The ketogenic diet is most often used in epilepsy centers for children with uncontrolled seizures. The diet should only be started under the co-direction of a physician and a dietician who are familiar with the diet. Modifications are often needed to make it more effective or tolerable to individual patients.
Traditionally (the "Hopkins" approach), diet is started in the hospital for the first 24-48 hours with no food and limited fluids. The child’s blood sugar level falls during starvation. If the fall in blood sugar is too great, the child may become pale, sweaty, tremorous, irritable, confused, and unresponsive, or may vomit or even have seizures, and will need some sugar or other carbohydrate supplementation. The blood sugar level can be safely monitored in the hospital. Dehydration can also occur and must be watched closely if fluids are restricted. After starvation, the ketones in the blood and urine rise, and ketogenic food is gradually introduced: one-third of the diet on the following day, two-thirds the next day, and then the full diet.
Many epilepsy centers initiate the diet outside of the hospital, without starvation or fluid restrictions. This more gradual outpatient regimen has fewer side effects, reduced physical and emotional stress on the patient and family and reduced costs (especially for the uninsured). Furthermore, the inpatient starvation phase is not tolerated by some patients, whose parents may then not want to consider the diet although their child may have had good seizure control on the diet.
The diet can be monitored with urine ketones that can be easily measured at home with an indicator strip. Urine ketones indicate that the diet has achieved its metabolic goal of ketosis; higher ketone levels correlate with improved seizure control in many children.