Genetics of Autism – PediaCast 190
Join Dr. Mike as he and special guest Dr Gail Herman weigh in on the genetics of autism today on PediaCast.
- Genetics of Autism
- Dr Gail Herman
Center for Molecular and Human Genetics
Nationwide Children's Hospital
- Center for Autism Spectrum Disorders at Nationwide Children's
- Center for Molecular and Human Genetics (NCH)
- Autism Speaks
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children'. And this is episode 190, The Genetics of Autism.
I think this one will be an interesting one for a lot of folks out there. It's November 22nd 2011, so Happy Thanksgiving to those of you in the United States or any other, I think it's just the United States that celebrates Thanksgiving in November. But anyway, Happy Thanksgiving!
We have a special guest in the studio today, Dr. Gail Herman, MD, PhD. She is a Principal Investigator with the Center for Molecular and Human Genetics here at Nationwide Children's. We will get to her in just a moment.
I want to remind you that if there's a topic that you'd like us to talk about or you have a question for us here at PediaCast, it's easy to get a hold of me, just go to pediacast.org and click on the Contact link. You can also email firstname.lastname@example.org or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S and you just leave your message there, we will get to your question.
Also, I have to remind you the information presented in each and every episode of this program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right. So without further ado let's get to our studio guest today. Dr. Gail Herman, MD, PhD, is a Principal Investigator with the Center for Molecular and Human Genetics here at Nationwide Children's Hospital. She is a Professor of Pediatrics at the Ohio State University College of Medicine and a board certified pediatrician and clinical geneticist. She is also president-elect of the American College of Medical Genetics.
Dr. Herman earned her medical degree and a PhD in biochemistry at Duke University and completed her pediatric residency in genetics fellowship at Baylor. She has a special interest in the genetic evaluation of children with autism, which is why she stops by the studio today.
So welcome to the show Dr. Herman!
Dr. Gail Herman: Thanks so much for having me.
Mike Patrick: We appreciate you stopping by. Before we get started with the relationship between genetics and autism, I just wanted to sort of review about genetics in general. I think a good place to start is how is it that genes relate to disease?
Dr. Gail Herman: OK. Genes which are made of DNA in code proteins, which are the building blocks, the workhorses of the cell, the performer of the functions that we need to grow and develop normally. And if a gene has a change in it that we call mutation, it can make an abnormal protein that doesn't work properly or doesn't really work at all.
Mike Patrick: And then by having that abnormal protein then that leads to symptoms because some job is not getting done that's supposed to get done.
Dr. Gail Herman: Get done. Correct.
Mike Patrick: How can the study of genes help us diagnose disorders?
Dr. Gail Herman: Well the gene is the starting place, so if there is a genetic disease, if we can find the change in the gene and there are now very good techniques to look at those in a clinical laboratory, we can tell what the specific disorder and even the specific change in a protein is.
For some diseases it's easy to do a blood test like sickle-cell disease or biochemical disorders. For other disorders such as those involving the brain there really is no good marker in the blood and so until we have a gene we really can't diagnose the condition.
Mike Patrick: So once you know that there's a particular abnormal gene that's associated with that particular condition and if you suspect that condition you can go on a lookout for the abnormal gene and just to confirm the diagnosis you're making clinically.
Dr. Gail Herman: Correct.
Mike Patrick: Now, how can genes help us treat and is it possible to cure disorders by manipulating genes?
Dr. Gail Herman: OK. That's a much tougher issue.
So it's much easier to diagnose a disorder than to treat or cure it. Probably the best examples where we can do very good treatments are in some of the newborn screening disorders or the metabolic disorders. So PKU (Phenylketonuria) for example, we know that having too much of a particular amino acid in protein in our diet causes problems so if you restrict that you're not curing but you're treating so the children don't have mental retardation.
For other disorders, structural proteins like the one that causes muscular dystrophy, much harder to treat. But there are now clinical trials going on, some at Nationwide Children's, where understanding what the gene and protein do are enabling doctors to start trying to treat them.
Mike Patrick: I was just going to say by understanding which protein's involved then you can kind of come up with the treatment strategy. I mean, sometimes.
