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Transcript
Feeding Symptoms, Dietary Patterns, and Growth in Young Children With
Autism Spectrum Disorders
Alan Emond, Pauline Emmett, Colin Steer and Jean Golding
Pediatrics 2010;126;e337; originally published online July 19, 2010;
DOI: 10.1542/peds.2009-2391
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/126/2/e337.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
ARTICLES
Feeding Symptoms, Dietary Patterns, and Growth in
Young Children With Autism Spectrum Disorders
AUTHORS: Alan Emond, MD, Pauline Emmett, PhD, Colin
Steer, MSc, and Jean Golding, PhD
Centre for Child and Adolescent Health, Department of
Community Based Medicine, University of Bristol, Bristol, United
Kingdom
KEY WORDS
autism, autism spectrum disorders, feeding, diet, pervasive
feeding disorder, ALSPAC
ABBREVIATIONS
ASD—autism spectrum disorder
ALSPAC—Avon Longitudinal Study of Parents and Children
OR— odds ratio
CI— confidence interval
WHAT’S KNOWN ON THIS SUBJECT: Children with ASDs are often
reported to have limited food preferences and behavioral
difficulties associated with feeding. However, the age of onset of
feeding symptoms and the impact on diet and growth are poorly
understood.
WHAT THIS STUDY ADDS: Using prospectively reported data the
authors found that children with ASDs showed feeding symptoms
from infancy and had a less varied diet from 15 months of age,
but energy intake and growth were not impaired.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2391
doi:10.1542/peds.2009-2391
Accepted for publication Apr 27, 2010
Address correspondence to Jean Golding, PhD, Centre for Child
and Adolescent Health, Barley House, Oakfield Grove, Bristol BS8
2BN, United Kingdom. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
abstract
OBJECTIVE: To investigate the feeding, diet and growth of young children with autism spectrum disorders (ASD).
METHOD: Data on feeding and food frequency were collected by questionnaires completed at 6, 15, 24, 38 and 54 months by participants in
the Avon Longitudinal Study of Parents and Children. A food variety
score was created, and the content of the diet was calculated at 38 m.
The feeding and dietary patterns of 79 children with ASD were compared with 12 901 controls.
RESULTS: The median ages of ASD children were 28 months at referral
and 45 months at diagnosis. ASD infants showed late introduction of
solids after 6 months (p ⫽ .004) and were described as “slow feeders”
at 6 months (p ⫽ .04). From 15–54 months ASD children were consistently reported to be “difficult to feed” (p ⬍ .001) and “very choosy”
(p ⬍ .001). From 15 months, the ASD group had a less varied diet than
controls, were more likely to have different meals from their mother
from 24 months, and by 54 months 8% of ASD children were taking a
special diet for “allergy.”
ASD children consumed less vegetables, salad and fresh fruit, but also
less sweets and fizzy drinks. At 38 months intakes of energy, total fat,
carbohydrate and protein were similar, but the ASD group consumed
less vitamins C (p ⫽ .02) and D (p ⫽ .003). There were no differences in
weight, height or BMI at 18 months and 7 years, or in hemoglobin
concentrations at 7 years.
CONCLUSIONS: ASD children showed feeding symptoms from infancy
and had a less varied diet from 15 months, but energy intake and
growth were not impaired. Pediatrics 2010;126:e337–e342
PEDIATRICS Volume 126, Number 2, August 2010
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
e337
Autism spectrum disorders (ASDs) are
characterized by impairments in social interaction and communication
and stereotypical and repetitive behaviors. People with ASDs are often resistant to change and have a narrow
range of interests, which can extend to
the foods they like.1 Children with ASDs
are often reported to have unusual eating patterns with a restricted range of
food choices.2 However, the differences are not only a result of impairments intrinsic to the child with an
ASD; a questionnaire survey of parents
of children with ASDs revealed that
family food preferences seemed to influence food selection more than the
diagnostic characteristics of autism.3
Other feeding symptoms have also
been reported. A retrospective study of
children with ASDs revealed that vomiting, reflux, colic, and failure to feed
were more common in those with Asperger syndrome than in those with
other autism disorders.4
Much of the published literature has
been based on small clinical samples
with no control group, and some have
used retrospectively collected data on
feeding. We have used a populationbased cohort to investigate feeding
patterns, diet, and growth of children
with ASDs and used prospectively reported data collected before the diagnosis of an autism disorder had been
made.
