Speaker 1: From CurtCo Media.
Bill Curtis: More strange days. COVID again on the rise. So many
Bill Curtis: important procedures and medical needs are still being allowed to fester
Bill Curtis: because people are afraid to go to their doctor, let
Bill Curtis: alone a hospital. So this pandemic is claiming lives from
Bill Curtis: people who don't even catch the disease. One specialty that
Bill Curtis: can't wait for COVID to be in our rear view
Bill Curtis: mirror is neonatology, the care necessary for some of the
Bill Curtis: smallest of us to survive catastrophic challenges. We have a
Bill Curtis: special guest today from a hospital that is leading the
Bill Curtis: country in the quest to place the odds in the
Bill Curtis: newborns' favor. Welcome to " Medicine, We're Still Practicing." I'm Bill
Bill Curtis: Curtis. Of course, first, my friend and cohost, Dr. Steven
Bill Curtis: Taback. He's the quadruple board- certified doctor of internal medicine,
Bill Curtis: pulmonary disease, critical care and neuro- critical care. These days,
Bill Curtis: he continues to fight on the front lines of the
Bill Curtis: COVID battle in California, for which we are eternally grateful.
Bill Curtis: Steve, how you doing?
Steven Taback: I'm well. Thank you. It's good to be here, Bill.
Bill Curtis: I'm sure you've heard of Children's Hospital of Los Angeles,
Bill Curtis: known as CHLA. U. S. News and World Report has
Bill Curtis: consistently ranked CHLA in the top five nationally and the
Bill Curtis: number one pediatric hospital in California for 30 years running.
Bill Curtis: This remarkable nonprofit children's care hospital is nationally known for
Bill Curtis: neonatal research and care that is funded entirely by generous
Bill Curtis: philanthropists. Dr. Philippe Friedlich is Chief of Neonatology at Children's
Bill Curtis: Hospital. He is also co- director of the Fetal and
Bill Curtis: Neonatal Institute, and he is professor of Clinical Pediatrics and
Bill Curtis: Surgery at the renowned Keck School of Medicine at USC,
Bill Curtis: where he's published over 150 abstracts, peer review articles and
Bill Curtis: book chapters. Dr. Friedlich is a rock star in one of
Bill Curtis: the world's most complicated, pressure- filled and delicate specialties that
Bill Curtis: include newborn respiratory failures, newborn pulmonary hypertension, even surgery on
Bill Curtis: unborn babies. Can you imagine? Welcome, Dr. Philippe Friedlich. It is
Bill Curtis: an honor to have you here tonight.
Philippe Friedlich: Thank you for having me.
Bill Curtis: So doctor, can you just bring our listeners up to
Bill Curtis: speed on CHLA and your mission there?
Philippe Friedlich: Children's Hospital of Los Angeles' mission is to care for
Philippe Friedlich: sick children. No matter what their background, their cultural background
Philippe Friedlich: or insurance they have, we are a place to care
Philippe Friedlich: for families and children and babies when there's no other
Philippe Friedlich: place that could care for them.
Bill Curtis: Are we talking about one of the few medical specialties
Bill Curtis: that truly couldn't wait for COVID to pause?
Philippe Friedlich: That's a great question. Fortunately, for many children, COVID has not
Philippe Friedlich: been as impactful. There are some babies and children that are sick, but
Philippe Friedlich: by far, unless we compare it to adults, we are
Philippe Friedlich: fairly lucky so far.
Bill Curtis: So we're not going to spend the whole show on
Bill Curtis: COVID because frankly, I think people want to know much
Bill Curtis: more about your specialty, but maybe you could tell us
Bill Curtis: a little about what kind of a regimen has CHLA
Bill Curtis: developed uniquely for this pandemic, and what are some of
Bill Curtis: the special things that you do at your hospital to manage this?
Philippe Friedlich: A lot of it has to do with making sure
Philippe Friedlich: that we can screen families and staff when they arrive
Philippe Friedlich: at the hospital and make sure that the environment for caring
Philippe Friedlich: for those children, regardless of the reason why they're in
Philippe Friedlich: the hospital, is optimal. And so the hospital has spent
Philippe Friedlich: significant resources to ensure that we screen families and visitors
Philippe Friedlich: and parents when they arrive.
Bill Curtis: Psychologically, how do you get your clientele to feel safe
Bill Curtis: under these circumstances?
Philippe Friedlich: That has been a (inaudible) challenge. As you can
Philippe Friedlich: imagine, a lot of families are scared to even go
Philippe Friedlich: close to a hospital. So certainly our data suggesting that
Philippe Friedlich: we can provide a safest environment to bring sick children
Philippe Friedlich: and care for them, but it is a concern, so now
Philippe Friedlich: we can see that visits to the emergency room are
Philippe Friedlich: significantly down. Obviously a lot of the outpatients clinic, I've
Philippe Friedlich: had to restructure their environment. But I think that honest
Philippe Friedlich: conversations with family and trying to make sure that vulnerable
Philippe Friedlich: children still can get the care they need so they don't
Philippe Friedlich: have complications from their disorders and diseases, or we try
Philippe Friedlich: to do our best to get the message across.
