CHAPTER XXI. CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN BABY. New Functions. Description. Growth and Development. Weight. Height. Head and Chest. Fontanelles. Teeth. Stools and Urine. Skin. Tears. General Behavior.

CHAPTER XXII. NURSING CARE OF THE NEW-BORN BABY. Mortality of First Months and Year of Life. Preventable Causes. Dangers of Babyhood. Essential Features of Early Care. Daily Schedule. Bath. Clothes. Fresh Air. Exercise. Training the Baby. Bowels. Thumb-sucking. Ear-pulling. Crying. Ruminating. Feeding: Breast Feeding. Artificial Feeding. Necessary Characteristics of Artificial Food. Requirements for Milk Used. Articles Needed in Preparing Food. Preparation of Milk. Pasteurization. Boiling. Giving the Bottle. Ingredients of Food. Percentage Feeding. Average Formulae. Mixed Feeding. Commercial Baby Foods. Proprietary Foods, Canned Milks, Milk Powders. Other Articles of Food Sometimes Included in Baby Diet. Travelling. The Premature Baby. Summer Care of the Baby.

CHAPTER XXIII. COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY. Malnutrition, Marasmus and Inanition. Diarrheal Diseases: Acute Gastro-enteritis. Symptoms. Treatment and Nursing Care. Acidosis. Colic, Constipation, Convulsions, and Vomiting. Infections: Ophthalmia Neonatorum. Symptoms, Treatment, and Nursing Care. Syphilis. Thrush, or Sprue. Impetigo. Pemphigus. Vaginitis. Abnormalities: Icterus or Jaundice. Cephalhematoma. Club Foot. Engorgement of Breasts. Hare Lip. Cleft Palate. Hernia.

An excellent device for protecting the baby’s arms and chest and keeping him generally well covered is the poncho (Fig. 162) devised by Dr. Lucy Porter Sutton of Bellevue Hospital. The poncho is a rectangle made of flannel, outing flannel or an old blanket and cut large enough to tuck well under the head and sides of the mattress and extend below the baby’s feet. The baby’s head slips through an opening, which is almost a right-angled slit, near the centre of the poncho and about 20 inches from the top. The slit is firmly bound and provided with tapes to tie it together after the baby is put in. The poncho should be put on loosely enough to permit the baby to move about at will beneath it. After it is adjusted the bed is made up as usual with additional blankets.

Under all conditions the baby’s airings must be increased gradually, both as to lowering the temperature and lengthening the time, and always adjusted to the vigor and reaction of the individual baby. He must be warm, but not too warm; he must be protected from wind and dust, and his eyes shielded from glare and from flickering light such as may be caused by a tree in a light breeze.

Exercise. Although the baby should not be handled unnecessarily nor tossed about and played with by friends and relatives, it is important that his muscular development be promoted by regular and carefully planned exercise. It is usually considered best for the baby to lie quiet and undisturbed in his crib most of the time during the first three or four weeks. Dr. Griffith begins the baby’s exercise about that time by having the nurse take him in her arms on a pillow and carry him about for a few moments, several times daily. After a week or two of this form of exercise, the nurse carries the baby without a pillow but supports his head and back.

The position of the baby’s body is changed by being carried about in this way, while the movement of the nurse as she walks about causes a certain amount of motion of the baby’s muscles, constituting a gentle exercise.

This exercise, in the form of picking up and carrying about is regarded by many pediatricians as of great importance. There is a possibility that lack of this form of “mothering” is one reason why babies in hospital practice sometimes fail to progress as they should. Certainly lying too long in one position is harmful. The nurse should carry the baby first on one arm and then on the other in order that both sides of his body may be equally exercised. By the third or fourth month he sits up in her arms as she carries him about, and he may be placed on the outside of his crib coverings for a little while every day, to kick and struggle at will. His skirts should be rolled up under his shoulders, or removed entirely, to leave his legs quite free, care being taken that the room is warm and that he has on stockings.

By about the sixth month he will usually begin to make an effort to creep, if turned over on his stomach and helped a little, and he may be propped up in the sitting position, in his crib, for a few moments every day. As he gives evidence of having enough energy to creep farther than the size of his crib permits, he may be put into a creeping-pen, or upon the floor under certain conditions. It must be remembered that the floor is likely to be cold, drafty and dusty. The nurse must assure herself, therefore, that the floor is warm; must cut off all drafts and spread a clean sheet or quilt on the floor before the baby is put down to creep. When the sheet is taken up, it is folded with the upper surface inside in order that when it is again put down the baby will play on the clean side and not on the side that has been next the floor.

A creeping-pen or cariole or some such provision is often more satisfactory than the floor, consisting as it does of a railed-in platform raised about six or eight inches from the floor.

The suggestions for exercise, like those for the baby’s airing, must be very general since it must always be adjusted to the powers of the individual baby and under the doctor’s supervision.

TRAINING THE BABY

Bowels. It is possible to train even a very young baby to have regular daily bowel movements; this training should be started when the baby is about a month old. At the same hour each day he may be laid on a padded table, or taken in the nurse’s lap, a small basin being placed against or under the buttocks, and a soap stick introduced an inch or two into the rectum and moved gently in and out. This slight irritation will usually result in the baby’s emptying his bowels almost immediately. Or he may be held on a small chamber on the nurse’s lap, in a comfortable reclining position (Fig. 163) or with his back supported against her chest, and the desire to empty the bowels stimulated by using the soap stick.

It is of greatest importance that the position and method which are adopted, be employed at exactly the same time each day. If this is done, and the baby is being properly fed, it will usually be found that, before he is many months old, his bowels will move freely and regularly without the stimulation of the soap stick and only when he is resting on the small basin or chamber. This establishment of a regular bowel movement not only simplifies the laundry work but is of great moment to the baby’s health.

Thumb-Sucking. It is scarcely necessary to remind a nurse that the baby must not be allowed to suck on an empty bottle or a pacifier nor be permitted to suck his thumb. The habits are very dirty and help to spread infections. The baby may swallow air while practicing them, with colic as a result, and he may so deform the shape of his upper jaw that, later in life, the upper and lower teeth will not meet as they should when he masticates; his front teeth may protrude in a disfiguring manner; and by narrowing and elongating the roof of his mouth the structure of the air passages is altered, with respiratory troubles and adenoids as a frequent consequence. Thumb-sucking may be prevented by the simple procedure of putting stiff cuffs on the baby’s elbows (Fig. 164) which make it impossible for him to reach his mouth with his thumb. These cuffs may be made by covering pieces of cardboard with muslin and attaching tapes with which to tie them on the baby’s arms. His hands may be put into celluloid or aluminum mitts, or little bags made of stiff, heavy material, which in turn are tied to his wrists, or his sleeves may be drawn down over his hands and sewed or pinned with safety pins. It should be borne in mind that a baby sometimes sucks his thumb because he is hungry or thirsty and gives up the practice when his food is increased or when he is regularly given water to drink.

Ear Pulling is not uncommon among young babies and if allowed to continue a long, misshapen ear may result. This may be prevented by using a thin, close fitting cap which ties under the chin, or by using the same kind of elbow splints as for thumb-sucking.

Crying. It is very easy to allow the baby to develop the crying habit, but very difficult to break it up. A baby who is properly fed, kept dry and warm but not too warm, and whose clothes are comfortable will usually cry very little if wisely handled. But a baby may cry because he is hungry, thirsty, wet, cold, over-heated, sick or in pain or simply because he wants to be taken up and entertained and has learned that the way to realize his wish is to cry. By closely observing the baby’s habits and his condition the nurse will usually be able to ascertain the cause of the crying. Very often a drink of fairly warm, sterile water will quiet him, particularly at night. But both the nurse and the mother should refrain from taking the crying baby up and carrying him or holding him when it is discovered that this attention stops his crying. Persistent crying should always be reported to the doctor, as it may have serious significance.

