ANeustart: Advancing the Standard of Care in Autism and Developmental Delays

ANeustart Builds on the Science of Brain Development

Brain Development in Autism

Autism is a developmental disorder affecting 1 in 100 children worldwide. While much of the etiology of autism is still unknown, either genetic, environmental, or both can impact prenatal brain development. Altered brain connectivity occurs when too few connections are made or when an abundance of inefficient brain connections is not eliminated, leading to inefficient communication. Efficient communication between cells is the basis of a child’s ability to learn, play, and socialize.  

Nutrient needs in brain development 

At certain stages of development, one million brain connections are made every second, leaving the process of brain development particularly vulnerable to deficiencies or imbalances. Brain development requires protein, minerals such as iron, zinc, selenium, iodine, and vitamins such as folate, vitamin A, choline, and long-chain polyunsaturated fatty acids, and more as the precursors for the metabolic process needed to build synapses. Different brain areas maturate at different times, and any imbalance can leave specific brain areas with the inability to cultivate efficient synapses3.

 

Nutrient Imbalances in Autism 

Alterations in brain connectivity in development and functional differences observed postnatally as mentioned above (as reduced synaptic pruning, neuroinflammation, comorbid immune conditions, microbiome dysbiosis, mitochondrial dysfunction, and increases in oxidative stress) all deplete resources or divert resources for use by other systems that are needed metabolically for brain function. Indeed, children with autism show various imbalances in vitamins, minerals, and important biological compounds. Adams et al. 201116 specifically showed reduced levels of biotin, magnesium, calcium, and sulfate and dysregulation in glutathione pathways, and ATP was lower than in control children. In contrast, iron, copper, phosphorus, and choline levels were higher in ASD children with high variability. In a large cohort of 274 children in China, Gau M et al. 2020, found that vitamin D, folate, calcium, magnesium, iron, and zinc were lower in ASD children. Interestingly, no differences were found in vitamin A levels between groups. However, stratifying according to vitamin A status reveals worse symptoms in children with vitamin A deficiency. 

Dietary Interventions

Adams LB et al. 201819 used a 12-month random controlled trial with comprehensive nutritional intervention including vitamins, minerals, amino acid combination, and a gluten-free casein-free diet. The participants were ages 3-58. The results were highly variable, but several improvements have been reported, specifically changes in the Autism Treatment Evaluation Checklist (ATEC).

A meta-analysis performed on gluten-free casein-free diets for 297 patients who had received the diet by Quan et al. 2022 showed overall improvements in repetitive behaviors and cognition in children on the diet. In a review by Whiteley et al. 201521, the authors conclude that the diet may benefit certain groups of children specifically due to heterogeneity reported in intervention studies. Finally, in a study comparing the outcomes of a ketogenic intervention vs. gluten-free casein-free children 3-8 years old, El-Rahidy et al. 201722 showed that both types of dietary interventions improve Children's Autism Rating Scale (CARS) and ATEC scores. The ketogenic diet intervention led to a more significant improvement in sociability and cognition subscales in the ATEC. In contrast, gluten-free casein-free diets showed more significant changes in the health and behavior subscale of the ATEC questionnaire. 

 

Evidence for nutrient-based therapy in autism. 

Single Vitamin Interventions

In a review of vitamin supplementation in ASD children, Robea et al. 202023 review the positive impacts of supplementation individually of B1, B6, B12, vitamin D, and vitamin A on autism symptoms. Vitamin D helped improve hyperactivity, while supplementation of B6 and magnesium improved both core one and core two symptoms of autism. Both vitamin B6 and B12 independently were also able to improve ATP and glutathione levels (reported to be low in ASD). Weekly supplementation with Vitamin A in general and specifically, a 6-month intervention with vitamin A to ASD children with vitamin A deficiency showed that vitamin A improves vitamin A status and social responsiveness. The effect was found to act through oxytocin receptors, and possibly increasing Bacteroidetes in the gut helped to improve social behavior24. 

 

Several papers have also focused on supplementing folinic acid, a form of folate that more readily crosses the blood-brain barrier. It was shown that a subset of children with autism has autoantibodies to the folate transporter, which is responsible for carrying folate into the brain, effectively blocking its transport to the brain. In Frye R.E et al. 202025, a review of studies using d,l-leucovorin (folinic acid) showed a slight improvement in verbal communication as measured by changes in standard deviation in children with autism who were supplemented. Children who were positive for antibodies showed better improvement in verbal communication. 

