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Nutrition in Clinical Practice
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DOI: 10.1177/0884533614521242
2014 29: 192 originally published online 12 February 2014 Nutr Clin Pract
Meheret Asfaw, Jillian Mingle, Jessica Hendricks, Maegan Pharis and Anita M. Nucci
Nutrition Management After Pediatric Solid Organ Transplantation

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Nutrition in Clinical Practice
Volume 29 Number 2
April 2014 192 200
2014 American Society
for Parenteral and Enteral Nutrition
DOI: 10.1177/0884533614521242
ncp.sagepub.com
hosted at
online.sagepub.com
Invited Review
Transplantation of the liver, kidney, and heart has been suc-
cessfully performed in the pediatric population for several
decades.
1
Survival rates of solid organ transplant recipients
have appreciably improved over this period with greater than
80% of patients now surviving into adolescence and young
adulthood.
2-6
Advancements in surgical techniques and immu-
nosuppressive therapies have contributed greatly to these
improved rates. While transplant patients face many complica-
tions following surgery, the success of solid organ transplanta-
tion has transformed what once was an end-stage disease into a
more manageable clinical situation.
The diagnoses that lead to the majority of liver transplants
in children include biliary atresia, acute hepatic necrosis, and
metabolic disease.
1
Children with kidney dysplasia, obstruc-
tive uropathy, or glomerular sclerosis may be considered can-
didates for kidney transplant while congenital disease and
cardiomyopathies are the most common indications for heart
transplantation.
1
A distinct challenge to the pediatric transplant
population and their healthcare providers is achieving normal
growth following transplantation. The essential immunosup-
pressive drugs and steroids needed for posttransplant patients
and allograft survival are accompanied by growth-inhibiting
side effects.
7
Oftentimes, the pediatric patient has already
experienced a degree of growth delay due to his or her pre-
transplant disease state.
8
Optimal nutrition, both pre- and post-
transplant, is imperative for posttransplant recovery and
continued growth and development. Medical nutrition therapy
is an essential component of postoperative pediatric transplant
patient care to support catch-up growth, neurodevelopment,
and quality of life.
Childrens Healthcare of Atlanta has performed more than
1000 pediatric transplants since the inception of the transplant
services program and is one of the leading pediatric hospitals
in the United States for pediatric transplantation.
9
Clinical
dietitians in the hospital Department of Clinical Nutrition par-
ticipate in the interdisciplinary care of these children during
hospitalization and outpatient clinic visits. The purpose of this
study is to review posttransplant nutrition assessment, nutrition
requirements, and nutrition management approaches with each
of the following solid organs: liver, kidney, and heart. In addi-
tion, 3 case studies will highlight nutrition problems com-
monly encountered in this population.
521242NCPXXX10.1177/0884533614521242Nutrition in Clinical PracticeAsfaw et al.
research-article2014
Asfaw et al
From the
1
Department of Clinical Nutrition, Childrens Healthcare of
Atlanta, Atlanta, Georgia, and
2
Department of Nutrition, Georgia State
University, Atlanta, Georgia.
Financial disclosure: None declared.
This article originally appeared online on February 12, 2014.
Corresponding Author:
Anita M. Nucci, PhD, MPH, RD, LD, Department of Nutrition, Georgia
State University, PO Box 3995, Atlanta, GA 30302-3995, USA.
Email: anucci@gsu.edu
Nutrition Management After Pediatric Solid Organ
Transplantation
Meheret Asfaw, MMSc, RD, CSP, CNSC, LD
1
; Jillian Mingle, MS, RD, CSP, LD
1
;
Jessica Hendricks, MS, RD, CSP, LD
1
; Maegan Pharis, MS, RD, LD
1
; and
Anita M. Nucci, PhD, MPH, RD, LD
2
Abstract
Survival rates for pediatric transplant recipients and organ grafts have increased due to improvements in surgical techniques and with
immunosuppressant treatment therapies. Interdisciplinary management after pediatric organ transplantation is essential to assist not only
with the complex medical issues and complications that can result from immunosuppressant therapy but also with the achievement
of normal growth and development. Impaired growth is a complication frequently experienced by pediatric transplant patients. The
presence or absence of impaired growth is affected by the length of illness prior to transplant, graft function, the use of corticosteroids,
and the development of infectious complications after surgery. A review of posttransplant nutrition assessment, nutrition requirements,
and nutrition goals is provided. In addition, a case series of experiences with nutrition management of pediatric solid organ transplant
recipients is described. (Nutr Clin Pract. 2014;29:192-200)
Keywords
pediatrics; nutrition assessment; nutrition therapy; nutritional support; organ transplantation
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Asfaw et al 193
Nutrition Assessment
A thorough pretransplant nutrition assessment is essential to
determine anthropometric status; evaluate signs of nutrient
deficiency; assess biochemical tests to determine the need to
adjust nutrients and electrolytes in the oral, enteral nutrition
(EN), or parenteral nutrition (PN) prescription; and obtain a
dietary history for preferences and tolerances. This process
will help to maximize a childs nutrition status and increase
the chance of successful outcome after transplantation.
