NEONATOLOGY ON THE WEB

Premature and Congenitally Diseased Infants

Part II.
Nursing and Feeding Care

Chapter VII.
Care and Nursing of Premature Infants.

All infants born three weeks or more before full term should be considered premature and treated as such. Every infant born after the sixth month should be given an opportunity for life by the administration of `necessary care and diet. Healthy premature infants when properly cared for will frequently reach the full development of the full-term infant by the end of the first year, and the majority of those surviving usually develop a normal body and mind, notwithstanding the fact that they are more commonly subject to megacephalus, rickets, spasmophilia, anemia, gastro-intestinal, respiratory and circulatory affections, ' all of which can be overcome without leaving any sequelae, unless based upon some congenital anomaly.

To be successful with these infants a certain routine must be followed:

1. Preparation for their home or hospital care must be made, whenever possible before labor.begins.

2. Their immediate care after birth is of greatest importance.

3. Their general care must be adapted to their individual needs.

(a) Refrigeration must be prevented.

(b) Skilled nursing is essential.

4. Human milk must be provided for those born before the thirty-sixth week.

5. The daily routine must be adapted to the infant's age and development.

6. Contact between the infant and individuals not concerned in its immediate care must be avoided. Attendants ill with colds and other forms of infection should observe most rigid rules of asepsis to avoid cross infections.

In case of expected premature labor immediate preparations must be made for the reception of the infant into a proper environment. The preparation must not be delayed until labor has begun, otherwise many viable premature infants will be lost. If the proper facilities cannot be furnished in the home, the mother should be persuaded to enter a hospital before confinement. She should be impressed with the fact that every day of added intra-uterine life will improve the infant's chances not only for life, but also for normal development.

Preparation for the proper conduct of labor should be complete whether in the home or hospital. The mother should be prepared with great care and every effort made to conduct an aseptic labor. The room should be selected and prepared to meet the needs for labor and the requirements of the infant. It should be well ventilated and properly heated to at least 70° F. Blankets and pads into which the baby is to be received should be warmed. The basket-bed or incubator-bed should be prepared for its reception by proper sterilizing and heating, so that all exposure to cold will be avoided. Everything must be in readiness for the care of the cord, eyes, mouth, skin and treatment of asphyxia. These should include a catheter and hot bath, and facilities for transportation of the infant to a hospital, if necessary.

Asepsis.-The greater susceptibility of the prematures demands even more painstaking observation of the rules that hold good for new-born infants in general. These infants succumb more readily to infection and are much less resistant than are the full-term infants. Again, the frequently complicated feeding technic gives more opportunity for disturbances of the digestive tract so that in every form of indirect feeding careful attention to details must be insisted upon. Also the danger of infection of the respiratory passages by careless exposure and aspiration of food are not to be underestimated.

Reception of the Infant.-A warm sterile pad, towel or preferably a blanket should be in readiness to receive the infant. As soon as the head is born the face and eyelids should be gently sponged with'sterile warm water, and the mucus should be removed from the air passages by carefully wiping the nose and mouth with a soft pledget of gauze. The body and cord should be protected from all contact with feces and other infected matter. After the body is born the infant should be placed so that the head is dependent, allowing the mucus and secretions which may have accumulated in the respiratory passages to escape.

Preservation of Body Temperatures.-The preservation of temperature demands a very careful supervision immediately following birth, proper attention must be paid to the thermolability and tendency to subnormal temperatures. The chief object in the preservation of the temperature is the prevention of excessive heat loss, which in itself may be a danger to the infant, This will also diminish the energy loss. The infant must be wrapped in material with poor heat conduction, and then placed in a warmed bed. Both are essential to a successful maintenance of body temperature.

The preservation of heat must be begun immediately after birth of the infant, preferably on the confinement bed itself, as the extent of the initial temperature loss is of no mean consequence to a premature infant. After severing the cord the infant should be placed in a heated basket or incubator-bed, which should be a part of the equipment of the delivery-room.

In the home, hot-water bottles, a properly protected electric pad (p. 224), or an improvised incubator (p. 223) will answer the purpose. It should be remembered that these infants are easily burned and such burns are usually fatal.

In small prematures the cotton-pack, completely enveloping the infant, except for the face and genito-anal region; answers very well. To the genital region and anus a napkin of cotton or gauze , combination may be applied. A jacket may be placed on the outside of the cotton to hold it in place.

Treatment of the Cord.-The time of tying and section of the cord will depend entirely on the general condition of the infant and to some extent on the obstetrician's ability to prevent undue exposure of the, infant to cold. In the absence of marked asphyxia it is well to allow the pulsation of the cord to become weakened or to disappear before ligation. This usually requires from one to five minutes during which time the infant will receive from 30 to 60 cc of blood from the placenta. This blood should be conserved, when possible.

The cord should not be tied too close to the skin. Great care must be exercised in tying the cord to prevent cutting it in two with the ligature which is easily accomplished in the premature, therefore it is always well to leave sufficient space for a second ligature behind the first in case of an accident.

Asphyxia.-The possibility of asphyxiation of the premature infant must be borne in mind throughout the entire labor. The heart tones should be carefully watched and in cases of prolapse of the cord, if it cannot be successfully replaced, it may be necessary to induce a rapid delivery of the infant. Any accumulated secretions or aspirated material must be removed by inversion of the child and if necessary by aspiration by means of a catheter. In more extreme degrees of asphyxia early separation of the cord may be necessary so that artificial respiration and a hot bath may be instituted (p. 244).

The irritation of the catheter in the pharynx will frequently reflexly stimulate respiration. It should, however, be remembered that the use of the catheter is not without danger to the operator because of the frequency of syphilis as a cause of premature birth. If these procedures fail to bring about the desired result the infant should be suspended by the feet, the forehead resting lightly on the bed or table so as to deflect the chin and. straighten out the trachea and then the chest is compressed between the thumb of the right hand resting on the back and the four fingers of the same hand resting on the anterior wall of the chest.

