Use of the ketogenic diet in the neonatal intensive care unit—Safety and tolerability

Abstract

Drug-resistant epilepsy poses a challenge in neonatal patients, especially those in the neonatal intensive care unit (NICU), who have various secondary comorbidities. We present results of four children with a history of drug-resistant epilepsy for whom a ketogenic diet was initiated and used in the NICU. A nonfasting induction into ketosis over 1-2 weeks was utilized, with gradual increases in the ketogenic ratio every 2-3 days. Data were collected retrospectively from a database, which included medical history, daily progress notes, relevant laboratory data, and imaging and diagnostic information. The ketogenic diet was well tolerated in all cases. The most common side effects observed were constipation, hypoglycemia, and weight loss. Serum β-hydroxybutyrate levels demonstrated improved reliability as a marker of ketosis when compared to urine ketones in this population. Perceived benefits to the infants included improved seizure control, increased alertness, and decreased need for invasive respiratory support. These cases demonstrate that the use of the ketogenic diet for treatment of neonatal encephalopathy and refractory epilepsy can be undertaken safely in the NICU and is well tolerated by carefully screened neonates and infants.

Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group

“…A recent case report illustrates that KDTs are safe and effective for infants as young as 6 weeks. 11 In fact, there is now preliminary evidence that children younger than age 2 years may be an ideal age population in which to start the KD. 12,13 Specific guidelines for prescribing KDTs to infants have been created in Europe.…”

“…In addition, breastfeeding is possible by either calculating the amount of breastmilk into a 3:1 formula or potentially allowing it briefly on demand. 11,14 The KD may also be delivered as a blenderized formula created from pureed foods, although there are no published clinical trials regarding its use at this time. The blenderized formula should be prepared with a high-quality blender to prevent blockage of the feeding tube, with the addition of a liquid fat source, diluted with water, and supplemented with micronutrients.…”

Cognitive benefits of the ketogenic diet in patients with epilepsy: A systematic overview

“…In our search, we also uncovered several studies that examined a specific age range. For instance, three studies investigated KD in infants (zero-two years old) [27,32,33], and 13 studies included children between one and 18 years of age [21, 24, 28, 34-38, 41, 43, 46, 53, 54]. Additionally, our search retrieved four studies investigating cognitive improvements in adult patients with epilepsy [44,47,49,51].…”

Advances in Ketogenic Diet Therapies in Pediatric Epilepsy

“…Most patients are good responders, weaning off infusion and successfully reaching ketosis, but the number of AEDs did not change significantly before and after undertaking a KDT [40,43]. The age of patients has varied across studies, but even 6 to 10-week-old neonates with RE are reported to tolerate KDTs well [42,50]. Intravenous (IV) KDT is recommended for patients with underlying concomitant ileus [41,44,48], and early administration of IV KDT should be considered before switching to an enteral route [44].…”

“…Contrary to a conventional view, under 2 years of age may be the optimum time to initiate a KDT because of the metabolic advantages of infants [50][51][52][53][54][55]. Numerous studies provide evidence for the advantages of using KDTs in infants with RE.…”