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Brief Report: Decreased Bone Health in Children with Autism Spectrum Disorder and Avoidant Restrictive Food Intake Disorder

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Title: Brief Report: Decreased Bone Health in Children with Autism Spectrum Disorder and Avoidant Restrictive Food Intake Disorder
Language: English
Authors: Noreen Islam (ORCID 0000-0002-6117-5440), Kristin L. Hathaway, Brooke S. Anderson, William G. Sharp, Karen J. Loechner
Source: Journal of Autism and Developmental Disorders. 2025 55(6):2179-2185.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 7
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Child Health, Autism Spectrum Disorders, Males, Eating Disorders, Physical Health, At Risk Persons, Nutrition
DOI: 10.1007/s10803-023-05976-x
ISSN: 0162-3257
1573-3432
Abstract: Purpose: Children with autism spectrum disorder (ASD) and food selectivity are at increased risk for nutritional deficiencies which could affect bone health. Methods: We report on four male patients with ASD and avoidant restrictive food intake disorder (ARFID) with significant bone conditions including rickets, vertebral compression fractures, osteopenia, and slipped capital femoral epiphyses. Results: Each patient was at risk for at least one nutritional deficiency. Two out of four patients had deficiencies in Vitamins A, B12, E, and zinc. Calcium and Vitamin D deficiency were noted in all four. Two out of four patients with Vitamin D deficiency developed rickets. Conclusion: Provisional evidence suggests that children with ASD and ARFID are at elevated risk for serious adverse bone health outcomes.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1470810
Database: ERIC
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  Value: <anid>AN0185099684;aut01jun.25;2025May14.02:48;v2.2.500</anid> <title id="AN0185099684-1">Brief Report: Decreased Bone Health in Children with Autism Spectrum Disorder and Avoidant Restrictive Food Intake Disorder </title> <p>Purpose: Children with autism spectrum disorder (ASD) and food selectivity are at increased risk for nutritional deficiencies which could affect bone health. Methods: We report on four male patients with ASD and avoidant restrictive food intake disorder (ARFID) with significant bone conditions including rickets, vertebral compression fractures, osteopenia, and slipped capital femoral epiphyses. Results: Each patient was at risk for at least one nutritional deficiency. Two out of four patients had deficiencies in Vitamins A, B12, E, and zinc. Calcium and Vitamin D deficiency were noted in all four. Two out of four patients with Vitamin D deficiency developed rickets. Conclusion: Provisional evidence suggests that children with ASD and ARFID are at elevated risk for serious adverse bone health outcomes.</p> <p>Keywords: Autism spectrum disorder; Bone mineral density; Avoidant restrictive food intake disorder; Rickets; Vertebral compression fractures; Medical and Health Sciences Clinical Sciences</p> <hd id="AN0185099684-2">Introduction</hd> <p>Childhood and early adolescence are critical periods for bone accrual that affect peak bone mineral density (BMD) and future fracture risk. Preliminary evidence suggests that autism spectrum disorder (ASD) is associated with decreased BMD in children (Hediger et al., [<reflink idref="bib15" id="ref1">15</reflink>]), peripubertal boys (Neumeyer et al., [<reflink idref="bib26" id="ref2">26</reflink>]), and adolescents (Ekhlaspour et al., [<reflink idref="bib12" id="ref3">12</reflink>]). As a result, this population is at an increased risk of fractures. In addition, BMD "catch-up" bone accretion appears absent in children and adolescents with ASD, and microarchitectural changes reflecting a reduction in cortical bone (Hediger et al., [<reflink idref="bib15" id="ref4">15</reflink>]) and decreased bone strength estimates persist over time (Neumeyer et al., [<reflink idref="bib28" id="ref5">28</reflink>]). This body of research, however, has yet to identify the cause(s) for these elevated risks. Putative factors include nutritional deficiency, low physical activity, and altered gut microbiome (McElhanon et al., [<reflink idref="bib24" id="ref6">24</reflink>]; Neumeyer et al., [<reflink idref="bib27" id="ref7">27</reflink>]; Pan & Frey, [<reflink idref="bib29" id="ref8">29</reflink>]; Sharp et al., [<reflink idref="bib33" id="ref9">33</reflink>]). Given that ASD affects as many as 14 children per 1000 (Christensen et al., [<reflink idref="bib7" id="ref10">7</reflink>]) impaired BMD in this population poses a public health challenge. While some studies have evaluated nutrition in children with ASD and without ASD, only two studies to date have provided comprehensive nutrient analysis results for children with ASD as it is related to BMD status (Neumeyer et al., [<reflink idref="bib28" id="ref11">28</reflink>]; Barnhill et al., [<reflink idref="bib3" id="ref12">3</reflink>]). This study aims to add to this body of literature.