Steven Taback: In your infected pregnant women, what percentage of the infection
Steven Taback: will affect the neonates?
Philippe Friedlich: Well, it depends how you define " affect the neonates" that
Philippe Friedlich: we have not seen certainly in our area any children
Philippe Friedlich: or neonates infected with the virus. There's very few reports
Philippe Friedlich: in the world around that. What we do see though, is mother who
Philippe Friedlich: gets sick with the COVID- 19 illness and systemic inflammatory response,
Philippe Friedlich: and then for maternal reason, the baby has to be
Philippe Friedlich: delivered early.
Steven Taback: So more of a high- risk delivery, as opposed to
Steven Taback: a neonatal issue, per se.
Philippe Friedlich: Right. And so premature babies that are born because the
Philippe Friedlich: mother is sick is something that we see. They're not sick
Philippe Friedlich: with COVID, but they have all the risks of complications
Philippe Friedlich: from the prematurity.
Bill Curtis: You use the term " premature," and for our listeners, we
Bill Curtis: think we know what that means, but can you define
Bill Curtis: it` at what level does it become a problem? And I
Bill Curtis: also understand that your hospital very often doesn't get the
Bill Curtis: babies until there's a problem. You just suddenly get a
Bill Curtis: call that there's a need.
Philippe Friedlich: That's correct. Prematurity is defined in general in any pregnancy
Philippe Friedlich: that does not reach 38 weeks, but obviously there are gradation of
Philippe Friedlich: prematurity. And in this country, we have made remarkable advances in
Philippe Friedlich: the support of premature infants. Right now, we care routinely
Philippe Friedlich: for babies at the limited viability, and that's around 23
Philippe Friedlich: weeks of gestation. So before 28 weeks, it's fair to
Philippe Friedlich: say that those babies are at the highest risk of complications,
Philippe Friedlich: and after 28 weeks, the outcomes in this country are
Philippe Friedlich: really, really good.
Bill Curtis: What kind of complications do you deal with when it's
Bill Curtis: actually 10 weeks too early?
Philippe Friedlich: There are lots of complications that those babies can be
Philippe Friedlich: subjected to. There are complications involving the brain, so these babies'
Philippe Friedlich: brains are very fragile, and they can have significant damages
Philippe Friedlich: to their brain. But all the organs are very fragile.
Philippe Friedlich: The good news is that most babies do quite well and
Philippe Friedlich: can recover. What we worry the most is obviously the
Philippe Friedlich: organs that once damaged, don't recover, such as the brain
Philippe Friedlich: or the eyes. But by far, with the technology that
Philippe Friedlich: we have in this country, most babies do quite well.
Bill Curtis: I watched one of your videos where you were talking
Bill Curtis: about brain issues and that you have a procedure whereby you
Bill Curtis: cool brains inside an MRI. Can you describe that a bit?
Philippe Friedlich: Yeah. What you're referring to is therapy called " select hypothermia."
Philippe Friedlich: So it's a technique that is used for larger baby.
Philippe Friedlich: So those are not premature babies, but those are babies
Philippe Friedlich: who have had complication in the last stage of labor, when
Philippe Friedlich: the mom is in labor, and have a sudden lack
Philippe Friedlich: of oxygen or blood flow. And so this is very
Philippe Friedlich: similar to the techniques that are used in adults when they have strokes
Philippe Friedlich: to try to minimize the brain injury. And so in
Philippe Friedlich: newborns, for the last now 10 years, we have used
Philippe Friedlich: this technique to cool the baby's brain for around three
Philippe Friedlich: days in the hope that we can minimize the injury
Philippe Friedlich: that is involved with a lack of oxygen or blood
Philippe Friedlich: flow during the last stage of labor. The idea is
Philippe Friedlich: to get the brain temperature in a selective range. And
Philippe Friedlich: you mentioned MRI before. We were a pioneer in developing
Philippe Friedlich: techniques where we actually can measure the brain temperature of
Philippe Friedlich: babies doing cooling with MRI technology.
Steven Taback: What is your end point? For us, in post- cardiac
Steven Taback: arrest, it's 24 hours at the target temperature. What's the
Steven Taback: protocol for a brain- injured or a hypoxemic infant?
Philippe Friedlich: Yeah. So for babies that suffer from HIE, or hypoxemic- ischemic encephalopathy,
Philippe Friedlich: we cool them for 72 hours if they can tolerate that length of time.
