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: 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?
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
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
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