Aims: There is international consensus that the Ketogenic Diet (KD) is a treatment option in most types of drug refractory epilepsy (DRE). Practical aspects, clinical & nutritional monitoring, and factors that influence success are discussed.Method: In a retrospective review at a tertiary hospital, we analyzed clinical data for 25 children who were treated with any form of KD for at least 3 months.Results: The indications for initiation of Ketogenic Diet were DRE (23/25), and diagnosis of glucose transporter disorder (2/25). All patients except one had prior treatment with at least 3 anti-epileptic drugs (AEDs). The KD was initiated orally (14/25) or via a nasogastric tube, gastrostomy or gastro-jejenal tube (11/25) depending on age, usual method of feeding, palatability and acceptability. Reasons for discontinuation were lack of significant benefit on seizure control, gastrointestinal side effects, and compliance issues. Daily monitoring of blood sugar and ketone levels was required on initiation with less frequent checks thereafter. Clinical and nutritional monitoring was undertaken at 3-6 monthly intervals. Patients tended to discontinue the diet between 6-12 months of use, if seizures were not significantly reduced, but 11/25 (45%) persevered for > 12 months. In addition to better seizure control, improved alertness and cognitive functioning, and reduced AED burden, were major factors influencing perception of the KD as a successful treatment for children with DRE.Conclusion: The ketogenic diet is well tolerated, with few side effects. Clinical benefit is apparent by 6 months, and may extend beyond better seizure control to improved quality of life.