Epilepsi

The Canadian Journal of Clinical Nutrition, Volume 6, Issue 2, June 2018
ISSN 1927-8942 (Print Edition), ISSN 1927-8950 (Online Edition)
Review Article Page 105-125
Effectiveness of Ketogenic Diet in Children with Epileptic Disorders: A Meta-

Analysis and Systematic Review
Duha Janahi1, Feras Alhussainy1, Fatimah Al Hassan1, Taiba Alhumaidi1, Deema

Altamimi1, Saad Alharbi1, Omar Zainal1, Haitham Jahrami1, 2*, Mo’ez Al-Islam Faris3
1
College of Medicine and Medical Sciences, Arabian Gulf University; 2Ministry of Health,
Kingdom of Bahrain; 3Department of Clinical Nutrition and Dietetics, College of Health
Sciences/Sharjah Institute for Medical Research (SIMR), University of Sharjah, Sharjah,
United Arab Emirates
*Corresponding Author Email Address: hjahrami@health.gov.bh
ABSTRACT
Background: Epilepsy is a central nervous disorder that affects children at great magnitude.
Cognitive, emotional, and behavioral symptoms are common. The ketogenic diet (KD) is a
dietary treatment option, particularly for intractable seizures. The effectiveness of KD in the
management of epileptic disorders (ED) varies between studies. Objective: The aim of this
meta-analysis and systematic review is to determine the effectiveness of KD in the
management of ED in children. Methods: A literature search was performed using relevant
key terms to identify studies published from 1998 to 2017 on KD, ED, and children. Studies
were identified through an electronic search of Embase, MEDLINE, and ProQuest databases.
The main outcomes and measures were ≤ 50% reduction of seizure episodes at one month,
three months, six months and twelve months of treatment. Data were pooled using random
effects meta-analysis technique. Results: Fourteen studies were included in the meta-analysis
and systematic review including 1276 participants. Reductions of seizure episodes by ≥50%
(which is clinically relevant) using KD were 22.9%, 49.9%, 37.9% and 30.8% after one
month, three months, six months and twelve months of treatment, respectively. Conclusion:
There is some evidence that KD is effective in the management of some cases of ED.
Reduction of ≥ 50% seizure episodes is seen mainly at the first three months and declines
thereafter, possibly due to the side effects or non-adherence with KD. The decision to adopt
this type of diet should be based on both short-term and long-term goals, taking into
consideration the cost, safety and efficacy of the treatment. Effectiveness in the first three
months appears to be an indicator of the outcomes of interest.
Keywords: Ketogenic Diet, Epileptic Disorder, Children, Meta-analysis, Systematic Review
Citation: Janahi D, Alhussainy F, Al-Hassan F, Alhumaidi T, Altamimi D, Alharbi S, Zainal

105
O, Jahrami H, Faris MAI. Effectiveness of Ketogenic Diet in Children with Epileptic

Disorders: A Meta-Analysis and Systematic Review. Canad J Clin Nutr 2018; 6 (2): 105-125.
Page
DOI: http://dx.doi.org/10.14206/canad.j.clin.nutr.2018.02.09
The Canadian Journal of Clinical Nutrition is published by Global Science Heritage, (http://www.globalscienceheritage.org)
Registered publisher by the Library and Archives/Government of Canada, (www.collectionscanada.gc.ca)
INTRODUCTION
Seizure is a sudden disruption of the brain’s normal electrical activity accompanied by
altered consciousness and other neurological and behavioral manifestations (1). Epileptic
disorders (ED) are a condition characterized by recurrent seizures that may include
repetitive muscle jerking called convulsions and starts in childhood in more than half of
the cases (2). Manifestations of this condition depend on the affected site of the brain,
which could be sensory, motor, or autonomic functions, and can predispose to an aura in
a certain type of epilepsy (3). Epilepsy is a multifactorial disease that leads to an
imbalance between brain excitatory and inhibitory signals, of which about 70% is
idiopathic, while other etiologic factors could be genetic, head trauma, neurologic
diseases, or metabolic disorders (3). Laboratory studies such as a complete blood count,
blood chemistry profiles, liver, and thyroid function tests, an electroencephalogram, and a
brain study with magnetic resonance imaging are indicated for diagnosing epilepsy.
Computed tomography scanning in an emergency or for very young children to help
aiding the diagnosis (4).
The mainstay of treatment is antiepileptic drug (AED) therapy which has four aims:
elimination of seizures or reduce their frequency to the maximum degree possible, to
evade the adverse effects associated with long-term treatment, and to aid patients in
maintaining or restoring their usual psychosocial and vocational activities and in
maintaining a normal lifestyle (4). Seizures, including febrile convulsions, occur in 3-5%
of children. Epilepsy, that is susceptibility to continuing seizures, occurs in 0.5-1.0% of
the population and is intractable to current antiepileptic drug treatment in 20-25%.
Intractable seizure is defined when the patient fails to manage his or her attack in the
following situation: (i) failure reduction of attacks with the use of two types of
anticonvulsant drugs, (ii) occurrence of average at least one seizure per month, (iii) three
months or less free of seizure in a year (5).
The ketogenic diet (KD) is a type of therapeutic diet that is high in fat and low in
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carbohydrates. It aims to induce the metabolic effects of fasting. Many types of KD are
used nowadays including classical ketogenic diet, the medium-chain triglycerides diet,
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the modified Atkins diet (MAD) and the low glycemic index diet. Possible mechanisms
of action of KD in epilepsy were summarized in a recent review: evidence suggest that

