The frequency of seizure recurrence in 283 children presenting with a first unprovoked seizure was studied in the Montefiore/Einstein Epilepsy Management Center, Bronx, NY; Yale University School of Medicine, New Haven, CN; and Columbia College of Physicians and Surgeons, New York, NY. Seizures recurred in 101 children (36%). The mean time interval of recurrence was 9.2 months (median 6 months). Risk of recurrence was greatest in the first few months after the first seizure; 51% within six months. The cumulative risk of seizure recurrence for the entire group was 26% at 12 months, 36% at 24 months, 40% at 36 months, and 42% at 48 months. The risk of recurrence in children with an idiopathic first seizure was significantly lower than those with symptomatic seizures. An abnormal electroencephalogram was the most important predictor of recurrence in children with an idiopathic first seizure. A history of epilepsy in a first degree relative was a significant risk factor only in idiopathic cases with abnormal electroencephalograms. A history of prior febrile seizures or a partial seizure were significant predictors of recurrence in children with a remote symptomatic first seizure. The age at the first seizure and duration of seizure were not predictive in either the idiopathic or remote symptomatic group. The majority (84%) were not treated with antiepileptic drugs or were treated for less than two weeks. The risk of recurrence was not affected by treatment. In the opinion of the authors even children with risk factors for recurrence should not be routinely treated following a first unprovoked seizure. In the two major high risk groups, 1) remote symptomatic patients; and 2) idiopathic patients with abnormal EEG’s, recurrence risk is estimated at 50% at two years following the initial seizure. 
COMMENT. The growing concern and awareness of the potential adverse effects of long-term antiepileptic medications in children have led to an increasing reluctance to prescribe regular prophylactic therapy except in patients with multiple risk factors. To treat or not to treat is an individualized decision depending on many criteria: 1) Risk of seizure recurrence and associated brain injury; 2) Adverse effects of antiepileptic medications particularly on cognitive function and behavior; 3) Psychosocial consequences; 4) Geographic location and proximity of physician or hospital emergency services; and 5) Parental compliance and ability to provide CPR and first aid care at seizure recurrence. The more conservative the treatment approach the greater the time required in counseling parents regarding emergency medical care and treatment of the acute seizure. Further trials of efficacy and safety of rectal preparations of anticonvulsants are needed so that FDA approval may be extended to their use by parents in the home. Epilepsy in brain-injured children and the effects of seizures on brain damage and brain function are reviewed by Aicardi J.