NERVOUSNESS IN EARLY INFANCY
We may now pass back to consider the nervous system of the child in
infancy. There, too, from the moment of birth there are clearly-marked
differences between individuals. The newborn baby has a personality of
his own, and mothers will note with astonishment and delight how
strongly marked variations in conduct and behaviour may be from the
first. One baby is pleased and contented, another is fidgety,
restless, and enterprising. At birth the baby wakes from his long
sleep to find his environment completely changed. Within the uterus he
lies in unconsciousness because no ordinary stimulus from the outer
world can reach him to exert its effect. He lies immersed in fluid,
which, obeying the laws of physics, exercises a pressure which is
uniformly distributed over all points of his body. No sound reaches
him, and no light. After birth all this is suddenly changed. The sense
of new points of pressure breaks in upon his consciousness. Cold air
strikes upon his skin. Loud sounds and bright lights evoke a
characteristic response. A placid child who inherits a relatively
obtuse nervous organisation will be but little upset by this sudden
and radical change in the nature of his environment. His brain is
readily but healthily tired by the new sensations which stream in from
all sides, and he falls straight away into a sleep from which he
rouses himself at intervals only under the impulse of the new
sensation of hunger.
Babies of nervous inheritance, on the other hand, will show clearly by
the violence of the response provoked that their nervous system is
easily stimulated and exhausted. They will wriggle and squirm for
hours together, emitting the same constant reflex cry. The whole body
will start convulsively at a sudden touch or a loud sound which would
evoke no response from a more stolid infant. The sleeplessness and
crying exhaust the baby, rendering the nervous system more and more
irritable, while the sensation of hunger which is delayed in other
children by twelve hours or more of deep sleep appears early and is of
extreme intensity. We must see to it that sense stimuli are reduced to
the lowest possible level. True, we cannot again restore the child to
a bath of warm fluid, of the same temperature as his body, where he
can be free from irksome pressure and from all sensations of sound and
light, but we can so arrange matters that he is not disturbed by loud
sounds and bright lights, and that he is not moved more than is
necessary. Sudden unexpected movements are especially harmful. Jogging
him up and down, patting him on the back, expostulation, and
entreaties are all out of place and do all the harm in the world. The
first bath should be as expeditious as possible, and above all the
baby must not be chilled by tedious exposure. Cold irritates his
nervous system more than anything else, unless it be excessive warmth.
In preserving the proper temperature so that we do not render the
child restless by excess of heat or by excess of cold, we
too-civilised people have made our own difficulties. We have
exaggerated the completeness of the sudden separation of mother and
child which nature decrees. It is the function of all mother animals
to approximate the unstable temperature of the newly born to their own
by the close contact of their bodies, which provide just the proper
heat. Labour is nowadays so complicated and exhausting a process for
mothers that, all things considered, we are wise in completing the
separation of mother and child and in removing the baby to his own
cot. But the difficulty remains, and we must arrange that any
artificial heating needed is constant and of proper degree.
If the baby is very restless and irritable, too wide awake and too
conscious of his surroundings, the all-important task of getting him
to the breast and getting him to draw the milk into the breast is apt
to be difficult. His sucking is a purely reflex and involuntary act.
