NEONATOLOGY ON THE WEB

L. E. La Fétra, M.D., Associate in Diseases of Children, Columbia University, College of Physicians and Surgeons; Visiting Physician to the Children's Wards, Bellevue Hospital, New York.

Published in Transactions of the American Pediatric Society 28:90-101, 1916.

The first page of the original La Fétra paper.

At the outset I wish to say that this is not a general discussion of the topic, but a resume of my personal experience in the observation and treatment of these cases.

In the past two years there have been admitted to the infants' ward of Bellevue Hospital 278 premature infants. Of these thirteen are still in the warm ward specially provided for premature infants and 265 have been discharged. There are three reasons for the very large number of this class of patients admitted to Bellevue: first, because there is a large maternity ward on the floor just above the infants' wards; second, because Bellevue is a city institution to which the police department brings all the foundlings, and third, because the hospital is known to have special facilities for taking care of these tiny patients. There is, so far as I know, no other institution, either here or abroad, that has so many such cases.

These mites are brought to us in the most diverse and curious wrappings; some beautifully swathed in cotton and warm flannels, with hot water bottles around them, and many others stiff and blue from exposure and insufficient covering. Naturally, many of the latter have received so severe a shock that the small spark of life cannot be fanned into a sufficient flame; it flickers for a day or so and then goes out. This means that the mortality is very high, and the most of it during the first few days after admission to the hospital. But a great deal can be done for even the smallest and feeblest of them, and it is on this account that a consideration of the measures we have found most useful may be of interest to all who are called on in private work to care for these interesting little patients.

I have recently gone through the records of the last 200 patients discharged and find that there were thirty saved, discharged cured, as we say; that is, they were discharged from the hospital in strong enough condition and with sufficient weight to make it probable that their mothers could care for them successfully. Of the 170 that died in this last 200 patients ninety died on the first day, many within an hour or so of the time of admission; twenty-eight more died on the second and third days, making 118 that died in the first three days. This means that there were thirty that lived out of the eighty-two strong enough to survive the first three days of life, that is, 36 per cent. were saved of those that survived beyond three days. Of those that died, the baby with the highest admission weight was an infant weighing 4 pounds 14 ounces. This baby died of general septicemia. One baby reached 4 pounds 10 ounces and died of gastro-enteritis. Another gained from 2 1/2 pounds up to 4 pounds and then died of acute bronchitis. Still another gained from 2 pounds 3 ounces, its admission weight, to 4 pounds 11 ounces, then it had an infection and died in a few days, much to our chagrin. The lowest weight of those that died was I pound I ounce, that of an infant of five and a half months' uterogestation. There were many that weighed from 1 pound 12 ounces to 2 1/2 pounds.

The smallest infant that was discharged cured had an admission weight of 2 pounds 13 1/2 ounces. The baby remained in the hospital seven months and weighed 5 pounds 6 1/2 ounces at the time of discharge. The next smallest baby that was discharged cured weighed 3 pounds on admission and after four months in the hospital was discharged weighing 5 pounds 5 ounces.

Three years ago, while visiting the children's clinics on the Continent, I learned that in Paris the smallest premature infant they had reared successfully weighed 800 gm., and in Berlin at Langstein's Hospital an infant of 750 gm., a case of L. F. Meyer, had been successfully reared. It is most unusual, however, that any baby weighing less than 2 1/2 pounds is saved. The smallest child reported saved is that of Rodmann, weight 719 gm.

The great majority of the babies admitted to the premature ward have a history of uterogestation between seven and seven and a half months. But it must be emphasized that the history is not to be depended on. In our experience, in cases in which the history has seemed more than usually reliable, babies of six months' uterogestation weighed from 1 1/2 to 2 pounds; those of seven months weighed from 2 3/4 to 4 pounds, and those of eight months weighed from 4 1/2 to 5 1/2 pounds.

These are to be taken only as general averages; there are many exceptions, both in the direction of the earlier born, weighing more than these figures, and of the later born, weighing less. This is particularly true in the case of multiple births, such as twins or triplets.

Causes of Prematurity -- Aside from mental or physical shock, the result of an accident, the causes of prematurity are, briefly, syphilis, some acute disease in the mother, extreme youth of the mother or of both parents, and, connected with this, illegitimacy. The occurrence of twins or triplets or other multiple pregnancies is a very important factor.

