as Kidney Diseases Improving Global Outcomes and Pediatric Renal Nutrition Taskforce are opinion-based rather than evidence-based. There is exciting ongoing research to improve nutrition in children with CKD to help them thrive.

Dietary intake, body composition and micronutrient profile of patients on maintenance hemodialysis attending Kiruddu National Referral Hospital, Uganda: A cross sectional study

Patients on maintenance hemodialysis are at a great risk for altered nutritional status, characterized by protein energy wasting and micronutrient deficiency due to medication interactions and dietary restrictions. This study determined the dietary intake, micronutrient profile and body composition of patients on maintenance hemodialysis at Kiruddu National referral hospital (KNRH), Uganda. A cross sectional study was done among adult CKD patients on maintenance hemodialysis therapy at KNRH. Data concerning patients' demographics, clinical history and dietary intake was obtained using interactive and quantitative food frequency questionnaires. Body composition was obtained using the TANITA BC-351, Japan weighing Bathroom scale and anthropometric measurements using standard methods and procedures. Serum micronutrient profile assessment was done using the COBAS Auto analyzer. Data analysis was done using the SPSS software version 20. T-test was used to make comparisons and logistic regression analysis was done to check for any correlations. A P-value of < 0.05 was considered statistically significant. Among the 63 hemodialysis patients, 38% were female, with a median duration of hemodialysis of 12 months and the overall age range of patients was 31-40 years. Majority (92.1%) of the patients had hypertension. Carbohydrates like maize flour were highly consumed, in addition to eggs among the proteins on the daily basis. Fruits and vegetables were not highly consumed. Regarding body composition; 75% of the study participants had normal Body mass Index (BMI), the mean muscle mass was 51.94±8.68, body fat was 15.25±7.35, bone mass was 2.77±0.46 and body water was 62.04±9.06. Patients had deranged micronutrient levels especially for Vitamin D, Potassium and phosphorus. In conclusion, hemodialysis patients at KNRH, have altered nutritional status as evidenced by altered body weight for some patients and deranged micronutrient levels. We recommend that hemodialysis patients should be regularly assessed for nutritional status, appropriately treated and educated about their nutritional status.

Nutrition for critically ill children and neonates requiring dialysis: Application of clinical practice recommendations

Approximately 30% of all children and neonates admitted to the intensive care unit (ICU) experience acute kidney injury (AKI). Children with AKI are largely poorly fed and experience high rates of malnutrition. Nutrition prescription and provision are exceptionally challenging for critically ill neonates, infants, and children with AKI given the dynamic nature of AKI and its respective treatment modalities. Managing the nutrition prescription of critically ill neonates, infants, and children with AKI requires nutrition support clinicians to have a high-level understanding of the various treatment modalities for AKI, which can affect the patient's protein, fluid, electrolyte, and mineral needs. Accurate and timely nutrition assessment in critically ill neonates and children with AKI can be flawed owing to difficulty obtaining accurate anthropometric parameters. Recently, the Pediatric Renal Nutrition Taskforce introduced clinical practice recommendations for the nutrition management of children with AKI. In this review, we will discuss the practical implications of these recent guidelines and work to bridge the knowledge and practice gaps for pediatric and neonatal nutrition support clinicians providing nutrition therapy for patients with AKI in the ICU. We also appraise special nutrition-related considerations for neonates with AKI given newer available renal replacement treatment modalities.

Diagnosis and management of mineral and bone disorders in infants with CKD: clinical practice points from the ESPN CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce

BACKGROUND

Infants with chronic kidney disease (CKD) form a vulnerable population who are highly prone to mineral and bone disorders (MBD) including biochemical abnormalities, growth retardation, bone deformities, and fractures. We present a position paper on the diagnosis and management of CKD-MBD in infants based on available evidence and the opinion of experts from the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce.

METHODS

PICO (Patient, Intervention, Comparator, Outcomes) questions were generated, and relevant literature searches performed covering a population of infants below 2 years of age with CKD stages 2-5 or on dialysis. Clinical practice points (CPPs) were developed and leveled using the American Academy of Pediatrics grading matrix. A Delphi consensus approach was followed.

RESULTS

We present 34 CPPs for diagnosis and management of CKD-MBD in infants, including dietary control of calcium and phosphate, and medications to prevent and treat CKD-MBD (native and active vitamin D, calcium supplementation, phosphate binders).

CONCLUSION

As there are few high-quality studies in this field, the strength of most statements is weak to moderate, and may need to be adapted to individual patient needs by the treating physician. Research recommendations to study key outcome measures in this unique population are suggested. A higher resolution version of the Graphical abstract is available as Supplementary information.

