Treating children is complicated by the fact that they are still growing and developing, and chronic kidney disease (CKD) interferes with this normal growth and development. Thus pediatric nephrology nurses must have a comprehensive knowledge of pediatric nursing and childhood growth and development.
What is family-centered care in a pediatric patient population?
The concept of family-centered care developed from an awareness that young patients’ emotional and developmental needs are best met by incorporating their families into the plan of care.
What are the staffing considerations for a pediatric hemodialysis population?
The hybrid of services that a pediatric dialysis facility provides necessitates a good method of matching resources to patient workload activity. The best choice is a time-motion study–based, statistically validated patient-dependency classification system. A patient-dependency system takes into account such factors as developmental age versus chronologic age and matches care requirements to the appropriate number of staff at each skill level. The patient-dependency system captures the care requirements of a patient who may be less ill but more dependent due to age, developmental level, or cultural requirements or who requires more frequent or different types of interventions than other patients with the same diagnosis. Because of the many pediatric patient-dependency categories, staffing requirements for pediatric care comprise a complex matrix that is most easily implemented with a staffing and scheduling system that targets staffing by skill level. As a patient’s dependency level increases, increased caregiver skills are usually required. The system must also recognize the potential for day-to-day variation in an individual child’s care requirements and in the staff required to provide that care. Determining staffing by matching caregiver-to-patient ratios to patient ages or sizes can be a disadvantage because ratios presume that all patients of the same age or weight necessarily require the same level of care every day.
How can a pediatric facility maximize operations when it has a small patient base?
Many pediatric dialysis facilities maximize operations by cross training nursing staff in both acute and chronic renal replacement therapy. During orientation the pediatric dialysis nurse learns how to manage all of the therapies furnished by a particular facility. Commonly these include the pediatric modalities of hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Some pediatric dialysis facilities offer additional extracorporeal therapies, such as hemoperfusion and plasmapheresis. Orientation can take anywhere from six weeks to three months, depending on prior experience and learning opportunities. Simulated clinical experiences in a skills laboratory can supplement learning experiences. A broad orientation plan and a gradual progression to independence with a designated preceptor guiding the progress toward acquisition of knowledge and mastery of skills have worked best in our experience.
Is there a place for technical support in the care of children on hemodialysis?
Some programs employ technicians for well-defined tasks, such as preparing equipment for dialysis or assisting registered nurses with children who are not developmentally delayed and who weigh more than 35 kg. A well-defined orientation plan, competency list, and method of documenting progress are important. Some states have specific stipulations for technical support personnel; check with the state department of health for specific state guidelines.
What are the causes of acute kidney injury in children?
Acute kidney injury in children usually results from hypoperfusion of the kidneys due to septic shock, hypotension, and severe dehydration from gastroenteritis or from acute blood loss from surgery or an accident. The pathology is that of acute tubular necrosis. Acute tubular necrosis can also occur after nephrotoxic drugs, especially aminoglycoside antibiotics and amphotericin B. The most common cause of primary acute kidney injury in children in North America is hemolytic uremic syndrome. Acute poststreptococcal glomerulonephritis, although common in children, rarely leads to acute kidney injury severe enough to warrant dialysis.
What are the causes of chronic kidney disease in children?
The causes of CKD are different in children than in adults. About two thirds of the cases in children are caused by congenital urinary tract anomalies, such as posterior urethral valves, obstructive uropathy, reflux nephropathy, renal dysplasia, and neurogenic bladder associated with spina bifida, or hereditary diseases, including cystinosis, hyperoxaluria, and autosomal recessive polycystic kidney disease. The other one third of cases in children are caused by acquired kinds of glomerulonephropathy, such as focal segmental glomerulosclerosis or membranoproliferative glomerulonephritis. Unlike CKD in adults, diabetic nephropathy, chronic hypertension, autosomal dominant polycystic kidney disease, and membranous glomerulonephritis are rarely causes of CKD in childhood and adolescence.
When is hemodialysis the right choice for pediatric patients requiring chronic replacement therapy?
