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Available online at www.sciencedirect.com
ScienceDirect
journal homepage: http://www.pediatr-neonatol.com
Review Article
Managing constipation in children with ASD
e A challenge worth tackling
Kalyani Vijaykumar Mulay a,b,
Sivaramakrishnan Venkatesh Karthik a,b,*
a
Khoo Teck Puat-National University Children’s Medical Institute, National University Health System,
Singapore
b
Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore,
Singapore
Received Jun 8, 2021; received in revised form Oct 24, 2021; accepted Nov 12, 2021
Available online - - -
Key Words
ASD;
autism;
behavioral;
constipation;
laxatives
Autism Spectrum disorder (ASD) is well known to be associated with significantly high rates of
gastrointestinal problems, constipation being common among them, imposing a significant
burden on child and the family. On account of multiple underlying factors, both diagnosis
and subsequent management of constipation in children with ASD are much more challenging
as compared to managing constipation in ‘neurotypical’ children. Associated higher rate of
presentation to the hospital emergency and subsequent hospital admission rates add to the
burden. Hence, there is a need for recognizing constipation as a problem in children with
ASD. This review summarizes optimization of its management by adopting a multidisciplinary
holistic approach to achieve good outcomes and enhance the quality of life for the child
and the family.
Copyright ª 2022, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
1. Introduction
* Corresponding author. Khoo Teck Puat-National University
Children’s Medical Institute, National University Health System,
Department of Paediatrics, NUHS Tower Block Level 12, 1E Kent
Ridge Road, Singapore, 119228. Fax: þ65 6779 5678.
E-mail address: venkatesh_karthik@nuhs.edu.sg (S.V. Karthik).
Autism Spectrum disorder (ASD) is a challenging and
increasingly diagnosed developmental disorder with prevalence estimates indicating that as many as 1 in 59 children
in the USA suffer from this condition.1 ASD is well known to
be associated with significantly high rates of gastrointestinal problems with prevalence rates varying greatly.2
Constipation is very common with prevalence rates of
around 50% or higher.2,3 It imposes a significant and
https://doi.org/10.1016/j.pedneo.2021.11.009
1875-9572/Copyright ª 2022, Taiwan Pediatric Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: K.V. Mulay and S.V. Karthik, Managing constipation in children with ASD e A challenge worth tackling, Pediatrics
and Neonatology, https://doi.org/10.1016/j.pedneo.2021.11.009
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K.V. Mulay and S.V. Karthik
clinical features are indicative of possible Hirschsprung’s
disease.
Recently there have been reports about potential association of constipation with mitochondrial disorders.11,12
Oliviera et al. in their study screened for associated medical conditions in 120 children with ASD.11 Plasma lactate
levels were measured in 69 of these children with 14 having
elevated plasma lactate. Five of these 69 children (7.2%)
were subsequently diagnosed to have co-existing mitochondrial respiratory chain disorders. Weismann et al.
described 25 children with ASD, who were later found to
have either an enzyme-defined or mutation-defined mitochondrial disorder.12 These studies illustrate the need for
careful clinical and biochemical assessment even in children with a confirmed ASD diagnosis, especially when they
present with or develop abnormal neurological deficits,
unexplained neuro-regression, hyperlactatemia or unexplained liver function test abnormalities.