Amino Acid Interventions

A double-blind, randomized clinical trial of levocarnitine by Geier et al. 26 or L-carnitine therapy (50 mg/kilogram-body weight/day) administered for three months significantly improved CARS and ATEC symptom scales. Specifically, in the ATEC, there were significant improvements in the cognition subscale. Another study by Farid et al. 201327 using (100 mg/kg body weight/day) for six months showed significant improvement in CARS scores and significant differences in free and total carnitine levels. Improvements due to carnitine intervention presumably improve mitochondrial function since carnitine facilitates the transport of long-chain fatty acids from the cytosol into the mitochondrial matrix, where fatty-acid oxidation occurs. 

Bioactive compound interventions 

In Bent et al. 201828, children with ASD gave urine samples and then started a 12-week open-label supplementation of sulforaphane (extracted from broccoli seeds). Urinary metabolites that were correlated with changes in symptoms and additionally mild improvements were seen in hyperactivity behaviors in the classroom setting. 

A follow-up to the study was a 15-week randomized parallel, double-blind placebo-controlled clinical trial with 15-week open-label treatment and 6-week no-treatment extensions29. The children showed more than 20% improvement in the aberrant behavior checklist (ABC), numerous physiological changes from reduced immune markers, improvement in mitochondrial function, and specifically increases in ATP-linked respiration that correlated with improvement in the ABC checklist. However, there were no changes in their primary outcome measured by the Ohio Autism Clinical Impressions Scale, so they considered the study results mild or ineffective at changing overall autism symptoms. 

 

Microbiome-based interventions

Several interventions have been tested to increase the healthy flora in children with autism. Among them are antibiotics, prebiotics, probiotics, and fecal microbial transplants. Studies using antibiotics or probiotics that affect Clostridium have shown at least some benefit in symptoms related to communication and behavior. Lactobacillus acidophilus improved behavioral symptoms and reduced the ratio of candida markers of d-arabinitol and l-arabinitol30. In rodent models, the L. reuterii strain increased pro-social oxytocin levels and social behavior31. In Grimaldi R et al. 201832, prebiotic B-GOS intervention improved gastrointestinal symptoms in a child on an unrestricted diet and showed accompanying changes in urine metabolites. Fecal transplant has also shown changes in the Clostridium population and accompanying behavioral improvements. However, choosing the right donors and correct timelines for therapy have yet to be fully understood7.

1.     Baio, J. et al. Prevalence of autism spectrum disorder among children aged 8 Years - Autism and developmental disabilities monitoring network, 11 Sites, United States, 2014. MMWR Surveill. Summ. 67, (2018).

2.     Regev, O. et al. Association Between Abnormal Fetal Head Growth and Autism Spectrum Disorder. J. Am. Acad. Child Adolesc. Psychiatry 60, 986–997 (2021).

3.     Cusick, S. E. & Georgieff, M. K. The Role of Nutrition in Brain Development: The Golden Opportunity of the “First 1000 Days”. J. Pediatr. 175, 16 (2016).

4.     Theoharides, T. C. et al. Mast cell activation and autism. Biochim. Biophys. Acta - Mol. Basis Dis. 1822, 34–41 (2012).

5.     Theoharides, T. C., Tsilioni, I., Patel, A. B. & Doyle, R. Atopic diseases and inflammation of the brain in the pathogenesis of autism spectrum disorders. Transl. Psychiatry 6, (2016).

6.     Nardone, S. et al. DNA methylation analysis of the autistic brain reveals multiple dysregulated biological pathways. Transl. Psychiatry 4, e433 (2014).

7.     Mehra, A. et al. Gut microbiota and Autism Spectrum Disorder: From pathogenesis to potential therapeutic perspectives. J. Tradit. Complement. Med. 13, 135–149 (2023).

8.     Thomas, R. H. et al. The enteric bacterial metabolite propionic acid alters brain and plasma phospholipid molecular species: Further development of a rodent model of autism spectrum disorders. J. Neuroinflammation 9, (2012).

9.     Xiong, X., Liu, D., Wang, Y., Zeng, T. & Peng, Y. Urinary 3-(3-Hydroxyphenyl)-3-hydroxypropionic Acid, 3-Hydroxyphenylacetic Acid, and 3-Hydroxyhippuric Acid Are Elevated in Children with Autism Spectrum Disorders. Biomed Res. Int. 2016, (2016).