METHODS
The Avon Longitudinal Study of Parents
and Children (ALSPAC) is a longitudinal
cohort study that follows the health
and development of children who had
an expected date of delivery between
April 1991 and December 1992 and resided in the Avon area of southwest
England at the time of their birth.
Mothers (n ⫽ 14 541) enrolled during
pregnancy, and those pregnancies resulted in 14 062 live births, of whom
13 971 survived their first 5 years.5 Full
e338
EMOND et al
details of the questionnaires used, the
biological samples retained, the examinations, and observations of the children are available on the ALSPAC Web
site.6 Ethical approval for the study
was obtained from the ALSPAC Law and
Ethics Committee and the local research ethics committees.
score. The higher the score, the less
variety in the diet.
Identification of Cases of ASD
Weight and height measurements collected by health visitors as part of routine preschool-aged child health surveillance were extracted from the Avon
Child Health Computer database. At the
age of 7 years, all children in the
ALSPAC were invited to a special research clinic at which they were
weighed and measured.
The children within the ALSPAC with a
diagnosis of ASD by the age of 11 years
were identified from 2 independent
sources: (1) the clinical records of all
children in the cohort investigated for
a suspected developmental disorder
by a multidisciplinary assessment; and
(2) the national educational database
in England (Pupil Level Annual School
Census [PLASC]), which identified all
children in state schools (⬎90% of
children) who needed special educational provision because of ASDs in
2003. Details of the methods used in
the identification of ASDs and the demographic characteristics of the autistic children in the ALSPAC cohort
have already been reported.7 A total of
86 children were identified, giving a
prevalence of 62 per 10 000 children
aged 11 years. There were 30 children
with classical childhood autism, 15
with atypical autism, and 23 with Asperger syndrome; 18 of the ASD cases
could not be classified. The median age
of referral was 28 months, and the median age of diagnosis of childhood autism was 45 months.
Feeding and Dietary Data
Questions on the child’s feeding and
the frequency with which different
foods were eaten were included in
questionnaires completed by the main
caregiver at 6, 15, 24, 38, and 54
months. A food-variety score was created from the food-frequency questionnaires: a total of 56 different foods
and drinks were included, and the
number of times “never” was reported
was summed to give the food-variety
The content of the diet was assessed
from the food-frequency questionnaire
completed by the caregiver when the
child was 38 months of age.
Growth Data
Hemoglobin Data
Children who attended the ALSPAC research clinic at 7 years of age had venous blood samples taken for hemoglobin analysis by the HemoCue (L.E.
West, Ltd, Barking, United Kingdom)
method (n ⫽ 5859).
Statistical Analyses
Logistic regression was used to analyze associations between ASDs and
feeding patterns by using Stata 9.2
(Stata Corp, College Station, TX). Because of the strong association between gender and ASDs (odds ratio
[OR]: 6.40 [95% confidence interval
(CI): 3.42–12.14]), analyses were adjusted for gender. A linear relationship
was assumed for continuous variables
(food-variety score and dietary intakes). Effect sizes were reported for a
1-SD increase. Categorical variables
(feeding patterns) were dichotomized
according to the worst versus the rest
of the categories. Repeated measures
at different ages were analyzed simultaneously in a combined analysis but,
for clarity, are reported separately. In
these combined analyses, additional
adjustment was made for age, and differences in effects across time were
assessed through an interaction test.
