ARTICLE

Optimizing Nutrition in Neonates with

Kidney Dysfunction
Saudamini Nesargi, DNB,* Heidi Steflik, MD, MSCR,† Nivedita Kamath, MD, DNB, DM,‡ David Selewski, MD, MS,§
Katja M. Gist, DO, MSCS,¶ Shina Menon, MDk
*Department of Neonatology, St. Johns Medical College Hospital, Bangalore, India
†
Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
‡
Department of Pediatric Nephrology, St. Johns Medical College Hospital, Bangalore, India
§
Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
¶
Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati
College of Medicine, Cincinnati, OH
k AUTHOR DISCLOSURES Dr Steflik works
Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine,
under a grant from Baxter, has received
Seattle, WA
honoraria for speaking and reviewing at the
Medical University of South Carolina and
MedLink Neurology, respectively, and is an
unpaid board member for the Southern
Society of Pediatric Research. Dr Gist works
PRACTICE GAP under a grant from The Gerber Foundation
and has received consulting fees from
Neonates with kidney disease have complex nutritional requirements Bioporta Diagnostics and Portero Medical.
based on their underlying kidney dysfunction. New clinical guidelines are Dr Menon works under a grant from The
Gerber Foundation and has received
available, but they focus on children of all ages and are not exclusive to consulting fees from Medtronic and Nuwellis.
neonates. Therefore, significant gaps remain, particularly with respect to Dr Selewski works under a grant from and
acute kidney injury and renal replacement therapy in the neonatal has served on an advisory board for
Pharmacosmos. Drs Nesargi and Kamath
population.
disclosed no financial relationships relevant
to this article. This commentary does not
contain a discussion of an unapproved/
OBJECTIVES After completing this article, readers should be able to: investigative use of a commercial product/
device. Drs Nesargi and Steflik contributed
equally to this work.
1. Summarize the pathophysiology of compromised nutrition in neonates
with kidney disease and discuss the key nutritional aspects of acute
ABBREVIATIONS
kidney injury and chronic kidney disease.
AKI acute kidney injury
2. Assess the nutritional needs of neonates with chronic kidney disease ARA arachidonic acid
and apply the Pediatric Renal Nutrition Taskforce clinical practice BMI body mass index
BSA body surface area
recommendations. CKD chronic kidney disease
CRRT continuous renal replacement
3. Recognize the nutritional implications of the use of continuous renal
therapy
replacement therapy for acute kidney injury in neonates. DHA docosahexaenoic acid
EN enteral nutrition
ESPGHAN European Society for Pediatric
ABSTRACT Gastroenterology, Hepatology,
and Nutrition
The nutritional management of neonates with kidney disease is GIR glucose infusion rate
complex. There may be significant differences in nutritional needs based iHD intermittent hemodialysis
IV intravenous
on the duration and cause of kidney dysfunction, including acute kidney KDOQI Kidney Disease Outcomes
injury (AKI) and chronic kidney disease (CKD). Furthermore, the Quality Initiative
treatment modality, including acute (continuous renal replacement PD peritoneal dialysis
PN parenteral nutrition
therapy and peritoneal dialysis [PD]) and chronic (intermittent PRNT Pediatric Renal Nutrition
hemodialysis and PD) approaches may differentially affect nutritional Taskforce
losses and dietary needs. In this review, we discuss the pathophysiology REE resting energy expenditure
RRT renal replacement therapy
of compromised nutrition in neonates with AKI and CKD. We also
SDI suggested dietary intake

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 summarize the existing data and consensus recommendations on the provision of nutrition to neonates with AKI and
CKD. We highlight the paucity of data on micronutrient losses and the need for future prospective studies to enhance
nutritional supplementation to hopefully improve outcomes in these patients.
INTRODUCTION
Nutritional requirements during the neonatal period are
of particular importance as growth rates are higher during
infancy. In critically ill neonates, this is often compounded
by multiple complications related to their underlying path-
ophysiology; therefore, nutrition should be individualized
to optimize the neonates’ nutritional status and growth.
Neonates with kidney dysfunction represent one such
group with unique nutritional needs relative to other criti-
cally ill neonatal populations.
The nutritional considerations in neonates with kidney
dysfunction encompass a broad spectrum related not only
to the acuity or chronicity of kidney dysfunction but also
to the unique aspects of renal replacement therapy (RRT).
Significant differences in nutritional needs in kidney dis-
ease based on the duration and cause of kidney dysfunc-
tion including acute kidney injury (AKI) and chronic
kidney disease (CKD) exist. As the epidemiology and im-
pact of neonatal AKI have become clearer, there has been
a push to optimize the care of these patients, including
nutritional support.
