THE CARE OF THE CHILD (Cont’d)
=Constipation= in the newborn may come from many causes. The amount of
food may be so inadequate that no residue is left, and the bowels move
only once in forty-eight hours. Over-stimulation of the bowel by castor
oil or colonic flushings in the early weeks of life to correct colic may
diminish its sensitiveness and produce atonic constipation. In the
artificially fed infant too much fat in the food is a very common cause
of the trouble.
_Treatment._—Correct the amount of fat in the milk. If the child is
breast-fed, the mother’s diet should be non-nitrogenous and vegetables
should preponderate. Drugs should not be given until all else has been
tried. Gluten suppositories will furnish a mild irritation to the
rectum. Orange juice and prune juice may be given, or Mellin’s food or
oatmeal water added to the milk. Milk of magnesia ½ to 1 teaspoonful, or
Husband’s magnesia, in same dosage, may be given daily. Senna is also
efficacious.
=Diarrhœa= is generally significant of an error in diet which is usually
a plain indigestion, though there may be too much sugar in the food.
The stools are more frequent and always softer than usual, possibly
fluid.
Diarrhœa means increased intestinal action due to irritation from
_something_. It may be due to indigestion, to the presence of hard
curds, to acidosis, or it may accompany almost any disease of infancy as
a symptom merely. The odor is due to gases formed in the canal by
bacterial action. There is but little odor in fermentation, but much in
putrefaction. Mucus appears either as balls or strings. The balls come
from the small intestine, strings from colon. Blood indicates ulceration
at some point in the bowel, or an erosion just above the sphincter.
[Illustration: Fig. 127.—Proper position for introduction of a
suppository. (Grulee.)]
Fatty curds may be either white, granular, sand-like masses, or small,
soft, and yellow. The protein curd is large and smooth, or white and
bean-like. Both occur only when the artificially fed infant is given raw
milk (Brenneman). If the milk is boiled for two minutes these masses
will not form.
The cause must be determined. The frequent stools, however, are
exhausting, and may have to be checked with opiates or mechanical
astringents.
When due to indigestion, all food by mouth may be stopped for two or
three days and only barley water administered.
In a breast-fed child, diarrhœa is sometimes checked by diluting the
milk with a little barley water, given just before nursing. With these
infants, not much change in the sugar content can be made by alterations
of the maternal diet, but where artificial food is used, the amount of
sugar is easily reduced to a satisfactory degree.
=Colic= is a cramp-like pain of the bowels. Previous to the attack the
child is restless, expels some gas, and has the “colic smile,” which
leads the mother to believe the child is quite well. When the attack
comes on, the thighs are flexed on the abdomen, and the legs on the
thighs. The child has a sharp cry, that is nearly continuous, but in
some way related to the nursing period, for the attack comes on a few
minutes, and sometimes an hour, after taking the breast. The belly is
rigid, the arms wave aimlessly. Diarrhœa may be present, and the
movements are accompanied by much flatus. Distention is nearly always
present. When the belly is tapped it gives a drum-like note and the
child belches gas, sometimes accompanied by milk, which seems to
relieve.
_Treatment._—Colonic flushings to relieve the bowel of irritating curds.
The child may be laid face down with a bag of hot water under the belly.
Mixture of asafœtida gtts. xx to xl, or whiskey and hot water should be
given for the attack, followed later by a full dose of castor oil. The
diet should be rigorously investigated.
=Vomiting= may or may not be serious. The child may nurse too rapidly or
too much, and the over-distended stomach simply empties itself. Many
infants “spit up” their excess of milk, and thus relieve themselves.
This is a simple regurgitation, usually of unchanged milk, though it may
be acid from admixture with the gastric juice.
Vomiting, in a breast-fed child, may come during an attack of colic when
the eructations of gas appear. It may be a symptom of gastrointestinal
intoxication, of too much fat in the food, too short intervals between
feedings, or too much sugar in the food.
Projectional vomiting awakens suspicion of a pyloric stenosis or
meningitis, and must be reported to the physician at once.
Vomiting which occurs within twenty minutes after feedings is not
serious ordinarily, even though gas and large curds are expelled, but
all vomiting later than this, is significant of a pathology.
_Treatment._—Regulation of the hours of feeding is most important, and
next, the character of the food. If the child vomits an hour or so after
nursing, it may be that the milk is too rich (fat). Try a longer
interval, or give an ounce or so of cereal water before putting the
child to the breast.
=Prematurity= exposes the child to three distinct dangers, which arise,
respectively, from atmosphere, food, and infection. Very few children
born before the seventh month survive. A child born at the eighth month,
or with a weight of three pounds, or more, can be saved almost always.
The premature child up to the time of birth, has been protected very
carefully against temperature variations by the liquor amnii, and when
suddenly precipitated into a new environment, which its vitality barely
tolerates, the consequences are serious.