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ARTICLES
TABLE 1 Feeding Symptoms in Children With ASDs and Controls up to 54 Months
Slow feeding
1 mo
6 mo
Pooled estimate
Interaction with age
Acceptance of solids
0–3 mo
4 mo
ⱖ5 mo
Very difficult to feed
15 mo
24 mo
38 mo
54 mo
Pooled estimate
Interaction with age
Very choosy
15 mo
24 mo
38 mo
54 mo
Pooled estimate
Interaction with age
Pica
38 mo
54 mo
Pooled estimate
Interaction with age
Children With
ASDs, % (n)
Controls, % (n)
OR (95% CI)
P
47.3 (35)
40.6 (28)
—
—
40.0 (4894)
30.7 (3497)
—
—
1.35 (0.85–2.14)
1.66 (1.02–2.69)
1.49 (1.06–2.08)
—
.20
.04
.02
.55
61.8 (42)
29.4 (20)
8.8 (6)
72.8 (8183)
23.2 (2606)
4.0 (451)
0.60 (0.35–1.03)
1 (reference)
1.93 (0.77–4.87)
—
—
.004
8.1 (6)
15.5 (11)
11.9 (8)
26.2 (17)
—
—
3.4 (374)
4.5 (467)
5.1 (515)
10.0 (961)
—
—
2.71 (1.16–6.31)
3.67 (1.91–7.05)
2.40 (1.14–5.07)
2.90 (1.66–5.07)
2.92 (2.08–4.09)
—
.02
⬍.001
.02
⬍.001
⬍.001
.86
9.5 (7)
20.0 (14)
28.4 (19)
37.5 (24)
—
—
5.4 (595)
9.5 (979)
14.5 (1451)
13.9 (1324)
—
—
1.92 (0.87–4.21)
2.45 (1.36–4.43)
2.23 (1.30–3.81)
3.47 (2.08–5.79)
2.55 (1.91–3.40)
—
.10
.003
.003
⬍.001
⬍.001
.54
12.3 (8)
12.5 (8)
—
—
2.3 (226)
0.7 (68)
—
—
6.09 (2.85–13.01)
21.37(9.59–47.61)
9.82 (5.66–17.03)
—
⬍.001
⬍.001
⬍.001
.03
— indicates not applicable.
Data on feeding and dietary patterns
were available for 79 children with
ASDs and 12 901 controls. Actual numbers varied for each explanatory variable and were in the range of 64 to 74
for children with ASDs and 9550 to
12 249 for controls.
No group differences were apparent in
maternal diet during pregnancy,
breastfeeding rates, or infant foodvariety score at 6 months. In infancy,
the children subsequently diagnosed
with ASDs were more likely than controls to have late acceptance of solid
food (P ⫽ .004) and to be described by
their mothers as “slow feeders” (P ⫽
.02) (Table 1).
Between 15 and 54 months of age, the
children with ASDs were consistently
reported to be difficult to feed (P ⬍
.001) and very choosy (P ⬍ .001). Results of combined analyses suggested
PEDIATRICS Volume 126, Number 2, August 2010
that these differences were present at
15 months. From 15 months, the children with ASDs had a significantly less
varied diet, which became progressively more different than controls
with increasing age (interaction P ⫽
.002). The diet was least varied in children with classical autism (Fig 1). At 38
months the food-variety score was
normally distributed, with a mean of
21 (SD: 6; range: 2– 48).
4.0
3.5
Classical autism
Other types of ASDs
b
3.0
Odds ratio
RESULTS
2.5
a
By 24 months of age, the children with
ASDs were more likely to be having a
different diet than the rest of their family, and by 54 months 8% of the children with ASDs were taking a special
diet for “allergy,” compared with 2% of
controls (OR: 3.41 [95% CI: 1.35– 8.63];
P ⫽ .01). Children with ASDs were
much more likely than controls to
show pica behavior at 38 and 54
months (Table 1).
The food-frequency data showed that,
compared with controls, the children
in the ASD group ate fewer vegetables,
salads, and fresh fruit but also consumed fewer sweets and fizzy drinks.
