Biomedical Treatments for
Neurodevelopmental,
Autoimmune and other Chronic
Disorders
David Berger, MD
Medical Director
Wholistic Pediatrics
Tampa, FL
(813) 960-3415
www.wholisticpeds.com
Autistic Spectrum Disorders
ADHD Asperger’s PDD Autism
Syndrome
In many of our patients, there are multiple
biological abnormalities
Discover Magazine, 3/14/07
Intestinal
Abnormal flora (dysbiosis)
Abnormal permeability (leaky gut)
Illeal lymphoid hyperplasia
Persistent Measles virus
Immune System
Th1 Th2 type of WBC
Low TH1 can cause susceptibility to
infections, with potential increased
exposure to antibiotics.
– Related Yeast Overgrowth in Intestinal Tract
as well as Clostridia and Parasites
High TH2 can lead to inappropriate
antibody formation
– Auto-antibodies
– Food antibodies
Biochemical Abnormalities
Low sulfur amino acids
Low zinc levels
Low selenium levels
High copper to zinc ratios
Low omega – 3 fatty acids
High ammonia levels
Abnormal methylation metabolism
High microbial metabolites
Elemental Toxins: Mercury, Lead, etc
Robert Cade, MD, Professor,
University of Florida Medical
School
“A gluten and casein free
diet resulted in significant
improvement in 81% of
children with autism within
three months.”
Rationale for Casein/Gluten
Free Diet
Gluten and casein have immune, as well as
neurotransmitter impacts.
Many ASD children have food hypersensitivities
Improper digestion leads to buildup of opiate-like
peptides. These can be identified in the urine of
many children with ASD.
Dr Cade at UF recently injected rats with
casomorphin, causing the rats to develop autistic-
like behaviors
DPP-IV
Dipeptidyl Peptidase IV, carboxypeptidase A, and aminopeptidase are some
of the main enzymes that brake down the opiate peptides.
Some of the enzymes are zinc dependent, and it’s activity can be inhibited
by mercury, among other things.
A first generation enzyme containing DPP-IV is available from Kirkman
Labs. Although for most children it can not serve as a sole replacement for
the C/G free diet, giving it with these foods allow some children to take c/g
foods with out negative reactions, and it can be administered in cases of
accidental exposure
Dr. Lewis’
book is the
essential
starting point
for a gluten
and casein
free diet.
Milk: It does your body good?
Frank Oski -
Past chairman of
Johns Hopkins
Department of
Pediatrics and Past-
President of the
American Academy of
Pediatrics
Evaluating Children
Urine and Stool Studies
Thyroid profile
Toxic Metals
Inborn Errors of Amino Acids
Fragile X, Chromosomal Analysis
Metallothionein analysis
RBC Fatty Acids
Brain auto-antibodies
Immunoglobulins, WBC activity
Detoxification Metabolism
Hormone Profiles
Autism Speaks Launches Pediatrician
Outreach Initiative to Increase Awareness
about the Diagnosis and Treatment of
Gastrointestinal Problems
Consensus Statement Developed by Expert Panel Includes
Recommendations for Care Specific to Children with
Autism
February 28, 2007
Abnormal Stool & Urine
Findings
Best, and in some cases imperative to treat these
prior to starting more advanced therapies such as
chelation
Stool : Yeast (Candida), Parasites (Giardia,
Dientameoba, and others), Malabsorption, Blood,
etc.
Urine : Yeast and Bacterial metabolites, abnormal
Kreb’s cycle metabolites, oxalates, opiate
peptides, etc
Treat Stool & Urine Findings
Yeast Killers: Nystatin, Diflucan, Sporonox,
Uva Ursi, MCT, goldenseal, Garlic, Candex
(digestive enzyme) and others.
Clostridia Killers: high dose lactobacillus,
Metronidazole (benzoate by compounding),
Vancomycin
Parasites: the ones we see most often are
also sensitive to Metronidazole Benzoate,
other specific natural and pharmacological
agents used depending on the particular
organism
OAT test
OAT After Culturelle and Nystatin
Nicholas (8 y/o)After Culturelle and
Nystatin
(3 months later)
Attention span has definitely improved since the last visit.
getting very good reports fro the teachers
more "with it", not spacey
now will respond much faster when spoken to.
Reading skills vastly improved, with good comprehension skills.
Reading instruction manuals and understanding it. Wants to
keep reading on and on.
performing skills at school that he never did before. Amazing
memory for spelling.
Learned how to tell time.
Can perform addition.
less problems with interactions with his peers, but he prefers
solitary play when in his house. When visiting others he will
interact more. He does much better in small and quiet groups
getting better balance of his body.
Sulfation
Sulfur is an element critical to the structure and
functioning of body mechanisms.
Dr. Rosemary Waring reports that most autistic children
show a deficiency of sulfates in their plasma. Of the
autistic children she tested, 92% had sulfate levels that
were only 12% of normal
Low sulfates can lead to a leaky gut, as well as a
weakness in the phenolsulfotransferase (PST) system.
the PST pathway is important in removing toxins
A weakness in the PST system is often characterized by
night sweats, red face and ears, allergies, and keratosis
pilaris (red bumps on back of arms)
Tx: Epsom Salt by bath or transdermal application, or
oral sulfates such as glucosamine sulfate and MSM
After Epsom Salt Baths
Eric’s (6 y/o) Response to Epson
Salt Baths
•Making new statements. Becoming more creative with
language. Responding to answers appropriately
•still needs help focusing for long periods of time, but
paying more attention
•echolalia is gone
•showed much more interest in presents that he received
for the holidays.
•getting more involved with his brother, they are fighting a
bit now.
Ammonia
•Ammonia is a known toxin to the brain.
