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Schoeler NE, Ridout D, Neal EG, Becirovic M, Whiteley VJ, Meskell R, Lightfoot K, Mills N, Ives T, Bara V, Cameron E, Thomas P, Wilford E, Fox R, Fabe J, Leong JY, Tan-Smith C. Maintenance of response to ketogenic diet therapy for drug-resistant epilepsy post diet discontinuation: A multi-centre case note review. Seizure 2024; 121:78-84. [PMID: 39121817 DOI: 10.1016/j.seizure.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/01/2024] [Accepted: 08/03/2024] [Indexed: 08/12/2024] Open
Abstract
PURPOSE There is limited research on the proportion of individuals with epilepsy who maintain response to ketogenic diet therapy (KDT) after discontinuing treatment. We aimed to determine the proportion of individuals who did / did not maintain response post KDT and explore factors that may influence the likelihood of maintaining response. METHODS Retrospective data were collected from 97 individuals from 9 KDT centres. Individuals had achieved ≥50 % seizure reduction on KDT for at least 12 months, with seizure frequency data available at 3 months+ post diet. Outcome 1 was: recurrence of seizures or increase in seizure frequency post diet; outcome 2: recurrence of seizures, increase in seizure frequency or an additional anti-seizure treatment started post diet. RESULTS 61/97 (62.9 %) individuals maintained response at latest follow-up (mean 2.5[2.0] years since stopping KDT). Approximately one third maintained response without further anti-seizure treatments. One quarter of individuals had an increase in frequency or recurrence of seizures within 6 months (95 %CI 4, 12) for outcome 1 and within 3 months (3, 6) for outcome 2. Individuals who did not achieve seizure freedom on diet were significantly more likely to have an increase in seizures or to require additional anti-seizure treatments post diet compared to those who were seizure-free on diet (hazard ratio 4.02, 95 %CI (1.46, 11.16) p < 0.01). CONCLUSION Our findings should help guide clinical teams with the information they provide patients and their families regarding likelihood of long-term seizure response to KDT. Realistic costings for KDT services may need to be considered.
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Affiliation(s)
- Natasha E Schoeler
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK; Great Ormond Street Hospital for Children, Great Ormond St, London WC1N 3JH, UK.
| | - Deborah Ridout
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Elizabeth G Neal
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Marisa Becirovic
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | | | - Rachel Meskell
- Leeds Children's Hospital, Clarendon Wing, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - Kathryn Lightfoot
- Leeds Children's Hospital, Clarendon Wing, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - Nicole Mills
- Cambridge University Hospitals, Hills Rd, Cambridge CB2 0QQ, UK
| | - Tammy Ives
- Royal Berkshire Hospital, London Rd, Reading RG1 5AN, UK
| | - Vanessa Bara
- Bristol Royal Hospital for Children, Upper Maudlin St, Bristol BS2 8BJ, UK
| | - Emma Cameron
- Bristol Royal Hospital for Children, Upper Maudlin St, Bristol BS2 8BJ, UK
| | - Phillipa Thomas
- Bristol Royal Hospital for Children, Upper Maudlin St, Bristol BS2 8BJ, UK
| | - Ellen Wilford
- Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - Rachel Fox
- Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
| | - Jennifer Fabe
- McMaster Children's Hospital, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Jia Yi Leong
- Christchurch Hospital, 2 Riccarton Avenue, Christchurch Central City, Christchurch 4710, New Zealand
| | - Charlene Tan-Smith
- Christchurch Hospital, 2 Riccarton Avenue, Christchurch Central City, Christchurch 4710, New Zealand
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Metzger S, Lee J, McDavid L. Literature Review: Support for caregivers of children on the ketogenic diet for epilepsy and other neurologic disorders. Epilepsy Behav 2024; 156:109830. [PMID: 38759426 DOI: 10.1016/j.yebeh.2024.109830] [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: 02/06/2024] [Revised: 04/07/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024]
Abstract
Epilepsy affects millions of people and when medications are insufficient to maintain seizure control, individuals are diagnosed with refractory epilepsy (RE). Medical ketogenic diet therapy (KDT), a diet high in fat and low in carbohydrates and sufficient in protein, is a well-established treatment for RE. However, compliance is one of the main reasons for discontinuation of KDT and, with pediatric RE patients, the ability of informal caregivers, typically family members, to maintain diet adherence is vital for successful KDT treatment. The central role that informal caregivers play for effective KDT implementation is recognized, however, there is a need to elucidate the rationale and theoretical underpinnings of effective KDT caregiver support programs to inform best practices. Therefore, this systematic literature review aims to identify the existing fundamental understandings of KDT caregiver support to help build a foundation of theory-based knowledge to promote evidenced practice. After screening 137 publications, three studies that discussed potential underlying components of effective caregiver support were included in this review. These articles followed a similar approach as they 1) employed qualitative methods delving into caregiver needs, 2) findings highlighted the importance of support from family, friends, fellow caregivers and their child's medical team, and 3) the inclusion of caregiver support findings were a supplement to the main purpose of the manuscript. Research focused on KDT caregivers is in its infancy. There is a clear need for the systematic examination of support for KDT caregivers to build a foundation for effective support programs and to increase the access to quality support programming to foster KDT implementation, desirable patient outcomes, and caregiver well being. In this article we discuss opportunities to apply self-determination theory to the KDT caregiver support research and practice.
