P2.M245: Nutritional Deficiencies in Children with Autism Spectrum Disorder-Related Food Selectivity: Implications for the Pediatric Hospitalist.

Introduction: Autism Spectrum Disorder (ASD) is commonly associated with food selectivity. Many children with food selectivity restrict or omit fruits and vegetables, putting them at increased risk for nutritional deficiencies. It important for pediatricians to take a careful dietary history and have a high clinical suspicion for nutritional deficiencies in this population.

Case Description: A five-year-old male with ASD and food selectivity presented with productive cough and emesis. Initial laboratory findings showed compensated metabolic acidosis, hypophosphatemia, and hypokalemia. It was suspected that he had electrolyte abnormalities at baseline. After repletion, he was discharged with a multivitamin and close outpatient follow up. Vitamin C and D levels returned following discharge and were 0.2 mg/dL and 3.4 ng/mL, respectively. With supplementation, vitamin levels improved.

A three-year-old boy with ASD and food selectivity presented with a three-week history of difficulty walking and low-grade fever. Abdominal radiograph showed findings consistent with rachitic rosary. Magnetic resonance imaging (MRI) of the lower limbs showed extensive abnormal marrow signal changes and periosteal reaction. Bone marrow biopsy was negative for leukemia. He was started on ketorolac and vitamin C supplementation. After a few days, his leg pain resolved. He was discharged with vitamin supplementation. Following discharge, vitamin C level obtained on admission returned as undetectable.

A twelve-year-old male with ASD and food selectivity presented with a three-week history of emesis and low-grade fever. Initial laboratory findings showed hypoglycemia and compensated metabolic acidosis. After receiving dextrose-containing IV fluids, he developed signs of refeeding syndrome. Electrolytes were repleted. Vitamin C level was undetectable and Vitamin D level was 10.0 ng/mL. He was discharged on daily vitamin supplementation.

Discussion: Manifestations of nutritional deficiencies might not be clinically obvious. Given the potential for significant morbidity and mortality from untreated nutritional deficiencies, it is crucial for clinicians to have a high suspicion for nutritional deficiency in children with ASD-related food selectivity to initiate repletion and feeding therapy if indicated. Additionally, sequelae of nutritional deficiencies may mimic other illnesses. In children with ASD, it is important to correlate imaging findings with clinical presentation and consider severe nutritional deficiency as a potential source. Awareness of the potential for malnutrition in hospitalized children with ASD is also important due to the risk for refeeding syndrome. Many children with ASD-related food selectivity have chronic malnutrition. Upon initiation of parenteral or enteral nutrition, close observation is necessary to monitor for electrolyte abnormalities.

Conclusion: The cases presented above highlight that children with ASD with severe food selectivity are at risk for multiple specific nutritional deficiencies. Thorough history-taking and a high clinical suspicion for nutritional deficiency in children with ASD are essential to initiate timely treatment and prevent long-term morbidity and mortality.