•High enough levels can cause can cause neurological
symptoms, even coma. This is usually associated with liver
disease
•About 5-10% of ASD patients we check have mild to moderate
elevations in Ammonia levels (in the presence of normal liver
tests)
•Proposed mechanism: Proteins >> Amino Acids >>Ammonia
>>liver fuses 2 ammonia molecules to form urea >> excreted
in urine. Gut pathogens >> leaky gut. Urease enzyme made by
certain gut pathogens >> Urease enters the bloodstream >>
splits urea back to ammonia at a pace faster then urea can be
formed.
Connor’s original Ammonia level
Connor’s ammonia after 2 capsules of
alpha ketoglutaric acid
•Increased speech, repeating everything
•socializing better, especially with sister
•Separation still a problem when school starts
•When peer tantrums, Conor gets upset. He did approach a
crying child instead of running away, and when sister was crying
he sought help instead of withdrawing
Connor After 4 capsules of Alpha Ketoglutaric
Acid
•No more episodes of the rapid eye blinking or enlarged pupils
•interacting better with sister
•less melt-downs when others tantrum
•speech improving on a weekly basis
sound sensitivities seem to no longer be a problem
Essential Fatty Acids
The Omega Factor
Omega 3’s in Autism
Replacing and Omega-3 deficiency
(source independent)
Vs.
Addressing Omega deficiency and
Supplementing with natural Vitamin A
(Cod Liver Oil)
Immunity is complex and impacts
every system in the body. It
isn’t surprising that it effects
child behavior and development.
Immune System
TH1 TH2 type of WBC
Viral Stimulation
Inappropriate antibody formation
– Auto-antibodies
– Food antibodies
Frequent Infections - Especially Ear
Related Yeast Overgrowth in Intestinal
Tract w/ Clostridia and Parasites
IMMUNIZATIONS
I am not suggesting that we abandon our
vaccination policy
I am concerned about the growing number
of chronically ill children
There are more children with learning
disabilities and autoimmune disorders then
there has ever been in the history of
medicine.
Concerns about Vaccines
Are we unnaturally stressing underdeveloped
immune systems beyond their capabilities in our
effort to keep the children from becoming ill?
There are inadequate safety studies for the
vaccines that are currently on the market
Are we giving too many vaccines over a short
time span?
We do not have a clear understanding of the
effects of some of the vaccine components such as
thimerosal, aluminum, formaldehyde, and human
fetal tissue.
What’s Going On?
Social deficits, shyness, social withdrawal
Repetitive, perseverative, stereotypic behaviors; obsessive-compulsive
tendencies
Irritability, aggression, temper tantrums
Lacks eye contact; impaired visual fixation
Loss of speech, delayed language, failure to develop speech
Speech comprehension deficits
Sound sensitivity; mild to profound hearing loss
Abnormal touch sensations; touch aversion
Flapping, myoclonal jerks, choreiform movements, circling, rocking, toe
walking, unusual postures
Poor concentration, attention, response inhibition
Self injurious behavior, e.g. head banging
ADHD traits
Sleep difficulties
Diarrhea; abdominal pain/discomfort, constipation
ALL SIGNS AND SYMPTOMS OF…
MERCURY TOXICITY
MERCURY
Statement:Pediatrics 2001 Jul, American Academy of Pediatrics: Committee on
Environmental Health.
The developing fetus and young children are thought to be disproportionately
affected by mercury exposure, because many aspects of development,
particularly brain maturation, can be disturbed by the presence of mercury.
Minimizing mercury exposure is, therefore, essential to optimal child
health…..Mercury in all of its forms is toxic to the fetus and children, and
efforts should be made to reduce exposure to the extent possible to
pregnant women and children as well as the general population.
_______________________________________________________________
Vaccine inserts would typically say “0.01% thimerosal as a preservative”, which
to anyone would sound like an extremely small amount. When called to testify
in front of the Institute of Medicine, an independent group formed by our
government to monitor safety issues, Dr. Neil Halsey of Johns Hopkins
University, and head of the vaccine recommendation committee that reports to
the CDC, went on record as saying “No one ever did the math…. No one
knows what dose of mercury, if any, from vaccines is safe. We can say there is
no evidence of harm but the truth is no one has looked”
Mercury/Thimerosal
Thimerosal is Ethylmercury, a neurotoxin
Mercury was found in the blood of
newborns even before Hepatitis B shot, and
higher levels after the shot.
• Journal of Pediatrics, May 2000
In some pre-term infants, mercury levels
were 10 times that of term infants
Pre-term babies are vaccinated according to
chronological age, not gestational age.
Mercury/Thimerosal
Intrauterine sources may include:
• maternal fish consumption
• mercury amalgam fillings
•Rhogam (given to Rh (-) mothers, no longer present)
•Influenza vaccine (still present)
Mercury/Thimerosal
Hepatitis B vaccine was introduced in 1991-
with most newborns getting the first dose
before leaving the hospital
Hep B vaccine had contained 12.5 mcg of
thimerosal = 6.25mcg mercury
EPA established the “safe limit” at 0.1
mcg/kg/day, approximately 0.4 mcg/day for
an 8 pound newborn
Mercury/Thimerosal
Typical Thimerosal Exposure for 2 month old infant:
Hep B 12.5 mcg
DTaP 25 mcg
Hib 25 mcg
Total 62.5 mcg
of which 50% is ethylmercury = 31.25mcg
Total “safe” dose for 10 pound (2 month old) baby
by EPA standards: 0.5 mcg. The average 2 month
old received ~60x the EPA limit
Mercury/Thimerosal
By 6 months of age, a fully vaccinated infant
would have received:
– 3 DTP 75 mcg thimerosal
– 3 Hib 75 mcg thimerosal
– 3 Hep B 37.5 mcg thimerosal
Total 187.5 mcg thimerosal
93.75 mcg mercury
1999 FDA Center for Biologics Evaluation and Research
Heavy Metal Exposures
After exposure to mercury, the length of time to be eliminated
varies for different organs:
Blood and Hair: 4-6 months
Non CNS organs: several years
Brain: 20 years
(Boyd Haley, PhD, University of Kentucky, Dept of
Chemistry)
Lead typically deposits into brain and bone. After exposure to
lead, within several months the blood and urine levels will
be normal even if the lead is still in the bone and brain
(Clarkson, 2002)
Who’s looking into all of this?
