Background. Although the ketogenic diet (KD) is a well-established non-pharmacologic treatment for intractable epilepsy in pediatric patients, it is still perceived as theoretical information contained within textbooks rather than implementation in daily clinical practice. The aim of the present study was to primarily determine KD implementation frequency in daily clinical practice, the number of pediatric patients with intractable epilepsy, the conditions that hindered or facilitated KD implementation, and to provide a roadmap to improve patient outcomes. Methods. A total of 27 pediatric neurologists, who were experienced in intractable epileptic pediatric patients and the implementation of KDs, responded to a 24-question survey. The survey was structured to outline patient selection criteria for KDs, prevalent treatment approaches in daily clinical practice for intractable epilepsy, level of physician awareness and impediments in KD implementation. Results. Intractable epilepsy was diagnosed predominantly in children within the 7 to 12-year age group (44%). KD implementation was hindered mainly by lack of an adequate number of personnel (53.8%), lack of a dietitian (52%), inadequate training of patients (24%), and inadequate experience of healthcare professionals (23.1%). Lack of guidance in treatment, physician’s hesitations due to probable problems, inadequate time spent for each patient, lack of awareness for KD therapy, and loss of appetite in these patients were also emphasized by the participants (each 16.7%). Additional drawbacks were non-appealing taste (76.9%), need for continuous supervision (76.9%), and low patient motivation (73.1%). The treatment failure causes for KDs were ranked as imprecise cooking of recipes (94%), inadequate family support (92.3%), inadequate consumption of meals (73%), incorrect indication (53.9%), and inefficiency of KD despite correct application (42.3%). Conclusion. The panoramic view of KDs in Turkey indicates that a National Guideline would increase both physician awareness level for KD, and the rate of structured therapy implementation in pediatric patients, who suffer from inadequate treatment.
___
1. Wilder RM. The effect of ketonemia on the course of epilepsy. Mayo Clin Bull 1921; 2: 307-308.
2. Kosoff EH, Zupec-Kania BA, Auvin S, et al; Charlie Foundation; Matthew’s Friends; Practice Committee of the Child Neurology Society. Optimal clinical management of children receiving dietary therapies for epilepsy: updated recommendations of the International Ketogenic Diet Study Group. Epilepsia Open 2018; 3: 175-192.
3. Hartman AL, Gasior M, Vining EP, Rogawski MA. The neuropharmacology of the ketogenic diet. Pediatr Neurol 2007; 36: 281-292.
4. Nordli DR Jr, Kuroda MM, Carroll J, et al. Experience with the ketogenic diet in infants. Pediatrics 2001; 108: 129-133.
5. Lin A, Turner Z, Doerrer SC, Stanfield A, Kossoff EH. Complications during ketogenic diet initiation: prevalence, treatment, and influence on seizure outcomes. Pediatr Neurol 2017; 68: 35-39.
6. Kossoff EH, Pyzik PL, McGrogan JR, Rubenstein JE. The impact of early versus late anticonvulsant reduction after ketogenic diet initiation. Epilepsy Behav 2004; 5: 499-502.
7. Kossoff EH, Zupec-Kania BA, Amark PE, et al; Charlie Foundation, Practice Committee of the Child Neurology Society; Practice Committee of the Child Neurology Society; International Ketogenic Diet Study Group. Optimal clinical management of children receiving the ketogenic diet: recommendations of the International Ketogenic Diet Study Group. Epilepsia 2009; 50: 304-317.
8. Neal EG, Chaffe H, Schwartz RH, et al. The ketogenic diet for the treatment of childhood epilepsy: a randomized controlled trial. Lancet Neurol 2008; 7: 500-506.
9. Kossoff EH, Caraballo RH, du Toit T, et al. Dietary therapies: a worldwide phenomenon. Epilepsy Res 2012; 100: 205-209.
10. Gerges M, Selim L, Girgis M, El Ghannam A, Abdelghaffar H, El-Ayadi A. Implementation of ketogenic diet in children with drug-resistant epilepsy in a mediumresources setting: Egyptian experience. Epilepsy Behav Case Rep 2018; 11: 35-38.
11. Wibisono C, Rowe N, Beavis E, et al. Ten-year singlecenter experience of the ketogenic diet: factors influencing efficacy, tolerability, and compliance. J Pediatr 2015; 166: 1030-1036.e1.