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WHY IS A SPECIAL DIET NECESSARY ON DIALYSIS ?

Kidneys normally remove waste products such as phosphate, potassium, urea and extra fluid from the body. These waste products and fluids come from foods you eat and liquids you drink. Dialysis is used to help remove these waste products but unlike normal kidneys, it is unable to remove them completely. Diet is therefore important in the management of children on dialysis. The diet will help to control blood levels of phosphate, potassium and urea whilst making sure that your child gets enough energy and protein to grow and gain weight properly.

Dietary advice may change with time and will depend upon your child’s growth and body weight, blood results and appetite. You may be asked to record the food that your child eats over a period of 2 to 4 days to provide the dietician with enough information to advise on any changes required.

The dietary advice is just as important as dialysis and medications that your child may be prescribed

GENERAL AIMS OF THE SPECIAL DIET

the aims of the diet whilst on Dialysis are :

PROVIDE ENOUGH :
Energy and Protein
Vitamins and Minerals
Dietary Fibre

REDUCE INTAKE OF :
Salt (sodium)
Potassium
Phosphate

Drinks may have to be reduced in children who produce little urine. This guide contains information to help your child eat the right diet whilst on dialysis.

Dietary Advice is just as important as the dialysis and medications that your child may prescribed.

ENERGY
The body converts food into energy which is then used or stored. The amount of energy is measured in calories (kcal). Your child will need enough energy in the diet to grow and lead a normal active life.

CARBOHYDRATES (starches and sugars), and FATS AND OILS are the main sources of energy in the diet

CARBOHYDATES
STARCH Eat plenty of :
Breakfast cereals
Bread
Chapatis, pitta bread
Potatoes
Rice
Spaghetti, other pasta

USEFUL TIPS : Vary white and wholemeal bread & wholewheat cereals or bread/cereals containing added dietary fibre. They are also a good source of vitamins and minerals. Don’t forget high fibre cereals are a rich source of phosphate.

SUGAR

For Extra energy have :
Jam, marmalade, honey, sweets, jellies
Sugary squashes, fizzy drinks and Lucozade
Cakes and biscuits

USEFUL TIPS: Flapjack or rice cakes are a great energy snack. Note : - if you are advised to consume more sugary foods and drinks try to protect your teeth by including it at mealtimes rather than as a snack

REMEMBER TO CLEAN YOUR TEETH AT LEAST TWICE A DAY AND AVOID SUGARY DRINKS AFTER YOU HAVE CLEANED YOUR TEETH AT NIGHT

FATS & OILS

Saturated Fats (solid fats) Monounsaturated Fats Polyunsaturated Fats
  • Butter
  • Lard/pastry
  • Olive Oil
  • Rapeseed Oil

Sunflower oil/margarine, corn, groundnut, or canola oils

High fat foods which provide more energy may be encouraged when your child’s appetite is reduced.

Try to have a balance between polyunsaturated and monounsaturated fats.

At meal times Try to swap foods high in saturdated fat for healthier foods containingt mono/polyunsaturdated fat.

A diet high in saturdated fat tends to raise the blood cholesterol level, increasing the risk of heart disease in the future.

TRY TO AVOID
Butter/ghee
Lard/suet
Fatty cuts of meat

TRY TO USE
Olive/vegetable or
sunflower margarine or oil

PROTEIN

Why do we need protein?

Protein is needed for growth, building muscles and the repair of tissues. urea is a waste productof protein metabolism, which is normally excreted into the urine by the kidneys. A build up of urea in the blood is called urawmia and can cause poor appetite or a feeling of sickness. Dialysis helps to remove urea, but it is not as good at removing it as kidneys that are working well. Eating too much protein increases your urea level in the blood. However, it is important your child gets enough to grow properly and replace the protein that is lost in dialysis fluid.

Animal sources of protein

  • Meat
  • Poultry eg: chicken, turkey
  • Fish
  • Milk, yoghurt, fromage frais, cheese and eggs.

Remember: dairy products are high in phosphate.

Daily recommended intake

  • ONE portion of animal rich protein
  • 1-2 portions of vegetable protein (more if following a vegetarian diet)

Vegetable sources of protein

  • Peas, beans and lentils (pulses)
  • Tofu (soya bean curd)
  • Quorn (mycoprotein)

FACT :
A number of high protein body building supplements are available to buy. We would not recommend these products as they put greater demands on kidneys that are not working well.

PHOSPHATE
Calcium and phosphate are important for the growth and development of strong bones. Phosphate is released from food into the stomach during digestion and is then absorbed into the blood. Healthy kidneys clean the blood by removing phosphate. when the kidneys are not working well calcium and phosphate can build up in your blood.

EFFECTS OF HIGH PHOSPHATE
Your child may not be aware of any symptoms of high phosphate level, but serious changes may be happening causing problems in the future.