Ruminating. Some babies have the habit, called “ruminating,” of bringing up food; chewing it; moving it about and finally rolling it out of their mouths. Although this habit has not been recognized until comparatively recently, it is now believed to be of fairly common occurrence and often mistaken for vomiting. It is seen as a rule in precocious babies who take more interest in their surroundings than the average, more placid infant, beginning very early to fix their attention upon light, sounds and moving objects. The ruminator begins by bringing up a small amount of his last nourishment, then a little more and a little more until finally he has brought up nearly or quite all of it, apparently deriving a certain amount of pleasure and satisfaction from the procedure. Quite obviously, a continuation of this practice results in undernourishment, sometimes even starvation, since the baby actually retains very little if any of his food. As liquids come up more easily than fluids, the first step toward breaking up this habit is usually to give the baby more solid and concentrated food than he has been taking and to carry him about, talk to him and entertain him for about an hour after feedings, for if his attention is otherwise engaged, he is not likely to ruminate. Another efficacious measure is the use of a cap (See Fig. 165) so constructed and tied under his chin that the baby’s jaws are held tightly together and he is unable to make the movements which are necessary to rumination. (Fig. 166.)

FEEDING THE BABY

Proper feeding is probably the most decisive single factor in the routine care of the baby.

In order that the food be satisfactory it must be not only suitable in composition for the individual baby, but it must be clean, fresh and at the right temperature; given in suitable amounts and at suitable and regular intervals; it must be given properly—not too fast nor too slowly and it must be given under favorable conditions.

Moreover, the baby himself must be kept in a general condition which will favor the digestion and assimilation of the food that is given to him. Fresh air, suitable clothing, an even body temperature, gentle handling, proper bathing, regular sleep, freedom from excitement, fatigue and irritation, all promote the baby’s ability to use his food to advantage. Reverse influences all work against it.

The character, amount and intervals of the baby’s feeding are definitely ordered by the doctor, but the many factors which influence the baby’s nutrition are so largely a matter of nursing that the nurse has grave responsibilities in connection with his nourishment.

After other conditions have been made favorable, the factors which determine the character of the baby’s food are the kind and amount of food materials which are needed by his growing body and the powers of his digestive organs. If he is given less food than he needs at each stage of his progress he will not be properly nourished; but if he is given food materials in quantities, proportions or character which are beyond the power of his immature alimentary tract to digest, he not only will not be properly nourished but probably will be made ill.

There are three methods of nourishing the baby: breast feeding, artificial feeding and a combination of the two, termed mixed or supplementary feeding.

Breast Feeding. From all standpoints, maternal nursing under normal conditions is the most satisfactory method of infant feeding. If the breast milk is suitable it meets all of the baby’s requirements and the proportion and character of its constituents are exactly suited to his digestive powers.

In order that the nursing be entirely satisfactory, the condition of both mother and baby must be favorable to its success. The preparation and care of the mother have been described: her general condition and state of nutrition; the care and condition of her nipples, flat or retracted nipples being brought out if possible, and if not, the nursing facilitated by the use of a shield. If the baby’s diaper is wet or soiled, it should be changed before he is put to the breast, partly to make him comfortable and partly to avoid disturbing him after his feeding. His mouth is gently swabbed with boric soaked cotton, if this is ordered, he is wrapped in a little blanket and carried to his mother dry and warm and comfortable. (Fig. 167.) Although nursing is an instinct, the baby sometimes has to learn or to acquire the habit which is one reason for putting him to the breast during those first two or three days when he obtains little or no actual food. (See Chapter XVI.) As he expresses the milk by a squeezing and suction made possible only when the nipple is well back in his mouth, he must take into his mouth practically the entire pigmented area which surrounds the nipple. To do this he lies in the curve of his mother’s arm as she turns slightly to one side, and holds her breast away from his nostrils in order that he may breathe freely.

Sometimes even when other conditions are favorable, the baby is unable to nurse because of some physical disability. He may be too feeble; have a cleft palate or find suckling painful because of an abrasion of the mucous membrane which occurred when his mouth was bathed just after birth. The manner in which the baby nurses, therefore, may be significant and should be carefully noted and described to the doctor.

There is a difference of opinion among doctors concerning the interval between feedings which is most satisfactory. Some have the baby nurse every four hours and others every three hours during the early months of life. It is believed by some doctors that although a baby who is fed on a four-hour schedule may regain his birth weight more slowly than the baby who is fed every three hours, he suffers less from digestive disturbances and ultimately makes an entirely satisfactory gain in weight. Another point in favor of the four-hour interval is the longer period of freedom which this gives to the mother and this may influence her willingness to nurse her baby. But other doctors, both pediatricians and obstetricians, feel that the four-hour interval is too long for most babies.

Whether the baby shall nurse from one or both breasts at each feeding is another moot question. Some doctors believe that the results are better if both breasts are partially emptied at each nursing, while others feel that the function of the breasts is more satisfactorily promoted by completely emptying one breast at a time, at alternate nursings. Although the baby should pause every four or five minutes to prevent his nursing too rapidly, which is a common cause of colic, neither he nor his mother should be allowed to sleep during the nursing periods. When he has finished, he should be taken up very gently and placed in his crib and left to sleep. If he is nursing satisfactorily, he will be sleepy and contented after nursing and will sleep for two or three hours afterwards; he will seem generally good humored and comfortable while awake; he will have good color; gain weight steadily and have two or three normal bowel movements daily. The normal stool in breast fed babies is bright yellow, smooth and with no evidences of undigested food.

If he is not being adequately nourished, he will present exactly the opposite picture, in some or all of these respects. He will be unwilling to stop nursing after the normal length of time and will give evidence of not being satisfied when taken from his mother. He may be listless and fretful and sleep badly. He will not gain weight as he should, and he may vomit or have colic after nursing.

To ascertain whether or not such a baby is getting enough milk it is customary to weigh him, without undressing him, before and after each nursing. Each fluid ounce of food will increase his weight one ounce. If the baby is not getting a normal amount of milk at each nursing he is often given enough modified milk after each meal to supply the deficit, but at the same time an effort is made to increase the supply of breast milk by improving the mother’s personal hygiene.

The amount which the baby needs at each feeding varies, not only according to his weight and age, but also according to his vigor and activity, and must always be figured for the individual baby. A very general estimate of the amount taken by the average well baby at each feeding, is about as follows:

Artificial Feeding. There is no entirely adequate substitute for satisfactory maternal nursing, and any other food that is given to the young baby is at best a makeshift. Considering the baby’s delicacy, therefore, and his urgent needs, no pains should be spared to make any artificial food which is given to him as satisfactory as possible. In preparing and giving artificial food it must be borne in mind that normal breast milk:

1.

Is exactly right in quantity, quality and proportion.

2.

Is fresh, clean and sweet.

3.

Is free from bacteria.

4.

Tends to protect the baby from infection.

5.

Definitely protects him from certain nutritional diseases.

Cows’ milk, suitably modified, is apparently the best available substitute for mother’s milk, but it must first meet certain requirements and then be handled with scrupulous cleanliness and care, if it is to be at all satisfactory.

The requirements are that the milk shall be:

1.

Whole milk. It must not be altered by the removal of cream nor the addition of such preservatives as salicylic acid, formaldehyde or boracic acid.

2.

Its composition must not vary greatly from day to day.

3.

It must be clean and free from disease germs; other organisms should not be present in excessive numbers.

4.

It must be fresh: less than 24 hours old when it is delivered.

All of this means that the milk must come from a herd of healthy, tuberculin-tested cows. The milk from a single cow may vary markedly from day to day but that from several cows is nearly constant. The stables and the cows must be kept clean, the udders carefully washed before each milking; the milkers themselves must wear freshly washed clothing, scrub their hands thoroughly and milk into sterile receptacles; the milk must be immediately covered and cooled to a temperature of 45° F. or 50° F. and kept there.

