Research

Inside story
Evidence of a connection between
the gut and autism is now well
established. But gastroenterologist
Dr Federico Balzola goes further in
saying his research highlights
differences in the gut between
people with and without autism.
NHS consultant Dr Ben Marlow
interviews him about his findings

Q Dr Balzola, great to
meet you at the recent
Thinking Autism conference
in London.
Please give a brief
background to your career,
how you became involved in
the autism field, and where
you work.
disease. Very often patients live
with severe constipation, diarrhoea
or gastric reflux from birth and
these symptoms produce over time
antalgic behaviour, or positions
which help the patient to cope with
the pain.
These behaviours, when not
considered from another

A I’m a gastroenterologist and I

work in the hepatic intensive
care unit of one of the biggest
university hospitals in Italy
(Azienda Ospedaliero-Universitaria
Città della Salute e della Scienza di
Torino), where I became a medical
doctor in 1989.
I work in the field of liver
transplantation and intestinal
failure. From 1994 to 1995, I
worked in London on a project
about Crohn’s disease.
Once I came back to Italy, I
continued my studies on chronic
inflammatory bowel diseases in
autism patients.
perspective, are often believed to
be stereotypical movements and
defined autistic behaviour. Many
studies, such as the one conducted
by Adams in 20111 or the one by
Rose in 20182, show that the
Results are very
often amazing,
especially if treatment
starts in an early phase”
Gut issues:
severity of autistic behaviours is an illustration
correlated to the severity of of gut micro-

Q Please give me a few of

the ‘typical’
gastroenterological
gastrointestinal symptoms.

Q What is your view on the

underlying development
organisms.
Dr Balzola
says he sees
(GI) presentations you see in of autism? the severity of
children with autism. Does
the severity of the GI issues
mirror their ASD severity?
A The medical history that
patients tell is always similar
and sometimes so obvious that it
gastrointestinal
symptoms
in children

A Definitively, yes. Intestinal

symptoms have a higher
prevalence in autistic patients
compared to the general
population and often precede the
onset of neuro-behavioural
slips unnoticed: at first a
complicated pregnancy, a
premature birth, a caesarean
with autism
reflected in
how impacted
section or a clinical complication at they are by the
childbirth. Then oesophagus, condition
gastric or intestinal motility

