THE CARE OF THE CHILD (Cont’d)
=Tongue-tie= is not met with so frequently as in the old days. If the
child can suck and nurses energetically, this complication can be
excluded. It may, however, occur. In such a case, the frænum is
unusually broad and seems to extend clear to the tip of the tongue,
which apparently is bound down to the gum and to the floor of the mouth.
The thin membrane may be snipped with the scissors close to the tongue
and then torn back with the finger.
=Harelip and cleft palate= interfere with nursing and require continual
attention to keep mucus out of the throat. Brophy has a rubber flap
placed over the nipple of the bottle in such a way as to occlude the
split tissue and thus enables the child to get nourishment.
These babies must be fed systematically by gavage, if necessary, until
the deformity can be repaired.
=Hernia= at the navel is a common complication of infancy. It is not due
to crying, to improper tying of the cord, nor to neglect by the nurse,
as frequently charged. It is a congenital fault, wherein the cord
opening does not close, and in time, crying and straining will drive the
intestines out of the aperture like a pouch. The defect is revealed by
the bulging outward of the navel when the child cries. Ordinarily the
breach will close of its own accord.
[Illustration: Fig. 123.—Cleft palate nipple. (Brophy.)]
[Illustration: Fig. 124.—The device for feeding the child with cleft
palate at the breast. (Brophy.)]
_Treatment_ consists in folding up the skin of the abdomen so that the
groove will be over the umbilicus and include it. Then adhesive tape is
put on to hold it. The surfaces of skin thus coming in contact should be
dusted with rice powder or stearate of zinc. Another method of treatment
is to place a wooden button form, round side down, on cotton, over the
opening, and bind it on with a zinc adhesive plaster. The dressing
should be changed at least once a week.
=Inguinal hernia= usually heals spontaneously also, but a truss may be
required.
[Illustration: Fig. 125.—Device for assisting the cleft palate child to
nurse. (Brophy.)]
=Hæmorrhage= of the newborn is either accidental or spontaneous.
_Accidental_ hæmorrhage may arise from an imperfectly tied cord, or it
may be an effusion, through compression or rupture, into any of the
internal organs, such as the brain, lungs, or abdominal viscera. These
latter conditions rarely give rise to symptoms, and are seldom
recognized during life. There is no treatment.
The intracranial hæmorrhages are open to diagnosis through the presence
of pressure symptoms, but these, too, are impervious to treatment unless
a vessel can be tied, like the middle meningeal artery.
_Spontaneous_ hæmorrhages may develop during the first few days of life
from sepsis, syphilis, Buhl’s disease, hæmophilia, and true melæna
neonatorum. The fragile condition of the blood vessels, the great
changes in the blood and circulation after birth, as well as
constitutional dyscrasias, are etiological factors of importance. All
the causes are not as yet known.
[Illustration: Fig. 126.—Method of strapping an umbilical hernia.]
The blood may come from the umbilicus, the mucous membranes of the eyes,
nose, mouth, stomach and intestines. It may be effused into the tissues
beneath the skin, or into any organ of the body. Marked nosebleed is
generally syphilitic in origin.
As a rule hæmorrhages in the newborn are most common in males, and
strongly hereditary.
The tendency to bleed lasts only a few weeks, and if recovery takes
place, it is permanent. In some cases, however, where hæmorrhage has
developed in the brain, clots may form in important centers, and the
child be permanently paralyzed in speech, sight, hearing, or
intelligence.
_Symptoms_ of hæmorrhage begin during the first week and almost never
after the twelfth day. The appearance of blood is the earliest and the
most definite sign. The bleeding may come first from the umbilicus, or
from the stomach, or from the intestines (melæna neonatorum). The amount
lost is small, but the oozing is continuous. The temperature may be high
or subnormal, and may or may not be due to the hæmorrhage. The skin is
pale, the pulse feeble, prostration marked, and weight is lost rapidly.
Convulsions are not infrequent.
_The diagnosis_ of the condition is simple. It is only necessary to be
certain that the blood is really effused, and not a temporary or
accidental event such as the regurgitation of swallowed blood. Black
tarry stools will show blood if placed in water.
The _prognosis_ is not good. About two-thirds of these babies die.
_The treatment_ is to stop the hæmorrhage by ligature, suture, or
compression if possible and to alter the character of the blood by
adding to its fibrin content. This is brought about, if at all, by the
administration of coagulose, coagulen ciba, or by transfusion from an
adult—preferably the father.
