To the Editors:
Approximately 10–20% of children with epilepsy will have difficult-to-control seizures despite high doses of several anticonvulsant drugs (Camfield et al., 1997; Berg et al., 2001). The prevalence of childhood intractable epilepsy is similar in developing countries; however, these nations encompass 97% of the world's population (Dua et al., 2006). Unfortunately, the costs and lack of availability of anticonvulsant drugs can be problematic (Shorvon & Farmer, 1998; Meinardi et al., 2001; Dua et al., 2006). The ketogenic diet (KD) is also not offered in most of these areas as well due to both a lack of dietitian availability and the relatively higher price of dairy, oils, and meats required for this diet compared to grains, fruits, and rice (Kossoff & McGrogan, 2005).
The patient was born at term in Tegucigalpa, Honduras after a normal pregnancy and delivery, weighing 2.7 kg with a head circumference of 33 cm. He was noted to have early spastic quadriparesis at 6 months of age and was diagnosed on MRI with bilateral perinatal infarctions. At that time, he developed infantile spasms, which rapidly progressed into Lennox–Gastaut syndrome. By 11 months of age, he was having at least 50 tonic and absence seizures per day, which did not respond to phenobarbital, clobazam, phenytoin, or valproate.
At 19 months of age, a discussion was held between his consulting neurologists (MRM and KRH) and parents regarding the traditional KD. Due to costs of foods and lack of a formal KD team including a dietitian, it was not believed to be a feasible therapeutic option. At 27 months of age, written information e-mailed by a pediatric epileptologist (EHK) regarding the modified Atkins diet was translated into Spanish and shared with the child's parents. High fat and low-carbohydrate foods were purchased and the child also started a daily multivitamin (one-half a chewable Flintstones vitamin [Bayer, Morristown, NJ, U.S.A.]) and calcium (TUMS [GlaxoSmithKline, Research Triangle Park, NC, U.S.A.]). Bayer Ketostix were provided and urine ketones checked intermittently. A baseline 3-day food record was obtained (Table 1).
|Before starting the diet|
|16 ounces of whole milk|
|1 cup of cereal|
|1 vanilla cookie|
|4 ounces of water|
|2 ounces of orange juice|
|1 banana yogurt|
|1 cup of mixed rice, chicken and carrots pureed|
|Carbohydrates: 173 g; protein: 44 g; fat: 41 g.|
|Ketogenic ratio (fat: carbohydrate and protein): 0.2:1.|
|At 15 months on the diet|
|1 slice yellow American cheese|
|2 tablespoons of heavy whipping cream|
|1 tablespoon of olive oil|
|½ cup of spinach|
|½ portion of chicken|
|1 tablespoon of butter|
|½ cup of sugar-free jello|
|6 ounces of water|
|Carbohydrates: 20 g; protein: 47 g; fat: 61 g.|
|Ketogenic ratio (fat: carbohydrate and protein): 0.9:1.|
Within 1 month, his seizures had decreased by 60% to 20 tonic seizures per day with trace urinary ketosis. Two months later, the child was having only five tonic seizures per day and was described as more alert. Over the next 6 months, phenobarbital and clobazam were gradually discontinued while valproate was maintained.
At his most recent evaluation at 3.5 years of age (15 months diet duration) he was having 1–2 seizures per day. In addition, seizures were reported as less severe and now only 5 sec duration. Weight was 12.3 kg (baseline 11.5 kg) and length 91 cm (baseline 81 cm). A 3-day food record was reanalyzed (Table 1). Due to costs, this was the first time complete follow-up laboratory values were obtained. All results were normal except total cholesterol of 220 mg/dL (triglycerides 91 mg/dL). The mother only reported mild constipation as an adverse effect. At this time, she is teaching two other families of children with epilepsy in Honduras to start the modified Atkins diet with neurologist supervision.
This case demonstrates several unique aspects of epilepsy care and suggests opportunities for future treatment. First, unlike the KD, the modified Atkins diet was started and maintained via email using written instructions and only limited dietitian involvement. Secondly, the modified Atkins diet was relatively cost-effective, which increases its value for developing countries (Table 2). This child was able to successfully discontinue two of his three anticonvulsants, which were not covered by any insurance and had to be paid in cash by the family. Lastly, considering this was a mother with limited nutritional knowledge, reading information translated from English, with no admission education process with a KD-trained neurologist and dietitian, his modified Atkins diet was quite similar to foods eaten as part of a formal research study (Kossoff et al., 2007).
|Before starting the diet||On modified Atkins diet (15 months)|
|Supplements (½ Flintstones multivitamin and Tums per day)||$0||$5|