Anthropometric measures, including weight, recumbent
length (until 2 years of age) or height, weight-for-length or
height, and occipital head circumference (if <3 years of age),
should be plotted over time using the World Health
Organization growth standards for children 02 years of age
and the Centers for Disease Control and Prevention growth
standards for children 2 years and older in the United States.
10

Body mass index (BMI) should also be calculated and moni-
tored in children >2 years of age. In addition, z scores should
be calculated as they provide a more precise description of
anthropometric status than percentiles. The severity of malnu-
trition can be classified using newly published cutoffs as fol-
lows: mild malnutrition or at risk of malnutrition (z score
<1), moderate malnutrition (z score between 2 and 3), or
severe malnutrition (z score <3).
11
Feeding Assessment
A feeding assessment may be warranted for children who
have received long-term EN or PN as normal feeding and
swallowing development may have been missed. Maintaining
oral stimulation before and after transplant may assist with
the transition from enteral to oral feedings. Children with oral
aversion or other feeding problems should undergo a thor-
ough feeding evaluation and therapy by a specialist in feeding
disorders.
12
Nutrition Requirements
Energy requirements for children on oral nutrition or EN are
generally based on the Dietary Reference Intakes (DRI) for age
with adjustments made to maintain or support catch-up growth
and development.
13
Calorie requirements for children receiv-
ing a combination of EN or PN are generally estimated to be
5%10% lower than requirements for oral/enteral intake alone.
Children receiving only PN will likely require even fewer calo-
ries. Indirect calorimetry is the most accurate method to assess
basal metabolic requirements.
14,15
Protein requirements are
generally based on the DRI for age with adjustments made
based on the childs liver and renal function.
16
While these gen-
eral recommendations apply to most pediatric transplant recip-
ients, there are some organ transplantspecific nutrition
concerns as outlined below.
Nutrition Recommendations for Liver
Transplant Recipients
The nutrition recommendations for pediatric liver transplant
recipients are shown in Table 1. PN may be required if the
child is malnourished, has had complications, or if a lengthy
recovery period is anticipated.
17
An enteral tube feeding can be
used to provide total nutrition or in conjunction with an oral
diet if enteral intake is suboptimal. Oral aversion may occur in
those who required long-term EN, PN, or mechanical ventila-
tion.
17
Energy requirements during both the acute posttrans-
plant phase and chronic/stable phase should be individualized
based on the childs age, activity, and pattern of growth.
17,18

Calories in excess of the DRI may be needed in children with
severe growth delay.
18
Protein intake during the chronic/stable
period should provide 15%20% of total energy consumed and
be restricted only in the case of significant renal insuffi-
ciency.
17,18
Glucose intolerance is a complication of immuno-
suppressive medication use in the early posttransplant period
19

and may require dietary restriction of simple sugars. The inci-
dence of diabetes mellitus in the liver transplant population has
been reported to be between 7% and 30% with predictors that
include glucose intolerance prior to transplant, central obesity,
and long-term use of corticosteroids.
20
A healthy balanced diet
for age consistent with the 2010 Dietary Guidelines for
Americans
21
is recommended with adjustments given for com-
plications, including renal impairment, hypertension, hyperka-
lemia, and diabetes mellitus.
17
Intake of solid fats such as
saturated or trans fatty acids should limited to <10% of energy
and replaced with polyunsaturated or monounsaturated fats.
Cholesterol intake should not exceed 300 mg/d. A dietary
sodium restriction may be necessary if the child becomes
hypertensive. In a population of 167 children who have sur-
vived >10 years after liver transplantation, Ng et al
22
reported
rates of hypercholesterolemia and hypertriglyceridemia at 20%
and 26%, respectively. Moreover, elevated blood pressure
measurements have been reported in 17.5%27.5% of liver
transplant recipients between 5 and 10 years posttransplant.