Rural-urban differentials in child body mass index over time

BACKGROUND

The body mass index is a simple index based on weight and height that can be used to screen children and adults for potential weight problems. The objective of this study was to investigate urban-rural variations in child BMI and its distribution from 2006 to 2016 in four low and middle-income countries.

METHODS

This study used data from the Young Lives prospective cohort study conducted in Ethiopia, India, Peru, and Vietnam to assess the BMI change for children aged 5 to 15 between 2006 and 2016. We adopted a mixed-effect model to analyze the data.

RESULTS

The study revealed substantial changes and rises in BMI in Vietnam, Peru, India, and Ethiopia between 2006 and 2016. Peru had the highest BMI changes in both urban-rural areas. A low BMI was observed in Ethiopia and India. Urban-rural differences had a significant role in determining BMI variation. In urban Ethiopia, the mean BMI increased from 14.56 kg/m2 to 17.52 kg/m2, and in rural areas, it increased from 14.57 kg/m2 to 16.67 kg/m2. Similarly, in urban Vietnam, the BMI increased from 16 kg/m2 to 20.3 kg/m2, and in rural areas, it increased from 14.69 kg/m2 to 18.93 kg/m2.

CONCLUSIONS

The findings showed an increase in BMI changes in Ethiopia, India, Peru, and Vietnam from 2006 to 2016. Urban-rural differences have a significant contribution to determining BMI variation.

Nutrition Management for Chronic Kidney Disease: Differences and Special Needs for Children and Adults

Common goals of nutritional therapy across the spectrum of pediatric and adult chronic kidney disease (CKD) include maintaining normal body mass and composition and reducing associated morbidity and mortality. Adult nephrologists caring for children and adolescents may be challenged by the existing complexities in identifying and interpreting the nutritional status and growth in children. Pediatric nephrologists may face situations that call for a sound knowledge of assessing nutritional status and providing nutrition therapy for adolescents and young adults. One important additional nutrition goal in children is to achieve normal growth and development. Children are growing and therefore need more calories and nutrients than just maintaining their body weight and composition. Lack of weight and height gain actually is considered failure to thrive in children. Some fundamental differences in approaches to nutritional therapy in CKD are necessitated based on the etiology of CKD. A large proportion of adults with CKD are diabetics, so the approach would be a low-carbohydrate diet. Children with CKD, especially young ones, often are anorexic, so calorie supplements that could include quite a lot of carbohydrates often are prescribed. More adults with CKD have hypertension and atherosclerotic comorbidities, which result in recommendations for low-salt and low-fat diets. Children with CKD often have salt and electrolyte wasting disease states and would require normal- or even high-salt diets, and fats often are included in supplements to bolster calorie intake. Low-protein diets often are recommended in adults with predialysis CKD to slow disease progression. Children are growing and have a higher protein daily requirement. Low-protein diets have not been found to be efficacious in children with CKD, in achieving normal growth, or in slowing disease progression. Adult nephrologists caring for children and adolescents may be challenged by the existing complexities in identifying and interpreting nutritional status and growth in children. Pediatric nephrologists may face situations that call for a sound knowledge of assessing nutritional status and providing nutrition therapy for adolescents and young adults. This article discusses the differences in the assessment of nutritional status between children and adults, as well as provides a comprehensive approach to nutritional management for CKD across the age spectrum. Semin Nephrol 43:x-xx © 2023 Elsevier Inc. All rights reserved.

Malnutrition Patterns in Children with Chronic Kidney Disease

Malnutrition is frequent in children with chronic kidney disease (CKD). Apart from undernutrition and protein energy wasting (PEW), overnutrition prevalence is rising, resulting in fat mass accumulation. Sedentary behavior and unbalanced diet are the most important causal factors. Both underweight and obesity are linked to adverse outcomes regarding renal function, cardiometabolic risk and mortality rate. Muscle wasting is the cornerstone finding of PEW, preceding fat loss and may lead to fatigue, musculoskeletal decline and frailty. In addition, clinical data emphasize the growing occurrence of muscle mass and strength deficits in patients with fat mass accumulation, attributed to CKD-related wasting processes, reduced physical activity and possibly to obesity-induced inflammatory diseases, leading to sarcopenic obesity. Moreover, children with CKD are susceptible to abdominal obesity, resulting from high body fat distribution into the visceral abdomen compartment. Both sarcopenic and abdominal obesity are associated with increased cardiometabolic risk. This review analyzes the pathogenetic mechanisms, current trends and outcomes of malnutrition patterns in pediatric CKD. Moreover, it underlines the importance of body composition assessment for the nutritional evaluation and summarizes the advantages and limitations of the currently available techniques. Furthermore, it highlights the benefits of growth hormone therapy and physical activity on malnutrition management.

