Approved MRB: March 8, 2000
Approved BOT: June 21, 2000
These recommendations for dialysis care are applicable to the pediatric patient population with some modifications. The following document outlines specific minimal guidelines which apply to all dialysis facilities providing ESRD care to pediatric patients (defined as 17 years of age and under).
When pediatric patients are cared for in the adult dialysis unit setting, it is recommended that a consulting relationship be arranged with a pediatric dialysis program. When the recommendations are not met, it is the expectation that the medical record will reflect appropriate interventions taken to achieve the goal and/or provide identification of circumstances which affect the goal outcome.
1.) CARING FOR PEDIATRIC PATIENTS: Dialysis facilities which treat pediatric patients should, to the extent possible, maintain the following criteria. If a dialysis facility treating pediatric patients is unable to maintain one or more of these criteria, it will be reflected in the documentation in the patient's medical record, along with the alternatives which are provided.
- Provide services for patients from 0 to 17 years of age, including chronic outpatient hemodialysis, peritoneal dialysis, and home training for peritoneal dialysis.
- Provide medical care and supervision by a pediatric nephrologist, certified by the American Board of Pediatrics, or a nephrologist in consultation with a pediatric nephrologist.
- Provide nursing care by nurses experienced in pediatric dialysis. Specific training is arranged for the dialysis nursing staff as necessary.
- Provide care through staffing levels which reflect the physical, medical, and psychological needs of the patient.
- Provide psychosocial services by a qualified renal social worker with pediatric expertise. These services are provided directly, or by arrangement.
- Provide assessments of and services to promote optimal growth and nutrition by a registered dietitian with pediatric dietary expertise. These services are provided directly or by arrangement.
- Promote developmental progress through use of play guided by a Child Life Worker, and through schoolwork guided by a teacher. These services should be provided directly or by arrangement.
- Provide delivery of care through use of equipment and supplies which are appropriate for age and size of the patient.
- Obtain written assent for treatment from all patients aged 12 to 17 years.
- Provide histocompatibility and transplantation services directly or by arrangement.
2.) BLOOD PRESSURE CONTROL: The diastolic blood pressure is targeted to the 95th percentile for normal children of the same age, height percentile, and sex (reference: Rosner, et.al., J. Pediatr. 1993 Dec; 123 (6): 871-886).
3.) DEVELOPMENTAL ASSESSMENT:
- The medical record contains documentation that a developmental assessment has been performed at least semi-annually on children 36 months and annually on all children >36 months of age.
- The developmental assessment includes, but is not limited to, age-related milestones, school performance, cognitive, psychosocial, sexual, behavioral, and motor development.
- Appropriate interventions are made based on the developmental assessment.
4.) METABOLIC CONTROL:
- Serum potassium (K+) is drawn monthly, with the target values of K+ 6.0 mEq/l for both hemodialysis (pre-dialysis K+) and peritoneal dialysis therapies.
- Serum bicarbonate should be drawn monthly; adjustments should be made as necessary.
- Adherence to fluid, sodium, potassium and phosphorus restrictions, as indicated by monthly chemistries and interdialytic weight gain should be monitored by the dialysis team.
5.) ADEQUACY OF TREATMENT: Small solute clearance is monitored routinely and whenever a substantial change is made in the dialysis prescription. This monitoring is accomplished in accordance with the recommendations of the DOQI guidelines.
6.) RENAL OSTEODYSTROPHY: Serum calcium, phosphorus, and alkaline phosphatase are measured monthly at minimum. The serum intact PTH level is measured quarterly at minimum.
- Serum phosphorous and serum calcium levels are targeted within normal range (as stated by the laboratory performing the testing) by age level.
- Pediatric patients should not receive aluminum continuing phosphate binders.
- Serum PTH (intact) is monitored and targeted at two to three times the upper limit of normal for the PTH assay.
- Phosphate binders and Vitamin D therapy are used to control hyperparathyroidism.
- An assessment of the patient�s eligibility for transplant is made by a member of the transplant team and/or the transplant designee at the onset of ESRD and at least annually thereafter.
- The patient's parent(s)/guardian(s) have been informed of transplantation as an option. The medical record includes documentation by a member of the transplant team (or designee) that patient/parent(s)/guardian(s) have received basic transplant information.
8.) ANEMIA CONTROL:
- Hemoblogin levels should be maintained, at minimum, to 11 gm/dl.
- An anemia work-up should be initiated if the hemoglobin level drops below 11 gm/dl. The work-up should be conducted to determine if the cause of the drop can be corrected prior to initiation of erythropoietin therapy.
- Recombinant erythropoietin is used in conjunction with appropriate iron therapy.
- Patients requiring transfusion(s) receive leukocyte reduced blood products.
9.) INFECTION CONTROL:
- Immunizations should be evaluated annually to ensure they are up-to-date.
- Patients one year of age should have a skin test annually for tuberculosis. (PPD with appropriate controls.)
- Patients who have been exposed to communicable diseases should be evaluated for the need for isolation during treatment or clinic visit.
10.) NUTRITION THERAPY SERVICES/GROWTH ASSESSMENT:
- Patients <36 months of age have monthly dry weight, length and head circumference plotted on a growth chart. Patients aged 36 months to 17 years have height and weight plotted on growth chart quarterly. Deviation from the expected growth should be evaluated.
- The dietitian performs ongoing assessments for adequacy of caloric and protein intake as follows: children <24 months are monitored monthly; children aged 24 months or older are monitored quarterly.
- Growth hormone therapy should be considered for patients with delayed growth.
- The medical record shows monthly documentation by the renal dietitian on serum albumin, serum bicarbonate, BUN, calcium, phosphate, potassium, average interdialytic weight change and change in dry weight for:
- All patients 36 months of age or less
- All patients during their first three months of treatment
- The medical record shows, at minimum, monthly documentation of the above stated indicators for patients who are three years of age or older and who have been on maintenance dialysis three months or more.
11.) SOCIAL WORK:
- It is strongly encouraged that a social worker is involved at the earliest possible opportunity for the patient commencing maintenance dialysis. The medical record shows:
- A psychosocial assessment was initiated in the first month and completed within three months of the first maintenance dialysis.
- The social worker has contact monthly with all pediatric patients, and their parents/guardian(s) during the first three months after commencing dialysis and, at minimum, quarterly thereafter, or as intervention is needed.
- The social worker has contact monthly with the patient/parents/ guardian(s) of patients aged 36 months or less.
- The medical record indicates the patient and parent(s)/guardian(s) have received the following information within the first three months of treatment and in an ongoing manner thereafter.
- Effects of ESRD and its treatment in the families of pediatric patients including:
- Typical parental responses and the special needs of parents
- Typical sibling reaction and the special needs of siblings
- Care of the dialysis patient.
- Information on human sexuality and reproductive potential for patients entering puberty (Tanner stage 2 or menarche).
- The medical record contains documentation that the following assessments have been performed:
- An assessment of medical coverage and other financial resources
- An assessment of the patient's school participation.
- An assessment of the extended family and support system available to the patient.