1. Complications during Ketogenic Diet Initiation
Allison Fedders

2. Objectives Review epilepsy Review ketogenic diet
Discuss two methods of KD initiation
Understand adverse effects related to ketogenic diet initiation
Discuss critical thinking questions

3. Facts About Epilepsy 65 million people worldwide
Diagnosed by occurrence of 2 or more unprovoked seizures
30% do not respond to anti-seizure medications
Many treatment options
Ketogenic Diet

4. Ketogenic Diet Overview
High fat, low carbohydrate, adequate protein diet
Starvation/fasting
Causes body to produce ketones
Higher ketone levels = improved seizure control
Classic KD –
4:1, 3.5:1, 3:1

5. Typical KD Initiation Adverse effects during initiation
Many hospitals will admit children for initiation of KD diet
Patient safety
Two methods of initiation:
Fasted
Non-fasted/Gradual
Adverse effects during initiation
Hypoglycemia
Dehydration
GI disturbance
Food refusal

6. Purpose:
characterize the adverse effects during the KD inpatient initiation, and then evaluate whether the severity of adverse effects KD initiation correlated with seizure reduction at 3 months.

7. Method: Retrospective study Johns Hopkins Hospital
January 2011-July 2016
Chart review 158 patients
3-month outcome was defined by reduction in seizure frequency classified as:
<50%
50-89%
90-99%
seizure-free

8. Method Cont. Mean age at start of the KD was 4.6 years
Avg. seizures per day 4.5 (range: 0-240)
Actively receiving a mean of 2.3 anti-seizure drugs per day

9. Method cont. Gradual Initiation: Fasting Initiation
3 day admission period starting with meals one-third of the full calorie quota on the first day of initiation, and advancing the caloric content by one-third each day
Fasting Initiation
Fasting for 18 hours with clear carbohydrate-free fluids ad lib prior to beginning ketogenic foods

10. Adverse effects during initiation:

11. 3 month follow-up
70% reported a reduction in seizure frequency of 50% or greater.
Of these, 28 were seizure-free, 22 reported a 90-99% reduction, and 60 reported a 50-89% reduction
Neither initiation protocol nor severity of issues arising during the KD admission was shown to correlate with 3-month seizure outcomes

12. Results
No significant evidence to link initial adverse effects with KD inefficacy
Gradual KD initiation without fasting reduces complications during initiation with no significant lessening of 3-month outcomes
Fasting can lead to more immediate reduction of seizures

13. Results cont.
Younger children on average were more likely to have significant adverse effects, including hypoglycemia
avoid fasting in children under age 2 years
Avoid fasting in older children who are poor eaters, multiple medical comorbidities, or children who have limited communication skills and cannot report subjective complaints of fatigue or nausea

14. Critical thinking questions:
1. If you were the new ketogenic RD and had the opportunity to implement the ketogenic diet, would you choose to initiate fasting or gradually? Why?
2. How can we as RD’s assist patients and families in sticking with the ketogenic diet during adverse side effects?

15. Resources
The Charlie Foundation for Ketogenic Therapies. Ketogenic Therapies for Epilepsy. Accessed January 8, 2016.
Lin A, Turner Z, Doerrer SC, Stanfield A, Kossoff EH. Complications during ketogenic diet initiation: prevalence, treatment and Influence on seizure outcomes. Pediatric Neurology
Bergqvist, A. G. C., Schall, J. I., Gallagher, P. R., Cnaan, A. and Stallings, V. A. (2005), Fasting versus Gradual Initiation of the Ketogenic Diet: A Prospective, Randomized Clinical Trial of Efficacy. Epilepsia, 46: 1810–1819. doi: /j x