Diarrhea
What is Diarrhea?
Diarrhea is defined as loose, watery stools occurring three or more times per day. Diarrhea is a nutritional concern because it can lead to dehydration and malabsorption of nutrients (and potentially nutrient deficiencies).
Diarrhea can be acute (lasting 1-2 days and resolving on its own), persistent (lasting 2-4 weeks) or chronic (lasting longer than 4 weeks). [1]
Gastrointestinal complaints are very common among children with autism, with diarrhea being among the most common symptoms. Gastrointestinal symptom severity correlates positively with autism severity.
Dietary changes, supplements, and lifestyle adjustments can help manage, prevent, and treat short-term or chronic diarrhea. See the “Next Steps” section below for more details.
Signs & Symptoms
Urgent need to use the bathroom
Abdominal pain or cramping
Nausea
Possible loss of bowel control
Dehydration
Symptoms of dehydration include:
Thirst
Fatigue and lack of energy
Dark colored urine
Decreased urine output
Dry mouth
Sunken eyes and cheeks
Lightheadedness
Decreased skin turgor which means if you pinch their skin, it does not quickly flatten back down
Malabsorption of nutrients
Symptoms of malabsorption include:
Gas
Bloating
Appetite changes
Weight loss or poor weight gain
Greasy or foul smelling bowel movements
Unexplained worsening of nonverbal behaviors (agitation, anxiety, aggression, self-injury, sleep deprivation) should alert professionals about the possibility of GI issues, especially among children who are non-verbal.
Source: Autism Dietitian Instagram
Next Steps
Diet
Consuming certain foods may be a short-term solution to managing diarrhea
The “BRAT” Diet is a common diet used for diarrhea. BRAT stands for Bananas, Rice, Applesauce, and Toast. This diet is not sustainable and should not be consumed long-term due to its low nutrient content, but may be helpful to manage symptoms short-term.
Increase foods containing soluble fiber like apples, oats, and beans. Read more about fiber in the fiber note.
Diarrhea increases risk of dehydration due to the excessive water lost through stool. Avoid dehydration by increasing fluid intake and electrolytes. Coconut water is naturally a good source of electrolytes. See supplement recommendations in the “Supplement Considerations” section below
There are a variety of potential nutritional causes of diarrhea, depending if it is chronic or sudden: [1]
Sudden diarrhea
Chronic diarrhea
Food reactions such as lactose intolerance, gluten sensitivity, or Celiac disease
Fat malabsorption
Certain medications
Problems within the gastrointestinal tract including inflammatory bowel disorders (IBD) like Crohn’s or Colitis, irritable bowel syndrome (IBS), small intestinal bacterial overgrowth (SIBO)
Hyperthyroidism
Infection or imbalance of the gut microbiome can cause both sudden and chronic. Pathogens of concern include:
Bacterial infection (e.g. C. difficile, E. coli, among others)
Bacterial overgrowth (e.g. Staphylococcus, Morganella, Klebsiella, among others)
Fungal overgrowth (e.g. Candida, Microsporidia, among others)
Parasites (e.g. Giardia, Cyclospora, Blastocystis hominis, among others)
Worms (e.g. Whipworm, Tapeworm, among others)
Viruses (e.g. Adenovirus, Norovirus, among others)
Addressing these nutritional causes or pathogens may resolve diarrhea. To rule out pathogens, we recommend asking your healthcare provider to order a specialized stool panel, such as the GI-MAP by Diagnostic Solutions or Gut Zoomer by Vibrant America. A basic stool panel from a local lab is unlikely to test for these pathogens. Consult with your physician if diarrhea persists longer than 3 days.
Supplements
Supplementing with electrolytes can help resolve electrolyte imbalance caused by diarrhea. Many populate electrolyte replacements contain unfavorable ingredients such as excessive sugar, sugar alcohols, food dyes, high fructose corn syrup, and artificial flavors, among others.
Soluble fiber supplements. Read more about fiber in the fiber note.
