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Chronic Kidney Disease (CKD) in Infants <1 Year: Formula Nutrition for Achieving
Optimal Growth and Development

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Alyssa Specht
Staci Freeworth
FN 4350
12 December 2013

Table of Contents

Introduction......................................................................................................................................3
Method.............................................................................................................................................5
Experimental Design............................................................................................................5
Subjects................................................................................................................................6
Procedures............................................................................................................................7
Instruments Used for Data Collection................................................................................11
Data Analysis Methods......................................................................................................13
Results................................................................................................................................14
Discussion..........................................................................................................................18
References..........................................................................................................................22

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I. Introduction
Chronic kidney disease (CKD) is defined as any abnormality that that causes the kidneys
to function less efficiently in a progressive decline over time. (2) Renal dysplasia is the most
common form, which is CKD due to congenital abnormalities (malformations present at birth).
This type of CKD is the diagnosis for half of all infants with CKD. Exact causes are unknown,
but possible causes are due to maternal intra-uterine obstruction, syndromes, or genetic defects.
(4) This is a highly specific population with several complications that may result from CKD
including hypertension, anemia, weak bones, and malnutrition. All of these complications
contribute to growth failure of infants with CKD. Classified into five stages, CKD progression
eventually requires dialysis and/or transplantation for treatment. Therefore, prevention of
complications and delaying of CKD progression is critical.
Nutritional requirements for CKD patients are particularly challenging, and malnutrition
is a major contributor to growth retardation for infants within the first year, which occurs in 50%
of all CKD infants. (1, 2, 4) A further contraindication is that there are no specific
recommendations for CKD infant nutrition. As a primary a goal is to prevent and delay
problems rather than to treat them as they arise, it is crucial that health care providers look to the
first year of a CKD infants development as the critical period for optimal nutrition delivery and
prevention. As the current standards for CKD infants >1 year are the same as healthy infants > 1
year, further observation and study of this population is required to reveal the possibility of
nutrient adjustment for CKD patients past the first year. As with many chronic diseases,
progression varies from patient to patient, so it is never too early to begin preventative measures.

Due to the various natures of CKD in infants, several specifics must be considered when
monitoring nutrition of the infant <1 year, which consequently complicates proper nutritional
delivery. While adequate energy intake is of greatest concern, the macronutrient protein and
minerals calcium, vitamin D, phosphorous, sodium, and potassium also play crucial roles in
CKD infant development and often require the most immediate attention in nutrition
intervention. It has been observed that proper amounts of these nutrients being successfully
delivered may prevent dialysis, delay transplantation or ready the infant for transplantation,
prevent hyperkalemia, prevent anemia, prevent mineral bone disorder, and reduce the chance of
poor neurological and physical development. (3) Several challenges are faced with these specific
nutrients as several balances must be maintained in the infants body. Infants with high levels of
one nutrient may be reaching toxicity levels to achieve adequate levels of other nutrients, which
can enhance CKD progression. For example, an excessive vitamin D intake promotes rather than
prevents mineral bone disorder (a barrier to optimal linear growth), subject to the calciumvitamin D-phosphorous complex. (4, 6) Another significant balance is the sodium-potassium
complex; too much or too little has several consequences that do not affect healthy infants. (2)
Complete growth assessment serves as the best indicator of CKD infant development, as it
provides a big picture of the status of multiple components. Because optimal growth is the best
indicator of optimal nutrition, these measurements plus biochemical values are useful in
determining the relative successes that CKD infants will have as they continue to develop.
Several infant formulas on the market provide nutrients tailored for high risk infants and
are thus administered to CKD infants. These formulas alone, however, are not necessarily
adequate as evidenced by the extremely high rate of growth failure for CKD infants. The stage of

