MWSP EP 18 - Dr. Philippe Friedlich: Pediatric Surgery, Neonatal Therapeutic Hypothermia, Pre-Mature Births, and CHLA

 

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Speaker 1: From  CurtCo  Media.

 

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Bill Curtis: More  strange  days.  COVID  again  on  the  rise.  So  many  important  procedures and  medical  needs  are  still  being  allowed  to  fester  because  people  are  afraid  to  go  to  their  doctor,  let  alone  a  hospital.  So  this  pandemic  is  claiming  lives  from  people  who  don't  even  catch  the  disease.  One  specialty  that  can't  wait  for  COVID  to  be  in  our  rear  view  mirror  is  neonatology,  the  care  necessary  for  some  of  the  smallest  of  us  to  survive  catastrophic  challenges.  We  have  a  special  guest  today  from  a  hospital  that  is  leading  the  country  in  the  quest  to  place  the  odds  in  the  newborns'  favor.  Welcome  to " Medicine,  We're  Still  Practicing."  I'm  Bill  Curtis.  Of  course,  first,  my  friend  and  cohost,  Dr.  Steven  Taback.  He's  the  quadruple  board- certified  doctor  of  internal  medicine,  pulmonary  disease,  critical  care  and  neuro- critical  care.  These  days,  he  continues  to  fight  on  the  front  lines  of  the  COVID  battle  in  California,  for  which  we  are  eternally  grateful.  Steve,  how  you  doing?

 

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Steven Taback: I'm  well.  Thank  you. It's good  to  be  here,  Bill.

 

00:01:13
Bill Curtis: I'm  sure  you've  heard  of  Children's  Hospital  of  Los  Angeles,  known  as  CHLA.  U. S.  News  and  World  Report  has  consistently  ranked  CHLA  in  the  top  five  nationally  and  the  number  one  pediatric  hospital  in  California  for  30  years  running.  This  remarkable  nonprofit  children's  care  hospital  is  nationally  known  for  neonatal  research  and  care  that  is  funded  entirely  by  generous  philanthropists.

 

 Dr.  Philippe  Friedlich  is  Chief  of  Neonatology  at  Children's  Hospital.  He  is  also  co- director  of  the  Fetal  and  Neonatal  Institute,  and  he  is  professor  of  Clinical  Pediatrics  and  Surgery  at  the  renowned  Keck  School  of  Medicine  at  USC,  where  he's  published  over  150  abstracts,  peer  review  articles  and  book  chapters.  Dr.  Friedlich is  a  rock  star  in  one  of  the  world's  most  complicated,  pressure- filled  and  delicate  specialties  that  include  newborn  respiratory  failures,  newborn  pulmonary  hypertension,  even  surgery  on  unborn  babies.  Can  you  imagine?  Welcome,  Dr. Philippe  Friedlich.  It  is  an  honor  to  have  you  here  tonight.

 

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Philippe Friedlich: Thank  you  for  having  me.

 

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Bill Curtis: So  doctor,  can  you  just  bring  our  listeners  up  to  speed  on  CHLA  and  your  mission  there?

 

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Philippe Friedlich: Children's  Hospital  of  Los  Angeles'  mission  is  to  care  for  sick  children.  No  matter  what  their  background,  their  cultural  background  or  insurance  they  have,  we  are  a  place  to  care  for  families  and  children  and  babies  when  there's  no  other  place  that  could  care  for  them.

 

00:02:43
Bill Curtis: Are  we  talking  about  one  of  the  few  medical  specialties  that  truly  couldn't  wait  for  COVID  to  pause?

 

00:02:50
Philippe Friedlich: That's  a  great  question.  Fortunately,  for  many  children,  COVID  has not  been  as  impactful.  There  are  some  babies and children that  are  sick,  but  by  far,  unless  we  compare  it  to  adults,  we  are  fairly  lucky  so  far.

 

00:03:05
Bill Curtis: So  we're  not  going  to  spend  the  whole  show  on  COVID  because  frankly,  I  think  people  want  to  know  much  more  about  your  specialty,  but  maybe  you  could  tell  us  a  little  about  what  kind  of  a  regimen  has  CHLA  developed  uniquely  for  this  pandemic,  and  what  are  some  of  the  special things that you  do  at  your  hospital  to  manage  this?

 

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Philippe Friedlich: A  lot  of  it  has  to  do  with  making  sure  that  we  can  screen  families  and  staff  when  they  arrive  at  the  hospital  and  make  sure  that the  environment  for  caring  for  those  children,  regardless  of  the  reason  why  they're  in  the  hospital,  is  optimal.  And  so  the  hospital  has  spent  significant  resources  to  ensure  that  we  screen  families  and  visitors  and  parents  when  they  arrive.

 

00:03:49
Bill Curtis: Psychologically,  how  do  you  get  your  clientele  to  feel  safe  under  these  circumstances?

 

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Philippe Friedlich: That  has  been  a  (inaudible)   challenge.  As  you  can  imagine,  a  lot  of  families  are  scared  to  even  go  close  to  a  hospital.  So  certainly  our  data  suggesting  that  we  can  provide  a  safest  environment  to  bring  sick  children  and  care  for  them,  but  it  is  a  concern,  so now  we  can  see  that  visits  to  the  emergency  room  are  significantly  down.  Obviously  a  lot  of  the  outpatients  clinic,  I've  had  to  restructure  their  environment.  But  I  think  that  honest  conversations  with  family  and  trying  to  make  sure  that  vulnerable  children still  can  get  the  care  they  need  so  they  don't  have  complications  from  their  disorders  and  diseases,  or  we  try  to  do  our  best  to  get  the  message  across.