High-quality probiotics. There is some research to indicate that probiotics containing certain strains may be more helpful for diarrhea including: Lactobacillus casei, paracasei, reuteri, and rhamnosus; Saccharomyces boulardii; and Bifidobacterium lactis, logum, and infantis.
Other gut & digestion support supplements including digestive enzymes, L-glutamine, and antimicrobial herbs.
Supplement recommendations and dosages will depend on the underlying gastrointestinal issue and severity of the condition
Supplements should always be individualized to address the underlying issue. Biomedical testing, such as stool analysis, can help identify the root cause(s). Consult your healthcare provider about next steps. We recommend asking your healthcare provider to order a specialized stool panel, such as the GI-MAP by Diagnostic Solutions or Gut Zoomer by Vibrant America. A basic stool panel from a local lab is unlikely to test for these pathogens.
Replenish nutrients lost by chronic diarrhea with supplementation of a variety of different vitamins and minerals (i.e. a multivitamin)
Lifestyle
Consider increasing hygiene standards such as water filtration, washing produce well before consuming, and routine hand-washing.
Keep a food journal to help determine if diet is an underlying factor for chronic diarrhea.
Addressing certain lifestyle factors may alleviate or resolve diarrhea. Remember that the root cause may be due to multiple factors.
DISCLAIMER: Before starting any supplement or medication, always consult with your healthcare provider to ensure it is a good fit for your child. Dosage can vary based on age, weight, gender, and current diet.
Diarrhea & Autism in the Research
Prevalence in Autism
Among research studies on gastrointestinal symptoms and children with ASD, diarrhea is consistently among the most frequently reported GI symptoms [3, 12]
Diarrhea is a common GI symptom among those with ASD. [11, 13]
Children with ASD were three times more likely to experience GI symptoms than typically developing peers. [14]
Potential Causes
GI symptoms may be due in part to the presence of an abnormal microbiota as well as aberrant immune function in the GI tracts of these children. [5]
Early antibiotic exposure, due in part to this population’s increased incidence of ear infections, is also associated with ASD and perturbs the gut microbiota leading to dysbiosis and gastrointestinal problems. [5, 16]
GI problems (feeding problems, dysphagia, nausea, bloating, profound constipation, diarrhea or functional abdominal pain) can reflect functional GI dysmotility and can be considered symptoms of dysautonomia, which is a dysfunction of the nerves that regulate involuntary body functions.[7]
Correlations between ASD and GI symptoms may be driven by differences in function of the microbiota, such as the metabolites that they produce, that may affect neuronal processes. [16]
Symptoms and Co-Occurring Conditions
Increased GI symptoms are associated with increased problem behaviors like self-injurious behaviors, restricted stereotyped behaviors, aggressive behaviors, sleep problems and attention problems in both ASD and typical children. [10, 14]
Frequent gastrointestinal manifestations of mitochondrial disorders include constipation, poor appetite, gastroesophageal sphincter dysfunction, dysphagia, vomiting, gastroparesis, GI pseudo-obstruction, diarrhea, or pancreatitis and hepatopathy. [15]
Due to similarity in symptoms, with alternating constipation and diarrhea, it is postulated that a significant proportion of children with ASD and chronic GI symptoms, have a form of IBS.[6]
Participants with gastrointestinal problems had significantly higher levels of affective (mood) problems. [8]
Clinicians should consider behavioral manifestations as a possible expression of GI problems in ASD subjects. [7, 9]
Compared with non-ASD children, the gut microbiota of children with ASD is less diverse and exhibits lower levels of Bifidobacterium, Prevotella, Coprococcus, unclassified Veillonellaceae and Firmicutes and higher levels of Lactobacillus, Clostridium, Bacteroidetes, Desulfovibrio, Caloramator and Sarcina. [17]