The derived dietary data at 38 months
(Table 2) revealed no differences between children with ASDs and control
children in the reported intake of energy, total fat, carbohydrate, proteins,
and minerals, but the group of children with ASDs had less variety in their
diet (higher variety score). The details
of the diet are contained in the Appendix, which shows that the dietary content of children with classical autism,
atypical autism, and Asperger syndrome were similar. Compared with
controls, children with ASDs consumed less vitamin C (P ⫽ .007) and
vitamin D (P ⫽ .004) and more iodine
(P ⫽ .01), but estimates were imprecise because of small sample sizes
within some groups.
There were no group differences between children with ASDs and controls
in mean weight, height, or BMI at 18
months and 7 years. Although children
with ASDs had slightly lower mean hemoglobin levels (122.7 vs 124.5 g/L), this difference was not significant (P ⫽ .320).
a
2.0
DISCUSSION
1.5
1.0
0.5
0.0
6 mo
15 mo
24 mo
38 mo
age
FIGURE 1
Food-variety score and type of ASD (odds ratio
for a 1-SD increase). ap ⬍ .05, bp ⬍ .01.
The results of this prospective study
show that children on the autism spectrum demonstrated feeding symptoms
from infancy and had a progressively
less varied diet from 15 months of age.
However, energy intake and growth
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
e339
TABLE 2 Dietary Consumption at 38 Months in Children With ASDs Compared With Controls
ASDs (n ⫽ 64)
Variety score
Energy
Total fat
Protein
Carbohydrates
Classical Autism (n ⫽ 23)
Atypical Autism (n ⫽ 11)
Asperger Syndrome (n ⫽ 17)
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
1.84
0.98
1.01
0.93
0.97
1.48–2.29
0.77–1.26
0.79–1.29
0.72–1.19
0.76–1.24
⬍.001
.894
.926
.545
.837
2.25
0.72
0.78
0.69
0.70
1.59–3.20
0.45–1.13
0.50–1.21
0.44–1.09
0.44–1.11
⬍.001
.154
.260
.110
.131
1.36
1.14
1.18
1.19
1.08
0.78–2.36
0.66–1.97
0.69–2.04
0.69–2.07
0.62–1.89
.279
.638
.542
.531
.782
1.95
0.97
1.00
0.98
0.91
1.29–2.96
0.60–1.55
0.63–1.60
0.61–1.58
0.56–1.48
.002
.884
.997
.947
.715
The variety score is derived from 56 food-frequency questionnaire questions and reflects the number of times that “never” was reported. The logistic regression analyses adjusted for
gender. ORs are for a 1-SD increase. Controls: n ⫽ 9796.
were not impaired. The limitation in
number of foods accepted was most
apparent in children with classical autism, but no other differences were apparent between different types of autism disorders in feeding symptoms,
diet, or growth.
The strengths of the study are that the
sample is population based, which
provides a good normal comparative
group and that feeding data have been
collected prospectively before ASD
was diagnosed. Limitations are that
ASDs in the children were diagnosed
by clinical teams rather than by a
structured research assessment, and
the feeding and dietary data were reported by the mother with no objective
validation.
The finding that breastfeeding rates of
the children with ASDs were no different than those of controls is consistent
with the results of an earlier study
from North Dakota.8 The difficulty in accepting solids and the description of
slow feeding in infancy could be seen
as early symptoms of an autistic
child’s difficulty in accepting change.
Other feeding symptoms such as fussiness became more obvious with increasing age and are most marked in
the children with classical autism. The
restrictions in types of food accepted
by the child with an ASD were apparent
from 15 months of age, often before
referral for specialist autism assessment, and became progressively more
obvious.
A clinical implication of these findings
is that the possibility of an ASD should
e340
EMOND et al
be considered for young children who
present with feeding problems, pervasive food refusal, and limited food preferences, and appropriate questions
should be asked about the child’s social communication, shared attention,
and stereotypic and self-stimulatory
behaviors.
