Ketogenic Diet Through an IV? A New Expert Guideline is Published

One of the fastest growing uses of the ketogenic diet is for the emergency treatment of status epilepticus, which we first profiled in Keto News exactly 10 years ago. The diet is provided in this situation as a formula through a feeding tube for a child or adult with epilepsy in an intensive care unit (ICU) setting.

But what can be done when there is no ability for adequate nutrition because the stomach and intestines aren’t working well?

In these situations, we are often asked about the possibility of creating a high fat, low carbohydrate intravenous (IV) solution to mimic the oral ketogenic diet, usually temporarily. I highlighted this four years ago when a case report from Taiwan was published, adding to the early literature on “Keto-TPN” (total parenteral nutrition).

Keto-TPN in 2019

Fast-forward to 2019, and we are seeing more centers than ever using “Keto-TPN” in intensive care units. As a result of all this interest, 14 ketogenic diet experts came together for a meeting, examined the published articles (8 publications with 34 cases at the time) and created a survey that they sent to an additional 150 ketogenic diet centers.

They published an expert consensus guideline focused on the use of ketogenic parenteral nutrition (IV formulations), and it was published online this July in the journal Developmental Medicine and Child Neurology. I was kindly asked by the authors to review their document for comments before they submitted it for publication, and also later asked by the journal to write an editorial about it.

What were they key points in the consensus guideline?

• Ketogenic TPN should only replace oral ketogenic diets temporarily. If an oral possibility is available (e.g., a nasogastric tube and working gut), use it.
• Even though most patients are on high ketogenic ratios (e.g., 4:1 – ratio of grams of fat to carbohydrate and protein combined), in some cases of Keto-TPN, a lower ratio (e.g., 1:1 or 2:1) is the only ratio possible.
• Prioritize protein over carbohydrate.
• Make sure the patient gets plenty of fluid and calories.
• The general goal of fat should be 3-4 grams per kilogram body weight per day.
• Any child or adult receiving Keto-TPN should be in an ICU and cared for by an experienced ketogenic diet team.

The Future

I think we’ll be seeing more patients in ICUs who are started on the ketogenic diet by IV. Just last month, another paper was published by Dr. Armeno and her team from Argentina about 3 additional children with migrating focal seizures who did well with 1.5:1 ketogenic TPN. More studies will undoubtedly follow as this unique way to provide ketogenic dietary therapy becomes widely used.

References

Armeno M, Verini A, Araujo MB, Reyes G, Caraballo RH. Ketogenic parenteral nutrition in three paediatric patients with epilepsy with migrating focal seizures. Epileptic Disord. 2019 Oct 16. doi: 10.1684/epd.2019.1095. [Epub ahead of print]

van der Louw E, Aldaz V, Harvey J, Roan M, van den Hurk D, Cross JH, Auvin S; Review Group. ;Optimal clinical management of children receiving ketogenic parenteral nutrition: a clinical practice guide. Dev Med Child Neurol. 2019 Jul 16. doi: 10.1111/dmcn.14306. [Epub ahead of print]

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. J Parenter Enteral Nutr 1990 Sep-Oct;14(5):543-5.

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.