In this review, we will briefly examine nutrition in
healthy neonatal populations, describe the pathophysiology
and nutritional considerations in neonates with AKI and
CKD, and highlight areas for future research.
NUTRITIONAL NEEDS OF HEALTHY NEONATES
The provision of nutrition to neonates depends on numer-
ous factors including gestational age, degree of illness and
comorbidities, postnatal age, and method of feeding. Herein,
we provide a summary that is separated into preterm and
term neonates.
Table 1. Recommended Nutritional Intakes Based on Estimated Nutritional Needs in Healthy Term and Preterm
Infants
Nutritional Components Term Infants
Energy 75–85 kcal/kg per day (maximum: 100 kcal/kg per day)
Enteral: 10–14 g/kg/day
Parenteral (Glucose Infusion Rate): 2.5–10 mg/kg/min
Carbohydrates 2.5–10 mg/kg per minute
Protein and amino acids 1.5–2.5 g/kg per day
Lipids 5–6 g/kg per day
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Preterm Neonates
In preterm infants, postnatal growth should approximate
the growth of a fetus of the same gestational age in utero.
The recommended energy and carbohydrate prescriptions
vary depending on the route of feeding and individual pa-
tient parameters including weight, clinical status, and es-
tablished growth pattern, and thus must be individualized
(Table 1). (1) In all cases, energy intake in preterm infants
must equal the sum of energy expenditure. This includes
energy excreted through losses in stool and urine; energy
expended in basal metabolism, thermoregulation, activity,
and new tissue synthesis; and energy stored as fat, pro-
tein, and glycogen. (1) Significant variations exist in energy
and carbohydrate requirements even in preterm infants.
The 2022 European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (ESPGHAN) position paper on
enteral nutrition (EN) in preterm infants recommends a
total energy intake of 115 to 140 kcal/kg per day for enter-
ally fed preterm infants who are healthy and growing,
though more than 140 kcal/kg per day may be needed in
some cases. (2) Parenterally supported infants require
fewer kilocalories (as a result of reduced energy costs for nu-
trient absorption and reduced fecal energy losses), whereas
enterally fed neonates require more kilocalories because of
increased diet-induced thermogenesis and increased fecal
energy losses. (2)
Sources of Energy
Glucose is the body’s major energy source and is particu-
larly important for the brain and heart. However, lactose
is the primary carbohydrate found in human milk. Lactose
is incompletely digested in preterm infants, leading to
concerns of increased risk for necrotizing enterocolitis
Preterm Infants
90–130 kcal/kg per day
4–10 mg/kg per minute
Enteral: 11–15 g/kg/day
Parenteral (Glucose Infusion Rate): 4–10 mg/kg/min
2.5–4.5 g/kg per day
4.1–7.4 g/100 kcal
 secondary to carbohydrate malabsorption in this popula-
tion. However, the substitution of lactose with more read-
ily digestible glucose has not been shown to improve
feeding tolerance or weight gain in preterm infants. (2)
Full enteral carbohydrates in preterm neonates should to-
tal 11 to 15 g/kg per day. (2) In parenterally fed preterm
neonates, glucose supplementation should provide appropri-
ate calories for basal glucose metabolism while maintaining
a normal plasma glucose concentration (ie, 54–108 mg/dL).
In term newborns, this typically requires a glucose infusion
rate (GIR) of 6 to 8 mg/kg per minute, but in very-low-birth-
weight preterm infants who are at risk for significant hyper-
glycemia, lower initial rates of 3 to 6 mg/kg per minute may
be more appropriate. (3) GIR can safely be advanced daily by
1 to 2 mg/kg per minute to a goal of 7 to 10 mg/kg per mi-
nute if serum glucose levels remain within normal limits.
Notably, higher GIR (ie, 9–12 mg/kg per minute or higher)
may be needed in very preterm or growth-restricted neonates
with hyperinsulinism-like disorders.
