Chapter XXIII: Common Disorders and Abnormalities of Early Infancy

The common ills of early infancy are due largely either to errors in
feeding or to infection or both. Of the nutritional disturbances,
rickets and scurvy were discussed in the chapter on nutrition, but
the obstetrical nurse will sometimes see also, malnutrition,
marasmus, inanition, diarrheal diseases, acidosis, colic,
constipation and vomiting.

All of these disorders are practically preventable through suitable
feeding, good care and hygienic surroundings. The nurse’s part in
this prevention consists in giving the painstaking care which was
described in the preceding chapter.

The terms _malnutrition_, _marasmus_, and _inanition_ designate
different forms and degrees of starvation, and are characterized by
loss of weight, prostration, feeble powers of assimilation, general
weakness and arrested growth. The temperature is likely to be low,
but in acute inanition, a rapid loss in weight may be accompanied by
a sudden rise in temperature. (Charts 6, 7, and 8.)

These so-called “wasting diseases” are frequently seen in children
who have congenital nervous instability and those born of
tuberculous, syphilitic or otherwise delicate parents. The treatment
is suitable food; fresh air and sunshine; an abundance of fluid by
mouth, rectum, subcutaneously or intraperitoneally; clean
surroundings and good nursing care.

THE DIARRHEAL DISEASES

These are among the most frequent and most serious illnesses of
early infancy. They may result from mechanical causes, such as a
mass of undigested food, which produces increased intestinal
secretion and peristalsis; from the action of bacteria, or their
toxins, together with the inability of an enfeebled digestive tract
to meet the needs of a rapidly growing body; or from such reflex
causes as sudden chilling of the body, excitement, fatigue or the
prostration resulting from excessively hot weather.

=Acute gastro-enteritis=, the diarrheal disease which is so common
and so fatal during the hot months of July and August, is often
referred to as “summer complaint” or “summer diarrhea.” It is so
largely avoidable through good nursing that the methods of its
prevention were described in connection with the care of the baby
during the Summer, resolving itself, as it does, into feeding the
baby properly and keeping him clean and cool and quiet.

=Symptoms.= While there are different forms of summer diarrhea, the
general symptoms are much the same and may develop gradually after
some evidence of indigestion, or suddenly with a rise of temperature
to 101° F. or 102° F., or even as high as 106° F., accompanied by
pain and vomiting. The baby is usually restless, fretful and thirsty
and his skin is hot and dry. He gives evidence of pain by shrill
crying, drawing up his legs and flexing them on his abdomen.
Diarrhea is the conspicuous symptom and there may be anywhere from
four to twenty movements in the course of 24 hours. The stools are
largely fecal matter at first but they finally become fluid and
contain mucus. They may be expelled with a good deal of force and a
quantity of gas come with them. The baby grows very weak, thin and
hollow-eyed, if the diarrhea persists and unless promptly treated
the end may be fatal.

=Treatment and Nursing Care.= The first step is to stop all food and
to give water freely. When water is not retained by mouth it is
frequently given by rectum, into the tissues or intraperitoneally.
The pain may be relieved by applying hot stupes.

Feeding is resumed very gradually and cautiously for one attack of
summer complaint predisposes to another and every precaution is
taken to prevent a recurrence. Thin barley water or broth is usually
given first, followed by whey, protein milk, buttermilk or diluted
skim-milk in small amounts and at comparatively long intervals.

CHART 6.—Weight chart showing normal loss and gain during the first
fourteen days of life.
]

CHART 7.—Chart showing loss of weight in inanition fever.
]

CHART 8.—Temperature chart showing sudden elevation of temperature,
coincident with the marked loss of weight, in inanition fever.
]

The baby should be lightly clad; should be kept quiet and in a cool,
shady place out-of-doors as much as possible. During the warmest
part of the day, however, he will often be much better off and more
comfortable in the house, in a room with the shutters closed. But
while keeping the baby cool, the nurse must bear in mind the harm
that will be done by chilling him or exposing him to a cold draft or
wind. Several tub baths, daily, are often given, at a temperature of
100° F., rather than cool sponge baths because of the baby’s
feebleness and inability to react to cool bathing. Packs are also
employed, both for high temperature and restlessness and may be cool
(80° F.), tepid (100° F.) or hot (105° F. to 108° F.) according to
the doctor’s orders; intestinal irrigations; lavage and gavage.

FIG. 177.—Putting the baby in a wet pack.
]

To give a =pack=, the nurse will cover the bed with a rubber and
sheet and bring to the bedside a basin containing a sheet wrung from
water of the specified temperature; a basin containing ice and
compresses for the baby’s head, and a flannel covered hot-water
bottle at 120° F., for his feet. The baby is laid on the upper half
of the folded wet sheet, and an upper corner wrapped about each arm
(Fig. 177), and the sides folded around his legs. The lower half is
brought up between his feet to cover his entire body and tuck around
his shoulders. The hot-water bottle is placed at his feet and an ice
compress on his head. (Fig. 178.) If the sheets are wrung from warm
or hot water, the baby is covered with a blanket after he is put
into the pack.

