World Journal of

WJ C P Clinical Pediatrics
Submit a Manuscript: https://www.f6publishing.com World J Clin Pediatr 2021 May 9; 10(3): 15-28

DOI: 10.5409/wjcp.v10.i3.15 ISSN 2219-2808 (online)

EDITORIAL

Autism medical comorbidities

Mohammed Al-Beltagi

ORCID number: Mohammed Al- Mohammed Al-Beltagi, Department of Pediatrics, University Medical Center, King Abdulla
Beltagi 0000-0002-7761-9536. Medical City, Arabian Gulf University, Manama P.O. Box 26671, Bahrain, Bahrain

Author contributions: Al-Biltagi M Mohammed Al-Beltagi, Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta
wrote and revised the whole 0000000, Al Gharbia, Egypt
manuscript.
Corresponding author: Mohammed Al-Beltagi, MD, PhD, Chairman, Professor, Department of
Conflict-of-interest statement: The Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University,
author declares that he has no King Abdulaziz Avenue, Manama P.O. Box 26671, Bahrain. mbelrem@hotmail.com
conflict of interests for this article.

Open-Access: This article is an Abstract

open-access article that was
Medical comorbidities are more common in children with autism spectrum
selected by an in-house editor and
disorders (ASD) than in the general population. Some genetic disorders are more
fully peer-reviewed by external
common in children with ASD such as Fragile X syndrome, Down syndrome,
reviewers. It is distributed in
Duchenne muscular dystrophy, neurofibromatosis type I, and tuberous sclerosis
accordance with the Creative
complex. Children with autism are also more prone to a variety of neurological
Commons Attribution
disorders, including epilepsy, macrocephaly, hydrocephalus, cerebral palsy,
NonCommercial (CC BY-NC 4.0)
migraine/headaches, and congenital abnormalities of the nervous system.
license, which permits others to
Besides, sleep disorders are a significant problem in individuals with autism,
distribute, remix, adapt, build
occurring in about 80% of them. Gastrointestinal (GI) disorders are significantly
upon this work non-commercially,
more common in children with ASD; they occur in 46% to 84% of them. The most
and license their derivative works
common GI problems observed in children with ASD are chronic constipation,
on different terms, provided the
chronic diarrhoea, gastroesophageal reflux and/or disease, nausea and/or
original work is properly cited and
vomiting, flatulence, chronic bloating, abdominal discomfort, ulcers, colitis,
the use is non-commercial. See: htt
inflammatory bowel disease, food intolerance, and/or failure to thrive. Several
p://creativecommons.org/License
categories of inborn-errors of metabolism have been observed in some patients
s/by-nc/4.0/
with autism including mitochondrial disorders, disorders of creatine metabolism,
Manuscript source: Invited selected amino acid disorders, disorders of folate or B12 metabolism, and selected
manuscript
lysosomal storage disorders. A significant proportion of children with ASD have
evidence of persistent neuroinflammation, altered inflammatory responses, and
Specialty type: Pediatrics immune abnormalities. Anti-brain antibodies may play an important pathoplastic
mechanism in autism. Allergic disorders are significantly more common in
Country/Territory of origin: Bahrain individuals with ASD from all age groups. They influence the development and
severity of symptoms. They could cause problematic behaviours in at least a
Peer-review report’s scientific significant subset of affected children. Therefore, it is important to consider the
quality classification child with autism as a whole and not overlook possible symptoms as part of
Grade A (Excellent): 0 autism. The physician should rule out the presence of a medical condition before
Grade B (Very good): B moving on to other interventions or therapies. Children who enjoy good health
Grade C (Good): C have a better chance of learning. This can apply to all children including those
Grade D (Fair): 0 with autism.

WJCP https://www.wjgnet.com 15 May 9, 2021 Volume 10 Issue 3

Al-Beltagi M. Autism medical comorbidities

Grade E (Poor): 0
Key Words: Autism; Children; Medical comorbidity; Epilepsy; Sleep disorders; Allergy;
Received: January 23, 2021 Gastrointestinal diseases
Peer-review started: January 23,
2021 ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
First decision: February 12, 2021
Revised: February 12, 2021
Core Tip: Medical comorbidities are common in children with autism. Some genetic
Accepted: March 17, 2021
disorders are more common in children with autism spectrum disorders. Medical
Article in press: March 17, 2021
comorbidities have a significant impact on the child’s behaviour and development.
Published online: May 9, 2021 Early identification and treatment of these comorbidities will help to improve the
child’s ability to learn and improve his or her circumstances and those of his or her
P-Reviewer: Ding N, Sergi CM
family.
S-Editor: Gao CC
L-Editor: A
P-Editor: Yuan YY
Citation: Al-Beltagi M. Autism medical comorbidities. World J Clin Pediatr 2021; 10(3): 15-28
URL: https://www.wjgnet.com/2219-2808/full/v10/i3/15.htm
DOI: https://dx.doi.org/10.5409/wjcp.v10.i3.15