 

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Steven Taback: In  your  infected  pregnant  women,  what  percentage  of  the  infection  will  affect  the  neonates?

 

00:04:47
Philippe Friedlich: Well,  it  depends  how  you  define " affect  the  neonates"  that  we  have  not  seen  certainly  in  our  area  any  children  or  neonates  infected  with  the  virus.  There's  very  few  reports  in  the  world  around that. What we  do  see  though,  is  mother  who  gets  sick  with  the  COVID- 19 illness  and  systemic  inflammatory  response,  and  then  for  maternal  reason,  the  baby  has  to  be  delivered  early.

 

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Steven Taback: So  more  of  a  high- risk  delivery,  as  opposed  to  a  neonatal  issue,  per  se.

 

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Philippe Friedlich: Right.  And  so  premature  babies  that  are  born  because  the  mother  is  sick  is  something  that  we  see. They're  not  sick  with  COVID,  but  they  have  all  the  risks  of  complications  from  the prematurity.

 

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Bill Curtis: You  use  the  term " premature,"  and  for  our  listeners,  we  think  we  know  what  that  means,  but  can  you  define  it`  at  what  level does  it  become  a  problem?  And  I  also  understand  that  your  hospital  very  often  doesn't  get  the  babies  until  there's  a  problem.  You  just  suddenly  get  a  call  that  there's  a  need.

 

00:05:48
Philippe Friedlich: That's  correct.  Prematurity  is  defined  in  general  in  any  pregnancy  that  does  not  reach  38  weeks,  but  obviously  there are gradation  of  prematurity.  And in  this  country,  we  have  made  remarkable  advances  in  the  support  of  premature  infants.  Right  now,  we  care  routinely  for  babies  at  the  limited  viability,  and  that's  around  23  weeks  of  gestation.  So  before  28  weeks,  it's  fair  to  say  that  those  babies  are at  the  highest  risk  of  complications,  and  after  28  weeks,  the  outcomes  in  this  country  are  really,  really  good.

 

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Bill Curtis: What  kind  of  complications  do  you  deal  with  when  it's  actually  10  weeks  too  early?

 

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Philippe Friedlich: There  are  lots  of  complications  that  those  babies  can  be  subjected  to. There  are  complications  involving  the  brain,  so  these  babies'  brains  are  very  fragile,  and  they  can  have  significant  damages  to  their  brain.  But  all  the  organs  are  very  fragile.  The  good  news  is  that  most  babies  do  quite  well and  can  recover.  What  we  worry  the  most  is  obviously  the  organs  that  once  damaged,  don't  recover,  such  as  the  brain  or  the  eyes.  But  by  far,  with  the  technology  that  we  have  in  this  country,  most  babies  do  quite  well.

 

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Bill Curtis: I  watched  one  of  your  videos  where  you  were  talking  about  brain  issues and  that  you  have  a  procedure  whereby  you  cool  brains  inside  an  MRI.  Can  you  describe  that  a  bit?

 

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Philippe Friedlich: Yeah.  What  you're  referring  to  is  therapy  called " select  hypothermia."  So  it's  a  technique  that  is  used  for  larger  baby.  So  those  are  not  premature  babies,  but  those  are  babies  who  have  had  complication  in  the  last  stage  of  labor, when  the  mom  is  in  labor,  and  have  a  sudden  lack  of  oxygen  or  blood  flow.  And  so  this  is  very  similar  to  the  techniques  that are used in  adults  when  they  have  strokes  to  try  to  minimize  the  brain  injury.  And  so  in  newborns,  for  the  last  now  10  years,  we  have  used  this  technique  to  cool  the  baby's  brain  for  around  three  days  in  the  hope  that  we  can  minimize  the  injury  that  is  involved  with  a  lack  of  oxygen  or  blood  flow  during  the  last  stage  of  labor.  The  idea  is  to  get  the  brain  temperature  in  a  selective  range.  And  you  mentioned  MRI  before.  We  were  a  pioneer  in  developing  techniques  where  we  actually  can  measure  the  brain  temperature  of  babies  doing  cooling  with  MRI  technology.

 

00:08:18
Steven Taback: What  is  your  end  point?  For  us,  in  post- cardiac  arrest,  it's  24  hours  at  the  target  temperature.  What's  the  protocol  for  a  brain- injured  or a  hypoxemic  infant?

 

00:08:29
Philippe Friedlich: Yeah.  So  for  babies  that  suffer  from HIE, or  hypoxemic- ischemic  encephalopathy,  we  cool  them for  72  hours  if  they  can  tolerate that length of time.

 

00:08:37
Bill Curtis: My goodness. I also understand  that  premature  babies  have  all  kinds  of  pulmonary  issues,  including,  in  one  of  your  videos,  you  actually  said  they  forget  to  breathe  when  they're  sub  34  weeks.  But  I  was  told  that  you  have  an  expertise  there  at  the  hospital  where  you  incorporate  the  use  of  an  ECMO  machine  for  certain  babies.  Can  you  describe  that?