It can be produced by anything which gently presses down the tongue,
and a finger placed in the proper position will provoke the movement
without the child's consciousness being aroused. The placid child
whose mind is at rest will suck well and strongly. If, on the other
hand, the brain is too much stimulated and the child is restless and
irritable, the reflex act of suction is inhibited, and it is a
difficult matter to get the child to the breast. He is too eager,
mouthing, and gulping, and spluttering. Or sometimes his mental
sufferings seem too much for his appetite, and though wide awake and
crying loudly, he refuses to grasp the nipple, turning his head away
and wriggling blindly hither and thither. This effect of mental unrest
on the newborn infant is often disastrous, because it is one of the
common causes of the failure of women to nurse their children. This is
not the place to sketch in detail a scheme for the proper technique of
breast nursing, a matter which is much misunderstood at the present
day. It will be enough shortly to say that an efficient supply of milk
depends upon the complete and regular emptying of the breast. The
breasts of all mothers will secrete milk if strong and vigorous
suction is applied to the nipple by the child. If anything interferes
with suction, the milk does not appear or, if it has appeared, it
rapidly declines in amount. The mother's part is to a great extent a
passive one, provided that she can supply one essential--a nipple that
is large enough for the child to grasp properly. Within wide limits
what the mother eats or drinks, whether she be robust or whether she
has always been something of an invalid, matters not at all. A frail
woman may naturally not be able to stand the strain of nursing for
many months, but that is not here the point in question. We are
dealing only with the establishment of lactation and with the milk
supply of the early days and weeks which is of such vital importance
for the child. If the mother is ill, if, for example, she has
consumption, we may separate her from the child in the interests of
both; but if this is not done, she will continue to secrete milk for a
time as readily as if she were in perfect health, and the breasts of
many a dying woman are to be seen full of milk. Mothers are too apt to
attribute the disappointment of a complete failure to nurse to some
weakness or want of robustness in their own health. This is never the
reason of the failure, and the fault, if the mother has a well-formed
nipple, is generally to be found in some disturbance in the child.
Prematurity, with extreme somnolence, breathlessness from respiratory
disease, nasal catarrh, which hinders breathing through the nose,
infections of all sorts, are common causes of this failure to suck
effectively. But perhaps the most common cause of all is the
inhibition from nervous unrest of that reflex act of sucking which
works so well in the placid and quiet child. It is a point to which
too little attention is paid, and mothers and the books which mothers
read commonly neglect the nervous system of the child and devote
themselves to such considerations as the relative merits of two-hourly
and four-hourly feedings--important points in their way, but less
important than this.
The matter is complicated in two other ways. In the first place, the
nervous baby, just because he is so active and wakeful and restless,
is apt rapidly to lose weight and to have an increased need for food.
The restlessness is generally attributed to hunger, and this is true,
because hunger is soon added to the other sensations from which he
suffers, and like them is unduly acute. It is difficult not to give
way and to provide artificial food from the bottle. Yet if we do so we
must face the fact that these restless little mortals are quicker to
form habits than most, and once they have tasted a bottle that flows
easily without hard suction, they will often obstinately refuse the
ungrateful task of sucking at a breast which has not yet begun to
secrete readily. The suction that is devoted to the bottle is removed
from the breast, and the natural delay in the coming in of the milk is
increased indefinitely. At the worst, the supply of milk fails almost
at its first appearance. We must devote our attention to quieting the
nervous unrest by removing all unnecessary sensory stimulation from
the baby. He must be in a warm cot, in a warm, well-aired, darkened,
and silent room, and the necessary handling must be reduced to a
minimum. Sometimes sound sleep will come for the first time if he is
placed gently in his mother's bed, close to her warm body. If he is
apt to bungle at the breast from eagerness and restlessness, it is not
wise always to choose the moment when he has roused himself into a
passion of crying to attempt the difficult task. So far as is possible
he should be carried to the breast when he is drowsy and sleepy, not
when he is crying furiously, and then the reflex sucking act may
proceed undisturbed.
In the second place, we must guard against the ill effect which the
ceaseless crying of these nervous babies has upon the mother. She may
be so exhausted by the labour that her nerves are all on edge, and she
grows apprehensive and frightened over all manner of little things.
The tired mother is apt to fear that she will have no milk, and her
agitation grows with each failure on the part of the child. Now the
first secretion of milk is very closely dependent upon the nervous
system of the mother. We have said that within wide limits her
physical condition is of less importance, but her peace of mind is
essential. And so it is wise for some part of the day to keep the
nervous baby out of hearing of the mother, and so far as possible to
choose moments when the child is quiet to put him to the breast. A
nurse with a confident, hopeful manner will effect most; a fussy,
over-anxious, or despondent attitude will do untold harm. We shall
sometimes fail if the nervous unrest is very obstinate either in
mother or in child, but we shall fail less often if we diagnose the
cause correctly in the cases we are considering. Lastly, it is
possible to control the condition in both mother and child by the
careful use of bromide or chloral.