Proteins are vital for adequate growth as they are the
key structural component of all human cells and the main
driver of lean body mass growth. In preterm newborns,
protein supplementation should begin immediately after
birth at 1.5 to 2.5 g/kg per day. After 1 to 2 days, the pro-
tein prescription can be advanced to 3.5 g/kg per day. (4)
In extremely preterm newborns, a combination of EN and
parenteral nutrition (PN) is provided, with slow uptitration
of EN accompanied by downtitration of PN over the first
weeks of age. In transitioning from primarily PN to EN,
first-pass amino acid metabolism must be considered, and
protein content in PN should not be downtitrated before
enteral intake exceeds 75 mL/kg per day and not discontin-
ued until full enteral feedings are achieved. (5) In ex-
tremely preterm neonates receiving full EN, ESPGHAN
recommends 4 g/kg per day of enteral protein for ade-
quate growth, but a higher intake of up to 4.5 g/kg per
day may be needed for optimal weight gain. (2) Typical
preterm formulas contain 2.6 g of protein per 100 mL,
which corresponds to a protein intake of 3.9 to 4.7 g/kg per
day at enteral intakes of 150 to 180 mL/kg per day. Human
milk, particularly donor human milk, is low in protein un-
less provided in volumes greater than 200 mL/kg per day;
thus, multi-nutrient fortification is necessary to achieve the
desired protein concentrations of 4.5 g/kg per day. (2)
Lipids provide preterm infants with most of their en-
ergy requirements, and consequently, a relatively high die-
tary lipid content to supply 36% to 67% of energy intake
is recommended. (6) In preterm infants with a daily en-
ergy intake of 110 kcal/kg, lipid intake is approximately 4.1
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to 7.4 g of fat per 100 kcal, depending on the fat content
of the feedings. There are significant intra- and interindi-
vidual variations in human milk lipid content. In enterally
fed preterm neonates, ESPGHAN recommends a total fat
intake of 4.8 to 8.1 g/kg per day but notes higher intake
may be safe. (2) Long-chain polyunsaturated fatty acids, es-
pecially arachidonic acid (ARA) and docosahexaenoic acid
(DHA) are critical to supplement in preterm neonates, as
active placental transfer of these important fatty acids oc-
curs during the third trimester of pregnancy. These fatty
acids, when supplied in appropriate amounts to preterm
infants (DHA intake of 0.5%–1% of total fatty acids,
30–65 mg/kg per day; dietary ARA/DHA ratio of 0.5–2),
are associated with improved short-term neurologic out-
comes. (2)(6) In preterm infants requiring PN, lipids are
typically initiated at 1 to 2 g/kg per day of intravenous (IV)
lipid emulsion and can be advanced to 2 to 3 g/kg per day
as tolerated.
Term Neonates
Nutrition prescriptions in term neonates are more straight-
forward than in preterm neonates. EN should be provided
with human milk, and formula should be used if essential.
(7) PN may be needed in term infants such as those with
preexisting congenital anomalies of the gastrointestinal
tract or in those with or at risk for intestinal malperfusion
(ie, some neonates with critical congenital heart disease).
The daily recommended energy requirement for term neo-
nates varies from 75 to 120 kcal/kg per day and 105 to 130
kcal/kg per day depending on the guidelines (Table 1).
(8)(9) There are several factors that may alter this require-
ment, including the use of PN, and the general metabolic
demands of the neonate. In general, if PN is used, the daily
energy requirement is reduced by 10% to 30%. (10)
Sources of Energy
Neonates able to enterally feed with human milk or for-
mula receive 10 to 14 g/kg per day of carbohydrates, which
is usually sufficient for growth. In those requiring PN, a
GIR ranging from 2.5 mg/kg per minute on day 1 to a
maximum of 10 mg/kg per minute is recommended. (11)
Hyperglycemia should be anticipated and managed ac-
cordingly. Neonates who exceed the GIR requirements re-
quire further evaluation.
Protein requirements are lower in term than in preterm
neonates. (8) Human milk and infant formulas provide
sufficient protein (1.5–2.5 g/kg per day) for a term neonate
if consumed in amounts sufficient to meet energy needs.
Human milk is whey predominant, though the ratio of
Vol. 25 No. 1 JANUARY 2024 e27
 whey to casein varies over time, ranging from 90:10 in
the colostrum to 60:40 in mature milk. Whey is more eas-
ily digestible and absorbable and adds a lower solute load
on the kidney. (12) Most commercially available formulas
designed for term infants have a whey-to-casein ratio of
60:40. Proteins when given by PN may be started at 1.5 g/kg
per day. In hospitalized neonates, catabolism is often present,
and protein requirements are often increased up to 3 g/kg
per day. Protein utilization for growth, and not energy, is best
when 30 to 40 kcal/g of protein is provided. (13) Most paren-
teral protein solutions contain essential amino acids.
Approximately 5 g/kg per day of fat is needed in term
neonates. Both human milk and infant formula provide a
sufficient quantity of lipids. In term infants, parenteral
lipid intake should not exceed 4 g/kg per day. (14) Formu-
lations that have essential fatty acids should be used.
