Care of the Patient on the Ketogenic Diet (15.

3)

PURPOSE: To describe the multi disciplinary care of patients admitted for initiation of
the Ketogenic Diet.

LEVEL: Interdependent

SUPPORTIVE DATA:
A. Objective
1. Safely initiate the Ketogenic Diet.
B. Indications
1. Children ages > one year of age with intractable epilepsy uncontrolled
sufficiently by medication.
C. Contraindications
1. Children/Families unable to maintain the diet.
2. Children who are not medically/metabolically stable.
D. Information
1. The Ketogenic Diet reportedly will provide reasonable control of
seizures in approxiamately 38% of children. Of these however many remain on
medications as weel as the diet
2. The diet is most often prescribed for young children ages three to eight
years of age whose seizures are otherwise uncontrolled. Some infants
over twelve months of age have been treated with the diet however any
child under three years of age much be monitored very carefully for
growth. Older children may be tried on the diet provided they and their
families are highly motivated and willing to resist food temptations
outside the home.
3. Families are asked to make a minimal commitment to the Ketogenic Diet
for a two month period.
4. Hospitalization of about two to five days is required to monitor the child
during initiation of the diet. This also serves as an intense training period
for the family with supervision of a dietitian trained in the intricacies of
the diet.
5. The Ketogenic Diet is rigidly supervised by a MD/NP/RD team. It is high
in fat, adequate in protein and low in carbohydrate. All three features
must be present for a positive response to the diet. Calorie intake is based
on typical intake specific to each child, given he is at appropriate weight
for height and age. The diet generally provides maintenance fluid.
Calories are provided in a ratio of 3.0:1 to 4.0:1 fat to protein plus
carbohydrate. Protein is provided at grams/kg/day appropriate for age.
The diet is severely carbohydrate restricted. No unauthorized
carbohydrate is allowed (including medications and IVF). A multivitamin
and other necessary supplements is required each day.
ASSESSMENT/INTERVENTION/EVALUATION:
A. Preadmission steps?.
B. Draw baseline labs if not previously completed during outpatient visit prior to
admission. The following labs should be performed: CMP, Ica, Mg, Phos., LFTs,
Carnitine, CBC with diff, TG, Chol., Prealbumin, Vitamin D-25, hydroxyl, Zinc.
C. Employ seizure precautions (see protocol - Care Of The Patient With Seizures).
D. Use seizure flow sheet (see guideline: Seizure Flow Sheets 15.4).
E. Notify neurology NP if a seizure is prolonged or unusually severe.
F. Height and weight will be performed by nursing or the dietitian. Triceps
skinfold and mid-arm muscle circumference will be performed by dietitian.
G. Assess for signs and symptoms of hypoglycemia immediately upon admission
and every four hours throughout hospitalization.
1. Contact the neurology NP/Attending Neurologist with results. Results are
reviewed with the attending neurologist.
2. Treat symptomatic hypoglycemia only (seizures, lethargy, coma).
3. If serum glucose drops to 40mg%, obtain a repeat glucose in two hours.
4. If glucose drops below 30mg%, watch patient carefully for symptoms of
hypoglycemia, give 1 ounce of apple juice and repeat the serum glucose in
one hour..
5. If further treatment is required, discuss with the NP/attending neurologist.

H. Assess urine ketone level every four hours, or more frequently as needed.
Knowledge of current ketone levels allows for appropriate adjustment of the diet.
I. Patient Meals
1. Day one: Patient receives three or more “meals” in the form of eggnog
shakes or tube feedings. The first “meal” is provided shortly after admit.
As the patient is not fasting, this meal does not require delay until initial
labs are drawn. The first meal is 1/3 strength ratio and ¼ total calories.
The second meal is 2/3 strength ratio and ¼ total calories. The third meal
is 2/3 strength ratio and ¼ total calories. Eggnog shakes or formula will
be available in the floor refrigerator labeled by strength. The shakes can be
mixed with diet soda, water or liquid saccharin (provided by the kitchen)
as desired. The patient should be given water or diet soda every three to
four hours within the fluid goal set by the dietitian (refer to initial nutrition
assessment).
2. Day two: Patient receives four “meals”. The first is a full strength eggnog
shake, followed by three full strength meals (food). Each eating
opportunity provides ¼ total calories. The patient should be given water
or diet soda every three to four hours within the fluid goal set by the
dietitian.
3. Day three: Patient continues to receive full strength meals. The patient
should be given water or diet soda every three to four hours within the
fluid goal set by the dietitian. The patient should be given water or diet
soda every three to four hours within the fluid goal set by the dietitian.
J. Weigh daily. Expect immediate weight loss upon initiation of the diet.
DOCUMENTATION:
A. Nursing
1. Document Standard patient charting and every four 4 hour neuro-checks
on nursing flow sheet.
2. Document ketones and blood glucose checks on Ketogenic Diet Flow
sheet (source?). IT IS SOMEWHERE ON NTU BUT WOULD BE
WELL TO BE AN APPENDIX HERE
3. Document family/ patient teaching and response to teaching in the
progress note or designated teaching record.
4. Record seizure activity on the seizure flow sheet (source?). same as
above
B. Dietitian
1. Dietitian to complete a nutrition assessment on the day of admission and
throughout hospitalization as needed.
2. Nutrition assessment(s) is placed in the medical record. It will contain the
following information;
a. Current anthropometrics
b. Estimated energy/protein/fluid needs
c. Ketogenic Diet ratio
d. Meal distribution
e. Recommended supplements and change of medication form as needed
f. Education provided