The preferred modality of treatment for most pediatric patients who require maintenance dialysis is renal transplantation. If a pediatric patient needs chronic dialysis, home peritoneal dialysis is the usual choice, but may not always be possible. Some family situations are unable to support chronic peritoneal dialysis. Some patients may have lost peritoneal function from previous abdominal surgery or peritonitis. Currently younger children, including infants and toddlers with CKD, who have failed peritoneal dialysis and who are not yet eligible for transplantation or who are waiting on the deceased donor transplantation list, require chronic hemodialysis. The U.S. Renal Data System found that, in 2007, there were 1263 prevalant hemodialysis patients, 877 peritoneal dialysis patients, and 5396 transplant patients who were 19 years or younger. Technical advances in equipment and vascular access catheters have made chronic hemodialysis possible even in small children. Some adolescents may choose hemodialysis because of concerns about body image or their ability to comply with the discipline of chronic peritoneal dialysis and the need for daily treatment.
What is the significance of body surface area to renal function in pediatrics?
Normal serum creatinine concentration increases with age and body mass. The normal serum creatinine level in a 2-year-old is 0.4 mg/dL, whereas in an adult it is about 1.0 mg/dL. If it were 1.0 mg/dL in a 2-year-old, that child would have renal failure with about a 60% reduction in renal function. To compare parameters of renal function in different-size pediatric patients from infancy to adolescence, creatinine clearance and other measures of glomerular filtration rate are usually normalized to the average adult body surface area of 1.73 m2. The normal range for creatinine clearance in a pediatric patient older than 2 years is 100 to 120 mL/min/1.73 m2. When the creatinine clearance decreases to less than 10 mL/min/1.73 m2, the pediatric patient has stage 5 chronic kidney disease.
Is there a preferred measure of weight for children?
The preferred measure of weight for children is metric because most therapies are prescribed per weight in kilograms. Consistent use of the metric system to measure weight in children lessens calculation error. If a kilogram scale is not available, convert pounds to kilograms by dividing by a factor of 2.2.
Are there particular considerations when choosing a hemodialysis station location for the child dialyzing in an integrated pediatric and adult care facility?
Because of the higher dependency of the pediatric hemodialysis patient, especially those weighing less than 35 kg, the station for hemodialysis should be within easy access and centrally visible. In the event of an emergency in another patient, every effort should be made to protect the child from viewing the stressful event.
Do children ever require isolation?
Communicable diseases, such as varicella (chickenpox), are common in childhood. In addition to isolation for blood-borne pathogens, children may need to be isolated during periods when they are at risk of manifesting communicable diseases after recent exposure. Each facility should develop general recommendations for isolation for children exposed to communicable diseases like varicella to avoid exposure of susceptible adult patients.
What is the safe limit for extracorporeal volume in a child?
The safe limit for extracorporeal volume in a child is 10% or less of the child’s blood volume (Table 21-1). This blood is returned to the patient at the end of the treatment, unless it is needed for laboratory tests. In this case, no more than 3% to 5% of the child’s blood volume should be removed on a given day. Many laboratories have microcontainers for blood sampling for small children or use minimal blood volumes for tests to help avoid excess blood loss in pediatric patients.
Table 21-1 Approximate Blood Volume by Age
|
Age |
Total blood volume |
|
Premature infants |
90 to 105 mL/kg |
|
Term newborns |
78 to 86 mL/kg |
|
>1 mo to 1 yr |
78 mL/kg |
|
>1 yr to adult |
74 to 82 mL/kg |
|
Adult |
68 to 78 mL/kg |
How does one calculate extracorporeal volume?
Extracorporeal volume is the total volume of the dialyzer plus the bloodlines. Specific values are available from product manufacturers.
Can hemodialysis treatment be done when the extracorporeal volume exceeds the safe limits?
When extracorporeal volume is 10% to 12.5% of blood volume, the system must be primed with a volume expander such as 5% albuminized saline. When extracorporeal volume exceeds 12.5% of blood volume, reconstituted whole blood may be the safest for priming and is imperative when extracorporeal volume is 15% or more. There are specific dialysis products designed to minimize extracorporeal blood volume for small children, and these must be used to avoid the expense and risk of using blood products routinely. The pediatric nephrologist decides how much, if any, of the system prime is returned to the patient at the end of the treatment, based on the patient’s specific albumin or hemoglobin deficit.
