STEP 6

Heal Your Child’s Gut

Gastrointestinal problems involving the esophagus, stomach, small intestine, and colon are very common among children with autism. In fact, recent research shows that GI problems are more prevalent in autistic kids than other children, a notion that the medical community had long dismissed as improbable. In a study published in the Journal of the Developmental and Behavioral Pediatrics in 2006, 70 percent of autistic children were found to have a lifetime history of gastrointestinal symptoms such as abnormal stools, constipation, frequent vomiting, and abdominal pain. Other research studies indicate that children with autism have high rates of lymphonodular hyperplasia (LNH), esophagitis, gastritis, duodenitis, and colitis as well as low levels of intestinal carbohydrate digestive enzymes. The symptoms of gastrointestinal problems, which range from mild to severe, can have a major impact on both your child’s health and his behavior. If your child suffers from one or more of the symptoms listed below, a gastrointestinal disorder may be the culprit:

• abdominal pain

• bloating

• gaseousness

• constipation

• reflux

• vomiting

• diarrhea

If your child is indeed suffering from a gastrointestinal disorder, effective treatment will resolve his symptoms, which in turn should improve some of his behaviors.

We don’t know exactly why such a large percentage of autistic children suffer from gastrointestinal disorders, but there are countless theories. Some believe that autistic children suffer from leaky gut syndrome (increased intestinal permeability); others think that it’s due to an imbalance of microflora in the gastrointestinal tract (specifically, the overgrowth of Candida albican yeast). Some believe an autoimmune disease is to blame, and still others think it’s caused by IgG food sensitivities or carbohydrate digestive enzyme deficiencies. There’s also talk about a new variant form of inflammatory bowel disease called autistic entercolitis, which was first reported by gastroenterologist Dr. Andrew Wakefield and is very controversial. In the end, it doesn’t really matter why your child is more prone to GI problems; what matters is identifying and healing the problem.

ELIMINATION PROBLEMS

The most common complaints children with autism seem to have when it comes to GI problems is chronic constipation, chronic diarrhea, and loose or nonformed stools. Research confirms that constipation is more common in children with autism than other children. Abdominal X-rays of children with and without autism who are experiencing stomach pain have shown that autistic children have a significantly higher rate of excess stool in the colon. Children with chronic constipation often associate bowel movements with pain and deliberately hold in their stool to avoid a bowel movement. Holding in their stool causes them to lose the urge to have a bowel movement, which completes the vicious cycle that is chronic constipation. If your child is experiencing chronic constipation, he’s at the very least uncomfortable and may well be in pain. As you may remember from my discussion of chronic constipation in Step 5 (see page 66), it can result in physical issues such as megacolon and encopresis and behavioral issues that contribute to feeding problems.

To help you assess whether your child may be constipated, the chart below shows the average number of bowel movements you should expect from your child throughout his childhood years. If he’s falling short within his age group, talk to his physician.

Age	Number of Bowel Movements
	per Day	per Week
0-3 months
breastfed	2.9	5-40
formula fed	2.0	5-28
6-12 months	1.8	5-28
1-3 years	1.4	4-21
Over 3 years	1.0	3-14

Source: ACTA Paediatrica Scandinavica (Stockholm) 1989; 78:682-4

On the other end of the spectrum, autistic children also tend to have problems with chronic diarrhea, loose stools, nonformed stools, or a combination of all three at different times. Many parents describe their child as never having had a normally formed stool. Chronic diarrhea is diarrhea that’s present for more than three weeks and is not associated with an illness. Many medical professionals refer to it as chronic nonspecific diarrhea (CNSD). If a child with CNSD continues to gain weight and grow taller at a normal rate, many medical professionals don’t consider it a significant health problem or suggest any specific medical treatment to resolve the issue. Parents, however, are usually very concerned about their child’s abnormal stools and rightly so. If your child is having difficulty controlling his bowel function, it will impact him in many ways. For instance, having chronic diarrhea, loose stools, and/or nonformed stools will affect his ability to potty train, forcing you and other caregivers to continue changing diapers beyond the typical age. Your child’s bowel function issues may make him feel uncomfortable and self-conscious, which will affect his sensory system and can lead to behavioral problems. He may also encounter nutritional deficiencies because chronic diarrhea causes malabsorption of vitamins, minerals, omega-3 fatty acids, and other nutrients. This impedes his body’s ability to repair the lining of the GI tract, which serves only to exacerbate his malabsorption of nutrients. This vicious cycle of chronic diarrhea, malabsorption, and nutrient deficiencies can compromise your child’s overall health, brain function, and behavior.