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Located in London, Kestrel House School is a small and
friendly independent specialist school for pupils aged 5 – 16
years who have autism, additional learning difficulties and
complex needs. We provide each child with an autism
friendly environment, an appropriate curriculum and
specific interventions to meet their needs and
equip them for adult life.
To find out more about Kestrel House
School or to book a visit please
email s.vane@acorncare.co.uk
or call 07912310053.
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Research
disturbances such as constipation,
diarrhoea or reflux, which appear
very early during breastfeeding or
weaning, and also early use of
antibiotics.
Therefore, it is probably not just in the brain.
a single cause but a number of In our centre,
Dr Federico Balzola conditions that, together with a more than 350 this category of
holds board predisposing genetical patients with patients, we obtain
certification in background, favour the emergence gastrointestinal very good results on
Gastroenterology and of an intestinal dysbiosis able to symptoms have been submitted to antalgic, or pain-
Digestive Endoscopy. induce inflammation, with a slow or endoscopic examinations, with the avoidance
He attended Turin sub-clinical but progressive loss of result that more than 80 per cent behaviours. Mitigating their pain,
University School of intestinal barrier capacity. of them were showing a they become more easy-going and
Medicine, where he This is followed by an increase microscopic bowel inflammation less aggressive towards
completed his of permeability that allows bacterial picture detectable only on themselves and parents, which
gastroenterological toxins and a number of substances biopsies in different parts of the improves the quality of both
residency, and is to enter the blood flow and reach digestive tract. patients’ and their families’ lives,
driving clinical other organs, such as the brain. This inflammation is their social relationships, and
research in Italy on The final result is the characterized by an excess of reduces the dose of drugs used
the identification and appearance of a systemic, lymphocytes or eosinophils as sedatives.
treatment of the
autistic enteropathy
with dietetic and
inflammatory, chronic, non-infective
disease. Next, infectious episodes
or environmental triggers end up
infiltrating the bowel wall. Treatment
of the inflammation allowed us to
improve gastrointestinal and
Q How would you
normally investigate
these children and what do
pharmacological making chronic inflammation worse behavioural symptoms, as you see?
approaches. and affecting organs that are
metabolically active in childhood,
such as the central nervous system.
described in our recent paper in
A We usually ask for the precise
patient history from pregnancy
until the present day. We run blood
This evolution produces Probiotics and stool tests and a bowel
symptoms that will categorize the could be thought ultrasound, really the same exams
patient only as a neuropsychiatric that we usually run to a non-autistic
one, even though parents report of as drops in a lake patient with the same symptoms.
that gastrointestinal and nutritional compared to the If inflammation is evident at this
Dr Ben Marlow is a symptoms have always been stage we treat the patient with
1.5 kilogrammes of
consultant
paediatrician for the
prevalent and the first to appear.
Precious time is therefore wasted, bacteria living in
symptomatic drugs, probiotics and
an exclusion diet to improve
NHS specialising in postponing interventions on the intestinal bacterial flora, reduce
the bowel”
neurodisability. He
trained at UCL
gastrointestinal and systemic
inflammatory disease.
bowel permeability and therefore
systemic inflammation. If then
London and spent the These patients’ difficulties in the Journal of Pediatric improvements are not satisfactory,
majority of his career communication make it even more Gastroenterology and Nutrition4. we carry out endoscopy with
in Luton, which has
the second largest
population of children
complicated to get to a gastro-
intestinal diagnosis for patients on
the autistic spectrum when
Q Is there a clinical
course you see as
children get older without
biopsies to better characterize
inflammation and the prevalent
localization of the disease.
treatment?
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in the UK. He also
has a background in
biochemistry through
showing the same symptoms.
Q In your view, how are
the GI issues linked to a
A We obtain the best
behavioural improvements
when treating the endoscopically
information to treat the patient with
a more selected and tailored
therapy. We use mesalazine,
person’s overall
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a previous degree. He diagnosed bowel diseases as soon budesonide, steroids,
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has a son, Freddie, constitution? Does GI as possible and especially in very immunosuppressive or biologic
inflammation affect other
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who has autism young children. These results are drugs according to an approved
Approaches
body systems? very often astonishing. treatment for other chronic
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A It’s clear nowadays, as
different studies show (M.
Careaga in 20173), that autism can
Unfortunately, it is very difficult
to achieve improvements in adult
patients who have had symptoms
inflammatory bowel diseases.
Results are very often amazing,
especially if treatment starts in an
be classified both as inflammatory for many years, especially early phase.
and non-inflammatory.
An early classification at
diagnosis could permit a rapid
concerning their brain function.
These are the cases in which other
factors also play a role in cognitive
Q How would you
treat? Please give
some examples.
therapeutic intervention on bowel
and systemic inflammation, with
consequent rapid reductions of
impairment, such as social isolation
or the stay in facilities for
psychiatric patients for many years.
A We use the same treatments
scientifically demonstrated to
be effective in all other
other organ impairments, including On the other hand, however, for inflammatory bowel diseases.
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 Research
In particular, because of the
predominant eosinophilic
component [an abnormal increase
in a type of white blood cell that is
characteristic of allergic states and
various parasitic infections], these
patients respond very well to a low-
FODMAPs diet [a diet low in
fermentable carbohydrates],
ketotifen, probiotics, anti-secretive
drugs and laxatives.
The first attempts to remove big
proteins such as gluten or casein
from the patients’ diet are very
often made by parents before even
coming to our visits, for they have
already realized that many of the
intestinal symptoms are related to
the assumption of particular types
of food.
In other cases, however, it’s the
patients who avoid eating certain
types of food, removing from their
diet all the food they trace back to
Q
their symptoms.
What do you see as the
future of therapeutics?
What is your view on faecal
transplant – do you have any
experience with it?
A Every drug or medical
treatment that will demonstrate
to work on the microbiome and
treat the dysbiosis, which is the
cause of inflammation, will
probably be effective.
Current treatments on
microbiota are, at the time, not very
effective: probiotics, for example,
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still know very little about
microbiota and we do not know
long-term effects of the therapy.
It’s nowadays well known that
microbiota acts on the 23,000
active genes of our entire DNA and
it’s able to switch on and off
different genes based on its
differentiation inside our bowel.
We can then easily imagine that
after a faecal transplant a huge
number of potential interactions
can develop between the new
microbiota and the patient’s DNA.
We can say we are like children
who own a Ferrari and are trying to
drive it: we have a lot of beneficial
potentials, but we have to drive it
with caution. In any case, potential
benefits are enormous in a large
number of human diseases.
We can say we
are like children
who own a Ferrari and
are trying to drive it:
we have a lot of
beneficial potentials,
but we have to drive
sit with caution”
Q What is the overlap with
other immunological
conditions relating to
CHARTWELL
TRUST
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development. Also, minimal
Making a positive difference
alterations of this delicate evolutive
balance could provoke an
unexpected inflammatory process
that can lead to important
consequences on the growth
to young people with Autism.
factor’s production of the central
nervous system, essential for the
first development outside the
mother’s womb.
Paediatricians consider the first
1,000 days after childbirth as
fundamental for the future of the Our residential and supported living services
provide expert support for young people with
subject health.
Q What is your view on
virtual clinics and
collaborating with clinicians
autism who are in transition to adult services.
and patients in different
countries?
A I think a multidisciplinary
approach is essential and
fundamental to treat such a
complex and multiorgan syndrome. With a focus on developing
I’m really positive about future
technological and pharmacological
independence skills for young adults
with autism, our services offer:
improvements, especially because
the growing scientific interest on
microbiota is leading clinicians to
use the same “bacteria” language
in several different diseases.
This new approach will permit )
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us to exchange each other’s
opinions about the etiology
[causes] of different diseases that
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could be thought of as drops in a
lake compared to the 1.5
kilogrammes of bacteria living in
the bowel. Likewise, anti-
inflammatory drugs and biologic

