Chapter XXII: Nursing Care of the Average New-Born Baby (1)

It is estimated that out of every thousand babies born alive, in this country, forty die during the first month of life, and that more than as many again, or about eighty-five all told, perish before reaching the first birthday.

So hazardous is this period of early infancy, in the United States, that our annual loss of baby life is between seven and eight times as great as was the yearly toll of our young men during the war, for upwards of 200,000 babies less than a year old die each year. That the first month of life is fraught with greater danger than any which follow is shown by the fact that about 100,000 of these deaths occur during the first four weeks.

The tragedy of these figures is made darker by the knowledge that at least half of the babies who are lost die from preventable causes. In other words, they die from lack of proper care.

That is the significant fact for the obstetrical nurse, since more and more frequently she has the young baby in her care during the crucial first month and inevitably plays an important part in increasing his chances to live. She does this by helping to keep the well baby well, rather than by nursing a sick baby.

The dangers which make babyhood such a precarious period may be grouped very largely under the general headings of unfavorable ante-natal conditions, nutritional disturbances and infections. The care and supervision of the expectant mother will remove many of the unfavorable ante-natal causes. Nutritional disturbances and infections must be dealt with after birth.

Faulty nutrition may result in rickets, scurvy, malnutrition, marasmus, acute inanition or the less serious colic, constipation or diarrhea. The most frequent results of infection among young babies are the respiratory diseases in winter, such as bronchitis and pneumonia, and the intestinal disorders in summer, commonly referred to as “summer complaint.” Since undernourished babies are very susceptible to infection, the two conditions are frequently coincident.

With the baby’s frailty and imperfect development in mind, as well as the needs of his growing body and the evils that beset his way, we can understand the reasons for the painstaking, protecting care which he is given during the early weeks of his life.

The essential features of this care are as follows:

1. Proper feeding.

2. Fresh air.

3. Regularity in his daily routine.

4. Cleanliness of food, clothing and surroundings.

5. Maintenance of an equable body temperature.

6. Conservation of his forces.

These requirements seem so rational that one might expect them to be met as a matter of course; but the annual sickness and death rate among babies are a constant reminder that they are not.

The nurse should begin by arranging a daily schedule for the baby’s feedings, fresh air, bath, sleep and exercise, and follow it with unfailing regularity. The hours for the nursings, which vary with different doctors, will constitute the greater part of the daily schedule, and for a baby on four hour feedings, for example, some such program as the following may be arranged:

6 a.m. Feeding.
8 a.m. Orange juice (when ordered).
9 a.m. Bath.
10 a.m. Feeding.
10.30 to 2 p.m. Out of doors.
2 p.m. Feeding.
2.30 to 4 p.m. Out of doors.
4 p.m. Orange juice (when ordered).
4 to 5.30 p.m. In-door airing and exercise (when ordered).
5.30 p.m. Preparation for the night.
6 p.m. Feeding.
10 p.m. Feeding.
2 a.m. Feeding (when ordered).

The importance of punctuality in the daily routine cannot be stressed too often and it is one aspect of the baby’s care for which the nurse is absolutely responsible. No matter how well the baby is nursed, in other respects, nor how skillfully the doctor directs his care, the baby cannot be expected to progress satisfactorily if his life is irregular.

=The Bath.= The first office which the nurse usually performs for the new-born baby, and which she repeats daily, is to bathe and dress him. The bath may be given in a tub, under a spray or in the nurse’s lap, according to the wishes of different doctors, while sponge baths are sometimes given with soap and water and sometimes with oil.

The first bath, particularly, is likely to be an olive oil sponge, given immediately after birth, before the baby is taken from the mother’s bedside, and many doctors have the sterile cord dressing and abdominal binder applied at this time. This oil bath is given, not alone for the purpose of removing the vernix caseosa, but also, to lessen the radiation of body heat, which the baby can ill afford to lose. When such a practice is followed it only remains for the nurse to dress the baby and place him in his crib to sleep undisturbed for several hours.

Some doctors have the baby sponged every morning with albolene or olive oil, instead of with soap and water, until the cord separates, when tub bathing is adopted. When the daily bath is given with oil, the baby’s thighs and buttocks are wiped clean with an oil sponge each time that the diaper is changed. Other doctors have the baby’s first bath given in a tub, with soap and water, while still others who fear that the cord may be infected by immersing the baby, have him sponged with soap and water, after the vernix caseosa has been softened with oil.

Sponge bathing is commonly employed for all babies until the cord separates and for frail delicate babies or those suffering from skin trouble. The sponge bath may be given in the nurse’s lap or on a table covered with a pad, either method being satisfactory if the baby is kept warm and comfortable. But one inclines to the idea of having the baby bathed in the nurse’s lap for he seems happier there; more comfortable and less frightened and we cannot be sure that these factors are unimportant.

The best time for the daily bath, during the first three or four months, is about an hour before the second feeding in the morning. After this age the full bath is sometimes given before the six o’clock feeding, in the evening, for a bath at this hour is soothing and restful and often helps toward giving the baby a good night.

Preparation for the bath should made with its possible effects, both good and bad, in mind, for the baby may be helped or harmed according to the skill with which he is bathed. He must not be chilled during his bath, and fatigue and irritation must be avoided by giving it quickly and with the least possible handling and turning. These ends may be served by conveniently arranging all of the articles which will be needed, on a low table at the right hand side of the nurse’s chair, before the baby is undressed.

