NEONATOLOGY ON THE WEB

The Nursling

Lecture 5

Gentlemen:

Hitherto we have been considering the congenitally feeble infant; to-day I shall speak to you of the infant born at term. And I shall discuss chiefly its feeding in the first ten, twelve, or fifteen days of life, during which, perhaps, it remains with its mother in a maternity hospital.

An infant, according to researches published by Bouchaud in 1864, during the first twenty-four hours takes practically nothing when put to the breast. The first day it ingests, maybe, less than 30 grams of milk; the second, a little more than 150; the third, 400; the fourth and fifth, 550; and then, almost 600 grams. Some, however, take rather more at the beginning; these are mainly well-developed infants born of multiparous mothers, whose mammary secretion becomes quickly established, or infants to whom a wet-nurse has been given immediately after birth.

On the first day an infant generally takes nothing. If he cries before the mother is able to minister to his wants, a few spoonfuls of sterilised milk and water, slightly sugared, may be given to him, but syrups and similar fluids must be avoided.

When the milk function is fully established the mother should feed the infant with a certain regularity; every two hours during the day and twice during the night is a good rule. In this way he will have eight to ten meals in twenty-four hours. Here, at the Clinique, I demand great exactitude from the staff in this particular. I have made a small chart, on which are noted the hours of the meals, and the quantity and source of the milk taken by the infant; by this means the total can be easily ascertained (see Appendix).

The newly born ought seldom to remain at the breast longer than ten minutes, or at most fifteen. Too long a stay is undesirable for both mother and infant. The nipple, by remaining long in the mouth of the child, becomes macerated; fissures and cracks may then appear, which are not only painful, but pave the way for more serious affections of the breast. On the other hand, if too much milk is ingested, the infant acquires digestive troubles, vomiting, colic, and diarrhoea.

That we may follow exactly the changes which take place in its general state, the infant must be weighed. Only the balance will enable us to determine with certainty its augmentation or diminution, the sufficiency or otherwise of its diet.

An ordinary balance may be used, but for greater convenience one of the scales is usually replaced by a small cloth hammock supported by metal rods, or by a small wicker cradle fixed by wires to the steel bars destined to receive the scales. Many kinds are sold specially constructed for infant-weighing, and are called "baby scales."

An infant may be weighed naked, but certain precautions are then necessary to guard against cold. This small operation is generally performed when the baby has just been bathed; having been dried with a warm towel, and wrapped in flannel, it is put on the balance. From the figure obtained we need only subtract the weight of the flannel in order to know that of the infant. If, for example, the baby in flannel weighs 3350 grams, and the flannel alone 350 grams, the baby's weight is, of course, 3000 grams.

For several years I have used charts on which to record the infant's weight. If all the figures within the probable range were to be printed on the chart, it would be either too large to be easily handled, or, if the chart were reduced to a convenient size, the variations of the curve would be so small as to be almost imperceptible. My charts are of a uniform and manageable size, 36 cm. long and 26 cm. broad (Fig. 44). The space between each of the fine horizontal lines represents a difference of 5 grams; before the lines of medium thickness are placed the figures 25, 50, 75; and heavy lines indicate the hundreds. As the latter on the printed chart are represented by zeros only, we have at our disposal a sort of movable scale. It is necessary only to place before the zeros the figures representing in hundreds the weight in grams at birth. If, for example, the infant weighs 3500 grams, 35 is written before the two zeros. As the length of the chart allows a difference of 600 grams, there is generally sufficient scope to record all the variations which may arise during a stay in hospital of twenty days.

During the first two or three days subsequent to birth the infant loses weight. The amount varies, but on an average it equals 150 to 200 grams. This is due to the evacuation of meconium and urine, exhalation from the lungs, and perspiration. But the infant, being fed, begins to augment; towards the seventh day he has regained what he had lost; and on the tenth he weighs 100 grams more than he did at birth.

In some rare cases the infant seems not to lose, or to lose but little. This occurs when he has voided urine and meconium during delivery, which often happens, for example, in pelvic presentations; or when the infant, immediately after birth, is suckled by a wet-nurse or a multiparous mother with abundance of milk.

