1. Comprehensive clinical and nutritional status evaluation before treatment: Before starting the ketogenic diet, a detailed history and examination, especially the child’s eating habits, are needed to give records for archival purposes to evaluate the type of attack and exclude contraindications to the ketogenic diet; to estimate risk factors that predispose to complications; and to improve relevant examinations. These include height and weight measurements, blood biochemistry (liver and kidney function, lipids, uric acid, electrolytes, trace elements), blood and urine routine, ultrasound of gallbladder and urinary tract, bone metabolism (bone age/bone density), EEG and cranial MRI (if not done recently), blood levels of antiepileptic drugs, blood ketones and blood glucose (measured every 6 hours during hospitalization starting from fasting). Those without dysplasia, absolute contraindications, and normal blood ketones can start ketogenic diet.
2. Select reasonable food to start treatment: First, fast for 24-48 hours, monitor vital signs and trace blood glucose, blood ketones and urinary ketones, if blood glucose is lower than 2.2 mmol/L or blood ketones are greater than 3.0 mmol/L, start to give ketogenic diet. The ideal range of blood ketones is between 3-7 mmol/L. However, there are individual differences. However, there are individual differences and no generalizations can be made. Be careful that all household products are formulated without sugar, including toothpaste, medications, skin care products, etc. Buy any household products medications with no sucrose, sugar or carbohydrates in them; low temperatures may also have an effect on blood ketones, so you can warm up the room properly; and temporarily adjust the diet ration. It should also be reminded that sometimes children and parents “do not tell the truth”, obviously eat more, poor compliance with the diet, but do not tell the doctor what they have eaten, which will affect the effectiveness of treatment.
3. Proper management of common problems in the early stage of treatment: Common side effects in the early stage include: hypoglycemia, excessive ketosis, ketosis deficiency, nausea/vomiting, sleepiness or drowsiness, increased or ineffective seizures, etc., which require symptomatic management. During the ketogenic diet, if there are signs of dehydration, such as dry lips, reduced skin elasticity, sunken eye sockets, less tears when crying, and low urine output, appropriate hydration can be provided, not exceeding 120 ml at a time, to avoid fluctuations in ketosis status. If blood ketones are too high, blood gas analysis should be done promptly, and it is possible to terminate the ketogenic diet. If blood glucose is lower than 2.2 mmol/L and hypoglycemia is present, 30 ml of orange juice can be given orally. Children on the ketogenic diet have a higher chance of calcium deficiency and stones. Therefore, it is important to take multivitamins, minerals, and calcium tablets for a long time. To prevent low potassium and stones, potassium citrate oral solution should be used daily. To relieve the symptoms of digestive system, you can also use scopolamine tablets.
4. Follow-up: Closer contact should be maintained with family members in the beginning stages, and follow-up visits should be made once every 3-6 months after stabilization. Parents should keep a daily diary of seizures (number of seizures, degree, cognitive condition). Monitor urine ketones, blood ketones, and blood glucose daily. Monthly review of height and weight, blood biochemistry, routine blood count, trace elements. Quarterly review of EEG, ultrasound, cognitive function. Bi-annual review of cardiac ultrasound, bone age.