protectors cannot be justified since the chief reason for putting
them on a baby is to avoid the necessity of changing his diaper as
soon as it is wet. Under special circumstances such as a drive, a
short journey or visit the diaper may be protected by water-proof
drawers. Their habitual use saves work for the nurse but makes the
baby uncomfortable and unhappy.
The =petticoat= should be of light-weight, cotton and wool flannel,
cut after the familiar Gertrude pattern and hang straight from the
shoulders. It may fasten in the back or on the shoulders, with small
buttons or with tapes. Tapes are often objected to on the ground
that the baby tangles them up with his fingers, which annoys him,
and often puts them in his mouth. This petticoat is worn practically
all the time, except during very warm weather.
The =slips or dresses= are most satisfactory if cut after the same
pattern as the petticoat, with the addition of sleeves which may be
set in, or of the kimono style. The dresses serve chiefly to keep
the petticoats clean and make the baby look dainty, and are
accordingly made of soft cotton material such as nainsook, cambric
or lawn. In summer, it is true, the petticoat is often discarded and
the thin slip put on over the shirt and diaper.
The =night gowns= are made like the dresses but are of soft flannel
or stockinette, in cold weather, and tape is often run through the
hems in order that they may be drawn up, bag-fashion, to keep the
baby’s feet warm. During very warm weather the baby sleeps in a thin
cotton slip.
In addition to these garments there are many times when a soft
little sacque or wrapper is used to keep the baby warm, and one or
two flannel squares (one yard), to wrap around him when he is
carried about the house are practically indispensable.
The petticoats, dresses and night gowns are cut about twenty-seven
inches long and many doctors feel that they offer sufficient
protection for the feet of the average baby to make stockings
unnecessary until he is from four to six months old. The skirts may
then be shortened to ankle length and stockings added to the little
wardrobe. Some doctors think it wiser to put knitted socks or part
wool stockings on the new baby particularly if he is born during
cold weather.
When the baby begins to creep, he should wear soft soled shoes, part
wool stockings in cold weather and thin cotton or silk ones during
the summer, and firm but flexible soled shoes as soon as he tries to
stand alone or to walk.
During the first month or two, the baby scarcely needs special
clothing for out-door wear, as he may be warmly wrapped in one of
the flannel squares by being placed on it diagonally, the upper
corner folded about his head to form a hood and held under his chin
with a safety pin. The corners on the sides are folded about his
shoulders, the lower one brought up over his feet and limbs and the
additional blankets tucked in over all. But as he grows older and
moves about in his carriage, he will need a cap and cloak or wrap
with hood attached. In cold weather the cap should be knitted or
wool lined and the cloak of soft woolen material or wool lined. In
moderate weather the cap may be of one thickness of cotton or silk,
or very light flannel, while on very warm days he will need no head
covering.
To sum up: The baby’s clothes should be simple in design, hang from
the shoulders, fit smoothly but loosely and have no constricting
bands; they should be soft, light and porous, their warmth always
adjusted to the immediate temperature so that the baby will be
protected from being either chilled or overheated. And his clothing
must always be clean and dry.
=Fresh Air.= An abundance of fresh air is one of the baby’s greatest
needs as it increases his resistance and recuperative powers,
improves his appetite and aids digestion. In general, the more the
baby is in the open air and the more fresh air he has while in the
house, the better.
The two factors which must be considered in supplying the baby with
fresh air are the condition and vigor of the baby himself and the
immediate temperature and state of the weather. His age and the
season of the year can be only partial guides because of the
difference between individual babies of the same age and the
variations in temperature, winds and moisture during any one season.
The air of the room which the baby occupies should be changing
constantly in order that it may always be fresh, but the temperature
should be equable and the baby protected from drafts. As the
tendency here, as with the baby’s clothes, is toward overheating,
the nurse will do well to remember that the new baby who lies
covered up in his crib, may usually be kept in a colder room than is
advisable for an older one who is creeping or walking about.
During cold weather the baby’s bed should not be directly in front
of an open window and he should be protected from direct currents of
cold air by a sheet hung over the head and side of his crib. (See
Fig. 153.)
Two or three times daily, while the baby is out of the room, the
windows should be opened wide to air the room thoroughly, one of
these airings being just before the baby is put to bed for the
night.
The usual instructions concerning the temperature of the nursery are
to keep it from 68° F. to 70° F. during the day and about 65° F. at
night, during the first three months and lower it gradually to 64°
F. during the day and about 55° F. at night as the baby grows older.
It is customary to begin to open the nursery window at night when
the baby is three or four months old, if he is well and the
temperature is above freezing.
In planning to take the baby out-of-doors it is wiser, as a rule, to
begin with the indoor airing when he is about a month old, except,
of course, during the moderate or mild months of the year, when he
is taken out at once. If the weather is cold, the baby may be
protected with extra wraps and carried in the nurse’s arms, into a
room in which the windows are open and kept there for fifteen or
twenty minutes. This indoor airing is increased by being gradually
lengthened to two or three hours and by having the windows opened
wider and wider. By the time he is two or three months old he is
taken out of doors on clear, bright days, the best time being
between ten and three o’clock, when the sun is high. If he is
carried in the nurse’s arms at first the warmth of her body serves
as a protection and helps to accustom him to the out-of-door life,
when he spends a good deal of his time out of doors in his carriage.
On windy, stormy days or when there is melting snow on the ground
the baby may be given his airing on a protected porch or in a room
with the windows open. He is not usually taken out if the
temperature is below freezing until the third or fourth month. After
this time the average baby is taken out when the temperature is not
lower than 20° F.
When the baby is dressed in his extra wraps he must be taken out of
doors or the windows opened immediately, for otherwise he will
become overheated and be in danger of chilling when taken into the
colder air.
Warm hands and feet, a good color and the baby’s tendency to sleep
most of the time while out-of-doors are evidences of his being
adequately clothed for his airing, while the reverse is true if he
is not warm enough.
