Download PDF
CC BY-NC-ND 4.0 · International Journal of Epilepsy 2014; 01(01): 027-035
DOI: 10.1016/j.ijep.2014.03.002
Review Article
Thieme Medical and Scientific Publishers Private Ltd.

Dietary therapy in childhood epilepsy, an overview

Sheffali Gulati
1   Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 029, India
,
Biswaroop Chakrabarty
1   Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110 029, India
› Author Affiliations
Subject Editor:
Further Information

Publication History

Received: 07 February 2014

Accepted: 21 March 2014

Publication Date:
04 May 2018 (online)

   Permissions and Reprints

Abstract

This review highlights the current consensus guidelines regarding use of dietary therapy in childhood epilepsy. Comprehensive search was done in the electronic database, journals, reference lists and dissertations related to the field. In childhood epilepsy, about one-third patients are medically refractory. Surgical resection is an effective modality only in a third of these cases. Dietary therapy causes upto 30–40% reduction in seizure frequency in drug refractory epilepsy. The various forms of dietary therapies described are ketogenic diet, modified Atkins diet and low glycemic index treatment. Apart from ketogenesis, the ketogenic diet also exerts its effect by modulating brain energetics and neurotransmitter circuitry. The classical ketogenic diet comprises of fat to carbohydrate ratio of 4:1 (in terms of weight in grams). Modified Atkins diet is restrictive only for carbohydrates (≤20 g per day). Low glycemic index treatment allows carbohydrate of upto 60 g per day with food items having glycemic index of less than 50. Consensus recommendations for indications and contraindications of dietary therapy in childhood epilepsy have been formulated. Moreover caution has to be warranted for various metabolic and systemic side effects described with this form of therapy. Laboratory and clinical assessment prior to initiation and periodically on therapy is recommended. A trial of dietary therapy is labeled as failure only if there is no response even after 12 weeks of therapy. There is research ongoing globally on dietary therapy with preliminary encouraging reports in status epilepticus and other neurological conditions like migraine, brain tumor and autism.

Keywords

Epilepsy - Ketogenic diet - Intractable - Low glycemic index therapy - Modified Atkins diet
 