THE GI DISORDER—BEHAVIOR CONNECTION

Undiagnosed GI disorders can cause serious behavioral problems in autistic children, particularly those who are unable to verbally express the pain they’re feeling. If your child is nonverbal, the only way he can communicate how he feels is through his behavior. Some common behaviors that may indicate your child has a GI disorder are the following:

• food refusal

• accepting a limited variety of foods

• mealtime tantrums

• irritability

• self abuse

Unfortunately, too often these symptoms are dismissed “typical” autistic behaviors as opposed to attempts to communicate what can’t be put into words. Identifying and correcting your child’s GI disorder will lead to significant improvement in the way he behaves.

Sara’s Story

Eight-year-old Sara was diagnosed with autism; she was nonverbal and had severe behavioral problems, including self abuse. Sara’s mother informed her speech and language therapist that Sara was a picky eater (she was really a problem eater as she ate only three foods) and had severe behavioral problems at mealtime, such as throwing food, crying, tantrums, and biting herself. Since Sara was nonverbal, the first thing the SLP did in speech therapy was to teach Sara to use colors as a way to express herself. Each color represented a feeling; for example, the color red meant mad, angry, pain, or hurt. After Sara learned the colors, the SLP encouraged her to draw a picture. Sara took a crayon and drew a stick figure of a person. Then she picked up the red crayon and drew a red ball in the stomach area and a red line up to the center of the chest area of the stick figure. The SLP shared the picture with Sara’s parents, who took her to a pediatric gastroenterologist. The GI specialist performed several studies, including an upper GI endoscopy, and discovered Sara was suffering from GERD with severe esophagitis. Sara had probably been suffering from undiagnosed GERD and esophagitis for years, experiencing severe pain after mealtime but unable to verbally express how she felt. Sara’s behavior at mealtime was her way of communicating her pain, but instead everyone thought she was merely having typical autistic behavioral problems.

CONTRIBUTING FACTORS

The factors that contribute to gastrointestinal problems can be split into two categories: dietary and physical. If your child is expressing one or more of the GI symptoms listed on page 79, you need to figure out what specific factors are contributing to his symptoms. Then you’ll be able to determine the medical and dietary treatments that are right for him. Common contributing factors include the following:

• inadequate water intake

• inadequate dietary fiber intake

• low muscle tone (hypotonia) or increased muscle tone (hypertonia)

• decreased physical activity

• irregular toilet habits

• unable to communicate the need to have a bowel movement

• holding in his stool

• medication side effects

• excessive or long-term use of laxatives, suppositories, and enemas

• malnutrition

• cow’s milk allergy

• medical conditions

DIETARY TREATMENT

The first thing you should do is adjust your child’s diet. Making specific dietary modifications, adding basic and advanced supplements to his diet, and identifying and eliminating problematic foods can vastly improve or even eliminate your child’s GI issues. I strongly encourage you to take your child to a registered dietitian for professional advice and help in implementing the dietary modifications I discuss below.

Step 1: Make Appropriate Dietary Modifications

Making sure your child is getting enough fiber and water in his diet and limiting his consumption of fruit juice will promote normal daily bowel movements, which is the first basic step in healing his gut problems. Autistic children tend to accept a very limited variety of foods, so their fiber intake is usually inadequate. Refer back to page 29 in Step 2 for details on how much fiber and water (page 37) your child should have. Appendix 2 on page 216 provides a list of high-fiber foods you can offer your child. If your child has feeding problems and is unwilling or unable to eat more high-fiber foods, you may need to add a fiber supplement to his diet. However, it’s important that you consult with a registered dietitian or a gastroenterologist before starting your child on a fiber product. If your child has an intestinal obstruction, fecal impaction, or narrowing of the gastrointestinal tract, a fiber supplement could cause an impaction of stool in the colon. You should also consult a registered dietitian or gastroenterologist if your child has low muscle tone. He may be unable to push stool through his lower gastrointestinal tract, and adding too much dietary fiber or a fiber supplement to his diet could result in a stool impaction.

