How to Get Your

Mainstream Physician To
See Beyond Autism
Autism ONE Conference May
2009

Sonja Hintz, RN, BSN

Sym Rankin, CRNA, APN
True Health Medical Center
Naperville, Illlinois
 Autism
• ICD 9 Code VS DSM4R VS
IFP/IEP
• Autism’s presentation of external
behaviors are the result of internal
physiology.
• Our presentation will focus on how the
behaviors correlate with physical
issues.
• Attempt to see all behaviors your child
has as a means of communication of
his/her physical self.
 Mainstream Views on
Autism
http://www.ninds.nih.gov/disorders/autism/detail_autism.htm#133913082

• How is autism treated?

•  There is no cure for autism. Therapies and behavioral interventions
are designed to remedy specific symptoms and can bring about substantial
improvement.  The ideal treatment plan coordinates therapies and
interventions that target the core symptoms of autism:  impaired social
interaction, problems with verbal and nonverbal communication, and obsessive
or repetitive routines and interests.  Most professionals agree that the earlier
the intervention, the better.

• Educational/behavioral interventions:  Therapists use highly

structured and intensive skill-oriented training sessions to help children develop
social and language skills.  Family counseling for the parents and siblings of
children with autism often helps families cope with the particular challenges of
living with an autistic child. 

• Medications:  Doctors often prescribe an antidepressant medication to

handle symptoms of anxiety, depression, or obsessive-compulsive disorder. 
Anti-psychotic medications are used to treat severe behavioral problems. 
Seizures can be treated with one or more of the anticonvulsant drugs. 
Stimulant drugs, such as those used for children with attention deficit disorder
(ADD), are sometimes used effectively to help decrease impulsivity and
hyperactivity.
 Autism can be treated!
• 1 of 150 kids have autism.
• Children that have recovered,
actually had a diagnosis of Autism.
• It is unethical to withhold medical
treatment, for a medical condition.
• Keeping autism as a behavioral
disorder allows medical treatment to
be denied.
 The Pediatrician’s Paradigm

299.00 = Current ICD9 diagnosis code for

Autism
(not reimbursable by insurance as a
medical code because autism is a
behavioral disorder and is not a medical
condition)
http://www.talkaboutcuringautism.org/health
Look at your child as having physical
issues that impact their behavior, relay
this to others.
i.e. Make a list of these physical
Paradigm Shift:
This is one picture with two animals
represented at the same time. Autism is both
physical and behavioral.
 Autism defined as a physical
illness
Implies Treatment is Necessary
• You are the Coach, assemble your
team players.
• Sometimes the team players need to
be traded.
• Educate the professional team
players about your child’s physical
condition, writing down specifics.
 Examine your Child
• Write down a concern/observation
• Ask yourself specific questions:
– When does this behavior happen?
– What occurs before I see this behavior?
– What did he/she eat today?
– Are there any signs of pain?
– What happens after you intervene?
True Health Medical Center
• Our practice currently treats over
1500 children world wide.
• Our patients have physical issues
that impact their physical well being.
• Assessment and treatment of their
physical well being brings around a
positive change in that child's life.
Behavioral presentation and labs used
to assess the physical well being
Behavioral Observations
 General Labs
• Basic Labs • Reasons to run
– CBC with labs
differential – Weight loss
– Comprehensive – Frequent infections
Metabolic Panel – Pica
– Iron and Ferritin – Poor attention
Level
– Hyperactivity
– Thyroid panel
– Picky eater
– Blood Lead level
– Maldigestion
– Plasma Zinc
– Malabsorption
– Vitamin D 25 OH
– Poor Growth
– Blood Ammonia
– Serum Copper
 OCD Behaviors
• Stimmy behavior: Verbal,
Perseverative, Scripting, Rewinding
Videos
• Obsesses on placement of objects
 Mitochondria
• Mitochondria • Physical
Dysfunction is a Presentation in
common finding in Autism
Autism – Headaches/Headba
nging
– Low muscle
• Mitochondria are tone/hypotonia
the energy power – Poor coordination
house of our body – Fatigue with activity
– Failure to gain
weight
– Intolerance to
fasting
 Mitochondria Testing
• Screening from the • Our Practice:
pediatrician: – Organic acid test
– Ammonia plasma – Metabolic Analysis
level Profile
– Lactic Acid (blood) • These test look
– Carnitine level at the Kreb cycle
(blood) metabolites
– Pyruvic Acid (blood)
– Urinary
Methylmalonic Acid
 Mitochondrial Dysfunction
Research
Developmental regression and mitochondrial dysfunction in
a child with autism. Child Neurol. 2006 Feb;21(2):170-2. Poling JS
• Aspartate aminotransferase was elevated in 38% of patients with autism compared
with 15% of controls (P <.0001). The serum creatine kinase level also was
abnormally elevated in 22 (47%) of 47 patients with autism. These data suggest that
further metabolic evaluation is indicated in autistic patients and that defects of
oxidative phosphorylation might be prevalent.