Milk produced under such conditions is usually described as “certified milk” and is often prescribed as infant food without being pasteurized or sterilized. But if there is any doubt about the source of the milk and the method of its handling, it should be strained into a clean receptacle through filter paper or a thick layer of absorbent cotton and subsequently boiled or pasteurized.

When the nurse is in a position to offer advice about the baby’s milk she must explain the importance of always obtaining the freshest, cleanest and purest milk possible, no matter what it costs.

Whether certified or not the milk must always be placed in the refrigerator or some other place at a temperature of 50° F. as soon as it is received and it must be kept cool and clean. Mother’s milk, which is being imitated, is clean and sweet and free from disease germs.

Keeping the milk cool means keeping it at a temperature of 50° F. Keeping it clean implies cleanliness of the milk itself, the utensils, the nurse’s hands and the destruction, by sterilization or pasteurization, of disease germs. Those which are likely to be present in infected milk are streptococci, tubercle bacilli, colon bacilli, germs of typhoid, diphtheria and scarlet fever.

The amounts and proportions of the constituents of the substitute feeding will be specified by the doctor, as well as the intervals between feedings and the amount to be given each time. But the doctor’s careful adjustment of the milk formula to the baby’s immediate needs and digestive powers will be set at naught unless the nurse is absolutely accurate in preparing and giving the milk.

The nurse’s invariable responsibility, therefore, is to keep the milk cool and clean and prepare and give it accurately.

The nurse will appreciate the necessity and principles of modifying cows’ milk for the human infant if she will consider for a moment, the differences between mother’s milk and cows’ milk, as indicated by the following table, and the reasons for these differences:

It will be remembered that the tissues and bony skeleton are built by the proteins and salts (lime and phosphorus). Accordingly Nature supplies these in greater abundance to the calf, who grows so fast as to double his birth weight in about 47 days, than to the baby who scarcely doubles his within 180 days. The calf begins life with a physical need for the abundance of proteins and salts which are present in cows’ milk, and with digestive organs that can cope with them, but the baby needs less, can digest less and therefore must be given less. There are, of course, other and finer differences between the two milks and an attempt is sometimes made to meet these. For example, mother’s milk is slightly alkaline and cows’ milk slightly acid and the curd of cows’ milk is larger, tougher and harder to digest than that formed by mother’s milk. Accordingly some doctors add lime water to cows’ milk to make it alkaline, and render the curd softer, finer and more digestible by boiling it.

It is often not possible to give a bottle-fed baby the full 4% of fat which mother’s milk contains, and some doctors make the protein of the artificial mixture very much larger in amount than is found in human milk. The nurse will see that this is a matter which can be decided only by the physician.

Articles Needed in Preparing the Baby’s Food. A complete equipment for preparing and giving the baby’s milk should be assembled, kept in a clean place, separate from utensils in general use, and never put to any other service. A satisfactory outfit for this purpose comprises the following articles:

• One dozen graduated nursing bottles.
• One dozen nipples.
• Clean, new corks or a package of sterile, non-absorbent cotton for stoppers.
• Bottle brush.
• Covered kettle, capacity one gallon, for boiling bottles and possibly pasteurizing milk.
• Pasteurizer or wire bottle rack.
• Small kettle, about one quart size.
• Graduated pint or quart measuring glass.
• Pitcher, two quart size.
• Long-handled spoon for mixing.
• Funnel.
• Measuring spoons—table and tea sizes.
• Double boiler.
• Thermometer which will register at least 212° F.
• Cream dipper (if ordered).
• Two small covered jars for sterile and used nipples.
• Sugar (lactose, maltose or cane sugar according to orders).
• Lime water, if ordered.

Utensils of enamel or aluminum ware are probably the most satisfactory ones to use as they are easily kept clean, while bottles with wide mouths and curved bottoms and inner surfaces can be thoroughly washed more easily than those with small necks and sharp corners. Nipples that can be turned inside out to be washed should be selected as it is almost impossible to clean thoroughly those with tubes or narrow necks. New bottles will be rendered less breakable if placed in cold water, which is gradually heated, allowed to boil for half an hour and cooled before the bottles are removed.

The bottles should be rinsed with cold water after each feeding and then carefully washed and scrubbed with the bottle brush in hot soapsuds or borax water, containing two tablespoonsful to the pint. They may be kept full of water while not in use or rinsed with hot water and stood upside down until they are all boiled on the following morning, preparatory to being filled with the freshly prepared milk. The baby’s bottles should never be washed in dishwater nor dried on a towel. The nipples should be rinsed in cold water, turned inside out and scrubbed with a brush, in hot soapsuds or borax water; rinsed and placed in a jar ready to be boiled with the bottles.

Preparation of Milk. The full quantity of milk which the baby will take in the course of twenty-four hours is prepared at one time and the prescribed amount for each feeding poured into as many separate bottles as there will be feedings. (Fig. 168.)

The nurse should first boil for five minutes all of the articles that will come in contact with the milk, including the full number of bottles and nipples and the jars in which the nipples are kept; remove them with the long-handled spoon without touching the edges or inner surfaces and place them on a clean table, dropping the nipples into one of the sterile jars.

She should wash the mouth of the milk bottle before removing the cap and pour the amount which the formula calls for into the sterile pitcher. To this is added the sterile water in which the sugar has been dissolved in the glass graduate, and the potato or barley water, the lime water or soda solution as ordered. This mixture is thoroughly stirred and the amount for one feeding at a time measured in the graduate and poured into the specified number of bottles which are then stoppered.

If certified milk is used for the milk mixture it is often given to the baby without being pasteurized, in which case the bottles are placed in the refrigerator as soon as they are filled and stoppered. Very frequently, however, the milk is sterilized or pasteurized. The nurse will feel surer of keeping the mouths of the bottles clean if she covers them with squares of gauze or muslin before they are sterilized, holding the caps in place with tapes or rubber bands. Pasteurization as applied to infant feeding consists of heating the milk to 140–165° F. and keeping it at that temperature 20 to 30 minutes.

There are many excellent pasteurizers for home use on the market, or entirely satisfactory results may be obtained by using a wire bottle rack (See Fig. 168) and the large kettle already provided. One method is to place the rack containing the bottles in the kettle which is filled with cold water to a level a little above the top of the milk in the bottles, and allow the water to come to the boiling point. The kettle is removed from the fire, covered tightly and the bottles allowed to stand in the hot water for twenty minutes. Cold water is then run into the kettle to cool the milk gradually and avoid breaking the bottles, after which they are placed in the refrigerator, well or spring-house and kept at a temperature of 50° F. until they are taken out one at a time for feedings. If a wire rack is not available the bottles may be stood on a saucer or a thick pad of folded newspapers in the bottom of the kettle.

Pasteurization does not destroy all germs that may be in the milk, but it kills the more important ones and apparently impairs the nutritive and protective properties of the milk less than boiling. However, pasteurized milk must be kept cold and must be used within twenty-four hours, for the nurse will recall that aging of milk is quite as undesirable as souring.

Scalding is another method of destroying germs in milk. The milk is placed in an open vessel and the temperature raised to about 180° F., or until bubbles appear around the edge and the milk steams in the centre, after which it is cooled and kept at a temperature of 50° F.

Many doctors prefer to have the baby’s milk boiled, since boiling insures absolute sterilization and also renders the curd more digestible. Other changes are produced by boiling, however, which make it important to add an anti-scorbutic and cod-liver oil to the baby’s diet at an early date.

Milk may be boiled directly over the flame for a time varying from three to forty-five minutes, or it may be placed in a double boiler, the water in the lower receptacle being cold, and allowed to remain until the water has boiled from six to forty-five minutes. All of these points are definitely specified by the doctor.

When milk is boiled or scalded the other ingredients are added beforehand, as a rule, after which it is measured and poured into the bottles. Or the milk mixture may be poured into the bottles as for pasteurization and the bottles kept in the actively boiling water for any desired length of time.