Bill Curtis: My goodness. I also understand that premature babies have all kinds of pulmonary issues,
Bill Curtis: including, in one of your videos, you actually said they
Bill Curtis: forget to breathe when they're sub 34 weeks. But I
Bill Curtis: was told that you have an expertise there at the
Bill Curtis: hospital where you incorporate the use of an ECMO machine
Bill Curtis: for certain babies. Can you describe that?
Philippe Friedlich: Yeah. So ECMO stands for " extracorporeal membrane oxygenation."
Bill Curtis: Easy for you to say.
Philippe Friedlich: It's a technique that actually is used in adult and in
Philippe Friedlich: pediatrics and in neonates. It actually was used since the mid-
Philippe Friedlich: seventies and eighties, and in California was actually some of
Philippe Friedlich: the first sites. And since 1997, we actually have used
Philippe Friedlich: the technique at CHLA. It's a technique that is used
Philippe Friedlich: in larger baby. You have to be at least two kilos
Philippe Friedlich: and at least 34 weeks of gestation at birth to
Philippe Friedlich: be able to be enrolled in the programs. It's used
Philippe Friedlich: for babies who have significant and severe respiratory or cardiac insufficiency,
Bill Curtis: For the layman's term, is it you're actually oxygenating the blood?
Philippe Friedlich: Yeah. We take over both the heart and the lungs
Philippe Friedlich: and wait for their recovery while the machine is doing
Philippe Friedlich: the work for the baby. It's a very similar machine
Philippe Friedlich: that adults use, for example, for heart- lung bypass surgery.
Bill Curtis: And Steve, I think you mentioned in the past that
Bill Curtis: you guys, that Provenance have been known to use ECMO
Bill Curtis: when necessary for COVID patients.
Steven Taback: We do. I think we've used ECMO once for COVID, but
Steven Taback: we've used ECMO quite a bit during the influenza pandemic.
Steven Taback: And we've had great results during influenza because the lung
Steven Taback: heals very well, even after 60 days. We had good
Steven Taback: results with one COVID patient at St. Joe's as well,
Steven Taback: but it is used frequently for COVID worldwide. And we've
Steven Taback: had a fairly robust-- for a private community hospital, that is--
Steven Taback: we've had a fairly robust ECMO program for the past
Steven Taback: several years.
Bill Curtis: Doctor, we're going to be asking you about a number
Bill Curtis: of the issues that you're dealing with at CHLA, but I
Bill Curtis: wonder if we could talk about one in particular that
Bill Curtis: I found fascinating in some of the videos that you
Bill Curtis: have produced, where they're actually unborn babies, where you've had
Bill Curtis: to perform something you called " keyhole surgery repairs," as in
Bill Curtis: spinal bifida repair, for a developing fetus. Sounds pretty scary.
Philippe Friedlich: Yeah. I'm very lucky to be part of a new
Philippe Friedlich: institute that brings together all the subspecialty, including fetal surgery.
Philippe Friedlich: And at CHLA and at USC, we have Dr. Ramen Chmait,
Philippe Friedlich: who's a fetal surgeon, and he's the one actually that
Philippe Friedlich: performed the surgery. Dr. Chmait is internationally recognized and has
Philippe Friedlich: the expertise to really, with minimal techniques, to approach the
Philippe Friedlich: fetus through the mom's abdomen, place cameras and instruments, and
Philippe Friedlich: now can actually repair those neural tube defects, so the
Philippe Friedlich: spinal cord defects, early on, so that we can protect
Philippe Friedlich: the spinal cord from being exposed to the amniotic fluid.
Philippe Friedlich: There's a lot of evidence that it is that exposure
Philippe Friedlich: in utero over time that can really scar and injure the
Philippe Friedlich: spinal cord and cause scar tissues, and the idea is
Philippe Friedlich: we can cover the defect, then the longterm outcomes will
Philippe Friedlich: be better. And in fact, there's quite a bit of
Philippe Friedlich: an evidence that the longterm outcomes such as the ability to walk
Philippe Friedlich: independently, bladder function and things like that are better. It
Philippe Friedlich: obviously comes at significant risk. Obviously you have to do
Philippe Friedlich: the surgery and place the mother under anesthesia while she's
Philippe Friedlich: pregnant. You have to enter the uterus with cameras, and
Philippe Friedlich: that can sometimes cause preterm labor. So it is not
Philippe Friedlich: a technique that is yet completely proven, and we are
Philippe Friedlich: part of multi- center trials to show hopefully that we
Philippe Friedlich: can demonstrate its usefulness and its safety of such procedures.
Steven Taback: Takes a very courageous staff, and also a very courageous mother
Steven Taback: to undergo that kind of testing.
