Maria Raspolic MS, RD Santa Clara Valley Medical Center Objectives: Review most common nutritional issues in AHC Provide recommendations to minimize above issues Review ketogenic diet as treatment for seizures Poor growth Dehydration Constipation Decreased bone mineral density Inadequate nutrient intakes Decreased muscle tone Oral motor dysfunction Limited growth potential Frequent illness, fatigue, infections 1. Provide food of high nutritional quality Breakfast: oatmeal, eggs, cream of wheat, yogurt, Carnation Instant Breakfast, meat Lunch/Dinner: refried beans/cheese, lentils, tofu, almond/nut butter, avocados, fatty fish, meat, sweet potatoes, fried rice/mex rice Snacks: milk shakes/smoothies, cheese stick 2. Liquid supplements Concentrate infant formula to 24-30 kca/oz Pediasure, Boost Kids Essential, Nutren Jr Ensure, Nutren, Boost Carnation Instant Breakfast 1.5 and 2 cal/cc formulas 3. Supplemental tube feeding Child not able to gain weight adequately Excessive time needed to feed Difficult decision for parents Goal: improved quality of life Dramatic improvement in nutritional status Inadequate fluid intakes Excessive fluid loss Need for thickened liquids Result in constipation, decreased appetite Kidney stones, UTI, thickening of secretions Monitor number of diapers, UA 100 cc/kg of body wt for the first 10 kg 50 cc/kg for the second 10 kg 20 cc/kg for the additional kgs 44 lbs :2.2 = 22 kg 1000 + 500 + 40 = 1540 cc 1540: 30 = 51 oz Provide hi nutritional value liquids: Milk, soy, rice, almond, coconut Smoothies, milkshakes ? juice Multifactorial cause Poor intakes of fluids and solids Low muscle tone/ GI motility Low activity levels Low fiber diet Contributes to poor appetite Abdominal distention/discomfort Irritability Adequate fluid intakes and fiber Hi fiber foods: cereal (5 gr/serving), legumes Sweet potatoes, fruits/vegetables Prune or pear juice If additional help needed: Milk of magnesia Lactulose Miralax Benefiber Limited ambulation Inadequate intakes of Ca, Phos, Vit D Anticonvulsant therapy Limited sun exposure If untreated may lead to osteoporosis, bone deformities and fractures 1-3 years: 500mg 4-8 years 800 mg 9-18 years 1300 mg Calcium Sources in Food Food Source almonds blackstrap molasses broccoli (cooked) Serving Size 3 ounces Amount of Calcium per Serving 210 milligrams (mg) tablespoon 170 mg Food1 sources/ table 1 cup 60 mg 3 ounces 180 mg 3 ounces 325 mg 1 cup 1 cup 265 mg 155 mg 1 ounce 225 mg 1 cup 1 cup 95 mg 300 mg mozzarella cheese 1 ounce 200 mg rhubarb (cooked) 1 cup 345 mg ricotta cheese spinach (cooked) yogurt 1⁄2 cup 1 cup 8 ounces 335 mg 245 mg 425 mg canned salmon (with bones) canned sardines (with bones) collards cottage cheese hard cheese (cheddar, swiss) kale (cooked) milk Calcium Carbonate Viactiv, Tumbs, Caltrate Calcium Citrate Citracal Oyster Shell, Bone Meal Sunshine Vitamin Sunblock use prevents Vit D production Anticonvulsant meds (Phenobarb, Dilantin) Decreased absorption of Calcium Limited food sources: fish liver oil, fatty fish, egg yolk, mushrooms, milk (fortified) Recommend to check blood levels yearly Goal: 30-60 mmol/dl Supplement 1000 IU/day 50 000 IU/ week Vit D3 (cholecalciferol) in the skin by sun expo Vit D2 (ergocalciferol) synthesized by plants 15 min sun exposure prevent Vit D deficiency Borusiak et al, 2012 128 children receiving one AED 24 % hypocalcemia 25% hypophosphatemia 13% low vit D Phenobarb, Depakote, Trileptal, Dilantin Common in children with AHC Complete MVI recommended Chewable tablet preferred Liquid/soft gummy vits less minerals Bugs Bunny, Flinstone’s, Scooby Doo, NanoVites How does it work? Brain needs glucose from food 24 hours supply Breakdown of fat produces ketones ??? Prevention of seizures 2-3 months trial 30% of the children seizure free 30% significant reduction in seizures, reduction in medication or no medication Reminder do not respond or find it to hard to continue Dehydration-check urine daily with keto stick Constipation-MOM, Miralax Kidney Stones- UA, trace amount of blood Nutrient deficiency- complete MVI, ck blood levels ZN, Se, Vit D Decreased growth- adjust protein, kcal Hi Cholesterol- replace butter with olive oil, supplement with carnitine Gradual decrease in CHO over one week 2-3 day hospital admission Fasting only in the AM At lunch time full keto meal Allow fluids to meet hydration need Spec. gravity and ketones check with every void Teach families how to calculate and prepare meals Keto meal planer Complexity of meals controlled by parents Ready to feed Ketogenic formula; Ketocal RCF for tube feeding Reduction of the ratio over couple of months Most parents find diet easier than anticipated Ketogenic diet is the most effective available treatment for intractable epilepsy today Atkins diet