Giving the Baby His Bottle. At feeding time, the bottle should be taken from the refrigerator, the stopper removed and a nipple taken up by the margin and put on the bottle without touching the mouthpiece. The milk is brought to a temperature of about 100° F. by standing the bottle in a deep cup or kettle of warm water and placing it on the fire. The temperature of the milk may be tested by dropping a few drops on the inner side of the wrist or forearm where it should feel warm but not hot. This dropping will also indicate if the hole in the nipple is of the proper size to allow the milk to drop rapidly in clean drops but not to pour. If the hole is too small, the drops will be small and infrequent and the baby will be obliged to work too hard to obtain it; while if the hole is too large the baby will feed too rapidly and may have colic as a result.

The baby’s diaper should be changed if it is soiled or wet before he is given the bottle and he should be held comfortably in a reclining position on the nurse’s arm while she holds the bottle with her free hand. (Fig. 169.) The bottle should be inclined sufficiently to keep the neck full of milk; otherwise the baby may draw in air as he nurses. He should be kept awake while feeding but he should be allowed to pause every three or four minutes in order not to take his milk too rapidly. Not less than ten nor more than twenty minutes is devoted to a feeding, as a rule, and if the baby refuses a part of his milk, it should be thrown away; never warmed over for another time.

After being fed, the baby should be held upright against the nurse’s shoulder for a moment or two (Fig. 170), and ever so gently patted on the back to help bring up any air which he may have swallowed. He should on no account be rocked or played with after taking the bottle, but should be placed gently in his crib, warm and dry and left alone to sleep. Turning him or moving him about even to the extent of changing his diaper at this time may cause vomiting.

The evidences of satisfactory and unsatisfactory feeding in the bottle-fed baby are about the same as in the baby who is fed at the breast, except that the gain in weight on artificial food may be a little slower and less steady than on maternal nursing; the stools have a characteristic sour odor; are a little lighter in color and may contain white lumps of undigested fat; are usually dryer than in breast-feeding and may be formed in even a very young baby.

It is fairly generally agreed that all babies, whether breast-fed or on the bottle, require a certain amount of cool boiled water to drink between feedings. A small amount is given at first and gradually increased according to the doctor’s instructions, and it may be given from a bottle, a medicine dropper or poured slowly from the tip of a teaspoon.

Ingredients of the Baby’s Food. In referring to the ingredients of the baby’s food we cannot use the terms “sugar” or “milk” as though they indicated definite and unvarying materials.

There are three kinds of sugar which are commonly used in modified milk: cane or granulated sugar; lactose or milk sugar and maltose. Cane sugar, the one most widely used, is the least expensive of the three and it apparently is satisfactory for most babies. Lactose is fairly expensive and while it causes diarrhea in some babies, others digest it more easily than cane sugar. Lactose is lighter than cane sugar, three spoonfuls being equal in weight to two of cane sugar. The maltose-dextrine preparations are easily digested and somewhat laxative. Some babies gain more rapidly when maltose constitutes part of the sugar in their food than when only lactose is used.

The question of milk is somewhat complicated and though the doctor will specify what percentage of fat shall be in the milk which is used in each case, the nurse must know how to obtain it from the milk at her disposal. If the formula is made up with “whole milk,” which contains 4 per cent. fat, the bottle in which it was delivered should be turned upside down and shaken vigorously in order that the cream which has risen to the top may be redistributed evenly throughout the fluid.

If the doctor employs what is termed “percentage feeding,” he may use whole milk, skimmed milk, or top milk. What he is endeavoring to do is to prepare a food which contains definite known percentages of the different ingredients, fat, carbohydrates and protein. Where a mixture is desired which contains more fat than it does protein, the milk to be employed is obtained by discarding a certain amount from the bottom of the jar of milk, the remainder being then called “top milk.” When he wishes the fat to be lower than the protein percentage, he discards some of the top milk in the jar, using the rest, which is then a partially skimmed milk. The upper 2 ounces in a quart bottle of milk contains 24 per cent. fat; the upper 8 ounces is 12 per cent. fat; the upper 16 ounces is 8 per cent. fat and the upper 24 ounces is 5 per cent. fat. If the formula calls for 6 ounces of the upper 8 ounces of milk, therefore, the nurse will see that it is very important that she remove the full 8 ounces and use 6 ounces of the milk which she has removed and not simply take the upper 6 ounces, as this would contain a higher percentage of fat than is ordered. (Figs. 171, 172, Dr. Griffith’s tables of fat percentages.)

Top milk may be removed by tipping the bottle gradually and slowly pouring the designated amount into a measuring glass, or it may be removed by pushing a cream dipper, especially made for this purpose and holding one ounce, down into the bottle until the cream flows in. Another method is to syphon off the lower milk through a bent glass tube, leaving in the bottle the desired amount of top milk.

Many doctors feed the baby according to his caloric needs and prepare the formula from whole milk, sugar and water, determining the amounts of each according to the age and weight of the baby.

Under any condition it is so necessary that the amount and composition of each baby’s food be adjusted to his needs, that it is not considered possible to make out any formulae or feeding schedules which would be safe or satisfactory for general use.

The baby should be lightly clad; should be kept quiet and in a cool, shady place out-of-doors as much as possible. During the warmest part of the day, however, he will often be much better off and more comfortable in the house, in a room with the shutters closed. But while keeping the baby cool, the nurse must bear in mind the harm that will be done by chilling him or exposing him to a cold draft or wind. Several tub baths, daily, are often given, at a temperature of 100° F., rather than cool sponge baths because of the baby’s feebleness and inability to react to cool bathing. Packs are also employed, both for high temperature and restlessness and may be cool (80° F.), tepid (100° F.) or hot (105° F. to 108° F.) according to the doctor’s orders; intestinal irrigations; lavage and gavage.

To give a pack, the nurse will cover the bed with a rubber and sheet and bring to the bedside a basin containing a sheet wrung from water of the specified temperature; a basin containing ice and compresses for the baby’s head, and a flannel covered hot-water bottle at 120° F., for his feet. The baby is laid on the upper half of the folded wet sheet, and an upper corner wrapped about each arm (Fig. 177), and the sides folded around his legs. The lower half is brought up between his feet to cover his entire body and tuck around his shoulders. The hot-water bottle is placed at his feet and an ice compress on his head. (Fig. 178.) If the sheets are wrung from warm or hot water, the baby is covered with a blanket after he is put into the pack.

Intestinal irrigations, of normal salt solution are often given to babies suffering from intestinal disorders, sometimes once or twice daily to wash out the lower bowel, or a cool irrigation may be given to reduce temperature, the amounts varying from ½ to 2 gallons of solution. The baby should be placed on a pillow and rest on a bed-pan, being protected from chilling as for, an enema (See Fig. 186), and provision made for a two-way flow of the fluid. A small catheter attached by means of a connecting glass nozzle to the tubing on the irrigation bag may be passed into a slightly larger catheter, which is inserted into the rectum about six inches, the fluid flowing in through the small inner tube and out through the larger one which encases it. Or a small catheter for the outflow may be inserted in the rectum alongside the one through which the solution is introduced. Normal salt solution, glucose or bicarbonate of sodium solution are sometimes given by the drip method at the rate of 20 to 40 drops per minute. In this case a glass tube is introduced at some point in the rubber tubing in order that the rate of flow may be watched and regulated by means of a clamp or a stop-cock. The catheter is inserted in the rectum about six inches and held in place by strips of adhesive plaster.

Lavage and Gavage. Sometimes when the baby vomits persistently the stomach is washed out and a small amount of water or nourishment given before the tube is withdrawn. A tray containing the following articles should be carried to the bedside:

A glass funnel attached to a rubber tubing which connects with a small rubber catheter by means of a glass nozzle.