 

00:08:58
Philippe Friedlich: Yeah.  So  ECMO  stands  for " extracorporeal  membrane  oxygenation."

 

00:09:03
Bill Curtis: Easy  for  you  to  say.

 

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Philippe Friedlich: It's  a  technique that  actually  is  used  in  adult  and  in  pediatrics  and  in  neonates. It  actually  was  used  since  the  mid- seventies  and  eighties,  and  in  California  was  actually  some  of  the  first  sites.  And  since  1997,  we  actually  have  used  the  technique  at  CHLA.  It's  a  technique  that  is  used  in  larger  baby. You  have  to  be  at  least  two  kilos  and  at  least  34  weeks  of  gestation  at  birth  to  be  able  to  be  enrolled  in  the  programs.  It's  used  for  babies  who  have  significant  and  severe  respiratory  or  cardiac  insufficiency,

 

00:09:41
Bill Curtis: For  the  layman's  term,  is  it  you're  actually  oxygenating  the  blood?

 

00:09:45
Philippe Friedlich: Yeah.  We  take  over  both  the  heart  and  the  lungs  and  wait  for  their  recovery  while  the  machine  is  doing  the  work  for  the  baby.  It's  a  very  similar  machine  that  adults  use,  for  example,  for  heart- lung  bypass  surgery.

 

00:09:58
Bill Curtis: And  Steve,  I  think  you  mentioned  in  the  past  that  you  guys,  that  Provenance  have  been  known  to  use  ECMO  when  necessary  for  COVID  patients.

 

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Steven Taback: We  do. I  think  we've  used  ECMO  once  for  COVID,  but  we've  used  ECMO  quite  a  bit  during  the  influenza  pandemic.  And  we've  had  great  results  during  influenza  because  the  lung  heals  very  well,  even  after  60  days.  We  had  good  results  with  one  COVID  patient  at  St.  Joe's  as  well,  but  it  is  used  frequently  for  COVID  worldwide.  And  we've  had  a  fairly  robust-- for  a  private  community  hospital,  that  is-- we've  had  a  fairly  robust  ECMO  program  for  the  past  several  years.

 

00:10:34
Bill Curtis: Doctor,  we're  going  to  be  asking  you  about  a  number  of  the  issues  that  you're  dealing  with at  CHLA,  but  I  wonder  if  we  could  talk  about  one  in  particular  that  I  found  fascinating  in  some  of  the  videos  that  you  have  produced,  where  they're  actually  unborn  babies,  where  you've  had  to  perform  something  you  called " keyhole  surgery  repairs,"  as  in  spinal  bifida  repair,  for  a  developing  fetus.  Sounds  pretty  scary.

 

00:10:58
Philippe Friedlich: Yeah.  I'm  very  lucky  to  be  part  of  a  new  institute  that  brings  together  all  the  subspecialty,  including  fetal  surgery.  And  at  CHLA  and  at  USC,  we  have  Dr. Ramen  Chmait,  who's  a  fetal  surgeon,  and  he's  the  one  actually  that  performed  the  surgery.  Dr.  Chmait  is  internationally  recognized  and  has  the  expertise  to  really,  with  minimal  techniques,  to  approach  the  fetus  through  the  mom's  abdomen,  place  cameras  and  instruments,  and  now  can  actually  repair  those  neural  tube  defects,  so  the  spinal  cord  defects,  early  on,  so  that  we  can  protect  the  spinal  cord  from  being  exposed  to  the  amniotic  fluid.  There's  a  lot  of  evidence  that  it  is  that  exposure  in  utero  over  time  that  can  really  scar  and injure  the  spinal  cord  and  cause  scar  tissues,  and  the  idea  is  we  can  cover  the  defect,  then  the  longterm  outcomes  will  be  better.  And  in  fact,  there's  quite  a  bit  of  an  evidence  that  the  longterm  outcomes  such  as the ability  to  walk  independently,  bladder  function  and  things  like  that  are  better.

 

 It  obviously  comes  at  significant  risk.  Obviously  you  have  to  do  the  surgery  and  place  the  mother  under  anesthesia  while  she's  pregnant.  You  have  to  enter  the  uterus  with  cameras,  and  that  can  sometimes  cause  preterm  labor.  So  it  is  not  a  technique  that  is  yet  completely  proven,  and  we  are  part  of  multi- center  trials  to  show  hopefully  that  we  can  demonstrate  its  usefulness  and  its  safety  of  such  procedures.

 

00:12:42
Steven Taback: Takes  a  very  courageous  staff,  and  also a  very  courageous  mother  to  undergo  that  kind  of  testing.

 

00:12:47
Bill Curtis: So  what  are  some  of  the  other  focuses  where  you  find  yourselves  with  some  pretty  remarkable  challenges,  and  CHLA and you and  your  fellow  doctors  have  attacked  the  problem,  and  you  feel  there  have  been  significant  advancements  in  the  recent  years?