FIG. 178.—Baby in pack with hot-water bag at feet and cold compress on
head. (Figs. 177 and 178 from photographs taken at Johns Hopkins
Hospital.)
]

FIG. 179.—Diagrams showing successive steps in putting baby in pack
shown in Figs. 177 and 178.
]

=Intestinal irrigations=, of normal salt solution are often given to
babies suffering from intestinal disorders, sometimes once or twice
daily to wash out the lower bowel, or a cool irrigation may be given
to reduce temperature, the amounts varying from ½ to 2 gallons of
solution. The baby should be placed on a pillow and rest on a
bed-pan, being protected from chilling as for, an enema (See Fig.
186), and provision made for a two-way flow of the fluid. A small
catheter attached by means of a connecting glass nozzle to the
tubing on the irrigation bag may be passed into a slightly larger
catheter, which is inserted into the rectum about six inches, the
fluid flowing in through the small inner tube and out through the
larger one which encases it. Or a small catheter for the outflow may
be inserted in the rectum alongside the one through which the
solution is introduced. Normal salt solution, glucose or bicarbonate
of sodium solution are sometimes given by the drip method at the
rate of 20 to 40 drops per minute. In this case a glass tube is
introduced at some point in the rubber tubing in order that the rate
of flow may be watched and regulated by means of a clamp or a
stop-cock. The catheter is inserted in the rectum about six inches
and held in place by strips of adhesive plaster.

FIG. 180.—Baby wrapped in blanket, before being given gavage or eye
irrigation, to keep him warm and hold his arms and legs to his
sides. (From photograph taken at Johns Hopkins Hospital.)
]

FIG. 181.—Gavage. (From photograph taken at Johns Hopkins Hospital.)
]

=Lavage= and =Gavage=. Sometimes when the baby vomits persistently
the stomach is washed out and a small amount of water or nourishment
given before the tube is withdrawn. A tray containing the following
articles should be carried to the bedside:

A glass funnel attached to a rubber tubing which connects with a
small rubber catheter by means of a glass nozzle.

Basin to receive stomach contents.

Small rubber, towel and curved basin to place under baby’s chin.

Glass graduate containing warm water for washing out stomach.

Food or solution which is to remain in stomach, standing in cup
of warm water.

Glycerin to lubricate tube.

Mouth gag, if necessary, or roll of bandage to hold jaws apart.

The baby should be wrapped tightly (Fig. 180) to prevent
interference by his struggling and turned slightly to the left side.
(Fig. 181.) The catheter is lubricated with glycerin or water and
passed back over the tongue and quickly downward until an air bubble
is heard as it enters the stomach. The length of tubing which is to
be inserted may be anticipated by marking a point on the tube which
is the same distance from the end as the baby’s mouth is from its
umbilicus. The possibility and the serious consequences of
introducing the tube into the trachea instead of into the esophagus
must be borne in mind. Although the baby will often choke and
struggle when the tube is properly introduced, he will not cough
violently and stop breathing as he will if it enters the air
passage. Further information is obtained by inverting the funnel in
a basin of water after the tube is inserted; if it is in the stomach
there will be no result, but if it is in the trachea air will be
expelled and bubbles will rise through the water. To wash out the
stomach, the funnel is filled with warm water and slightly raised so
that the water will run in slowly, after which the funnel is turned
upside down into a basin which is lower than the baby’s body, and
the stomach contents allowed to run out. This is repeated four or
five times, or until the solution returns clear, and the food which
is to remain in the stomach is poured in slowly. Before the tube is
quite empty it is pinched off with the fingers and quickly
withdrawn.

=Acidosis.= The diarrheal diseases are sometimes complicated by
acidosis, a condition in which the relative amounts of acid in the
blood are so increased that the normal alkalinity is markedly
diminished. This condition may result from an excessive intake of
acids; an overproduction of acids in the course of normal
metabolism; a decrease in the reserve of normal alkali in the body
or a failure in the mechanism by means of which excessive acids are
usually neutralized or eliminated. Acidosis is a serious
complication and often fatal.

FIG. 182.—Method of obtaining a fresh specimen of urine in a test
tube.
]

The treatment is directed toward preventing the production of more
acids within the body; restoring the alkali reserve and promoting
elimination of the excessive acids and their salts. Solutions of
glucose, bicarbonate of sodium and salt are used and are given by
mouth, rectum, intravenously and intraperitoneally. Subcutaneous
injections are not wholly satisfactory, because of the small amounts
which may be given in this way. From 150 to 400 cubic centimetres
are given into the peritoneal cavity and as the solution absorbs
readily these injections are sometimes repeated every eight or
twelve hours, an infusion bottle and short infusion needle being
used. From 75 to 300 cubic centimetres of glucose solution (5 per
cent. or 10 per cent.) is given intravenously, while as much as 1000
cubic centimetres is sometimes given per rectum in the course of 24
hours by the drip method. Soda solution (4 per cent.) is often given
by mouth, if the baby is able to retain it, or intravenously, as
frequently as the condition of the urine indicates is necessary.
From 75 to 100 cubic centimetres is given at one time to young
babies.

