Abstracts

RATIONALE: The ketogenic diet, KD, is an effective treatment to control intractable epilepsy in children. Children who received the KD via gastrostomy tube had an increased nutritional risk for hypoproteinemia compared with children who fed orally.
METHODS: Children were admitted for the KD from June 1995- August 2000. Admission criteria include: 1)Referral by a pediatric neurologist; 2)1 - 16 years of age; 3)Seizures not responding to AEDs; and 4) Have no chronic illness. The classic consists of a 4:1 ratio of fat to protein and carbohydrate by weight providing 90% energy from fat. As per standard protocol, energy was restricted to 75% of energy requirements and protein meeting the Recommended Nutrient Intakes (R.N.I), generally 1 g/kg. Liquid KDs for our patients with gastrostomy tubes consisted of three ingredients:
1.Ross Carbohydrate Free formula, which provided the protein requirement, and a small component of fat to the feed.
2. Microlipid, an emulsified fat of safflower oil provided the remaining fat to the feed.
3. Polycose or Caloreen powder, a glucose polymer provided the caloric source of carbohydrate in the diet prescription.
RESULTS: Of fifteen children (9 boys, 6 girls) 6 presented with hypoproteinemia. The mean age was 6.3 years (2 - 14 years). The tube feedings before the diet provided a dietary protein intake of 1.34 g/kg - 3.27 g/kg body weight (average 2.00g/kg.) The change in protein from the child[ssquote]s previous feed to the initiation of the KD was 0.28 g/kg - 1.77 g/kg less protein (average 0.86g/kg). The dietary protein prescribed for each diet prescription ranged from 0.9 g/kg to 1.5g/kg at start (average 1.17g/kg). The 0.9g/kg (protein/kg actual weight from 1 of the 6 subjects) is a reflection of an older child where a low protein quantity per kilogram body weight is used to achieve a 4:1 ratio of fat to protein and carbohydrate by weight. Despite using the R.N.I for dietary protein these 6 children presented with hypoproteinemia. Four patients were symptomatic within the first 6 months and 2 post 1 year on the diet. Serum protein returned to normal upon alteration of the diet prescription to provide an increase in dietary protein in 3 of the children. The average increase of protein was 0.17g/kg, which assisted in the correction of the serum values and edema.
CONCLUSIONS: We Recommend:
1. A diet prescription of more than 1 g/kg dietary protein when possible.
2. Providing KD ratios of 3.5:1 or 3:1 to maintain adequate protein intake especially in older children.
3. Monitoring the serum total protein and albumin for all children fed the KD.
4. Educating parents about symptoms of hypoproteinemia.