CKD that the infant has also contributes markedly to nutritional status and development. (3)
While every infant differs in development, general patterns can be determined with growth when
proper nutrition is provided. It is therefore imperative to examine the potential differing effects
that the various infant formulas have upon growth in CKD infants. The purpose of this study is to
achieve a better understanding of the currently used infant formulas and determine if one formula
is better than others in terms of nutrition delivery to CKD infants <1 year, and to further the goal
of establishing relative standards of preventive nutritional delivery for this population.
II. Method
A. Experimental Design
As with healthy infant nutrition, there is currently no template for CKD treatment via
infant formula nutrition within the first year of life. This experiment will study the growth
progression of CKD infants <1 year of age (a beginning age between birth and two months) that
have been diagnosed with renal dysplasia. This type of CKD represents half of all CKD infants
and therefore is the best benchmark for developing a standard method of treatment for health
care providers when delivering nutrition to this population.
The infants in the study have diagnoses renal dysplasia CKD from stages 1 to 3, where
transplantation preparation and dialysis are not present nutritional concerns. A goal of the study
is to shed some light on the optimal prevention/delayed progression of the need for
transplantation and/or dialysis within these earlier stages of renal dysplasia CKD.
Infants of the study will be provided infant formulas on the current market that meet the
agreed upon nutritional standards, but with slight variations over nutrient compositions that may
or may not have an effect on CKD. Infant formula only is used for the study rather than breast

milk, for the precise amount of nutrients can regulated assuming that the infants consume the
recommended amount of formula. Tube feeding will not be used to ensure exact amounts unless
the infant requires such nutrition intervention prior to the completion of the study.
The main nutrients of concern are total energy, protein, calcium, vitamin D, phosphorous,
sodium, and potassium. Energy requirements for CKD infants are 100% of EER, the same as
typical infants. Protein intakes vary depending upon the stage of CKD, and is one reason why
only CKD from stages 1 to 3 are studied; at stages 4 and 5 protein needs can drastically increase.
(3) However, protein is an unwanted source of phosphorous and the result presents a challenge to
maintain protein needs. Phosphorous therefore will be monitored, especially after the
introduction of solid foods for infants, but infant formula will be the only fluid source within the
first six months. Introduction of solid foods will occur to continue with optimal development of
the individual infants. Calcium and vitamin D will also be monitored along with the relative bone
development of the child; whether or not standards for these micronutrients should be set may be
determined. Sodium and potassium are of concern, as both should remain in balance to prevent
volume overload. Typically, infants with stages 1 to 3 CKD need to maintain proper amounts of
sodium as too much may increase hypertension and too little delays development; sodium will
remain above the minimum recommendation of 120mg/d. Hyperkalemia (elevated serum
potassium) may result in infants with CKD, and no infant formulas are low in potassium. To
counter this possibility, infant formulas treated with sodium polystyrene and an adult formula
lower in potassium will be will be used. It is significant to note that known guidelines will not be
altered; rather the guidelines that have been of debate for nutritional prevention are the objectives
being studied.

B. Subjects
A 6-patient group of full term CKD infants, aged 0 to 2 months at the beginning of the
study, all diagnosed with renal dysplasia CKD between stages 1-3. The infants must qualify as
full-term infants to reduce the number of variables being observed, as preterm infants have
different nutrition needs and are also a high risk group. Other considerations for the CKD
population that affect nutrition are a predisposition to anorexia and vomiting, poor appetite, and
periods of fasting surrounding medical procedures. Protein and calorie requirement is extremely
high, especially since the role of GH (growth hormone) is immature in infants. (3, 4) CKD
infants with symptoms of uremia, bone disease, and/or are already on dialysis, have increased
nutritional needs and modifications. All of the above reasons are why only stages 1-3 are being
observed, as the stage of CKD determines the level of aggression needed for nutrition
intervention. A 6-patient group of full term, renal dysplastic CKD infants is a relatively large
group to study, as current statistics state that CKD is diagnosed in every 12 out of 1,000,000
children. (4)
C. Procedures
The 6-patient group will be divided: 3 will each be fed one of three infant formulas
Enfamil A+, Good Start, or Similac PM 60/40, and 3 will each be fed one of three diluted adult
formulas Suplena, Nepro Carb Steady, or Renalcal with modular supplementation. Polycose
modular will be used for caloric supplementation because the infants protein needs are not yet
>140% DRI. (3) If for some other reason protein needs are not met, Beneprotein will be used if
the infant is showing no signs of elevated phosphorous. The three infants that are fed infant
formula will continue to have the formula after 6 months, but with the introduction of solid

foods, the formula will be treated with sodium polystyrene to compensate for the increase in
dietary potassium if the infant has elevated potassium levels. (5) An infant will be removed from
the study if it becomes clear that its individual treatment is not adequate for its development or
its CKD is progressing in some way due to its nutrition. In the case of the latter, the infant may
still be observed for development after additional nutrition intervention.
Table 1 Current intakes for healthy newborn infants of the listed nutrients are as follows (3)
Nutrient