23

Therefore, it is important to monitor both cardiovascular and
renal disease risk factors in liver transplant recipients to avoid
long-term complications.
24
Chronic anemia, which can affect growth and development
as well as quality of life, has been reported in a high percentage
(24%) of pediatric liver transplant recipients during the first
5 years posttransplant.
25
Factors associated with anemia
include the presence of gastrointestinal (GI) bleeding, persis-
tent leukopenia, corticosteroid use, cyclosporine Abased
immunosuppressive therapy, and reduced renal function.
Vitamin and mineral supplementation may be necessary if
dietary intake is inadequate. Vitamin D insufficiency and defi-
ciency is common in children with end-stage liver disease and
has been shown to remain during the initial posttransplant
period.
26
Liver transplant recipients should be monitored and
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194 Nutrition in Clinical Practice 29(2)
treated for vitamin D insufficiency and deficiency to maintain
serum levels >20 ng/mL. Fluid intake after transplant is gener-
ally unrestricted but may need to be modified based on weight
and renal and cardiopulmonary function.
17
Nutrition Recommendations for Kidney
Transplant Recipients
The nutrition recommendations for pediatric kidney transplant
recipients are shown in Table 2.
17
Complications such as
hypertension, hyperglycemia, hyperlipidemia, and anemia
27

may be caused by medications or preexisting conditions.
Hypertension can be treated with a sodium-restricted diet,
diuretics, and antihypertensive drugs. Simple sugars should be
avoided in the presence of hyperglycemia until glucose levels
return to normal. A moderate-fat diet with an emphasis on
healthy fats such as olive oil, fish, and nuts is indicated with
hyperlipidemia, and lipid profiles should be monitored regu-
larly. Brodersen et al
28
reported a high prevalence of hypovita-
minosis D (54%) in a population of 35 pediatric kidney
transplanted patients. Vitamin D deficiency in children with
renal failure may be the result of renal insufficiency, as the
kidney transforms the circulating form of vitamin D (25-dihy-
droxyvitamin D) into the biologically active form (1,25-dihy-
droxyvitamin D), and lack of sun exposure. After transplant,
patients are advised to avoid sun exposure due to the increased
risk of skin cancer with immunosuppressive therapy. The
authors suggested that vitamin D status be monitored biannu-
ally in children and adolescents who have received a kidney
transplant so that vitamin D deficiency can be corrected and
that the associated detrimental effects of hypovitaminosis D on
calcium-phosphate homeostasis and bone metabolism can be
avoided.
Nutrition Recommendations for Heart
Transplant Recipients
As it is the case with other organ transplant recipients, hyper-
tension, hyperglycemia, hyperlipidemia, and weight gain are
common side effects of medications and immunosuppression
Table 1. Nutrition Recommendations for Pediatric Liver Transplant Recipients.
Nutrient Acute Posttransplant Phase Chronic/Stable Phase
Energy DRI for age (individualized for wound healing and growth) DRI for age
Protein 15%20% of total energy
Enteral:
Infants: 33.5 g/kg dry body weight
12 years: 2.53.5 g/kg dry body weight
313 years: 1.52.5 g/kg dry body weight
Adolescents: 1.52 g/kg dry body weight
Parenteral:
Infants: 33.5 g/kg dry body weight
12 years: 2.53 g/kg dry body weight
313 years: 1.52.5 g/kg dry body weight
Adolescents: 11.5 g/kg dry body weight
Begin at 1 g/kg dry body weight and advance by 0.5 g/kg/d to goal
15%20% of total energy
Carbohydrate 45%55% of energy
Limit simple sugars
50%60% of energy
Encourage intake of complex carbohydrates
Fat Enteral:
30%40% of energy
Parenteral:
23 g/kg dry body weight
Begin at 0.5 g/kg dry body weight for infants <1 year of age and at 1 g/
kg dry body weight for children 1 year and older; advance by 0.5 g/
kg/d dry body weight to goal
2010 Dietary Guidelines for Americans
Electrolytes Mild sodium restriction may be necessary to prevent corticosteroid-
induced fluid retention; potassium restriction if blood level is
elevated
Sodium is unrestricted unless hypertensive
Vitamins Supplement with age-appropriate multivitamin with minerals;
additional vitamin D may be required
Multivitamin with minerals if dietary intake is
inadequate
Fluids Unrestricted Unrestricted
DRI, Dietary Reference Intakes. From Nucci A, Strohm S, Katyal N, Lytle B. Organ transplantation. In: Corkins MR, ed. The A.S.P.E.N. Pediatric
Nutrition Support Core Curriculum. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2010:172. Reprinted with permission
from the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
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Asfaw et al 195
therapy in pediatric heart transplant recipients.