This act should be repeated from sixteen to twenty times a minute by compressing and suddenly relaxing the chest wall. This should be continued for at least one minute in severe cases to insure success. At the same time a nurse or assistant should wipe the excess of mucus from the nose and throat. The child is then placed in a warm bath (about 105° F.) for five minutes, and then placed in a heated bed. In extreme cases the procedure must be repeated. Administration of oxygen, about 120 bubbles per minute, may be of value, if administered through a catheter inserted in the mouth or a properly constructed mask. Careless handling and traumatizing the infant or too rapid performance of artificial respiration is productive of more harm than good and must therefore be avoided. There must be definite indications for all manipulations undertaken. If the infant appears to be recovering spontaneously it should be left alone.

It must be borne in mind in the conduct of all premature labors that the anesthetics, if used in labor, tend to weaken the uterine contractions, thus prolonging labor and favoring asphyxia and a sufficient quantity of the drug may pass into the infant to seriously affect it, which is especially true of scopolamine-morphine anesthesia.

All premature infants whether asphyxiated at birth or not should be carefully watched for cyanotic attacks during the first days of life, as such attacks may develop suddenly and without warning. They may be due to a disturbance in the pulmonary circulation, to a congenital atelectasis, or to injury of, or hemorrhage into the respiratory center in the medulla. At other times they are precipitated by intra-abdominal distention which may interfere with cardiac or respiratory action. For further discussion of this condition see Cyanosis (p. 241).

Care of the Mouth and Nose.-Every effort must be made to avoid trauma of the mucous membranes of the nose and mouth, because of the danger of secondary infections. Cleansing of the nose should be done by the use of soft cotton pledgets or applicators. In wiping out the mouth only soft material is permissible. Much can be accomplished by facing the child with the mouth downward or laterally with the trunk elevated, so that the mucus can gravitate toward the mouth.

Care of the Eyes. -- One per cent silver nitrate solution or 25 per cent argyrol should be used to prevent ophthalmia neonatorum. The nitrate of silver solution should be neutralized with a normal saline solution instilled in the eyes. Not infrequently the application of silver nitrate will result in some inflammatory reaction of the conjunctiva in the first six to twelve hours after its application. This is especially frequent in premature infants and is usually relieved by the application of cold boric-acid solution to the lids. It is not to be confused with the more serious specific ophthalmic which develops on the second or third day. In case of doubt a microscopic examination of the purulent discharge must be made. In all cases an old silver nitrate solution which has undergone decomposition should be avoided, as such solutions are far more prone to irritate the sensitive conjunctiva.

Care of the Skin and Genitalia.-It is of the' greatest importance that premature infants shall be handled as little as possible. And when there is doubt as to the advisability of giving the initial warm bath, it is best omitted, because of the danger of causing a collapse. When the bath can -be given without chilling it is indicated in most infants weighing 1500 gm. or more. In smaller infants and those showing evidence of atelectasia or asphyxia, it may be needed to stimulate the respiratory functions. Oiling the body is unnecessary and is to be avoided. The genitalia should be carefully cleansed with a boric-acid solution or sterile water without trauma. The same is true of the buttocks, after which a small pad of cotton or combination is applied to the genitalia and buttocks.

Dressing the Cord.-Either a dry or alcohol dressing should be applied. The cord usually dries by mummification and drops off in most instances by the end of the first week, averaging somewhat later than in full-term infants. Every precaution should be taken to prevent trauma of the stump and secondary infection. This applies more especially to the bathing of the infants in emergencies for cyanotic spells and hypothermia.

Examination for Congenital Anomalies and Disease.-Before the infant is left by the physician it should be examined for congenital anomalies and evidence of syphilis and other diseases.

Requirements of a Hospital Nursery Unit.-This depends greatly upon the method used for maintaining external heat.

1. Superheated rooms without heated beds.

2. Individual heated beds.

When the superheated rooms are in use separate rooms for the older and better-developed infants must be supplied to gradually accustom them to ordinary room temperature. However, this extra room is not necessary when external heat is applied in individual beds in which the temperature can be regulated to meet the needs of each infant. In using the latter the room can be held at a temperature approximating 70° F. In point of economy of space and special care for the infant the latter method has every advantage.

When individual heated beds are used the following units are required in a properly regulated department.

Room Containing Heated Bed.-A room with a south exposure is preferable. In such a room the matter of ventilation will depend to a large extent upon the type of heated bed which is used. When the old type of closed incubator is used, it must necessarily receive fresh air through a pipe passing through the wall of the building or an opening in a window, thereby supplying the bed with air from the outside (Fig. 136). When an' electrically heated bed or home improvised bed is used the infant is dependent upon the general ventilation of the room for its supply of fresh air.

Such a room is best constructed with double windows and transom which can be regulated at will according to the season and existing weather conditions. Such a system of ventilation should be sufficiently flexible to permit regulation to meet exigencies which may arise due to instability of the general heating plant. It has been our experience that when a well-constructed superheated bed is used, variations of from 6 ° to 8° F. in the room temperature during the twenty-four hours cause little inconvenience to the infant.

It should be remembered that the beds should not be placed in a direct line of draft between the windows and the doors. The room should be built or selected with this in mind. Such a room should also contain a hygrometer and special thermometers which register not only the present temperature but also the extremes for twenty-four hours (Taylor Instrument Company). Such a thermometer is one of the best methods of testing an efficient nursery. Further discussion of incubator rooms, incubators, superheated beds and similar apparatus are covered under the special chapter on Incubators.

This room is to be used only for well new-born prematures in their individual beds and older infants who have been gradually accustomed to ordinary room temperature.