Dietary contribution is often a relevant factor in the
development of constipation. Stereotypic diets lacking in
natural fiber, higher intake of processed and refined food,
lower fluid intake and medications for associated medical
problems have been suggested to be underlying causes.6
Food selectivity and eating patterns play an important
role in development of constipation in ASD children. Harris
et al. examined the association between childhood autistic
traits and constipation, focusing on the role played by food
selectivity and eating behaviors.13 Their study revealed a
strongly positive association between parent-reported
childhood ASD traits and constipation (r-0.08, p < 0.001)
at 10 years of age. The study identified a significant indirect
effect of ASD traits on constipation symptoms through food
selectivity (b 0.008; 95% CI: 0.002e0.014). This opens the
potential for behavioral intervention strategies targeting
food selectivity. Children with ASD are also disproportionately affected by pica. An American study found an association of pica with both constipation and painful
defecation in these children.14
The gut microbiome is intricately linked with gut function and well being. Altered gut microbial profile is well
documented in ASD children and those with functional
constipation.15,16 Children with ASD might have a distinctive and underdeveloped range and volume of gut bacteria,
unrelated to their diet.17 This study, carried out in young
pre-school children found a preponderance of Clostridium,
Dialister and Coprobacillus. Clostridia species have been
linked with ASD potentially through toxins produced, with
their possible deleterious effects on the developing central
nervous system. Several studies have shown that patients
with ASD have significantly altered bacterial gut microbiota.18,19 This has been the situation even in developing
countries.20 Many studies showed not only the prevalence
of Clostridia species in excess but also a decrease in the
Bacteroides/Firmicutes ratio.19 It is postulated that this
predominance of Firmicutes through production of surplus
amounts of carbohydrates (by degradation of polysaccharides in the intestine) causes neurobiological and
behavioral problems associated with ASD.17,21 Diet is known
to affect the composition of gut bacteria.22 The phenomenon of food selectivity and strong preference for a narrow
food range may lead to lower counts of potentially beneficial bacteria. A recent study by Dan Z et al., employing
challenging burden on both the child and the family in
terms of its pronounced impact on quality of life. Both
diagnosis and management of constipation in children with
ASD are much more challenging as compared to ‘neurotypical’ children. Additionally there is a higher rate of
hospital emergency department attendances and admission
rates in ASD children.4 This puts families under significant
psychological and financial stress resulting in families often
expressing dissatisfaction with overall care services.5
Hence there is a strong need for recognizing constipation
in children with ASD and optimizing its management by
adopting a multidisciplinary holistic approach to achieve
good outcomes and enhance quality of life for these children and their families.
2. The scale of the problem and evolution
Epidemiological studies of GI problems in children with ASD
have been plagued by methodological limitations. Prevalence estimates of all GI disorders in ASD, range from 9 to
90%.2,3 A recent review revealed rates from 4.3 to 45.5% for
constipation with a median of 22%.2 Heterogeneity in terms
of adopting a standard definition for ascertainment of the
clinical problem, wide variation in the study populations,
the wide spectrum of severity of the underlying ASD, and
the retrospective and/or observational nature of these
studies were the main limitations.2 The methods employed
for data collection such as different types of questionnaires, varying access to medical records and importantly
the presence or lack of physician input (particularly from
the developmental pediatrician and/or pediatric gastroenterologist) further contributed to this potential underestimation of actual prevalence.
Conventionally, constipation has been defined as
reduced frequency and/or difficulty in defecation for 2
weeks or more (arbitrarily defined as less than 3 times per
week). Constipation is difficult to diagnose early in ASD as
most of the existing clinical practice guidelines are not
designed to routinely interrogate and capture data relevant
to GI issues in these children.6 As compared to ‘neurotypical’ children, those with ASD present significant challenges in terms of primary recognition of constipation and
its diagnostic evaluation due to the inherent behavioral and
communication difficulties in children with ASD. Severe
non-verbal ASD Children tend to present atypically.
Therefore, parents are unable to recognize underlying
constipation leading to delayed diagnosis.4,6
Most children with ASD suffer from functional constipation. Delayed or absent bowel training and control
often secondary to sensory perception and processing difficulties and sometimes recto-sphincteric dyssynergia contributes to development of abnormal defecation reflexes.7
Although there is no direct confirmed link between ASD
and Hirschsprung’s disease, the co-existence of these two
entities has been described.8e10 Recent studies have
revealed that mutations in the BAF complex subunits are
linked to neurodevelopmental disorders including ASD and
Hirschsprung’s disease.10 Haploinsufficiency of the FOXA
gene has been associated with multi-system as well as
neuro-developmental disorders including ASD.9 Therefore,
detailed evaluation by pediatric surgeons is warranted if
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demonstrated by anorectal manometry.32 However, this is
not routinely recommended on account of being mildly
invasive and cumbersome. Although these investigations
may help quantify severity, their contribution to active
management may be minimal and hence they should be
used with discretion.