Mitochondrial dysfunction in autism spectrum disorders: a

population-based study. Dev Med Child Neurol. 2005 Mar;47(3):185-9
Oliveira G
• Plasma lactate levels were measured in 69 patients, and in 14 we found
hyperlactacidemia. Five of 11 patients studied were classified with definite
mitochondrial respiratory chain disorder, suggesting that this might be one of the
most common disorders associated with autism (5 of 69; 7.2%) and warranting
further investigation.

Relative carnitine deficiency in autism.

J Autism Dev Disorder. 2004 Dec;34(6):615-23 Filipek PA
• Values of free and total carnitine (p < 0.001), and pyruvate (p = 0.006) were
significantly reduced while ammonia and alanine levels were considerably elevated
(p < 0.001) in our autistic subjects. The relative carnitine deficiency in these
 Immunizations
• Traditional medical practice is one
size fits all
• Titer Levels can be checked to assess
for immunity after a vaccination is
given
• When checking immunity IgG
QUANTITATIVE titer needs to be done
– this gives you a level of immunity with
a number
– i.e. Measles IgG quantitative titer
Puzzle Pieces related to the GI
Tract
• Constipation/Stomach Problems can present
with:
– Food refusals
– Arching of the back
– Toe walking
– Bloated stomach
– Daily BMs, yet stools are large or scanty
– Laying over objects to put pressure on the
stomach
– Head Banging
– Sour Breath
– Frequent night waking
– History of colic
– Excessive chewing or biting of the arm
 Gastrointestinal Abnormalities
• Maldigestion
– Decreased activity of digestive enzymes (Horvath,1999. Buie, 2004)
– High levels of opioid peptides found in urine of autistics. (Reichelt, 1997)
– IgG Food Sensitivities
• Malabsorption
– Fat Soluble Vitamin Deficiencies
– Essential Fatty Acid Deficiencies, Omega 3 Deficiencies
– Essential Amino Acid Deficiencies
• Dysbiosis
– Dysbiosis or altered bowel flora (Rossenau, 2004)
– Clostridial overgrowth (Sandler, 2002, McFabe 2007)
– Persistent measles virus (Wakefield, Krigsman)
• Gut Inflammation
– Autistic Enterocolitis, Lymphoid Hyperplasia (Wakefield,1998)
– Increased intestinal permeability leading to food sensitivities and autoimmunity
(Vodjani, 2002)
– Increased pro-inflammatory cytokines – LP, TNF alpha, IFN gamma
(Ashwood, 2004; Jyonuchi 2005)
– Proinflammatory response to dietary proteins (Jyonuchi, 2004)
– Proinflammation similar to Autistics found in immunized Monkeys (Hewitson,
2008)
 Gastrointestinal Treatment
• GI doctors need to be team players.
• Present a detailed account of the observed
behaviors and how you see this relates to his
physical well being and/or pain.
– When my child has a BM he cries, he refuses to
use the toilet.
– When my child eats, I see him arch his back, and
he burps a lot.
– My child is able to defecate a stool the size of the
Sears (Willis) Tower, and I keep a plunger on
hand at all times.
– Because he has a hard time going he is using his
finger to empty the stool out himself.
 GI Testing
• Behaviors you might • Stool Test
see: • Upper
– Picking or scratching Endoscopy
at the rectum • Lower
– Frequent night Endoscopy
waking
– Smelly stools
• Contact
– Refusal to be toilet
other
trained due to pain parents to
with stooling. find MD in
your area.
 How to be noticed at your next GI
appointment
• A picture is worth a
thousand words.
– Take a picture of
your child’s stool if
you find it to be
abnormal
– Video tape a
concerning
behavior that shows
your child’s
distress.
– Keep a chart of the
types of stool using
 Comprehensive Stool Microbiology