How is replacement blood transfusion volume calculated if a pediatric hemodialysis patient suffers an acute blood loss (i.e., clotted system)?
To replace acute blood loss associated with hemodynamic instability, transfuse packed red blood cells at 10 mL/kg body weight or more, depending on the estimated amount of blood lost and the child’s hemoglobin before the loss.
What are the vascular access considerations in pediatrics?
The smaller the pediatric patient, the more difficult it will be to establish adequate access for hemodialysis. In patients weighing less than 10 kg, an indwelling catheter of appropriate diameter placed in a major vessel will be the only option. It is important that the catheter not come close to or exceed the vessel size, which will lead to obstruction of normal venous flow. Dual and single lumen cuffed catheters are now available for even very small children (5 to 10 kg body weight). In the hands of a skilled pediatric access surgeon, an arteriovenous loop graft in the thigh may be possible for patients weighing more than 10 kg, and a primary arteriovenous fistula in the forearm may be possible for patients weighing more than 15 kg. In general, permanent access is extremely difficult when the patient weighs less than 20 kg and should be placed only by a surgeon or pediatric nephrologist skilled in these procedures.
Do children require special dialyzers?
In choosing the dialyzer for a pediatric hemodialysis patient, the dialyzer surface area (available from the product manufacturer) often approximates the child’s body surface area. Dialyzers as small as 0.22 m2 are available. The type chosen should be based on the blood volume of the dialyzer as well as the prescription for dialysis adequacy and the ultrafiltration (UF) coefficient. Hollow-fiber dialyzers are preferred because of their low compliance.
Are there special pediatric bloodlines?
Many manufacturers offer neonatal or pediatric-size bloodlines, which offer a substantial decrease in volume over adult lines. Because these specialized bloodlines tend to be shorter, caution should be taken to secure the lines so that there is no tension on the patient’s access site.
Are there hemodialysis machines specifically for children?
Volumetric hemodialysis equipment that is used for adults can be safely used for children. Volumetric equipment decreases the margin of error for fluid removal. Note that all hemodialysis system manufacturers warn of the potential variance from target of 10% for fluid removal, which is especially important in the small patient, where 10% can be a substantial amount compared with the patient’s total body water.
Can reprocessed dialyzers be safely used for children undergoing hemodialysis?
Only a few pediatric care facilities practice reuse. Reuse is more widely practiced in larger integrated pediatric and adult care facilities.
How is pain associated with hemodialysis managed in children?
For the discomfort of fistula needle insertion, pain management options include topical anesthetics (e.g., EMLA cream) or subcutaneous 1% lidocaine at the needle insertion sites. Some children, often preschoolers, find topical anesthetics ineffective and consider subcutaneous 1% lidocaine “just another stick.” For these patients a fistula needle insertion without anesthetic may be the best-tolerated option. Additional pain management techniques include deep breathing, distraction (e.g., blowing bubbles or inverting a glitter wand), or visual imagery, such as focusing on a soft-colored light. Remember that crying is a normal response to pain or to fear of a needle before there is pain. The key to pain management success is a consistent approach and good communication with the patient and family. The team should take every opportunity to soothe anxieties, to offer an array of pain management options, and to positively reinforce desired behavior, such as holding still.
If a child must be immobilized for needle insertion, minimize the number of personnel involved and focus on immobilizing the child’s joints to prevent movement that will interfere with successful needle placement. Children who weigh less than 10 kg are best swaddled. Only rarely should a child require restraints, and then only for a short time period. When restraint is deemed necessary, a medical order should be written and refreshed with each hemodialysis treatment for which restraint is used.
Is sequential ultrafiltration used in children?
UF is only appropriate in older children and adolescents. Small infants requiring 5% albuminized saline or reconstituted whole blood prime should not have sequential UF. Prolonged UF in a small child can lead to hypothermia because the blood compartment will not be warmed by dialysis fluid.
How does one determine the target weight for a child on hemodialysis?
