CHAPTER XXI
CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN BABY
Before undertaking the care of the new-born baby the nurse should stop and consider him for a moment and review in her mind just what he represents; what he has been through; what struggles and dangers are ahead of him; what are the weaknesses of his equipment to meet these perils and what must be the character of her service to him if she is to do all in her power to help him safely over that most hazardous period in the entire span of his existence: the first month of his life.
That little new-born baby is quite as helpless and appealing as he looks, for his chances for present and future health lie very largely in the hands of those who care for him during these early weeks, and any injury which is done at this time, either through acts of omission or commission, can never be entirely repaired.
At the time of birth, the baby makes the most complete and abrupt change in his surroundings and condition that he will make during his entire lifetime.
He has existed and evolved as a parasite for nine months, during which time he has been protected from injury; kept at the temperature which was best for him, and above all has been furnished with exactly the proper amount and character of nourishment necessary for his growth and development.
Suddenly he emerges from this completely protecting environment into a more or less hostile world, where he must begin life as a separate entity with a frail little body that in many respects is only imperfectly developed. And yet the baby must not only continue the bodily functions and activities that were begun during his uterine life, but must also elaborate and establish others which were imperfect or were performed for him. Otherwise he will not live.
The nurse will recall that the fetus received its nourishment and oxygen, and gave up waste material, through the placental circulation; that the lungs were not inflated and that most of the blood flowed through the foramen ovale instead of through the pulmonary vessels, as it does after birth. The digestive tract, excretory organs and nervous system were not needed during fetal life and therefore are imperfectly developed at birth and are capable of functioning only within very narrow limits.
The pulmonary circulation usually is established immediately after birth, and when the baby cries vigorously the lungs are expanded and filled with air and the respiratory function is inaugurated. The ductus arteriosus, ductus venosus and two hypogastric arteries are gradually obliterated, as the normal circulation of the blood becomes established and the foramen ovale is closed. See Figs. 28 and 29.
The other functions are established more slowly and the care of the baby must be such that the immature, unused organs will not be overtaxed, and yet that their development will be promoted through activity.
The new-born baby weighs 3250 grams, or 7¼ pounds, and is about 50 centimetres, or 20 inches long. The body is well rounded and the flesh firm. The skin is a deep pink, or even red, and is covered with a white, cheesy substance, the vernix caseosa, which is likely to be thickly deposited in the folds of the skin, in the creases of the thighs and axillæ and over the back. Some babies still have the fine, downy lanugo hair over parts or all of the body.
The head and abdomen are relatively large, the chest narrow and the limbs short. The legs are so markedly bowed that the soles of the feet may nearly or quite face each other, but they finally assume a normal position. The bones are largely cartilage and the entire body is therefore very flexible. Some of the bones, which are separate at birth unite later in life and the adult skeleton finally becomes firm and rigid.
Most babies have faded blue eyes at birth, the permanent color appearing gradually, while the amount and color of the hair varies greatly, some babies being bald and others having abundant hair from the beginning.
The shape of the baby’s head is sometimes distorted at birth, being so elongated from chin to occiput as to give the parents deep concern. But they may be confidently assured that in the course of a few days the head will assume the lovely rounded contour, so characteristic of babyhood. The temporary deformity is caused by a moulding and overlapping of the bones of the skull as it is forced through the birth canal, and sometimes also to a collection of fluid under the scalp, called the _caput succedaneum_, and which, too, is due to pressure during birth. Both the anterior and posterior fontanelles may be felt at birth.
GROWTH AND DEVELOPMENT. The progress during the first year, of average, normal babies who are satisfactorily nourished and cared for, is fairly uniform and the accepted average is suggested by the following schedules which are based upon observations made upon a large number of normal, healthy infants.
=Weight.= The average baby boy weighs at birth, 7¼ to 7½ pounds and girls a little less, as a rule. There is an initial loss of from six to ten ounces during the first week, through body waste and the passage of meconium and urine, before the full amount of nourishment is taken and assimilated, large babies losing more than small ones. (Chart 5.) From this time the gain is usually from four to eight ounces, each week, during the first five months, after which it is only about half as rapid, or at the rate of from two to four ounces weekly. At six months, therefore, the average baby weighs from fifteen to sixteen pounds, or double the normal birth weight of 7½ pounds, and at twelve months, from twenty to twenty-two pounds, or three times the average birth weight. The weight is perhaps the most valuable single index to the baby’s condition, that we have, but at the same time, it must be remembered that a baby whose food is rich in carbohydrates may be of normal weight, or over, but be incompletely nourished and very susceptible to infection. Other babies who are small and seem to gain unsatisfactorily are sometimes very well and vigorous. And very commonly there are periods in the lives of entirely normal babies when there is little or no gain in weight. This may occur during the period from the seventh to the tenth month, for example, or during very warm weather. But the baby’s weight should be watched carefully, for a loss or prolonged failure to gain may be an evidence of faulty nutrition or disease.
=Height.= The average height at birth is 20 inches, though boys may measure a little more and girls a little less; at six months, 25 to 25½ inches and at one year, 28 to 29 inches.
