PRACTICE APPLICATIONS

Topics of Professional Interest

Nutrition Management of Gastrointestinal

Symptoms in Children with Autism Spectrum
Disorder: Guideline from an Expert Panel

UTISM SPECTRUM DISORDER

(ASD) is characterized by a
core decit in social communication with concomitant
repetitive/perseverative behaviors and
restriction in interests,1 and individuals
with ASD experience varying degrees
of impairment.2 The estimated prevalence of ASD in pediatric populations
has climbed dramatically during the
past decade, with approximately 1 in
every 68 children currently meeting
diagnostic criteria in the United States.3
High prevalence occurs against a
backdrop of increased health care
costs 4 and social burden. 5 Medical

This article was written by Rashelle C.

Berry, MPH, MS, RD, CSP, lead nutritionist, Pediatric Feeding Disorders
Program, Marcus Autism Center,
Atlanta, GA; Patricia Novak, MPH, RD,
EMPOWER project coordinator, Childrens Hospital of Los Angeles, Los
Angeles, CA; Nicole Withrow, PhD, RD,
assistant professor and dietetic internship coordinator, University of Northern
Colorado, Greeley; Brianne Schmidt,
RD, clinical nutrition specialist, Division
of Neurodevelopmental and Behavioral
Pediatrics, Golisano Childrens Hospital
at Strong, University of Rochester
Medical Center, Rochester, NY; Sheah
Rarback, MS, RD, director of nutrition,
Mailman Center for Child Development,
Miller School of Medicine, University of
Miami, Miami, FL; Sharon Feucht, MA,
RD, nutritionist, Center on Human
Development and Disability, University
of Washington, Seattle; Kristen K.
Criado, PhD, psychologist, Pediatric
Feeding Disorders Program, Marcus
Autism Center, Atlanta, GA, and assistant professor, Department of Pediatrics, Emory University School of
Medicine, Atlanta, GA; and William G.
Sharp, PhD, director, Pediatric Feeding
Disorders Program, Marcus Autism
Center, Atlanta, GA, and assistant professor, Department of Pediatrics, Emory
University School of Medicine, Atlanta,
GA.
http://dx.doi.org/10.1016/j.jand.2015.05.016

2015 by the Academy of Nutrition and Dietetics.

comorbidities are signicantly overrepresented compared with other

pediatric populations, and children
with ASD often present with medical
conditions affecting multiple organ
systems.6 Dysfunction of the gastrointestinal (GI) tract is among the
most frequently cited comorbidities.
A recent meta-analysis indicated that
children with ASD were four times
more likely to experience general
GI complaints, are more than three
times more prone to experience constipation and diarrhea, and complain
twice as frequently about abdominal
pain compared with peers.7 Lack of
data prevented analysis of other
GI symptoms (eg, gastroesophageal
reux, celiac disease, lactose intolerance) typically associated with organic etiologies; however, a 2010
consensus report concluded that, at
a minimum, rates of other GI pathophysiology in ASD should be viewed
as occurring at similar levels to
those observed in the general population.8 This includes consideration of
the potential contribution of factors
such as GI motility, altered gut microbiome, immune abnormalities,
and food allergy when GI symptoms
are detected.7 In addition to calling
for greater research scrutiny in this
area, the expert panel of pediatric
gastroenterologists also emphasized
the need to develop evidence-based
standards for the evaluation and
treatment of GI symptoms in ASD.
Nutrition management is often critical
in the treatment of GI symptoms in other
pediatric populations9,10; however, no
guidelines are available for adapting
existing practices for use among children with ASD. Current standards of care
might be neither practical nor feasible,
given the combination of behavioral,
developmental, medical, and social deficits associated with the condition. For
example, children with ASD often present with limited communication and,

