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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 hungry 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 unlimited, carbohydrate-free water.

  • Before the NPO time for clear liquids, give your child 1 carb exchange every three or four hours of a keto kid approved clear fluid. This will help maintain their blood glucose.

    • Example: 8.5 mL apple juice OR 40 mL Pedialyte® (though the volume is different, they contain the same amount of carbohydrates).

  • Avoid bottled water with carbohydrates on the ingredients list. Check the ingredients of bottled water to see if there are any carbohydrates.

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.

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


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

  • Ask your provider to prescribe medications that contain the least amount of carbohydrates.

  • Ask for crushed tablets and opened capsules as they have the least amount of carbohydrate.

  • Avoid chewable and liquid medications.

If the provider asks why, tell them extra carbohydrates lower the effectiveness of the keto diet, which may lead to your child having increased seizures and even status epilepticus.

If your child's surgery is at CHOP or you have questions about medications, ask the surgical team for help. They can contact the Keto Team or a clinical pharmacist (pager: 11548).

Blood glucose

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

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

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

Treatment options include (1 carbohydrate exchange):

IV: 20 ml of D5/W

PO or tube-fed:

  • 8.5mL of apple juice

  • 33mL Enfalyte®

  • 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.

Contact the CHOP keto team with questions or concerns.

Dietary Treatment Program:


Ask to speak with a keto diet provider, nurse, or dietician.


Reviewed May 2024 by Christina Bergqvist MD

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