The Nursery.-The nursery should be a room independent of the station in which the superheated beds are kept. It should be provided with double windows, a good system of heating, and must be kept immaculately clean. Good ventilation and general cleanliness are essential. Unless a special bathroom can be provided, the nursery should be furnished with the following equipment.

1. A bathing slab or board. We find a metal jacket which can be filled with warm water very serviceable (Fig. 64). The Divan bath with thermostatic mixing valve is well designed for this' purpose.

2. A heated dressing table provided with cabinets for storing and warming clothes.

3. Supply closets for linens.

4. A well-constructed balance scale graduated to 4 gm.

5. A hygrometer (Figs. 69 and 70).

6. Thermometers registering the present and extreme temperatures for twenty-four hours (Fig. 70).

7. A time clock should also be provided and all feedings registered by this method, so that the supervisor may have a constant check on the activities of her assistants.

The general hygiene and care of the infant in the nursery is second only in importance to an ample supply of human milk and a maintenance of the body temperature of the infant.

Milk Stations.-A milk station for preserving and dispensing breast milk and artificial diets should be a part of the equipment of every general and special hospital (Fig. 72).

Wet-nurses' Quarters.-Wet-nurses' quarters should provide living and sleeping-rooms for the wet-nurses and their babies. The ideal requirements for such a unit are described under the chapter on Wet-nurses, p. 117.

A shower bath and toilet facilities should be provided for the . special use of wet-nurses but not in living quarters.

It is of the greatest importance that infected premature infants be grouped according to their ailments and that complete facilities for caring for these infants be established, in order to avoid cross infections. Two such units should be provided whenever it is expected that a considerable number of premature infants are to be cared for, and should include facilities for bathing, feeding, and the general care of patients. Gastro-intestinal and respiratory infections must be kept separated and treated as septic cases. Syphilitic infants and cases of gonorrheal ophthalmia must also be provided with separate quarters. Thrush and furunculosis which frequently develop into severe types should also be isolated.

Aseptic nursing is imperative to the welfare of the department. Soiled. linens, clothes, bottles, thermometers and all other utensils must be handled as infected material.

A complete department should therefore provide for:

A. Well Infants.-A room containing heated beds for the early care and cribs for graduates. The further needs are:

A heated dressing table, a supply closet, thermometer (high and low), hygrometer, time clock, electric heater for emergency, screens and a lavatory.

A nursery with bathing facilities, supplied with: A bath slab, a lavatory, a heated dressing table, shelves for toilet articles, a gas or electric plate, an electric heater for emergency, a scale, thermometer, supply closet.

A special bath-room when possible should be provided so that bathing in the nursery may be avoided.

Quarters for wet-nurses with independent bath and toilet facilities, equipped with: Beds, cribs, chiffoniers, dressing table, nursery chairs and lavatory. The bath room should have a shower bath, dressing room, toilet and lavatory.

A milk station containing a sink, refrigerator, work table, tubs for washing utensils, steam sterilizer, bottle and food racks.

Nursing staff including a directing nurse and assistants.

Wet nurses.

B. Infected Infants.-Room equipped with heated beds and cribs and provided with bathing facilities. This room should further contain a lavatory, heated dressing table, scale, thermometer, hygrometer, emergency electric heater, supply closet and screens. The bath tub in this room may be of the small ambulatory type or of the Divan slab type. Both may be easily sterilized.

The nursery should be considered as the center of the unit and when a separate bath room is provided, the former may be used for housing the graduates. The temperature of this room should range between 78 and 80° F. during the hour of bathing, at other times 70 to 75° F. The entire station must be thoroughly cleaned at least every second day and disinfected by scrubbing immediately after the diagnosis and removal of infectious cases.

The Nursery Staff.-The selection of a personnel for the nursing staff of a unit established for the care of premature infants requires great care. Nurses assuming these responsibilities must be intensely interested in their work. They must be willing to make many necessary sacrifices while the infant is passing through the critical stages. They must, at all times, be prepared to meet the emergencies of asphyxia and to counteract the spells of cyanosis. These two factors in themselves require almost constant diligence, otherwise the work of previous days will go unrewarded. They must use good judgment to prevent over- and underfeeding, as to a very great extent the size of the individual meal will be dependent upon the physical condition of the infant at the time of feeding. In no other class of patients is it so necessary to change or modify on short notice previous orders for diet. The nurse must know the indications for and the methods of administering catheter feedings, colonic flushing, tubbing and the application of artificial respiration.

In our hospital wards we have found the constant changing of nurses, as is so frequently the case in meeting the curriculum for nurses' training in general hospitals, to be of the greatest disadvantage. Far better results are obtained when the nurse in charge has under her care assistants who need not necessarily be nurses in training, but preferably young women who are especially preparing themselves for the care of young infants, and who can be relied upon to stay in the station for long periods of time. Such women become expert in the handling of these infants, can frequently feed them with a minimum of excitement of their reflexes, and soon learn to bathe and give them their exercise and massage, which is so essential to every infant in order to prevent "hospitalization."

The ideal nursing staff for such a station is, therefore, one consisting of a well-trained supervising nurse and a corps of assistants desiring this training, and who are willing to remain in this service for a long period of time.

Removal of Infants from Their Beds.-The position of the infant in bed should be changed at regular intervals. The removal of infants from their beds should be practised with forethought. The small infants should, so far as possible, be manipulated only upon a definite indication: (1) For cleanliness, including bathing; (2) exercise, including gentle massage after the first week or two. In most instances the food, when administered other than by catheter, can be given without removing the baby from the bed. Catheter feeding in infants not subject to cyanotic spells can often be performed to advantage without removal from the bed. When cyanosis is present or easily precipitated the infant should be removed from the bed during feeding.

In preparing the infant for permanent removal from the heated bed the room temperature should be gradually lessened until 70' F. is approached.