 

00:13:03
Philippe Friedlich: There  are  many,  and  I'm  glad  you  asked  the  questions.  You  know,  I  think  that nearly 20 years  ago,  we  established  the  fetal- neonatal  institute,  and  that  was  one  of  the  first  in  the  country  that  was  establishing  a  comprehensive  team  to  care  for  not  only  the  mother,  her  pregnancy,  care  for  the  fetus  and  also  plan  that  postnatal  care.  There  are  very  few  centers  in  the  country that can  do  it  and  do  it  well. There are  a  few  examples  that  I  could  name,  for  example,  our  ability  now  to  really  diagnose  very  specifically  what  is  the  specific  problem  in  a  fetus.  Our  cardiologists  and  fetal  cardiologists  now  can  enter  and  repair  some  of  the  baby's  heart  valve  around  20  to  25  weeks  of  gestation.  So  our  team  at  CHLA  has  done  that.  And  to  me,  that's  amazing  when  you  think  that  a  baby's  heart  is  probably  smaller  than  the  nail  of  my  little  finger,  and  they  are  able  to  place  a  catheter  and  open  a  valve.

 

00:14:07
Bill Curtis: Is  that  done  with  the  DaVinci  robot,  or  that's  actually  done  by  hand?

 

00:14:10
Philippe Friedlich: No,  again,  they  use  technique  where  they  enter  the  fetal  circulation  through  the  umbilical  vein  and  vessels.  And  they  are  able  to  guide  this  wire  into  the  baby's  heart,  just  like  adults  undergo  now  noninvasive  techniques  for  heart  repair.  So  I  think  that  that  is  something  that  is  pushing  the  envelope,  but  daily,  we  actually  now  are  able  to  get  to  the  specific  diagnosis  before  a  baby's  born  so  that  we  can  prepare  both  the  family,  the  site  of  delivery,  and  be  present  to  avoid  all  the  complication  that  those  infants  used  to  be  exposed  to,  and  then  bring  them  to  CHLA  so  that  our  surgeons  and  our  subspecialists  can  do  the  right  thing  at  the  right  time  and  then  avoid  a  series  of  complications  that  were  unavoidable  in  the  past.  And  now  these  children  can  live  life  without  the  sequela  of  their  disorder.
 And  that's  something  that  is  so  satisfying  and  that's  changed  so  rapidly.  I've  been  in  the  field  20  years  now.  And  in  those  20  years,  every  five  years,  I  see  huge  change  in  those  outcomes.

 

00:15:19
Steven Taback: But  on  a  personal  note,  I  remember  back  in  medical  school,  when  you're  trying  to  figure  out, " What  is  going  to  be  my  specialty  of  choice?"  And  I have  found  that  most  of  my  colleagues  were  making  a  choice  based  on  deduction,  and  they  knew  exactly  which  fields  they  did  not  want  to  go  into.  And  it's  certainly  for  me,  it  had  anything  to  do  with  children  because  treating  children  terrify  the  heck  out  of  me.  The  idea  of  possibly  doing  harm  is  always  bad,  but  to  a  child  is  something  that  I  couldn't  even  conceive  of.  What  got  you  interested  in  the  field  of  neonatology?  What  made  you  make  that  decision  to  go  completely  opposite  direction  that  I  went?

 

00:15:56
Philippe Friedlich: It's  a  question  that  I  often  get  asked,  and  I  think  many  physicians, it was the  relationship.  I  had  not  thought  of  neonatology  as  the  career,  was  late  even  to  pediatrics.  I  thought  I  was  going  to  be  a  surgeon.  And  then  for  reason  that  I  cannot  even  explain,  I  one  day  got  the  opportunity  to  meet  Dr.  Robert  deLemos,  who  was  the  Chief  of  Neonatology  at  USC.  And  he  just  had  finished  a  series  of  years  developing  high- frequency  ventilation.  He  was  one  of  the  forefathers,  and this  is  the  kind  of  relationship  that  in  a  couple  of  days,  I  knew  that's what  I  wanted  to  do for  the  rest  of  my  life.  So  I've  been  very  blessed  with  many  relationships  during  my  training  and  since  then,  and  one  of  the reasons  that  I've  never  left  CHLA  since  the  early  days  of  my  internship.

00:16:42
Bill Curtis: In  past  episodes,  Dr.  Steve  and  I  have  talked  to  people  about  robotic  mechanized  doctors,  and  in  your  specialty,  I  can't  imagine  the  training  and  expertise  and  very  soul  that  must  go  into  communicating  with  the  parents,  just  managing  that  relationship.  It's  certainly  something  that  a  robot's  never  going to be able  to  do.  How  did  you  learn  to  do  that  well,  or  is  there  such  a  thing?

 

00:17:07
Philippe Friedlich: Yeah,  I  think that  you're  posing  a  really  difficult  question  to  ask.  I  think  there  are  some  people  that  naturally  are  more  empathetic  than  others,  and  certainly  that  helps.  For  others,  hopefully,  they  can  learn  some  of  those  skills.

 

 It  does  help,  I  think,  to  have  your  own  family.  When  I  think  about  how  I  used  to  address  parents  when I  didn't  have  that  experience,  they  don't  keep  you  that necessarily  in  medical  school,  you're  a little  bit  more  in  tune  to  how  difficult  it  is  to  worry  about  your  child,  even  if  it's  a  simple  fever  or  cough,  to  a  parent,  whether  it's  the  unknown  and  that  constant  worry.  And  so  when  you're  exposed  to  that,  I  think  that  you  become  a  better  doctor,  and  this  is  a  field  where  you  have  to  be  really  in  tune  with  the  family.  It's  amazing,  in  fact,  that  as  much  as  we  have  improved  our  medicine  or  our  techniques  and  our  technology,  there  is  one  fact  that  still  to  this  day  just  astonished  me,  is  that  the  best  predictors,  longterm  neurodevelopmental  outcome  in  premature  infant,  is  actually  maternal  involvement  in  education.