There should be a pitcher of hot and one of cold water; a bath thermometer; two soft wash-cloths; soft towels; bath blankets; Castile, or some other mild soap; boracic acid solution; sterile cotton pledgets; large and small safety pins, or large ones and a needle and thread if the band is to be sewed on; unscented talcum powder; sterile albolene or olive oil; soft hair brush and a complete outfit of clothing. The little garments should be arranged in the order in which they will be put on, the petticoat slipped inside the dress, and all hung before the fire or heater, to warm.

The temperature of the room should be about 72° F. and if it is possible to bathe the baby before an open fire or a heater, so much the better. In any case he must be protected from drafts. A sheet hung over the backs of two straight chairs will serve very well as a screen if no other is available.

The tub or basin should be about three-quarters full of water at 100° F. for the new baby; about 95° after the third month and gradually lowered to 85° F. or 90° F. for the baby a year old. The temperature of the water should not be guessed at, but tested with a thermometer, though in an emergency the nurse may safely use water that feels comfortably warm to her elbow.

It is a good plan to lay a folded towel in the bottom of the tub, before beginning, as babies are often frightened by coming in contact with the hard surface.

FIG. 153.—Nursery at Manhattan Maternity Hospital. Note beam scales,
low table with articles for bath, and method of protecting babies’
heads from drafts.
]

The nurse should wear a waterproof apron, covered with one of flannel over which is laid a soft towel until the bath is finished, when it is slipped out, leaving the dry flannel apron to wrap about the baby. She should wash her hands thoroughly with hot water and soap; sit squarely, with her knees together, in a chair without arms; take the baby in her lap and undress him under a blanket.

In order that the bath may be given deftly and quickly, it is a good plan to give the different parts in the same order every day, for practice makes perfect.

It is usually a routine to weigh the baby every morning, during the first two or three weeks and once or twice a week afterwards. Premature babies and those who are very frail are weighed at longer intervals because of the inadvisability of disturbing them so often. The baby is undressed for his bath, wrapped in a blanket, and laid in the scoop or basket of a beam scale (Fig. 153) and a note made of the entire weight, for if he is placed in the scales without protection he is likely to be chilled and frightened. The weight of the blanket is ascertained separately and deducted from the total thus giving the baby’s exact weight.

The eyes should be bathed first, with pledgets of sterile cotton dipped in warm boracic acid solution, each pledget being used but once. To prevent the solution from running from one eye into the other, the baby’s head is turned slightly to one side and the lower eye wiped gently from the nose outward. The lids may then be separated by placing one thumb below the brow and lifting it slightly, and the eye flushed with a gentle stream by squeezing a freshly soaked pledget just above it. The head is turned to the other side and the eye on that side bathed in like manner.

The mouth is swabbed out _very gently_ with boric-soaked cotton wrapped about the tip of the little finger, care being taken not to abrade the delicate mucous lining. The nostrils are cleaned with little spirals of cotton dipped in liquid petrolatum or olive oil.

The face is then washed with warm water, no soap, and patted dry. The scalp, neck and ears are washed with soap and water and thoroughly dried by patting and wiping gently in the creases. The body should then be well soaped, with the nurse’s hand, only one part being exposed at a time, to avoid chilling. To place the baby in the tub the nurse may slip her left hand under his head in such a way that his head will rest upon her wrist, her fingers support his shoulders and her thumb curve over and hold the upper part of his arm. She may then grasp his ankles with her right hand and lower the little body into the water, feet first. If his arm and shoulder are firmly held and supported by the left hand it is an easy matter to steady the entire body and keep the baby’s head out of the water while giving the bath with the right hand. (Fig. 154.) The new baby is not usually kept in the tub for more than two or three minutes, but when he is three or four months old he may stay in for five minutes and still longer as he grows older.

FIG. 154.—Method of supporting baby’s head above water while giving
tub bath.
]

Hot water should not be poured into the bath after the baby has been placed in it but cold water is often added, for a three or four months old baby, or the warm bath followed by a quick sponge with cold water. The little body is quickly patted dry and rubbed briskly with the palm of the nurse’s hand; the legs and arms stroked toward the body; the back from the neck downward and the chest and abdomen with a circular motion. Babies who react well to cold baths are benefited by them but such “toughening” methods have to be tempered to the resistance of the individual baby and are employed only under the supervision of the doctor.

FIG. 155.—Preparation for circumcision. (From photograph taken at The
Cleveland Maternity Hospital, with description, by courtesy of Miss
MacDonald.)
]

_On Table at Left_:

Basin of sterile water.
3 sterile towels.
12 small sponges.
6 cotton pledgets.
1 inch gauze bandage.
Tube of 00 plain catgut with small needle.
Needle holder.
2 small hemostats.
Curved Kelly clamp.
Sharp pointed curved scissors.
Blunt dissector.
Mouth tooth forceps.

_Stand at Right_:

Large basin of sterile water.

_For Baby_:

Brandy, 1 dram. } In sterile medicine glass with
Sterile water, 6 drams. } dropper.
Sugar, ½ dram. } Used for anesthetic.

