Ketogenic Diet Following Moderate to Severe Pediatric Traumatic Brain Injury

The KD is an alternative feeding regimen that has been in use since 1921. It is a high fat, low carbohydrate and moderate protein diet. There are various forms of the KD. The classic KD consists of long-chain triglycerides with a fat-to-combined-protein-and-carbohydrate ratio that can vary. At our institution, it is standard of care to initiate a ketogenic diet at a ratio of 2:1, and to increase the ratio to 3:1 or 4:1 as needed to achieve ketosis. Clinically, the KD has been proven to be an effective therapy in children and adolescents with refractory epilepsy, as well as for those with type II diabetes. In addition, an international consensus was published in 2009 that recommended the use of the KD to treat epilepsy refractory as an alternative to at least two antiepileptic medications. Before initiating the KD for epilepsy management, labs such as urine and blood ketones, blood glucose and a basic metabolic panel including magnesium are commonly recommended. Risks for long-term use of the KD include but are not limited to the following: hypercholesterolemia, mineral deficiencies, acidosis, constipation, weight loss and nephrolithiasis. However, short-term use should significantly limit the occurrence of these potential complications.

• Ketogenic Diet (Other), also known as Keto: The ketogenic diet (KD) is an alternative feeding regimen that has been in use since 1921. It is a high-fat, low carbohydrate, and moderate protein diet. There are various forms of the KD. The classic KD consists of long-chain triglycerides with a fat-to-combined-protein-and-carbohydrate ratio that can vary. At the investigating institution, it is standard of care to initiate a ketogenic diet at a ratio of 2:1, and to increase the ratio to 3:1 or 4:1 as needed to achieve ketosis.

Primary outcomes

• Ability to complete a course of the ketogenic diet (KD) [14 days]: Safety and feasibility will be determined by the ability to complete a 14-day course of the KD after TBI without needing to terminate the diet due to intolerance resulting from gastrointestinal side effects (for example, nausea and vomiting, diarrhea, or acidosis), or due to abnormal findings on laboratory tests. Outcome is reported as the number of participants who complete the 14-day keto diet treatment.

Secondary outcomes

• Duration of Unconsciousness [14 days]: Outcome is reported as the length of time (in hours) a participant is unconscious following their injury.
• Need for Surgeries [14 days]: Outcome is reported as the number of surgeries required in each group following injury.
• Duration of Acute Hospitalization [14 days]: Outcome is reported as the length (in days) of acute hospitalization following injury.
• Duration of Post-traumatic Amnesia [14 days]: Outcome is reported as the length of time (in days) that a participant experiences amnesia following their injury.

Sex: All, ages: 2 Years to 17 Years

Inclusion Criteria:

* Age limits met at the time of injury and admission
* Participants with moderate to severe traumatic brain injury defined as a Glasgow Coma Scale Score of 3-12 (lowest score in the first 24 hours after injury). Individuals requiring craniotomy and/or evacuation of intracranial hemorrhage may be included.

Exclusion Criteria:

* Currently on an oral diet at time of screening or currently on IV-only and in opinion of Pediatric Intensive Care Unit intensivist will be transitioning to an oral diet, not tube-feeding
* Anoxia/ischemia as a significant portion of injury, including near-drowning
* Non-accidental traumatic brain injury (i.e., assault, abuse)
* Penetrating injury including gunshot wounds
* Pregnancy
* Any condition that in the opinion of the Pediatric Intensive Care Unit or neurosurgery medical staff warrants exclusion from the study

• Linda Krach, MD, Principal investigator, Department of Physical Medicine and Rehabilitation
• Angela Sinner, DO, Principal investigator, Department of Physical Medicine and Rehabilitation