 

00:18:12
Steven Taback: Wow.

 

00:18:13
Philippe Friedlich: And  so  to  be  able  to  bring  the  family  early  on  at  the  bedside  so  that  we  can  really  optimize  the  bonding  is  something  that  cannot  be  dismissed.  I've  witnessed  some  events  that  the  medicine  cannot  explain.  So  I  think  we  need  to  be  a  little  bit  humble  and  make  sure  that  we  communicate  with  families  so  that  they  understand  that  their  role  at  the  bedside  is  just  as  important  as  everything  else.

 

00:18:39
Steven Taback: Outside  of  medicine,  would  you  then  advocate  that  the  mother  stay  at  home  during  the  early  formative  years  for  the  child?  We  live  in  a  society  of  two  working  parents.  You  think  that  that  has  a  negative  impact?

 

00:18:52
Philippe Friedlich: I  think  that  the  involvement  of  the  mother  or  the  extent  of  the  family  around  the  child  is  they  are  important.  If  you  look  at  and  compare  other  countries  and  their  social  environment,  I  think  it's  fair  to  say that  I  am  not  sure  that  in  this  country,  we  have  the  best  model.  So  I  do  believe  that  a  child  should  have  a  social  environment  that  is  robust, that  is  interactive  with  family  members.

 

00:19:19
Bill Curtis: We're  going  to  talk about that in just  a  minute.  We'll  be  right  back  with  Dr.  Philippe  Friedlich and  Dr.  Steven  Taback.

 

00:19:26
Speaker 2: A  moment  of  your  time.  A  new  podcast  from  CurtCo  Media.

 

00:19:30
Speaker 3: Currently  21  years  old,  and  today,  I'm  going  to  read  a  poem  for  you...

 

00:19:33
Speaker 4: It  felt  like  magic  extended  from  her  fingertips  down  to  the base of my spine.

 

00:19:36
Speaker 5: Well, you have to take care of yourself, because the  world  needs  you  and  your  work.

 

00:19:39
Speaker 6: Trust  me,  every  do- gooder  that  asked  about  me  was  ready  to  spit  on  my  dreams.

 

00:19:42
Speaker 7: ... fingers  were  facing...

 

00:19:44
Speaker 8: You  feel  like  your  purpose  and  your  worth  is  really  being  questioned.

 

00:19:47
Speaker 9: It couldn't me  from  playing  the  piano.

 

00:19:49
Speaker 10: She  buys  walkie  talkies,  wonders  to  whom  she  should  give  the  second  device.

 

00:19:52
Speaker 11: Pets  don't  love  humans.  We  never  did.  We  never  will.  We  just  find  ones  that are...

 

00:19:56
Speaker 12: The beauty of  rock  climbing  is  that  you  can  only  focus  on  what's  right  in  front  of  you.

 

00:20:00
Speaker 13: And so  our  American  life  begins.

 

00:20:04
Speaker 2: We  may  need  to  stay  apart,  but  let's  create  together.  Available  on  all  podcast  platforms.  Submit  your  piece  at  curtco. com/ amomentofyourtime.

 

00:20:16
Bill Curtis: We're  back  with  Dr. Philippe  Friedlich  from  CHLA  and  Dr.  Steven  Taback.  So  before  the  break,  doctor,  you  were  talking  about  witnessing  some  maternal  effect,  especially  in  cases  where  there  were  babies  at  risk,  that  you  said  medicine  could  not  explain.  Can  you  be  more  specific?

 

00:20:33
Philippe Friedlich: Yeah.  I  think  that  despite  all  the  medical  intervention, then the  medical  discoveries  that  have  helped  tremendously  in  the  survival  of  our  most  fragile  infant,  there  are  still  an  aspect  of  bonding  maternal  or  even  paternal  involvement  that  has  shown  to  improve  outcomes  of  babies,  especially  in  our  intensive  care  units.  A  mother's  voice,  the  mother's  touch,  is  really,  really  important, and what  we  see  in  the  intensive  care  arena  is  that obviously,  one  of  the  first  reaction  from  the  family  is  to  get  very  scared  and  to  withdraw  from  sometimes  coming  at  the  bedside,  talking  to  their  child  or  touching  their  child.  And  it's  been  shown  that  mothers  who  speak  to  their  premature  infant  in  the  ICU,  sing  or  talk  to  them,  have  better  outcomes,  even  if  you  control  for  all  other  variables.

 

00:21:30
Bill Curtis: Is  there  any  positive  impact  that  daddies  have,  or  is  that  just  all  about  earning  college  tuition  for  sometime  later?

 

00:21:36
Philippe Friedlich: No,  the  father  is  also  very  important.  In  the  care,  we  encourage  fathers  to  bond  with  their  child  as  well.  As  a  matter  of  fact,  you  may  have  heard  of  the  term " kangaroo  care,"  and  that's  when  we  really  encourage  families  to  actually  have  skin- to- skin  time  with  their  baby.  And  so  it  is  very  powerful  when  we  see  a  father  that  is  also  doing  that  kind  of  bonding.