Bill Curtis: So what are some of the other focuses where you
Bill Curtis: find yourselves with some pretty remarkable challenges, and CHLA and you and your
Bill Curtis: fellow doctors have attacked the problem, and you feel there
Bill Curtis: have been significant advancements in the recent years?
Philippe Friedlich: There are many, and I'm glad you asked the questions.
Philippe Friedlich: You know, I think that nearly 20 years ago, we established the fetal-
Philippe Friedlich: neonatal institute, and that was one of the first in
Philippe Friedlich: the country that was establishing a comprehensive team to care
Philippe Friedlich: for not only the mother, her pregnancy, care for the
Philippe Friedlich: fetus and also plan that postnatal care. There are very
Philippe Friedlich: few centers in the country that can do it and do it
Philippe Friedlich: well. There are a few examples that I could name, for example,
Philippe Friedlich: our ability now to really diagnose very specifically what is
Philippe Friedlich: the specific problem in a fetus. Our cardiologists and fetal
Philippe Friedlich: cardiologists now can enter and repair some of the baby's
Philippe Friedlich: heart valve around 20 to 25 weeks of gestation. So
Philippe Friedlich: our team at CHLA has done that. And to me,
Philippe Friedlich: that's amazing when you think that a baby's heart is
Philippe Friedlich: probably smaller than the nail of my little finger, and
Philippe Friedlich: they are able to place a catheter and open a valve.
Bill Curtis: Is that done with the DaVinci robot, or that's actually
Bill Curtis: done by hand?
Philippe Friedlich: No, again, they use technique where they enter the fetal
Philippe Friedlich: circulation through the umbilical vein and vessels. And they are
Philippe Friedlich: able to guide this wire into the baby's heart, just
Philippe Friedlich: like adults undergo now noninvasive techniques for heart repair. So
Philippe Friedlich: I think that that is something that is pushing the
Philippe Friedlich: envelope, but daily, we actually now are able to get
Philippe Friedlich: to the specific diagnosis before a baby's born so that
Philippe Friedlich: we can prepare both the family, the site of delivery,
Philippe Friedlich: and be present to avoid all the complication that those
Philippe Friedlich: infants used to be exposed to, and then bring them
Philippe Friedlich: to CHLA so that our surgeons and our subspecialists can
Philippe Friedlich: do the right thing at the right time and then
Philippe Friedlich: avoid a series of complications that were unavoidable in the
Philippe Friedlich: past. And now these children can live life without the
Philippe Friedlich: sequela of their disorder. And that's something that is so
Philippe Friedlich: satisfying and that's changed so rapidly. I've been in the
Philippe Friedlich: field 20 years now. And in those 20 years, every
Philippe Friedlich: five years, I see huge change in those outcomes.
Steven Taback: But on a personal note, I remember back in medical
Steven Taback: school, when you're trying to figure out, " What is going
Steven Taback: to be my specialty of choice?" And I have found that
Steven Taback: most of my colleagues were making a choice based on
Steven Taback: deduction, and they knew exactly which fields they did not
Steven Taback: want to go into. And it's certainly for me, it
Steven Taback: had anything to do with children because treating children terrify
Steven Taback: the heck out of me. The idea of possibly doing
Steven Taback: harm is always bad, but to a child is something
Steven Taback: that I couldn't even conceive of. What got you interested
Steven Taback: in the field of neonatology? What made you make that
Steven Taback: decision to go completely opposite direction that I went?
Philippe Friedlich: It's a question that I often get asked, and I
Philippe Friedlich: think many physicians, it was the relationship. I had not thought of neonatology
Philippe Friedlich: as the career, was late even to pediatrics. I thought
Philippe Friedlich: I was going to be a surgeon. And then for
Philippe Friedlich: reason that I cannot even explain, I one day got
Philippe Friedlich: the opportunity to meet Dr. Robert deLemos, who was the
Philippe Friedlich: Chief of Neonatology at USC. And he just had finished
Philippe Friedlich: a series of years developing high- frequency ventilation. He was
Philippe Friedlich: one of the forefathers, and this is the kind of relationship
Philippe Friedlich: that in a couple of days, I knew that's what I
Philippe Friedlich: wanted to do for the rest of my life. So I've
Philippe Friedlich: been very blessed with many relationships during my training and
Philippe Friedlich: since then, and one of the reasons that I've never left
Philippe Friedlich: CHLA since the early days of my internship.
Bill Curtis: In past episodes, Dr. Steve and I have talked to
Bill Curtis: people about robotic mechanized doctors, and in your specialty, I
Bill Curtis: can't imagine the training and expertise and very soul that
Bill Curtis: must go into communicating with the parents, just managing that
Bill Curtis: relationship. It's certainly something that a robot's never going to be able to
Bill Curtis: do. How did you learn to do that well, or
Bill Curtis: is there such a thing?