Dr. Gail Herman: Sometimes. And for the brain it's particularly hard because whilst brain development occurs and continues after birth, a lot of it has gone on before and then there's the blood-brain barrier which prevents a lot of chemicals and proteins that are in the rest of our body from getting into the brain. So even if you could develop a drug or treatment sometimes it's very hard to get it into the brain to do what would need to be done.
Mike Patrick: Sure. From the outside it sounds simple enough. OK, you're making an abnormal protein, just give him a pill with the normal protein in it. But that doesn't mean it's going to get to where it needs to go.
Dr. Gail Herman: Correct. There are actually now are examples in things that we call 'storage diseases' where you can't break down material Tay-Sachs, Gaucher's disease where for some of them, not Tay-Sachs yet, but for Gaucher's a recombinant or an artificial synthetic protein has been made and is now FDA approved to treat the disorders. And there've been dramatic results.
Mike Patrick: So that's a good example of genes helping us figure out how to treat disorder. What about cures? We hear about gene therapy, I mean it still sounds like something in the future.
Dr. Gail Herman: People were doing clinical trials with gene therapy. Cures, I think for most genetic diseases are a long way off or may not be possible at all. Treatment before there are symptoms and still prevention I think are going to be the mainstays for a long time.
Mike Patrick: Sure. We actually have a show coming up early next month on sickle-cell, so I guess that's one example with the bone marrow transplant you may be able to cure it.
Dr. Gail Herman: And there are some small molecule treatments, things like that.
Mike Patrick: When you're looking for the genetic place where the abnormality resides, how do you know where to look? It's a big neighborhood. When you look at all the chromosomes and the different genes, how do you know where to start looking?
Dr. Gail Herman: True. It is a big neighborhood. Needle in a hay stack is the way a lot of people think about it. Different ways for different disorders. The classic way for say a single gene disorder like cystic fibrosis was to trace it in families. That's what we call 'linkage' and those are kind of classic principles of genetics using the genetics we know in the family to find the gene.
Sometimes, one can get lucky and you can have a change in the chromosomes such as a little tiny piece of chromosome missing that will tell you right where a gene lives if you've got that chromosome changed in someone that has the disorder. That's how the Duchenne muscular dystrophy gene was found.
For more common disorders – diabetes, autism – people have done what they call association studies where you take large populations and try to find regions that people with the disorder have in common versus those without. Those have made a little progress but not a whole lot.
One can look at candidate genes. So if you have an idea what the gene should do like you have a congenital heart arrhythmia so that you're not pulsing the heart properly, then you might look at genes that encode sodium, potassium or calcium channels and people have found genes that way.
And then finally, there's a new technology now that's available for research and becoming available clinically where it's actually cheaper and easier to look at all the genes and then let the informatics and the data analysis figure out which one's the right one.
Mike Patrick: Right. Moving on the autism a little bit in particular with genetics, how did you become interested in studying the genetics of autism? You were trained as a pediatrician first.
Dr. Gail Herman: Correct.
Mike Patrick: Then you also have a PhD in biochemistry and have done some bench research, but you still see patients as well.
Dr. Gail Herman: Absolutely.
Mike Patrick: And I would take it that you have a passion for kids with autism. How that get started?
Dr. Gail Herman: Yeah. Like many clinical geneticists, we did not see many children with autism in our regular genetics clinic until five, six years ago. There are some geneticists who've had a long standing interest and have done this their whole career, but when you look at what we seen in a normal genetics clinic it wasn't autism.
And then around 2005 there was a burst of new technology, what we call microarrays where we could actually make a genetic diagnosis in a higher percentage of children with autism. And I heard about this in a meeting and I said, "Wow! We need to see these kids!"
And so I got together with our developmental pediatricians and folks at the Autism Center and we came with a guideline of what genetic testing should be done, when should a child get referred and slowly I started seeing more and more children with autism. So probably 70-80% of the new patients I see are those with autism.
Mike Patrick: What do we already know regarding a genetic basis for autism?
Dr. Gail Herman: OK. We know a lot in terms of the fact that autism is mostly caused by our genes. It's been estimated that 80-90% of the risk for a child with isolated autism and I should mention that autism is very heterogeneous and when I say autism I mean the whole spectrum, from PDD to Asperger's, we call it overall now autism spectrum but I may just use autism.
Mike Patrick: Sure.
