Table 9.

Summary of recommendations

	Category	Recommendation	Grade
1	Dietary sources
	1.1 Dietary sources of Ca	The main dietary sources of Ca for children are milk, milk products, breast milk and manufactured infant formulas. Statutory or voluntary fortification of foods with Ca can increase the contribution from other foods.	Ungraded
	1.1 Dietary sources of P	The main dietary sources of P for children are milk (including milk products, breast milk and manufactured infant formulas), cereals (grains) and cereal products, and meat and meat products. Inorganic P added to some processed foods is readily absorbed and can significantly increase P intake.	Ungraded
2	Assessment of Ca and P intake in healthy children and children with CKD2-5D	We suggest that in healthy children and those with CKD2-5D a diet history of a typical 24-hour period be used to rapidly identify the main sources of Ca and P, including P additives in processed foods. A 3-day prospective diet diary/food intake record may be used when detailed information is required An estimate of the total Ca and P intake should consider contributions from diet, nutritional supplements, dialysate and medications including P binders.	C (weak recommendation)
3	Requirements of Ca and P
	3.1 Requirements in healthy children	We describe the Ca and P requirements for healthy children as background and justification for estimating the requirements for children with CKD2-5D; specific recommendations for healthy children are outside the scope of this document.	Ungraded
	3.2 Requirements in children with CKD2-5D	3.2.1 We suggest that the diet of children with CKD2-5D should be regularly assessed for total Ca and P content. The contribution of P additives to total P intake cannot be quantified, but dietary sources of P additives should be identified where possible. Frequency of assessment is based on the child’s age, CKD stage and trends in serum Ca, P and PTH.	Ungraded
		3.2.2 We suggest that the total Ca intake from diet and medications, including P binders, should be within the SDI, and be no more than twice the SDI, unless in exceptional circumstances.	C (weak)
		3.2.3 In special circumstances, such as for infants with CKD or those with mineral depleted bone, a higher Ca intake may be considered with careful monitoring.	C (weak)
		3.2.4 We suggest that the dietary P intake of children with CKD should be within the SDI for age, without compromising adequate nutrition	C (weak)
4	Managing the Ca and P requirements in children with CKD2-5D	4.1 We suggest that intake of Ca and P is adjusted to maintain serum Ca and P levels within the age-appropriate normal range, without compromising nutrition. Changes in management should be based on trends of serial results rather than a single result, with integration of serum Ca, P, PTH, alkaline phosphatase and 25-vitamin D levels.	C (weak)
		4.2 We suggest that children with CKD who have hyperphosphatemia or hyperparathyroidism will require further dietary restriction of P, potentially to the lower limit of the SDI, without compromising adequate nutrition. Advice to limit the P contribution from phosphate additives should be given. Use of P binders for further control of serum P and PTH levels is often required, in addition to dietary restriction.	C (weak)
		4.3 We suggest that children with persistent hypocalcaemia or a high PTH may require a Ca intake above 200% of the SDI for calcium for short periods and under close medical supervision. Calcium can be provided through Ca supplementation, together with vitamin D (usually both native and active forms), as well as other sources of Ca such as a high Ca dialysate.	C (weak)
		4.4 We suggest that children with persistent hypophosphatemia should have their dietary P intake increased. P supplements may be necessary in some patients, particularly those on intensified dialysis or with renal wasting of P.	C (weak)
5	Management of hypercalcemia	5.1 Acute, severe hypercalcemia can be life-threatening and requires rapid medical intervention.	X (strong)
		5.2 In a child with persistent mild to moderate hypercalcemia, we suggest a stepwise approach with reducing or stopping Ca supplements, Ca-based P-binders, and native and active vitamin D and using lower calcium dialysate. Transient reduction of dietary Ca, without compromising adequate nutrition, may be necessary. Regular reassessment is required, especially when Ca intake is reduced below the SDI.	C (weak)