carbohydrate reduction may contribute to the activation of ATP-sensitive potassium
channels by mitochondrial metabolism, inhibition of glutamatergic excitatory synaptic
transmission, inhibition of the mammalian target of rapamycin pathway (6).
KD is suitable regime for children who have failed to manage their epilepsy episodes by
using two to three antieplieptic therapy medications particularly those who suffered from
generalized epilepsy, or those who have been referred to a tertiary pediatric epilepsy
specialist. Regardless the effect of KD, it is contraindicated in children who have known
case of pyruvate carboxylase deficiency, β-oxidation defects, primary carnitine
deficiency and porphyria disorders (6). Clinicians observed multiple short-term side
effects when initiating KD in pediatrics, including vomiting, anorexia, acidosis,
constipation, gastro-esophageal reflux disease, fatigue, exacerbation of seizures and
hypoglycemia. Long-term side effects may include vitamin D deficiency, increased risk
of bone fractures by decrease bone mineral density, growth disturbance after age of 6-12
years, cardiovascular disease and kidney stones. Patients treated with KD need to
undergo regular clinical visits upon the initiation of the diet and during treatment at three
months, six months, twelve months for monitoring the therapeutic effect of the diet and
the avoidance of side effects (6). Variable findings have been reported regarding the
effectiveness of KD in treating and alleviating the symptoms of ED with variable
treatment periods. Therefore, the aim of this meta-analysis and systematic review is to
determine the effectiveness of KD in the management of ED in children.
METHODS
This systematic review and meta-analysis followed the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) statement as a guideline for reporting
(7).
Databases searches: In January 2018, the authors conducted EMBASE, MEDLINE (via
PubMed), ProQuest Medical and Google Scholar. The review team developed a list of
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search strategy, including terms ketogenic diet, epilepsy, seizures, epileptic disorders,
seizure disorders, and children. Furthermore, the review team manually screened the
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references of the found papers for potential inclusion in the review. English language and
human studies were set as limits.
The authors included all studies that aimed to study the effectiveness of KD in children
with ED. Included studies satisfied the following criteria: (i) they were published in the
English language; (ii) published between 1998 and 2017, and (iii) the focus of the study
was to examine the effectiveness of KD in children with ED. The outcome of interest was
50% reduction in seizure frequencies.
Data synthesis and statistical analyses: Two review authors independently assessed each
study. The agreement was reached after panel discussion, and then eligibility was
determined. For each study, the following data were extracted: study ID, year of study,
country, study design, sample size, sample characteristics, age at start of the KD, main
results/findings, and any other significant clinical notes.
The data were pooled in this meta-analysis using random-effects model using the
DerSimonian-Laird method, reporting the pooled prevalence and corresponding 95%
confidence interval. Data were presented using Forest plot. When two or more studies
reported the same dataset, the first publication was included in the meta-analysis. An
assessment of studies heterogeneity using the I2 statistic was performed; the value ≥ 75%
was used to represent high heterogeneity.
Ethical considerations: As this review is a sort of secondary analysis aiming at assessing
data from publications that are already indexed and available in the public domain, no
ethical approval nor informed consent were applicable.
RESULTS
Study characteristics: As presented in Table 1, fourteen studies, accounting for 1276
participants in eight different countries were included in the analysis. Female participants
were 42%. The age range was two months to eighteen years of age. The median age at
the start of KD was 40 months of age (range 20-90 months), while the median number of
AED used by participants were three AED (range 2-8 medications). The median number
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of participants per study was 49 (range 9-317). Five out of the fourteen studies used
observational research design (mainly cohort design), and the remaining nine used
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experimental research design to report the effectiveness of KD in the management of ED.
The effectiveness of KD in children with ED: The number of participants experienced

