Recommendations for Treating GI Tract Symptoms in Children With Autism Issued

Pauline Anderson

January 04, 2010

January 4, 2010 — In the absence of evidence-based guidelines specific to children with autism spectrum disorder (ASD), clinicians can use new expert opinion recommendations for the identification and treatment of gastrointestinal (GI) tract disorders in this patient population.

The recommendations are published in the January 2010 issue of Pediatrics.

It can be challenging for clinicians to determine the source of GI tract disorders in children with ASD. These youngsters may have trouble communicating information about symptoms. They may also be unable to follow instructions for certain procedures (eg, drinking barium to determine the source of gastroesophageal reflux symptoms, or fasting overnight for a lactose breath test).

For this article, 8 pediatric gastroenterologists reviewed published guidelines for the management of GI tract symptoms that occur frequently in the general pediatric population. On the basis of their clinical experience, they then adapted current best practices to the diagnostic evaluation and treatment of children with ASDs.

The prevalence of GI tract symptoms in children with ASD is reported to range from 9% to 70% or higher.

Recommendations for Various GI Tract Disorders

The recommendations pertain to chronic abdominal pain (intermittent or constant abdominal pain that lasts more than 1 or 2 months), chronic constipation (delay or difficulty in defecation for approximately 2 weeks), chronic diarrhea (loose stool persisting for at least 2 weeks), and symptoms of gastroesophageal reflux disease (passage of gastric contents into the esophagus). The study authors provide information on differential diagnosis, evaluation, and treatment considerations for these GI tract conditions.

Primary care clinicians can use these recommendations as a "guide" when evaluating a child with ASD who presents with symptoms and/or signs that suggest abdominal distress.

Clinicians should be alert to behavioral manifestations of GI tract disorders in patients with ASDs who may have impaired language skills, the study authors state. These children might indicate the presence of GI tract discomfort by, for example, pressing on their abdomen or exhibiting self-injurious behavior.

Thorough History and Physical Examination, Tests

The diagnostic evaluation of GI tract symptoms begins with a thorough medical history and physical examination, noting that the expression of disease can be as diverse in children with ASDs as in the general pediatric population.

"Information from the medical history, including the presence of red-flag findings, the characterization or definition of a problem (as for chronic constipation), and the age of symptom onset (as for chronic diarrhea), can clarify the clinical picture and help determine the need for further evaluation," the study authors write.

In cases of constipation, every attempt should be made to examine the rectum, although at times this might not be possible. "The rectal examination enables assessment of stool retention, anal tone, and occult mass, as well as the presence or absence of blood and helps to reassure the family that their child's anatomy is normal," they write.

For chronic diarrhea, the study authors note that the causes of this condition could include functional disorders, malabsorption syndromes, and inflammatory bowel disease. Determining the presence of lactose intolerance (which requires a strict lactose elimination diet) may be difficult in children in whom food choices are limited, they said.

All children with an ASD and GI tract symptoms should be assessed for celiac disease, the authors suggest. Clinicians should also consider testing for celiac disease in children receiving a gluten-free diet when gluten is reintroduced.

Because many tests are not feasible for patients who are unable to cooperate, the authors suggest that multiple diagnostic tests be performed during a single examination with the patient under anesthesia.

The new recommendations do not replace clinical guidelines. However, they may be used until well-designed trials produce an evidence base for optimal diagnostic and treatment strategies to manage GI tract disorders in children with ASDs, the authors note.

Harland Winter, MD, has consulting agreements with AstraZeneca; P&G; Salix Pharmaceuticals, Ltd; Takeda Pharmaceuticals North America, Inc; and UCB Inc Pharma and has received research grants from AstraZeneca; Centocor, Inc; P&G; Nutricia North America Inc; SHS; Takeda Pharmaceuticals North America, Inc; UCB Pharma; and Wyeth Pharmaceuticals. The Autism Forum provided honoraria to all authors.

Pediatrics. 2010;125:S19-S29.

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