Will whole-genome sequencing create a new liability tsunami for physicians?

Will whole-genome sequencing create a new liability tsunami for physicians? - Just over 10 years ago, the sequencing of the first human genome was announced at a White House press conference. In the decade since, the practical application of genomic information has been disappointingly slow. That is about to change. We are rapidly—much faster than many anticipated—approaching the widespread clinical use of whole-genome sequencing. WGS involves the complete sequencing of all 6 billion-plus base pairs of DNA in our individual genomes.

Just 10 years ago, it cost $100 million to sequence an entire genome. Today, WGS is commercially available for less than $10,000, and several companies are racing to get the cost below $1,000 within the next few years. The $1,000 price tag is the magical flip point at which the National Institutes of Health and many experts in the field believe WGS will be economically feasible for routine use in medical care.

Though we haven’t reached that $1,000 milestone yet, WGS is already being rapidly adopted across the country. In 2009, fewer than 100 people had ever undergone WGS, but that number jumped to more than 2,000 in 2010 and is expected to reach 30,000 this year. The accelerating adoption of WGS brings with it much promise, but as with any rapid technology change, it will also have disruptive consequences, at least in this transition period. Unfortunately for doctors, they will likely bear much of the brunt of this disruption.

As genome sequencing becomes more affordable, more patients are going to be asking doctors very difficult questions

On the positive side, a number of patients have already reaped dramatic benefits from WGS. A 6-year-old Wisconsin boy received a life-saving umbilical-cord-blood transplant after WGS showed that a unique DNA mutation was responsible for his mysterious bowel disease. A pair of 14-year-old San Diego twins suffering from a debilitating movement disorder were successfully treated after WGS revealed they had a rare mutation that could be corrected by a simple amino acid supplement. A family of four in Silicon Valley recently underwent WGS, revealing that a teenage daughter had several mutations putting her at high risk of blood clots. That information will help let her doctors treat her before the blood clots become a problem, instead of only when the damage has been done. More generally, a growing number of cancer patients have benefited from tailored therapies based on new mutations in their tumor discovered by comparing the complete genomes of their healthy cells with those of their tumor cells.

Given these dramatic successes, it seems clear that WGS is going to be good for patients, enabling them to receive treatment tailored to their personal genetic makeup. However, should genomic sequencing become nearly as routine as, say, a colonoscopy or cholesterol check, doctors—most of whom have no formal genetics training—may find themselves in a precarious position. These doctors may be extraordinarily vulnerable to lawsuits regardless of whether they embrace or resist the use of WGS with their own patients. While other players such as the testing labs may also be subject to lawsuits if they negligently conduct or interpret genetic tests, it is doctors who will be required to communicate and explain test results to patients, which is the step that involves the greatest duty to the patient and carries the biggest risk of liability.

As with any new technology, many doctors will resist adopting WGS, at least initially. As the cost of sequencing continues its precipitous decline, and ever-more doctors and patients use the technology, the performance gap between those who adopt it and those who resist will inevitably grow larger. At the same time, many courts are moving toward a national rather than local standard of care. Essentially, this means that doctors, whether they work in underfunded hospitals or prestigious academic medical centers, are expected to offer the same quality of care. Let’s say that two patients, living across the country from each other, are suffering from the same medical problem. The one in a rich, technology-friendly hospital is offered WGS by her doctor. Her life is saved as a result. But the other patient, either because his hospital doesn’t have the resources or because his doctor is not comfortable with WGS, doesn’t have the test and dies as a result. That doctor may be now be liable for that patient’s death.

Even doctors who eagerly adopt WGS will be vulnerable to lawsuits. It is estimated that each of us have more than 100 variants that could significantly increase our risk of genetic diseases. WGS can detect every one of those variants. That’s an overwhelming number of potential problems for doctors to evaluate. There are nowhere near enough genetic counselors or medical geneticists to meet this demand, leaving the burden of understanding and communicating this information to doctors who have little or no training in genetics. Under these circumstances, it is likely that many doctors will fail to recognize some of these variants’ potential significance—and if that happens, a doctor can expect a major malpractice claim when his patient suffers illness or death that could have been prevented. A number of court cases dealing with existing genetic testing demonstrate that juries fully expect doctors to recognize and understand a broad range of genetic conditions, no matter how rare. For example, a Florida doctor recently was hit with a $23.5 million verdict for failing to recognize a rare genetic condition called Smith-Lemli-Opitz syndrome. When these expectations are applied to the hundreds of variants that will inevitably be revealed in every use of WGS, doctors will be easy prey for savvy trial lawyers.

