The Castang Foundation, Bath Unit for Research in Paediatrics, National Institute of Health Research, the Royal United Hospitals Bath NHS Foundation Trust, BRONNER-BENDER Stiftung/Gernsbach, University Children's Hospital Zurich.

SUMMARY The lactulose/L-rhamnose urinary excretion ratio during continued infusion of milks containing both sugars was used as an index of the permeability of the neonatal bowel to large and small molecules. Healthy infants of gestational age 31-36 weeks proved to have a period of enhanced permeability to lactulose during the first week of life, the lactulose/L-rhamnose excretion ratio being significantly higher on day 2 than on days 9 or 16 when a mature pattern of permeability could be seen. In infants traumatised by asphyxia or sepsis this change was much less pronounced. Healthy preterm infants of gestational age 26-29 weeks showed a 'mature' pattern of permeability at birth, followed by a temporary period of enhanced permeability after 3-4 weeks of life. It is proposed that enhanced permeability to larger molecules is a specific temporary condition of the neonatal bowel in man as in other mammals, but the immunological implications in man remain to be established.

Background: Failure to recognise diagnostic uncertainty between the epilepsies and non-epileptic events may be a factor in high rates of misdiagnosis. Aims: To explore the results of acknowledging diagnostic uncertainty in a cohort of children presenting with paroxysmal events. Methods: Children (29 days-16th birthday) with new presentations of paroxysmal disorders were ascertained through outpatients, admissions, and accident and emergency over a two year period in a district hospital with a catchment population of 500 000. Cases were classified by diagnosis at entry and 6-30 months later. A random selection of cases was independently assessed. Results: A total of 684 cases were ascertained. Attacks were initially classified as febrile seizures (n = 212), acute symptomatic epileptic seizures (n = 5), epilepsies (n = 83), unclassified (possible epilepsy) (n = 90), isolated epileptic seizures (n = 51), and non-epileptic events (n = 243). Case review enabled reclassification of 61 of those initially unclassified-31 to an epilepsy and 27 to non-epileptic events. In 29 the final diagnosis was never clarified. These were 23 cases with confusing or absent histories and six with short lived seizure clusters. Prognosis for these 29 cases was good; 75% had been discharged. None were on long term medication. The diagnosis in the 131 cases confirmed as epilepsy was stable. Independent review of a random sample showed full concordance with one neurologist and 20% uncertainty with another. Conclusion: In addition to definite epilepsy or non-epileptic events it is helpful to recognise a group of cases where the diagnosis is uncertain-unclassified paroxysmal events. Reassessment of these cases enables accurate diagnosis and may prevent a hasty and incorrect diagnosis of epilepsy.

Gastrointestinal permeability has been studied in a group of clinically proven food-allergic eczematous children and compared with a control group using lactulose and L-rhamnose as probe markers. No significant difference was demonstrated in baseline permeability measurements between eczematous and control children using isotonic or hypertonic oral loading. Similarly after antigen-challenge permeability results showed no significant difference from the controls although two of the ten eczematous children challenged showed increased permeability to lactulose. These findings support the hypothesis that once sensitized the physiological absorption of dietary antigen may be sufficient to maintain an allergic response in the skin.

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We did not find social inequalities in the incidence of epilepsy in children. Nor was there evidence for the inverse care law in the investigation or treatment of epilepsy in children.

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