If the patient is growing, his or her weight should be gradually increasing. Target weight is the weight at which a patient with an adequate Kt/V is normotensive and euvolemic. Noninvasive in-line monitoring devices, such as the Crit-Line, can help to refine target weight determinations during a dialysis treatment. In growing children target weight should be reassessed at least monthly or more often when indicated by hypertension. Fluctuations in weight can occur frequently in children due to changes in dietary intake, compliance with fluid restrictions, or vomiting and diarrhea. Chronic fluid overload in children may masquerade as false weight gain and fool even the experienced dialysis nurse.
What is the optimal blood flow rate for a pediatric hemodialysis patient?
The optimal blood flow rate (Qb) is a function of what the access will allow as well as the desired Kt/V. A Qb of 200 to 350 mL/min/1.73 m2 has been optimal to achieve these goals in our pediatric unit.
How does intradialytic monitoring differ in children?
The advent of volumetric hemodialysis equipment has made the procedure much safer in children. Blood pressure monitoring intervals should match the individual patient’s care requirements. Blood pressure should always be done immediately after initiating the hemodialysis and at least hourly thereafter. When a patient is perceived to be unstable, monitoring intervals should decrease. Resist the urge to take blood pressure measurements every 15 minutes or half hour just because the patient is a child. The child may become agitated and uncooperative, creating technical difficulty in obtaining reliable readings. Monitors designed to noninvasively and automatically measure systolic and diastolic pressure, mean arterial pressure, and pulse rate for neonatal or pediatric patients are effective and versatile. They continue to monitor during most clinical crises when other indirect measurement methods may fail. Acute hemodialysis treatments in unstable patients nearly always require continuous arterial pressure monitoring for safety.
In addition to blood pressure measurement in patients weighing less than 20 kg, continuous monitoring of heart rate (electrocardiogram) and oxygenation (pulse oximeter) is required to detect deterioration in patient condition, which is most often related to acute fluid removal. Continuous nursing assessment is also needed to pick up subtle changes of impending hypotension, such as irritability or yawning or fidgety movements. Because these subtle signs vary from patient to patient, their inclusion in the individual patient’s plan of care will facilitate communication of a particular patient’s care to the entire team.
What is high blood pressure in children?
The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents recommends that the target blood pressure in children with CKD be less than the 90th percentile and adjusted for age, gender, and height, or set at less than 120/80 mm Hg, whichever is lower (Table 21-2). Blood pressure differs by gender and increases with age and size, so parameters for hypertension will be different from those for adults, as shown in Table 21-3 for boys. Girls and shorter children at a given age have slightly lower blood pressure than boys and taller children for age. Blood pressure must be taken with an appropriately sized cuff, the air-filled bladder of which should have a width equal to approximately 40% of the circumference of the arm, measured at a point midway between the olecranon and acromion, and a length sufficient to extend around the arm at least 80% of the circumference. Cuff size is not standardized by industry, so the label “infant,” “child,” or “small adult” on the cuff should be disregarded and the above parameters should be followed for proper sizing. If a cuff is too small, the blood pressure measurement will be falsely high. An oversized adult cuff or large thigh cuff will be needed for obese adolescents.
Table 21-2 Classification of Hypertension in Children and Adolescents
|
Blood Pressure Classification |
Systolic or Diastolic Blood Pressure Percentile * |
|
Normal |
< 90th |
|
Prehypertension |
90th to 95th or if BP exceeds 120/80 even if < 90th percentile up to < 95th percentile |
|
Stage 1 Hypertension |
95th to 99th percentile plus 5 mm Hg |
|
Stage 2 Hypertension |
> 99th percentile plus 5 mm Hg |
* For gender, age, and height measured on at least 3 separate occasions; if systolic and diastolic categories are different, categorize by the higher value.
Adapted from National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents, Pediatrics 114(2):555–576, 2004.
Table 21-3 High Blood Pressure (> 95 percentile for age)
|
SIGNIFICANT BP* BASED ON HT PERCENTILE |
|||
|
Age group (boys) |
Percentile of Ht = 5% |
Percentile of Ht = 95% |
|
|
BP percentile |
95% |
95% |
|
|
1 year |
98/54 |
106/58 |
|
|
2 years |
101/59 |
110/63 |
|
|
4 years |
106/66 |
115/71 |
|
|
6 years |
109/72 |
117/76 |
|
|
8 years |
111/75 |
120/80 |
|
|
10 years |
115/77 |
123/82 |
|
|
12 years |
119/78 |
127/83 |
|
|
14 years |
124/80 |
132/84 |
|
|
16 years |
129/82 |
137/87 |
|
BP, Blood pressure; Ht, height.
