THE CARE OF THE CHILD
Hitherto the mother and the complications and changes peculiar to her
condition have been selectively considered, to the neglect of the child;
but the labor being over, and the nurse having assured herself that the
uterus is hard, that there is no hæmorrhage, and that the mother is
resting, now turns to the child lying in its blanket. A hot water bag,
carefully tested, should lie at its feet wrapped in toweling or napkins.
The eyes have already received the Credé treatment, 1 per cent solution
of silver nitrate or possibly a 15 per cent solution of argyrol for
prevention of ophthalmia, and a thorough cleansing comes next.
In a warm room, away from drafts, the nurse takes the child in her lap,
or on a table, with a blanket underneath. She first anoints the child
all over, either with benzoated lard, liquid albolene, sterile vaseline,
or olive oil. This softens the vernix caseosa that covers the child and
aids its removal.
The skin is wiped carefully with cotton or a soft cloth, paying
particular attention to the folds of the groin, the arm pits, and the
genitals. The nostrils are gently wiped out with applicators dipped in
oil.
The child must be covered as much as possible during the operation and
the work finished quickly. The whole period should not exceed twenty
minutes.
During the cleansing process the nurse should look closely for anomalies
or anatomical imperfections, like an imperforate anus or urethra,
supernumerary digits, etc.
=The Bath.=—Daily, until the cord comes off, the baby is sponged with
oiled pledgets, followed by a spray bath, or a sponging with lukewarm
water and castile soap. The child must not be put into a full bath tub
on account of danger of infecting the umbilicus. The bath water in a tub
or basin quickly becomes filled with bacteria from the surface of the
child’s body and may be conveyed quite easily to a raw wound.
[Illustration: Fig. 112.—Rubber bath tub.]
All discharges must be wiped away, and the buttocks cleansed with oil.
If the skin becomes irritated by urine or otherwise, the child should be
well covered with talcum powder, especially in the folds of the groin
and in the genital crease. All infants are benefited by a little mild
massage after the bath.
If other babies are handled, a child with infected eyes, or skin
eruptions, must be quarantined and cared for separately by a special
nurse. The color of the skin should be pink, changing under manipulation
to red. If there is mucus in the mouth, it may be wiped out with an
applicator, if in the throat, the child may be held up by the feet and
the head drawn back for a few minutes so that gravity will aid the
discharge of the obstruction.
After cleansing the skin, the nurse sterilizes her hands and dresses the
cord. The gauze which was temporarily wrapped around the stump is
removed, the cord and adjacent skin washed with alcohol and dried. The
stump is powdered above and at the sides with a mixture of equal parts
of boric acid and subnitrate of bismuth, and then wrapped in gauze. The
band is put on, the temperature taken, and the baby dressed. Some
physicians prefer to have the cord dressed in 95 per cent alcohol, which
is frequently renewed. The normal separation of the cord takes place
through a kind of dry gangrene, which should be favored by dry rather
than wet dressings. The 95 per cent alcohol does not remain at 95 per
cent after it is exposed to air, hence it does not absorb moisture from
the cord as absolute alcohol would. However, the attending man is
responsible, and his orders must be followed.
=The Umbilicus.=—The cord may be severed as soon as the child has cried
lustily or the cessation of pulsation may be awaited, in either case the
child secures a little more blood, which gives him a better start in
life.
Two tapes are tied about the cord, one close to the skin margin of the
child and the cord is cut between them. A kind of mummification or dry
gangrene normally develops and the stump falls off, as a rule, about the
fifth day, leaving a moist, granulating area, which forms the umbilicus.
A metal clamp may be used in place of a tape to compress the cord. The
advantage of the clamp is that on account of its greater width and
rigidity it does not cut through the cord when applied. Furthermore, it
can be made and kept more nearly aseptic. It does not soak up the juices
from the cord and form a culture medium for germs. It can be removed on
second day. The cord usually comes off a day or so sooner than when the
tape is used.
[Illustration: Fig. 113.—The Pettit cord clamp.]
The care of the cord is extremely important, as many infections can be
transmitted through it to the child. At each dressing the cord is
inspected, and whether it is dry or moist, offensive or inodorous,
should be noted. These facts, with the falling off of the cord, are put
down on the history sheet as they are observed. The binder, after each
removal, is not pinned, but sewed on. The sewing should begin below and
go up in order to have the tightness low down.
=Eyes.=—After the first instillation of silver nitrate solution, a
reaction appears with redness, swelling, and discharge, which passes off
without treatment in two or three days. During the bath, care must be
used not to get anything into the eyes nor anything from the eyes or
nose upon the navel.
At each dressing the nurse should irrigate the edges of the lids gently
with boric acid solution. If the eyes become red, swollen, and have a
purulent discharge after the second day, the case is possibly ophthalmia
and they must be watched with extreme vigilance. A smear should be taken
for the microscope and preparations made for energetic treatment.
The following summary may be of service in memorizing the routine of
nursery procedure.
