Ketogenic diet in childhood epilepsy: clinical algorithm in a tertiary care center.

Background: Dietary therapies play a crucial role in managing patients, especially those who have specific types of epilepsy, display adverse effects, or are not responding to pharmacological treatments. The ketogenic diet (KD) is a high-fat, restricted carbohydrate, and adequate protein regimen. The KD has proven to be an effective nonpharmacological treatment for drug-resistant epilepsy (DRE) by generating ketones that act as an alternative fuel source for the brain, thereby reducing the occurrence of seizures. The advantages of KD have been attributed to its universal availability, numerous administration techniques, and affordability. Objective: This article presents the KD algorithm developed by a multidisciplinary team of experts at the Children's Hospital, Ain Shams University, Egypt. The algorithm serves as a guide for implementing the KD in the treatment of DRE in children. The algorithm has been previously validated through a study. Methods: The algorithm consists of seven essential stages: (1) referral of patients to the Complex Epilepsy Committee, (2) pre-diet assessment of patients, (3) referral of patients to the Clinical Nutrition (CN) team, (4) diet selection and initiation, (5) seizure follow-up and diet fine-tuning, (6) diet reassessment after 3 months, and (7) evaluation of the KD journey after 24 months. Results: The KD algorithm was systematically developed and proved highly influential in facilitating the implementation of the KD. The algorithm yielded significant health benefits in pediatric patients. Conclusion: The KD algorithm provides a systematic approach to implementing the ketogenic diet and has demonstrated positive health outcomes in pediatric patients.

Ketogenic diet for epilepsy control and enhancement in adaptive behavior.

The Ketogenic Diet (KD) is gaining attention as a management line in childhood drug resistant epilepsy (DRE). The objective of this study was to highlight KD benefits for Ain Shams University (ASU) Children's Hospital patients. This cross-sectional study included all patients at the Ketoclinic of ASU Children's Hospital since it started. Anthropometric measurements and laboratory data were recorded. Chalfont severity score and daily frequency of epileptic attacks were used to evaluate KD efficacy. Vineland test was used to demonstrate the adaptive behavior of a selected group of patients. ASU Children's Hospital Ketoclinic records included 143 patients. During KD therapy, the weight and height/length assessment showed significant increase with significant decrease in the severity of seizures and its frequency. There were no significant changes in the lipid profile of the patients. Vineland test showed significant improvement in the adaptive behavior in 65% of patients. The Ketoclinic data proves that KD is a tolerable, safe, and effective line of therapy for DRE in children without significant negative impact on their anthropometric measurements or lipid profile. Furthermore, the enhancement in adaptive behavior is a promising finding. It is prudent to recommend wider scale studies for longer duration to demonstrate additional cognitive benefits of KD in pediatric age group.

Nutritional rehabilitation of malnourished children: are nutritional supplements a must?

OBJECTIVE: Malnutrition threatens children worldwide. The objective of the current study was to highlight the role of nutritional screening, evaluate the effectiveness of nutritional intervention program, and whether nutritional supplements have surplus benefit. PATIENTS AND METHODS: Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) was used to screen 3640 clinically stable 2-5 years old children recruited from the outpatient clinics, Children's Hospital, Ain Shams University. A total of 100 patients at high risk of malnutrition were enrolled. Full nutritional assessment was done and according to the distribution of the calories in the daily meal plan, the patients were randomly divided into two groups each comprised 50 patients. Group A received tailored nutritional dietary rehabilitation plan including dietary supplements, while Group B received only dietary advice. Anthropometric measurements, laboratory tests, as well as STAMP scoring were reassessed after the nutritional rehabilitation programs. RESULTS: Nutritional screening revealed that 5.14% were at high risk of malnutrition. Both studied groups showed significant improvement in caloric intake and all anthropometric measurements upon nutritional rehabilitation, except for the height z scores. Patients who received nutritional supplements showed significantly better changes regarding weight, BMI, caloric intake, and hemoglobin. Regarding STAMP categories during follow up, Group A had only 6% of the patients still in the high-risk category and 76% were at low risk compared to 14% high risk and only 54% were at low risk in Group B. CONCLUSIONS: Nutritional screening in pediatric outpatient facilities can lead to implementing prompt nutritional rehabilitation, which can reflect on the patients' overall health. Tailored nutritional plan can accomplish good response in terms of improvement of caloric intake, anthropometric measurements and laboratory parameters. Adding a nutritional supplement to the dietary plan during nutritional rehabilitation isn't a must but it ensures superior goal achievement.

