Breastfeeding and SIDS prevention - and sleep apnea? and orthodontics?

Brian Palmer is quite an interesting dentist. He has an entire website (albiet in premodern html) devoted to the importance of breastfeeding. He maintains that infant feeding techniques have an enormous impact on the human oral cavity and airway, which in turn has an effect on infant problems such as SIDS and ear infections, adolescent problems such as overbites, and even adult disorders such as obstructive sleep apnea.

I won't get into all of his hypotheses here, but I was interested in what he says about SIDS. Human babies have unique mouths and airways. Their epiglottis, or the flap that covers the airway when you swallow, is high up in the back of the mouth. It comes into contact with the soft palate, or the soft back of the roof of the mouth. The soft human nipple encourages the tongue and lower jaw to come forward in the mouth, and pulls the epiglottis up, reinforcing its position.

The epiglottis is that thin white thing clamping onto the back of the roof of the mouth, preserving airflow from the nose to the lungs. From a slide by Palmer.

This is the position all other mammals have as well. It lets them hork down food more safely while still breathing. Eventually, however, your baby's epiglottis will adopt a position lower in the throat. This is weird and complicated and unlike other mammals, but it does two things: it enables human speech, and it enables the tongue to drop back and block the entire airway (which is what happens with obstructive sleep apnea). But you were breastfeeding, so your kid's tongue and lower jaw will be anatomically correct position: forward and away from the nose-to-lung airway path. Human nipple feeding also molded your baby's hard palate (the bony roof of the mouth), making it wider, which enhances airflow around the tongue.

Note the gap between the epiglottis and the roof of the mouth, allowing the tongue to nearly block the airway. Also note the lower jaw is pushed back. Palmer notes this adult probably had sleep apnea. In an infant this may cause SIDS.

Using a hard preshaped plastic nipple pushes the tongue and jaw back and the epiglottis down. It also mis-molds the hard palate into a more narrow shape. Excessive pacifier use does these things as well. Significantly, the epiglottis drop normally happens after the age of SIDS prevalence (5-6 months or so), presumably when the baby can stir itself to reposition and breathe should the airway become blocked. Forcing this to occur early may be a contributing cause of SIDS, allowing the tongue to fall back and block the entire airway.

You can read his presentations (in PDF format) on SIDS and breastfeeding here. They're a bit anatomy-heavy but have fun slides like this:

Those are some nice teeth.

He also theorizes that this same process of bad mouth molding due to poor infant feeding practices contributes to obstructive sleep apnea in children and adults, otitis media in children, of course there are the dental and orthodontic implications of having your bite messed up by plastic nipples and pacifiers. I haven't even begun to dig through his three-part text The Importance of Breastfeeding to Total Health which may cover all these topics more generally.

Maybe this doesn't seem interesting to everyone, but to me, SIDS is a perplexing event that requires explanation. Also weird is the occurrence of "difficult airways" at work: people who are just really difficult to intubate. Sometimes it's due to overweight, or biting, but I wonder how often it's due to misshapen palates, jaws, and oropharynxes. A difficult intubation in an emergency can be absolutely fatal. Breastfeeding might help in more ways than we have previously imagined.

The Illinois Home Birth Safety Act did not pass

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So SB 3712, the Illinois Home Birth Safety Act, did not pass. Despite passing the Senate it failed to pass the House by a larger margin than any of us thought it would, mostly because the Illinois State Medical Society went completely apes**t about it.

The good news is that they really paid attention to this bill. You can see on their website that the ISMS is still freaking out about the midwife bill:

Seriously? Seriously.

The bad news is that the ISMS and the American Medical Society (which is centered in Chicago) have a lot more money and lobbying power to defend their market. It's amazing to what extent the Illinois State Medical Society was willing to jump to conclusions about midwives to scare people about this bill, neglecting to mention that more than half of the United States can safely use legal certified professional midwives. But despite the ISMS's "action alerts," nobody I know in real life was concerned about this bill, and most people didn't even know it existed. I don't think their campaign reached that many voters. Maybe it wasn't intended to. But apparently enough State Representatives were concerned about this bill -- representatives who probably don't have to answer to too many home birthing families at fundraising dinners. Physicians and physician lobbies are another financial matter altogether, and probably explains why a disproportionate number of reps were concerned when the general public and the news media were not. This is what the ISMS means by "physician support" against the bill.

The fact of the matter is that physician groups in this state, notably the ISMS, the American Congress of Ob-Gyns, and the American Medical Association, have a history of refusing to look at new and more efficient models of care, regardless of what the people want. They fought or tried to restrict the very existence of advanced practice nurses, nurse practitioners, nurse anesthetists, and nurse midwives, and they lobbied against and tried to restrict pharmacy clinics. This despite the improved patient safety, patient outcomes, and decreased patient costs that these entities have brought to Illinois. CPMs are another group of practicing professionals who, despite being tested and proven in the rest of the USA, threaten the inflated practice costs and the exclusive domains of practice that physicians are trying to maintain.

The Illinois State Medical Society is right: some form of this bill will be back. It has to. Our society and our market are not going to continue to support the higher expense and poorer outcomes that occur when birth is the exclusive domain of surgeons and hospitals. The only thing holding it back is the money physicians already have, and in this economy that might not last forever.