Philippe Friedlich: Yeah, I think that you're posing a really difficult question to
Philippe Friedlich: ask. I think there are some people that naturally are
Philippe Friedlich: more empathetic than others, and certainly that helps. For others,
Philippe Friedlich: hopefully, they can learn some of those skills. It does
Philippe Friedlich: help, I think, to have your own family. When I
Philippe Friedlich: think about how I used to address parents when I didn't
Philippe Friedlich: have that experience, they don't keep you that necessarily in medical
Philippe Friedlich: school, you're a little bit more in tune to how difficult
Philippe Friedlich: it is to worry about your child, even if it's
Philippe Friedlich: a simple fever or cough, to a parent, whether it's
Philippe Friedlich: the unknown and that constant worry. And so when you're
Philippe Friedlich: exposed to that, I think that you become a better
Philippe Friedlich: doctor, and this is a field where you have to
Philippe Friedlich: be really in tune with the family. It's amazing, in
Philippe Friedlich: fact, that as much as we have improved our medicine
Philippe Friedlich: or our techniques and our technology, there is one fact
Philippe Friedlich: that still to this day just astonished me, is that
Philippe Friedlich: the best predictors, longterm neurodevelopmental outcome in premature infant, is
Philippe Friedlich: actually maternal involvement in education.
Steven Taback: Wow.
Philippe Friedlich: And so to be able to bring the family early
Philippe Friedlich: on at the bedside so that we can really optimize
Philippe Friedlich: the bonding is something that cannot be dismissed. I've witnessed
Philippe Friedlich: some events that the medicine cannot explain. So I think
Philippe Friedlich: we need to be a little bit humble and make
Philippe Friedlich: sure that we communicate with families so that they understand
Philippe Friedlich: that their role at the bedside is just as important
Philippe Friedlich: as everything else.
Steven Taback: Outside of medicine, would you then advocate that the mother
Steven Taback: stay at home during the early formative years for the
Steven Taback: child? We live in a society of two working parents.
Steven Taback: You think that that has a negative impact?
Philippe Friedlich: I think that the involvement of the mother or the
Philippe Friedlich: extent of the family around the child is they are
Philippe Friedlich: important. If you look at and compare other countries and
Philippe Friedlich: their social environment, I think it's fair to say that I
Philippe Friedlich: am not sure that in this country, we have the
Philippe Friedlich: best model. So I do believe that a child should
Philippe Friedlich: have a social environment that is robust, that is interactive with
Philippe Friedlich: family members.
Bill Curtis: We're going to talk about that in just a minute. We'll be right back
Bill Curtis: with Dr. Philippe Friedlich and Dr. Steven Taback.
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Bill Curtis: We're back with Dr. Philippe Friedlich from CHLA and Dr. Steven
Bill Curtis: Taback. So before the break, doctor, you were talking about
Bill Curtis: witnessing some maternal effect, especially in cases where there were
Bill Curtis: babies at risk, that you said medicine could not explain.
Bill Curtis: Can you be more specific?
Philippe Friedlich: Yeah. I think that despite all the medical intervention, then the medical
Philippe Friedlich: discoveries that have helped tremendously in the survival of our
Philippe Friedlich: most fragile infant, there are still an aspect of bonding
Philippe Friedlich: maternal or even paternal involvement that has shown to improve
Philippe Friedlich: outcomes of babies, especially in our intensive care units. A
Philippe Friedlich: mother's voice, the mother's touch, is really, really important, and what we
Philippe Friedlich: see in the intensive care arena is that obviously, one of
Philippe Friedlich: the first reaction from the family is to get very
Philippe Friedlich: scared and to withdraw from sometimes coming at the bedside,
Philippe Friedlich: talking to their child or touching their child. And it's
Philippe Friedlich: been shown that mothers who speak to their premature infant
Philippe Friedlich: in the ICU, sing or talk to them, have better
Philippe Friedlich: outcomes, even if you control for all other variables.
Bill Curtis: Is there any positive impact that daddies have, or is
Bill Curtis: that just all about earning college tuition for sometime later?
Philippe Friedlich: No, the father is also very important. In the care,
Philippe Friedlich: we encourage fathers to bond with their child as well.
Philippe Friedlich: As a matter of fact, you may have heard of
Philippe Friedlich: the term " kangaroo care," and that's when we really encourage
Philippe Friedlich: families to actually have skin- to- skin time with their
Philippe Friedlich: baby. And so it is very powerful when we see
Philippe Friedlich: a father that is also doing that kind of bonding.
Bill Curtis: So is it still practiced that after birth, babies are
Bill Curtis: taken to a very brightly lit room where they're watched
Bill Curtis: in plastic bassinets and eventually get back in their mother's
Bill Curtis: hands, but is that still practiced?