as a result, their symptom presentation

may be unusual compared with that of
their peers.7,8,11,12 In many cases, GI
symptoms might only manifest as a
change in behavior, such as the emergence or exacerbation of problem behaviors like aggression, self-injury, sleep
disturbance, or irritability.7,13 As a result,
recognition and treatment of GI disorders in children with ASD remain
ill-dened and poorly understood,11
particularly when it comes to the challenge of untangling the relative contribution of diet when underlying GI
pathology is suspected.
The diagnostic and intervention process is further complicated by the high
prevalence of feeding problems in ASD.
Evidence suggests children with ASD
have a vefold increase in problematic
eating and feeding behaviors compared
with typically developing peers.14 Food
selectivity, dened as a limited food
repertoire (eg, only eating a few foods
and/or rejection of one or more food
groups) or high intake of a single food,15
is the most frequently documented
feeding issue associated with ASD. Dietary intake in ASD often involves strong
preferences for highly processed foods,
snacks, and sweets,16 and a lower intake
of fruits and vegetables.15,17,18 High intake of simple carbohydrates and fat
coinciding with low intake of ber
complicates the diagnostic process,
making it difcult to determine whether
food selectivity directly contributes to
the onset of GI symptoms or simply exacerbates a preexisting GI condition.19
For example, a child may be constipated due to poor motility as the result
of impaired gastric emptying and/or low
muscle tone, with more severe symptom
presentation in cases involving poor
dietary diversity. Alternatively, constipation could be the direct result of a
diet lacking in fruits, vegetables, and
whole grains and, therefore, low in
ber and uid.7 In both cases, nutrition intervention can improve overall

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PRACTICE APPLICATIONS
symptom presentation, however, a more
detailed medical workup (eg, allergy, GI)
would also be necessary if possible
organic etiology is suspected.
When developing a nutrition intervention, food selectivity may place
limits on introducing and/or removing
foods from the diet. Specically, restricted patterns of intake in ASD are
often maintained by refusal behaviors
(eg, tantrums, aggression) in response to
the presentation of nonpreferred foods
or novel feeding demands.20 As a result,
caregivers may be unable to adhere to
clinical recommendations due to the
intensity of their childs behavioral
response to the new therapeutic diet. In
addition, it may be difcult to anticipate
how a child will respond to efforts to
remove and/or replace preferred foods,
including the possibility of further selfimposed dietary restriction after intervention beyond targeted foods. With
this in mind, the clinician must determine how to best manage the childs
nutrition while considering his or her
overall medical status.
Nutrition management must also account for the proliferation of caregiver-

mediated dietary restrictions in the

ASD community. Children with ASD are
signicantly more likely to be placed
on caregiver-initiated complementary/
alternative diet therapies as compared
to peers.21 Common dietary interventions applied in this population are
listed in Figure 1. In general, these diets
restrict or completely eliminate certain
food groups. For example, the glutenfree, casein-free diet, arguably the
most well-known type of dietary
manipulation in ASD, eliminates gluten
(found in wheat, barley, and rye) and
casein (found in cows milk dairy
products).28 Without the guidance of
a registered dietitian nutritionist (RDN),
this level of restriction may increase
risk of macronutrient and micronutrient
deciencies in a population already
prone for underlying dietary insufciencies related to food selectivity,14
and the potential for further nutritional decits and associated health
concerns presents unique challenges
for designing interventions. When a
caregiver-initiated or other restrictive
diet is in place, the RDN must work with
the family to determine which foods (if

Diet

Foods restricted

Elimination diets/elemental
diet22,23

Elimination diet (6 foods): milk, egg, wheat, soy,

peanuts/tree nuts, sh/shellsh
Elemental: all foods except an amino acid

based formula

Fermentable oligo-dimonosaccharides and

polyols24,25

Foods containing fructose (eg, fruit, highfructose corn syrup), lactose (eg, cows milk
dairy), fructans (eg, wheat, onion, garlic),
galactans (eg, legumes), and polyols (eg,
sorbitol, cherries, avocados)

Food coloring/food additives

avoidance26,27

Foods that contain food color additives (food

dye)

Gluten-free, casein-free28-30

Foods containing gluten (eg, bread, pasta) and

casein (eg, cows milk, yogurt)

Ketogenic diet or modied

Atkins diet31,32

Carbohydrate-rich foods, including sugar

Specic carbohydrate
diet29,33,34

Cereal grains (eg, wheat, oats, rice), processed

meats (eg, lunch meats, hot dogs), canned
vegetables, canned fruits, most fruit juices, soy
beans, chick peas, bean sprouts, mung beans,
fava beans, yogurt, milk, processed cheese,
tubers (eg, potatoes, yams), curry, onion
powder, garlic powder

