Bone Mineral Density in Boys Diagnosed with Autism Spectrum Disorder: A Case-Control Study

The Determinants of Bone Health in Children With Autism Spectrum Disorder: A Systematic Narrative Review

Autism spectrum disorder (ASD) is a complex disorder associated with social and communication impairments and repetitive and restrictive behavioural patterns. Children with ASD often present with concurrent conditions, including poor bone health, which affect long-term health. Although there is compelling evidence to suggest that children with ASD have poorer bone traits than typically developing children, the primary factors associated with these differences are unclear. This review will explore the potential role that factors such as physical activity, nutrition (calcium, protein, vitamin C, vitamin D) and lifestyle (sleep, medication) play on bone health in children with ASD. Having a greater understanding of the influencing factors of low BMD and how these might interact in a synergistic manner in ASD children will provide an opportunity to develop targeted interventions to improve bone health aiming to avert attainment of suboptimal peak bone mass which may lead to early onset osteoporosis, fracture and muscle deconditioning in this paediatric population.

Brief Report: Decreased Bone Health in Children with Autism Spectrum Disorder and Avoidant Restrictive Food Intake Disorder

PURPOSE

Children with autism spectrum disorder (ASD) and food selectivity are at increased risk for nutritional deficiencies which could affect bone health.

METHODS

We report on four male patients with ASD and avoidant restrictive food intake disorder (ARFID) with significant bone conditions including rickets, vertebral compression fractures, osteopenia, and slipped capital femoral epiphyses.

RESULTS

Each patient was at risk for at least one nutritional deficiency. Two out of four patients had deficiencies in Vitamins A, B12, E, and zinc. Calcium and Vitamin D deficiency were noted in all four. Two out of four patients with Vitamin D deficiency developed rickets.

CONCLUSION

Provisional evidence suggests that children with ASD and ARFID are at elevated risk for serious adverse bone health outcomes.

Bone health in children and youth with ASD: a systematic review and meta-analysis

Higher risk of fracture reported in individuals with autism spectrum disorder (ASD) might be linked to poor bone health and development in childhood. This study aimed to systematically review studies comparing imaged bone outcomes between children with ASD and typically developing children (TDC) or reference data, and to perform a meta-analysis comparing commonly reported bone outcomes. We searched articles published since August 2020 from PubMed, Cochrane Library, Web of Science, EMBASE, and Scopus databases. We included studies comparing areal bone mineral density (aBMD) between children with ASD and TDC in the qualitative analysis (meta-analysis), and evaluated other imaged bone outcomes qualitatively. Seven publications were identified for the systematic review, and four studies were included in the meta-analysis. The meta-analysis indicated lower aBMD at the total body (standardized mean difference = - 0.77; 95% CI, - 1.26 to - 0.28), lumbar spine (- 0.69; - 1.00 to - 0.39), total hip (- 1.00; - 1.82 to - 0.17), and femoral neck (- 1.07; - 1.54 to - 0.60) in children with ASD compared to TDC. Based on our qualitative review, limited evidence suggested 13% lower bone mineral content at the total body and 10-20% lower cortical area, cortical and trabecular thickness, and bone strength at the distal radius and tibia in children with ASD. Children with ASD have lower aBMD at the total body, lumbar spine, and hip and femoral neck compared to TDC. Limited evidence also suggests deficits in bone mineral content, micro-architecture, and strength in children with ASD.

Altered Bone Status in Rett Syndrome

Rett syndrome (RTT) is a monogenic neurodevelopmental disorder primarily caused by mutations in X-linked MECP2 gene, encoding for methyl-CpG binding protein 2 (MeCP2), a multifaceted modulator of gene expression and chromatin organization. Based on the type of mutation, RTT patients exhibit a broad spectrum of clinical phenotypes with various degrees of severity. In addition, as a complex multisystem disease, RTT shows several clinical manifestations ranging from neurological to non-neurological symptoms. The most common non-neurological comorbidities include, among others, orthopedic complications, mainly scoliosis but also early osteopenia/osteoporosis and a high frequency of fractures. A characteristic low bone mineral density dependent on a slow rate of bone formation due to dysfunctional osteoblast activity rather than an increase in bone resorption is at the root of these complications. Evidence from human and animal studies supports the idea that MECP2 mutation could be associated with altered epigenetic regulation of bone-related factors and signaling pathways, including SFRP4/WNT/β-catenin axis and RANKL/RANK/OPG system. More research is needed to better understand the role of MeCP2 in bone homeostasis. Indeed, uncovering the molecular mechanisms underlying RTT bone problems could reveal new potential pharmacological targets for the treatment of these complications that adversely affect the quality of life of RTT patients for whom the only therapeutic approaches currently available include bisphosphonates, dietary supplements, and physical activity.