One nurse holds the baby by his knees with his hands under her arms. The second nurse begins the anesthetic, three minutes before doctor begins to operate, by dropping brandy and water on small piece of sterile cotton in gauze in baby’s mouth.

The genitals should be bathed and dried with care; inspected daily
and any abnormality reported to the doctor. It is not uncommon for
girl babies to have a slight bloody discharge from the vagina. This
is unimportant and soon disappears, but a purulent discharge is
likely to be an evidence of gonorrheal vaginitis. It is routine in
many hospitals to retract the foreskin of male babies every morning
at the time of the bath by rubbing it back with gauze or cotton,
taking pains that it is again pulled forward into the original
position after the part underneath has been bathed with boracic acid
solution. If retraction is impossible after several successive daily
attempts, the baby is not infrequently circumcised. (Figs. 155,
156.)

FIG. 156.—Baby in Fig. 155 draped with sterile sheet.
]

When the entire body, including creases and folds, has been patted
quite dry, it may be dusted with an unscented talcum powder, but
this powdering must not be resorted to as an aid in drying the skin.
In order to prevent chafing, the buttocks and thighs should be wiped
clean with oil or bathed with warm water, no soap, patted dry and
powdered or oiled each time that the diaper is changed.

FIG. 157.—Cord stump dressed with dry sterile gauze. (From photograph
taken at Johns Hopkins Hospital.)
]

If the first bath is a tub bath the cord is dressed after the baby
is dried and powdered. The form and method of cord dressings vary
somewhat with different doctors but in practically all instances the
dressings are sterile, to prevent infection, and porous in order
that air may gain access to the cord and promote the drying,
separating process. The dressing itself may consist of dry, sterile
gauze or gauze wet with alcohol, applied to the cord in the manner
of a finger bandage (Fig. 157); or it may consist of squares of
sterile gauze or muslin with holes in the centres to fit around the
cord, and dusted with some such powder as boric acid, bismuth or
salicylic acid and starch. These squares are folded about the cord
stump which is laid over on the abdomen, being directed upward to
prevent its being wet with urine. A gauze sponge is placed over the
dressing and the binder applied with firm, even pressure, but not
tightly, and sewed on or held in place with safety pins. (Fig. 158.)
The cord dressing is not removed until the cord separates, unless it
is wet or soiled, but as a rule the band is removed every morning at
the time of the bath, or whenever it is soiled.

FIG. 158.—Flannel band applied over cord dressing.
]

After the band has been applied the warmed shirt, diaper, petticoat
and dress are put on, with the fewest possible motions, and the
baby’s hair brushed upward from the neck and back from his forehead.
He should be wrapped in a small blanket, fed and laid quietly in his
crib to sleep. If his hands and feet are cold a hot-water bottle at
125° F. with a flannel cover, may be placed beside him.

When the baby is made ready for the night he may have either a
sponge bath or simply have his face and hands sponged with warm
water, according to the wishes of the doctor. The clothing which the
baby has worn during the day should be replaced by an entirely fresh
outfit. The day and night clothing may be worn more than once, if
clean and if aired between times, but it is better not to have the
baby wear the same clothes day and night.

=Clothes.= The baby’s clothes may play an important part in
promoting his well-being, and to accomplish this they must be warm,
light-weight, soft and porous. They should be simple; fit smoothly
and be loose enough and short enough to permit the baby to move
unhampered. In order that his body may be kept at an even
temperature their weight must always be adjusted to the needs of the
moment. The general tendency is to dress the baby too warmly, as a
result of which he perspires; is listless, pale, fretful; sleeps
badly; is susceptible to colds and other infections and has poor
recuperative powers. His digestion is likely to be deranged and he
may have prickly heat. On the other hand, if the baby is not dressed
warmly enough his hands and feet will be cold and his lips blue; he
will cry from discomfort and the general result may be lowered
vitality and disturbed digestion. If the baby’s clothes are not
comfortable, if they pull and drag or have tight bands, he will be
fretful and restless, with disturbed sleep and digestion in
consequence.

The little wardrobe will be entirely adequate, under ordinary
conditions, if it consists of shirts, bands, diapers, flannel
petticoats, dresses, flannel wrappers and sacques with a cap and
cloak for extra warmth during in- or out-door airing. (Fig. 159.)

The =shirts= should have long sleeves and high necks; they should
open all the way down the front and come well down over the hips.
During the cold months they should be of silk, silk and wool or
cotton and wool, as all wool shirts are usually too warm, and during
the summer months they should be of all cotton and very thin. Size
No. 2 is the best size to start with as the smaller size is soon
outgrown.

FIG. 159.—An outfit of practical baby clothes:

A. Thin cotton dress, open down the back.
B. Flannel night-gown with set-in-sleeves.
C. “Gertrude” petticoat, open down the back.
D. Shirt, opened all the way down the front.
E. Flannel night-gown with kimono sleeves.
F. Knitted band with shoulder straps.
G. Flannel square with tapes run through casings to form hood of one
corner.
H. Bag, with hood, suitable for premature baby or for outdoor
sleeping.
]

The first =bands= usually consist of strips of all wool or cotton
and wool flannel about six inches wide and eighteen or twenty inches
long, torn across the width of the material and not hemmed. This
straight binder is worn until the cord dressing is discontinued,
when it is replaced by a knitted band with shoulder straps. If the
cord dressing is held in place by a gauze binder, the knitted band
with straps is used from the beginning. Whether the binder be
flannel or gauze, it must be applied firmly and with even pressure,
but not tight. It is a mistake to think that a tight band
strengthens the baby’s abdominal muscles for it has the opposite
tendency. A tight band may give pain or discomfort and even cause
colic or vomiting.

