Maria Raspolic, RD - International Foundation for Alternating

Maria Raspolic MS, RD
Santa Clara Valley Medical Center
 Review most common nutritional issues in
 Provide recommendations to minimize
above issues
 Review ketogenic diet as treatment for
Poor growth
Decreased bone mineral density
Inadequate nutrient intakes
Decreased muscle tone
Oral motor dysfunction
Limited growth potential
Frequent illness, fatigue, infections
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
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
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
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
blackstrap molasses
broccoli (cooked)
Serving Size
3 ounces
Amount of Calcium per Serving
210 milligrams (mg)
170 mg
Food1 sources/
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)
1⁄2 cup
1 cup
8 ounces
335 mg
245 mg
425 mg
canned salmon (with
canned sardines (with
cottage cheese
hard cheese (cheddar,
kale (cooked)
Calcium Carbonate
Viactiv, Tumbs, Caltrate
Calcium Citrate
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,
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
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
Teach families how to calculate and prepare
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

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