 

00:22:03
Bill Curtis: So  is  it  still  practiced  that  after  birth,  babies  are  taken  to  a  very  brightly  lit  room  where  they're  watched  in  plastic  bassinets  and  eventually  get  back  in  their  mother's  hands,  but  is  that  still  practiced?

 

00:22:16
Philippe Friedlich: We  try  very  hard  to  actually  bond  the  baby  with  their  mother  at  the  time  of  delivery,  even  if  they  are  premature,  or  even  if  they  have  significant  other  conditions,  because  we  believe  that that  first  few  minutes  with  the  mom  can  change  many  things,  both  social  bonding,  but  has  been  shown  also  that  even  the  microbiome  of  those  infants  can  be  altered.  Having  said  that,  we  have  sometimes  to  weigh  the  consequence  of,  and  sometimes  have  to,  take  the  baby  away  fairly  quickly.

 

00:22:50
Steven Taback: Anything  in  the  cutting  edge  over at  CHLA  in  terms  of  brain  development  that  may  be  going  on  other  than  just  the  nurturing  bond  of  a  mother  and  baby?

 

00:23:01
Philippe Friedlich: Yes,  there  are,  for  example,  different  approach  to  manipulate  the  survival  of  neurons.  We  are  using  now  some  medications  that  are  called  anti- apoptotic  drugs.  For  example,  erythropoietin  is  now  given  to  some  high- risk  newborn  to  try  to  minimize  brain  damage.
 So there  are  things  that  we  are  certainly  studying  and  evaluating  in  terms  of  optimizing  the  chance  of  babies  having  normal  outcomes  for  a  long  time.  We  didn't  know,  for  example,  how  much  oxygen  was  necessary  for  better  outcome.  And  you  probably  have  heard  that  actually  premature  infants  are  kept  in  a  lower  oxygen  range  than  older  children. And that  has  changed  a  lot  of  their  outcomes  and  decreased  the  number  of  babies  who  have  blindness  as  sequela  from  their disorders.

 

00:23:52
Steven Taback: Are  neonates  more  responsive  to  stem  cell  therapy?

 

00:23:55

Philippe Friedlich: I'm  glad  you  asked.  It's  an  area  that  really  is  uncharted,  yet  there  are  some  centers  in  the  country  that  are  looking  at  the  feasibility  of  stem  cell  research  in  premature  infants  and  in  older  children.  USC  is,  for  example,  looking  at  cardiac  stem  cells.  Our  urologists  are  doing  tissue  engineering  with  stem  cells.  It's,  I  think,  going  to  be  probably  big  time  in  the  next  decade,  but  not  yet.

 

00:24:22
Bill Curtis: What  percentage  of  babies  these  days  are  born  prematurely?

 

00:24:26
Philippe Friedlich: Too  many,  that's  for  sure,  especially  in  this  country  when  you  compare  with  other  countries  that there  are  of  similar  economic  ability.  One  of  the  things  that  we  say,  around  10%  of  babies  are  born  prematurely,  so  if  you  believe  that there  are  4  million  babies  born  every  year  in  this  country,  that's  400,000.
 Now,  the  good  news  is  that  most  of  those  babies  are  the  big  premies,  and  they  do  pretty  well. Having  said  that,  there's  been  a  big  push  in  California,  in  this  country  by  agencies,  such  as  the  Association  of  Gynecology  and  Obstetrics  and  the  American  Academy  of  Pediatrics,  to  really  mandate  hospitals  and  physicians  to  publish,  for  example,  their  C- section  rates.  And  the  impetus  for  that  is  really  to  try  to  minimize  any  birth  before  39  weeks.  Sometimes,  parents  and  family,  or  even  physicians  would  plan  a  delivery  just  before  39  weeks.  And  although  those  babies  do  quite  well,  they  don't  do  as  well  as  a  full- term,  39- week  baby. If  you  compare,  for  example,  38- week,  just  one  week  shy  of  being  39,  those  babies  don't  do  as  well  later  on  in  school  and  things  like  that.  So  there  has  been  a  big  push  to  minimize  what  we  can  prevent.  So  we  can't  prevent  early  birth  on  the  basis  of  just  scheduling  a  C- section  because  of  family  intervention,  and  that  is  going  to  have  a  significant  effect.  We  still  are  not  good  enough  to  prevent  those  very  preterm  births,  but  preventing  unnecessary  preterm  births  is  going  to  have  a  great  impact  in  this  country.

 

00:26:02
Bill Curtis: Do  you  get  advance  knowledge  that  you're  about  to  get  a  client?  Does  the  delivery  team  know  that  a  baby  is  about  to  be  born  with  severe  challenges  and  that  they're  going  to  have  to  transfer  the  baby  to  you?  Can  you  describe  that  whole  moment,  as  well  as  how  do  you  transfer  a  baby  that's  in  that  kind  of  shape  over  to  you  guys?

 

00:26:21
Philippe Friedlich: So  most  of  the  time,  we obviously get  advance  notice,  and  if  we  know  of  a  prenatal  condition,  then  we  have  an  entire  team  that  is  dedicated  to,  to facilitate  the  transport.  But  as  soon  as  the  baby  is  stabilized  in  the  community  hospital,  or  one  of  our  partnership  hospitals,  depending  on  the  distance,  we  have  at  CHLA  two  helicopters  that  are  ready  on  a  moment's  notice,  and  actually,  we  are  very  proud  that  we  can  dispatch  a  team  in  less  than  30  minutes  anywhere.  We  have  a  special  transport  team  with  specialized  physicians,  nurses,  respiratory  therapists,  that  can  go  on  a  moment's  notice  to  pick  up  any  child,  whether  it's  a  18- year- old  or  a  newborn.

