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. [1]

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).