Effect of ketogenic diet for drug-resistant epilepsy on immunological cells.

BACKGROUND AND AIM OF THE WORK: Ketogenic diet (KD) is one of the treatments in drug-resistant epilepsy (DRE). The current study aimed at assessing the effect of KD-induced ketosis on different immunological cells since ketosis is reported to affect neutrophil function. METHODOLOGY: We recruited 21 pediatric patients diagnosed with DRE assigned to start KD. Anthropometric measurements, complete blood picture with differential count, phagocytic function, lymphocyte subsets, and IgG estimation were estimated initially and after 6 months of KD. RESULTS: There were no differences between the initial total leucocytic, neutrophil, and lymphocytic counts as well as the lymphocyte subsets, and the values after 6 months of KD. IgG values showed significant increase yet the values were still within the reference ranges. For the innate immune system, the phagocytic index was assessed and it showed a marked statistical reduction in patients after KD. CONCLUSION: KD has no effect on neutrophil and lymphocytic counts as well as the number of adaptive and immune cells; nevertheless, it causes a reduction in phagocytic index in DRE. Accordingly, further detailed study for the full immunological profile and function is needed to ensure the safety of this therapeutic line and correlate it with the clinical history.

Is There a Benefit of Vitamin D Supplementation in Deficient Children and Adolescents Suffering from Obesity? A Meta-Analysis.

This systematic review/meta-analysis aims to highlight the effect of vitamin D supplementation in deficient children suffering from obesity. Published clinical studies on vitamin D supplementation in obese children and adolescents with vitamin D deficiency were identified through a comprehensive MEDLINE/PubMed search (from July 1966 to November 2017). Outcomes intended after vitamin D supplementation were improvements in vitamin D status, BMI alterations and appetite changes. The inclusion criteria were children aged 2 to 18 years of both sexes in clinical trials that specified the oral and/or intramuscular dose of vitamin D supplementation. Ten studies were retrieved, but only 6 were relevant. First, supplemented obese children and adolescents were compared to non-obese controls; thereafter, supplemented obese children and adolescents were compared to matching obese peers given placebo. Pooled risks from the 2 studies that evaluated the number of obese and non-obese children and adolescents who improved upon vitamin D supplementation revealed that obesity poses a risk for not benefiting from the vitamin D supplementation regardless of the dose and the duration of supplementation. Pooled results from the 6 retrieved studies that compared supplemented obese children and adolescents to matching non-obese or obese peers given placebo revealed significantly lower vitamin D levels in obese participants than in non-obese peers. Vitamin D levels are significantly lower in obese children and adolescents with obesity, posing a risk for not benefiting from vitamin D supplementation regardless of the dose and duration of supplementation.

Effect of COVID-19 Lockdown on Young Egyptian Soccer Players.

The present study was designed to highlight the physical and psychological health hazards that a young Egyptian soccer team faced during the first COVID-19 wave lockdown. The study included 37 young Egyptian male soccer players. History taking and anthropometric measurements were taken. Two questionnaires were filled covering the athletes'` sleep habits and quality of life (QoL). Finally, the mothers were asked to fill in a questionnaire concerned with depression, anxiety, and stress. More than 50% of the enrolled athletes gained weight during the lockdown especially those without compliance to home exercises. The mothers' anxiety score correlated positively with the increased body mass index (BMI) of the athletes. The athletes mean QoL Score worsened significantly and significant negative correlation was found between the increased BMI and the change of QoL. The increased BMI was significantly reported among the athletes who didn't do home exercises and had a negative correlation with their QoL change throughout the lockdown. The mothers' anxiety had a possible reflection on their youngsters' weight gain. These findings highlight the need for weight control when outdoors physical activity is restricted during pandemics with better compliance to home exercising schedules and less screen time.