FIG. 183.—Obtaining a 24–hour specimen of urine through curved glass
tube attached to rubber tubing which empties into bottle tied to
side of bed. (From photographs taken at Johns Hopkins Hospital.)
]

FIG. 184.—Muslin band with cuffs and tape used to keep the baby from
kicking while a specimen of urine is being obtained. The tapes are
tied tightly to the sides of the crib and the cuffs fastened around
the baby’s ankles with safety pins. See Figs. 182 and 183.
]

In preparing the soda solution it must be remembered that boiling
drives off carbonic acid and forms sodium carbonate and that its
reconversion into sodium bicarbonate is a complicated procedure.
Howland and Marriott[16] say in this connection: “Oscar Schloss has
found that sodium bicarbonate in bulk is always sterile. It is
probably therefore sufficient to add the bicarbonate with proper
precautions to sterile water.”

Since the results of urine tests frequently indicate the treatment
in acidosis, it is of very great importance that the nurse be able
to obtain specimens from young babies. (Figs. 182, 183, 184 and 185
for methods of obtaining fresh and 24–hour specimens from babies.)

=Colic=, =Constipation=, =Convulsions= and =Vomiting= so frequently
seen in young babies are symptoms rather than diseases.

=Colic= usually consists of paroxysms of pain in the stomach or
intestines, due to distension or to spasmodic, muscular
contractions. The indirect cause may be unsuitable food or food
given too rapidly; chilling of the surface of the body, excitement
or fatigue. The distension may be due to air swallowed by the baby
while nursing or gas formed by carbohydrate fermentation. Excess of
protein may form an irritating mass in the intestines and cause a
cramp.

FIG. 185.—Belt used to hold tube in place while obtaining specimen of
urine as indicated in Figs. 182 and 183. The tube is passed through
the hole in the tab and adjusted over penis or between labia; the
belt fastened around the waist and straps passed between the thighs
and fastened to belt.
]

While colic frequently accompanies malnutrition and constipation, it
is often seen in otherwise well and happy babies, and usually before
the fifth month. The attacks are usually sudden and may occur
several times a day after feeding, or only in the late afternoon or
at night. The baby cries shrilly; his face is drawn and may be
flushed, from crying, or cyanotic; his fists are clenched and
pressed to his body and his feet and hands are cold. His abdomen is
hard and distended and during a pain the baby flexes his thighs upon
it and afterward extends them with a jerk. This painful seizure may
last only a few moments or it may persist for hours, leaving the
baby exhausted.

The chief preventive measures are found in the precautions and
attention to detail which have been described, and which should be
included in the care of all babies. In a bottle-fed baby it is often
found that recurrence of attacks of colic may be averted by a slight
change in the milk formula; by giving more water to drink; by
lengthening the intervals between feedings; by giving the milk more
slowly or by omitting the 2 a.m. feeding, thus giving the baby more
digestive rest.

With breast-fed babies, prevention is often accomplished by having
the mother nurse her baby more slowly, lengthening the intervals and
by improving her own hygiene; particularly by increasing her
recreation and out-of-door exercise and relieving constipation.
Women who lead sedentary lives and eat rich food very often have
colicky babies as do those who are nervous, irritable and inclined
to worry. (See chapter on the nursing mother.)

When attacks of colic occur, the pain usually may be relieved by
giving half of a soda-mint tablet in a little warm water and an
enema of about eight ounces of soap-suds or salt solution at 110°
F., given through a small catheter inserted about six inches. The
baby will experience almost immediate relief through the expulsion
of gas and feces and he may be made still more comfortable by
placing a hot-water bag at his cold feet; rubbing his abdomen with
vaselin and applying hot stupes. Sometimes the first feeding which
falls due after an attack is omitted and a little warm water or
barley water is given instead, in order that the digestive tract may
rest.

=Constipation= is very common among young infants and may be
manifest by the stools being too small, too dry or too infrequent.
The commonest causes are:

1. =Faulty diet=—possibly too much protein or too little fat or
sugar.
2. =Intestinal atony=, due to undernourishment, rickets or anemia.
3. =Anal fissure= which makes the baby unwilling to empty his bowels
because of pain.
4. =Absence of habit= of emptying the bowels regularly.

The prevention of this very troublesome condition lies largely in
suitable food; constant fresh air; regularity in the daily routine
and training the baby to empty his bowels at the same time every
day.