Symptoms -- Aside from the small size and weight of the premature baby, the usual symptoms manifested are, in the first place, extreme muscular feebleness, which extends even to the muscles involved in sucking and swallowing. Inability to nurse, that is, to make sufficiently strong suction to withdraw the milk from the mother's breast, is the regular condition, and in very many instances it is the underlying cause of fatal inanition; that is to say, the mother may, after a few days, have abundant, normal milk and the baby may have a good digestion, but on account of feebleness of its muscular power the baby is unable to obtain the nourishment.

Another symptom manifested by nearly all of these babies, partly on account of their small size, but for other reasons which will be mentioned, is a temperature far below normal. The skin is imperfectly developed and the subcutaneous fat is deficient or lacking, so that the baby radiates more heat proportionately than an infant of normal size. Again, the heat regulating center seems not to be in satisfactory operation, so that the baby is thermolabile, very susceptible to the heat changes of its environment. With regard to the skin, babies born very early may have a skin which is partly translucent, having the appearance of solidified gelatin. These babies with gelatinous skin are seldom able to survive.

Another symptom which these babies show is a great tendency to attacks of cyanosis. This in some instances is due to pressure of the clothes or the weight of the arms on the chest, but in other instances it seems to be related to the feeble muscular power and easy fatigue which the muscles of respiration undergo. The attacks may be so serious as to prove fatal, so that constant care is necessary to prevent bad results. Another cause of cyanosis is insufficient food.

These babies also have an extreme susceptibility to all sorts of infection. The skin and mucous membranes are very permeable to germs, so that extreme care is necessary to prevent abrasions and to avoid contagion from other persons or from contaminated clothing or apparatus.

Absorption from the gastrointestinal tract of deleterious substances, whether as the result of fermentative processes in the intestines or of germ infection, may cause profound and even fatal disturbance in a very short time. General sepsis may arise from this source or may come from the umbilical wound or from abrasions of the skin. On the other hand, occasionally one sees localized infections that cause comparatively little disturbance. This principally occurs in the hands and feet, where the blood supply is very good.

Not always, however, does a serious disease prove fatal to the premature infant. Baby 786, weighing 4 pounds, had an attack of bronchopneumonia, with temperature ranging up to 104 F. for over a week, recovered and afterward gained in weight and was discharged from the hospital in good condition.

Treatment

General Management -- So far as is possible it is the aim in the general management of the baby to reproduce the conditions of intrauterine life, conditions which the baby should have been entitled to until the ordinary full period of intrauterine development; that is to say, the baby should be kept in an even temperature approximating that of the human body and should be shielded from all sorts of external shocks, whether thermal or mechanical. The skin should be protected from chances of contagion and injury and the eyes should be protected from light. The inhaled air should be moist and comparatively warm and as free as possible from germs, and the food should be such as to require the least possible amount of digestive effort on the part of the baby. To secure as far as possible the conditions mentioned, certain specific factors are of the greatest importance. First, the temperature of the environment. This is much more readily managed in summer than in winter, but with a little care and attention very satisfactory conditions can be obtained, even in any home. The first question that will arise on the part of the family and the physician in the management of a premature baby is whether or not it should be put into an incubator. My experience with most Incubators and their methods of management would lead me to give a decided negative to this question. Incubators are expensive; they are complicated. It is inconvenient to change the baby's clothing while it is in an incubator, and most of all, an incubator is difficult to ventilate and to keep free from germ contamination. Moreover, to keep the temperature equable in them and the ventilation proper requires a nurse who is thoroughly familiar with the use of the particular incubator installed.

As regards incubators, probably the most satisfactory one up to the present time is that devised by Dr. Edwin B. Cragin and described in the Journal of the American Medical Association for Sept. 12, 1914. Dr. Cragin devised his incubator to overcome the objections he had to others, namely, insufficient air space, insufficient circulation of air and difficulty of maintaining a constant temperature. Accordingly he made his incubator much larger, holding two basins arranged with electric fan to draw through a current of filtered air and made use of a series of electric bulbs for heating. The air is moistened by evaporation of a pan of water placed in the lower part of the incubator. A thermometer and a hygrometer show the heat and moisture. Altogether, however, there are so many disadvantages in the use of incubators, as compared to their advantages, that the plan of setting aside a small room as an incubator room and having that kept at the proper temperature is much more satisfactory in every way. Here the baby does not have to undergo any chilling when the clothing is removed for any purpose.