ACUTE KIDNEY INJURY
Pathophysiology of Compromised Nutrition
Critical illness is often characterized by a catabolic state,
with muscle protein breakdown and lipolysis, and deterio-
ration in nutritional status is common. (15)(16) This is am-
plified in neonates who have high nutrition requirements
for their rapid rate of growth yet have limited nutrition re-
serves. In addition to protein catabolism, other metabolic
abnormalities seen in AKI include altered amino acid me-
tabolism, peripheral insulin resistance, and induction of a
proinflammatory state that can affect immune function.
(17) Hyperglycemia due to peripheral insulin resistance
and hepatic gluconeogenesis is common. While these fac-
tors lead to a loss of existing protein and energy stores, op-
timal nutrition delivery in neonates and infants with AKI
is also exceptionally challenging. Pathologic positive fluid
balance and fluid overload present in the setting of AKI of-
ten require fluid restriction, which makes it harder to pro-
vide optimal nutrition. As a result, critically ill neonates
(and infants and older children) with AKI are frequently
underfed and more likely to be fasting, thus placing them
at even greater risk for malnutrition. (18) Finally, AKI is
also associated with electrolyte derangements such as hy-
ponatremia, hyperkalemia, hyperphosphatemia, and meta-
bolic acidosis, all of which may necessitate modifications
to EN or PN.
A small subset of patients with severe AKI may require
RRT, either as continuous RRT (CRRT) or peritoneal dial-
ysis (PD). Despite the advances in technology, CRRT pre-
scriptions in neonates, infants, and children have been
largely extrapolated from adults. In adults, the CRRT dose
at initiation of therapy was standardized after the results
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of 2 large randomized controlled trials. (19)(20) An initial
CRRT dose prescription of 25 to 30 mL/kg per hour is rec-
ommended in adults. (21) In pediatric patients, a corre-
sponding dose of 2,000 mL/1.73m2 per hour is used. (22)
While the conversion from a weight-based dose in adults
matches well with a body surface area (BSA)–based dose
in older children, the nonlinear relationship between weight
and BSA results in a disproportionately higher dose in neo-
nates and infants. (23) The impact of this difference in
CRRT dosing on nutritional needs in neonates has not been
well studied.
Malnutrition is extremely common in patients with
AKI receiving CRRT, with a reported incidence of 30% to
55%. (24) One multicenter study of children receiving
CRRT showed that many were receiving insufficient pro-
tein. (25) Additionally, CRRT may result in the depletion
(loss) of important solutes necessary for growth and devel-
opment. This loss of proteins appears to be dependent on
the dialysis dose. (26) A study in adults showed that pa-
tients with severe AKI, even without CRRT, had micronu-
trient concentrations below the reference range that were
not different from those receiving CRRT. (27) These data
suggest that micronutrient absorption and utilization may
be impaired in AKI in general. (27) Zappitelli and col-
leagues evaluated nutritional losses in children receiving
CRRT and reported that 10% of total amino acid intake was
lost during CRRT. (28) Furthermore, patients had a nega-
tive nitrogen balance despite protein provision of approxi-
mately 2 g/kg per day. (28) The authors also identified loss
of folate and selenium during CRRT and suggested that
standard supplementation of these micronutrients may not
be sufficient. A second study from the same center (n515,
median age of 2 years) found that CRRT resulted in a me-
dian loss of 14.6% of prescribed protein. (26) Finally, in a
single-center prospective observational study of 174 children
receiving CRRT (median age of 18 months), 56% had acute
protein-energy wasting, defined as weight greater than the
3rd percentile. (29) Only protein energy wasting was associ-
ated with mortality in this cohort. (29) Unfortunately, most
of these studies include older children. There is limited
data on how these losses affect neonates who are in a criti-
cal stage of growth and development.
Feeding modality may also be a barrier to the provision
of adequate nutrition in neonates with severe AKI, includ-
ing those who require CRRT. A recent single-center study
evaluated 41 patients (median age of 9 years) receiving
CRRT. (30) Approximately 50% of patients received a com-
bination of PN and EN, with 34% receiving exclusively PN
and 12% receiving only EN. The percentage of time meeting
 protein goals by feeding modality was 65% for EN1PN,
34.6% for PN only, and 27.6% for EN only. Interestingly,
when these patients were weaned to EN only from PN1EN,
the average percentage of time protein goals that were met de-
creased to 20%. While this study included older children,
these data highlight that children with AKI are at significantly
increased nutritional risk when they transition from PN to EN.