</p> <p>Children with ASD are five times more likely to have a feeding problem compared to peers of the same age (Sharp et al., [<reflink idref="bib33" id="ref13">33</reflink>]). Food selectivity (eating a narrow variety of foods) is the most common feeding problem in children with ASD (Cermak et al., [<reflink idref="bib6" id="ref14">6</reflink>]). Maladaptive dietary patterns in children with ASD often include a strong preference for processed foods, snacks, and starches, coinciding with frequent rejection of fruits, vegetables, and dairy (Cornish, [<reflink idref="bib9" id="ref15">9</reflink>]). In severe cases, food selectivity can involve complete omission of one or more food groups, increasing the risk of nutritional deficiencies. In a study of 48 children with ASD (mean age 6.6 years), Bandini (Bandini et al., [<reflink idref="bib2" id="ref16">2</reflink>]) reported that 18.7% consumed a diet that was inadequate in five or more nutrients compared with 7.1% of 58 non-ASD control children (mean age 6.7 years). In a separate study, Zimmer et al. ([<reflink idref="bib38" id="ref17">38</reflink>]) reported that children with ASD (mean age 8.2 years) consumed lower amounts of protein, calcium, vitamin B12, and vitamin D compared to children without ASD (mean age 8.1 years). A meta-analysis summarizing nutrient data indicated a significantly lower intake of calcium compared with non-ASD peers (Sharp et al., [<reflink idref="bib33" id="ref18">33</reflink>]). Collectively, these results indicate that children with ASD are at high risk for nutritional inadequacies. Not surprisingly, children with ASD and severe food selectivity are at the highest risk for nutritional deficiency syndromes, with reports that document scurvy (Ma et al., [<reflink idref="bib21" id="ref19">21</reflink>]), rickets (Stewart & Latif, [<reflink idref="bib35" id="ref20">35</reflink>]), vision loss (McAlbee et al., [<reflink idref="bib23" id="ref21">23</reflink>]), iron deficiency anemia (Latif et al., [<reflink idref="bib17" id="ref22">17</reflink>]), and compromised BMD in children with ASD (Hediger et al., [<reflink idref="bib15" id="ref23">15</reflink>]). This level of dietary restriction meets diagnostic criteria for avoidant restrictive food intake disorder (ARFID) when it is associated with faltering growth, significant nutritional deficiencies, dependence on enteral or oral formula supplementation, and/or marked interference with psychosocial functioning (American Psychiatric Association [<reflink idref="bib1" id="ref24">1</reflink>]).</p> <p>The International Society for Clinical Densitometry (ISCD)'s definition of osteoporosis includes0 Z-score ≤ -−2.0 age-appropriate mean PLUS (at least one of the following): ≥2 long bone fractures by 10 years old, ≥3 long bone fractures at any age up to 19 years old; or ≥ 1 vertebral compression fractures (VCFs) (Bianchi et al., [<reflink idref="bib4" id="ref25">4</reflink>]; Crabtree et al., [<reflink idref="bib10" id="ref26">10</reflink>]). The ISCD position also states that children at high risk for secondary bone disease (e.g., malabsorption conditions) warrant increased evaluation to decrease the risk of fracture (Gordon et al., [<reflink idref="bib13" id="ref27">13</reflink>]). One of the major changes in the 2014 Consortium Statement on Pediatric Osteoporosis is the inclusion of VCFs under pathological fractures. The presence of VCFs is well documented in adults, including those with ASD (Neumeyer et al., [<reflink idref="bib27" id="ref28">27</reflink>]). In addition, VCFs can be the first fractures to occur secondary to osteopenia (Grigoryan et al., [<reflink idref="bib14" id="ref29">14</reflink>]), are predictive of future vertebral and non-vertebral fractures (Jacobs-Kosmin et al., [<reflink idref="bib16" id="ref30">16</reflink>]), and may go undetected (Chapurlat et al., [<reflink idref="bib5" id="ref31">5</reflink>]; Lewiecki & Laster, [<reflink idref="bib18" id="ref32">18</reflink>]), because only about one-third are symptomatic (Damiano et al., [<reflink idref="bib11" id="ref33">11</reflink>]).</p> <p>In this report, we present four male patients with a prior diagnosis of ASD who were evaluated at two subspecialties clinics—a pediatric endocrinology clinic and a multidisciplinary feeding program. The four patients first came to the attention of endocrinology via both inpatient and outpatient settings when they presented with either orthopedic concerns or poor weight gain. This dual approach and detailed level of evaluation included laboratory, radiological, and nutritional assessments, as well as a diagnostic interview and meal observation with a licensed psychologist who specializes in assessment and treatment of ARFID. The psychologist confirmed the diagnosis of ARFID during a multidisciplinary evaluation (i.e., dietitians, nurse practitioner, speech language pathologist). Findings from these four patients provide evidence of diminished bone health due to severe food selectivity leading to nutritional deficiencies. Moreover, the presence of a nutritional deficiency existed in three out of four patients despite a normal Body Mass Index (BMI; kg/m2) percentile, such that it appears the selectivity, and not caloric density, of the food consumed is a key factor in this population.