A robust baby who has been gradually accustomed to being
out-of-doors during the day will usually be much benefited by
sleeping out at night. But he must be protected from winds and his
clothing so arranged that he cannot be chilled. Knitted or flannel
sleeping garments or sleeping bags (See Fig. 159) are valuable and
in addition, the blankets which cover the baby should be securely
pinned to the mattress with safety pins and tucked well under it at
the sides and foot. The baby should wear a warm cap and the bed
should be warmed before he is put into it. Or better still, he may
be dressed for the night, put to bed in a warm room and the crib
then moved out on the sleeping-porch.
[Illustration:
FIG. 162.—Sutton poncho which keeps the baby warm by covering all but
his head. The insert shows slit for his head. The regular bedding is
temporarily turned back in this picture. (From photograph taken at
Bellevue Hospital.)
]
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.
[Illustration:
FIG. 163.—A comfortable position for the baby being trained to use
chamber.
]
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.
[Illustration:
FIG. 164.—Stiff cuffs to prevent thumb sucking. (From photograph taken
at Johns Hopkins Hospital.)
]
=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.
[Illustration:
FIG. 165.—Cap, to prevent ruminating. (Devised by Miss Hammer.)
]
=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.)
[Illustration:
FIG. 166.—Ruminating cap applied. (From photograph taken at Johns
Hopkins Hospital.)
]
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.
[Illustration:
FIG. 167.—Proper method of carrying baby to support head and back.
(From photograph taken at Johns Hopkins Hospital.)
]
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:
First week 1½ to 2½ ounces
Second and third week 2 to 4 ounces
Fourth to ninth week 3 to 4½ ounces
Tenth week to fifth month 3½ to 5 ounces
Fifth to seventh month 4½ to 6½ ounces
Seventh to twelfth month 6½ to 9 ounces
=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:
_Mother’s Milk._ _Cows’ Milk._
Fats 3.5 to 4. % 3.5 to 4. %
Sugar 6.5 to 7.5% 4.5 to 4.75%
Proteins 1. to 1.5% 3.5 to 4. %
Salts .2% .7 to .75%
Water 87 to 88. % 87. %
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.
[Illustration:
FIG. 168.—Preparing the baby’s milk. (From photograph taken at Johns
Hopkins Hospital.)
]
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.
[Illustration:
FIG. 169.—Proper position in which to hold baby and bottle during
feeding.
]
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.
[Illustration:
FIG. 170.—Holding the baby upright and gently patting his back to
bring up air immediately after feeding.
]
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.
Ready Method for Selecting Amounts to be Employed in Making
Various 20–Oz. Milk-Mixtures, and the Caloric Values Resulting
[Illustration:
READY METHOD FOR SELECTING AMOUNTS TO BE EMPLOYED IN MAKING
VARIOUS 20–OZ. MILK-MIXTURES, AND THE CALORIC VALUES RESULTING
┌────────────────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┐
│ Percentages │Lower│Lower│Lower│Whole│Upper│Upper│Upper│Upper│
│ desired of │8 oz.│ 16 │ 28 │Milk │ 24 │ 20 │ 16 │ 10 │
│ │ │ oz. │ oz. │ │ oz. │ oz. │ oz. │ oz. │
│ │ │ │ │ │ │ │ │ │
├───┬─────┬──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│Fat│Sugar│Prot’n│ │ │ │ │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│0.5│5 │1 │ │ │ 5 │ │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│0.5│6 │2 │ │10 │ │ │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│1 │6 │1 │ │ │ │5 │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│1 │6 │1.5 │2.5 │ │ │5 │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│1 │6 │2 │ │ │10 │ │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│1.5│6 │1 │ │ │ │ │ │5 │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│1.5│6 │1.5 │ │ │ │7.5 │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│2 │6 │1.5 │2.5 │ │ │ │ │ │5 │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│2 │6 │2 │ │ │ │10 │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│2.5│6 │1.5 │2.5 │ │ │ │ │ │ │5 │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│2.5│6 │2 │ │ │ │ │10 │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│2.5│6 │2.5 │ │ │ │12.5 │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│3 │6 │1 │ │ │ │ │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│3 │6 │1.5 │2.5 │ │ │ │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│3 │6 │2 │ │ │ │ │ │10 │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│3 │6 │3 │ │ │ │15 │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤
│4 │4 │4 │ │ │ │20 │ │ │ │ │
└───┴─────┴──────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┘
┌────────────────┬─────┬─────┬─────┬───────┬────────┐
│ Percentages │Upper│Water│Sugar│Caloric│Calories│
│ desired of │8 oz.│ oz. │ oz. │ Value │per oz. │
│ │ │ │ │ of │ │
│ │ │ │ │Mixture│ │
├───┬─────┬──────┼─────┼─────┼─────┼───────┼────────┤
│Fat│Sugar│Prot’n│ │ │ │ │ │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│0.5│5 │1 │ │15 │0.8 │175 │ 8.75 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│0.5│6 │2 │ │10 │0.8 │225 │11.25 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│1 │6 │1 │ │15 │1 │225 │11.25 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│1 │6 │1.5 │ │12.5 │0.9 │237.5 │11.88 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│1 │6 │2 │ │10 │0.8 │250 │12.5 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│1.5│6 │1 │ │15 │1 │250 │12.5 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│1.5│6 │1.5 │ │12.5 │0.9 │262.5 │13.13 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│2 │6 │1.5 │ │12.5 │0.9 │287.5 │14.38 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│2 │6 │2 │ │10 │0.8 │300 │15 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│2.5│6 │1.5 │ │12.5 │0.9 │312.5 │15.63 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│2.5│6 │2 │ │10 │0.8 │325 │16.25 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│2.5│6 │2.5 │ │7.5 │0.7 │337.5 │16.88 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│3 │6 │1 │5 │15 │1 │325 │16.25 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│3 │6 │1.5 │5 │12.5 │0.9 │337.5 │16.88 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│3 │6 │2 │ │10 │0.8 │350 │17.5 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│3 │6 │3 │ │5 │0.4 │375 │18.75 │
├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤
│4 │4 │4 │ │0 │ │400 │20 │
└───┴─────┴──────┴─────┴─────┴─────┴───────┴────────┘
FIG. 171. Table of fat percentages, by permission, from “The
Diseases of Infants and Children,” by J. P. Crozer Griffith,
M.D.