FIG. 160.—Appearance of properly adjusted diaper which has been folded
diagonally.
]

FIG. 161.—Appearance of properly adjusted diaper which has been folded
longitudinally.
]

The knitted band is usually worn for three or four months,
particularly in cold weather, to provide a little extra warmth over
the abdomen. Thin, delicate babies sometimes need this band for a
year or more.

The =diapers= should be of soft, absorbent material, of a loose
weave, such as cheese cloth, bird’s-eye, stockinette, thin Turkish
towelling or outing flannel; should be 18 or 20 inches square and
hemmed. There are two methods of putting on the diaper. One is to
fold the square diagonally and bring the diagonal fold around the
baby’s waist. One of the lower corners is drawn up between the
thighs, the two corners from the sides brought over this and the
fourth corner brought up over these and all pinned securely with a
safety pin. (Fig. 160.) Small safety pins hold the margins together
above the knees. The other method is to fold the diaper straight
through the centre, forming a rectangle, twice as long as it is
wide; lay the baby on it lengthwise, draw it up between his thighs
and pin it on each side at the waist line and above the knees. (Fig.
161.)

In either case the diaper must be put on smoothly and care taken to
avoid forming a thick pad between the thighs as this will tend to
curve the bones of the legs. Squares of soft, absorbent material,
which may be burned, placed inside the diapers, will greatly
facilitate the laundry work. In some hospitals a very soft absorbent
paper is used for this purpose, sometimes being covered with gauze.

The baby’s diaper should be changed whenever it is wet or soiled,
for in addition to making him restless and fretful for the time
being, the skin about the thighs and buttocks will grow red and
chafed if he is allowed to wear wet diapers. Wet diapers should not
be dried and used again but washed with a mild soap, boiled and
whenever possible, dried in the open-air and sunshine.

All of this makes it apparent that the regular use of waterproof
protectors cannot be justified since the chief reason for putting
them on a baby is to avoid the necessity of changing his diaper as
soon as it is wet. Under special circumstances such as a drive, a
short journey or visit the diaper may be protected by water-proof
drawers. Their habitual use saves work for the nurse but makes the
baby uncomfortable and unhappy.

The =petticoat= should be of light-weight, cotton and wool flannel,
cut after the familiar Gertrude pattern and hang straight from the
shoulders. It may fasten in the back or on the shoulders, with small
buttons or with tapes. Tapes are often objected to on the ground
that the baby tangles them up with his fingers, which annoys him,
and often puts them in his mouth. This petticoat is worn practically
all the time, except during very warm weather.

The =slips or dresses= are most satisfactory if cut after the same
pattern as the petticoat, with the addition of sleeves which may be
set in, or of the kimono style. The dresses serve chiefly to keep
the petticoats clean and make the baby look dainty, and are
accordingly made of soft cotton material such as nainsook, cambric
or lawn. In summer, it is true, the petticoat is often discarded and
the thin slip put on over the shirt and diaper.

The =night gowns= are made like the dresses but are of soft flannel
or stockinette, in cold weather, and tape is often run through the
hems in order that they may be drawn up, bag-fashion, to keep the
baby’s feet warm. During very warm weather the baby sleeps in a thin
cotton slip.

In addition to these garments there are many times when a soft
little sacque or wrapper is used to keep the baby warm, and one or
two flannel squares (one yard), to wrap around him when he is
carried about the house are practically indispensable.

The petticoats, dresses and night gowns are cut about twenty-seven
inches long and many doctors feel that they offer sufficient
protection for the feet of the average baby to make stockings
unnecessary until he is from four to six months old. The skirts may
then be shortened to ankle length and stockings added to the little
wardrobe. Some doctors think it wiser to put knitted socks or part
wool stockings on the new baby particularly if he is born during
cold weather.

When the baby begins to creep, he should wear soft soled shoes, part
wool stockings in cold weather and thin cotton or silk ones during
the summer, and firm but flexible soled shoes as soon as he tries to
stand alone or to walk.

During the first month or two, the baby scarcely needs special
clothing for out-door wear, as he may be warmly wrapped in one of
the flannel squares by being placed on it diagonally, the upper
corner folded about his head to form a hood and held under his chin
with a safety pin. The corners on the sides are folded about his
shoulders, the lower one brought up over his feet and limbs and the
additional blankets tucked in over all. But as he grows older and
moves about in his carriage, he will need a cap and cloak or wrap
with hood attached. In cold weather the cap should be knitted or
wool lined and the cloak of soft woolen material or wool lined. In
moderate weather the cap may be of one thickness of cotton or silk,
or very light flannel, while on very warm days he will need no head
covering.

To sum up: The baby’s clothes should be simple in design, hang from
the shoulders, fit smoothly but loosely and have no constricting
bands; they should be soft, light and porous, their warmth always
adjusted to the immediate temperature so that the baby will be
protected from being either chilled or overheated. And his clothing
must always be clean and dry.