</p> <hd id="AN0185099684-3">Case Presentations</hd> <p></p> <hd id="AN0185099684-4">Patient 1</hd> <p>This patient is a 14-year-old male with history of ASD, peanut allergies, constipation, and encopresis who was first seen by endocrinology during an admission under the general pediatrics team for evaluation of poor weight gain. At admission, his mother reported that the patient's diet was poor and absent of dairy. Outpatient laboratory work-up obtained by his pediatrician prior to the admission demonstrated low calcium level (6.2 mg/dL, albumin level not available), an undetectable 25-hydroxyvitamin D (25-OHD) level, and concomitant elevated alkaline phosphatase level (1345 IU/L). On exam, he was noted to have mild wrist widening and a rachitic rosary was palpated. Further laboratory evaluation included magnesium and phosphorous levels that were both in normal range for age; however, intact parathyroid hormone (PTH) and 1,25 dihydroxyvitamin D levels were both elevated (1581 pg/mL and >600.0 pg/mL, respectively). A wrist radiograph demonstrated widened, irregular, and frayed metaphyses, consistent with rickets (Fig. 1a). He was diagnosed with nutritional rickets secondary to vitamin D deficiency and was started on 6000 international units (IU) of cholecalciferol daily and 100 mg per kilogram per day (mg/kg/day) of elemental calcium carbonate. He was seen in the outpatient bone clinic 2 months after initial admission at which time repeat calcium level was 9.8 mg/dL, repeat 25-OHD level was 58.8 ng/mL, and repeat 1,25 dihydroxyvitamin D level was 149.0 pg/mL (elevated but significantly improved). The urine calcium to creatinine ratio was obtained and was normal. Repeat intact PTH level was unfortunately not run by lab. His supplemental calcium dose was then decreased, high dose vitamin D was discontinued, he was counseled to continue taking a multivitamin, and he was referred to a multidisciplinary feeding program for further evaluation. At this point it was determined the patient presented with severe food selectivity, failure to achieve expected weight gain, and moderate malnutrition and, therefore, he met diagnostic criteria for ARFID based on presence of nutritional deficiencies and faltering growth combined with intense and persistent refusal behaviors during meals. More specifically, he had a weight z-score of –2.18, height z-score of –1.65, BMI z-score of -1.91, and BMI percentile of 2.80. His diet consisted of chicken nuggets, pepperoni and beef on pizza, pasta, cereal, crackers, waffles, chips, pizza rolls, French fries, and soda. He rejected all fruits, vegetables, and dairy products. This restricted diet had been in place since age 2. Analysis of a three-day food record (Table 1) indicated high risk for nutritional deficiencies, including Vitamins A, B12, C, D, and E, folic acid, calcium, and zinc. He was subsequently referred for intensive feeding therapy to improve both the volume and variety of food consumed during meals.</p> <p>Graph: Fig. 1 Adverse bone health outcomes for each case. Panels A and B: wrist x-rays demonstrating finding of rickets in patient 1 (Panel A) and patient 2 (Panel B). Panel C: spine films demonstrating multiple thoracic compression fractures and L5 vertebral compression fracture in patient 3. Panels D and E: spine films demonstrating multiple thoracic vertebral compression fractures (Panels D and E) and L4 vertebral compression fracture (Panel E) in patient 4</p> <p>Table 1 A summary of a three-day food intake record analysis conducted at the multidisciplinary feeding evaluation for Patients 1, 2, and 3. Deficiencies for each participant are bolded</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2"><p>Nutrient</p></th><th align="left" colspan="3"><p>Patient 1</p></th><th align="left" colspan="3"><p>Patient 2</p></th><th align="left" colspan="3"><p>Patient 3</p></th></tr><tr><th align="left"><p>Average daily intake</p></th><th align="left"><p>DRI</p></th><th align="left"><p>Percent of DRI</p></th><th align="left"><p>Average daily intake</p></th><th align="left"><p>DRI</p></th><th align="left"><p>Percent of DRI</p></th><th align="left"><p>Average daily intake</p></th><th align="left"><p>DRI</p></th><th align="left"><p>Percent of DRI</p></th></tr></thead><tbody><tr><td align="left"><p>Calories (kcal)</p></td><td align="left"><p>2435</p></td><td align="left"><p>1954</p></td><td