29,30
Therefore,
dietary modifications such as limiting sweets and foods high in
concentrated sugar; reducing foods high in total fat, saturated
fat, and cholesterol; and limiting salt intake may be necessary.
Osteoporosis is also common among pediatric transplant recip-
ients due to the combined effects of nutrition status before
transplant and the decreased calcium absorption and bone for-
mation that result from the use of immunosuppressive medica-
tions and steroids.
31
Supplemental vitamin D and calcium may
be required.
Nutrition Goals
General goals for pediatric transplant recipients are to support
growth and physical development, transition to an oral diet,
and prevent nutrition-related posttransplant complications.
While there are common problems and treatments among all
pediatric transplant populations, there are some specific rec-
ommendations for these complications based on the type of
organ transplanted.
Liver Transplant Recipients
Goals for patients after liver transplant include optimization
of linear growth and physical development and resuming par-
ticipation in daily activities.
17
Linear growth delay is common
after liver transplant due to the nutrition impact of the original
illness and corticosteroid usage. In the presence of adequate
graft function, weight gain generally recovers after transplan-
tation.
32
Energy requirements should be based on age, activity,
and rate of growth. Children with linear growth impairment
should have their energy goals based on the DRI for height
age. Pediatric liver transplant recipients who were obese at
transplant have been found to be at an increased long-term
mortality risk.
33
Perito et al
34
found that 20%50% of children
transplanted between 1987 and 2010 were overweight or
obese 10 years after transplant. The factor found to be most
consistently associated with overweight/obesity after liver
transplant was weight status at transplant, with those over-
weight/obese at transplant likely to remain so at 1, 2, and
5 years posttransplant.
Kidney Transplant Recipients
Long-term goals for pediatric patients after kidney transplant
include promoting adequate growth, minimizing side effects of
medications, maintaining serum mineral and electrolyte bal-
ance, and maintaining blood pressure within normal limits.
17

Although the development of immunosuppression protocols
that minimize the use of corticosteroids aids in the prevention
of obesity and stunted growth posttransplant, children trans-
planted at a young age (<5 years) have been found to have the
greatest improvement in linear growth velocity.
35
This empha-
sizes the need to maximize growth prior to transplant. An age-
appropriate diet can be started once bowel function has
resumed after surgery. If gastrostomy tube (GT) feedings were
required prior to transplant, it may be necessary to continue
the tube feeding after surgery and gradually wean to oral diet.
The GT should not be removed until fluid and energy require-
ments are met orally.
36
Heart Transplant Recipients
Most heart transplant patients progress to a full oral diet within
1 week after transplant. However, children who were receiving
EN prior to transplant will require a gradual transition to an
oral diet and may require oral rehabilitation therapy. Failure to
thrive is common in children with congenital heart disease or
Table 2. Nutrition Recommendations for Pediatric Kidney Transplant Recipients.
Nutrient Immediately Posttransplant Later After Transplant
Calories DRI for height-age. May need additional calories if
patient is underweight prior to transplant
DRI for height-age
Protein 125%150% DRI for age DRI for age
Carbohydrates Avoid simple sugars Unrestricted unless obesity is present
Fat 30%40% of total calories 30%40% of total calories
Phosphorus May need higher intakes, provide supplementation as
necessary
May need higher intakes, provide supplementation as
necessary
Calcium Unrestricted Unrestricted
Potassium Unrestricted unless necessary Unrestricted
Sodium Mildly restricted Unrestricted unless hypertension or edema is present
Iron Supplement as indicated by serum values Supplement as indicated by serum values
Fluids Unrestricted Unrestricted
Vitamins DRI. Supplementation usually not necessary unless
severely malnourished prior to transplant, vitamin D
if indicated
DRI. Supplementation usually not necessary unless severely
malnourished prior to transplant, vitamin D if indicated
DRI, Dietary Reference Intakes.
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196 Nutrition in Clinical Practice 29(2)
cardiomyopathy with end-stage heart failure and may continue
in those who progress to transplantation without intervention.