It is not, of course, suggested that these drugs should be given
freely or as a routine to every hungry baby wailing for the breast, or
that we can hope to combat or ward off an inherited neuropathy by a
few doses of a sedative. There are, however, not a few babies in whom
there develops soon after birth a sort of vicious circle. They can
suck efficiently and digest without pain only when they sleep soundly.
If they are put to the breast after much crying and restlessness,
each meal is followed by flatulence, colic, and renewed crying. The
only effective treatment is to secure sleep and to carry a slumbering
or drowsy infant to the breast. Then the sucking reflex comes to its
own again, the breast is drained steadily and well, and digestion
proceeds thereafter without disturbance and during a further spell of
sleep. Two or three times in the day we may be forced, as meal-time
approaches, to cut short the restlessness of the child by giving a
teaspoonful of the following mixture:
Pot. brom., grs. ii. [2 grains]
Chloral hydrate, gr. i. [1 grain]
Syrup, M x. [10 minims]
Aq. menth. pip., ad 3 i. [1 dram]
After this has been taken the child should be laid down for a quarter
of an hour until soundly asleep. Then very gently he can be carried to
his mother and the nipple inserted. If in this way a few days of sound
sleep and less disturbed digestion can be secured, the difficulty will
in most cases permanently be overcome. The steadier suction and more
efficient emptying of the breast will promote a freer flow of milk,
and the deeper and more prolonged sleep will lower greatly the needs
of the child for food. Most of the babies who show this fault are
thin, meagre, and fidgety, and with some increase of muscular tone.
The head is held up well, the limbs are stiff, the hands clenched, the
abdomen retracted, with the outline of the recti muscles unusually
prominent. If we can relax this exaggerated state of nervous tension,
if we can help them to become fatter and to put on weight, the
dyspepsia will disappear with the other symptoms.
It is a question still to be answered whether the rare conditions of
pyloric spasm and pyloric hypertrophic stenosis are not further
developments of the same disturbance. Certainly these grave
complications appear most commonly in infants with a pronounced
nervous inheritance, and, as might be expected, they are more commonly
found in private practice than among the hospital classes.
In passing, we may note that there are babies who exhibit the opposite
fault, and in whom the contrary regimen must be instituted. Premature
children, children born in a very poor state of nutrition, and
children born with great difficulty, so that they are exhausted by the
violence of their passage into the world, are apt to show the opposite
fault of extreme somnolence. They are so little stimulated by their
surroundings, and they sleep so profoundly, that the sucking reflex is
not aroused. Put to the breast they continue to slumber, or after a
few half-hearted sucking movements relapse into sleep. We must rouse
such children by moving them about and stirring them to wakefulness
before we put them to the breast.
Once the child has been got to the breast, once the milk has become
firmly established, we have overcome the first great difficulty which
besets us in the management of nervous little babies, but it is by no
means the last. Restlessness and continual crying must be combated or
digestion suffers, and may show itself in a peculiar form of explosive
vomiting, which betokens the reflex excitability and unrest of the
stomach.
The sense of taste is as acute as all other sensations. If the child
is bottle-fed, the slightest change in diet is resented because of the
unfamiliar taste, and the whole may promptly be rejected. The tendency
to dyspeptic symptoms is apt to lead to much unwise changing of the
diet, and everything tried falls in turn into disrepute, until perhaps
all rational diets are abandoned, and some mixture of very faulty
construction, because of its temporary or accidental success, becomes
permanently adopted--a mixture perhaps so deficient in some necessary
constituent that, if it is persisted with, permanent damage to the
growth of the child results. We must pay less attention to changes of
diet and explore our management of the child to try and find how we
can make his environment more restful.