The use of the balance is of the greatest service in detecting whether an infant is taking insufficient or excessive quantities of milk. Certain nurslings, when they are underfed, cease to cry, and fall into a state of torpor which is easily mistaken for tranquility. They pass but little urine; they are constipated, or rather their motions are rare; they are almost constantly asleep; they linger long at the breast when being fed; but although they appear to perform the suction movements necessary, on close observation they are seen not to be swallowing at all. On December 26, 1891, just as I was leaving Paris for several weeks, I assisted at the birth of a large boy who weighed 4500 grams. The father, who had to keep me informed of the child's progress, wrote that his son appeared to be doing well, but, strange to relate, was almost always sleeping. I telegraphed to weigh him at once and tell me the result. He had diminished enormously. My orders to weigh him every morning had been neglected by the nurse. The mother had practically no milk, and no one had sought to find if he was getting enough. On each insufficient maternal feed being supplemented with cows' milk, the baby quickly regained the weight lost (Fig. 45).

If the real situation be not recognised, the infant, through want of food, soon dies. If we wait too long it becomes incapable of swallowing even from a spoon. It must then be regarded and cared for as a weakling. It should be rubbed and massaged, put into an incubator to avoid cold, and fed by gavage. Under proper treatment the weight ceases to diminish, the infant begins to swallow, and, finally, is able to suck.

I have already had occasion to publish cases of this kind. Here, for example, is the curve of an infant Augustine S____, born in the Clinique on December 3, 1887, with a weight of 3080 grams (Fig. 46). On the fifth day it had fallen to 2790 grams. By weighing the child before and after each meal we found that the mother was furnishing very little milk. She was therefore supplemented by a wet-nurse, but the diminution continued. On the eighth day its weight was taken before and after each occasion on which it was put to the breasts of the mother and wet-nurse; it was then discovered that in twenty-four hours, each gave him 100 grams, which was a daily ration of only 200 grams. By the morning of the ninth day it weighed only 2620 grams, and was no longer able to swallow. A good wet-nurse was chosen; she commenced by drawing off her milk and feeding him by gavage. On the tenth day he gained 10 grams and on the eleventh 30 grams. He began to suck again, and his weight steadily increased.

Sometimes a mother is unwilling, although, quite able, to nurse her infant. For example, on December 3, 1887, a woman, named Adele F____, gave birth here to a boy weighing 2520 grams. On the fifth day he weighed only 2180 grams. I recommended that he be put to the breast every two hours, and that the mother be watched day and night. As on the sixth day he weighed 2225 grams, on the seventh 2265, on the eighth 2285, and on the eleventh 2390, the influence of incessant supervision of the maternal feeding was a gain of 210 grams in six days, or an average of 35 grams per day (Fig. 47).

Still more conclusive was the case of the infant Go____, who had weighed 3550 grams at birth (Fig. 48). The second day it had lost 50 grams. Then it rapidly increased, and reached 3690 on the fifth day. On the seventh its weight was only 3630 grams; the diminution continued on the eighth, and it was then discovered that the mother, a woman of small intelligence, did not wish to rear the child. She was supervised, and on the ninth day the infant increased 20 grams; as on the tenth it diminished again, I demanded an explanation from the nurse in charge of the case. She confessed she had been too busy to keep proper watch, but promised to do so faithfully in future. On the eleventh day the infant weighed 3610 grams, on the twelfth 3650, and, the supervision being again neglected, on the thirteenth day the weight remained stationary. As I stimulated anew the zeal of the staff, its weight rose to 3690 grams by the fourteenth day, 3750 by the fifteenth, and 3810 by the sixteenth, an increase of 160 grams in three days.

The balance must therefore be used as a control for the feeding.

Some newly-born infants will not suck, and others cannot. You saw an infant recently who, born at full term and with a normal weight, absolutely refused to be suckled either by mother or by wet-nurse. As it would not swallow the milk even from a spoon, it had to be gavaged. After several days it unbent so far as to drink from a glass, and at the end of twelve days consented to suck. It left the hospital in perfect health fed by its mother.

You have just seen another case equally interesting, in which the infant seemed to have a normal conformation. Put to the breast, he appeared to suck, and yet his weight did not increase. On weighing him before and after meals, to my great surprise, I found he was taking absolutely nothing. He was given a good wet-nurse, but with the same result. Then his mouth was carefully examined; his lips were well-formed, he was quite a pretty infant, but he had a cleft palate which had never been suspected and which rendered sucking impossible. He was suitably fed, and soon began to thrive.

There are other infants who, although taking an normal quantity, do not increase in weight, for they do not assimilate what they ingest. In these circumstances, which are far from rare, the administration of a small quantity of pepsin makes the curve rise steadily.

It sometimes happens that the infant does not augment because, at the beginning, the mother does not yield the amount of milk sufficient for his needs. If her supply is supplemented the mother, unaided, will after a time furnish enough to satisfy his wants.

