Feeding your baby or child with chronic kidney disease

Normal stages of feeding

All babies need to go through stages of feeding – starting with taking milk (usually breast milk, but sometimes a formula is used), and then weaning, or starting to eat solids, often starting with pureed (mashed up) foods, and then on to lumpy and finger foods, before moving on to family foods.

There are key ‘windows’ of time when a baby can start weaning. The following is normally recommended for healthy babies:

• about 6 months – start eating pureed (mashed up) foods
• about 8 or 9 months and after they have mastered pureed foods – start eating lumpy foods.

Monitoring feeding and weight gain

Your healthcare team will check that baby is getting enough milk to meet his or her needs. They will weigh your baby at each appointment, or as regularly as needed.

If your baby’s weight gain is slow, your dietitian may make formula milk more concentrated so it is higher in energy. If there are concerns about your baby’s feeding, it may be helpful to keep a diary. You can include:

• the date
• the type of milk (breast milk or formula)
• the amount of milk your baby has taken
• any comments – including whether your baby is well, or has reflux or is vomiting.

Weaning

CKD does not change the time of weaning. Solids provide extra energy. It is usual to introduce solids when babies are about six months of age. In some cases, the dietitian may encourage it after four months. Babies should not be weaned before four months of age.

Tips for weaning

Start with smooth pureed food.

Your baby may not swallow the food at first. New experiences of taste and a variety of flavours and textures are just as important as quantity. Don’t worry if your baby does not eat much – just work on his or her acceptance of tastes.

Let your baby be independent, get messy and really enjoy the feeding experience, regardless of what actually reaches the stomach.

Encourage progress with lumpy textures if you can. It is important your baby develops chewing skills at this stage. This will help him or her to develop tongue and jaw movement and speech. All babies gag on lumps from time to time. Don’t see this as a sign that your baby is trying to be sick. Try again, perhaps just giving the lumpier texture for a few mouthfuls. Try the same approach with finger foods.

More advice

More information about weaning to solid food (NHS Choices)

Weaning and how to introduce solid food (NHS Start for Life)

Special diets for older babies

Some babies with CKD need a special diet as well as special formula milk. This is usually only needed for babies who are eating a significant amount of food (more than a few tastes or spoonfuls). If your baby needs a special diet, the dietitian will give you advice on which foods to choose or avoid.

It is very important not to add salt to any baby’s food. Ready-made or convenience meals often have a lot of salt. Speak with your dietitian before giving these foods to your child.

Why does my baby or child have feeding problems?

Your child may find that food tastes different. This may affect which foods he or she prefers.

• Your child may not want to eat much because poor kidney function has an influence on appetite.
• Gastro-oesophageal reflux (also called acid reflux) – when what is eaten comes up from the stomach and back into the food pipe (oesophagus) – is very common in babies and children. It may more severe in those with CKD. Reflux can lead to regurgitating (bringing up the food into the mouth) or vomiting (being sick).
• Your child may feel nauseous (sick) or vomit. You may like to offer different foods to see which ones your child can tolerate.
• Your child may have unpleasant early experiences linked to eating. For example, if he or she repeatedly vomits, has gastro-oesophageal reflux or takes medicines that do not taste pleasant, your child may not enjoy eating.
• Your child may gag when you use feeding tubes, oral syringes or unpleasant tasting medicines. He or she may develop a fear of placing anything in their mouth.

Illness and feeding problems can mean there are fewer opportunities to offer the right types and textures of food.

What you can do

Feeding a baby or child with feeding problems can be a difficult and challenging experience. It is natural that this may cause anxiety. Providing a calm, safe and happy environment when feeding your child will allow him or her develop positive associations with food. Avoid distractions such as the phone or television, and take your time.

It is important to access the right support. You may wish to talk to someone – a family member, friend or healthcare professional. This will help you to stay calm and in control, without leaving you feeling that you will raise your voice or force feed your child.

Providing a calm, safe and happy environment when feeding your child will allow him or her to develop positive associations with food. Avoid distractions such as the phone or television, and take your time.

General tips

Keep calm and comfort your baby or child as he or she feeds or eats. This gives the message that feeding times can be happy and safe. Reassure your child if he or she is finding this difficult.

• Eat as a family as often as possible. Give your child lots of attention during feeds. If he or she is older, your child can learn by watching others.
• Praise your child, even if he or she just touches, licks or has a small taste of foods. Children respond much better to praise than they do to bribes, threats or punishments.
• Allow your child to get messy and have fun at mealtimes. Feeling and touching food is a great learning process. Try using foodstuffs such as dough, mashed potato, a coloured cornflour and water slimy mix, wet and dry pasta, chocolate finger painting. When this is mastered, your child may be ready for some basic cooking!
• Encourage an older baby or toddler to feed themself while you supervise him or her – so that he or she grows in confidence and control.
• Give your child an amount of food that is right for him or her and that has a texture (smooth or lumpy) he or she can easily manage. For chopped or finger food, give your child pieces that are a sensible size. Speak with your doctor or renal team if you are unsure, or if a problem arises.
• If your child can manage pureed food, make this thicker. Lumpy foods of mixed texture may not be easy to start with. ‘Bite and dissolve’ foods can really help. Your dietitian can give you more ideas for your child.
• Once some food is accepted, it is important to try to move forward with new tastes and textures – even if the amount of food eaten is tiny. However, if your child really dislikes a certain food after several tries, do not force it. A toddler may need to try a food up to ten times before he or she decides whether they like it or not, so just give your child plenty of opportunity to try the same food, but with no pressure.
• Avoid hiding new foods within a food that your child will eat. Your child needs to trust you – this approach could stop him or her eating foods that he or she does like.
• Try not to worry about what your child is eating at this stage. Your dietitian will make sure that your child’s nutritional needs are met, according to their stage of development.