drugs work only on symptoms.
Faecal transplant from healthy
donors is an ancient and efficient
treatment practiced by
veterinaries, who have used it
for many centuries, but is new for
human medicine.
At the moment, this approach is
very promising, even though we
digestive issues triggered by
a previous medical problem?
A The fragile balance between
intestinal flora and the immune
system has been crucial in human
evolution. With the control of
infective diseases, this process has
suffered from several
environmental, but not genetic,
interferences because of the short
period of time since antibiotics
have been available.
Bacteric farming is crucial since
childbirth for immune system
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have been treated by different
specialists for many years. )
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We will go back to be medical
doctors, starting from symptoms
and not only from blood tests or
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imaging results.
We will probably understand
that what we now consider
different diseases may be different
expressions of the same disease, 
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just on a different genetic level or
in a different moment of life.
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carefully to our patients.

REFERENCES:
1
Adams, JB et al: ‘Gastrointestinal flora and gastrointestinal status in children with autism-comparisons to typical children and correlation
with autism severity’ BMC Gastroenterol, 2011, https://www.ncbi.nlm.nih.gov/pubmed/21410934
2
Rose, DR et al: ‘Differential immune responses and microbiota profiles in children with autism spectrum disorders and co-morbid
gastrointestinal symptoms’, Brain Behav Immun, 2018, https://www.ncbi.nlm.nih.gov/pubmed/29571898
0116 368 0990  !$ 
 RATED GOOD
3
Careaga, M et al: ‘Immune Endophenotypes in Children With Autism Spectrum Disorder’, Biol Psychiatry, 2017,
https://www.ncbi.nlm.nih.gov/pubmed/26493496 24hr free phone referral line: 0800 080 3804
4
Alessandria, C et al: ‘HLA-DQ Genotyping, Duodenal Histology, and Response to Exclusion Diet in Autistic Children With Gastrointestinal
Symptoms’, JPGN, 2019, https://journals.lww.com/jpgn/Abstract/2019/07000/HLA_DQ_Genotyping,_Duodenal_Histology,_and.8.aspx info@chartwelltrust.org
16 Au t i s m | e y e I s s u e 3 6 2 0 1 9 - 2 0 www.autismeye.com
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