On February 13, 1888, I delivered a doctor's wife of a baby boy who weighed 3250 grams (Fig. 49). On the third day he took 218 grams of milk from the mother's breast, the fourth 220 grams, which was supplemented by 202 grams of asses' milk; on the subsequent days the figures were:--

Day	Maternal Milk	Asses' Milk	Total
5th	288 grams	258 grams	546 grams
6th	299	226	525
7th	346	189	535
8th	382	118	500
9th	387	155	542
10th	423	180	603
11th	397	80	477
12th	482	75	557
13th	411	40	451
14th	504	0	504

If, ignoring the details, we study the curve as a whole, we see that in proportion as the quantity of the maternal milk increases the asses' milk was diminished, till on the fourteenth day the former had attained 504 grams and the latter zero. During this time the infant's weight followed practically the normal curve; after an initial loss of 190 grams, which he regained on the ninth day, he reached 3380 grams on the fourteenth day, after which the mother alone sufficed for the feeding.

On June 11, 1898, I delivered a patient of a full-term infant which weighed 3490 grams (Fig. 50). On June 12 the mother's breasts were swollen, hard, and very painful, but the infant, when put to them, could obtain no milk. This lasted until June 16. The infant was meantime given 100, 150, 300, and 400 grams of sterilised cows' milk, as is shown on the curve. On June 16, the breasts, being softer and less painful, yielded 80 grams in the twenty-four hours. This amount gradually increased and the supply of cows' milk was correspondingly reduced.

Date	Mother's Milk	Cows' Milk
June 16	80 grams	360 grams
" 17	140	225
" 18	180	225
" 19	230	215
" 20	240	225
" 21	340	185
" 22	395	200
" 23	315	150
" 24	460	150

As the infant, who had fallen to 3450 grams on June 14, reached 3800 grams on June 24, an increase of 350 grams in ten days, or an average increase every day of 35 grams, had taken place. Not till July 14, however, was the mother able adequately to fulfil her function as nurse. Thus, a mother who has no milk at the beginning may ultimately be able to suckle her child. Even after five or six days one must not despair. Her own infant, or, if practicable, a strong and vigorous substitute, should continue regularly to be put to her breast. After a certain time the milk will flow, at first in small quantities, and then more abundantly, until an excellent supply may be forthcoming.

Sometimes, on the other hand, it is the very abundance of the mother's milk which is the source of the trouble. The infant drinks gluttonously and ingests enormous quantities of milk; it micturates almost constantly, the motions are frequent, and the weight augments in exaggerated proportions. Soon, however, this increase stops, and colic, diarrhoea, and other symptoms of digestive trouble make their appearance.

Here is an instance I recorded eleven years ago. A woman, Car___, gave birth to a boy weighing 3570 grams (Fig. 51). As the mother had plenty of milk, the infant weighed on the second day 3640 grams, and continued to increase in an almost incredible fashion; on the fourth day he was 3740 grams; on the fifth, 3900; on the seventh, 4000; on the eighth, 4170; on the tenth, 4280. Since birth he had augmented 720 grams, which was an average gain of 72 grams per day. Not without misgiving did I watch his fantastic curve. The balance showed that this infant was taking at each meal 100, 150, and even 160 grams of milk. From the tenth to the twelfth day he had diarrhoea, and increased only 40 grams, and on the thirteenth he lost 10 grams. On the fourteenth day he left hospital. Following my advice, the mother fed the baby regularly every two hours, and before putting it to the breast expressed the aqueous milk that had accumulated in the mammary ducts. The infant thus received milk less in amount but more nutritive in quality.

Not only must the quantity of an infant's meal be regulated, but also the hours at which it is fed. On January 3, 1899, a woman, G____, was delivered of a boy who weighed 2550 grams (Fig. 52). He had the usual fall in weight, and then began to augment. In spite of our remonstrances the mother put him to the breast every moment of the day and night, with the inevitable digestive disturbances. After gaining 50, 20, and then 15 grams per day he became stationary. Diarrhoea followed, and his weight of 2485 grams became 2275. He was taken from his mother and carefully dieted. On January 10 she was allowed to give him only 300 grams; 11th, 355; 12th, 385; 13th, 425; 14th, 480; and 15th, 460. He quickly recovered, his stools became yellow again, and he rose from 2275 to 2545 grams between January 10 and 17.

In case of illness of either mother or child most minute attention must be paid to the latter. The woman, Sch____, was delivered of a daughter on February 21, 1888, who weighed 3090 grams (Fig. 53). On the sixth day she was 3070 grams, and had thus nearly regained her initial weight. As the mother was then attacked by mastitis, the infant steadily lost weight, till on the ninth day she was only 2990 grams. Asses' milk was given, and the curve rose once more.

