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What Does 'Going Into Ketosis' Look Like?

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Carrie has been administering and monitoring the Classical Ketogenic Diet for the past 10 years in the USA and here she shares with us some of the symptoms she has witnessed during this time.  Some children may suffer a few of the symptoms she lists below and other may not, it always depends on the individual child.  If you are worried about ANYTHING then please consult your team and/or your Doctor.

  What does going into ketosis look like?
      As witnessed by Carrie Loughran RD,CSP,LD

The following symptoms tend to occur during the initiation into ketosis (whether by fasting or with a slow gradual ratio change). The faster the initiation process and higher the ratio (4:1) started at, the stronger they will present themselves.  These symptoms will go away with time or can be avoided with appropriate intervention.

The first stages of ketosis

Lethargy (being tired) it is common for kids to sleep a lot at this stage. They can loose interest in everything from playing to eating. Hydration is the top priority at this time.

Hypoglycemia (glucose levels below 55mg/dl or 3.0).  Going into ketosis suppresses appetites.  The more body fat the child has, the longer the suppression tends to occur.  This is easily treated with 5-10ml of fruit juice.
The leaner the child tends to mean the faster the child goes into ketosis.

Excessive ketosis (blood ketones read “high” or urine ketones that turn the stick black).  This can be due to two things; hydration and hypoglycemia.
It is probably safe to assume more fluids can be administered. Hypoglycemia can be checked with a blood glucose level. It is not uncommon that when children go into ketosis they are not interested in food and can be nauseous( thus not wanting to drink fluids). This can be treated with extra water and 5-10 ml of fruit juice. If nausea is a problem,  Then flattened diet lemon/lime soda can be sipped on until resolved.

Dehydration resolved with fluids. Flattened diet lemon/lime soda can be sipped on until resolved.

Changes in urine output; resolved with time and monitoring fluids. It is common for kids to only urinate two-three times/day for the first week or so.
Usually those in diapers notice two “super-soaked” diapers/day.  This usually goes away with days to a couple of weeks.

Vomiting usually occurs when the stomach is either too empty and bile is accumulating or too much ketogenic food at too high of ratio was consumed.
Both resolved with time and extra fluids if needed. Check blood ketone levels to rule out excessive ketosis. For those kids who have not eaten, they feel better once the bile is gone and may be ready to eat. For those who ate and now are suffering, it makes for a slow start to get them to want to eat the food for a day or so. Again, hydration is most important along with avoiding hypoglycemia. Medications can also help with reflux once the child is eating well.

Respiratory Acidosis: A shallow panting. Usually a sign of excessive ketosis.  May be resolved with a lower ratio. It also could be a sign that ketosis isn’t tolerated at that degree.  A call to the doctor is important if this occurs.

Behavioral issues:

Food refusal: resolved with time, persistence and consistency. It helps to
Provide foods that the child is familiar with and has eaten in the past.

Begging for food: resolved with tears, temper tantrums, time, persistence and consistency. It can take a month before some children resolve to the diet.

Food fixation: resolved with allowing choices, helping with food preparation (if appropriate), reasoning, time and consistency. It isn’t uncommon for kids to want to eat foods that look normal (like eggs and butter).  Try to avoid food jags by providing a variety of meals to ultimately avoid burn-out with that one food.  There are many good recipes around these days!

These issues are often the most challenging for families.  There are behavioral strategies that ease some of the difficulty.  Talk to your support system like those here on the Matthews Friends forum.

Other issues to look for:

Reflux:  The higher the ratio, the more likely this will occur. Usually seen with ratios > 3:1.  This tends to effect the child’s eating. You may smell “sour breath” with wet burps. Some children will say they are “throwing up” in the back of their throats.  Most children will refuse to eat or swallow the fat source.  Some children will eat well one day then tend not to eat well for two days after.  Dividing meals into smaller more frequent meals, separating fluids from meals, keeping the child up-right after eating can help some. The higher the ratio, the more likely medication will be needed to manage the reflux. If not addressed in a timely manor, Lip-locking (food refusal) along with an association of food = pain will develop. This cycle is harder to break the longer it goes on.

Constipation:  Two things to look at. One is frequency of the stool, and the other is consistency of the stool.  Ideally a stool is passed every day.  Realistically a stool should be expelled no later then every third day or a “plug” can develop and these tend to hurt to pass and can trigger seizures.
Consistency of the stool can be manipulated by fluids, the carbohydrate source, digestive enzymes, and when needed a stool softener. The higher the ratio, the more likely the harder the stool.
If your child has a soft stool but has trouble passing or initiating it, a trail of digestive enzymes with a higher level of  “lipase” can be tried.

Slowed Growth:  The higher the ratio, the more likely one may see a slowing of the heightening process especially at a 4:1 ratio. 

Kidney Stones: Mostly seen in those children who have a family history of them or can’t tolerate adequate fluid levels.
Let your team know if this is the case. Try to keep the highest level of hydration your child can handle without loss of seizure control.
First indications can look like crystals in the urine or  “sludge” ( brown sand) in the urine.


YOU MUST consult your own medical Keto Team before making ANY changes to your childs treatment,
Matthews Friends cannot be held responsible if you do not heed this warning.
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