Autistic Spectrum Disorders are the result of a Bowel Disorder?

Diagnostic Problems.

Multiple Diagnostic ‘Criteria’Multiple Diagnostic ‘Criteria’ Overlap with Attention Deficit, Dyspraxia Overlap with Attention Deficit, Dyspraxia

and Dyslexia.and Dyslexia. Children with severe Global Developmental Children with severe Global Developmental

delay.delay. The role of Genetic Factors – specific The role of Genetic Factors – specific

Chromosome Disorders and less specific Chromosome Disorders and less specific genetic factors.genetic factors.

Patterns of Presentation.

Features from early infancy.Features from early infancy. Plateauing of Development.Plateauing of Development. Regression, particularly in second year of Regression, particularly in second year of

Life.Life.

Features of Regressive Pattern

Clear evidence of normal development in Clear evidence of normal development in first year.first year.

High incidence of allergic disorders in child High incidence of allergic disorders in child and family.and family.

Probable increased frequency of Low IgA.Probable increased frequency of Low IgA. Frequent Upper Respiratory infections in Frequent Upper Respiratory infections in

the first year of life.the first year of life.

Features of Regressive Pattern

Frequent incidence of bowel symptoms - ?Frequent incidence of bowel symptoms - ?finding of lymphoid nodular hypoplasia.finding of lymphoid nodular hypoplasia.

History of frequent use of antibiotics in first History of frequent use of antibiotics in first year of life.year of life.

Preliminary Review 1997-99.

57 Cases.

Age Range: 2-15 years.Age Range: 2-15 years. Mean Age 4 years 1 mont.Mean Age 4 years 1 mont. Number with regression 35.Number with regression 35. Average age of regression 16 months.Average age of regression 16 months. Bowel symptoms : 36Bowel symptoms : 36 Excessive Thirst: 33Excessive Thirst: 33

Recommended Treatment.

NoneNone 1313 Anti-fungalAnti-fungal 2424 Gluten/Casein FreeGluten/Casein Free 99 Anti-fungal & Gluten/Casein Free Diet. 11.Anti-fungal & Gluten/Casein Free Diet. 11.

Outcomes.

Definite and sustained improvementDefinite and sustained improvement 28 28

(15 reporting deterioration when intervention (15 reporting deterioration when intervention discontinued).discontinued).

Uncertain improvement.Uncertain improvement. 66

A Review of Children referred for Consideration of Dietary Management for the Autistic

Continuum.2001.

Dr. Clive Jones.

Pattern of referrals reviewed.

Number 69

Male 58(84%)

Definite ASD 62(90%)

Age of Onset /symptoms noted.

16.7 months. (S.D.6.1, Range 6-36

months)

Pattern of Symptoms.

Regression 50 (73%).(Average age at

regression 17.9%)Plateauing 16 (23%)

Early Delay 3 (4%)

Comorbidity

1 child previously diagnosed as Coeliac.1 child previously diagnosed as Coeliac. 1 child previously diagnosed as ?Gluten 1 child previously diagnosed as ?Gluten

enteropathy.enteropathy. 1 child suffered myoclonic seizures.1 child suffered myoclonic seizures.

Associated Symptoms.Bowel Problems 44 (64%).

Constipation 15

Diarrhoea 13

AlternatingConstipation/

Diarrhoea

16

Abdominal Pain 13

Allergic Features.43 (62%).

Asthma 6

Eczema 11

Urticaria 8

Rhinitis 22

Allergic reaction toingested foods.

4

Combination of allergy / bowel symptoms. Number with >1 allergic featureNumber with >1 allergic feature 2222 Number with >2 allergic featuresNumber with >2 allergic features 1111 Number with allergic features and bowel Number with allergic features and bowel

symptoms.symptoms. 22 (38%).22 (38%). Number who had either bowel or allergic Number who had either bowel or allergic

features.features. 58(84%).58(84%).

‘Soft Symptoms’

Excessive Sweating 39 (56%).

Excessive Thirst 41(59%)

Otitis Media.(Grommets)

20(28%)6 (9%)

Disturbed Sleep 23(33%)

Other features.

5 had a history of diarrhoea after ingestion 5 had a history of diarrhoea after ingestion of soya.of soya.

13 had a history of food cravings or 13 had a history of food cravings or dislikes.dislikes.

11 had evidence of prior fungal infection.11 had evidence of prior fungal infection. 30 had a history of prior antibiotic therapy.30 had a history of prior antibiotic therapy.

Clinical Findings.

Allergic Facies 20 (29%)

Rhinitis 22(32%)

Ligamentous Laxity 27 (39%)

Family History

1st. degree relativewith Autistic traits

10

1st. Degree relativeswith atopy.

