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www.pediatrics.org/cgi/doi/10.1542/peds.2009-2391
doi:10.1542/peds.2009-2391
Accepted for publication Apr 27, 2010
Address correspondence to Jean Golding, PhD, Centre for Child
and Adolescent Health, Barley House, Oakeld Grove, Bristol BS8
2BN, United Kingdom. E-mail: jean.golding@bristol.ac.uk
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
abstract
OBJECTIVE: To investigate the feeding, diet and growth of young children with autism spectrum disorders (ASD).
METHOD: Data on feeding and food frequency were collected by questionnaires completed at 6, 15, 24, 38 and 54 months by participants in
the Avon Longitudinal Study of Parents and Children. A food variety
score was created, and the content of the diet was calculated at 38 m.
The feeding and dietary patterns of 79 children with ASD were compared with 12 901 controls.
RESULTS: The median ages of ASD children were 28 months at referral
and 45 months at diagnosis. ASD infants showed late introduction of
solids after 6 months (p .004) and were described as slow feeders
at 6 months (p .04). From 1554 months ASD children were consistently reported to be difcult to feed (p .001) and very choosy
(p .001). From 15 months, the ASD group had a less varied diet than
controls, were more likely to have different meals from their mother
from 24 months, and by 54 months 8% of ASD children were taking a
special diet for allergy.
ASD children consumed less vegetables, salad and fresh fruit, but also
less sweets and zzy drinks. At 38 months intakes of energy, total fat,
carbohydrate and protein were similar, but the ASD group consumed
less vitamins C (p .02) and D (p .003). There were no differences in
weight, height or BMI at 18 months and 7 years, or in hemoglobin
concentrations at 7 years.
CONCLUSIONS: ASD children showed feeding symptoms from infancy
and had a less varied diet from 15 months, but energy intake and
growth were not impaired. Pediatrics 2010;126:e337e342
e337
METHODS
The Avon Longitudinal Study of Parents
and Children (ALSPAC) is a longitudinal
cohort study that follows the health
and development of children who had
an expected date of delivery between
April 1991 and December 1992 and resided in the Avon area of southwest
England at the time of their birth.
Mothers (n 14 541) enrolled during
pregnancy, and those pregnancies resulted in 14 062 live births, of whom
13 971 survived their rst 5 years.5 Full
e338
EMOND et al
Weight and height measurements collected by health visitors as part of routine preschool-aged child health surveillance were extracted from the Avon
Child Health Computer database. At the
age of 7 years, all children in the
ALSPAC were invited to a special research clinic at which they were
weighed and measured.
Hemoglobin Data
Children who attended the ALSPAC research clinic at 7 years of age had venous blood samples taken for hemoglobin analysis by the HemoCue (L.E.
West, Ltd, Barking, United Kingdom)
method (n 5859).
Statistical Analyses
Logistic regression was used to analyze associations between ASDs and
feeding patterns by using Stata 9.2
(Stata Corp, College Station, TX). Because of the strong association between gender and ASDs (odds ratio
[OR]: 6.40 [95% condence interval
(CI): 3.4212.14]), analyses were adjusted for gender. A linear relationship
was assumed for continuous variables
(food-variety score and dietary intakes). Effect sizes were reported for a
1-SD increase. Categorical variables
(feeding patterns) were dichotomized
according to the worst versus the rest
of the categories. Repeated measures
at different ages were analyzed simultaneously in a combined analysis but,
for clarity, are reported separately. In
these combined analyses, additional
adjustment was made for age, and differences in effects across time were
assessed through an interaction test.