Thyroid function test, coeliac screen, serum calcium and
lead levels may be checked. If Hirschsprung’s disease is
suspected, rectal manometry and/or biopsy may be
necessary. Spinal neuroimaging and other investigations for
neuromuscular problems are not routinely recommended
and should be carried out only after specific input is sought
from a pediatric neurologist. Gastrointestinal endoscopy is
also not routinely recommended.
ribosomal RNA sequencing, revealed altered gut microbial
profile potentially associated with abnormal metabolic activity in children with ASD.23 This study revealed a plausible
link between the atypical metabolites and evolution of
chronic constipation employing liquid chromatographymass spectrometry techniques.
3. Clinical evaluation and investigations
All children with ASD should be proactively assessed for
gastro-intestinal issues. A thorough medical history should
be obtained from parents, caregivers and from verbally
competent children. Frequency of bowel movements,
consistency and size of stools passed, abdominal and/or
perianal discomfort, any blood streaking of stools and stool
withholding behaviors should be ascertained. Behavioral
alterations as well as their temporal associations with
defecation and/or attempts at defecation should be specifically sought for. Additional input from medical records,
past episodes of hospital visits/admissions, new medications, recent significant events like dietary changes and/or
change of school/care centers should be obtained whenever possible.
Most often, constipation in children with ASD tends to be
of mild-to-moderate severity. Studies have shown a wide
range of prevalence varying between 4.3 and 45.5%, with a
median of 22%.2 In those who can verbally communicate, it
can present with recurrent abdominal pain or discomfort
(prevalence range 2.1e46.6%; median 14%).2 Chronic or
persistent constipation with/without associated findings,
such as blood-streaked stools, was found to have a prevalence ranging between 8.8 and 38.5% (median 19.7%) in this
review.2 Fecal and urinary incontinence with encopresis
can occur. Niemczyk et al. found a 12% median prevalence
of encopresis.24
In many ASD children, especially non-verbal ASD, atypical behavioral presentations predominate. Atypical presentations include abnormal posturing such as bending over
or pressing over furniture and clutching or pressing/hitting
on abdomen. Atypical behaviors including aggression, headbanging, biting and hitting were observed in 53% by
Mazurek et al.25 Exaggeration of vocal stereotypy and/or
repetitive behavior and other primary ASD features have
also been described.26 Gait abnormalities including narrow
gait walking and/or crossing legs were observed in
20e50%.27
Physical examination to look for palpable fecal masses,
especially in the left lower quadrant of the abdomen, is
essential. Per rectal examination, if feasible, may help
assess anal tone and stool retention. Incidental detection of
fecal impaction on routine physical examination including
per rectal examination was identified in 9% of the study
population in one study.28 However no validated scoring
systems exist which would help objectively quantify
severity of constipation in children with ASD. Although
routine abdominal radiographs are not recommended, fecal
loading may be seen on individual films taken for other
reasons.29 Radio nuclear scintography using isotope labeled
studies may show slow transit.30 Colonic transit studies
using activated charcoal or radiopaque markers may help
quantify severity.31 Dyssynergy at defecation can be
4. Objective assessment and evaluation
A recent review studying ascertainment and prevalence of
GI symptoms in children with ASD identified that 83/144
studies included only employed questionnaires administered to parents/caregivers.2 Only 12.5% sought additional
input from the caregiver/physician or medical records.
