THE CARE OF THE CHILD (Cont’d)
=Heart.=—The heart tones while in the uterus may vary between 138 and
150 per minute, but when higher than 160 or lower than 120, danger is
near. After delivery, the heart runs from 130 to 140, and during the
first year gradually drops to 115, approximately.
=Asphyxia neonatorum= is a condition, wherein, for some reason, the
child fails to breathe after delivery. Out of every one hundred babies
born, about six will die at birth or within the first ten days, and a
large proportion of them from asphyxia in some form.
Asphyxia is found in two degrees: asphyxia livida (blue) and asphyxia
pallida (white).
In the first, the child is deeply cyanosed. This may be due to patency
of the foramen ovale, and yet it is a question whether this cyanosis is
not really a normal process. The child does not undertake its first
respiration because it needs oxygen, but because an excess of carbon
dioxide (CO_{2}) in the blood acts as a stimulant to the respiratory
center, which is thus set to work, with the result that oxygen is taken
in. The blue asphyxias, therefore, may be only the first step in the
physiological process of respiration. In these cases, the pulse is
strong and full, and the muscular tone is preserved, as well as the
sensibility of the skin.
In the second degree, the condition is quite different. The face is pale
though the lips may be blue. The heart is irregular and many times can
not be felt. The cord is soft and flaccid, with its vessels nearly
empty. The reflexes are abolished, the skin and extremities cold. A few
convulsive efforts at breathing may occur, but they soon cease.
_Treatment_ is directed first, to opening up the respiratory passage.
The child is held up by the feet so the mucus, blood, and fluids may
escape from the mouth. Compression of the chest wall will aid. The
tracheal catheter is passed into the trachea and the mucus sucked out.
Next, the skin reflexes are stimulated by slapping the back, or
buttocks, and by blowing upon the face.
[Illustration: Fig. 117.—Method of passing the tracheal catheter.
(Hammerschlag.)]
The child at this time may be dipped in a tub of very warm water, (112°
F.) and the chest and face sprinkled with cold water. Meanwhile,
Laborde’s method of traction on the tongue may be tried. The tongue is
seized with tongue forceps (handkerchief, napkin, or piece of gauze will
do) and rhythmically drawn out and released about ten times per minute.
Further, the Byrd method of artificial respiration must be employed.
[Illustration: Fig. 118.—Byrd’s method of artificial respiration.
Extension and inspiration. (Edgar.)]
[Illustration: Fig. 119.—Byrd’s method of artificial respiration.
Beginning flexion and expiration. (Edgar.)]
The back of the child is held in the right hand, so that the thumb and
forefinger grasp the neck loosely, the other hand holds the buttocks
from behind and the body is slowly but firmly flexed between them until
the thorax is compressed, then the grip is relaxed and the body widely
extended to allow the air to rush into the lungs. This maneuver should
be repeated about twelve times per minute. When the heart ceases to
beat, the child is dead and respiration can not be established.
[Illustration: Fig. 120.—Byrd’s method of artificial respiration.
Flexion and compression. Note position of child which aids the escape of
fluids from the mouth and nose. (Edgar.)]
The same treatment is employed for the apnœic child born in Cæsarean
section and the oligopnœic child born under “Twilight Sleep.” The method
called “Schultze Swinging” is not to be recommended generally, on
account of the chilling which is so necessarily associated with the
exposure. The nurse should learn to practice all these methods of
resuscitation.
After the child breathes it must be watched carefully for at least
forty-eight hours, lest the symptoms recur, and the child die.
=Asphyxia Neonatorum—=
(a) Livida—body congested—blue.
(b) Pallida—body limp and pale.
Remember possibility of patent foramen ovale.
_Etiology._—
Too long compression of cord.
Diminished irritability of medulla.
Compression of brain during extraction.
Shock during version.
Aspiration of mucus.
_Treatment._—
Hold child by heels with head pulled back to straighten the
trachea, and wipe out mouth and pharynx _gently_ with cotton
wound about the finger.
Stimulate skin reflexes by slapping and blowing.
Tracheal catheter, artificial respiration (Byrd) 8 to 10 times per
minute.
Hot and cold bath alternately—rub the skin and knead the muscles.
Laborde’s method of traction on tongue 10 to 12 times per minute.
Continue efforts so long as heart beats.
