Four to eight percent of Australian children experience food allergies and approximately 25% of the population suffer from food intolerance, which are some of the highest statistics in the world.¹ 

However, beyond the obvious immunologically generated consequences, food allergies and intolerances can also interfere with cognitive function and mood, and have been shown to contribute to neuropsychiatric conditions.² These symptoms can dramatically interfere with a patient’s life and can easily go unnoticed by the patient or remain undiagnosed. The below case provides an example of how simple dietary interventions and digestive support can produce life-changing effects.

Initial presentation and case history

Erica presented to clinic with her six-year-old daughter Laura. Two years prior, Laura had start falling behind in her developmental milestones. Specifically, her language progression had halted, her vocabulary range was decreasing, and she was speaking less. Furthermore, her cognitive processing had reduced, she was reluctant to socially interact and struggled to make eye contact. Initially Erica observed that Laura was becoming more introverted and distant and had stopped playing with her siblings or other children at day care. She had also become increasingly nervous and developed hand flapping during times of stress (several times daily). After investigation with the doctor, Laura was diagnosed with autism spectrum disorder (ASD).

Laura’s other symptoms included constipation with 2-3 bowel motions a week that were ‘sticky’ and difficult to evacuate, and she often had daily stomach aches. Laura was a very fussy eater and only ate foods of particular colours and textures, as is common in ASD. Her diet was high in bread and cereals, and she regularly consumed strawberry milk and yoghurt most days. Carrots were the only vegetable or fruit consumed. She also experienced headaches 3-4 days a week, slept poorly due to regular nightmares, and experienced bed-wetting. Between 18 months and 3 years of age Laura experienced recurrent otitis media which was treated with multiple rounds of antibiotics.  It was after this time that Erica started noticing changes in Laura’s personality.  

During the 60-minute initial consultation, Laura constantly held on to her mother and became nervous and agitated three times. This involved hand flapping and crying, and she was only able to fleetingly look at the practitioner twice. 

Medications

At the time of presentation Laura was not taking any medications.

Treatment Aims

• Improve cognition.
• Identify potential food allergies / intolerances.
• Correct gut-brain axis.
• Support stress resilience.

Prescription 

• Gluten- and casein-free (GFCF) diet with strict avoidance for at least two weeks.
• Gut healing and liver support powder containing; Turmeric (Curcuma longa), deglycyrrhizinised Licorice (Glycyrrhiza glabra), St. Mary's Thistle (Silybum marianum), Slippery elm (Ulmus rubra), Marshmallow (Althaea officinalis), glutamine.
• Natural chocolate flavoured rice-based protein powder, high in glutamine. This was used as a carrier to cover the gut and liver supportive powder.*
• Herbal formula with Chamomile (Matricaria chamomilla), Lemon balm (Melissa officinalis), St John’s Wort (Hypericum perforatum), Bacopa (Bacopa monnieri).
  • Dose: 20 drops TDS – mix with favourite fruit juice to cover the taste.
• Swap to gluten-free bread and look at rice milk as dairy alternative. Increase water consumption.

*Erica was advised to mix up the rice-based protein powder and gut and liver formula when Laura wasn’t watching so she didn’t realise it was ‘medicine’.

2-Week Follow-Up

Laura had been able to adhere to the GFCF diet well and Erica commented that within a couple of days she had noticed improvements in Laura’s digestive health which continued over the fortnight. Stools were no longer hard to move, were well formed and frequency had improved to every second day. Stomach aches had reduced in severity and were now on alternate days, which coincided with days without a bowel motion.

The previous day Laura had maintained eye contact when talking with her mother during a short interaction, which would normally not occur. There were no noticeable changes in headaches, bed wetting or nightmares. Laura had managed to take the powdered formulations but was struggling with the herbs on some days.

Prescription 

• Continue everything as prescribed.
• Discussed mixing herbal formula into a glass of juice (without Laura noticing) to enhance compliance.

