This month’s Keto News highlights an interesting article published by the team from Chang Gung Children’s Hospital in Taiwan. It is a case report in which a nearly 7-year-old boy with epilepsy controlled previously for several months by levetiracetam unfortunately became worse and developed refractory status epilepticus (seizures that would not stop with abortive medications such as Valium and Dilantin). Forty hours after his admission, he was started on the ketogenic diet, which is not necessarily a new idea for status epilepticus. What was a new idea was to try and give his ketogenic diet as an IV (intravenous) solution directly into his veins instead of by nasogastric tube, as is typically done in this situation. This boy couldn’t tolerate feeding through his stomach, so he was only getting IV nutrition.
The authors were able to create an IV ketogenic diet to make a 4:1 ketogenic ratio, gradually increasing calories over 5 days. The final solution included 20% SMOF™ lipid emulsion, 4% Aminosteril Infant™ solution, and 5% dextrose water. Within 24 hours, the boy had serum ketones present, and after 5 days he was switched over to a ketogenic diet formula based on MCT oil. He did well and stayed on the diet for a total of 3 months.
As a side note, I also think it was clever that the authors of this paper came up with a very creative name for their study group: the “CHEESE” Study Group (CHildren with Encephalitis/Encephalopathy related Status Epilepticus and Epilepsy).
Two other notable recent papers (Strzelcyzk, et al. in 2013 – 1 patient; and Jung et al. in 2012 – 10 patients) had reported this idea of using an IV ketogenic diet before. Probably the first article on this idea though was published by Dr. Rosenthal in 1990 using an IV form of MCT triglycerides in a 5-year-old girl. All of these papers (including the most recent one from Taiwan) share one major similarity: the IV ketogenic diet was only temporary and used for a few days until an actual ketogenic diet formula could be given by nasogastric tube.
This is very exciting as a way to provide the diet for children who have severe seizures in an ICU but are not allowed to eat for safety purposes. This situation is a major barrier to using the ketogenic diet to break refractory status epilepticus (and an exclusion criteria in some clinical trials looking at the diet for status epilepticus in fact). If an IV ketogenic diet can be easily made and given, it might buy the ICU and ketogenic diet team some time while the patient’s stomach recovers enough to tolerate a ketogenic diet formula.
Lin JJ, Lin KL, Chan OW, Hsia SH, Wang HS. Intravenous ketogenic diet therapy for treatment of the acute stage of super-refractory status epilepticus in a pediatric patient. Pediatr Neurol 2015;52:442-445.
Rosenthal E, Weissman B, Kyllonen K. Use of parenteral medium-chain triglyceride emulsion for maintaining seizure control in a 5-year-old girl with intractable diarrhea. JPEN 1990;14:543-545.
Jung da E, Kang HC, Lee JS, Lee EJ, Kim HD. Safety and role of ketogenic parenteral nutrition for intractable childhood epilepsy. Brain Dev 2012;34:620-624.
Strzelczyk A, Reif PS, Bauer S, Belke M, Oertel WH, Knake S, Rosenow F. Intravenous initiation and maintenance of ketogenic diet: proof of concept in super-refractory status epilepticus. Seizure 2013;22:581-583.