Boyd Haley, PhD, Department of Chemistry Chairman,
University of Kentucky. Dr Haley is considered one of the
leading researchers in America on Heavy Metal toxicity
• He reports that exposing neurons to thimerosal rapidly
results in the stripping of tubuluin from the nerve axon,
and also reduces the viability of actin. Actin and tubulin
are proteins that are critically important for the growth of
dendrites and to maintain the structure of the axon.
•On exposing neurons grown in culture for 24 hours, then
exposed to vaccines with thimerosal and thimerosal-free
vaccines. There was significantly more cell death in those
exposed to thimerosal vaccines. The most concerning part
about this was that there was an extremely low amount of
thimerosal used in the study, 10K less then the
concentration found in most vaccines
Who’s looking into this (cont)
•Holloway et al, Arizona State:Oral antibiotics have been shown in rats
to increase the half-life for excretion of mercury from 10 days to over
100 days. (Doctors have been told it is OK to vaccinate children as
long as they are not seriously sick, with high fevers, and there is no
recommendations not to vaccinate children on antibiotics)
•Holloway et all, Arizona State 2002 carried out a DMSA challenge
study involving 15 children with autism and 15 typical children. The
children received a single dose of meso-2,3-dimercaptosuccinic acid
(DMSA), at a dose of 10 mg/kg, followed by a 10-hour urine collection.
The DMSA resulted in a much greater increase in heavy metal
excretion in the children with autism compared to the controls. Many
of the children with autism excreted high levels of one or more heavy
metals, although there was wide variation in the amount and type of
metal excreted. (The data suggests that many children with autism
have a greatly diminished ability to excrete heavy metals, and thus
would be unusually vulnerable to exposures to those metals)
Mercury Testing
As there is a relative short half life of mercury in serum,
blood and urine testing will often be negative if more then
6 months have passed between exposure and testing
Hair tests can be falsely positive if there are metals in
shampoos, conditioners, or water. Also, there is evidence
that mercury levels in the hair of autistic children is less
than in controls (Cave and Holmes)
For me, the best test is an oral chelation challenge,
extracting the heavy metal and excreting it in the urine.
This can document that the metal is present, it is not being
excreted under normal circumstances, AND that the
chelation agent and the route of administration given
works for the individual
Mercury Removal: Chelation
Agents
EDTA, Dimercaprol (BAL), DMSA, DMPS, and DMPA all have
heavy metal binding activity
Marked specificity for heavy metals, but also can cause decreases in
trace elements and micronutrients (and these should be tested for
periodically)
Mercury is essentially irreversibly bound to DMSA, so mercury is
not deposited in other tissues, even the kidney.
DMSA/DMPS works through increasing urinary excretion.
DMSA/DMPS does not cross the blood-brain barrier, so no risk of
delivering bound mercury to the brain
Very low toxicity. Side effects may include anorexia, nausea,
vomiting, diarrhea, rash and a transient increase in liver enzymes.
There are no known adverse drug interactions with DMSA/DMPS.
EDTA: disodium vs Calcium disodium. Disodium EDTA given
rapidly by IV can suddenly drop serum calcium levels. Only
should use CaNa2 EDTA
Mercury Removal: Chelation
• oral (DMPS and DMSA)
• IV (DMPS and CaNa2 EDTA)
• Rectal (DMPS, DMSA, CaNa2 EDTA
[detoxamin]).
– best to have stool passage before insertion
– CaNa2 EDTA seems to cause less yeast
exacerbation
• TD – emu oil seems the best vehicle
– seen very little benefit/movement with DMPS
– seen some positive excretions with DMSA
– CaNa2 very difficult to keep in suspension without
precipitation
Single dose chelation challenge
– baseline urine taken before dose given
– 8 hour urine collection regardless of
type/route
– empty bladder before giving dose
– DMSA (oral or rectal 25mg/kg)
– DMPS (3mg/kg for IV, 10mg/kg for
rectal, 5-10mg/kg oral)
– CaNA2 EDTA (25-50mg/kg regardless
of rout, maximum of 1500mg)
– May need to do more than 1 challenge
with different agents/routes
(DAN! 2005 Consensus Paper)
Antonio (7 y/o) on first chelation challenge with DMSA
Antonio, after 4 cycles of DMSA
Antonio, after 8 cycles of DMSA
Antonio After Chelation with DMSA
Has bad gas during the DMSA days, and is moody,
then this goes away when the DMSA is finished.
Doing better and better in speech therapy
If he does not want to do things he cries.
Teachers are reporting improvements seen on a
month-to-month basis
More hand gesturing
In a more advanced class. The mimicry behavior has
stopped.
At this point language is the major barrier, behaviors
and stemming are under control
Richard (6 y/o) on first DMSA Challenge
Richard after 2 mo of DMSA
Richard Before Chelation
•No self help skills
•No bathroom skills
•No attention span
•No learning anything at school
Richard After Chelation
•Using the bathroom appropriately
•Will sit still for haircuts
•Focus and attention significantly improved
•Knows his letter, numbers and colors
•Excelling in all areas of education except for verbal speech, though is
vocalizing more then every before
Baseline
DMPS/Glutathione-IV
DMPS/Glutathione-Rectal
Urine Porphyrins
Porphyrins represent a group of uniquely
structured compounds that can surround
different types of ions/metals. Each has a
specific biological function
– Hemoglobin
– Myoglobin
– Chlorophyll
Biochemistry 101
Enzymes – the keys to life
A+B 0 C 0 D
A & B are substrates, the ingredients being
“mixed” together
0 is the enzyme, the catalyst that makes the
reaction proceed.