Intake 0-6 months

Intake 7-12 months

Energy (kcal)

108kcal/kg/d

98kcal/kg/d

Protein

2.2g/kg/d

1.6g/kg/d

Sodium

120mg/d

120mg/d

Calcium

200mg/d

260mg/d

Phosphorous

100mg/d

275mg/d

Vitamin D

400 IU/d

400 IU/d

Potassium

400mg/d

700mg/d

Iron (mg)

N/A

11mg/d

Table 2 Energy and Protein Requirements for infants up to stage 3 CKD (3)
Age of Infant

Energy (kcal/d)

Protein (g/kg/d)

0-3 months

[89 x weight(kg) - 100] + 175

1.5-2.1

4-6 months

[89 x weight(kg) - 100] + 56

1.2-1.7

7-12 months

[89 x weight(kg) - 100] + 22

1.05-1.5

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Table 3 Typical amounts of formula consumption:

Age of infant

Typical Intakes of Formula

per Day

0-1 mo.

16-20 fluid oz.

1-2 mo.

18-26 fluid oz.

2-3 mo.

22-30 fluid oz.

3-4 mo.

24-32 fluid oz.

Table 4 Infant Formulas Nutrition (3)

Per 100 mL

Similac PM 60/40

Enfamil A+

Goodstart

Energy (kcal)

68

68

67

Protein (g)

1.6

1.42

1.5

Protein source
(whey:casein)

60% whey, 40%

casein

60% whey, 40%

casein

100% whey

Sodium

.70 mmol

.8 mmol

.78 mmol

Calcium (mg)

38

53

44

Phosphorous (mg)

19

29

24

Vitamin D (IU)

43.2

52.3

40.2

Potassium

1.5 mmol

1.87 mmol

1.85 mmol

Iron (mg)

0.15

1.2

Table 5 Adult Formula Nutrition (3)

Per 100 mL

Suplena

Nepro Carb Steady

Renalcal

Energy (kcal)

200

180

200

Protein (g)

8.1

3.44

Protein source
(casein: whey)

100% casein

>74% casein

100% whey

Per 100 mL

Suplena

Nepro Carb Steady

Renalcal

Sodium (mmol)

0.3

4.6

Calcium (mg)

139 mg

106

Phosphorous (mg)

74

72

10

Vitamin D (IU)

0.99

20

Potassium (mmol)

2.7

Iron (mg)

1.9

1.9

1.9

Table 6 Modular Nutrition (3)

per 100g

Polycose

Energy (kcal)

380

CHO (% kcal)

100

CHO (g)

94

Protein (g)

Sodium (mg)

130

Potassium (mg)

10

Calcium (mg)

<30

Phosphorous (mg)

<15

Iron (mg)

0.095

Table 7 Beneprotein Nutrition (3)

per 7 g packet serving

Beneprotein

Energy (kcal)

25

Protein (casein:whey)

100% whey

Protein (g)

Sodium (mg)

15

per 7 g packet serving

Beneprotein

Calcium (mg)

30

Phosphorous (mg)

15

Potassium (mg)

30

Iron (mg)

