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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.

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.

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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.

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OBJECTIVES: This study evaluated the adequacy of micronutrient intake from the ketogenic diet (KD) with and without micronutrient supplementation according to age in Brazilian children and adolescents with refractory epilepsy undergoing KD treatment. METHODS: This study enrolled children and adolescents with refractory epilepsy who were up to 19 y of age. Nutrient intakes were monitored using 3 d food records before introducing micronutrient supplementation and 3 mo after starting KD treatment. The prevalence of micronutrient inadequacy was estimated by sex and age according to the estimated average requirement cutoff values. RESULTS: This study included 39 children and adolescents. The KD did not provide enough content of folate, calcium, and magnesium in all patients according to the dietary reference intake. Even after starting supplementation, calcium, phosphorus, and magnesium intake remained inadequate in the majority of patients. The supplementation effectively met the vitamin B12 recommendation in all age groups. CONCLUSIONS: KD treatment did not provide adequate levels of the monitored micronutrients. The supplementation improved but did not prevent the inadequacy of micronutrients such as calcium, magnesium, and phosphorus. The results highlight the importance of individual supplementation protocols and the need to monitor micronutrient intake according to age and sex.

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Summary Background & aims: Diet is a modifiable risk factor, which may influence the gene expression and the concentration of inflammatory biomarkers related to obesity and atherosclerosis. In this sub study from Brazilian Cardioprotective Nutritional (BALANCE) Program, we hypothesized that a nutritional intervention based on the usual Brazilian diet modulates the expression of genes involved with atherosclerosis and inflammatory biomarkers in male patients, in the secondary prevention for cardiovascular disease. Methods: Six male patients, aged 45 years or older, obese, were selected to follow a qualitative-quantitative food plan for 6 months. Glycemia, insulinemia, lipid profile, plasma concentration of inflammatory biomarkers (interleukin (IL) -1b), IL-6, IL-8, IL-10, IL-12, tumor necrosis factor alpha, C-reactive protein and adiponectin, and expression of 84 atherosclerosis-related genes in total peripheral blood cells, were measured. Results: After nutritional intervention, the participants reduced weight (p<0.04), waist circumference(p<0.04), Homeostasis Model Assessment index for insulin resistance (p»0.046) and overall leukocyte count (p»0.046) and neutrophils (p»0.028). There was no significant modification in the plasma concentration of the inflammatory biomarkers, however, there was a significant increase in the expression of Apo A1 (p»0.011), ELN (p»0.017) and IL4 (p»0.037) genes. Conclusions: The BALANCE Program, the qualitative-quantitative food plan composed of Brazilian usual foods, did not reduce the concentration of inflammatory biomarkers, but increased in total peripheral blood cells the expression of genes involved in reducing the risk of cardiometabolic in obese patients, in secondary prevention for cardiovascular disease. The clinical trial is registered athttps://clinicaltrials.gov/and the unique identifier is NCT01620398.

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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.

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To identify which sociodemographic factors are associated with early weaning and compare the duration of exclusive breast feeding between mothers which received counseling about maternal feeding and mothers which was not guided for these practices METHODS: A cross-sectional study with 25 mothers that received counseling about the benefits of maternal feeding in the human milk bank and 25 from a university hospital that were not counseled. Data were collected using a structured questionnaire addressing mother-related data, the infant and the breastfeeding in the first semester. Comparison and odds ratio were the statistical analyses adopted RESULTS: There was not a significant difference of the duration of exclusive breast-feeding between the two groups (p = 0,524). Among mothers in the human milk bank group that discontinued early exclusive breast-feeding, fewer children (p=0,034) and a higher frequency of maternal work (p = 0,022) were observed. Wile, in the university hospital group low education (p < 0.001) and lower income (p = 0.009) were prevalent. In the totality of the sample, the interruption of exclusive breast-feeding was associated with <1 children (OR = 0.21, p = 0.030), the presence of a partner (OR = 0.046, p = 0.001) and the use of bottles or pacifiers (OR = 87.5, p <0.001). In both groups, the most cited motivation for exclusive breast-feeding discontinuation was the medical assistance. It was observed the absence of a specific standard guideline provided in the Human Milk Bank, and less than the recommended number of consultations in the literature CONCLUSIONS: Socioeconomic factors and inadequate incentives negatively influence the duration of exclusive breast feeding. It was verified the need to provide standardized and more frequent counseling for effective reduction of early weaning.