≥50% reduction in seizures frequency were pooled using random effects meta-analysis
after one month, three months, six months and twelve months of treatment.
One month: As depicted in Figure 1, three studies reported the effectiveness of KD after
one month of treatment. The results indicated that 22.9% benefited from the diet (21/98
children, 95% CI 0%-47.5%); with statistically significant evidence of between-study
heterogeneity I2 = 93.1%, P<0.001.
Three months: Six studies reported the effectiveness of KD after three months of
treatment. Results indicated that 49.9% benefited from the diet (269/830 children, 95%
CI 23.3%-76.5%); with statistically significant evidence of between-study heterogeneity
I2 = 98.8%, P < 0.001 (Figure 2).
Six months: As shown in Figure 3, four studies reported the effectiveness of KD after six
months of treatment. Results indicated that 37.9% benefited from the diet (320/872
children, 95% CI 24.1%-51.7%); with statistically significant evidence of between-study
heterogeneity I2 = 94.45%, P < 0.001.
Twelve months: Three studies reported the effectiveness of KD after twelve months of
treatment. The results indicated that 30.8% benefited from the diet (237/806 children,
95% CI 17.5%-44.1%); with statistically significant evidence of between-study
heterogeneity I2 = 94.47%, P < 0.001 (Figure 4).
DISCUSSION
This review aimed to assess the effectiveness of KD as a therapeutic modality for
children with ED using a meta-analysis technique. This reviewing approach was designed
to complement previous studies by providing an analysis of what data available; insofar it
applies a rigorous statistical method to quantitatively define the efficacy of this treatment
in those patients for whom there is limited number of studies.
The findings from the fourteen included studies (total of 1276 participants) suggest there
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is an evidence that KD is effective in the management of some cases with ED, not all
cases. Reductions of seizure episodes by ≤ 50% using KD were 22.9%, 49.9%, 37.9%
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and 30.8% for one month, three months, six months and twelve months of treatment,
respectively.
It is clearly noticed that beyond three months of treatment with KD, the number of
participants experiencing ≤ 50% reduction of seizure frequency is much less than those at
three months of treatment. Many possible causes could have contributed to these results.
One possible cause is that participants may quit using KD after three months when they
start to experience side effects. Some of these side effects are life-threatening, including
metabolic acidosis (8). Other reported side effects are serious infections, development of
renal stones and hyperuricemia, significant gastrointestinal disturbances and allergic
reactions to KD (9,10). Recent report revealed that side effects of KD were reported in
about 80% (126 out of 158) of recruited children, most commonly emesis, food refusal,
and hypoglycemia (11). Interestingly, researchers did not find statistically significant
correlation between the severity of adverse effects and the three-month seizure reduction.
Other possible causes are that some patients withdraw from these studies when noticing
there is no change with the seizures frequency from the pre-KD period. Another possible
cause of why beyond three months the reduction rate is much less is that the age at which
the KD has started is variable in each study. Those who started KD treatment earlier in
their life will showed better outcomes over time even beyond three months of treatment.
On the other hand, late starting time of KD may not show obvious benefits beyond three
months of treatment.
Several studies demonstrate the major mechanisms that explain the increased inhibition
and/or decreased excitation induced by the KD. These involve the neurotransmitters
gamma-aminobutyric acid (GABA), brain glutamate, ketone bodies (KBs) such as β-
hydroxybutyrate (BHB), acetoacetate and acetone. KBs act not only as energy sources for
brain cells but also contribute to reducing their glucose consumption by modulating the
activities of neurotransmitters (12–14). However, there is growing evidence that KBs are
more than just energy sources for brain cells, in that they can exert profound cellular,
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biochemical, and epigenetic changes able to attenuate brain network excitability such that
occurs in epileptic patients. Recent experimental studies have appealed ketone-mediated
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effects on both excitatory (e.g., vesicular glutamate transporters) neurotransmission,
inhibitory (e.g., GABAergic, purinergic and ATP-sensitive potassium channels) and as