Dr. Gail Herman: But we've known that for many years that it's mostly genetics. What we don't know still is what most of those genes are.
Mike Patrick: And how do we know that it's genetic? Is it because we see it running in families?
Dr. Gail Herman: Yeah. That's part of it. So there are several lines of evidence that support it being genetic. The first is when you look at twins. So identical twins share all their genetic information and if it was purely genetic we would expect that two identical twins would both have the same condition.
Mike Patrick: Right.
Dr. Gail Herman: If it wasn't genetic at all, it would be more random. So there's a very high what we call concordance, so if one identical twin has an autism spectrum disorder 70-90% of time the other twin will have it, but it's now 100%.
And with fraternal twins, they are just like siblings, the incident is lower. So they share half their genes and we would expect 25% of the time.
Mike Patrick: Right. And if it was just environmental you would think fraternal twins are in the same environment, probably…
Dr. Gail Herman: Some. So it's hard to sort out the environment from the genetics, but that's one line of evidence. And there are sophisticated models that people can use to estimate from twins what the genetic component would be.
Mike Patrick: Right.
Dr. Gail Herman: You also mentioned running in family, so that's good evidence that if you have one child with autism, there's a much higher chance than in the general population of having another child with autism. And a recent study actually says that that chance overall may be as high as 20%.
And if you have two children with autism the risk for a third child could be high as 30%, which is higher than our simple Mendelian recessive inheritance. That study needs to be replicated, but there is evidence now, again, that there are large genetic contributions although the patterns of inheritance aren't simple.
Mike Patrick: Yeah. I don't want to dwell too much on this but I do think it's important to mention that there really are no well-done studies that showed that immunizations or the MMRs are related to autism at all.
Dr. Gail Herman: Absolutely not. So there have been several large studies done in Europe and there's been analysis of all the data together. CDC, the National Academy of Sciences have all come out very strongly that there is no evidence implicating that thymerisol or vaccines in autism.
Mike Patrick: Yeah. And I think it is important to mention that it's not just in the United States these studies are done but really around the world, because some people would say, well the government wants to hide this or there's a conspiracy. But when you look at academic institutions around the world there's not a global conspiracy
Dr. Gail Herman: No. And these other countries have nationalized health care so they can get good data on every child born, sometimes better than we can.
Mike Patrick: Sure. Now do you think that all newly diagnosed kids with autism should be referred for genetic testing?
Dr. Gail Herman: Yes and no. So I think all newly diagnosed children should have a minimal set of genetic test done. Should they be referred to a geneticist to have that testing done, probably not. Some physicians and health care providers are a little afraid when they hear the word genetic test because some of them can be difficult to understand the result. But the first line testing, I think, should be done by a primary care provider or by a developmental pediatrician as part of the autism evaluation because the diagnosis of autism itself is still made based on clinical evaluation and psychological testing.
Mike Patrick: The type of testing that you're talking about, is this to look for other disorders that are associated with autism?
Dr. Gail Herman: So the two tests that now should be considered, first tier, every newly diagnosed child with autism should have is a test for fragile X syndrome, both in boys and girls. And that is looking for underlying single gene disorder where autism is very common.
And the other test is something called a microarray, some people call it a chip test, but it's a much higher resolution chromosome test that has replaced the regular chromosome test in the diagnosis of autism. And there we are looking for large changes in the genetic material that might be syndromic. But we're mostly looking for much smaller rearrangements, pieces missing, deletions or extra pieces/duplications that are known to be major genetic risk factors for autism.
Mike Patrick: Sure. You know, here in Central Ohio it's easy to get kids plugged in to the system. So if you're a pediatrician and you're practicing in a large city with a big pediatric hospital and you suspect a kid has autism, you can refer him to behavioral pediatrics or an autism clinic and they can get this testing done.
But there are a lot of kids out there in smaller communities who have good doctors who just aren't aware of what test that they should be doing. So sometimes parents have to take the driver's seat and say, hey, shouldn't this testing be done?
So what kinds of resources are available for folks who live beyond the scope of a big tertiary care center?
Dr. Gail Herman: Good question. Probably one of the best things that happened for autism is parental support and interest. This is common enough that there are many, many families out there and there have been some very wealthy families that have set up organizations to fund researches as well as awareness, probably the largest is Autism Speaks.
