Ok guys, for those of you who were following the blog last summer, you’ve probably wondered where the heck I’ve been the last few months. Don’t worry! I’m still around – I’ve just been really busy providing face-to-face care for folks, and I’ve had less time to write and answer questions online.
That being said, I have received some questions in recent weeks, and I want to get back to posting regularly. Do YOU have a nutrition question you’d like answered? If so, please send your question(s) to anna@foodsmartsnutrition.com. Don’t worry – if you’d prefer your name not be published along with your question, simply let me know, and I’ll keep your identity secret.
Now, let's check out this week's question . . .
Today we're talkin' about infant nutrition. Can we just take a minute, though, to talk about how baby mugshots were a thing in the '80s? The bow scotch-taped to my bald head really makes the picture. #stylin #beforephotoshop
This week’s Q & A format is going to be a little different. It’s really more of a myth-busting post. The myth we're busting is all about the infant diet and ketosis. In the last month, I’ve run into multiple people (in several different online nutrition forums, and also a few in person) who have been told at one point or another that infants, from birth, are in ketosis.
The long and short of it is this:
Myth: Babies are in ketosis and eat keto throughout infancy, until they transition to a solid-food diet.
Fact: Babes are NOT in ketosis and are not eating keto during infancy if they are consuming breastmilk or standard infant formula. The only time that babies are maintained in ketosis is during a medically-supervised ketogenic feeding intervention, with special, prescription formula.
The first time I ran into this myth, I brushed it off as a one-off misunderstanding. The person who said it was literally in a bar, talking with friends about his ketogenic diet, and said something along the lines of, “I mean, we eat ketogenic from the time we’re born until we are toddlers….”
I’ll be honest, the dietitian in me was like, “What fresh hell is this?”
But, the realist in me recognized that the bar is not the place to have an in-depth conversation about infant metabolism with a perfect stranger. Plus, by that time I’d paid for my bourbon. #priorities
Later, I saw similar conversations online in a couple different forums, all from very well-meaning, intelligent people. Finally, an acquaintance asked me if it was true – that babies are on a “ketogenic diet” as long as they are on breastmilk or formula. It was at that point I figured this topic needed to be addressed in a weekly Q & A.
First off, let’s establish exactly what a ketogenic diet is, in brief.
A ketogenic diet is a type of diet that shifts the body’s metabolism from a carbohydrate-based metabolism to a lipid (fat) based metabolism. In recent years, the ketogenic diet has become popular among some adults who are using it as a means for weight loss. One important fact to know is that the ketogenic diet is NOT the same as a “low carb” or “Paleo” diet. So – if you’re thinking in terms of “low carb,” wipe that from your mind for now. The ketogenic diet is a whole different thing. Detailed discussion of this is beyond the scope of this article, but if you would like to get into the nitty gritty of the ketogenic diet versus other diets, check out [this fabulous article from Precision Nutrition.]
Originally, the ketogenic diet was not a weight-loss plan. It was developed in the 1920s, after researchers discovered that children with epilepsy found remission from seizures when placed on a very-low-carbohydrate diet. The ketogenic diet is still used for seizure control in children, and up until the last few years, this was the only major application for the diet. This type of therapeutic ketogenic diet can be very successful in treating seizure disorders when other medical management has failed.
Children who have to follow the ketogenic diet see specialist dietitians who are highly trained in this very unique and specific area of nutrition. Luckily, my friend and colleague Brittany Stanley is one of these rare dietitians working with the pediatric keto population, and she graciously agreed to be an expert contributor for this article. (Thank you so much, Brittany!) Brittany works closely with a medical team to prescribe ketogenic diets for infants and children with seizure disorders, and she is truly brilliant at what she does. Read on for some in-depth discussion with Brittany, after we lay some basic groundwork here.
Infographic: Food Smarts Nutrition, LLC
As you can see in the infographic above, infants who consume breastmilk or formula are definitely not in ketosis. In the pediatric ketogenic diet, carbohydrates cannot provide more than approximately 5% of total calories. Breastmilk and standard infant formulas provide anywhere from 42-48% of total calories. Ketogenic diets require at least 75% of calories from fat, while breastmilk and standard formulas provide only 44-49% calories from fat.
Guest Expert:
For those who may be interested in learning more about the pediatric, therapeutic ketogenic diet, let’s take a look at my conversation with Brittany Stanley, Registered Dietitian Nutritionist and ketogenic diet expert.