C & D are products made by the reaction,
which can then go on to be substrates
(ingredients) in other reactions
Some enzyme reactions can go both directions
Biochemistry 101
A+B 0 C 0 D
What can cause an enzyme not to work?
•Not enough or particular substrate
•The genes that code for the enzyme are
abnormal, creating a damaged or inefficient
enzyme
•Something “poisons” the enzyme so it won’t
work
•Too much of a product (D) drives the reaction
in the other direction
Urine Porphyrins
Certain toxins, such as heavy metals and pesticides can inhibit
certain enzymes in the heme porphyrin pathway, leading to
specific porphyrin profiles being excreted into the urine. If an
enzyme is inhibited, the substrate “upstream” can build up.
Aluminum and dioxin inhibit uropophyrin decaboxylase.
Mercury inhibits coproporphyrinogen oxidase.
Lead inhibits coproporphyrinogen oxidase and aminolevulinic
acid dehydratase.
(Woods, 1996)
Second urine void of the day is the best collection, as supplements
that cause oxidation if mixed with the porphyrins overnight in
the bladder can change the structure of the porphyrin lead to
false values (Martin, 1996)
Urine Porphyrins
Coproporphyrin (copro) is a general marker for
overall toxic metal burden. It is seen elevated in
the presence of mercury, lead and arsenic
Precoproporphyrin (preco) – an atypical porphyrin
that only appears in the presence of mercury
Heptacarboxyporhyrin and uroporphyrin is high
on exposure to pesticides, PCBs, arsenic and
aluminum
(Woods, 2005)
Urine Porphyrins
Children with autism have significantly higher
levels of copro and preco porphyrins compared to
controls (Nataf, 2006; Geier, 2006)
Nataf also found that the severity of autistic
symptoms correlated with the copro level, and that
children with autism and seizures had the highest
copro levels.
Urine porphyrin levels decrease with chelation
(Pingree, 2001)
Urine Porphyrins
(how/when I use the test)
I only send to Dr Nataf’s lab in France. They are the only
commercial lab that has ranges for children and that autistic
children has been studied at. The large US labs are not
calibrated to test for levels under that which is seen in genetic
porphyrin diseases which produce much higher porphyrin levels
I prefer using the chelation challenge test, as it also tells me if
the chelation agent/route of administration is working, not just if
the metals are present.
I order this test for:
– families who do not wish to expose their children to a
chelation agent unless there is proof of metals.
– If chelation challenge tests are negative but we still suspect
metals are present
– Once chelation challenge tests are negative after cycles of
chelation, if we still suspect metals are present
Overview of The Methylation / Transsulfuration Pathway
Methionine Protein synthesis
MAT
THF
SAM
Methylation of DNA, RNA,
MTase
proteins, membrane
MS BHMT phospholipids, creatine,
MTHFR
MB12 SAH neurotransmittors
Betaine
SAHH AK
5-CH3THF Choline Adenosine AMP
Homocysteine ADA
B6 CBS
Inosine
THF: tetrahydrofolate
Betaine:TMG Cystathionine
B6
Cysteine
Glutathione
The Methylation / Transsulfuration Pathway
The Enzymes:
MS: Methionine synthase
MAT: Methionine adenosyltransferase
MTase:Methyltransferase
MTHFR: Methylenetetrahydrofolate Reductase
SAHH: S-adenosylhomocysteine Hydrolase
CBS: Cystathione beta synthase
BHMT: betaine-homocysteine methyltransferase
The Methionine Cycle: Remethylation of Homocysteine
Methionine Protein synthesis
MAT
THF Methylation of DNA, RNA,
SAM
proteins, histones,
MTase membrane phospholipids,
MS neurotransmitters
MB12 SAH
SAHH AK
5-CH3THF Adenosine AMP
Homocysteine ADA
Inosine
THF: tetrahydrofolate
The Methionine Cycle: Remethylation of Homocysteine
Methionine Protein synthesis
MAT
THF
SAM
Methylation of DNA, RNA,
MTase proteins, histones,
MS membrane phospholipids,
B12 SAH neurotransmitters
SAHH AK
5-CH3THF Adenosine AMP
Homocysteine ADA
Inosine
THF: tetrahydrofolate
Effect of Oxidative Stress on Methionine Transsulfuration
Methionine Protein synthesis
MAT
THF
SAM
MTase Methylation of DNA, RNA,
MS proteins, membrane
BHMT
phospholipids, creatine,
B12 SAH neurotransmittors
Betaine
5-CH3THF Choline SAHH Adenosine ( AK and/or ADA)
Homocysteine
B6 CBS
THF: tetrahydrofolate
Cystathionine
B6
Cysteine
GSH GSSG
Neurotoxicity of Thimerosal in Human Brain Cells
is Associated with Glutathione Depletion:
Protective Effect of Cysteine or Glutathione
Supplementation
S. Jill James, William Slikker, Elizabeth New,
Stefanie Jernigan, Stepan Melnyk
Department of Pediatrics
University of Arkansas for Medical Sciences
Little Rock, AR
Neurotoxicity of Thimerosal in Human Brain Cells
is Associated with Glutathione Depletion:
Protective Effect of Cysteine or Glutathione
Supplementation
WORKING HYPOTHESIS
• Ethyl mercury in Thimerosal binds to cysteine thiol (–
SH) groups on intracellular proteins and inactivates
function.
• The cysteine-rich antioxidant, glutathione, binds
mercury and protects essential proteins from functional
inactivation.
• The neurotoxicity of Thimerosal is associated with
depletion of glutathione, the major intracellular
antioxidant.
