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Maintenance of Ketogenic Therapy - Pediatric - Inpatient/Ambulatory

Maintenance of Ketogenic Therapy - Pediatric - Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


1
Maintenance of Ketogenic Therapy –
Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 3
METHODOLOGY .................................................................................................................... 4
INTRODUCTION ..................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................ 6
1. IV Fluids ................................................................................................................................ 6
2. Medications ......................................................................................................................... 7
3. Blood Glucose Monitoring ................................................................................................... 8
4. NPO & Nutrition ................................................................................................................... 9
5. Sick Day Regimen ............................................................................................................... 10
6. Laboratory Monitoring ...................................................................................................... 10
7. Acid/Base Status and Respiratory Considerations ............................................................ 11
UW HEALTH IMPLEMENTATION ........................................................................................... 12
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 14
APPENDIX B. PHARMACEUTICAL INGREDIENTS .................................................................... 15
REFERENCES ........................................................................................................................ 16
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2
Contact for Content:
Name: Hrissanthi (Chris) Ikonomidou, MD – Pediatric Neurology
Phone Number: (608) 265-6470
Email Address: ikonomidou@neurology.wisc.edu
Contact for Changes:
Name: Lindsey Spencer, MS - CCKM
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Guideline Author(s):
Nora McCormick, MS, RD, CD – Clinical Nutrition
Emily Wallace, MS, RD, CD, CNSC – Clinical Nutrition
Coordinating Team Members:
Daniel Sklansky, MD – Pediatric Hospitalist, Associate Pediatric Resident Director
Mary Ehlenbach, MD – Pediatrics
Ryan Coller, MD -- Pediatrics
David Yang, MD – Pathology
Hrissanthi (Chris) Ikonomidou, MD – Pediatric Neurology
David Hsu, MD – Pediatric Neurology
Meghan Furstenberg-Knauff, APNP – Pediatric Neurology
Kamilee Conaway, RN, BSN – Pediatric Neurology
Haylee Lindsey, RN, BSN – Pediatric Neurology
Elizabeth Felton, MD, PhD - Neurology
Nora McCormick, MS, RD – Clinical Nutrition
Emily Wallace, MS, RD, CNSC – Manager, Clinical Nutrition
Susan Stone, PharmD, RPH, BCNSP, CNSC - Pharmacy
Josh Ross, MD – Emergency Medicine
Lori Williams, DNP, RN, RNC-NIC, CCRN, NNP-BC - Nursing
Laura Ahola, MSN, RN, CNML – Nurse Manager, Pediatric Universal Care
Megan Waltz, MS, RD – Director, Clinical Nutrition & Culinary Services
Josh Vanderloo, PharmD- Drug Policy Program
Committee Approvals/Dates:
Nutrition Committee (Last Periodic Review: 03/23/17)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 06/22/2017)
Release Date: June 2017 | Next Review Date: July 2020
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3
Executive Summary
Guideline Overview
This clinical practice guideline is an internal creation based upon current evidence, expert
opinion and external tools for initiation and management of ketogenic therapy (KT). It was
developed to improve safety, consistency of care, and to reflect standards of practice for
patients receiving KT.
Key Revisions (2017 Periodic Review)
No major changes made to clinical practice guideline since being published in 2014.
Key Practice Recommendations
1. Avoid intravenous dextrose and carbohydrate-containing medications.
2. Monitor blood glucose if NPO every 4 hours (if > 1 year of age) or every 2 hours (if < 1 year
of age).
3. Maintain ketogenic therapy at all times during hospitalization, even when NPO.
4. Initiate Sick Day Regimen if KT cannot be maintained due to illness.
5. Interpret labs in a timely fashion to remedy any abnormalities (e.g., acidosis, specific gravity,
etc.).
Companion Documents
1. UW Health Pediatric Hypoglycemia Algorithm
Scope
Disease/Conditions:1,2
ξ Epilepsy
ξ Infantile Spasms
ξ Tuberous Sclerosis
ξ Lennox-Gastaut Syndrome
ξ Doose syndrome
ξ Dravet syndrome
ξ Any seizure disorder
ξ Glucose-1-Transporter Deficiency
ξ Pyruvate Dehydrogenase Syndrome
ξ Select mitochondrial diseases
ξ Glycogenosis type V
ξ Landau-Kleffner syndrome
ξ Lafora body disease
ξ Subacute sclerosing panencephalitis
ξ Others as approved by medical director
Clinical Specialty:
Maintenance of ketogenic therapy:
Pediatric Neurology, Clinical Nutrition, AFCH Nursing, AFCH Speech Language Therapy, AFCH
Respiratory Therapy, AFCH Hospitalists, any AFCH Specialty (Nephrology, Surgery,
Neurosurgery, Gastroenterology, Complex Care, Endocrinology, Cardiology, Oncology, Rehab,
etc.), Pharmacists, Primary Care and Emergency Care Physicians
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4