Figure 1. Possible caregiver-initiated restrictions in autism spectrum disorder (in

alphabetical order).
2

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

any) can be added, removed, and/or

reintroduced to alleviate GI concerns,
while concurrently attempting to best
meet nutrition needs. Many caregivers,
however, may be resistant to incorporate recommendations that involve the
reintroduction of currently restricted
foods. If specic foods previously
removed place the child at nutrition risk
and cannot be reintroduced, appropriate substitutions need to be identied; although this may be difcult in
cases involving extremely limited food
repertoires and resistance to the introduction of new foods.
The unique dietary, medical, and
behavioral challenges observed in
children with ASD combined with an
overall lack of data on management of
GI disorders in this population11 presents a pressing need to develop a
guideline for nutrition intervention.
Consistent with previous work to
develop standards of care in ASD,11
expert opinion was viewed as a critical rst step in this process, given the
absence of relevant data. Therefore, a
committee of RDNs specializing in the
nutrition care of children with ASD was
formed and a focus group was conducted to develop a clinical practice
guideline. This article describes the
process of convening the expert committee, outlines considerations for
adapting existing nutrition practice,
and presents a guideline for the nutrition management of GI symptoms in
children with ASD.

FOCUS GROUP MEETING AND

ALGORITHM DEVELOPMENT
The rst step toward creating a standard of care for RDNs to use when
working with children with GI symptoms and ASD involved identifying experts in the eld. Our search process
consisted of contacting major autism
treatment centers in the United States,
listserv solicitation through the Autism
Speaks Autism Treatment Network,
and comprehensive review of the
literature. The selection criteria
required committee members to be
certied as an RDN; spend at least 25%
of professional time engaged in clinical
nutrition activities (assessment and/or
treatment) with children with ASD;
have practiced in the eld of nutrition
for at least 3 years; and possess experience (past or current) working in a
multidisciplinary environment (eg,
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PRACTICE APPLICATIONS
medical or research center, feeding
clinic). The nal six-member committee (authors Berry, Novak, Withrow,
Schmidt, Rarback, and Feucht) has a
combined 125 years of clinical experience working in the eld of nutrition
and with children with ASD.
Once identied, the expert panel
assembled for a focus group in August
2014. A trained facilitator moderated
the meeting using a semi-structured
interview guide to elicit information
about nutrition management of GI
symptoms in this population. The
committee subsequently used this information to develop clinical practice
recommendations for conditions in
which nutrition management is clinically indicated based on established
models of care.35 Available guidelines
and algorithms for constipation management in children11,35 served as templates for an ASD-specic algorithm and
accompanying text. The Pediatric Nutrition Care Manual,9 which provides
evidence-based practice guidelines for
pediatric RDNs working in a variety of
clinical settings, also informed the
development process. To ensure relevant evidence was not omitted from the
algorithm, comprehensive literature reviews regarding GI concerns,7 prevalence of feeding problems,14 and
treatment of feeding disorders36 in ASD
were reviewed for additional data.

DESCRIPTION OF THE
ALGORITHM
Evaluation and intervention recommendations were designed to assist
clinicians with navigating potential
barriers associated with food selectivity,
caregiver-initiated complementary/alternative diet therapies, and/or nutritional decits/excesses often observed
in this population.14,37 The committee
also emphasized the importance of a
multidisciplinary
approach
during
assessment and intervention to elucidate the causal relationship between
nutritional intake and possible organic
etiology, as well as provide complementary treatment avenues in cases
involving severe food selectivity and/or
lack of response to dietary intervention.
This included coordinating care with
input from medicine, behavioral psychology, occupational therapy, and
speech-language pathology.38 Finally,
the committee highlighted the need to
consider a childs possible behavioral
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response (eg, tantrums, aggression) to