AH: Brittany, what are some of the therapeutic uses of the ketogenic diet?
BS: The strongest evidence for the ketogenic diet is for treatment of epilepsy. There is some emerging evidence that it may be helpful with other neurological or brain disorders, but the research is ongoing for now.
AH: So what would you say are the main differences between the ketogenic diet that some adults are following these days, versus the therapeutic ketogenic diet you prescribe for children with epilepsy?
BS: The biggest difference I notice is that when people say they are on a “ketogenic” diet for weight loss – they’re often just on a low carbohydrate diet, which is different. They’re not actually consuming enough fat to really be in ketosis. Usually, they’re eating an excessive amount of protein as well. The macros just aren’t the same as what’s required for a therapeutic keto diet. It’s pretty difficult for the average person to eat the amount of fat required for a true ketogenic diet, while also restricting protein and carbs.
Another difference I see is that adults following the ketogenic diet typically don’t weigh or measure their foods at all times. They often “eyeball it.” For children following the ketogenic diet for epilepsy, everything has to be VERY exact. There are NO free foods or cheat days – ever -- and amounts and ratios are extremely important.
AH: Wow, so it’s a pretty complicated diet to follow. What about monitoring – what are the differences for adults on the diet versus kids who need the diet for epilepsy?
BS: A big difference is the way we monitor ketones. Labs are monitored routinely – before and during the diet. With kids, we measure ketones in both the urine and blood to ensure we’re at a level of ketosis that is therapeutic. For the average adult on the ketogenic diet, they might measure urine ketones, but not likely blood ketones. On average, adults following a ketogenic diet are not at a very high level of ketosis compared to kids on the therapeutic diet.
AH: Tell me a little more about “levels” of ketosis – this likely will be new to some of our readers. Are you saying that there is a range for ketosis, and that different types of tests will tell you more precisely where you are in that range?
BS: Yes. There is a range, and it is possible to go too far into ketosis. Urine tests are a fairly crude measurement, which show either small, moderate, or large ketones in the urine. This gives some basic information, but doesn’t give you an exact idea of where in ketosis you are. For example, if you have “large” ketones in the urine, your blood ketones could be at a 1, or greater than 7. A result of 1 in the blood is not therapeutic, whereas a result greater than 7 is bad – it’s too far into ketosis. For children on the diet, it’s important to have a precise measurement of where they are, to make sure their level of ketosis is actually therapeutic for seizure control.
AH: Yeah, so that’s a pretty significant difference. Tell me a little more about what it means to be “too far into ketosis.”
BS: So the problem of getting too far into ketosis is that the body and blood can become very acidic. The ketogenic diet is a very acidic diet as-is. If you get too far into ketosis, your blood sugar can become extremely low. A child in this condition might become very flushed; have shallow, rapid breathing; be very lethargic; or even difficult to arouse.
AH: That sounds like that would be a real medical emergency if that were to happen.
BS: Yes – without intervention, this could lead to severe complications and even death. One scary thing about this is, if you put a child on a ketogenic diet and weren’t being followed by a medical team, and your child exhibited these symptoms, it could be mistaken for DKA [diabetic ketoacidosis] in the emergency medicine setting. For DKA, you wouldn’t give dextrose [a carbohydrate solution used to raise the blood sugar], but in this dangerous ketosis situation, the child really NEEDS dextrose. If they didn’t receive the right treatment fast, complications could definitely happen.
AH: So it’s pretty important then that kids of all ages be followed closely by a specialty team if they’re going to be on the ketogenic diet, right? Like, not just infants – babies – but also toddlers, kids, and adolescents?
BS: Yes, it is very important that children are followed medically while on a ketogenic diet. Parents should not try to place their kids on a ketogenic diet without getting their child evaluated first to see if it’s even an option, and then allowing their child to have regular monitoring by an experienced keto team.
AH: What are some of the reasons why you should have your child evaluated before starting a ketogenic diet?
BS: First off, it’s important to have tests done to rule out several other metabolic disorders that would show if a ketogenic diet would be contraindicated.
AH: Some kids could have problems that would mean the ketogenic diet would not be an option or could be dangerous for the child?
BS: Right. There can be problems with fat metabolism in children that could be deadly if the child were placed on a ketogenic diet. There is no way you would know your child had a disorder of fat metabolism if you had no reason to check for it. Plus, there are several other disorders and metabolic conditions that need to be ruled out before starting the ketogenic diet.