Yet another potential source of liability will relate to a doctor’s duty to disclose medically significant genetic findings to a patient’s relatives. Unlike most medical tests, genetic information is relevant not only to the individual patients being tested but also to their family members, since they may harbor the same genetic variants. While physicians’ professional codes of ethics and federal laws discourage disclosure of genetic test results to family members, courts have decided this issue inconsistently to date, in some cases holding doctors liable for failing to warn family members about potential genetic risks. Settled legal and ethical principles on confidentiality and disclosure issues will be upended by widespread use of WGS.

Other dynamics of WGS will exacerbate these physician liability risks. There will be constant and rapid changes in our knowledge about the significance of various genetic variants, requiring doctors to constantly re-evaluate the diagnosis, prognosis, and treatment of their patients. Moreover, as patients become increasingly familiar with genetics, they’ll start asking more informed and nuanced questions of their doctors about genetic factors, creating new liability risks if the physician fails to respond accurately or completely. For example, consider a patient who expresses concern about his or her risk for a particular type of cancer, which may be affected by dozens of genes. If the doctor fails to note a significant mutation in one of those genes, she may be at an increased risk for liability given her affirmative assurance to the patient. In this environment, doctors will be forced to learn genetics on the job (and quickly) or will be spending much of their time and income in litigation. Perhaps the greatest hope is that a new generation of doctors being trained today will respond to these potential issues before they are overwhelmed by them, though most medical schools are not training today’s students to deal with the challenges and implications of WGS.

There is one thing we do know. As instructors of a Genetics & Law course at a law school, a new generation of law students will be ready and hungry to jump on the coming tidal wave of genetics-based medical malpractice lawsuits. It remains to be seen whether the medical profession will step up to the plate and meet this challenge, but they better start soon. If not, it will be a good time to be a patient, and a lawyer, but perhaps not a physician. ( slate.com )

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New Male Birth Control Concept Shows Promise

New Male Birth Control Concept Shows Promise - Equality for men may be on the horizon, contraceptive equality, that is. For just over a half century, women have been able to pop a pill to prevent pregnancy, but a pharmaceutical alternative has never emerged for men.

Now, research to interfere with the body's ability to use vitamin A is showing some promise, because, in men, vitamin A is necessary for the production of sperm.

One recent study found that a compound that interferes with the body's ability to use vitamin A rendered male mice sterile while they were receiving 8- or 16-week courses. But once the mice were taken off the compound, they resumed making sperm. Significantly, the researchers found no side effects, and the testosterone levels of the mice stayed normal, meaning no fluctuations in mousey libido.

"Our mice, they mate quite happily, so that is not something we have interfered with," said Debra Wolgemuth, one of the study researchers and a professor of genetics and development at Columbia University Medical Center.

Options

The female birth control pill uses hormones — chemical signals — to short circuit the release of a mature egg, known as ovulation. A similar approach can work in men, using hormones like progestins and testosterone, to suppress the production of sperm.

Although effective techniques have been developed, none have received approval by the Federal Drug Administration, according to Diana Blithe, program director for the contraceptive development centers program and contraceptive clinical trials network at the National Institute for Child Health and Human Development.

"The reality is we could get a product out there very quickly if companies would aggressively take on the process of making it happen," she said.

Hormones don't suppress sperm production in a small number of men; however, these men could easily be identified and advised to use a different method, she said

Some researchers, like Wolgemuth and her colleagues at Columbia, are exploring nonhormonal methods to interfere with the production or function of sperm.

The pathway

When you consume vitamin A, your body converts it into the metabollically active form, retinoic acid, which binds to a protein in your cells called a retinoic acid receptor. Then, the receptor protein can initiate the expression of genes necessary for the creation of sperm, if you are a man.

The compound Wolgemuth's team tested blocks the retinoic acid from binding to the receptor and so prevents the formation of new sperm.

"The long and short of what we know is vitamin A and its metabolite are absolutely essential for the production of male germ cells, or sperm," she said.

