Day 2 (Tuesday): Child is given ‘‘eggnog’’ for dinner
(1/3 of the maintenance calorie allotment for dinner);
blood glucose checks are discontinued. The parents
are asked to start checking the child’s urine ketone
levels. Ketone levels should be between 80 and 160
mg/dL when the diet is working properly.
Day 3 (Wednesday): Breakfast and lunch are given as
eggnog (1/3 of the maintenance calorie allotment for
those meals); dinner (more eggnog) is increased to
2/3 maintenance level.
Day 4 (Thursday): Breakfast and lunch are given at
2/3 maintenance level; dinner is the child’s first full
ketogenic meal (not eggnog).
Day 5 (Friday): After a full ketogenic breakfast, the
child’s prescriptions are reviewed, follow-up is
arranged, and the child is discharged from the
hospital.
Some hospital programs do not require fasting to
initiate the child’s diet. Follow-ups for most children
take place at three-month intervals, although infants
may be seen monthly. Children must take multivita-
mins and mineral supplements (particularlycalcium)
while on the ketogenic diet. Anticonvulsant medica-
tions are usually continued for the first few months of
the diet, but may be given in lower dosages if the child
responds well to the diet, or even discontinued
altogether.
SAMPLE MENUS.A typical day’s menu for a child
on the standard 4:1 ratio diet, allowing 1500 calories
per day:
Breakfast: egg with bacon, made with heavy whip-
ping cream and butter, plus an apple
Snack: peanut butter mixed with butter
Lunch: tuna salad made with celery, mayonnaise,
and heavy whipping cream, served with lettuce
Snack: keto yogurt (made with heavy whipping cream,
sour cream, strawberries, and artificial sweetener)
Dinner: cheeseburger with lettuce and green beans
Snack: keto custard (heavy whipping cream, egg, and
pure unsweetened vanilla flavoring)
A computer program is available (listed in the
resources below) to help parents and dietitians devise
menus that will take the individual child’s food pref-
erences into account as well as keep the meal selections
within the correct nutritional ratio.
TAPERING AND TERMINATION.The ketogenic diet
is a long-term diet but is not intended for indefinite use
in children. Most children who respond favorably to it
remain on it about two years. The diet must not be
stopped abruptly, however; most doctors recommend
that parents slowly start to add regular foods to the
child’s menu to see whether the seizures are still
controlled.Sanggye Paik Hospital diet
The Sanggye Paik Hospital diet is a version of the
ketogenic diet developed in Korea for the treatment of
Asian children, whose diets typically contain much
less fat than the diets of Western children. The Sang-
gye Paik protocol does not require an introductory
fast and introduces high-fat foods to the patient’s
diet gradually, although it uses the same 4:1 ratio of
fats to protein and carbohydrates as the Johns Hop-
kins protocol. It is reported to have the same propor-
tion of successes in patients as the Johns Hopkins
ketogenic diet.Modified Atkins diet
In 2003 the Johns Hopkins treatment center ini-
tiated a case series of six children and adults who used
a modified version of theAtkins dietto control seiz-
ures rather than the classic 4:1 ketogenic diet. These
patients were not admitted to the hospital; did not
have to fast at the beginning of the diet; did not have
calories, protein, or fluid intake restricted; were lim-
ited to 10–grams of carbohydrates per day; and were
encouraged to eat foods rich in fats. Half the patients
showed a marked reduction in seizures.
Based on this initial success, the Johns Hopkins
doctors drew up a modified Atkins diet protocol for a
group of 20 children, as follows:
A carbohydrate counting guide is given to the
patient’s family.
Carbohydrate intake is limited to 10g per day for the
first month.
A generous intake of fats in the form of mayonnaise,
butter, oils, heavy cream, etc. is encouraged,
although precise amounts are not defined.
Clear carbohydrate-free fluids and calories are
unrestricted.
The patient is given a low-carbohydrate multivita-
min and a calcium supplement.
Ketones in the urine are checked twice a week and
weight once a week.
Low-carbohydrate store-bought products (shakes,
snack bars, etc.) are discouraged for at least the
first month.
The patient is given a complete blood test and meta-
bolic workup every three months.
Of the 20 patients, two-thirds had a significant
reduction in seizures, 9 were able to reduce medication
dosages, and none developed kidney stones.Ketogenic diets