So Autism Speaks website has information about diagnosis, treatment, what family should do. There is an Autism Treatment Network funded by Autism Speaks that Nationwide Children's is now a part of. Dr. Eric Butter up at the Autism Center is our site principal investigator.
Mike Patrick: Sure.
Dr. Gail Herman: And they are coming up with guidelines for diagnosis and they are approaching primary care providers. The goal is so that they will have a guideline, a schematic of what can be ordered.
The genetic test can be ordered through many laboratories, I mean, lab tests can get sent in from close to homes or elsewhere to children. There are private companies, many different academic institutions that offer the testing.
So I think it's no that hard to get the test done. I think it's important that the test, particularly this microarray is interpreted properly. And so if a family or a primary care provider can't get someone who has an abnormal test to a geneticist easily they ought to work with a laboratory that has genetic councilors on staff that can provide guidance.
And there are companies as well as academic institutions including our own lab who have full time genetic councilors to talk to physicians about what the testing means, what it doesn't mean, things like that.
Mike Patrick: Sure. So that they could do a consult even if they're far away they can do that by phone, they can have blood drawn at an off-site and sent to a place like this.
Dr. Gail Herman: Absolutely. There's nothing that replaces in-person visit with a clinical geneticist, genetic councilor, that's why I hate doing counseling over the phone. But it's better to be diagnosed early. It's better to know what's going on so you can get into therapy…
Mike Patrick: And support.
Dr. Gail Herman: And support and all. So if you can't see a geneticist right away, dealing with a good laboratory is the alternative.
Mike Patrick: And I would've mentioned this before even though we're in Central Ohio we certainly here at Nationwide Children's we are one of the largest pediatric facilities in the country and we see folks from all over the place and have a great Ronald McDonald house and community resources that if you wanted to come and get a second opinion it's easy to get here and get that sort of thing done.
And we'll put a link to Behavioral Pediatrics and to the Genetics here at Nationwide Children's so folks can get in touch if they're interested in doing that. I'll have to put a link to Autism Speaks on there as well.
Dr. Gail Herman: Absolutely.
Mike Patrick: Now, as we're doing research to try to figure out which genes specifically involved in autism and kind of from the beginning of our conversation by knowing which genes are involved that help with diagnosis and it may help to formulate treatments in the future as well is you know better which proteins are involved and that sort of thing; and in researching this there's something called the Central Ohio Registry for Autism. Talk a little bit about what that is.
Dr. Gail Herman: OK. So that's kind of my baby that we started in 2006. So there is lots and lots of research going on around the country and around the world in autism. There are several international registries and large consortia of researchers to try to identify the genes that predispose or cause autism.
With this microarray and fragile X and some other single gene testing done in certain cases, up to 25% of children with an autism diagnosis can get a major genetic diagnosis. That means the other 75% we're still looking for the genes.
And it's virtually for sure that those are combinations of genes from both sides of the family with some environmental component on top. So you need lots and lots of families for the research, probably thousands.
And when I started getting interested in autism while we had all sorts of resources and wonderful behavioral health and ABA treatment, there is not much genetic resources here. And so I started the registry to try to collect medical information as well as DNA samples on local families to get them involved in research, to participate in these large efforts and also so they could be a resource for researchers here. And that's what the registry has become.
Mike Patrick: And this then helps you try to find those patterns.
Dr. Gail Herman: Find those genes.
Mike Patrick: Yeah. Are you still looking for people to be included?
Dr. Gail Herman: Oh, absolutely! Absolutely!
Mike Patrick: Are there specific criteria that people have to meet to be involved with the registry?
Dr. Gail Herman: Right. And I should mention, the registry is mostly in Central Ohio. We have an IRB protocol here at Nationwide Children's but very early on we developed the collaboration with Developmental Pediatricians at Wright-Patterson Air Force Base down the road.
They're an exceptional family-member base, which means that a lot of military families who have children with autism will settle there because they get more services. And so they have an active IRB protocol, we recruit from there and that actual enabled us to get funding from the Department of Defense for our work.
But going back, we've enrolled over 200 families. Our goal is probably to enroll 500. And to be included we needed at least one biologic parent available, we prefer two because we're doing genetic studies. They have to have a confirmed diagnosis of an autism spectrum disorder by reputable psychological testing and psychologist or psychiatrist.
