1
|
Cameron T, Allan K, Kay Cooper. The use of ketogenic diets in children living with drug-resistant epilepsy, glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency: A scoping review. J Hum Nutr Diet 2024; 37:827-846. [PMID: 38838079 DOI: 10.1111/jhn.13324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/10/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The ketogenic diet (KD) is a high fat, moderate protein and very low carbohydrate diet. It can be used as a medical treatment for drug-resistant epilepsy (DRE), glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency. The aim of this scoping review was to map the KD literature, with a focus on epilepsy and associated metabolic conditions, to summarise the current evidence-base and identify any gaps. METHODS This review was conducted using JBI scoping review methodological guidance and the PRISMA extension for scoping reviews reporting guidance. A comprehensive literature search was conducted in September 2021 and updated in February 2024 using MEDLINE, CINAHL, AMED, EmBASE, CAB Abstracts, Scopus and Food Science Source databases. RESULTS The initial search yielded 2721 studies and ultimately, data were extracted from 320 studies that fulfilled inclusion criteria for the review. There were five qualitative studies, and the remainder were quantitative, including 23 randomised controlled trials (RCTs) and seven quasi-experimental studies. The USA published the highest number of KD studies followed by China, South Korea and the UK. Most studies focused on the classical KD and DRE. The studies key findings suggest that the KD is efficacious, safe and tolerable. CONCLUSIONS There are opportunities available to expand the scope of future KD research, particularly to conduct high-quality RCTs and further qualitative research focused on the child's needs and family support to improve the effectiveness of KDs.
Collapse
Affiliation(s)
- Tracy Cameron
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, Scotland, UK
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Karen Allan
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
| | - Kay Cooper
- School of Health Sciences, Robert Gordon University, Aberdeen, Scotland, UK
- Scottish Centre for Evidence-based, Multi-professional Practice: A JBI Centre of Excellence, Aberdeen, Scotland, UK
| |
Collapse
|
2
|
van der Louw E, Trimmel-Schwahofer P, Devlin A, Armeno M, Thompson L, Cross JH, Auvin S, Dressler A. Human milk and breastfeeding during ketogenic diet therapy in infants with epilepsy: Clinical practice guideline. Dev Med Child Neurol 2024. [PMID: 38669468 DOI: 10.1111/dmcn.15928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 04/28/2024]
Abstract
Ketogenic diet therapy (KDT) is a safe and effective treatment for epilepsy and glucose transporter type 1 (GLUT1) deficiency syndrome in infancy. Complete weaning from breastfeeding is not required to implement KDT; however, breastfeeding remains uncommon. Barriers include feasibility concerns and lack of referrals to expert centres. Therefore, practical strategies are needed to help mothers and professionals overcome these barriers and facilitate the inclusion of breastfeeding and human milk during KDT. A multidisciplinary expert panel met online to address clinical concerns, systematically reviewed the literature, and conducted two international surveys to develop an expert consensus of practical recommendations for including human milk and breastfeeding in KDT. The need to educate about the nutritional benefits of human milk and to increase breastfeeding rates is emphasized. Prospective real-world registries could help to collect data on the implementation of breastfeeding and the use of human milk in KDT, while systematically including non-seizure-related outcomes, such as quality of life, and social and emotional well-being, which could improve outcomes for infants and mothers.
Collapse
Affiliation(s)
- Elles van der Louw
- Department of Internal Medicine, Division of Dietetics, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Petra Trimmel-Schwahofer
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
- European Reference Network, EpiCARE
| | - Anita Devlin
- Paediatric Neurology, Great North Children's Hospital, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Marisa Armeno
- Department of Nutrition, Hospital de Pediatria Prof. Dr. J.P. Garrahan, Buenos Aires, Argentina
| | - Lindsey Thompson
- Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA
| | - J Helen Cross
- UCL NIHR BRC Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Stéphane Auvin
- European Reference Network, EpiCARE
- APHP, Service de Neurologie Pédiatrique, Hôpital Robert Debré, Paris, France
- Université Paris-Cité, INSERM Neuro Diderot, Paris, France
- Institut Universitaire de France (IUF), Paris, France
| | - Anastasia Dressler
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
- European Reference Network, EpiCARE
| |
Collapse
|
3
|
Armeno M, Calligaris S, Gagiulo D, Cresta A, Vaccarezza MM, Diez CG, Alberti MJ, Viollaz R, Vilavedra F, Caraballo RH. Use of ketogenic dietary therapy for drug-resistant epilepsy in early infancy. Epilepsia Open 2024; 9:138-149. [PMID: 37759424 PMCID: PMC10839363 DOI: 10.1002/epi4.12836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE There is growing evidence that ketogenic dietary therapy (KDT) can be safely and efficiently used in young children, but little evidence exists on its use in newborns. Developmental and epileptic encephalopathies starting in the neonatal period or early infancy usually present a poor prognosis. The aim of this study was to evaluate effectiveness, safety, and survival of infants younger than 3 months of age with drug-resistant epilepsy in whom KDT was used. METHODS A retrospective study was conducted to evaluate neonates and infants younger than 3 months who started KDT for drug-resistant developmental and epileptic encephalopathies at three referral centers. Data were collected on demographic features, time of epilepsy onset, epilepsy syndrome, seizure type, seizure frequency at diet onset, etiology, details regarding diet initiation, type of ketogenic formula, breastfeeding, route of administration, blood ketones, growth, length of NICU stay, and survival. RESULTS Nineteen infants younger than 12 weeks of life who received KDT with a minimum follow-up of 1 month were included; 13 had early-infantile developmental and epileptic encephalopathy, four epilepsy of infancy with migrating focal seizures, and two focal epilepsy. A >50% response was observed in 73.7% at 1 month on the diet; 37% achieved a > 75% seizure reduction, and 10.5% became seizure free. At 3 months, a >50% decrease in seizure frequency was observed in 72.2%; 15.8% had a >75% reduction; 21% became seizure free. Overall survival was 76% at 1 year on diet. Incidence of acute and late adverse effects was low and most adverse effects were asymptomatic and manageable. SIGNIFICANCE Our experience suggests that KDT is safe and effective in newborns and very young infants; however, further studies on the management of the diet in this vulnerable age group are necessary.
Collapse
Affiliation(s)
- Marisa Armeno
- Hospital de Pediatría Prof. Dr. J.P GarrahanBuenos AiresArgentina
| | | | - Daniela Gagiulo
- Hospital de Pediatría Prof. Dr. J.P GarrahanBuenos AiresArgentina
| | - Araceli Cresta
- Hospital de Pediatría Prof. Dr. J.P GarrahanBuenos AiresArgentina
| | | | | | | | | | | | | |
Collapse
|
4
|
Zhao X, He Z, Li Y, Yang X, Li B. Atypical absence seizures and gene variants: A gene-based review of etiology, electro-clinical features, and associated epilepsy syndrome. Epilepsy Behav 2024; 151:109636. [PMID: 38232560 DOI: 10.1016/j.yebeh.2024.109636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/01/2024] [Accepted: 01/05/2024] [Indexed: 01/19/2024]
Abstract
Atypical absence seizures are generalized non-convulsive seizures that often occur in children with cognitive impairment. They are common in refractory epilepsy and have been recognized as one of the hallmarks of developmental epileptic encephalopathies. Notably, pathogenic variants associated with AAS, such as GABRG2, GABRG3, SLC6A1, CACNB4, SCN8A, and SYNGAP1, are also linked to developmental epileptic encephalopathies. Atypical absences differ from typical absences in that they are frequently drug-resistant and the prognosis is dependent on the etiology or related epileptic syndromes. To improve clinicians' understanding of atypical absences and provide novel perspectives for clinical treatment, we have reviewed the electro-clinical characteristics, etiologies, treatment, and prognosis of atypical absences, with a focus on the etiology of advancements in gene variants, shedding light on potential avenues for improved clinical management.
