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Nutritional disorders, obviously, can not entirely be classed among functional disorders, and yet there are a large group of peculiar appearances in the premature infant for which no other cause than the inherent defects of the premature birth can be assigned. One such condition is anemia.
Several writers have drawn attention to the peculiar tendency of the premature infant to become very anemic. Now, since the infant born at term, according to Bunge, has an excess of iron stored in the liver, the deficiency of iron in human milk is perfectly compensated, at least during the period of the first half year. However, if the baby is born before term, it has been assumed that there is no accumulation of iron in the liver; I am not sure that any comparative analyses have been made to establish this assumption. At any rate, the hypothesis that premature babies become very anemic because an inadequate supply of iron exists in the liver rests on a very shaky foundation. My own experience in private practice with several premature infants not kept in an incubator, fed on mother's milk, and digestion good, sustains the position that premature infants have no special tendency to become anemic.
Quite different results were obtained at the World's Fair Baby Incubators. The tendency to anemic condition was very strong. Practically, all the infants became very anemic after a few weeks, one or two extremely so. Thus Mildred, examination October 1st, in incubator five weeks, showed a hemoglobin content of 45 per cent (Talquist); and Jack, who had been in the incubator somewhat longer, gave 65 per cent. It is true, however, that the older the infant the less liability to this anemia, e.g., Annie (weight at birth, 2456 grams), after six weeks, 70 per cent; John H., weight 1790 grams, six weeks old, hemoglobin 65 per cent. One month later the hemoglobin of John H. had fallen to 40 per cent. There can be no doubt that severe indigestion predisposes to this anemia; in the case of St. Louis, for example, six weeks in the incubator caused the hemoglobin to fall to 60 per cent. Meanwhile the infant had severe indigestion which persisted, and one month later, while the baby was very much improved and had gained in weight, the hemoglobin had fallen to 35 per cent.
Ballantyne recommends the administration of the peptonate of iron and manganese to premature infants to prevent anemia. We used iron vitellin, giving 15 drops of the well-known solution to each infant three times a day. There was some benefit, but it did not altogether prevent the loss in hemoglobin. Omega, weight 2158 grams, hemoglobin on admission 100 per cent, was given iron vitellin three times a day and yet in one month the hemoglobin had fallen to 85 per cent. In the case of Pearl, also, in spite of the additional iron the hemoglobin fell 15 per cent in one month. The administration of broths in a few cases had no effect on the hemoglobin.
Only my general impressions can be given as to the actual cause of the anemia. The incubator seems to predispose, if not actually cause, a loss of hemoglobin. The following deductions seem fairly well established from my observations:
It is clear, then, to treat this anemia, in addition to the administration of iron, the infant should be removed from the incubator as soon as possible.
Premature infants show a remarkable predisposition to the appearance of edema. It occurs especially in connection with anemia, but it may appear in those whose blood shows little diminution in hemoglobin. Indigestion and malnutrition favor its appearance in a marked degree. Several of such cases occurred among the babies on the "Pike." One observation made, appears to correlate very forcibly the fact established by Widal, etc., that an excess of sodium chloride in the blood favors the retention of serum in the tissues. In two cases, in which on account of an irritable stomach an insufficient supply of food was given and a 1 per cent solution of sodium chlorid was administered by the mouth and rectum, edema in a severe degree appeared. This disappeared promptly on the withdrawal of the salt.
Here I can not refrain from suggesting, parenthetically, that cases of obscure edema in infancy may be explicable on the ground that too much salt has been added to broths or cereal decoctions.
We gave adrenalin chlorid for the edema without definite results. The treatment depends on the other conditions -- indigestion and malnutrition.
The artificial conditions under which the premature infant is reared predisposes to inanition and atrophy, even when the imperfect development of the digestive system is not considered. When, in addition, premature infants are housed together in the same room and hospitalism has its full force, the occurrence of such cases are only to be expected. Still there can be little doubt that the careful supervision of the nutritive processes will entirely prevent this.
When I took charge of the incubators there were two extreme cases of atrophy in the incubators. Both recovered. Their records, briefly told, are given as contributions not only to the subject of premature infants but also to the general subject of infantile atrophy from a clinical and, especially, therapeutic standpoint.
Case 5. -- Jack, admitted May 9, 1904; age uncertain, but born several days before admission, gestation 30 weeks (doubtful), weight less than 1000 grams; received in atrophic condition; was placed in incubator at 35° C. Eight hours later, with the incubator at 36° C., the rectal temperature rose to 103° F. The infant showed signs of weakness and was given whisky (full dose). The food given was a modification of cows' milk (exact composition not recorded), in quantities of 8 to 15 cc. After twenty-four hours the incubator temperature was reduced to 30° C., when the rectal temperature fell to 97.2° F. The baby refused his food, gavage was employed, and the milk peptonized. On the third day the rectal temperature fell to 96° F. On the fourth day I find the following order: "Temperature of the incubator to be 36° C if the temperature of the body is below 100° F."
