Use of Renastart™ in an infant with CKD 4-5 | Case Study

• Prematurity – Born at 30+1 weeks gestation.
• Respiratory distress syndrome.

Day 30 of admission

Anthropometry

• Weight 2180 g (10-50th centile on Fenton Charts 2013); increased by 14 g/kg/day the previous week (aiming 15-20 g/kg/ day).
• Length 41.5 cm (2-9th centile on Fenton Charts 2013); decreased from 25-50th centile at birth.

At the time of the review, the patient was on 3 hourly oral feeds of 45ml, alternating every second feed between:

• Expressed breast milk (EBM) + 3.4% Renastart providing approximately 345 kJ/83 kcal and 1.6 g protein per 100 ml. Renastart powder is added directly to EBM. Note: Pre-term EBM composition calculated using 275 kJ/66 kcal and 1.3 g protein per 100 ml1 .
• 16.9% dilution Renastart providing 350 kJ/84 kcal and 1.3 g protein per 100 ml.

Provides: 360 ml (165 ml/kg/day)

1255 kJ/300 kcal (577 kJ/138 kcal/kg/day)

5.24 g protein (2.4 g/kg/day)

Plus breast contact to support transition to breastfeeding.

Biochemistry

Ref* Hospital reference range.

Relevant medications include

Sodium bicarbonate (due to metabolic acidosis).

Aims

• Maintain potassium levels within normal range using a dietary potassium restriction.
• Optimise nutrition for growth and development.
• Encourage normal feeding development.

Management plan

Increase energy and protein content of feeds from 345 kJ/82 kcal - 350 kJ/84 kcal/100 ml to 380 kJ/91 kcal/100 ml to promote adequate weight gain:

• increased EBM fortification to 5% Renastart.
• increased full Renastart feeds to 18.4% concentration.

Agreed with multidisciplinary team to optimise normal feeding development with a trial offer of one breastfeed per day in place of fortified EBM bottle feed with top-up feed of 30 ml EBM + 5% Renastart via bottle if required.

Monitor biochemistry, weight, growth and tolerance of feed following implementation of updated plan.

Day 35 admission (5 days post intervention)

• Tolerated increased feed fortification.
• Breastfed well for at least 5-10 minutes when offered once each day.
• Net 22 g/kg/day weight gain in 5 days; returned to tracking just below 50th centile (Fenton Charts 2013).
• Biochemistry stable; potassium remained <6.0 mmol/L.

3 months post intervention

• Discharged home on approximately 3 hourly demand feeds (i.e. approximately 8 feeds per day); 4 full breastfeeds and 4 bottles of 18.4% Renastart.
• Weight continues on the 50th centile and biochemistry remains stable allowing for ongoing breastfeeding.
• Patient not yet showing signs of readiness for introduction of solid foods. Therefore plan to wait until 4 months corrected age and when showing appropriate signs of readiness for feeding.
• Ongoing challenges with administering medications orally due to taste. Therefore medications are not added to bottle feeds currently.
• Renal function is expected to decline and there will be a need for renal replacement therapy. It is likely that a gastrostomy will be inserted at time of peritoneal dialysis catheter insertion to manage anticipated nutritional challenges.

• Renastart can be used for feed fortification. The reduced potassium content of Renastart allows for less restriction of breastfeeding or expressed breast milk intake.
• Despite prematurity and medical issues, breastfeeding was successful, encouraging both oral feeding as well as mother-baby contact and connection.

1. Boyce C, Watson M, Lazidis G et al. Preterm human milk composition: a systematic literature review. British Journal of Nutrition. 2016; 116(6):1033-45.