VIABILITY OF GLIOBLASTOMA AND NEUROBLASTOMA
CELLS WITH INCREASING DOSE OF THIMEROSAL
Viability (MTT OD)
1.2 Glioblastoma Cells Neuroblastoma Cells
0.5
(48 hr Exposure) (3 hr Exposure)
1.0
0.4
0.8
0.3
0.6
0.2
0.4
0.1
0.2
0.0 0.0
0 2.5 5 10 20 0 0 2.52.5 5 510 10 20
20
M Thimerosal M Thimerosal
Viability of Glioblastoma cells exposed to 15 M
Thimerasol in the presence of GSH-ester, Cystine, N-
acetylcysteine (NAC), or Methionine
0.9
0.8
0.7
0.6
O.D. (Viability)
0.5
0.4
0.3
0.2
0.1
0
Control Thimerosal +GSH + Cystine +NAC + Methionine
Methyl-B12, Folinic Acid, and Betaine
Supplementation in 8 Children with Autism
Injectible Methyl-B12 (75 µg/Kg b.i.d.) was given to the 8
children who had been taking folinic and and betaine
supplements for 3-4 months
Plasma thiol profile was repeated in the 8 children after
4 weeks of combined folinic acid, betaine, and methyl
B12
Transmethyation Metabolites after addition of Methyl-B12 to
Folinic Acid and Betaine Supplementation in 8 Autistic Children
Methionine S-Adenosylmethionine
50 140
40 120
100
30
80
20 60
Control Before Folinic Folinic 40
10 Control Before Folinic Folinic
Betaine Betaine Betaine Betaine
Me-B12 20
Me-B12
0
0
S-Adenosylhomocysteine Adenosine
0.6
40
0.5
30 0.4
0.3
20
0.2
Control Before Folinic Folinic
10 Control Before Folinic Folinic
Betaine Betaine 0.1 Betaine Betaine
Me-B12 Me-B12
0 0
Transsulfuration Metabolites after addition of Methyl-B12 to
Folinic Acid and Betaine Supplementation in 8 Autistic Children
Homocysteine Cysteine
10 250
8 200
6 150
4 100
Control Before Folinic Folinic
Control Before Folinic Folinic 50
2 Betaine Betaine
Betaine Betaine
Me-B12
Me-B12
0 0
Cystinyl-Glycine 12 Total Glutathione tGSH)
70
60 10
50 8
40
6
30
4
20 Control Before Folinic Folinic
Control Before Folinic Folinic
10 Betaine Betaine 2 Betaine Betaine
Me-B12
Me-B12
0 0
Glutathione Redox Potential after addition of Methyl-B12 to
Folinic Acid and Betaine Supplementation in 8 Autistic Children
Total Glutathione (tGSH) 0.8
Oxidized Glutathione (fGSSG)
12
10
0.6
8
6 0.4
4 Control Before Folinic Folinic 0.2 Control Before Folinic Folinic
2 Betaine Betaine Betaine Betaine
Me-B12 Me-B12
0 0
GSH/GSSG Ratio
40
30
20
10 Control Folinic Folinic
Before Betaine Betaine
Me-B12
0
So, Why is this happening?
Certain toxins such as mercury can inhibit the
enzymes of this pathway.
Dr James has looked at the DNA sequences that
code for the proteins that make up these enzymes
and has found that autistic children have up to 3
times as many single DNA mutations
(polymorphisms, SNPs) as do children without
autism
We have identified these SNPs in children with
other neurodevelopmental disorders
OPEN CLINICAL TRIAL
METHYLCOBALAMIN STUDY
JAMES A. NEUBRANDER, M.D.,
F.A.A.E.M.
EDISON, N.J. 08837
OPEN CLINICAL TRIAL
METHYLCOBALAMIN STUDY
Total number of children included in the data: 85
•71 males 51 males responded
•14 females 12 females responded
•84% males
74.1 % of the
•16 % females
children
responded
positively!
OPEN CLINICAL TRIAL
METHYLCOBALAMIN STUDY
THE TOP TEN
Symptoms Parents Reported Were Helped Most Often
Language 71% Better Behavior 35%
Awareness 65% More Focused 35%
Cognition 52% Understanding 35%
Engagement 43% Vocalization 35%
Eye Contact 37% Trying“New Things” 33%
OPEN CLINICAL TRIAL
METHYLCOBALAMIN STUDY
Side Effects Parents Reported
Hyperactivity 10%
Sleep Patterns Disrupted Or Worsened 6%
Uncontrolled Or Unusual Laughter 3%
Increased Aggression 2%
Biting Objects 2%
More Distractible 2%
Eczematous Symptoms Worse 2%
Increased Stimming 2%
Silliness, Unusual And Unexplained 2%
Teeth Grinding 2%
Tongue Tingles 2%
•All reported side effects faded upon stopping therapy
• Most parents chose to resume therapy b/c benefits
outweighed the side-effects
Oxalates
Oxalates are small carbon and oxygen containing molecules that
are found in certain types of fruits and vegetables. Also most
nuts and seeds have oxalates.
For most people, oxalates in the diet are not absorbed in great
amounts into the bloodstream. They are usually metabolized by
intestinal flora and excreted in the feces.
In the presence of intestinal inflammation and leaky gut, larger
amounts of oxalates can get into the bloodstream and be
transported to tissues
Under certain conditions they can crystallize and become
deposited in tissues. The crystals can grow and become stones
(kidney stones are calcium oxalate)
When lodged in tissues, these crystals can produce irritation and
pain.
Oxalates
Oxalates seem to accumulate more in conditions of
glutathione deficiency and oxidative stress.
Vitamin B6 (pyridoxine) is a necessary cofactor for
enzymes that help prevent the formation of oxalates
When sulfur is deficient, it becomes extremely difficult to
keep the body from making excess oxalates.
High oxalates are associated with certain conditions like
vulvodynia, prostatitis, irritable bowel syndrome,
fibromyalgia, interstitial cystitis, and skin sensitivity. Some
people may get a sense of urinary urgency and frequent
urination, and sometimes the patient would have trouble
urinating (Solomon, VP Foundation)
High oxalates are often seen in patients with
recurrent/resistant yeast infections and glycine intolerance.