Estimating Nutritional Needs in AKI
Estimating nutritional needs in critically ill neonates, in-
fants, and children is very challenging. Direct measures of
energy expenditure and indirect calorimetry are not usu-
ally available in clinical practice, and resting energy expen-
diture (REE) may be calculated using the World Health
Organization or the Schofield equations. (24) In critically ill
children, in the acute phase, caloric needs equal REE. (24)
The subsequent recovery phase should incorporate addi-
tional energy requirements for rehabilitation and growth.
Early and repeated nutrition screening and assessment
are recommended to identify children at risk for malnutri-
tion. (24) While there are no screening tools specific to
AKI in neonates, accurate anthropometric measurements
should be obtained early and repeated at least weekly.
These include euvolemic weight, recumbent length, head
circumference, and assessment of muscle and fat distribu-
tion by measuring middle upper arm circumference and
skinfold thickness. Reference values for arm circumfer-
ence and skinfold thickness from the World Health Orga-
nization are only available after 3 months of age, but there
are other smaller studies that have looked at these meas-
urements in neonates. (31)(32) Fluid balance may interfere
with the use of weight as a marker of nutritional status in
those with AKI. Other measures such as net fluid balance,
bioimpedance electrical analysis, or point-of-care ultraso-
nography may help delineate volume status. Bioimpe-
dance analysis can estimate body composition (particularly
total body water and lean mass) by measuring opposition
to electrical flow through tissues with the current and de-
tection electrodes placed on the infant’s wrist and ankle.
(32) However, the prediction equations using this method
are less accurate for neonates as compared to older chil-
dren. (32) Point-of-care ultrasonography may be used for
Table 2. Modifications to the Suggested Dietary Intake of Calories and Proteins in Healthy Term Neonates and
Those on Chronic Dialysis
Energy
Term neonate 93–107 kcal/kg per day
Peritoneal dialysis Deduct 7–9 kcal/kg per day
Hemodialysis Deduct 3 kcal/kg per day
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the assessment of intravascular volume as well as extravas-
cular fluid (such as free intra-abdominal fluid and pleural
effusion). (33)
Nutrition Prescription in Neonates with AKI
The diagnosis of AKI has several potential implications for
nutrition assessment and provision in neonates. The goal
is to provide appropriate nutrition while achieving fluid
homeostasis and avoiding dehydration or progressive volume
overload. This goal can be difficult to achieve, especially if
fluid restriction is necessary in the setting of oliguria or an-
uria. (34) The inability to provide nutrition secondary to fluid
restriction in AKI is an indication of RRT.
Energy expenditure in neonates with AKI may depend
more on the underlying disease, the preexisting nutritional
status, and the coexistence of acute and chronic comorbid-
ities. Based on the phase of AKI, the caloric prescription
must account for rehabilitation and growth. It may also
need to be modified to account for RRT-related net gain or
loss of energy. Both CRRT and PD provide other sources
of calories for nutrition. For CRRT, this includes citrate
(3 kcal/g) from the anticoagulant used, and lactate (3.62 kcal/g)
and glucose from the dialysis fluid. PD provides calories from
the glucose in the dialysis fluid (7–9 kcal/kg per day), which
should be a part of the prescription. (35) Critically ill neonates
with AKI may require higher protein intake to limit negative
protein balance. Protein restriction to lower blood urea ni-
trogen levels or delay RRT initiation is not recommended.
(21)(35) Protein losses may occur during PD, on the order
of approximately 0.1 to 0.28 g/kg per day, and additional
protein intake of at least 0.1 g/kg per day should be pro-
vided to infants on PD. (35) Table 2 summarizes the sug-
gested dietary intake (SDI) in healthy term neonates and
those treated with RRT.
It is also important to appropriately supplement micro-
nutrients (vitamins, trace elements, and carnitine). Sup-
plemental vitamin A should be avoided in all neonates
with AKI because impaired kidney function is associated
with reduced excretion of vitamin A, as well as elevated lev-
els of retinol, both of which may result in hypercalcemia and
hypervitaminosis A. (24) Those requiring RRT may need
supplemental water-soluble vitamins, trace elements (copper,
Protein
1.5–2.5 g/kg per day
Add 0.15–0.3 g/kg per day
Add 0.1 g/kg per day
Vol. 25 No. 1 JANUARY 2024 e29
 zinc, selenium), and carnitine. There are no data to recom-
mend routine measurement of serum concentrations of mi-
cronutrients unless a deficiency or toxicity is suspected based
on clinical signs.