When adding fiber to your child’s diet, it’s important to go slowly and make sure he’s getting enough water in his diet before you increase his fiber. Your child should be drinking at most one cup of fruit juice a day, especially if he has loose stools. If he’s got chronic constipation, offer him pear or apple juice, which will help to increase the water content of his stools and the frequency of his bowel movements. Prune juice is also a great choice for constipation because it contains dihydroxyphenyl isatin, a natural laxative substance that promotes bowel movements. I recommend mixing one to two ounces of prune juice into pear or apple juice on a daily basis.

Step 2: Try Basic Supplements

Basic supplements, such as probiotics, anti-fungals, and digestive enzymes, play a major role in healing your child’s GI tract. The right combination of these basic supplements will support and maintain a healthy balance of naturally occurring microorganisms in your child’s gastrointestinal tract.

Probiotics

The GI tract contains “good bacteria,” “bad bacteria,” and yeast, all of which must be maintained at an ideal balance in order to support the immune system and the production of certain vitamins and digestive enzymes. Research shows that children with autism have significant imbalances in their upper and lower gut microflora. A study published in the Journal of Medical Microbiology in 2005 indicated that severe gastrointestinal problems in children with autism may be due to an imbalance of the gut microflora, and that rebalancing the microflora may help to alleviate gastrointestinal disorders common in autistic children. Probiotics, which are live microorganisms that are similar to the beneficial “good bacteria” found in the gut, can help improve the microflora balance in your child’s gastrointestinal tract. Probiotic supplements also work to accomplish the following:

• enhance the immune system

• decrease the frequency of acute and chronic diarrhea

• create better-formed stools

• improve dermatitis and eczema

• maintain remission in ulcerative colitis and Crohn’s disease

• improve integrity of the gut barrier

• decrease GI symptoms, gut inflammation, and intestinal permeability

Most often, the bacteria used for probiotics come from two groups, Lactobacillus or Bifidobacterium. Within each group, there are different species (for example, Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium infantis, and Bifidobacterium lactis), and within each species there are different strains (or varieties). Bifidobacterium, especially Bifidobacterium lactis, is the most prevalent bacteria found in breastfed babies, making it the better supplement choice for infants and young children. Saccharomyces boulardii are yeasts that have probiotic properties and are often used in conjunction along with other probiotic supplements.

Probiotic supplements come in capsule, powder, chewable, and liquid form, making them easy for most autistic kids to ingest. If you choose a liquid probiotic supplement, be aware that it has a much shorter shelf life than the capsules, chewables, and powders. You can find probiotic supplements at most pharmacies, supermarkets, and health food stores, or they can be ordered online. (For instance, Kirkman offers a wide variety of high-quality probiotic supplements on its Web site www.kirkmangroup.com, or you can call toll-free at 800-245-8282.) When choosing one for your child, make sure it has at least 5 billion colony-forming units (CFU) per dose, as that’s the minimum amount of CFU recommended by the Natural Health Products Directorate of Canada for a beneficial effect. Also be sure that your child takes the probiotic every day. Studies show that once a probiotic supplement is discontinued from the diet, the GI microflora returns to its presupplementation levels. I often recommend Culturelle, a well-known probiotic supplement that contains Lactobacillus rhamnosus GG, a specific strain with many well-documented health benefits. It’s guaranteed to deliver a minimum of 10 billion CFU in each capsule and survive the strong acid of the stomach. (For a probiotic supplement to be effective, it must be able to survive the stomach acid so it can be delivered and colonize in the small intestines and colon.) It’s also good to know that probiotic supplements often contain fructooligosaccharides (FOS), which is a nondigestable carbohydrate. FOS is considered a prebiotic because it promotes the growth of Lactobacilli and Bifidobacteria.

Antifungals

Herbs and natural food sources that have antifungal properties are often used in conjunction with probiotics. They help support a healthy balance of intestinal bacteria and yeast by keeping Candida albican yeast growth under control. Unlike probiotics, your child should not take an antifungal product on a daily basis. Antifungal products are typically taken for a short period of time just to assist in healing your child’s GI tract, and then they’re discontinued. Antifungal products contain herbs such as pau d’arco and other natural food sources that have antifungal properties such as garlic extract, grapefruit seed extract, and caprylic acid. Although most herbs are free of known side effects, there may be potential contraindications, precautions, and adverse reactions to consider, especially for children, pregnant women, and nursing mothers. You should talk to a registered dietitian or a nutrition-oriented physician for specific recommendations for your child. Some good antifungal products on the market are Yeast Fighters, manufactured by TwinLab, and YeastAid by Kirkman.

