Clinic Management Of The Ketogenic Diet On Children With Refractory Epilepsy

Background Nowadays there are drugs,surgery,nerve stimulation,dietotherapy etc for the treatment of children with refractory epilepsy,whereas the complexity of the etiology and the difficulty of the treatment of refractory epilepsy,most patients' prognosis are still poor after remedy and it seriously affects the quality of life of the patients and their families.The ketogenic diet(KD)which used as one therapy for refractory epilepsy,The exact mechanisms of the diets antiepileptic effects remain unclear,after nearly a century's development and test,its effectiveness is continuing to be confirmed,and it is accepted and promoted by more and more people.It is known that the fat accounts for only about 30% in normal diet of children,While it is the main(which accounts for almost 80% of the total intake)fuel material for patients receiving KD.The dietary structure has undergone tremendous change,which may result in some side effects and safety problems,so most medical institutions remain cautious ketogenic treatment in hospital.While most of the children coming to visit are from remote areas,the economic conditions and traffic problems often limit the patients to be treated availably,So it is becoming more and more important to administer this chronic disease in the clinic with long term to medical workers and patients.Objective This paper is mainly to evaluate the safety and efficacy of KD in the treatment of children with refractory epilepsy in the clinic,and to search for child-related factors that can impact its efficacy at 12 months follow-up.Methods 1?Materials:We have done a prospective study of 10 children with refractoryepilepsy treating with KD from June 2013 to December 2014 in the clinic of Liao Ning Epilepsy Treatment Center in the Second Affiliated Hospital of Dalian Medical University,end date of follow-up was December 31 st,2015.2?Research methods:(1)Before diet initiation,all patients had to be carried out a series of rigorous screening on indications,meanwhile the caregiver's own conditions and family economic conditions must be considered,patients and caretakers were educated about suitable food items,the calculation,and the preparation of ketogenic meals by the dieticians;Nutritionists and medical workers together drafted specific guiding management solutions and return visit system of KD for individuals.(2)After diet initiation,we did follow-up through telephone or outpatient clinic in one,three,six,twelve months respectively and evaluated their treatment efficacy(?50% reduction in seizures,we used the Engel grading standard to do the efficacy evaluation)and retention rate(the ratio of adhering to the treatment),and recorded the children's height,weight,adverse reactions and the reasons of stopping treatment,all the patients had been observed for at least three months;Family caregivers recorded the management log of KD every day and we established information network platforms such as Wechat,QQ which participated by the patients,the nutritionists and the medical staff;Then we evaluated the patient characteristics(gender,age at epilepsy onset,age at diet initiation,time elapsed between epilepsy onset and diet initiation,diagnosis of epilepsy type,family history related epilepsy and number of anti-epilepsy drugs(AEDs)used before diet initiation)and success of the KD at 3 months follow-up with respect to their possible influential value for a successful treatment outcome at 12 months.Finally,we recorded the the cost of inventory in outpatient clinic and inpatient management of KD,then made comparison and analysis with the data.Results 1?In our study,out of the 10 children,7 were male and 3 were female.The average age at seizure onset was 7.42 months(range: 0-19 months).The starting age of the KD ranged from 14 months to 18 months,with a mean of 31.9 months.Mean time elapsed between epilepsy onset and initiation of the KD was 23.60 months(range: 7-36month).Children had received an average of 3.3 AEDs prior to treatment with the KD(range: 2-6 AEDs).4 children had family history related epilepsy.Six children had West syndrome,one children had Dravet syndrome,and three children had other unknown electro-clinical syndromes.2?One,three,six,and twelve months after diet initiation,there were 10(100%),10(100%),8(80%)and 7(70%)of children remained on the diet.And 5(50%),6(60%),6(60%)and 5(50%)of children had a ?50% seizure reduction respectively;Among the relatively constant group of five children,two were free of seizures within three months after diet initiation and kept seizure-free during diet treatment at 12 months follow-up.But no children reached a 90%~99% seizure reduction within three,six,twelve months of diet treatment.3?We found that success of KD treatment at three months is related to a successful outcome at 12 months after diet initiation(P<0.05);but no patient-related variables known at diet initiation could impact efficacy at 12 months follow-up(P>0.05).4?Adverse reactions were gastrointestinal discomfort(vomiting,constipation,diarrhea)these symptoms were mild,most could be alleviated after proper symptomatic treatment;One(10%)children hospitalized for pneumonia during the period of treatment,but had no influence on the administration of KD;Out of all cases,there were three cases of abnormal blood lipid,their triglyceride and cholesterol increased slightly and persistently,but did not affect the treatment;After three,tweleve months of the KD,linear growth status declined while weight status were unchanged.But all the patients had no low protein,low blood sugar,electrolyte disturbance,acid poisoning and other life-threatening adverse reactions.Out of three cases(30%)whom stopped KD,two children discontinued the treatment due to ineffective or seizures increased again in six months resulting from weak compliance(food refusal),one suspended food for the KD didn't work well throughout the whole treatment.5?The comparison of cost in inpatient and outpatient KD showed that outpatient spent less than hospitalizations.Outpatient service saved a total of RMB(8591-13786),including the requirement of starting the ketogenic diet in hospital for two weeks,the hospital examination,the hospital treatment,medical,nurse and escort the additional costs of living and the loss of lost wages.As the children are our first-to receive the treatment of KD in our outpatient clinic,the number of cases were limited,and the main aims of this article were to explore the safety and efficacy of the KD by clinic management,so we just did a preliminary budget on the economics of KD,and the specific situation remains to be the a further study with large sample and contrast research.Conclusion 1?This preliminary investigation shows clinic management of KD was probably asafe and effective therapy.2?Children with a successful response at 3 months were more likely to achieve success at 12 months of KD treatment.3?Gender,age at epilepsy onset,age at diet initiation,time elapsed between epilepsy onset and diet initiation,diagnosis of epilepsy type,family history related epilepsy,number of AEDs used before diet initiation may not be the influential factors of the efficacy at 12 months of KD treatment.4 ? Compared with inpatient management,the preliminary budget of KD in outpatient clinic was much better in efficacy-cost.