Collapse
Affiliation(s)
| | - Zimeng He
- Shandong University, Jinan, Shandong, China
| | - Yumei Li
- Shandong University, Jinan, Shandong, China
| | - Xiaofan Yang
- Shandong University, Jinan, Shandong, China; Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| | - Baomin Li
- Shandong University, Jinan, Shandong, China; Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| |
Collapse
|
5
|
Faheem Y, Jaiswal A, Shergill K, Boppana K, Almansouri NE, Bakkannavar S, Yu AK. Keto Clarity: A Comprehensive Systematic Review Exploring the Efficacy, Safety, and Mechanisms of Ketogenic Diet in Pediatric Epilepsy. Cureus 2024; 16:e54863. [PMID: 38533170 PMCID: PMC10964213 DOI: 10.7759/cureus.54863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/23/2024] [Indexed: 03/28/2024] Open
Abstract
Epilepsy, a widespread neurological disorder characterized by recurrent seizures, affects millions globally, with a significant impact on the pediatric population. Antiepileptic drugs (AEDs) constitute the primary treatment; however, drug-resistant epilepsy (DRE), especially in children, poses a therapeutic challenge. Alternative interventions, such as surgery, vagus nerve stimulation, and the ketogenic diet (KD), have been explored. This systematic review aims to investigate various types of KDs, their distinctions, their effectiveness, and their safety concerning the reduction of seizure frequency, achieving seizure freedom, and the occurrence of adverse events. The study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A comprehensive search was conducted using databases such as PubMed Central (PMC), MedLine, and Science Direct to identify relevant articles. Eligibility criteria and quality assessment tools were applied to evaluate the potential risk of bias and select 11 articles for inclusion in this review. The selected articles encompassed four randomized controlled trials (RCTs), two systematic reviews, and five narrative reviews. The data collected for this review was completed on October 2, 2023. Challenges, such as palatability, cultural factors, and adherence difficulties, were identified. Family or caregiver involvement plays a pivotal role in treatment success. Despite numerous RCTs and reviews, information gaps persist, hindering conclusive outcomes. Evaluating the risk-benefit ratio is crucial, considering potential side effects. The highly individualized nature of KD therapy, influenced by diverse seizure types and syndromes, necessitates a trial-and-error approach monitored by a multidisciplinary team. Long-term safety and efficacy demand continuous real-life patient data review. In summary, while KD presents a promising alternative for DRE, its success relies on meticulous planning, individualized implementation, and ongoing research to address existing challenges and information gaps.
Collapse
Affiliation(s)
- Youmna Faheem
- Pediatrics, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Amisha Jaiswal
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kainaat Shergill
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kusalik Boppana
- Internal Medicine and Gastroenterology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Naiela E Almansouri
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, University of Tripoli, Tripoli, LBY
| | - Saloni Bakkannavar
- Pediatrics, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ann Kashmer Yu
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| |
Collapse
|
6
|
Falsaperla R, Sortino V, Collotta AD, Privitera GF, Palmeri A, Mauceri L, Ruggieri M. Ketogenic Diet in Neonates with Drug-Resistant Epilepsy: Efficacy and Side Effects-A Single Center's Initial Experience. Neuropediatrics 2023; 54:315-321. [PMID: 37321250 DOI: 10.1055/s-0043-1769505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND For patients with pharmacoresistant epilepsy, a therapeutic option is ketogenic diet. Currently, data on young infants are scarce, particularly during hospitalization in the neonatal intensive care unit (NICU). OBJECTIVE The aim of the present study was to evaluate the short-term (3-month) efficacy and side effects of ketogenic diet in infants with "drugs-resistant" epilepsy treated during NICU stay. METHODS This retrospective study included infants aged under 2 months started on ketogenic diet during NICU hospitalization to treat drug-resistant epilepsy from April 2018 to November 2022. RESULTS Thirteen term-born infants were included, three (23.1%) of whom were excluded because they did not respond to the ketogenic diet. Finally, we included 10 infants. Six (60%) patients took three antiepileptics before starting the ketogenic diet, while four (40%) took more drugs. Diet had a good response in four (40%) patients. In four patients, the ketogenic diet was suspended because of the onset of serious side effects. The emetic levels of sodium, potassium, and chlorine, pH, and onset of diarrhea, constipation, and gastroesophageal reflux showed significant differences. Ketonuria was higher and blood pH lower in the group that took more than three drugs than in the group taking fewer than three drugs. CONCLUSION The ketogenic diet is efficacious and safe in infants, but the early and aggressive management of adverse reactions is important to improve the safety and effectiveness of the ketogenic treatment.
Collapse
Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico "Rodolico-San Marco," San Marco Hospital, University of Catania, Catania, Italy
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco," San Marco Hospital, Catania, Italy
| | - Vincenzo Sortino
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco," San Marco Hospital, Catania, Italy
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Ausilia Desiree Collotta
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero-Universitaria Policlinico, "Rodolico-San Marco," San Marco Hospital, Catania, Italy
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Grete Francesca Privitera
- Unit of Math and Comp Science, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonio Palmeri
- Postgraduate Training Program in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura Mauceri
- Neonatal Intensive Care Unit and Neonatal Accompaniment Unit, Azienda Ospedaliero-Universitaria Policlinico "Rodolico-San Marco," San Marco Hospital, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Unit of Clinical Pediatrics and Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Policlinico Hospital, Catania, Italy
| |
Collapse
|
7
|
Hsieh TY, Su TY, Hung KY, Hsu MS, Lin YJ, Kuo HC, Hung PL. Feasibility of ketogenic diet therapy variants for refractory epilepsy in neonates to infants under 2 years old. Epilepsy Behav 2023; 146:109315. [PMID: 37549465 DOI: 10.1016/j.yebeh.2023.109315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Ketogenic diet Therapy (KDT) has been reported as a possible beneficial management strategy for controlling seizures in infants aged <2 years, but the safety and efficacy of this therapy remain to be investigated. We investigated the achievability, tolerability, efficacy, and safety of KDT for patients under 2 years old. MATERIALS AND METHODS Infants younger than 2 years old with pharmacoresistant epilepsy were enrolled in this prospective study. We divided cases into three age groups: I) neonates; II) infants aged 1-12 months; III) infants aged 12-24 months. KDT initiation protocol were administration through parenteral route, enteral route or oral feeding. Seizure reduction rate, physical growth, and adverse effects were assessed at monthly visit. RESULTS Thirteen patients who completed 6 months of KDT were recruited. There was one neonate in group I, 9 infants in group II, and 3 infants in group III. Eleven of them (11/13, 84.6%) were responders to KDT. All infants with underlying genetic etiology were seizure free after treating with KDT. The starting keto ratio was 1.1 mmol/L in group I, 2.3 mmol/L in group II, and 2.8 mmol/L in group III, which gradually approached 3:1-4:1 over 5-7 days. There were no symptomatic adverse effects or growth retardation in any of the study subjects. CONCLUSIONS KDT is a promising alternative therapy with high feasibility, safety, and efficacy for pharmacoresistant epilepsy in infants under 2 years old, especially for those with genetic etiology. The starting keto ratio should be lower, and the keto ratio titration period should be longer than for children older than 2 years.