In a population of 105 children who underwent heart transplan-
tation between 1985 and 2004, Rossano et al
37
reported that
21% were underweight (<5th percentile) and 8% were over-
weight (95th percentile) at the time of transplant. Peterson
et al
38
observed a significant gain in z scores for weight and
BMI but not length/height in a population of 46 infants and
children within 6 months posttransplant. The authors reported
that 17% of the population became overweight by 2 years post-
transplant and noted that increases in weight without corre-
sponding height may result in obesity. In a more recent study of
130 pediatric heart transplant recipients, Bannister et al
39

reported that enteral feeding support during the posttransplant
period significantly improved rates of weight and height gain.
However, anthropometric measures did not reach normal
values during the study follow-up period (median 4.4 years
after transplantation).
In all types of transplantation, studies support the need to
routinely monitor growth parameters in the early and later
posttransplant period so that alterations in diet can be made if
necessary to achieve and maintain ideal body weight.
Nutrition and Growth Effects of
Immunosuppressive Medications
Immunosuppressive medications commonly used include
tacrolimus, cyclosporine, prednisone, mycophenolate, siroli-
mus, and azathioprine (Table 3).
40-48
The side effects
associated with medications and immunosuppressant therapy
that are common in liver and kidney transplant patients (hyper-
tension, hyperglycemia, and hyperlipidemia) are also common
in posttransplant pediatric heart recipients.
49-52
Medication
doses are measured in the blood, and adjustments are deter-
mined from these levels. Food can alter the absorption of these
drugs. Therefore, patients and families are instructed to admin-
ister these medications either fasting or with meals on a consis-
tent basis. Vomiting or diarrhea can influence the drug level,
and other medications such as antacids, antibiotics, and anti-
fungals can also interfere with immunosuppressant levels.
Grapefruit, grapefruit juice, or juice that contains grapefruit
juice is discouraged because it has also been shown to alter
levels.
53
Food Safety
Most transplant recipients are receiving immunosuppressive
medications and are susceptible to foodborne illness caused by
food contaminated with bacteria and other pathogens.
54

Therefore, it is important to educate patients and families on
the Food Safety and Inspection Service of the U.S. Department
of Agriculture 4 basic steps to food safety: (1) always wash
food, hands, counters and cooking tools as bacteria can be
spread from surfaces to food; (2) separate meat, poultry, sea-
food, and eggs from ready-to-eat foods to avoid cross-contam-
ination; (3) cook foods to safe temperatures (140F or above);
and (4) refrigerate or freeze foods within 2 hours of cooking or
buying from the store. It is also important to adhere to
Table 3. Description of Common Immunosuppressive Medications used in Organ Transplantation.
Medication Name Brand Name Mechanism of Action Diet Instructions
Tacrolimus Prograf (Astellas Pharma,
Northbrook, IL)
Inhibits T-cell lymphocyte
activation; exact mechanism of
action is not known
Avoid eating grapefruit or drinking
grapefruit juice
Cyclosporine Gengraf (Abbvie, Inc, North Chicago,
IL)
Neoral (Novartis Pharmaceuticals
Corporation, East Hanover, NJ)
Inhibits T-cell activation Avoid eating grapefruit or drinking
grapefruit juice; foods high in
potassium may need to be restricted
Prednisone Inhibits antigen presentation,
cytokine production, and
proliferation of lymphocytes
Foods high in salt may be restricted; a
diet high in potassium or calcium or a
potassium or calcium supplement may
be prescribed
Mycophenolate CellCept (Genentech, Inc, San
Francisco, CA)
Myfortic (Novartis Pharmaceuticals
Corporation)
Inhibits an enzyme required for the
growth of T cells and B cells
No restrictions
Sirolimus Rapamune (Pfizer, Inc, New York,
NY)
Inhibits proliferation of T cells, B
cells, and antibody production
Avoid drinking grapefruit juice
Azathioprine Imuran (Pharmaceutics International,
Inc, Hunt Valley, MD)
Azasan (salix Pharmaceuticals, Inc,
Raleigh, NC)
Unknown No restrictions
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Asfaw et al 197
manufacturer Sell-by and Use-by dates when purchasing
and consuming foods. Caution should be used when eating out,
and buffet-style meal service should be avoided. Transplant
recipients should avoid consuming unpasteurized milk, juices,
and ciders; soft cheeses made from unpasteurized milk; raw
sprouts; and raw or undercooked meat, poultry, fish, or eggs or
prepared products containing these items. They should care-
fully wash all produce before peeling, slicing, juicing, or eat-
ing, including uneaten rinds of products such as melons and
mangoes.