10.   Gevi, F., Zolla, L., Gabriele, S. & Persico, A. M. Urinary metabolomics of young Italian autistic children supports abnormal tryptophan and purine metabolism. Mol. Autism 7, 47 (2016).

11.   Siddiqui, M. F., Elwell, C. & Johnson, M. H. ECSA 141210_e_bulletin.pdf. 6, (2016).

12.   Rossignol, D. A. & Frye, R. E. Mitochondrial dysfunction in autism spectrum disorders: a systematic review and meta-analysis. Mol. Psychiatry 17, 290–314 (2012).

13.   Giulivi, C. et al. Mitochondrial Dysfunction in Autism. JAMA 304, 2389–2396 (2010).

14.   Goldenthal, M. J. et al. Mitochondrial enzyme dysfunction in autism spectrum disorders; A novel biomarker revealed from buccal swab analysis. Biomark. Med. 9, 957–965 (2015).

15.   Pangrazzi, L., Balasco, L. & Bozzi, Y. Oxidative stress and immune system dysfunction in autism spectrum disorders. Int. J. Mol. Sci. 21, (2020).

16.   Adams, J. B. et al. Nutritional and metabolic status of children with autism vs. neurotypical children, and the association with autism severity. Nutr. Metab. (Lond). 8, 34 (2011).

17.   Mussap, M. et al. The urine metabolome of young autistic children correlates with their clinical profile severity. Metabolites 10, 1–21 (2020).

18.   Chauhan, A. & Chauhan, V. Oxidative stress in autism. Pathophysiology 13, 171–181 (2006).

19.   Adams, J. B. et al. Effect of a vitamin/mineral supplement on children and adults with autism. BMC Pediatr. 11, 111 (2011).

20.   Quan, L. et al. A systematic review and meta-analysis of the benefits of a gluten-free diet and/or casein-free diet for children with autism spectrum disorder. Nutr. Rev. 80, 1237–1246 (2022).

21.   Whiteley, P. Nutritional management of (some) autism: a case for gluten- and casein-free diets? Proc. Nutr. Soc. 74, 202–207 (2015).

22.   El-Rashidy, O. et al. Ketogenic diet versus gluten free casein free diet in autistic children: a case-control study. Metab. Brain Dis. 32, 1935–1941 (2017).

23.   Robea, M. A., Luca, A. C. & Ciobica, A. Relationship between vitamin deficiencies and co-occurring symptoms in autism spectrum disorder. Med. 56, (2020).

24.   Lai, X. et al. A weekly vitamin A supplementary program alleviates social impairment in Chinese children with autism spectrum disorders and vitamin A deficiency. Eur. J. Clin. Nutr. 75, 1118–1125 (2021).

25.   Frye, R. E. et al. Treatment of Folate Metabolism Abnormalities in Autism Spectrum Disorder. Semin. Pediatr. Neurol. 35, (2020).

26.   Geier, D. A. et al. A prospective double-blind, randomized clinical trial of levocarnitine to treat autism spectrum disorders. Med. Sci. Monit. 17, 15–23 (2011).

27.   Farid, S., El-Hamamsy, M., Zaki, O. & Badary, O. L-Carnitine supplementation improves the behavioral symptoms in autistic children. Res. Autism Spectr. Disord. 7, 159–166 (2013).

28.   Bent, S. et al. Identification of urinary metabolites that correlate with clinical improvements in children with autism treated with sulforaphane from broccoli. Mol. Autism 9, 35 (2018).

29.   Zimmerman, A. W. et al. Randomized controlled trial of sulforaphane and metabolite discovery in children with Autism Spectrum Disorder. Mol. Autism 12, 38 (2021).

30.   Cekici, H. & Sanlier, N. Current nutritional approaches in managing autism spectrum disorder: A review. Nutr. Neurosci. 22, 145–155 (2019).

31.   Dinan, T. G. & Cryan, J. F. Gut instincts: microbiota as a key regulator of brain development, ageing and neurodegeneration. J. Physiol. 595, 489–503 (2017).

32.   Grimaldi, R. et al. A prebiotic intervention study in children with autism spectrum disorders (ASDs). Microbiome 6, 1–13 (2018).