GI issues of children with autism

What are the gastro-intestinal issues of children with autism? (include information about allergies, dysmotility, constipation, etc)

A recent study was completed by ATN (Autism Speaks Autism Treatment Network) that showed that GI problems occurred in 45% of children with Autism. The research was an online questionnaire that was completed by 1420 children, age 2-18.  GI information was received from 1185 children. GI complaints within 3 mo of the study were abdominal pain (59%), constipation (51%), diarrhea (43%), other (40%), nausea (31%), bloating (26%).  GI symptoms increased with age, 39% under age 5, 51% age 7+. Children with GI symptoms reported more problems with emotionally reactive, anxious/depressed, somatic complaints, sleep problems, internalizing problems, affective problems and anxiety problems compared to without GI problems.  GI problems did not differ by gender, ASD subtypes, race, or IQ. (Williams etal 2010).

Another study in MN-longevity study with 121 ASD and 200+control, discovered that constipation and food selectivity is higher in ASD but not celiac disease, or other GI diagnosis.   They reported that the “ritualistic tendencies, need for routine, and insistence on

sameness that are characteristic of children with autism may lead these children to choose and demand stereotyped diets that may result in an inadequate intake of fiber, fluids, and other food constituents.17 Thus, behaviorally related food selectivity may, in turn, lead to constipation.”

Treatment with stimulant medication to control hyperactivity, impulsivity, and inattention can cause appetite suppression (side effect) that could also change the eating habits/behaviors of ASD except Risperdal which increases appetite and may increase weight gain. Seizure medication affects the metabolism of calcium, vitamin D and folate.

Leaky Gut:

I am quoting Jody Goddard as I feel that she very nicely explains the leaky gut and its relationship to inflammation.

“Altered intestinal permeability was found in 43% of autistic patients, but not found in any of the controls (Harvard University). Intestinal permeability, commonly called "leaky gut", means that there are larger than normal spaces present between the cells of the gut wall. When these large spaces exist in the small intestine, it allows undigested food and other toxins to enter the blood stream.” The peptides have an opiod-effect on the body.  “When incompletely broken down foods enter the body, the immune system mounts an attack against the "foreigner" resulting in food allergies and sensitivities. The release of antibodies triggers inflammatory reactions when the foods are eaten again. The chronic inflammation lowers IgA levels. Sufficient levels of IgA are needed to protect the intestinal tract from clostridia and yeast. The decreasing IgA levels allow for even further microbe proliferation in the intestinal tract. Vitamin and mineral deficiencies are also found due to the leaky gut problem.”  The first vitamin deficiency in the leaky gut is Vitamin B12, as it is absorbed in the iliem (last section of the small intestines).  So it enters the bloodstream before it is absorbed. http://www.breakingtheviciouscycle.info/autism/autism_and_gi_problems.htm

The flora can become disrupted in children with GI problems, especially if they have a history of taking antibiotics.  This may allow bacteria and yeast microbes to enter the colon/intestines and disrupt digestion.  Probiotics have been shown to help maintain a balanced flora.  It is used for general GI health.

Dysmotility is the decreased ability to move tfood through the GI tract.  It is often due to abnormal muscle contractions of the gut wall.  Delayed gastric emptying, referred to as gastroparesis, is also known as dysmotility.  Dysmotility can lead to constipation. Dysmotility may happen from wheat intolerance and food allergy and present with gastroesophageal reflux and constipation.  (Gibney 2005)

Food allergies and hypersensitities (neg allergy test) will benefit from special diets. Multiple researches have not shown that children with autism have a higher rate of celiac disease or the need for a GFCF diet.  Although people may report that behaviors improve on GFCS diet there is no significant decrease in the urinary compounds secreted compared children eating gluten and casein.(Whiteley 1999)

Schematic summary of the
gastrointestinal abnormalities reported
in children with autism. (Horvarth)

Selective food preferences and dairy –free diets put children at risk for calcium and Vitamin D deficiencies.  A study was done on 75 boys with autism; age 4-8 that showed significant thinner bones than typically developing boys of the same age.    (Hediger etal 2008)

Gluten-free diet is at risk for deficiencies in these nutrients: iron, zinc, B vitamins and folate

Dairy-free diet is at risk for deficiencies in these nutrients: calcium, vitamin D, vitamin B2 and protein.