PATIENT/FAMILY INSTRUCTIONS:
A. Dietitian teaches guardian(s):
1. The Ketogenic Diet and meal planning for use in the hospital and at home.
2. How to read labels to identify appropriate foods for the Ketogenic Diet.
3. An understanding of all aspects of the Ketogenic Diet.
4. How to weigh food on gram scale in order to appropriately conform to
menus.
B. Dietitian provides/ensures that patient/family has the following equipment;
1. Gram scale.
2. Three month prescription(s) for appropriate multivitamin supplement(s).
Refer to nutrition assessment for specific recommendations.
3. Three month supply of ketone strips.
4. A box meal(s) for those children who will be traveling long distances
home. The dietitian will organize sack lunches with the kitchen. These
sack lunches will be placed in a cooler supplied by the patient’s family. If
the family forgets the cooler, call the dietitian or patient representative.
C. Nursing teaches guardian(s):
1. How to test urine with ketone strips.
2. Signs and symptoms of hypoglycemia and appropriate interventions.
3. Anticonvulsant medication education.
DISCHARGE PLANNING:
A. After receiving and tolerating regular diet plan meals, education is complete, and
patient is medically stable, he is ready to be discharged.
B. Discharge and follow-up by Neurology - House staff and Nurse Practitioner
1. Write prescriptions as requested by the dietitian.
2. Write prescriptions for anticonvulsant as necessary.
3. Arrange telephone follow-up with NURSE PRACTITIONER 2 days after
discharge.
4. Arrange clinic follow-up with the nurse practitioner and dietitian one
month after discharge.
5. The patient and family will follow-up with the physician one, three, six,
and twelve months after discharge. After these dates, it will be on a PRN
basis.
6. The following labs will be performed at three and six months; BMP, Ica,
Mg, Phos., LFTs, Carnitine, CBC with diff, TG, Chol., Prealbumin,
Vitamin D-25, hydroxyl, Zinc.
7. Labs every year are as above.
8. If patient has a problem with lethargy, carnitine and/or ammonia level(s)
will be performed and assessed.
C. Discharge and follow-up by dietitian
1. Explain protocol for follow-up (parents to call dietitian weekly with
progress x two months).
2. Meet with the family at one month, three month, six month and other
follow-up appointments with neurology.
3. Calories and ratio changes are made intermittently as needed to provide
appropriate nutrition care, promote desired growth, control seizure
activity, etc.
SAFETY:
A. Employ safety precautions to be taken with any patient admitted with the
diagnosis of seizures. See Protocol and Procedure: Care of the Patient with
Seizures (15.2).
B. Employ safety precautions related to the occurrence of hypoglycemia as outlined
under Complications/Emergency Measures.
C. All idiosyncratic reactions must be discussed with the neurology team in order to
provide intervention that is appropriate but does not affect the status of the diet.

COMPLICATIONS/EMERGENCY MEASURES:
A. Signs or symptoms of hypoglycemia (seizure, lethargy or coma)
1. Call the attending neurology NP/neurologist immediately.
B. Prolonged seizure, or one that is not typical of the documented pattern
1. Call the attending neurology NP/neurologist immediately. If unavailable,
call the neurologist on call.
2. See Protocol and Procedure: Care of the Patient with Seizures (15.2).
C. Loss of ketosis
1. Call the Ketogenic Diet dietitian, attending neurology NP/neurologist
or neurologist on call.
D. Questions regarding the eggnog shakes or meal plans
1. Call/page the Ketogenic Diet dietitian.

REFERENCES:
Freeman, J.M., Kelly, M.T., Freeman, J.B. (1996) THE EPILEPSY DIET
TREATMENT; An Introduction To The Ketogenic Diet (2nd ed). New York: Demo
Publications.