Next the infant is placed in an infant's crib, the sides of which have been padded to prevent extreme currents of air from coming in contact with the infant and thereby increasing radiation. These cribs may remain in the same. room as the individual heated beds, or may be kept in the nursery if it be the more desirable room of the two, when there is a separate bath room. The infant should not be kept permanently in a room in which a considerable number of infants are being bathed throughout the day. There is no need for shortening the stay of the infant in the heated bed if the temperature of the surrounding air is gradually being lowered as the infant. develops. Depending upon the age and development, the average length of time in a heated bed varies from one to six weeks. It is good practice to place the older infants in the crib during the day and to replace them in the heated bed during the night when the heating of the house or ward is uncertain.

The Bath.-In the very weak infants it is frequently advisable to omit the first and the daily bath for two or three days. It may, however, be necessary to use the warm bath to stimulate the infant during its cyanotic attacks.

It should be a fixed rule in the care of premature infants to handle them as little as possible, because of the danger of provoking cyanotic attacks and the regurgitation of food. It should be our object to keep the skin clean and active. The practice of oiling the infant as a routine measure is to be avoided. If the bath cannot be undertaken without danger of chilling the infant, it should be either dispensed with or postponed for a more opportune time; or a partial bath may be given without removing it from the heated bed by washing the face, buttocks and genitalia.

Indications for and Methods of Administering Baths. -- The earliest baths should consist of a sponging with water at 105° F., one part of the body only being exposed at a time to prevent chilling and the process carried forward as rapidly as possible in a room of not less than 75° F., otherwise it is best omitted in the very small infants.

As infants grow older they may be dipped in or sprayed with water heated to 100° F., and this may be gradually lowered to 95° F.

Under no circumstances should the infant be bathed without first taking the temperature of the water and the room.

Infants with subnormal temperature may frequently be stimulated and the temperature raised by placing them in a warm bath which is held between 103° and 106° F.

In cases of hyperpyrexia a bath from 4° to 5° lower than the infant's temperature with cold to the head is of therapeutic value.

In the presence of cyanotic attacks the plain warm bath or weak mustard bath with slight friction repeated as indicated are probably the best therapeutic measures. During such attacks the infant should be handled gently as not infrequently careless and rough handling will result in death during these cyanotic attacks.

All bathing before separation of the cord should be carried out with the idea of promoting surgical cleanliness.

Gentle friction and light massage are of great value following the bath. Neither of these methods of stimulating the circulation must be overdone. Bathing should always be done before feeding.

Care of the Eyes.-If properly cared for at the time of delivery and if there is no reaction to the solutions used at that time, they require no further attention except ordinary cleanliness. The nurse should be warned against getting bath water, or more dangerous, mustard water in the eyes. In cases of ophthalmia the treatment is practically that as used for full-term infants with greater care for the prevention of trauma and destruction of the eye.

The Nose and Mouth.-Unless there is a direct indication due to plugging of the nose or an infection of the nose and mouth, there should be no manipulation of these mucous membranes, because. of the danger of abrading them and opening fresh surfaces for infection. In the presence of upper respiratory tract infections or stomatitis, the greatest care should be taken in applying local treatment as advised in the special chapter dealing with these diseases.

The use of the nasal catheter is always a dangerous procedure and even the passing of the catheter through the mouth may result in trauma if not carefully performed.

The Breasts.-In simple mastitis the breasts should be anointed with camphorated oil and a light pad of cotton held in place by a snug breast binder. The dressing may be changed every second, third or fourth day as indicated. In case of abscess formation, which is of very infrequent occurrence in prematures, incision and drainage should be performed.

The Genitalia.-The genitalia more especially the vulva in girls should be handled with extreme care in order to avoid trauma and infection. Small cotton combination pads should be applied to the buttocks and genital organs in order to receive the feces and urine. They should be frequently changed in order to avoid irritation from the excreta. By the use of these small pads which are described under the chapter on clothing, the frequent change of diapers can be avoided.

When there is evidence of infrequent or painful urination, which is more especially true in a male infant, it should be immediately inspected for evidence of occlusion due to the drying of secretion or exudate in the presence of an ulcer at the meatus. The buttocks are easily irritated by the decomposing urine and acid stools, and these parts readily become infected. In most instances the napkin can be changed .without removal from the bed. In the treatment of all lesions about the genitalia an attempt should be made to keep the parts dry and clean. If water proves irritating a starch water may be substituted or the parts may be cleansed with benzoated lard. The parts are then dusted with stearate of zinc or rice starch. When these simple methods fail, a 1 per cent mixture of balsam of Peru in castor oil or lanolin maybe used. Our best results have been obtained in older infants when the buttocks are exposed to warm dry air through the medium of an incandescent electric light or sunlight if the latter is possible without the danger of chilling the infant. In small prematures the parts may be left uncovered in the heated bed. Small rolls of cotton may be used to separate the folds of the skin.

The present-day use of washing powders, which are retained in improperly rinsed diapers and which lead to a rapid decomposition of the urine, may be a source of intertrigo.

Delayed urination is not infrequent and should lead to an inspection of the genital organs. A delay of twenty-four hours in the passage of the first urine is quite common in premature infants. If the infant is otherwise apparently normal, it should not be a cause for too great concern, and it is to be remembered that a small quantity of colorless urine may dry out and go unobserved. The best treatment is the administration of fluids approximating one-twelfth to one-twentieth of the body weight of the infant during the first day or two, and later approximating one-sixth of the body weight. This is inclusive of all fluids administered. A warm moist pad over the lower abdomen and pelvis or a warm bath will frequently cause spontaneous urination.

Uric-acid crystals and urates are very commonly found in the urine of the premature causing a pinkish stain on the napkin and are most commonly due to marked concentration of the urine. At autopsy, however, more frequently than in the full term, do we find these salts deposited in the kidneys. Considerable pain may be caused by the passage of these deposits through the ureter. In every case fluids should be pushed.

