There has been a fair amount of discussion on these photos in the comments of my posts. So, I asked Doc to weigh in on the boys in blue. Here is what he had to say about the pictures:

"In this picture with Willow, the baby in the airplane with a blue sweater shows no signs of Downs syndrome and looks to be 2-3 months old.

I’m saying this based on level of alertness, and hands still clenched at rest for a baby that age.

If Trig truly has Down syndrome, as I believe he does based on our previous post and analysis, then this just cannot be him.

     

The second picture, its hard to tell, but the baby probably does have Ds. The baby looks a bit older than 1 month in this photo, maybe 1-2 months.

I do see the nasal cannula. Certainly looks like a nasal cannula, but also could be a feeding tube. It’s hard to tell if it goes across the whole face or just over the left cheek. I can't do any measurements as his head is looking off to the side.

Since it’s an outside shot, with everyone wearing shorts and light jackets, it’s definitely not early spring in Alaska. What, and no hat on the baby?

Bristol looks very young in that picture, much younger than she looked during the campaign. Why is she always holding her "mother's" baby?

Does Sarah ever hold the kid except in PR photos?

This baby in blue? 6-7 weeks old is a good estimate. Weeks, not months."    

On Allie RN’s post:

"I didn't know about a possible tubal ligation or hysterectomy. If I understand Sarah’s religious beliefs, I can't imagine she would have a voluntary sterilization procedure. If that came out (and someone, somewhere must know), it would totally invalidate the whole pregnancy scam. There's got to be someone out there willing to talk.

As a Neonatologist, I don't know enough about hysterectomies to comment on the need for a perfusionist, but it could make sense, especially if she has a bleeding tendency. There are several reasons a "healthy" woman in her 30s would need one that come to mind: malignancy, severe fibroids, chronic pelvic pain, menorrhagia or complications from delivery.

If Sarah Palin had a tubal ligation, it would make it very difficult for her to be Trig's birth mother.

If Sarah Palin had a hysterectomy, it would make it impossible for her to be Trig's birth mother."

Thank you, Doc, for taking the time to give us your responses to this material.

In my last conversation with the neonatologist, we learned why it is possible, through specific calculations, to medically question the age of the baby presented as Trig Palin, 12-hours old. And for what it’s worth, three other doctors independently told me they agreed with the assessment that the “newborn” was actually days, if not weeks or months older.

But the photo of Trig Palin in the family’s kitchen, weeks later, on May 3rd, troubles many readers, also because of his size. The baby, held by Mercede Johnston, appears smaller than the Trig held by Sarah Palin’s mother on April 18, 2008. 

And of course, there is the ear. But for the uninitiated who don’t know the entire story, let’s just begin with size and coloring.

LN:  Doc, do you think this baby on the right can be the same as on the left, only a few weeks older?

DOC: Objectively, these two pictures pose a problem, I have no way to measure the babies, no single point of reference like the ICD (inter-canthal distance) of an adult or something else of known length. Both babies also have a similar face structure: Both have down-turned lips and a flattened nasal bridge typical of Down syndrome.

The 12-hour-old picture shows very little of him other than his face and not even his ears. He is wearing a standard-issue hospital hat and as I mentioned before, he looks chubby and pale which is not consistent with a typical premature newborn. The picture with Mercede shows a baby who very well could have been a preemie, much less chubby and somewhat ruddy. Of course, babies generally lose weight after birth and this is especially if they are poor feeders which is common with Down syndrome. My opinion is that the baby on the right is younger than the one on the left. As for them being different babies, I can’t really conclude anything.

LN:  He’s also unwrapped. That could account for some of the disconnect here.

DOC: Sure, you can see more of the baby on the right. His leg position suggests hypotonia, also consistent with Down’s syndrome. My opinion still is that they could be the same baby, but the one on the right looks younger.

LN: I think a lot of people have speculated the same thing. The baby on the right does look younger. But how can that be? That photo was supposedly taken on May 3rd, for Levi’s birthday.

DOC:  The only other possible explanation is that Down syndrome babies can be poor feeders, so it’s possible the May 3rd picture shows a baby who is calorically deficient. However, he’d probably have a feeding tube if that was the case.

LN:  People have said they don’t believe the baby in Sadie’s arms has Down syndrome. I have always thought it appears to have the features. Here is another comparison with Trig, presented by his parents at reportedly 3-days old, and Trig, at the baby shower a few weeks later:

DOC: They both almost certainly have Downs. The epicanthal folds, the down turned mouth, recessed nasal bridge and broad forehead. The nose is not upturned.

While we’re on this picture, look at the lips. Notice that the baby on the left has less rosy lips (either pale or dusky, hard to tell from the picture) than the one on the right. Generally, babies become less ruddy over time, so unless there was an issue with oxygenation (congenital heart disease) the baby on the right looks younger. Also look at the hands. A newborn will have wrinkled hands from the amniotic fluid. An older baby’s hand will have smoother, more full looking hands. The hands on the baby on the left, though blurry, seem to be more full than the ones on the right.

LN:  I thought the same thing but purposely didn’t point it out to you. His skin is more veinous too, on the right. And the eyelids more red. Could it be a rash? It’s almost as if there’s a blue mask around his nose and mouth area.

DOC: Yes, the baby on the right does look a little cyanotic (blue) but don’t think there’s any rash over the eyelids.  Both findings go along with a higher red blood cell count, usually seen in a younger baby.

LN:  Another possible diagnosis readers have raised is Fetal Alcohol Syndrome, or FAS. What is your response to that?

DOC: FAS kids often (but not always) have a distinctive appearance, but there are differences from Down’s. I’m not sure why anyone thinks of FAS in this case and I certainly don’t want to speculate on Bristol’s drinking habits. Sure the babies both have flat nasal bridges and epicanthal folds, but they don’t have a smooth philtrum or a thin upper lip. Look at this diagram with common facial features of FAS from this excellent AAFP article. 

LN:  But you think they both look like they have Downs?

DOC:  Yes. I think most people can make the diagnosis of Down syndrome without the need to go to medical school. When a baby is born with Down’s syndrome, not prenatally diagnosed, the parents (and all the staff) usually come up with diagnosis themselves rather quickly in the delivery room.

LN:  You mentioned the “ear.” Perhaps nothing rocked the Palin-watching blogosphere quite like Gryphen’s Tale of Two Babiespost in February of last year. 

His discovery of Trig as a newborn with a deformed ear was stunning.  I believe this is a tight shot from this photo at the baby shower (same occasion as the right hand photo above.) 

And as Gryphen pointed out, the deformed ear is also visible close-up on the Sadie-in-the-kitchen photo. 

But the discovery but it led to further speculation that the infant with a cauliflower ear could not possibly be the same baby presented to the world at the Republican National Convention and then later at the presidential debate.

In fact, following that amazing post, the Internet began collectively calling the baby, Ruffles. What’s your initial response?

DOC:  I'm not sure what I can add to that excellent Gryphen post other than agree with the general principle that the “ruffled ear” is unlikely to ever look normal.

At first glance, I thought the hole in front of the ear was a preauricular pit which occurs in up to 1% of newborns. It's not particularly associated with Down syndrome and usually doesn't cause any serious problems, besides getting infected.