When constipation is due to insufficient fat in the food, cod-liver
oil is sometimes given, 15 to 30 drops three or four times a day; or
a teaspoonful of olive oil two or three times a day. Maltose, malt
soup, malted milk, milk of magnesia, liquid petrolatum,
oatmeal-water and orange juice are all found among the remedies for
constipation; while soap sticks, suppositories and enemata of oil or
soap-suds sometimes have to be resorted to.

FIG. 186.—Giving an enema. The baby lies comfortably on a pillow which
reaches to the bed pan, the latter being covered with a diaper where
the baby rests upon it. He is well protected to prevent chilling.
]

In giving an enema to relieve constipation, the baby should be
protected from chilling, laid on a pillow and the pan so placed that
he will be comfortable and not inclined to move, and from 100 to 300
cubic centimetres of soap-suds, at 105° F., given with a small
hard-rubber nozzle. (Fig. 186.) When warm olive oil is given at
night (1 to 2 ounces through a catheter introduced about 6 inches),
it is very often retained and the feces so softened that the baby
empties his bowels freely the next morning with little or no
assistance.

Abdominal massage will often help to increase the intestinal tone
and make peristalsis more vigorous. The abdomen should be rubbed
with a circular stroke, beginning in the right groin and following
the course of the colon up to the margin of the ribs, across to the
left side and down to the groin. This is often given for about ten
minutes every day, preferably at night but never just after a
feeding.

Constipation is sometimes entirely cured by a suitable dietary; an
abundance of drinking water; an out-of-door life; massage, and above
all, the unremitting effort to establish a regular habit. The latter
is the nurse’s responsibility and she should exercise the greatest
patience in trying to accomplish the desired end.

=Convulsions= are a symptom of several disorders of early infancy,
which may occur unexpectedly and which the nurse may suddenly be
called upon to relieve in the absence of the doctor. Convulsions may
be due to brain lesions; to spasmophilia or a special tendency to
convulsive disorders; gastro-intestinal disorders; toxemia or
syphilis. They may be the initial symptom of an acute infectious
disease or may occur on slight provocation in a frail,
undernourished baby or one suffering from rickets or tetany. For
this reason one sometimes sees convulsions in a baby who is teething
or has colic or indigestion.

As convulsions are a symptom of some abnormal condition, the doctor
will often prescribe a sustained treatment designed to remove or
relieve the cause. But when an attack occurs unexpectedly, and the
doctor cannot come at once, the nurse may often terminate the
seizure by employing measures that will quiet and relax the
struggling baby. The room should be quiet and darkened and the baby
handled with utmost gentleness because of the extreme irritability
of his nervous system. As a rule, the most satisfactory course is to
immerse the baby in water at 100° F., and keep him there for five or
ten minutes, supporting his head and shoulders meantime. Someone
else should place cold compresses on his head and change them
frequently. When removed from the bath, the baby should be wrapped
in a blanket, kept very quiet and the cold applications to his head
continued.

When it is known that the convulsions are due to indigestion the
stomach is often washed out and a high colonic irrigation given
before the baby is quieted by the bath. In tetanoid convulsions the
baby may take a long deep inspiration and fail to expire.
Respirations should be stimulated, in such a case, by spanking him
sharply or by dashing cold water on his face and chest. When the
attacks are recurrent the nurse may be instructed to terminate them
by giving the baby a few whiffs of chloroform, which, with an
inhaler is kept in readiness for instant use.

Mustard baths and packs are sometimes given when the need for
counter irritation is indicated. For a bath, one ounce, or six level
tablespoonfuls of dry mustard is added to one gallon of water at
105° F. and the baby kept in it for about ten minutes, or until the
skin is well reddened. He is then wrapped in a warm blanket and
surrounded by hot-water bottles, with cold compresses applied to his
head. The mustard pack is given in the manner of other packs, with a
sheet wrung from mustard water which is possibly a little warmer and
stronger than that for the bath, care being taken that the sheet is
not cooled before it is wrapped about the baby. He is usually left
in the pack for about ten minutes or until his skin is reddened, and
then wrapped in warm blankets, with cold compresses to his head.

It is often helpful to the doctor if the nurse is able to describe
the onset of the convulsions and tell him where the twitching began,
how it progressed and whether or not it was preceded by a cry.

=Vomiting= during early infancy is a symptom of any one of several
conditions, the nature of which sometimes may be revealed by the
character of the attacks. The commonest causes and varieties of
vomiting are as follows:

1. =Too rapid feeding= or =too large amounts of food= given at
one time. The vomiting amounts to little more than regurgitation
and is often induced by moving or handling the baby immediately
after feeding him.

2. =Acute gastric indigestion.= Sour stomach contents may be
vomited immediately after feeding, or not until several hours
later and may be followed by mucus and bile. The baby is usually
pale, particularly about the mouth; he may perspire about the
forehead and give evidence of pain, being relieved by the
vomiting.