]
* * * * *
[Illustration:
─────────────────────────────────────────────────────
TABLE GIVING APPROXIMATE PERCENTAGE-STRENGTHS OF
DIFFERENT LAYERS OF MILK
Per cent. Per cent. Ratio
Fat Protein
and Sugar
Upper 2 oz. 24 4 6 to 1
Upper 4 oz. 20 4 5 to 1
Upper 6 oz. 16 4 4 to 1
Upper 8 oz. 12 4 3 to 1
Upper 10 oz. 10 4 2.5 to 1
Upper 16 oz. 8 4 2 to 1
Upper 20 oz. 6 4 1.5 to 1
Upper 24 oz. 5 4 1.25 to 1
Upper 32 oz. whole milk 4 4 1 to 1
Lower 30 oz. 3 4 .75 to 1
Lower 28 oz. 2 4 .50 to 1
Lower 16 oz. 1 4 .25 to 1
Lower 8 oz. 0.5 4 .0 to 1
─────────────────────────────────────────────────────
* * * * *
TO FIND THE AMOUNT OF ANY LAYER OF MILK TO BE USED TO GIVE
PERCENTAGES DESIRED
Equation:
Total amount of food × Percentage of fat desired Amount of
———————————————————————————————————————————————— = this milk in
Fat-strength of layer of milk used the mixture.
(1) Select from the “Layers of Milk” Table the milk which possesses
the desired ratio of fat to protein.
(2) Substitute in the equation.
(3) As the sugar-percentage has been reduced equally with that of
the protein, add sufficient sugar to raise to the desired
percentage.
EXAMPLE: 20–oz. mixture desired. Percentages desired = Fat 3, Sugar
6, Protein 1. Use upper 8 oz. (fat 12%, protein 4%, viz.: 3:1).
Then 20 × 3/12 = 5 oz. of upper 8 oz., with 15 oz. of water in
the 20–oz. mixture. The protein necessarily becomes 1%, and the
sugar likewise. The mixture already containing 1% of sugar, add
5% of 20 oz., i. e., 1 oz. of sugar to increase this to the 6%
desired.
* * * * *
TO DETERMINE THE PERCENTAGES PRESENT IN ANY MILK-MIXTURE ALREADY
IN USE
Quantity of substance used
(milk, cream, or skimmed milk)
× Its percentage-strength
————————————————————————————— = Percentage of element
Total Quantity of Food (F., S. or P. in the mixture.)
EXAMPLE: The mother has mixed: Upper 8 oz.; 6 oz.—Lower 8 oz.; 3
oz.—Milk-sugar 3 level tablespoonfuls.—Water 27 oz. Total
quantity = 36 oz. The upper 8 oz. contains 12% fat (see Table).
Both top and bottom milk contain 4% protein and sugar. Three
tablespoonfuls sugar = approximately 1 oz. The fat of the lower
8 oz. may be ignored. Then 6 × 12/36 = 2 = Fat percentage from
the top-milk. 3 × 0/36 = 0 = Fat-percentage from the bottom
milk. 9 × 4/36 = 1 = Protein and sugar percentages from combined
top and bottom milk. The 1 oz. additional sugar divided by 36 =
approximately 3% sugar added. There being already 1% sugar
derived from the milk, the total sugar = 4%.
* * * * *
FIG. 172. Reverse side of card in Fig. 171.
]
Moreover, it does not ordinarily devolve upon the nurse to do more
than prepare and give the baby’s food as ordered by the doctor, but
situations sometimes do arise when the doctor is not within reach
which the nurse must meet as best she can. In such an emergency she
might be guided by the following suggestions contained in a pamphlet
entitled, “Save the Babies,” prepared by Dr. L. Emmet Holt and Dr.
H. K. L. Shaw and published by the American Medical Association,
remembering that they are intended for the average, normal baby and
are not necessarily suitable for all babies:
“The simplest plan is to use whole milk (from a shaken bottle)
which is to be diluted according to the child’s age and
digestion.
“Beginning on the third day, the average baby should be given 3
ounces of milk daily, diluted with seven ounces of water. To
this should be added one tablespoonful of lime water and 2 level
teaspoonfuls of sugar. This should be given in seven feedings.
“At one week, the average child requires 5 ounces of milk daily,
which should be diluted with 10 ounces of water. To this should
be added 1½ even tablespoonfuls of sugar and one ounce of lime
water. This should be given in seven feedings.
“The milk should be increased by ½ ounce about every 4 days.
“The water should be increased by ½ ounce about every 8 days.
“At three months the average child requires 16 ounces of milk
daily, which should be diluted with 16 ounces of water. To this
should be added 3 tablespoonfuls of sugar and 2 ounces of lime
water. This should be given in 6 feedings.
“The milk should be increased by ½ ounce about every 6 days.
“The water should be reduced by ½ ounce about every 2 weeks.
“At 6 months the average child requires 24 ounces of milk daily,
which should be diluted with 12 ounces of water. To this should
be added 2 ounces of lime water and 3 even tablespoonfuls of
sugar. This should be given in 5 feedings.
“The amount of milk should be increased by ½ ounce every week.
“The milk should be increased only if the child is hungry and
digesting his food well. It should not be increased unless he is
hungry, nor if he is suffering from indigestion even though he
seems hungry.
“At 9 months, the average child requires 30 ounces of milk
daily, which should be diluted with 10 ounces of water. To this
should be added 2 even tablespoonfuls of sugar and 2 ounces of
lime water. This should be given in 5 feedings.
“The sugar added may be milk sugar or, if this cannot be
obtained, cane (granulated) sugar or maltose (malt sugar).
“At first plain water should be used to dilute the milk.
“At three months, sometimes earlier, weak barley water may be
used in the place of plain water; it is made with ½ level
tablespoonful of barley flour to 16 ounces of water and cooked
20 minutes.
“At six months the barley flour may be increased to 1½ even
tablespoonfuls, cooked in the 12 ounces of water.
“At nine months, the barley flour may be increased to 3 level
tablespoonfuls, cooked in the 8 ounces of water.
“A very large baby may require a little more milk than that
allowed in these formulas. A small delicate baby will require
less than the milk allowed in the formulas.”