char="." align="char"><p>124.00</p></td><td char="." align="char"><p>2019.05</p></td><td align="left"><p>1850</p></td><td char="." align="char"><p>109.00</p></td><td char="." align="char"><p>2081.33</p></td><td align="left"><p>2075</p></td><td char="." align="char"><p>100.30</p></td></tr><tr><td align="left"><p>Protein (g)</p></td><td align="left"><p>63</p></td><td align="left"><p>30</p></td><td char="." align="char"><p>210.00</p></td><td char="." align="char"><p>47.69</p></td><td align="left"><p>57.2</p></td><td char="." align="char"><p><bold>83.00</bold></p></td><td char="." align="char"><p>63.73</p></td><td align="left"><p>47.43</p></td><td char="." align="char"><p>134.37</p></td></tr><tr><td align="left"><p>Carbohydrates (g)</p></td><td align="left"><p>330</p></td><td align="left"><p>255</p></td><td char="." align="char"><p>129.00</p></td><td char="." align="char"><p>369.04</p></td><td align="left"><p>254.38</p></td><td char="." align="char"><p>145.00</p></td><td char="." align="char"><p>293.68</p></td><td align="left"><p>285.31</p></td><td char="." align="char"><p>102.93</p></td></tr><tr><td align="left"><p>Fat (g)</p></td><td align="left"><p>99</p></td><td align="left"><p>58</p></td><td char="." align="char"><p>171.00</p></td><td char="." align="char"><p>49.28</p></td><td align="left"><p>57.46</p></td><td char="." align="char"><p><bold>86.00</bold></p></td><td char="." align="char"><p>72.07</p></td><td align="left"><p>64.56</p></td><td char="." align="char"><p>111.64</p></td></tr><tr><td align="left"><p>Vitamin B12 (mcg)</p></td><td align="left"><p>1.55</p></td><td align="left"><p>2.4</p></td><td char="." align="char"><p><bold>65.00</bold></p></td><td char="." align="char"><p>25.94</p></td><td align="left"><p>1.8</p></td><td char="." align="char"><p>1441.0</p></td><td char="." align="char"><p>0.06</p></td><td align="left"><p>2.4</p></td><td char="." align="char"><p><bold>2.70</bold></p></td></tr><tr><td align="left"><p>Vitamin D (IU)</p></td><td align="left"><p>0</p></td><td align="left"><p>15</p></td><td char="." align="char"><p><bold>0.00</bold></p></td><td char="." align="char"><p>752.83</p></td><td align="left"><p>600</p></td><td char="." align="char"><p>125.00</p></td><td char="." align="char"><p>0.00</p></td><td align="left"><p>15</p></td><td char="." align="char"><p><bold>0.00</bold></p></td></tr><tr><td align="left"><p>Calcium (mg)</p></td><td align="left"><p>528</p></td><td align="left"><p>1300</p></td><td char="." align="char"><p><bold>41.00</bold></p></td><td char="." align="char"><p>1069.53</p></td><td align="left"><p>1300</p></td><td char="." align="char"><p><bold>82.00</bold></p></td><td char="." align="char"><p>389.57</p></td><td align="left"><p>1300</p></td><td char="." align="char"><p><bold>29.97</bold></p></td></tr><tr><td align="left"><p>Zinc(mg)</p></td><td align="left"><p>5</p></td><td align="left"><p>11</p></td><td char="." align="char"><p><bold>45.00</bold></p></td><td char="." align="char"><p>15.31</p></td><td align="left"><p>8</p></td><td char="." align="char"><p>191.00</p></td><td char="." align="char"><p>0.81</p></td><td align="left"><p>11</p></td><td char="." align="char"><p><bold>7.33</bold></p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0185099684-5">Patient 2</hd> <p>This patient is a 12-year-old male with history of ASD who was first seen by endocrinology in the hospital for evaluation of leg pain and difficulty with ambulation. His physical exam was unremarkable. His mother reported he had a history of food selectivity since early childhood and that his appetite decreased further over the past few weeks, such that he did not like, or consume, dairy products (e.g., milk, cheese, ice cream, or yogurt). Initial laboratory workup showed a low calcium level of 5.4 mg/dL (with a normal albumin level of 4.2 g/dL), low 25-OHD level (5.8 ng/mL), phosphate level at the lower limit of normal (4.3 mg/dL), elevated alkaline phosphatase level (1343 U/L), and an elevated intact PTH level (795 pg/mL). ECG showed prolonged QT interval presumed due to his ambient calcium level. Wrist radiograph had findings consistent with rickets (Fig. 1b). He was diagnosed with vitamin D deficiency rickets and started on approximately 20 mg/kg/day of calcium carbonate, calcitriol 1 µg (mcg) twice daily (due to degree of hypocalcemia), and cholecalciferol 10,000 IU daily. He was discharged home on 30 mg/kg/day of elemental calcium and cholecalciferol 4000 IU daily. As part of his education for discharge, the patient was informed of the importance of, and was successful, in his ability to drink milk and consume other sources of calcium. Repeat ECG prior to discharge showed resolution of prolonged QT interval and calcium level was 8.1 mg/dL.