A case study highlighting some of the key benefits of using K.Flo as an enteral tube feed as part of a ketogenic diet.
The patient is an 18 year old female who lives at home with parents and older siblings. She attends a school for children with special educational needs and has regular respite.
Severe drug resistant epilepsy, secondary to pneumococcal meningitis in infancy. Constipation.
Prior to commencing a ketogenic diet (KD), the patient had daily seizures including generalised tonic clonic seizures, tonic seizures, atonic seizures and absences.
At the age of 14 years old, she was commenced on a 4:1 classical KD via a gastrostomy. She had been fully gastrostomy fed for many years due to a reduced oral intake and poor weight gain.
Previously tried medication: Clobazam, Clonazepam, Sodium Valproate, Lamotrigine, Carbamazepine, Topiramate, Rufinamide
Current medication: Levetiracetam liquid 7.5ml bd and Laxido - 2 sachets per day.
She had a good response with seizure control continually improving throughout her first two years on the KD. She achieved periods of seizure freedom and was much more alert and brighter on the diet.
She maintained a good level of ketosis and it was noted that if her ketones were high, her seizure control was better.
After 2 years, and in a period of relative stability and good seizure control, a wean off KD was attempted. Unfortunately, on reducing the ratio of feed to 2.5:1, her status was deemed much worse and the feed ratio was increased back up to 4:1. Ketones increased again up to 4-5mmol/l and the patient was clinically much improved, she was still having daily seizures but they were not as severe and long lasting.
After 4 years on KD, the patient participated in the K.Flo clinical trial. At this point she was having 2 - 3 tonic clonic seizures per day and was on the waiting list for vagal nerve stimulation (VNS) therapy.
Classical 4:1 ratio
|Daily estimated energy requirements (EER)1||1410kcal/d*|
|Minimum safe level of protein (0.82g protein/kg/day)3||41.1g/d|
*calculated using low physical activity level factor
Feed: Proprietary ketogenic 4:1 liquid feed
Target Feed Volume: 940ml/24hrs
|Feed plan provided:|
|Protein (0.58g /kg/day)||29g/d (70% min safe level of protein)|
***Target fluid intake was achieved with regular 60ml of water flushes throughout the day and before and after each feed.
Due to the patient’s low energy requirements and need for a high ratio feed, it had been an ongoing challenge to achieve the minimum safe level of protein. It was not possible to meet the patient’s minimum safe protein intake whilst maintaining a 4:1 ratio, without dramatically increasing energy (kcal) and her weight had already increased significantly prior to starting the trial.
Direct swap from proprietary ketogenic 4:1 liquid feed to K.Flo
Target feed volume: As above - 940ml/24rs
|K.Flo feed plan provided:|
|Protein (0.64g /kg/day)||32g/d (78% min safe level of protein)|
The protein intake was still suboptimal and did not meet the patient’s minimum safe level of protein, however, it was reassuring that K.Flo pushed her protein intake in the right direction and both the pre trial feed and K.Flo met the UK reference nutrient intake (RNI) for all micronutrients.
Weight: On starting trial: 50.1kg (between the 9th and 25th centile)5. Unfortunately, no further weight was obtained at the end of the 1 month trial as the family were unable to get the patient weighed due to Covid-19 restrictions. Her weight 1 year later was 51.4kg which remained between the 9th and 25th centile.
Patient maintained a good level of ketosis for the duration that they were on K.Flo with ketones consistently 4+mmol/l. Six monthly routine keto bloods were all acceptable and not of concern before the K.Flo trial and for the duration that the patient was on K.Flo.
For the duration of the trial, the patient had a period of stability. Her seizure control did not change and there was no change to her anti-epileptics during the trial period.
The patient has always suffered from constipation. Prior to starting the K.Flo trial, she was on a daily laxative, Laxido, to help maintain a regular bowel movement and this was reduced to 2-3 times per week.
During the trial her parents noted that the need for daily Laxido reduced and they attributed this from swapping to K.Flo. K.Flo contains more fibre# than the pre-trial proprietary ketogenic feed, increasing total fibre from 10.5g to 13.2g fibre per day.
The patient adhered to the use of K.Flo for the duration of the trial. She maintained a good level of ketosis and no change was noted in seizure activity. Her parents were keen to continue K.Flo as the benefit to her bowel health was maintained, her bowels opened much better and she required less Laxido.
The patient remained on K.Flo after the completion of the 4 week trial period