Amount and addition of supplementation will be according to individual infant nutrition needs.
Linear growth development will be assessed weekly, and serum values will be assessed biweekly. This is based on the notion that infants with CKD should be assessed at least twice as
much as healthy infants. (1, 3) Volume status will also be assessed as some CKD infants can
become volume overloaded. (2, 4)
D. Instruments Used for Collecting Data
1. Complete nutrition and growth assessment. It has been suggested that infants with CKD be
evaluated at least as twice as much as typical infants; to monitor the patients, a complete
growth assessment will be conducted biweekly. (3) The WHO growth charts will be used for
the study, as it has been suggested that these charts are more suitable for plotting CKD infant
growth. (1, 3) The following will be measured at each physical assessment:
a. Dietary intake
b. Length for age
c. Estimated dry weight and weight for age
d. BMI for height age
e. Head circumference for age
2. Biochemical assessment of biweekly blood tests for patients:

a. Blood creatinine test: measures the level of the waste product creatinine in the blood
and urine. A low level in the urine indicates a high level in the blood, showing poor
kidney function
b. Blood Urea Nitrogen (BUN) test: measures the functional status of the kidneys, the
stage of CKD, and effectiveness of treatment
c. Carbon Dioxide (bicarbonate) blood level test: bicarbonate is a waste product of the
metabolism; blood level is balanced by the kidneys.
d. Total Serum Protein blood test for albumin: check status of kidney function
e. Alkaline Phosphatase: check the levels of parathyroid hormone, which controls bone
growth
f. Calcium (Ca) blood level test: check the bodys calcium level outside of the bones;
sign of bone and kidney problems
g. Phosphate blood level test: high levels indicate functional problem in the kidneys
h. Potassium (K) blood level test: determine status of blood levels; often change with
sodium level. Potassium levels also assess potential development of hyperkalemia
(elevated serum potassium) within the patients, especially after the introduction of
solid foods.
i. Sodium (Na) blood level test: determine the water and electrolyte balance of the body
and measure the progression of CKD.
j. Parathyroid hormone (PTH) test: affects calcium, phosphorous, and vitamin D levels;
levels too high or low is a source of kidney problems.

The goal of these tests is to determine if results in these various areas can be attributed to
one formula over another, or if certain nutrient levels are more beneficial than different levels.
Lab values, physical assessment, and growth measurements will aid in finding a standard option
for initial delivery of CKD infants notwithstanding individual complications. For each infant,
the goal is to keep it on the same formula as long as there are no immediate identifiable concerns
related to the specific formula in use.
3. The study will include 52 weeks of data collection of the 6 infant patients. There will be 26
complete nutrition and growth assessments and 26 biochemical assessments of lab values of the
listed blood tests. After each infant-formula fed patient has reached the 6 month milestone,
formula will be treated with sodium polystyrene with the introduction of solid foods. Any enteral
tube feedings, if necessary, will be documented in observations.
E. Data Analysis Methods
The data analysis methods used will be to determine if any connections of positive or
negative growth outcomes associate with type of formula/nutrient breakdown. The data for each
patient regarding the above measurements and tests will be compared to normal growth and
development as well as other patients respective developments. Infants at stage 1 CKD will be
compared with other stage 1 CKD infants, and the same will occur for stages 2 and 3 infants, if
possible. The levels of each nutrient being examined will be compared to the nutrient levels of
the given formula within each infant. Each patients nutrient levels will be compared by nutrient
to the other patients to determine if there is any correlation between growth, CKD development,
or complications.

III. Results
The results below are shown due to the significance of the data. The patient entry data and post
study data are shown in Tables 8 and 8.1. Charts for protein, calcium, phosphorous, vitamin D,
sodium, and potassium intakes are included. Complications/risks are listed in Table 8.1. One
patient (patient 6) progressed from stage 2 CKD to stage 3 CKD. The progression of all other
patients remained unchanged.
Table 8 Patient Entry Status
Subjects

Age

CKD Stage

Weight
(kg)

Length
(cm)

Patient 1

1 mo.

3.4

50.1

Patient 2

0 mo.

3.2

48.1

Patient 3

1 mo.

3.37

49.7

Patient 4

0 mo.

2.89

47.8

Patient 5

2 mo.

3.62

52.3

Patient 6

0 mo.

2.59

47.4

Table 8.1 Patient Status at 52 Weeks

Subjects

Age

CKD
Stage

Weight
(kg)

Length*

Complications/Risk

Patient 1

13 mo.

9.98

62.6
(92%)

hypocalcemia

Patient 2

12 mo.