But then I looked at a close-up of the ear and thought that the hole in front of the ear may actually be the ear canal itself, because it's way too big to be a preauricular pit, which are tiny. What I don’t see is any evidence of a “tragus”. That’s the piece of cartilage that sits in front of the ear canal opening, partially covering it.

I think the ears on baby #1 look a lot like this picture (without the abnormal opening)

LN: I know that you and I both want to delve further into this, but for now, you agree with the assessment of the doctors Gryphen interviewed? 

DOC: Yes. There's no way that these small, low set, posteriorly rotated and deformed ears in picture #1 could look relatively normal several months later. But I’m not an ENT and I’d really like to hear what one would say before I’d definitively call these different babies.

LN:  For what it’s worth I ran this same series of photos by another doctor. This was his response:

Photo #1 (THE CLOSE SHOT OF RUFFLED EAR) is an ear with a deformity that I have never seen. Not only is the cartilage misshapen, but the shadow in front of the ear makes it appear that there is a second abnormality.

On the three photos, from the left: the first one looks like the same photo as #1. The last 2 show the bottom of the ear lobe for the first time, so I can't compare that. The upper portion is very different, and appears to be of a different baby, not just an older baby. I would want to know what kind of plastic surgery can be performed on a deformed ear before I would call it a different baby.

LN:  The same reader who has provided me with some of these composites, also made this one:

These are a chronology of Trig's ears.  She also provided some interesting photos from Frank Bailey’s book that show the deformed ear, but I wasn’t keen on using those for copyright purposes. You had a brief thought about these?

DOC: Just that the pinnae looks too “normal” in the three pictures on the right. Those three could be the same ear, but not the original “ruffled” ear. That one’s got to be different.

LN:  And then there is this composite:

DOC:  The only really interesting thing here is that both Sarah and the baby have what looks like two ridges (concha) in the middle of the pinna. It doesn’t look like Bristol has that. Otherwise the ear of the baby is typical of Down syndrome, low set and posteriorly rotated. The helix is abnormal, but not as abnormal as “ruffles”.

LN:  What I find so glaring about this set of photos is how similar Bristol and Trig’s ears are in terms of having a “bat wing” shape to them. Can these sorts of things be inherited?

DOC: I don't think anyone knows how ear shape is inherited. It's one of those things that is too complicated and not important enough to study. Many traits, however, can skip generations. They tend to be recessive traits. It looked like Sarah and Trig both had two anti-helices and two conchae. Bristol only had one.  

Thank you again, Doc. I know we left some questions on the table, but I am working on finding out some more information on these ears from other pediatric specialists. Because I know readers have more questions about it.

DOC:  I’d love to hear an ENT doc’s opinion on this. I also have one more question about that excellent Gryphen post. Why in the hell is Levi Johnson holding Trig if he's not the father? Would you let your daughter's boyfriend hold your baby? Or, put another way, why would your daughter's boyfriend want to hold your baby?

LN:  Ah, therein lies the rub. Sometimes in life there are some things that are never fully explained. 

LN:  Mr. McCain?  Mr. Schmidt? Ms. Wallace? Anyone? Bueller? Anyone?

Thank you again, Dr. Neonatologist, for all your time and energy.  And H/T to the amazing commenter who put these photos together.  Thank you!

When we last left the neonatologist who graciously gives us his time on this blog, mention was made of the Trig Palin photos reportedly taken when he was less than 24-hours old.  Here is the baby being held by the governor’s mother, reportedly within 12 hours of being born. 

LN:  No reason to dance around here, Doc, what do you see?

DOC: This baby looks to be about 1-2 months old and doesn’t look premature. Premature babies don’t have a lot of subcutaneous fat. This baby is chubby. He has epicanthal folds, flat nasal bridge and a recessed chin, which are suggestive of Down syndrome. Down syndrome babies can be chubby, but if they’re premature, it’s not so prominent.

LN:  What don’t you see?

DOC:  First, the baby does not look plethoric (ruddy) and may look just slightly jaundiced. Most babies are born with extra red blood cells and look ruddy at birth. This is especially true of preemies because their skin is thinner. As that extra blood is broken down, it releases bilirubin, a pigment that turns the skin yellow. At 24 hours of age, most babies will still be ruddy. Visible jaundice usually develops between 24 and 72 hours of age.

Another clue to me is the absence of milia. Milia are tiny white bumps that are usually seen on the nose, cheeks and chin. They are caused by dead skin clogging up the pores and are a normal finding in newborns that can persist for a few weeks. Most newly born babies will have some of this.

Newborns are born with extra fluid in their bodies. Most newborns will show some evidence this in their face. The eyelids are often puffy. This can disappear after 24 hours of age, so it’s not as good for timing the picture, but I can’t see any eyelid edema on this baby.

One more thing that may be missing from this picture is lanugo. This is hair that we see mostly on the arms and back, but also often on the cheeks of premature babies. It disappears after about 35 weeks so it doesn’t precisely age this baby, but does suggest an age greater than 35 weeks.

LN:  How do we know that it isn’t just the zoom on the camera.  Perhaps at this distance you can see a baby who was said to be less than one day old?

 

DOC: I think this is just a zoom of the first picture; even the wrinkles in the blanket are the same. It’s really hard to estimate the size of the baby, but he doesn’t look all that small to me. I have nothing to compare him to. Compare the color of his skin to the person holding him. It’s not that different. In this picture he doesn’t look ruddy or jaundiced at all. Perhaps they adjusted the color of the first photo to enhance the jaundice? 

LN:  I’m trying not to grasp at straws, but how about how tiny he looks in this photo with Mr. and Mrs. Palin?

DOC: He doesn’t look all that tiny to me, but since I usually take care of babies in the 1 to 5 pound range, normal newborns look huge. I did something interesting with this picture. I measured the ratio of intercanthal distance (ICD) between the baby and his parents. The ICD is the distance between the inner aspects of the eyes. The normal newborn ICD is 22 mm (in Caucasian babies) and for adults it’s 28.5 mm. This gives you a ratio of 0.77 (newborn/adult), which means that the normal newborn measurement is 77% of an average adult. I used this ratio, because I don’t have any other way of figuring out the actual measurements in this picture. I measured the ratio from the picture and got a ratio of 0.76 (76%), which suggests that this is a full term baby. Babies with Down syndrome often have closely spaced eyes, so you would expect an even lower value. Just to be fair, the major weaknesses of my calculations are that none of them are looking straight at the camera and there is variation between people.

(I’ve included a link at the end to the actual scientific paper that this comes from)

By the way, Sarah looks good for someone who just had a baby 3 days ago.

LN:  And yet it’s evident this baby has Down syndrome, because infants are nose breathers, so I have to assume his mouth is open for reasons related to the Down syndrome.

DOC: Babies with Down syndrome have macroglossia (enlarged tongue) and you can see that clearly from this picture; that’s why the mouth looks open. They also have low muscle tone so that sometimes the mouth just opens due to gravity. You might think this baby looks ruddy, but it’s only in the cheeks, so that’s more likely a rash. You can see facial rashes like that on newborns, but they’re more common in slightly older babies. To me this baby does look slightly jaundiced, especially in the nose. The nose is often the first place you’ll see jaundice, but it’s also often the last place before the jaundice resolves.

LN:  Does this macroglossia look consistent with a baby older than 3 days? Does the condition increase, so to speak?
 
DOC: Not that I know of. The macroglossia stays stable in my experience.
 
