Abstract Ketogenic dietary therapies (KDTs) are a safe and effective treatment for pharmacoresistant epilepsy in children. There are four principal types of KDTs: the classic KD, the modified Atkins diet (MAD), the medium-chain triglyceride (MCT) diet, and the low glycemic index diet (LGID). The International Ketogenic Diet Study Group recommends managing KDTs in children with epilepsy. However, there are no guidelines that address the specific needs of the Brazilian population. Thus, the Brazilian Child Neurology Association elaborated on these recommendations with the goal of stimulating and expanding the use of the KD in Brazil.

Resumo As terapias dietéticas cetogênicas (TDC) são um tratamento seguro e eficaz para epilepsia farmacorresistente em crianças. Existem quatro tipos principais de TDCs: a dieta cetogênica (DC) clássica, a dieta de Atkins modificada (DAM), a dieta de triglicerídeos de cadeia média (DTCM) e a dieta de baixo índice glicêmico (DBIG). O Grupo Internacional de Estudos de Dietas Cetogênicas (International Ketogenic Diet Study Group) propõe recomendações para o manejo da DC em crianças com epilepsia. No entanto, faltam diretrizes que contemplem as necessidades específicas da população brasileira. Assim, a Associação Brasileira de Neurologia Infantil elaborou essas recomendações com o objetivo de estimular e expandir o uso da DC no Brasil.

Introduction: Quality Indicators for Nutritional Therapy (QINT) allow a practical assessment of nutritional therapy (NT) quality. Objective: To apply and monitor QINT for critically ill patients at nutritional risk. Methods: Cross sectional study including critically ill patients > 18 years old, at nutritional risk, on exclusive enteral (ENT) or parenteral nutritional therapy (PNT) for > 72 hours. After three consecutive years, 9 QINT were applied and monitored. Statistical analysis was performed with SPSS version 17.0. Results: A total of 145 patients were included, 93 patients were receiving ENT, among then 65% were male and the mean age was 55.7 years (± 17.4); 52 patients were receiving PNT, 67% were male and the mean age was 58.1 years (± 17.4). All patients (ENT and PNT) were nutritionally screened at admission and their energy and protein needs were individually estimated. Only ENT was early initiated, more than 70% of the prescribed ENT volume was infused and there was a reduced withdrawal of enteral feeding tube. The frequency of diarrhea episodes and digestive fasting were not adequate in ENT patients. The proper supply of energy was contemplated only for PNT patients and there was an expressive rate of oral intake recovery in ENT patients. Conclusion: After three years of research, the percentage of QINT adequacy varied between 55%-77% for ENT and 60%-80% for PNT. The results were only made possible by the efforts of a multidisciplinary team and the continuous re-evaluation of the procedures in order to maintain the nutritional assistance for patients at nutritional risk.

Introducción: los indicadores de calidad en terapia nutricional (ICTN) permiten evaluar la calidad de la terapia nutricional (TN) de forma práctica. Objetivo: implementar y monitorizar los ICTN en pacientes críticos con riesgo nutricional. Métodos: estudio transversal con pacientes críticos > 18 años en riesgo nutricional, en terapia nutricional enteral (TNE) o parenteral (TNP) exclusiva a > 72 horas. Después de 3 años consecutivos, 9 ICTN fueron implementados y monitorizados. El análisis estadístico fue realizado con el software SPSS, versión 17.0. Resultados: fueron incluidos 145 pacientes, siendo 93 en TNE, 65% eran de sexo masculino, con edad promedio de 55,7 años (± 17,4); 52 pacientes que estaban en TNP, 67% eran de sexo masculino, con edad promedio de 58,1 años (± 17,4). Todos los pacientes (TNE y TNP) fueron cribados en la admisión, los cálculos de las necesidades calóricas y proteínicas fueron individualizados. Apenas la TNE fue precoz, > 70% del volumen prescrito fue administrado y fue visto una reducida pérdida de la sonda nasoenteral. Las frecuencias de diarrea y ayuno digestivo no fueron adecuadas en TNE. La administración adecuada de energía fue contemplada apenas en TNP y hubo una significativa tendencia de recuperación en la vía oral en TNE. Conclusión: después de 3 años de estudio, el porcentaje de adecuación de los ICTN varió entre 55%-77% para TNE y 60%-80% para TNP. Los resultados reflejan los esfuerzos del equipo multiprofesional de TN en mantener la calidad de la asistencia nutricional en los pacientes críticos con riesgo nutricional.

