Delivery of a nutritional prescription by enteral tube feeding in children with chronic kidney disease stages 2–5 and on dialysis—clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Abstract

The nutritional prescription (whether in the form of food or liquid formulas) may be taken orally when a child has the capacity for spontaneous intake by mouth, but may need to be administered partially or completely by nasogastric tube or gastrostomy device ("enteral tube feeding"). The relative use of each of these methods varies both within and between countries. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) based on evidence where available, or on the expert opinion of the Taskforce members, using a Delphi process to seek consensus from the wider community of experts in the field. We present CPRs for delivery of the nutritional prescription via enteral tube feeding to children with chronic kidney disease stages 2-5 and on dialysis. We address the types of enteral feeding tubes, when they should be used, placement techniques, recommendations and contraindications for their use, and evidence for their effects on growth parameters. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgement. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

Feasibility of percutaneous endoscopic gastrostomy insertion in children receiving peritoneal dialysis

“…18 As a consequence and, in the absence of larger prospective studies, current clinical practice recommendations by Pediatric Renal Nutrition Taskforce suggest open gastrostomy or PLAG in patients already treated with PD, as these techniques are supposed to have a lower risk of periinterventional peritonitis. 13 Theoretically, the surgical procedure limits the risk of infection, as the stomach is secured to the abdominal wall by sutures. 3 For laparoscopic gastrostomy a similar safety profile is reported compared to open gastrostomy, 19 while the incidence of peritonitis after laparoscopic gastrostomy was lower compared to open gastrostomy.…”

“…In general, the use of antibiotic and antimycotic drugs and open or laparoscopic gastrostomy or PLAG have been reported. 12,13 Furthermore, a temporary discontinuation of PD after gastrostomy placement and reduced fill volume after resumption are suggested even if there is a lack of data to prove the benefit of these measures. 12,14 Here, we report on children who received PEG placement during PD under a peri-interventional prophylactic antibacterial and antifungal therapy accompanied by a modified PD programme.…”

“…Placement of PEG in children on peritoneal dialysis (PD) is considered as an additional risk factor for PD-associated peritonitis. 12,13 Therefore, PEG placement is recommended before PD initiation. 13 Only limited data are available about peri-interventional strategies to minimise the risk of peritonitis when PEG insertion is performed after initiation of PD.…”

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

“…In children on PD, the energy intake from dialysate must be considered, with a report of 9.08 ± 4.13 kcal/kg/day contributing to total energy intake [ 73 ], with variation depending on peritoneal glucose exposure and peritoneal membrane transporter status. Dietary modifications for CKD and enteral tube feeding to protect from underweight may also increase the risk of developing obesity if not carefully managed [ 4 , 74 ]; these issues have been discussed in the PRNT’s recommendations on enteral feeding [ 74 ].…”

Early clinical management of autosomal recessive polycystic kidney disease

“…Peritoneal dialysis will require filling of the abdominal cavity, which may add up with enlarged kidneys, although the previously mentioned study on peritoneal dialysis in ARPKD did not find differences in growth or body mass index between the three groups that were compared. The importance of gastrostomies for long-term supplemental or exclusive enteral tube feeding in children with CKD has recently been pointed out by the pediatric renal nutrition taskforce [ 65 ]. There have, however, been concerns about gastrostomies in ARPKD as there have been reports on an increased risk of spleen injury in cases of splenomegaly in patients with liver disease and portal hypertension due to other underlying disorders.…”