And then the family has to be willing to donate a blood sample to make DNA and to provide medical information. With the blood sample, in addition to making DNA, we make what's called a permanent cell line. We take some of the blood cells and we can transform them so that there will be an endless supply to make DNA so we don't have to go back and stick the child again for more blood.
Mike Patrick: Oh, very nice.
Dr. Gail Herman: Yeah.
Mike Patrick: Do folks have to be in Central Ohio?
Dr. Gail Herman: They don't. Most of our families have come from Central Ohio. We've had several military families who've moved away that we're still in contact with. The nice part about being from Central Ohio is we can go back and recontact the families. So as we've learned more about genes or we need this piece of medical information we can collect it again.
Mike Patrick: Sure.
Dr. Gail Herman: I'll just mention, there are certainly other national registries. Probably the most well-known is the AGRE, the Autism Genetics Resource Exchange, out of California funded by Autism Speaks. And so for families anywhere else in the country they might want to check out that one.
Mike Patrick: And if they go to Autism Speaks they'd be able to and again we'll put a link to that in the Show Notes.
Dr. Gail Herman: Absolutely.
Mike Patrick: Very nice. So I guess the major question before your research project that you're doing now obviously is what genes are involved with autism. Are you close to that or where are you with the study at this point?
Dr. Gail Herman: Let me just back up one minute and say that a registry by its nature we developed it as a resource. So if people can use the identified information and we collect a lot of information, we have a database we built to keep it, so if you wanted to know the incidents of seizures or how many families have a child on Risperdal or we're collaborating with someone who's interested in immune function, someone who's interested in treatment of ADHD, which often goes along with autism, they can get information out of the database.
And then if they wanted to do some genetic studies related to their topic, we can provide DNA. If there are new studies that require them talking to patients, getting new information then we can provide a flier or contact our families but the family would have to go to that researcher and they would have to obtain a new consent.
So deidentified we can do from the registry, families consent to that. New studies require additional consent. The family has to agree again to participate.
Mike Patrick: Sure.
Dr. Gail Herman: In terms of genes, we have published a manuscript with one candidate gene. It's rare like most of these. What researchers around the world now have basically come to is there is not an autism gene, there is not even a couple that are found in 20, 50%. The highest genes or chromosome locations identified so far are found in maybe 1% of families. So it's lots and lots of genes, different genes in different families and even different genes within a single family.
Mike Patrick: Do they tend to be on one or a cluster of chromosomes or are they just..
Dr. Gail Herman: They're all over. They're all over. If one looks are there any similar characteristics many of them are involved at the synapse, so with the ends of nerves that talk to each other. Others are involve in communicating, neurotransmitters communicating between nerves which makes sense. But there are many different proteins. And I think what's now making it possible to identify which subsets of genes are in which families is this new technology that we call 'next-generation sequencing'.
Mike Patrick: And how far are we out with that being something that's usable?
Dr. Gail Herman: We're doing it at the Research Institute at Nationwide Children's. We have one of the latest generations of 'next-generation sequencers' as do many, many sites around the country and the world. So if the first human genome that was sequenced took 15 years and $3 billion, one can now sequence a human genome depending on exactly the machine and all in maybe a week or two at a cost of less than $10,000.
The problem is putting the information together and sorting out what's important, what's just normal variation. But using this technology people are sequencing hundreds and thousands of genomes from autism families and then trying to sort out which groups of genes might together cause the autism. And that's how I think we're going to actually identify most or all of this other 75%, probably within the next three to five years because it's coming out so fast.
Mike Patrick: Yeah. That is exciting.
Dr. Gail Herman: It is really exciting.
Mike Patrick: Now, when you talk about any particular abnormality in the genes being as high just 1% or so, so even with Asperger's you don't think that there's one specific thing within the spectrum when you narrow it down and say this type of autism there's still a big variety even there.
Dr. Gail Herman: Big variety. And I think people had hoped that based on the psychological testing, based on the presentation, based on scores and areas of strength saying Asperger's, whether high functioning, with no language delay that would define a class of individual. It hasn't panned out that way.
