P19 Development of a guideline on management of medicines for patients on a ketogenic diet

2018 ◽  
Vol 103 (2) ◽  
pp. e2.21-e2
Author(s):  
Anneka Sareen
Keyword(s):  
Ketogenic Diet ◽  
Carbohydrate Content ◽  
List Type ◽  
Street Hospital ◽  
Practical Advice ◽  
Diagnosis And Management ◽  
Children's Hospital ◽  
Ketogenic Diets ◽  
Children’S Hospital ◽  
Carbohydrate Contents

AimThe National Institute for Health and Care Excellence (NICE) states that initiation of a ketogenic diet should be considered for children and young people whose epilepsy has not responded to anti-epileptic drug therapy.1 At present, no guideline exists within the Trust about ketogenic diets and so it was agreed that some guidance would be appropriate to guide doctors, nursing staff and pharmacists about how to manage medication for paediatric patients on a ketogenic diet.MethodA literature search was conducted using Embase and Medline with the search terms ‘ketogenic diet’ and ‘epilepsy.’ The only filters included in the search were to ensure information was in English and that human subjects were the focus. Guidance used within other Trusts and recommendations from the International Ketogenic Diet Study group were also considered.There is a paediatric ketogenic dietician within the Trust and so she was consulted for her advice throughout guideline development.ResultsA guideline has been produced that addresses how medicines should be managed for patients on a ketogenic diet. If any new medicines are initiated within hospital, practical advice is given on how to ensure the carbohydrate content is minimal, and the importance of ensuring ketone levels are monitored.The guideline also briefly considers the acute and chronic effects of the ketogenic diet and how these may result in other medicines and supplements being prescribed. Given that there is no nationally recognised resource available for identifying the carbohydrate contents of medicines, all oral anti-epileptic medication, analgesics and antibiotics that could be used within the Children’s Hospital were considered and the carbohydrate contents confirmed with the relevant manufacturers, with the aim of guiding prescribing decisions about the management of pain, infections and epilepsy.Despite many liquid medicinal preparations stating that they are ‘sugar free,’ they will often contain large amounts of sorbitol and other ingredients that are sources of carbohydrate, which will be problematic for ketogenic diet patients.2 Given that liquid preparations are largely used within the Children’s Hospital, the guideline gives practical advice about key sources of carbohydrate that may be found in liquid medicines and hence ingredients that should be avoided where possible.ConclusionThe research conducted to develop this guideline has shown that ketogenic diets can be a very effective method for reducing seizure activity.2 Considering that the carbohydrate content of medication can affect whether a patient is in a state of ketosis, it is important for healthcare professionals to acknowledge how to manage any changes to a patient’s medication. It is hoped that by providing the carbohydrate content of certain medicines within the guideline, patients will be treated in hospital without ketone levels being compromised.ReferencesNational Institute for Health and Care Excellence. Epilepsies: Diagnosis and management (CG137). Available from: https://www.nice.org.uk/guidance/cg137/resources/epilepsies-diagnosis-and-management-35109515407813 [Accessed: 4th July 2016].Great Ormond Street Hospital NHS Trust for Children. Ketogenic diet. Available from: http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/ketogenic-diet [Accessed: 5th July 2016].

scholarly journals P53 A review of the use of intravenous immunoglobulin (IVIG) in paediatric neurology patients at a children’s hospital from April 2017 to April 2019

2020 ◽  
Vol 105 (9) ◽  
pp. e34.2-e35
Author(s):  
Olivia Stillwagon
Keyword(s):  
Intravenous Immunoglobulin ◽  
Electronic System ◽  
List Type ◽  
National Guidelines ◽  
Request Form ◽  
Children's Hospital ◽  
Acute Flaccid Myelitis ◽  
Department Of Health ◽  
Audit Data ◽  
Children’S Hospital