Basin to receive stomach contents.

Small rubber, towel and curved basin to place under baby’s chin.

Glass graduate containing warm water for washing out stomach.

Food or solution which is to remain in stomach, standing in cup of warm water.

Glycerin to lubricate tube.

Mouth gag, if necessary, or roll of bandage to hold jaws apart.

The baby should be wrapped tightly (Fig. 180) to prevent interference by his struggling and turned slightly to the left side. (Fig. 181.) The catheter is lubricated with glycerin or water and passed back over the tongue and quickly downward until an air bubble is heard as it enters the stomach. The length of tubing which is to be inserted may be anticipated by marking a point on the tube which is the same distance from the end as the baby’s mouth is from its umbilicus. The possibility and the serious consequences of introducing the tube into the trachea instead of into the esophagus must be borne in mind. Although the baby will often choke and struggle when the tube is properly introduced, he will not cough violently and stop breathing as he will if it enters the air passage. Further information is obtained by inverting the funnel in a basin of water after the tube is inserted; if it is in the stomach there will be no result, but if it is in the trachea air will be expelled and bubbles will rise through the water. To wash out the stomach, the funnel is filled with warm water and slightly raised so that the water will run in slowly, after which the funnel is turned upside down into a basin which is lower than the baby’s body, and the stomach contents allowed to run out. This is repeated four or five times, or until the solution returns clear, and the food which is to remain in the stomach is poured in slowly. Before the tube is quite empty it is pinched off with the fingers and quickly withdrawn.

Acidosis. The diarrheal diseases are sometimes complicated by acidosis, a condition in which the relative amounts of acid in the blood are so increased that the normal alkalinity is markedly diminished. This condition may result from an excessive intake of acids; an overproduction of acids in the course of normal metabolism; a decrease in the reserve of normal alkali in the body or a failure in the mechanism by means of which excessive acids are usually neutralized or eliminated. Acidosis is a serious complication and often fatal.

The treatment is directed toward preventing the production of more acids within the body; restoring the alkali reserve and promoting elimination of the excessive acids and their salts. Solutions of glucose, bicarbonate of sodium and salt are used and are given by mouth, rectum, intravenously and intraperitoneally. Subcutaneous injections are not wholly satisfactory, because of the small amounts which may be given in this way. From 150 to 400 cubic centimetres are given into the peritoneal cavity and as the solution absorbs readily these injections are sometimes repeated every eight or twelve hours, an infusion bottle and short infusion needle being used. From 75 to 300 cubic centimetres of glucose solution (5 per cent. or 10 per cent.) is given intravenously, while as much as 1000 cubic centimetres is sometimes given per rectum in the course of 24 hours by the drip method. Soda solution (4 per cent.) is often given by mouth, if the baby is able to retain it, or intravenously, as frequently as the condition of the urine indicates is necessary. From 75 to 100 cubic centimetres is given at one time to young babies.

In preparing the soda solution it must be remembered that boiling drives off carbonic acid and forms sodium carbonate and that its reconversion into sodium bicarbonate is a complicated procedure. Howland and Marriott^[16] say in this connection: “Oscar Schloss has found that sodium bicarbonate in bulk is always sterile. It is probably therefore sufficient to add the bicarbonate with proper precautions to sterile water.”

Since the results of urine tests frequently indicate the treatment in acidosis, it is of very great importance that the nurse be able to obtain specimens from young babies. (Figs. 182, 183, 184 and 185 for methods of obtaining fresh and 24–hour specimens from babies.)

Colic, Constipation, Convulsions and Vomiting so frequently seen in young babies are symptoms rather than diseases.

Colic usually consists of paroxysms of pain in the stomach or intestines, due to distension or to spasmodic, muscular contractions. The indirect cause may be unsuitable food or food given too rapidly; chilling of the surface of the body, excitement or fatigue. The distension may be due to air swallowed by the baby while nursing or gas formed by carbohydrate fermentation. Excess of protein may form an irritating mass in the intestines and cause a cramp.

While colic frequently accompanies malnutrition and constipation, it is often seen in otherwise well and happy babies, and usually before the fifth month. The attacks are usually sudden and may occur several times a day after feeding, or only in the late afternoon or at night. The baby cries shrilly; his face is drawn and may be flushed, from crying, or cyanotic; his fists are clenched and pressed to his body and his feet and hands are cold. His abdomen is hard and distended and during a pain the baby flexes his thighs upon it and afterward extends them with a jerk. This painful seizure may last only a few moments or it may persist for hours, leaving the baby exhausted.

The chief preventive measures are found in the precautions and attention to detail which have been described, and which should be included in the care of all babies. In a bottle-fed baby it is often found that recurrence of attacks of colic may be averted by a slight change in the milk formula; by giving more water to drink; by lengthening the intervals between feedings; by giving the milk more slowly or by omitting the 2 a.m. feeding, thus giving the baby more digestive rest.

With breast-fed babies, prevention is often accomplished by having the mother nurse her baby more slowly, lengthening the intervals and by improving her own hygiene; particularly by increasing her recreation and out-of-door exercise and relieving constipation. Women who lead sedentary lives and eat rich food very often have colicky babies as do those who are nervous, irritable and inclined to worry. (See chapter on the nursing mother.)

When attacks of colic occur, the pain usually may be relieved by giving half of a soda-mint tablet in a little warm water and an enema of about eight ounces of soap-suds or salt solution at 110° F., given through a small catheter inserted about six inches. The baby will experience almost immediate relief through the expulsion of gas and feces and he may be made still more comfortable by placing a hot-water bag at his cold feet; rubbing his abdomen with vaselin and applying hot stupes. Sometimes the first feeding which falls due after an attack is omitted and a little warm water or barley water is given instead, in order that the digestive tract may rest.

Constipation is very common among young infants and may be manifest by the stools being too small, too dry or too infrequent. The commonest causes are:

• 1. Faulty diet—possibly too much protein or too little fat or sugar.
• 2. Intestinal atony, due to undernourishment, rickets or anemia.
• 3. Anal fissure which makes the baby unwilling to empty his bowels because of pain.
• 4. Absence of habit of emptying the bowels regularly.

The prevention of this very troublesome condition lies largely in suitable food; constant fresh air; regularity in the daily routine and training the baby to empty his bowels at the same time every day.

When constipation is due to insufficient fat in the food, cod-liver oil is sometimes given, 15 to 30 drops three or four times a day; or a teaspoonful of olive oil two or three times a day. Maltose, malt soup, malted milk, milk of magnesia, liquid petrolatum, oatmeal-water and orange juice are all found among the remedies for constipation; while soap sticks, suppositories and enemata of oil or soap-suds sometimes have to be resorted to.

In giving an enema to relieve constipation, the baby should be protected from chilling, laid on a pillow and the pan so placed that he will be comfortable and not inclined to move, and from 100 to 300 cubic centimetres of soap-suds, at 105° F., given with a small hard-rubber nozzle. (Fig. 186.) When warm olive oil is given at night (1 to 2 ounces through a catheter introduced about 6 inches), it is very often retained and the feces so softened that the baby empties his bowels freely the next morning with little or no assistance.

Abdominal massage will often help to increase the intestinal tone and make peristalsis more vigorous. The abdomen should be rubbed with a circular stroke, beginning in the right groin and following the course of the colon up to the margin of the ribs, across to the left side and down to the groin. This is often given for about ten minutes every day, preferably at night but never just after a feeding.

Constipation is sometimes entirely cured by a suitable dietary; an abundance of drinking water; an out-of-door life; massage, and above all, the unremitting effort to establish a regular habit. The latter is the nurse’s responsibility and she should exercise the greatest patience in trying to accomplish the desired end.