* Prehypertension in children is defined as average systolic blood pressure (SBP) or diastolic blood pressure (DBP) levels that are ≥ 90th percentile but < 95th percentile.
Adapted from National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents: The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents, Pediatrics 114(2):555–576, 2004.
What is the significance of latex in the pediatric hemodialysis setting?
Certain groups of children are at high risk for developing latex allergy. Children with spina bifida have a 10% to 60% risk of developing an allergy to latex. Other children who require clean intermittent urinary catheterization are also at high risk. Repeated exposure to latex products is purported to be a significant risk factor that can trigger a reaction, which can begin as contact urticaria or can be as dramatic as an anaphylactic reaction. There are two basic exposure routes: direct mucosal contact and airborne latex particles. Treatment of latex allergy is best directed toward preventing exposures to the numerous items, such as gloves and catheters, that contain latex. In addition to identifying pediatric patients at risk, each facility should develop protocols for latex precautions.
Are there any differences in heparin requirements during a pediatric hemodialysis?
The adult guidelines for heparinization and activated clotting time (ACT) monitoring can be used for children. To achieve a target ACT of 1.5 times normal, begin with a loading dose of 25 to 50 units/kg and a continuous infusion of 10 units/kg/h. Increase the loading dose by 10 to 25 units/kg and the continuous infusion by 5 units/kg/h as needed to achieve the desired ACT. When the usual heparin requirement is established for a given patient, one should resist the temptation to sample blood unnecessarily for ACTs. Heparin requirements may be different if a chronic patient receives new vascular access or has surgery or gastrointestinal bleeding. Neonates, especially premature infants, who require hemodialysis or continuous renal replacement therapy need tight heparinization because they are at high risk for cerebral hemorrhage.
How does anemia management differ in children?
Two multicenter trials have shown that pediatric patients younger than 5 years old frequently require initial recombinant human erythropoietin in higher doses, approximately 300 units/kg/wk, than those required by older pediatric patients and adults. Achieving target iron levels to support erythropoiesis requires the administration of supplemental iron, either orally or intravenously. When administering intravenous iron dextran, heed the differences in pediatric test doses, such as 10 mg for patients weighing less than 10 kg and 15 mg for those weighing 10 to 20 kg, and pediatric dosing by body weight. The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines note the differences in anemia management in children and are a good guideline to follow for pediatric care. The dose of erythropoiesis-stimulating agent (ESA) will vary depending on the patient’s treatment modality, route of administration, and age. The NKF KDOQI guidelines for pediatric clinical practice were updated in 2006. The guidelines recommend that evaluating for anemia should begin when the hemoglobin falls below the 5th percentile for age and sex. The goal for hemoglobin for children is the same as for adults, 11 to 12 g/dL. (See page 365 for additional information on NKF KDOQI.)
Why are children with chronic kidney disease short in stature?
Growth retardation is a significant consequence of CKD in children. The age of onset is an important variable affecting growth: the younger the patient at the onset of CKD, the greater the potential for growth retardation. Many factors contribute to poor growth, including chronic metabolic acidosis, sodium wasting and chronic dehydration, chronic fluid overload, poorly controlled renal osteodystrophy, anorexia and malnutrition from poor caloric intake, steroid therapy for underlying renal disease control, and disturbances of normal growth hormone regulation. To best achieve normal or catch-up growth, efforts should be made to correct as many of these abnormalities as possible before the patient needs chronic dialysis.
How can growth be maximized in a pediatric hemodialysis patient?