A high bar

Other research is looking at ways to use this pathway to render men temporarily sterile. Dr. John Amory, a professor of medicine at the University of Washington, has been working with a drug that interferes with the action of an enzyme that converts vitamin A to its biologically active form in the testis.

One of the barriers to the development of a pharmaceutical contraceptive for men is a high bar for safety, according to Amory.

"For women the small risks of birth control have been always been justified by the larger risk of pregnancy or unintended pregnancy," he said. For instance, hormonal contraception carries a risk of blood clots that is dwarfed by the risk created by pregnancy.

"You can't use the same justification for a male contraceptive," he said.

The work by the team from Columbia supports the idea that interfering with the retinoic acid pathway can render male animals temporarily sterile, he said. Even though side effects have yet to show up in their work with the compound, he said: "The concern I have as a clinician about their approach is retinoic acid has multiple functions in multiple tissues so blocking the activity by blocking the receptor, I have concerns that could cause side effects."

Retinoic acid is important for vision, a healthy immune system and other functions.

The Columbia team's latest work is scheduled for presentation today (June 4) at the conference for endocrinologists, ENDO 2011, in Boston. ( LiveScience.com )

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New Drug Extends Survival for Men With Advanced Prostate Cancer

New Drug Extends Survival for Men With Advanced Prostate Cancer -- For men with advanced hormone-resistant prostate cancer who have also failed chemotherapy, the new drug Zytiga (abiraterone acetate) along with the steroid prednisone appears to boost survival, researchers report.

Based on data from the ongoing clinical trial, Zytiga was approved by the U.S. Food and Drug Administration in April. It works by inhibiting the production of the male hormone testosterone, which promotes the growth of cancer cells. In this regard, the drug mimics hormone therapy.

Zytiga "prolonged overall survival in this patient population that had extremely limited therapeutic options after chemotherapy," lead researcher Dr. Fred Saad, chief of urology at Notre-Dame Hospital in Montreal, said during a Monday morning press conference.

Men taking the drug combination had an average survival of 14.8 months, compared with 10.9 months for men taking a placebo.

"Abiraterone represents a valuable treatment option for patients with metastatic, castration [hormone]-resistant prostate cancer who had been treated previously with chemotherapy, with very manageable treatment-related toxicity," Saad said.

The study was published in the May 26 issue of the New England Journal of Medicine. The findings had also been presented May 16 at the American Urological Association's annual meeting, in Washington D.C.

The study included 1,195 men with prostate cancer who did not respond to hormone therapy and had failed earlier chemotherapy. The researchers, from 147 hospitals across 13 countries, randomly assigned the men to take either Zytiga plus prednisone, or a placebo.

The drug combination was well tolerated and resulted in less fatigue, back pain and spinal compression among the men taking it, compared with the placebo, Saad said.

The most common side effects among those taking Zytiga and prednisone were lower levels of white blood cells, fluid retention, low potassium levels, abnormal liver function tests, high blood pressure and heart problems, the researchers noted.

A one-month supply of 120 pills of Zytiga costs $5,000, said Kelly McLaughlin, a spokeswoman for Centocor Ortho Biotech Inc., the drug's maker and a sponsor of the study.

"This study tells us that there is a form of hormonal therapy, abiraterone, that works in people who had standard hormonal therapy and chemotherapy," said prostate cancer expert Dr. Anthony D'Amico, chief of genitourinary radiation oncology at Brigham and Women's Hospital in Boston.

"It will provide people with late-stage disease with an opportunity for an extended survival that they didn't have before. I can't say it's a home run because it's only a few months improvement," he added.

Very aggressive prostate cancer may be able to make its own testosterone, which the cancer cells need to grow. "Zytiga blocks that," D'Amico explained.

"This drug provides longer life and better quality of life to men with very advanced prostate cancer," D'Amico said. "There are studies now to see if this drug will improve cure rates in men with advanced, but not metastatic [cancer that has spread to other organs], prostate cancer," he added. ( HealthDay News )

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Native American Children Have More Tooth Decay

Native American Children Have More Tooth Decay -- Native American children in the United States and Canada have three times the rate of untreated cavities compared to other kids, according to a new policy statement from a pediatricians group that recommends doctors pay more attention to the oral health of those patients.