well as mitochondrial targets (e.g., respiratory chain and mitochondrial permeability
transition). Moreover, BHB appears to exert both epigenetic (i.e., inhibition of histone
deacetylases or inhibition of histone deacetylases or HDACs) and anti-inflammatory (i.e.,
peripheral modulation of hydroxycarboxylic acid receptor and inhibition of the nucleotide
oligomerization domain-like receptor protein 3 or NRLP3 inflammasome) activity. While
the latter two effects of BHB have yet to be directly linked to ictogenesis and/or
epileptogenesis, parallel evidence indicate that HDAC inhibition and a reduction in
neuroinflammation alone or collectively can block seizure activity (15).
The modulation of biogenic monoamine levels was proposed as a plausible mechanism
for interpreting the anticonvulsant effects of the KD. However, the specific mechanisms
underlying such activities remain unclear. One study on biogenic monoamines in the
cerebrospinal fluid of children treated with the KD showed that their dopamine and
serotonin levels were significantly reduced from 410 to 342 and from 158 to 137 nmol/L
(16.6 and 13.3% reductions, respectively) after a three- month treatment, whereas their
norepinephrine levels (from 51.7 to 51.0 nmol/L, 1.4% reduction) remained unchanged
(16). Those authors proposed that changes in biogenic monoamine levels are also
dependent upon whether children are respondent or non-respondent to the KD.
These fourteen studies critically and systematically reviewed have dealt with the
treatment of the KD in different epileptic syndromes. Different epileptic syndromes
respond differently to KD. For example, patients with Doose syndrome respond
significantly to KD with a reduction rate up to 100%, yet such a syndrome is so rare (17).
One possible reason why one month of treatment did not show significant reduction rate
is that it takes more than one month for KD to work on the brain and exert its anti-
epileptic effect. These variations in epilepsy syndrome types with multiple etiologies
represent an important limitation in understanding the relationships between KBs, KD,
and the neuronal mechanisms in the way of seizure control. Thus, some researchers
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proposed variable considerations that should be taken into account upon studying these
relationships: (i) chemical or physical mechanisms employed to induce seizures should
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follow standardized protocols; (ii) the etiologies of epilepsy are better characterized in
future clinical trials; (iii) the physiological levels of KBs should be more frequently
considered in experimental treatments; (iv) the potential side effects of treatments should
be systematically monitored; (v) biomarkers of treatment efficacies (levels of GABA,
KBs and biogenic monoamines) should be evaluated; and (vi) novel mechanisms of
action of KBs should be evaluated (18).
The study suggests multiple strength factors: it is a meta-analysis allowing a basic
resource of collection of scientific evidence studies, the fourteen studies analyzed in this
review were based on clinical results and showed reduction in seizures frequency used by
two different types of therapeutic diets (KD and Atkins diet) in different time periods;
one month, three months, six months, twelve months.
The review entails a list of limitations: it based on fourteen studies within a period of ten
years, only confined to the English language, and that the age group of children varies
greatly from few months and up to 17 years of age. Previous studies showed that KD is
effective for short-term use; therefore, it is recommended that it should be worked on to
prolong its effect in the involved patients.
CONFLICTS OF INTEREST
The authors declare no conflict of interest.
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Figure 1. The effectiveness of KD in children with ED after one month of treatment.
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Figure 2. The effectiveness of KD in children with ED after three months of treatment.
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Figure 3. The effectiveness of KD in children with ED after six months of treatment.
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Figure 4. The effectiveness of KD in children with ED after twelve months of treatment.
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Table 1: Systematic summary of the studies investigating the effectiveness of KD diet in children with ED included in the review
Study Authors Year Country Research Sample Sample Age at KD Main Results Notes
number Design size Characteristics
1. Dominique M. IJff19 2016 Netherland Experimental 50 Age of KD The Profile of Eight patients
study Age =1-18 years introduction Mood States dropped out
having =7.85 years vigor/activity = before the study
Refractory Age of seizure 20.86 16.50 endpoint of 4
seizure. onset=2.3 P=0.005* months (five
Female= 42% years The Personal patients from the
Male= 58% Adjustment and KD group and
KD = 28 Role Skills Scale- three patients
care-as-usual = 22 Third Edition from the care-as-
productivity = 9.31 usual group).
7.42
P=0.039* The
Hague Restrictions
in Childhood
Epilepsy Scale
rating severity of
seizures= 6.06 7.29
