Review articleA Systematic Review of the Use of the Ketogenic Diet in Childhood Epilepsy
Introduction
Fasting has been used in the treatment of epilepsy since Biblical times (Matthew 17:5-21). The first modern reports of its use in the medical literature were by Guelpha in 1911 and Conklin in 1921 [1]. Their hypothesis was that prolonged fasting resulted in detoxification of the gut, resulting in a decrease in the frequency of seizure occurrence. In 1921, Wilder postulated that the antiepileptic effect of the diet was related to the production of ketones and not to starvation [1]. He proposed that increasing the fat content in the diet while reducing the carbohydrate would lead to reduction in seizure frequency. Based on Wilder’s hypothesis, Talbot in 1927 developed a ketogenic diet protocol similar to present-day diet which consisted of a period of fasting followed by the introduction of a 4:1 fat to carbohydrate ratio diet in association with restriction in water intake [1]. With the development of newer antiepileptic drugs with improved efficacy and convenience, there was a significant decrease in the use of the ketogenic diet until recently. With the publicity in the lay press of the case of “Charlie” in 1994, a renewed interest and popularity of the diet has occurred. Several studies since that time have suggested that the diet could be an effective alternative to treatment for children with refractory epilepsy [1]. The purpose of this paper was to review the evidence in the medical literature for the efficacy, safety, and cost of treating a child with the classic form of the ketogenic diet.
Section snippets
Method of Search
A search of the medical literature databases PubMed and Ovid was performed using the keywords “epilepsy/therapy” cross-referenced with the text word “ketogenic diet”, followed by using the keyword “dietary therapy” cross-referenced to text word “epilepsy”. Search for reported adverse reactions while on the ketogenic diet was performed using the same database with keyword “epilepsy” cross-referenced to “toxicity/adverse results” followed by “ketogenic diet”. Search for the cost of treatment
Efficacy of the Ketogenic Diet
Since 1990, a total of 26 studies were identified that meet the above stated criteria [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]. No papers met the criteria for Class One Evidence. Seventeen papers met the criteria for Class Two Evidence [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]; however, three of these papers were excluded as
Discussion
To establish the efficacy of a new antiepileptic agent for marketing, it must be demonstrated to decrease the frequency of seizures more than the control in a safe manner [38]. This procedure requires the development of a blinded prospective study using a well-defined cohort and sufficient sample size to demonstrate efficacy of the agent (i.e., Class One Evidence). To date, no studies met the criteria for Class One Evidence for efficacy in the use of ketogenic diet in children with refractory
References (45)
- et al.
The use of diet in the treatment of epilepsy
Epilepsy Behav
(2005) - et al.
The Ketogenic dietA review of the experience at the Connecticut Children’s Medical Center
Pediatr Neurol
(2002) - et al.
The ketogenic diet in children, adolescents and young adults with refractory epilepsyAn Italian multicentric experience
Epilepsy Res
(2002) - et al.
Efficacy of the ketogenic diet in focal versus generalized seizures
Pediatr Neurol
(2001) - et al.
Ketogenic diet in the treatment of refractory epilepsy in childhood
Pediatr Neurol
(1999) - et al.
Ketogenic dietOutpatient initiation, without fluid or caloric restrictions
Pediatr Neurol
(2004) - et al.
Management of intractable childhood seizures using the non-MCT oil ketogenic diet in 20 patients
J Am Diet Assoc
(1996) - et al.
The ketogenic diet1997
Advances in Pediatrics
(1997) Clinical efficacy of the ketogenic diet
Epilepsy Res
(1999)- et al.
Ketogenic dietAn alternative treatment for refractory epilepsy of childhood
J Med Assoc Thai
(2001)