3. =Stenosis of the pylorus.= The vomiting from this cause is
projectile in character and may occur immediately after food is
taken into the stomach, or, some time later without apparent
cause, a larger amount of fluid may be expelled than was given
at the preceding feeding. The vomiting may begin a few days
after birth or several weeks afterwards in a baby who has been
well previously.

4. =Intestinal obstruction= due to congenital obstruction, which
causes persistent vomiting from birth; or due to intussusception
of the intestines, when vomitus consists first of stomach
contents which later becomes bile stained and sometimes contains
fecal matter, blood and mucus. It is attended by prostration,
and after fecal matter is passed at the beginning, there is
frequent evacuation of blood and mucus.

5. =Chronic= or =habit vomiting=, sometimes occurring in early
infancy, may be difficult to control because of being incited by
such slight causes as laughing, crying or being moved.

In addition to being caused by the above mentioned conditions,
vomiting in young babies may usher in an acute infectious disease,
as a chill does in an adult, or it may accompany such diseases as
peritonitis, meningitis, brain tumors and toxic conditions such as
uremia.

INFECTIONS

The infectious diseases which the obstetrical nurse is most likely
to see in her baby patient are ophthalmia neonatorum; syphilis;
impetigo; pemphigus and vaginitis.

=Ophthalmia Neonatorum=, inflammation of the eyes of the new-born or
“babies’ sore eyes,” is one of the common diseases of infancy and
certainly one of the most dreaded because of the tragedy of lifelong
blindness which may follow in its wake. In the early days of
organized work for the prevention of blindness the term “ophthalmia
neonatorum” implied a gonorrheal infection, but it is now known that
inflamed eyes and subsequent blindness may result from infection of
innocent origin. Accordingly, in those states where it is required
that the disease be reported, ophthalmia neonatorum is defined as
inflammation of the eyes of new-born babies, irrespective of the
cause. The disease is frequently due to the gonococcus, the baby’s
eyes being infected from the mother during passage through the birth
canal or infected later by her hands or clothing. Or the
inflammation may be caused by the streptococcus, pneumococcus or the
colon, diphtheria, or influenza bacilli while very frequently the
infection is mixed.

It is estimated that about 20 out of every 1000 new-born babies have
sore eyes, and though many of the infections are mild, between 5 and
8 of these 20 cases are capable of becoming serious and causing
blindness if not speedily and skillfully treated. The number of
cases which are neglected is suggested by the fact that about 10 per
cent. of all blindness, the world over, is due to infant ophthalmia
and that about 20 per cent. of the inmates of schools for the blind
in this country are sightless from this cause. This does not take
into account the unnumbered army of those who are partially blind,
or blind in one eye, and thus seriously handicapped, as a result of
this disease.

=Symptoms.= The first symptoms are redness and swelling of the lids,
usually accompanied by a discharge of pus from the beginning, and
they ordinarily appear during the first few days of life, but
sometimes develop as late as the second or third week. The disease
may run a very rapid course and cause blindness in 48 hours from the
time the first symptoms appear, or it may persist for weeks.
Ulceration of the cornea is the dreaded consequence of the
inflammation as ulcers are followed by scars. When the scar is
small, or to one side of the pupil, there may be little or no
impairment of vision, but if it is large and centrally located it
forms an opaque screen and causes blindness by shutting out the
light, although the interior of the eye behind the scar is sound and
uninjured. Sometimes the ulcer causes a perforation of the cornea
through which the lens and vitreous humor are discharged.

Attempts have been made to remove the scar following a centrally
located ulcer and replace it with a clear cornea from some such
animal as a guinea pig, but the operation apparently has not been
perfected. When it is, many blind persons may have their sight
restored to them.

=Prevention.= It may be stated almost without qualification that
ophthalmia neonatorum is a preventable and curable disease, and
accordingly that blindness from this cause is inexcusable.
Prevention lies first, in wiping the baby’s eyes immediately after
birth and instilling a drop or two of a silver salt, such as nitrate
of silver, argyrol or protargol, or bathing them with boracic acid
solution; and second, in close watching for early symptoms and
giving speedy treatment when they appear. This is urgent because
there is no way of determining in the beginning whether the
infection is mild or virulent. Nitrate of silver solution, 1 per
cent., is the prophylactic most commonly employed and its use is now
routine in most hospitals and in the practices of many physicians in
this country. The solution is sometimes dropped between the baby’s
lids, immediately after the birth of the head, and before the birth
of the entire body, and sometimes immediately after delivery is
completed. Many doctors follow the silver drops with normal salt
solution to prevent the slight silver catarrh which so frequently
occurs otherwise, and which may be confused with early symptoms of
ophthalmia. Still others prefer simply to bathe the eyes with
boracic acid solution (unless they know that the mother has
gonorrhea) and to watch them closely for the slightest redness,
swelling or discharge and give prompt treatment if these appear.

