The efficacy and long-term treatment outcome of a classic ketogenic diet (KD) addon treatment (4:1 lipid/nonlipid ratio, without initial fasting and fluid restriction) were evaluated retrospectively in 47 children with intractable epilepsy and focal malformation of cortical development, in a study at Severance Children’s and Sanggye Park Hospitals, Seoul, Korea. At 3 months after diet initiation, 21 (44.7%) were seizure free, and 29 (62%) had >50% seizure reduction. Of 21 with complete seizure control at 3 months, 16 (76%) continued the diet for 2 years without relapse; 10 (48%) remained seizure-free after discontinuing the diet, at mean follow-up of 3 years 10 months. Diet was discontinued in 2 patients who developed hemorrhagic gastritis, and diet intolerance occurred in 5 patients. Of 19 patients whose seizures were not completely controlled during the KD and in 3 who had recurrences after diet withdrawal, 13 (59%) became seizure-free after undergoing epilepsy surgery. All patients were followed for at least 12 months after completion of the KD. In the management of intractable seizures due to focal cortical maldevelopment, patients who become seizure free within 3 months of initiating the KD have an excellent long-term outcome. [1]

COMMENT. The ketogenic diet (KD) was first introduced for the treatment of epilepsy at the Mayo Clinic (Wilder RM. Mayo Clin Bull 1921;2:307). Unlike the later Johns Hopkins protocol [2; 3], the classic Mayo KD is introduced without initial fasting (NFKD) and usually, without admission to hospital. In my experience using the NFKD, a smaller ratio of ketogenic to antiketogenic items than that employed by the present authors has usually been successful in younger children, the higher 4:1 ratio being necessary only in older children (JAMA 1966; 198:210)[4]. In a Korean multicenter study involving 199 patients, a comparison of the modified Mayo non-fasting KD and the Hopkins fasting KD, found that by omitting the fasting period, especially in young children, acute dehydration was prevented, with no difference in the time to ketosis or in the efficacy of the diet. However, by employing the relatively high 4:1 ratio, favored by the Hopkins method, serious adverse effects were not avoided, including 5 deaths related to lipoid aspiration pneumonia, serious infection, and nutritional problems. (Ped Neur Briefs Feb 2005:19:12-13).[5]