Table 2.

Factors affecting enteral feeding choices to optimize growth in pediatric CKD.

Growth	Meeting growth chart and monthly weight gain expectations in grams; assessing for emesis and adequacy of feeds
Biochemical	Assessment of electrolytes for adjustment to feeds; changing an enteral product, adding medication such as SPS or sodium bicarbonate, modulating or mixing of enteral products
Route	If any sign of poor intake, consider placement of gastrostomy, gastrostomy preferred for later transition to oral diet; typically difficulty meeting oral intake needs spontaneously; consider use and adjustment of continuous and bolus feeds to meet child's individual tolerance needs
Renal Replacement Therapy	CKD patients may need to limit protein, have more freedom with electrolytes; hemodialysis must tightly limit electrolytes typically, PD patients may have needs that depend on transport status – such as varying needs for protein, potassium, etc.
Original Kidney Disease	Renal tubular disorders typically involve high sodium needs, tight potassium needs and fluid loss, while other conditions typically require stricter electrolyte control overall
Macro and Micronutrients	Balance of macronutrients is ideal, titrating for protein needs; micronutrients should meet DRI standards while avoiding exceeding UL's; specific micronutrients may be in abundance or shortage in CKD; close attention to electrolytes and other biochemical indices is necessary
Comorbidities	Considerations include gastrointestinal impairment, need for hydrolyzed or milk-soy free formula, other organ involvement; manifestations of specific original kidney disease
Volume concerns	Children with tubular disorders may need adequate fluid intake due to high volume losses; other children may need tight limitations, or have to limit fluid as urine output declines; factors such as emesis and gastric emptying may alter rate and times which fluid may be given
Psychosocial	Family and patient challenges as to complexity of formula and feeding regimen must be addressed with consideration of educational, financial, literacy and other needs, including family stressors and burdens