The acceptability of phenobarbital as a first-line drug for childhood epilepsy in rural settings in developing countries was studied using a randomized comparison of phenobarbital and phenytoin as monotherapy in West Bengal, India, and results were analyzed at the Institute of Child Health, University College London, UK, the MRC Biostatistics Unit, Cambridge, and Child-in-Need Institute, Daulutpur, West Bengal, India. Phenobarbital (1.5 mg/kg daily for 2 weeks; 3.0 mg/kg daily maintenance dose; n=47) compared to phenytoin (2.5 mg/kg daily increasing to 5.0 mg/kg daily; n=47) showed no difference in efficacy over a 12 month period, and no excess of behavioral side-effects for phenobarbital based on Conners parent rating scales. 
COMMENT. Phenobarbital appears to be an acceptable first-line treatment for childhood epilepsy in a rural community in India. Compared to phenytoin, phenobarbital is equal in efficacy and has no excess of behavioral side effects. The WHO recommendation of phenobarbital for the treatment of partial and generalized tonic-clonic epilepsies in developing countries is justified. Phenytoin is slightly more expensive whereas carbamazepine and sodium valproate cost many times more than phenobarbital and generally require much closer monitoring. The reported behavioral side effects of phenobarbital may be over estimated in comparison with alternative antiepileptic drugs.