AimTo determine if the use of IVIG in neurology patients at a children’s hospital was appropriate according to local1 and national guidance2 3.MethodAll paediatric neurology patients supplied with IVIG from the hospital pharmacy from April 2017 to April 2019 were identified retrospectively using the pharmacy dispensing system. The standards were based on local and national guidelines from the Department of Health (DoH). Patients’ details, for example indication and dose, were recorded and analysed on Microsoft Excel.Standards100% of patients will have an IVIG request form completed.100% of patients will have IVIG prescribed for indications approved by the DoH.100% of patients will have panel approval before being supplied with IVIG.100% of patients will have the appropriate dose and duration of IVIG for the corresponding indication according to guidelines.ResultsA total of 20 patients were identified for this audit with 4 patients from 2017/18 and 16 from 2018/19. Standard 1 was met by 100% of patients. 8 patients (40%) were given IVIG for indications that do not have automatic approval from the DoH guidelines, i.e. for indications under ‘grey’ or ‘black’ categories. 2 patients (10%) did not have panel approval and both of these patients had acute flaccid myelitis, which is a ‘black’ indication. 16 (80%) patients were prescribed IVIG at a dose or duration advised by local and DoH guidelines.Conclusion and DiscussionDuring the study period the method for completing the IVIG request forms changed to a new electronic system. The two patients with acute flaccid myelitis were incorrectly approved by the IVIG panel due to an error in the new electronic request form. The approval system was updated to prevent this error from reoccurring. All other patients that did not have automatic approval from the DoH guideline were approved by the local IVIG panel before use. Overall cost and usage increased significantly from 2017/18 to 2018/19; approximately £9,300 and £57,000 respectively. One patient was given a higher dose over a shorter period but the total dose for each course was the same. The shortened regimen meant that doses were rounded to the nearest vial size, which reduced wastage. The demand for IVIG is increasing and due to its limited availability and high cost, it is important that IVIG is only given to patients that meet the specified requirements.RecommendationsEnsure patients are only supplied with IVIG if the above standards are metNeurology pharmacist to re-audit data annually to ensure that IVIG is being given according to guidelinesReferencesPharmacists in a children’s hospital. 2017. Clinical guideline: human intravenous immunoglobulin (Privigen 100 mg/ml).Department of Health. Clinical Guidelines for Immunoglobulin Use. 2011. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216671/dh_131107.pdfDepartment of Health. Updated Commissioning Criteria for the use of therapeutic immunoglobulin (Ig) in immunology, haematology, neurology and infectious diseases in England January 2019. Available from: http://igd.mdsas.com/wp-content/uploads/Ig-PWG-Guidance-for-the-use-of-Ig-V1.3-12022019.pdf

Carbohydrate and Alcohol Content of 200 Oral Liquid Medications for Use in Patients Receiving Ketogenic Diets

PEDIATRICS ◽  
1996 ◽  
Vol 97 (4) ◽  
pp. 506-511
Author(s):  
Thomas J. Feldstein
Keyword(s):  
Health Care ◽  
Ketogenic Diet ◽  
Drug Product ◽  
Pharmaceutical Products ◽  
Carbohydrate Content ◽  
Alcohol Content ◽  
Care Givers ◽  
Ketogenic Diets ◽  
Oral Liquid ◽  
Liquid Products

Objective. The ketogenic diet is used in patients with intractable seizure disorders. To maintain a ketotic state, patients on this diet must maintain a strict low-carbohydrate intake. Because these patients often require medication, and because many pharmaceutical products (especially liquid formulations) contain significant quantities of carbohydrates, it is important that each drug product be evaluated before proceeding with the ketogenic diet. The purpose of this study was to compile the carbohydrate content of oral liquid products for patients on or considering a ketogenic diet. Methods. A list of 200 oral liquid drug products and their manufacturers was compiled using the Children's Health Care-Minneapolis pharmacy purchasing database, the Physicians' Desk Reference, and previously published lists of oral liquid medications. Manufacturers were contacted either by telephone or by letter and asked specifically about the sucrose, fructose, sorbitol, glycerin, and alcohol content of these liquid formulations. Results. The carbohydrate and alcohol content of 200 oral liquid products was determined and shown in an accompanying table. Conclusions. Many oral liquid medications contain significant amounts of carbohydrate. Tablet and capsule formulations are preferred when possible. To date, it has been difficult to quantify the carbohydrate content of liquid medications because of unavailability of this information. The carbohydrate content of 200 oral liquid medications is provided here to assist health care practitioners, patients, and care givers in designing drug regimens low in carbohydrates for patients on or considering a ketogenic diet.

scholarly journals Using machine learning to guide targeted and locally-tailored empiric antibiotic prescribing in a children’s hospital in Cambodia

2018 ◽  
Author(s):  
Mathupanee Oonsivilai ◽  
Mo Yin ◽  
Nantasit Luangasanatip ◽  
Yoel Lubell ◽  
Thyl Miliya ◽  
...  
Keyword(s):  
Machine Learning ◽  
Decision Support ◽  
Patient Outcomes ◽  
Empiric Therapy ◽  
Patient Data ◽  
Machine Learning Algorithms ◽  
List Type ◽  
Children's Hospital ◽  
Empiric Antibiotic ◽  
Children’S Hospital