=Fresh Air.= An abundance of fresh air is one of the baby’s greatest
needs as it increases his resistance and recuperative powers,
improves his appetite and aids digestion. In general, the more the
baby is in the open air and the more fresh air he has while in the
house, the better.

The two factors which must be considered in supplying the baby with
fresh air are the condition and vigor of the baby himself and the
immediate temperature and state of the weather. His age and the
season of the year can be only partial guides because of the
difference between individual babies of the same age and the
variations in temperature, winds and moisture during any one season.

The air of the room which the baby occupies should be changing
constantly in order that it may always be fresh, but the temperature
should be equable and the baby protected from drafts. As the
tendency here, as with the baby’s clothes, is toward overheating,
the nurse will do well to remember that the new baby who lies
covered up in his crib, may usually be kept in a colder room than is
advisable for an older one who is creeping or walking about.

During cold weather the baby’s bed should not be directly in front
of an open window and he should be protected from direct currents of
cold air by a sheet hung over the head and side of his crib. (See
Fig. 153.)

Two or three times daily, while the baby is out of the room, the
windows should be opened wide to air the room thoroughly, one of
these airings being just before the baby is put to bed for the
night.

The usual instructions concerning the temperature of the nursery are
to keep it from 68° F. to 70° F. during the day and about 65° F. at
night, during the first three months and lower it gradually to 64°
F. during the day and about 55° F. at night as the baby grows older.
It is customary to begin to open the nursery window at night when
the baby is three or four months old, if he is well and the
temperature is above freezing.

In planning to take the baby out-of-doors it is wiser, as a rule, to
begin with the indoor airing when he is about a month old, except,
of course, during the moderate or mild months of the year, when he
is taken out at once. If the weather is cold, the baby may be
protected with extra wraps and carried in the nurse’s arms, into a
room in which the windows are open and kept there for fifteen or
twenty minutes. This indoor airing is increased by being gradually
lengthened to two or three hours and by having the windows opened
wider and wider. By the time he is two or three months old he is
taken out of doors on clear, bright days, the best time being
between ten and three o’clock, when the sun is high. If he is
carried in the nurse’s arms at first the warmth of her body serves
as a protection and helps to accustom him to the out-of-door life,
when he spends a good deal of his time out of doors in his carriage.

On windy, stormy days or when there is melting snow on the ground
the baby may be given his airing on a protected porch or in a room
with the windows open. He is not usually taken out if the
temperature is below freezing until the third or fourth month. After
this time the average baby is taken out when the temperature is not
lower than 20° F.

When the baby is dressed in his extra wraps he must be taken out of
doors or the windows opened immediately, for otherwise he will
become overheated and be in danger of chilling when taken into the
colder air.

Warm hands and feet, a good color and the baby’s tendency to sleep
most of the time while out-of-doors are evidences of his being
adequately clothed for his airing, while the reverse is true if he
is not warm enough.

A robust baby who has been gradually accustomed to being
out-of-doors during the day will usually be much benefited by
sleeping out at night. But he must be protected from winds and his
clothing so arranged that he cannot be chilled. Knitted or flannel
sleeping garments or sleeping bags (See Fig. 159) are valuable and
in addition, the blankets which cover the baby should be securely
pinned to the mattress with safety pins and tucked well under it at
the sides and foot. The baby should wear a warm cap and the bed
should be warmed before he is put into it. Or better still, he may
be dressed for the night, put to bed in a warm room and the crib
then moved out on the sleeping-porch.

FIG. 162.—Sutton poncho which keeps the baby warm by covering all but
his head. The insert shows slit for his head. The regular bedding is
temporarily turned back in this picture. (From photograph taken at
Bellevue Hospital.)
]

An excellent device for protecting the baby’s arms and chest and
keeping him generally well covered is the poncho (Fig. 162) devised
by Dr. Lucy Porter Sutton of Bellevue Hospital. The poncho is a
rectangle made of flannel, outing flannel or an old blanket and cut
large enough to tuck well under the head and sides of the mattress
and extend below the baby’s feet. The baby’s head slips through an
opening, which is almost a right-angled slit, near the centre of the
poncho and about 20 inches from the top. The slit is firmly bound
and provided with tapes to tie it together after the baby is put in.
The poncho should be put on loosely enough to permit the baby to
move about at will beneath it. After it is adjusted the bed is made
up as usual with additional blankets.

Under all conditions the baby’s airings must be increased gradually,
both as to lowering the temperature and lengthening the time, and
always adjusted to the vigor and reaction of the individual baby. He
must be warm, but not too warm; he must be protected from wind and
dust, and his eyes shielded from glare and from flickering light
such as may be caused by a tree in a light breeze.

=Exercise.= Although the baby should not be handled unnecessarily
nor tossed about and played with by friends and relatives, it is
important that his muscular development be promoted by regular and
carefully planned exercise. It is usually considered best for the
baby to lie quiet and undisturbed in his crib most of the time
during the first three or four weeks. Dr. Griffith begins the baby’s
exercise about that time by having the nurse take him in her arms on
a pillow and carry him about for a few moments, several times daily.
After a week or two of this form of exercise, the nurse carries the
baby without a pillow but supports his head and back.