ARTICLES
Slow feeding
1 mo
6 mo
Pooled estimate
Interaction with age
Acceptance of solids
03 mo
4 mo
5 mo
Very difcult to feed
15 mo
24 mo
38 mo
54 mo
Pooled estimate
Interaction with age
Very choosy
15 mo
24 mo
38 mo
54 mo
Pooled estimate
Interaction with age
Pica
38 mo
54 mo
Pooled estimate
Interaction with age
Children With
ASDs, % (n)
Controls, % (n)
OR (95% CI)
47.3 (35)
40.6 (28)
40.0 (4894)
30.7 (3497)
1.35 (0.852.14)
1.66 (1.022.69)
1.49 (1.062.08)
.20
.04
.02
.55
61.8 (42)
29.4 (20)
8.8 (6)
72.8 (8183)
23.2 (2606)
4.0 (451)
0.60 (0.351.03)
1 (reference)
1.93 (0.774.87)
.004
8.1 (6)
15.5 (11)
11.9 (8)
26.2 (17)
3.4 (374)
4.5 (467)
5.1 (515)
10.0 (961)
2.71 (1.166.31)
3.67 (1.917.05)
2.40 (1.145.07)
2.90 (1.665.07)
2.92 (2.084.09)
.02
.001
.02
.001
.001
.86
9.5 (7)
20.0 (14)
28.4 (19)
37.5 (24)
5.4 (595)
9.5 (979)
14.5 (1451)
13.9 (1324)
1.92 (0.874.21)
2.45 (1.364.43)
2.23 (1.303.81)
3.47 (2.085.79)
2.55 (1.913.40)
.10
.003
.003
.001
.001
.54
12.3 (8)
12.5 (8)
2.3 (226)
0.7 (68)
6.09 (2.8513.01)
21.37(9.5947.61)
9.82 (5.6617.03)
.001
.001
.001
.03
Classical autism
Other types of ASDs
b
3.0
Odds ratio
RESULTS
2.5
2.0
DISCUSSION
1.5
1.0
0.5
0.0
6 mo
15 mo
24 mo
38 mo
age
FIGURE 1
Food-variety score and type of ASD (odds ratio
for a 1-SD increase). ap .05, bp .01.
e339
TABLE 2 Dietary Consumption at 38 Months in Children With ASDs Compared With Controls
ASDs (n 64)
Variety score
Energy
Total fat
Protein
Carbohydrates
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.84
0.98
1.01
0.93
0.97
1.482.29
0.771.26
0.791.29
0.721.19
0.761.24
.001
.894
.926
.545
.837
2.25
0.72
0.78
0.69
0.70
1.593.20
0.451.13
0.501.21
0.441.09
0.441.11
.001
.154
.260
.110
.131
1.36
1.14
1.18
1.19
1.08
0.782.36
0.661.97
0.692.04
0.692.07
0.621.89
.279
.638
.542
.531
.782
1.95
0.97
1.00
0.98
0.91
1.292.96
0.601.55
0.631.60
0.611.58
0.561.48
.002
.884
.997
.947
.715
The variety score is derived from 56 food-frequency questionnaire questions and reects the number of times that never was reported. The logistic regression analyses adjusted for
gender. ORs are for a 1-SD increase. Controls: n 9796.
EMOND et al
ARTICLES
cate. Although many parents of children with ASDs do try special diets
for their children, a recent update of
a Cochrane review on gluten- and
casein-free diets in children with
ASDs concluded that the evidence for
the efcacy of these diets remains
poor.16
The normal dietary consumption of energy by the children with ASDs in our
study is reected in their normal
growth parameters, consistent with
the literature on growth in children
with autism disorders.17 However, in
some societies, children with autism are
at higher risk of being overweight.18
CONCLUSIONS
Children on the autism spectrum demonstrated feeding symptoms from infancy and had a less varied diet from
15 months of age, but energy intake
and growth were not impaired. Feeding behavior in children with ASDs reects limited interests and difculty in
accepting change and, in an extreme
form, can present as a pervasive eating disorder.
ACKNOWLEDGMENTS
The UK Medical Research Council, the
Wellcome Trust, and the University of
Bristol provide core support for the
A. The prevalence and characteristics of autistic spectrum disorders in the ALSPAC cohort. Dev Med Child Neurol. 2008;50(9):1 6
Burd L, Fisher W, Kerbeshian J, Vesely B,
Durgin B, Reep P. A comparison of breastfeeding rates among children with pervasive developmental disorder, and controls.