Case Presentations
Case 1
Growth failure is a common occurrence in children with end-
stage liver disease and is due to malnutrition secondary to fat
malabsorption, abnormal nitrogen metabolism, increased
energy expenditure, and possibly growth hormone resis-
tance.
32,55,56
Although prolonged exposure to corticosteroids
posttransplant is associated with a reduced rate of catch-up
growth, the best predictor of catch-up growth is weight and
height z score at the time of transplant.
56
A 9-month-old
appropriate for gestational age female infant had undergone a
whole-organ orthotopic liver transplant with Roux-en-Y cho-
ledochojejunostomy for extra hepatic biliary atresia with a
failed Kasai. Preoperative nutrition management included the
switch from a standard infant formula to a more easily digest-
ible product that contained partially hydrolyzed protein and
55% medium-chain triglyceride (MCT) at approximately
4 weeks of age, which was progressively advanced to 30 calo-
ries/oz to promote growth. Due to inadequate weight gain with
oral feeding, supplemental nocturnal continuous drip feedings
to supply 75 kcal/kg or ~50% of estimated caloric needs was
provided. At the time of transplant, her length-for-age, weight-
for-age, and weight-for-length plotted below the third percen-
tile (z scores = 2.23, 2.5, and 2.19, respectively). Her head
circumference was at the 25th percentile. The physical exami-
nation revealed an enlarged abdomen with wasted extremities.
On posttransplant day 4, one day after extubation, oral feed-
ing was initiated with a polymeric age-appropriate cows milk
based formula at 20 calories/oz ad libitum, and a daily liquid
multivitamin supplement was restarted. However, because her
intake of formula on the first 2 days of observation was very
low, the formula concentration was advanced to 24 calories/oz.
In addition, a nasogastric nocturnal drip feeding was started
and progressively increased to provide ~40% of her estimated
daily requirements of 130 kcal/kg and 2.5 g protein/kg (~130%
and 150% of the DRI for calories and protein, respectively). At
the time of discharge, 14 days after transplant, the overnight
tube feeding was discontinued because oral intake had signifi-
cantly improved. The infant was sent home on a 24-calorie/oz
formula and an age-appropriate oral diet, as well as a daily
liquid multivitamin supplement.
Although weight gain may recover in children with a fully
functioning graft who were previously malnourished, linear
catch-up growth may not occur until the second year and is
largely dependent on steroid exposure.
32
The Studies of
Pediatric Liver Transplantation (SPLIT) registry has revealed
that up to 25% of pediatric liver transplant recipients have
height measures at less than the 5th percentile over the long
term.
56
After the patient in case 1 was discharged from the hos-
pital, she was followed closely by nutrition during the initial
6 months to assess diet history and growth and to provide
dietary guidance to maximize energy and nutrient intake. By 8
months posttransplant, some catch-up growth was observed
with weight, length, and head circumference measures plotting
at the 5th, 10th, and 50th percentiles, respectively. On long-
term follow-up, 120 months posttransplant, her weight has fol-
lowed the 10th percentile curve, but height has essentially
remained at the third percentile. Her most recent BMI was cal-
culated to be 16.9, which is at approximately the 50th percentile
for age. Mid-parental height is calculated to be at the 75th per-
centile. Endocrinology was consulted to assess short stature.
To encourage growth, immunosuppression should be mini-
mized during the first 612 months after transplantation and
growth parameters should be routinely monitored to identify
those who may benefit from reduced corticosteroid exposure.
32

The infant received immunosuppressive medications, includ-
ing parenteral corticosteroids, during the initial postoperative
period and upon very infrequent hospitalizations for rejection.
Her maintenance immunosuppressive regimen included tacro-
limus, mycophenolate mofetil, and oral corticosteroids with
doses ranging between 2.5 and 5 mg daily. Some of the side
effects of these medications that the infant experienced
included infections and mildly elevated serum levels of potas-
sium, serum urea nitrogen, and creatinine as well as acidosis.
Nutrition interventions used to treat these biochemical imbal-
ances included increasing fluids, and instruction was given to
avoid foods high in potassium. Acidosis was treated with an
oral alkalinizing agent.
Case 2
PN or EN support is rarely needed after kidney transplant.