</p> <p>At his follow-up visit in the bone clinic, he showed normalization of calcium levels with improved dietary intake, supplemental calcium, and supplemental vitamin D. His 25-OHD level improved to 25 ng/mL. Intact parathyroid hormone levels remained mildly elevated at follow-up visits. At this visit, the patient's consumption of milk maintained, as well as other sources of dairy.</p> <p>The patient's ambulatory status was noted to have improved at his follow-up visits as well. He was unfortunately lost-to-follow-up 1 year after admission.</p> <p>Evaluation at the multidisciplinary feeding program subsequently confirmed that the patient met diagnostic criteria for ARFID based on severe food selectivity resulting in significant nutritional deficiencies and significant refusal behaviors when presented with non-preferred and novel foods. Specifically, his diet consisted of chicken, eggs, oatmeal, milk, yogurt smoothies, cheese, pop tarts, pizza, zebra cakes, and Sunny-D. Although he increased his dietary variety to include dairy products from his initial endocrinology appointment, he still refused all fruits (except for an occasional apple slice) and vegetables.</p> <p>He had a weight z-score of 1.62, height z-score of 0.68, BMI z-score of 1.60, and BMI percentile of 94.56. His BMI percentile indicated he was overweight. Analysis of a three-day food record (Table 2) indicated high risk for nutritional deficiencies, including zinc and Vitamin E. However, he relied on a multivitamin to replete his Vitamin D levels, as well as other micronutrients, through his work with endocrinology. This multivitamin was added after the discovery of bone disease through endocrine and remained in place at the time of the nutrition evaluation. Additionally, his intake was adequate to meet his caloric needs but not his nutritional needs. He was subsequently referred for intensive feeding therapy to improve the variety of food consumed during meals.</p> <p>Table 2 A summary of each participant's BMI z-score, BMI percentile, and weight status</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>Patient 1</p></th><th align="left"><p>Patient 2</p></th><th align="left"><p>Patient 3</p></th><th align="left"><p>Patient 4</p></th></tr></thead><tbody><tr><td align="left"><p>BMI Z-Score</p></td><td align="left"><p>−1.91</p></td><td align="left"><p>1.60</p></td><td align="left"><p>−0.19</p></td><td align="left"><p>2.26</p></td></tr><tr><td align="left"><p>BMI percentile</p></td><td align="left"><p>2.80</p></td><td align="left"><p>94.56</p></td><td align="left"><p>42.65</p></td><td align="left"><p>98.8</p></td></tr><tr><td align="left"><p>BMI weight category</p></td><td align="left"><p>Underweight</p></td><td align="left"><p>Overweight</p></td><td align="left"><p>Normal weight</p></td><td align="left"><p>Obese</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0185099684-6">Patient 3</hd> <p>This patient is a 13-year-old male with a history of ASD and developmental delay admitted initially to the orthopedics service for evaluation of inability to bear weight. Radiographic evaluation diagnosed him with a right femoral neck fracture and acute on chronic slipped capital femoral epiphysis (SCFE). He was taken to the operating room for closed reduction and percutaneous pinning of the right femoral neck fracture. During the hospitalization, thyroid studies were obtained as hypothyroidism can be associated with SCFE (Moyer et al., [<reflink idref="bib25" id="ref34">25</reflink>]). The results showed a mildly elevated free T4 (1.47 ng/dL) with a normal TSH (1.00 uIU/mL). Endocrinology was consulted for evaluation of the thyroid levels, and then also recommended laboratory tests including complete metabolic panel and 25-OHD level. Calcium was found to be low (5.2 mg/dL) in the setting of a low albumin (3.1 g/dL (calcium level is 5.92 mg/dL when corrected to an albumin of 4 g/dL). Alkaline phosphatase was elevated (852 U/L), intact PTH was elevated (505 pg/mL), 25-OHD was undetectable, and 1,25 dihydroxyvitamin D was elevated (157 pg/mL). Magnesium and phosphorous were both in normal range for age. Of note, his mother described the patient as a picky eater emphasizing a lack of good calcium sources, particularly no dairy products or green vegetables. A skeletal survey noted multiple thoracic vertebral body compression fractures (Fig. 1c), and sclerotic markings at the metaphyses of the distal radius and ulna, distal femurs, and proximal and distal tibiae and fibulae. A DXA scan showed low bone density: total body less head z-score of −3.3, anterior/posterior spine (AP spine) z-score of −3.8, and hip z-score of −3.1. Distal radius z-score not documented. (Note: his height was 165 cm and height adjusted z-score for TBLH done using CHOP protocol is 0.30). ECG showed mildly prolonged QT interval. He was started on calcium carbonate 125 mg/kg/day and cholecalciferol 50,000 IU weekly. Since that hospitalization, the patient has been able to maintain normal calcium and 25-OHD levels off calcium supplementation and maintenance vitamin D dosing.