Intended Users:
Any physician, physician assistant, nurse practitioner, registered nurse, respiratory therapist,
pharmacist or registered dietitian caring for a patient already receiving KT.

Objective(s):
To provide evidence-based guidelines for health care professionals responsible for the care of
patients receiving KT.

Target Population:
All pediatric patients already on KT receiving care at AFCH in the inpatient, outpatient (including
primary care) or emergency setting.

Interventions and Practices Considered:
1. Expert opinion and resources on management of patients on KT.
2. Published literature on management of patients on KT.

Major Outcomes Considered:
Uninterrupted and safe KT provision, in particular avoidance of excess carbohydrate provision
from medications, fluids and food, to aid in the reduction of seizure activity.
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using scheme adapted
from the Grading of Recommendations Assessment, Development and Evaluation (GRADE)
methodology developed by the American Heart Association and American College of Cardiology
(see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: A review of the literature did not identify
any disparities specifically for pediatric patients receiving ketogenic therapy. However,
researchers have attempted to identify healthcare disparities for epilepsy care in general.
Findings were delineated by The North American Commission of the International League
Against Epilepsy via a systematic review of the published literature.3
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Overall, there is little direct research regarding healthcare disparities in epilepsy care. There has
been some evaluation of the roles of socioeconomic status (SES), gender, race/ethnicity, age,
education, and comorbidities in relation to outcomes following medical treatment for people with
epilepsy. There is a demonstrated disparity related to SES and race/ethnicity in terms of access
to health insurance in the United States, which directly affects access to care for children with
epilepsy. However, among all patients with epilepsy, children have a higher use of neurologists,
the emergency room, and hospital admissions independent of socioeconomic status or
urban/rural residence. Further, direct research using larger sample sizes to evaluate patient
factors (including SES, race/ethnicity, gender, geographic locations) and their role in clinical
outcomes is needed.3
Introduction
Ketogenic Therapy (KT) is an effective treatment option for childhood epilepsy, often considered
when epilepsy is deemed intractable, or after 2-3 failed antiepileptic therapy trials that were
appropriately dosed and tolerated. Early consideration of KT is encouraged.4 The therapy can
be used in infancy through adulthood, with literature supporting use in as young as the neonatal
period.5,6 Highest compliance has been reported in children up to 5 years of age.1

KT is a high fat, low carbohydrate medical nutrition therapy used to induce and maintain a state
of ketosis by using fat as the primary energy substrate, similar to fasting or starvation, while
supporting growth and development.1,7,8 At AFCH, the two forms of ketogenic therapy that are
provided are classic, where the child is admitted for initiation and is the strictest form, and
modified, which is less strict and is started in the outpatient setting as an RD/RN education
session.