42

1st degree relativeswith migraine.

14

Maternal Thrush 28

> 2 of above 15

Prior Management

22 had had urinalysis at University of 22 had had urinalysis at University of Sunderland. 9 positive for casomorphine and 5 Sunderland. 9 positive for casomorphine and 5 for glutamorphine.for glutamorphine.

41 had tried gluten free/casein free diet to some 41 had tried gluten free/casein free diet to some degree, often without adequate support. Many degree, often without adequate support. Many reported improvement with this, especially with reported improvement with this, especially with casein free diet, those who reported casein free diet, those who reported improvement generally reported initial improvement generally reported initial regression.regression.

Prior Management

Many were on a complex mixture of other Many were on a complex mixture of other supplements, interventions including DMG. supplements, interventions including DMG. Some had tried secretin (real or Some had tried secretin (real or homoeopathic without clear benefit).homoeopathic without clear benefit).

10 were on an educational type intervention 10 were on an educational type intervention - 7 using LOVAAS & 3 ABA.- 7 using LOVAAS & 3 ABA.

Interventions recommended.

A preliminary assessment of likelihood of A preliminary assessment of likelihood of responding to nutritional interventions.responding to nutritional interventions.

A review of the current interventions, A review of the current interventions, including supplements and the nutritional including supplements and the nutritional adequacy of the diet being followed.adequacy of the diet being followed.

Low sugar/low yeast diet with nystatin in Low sugar/low yeast diet with nystatin in 40 Gluten Free/Casein Free diet in 5.40 Gluten Free/Casein Free diet in 5.

Nystatin Therapy.

Effectiveness of nystatin in Effectiveness of nystatin in polysymptomatic patients. A randomized, polysymptomatic patients. A randomized, double-blind trial with nystatin versus double-blind trial with nystatin versus placebo in general practice. placebo in general practice. Heiko Santelmann, Even Laerum, Joergen Heiko Santelmann, Even Laerum, Joergen Roennevig and Hans E Fagertun. Family Roennevig and Hans E Fagertun. Family Practice, Vol.18, No. 3. 258-265.Practice, Vol.18, No. 3. 258-265.

Response to treatment.

Almost all children reacted to the Almost all children reacted to the introduction of nystatin with an increase in introduction of nystatin with an increase in symptoms, most requiring subsequent symptoms, most requiring subsequent titration of the dose to see optimum titration of the dose to see optimum improvement. (This is a reaction not improvement. (This is a reaction not generally seen when children or adults are generally seen when children or adults are treated with nystatin).treated with nystatin).

Response to Treatment.

Data on 13 children treated with nystatin Data on 13 children treated with nystatin followed through for at least 6 months.followed through for at least 6 months.

8M & 3F appeared to exhibit very positive 8M & 3F appeared to exhibit very positive responses in both autistic and associated responses in both autistic and associated symptoms - usually substantiated by reports symptoms - usually substantiated by reports from other professionals.from other professionals.

Average age of this group at inital Average age of this group at inital consultation was 4.1 years. (Range 2.5-7.2)consultation was 4.1 years. (Range 2.5-7.2)

Conclusions.

In addition to earlier reports these data In addition to earlier reports these data indicate a potential for managing some indicate a potential for managing some children in the autistic continuum with diet children in the autistic continuum with diet and or anti-fungal treatment. There is and or anti-fungal treatment. There is clearly a need for further prospective clearly a need for further prospective studies, however there will be considerable studies, however there will be considerable problems in arranging these on a double problems in arranging these on a double blind basis. blind basis.

Conclusions.

This data has further refined the clinical This data has further refined the clinical criteria that should be used to identify criteria that should be used to identify children to be entered into such a study.children to be entered into such a study.

The clinical input appears to have helped The clinical input appears to have helped some parents to recognise that dietary some parents to recognise that dietary approaches were unlikely to be helpful for approaches were unlikely to be helpful for their own child, and thereby helped to their own child, and thereby helped to rationalise prior interventions.rationalise prior interventions.

The Way Ahead?

A Double Blind Placebo Controlled Trial of A Double Blind Placebo Controlled Trial of Nystatin in a specific sub-group of patients. Nystatin in a specific sub-group of patients. (MRC has recognised a need for research (MRC has recognised a need for research into Bowel disorders and bowel flora and into Bowel disorders and bowel flora and autistic spectrum disorders).autistic spectrum disorders).

In the interim follow the principal of In the interim follow the principal of sequential intervention and ensure that any sequential intervention and ensure that any changes do not cause more problems.changes do not cause more problems.