These formulas may be tabulated as follows:
────────┬────────┬────────┬────────────┬────────────┬──────────────
Age │ Milk │ Water │Barley-Water│ Lime-Water │ Sugar
────────┼────────┼────────┼────────────┼────────────┼──────────────
│ │ │ │ │
════════╪════════╪════════╪════════════╪════════════╪══════════════
3–7 days│ 3 ozs.│ 7 ozs.│ 16 ozs. │ ½ ozs.│2 teaspoons
2d week │ 5 ozs.│10 ozs.│ 15 ozs. │ 1 ozs.│1½ tablespoons
3d week │ 6 ozs.│10½ ozs.│ 14 ozs. │ 1 ozs.│1½ tablespoons
1 month │ 7 ozs.│11 ozs.│ 12 ozs. │ 1 ozs.│2 tablespoons
2 month │11 ozs.│13 ozs.│ 12 ozs. │ 1½ ozs.│2½ tablespoons
3 month │16 ozs.│ │ 11 ozs. │ 2 ozs.│3 tablespoons
4 month │19 ozs.│ │ 10 ozs. │ 2 ozs.│3 tablespoons
5 month │21½ ozs.│ │ │ 2 ozs.│3 tablespoons
6 month │24 ozs.│ │ │ 2 ozs.│3 tablespoons
7 month │26 ozs.│ │ │ 2 ozs.│3 tablespoons
8 month │28 ozs.│ │ │ 2 ozs.│2½ tablespoons
9 month │30 ozs.│ │ │ 2 ozs.│2 tablespoons
────────┴────────┴────────┴────────────┴────────────┴──────────────
────────┬───────────────┬────────────────
Age │No. of feedings│ Hours
────────┼───────────────┼──────────┬─────
│ │ Day │Night
════════╪═══════════════╪══════════╪═════
3–7 days│ 7 │6–9–12–3–6│10–2
2d week │ 7 │6–9–12–3–6│10–2
3d week │ 7 │6–9–12–3–6│10–2
1 month │ 7 │6–9–12–3–6│10–2
2 month │ 7 │6–9–12–3–6│10–2
3 month │ 7 │6–9–12–3–6│10–2
4 month │ 6 │6–9–12–3–6│10
5 month │ 6 │6–9–12–3–6│10
6 month │ 5 │6–10–2–6 │10
7 month │ 5 │6–10–2–6 │10
8 month │ 5 │6–10–2–6 │10
9 month │ 5 │6–10–2–6 │10
────────┴───────────────┴──────────┴─────
=Mixed Feeding.= Under some conditions the breast-fed baby is given
also a certain amount of modified milk, and this combination of
natural and artificial feeding is termed mixed or supplementary
feeding.
A deficiency in the breast milk, ascertained by weighing the baby
before and after each nursing, may be supplied by following each
nursing with a bottle feeding; or one or two breast-feedings, in the
course of the day may be replaced by entire bottle feedings. In any
case the milk mixture to be used as supplementary feeding is
prepared with exactly the same painstaking care as is the milk for
entire artificial feeding.
If supplementary food is given because of an inadequate supply of
breast milk, it is of great importance that the baby be put to the
breast regularly, no matter how little food he obtains, for his
suckling is the best possible means of stimulating the breasts to
secrete more milk and of equal importance is the fact that they will
tend to dry up if the baby nurses less than about five times in
twenty-four hours. Moreover, even a little breast milk is valuable
to him and he should have the benefit of all there is to be had.
An entire bottle feeding is sometimes given to a baby who is nursing
satisfactorily at the breast, in order to give his mother an
opportunity to take longer outings than are possible between the
regular nursings. And sometimes it is to the mother’s advantage, and
therefore to the baby’s, to give him a bottle during the night and
thus allow her to sleep undisturbed.
COMMERCIAL BABY FOODS
Since the baby’s food is prescribed by the doctor, the nurse has
little concern with the various proprietary baby foods and the
canned and powdered milks which are so persuasively advertised to
young mothers. It is hoped, however, that the discussions on
nutrition in general and on baby feeding in particular, have made it
clear to the nurse that these foods cannot be expected to be
satisfactory if used as a sole article of diet throughout the
bottle-feeding period.
There are many times and circumstances, however, when the temporary
use of a prepared infant food or canned or powdered milk is
advantageous. In some cases of intestinal disturbance, for instance,
or while the mother is traveling and is unable to have freshly
prepared milk formulas supplied to her along the way; during the
summer, while staying at a hotel or boarding house where the
freshness, cleanliness or purity of the milk are uncertain; or
during a sudden shortage of fresh milk, as may occur during a strike
or severe storm when transportation is interfered with, a
proprietary food may be a great boon.
If the nurse is confronted with the necessity of choosing and making
temporary use of a prepared food she may be guided by considering
the general principles of baby feeding and the character of the
materials at her disposal.
=The Proprietary Foods= may be divided into two general groups: one
kind contains milk powder and is usually added to water while the
other consists largely of sugar and starch and is added to fresh
milk before being given to the baby.
=Canned Milk= is of two kinds; evaporated, which is unsweetened, and
condensed, which is sweetened. _Evaporated milk_ is whole milk from
which part of the water has been removed, the milk then being canned
and sterilized. The addition of water to evaporated milk restores it
to the composition of whole milk in many respects, but it is still
milk that has been heated. _Condensed milk_ is evaporated milk to
which cane sugar has been added to aid in its preservation. Since
bacteria do not grow well in highly sweetened foods, it is not
necessary to bring sweetened condensed milk to as high a temperature
as the unsweetened product, to prevent subsequent bacterial
decomposition. The high percentage of sugar in condensed milk quite
obviously renders it unsuitable for continuous use as the sole
article in a baby’s dietary.
=Milk Powders or Dried Milks= are prepared by rapidly evaporating
the water from whole milk, skimmed milk or partly skimmed milk,
leaving the solid constituents in the form of a light, white powder.