Additional electrolyte abnormalities seen in AKI may
require modification of the nutrition prescription. Normal
values of plasma potassium in neonates are higher com-
pared to levels in older infants, children, and adults, and
appropriate interpretation requires the use of age-based
normative values. (36) For infants with AKI and hyperkale-
mia, human milk, which is naturally low in potassium
compared to standard infant formulas, may be used. Alter-
native approaches include decanting milk with potassium-
binding resins, use of low-potassium infant formulas, or a
brief period of discontinuing EN and supplementing with
IV fluids or PN without potassium. If the patient is already
receiving nutrition exclusively via IV fluids or PN, potassium
should be removed from these fluids until hyperkalemia is
corrected. The enteral or rectal use of sorbitol-based resins
such as sodium polystyrene should be avoided in neonates
because of the risk of intestinal perforation and obstruction.
(36) Hyperphosphatemia may require phosphate restriction
and transition to a low-phosphorous renal infant formula or
treatment with a calcium-based phosphate binder. Hypophos-
phatemia is common during CRRT, and phosphorus supple-
mentation is often needed to avoid complications such as
respiratory muscle weakness, myocardial dysfunction, and en-
cephalopathy. Phosphate is commonly provided as an additive
to CRRT solutions, though in recent years, commercially
available phosphate-containing CRRT solutions have become
available. Patients often need additional supplementation ei-
ther orally or in the PN. Table 3 summarizes the electrolyte
requirements in healthy neonates and those with AKI.
CHRONIC KIDNEY DISEASE
Pathophysiology of Compromised Nutrition
The altered metabolic milieu found in patients with AKI is
also seen in those with CKD. Additional changes include
anorexia secondary to abnormalities in the hormonal and
Table 3. Electrolyte Requirements in Healthy Term Neonates and Typical Changes seen in Patients with Acute
Kidney Injury Compared to Normal
Healthy Term Neonates
Sodium (mEq/kg/day) 2-5
Potassium (mEq/kg/day) 2-4
Calcium (mMol/kg/d) 0.25-2
Phosphorus (mMol/kg/d) 0.5-2
Magnesium (mMol/kg/d) 0.15-0.25
Acetate/bicarbonate As needed
RRT, renal replacement therapy; iHD, intermittent hemodialysis; PD, peritoneal dialysis; CRRT, chronic RRT
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hypothalamic neuronal circuits that control appetite. (37)
There are also higher circulating concentrations of cyto-
kines, such as leptin, tumor necrosis factor a, and inter-
leukins 1 and 6, which further lead to cachexia. (37)
Estimating Nutritional Needs in CKD
Regular assessment by a pediatric dietitian experienced in
caring for neonates with CKD is imperative, and the Kidney
Disease Outcomes Quality Initiative (KDOQI) clinical prac-
tice guideline includes specific recommendations for regular
evaluations of growth and nutritional status in these neo-
nates. These recommendations include a review of dietary
intake and assessments of length for age, estimated euvole-
mic or “dry” weight and weight for age, body mass index
(BMI) for height/length for age, and head circumference.
(38) This is echoed by the more recent Pediatric Renal Nutri-
tion Taskforce (PRNT) (39) guidelines that recommended as-
sessment of these parameters at least twice as frequently as
they would be performed in a healthy neonate, although
more frequent assessments may be needed in neonates with
severe disease or complications (polyuria, growth delay, de-
creasing/low BMI, comorbid pathologies impacting growth
or nutrient intake, and recent acute medical status changes).
(38) For preterm infants born between 32 and 37 weeks’ ges-
tation, PRNT recommends plotting anthropometric measure-
ments for both gestational and chronologic age for the first
year after birth, and for those born before 32 weeks’ gesta-
tion, these measurements should be obtained through 2 years
of age. (39) Consideration of the underlying pathology of
CKD is also important when nutritional prescriptions are de-
termined; infants with congenital nephrotic syndrome, for ex-
ample, experience excessive protein losses and may require
additional protein/amino acid supplementation beyond that of
infants with CKD secondary to other causes. Careful assess-
ment of body weight and fluid balance is of paramount im-
portance given that the prescription of nutrition is often based
on body weight and both volume overload and that depletion
can occur in neonates with CKD. Dry weight should be fre-
quently reassessed by evaluating body weight along with the
Term infants With Acute Kidney Injury
No RRT iHD PD CRRT
May decrease May decrease May decrease May decrease
Lower Unchanged /lower Unchanged /lower Higher
Higher Higher Higher Higher
Lower Unchanged /lower Unchanged /lower Higher
Unchanged Unchanged Unchanged Higher
Higher Unchanged Unchanged Lower
 presence or absence of edema, blood pressure, laboratory val-
ues, and dietary intake. (38) Individualized counseling and in-
terventions, as well as frequent reevaluations and potential
modifications to nutrition plans of care, may be needed. This
requires the coordinated efforts of a dietitian with expertise in
pediatric and renal nutrition, as well as a multidisciplin-
ary team including the child, caregivers, and the pediatric
nephrology team.