INTRODUCTION
Comorbidity is the presence of one or more additional diseases or disorders that
coincide with a primary disease or disorder. A comorbid condition is a 2nd order
diagnosis that has core symptoms that are distinct from the primary disorder.
Comorbidity is much more common in people with autism spectrum disorders (ASD)
than in the general population. For example, patients with autism are 1.6 times more
likely to have eczema or skin allergies, 1.8 times more likely to have asthma and food
allergy, 2.1 times more likely to have frequent ear infections. 2.2 times more likely to
have severe headaches, 3.5 times more likely to have diarrhoea or colitis, and 7 times
more likely to report gastrointestinal (GI) problems[1].
A child with autism may have symptoms of other comorbidities in addition to the
core symptoms of autism (e.g., social deficits, language impairment, repetitive
behaviours, etc.). Recognising these medical conditions is important because many of
the medical conditions could stimulate or exacerbate the abnormal behaviour that
occurs in children with autism. Once these medical conditions are treated, the
behaviours stop. Because unwell people do not perform adequately, some children
with autism may lose skills and/or fail to retain skills because of their medical
conditions. Effective learning requires a healthy state. Comorbid conditions may be
markers of the underlying pathophysiology and require a more sophisticated
therapeutic approach. In the meantime, it is more likely that the increased mortality
risk associated with ASD is related to the presence of comorbid medical conditions
and intellectual disabilities than to ASD itself. Since most of them are treatable, the
treatment of comorbid medical conditions can lead to a substantial improvement in
the quality of life of the child and the family[2,3]. However, it is not always easy to
identify comorbid conditions in children with ASD due to several factors, such as
communication disorders, the ambiguity of symptoms, their deviation from those in
the general population, or their change over time. These factors are also compounded
by the widespread belief that deviant behaviours and symptoms are ‘just part of
autism’. The lack of diagnostic tools available to screen for these disorders is another
important limitation[4]. Many symptoms and behaviours commonly attributed to
autism, may reflect the presence of other organic disorders. For example, headbanging
could be due to the presence of headaches, or pain when frustrated and the inability to
communicate these symptoms. If the child fidgets frequently, he or she could have
complaints related to constipation. Aggression and self-injurious behaviour could also
be related to the presence of the pain and the child’s inability to communicate about
his/her condition. Pica could also be a sign of nutrient deficiencies, particularly iron,
which is relatively common in children with autism. Food refusal may be related to the
high food selectivity observed in children with autism but could also reflect the
presence of food allergy or intolerance or be due to a more local cause such as the
presence of dental problems[5]. Table 1 showed the different comorbidities that could
present in children with autism.

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 Al-Beltagi M. Autism medical comorbidities

Table 1 Autism comorbidities

Related disorders
Anxiety disorder

Obsessive-compulsive disorders

Attention deficit hyperactivity disorders

Mood disorders

Sleep disorders: Difficulty falling asleep, inability to sleep in a flat position, nighttime reawakenings, sleepwalking

Epilepsy

Systemic medical disorders

Accidents

Injuries, drowning, suffocation, etc.

Genetic disorders

Fragile X syndrome, Down syndrome, Duchenne muscular dystrophy, neurofibromatosis type I, and tuberous sclerosis complex

Metabolic disorders

Mitochondrial disorders, disorders of creatine metabolism, selected amino acid disorders, disorders of folate or vitamin B12 metabolism, and selected
lysosomal storage disorders

Endocrine disorders

e.g., hypothyroidism

Neurological disorders

Congenital abnormalities of the nervous system, epilepsy, macrocephaly, hydrocephalus, cerebral palsy, migraine/headaches, paralytic muscular
disorders like Duchenne muscular dystrophy, increase in sympathetic and a decrease in parasympathetic activity, and dysautonomia

Immune dysfunction

Neuroinflammation, immune deficiency and dysfunction

GI disorders

Chronic constipation, chronic diarrhea, eosinophilic esophagitis, gastroesophageal reflux and/or disease, nausea and/or vomiting, chronic flatulence,
abdominal discomfort, ulcers, colitis, inflammatory bowel disease, food intolerance, and/or failure to thrive

Feeding disorders

Selective eating, difficulty swallowing, abnormal behaviors during meals such as ritualistic behaviour, throwing tantrums or gagging and vomiting

Allergic disorders

Asthma, nasal allergies, atopic diseases (immunoglobulin E-mediated), food allergies and intolerances

Toileting problems

Difficulties in learning how to use the toilet during the day and at night, knowing when they need to use the toilet, communicating the need to use the
toilet, being able to get to the toilet independently or in time, learning to use different toilets with which they are unfamiliar, wiping themselves, sensory
differences (dislike of the noise made by toilets, the sensation of passing urine/faeces, a cold toilet seat, or a preoccupation with water in the toilet),
smearing faeces, a range of continence-specific difficulties, including bowel or bladder difficulties such as bedwetting and constipation

GENETIC DISORDERS
Certain known genetic disorders are associated with an increased risk of autism,
including but not limited to Fragile X syndrome (FXS), Down syndrome (DS),
Duchenne muscular dystrophy, neurofibromatosis type I (NF1), and tuberous sclerosis
complex (TSC). It may be useful to view ASD as a cloud, representing the interaction
of several different genetic and other etiologies that end with abnormal brain wiring.
FXS is the most common cause of inherited intellectual disability; characterized by the
presence of abnormal patterns of neural “wiring” or connectivity that leads to ASD
symptoms, including impaired communications. FXS is the most common-known
single-gene disorder in all ASD cases. It has been observed that about 2%-3% of all
children with ASD cases have FXS, and about 25%-33% of FXS patients have ASD.
Children with both FXS and ASD have higher rates of social anxiety, intellectual
disability, hyperarousal, repetitive behaviors, and other FXS-related differences than
those with ASD of unknown cause[6].

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