Serum 25-hydroxyvitamin D status and wheezing in pre-school children, Kuwait.

BACKGROUND: There has been growing recognition of the critical extra-skeletal roles for vitamin D including lung disease. AIMS: This study was performed to explore the possible role of vitamin D on wheezing occurrence among Kuwaiti preschool children. METHODS: Out of 244 children from Al-Adan Hospital, Kuwait, 151 cases were enrolled as wheezers while the rest served as controls. The wheezers were subdivided into episodic wheezers (EW) and multiple trigger wheezers (MTW). Detailed history of the wheezing attacks, previous hospitalizations, and intensive care admission were recorded as well as their serum 25-hydroxyvitamin D [25(OH)D] levels. RESULTS: Serum 25(OH)D was significantly lower in the wheezing group, and its decrease was a risk factor for wheezing. Moreover, serum 25(OH)D was not significantly different between EW and MTW; nevertheless, its low level could be linked to MTW. CONCLUSIONS: Vitamin D deficiency increases the risk of wheezing among preschoolers in Kuwait. A possible link between low serum 25(OH)D and MTW could highlight a specific role for vitamin D in relation to atopy. Prevention and prompt management of vitamin D deficiency should be considered among infants and children with wheezing.

Nutritional risk screening of hospitalized children aged < 3 years.

BACKGROUND: Identification of children at risk of malnutrition is not easily achieved in hospital settings. AIMS: To assess the merits of using the Screening Tool for Risk on Nutritional status and Growth (STRONGkids) as a nutrition screening tool in hospitalized children aged < 3 years and correlate it with the severity of their nutritional derangements. METHODS: This cross-sectional study was conducted on 500 children aged < 3 years admitted to the Children's Hospital, Ain Shams University, Cairo, Egypt. STRONGkids score was used to assess the risk for nutritional derangements and World Health Organization growth charts were used to define underweight, wasted and stunted patients upon admission and discharge. RESULTS: According to STRONGkids score, 19.6% of patients were low risk, 42.6% were moderate risk and 37.8% were high risk. Out of the enrolled patients, 62.4% were underweight, 58.4% were stunted and 57.8% were wasted. Among the 66 patients with severe wasting, nutritional status improved in 6.06% while deterioration was observed in 13.0% of the moderately wasted patients. STRONGkids score was worse among those who deteriorated, which together with its significant positive correlation with the duration of hospital stay, emphasized that STRONGkids score can be a predictive tool. CONCLUSIONS: The use of STRONGkids screening tool can ensure early identification of children vulnerable to malnutrition, ensuring prompt interventions that may contribute to overall improvements in patient care, as well as shortening hospitalization period.

Imaging In Acute Bronchiolitis: Evaluation of The Current Practice In a Kuwaiti Governmental Hospital and Its Possible Impact on Hospitalization Period.

BACKGROUND AND OBJECTIVES: Guidelines for acute bronchiolitis recommend primarily supportive care, but unnecessary treatment measures remain well documented. This study was designed to assess the Al-Adan Hospital pediatricians` attitude towards imaging of inpatients with bronchiolitis aiming to evaluate its utilization and possible impact on patients` management and length of hospital stay. SUBJECTS AND METHODS: This study included 194 cases of acute bronchiolitis admitted to Al-Adan Hospital. Number of X-Rays done following admission and reasons stated in the files were recorded. Bronchiolitis severity was estimated from the data obtained. RESULTS: Chest X-Rays were ordered in 52.1% of our inpatients with acute bronchiolitis. In nearly half of those cases, the reason for X-Ray request is a clinical severity factor, namely desaturations and apneas, and in rest of the cases, no specific reason for ordering X-Rays was documented. Significantly more patients who had two or more X-Rays were prescribed antibiotics and had statistically longer hospital stay. The number of X-Rays performed during admission was not a significant contributor to the need for PICU care, however, it was a significant factor affecting the length of hospital stay. CONCLUSION: The implementation of acute bronchiolitis guidelines regarding imaging in admitted cases with acute bronchiolitis is highly recommended in Al-Adan hospital. Clear documentation for the reasons behind ordering X-Rays is needed for those cases. A decrease in the X-Ray utilization and subsequent unnecessary antibiotic use can help in decreasing the costs and hazards of hospitalization for patients with acute bronchiolitis.

