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Management of Nutritional Issues Associated with Alternating
Hemiplegia of ChildhoodMaria Raspolic MS, RD
Santa Clara Valley Medical Center
Objectives: Review most common nutritional issues in
AHC Provide recommendations to minimize
above issues Review ketogenic diet as treatment for
seizures
Management of Nutritional Issues Associated with Alternating Hemiplegia of Childhood
Poor growth Dehydration Constipation Decreased bone mineral density
Common Nutritional Issues Associated with AHC
Inadequate nutrient intakes Decreased muscle tone Oral motor dysfunction Limited growth potential Frequent illness, fatigue, infections
Poor Growth
Growth Assessment
1. 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
Intervention
2. 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
Intervention con’t.
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
Intervention con’t.
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
Dehydration
100 cc/kg of body wt for the first 10 kg50 cc/kg for the second 10 kg20 cc/kg for the additional kgs
44 lbs :2.2 = 22 kg1000 + 500 + 40 = 1540 cc1540: 30 = 51 oz
How much fluid?
Provide hi nutritional value liquids: Milk, soy, rice, almond, coconut Smoothies, milkshakes ? juice
Recomendation
Multifactorial cause Poor intakes of fluids and solids Low muscle tone/ GI motility Low activity levels Low fiber diet
Constipation
Contributes to poor appetite Abdominal distention/discomfort Irritability Adequate fluid intakes and fiber Hi fiber foods: cereal (5 gr/serving),
legumes Sweet potatoes, fruits/vegetables Prune or pear juice
Constipation con’t.
If additional help needed:Milk of magnesiaLactuloseMiralaxBenefiber
Constipation con’t.
Limited ambulation Inadequate intakes of Ca, Phos, Vit D Anticonvulsant therapy Limited sun exposure If untreated may lead to osteoporosis,
bone deformities and fractures
Low Bone mineral Density
1-3 years: 500mg4-8 years 800 mg9-18 years 1300 mg
How Much Calcium is Needed?
Food sources/ table
Food Source Serving SizeAmount of Calcium per
Servingalmonds 3 ounces 210 milligrams (mg)
blackstrap molasses 1 tablespoon 170 mg
broccoli (cooked) 1 cup 60 mg
canned salmon (with bones)
3 ounces 180 mg
canned sardines (with bones)
3 ounces 325 mg
collards 1 cup 265 mg
cottage cheese 1 cup 155 mghard cheese (cheddar, swiss)
1 ounce 225 mg
kale (cooked) 1 cup 95 mg
milk 1 cup 300 mg
mozzarella cheese 1 ounce 200 mg
rhubarb (cooked) 1 cup 345 mg
ricotta cheese 1⁄2 cup 335 mg
spinach (cooked) 1 cup 245 mg
yogurt 8 ounces 425 mg
Calcium Sources in Food
Calcium CarbonateViactiv, Tumbs, Caltrate
Calcium CitrateCitracal
Oyster Shell, Bone Meal
Calcium Supplements
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)
Vitamin D
Recommend to check blood levels yearlyGoal: 30-60 mmol/dlSupplement 1000 IU/day
50 000 IU/ weekVit D3 (cholecalciferol) in the skin by sun expoVit D2 (ergocalciferol) synthesized by plants
15 min sun exposure prevent Vit D deficiency
Vitamin D con’t.
Borusiak et al, 2012128 children receiving one AED24 % hypocalcemia25% hypophosphatemia13% low vit DPhenobarb, Depakote, Trileptal, Dilantin
Vitamin D con’t.
Common in children with AHC Complete MVI recommended Chewable tablet preferred Liquid/soft gummy vits less minerals Bugs Bunny, Flinstone’s, Scooby Doo,
NanoVites
Vitamin and Mineral Deficiencies
How does it work? Brain needs glucose from food 24 hours supply Breakdown of fat produces ketones ??? Prevention of seizures
Ketogenic Diet
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 continue
Chances of success?
Dehydration-check urine daily with keto stickConstipation-MOM, MiralaxKidney Stones- UA, trace amount of bloodNutrient deficiency- complete MVI, ck blood
levels ZN, Se, Vit DDecreased growth- adjust protein, kcalHi Cholesterol- replace butter with olive oil,
supplement with carnitine
Side Effects of the diet
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
void
Initiation of the diet
Teach families how to calculate and prepare meals Keto meal planer Complexity of meals controlled by parents Ready to feed Ketogenic formula; Ketocal RCF for tube feeding
Initiation of the Diet con’t.
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
Discontinuation of the diet
ANY QUESTIONS OR COMMENTS?
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