Participants with ASD had a lower abundance of Akkermansia, Bacteroides, Bifidobacterium, E. coli, and Enterococcus, a higher abundance of Faecalibacterium and Lactobacillus, and a slightly increased abundance of Ruminococcus and Clostridium. It is possible that the reduced levels of beneficial bacteria combined with the increased levels of harmful bacteria contribute together to ASD symptoms. [20]
Various Treatment Options
Vancomycin, a poorly absorbed antibiotic known to destroy Clostridia and other gram positive organisms, demonstrated an improvement in diarrhea and more normal behavior when given short-term. [6]
Probiotics are hypothesized to positively impact gut microbial communities and alter the levels of specific potentially harmful metabolites in children with ASD. [6]
Fecal microbiota transplantation (FMT) resulted in 80% reduction of GI symptoms at the end of treatment, including significant improvements in constipation, diarrhea, indigestion, and abdominal pain as well as behavioral ASD symptom improvement, all of which remained improved 8 weeks after treatment ended. [2]
Fecal microbiota transplantation led to overall bacterial diversity and the abundance of Bifidobacterium, Prevotella, and Desulfovibrio among others and these changes persisted after treatment stopped (followed for 8 weeks). [2]
An open-label study and a two-year follow-up suggest that microbiota transplant therapy (MTT) is relatively safe and effective in significantly reducing gastrointestinal disorders and autism symptoms, changing the gut microbiome structure, and increasing gut microbial diversity. [4]
Bovine colostrum product appears to be well-tolerated among a small sample of ASD children with GI symptoms as its own treatment as well as when combined with the probiotic B. infantis. [5]
The appropriate strain of probiotic and mechanism of action will depend upon the cause. [18, 19]
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[1] Information, H., Diseases, D., Center, T. and Health, N., 2020. Diarrhea | NIDDK. [online] National Institute of Diabetes and Digestive and Kidney Diseases. Available at: <https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea> [Accessed 25 September 2020].
[2] Kang DW, Adams JB, Gregory AC, et al. Microbiota Transfer Therapy alters gut ecosystem and improves gastrointestinal and autism symptoms: an open-label study. Microbiome. 2017;5(1):10.
[3] Holingue C, Newill C, Lee LC, Pasricha PJ, Daniele Fallin M. Gastrointestinal symptoms in autism spectrum disorder: A review of the literature on ascertainment and prevalence. Autism Res. 2018;11(1):24-36.
[4] Adams JB, Borody TJ, Kang DW, Khoruts A, Krajmalnik-Brown R, Sadowsky MJ. Microbiota transplant therapy and autism: lessons for the clinic. Expert Rev Gastroenterol Hepatol. 2019;13(11):1033-7.
[5] Sanctuary MR, Kain JN, Chen SY, et al. Pilot study of probiotic/colostrum supplementation on gut function in children with autism and gastrointestinal symptoms. PLoS ONE. 2019;14(1):e0210064.
[6] Navarro F, Liu Y, Rhoads JM. Can probiotics benefit children with autism spectrum disorders. World J Gastroenterol. 2016;22(46):10093-102.
[7] Wasilewska J, Klukowski M. Gastrointestinal symptoms and autism spectrum disorder: links and risks - a possible new overlap syndrome. Pediatric Health Med Ther. 2015;6:153-66.
[8] Mazefsky CA, Schreiber DR, Olino TM, Minshew NJ. The association between emotional and behavioral problems and gastrointestinal symptoms among children with high-functioning autism. Autism. 2014;18(5):493-501.
[9] Prosperi M, Santocchi E, Muratori F, et al. Vocal and motor behaviors as a possible expression of gastrointestinal problems in preschoolers with Autism Spectrum Disorder. BMC Pediatr. 2019;19(1):466.
[10] Zhu J, Guo M, Yang T, et al. [Association between behavioral problems and gastrointestinal disorders among children with autism spectrum disorder]. Zhonghua Er Ke Za Zhi. 2017;55(12):905-10.
[11] Martínez-González AE, Andreo-Martínez P. The Role of Gut Microbiota in Gastrointestinal Symptoms of Children with ASD. Medicina (Kaunas). 2019;55(8):E408.
Authors
Brittyn Coleman, MS, RDN/LD, CLT
Elisa Rocks, RDN