The Bowels.-The anus should be carefully inspected shortly after birth to ascertain the presence or absence of anomalies. Delay in passing the first stool may be due to one of many causes, such as delayed peristalsis, weak abdominal wall, contracted sphincter and accumulation of feces, most commonly in the sigmoid or cecum.

We believe it is a good custom to attempt to promote a bowel movement before the beginning of milk feedings. Frequently the. administration of inert fluids per mouth will promote peristalsis. We do not hesitate to give a 1- or 2-ounce normal saline colonic flushing. The amount used depends upon the development of the infant. A small glycerin or soap suppository answers. If there remains doubt as to the patency of the intestinal tract, a small dose of castor oil, 0.5 to 1 cc (8 to 15 drops), may be administered per mouth. Once the patency of the intestinal tract has been established, intestinal evacuations are usually spontaneous, more especially so with infants fed on breast milk or with high carbohydrate mixtures. For further_. treatment see Constipation.

Care of the Skin.-The skin of the premature is very delicate and covered with lanugo and prominent sebaceous glands. There is a great tendency for the skin to dry and crack and to desquamate in large flakes. This is especially true in infants suffering from marked jaundice. There is also great tendency for papular, vesicular and pustular eruptions of various types to develop. Erythematous eruptions are of frequent occurrence. All of these conditions will call for a modification of the daily routine, insofar as the baths and local skin care are concerned. The greatest danger is due to secondary skin infections which is especially true of the syphilitic infant. The various forms of dry treatment of these lesions offer the best results with the least danger of spreading. The application of silver nitrate to. each pustule and vesicle after cleansing with alcohol have given us the best results, except in the case of syphilitic infants where local mercurial treatment is indicated.

The daily care of the skin should therefore consist of the avoidance of trauma and exposure to secondary infections in the bathing and handling of the infant, the removal of all excretions, the separation of-irritated folds by a layer of cotton, and the dry treatment of all non-suppurating skin lesions, and antiseptic treatment, cauterization or specific treatment of open lesions.

Delayed Separation of the Cord.-Delayed separation of the cord may be hastened by the application of 5 per cent silver nitrate solution or 50 per cent alcohol dressings. In the use of the latter a few drops of alcohol may be applied to the dressing at regular intervals. When the hard, dry cord remains intact far beyond the usual time for separation it may be necessary to cut through the remaining strands, using great care to avoid the live tissues. Granulations are best treated by the application of silver nitrate solution or hard stick.

Body Temperature.-The body temperature must be taken through the rectum. It should be recorded morning and evening. An individual thermometer should be furnished for each infant. Fluctuations in body temperature are more marked than in the full term infant with a tendency toward hypothermia. A minimum of 97° F. should be considered the lowest compatible with progress. Attempts should be made to limit the daily fluctuations to 1.5° F.

Subnormal temperature may result from undue exposure at birth, subsequent carelessness, lack of development of the nervous system, absence of a good layer of subcutaneous fat, respiratory insufficiency circulatory weakness and insufficient heat production due to lack of food or defective metabolism.

These etiological factors are to be counteracted by definite therapeutic measures.

Prevent undue exposure and trauma from the moment of birth. The infant should be placed in a heated bed of proper construction and kept there under constant supervision. The temperature of the heated bed should be varied with the needs of the individual infant. Small prematures and congenital weaklings with marked hypothermia should temporarily have a surrounding temperature varying from 85° to 95° F. Older and stronger infants are better placed in a bed at 75° to 80° F. As the infant develops its vital functions and the subcutaneous fat increases, the temperature of the bed should be gradually lowered to that of the nursery, which should be kept at about 70° to 75° F. It should be the rule to regulate the temperature of the heated bed by the rectal temperature curve, and while it may be impossible to bring the body temperature to normal, the degree of hypothermia is our best guide in the application of external heat.

It may be necessary to place the infant in a hot bath to raise the temperature and stimulate respiratory and cardiac function following syncope.

Removal from the bed should follow definite indications, ordinary feeding, changing napkins and the ordinary routine measures can be carried out in the bed.

The body must be insulated by proper clothing to be described. The body fluids, after the first few days, must be maintained by an intake of from one-sixth to one-eighth of the body weight in fluids in twenty-four hours, and this must include a caloric intake of more than a sustaining diet, 70 calories per kilo after the first ten days of life (p. 180).

Respiratory and circulatory functions must be protected and at times stimulated.

Hyperpyrexia frequently results from an overheating of the bed, and when a high temperature is noted the temperature of the 'bed should be considered as a possible cause.

Infections of all kind tend to the development of fever, but on the whole ,the reaction is less than in the full term, however, the exception may be true. We have found massive pneumonias at autopsy which were unassociated with temperature above the average normal.

The Pulse. -- The pulse may be imperceptible in the extremities and require auscultation of the heart for timing. The cardiac action will usually. range from 100 to 180 per minute in the small and weak infants, although occasionally a very slow pulse is noted, which latter usually precludes a bad prognosis. The best indicator of proper cardiac function is the infant's general circulatory condition; it gives far more information than the number of heart beats.

Respiration.-The respirations normally vary from 20 to 60 per minute in different infants and are to a large extent dependent on the heart action in infants not suffering from atelectasis or central disturbances. During cyanotic attacks they become almost imperceptible and may be temporarily suppressed. Again the general condition of the infant is the best guide.

Weighing should be done at a specified time each day as part of the general routine, with a good scale. The infant should, unless contraindicated, be undressed for this purpose, and this is best done before the bath. The relation between the time of the last feeding and passing of feces should be noted.

In older well infants daily weighing may not be indicated but in prematures it should be done as a routine, more especially in difficult feeding cases. Those fed at the breast must be weighed before and after nursing, and the food taken is to be recorded.