LN:  So if this baby was 1-2 months old, do you see any indications that he was a preemie then? Or do you see signs then that this baby was born at normal gestational age? 
 
DOC: The Palins claim that Trig was born at 35 weeks but these pictures seem to show a baby who is the size of full-term baby, without a lot of the findings that you see in the newly born. This suggests that he was born prematurely and is now old enough that it’s around his due date.

LN:  You refer to this as the “adjusted age”, correct? Can you explain that further to our readers who might be unfamiliar with the term?

DOC: “Adjusted” age is a way of referring to a baby’s age in terms of their due date. A preemie who was born 5 weeks early (35 weeks) is only 1 month old “corrected” when they are 10 weeks old because they are 5 weeks older than their due date.

LN:  And how would this tie in to the heart defect that this Down syndrome baby might have had at birth. Any indication that that the baby Trig, above, has already been operated on?
 
DOC: An atrial septal defect (ASD) would not be apparent. If the baby had an unprepared ventricular septal defect (VSD) or an endocardial cushion defect (ASD + VSD), he might have been somewhat cyanotic (blue). Most VSDs are repaired before 6 months of age, so I wouldn’t expect to see anything at this point. He looks pink to me, so I don’t see anything significant here.

LN:  Now, take a look at this photo of a different baby. What do you see here?
 

DOC: This baby is very ruddy, with perhaps a trace of jaundice. Look at difference between the color of the baby and the adult’s hand. I can’t tell size from this picture, but this baby was recently born, and is probably no more than 1-2 days old.

LN: Here’s another picture, what can you conclude from this one?

DOC:  This picture shows a baby who is more jaundiced than ruddy, so this baby is probably a few days old. I may see a bit of milia here, but I can’t be sure. However, there is a ruler in this picture so I can actually measure the ICD. Using the markings on the suction/feeding tube, which are always in centimeters, I can see that the ICD of this baby is about 20mm (I’m probably overestimating, since the tube is not exactly parallel to the plane of the picture). That puts this baby into the premature range, at least in terms of size. Go back and compare this picture to the pictures of Trig. You can clearly see that Trig is much less ruddy. This is a newly born baby and the pictures of Trig show a baby who is probably about 1-2 months old. The ICD measurements back this up. This baby is premature (at least by size) and the pictures of Trig show a full term-sized baby.

LN:  As you now know, these photos are of my son. But I want to be clear that you did not know this before you analyzed the photos.

Now I will tell you that in the first photo, he is about 15 hours old. Compare that look to the photo of Trig at about 12 hours old.

In the second photo, he is either 2 or 3 days old, I can’t be sure because I hadn’t yet seen him (I as still in the birth hospital) and didn’t take this photo.  He was born prematurely at 36 and 5/7 weeks. So in this second photo, he’s just hitting 37 weeks gestation.

DOC: That makes sense. He’s quite ruddy in the first picture and more jaundiced than ruddy in the second. His ICD is smaller than normal term size too. When you consider the pictures of Trig and your son together, it’s pretty apparent that they are very different. I think most people would agree. It’s very helpful to have real pictures of baby with a known age and gestation to compare to Trig. 

LN:  In a recent post, I embedded a clip of comedian Kathy Griffin riffing on Levi Johnston and Bristol Palin. In it, Griffin says that Bristol got pregnant at 16. I think it’s common knowledge that Levi confided in Kathy. If this is true, how does a 16-year-old hide a premature baby for 2 months?
 
DOC: Most 35-weekers don’t spend a lot of extra time in the hospital. About half of them don’t even go to the NICU, even for babies with Down syndrome.  It’s possible that he went home shortly after delivery and was kept quiet. Wasn’t Bristol home with “mononucleosis” for 6 months? That could explain it.
 
LN:  I know from experience that when a hospital is ready to discharge, they discharge. I always wondered if the Wild Ride was due to the news, not that labor had started, but that discharge was underway.
 
DOC: Hospital discharge from the newborn nursery is driven by insurance, while NICU discharge is driven by the baby’s status. However, if we are to suspect that people at the hospital are participating in a cover-up, I’m sure they could figure out a way to keep the baby longer. So the question in my mind is, how do we explain the need for the so-called “wild ride” if the baby was already born? I’m not sure I have an answer for that.

LN:  But one thing that many people are likely not familiar with is that babies who are in a NICU have, quite literally, never been out in the world, other than transport. They have not lived anywhere else.  When a baby who has been discharged from a NICU later becomes sick or has surgery, they almost always go to a PICU (pediatric ICU) or to a floor. That of course is because they have already been exposed to germs that newborns in a NICU have not.

In such a case, a baby who was readmitted to the hospital down the road might go to a regular pediatric ward, in, say, a smaller, regional hospital, and not a NICU.

DOC: That’s correct, once discharged to home, most babies if readmitted would go to a general pediatric floor or PICU. Are you asking if Trig might have been discharged from a pediatric floor for treatment of something due to his heart or some infection? If so, the rules for discharge are much stricter from these settings than from the NICU. They wouldn’t let him stay longer if he was well.

LN:  A final thought for me is that I recall a famous case in California where the children ended up down the hallway from us when my son was once on “the floors.”  It became apparent who these children were, and I even got a nurse to admit it to me! But they had fake names on the outside of the door. But there was just a frisson in the air. People knew who these kids were, even though the hospital tried to hide it.

DOC: It’s our hospital’s policy to use the patient’s real name in the electronic medical record. However, there are no names on the doors and we only use initials on the whiteboards, per HIPAA guidelines. Unless you knew a VIP was in a particular room, you wouldn’t be able to tell by what’s written on the door.

LN: So, in summary, what do you think about these photos of Trig Palin. What’s your margin of error?

DOC:  These pictures of Trig appear to show a full term size baby who was probably born a month or so ago. I base these conclusions on skin color and the imperfect ICD measurements. None of these findings are absolute, as babies can vary in size and color, but if I had to bet money, I’d say that Trig wasn’t born yesterday, so to speak, in these pictures.

Reference:

Facial Measurements in the Newborn; Omotade, OO http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1017131/pdf/jmedgene00044-0014.pdf

Ah, the doctor’s letter. This would be the version of Mrs. Palin’s “medical records” that she promised during the campaign.

The letter is short, as was President Obama’s, but it was only released by the McCain campaign an hour or so before midnight on election eve, 2008. It also differed from Mr. Obama’s in that the bulk of it concentrated on the birth of Trig Palin. The Obama children, their births and health, were not mentioned in his letter.

Much has been written on several excellent blogs about Mrs. Palin’s letter. Cathy Baldwin-Johnson, who calls herself the Palin family physician, signed the letter. A PDF of the document archived with the Los Angeles Times can be found HERE.

And Regina at Palingates recent post on the matter can be found HERE.

Others have questioned everything about the letter, from the doctor’s signature, to the formatting, to the passive voice. I found the letter odd in several ways, not the least being the fact that the McCain campaign released it, purposefully of course, at a time when no reporter could scrutinize it or press for answers. 

Why was that, Steve Schmidt?

To sort out what others see as discrepancies, I asked the neonatologist, with whom I have been speaking on this blog, to offer his expert opinion.

LN:  So, does this letter state that Sarah Palin was pregnant and gave birth to Trig Palin in 2008?