Gastro-oesophageal reflux and vomiting

If your child has gastro-oesophageal reflux or vomits, tell your doctor. Treatments are available and may include:

• medicines to help with gastro-oesophageal reflux – these may need to be adjusted over a few weeks, so always report back to your child’s healthcare team if things do not get better
• using a feed thickener
• smaller, more frequent feeds
• positioning changes – for example by propping up the head of the cot
• keeping your baby upright for a short time after feeding.
• giving the feed slowly through a feeding tube

Support

Healthcare professionals are experienced and trained to help you manage this and will support you if you have any problems.

Renal team and health visitors

The renal team can offer you support and will link in with your local team so that you have help nearer to home. It is useful to involve health visitors, nursery or school staff, and speech and language therapists.

Regularly offload any worries and discuss issues with your health visitor and/or renal team.

Teachers and nursery staff

You can speak to professionals – such as teachers or nursery staff – about your child’s eating difficulties and needs. Your renal team can also share feeding plans and recommendations with them. They may be able to encourage food experiences (like messy food play) in preschool or school settings.

Speech and language therapist

If your child has problems with chewing and swallowing foods, you may need advice from a speech and language therapist. The therapist can use techniques to encourage your child to develop eating skills, so that he or she can be given small amounts of food successfully. Some children will find it difficult to manage certain textures – chewing skills take time to develop. Toddlers need time to gain confidence with new textures. The speech and language therapist can also give advice around how to help your child with this.

If your child does not eat normally

Despite such help, some children with CKD do not eat normally until they have a kidney transplant. Keep up messy play and involvement at mealtimes, even if no food is eaten.

Types of feeds

There are two ways to feed your child using a nasogastric tube or gastrostomy: by bolus or by pump. You may need to use both methods at different times of the day.

Bolus feeds

Bolus feeds are done at regular times of the day. A syringe is attached to the feeding tube or button. The feeds flow by gravity into your child’s stomach, for 15–20 minutes each time.

Pump feeds

Pump feeds are done for longer periods of time and at a slower rate. An electric pump is attached to the feeding tube or button, and the right amount of feed is slowly given over the set time – this may be overnight.

Effect on appetite

Many children start using feeding devices because their appetite is already reduced. Some children need continuous pump feeds because of excessive vomiting (being sick). The tube feeding will make sure they have the nutrition that they need to develop and grow.

Speak with your dietitian if you are concerned. Your dietitian may be able to change the feeding regimen – when and how your child feeds – so that he or she feels more hungry at mealtimes and is more likely to eat.

Oral feeding with tube feeding

Remember it is important that eating skills that have been learnt are not forgotten. Keep some oral feeding going if possible and continue to encourage variety, even if it is just with small tastes.

Tube feeding can be a very positive step towards making sure your child gets the nutrition and fluids he or she needs to stay healthy. It can be reassuring to know that there is no need to worry if your child does not eat anything.

However, it is very important that your child keeps and develops his or her feeding skills wherever possible. Remember that eating is generally an enjoyable pleasure and is a chance for a child to socialise and communicate, as well as develop skills.

Babies

Your baby can still breastfeed, bottle feed and wean while being tube fed. If you find a dummy (pacifier) helpful, offer this – it can be dipped in milk. You can also give small amounts of milk from a breast, bottle or feeding cup. Doing this at the time of a tube feed helps your child to associate sucking with a feeling of fullness.

All children

If possible, tube feed your child at meal times to keep a normal routine. Try not to be too busy or distracted, and enjoy the time together.

You can help your child associate food with a nice feeling of satisfaction, even if it is just by sight, smell and touch. If your child takes even small amounts or tastes of food, this will help to accept tastes and textures. This will also encourage your child to accept food later on.

Tube feeding after a kidney transplant

After a kidney transplant, your child may feel more hungry. You may be able to slowly reduce the tube feeding, which can also encourage eating. Speak with your dietitian or doctor before doing this. Ask whether it is okay for your child to have a period of slower weight gain while they are gaining their appetite for eating.

Feeding tubes are not ‘forever’. The majority of children take enough food and drink for their needs within a year of having a kidney transplant.

© BAPN and Kidney Care UK 2013-2022, all rights reserved.

For details on any sources of information used in this topic, please contact us through the contact us form on our website www.infoKID.org.uk.

We take great care to make sure that the information in this leaflet is correct and up-to-date. However, it is important that you ask the advice of your child’s doctor or nurse if you are not sure about something. This information is intended for use in the United Kingdom, and may not apply to other countries. The British Association of Paediatric Nephrology (BAPN), Kidney Care UK and the contributors and editors cannot be held responsible for the accuracy of information, omissions of information, or any actions that may be taken as a consequence of reading this information.