Many children have inflammation consistent with gastroesophageal reflux disease with symptoms of abdominal pain, nighttime awakening and sudden daytime irritability. Other findings included chronic colitis.  A consistency in inflammation is common in children with autism that have GI symptoms.  (Horvath 2002)

If a child is having GI difficulties, it is best to look at some form of treatment as it manifests all other health complications like sleeping and attention, not to mention difficulties years later.  Especially since children with autism have communication impairments, understanding unusual/atypical presentations of GI disorders including sleep disorders and problem behaviors is important.

 

Buie, T. Campbell, D., Fuchs lll, G., Furuta, G., Levy, J., VandeWater, J., Whitaker, A., Atkin, D. Bauman, M., et al, (2010) Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals with ASDs: A consensus report. Pediatrics 125: S1-S18.

Gibney, M., Elia, M., Ljungqvist, O. (2005) Clinical Nutrition 107

Hediger ML; England LJ; Molloy CA; Yu KF; Manning-Courtney P; Mills JL(2008) Reduced bone cortical thickness in boys with autism or autism spectrum disorder. Journal of Autism & Developmental Disorders, 2008 May; 38 (5): 848-56

Horvath, K., Perman, J. (2002) Autism and Gastrointestinal Symptoms. Current Gastroenterology Reports 4:251–258

Ibrahim, S.H., Voigt, T.G., Katusic, S.K., Weaver, A., Barbaresi, W. (2009) Incidence of Gastrointestinal Symptoms in children with Autism: A population-based study.  Pediatrics 124:680-686

Williams, K, Fucha, G., Furuta, M., Marcon, M., Coury, D. (2010) GI Symptoms in Autism Spectrum Disorders (ASD): An Autism Treatment Network Study. Symposium session for Pediatric Acedemic Societies Annual Meeting.

Summarize 3 articles

Summarize at least 3 articles that explore the GI and feeding challenges of children with autism.

Childhood autism, feeding problems and failure to thrive in early infancy

This article did a case study on seven children with autism and looked at their early eating/feeding habits and failure to thrive diagnosis. These children had very low BMI. Eating disorders are common in 25-30% general population but 80% of developmental delays. The article discusses “the physical process of feeding can be disrupted through structural abnormalities or neurodevelopmental disabilities. Disruption of the process of learning to eat and accept new tastes during the critical ‘‘window’’ of opportunity can result in both oral-sensory and oral-motor dysfunction. Infants experiencing early adverse feeding experience such as recurrent vomiting (especially gastrooesophageal reflux) are particularly at risk for failure to thrive.”  The study showed that all children had problems early on, some had difficulty breast-feeding or bottle-feeding, all had difficulties weaning to solids. All had either selective eating or refusal to eat between 2-5 years of age.  The outcomes ranged 5-13 years showed better BMI and better growth but many still had ritualistic eating, selective eating, texture issues, and one child continues to be fed via gastrostomy.  This research article wants clinicians to be alert to feeding problems and FTT in young children as a potential child with ASD.

Correlates of Specific Childhood Feeding Problems

This article looks at five defined feeding problems: food refusal, food selectivity by type, food selectivity by texture, oral motor delays and dysphagia. They compared this to predisposing factors including developmental disabilities, GI problems, cardiopulmonary problems, neurological problems, renal disease and anatomical anomalies (like cleft palate).  It was discovered that gastro-esophageal reflux was the most prevalent condition associated with food refusal.  The three categories of developmental disabilities in this study were autism, Down syndrome, and cerebral palsy.  Autism had the highest rating for food selectivity and the lowest of the three developmental disabilities for food refusal, oral motor delays and dysphagia.  They also noted that constipation was very common in children with autism.  They reported that if constipation is resolved, children will have increased appetite and improved feeding. They report that behavioral therapy has proven to be effective in treating food refusal and food selectivity.

Feeding Problems in Children with Autism Spectrum Disorders: A Review, Focus on Autism and other Developmental Disabilities

This article looks at research regarding feeding issues/behaviors (selective eating, refusal to eat with no medical condition) and intervention with children with autism. It discusses “a number of reasons have been suggested for the prevalence of feeding problems in children with ASD, including a concentration on detail, perseveration, impulsivity, fear of novelty, sensory impairments, deficits in social compliance, and biological food intolerance. Parental anxiety, reinforcement of negative feeding patterns, and communication difficulties have been suggested as additional social reinforcers that contribute to the maintenance of maladaptive feeding behaviors in this population.”

