Ketogenic diet: an alternative treatment for refractory epilepsy in children.

RATIONALE: The aim of this study was to establish the first ketogenic diet treatment program for refractory epilepsy in Thailand and to assess its feasibility as well as its efficacy. METHOD: Children with refractory epilepsy were enrolled in the study. This was a prospective open trial study with 35 children (16 boys and 19 girls). Not all patients started on the diet at the same time. Each patient was cumulatively enrolled in this study over the period of 4 years. The mean age on diet was 5.37 +/- 3.57 years (2 months-13 years), mean age of onset of seizures was 19.2 +/- 27.47 months (1 days-8 years), and an average duration on ketogenic diet was 7.67 months (6 days to 29 months). The classic "4:1" formula ketogenic diet was used with some modification. The patient's parents were allowed to improvise and use any fatty diets available in the market such as coconut milk if needed. Parents were closely supervised and instructed on how to prepare the patient's own meals while in the hospital and continued to attend neurology and nutrition clinics. The seizure outcome and side effects were monitored as well as a daily test for urine ketone. RESULTS: At 1 month, 3 months, 6 months, and 12 months duration on the diet, 90 per cent seizure reductions were achieved in 62.5 per cent, 68.18 per cent, 75 per cent, and 66.67 per cent of patients remaining on the diet, respectively. The number of antiepileptic drugs (AEDs) used by each patient also decreased as a result of better seizure control. CONCLUSION: Ketogenic diet can be tried as a management option for refractory epilepsy. It is not difficult to implement even in a developing country like Thailand where resources are limited. It may also help reduce the cost of treatment especially in view of the high prices of the new AEDs.

Carbohydrate and electrolyte contents in commercial fruit juices.

Forty kinds of commercial fruit juices sold in Thailand were analyzed for types and contents of carbohydrates, electrolytes as well as osmolarity and pH. Each juice was analyzed three times and the results were averaged. A few kinds of fruit juices have high sorbitol contents (> 10 g/L). There are some juices which have a high fructose to glucose ratio (> 1.5:1). Sodium contents in juices ranged from 19 to 1405 mg/L. The osmolarity of the juices ranged from 500 to 1200 mOsmol/L. Most juices have acid pH which ranged between 2.8 and 5.0. It is concluded that each fruit juice has a unique set of properties. Consumers should know the properties of each juice because chronic intake and large amount intake of the juice could have detrimental effects on the health of the consumer.

A rice starch added follow-on formula for infants with sleeping difficulty.

A total of 15 infants aged between 4-12 months with sleeping difficulty were enrolled in the study. All participants were given a test follow-on formula (cow's milk based), with added rice starch. The test formula was advised to be given at night-time for a 7-day period. Sleeping patterns were recorded 2 days prior to the study and during the 7-day study period. It was shown than 11 out of 15 cases (73.3%) had satisfactory results. Two cases (13.3%) were withdrawn from the study by their parents due to vomiting after taking the formula. We found that both cases developed concomitant respiratory tract infection one day after starting the study, and 2 cases (13.3%) were lost to follow-up. In conclusion, the majority of cases showed satisfactory results in terms of night sleeping pattern after switching to the rice starch added follow--on formula.

Adolescent height: relationship to exercise, milk intake and parents' height.

The investigators studied the height of adolescents in the age range of 12 to 18 years from 2 schools in Bangkok. Questionnaires asking their rates of organised exercise per week, of milk intake per day and their parental heights were given to a total of 545 male and 615 female students. The completed questionnaires were analyzed. We could categorize these subjects into 3 groups according to their heights which were Group I (height > 97th%-ile), Group II (height between 50-97th%-ile) and Group III (height < 50th%-ile). Those in Group I had parents, whose height was significantly greater than those of the other groups. There was no difference in organized exercise among the 3 groups. Milk intake of female adolescents from Group I was significantly more than the other groups. It is concluded that parents' height in both males and females and milk intake in females contribute to a greater adolescent height.

Comparison of oral rehydration solutions made with rice syrup solids or glucose in the treatment of acute diarrhea in infants.

