Feeding dysfunction in infants with severe chronic renal failure after long-term nasogastric tube feeding.

Nasogastric tube feeding (NGTF) is frequently necessary to overcome the inadequate caloric intake of children with severe chronic renal failure (CRF). In a multicenter retrospective study, we evaluated feeding dysfunction after tube feeding withdrawal in children with severe CRF who started long-term enteral nutrition early in childhood. We considered, almost exclusively, infants who had started NGTF very early and continued to be tube fed for at least 9 months. Twelve patients were included in the study: 8 showed significant and persistent eating difficulties, with difficulties in chewing and swallowing in 7 and food refusal in 6. For 2 patients "panic attacks" from swallowing were repeatedly reported. These problems persisted for more than year in 5 patients and between 1 and 6 months in 4. The possible feeding difficulties that may follow NTGF must be carefully evaluated. A possible means of overcoming these difficulties might include: encouraging the use of a pacifier, proposing water for spontaneous assumption, leaving the child the possibility of eating food spontaneously during the daytime, and increased support for the parents during weaning. These need prospective study.

[Alteration of the taste for sugar in renal insufficiency: study in the child]. / Altération du goût pour le sucre dans l'insuffisance rénale: étude chez l'enfant.

Children with chronic renal failure (CRF) show a reduced appetite for sweet foods. Sensory responses to sweet stimuli were investigated in 45 children with CRF, 39 dialyzed patients (HD) and 25 controls(C). Two familiar foods were prepared in 5 sucrose concentrations: 1, 5, 10, 15, 20% for soft white cheese (SWC): 10, 20, 30, 40, 60% for apple sauce (AS). When identifying the sweeter of two SWC samples, CRF(15%) and HD (18%) made more mistakes than C (5%). When testing AS, mistakes were comparable between groups (25, 21, 19%). Preferences differed according to diagnosis group. The sweetest SWC was preferred by 40% of CRF and C and by only 22% HD; the least sweet SWC was preferred by 5% of C, 10% of CRF and 16% of HD. In AS, the highest concentrations were preferred by CRF and C, median concentration by HD. Plasma zinc had no clear effect on taste. Altered preferences for sweet foods in patients suggest post-ingestive adverse effects of sucrose resulting from an altered sucrose metabolism.

[Drinking water]. / L'eau.

Water is essential for life. Thirst is a pressing need which always has to be satisfied. Infants need 3 times more water than adults if the requirements is calculated according to body weight. A correct balance in the sensory, physical, chemical and bacteriological qualities of water make it drinkable. Two laws have been passed recently concerning drinking water in France: one deals with water for human consumption (January 3 1989 decree), and the other deals with drinkable bottled mineral water (June 3 1989 decree). Tap water and bottled water are under strict vigilance. For babies under 4 months of age, it is better to use bottled water with a low mineral content (nitrates less than 15 mg/l). Hard water is safe; water softeners are useful only for hot water. Fluorination supplies of water is good for dental health at a concentration of 1 mg/l. Plastic bottles are as safe as glass ones.

Renal functional reserve in children with reduced renal mass: study by two dietary periods.

It has been suggested that the "renal functional reserve" (RFR) defined by the rise in glomerular filtration rate (GFR) after a protein load could disappear in patients with severe nephron loss but with a normal GFR. This study compared, in 17 children, inulin clearance (Cin) measured by the plasma inulin plateau at the end of two 14-day randomized periods differing in protein intake: 100% (low protein, LP), or 200% (high protein, HP) of recommended dietary allowances (RDA). Diets were aimed at maintaining food habits and energy intake. Compliance was assessed by records of the last 3-4 days, an interview with the dietician and by urinary nitrogen measurements. Mean actual protein intake was 109% (56%-139%) RDA for the LP period and 220% (163%-319%) RDA for the HP period. Cin did not change in 14 children with GFR below (n = 7) or within (n = 7) the normal range. Cin was higher in the HP period than in the LP period (+32, 50, 63%) in 3 children who had a 50% (single kidneys) or a 25% (sclerosed glomeruli) nephron loss. Non-responding children had a GFR below 105 ml/min per 1.73 m2. Nephron loss (70% sclerosed glomeruli) was estimated in only 1 child with no RFR. The results suggest that GFR measurement after prolonged dietary stimulation could help in evaluating the severity of nephron loss in children with normal or borderline GFR. The prognostic value of this test has to be confirmed by long-term follow-up.

Perceptions of and preferences for sweet taste in uremic children.