For children who have ASDs and pervasive eating problems, effective behavioral strategies need to address both
the neophobia and sensory sensitivities (color, taste, texture) of the autistic child. Tools such as the Brief Autism
Mealtime Behavior Inventory (BAMBI)9
have been developed to assess feeding
problems in children with ASDs and
provide a useful objective measure to
monitor response to behavioral interventions to improve the range of foods
taken.
Clinicians and parents will be reassured by the finding that, despite the
limited food preferences, the children
with ASDs took adequate amounts of
energy from their diet and grew normally. No differences were found between children with ASDs and their
peers in the balance of carbohydrates,
protein, and fats consumed, which
suggests that satiety mechanisms are
not impaired in ASDs. No differences
were apparent in minerals in the diet,
including iron and calcium. Our results
are consistent with those of recent descriptive studies that also found that,
although the parents of children with
ASDs reported that they were picky
eaters and resisted trying new foods,
the measured nutrient intake of the
children with ASDs was similar to that
of age-matched controls.10
With ⬎30 dietary components being
compared, some associations may be
have been a result of chance, so the
finding that 2 vitamins were reduced in
the ASD diet needs to be treated with
caution. The lower vitamin C intake is
derived from the lower consumption by
the children with ASDs of fruits and vegetables reported in the food-frequency
questionnaires. However, the children
with ASDs had similar iron intake and
hemoglobin levels to those of controls. The children with ASDs also
less frequently accepted dietary
sources of vitamin D and had more
iodine in their diet, but the clinical
significance of these findings is uncertain. In comparison, a recent
smaller, detailed study that compared 3-day dietary diaries of children with ASDs and children with typical development11 revealed that
children with ASDs consumed more
vitamins B6 and E and nondairy protein but less calcium with fewer
dairy servings.
A few autistic children in the ALSPAC
were placed on special diets after the
diagnosis of ASD had been made, with
the parents citing allergy as the reason for the diet, but we did not have
information on how food allergy was
diagnosed. The dietary changes may
have been made in response to the
gastrointestinal symptoms that are reported for autistic children12–15 or to
attempt to improve core autistic behaviors such as ability to communi-
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
ARTICLES
cate. Although many parents of children with ASDs do try special diets
for their children, a recent update of
a Cochrane review on gluten- and
casein-free diets in children with
ASDs concluded that the evidence for
the efficacy of these diets remains
poor.16
The normal dietary consumption of energy by the children with ASDs in our
study is reflected in their normal
growth parameters, consistent with
the literature on growth in children
with autism disorders.17 However, in
some societies, children with autism are
at higher risk of being overweight.18
CONCLUSIONS
Children on the autism spectrum demonstrated feeding symptoms from infancy and had a less varied diet from
15 months of age, but energy intake
and growth were not impaired. Feeding behavior in children with ASDs reflects limited interests and difficulty in
accepting change and, in an extreme
form, can present as a “pervasive eating disorder.”
ALSPAC. This study was funded by the
Medical Research Council: all researchers on this study are independent from
the funding body, and there are no competing interests to declare. This publication is the work of the authors, and Drs
Emond and Steer will serve as guarantors for the contents of this article.
ACKNOWLEDGMENTS
The UK Medical Research Council, the
Wellcome Trust, and the University of
Bristol provide core support for the
We are extremely grateful to all the
families who took part, the midwives
for help in recruiting them, and the
whole ALSPAC team, which includes interviewers, computer and laboratory
technicians, clerical workers, research scientists, volunteers, managers, receptionists, and nurses.
A. The prevalence and characteristics of autistic spectrum disorders in the ALSPAC cohort. Dev Med Child Neurol. 2008;50(9):1– 6
Burd L, Fisher W, Kerbeshian J, Vesely B,
Durgin B, Reep P. A comparison of breastfeeding rates among children with pervasive developmental disorder, and controls.