Testing for High Oxalates
There is no perfect test right now.
Urine testing is most often used. If high values are seen
then this is a strong indicator, but people secrete oxalates
in their urine at different times of the day (it may be most
accurate to collect multiple urine specimens during the
day), and relative to food intake so there can be false
negatives.
Great Plains Lab full organic acid test reports a spot oxalic
acid value. They also report other substances that are high
when there are oxalate issues: glyceric and glycolic acid
Quest Labs has both random and 24 hour urine oxalate
tests, both as an individual value as well as relative to
oxalate. I usually get 24 hour collection with oxalate.
Treating High Oxalates
The low oxalate diet. Full information can
be found at several sources:
– Yahoo Group: Trying_Low_Oxalates
–
Treating High Oxalates
The Low Oxalate Cookbook is published by the Vulvar
Pain Foundation, contains over 250 recipes.
The book has lists of foods with actual amount of oxate per
serving of a food.
Aim to keep oxalate intake down to under 40-60mg oxalate
a day.
Food Lists and summary can be found on “Medical
Topics” section of my webpage
Probiotics: VSL#3: 1/2 to 1 capsule daily or ¼ to ½
packet of the unflavored powder daily
Reduce vitamin C to 250mg or less a day, including foods
(oxalates can be converted to vitamin C)
Calcium citrate supplementation - given with meals to
help bind and excrete the oxalates.
Elevated Male Hormones/Androgens
Several studies have demonstrated that children with
Autism Spectrum Disorders have elevated androgens,
including testosterone, dihydrotestosterone,
androstendione and DHEA (Torjman, 1997; Knickmeyer,
2005; Geier,2006)
Although not exclusive, increased androgens have been
associated with increased masturbation and genital
rubbing, aggressiveness, hyperactivity, self-stimming, and
increased body hair (legs and back),
Elevations have been seen in male and female patients
I use LabCorp for my testing. They have the most specific
reference ranges for both sex and age of patient.
Elevated Male Hormones/Androgens
The enzyme that converts DHEA to DHEA-S
(storage hormone) is sulfotransferase, which is
glutathione dependant. When this enzyme is not
working, there is a build up of DHEA which then
gets sent to androstenedione and then
testosterone
Treating elevated Androgens
Geier – Lupron.
– belongs to a class of drugs called gonadotropin-releasing
hormone (GnRH) agonists.
– It is used to decrease the body’s production of specific
hormones, natural chemicals that influence the behavior of
certain cells. Because Lupron Depot can reduce the
production of both male and female hormones, it is used to
treat specific conditions in men, women, and children
(www.lupron.com)
Bradstreet – Spironolactone,
– a potassium sparing diuretic, also has action of blocking the
receptor for dihydrotestosterone.
– Androgen levels should not go down with this treatment, but
the effects of the hormone are blocked.
Treating elevated Androgens
Berger (VERY NEW)
– Glycyrrhizin – the active ingredient in licorice root
– decreases testosterone level by inhibiting the enzyme which
converts of 17-OH progesterone to DHEA (Armanini, 1999)
– Inhibits the enzyme that converts Androstendiaone to Testosterone
(Fukui, 2003).
– High doses can affect blood pressure and fluid retention, but doses
21%)
Traditional HBOT – a hard walled chamber that
exposes the patient to a maximum of 3ATA
(monoplace-1 patient) or 6ATA (multiplace - >1
patient) at 100% oxygen
Mild HBOT (mHBOT) - a soft walled chamber
that exposes the patient to a maximum of 1.3ATA
and <100% oxygen
Hyperbaric Oxygen Therapy
Laws of Physics
Henry’s Law - the amount of a gas absorbed by a
liquid is in proportion to the pressure of the gas
above the liquid, provided that no chemical action
occurs.
Boyle’s Law - at a constant temperature, the
volume and the pressure of a gas are inversely
proportional. In other words, a gas will compress
proportionately to the amount of pressure exerted
on it.
Examples of these laws:
– a bottle of soda
– A scuba diver
Hyperbaric Oxygen Therapy
History
In 1662, British Physician Dr. Henshaw first used
compressed air in an attempt to treat pulmonary disease.
His first chamber was called the “Domicilium”. Chamber
pressure was either raised or lowered with organ bellows
In 1879, French surgeon Fontaine created a mobile
chamber. He was able to increase the amount of oxygen
carried in the blood during the administration of nitrous
oxide anesthesia. This prevented blood oxygen levels from
decreasing, which typically happened from surgical
anesthesia
In 1921 Cunningham constructed a 20 meter round ball
that was the largest Hyperbaric Chamber ever built. It
contained a smoking lounge, dining facilities, rich
carpeting, and private quarters.
Hyperbaric Oxygen Therapy
Cunningham’s Sanitarium -1921
Later it was scraped for metal during World War II.
Hyperbaric Oxygen Therapy
History
In 1934, US Naval Submarine Officer, Dr. Behnke
proposed using oxygen plus recompression for
Decompression Sickness (the bends). This information was
ignored until 1967
In 1955, Dutch thoracic surgeon, Dr. Boerma removed the
red blood cells from pigs and found they could survive
with oxygen dissolved in plasma by use of hyperbaric
Oxygen.
In 1961 Danish Dr. Brummelkamp, Published on the
ability of HBOT to inhibit the growth of anaerobic
bacteria - organisms that live where there is low or no
oxygen, such as gangrene or tetanus.
In June 2006 Tampa Pediatrician David Berger obtained
his first mHBOT chamber, getting a second one the month
later. The world has never been the same since.
