gastrointestinal disorders of children with autistic spectrum disorders l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Gastrointestinal Disorders of Children with Autistic Spectrum Disorders PowerPoint Presentation
Download Presentation
Gastrointestinal Disorders of Children with Autistic Spectrum Disorders

Loading in 2 Seconds...

play fullscreen
1 / 45

Gastrointestinal Disorders of Children with Autistic Spectrum Disorders - PowerPoint PPT Presentation


  • 227 Views
  • Uploaded on

Gastrointestinal Disorders of Children with Autistic Spectrum Disorders. Joseph Levy, M.D. Professor of Clinical Pediatrics Director, Program in Neurogastroenterology Columbia University Medical Center Morgan Stanley Children’s Hospital of NY Presbyterian. Outline and Goals.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Gastrointestinal Disorders of Children with Autistic Spectrum Disorders' - Jimmy


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
gastrointestinal disorders of children with autistic spectrum disorders
Gastrointestinal Disorders of Children with Autistic Spectrum Disorders

Joseph Levy, M.D.

Professor of Clinical PediatricsDirector, Program in Neurogastroenterology

Columbia University Medical Center

Morgan Stanley Children’s Hospital of NY Presbyterian

outline and goals
Outline and Goals
  • Review the GI and nutritional issues impacting on the health of children on the autism spectrum
  • Prepare parents and professionals to critically appraise the pertinent information…or how much can we trust anecdotes?
  • Propose guidelines for assessing adequacy of nutritional intake and the need for supplements
autistic spectum disorders
Autistic Spectum Disorders
  • Social interaction
  • Verbal and nonverbal communication
  • Repetitive behaviors or interests
  • ? GI disorders
gi symptoms reported in asd
GI symptoms reported in ASD
  • Nonspecific symptoms:
    • Chronic Diarrhea
    • Constipation
    • Foul-smelling stools
    • Excessive gas
    • Abdominal bloating
    • Abdominal pain
    • Vomiting
gi symptoms in asd
GI symptoms in ASD
  • Do children with ASD really have more gastrointestinal symptoms than other children?
  • Lack of published rigorous data that show increased GI symptoms in children with ASD
prevalence of gi symptoms a little perspective
Prevalence of GI symptoms:A Little Perspective
  • Gastrointestinal complaints are very common in children with normal development:
    • Constipation rates 16%-37%
    • Cow’s milk protein intolerance 0.3-7.5% of otherwise normal infants

Loening-Baucke, NEJM 1998

prevalence of gi symptoms
Prevalence of GI symptoms
  • There is very little reliable information about whether GI symptoms are part of ASD.
  • Bias:
    • Selection
    • Referral
    • Recall
prevalence of gi symptoms8
Prevalence of GI symptoms
  • Retrospective survey comparing 412 children with ASD and 43 siblings:
    • 85.3% ASD had at least one GI symptom compared to 28.6% siblings.

Horvath & Perman, Current Gast Reports 2002a, CurrentOp Ped 2002

prevalence of gi symptoms9
Prevalence of GI symptoms
  • Survey of 500 parents:
    • 50% reported daily loose stools or frequent diarrhea
    • 33% abdominal pain
    • 20% more than 3 stools a day
    • No control group, no note of selection criteria

Lightdale, Siegel & Heyman, Clin Perspect Gast, 2001

prevalence of gi symptoms10
Prevalence of GI symptoms
  • Review of medical histories of 285 children with PDD, 48 non-autistic siblings, and 102 unrelated controls:
      • 19% of children with PDD had constipation
      • 19% diarrhea, 7% alternating constipation/diarrhea.
      • <10% controls had diarrhea or constipation.

Melmed, Schneider, Fabes, Phillips & Reichelt, J Ped Gastro & Nut, 2000

prevalence of gi symptoms asking a few questions goes a long way
Prevalence of GI symptoms: Asking a few questions goes a long way…
  • How was the survey developed?
  • How were the patients selected?
  • Was information obtained from the parents or from medical records?
  • What was the working definition of ‘diarrhea’ and ‘constipation’ ?
prevalence of gi symptoms a matter of timing
Prevalence of GI symptoms: A matter of timing
  • Case-controlled study from UK evaluated the frequency of GI complaints before ASD was diagnosed:
    • Exactly the same percentage (9%) of autistic and normally developing children had GI symptoms before the date of diagnosis.

