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These guidelines have been prepared for the use of ward staff (nursing, dietetic, medical) dealing with children already established on the Ketogenic Diet (KD) who are admitted electively or due to illness.
These guidelines have been produced following discussion with consultant colleagues in paediatric epilepsy with KD experience outside this NHS trust and with the Ketogenic Diet team within Royal Hospital for Children, Glasgow. They have also been discussed within KETOPAG, a group of UK paediatricians, dietitians and epilepsy nurses experienced in the use of the KD (Evidence Level V).
These guidelines have been written with aim of helping nursing, dietetic, junior and senior medical staff give appropriate and optimal care to children on the KD as part of their epilepsy treatment.
Inpatients on the ketogenic diet:
Medical and nursing staffs on the wards may have to care for patients on the ketogenic diet in the following circumstances:
Occasionally ketone levels can become too high. This may occur after starting the diet or during illness.
Rapid panting breathing, increased heart rate, facial flushing, irritability, vomiting and unexpected lethargy. Excess ketosis may also mimic non convulsive status as the children are often less responsive.
All children on the ketogenic diet will have a lower serum bicarbonate as an expected consequence of the diet. We would not normally expect children to have a significant metabolic acidosis (low pH).
Patients at Risk:
Increased seizures, clamminess and pale skin, confusion, in severe forms- ‘Kussmaul’ breathing (increased rate and depth of breathing)
Check blood sample/ lab sugar and treat if appropriate as below
Management of symptomatic hypoglycaemia
Treating hypoglycaemia using rapidly absorbed carbohydrate Use one of the following:
If the response is inadequate, more can be administered after 10-15 minutes
Treating hypoglycaemia using Glucogel (formerly known as Hypostop)
Give Glucogel (formerly known as Hypostop)
½ of a 25g tube = 5g carbohydrate
This can be squeezed into the child’s mouth if the child is uncooperative, or not able to take the items suggested above (child must be allowed to have foods orally)
If IV fluids are required
Severe symptomatic hypoglycaemia should be treated as per APLS Guidelines with 2mls/kg of 10% dextrose followed by infusion of 2.5% or 5% dextrose.
The high fat diet regimen of the ketogenic diet (70-90% of calories) forces the body into a dietary induced ketosis. The acidosis that occurs when the diet is first initiated corrects itself within days and is not sustained.
The literature on the ketogenic diet and GA is scarce, with very little consensus on management. The most comprehensive study undertaken so far suggests that carbohydratefree solutions are safe and blood glucose remains stable throughout surgical procedures up to 11.5 hours. The most common effect noted in procedures > 3 hours was a significant decrease in pH, requiring IV bicarbonate. Current advice suggest therefore monitoring blood pH in procedures > 3 hours and administering IV Bicarbonate where necessary. (Valencia et al, 2002; Epilepsia; vol 43, issue 5; p525)
Where possible, avoid sugar and carbohydrate containing drugs and IV solutions. If you are unsure of the carbohydrate content of medications, you should contact the ward pharmacist, or contact medicines information. If in doubt, substances ending in “ose” or “ol” are usually converted to glucose in the body (cellulose is an exception and is suitable).
Dr Andreas Brunklaus
Dr Lesley Nairn
Out of Hours Consultant
Last reviewed: 15 September 2020
Next review: 15 September 2022
Author(s): Janette Buttle & Andreas Brunklaus
Approved By: Paediatric Clinical Effectiveness & Risk Committee