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Udell-Lecture.Pdf www.childdev.org www.theautismdoctor.com October 19, 2018 Brian D. Udell MD FAAP Medical Director Child Development Center of America Davie, FL 33314 954-873-8413 [email protected] Nutritional Evaluation of the Patient with Developmental Challenges • Understanding the scope of autism - Multiple causes and Multiple presentations • Evaluation of the medical status of the patient with developmental concerns • Treatment and documentation of progress • No disclosures • This presentation does not represent Nova University policies or recommendations. Autism Spectrum Disorders Autism Spectrum Disorders Individual susceptibility Environmental event(s) Phenotypic presentation ? Cause(s) Autism Spectrum Disorder DSM IV to DSM 5.0: Speech and Early and Language Significant Movement Social Movement Social Learning Cognition Reading Arithmetic Seizures Metabolic Environment, Hypotonia, Processing Intrinsic Repetitive Apraxia CNS Hyperactivity Sensory Genetic Restricted Skin Eczema AutoImmunity Inflammation Immune Infections Aggression Gut Constipation/Diarrhea microbiome, nutrition Focus/Attention Autism Spectrum Disorders Types Genetic – Fragile X, Rett’s S., Trisomy 21?, Copy number variations Syndromes – Metabolic disturbances, Unclassified Gastro-intestinal Most common in practice If a person acts like they have ‘ants in their pants’, sometimes they actually do! In 8/11 originally described ASD patients (Kanner), disturbances documented Immunologic – Asthma, eczema, food sensitivities, frequent ear infections, ?vaccination Microbiome alterations Birth complications – Cerebral palsy, Genito-urinary, Gastrointestinal, “Premies’ Metabolic & Nutritional – Vitamin deficiency, Lipid abnormalities, Picky eaters, MTHFR Boy vs. Girl Early vs. Late Autism Spectrum Disorders Journal of the American Dietetic Association MEDICAL NUTRITION THERAPY Nutritional Assessment of Children with Autism SCChapmanRDMJLucasMS, RD, LDSMcCammanMS, RD, LD September 1998 9 males, 7-10 yo Boys with autism appear to have dietary intakes different than those recommended by the Pyramid and RDA with low kcals, high protein intake, low consumption of milk, vegetables and high consumption of fat. However, anthropometric measurements were close to the 50th percentile except for greater WT/HT. The investigators suggest monitoring dietary intake and nutrition counseling for children with autism to prevent low or excess intake. Autism Spectrum Disorders April 2013 Nutritional status survey of children with autism and typically developing children aged 4–6 years in Heilongjiang Province, China Caihong Sun, et.al. Parent questionnaire, dietary log of 53 ASD vs. NT Children with autism exhibited several abnormalities in terms of eating behavior and gastrointestinal symptoms. Levels of vitamins A and B6, Zn and Ca intakes were <80 % of the dietary reference intakes in both groups. The proportions of vitamin C and Ca intake deficiencies in the autism group were significantly higher than those in the control group. Autism Spectrum Disorders April 2013 Nutritional status survey of children with autism and typically developing children aged 4–6 years in Heilongjiang Province, China Caihong Sun, et.al. Serum Zn level was less than the normal reference range in both the groups. Serum Ca, vitamin A and folate levels in children with autism were significantly lower when compared with children without autism. Mean BMI, weight-for-height Z-score (ZWH) and BMI for age Z-score (ZBMIA) of children with autism were significantly higher than those of the typically developing children. Autism Spectrum Disorders July 2014 This assessment is intended to help families, nutritionists and researchers make a rough estimate of the quality of diet and nutritional supplementation of a person with autism. Quality of diet Based on score parent may make more informed dietary decisions: Autism Spectrum Disorders July 2014 Autism Spectrum Disorders January 2015 Selective eating is a common characteristic in ASD children. Many parents impose gluten-free and/or casein-free diets on their children. These factors put ASD children at risk of nutritional deficiency and delayed growth. Autism Spectrum Disorders June 2015 80 autistic children, divided into two groups: 3- 5 years and 6-9 years Autistic children suffered inadequate intake of some micronutrients such as vitamin D and C, calcium, folate, magnesium, phosphorus, zinc, and iron, some deficiencies were highly significant especially at older age. Tailoring a specially designed balanced diet with appropriate micronutrient supplementation may ameliorate the severity of autism symptoms and related abnormal behaviors. Autism Spectrum Disorders Nutritional Status of Individuals with Autism Spectrum Disorders: Do We Know Enough? Sobhana