To maximize growth potential during chronic hemodialysis, efforts should continue to include correcting acidosis, minimizing fluid overload, controlling renal osteodystrophy, and promoting optimum nutrition, and should include optimizing dialysis adequacy. Each patient’s height and target weight should be monitored closely (at least every three months) until the bone growth plates close. Head circumference as well as length and target weight should be measured in children younger than 3 years. Gender-specific growth charts should be maintained and plotted quarterly, or more frequently if the patient is falling off his or her percentile on the growth chart. When height falls below the 5th percentile for age in a child more than 1 to 2 years old, initiation of recombinant human growth hormone therapy should be considered. Children with CKD are relatively resistant to normal levels of growth hormone, so supplementation can help to normalize their growth and improve muscle mass. The NKF KDOQI guidelines revised the recommendations for the nutritional needs of children with CKD and include the dietary intake of sodium, potassium, calcium, phosphorous, and fat. Other topics include nutritional assessment, management of acid-base balance, use of kinetic modeling, energy and protein intake, and vitamin and mineral requirements (NKF, 2008).
What are the toileting concerns in the child with end-stage renal disease?
Facilitate toilet training when the child is developmentally ready. The child with CKD may have no urine output or only a small amount of urine daily. Some children, usually those with congenital renal disease, such as dysplasia or obstructive uropathy, may have a large volume of urine output daily and little concentrating ability. Young children with large urine volumes often continue to have nighttime bed-wetting because they are too sleepy to feel the need to get up and urinate in the toilet.
Can children who are receiving hemodialysis treatments attend school regularly?
Most school-age children on hemodialysis are able to attend school regularly with their peers. Missing school is often related to hospitalizations or to the hemodialysis treatment schedule. When scheduling hemodialysis, every attempt should be made to facilitate school attendance. School constitutes a framework for daily behavior that imposes discipline and regularities, skills that are essential to achieving adult independence and ultimately entering the job market.
What are options for measuring functional status in children?
Denver II developmental screening tests are easy to perform and are recommended for the assessment of children less than 6 years of age. Developmental delays are not uncommon in this chronically ill population. Another functional status tool for older children is the Children’s Health Questionnaire, which is the pediatric version of the Short Form 36.
How does emergency preparedness need to be adapted when caring for children?
Medical emergency.
The facility must be equipped with the appropriate pediatric-size airways, air mask bag units, and endotracheal tubes. Because most pediatric drug doses are based upon patient weight, it is wise to have an emergency drug list with precalculated doses for each individual pediatric patient. A pediatric advanced life support (PALS)–certified nurse and nephrologist should always be readily available.
Fire.
Fire drills must be adapted to each child’s developmental understanding. Many child-friendly resources, such as coloring books and fact sheets, are available through the National Fire Protection Association or the fire division of the local department of public safety.
Disasters.
When local disasters such as floods, tornados, hurricanes, or earthquakes strike, pediatric hemodialysis treatment becomes a priority. If a disaster can be anticipated, some pediatric patients may benefit from preemptive hospitalization.
Does pediatric hemodialysis cost more than adult hemodialysis?
Pediatric hemodialysis costs are higher because of the increased cost of supply items and services. Pricing is not as competitive for disposables in this low-volume specialized market. Staffing for the increased patient dependency in pediatrics demands increased caregiver skills or more nurses. Exception requests based on atypical service intensity are available through the Centers for Medicare & Medicaid Services (CMS) to enable pediatric centers to increase their center-specific Medicare reimbursement rate to compensate for more costly operating conditions.
When do children transition to adult care?
Optimally, early preparation should begin during the stage of late adolescence (ages 17 to 21 years), which is characterized by a teenager’s having developed the ability to define future goals, make close and intimate friendships, and begin rapprochement with parents and other authoritative adults. During the stage of midadolescence (ages 14 to 17 years), a teenager is at the height of risk-taking behavior, peer conformity, poor future orientation, and parental conflict, which is a very difficult time to implement the transition to adult responsibilities. Some patients who are developmentally delayed may not be ready for transition at age 17 years. Transition preparation includes teaching self-care skills, such as taking responsibility for adhering to a medication schedule, arranging clinic visits, and arriving for treatments on time. Ideally, late preparation should also incorporate a visit to the adult dialysis center, accompanied by a trusted nurse or social worker. Actual transfer to adult care should occur between 18 and 21 years of age, depending on patient readiness, disease management, and availability of service. Being in an integrated pediatric and adult care facility should not preclude having the adolescent participate in a defined transition preparation program to be sure the patient is ready for the demands of adult-oriented care.