Philippe Friedlich: We try very hard to actually bond the baby with
Philippe Friedlich: their mother at the time of delivery, even if they
Philippe Friedlich: are premature, or even if they have significant other conditions,
Philippe Friedlich: because we believe that that first few minutes with the mom
Philippe Friedlich: can change many things, both social bonding, but has been
Philippe Friedlich: shown also that even the microbiome of those infants can
Philippe Friedlich: be altered. Having said that, we have sometimes to weigh
Philippe Friedlich: the consequence of, and sometimes have to, take the baby
Philippe Friedlich: away fairly quickly.
Steven Taback: Anything in the cutting edge over at CHLA in terms of
Steven Taback: brain development that may be going on other than just
Steven Taback: the nurturing bond of a mother and baby?
Philippe Friedlich: Yes, there are, for example, different approach to manipulate the
Philippe Friedlich: survival of neurons. We are using now some medications that
Philippe Friedlich: are called anti- apoptotic drugs. For example, erythropoietin is now
Philippe Friedlich: given to some high- risk newborn to try to minimize
Philippe Friedlich: brain damage. So there are things that we are certainly studying
Philippe Friedlich: and evaluating in terms of optimizing the chance of babies
Philippe Friedlich: having normal outcomes for a long time. We didn't know,
Philippe Friedlich: for example, how much oxygen was necessary for better outcome.
Philippe Friedlich: And you probably have heard that actually premature infants are
Philippe Friedlich: kept in a lower oxygen range than older children. And that has
Philippe Friedlich: changed a lot of their outcomes and decreased the number
Philippe Friedlich: of babies who have blindness as sequela from their disorders.
Steven Taback: Are neonates more responsive to stem cell therapy?
Philippe Friedlich: I'm glad you asked. It's an area that really is
Philippe Friedlich: uncharted, yet there are some centers in the country that
Philippe Friedlich: are looking at the feasibility of stem cell research in
Philippe Friedlich: premature infants and in older children. USC is, for example,
Philippe Friedlich: looking at cardiac stem cells. Our urologists are doing tissue
Philippe Friedlich: engineering with stem cells. It's, I think, going to be
Philippe Friedlich: probably big time in the next decade, but not yet.
Bill Curtis: What percentage of babies these days are born prematurely?
Philippe Friedlich: Too many, that's for sure, especially in this country when
Philippe Friedlich: you compare with other countries that there are of similar economic
Philippe Friedlich: ability. One of the things that we say, around 10%
Philippe Friedlich: of babies are born prematurely, so if you believe that there
Philippe Friedlich: are 4 million babies born every year in this country,
Philippe Friedlich: that's 400,000. Now, the good news is that most of
Philippe Friedlich: those babies are the big premies, and they do pretty
Philippe Friedlich: well. Having said that, there's been a big push in California,
Philippe Friedlich: in this country by agencies, such as the Association of
Philippe Friedlich: Gynecology and Obstetrics and the American Academy of Pediatrics, to
Philippe Friedlich: really mandate hospitals and physicians to publish, for example, their C-
Philippe Friedlich: section rates. And the impetus for that is really to
Philippe Friedlich: try to minimize any birth before 39 weeks. Sometimes, parents
Philippe Friedlich: and family, or even physicians would plan a delivery just
Philippe Friedlich: before 39 weeks. And although those babies do quite well,
Philippe Friedlich: they don't do as well as a full- term, 39-
Philippe Friedlich: week baby. If you compare, for example, 38- week, just one
Philippe Friedlich: week shy of being 39, those babies don't do as
Philippe Friedlich: well later on in school and things like that. So
Philippe Friedlich: there has been a big push to minimize what we
Philippe Friedlich: can prevent. So we can't prevent early birth on the
Philippe Friedlich: basis of just scheduling a C- section because of family
Philippe Friedlich: intervention, and that is going to have a significant effect.
Philippe Friedlich: We still are not good enough to prevent those very
Philippe Friedlich: preterm births, but preventing unnecessary preterm births is going to
Philippe Friedlich: have a great impact in this country.
Bill Curtis: Do you get advance knowledge that you're about to get
Bill Curtis: a client? Does the delivery team know that a baby
Bill Curtis: is about to be born with severe challenges and that
Bill Curtis: they're going to have to transfer the baby to you?
Bill Curtis: Can you describe that whole moment, as well as how
Bill Curtis: do you transfer a baby that's in that kind of
Bill Curtis: shape over to you guys?
Philippe Friedlich: So most of the time, we obviously get advance notice, and if
Philippe Friedlich: we know of a prenatal condition, then we have an
Philippe Friedlich: entire team that is dedicated to, to facilitate the transport. But
Philippe Friedlich: as soon as the baby is stabilized in the community
Philippe Friedlich: hospital, or one of our partnership hospitals, depending on the
Philippe Friedlich: distance, we have at CHLA two helicopters that are ready
Philippe Friedlich: on a moment's notice, and actually, we are very proud
Philippe Friedlich: that we can dispatch a team in less than 30
Philippe Friedlich: minutes anywhere. We have a special transport team with specialized
Philippe Friedlich: physicians, nurses, respiratory therapists, that can go on a moment's
Philippe Friedlich: notice to pick up any child, whether it's a 18- year-
Philippe Friedlich: old or a newborn.