Milk powder readily dissolves in water, forming a “reconstructed
milk” which closely resembles the fresh milk from which it was
prepared. But it must not be forgotten that reconstructed milk has
been heated. Many doctors consider whole milk powder the most
satisfactory form of preserved milk which is available for baby
food. Should it be used, however, the importance of keeping it
tightly covered and in a cold place must be recognized, for the
presence of fat renders it likely to become rancid if not kept cold.
ARTICLES OF FOOD WHICH ARE SOMETIMES INCLUDED IN THE BABY’S DIETARY
=Barley Water=, sometimes used to dilute whole milk, is made by
mixing the barley flour to a smooth paste in cold water, adding
boiling water and boiling for twenty minutes or cooking in a double
boiler for an hour, straining and adding enough water to replace the
amount lost in cooking. The proportions for different ages are as
follows:
Three months, ½ level tablespoonful barley flour to 16 oz. water
Six months, 1½ level tablespoonful barley flour to 12 oz. water.
Nine months, 3 level tablespoonfuls barley flour to 10 oz. water.
=Potato Water.= One tablespoonful of thoroughly boiled potato is
mashed into one pint of the water in which the potato was boiled and
carefully strained.
=Spinach.= Spinach is carefully washed, steamed for half an hour and
mashed through a fine sieve. It is sometimes started at the sixth
month; one teaspoonful daily, gradually increased to one or two
tablespoonfuls daily.
=Orange Juice.= The orange should be dipped in boiling water and
wiped on a clean towel before being cut and squeezed, to avoid
possible infection of juice. It is usually given to babies getting
heated milk, sometimes as young as one month old. It is carefully
strained and started gradually by giving one teaspoonful in water
once or twice daily between feedings and increasing to ½ or 1 ounce
by the sixth month and 1½ to 2 ounces by the end of the first year.
=Infusion of Orange Peel.= This is sometimes used instead of orange
juice, and is made by boiling one ounce of finely grated orange peel
in two ounces of water, adding a little sugar to counteract the
bitter taste and adding enough sterile water to bring it up to two
ounces.
=Tomato Juice.= Canned tomato strained through a fine sieve, is
sometimes given to a baby a few weeks old, starting with one dram
and gradually increasing to four to six ounces daily.
=Whey.= One quart of whole milk heated to 98° F. or 100° F. and
one-half ounce of liquid rennet or one junket tablet stirred into it
and allowed to stand half an hour or until firm and solid, is poured
into a cheese-cloth bag and allowed to drain for about an hour
without being squeezed.
=Protein Milk.= The curd from one quart of milk, which remains after
the whey is drained, as directed above, is mashed through
cheese-cloth in a fine wire sieve, with a potato-masher or bowl of a
spoon and the curd washed through with one pint of water. A pint of
buttermilk is added and the mixture boiled while being stirred
constantly. This is sometimes given in diarrhea.
=Beef Juice.= One pound of thick round steak, slightly broiled, is
cut into small pieces and the juice expressed with a meat press or a
lemon squeezer, the amount varying from 2 to 3 ounces. It may be
diluted with an equal amount of warm water, or slightly warmed by
being placed in a cup standing in hot water, and salted to taste.
=Broths.= One pound of lean meat, all fat and gristle removed, is
allowed to one pint of water. The meat is cut finely and put on in
cold water, heated slowly and allowed to simmer for three or four
hours, when water is added to replace what was lost in cooking. It
is strained, the fat removed and slightly salted.
=Oatmeal Water.= Two level tablespoonfuls of oatmeal in a pint of
boiling water is cooked in a double-boiler for two hours, strained
and enough boiling water added to replace the amount lost in
cooking.
TRAVELING
[Illustration:
FIG. 173.—The baby will travel comfortably in a basket converted into
a bed. (Courtesy of the Maternity Centre Association.)
]
The difficulties of traveling with a young baby may be greatly
lessened by making certain preparations. If the baby is bottle-fed,
the preparations will depend upon the length of the journey and
whether or not it will be possible to have freshly prepared
feedings, for each twenty-four hours, put on the train from
laboratories along the way. If this is not possible and the journey
is not to take more than twenty-four hours, the entire quantity of
food, ice cold, may be carried in a thermos bottle. The requisite
number of sterile nursing bottles may be taken or one bottle which
is boiled before each feeding. Or the milk may be prepared as usual
and the bottles packed in a portable refrigerator. Such a
refrigerator may be bought or one may be improvised. The bottles are
placed in a covered pail and packed solidly in crushed ice; this is
placed in a second pail or a box with a diameter which is at least
two inches larger than the inner pail and the space between the two
packed firmly with sawdust. Several thicknesses of newspapers should
be pressed down over the top and a tight cover fitted to the outer
receptacle.
The sterile nipples may be taken in a sterile jar and a deep cup or
kettle will be needed in which to warm the bottle before each
feeding. It is usually possible to obtain water on the train which
is hot enough for this, or cans of solid alcohol, a stand and a
metal tray may be added to the traveling outfit. If fresh formulae
cannot be delivered to the train, daily, and the journey is to last
more than twenty-four hours, one of the proprietary foods or a
powdered milk will often prove to be a satisfactory solution to the
problem of feeding.
The baby will usually travel more comfortably and sleep better if he
is carried in a basket. A large market basket with a handle or a
small clothes basket will serve. It may be lined with a sheet or a
blanket; have a small hair pillow or folded blanket in the bottom
and be made up like a crib. (Fig. 173.) If this basket stands on the
car seat during the day, and on the foot of the nurse’s berth at
night, the baby will be cleaner, quieter and less exposed to drafts
than if carried in the arms.
THE PREMATURE BABY
All of the precautions and gentleness which are necessary in the
care of the normal baby, born at term, must be greatly increased in
caring for the baby who is born prematurely.
As was explained in Chapter III the premature baby’s prospects of
living increase with the length of his uterine life, and it is often
possible to estimate this by measuring and weighing him. During the
last five months the child’s length in centimetres divided by five
gives the month of pregnancy, according to the following table by
Dr. Williams:[15]
At the fifth month of pregnancy 5×5, fetus is 25 cm. long
At the sixth month of pregnancy 6×5, fetus is 30 cm. long
At the seventh month of pregnancy 7×5, fetus is 35 cm. long
At the eighth month of pregnancy 8×5, fetus is 40 cm. long
At the ninth month of pregnancy 9×5, fetus is 45 cm. long
At the tenth month of pregnancy 10×5, fetus is 50 cm. long
But consideration of the baby’s weight is also of importance when
attempting to forecast his chances of living. A baby weighing less
than 2500 grams or about 5½ pounds should be regarded, and treated,
as premature, unless it is more than 45 centimetres, or about 18
inches long. This length would indicate greater maturity, and
therefore greater viability than would be expected from the weight.