</p> <p>As with the previous cases, he was referred to the multidisciplinary feeding program for further evaluation. The multidisciplinary team confirmed the patient met diagnostic criteria for ARFID based on severe food selectivity resulting in significant nutritional deficiencies maintained by active food refusal of non-preferred food. Specifically, his diet consisted of chicken nuggets, juice, french fries, popcorn, crackers, and pizza. He refused all fruits (except orange and apple juice), vegetables, and dairy products (except for pizza). This restricted diet had been in place since early childhood. His BMI percentile and weight were in the normal range with a weight z-score of −0.34, height z-score of −0.56, BMI z-score of −0.19, and BMI percentile 42.65. Analysis of a three-day food record (Table 2) indicated high risk for nutritional deficiencies, including Vitamins A, B12, D, E, K, calcium, and zinc. He relied on a multivitamin to replete his Vitamin D and calcium levels, in addition to calcium fortified orange juice from his work with the endocrinology team. Additionally, his intake was adequate to meet his caloric needs but not his nutritional needs. He was also referred for intensive feeding therapy to improve the variety of food consumed during meals; however, logistical barriers prevented participation in treatment. Following the evaluation, he experienced acute exacerbations of his selective eating over subsequent years underscoring the need for ongoing surveillance for severe food selectivity and bone health.</p> <hd id="AN0185099684-7">Patient 4</hd> <p>This patient is a 17-year-old male with a history of nonverbal ASD, seizures, and hypothyroidism (likely related to taking oxcarbazepine), who was first seen by endocrinology in the outpatient clinic at 16 years for evaluation of thoracic vertebral compression fractures. He had a history of multiple extremity fractures after jumping from small heights (e.g., off a chair), and vertebral fractures were documented on spine radiographs obtained to evaluate perceived back pain after the falls. He was already taking cholecalciferol 2000 IU daily. Other medications included oxcarbazepine and gabapentin. He was reported to not eat milk, cheese, yogurt, or vegetables, and avoided dairy and grains (listed as allergies as he experienced emesis with intake in the past). On physical exam, he was nonverbal but exam was otherwise unremarkable. Initial laboratory workup showed normal serum calcium level with an alkaline phosphatase level that was mildly elevated for age (399 U/L), low/low normal 25-OHD level (24 ng/mL), and mildly elevated intact PTH level (90 pg/mL). Thyroid studies were also obtained and revealed central hypothyroidism (TSH level was normal at 2.35 mIU/L with a low free T4 level of 0.6 ng/dL). DXA scan was obtained and confirmed low bone density: TBLH z-score of –4.0, A/P spine z-score of −2.2, and distal radius z-score of −2.4. (Note: his height was 177 cm and height adjusted z-score for TBLH done using CHOP protocol is 0.43). Dedicated spine films showed compression fracture of L4 and multiple thoracic compression fractures, most pronounced at T8 (Fig. 1d, e). Recommendation was made to continue cholecalciferol 2000 IU daily, increase dietary calcium, and to start bisphosphonate infusions given the back pain and multiple vertebral compression fractures. After repeat thyroid studies confirmed hypothyroidism, he was started on levothyroxine. Thyroglobulin and thyroid peroxidase antibodies were negative, and it was presumed his hypothyroidism was secondary to a side effect of taking oxcarbazepine.</p> <p>To date, this patient has received 4 pamidronate infusions (receiving maximum dose of 60 mg per infusion) and his DXA scans have improved with the most recent scan reporting the following z-scores: TBLH z-score of −1.9, spine with z-score −0.8, and distal radius z-score of −3.0 (of note, spine compressions can affect the reading and actually "increase" the measured bone density on DXA (Takahashi et al., [<reflink idref="bib36" id="ref35">36</reflink>]). He also did not develop any new vertebral compression fractures in this time frame.</p> <p>During subsequent evaluation at the multidisciplinary feeding program, it was confirmed that the patient met criteria for ARFID due to severe food selectivity resulting in significant nutritional deficiency combined with intense refusal behaviors when presented with non-preferred food Specifically, his diet consisted of proteins, starches, chips, cookies, and almond or coconut milk. He occasionally consumed small amounts of a limited variety of fruits and vegetables. This restricted diet had been in place since early childhood. He had a weight z-score of 2.47, height z-score of 0.51, BMI z-score of 2.26, and BMI percentile of 98.8. His BMI percentile indicated he was obese. Labs completed one month prior in the hospital indicated nutritional deficiencies, including Vitamin D, calcium, and magnesium; however, he relied on a multivitamin to replete his Vitamin D, calcium, and magnesium levels. Therefore, a dietary analysis was not completed at his feeding evaluation in the multidisciplinary clinic. Additionally, his intake was adequate to meet his caloric needs but not his nutritional needs. He was subsequently referred for intensive feeding therapy to improve the variety of food consumed during meals.