Hyperbaric Oxygen Therapy
Official Medical Indications
• Air or Gas Embolism • Exceptional Blood Loss
• Carbon Monoxide (Anemia)
Poisoning and Smoke • Necrotizing Soft Tissue
Inhalation Infections
• Carbon Monoxide • Osteomyelitis
Poisoning Complicated (Refractory)
by Cyanide Poisoning • Radiation Tissue
• Clostridial Myonecrosis Damage
(Gas Gangrene) (Osteoradionecrosis)
• Crush Injury, • Skin Grafts and Flaps
Compartment (Compromised)
Syndrome, and other • Thermal Burns
Acute Traumatic
Ischemias
• Decompression Sickness
(the "Bends")
• Enhancement of Healing
in Selected Problem
Wounds
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
• Correct Cerebral hypoperfusion (low blood flow)
• Correct Cerebral Hypoxia (low oxygen levels)
• Decrease Neuroinflammation
• Decrease Intestinal Inflammation
• Improve Immune Function
• Reduce Oxidative Stress
• Correct Neurotransmitter Abnormalities
• Treat Intestinal Dysbiosis
Rossignol DA, Hyperbaric oxygen therapy might improve certain
pathophysiological findings in autism. Med Hypotheses (2006)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Rossignol DA, Hyperbaric oxygen therapy might
improve certain pathophysiological findings in
autism. Med Hypotheses (2006)
• Differing levels of pressure and oxygen were used in
the various studies that are discussed
• Some may be at pressures that are not being
recommended for children with Neurodevelomental
disorders
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Cerebral Hypoperfusion and Hypoxia in Autism
• Multiple studies have shown hypoperfusion to areas of the
brain of children with autism, especially the temporal lobes.
(Rye, 1999; Zilbovicius, 2000; Ohnishi, 2000)
• The low blood flow was more profound the older a child is.
(Wilcox, 2002)
• Autistic children often do not increase their cerebral blood
flow when doing tasks and when listening and trying to
speak, as seen in neurotypical children. (Critchley 2000,
Allen 2003).
• Decreased blood flow to the thalamus as seen on SPECT
scans has been associated with repetitive and self-stimming
behaviors (Starkstein, 2000)
• Decreased blood flow to Wernicke’s and Brodmann’s areas
(speech areas of the brain) has been associated with
decreased auditory processing (Bodaert, 2002) and
language development (Wilcox, 2002)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Treating Hypoperfusion with HBOT
• HBOT may overcome the effects of the hypoperfusion by
providing the brain with more oxygen (Sheffield, 1976;
Neubauer, 1998)
• HBOT may increase new blood vessel growth (Al-Waili,
2006)
• Hypoperfusion may be due to inflammation. Inflamed
vascular cells can lead to diminished blood flow, and
inflammation in tissue prevents maximal uptake of oxygen
by cells
• HBOT can increase the distance that Oxygen can travel
between cells (Williams, 1997)
• Increased blood flow to the brain also means increased
blood flow from the brain, potentially increasing the flow of
toxins away from the brain. This could bring a synergistic
effect with chelation.
SPECT Scans in a 4 year old autistic child
after 10 dives mHBOT at 1.3 atm and 24% oxygen
Before After Mild HBO
Heuser et al., 2002
Best Publications; 2002:109-15
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Neuroinflammation and Autism
• Of recent, several studies have demonstrated
evidence that children with autism have increased
neuroinflammation.
• Increased inflammatory cells and pro-
inflammatory chemical mediators (cytokines)
have been found in the CSF of Autistic Children
(Weizman, 1982; Vargas, 2005).
• Increased brain auto-antibodies have been
demonstrated in children with Autism (Connolly,
1999; Singh, 1997; Vojdani, 2002; Singer, 2006)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Gastrointestinal Inflammation and Autism
• A subset of children with Autism have demonstratable
inflammation of their stomach, small intestine and colon
(Furlano, 2001; Uhlmann, 2002; Balzola, 2005; Wakefield,
2005)
• Both inflammatory cell and cytokines (TNF-ά, IL-1Β, IL-6)
have been seen in increased amounts in the gastrointestinal
lining in some children with Autism (Jyonouchi, 2001;
Ashwood, 2003 & 2004)
• Many children with autism have increased serum antibodies
directed against casein and gluten based peptides (Vojdani,
2003; & 2004)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Treating Inflammation with HBOT
• HBOT had been demonstrated to have anti-inflammatory
affects on tissues (Al-Waili, 2006)
• HBOT can decrease the production of the cyctokines that
are pro-inflammatory such as IL-6 and IL-1(Weisz, 1997)
and TNF-ά, (Yang, 2006)
• HBOT can increase the production of cytokines that
decrease inflammation such as IL-10 (Buras, 2006)
• HBOT has been shown in animal studies to reduce
symptoms and inflammation of arthritis (Warren, 1979) and
peritonitis (Tokar, 2003)
• There is evidence that HBOT can facilitate remission for
non-responsive Crohn’s Disease (Brady, 1989; Columbel,
1995) and Ulcerative Colitis (Buchman, 2001; Gurbuz,
2003)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Abnormal Immune Function and Autism
• 5% of Children with Autism have low serum IgA levels
(Gupta, 1996)
• Compared to typical children, many Autistic children have
elevated IgE levels (Gupta, 1996; Lucarelli, 1995)
• Some children with Autism have reduced levels of T-helper
cells (Warren, 1986)
• Some children with Autism have decreased lymphocyte
activity/responsiveness (Stubbs, 1977)
• Warren (1987) demonstrated decreased Natural Killer Cells
in Autistic Children compared to controls
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Treating Immune Abnormalities with HBOT
• In patients with MS, HBOT significantly
increased the production in total an helper T-
Lymphocyte levels as well as IgA serum levels
(Nyland, 1989)
• In patients with atopic dermatitis, HBOT
decreased IGE levels as well as symptoms
(Olszanski, 1992).