Bill Curtis: Is this like a big plastic bubble that has all
Bill Curtis: kinds of functionality to it and support systems? Tell me a little about
Bill Curtis: that transfer. It sounds scary.
Philippe Friedlich: No, our transport team have special beds. For newborn, there
Philippe Friedlich: are special transport (inaudible) that has the entire panoply
Philippe Friedlich: of equipment because we have to mimic the intensive care
Philippe Friedlich: unit in that transport. We can transport with special medications.
Philippe Friedlich: And so it's really a team that does an amazing
Philippe Friedlich: job under very difficult circumstances, because you can imagine the
Philippe Friedlich: helicopter, although it's a pretty big helicopter, the space is constrained.
Philippe Friedlich: But if you have ever seen our helicopter, what I
Philippe Friedlich: love is that on the belly of the helicopter, there's
Philippe Friedlich: a big yellow sign, says " Baby on board," that I
Philippe Friedlich: always feel really good when I see that.
Steven Taback: I have a dangerous question to ask you. Kind of diverting
Steven Taback: completely to a different level, neonatologists and the team that you
Steven Taback: deal with, do you think that that changes or influences
Steven Taback: one's perspective on being pro- life slash pro- choice? Does
Steven Taback: it have any impact, or do you think that's a
Steven Taback: total separate issue relative to a woman's choice?
Philippe Friedlich: As healthcare providers and physicians especially in that arena or
Philippe Friedlich: where we cross the care of both the mom, the
Philippe Friedlich: fetus and the newborn, we have to remember that the fetus
Philippe Friedlich: really cannot talk to us. It's an individual that ethically
Philippe Friedlich: does not have his own voice. And so regardless of
Philippe Friedlich: your political or ethical views on the matter, I think
Philippe Friedlich: the best approach is to try to respect the parental
Philippe Friedlich: wishes. We spend a lot of time and are not
Philippe Friedlich: gifted to have people like ethicists and psychologists because the
Philippe Friedlich: reality is that it is the parents that are going
Philippe Friedlich: to have to live for a long time, if not
Philippe Friedlich: for the rest of their life, with their children, and
Philippe Friedlich: for us to be making decision because of our belief, I
Philippe Friedlich: don't think is necessarily the best approach. I think the
Philippe Friedlich: best approach is to try to do the best we
Philippe Friedlich: can to try to educate families about the things that
Philippe Friedlich: we know, to make them aware of the things that
Philippe Friedlich: we don't know, and for them to make the decision about
Philippe Friedlich: possibility of terminating pregnancy or not.
Bill Curtis: Let's talk a little bit about pregnant moms and some of
Bill Curtis: the things that you have found more recently that might
Bill Curtis: affect the outcome, the likelihood of a healthy baby. And
Bill Curtis: I realize that this is not directly your specialty, but
Bill Curtis: I know that you've seen the ramifications of the wrong
Bill Curtis: moves, and there's so many wives tales. Everybody knows that
Bill Curtis: pregnant mothers should not be excessively drinking or drinking at
Bill Curtis: all, too much coffee, no drugs. That goes without saying,
Bill Curtis: but what about exercise? Do you believe in a certain
Bill Curtis: amount of rest necessary? What are some advice we can
Bill Curtis: give to the moms that are listening?
Philippe Friedlich: Yeah, I would certainly tell them to listen to the obstetricians. I think it makes sense that minimizing stress, and there
Philippe Friedlich: are stresses that are probably not good for a pregnant
Philippe Friedlich: mother, and optimizing healthy lifestyle. So I do believe that
Philippe Friedlich: exercise or meditation or wellness is very important for the
Philippe Friedlich: mom and her baby. Having said that, I think we're
Philippe Friedlich: in a country that places a lot of emphasis on
Philippe Friedlich: working and how to support the economy of having a
Philippe Friedlich: family. And I think that when you see other countries
Philippe Friedlich: where there are a big emphasis in trying to get also
Philippe Friedlich: some rest for the pregnant mother and minimize the stress
Philippe Friedlich: of the fetus, I think that it makes sense. So
Philippe Friedlich: I do think that we should look at optimizing better lifestyle
Philippe Friedlich: for most women. I think in this country, there are large
Philippe Friedlich: gap in healthcare, in the opportunity to have access to
Philippe Friedlich: care, and obviously we are probably the country has the
Philippe Friedlich: best resources to get the best healthcare for some, but
Philippe Friedlich: not to all. And I think that unfortunately, we could do better.