 

00:27:07
Bill Curtis: Is  this  like  a  big  plastic  bubble  that  has  all  kinds  of  functionality  to  it  and  support  systems?  Tell me a little  about  that  transfer.  It  sounds  scary.

 

00:27:16
Philippe Friedlich: No,  our  transport  team  have  special  beds.  For  newborn,  there  are  special  transport  (inaudible)   that  has  the  entire  panoply  of  equipment  because  we  have  to  mimic  the  intensive  care  unit  in  that  transport.  We  can  transport  with  special  medications.  And  so  it's  really  a  team  that  does  an  amazing  job  under  very  difficult  circumstances,  because  you  can  imagine  the  helicopter,  although  it's  a pretty  big  helicopter,  the  space  is  constrained.  But  if  you  have  ever  seen  our  helicopter,  what  I  love  is  that  on  the  belly  of  the  helicopter,  there's  a  big  yellow  sign,  says " Baby  on  board,"  that  I  always  feel  really  good  when  I  see  that.

 

00:27:53
Steven Taback: I have  a  dangerous  question  to  ask  you.  Kind  of  diverting  completely  to  a  different  level,  neonatologists and  the  team  that  you  deal  with,  do  you  think  that  that  changes  or  influences  one's  perspective  on  being  pro- life  slash  pro- choice?  Does  it  have  any  impact,  or  do  you  think  that's  a  total  separate  issue  relative  to  a  woman's  choice?

 

00:28:14
Philippe Friedlich: As  healthcare  providers  and  physicians  especially  in  that  arena  or  where  we  cross  the  care  of  both  the  mom,  the  fetus  and the  newborn,  we  have  to  remember  that  the  fetus  really  cannot  talk  to  us.  It's  an  individual  that  ethically  does  not  have  his  own  voice.  And  so  regardless  of  your  political  or  ethical  views  on  the  matter,  I  think  the  best  approach  is  to  try  to  respect  the  parental  wishes.  We  spend  a  lot  of  time  and  are  not  gifted  to  have  people  like  ethicists  and  psychologists  because  the  reality  is  that  it  is  the  parents  that  are  going  to  have  to  live  for  a  long  time,  if  not  for  the  rest  of  their  life,  with  their  children,  and  for  us  to  be  making  decision  because  of  our belief,  I  don't  think  is  necessarily  the  best  approach.  I  think  the  best  approach  is  to  try  to  do  the  best  we  can  to  try  to  educate  families  about  the  things  that  we  know,  to  make  them  aware  of  the  things  that  we  don't  know, and  for  them  to  make  the  decision  about  possibility  of  terminating  pregnancy  or  not.

 

00:29:18
Bill Curtis: Let's  talk  a  little  bit about  pregnant  moms  and  some  of  the  things  that  you  have  found  more  recently  that  might  affect  the  outcome,  the  likelihood  of  a  healthy  baby.  And  I  realize  that  this  is  not  directly  your  specialty,  but  I  know  that  you've  seen  the  ramifications  of  the  wrong  moves,  and  there's  so  many  wives  tales.  Everybody  knows  that  pregnant  mothers  should  not  be  excessively  drinking  or  drinking  at  all,  too  much  coffee,  no  drugs.  That  goes  without  saying,  but  what  about  exercise?  Do  you  believe  in  a  certain  amount  of  rest  necessary?  What  are  some  advice  we  can  give  to  the  moms  that  are  listening?

00:29:53
Philippe Friedlich: Yeah, I would certainly tell them to listen to the obstetricians.  I  think  it  makes  sense  that  minimizing  stress, and  there  are  stresses  that  are  probably  not  good  for  a  pregnant  mother,  and  optimizing  healthy  lifestyle.  So  I  do  believe  that  exercise  or  meditation  or  wellness  is  very  important  for  the  mom  and  her  baby.
 Having  said  that,  I  think  we're  in  a  country  that  places  a  lot  of  emphasis  on  working  and  how  to  support  the  economy  of  having  a  family.  And  I  think  that  when  you  see  other  countries  where there  are  a  big  emphasis  in  trying  to  get  also  some  rest  for  the  pregnant  mother  and  minimize  the  stress  of  the  fetus,  I  think  that  it  makes  sense.  So  I  do  think that  we  should  look  at  optimizing  better  lifestyle  for  most  women.  I  think  in  this  country, there  are  large  gap  in  healthcare,  in  the  opportunity  to  have  access  to  care,  and  obviously  we  are  probably  the  country  has  the  best  resources  to  get  the  best  healthcare  for  some,  but  not  to  all.  And I think  that  unfortunately,  we  could  do  better.

 

00:31:00
Steven Taback: Do  you  think  that  autism  is  a  neonatal  issue?  When  I  was  growing  up  in  America,  every  once  in  a  while,  we  would  see  a  child,  one  of  our  classmates  that  obviously  was  on  the  spectrum.  It  was  maybe  one  per  class.  And  now  it  seems  so  pervasive.  Is  this  a  developmental  issue? Do  you  have  any  thoughts  of  theories  about  where  this  is  coming  from?  Why  is  it  so  prevalent,  and  is  it  in  your  realm,  or  is  it  more  even  before  your  realm  and  the  genetic  side  of  things?

