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.
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:
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.
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.
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.
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)
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:
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:
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?
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!