AbstractBackgroundEarly and appropriate empiric antibiotic treatment of patients suspected of having sepsis is associated with reduced mortality. The increasing prevalence of antimicrobial resistance risks eroding the benefits of such empiric therapy. This problem is particularly severe for children in developing country settings. We hypothesized that by applying machine learning approaches to readily collected patient data, it would be possible to obtain actionable and patient-specific predictions for antibiotic-susceptibility. If sufficient discriminatory power can be achieved, such predictions could lead to substantial improvements in the chances of choosing an appropriate antibiotic for empiric therapy, while minimizing the risk of increased selection for resistance due to use of antibiotics usually held in reserve.Methods and FindingsWe analyzed blood culture data collected from a 100-bed children’s hospital in North-West Cambodia between February 2013 and January 2016. Clinical, demographic and living condition information for each child was captured with 35 independent variables. Using these variables, we used a suite of machine learning algorithms to predict Gram stains and whether bacterial pathogens could be treated with standard empiric antibiotic therapies: i) ampicillin and gentamicin; ii) ceftriaxone; iii) at least one of the above.243 cases of bloodstream infection were available for analysis. We used 195 (80%) to train the algorithms, and 48 (20%) for evaluation. We found that the random forest method had the best predictive performance overall as assessed by the area under the receiver operating characteristic curve (AUC), though support vector machine with radial kernel had similar performance for predicting Gram stain and ceftriaxone susceptibility. Predictive performance of logistic regression, simple and boosted decision trees and k-nearest neighbors were poor in comparison. The random forest method gave an AUC of 0.91 (95%CI 0.81-1.00) for predicting susceptibility to ceftriaxone, 0.75 (0.60-0.90) for susceptibility to ampicillin and gentamicin, 0.76 (0.59-0.93) for susceptibility to neither, and 0.69 (0.53-0.85) for Gram stain result. The most important variables for predicting susceptibility were time from admission to blood culture, patient age, hospital versus community-acquired infection, and age-adjusted weight score.ConclusionsApplying machine learning algorithms to patient data that are readily available even in resource-limited hospital settings can provide highly informative predictions on susceptibilities of pathogens to guide appropriate empiric antibiotic therapy. Used as a decision support tool, such approaches have the potential to lead to better targeting of empiric therapy, improve patient outcomes and reduce the burden of antimicrobial resistance.Author summaryWhy was this study done?Early and appropriate antibiotic treatment of patients with life-threatening bacterial infections is thought to reduce the risk of mortality.In hospitals that have a microbiology laboratory, it takes 3-4 days to get results which indicate which antibiotics are likely to be effective; before this information is available antibiotics have to be prescribed empirically i.e. without knowledge of the causative organism.Increasing resistance to antibiotics amongst bacteria makes finding an appropriate antibiotic to use empirically difficult; this problem is particularly severe for children in developing country settings.If we could predict which antibiotics were likely to be effective at the time of starting antibiotic therapy, we might be able to improve patient outcomes and reduce resistance.What Did the Researchers Do and Find?We evaluated the ability of a number of different algorithms (i.e. sets of step-by-step instructions) to predict susceptibility to commonly-used antibiotics using routinely available patient data from a children’s hospital in Cambodia.We found that an algorithm called random forests enabled surprisingly accurate predictions, particularly for predicting whether the infection was likely to be treatable with ceftriaxone, the most commonly used empiric antibiotic at the study hospital.Using this approach it would be possible to correctly predict when a different antibiotic would be needed for empiric treatment over 80% of the time, while recommending a different antibiotic when ceftriaxone would suffice less than 20% of the time.What Do These Findings Mean?Using readily available patient information, sophisticated algorithms can enable good predictions of whether antibiotics are likely to be effective several days before laboratory tests are available.Algorithms would need to be trained with local hospital data, but our study shows that even with relatively limited data from a small hospital, good predictions can be obtained.Used as part of a decision support system such algorithms could help choose appropriate antibiotics for empiric therapy; this would be expected to translate into better patient outcomes and may help to reduce resistance.Such as a decision support system would have very low costs and be easy to implement in low- and middle-income countries.

Paediatric tracheostomy tubes: recent developments and our current practice

2018 ◽  
Vol 132 (11) ◽  
pp. 961-968 ◽  
Author(s):  
D J Tweedie ◽  
J Cooke ◽  
K A Stephenson ◽  
S L Gupta ◽  
C M Pepper ◽  
...  
Keyword(s):  
Tracheostomy Tube ◽  
Current Practice ◽  
Small Range ◽  
Street Hospital ◽  
Children's Hospital ◽  
Great Ormond Street Hospital ◽  
Design Changes ◽  
Children’S Hospital ◽  
Recent Developments ◽  
Tracheostomy Tubes

AbstractObjectiveA variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital.MethodsThis paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments.ResultsOur preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes.ConclusionThe choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.

