If tolerating fluids and vomiting/diarrhea has improved, start with ½ of a keto meal without the added fat (butter/oil) then advance to the ½ meal with the fat included, and finally back to goal meals as able. If your kiddo is struggling with getting back to goal keto meals, try baked chicken and soft, cooked vegetables without the fat source (or a reduced amount of fat). Cauliflower rice with chicken and a little butter is a great option. This is also where chicken or vegetable broth can be well-tolerated.
For those on a tube feeding once fluids are tolerated, start with ½ strength ketogenic formula and advance back to your goal as able.
Most of the time both oral and tube-fed children can be back to their goal keto plans within 2-3 days. Keep in mind that appetite recovery can take longer. When you think about an individual who is not on a ketogenic diet, we expect a decreased appetite during illness. Keto kids are no different! So, it’s okay if you work back up to goal calories slowly, but symptoms of vomiting and diarrhea should not be persistent. If your child is unable to advance to ½ strength formula or meals after clear liquids for 24 hours, call your medical team.
What Are Some Tips for Combating Nausea?
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Offer smaller more frequent meals. Not eating anything can often worsen nausea. Even just sipping on broth can help settle the stomach.
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Try carb-free herbal teas such as mint or ginger
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Reintroduce foods starting with broths, chilled avocado with olive oil, plain scrambled eggs, keto crackers (such as these flax-hemp crackers from the Charlie Foundation), nuts or nut butters, chia seed pudding, or flaxseed porridge
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Stick to cool/cold or room temperature foods
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Foods with less or no odor may be better tolerated
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Try carb-free, carbonated beverages such as diet ginger ale
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If MCT oil is part of your plan, titrate up slowly (even start at 5 mL every other meal) because small volumes have less of a chance to adversely affect nausea.
How Long Should I Let My Child Have Vomiting or Diarrhea Before Telling Someone?
Let your keto team know anytime your keto superstar is vomiting or having diarrhea. They should know on day 1 to best guide on preventing dehydration and maintaining ketosis versus reacting to treatment of dehydration.
What Are Symptoms of Illness That Are Alarming?
If your child experiences any indications of excessive ketosis such as the combination of flushed cheeks, increased work of breathing, increased heart rate, vomiting, lethargy, and/or a decreased appetite you should notify a healthcare provider. When these symptoms present together, an ER visit for hydration and monitoring may be necessary. Staying hydrated is your best defense against excessive ketosis.
What Will Happen If We Are Admitted to the Hospital Due to Illness?
If you are admitted to the hospital due to illness, plan to bring at least a day’s worth of keto food/formula (longer if admitted on the weekend) to the hospital already prepared. Hospital cafeteria hours vary, and food service staff may not have all the necessary food needed for an unplanned hospital admission. This is particularly true if you are admitted in the evening or weekend.
If you are at the hospital facility that is the same as your keto team, your keto RD will likely follow your admission closely and provide the medical team with guidance on oral hydration, IV fluid, lab work, and advancement of diet. If you are at a hospital facility that does not have a specific keto program, ask the local team to contact your keto team for guidance.
Always remind the medical team that your child is on a ketogenic diet and should not have any liquid medications unless discussed with your keto team. In addition, in settings like the ER or other areas of the hospital that may not be as familiar with ketogenic diet therapy, gently remind them that IV fluid (if needed) should not contain dextrose or at most be a dextrose 2.5% solution to prevent a rapid rise in glucose. The standard dextrose solution in any hospital is 5% dextrose which is generally not compatible with a ketogenic diet.
Glucose levels may be checked during a hospital admission. Keep in mind that normal glucose for a ketogenic diet is 50-70 mg/dL – For those kiddos not on a ketogenic diet generally glucose goals are >70 mg/dL so there is a difference here. The medical team may need reminding that slightly lower glucose levels are expected for ketogenic diet therapy but again – too low of glucose levels (<40 or 50 mg/dL depending on your keto goals) can happen during illness and should be treated.