=Paralysis of the face (Bell’s paralysis)= may follow the use of
forceps. The prognosis is favorable. Paralysis of the nerve in the neck
(musculospiral) is sometimes known as Erb’s paralysis. It happens in
consequence of difficult breech deliveries or of vertex labors when much
force is required to extract the shoulders.
The deltoid, biceps, and other muscles are affected so that the arm can
not be raised. The failure to raise one arm will be the symptom that
will attract the attention of the nurse. Some cases recover in a month
or so, either spontaneously or by the aid of electricity. If not, the
injured nerve must be cut down upon and its continuity restored.
=Ophthalmia neonatorum= is an infection of the eyes of the newborn by
the gonococcus. The infection occurs as the child passes through the
vagina or vulva, or when an unclean finger is put into the eye.
The reaction is violent. The discharge at first is thin, then thick,
pus. If untreated, the eyesight may be lost by ulceration. In the
asylums twenty-five per cent of the inmates are blind from this
infection; and as late as 1896, seven per cent of the blindness in the
state of New York could be traced to this avoidable disease.
_The preventive treatment_ consists in the frequent douching of the
vagina before labor with potassium permanganate solution 1:5000, or
chinosol 1:1000. After labor, a drop or so, of 1 per cent solution of
nitrate of silver is dropped into each eye and _not_ neutralized.
_After the infection has occurred_, iced compresses are applied to the
eye, night and day, and a solution of argyrol 15 to 20 per cent
instilled into the outer corner, twice a day. In female infants with
ophthalmia, the vagina must be watched for discharge which does not fail
to appear in most cases. Argyrol (20 per cent) should be injected with a
medicine dropper and left to drain out spontaneously. All dressings used
about the child should be destroyed, and the nurse should use the most
scrupulous cleanliness and care of her own person.
=Separation of the cord= may be delayed in puny babies and in cases
where the cord is large and thick.
Some of these cases are doubtless due to a patency or fistulous
condition of the urachus. Usually the separation may be hastened by
touching the constrictured part with silver nitrate. Or, if the cord
does not separate before the second week, it may be desirable to cut off
the hanging fragment and touch the base with silver nitrate or dust with
alum powder.
=Granulations= may protrude like a mulberry from the stump of the navel
(“proud flesh”). These are touched with nitrate of silver stick.
=Menstruation= may appear occasionally from the vulva of the newborn. It
is really a hæmorrhage, a menstrual flow, which is associated with
uterine activity, but rarely significant. There is no treatment. It
disappears spontaneously.
=The breasts of the newborn= may fill with milk and become indurated and
tender. Nothing should be done to them. Let them alone and the swelling
will subside in a few days and the milk (“witches’ milk”) disappear.
=Icterus= may develop from the third to the sixth day. The child becomes
yellow and stays yellow for a week, when the color gradually leaves. It
is thought to be due to the liberation of some embryonic residue in the
fœtus, but nothing is known certainly. For the simple form no treatment
is required. Recovery is prompt and uneventful. However, jaundice is
associated with other conditions that prove fatal, hence every icterus
should be watched carefully until it disappears.
=Child’s Nails.=—The nails are frequently rough and ragged at ends and
sides. They should be smoothly trimmed lest they become infected at the
junction with the skin and give rise to paronychia. If infection does
occur, the skin and flesh may be pushed back with a sterile applicator,
and the point touched with peroxide of hydrogen. A syphilitic history
may be traced in some of the babies.
=Thrush= is a form of contagious soreness, characterized by white flakes
or patches on the mucous membrane of mouth or anus which look like milk,
but can not be wiped off.
It is due to a vegetable fungus and occurs most frequently among anæmic
or poorly nourished babies or those suffering from harelip. It is
associated with symptoms of indigestion.
It may always be prevented by keeping the mouth and nipples clean, as
directed on another page, and by keeping the bottles and rubber nipples
in a solution of boric acid when not in use. When the disease appears,
the mouth must be swabbed three or four times a day with an applicator
soaked in saturated solution of boric acid. This is curative.
=Aphthæ or stomatitis= is the name given to whitish vesicles, followed
by superficial ulcers that occur upon the inside of mouth and lips of
the infant. It is rare in the newborn child. Boric acid solution is
cleansing, and stick alum, frequently applied, will effect a cure.