Mealtime behavior and eating problems aren’t necessarily assessed until a child is diagnosed with failure to thrive and at that point growth rates are well below average.

These studies in other populations have investigated numerous interventions, including differential reinforcement, escape extinction, the Premack principle (eat non-preferred food then can eat preferred food), behavioral momentum, and textural manipulation.  All the interventions had a positive outcome. 

I feel this article did a nice job summarizing feeding issues and some of the research.  After reading this article and a few others, it appears that once the GI issues are resolved, a behavioral program will need to be implemented to change the eating habits/fears/etc. for the best outcome.

Field, D., Garland, M., Williams, K. (2003) Correlates of Specific childhood feeding problems Journal of Paediatric Child Health 39:299-304

Keen, D., (2008) Childhood autism, feeding problems and failure to thrive in early infancy.  European Child Adolescence Psychiatry 17:209-216.

Ledford, J., Gast, D. (2006) Feeding Problems in Children with Autism Spectrum Disorders: A Review, Focus on Autism and other Developmental Disabilities 21:3 153-166

Medical and therapy interventions

What are the medical and therapy interventions? Describe each intervention and it’s expected outcomes, as well as potential side effects.

Many people are familiar with DAN! Diet (Defeat Autism Now).  There is a summary of their protocol in which I am quoting from http://www.autisticsociety.org/News/article/sid=541.html:

“The DAN (Defeat Autism Now) Protocol involves a combination of changes to the diet and implementation of vitamin supplement therapy as a means of producing changes in autistic behaviors. These changes include the following steps, according to published information.

1. Eliminate dairy products. The introduction of casein free diet appears to be primary in the treatment of autism by means of this protocol. Instead of cow's milk, substitute rice or soy milk or use Vitamite (chocolate) as a replacement.

2. Eliminate cereal grain products. Gluten has been shown to aggravate the digestive systems of individuals and with the known bowel involvement found in children on the autism spectrum, this action helps to relieve these problems. Instead substitute rice or another product for the gluten containing wheat.

3. Eliminate junk foods and other food products that contain refined sugars. These are not necessary to good health and in fact have been shown to be harmful, due to their chemical composition and the artificial additives that are included in many of them. A "natural" source of sugar, such as fruit offers a much better alternative.

4. Supplement the diet with the vitamin and mineral therapy. Below is a list of the supplements and their dosages which are recommended:

Calcium: 300 mg twice a day. This can be done in two doses, or once at bedtime to facilitate sleep.
Magnesium: 50 mg twice a day
Vitamin C: 50 mg twice a day
Vitamin B5: (Pantothenic Acid) 500 mg twice a day
Vitamin B6: 100 mg twice a day
1 multiple vitamin daily
DMG: 125 mg twice a day
Pycnogenol: 50 mg twice a day
Gaba: 75 mg twice a day

If your child is currently taking any medications especially those such as Prozac or Ritalin, it is recommended that you discontinue use before beginning Secretin infusions.” (http://www.autisticsociety.org/News/article/sid=541.html)

I believe the first three have been discussed in earlier post.  All the supplements are necessary, as children with autism usually have deficiencies or mal-absorption in these vitamins and minerals. 

   GABA (gamma-aminobutyric acid) is an inhibitory neurotransmitter which helps to regulate firing of neurons.  This helps to slow things down like hypertonia and the ability to slow/stop thinking and moving. (http://www.gabasupplement.com/)

   Pycnogenol is a natural extract from a bark of a maritime pine tree grown in southern France.  It is an antioxidant, acts like a natural anti-inflammatory, selectively binds to collagen and elastin and aids in the production of endothelial nitric oxide, which helps to dilate and strengthen blood vessels.  There is one article that reports it may decrease hyperactivity and increase attention in ADHD children (June 17 edition of the journal of European Child and Adolescent Psychiatry) (http://www.pycnogenol.com/health/health_faq.php)

   DMG  is a metabolic enhancer and helps the immune system and enhance neurotransmitter production (http://www.dmgdoctor.com/dmg.php) It has been reported to show improvements in speech, eye contact and improved frustration tolerance (http://www.healing-arts.org/children/nutritional.htm).

