Ketogenic Diet-Induced Severe Ketoacidosis in a Lactating Woman: A Case Report and Review of the Literature

Abstract

The ketogenic diet (KD) is a high-fat, adequate-protein, and low-carbohydrate diet that leads to nutritional ketosis and weight loss. It is known to induce ketosis but is not an established cause of clinically significant ketoacidosis. Lactation ketoacidosis is well established in bovine literature but remains a rare phenomenon in humans. Here we present a life-threatening case of severe ketoacidosis in a nondiabetic lactating mother on a strict ketogenic diet. We review the available case reports of lactation ketoacidosis in humans and the mechanisms thereof. Although ketogenic diet has been shown to be safe in nonpregnant individuals, the safety of this diet in lactating mothers is not known. Health professionals and mothers should be made aware of the potential risk associated with a strict ketogenic diet when combined with lactation. Prompt diagnosis and immediate treatment cannot be overemphasized. To our knowledge, this is the first reported case of life-threatening lactation ketoacidosis associated with ketogenic diet while consuming an adequate number of calories per day.

Lactation Ketoacidosis: A Systematic Review of Case Reports

“…In the end, 17 articles, 16 case reports, and 1 case series reporting on 18 patients with lactation ketoacidosis were included ( Table 2 and Table 3 ) [ 4 , 5 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ]. All of these case reports and case series met the criteria for good quality.…”

“…Intravenous (IV) dextrose was the primary treatment in 89% (16/18) of the patients ( Table 2 ). IV sodium bicarbonate was administered in 44% (8/18) of the patients ( Table 1 ) [ 9 , 11 , 12 , 13 , 14 , 18 , 19 , 20 ]. The patients with severe acidosis, i.e., lower pH, were more likely to be given IV sodium bicarbonate.…”

“…However, there was no significant difference in the time needed for the resolution of the ketoacidosis between both groups. IV insulin was administered to three patients to suppress ketogenesis [ 4 , 16 , 20 ], but it was not associated with early resolution of ketoacidosis. In addition, other treatments included the rehydration, monitoring, and replacement of electrolytes, treating the underlying cause, and resumption of a regular diet.…”

“…In general, the high strength of dextrose (20–50%) should be used to treat hypoglycemia, while 5–10% dextrose should be used for hydration and as a maintenance fluid therapy. Additionally, sodium bicarbonate was used in some cases [ 9 , 11 , 12 , 13 , 18 , 19 , 20 ]. Administration of sodium bicarbonate was not associated with early resolution of ketoacidosis.…”

“…Based on previous studies for the management of acute metabolic acidosis, we suggest considering IV sodium bicarbonate only for the treatment of severe lactation ketoacidosis (i.e., pH < 7.1) [ 48 , 49 , 50 ]. Moreover, insulin was used in a few cases of lactation ketoacidosis [ 4 , 16 , 20 ]. Insulin suppresses ketogenesis and fatty acid breakdown [ 25 ].…”