Nutrition Prescription in Neonates with CKD
KDOQI recommends centering nutritional care to achieve
the following goals:
1. “maintenance of an optimal nutritional status (ie,
achievement of normal pattern of growth and body com-
position by intake of appropriate amounts and types of
nutrients),
2. avoidance of uremic toxicity, metabolic abnormalities,
and malnutrition, and
3. reduction of the risk of chronic morbidities and mortal-
ity in adulthood.”(38)
More recently Shaw and colleagues from PRNT pro-
vided an update on energy and protein requirements for
children with CKD stages 2 to 5 and on dialysis. (35) Given
the varying national and international terms and defini-
tions for energy and protein requirements, PRNT intro-
duced the term “suggested dietary intake” (SDI) for their
recommendations. In CKD stages 2 to 5, initial prescrip-
tions for nutrition should approximate that of healthy chil-
dren of the same chronologic age, and when weight gain
is suboptimal, the prescription should be adjusted toward
the higher end of the SDI. In infants at risk for obesity,
the nutrition should be adjusted to achieve appropriate
weight gain without compromising the delivery of protein,
fat, carbohydrates, and macro- and micronutrients. In neo-
nates, human milk is preferred, with appropriate fortifica-
tion, when necessary, in the setting of fluid restriction, or
when additional calories are required without increasing
total volume. A whey-dominant formula is recommended
when supplemental feedings are required. Methods of
fortification of human milk with whey-based formulas
have been described elsewhere. (40) A feeding volume of
150 mL/kg per day may be sufficient to meet the nutri-
tional needs of an infant with CKD. However, an infant
with polyuria with a higher-than-normal fluid require-
ment may need additional fluid given either as free water
in between feedings or mixed in to prepare dilute formula.
(40)
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Neonates with CKD requiring RRT warrant special con-
sideration regarding their nutritional needs. Some of these
needs are similar to those discussed for AKI. Adequacy of
nutrition provision is of particular importance during PD
catheter placement because malnutrition with subsequent
abdominal muscle wasting can lead to poor stability of the
catheter, potential leakage, and impaired wound healing.
(41) In children receiving PD, the energy intake from
the dialysate should be considered to range from 7 to
9 kcal/kg per day depending on the dextrose concentra-
tion of the dialysate, the time on dialysis, number of
cycles, dwell times, and the peritoneal membrane trans-
porter status. If there is excessive weight gain in these
children, this energy source needs to be taken into con-
sideration. Dialysate protein loss should be accounted
for, and the recommended protein intake is higher than the
SDI for neonates managed conservatively, with an addi-
tional 0.15 to 0.3 g/kg per day recommended on PD and
0.1 g/kg per day on intermittent hemodialysis (Table 3).
(40) Neonates on PD frequently experience vomiting, poor
appetite and oral intake, and delayed gastric emptying,
which can exacerbate nutritional deficiencies and losses.
(41) Adequate growth and even catch-up growth can be
achieved with appropriate nutrition provision in neonates
with CKD with or without RRT.
The intake of calcium should be maintained between
100% and 200% of SDI. The calcium intake from medica-
tion and dialysate should be considered. The dietary phos-
phate intake should be within the SDI. Human milk and
whey-dominant formula are low in phosphate. (42) Potas-
sium intake should be based on renal function and serum
potassium levels. Human milk has a low potassium con-
tent. In neonates with hyperkalemia, human milk may be
substituted with a low-potassium formula. In formula-fed
infants, the potassium-binding resin can be added to the
formula and decanted. (43)
While the preferred route for the provision of nutrition is
oral, enteral tube feeding via a nasogastric tube or gastrostomy
device may be occasionally needed. PRNT recommends sup-
plemental or exclusive enteral tube feeding in children with
CKD who are unable to meet their nutritional requirements
orally. (35) Despite these recommendations, various studies
have shown limited use of enteral tube feeding outside North
America and some European countries. (44)(45)(46) For short-
term enteral feeding needs, a nasogastric tube is preferred,
whereas a gastrostomy device is preferred for long-term use.