DOC:  It does say that she was pregnant and delivered a baby with Down’s syndrome in 2008 at 35 weeks gestation. It’s very vague and doesn’t mention a birth date, but it does spend more time on this pregnancy than any of the others. Others have noticed that it leaves out her two miscarriages and gets the year of Piper’s birth wrong.

I’m most interested in the part that says that the diagnosis of Down’s syndrome was made early in the 2nd trimester and confirmed by amniocentesis. I find this point interesting, because most pro-life or highly religious parents who I work with decline amniocentesis. In fact, they often get offended when I ask them about the pre-natal genetic testing. I often hear “It’s god’s will and we’ll accept the baby that god gives us”.  Amniocentesis carries a 1-2% miscarriage risk, and even if positive for something serious, the parents aren’t going to terminate the pregnancy based on the information they receive. There’s a rule in medicine: “Don’t do a test if you aren’t going to do anything with the results” and it certainly applies here.

The generic nature of the narrative suggests to me that she could have easily been describing Bristol Palin’s pregnancy. Perhaps Bristol, without strongly held beliefs about abortion like her mother, wouldn’t have objected to an amniocentesis in the face of suspicion of Down’s syndrome.

LN:L What do you make of the fact that the baby’s specific birth DATE is missing?  Would you put a date in a letter if you were writing it? Is that important?

DOC: Dates are critical in neonatology as we deal in premature babies and want to know exactly how premature a baby is. The exact date of Trig’s birth is very important. If Trig was born 3 or 4 weeks earlier than otherwise claimed, Bristol could have been the mother of both babies. The letter does not give a specific date for Trig’s birthday and if the letter were written for the implicit purpose of confirming Trig’s parentage, a specific date would have been expected. On the other hand, in most medical records that I read, only the year is given, so I don’t want to read too much into this.

LN:  Is there anything out of the ordinary in the letter?

DOC: It says nothing out of the ordinary except that the doctor changed her status at the hospital on June 1, 2008 to "devote more time to my work in the area of child abuse evaluation and prevention". The timing is interesting. If CBJ was board certified in 1983 then that puts her age somewhere in the 50s assuming a normal career path. Most doctors don’t start cutting back their time until they reach their 60s. Also, how is this relevant to Sarah Palin’s health? Why include this in a letter about her?

LN:  Do you surmise from it that the doctor is telling the truth (passive voice and odd narrative not withstanding.)

DOC:  I'm actually not all that bothered by the use of passive voice in the letter. It's pretty typical of medical written communication. That's what they tell us to do in medical school. I think she's telling as much of the truth that she can except for Trig's pregnancy. I'd still like to know if she was Bristol's doctor too, but there’s no reason to put that in the letter.

LN:  So what do you mean except for Trig's pregnancy?  Doesn't she say that she was Mrs. Palin’s doctor during this pregnancy and that she followed routine prenatal care?  Tell me if there is a clue as to what's missing.

DOC:  I mean that she tried to include as much factual information in the letter as possible to give it credibility. From the letter, we are supposed to assume that she was Sarah Palin's doctor during Trig's "pregnancy". I don't see any clues to anything amiss in the letter. However, it would be simple for her to attribute the care of Bristol Palin's pregnancy with Trig to that of Sarah.

LN:  In other words, mix two cases or names:  Blend the daughter’s possible pregnancy chart and attribute it to the mother?

DOC: Yes, that’s exactly what I’m saying.

LN:  But isn’t that precisely what would be unethical, if not illegal?  Isn’t the entire point of a medical record to go on the record about that one patient?

DOC:  Yes, and that’s why I find the fact that she went off active status in June 2008 to be interesting. If she had continued on after that point, her medical records might have received extra scrutiny by the credentialing committee at the hospital that she didn’t want to deal with.

LN:  So herein lies the rub:  If a doctor fibs about a patient to the public, that’s one thing. But any record of that can be discovered by the State during an audit for credentialing. And that could jeopardize an entire facility. So, is it possible she bowed out of her role there in order to staunch any bleeding that could occur down the road for the hospital itself? No matter how entwined she was with them?

DOC: The state handles licensing and each hospital handles credentialing. The state usually doesn’t act against a practitioner unless there is a specific complaint or if standard requirements aren’t met. Hospital rules for credentialing vary, but most require renewal every 2-4 years and any concerns or complaints are evaluated by the credentialing committee. Obviously, the process for “active” staff is more robust than for “courtesy” staff. In this particular case, it wouldn’t surprise me if CBJ struck some kind of deal with the hospital that she would downgrade to courtesy staff and they wouldn’t push back with any kind of investigation. Hospital administrators hate controversy.

LN:  Would you write that letter if you were NOT that woman's doctor? (May not be illegal, but it's sure a lie or unethical.)

DOC:  No way! If I was given access to her medical record and wasn't her doctor, I would make it clear that I wasn’t her personal physician.

LN:  So either this truly is Mrs. Palin’s doctor writing the truth, or…tell us under what circumstances a doctor might do this? Have you ever known one to not tell the whole truth in a letter like this?

DOC: I think CBJ may have already been too deep in this mess to bail out. If she had lied about Trig’s mother, she would have to continue to support that lie to keep her professional status intact. I don’t know of any cases in my experience like this, but as I have mentioned before, it is very easy for a doctor to get caught between doing the right thing and doing what their patients ask them to do.

LN: One of the things people have criticized is that the letter does not state that Dr. Baldwin-Johnson delivered the baby Trig. I don't see any issue about naming who actually delivered the child. It could well have been the OB on call at that hour, especially if Dr. CBJ induced labor at 11:30pm. She might simply have gone home.

DOC:  Absolutely, the on-call doc for the practice handles the delivery. No one but the most important VIP gets a guarantee to have their doctor at their delivery. The only exception would be the rare case of a true solo-practitioner. I will say, however, that OBs (and Neonatologists) often do 24-hour shifts for continuity of care.

LN:  Well, for a little levity, allow me to say I am flattered. My OB put in a 12-hour day and stayed to deliver my son and I was little more than a TV reporter (34-years-old, prima gravida. Etc., etc, and yes, she and I could both say exactly where and when he was born without mixing up our stories!)

DOC: Well speaking of that kind of wording (prima gravida et al.), I wonder if the records from Bristol’s "2nd" pregnancy indicate anything about her past OB history. Did someone write anything in her chart like her being a G2 P0101, which is OB for "2 pregnancies, one living preterm birth"? HIPPA protected, for sure, but interesting. Maybe Bristol will some day run for political office and have her medical records disclosed.

We often have moms who come in and say its their first pregnancy, but when the OB examines them, it's clear that they have episotomy or perineal laceration scars. That could also be in the chart.

LN:  So you think this letter could have been referring to Bristol giving birth to Trig?

DOC:  The letter doesn’t answer that question directly, but it certainly doesn’t settle the issue either.

LN:  And that’s the key here, in my opinion. They release a letter at, literally, the eleventh hour, with all this wording in order to settle a controversy, and yet it does precisely the opposite:  It remains vague and scattered enough to ensure that the controversy continues.  Why is that?

DOC:  I’m not sure what the law says about this, but the purpose of a doctor’s letter is to attest that a candidate has no significant health problems that would prevent them from fulfilling the office that they aspire to. In this case, they had a dual purpose. One was the standard statement of good health. The second was to use this as an opportunity to support the vice presidential candidate’s claim that she was Trig’s mother. The fewer details that CBJ put in the letter, the fewer details she could potentially have to defend later if/when the medical records are examined. However, it’s more of a political question than a medical question. I’m sure the McCain/Palin people went over that letter with a fine-toothed comb before releasing it.