Only 94 studies assessed constipation. McElhanon’s systematic review (15 studies, 2215 children) showed that
children with ASD as compared to controls experienced
higher prevalence of constipation (Odds ratio of 3.86).33
Significant heterogeneity is observed in the above reviews
that included several questionnaires. Table 134e39 illustrates some of the questionnaires employed. It is evident
that almost all of these questionnaires have significant
drawbacks and many of them are not validated. GI symptoms including constipation were neither explored in detail
nor defined objectively. The Childhood Autism Risks from
Genetics and the Environment (CHARGE) is a very useful 10item questionnaire that not only focuses on the presence/
absence of GI-symptoms but also quantifies symptom
severity on a Likert scale of 1e10.37 Additional advantages
include ability to collect data on food allergies and dietary
restrictions, thereby investigating their potential association with constipation. The major limitation of this questionnaire is its inability to collect behavior-related data
that might have correlation with constipation.
The broad-based Rome 2 criteria adapted GI questionnaire elicits long-term history of both GI symptoms and
feeding/food-related issues in depth.39 Once again, there is
no behavior-related data that can be gleaned. An
advancement on this was the Questionnaire on Pediatric
Gastrointestinal Symptoms (Rome 3 QPGS).36 Although this
explored GI symptoms in greater detail with clinical input,
the behavior-related aspects were not focused on as this
was based on a single physician encounter.
The Autism Treatment Network (ATN) gastrointestinal
symptom inventory is superior in terms of not only ascertaining the presence and nature of GI symptoms but also
evaluating associated behaviors associated with GI symptoms. The drawback of this questionnaire is its inability to
collect information on dietary components, food allergies/
intolerance and meal-time behaviors.34 Other methods
using Chandlers’ questionnaire as well as the ATEC criteria
have significant limitations with not much focus on constipation.35,38 Thus, there is a need for an objective
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Table 1
Questionnaire-based evaluation of constipation in children with ASD.
Questionnaire and
study
Number of children
included in study
Number of GI
symptoms
included
Data collected
Data source
Comments
CHARGE (Childhood
Autism Risks from
Genetics and the
Environment),
Gastrointestinal
history form
Hansen et al.37
333
10 items
GI symptoms and
severity using
Likert scale
Parents
Atypical
behavioral
symptoms not
ascertained.
The Gastrointestinal
questionnaire
(ROME II criteria
based)
Valicenti McDermott
et al.39
100
8 items
Parents
Questionnaire on
Pediatric
Gastrointestinal
Symptoms eROME
III (QPGS)
Gorrindo et al.36
121
71 items
The Gastrointestinal
symptom
inventory (Autism
Treatment
Network)34
Chandler’s 20-item GI
symptom
questionnaire
Chandler et al.35
The Autism treatment
Evaluation
Checklist (ATEC)
subscale
(Developed by
Autism Research
institute
Rimland and
Edelson38
Research questionnaire
designed for use
77 items
Presence and
duration of GI
symptoms
Parents
132
20 items
Parents
1358
77 items
GI symptoms for
current (3 months)
and past
symptoms
4 items pertinent
to GI symptoms
- Assesses concurrent and past
clinical problems
in detail.
- Behavioral issues
were not
ascertained.
- Based on wellaccepted ROME
III criteria with
clinical
evaluation.
- Physician evaluation limited to
single encounter
only.
Mealtime
behaviors and
correlation with
dietary factors not
fully explored.
Less focus on
constipation.
No physician
input.
Limited
applicability in
evaluation of
constipation
- Food
allergies
and dietary restrictions
information
- Current
GI
symptoms
- Lifetime history
of concomitant
gastrointestinal
and feeding
problems
GI symptoms only
Parents
Parents/
caregivers/
teachers
issue and summarizes research that looked at primary ASD
variables and potential associations with constipation in
children with ASD. Wang et al., in their caseecontrol study
based on parental recall, reported a 20% prevalence of
constipation.3 Conditional logistic regression analysis
revealed that increased autism severity was associated
with higher odds of constipation. Gorrindo et al. found that
younger, more socially impaired and non-verbal children
had an increased odds ratio for constipation.36 However,
other studies did not demonstrate correlation between
severity of ASD and the presence and/or severity of constipation.35,45,48 Some investigators looked at language
questionnaire, which would help precisely define clinically
relevant details for assessment of constipation in children
with ASD.