It is wise to accustom a nervous child from a very early age to take a
little water or fruit juice from a spoon every day. Otherwise when
breast-feeding or bottle-feeding is abandoned one may meet with the
most formidable resistance. Infants of a few months can be easily
taught; the resistance of a child of nine months or a year may be
difficult to overcome. The difficulty of weaning from the breast
recurs with great constancy in nervous children. By this time the
influence of environment has become clearly apparent. The child is
often enough already master of the situation, and is conscious of his
power. Such children will sometimes prefer to starve for days
together, obstinately opposing all attempts to get them to drink from
a spoon, a cup, or even a bottle. When this happens, sometimes the
only effective way is to change the environment and to send the baby
to a grandmother or an aunt, where in new surroundings and with new
attendants the resistance which was so strong at home may completely
disappear. When weaning is resented, and difficulties of this sort
arise, it is clear that the mother, whose breast is close at hand, is
at a great disadvantage in combating the child's opposition.
For nervous infants, alas! broken sleep is the rule. What, then, is to
be done? It is astonishing to me that any one who has studied the
behaviour of only a few of these nervous and restless infants should
uphold the teaching that the crying of the young infant is a bad
habit, and that the mother who is truly wise must neglect the cry and
leave him to learn the uselessness of his appeals. It is true that the
youngest child readily contracts habits good or bad. Either he will
learn the habit of sleep or the habit of crying. Mercifully the
inclination of the majority is towards sleep. But to encourage habits
of restlessness and crying there is no surer way than to follow this
bad advice and to permit the child to cry till he is utterly exhausted
in body and in mind. It is unwise _always_ to rock a baby to sleep; it
is also unwise to allow him to scream himself into a state of
hysteria. A quiet, darkened room, the steady pressure of the mother's
hand in some rhythmical movement, will often quiet an incipient
storm. The longer he cries, the more trouble it is to soothe him.
Sleep provokes sleep, so that often we find restlessness and sound
sleep alternating in a sort of cycle, a good week perhaps following a
bad one. The nurse who is quick to cut short a storm of crying and to
soothe the child again to sleep is helping him to form habits of
sleep. The nurse who leaves him to cry, believing that in time he will
of his own accord recognise the futility of his behaviour, is making
him form habits of crying. A rigid routine in sleep is a good thing,
but the routine belongs to the baby, not to the nurse. The child must
be educated to sleep, not taught to cry. A baby has but little power
of altering his position when it becomes strained or uncomfortable. He
cannot turn over and nestle down into a new posture. If we watch him
wake, the first stirring may be very gradual, and in a moment he may
fall again to sleep. A few minutes later he stirs again more strongly,
and is wider awake and for longer. It may only be after a third
waking, by a summation of stimuli, that he is finally roused and
breaks into loud crying. The nurse who is on the watch, who, sleeping
beside him, wakes at the slightest sound and is quick to turn him over
and settle him into a new position of rest, will probably report in
the morning that the baby has had a good night. The nurse who lets the
child grow wide awake and start crying loudly, will spend perhaps many
hours before quiet is again restored. Of the voluntary, purposive
crying of infants a little older I am not here speaking. Infants in
the second six months are quite capable of establishing a "Tyranny of
Tears" and feeling their power. Fortunately it requires no great
experience to distinguish one from the other, and to adopt for each
the appropriate treatment.
Again, in elementary teaching upon the management of infants stress is
laid, rightly enough, upon the importance of regularity in the times
of feeding, and on the observance in this respect also of a very
strict routine. But in the case of the very nervous infant a certain
latitude should be allowed to an experienced nurse or mother. We may
wreck everything by a blind adhesion to a too rigid scheme, which may
demand that we leave the child to scream for an hour before his meal,
or that, when at length he has fallen into a sound sleep after hours
of wakefulness, we should proceed to wake him.
Symptoms of dyspepsia which are due to continued nervous excitement
demand treatment which is very different from that which would be
appropriate to dyspepsia which is due to other causes, such as
overfeeding or unsuitable feeding. The temporary restriction of food,
which is commonly ordered in dyspepsia from these causes, is very
badly supported by the nervous infant. Hunger invariably increases the
unrest, and the unrest increases the dyspepsia.
The difficulties of managing a nervous infant are very real, and call
for the most exemplary patience on the part of the mother and the
clearest insight into the nature of the disturbance.