Digestive Enzymes

Digestive enzymes are secreted in the mouth, stomach, and small intestines to break down food so the body can absorb and utilize the nutrients. Studies have indicated that some autistic children have low levels of intestinal carbohydrate digestive enzymes, so a digestive enzyme supplement with meals may help them better digest their food and improve GI symptoms such as bloating, gas, diarrhea, and constipation.

The body produces different digestive enzymes to break down different types of food, so I recommend that you select a basic multispectrum digestive enzyme product that contains a blend of several different digestive enzymes. This will ensure your child will be able to handle a wide range of foods. Some examples of important digestive enzymes you should look for include the following:

• protease—breaks down protein into amino acids

• lipase—breaks down fats

• amylase—breaks down carbohydrate

• lactase—breaks down lactose into glucose and galactose

• sucrase—breaks down sucrose into glucose and fructose

There are also specialty digestive enzyme products available with higher potency levels as well as products formulated to target specific macronutrients, such as protein, fat, or carbohydrate. However, you should consult with a registered dietitian before choosing a higher potency or specially formulated product for your child. Over-the-counter digestive enzymes are usually plant-derived, well tolerated, and come in capsule form. If your child can’t swallow a capsule, pull the capsule apart and mix the powder into a small amount of food or beverage at the beginning of his meal. Digestive enzyme products don’t require a prescription from a physician and can be purchased at most pharmacies, supermarkets, and health food stores or ordered online. Kirkman offers a wide variety of basic, higher potency, and specially formulated digestive enzyme products (www.kirkmangroup.com).

Step 3: Consider Trying Advanced Supplements

It’s worthwhile to talk with a pediatric registered dietitian and/or a gastroenterologist about trying your child on therapeutic levels of omega-3 fatty acids and glutamine to combat his gastrointestinal problems.

As you read earlier in this chapter, a significant number of children with autism have inflammation throughout their GI tract. Omega-3 fatty acids have natural anti-inflammatory properties, and research suggests that omega-3 fatty acid supplements may reduce the pain and inflammation associated with inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis. If your child has severe gastrointestinal symptoms or if the gastroenterologist has identified any gastrointestinal inflammation, a therapeutic level of omega-3 fatty acids for a short period of time may be a good option for him. Keep in mind that it’s very important you consult a registered dietitian or physician before giving your child a therapeutic level because there are potential health risks associated with taking too much omega-3 fatty acids. (See Step 4 for more information on the benefits and risks of omega-3 fatty acids.)

Glutamine is an amino acid necessary for brain, immune, and gastrointestinal functions. One of its most important roles is to help protect the lining of the gastrointestinal tract known as the mucosa. Recent research studies have linked glutamine to several other GI health benefits, such as aiding in the maintenance of the gut barrier, promoting intestinal cell growth, promoting healing of the mucosa, inhibiting the growth of “bad bacteria” in the gut, improving diarrhea, and reducing the symptoms of inflammatory bowel diseases.

Glutamine is manufactured by the body, but it’s also found in many dietary sources, such as beef, pork, chicken, fish, eggs, milk, dairy products, cabbage, spinach, and parsley. If your child has a very poor diet or suffers from certain medical conditions, infections, or prolonged stress, his glutamine level may be depleted and he could benefit from a glutamine supplement.

Glutamine supplements are generally labeled as L-glutamine and are sold as an individual supplement and as part of a protein supplement. They are available in capsule, tablet, powder, and liquid form. There’s no RDA for glutamine, so you need to talk to your child’s physician about proper dosage. The physician may order a serum amino acid lab test to determine if your child has any amino acid deficiencies before recommending a glutamine supplement. It’s important to avoid a situation where your child is getting too much glutamine because excess glutamine is converted to glutamate and ammonia, which are neurotoxic in high concentrations.

Step 4: Identify and Eliminate Problematic Foods

Common gastrointestinal symptoms such as reflux, vomiting, abdominal pain, abdominal distension, gaseousness, loose stools, diarrhea, and chronic constipation are indications that your child may have an allergy, sensitivity, or intolerance to one or more foods. The most common food allergies among children are cow’s milk, wheat, egg, soy, peanuts, and tree nuts. Problematic foods can have a huge impact on your child’s overall health, gut function, brain function, feeding, and behavior, so it’s crucial to identify and eliminate them from his diet. The good news is that if your child’s GI symptoms are indeed being caused by one or more problematic foods, you’ll quickly see a significant improvement in his symptoms once the foods are eliminated.