Collapse
Affiliation(s)
- Tzu-Yun Hsieh
- Division of Pediatric Neurology, Department of Pediatrics at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Pediatric Neurologic Rare Disease Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ting-Yu Su
- Division of Pediatric Neurology, Department of Pediatrics at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Pediatric Neurologic Rare Disease Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kai-Yin Hung
- Department of Nutritional Therapy at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mei-Shin Hsu
- Division of Pediatric Critical Care, Department of Pediatrics at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Jui Lin
- Division of Pediatric Critical Care, Department of Pediatrics at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsuan-Chang Kuo
- Division of Pediatric Critical Care, Department of Pediatrics at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pi-Lien Hung
- Division of Pediatric Neurology, Department of Pediatrics at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Pediatric Neurologic Rare Disease Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| |
Collapse
|
8
|
de Brito Sampaio LP, Henriques-Souza AMDM, Lin K, Neri LDCL, Inuzuka LM, Uchôa LIDL, Gregório MMDO, Guilhoto LM, Montenegro MA, Lunardi M, Veiga M, de Lima PA, Braatz V. Ketogenic therapy in childhood and adolescence: recommendations of the Brazilian experts group. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:597-606. [PMID: 37379871 PMCID: PMC10658610 DOI: 10.1055/s-0043-1768676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/15/2023] [Indexed: 06/30/2023]
Abstract
Ketogenic dietary therapies (KDTs) are a safe and effective treatment for pharmacoresistant epilepsy in children. There are four principal types of KDTs: the classic KD, the modified Atkins diet (MAD), the medium-chain triglyceride (MCT) diet, and the low glycemic index diet (LGID). The International Ketogenic Diet Study Group recommends managing KDTs in children with epilepsy. However, there are no guidelines that address the specific needs of the Brazilian population. Thus, the Brazilian Child Neurology Association elaborated on these recommendations with the goal of stimulating and expanding the use of the KD in Brazil.
Collapse
Affiliation(s)
- Letícia Pereira de Brito Sampaio
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas,
Instituto da Criança e Adolescente, São Paulo SP, Brazil.
| | | | - Katia Lin
- Universidade Federal de Santa Catarina, Departamento de Medicina Interna,
Divisão de Neurologia, Florianópolis SC, Brazil.
| | - Lenycia de Cassya Lopes Neri
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas,
Instituto da Criança e Adolescente, São Paulo SP, Brazil.
| | | | | | | | - Laura Maria Guilhoto
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo,
Brazil.
- Universidade de São Paulo, Hospital Universitário, Divisão de Clínica
Pediátrica, São Paulo SP, Brazil.
| | | | - Mariana Lunardi
- Universidade Federal de Santa Catarina, Programa de Pós-Graduação em Ciências
Médicas, Florianópolis SC, Brazil.
| | - Marielza Veiga
- Hospital Universitário Professor Edgard Santos, Salvador BA,
Brazil.
| | | | - Vera Braatz
- Universidade da Região de Joinville, Departamento de Medicina, Divisão de
Neurologia, Joinville SC, Brazil.
| |
Collapse
|
9
|
Phitsanuwong C, Kim JA, Schimpf S, Nordli DR. Experience with the ketogenic diet in premature neonates. Epilepsia Open 2023; 8:200-204. [PMID: 36398475 PMCID: PMC9977748 DOI: 10.1002/epi4.12673] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/15/2022] [Indexed: 11/20/2022] Open
Abstract
The ketogenic diet is a time-tested, potent, nonpharmacological treatment of epilepsy. However, the use of the ketogenic diet in premature neonates with epilepsy has not been previously reported. We share our experience with the use of ketogenic diet therapy in two premature neonates. Two identical twin premature neonates with SCN2A-related developmental and epileptic encephalopathy, whose seizures were refractory to multiple anti-seizure medications, were started on the classic ketogenic diet at the conceptual age of 35 weeks. Ketosis was achieved and maintained (range 2-5 mmol/L of serum beta-hydroxybutyrate level). Seizure frequency was significantly reduced (>90% reduction in both patients), and some anti-seizure medications were able to be discontinued. Initial transient weight loss and one episode of asymptomatic hypoglycemia were observed and corrected. The ketogenic diet was found to be a safe, well-tolerated, and effective treatment for seizures in two premature neonates. The side effects are tolerable and correctable. The ketogenic diet, therefore, is a treatment option for refractory seizures in this age group, when administered under expert guidance.
Collapse
Affiliation(s)
- Chalongchai Phitsanuwong
- Section of Child Neurology, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Jeong-A Kim
- Section of Child Neurology, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Stephanie Schimpf
- Section of Child Neurology, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Douglas R Nordli
- Section of Child Neurology, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
10
|
Sharma S, Whitney R, Kossoff EH, RamachandranNair R. Does the ketogenic ratio matter when using ketogenic diet therapy in pediatric epilepsy? Epilepsia 2023; 64:284-291. [PMID: 36471628 DOI: 10.1111/epi.17476] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/26/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
The ketogenic diet (KD) is a widely used therapeutic option for individuals with medically refractory epilepsy. As the diet's name implies, ketosis is a historically important component of the diet, but it is not well understood how important ketosis is for seizure control. The ketogenic ratio is defined as the ratio of fat to carbohydrate plus protein by weight in the diet (grams). Traditionally, the classic KD contains a 4:1 ratio, and a very high proportion of fat in the diet. The classic KD, with its high proportion of fat and limited carbohydrate intake can be restrictive for patients with epilepsy. Recently, there is experience with use of lower ketogenic ratios and less-restrictive diets such as the modified Atkins diet and the low glycemic index treatment. In this narrative review, we examine the role of ketosis and ketogenic ratios in determining the efficacy of the KD in children with epilepsy.
Collapse
Affiliation(s)
- Suvasini Sharma
- Neurology Division, Department of Pediatrics, Lady Harding Medical College and Associated Kalawati Saran Children Hospital, New Delhi, India
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Eric H Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rajesh RamachandranNair
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
11
|
Abstract
The prevalence of neonatal hypoxic-ischemic encephalopathy (HIE), a devastating neurological injury, is increasing; thus, effective treatments and preventions are urgently needed. The underlying pathology of HIE remains unclear; recent research has focused on elucidating key features of the disease. A variety of diseases can be alleviated by consuming a ketogenic diet (KD) despite differences in pathogenesis and features, given the common mechanisms of KD-induced effects. Dietary modification is the most translatable, cost-efficient, and safest approach to treat acute or chronic neurological disorders and reduces reliance on pharmaceutical treatments. Evidence suggests that the KD can exert beneficial effects in animal models and in humans with brain injuries. The efficacy of the KD in preventing neuronal damage, motor alterations, and cognitive decline varies. Moreover, the KD may provide an alternative source of energy, enhance mitochondrial function, and reduce the expression of inflammatory and apoptotic mediators. Thus, this diet has attracted interest as a potential therapy for HIE. This review examined the role of the KD in HIE treatment and described the mechanisms by which ketone bodies (KBs) exert effects under pathological conditions and protect against brain damage; the evidence supports the implementation of dietary interventions as a therapeutic strategy for HIE. Future research should aim to elucidate the underlying mechanisms of the KD in patients with HIE and determine whether the effect of the KD on clinical outcomes can be reproduced in humans.
Collapse
Affiliation(s)
- Yue Zhou
- Department of Pharmacy, Xindu District People's Hospital of Chengdu, 610500 Chengdu, China
| | - Luqiang Sun
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, 610075 Chengdu, China
| | - Haichuan Wang
- Department of Paediatrics, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, 610072 Chengdu, China
| |
Collapse
|
12
|
Skrobas U, Duda P, Bryliński Ł, Drożak P, Pelczar M, Rejdak K. Ketogenic Diets in the Management of Lennox-Gastaut Syndrome-Review of Literature. Nutrients 2022; 14:4977. [PMID: 36501006 PMCID: PMC9740154 DOI: 10.3390/nu14234977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/16/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022] Open
Abstract
Epilepsy is an important medical problem with approximately 50 million patients globally. No more than 70% of epileptic patients will achieve seizure control after antiepileptic drugs, and several epileptic syndromes, including Lennox-Gastaut syndrome (LGS), are predisposed to more frequent pharmacoresistance. Ketogenic dietary therapies (KDTs) are a form of non-pharmacological treatments used in attempts to provide seizure control for LGS patients who experience pharmacoresistance. Our review aimed to evaluate the efficacy and practicalities concerning the use of KDTs in LGS. In general, KDTs are diets rich in fat and low in carbohydrates that put the organism into the state of ketosis. A classic ketogenic diet (cKD) is the best-evaluated KDT, while alternative KDTs, such as the medium-chain triglyceride diet (MCT), modified Atkins diet (MAD), and low glycemic index treatment (LGIT) present several advantages due to their better tolerability and easier administration. The literature reports regarding LGS suggest that KDTs can provide ≥50% seizure reduction and seizure-free status in a considerable percentage of the patients. The most commonly reported adverse effects are constipation, diarrhea, and vomiting, while severe adverse effects such as nephrolithiasis or osteopenia are rarely reported. The literature review suggests that KDTs can be applied safely and are effective in LGS treatment.