=Convulsions= occur not infrequently during the first few weeks. They
may develop as a result of injuries to the head during labor, or as a
symptom of toxæmia. They may arise from constipation, from intestinal
indigestion with curds, from fever or from hæmophila. Meningitis and
other infections are associated with this symptom, and occasionally
atelectasis. They may also be the manifestation of a spasmophilic
diathesis. The attack may begin with such premonitory phenomena as
restlessness, muscular twitching, and staring of the eyes, but more
frequently the onset is without warning. The facial muscles are
contracted, the neck thrown back, the hands clenched and the extremities
spasmodically cramped and tightened. There may be frothing of the mouth
and consciousness is lost. Respiration is feeble, shallow and irregular.
The face is discolored and strange rattling noises come from the larynx.
The bowels and bladder may move involuntarily. The attack lasts from a
few minutes to half an hour.
Convulsions are not serious in all cases.
The responsibility for the management of this complication usually falls
upon the nurse. She calls the doctor, to be sure, but the attacks in
many cases have ceased and the child may either be dead or out of danger
of a recurrence before his arrival.
The hot bath is a universal remedy and quite as efficient as anything.
The temperature should be taken and the bowels washed out.
If the fontanelles are tense when the doctor arrives, a spinal puncture
may relieve the tension. A specimen of the blood is drawn through a
needle and sent to the laboratory for examination.
The cause must be found, if possible, and removed. A change of food may
be all that is required. Cod-liver oil may be added to the diet in dram
doses, three times a day, and milk curds, suspended in arrow-root water.
For the acute condition, chloral hydrate is best. It is given by rectum,
one or two grains in an ounce of water, and may be repeated in four
hours.
=Atelectasis= is the name given to a failure of the lungs wholly to
expand during the efforts at respiration. The child may live for weeks
with this affection, but usually it expires within a few days.
In this condition, the child has a constant tendency to get blue, the
color deepens, and death may occur in spite of every aid. The treatment
may be permanently efficacious in some cases, but in most, the revival
is only temporary. Again, the child may live, but in a weakly, declining
state for days, until death comes.
Aside from the physical signs of dullness elicited by percussion over
the lungs, the most conspicuous _symptoms_ are the cyanosis and the
intermittent but persistent whining cry.
[Illustration: Fig. 121.—Method of giving gavage. (Grulee.)]
_Treatment_ is by daily or hourly spanking, and by alternating hot and
cold baths, by sprinkling with cold water or by massage to stimulate the
skin reflexes. The treatment may have to be repeated every twenty or
thirty minutes, and the earlier it is instituted, the more persistently
carried out, the _more chance of success_.
=Exercise= is just as important to the infant as to the adult. The
kicking of the legs, moving of the arms and lusty cry are all means of
stimulating the circulation, the muscular development, and the expansion
of the lungs. The position should be changed occasionally in the crib
from back to side and from side to back. Also the child’s legs and back
should be rubbed and massaged until the skin is red every time the bath
is given.
=Flushings.=—The child is laid across the lap, or on a table. A rubber
sheet is so arranged that the discharge will drain away.
A soft rubber catheter, No. 18–20 French scale, is attached to a small
funnel. The apparatus is boiled and filled with normal saline, or
sterile water, at a temperature of 85° F. to 95° F. Half a pint to a
pint may be required.
The catheter is oiled and passed into the rectum just beyond the
sphincter. It must not go farther. The funnel is then raised and the
fluid flows into the bowel. This flushing must not be confused with the
administration of an enema for constipation, for which, however, it is
often an excellent substitute.
=Gavage= is forced feeding by means of a tube. A soft rubber catheter or
tube, about No. 7, French scale, is lubricated with albolene, vaseline
or sweet oil. The upper end is connected with a small tube or glass
funnel holding two or three ounces.
The child is laid upon its back in the arms of mother or nurse, the
baby’s arms are held and the head steadied.
In case of diphtheria or scarlet fever, the tube may be passed through
the nose and down the pharynx and into the œsophagus five or six inches,
or even into the stomach. It is more convenient and easier when possible
to pass it through the mouth directly into the stomach. The food is then
poured into the funnel, which, by elevation, empties itself into the
stomach. If regurgitated, more food must be given. When withdrawn, the
tube should be pinched to prevent leakage into the trachea.
[Illustration: Fig. 122.—Apparatus for gavage or lavage. (Tuley.)]
The great danger in these cases is the ease of overfeeding.
=Lavage= or washing of the stomach may be performed in the same way with
the above apparatus, when necessary. As soon as the stomach is filled,
the tube is lowered and the fluid siphoned out.