The ketogenic diet has
been used for the treatment of epilepsy in children for almost 100 years.
Originally, it was determined that individuals with seizures found benefit
from starvation; subsequently a diet was proposed which was high in fat
content, the breakdown of fat for energy producing ketones and therefore
mimicking starvation(1). This was subsequently found to be effective in
treating recurrent seizures. Many open label studies over the years
suggested considerable benefit could be achieved in children with
epilepsy; it went out of favor with the advent of anticonvulsants but
further interest in the 1990s led to an increase in evaluation and use.
However, despite the belief in its efficacy, repeatedly systematic reviews
commented on the lack of randomized controlled data(2,3). It was only last
year that the first randomized controlled trial was published, defining
without doubt the efficacy of the ketogenic diet in children with drug
resistant epilepsy(4).
Over the past 10 years, an increasing number of
publications have confirmed the considerable interest in its use. This has
included the appreciation of its use worldwide(5). With increased data on
implementation and alternative ways of giving the diet, a consensus
document was drawn up by professionals around the world(6), including Dr
Nathan responsible for the study published here(7).
The study published in this issue of Indian
Pediatrics highlights how administration of the ketogenic diet with
cultural adaptation is achievable and effective. The authors highlight the
difficulties with the high drop out rate, but, accepting this to be an
open label study, the efficacy is quite astounding. The cost effectiveness
with reduction of anticonvulsants, let alone with the well being of the
children, is self apparent. This aside, a certain degree of monitoring of
individuals on the diet has been advocated(6). This study does not report
the monitoring or supplementation undertaken, both important to document.
Some of the concerns about bone mineralisation and vitamin D status may
indeed not apply within the context of application within this climate, as
opposed to in northern countries.
How long individuals need to be maintained on the diet
remains in question and often is individually assessed. Some children on
weaning do not return to their baseline seizure rate. It is commented
within this paper that individuals with 100% efficacy were weaned from the
diet. It is not clear at what point and whether improvement was sustained.
Further follow-up of this group would provide useful data.
These comments aside, the ketogenic diet is
demonstrated here to provide a feasible alternative in drug resistant
epilepsy in children within an Indian culture. Although it cannot be
regarded as a natural treatment, it may also prove a useful alternative to
consider in resource poor situations; although a high degree of support
may be required to maintain appropriate nutritional intake.
Funding: Professor JH Cross has received honoraria
and educational grants from SHS international, UCB, Eisai and Janssen
Cilag.
Competing interests: None stated.
References
1. Wilder RM. The effects of ketonemia on the course of
epilepsy. Mayo Clin Proc 1921; 2: 307-308.
2. Lefevre F, Aronson N. Ketogenic diet for the
treatment of refractory epilepsy in children: a systematic review of
efficacy. Pediatrics 2000; 105: e46.
3. Keene DL. A systematic review of the use of the
ketogenic diet in childhood epilepsy. Pediatr Neurol 2006; 35: 1-5.
4. Neal EG, Chaffe HM, Schwartz RH, Lawson MS, Edwards
N, Fitzsimmons G, et al. The ketogenic diet for the treatment of
childhood epilepsy: a randomised controlled trial. Lancet Neurol 2008; 7:
500-506.
5. Kossoff EH, McGrogan JR. Worldwide use of the
ketogenic diet. Epilepsia 2005; 46: 280-289.
6. Kossoff EH, Zupec-Kania BA, Amark P, Ballaban-Gill
K, Bergquist AGC, Blackford R, et al. Optimal clinical management of
children receiving the ketogenic diet: Recommendations of the
International Ketogenic Diet Study Group. Epilepsia 2008; 47: 1-14.
7. Nathan JK, Purandare AS, Parekh ZB , Manohar HV.
Ketogenic diet in Indian children with uncontrolled epilepsy. Indian
Pediatr 2009; 46: 669-673 . |