J Dev Behav Pediatr. 1988;9(5):247–251
Lukens CT, Linscheid TR. The Brief Autism
Mealtime Behavior Inventory (BAMBI). J Autism Dev Disord. 2008;38(2):342–352
Lockner DW, Crowe TK, Skipper BJ. Dietary
intake and parents’ perception of mealtime
behaviors in preschool-age children with
autism spectrum disorder and in typically
developing children. J Am Diet Assoc. 2008;
108(8):1360 –1363
Herndon AC, DiGuiseppi C, Johnson SL, Leiferman J, Reynolds A. Does nutritional intake
differ between children with autism spectrum disorders and children with typical
development? J Autism Dev Disord. 2009;
39(2):212–222
Sandhu B, Steer C, Golding J, Emond. A The
early stool patterns of young children with
autistic spectrum disorder. Arch Dis Child.
2009;94(7):497–500
13. Molloy CA, Manning-Courtney P. Prevalence
of chronic gastrointestinal symptoms in
children with autism and autistic disorders.
Autism. 2003;7(2):165–171
14. Erickson CA, Stigler KA, Corkins MR, Posey
DJ, Fitzgerald JF, McDougle CJ. Gastrointestinal factors in autistic disorder: a critical
review. J Autism Dev Disord. 2005;35(6):
713–727
15. Ibrahim SH, Voigt RG, Katusic SK, Weaver AL,
Barbaresi WJ. Incidence of gastrointestinal
symptoms in children with autism: a
population-based study. Pediatrics. 2009;
124(2):680 – 686
16. Millward C, Ferriter M, Calver S, ConnellJones G. Gluten- and casein-free diets for
autistic spectrum disorder. Cochrane Database Syst Rev. 2008;(2):CD003498
17. Curtin C, Bandini LG, Perrin EC, Tybor DJ,
Must A. Prevalence of overweight in children and adolescents with attention deficit
hyperactivity disorder and autism spectrum disorders: a chart review. BMC Pediatr. 2005;5:48
18. Xiong N, Ji C, Li Y, He Z, Bo H, Zhao Y. The
physical status of children with autism in
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e341
APPENDIX Details of the Diet of Children With ASDs at 38 Months Compared With Controls
ASDs (n ⫽ 64)
Calcium
Carotene
Cholesterol
Omega-3 from fish
Docosahexaenoic acid
Eicosapentaenoic acid
Folate
Iodine
Iron
Magnesium
Monounsaturated fat
Niacin
Non–milk-extrinsic sugar
Fiber
Phosphorus
Polyunsaturated fat
Potassium
Retinol
Riboflavin
Saturated fat
Selenium
Sodium
Starch
Sugar
Thiamin
Vitamin C
Vitamin B6
Vitamin B12
Vitamin D
Vitamin E
Zinc
Classical Autism (n ⫽ 23)
Atypical Autism (n ⫽ 11)
Asperger Syndrome
(n ⫽ 17)
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
1.04
0.74
0.89
0.85
0.73
0.80
0.74
1.61
0.93
1.20
0.95
0.81
1.01
1.12
1.12
0.87
0.95
1.02
1.07
1.34
1.17
1.02
1.05
0.92
0.77
0.65
0.58
0.90
0.63
0.85
1.02
0.69–1.57
0.56–0.99
0.64–1.22
0.63–1.13
0.52–1.01
0.59–1.09
0.51–1.07
1.12–2.31
0.61–1.42
0.81–1.77
0.52–1.76
0.53–1.23
0.70–1.45
0.81–1.54
0.69–1.84
0.64–1.20
0.59–1.52
0.75–1.37
0.74–1.56
0.85–2.11
0.85–1.61
0.63–1.66