The Credé method, made famous by the Viennese obstetrician who
introduced it in 1881, was to drop from a glass rod, a single drop
of nitrate of silver, 2 per cent., into each eye immediately after
birth. The routine use of this prophylaxis reduced the occurrence of
ophthalmia in Credé’s clinics from 10 per cent. to .1 per cent.
among the new-born babies.

Since it is now believed that close vigilance and subsequent care
are equally as important as the prophylactic drops, the Credé
treatment has been variously modified and other and weaker silver
solutions are frequently used, and with satisfactory results. The
dropping of a germicide into the baby’s eyes kills the organisms
which may be present at the time, but it does not protect against
subsequent infection. For this reason the nurse cannot be charged
too earnestly to watch the baby’s eyes closely for the first
evidence of infection, and report it to the doctor immediately, day
or night, for the late infections are as destructive of sight as
those which occur before or during birth.

FIG. 187.—Irrigating the eye with a blunt nozzle, the irrigation bag
hanging low in order that the stream may be gentle. (From a
photograph taken at Johns Hopkins Hospital.)
]

=Treatment and Nursing Care.= The treatment and nursing care in
ophthalmia frequently require the greatest skill. There may be
merely an application of silver and sponging with boracic acid
solution or a gentle irrigation with a blunt nozzle (Fig. 187), or
the preservation of the baby’s sight may necessitate dressings and
treatment which will require elaborate preparation (Fig. 188), and
may also require some form of treatment every quarter- or half-hour,
day and night and occupy the entire time of two or three special
nurses. The nurse’s duties in caring for the eyes will be explicitly
defined by the doctor, but in general she must remember that she is
nursing a baby suffering from an acutely infectious disease, who
should be strictly isolated, and that as a rule she should wear a
gown, rubber gloves and protective goggles while caring for him. All
of her attentions to the inflamed eyes must be given with the
_greatest gentleness_ in order to avoid abrasion of the conjunctiva
or injury of the cornea. Moreover, the baby with suppurative
conjunctivitis is a sick baby often fighting for his life as well as
his sight, and every effort must be made to preserve his strength
and increase his resistance. Fresh air and careful feeding are
imperative. Breast-fed babies have a distinct advantage over
bottle-fed babies and for this reason the mother should always
accompany the nursing baby if he is taken from his home to a
hospital to be treated for ophthalmia neonatorum, unless there is a
wet nurse available at the hospital.

FIG. 188.—Method of holding baby for eye examination or treatment.
(Photograph and appended notes by courtesy of Dr. W. Gordon M.
Beyers, Royal Victoria Hospital, Montreal.)

“The child’s body is swathed in a sheet or blanket in such a way that
the arms are lightly, but securely, fixed against the sides. The
nurse can easily support the body with one hand, and with the other
draw down the lower lid (as shown in the photograph), or otherwise
assist the physician. The doctor sits opposite the nurse, with a
rubber sheet across his knees, and upon this a sterile towel. He
holds the baby’s head gently, but firmly, between his knees, thus
freeing both his hands for necessary manipulations. In the picture
the physician is represented as about to apply a solution of nitrate
of silver with an applicator of sterile absorbent cotton.

“Close at hand is a table on which are a bowl of boracic acid solution
and sterile absorbent cotton for irrigating the eyes; an undine (if
one prefers) for the same purpose; a kidney dish for collecting the
washings; sterile applicators, and small dishes for nitrate of
silver solution and for saline solution (to neutralise): besides
bottles containing solutions of cocaine, atropine, and fluorescein.
Culture tubes, sterile swabs, cover slips, forceps, and a spirit
lamp are ready for bacteriological examinations; and in a glass are
displayed lid retractors, which are usually indispensable to a
thorough examination of the cornea. On the floor is a paper bag,
which, with the contaminated swabs, applicators, etc., is burned on
the completion of the treatment. Other articles may be added as
required; but the important point is, that everything should be at
hand before the examination is begun.

“The physician and the nurse are clothed in surgical gowns; and wear
rubber gloves, which heighten cleanliness, and safety and comfort.
It is to be carefully noted that they both are provided with
protective glasses; for under no circumstances should this
precaution be omitted in treating the purulent ophthalmias.