changes in mealtime routine (eg,
introduction of novel or non-preferred
feeding demands) when planning an
intervention.
The derived algorithm describes 11
steps in nutrition evaluation and
management of GI concerns in children
with ASD to guide development and
application of a prescriptive diet
(Figure 2). A smooth-edged box represents a starting or ending point, a diamond shape indicates a question or
decision, and a sharp-edged box corresponds to specic action or process
undertaken by the clinician. Each shape
is assigned a number that corresponds
to accompanying text providing further
detail (Figure 3). The algorithm begins
with development of a prescriptive diet
to alleviate GI dysfunction, which involves identifying potential barriers (ie,
food selectivity, caregiver-initiated restrictions, gaps in knowledge) that
would limit possible therapeutic foods.
In cases involving dietary restriction
(either child- or caregiver-mediated),
the RDN must determine whether
there is enough exibility within the
diet to develop an intervention. If foods
are available, the prescriptive diet involves working within the connes of
dietary restriction to increase daily
servings of target foods and/or
concurrently reduce intake of highly
preferred food items (eg, crackers,
chips). In cases involving severe food
selectivity (ie, eating fewer than six
different food items), nutrition therapy
should occur concurrently with feeding
therapy. During the assessment process, the RDN can help to identify safe
foods as well as determine which foods
might be causing the child pain and
should therefore be avoided. Feeding
therapy focuses on acceptance and
increased (or decreased) intake of targeted foods for the dietary intervention.20,39 Greater exibility with meal
planning is possible for cases in which
a family is willing to consider modications to previously recommended
and/or implemented diets. In such
cases, the RDN has a greater palette of
foods available with which to create a
prescription diet to address GI symptoms consistent with medical nutrition
therapy guidelines.9 With this said,
insistence on sameness and behavioral
rigidity are core features of ASD1 and
the possibility of a reaction to the
therapeutic diet should be considered

throughout the assessment and treatment process. If a strong reaction is

anticipated, caregivers are resistant to
or are unwilling to modify or discontinue a current dietary treatment (eg,
gluten-free, casein-free), and/or no
foods can be identied for intervention,
alternative medical strategies should
be considered in consultation with a
pediatric gastroenterologist.
The algorithm also involves determining whether there are remaining
gaps in the diet that need to be targeted by feeding intervention and/or
the use of nutrition supplementation
before arranging follow-up care. Supplementation in the form of vitamins
and/or minerals, in cases of micronutrient decits, or nutritionally complete drinks, in cases of energy decits
and/or macronutrient decits in addition to micronutrient decits, may be
indicated if the child is not able to
consume a nutritionally complete diet
using food alone. This may be due to
caregiver restriction or medically indicated elimination (ie, allergy/intolerance). Consistent with nutrition
therapy in the general population, this
should include use of elemental formula when medically suggested for
conditions such as eosinophilic esophagitis (EoE), milk-protein intolerance,
and multiple food allergies. The use of
supplementation should also be
considered if the current diet does not
meet nutrition needs due to food
selectivity, while concurrently referring to feeding therapy. As noted in the
algorithm (Figure 3), the nutrition
assessment should include screening
for food intolerances, food allergies,
and foods causing GI discomfort.
Finally, to help practitioners apply this
approach in the community setting and
support future evaluation of the algorithm, descriptions on the application
of the model with constipation and EoE
were completed (Figure 4). Constipation was selected because it is one
of the most common GI disorders
among children with ASD7,11; EoE was
chosen as an example due to established evidence regarding dietary
intervention as a treatment for this GI
disorder.40

IMPLICATIONS FOR CLINICAL

PRACTICE
Greater risk of general GI symptoms
among children with ASD is well

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JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Food selectivity a
concern?
2

Caregiver initiated
diet in place?

No

Gaps in caregiver
knowledge?

No
3

No
4

Provider works to identify

barriers to diet recs
4a

Yes

Yes

Yes
Caregiver willing to
adjust diet?
3a

RD identifies barriers to meeting

appropriate volume of target foods

Provider works to
identify foods within diet
restrictions

No

3b

2a
Yes
Foods within existing
repertoire?
2b

Barriers within scope

of practice?
4b

Yes
No
Foods within existing
repertoire?
3c

Yes
Yes

RD counsels family on treatment

approach: Readjust diet to involve
rec volume of target foods

RD counsels family on treatment

approach: Increase or decrease
volume of select target foods
5

No
RD assess possible nutrition
concerns (Box 9) and refers to
appropriate medical intervention
(Box 11)
3d

Diet nutritionally
adequate?