The presence of ketosis, and thus adherence to KT, is associated with reduced or eliminated
seizures, positive impacts on behavior and cognition and improved quality of life for patients of
all ages.2,4,6,7,8 KT requires vigilance on the part of the parents, caregivers, and all healthcare
providers to safely maintain therapy, maintain ketosis and prevent excess carbohydrate
administration.4,9,10

KT has side effects that can typically be ameliorated with appropriate interventions. The risk of
serious adverse events, however, is low and therapy does not need to be discontinued for most
patients. The most common side effect of ketogenic therapy is constipation.4,9 Other adverse
effects may include:1,2,4,6,11,12,13
ξ gastrointestinal (vomiting, diarrhea, abdominal pain, exacerbation of gastroesophageal
reflux secondary to slow gastric emptying)
ξ metabolic (hypomagnesemia, hyponatremia, decreased amino acid levels, acidosis,
weight loss, inadequate growth, hyperlipidemia, hypercholesterolemia, hyperglycemia,
elevated liver function tests, hyperuricemia, carnitine deficiency, hypoproteinemia)
ξ cardiac (prolonged QT interval, cardiomyopathy)
ξ renal (nephrolithiasis, Fanconi renal tubular acidosis)
ξ neurological (basal ganglia changes, coma, obtundation, optic neuropathy secondary to
thiamine deficiency)
ξ hematologic abnormalities (anemia, increased bruising, leukemia)
ξ pancreatitis
ξ dehydration

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NOTE: This guideline is intended for patients on ketogenic therapy
(KT) post therapy initiation.
General questions regarding KT should be directed to the On-Call Pediatric Neurologist.
Medication questions should be directed to the AFCH Outpatient Pharmacy (ambulatory) or
unit pharmacist (inpatient).

Recommendations

Carbohydrates from all sources should be limited as ingestion can quickly reverse
ketosis and can increase seizures.10 (UW Health Class I, LOE C)




All KT patients should receive at least maintenance fluids per the Holiday-Segar calculation,
either by mouth, via a feeding tube or through a combination of oral and feeding tube use.10 (UW
Health Class I, LOE C)

Fluids are important to help reduce the risk of constipation, dehydration and kidney
stones.7,9,10,13 (Class I, LOE C) If a KT patient is NPO for > 4 hours or is following Sick Day
Regimen, and not able to maintain maintenance fluids, IV fluids may be necessary.14

1. IV Fluids

Avoid IV dextrose when administering IV fluids.10 (UW Health Class I, LOE C)
a. If IV fluids are necessary, provide dextrose-free solutions: normal saline, ½
normal saline or lactated ringers.

b. If NPO ensure blood glucose is being monitored 10 (UW Health Class I, LOE C)
See Blood Glucose Monitoring for treatment parameters.

c. Fluids containing 2.5% or 5% dextrose should only be used during extended
periods of NPO (>15 hours) with the guidance and agreement of the ketogenic
therapy team. (UW Health Class I, LOE C)

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In addition to IV fluids, medications can provide a significant amount of carbohydrate. Patients
on KT should be limited to no more than 1 gm (1000 mg) daily of carbohydrates from all
combined medications and supplements (vitamins, minerals, herbs, any product used to boost
nutrition content) per previously published guidelines for KT.10 The carbohydrate content in
medications can be most accurately determined using information on digestible and indigestible
carbohydrates versus total carbohydrates. However, as this information is not always readily
available on packaging, a list of carbohydrate containing ingredients in medications can be
found in Appendix B. This list can be used to determine medications with lower carbohydrate
content (see Appendix B: Carbohydrate Ingredient Table). In general, syrups, elixirs and
chewable tablets contain more carbohydrate than tablets, therefore use should be limited.10

The impact of carbohydrate changes in medications can disrupt ketosis leading to seizure
activity.10 When admitted to the hospital, home medications should be continued to prevent
disruption in therapy due to medication changes. All KT patients have their medications
switched to the lowest carbohydrate form prior to KT initiation; therefore, use of a patient’s own
supply of medications is necessary if the hospital does not stock the formulation they are using
at home (e.g. specific manufacturer, compounded preparations).