Identificar quais fatores sociodemográficos estão associados ao desmame precoce e comparar a duração do aleitamento materno exclusivo entre mães que receberam orientações sobre aleitamento materno e mães que não receberam MÉTODO: Estudo transversal realizado com 25 mães orientadas sobre aleitamento materno no Banco de Leite Humano e 25 não orientadas, provenientes de um Hospital Universitário. Os dados foram coletados por meio de questionário estruturado abordando dados relacionados à mãe, ao lactente e ao aleitamento materno no primeiro semestre. Comparação e razão de chances foram as análises estatísticas adotadas RESULTADOS: Não houve diferença significativa na duração do aleitamento materno exclusivo entre os grupos (p = 0,524). Entre as mães que interromperam precocemente o aleitamento materno exclusivo, menor número de filhos (p = 0,034) e maior frequência de trabalho materno (p = 0,022) foram observados. Já, no segundo grupo a baixa escolaridade (p < 0,001) e a menor renda (p = 0,009) foram mais frequentes. Na população total, associaram-se à interrupção do aleitamento materno exclusivo o número de filhos inferior a 1 (OR = 0,21; p = 0,030), presença de cônjuge (OR = 0,046; p = 0,001) e a utilização de bicos artificiais (OR = 87,5; p < 0,001). O motivo mais citado para tal interrupção foi a orientação do médico em ambos os grupos. Observou-se inexistência de um padrão específico de orientações prestadas no Banco de Leite Humano, além de uma média de consultas inferior ao recomendado na literatura CONCLUSÕES: Fatores socioeconômicos e incentivo inadequado exercem influência negativa na duração do aleitamento materno exclusivo. Observa-se a necessidade de fornecer orientações padronizadas e mais frequentes às lactantes, para redução eficaz do desmame precoce.

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OBJECTIVE: To identify which sociodemographic factors are associated with early weaning and compare the duration of exclusive breast feeding between mothers which received counseling about maternal feeding and mothers which was not guided for these practices METHODS: A cross-sectional study with 25 mothers that received counseling about the benefits of maternal feeding in the human milk bank and 25 from a university hospital that were not counseled. Data were collected using a structured questionnaire addressing mother-related data, the infant and the breastfeeding in the first semester. Comparison and odds ratio were the statistical analyses adopted RESULTS: There was not a significant difference of the duration of exclusive breast-feeding between the two groups (p = 0,524). Among mothers in the human milk bank group that discontinued early exclusive breast-feeding, fewer children (p=0,034) and a higher frequency of maternal work (p = 0,022) were observed. Wile, in the university hospital group low education (p < 0.001) and lower income (p = 0.009) were prevalent. In the totality of the sample, the interruption of exclusive breast-feeding was associated with <1 children (OR = 0.21, p = 0.030), the presence of a partner (OR = 0.046, p = 0.001) and the use of bottles or pacifiers (OR = 87.5, p <0.001). In both groups, the most cited motivation for exclusive breast-feeding discontinuation was the medical assistance. It was observed the absence of a specific standard guideline provided in the Human Milk Bank, and less than the recommended number of consultations in the literature CONCLUSIONS: Socioeconomic factors and inadequate incentives negatively influence the duration of exclusive breast feeding. It was verified the need to provide standardized and more frequent counseling for effective reduction of early weaning.(AU)

OBJETIVO: Identificar quais fatores sociodemográficos estão associados ao desmame precoce e comparar a duração do aleitamento materno exclusivo entre mães que receberam orientações sobre aleitamento materno e mães que não receberam MÉTODO: Estudo transversal realizado com 25 mães orientadas sobre aleitamento materno no Banco de Leite Humano e 25 não orientadas, provenientes de um Hospital Universitário. Os dados foram coletados por meio de questionário estruturado abordando dados relacionados à mãe, ao lactente e ao aleitamento materno no primeiro semestre. Comparação e razão de chances foram as análises estatísticas adotadas RESULTADOS: Não houve diferença significativa na duração do aleitamento materno exclusivo entre os grupos (p = 0,524). Entre as mães que interromperam precocemente o aleitamento materno exclusivo, menor número de filhos (p = 0,034) e maior frequência de trabalho materno (p = 0,022) foram observados. Já, no segundo grupo a baixa escolaridade (p < 0,001) e a menor renda (p = 0,009) foram mais frequentes. Na população total, associaram-se à interrupção do aleitamento materno exclusivo o número de filhos inferior a 1 (OR = 0,21; p = 0,030), presença de cônjuge (OR = 0,046; p = 0,001) e a utilização de bicos artificiais (OR = 87,5; p < 0,001). O motivo mais citado para tal interrupção foi a orientação do médico em ambos os grupos. Observou-se inexistência de um padrão específico de orientações prestadas no Banco de Leite Humano, além de uma média de consultas inferior ao recomendado na literatura CONCLUSÕES: Fatores socioeconômicos e incentivo inadequado exercem influência negativa na duração do aleitamento materno exclusivo. Observa-se a necessidade de fornecer orientações padronizadas e mais frequentes às lactantes, para redução eficaz do desmame precoce.(AU)

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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.