RD refers to appropriate
behavioral (Box 8) medical
intervention (Box 11)
4c

No

--

Referral to behavioral intervention

specialist to address food
selectivity/meal structure

No

No

Yes

Consider supplementation (e.g.,

nutritionally complete drink)

2015 Volume

Arrange follow-up to meet treatment goals

10

Number

Adjust nutritional recommendations (if applicable) AND

GI consult to identify red flags or medical alternatives
11

No

Treatment
reduces/eliminates
symptoms?
10

Yes

Figure 2. Algorithm for nutrition management of gastrointestinal concerns in children with autism spectrum disorder.

Continue Therapy/Arrange long term follow-up

10

PRACTICE APPLICATIONS

Suspected or confirmed GI problem and nutrition

intervention clinically indicated, begin with nutrition
assessment
1

PRACTICE APPLICATIONS
Box

Details

Full nutrition assessment after referral to address GI symptoms. In addition to a standard assessment (ie, food intake
analysis, anthropometrics, labs), assessment should include detailed discussion and identication of potential foods that
may be causing an adverse reaction in the child. This includes assessment of known food allergies, as well as evaluation
of risk for additional food allergies, food intolerances (ie, lactose intolerance), and other potential adverse reactions to
foods (ie, celiac disease).

Food selectivity is present if child has a limited food repertoire, high-frequency consumption of a few foods, and
signicant problem behaviors, including, but not limited to crying, leaving the meal, gagging, aggressing, and/or
vomiting when nonpreferred foods are presented.

2a

Full assessment of dietary repertoire, including detailed examination of foods accepted by major food group (fruits,
vegetables, meats/beans, dairy, grains).
 Include questions to determine the volume and frequency of intake.
 Assess responses to changes in meal routines, such as environment, temperature, method of presentation, and
food type/texture presented.

2b

Current list of accepted foods evaluated to determine if consistent with proposed medical nutrition therapy guidelines.

Caregiver-initiated diet includes alternative diet therapies (eg, gluten-free, casein-free) and medically prescribed diets
(eg, hypoallergenic).

3a

Discuss with caregiver acceptability and ability to veer from current dietary plan. This precludes medically indicated
diets based on underlying organic pathology (eg, celiac disease, food allergy).

3b

Full assessment of acceptable foods within dietary restrictions, including detailed examination of foods accepted by
major food group (fruits, vegetables, meats/beans, dairy, grains).
 Include questions to determine the volume and frequency of intake.
 Assess behavioral response to changes in meal routines, such environment, temperature, method of presentation, and food presented.
 Consider how dietary changes will impact development and social inclusion.

3c

Clinician works to nd foods that are congruent with dietary repertoire and will meet medical nutrition therapy
guidelines for GI symptoms.

3d

If nutrition intervention is not possible based on restrictions, a two-pronged approach is warranted:

 Assess for any nutritional insufciencies and whether supplementation is indicated.
 Determine the most effective method to assure formula acceptance.
 Refer to medical provider to consider alternative treatment approaches.

No level of dietary restriction (food selectivity or caregiver-initiated) identied. Caregiver and child will be able to follow
recommendations as outlined by registered dietitian nutritionist.

4a

Typical nutrition assessment of factors inuencing nutritional status, such as meal planning, food security, and ability to
prepare food. Additional barriers to consider can include the childs general behavior, sensory processing, cognitive
development, communication skills, oral health and motor planning, family socioeconomic circumstances, and
community support and resources.

4b

Assess whether barriers fall within the scope of dietetics. Concerns falling outside of scope include need for parent
training to address disruptive behavior, motor dysfunction, sensory concerns, and/or possible neglect.

4c

If nutrition intervention is not possible based on restrictions, a two-pronged approach is warranted:

 Refer to feeding team.
 Refer to medical provider to consider alternative treatment approaches (including nonoral feeds, if indicated).

Treatment approach involves using only preferred foods to create a prescription diet to address GI concerns. Volumes of
foods typically presented might be adjusted to meet treatment needs.
(continued on next page)

Figure 3. Accompanying text for algorithm for nutrition management of gastrointestinal concerns in children with autism spectrum
disorder.