LN:  But this is all just speculation, because the truth is, we’ll never know, am I right? Especially with a famous patient.

DOC:  There is no obligation to release medical records for public examination. Eventually, they may leak out to the public, but I wouldn’t hold my breath. It’s no different for a famous patient. When doctors have a famous patient, the rules are very simple. If you say anything to anybody about their health information, even to your own friends and family, you can look for a new job. We once had a prominent football player's baby in our nursery. Some staff that weren't caring for the baby or mother opened up the mother’s electronic medical record out of curiosity and were promptly fired.

LN:  So, bottom line, if you were NOT Mrs. Palin’s doctor, you would not have written this letter? So, we have to assume that Cathy Baldwin-Johnson was on the up-and-up here.

DOC:  She says that SP was seen "as a patient in our clinic since 1991". I see no reason to doubt that.

LN:  Except that they shared a religious affiliation that oversaw the Board of the hospital. Long time followers of the story can add more detail to this, I am sure.

DOC:  Now that's scary. Especially since Sarah flew quite a long way to deliver at this specific little hospital. That's the part that makes the least sense in the whole story.

LN:  So, what, if anything, leaves any doubt or questions in your mind about this letter?

DOC:  It’s a rather bland, routine medical letter as it should be. I have no idea why the “FP” at the end of FAAFP is in different color. Not sure it means anything. The three things that strike me as unusual or suspicious are Dr. CBJ resigning from active status at the hospital shortly after Trig’s birth, the amniocentesis, and the fact that Trig’s birth date is not given.

LN:  Let’s talk soon about the photos of the alleged newborn Trig. I have some thoughts about them but more importantly I’d love it if you could offer your own perspective as someone who has specialized in the care of high-risk and medically fragile newborns and children.

DOC: I assume you’re talking about the photos of him being held by friends and family, looking chubby and pink? I don’t see any jaundice in those pictures, nor do I see the normal “plethora” (or ruddiness) that most babies have in the first day or two of life. He also looks too chubby for a newly born baby; at least a few weeks old, but definitely not a new 6lb, 35 weeker. That looks more like one of those babies they use on soap operas who is 1-2 months old playing a newborn.

LN:  Thank you, Doc! That comment alone should get everyone’s juices flowing. I’ll try to pull together the photos and we’ll dissect them. 

The second of the two pediatric specialists I've been speaking with had this to say about Mrs. Palin's pregnancy:



I’ll start off by saying that most doctors are honest and try to follow all applicable rules and laws. Of course there are some bad eggs that will lie, cheat and steal but they are the exception.

As a doctor you are often caught between conflicting interests. On one hand you have sworn to “do no harm” via the Hippocratic Oath, thereby putting the patient first. On the other hand, you have to make a living, remain accountable to your practice or employer, and don’t forget the insurance company that pays the bills. I’ll start with a few real life examples to make the point.

Often, I’ll have a parent who asks me to keep their baby in the hospital an extra day or two because they aren’t able to take her home on a particular day. Sometimes it’s because they can’t get off from work, other times it’s because they’re moving. My rule is to look at each situation individually. If the parent has a solid reason for not taking their baby home on a particular day, and the baby could potentially be harmed by the discharge, I’ll put the reason in the note and generally, the insurance company will pay for the extra day. If the parent’s reason for delaying discharge is simply for their convenience, I warn them that the insurance company may deny the extra day and they could get the bill. I will not “fudge” my note.

Of course, there is a gray zone between a solid reason to delay discharge and a flimsy one. One time, I had a parent who was very scared to take her baby home. He was a tiny preemie and had been medically unstable for a long time and had finally straightened himself out. I warned the parents ahead of time that the discharge say was coming. On the discharge day, I called the mother and she said she couldn’t take her baby home. It turns out that she had called in the pest control folks and they would be fumigating her home that day. I’m sure that she purposely scheduled that appointment on the discharge day as a delaying tactic.

I called the case manager, the intermediary between the doctor and insurance company. She reads the charts every day and advises us on insurance issues. She said the extra day would be denied if I thought the baby was otherwise medically ready for discharge. I was between a rock and a hard place. However, this mother was very resourceful and she figured out how to assure that her baby wasn’t going home that day. She had delayed taking the baby’s prescriptions to the pharmacy and they wouldn’t be ready until the next day. I couldn’t send the baby home without his medications, so that settled it.

If I have a difficult parent who is demanding that I do something improper or unethical, and I realize I can’t solve the problem myself, I go straight to risk management. They contact a lawyer and advise me on how to proceed. They usually start by helping me with the language in my notes that explains the situation and would protect the hospital and myself from liability. If the situation escalates, I would let the lawyers handle all of the communication.

Ok, now lets move from reality to the wildly hypothetical. Let think about a big lie, like a fake pregnancy. They say if you drop a frog in boiling water it will jump out, but if you put one in warm water and turn up the heat, it will slowly get cooked. This probably isn't true, but does explain the two ways a big lie like this could proceed.

What if a patient asked their doctor to lie about their pregnancy? This is an easy one. No doctor who cared about their professional standing and their ability to practice medicine in the future would do this. No one who gave up at least 7 years of their life after college to become a doctor would willingly say yes. End of story.

However, let's say the doctor started by caring for a pregnant teenager. At first they were just asked to keep it quiet and not talk about the case with anyone. This is not unusual and is probably how it would start. At some point, however, what if the parent asked for a note from the doctor that the teenager needs to stay home from school for something other than pregnancy, such as mono? Now a line is being crossed, but it still is somewhat understandable and a doctor wanting to please their patient might do this, especially if they’ve known the family for a long time

What if the mother then asks that the name on the records be changed to her name? What if the teenager’s mother starts wearing a pillow under her shirt and claims she is pregnant? What if this mother is a prominent public figure? At this point the doctor is past the point of no return and probably feels like she has no choice but to follow through with the whole lie. Time to get a good lawyer and let them take care of the transition from doctor to defendant.

The high risk portion of my pregnancy lasted four months, during which my husband and I met many fetal/maternal specialists. Our son's life in the intensive care nursery lasted three months, during which we encountered every pediatric specialist known to mankind. It was our experience that medical people are precise, caring, cautious and meticulous. Our son's life was always in their hands. And we trusted them implicitly.  

People who ponder the Palin pregnancy story have often asked the general question, Do Doctors Lie?  I asked the two specialists who have weighed in on this blog before.  Here is the first doctor's reply. You are welcome to weigh in as well.


There are a lot of subtleties to this story. Usually when the patient/parent wants you to lie for them, it’s insurance fraud, either commercial or Medicaid. They might ask you to lie to get the insurance to cover something they otherwise wouldn’t.  That's not going to fly. It’s a huge legal risk and you wouldn't trust a parent that asked you to lie for them to keep quiet. Their very request makes them as untrustworthy as the doctor would be if he or she lied.

But doing something to help a patient without the patient actually know you're doing it? Probably happens, more in the heyday of managed care than now. Using words in an authorization request that you know will get something approved but aren’t necessarily “nothing but the truth” happens. But that is not the same thing as lying. It’s a way of assuring care for children.