0.68–1.63
0.59–1.43
0.51–1.15
0.47–0.89
0.38–0.89
0.65–1.25
0.46–0.86
0.63–1.14
0.67–1.58
.842
.042
.467
.265
.061
.163
.111
.010
.733
.358
.880
.319
.961
.490
.640
.399
.819
.922
.709
.203
.349
.930
.811
.698
.206
.007
.012
.536
.004
.279
.911
1.35
1.12
0.70
0.97
0.98
0.96
0.61
1.42
0.79
1.23
1.01
0.68
0.88
1.20
1.23
0.56
0.95
0.80
1.12
1.87
1.13
0.61
0.98
0.92
0.83
0.69
0.50
0.84
0.48
0.55
1.07
0.67–2.75
0.74–1.69
0.38–1.27
0.62–1.53
0.62–1.54
0.60–1.52
0.32–1.19
0.73–2.74
0.37–1.71
0.62–2.46
0.34–2.98
0.32–1.44
0.44–1.78
0.69–2.10
0.51–2.93
0.31–1.02
0.41–2.20
0.41–1.59
0.58–2.16
0.87–4.01
0.63–2.03
0.26–1.46
0.43–2.20
0.40–2.10
0.41–1.70
0.41–1.18
0.24–1.05
0.47–1.51
0.27–0.84
0.30–0.98
0.50–2.30
.399
.603
.241
.903
.925
.847
.148
.303
.553
.551
.983
.317
.727
.522
.647
.059
.909
.530
.746
.110
.677
.267
.957
.847
.619
.176
.069
.557
.011
.044
.863
0.52
0.62
1.00
1.04
0.77
0.96
1.04
1.76
1.44
1.55
1.36
1.25
0.97
1.70
1.10
1.28
1.10
1.46
0.89
1.15
1.49
2.51
1.04
0.67
0.79
0.87
0.65
1.22
0.63
1.13
1.22
0.19–1.42
0.29–1.29
0.49–2.06
0.57–1.88
0.36–1.64
0.51–1.81
0.45–2.43
0.76–4.11
0.56–3.67
0.64–3.74
0.34–5.43
0.49–3.15
0.43–2.21
0.86–3.37
0.35–3.44
0.65–2.54
0.37–3.29
1.09–1.96
0.37–2.16
0.39–3.37
0.74–3.02
0.85–7.48
0.39–2.75
0.24–1.89
0.31–2.01
0.45–1.69
0.24–1.73
0.62–2.40
0.30–1.33
0.59–2.18
0.45–3.33
.202
.198
.990
.903
.494
.904
.927
.189
.449
.326
.665
.643
.946
.129
.871
.476
.869
.012
.792
.803
.263
.097
.941
.452
.618
.679
.386
.565
.229
.713
.695
0.92
0.64
1.60
1.02
0.83
0.96
1.13
2.42
0.78
0.95
0.97
0.97
0.62
0.84
1.04
0.82
0.91
0.92
1.00
1.32
1.35
1.63
1.53
0.51
0.70
0.48
0.85
1.19
0.95
0.75
0.92
0.41–2.06
0.35–1.15
0.97–2.62
0.62–1.68
0.46–1.49
0.57–1.62
0.56–2.29
1.28–4.56
0.33–1.82
0.43–2.06
0.30–3.18
0.44–2.16
0.28–1.39
0.44–1.62
0.40–2.69
0.44–1.51
0.36–2.27
0.47–1.79
0.48–2.08
0.55–3.17
0.74–2.48
0.64–4.14
0.68–3.45
0.20–1.27
0.32–1.55
0.23–0.98
0.38–1.92
0.67–2.13
0.53–1.70
0.41–1.36
0.40–2.13
.843
.136
.065
.947
.537
.878
.725
.006
.566
.889
.964
.943
.246
.606
.941
.519
.833
.800
.944
.538
.333
.308
.305
.148
.378
.043
.702
.548
.866
.339
.844
The variety score is derived from 56 food-frequency questionnaire questions and reflects the number of times that “never” was reported. Logistic regression analyses were adjusted for
gender (and energy, except for energy, total fat, protein, and variety). ORs are for a 1-SD increase. Controls: n ⫽ 9796.
e342
EMOND et al
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Feeding Symptoms, Dietary Patterns, and Growth in Young Children With
Autism Spectrum Disorders
Alan Emond, Pauline Emmett, Colin Steer and Jean Golding
Pediatrics 2010;126;e337; originally published online July 19, 2010;
DOI: 10.1542/peds.2009-2391
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