Collapse
Affiliation(s)
- Urszula Skrobas
- Department of Neurology, Medical University of Lublin, 20-090 Lublin, Poland
| | | | | | | | | | | |
Collapse
|
13
|
Turck D, Bohn T, Castenmiller J, De Henauw S, Hirsch‐Ernst KI, Maciuk A, Mangelsdorf I, McArdle HJ, Naska A, Pelaez C, Pentieva K, Siani A, Thies F, Tsabouri S, Vinceti M, Cubadda F, Frenzel T, Heinonen M, Prieto Maradona M, Marchelli R, Neuhäuser‐Berthold M, Poulsen M, Schlatter JR, van Loveren H, Albert O, Goumperis T, Knutsen HK. Safety of β-hydroxybutyrate salts as a novel food pursuant to Regulation (EU) 2015/2283. EFSA J 2022; 20:e07449. [PMID: 36254193 PMCID: PMC9558159 DOI: 10.2903/j.efsa.2022.7449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on β-hydroxybutyrate (BHB) salts as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The NF consists of sodium, magnesium and calcium BHB salts, and is proposed to be used by adults as a food ingredient in a number of food categories and as food supplement. The data provided by the applicant about the identity, the production process and the compositional data of the NF over the course of the risk assessment period were overall considered unsatisfactory. The Panel noted inconsistencies in the reporting of the test item used in the subchronic toxicity study and human studies provided by the applicant. Owing to these deficiencies, the Panel cannot establish a safe intake level of the NF. The Panel concludes that the safety of the NF has not been established.
Collapse
|
14
|
Tong X, Cai Q, Cao D, Yu L, Sun D, Yang G, Wang J, Li H, Li Z, Wang J, Huang S, Ding M, Fang F, Wang Q, Luo R, Liao J, Qin J. Chinese expert recommendations on ketogenic diet therapy for super-refractory status epilepticus. ACTA EPILEPTOLOGICA 2022. [DOI: 10.1186/s42494-021-00078-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractSuper-refractory status epilepticus (SRSE) is a serious and life-threatening neurological condition. Ketogenic diet (KD) is a diet characterized by high fat, low carbohydrate, and moderate protein. As KD shows effectiveness in controlling seizures in more than half of SRSE patients, it can be a treatment option for SRSE. Currently, KD treatment for SRSE is based on personal experience and observational evidence has been published. In the context of a lack of a validated guideline, we convened a multicenter expert panel within the China Association Against Epilepsy (CAAE) Ketogenic Diet Commission to work out the Chinese expert recommendations on KD for SRSE. We summarize and discuss the latest clinical practice of KD for SRSE in critical care settings. Recommendations are given on patient selection, the timing of KD, diet implementation, and follow-up. More research data are needed in this area to support better clinical practice.
Collapse
|
15
|
Ko A, Kwon HE, Kim HD. Updates on the ketogenic diet therapy for pediatric epilepsy. Biomed J 2021; 45:19-26. [PMID: 34808422 PMCID: PMC9133260 DOI: 10.1016/j.bj.2021.11.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/25/2021] [Accepted: 11/07/2021] [Indexed: 12/11/2022] Open
Abstract
The ketogenic diet (KD) is a high-fat, low-carbohydrate diet, in which fat, instead of glucose, acts as a major energy source through the production of ketone bodies. The KD was formally introduced in 1921 to mimic the biochemical changes associated with fasting and gained recognition as a potent treatment for pediatric epilepsy in the mid-1990s. Recent clinical and scientific knowledge supports the use of the KD in drug-resistant epilepsy patients for its anti-seizure efficacy, safety, and tolerability. The KD is also receiving growing attention as a potential treatment option for other neurological disorders. This article will review on the recent updates on the KD, focusing on its mechanisms of action, its alternatives, expansion on its use in terms of age groups and different regions in the world, and future issues.
Collapse
Affiliation(s)
- Ara Ko
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Hye Eun Kwon
- Department of Pediatrics, International St. Mary's Hospital, Catholic Kwandong University, College of Medicine, Incheon, Republic of Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
16
|
Иванникова ЕВ, Алташина МВ, Трошина ЕА. [The ketogenic diet: history, mechanism of action, indications and contraindications]. PROBLEMY ENDOKRINOLOGII 2021; 68:49-72. [PMID: 35262297 PMCID: PMC9761873 DOI: 10.14341/probl12724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 10/20/2021] [Accepted: 11/01/2021] [Indexed: 01/09/2023]
Abstract
Low-carb diets have been successfully used to alleviate a number of severe neurological diseases for about 100 years. The publication of the results of new studies suggesting that this type of diet may play a therapeutic role in other pathologies such as diabetes, obesity, polycystic ovary syndrome, and oncology is of particular interest for both doctors and the public. However, the long-term safety of using a low-carb or ketogenic diet, as well as its impact, primarily on the risks of developing cardiovascular diseases, remains poorly studied. This article presents the results of observation of patients against the background of a low-carbohydrate diet, both in the short-term perspective as well as provides an assessment of its long-term consequences.
Collapse
Affiliation(s)
| | - М. В. Алташина
- Национальный медицинский исследовательский центр
эндокринологии
| | - Е. А. Трошина
- Национальный медицинский исследовательский центр
эндокринологии
| |
Collapse
|
17
|
Abstract
AbstractThe ketogenic diet (KD) is a high-fat, low-carbohydrate diet, in which fat is used as the primary energy source through the production of ketone bodies (KBs) in place of glucose. The KD was formally introduced in 1921 to mimic the biochemical changes associated with fasting and gained recognition as a potent treatment for pediatric epilepsy in the mid-1990s. The clinical and basic scientific knowledge that supports the anti-seizure efficacy, safety, and feasibility of using the KD in patients with epilepsy is huge. Additionally, the International Ketogenic Diet Study Group’s consensus guidelines provide practical information in 2009 and 2018. The KD is a broad-spectrum therapy for drug resistant epilepsy and is gaining attention as a potential therapy for other neurological disorders. This article will review recent aspects on the use of the KD, including its mechanisms of action, KD alternatives, expanding its use across different age groups and regions, its use as a treatment for other neurologic disorders, and future research subjects.
Collapse
|
18
|
Yao A, Li Z, Lyu J, Yu L, Wei S, Xue L, Wang H, Chen GQ. On the nutritional and therapeutic effects of ketone body D-β-hydroxybutyrate. Appl Microbiol Biotechnol 2021; 105:6229-6243. [PMID: 34415393 PMCID: PMC8377336 DOI: 10.1007/s00253-021-11482-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/31/2022]
Abstract
Abstract d-β-hydroxybutyrate (d-3HB), a monomer of microbial polyhydroxybutyrate (PHB), is also a natural ketone body produced during carbohydrate deprivation to provide energy to the body cells, heart, and brain. In recent years, increasing evidence demonstrates that d-3HB can induce pleiotropic effects on the human body which are highly beneficial for improving physical and metabolic health. Conventional ketogenic diet (KD) or exogenous ketone salts (KS) and esters (KE) have been used to increase serum d-3HB level. However, strict adaptation to the KD was often associated with poor patient compliance, while the ingestion of KS caused gastrointestinal distresses due to excessive consumption of minerals. As for ingestion of KE, subsequent degradation is required before releasing d-3HB for absorption, making these methods somewhat inferior. This review provides novel insights into a biologically synthesized d-3HB (d-3-hydroxybutyric acid) which can induce a faster increase in plasma d-3HB compared to the use of KD, KS, or KE. It also emphasizes on the most recent applications of d-3HB in different fields, including its use in improving exercise performance and in treating metabolic or age-related diseases. Ketones may become a fourth micro-nutrient that is necessary to the human body along with carbohydrates, proteins, and fats. Indeed, d-3HB being a small molecule with multiple signaling pathways within the body exhibits paramount importance in mitigating metabolic and age-related diseases. Nevertheless, specific dose–response relationships and safety margins of using d-3HB remain to be elucidated with more research. Key points • d-3HB induces pleiotropic effects on physical and metabolic health. • Exogenous ketone supplements are more effective than ketogenic diet. • d-3HB as a ketone supplement has long-term healthy impact.