A survey of 2,633 children aged 2 to 5 born to indigenous populations in the United States, Alaska and Canada found that 68 percent had untreated cavities. In some Canadian indigenous communities, more than 90 percent of children have tooth decay (dental caries).

"The influence of early childhood caries on overall childhood health and well being goes well beyond the mouth, and many of our indigenous children have not benefited fully from the many advances to improve oral health in North American children," Dr. James Irvine, co-author of the American Academy of Pediatrics' policy statement, said in a news release. "In fact, there are remarkable similarities in health issues and living circumstances of indigenous children in the U.S. and Canada."

The policy statement is published in the June issue of Pediatrics.

Researchers concluded that young indigenous children should have access to oral health care, in conjunction with other preventive measures under the guidance of a pediatrician.

"Many physicians continue to view early childhood caries as a dental problem to be treated by dentists," noted study co-author Dr. Steve Holve. "We want to emphasize that early childhood caries is an infectious disease, knowing that infectious diseases are problems in which pediatricians and primary care providers are experts. The skills of our dental colleagues are highly valued, but we hope to shift the focus of treatment for early childhood caries to primary care providers and preventive measures such as topical fluoride varnishes."

In encouraging pediatricians to assume a larger role in the prevention of tooth decay among indigenous children in the United States and Canada, the American Academy of Pediatrics recommended:

• Parents and caregivers of infants and children should be educated on proper oral hygiene and diet.
• After their first tooth comes in, children should use fluoridated toothpaste under proper supervision.
• Pregnant women should have access to prenatal screening for dental health and referrals for dental care.
• Children should have access to oral health prevention and treatment services, such as fluoride varnish programs. ( HealthDay News )

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11 Ways to Reduce Morning Stress

11 Ways to Reduce Morning Stress - Find yourself feeling tense in the morning? Here are 11 great tips for cutting your stress levels.

Mornings can be the most stressful part of our day if we fail to manage our time and health needs appropriately. Many of us deal with the dizziness of an unpleasant, hectic rush every morning in preparation for work or school, but it doesn’t have to be this way. With a little sensible time management, these eleven steps can help you drastically cut down on your morning stress.

1. Create an Evening Preparation Routine

An evening routine in preparation for the morning, that is. Iron your clothes, prepare your lunch, locate your keys, plan a nutritious breakfast, etc. These simple tasks will take you less than thirty minutes to complete each evening and will save you a huge headache every morning.

2. Plan a Realistic Day

Write a short “Must Do Today” list every evening for the following day. Never fill your mind with unnecessary worries in the excess of this list. Write down anything that cannot be pushed off to the following day. Avoid the tendency to overpopulate this list, and thus your schedule, with unrealistic goals.

3. Eliminate Known Aggravations

If your alarm clock makes a horribly annoying sound, the electric razor burns your skin, and your car’s windshield wipers are faulty … you get the idea. Fix the problems and eliminate the stress factors permanently from your life. There’s absolutely no reason to deal with habitual aggravations that can easily be resolved with a little time and money.

4. Get a Good Night’s Sleep

Make sure you start winding down for bed at a reasonable hour to allow enough time for a healthy night’s sleep. Most people require between seven and eight hours each night. If needed, set a bedtime reminder alarm on your alarm clock. Always keep the temperature in your bedroom comfortably cool. Studies from the National Sleep Foundation suggest the ideal temperature for sleeping is somewhere between 54 and 75 degrees Fahrenheit. Also, go easy on afternoon caffeine intake. When you consume caffeine late in the day, the quality of your sleep usually suffers.

5. Wake up Thirty Minutes Earlier

An extra thirty minutes in the morning is the difference between peaceful harmony and rapid-fire pandemonium. As long as you get to bed on time, waking up thirty minutes earlier should seem natural after just a few days. Use this time to think, stretch, shower, eat breakfast, and account for any unanticipated bumps in your morning routine.

6. Drink a Glass of Water First Thing

Water makes up 60 to 70 percent of our body composition, so it’s absolutely vital to stay properly hydrated. Even mild dehydration can cause your blood to thicken. This forces your heart to work double-time in order to push the necessary blood to your organs, which will result in noticeable mental fatigue. Also, a hydrated body is more efficient at dispersing energy-building nutrients to all its extremities. Since the average human body becomes slightly dehydrated over the course of a long sleep, you should drink a tall glass of water first thing when you wake up.

