title: The ketogenic diet: initiation at goal calories versus gradual caloric advancement.
abstract: BACKGROUND
  Inpatient initiation of the ketogenic diet has historically involved fasting followed by gradual advancement of calories and/or diet ratio. Complications during this initiation period are common. We sought to determine if the initiation of the diet at goal calories would reduce these complications while maintaining efficacy.
  
  
  METHODS
  Sixty patients were admitted to a tertiary care hospital for elective initiation of the ketogenic diet between October 2007 and January 2013. All patients were placed on a ketogenic diet initiation pathway. In 2010, the pathway was modified from gradual caloric advancement to initiation at goal calories. We selected 30 consecutive patients before and after the change for comparison. Each child's record was reviewed for the occurrence of hypoglycemia, number of days to reach full ketosis (defined as 4 + urine ketones), acidosis requiring commencement of sodium citrate, length of admission, and long-term efficacy.
  
  
  RESULTS
  Both methods of initiation had similar rates of dehydration, vomiting, lethargy, and irritability. More patients initiated at goal received sodium citrate (P = 0.005); however, mean daily values of carbon dioxide were not significantly different. Onset of ketosis was slightly delayed (P = 0.009) in patients initiated at goal, but length of stay was not affected (P > 0.1). Hypoglycemia was uncommon and rates were similar between the groups. Efficacy at 3 months was better in patients initiated at full calories (P < 0.05).
  
  
  CONCLUSIONS
  Initiation of the ketogenic diet full calories is a reasonable alternative to the current standard practice of gradual advancement of calories and/or diet ratio.
authors.affiliation: Department of Neurology, Children's National Medical Center, Washington, DC. Electronic address: sbansal@luriechildrens.org.
authors.forename: Seema
authors.initials: S
authors.lastname: Bansal
authors.affiliation: Department of Food and Nutrition, Children's National Medical Center, Washington, DC.
authors.forename: Laura
authors.initials: L
authors.lastname: Cramp
authors.affiliation: George Mason University, Fairfax, Virginia.
authors.forename: Dan
authors.initials: D
authors.lastname: Blalock
authors.affiliation: Department of Neurology, Children's National Medical Center, Washington, DC.
authors.forename: Tesfaye
authors.initials: T
authors.lastname: Zelleke
authors.affiliation: Department of Neurology, Children's National Medical Center, Washington, DC.
authors.forename: Jessica
authors.initials: J
authors.lastname: Carpenter
authors.affiliation: Department of Neurology, Children's National Medical Center, Washington, DC.
authors.forename: Amy
authors.initials: A
authors.lastname: Kao
mesh_terms: D002150:Caloric Tests; D002675:Child, Preschool; D055423:Diet, Ketogenic / Q000379:methods*; D002149:Energy Intake / Q000502:physiology*; D004827:Epilepsy / Q000178:diet therapy*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D013997:Time Factors
keywords: children; epilepsy; initiation; ketogenic diet; nonfasting