DAILY PROBLEMS:

  • Itchy skin
  • Red eyes
  • Bone pain
  • Joint pain

SERIOUS PROBLEMS

  • Bone disease
  • Heart disease
  • Build up of mineral deposits in your blood vessels

How to reduce your phosphate intake :

Dairy quota

FACT : symptom Cottage cheese and full fat cream cheese, eg. Philadelphia, contain about half the amount of phosphate compared to other cheeses. Feta and mozzarella cheese are also lower phosphate options.

AVOID : Processed cheese, eg. Primula, Dairylea, Laughing Cow. If your child is finding it difficult to restrict their milk intake there are some alternatives to cows milk, ef. SnoPro, or ProZero. Ask your Dietitian.

PHOSPHATE

Other foods high in phosphate to limit :

Nuts and peanut butter
Cocoa and chocolate
Cola drinks
Shellfish, eg prawn, mussels, fish paste
Oily fish, eg sardine, pilchard, herring & trout

FACT:
Tinned salmon and mackerel are lower in phosphate if the BONES are removed

PHOSPHATE BINDERS work like magnets. they bind to the phosphate released from food in the stomach and stop it from being absored into the blood.

Some phosphate binders can be swallowed whole, whilst others are chewed. The most common ones are made from calcium carbonate.

If you eat snacks between meals you may need to take a phosphate binder with each snack. If you miss a meal you do not need to take a binder.

Speak to your dietician about which is best for you.

POTASSIUM

The postassium in the foods and drinks you consume need to be reduced if the level of potassium in the blood is high. A high level can be dangerous as it can be harmful to the heart.

Your dietician will advise you on the level of restriction required, as this will vary depending upon the amount removed by dialysis and the amount lost in urine.

FOODS LOWER IN POTASSIUM

  • Squash, water, carbonated drinks
  • Apples, pears, satsumas, clementines, raspberries,
  • small portion of grapes
  • Tinned fruit in syrup, eg peaches, mandarin, 1 slice
  • pineapple, plum
  • Vegetables - carrot, cucumber, cauliflower, frozen
  • mixed veg, green pepper
  • Corn, rice, wheat snacks or lightly salted tortilla chips

Remember
Savoury, snacks are high in salt, so should not be eaten every.

TIP
Rather than steaming, grilling, frying or microwaving, boil all vegetables to remove some
potassium and discard the water.

Useful Tip: A portion is equivalent to the amount a child can hold in the palm of one hand.

Speak with your dietician about more detailed advice.

POTASSIUM

FOOD HIGH IN POTASSIUM

Instant coffee, fresh fruit juice, milk shake and takeaway hot chocolate. Milk (keep to your allowance) Bananas, blackcurrants, dried fruit eg raisins or sultanas, honeydew melon, orange, kiwi, mango, blackberries, strawberries.

POTASSIUM

FOOD HIGH IN POTASSIUM

Mushrooms, tomatoes, brussel sprouts, parsnips Potato crisps, chips, jacket potatoes Nuts, fruitcake Plain, milk or white chocolate, coffees and fudge Salt substitutes, eg. Lo Salt Lower salt products may contain potassium instead of sodium, so check the ingredients first.

POTATOES
To help remove potassium it is best to peel, slice and soak potatoes, then boil. After boiling they can be mashed, fried or roasted.

USEFUL TIP:
Red skin potatoes peeled make better chips as they keep their shape after boiling!

More details will be given by your dietician.

SALT

Salt (sodium chloride) makes your body retain water and it can contribute to high blood pressure. Salty food also makes you thirsty.

Salt intake is usually restricted to a NO ADDED SALT DIET. This means you should avoid adding salt when cooking and avoid adding it to food at the table. You should also avoid foods that are high in salt. Below is a list of foods high in salt and some ideas of lower salt foods you could swap to:

Salty foods to avoid or reduce:

  • Salted crisps, nuts, savoury snacks
  • Other tinned foods with added salt Eg baked beans or canned vegetables
  • Smoked meats and fish
  • Bacon, sausages, sausage rolls and other Processed meats
  • Chicken nuggets, dippers/dinosaurs
  • Potato products (waffles, alphabites, faces)
  • Most cheeses, eg cheddar, edam, stilton, Cheese spread, processed cheese
  • Do not use a salt substitute as they are usually high in potassium, eg. Lo Salt

Lower salt alternatives:

  • Lightly salted tortilla chips or corn snacks
  • Sweet snacks instead of savoury
  • Unsmoked meat and fish
  • Low salt stock cube or gravy powder
  • Lower salt tinned products, eg reduced salt baked beans
  • Unsalted margarine
  • Fresh fish, poultry and meat
  • Cottage cheese, full fat soft cheese

FOOD LABELS

Looking at food labels when shopping will allow you to choose foods lower in salt (sodium).