   Vitamin B6 research showed that children with autism excreted abnormal metabolites in their urine which was cleared up with vitamin B6.  Given in large quantities with magnesium showed improved behavior of improved eye contact, less stimulatory behavior, fewer tantrums and improved speech. (http://legacy.autism.com/ari/editorials/ed_vitb6.htm)

   Magnesium is usually deficient and mal-absorbed, it is associated with lung function and a deficiency can accentuate the allergic situation.  Signs of low magnesium in children with autism include “restless, can’t keep still, body rocking, grinding teeth, hiccups, noise sensitive, poor attention span, poor concentration, irritable, aggressive, ready to explode and easily stressed.” Some reasons why magnesium is deficient is because food as less mineral content, leaky gut syndrome, oral supplements are not easily absorbed.  Magnesium helps maintain potassium, which is needed for the sodium-potassium pump. (http://magnesiumforlife.com/medical-application/magnesium-and-autism/)

   Calcium is important especially if the child is on a casein free diet.  It is beneficial for twitching during sleep.

Other forms of treatment include:

   Aloe Vera taken in a liquid form is to help food digest better and behavior improves.  If taken before a meal it may prevent leaky gut. (http://www.healing-arts.org/children/nutritional.htm)

Flower of Sulphur is suppose to return the ph balance in the stomach so foods are digested better. (http://www.healing-arts.org/children/nutritional.htm)

   Secretin is a hormone that mostly benefits digestion and has shown improved behaviors in children with autism.  It is newly researched and unknown at this time why it shows improvements.  One theory is that secretin stimulates the pituitary adenylate cyclase which increases intracellular camp in parts of the brain.  Secretin may lower the camp brought about by opioids as in the leaky gut theory. (http://www.nichd.nih.gov/news/releases/secretin.cfm)

   Probiotics have shown improvements in helping with irritability in infants, and improvement in diarrhea. (Kligler 2007)
There are many other vitamins and minerals that are included in treatment but had limited research and is exhaustive and is not included in this blog.

Since the body is a delicate balance, disturbing this balance can cause more problems. The critical metabolic and nutritive functions of the gut flora include digestion, absorption, fermentation, vitamin synthesis, biotransformation, and energy production. Various diets that eliminate a food source can cause mal-nutrition.  High dosages of vitamin and minerals may cause other vitamins to not be effective.  It may also cause toxicity in the body.  Even if a person has a “well balanced diet”, their body may not be absorbing the vitamins and minerals to benefit the body.  Decreasing gluten or having a "white colored food diet"  may increase constipation since you are eliminating many sources of fiber.  As I researched this topic, I was amazed at the amount of information available and how overwhelming it may be to a parent.  Many of the websites (not research based) have a ”how to do” approach with very little claims to seek professional help.  I feel that many of these therapies/interventions may be helpful but is best done with blood/urine test rather than a trial and error.  A trial and error approach can completely disrupt a body’s system and cause major impact.
 

Buie, T., Fuchs, G., Furuta, G.T., Kooros, K., Levy, J., Lewis, J., Wershill, B., Winter, H., (2010) Recommendatins for evaluatin and treatment of common gastrointestinal problems in children with ASDs, Pediatrics 125, S19-S29

Kligler, B., Hanaway, P., Cohrssen, A. (2007) Probiotics in Children Pediatric Clinics of North America 54 949-967

http://www.autism.com/pro_gastro.asp

http://www.autisticsociety.org/News/article/sid=541.html

http://www.dmgdoctor.com/dmg.php

http://www.gabasupplement.com/

http://www.healing-arts.org/children/nutritional.htm

http://legacy.autism.com/ari/editorials/ed_vitb6.htm

http://magnesiumforlife.com/medical-application/magnesium-and-autism/

http://www.nichd.nih.gov/news/releases/secretin.cfm

(http://www.pycnogenol.com/health/health_faq.php)

 

Implication of selective/restrictive diets

What are the implications for selective/restrictive diets (ie: great white diet) for children with autism? Consider physiological (such as impact of protein imbalance or limited ingestion of lysine, etc) and activity restrictions.