=Nursery Rules=
1. Keep temperature of nursery 68° to 72° F.
2. During bath, keep temperature of nursery 75° to 80° F.
3. Temperature of bath water 98° to 99° F.
4. Never use a diaper that has not been laundered.
5. Tie case number on child’s arm before leaving delivery room.
6. Watch cord for hæmorrhage.
7. Record temperature, stools and urine.
8. Give water freely between feedings.
9. Put to breast twelve hours after birth, and every three hours
thereafter until the child begins to gain, then one and
_possibly_ (?) two night feedings may be omitted.
10. Change binder daily.
11. Oil bath first, then shower bath on subsequent days.
12. Dress cord with alcohol 95 per cent, dry and apply bismuth
subnitrate and boric acid powder (equal parts) into crevices
beneath clamp or tape and under edges of the crust. Change
dressing daily. Cord should fall off fifth day. Report failure to
do so.
13. Clamp may be removed on second day.
_Routine for the Child._—
1. Temperature.
2. Undress.
3. Weight.
4. Shower bath.
5. Dress cord—record condition.
6. Binder daily until discharged.
7. Diaper and dress.
8. Sponge eyes with boric solution.
9. Cleanse nostrils with albolene.
10. Brush hair.
11. Drink of warm water.
12. Observe case number daily.
=Clothing.=—(See Infant’s Outfit, p. 101.) The clothing must be light,
loose, warm, and not irritating to the skin. The outside garment should
have wing sleeves which permit free motion of the hands, but do not
permit them to reach the eyes.
The band of plain outing flannel should always be worn for the first few
weeks.
Birds-eye linen makes the best diapers on account of its superior
absorbent qualities.
The feet must be kept warm by stockings, and artificial heat, if
necessary. On hot days much of the clothing may be removed and the
shirt, band and diaper may be all that are needed.
The care of the shirts and bands is part of the daily duty of the nurse.
They must be washed daily, either by the nurse herself or under her
supervision, as they are easily injured. After washing, in soft water,
if possible, and with wool soap, they must be dried on a stretcher.
Diapers must be put directly into cold water. Fæces may be brushed off
with a whisk broom, and the napkin rinsed, boiled and again rinsed. No
diaper should be used a second time until this has been done. No bluing
may be used on the diapers and the soap must be mild, otherwise chafing
and intertrigo will follow.
The infant’s toilet basket must contain:
4 soft bath towels.
1 pound of absorbent cotton.
1 dozen wash cloths of soft material.
1 small hair brush.
1 pair nail scissors.
Talcum powder.
Bath thermometer.
Hot water bottle.
Albolene.
Castile soap.
8 oz. boric acid solution.
8 oz. benzoated lard.
Paper bags for waste.
Pitchers and basins.
[Illustration: Fig. 114.—_A_, standard breast pump; _B_, standard
nursing bottle; _C_, the breast tray; _D_, the Wansbrough lead nipple
shield; _E_, the Brophy nipple for harelip and cleft palate.]
=Weight.=—The weighing of the child should precede, for convenience, the
first cleaning of the skin and the daily bath. The child is either put
on the scale naked or weighed in a blanket, and the weight of the
blanket, ascertained before or after, is subtracted. The daily weight
record is just as important as the temperature. A scale that registers
ounces and fractions thereof must be used, and the child should be
guarded from falling during the performance. Usually the child loses
from eight ounces to a pound the first week, but it should gain back to
its birth weight, by the end of the second week. If the child does not
gain, it may be due to lack of milk from the breast, and the weight may
be taken before and after feeding to verify or refute the suspicion.
=The mouth= should be inspected each morning, but not cleansed with the
boric acid solution unless definitely indicated. Spots or any unusual
appearance should be reported.
=The Genitals.=—The vulva of the female infant usually requires but
little care besides cleanliness. There is sometimes a whitish discharge
which disappears spontaneously in a few days. It is a drainage of
vernix, smegma and epithelium from the vagina and labia.
With a male, the prepuce must be inspected when the child is about a
week old. If it is long and the orifice small, circumcision may be
suggested. Under any circumstances, the foreskin must be retracted, the
adhesions broken up, and the smegma removed. This must be repeated daily
until the adhesions do not recur. The maneuver should be done the first
few times by the physician, for fear of a paraphimosis.
=Sleep= in the newborn is normally quite deep and almost continuous,
probably twenty-two hours a day, for the first week. The rather fast
respiration of the child, even when sleeping, is no cause for alarm. A
healthy infant breathes about twenty-five times a minute. The child
should not be rocked, carried about, exhibited, or handled more than
necessary. It should not sleep with the mother, lest it become too hot
or too cold, be overwhelmed by bedding, or overlaid by the mother.
=Bowels.=—The first stools are black and tar-like,—this is meconium. It
disappears by the end of the first week. The presence or absence and the
character of an evacuation, as well as the number in twenty-four hours,
must be daily recorded. For a breast-fed child, there should be three or
four a day, for the first ten days and the number should gradually
diminish until a routine of two a day is obtained.