Convulsions are a symptom of several disorders of early infancy, which may occur unexpectedly and which the nurse may suddenly be called upon to relieve in the absence of the doctor. Convulsions may be due to brain lesions; to spasmophilia or a special tendency to convulsive disorders; gastro-intestinal disorders; toxemia or syphilis. They may be the initial symptom of an acute infectious disease or may occur on slight provocation in a frail, undernourished baby or one suffering from rickets or tetany. For this reason one sometimes sees convulsions in a baby who is teething or has colic or indigestion.

As convulsions are a symptom of some abnormal condition, the doctor will often prescribe a sustained treatment designed to remove or relieve the cause. But when an attack occurs unexpectedly, and the doctor cannot come at once, the nurse may often terminate the seizure by employing measures that will quiet and relax the struggling baby. The room should be quiet and darkened and the baby handled with utmost gentleness because of the extreme irritability of his nervous system. As a rule, the most satisfactory course is to immerse the baby in water at 100° F., and keep him there for five or ten minutes, supporting his head and shoulders meantime. Someone else should place cold compresses on his head and change them frequently. When removed from the bath, the baby should be wrapped in a blanket, kept very quiet and the cold applications to his head continued.

When it is known that the convulsions are due to indigestion the stomach is often washed out and a high colonic irrigation given before the baby is quieted by the bath. In tetanoid convulsions the baby may take a long deep inspiration and fail to expire. Respirations should be stimulated, in such a case, by spanking him sharply or by dashing cold water on his face and chest. When the attacks are recurrent the nurse may be instructed to terminate them by giving the baby a few whiffs of chloroform, which, with an inhaler is kept in readiness for instant use.

Mustard baths and packs are sometimes given when the need for counter irritation is indicated. For a bath, one ounce, or six level tablespoonfuls of dry mustard is added to one gallon of water at 105° F. and the baby kept in it for about ten minutes, or until the skin is well reddened. He is then wrapped in a warm blanket and surrounded by hot-water bottles, with cold compresses applied to his head. The mustard pack is given in the manner of other packs, with a sheet wrung from mustard water which is possibly a little warmer and stronger than that for the bath, care being taken that the sheet is not cooled before it is wrapped about the baby. He is usually left in the pack for about ten minutes or until his skin is reddened, and then wrapped in warm blankets, with cold compresses to his head.

It is often helpful to the doctor if the nurse is able to describe the onset of the convulsions and tell him where the twitching began, how it progressed and whether or not it was preceded by a cry.

Vomiting during early infancy is a symptom of any one of several conditions, the nature of which sometimes may be revealed by the character of the attacks. The commonest causes and varieties of vomiting are as follows:

1. Too rapid feeding or too large amounts of food given at one time. The vomiting amounts to little more than regurgitation and is often induced by moving or handling the baby immediately after feeding him.

2. Acute gastric indigestion. Sour stomach contents may be vomited immediately after feeding, or not until several hours later and may be followed by mucus and bile. The baby is usually pale, particularly about the mouth; he may perspire about the forehead and give evidence of pain, being relieved by the vomiting.

3. Stenosis of the pylorus. The vomiting from this cause is projectile in character and may occur immediately after food is taken into the stomach, or, some time later without apparent cause, a larger amount of fluid may be expelled than was given at the preceding feeding. The vomiting may begin a few days after birth or several weeks afterwards in a baby who has been well previously.

4. Intestinal obstruction due to congenital obstruction, which causes persistent vomiting from birth; or due to intussusception of the intestines, when vomitus consists first of stomach contents which later becomes bile stained and sometimes contains fecal matter, blood and mucus. It is attended by prostration, and after fecal matter is passed at the beginning, there is frequent evacuation of blood and mucus.

5. Chronic or habit vomiting, sometimes occurring in early infancy, may be difficult to control because of being incited by such slight causes as laughing, crying or being moved.

In addition to being caused by the above mentioned conditions, vomiting in young babies may usher in an acute infectious disease, as a chill does in an adult, or it may accompany such diseases as peritonitis, meningitis, brain tumors and toxic conditions such as uremia.

INFECTIONS

The infectious diseases which the obstetrical nurse is most likely to see in her baby patient are ophthalmia neonatorum; syphilis; impetigo; pemphigus and vaginitis.

Ophthalmia Neonatorum, inflammation of the eyes of the new-born or “babies’ sore eyes,” is one of the common diseases of infancy and certainly one of the most dreaded because of the tragedy of lifelong blindness which may follow in its wake. In the early days of organized work for the prevention of blindness the term “ophthalmia neonatorum” implied a gonorrheal infection, but it is now known that inflamed eyes and subsequent blindness may result from infection of innocent origin. Accordingly, in those states where it is required that the disease be reported, ophthalmia neonatorum is defined as inflammation of the eyes of new-born babies, irrespective of the cause. The disease is frequently due to the gonococcus, the baby’s eyes being infected from the mother during passage through the birth canal or infected later by her hands or clothing. Or the inflammation may be caused by the streptococcus, pneumococcus or the colon, diphtheria, or influenza bacilli while very frequently the infection is mixed.

It is estimated that about 20 out of every 1000 new-born babies have sore eyes, and though many of the infections are mild, between 5 and 8 of these 20 cases are capable of becoming serious and causing blindness if not speedily and skillfully treated. The number of cases which are neglected is suggested by the fact that about 10 per cent. of all blindness, the world over, is due to infant ophthalmia and that about 20 per cent. of the inmates of schools for the blind in this country are sightless from this cause. This does not take into account the unnumbered army of those who are partially blind, or blind in one eye, and thus seriously handicapped, as a result of this disease.

Symptoms. The first symptoms are redness and swelling of the lids, usually accompanied by a discharge of pus from the beginning, and they ordinarily appear during the first few days of life, but sometimes develop as late as the second or third week. The disease may run a very rapid course and cause blindness in 48 hours from the time the first symptoms appear, or it may persist for weeks. Ulceration of the cornea is the dreaded consequence of the inflammation as ulcers are followed by scars. When the scar is small, or to one side of the pupil, there may be little or no impairment of vision, but if it is large and centrally located it forms an opaque screen and causes blindness by shutting out the light, although the interior of the eye behind the scar is sound and uninjured. Sometimes the ulcer causes a perforation of the cornea through which the lens and vitreous humor are discharged.

Attempts have been made to remove the scar following a centrally located ulcer and replace it with a clear cornea from some such animal as a guinea pig, but the operation apparently has not been perfected. When it is, many blind persons may have their sight restored to them.

Prevention. It may be stated almost without qualification that ophthalmia neonatorum is a preventable and curable disease, and accordingly that blindness from this cause is inexcusable. Prevention lies first, in wiping the baby’s eyes immediately after birth and instilling a drop or two of a silver salt, such as nitrate of silver, argyrol or protargol, or bathing them with boracic acid solution; and second, in close watching for early symptoms and giving speedy treatment when they appear. This is urgent because there is no way of determining in the beginning whether the infection is mild or virulent. Nitrate of silver solution, 1 per cent., is the prophylactic most commonly employed and its use is now routine in most hospitals and in the practices of many physicians in this country. The solution is sometimes dropped between the baby’s lids, immediately after the birth of the head, and before the birth of the entire body, and sometimes immediately after delivery is completed. Many doctors follow the silver drops with normal salt solution to prevent the slight silver catarrh which so frequently occurs otherwise, and which may be confused with early symptoms of ophthalmia. Still others prefer simply to bathe the eyes with boracic acid solution (unless they know that the mother has gonorrhea) and to watch them closely for the slightest redness, swelling or discharge and give prompt treatment if these appear.

The CredÉ method, made famous by the Viennese obstetrician who introduced it in 1881, was to drop from a glass rod, a single drop of nitrate of silver, 2 per cent., into each eye immediately after birth. The routine use of this prophylaxis reduced the occurrence of ophthalmia in CredÉ’s clinics from 10 per cent. to .1 per cent. among the new-born babies.