6.72

53.5
(80%)

hypocalcemia
malabsorption

Patient 3

13 mo.

7.78

57.28
(84%)

anemia

Patient 4

12 mo.

7.23

52.45
(78%)

anemia
hyperphosphatemia
malabsorption

Subjects

Age

CKD
Stage

Weight
(kg)

Length*

Complications/Risk

Patient 5

14 mo.

9.23

59.3
(84%)

hyperphosphatemia
hypertension
malabsorption

Patient 6

12 mo.

5.1

50.3
(75%)

hyperkalemia
anemia
hypertension
malabsorption

(*Percent of minimum expected growth of 1.5-2cm/mo. from 0-6mo., 1 cm/mo. from 7-12mo.)

Table 9 Infant Formula Distribution

Subjects

Formula

Modular/Supplement

Patient 1

Similac PM 60/40

200IU Vit D

Patient 2

Enfamil A+

200IU Vit D

Patient 3

Goodstart

200IU Vit D

Patient 4

Suplena

400IU Vit D

Patient 5

Nepro Carb Steady

400IU Vit D

Patient 6

Renalcal

400IU Vit D, 200mg Ca

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Chart 1
Avg. Casein/Whey Protein Intakes of Patients

whey protein

casein protein

12

Milligrams Protein
Patient 1
Patient 5

Patient 2
Patient 6

Patient 3
Breastmilk

Patient 4

Chart 2
Avg. Nutrient Intakes from Formula (Ca, Vit D, Phosphorus)
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Recommendations
0

100

200

300

Milligrams Nutrient
Calcium

Phosphorous

Vitamin D

400

Chart 2.1

Avg. Nutrient Intakes from Formula w/ Supplementation (Ca, Vit D)

Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Recommendations
0

100

200

300

400

Milligrams Nutrient
Chart 3
Avg. Nutrient Intakes of from Formula (Potassium, Sodium)

Potassium

Sodium

10

15

20

Meq Nutrient
Patient 1
Patient 6

Patient 2
Recommendations

Patient 3

Patient 4

Patient 5

The above charts show the nutrient intakes based off of the average entry weight of the
patients (shown in Table 8), which was 3.18 kg, or 6.99lbs. This average weight was used to
average the EER amongst the patients. The intakes did not vary significantly among the patients,
for they were of similar weights. The majority of patients were also in stage 2 of CKD, so the
data could be averaged without sacrificing relevance to the population.
Table 9 lists the supplementation needed with each formula; vitamin D was necessary for
recommendations of all patients, and calcium was necessary in patient 6. The intakes of these
nutrients improved within 80% of the current recommendations. All patients did not triple their
weight by 12 months, and all patients did not achieve their full length growth potential.
Complications listed in Table 8.1 were included after confirmation was given via the
biochemical assessments. A correlation between blood levels and intake was observed in all
nutrients with the exception of the casein/whey ratio. The charts displaying intake
simultaneously reflect the lab values of the patients.
IV. Discussion
As mentioned previously, a goal of this study was to isolate a standard for nutrition
delivery amongst CKD infants diagnosed with renal dysplasia. Common problems within this
population is balancing energy intake with protein, calcium, and vitamin D with phosphorous,
potassium, and sodium levels. The primary difficulty of this study was maintaining enough
kilocalories without elevating phosphorous levels, which in turn lower calcium levels.
Supplementation of calcium and vitamin D was required, and it may be necessary to introduce
them along with infant formula for any infant whose PTH levels and blood phosphate levels are
normal, but is beyond stage 1 CKD.