Nutritional management of the infant with chronic kidney disease stages 2-5 and on dialysis

The nutritional management of children with chronic kidney disease (CKD) is of prime importance in meeting the challenge of maintaining normal growth and development in this population. The objective of this review is to integrate the Pediatric Renal Nutrition Taskforce clinical practice recommendations for children with CKD stages 2-5 and on dialysis, as they relate to the infant from full term birth up to 1 year of age, for healthcare professionals, including dietitians, physicians, and nurses. It addresses nutritional assessment, energy and protein requirements, delivery of the nutritional prescription, and necessary dietary modifications in the case of abnormal serum levels of calcium, phosphate, and potassium. We focus on the particular nutritional needs of infants with CKD for whom dietary recommendations for energy and protein, based on body weight, are higher compared with children over 1 year of age in order to support both linear and brain growth, which are normally maximal in the first 6 months of life. Attention to nutrition during infancy is important given that growth is predominantly nutrition dependent in the infantile phase and the growth of infants is acutely impaired by disruption to their nutritional intake, particularly during the first 6 months. Inadequate nutritional intake can result in the failure to achieve full adult height potential and an increased risk for abnormal neurodevelopment. We strongly suggest that physicians work closely with pediatric renal dietitians to ensure that the infant with CKD receives the best possible nutritional management to optimize their growth and development.

Analysis of dynamic change of nutrition status in primary school children of Furong District of Changsha City from 2019 to 2020

OBJECTIVE

To analyze the nutritional status of primary school children in Furong District of Changsha from 2019 to 2020.

METHODS

The physical examination data of students from 35 primary schools (grade 1-6) in Furong District of Changsha in Hunan Provincial People's Hospital from September 2019 to October 2020 were analyzed retrospectively. General information of all children was collected for statistical analysis of malnutrition among children of different gender and age groups.

RESULT

The overnutrition rate was 32.73% in 2020. This was 7.42% higher than 25.31% in 2019. The undernourishment rate was 4.70% in 2020. This was 3.94% lower than 8.64% in 2019. In 2019 and 2022, the obesity and overweight rates of boys were higher than those of girls (both P < 0.05). The rates of growth retardation (0.36%, 0.37%) for boys were higher than those for girls (0.27%, 0.24%). The rates of mild wasting (4.31%, 2.36%) were lower than those for girls (4.00%, 2.39%) in 2020 and 2019. The rates of moderate and severe wasting (4.06%, 1.98%) were higher than those for girls (2.75%, 1.47%). In 2020, the undernourishment rate for boys decreased by 4.02% compared to 2019. The undernourishment rate for girls decreased by 2.91% compared to 2019. The growth retardation rate for boys increased by 0.01% compared to 2019. The growth retardation rate for girls decreased by 0.03% compared to 2019. The mild wasting rate for boys decreased by 1.95% as compared to 2019. The mild wasting rate for girls decreased by 1.61% as compared to 2019. The moderate to severe emaciation rate in boys was 2.08% lower in 2020 than in 2019 and 1.28% lower in girls than in 2019. The malnutrition rates of children aged 6-11 decreased by 4.20%, 4.85%, 3.83%, 9.45%, 6.65%, and 6.45% in 2020 compared with that of 2019.

CONCLUSION

Compared to 2019, the primary school students in Furong District had abnormal nutritional status in 2020. It is necessary to strengthen the management of children's health care to ensure the healthy growth of children.

Utility of muscle ultrasound in nutritional assessment of children with nephrotic syndrome

BACKGROUND

Nutritional status assessment in children with nephrotic syndrome (NS) is critical for identifying patients who are at risk of protein-energy wasting (PEW) and for determining their nutritional needs and monitoring nutritional intervention outcomes.

METHODS

In a case-control study, we enrolled 40 children (age range: 2-16 years) with NS and 40 apparently healthy children (age and sex-matched) as a control group. Anthropometric data, as well as demographic, clinical, and laboratory data, were collected. A dietary intake assessment using a 3-day food intake record was done, and the quadriceps rectus femoris thickness (QRFT) and quadriceps vastus intermedius thickness (QVIT) were assessed using B-mode ultrasound and compared between both groups.

RESULTS

Children with NS had lower QRFT and QVIT measurements than control groups (p < 0.001). Inadequacy in protein intake occurred in 62.5% and 27.5% of the NS and control groups, respectively (p = 0.002). The thickness of the rectus and vastus muscles by ultrasound was significantly associated with the percentage of protein intake (p < 0.001). The ROC curve revealed that the best cutoff value of QRFT for the prediction of the patient at risk of malnutrition was ≤ 1.195 with an area under curve of 0.907, with p < 0.001.