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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. .

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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±277.1 kcal/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.

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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. .

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The biggest diffi culty for the study of metabolic syndrome in adolescence is the lack of consolidated cut points for this age group. This study characterizes the risk factors for metabolic syndrome in female adolescents and verifi es the possible existing correlations between the variables analyzed. It was carried out with 60 female adolescents between 14 and 18 years old. The body mass index and its derivatives, the circumferences of the waist (W) and hip (H), the body fat percentage (%BF) and the plasma levels of total cholesterol (TC), fractions (LDL and HDL) and fasting glucose were analyzed. Despite the predominance of eutrophic adolescents (90%), important alterations have been found: raised body fat percentage (78.3%), modifi ed fat plasma levels of 23.3% (TC), 15% (LDL) and 5% (HDL), besides impaired fasting glucose (6.7%). Moreover, one of the adolescents was diagnosed with diabetes mellitus. Signifi cant correlations between HDL and W/H ratio (r =-0.276; p=0.032), LDL and %BF (r = 0.296; p=0.021) and between the number of risk factors observed for the adolescents and the values of %BF (r=0.300, p=0.020), TC (r=0.536, p<0.001) and LDL (r=0.506, p<0.001) have been found. The importance of such alterations in this age group is justifi ed by its clinical meaning, since they will increase the risk of morbidity and mortality due to chronic diseases in adult life.

La mayor difi cultad para el estudio del síndrome metabólico en la adolescencia es la falta de puntos de corte consolidados para esa faja de edad. El objetivo de este estudio fue investigar los marcadores de riesgo para síndrome metabólico en adolescentes de sexo femenino y verifi car posibles correlaciones existentes entre las variables analizadas. Fue conducido con 60 adolescentes de sexo femenino, entre 14 y 18 años de edad. Se determinaron: el índicede masa corporal (IMC); circunferencias de cintura y cadera; porcentaje de grasa corporal total (%G); niveles sanguíneos de colesterol total (CT) y fracciones (LDL y HDL); glucemia de ayuno. Aunque la eutrofi a predominaba (90%), se detectaron alteraciones importantes: elevado porcentaje de grasa corporal (78.3%); alteraciones de los lípidos sanguíneos, 23.3% (CT), 15% (LDL) y 5% (HDL); glucemia de ayuno alterada (6.7%) y en una adolescente fue diagnosticada diabetes mellitus. Había correlación signifi cativa entre HDL y la relación cintura-cadera (RCQ) (r = -0.276; p=0,032); entre LDL y %G (r = 0.296 p=0,021); entre el número de alteraciones presentes en las adolescentes y %G (r=0,300, p=0,020); entre CT (r=0,536, p<0,001) y LDL (r=0,506, p<0,001). Las alteraciones observadas en esta faja etaria son altamente signifi cativas por su implicancia clínica de elevado riesgo de enfermedades crónicas en la vida adulta.

O maior entrave para o estudo da síndrome metabólica na adolescência consiste na carência de pontos de corte consolidados para tal grupo etário. O presente estudo se propôs a caracterizar os marcadores de risco para a síndrome metabólica em adolescentes do sexo feminino e verificar as possíveis correlações existentes entre variáveis analisadas. Tal estudo foi realizado com 60 adolescentes, do sexo feminino, entre 14 e 18 anos de idade. Foram analisados o índice de massa corporal e seus derivados, as circunferências da cintura (C) e quadril (Q), o percentual de gordura corporal (%G) e as dosagens plasmáticas de colesterol total (CT), frações (LDL e HDL) e glicemia de jejum. Apesar da predominância da eutrofi a (90%), encontraram-se alterações importantes: elevado percentual de gordura corporal (78,3%), níveis alterados de lipídios sangüíneos, 23,3% (CT), 15% (LDL) e 5% (HDL), glicemia de jejum alterada em 6,7%, sendo que em uma das adolescentes foi diagnosticado o diabetes Mellitus. Observaram-se correlações signifi cantes entre HDL e relação C/Q (r = -0,276; p=0,032) e LDL e %G (r = 0,296; p=0,021) e entre o número de alterações apresentadas pelas adolescentes e os valores %G (r=0,300, p=0,020); CT (r=0,536, p<0,001) e LDL (r=0,506, p<0,001). A importância de tais alterações neste grupo etário se justifi ca em função do seu signifi cado clínico, uma vez que irão predispor ao aumento das taxas de morbi-mortalidade por doenças crônicas não transmissíveis na vida adulta.

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