Overall, maintaining energy intake is one area that must be strongly emphasized to health
care providers. (4) Infants with CKD are more vulnerable to developing feeding problems and
discomfort when feeding, causing a dislike of mealtimes for infants and family members alike.
While it is necessary to meet the nutrient needs as best as possible for optimal growth, promoting
quality of life and satisfaction with health care is absolutely critical. Regardless of outstanding
complications, feeding problems are a major source of insufficient intake, and a more probable
goal for CKD infant consumption may need to be within 80% of EER. (1) Also, as CKD
progresses, complications become more likely and feeding problems may increase as well; this is
partially dependent upon the infants temperament, but as shown in Table 8.1, linear growth is
best in the lesser stages of CKD and poorest in the more progressive stages. Linear growth was
the best indicator of the overall status of the infant; this confirms previous assertions that linear
growth is the best way to determine CKD infant health status. (3)
Weight, while also significant in this study, is a less reliable benchmark due to the
probability of infants being volume overloaded or depleted due to the varying electrolyte
balances. (3, 5) This is highlighted simply by the electrolytes potassium and sodium varying
between formula and patient intake. Linear growth also determines the significance of weight
for CKD infants; while none of the patients achieved optimal linear growth, weight gain goals
were determined based upon linear measurement. Certainly, it cannot be expected of these
infants with suboptimal linear growth to be at normal weight for age interpretations. (3)
Another factor that requires attention is the protein composition of the formulas. 100%
whey or 100% casein is more difficult for infant absorption. Complicating this ratio is the effect
that whey protein has upon gastric emptying; as shown in the study, patients 5 and 6 had the

most whey protein, and these patients had difficulty with malabsorption. Similarly, patient 4 had
difficulty gaining weight. Patients 4 and 6 developed warning signs of anemia. The risk for
anemia was possibly due to the lack of interest that these infants had in feeding, as these ratios of
protein were too far deviated from breast milk for the infants gastrointestinal system to properly
metabolize. In the case of whey, calcium and vitamin D levels, as well as electrolyte losses,
became a concern. It is advisable to remove the formulas Renalcal and Suplena as recommended
options based upon this information.
One further area of attention is the vitamin D, calcium, and phosphorous complex.
Patients 2, 4, and 5 had elevated blood phosphate levels, although patient 2s levels were almost
within the normal range. Patients 1 and 2 had blood levels leading to hypocalcemia, which could
lead to mineral bone disorder later on in CKD. Further calcium supplementation was necessary
to balance blood levels. Patients 4 and 5 developed hyperphosphatemia, further proving that
adult formula, while possibly beneficial for potassium levels, was potentially disrupting calcium
absorption and also putting these patients at later risk for mineral bone disorder. For healthy
infants, calcium absorption is high within the first year; for CKD infants, who struggle with
growth and malnutrition, calcium supplementation is again recommended. Also, this perspective
further supports removal of Renalcal and Suplena from CKD infant recommendations. (4)
This study was not without error; due to the esoteric nature of CKD in many patients,
there were many variables that could not be accounted for, such as infant feeding at home, the
stages of CKD of infants, the temperaments of the infants (and subsequent feeding problems),
and various natures of CKD amongst the patients. Although renal dysplasia was the CKD in the
study, this encompasses a broad range of abnormalities in the kidneys. The data from this study

should be consulted when questioning which formula to use based on blood levels of the
individual infant. Adult formulas are not recommended based on this study. Similac PM 60/40
and Enfamil A + appear to have the greatest potential for benchmark formula recommendations
along with vitamin D and calcium supplementation.

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Reference list
1. Recommendation 3: nutritional management and counseling. Am J Kidney Dis. 2009 Mar;
53(3): 31-34.
2. Fact Sheet: Nutrition for chronic kidney disease in children. [Internet]. National Kidney and
Urologic Diseases Information Clearinghouse. National Institute of Health (US); 2011 April.
[cited 2013 Sep 15]. Available from: www.kidney.niddk.nih.org.
3. Foster BJ, Mccauley L, Mak RH. Nutrition in infants and very young children with chronic
kidney disease. Pediatr Nephrol. 2012 Aug; (9):1427-39.
4. Reyes L. Chronic kidney disease (CKD). In: Elzouki AY, editor. Textbook of clinical
pediatrics. Spring-Verlag Berlin Heidelberg; 2012.
5. VanDeVoorde RG, Warady BA. Management of chronic kidney disease. In: Elzouki AY,
editor. Textbook of clinical pediatrics. Spring-Verlag Berlin Heidelberg, 2012.
6. Bunchman TE. Nutritional delivery in infants with CKD:techniques to avoid hyperkalemia. J
Renal Nutr. 2013 Sep; 23(6): 387-388.

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