Collapse
Affiliation(s)
- Aliya Yao
- MedPHA Bioscience Co. Ltd., Traditional Chinese Medicine Science and Technology Industrial Park of Co-Operation Between Guangdong and Macau, Building No.103, 36 Doukou Rd, Hengqin District, Zhuhai, 519030, Guangdong Province, China
| | - Zihua Li
- School of Pharmaceutical Sciences, Tsinghua University, Beijing, 100084, China
| | - Jinyan Lyu
- MedPHA Bioscience Co. Ltd., Traditional Chinese Medicine Science and Technology Industrial Park of Co-Operation Between Guangdong and Macau, Building No.103, 36 Doukou Rd, Hengqin District, Zhuhai, 519030, Guangdong Province, China
| | - Liusong Yu
- MedPHA Bioscience Co. Ltd., Traditional Chinese Medicine Science and Technology Industrial Park of Co-Operation Between Guangdong and Macau, Building No.103, 36 Doukou Rd, Hengqin District, Zhuhai, 519030, Guangdong Province, China
| | - Situ Wei
- MedPHA Bioscience Co. Ltd., Traditional Chinese Medicine Science and Technology Industrial Park of Co-Operation Between Guangdong and Macau, Building No.103, 36 Doukou Rd, Hengqin District, Zhuhai, 519030, Guangdong Province, China
| | - Lingyun Xue
- MedPHA Bioscience Co. Ltd., Traditional Chinese Medicine Science and Technology Industrial Park of Co-Operation Between Guangdong and Macau, Building No.103, 36 Doukou Rd, Hengqin District, Zhuhai, 519030, Guangdong Province, China
| | - Hui Wang
- Department of Colorectal Surgery, Guangdong Province Biomedical Material Conversion and Evaluation Engineering Technology Center, Institute of Biomedical Innovation, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510655, Guangdong Province, China
| | - Guo-Qiang Chen
- MedPHA Bioscience Co. Ltd., Traditional Chinese Medicine Science and Technology Industrial Park of Co-Operation Between Guangdong and Macau, Building No.103, 36 Doukou Rd, Hengqin District, Zhuhai, 519030, Guangdong Province, China. .,School of Pharmaceutical Sciences, Tsinghua University, Beijing, 100084, China. .,School of Life Sciences and Dept Chemical Engineering, Center for Synthetic and Systems Biology (CSSB), Tsinghua University, Beijing, 100084, China.
| |
Collapse
|
19
|
Calcaterra V, Verduci E, Pascuzzi MC, Magenes VC, Fiore G, Di Profio E, Tenuta E, Bosetti A, Todisco CF, D'Auria E, Zuccotti G. Metabolic Derangement in Pediatric Patient with Obesity: The Role of Ketogenic Diet as Therapeutic Tool. Nutrients 2021; 13:2805. [PMID: 34444964 PMCID: PMC8400548 DOI: 10.3390/nu13082805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/22/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022] Open
Abstract
Obesity is defined as a condition characterized by an excessive fat accumulation that has negative health consequences. Pediatric obesity is associated with an increased risk for many diseases, including impaired glycemic and lipidic control that may lead to the development of chronic, and potentially disabling, pathologies, such as type 2 diabetes mellitus (T2DM) and cardiovascular events, in adult life. The therapeutic strategy initially starts with interventions that are aimed at changing lifestyle and eating behavior, to prevent, manage, and potentially reverse metabolic disorders. Recently, the ketogenic diet (KD) has been proposed as a promising dietary intervention for the treatment of metabolic and cardiovascular risk factors related to obesity in adults, and a possible beneficial role has also been proposed in children. KD is very low in carbohydrate, high in fat, and moderate to high in protein that may have the potential to promote weight loss and improve lipidic derangement, glycemic control, and insulin sensitivity. In this review, we present metabolic disorders on glycemic and lipidic control in children and adolescents with obesity and indication of KD in pediatrics, discussing the role of KD as a therapeutic tool for metabolic derangement. The results of this review may suggest the validity of KD and the need to further research its potential to address metabolic risk factors in pediatric obesity.
Collapse
Affiliation(s)
- Valeria Calcaterra
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Elvira Verduci
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Health Sciences, University of Milano, 20142 Milano, Italy
| | - Martina Chiara Pascuzzi
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Vittoria Carlotta Magenes
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Giulia Fiore
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Health Sciences, University of Milano, 20142 Milano, Italy
| | - Elisabetta Di Profio
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Elisavietta Tenuta
- Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Alessandra Bosetti
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
| | - Carolina Federica Todisco
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Enza D'Auria
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, "Vittore Buzzi" Children's Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science "L. Sacco", University of Milan, 20157 Milan, Italy
| |
Collapse
|
20
|
Abstract
Seizures are the most common neurological emergency in the neonates, and this age group has the highest incidence of seizures compared with any other period of life. The author provides a narrative review of recent advances in the genetics of neonatal epilepsies, new neonatal seizure classification system, diagnostics, and treatment of neonatal seizures based on a comprehensive literature review (MEDLINE using PubMED and OvidSP vendors with appropriate keywords to incorporate recent evidence), personal practice, and experience. Knowledge regarding various systemic and postzygotic genetic mutations responsible for neonatal epilepsy has been exploded in recent times, as well as better delineation of clinical phenotypes associated with rare neonatal epilepsies. An International League Against Epilepsy task force on neonatal seizure has proposed a new neonatal seizure classification system and also evaluated the specificity of semiological features related to particular etiology. Although continuous video electroencephalogram (EEG) is the gold standard for monitoring neonatal seizures, amplitude-integrated EEGs have gained significant popularity in resource-limited settings. There is tremendous progress in the automated seizure detection algorithm, including the availability of a fully convolutional neural network using artificial machine learning (deep learning). There is a substantial need for ongoing research and clinical trials to understand optimal medication selection (first line, second line, and third line) for neonatal seizures, treatment duration of antiepileptic drugs after cessation of seizures, and strategies to improve neuromorbidities such as cerebral palsy, epilepsy, and developmental impairments. Although in recent times, levetiracetam use has been significantly increased for neonatal seizures, a multicenter, randomized, blinded, controlled phase IIb trial confirmed the superiority of phenobarbital over levetiracetam in the acute suppression of neonatal seizures. While there is no single best choice available for the management of neonatal seizures, institutional guidelines should be formed based on a consensus of local experts to mitigate wide variability in the treatment and to facilitate early diagnosis and treatment.