  • References

  • 1 Berg AT. Defining intractable epilepsy. Adv Neurol 97 2006; 5-10
    PubMedGoogle Scholar
  • 2 Schuele SU, Lüders HO. Intractable epilepsy: management and therapeutic alternatives. Lancet Neurol 7 2008; 514-524
    CrossrefPubMedGoogle Scholar
  • 3 Kwan P, Arzimanoglou A, Berg AT. et al. Definition of drug resistant epilepsy: consensus proposal by the adhoc task force of the ILAE commission on therapeutic strategies. Epilepsia 51 2010; 1069-1077
    PubMedGoogle Scholar
  • 4 Levy RG, Cooper PN, Giri P, Pulman J. Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database Syst Rev 3 2012; CD001903
    PubMedGoogle Scholar
  • 5 Kossoff EH, Zupec-Kania BA, Rho JM. Ketogenic diets: an update for child neurologists. J Child Neurol 24 2009; 979-988
    CrossrefPubMedGoogle Scholar
  • 6 Danial NN, Hartman AL, Stafstrom CE, Thio LL. How does the ketogenic diet work? Four potential mechanisms. J Child Neurol 28 2013; 1027-1033
    CrossrefPubMedGoogle Scholar
  • 7 Stafstrom CE, Rho JM. The ketogenic diet as a treatment paradigm for diverse neurological disorders. Front Pharmacol 3 2012; 1-8
    PubMedGoogle Scholar
  • 8 Kossoff EH, Zupec-Kania BA, Amark ZE. et al. Optimal clinical management of children receiving the ketogenic diet: recommendations of the International Ketogenic Diet Study Group. Epilepsia 50 2009; 304-317
    CrossrefPubMedGoogle Scholar
  • 9 Neal EG, Chaffe HM, Edwards N, Lawson MS, Schwartz RH, Cross JH. Growth of children on classical and medium chain triglyceride ketogenic diets. Pediatrics 122 2008; 334-340
    CrossrefPubMedGoogle Scholar
  • 10 Raju KNV, Gulati S, Kabra M. et al. Efficacy of 4:1 (classic) versus 2.5:1 ketogenic ratio diets in refractory epilepsy in young children: a randomized open labeled study. Epilepsy Res 96 2011; 96-100
    CrossrefPubMedGoogle Scholar
  • 11 Kossoff EH, McGrogan JR, Freeman JM. Benefits of an all-liquid ketogenic diet. Epilepsia 45 2004; 1163
    CrossrefPubMedGoogle Scholar
  • 12 Hosain SA, La Vega-Talbott M, Solomon GE. Ketogenic diet in pediatric epilepsy patients with gastrostomy feeding. Pediatr Neurol 32 2005; 81-83
    CrossrefPubMedGoogle Scholar
  • 13 Kossoff EH, McGrogan JR, Bluml RM, Pillas DJ, Rubenstein JE, Vining EP. A modified Atkins diet is effective for the treatment of intractable pediatric epilepsy. Epilepsia 47 2006; 421-424
    CrossrefPubMedGoogle Scholar
  • 14 Klepper J, Leiendecker B. GLUT1 deficiency syndrome. Dev Med Child Neurol 49 2007; 707-716
    CrossrefPubMedGoogle Scholar
  • 15 Wexler ID, Hemalatha SG, McConnell J. et al. Outcome of pyruvate dehydrogenase deficiency treated with ketogenic diets. Studies in patients with identical mutations. Neurology 49 1997; 1655-1661
    CrossrefPubMedGoogle Scholar
  • 16 Stainman RS, Turner Z, Rubenstein JE, Kossoff EH. Decreased relative efficacy of the ketogenic diet for children with surgically approachable epilepsy. Seizure 16 2007; 615-619
    CrossrefPubMedGoogle Scholar
  • 17 Wheless JW. The ketogenic diet: an effective medical therapy with side effects. J Child Neurol 16 2001; 633-635
    CrossrefPubMedGoogle Scholar
  • 18 Sharma S, Gulati S, Kalra V, Agarwala A, Kabra M. Seizure control and biochemical profile on the ketogenic diet in young children with refractory epilepsy–Indian experience. Seizure 18 2009; 446-449
    CrossrefPubMedGoogle Scholar
  • 19 Bergqvist AG, Schall JI, Gallagher PR, Cnaan A, Stallings VA. Fasting versus gradual initiation of the ketogenic diet: a prospective, randomized clinical trial of efficacy. Epilepsia 46 2005; 1810-1819
    CrossrefPubMedGoogle Scholar
  • 20 Kossoff EH, Pyzik PL, Rubenstein JE. et al. Combined ketogenic diet and vagus nerve stimulation: rational polytherapy?. Epilepsia 48 2007; 77-81
    PubMedGoogle Scholar
  • 21 Pfeifer HH, Thiele EA. Low-glycemic-index treatment: a liberalized ketogenic diet for treatment of intractable epilepsy. Neurology 65 2005; 1810-1812
    CrossrefPubMedGoogle Scholar
  • 22 Freeman JM, Kossoff EH, Freeman JB, Kelly MT. The Ketogenic Diet: A Treatment for Epilepsy in Children and Others. 4th ed.. 2006. Demos; New York:
    Google Scholar
  • 23 Martinez CC, Pyzik PL, Kossoff EH. Discontinuing the ketogenic diet in seizure- free children: recurrence and risk factors. Epilepsia 48 2007; 187-190
    PubMedGoogle Scholar
