During ketogenic diet initiation children are routinely monitored for complications that may arise. Blood glucose levels are checked every 2 h for infants and 4 h for children over the age of one year then reduced to every 4-6 h, respectively, once a child is stable and the diet is being well tolerated. Symptoms of hypoglycemia include dizziness, fatigue, and nausea. If the blood glucose level drops below 50 mg/dL, the child is treated with 15-30 cc of apple juice and rechecked in 30-60 min. If the child is unable or refuses to consume the juice orally or enterally, an iv bolus of glucose (0.25 g/kg) may be given. Theoretically, children who are very active, very young, or very thin have minimal glycogen stores and thus become hypoglycemic more easily than children who are at or above their ideal weight or who are inactive. Untreated hypoglycemia may result in excessive ketosis.
Ketosis is measured with urine test strips upon each urine void that the child produces. Ketone levels usually appear in the urine when glucose levels fall below 70 mg/dL. If the child is monitored appropriately for hypoglycemia, it is unlikely that excessive ketosis will occur (unless there is an underlying metabolic disorder). Symptoms of excessive ketosis include lethargy, nausea, vomiting, and rapid shallow breathing (Kussmaul respirations). The condition can progress to coma and even death if untreated. Excessive ketosis can be remedied with glucose administration as described in the paragraph above. The caregiver needs to be instructed on how to remedy hypo-glycemia and excessive ketosis, should these symptoms develop at home.
During ketogenic diet initiation it is important to monitor the hydration status of the individual. A urine specific gravity test performed at bedside can quickly determine urine concentration. A fluid "schedule" should be outlined with reasonable quantities of calorie-free, caffeine-free fluids to be consumed daily based on the child's maintenance fluid goals. If the child is unable to meet these goals and the urine specific gravity is overconcentrated, i.e., >1.020 on a Bayer Multistix 10SG, a bolus of iv fluids without dextrose should be given. Continuous intravenous administration may discourage the child from drinking fluids and should be avoided.
The child's vital signs should be checked every 8 h during ketogenic diet initiation, until they are stable and the child is tolerating the full diet. The child's weight should be measured daily in the hospital and weekly at home. Children often experience weight loss during the initial stages of the diet as a result of the diets diuretic effect. However, the weight should stabilize and return to baseline in a few weeks.
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