The position of the baby’s body is changed by being carried about in
this way, while the movement of the nurse as she walks about causes
a certain amount of motion of the baby’s muscles, constituting a
gentle exercise.

This exercise, in the form of picking up and carrying about is
regarded by many pediatricians as of great importance. There is a
possibility that lack of this form of “mothering” is one reason why
babies in hospital practice sometimes fail to progress as they
should. Certainly lying too long in one position is harmful. The
nurse should carry the baby first on one arm and then on the other
in order that both sides of his body may be equally exercised. By
the third or fourth month he sits up in her arms as she carries him
about, and he may be placed on the outside of his crib coverings for
a little while every day, to kick and struggle at will. His skirts
should be rolled up under his shoulders, or removed entirely, to
leave his legs quite free, care being taken that the room is warm
and that he has on stockings.

FIG. 163.—A comfortable position for the baby being trained to use
chamber.
]

By about the sixth month he will usually begin to make an effort to
creep, if turned over on his stomach and helped a little, and he may
be propped up in the sitting position, in his crib, for a few
moments every day. As he gives evidence of having enough energy to
creep farther than the size of his crib permits, he may be put into
a creeping-pen, or upon the floor under certain conditions. It must
be remembered that the floor is likely to be cold, drafty and dusty.
The nurse must assure herself, therefore, that the floor is warm;
must cut off all drafts and spread a clean sheet or quilt on the
floor before the baby is put down to creep. When the sheet is taken
up, it is folded with the upper surface inside in order that when it
is again put down the baby will play on the clean side and not on
the side that has been next the floor.

A creeping-pen or cariole or some such provision is often more
satisfactory than the floor, consisting as it does of a railed-in
platform raised about six or eight inches from the floor.

The suggestions for exercise, like those for the baby’s airing, must
be very general since it must always be adjusted to the powers of
the individual baby and under the doctor’s supervision.

TRAINING THE BABY

=Bowels.= It is possible to train even a very young baby to have
regular daily bowel movements; this training should be started when
the baby is about a month old. At the same hour each day he may be
laid on a padded table, or taken in the nurse’s lap, a small basin
being placed against or under the buttocks, and a soap stick
introduced an inch or two into the rectum and moved gently in and
out. This slight irritation will usually result in the baby’s
emptying his bowels almost immediately. Or he may be held on a small
chamber on the nurse’s lap, in a comfortable reclining position
(Fig. 163) or with his back supported against her chest, and the
desire to empty the bowels stimulated by using the soap stick.

It is of greatest importance that the position and method which are
adopted, be employed at exactly the same time each day. If this is
done, and the baby is being properly fed, it will usually be found
that, before he is many months old, his bowels will move freely and
regularly without the stimulation of the soap stick and only when he
is resting on the small basin or chamber. This establishment of a
regular bowel movement not only simplifies the laundry work but is
of great moment to the baby’s health.

=Thumb-Sucking.= It is scarcely necessary to remind a nurse that the
baby must not be allowed to suck on an empty bottle or a pacifier
nor be permitted to suck his thumb. The habits are very dirty and
help to spread infections. The baby may swallow air while practicing
them, with colic as a result, and he may so deform the shape of his
upper jaw that, later in life, the upper and lower teeth will not
meet as they should when he masticates; his front teeth may protrude
in a disfiguring manner; and by narrowing and elongating the roof of
his mouth the structure of the air passages is altered, with
respiratory troubles and adenoids as a frequent consequence.
Thumb-sucking may be prevented by the simple procedure of putting
stiff cuffs on the baby’s elbows (Fig. 164) which make it impossible
for him to reach his mouth with his thumb. These cuffs may be made
by covering pieces of cardboard with muslin and attaching tapes with
which to tie them on the baby’s arms. His hands may be put into
celluloid or aluminum mitts, or little bags made of stiff, heavy
material, which in turn are tied to his wrists, or his sleeves may
be drawn down over his hands and sewed or pinned with safety pins.
It should be borne in mind that a baby sometimes sucks his thumb
because he is hungry or thirsty and gives up the practice when his
food is increased or when he is regularly given water to drink.

FIG. 164.—Stiff cuffs to prevent thumb sucking. (From photograph taken
at Johns Hopkins Hospital.)
]

=Ear Pulling= is not uncommon among young babies and if allowed to
continue a long, misshapen ear may result. This may be prevented by
using a thin, close fitting cap which ties under the chin, or by
using the same kind of elbow splints as for thumb-sucking.

FIG. 165.—Cap, to prevent ruminating. (Devised by Miss Hammer.)
]

=Crying.= It is very easy to allow the baby to develop the crying
habit, but very difficult to break it up. A baby who is properly
fed, kept dry and warm but not too warm, and whose clothes are
comfortable will usually cry very little if wisely handled. But a
baby may cry because he is hungry, thirsty, wet, cold, over-heated,
sick or in pain or simply because he wants to be taken up and
entertained and has learned that the way to realize his wish is to
cry. By closely observing the baby’s habits and his condition the
nurse will usually be able to ascertain the cause of the crying.
Very often a drink of fairly warm, sterile water will quiet him,
particularly at night. But both the nurse and the mother should
refrain from taking the crying baby up and carrying him or holding
him when it is discovered that this attention stops his crying.
Persistent crying should always be reported to the doctor, as it may
have serious significance.

