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Controlled Enteral and Parenteral
Nutrition in Children on Dialysis

27

Bethany J. Foster and Anne Tsampalieros

Introduction
Growth retardation is common among children
with chronic kidney disease (CKD). As a result,
adequacy of nutritional intake is a frequent preoccupation of professionals caring for these children. While optimized oral intake is preferred,
this is not always feasible. When oral intake is
insufficient to meet requirements for normal
growth and development, enteral or, less commonly, parenteral nutritional supplementation is
needed. Enteral nutrition, via nasogastric or gastrostomy tube, is always preferred over the parenteral route.
This chapter will review the rationale for
nutritional supplementation in pediatric CKD,
causes of inadequate intake, indications for
enteral and parenteral nutritional supplements,
and evidence for the benefits of each method of
supplementation. We will also consider the
advantages and disadvantages of nasogastric versus gastrostomy tube feeding, highlight the
potential complications of each, and review the

B. J. Foster (*)
Department of Pediatrics, Montreal Children’s
Hospital of the McGill University Health Centre,
Montreal, QC, Canada
e-mail:
A. Tsampalieros
Children’s Hospital of Eastern Ontario Research
Institute, Ottawa, ON, Canada
e-mail:

challenges of transitioning to full oral feeding
after a period of tube feeding.

Rationale for Nutritional
Supplementation in Pediatric CKD
Growth impairment, defined as a height-for-age
or height velocity-for-age standard deviation
score (SDS) of less than −1.88, [1, 2], is a common complication of pediatric CKD.  In the
period 1992–2001, 40.5% of children undergoing
kidney transplant had a height more than 2.0 SD
below the average for children of the same age
and sex. Although this percentage dropped to
32.8% in the interval 2002–2011, growth restriction remains very prevalent [3]. Severe (height-­
for-­age SDS  <  −3.0) and moderate
(−3.0 > height-for-age SDS < −2.0) growth failure are associated with an increased risk of mortality [4] and poorer quality of life [5]. Children
starting dialysis with a height-for-age less than
the first percentile (SDS  <  −2.5) had a twofold
higher risk of death compared to those with a
height-for-age greater than −2.5 SDS [6].

The severity of growth failure is correlated
with the degree of renal impairment and is most
pronounced once the GFR falls below 25  ml/
min/1.73m2 [7–9]. A report from the North
American Pediatric Renal Trials and Collaborative
Studies (NAPRTCS), including more than 5000
children, showed that over 35% of children with
a creatinine clearance <75 ml/min/1.73m2 had a

© Springer Nature Switzerland AG 2021
B. A. Warady et al. (eds.), Pediatric Dialysis, />
489