New medications, initiated in the inpatient, outpatient or emergency settings, should be
evaluated to determine lowest carbohydrate form available prior to administering. (UW Health
Class I, LOE C)

Sugar-free is not equivalent to carbohydrate-free and is thus not always the lowest carbohydrate
option. Commonly ordered medication injections/infusions may contain dextrose. The base
solution of an infusion should be changed to 0.9% sodium chloride or straight drug whenever
possible. (UW Health Class I, LOE C)
2. Medications
Avoid carbohydrate containing medications, especially syrups, elixirs or chewable
tablets.10 (UW Health Class I, LOE C)

Home medications are already in the lowest carbohydrate form; therefore home
medications should be continued when admitted. (UW Health Class I, LOE C)

Contact the pharmacist (inpatient or outpatient as appropriate) for assistance with
determining the lowest carbohydrate medication options.8 (UW Health Class I, LOE C)
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Blood glucose levels in patients receiving KT typically range from 55-75 mg/dL, which is lower
than the general population. 9 If a patient fails to maintain their feeding regimen, as prescribed
during KT initiation, due to failure to eat, illness, feeding intolerance, or NPO status, blood
glucose monitoring is indicated.10

Fasting for long periods of time without maintaining a stable glucose level is contraindicated for
patients receiving KT.9,10 Any blood glucose level < 50 mg/dL is to be treated according to
previously published guidelines for ketogenic patients.9,10 A set dose of 2.5 gm of IV dextrose or
15 mL juice should be used regardless of age or weight. Providing a dose based on age or
weight would potentially provide more dextrose or sugar than needed, possibly weaken ketosis
and increase seizure activity.
3. Blood Glucose Monitoring
Blood glucose should be monitored when NPO > 4 hours or if failure to eat/tolerate at
least 75% of a solid food or formula meal.10 (UW Health Class I, LOE C)
a. > 1 year of age: check point of care glucose level every 4 hours
b. < 1year of age: check point of care glucose level every 2 hours

Blood glucose goal: > 50 mg/dL
a. If blood glucose < 50 mg/dL, treat initially with 15 mL juice and recheck glucose
in 15 minutes.
b. If blood glucose < 50 mg/dL and NPO, treat initially with 2.5 gm IV dextrose
(e.g. 25 mL D10%, 5mL of D50%) and recheck glucose in 15 minutes.
c. Additional treatment will be based upon effect of initial dose. Repeated
treatment may not be warranted if glucose is showing a positive trend;
overtreatment may cause glycemic excursions that can disrupt treatment goals.


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4. NPO & Nutrition
KT should be maintained at all times, even when NPO (AFCH Keto team standard
of care). (UW Health Class I, LOE C)

If NPO > 4 hours, monitor blood glucose. (UW Health Class I, LOE C)
See Blood Glucose Monitoring.

Strict adherence of the Meal and Fluid schedule, as prescribed during KT initiation,
is essential. If the schedule cannot be maintained due to illness, sick day regimen
should be started. Sick Day Regimen provides some carbohydrate and electrolytes
to help prevent dehydration, hypoglycemia and unwanted acidosis.10 (UW Health
Class I, LOE C)

If unable to maintain KT enterally consider ketogenic TPN.9,10,15 (UW Health Class I,
LOE C) and consult Clinical Nutrition and the Pediatric Nutrition Support Team.


Classic KT requires all foods and formula to be weighed out on a gram scale according to pre-
calculated recipes to ensure correct KT balance. Nutrients are individualized to meet clinical and
nutrition needs while providing a very low carbohydrate, high fat nutrition plan. Meals must be
consumed in their entirety. Carbohydrates from non-food sources are limited to 1 gm or less per
day.10

KT is continued when the patient is NPO by preventing excess carbohydrate administration,
monitoring blood glucose and administering appropriate IV fluids to provide minimum
maintenance fluids.

When a patient is not tolerating their feedings, Sick Day Regimen should be implemented. (UW
Health Class I, LOE C) Sick Day Regimen provides maintenance fluids using a carbohydrate and
electrolyte solution. While it does provide more carbohydrate than the prescribed KT, it helps
prevent hypoglycemia, excess ketosis and dehydration. When feeling better, oral or enteral KT
foods and/or formula are increased in a stepwise fashion to return to their Meal and Fluid
Schedule.10

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5. Sick Day Regimen
Sick Day Regimen: 10 (UW Health Class I, LOE C)

a. Formula fed children
ξ Replace all fluids including formula volume with Pedialyte
ξ Advance as tolerated to ½ strength formula mixed with Pedialyte.
ξ When tolerating ½ strength formula, advance to full strength resuming
prescribed fluid and meal plan.

b. Orally fed children
ξ First:
a. Offer only approved clear liquids: water, Pedialyte, sugar-free
Jell-O and calorie-free/caffeine-free soda.
b. May have up to 2 saltine crackers with recommended fluids.
c. May have bouillon soup.
ξ If able to tolerate soup and cracker, advance to ½ of a KT meal without
added fat (heavy whipping cream, butter or oil).
ξ When tolerated, advance to a full KT meal without added fat.
ξ Finally, resume full KT meals with fat component per prescribed fluid
and meal plan

If patient does not tolerate Sick Day Regimen, avoidance of dehydration,
hypoglycemia and excess ketosis can be achieved by making patient NPO (See
NPO & Nutrition), monitoring blood glucose (See Blood Glucose Monitoring) and
initiating appropriate intravenous fluids (See IV Fluids).10 (UW Health Class I, LOE C)


6. Laboratory Monitoring 9,10,16 (UW Health Class II, LOE B)

If a patient on KT is admitted, the following labs may be helpful.
a. Blood glucose (See Blood Glucose Monitoring)
b. Comprehensive Metabolic Panel: Electrolytes, Glucose, BUN, Creatinine,
Calcium, Albumin, Total Protein, Total Bilirubin, AST, ALT, Alkaline
Phosphatase
c. CBC
d. Ammonia
e. Urinalysis
f. Beta-hydroxybutyrate*
g. Venous Blood Gas
h. Anti-epileptic drug levels as requested by Pediatric Neurology
*requires Pediatric Neurology KT Team interpretation

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Laboratory monitoring is helpful during admission for patients on KT who are ill. If planning to
consult Pediatric Neurology, obtaining a beta-hydroxybutyrate (BHB) with the initial lab draw is
helpful to prevent another draw. BHB is interpreted by the Pediatric Neurology Ketogenic
Therapy Team to determine therapy compliance, possible unintentional carbohydrate
consumption or administration and KT adjustments. As a BHB is usually obtained, urine ketones
are not routinely checked for patients already on KT while in the hospital. Additional antiepileptic
drug levels may be recommended by Pediatric Neurology.

As serum bicarbonate does not always reflect acidosis, venous blood gas should be checked
with routine electrolyte monitoring. Treatment for acidosis varies based upon respiratory status
(see Acid/Base Status and Respiratory Considerations).





7. Acid/Base Status and Respiratory Considerations
a. Serum bicarbonate level does not necessarily reflect degree of acidosis. Venous
blood gas should be obtained with routine electrolyte monitoring to determine
degree of acidosis, especially in acutely ill patients. (UW Health Class I, LOE C)

b. If venous pH < 7.20, AND PVCO2 < 40, consider treatment with sodium
bicarbonate. (UW Health Class I, LOE C)
i. Repeat venous blood gas 4 hours after administration to monitor effect and
titrate as necessary

c. Bicarbonate should not be given to patients with poor respiratory compensation
for metabolic acidosis, as evidenced by PVCO2 > 40. Patients with poor respiratory
compensation may be harmed by administration of bicarbonate due to paradoxical
worsening of intracellular acidosis. (UW Health Class I, LOE C

d. If acidosis is thought to be clinically significant, but respiratory compensation is
insufficient, discuss options for improving the patient's ventilatory status with
hospitalist or PICU teams. (UW Health Class I, LOE C)

e. Potassium containing bases (sodium citrate, etc.) may prevent renal stones and
are likely safe in maintenance dosing.7,10,13 (UW Health Class I, LOE C) However, they
should not be used for acute treatment of acidosis as they may lead to
hyperkalemia, increasing the risk of arrhythmia and other morbidities. (UW Health
Class I, LOE C)