</p> <hd id="AN0185099684-8">Discussion</hd> <p>Provisional evidence suggests that children with ASD and ARFID in the form of severe food selectivity are at elevated risk for serious adverse bone health outcomes including rickets, decreased BMD and resultant VCFs. In this case series, because of their severe food selectivity, each of the four male patients were at risk for at least one nutritional deficiency. For example, two out of four patients presented at risk for deficiencies in Vitamin A, B12, E, and zinc. Additionally, common nutritional deficiencies in children with restricted diets include calcium and Vitamin D, which we noted for all four of these patients. As a result of Vitamin D deficiency, two out of four patients developed rickets. A key step for improving the care of children with ASD and severe food selectivity would, therefore, necessitate the analysis of the degree of dietary restriction and associated calcium and vitamin D deficiencies. Analyses should also consider other macronutrient or micronutrient deficiencies associated with bone health, such as Vitamin K (Rodgriguez & Curiel, [<reflink idref="bib30" id="ref36">30</reflink>]), zinc (Lobene et al., [<reflink idref="bib19" id="ref37">19</reflink>]) and B12 (Clemens, [<reflink idref="bib8" id="ref38">8</reflink>]), as well as trace minerals such as manganese (Rondanelli et al., [<reflink idref="bib31" id="ref39">31</reflink>]). Another aspect for improving care is to consider any gastrointestinal symptoms in children with autism that may implicate feeding or nutritional status, and subsequently bone health, as children with autism are more likely to exhibit gastrointestinal disorders (Madra et al., [<reflink idref="bib22" id="ref40">22</reflink>]).</p> <p>The next step in clinical management is to determine whether deficiencies have concomitant bone health issues. Based on exam, screening for rickets (joint radiograph in growing children/teens) and DXA scan (for BMD, height adjusted) represent appropriate screening tools. In a pilot study, we have found that even children with severe ASD can successfully complete such studies (Loechner et al., [<reflink idref="bib20" id="ref41">20</reflink>]). Moreover, severe food selectivity, once diagnosed, can affect approaches for nutrient replacement in this population due to inherent difficulty in implementing traditional management approaches (e.g., refusal to accept supplements). In our cases, the resources provided by the multidisciplinary feeding program were utilized when possible.</p> <p>Children with restricted diets may present with weight or BMI percentile in the normal to overweight range which may mask underlying nutritional risk (Sharp et al., [<reflink idref="bib33" id="ref42">33</reflink>]). As demonstrated in these four cases, three out of four patients had BMI percentiles between normal and obese ranges. This further highlights the importance of dietary screening to identify health risks in children with ASD and ARFID in the form of severe food selectivity. These cases also demonstrate the potential detrimental impact of restricted diets on bone health. Specifically, two out of the four patients had evidence of rickets, and two patients had vertebral compression fractures, one of which led to initiation of bisphosphonate therapy due to associated back pain. When identified, dietary plans, including calcium and vitamin supplementations, that are appropriate for the patient should be made to prevent potential effects on bone health. Feeding therapy can complement medical management with a focus on introducing a nutritionally complete diet (Volkert et al., [<reflink idref="bib37" id="ref43">37</reflink>]).</p> <p>There are limitations to this case series. For example, this case series relied on information obtained during our standard clinical assessment process in each subspecialty clinic. The assessment process unfortunately did not include measurement of physical activity, a known factor in determining bone development and overall health for all children, including those with ASD (Rostami Haji-Abadi et al., [<reflink idref="bib32" id="ref44">32</reflink>]). Future studies should collect and analyze data on physical activity in addition to dietary analysis and laboratory/radiological testing. Furthermore, the cases represent patients who were identified for evaluation at a subspecialty clinic triggered by orthopedic concerns due to prolonged dietary restriction, such that there is an ascertainment bias for evaluation and may not reflect the overall risk for ARFID and impaired bone health in a more general ASD population. Our findings, however, reinforce earlier work emphasizing that evaluation of dietary patterns as part of routine medical work-up with patients with ASD given the ubiquity of food selectivity in this pediatric population (Sharp et al., [<reflink idref="bib34" id="ref45">34</reflink>]).