=Wheals, urticaria or “stomach spots”= appear as generally distributed
small spots about the size of a split pea, with a white center and a red
periphery. They appear about the third day and last twenty-four hours.
They may be mistaken for insect bites and they may, or may not, be
accompanied by temperature, which is probably only a coincidence.
The wheals disappear spontaneously without treatment.
=Bednar’s disease= is characterized by the appearance of two ulcers on
the hard palate, one on either side and just above the spot where the
last tooth will erupt. It is most liable to occur in sickly infants and
supposedly arises from the abrading of the mucous membrane by a rubber
nipple or through the rough cleansing of the mouth. It is very resistant
to treatment. The child must be put in good condition by attention to
the nourishment and the spots touched with tincture of iodine on an
applicator.
=The exudative diathesis= is indicated superficially by a definitely
bounded red patch on either cheek, which is not relieved, or only
temporarily, by the common ointments and powders. The mother says the
“face is chapped,” or that the baby has a “milk eczema.” Otherwise the
skin is pale.
These children are frequently fat, but the tissue is flabby. The urine
is sometimes ammoniacal. There is no marked disturbance of temperature.
Fretfulness and constipation are the principal symptoms.
The condition is due to too much fat in the food. A skimmed-milk diet is
best for a time. The fat can be added gradually until the limit of
tolerance is found.
If chalky masses appear in the stools, the fat must be reduced again.
Occasionally the child must be taken off the milk entirely, and a soup
or gruel diet substituted.
For local application, the following formula is sometimes beneficial:
(Grulee.)
℞ Naphthalene ℥i
Starch ʒiv
Zinc stearate ʒiv
M.
Sig. Apply frequently.
=The “cradle cap”= is a frequent sign of the exudative diathesis in its
milder stages.
The term is applied to a yellowish-gray patch over the large fontanelle.
The mother calls it “dirt,” which she finds hard to remove and it always
recurs. The mass is composed of dry scales, which gradually change into
an eczema. Vaseline or sweet oil left on over night makes the removal of
the scales quite easy the next day. If a raw surface is left, zinc
ointment should be applied. The diet must be changed as previously
described.
=Erythema=, especially of the diaper region, is sometimes a
manifestation of congenital syphilis. It is usually limited to the inner
side of the thighs, the perineum, scrotum or vulva, and buttocks. It
must be associated with other and more characteristic signs, however,
such as snuffles, cachexia, etc., before it becomes diagnostic of
syphilis. Most erythemas of this area are due to irritation from moist
or soiled diapers, but other factors may be important. Bluing in the
diaper, gastrointestinal troubles, and circulatory disturbances are
contributing causes. The local treatment is the same as for intertrigo.
If the child is syphilitic, systemic measures must be instituted.
=Intertrigo=, or chafing, is a form of eczema due to moisture, bluing in
the diapers or uncleanliness. The child should be cleaned with oil
instead of water, and well powdered with stearate of zinc or zinc
ointment may be used. Talcum powder which contains boric acid is
contraindicated.
=Pemphigus neonatorum= is an eruption of blisters or blebs which seem to
follow infection from the maternal passages or to be communicated by
other babies who have the disease.
From three to fourteen days after birth, the blebs develop on the
abdomen, neck or thighs, and show a tendency to spread to other parts of
the body. The vesicles vary in size from one-fourth of an inch to two
inches in diameter, and contain a serous, purulent, or bloody fluid.
Other signs of general sepsis may appear.
_In diagnosis_ care must be used to exclude syphilis, which also
exhibits blebs, but usually on the soles of the feet or the palms of the
hands. Besides, a nonsyphilitic child is generally better nourished. The
prognosis is unfavorable if the child is weakly, if the blebs spread
rapidly over a large area, or if the infection attacks the umbilicus.
_Treatment._—A rigid quarantine must be enforced. In the hospital no new
cases can be admitted. The alimentation must be increased, the blisters
evacuated, and the surfaces cleaned and covered with a 25 per cent
ointment of ichthyol, or an ointment of ammoniated mercury 2 per cent.
=Strophulus, red gum, or miliaria rubra= are names applied to an
inflammation of the sweat glands when their secretion is retained. It is
a “sweat rash” characterized by an eruption of scattered red papules or
small vesicles which commonly appear on the cheeks or neck of young
infants, or where skin surfaces come in contact. It is due to excessive
clothing or heat. It is really a prickly heat. The _treatment_ consists
in the removal of the cause, and a generous use of stearate of zinc
powder or rice powder.