7. Do a Light Ten-Minute Stretching Workout

Do you feel a little groggy when you first wake up? This is completely normal. All you need to do is get your blood flowing, which will assist your body in transitioning between the sleeping and awake states. Once you do, you’ll feel great. Place a mat or towel on a carpeted floor. Lie on your back and stretch your arms as far as you can in one direction while stretching your toes out in the opposite direction. Then stand up and do some knee raises and toe touches. If you are feeling up to it, add in a few sit-ups and push-ups.

8. Listen to Music and Take a Hot Shower

Music injects positive, motivational influence into your mind. You should listen to music that makes you happy every morning while you progress through your routine. Also, a hot shower can be one of the most soothing experiences early in the morning. The fresh, revitalized feeling you have after stepping out of the shower will spill over as positivity into your first few tasks of the day.

9. Keep a Clean, Organized Living Space

Create order in your life and living space. Organize your home so that you always know exactly where your belongings are. Then, consciously put your belongings away in their proper place each time you use them. Doing so will eliminate the unproductive, stress filled moments of searching for something you’ve misplaced.

10. Never Drive Home with an Empty Gas Tank

Filling up a car’s gas tank is so darned easy, but it does take a few minutes of your time. Why then, do so many people procrastinate on filling up their cars with gas until the busy mornings when they can’t spare any time without being late? Never do this! Check your gas tank level on the way home. If it’s getting low, pull into a gas station and fill it up immediately.

11. Schedule Something You Love Daily

Getting up to face a new day is far more satisfying when you have something to look forward to. Life is short. Make sure you manage your time effectively so that you have time to engage in something you love on a daily basis.

There will always be exceptions, but faithfully following the steps above should help you conquer most of your mornings with reduced stress and a lot more grace.

Lose an hour in the morning, and you will be all day hunting for it.—Richard Whately ( gimundo.com )

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How To: Do Relaxation Breathing

Proper breathing is actually a learned technique, and once you know how to do it, you may find yourself much more able to manage stress throughout the day. Follow the simple breathing exercises in this video and see what a difference they make for you.

Follow These Five Easy Steps

1. Find a quiet place

Sit comfortably in an area that is relatively quiet. Turn off any cell phones or anything else that might disturb you.

Time Inc. Studios

2. Sit on a towel or blanket

Place a small, folded towel under your buttocks. This will make you sit up straighter, which will open up your chest and lungs and allow you to breathe more deeply.

Time Inc. Studios

3. Focus on your breathing

Close your eyes and start to focus on your breathing. Notice how deep or shallow your breaths are.

Tip: The goal here is to focus only on your breath, pushing all other (potentially stress-triggering) thoughts from your mind.

Time Inc. Studios

4. Repeat for 10 to 20 minutes

Perform this breathing and focusing exercise for 10 to 20 minutes a day.

Time Inc. Studios

5. Take a break with one slow, deep breath

For a quick boost in the middle of your day (or anytime you find your stress level rising), take one slow deep breath in, hold it for a count of four, and then exhale slowly. ( realsimple.com )

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Too Many Kids Getting Antibiotics for Asthma

Too Many Kids Getting Antibiotics for Asthma -- Although guidelines don't recommend antibiotics for asthma, almost 1 million children with the respiratory condition are prescribed the medications each year in the United States, a new study finds.

"We are trying to reduce unnecessary antibiotic prescriptions, and this suggests that we as pediatricians are prescribing them way too often," said lead researcher Dr. Ian M. Paul, an associate professor of pediatrics at the College of Medicine of Pennsylvania State University in Hershey.

Why doctors are prescribing antibiotics for asthma is not clear, Paul said. One reason might be that doctors treating severe asthma attacks "feel the need to cover all their bases by also prescribing antibiotics," he suggested.

Sometimes parents may ask doctors to give their child antibiotics, but it doesn't seem to be a big factor, Paul noted. "It probably exists to some degree in clinical practice, but I don't think it happens all that frequently -- certainly not in one in every six visits for asthma," he said.

"The one encouraging finding was, when asthma education was delivered as part of the visit, antibiotics were less likely to be prescribed," he added. When asthma education was not part of the visit, 19 percent of the time antibiotics were prescribed, compared with 11 percent when asthma education was given.