Uremic children have low energy intakes, with little appetite for sweet foods. Likewise, sucrose-rich diets are poorly accepted by uremic rats, which suggests that uremia causes a relative aversion for sucrose. Hemodialyzed children (no. = 39, mean age = 160 mo) and healthy controls (no. = 25, mean age = 122 mo) were compared for perception of sweet taste intensity in two familiar foods (soft white cheese and apple sauce) and for preference for sweetness. The food stimuli were prepared in five sucrose concentrations: 1%, 5%, 10%, 15%, and 20% for cheese; 10%, 20%, 30%, 40%, and 60% for apple sauce. Children were presented with pairs of stimuli of adjacent concentrations and asked, in a forced choice, to identify the sweeter stimulus and to express their preferences. The hemodialyzed children made more mistakes (19%) than the controls (5%) when asked to rank sweetness in the soft cheese (i.e., with low concentrations). Both groups made an equal number of mistakes when asked to rank sweetness in the apple sauce. Preferences for sweetness were markedly different. In cheese, the highest sucrose concentration was preferred by 21.9% of the hemodialyzed children vs 41% of the controls. The lowest sucrose concentration was selected by 15.6% of the hemodialyzed children vs 4.6% of the controls. Similar preference trends were observed for apple sauce. We conclude that abnormally low preferences for sweet foods can contribute to insufficient caloric intake in uremic children.

[Kidney functional reserve. Studies in humans]. / Réserve fonctionnelle rénale. Etudes chez l'homme.

The glomerular filtration rate (GF) of each nephron can vary, with increases being caused by stimuli such as nephron reduction and ingestion of proteins. This "functional reserve" (FR), detectable by protein load tests, may be lost in extensive renal destruction where the remaining nephrons are in a permanent state of maximal stimulation. If this hypothesis is true, FR determinations would be of greater value than baseline GFR measurements for evaluating the condition of the remaining parenchyma. A very large number of studies have addressed the FR in normal subjects and have used either diets containing variable amounts of proteins or acute loads given orally (approximately 1 g/kg cooked meat) or intravenously (amino acids). All these studies have evidenced increases in the GFR after the load, regardless of its type, but with major variations across studies and patients. Subjects with a single healthy kidney seem to retain a FR whose magnitude is equal to or smaller than the FR in normal subjects. Conflicting data have been reported in more extensive destruction of the parenchyma, where the FR has been shown to either disappear or persist with no change in percentage. Thus, the practical value of GFR determinations after protein loads has not as yet been established and should be specified using better standardized methods that do not rely on creatinine clearance, at least during oral load tests where serum creatinine levels increases and is no longer stable.

[Computer-assisted diet therapy in pediatric kidney diseases]. / Logiciel d'aide à la diététique appliqué à la néphrologie pédiatrique.

The authors present a computer program written in UCSD Pascal) which monitors the dietary management of children with kidney diseases. Diet is established according to height, weight, chronological and statural age and recommended dietary allowances (USRDA). The composition of the prescribed diet and of food intake is given as amounts of animal and vegetable protein, fat, carbohydrates, energy, water, Na, K, Ca, P and renal solute load, per day and per kilo BW as compared to RDA. The amount of food is presented in tabular form, per day, per meal, per feed, or per tube-feeding with the schedule. It is possible to calculate the nutrients of food recipes. The food table includes 500 items, that can be modified as required. The drug table contains 100 items. The program calculates also average food consumption for dietary surveys. Diets, recipes and food tables may be viewed and modified before print out at each step of the calculation. The diet data bank stores 100 diets per floppy disk.

Comparison of three low-nitrogen diets containing essential amino acids and their alpha analogues for severely uremic children.

Six infants, 4.5 to 19 months old, whose creatinine clearance was less than 6 ml/min/1.73 m2 received, successively, three low-nitrogen diets. Diet A contained 9.3 g of human milk protein; and diet B, 4.2 g of human milk protein plus synthetic essential amino acids. Diet C was the same as B except that five essential amino acids were replaced by alpha-keto and hydroxy analogs. Serum urea decreased as the infants were transferred from diet A to diets B and C, and the serum urea/creatinine ratio decreased from diet A to diet B and from diet B to diet C. Urea appearance was 14.8 +/- 4.5, 9.1 +/- 4.3, and 6.9 +/- 1.7 mmoles/day, with diets A, B, and C, respectively. Weight gain was also lowest with diet C, as was the difference between nitrogen intake and urea nitrogen appearance, an indicator of nitrogen balance. Plasma free amino acids were not modified by diets A and B, but valine, leucine, and the plasma free essential amino acid pool decreased significantly with diet C.

Growth and development of nondialyzed children with chronic renal failure.