Fudging records just doesn't work. Period. Too many people see them. Nurses, technicians, insurance companies. It’s too easy to get caught and doctors don't have the training to get away with it. Doctors aren’t trained in fraud.  With electronic medical records, it's now close to impossible. Because they all have audit trails so that changes are all recorded by what was changed and by whom. And any time someone logs into a record to view it, that is recorded as well. A hospital can tell who is viewing a famous patient’s record.

And even if someone “snooped” in to a famous person’s medical records, to release that information in any way is both illegal and punishable by law. It has happened multiple times.

I think the family practitioner had an attorney to keep the newspaper honest, both legally and as a witness. Perhaps she wasn’t worried about what she had to say, but she certainly would have been concerned about being misquoted.

No doctor is going to put him or her self in jeopardy for a patient that is likely to be under the microscope like Palin. Even if this whole birth thing happened before she was nationally or world famous. There are too many witnesses in a hospital.

Ask Michael Jackson's doc how he feels about cover-ups now. The truth tends to find a way out.

And as far as the idea that someone was stuffing a pillow under their clothes for a month-long public pregnancy and that a doctor would sign a letter stating she took care of this patient while pregnant, that is just not going to happen.  There is no penalty for the “patient” but the doc could lose their license.

I would still say her water broke and she went home to have the kid in relative privacy. In the end, “No harm, no foul”.  Her actions may have been risky or inadvisable, if in fact the story of leaking fluid is true. But would a doctor lie about it?  I don’t believe so.

By the way, anyone seen a long form on Palin?

This is my second interview with a pediatric specialist. In this case, the doctor is a neonatologist. That is a pediatrician who does an extra 3-year post-residency fellowship in order to specialize in the intensive care of newborns. Neonatologists care for newborns that are hospitalized due to complications of prematurity as well as full term babies needing critical care, such as those born with serious birth defects needing surgery, such as my son. 


On delivering babies early:
Some percentage of babies born at any age will have problems. The more premature a baby is, the more likely the problems. The most common problem is respiratory distress syndrome (RDS). This is a condition where the lungs lack a chemical called surfactant. Near term babies (35+ weeks) with RDS can be some of the sickest babies we take care of. Many of these babies will need to go on a mechanical respirator and some of them will need extra-corporeal membrane oxygenation (ECMO), which is very similar to heart/lung bypass. Most hospitals don’t have the capability to take care of these patients. A typical community hospital has a level 1 neonatal intensive care unit (NICU), which probably does not even have a respirator for a baby and/or the people qualified to operate it.

Inducing a 44-year-old multipara woman carrying a 35-week Down syndrome fetus:
In order to justify an induction at 35 weeks, there has to be a significant risk to the mother’s or baby’s health. Down’s syndrome in itself is not such a reason. There are tests to evaluate lung maturity. They require an amniocentesis, which carries its own risks and are far from 100% accurate.

Sarah Palin states she began leaking amniotic fluid in Dallas 24 hours before she delivered and flew for 8 of those:
Aside from the mess associated with leaking amniotic fluid (was she wearing an adult diaper to catch the fluid? There can be a lot of it), medically, it makes no sense. The longer that the membranes are ruptured, the higher the risk of infection to the mother and fetus. The risk rises more rapidly after 24 hours and mothers ruptured that long should be monitored in a hospital and probably should be given IV antibiotics. Any doctor who tells her patient with ruptured membranes that it’s ok to travel for 10 hours better have good malpractice insurance. Once the membranes rupture, the onset of labor can happen at any time. A woman who has had several children will often have a shorter labor and can deliver shortly after labor begins. This is variable, of course, but who would want to take this risk?

What would happen to a baby born on an airplane:
If a baby was born on an airplane, the odds that someone knows what to do are fairly small and the equipment to handle a delivery will certainly not be available. Most doctors who aren’t in OB/Gyn or Pediatrics haven’t been to a delivery since medical school. They would probably do fine if the mother and baby had no real problems, but in the case of premature baby, possibly infected, possibly with a heart defect and known to have Down’s syndrome, many things could go wrong. At best, the plane would have to make an emergency landing and the mother/baby taken to the nearest hospital.

Delivering in small hospital without NICU:
For a full term baby with no known problems, this is fine because most babies and mothers do well. The equipment and personnel to resuscitate a baby would be there and the baby could be stabilized and transported to hospital with a higher level of care. However, when there are known problems with the baby, it makes no sense to take unnecessary risks that the baby will need immediate intervention that cannot be provided in community hospital.

Delivery of a Ds baby by a Family Practitioner:
This, I have no problem with. A family practitioner (FP) who routinely does deliveries can handle this, as long as there is an OB/GYN back up in case a C-section is needed. Keep in mind that an FP could also help with the resuscitation of a sick baby, but that would divert him/her from the care of the mother and someone’s care would be compromised. Often, there is a pediatrician on call, but they may not be immediately available and would likely get there after the baby had already delivered. Again, this is fine for most cases, but when there are known issues with the baby, it makes no sense.

Down syndrome heart defects :
About half of babies with Down’s syndrome will have a heart defect. Many of these do not cause immediate problems, but will usually need surgical correction in the first year of life and need to be watched closely in the hospital before discharge to determine the timing of follow-up. Of course, this is not true of all heart defects and some will need immediate intervention from a cardiologist and pediatric cardiac surgeon. Not all congenital heart defects can be detected on prenatal ultrasound and it is recommended that all babies with Down’s syndrome have an early evaluation by a pediatric cardiologist. While this can be done in some community hospitals, it isn’t always easy.

There is another condition that occurs more often in babies with Down’s syndrome called persistent pulmonary hypertension (PPHN). This cannot be predicted prenatally and can be very serious. In this condition, the blood vessels in the baby’s lungs are constricted and very little blood flows through the lungs. This means that the baby has a hard time getting oxygen into their blood even if they are breathing normally. The usual treatment ranges from small amounts of supplemental oxygen, above concentration of oxygen in the air, delivered via an oxygen tent or nasal canula, to a mechanical respirator, to ECMO (heart-lung bypass, described above). This is more often associated with premature babies, but can happen at any age.

Photo of Trig seemingly with a nasal canula for oxygen:

If Trig required a nasal canula, there are many possible reasons. The most common would be “delayed transition” where he simply needed some support while he cleared fluid from his lungs. This could be exaggerated in a baby with low muscle tone due to Down’s syndrome. This generally gets better over time, but this is care that is over and above the capability of a level 1 NICU in a community hospital. He could also have some PPHN as I described above or even some RDS due to prematurity.

Taking a 3-day-old newborn to work:

Babies in general are very susceptible to infection. A baby with a heart defect and/or lung disease could get very ill if they get an upper respiratory infection. It is not recommended that newborns be taken out where they could be exposed to people who are sick.

Feeding issues:
The feeding issues associated with Down’s syndrome are usually related to the low muscle tone. Swallowing and breathing are two things we take for granted in a baby. In a premature and/or Down’s syndrome baby, they may not be able to do this right away and may need a feeding tube for a period of time. Often, the cardiac surgeons want a baby to gain weight before they operate on a heart defect. The heart defect can also make it harder for the baby to gain weight with a normal food intake. Oral feedings are often supplemented by tube feedings in these babies.

Down’s syndrome can affect almost any system in the body. They have an increased incidence of intestinal blockages, needing surgery shortly after birth. They can also have abnormalities of the blood. They can have low platelet counts (platelets are the cells in the blood that are involved in forming clots) and have a higher incidence of neonatal leukemia.