The most complete incubator rooms have the air drawn in front doors from some uncontaminated source (in cities usually best from the roof) and it is then warmed, filtered and moistened. The temperature of the room is regulated automatically and the degree of the heat can be adjusted. Such an installation is quite expensive. The Babies' Hospital in New York has such a room which was installed under Dr. Holt's direction.

At Bellevue Hospital, because of the prospect of entirely new children's wards, a very simple and inexpensive Premature ward was devised for temporary use. The sunny corner of a ward facing southwest was partitioned off and double windows with transoms were installed and the number of radiators was increased, so as to furnish sufficient heat on the coldest days. Ventilation was secured by means of the transoms and the door leading into the rest of the ward, where three wet nurses and their babies have their beds. The premature room has a capacity of ten cribs, with a cubic air space of 1,000 feet per crib. Moisture for the air is obtained by keeping a large pan of water simmering on an electric stove. After much experimenting we found that the babies do best, as a rule, when the temperature is kept from 76 to 80 F. with a humidity between 60 and 70 percent. Without this degree of moisture the room temperature had to be much higher, and even then the babies' mouths got very dry, and their appetites and digestion did not seem so good. Very feeble infants are not only wrapped in cotton, but hot water bottles are put at the bottom and sides of the crib until the baby gains enough strength to keep an even temperature without them. Few need the bottles for more than a week.

Incidentally, we have found the warm ward of the greatest advantage in managing feeble infants that are not premature, such as those weighing 6 pounds at 6 months and having a subnormal temperature. On being put into the warm ward the temperature comes up to normal and they soon begin to assimilate and utilize the same food which seemed to be of little use when their temperature was subnormal.

The baby should be handled only when absolutely necessary. For the first few days after the initial anointing with oil there should be no undressing of the baby, the only handling being that necessary to change the gauze diaper. The clothing should be the simplest possible. Babies under 4 pounds are best wrapped in cotton and kept so swathed until the temperature remains constantly at normal and the weight has risen to 4 or 4 1/2 pounds.

After the initial sponge bath and oiling no bath needs to be given for 4 or 5 days; then a sponge bath may be given every other day for a few days, and later every day.

Diet and Method of Administration -- Of equal importance with the maintenance of body heat is the diet and its administration. In order, then, to feed these babies we must put the food into their mouths and often even into the stomach. In general, the most satisfactory means of administering the food is to use a Breck feeder. This is a large graduated tube with a rubber bulb at one end and a small nipple at the other. After the warm food is put into the tube, the nipple is inserted into the baby's mouth, the bulb adjusted and then slight pressure will express a small amount of food through the nipple into the baby's mouth. This has the advantage of teaching the baby to draw on the nipple, but without exhausting the baby's strength. Feeding by the medicine dropper is not nearly so satisfactory, because it does not teach the baby the proper movements of the tongue and and because, also, it is a much slower method of administering food. In some cases the baby cannot swallow satisfactorily and then it is necessary to resort to gavage, a very small, soft rubber catheter being passed through the mouth or through the nose. It is found that the baby is less apt to vomit when it is passed through the nose.