Ranjan* and Jennifer A Nasser July 2015 Nutritionally vulnerable population Accelerated growth but variable BMI vs. NT Research lacking about AA metabolism, homocysteine, folate, vitamins Selective eating patterns As population ages, problem becomes even more complicated Autism Spectrum Disorders Pediatrics Nutritional and Dietary Interventions for Autism Spectrum Disorder: A Systematic Review Nila Sathe, Jeffrey C. Andrews, Melissa L. McPheeters, Zachary E. Warren June 2017 Studies of gluten- or casein-containing challenge foods reported no effects on behavior or gastrointestinal symptoms with challenge foods (insufficient SOE); 1 RCT reported no effects of camel’s milk on ASD severity (insufficient SOE). Harms were disparate. Autism Spectrum Disorders Common History & Physical Examination Detailed Pregnancy, Labor and Delivery, Developmental Milestones, Family history, Review of systems, Observation, Interview Initial laboratory evaluation* Initial interventions* Close follow-up* Autism Spectrum Disorders Initial Laboratory Examination Blood – Complete blood count, Comprehensive metabolic profile, Lipid panel, Vitamin D, Calcium, Magnesium, Thyroid, Folate, B12, MTHFR, Genetic Food allergy, Heavy metals Urine – peptides for ‘leaky gut’, toxins Stool – comprehensive for digestion and pathogens Appropriate additional testing Autism Spectrum Disorders Protein & Amino Acids Lipids Carbohydrates Vitamins Minerals Trace elements Autism Spectrum Disorders The total protein test measures the total amount of two classes of proteins found in the fluid portion of your blood. ... Proteins, made of amino acids, are important parts of all cells and tissues. Two classes Albumin is a protein made by your liver. Affects Colloid Osmotic Pressure – the ability to keep fluid in your bloodstream so it doesn't leak into other tissues. It is also carries various substances throughout your body, including hormones, vitamins, and enzymes. Globulins are important to immune function Best to measure serum AND urine amino acid to elucidate problem Autism Spectrum Disorders Plasma Amino Acids Profiles in Children with Autism: Potential Risk of Nutritional Deficiencies August 2003 Georgianne L. Arnold, Susan L. Hyman, Robert A. Mooney Plasma amino acid profiles of 36 children with ASD Ten of the children were on gluten and casein restricted No amino acid profile specific to autism was identified. However, children with autism had more essential amino acid deficiencies consistent with poor protein nutrition than an age/gender matched control group. There was a trend for children with autism who were on restricted diets to have an increased prevalence of essential amino acid deficiencies and lower plasma levels of essential acids including the neurotransmitter precursors tyrosine and tryptophan than both controls and children with autism on unrestricted diets. The high rate of tryptophan and tyrosine deficiency in this group is also of concern given their role as neurotransmitter precursors. Autism Spectrum Disorders Plasma Amino Acid Levels in Children with Autism and Their Families February 2003 Sarah AldredKieran M. MooreMichael FitzgeraldRosemary H. Waring Plasma amino acid levels were measured in autistic and Asperger syndrome patients, their siblings, and parents. The results were compared with values from age-matched controls. Patients with autism or Asperger syndrome and their siblings and parents all had raised glutamic acid, phenylalanine, asparagine, tyrosine, alanine, and lysine (p < .05) than controls, with reduced plasma glutamine Results show that children with autistic spectrum disorders come from a family background of dysregulated amino acid metabolism and provide further evidence for an underlying biochemical basis for the condition. Autism Spectrum Disorders Laboratory reporting is mostly detailing risk of arteriosclerosis and coronary risk. High may indicate familial tendencies and therefore later risk, and may help physician counsel parent to afford a healthier diet. In ASD population, low is important in CNS function – the brain is a fatty organ due to the deposit that enables conduction and insulation. Autism Spectrum Disorders July 2006 Abnormalities of cholesterol metabolism in autism spectrum disorders Tierney E, Bukelis I, Thompson RE, Ahmed K, Aneja A, Kratz L, Kelley RI. Smith-Lemli-Opitz Syndrome (SLOS), a genetic condition of impaired cholesterol biosynthesis, is associated with autism. Studied a cohort of subjects with ASD from families in which more than one individual had ASD. Although no sample had sterol levels consistent with SLOS, 19 /100 samples had total cholesterol levels lower than 100 mg/dl, which is below the 5th centile for children over age 2 years. These findings suggest that, in addition to SLOS, there
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