A baby weighing less than 1500 grams (3 pounds and 5 ounces) can
scarcely be expected to live.
The premature baby is not only small, but in general is imperfectly
developed, having slenderer powers than the full-term baby and at
the same time much greater needs. His respiratory and digestive
organs are less ready to function than in the full-term baby; his
muscles and nerves are feeble; his heat-producing mechanism is
unstable and yet there is an excessive radiation of body heat
through the relatively large area of skin.
Accordingly, the baby who has been deprived of those valuable last
weeks of growth and development is small and limp; lies quietly most
of the time and moves very feebly if at all. He is often too weak to
nurse at the breast and may swallow with difficulty. His temperature
is low, his respirations irregular and he is frequently cyanotic.
[Illustration:
FIG. 174.—Quilted robe, with hood, for the premature baby.
]
The care of this frail little body practically resolves itself into:
1. Maintaining a normal body temperature.
2. Promoting and maintaining normal respirations.
3. Supplying adequate and suitable nourishment.
4. Conserving his strength.
5. Preventing infection.
[Illustration:
FIG. 175.—Premature baby in basket lined with quilted pad; wearing
quilted robe and being fed from a Boston feeder. The blanket is
turned back showing hot-water bag. (From photograph taken at Johns
Hopkins Hospital.)
]
To maintain a normal body temperature it is necessary to give
special thought to the baby’s clothing, bed and room. He should be
oiled with warm olive oil and entirely wrapped in cotton batting or
flannel or enveloped in a quilted garment, with hood attached, made
of cheese-cloth or flannel and cotton batting. (Fig. 174.) Diapers
are often omitted in caring for very feeble babies, a pad of cotton
being slipped under the buttocks instead as this may be changed with
less disturbance to the baby than a diaper.
[Illustration:
FIG. 176.—Model of improvised bed for premature baby: closely woven
clothes basket with padded bottom and four, flannel-covered bottles
of hot water attached to the sides. Thermometer and feeder are shown
in basket. (By courtesy of Dr. Alan Brown, Hospital for Sick
Children, Toronto.)
]
His bed consists of a box or basket, with the bottom well padded
with several inches of cotton, a small pillow or a soft blanket
folded to the proper size, covered with rubber or oiled muslin and a
cotton sheet. The sides of the basket should be lined with heavy
quilted material (Fig. 175), to shut out drafts and help to preserve
an even temperature of the air immediately around the baby. A
flannel covered hot-water bag at 110° F. may be placed beside the
baby, or two, three or four glass bottles, each holding about a
pint, containing water at 100° F. and securely stoppered, may be
hung in the corners of the basket. (Fig. 176.) A thermometer should
hang in the basket also, and the temperature kept between 80° F. and
90° F. It is easier to keep the temperature even if the bottles are
filled in rotation instead of all at the same time.
The amount of heat needed around the baby is decided by taking his
temperature (by rectum) at regular intervals; supplying more heat if
the temperature is low and less if it is at or above normal. Some
doctors have the temperature taken every four hours; others twice
daily. As the baby grows able to maintain a temperature of 98° F. to
100° F., unassisted, the surrounding heat is gradually reduced and
finally removed, and flannel clothing replaces the quilted robe.
In many hospitals there are special rooms for premature babies,
which are divided by glass partitions into cubicles so that each
baby is in a three-sided enclosure. The rooms are usually darkened
to save the baby from the needless irritation of light, and are
supplied with constantly changing fresh, moist, filtered air, the
temperature being kept at from 80° F. to 90° F.
In a patient’s home or in a hospital where there is no special room
for premature babies, a cubicle may be improvised by placing the
basket in which the baby lies, in the corner of a room and placing a
screen parallel with one of the walls. Such a room should be
darkened, well ventilated and have in it a large open vessel of
water.
Since the premature baby’s lungs are not fully expanded,
respirations are likely to be shallow and irregular, thus failing to
supply the amount of oxygen which he sorely needs. As crying
inevitably involves deep breathing, it is a common practice to make
the premature baby cry at regular intervals during the day in order
to promote the respiratory function. Dr. Griffith further recommends
plunging the baby into a mustard bath at 100° F. or 105° F. if
necessary to make him cry vigorously. It is also important to turn
the premature baby from side to side, several times a day to prevent
fluid from collecting in the lowermost part of the lung, a condition
favorable to the development of pneumonia.
In feeding premature babies, breast milk is ordinarily the most
desirable food. If the baby is too feeble to nurse, as frequently
occurs, the milk may be expressed from the breast of his mother or a
wet nurse, by stripping or pumping, into a sterile receptacle, and
if not used immediately it should be covered and placed in the
refrigerator. Breast milk is sometimes used whole and sometimes
diluted with water, and is given by gavage if the baby is very
feeble; from a medicine dropper or a special feeder. Such a feeder
consists of a glass tube with a small nipple on one end and a rubber
bulb on the other, by means of which the milk may be gently
expressed into the baby’s mouth, thus minimizing his effort to
obtain it. (See Fig. 175.)
The amount and intervals for feeding the premature baby have to be
adjusted to the individual with even greater care than for a normal
baby, for he needs more fuel and building material, because of his
imperfect development and yet because of that same imperfect
development his digestive powers are feebler than those of the
full-term baby. During the first day or two, he is sometimes given
nothing but water or sugar solution, the milk being started
gradually when the baby is from thirty-six to forty-eight hours old.
He may be given a very small quantity every two hours, or he may be
fed at three- or four-hour intervals, depending entirely upon his
condition and progress. It is usually considered very important for
the premature baby to have sterile water or sugar solution to drink
between feedings, and this is given in the same manner as his milk.
Unlike the normal baby he is not taken from his bed to be fed,
unless he nurses at the breast.