4/10/08
8/15/0
8
 Resources
• http://www.autism.com - Autism Research
Institute
• Pub Medline is an online medical journal
web site:
http://www.ncbi.nlm.nih.gov/sites/entrez
• Book: Dorland’s Illustrated Medical
Dictionary
• Book: Prescription for Nutritional Health and
Healing by Balch and Balch
• Keep all your reports in a binder
• Join parent support groups in your area
• Join yahoo groups
 Part 2: Anesthesia

Surgical Anesthesia and

Autism
http://www.autism.com/families/life/kirz.h
 Dental Anesthesia for the
•
Autistic Child
http://www.autism.com/families/life/denta

• “There are no data that any anesthetic

drug(s) cause or worsen autism, nor
are there any published data on
preferred drugs for anesthetizing
autistic children.”
 The American Academy of
Pediatrics Treatment Plan for
Autism
“Caring for Children with Autism
Spectrum Disorders: A Resource Toolkit
for Clinicians”
http://www.aap.org/healthtopics/Autism.cfm

Professional Resources
Identification and Evaluation of Children
Management of Children with Autism Sp
What Your Anesthesiologist Does
Not Know
• That your child has a medical disease
not a mental disease.
• Our children have gastrointestinal
dysfunction, immune system
dysregulation, inflammation,
mitochondrial dysfunction, heavy
metal poisoning, oxidative stress,
chronic inflammation.
• May not be able to metabolize drugs
efficiently; impaired detoxification.
Awareness
Cerebral Palsy vs Autism
 ANESTHESIA

• Amnesia (sleep, forget)

• Analgesia (pain relief)

• Muscle Relaxation (immobilization)

 Induction of Anesthesia

• Intravenous
 

• Inhalation
 Versad
Midazolam
• A benzodiazepine that is used for
sedation, amnesia, anti-anxiety.
• Short acting; used in surgery
settings; given as pre-op medication.
• Oral, nasal, IM or IV.
• May be combined with ketamine and
atropine in oral or IM.
 Diprivan
Propofol

• A short-acting intravenous agent

used for induction and maintenance
of general anesthesia; also used for
sedation. It is not an analgesic (pain
relief).

• Caution with allergy to soy or egg.

Contains soybean oil and egg
phospholipid.
 Sevoflourane
Ultane

• Used as an anesthetic gas for

inhalation induction in children and
for maintenance of anesthesia.

• Only 2-5 % of the drug is

metabolized in the body.
• Potent short acting narcotic for pain.

• Used in a hospital setting.

 Ketamine

• Dissociative anesthetic.
• Does not depress respirations.
• Used as injection for sedation to start
an IV and for short surgical procedures.
• Given orally, IM or IV.
• May be given with Versad.
• Typical side effects include open eyes,
nystagmus, increased salivation and
emergence delirium.
 Nitrous Oxide

• Used as an anesthetic gas for sedation.

• Used as a carrier gas with sevoflourane for
induction.
• Not used as frequently now due to side
effects.
• Depletes B12/ folate system.
• Deactivates methionine synthase;
restoration takes several days; dependent
on genetics; MTHFR (C677T).
• Increases homocysteine; promotes
increased oxidative stress; may activate
NMDA glutamate receptors.
Adverse Effect of Nitrous Oxide in
a Child with 5,10-
Methylenetetrahydrofolate
Reductase Deficiency

• Rebecca R. Selzer, Ph.D., David S.

