Tapering of the ketogenic diet should occur after 1-2 yr of successful seizure control. Reduction in the ratio is used to gradually reduce ketosis and taper off the diet. Ketone levels should be checked after each reduction in the ketogenic diet ratio. Children usually remain on the 4:1 ratio (or the ratio that has enabled them to produce large ketones consistently) for up to 2 yr. The ratio can be gradually tapered to 3:1 for 6 mo then 2:1 for another 6 mo. Carbohydrate can be gradually added to the diet in the form of bread, pasta, rice, cereal, crackers, and dairy products to eliminate the remaining ketosis. Milk may not be tolerated initially because after a long period on the ketogenic diet, there may be no lactase stimulation in the gut.
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