Besides breast troubles, mothers not infrequently have sore throat, bronchitis, influenza, and other acute affections of short duration. The milk may then be produced in smaller quantity, or its quality may be modified. The balance may show that the infant no longer gains, and it may even lose weight. Without interrupting the maternal feeding, precautions should be taken to guard the infant from the passing malady of the mother, and, if its nutrition becomes insufficient, mixed feeding may be temporarily practised.

If the infant be ill, its weight rapidly diminishes, especially if the affection gives rise to interference with sucking or swallowing. The infant So____ was born on February 18, 1888, with a weight of 2370 grams (Fig. 54). Having gained 80 grams by the sixth day, it was seized with coryza, and in spite of our care, decreased considerably in weight. On the fourteenth day it was only 2170 grams, and had to be gavaged.

Thrush also causes much loss of weight, perhaps because sucking gives the infant pain. Baby Bron____, born on February 15, 1888, weighed 3560 grams (Fig. 55). On the ninth day it took thrush, and lost 170 grams in four days. Once cured and able to suck freely again, it soon regained what it had lost. In these cases, where the infant ceases to take sufficient nourishment at the breast, you must feed it by glass or spoon, or even by gavage.

Most febrile pathological states in infants are accompanied by loss of weight. A little girl born in hospital on January 4, 1888, had reached on the ninth day a weight of 3350 grams. She then took bronchitis, and on the fourteenth day her weight was 3250 grams. Although cured when she left on the twentieth day, she was still only 3230 grams.

However, it is not always thus: infants may be ill, even very seriously ill, and yet continue to increase in weight. As far back as 1888 I wrote as follows: "Infants attacked with inflammation in the region of the umbilicus usually lose weight, but, curious to relate, when well fed they may continue to gain slightly, although they may be dying from septic infection;" and later, in my book for midwives, I said: "In cases of inflammation in the neighbourhood of the umbilicus, and even sometimes in bronchitis, the weight may be seen to increase persistently until death."

You have lately seen two cases of this kind. One was an infant, No. 1560, born on November 17, 1898, with a weight of 3040 grams, who lived in the wards for many months. On January 1, 1899, he weighed 4300 grams. On January 2 he began to cough; on the 3rd fine crepitations were heard in his chest; on the 4th his rectal temperature was 38° C.; and on the 5th he presented all the symptoms of broncho-pneumonia. On this date he weighed 4075 grams; his temperature remained high; yet on the 6th he was 4125 grams, and on the 7th, 4170. His weight fell to 4065 grams, and then continued to rise, although the affection did not improve for eight days (Fig. 56).

Baby Réné X_____ (No. 1612), born on November 28, 1898, weighed 3400 grams. On the ninth day, December 7, having just regained his initial weight, he developed a lymphangitis in the neighbourhood of the umbilicus. His temperature rose to 38° C. on the 12th, and 39° C. on the 15th; extensive ulceration took place, and yet his weight was not greatly affected. On December 8 he remained stationary; on the 9th there was a loss of 60 grams; but thenceforth, increasing daily, he attained on the 17th, 3655 grams. There was thus an increase of 315 grams in eight days, and an average gain per day of 39 grams (Fig. 57).

The regular and progressive increase in weight of a newly-born infant is of great importance, but it must not be considered to have an absolute significance. In this connection let me point out to you an interesting fact. In the Maternité in 1895 I noticed that not only might dying infants increase till the last, but some of them, for two or three days previous to the end, or even on the very day of death, show an abrupt and considerable augmentation in weight. Generally in these cases no more milk is absorbed than the infant has been accustomed to take; but on the other hand the urine diminishes greatly in amount and a partial or generalized oedema develops.

Baby El___ H____ (No. 366), born on November 4, 1895, was brought to the Maternité weighing 1990 grams and with a rectal temperature of only 32° C. He progressed slowly, and on November 30 he weighed only 2110 grams. On December 2 he took influenzal coryza and diminished slightly; on December 18 he weighed 1930 grams, when suddenly he began to increase remarkably.

On December 19 his weight was 2025 grams.

On December 20 his weight was 2100 grams.

On December 21 his weight was 2160 grams.

In three days he had increased 230 grams. There was oedema of the right foot. His temperature remained normal till the day he died, when it suddenly rose to 40.6° C.

The quantities of milk taken in the last days were: December 14, 510 grams; 15th, 490; 16th, 580; 17th, 635; 18th, 600; 19th, 530; and 20th, 495 grams. In the forty-eight hours preceding death, therefore, there was no increase in the amount ingested.