Loss of Body Weight during the First Days of Life.-This occurs almost constantly in premature infants, the percentage loss being greater in the premature than in the full-term infant, and, on the whole, they are much slower in regaining their birth weight. In the group of cases studied by the author the average loss in the cases weighing between 1000 and 2000 gm. was 10.9 per cent. More recently we have been able to reduce the initial loss to approximately 5 per cent in a number of cases by carefully increasing the fluid intake after the first twelve hours.

Most of our cases have regained their birth weight by the eighteenth to the twenty-first day, with a daily gain averaging from 12 to 40 gm. after reaching their lowest weight, which is usually about the fifth day. Infants under 1500 gm. may be considered as progressing satisfactorily on an average of from 10 to 20 gm., and doubling their birth weight in seventy-five to one hundred days; and those from 1500 to 2000 gm. when they are making a daily gain of from 15 to 25 gm. after they have reached or passed their birth weight with a doubling of that weight in from fifty to one hundred days.

The Infant's Clothes.-The wardrobe should be planned and completed in advance of labor. In emergencies this may not be possible. It is imperative to remember that preservation of the body heat must be begun immediately after birth; on the confinement bed itself. Insulation of the body is the prime thought to be borne in mind when planning the wardrobe. The clothes must fit the body snugly, providing only for a thin layer of air between the body and the dress. The material must be selected with some knowledge of the method by which external heat is to be supplied. The head, except the face, and the extremities must be equally protected with the body.

At birth the infant is received into a warm blanket and immediately placed in a heated basket, heated bed or incubator.

In supplying external heat it should be remembered that these infants are easily burned, and such burns are usually fatal.

In small prematures for temporary emergency use a sterile cotton-pack which completely envelopes the infant, except for the face and gentao-anal region, may be applied. It should, however, be remembered that cotton is far inferior to wool in prevention of heat radiation. An improvised jacket, preferably of flannel, may be placed oil the outside of the cotton to hold it in place.

To the genital region and anus an easily changed small pad of cotton or gauze combination may be applied. Whenever the infant becomes soiled, it is only necessary to change the pad. This should not be neglected.

If special outer garments are not available, the infant should at once be wrapped in a small heavy woolen blanket, or cotton combination, which can be fastened about the body loosely by bandages or safety-pins in papoose fashion. The greatest disadvantage of such a dress is the limitation of body movements, which is of considerable importance even in these infants. All pressure and constriction must be avoided (Figs. 75, 76 and 77).

In a well-equipped station several sets of special cloths should be provided. These should be kept sterilized in packets. The outfits will differ somewhat, depending upon whether the open or closed incubator beds are used.

With the open type of heated beds, all garments next to the body, except the napkins, should be made of light-weight flannel.

A set of clothing should consist of woolen bands of small size; small woolen undershirts; overshirts; pinning skirts; woolen stockings; diapers; pads; bibs; and a woolen bag, with an attached head-piece, with a slit over the upper part in front to allow passing over the head. The bag should be open at the bottom to allow of its being raised for changing of napkins, dressing the cord and general care of the infant (Fig. 77). The overskirt should be somewhat longer and larger than the undershirt and may to very good advantage be made from French pique which is less impervious to air than flannel.

In the absence of a sleeping bag the infant may be wrapped in a light flannel blanket, so applied that the upper part will form a hood.

With the closed type of bed, the sleeping bag and blanket are unnecessary.

A complete outfit for use with an open bed should contain:

Four bands 12 inches long and 4 inches wide (flannel or knit wool).

Four undershirts with blind sleeves and draw string at neck (flannel).

Four overshirts (flannel or French pique fleeced).

Four pinning skirts (French pique 24 by 28 inches).

Two bags with hoods 30 inches long and 20 inches wide (woolen). Or two blankets 1 yard square (flannel, knit wool or cashmere).

Four pairs of stockings (woolen).

Two dozen diapers size 18 by 20 inches (fine bird's eye).

Small genital pads (absorbent cotton and gauze).

Bibs (same material as jackets).

How to Dress the Baby.-The clothes must be put on quickly without undue exposure. First, the abdominal band is applied, if needed to retain cord dressing, otherwise it may be omitted, then the undershirt, followed by the overshirt, both of which are pinned at the side, next the small genital pads and diapers, to be followed by the pinning blanket, the latter being turned up over the feet and pinned at the back.

The infant may then be placed directly in its bed and its head and body covered by a blanket, or it may be put in one of the woolen bags before being put in its bed. The selection of the last article of dress will depend largely on the condition of the infant.

The essentials of the dress are:

1. Good insulation.

2. Cleanliness.

3. Protection from changes in temperature.

4. Ease of application and removal with a minimum manipulation of the infant.

In the emergency and in very small and weakly infants these indications may be met temporarily by a complete envelopment in cotton, but as soon as safe and convenient the infant should be dressed in the simple and easily applied garments described. These garments are so applied that they may be described as upper and lower garments. For the changing of soiled napkins the upper half of the clothes need not be removed. Complete undressing is required only for the purpose of bathing.

Many of these little infants vomit repeatedly and if it were. not for the heavy texture of bib and jacket, it would necessitate very. frequent complete undressing of the infant, instead of removal of the soiled linen only, which is but part of his dress. These clothes are easily ironed. Absorbent cotton can be used as a bib. We also provide for fresh bedding preferably by the use of untarred jute in our bed and pillows, if the latter are used, which can be thrown away at will because of its cheapness.