 

00:31:29
Philippe Friedlich: Yeah,  I  think  the  spectrum  of  causation  for  autism,  I  believe  there's  a  genetic  basis  for  many.  I  believe  that  there  is  also  environmental  overlay,  probably  even  starting  in  utero.  We  know,  for  example,  that  pollution  mothers  are  exposed  to  impact  the  brain  of  babies.  Actually,  USC  is  doing  a  fascinating  study  looking  at  pregnant  women  and  where  they  are  living  and  traveling  to.  And  so  there  is  no  question  that  we  may  be  able  to  diagnose  or  classify  autism  maybe  differently  than  the  past.  But  I  do  think  that  our  environment  in  our  society  has  also  exposed  more  children  to  the  effect  of  developing  different  brain  disorders,  including  autism.

 

00:32:11
Steven Taback: So  very  clearly,  your  perspective,  do  vaccinations  have  anything  to  do  with  the  causation  of  autism?

 

00:32:18
Philippe Friedlich: No,  absolutely  not.

 

00:32:21
Steven Taback: If  there  was  some  way  on  this  show  to  keep  saying  that  several  times  so  that  the  general  public  would  hear  it  and  process  it,  that  would  be  wonderful.  But  I  appreciate  your  very  clear  and  succinct  answer.

 

00:32:31
Bill Curtis: Doctor,  if  you  could  pick  one  advancement  that  CHLA  has  made  in  your  specialty  over  the  last  decade,  is  there  something  that  you're  particularly  proud  of  that  you  can  tell  us  about  here?

 

00:32:43
Philippe Friedlich: There  are a few  in  my  field.  I  think  that  the  ability  to  care  for  babies with  very  fragile  lungs  has  been  very  rewarding.  We  often  care  for  babies  that  are  referred  to  us  because  their  lungs  are  very  injured  from  their  disease,  and  our  ability  to  be  expert  at  managing  those  special  ventilators  has  been  tremendous.

 

00:33:08
Bill Curtis: There's  actually  a  kind  of  a  ventilator  that  is  so  subtle  and  careful  that  it  can  handle  the  fragility  of  a  newborn  lung?

 

00:33:17
Philippe Friedlich: Yeah.  It's  obviously  the  machine,  but  it's  much  more  than  that.  It's  really  the  approach,  the  rationale  to  use  a  specific  modality.  We  have  very  specific  breathing  machines  that  can  deliver  very,  very  small  volumes  to  protect  the  lungs  at  a  very  fast  rate.  And  so  the  good  news  is  that  the  lungs  has  a  tremendous  ability  to  heal.  We  are  born  only  with  a  fraction  of  our  alveoli,  or  the  air  cells.  And  if  we  can  protect  them  from  further  injury,  we  know  that  the  lung  will  grow  back,  so  to  speak.  And  so  there  are  many  children  who  are  in  a  dire  situation  as  newborn,  and  with  those  special  techniques,  we  can  now  really  allow  them  to  have  normal  lives.  And  that  has  been  certainly  a  tremendous  feeling  of  success.

 

00:34:06
Bill Curtis: It's  a  truly  amazing  statement  about  our  society  and  nice  in  these  days  that  we're  living  in  that  you  can  have  a  bright  side  like  this.  And  I  know  that  I  have  spent  a  good  part  of  my  life  enamored  with  my  friend,  Dr.  Steve,  because  of  the  dedication  that  he  brings  to  his  science  and  his  art.  Dr.  Friedlich,  I  am  absolutely  honored  to  have  spent  the  last  hour  or  so  with  you  inspired.  And  I  think  that  what  you  do  in  your  hospital  is  really  a  bright  side  for  us.  And  thank  you  very  much  for  joining  us  here  today.

 

00:34:36
Steven Taback: I  echo  that  sentiment  as  well,  really.  Thank  you  for  being  here.  It's  been  truly  a  pleasure.

 

00:34:41
Philippe Friedlich: It  was  my  pleasure.  Thank  you so much.

 

00:34:43
Bill Curtis: Well,  that's  it  for  us  today.  Thank  you,  Dr.  Philippe  Friedlich and  Dr.  Steven  Taback.  Doctor,  how  can  people  follow  you  if  they  want  to  keep  track  of  your  activities  and  breakthroughs?

 

00:34:53
Philippe Friedlich: I  would  say  CHLA  has  a  great  website,  and  anyone  that wants  to  support  our  cause  to  deliver  better  care  and  better  outcomes,  I  would  just  engage  them  to  support  CHLA.

 

00:35:03
Bill Curtis: " Medicine,  We're  Still  Practicing"  is  produced  and  edited  by  A. J.  Mosley  Sound  Design  and  Sweetening  by  Michael  Kennedy.  Music  is  composed  and  performed  by  Celeste  and  Eric  Dick.  If  you  found  this  as  informative  as  I  did,  please  forward  the  link  to  your  friends,  and  don't  forget  to  subscribe.  Thanks  for  joining  us.  We'll  see  you  next  week.

 

00:35:36
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