The best way to identify problematic foods for your child is through the Elimination /Challenge Diet, which I discuss in detail in Step 7. The Gluten Free Casein Free Diet (GFCF) is also an elimination/challenge diet, but it’s specifically used to determine if gluten and casein are a problem for your child. In my clinical practice, I’ve had great success with the GFCF Diet and believe it’s one of the most effective dietary treatments to improve an autistic child’s GI symptoms. Turn to Step 8 on page 103 for an in-depth discussion on this diet.

MEDICAL TREATMENT

If your child still has GI symptoms after working with a registered dietitian and trying the basic nutritional interventions, his physician will need to refer him to a pediatric gastroenterologist. A pediatric gastroenterologist will examine your child for more serious GI disorders, such as gastroesophageal reflux disease (GERD), eosinophilic gastrointestinal disorders (EGID), celiac disease, lactose intolerance, sucrose or fructose malabsorption, fat malabsortion, bacteria overgrowth, inflammatory bowel disease (IBD), abnormal anatomy of the intestinal tract, and parasites. The gastroenterologist may have to perform certain procedures to make his diagnosis, such as an abdominal X-ray, a gastric-emptying study, an upper GI endoscopy, colonoscopy, or a pH probe. He’ll also order a number of laboratory tests to rule out biomedical abnormalities that could be contributing to your child’s GI symptoms, such as:

• Thyroid Panel, T3, T4, TSH (this test checks for hypothyroidism, which contributes to constipation; and hyperthyroidism, which contributes to diarrhea)

• Comprehensive Metabolic Panel (this test checks for hypercalcemia and hypokalemia, both of which contribute to constipation)

• Complete Blood Count (this test checks for iron deficiency anemia)

• Celiac Disease Panel (this test checks for celiac disease, which contributes to both constipation and diarrhea)

• Blood Lead (this test checks for abnormally high lead levels, which contribute to constipation)

• Serum Carnitine (this test checks for a carnitine deficiency, which contributes to constipation)

• Stool Analysis (this test checks for parasites, harmful bacteria, and fat malabsorption)

The results of the testing will help the gastroenterologist recommend the appropriate medical treatment, which may include medication and additional dietary interventions.

PROJECT NO. 6:

Take the following quiz to determine if your child is suffering from GI disorder symptoms:

As an infant, did your child have any of the following?

Gastroesophageal Reflux Disease (GERD)	_____ No	_____ Yes
Reflux	_____ No	_____ Yes
Projectile vomiting	_____ No	_____ Yes
Sensitivity to cow’s-milk-based infant formula	_____ No	_____ Yes
Required a special infant formula	_____ No	_____ Yes
Does your child currently have any of the following?
Bloated stomach	_____ No	_____ Yes
Stomach aches	_____ No	_____ Yes
Gaseousness	_____ No	_____ Yes
Chronic constipation	_____ No	_____ Yes
Chronic diarrhea	_____ No	_____ Yes
Loose stools	_____ No	_____ Yes
Rarely has a normal formed stool	_____ No	_____ Yes
Visible undigested food in stool	_____ No	_____ Yes
Does your child have any of the following behavioral issues?
Mealtime tantrums	_____ No	_____ Yes
Consumes a limited variety of foods	_____ No	_____ Yes
Refuses to eat	_____ No	_____ Yes

If you answered “yes” to at least one of the infant and child questions, or if your child has one or more chronic GI symptoms, you should talk to a registered dietitian about basic nutritional interventions that can help.

Next, get a referral to a pediatric gastroenterologist for further testing if your child’s GI symptoms persist after implementing the dietitian’s recommendations.

 

Autism and gastrointestinal disorders often go hand in hand, and GI symptoms can be a major contributing factor to your child’s behavioral issues, feeding problems, and other autistic symptoms. Identifying and treating undiagnosed GI disorders is a critical part of treating your child’s autism. Once you’ve completed Step 6, you should see a significant improvement in your child’s autistic symptoms. If your child suffers from a food allergy, sensitivity, or intolerance, Step 7 will show you exactly how to identify and eliminate any foods that are creating a problem.