Diet, Supportive Care and Parent Counselling in Nephrotic Syndrome

Malnutrition and nephrotic syndrome are clinically distinct. A malnourished child typically has a pot belly from reduced muscle rather than true fluid-filled swelling, no puffiness around the eyes, and serum albumin is rarely below 2.5. In nephrotic syndrome, parents will describe a clear pattern of oedema starting around the eyes, then spreading to the face, hands, legs, abdomen and genitals, along with breathing or walking difficulty from the fluid accumulation, and albumin drops well below that malnutrition threshold.

Albumin infusion alongside diuretics is reserved for children with resistant, severe oedema, generalised swelling causing respiratory or genital distress, or an albumin level around 1.5 or below. A child with just mild eyelid swelling from a relapse does not need diuretics: the relapse itself is treated first, typically with steroids and review every third day, and diuretics are added only if the swelling is not settling, partly because prolonged oedema is an excellent medium for secondary bacterial infection, including spontaneous bacterial peritonitis.

It follows the same mechanism as the rest of the oedema: low albumin causes fluid to shift into dependent spaces in the body, and the right lung is affected somewhat more often than the left. The underlying pathophysiology is hypoalbuminaemia driving fluid out of the vascular space into surrounding tissue, known as third spacing.

Abdominal pain in these children usually has a few overlapping causes: spontaneous bacterial peritonitis, treated with a third-generation cephalosporin, since a diagnostic ascitic tap is no longer recommended because the puncture site tends to leak and add a further infection risk; stretching of the liver capsule; and simply the physical discomfort of a child's abdomen suddenly distending, similar in scale to a late-term pregnancy, which makes walking and daily activity very difficult. Swelling of the intestines themselves also contributes to the pain and can cause diarrhoea.

Children who present soon after a relapse with only mild eyelid swelling respond to steroids alone and do not need diuretics. Children with full-body swelling, low albumin around 1.5 or below, and no response to oral diuretics need albumin infusion alongside diuretics, and are identifiable clinically by severe swelling causing breathing difficulty or genital oedema. Oral diuretics alone are for children who have been on steroids for 10 to 14 days, are heading into remission, but still have uncomfortable, spreading facial swelling.

No. Regular, adequate protein intake, generally around 2 g per kg per day, is recommended, since restricting protein too far tends to worsen oedema and infection risk rather than reduce protein loss.

Daily home dipstick urine testing during infection-prone seasons helps catch a relapse early, alongside watching for swelling, unusual sleepiness and reduced urine output, and keeping vaccinations, including pneumococcal and influenza vaccines, up to date.