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Affiliation(s)
- Sarah Metzger
- SarahMetzgerNutrition, LLC 1418 Wembley Ct NE Atlanta, GA 30329, United States.
| | - Jessica Lee
- Co-Founder of Keto Hope Foundation and Director of Keto Friends support network. 845 Houston Northcutt Blvd #1066, Mt Pleasant, SC 29464, United States
| | - Lindley McDavid
- Senior Evaluation and Research Associate, Evaluation and Learning Research Center, Purdue University, 100 North University Street, West Lafayette, IN, United States
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Carroll JH, Parkin T, Cross JH, Hickson M, Williams E, Aldridge V, Collinson A. Drug-resistant epilepsy and ketogenic diet therapy - a qualitative study of families' experiences. Seizure 2024; 118:137-147. [PMID: 38703599 DOI: 10.1016/j.seizure.2024.04.024] [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: 03/19/2024] [Revised: 04/18/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND A diagnosis of drug-resistant epilepsy is life changing for a family. Ketogenic diet therapy (KDT) can offer hope when other treatments have failed. However, it often requires a significant change in daily routine and dietary habits. This qualitative descriptive study aimed to explore families' experiences of epilepsy and KDT. METHODS Parents of a child aged ≤18 years with epilepsy, currently or recently treated with KDT, were recruited from the UK and internationally via UK Ketogenic Diet (KD) centres, charities, and social media. Semi-structured interviews were audio recorded, transcribed verbatim, anonymised, coded using Nvivo (V12), and inductive thematic analysis undertaken. RESULTS Twenty-one parents participated. Four themes and 12 subthemes emerged: 1. 'Epilepsy is all consuming' explored the impact of epilepsy on the family. 2. 'KD provides a window to new opportunities' explores the motivators for KDT and positive outcomes. 3. 'The reality of KD' explores day to day life and how families adapt to KD. 4. 'Looking to the future' explores the factors that may make KD easier for families. All were glad their child trialled KD, even when less successful. The importance of a support network including family, friends, charity organisations and the KD team was evident across all themes. CONCLUSIONS We conclude with five recommendations to help support families in their management of KDT; Improved access to KDT and transition to adult services, access to quality education and support, enhanced variety of KD foods, regular social education and finally consideration of peer mentoring.
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Affiliation(s)
- Jennifer H Carroll
- School of Health Professions, Faculty of Health, University of Plymouth, Devon, United Kingdom.
| | - Tracey Parkin
- School of Health Professions, Faculty of Health, University of Plymouth, Devon, United Kingdom
| | - J Helen Cross
- Developmental Neurosciences, UCL - NIHR BRC Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Mary Hickson
- School of Health Professions, Faculty of Health, University of Plymouth, Devon, United Kingdom
| | - Emma Williams
- Matthew's Friends, Lingfield, Surrey, United Kingdom
| | - Val Aldridge
- Matthew's Friends, Lingfield, Surrey, United Kingdom
| | - Avril Collinson
- School of Health Professions, Faculty of Health, University of Plymouth, Devon, United Kingdom
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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.
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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
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Orr E, Whitney R, Nandeesha N, Kossoff EH, RamachandranNair R. Ketogenic Diet: Parental Experiences and Expectations. J Child Neurol 2024; 39:45-54. [PMID: 38314711 PMCID: PMC11083737 DOI: 10.1177/08830738241227066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 10/07/2023] [Accepted: 12/31/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND The ketogenic diet may be difficult for some patients and their families to implement and can impact physical, emotional, and social well-being. METHODS Through principles of fundamental qualitative description, we completed an exploratory study on parents' experiences and expectations on the use and efficacy of the ketogenic diet for children with medically refractory epilepsy. RESULTS Seventeen parents (10 mothers and 7 fathers) of 12 children with epilepsy participated. At the time of the interview, parents had experienced an average of 25 months of ketogenic diet treatment for their child (range 2 months to 98 months). Half of the caregivers learned about the ketogenic diet from their neurologist, whereas the remainder had heard about it from another source (ie, the internet). Most caregivers' (n = 13) diet expectations were related to seizure control. However, child development (n = 5) and quality of life (n = 5) were also crucial to some. Physical impacts of the diet were most commonly gastrointestinal for children (n = 9). Social and emotional effects were noted in some older children with typical development. Most caregivers described negative impacts on finances (n = 15), relationships (n = 14), and emotional well-being (ie, stress) (n = 12). Caregivers benefited from the ketogenic diet team's regular communication, close follow-up, and family-centered care. CONCLUSIONS Despite the impacts that the ketogenic diet may have on caregivers' emotional and social well-being, the positive impacts of the diet were felt to outweigh any perceived risks. Effects (both positive and negative) on quality of life and child development (eg, social, emotional, cognitive) are essential for caregivers and require additional investigation.
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Affiliation(s)
- Elizabeth Orr
- Department of Nursing, Faculty of Applied Health Sciences, Brock University, St. Catharines, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Canada
| | | | - Eric H. Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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