Many articles have researched the food selectivity/restriction via questionnaires to the caregivers.  It has been determined that the fewer food items the family eats, the fewer food items the child will eat. Studies conflict as to whether sensory affects the selectivity. (Shreck and Williams2006)

Food preferences of children with autism are usually related to high sugar content like cake, cookies, white bread, grapes, pizza, ice cream.  Most of these foods are on the high glycemic index, which measures how quickly digestion of carbohydrates triggers a peak in blood sugars. Further research to explore how food consumption, change in blood sugar results in immediate behavioral changes was recommended. (Shreck and Williams2006)

Another theory is the sensitivity could be related to physiological component that the composition of the tongue may be extremely sensitive to bitter taste which may result in an aversion and food selectivity. (Shreck and Williams2006)

A research article had 31 children go on a gluten free diet with urinalysis prior and after removal and then the return of gluten.  22 children were successful in completing the diet.  Behavior rating was done prior to the diet and then five months of being gluten-free.  Behaviors may worsen up to 21 days after starting a GF diet like anxiety, clinginess, crying, flu-like symptoms, and increased urination.  Behaviors that showed the most significant differences after the five months was the increased desire to interact, increased curiosity/interest and increased number of “good days”, increased smiling, eye contact and play behavior, increased attempts to communicate and an increased number of initiations of interactions, decrease in self-injurious behaviors.  Behaviors worsened upon re-introduction of gluten.  The urinalysis showed an overall reduction in the urinary IAG excretion and creatinine levels except in one case. There is no correlation between the reduction in IAG and improvements in behaviors. (Whiteley 1999)  Another study looked at levels of IAG in children with ASD to TD children and found no difference in the amount that is secreted showing that IAG levels are not correlated with autism. (Wright 2005) Research is questioning the relationship of opioid-SIB relationship through a possible reorganization of abnormal functioning of pain receptors, governed by the presence of elevated levels of opioid peptides. (Whiteley 1999)  A more recent case study believes that gluten and casein are triggers for neurodevelopmental dysfunction.  Further theories are exploring the pathophysiologic mechanisms that may provoke the central nervous system.  The leaky gut is one theory; another is that casein and gluten trigger inflammation in the gut leading to autoimmune illness or cross reactivity with other potential CNS antigens.  Another theory is the gut inflammation in celiac patients can precipitate underlying malabsorption of nutrients required for the CNS functions.  Certain essential nutrients can result in brain malfunction, potentially manifesting as a developmental disorder.  This study recommends testing for celiac disease in children diagnosed with autism even if there are no symptoms which conflicts with earlier reports.

A study that looked at the amino acid profile of TD children, children with autism-no diet restrictions, children with autism on a gluten free casein fee diet.  Both autistic groups had frequent essential amino acid deficiency suggesting of poor protein intake. Children with autism on unrestricted diets compared to control group had deficiencies in valine, isoleucine, leucine, phenylalanine, and lysine.  Lysine and Leucine were significant difference.  Children with autism on restricted diet in addition had defiency in tryptophan than children with autism on unrestricted diet.  These restrictive diets can put the developing brain under increased risk secondary to protein malnutrition.  There may also be a link between decreased tryptophan (amino acid) which would decrease serotonin (neuro transmitter) levels. Many of the amino acids are preceptors to the neurotransmitter of serotonin.

Many Asperger Syndrome will complain of being confused or having difficulty concentrating when drinking milk.  Other will “hate milk” or say it is “slimy”.  Some people don’t have the enzyme to complement or metabolic processing ability (sunderlandprotocol).  A child that reacts to milk may vomit, eczema (especially behind the knees or in the crook of the elbow), early ear infections, constipation, diarrhea and respiratory problems resembling asthma are all side effects.

If a diet is restricted (gfcf) and the child doesn’t expand their diet, it may mean that the offending food is still part of the diet.  Without appropriate levels of essential nutrient elements the normal metabolic process of digestion and absorption will be severely impaired in any case.

Zinc helps to decrease aluminum and also is desirable for normal metabolic reactions.