17

However, children who were fed via GT prior to transplant
may require continued support to promote anabolism and
achieve or maintain adequate growth until a full oral diet is
established. A 2-year-old girl with bilateral congenital cystic
renal dysplasia was admitted for a cadaveric donor kidney
transplant. She had been maintained on hemodialysis for 15
months prior to transplant. Her past medical history is signifi-
cant for failure to thrive and GT placement. She was small for
age with a weight-for-age at the 5th percentile (z score = 1.56)
and a height-for-age <5th percentile (z score = 2.42) with
mild stunting. BMI was within normal limits. At the time of
admission, she was receiving a diluted adult renal formula
(29 calories/oz) through her GT, which was supplying 100% of
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198 Nutrition in Clinical Practice 29(2)
her estimated calorie and protein requirements (97 kcal/kg/d
and 1.2 g protein/kg/d or 1.2 times the DRI for age).
10
She
would only take sips of liquids orally. Children who receive
long-term enteral feedings are at risk for oral aversion due to
the lack of oral feeding, since normal feeding and swallowing
development during infancy may have been missed. Providing
small amounts of food of varying tastes and textures to chil-
dren who are able to swallow should be encouraged.
Maintaining oral stimulation prior to transplant may assist with
the transition from enteral to oral feeding after surgery.
17
The child was started on a clear liquid diet on postoperative
day 2. GT feedings of a pediatric oral electrolyte solution were
started on postoperative day 3, and she was transitioned to a
pediatric enteral formula with fiber (1 kcal/mL) on postopera-
tive day 4. She had difficulty achieving the goal feeding vol-
ume secondary to abdominal distention. An x-ray of the
kidneys, ureters, and bladder (KUB) was performed and did
not show obstruction. The differential included mass effect
from new kidney, opioids, or postsurgical ileus, although she
was having bowel movements. The enteral formula prescrip-
tion was changed from a fiber-containing formula to a standard
pediatric formula (1 kcal/mL) on postoperative day 7 and toler-
ance improved. She reached her goal formula volume of 1020
mL/d on postoperative day 10 and was transitioned to a home
schedule of 135-mL bolus feedings every 3 hours during the
day (4 times) plus night continuous feedings of 60 mL/h over 8
hours on postoperative day 11. She was discharged home meet-
ing 100% of her nutrition requirements (102 kcal/kg/d and 23
g protein/kg/d)
57
through her GT. Speech therapy was con-
sulted for a feeding trial and did not find any clinical signs of
aspiration or aversive behaviors. The speech therapist did note
that there were self-limiting behaviors and that she presented
with a mild speech-language delay. The recommendation was
made for early intervention services through the state Babies
Cant Wait program.
58
The child had loose stools throughout
the admission, which was thought to be related to mycopheno-
late mofetil, but the condition was not significant enough to
warrant changing her immunosuppression therapy.
At her 3-month posttransplant visit, she was receiving
approximately 90%100% of her estimated nutrition require-
ments via GT. Her growth was excellent as she had a weight
velocity for age at the 50th75th percentile.
59
The childs
mother stated that she wanted to wait until the patient was fur-
ther out from her transplant before pursuing outpatient speech
therapy. At her 5-month posttransplant visit, the mother
reported her child was consuming 3 meals per day by mouth,
including drinking whole milk, and that she discontinued
the daytime bolus feedings. Nighttime continuous feedings
were supplying ~40% of her estimated nutrition needs. By
10 months posttransplant, she was eating a variety of regular
table foods and drinking 1 can of a pediatric enteral formula
per day. Therefore, the nighttime tube feedings were discontin-
ued. Her anthropometric measures were as follows: weight-
for-age = 13 kg (25th percentile; z score = 0.61), height-for-age
= 89 cm (<5th percentile; z score = 1.76), and BMI = 16.4
(~75th percentile; z score = 0.75). She exhibited excellent
catch-up growth with a weight gain of 3 kg and linear growth
of 9 cm in 10 months. The patients mother reported that she
wished to have the GT removed. After 3 additional months of
appropriate weight gain, the decision was made to remove the
enteral feeding tube.
Case 3
Children with coronary heart disease or cardiomyopathy with
end-stage heart failure are at risk for failure to thrive due to
multiple hospitalizations for surgical procedures,
39
feeding
intolerance and malabsorption,
60
and possibly increased energy
requirements.
61
The effect of undernutrition on adverse out-
comes is unclear. Children who are underweight at the time of
transplant have been found to develop acute rejection earlier
and have decreased graft survival
62
and overall survival.