Since it is now believed that close vigilance and subsequent care are equally as important as the prophylactic drops, the CredÉ treatment has been variously modified and other and weaker silver solutions are frequently used, and with satisfactory results. The dropping of a germicide into the baby’s eyes kills the organisms which may be present at the time, but it does not protect against subsequent infection. For this reason the nurse cannot be charged too earnestly to watch the baby’s eyes closely for the first evidence of infection, and report it to the doctor immediately, day or night, for the late infections are as destructive of sight as those which occur before or during birth.

Treatment and Nursing Care. The treatment and nursing care in ophthalmia frequently require the greatest skill. There may be merely an application of silver and sponging with boracic acid solution or a gentle irrigation with a blunt nozzle (Fig. 187), or the preservation of the baby’s sight may necessitate dressings and treatment which will require elaborate preparation (Fig. 188), and may also require some form of treatment every quarter- or half-hour, day and night and occupy the entire time of two or three special nurses. The nurse’s duties in caring for the eyes will be explicitly defined by the doctor, but in general she must remember that she is nursing a baby suffering from an acutely infectious disease, who should be strictly isolated, and that as a rule she should wear a gown, rubber gloves and protective goggles while caring for him. All of her attentions to the inflamed eyes must be given with the greatest gentleness in order to avoid abrasion of the conjunctiva or injury of the cornea. Moreover, the baby with suppurative conjunctivitis is a sick baby often fighting for his life as well as his sight, and every effort must be made to preserve his strength and increase his resistance. Fresh air and careful feeding are imperative. Breast-fed babies have a distinct advantage over bottle-fed babies and for this reason the mother should always accompany the nursing baby if he is taken from his home to a hospital to be treated for ophthalmia neonatorum, unless there is a wet nurse available at the hospital.

It is of interest to nurses that the effort to safeguard the eyes of babies through preventive treatment and early care was developed into a national movement by one who also was influential in starting the training of nurses in this country, Miss Louisa Lee Schuyler. The lay work for the prevention of blindness, which is now country-wide, was started by the New York State Committee for Prevention of Blindness, which was organized by Miss Schuyler in 1908. She was its first Chairman and skillfully directed the work of the Committee for ten years. During the Civil War Miss Schuyler was a member of the Sanitary Commission and afterwards was one of the group which was responsible for starting at Bellevue Hospital, in New York City (in May, 1873), the first training school for nurses in this country, planned in accordance with Miss Nightingale’s standards for the organization and conduct of a school for nurses. Later, in 1911, the Bellevue School for Midwives was established as a result of the combined efforts of the Hospital Trustees and Miss Schuyler’s Committee for Prevention of Blindness, the course of training being outlined by a sub-committee composed of Miss Lillian D. Wald, Dr. J. Clifton Edgar and myself. So far as it is possible to learn this school was the first in this country to be conducted along the lines of a school for nurses, or after the manner of the midwife schools in England.

Syphilis, which ranks high among the scourges of mankind, is seen with distressing frequency among young babies. It may be contracted during uterine life, when it is said to be “inherited,” or it may be “acquired” after birth by kissing a syphilitic person or coming in contact with contaminated articles, such as clothing, or nursing from a diseased breast.

The most conspicuous symptoms are the familiar “snuffles;” the scaling, fissures or eruption on the soles, palms, buttocks and about the mouth; shrill, hoarse crying; swollen painful joints; partial paralysis and a general feebleness and inanition. Some or all of these symptoms may be present when the baby is born or they may develop any time within the first two or three months of life.

Babies of syphilitic mothers are often given mercurial inunctions immediately after birth, even though they have no symptoms of the disease as it is very likely to be present in a latent form. This is one reason for the routine inspection of the placenta, since in it is sometimes found the only indication for treating the baby. An infant who is known to have syphilis is given mercurial inunctions or baths, the ointment being rubbed into the groin, axilla, back and abdomen in rotation on successive days, to prevent irritation of the skin. The nurse should protect herself with rubber gloves, wash the area with warm water and soap and thoroughly rub in the ointment. Sometimes the ointment is put on the inside of the back of the baby’s binder, by which means he rubs it in himself. The syphilitic baby should be isolated and should not be put to the breast of an uninfected woman, but he may nurse from a syphilitic woman without harm to either her or himself. Good general care, including fresh air and sunshine are important to the baby suffering from syphilis.

Thrush or Sprue is a highly communicable disease of the mouth of new-born babies, due to one of the fungi. It is common among sickly, undernourished babies and those living in unhygienic surroundings, but it is seldom seen in healthy babies who are cared for with absolute cleanliness. The disease is characterized by small raised, white spots in the baby’s mouth, frequently on the back of the tongue and inner surface of the cheeks.

Prevention lies in good care and in cleanliness of the mother’s nipples, or the bottles and nipples for artificially fed babies, and of all other articles coming in contact with the baby, particularly his mouth. Some doctors have the baby’s mouth bathed before each feeding, as a preventive measure, while others feel that a gentle swabbing once daily is sufficient, if the nipples are kept clean, since an abrasion of the mucous lining is easily caused and is favorable to the development of thrush.

Treatment consists in cleanliness and in gently swabbing the spots, three or four times a day, with sterile cotton wet with an alkaline solution such as borax (10%), bicarbonate of sodium (6%) and sometimes with formalin (1%) or a weak solution of permanganate of potassium.

Impetigo and Pemphigus are highly infectious skin diseases of early infancy which are seen more often in hospitals than in patients’ homes. The treatment of the raised blisters that appear on different parts of the body is entirely a medical question, but in caring for the patients suffering from either of these infections the nurse must take every precaution to avoid extending the trouble on the skin of the infected baby, himself, and of communicating it to other babies in the ward. Strict isolation is imperative; gentle handling and frequent changing of the underclothing to prevent extending the disease to uninfected areas.

Vaginitis. This highly infectious malady is considered troublesome rather than serious, as a rule, though it may be complicated by ophthalmia or arthritis. Gonorrheal vaginitis is the commonest form seen in early infancy and may be due to infection which the baby acquired during its passage through the birth canal or later from the mother’s hands or clothing. The symptoms are a vaginal discharge, which may be thin and serous or thick and yellow and purulent and it may be scanty in amount or abundant; a reddened, swollen condition of the vagina and vulva and sometimes redness and excoriation of the inner surface of the thighs. The nurse’s chief responsibilities are to be constantly on the alert to detect evidences of the disease and report them promptly to the doctor, and to observe strict isolation in caring for the baby while carrying out the doctor’s orders for douches or suppositories.

COMMON ABNORMALITIES OF THE NEW-BORN

Icterus or Jaundice, which is so frequently seen in new-born babies, is occasionally a symptom of some septic condition; of syphilis or congenital cirrhosis of the liver or obstruction of the bile ducts, but as a rule it is without any serious significance. The jaundiced appearance usually begins on the second or third day and may continue for two or three weeks or it may subside in three or four days. The depth of the color varies, being very pale in some cases and almost green in others. When this discoloration of the skin is unaccompanied by other symptoms, no treatment is given.

A Cephalhematoma is a tumor of blood between the periosteum and the bones of the skull of the new-born baby. It is often due to some injury sustained during birth and is most frequently seen after prolonged labors. Cephalhematoma is sometimes confused with a caput succedaneum, but whereas the caput disappears in a few days the cephalhematoma may not be entirely absorbed for two or three months. Although certain conditions sometimes indicate the advisability of surgical treatment, the nurse’s care consists solely of protecting the tumor from injury.

Club foot is one of the commonest deformities of the extremities of young babies, occurring once in about every 1000 births. It may be congenital or caused by injury or it may be due to such diseases as cerebral paralysis or poliomyelitis. The nurse should watch for any abnormality in the structure or position of the feet, for the earlier treatment is started, the better is the prospect of a cure.

