NHD Paediatric Hub

Autism: risks, concerns and mealtime strategies

Autism, or autistic spectrum disorder (ASD), is a lifelong neurological condition that manifests in childhood. The incidence of autism has increased significantly over the last 20 years and it is now estimated that one in every 100 people will have a diagnosis of autism. (1)

Autism presents with a variety of symptoms. Individuals can be affected by cognitive or sensory difficulties; they may have difficulties communicating and some individuals with autism may struggle with social interaction.

Children with autism may struggle with dietary intake for a variety of reasons. Whilst some of these children may struggle to gain adequate weight, the majority appear to grow well. However, of more concern is the micronutrient status of these children. Children with autism are often sensitive to light, touch, sound, smell, temperature and taste. All of these factors may influence the food that they eat.

Over the years, there have been dietary theories analysed to see if they can have a positive impact on an individual with autism. Examples of these include a gluten- and casein-free diet or the ketogenic diet. Current evidence tells us that these diets do not influence the symptoms of a person with autism and merely limit their diet further. There are no associated positive outcomes and these diets should not be recommended. (2)

Due to the sensory issues around food, children with autism often develop a preference for food textures, brands and the appearance of food. Children with autism will often want plainer foods and want food presented in the same way. Children with autism usually prefer foods that they know will taste the same on each exposure; therefore, they may have a preference for crisps, biscuits, white bread, etc, and be less keen on foods such as fruit or vegetables or food mixed with sauces where the taste and feel could change depending on the ripeness of the food or the volume of sauce mixed with it. (2,3)

MONITORING INTAKE AND GROWTH

Dietetic concerns: adequate calories

Children with autism often have limited diets, but the majority of children and young people will have an adequate intake of calories. This means that growth is often acceptable, with children tracking appropriate centile lines.

Dietetic concerns: micronutrients

Children with autism and restricted diets are often at an increased risk of micronutrient deficiencies. As their diets often focus on processed foods the availability of micronutrients in these foods is often poor. Micronutrient deficiency can have significant morbidity and will lead to increase investigations and potential trauma for the young person due to blood testing. The incidence of micronutrient deficiency in this patient group is unknown.

In the literature there are multiple case reports of micronutrient deficiency of the following:

  • Vitamin A deficiency, which can cause issues with eye sight and eye health
  • Vitamin C deficiency, which can cause issues with scurvy (delayed wound healing and bleeding gums)
  • Vitamin D deficiency, which can cause an increased risk of rickets and poor bone health
  • Iron deficiency, which can lead to iron deficiency anaemia
  • Calcium deficiency, which can lead to bone mineral issues

As the diet is limited, the families and young person are often restricted as to the changes they can make and, therefore, micronutrient supplements may need to be considered to prevent deficiencies.

MEALTIME ADVICE

Simple mealtime advice may not be beneficial for families of a young person with ASD. Due to the complexities and behaviours associated with ASD, the families are unlikely to be able to make many changes to the environment that will positively impact the young person’s oral intake. Some mealtime suggestions are listed below, which families may find useful/reassuring to help support them.

Mealtime strategies

  • Try to keep mealtimes enjoyable and relaxed.
  • Set a regular mealtime, including a maximum length of time for meals.
  • Provide sensible portions.
  • Ensure a consistent approach to mealtimes from family members and other care givers.
  • Involve the young person in meal preparation if possible.
  • Positive reinforcement – recognise progress made even if it’s not as much as a parent would like (i.e. licking new food is significant progress even if unable to eat the rest of the food).

Messy play strategies

  • Use books and cards to educate the young person around our body and nutrients to empower them to understand the importance of good nutrition.
  • Avoid force feeding or hiding foods.
  • Avoid giving too many options.
  • Avoid pressure to eat.
  • Avoid grazing through the day and ensure liquid volumes are kept to an acceptable level around mealtimes.
  • Avoid reacting negatively if food is spat out – this may be significant progress.

FOOD CHAINING

Food chaining is a strategy used to expand the variety of foods that a child or young person eats by starting with foods that are well tolerated and making small changes to these foods over time. (3) With the slow introduction of new foods and small changes, the hope is that the changes are tolerated better in an environment where the child feels safe without the experience being overstimulating or making them anxious.

Food chaining is an exposure process that is flexible and adaptable to the needs of each child. It should be done at the pace of the child, with it often taking a prolonged period of time to make a small change and parents should be made aware of this at the start of the process.

To begin food chaining, the first step is to determine the list of foods currently accepted by your child then you would make small changes to one specific food – this may be serving the food a different colour, different temperature or different shape. Once the new formation is accepted, you continue to make small changes to widen the variety.

It has been recognised that it will take the child around 25-30 tastes of a new food to determine acceptance, so they should be encouraged to try it more than once.

It may be that the first step of the process is to allow the new food to be on their plate with familiar food and then to smell it, lick it, bite it and spit it out before finally eating it successfully – all small steps of progress should be recognised.

CONCLUSION

Children and young people with autism often have restricted diets. Whilst they have adequate calories, the micronutrient content is often poor. This results in these young people being at increased risk of deficiencies. Mealtime strategies can be adopted to try and improve oral intake and some children and young people may respond to food chaining strategies. Parents require support to implement the strategies and often require reassurance regarding dietary intake.

Instagram: kidsnutritionrd
Website: www.kids-nutrition.com

Hazel Duncan, RD

Paediatric Dietitian, Kids Nutrition

References

  1. Ginny Russell, Sal Stapley, Tamsin Newlove-Delgado, Andrew Salmon, Rhianna White, Fiona Warren, Anita Pearson, Tamsin Ford (2021) Time trends in autism diagnosis over 20 years: a UK population-based cohort study. The Journal of Child Psychology & Psychiatry 63 (6) 674-682
  2. Arija V, Esteban-Figuerola P, Morales-Hidalgo P, Jardi C and Canals-San J (2023) Nutrient intake and adequacy in children with autism spectrum disorder: EPINED epidemiological study.  Autism 27(2) 371-388
  3. Esposito M, Mirizzi P, Fadda R, Pirollo C, Ricciardi O, Mazza M and Valenti M (2023) Food Selectivity in Children with autism: Guidelines for Assessment and Clinical Interventions. International Journal of Environmental Research and Public Heath 20, 5092

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