63

However, in a multicenter study with more than 2300 pediatric
heart transplant patients >2 years of age, morbidity and mortal-
ity outcomes did not differ between those who were wasted
(23%; BMI <5th percentile) or obese (8%; >95th percentile) vs
those who had a normal BMI (5th95th percentile) at the time
of transplant.
64
A 4-year-old girl was admitted to the hospital
with edema, feeding intolerance, and decreased ventricular
function noted on echocardiogram. Her past medical history
included hypoplastic left heart syndrome, aortic and mitral
atresia, dysphagia, and seizure disorder. Prior to admission, she
had undergone several palliative surgical procedures, includ-
ing Norwood/Sano shunt, bidirectional Glenn, tricuspid valve
replacements, and an epicardial pacemaker. Growth parame-
ters on admission were marginal, with a medication dosing
weight of 12 kg (~10th percentile; z score = 1.25) and a
height-for-age of 83.8 cm (<5th percentile; z score = 3.11)
that was indicative of mild chronic stunting (height was 90% of
the standard at the 50th percentile). On physical examination,
the child presented with a swollen face and abdomen, but she
had minimal subcutaneous tissue in her extremities. She was
not a candidate for further palliative operations (eg, Fontan
procedure) given the severity of her ventricular function.
In a cohort of 130 pediatric heart transplant recipients
(median age at transplant = 2.7 years), Bannister et al
39
reported
that the use of enteral feeding support prior to pediatric heart
transplant was not associated with anthropometric growth.
Although posttransplant enteral feeding support was associ-
ated with a faster increase in weight and height z scores over
the 4-year follow-up period, values plateaued at 18 months
posttransplant and the measures did not reach normative val-
ues. Prior to transplant, the child was receiving enteral tube
feedings as her primary source of nutrition. Due to a history of
feeding intolerance and oral aversion, the enteral prescription
included bolus feedings of a pediatric peptide formula diluted
to 20 calories/oz at 100 mL every 3 hours during the day
(4 feedings) in addition to continuous overnight feedings at
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Asfaw et al 199
56 mL/h 9 hours. This feeding regimen provided 50 kcal/
kg/d, which was equivalent to her estimated basal metabolic
requirements based on the Schofield equation.
65
Approximately
1 month after admission, her heart function had worsened,
which led to increased feeding intolerance and weight loss
(11.2 kg). Due to the weight loss, energy requirements were
increased to 80 kcal/kg/d based on the DRI. The enteral for-
mula volume was decreased and met only 21% of her estimated
energy requirements. PN support was initiated to provide the
remaining 80% of her caloric requirements until transplanta-
tion occurred.
Following heart transplant, the child was extubated on post-
operative day (POD) 2 and trophic enteral feedings were
started on POD 3. Between POD 10 and 12, the continuous
enteral feeding prescription was advanced to goal (45 mL/h).
She was discharged home on POD 24 with a feeding regimen
that included boluses of 105 mL every 3 hours during the day
(4 feedings) in addition to continuous overnight feeds at
55 mL/h 10 hours of a full-strength (30 calories/oz) pediatric
peptide formula that provided 80 kcal/kg/d (based on a weight
of 12 kg).
At 6 months postoperatively, the child was admitted for
24-hour observation after a cardiac catheterization and
biopsy. At that time, weight gain averaged 12 g/d and had
increased 2.1 kg from discharge with percentiles tracking
just below the 25th percentile weight-for-age. Although EN
still served as the patients primary source of nutrition, a diet
recall obtained from her mother revealed increased oral
intake. Now at 1 year and 2 months posttransplant, her
weight-for-age continues to trend between the 10th and 25th
percentile. Although length-for-age percentile remains low,
her BMI is within normal limits at the 70th percentile.
Analysis of her 3-day food record revealed that she is con-
suming 65%70% of her estimated energy requirements. Her
remaining calories are provided via supplemental overnight
low-volume tube feedings. The nutrition goal for the next
36 months is to continue weaning overnight enteral formula
volume until it is discontinued. The child will continue to
receive nutrition follow-up through the outpatient transplant
clinic.
Conclusions
Our experience with pediatric solid organ transplant is consis-
tent with that reported in the literature. We observed delayed
growth and the need for supplemental EN at the time of trans-
plant and a continued requirement for enteral support after
transplant. Although each case presented weaned to an oral
diet after transplantation, catch-up growth remains a concern.
Improvements in immunosuppressant therapies with reduc-
tion or elimination of corticosteroid usage will result in
improved growth and quality of life in this medically chal-
lenging population.
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