The rising tide of overweight among Kuwaiti children: study from Al-Adan Hospital, Kuwait.

OBJECTIVE: This study was designed to screen patients who sought medical services in the Pediatric Outpatient Department, Al-Adan Hospital, Kuwait for overweight. SUBJECTS AND METHODS: Body mass index (BMI) was used to screen 361 children (≤10 years old) for risk of overweight and overweight (BMI between 85th and 94th, and ≥95th percentile, respectively). Overweight children were fully examined and abdominal ultrasound was done for each of them. RESULTS: Of the 361 children, 52 (14.41%) and 77 (21.33%) were at risk of overweight and overweight, respectively. There was a slight male predominance for overweight (40 males, 51.95%, compared to 37 females, 48.05%) and within the overweight category; 28 males (70%) and 26 females (70.27%) were above 6 years of age. In overweight children over 6 years, 4 (7.41%) had hepatomegaly with fatty changes and 3 (5.56%) had blood pressure above the 95th percentile for age and sex. CONCLUSION: Childhood overweight at Al-Adan Hospital was high and increased with age. Hence childhood screening for overweight is recommended at an early age because it is an important risk factor of chronic diseases.

Vitamin D status and scholastic achievement in middle age childhood.

Non-classical effects of vitamin D are not surprising in that many tissues, including neurons, possess vitamin D receptors. Thirty school aged children with delayed scholastic achievement and 15 normal ones were enrolled in the current study to identify the serum 25-hydroxy vitamin D [25(OH) D] status in school aged children in relation to their scholastic achievement. Besides estimation of serum 25(OH) D levels, neuro-developmental assessment was done using the Wechsler Intelligence Scale for Children (WISC) and the Benton's Visual Retention Test (BVRT). Serum 25(OH) D was significantly lower in children with delayed scholastic achievement. Picture completion scores were significantly lower in children with deficient and inadequate serum 25(OH) D. There were positive correlations between serum 25(OH) D level and values of WISC. Regarding BVRT results, good memory was associated with adequate serum 25(OH) D. In conclusion, serum 25(OH) D is deficient in children with delayed scholastic achievement causing affection of memory and learning process. Larger scale studies using learning assessment tools are thus recommended to further prove this point and search the impact of vitamin D supplementation on the school achievement in this age group.

Language skills and intelligence quotient of protein energy malnutrition survivors.

The study was conducted on 33 children aged 3-6 years who suffered from protein energy malnutrition (PEM) during infancy in comparison to 30 matching children to assess the long-term deficits in cognition and language skills. The patients' files were revised to record their admission and follow-up data and history, clinical examination, intelligence quotient and language assessment were done. The study revealed that 2-5 years from the acute attack the PEM patients were still shorter than the controls and their cognitive abilities were poorer. Their mental ages and language skills were mostly determined by their height and the duration of follow-up during their acute illness. Additionally their diet after the 3-5 years is still defective and does not meet their recommended daily allowance. These observations urge us to continue following these patients for longer durations to make sure no permanent damage occurs due to the PEM insult to the growing brain.

Neuro-developmental outcome and brain-derived neurotrophic factor level in relation to feeding practice in early infancy.

