The child is hospitalized to initiate the KD. In our hospital, a KD team is composed of a physician, a registered nurse, and a registered dietitian. During the diet, the physician evaluates and manages complications of KD. Right after the physician, the head of the team, decides to start the KD program, the dietitian provides nutritional management to maintain the KD, and the nurse examines child for tolerance toward the KD diet and educate caregivers how to care child with the KD at home. Frequent communications between caregivers and the KD team are necessary to continue the KD program.

Our KD program starts without initial fasting. Total fat contents in a patient's meal is gradually increased within 3 days. On the first day the meals provide an 1/3 of energy of daily requirement with a desired ratio of major nutrients. On the second day, content of energy in the meals is increased to 2/3 of daily requirement and achieved to full energy requirements on the third day (Figure 1).

Before starting the KD, the dietitian evaluates the nutritional status of the child at the initial day and evaluates his or her ability to take food, activity level and growth pattern such as current height, weight and weight change.

For the meal planning, the dietitian has to decide nutritional requirement of energy and nutrient distribution. In general case, calories for the KD are allowed up to 85~95% of daily requirement. Total 90% of calories are from fat, 6~8% of calories are from protein and remaining calories are from carbohydrate. Protein can be adjusted by child's current weight.

For general case example, a meal plan for a five-year-old child, with 108 cm, 18 kg, PIBW 99.4%, has an energy goal of 1,200 kcal with 4:1 of fat and non-fat ratio. This goal is achieved by meals composed of 120 g of fat, 18 g of protein and 12 g of carbohydrate per day, which makes the ratio of fat (120 g) to nonfat (30 g) is 4:1. Then these amounts from each nutrient is divided by the numbers of meal supply.