AH: Gotcha. What about other tests – like general labs and things. What sort of labs to they have to test before starting a child on this diet?
BS: You have to monitor the kidneys due to the acidity of the ketogenic diet, especially monitoring for kidney stones. Kidney function labs would be examined, and so would family history of kidney stones. If there’s family history there, or if the child has already had kidney stones in the past, the ketogenic diet may not be a good choice.
AH: What about blood lipid levels, like cholesterol and triglycerides?
BS: When starting diet, you do need to watch cholesterol and triglycerides because they become elevated at first. It takes the body a little bit of time to get used to the ketogenic diet and metabolize that fat. We have to monitor lipid levels closely to make sure don’t go up too high and that they come back down to normal. If they don’t come down, we may need to add specialty supplements or change fat sources to avoid cardiovascular problems. It is a very high fat diet, so while it does work for epilepsy, it can cause other problems.
AH: Aside from kidney and blood-lipid issues, are there any development or general nutrition issues you have to watch for with the ketogenic diet?
BS: Because it’s so low in carbs, it lacks a lot of micronutrients and vitamins that babies and kids need to grow. Cutting out fruits cut out lots of vitamins and fiber. You must use vitamin and mineral supplements including calcium on this type of diet to support good growth and development. Also – the ketogenic diet is low to moderate in protein. Sometimes it’s as low as 10% protein, so watching growth is important because growth restriction can happen.
AH: With so much to consider, is there an age requirement for the ketogenic diet? Like, do kids have to be a certain age before they can start it?
BS: No – as soon as assessment and testing can be done, they can start the diet. Infants, soon after birth, can begin a ketogenic diet with specialty ketogenic formula.
AH: For readers who aren’t very familiar with baby formulas, tell me a little more about what this formula is like. Is this a formula you can just get from a store, or how is it made?
BS: Ketogenic infant formulas are by prescription only and are highly individualized. That’s one reason it’s so important to work with an experienced keto dietitian to get the right formulation. The formula will have multiple ingredients that must be measured and added very precisely.
AH: What about breastmilk? Can any breastmilk be used for babies on ketogenic diets?
BS: Breastmilk can be used to a degree. When parents want to breastfeed a baby who needs a ketogenic diet, they have to follow some specific steps. Usually what they will do is have the child begin their feeding by drinking several ounces of ketogenic formula. Mom will pump for about 10 minutes and get rid of the pumped milk. The hind milk that comes at the end is higher in fat, so Mom can let the baby nurse on that higher-fat milk for about 5 minutes.
AH: So breastmilk is more like a supplement for these babies – not a major source of calories and nutrients?
BS: Right. It’s only a small amount of breastmilk that the baby can consume. In these cases, the breastfeeding is mostly for comfort, rather than nutrition. The vast majority of nutrients have to come from formula to keep the baby in ketosis. Even with such a small amount of breastmilk, it’s really important to monitor ketosis closely.
Ok Food Smarties – thanks for joining us this week for our weekly Q&A. Have you learned something new today? Do you have an experience with the ketogenic diet you’d like to share? Join the discussion below in the comments, or follow along on Facebook and Instagram. And don’t forget to send in YOUR pressing nutrition questions to anna@foodsmartsnutrition.com!
Eat smart –
-Anna
Reference List:
Akers S, Groh-Wargo S. Infant nutrition. In Seymour PQ, King L, eds. Essentials of Pediatric Nutrition. Burlington, MA : Jones & Bartlett Learning; 2013 : 55-70.
Barbas KH, Fulhan, J. Breastfeeding and human milk. In Sonneville K, Duggan, C, ed. Manual of Pediatric Nutrition. Shelton, CT : People’s Medical Publishing House – USA; 2014 : 64-80.
Cloud HH. Developmental disabilities. In Seymour PQ, King L, eds. Essentials of Pediatric Nutrition. Burlington, MA : Jones & Bartlett Learning; 2013 : 139-151.
Fenton C, Randall R, Groveman SA, Chee CM, Bergqvist AGC. Use of expressed breast milk with the ketogenic diet. ICAN. 2015; 7 (6) : 342-346.
Green-Corkins K, Sentongo T. Infant formulas and complementary feeding. In Corkins MR, ed. The A.S.P.E.N. Pediatric Nutrition Support Core Curriculum. Silver Spring, MD : American Society for Parenteral and Enteral Nutrition; 2010 : 129-142.
Hartman AM, Stanley BN. Therapeutic pediatric ketogenic diets. Personal interview. October 2017.