5. Constipation-relationship with primary ASD
features
It is debatable as to whether the presence of gastrointestinal symptoms, in particular constipation and its severity,
has any association or correlation with severity of core ASD
symptoms. Table 23,25,26,35e37,39e49 attempts to address this
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Table 2
Association between primary ASD features and constipation in children with ASD.
Primary ASD feature
Constipation characteristics
Severity of ASD
Conflicting evidence as regards ASD severity and occurrence/
severity of constipation3,35,36,45,48
Younger and non-verbal children had higher prevalence of
constipation36,46
Conflicting evidence as regards language regression and
constipation occurrence/severity35,37,39,40,45,47
Potential association with aggressive/oppositional behavior25,26
Potential association with rigid compulsive behavior43
Association with ADHD41,42,46
Association of constipation with higher scores on ASD co-morbidity
scores42 and Anxiety44,46,48,49
Language and communication difficulties
Language regression
Behavioral problems
Co-morbid psychopathology
constipation. Neumeyer et al. further highlighted this association.46 Their large multi-center study included 2114
ASD children under 5 years of age and 1221 ASD children
between 6 and 17 years. They found that the prevalence of
seizure disorder was 2.5% in children under 6 years and 3.4%
in the 6e17 year age group.46 Strasner et al. performed a
meta-analysis of 19 studies showing a pooled ASD prevalence of 6.3% in children with epilepsy.52
Neumeyer et al. also found a prevalence of 26.8% for
sleep disorders in children under 6 years and 24.3% in older
children.46 Sleep issues included sleep disturbances of nonspecific nature, insomnia, inadequate sleep hygiene and
behavioral insomnia of childhood. This study revealed a
strong association between constipation and co-occurrence
of sleep disorders in their ASD cohort. A similar association
between sleep disorders and constipation was also
observed by Aldinger et al. in children with ASD under 5
years of age.53 Mannion et al. found a prevalence of over
80% for sleep problems with many having constipation and/
or abdominal pain in 2 separate studies.42,54 The prevalence of sleep disorders associated with constipation in ASD
children varied from 50 to 80%.55
regression and found a high incidence of constipation or
blood in stools and abnormal stool patterns.39,47 Two
studies found that speech and language disorders as well as
communication difficulties were associated with constipation.36,46 Other studies did not see this
association.35,37,40,45
6. Constipation-association with behavioral
problems in children with ASD
As regards behavioral problems, the evidence is equivocal.
Although Mazurek et al. demonstrated an association between aggressive behavior and GI problems including constipation, the presence of GI problems was not a significant
predictor of aggressive behavior.25 Another study revealed
that constipation in ASD was potentially associated with
argumentative, oppositional or destructive behavior.26
Constipation in children with ASD has been associated
with hyperactivity and maladaptive behavior.41 Mannion’s
series showed an 18% prevalence of ADHD.42 Neumeyer46
found prevalence rates of 6.4% for ADHD in children under
6 years. This was significantly higher at 34.5% for children in
the 6e17 years age group. However, they did not see a
significant correlation with constipation on paired data
odds-ratio analysis. Functional constipation was associated
with rigid compulsive behaviors in another study.43 The link
between ASD associated constipation and co-morbid psychopathology was seen in both pre-school as well as older
children.42 Constipation correlated with higher predicted
total scores on the ASD-CC (ASD-comorbid for children)
scoring system. Other studies showed significant correlation
of constipation with anxiety, irritability and social
withdrawl.44,46,48,49
8. Management
The basic principles underlying the management of constipation in ‘neurotypical’ children are also applicable to
children with ASD suffering from constipation.29 Nevertheless, the need for adequate attention and focus on the
behavioral and functional aspects of constipation makes
management more challenging. Optimal management will
improve clinical outcomes and enhance quality of life.