Steven Taback: Do you think that autism is a neonatal issue? When
Steven Taback: I was growing up in America, every once in a
Steven Taback: while, we would see a child, one of our classmates
Steven Taback: that obviously was on the spectrum. It was maybe one
Steven Taback: per class. And now it seems so pervasive. Is this
Steven Taback: a developmental issue? Do you have any thoughts of theories about
Steven Taback: where this is coming from? Why is it so prevalent,
Steven Taback: and is it in your realm, or is it more
Steven Taback: even before your realm and the genetic side of things?
Philippe Friedlich: Yeah, I think the spectrum of causation for autism, I
Philippe Friedlich: believe there's a genetic basis for many. I believe that
Philippe Friedlich: there is also environmental overlay, probably even starting in utero.
Philippe Friedlich: We know, for example, that pollution mothers are exposed to
Philippe Friedlich: impact the brain of babies. Actually, USC is doing a
Philippe Friedlich: fascinating study looking at pregnant women and where they are
Philippe Friedlich: living and traveling to. And so there is no question
Philippe Friedlich: that we may be able to diagnose or classify autism
Philippe Friedlich: maybe differently than the past. But I do think that
Philippe Friedlich: our environment in our society has also exposed more children
Philippe Friedlich: to the effect of developing different brain disorders, including autism.
Steven Taback: So very clearly, your perspective, do vaccinations have anything to
Steven Taback: do with the causation of autism?
Philippe Friedlich: No, absolutely not.
Steven Taback: If there was some way on this show to keep
Steven Taback: saying that several times so that the general public would
Steven Taback: hear it and process it, that would be wonderful. But
Steven Taback: I appreciate your very clear and succinct answer.
Bill Curtis: Doctor, if you could pick one advancement that CHLA has
Bill Curtis: made in your specialty over the last decade, is there
Bill Curtis: something that you're particularly proud of that you can tell
Bill Curtis: us about here?
Philippe Friedlich: There are a few in my field. I think that the ability
Philippe Friedlich: to care for babies with very fragile lungs has been very
Philippe Friedlich: rewarding. We often care for babies that are referred to
Philippe Friedlich: us because their lungs are very injured from their disease,
Philippe Friedlich: and our ability to be expert at managing those special
Philippe Friedlich: ventilators has been tremendous.
Bill Curtis: There's actually a kind of a ventilator that is so
Bill Curtis: subtle and careful that it can handle the fragility of
Bill Curtis: a newborn lung?
Philippe Friedlich: Yeah. It's obviously the machine, but it's much more than
Philippe Friedlich: that. It's really the approach, the rationale to use a
Philippe Friedlich: specific modality. We have very specific breathing machines that can
Philippe Friedlich: deliver very, very small volumes to protect the lungs at
Philippe Friedlich: a very fast rate. And so the good news is
Philippe Friedlich: that the lungs has a tremendous ability to heal. We
Philippe Friedlich: are born only with a fraction of our alveoli, or
Philippe Friedlich: the air cells. And if we can protect them from
Philippe Friedlich: further injury, we know that the lung will grow back,
Philippe Friedlich: so to speak. And so there are many children who
Philippe Friedlich: are in a dire situation as newborn, and with those
Philippe Friedlich: special techniques, we can now really allow them to have
Philippe Friedlich: normal lives. And that has been certainly a tremendous feeling
Philippe Friedlich: of success.
Bill Curtis: It's a truly amazing statement about our society and nice
Bill Curtis: in these days that we're living in that you can
Bill Curtis: have a bright side like this. And I know that
Bill Curtis: I have spent a good part of my life enamored
Bill Curtis: with my friend, Dr. Steve, because of the dedication that
Bill Curtis: he brings to his science and his art. Dr. Friedlich,
Bill Curtis: I am absolutely honored to have spent the last hour
Bill Curtis: or so with you inspired. And I think that what
Bill Curtis: you do in your hospital is really a bright side
Bill Curtis: for us. And thank you very much for joining us
Bill Curtis: here today.
Steven Taback: I echo that sentiment as well, really. Thank you for
Steven Taback: being here. It's been truly a pleasure.
Philippe Friedlich: It was my pleasure. Thank you so much.
Bill Curtis: Well, that's it for us today. Thank you, Dr. Philippe
Bill Curtis: Friedlich and Dr. Steven Taback. Doctor, how can people follow you
Bill Curtis: if they want to keep track of your activities and breakthroughs?
Philippe Friedlich: I would say CHLA has a great website, and anyone
Philippe Friedlich: that wants to support our cause to deliver better care and
Philippe Friedlich: better outcomes, I would just engage them to support CHLA.
Bill Curtis: " Medicine, We're Still Practicing" is produced and edited by A.
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