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When I was a young doctor I was once given the task of approaching a national chain store for a supply of free cream so that a family could afford to start their child on a ketogenic diet. I have followed the ups and downs of the diet’s popularity since then with some interest (but I’ve never had to beg again). It was first used for difficult childhood epilepsy in the USA in the early 1920s. At Johns Hopkins Hospital it has been in use since the 1930s and paediatric neurology staff there retain their enthusiasm for it. They have reported its use in 150 consecutive children (John M Freeman and colleagues. Pediatrics1998;102:1358–63). Over a period of 24 months in 1994–96 the diet was prescribed for 150 children aged 1–16 who had a mean of 410 seizures a month despite having been treated with an average of more than six antiepileptic drugs. By three months seizure frequency had decreased by 50% or more in 89 (55%) children and by 90% or more in 50 (33%). By one year these figures were 50% and 27%. Younger children were somewhat more likely to respond but seizure type or sex made no significant difference although, as might be expected, many of the children had refractory seizure types of the kind often seen in Lennox-Gastaut syndrome. Fifty five per cent remained on the diet at one year and those who stopped it usually did so because it was not effective. The Johns Hopkins team consider the ketogenic diet to be more effective for these children than many of the newer drugs, and their families are usually prepared to carry on with it as long as they feel it is effective. Some of the success could possibly be related to the fact that the same dietician has been in charge of the diet at Johns Hopkins for many years.