4-Week Follow-Up

Upon returning for the third consultation, changes were immediately evident in Laura. She was not clinging to her mother and seemed to be listening during the consultation. Erica commented that during the third week on the diet it was as if Laura “woke up”. She started to talk a little more and didn’t seem as distant.  Speech was still minimal, but attention had greatly improved. During dinners it was clear that Laura was paying attention to the family conversation and even laughed once with the family.

In the past week she had only experienced one nightmare and there had not been any bed wetting or headaches. Laura was less nervous when being dropped off to day care, although hand flapping was still occurring at times during the day when she felt stressed. Bowel movements were formed and moving daily, and stomach aches had resolved. She was still following the GFCF diet, taking the powdered formulations daily and was compliant with the herbal mix most days now that it was disguised in her juice.

Prescription 

• Continue everything as prescribed.
• Try to gradually include vegetables in the diet to support microbiome diversity and nutrient intake.

12-Week Follow-Up

Laura continued the same prescription with check-in consults every 2 weeks to ensure everything was progressing smoothly. By 12 weeks she was talking and interacting more like a six-year-old. During the consultation, she was playing with the toys and even said hello and goodbye. Day care had commented that she was more engaged and socialised with the class, interacted with staff and did not seem to suffer from the same anxiety and apprehension. Hand flapping had markedly reduced to once or twice weekly from several times daily. However, Erica was able to talk to Laura about it and she was becoming self-aware of the habit and able to stop it when it arose.

Erica had been able to gradually include some new foods in Laura’s diet as she was becoming less fussy. It was still limited, but vegetable intake had progressively been increasing. Laura was happy on the diet, but on one occasion when she had some dairy regressive behaviour a change was observed for approximately three days. Laura was moving her bowels daily with healthy formed stools and full evacuation. No stomach aches, headaches, nightmares or bedwetting for the past four weeks. Erica remarked that Laura had returned “back to her old self” and she “had her daughter back again”.

Heal the gut to heal the mind

Individuals with ASD commonly display gastrointestinal symptoms and studies have shown an increased inflammatory response when exposed to foods such as dairy, gluten and soy. Gluten and casein have been dubbed ‘exorphins’ for their ability to bind to opioid receptors within the brain and potentially interfere with cognitive processes and mood. It is thought that if not correctly broken down within the digestive tract and in the presence of hyperpermeability of the intestinal epithelium and blood-brain barrier, these peptides can translocate to the brain and may play a role in autism and other psychiatric conditions such as schizophrenia.² A 2021 systematic review and meta-analysis was unable to demonstrate consistent benefits from a GFCF diet in ASD due to limitations in study designs.³ However, other studies have shown significant improvements,⁴ and increased intestinal permeability has been found to be increased in those with ASD.⁵ While GFCF is obviously not the sole driver of ASD and may not even play a contributory role in some presentations, ASD represents a good example of why addressing the gut-brain connection is paramount in patients with gastrointestinal and cognitive symptoms. This case serves as a valuable reminder that when consulting with patients with neuropsychiatric symptoms (especially children), it is important to consider food allergies or intolerances and support the gut-brain axis to produce lasting results.

References

1. RACGP. Anaphylaxis: Identification, management and prevention. Aust Fam Physician. 2013;42(1)
2. Elder JH, Shankar M, Shuster J et al. The gluten-free, casein-free diet in autism: results of a preliminary double blind clinical trial. J Autism Dev Disord. 2006;36(3):413-20.
3. Keller A, Rimestad ML, Friis Rohde J et al. The effect of a combined gluten- and casein-free diet on children and adolescents with autism spectrum disorders: A systematic review and meta-analysis. Nutrients. 2021;13(2):470. 
4. Cade R, Privette M, Fregly M et al. Autism and schizophrenia: Intestinal disorders. Nutr Neurosci. 2000;3(1):57-72.
5. Esnafoglu E, Cırrık S, Ayyıldız SN et al. Increased serum zonulin levels as an intestinal permeability marker in autistic subjects. J Pediatr. 2017;188:240-244.