This study was designed to assess brain-derived neurotrophic factor (BDNF) as a possible candidate for enhanced cognition in breastfed infants. The study was conducted on 42 infants, 4-6 months old, who were classified according to their feeding pattern into breastfed group, formula-fed group and mixed-feeding group. Each infant was subjected to history taking, clinical examination, estimation of the level of BDNF by Enzyme-Linked Immunosorbent Assay (ELISA) technique and assessment by Bayley scale of infant development-second edition (BSID-II). The current study revealed that breastfed group had higher BSID-II scores followed by mixed-fed group then formula-fed one, yet these results reached statistical significance only in total behaviour rating scale (TBRS) and Motor Quality Percentile rank values. Additionally, breastfed infants had significantly higher values of BDNF when compared to those receiving formula milk. Negative correlations between BDNF and both weight for age and weight for length scores were detected. Furthermore, significant positive correlation was detected between BDNF and TBRS. Regression analysis studies revealed that breastfeeding is the most determinant factor for BDNF, TBRS and Motor Quality Percentile rank values. Serum BDNF levels are significantly higher in breastfed infants and shows positive correlations with the results of BSID-II. Given that simultaneous increase in brain BDNF occurs due to onsite production, transport from the periphery or both, it is prudent to hypothesize that BDNF could be one of the factors responsible for the enhanced cognition detected in breastfed infants.

Effect of honey on 50% complement hemolytic activity in infants with protein energy malnutrition: a randomized controlled pilot study.

Protein energy malnutrition (PEM) is associated with a significant impairment of cell-mediated immunity and complement system, which may be responsible for the high incidence of infections among these patients. This study was designed to examine the effect of honey, as a natural substance, on the 50% complement hemolytic activity (CH50) in patients with PEM. Thirty patients with PEM and 20 healthy infants serving as controls participated in this study. The patients were randomized to receive either honey (group 1) or placebo (group 2), in addition to conventional nutritional rehabilitation therapy. Measurements of weight, midarm circumference, skin fold thickness, serum albumin, and CH50 were done for all patients before and after 2 weeks of rehabilitation. Before nutritional rehabilitation, the CH50 was significantly lower in the PEM groups compared with the control. However, after rehabilitation, the CH50 increased significantly in both PEM groups, compared with the pre-interventional state and with the controls. Moreover, the rise of CH50 was significantly more in the honey group compared with the placebo. On the other hand, the improvement in the anthropometric measures and serum albumin did not differ significantly between the honey and placebo groups after rehabilitation. Thus honey supplementation in patients with PEM increased the level of CH50. Whether this would have an effect on the frequency and severity of infections in patients with PEM needs further studies.

Effect of honey on gastric emptying of infants with protein energy malnutrition.

BACKGROUND: Patients with protein-energy malnutrition (PEM) have delayed gastric emptying time (GET) which may affect nutritional rehabilitation. This study was designed to examine the effect of honey on GET during nutritional rehabilitation of PEM patients. PATIENTS AND METHODS: Thirty patients were enrolled and randomly assigned to one of two equal groups. One group received conventional nutritional rehabilitation therapy and the other received honey in addition. They were compared with 20 age- and sex-matched controls. History taking, clinical examination and laboratory tests were performed for enrolled cases and GET was assessed using abdominal ultrasonography. These parameters were performed before and 2 weeks after nutritional rehabilitation. RESULTS: The GET was significantly delayed in the PEM groups compared with the controls. Further significant delay occurred in the honey supplemented group after nutritional rehabilitation, while the un-supplemented group showed significant shortening of GET. The improvement of anthropometric measurements and laboratory parameters was equally noticed in the two PEM groups upon nutritional rehabilitation but their rate of change was distinctly higher, although non-significant, in the group supplemented with honey. CONCLUSION: Honey supplementation increased GET in PEM patients with positive effect on the improvement in the anthropometric measurements and serum albumin which makes us wonder that this delay in GET might be primarily a compensatory phenomenon and it was augmented by the use of honey. Larger scale studies with longer term follow up are recommended to further clear this point and assess any changes in the absorptive indices in honey supplemented PEM patients.