The infants should be watched very closely and the wet and soiled linen changed immediately to prevent intertrigo, as the urine dries very quickly in the heated bed and when concentrated erodes the skin, which is severe and disastrous to these children. After each change the infant should be carefully cleansed, either with water, benzoated lard or mineral oil, before being replaced in the heated bed. The clothes should fit snugly and are to be preheated before applying and must be absolutely dry. This especially applies to diapers. In laundering the baby's clothes no bluing, lye or strong alkaline soaps should be used, the best for this purpose being a neutral or nearly neutral soap of the type of which Ivory soap is an example. The clothes should then be rinsed in pure water before drying.

The child should not be wiped with the soiled diaper, but with absorbent cotton which can then be destroyed. The same should apply for bathing purposes, where cotton is far more cleanly than a sponge.

Arranging the articles on and in a heated dressing table expedites dressing the infants with the above style of dress. The child can be dressed in one or two minutes without undue manipulation.

Watch for Sickness.-The possibility of grave pathological changes with minor clinical manifestations must be constantly borne in mind in the care of prematures. In order to diagnose and properly counteract the dangers which may follow the overlooked simple ailments, at least one daily general inspection and examination, quickly but carefully performed, is required. The exception to this rule is the immediate danger due to handling extremely delicate infants.

In no other group of infants is a careful study of the individual functioning of the heat centers and the respiratory,, circulatory, nervous, genito-urinary and gastro-intestinal organs so imperative.

The Hospital Records.-The records should include the. following forms'

1. A history and physical examination blank (Fig. 85).

2. A graphic record chart (Fig. 86).

3. A special feeding card for recording the amount of individual feedings and stamped by the time clock. Time of urination and stools and a description of the latter can be recorded on this same card. Inspection of the infant at feeding times will prevent neglect in changing the infant and assist in the prevention of local and ascending bladder infections. The data from the feeding card should be transposed to the graphic record sheet daily (Fig. 87).

4. Temperature chart for room and bed. On this sheet is recorded the temperature of the bed in which the baby is kept. It should be charted at six-hour intervals, best at 6 A.M., 12 M. and 6 and 12 P.M. These are the most likely times for maximum changes in the ward temperature which might call for an increase or decrease in the external heat to be applied to meet the desired bed temperature. At the same time the ward temperature should be recorded and the humidity in the room and bed should be noted and recorded (Fig, 88).

5. Physician's order blank (Fig. 89).

6. Milk station order blank (Fig. 90).

7. Wet-nurse's record blank (Fig. 91).

The Clinical Record.-A careful history is most important, as much evidence which will have a direct bearing on the prognosis will frequently be elicited as well as suggestions for feeding and therapy. The maternal history as to illness, previous pregnancies and their outcome must be elicited. The paternal history is. Also of prime importance. The presence or absence of acute illness in the home, more especially whooping-cough, scarlet fever, diphtheria and septic infections should be investigated before the infant is discharged.

Every hospital record should show the data of at least two social-service investigations. This, while usually neglected, frequently reveals conditions in the home which make the early discharge of these, retarded infants impossible, if their lives are to be conserved.

The first investigation should be made in the shortest time possible after the infant enters the hospital, the last just previous to the infant's discharge.

Conserving the Mother's Breasts,-If the mother does not accompany the infant she should be encouraged to conserve her breast milk. This may be accomplished by one of several methods: (1) By expression at regular intervals, and if this is the method used she should be encouraged to send her milk, to the hospital once or twice daily, if for no other reason than to keep a record of her faithfulness. (2) By nursing a neighbor baby, one loaned to her from the hospital or some other source. Later by having her come to the institution to nurse her own or a full-term hospital baby. (3) By placing a puppy to her breasts. While this latter at first thought may seem repulsive, it has in our own experience proved to be a most desirable expedient.

The establishment and maintainance of properly equipped hospital stations are essential to the lowering of mortality, more especially in the large cities and particularly among the poorer classes. A careful consideration of the requirements for and results to be expected from their care in the home is equally essential.

In many instances the premature is born unexpectedly with little time for preparation for its reception. The expectancy of a-premature labor is almost always associated with more or less excitement in which thought for the baby's needs are likely to be overlooked, the mother usually being given first consideration.

It will, therefore, be our object to outline a proper routine for the establishment of an emergency home unit.

In the home care of these infants the same rules for hygienic maintainance of body temperatures, breast feeding, and daily routine must be maintained as suggested for their hospital care.

The Nursery Unit. -- Whenever possible two rooms should be set aside for the infant's use; one equipped as a nursery with furnishings similar to those described for the hospital nursery. The second room is to be used for sleeping quarters and must be equipped with a heated bed. These rooms must be well ventilated and at the same time well heated. In both these rooms all draperies and unnecessary furniture must be removed.

A bath room properly equipped (Fig. 92) makes a splendid second room in which the general care of the infant can be administered. This room should be given over to the exclusive use of the infant. When such a bath room is available only one other room is needed.

When the baby is being dressed or bathed the nursery or bathroom temperature should be in the neighborhood of 80° F. A gas or electric stove will be of assistance in accomplishing this. When a superheated bed is in use the sleeping room may be kept between 70 to 75° F. All visitors other than the attendants and physician must be excluded.

The equipment of the room or rooms should include a heated bed, a dressing table, preferably heated, or placed over a warm radiator, a small electric or gas stove for emergency use, a scale, bathing and feeding utensils, a thermometer, a hygrometer and surgical supplies (Fig. 93).

The Superheated Bed. In the home hot-water bottles, a properly protected electric pad or an improvised incubator will answer the purpose (p. 223).

A thermometer should be placed alongside the baby as too great emphasis cannot be laid on the dangers and fatalities due to overheating and burning of prematures. There is a great tendency to hyperthermia which must be recognized and properly interpreted. There is usually a rapid return to normal body temperature without bad effects upon removal of the cause unless too long continued. The general care of the heated bed has been described on p. 218.