Evidently this was carrying out Blair's recommendations (Loc. cit.). The rectal temperature then rose, but the incubator was again reduced. On May 13th, the rectal temperature dropped to 94° F. There were as yet no dyspeptic symptoms, but on the following day slight bloody stools appeared. A purulent ophthalmia also showed itself which was treated by applications of boric acid solution and some ointment. The stools showed no blood after the second day of illness; the temperature remained practically normal but the temperature of the incubator was not recorded.
May 17th the rectal temperature again fell to 94° F. On the following two days it varied between 95° and 99.5° F. Gavage was usely employed. Food 15 cc. every two hours. On May 24th the order reads to keep the incubator temperature not higher than 94° F.
May 30th the baby was receiving 15 to 30 cc. of milk mixture every two hours. Digestion fair; temperature not recorded. No weight has been recorded.
June 3d the rectal temperature 98 to 99° F. Incubator temperature 34 to 36° C. [It is remarkable what adaptation of the organism to high heat has occurred.]
June 5th the rectal temperature 99.6 to 101.2° F. Incubator temperature 30 to 31° C. Stools showed signs of indigestion, because of this and slight growth, beef juice and panopepton were given.
June 9th the feeding was changed, 30 cc. of mother's milk were given at a feeding -- eleven feedings daily; this represents about 230 calories. As the weight of the infant is not recorded the energy quotient can not even be approximated. But as the infant was still very small, the energy quotient must have been about 200. Food was slightly reduced ion the following days. In spite of this the infant cried at times as if hungry. Modified cows' milk had to be substituted occasionally. Rectal temperature normal (between 97.6 and 99° F.), incubator temperature not recorded. The food a few days later was again reduced -- mother's milk, 15 cc., eleven feedings daily.
June 25th the weight recorded was 1230 grams; is taking mother's milk having an equivalence of about 200 calories (E.Q.). Temperature normal, incubator temperature not recorded. On the following day the baby was put to breast several times, signs of indigestion were present, and the temperature dropped to 95° F. on one occasion. The baby was fed irregularly -- put to breast, mother's milk from bottle and occasionally given a modification of cow's milk, panopepton as a tonic. Stools not loose, in fair condition. The supply of mother's milk giving out, the infant, in July, received cow's milk again.
July 19th he was placed on Eskay's food; he was given about 45 cc. every two hours. After a few feedings he refused to nurse and gavage was employed. He vomited several times and the stools became worse. Mother's milk had to be used again. A few days later he was again placed on Eskay's food, 30 cc. every two hours.
July 26th the infant was very weak; solution of glonoin and whisky were used. He revived again and seemed better after a few days and was again placed on food in quantities varying from 30 to 60 cc.
About August 10th Eskay's food was increased to 60 cc., when the stools became very free and large. This continued for several days without improvement. Human milk had to be used again.
September 2. (I took charge). Found a small atrophic infant, skin appeared very pale, weight 1690 grams. The incubator was lowered to 84° F., this was again lowered in a few days to 82° F. and in about two weeks to 80° F. Milk prescribed was human milk, 60 cc. every two or three hours, nine to ten feeding daily. In spite of this large quantity of human milk the infant did not gain. The stools were large and pasty and the temperature normal.
After a few days an attempt was made to stimulate absorption. The mother's milk was reduced to 30 cc every two hours, or about 200 calories daily, which still made the energy quotient fully 150. Since it has been shown that small quantities of peptone or albumose stimulates absorption, 3 grams of somatose were given with each feeding, commencing September 9th. The infant was also put to breast at times, and weighing showed that about 1 1/4 ounces was ingested. The somatose was continued for one week without any special gain in weight. Unfortunately, a modification of cows' milk (whey and cream mixture) had to be substituted frequently as human milk was deficient. This mixture was Formula I, and had a caloric strength of only 11 to the ounce (see Section IV). On September 21st the milk was increased to 45 cc., ten feedings daily, this gives an energy quotient of nearly 200; but still there was little gain in weight. The use of wine of cod liver oil (Merck) in 20 drop doses had slight effect.
September 30th Dr. O'Neal made the following note: For the past week or two the head had a hydrocephalous aspect, the hair thin, rather inclined to be long, veins prominent over the parietal eminences; posterior half of the head large and full; forehead prominent but not protruding. Mouth breather.
On October 1st the milk was diminished to nine feedings daily, of 30 cc. each, representing an energy quotient of 120 calories. Some meat broth (4 cc. in 8 cc. of barley water) was given with each feeding as a tonic. The incubator gained on this steadily. The baby was taken out of the incubator every day for at least two hours.
October 6th the head measurements were: Circumferences, occipitofrontal, 13 1/2 inches; parietofrontal, 13 inches; sub occipitobregmatic, 13 inches. For constipation 1/2 teaspoonful of olive oil twice daily.