The use of sulphate in the system affects the immune system, the effectiveness of hormones and maintaining integrity of the intestinal function, kidney function and detox of systems.  Sulphation in chemical bodies of glycosaminoglycans have implications on brain development.  Inflammation would deplete the sulphar.  Sulphar is better absorped through the skin (Epsom salt water baths) sunderlandprotocol

Lysine is an essential amino acid.  That means that we can’t synthesize it, we need to get it from our dietary intake.  It is a building block for all protein in the body.  It helps with calcium absorption, hormones, enzymes and antibodies.  It also serves to decrease serotonin receptors in the intestinal tract.  This will help to decrease anxiety and anxiety induced diarrhea.  Lycsine defiency also leads to an increase of serotonin in the amygdala which affects emotional regulation.

Coeliac disease is an autoimmune disorder of the small intestine.  Symptoms include chronic diarrhea, failure to thrive, fatigue.  Changes in the bowel may make it harder for the body to absorb nutrients and minerals and fat soluble vitamins (A,D, E,K).  Untreated can have symptoms like cerebellar ataxia, peripheral neuropathy, schizophrenia, and autistic like features.

Iron deficiency or anemia may cause malabsorbtion of folic acid and vitamin B12.  Iron deficiency may have symptoms that include constipation, sleepiness, depression, twitching muscles, poor appetite, and restless leg syndrome.  During infant development, Iron deficiency would affect neurological development by decreasing learning ability, altering motor function and reducing the number of dopamine receptors and serotonin levels.  It can also lead to reduced myelination of the spinal cord and affect the growth hormone.

Emerging evidence confirms that deficiency of assorted nutrients such as folate, vitamin D, or essential fatty acids41 may impair various biological processes required for normal metabolic and neurological functioning.

If a child has GI issues, this may affect all levels of functioning.  They will be irritable, tired, have decreased concentration, decreased retention of information.  Malabsorbtion can lead to nutrional defiency and the body will start to break down due to malnourishment.  Many behavioral signs may be worsened.  Since diet affects all levels of functioning in the body, looking into the nutrient involvement of the child is important.  Studies are conflicting as to the lack of nutritional input the child with ASD receives.  But a minor change in the essential amino acids or vitamins could have symptoms that mirror ASD.  Many caregivers do a “shot gun” approach to treatment (different diets, vitamins, supplements) rather than a biochemical approach.  This is not optimal as they don’t identify the nutritional status of the individual and may not target specific biochemical deficiencies that may be causing abnormalities responsible for the central nervous system dysfunction.

Genuis and Bouchard have 3 recommendations based on the emerging information that micronutrient deficiency may be a determinant of central nervous system dysfunction:

1. All children with developmental, behavioral, and inexplicable central nervous system disorders should be routinely screened for celiac disease.

2. Considering the escalating public health problem with pervasive developmental disorders, further study into the correlation between micronutrient deficiency and neuropsychiatric problems is in the public interest and should be undertaken.

3. Recognizing that neuropsychiatric dysfunction exacts an enormous cost both financially and personally, micronutrient screening is recommended for all children with significant central nervous system dysfunction. Such screening should include plasma amino acid status, serum screen for coenzyme Q10 and fat-soluble vitamins, red blood cell mineral status, serum folate, plasma fatty acid profile, and urine organic acids to assess functionality of nutrient physiology.

Arnold, G., Hyman, S., Mooney, R. Kirby, R., (2003) Plasma Amino Acids Profiles in Children with Potential Risk of Nutritional Deficiencies.   Journal of Autism and Developmental Disorders 33:4 449-454

Genuis, S., Bouchard, T. (2010) Celiac Disease Presenting as Autism.  Journal of Child Neurology 25:1 114-119

Schreck, K.A., Williams, K. (2006) Food preferences and factors influencing food selectivity afor children with autism spectrum disorders.  Research in Developmental Disabilities 27: 4: 353-363

The Sunderland Protocol: A logical sequencing of biomedical interventions for the treatment of autism and related disorders. (2000) Autism Research Unit

Whiteley, P., Rodgers, J.,  Savery, D., Shattock, P.(1999) A gluten-free diet as an intervention for autism and associated spectrum disorders: preliminary findings.  Autism 3:1 45-65.

Wright, B., Brzozowski, A.M., Calvert, E., Farnworh, H., Holbrrok, I. Imrie, G. etal. (2005)  Is the presence of urinary indolyl-3-acryloylglycine associated with autism spectrum disorder? Developmental Medicine and Child Neurology 47: 190-192