The media and the “Spiral of Silence”:
This is out of my area of expertise, but I can say this: Until recently, there was a line of respect for public figures that the media was not willing to cross. A politician’s children were generally off-limits for criticism and that probably explains the silence. However, it seems like everything is fair game these days.

Trig and Trisomy G:
I have never heard Down’s syndrome called “Trisomy G”. A quick Google search tells me that the Merck Manual has that name, but I’ve never heard it mentioned by anyone. We either call it Down’s syndrome or Trisomy 21, as the baby will have three copies of chromosome 21, instead of the usual two.

What a parent names their child is their decision. I’ve seen some crazy names over the years and Trig (Trisomy G?) is no big deal. What would you do if your parents named you “Shi’thead” or “Chlamydia”? Once we had a teen mother try to name her baby “Diarrhea” but we convinced her it wasn’t a good idea. My favorite baby name was pronounced “An-yae” but it was spelled “Etienne”. Apparently, the mother took the wrong name off her Etienne-Aigner purse when filling out the birth certificate. As we often say, “You need a license to drive a car, but not to have a baby.”

Ruffled ear defect:
I don’t know much about this. Generally, when a ear is deformed by the baby’s position in the womb, it will return to a normal shape after a few weeks. Rarely, some splinting is needed to re-shape the ear. This is not the case for developmental abnormalities of the ear. When an ear is malformed, surgical correction is needed to give the ear a normal appearance.

Downs and age:
The incidence of giving birth to a baby with Down’s syndrome rises with the age of the mother. It can be as high as 1 in 60 for a mother in her mid-40s. However, any mother of any age can have a baby with Down’s syndrome. It does happen in teenage mothers, but their risk is more like 1 in 1250.

A hoax?
Has a mother ever hidden her teenage daughter’s pregnancy and birth? Of course, I’m sure this happens all the time. The daughter has the baby and they announce to the world that the mother had another baby. It saves them from difficult questions and possibly shame. I can imagine if a mother is a political figure and an advocate of abstinence-only education, she would not want her teenage daughter getting pregnant and having a baby in the public eye. It could be the end of her political career, or at least her credibility.

I remember hearing that Bristol Palin was out of school for about 6 months due to “mononucleosis”. While mono can make a teenager quite sick, the timing certainly is suspicious and the length of time out is much longer than most cases of mono would last.

This story of the birth of Trig Palin has intrigued me for the reasons I have stated in earlier posts. I had a high-risk pregnancy and a complicated delivery by a very careful and skilled surgeon (OB) in an urban hospital a mile from the children’s hospital where my son lived for the first few months of his life. I’ve written extensively about our experiences.

On the other hand, there is no clear, consistent account of Sarah Palin’s putative pregnancy and Trig Palin’s birth, while there is a lot of speculation about what was right, wrong, risky and/or foolish. Or true.

I spoke at length with a pediatric specialist who has worked in the field for 30 years, including Level 3 Neonatal Intensive Care Units. I was curious about his take on the stories and rumors. He spoke honestly, gently and without regard for what I or anyone else might want to hear.

Read his comments carefully. There is one section that some people might find difficult to read. It is blunt, but illustrative of how he knows all that he knows about cardiac anomalies in Down syndrome children.

I am presenting this informally. Take away from this conversation what you will. And if you have follow up questions that are reasonable for me to ask him, I’d be glad to.


On delivering babies early:

There’s a lot going on in the OB and medical safety literature right now about pushing back from this culture of “I’m gonna have my kid when I’m gonna have my kid”, rather than “I’m gonna have my kid when he’s ready”.

Your OB was ahead of the game, or it was far enough back in years. No more “let’s time our delivery because this is good for me, or because I want my kid born on 1/1/11”.  Clearly kids who are born prematurely have significant issues globally, even though that doesn’t mean every single one does. On average kids who are born early have more problems - even if that’s at 37 or 38 weeks. So there’s been increasing pushback on this culture of “I want it done my way.”


Inducing a 44-year-old multipara woman carrying a 35-week Down syndrome fetus:

What could explain her being induced? Unless there was a problem with the fetus itself there would be no reason to do this. And I don’t know of anything related to Downs that would push you to go in that direction


Sarah Palin states she began leaking amniotic fluid in Dallas 24 hours before she delivered:

Leaking fluid is a relative indication that labor needs to be induced because of risk of infection. You don’t want that to go on for long period of time. The situation is more difficult than just putting the mother on bed rest. You can put her on antibiotics but that won’t prevent infection. And the fetus can be more severely impacted by that kind of infection. They might push to deliver because of that.


Flying 10 hours while leaking amniotic fluid:

That’s an issue.  Why fly? If you’re leaking fluid you ought to go to the most reasonably near facility that can deal appropriately with your condition. Getting on an airplane when you might go into precipitous labor at any period of time seems unwise. If she’s leaking fluid she can go (into labor) anytime. Doesn’t have to leak for hours. And in an airplane you don’t have access to anything.  Best of circumstances you have half an hour before the plane can be on the ground and that’s if you’re flying over an airport.

So why would she take that risk if she didn’t have to?  In some sense it’s judgment call. If she wasn’t who she was would anyone say anything about it? Anybody would want to deliver close to home. For her, privacy invasion would be more likely at an out of town hospital. Is there risk? Yes, but relative to a delivery in rural Alaska?


If not leaking fluid, why induce at 35 weeks:
If Palin wasn’t leaking fluid?  Unless there was something going on with fetus you’re not aware of, it’s probably not a good idea to induce labor.


Delivering in small hospital without NICU:

But by itself, this is not a problem, no.  Downs babies may have things wrong with them, but as I recall there’s not really anything that you would expect to cause an immediate risk to health.  So they may have heart defects and that sort of thing. But they tend to be relatively stable during first month of life. 

Emergencies certainly happen and a diagnosis might not be made in advance. . But if someone just walked into hospital to deliver, it might be safer for them to deliver there than transport the mom - especially in a place like Alaska where transport can be hit-or-miss anywhere. You may say that you’re going to move them because of some health issue. But you may find that risk of transportation is more than risk of delivering.

But in terms of planning ahead to deliver this way, does it reach the level of being egregious? That would be hard to say without having a lot more information. The circumstances all seem kind of strange. If you’re concerned about the kid why do you deliver where the kid won’t have access to the appropriate level of care? And if kid is not having problems why are you delivering at all?

Now if you have all the resources of a possible candidate for the Vice Presidential nominee of the Republican party, you might want to go farther.  People are funny. They don’t always make rational choices. Quite possible she simply wanted to be closer to home rather than in some place where she would be covered by media all the time.

Clearly the kid didn’t have problems. So did she put the kid at more risk by doing what she did? Possibly.  But the difference would have been at the margin at best. Any normal hospital with routine OB work would be fine.  You wouldn’t want to go to a place that doesn’t have an OB service or delivered one baby a week. But a place that was set up to do things was probably fine.  



Delivery of a Ds baby by a Family Practitioner:

When you live in an urban area, you’re not used to this. But there are a lot a places where family practitioners do most of the deliveries. And having a Board Cert OB available is not necessarily easy.  I was delivered by my family practitioner.