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PRACTICE APPLICATIONS
Box

Details

Treatment approach involves developing meal plan to address GI concerns in line with medical nutrition therapy
guidelines. While consideration should be given to possible behavioral response to changes related to autism spectrum
disorders, greater exibility in treatment planning is possible due to lack of caregiver restriction.

Re-evaluation of diet, growth, and weight change occurs after prescription has been provided. This might include
dietary analysis using dietary recall or food intake records. Labs can be ordered if there is continued concern of dietary
insufciencies. Goal to assure overall nutrition planning with optimal energy and nutrient intake.

Referral to a feeding therapist is indicated if prescribed diet is not able to be followed due to mealtime difculties with
the introduction of nonpreferred foods or if general behavior-management during meals is needed due to changes in
meal routines.

Nutrition supplementation (vitamins, minerals, and/or nutritionally complete drink) is indicated if current diet does not
meet nutrition needs or if the level of dietary restriction needed (ie, allergies, GI concerns) does not allow for optimal
intake from foods alone.

10

Follow up includes reassessment of growth, nutrition, and alleviation of GI symptoms

11

Provider works to adjust nutrition recommendations to alleviate GI symptoms. If recommended diet is ineffective,
provider should refer back to physician to determine medical alternatives.

Figure 3. (continued) Accompanying text for algorithm for nutrition management of gastrointestinal concerns in children with
autism spectrum disorder.

documented, yet much remains unknown regarding the recognition and

treatment of these concerns due to lack
of conclusive research on this topic.7,8
Dietary modication often plays a
central role in managing GI symptoms
in pediatric populations, as highlighted
by a recent guideline for treating constipation in children with ASD.11 Clinical experience and review of the
literature, however, suggest that
high prevalence of food selectivity
combined with frequent use of
caregiver-initiated dietary restrictions
necessitates modications to existing
practice. By combining data from clinical expertise and the extant literature,
an expert committee established an
algorithm for applying evidence-based
nutrition practice guidelines9 to the
evaluation and management of GI
symptoms in ASD. In doing so, the
project represents a critical rst step
toward developing standards of care
that take into consideration the unique
combination of dietary restriction and
related medical/nutrition concerns in
this population.14
As emphasized by the algorithm,
nutrition management in ASD should
involve a tiered approach. This involves
rst identifying and working through
barriers that might impede the development of a prescriptive diet (eg, food
selectivity) targeting GI concerns, followed by a more general focus on
6

assuring that all nutrition-related concerns are evaluated and addressed

during the course of intervention.
Multidisciplinary collaboration in the
evaluation and treatment process is
also recommended, including coordinating care with a pediatric gastroenterologist, as well as involvement of
feeding therapy in cases where severe
food selectivity and/or behavior management during meals falls outside the
RDNs scope of practice. At this time,
behavioral intervention is the only
treatment for severe food selectivity in
ASD with well-established empirical
support,36,39 yet treatment must also
consider factors inuencing eating,
such as GI discomfort, food allergies,
sensory processing, and oral-motor
skills, during assessment and intervention to maximize effectiveness.38
Finally, RDNs should assess a childs
possible behavioral response (eg, tantrums, aggression) to change in the
meal, a consideration that should be
foremost in the minds of clinicians
when planning intervention, given the
ubiquity of feeding problems in this
population.14
A practice guideline of this nature
reects a more general need to further
elucidate the role of nutrition management in ASD. Diet and ASD are
frequently linked due to the prevalence
of food selectivity, frequent use of diet as
a complementary/alternative treatment

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

avenue in this population, and an

increased incidence of GI symptoms. In
addition, food selectivity increases the
risk of nutrition and/or medical concerns in ASD, including signicant specic decits (eg, lower intake of calcium
and protein) and a higher number of
overall nutritional decits.14 This risk,
however, may go undetected in pediatric settings without a detailed examination of nutrient intake because it does
not necessarily translate into compromised growth or decreased energy
intake, which typically trigger attention
in pediatric settings.7 Evidence indicates
that excessive consumption of processed snacks and calorie-dense foods is
associated with overweight and obesity,
which, in turn, is associated with
increased prevalence of diet-related
diseases (eg, obesity, cardiovascular
disease) in both children and adults.
Children with ASD experience obesity at
higher rates compared to peers.41,42 A
recent large-scale chart review suggests
this trend extends into adulthood.43
When compared to typically developing peers, adults with ASD experienced a 69% higher incidence of obesity,
42% greater risk of hypertension, and
50% increase in diabetes. This highlights
the need to enhance involvement
of RDNs in the broader diagnostic and
treatment process, which would necessitate more denitive guidance regarding the timing and scope of
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PRACTICE APPLICATIONS
Condition