You can read my summary of SB 3712 The Home Birth Safety Act here. (Be careful, it's soooo scary.)

Gabrielle Giffords and the drama of neuro-intensive care

US Rep. Gabrielle Giffords

Last night it was interesting watching Anderson Cooper and Sanjay Gupta sort of stumble over trying to describe the medical care someone receives after surviving a gunshot wound to the brain. They were, of course, talking about the assassination attempt on Rep. Gabrielle Giffords. They didn't seem very certain what they were talking about (at least, that's how it seemed, but it was closed captioned and I was running on a treadmill) but the AC360 blog video, "What Helped Giffords Survive Brain Shot", is a lot more clear. It's interesting to see the public news media grappling with the strange concepts that are dealt with in neurointensive critical care on a surprisingly frequent basis.  There are also articles trying to answer why Giffords is in a medically induced coma and highlighting the "new" procedure of decompressive craniectomy (I don't think it's that new?), with more or less accuracy.

Of course, the involvement of highly skilled neurointensive care nurses is apparently nil. It's made to sound as if neurosurgeons and doctors are at the bedside watching these patients 24 hours a day. But hey, that's the media.

It is (obviously) possible to survive being shot in the brain, depending on several factors. First, it depends on the round and the trajectory. It doesn't have to be a through-and-through injury, but it probably helps if it's clean through and not explosive.

Secondly, the problem with brain injuries of all types is that even if the initial injury is survivable, the "secondary injury"  is what kills or debilitates patients. I've heard war stories of soldiers being shot in the brain and surviving, awake and talking, for days, and then dying--presumably of swelling or sepsis. The brain swells like anything else after injury, but being in the rigid skull, it has nowhere to go. First the intracranial pressure compresses other brain structures (often the other cerebral hemisphere) which will cause neurological changes. Sooner or later the intracranial pressure can exceed the perfusion pressure of blood reaching the brain--we calculate this as a function of the blood pressure and using an intracranial pressure monitor, a thin catheter placed into the brain--and you have no flow. Swelling may also cause the brain to "herniate" through the hole in the bottom of the skull through which the spinal cord and brainstem connect to the brain, which also compresses those blood vessels, killing the brainstem. Spontaneous breathing stops, your most basic reflexes (coughing, gagging, and blinking) will cease, and there will be no response from the patient to painful stimuli. Death is inevitable unless the blood pressure is supported and they're on a ventilator, but a full brainstem herniation is ultimately unsurvivable. Persistent no flow and brain stem death will lead to a clinical diagnosis of brain death.

CT after craniectomy

So rapid transport to a hospital is critical, followed by rapid assessment, intubation to protect the airway, a head CT scan, and a neurosurgery evaluation. If the patient is a surgical option, they'll open the skull (a craniotomy) to remove clots, and may elect to leave the skull flap off (a craniectomy) to decompress the brain and allow it to swell. The skin is sutured back without the skull and we're on strict precautions (obviously) to leave that part of the head alone. The skull flap is preserved for later reattachment, sometimes in the patient's abdomen, sometimes presumably in some fridge somewhere in the hospital (hopefully labelled and dated appropriately, otherwise the secretary will throw it out--or maybe that's just my lunch).

After surgery the patient typically goes to a specialized neurosurgical or trauma critical care unit staffed by experienced nurses who take over the hour-to-hour care. The patient will be kept intubated and breathing by ventilator. The patient is sedated into the "medically induced coma" the media keeps mentioning, mostly to control pain and agitation. The brain injury, the surgery, the breathing tube, and being restrained to the bed by the wrists (which is done to protect the breathing tube, mostly) all lead to agitation,  which sharply elevates intracranial pressure, so the nurse will be continuously managing those drips as needed. Usually it's propofol because you can shut it off quickly, but the rapid-acting benzo Versed is also used; and a continuous fentanyl or morphine drip for pain.

The nurses will examine the patient hourly for the first day or more, then every two to four hours as the patient stabilizes. Sometimes this will involve turning off the sedation and seeing what the patient does - do they follow commands, open their eyes and track and focus, etc. Otherwise a significant amount of neurological information can be gained even with the patient out - do they react to pain, move all four extremities equally, still have all their reflexes? It's hard to overstate the importance of these exams; the patient can look the same and be totally stable but have a blown pupil or have a diminished reaction to pain in, say, the left arm - these are huge easily overlooked changes that can occur in an hour. We can also determine if we're sedating the patient too much and reduce the drips as needed. If an intracranial monitor or drain is placed it will be monitored fairly continuously. If anything changes, a stat head CT scan is done and the neurosurgeon and critical care physician are notified.  The patient might need more surgeries if there's rebleeding, more swelling, etc.  The nurses will also administer antiseizure meds, meds to reduce swelling, and keep track of the rest of your bodily functions--heart, lungs, etc.

If all goes well, the patient can survive. The patient may need a tracheostomy and feeding tube ("trach and peg"). They'll be taken off sedation and the ventilator if they're able to breathe on their own, but only time will tell if and to what degree there will be any disability, personality changes, or decrease in cognitive function. Some patients are unscathed and others are not.

That's the extent of what I see - the patient is usually transferred to rehab and I don't see them after that. But eventually the skull flap will be placed and stay a night or two in the same intensive care they started out in, which is sometimes nice for us to see.