"This suggests that we can educate families and patients and explain the causes of asthma and, hopefully, reduce unnecessary antibiotic prescribing," Paul said.

The dangers of overprescribing antibiotics are that it promotes the development of antibiotic-resistant bacteria and there are side effects for the drugs themselves, Paul pointed out.

The report was published in the May 23 online edition of Pediatrics.

For the study, Paul's team used data from the National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Survey to see the rate of antibiotics prescribed for children between 1998 and 2007.

Over that time, there were some 60.4 million medical care visits for children with asthma for which no prescription for antibiotics was warranted. However, antibiotics were prescribed 16 percent of the time, the researchers found.

Primary care doctors were most likely to prescribe antibiotics, while emergency department doctors were least likely to prescribe them, Paul said.

Other factors that were linked with increased antibiotic prescribing included use of inhaled corticosteroids and being treated in the winter, the researchers noted.

However, when visits to primary care doctors included asthma education, the rate of antibiotic prescribing went down, Paul stated.

In a second study in the same journal, Belgian investigators led by Dr. Kris De Boeck, from the department of pediatric pulmonology and infectious diseases at the University Hospital of Leuven, found similar overprescribing of antibiotics to asthmatic children.

These researchers found children treated with asthma medications were 1.9 times more likely to also get a prescription for antibiotics, compared with children not treated with asthma drugs.

In fact, 35.6 percent of children who were prescribed asthma drugs were also prescribed antibiotics, the researchers found.

"This finding highlights the need for educational opportunities to inform clinicians that such co-prescription should be limited," the authors concluded.

Commenting on both studies, Dr. Paul Krogstad, a professor of pediatric infectious diseases at the University of California, Los Angeles, and co-author of an accompanying journal editorial, said that "these articles indicate that asthma medications and antibiotics were very commonly prescribed in tandem both here and in Belgium, which conflicts with domestic and international recommendations that point out that antibiotics have no routine use in the care of asthmatics."

Antibiotic overuse confuses patients and family, Krogstad said. "They don't understand the true nature of asthma as an inflammatory, not an infectious disorder," he explained.

In addition, overprescribing antibiotics entails personal and societal risks, Krogstad said.

"Personal risks include allergic reactions, side effects, drug interactions and expense. Societal costs include medication-related costs and selection for drug-resistant bacteria. Antibiotic overuse is being reduced, but this remains an area where improvement is sorely needed," he said. ( HealthDay News )

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One in 38 kids in South Korea may have autism

One in 38 kids in South Korea may have autism – One out of every 38 children in South Korea may have autism, a surprisingly high number based on a new research approach that suggests autism is a global problem that is significantly underdiagnosed, researchers said on Monday.

The estimate, which translates into 2.64 percent of children, is far higher than the estimated 1 percent rate seen in studies in the United States and Europe.

The study is the first to estimate autism in South Korea, and while the study needs to be confirmed, it suggests autism may be more common than previously thought.

"Are we surprised? Yes," said Dr. Young-Shin Kim of Yale University, whose study was funded by the advocacy group Autism Speaks and published in the American Journal of Psychiatry.

Kim's team used a painstaking research method that involved screening 55,000 children aged 7 to 12 in the South Korean city of Goyang. The team surveyed parents about their children's behavior, then followed up with evaluations of at risk children to confirm their diagnosis.

This population-based approach was designed to capture cases that might not be detected with methods that use school or medical records to identify autistic children.

"The high prevalence comes from this new population we included in our study -- the kids without any previous developmental delays or mental health issues," Kim said.

The autism rate among children from special schools was 0.75 percent, compared with 1.89 percent in regular school classrooms.

Rates of autism have been climbing in the past decade, in part because of changes in how it is diagnosed.

Instead of a single diagnosis, autism is a spectrum of diseases ranging from a profound inability to communicate and mental retardation to relatively mild symptoms such as with Asperger's syndrome.

GLOBAL CONCERN

In Asia, parents are largely ignorant about the disorder, which has no cure, and are reluctant to face it.

"A lot of parents in Korea do not recognize autism symptoms. We are not sure if the figure is correct, but if it is, then numbers of autistic children may be underdiagnosed," said a spokeswoman working at a specialist clinic.