Rosenblatt, M.D., Renata Laxova, M.D.,
and Kirk Hogan, M.D., J.D.

The New England Journal of Medicine,

Volume 349:45-50
July 3, 2003, Number 1

• http://content.nejm.org/cgi/content/full/349/1/4
5
 When Nitrous Oxide is No
Laughing Matter

• Victor C. Baum, M.D., Departments of

Anesthesiology and Pediatrics,
University of Virginia, Charlottesville,
VA, USA

• Pediatric Anesthesia
Volume 17 Issue 9  Pages 824 - 830

• http://www.pedsanesthesia.org/meeting
s/2007winter/pdfs/BaumFriday3-9-07-
1050am.pdf
Nitrous Oxide Induced Elevation Of
Plasma Homocysteine And
Methylmalonic Acid Levels And
Their Clinical Implications
The Internet Journal of Anesthesiology 2004 : Volume 8
Number 2

Pramood C. Kalikiri M.D., PH.D. Dept of Physiology

Louisiana State University Medical Center New
Orleans LA USA
Reena Sachan Gajraj Singh Sachan M.D. Madras
Medical College Chennai India
 Early Exposure to Anesthesia and
Learning Disabilities in a Population-
based Birth Cohort

• Wilder, Robert T. M.D., Ph.D.; Flick,

Randall P. M.D., M.P.H.; Sprung, Juraj
M.D. et al
• Anesthesiology
The Journal of the American Society of
Anesthesiologist, Inc
April 2009
 What is the Toxic Tipping
Point?
• Nutritional status
• Genetics
• Infection
• Chemicals
• Antibiotic Use
• Environmental exposure
• Vaccines
• Liver detoxification status
• Drug exposure
• Timing
 Discuss with Your
Anesthesiologist
• Ask not to use nitrous oxide. Most of our
kids have a B12 deficiency.
• Discuss medical/metabolic problems of
your child.
• Consider placement of IV without sedation.
• Inform anesthesiologist of all medications,
supplements, and IgE allergies.
• Make sure it is understood that your child
has difficulty detoxifying drugs.
• Keep the anesthetic as simple as possible.
• Discuss any other drugs that might also be
given,
ex. Acetominophen, steroids,
 After the Anesthetic
Liver Detoxification Protocols

• Activated Charcoal
• DMG, TMG, methyl B12, methylfolate
• Epsom Salt Baths
• Silymarin (milk thistle)
• Bentonite Clay
• Antioxidants - Vitamin A, C , E
• Magnesium
• Reduced Glutathione
Other Drug
Considerations:
Augmentin (Amoxicillin
•Clavulanate)
Amoxicillin and Clavulanate Acid.

• Clavulanate acid fermentation

produces large amounts of urea and
ammonia.

• http://www.ncbi.nlm.nih.gov/pubmed/1560756
 Tylenol
Acetaminophen

• Reduces glutathione production

• Phenolic compound

• Rosemary Waring study — correlation

between low sulfate levels and ASD
– activity of phenylsulfotransferase (PST), the
enzyme catalyzing the sulfation of
acetaminophen, was abnormally low in autistic
children
 Other Options to Treat Fever

• Fever – a natural response to infection

• Tepid baths

• Cool damp cotton socks with dry wool socks

on top

• Peppermint essential oil in carrier oil on

bottom of feet

• Ibuprofen (dye free)

 References
• Eger E, Hogan K: Current Status of
Nitrous Oxide. March 2007
• Schure A: Difficult Pediatric Patients:
Anesthetic Considerations for Children
with Behavioral Problems. Current
Reviews for Nurse Anesthetist. Lesson
21 Volume 31 2/26/2009
• Van Der Walt JH et al: An audit of
perioperative management of autistic
children. Paediatric Anaesth 2001:
11:401-408
• Baum V: When nitrous oxide is no
laughing matter. Pediatric Anesthesia
2007: 17 ,824-830
 Thank You and
Good Luck on Your Journey

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