An oral electrolyte solution made with rice syrup solids was found to reduce fecal output more effectively than a comparable glucose-based solution in the early hours of treatment of infantile diarrhea. Administration of the rice syrup solids solution was also more effective in promoting absorption of fluid, sodium, and potassium. In some infants, the rapid, effective rehydration offered by this solution may prevent the need for hospitalization.

A summer camp for childhood obesity in Thailand.

The results of a 4-week summer camp for childhood obesity were reported. Twenty-one children with moderate to severe obesity, aged between 8-13 years, joined the program. Dietary restriction during the official hours and dietary self-control at home were implemented throughout the program. Exercise, swimming and group therapy were also implemented throughout the program. Weekly sight-seeing outside the camp was very interesting for the participants. After the program, all participants had lost weight which was about 5 per cent of their initial weight. Most of the weight loss was due to loss of body fat but not lean body mass. No complications occurred during the program. The 4-week summer camp is then practical for initiating weight loss for obese children. Long-term follow-up which is underway will be reported later.

High prevalence of Cryptosporidium in young children with prolonged diarrhea.

A prospective study was done to identify Cryptosporidium in the stools of young children, aged 2 months to 3 years, admitted to hospital. Of a total of 387 stool samples from 387 individuals, 131 stool specimens forming the control group were from children with non-diarrheal, respiratory tract infections, 200 and 56 stool samples were from children with acute diarrhea and prolonged diarrhea, respectively. No Cryptosporidium was discovered in the control group. Only 1 sample positive for Cryptosporidium was found in the group with acute diarrhea, whereas 4 samples of Cryptosporidium were found in the group with prolonged diarrhea. The prevalence of Cryptosporidium in the group with prolonged diarrhea was significantly higher than the other two groups (p < 0.05). In those children with prolonged diarrhea, Cryptosporidium should always be included in the differential diagnosis.

Improvement of forced vital capacity in obese children during summer camping.

Twenty-one obese children who attended a 4-week summer camping in Siriraj Hospital were evaluated for their lung function before and after camping. Twelve out of 21 children (57%) were found to have restrictive lung before camping. Of these 12 children, 6 of them (50%) had improvement of lung function, whereas 4 out of those with abnormal lung function (33%) had normal lung function after campings.

Compartmental change after weight reduction in childhood obesity.

Ten obese children aged 8-13 years participated in a 4-week program of weight reduction. Dietary restriction of 800 kcal/day and mild exercise were the two features of the program. With this regimen the investigators expected that their lean body mass would be preserved while body fat would decrease. After the 4-week program, we found that those who were mildly and moderately obese lost more than 5 per cent of their body fat but less than 1 per cent of lean body mass. Those children with morbid obesity lost more than 5 per cent of body fat and lean body mass. It is concluded that the regimen is suitable for mild and moderate obesity, but for morbid obesity, a new regimen with higher energy and higher protein in the diet may be more suitable than the current one.

The correlation between osmolality and specific gravity of parenteral nutrition solution.

The correlation between osmolality and specific gravity of parenteral nutrition solutions containing various concentrations of amino acid and glucose were studied. There is good correlation between osmolality and specific gravity up to 1,000 mOsmol/kg H2O and 1.050, respectively. There are strong correlations between osmolality and amino acid concentration at each concentration of glucose. An equation which can be applied for quick calculation of osmolality of the solution from amino acid and glucose concentrations is: Osmolality (mOsmol/kg H2O) = 74.36 G + 163.91 A - 36.56. The results of this study can be adopted by all physicians for quick assessment of the osmolality of the PNS before administration to patients.

Gastric emptying pattern in Thai infants.

Gastric emptying of milk from the stomach of Thai infants shows a biphasic pattern. At 40 minutes the amount of stomach contents is more than at 20 minutes. At 100 minutes, only 16 per cent of the initial amount was recovered. The results of our study can be used as a standard reference for further study in infants with other diseases.

Bacterial and fungal contaminations in parenteral nutrition admixtures.

