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editorial

Indian Pediatr 2009;46: 663-664

Ketogenic Diet in the Management of Childhood Epilepsy


J Helen Cross

The Prince of Wales’s Chair of Childhood Epilepsy and Head of Neurosciences Unit, UCL-Institute of Child Health, Great Ormond Street Hospital, London and National Centre for Young People with Epilepsy, Lingfield, UK.
 

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.

 

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