CONCLUSION

In children with NS, skeletal muscle ultrasound is a simple and easy-to-use bedside technique for the identification of patients at risk of malnutrition. A higher resolution version of the Graphical abstract is available as Supplementary information.

Managing the Nutritional Requirements of the Pediatric End-Stage Kidney Disease Graduate

The pediatric patient with end-stage kidney disease who transitions to the adult dialysis unit or nephrology center requires a unique nutritional focus. Clinicians in the adult center may be faced with complex issues that have often been part of the patient's journey since early childhood. The causes of kidney disease in children are often quite different than those which affect the adult population and may require different nutritional priorities. Abnormal growth including severe short stature, underweight, overweight or obesity, and poor musculature may affect the long-term health and psychosocial well-being of these patients. Nutritional assessment of these patients should include a focus on past growth and anthropometric data, dietary information, including appetite, quality of diet, and assessment of biochemical data through a pediatric lens. This review discusses the unique factors that must be considered when transitioning pediatric patients and notes major recommendations from a compilation of pediatric guideline statements.

Subjective global nutritional assessment [SGNA] in children on chronic dialysis- A prospective observational study

Introduction:

Nutritional assessment in children undergoing chronic dialysis is challenging as no single objective reference tool is available. There is a need to explore the application of the subjective global nutritional assessment (SGNA) tool in these children. This study assessed the nutritional status of children on chronic dialysis using SGNA, evaluated the utility of SGNA parameters in the longitudinal assessment of nutrition, and compared the SGNA tool with other nutritional measures.

Methods:

Children 2-18 years of age on chronic dialysis for at least 1 month were prospectively studied over a period of 18 months with two follow-up visits at least 3 months apart. Malnutrition was diagnosed by SGNA (well-nourished, moderately, and severely malnourished), mid-arm circumference <5^th centile for age and gender, and serum albumin <3.8 g/l at baseline and follow-up.

Results:

In 41 children on dialysis (age: 124.8 ± 32 months), 73% had moderate or severe malnutrition by SGNA. Height for age (P = 0.008), weight for height (P = 0.004), dietary intake (P = 0.025) functional capacity (P = 0.001), loss of subcutaneous fat (P < 0.001), and muscle wasting (P < 0.001) were significantly associated with the presence and severity of malnutrition. SGNA showed a poor agreement with MUAC and serum albumin. On follow-up, there was no significant change in the category of nutritional status (P = 0.63) and no individual SGNA parameter was associated with the presence or severity of malnutrition.

Conclusion:

Two-thirds of the children on chronic dialysis were diagnosed with moderate to severe malnutrition by SGNA, while the majority remained in the same category of nutritional status on follow-up. Only half of the parameters used for assessment were strongly associated with the presence and severity of malnutrition. SGNA showed a poor agreement with objective nutritional measures and was not responsive in identifying a change in the nutritional status on follow-up.

Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Obesity and metabolic syndrome (O&MS) due to the worldwide obesity epidemic affects children at all stages of chronic kidney disease (CKD) including dialysis and after kidney transplantation. The presence of O&MS in the pediatric CKD population may augment the already increased cardiovascular risk and contribute to the loss of kidney function. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists who develop clinical practice recommendations (CPRs) for the nutritional management of children with kidney diseases. We present CPRs for the assessment and management of O&MS in children with CKD stages 2-5, on dialysis and after kidney transplantation. We address the risk factors and diagnostic criteria for O&MS and discuss their management focusing on non-pharmacological treatment management, including diet, physical activity, and behavior modification in the context of age and CKD stage. The statements have been graded using the American Academy of Pediatrics grading matrix. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. Research recommendations are provided. The CPRs will be periodically audited and updated by the PRNT.

Nutritional Assessment and Management in Paediatric Chronic Kidney Disease

Nutrition in paediatrics has always been one of the most important factors for optimal growth. Children with chronic kidney disease (CKD) need special consideration for better long-term outcomes, including nutritional status, optimal height, and cognitive function. Nonetheless, there are many obstacles to overcome to attain optimal linear growth and nutritional status in children with CKD. This review highlights the need for tools to assess the growth parameters in CKD. In addition, recommendations for dietary intake play a major role in controlling electrolyte disturbances in patients with CKD. For example, it is still unclear whether it is better to restrict phosphate sources in inorganic, organic, or food additives. The review also summarises different factors such as fluid intake, route of feeding, and essential nutrients that require particular attention in paediatric patients with CKD. In summary, a multidisciplinary team is needed to devise individual nutritional plans to achieve the best outcome and improve the quality of life of patients.