These infants have a poor heat production, and the natural warmth of the
body must be preserved. This is best done by incubators, which supply
air and moisture in stable and appropriate amounts. Chilling of the
child for even a few moments may be fatal. A room may be fitted up to
produce the necessary conditions of light, air, heat and moisture. The
child, wrapped in sheets of cotton, except the face, is then covered
with a blanket, and surrounded by a temperature varying from 88° to 95°
F., which is gradually lowered to 80° F. as the child gains strength. An
occasional whiff of oxygen, as prescribed for an atelectatic child, is
sometimes advantageous.
_Bathing._—Premature infants must not be bathed, but the skin should be
cleansed with cotton and warm sweet oil or albolene. All unnecessary
handling is to be avoided.
_Food._—Breast milk is the secret of success with these cases. Since
most of the infants are too weak to take the nipple, the breasts must be
pumped, and the child fed with spoon or pipette.
The interval between the feedings depends a little on the amount taken,
but it should not be less than one and one-half hours, nor more than two
hours. As the child gains, the interval may be lengthened to three
hours. Lack of sufficient nourishment is shown by cyanosis and loss of
weight, and overfeeding, by vomiting and diarrhœa.
The child must be fed by hand until strong enough to nurse the breast.
In certain cases of prematurity, as well as in diseases like pneumonia,
scarlet fever, and diphtheria, the child must be fed by gavage.
Nutritive inunctions of benzoated lard or cod-liver oil are also
valuable, not only for the passive exercise supplied, but for the
absorption of a certain amount of the unguent.
=Marasmus= means wasting, but the term is applied to infants that
steadily lose weight. The bodies of infants are so largely composed of
fluid, that loss of weight occurs quite easily and rapidly. Loss of
weight may be sudden or gradual. It comes on rapidly after acute
diarrhœa, either with or without vomiting, or it may follow persistent
vomiting without diarrhœa.
Malnutrition from defective feeding is the most common cause of wasting
in infants. This may be from lack of sufficient food or lack of proper
ingredients, as well as irregularity of intervals, and disease. Rickets,
congenital stenosis of the pylorus, congenital syphilis, and
tuberculosis are all possible factors in the etiology.
In any case, no treatment can be instituted until these conditions have
been confirmed or excluded.
=Pyloric stenosis= (the account follows Grulee) may be a thickening of
the muscular coat of the outlet of the stomach (pylorus) or a spasmodic
contraction. The condition is most frequent in males and in the first
born.
_Symptoms_ usually begin before the second week. There is constipation
with small ribbon-like stools, and the urine is scanty. The most marked
sign, however, when it is present, is the excessive, uncontrollable
vomiting, which ordinarily occurs fifteen to thirty minutes after
eating, but may be delayed for several hours. The vomiting may be of the
common type, but more frequently it is projectile in character, like
that seen in meningitis. The contents of the stomach are violently
expelled, sometimes several feet. Physical examination may reveal the
stomach bulging under the arch of the ribs and peristaltic waves moving
back and forth across its surface. The pylorus itself may sometimes be
felt as a lump or tumor.
_Prognosis._—About fifty per cent die.
_Treatment._—Dietetic and surgical. Grulee recommends small amounts of
food, poor in fat, be given at short intervals. If this fails, operation
is required.
=Pneumonia= in the newborn most frequently results from the aspiration
of mucus out of the maternal passages as the child is born. This may
happen when the cord is compressed, or at any time when a partial
asphyxiation impels the child to try to breathe.
It may also come on when a feeble child has been chilled by a prolonged
first bath.
The disease develops about twenty-four hours after birth in a child
apparently well. The temperature rises, respiration becomes rapid, and
cough develops. The child is fretful, restless, refuses the nipple, and
gasps for breath. It may become cyanotic. The prognosis in newborn
infants is very serious.
_Treatment_ is stimulation. A mustard bath will benefit where the
respiration is rapid and the child blue. Tincture of digitalis may be
administered in drop doses every three or four hours. Carbonate of
ammonia, ¼ gr., in mucilage of acacia, half a dram, may be given for
cough.
Child must be fed on mother’s milk _pumped from breast_.
=Snuffles= may be due to improper clothing, to drafts of air, or to
syphilis. If due to cold, camphorated oil may be rubbed on the nose and
the passages kept clean with an applicator soaked in albolene. If this
fails, a small pellicle of anæsthone may be placed in each nostril, and
the child laid upon its back until the ointment melts and runs back into
the pharynx.
=Furuncles= (boils) may be numerous. They come from irritation of the
skin by atmosphere, soap, water, and clothing, whereby infection enters.
This is especially liable to occur in the hair.