The infant Gabriel G______, born on September 24, 1895, was brought to the Maternité the following day weighing 1950 grams. He attained 2710 grams on November 26; then his wet-nurse took influenza, and on December 2 he began to cough. On December 14 he had fallen to 2600 grams, when in less than twenty-four hours he increased 150 grams and died. The night before his death his rectal temperature was 38.3° C.

The quantities of milk he took were relatively small: on December 11 he absorbed 580 grams; 12th, 600; 13th, 580; 14th, 540; and 15th, 480 grams.

I have seen a certain number of such cases; you, yourselves, have followed the two I am about to relate.

The first was that of an infant (No. 1703) born on December 24, 1898, with a weight of 3050 grams (Fig. 58). On January 6, 1899, he took erysipelas of the face, which invaded successively the different parts of the scalp, passing by the right, posteriorly, and then to the left. His weight remained almost stationary till January 8; on January 9 he had increased from 2950 to 3050 grams; on January 10, the day of his death, he weighed 140 grams. In two days he had gained 190 grams.

During these last days he had taken only a very moderate amount of milk; on January 5, 390; 6th, 375; 7th, 405; 8th, 400; and 9th, 415 grams.

Still more recently, on February 13, 1899, there was an infant (No. 196) born with a weight of 2800 grams, in whom convulsions commenced on the first day and did not cease till the fourth. On the fifth day he had diarrhoea with foetid stools, and his weight diminished; on the sixth day he was only 2300 grams, his face had a leaden tint, and his rectal temperature was 39° C. In the next three days he gained 50 grams, and in the twenty-four hours preceding death 250 grams (Fig. 59).

In the last three days, February 22, 23, and 24, he had taken 405, 390, and 380 grams respectively.

At the autopsy a general septic infection arising from a phlebitis in the umbilical blood-vessels was found.

When an abrupt and considerable increase in weight occurs in a sickly infant its imminent death is almost certainly indicated.

Not merely in these exceptional and somewhat deceptive cases, a knowledge of which is essential to avoid mistakes, is the great importance of the balance as a guide to the progress of the child indisputable. It is often said that simple inspection enables a practised eye to appreciate whether an infant is or is not thriving. Don't believe it. Obviously, the general aspect, the firmness of the tissues, the state of the sutures and fontanelles may furnish certain indications, but if you are dealing with several infants at the same time mistakes are easily made. How often at the beginning of my hospital career was I assured that an infant who seemed to me to be suffering was doing well, on having it weighed before me did I find that it had lost 400-500 grams and was already almost beyond remedial measures. But when at the bed of each mother the chart of the infant's weight is found, a simple glance informs you of its progress, and warns you to seek an explanation, on the slightest departure from the normal.

In your practice, therefore, always have recourse to the balance. Recommend its usage at all times, knowing that nothing can replace it as a means by which to estimate the development of nurslings.

	Fig. 44. Chart with moveable scale on which graphically to record the weight of an infant.
	Fig. 45. Normal curve of an infant's weight during the first ten days of life.
	Fig. 46. Curve of an infant showing great loss of weight, due to under-feeding. The total supply of mother and wet-nurse was insufficient.
	Fig. 47. Mother unwilling to suckle. Result of constant supervision from the fifth day.
	Fig. 48. Mother who did not wish to nurse. Effect of intermittent supervision.
	Fig. 49. Maternal feeding inadequate at first. Mother's efforts temporarily aided by asses' milk. Red, infant's weight; blue, mother's milk; black, asses' milk. Interrupted black line, total of the two milks.
	Fig. 50. Maternal milk did not appear till between the fifth and sixth days. Sterilised cows' milk was used first as a substitute, then as a supplement.
	Fig. 51. Infant who took too much milk. His weight increased considerably, but he had digestive troubles.
	Fig. 52. Digestive troubles and loss of weight due to feeding at irregular intervals. The infant recovered, and began to thrive when the feeding was rigorously regulated.
	Fig. 53. Mother had mastitis, infant lost weight.
	Fig. 54. Coryza. Loss of weight owing to interference with sucking.
	Fig. 55. "Thrush" (muguet). Loss of weight owing to the pain of sucking.
	Fig. 56. Weight increasing in the presence of broncho-pneumonia.
	Fig. 57. Persistent increase of weight during the course of an inflammatory process around the umbilicus.
	Fig. 58. Weight curve of an infant who died of erysipelas. Considerable rise in the last two days of life.
	Fig. 59. Weight curve of a dying infant, showing increase of 250 grams in the last twenty-four hours of life.