Ketogenic Diet and NPO Recommendations

Important information about the keto diet and surgery preparation

Your surgical provider will instruct your child not to eat or drink ahead of their surgery. This is called “NPO” which means nothing by mouth. These recommendations will help your child maintain blood glucose levels before and during surgery.

Instructions for continuing the Ketogenic 3% carbohydrate diet composition while NPO

  • Ask for an early morning (AM) surgical slot. This way your child does not need to be without food for a long period of time.

  • Tell schedulers, pre-op nurses, and the surgical team that your child is on a ketogenic diet. Explain that they may have more frequent or severe seizures if their keto diet is disrupted. Some providers may not be familiar with the keto diet.

NPO recommendations

Your child can follow standard NPO instructions. There will be one time listed to stop eating and another to stop clear liquids. If your child does not follow NPO times, the procedure or surgery must be rescheduled.

  • Give your child keto approved clear liquids:

    • unlimited water

    • up to 12 ounces of zero sugar sports drink like Gatorade®

  • Before the NPO time for clear liquids, give your child 1 carb and then continue 1 carb every 3 hours until their procedure. 

  • One carb can be: 8.5 mL apple juice or 40 mL Pedialyte® or 16ml of any flavor regular Gatorade®.

Blood glucose

Check your child’s blood glucose levels every 4 hours, as indicated when NPO.

  • If blood glucose level is 40-45 mg/dL when tested, give 1 carbohydrate.

  • If blood glucose level is 30-39 mg/dL when tested, give 2 carbohydrates.

Treatment options (1 carbohydrate equals the following):

IV: 20 ml of D5/W

By mouth or by tube:

  • 8.5mL of apple juice

  • 33mL Enfalyte®

  • 16 ml of any flavor regular Gatorade

  • 40mL of any flavor of clear Pedialyte

If you treat a low blood glucose, recheck the blood glucose in 30 minutes and re-treat until the blood glucose reads 50 mg/dL or higher.

Intravenous fluids

Intravenous (IV) fluids are specially formulated liquids injected into a vein to keep your child hydrated while in surgery.

  • Ask your surgical team to give only carbohydrate-free IV fluids.

  • Avoid IV fluids that contain dextrose or glucose. 

  • Avoid Lactated Ringers (LR) unless medically necessary.

If a provider asks why, explain that dextrose reverses ketosis and may result in an increase in the number of seizures your child has or worsen how severe the seizures are.

Medicines

Medicines sometimes contain hidden carbohydrates as fillers, which your child needs to avoid.

  • Ask your provider to prescribe tablets or capsules for medicines. They contain the least amount of carbohydrates.

  • If needed, tablets can be crushed and capsules can be opened. Your pharmacist can show you how to do this.

  • Avoid chewable and liquid medicines.

For medicines given by IV, tell your providers not to mix the medicine with dextrose. If the provider asks why, tell them the extra carbohydrates lower the effectiveness of the keto diet, which may lead to your child having more seizures.

 

Contact the CHOP Keto team with questions or concerns by calling the main Neurology number: 215-590-1719. Ask to speak with a keto diet provider, nurse, or dietician.

 

Reviewed December 2025 by Christina Bergqvist MD, Marta Perkiss, RN, and Cagla Fenton, RD