By Donna L. Morton de Souza, MPH, RD, LD/N

Children on dialysis are just like other children. Ask adolescents or teens what their favorite mealtime foods are and you are likely to hear - pizza, cheeseburgers, chicken nuggets and french fries. Adolescents and teens on dialysis are faced with the same peer pressure as well as the daily emotions of a typical growing child. They are probably more interested in thinking about an upcoming party than the consequences of not adhering to their renal diet.

 How then do you motivate your child to want to adhere to his diet? This tall order includes avoiding foods and beverages that are high in phosphorus, potassium, sodium and sometimes limiting fluid intake. Some children on dialysis may need to focus on consuming sufficient calories and protein. If that weren't enough, kids on dialysis also need to remember to take several medications each day, including phosphate binders with all meals and snacks.

 Here are some suggestions to help motivate your child to follow his or her diet:

Reason With Your Child

 If children don't understand why they're being asked to do something, especially things that are difficult, they aren't very likely to do it. For example, make sure your child has been provided the basic information on the importance of choosing lower phosphorus foods. Give him the honest facts and let him think about it. Consider showing your children pictures of bones that are not healthy because of too much phosphorus in the diet. (Ask your renal healthcare team members for visuals and other assistance). Let your child know this condition is preventable when he chooses lower phosphorus foods on a regular basis.

Offer Rewards for Positive Efforts

 Education provides a foundation for compliance, but not the motivation to follow through. With the assistance of the dietitian, determine where the most improvement is needed.  Ask your child to set a small attainable goal each week. For example, taking lower sodium snacks to school, grocery shopping with a parent and selecting lower phosphorus foods and beverages or selecting lower potassium fruits and vegetables. Offer rewards when your child accomplishes his goals.  Let him choose an appropriate reward such as a new toy, going to see a movie, buying new clothes, playing a favorite game, etc. You may offer a more significant reward when his monthly lab values improve.

Provide an Appropriate Environment to Promote Success

 Stock the refrigerator and cupboards with lower phosphorus, potassium and sodium containing foods. Purchase apples, grapes and pineapples instead of bananas, oranges and cantaloupe.  Animal crackers, low sodium pretzels or unsalted crackers with jam are great snacks instead of salted chips and chocolate bars. Be sure to have appropriate beverages available such as lemonade, apple or cranberry juice.

Elicit the Support of Others

 Children may be influenced more by what they see others do than what is said to them. Let other family members know that their support is needed. Respected teachers, coaches, peers or other relatives who are important in the life of your child may help to provide encouragement and reinforcement. Try to find well-adjusted young adults who had chronic kidney disease during their childhood. They may be willing to talk with you and your child.

Encourage Independence

 The best strategy for improving overall compliance is to encourage independence. Children are more receptive to change when you give them some power. Ask your child to tell you which foods she wants to choose for meals and snacks. Ask her to choose a container to keep her phosphate binders in that will help her to remember to take them with school lunches and snacks. Encourage her to participate in meal preparation at home. Arrange doctor appointments around her schedule and give her time alone with healthcare professionals to ask questions.

Encourage Daily Exercise as Approved by the Physician

 Exercise promotes a healthy heart and helps your child perspire, thus eliminating excess fluid.  Walking and strength training strengthen bones and stimulate muscles and nerves that can help ease "restless leg syndrome." Encourage your child to participate in favorite sports and activities such as swimming, bicycling, dancing lessons, bowling and exercise classes. Daily walks can be a fun and healthy family activity. Engaging in physical activity seems to have a beneficial effect on the flow of conversation.  Enjoyable exercise habits developed in childhood are more likely to continue in adulthood.

Allow for "Cheat Treats"

 As teens struggle for independence from their parents, they may "rebel" by being non-compliant with diet and medications. A "small amount" of careful noncompliance may help promote increased compliance with the more important aspects of their treatment. Ask your child what food or beverage he would like to choose as a "cheat treat." Consuming the cheat treat on a dialysis day, two to three hours before their treatment is probably the best time to "cheat" and can be treated as a reward for having to receive dialysis treatments three times per week.  However, avoid cheat treats on the dialysis days that follow two or more days without dialysis. Consult your clinic's registered dietitian for more information on the appropriate timing and amounts of specific cheat treats.

Educational Games and Activities

 Research has demonstrated that humor has a positive influence on learning. Use your creativity to come up with fun learning experiences! For example, take your child to the supermarket to help select appropriate grocery items. Have a "Sodium Scavenger Hunt" where you ask your child to look at food labels to find items with the lowest sodium content. If your child is overweight, ask her to "hunt" for foods with the least fat.

 Recently, a board game has been designed for children with kidney disease called "Adventure ParkŪ" recommended for ages 8-18. The colorful game board looks like an amusement park. The game cards promote discussion about coping with kidney disease and its treatments. Information and how to order the game can be found by clicking here.

 To help pass the time spent on dialysis, an educational workbook entitled "FUN"damentals of Learning - brainteasers to help pass the time has been developed. The creative workbook features over 100 brainteasers such as word search, scrambles, mazes, crossword puzzles and picture games - all designed for people to learn more about kidney disease.

Educational games & motivational contests in the dialysis clinic

 Many dialysis clinics run special contests or play games such as "Nutrition Bingo" to help motivate patients to adhere to their diet and medications. Prizes including gift certificates and movie tickets have been used to reward positive changes in lab values or fluid gains. These clinic contests appear to have a beneficial effect especially when they are used on an ongoing basis.  Professionals looking for game and contest ideas can find them in the "Handbook of Creative Approaches to Patient Compliance"- a guide for renal dietitians working with dialysis patients.

 Information on how to order the "FUN"damentals of Learning - brainteasers to pass the time" and the "Handbook of Creative Approaches to Patient Compliance" can be found by clicking here.

Donna L. Morton DeSouza, MPH, RD, LD/N is a renal dietitian for Gambro Healthcare, Plantation, Florida and owner of Professional Nutrition Services, Inc. She authored the "Handbook of Creative Approaches to Patient Compliance" and continues to develop patient education tools. Donna is currently serving as secretary for the Florida Council on Renal Nutrition (FCRN). 

This article originally appeared in the March 2002 issue of aakpRENALIFE, Vol. 17, No. 5.

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