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Dietary Advice for Children on Dialysis

 
Cartoon of family reading leaflet

Written by Lisa Norman and Janet Coleman

Revised by Pearl Pugh and Alison Tooke


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 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.

GENERAL AIMS OF THE SPECIAL DIET

The aims of the diet whilst on Dialysis are to:

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

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.

This guide contains information to help children eat the right diet whilst on dialysis

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

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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.

CARBOHYDRATES

STARCH

Eat plenty of:

  • Breakfast Cereals
  • Bread
  • Chapatis, pitta bread
  • Potatoes
  • Rice
  • Spaghetti, other pasta
USEFUL TIPS:

Vary white and wholemeal bread and whole wheat 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.

toothbushNote:- if you are advised to consume more sugary foods and drinks 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 YOUHAVE CLEANED YOUR TEETH AT NIGHT

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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

A diet high in saturated fat tends to raise the blood cholesterol level, increasing the risk of Heart disease in the future

Try to swap foods high in saturated fat for healthier foods containing mono/polyunsaturated fat.

TRY TO AVOID

  • Butter/ghee
  • Lard/suet
  • Fatty cuts of meat

TRY TO USE

  • Olive/vegetable or
  • Sunflower margarine or oil
Butter dish
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PROTEIN

Why do we need protein?

Protein is needed for growth, building muscles and the repair of tissues. Urea is a waste product of protein metabolism, which is normally excreted into the urine by the kidneys. A build up of urea in the blood is called uraemia 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 in a dishPoultry 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.

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PHOSPHATE

Calcium and phosphate are important for the growth and development of strong bones. Phosphate is released from food into 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:

Try to restrict dairy products
Dairy quota

FACT:

Cottage cheese and full fat cream cheese, eg. Philadelphia contains 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 cow’s milk, eg. SnoPro or ProZero. Ask your dietician.

Other foods high in phosphate to limit:

  • Nuts and peanut butter
  • Cocoa and chocolate
  • Cola drinks
  • Shellfish, eg prawns, 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 absorbed 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.

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POTASSIUM

The potassium 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

  • Bunch of grapesSquash, 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 (refer to snack list)

REMEMBER

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

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.

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.
  • Mushrooms, tomatoes, brussel sprouts, parsnips.
  • Potato crisps, chips, jacket potatoes.
  • Nuts, fruitcake.
  • Plain, milk or white chocolate, toffees 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.

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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: Lower salt alternatives:
Salted crisps, nuts, savoury snacks Lightly salted tortilla chips or corn snacks
Other tinned foods with added salt Eg baked beans or canned vegetables Sweet snacks instead of savoury
Smoked meats and fish Unsmoked meat and fish
Low salt stock cube or gravy powder
Bacon, sausages, sausage rolls and other Processed meats Lower salt tinned products, eg reduced salt baked beans
Chicken nuggets, dippers/dinosaurs Unsalted margarine
Potato products (waffles, alphabites, faces) Fresh fish, poultry and meat
Most cheeses, eg cheddar, edam, stilton, Cheese spread, processed cheese Cottage cheese, full fat soft cheese

Do not use a salt substitute as they are usually high in potassium, eg. Lo Salt

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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).

To convert ‘sodium’ to ‘salt’, multiply the sodium value by 2.5. For example if a food contains 0.4g sodium this is equivalent to 1.0g salt. (0.4 × 2.5 = 1.0g).

TOP TIP:

Herbs and spices can be used in cooking instead of salt 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.

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
Liquid foods

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
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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:

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

VITAMINS AND SUPPLEMENTS

Vitamin lettersVitamins 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.

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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.

FOODS HIGH IN IRON:

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:

  • weightsIron 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

supplement drinkAt times when your child’s appetite is poor, nutritional supplements may be required to maintain their weight gain and growth. There are a range of nutritional supplements available which may be prescribed for your child.

Sometimes adequate 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.

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Content compiled by members of the Children’s Renal & Urology Unit, QMC Campus, Nottingham University Hospitals.


The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.