Transcript epilepsycasestudypresentation - EPILEPSY Association Of Sri Lanka

Epilepsy Case Study I
Amy Good
Priority Nutrition Care Distance Dietetic Intern: Community Rotation
January 2014
Contents
• Overview of client
• Description of epilepsy
– Prevalence
– Diagnosis
– Medical treatment
• Medical nutrition therapy for epilepsy
• Nutritional assessment of client
– Nutrition diagnosis
– Nutrition intervention
– Monitoring and evaluation
Client Overview
• Female
• 4 years and 10 months old
• Past medical history of hydrocephalous
• Current medical history of epilepsy
– Being treated with Keppra
What is epilepsy?
• Seizure disorder
• Seizure occurs when a rush of electrical impulses affects the
brain
• Epilepsy can be categorized as:
– Symptomatic – linked to a specific disease or abnormality or
– Cryptogenic – not linked to a specific disease
Prevalence of epilepsy
• <2 years old and >65 years old
• Male
• Racial minority
• 200,000 new cases of epilepsy each year
Medical diagnosis of epilepsy
• History of seizures
Two main types of seizures
Tonic-clonic (grand mal) seizure
– Frequency
– Type
Absence (petit mal) seizure
• Electroencephalograph (EEG)
Description
Lasts 1-2 minutes, groggy/disoriented for
minutes to hours after regaining
consciousness, postictal phase is
characterized by sleep, headache,
confusion, soreness
May appear to be daydreaming, lasts only
a few seconds, no postictal
fatigue/disorientation, no loss of
consciousness
Medical treatment of epilepsy
• Antiepileptic drugs
– Some antiepileptic medications increase vitamin D metabolism in
the liver
•
Inhibits the absorption of calcium in the intestines. Long term use of these
medications may result in osteomalacia or rickets.
– Side effects range from anorexia to upset stomach to suicidal
tendencies
• Important for doctors to be involved and have regular follow ups when
clients are taking antiepileptic drugs
Medical Nutrition Therapy: Ketogenic Diet
• Can be used for children with all types of seizures
• Last resort if medication is not working
• 1/3 of children following the ketogenic diet became seizure
free
• The diet initiates ketosis
– Ketones in the blood are elevated
– Ketones are formed when glycogen stores have run out
• Not yet understood how diet decreases seizure occurrence
Two types of ketogenic diet
• “Traditional” ketogenic diet
– Introduced in the 1920’s
– Diet begins with fasting to induce ketonuria
– 4:1 ratio of fats to protein/CHO
– Fats should make up typically 75% of calories
– Fluids are restricted to no more than 2L/day
– Foods such as bread and pasta are not allowed
– Vitamin and mineral supplementation is encouraged to provide full nutrition
“Traditional” Ketogenic Diet Breakdown
Sample meal plan for 2,000 calorie diet
Meal
Fat (g)
Protein (g)
Carbohydrates (g)
Calories (kcal)
Breakfast
40
20
0
440
Lunch
55
35
4
651
Dinner
60
50
4
756
Snack
15
5
0
155
Total
170
110
8
2002
Two types of ketogenic diet
• MCT-based approach
– Diet begins with fasting to induce ketonuria
– Replaces long-chain fats with medium-chain triglycerides
(MCT)
– Ketosis can be more easily achieved with MCT so
nonketogenic foods are allowed (carbohydrates)
– Fluid is not restricted
Typical Ketogenic Diet Menu Using MCT Oil
Food Item
Breakfast
White bread
Eggs, scrambled
Cream, heavy whipping
Margarine or butter
MCT oil
Fat
Drink sweetened w/
nonnutritive sweetner
Total
Lunch
American cheese
Ham
MCT oil mayonnaise
Fat
Drink sweetened w/
nonnutritive sweetener
Total
Dinner
Turkey
Tomato
Green beans
Potatoes
Margarine
MCT oil mayonnaise
Fat
Drink sweetened w/
nonnutritive sweetener
Amount (g)
Carbohydrates (g)
Protein (g)
Fat (g)
Energy (kcal)
5
48
2.8
0.4
6.1
0.2
5.5
13
74
10
0.3
0.3
3.8
36
5
5.0
45
12
11
12.0
11.0
108
99
240
2.8
6.8
37.5
375
2.2
0.7
2.8
3.7
3.6
3.9
52
53
11
11.0
99
19
19.0
171
12
23
240
2.9
6.5
37.5
375
0.5
0.6
1.4
6.3
0.1
0.2
0.2
0.7
0.0
0.0
0.0
15.0
32
3
3
8
135
11
11.0
99
10
10.0
90
36.7
111.7
370
1120
19
10
10
12
15
240
Total
Daily Total
MCT, Medium-Chain Triglyceride
Adapted from Krause’s Food and Nutrition Therapy 12th Edition.
2.8
8.5
6.8
20.1
Ketogenic diet
• Typically used for two years
• Caloric intake is the same as with any child
– Calculated by RD using age, gender, weight, height, and activity level
• Requires a lot of counseling
– New foods
– Compliance with diet
• Implications
– Growth problems
– Nutrient deficiencies
Client Assessment and Energy/Nutrient Requirements
Lab
Value
Age
4 years 10 months old
Height
46”
Weight
55#
BMI
18.3 (normal)
Hgb
13.5g/dl
• 1200 kcal/day
• 3-5 ounces of protein
• 1-1.5 cups of fruit
• 1.5-2.5 cups of vegetables
• 4-6 ounces of grains
• 2.5-3 cups of dairy
Current Client Medication and Nutrient Analysis
• Children’s
multivitamin
• Keppra (antiepileptic)
– Avoid consumption of
raw ginkgo seeds as it
can decrease
effectiveness of drug
Amount
Carbohydr
ates (g)
Fat (g)
Protein (g)
Calories
(kcal)
Frosted
Flakes
30g
27
0
1
110
2% milk
1 cup
11.4
4.8
8.1
122
1 sandwich
47
19
12
400
1 cup
11.4
4.8
8.1
122
Macaroni
and cheese
1 cup
48
3
1
260
2 % milk
1 cup
11.4
4.8
8.1
122
1 cup
38
0
1
140
Total
194.2
36.4
39.3
1,276
Percentage
of daily
calories
61%
26%
13%
Meal
Breakfast
Lunch
Peanut
butter and
jelly
sandwich
on white
bread
2% milk
Dinner
Snack
Grape juice
Nutrition Diagnosis, Intervention, Monitoring and Evaluation
• Diagnosis
– Food and nutrition related knowledge deficit related to the use
of a training cup as evidenced by training cup use after two years
of age
• Intervention
– Will offer a regular cup daily as opposed to a training cup to
decrease chance of dental carries
– Will offer 2 servings of quality protein daily, such as chicken,
eggs, or beans
– Will try to replace one carbohydrate serving at dinner with a fat
or protein serving, daily
• Monitoring and evaluation
– Follow up appointment to re-evaluate goals
– Referral to physician if necessary