Dietary interventions with autism have been investigated
with their primary objective of whether this improved
behavior as well as symptoms, which is especially relevant
to the gut in children with ASD.56 Conventional measures
such as increased consumption of fruits and vegetables,
avoiding refined foods lacking natural fiber and recommendations to increase fluid intake are not easy to implement in
children with ASD. The gluten-free, casein-free (GFCF) diet
was initially found to be associated with anecdotal benefits.
A 2012 study found that such diets were effective in
improving behavioral outcomes for children with constipation as compared to children with ASD who had no gut-
7. Constipation-association with medical and
psychiatric comorbidities in ASD children
ASD in childhood has well-recognized association with epilepsy, sleep problems, attention deficit and hyperactivity
disorder.41,50,51 Mannion et al. in their observational study
found a prevalence of 10% for epilepsy.42 Almost 80% of
children in this series had constipation and/or abdominal
pain. Many children with epilepsy had associated
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Table 3
Medical management-Pharmacotherapy options.
Medications
Dosage
Comments
Osmotic laxatives
Lactulose (Usually 70%
solution)
1e3 ml/kg/day in 2 divided
doses
Sorbitol (70% solution)
1e3 ml/kg/day in divided doses
Magnesium-based osmotic
laxatives such as Mg (OH)2
1e3 ml/kg/day Mg (OH)2 or in
tablet form
Polyethylene glycol (PEG 3350)
Fecal disimpaction with 1
e1.5 g/kg/day (very variable as
per response)
Maintenance at 1 g/kg/day
Usually well tolerated long term and palatable
Occasionally can cause flatulence and/or
crampy abdominal pain
Similar side effects as lactulose
Cheaper than lactulose but not universally
available
Not recommended in infants
Not safe long term
Inadvertent overdose can cause
hypermagnesemia, hypophosphatemia and
hypocalcaemia
Very well tolerated and good safety profile in
older children.
Limited experience in young children (preschool and infants)
High palatability and easy to use (dissolvable
powder)
Can also be used as osmotic enemas for severe
fecal impaction (administered orally or via
nasogastric tube)
Stimulant laxatives
Senna
Bisacodyl
2.5 ml/day for 2e6 years
5e15 ml/day for 6e12 years
Tablets/granules for older
children
Tablets and suppositories
Crampy abdominal pain, abnormal LFT,
reversible melanosis coli
Can potentially exacerbate behavioral
concerns (due to the pain/discomfort)
Best avoided in younger children
Abdominal pain, diarrhea and occasionally
dyselectrolytemias, particularly hypokalemia
Best avoided in younger children
Additional comments:
Mineral oil preparations and phosphate enemas are best avoided.
Glycerin and Bisacodyl suppositories are generally safe but can exacerbate stress and behavioral issues arising on account of
insertion.
related symptoms.57 However, a placebo effect could not be
ruled out because parental perceptions could be subjective.
A systematic review concluded that these diets are of no
value.58 Currently, there is lack of evidence to support the
hypothesis that ASD is associated with a significantly
increased incidence of food allergies/intolerance.
An algorithm for early recognition and management of
constipation in children with ASD is applicable for the majority.7 Personalized management plans might be beneficial. Pharmacotherapy in addition to behavioral
interventions form the mainstay of management. Table 3
summarizes the options available. The initial recommended options would be osmotic laxatives such as lactulose or sorbitol. These are more palatable and easier to
administer in terms of medication volumes. Further, they
have an established safety record. In severe and refractory
constipation unresponsive to lactulose or sorbitol as well as
for those with fecal impaction, the use of polyethylene
glycol (PEG 3350) is recommended. It is well tolerated with
an established safety profile in older children. Although
there is limited experience in pre-school children, evidence
is currently emerging favoring its use. Stimulant laxatives
like Senna or Bisacodyl are best suited for use as an adjuvant only along with osmotic laxatives. These should be
used only in severe and refractory constipation, ideally for
short periods of time. In younger non-verbal children, they
can cause abdominal discomfort, pain and even diarrhea.
