Framework to navigate food selectivity, alternative diets, nutritional deficits

A new guideline for the nutrition of management gastrointestinal symptoms in children with autism spectrum disorders (ASD) provides a framework for clinicians to navigate frequently seen issues such as food selectivity, alternative diets and nutritional deficits. The expert panel was convened at Marcus Autism Center, an affiliate of Children's Healthcare of Atlanta and the resulting guideline was published online by the Journal of the Academy of Nutrition and Dietetics (JAND).

"Children with autism are at increased risk for feeding and gastrointestinal (GI) concerns compared with peers and both of these issues involve nutrition management. We viewed the lack of an evidence-based guideline regarding nutrition management of GI symptoms in children with ASD as unacceptable," said co-author William Sharp, PhD, director of the Pediatric Feeding Disorders program at Marcus Autism Center and assistant professor of pediatrics at Emory University School of Medicine. "Our goal was to establish a standard manual of care for nutrition management which clinicians around the world could refer to."

The project involved a nationwide search to establish a six-member committee of expert dietitians with a combined 125 years of clinical experience working in the field of nutrition and autism. The resulting JAND paper includes a decision-making flowchart, detailed description of intervention steps, and management examples of two GI concerns, constipation and eosinophilic esophagitis (a chronic allergic inflammatory disease), conditions frequently managed with nutrition intervention.

"The committee developed the guideline with consideration of the unique dietary, medical, and behavioral challenges observed in children with ASD. This includes high rates of food selectivity observed in children with ASD, frequent use of caregiver-initiated complementary/alternative diet therapies, and growing concern regarding possible nutritional deficits and excesses often observed in this population," said co-author Rashelle Berry, lead dietician at Pediatric Feeding Disorders program at Marcus Autism Center.

Sometimes food selectivity contributes to GI symptoms, but in other cases the selectivity is in response to a preexisting problem such as a food allergy or gastroesophageal reflux. At the same time, alternative diets such as gluten-free, casein-free diets or other diets that restrict or eliminate certain food groups are often initiated by caregivers. Emerging evidence also suggests children with ASD may be at higher risk for nutrition-related conditions such as obesity or poor bone growth.

"Children with autism, like their typically developing peers, present with medical conditions that require nutrition intervention," said Berry. "Awareness of the unique challenges seen in this population is needed so that clinicians are well-equipped to plan effective interventions. The ultimate goal of nutrition management in autism is resolution of symptoms, promotion of adequate growth, and assurance of a nutritionally complete diet."

The guideline states that in cases of severe food selectivity, nutrition therapy should occur concurrently with feeding therapy. The guideline also advises on the use of nutritional supplements or liquid formulas in this population. Consultation with a registered dietitian nutritionist is recommended when working to create a nutritionally complete diet that also works to alleviate GI concerns.

"A key take home message from this guideline is that nutrition management in ASD should play a central role in a child's overall plan of care, ideally from the time of diagnosis," added Sharp.