Thirty-four children with severe kidney disease, either congenital (32 cases) or developing at birth, were followed until age 5 to 19 years. Overall growth retardation corresponded to -2.5 SD below the mean normal values. The retardation occurred almost exclusively before therapy for it was started. Fifteen children were first treated during infancy. In all of them except one, growth was dramatically improved following the first visit to our center, growth changing from slowed to normal rate, although catch-up growth was rare: the average change from normal mean height was -1.68 SD (or -5 SD per year) calculated for the infantile period up to the first visit to our clinic, followed by a change of +0.18 SD per year between first presentation and age 12 months, and +0.01 SD per year between first presentation and last observation at a mean age of 8.3 years. In the 19 patients who were treated after the first year of life, the mean change of height from birth to first presentation was -0.33 SD per year followed by a mean change of -0.04 SD per year up to the last observation (mean period, 7.3 years). Catch-up growth was exceptional. Five children entered puberty with a normal growth spurt. When GFR deteriorated, growth velocity was unchanged. Height calculated for corresponding bone maturity was reduced in half of the patients when first seen, but progressed to the same degree as height during follow-up, except in one patient. Mental development was normal in 31 of 34 patients. Conclusion. Normal growth rate and normal development is possible in children and even in infants with CRF chronic renal failure. The importance of instituting early conservative treatment to prevent height loss must be emphasized.

[Continuous enteral feeding in pediatric nephrology. Long-term results in children with congenital nephrotic syndrome, severe cystinosis and renal failure (author's transl)]. / Nutrition entérale à débit constant en néphrologie pédiatrique. Résultats à long terme de son utilisation dans les néphroses congénitales, les cystinoses graves et les insuffisances rénales.

This is the report of the results obtained with continuous enteral feeding in congenital nephrotic syndrome (3 cases), cystinosis (3 cases) and renal failure (3 cases). Ages of patients at the beginning of treatment ranged from 10 days to 3 years. Enteral nutrition was given for periods ranging from 4 to 37 months; mean energetic intake was 116% of the levels recommended according to developmental age and protein diets were 138%; 115% and 84% of the recommended amounts in nephrotic syndromes, cystinosis and renal failure, respectively. This treatment obtained the survival of most patients. In congenital nephrotic syndromes, growth improved clearly with acceleration of the curve and restoration of plasma albumin level. In cystinosis, a better fluid and electrolyte balance was obtained and growth curve sometimes improved in a spectacular fashion. Finally, in renal failure, effect on growth was favourable in 2 cases and nil in the third: these findings show that normalization of energetic intakes does not induce normal growth in children with uremia.

Plasma and muscle free amino acids in children at the early stages of renal failure.

Plasma and muscle free amino acid analyses have been performed on four groups of children with different levels of renal failure. Mean plasma creatinine of the groups 1 to 4 was respectively 1.3, 2.3, 3.3, and 4.9 mg/100 ml. Significant but different alterations of plasma and muscle amino acid pattern were found in the four groups of patients. In plasma, aspartic acid, citrulline, OH-proline, 1- and 3-methyl histidine were regularly increased, while threonine, valine, phenylalanine, isoleucine, leucine, tryptophane, tyrosine, and tyrosine/phenylalanine ratio were generally decreased. In muscle, glutamine was usually increased and alanine, valine and valine/glycine ratio decreased; significant increase of total amino acid content was only noted in group 4. Some amino acid alterations became worse with renal failure such as 3-methylhistidine increase or tyrosine/phenylalanine decrease, but group 3 patients had the greatest number of individual amino acid alternations. This group of patients also had the highest protein intake. Relationship between growth velocity and muscle amino acid pattern was found, a poor growth rate was associated with an increase of nonessential and essential amino acids with the exception of valine.

Insulin and growth hormone secretion in dialyzed children: influence of dietary manipulation.

The insulin and growth hormone responses to arginine and the growth hormone response to insulin were studied in 10 children undergoing chronic hemodialysis 1) under usual dietary prescription and 2) after 7 days of dietary manipulation (DM) decreasing mean carbohydrate intake from 48 to 36% and increasing lipid intake from 42 to 54% (percent of total energy) with the polyunsaturated/saturated fatty acids ratio being increased from 0.2 to 2. Mean fasting insulin and growth hormone were significantly decreased after DM: 10.3 +/- 3 muunits/ml and 19.9 +/- 3.5 ng/ml before and 4.3 +/- 0.8 muunits/ml and 9.3 +/- 2.4 ng/ml after DM. The mean arginine-induced insulin peak and the growth hormone peaks after arginine and insulin remained very high after DM. There was no decrease of mean plasma triglycerides: 214 +/- 30 mg/dl before and 237 +/- 26 mg/dl after DM. However, two children who had the greatest decrease in carbohydrate intake exhibited a decrease of triglycerides and of arginine-induced insulin secretion. The percent variation of insulin area after DM was significantly correlated with the percent variation of plasma triglycerides.