</p> <hd id="AN0185099684-9">Acknowldgements</hd> <p>Noreen Islam and Kristin L. Hathaway provided equal contribution.</p> <hd id="AN0185099684-10">Funding Statement</hd> <p>The authors did not receive support from any organization for the submitted work.</p> <hd id="AN0185099684-11">Data Availability</hd> <p>Data sharing is not applicable to this article as no new data were created or analyzed in this study.</p> <hd id="AN0185099684-12">Declarations</hd> <p></p> <hd id="AN0185099684-13">Conflicts of Interest</hd> <p>The author(s) declare(s) that there is no conflict of interest regarding the publication of this article.</p> <hd id="AN0185099684-14">Consent to Participate</hd> <p>Verbal informed consent was obtained from the parents prior to submission of the case report to the journal.</p> <hd id="AN0185099684-15">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0185099684-16"> <title> References </title> <blist> <bibl id="bib1" idref="ref24" type="bt">1</bibl> <bibtext> American Psychiatric Association. 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  Data: Brief Report: Decreased Bone Health in Children with Autism Spectrum Disorder and Avoidant Restrictive Food Intake Disorder
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  Data: <searchLink fieldCode="AR" term="%22Noreen+Islam%22">Noreen Islam</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-6117-5440">0000-0002-6117-5440</externalLink>)<br /><searchLink fieldCode="AR" term="%22Kristin+L%2E+Hathaway%22">Kristin L. Hathaway</searchLink><br /><searchLink fieldCode="AR" term="%22Brooke+S%2E+Anderson%22">Brooke S. Anderson</searchLink><br /><searchLink fieldCode="AR" term="%22William+G%2E+Sharp%22">William G. Sharp</searchLink><br /><searchLink fieldCode="AR" term="%22Karen+J%2E+Loechner%22">Karen J. Loechner</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. 2025 55(6):2179-2185.
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  Data: 10.1007/s10803-023-05976-x
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  Data: 0162-3257<br />1573-3432
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  Data: Purpose: Children with autism spectrum disorder (ASD) and food selectivity are at increased risk for nutritional deficiencies which could affect bone health. Methods: We report on four male patients with ASD and avoidant restrictive food intake disorder (ARFID) with significant bone conditions including rickets, vertebral compression fractures, osteopenia, and slipped capital femoral epiphyses. Results: Each patient was at risk for at least one nutritional deficiency. Two out of four patients had deficiencies in Vitamins A, B12, E, and zinc. Calcium and Vitamin D deficiency were noted in all four. Two out of four patients with Vitamin D deficiency developed rickets. Conclusion: Provisional evidence suggests that children with ASD and ARFID are at elevated risk for serious adverse bone health outcomes.
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      – SubjectFull: Child Health
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Males
        Type: general
      – SubjectFull: Eating Disorders
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      – SubjectFull: Physical Health
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      – SubjectFull: At Risk Persons
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      – SubjectFull: Nutrition
        Type: general
    Titles:
      – TitleFull: Brief Report: Decreased Bone Health in Children with Autism Spectrum Disorder and Avoidant Restrictive Food Intake Disorder
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            NameFull: Noreen Islam
      – PersonEntity:
          Name:
            NameFull: Kristin L. Hathaway
      – PersonEntity:
          Name:
            NameFull: Brooke S. Anderson
      – PersonEntity:
          Name:
            NameFull: William G. Sharp
      – PersonEntity:
          Name:
            NameFull: Karen J. Loechner
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 06
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 0162-3257
            – Type: issn-electronic
              Value: 1573-3432
          Numbering:
            – Type: volume
              Value: 55
            – Type: issue
              Value: 6
          Titles:
            – TitleFull: Journal of Autism and Developmental Disorders
              Type: main
ResultId 1