The Nurse. -- She must be experienced in the feeding and handling of such infants and must be tireless in her efforts to prevent complications. She must be diplomatic in order to permit the overcoming of the mother's anxiety, with its consequent effect upon her milk secretion. he must be able to control the habits of the wet-nurse, if one is employed. he must insist upon taking orders from the physician and no one else. She must be able to keep a careful record, practise aseptic nursing, avoid accidents and be cleanly in her personal habits.

A second person should be present, who can assist and relieve the nurse. She must be willing to work under the nurse's supervision. uch a person is indispensable in the presence of emergency. Only those directly interested in the care of the baby should come in contact with it.

The Infant's Food.-Breast milk should be considered indispensable and during the first days of life it may be necessary to obtain a temporary supply from a neighboring mother, a wet-nurse or a hospital. A small amount, 90 to 240 cc daily will usually meet the emergency. nly when these sources of supply fail absolutely should artificial feeding be instituted.

Preparation for Labor.-The protection of the infant must begin with the first stage of labor. The room, receiving clothes and its bed must be properly warmed. Refrigeration is the direct cause of more deaths among prematures than any other extraneous factor. All routine measures described for the hospital care in Chapter VII should be, so far as possible, observed in the home.

Clothes. -- The clothes best suited have been described. Simplicity in dress with is minimum manipulation or changing being the object to be attained, because or the dangers of exposure, trauma and infection. The infant should be received into warm blankets. One of the most; common errors is to allow the infant to remain in such a loosely applied robe, which does not provide for proper insulation of the skin because of the large air space between the blanket and the infant. This allows rapid radiation of the body heat. Therefore, at the earliest possible moment the infant should be protected from head to foot by closely applied warm clothes. The body, if woolen clothing is not at hand,, should be wrapped in cotton. The cotton should be applied in two parts, the upper half encircling the head except the face, together with the trunk and upper extremities, the lower half should encircle the lower extremities, a small pad being applied to the genitalia and buttocks. This allows for cleansing the genital region with a minimum of manipulation. The upper part of the body may then be covered by a small-sized infant's shirt on the outside of the cotton jacket and the infant is then wrapped in a woolen blanket in its bed. The clothes best adapted for later use can be made according to the description on page 155, and should be supplied as soon as possible. A woolen blanket should cover about three-quarters of the basket, the head being left open.

The Bath.-The advisability of giving a warm bath has been discussed but it is our desire to emphasize the conclusion that the initial bath is to be omitted whenever there is danger of unduly exposing the infant. In a proper environment the warm cleansing bath should be given in the absence of cardiac and respiratory complications.

Further Early Care.-The baby must, under all circumstances, be under constant observation during its first hours because of the dangers of cardiac and respiratory complications, over- and underheating, overcovering, and overlying, the latter due to careless placing of the infant in the bed. Whenever feasible the infant should be placed in a properly prepared room away from the mother. Its personal attendant, other than for special care, need not necessarily be a trained one. When a dependable person is not at hand it should be kept in the room with the mother.

The general care should be that as described for hospital care.

The Results Obtained.-With human milk, a skilled nurse, an adequate bed, a good nursery and proper feeding and nursing technic the same good results are to be expected as in hospital care.

Transportation to a Hospital.-Removal to a hospital station should not be delayed when nursing and feeding needs cannot be fulfilled in the home. It should be moved in a specially prepared bed so that it will not be exposed en route. When the infant is to be sent to the hospital which is provided with a transportation incubator, the institution should be called upon to transfer the infant.

	Fig. 64.-Hospital bathroom, located between two small wards for infants, showing two metal water jackets resting on a porcelain sink. These can be filled with water and have a registering thermometer for indicating the temperature before giving the. bath. They are covered with a clean towel for each baby. Baby is showered from an automatic mixing tank which registers temperature of the water in the tank. The room further contains a scale and a low dressing table with the various dressings, powders and ointments to be used. Also low nursery chairs, collapsible bags for soiled linen and waste basins.
	Fig. 65. Divan bath with thermostatic mixing control.
	Fig. 66. Electrically warmed dressing table. (DeLee.)
	Fig. 67. Large unheated dressing table, provided for dressing of two babies. Scale in center and closed cabinet for clothes. (Couney.)
	Fig. 68. Scale for weighing infants.
	Fig. 69. Thermometer registering present and extreme room temperature during the twenty-four hours. It is to be adjusted by a small magnet once daily.
	Fig. 70. Hygrometer. Wet and dry bulb.
	Fig. 71. Humidity table for use with wet and dry bulb hygrometer.
	Fig. 72. A milk station consisting of three rooms. Room 1.-For all used bottles, bottle washers and steam bottle sterilizers. Room 2.-A clean room for preparation of formulae. This room also contains milk separator, fat testing apparatus and butter churn. Room 3. -- Pasteurizing and sterilizing apparatus.
	Fig. 73.-Portable bath basin for individual use of infected infants. Basin can be removed for sterilization.
	Fig. 75. Emergency robe with hood made of gauze and cotton combination.
	Fig. 77. Woolen bag with hood. For further protection it may be drawn together beneath the infant's chin.
	Fig. 78. Wool flannel undershirt with closed sleeves.
	Fig. 79. Heavy overshirt made from French pique.
	Fig. 80. Pinning skirt or blanket for the lower half of the body. (Made from French pique.)
	Fig. 81. Bib.
	Fig. 82. Pattern for designing under- and overshirts. Diagram of body and sleeve patterns.
	Fig. 83. Dressing the baby. Under- and overshirts applied.
	Fig. 84. Dressing the baby. Under- and overshirts and pinning shirt applied.
	Fig. 92. Special bath room equipment for private home, showing dressing table (padded) with drawers, built over radiator. Shelves for dressing, etc., above the table. Bathing board over one end of bath tub.
	Fig. 93. Plan for arrangement of stations in a private home, consisting of one large, well ventilated and heated room and a bath room.