Neurokinin A level in hypoxic-ischemic encephalopathy.

BACKGROUND: The present study was performed to investigate the effect of neonatal hypoxic-ischemic encephalopathy (HIE) on the neurotransmitter neurokinin A (NKA) and determine its relation to the severity of neonatal hypoxia. METHODS: Eighteen neonates suffering from HIE were compared to 10 clinically healthy full-term neonates acting as the control group. Maternal history of each neonate was collected, then deliveries were attended, resuscitation details including the Apgar score and thorough clinical examination of the neonates were performed. Routine laboratory work-up was done for the enrolled neonates, including complete blood count and C-reactive protein as well as estimation of NKA by enzyme-linked immunosorbent assay in the cord blood and after clinical stabilization. RESULTS: NKA was significantly lower in HIE patients compared to the controls at delivery with improvement in the follow-up sample. Additionally, the maximum decrease was detected in the neonates who suffered severe hypoxia compared to those who suffered mild hypoxia. Significant positive correlations were demonstrated between NKA at birth and Apgar scores at the 10th and 15th min. Regression showed that stage of HIE was the strongest determinant factor for the level of NKA at birth. CONCLUSION: NKA levels are decreased in HIE and this is more profound in the severe degrees of hypoxia compared to the mild ones. This emphasizes its role in pathogenesis of HIE and further proves that an imbalance in the central neuropeptide system results from HIE in the neonatal period.

Early detection of protein energy malnutrition in Sharkia Governorate.

UNLABELLED: The objective of this cross-sectional study was to assess the nutritional status of children, aged 6 to 36 months, in Sharkia Governorate aiming for early detection of malnourished cases. METHODS: the present study was carried out on 1000 children aged 6 to 36 months, selected by a multistage random sample from 6 villages in two districts in Sharkia Governorate. Data were gathered by an interview questionnaire to the child's mother or care giver at their homes. Anthropometric measurements as height, weight, mid-arm, head circumference and skin fold thickness were assessed. Body mass index was calculated. Dietary evaluation was done by a 24 hours recall for amounts and frequencies of food and was transferred to their recommended daily allowance (RDA). The studied children were classified into three groups according to their weight for age percentiles, underweight children, borderline malnourished children and normal weight children. Serum hemoglobin, pre-albumin and albumin were assessed for a randomly selected number of the studied group. RESULTS: the study showed that all anthropometric measurements were lower than normal in underweight and borderline subjects. The prevalence rates of wasting, stunting and underweight were 15%, 24.4% and 15.4% in the studied infants in Sharkia Governorate, respectively. The study revealed that nutrient intake of the study subjects was lower than the RDA for the energy intake from carbohydrates, vitamin D, and iron, while it was higher than the RDA for the energy intake from lipids and vitamin A and equal to the lower level of the normal range of RDA for the energy intake from proteins. Most of the protein intake was of plant origin. Caloric intake was less than RDA in underweight and border line children, but more than RDA in normal children (86%, 90% and 102%). The ratios of caloric intake to the required calories according to weight were 90%, 98% and 108% in the three groups respectively. Chronic cough and chronic and recurrent diarrhea were more complained by underweight and borderline children. Underweight children were more infested with oxyurius and entamoeba histolitica than the other 2 groups. Serum hemoglobin, albumin and plasma pre-albumin levels were within normal range with significantly lower values in underweight and borderline infants compared to normal children. By multiple linear regression analysis, the most important factors affecting BMI were carbohydrate, lipid and caloric intake, serum albumin, plasma pre-albumin, vitamin A and D intake and protein intake. CONCLUSION: There is a high prevalence of wasting ,stunting and underweight among infants and children of the studied sample in Sharkia governorate explained by the low socioeconomic status, unbalanced diet. Early changes of protein energy malnutrition were detected, in spite of the fact that serum hemoglobin, albumin and plasma pre-albumin levels were within normal range, they were significantly lower in underweight and borderline infants compared to normal children.