What's really interesting is the same genetic change you might see in a child who's severely language impaired and in another child with Asperger's. Now presumably, when we get the rest of the genes, so if this 1% gene is a major contributor there are still probably other modifiers.
And the psychological testing hasn't helped in the separating who's going to have what gene. I'm sort of prejudiced but I think the genes lead the way and so I think we will understand more when we can sort out who has this group of genes and who has that group of genes.
And people are already doing that. So for some of the most common genetic changes people are now collecting hundreds of patients, because around the world you can find them or the common ones with that particular genetic change and seeing now are there any particular characteristics, particular comorbidity, seizures, sleep problems and particular treatments that might help if you know the major underlying change.
Mike Patrick: Yeah. And then we may be able to start saying OK, no, this characteristic and this gene abnormality now we can call that a specific disease instead of autism spectrum, I mean maybe.
Dr. Gail Herman: Maybe. I think in the new DSM-5, which is the new classification for psychiatric and behavioral disorders, the terms autism, PDD, Asperger are going away because it is a spectrum and everything will be called autism spectrum. And then people will characterize them by their strengths or their weaknesses. So sever language impairment but good social skills, things like that. And I think that's much more descriptive.
Mike Patrick: Yeah. And as we know more we'll have you back because I know there are a lot of families who are very interested in this.
Dr. Gail Herman: Well we hope so. And we would love to have families contact us about participating in the registry.
Mike Patrick: Sure. Sure. And again, we'll put links in the Show Notes, the Central Ohio Registry for Autism. There's actually a landing page for that here at Nationwide Children's where you can submit your information if you'd like to be contacted for more information, especially if you're in Central Ohio and want to be a part of that.
I suspect that if you really have a strong, you've noticed there's a definite family history in your family of autism even if you're outside of Central Ohio, you guys might be still be interested in?
Dr. Gail Herman: Definitely. When one does this next-generation sequencing right now having a hook or a trick makes it easier to sort through and see the genes. So having multiple family members, particularly cousins, things like that helps us narrow down common regions where those genes might lie. So definitely we're interested!
Mike Patrick: Yeah. And we'll put a link in the Show Notes and link to Autism Speaks and also our Molecular and Human Genetics program here at Nationwide Children's. So just head over to pediacast.org and you'll be able to find all that.
All right. Before we let you go, one of the things that we do here at PediaCast is all of our guests in the studio we ask about board games because we really try to encourage families to do something fun together that doesn't involve television screens and that sort of thing. So we're just asking everybody what's your favorite board game because we're trying to create a list.
Dr. Gail Herman: OK. It is hard. I have a 20-year old son now and when he was little we tried to play board games but he always wanted to do things on the computer and got me to learn a few computer games like Zelda and all. But I think my favorite board game was Stratego, I don't know if you've heard that one.
Mike Patrick: Oh yes. Yeah.
Dr. Gail Herman: Where you have to find the flag and there's strategy because the different pieces take each other and you get blown up by bombs. That was one of our favorites when I was growing up and playing with my son.
Mike Patrick: I've heard of it and I've never played it. I've never really heard of the description either but that sounds like something that would right up my son's alley.
Dr. Gail Herman: Yeah. It's great and we were a mom-son-single-parent family so it's something you can play with two people. You can't play it with 10 at a time.
Mike Patrick: Yeah. Yeah.
Dr. Gail Herman: For that we used to play Monopoly. But Stratego was great for two people and strategy's important.
Mike Patrick: Yeah. Is it a long game like Risk, as long as Risk?
Dr. Gail Herman: No. No. It can be half an hour to an hour, it depends.
Mike Patrick: Yeah. Yeah. That's nice. That's a nice time. Cool. All right. We will add Stratego to our list and again, Dr. Gail Herman, we really appreciate you stopping by.
Dr. Gail Herman: Thanks. It was great to be here.
Mike Patrick: And I also want to thank all of you out there for taking time out of your day. We know there are lots of places that you can get pediatric information and we just appreciate that you taking the time to make PediaCast one of those places.
I want to remind you that it's easy to get a hold of us, just go to pediacast.org and click on the Contact link. So if you have a show suggestion or a topic idea or a question for us because we do answer those as well, just send it in on the Contact page at pediacast.org.
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So I hope everyone in the United States has a happy Thanksgiving and until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.
So long everybody!
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