P=0.038* The
Social Emotional
Questionnaire
anxious and mood-
disturbed
behaviour= 8.73
15.22
P=0.049*
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Con…Table 1
2. Jeong A. Kim20 2016 Korea Experimental 104 Age =1-18 years Basal seizures
study Male= 55,7% At 12 weeks:
Female= 44,3% KD =38.6%
1 to 2 Y = 35,5% MAD =47.8%
2 to 6 Y = 31,7% Seizure freedom at
6 to 18 years = 12 weeks:
32.6% KD =53%
Anti-epileptic MAD =20%
drugs (mean)= 3 P-value=0,047
Used KD = 49%
Used MAD =51%
3. Tove Hallbook21 2014 Scandinavia Observational 290 Age = 0.5 – 18.6 5.3 years 121]42[(12 weeks) No statistically
study years 98]34[(24 weeks) significant
Male = 50.6% 95]33[(48 weeks) association was
Female = 49.3% 53]18[(96 weeks) found between
Anti-epileptic P-value = 0.03(12 treatment and no
drugs ≥ 6 weeks) treatment with
0.01 (24 weeks) any of the anti-
0.00(48 weeks) epileptic drugs
and seizure
reduction at any
month (p > 0.05)
4. Elisabeth Simon 2014 USA Experimental 9 Age=0.5-7 years Seizure
Tremblay17 study freedom=22.2%
Male=88.8% Complete seizure
Female=11.1% control = 77.7%
Age at first
seizure=27.1
months
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Anti-epileptic
drugs =3.7
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Con…Table 1
5. Ahmed Ghazavi22 2014 Iran Experimental 40 Age=1-16 years At 4 weeks
study Used Atkins=50% >50% reduction in
(70% male+30% Atkins
female) >55% reduction in
Used KD =50% KD
(65% male+35% At 8 weeks
female) 65% reduction in
Seizure frequency Atkins
before starting the 30% reduction in
diets: KD
KD =15.3 At 12 weeks
Atkins=14.1 70% reduction in
Atkins
70% reduction in
KD
6. Chenqu Suo23 2012 China Experimental 317 Age = 1.6 – 17.8 3.3 years 111]35[(12 weeks) Number of cases
study years 83]26.2[(24 weeks) related to the
Male = 64.9% 59]18.6[(48 weeks) etiologies of
Female = 35.1% At ]12 weeks[ seizure:
Anti-epileptic P-value = 0.039 in Idiopathic = 12
drugs ≥ 3 the difference < 10 Cryptogenic =
years and ≥10 years 161
age group. Symptomatic =
144
121
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Con…Table 1
7. Baomin Li24 2012 China Experimental 31 Age =0.58 – 7 2.5 years 16]51.61[(1week) Efficacy by
study years 21]67.74[(4 weeks) seizure
22]70.97[(12 syndromes:
Male = 61.2% weeks) Infantile spasms=
Female = 38.7% 81.25%
Lennox-Gastaut
Anti-epileptic syndrome=54.55
drugs ≥3 %
Doose
Syndrome=100%
Dravet
Syndrome=50%
8. Natacha Porta25 2009 France Observational 27 Female= 88% Mean = 2.7 Seizure reduction The decrease of
study Male= 12% years >50% serum
KD = 17 4 weeks =59% arachidonic acid
MAD = 10 (p = 0.28) levels might be
Anti-epileptic 12 weeks = 64% involved in the
drugs ≥ 3 (p = 0.03) anticonvulsive
24 weeks = the effects of KD or
different not MAD.
significant The sample size
(p = 0.24) had childhood
48 weeks= 6 epilepsy (more
remain on either than 2 seizures
diet per week)
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Con…Table 1
9. Myung-Kul Yum26 2008 Korea Observational 17 Age = 1- 3 years 1.7 years 10] 58.8[ KD may have an
study Male = 76.4% P-value=0.000 anticonvulsive
Female = 23.5% effect by
Anti-epileptic decreasing the
drugs ≥ 2.5 regularity of the
EEG dynamics.
10. Celina C. Martinez27 2007 USA Observational 66 Age: 0.16– 9.7 Y Seizure free: Compare the
Male: 58% 3.1 years 49% (1 w) recurrence rate of
Female: 42% 33% (6 m) using KD and
15% (> 6 m) ADE
P value=0.31 (1 W) Which was
*Seizure slightly lower by
recurrence: 20% in KD
20% (2.4 yr.)
11. Roberto Carabello28 2006 Argentina Experimental 11 Age of KD Mean=5 years 18.2% (seizure
study initiation=5 years free)
37% female 18.2%(75% to 99%
63% male reduction)
Anti-epileptic 18.2%(50% to 74%
drugs (mean)= reduction)
2.2 years at diet
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Con…Table 1
12. Hoon Chul Kang29 2005 Korea Observational 199 Age: 0.5–17.6 4.8 years Seizure > 50% Seizures were not
study years reduction: controlled by
Male: 55.3% 58% (24 weeks) combining three
Female: 44.7% 41% (48 weeks or more anti-
Seizure free: epileptic drugs in
33% (24 weeks) 199 patients.
25% (48 weeks) Two types of KD
protocol were
used.
No significant
variable was
related to the
efficacy but
patient with
symptomatic and
partial epilepsy
shows more
relapse after
completion of the
diet
13. G.Christina Burgqvist30 2005 USA Experimental The Age =1- 14 years At 12 weeks
study FAST- Age mean = 5.3 58 % of FAST- KD
KD years had > 50%
protocol reduction in
began Male= 71% seizure. Moreover,
with a fast Female= 29% 21% seizure -free.
lasting ≤
48 h. Anti-epileptic At 12 weeks, 67%
GRAD- drugs used prior of GRAD- KD had
124
KD= to KD = 7.7 > 50% reduction is
protocol Anti-epileptic seizure. In addition,
began on drugs used when 21% seizure-free.
Page
day 2 KD started= 2.3
with a 1:1
ratio Seizure per week
(fat: rate= 9.6 (mean)
carbohydr
ate +
protein)
by
weight,
full-
calorie-
goal
meals,
and then
daily
advanced
to a 2:1,
3:1.
14. Elisabeth B Marsh31 2005 USA Experimental 67 Age=0.5-15.7 From 67 cases:
study years 10 underwent
59.7% male surgery
40.2% female 3 underwent Vagal
Seizure Nerve Stimulation
frequency=921/mo implantation
nth Remaining 41 cases:
Anti-epileptic 21.9% (seizure free),
drugs =1.89 9.7% (>90%
reduction),
14.6%(50%-90%
reduction),
125
53.6% (<50%
reduction)
Page