113 Ketogenic diet services at children’s hospital across the united kingdom

2019 ◽  
Author(s):  
Zoe Simpson ◽  
Christin Eltze ◽  
Hannah Smith ◽  
Bahee Van de Bor ◽  
Victoria Urban ◽  
...  
Keyword(s):  
United Kingdom ◽  
Ketogenic Diet ◽  
Children's Hospital ◽  
The United Kingdom ◽  
Children’S Hospital

The Ketogenic Diet in Refractory Epilepsy: The Experience of Children's Hospital of Pittsburgh

2000 ◽  
Vol 39 (3) ◽  
pp. 153-159 ◽  
Author(s):  
Neelam G. Katyal ◽  
Anita N. Koehler ◽  
Bill McGhee ◽  
Catherine M. Foley ◽  
Patricia K. Crumrine
Keyword(s):  
Ketogenic Diet ◽  
Refractory Epilepsy ◽  
Children's Hospital ◽  
Children’S Hospital

Double Outlet Right Ventricle With Right-Sided Aorta From the Left-Sided Morphologically Right Ventricle in the Setting of Discordant Atrioventricular Connections

2017 ◽  
Vol 11 (4) ◽  
pp. NP72-NP76
Author(s):  
Sachin Talwar ◽  
Robert H. Anderson ◽  
Amolkumar Bhoje ◽  
Adrian Crucean ◽  
Saurabh Kumar Gupta ◽  
...  
Keyword(s):  
United Kingdom ◽  
Right Ventricle ◽  
Double Outlet Right Ventricle ◽  
Diagnosis And Management ◽  
Children's Hospital ◽  
The United Kingdom ◽  
Rare Combination ◽  
Children’S Hospital

We describe the anatomic findings in a 2-year-old patient with double outlet right ventricle with right-sided aorta in the setting of usual atrial arrangement and discordant atrioventricular connections, making comparison with a specimen from the pathological archive of the Birmingham Children’s Hospital in the United Kingdom having this rare combination of anatomic features. We discuss the challenges involved in diagnosis and management.

scholarly journals Severe ketoacidosis in a non-diabetic lactating woman on a ketogenic diet

2020 ◽  
Vol 20 (2) ◽  
pp. 145-146
Author(s):  
John Alexander ◽  
Dinesh Nagi
Keyword(s):  
Ketogenic Diet ◽  
Breast Feeding ◽  
Carbohydrate Content ◽  
Efficacy And Safety ◽  
High Fat ◽  
Term Efficacy ◽  
Ketogenic Diets ◽  
Low Carbohydrate

Ketogenic diets are high fat, moderate protein, low carbohydrate diets with carbohydrate content usually less than 50 g/day. They are a novel intervention in the management of obesity and there is emerging evidence that they are very effective. Evidence regarding the long-term efficacy and safety of this rather new and popular intervention is still emerging and there is a lack of data on the effect of this diet in specific populations such as breast feeding women. We describe a case of severe ketoacidosis in a non-diabetic breast feeding woman who was successfully treated with conservative measures. This case highlights the need by medical and dietetic professionals for extra caution in initiating special dietary measures in susceptible physiological states.

scholarly journals Experience of the ketogenic diet therapy of the ketogenic diet team in a third-line children’s hospital

2018 ◽  
Author(s):  
Aycan Ünalp ◽  
Gürkan Gürbüz ◽  
Selvinaz Edizer ◽  
Bahar Toklu Baysal ◽  
Zeynep Akışın ◽  
...  
Keyword(s):  
Ketogenic Diet ◽  
Diet Therapy ◽  
Children's Hospital ◽  
Children’S Hospital ◽  
Third Line

scholarly journals P.107 Response to the Ketogenic Diet in refractory epileptic spasms at BC Children’s Hospital

2021 ◽  
Vol 48 (s3) ◽  
pp. S49-S50
Author(s):  
PM Webb ◽  
A Datta
Keyword(s):  
Ketogenic Diet ◽  
Neurodevelopmental Outcome ◽  
Retrospective Chart Review ◽  
Optimal Time ◽  
Unknown Etiology ◽  
Seizure Type ◽  
Early Therapy ◽  
Children's Hospital ◽  
Epileptic Spasms ◽  
Children’S Hospital

Background: Epileptic spasms (ES) are a devastating seizure type with poor neurodevelopmental outcome; 1/3 are resistant to treatment with first line therapies. Recently attention has been drawn to the ketogenic diet (KD) as a potentially effective therapy, though data regarding optimal time of initiation, and its sustained effectiveness, are lacking. Methods: Retrospective chart review of all patients with ES treated with KD at BC Children’s Hospital between 2002 and 2020 (n=28) with comparison of spasm response based on age of initiation of KD in two groups: < 12 months (n=11) and ≥ 12 months (n=17). Results: Comparing the <12 months and ≥ 12 months groups showed: unknown etiology in 9% vs 25%; spasm freedom for 3 months on KD in 18% vs 41%; median time to spasm freedom was 2 vs 6 weeks; relapse after a period of spasm freedom occurred in 66% vs 70%. Conclusions: Although more effective in children ≥ 12 months of age in the first 3 months, spasm freedom in either group was not sustained with KD. KD is recommended as early therapy for refractory ES, but this study suggests clinicians be aware the KD has limited efficacy in long-term control of ES and must be used with other therapies.

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