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Subject:
From:
Magenta Raine <[log in to unmask]>
Reply To:
St. John's University Cerebral Palsy List
Date:
Tue, 4 Jul 2000 00:10:45 EDT
Content-Type:
text/plain
Parts/Attachments:
text/plain (230 lines)
from the stanford univ. site.
KETOGENIC DIET PROTOCOL

DISCLAIMERS:

The information provided herein have been checked for accuracy.
However, we cannot be responsible typographical errors. Futhermore,
the information is subject to change.

The information is NOT intended for the general public, but rather for
physicians, dieticians, and other health care providers to assist them in
administering the ketogenic diet. Please contact your health provider if
you wish more information about the ketogenic diet.




GENERAL DESCRIPTION

The ketogenic diet was initially studied in the 1920's as a treatment
option for those with intractable epilepsy. Since then, medications have
replaced the diet, but there is now a resurgence of interest in the
Ketogenic diet. The diet is high in fat, and low in carbohydrate and
protein, which results in ketosis. In addition, fluids are limited, which
helps contribute to the diet's success. This ketotic state exerts an anti-
epileptic effect, though its precise mechanism of action is not completely
understood.

GENERAL RULES FOR THE KETOGENIC DIET


1. Calorie intake should be approximately 75% of the recommended
calorie level for a child's age and ideal weight. Level may be higher for
an especially active child.

2. Ideal weight should be based on recognized standards.

3. Most children are on a 4:1 ketogenic ratio. Children under 15 months
or obese children may be started on a 3:1 or 3.5:1 ratio of FAT:PROTEIN
plus CARBOHYDRATES.

4. Liquid intake should be restricted to less than 1X maintenance
(approximately 75%). As a rule of thumb, a child should not drink more
cc's per day than the number of calories in the diet.

5. Diet must meet protein RDA as calculated by dietitian.

6. Diet must be supplemented daily with calcium, a sugar-free, lactose-
free MVI and fluoride if indicated.

CALCULATING THE DIET

1. AGE AND WEIGHT

AGE____________
WEIGHT_________

2. CALORIES/KG

Use chart for reference in determining the number of calories/kg:

Under 1 yr. 80 Kcal/kg
1-3 yrs.    75 Kcal/kg
4-6 yrs.    68 Kcal/kg
7-10 yrs.   60 Kcal/kg
11 and up   40-50 Kcal/kg or less

3. TOTAL CALORIES

Determine the total number of calories in the diert by multiplying the
weight by the calories/kg required.

WEIGHT_________ X CALORIES/KG________ = ____________ total
calories

4. DIETARY UNIT COMPOSITION

Dietary units are the building blocks of the ketogenic diet. A 4:1 diet has
dietary units made up of 4 grams of fat to each 1 gram of protein plus
carbohydrate. Because fat has 9 calories/gram, a dietary unit at a 4:1
ratio has 36 plus 4 = 40 calories. The caloric value and breakdown of
dietary units vary with the ketogenic ratio.

RATIO FAT CALORIES  TOTAL CARBOHYDRATE,
    CALORIES/DIETARY UNIT
PROTEIN CALORIES
________________________________________________________
____________________

2:1 2g X 9 Kcal/g = 18  1g X 4 Kcal/g = 4   18+4 = 22
3:1 3g X 9 Kcal/g = 27  1g X 4 Kcal/g = 4   27+4 = 31
4:1 4g X 9 Kcal/g = 36  1g X 4 Kcal/g = 4   36+4 = 40
5:1 5g X 9 Kcal/g = 45  1g X 4 Kcal/g = 4   45+4 = 49

5. DIETARY UNIT QUANTITY


Divide the total calories allotted (from #3 above), by the number of
calories in each dietary step (#4 above).

total calories___________ divided by _________ calories in dietary unit
=___________ dietary units/day

6. FAT ALLOWANCE

Multiply the number of dietary units X units of fat in the prescribed
ketogenic ratio to determine grams of fat/day.

____________dietary units X __________ units of fat = _________fat
grams/day

7. PROTEIN + CARBOHYDRATE ALLOWANCE

Dietary Units __________ X units of protein + carbohydrate (usually
1)________ = _____________ combined daily protein + carbohydrate
allowance.

