Seizures usually begin in the first few months of life, but may occur in utero or immediately at birth. The seizures are difficult to treat and refractory epilepsy is almost universal. Seizure onset almost always begins with infantile spasms which eventually evolve into a number of other difficult to control seizure types. A pediatric neurologist with expertise in the management of infantile spasms and medically refractory epilepsy is important for the long-term management of the seizures. Finding a balance between minimizing the frequency and severity of seizures, the adverse effects of the anti-epileptic drugs, and optimizing the quality of life for child and family is essential.