Black, Kaye & Jick, Brit Med J, 2002

prevalence of gi symptoms in asd vs controls
Prevalence of GI symptoms in ASD vs. Controls
  • Most recent study compared 50 ASD children with 50 having other developmental delays (DD) and 50 with normal development:

History of GI symptoms:

          • 70% ASD
          • 28% Normal Children
          • 42% Other DD

Valicenti-McDermott, McVicar, Rapin, et al. J Dev Behav Pediatr, 2006

prevalence of gi symptoms in asd vs controls14
Prevalence of GI symptoms in ASD vs. Controls
  • Abnormal stooling pattern:
        • 18% ASD
        • 4% Normal
        • 2% DD
  • Food selectivity:
        • 60% ASD
        • 22% Normal
        • 36% DD
prevalence of gi symptoms it s all over
Prevalence of GI symptoms: It’s all over!
  • Most of the data published regarding GI symptoms is derived from parental recall or medical records
  • Places the prevalence of GI symptom somewhere between…

17%-86%!

(Erickson, Stigler, Corkins, et al, J Autism & Dev Disorders, 2005)

what triggers gi symptoms
What Triggers GI Symptoms?
  • Immaturity of the nerves and muscles responsible for moving food along
  • Enzyme deficiencies
  • Malabsorption of nutrients (sugars, fats, proteins)
  • Immune-mediated inflammation and damage
sources of intestinal pain
Sources of Intestinal Pain
  • Overstretching of muscles (gas, spastic contractions)
  • Acid-mediated irritation of esophagus (GERD)
  • Hypersensitive “second brain” (The brain in the gut or the ENS)
  • Abnormal blood flow
consequences of gi dysfunction
Consequences of GI Dysfunction
  • Acute and chronic pain
  • Interference with consumption of adequate nutrients
    • Aversive conditionings
    • Food intolerance and protein allergy
    • Limited food choices
  • Abnormal stooling patterns
diet and nutrition
Diet and Nutrition
  • Repetitive behaviors and insistence on sameness in ASD can have negative effect on diet
  • Limited food choices is frequent complaint of families with autistic children
  • A higher incidence of pica has also been noted by parents of autistic children
diet and nutrition23
Diet and Nutrition
  • Nutritional status has been evaluated by several small controlled and uncontrolled studies
  • Overall, it appears their nutrition is adequate
  • Selectivity does not result in malnutrition

Raiten &Massaro, J Autism and Dev Disorders, 1986;

Shearer, et al, J Autism and Dev Disorders, 1982;

Ahearn et al, J Autism and Dev Disorders, 2001;

Field & Williams, J Ped Child Health, 2003

food intolerance and allergy
Food Intolerance and Allergy
  • Anecdotal reports from parents of children with ASD
  • Most report intolerance for
    • cow’s milk (casein protein) or
    • wheat (gluten protein)
food intolerance and allergy25
Food Intolerance and Allergy
  • In 1971 investigators reported a case of a child with ASD and celiac disease:
    • Autistic behaviors worsened when exposed to gluten after a period with gluten-free diet

(Goodwin, Cowen & Goodwin, J Autism Child Schizophrenia, 1971)

food intolerance and allergy26
Food Intolerance and Allergy
  • This case inspired a study which measured trancephalic direct current (TDC) in children with ASD and GI symptoms:
    • ASD children showed inhibition of frontal voltage in response to 1 g PO dose gliadin
    • No inhibition with 1 g sugar
    • Siblings and normal controls showed no response to either gliadin or sugar
    • “Gluten has a direct effect on the central nervous system”