=The diaper= of bird’s-eye linen should be large and thick; two may be
used if required. They should be carefully washed after soiling. Bluing
must not be used, because where this substance comes in contact with the
skin, irritation follows.
=Weaning= should be brought about by the gradual substitution of other
foods, somewhere between the sixth and twelfth months.
=Urination= should be copious. The child is always wet, and frequent
changes are necessary to keep the skin from getting raw and sore.
Both bowels and bladder should be emptied within the first twenty-four
hours. Failure to do so should be reported, as an imperforate anus or
urethra may exist.
Frequently a piece of ice whittled out like a lead pencil and passed
into the rectum will stimulate urination.
Catheterization is practically never necessary. The child _may_ go three
days without injury, but the condition of the bladder above the pubes
must be attentively watched and its degree of fullness appreciated by
percussion.
=Nursing.=—The child should be put to the breast twelve hours after
birth and every three hours thereafter—no more and no less without
definite reasons.
If the child is strong and vigorous, only one feeding may be given at
night, and even this may be omitted in some cases where the child gets
an abundance of food. Six or seven feedings a day are enough. The child
should stay at the breast from fifteen to twenty minutes, depending on
its activity and the rapidity of the milk flow, and then be removed. It
must not be permitted to sleep at the breast.
[Illustration: Fig. 115.—Proper position of mother while nursing child.
(Witkowski.)]
Care must be used that the child gets the nipple _over_ the tongue and
not under it. Many infants have to be taught to nurse. This may be due
to a lack of strong animal instinct in many cases. There may be an
abundance of milk and a good nipple, but the child will not learn to
nurse without a vast expenditure of time, patience, and energy on the
part of the nurse. Squeezing a little milk into the mouth or filling a
nipple shield with milk will sometimes aid in educating the infant, or
even starting the supply with a pump, as many nurses do, is
advantageous. Certain drugs, like castor oil and turpentine, taken by
the mother, may affect the taste of the milk, and be reason enough for
the refusal of the child to take hold. Other drugs like mercury,
arsenic, potassium iodide, and alcohol may go over in the milk to the
nursing child.
If the child is weak or premature, the milk must be pumped from the
breast and fed to it until strength comes. The difficulty about this is
the bad habit acquired, but there is no way to avoid it.
A child should get at each feeding half an ounce of milk to each pound
of weight. The capacity of the stomach at various months is given by
Hirst as, first week, ½ oz.; second week, 2½ oz.; third and fourth week,
3 oz.; third month, 5 oz.; fifth month, 9 oz.; ninth month, 12½ oz. Holt
says that the capacity at birth should be one ounce, and increase at the
rate of an ounce a month up to the sixth month.
As hunger stimulates the gastric and salivary glands, so the sight of
the child arouses some emotional center in the mother, which starts the
milk, and the mouth of the child provides an additional stimulus of
great power. About fourteen ounces is secreted by the seventh day, and
after the second month the daily average rises to three or four pints.
Milk secretion is favored by drugs and foods that raise the blood
pressure and diminished by substances that lower the blood pressure.
There may be too little milk in the breasts, and if so, the child will
lose weight daily; also the child will waken before nursing time, fret,
refuse water, but greedily seize the nipple if it is presented. It will
continue to nurse long after its time is up and cling and cry when
removed. The breast itself may seem flabby and loose, and no milk, or
very little, can be pressed from the nipple.
Normally, the breasts feel full and tense, both to patient and nurse,
just before feeding time. The real test, however, is in taking the
weight of the child before and after feeding. Where the milk is
insufficient, the scales will not vary, and after a few repetitions the
nurse can be certain. An infant should be handled as little as possible
after feeding lest the milk be vomited.
[Illustration: Fig. 116.—Proper method of taking rectal temperature.]
=Temperature= of the newborn child varies from 98° to 99° F. It should
be taken morning and evening, or oftener, if complications are
suspected.
The temperature often goes up on the third or fourth day, and may stay
up for several days. This phenomenon is called by some a _starvation_ or
_inanition fever_. The temperature may go to 106° F. and the rise is
generally associated with a hot dry skin, dry lips, weak pulse,
restlessness, and great prostration. The fontanelle may be sunken and
the cry sinks to a fretful, feeble whine.
It is important that the fever should be recognized and treated, since
the condition may terminate fatally. The _etiology_ is obscure. The
fever should not be confounded with pyogenic infections, for these
rarely begin before the fifth or sixth day.
The _treatment_ is simple. Give water regularly every two hours by
mouth, and rectal flushings of normal saline twice daily. The symptoms
rapidly subside if the child is properly nourished. Hence the breasts
should be inspected and the child weighed before and after feeding.
Usually the milk is poor and scanty. If the temperature does not soon
fall the child should be put to another breast or artificial feedings
should be instituted.