Engorgement of the Breasts. Not infrequently the breasts of new-born babies are engorged, in which state they are easily infected by being rubbed or squeezed. Since the greatest care must be taken to avoid bruising swollen breasts, they are sometimes protected by the application of a pad of sterile cotton. Hot compresses are sometimes applied when there is redness with the swelling, or a tiny ice-bag, made by tying off the fingers and thumb of a rubber glove, and partly filling it with finely crushed ice, after which the wrist is tightly tied.

Hare Lip. The fissured lip, which is not infrequently seen in new babies, may consist merely of a small notch or it may amount to a deep cleft reaching up into the nostril. It is due to a non-union of the frontonasal plate with the lateral processes and may occur on one or both sides, thus forming a single or double hare lip. An extensive fissure will usually interfere with suckling and the nurse may need both ingenuity and patience in feeding such a baby, for the prospect of successful treatment, which is surgical, increases with the baby’s age and improved nutrition. The longer she can feed the baby successfully, therefore, the better his chance of recovery.

Cleft palate, a common congenital abnormality, consists of a fissure of the soft, and sometimes of the bony, palate; it may be on one or both sides and may be continuous with a hare lip. The problem of feeding the baby with a cleft palate is very grave since the fissure may make it impossible for him to form the vacuum in the back of his mouth which is necessary for suckling. He is sometimes fed with a medicine dropper or by gavage or by means of a special nipple provided with a flap which fits into the roof of the mouth and closes the opening into the nasal passages. Even more than in the care of the baby with a hare lip is it important to nourish the baby with a cleft palate, and build him up for as long as possible before he is subjected to the strain and shock of the inevitable operation.

Hernia. Umbilical and inguinal hernias are both seen in young babies.

Umbilical hernia is the commoner type and is not uncommon in thin babies and those with indigestion and distension and in babies who cry violently. Such hernias are not regarded as serious if prompt measures are taken to reduce them as they usually respond very readily to treatment. But since neglect may have serious consequences, the nurse should watch for protrusions and report them promptly. She will often be instructed to reduce the hernia and apply adhesive strapping, in which case the following observations by Dr. Griffith will be helpful:

“Usually it is quite sufficient to draw the skin into two folds, one on each side of the hernia and meeting over it; holding these in place by straps of adhesive plaster crossing over the navel, or by a broad horizontal band of adhesive plaster reaching to the lumbar regions. Another method is the following: A silver quarter of a dollar is laid upon the adhesive surface of a piece of rubber plaster about two inches square; over this is placed the broad strap referred to, with its adhesive surface next to that of the smaller piece. After reducing the hernia and pressing the sides of the abdominal walls slightly together the band is applied with the quarter dollar directly over the position of the navel. My own preference is for a simple adhesive band without the use of the coin. The dressing should be worn constantly, changing it from time to time as the old one loosens. The dressing must, of course, not be removed during the bath. Several months are required before the opening is permanently closed. Occasionally the plaster produces a great deal of cutaneous irritation, especially in the first few months of life. The employment of zinc oxid plaster tends to avoid this difficulty.”^[17]

Inguinal hernia is less common in very young babies but it should be watched for since it usually may be easily reduced by the use of a truss, if discovered and treated early, but may be serious if neglected.

In general, the new baby who is ill, needs the same thoughtful, gentle, painstaking care that the nurse gives to the well baby, but these must be shaped to his immediate requirements and the doctor’s special instructions.

It will be well for us now to take a retrospective view of the various functions of the nurse which are associated with the phenomena of pregnancy, labor, the puerperium and the beginning of a new life. As we see these in perspective, our attention is fixed by a few important principles which stand out from the picture as a whole in clear and shining relief.

We see, for example, that no matter what else may become vague and unimportant, be changed or discarded, there remains the conspicuous, unalterable requirement that the nurse shall do clean work throughout this entire series of experiences. All maternity patients and all babies need scrupulously clean care no matter what else they may have or may lack.

But also must they all be watched throughout these transitional stages, in order that impending disaster may be apprehended and warded off. And that this watchfulness be intelligent, the nurse must of necessity know something of the normal physiological changes which occur during these momentous periods in the lives of her patients, lest she fail to detect evidence of abnormality, should it appear.

Since this invariable cleanliness and close watchfulness are needed by all patients, whether of high or low degree, and by those in the care of doctors with widely varied methods, the nurse must be able to make adaptations to each patient’s environment and temperament and to the doctor as well, if all of her patients are to be well and happily nursed. She must be clean, then, and watchful in her work, and adapt it to every conceivable condition. These features stand out clear and bold in the perspective. But to make these offices effective to their utmost, the nurse’s attitude and her care of her patient must be mellowed by an always deepening sympathy and understanding. She must endeavor, in each instance, to imagine the mental experience of the bewildered and timid expectant mother; of the terrified woman in labor and the discouraged young mother—these she must appreciate if she is to give of her best. And so, in the end, the character of the nurse’s work will be influenced, in fact almost determined, by her awareness of her patient’s needs, mental and physical, and the earnestness with which she tries to relieve them. More than this, the nurse whose skill is warmed by a sincere desire to give of her best will, by virtue of this very desire, learn something from each patient, and will be steadily enriched and broadened by her experiences. She will have more to give, and accordingly will derive increasing satisfaction from her service to each succeeding mother and baby that she takes into her care.

One word more. The maternity nurse almost inevitably becomes deeply attached to her baby patient, whether he is sick or well, and she is eager to protect him and safeguard him as long as possible. She may continue to serve him, even after he has passed from her trained hands, if she will teach his mother how to take care of him, should she be inexperienced, particularly if the young mother is to have full charge of her baby after the nurse leaves, or is to have only the assistance of a partly trained nursery maid. In such a case the nurse may often perform her most valuable and enduring service to the baby by gradually teaching his mother how to prepare the milk with cleanliness and accuracy, if he must be bottle-fed; how to give his bath deftly and comfortably, and impressing upon her the importance of fresh air and of regularity in the baby’s daily routine. All of these things, and also how to do the thousand and one other things that seem so trivial and yet mean so much to the baby’s immediate health and future well being.

The first day after the nurse leaves, and the first few after that are often very dark ones for the inexperienced young mother, and if she is alone they are likely to be filled with fear and misgivings. The nurse may rob these days of much of their discouragement by anticipating them; trying to imagine the young mother’s possible perplexities and then teaching her how to meet them. This teaching is perhaps not a part of the nurse’s professional obligation but it is one of the privileges, one of the gratifying by-paths of nursing that she may take for the sheer joy of it.

Not infrequently the young mother is so filled with awe over possessing anything so wonderful as her own baby that she is afraid to handle the exquisite little body; is fearful of harming it; and because of her timidity and inexperience she fails to give him the care that he needs, and that she wants to give. On the other hand, all too many young mothers have a blind confidence that the mere act of having a baby vests one, in some instinctive way, with the requisite knowledge and skill to care for it, and in this belief they are supported by a legion of women friends and relatives.

It would be difficult to imagine a single factor that works more destruction among babies than this one of ignorant motherhood. And the damage is equally great whether the ignorance arises from timidity or from overweening confidence.

“Is it not preposterous,” says Herbert Spencer, “that the fate of a new generation should be left to the chance of unreasoning custom, impulse, fancy, joined with the suggestions of ignorant nurses and the prejudiced counsel of grandmothers? To tens of thousands that are killed, add hundreds of thousands that survive with feeble constitutions, and millions that grow up with constitutions not so strong as they should be, and you have some idea of the curse inflicted on their offspring by parents ignorant of the laws of life.”

The nurse is in the most effective position possible, to help in dispelling maternal ignorance, during the long days of pleasant intimacy which she and the young mother spend together in devotion to the baby. And by helping the inexperienced young mother to give skilful care to her baby, with all of the gentleness and tenderness that a mother can lavish, the nurse will not only serve the baby; she also will awaken for many a young woman, an interest that will be ever fresh and absorbing, and point the way to unexpected joys and delights in her motherhood.