The premature baby is weighed as often as is safe for him, since the
suitability of his food is largely indicated by changes in his
weight. But sometimes very young and feeble babies are weighed only
once or twice a week because of the inadvisability of disturbing
them more frequently.
Avoidance of fatigue and the conservation of the premature baby’s
limited strength and energy are accomplished through reducing his
muscular activity to the minimum, by very little and very gentle
handling; and by minimizing his loss of energy in the form of heat
by keeping the little body warm and quiet.
In this connection the daily bath is of considerable importance. It
almost always consists of sponging the baby with warm olive oil as
he lies in his bed, and with the least possible exposure and
turning. It is given every day or every second or third day
according to his condition. The eyes are wiped with boric pledgets
and the nostrils with spirals of cotton dipped in oil. The buttocks
are wiped with an oil sponge each time the diaper is changed.
The premature baby is very susceptible to infection and strongly
predisposed to pneumonia. Infection in general is guarded against by
having everything that comes in contact with the baby scrupulously
clean; protecting him from drafts, chilling and dust; allowing no
one with a suspicion of a cold to come near him and by the nurse’s
wearing a clean gown and protecting her nose and mouth with a gauze
mask while attending him.
CARE OF THE BABY DURING THE SUMMER
The dangers of infancy are greatly increased in summer, more babies
dying during the hot months than any other time during the year. The
cause of these deaths is variously termed summer complaint, summer
diarrhea, acute gastro-enteritis and cholera infantum, and is due to
infected or decomposing food or both.
Clearly this malady is practically preventable through care.
Although such care as has been described in the preceding pages
largely constitutes the prevention of the much-to-be-dreaded summer
diarrhea, there are a few extra precautions and safeguards with
which the nurse must surround her little patient during the warm
weather.
She must bear in mind the character of the illness to be avoided:
indigestion associated with infection.
It becomes almost a matter of life or death, then, to give the baby
clean, suitable food and avoid deranging his digestion.
Babies suffer from the heat more than adults do and are often
excessively irritated and exhausted on warm days. And this
overheating, exhaustion and restlessness are of themselves enough to
affect his digestion.
Accordingly the scourge of summer diarrhea is prevented by giving
the baby proper food and keeping him clean, cool and quiet.
The baby should have maternal nursing if possible, for breast-fed
babies fall victim to summer diarrhea much less frequently than
bottle-fed babies. He should be fed with absolute regularity, and as
a rule, no matter what the nature of his food, it is reduced
one-quarter to one-third in amount during very warm weather and he
is given an increased amount of cool boiled water to drink. His
weight may increase very slightly, or even stand still for a short
time, as a result of his decreased food, but this is not usually
deplored, if he keeps well, for the important thing is to avoid
digestive disturbances while the weather is warm.
Cleanliness, as at other times, applies to the baby’s food, clothing
and surroundings. Many doctors think it safer to have all milk
boiled during the summer, and of course require flawless technique
in its preparation and administration. The baby’s soiled napkins
should be placed immediately in a covered receptacle containing
water, and not left for even a moment where they can be reached by
flies. They should be washed, boiled and dried in the open air and
sunshine as promptly as possible.
The baby should be protected from flies and mosquitoes by screens in
the windows and netting over his crib and carriage, both because
they make him restless and irritable and because flies particularly
are carriers of filth and disease—the kind of disease that kills so
many babies during the summer. Accordingly the nurse must always
regard flies with a deadly fear.
The baby should be kept away from dusty places and from cats and
dogs. And since babies will put their fingers in their mouths it is
a wise precaution to wash their hands several times a day.
The baby should be in the country, in the mountains or at the
seashore if possible during the warmest part of the summer at least,
but if he is in town there is much that the nurse can do to keep him
cool and comfortable. His clothing at this time must be adjusted to
his condition and the temperature of the moment just as it is in
cold weather. A thin shirt, band, diaper and cotton slip will
usually be enough for out-of-door wear, while in the house he may
often dispense with the slip and sometimes with everything but his
diaper.
During excessively hot days, the baby should have two or three cool
sponge baths, in addition to the soap and water bath, one of the
sponges being given before he is put to bed for the night. He should
sleep on a firm mattress, preferably curled hair but never feathers,
and in the coolest, best ventilated room available. During the day
it is usually best to take him out-of-doors early in the morning and
late in the afternoon, but to keep him indoors during the warmest
part of the day, when it is likely to be cooler indoors than out,
particularly if the blinds are closed. Quite naturally the nurse
will have to take into consideration the size, arrangement and
location of the baby’s home in her effort to keep him in cool,
quiet, shady places and out-of-doors as much as possible.
He must not be played with, held on hot laps nor subjected to the
entertainment and attention which misguided but well-meaning mothers
and friends are so eager to lavish on a hot, fretful baby.
Very often during warm weather a fine rash known as “prickly heat”
appears on the back of the baby’s neck and spreads over his head,
neck, chest and shoulders. This rash is due to too warm clothing or
to the hot weather or to both. Less clothing and frequent baths will
often give relief, but if the baby is very uncomfortable, he may be
greatly soothed by being immersed in cool baths containing soda,
bran or starch in the following proportions:
=Soda bath.= Two tablespoonfuls of baking soda to one gallon of
water.
=Bran bath.= A cheese-cloth bag about six inches square, partly
filled with bran, is soaked and squeezed in the bath water until it
is milky.
=Starch bath.= About eight ounces of cooked laundry starch to one
gallon of water.
No soap should be used while the baby has prickly heat and after the
bath he should be patted thoroughly dry and powdered with some such
soothing powder as the following:
Powdered starch one ounce
Oxide of zinc one ounce
Boracic acid powder 60 grains
As we look back over these pages of somewhat detailed description of
the case of the baby, it is borne in upon us that the nursing of
this unfailingly delightful and interesting little patient has
special adjustments and adaptations for different seasons and
circumstances; but that on the whole the care of all babies the year
around resolves itself into the observation of a few general
principles, namely: proper feeding; fresh air; regularity in his
daily routine; cleanliness of food, clothing and surroundings;
maintenance of an equable body temperature and conservation of his
forces.