Food labelling often doesn’t show the salt content but instead shows the sodium content (salt is sodium chloride)

On a food label:
Per 100g of food, 0.3g or more of sodium (0.7g salt) is
a lot (food should be avoided).

TOP TIP:
Herbs and spices can be used in cooking instead of sale to add flavour

FLUID

Fluid requirements will depend upon the amount of urine that the kidneys produce and the amount that is removed by dialysis

Fluid requirements will depend upon the amount of urine that the kidneys produce and the amount that is removed by dialysis.

Remember that some foods are mostly fluid and may need to be included within the total fluid allowance such as:

  • Ice lollies
  • Jellies
  • Yoghurt, custard
  • Gravy, sauces
  • Soup

HANDY MEASURES:

  • A mug = 300ml
  • A glass = 200ml
  • A can = 300ml
  • A carton of square = 200ml
  • An average bottle of mineral water = 500ml
  • A tbsp = 15ml
  • A small ice cube = 15ml

TOP TIPS:

  • Divide fluid between meals and snacks throughout the day
  • Suck on ice, frozen, low potassium fruit, eg. Grapes
  • Chew sugar free mints or gum
  • Take medicines with meal time liquids
  • Use a smaller cup
  • Measure cups/glasses so you know how much they hold
  • Use a drinking straw to make drinks last longer
  • Measure a jug of water every morning with your restricted amount for the day
  • Use the water from the jug throughout the day
  • Ice cold drinks last longer and quench thirst more effectively
  • When eating out, ask for ‘half a cup’ or a small glass – avoid free refills

DIETARY FIBRE

Foods containing fibre help to prevent constipation. However, they are a source of phosphate and should be encouraged with moderation. It is important to avoid constipation as this may reduce your child’s appetite or be responsible for poor drainage of dialysis fluid if on peritoneal dialysis.

High fibre foods to encourage include:

  • Fresh fruit and vegetables (up to 4 portions per day) within potassium allowance
  • White bread with added fibre or multigrain bread
  • Whole wheat breakfast cereals, eg. Weetabix, Shreddies, Cheerios vary with more refined cereals eg. Cornflakes, Rice Krispies
  • Whole wheat biscuits, eg. Digestive

Children on peritoneal dialysis in particular tend to be more prone to constipation. Your child may need a laxative to help prevent constipation

FACT:

High fibre foods are a source of phosphate. Try brands of white bread with added fibre

VITAMINS AND SUPPLEMENTS

Vitamins and minerals are required for growth and general good health. This is usually in the form of a tablet that can be crushed. Children on dialysis may have poor appetites and may need a special renal specific multivitamin supplement daily.

Some fruit and vegetables are restricted when trying to reduce potassium levels, this will reduce vitamin C intake.

Water soluble vitamins (mostly B and C) are lost into the dialysis fluid.

Vitamin A can accumulate to toxic levels when the kidney function is impaired. Fish oil supplements often contain high doses of Vitamin A. All vitamin supplements containing high doses of Vitamin A should be avoided.

Discuss with your dietician before using any over the counter vitamin supplements.

IRON

Your child may become anaemic because the hormone which stimulates the body to produce red blood cells and store iron is made by the kidneys. You should try to offer foods that are high in iron where possible but an iron supplement may also need to be prescribed.

Animal Sources

  • Beef/lamb/pork
  • Meat dishes – shepherd’s pie, curry
  • Poultry – contains less iron but is still a good source
  • Fish – oily fish, eg. Sardines, kippers
  • Egg – scrambled or omelette

Non-Animal Sources

  • Pulses (peas, beans eg. Baked beans,
  • Kidney beans, and lentils) tofu, dahl, hummus
  • Green vegetables, eg green beans, cabbage
  • Broccoli, spinach, leeks
  • Breakfast cereals fortified with iron
  • Whole wheat bread
  • Chappati, pitta, malt loaf, digestive biscuits
  • Fruit – fig rolls, apricots, prunes, sultanas

USEFUL TIPS :

  • Iron from cereal products is better absorbed in the presence of vitamin C
  • Fresh fruit juices are high in potassium but diluted fruit squashes have much less and are a good source of vitamin C
  • Give iron and vitamin supplements together and ideally not with food
  • Drinking tea with food reduces the amount of iron absorbed. Therefore, if your child likes to Drink tea, it is best between meals
  • If your child has an overnight feed, do not add iron to the feed but give as a bolus Beforehand

NUTRITIONAL SUPPLEMENTS

At times when your child’s appetite is poor, nutritional supplements may be required to maintain their weight again and growth. There are a range of nutritional supplements available which may be prescribed for your child.Sometimes ad equate nutrition cannot be achieved with oral supplements alone and a form of tube feeding may need to be considered. This will be discussed with you if it is necessary.

Compiled by members of the

More information about children and kidney problems at
www.emeesykidney.nhs.uk