Keep the boils washed with boric acid solution and open them as soon as
the focus, or head, appears.
=Phimosis= is such a close adjustment of the prepuce to the glans penis
that it can not be retracted. In some cases there may be obstruction to
the outflow of urine, but generally a tiny portion of the glans can be
seen. The prepuce may or may not be redundant. This condition makes
cleanliness impossible and balanitis may result.
On account of the straining required to urinate, prolapsus ani, hernia,
and hydrocele of the cord sometimes develop. Symptoms may arise from
preputial adhesions, as well as phimosis. Frequent or difficult
micturition, nocturnal incontinence, priapism, pruritus, and
masturbation may develop out of the irritation, as well as nervous
manifestations, such as insomnia and night terrors.
The condition should be recognized and corrected in infancy. If the
adhesions are dense, an incision can be made down the dorsum of the
prepuce, the tissue forcibly separated from the glans, and the flaps cut
off. Stitches may be required. In other cases circumcision may be
necessary.
=Paraphimosis.=—When a prepuce with a small orifice is forcibly
retracted over the glans, it occasionally happens that it cannot be
pulled forward again. If allowed to remain this way, the parts will
swell, and the penis become strangulated as if with a ligature.
The danger arises from the stoppage of the circulation, which may be
followed by ulceration and gangrene.
Reduction must be brought about by manipulation, if possible, but where
this fails, the constricting band must be cut through and sedative
applications used.
=Balanitis= is inflammation of the prepuce from the decomposition of
smegma, which collects under a tight foreskin. The condition is quickly
relieved by cleanliness and a few applications of vaseline or zinc oxide
ointment. Circumcision should not be done until the inflammation has
subsided.
=Circumcision=, either as a physical necessity or as a religious rite,
is frequently performed.
The nurse prepares a table with sterile linen, a basin with antiseptic
solution and sponges, sterile towel, and sterile vaseline, with a roll
of gauze bandage an inch wide.
The object of the operation is to remove the prepuce and leave the glans
exposed.
The instruments needed are a pair of sharp scissors, a pair of
dissecting forceps, two pairs of artery forceps, small, full curved
needles, and fine catgut.
The nurse gives the child some gauze to suck, which has been soaked in
brandy and sugar-water, brandy one dram to an ounce of water. Then
taking her place at the child’s head, she flexes the thighs back upon
the abdomen, and widely separates them. The field of operation is
thoroughly washed with soap and warm water, the prepuce is then
retracted and the smegma wiped away. Then the body and limbs should be
covered with clean linen, except the penis, or a sterile towel may be
used with a hole in it through which the penis is drawn. The redundant
tissue is removed and fine catgut sutures put in.
The operation being completed, the wound is covered with sterile
vaseline and wrapped with a sterile gauze bandage, leaving the end of
the glans exposed.
[Illustration: Fig. 128.—Hydrocephalus. (Bumm.)]
The gauze and vaseline are changed whenever saturated with urine.
Healing ought to be complete by the seventh day. The nurse should
examine the dressing at frequent intervals during the first twenty-four
hours, since serious hæmorrhages may occur from vessels that have not
been included in the sutures.
=Priapism= is a condition of functional fullness and firmness of the
penis that is more than ordinarily constant. Its importance lies in the
fact that it may be a symptom of spinal irritation, balanitis, worms, or
phimosis.
=Spina bifida= is the most common congenital deformity. It is
characterized by a fluid tumor, which protrudes from an opening in the
vertebral column. It may appear anywhere along the spine, but is found
most frequently in the lumbar or cervical region. The deformity is
supposedly due to an arrest of development. It is nearly always fatal
inside of two weeks, though cases have been known to reach mature years.
[Illustration: Fig. 129.—Anencephalus. (Williams.)]
There is no treatment except protection from injury.
=Hydrocephalus= is sometimes, but not necessarily, associated with
_spina bifida_.
The ventricles of the head are filled with cerebrospinal fluid, and the
fontanelles are widely separated. The cause of the anomaly is unknown.
This condition may render labor difficult or impossible until the
diagnosis is made and the skull perforated. Rupture of the uterus may
result from the futile efforts to expel the child. If born alive, the
child nearly always dies, or if it grows up, the intelligence is
imperfect in most cases.
=Anencephalus= is a monster, having a body, but only a part of a head.
The eyes protrude, the tongue may hang from the mouth, and the brain is
under-developed.
=Sudden death= of infants that are apparently healthy comes with a shock
to the physician as well as the parents, and in some instances, no
plausible reason can be assigned for it. Apoplexy, pneumonia and
stoppage of the trachea by milk curds may explain some cases.
Suffocation by lying on the face in wet bedding, or overlying by the
mother will account for others. Internal hæmorrhage into lungs, pleura,
stomach, or brain is also known to be causative.