Nutritional Rickets Due to Severe Food Selectivity in Autism Spectrum Disorder

OBJECTIVE

Studies have detected differences in various measures of bone health between individuals with autism spectrum disorder (ASD) and their peers. However, these measures do not amount to direct clinical evidence of increased orthopedic pathology in this population. Some of the most compelling evidence to this effect comes from case reports of nutritional rickets in children with ASD. We report on 1 such case that, to our knowledge, is the first report of nutritional rickets in ASD necessitating corrective surgery.

METHODS

Case report, review of relevant literature, and implications for further research.

RESULTS

An 11-year-old girl with ASD was admitted for postoperative medical comanagement after successful repair of bilateral genu valgum (knock knees). On admission, the patient's mother reported that the patient was a "picky eater." No cause had been determined preoperatively, although the deformity had developed at 10 years of age, thereby qualifying as pathologic. The medical team considered rickets because of the patient's limited diet. Subsequent laboratory work demonstrated hypocalcemia, vitamin D deficiency, and secondary hyperparathyroidism. The patient was diagnosed with nutritional rickets due to inadequate vitamin D intake, a consequence of severe food selectivity associated with ASD.

CONCLUSION

This case exemplifies the extreme orthopedic and metabolic complications that can result from food selectivity in children with ASD, pointing to the need for further research into the prevalence and causes of orthopedic pathology and nutritional rickets in this population. The case also underscores the need for evidence-based guidelines to prevent orthopedic pathology in children with ASD.

Risperidone accelerates bone loss in rats with autistic-like deficits induced by maternal lipopolysaccharides exposure

AIMS

Patients with neurodevelopmental disorders, usually suffer from bone diseases. Many studies have revealed a higher risk of fracture after atypical antipsychotic drug Risperidone (RIS) treatment, which is usually used to treat such disorders. It remains debatable whether neurodevelopmental disorders by itself are the cause of bone diseases or pharmacotherapy may be the reason.

MATERIALS AND METHODS

This study attempts to evaluate the biomechanical, histological, stereological, and molecular properties of bones in the offspring of Lipopolysaccharide (LPS) and saline-treated mothers that received saline, drug vehicle or the atypical antipsychotic drug risperidone (RIS) at different days of postnatal development. After postnatal drug treatment, animals were assessed for autistic-like behaviors. Then their bones were taken for evaluations.

RESULTS

Maternal LPS exposure resulted in deficits in all behavioral tests and RIS ameliorated these behaviors (p < 0.01& p < 0.05). The administration of LPS and RIS individually led to a significant decrease in the biomechanical parameters such as bone stiffness, strength and the energy used to fracture of bone. The numerical density of osteocalcin-positive cells were significantly decreased in these groups. These rats also had decreased RUNX2 and osteocalcin gene expression. When LPS rats were treated with RIS, these conditions were accelerated (p < 0.001).

DISCUSSIONS

The results of our preclinical study, consistent with previous studies in animals, explore that autistic-like deficits induced by prenatal exposure to LPS, can reduce bone stability and bone mass similar to those observed in neurodevelopmental disorders, and, for the first time, reveal that this condition worsened when these animals were treated with RIS.

Pharmacological, non-pharmacological and stem cell therapies for the management of autism spectrum disorders: A focus on human studies

In the last decade, the prevalence of autism spectrum disorders (ASD) has dramatically escalated worldwide. Currently available drugs mainly target some co-occurring symptoms of ASD, but are not effective on the core symptoms, namely impairments in communication and social interaction, and the presence of restricted and repetitive behaviors. On the other hand, transplantation of hematopoietic and mesenchymal stem cells in ASD children has been shown promising to stimulate the recruitment, proliferation, and differentiation of tissue-residing native stem cells, reducing inflammation, and improving some ASD symptoms. Moreover, several comorbidities have also been associated with ASD, such as immune dysregulation, gastrointestinal issues and gut microbiota dysbiosis. Non-pharmacological approaches, such as dietary supplementations with certain vitamins, omega-3 polyunsaturated fatty acids, probiotics, some phytochemicals (e.g., luteolin and sulforaphane), or overall diet interventions (e.g., gluten free and casein free diets) have been considered for the reduction of such comorbidities and the management of ASD. Here, interventional studies describing pharmacological and non-pharmacological treatments in ASD children and adolescents, along with stem cell-based therapies, are reviewed.

Brief Report: Estimating the Dental Age of Children with Autism Spectrum Disorders

Determining a patient's dental age is essential from the dental standpoint but can also have connotations of a forensic, anthropological and medicolegal nature. In this study, we assessed the correspondence between dental age and chronological age in a group of 50 children with autism spectrum disorders, with a chronological age range of 3-17 years. The dental age was calculated using panoramic radiography images, applying linear regression models derived from the classical indices by Nolla and Demirjian. In 2 of every 3 boys, the dental age was ahead of the chronological age, and in almost 1 of every 3 cases, the difference was ≥ 12 months. In the girls, conversely, we found no significant differences between dental age and chronological age.