• In mice studies, Lymphocyte activity and
lymphocyte counts were increased by HBOT
(Lee, 1993&1994)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Increased Oxidative Stress and Autism
• Many children with Autism show the presence of increased
oxidative stress/free radicals
• They have lower levels of glutathione (James, 2004)
• Increased RBC nitric oxide has been seen in some Autistic
children. This is a free radical and is a neurotoxin. (Sogut,
2003)
• Children with Autism demonstrate increased markers of
oxidative stress and lipid peroxidation such as
malondialdehyde (Chauhan, 2004)
• Children with Autism often have decreased activity of the
enzymes that produce antioxidants such as glutathione
peroxidase and superoxide dismutase (Yorbik, 2002)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Treating Oxidative Stress with HBOT
• There has been concern that HBOT could, thought increased
production of reactive oxygen species, increase oxidative
stress, and that taking alpha-liopic acid (an antioxidant)
could ameliorate this problem (Alleva, 2005).
• In animal studies, there is evidence that oxidative stress is
less of a concern at pressures < 2.0 ATA (Wada, 2001).
• Other animal studies have shown that at < 2.0 ATA, HBOT
may reduce oxidative stress by decreasing the peroxidation
of lipids (Ozden, 2004, Kudchakar, 2000).
• In other animal studies, HBOT has been demonstrated to
increase superoxide dismutase (Gregorevic, 2001) and
glutathione peroxidase (Gulec, 2004)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Abnormalities in Neurotransmitters and Autism
• Serotonin levels man be lower in children with autism
(Chugani, 1999; Connors, 2006)
• Compared to controls, children with Autism have lower
plasma tryptophan levels. Tryptophan is the amino acid
precursor of serotonin.
• Tryptophan uptake into brain cells was decreased in children
with Autism compared to controls when studies with PET
scans (Chugani, 1999)
• Some children with Autism may have increased dopamine
activity (Gillberg, 1997)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Correcting Neurotransmitter Abnormalities with
HBOT
• Serotonin uptake by endothelial cells of the lung
has been shown to be reduced [the same
mechanism as SSRIs] when HBOT was used
(Fisher, 1980; Block, 1981)
• Following brain injury, HBOT was demonstrated
to decrease dopamine release (Yang, 2002)
• Oxygen alone, without increased pressure, may
decrease brain extracellular dopamine levels
(Adachi, 2001)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Intestinal Dysbiosis and Autism
• Overgrowth of certain abnormal bacteria, and in particular
clostridia (anaerobic) bacteria, have been seen in many
children with autism compared to controls (Feingold, 2002;
Song, 2004; Parracho, 2005)
• An increased clostridial byproduct (HPHPA) is often seen
on urine organic acid testing of children with Autism.
• Improvements in Autistic symptoms have been
demonstrated in serial blinded psychological evaluations
after the administration of oral Vancomycin (Sandler, 2000)
• Intestinal overgrowth of yeast, viruses and parasites have
been documented in children with Autism (Cave, 2001)
Hyperbaric Oxygen Therapy
Proposed Mechanisms of Action
Treating Intestinal Dysbiosis with HBOT
• HBOT has been shown to decrease levels of
atypical bacteria overgrowth in the distal ileum
(Akin, 2001).
• HBOT has been demonstrated to be able to kill
many different types of bacteria, including
clostridia (Gotleib, 1971;Unsworth, 1984)
• Phagocytes, white blood cells that engulf bacteria,
depend on oxygen to kill the bacteria (Babior,
1978). Killing of Staph Aureus by these
leukocytes is enhanced by HBOT (Mader, 1980)
Hyperbaric Oxygen Therapy
Hard vs. Soft Chamber
• Cost: Hard chamber dives cost 2-6x that of mHBOT
• Time to depressurize if need to get out quickly. The higher
the pressure, the longer it takes to depressurize
• Oxygen Dangers/Flammability/fire and building codes
• Oxygen Delivery
– 100% in Hard Chamber. In most units, no special masks or
tubes are needed. Compliance may be easier with the Hard
Chamber
– 24 – 40% in mHBOT depending on how O2 is delivered
• Breaks vs. no breaks in therapy
• Accessibility/home use approval
• Is more better?
• Some may respond to hard but not soft (often see 1.75ATA
used for ASD, never more than 2.0ATA)
– certain conditions such as crush injuries, CP, anaerobic bone
infections
Hyperbaric Oxygen Therapy
And Seizure Risk
• There is a known entity called Oxygen seizures.
• Incidence of seizures has never been reported with
pressures <2.0ATA for 1 hour or less
• Davis (1989): In chart review, Overall incidence
of seizures was 0.01%, looking at 1505 patients
who did a total of 52,700 dives. 5 patients
developed seizures, all recovered completely.
Hyperbaric Oxygen Therapy
Hyperbaric Oxygen Therapy
Hyperbaric Oxygen Therapy
Our Proposed Study
This would be the first University based,
placebo-controlled, blinded study ever
performed using HBOT on children with
Autism
Joint project between Wholistic Pediatrics and
USF Child Psychiatry, Child Neurology and
Child Development teams
Hyperbaric Oxygen Therapy
Our Proposed Study
Subjects:
– Children with formal diagnosis of Autism
– Selecting kids that have not done any biomedical/dietary
interventions, only educational interventions
– Only educational changes allowed during treatment
period
– 10 children to receive treatment, 10 placebo. Will cross-
over the placebo group.
– 6-8 year old
– Must be able to comply with use of non-rebreather mask
Hyperbaric Oxygen Therapy
Our Proposed Study
Outcome measures:
• ADOS
• full neuropsychological evaluation
• Single subject design – since multiple N=1
• GI checklist
Will do evaluations at:
3 months prior to starting mHBOT
The week before starting mHBOT (to determine what a typical
3 months bring in terms of symptom changes)
At the end of 3 months of dives
3 months after dives start
Also will take selected data during 1-2 week intervals during
the dive phase for the single subject design
The Bottom Line:
We Need More
Research!
----The Bottom Line----The Bottom Line----The Bottom Line----The Bottom Line---