Precautions and special instructions in the care of children with nephrosis
Infections that are potentially serious
Children with nephrotic syndrome are prone to infections, particularly when
spilling protein in the urine (during a relapse) and especially if they are
receiving high doses of prednisone. The most common serious infections are
peritonitis (symptoms are fever, abdominal pain and vomiting) and pneumonia
(symptoms are fever, cough and difficulty breathing). In addition, there is a
higher incidence of sepsis (blood stream infection) and meningitis (infection in
the spinal fluid) in children with nephrosis. The risks of some of these
infections can be lowered (but not entirely eliminated) with a vaccination,
Pneumovax™. Moreover, since the availability of another vaccine, Prevnar™,
beginning in February 2000, routine immunization of infants during the first
year of life has included this vaccine. This means that most children now have
some degree of protection against the germ causing pneumonia. Routine
immunization of children with a vaccine against chickenpox (varicella), Varivax™
, which is usually given before the typical age of onset of nephrotic syndrome,
also provides some protection if the child later develops nephrosis and, while
receiving high doses of prednisone, happens to be exposed to a child with
chickenpox .Others types of infection cannot be prevented. If you think your
child has a serious infection, contact your pediatrician immediately.
The need for a sodium-restricted diet
During the period of illness when the kidney is leaking protein and has a
tendency to retain salt and fluid in the body, it is necessary to restrict salt
(sodium) in the diet. The exact amount of restriction will be determined by the
physician according to the individual child's needs, and sample diets can be
planned in consultation with our dietician. During a period of remission, when
the kidney is not leaking protein, there is less of a tendency to retain fluid
in the body. However, educating the child about a "no-added salt diet" (when
salt is not added during cooking or from the saltshaker during a meal) will make
for an easier adjustment to a low salt diet in the event that the child has
another relapse. Generally, it is not necessary to restrict the amount of fluid
the child drinks, provided the child's intake of salt is limited in accord with
the physician's order.
Physical activity/participation in sports
After a child has gone into remission, and is on a tapering schedule of
prednisone, he may participate in all the usual activities of childhood without
any restrictions. There is no evidence that prolonged bed rest is necessary in
such children nor is there any evidence that physical activity either makes the
disease worse or slows the healing process. The child should be encouraged to
return to his or her usual activities. The only exception: immediately following
a kidney biopsy, sports or vigorous physical activity should be limited for a
few weeks.
Going to school
There is no medical reason to avoid going to school. The only instance in
which caution is advised is if certain epidemic, contagious diseases are
spreading through the school population, such as chickenpox (varicella) or
measles (rubella). If a child has not previously had either of these diseases,
and has not received MMR™ or Varivax™ during infancy, these infections can be
more severe while receiving prednisone, Cytoxan™, or other immunosuppressive
medications. If there is a possibility that your child has been exposed to these
diseases, please call your physician promptly. However, since the widespread use
of vaccines to prevent chickenpox (Varivax™ ) and measles, mumps, or German
measles (MMR™ vaccine), which are received by most infants before the typical
age of onset of nephrosis, the risk of serious complications due to these
viruses is much less. If you are not sure that your child has received a full
set of immunizations, call your doctor and obtain a copy of your child's
immunization record.
The safety of immunizations
Most pediatric nephrologists believe that it is safe for a child with
nephrosis to continue to receive most of the usual childhood immunizations.
However, it is necessary to avoid immunizations or booster doses of vaccines
containing certain viruses while the child is receiving high doses of prednisone
or other immunosuppressive medications that interfere with the body's ability to
resist infections caused by certain viral vaccines given by injection (or, in
the case of oral polio vaccine, swallowed) .These “live-virus” vaccines include
MMR™, oral polio (inactivated polio vaccine given by injection is safe), and
Varivax™. One immunization, Pneumovax™, may reduce the chance of infection with
bacteria known as pneumococci, which can result in peritonitis, pneumonia or
other infections. Your child will receive this vaccine as part of the treatment
of nephrosis. Since the protection provided by Pneumovax™ may wear off after
several years, it may be necessary to receive a booster after 5 years if the
child continues to have relapses.