Nutrition Treatment

Autism Spectrum DisorderLSpecic Considerations

(Algorithm Box)

Constipation

Increase uid and ber in the diet (fruit,

vegetables, whole grains)

Will the child eat fruits, vegetables, and whole grains (2)?
If yes, are there enough accepted foods in the diet to create a
nutritionally adequate diet (7)?
If no, should the child be referred to feeding therapy (8)?
Are some whole-grain products restricted by caregivers (3)?
Is the caregiver open to adding whole-grain products to the
diet (3a)?
Are there other sources of ber in the childs diet (3c)?
Does the caregiver know to offer fruits, vegetables, and whole
grains (4)?

Daily physical activity

Does the child resist activity (4a)?

Does the child have motor-planning concerns that require a
specialist to determine physical activity options (4b)?

Add a bulk-forming agent/prebiotic/

probiotic to childs daily regimen

Will the child take the supplement (2)?

Does adding the supplement to food or drink increase the risk
of refusal (2a)?

Correct nutritional deciencies

Will the child eat the foods identied to correct nutritional

deciencies (2b)?
Is the child only eating pureed foods due to difculties
swallowing? Are these foods commercially prepared infant
foods (2)?
Is the RDNa able to create a nutritionally complete diet given
this selectivity (7)?
Will the child eat appropriate volumes of less preferred foods
to meet nutrition needs (5)?

Eliminate allergens in the diet

Are there enough foods in the childs repertoire once allergens

have been eliminated (2b)?
Is the allergen-free diet in conict with a caregiver-initiated
diet (3)?
Does the child need a supplement due to number of allergens
(9) and will the child accept the supplement (2)?

Counsel on elimination diet

Are there enough foods in the childs repertoire once allergens

have been eliminated (2b)?
Will the child need to participate in feeding therapy to
consume enough foods to create a nutritionally complete
diet (8)?
Should supplementation be considered, given diet
inadequacies (9)?

Eosinophilic
esophagitis

RDNregistered dietitian nutritionist.

Figure 4. Practical application of nutrition-management algorithm for gastrointestinal symptoms in autism spectrum disorder with
constipation and eosinophilic esophagitis.

involvement (possibly in a manner

similar to the current algorithm) in order to maximize the contribution and
subsequent benet of nutrition management in ASD.
Finally, recommendations were designed to provide clinicians with a
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general roadmap for nutrition intervention in ASD vs a model for counseling caregivers on the merits and
risks of elimination diets. Clinicians,
however, will likely encounter this
topic in practice, particularly when
making inquiries about the use of and

possible deviation from caregiverinitiated

complementary/alternative
diet therapies. With this in mind, an
overarching consideration for nutrition
management in ASD is to assure
a healthy and well-balanced diet.
In general, complementary/alternative

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PRACTICE APPLICATIONS
diets target core features of ASD (ie,
impairments in social communication,
restriction in interests, and repetitive
behaviors) as opposed to treating underlying GI concerns.44 Many different
dietary treatments have been proposed
to treat ASD, yet empirical investigation has not substantiated the use of
dietary manipulation as an ASDfocused treatment.28 Without RDN
guidance, the associated risks of these
diets may outweigh the benets. For
example, provisional evidence suggests
that use of a gluten-free, casein-free
diet can lead to greater decits in bone
development among children with
ASD.45,46 Despite the lack of evidence
on the effectiveness of dietary intervention
to inuence behavioral
expression of ASD, Elder and colleagues28 report that parents chose to
continue with the diet after study
conclusion due to perceived benet,
reinforcing the importance of nutrition
management to assure a childs diet is
nutritionally adequate.

assessment and intervention. These

limitations accentuate the need to
enhance our knowledge regarding
assessment of GI symptoms and disorders in ASD,7 including factors guiding
preference and response to novel
feeding demands in this population.14
With this in mind, this project represents an important rst step toward
developing and evaluating nutritionmanagement strategies specically
tailored to the distinct dietary challenges in this population. A detailed algorithm is provided for clinicians in the
hope of accelerating adoption of practice recommendations. Moving forward,
greater clinical and research scrutiny is
needed to increase awareness on this
topic and support development of the
best standards of care.