If the nurse fixes these principles firmly in her mind and acts upon
them, she will do a great deal to give her baby patient a fair start
on his life’s journey.
CHAPTER XXIII
COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY
The common ills of early infancy are due largely either to errors in
feeding or to infection or both. Of the nutritional disturbances,
rickets and scurvy were discussed in the chapter on nutrition, but
the obstetrical nurse will sometimes see also, malnutrition,
marasmus, inanition, diarrheal diseases, acidosis, colic,
constipation and vomiting.
All of these disorders are practically preventable through suitable
feeding, good care and hygienic surroundings. The nurse’s part in
this prevention consists in giving the painstaking care which was
described in the preceding chapter.
The terms _malnutrition_, _marasmus_, and _inanition_ designate
different forms and degrees of starvation, and are characterized by
loss of weight, prostration, feeble powers of assimilation, general
weakness and arrested growth. The temperature is likely to be low,
but in acute inanition, a rapid loss in weight may be accompanied by
a sudden rise in temperature. (Charts 6, 7, and 8.)
These so-called “wasting diseases” are frequently seen in children
who have congenital nervous instability and those born of
tuberculous, syphilitic or otherwise delicate parents. The treatment
is suitable food; fresh air and sunshine; an abundance of fluid by
mouth, rectum, subcutaneously or intraperitoneally; clean
surroundings and good nursing care.
THE DIARRHEAL DISEASES
These are among the most frequent and most serious illnesses of
early infancy. They may result from mechanical causes, such as a
mass of undigested food, which produces increased intestinal
secretion and peristalsis; from the action of bacteria, or their
toxins, together with the inability of an enfeebled digestive tract
to meet the needs of a rapidly growing body; or from such reflex
causes as sudden chilling of the body, excitement, fatigue or the
prostration resulting from excessively hot weather.
=Acute gastro-enteritis=, the diarrheal disease which is so common
and so fatal during the hot months of July and August, is often
referred to as “summer complaint” or “summer diarrhea.” It is so
largely avoidable through good nursing that the methods of its
prevention were described in connection with the care of the baby
during the Summer, resolving itself, as it does, into feeding the
baby properly and keeping him clean and cool and quiet.
=Symptoms.= While there are different forms of summer diarrhea, the
general symptoms are much the same and may develop gradually after
some evidence of indigestion, or suddenly with a rise of temperature
to 101° F. or 102° F., or even as high as 106° F., accompanied by
pain and vomiting. The baby is usually restless, fretful and thirsty
and his skin is hot and dry. He gives evidence of pain by shrill
crying, drawing up his legs and flexing them on his abdomen.
Diarrhea is the conspicuous symptom and there may be anywhere from
four to twenty movements in the course of 24 hours. The stools are
largely fecal matter at first but they finally become fluid and
contain mucus. They may be expelled with a good deal of force and a
quantity of gas come with them. The baby grows very weak, thin and
hollow-eyed, if the diarrhea persists and unless promptly treated
the end may be fatal.
=Treatment and Nursing Care.= The first step is to stop all food and
to give water freely. When water is not retained by mouth it is
frequently given by rectum, into the tissues or intraperitoneally.
The pain may be relieved by applying hot stupes.
Feeding is resumed very gradually and cautiously for one attack of
summer complaint predisposes to another and every precaution is
taken to prevent a recurrence. Thin barley water or broth is usually
given first, followed by whey, protein milk, buttermilk or diluted
skim-milk in small amounts and at comparatively long intervals.
[Illustration:
CHART 6.—Weight chart showing normal loss and gain during the first
fourteen days of life.
]
[Illustration:
CHART 7.—Chart showing loss of weight in inanition fever.
]
[Illustration:
CHART 8.—Temperature chart showing sudden elevation of temperature,
coincident with the marked loss of weight, in inanition fever.
]
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.
[Illustration:
FIG. 177.—Putting the baby in a wet pack.
]
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.
[Illustration:
FIG. 178.—Baby in pack with hot-water bag at feet and cold compress on
head. (Figs. 177 and 178 from photographs taken at Johns Hopkins
Hospital.)
]
[Illustration:
FIG. 179.—Diagrams showing successive steps in putting baby in pack
shown in Figs. 177 and 178.
]
=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.
[Illustration:
FIG. 180.—Baby wrapped in blanket, before being given gavage or eye
irrigation, to keep him warm and hold his arms and legs to his
sides. (From photograph taken at Johns Hopkins Hospital.)
]
[Illustration:
FIG. 181.—Gavage. (From photograph taken at Johns Hopkins Hospital.)
]
=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.
[Illustration:
FIG. 182.—Method of obtaining a fresh specimen of urine in a test
tube.
]
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.
[Illustration:
FIG. 183.—Obtaining a 24–hour specimen of urine through curved glass
tube attached to rubber tubing which empties into bottle tied to
side of bed. (From photographs taken at Johns Hopkins Hospital.)
]
[Illustration:
FIG. 184.—Muslin band with cuffs and tape used to keep the baby from
kicking while a specimen of urine is being obtained. The tapes are
tied tightly to the sides of the crib and the cuffs fastened around
the baby’s ankles with safety pins. See Figs. 182 and 183.
]
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.
[Illustration:
FIG. 185.—Belt used to hold tube in place while obtaining specimen of
urine as indicated in Figs. 182 and 183. The tube is passed through
the hole in the tab and adjusted over penis or between labia; the
belt fastened around the waist and straps passed between the thighs
and fastened to belt.
]
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.
[Illustration:
FIG. 186.—Giving an enema. The baby lies comfortably on a pillow which
reaches to the bed pan, the latter being covered with a diaper where
the baby rests upon it. He is well protected to prevent chilling.
]
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.
[Illustration:
FIG. 187.—Irrigating the eye with a blunt nozzle, the irrigation bag
hanging low in order that the stream may be gentle. (From a
photograph taken at Johns Hopkins Hospital.)
]
=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.
[Illustration:
FIG. 188.—Method of holding baby for eye examination or treatment.
(Photograph and appended notes by courtesy of Dr. W. Gordon M.
Beyers, Royal Victoria Hospital, Montreal.)