“The conditions here depicted will not always be possible of
fulfillment, but they represent the ideal for which one should
strive.”
]

It is of interest to nurses that the effort to safeguard the eyes of
babies through preventive treatment and early care was developed
into a national movement by one who also was influential in starting
the training of nurses in this country, Miss Louisa Lee Schuyler.
The lay work for the prevention of blindness, which is now
country-wide, was started by the New York State Committee for
Prevention of Blindness, which was organized by Miss Schuyler in
1908. She was its first Chairman and skillfully directed the work of
the Committee for ten years. During the Civil War Miss Schuyler was
a member of the Sanitary Commission and afterwards was one of the
group which was responsible for starting at Bellevue Hospital, in
New York City (in May, 1873), the first training school for nurses
in this country, planned in accordance with Miss Nightingale’s
standards for the organization and conduct of a school for nurses.
Later, in 1911, the Bellevue School for Midwives was established as
a result of the combined efforts of the Hospital Trustees and Miss
Schuyler’s Committee for Prevention of Blindness, the course of
training being outlined by a sub-committee composed of Miss Lillian
D. Wald, Dr. J. Clifton Edgar and myself. So far as it is possible
to learn this school was the first in this country to be conducted
along the lines of a school for nurses, or after the manner of the
midwife schools in England.

=Syphilis=, which ranks high among the scourges of mankind, is seen
with distressing frequency among young babies. It may be contracted
during uterine life, when it is said to be “inherited,” or it may be
“acquired” after birth by kissing a syphilitic person or coming in
contact with contaminated articles, such as clothing, or nursing
from a diseased breast.

The most conspicuous symptoms are the familiar “snuffles;” the
scaling, fissures or eruption on the soles, palms, buttocks and
about the mouth; shrill, hoarse crying; swollen painful joints;
partial paralysis and a general feebleness and inanition. Some or
all of these symptoms may be present when the baby is born or they
may develop any time within the first two or three months of life.

Babies of syphilitic mothers are often given mercurial inunctions
immediately after birth, even though they have no symptoms of the
disease as it is very likely to be present in a latent form. This is
one reason for the routine inspection of the placenta, since in it
is sometimes found the only indication for treating the baby. An
infant who is known to have syphilis is given mercurial inunctions
or baths, the ointment being rubbed into the groin, axilla, back and
abdomen in rotation on successive days, to prevent irritation of the
skin. The nurse should protect herself with rubber gloves, wash the
area with warm water and soap and thoroughly rub in the ointment.
Sometimes the ointment is put on the inside of the back of the
baby’s binder, by which means he rubs it in himself. The syphilitic
baby should be isolated and should not be put to the breast of an
uninfected woman, but he may nurse from a syphilitic woman without
harm to either her or himself. Good general care, including fresh
air and sunshine are important to the baby suffering from syphilis.

=Thrush= or =Sprue= is a highly communicable disease of the mouth of
new-born babies, due to one of the fungi. It is common among sickly,
undernourished babies and those living in unhygienic surroundings,
but it is seldom seen in healthy babies who are cared for with
absolute cleanliness. The disease is characterized by small raised,
white spots in the baby’s mouth, frequently on the back of the
tongue and inner surface of the cheeks.

Prevention lies in good care and in cleanliness of the mother’s
nipples, or the bottles and nipples for artificially fed babies, and
of all other articles coming in contact with the baby, particularly
his mouth. Some doctors have the baby’s mouth bathed before each
feeding, as a preventive measure, while others feel that a gentle
swabbing once daily is sufficient, if the nipples are kept clean,
since an abrasion of the mucous lining is easily caused and is
favorable to the development of thrush.

Treatment consists in cleanliness and in gently swabbing the spots,
three or four times a day, with sterile cotton wet with an alkaline
solution such as borax (10%), bicarbonate of sodium (6%) and
sometimes with formalin (1%) or a weak solution of permanganate of
potassium.

=Impetigo= and =Pemphigus= are highly infectious skin diseases of
early infancy which are seen more often in hospitals than in
patients’ homes. The treatment of the raised blisters that appear on
different parts of the body is entirely a medical question, but in
caring for the patients suffering from either of these infections
the nurse must take every precaution to avoid extending the trouble
on the skin of the infected baby, himself, and of communicating it
to other babies in the ward. Strict isolation is imperative; gentle
handling and frequent changing of the underclothing to prevent
extending the disease to uninfected areas.

=Vaginitis.= This highly infectious malady is considered troublesome
rather than serious, as a rule, though it may be complicated by
ophthalmia or arthritis. Gonorrheal vaginitis is the commonest form
seen in early infancy and may be due to infection which the baby
acquired during its passage through the birth canal or later from
the mother’s hands or clothing. The symptoms are a vaginal
discharge, which may be thin and serous or thick and yellow and
purulent and it may be scanty in amount or abundant; a reddened,
swollen condition of the vagina and vulva and sometimes redness and
excoriation of the inner surface of the thighs. The nurse’s chief
responsibilities are to be constantly on the alert to detect
evidences of the disease and report them promptly to the doctor, and
to observe strict isolation in caring for the baby while carrying
out the doctor’s orders for douches or suppositories.