11.

Furuta GT, Williams K, Kooros K, Kaul A,

Panzer R, Coury D, Fuchs D. Management
of constipation in children and adolescents with autism spectrum disorders.
Pediatrics. 2012;130(suppl 2):S98-S105.

12.

Graf-Myles J, Farmer C, Thrum A. Dietary

adequacy of children with autism
compared with controls and the impact of
the restricted diet. J Dev Behav Pediatr.
2013;34(7):449-459.

13.

Chaidez V, Hanse RL, Herz-Piccioto I.

Gastrointestinal problems in children
with autism, developmental delays, or
typical development. J Autism Dev Disord.
2014;44(5):1117-1127.

14.

Sharp WG, Berry RC, McCracken C, et al.

Feeding problems and nutrient intake in
children with autism spectrum disorders:
A meta-analysis and comprehensive review of the literature. J Autism Dev Disord.
2013;43(9):2159-2173.

15.

Bandini LG, Anderson SE, Curtin C, et al.

Food selectivity in children with autism
spectrum disorders and typically developing children. J Pediatr. 2010;157(2):
259-264.

16.

Schmitt L, Heiss CJ, Campdell E.

A comparison of nutrient intake and
eating behaviors of boys with and
without autism. Topics in Clin Nutr.
2008;23(1):23-31.

17.

Lukens CT, Linscheid TR. Development

and validation of an inventory to assess
mealtime behavior problems in children
with autism. J Autism Dev Disord.
2008;38(2):342-352.

18.

Martins Y, Young RL, Robson DC. Feeding

and eating behaviors in children with
autism and typically developing children.
J Autism Dev Disord. 2008;38(10):18781887.

19.

Slavin JL. Position of the American Dietetic Association: Health implications of

dietary ber. J Am Diet Assoc.
2008;108(10):1716-1731.

20.

Sharp WG, Jaquess DL, Morton JF,

Miles AG. A retrospective chart review of
dietary diversity and feeding behavior of
children with autism spectrum disorder
before and after admission to a day
treatment program. Focus Autism Other
Dev Disabil. 2011;26(1):37-48.

21.

Kirby M, Danner E. Nutritional deciencies in children on restricted diets.

Pediatr Clin N Am. 2009;56(5):1085-1103.

22.

McElhanon BO, McCracken C, Karpen S,

Sharp WG. Gastrointestinal symptoms in
autism spectrum disorders: A meta-analysis. Pediatrics. 2014;133(5):872-883.

Jyonouchi H. Food allergy and autism

spectrum disorders: Is there a link? Curr
Allergy Asthma Rep. 2009;9(3):194-201.

23.

Buie T, Campbell DB, Fuchs GJ III, et al.

Evaluation, diagnosis, and treatment of
gastrointestinal disorders in individuals
with ASDs: A consensus report. Pediatrics.
2010;125(suppl 1):S1-S18.

de Theije CG, Bavelaar BM, Lopes da

Silva S, et al. Food allergy and food-based
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24.

Nutrition Care Manual. Gastrointestinal

diseases. http://www.nutritioncaremanual.
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Gibson PR, Muir JG. Non-nutritional effects of food: An underutilized and

understudied therapeutic tool in chronic
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25.

Halmos EP, Power VA, Shepherd SJ,

Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable
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2014;146(1):67-75.e5.

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FUTURE DIRECTIONS
The use of the algorithm proposed here
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exacerbating potential nutrient decits
due to behavioral feeding concerns and
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promote optimal growth and development. Development of recommendations was based on expert opinion and
clinical experience due to lack of
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DISCLOSURES
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conict of interest was reported by the authors.

FUNDING/SUPPORT
This work was supported by a 2014 Education Grant from Nutricia North America.

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