=Ruminating.= Some babies have the habit, called “ruminating,” of
bringing up food; chewing it; moving it about and finally rolling it
out of their mouths. Although this habit has not been recognized
until comparatively recently, it is now believed to be of fairly
common occurrence and often mistaken for vomiting. It is seen as a
rule in precocious babies who take more interest in their
surroundings than the average, more placid infant, beginning very
early to fix their attention upon light, sounds and moving objects.
The ruminator begins by bringing up a small amount of his last
nourishment, then a little more and a little more until finally he
has brought up nearly or quite all of it, apparently deriving a
certain amount of pleasure and satisfaction from the procedure.
Quite obviously, a continuation of this practice results in
undernourishment, sometimes even starvation, since the baby actually
retains very little if any of his food. As liquids come up more
easily than fluids, the first step toward breaking up this habit is
usually to give the baby more solid and concentrated food than he
has been taking and to carry him about, talk to him and entertain
him for about an hour after feedings, for if his attention is
otherwise engaged, he is not likely to ruminate. Another efficacious
measure is the use of a cap (See Fig. 165) so constructed and tied
under his chin that the baby’s jaws are held tightly together and he
is unable to make the movements which are necessary to rumination.
(Fig. 166.)

FIG. 166.—Ruminating cap applied. (From photograph taken at Johns
Hopkins Hospital.)
]

FEEDING THE BABY

Proper feeding is probably the most decisive single factor in the
routine care of the baby.

In order that the food be satisfactory it must be not only suitable
in composition for the individual baby, but it must be clean, fresh
and at the right temperature; given in suitable amounts and at
suitable and regular intervals; it must be given properly—not too
fast nor too slowly and it must be given under favorable conditions.

Moreover, the baby himself must be kept in a general condition which
will favor the digestion and assimilation of the food that is given
to him. Fresh air, suitable clothing, an even body temperature,
gentle handling, proper bathing, regular sleep, freedom from
excitement, fatigue and irritation, all promote the baby’s ability
to use his food to advantage. Reverse influences all work against
it.

The character, amount and intervals of the baby’s feeding are
definitely ordered by the doctor, but the many factors which
influence the baby’s nutrition are so largely a matter of nursing
that the nurse has grave responsibilities in connection with his
nourishment.

After other conditions have been made favorable, the factors which
determine the character of the baby’s food are the kind and amount
of food materials which are needed by his growing body and the
powers of his digestive organs. If he is given less food than he
needs at each stage of his progress he will not be properly
nourished; but if he is given food materials in quantities,
proportions or character which are beyond the power of his immature
alimentary tract to digest, he not only will not be properly
nourished but probably will be made ill.

There are three methods of nourishing the baby: breast feeding,
artificial feeding and a combination of the two, termed mixed or
supplementary feeding.

=Breast Feeding.= From all standpoints, maternal nursing under
normal conditions is the most satisfactory method of infant feeding.
If the breast milk is suitable it meets all of the baby’s
requirements and the proportion and character of its constituents
are exactly suited to his digestive powers.

FIG. 167.—Proper method of carrying baby to support head and back.
(From photograph taken at Johns Hopkins Hospital.)
]

In order that the nursing be entirely satisfactory, the condition of
both mother and baby must be favorable to its success. The
preparation and care of the mother have been described: her general
condition and state of nutrition; the care and condition of her
nipples, flat or retracted nipples being brought out if possible,
and if not, the nursing facilitated by the use of a shield. If the
baby’s diaper is wet or soiled, it should be changed before he is
put to the breast, partly to make him comfortable and partly to
avoid disturbing him after his feeding. His mouth is gently swabbed
with boric soaked cotton, if this is ordered, he is wrapped in a
little blanket and carried to his mother dry and warm and
comfortable. (Fig. 167.) Although nursing is an instinct, the baby
sometimes has to learn or to acquire the habit which is one reason
for putting him to the breast during those first two or three days
when he obtains little or no actual food. (See Chapter XVI.) As he
expresses the milk by a squeezing and suction made possible only
when the nipple is well back in his mouth, he must take into his
mouth practically the entire pigmented area which surrounds the
nipple. To do this he lies in the curve of his mother’s arm as she
turns slightly to one side, and holds her breast away from his
nostrils in order that he may breathe freely.

Sometimes even when other conditions are favorable, the baby is
unable to nurse because of some physical disability. He may be too
feeble; have a cleft palate or find suckling painful because of an
abrasion of the mucous membrane which occurred when his mouth was
bathed just after birth. The manner in which the baby nurses,
therefore, may be significant and should be carefully noted and
described to the doctor.

There is a difference of opinion among doctors concerning the
interval between feedings which is most satisfactory. Some have the
baby nurse every four hours and others every three hours during the
early months of life. It is believed by some doctors that although a
baby who is fed on a four-hour schedule may regain his birth weight
more slowly than the baby who is fed every three hours, he suffers
less from digestive disturbances and ultimately makes an entirely
satisfactory gain in weight. Another point in favor of the four-hour
interval is the longer period of freedom which this gives to the
mother and this may influence her willingness to nurse her baby. But
other doctors, both pediatricians and obstetricians, feel that the
four-hour interval is too long for most babies.