  • 24 Neal EG, Chaffe HM, Schwartz RH. et al. The ketogenic diet in the treatment of epilepsy in children: a randomised, controlled trial. Lancet Neurol 7 2008; 500-506
    CrossrefPubMedGoogle Scholar
  • 25 Vining EPG, Camfield PR, Trevathan E. A multicenter study of the efficacy of the ketogenic diet. Arch Neurol 55 1998; 1433-1437
    CrossrefPubMedGoogle Scholar
  • 26 Freeman JM, Vining EP, Pillas DJ, Pyzik PL, Casey JC, Kelly LM. The efficacy of the ketogenic diet-1998: a prospective evaluation of intervention in 150 children. Pediatrics 102 1998; 1358-1363
    CrossrefPubMedGoogle Scholar
  • 27 Coppola G, Veggiotti P, Cusmai R. et al. The ketogenic diet in children, adolescents and young adults with refractory epilepsy: an Italian multicentric experience. Epilepsy Res 48 2002; 221-227
    CrossrefPubMedGoogle Scholar
  • 28 Mackay MT, Bicknell-Royle J, Nation J, Humphrey M, Harvey AS. The ketogenic diet in refractory childhood epilepsy. J Paediatr Child Health 41 2005; 353-357
    CrossrefPubMedGoogle Scholar
  • 29 Kang HC, Kim YJ, Kim DW, Kim HD. Efficacy and safety of the ketogenic diet for intractable childhood epilepsy: Korean multicentric experience. Epilepsia 46 2005; 272-279
    CrossrefPubMedGoogle Scholar
  • 30 Seo JH, Lee YM, Lee JS, Kang HC, Kim HD. Efficacy and tolerability of the ketogenic diet according to lipid: nonlipid ratios–comparison of 3:1 with 4:1 diet. Epilepsia 48 2007; 801-805
    CrossrefPubMedGoogle Scholar
  • 31 Mosek A, Natour H, Neufeld MY, Shiff Y, Vaisman N. Ketogenic diet treatment in adults with refractory epilepsy: a prospective pilot study. Seizure 18 2009; 30-33
    CrossrefPubMedGoogle Scholar
  • 32 Neal EG, Chaffe H, Schwartz RH. et al. A randomized trial of classical and medium-chain triglyceride ketogenic diets in the treatment of childhood epilepsy. Epilepsia 50 2009; 1109-1117
    CrossrefPubMedGoogle Scholar
  • 33 Sharma S, Sankhyan N, Gulati S, Agarwala A. Use of the modified Atkins diet for treatment of refractory childhood epilepsy: a randomized controlled trial. Epilepsia 54 2013; 1-6
    PubMedGoogle Scholar
  • 34 Sharma S, Sankhyan N, Gulati S, Agarwala A. Use of the modified Atkins diet in infantile spasms refractory to first-line treatment. Seizure 21 2012; 45-48
    CrossrefPubMedGoogle Scholar
  • 35 Kossoff EH, Turner Z, Bluml RM, Pyzik PL, Vining EP. A randomized, crossover comparison of daily carbohydrate limits using the modified Atkins diet. Epilepsy Behav 10 2007; 432-436
    CrossrefPubMedGoogle Scholar
  • 36 Kang HC, Lee HS, You SJ, Kang DC, Ko TS, Kim HD. Use of a modified Atkins diet in intractable childhood epilepsy. Epilepsia 48 2007; 182-186
    PubMedGoogle Scholar
  • 37 Kossoff EH, Rowley H, Sinha SR, Vining EPG. A prospective study of the modified Atkins diet for intractable epilepsy in adults. Epilepsia 49 2008; 316-319
    CrossrefPubMedGoogle Scholar
  • 38 Weber S, Molgaard C, Taudof K, Uldall P. Modified Atkins diet to children and adolescents with medical intractable epilepsy. Seizure 18 2009; 237-240
    CrossrefPubMedGoogle Scholar
  • 39 Miranda MJ, Mortensen M, Povlsen JH, Nielsen H, Beniczky S. Danish study of a modified Atkins diet for medically intractable epilepsy in children: can we achieve the same results as with classical ketogenic diet?. Seizure 20 2011; 151-155
    CrossrefPubMedGoogle Scholar
  • 40 Coppola G, D'Aniello A, Messana T. et al. Low glycemic index diet in children and young adults with refractory epilepsy: first Italian experience. Seizure 20 2011; 526-528
    CrossrefPubMedGoogle Scholar
  • 41 Shorvon Simon, Ferlisi Monica. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol. Brain 134 2011; 2802-2818
    CrossrefPubMedGoogle Scholar
  • 42 Strzelcyk A, Reif PS, Bauer S. et al. Intravenous initiation and maintenance of ketogenic diet: proof of concept in super-refractory status epilepticus. Seizure 22 2013; 581-583
    CrossrefPubMedGoogle Scholar
  • 43 Hallbook T, Ji S, Maudsley S, Martin B. The effects of ketogenic diet on behavior and cognition. Epilepsy Res 100 2012; 304-309
    CrossrefPubMedGoogle Scholar
  • 44 Maalouf M, Rho JM, Mattson MP. The neuroprotective properties of calorie restriction, the ketogenic diet, and ketone bodies. Brain Res Rev 59 2009; 293-315
    CrossrefPubMedGoogle Scholar
  • 45 Kossoff EH, Pyzik PL, McGrogan JR, Vining EPG, Freeman JM. Efficacy of the ketogenic diet for infantile spasms. Pediatrics 109 2002; 780-783
    CrossrefPubMedGoogle Scholar