SEATTLE – An aggressive ketogenic diet is safe and usually successful in terminating status epilepticus in children that has not responded to optimal medical therapy, suggests a study presented at the annual meeting of the American Epilepsy Society.
The diet, in which the ratio of fat to protein and carbohydrate was pushed as high as 5:1 – more aggressive than in many protocols – broke the status epilepticus in 82% of cases, lead investigator Yeou-Mei Christiana Liu, a dietitian at the Hospital for Sick Children in Toronto, reported in a poster session.
And with monitoring of urine ketones and blood glucose levels four times daily and frequent adjustments of the ratio and caloric intake as needed, none of the children experienced adverse effects related to the diet.
“My recommendation would be not to worry. Try to be as aggressive as you can because they only need like a few days with the high diet ratio, and then they will be out of risk and can be extubated,” Ms. Liu advised in an interview. “And they should start the diet as soon as possible … we found that if we can start the ketogenic diet as early as possible, usually the chance for them to be out of the super-refractory status epilepticus condition is much better.”
Ms. Yeou-Mei Christiana Liu
“For safety, we had no trouble,” she further commented. “I know the number of patients is not high, but we used this approach for all these kids and we didn’t see any terrible side effects as long as we taught the ICU [intensive care unit] to follow our protocol and they made sure [the children did not experience excessive] ketoacidosis. We want [the urine ketone level] slightly above 16 mmol/L, but we don’t want to go too high.”
In the study, the investigators retrospectively reviewed the records of 10 children with 11 episodes of super-refractory status epilepticus. Prior to treatment with the ketogenic diet, the episodes had continued or recurred despite 24 hours of high-dose suppressive therapy.
The children ranged in age from 6 months to 13 years and were receiving care in the ICU. Clinicians had already tried at least four or five anticonvulsants, including combination therapy, in most cases.
All children were started on the classic ketogenic diet by nasogastric tube. Diet ratios and calories were initially tailored to patient weight, age, bowel routine, and concomitant treatment (especially any steroid therapy and intubation).
“We tried to start for the infants with a lower ratio, but we did make some diet changes” subsequently, noted Ms. Liu, who disclosed that she had no relevant conflicts of interest. “Next time, if I have a little one, I will start more aggressive, at a higher diet ratio.”
Results showed that in 10 of 11 episodes, ketosis was achieved during the first day of ketogenic diet treatment, she reported.
The diet was successful in terminating status epilepticus in 9 of 11 episodes. “We had a pretty good success rate,” she commented. “When we looked into other facilities’ protocol, with our protocol, we are more aggressive. So maybe that’s one of the reasons contributing to the success.”
The successful cases had earlier initiation of the diet after ICU admission (mean, 12 days vs. 41 days) and had consistently more moderate to high ketosis as seen in the urine ketone range (4 to more than 16 mmol/L vs. 0.5-16 mmol/L).
In the two episodes in which the diet did not terminate the status epilepticus, the children were receiving extra carbohydrate from medications or intravenous fluids. One additionally had fat malabsorption.
After the status epilepticus was broken, the dietary ratio was reduced but the children were kept on and sent home on the diet. “We started with a high diet ratio, and as soon as they were stable as far as seizure control, we started dropping the ratio because this is too high in fat, we worry about side effects. So we start dropping it, but we dropped it really slowly, to prevent a seizure recurrence,” Ms. Liu explained. She said that she had no relevant conflicts of interest.