The food which is most suitable and requires the least digestive effort on the part of the baby is, of course, breast milk, but even this must usually be diluted and perhaps even predigested. At Bellevue three wet nurses are kept constantly to furnish milk for the premature babies, and often additional breast milk is bought from women in the neighborhood. This is a good charity for both the women and for the hospital baby. In all private cases the effort should be made to secure good breast milk, either obtained from some maternity hospital or better from a wet nurse who is in the house along with her own baby. This last is necessary in order to keep the breast milk from drying up. The milk is to be expressed from the breast two or three times a day and a requisite quantity mixed with either whey, barley water or granum water as a diluent and then fed to the baby from a Breck feeder. The mixture of breast milk which we generally employ in our premature wards in Bellevue Hospital is for the first few days one half whey and one half breast milk, 1 ounce being given every one and one half or two and one half hours, depending on the size of the baby and its stomach capacity. After a few days the strength of the breast milk is increased to three fourths, from 1 ounce to 1 1/2 ounces being given seven or eight times in twenty-four hours. We have had no success with the four-hour interval. On this food the babies will usually gain quite satisfactorily, though at first very slowly, and one should not be discouraged if the increase in weight is not more than 1 1/2 or 2 ounces per week. So long as the baby is comfortable and has a normal temperature one should be quite satisfied with such a gain. Later the breast milk can be increased to full strength and the quantity given in twenty-four hours also increased, so that the baby will be taking 2 ounces every three hours. This should be sufficient food for a baby weighing 4 1/2 or 5 pounds. If it is impossible to obtain breast milk one must then make use of some cow's milk modification. We have found it most satisfactory to use 6 per cent. top milk as the basis of the modification and to dilute this at first with whey or with a gruel made from Imperial Granum; often both the whey and the granum are used as a diluent. Five ounces of 6 per cent. milk, 10 ounces of whey and 5 ounces Imperial Granum water are used to make up a 20-ounce mixture. To this is added either milk sugar or more often dextrimaltose in quantity from 1/2 ounce to 1 1/2 ounces.

If the baby is very feeble, the food is always boiled to prevent the formation of firm casein curds, and also predigested with a pancreatic extract for the purpose not only of peptonizing, but also for the purpose of emulsifying the fat and converting into maltose part of the dextrin and starch in the diluent. Occasionally we have made use of potassium carbonate, 3 or 4 grains to the day's feeding, as an alkali to prevent any chance of acidosis, and occasionally also we have made use of sodium citrate, with the idea of hurrying the food through the stomach into the intestines.

The number of calories per kilogram required by premature babies is, as would be expected, much higher than for babies at full term. We have found by experience that giving the usual 100 calories per kilogram seldom results in a satisfactory gain. On the contrary, on account of the greater proportional surface area it is usually necessary to increase the number of calories from 1 1/4 to 1 1/2 times the ordinary requirements. In looking through the charts it is found that most of these premature babies do not gain until the calories per kilogram have reached at least 120 and many times as high as 150 or more per kilogram. As the baby increases in weight and its subcutaneous fat increases, the caloric requirement diminishes, so that by the time the weight of 5 pounds is reached the calories may generally be safely reduced to 110 or 120.

An important accessory apparatus in the premature room is a tank -of oxygen all coupled tip and ready for instant use in case of cyanotic attacks. It often proves life-saving.

Prognosis -- As to this, the period of uterogestation is of great importance, but not entirely conclusive. The weight is the best criterion, but we must not despair of even the very smallest babies. If the baby weighs under three pounds, the chances are very poor; every ounce over three pounds improves the prognosis. I have already mentioned cases of babies weighing 2 pounds 3 ounces and 2 pounds 13 ounces that gained most satisfactorily. Another baby on admission when 3 days old weighed 2 pounds 10 ounces, and at the age of 1 1/2 months had gained only I ounce, weighing 2 pounds 11 ounces. It became a very strong, vigorous infant weighing 4 pounds 13 ounces and was graduated from the hospital at the weight of 5 pounds. It must be remarked here that if the baby is over one week old, although very small, it has a much better chance to live, no matter what the weight. The very fact of having survived a week with so small a body augers a very good constitution, and with proper care there is every likelihood that the baby can survive.

Case Reports

Baby J. L. weighed at 10 days 2 pounds 3 ounces, 7 months' gestation, and was 43 cm. long. At first fed on breast milk one-half strength; later three-fourths breast milk and one-fourth whey, 177 calories, when eight feedings of 1 1/2 ounces were given. It gained well on this to 3 pounds 14 ounces. It then lost 1 ounce; then the food was Peptonized and potassium citrate added. It gained to 3 pounds 1 ounce, when it was put on whole milk 7 in 20 with 2 ounce dextrimaltose, seven feedings of 2 1/2 ounces. On this the baby gained up to 4 pounds 13 1/2 ounces. Then it suffered gonococcous infection and had to be removed from the premature ward for isolation. The infection and the less expert care caused the baby to lose rapidly and it died, weighing 4 pounds 4 ounces.