J Dev Behav Pediatr. 1988;9(5):247251
Lukens CT, Linscheid TR. The Brief Autism
Mealtime Behavior Inventory (BAMBI). J Autism Dev Disord. 2008;38(2):342352
Lockner DW, Crowe TK, Skipper BJ. Dietary
intake and parents perception of mealtime
behaviors in preschool-age children with
autism spectrum disorder and in typically
developing children. J Am Diet Assoc. 2008;
108(8):1360 1363
Herndon AC, DiGuiseppi C, Johnson SL, Leiferman J, Reynolds A. Does nutritional intake
differ between children with autism spectrum disorders and children with typical
development? J Autism Dev Disord. 2009;
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Sandhu B, Steer C, Golding J, Emond. A The
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e341
APPENDIX Details of the Diet of Children With ASDs at 38 Months Compared With Controls
ASDs (n 64)
Calcium
Carotene
Cholesterol
Omega-3 from sh
Docosahexaenoic acid
Eicosapentaenoic acid
Folate
Iodine
Iron
Magnesium
Monounsaturated fat
Niacin
Nonmilk-extrinsic sugar
Fiber
Phosphorus
Polyunsaturated fat
Potassium
Retinol
Riboavin
Saturated fat
Selenium
Sodium
Starch
Sugar
Thiamin
Vitamin C
Vitamin B6
Vitamin B12
Vitamin D
Vitamin E
Zinc
Asperger Syndrome
(n 17)
OR
95% CI
OR
95% CI
OR
95% CI
OR
95% CI
1.04
0.74
0.89
0.85
0.73
0.80
0.74
1.61
0.93
1.20
0.95
0.81
1.01
1.12
1.12
0.87
0.95
1.02
1.07
1.34
1.17
1.02
1.05
0.92
0.77
0.65
0.58
0.90
0.63
0.85
1.02
0.691.57
0.560.99
0.641.22
0.631.13
0.521.01
0.591.09
0.511.07
1.122.31
0.611.42
0.811.77
0.521.76
0.531.23
0.701.45
0.811.54
0.691.84
0.641.20
0.591.52
0.751.37
0.741.56
0.852.11
0.851.61
0.631.66
0.681.63
0.591.43
0.511.15
0.470.89
0.380.89
0.651.25
0.460.86
0.631.14
0.671.58
.842
.042
.467
.265
.061
.163
.111
.010
.733
.358
.880
.319
.961
.490
.640
.399
.819
.922
.709
.203
.349
.930
.811
.698
.206
.007
.012
.536
.004
.279
.911
1.35
1.12
0.70
0.97
0.98
0.96
0.61
1.42
0.79
1.23
1.01
0.68
0.88
1.20
1.23
0.56
0.95
0.80
1.12
1.87
1.13
0.61
0.98
0.92
0.83
0.69
0.50
0.84
0.48
0.55
1.07
0.672.75
0.741.69
0.381.27
0.621.53
0.621.54
0.601.52
0.321.19
0.732.74
0.371.71
0.622.46
0.342.98
0.321.44
0.441.78
0.692.10
0.512.93
0.311.02
0.412.20
0.411.59
0.582.16
0.874.01
0.632.03
0.261.46
0.432.20
0.402.10
0.411.70
0.411.18
0.241.05
0.471.51
0.270.84
0.300.98
0.502.30
.399
.603
.241
.903
.925
.847
.148
.303
.553
.551
.983
.317
.727
.522
.647
.059
.909
.530
.746
.110
.677
.267
.957
.847
.619
.176
.069
.557
.011
.044
.863
0.52
0.62
1.00
1.04
0.77
0.96
1.04
1.76
1.44
1.55
1.36
1.25
0.97
1.70
1.10
1.28
1.10
1.46
0.89
1.15
1.49
2.51
1.04
0.67
0.79
0.87
0.65
1.22
0.63
1.13
1.22
0.191.42
0.291.29
0.492.06
0.571.88
0.361.64
0.511.81
0.452.43
0.764.11
0.563.67
0.643.74
0.345.43
0.493.15
0.432.21
0.863.37
0.353.44
0.652.54
0.373.29
1.091.96
0.372.16
0.393.37
0.743.02
0.857.48
0.392.75
0.241.89
0.312.01
0.451.69
0.241.73
0.622.40
0.301.33
0.592.18
0.453.33
.202
.198
.990
.903
.494
.904
.927
.189
.449
.326
.665
.643
.946
.129
.871
.476
.869
.012
.792
.803
.263
.097
.941
.452
.618
.679
.386
.565
.229
.713
.695
0.92
0.64
1.60
1.02
0.83
0.96
1.13
2.42
0.78
0.95
0.97
0.97
0.62
0.84
1.04
0.82
0.91
0.92
1.00
1.32
1.35
1.63
1.53
0.51
0.70
0.48
0.85
1.19
0.95
0.75
0.92
0.412.06
0.351.15
0.972.62
0.621.68
0.461.49
0.571.62
0.562.29
1.284.56
0.331.82
0.432.06
0.303.18
0.442.16
0.281.39
0.441.62
0.402.69
0.441.51
0.362.27
0.471.79
0.482.08
0.553.17
0.742.48
0.644.14
0.683.45
0.201.27
0.321.55
0.230.98
0.381.92
0.672.13
0.531.70
0.411.36
0.402.13
.843
.136
.065
.947
.537
.878
.725
.006
.566
.889
.964
.943
.246
.606
.941
.519
.833
.800
.944
.538
.333
.308
.305
.148
.378
.043
.702
.548
.866
.339
.844
The variety score is derived from 56 food-frequency questionnaire questions and reects the number of times that never was reported. Logistic regression analyses were adjusted for
gender (and energy, except for energy, total fat, protein, and variety). ORs are for a 1-SD increase. Controls: n 9796.
e342
EMOND et al
References
Citations
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