Parenteral nutrition admixtures prepared in the incubator for sick newborn infants from three wards were cultured for bacteria and fungi. Of the total samples of parenteral nutrition solution being studied, 4.7 per cent had fungi and 14.1 per cent had bacteria. Solutions prepared in the intensive care unit, in the ward for sick newborn, and in the ward for sick preterm revealed fungal contaminations at about 11.1, 5.8 and 0.0 per cent respectively. Bacterial contaminations were higher and had a percentage of 11.1 from the intensive care unit, 23.5 from the ward for sick newborn and 10.3 from the ward for sick preterm. It was concluded that another more sterilized technique should be implemented for reduction of such a high rate of bacterial and fungal contaminations in the parenteral nutrition admixtures.

Massive chemotherapy and autologous bone marrow transplantation in Burkitt's lymphoma: the first two patients successfully treated in Thailand.

Massive chemotherapy and autologous bone marrow transplantation (ABMT) have been successfully used for the treatment of Burkitt's lymphoma. We report our first success with such treatment in two children with Burkitt's lymphoma in Thailand. Both patients had massive abdominal tumors with ascites and minimal bone marrow metastasis at the first presentation. They received induction chemotherapy and intensive treatment including central nervous system prophylaxis with cranial irradiation and intrathecal methotrexate until being in complete remission before starting massive chemotherapy, comprising the combination of BCNU, cytosine arabinoside, cyclophosphamide and 6-thioguanine followed by ABMT. Both patients recovered completely following intensive supportive treatments post ABMT and are still good health without evidence of the disease for 18 and 8 months after transplantation respectively. The role of massive chemotherapy and ABMT for the treatment of non-Hodgkin's lymphoma especially Burkitt's lymphoma was discussed.

Childhood malnutrition: Nutritional and social background analysis.

The analysis was done in 52 infants and Preschool children under 6 years of age who were referred to Pediatric nutrition clinic, Siriraj Hospital during September 1987 to August 1988 because of growth delay. AII of the patients, 18 boys and 34 girls were under 3rd percentile of body weight. 52% of the cases were 12.23 months old, while average age was 30 months. The onset of growth delay was noticed at the average age of 8.8 months. In 62% of the cases the onset was associated with breast milk weaning, while in 16% and 22% they were associated with additional food and illness (diarrhea, vomiting and measles) respectively. Eighty three percent of the cases was classified by modified Gomez’s criteria as having first degree malnutrition. While 17% was second degree. 29% was classified to be acute malnutrition. While another 29% was nutritional dwarfism and 40% was acute on chronic malnutrition by Waterloo’s classification. 71% and 96% of the cases were less than 10 percentiles of arm muscle area and arm fat area respectively. The three-day caloric count was completely performed in 20 patients. The caloric intake was found to be significantly lower than expected calories per both ideal body weight and recent weight. The average percentage of protein: fat: carbohydrate was 15: 30: 55.The amount of food and the way of feeding seemed to be more important to childhood malnutrition than the familial income.

An estimation of volume of fluid by using Polyethylene Glycols (PEG) as a marker: An in vitro study.

Polyethylene glycols are non-digestable and non-ansorbable substances, being used extensively in studies of the DI tracts. When amount and concentration of PEGs are known, then the volume of fluid could be estimated. From the in vitro study, we measured the substances at 5 different concentrations. The results showed that the volumes of fluid estimated were about 7 percent higher than the actual. From this study we could conclude that the accuracy of the measurement is within 7 percent of the estimated volume, which will be used as a reference for further related study.

Intestinal parasites in pediatric patients with diarrhoeal diseases in Bangkok.

Stool examinations of 147 pediatric patients with diarrhoeal disease were carried out at Siriraj Hospital, Bangkok by using the direct-smear technique. Stool of 27 patients (18.4%) were positive for intestinal parasites. Children under one year of age were free of intestinal helminths and protozoa. Parasites were equally prevalent in males and females and without any age group predilection. The prevalence of intestinal parasites were Entamoeba histolytica 6.8%, Giardia lamblia 6.1%, others were Ascaris lumbricoides, hookworm, Trichuris trichiura and Balantidium coli. Although the incidence of parasitism was not high as to be the main causatic agent of pediatric diarrhoea, the intestinal parasites may increase susceptibility to infection with other intestinal pathogens. The diagnosis of intestinal parasitoses can be determined by a simple direct faecal-smear technique and so that specific therapy can be instituted without delay in management of parasite-related diarrhoeas.