October 12th, ovoferrin, 20 gtts, three times daily. The broths were discontinued. Gain in weight very slow.
October 15th the infant was put on a minimal diet for a few days. Energy quotient less than 80 calories. His gain was about the same. In the next ten days with an average quotient energy of about 120 calories he gained only 4 ounces. But in the next two weeks with an energy quotient of about 100 calories there was practically no gain. After that the gain was steady on an energy quotient of 110 to 120 calories. His weight on leaving, November 30th, was 2186 grams. He graduated from the incubator November 13th.
This infant would probably have done much better out of the incubator. The prolonged early heating seemed to diminish vital activity. Even on large quantities of food (200 calories energy quotient) he did not gain in weight. A minimal feeding had no remarkable result. His best gain was on a food whose value was 125 energy quotient. Broths and medicines had little effect. I understand the infant has done very well since being taken home.
Case 35. -- Mildred, gestation 30 weeks, admitted a few hours after birth in good condition, weight 1475 grams. Date of admission August 17, 1904. Placed in incubator at 96° F. In another place (Section III) has already been told the effect of the high incubator temperature (see Chart 5). Its effect on the digestion has also been referred to. She was somewhat overfed the first week, became slightly cyanosed when nine days old, with a rectal temperature of 101° F.. She had green, undigested stools following the twelfth day of life. Her rectal temperature fluctuated from 96 to 101° F. When three weeks old she weight 1360 grams. Her food was exclusively human milk, in quantities represented by 80 to 90 calories energy quotient.
On September 2d, when she came under my care she weight 1200 grams. Why she had fallen off until she weighed so little I am still not able to determine. She was not greatly overfed, the only condition which I thought abnormal was the high incubator temperature in the early days. Probably, also, a mild infection had occurred.
On September 3d I ordered an increase of the milk, 15 cc. every hour and a half in the day time and two hours at night; incubator temperature 86° F. This increase of food gave the infant 110 calories energy quotient. This caused a gradual increase in weight for a few days. In her case, also, the administration of somatose was tried, with no effect. On September 18th she weight 1340 grams; in ten days her weight had dropped to 1135 grams and she seemed in a wretched condition. What caused this further drop? Possibly some infection, aided for overfeeding, for on September 20th for some reason she was given more milk (energy quotient, 170 calories). Vomiting and slight diarrhea ensued. The milk was at once brought down, and her rectum washed out daily with salt solution. For vomiting, solution of adrenalin was prescribed, which also acted as a stimulant.
On September 23d I had to reduce her to a minimal diet. For twenty-four hours the food represented energy quotient of 40 calories. This greatly lessed food quantity necessitated the raising of the incubator temperature again to 86° F. In spite of this great reduction in the food the digestive disturbance continued for days. Thin stools and tympanites were the principal symptoms and the infant became very weak. Whiskey and nux vomica had to be administered.
September 25th 4 cc. salt solution were added to the milk and sugar solution, but the salt was continued for two days only. On the 28th the food was increased to 15 cc. every hour and a half and the baby commenced to gain slowly.
It was a terrific fight. Marasmus and enteritis in a premature infant. For several days it seemed our efforts would be in vain. I do not know what saved it. I attribute most to the practical starvation for a few days, when only 1 dram of mother's milk in two drams of sugar solution were given every hour and a half.
October 8th there had been a marked gain in weight -- 1310 grams, but it was found to be caused by edema. Even at this time the stools were still slightly offensive. She was getting food representing an energy quotient of 130 calories.
October 9th this note was found: Several abrasions on the genitals, erythema on the right side, abdomen and legs; edema lessened; whole body very white, pasty color; leaden hue to eyes and lips at times. Has been very weak for the last two weeks.
October 14. -- Began the use of ovoferrin.
October 22. -- Improvement has continued. Weight, 1445 grams.
October 29. -- Weight 1568 grams; food, 160 calories energy quotient.
November 5. -- Weight, 1654; energy quotient 140 calories.
November 12. -- Weight, 1811 grams; E.Q. 140 calories.
November 19. -- Weight, 1888 grams; food, 135 E.Q.
November 26. -- Weight, 1938 grams; food, 146 E.Q.
The improvement continued. She did well when she left the incubators, when she was fed entirely on a whey and cream mixture. Weight, on the day of leaving incubators, 2002 grams. She had been out of the incubator for three weeks.
This case only serves to emphasize the fact that the treatment of inanition and atrophy consists in the careful observation of infinite details in everything concerning hygiene and nutrition. The practical lesson to be learned is that a high incubator temperature predisposes to atrophy. Several years ago ("Thermic Fever in Infants, Pediatrics, 1898) I called attention to the fact that atrophy is very liable to follow overheating in infants. My experience with incubators only confirms this statement. The forced pyrexia in the case of Mildred during the first week of life, was the principal cause of her subsequent inanition, even admitting that a milk infection occurred later.