The importance of nutrition in normal growth 1 Methods of assessing nutritional status 2 3 Anthropometric measures 2 2 4 5 6 9 Dietary assessment 10 3 11 2 Serum albumin 12 13 14 15 16 17 18 Dual energy X-ray absorptiometry (DEXA) and other methods 19 2 Nutritional requirements for normal children Recommended daily amounts (RDA) and recommended intakes (RI) for energy, protein and nutrients vary between countries. Regardless of the national dietary recommendations that are used it is important to consider that these are estimates of requirements for normal healthy populations of people and are not recommendations for absolute intakes for individuals. They serve as a guide for the energy and nutrients that an individual may require for normal growth, maintenance, development and activity. Requirements for any particular nutrient will differ between individuals. 20 The DRV for energy intake is assumed to be normally distributed and is expressed as the estimated average requirement (EAR). For protein and other nutrients, requirements are expressed as reference nutrient intakes (RNI), set at 2 SDs above the average. Therefore, intakes of protein and nutrients above this amount will almost certainly be adequate for all individuals in a population. For some nutrients where there is insufficient data to establish DRVs with great confidence safe intakes are set—a level or range of intake at which there is no risk of deficiency. 1 Table 1 20 mo yr Age EAR RNI RNI RNI RNI Energy (kcal) Protein (g) Calcium (mmol) Iron (mg) Vitamin C (mg) 0–3 mo 115–100/kg 2.1/kg 13.1 1.7 25 4–6 mo 95/kg 1.6/kg 13.1 4.3 25 7–9 mo 95/kg 1.5/kg 13.1 7.8 25 10–12 mo 95/kg 1.5/kg 13.1 7.8 25 1–3 yr 95/kg 1.1/kg 8.8 6.9 30 4–6 yr 90/kg 1.1/kg 11.3 6.1 30 7–10 yr 1,970/day 28.3/day 13.8 8.7 30 Boy 11–14 yr 2,220/day 42.1/day 25.0 11.3 35 Girl 11–14 yr 1,845/day 41.2/day 20.0 14.8 35 Boy 15–18 yr 2,755/day 55.2/day 25.0 11.3 40 Girl 15–18 yr 2,110/day 45.0/day 20.0 14.8 40 Nutritional requirements for children with CRF, on dialysis and post transplant Energy Dietary supplements 21 10 7 22 23 24 Protein 25 7 18 22 10 26 2 3 Table 2 10   Age (yr) RDA (g/kg/day) Protein intake for HD (g/kg/day) Protein intake for PD (g/kg/day) Infants 0–0.5 2.2 2.6 2.9–3.0 0.6–1.0 1.6 2.0 2.3–2.4 Children 1–6 1.2 1.6 1.9–2.0 7–10 1.0 1.4 1.7–1.8 11–14 1.0 1.4 1.7–1.8 Males 15–18 0.9 1.3 1.4–1.5 Females 15–18 0.8 1.2 1.4–1.5 Table 3 27   Age RNI (g/kg/day) Protein intake for HD (g/kg/day) Protein intake for PD (g/kg/day) Infants 0–3 mo 2.1 2.5 2.8–2.9 4–12 mo 1.5–1.6 1.9 2.2–2.3 Children 1–3 yr 1.1 1.5 1.8–1.9 4 yr–puberty 1.0 1.4–1.5 1.7–1.9 Pubertal 1.0 1.3–1.4 1.6–1.8 Post–pubertal 0.9 1.2–1.3 1.4–1.5 Post-transplant protein requirements should match those of normal children. Vitamins and minerals 4 Table 4 28   Infants Children Thiamin (mg) 0.2–0.3 0.5–1.0 Riboflavin (mg) 0.4 0.6–1.3 Niacin (mg) 3.8 8–18 Vitamin B6 (mg) 0.2–0.7 0.7–2.0 Vitamin B12 (μg) 0.3–0.5 0.5–1.5 Folic acid (μg)* 50–500 70–1000 Vitamin C (mg) 25 25–40 Vitamin A (μg)* 350 350–700 Vitamin D (μg)* 7–8.5 – Zinc (mg) 4.0–5.0 5.0–9.5 Copper (μg) 0.2–0.3 0.3–1.0 Vitamin A 29 Vitamin D Folic acid 30 31 2 Infants: 250 μg/kg to maximum of 2.5 mg daily Children 1–5 years: 2.5 mg daily Children >5 years: 5 mg daily 32 33 27 Vitamin C: 15 mg (infants)-60 mg (children) daily Vitamin B6: 0.2 mg (infants)-1.5 mg (children) daily Folate: 60 μg (infants)-400 μg (children) daily 34 10 There are no reported specific micronutrient requirements for children on HD and post transplant and 100% of the RNIs can be considered the goal for these children. Calcium and phosphate 2 Infants <10 kg: <400 mg daily Children 10–20 kg: <600 mg daily Children 20–40 kg: <800 mg daily Children >40 kg: <1,000 mg daily Iron, copper and zinc 35 10 Reports of spontaneous nutritional intake in children with CRF 2 36 14 12 37 2 38 39 2 40 13 35 38 35 37 40 41 37 40 42 The epidemiology of nutritional disturbances in renal disease, including height, weight and body composition Height and weight 43 44 46 43 46 47 49 50 43 47 43 46 2 51 53 2 44 54 55 56 50 57 58 43 46 59 Body composition 25 60 61 62 63 64 65 66 The pathological mechanisms underlying poor appetite, abnormal metabolic rate and endocrine disturbances in renal disease 67 68 69 68 69 70 67 69 68 69 71 72 73 71 73 74 Evidence for the benefit of dietetic input, dietary supplementation, nasogastric and gastrostomy feeds and intradialytic feeding 75 76 77 11 40 Dietary supplements 21 47 78 83 84 86 11 87 88 89 86 78 2 21 2 47 79 80 82 83 84 85 86 87 88 11 89 90 21 80 81 85 89 91 80 81 91 2 2 2 91 2 81 80 21 85 89 92 93 94 95 21 96 97 21 21 47 54 79 88 92 Essential aminoacid (EAA) supplements 98 99 100 2 101 102 Amino acid-containing peritoneal dialysis solutions 103 104 105 106 107 106 107 108 106 107 109 Intradialytic parenteral nutrition (IDPN) 110 111 112 113 Nutritional causes of poor growth not related to energy and protein Sodium 83 Acidosis 114 115 83 116 117 Anaemia 118 122 Vitamin D 123 124 125 126 Growth hormone There may be cases when, despite at least 6 months of adequate nutrition, growth continues to be poor. GH may be offered in these circumstances. The effect of dialysis adequacy on nutrition 2 2 127 128 129 130 131 2 2 132 133 134 The role of nutrition in the outcome of children with CRF 12 135 4 136 In conclusion Multiple choice questions (Answers appear following the reference list) true false Rate of growth is highest during prenatal life 50% of final height is achieved by the age of 2 years The infantile phase of growth is principally dependent on growth hormone Growth rate stays the same throughout the childhood phase of growth A pubertal growth spurt can occur without the development of secondary sexual characteristics It may be more appropriate to express measures of growth according to height age rather than chronological age The height standard deviation score (HtSDS) is the number of standard deviations from the mean for a normal population of the same age and sex 2 Low serum albumin is always an indication of malnutrition Peritonealprotein losses in dialysate are twofold greater in relation to body surface area in infants than in those >50 kg in weight The estimated protein requirement for a normal healthy 30-week-old girl weighing 6.0 kg (0.4th centile) and 59.0 cm in length (<0.4th centile) is >2.1 g/kg/day Her estimated energy requirement is 150 cal/kg/day The prescribed dietary protein intake for the same child on PD would be 2.8–3.0 g/kg/day Children with CRF or on dialysis need a calorie intake that exceeds the EAR for height age Supplements of vitamin A are necessary in children on dialysis Abnormal taste sensation can occur in CRF and on dialysis Leptin is produced by adipocytes and levels are high in CRF and on dialysis High leptin levels cause an increase in food intake and metabolic rate GH levels are normal or high and IGF-1 levels are low in CRF GH levels are normal or high and IGF-1 levels are low in malnutrition Salt restriction is important in all children with CRF Nutritional supplementation has not been shown to benefit children over two years of age Increasing dialysis dose in PD may increase peritoneal dialysate protein losses and contribute to obesity Sodium supplementation may be necessary in children on PD Gastrostomy placement is preferable before PD commences