Abstracts

Rationale: Initiation of the Ketogenic Diet (KD) varies from center to center, mostly with hospital admission as a primary common denominator. During our clinical practice at Children’s Hospital Colorado (CHCO) using our three day diet initiation protocol, we noticed that children were less likely to accept the liquid diet on day 2 of admission. Therefore, we decided to change the protocol to a faster progression to full calories and solid meals (if appropriate for the child) on day 2 of admission to improve diet initiation tolerance. The aim of this quality improvement project is to assess outcomes between the three-day versus two-day diet initiation protocol.Methods: We retrospectively reviewed 130 charts of patients initiated on the KD at CHCO from Jan 2011-Dec 2014. The three-day protocol ran between Jan 2011 and Dec 2012. The two-day protocol ran between Jan 2013 and Dec 2014. Our three-day protocol consisted of an overnight (12-18 hour) fast, followed by 1/3 calories on day one, 2/3 calories on day two, and full calories on day three and onward, with day one and two calories in the form of a liquid drink (Egg Nog or KetoCal). The two-day protocol consisted of an overnight fast, with ½ calories on day one from a liquid drink and progression to full calories on day two of admission. For this project, we measured diet toleration by the presence of emesis, need for IV fluids, and length of diet initiation.Results: There were 74 patients initiated on the three-day protocol and 54 patients on the two-day protocol. Statistical analysis revealed no statistically significant association between protocol and need for IV fluids (χ2(1) = .92, p = .34) and no statistically significant association between protocol and emesis (χ2(1) = .00, p > .99). Each protocol had a 50% emesis rate. A Mann-Whitney U test was performed to determine if there were differences in length of diet initiation between the protocols. Length of diet initiation for the three-day protocol (mean rank = 71.28, median = 4, range = 4) was statistically significantly longer than for the two-day protocol (mean rank = 57.36, median = 4, range = 5, U = 1612.5, p = .03). Mean length of diet initiation for three-day protocol was 4.7 days and mean length of diet initiation for the two-day protocol was 4.3 days.Conclusions: At our institution, discharge from diet initiation is based upon stability of lab values and the patient’s clinical appearance. Transitioning to the two-day protocol did result in a shorter length of diet initiation without any worsening of emesis or need for IV fluids. Therefore, we infer that the shorter length of stay for diet initiation suggests that the new two-day protocol is better tolerated by patients and is a preferable protocol for our institution. It would be beneficial to conduct controlled research studies to better assess diet tolerability using more specific lab measures in order to further assess the efficacy of a two-day Ketogenic Diet initiation protocol.