"One problem that seems to pop up frequently is that parents do not want to acknowledge that their child/children may be autistic," said the woman, who asked not to be named.

"Many do not recognize the need for clinical care, which is essential," said a doctor at another such clinic. "Korean culture may make it more difficult to (accept) autism."

The highly structured nature of South Korean schools -- in which the school day can exceed 12 hours -- may also contribute to the high numbers of children with undetected autism.

"For quiet, high-functioning children with autism spectrum disorders, this environment may reduce the likelihood of referrals to special education programs," the team wrote.

Geraldine Dawson of Autism Speaks said the study "confirms that autism is a significant global public health concern."

But it also suggests current research methods are underestimating autism in the United States and elsewhere.

The U.S. Centers for Disease Control and Prevention estimates autism affects nearly one in 110 children.

Dr. Marshalyn Yeargin-Allsopp, an epidemiologist at CDC, said it is likely the agency's method of estimating prevalence -- focusing on probable cases -- misses some children.

"We know that we are not capturing all of the cases," she told Reuters in a telephone interview.

As for the South Korean study, she said, "We are concerned that this prevalence is so high, but we have to bear in mind they are using different methodology. Using different methodology gives you different estimates," she said.

But Craig Newschaffer, an autism researcher at Drexel University in Philadelphia who has seen the study, said there may be other reasons the South Korean estimates are higher.

"Most of the cases came from the general population sample," he said, in which only about 60 percent of parents participated. He said parents in regular schools who had concerns about their child's development might have been more likely to participate than those who had no concerns.

But to Newschaffer, the numbers are less important than the finding that autism is so widespread.

"Autism is a major public health problem in the United States, Europe and most likely worldwide. I don't think this is a game changer, but I think we need to be paying more attention to figuring out why." ( Reuters )

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Top 10 tips for pleasing the pickiest toddler

Top 10 tips for pleasing the pickiest toddler - Parents often complain that there children just aren't interested in eating healthy foods, preferring instead to stick to a handful of favourites. Below are 10 tips to get the correct nutrients into the pickiest of eaters:

1. Offer small amounts of many different foods

Toddlers will notoriously put unusual bite sized objects in their mouths whether they are edible or not. So they are more likely to graze if confronted with a variety of different coloured and shaped foods.

Apple moons, banana slices, small broccoli trees or carrot sticks are more likely to tempt youngsters than a plate of nutritious, yet bland baby mush.

2. Offer dips

Most toddlers won't give up the chance to dip any object in something wet or gloopy. Cottage cheese, peanut butter or even pureed fruits can offer a way to get carrot or celery batons into the most obstinate youngster.

3. Turn it into a drink

Blending fruits and vegetables into drinks - with a straw - can often entice children to eat things which would usually make them turn up their noses. And it is an excellent way to sneak in supplements such as, egg powder, wheat germ, yogurt, honey, and peanut butter

4. Cut up food

How much a child will eat often depends on how you cut it. Cut sandwiches, pancakes, waffles, and pizza into various shapes using cookie cutters.

5. Get kids interested in vegetables

Encouraging your child to plant a garden and help care for plants before eating them will fire their interest in fruit and vegetables. Showing them pictures of food first can also encourage unwilling youngsters to try unknown foods.

6. Bear in mind how small kid's stomachs are

A young child's stomach is approximately the size of his fist. So dole out small portions at first and refill the plate when your child asks for more.

7. Make eating easier

Toddlers are often encouraged to sit at the table but dangling feet can make them restless. Maintaining a child table separate to the adults can improve dinner times.

8. Let them cook

Children are more likely to eat their own creations, so, when appropriate, let your child help prepare the food.Young hands are more than capable of tearing and washing lettuce, scrubbing potatoes, or stirring batter.

9. Pick the right foods

Choose foods that are high in nutrients so that a little goes a long way. The best are:

• Avocados
• Pasta
• Broccoli
• Peanut butter
• Brown rice and other grains
• Potatoes
• Cheese
• Poultry
• Eggs
• Squash
• Fish
• Sweet potatoes
• Kidney beans
• Tofu
• Yogurt

10. Camouflage

If all else fails try the old standby of "cheese in the trees" cheese melted on steamed broccoli florets. ( telegraph.co.uk )

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