Goodwin, Cowen & Goodwin, J Autism Child Schizophrenia, 1971

another source of bias
Another source of bias
  • All the ASD children in study had previous GI complaints.
  • Error:
    • Generalizing differences found in a subset of children
  • Do all children with ASD have changes in response to a gluten challenge?
    • We do not know
food intolerance and allergy28
Food Intolerance and Allergy
  • Long-term prospective study of gluten and milk-free diet in children with abnormal urinary peptide levels:
  • 15 children in first report, original 15 + 15 new participants in second report
    • Behavioral improvement noted by parents and teachers in both reports
    • Urine peptide levels normalized by one year

Reichelt, et al. J App Nutr, 1990

Reichelt, et al. Brain Dysfunction, 1991

food intolerance and allergy29
Food Intolerance and Allergy
  • Another study with 15 participants:
    • Improved behavior and communication after 1 and 4 year periods
    • Also limited to ASD children with abnormal urinary peptides; no control group
  • None of the studies controlled for concomitant educational or other behavioral interventions that could have caused improvement
food intolerance and allergy30
Food Intolerance and Allergy
  • Single study with control group and blinded evaluators:
    • Found significant improvement in social abilities, cognition and attention after 1 year

Knivsberg, et al, Scan J Edu & Research, 1995

Knivsberg et al, Nutri Neurosci 2002

food intolerance and allergy31
Food Intolerance and Allergy
  • Most studies of gluten and/or casein-free diets have included only children with abnormal urine peptide levels
    • Cannot generalize to all children with ASD
    • Little evidence that dietary protein intolerance is more prevalence in ASD population
  • Small sample size, lack of control group also make the studies hard to interpret.
the leaky gut hypothesis
The Leaky Gut Hypothesis
  • Based on the observations that autistic behaviors improved on dietary protein-free diets
  • Theory is that a ‘leaky’ intestinal mucosa allows foods to enter the bloodstream.
the leaky gut hypothesis33
The Leaky Gut Hypothesis
  • Digestion of gluten and casein releases short chain peptides which are similar to endorphins.
  • These peptides are called ‘exorphins’
    • Wheat products gliadomorphins
    • Milk protein caseomorphins

Zioudrou, Streaty, Klee. J Biol Chem. 1979

a close look at membranes
A Close Look At Membranes

www.biology.arizona.edu/

the leaky gut hypothesis37
The Leaky Gut Hypothesis
  • Orally administered gluten fragments have been detected in rat brains
  • Opiate receptors in brain bind gluten exorphins
  • Casein exorphins infused into bloodstream of rats activates the rat brain.

Dohan, Adv Biochem Psychopharmocol, 1980; Hemmings, Proc Roy Coc London Ser B, 1978)

the leaky gut hypothesis38
The Leaky Gut Hypothesis
  • Hypothesis: Gliadomorphins and casomorphins from partially digested gluten and casein are:
    • Absorbed through a leaky gut
    • Enter the CNS
    • Interfere with normal brain function by mimicking the opioid hormone beta-endorphin.
lnh what does it supposed to mean
LNH: What does it supposed to mean?...

Enhanced activation of lymphoid tissue in the intestine

Triggered by food or viral antigens

Causing an inflammatory reaction

Resulting in increased permeability and a leaky gut

asd and the gi tract

ASD and the GI Tract:

Lessons Learned

Future Directions and Challenges

getting it right commonsense principles
Getting It Right:Commonsense Principles
  • No two ASD/PDD children are exactly alike
  • Generalizing is always tempting and an easier path to take
  • Human behavior is controlled by a complex interplay of factors
  • “Cookbook” recommendations are not going to benefit all children
  • Pushing the envelope of conventional medicine is commendable…up to a point
expanding knowledge
Expanding Knowledge
  • Anecdotal reports are the landmines of medicine
  • Sound principles of science should not be sacrificed in the name of ideologies
  • Progress will only evolve from well gathered information and data interpretation
  • Medical providers and families can be a powerful team…or they can easily become antagonistic aliens!
summary
Summary
  • Providing adequate nutrition to children with ASD remains a major challenge
  • Working close with a nutritionist or dietitian is important to avoid preventable deficiencies (or excesses)
  • Understanding the neurobiology of autism will foster development of well founded interventions
and finally
And Finally….
  • To understand the proper role of GI complaints and nutritional issues impacting on the behavior of ASD children requires constant reevaluation and an open (but always critical) mind