A ketogenic diet is an important therapy used in the control of drug-refractory seizures. Many studies have shown that children and adolescents following ketogenic diets exhibit an over 50% reduction in seizure frequency, which is considered to be clinically relevant. These benefits are based on a diet containing high fat (approximately 90% fat) for 24 months. This dietary model was proposed in the 1920s and has produced variable clinical responses. Previous studies have shown that the mechanisms underlying seizure control involve ketone bodies, which are produced by fatty acid oxidation. Although the pathways involved in the ketogenic diet are not entirely clear, the main effects of the production of ketone bodies appear to be neurotransmitter modulation and antioxidant effects on the brain. This review highlights the impacts of the ketogenic diet on the modulation of neurotransmitters, levels of biogenic monoamines and protective antioxidant mechanisms of neurons. In addition, future perspectives are proposed.

Objetivo: Determinar os fatores que influenciam na adequação da terapia nutricional enteral em uma unidade de terapia intensiva. Métodos: Estudo prospectivo e observacional realizado em uma unidade de terapia intensiva entre 2010 e 2012. Foram incluídos pacientes >18 anos em terapia nutricional enteral exclusiva por ≥72 horas. As necessidades de energia e proteínas foram calculadas segundo protocolo da unidade. Foram coletados diariamente dados relacionados à nutrição enteral, causas de não conformidade e exames bioquímicos. Resultados: Dentre os pacientes internados na unidade, 93 foram avaliados, 82% iniciaram a terapia nutricional enteral precocemente e 80% atingiram a meta nutricional em <36 horas. Foram administrados 81,6% (±15,4) de volume de terapia nutricional enteral, com adequação de 82,2% (±16,0) de calorias, 82,2% (±15,9) de proteínas e balanço energético médio de -289,9 kcal/dia (±277,1). Houve correlação negativa da proteína C-reativa com o volume administrado e os balanços energético e proteico, e correlação positiva com o tempo para atingir a meta nutricional. A pausa para extubação foi a principal causa de interrupções (29,9% das horas de pausa) e os pacientes >60 anos apresentaram menor porcentagem de recuperação da via oral em relação aos mais jovens (p=0,014). Conclusão: O início precoce da terapia nutricional enteral, e a adequação do volume administrado, de energia e de proteínas estiveram de acordo com as diretrizes. A inadequação dos balanços energético e proteico parece estar associada à resposta inflamatória aguda (proteína C-reativa elevada). A principal causa de interrupção da oferta da terapia nutricional foi a pausa para extubação.

Objective: To determine the factors that influence the adequacy of enteral nutritional therapy in an intensive care unit. Methods: This prospective observational study was conducted in an intensive care unit between 2010 and 2012. Patients >18 years of age underwent exclusive enteral nutritional therapy for ≥72 hours. The energy and protein requirements were calculated according to the ICU protocols. The data regarding enteral nutrition, the causes of non-compliance, and the biochemical test results were collected daily. Results: Ninety-three patients admitted to the intensive care unit were evaluated. Among these patients, 82% underwent early enteral nutritional therapy, and 80% reached the nutritional goal in <36 hours. In addition, 81.6%±15.4% of the enteral nutrition volume was infused, with an adequacy of 82.2%±16.0% for calories, 82.2%±15.9% for proteins, and a mean energy balance of -289.9±277.1kcal/day. A negative correlation of C-reactive protein with the volume infused and the energy and protein balance was observed. In contrast, a positive correlation was found between C-reactive protein and the time required to reach nutritional goals. Extubation was the main cause for interrupting the enteral nutritional therapy (29.9% of the interruption hours), and the patients >60 years of age exhibited a lower percentage of recovery of the oral route compared with the younger patients (p=0.014). Conclusion: Early enteral nutritional therapy and the adequacy for both energy and protein of the nutritional volume infused were in accordance with the established guidelines. Possible inadequacies of energy and protein balance appeared to be associated with an acute inflammatory response, which was characterized by elevated C-reactive protein levels. The main cause of interruption of the enteral nutritional therapy was the time spent in extubation.