Whether the baby shall nurse from one or both breasts at each
feeding is another moot question. Some doctors believe that the
results are better if both breasts are partially emptied at each
nursing, while others feel that the function of the breasts is more
satisfactorily promoted by completely emptying one breast at a time,
at alternate nursings. Although the baby should pause every four or
five minutes to prevent his nursing too rapidly, which is a common
cause of colic, neither he nor his mother should be allowed to sleep
during the nursing periods. When he has finished, he should be taken
up very gently and placed in his crib and left to sleep. If he is
nursing satisfactorily, he will be sleepy and contented after
nursing and will sleep for two or three hours afterwards; he will
seem generally good humored and comfortable while awake; he will
have good color; gain weight steadily and have two or three normal
bowel movements daily. The normal stool in breast fed babies is
bright yellow, smooth and with no evidences of undigested food.

If he is not being adequately nourished, he will present exactly the
opposite picture, in some or all of these respects. He will be
unwilling to stop nursing after the normal length of time and will
give evidence of not being satisfied when taken from his mother. He
may be listless and fretful and sleep badly. He will not gain weight
as he should, and he may vomit or have colic after nursing.

To ascertain whether or not such a baby is getting enough milk it is
customary to weigh him, without undressing him, before and after
each nursing. Each fluid ounce of food will increase his weight one
ounce. If the baby is not getting a normal amount of milk at each
nursing he is often given enough modified milk after each meal to
supply the deficit, but at the same time an effort is made to
increase the supply of breast milk by improving the mother’s
personal hygiene.

The amount which the baby needs at each feeding varies, not only
according to his weight and age, but also according to his vigor and
activity, and must always be figured for the individual baby. A very
general estimate of the amount taken by the average well baby at
each feeding, is about as follows:

First week 1½ to 2½ ounces
Second and third week 2 to 4 ounces
Fourth to ninth week 3 to 4½ ounces
Tenth week to fifth month 3½ to 5 ounces
Fifth to seventh month 4½ to 6½ ounces
Seventh to twelfth month 6½ to 9 ounces

=Artificial Feeding.= There is no entirely adequate substitute for
satisfactory maternal nursing, and any other food that is given to
the young baby is at best a makeshift. Considering the baby’s
delicacy, therefore, and his urgent needs, no pains should be spared
to make any artificial food which is given to him as satisfactory as
possible. In preparing and giving artificial food it must be borne
in mind that normal breast milk:

1. Is exactly right in quantity, quality and proportion.

2. Is fresh, clean and sweet.

3. Is free from bacteria.

4. Tends to protect the baby from infection.

5. Definitely protects him from certain nutritional diseases.

Cows’ milk, suitably modified, is apparently the best available
substitute for mother’s milk, but it must first meet certain
requirements and then be handled with scrupulous cleanliness and
care, if it is to be at all satisfactory.

The requirements are that the milk shall be:

1. Whole milk. It must not be altered by the removal of cream nor
the addition of such preservatives as salicylic acid,
formaldehyde or boracic acid.

2. Its composition must not vary greatly from day to day.

3. It must be clean and free from disease germs; other organisms
should not be present in excessive numbers.

4. It must be fresh: less than 24 hours old when it is delivered.

All of this means that the milk must come from a herd of healthy,
tuberculin-tested cows. The milk from a single cow may vary markedly
from day to day but that from several cows is nearly constant. The
stables and the cows must be kept clean, the udders carefully washed
before each milking; the milkers themselves must wear freshly washed
clothing, scrub their hands thoroughly and milk into sterile
receptacles; the milk must be immediately covered and cooled to a
temperature of 45° F. or 50° F. and kept there.

Milk produced under such conditions is usually described as
“certified milk” and is often prescribed as infant food without
being pasteurized or sterilized. But if there is any doubt about the
source of the milk and the method of its handling, it should be
strained into a clean receptacle through filter paper or a thick
layer of absorbent cotton and subsequently boiled or pasteurized.

When the nurse is in a position to offer advice about the baby’s
milk she must explain the importance of always obtaining the
freshest, cleanest and purest milk possible, no matter what it
costs.

Whether certified or not the milk must always be placed in the
refrigerator or some other place at a temperature of 50° F. as soon
as it is received and _it must be kept cool and clean_. Mother’s
milk, which is being imitated, is clean and sweet and free from
disease germs.

Keeping the milk cool means keeping it at a temperature of 50° F.
Keeping it clean implies cleanliness of the milk itself, the
utensils, the nurse’s hands and the destruction, by sterilization or
pasteurization, of disease germs. Those which are likely to be
present in infected milk are streptococci, tubercle bacilli, colon
bacilli, germs of typhoid, diphtheria and scarlet fever.

The amounts and proportions of the constituents of the substitute
feeding will be specified by the doctor, as well as the intervals
between feedings and the amount to be given each time. But the
doctor’s careful adjustment of the milk formula to the baby’s
immediate needs and digestive powers will be set at naught unless
the nurse is absolutely _accurate_ in preparing and giving the milk.

The nurse’s invariable responsibility, therefore, is to keep the
milk _cool_ and _clean_ and prepare and give it _accurately_.

The nurse will appreciate the necessity and principles of modifying
cows’ milk for the human infant if she will consider for a moment,
the differences between mother’s milk and cows’ milk, as indicated
by the following table, and the reasons for these differences: