Escolar Documentos
Profissional Documentos
Cultura Documentos
STEFANIE WEINER
MARCH 6, 2015
Introduction
May
2102
GBM
Dedication
Why
the
KD?
Jury is
out
Powerful
CHOP
The Plan
Anatomy &
Physiology
Epilepsy
Medical
Treatment
Medical
Nutrition
Therapy
Presentation Wrap
of Patient
Up
Synapse
physical findings or
changes in behavior that
occur after an episode of
abnormal electrical
activity in the brain
Types of Seizures
Focal seizures
Simple
Complex
Generalized seizures
Tonic-clonic
Clonic
Tonic
Absence
Myoclonic
Atonic
Epilepsy
Definition
History
Etiology
Diagnosis
Medical Treatment
Non-Surgical
Surgical
Definition
2+ unprovoked seizures
Diagnosis of an epilepsy
syndrome
Resolved if:
Past applicable age of
age-dependent
syndrome
Seizure-free for 10
years, with no seizure
medicines for the last 5
years.
Epilepsy
Migraine
Stroke
Alzheimers
2.2
million
POP QUIZ
What did
Alexander the Great, Julius
Caesar, Joan of Arc, Hndel,
Flaubert, van Gogh, and Gershwin
have in common?
History
History
History
Helplessness
Unpredictable
Misconception
Stigma
Etiology
Genetic
Structural/Metabolic
Unknown
Diagnosis
Clinic Visit
Medical History
Seizure History
Neurological Exam
Laboratory Results
Imaging (EEG, MRI, CT)
Diagnosis
Medical Intervention
Seizure Medications
Surgical
Resection
Disconnection
Dietary Treatment
Stimulation
NONSURGICAL
Seizure Medications
Source: Brodie MJ. Antiepileptic drug therapy the story so far. Seizure. 2010; 19(10):650-655.
NONSURGICAL
Seizure Medications
Carbamazepine
Clobazam
Clonazepam
Mechanism: neurotransmitters
Lorazepam
Diazepam Phenobarbital
Divalproex
Sodium
Felbamate
Gabapentin
Lamotrigine
Levitracetam
Phenytoin
% Seizure Control
Pregbalin
Rufinamide
Topiramate
Valproic Acid
Vigabatrin
Zonisamide
1st
2nd
3rd+
Intractable
SURGICAL
TREATMENT
SURGICAL
Resection
SURGICAL
Disconnection
SURGICAL
Hemispherectomy
Last resort
< 13 years old
Intense rehab
Stimulation
NONSURGICAL
Dietary Treatment
Fasting
Source: Murray RK, Granner DK, Mayes PA, Rodwell VW, eds. Harpers Biochemistry. Norwalk, CT: Appleton & Lange, 1996.
NONSURGICAL
Dietary Treatment
Fasting
Ketogenesis Pathway
NONSURGICAL
Dietary Treatment
Fasting
NONSURGICAL
Dietary Treatment
Fasting
Source: Murray RK, Granner DK, Mayes PA, Rodwell VW, eds. Harpers Biochemistry. Norwalk, CT: Appleton & Lange, 1996.
Background
Nutrition Care Process
Assessment
Diagnosis
Intervention
Monitoring & Evaluation
MNT
Background
Dr. Russell Wilder
1921
Effects of fasting without starvation
Ketogenic
50-70% experience >50% seizure
reduction
Popular in 1920s and 1930s
MNT
Background
The Ketogenic
Diet
Ratio by weight
Total grams of fat : Total grams of protein + CHO
55
60%
40%
15
20%
30
90
0%
Typical
Ketogenic
CHO
Protein
Fat
MNT
Background
Charlie Abrahams
Dateline 1994
1971: 2-8 articles per year
Now: 40 articles per year
The Charlie Foundation
MNT
Nutrition Care
Process
Assessment
Medical History
Diet History
MNT
Nutrition Care
Process
Estimations
RDA
Assessment
Age
Kcal/kg
gm protein/kg
0-6 months
108
1.52 (AI)
7-12 months
98
1.2
Age
Males
Females
1-3 years
102
1.05
0-3
60.9W 54
61.0W 51
4-6 years
90
0.95
3-10
22.7W + 495
22.5W + 499
7-10 years
70
0.95
10-18
17.5W + 651
12.2W + 746
11-14 years
55
0.85 (14-18)
18-30
15.3W + 679
14.7W + 496
15-18 years
45
0.85
11-14 years
47
0.85 (14-18)
15-18 years
40
0.85
Activity
Factor
Indication
1.3
1.5
Fluid Requirements
1.7
1-10 kg
100 mL/kg
10-20 kg
1000 mL + 50 mL each kg
over 10 kg
>20 kg
1500 mL + 20 mL each kg
over 20 kg
MNT
Nutrition Care
Process
Diagnosis
MNT
Nutrition Care
Process
Intervention
Inpatient Admission
Advancement of ratio
Education
All-liquid
Parenteral administration
Supplements
MNT
Nutrition Care
Process
Intervention
MNT
Nutrition Care
Process
Intervention
MNT
Nutrition Care
Process
Intervention
GOALS
Seizure freedom/reduction
Age-appropriate weight gain
Linear growth
Increased cognition
MNT
Nutrition Care
Process
Monitoring &
Evaluation
Ketosis/Euglycemia
Other Labs
Food-Drug Interactions
Close Outpatient Follow-Up
Common Challenges
Discontinuation
MNT
Nutrition Care
Process
Monitoring &
Evaluation
Side Effects
Short Term
Long Term
Hypoglycemia
Hyperlipidemia
Acidosis
Heart disease
Dehydration
Kidney stones
Nausea/Emesis
Reflux
Diarrhea/Constipation
Lethargy
Osteoporosis
Anorexia
Vitamin deficiency
Weight loss
Pancreatitis
MNT
Nutrition Care
Process
FAQs
High cholesterol?
How strict?
Life long?
Presentation of Patient
Meet
SP
Admitted to CHOP for Ketogenic Diet
initiation on December 8, 2014
SP
Assessment
Social History
14 3/12 year old male
Sociable
Lives at home with
mother, father, younger
brother
SP
Assessment
Medical History
Followed by CHOP
Neurology since 2005
Myoclonic jerks in AM,
generalized seizure
every 2 weeks
MRI + EEG + cognitive
assessment
Generalized intractable
epilepsy and mental
retardation
SP
Assessment
Diet
History
Needs
3-day diet
record
REE =
1838 kcal
Creamy,
fatty foods
AF: 1.2-1.4
No rice,
pasta
Chocolate
milk
2205-2573
kcals per
day
Protein:
0.85
g/kg/day
Fluid: 18422456 mL/day
SP
Assessment
Medications
Labs
Klonopin
Glucose mg/dL
90
Cholesterol mg/dL
131
Triglyceride mg/dL
114
HDL Cholesterol
32 (L)
mg/dL
LDL-Cholesterol
76
mg/dL
Betahydroxybutyrate <0.30
mmol/L
Depakote
Topamax
Diastat
Tranxene
SP
Assessment
Weight
67.8 kg
75-90th %ile
120% IBW
Borderline obese
SP
Assessment
Height
170.5 cm
75th %ile
102% standard
height for age
SP
Assessment
BMI
23.32 kg/m2
85-90th %ile
SP
Assessment
Head
Circumference
56 cm
50-98th %ile
SP
Diagnosis
PES
Statement
Food- and
nutritionrelated
knowledge
deficit
related to
ketogenic
diet
initiation
as
evidenced
by need for
diet
instruction.
SP
Intervention
Meal plan
2456 kcal
Protein: 44.7 gm
CHO: 16.3 gm
Keto
Kitchen
Cooking
Demos
U Arts
Interns
Classes
Weighing
Food
Exchanges
SP
Monitoring &
Evaluation
Tolerated
advance
No N/V
Music
therapy &
video games
Complaints
of hunger
resolved
Hospital
Course
Progression
of ketosis
SP
Monitoring &
Evaluation
Ref.
Range
Dec 9
21:40
Dec 10
01:30
Glucose
70-106
mg/d
92
105
BHB
0.0-0.3
mmol/L
0.38 (H)
<0.30
Dec 10
09:00
<0.30
Dec 10
12:08
Dec 10
17:50
Dec 10
22:15
Dec 11
02:11
Dec 11
06:10
Dec 11
12:40
Dec 11
17:42
Dec 12
06:42
80
82
86
91
68 (L)
82
94
87
<0.30
1.40 (H)
1.10 (H)
1.00 (H)
1.00 (H)
Follow Up
Jan 22, 2015
No
seizures
since
1/6/15
- 1.3 kg
(2%) in
6 weeks
No
linear
growth
Struggle
to eat at
school
alert and
interactive
Summary
MERYL
Looking Ahead
Keto
Hindmilk? pill?
Asia
Other
applications
Comments
Mobile
app
Separation
from child
Dr.
Christina
Bergqvist
KD
room
service
Acknowledgements
Cagla Fenton, RD, LDN
Sue Groveman, MS, RD, LDN
Donna DiVito, RD, LDN, CNSC
Avi Weiner, DMD
Mollie & Ron Makar
Acknowledgements
References
Wheless JW. History of the ketogenic diet. Epilepsia. 2008; (Suppl. 8):3-5. doi: 10.1111/j.15281167.2008.01821.x
Zupec-Kania B, Neal E, Schultz R. An Update on Diet in Clinical Practice. Journal of Child Neurology.
Aug 2013;28:1015-1026. doi: 10.1177/0883073813487597
Questions?