Down syndrome heart defects at birth:

They can have heart defects but they are the type of defects that don’t usually require emergency intervention. They need to be assessed and potentially followed but that doesn’t mean they have to have a pediatric cardiologist waiting for them.

The way things work now, there are ultrasounds that are the size of your iPhone, so if you have a technician who knows what they are doing or can work with a cardiologist over the phone, they wouldn’t even necessarily have to be in the same state. That’s not 4 or 5 years ago, but now. If they had a responsibly competent, well-trained technician it might very well be able to do the echo on site and just transmit it to whomever to evaluate. If the quality was bad or something was question, they might call the kid in and repeat it on site.


Ds heart defects in general:

Thirty-five years ago it was the pioneering days of pediatric cardiac surgery. They did a lot of heart surgery on Downs kids for 2 reasons:  At the time they didn’t consider it a loss if they lost the kids. And because it was hard to kill them. They survived.  In some sense they were hardy. The surgeons were experimenting at the time. That’s one of the favorite aphorisms of a pediatric cardiac surgeon at the time: He’d lose a kid on the table, and look at the cardiac surgery Fellow and say, “it was all experimental anyway” and walk away. That’s a long time ago. But that’s the way it was. The survival rates seemed to be higher for the Downs kids than the other kids with heart problems. So having a Downs kid in a regional hospital with a sort of normal ability for OB and routine nursery care is probably not that out of the question.



Taking a 3-day-old newborn to work: 

I would say if the kid was born at 40 weeks and was otherwise normal, I still wouldn’t take him to work. I find it crazy when I walk into Safeway and see a kid who’s a couple of weeks old at best out with in public exposed to who-knows-who with who-knows-what potentially infectious respiratory problems. Why would you do that if you had a choice?  It seems showy. 

I’m constantly telling people the most dangerous place for your kid is the back seat of your car. If there is no one available to take the kid at home and you had to go to work, that’s one thing. But how many moms with newborns have to make that choice in the first place? You going to go Walmart to work with the kid and have them under the cash register? No, people find someone to leave the baby home with.

It’s a different society up there in Alaska.  It’s a frontier mentality. And people do things that we would consider out of place down here but might not be up there.


Feeding issues: 

Downs kids tend to be pudgy.  If they’re preemies, if they’re developmentally at 35 weeks, they may have some problems feeding. But feeding is variable. It’s not related to the Downs but to the gestational age.  The kids born at that age in the nursery are there mostly because they don’t feed well and they want to make sure they are feeding enough and gaining weight.  Some quite conceivably go home that day. 


Photo of Trig seemingly with a nasal canula for oxygen:

He may have had an RSV infection or bronchiolitis and needed extra oxygen. It makes you wonder what the source of the picture is. If they are on oxygen they are not at home. The other part of that is that some of the cardiac conditions, and I’m no expert, are in some sense oxygen sensitive. So that if you maintain your level of oxygenation, you prevent their circulation from screwing itself up. There are oxygen sensors in your circulatory system and blood vessels will expand or contract based on what they are seeing and maybe a little extra oxygen was to prevent an adverse reaction from happening. That’s before a heart defect is fixed.

Downs kids can have ventricular septal defects, and a lot of those are what are called muscular, and over time they functionally close if not anatomically close. And the atrial septal defects as well. There are two types of ASD’s and one closes spontaneously because it’s a physiologic opening, meaning it’s there to function during gestation so its supposed to be there. They don’t always close the way they are supposed to and they take time to seal. And if they seal you don’t have to do anything with them. So he may never have needed surgery.


The media:

If I were writing for the New York Times and I was the editor, I would say, it’s a waste of time, in that you can probably make something of this if you want to, but there’s really nothing of any great import here. If you’re working for People Magazine, then let’s throw this one out here and sell a few more copies.

There’s not much substance here. The kids doing okay now as far as we know, I think. So while the decisions may not have been 100% in line with conventional thinking, they weren’t so far off line that the kid has suffered any significant problems.



Risk:

There’s really not a whole lot to it. It’s a mom in the public eye trying to make decisions that seem appropriate to her. It’s easy to second guess. But I’m not sure a lot of other people would have done it differently, or she might have had she not been in public eye.  Having other kids certainly would help in the sense that she would be more comfortable taking a kid home. She’s been there before. If she’s saying, “he’s my kid and I’m going to treat him as normal kid,” then why not?

This is within the bounds of normal.  We have parents and patients all the time that do things different from what we recommend. But as long as they are not putting their kid at risk, there’s a limit to how much steering you can do. If I think a kid has cancer and I’ll push that. But if the lump has been there 6 months and hasn’t changed and mom isn’t concerned, then I’ll say ‘come back later’.



Trig and Trisomy G:

I don’t remember hearing that about Trisomy G.  I remember a kid I knew when I was 10 years old who parents named Twig Snodgrass. I’m not joking. And of course there’s the famous Ima Hogg.  Trig? Hmmm. So?  We see a lot worse names than that. There was a baby named Meconium in the nursery. I’m not kidding. The mom liked the sound of the word.  You know how psychotic parents can be.



Ruffled ear defect:

That kind of surgery isn’t going to get done by someone in the boondocks in Alaska. If the ear was crushed in the uterus it can look really weird and 4 or 5 months it can look perfectly normal. Kids heads look weird when they come out too, especially if there’s been a prolonged labor. And over time they straighten themselves out and look pretty good.  How much of this is artifact from the picture itself? The lighting or shadows or who knows what. And if it looks like the opening of ear canal is farther forward? Is it the ear canal or a shadow?

An ear defect does not necessarily have to do with Downs.



Ethical quandary:

I find the woman distasteful to say the least. But there are more important things to worry about with her than this.  There is no flag for me here.  In a lot of ways she is a modern woman. And not in the sense that she is looking out for women’s rights but rather that she is making decisions for herself and family and the public be damned. If you have a question about it, that’s too bad. 

As a doctor, I would have no ethical quandaries about this. 

It just seems like people trying to make something out of, not necessarily nothing, but certainly something that wouldn’t be at all a question if she wasn’t who she was. Would Child Protective Services be looking for her because she got on an airplane? Probably not.  When you’re in the public eye people will question anything you do. Obama has the same problem.  No matter what he says or does, people will disagree. It has nothing do with him. It has to do with we want to make noise.

There are far worse things going on and people being far more abusive to their kids than this is anywhere near. So from the perspective of someone who has seen parents neglectful to the point of abusive, this is nothing.  There are moms who have 5 or 6 kids in foster care and the next thing you know there’s another 30-week preemie in the nursery for the State to spend a million dollars on.  There are good moms and other moms. And when do you tell a mom they can’t have another kid? It’s America and we don’t do that. It’ may not be in the kid’s best interest to be had by that mom.  But the fundamental basis of America is liberty.



Downs and age:

Downs kids are far more likely in older parents. So, the chance that the teenager had a Downs baby?  It’s possible but probably less than 5%. Teenagers might have more babies, but on the basis of the babies they have, how many have Downs? It’s much smaller.


A hoax:

She’s weird in some ways. But she’s not that weird. To do things like fake a pregnancy. Those kinds of people don’t get through a nomination process because there would be too many flags. Because it’s not that they do one thing that’s weird. There would be a history. There’s politically weird and then there’s outrageous behavior. Did she baptize her kids in local stream in middle of winter?  Did she have the kid at home? No. Politically I don’t like her. But she’s not that weird.