Collapse
Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| |
Collapse
|
21
|
Falsaperla R, D'Angelo G, Praticò AD, Mauceri L, Barbagallo M, Pavone P, Catanzaro S, Gitto E, Corsello G, Ruggieri M. Ketogenic diet for infants with epilepsy: A literature review. Epilepsy Behav 2020; 112:107361. [PMID: 33181904 DOI: 10.1016/j.yebeh.2020.107361] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 12/20/2022]
Abstract
The ketogenic diet (KD) is an established, nonpharmacological treatment for drug-resistant epilepsy (DRE). Actually, KD and its variants have been shown to be elective and resolute for patients with glucose transporter type 1 (GLUT1) deficiency. The aim of this review was to study the use of KD and its variants in infancy, including the neonatal age, and demonstrate the safety and efficacy of this treatment in patients with the age of 0-23 months affected by DRE already subjected to pharmacological approach attempts. A literature search was conducted using PubMed as the medical database source. We used the age limit of 0-23 months, and we considered only articles published between the years 2015 and 2018, in light of increasing interest worldwide in the use of KD and its variants to manage DRE. We included 52 publications: 1 Cochrane study, 22 retrospective studies, 9 prospective studies, 4 randomized controlled trials (RCTs), 12 clinical cases, and 4 clinical reviews. Literature data showed that KD and its variants are safe and useful in patients with the age of 0-23 months with DRE. Classical KD is of first choice in the treatment of GLUT1 deficiency. Earlier introduction of KD in GLUT1 promises a better outcome and a decrease in seizure frequency in these patients.
Collapse
Affiliation(s)
- Raffaele Falsaperla
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Gabriella D'Angelo
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology of Adult and Childhood "G. Barresi", University Hospital "G. Martino", Messina, Italy
| | - Andrea D Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Italy.
| | - Laura Mauceri
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Massimo Barbagallo
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Piero Pavone
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico-Vittorio-Emanuele University Hospital, University of Catania, Catania, Italy
| | - Stefano Catanzaro
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Italy
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology of Adult and Childhood "G. Barresi", University Hospital "G. Martino", Messina, Italy
| | - Giovanni Corsello
- Department of Maternal and Child Health, University of Palermo, Palermo, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Italy
| |
Collapse
|
22
|
Welzel T, Ziesenitz VC, Weber P, Datta AN, van den Anker JN, Gotta V. Drug-drug and drug-food interactions in an infant with early-onset SCN2A epilepsy treated with carbamazepine, phenytoin and a ketogenic diet. Br J Clin Pharmacol 2020; 87:1568-1573. [PMID: 32737897 DOI: 10.1111/bcp.14503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 11/29/2022] Open
Abstract
Sodium channel 2 subunit α (SCN2A) mutations cause difficult-to-treat early-onset epilepsy. Effective treatment includes high-dose phenytoin or carbamazepine ± ketogenic diet (KD). We describe an infant with early-onset SCN2A-epilepsy with subtherapeutic carbamazepine concentration during transition from phenytoin treatment to avoid long-term neurotoxicity. The transition from high-dose phenytoin (20 mg kg-1 d-1 , concentration: ≥20 mg/L) with KD, to carbamazepine (50-75 mg kg-1 d-1 , concentration: 9-12 mg/L) lasted 85 days, which we suspected was due to significant drug-drug and/or drug-food interactions. Model-based analysis of carbamazepine pharmacokinetics quantified significant time- and dose-dependent phenytoin-mediated CYP3A4 induction and carbamazepine concentration-dependent auto-induction (apparent clearance increased up to 2.5/3-fold). Lower carbamazepine concentrations under KD were modelled as decreased relative bioavailability (44%), potentially related to decreased fraction absorbed (unexpected for this lipophilic drug), increased intestinal/hepatic metabolism and/or decreased protein-binding with KD. This suggests importance of carbamazepine-concentration monitoring during KD-introduction/removal and necessity of high carbamazepine doses to achieve therapeutic concentrations, especially in infants treated with high-dose phenytoin.
Collapse
Affiliation(s)
- Tatjana Welzel
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Victoria C Ziesenitz
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Pediatric Cardiology, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Weber
- Division of Pediatric Neurology and Developmental Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandre N Datta
- Division of Pediatric Neurology and Developmental Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes N van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Divison of Clinical Pharmacology, Children's National Hospital, Washington, D. C, USA
| | - Verena Gotta
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
23
|
Worden LT, Abend NS, Bergqvist AGC. Ketogenic diet treatment of children in the intensive care unit: Safety, tolerability, and effectiveness. Seizure 2020; 80:242-248. [PMID: 32674044 DOI: 10.1016/j.seizure.2020.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/27/2020] [Accepted: 07/02/2020] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The ketogenic diet (KD) is initiated emergently in the intensive care unit (ICU) for patients with super refractory status epilepticus (SRSE) and epileptic encephalopathies (EE). However, few data are available regarding safety, effectiveness, and long-term outcomes. METHODS We performed a retrospective cohort study of consecutive patients with KD initiated in the ICU from 2010 to 2018 for SRSE and EE. We characterized time to ketosis, adverse effects, and seizure outcomes. Responders were defined as having ≥50 % reduction in seizure frequency compared to prior to KD initiation. RESULTS We identified 29 patients. KD was initiated for SRSE in 12 patients, EE in 8 patients, and EE with SRSE in 9 patients. KD was initiated after a median of 9 days. Ketosis was achieved 2 days faster in fasted patients (p < 0.0001). All patients had at least 1 KD-related adverse effect, most often hypoglycemia, constipation, or acidosis. There was ≥50 % reduction in seizure frequency compared to prior to KD initiation by 1 week in 17/28 patients, seizure-freedom by 2 weeks in 7/28 patients, and weaned off anesthetics in 11/17 patients. All KD-responders at 1 month had continued response at 6 months. Mortality at 1 year was 24 %. There was no difference in KD response or mortality between KD indication groups. CONCLUSION Emergent KD initiation in the ICU is feasible, safe, and often effective for SRSE and EE. Expected adverse effects were common but treatable. Morbidity and mortality in this group was high. A ≥ 50 % reduction in seizure is achieved in most responders by 1-2 weeks.
Collapse
Affiliation(s)
- Lila T Worden
- Division of Neurology, Children's Hospital of Philadelphia, USA
| | - Nicholas S Abend
- Division of Neurology, Children's Hospital of Philadelphia, USA; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Departments of Anesthesia and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - A G Christina Bergqvist
- Division of Neurology, Children's Hospital of Philadelphia, USA; Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
24
|
Lin KL, Lin JJ, Wang HS. Application of ketogenic diets for pediatric neurocritical care. Biomed J 2020; 43:218-225. [PMID: 32641260 PMCID: PMC7424092 DOI: 10.1016/j.bj.2020.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/13/2020] [Accepted: 02/18/2020] [Indexed: 02/07/2023] Open
Abstract
In this review, we summarize the general mechanisms of the ketogenic diet, and the application of a ketogenic diet in pediatric intensive care units for the neurological disorders of children and young infants. A ketogenic diet is a high-fat, low-carbohydrate, adequate-protein diet. It can alter the primary cerebral energy metabolism from glucose to ketone bodies, which involves multiple mechanisms of antiepileptic action, antiepileptogenic properties, neuro-protection, antioxidant and anti-inflammatory effects, and it is potentially a disease-modifying intervention. Although a ketogenic diet is typically used for the chronic stage of pharmacoresistant of epilepsy, recent studies have shown its efficacy in patients with the acute stage of refractory/super-refractory status epilepticus. The application of a ketogenic diet in pediatric intensive care units is a challenge because of the critical status of the patients, who are often in a coma or have a nothing by mouth order. Moreover, a ketogenic diet needs to be started early and sometimes through parenteral administration in patients with critical conditions such as refractory status epilepticus or febrile infection-related epilepsy syndrome. Animal models and some case reports have shown that the neuro-protective effects of a ketogenic diet can be extended to other emergent neurological diseases, such as traumatic brain injury and ischemic stroke.
