Treatment strategies employed in 494 children with various seizure types and remission frequencies were studied prospectively at multiple hospital centers in the Netherlands. In 142 (29%) treatment was initially withheld, and after 2 years 17% were still untreated, none suffering serious complications. Of 416 treated with AEDs, 88% received valproic acid or carbamazepine initially, and 40% did not respond successfully. Reasons for treatment failures included recurrent seizures (28%), and intolerable side effects (11%). Rashes occurred in 15 (4%), 14 with carbamazepine (10% of all children who received carbamazepine). The chance of achieving remission was negatively associated with the number of AED regimens tried. Alternative AEDs included phenytoin, phenobarbital, ethosuximide, and vigabatrin. If 3 regimens had failed, the chance of remission with alternative therapy was only 10%. The epilepsy was considered intractable in only 7%. A distinction was made between acceptable control, with low seizure frequency or severity, and intractable epilepsy. 
COMMENT. The initial choice of AED therapy, mainly valproic acid or carbamazepine, fails to control childhood epilepsies in 40% of cases. Alternative therapies are necessary because of seizure recurrences or side effects, especially skin rash, a frequent complication of carbamazepine treatment. Newer AEDs such as gabapentin (Neurontin®), with a relatively low incidence of side effects, should increase the remission frequency of childhood epilepsies, especially partial seizures. In one large study of gabapentin as add-on therapy of 705 adult patients, skin rash was reported in only 0.5% compared to a 10% incidence with carbamazepine (Progress in Pediatric Neurology III, 1997; pp 122-125).