Discussion

DR. VEEDER: We have a room in the Children's Hospital in St. Louis similar to the one described by Dr. La Fétra. Our experience, however, has been somewhat different. We have wasted considerable money in trying to get a system of control for this room, and have been unsuccessful. We now open the transom over the top of the window and heat the room by means of radiators, having the nurses watch the temperature carefully. We keep the temperature at 85 F., and do not dress the child except in ordinary infant clothing, leaving it absolutely uncovered on the bed and we do not put it in cotton. We have noted that a great many children will not gain until they have a higher caloric value of the food. At times not 125 calories, but from 170 to 185 calories, seem necessary. The curve of gain is interesting. The babies gain only an ounce or so a week for a month or six weeks, and then begin to gain rapidly on the same food as before. After they have been in the warm room for about two months, the curve flattens out again, and another increase in weight cannot be obtained until the baby is taken from the warm room and placed in the ordinary ward. Then the weight goes up again.

DR. SEDGWICK: Dr. La Fétra has made a statement that I think I shall have to defend for my friend, Dr. J. C. Litzenberg of Minneapolis, who reported, in the section on diseases of children at the Atlantic City meeting of the American Medical Association in 1912, on the four-hour feeding of premature infants. I think that was the first report on the subject made in this country. Since then the newborn work has been transferred from obstetrics to pediatrics in teaching institutions, and we have had charge of the work. We have had success with the four-hour feedings of premature infants. Dr. La Fétra says that he has not. These infants are all well and blooming, and they are doing the same in other parts of the country. Last year Dr. Howland, who is not here, said, "We are doing it now, and it works"; so others get results with the four-hour interval. Of course, we have sometimes to use gavage. It can be done and it has many points in its favor.

DR. LA FÉTRA: In view of the fact that I made a point of our not having succeeded, I should like to have Dr. Sedgwick tell us the technic of the four-hour feeding. I shall be glad to make another trial. Dr. Hoobler and I made a trial in my wards, but we did not succeed in getting enough food into the baby in twenty-four hours by the four-hour feedings.

DR. SEDGWICK: We put in more than the ordinary chart of the stomach contents of premature infants would indicate as possible, for we know that the stomach contents of the infants move on, as we put the infants under the fluoroscope. The amount the child can take does not depend entirely on the anatomy of the stomach. We can get a sufficient number of calories in. We run from 120 to 150, and we have no trouble in getting more in, if necessary.

A point that Dr. Litzenberg brought out particularly was the fact that we have so little vomiting. We always feed these babies now by tubes. It is easier for the baby and easier for the nurse. The baby rests better. We can put more milk in and get the calories wherever we want them.

DR. LA FÉTRA: How much do you put in, and what?

DR. SEDGWICK: We always use breast milk, and put in enough to raise the calories to between 120 and 150. Did I answer your question?

DR. LA FÉTRA: Not exactly. How many ounces or cubic centimeters do you give?

DR. SEDGWICK: We have no rule in regard to that. We usually start with 10 or 15 c.c. five times a day, and raise it as rapidly as possible up to the amount necessary. We have no rule in regard to giving so much at a time. We put in a small amount at first and raise it as rapidly as possible, noting the results in the child.

DR. HOOBLER: I want to speak of the possibility of transferring what has been done in Bellevue Hospital into any home. Is it possible to provide this in a well-ordered home? I tried this out this winter, during very severe weather, with a 4-pound premature child. We were able to maintain the room temperature at the point which Dr. La Fétra has described as being the most satisfactory, with the humidity in proper proportion.

One additional thing we tried, and we believe it excellent for keeping the baby warm. We took a clothes basket and with barrel hoops made a little tent, covering it with a blanket. Under the blanket we hung a couple of ground-glass electric bulbs, and between these bulbs and the baby's face we hung a large piece of black cloth. We hung a thermometer within the tent, and we could regulate the temperature of the tent perfectly. We tried to keep the room temperature around 75 F., but in very severe weather this was sometimes difficult. We could, however, keep the temperature of the tent up to as high as 90 F., regardless of outdoor conditions. Keeping the baby under these favorable conditions seemed to assist greatly its nutrition.

Table 1. Length of Babies of Various Weights, on the Average.

Table 2. Premature Infants in Bellevue Hospital, June, 1915, Showing Relation of Weight to Length.

Table 3. Data of Infants Cured.