Collapse
Affiliation(s)
- Kuang-Lin Lin
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jann-Jim Lin
- Division of Pediatric Critical Care and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Pediatric Neurology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| |
Collapse
|
25
|
Wells J, Swaminathan A, Paseka J, Hanson C. Efficacy and Safety of a Ketogenic Diet in Children and Adolescents with Refractory Epilepsy-A Review. Nutrients 2020; 12:nu12061809. [PMID: 32560503 PMCID: PMC7353240 DOI: 10.3390/nu12061809] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023] Open
Abstract
Epilepsy in the pediatric and adolescent populations is a devastating condition where individuals are prone to recurrent epileptic seizures or changes in behavior or movement that is the direct result of a primary change in the electrical activity in the brain. Although many children with epilepsy will have seizures controlled with antiseizure medications (ASMs), a large percentage of patients are refractory to drug therapy and may consider initiating a ketogenic diet. The term Ketogenic Diet or Ketogenic Diet Therapy (KDT) refers to any diet therapy in which dietary composition results in a ketogenic state of human metabolism. Currently, there are 4 major Ketogenic diet therapies—the classic ketogenic diet (cKD), the modified Atkins diet (MAD), the medium chain triglyceride ketogenic diet (MCTKD) and the low glycemic index treatment (LGIT). The compositions of the 4 main KDTs differ and limited evidence to distinguish the efficacy among different diets currently exists. Although it is apparent that more randomized controlled trials (RCTs) and long-term studies are needed to evaluate efficacy, side effects and individual response to the diet, it is imperative to study and understand the metabolic profiles of patients with epilepsy in order to isolate which dietary restrictions are necessary to maximize clinical benefit.
Collapse
Affiliation(s)
- Jana Wells
- College of Allied Health Professions, University of Nebraska Medical Center, 984045 Nebraska Medical Center, Omaha, NE 68198-4045, USA;
- Correspondence:
| | - Arun Swaminathan
- Department of Neurological Sciences, University of Nebraska Medical Center, 988440 Nebraska Medical Center, Omaha, NE 68198-8440, USA;
| | - Jenna Paseka
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine 4350 Dewey Ave, Omaha, NE 68105, USA;
| | - Corrine Hanson
- College of Allied Health Professions, University of Nebraska Medical Center, 984045 Nebraska Medical Center, Omaha, NE 68198-4045, USA;
| |
Collapse
|
26
|
Armeno M, Caraballo R. The evolving indications of KD therapy. Epilepsy Res 2020; 163:106340. [PMID: 32330835 DOI: 10.1016/j.eplepsyres.2020.106340] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/14/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
Despite the rapid increase of clinical and basic-science knowledge on ketogenic diet therapies over the past years, it has not always been easy to determine the adequate indications of this treatment. Over the nearly 100 years of use, from being a last resource in the therapeutic algorithm, the diet has become one of the four main treatments for patients with difficult-to-control epilepsy together with antiepileptic drugs, surgery, and vagus nerve stimulation. The use of the diet has also changed. The current paper will briefly discuss the history of the diet together with a review of the literature regarding its most important indications and how they have evolved. The concept of the importance of defining the type of seizure, type of syndrome, and etiology in the selection of patients and timing of diet initiation has been gaining importance. This paper explores how the indications of the diet changed together with the shifting focus of epilepsy teams towards its use in different types of epilepsy and epilepsy syndromes and according to etiologies and as an alternative option in refractory and superrefractory status epilepticus.
Collapse
Affiliation(s)
- Marisa Armeno
- Department of Nutrition, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina.
| | - Roberto Caraballo
- Department of Neurology, Hospital de Pediatria Juan P Garrahan, Combate de los Pozos 1881, C1245 CABA, Buenos Aires, Argentina
| |
Collapse
|
27
|
Vinciguerra F, Graziano M, Hagnäs M, Frittitta L, Tumminia A. Influence of the Mediterranean and Ketogenic Diets on Cognitive Status and Decline: A Narrative Review. Nutrients 2020; 12:E1019. [PMID: 32276339 PMCID: PMC7231139 DOI: 10.3390/nu12041019] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/29/2020] [Accepted: 04/06/2020] [Indexed: 12/15/2022] Open
Abstract
Alzheimer's disease (AD) is the most common form of senile dementia, accounting for up to 70% of dementia cases. AD is a slowly progressive disease, which causes global mental deterioration by affecting various cognitive areas. A growing body of evidence has demonstrated that lifestyle habits and nutritional patterns could delay the natural course of the neurodegeneration process. There is no single dietary pattern unequivocally proven to prevent AD. Nevertheless, epidemiological data suggest that by adopting several dietary habits, especially if accompanied with a healthy lifestyle, the negative consequences of AD could potentially be delayed. Alongside with others, two specific eating patterns have been well investigated concerning their potential beneficial effect on cognitive status: the Mediterranean diet (MedDi) and the Ketogenic Diet (KD). Despite the different underlying mechanisms, both of them have demonstrated a fairly profitable role in reducing or delaying cognitive impairment. The aim of the present narrative review is to overview the existing research on the efficacy of MedDi and KD against AD-related cognitive decline, focusing on the proposed protective mechanisms of action. Although the current knowledge on this complex topic does not allow us, at this point, to make exhaustive conclusions, this information could be of help in order to better characterize the possible role of MedDi and KD as nonpharmacological therapies in the treatment of AD and, more generically, of neurodegenerative disorders.
Collapse
Affiliation(s)
- Federica Vinciguerra
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi Medical Center, Via Palermo 636, 95122 Catania, Italy; (F.V.); (M.G.); (M.H.); (L.F.)
| | - Marco Graziano
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi Medical Center, Via Palermo 636, 95122 Catania, Italy; (F.V.); (M.G.); (M.H.); (L.F.)
| | - Maria Hagnäs
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi Medical Center, Via Palermo 636, 95122 Catania, Italy; (F.V.); (M.G.); (M.H.); (L.F.)
- Center for Life Course Health Research, University of Oulu, Aapistie 5/PO Box 5000, 90014 Oulu, Finland
- Rovaniemi Health Center, Koskikatu 25, 96200 Rovaniemi, Finland
| | - Lucia Frittitta
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi Medical Center, Via Palermo 636, 95122 Catania, Italy; (F.V.); (M.G.); (M.H.); (L.F.)
- Diabetes, Obesity and Dietetic Center, Garibaldi Medical Center, Via Palermo 636, 95122 Catania, Italy
| | - Andrea Tumminia
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Garibaldi Medical Center, Via Palermo 636, 95122 Catania, Italy; (F.V.); (M.G.); (M.H.); (L.F.)
| |
Collapse
|
28
|
Enkhtuy B, Kwon HE, Kim HD. Advances in Ketogenic Diet Therapies in Pediatric Epilepsy. ANNALS OF CHILD NEUROLOGY 2019. [DOI: 10.26815/acn.2019.00192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
|
29
|
van Berkel AA, IJff DM, Verkuyl JM. Cognitive benefits of the ketogenic diet in patients with epilepsy: A systematic overview. Epilepsy Behav 2018; 87:69-77. [PMID: 30173019 DOI: 10.1016/j.yebeh.2018.06.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/01/2018] [Accepted: 06/01/2018] [Indexed: 01/28/2023]
Abstract
The ketogenic diet (KD) has been found to be effective in reducing seizures in patients with treatment-refractory epilepsy. Less attention has been paid to additional cognitive benefits of KD. The aim of the present paper was to provide a comprehensive overview of the studies reporting effects on cognition after KD treatment in adults and children with epilepsy. To address this aim, the clinical literature on cognitive effects of KD in patients with epilepsy was reviewed using a systematic approach. We conclude that using subjective assessments of the patient's experience, cognitive improvements are frequently reported during KD treatment in the domains of alertness, attention, and global cognition. Studies that used objective neuropsychological tests confirmed benefits on alertness but found no improvement in global cognition. There are indications that these improvements are caused by both seizure reduction and direct effects of KD on cognition. The improvements appear to be unrelated to medication reduction, age when KD is started, type of KD, and sleep improvement. The findings in the present overview contribute to a better understanding of the beneficial effects of KD in patients with epilepsy.