For high functioning ASD children, as well as children
who have the capacity to be co-opted in their care,
communication and counseling helps. They can be encouraged to include more fruits and vegetables in their diet.
These measures result in improved compliance with treatment. Behavioral interventions including routine toilet
attendance, particularly after main meals, can be advocated to parents and older co-operative children. This
might help in mitigating stool withholding behavior, which
worsens constipation and potentially results in encopresis.
Special situations such as encopresis often complicate
management of constipation in children with ASD. A recent
study demonstrated benefits with multi-disciplinary intervention involving not only pharmacotherapy but also
behavioral intervention.59 However, this small pilot study
involved use of rectal suppositories, which raises questions
about the sustainability of this strategy in the long term.
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9. Research ideas
Authorship
There is an urgent need for developing, validating and
carrying out psychometric testing on a standardized
questionnaire-based method for ascertainment of GI
symptoms for children with ASD. This could help design
suitable high-quality research studies. Most of the published research has been from the West and 94% of the
study subjects in pooled reviews were Caucasian patients.2
Although 144 studies assessed constipation in children with
ASD, only 6.9% were conducted in Asia and 1.4% in Africa.2
Perusal of this review revealed no further details regarding
patient population breakdown by ethnic groups. 48% did not
specify the race/ethnicity distributions of their sample
and, among the rest, 94% were almost all Caucasian children. Therefore, the most likely possibility is that the 6%
non-Caucasian children were most likely derived from the
ethnic minority population resident in Europe/North
America and Oceania that contributed in aggregate to more
than 75% of children in the studies included. A more recent
large series had a significant proportion (21%) of nonCaucasian children.46 This relative paucity of data raises
the need for prioritized research in under-represented nonCaucasian populations. Qualitative research exploring potential links between diet, socioeconomic status and GI
symptoms in ASD is also recommended. There is conflicting
evidence as regards the association between parental
socio-economic status and ASD as well as its severity
including associated gastrointestinal symptoms.60 It would
be plausible to infer that earlier and regular access to
healthcare is linked with socioeconomic status.
ASD-associated constipation can sometimes be more
challenging to manage in older children. Further studies in
this age group as well as qualitative research analyzing the
impact of constipation on their functioning, quality of life
and educational outcomes are imperative. Lastly, encopresis complicating severe constipation is very challenging to
manage. A systematic review of 33 studies showed a higher
prevalence of incontinence (both fecal as well as urinary)
and encopresis, as compared to typically developing children.24 A subsequent caseecontrol study by the same group
involving 37 children with ASD revealed a higher prevalence
of both nocturnal enuresis and day-time urinary incontinence.61 However, fecal incontinence incidence was not
statistically significant as compared to the healthy controls.
The mean age of children included in this study was 10.2
years and this might be a potential confounder. Further
research into intervention specifically addressing management of incontinence would be valuable.
Dr Kalyani Vijaykumar Mulay, and Dr Sivaramakrishnan
Venkatesh Karthik both conceptualized and wrote the
initial manuscript, and subsequently reviewed and revised
it. Both the authors approved the version to be published
and agree to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and
resolved.
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Declaration of competing interest
The authors have no relevant financial or non-financial interests to disclose.
Acknowledgement
We would like to thank Dr Dimple Rajgor for helping with
reviewing, editing, formatting, and submission of the
manuscript for publication.
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Gastrointestinal symptoms, particularly constipation, are
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ASD. Constipation can be difficult to manage and can often
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