8. PROTEIN ALLOWANCE: calculated by dietician; RDA requirement


9. CARBOHYDRATE ALLOWANCE

Carbohydrates are the diet's filler, and are always determined last.

Total carbohydrate + protein allowance__________ - protein allowance
_______ = ____________ carbohydrate allowance in grams.

10. MEAL ORDER
Divide the daily fat, protein, and carbohydrate allotments into 3 or 4 equal
meals. It is essential that the proper ratio of fat to protein + carbohydrate
be maintained at each meal.

11. LIQUIDS
Calculate at I X maintenance.

12. DIETARY SUPPLEMENTS

Every child should take a daily dose of 600 mg of oral calcium in a
sugar-free form such as Long's oyster shell calcium (500 mg) and a
sugarless MVI with Fe, such as Sugar-free Bugs Bunny Complete with
Iron. Sodium fluoride drops if child's water source does not contain
fluoride are also necessary.

---------------------------------------------------------------------------

IDEAL HOSPITALIZATION SCHEDULE

DAY 0 (AT HOME)

-Low carbohydrates or sweets
-Child fasts after dinner, except for water

DAY 1 (Admission to Hospital)
-Continue fast, child NEEDS fluids to prevent dehydration! -PO liquids at
3/4X maintenance; Water or diet, caffeine-free soda -Family meets with
dietition (order Nutrition consult) -order Social Work consult prn
-Baseline LABWORK: serum antiepileptic medication levels (AED),
lipoprotein profile, Chem 23 (if not done within last week at clinic)
-Baseline EEG (usually done within last few weeks)

-(IF CHILD IS ON PHENOBARBITAL, THIS WILL NEED TO BE
REDUCED, AS LEVELS MAY RISE DURING THE FAST) Other seizue
medications are usually decreased as well -IV start, may heparin lock
-parent to keep seizure diary
-strict Intake/Output (parents to keep diary of intake). Strict I/O EVERY
DAY OF HOSPITALIZATION

NURSING CARE:
-check urine for ketones q void
-check blood for glucose level (glucoscan) q 4-6 hrs, as ordered -weight
(after void, in early am) and vital signs (q 4 hours); head circumference
-teach family how to check urine for ketones and blood for glucose
-NOTE: CHILD CANNOT TAKE ANY MEDICATIONS, TOOTHPASTE,
MOUTHWASH WITH SUGAR OR CARBOHYDRATE IN THEM.

DAY 2
-Child begins to register elevated urine ketones (usually need 4+/large
for best results)
-Dietitian calculates meal plans
-Parents begin learning how to plan and prepare diet -Draw serum AED
levels and lytes
-weight and vital signs
-if child needs IV fluids, use a saline solution, NOT a dextrose IV fluid

NURSING CONTINUES TO MONITOR CHILD'S BLOOD FOR GLUCOSE,
URINE FOR KETONES

DAY 3

-Child, in ketosis, starts food with 1/3 strength meals -parents continue
with diet education
-AED levels and lytes
-weight in am and vital signs q 4 hours

NURSING CONTINUES TO MONITOR CHILD AND TEACH FAMILY HOW
TO TEST URINE, BLOOD

DAY 4

-Child progresses to 2/3 strength meals
-education continues
-AED levels and lytes
-weight and vital signs
CONTINUE MONITORING AND EDUCATION

DAY 5

-Child starts full diet, and if child is stable and parents understand diet,
child is discharged from hospital
-AED levels and lytes
-weight and vital signs


HYPOGLYCEMIA CHECKLIST:

-Often blood sugar falls to 40 without signs, while at other times child
becomes listless or vomits
-If glucose falls to 30 or 40, and child appears well, recheck glucose in 2
hours. If child is stable, no intervention. -If glucose drops below 30mg %,
watch child very closely, give 30 cc of orange juice
-If symptoms of hypoglycemia develop: nausea, weakness, increase in
sweating, dizziness, palor or very lethargic/sleepy, give 15-30 cc orange
juice and a cup of ice chips. Another 15 cc of juice may be given. Too
much juice will prevent ketosis.
-If child has seizures or major changes in LOC, or glucose drops below
25%, obtain order to administer 5% dextrose solution IV

**Please send family home with the digital food scale and 2 bottles of
urine "dip sticks" to test for ketones.

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