Collapse
Affiliation(s)
- Annemiek A van Berkel
- Department of Functional Genomics, Center for Neurogenomics and Cognitive Research, VU University Amsterdam and VU Medical Center, 1081 HV Amsterdam, The Netherlands
| | - Dominique M IJff
- Epilepsy Center Kempenhaeghe, Sterkselseweg 65, 5591 VE Heeze, The Netherlands
| | - Jan Martin Verkuyl
- Danone Nutricia Research, Uppsalalaan 12, 3584 CT Utrecht, The Netherlands.
| |
Collapse
|
30
|
Kossoff EH, Zupec-Kania BA, Auvin S, Ballaban-Gil KR, Christina Bergqvist AG, Blackford R, Buchhalter JR, Caraballo RH, Cross JH, Dahlin MG, Donner EJ, Guzel O, Jehle RS, Klepper J, Kang HC, Lambrechts DA, Liu YMC, Nathan JK, Nordli DR, Pfeifer HH, Rho JM, Scheffer IE, Sharma S, Stafstrom CE, Thiele EA, Turner Z, Vaccarezza MM, van der Louw EJTM, Veggiotti P, Wheless JW, Wirrell EC. Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open 2018; 3:175-192. [PMID: 29881797 PMCID: PMC5983110 DOI: 10.1002/epi4.12225] [Citation(s) in RCA: 358] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/14/2022] Open
Abstract
Ketogenic dietary therapies (KDTs) are established, effective nonpharmacologic treatments for intractable childhood epilepsy. For many years KDTs were implemented differently throughout the world due to lack of consistent protocols. In 2009, an expert consensus guideline for the management of children on KDT was published, focusing on topics of patient selection, pre‐KDT counseling and evaluation, diet choice and attributes, implementation, supplementation, follow‐up, side events, and KDT discontinuation. It has been helpful in outlining a state‐of‐the‐art protocol, standardizing KDT for multicenter clinical trials, and identifying areas of controversy and uncertainty for future research. Now one decade later, the organizers and authors of this guideline present a revised version with additional authors, in order to include recent research, especially regarding other dietary treatments, clarifying indications for use, side effects during initiation and ongoing use, value of supplements, and methods of KDT discontinuation. In addition, authors completed a survey of their institution's practices, which was compared to responses from the original consensus survey, to show trends in management over the last 10 years.
Collapse
Affiliation(s)
- Eric H Kossoff
- Departments of Neurology and Pediatrics Johns Hopkins Outpatient Center Baltimore Maryland U.S.A
| | | | - Stéphane Auvin
- Department of Pediatric Neurology CHU Hôpital Robert Debré Paris France
| | - Karen R Ballaban-Gil
- Department of Neurology and Pediatrics Montefiore Medical Center/Albert Einstein College of Medicine Bronx New York U.S.A
| | - A G Christina Bergqvist
- Department of Neurology The Childrens Hospital of Philadelphia Philadelphia Pennsylvania U.S.A
| | - Robyn Blackford
- Department of Nutrition Lurie Children's Hospital Chicago Illinois U.S.A
| | | | - Roberto H Caraballo
- Department of Neurology Hospital J P Garrahan, Capital Federal Buenos Aires Argentina
| | - J Helen Cross
- Department of Clinical & Experimental Epilepsy Great Ormond Street Hospital University College London London United Kingdom
| | - Maria G Dahlin
- Department of Clinical Neuroscience, Women's and Children's Health Karolinska Institute Stockholm Sweden
| | - Elizabeth J Donner
- Division of Neurology The Hospital for Sick Children Toronto Ontario Canada
| | - Orkide Guzel
- Department of Pediatric Neurology Izmir Dr. Behcet Uz Children's Hospital Izmir Turkey
| | - Rana S Jehle
- Department of Neurology Montefiore Medical Center Bronx New York U.S.A
| | - Joerg Klepper
- Department of Pediatrics and Neuropediatrics Children's Hospital Aschaffenburg Aschaffenburg Germany
| | - Hoon-Chul Kang
- Department of Pediatrics Pediatric Epilepsy Clinic Severance Children's Hospital Seoul Korea
| | | | - Y M Christiana Liu
- Department of Neurology The Hospital for Sick Children Toronto Ontario Canada
| | - Janak K Nathan
- Department of Child Neurology Shushrusha Hospital Mumbai India
| | - Douglas R Nordli
- Department of Neurology Children's Hospital of Los Angeles Los Angeles California U.S.A
| | - Heidi H Pfeifer
- Department of Neurology Massachusetts General Hospital Boston Massachusetts U.S.A
| | - Jong M Rho
- Department of Paediatrics Alberta Children's Hospital Calgary Alberta Canada
| | - Ingrid E Scheffer
- Epilepsy Research Centre The University of Melbourne Austin Health Heidelberg Victoria Australia
| | - Suvasini Sharma
- Department of Pediatrics Lady Hardinge Medical College New Delhi India
| | - Carl E Stafstrom
- Departments of Pediatrics and Neurology Johns Hopkins Hospital Baltimore Maryland U.S.A
| | - Elizabeth A Thiele
- Department of Neurology Massachusetts General Hospital Boston Massachusetts U.S.A
| | - Zahava Turner
- Department of Pediatrics The Johns Hopkins University Baltimore Maryland U.S.A
| | - Maria M Vaccarezza
- Department of Neurology Hospital Italiano de Buenos Aires Buenos Aires Argentina
| | - Elles J T M van der Louw
- Department of Dietetics Sophia Children's Hospital Erasmus Medical Centre Rotterdam The Netherlands
| | - Pierangelo Veggiotti
- Infantile Neuropsychiatry Neurological Institute Foundation Casimiro Mondino Pavia Italy
| | - James W Wheless
- Department of Pediatric Neurology University of Tennessee Memphis Tennessee U.S.A
| | - Elaine C Wirrell
- Department of Neurology, Child and Adolescent Neurology Mayo Clinic Rochester Minnesota U.S.A
| | | | | | | |
Collapse
|
31
|
Ketogenic Diet Therapy in Infants: Efficacy and Tolerability. Pediatr Neurol 2018; 82:13-18. [PMID: 29610033 DOI: 10.1016/j.pediatrneurol.2017.10.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/25/2017] [Accepted: 10/28/2017] [Indexed: 01/01/2023]
Abstract
PURPOSE This study evaluated tolerability and efficacy of the ketogenic diet in infants less than 12 months of age. METHODS Infants less than 12 months of age, commencing the ketogenic diet between September 2007 and July 2016 were identified. Records were reviewed for epilepsy details, diet initiation details, efficacy and tolerability. RESULTS Twenty-seven infants commenced the ketogenic diet (56% male, median age seven months). Median age at seizure onset was 1.9 months and 92% had daily seizures. An epilepsy syndrome was noted in 19 (West-11, epilepsy in infancy with migrating focal seizures-5, early myoclonic encephalopathy-1, Ohtahara-1, Dravet-1). Infants were on a median of two and had failed a median of one medications for lack of efficacy. All initiated a traditional ketogenic diet at full calories without fasting, and all but one started the diet in hospital. Significant hypoglycemia during initiation was seen in two - both had emesis +/- decreased oral intake. Eighty-eight percent developed urinary ketosis by 48 hours and all were successfully discharged on the diet (median ratio 3:1). Of those continuing dietary therapy, responder rates at one, six and 12 months were 68%, 82% and 91%, with 20%, 29% and 27% achieving seizure freedom. By 12 months, two stopped the diet for serious adverse effects, five discontinued for lack of efficacy, six were lost to follow-up and two died of unrelated causes. CONCLUSIONS The ketogenic diet is an effective and well-tolerated treatment for infants with intractable epilepsy. In-hospital initiation is strongly recommended due to risk of hypoglycemia with emesis or reduced intake.
Collapse
|