COMMON ABNORMALITIES OF THE NEW-BORN

=Icterus= or =Jaundice=, which is so frequently seen in new-born
babies, is occasionally a symptom of some septic condition; of
syphilis or congenital cirrhosis of the liver or obstruction of the
bile ducts, but as a rule it is without any serious significance.
The jaundiced appearance usually begins on the second or third day
and may continue for two or three weeks or it may subside in three
or four days. The depth of the color varies, being very pale in some
cases and almost green in others. When this discoloration of the
skin is unaccompanied by other symptoms, no treatment is given.

=A Cephalhematoma= is a tumor of blood between the periosteum and
the bones of the skull of the new-born baby. It is often due to some
injury sustained during birth and is most frequently seen after
prolonged labors. Cephalhematoma is sometimes confused with a caput
succedaneum, but whereas the caput disappears in a few days the
cephalhematoma may not be entirely absorbed for two or three months.
Although certain conditions sometimes indicate the advisability of
surgical treatment, the nurse’s care consists solely of protecting
the tumor from injury.

=Club foot= is one of the commonest deformities of the extremities
of young babies, occurring once in about every 1000 births. It may
be congenital or caused by injury or it may be due to such diseases
as cerebral paralysis or poliomyelitis. The nurse should watch for
any abnormality in the structure or position of the feet, for the
earlier treatment is started, the better is the prospect of a cure.

=Engorgement of the Breasts.= Not infrequently the breasts of
new-born babies are engorged, in which state they are easily
infected by being rubbed or squeezed. Since the greatest care must
be taken to avoid bruising swollen breasts, they are sometimes
protected by the application of a pad of sterile cotton. Hot
compresses are sometimes applied when there is redness with the
swelling, or a tiny ice-bag, made by tying off the fingers and thumb
of a rubber glove, and partly filling it with finely crushed ice,
after which the wrist is tightly tied.

=Hare Lip.= The fissured lip, which is not infrequently seen in new
babies, may consist merely of a small notch or it may amount to a
deep cleft reaching up into the nostril. It is due to a non-union of
the frontonasal plate with the lateral processes and may occur on
one or both sides, thus forming a single or double hare lip. An
extensive fissure will usually interfere with suckling and the nurse
may need both ingenuity and patience in feeding such a baby, for the
prospect of successful treatment, which is surgical, increases with
the baby’s age and improved nutrition. The longer she can feed the
baby successfully, therefore, the better his chance of recovery.

=Cleft palate=, a common congenital abnormality, consists of a
fissure of the soft, and sometimes of the bony, palate; it may be on
one or both sides and may be continuous with a hare lip. The problem
of feeding the baby with a cleft palate is very grave since the
fissure may make it impossible for him to form the vacuum in the
back of his mouth which is necessary for suckling. He is sometimes
fed with a medicine dropper or by gavage or by means of a special
nipple provided with a flap which fits into the roof of the mouth
and closes the opening into the nasal passages. Even more than in
the care of the baby with a hare lip is it important to nourish the
baby with a cleft palate, and build him up for as long as possible
before he is subjected to the strain and shock of the inevitable
operation.

=Hernia.= Umbilical and inguinal hernias are both seen in young
babies.

=Umbilical hernia= is the commoner type and is not uncommon in thin
babies and those with indigestion and distension and in babies who
cry violently. Such hernias are not regarded as serious if prompt
measures are taken to reduce them as they usually respond very
readily to treatment. But since neglect may have serious
consequences, the nurse should watch for protrusions and report them
promptly. She will often be instructed to reduce the hernia and
apply adhesive strapping, in which case the following observations
by Dr. Griffith will be helpful:

“Usually it is quite sufficient to draw the skin into two folds, one
on each side of the hernia and meeting over it; holding these in
place by straps of adhesive plaster crossing over the navel, or by a
broad horizontal band of adhesive plaster reaching to the lumbar
regions. Another method is the following: A silver quarter of a
dollar is laid upon the adhesive surface of a piece of rubber
plaster about two inches square; over this is placed the broad strap
referred to, with its adhesive surface next to that of the smaller
piece. After reducing the hernia and pressing the sides of the
abdominal walls slightly together the band is applied with the
quarter dollar directly over the position of the navel. My own
preference is for a simple adhesive band without the use of the
coin. The dressing should be worn constantly, changing it from time
to time as the old one loosens. The dressing must, of course, not be
removed during the bath. Several months are required before the
opening is permanently closed. Occasionally the plaster produces a
great deal of cutaneous irritation, especially in the first few
months of life. The employment of zinc oxid plaster tends to avoid
this difficulty.”[17]

=Inguinal hernia= is less common in very young babies but it should
be watched for since it usually may be easily reduced by the use of
a truss, if discovered and treated early, but may be serious if
neglected.

In general, the new baby who is ill, needs the same thoughtful,
gentle, painstaking care that the nurse gives to the well baby, but
these must be shaped to his immediate requirements and the doctor’s
special instructions.