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The Canadian Journal of Clinical Nutrition, Volume 6, Issue 2, June 2018

ISSN 1927-8942 (Print Edition), ISSN 1927-8950 (Online Edition)

Review Article Page 105-125

Effectiveness of Ketogenic Diet in Children with Epileptic Disorders: A Meta-

Duha Janahi1, Feras Alhussainy1, Fatimah Al Hassan1, Taiba Alhumaidi1, Deema

*Corresponding Author Email Address: hjahrami@health.gov.bh

Keywords: Ketogenic Diet, Epileptic Disorder, Children, Meta-analysis, Systematic Review

Citation: Janahi D, Alhussainy F, Al-Hassan F, Alhumaidi T, Altamimi D, Alharbi S, Zainal

O, Jahrami H, Faris MAI. Effectiveness of Ketogenic Diet in Children with Epileptic

of action of KD in epilepsy were summarized in a recent review: evidence suggest that

experimental research design to report the effectiveness of KD in the management of ED.

The effectiveness of KD in children with ED: The number of participants experienced

effects on both excitatory (e.g., vesicular glutamate transporters) neurotransmission,

inhibitory (e.g., GABAergic, purinergic and ATP-sensitive potassium channels) and as

Interventions: Explanation and Elaboration. PLOS Med 2009;6(7): e1000100.

children. Seizure 2013;22(3):174–178.

electroencephalographic features of children with drug therapy-resistant epilepsy.

Figure 1. The effectiveness of KD in children with ED after one month of treatment.

Figure 2. The effectiveness of KD in children with ED after three months of treatment.

Figure 3. The effectiveness of KD in children with ED after six months of treatment.

Figure 4. The effectiveness of KD in children with ED after twelve months of treatment.

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