(47) PRNT provides additional clinical practice recommenda-
tions for the optimal delivery of nutrition via enteral tube feed-
ing to children with CKD stages 2 to 5 and on dialysis. (47)
Vol. 25 No. 1 JANUARY 2024 e31
 CONCLUSION
Neonates with kidney dysfunction, be it AKI or CKD, have
unique nutrition needs. It is important to be aware of
their nutritional requirements, know how to assess them
and be able to provide appropriate nutrition, especially as
outlined by PRNT. Based on the type of kidney dysfunction
(acute or chronic) and the need for RRT (CRRT, intermit-
tent hemodialysis, or PD), the needs and losses of macro-
and micronutrients and trace minerals may vary, necessitat-
ing periodic laboratory monitoring and adjustment.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Know the differences in the nutritional
composition of human milk and infant formula.
• Know the importance of protein and nonprotein
nutrients in achieving optimal utilization of energy
and nitrogen.
• Know the etiology of electrolyte abnormalities in
the neonate.
• Know the impact of renal dysfunction on water
requirements.
• Know how to manage electrolyte abnormalities in
the neonate.
• Know the management of renal failure in the
neonate, including indications for and
complications of the use of hemofiltration,
peritoneal dialysis, and hemodialysis.
• Know the potential adverse effects of
pharmacologic use of fat-soluble vitamins.
• Know the medical indications for the use of
nonstandard infant formulas to meet the needs of
infants with special health problems.
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Vol. 25 No. 1 JANUARY 2024 e33
 NEOREVIEWS QUIZ

NEO
QUIZ

1. A preterm infant of 31 week’s gestation is starting enteral feeds. The NICU

team is working on calculating the caloric density of feeds to ensure
adequate growth. Which of the following statements describes an
appropriate daily total energy intake for this preterm infant?
A. 60 kcal/kg per day.
B. 75 kcal/kg per day.
C. 90 kcal/kg per day.
D. 120 kcal/kg per day
E. 150 kcal/kg per day.
REQUIREMENTS: Learners can
2. You are caring for an infant born at 25 week’s gestation who is advancing take NeoReviews quizzes and
enteral feeds. Previous studies have demonstrated that proteins are key claim credit online only at:
structural components of all human cells, vital for adequate growth, and a https://publications.aap.org/
main driver of lean body mass growth. What is the recommended amount of neoreviews.
enteral protein intake for adequate growth in an extremely preterm infant?
To successfully complete 2024
A. 11.5 g/kg per day NeoReviews articles for AMA PRA
B. 2 to 2.5 g/kg per day. Category 1 Credit™, learners
must demonstrate a minimum
C. 3 to 3.5 g/kg per day.
performance level of 60% or
D. 4 to 4.5 g/kg per day. higher on this assessment. If
E. 5 to 5.5 g/kg per day. you score less than 60% on the
assessment, you will be given
3. You are taking care of a critically ill term neonate with acute kidney injury additional opportunities to
(AKI). Infants with this condition are often in a catabolic state with muscle answer questions until an
protein breakdown and lipolysis. In addition to increased protein catabolism, overall 60% or greater score is
other metabolic abnormalities can occur in infants with AKI. All of the achieved.
following metabolic derangements can be observed in these patients except:
This journal-based CME activity
A. Altered amino acid metabolism. is available through Dec. 31,
B. Hypoglycemia. 2026, however, credit will be
recorded in the year in which
C. Impaired immune function.
the learner completes the quiz.
D. Peripheral insulin resistance.
E. Proinflammatory state.
4. AKI is a common complication in neonates with critical illness and can be
challenging to manage. Pathologic fluid balance and fluid overload often
require fluid restriction, making it difficult to provide optimal nutrition. In
addition to fluid overload AKI can contribute to each of the following 2024 NeoReviews is approved
for a total of 30 Maintenance of
electrolyte derangements EXCEPT:
Certification (MOC) Part 2
A. Hypercalcemia. credits by the American Board
B. Hyperkalemia. of Pediatrics (ABP) through the
AAP MOC Portfolio Program.
C. Hyponatremia.
NeoReviews subscribers can
D. Hyperphosphatemia. claim up to 30 ABP MOC Part 2
E. Metabolic acidosis. points upon passing 30 quizzes
(and claiming full credit for
each quiz) per year. Subscribers
can start claiming MOC credits
as early as October 2024. To
learn how to claim MOC points,
go to: https://publications.aap.
org/journals/pages/moc-credit.

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 5. An infant of 37 week’s gestation with AKI is requiring continuous renal
replacement therapy (CRRT). A common complication of CRRT is the removal
of important solutes necessary for growth and development. Of the patients
receiving CRRT, what percentage experience malnutrition and poor growth?
A. 10%
B. 25%.
C. 45%.
D. 60%.
E. 75%.

Vol. 25 No. 1 JANUARY 2024 e35

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