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12


UW Health Implementation
Potential Benefits:
ξ Maintenance of KT during admissions or appointments at AFCH
o Decreased seizures or risk of seizures in patients by maintaining ketosis through
excess carbohydrate administration prevention
o Improved quality of life, behavior, and cognition for patients on KT
o Prevention of hypoglycemia
o Maintaining or improving patient nutrition status
 Prevent or help treat malnutrition
ξ Improve clinician comfort and compliance caring for patients receiving KT

Potential Harms:
ξ Constipation
ξ Excess ketosis
ξ Hypoglycemia
ξ Acidosis
ξ Increased seizures

Qualifying Statements: This guideline is not intended to treat or diagnosis a patient not
followed by the AFCH KT Team. This guideline does not replace clinical judgment when treating
a patient on KT.

Pertinent UW Health Policies & Procedures
1. UWHC Policy 13.24AP- Hypoglycemia, Care of the Hospitalized Patient

Patient Resources
1. Health Facts For You #517- Starting Ketogenic Therapy in the Hospital

Guideline Metrics
1. Reduction in Patient Safety Net submissions for inappropriate management of patients
receiving KT. Plan to compare January to June 2014 data with January to June 2015 data.
2. Periodic chart audits to determine adherence to Clinical Practice Guideline.

Implementation Plan/Clinical Tools
1. Guideline will be posted on UConnect and uwhealth.org in a dedicated location for Clinical
Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Best Practice Alerts (BPA)
UWH B Ketogenic Diet BPA
UWIP Ketogenic Diet Banner

Order Sets & Smart Sets
IP – Ketogenic Diet – Pediatric – Admission [3313]

Miscellaneous
Ketogenic Therapy Mapping
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Daily Rounding Checklist

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by AHA/ACC









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Appendix B. Pharmaceutical Ingredients
For any questions regarding medications or medication ingredients, please contact the inpatient
pharmacist or the AFCH outpatient pharmacist.

Pharmaceutical Ingredients that Contain Carbohydrates
Ascorbic Acid MaltoDextrin
Erythritol Mannitol
Glycerin Sorbitol
Hydrogenated Starch
Hydrolysate (HSH)
Starches:
Cornstarch, Pregelatinized Starch,
Sodium Starch Glycolate
Isomalt Sugars:
Dextrose, Fructose, Glucose,
Lactose,
Levulose, Maltose, Sucrose, Xylose
Maltitol Xylitol

Pharmaceutical Ingredients that do not Contain Carbohydrates
Aspartame Magnesium Stearate
Asulfame Potassium Microcrystalline Cellulose
Carboxymethylcellulose Polyethylene Glycol
Cellulose Saccharine
Hydroxymethylcellulose

Information obtained from the Professional’s Guide to the Ketogenic Diet. Ketogenic Seminars. 2014.







Last reviewed: March 2017
Last revised: September 2014
Contact Pediatric Neurology with questions.
Contact CCKM for revisions.
Ketogenic Therapy Maintenance – Pediatric – Inpatient/Ambulatory Clinical Practice Guideline


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References
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3. Burneo JG, Jette N, Theodore W, et al. Disparities in epilepsy: report of a systematic
review by the North American Commission of the International League Against Epilepsy.
Epilepsia. Oct 2009; 50(10):2285-2295.
4. Kossoff EH et al. Optimal management of children receiving the ketogenic diet:
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5. Dressler A et al. The Ketogenic Diet in Infants—Advantages of Early Use. Epilepsy
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10. Zupec-Kania B. Professional’s guide to the ketogenic diet. Ketogenic Seminars. 2014.
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12. Ozdemir R et al. The Effect of the Ketogenic Diet on the Vascular Structure and
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13. Bergqvist AG. Long term monitoring of the ketogenic diet: do’s and don’ts. Epilepsy
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14. Kim JA et al. Efficacy of the classic ketogenic and the modified Atkins diets in refractory
childhood epilepsy. Elilepsia. 2016; 57(1):51-58.
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