=Head and Chest.= The circumference of the head and chest are about the same at birth, the chest being possibly a little smaller. Both measure about 13½ inches, increasing gradually to about 16½ inches at six months and 18 inches at the end of the first year.
=Fontanelles.= The posterior fontanelle usually closes in six or eight weeks but the larger, anterior fontanelle is not entirely obliterated until the baby is eighteen or twenty months old. Closure of the fontanelles is usually late in rickets, cretinism and hydrocephalus and early in cases of malnutrition and microcephalus.
=Teeth.= Although it occasionally happens that a baby has one or two teeth at birth, the average infant has none until the sixth or seventh month, when the two lower, central incisors appear. After a pause of a few weeks the two, upper, central incisors appear, followed by the two lateral incisors in the upper jaw. At the end of the first year, therefore, the average baby has six teeth, or eight, if the lower, lateral incisors have come through by the first birthday, as they sometimes do. (Fig. 148.) This is the usual course of dentition during the first year, but there are wide variations among entirely well and normal babies, the first tooth sometimes not appearing before the tenth, eleventh or even twelfth month. But as a rule if no teeth are cut by the time the baby is a year old, it is regarded as an evidence of faulty nutrition, perhaps bordering on rickets.
The baby who is properly fed and cared for cuts his teeth with little or no trouble, in spite of the widely current belief that a teething baby is a sick baby. We have no way of estimating the number of babies who die needlessly from infections and digestive disturbances because of this fallacious conviction. For if the baby is sick while teething, the disturbance is all too frequently accepted as a normal occurrence and nothing is done until too late.
Frail, delicate babies may have convulsions each time that a tooth is cut and if a baby is having digestive trouble it is likely to grow worse while he is teething. But dentition is a normal physiological process and the healthy, properly fed baby suffers little or no inconvenience at this time.
The care of the baby’s teeth should begin when the first tooth appears. It should be wiped, front and back, with a piece of gauze or cotton dipped in a solution of boracic acid, or sodium bicarbonate or some other weak alkaline wash, to neutralize the acid secretions of the mouth which start decay. After the baby has five or six teeth, the use of a very soft brush, with tooth paste, is often advised, the teeth being brushed with a circular motion or from the gums toward their edges. The teeth should be wiped, or brushed, morning and evening and after feedings. The reason for such close care of the temporary teeth is that they serve as a mould or brace to hold the jaws in proper shape for the permanent teeth which appear later. If the “milk” or deciduous teeth decay or crumble away before the jaws are developed to the point when the permanent teeth appear, these second teeth are likely to be crooked and uneven.
=Stools and Urine.= During the first two or three days, the stools are of dark green, tarry material called meconium. Meconium consists of cast-off cells from the skin and intestines, fat, mucus, hairs and bile pigment. In the course of two or three days, the stools begin to grow lighter and shortly the normal, milk-feces appear, being bright yellow, of a smooth pasty consistency and having a characteristic odor. During the first month or six weeks the baby’s bowels may move three or four times daily, but after this they usually move but once or twice in the course of twenty-four hours. As the diet is increased, the stools grow somewhat darker and firmer and finally become formed.
The new-born baby’s bladder usually contains urine which may be voided immediately after birth or not until several hours later. After the first voiding the bladder may be emptied five or six times a day, or oftener. The nurse should watch for the first evacuation of the bowels and bladder, and if they do not occur during the first few hours, the fact should be reported to the doctor, as the omission may be due to an imperforate anus or meatus.
=Cord.= Within a few days after birth the stump of the umbilical cord begins to shrivel and turn black, and a red line of demarcation appears at the junction of the cord with the abdomen. By the eighth or tenth day, as a rule, the cord has atrophied to a dry black string, when it drops off and leaves an ulcer, or small granulating area which heals entirely in a few days. (Figs. 149, 150, 151, 152.) Before the days of sepsis, infections of the cord were not uncommon and babies frequently died of tetanus, streptococcus and other infections. But at the present time an infected cord is a rare, and, it may be added, an almost inexcusable occurrence.
=Skin.= By the end of the first week any lanugo remaining usually disappears and there is frequently a scaling of the superficial layers of the skin which lasts for two or three weeks, while a delicate pink tint replaces the deeper color of the skin in the course of ten days or two weeks. The baby does not perspire until after the first month, as a rule, when insensible perspiration begins, gradually increasing until perspiration is free by the time the baby is a few months old.
=Tears.= There are no tears at birth and opinions differ as to whether they appear in the course of two or three weeks, or three or four months. The absence of the lachrymal secretion is one explanation for the necessity of bathing the baby’s eyes during the early days and weeks, for if dust or other foreign material gains entrance it is not washed out by the tears as it is later.
=General Behavior.= During the first few weeks the average baby sleeps most of the time: that is from nineteen to twenty-one hours daily. He gradually sleeps less, as the special senses develop and will sometimes lie quietly for an hour or more with his eyes open, sleeping only sixteen or eighteen hours daily at six months and fourteen to sixteen hours at the end of a year.
The baby begins to make noises and “coo” at about two months and to utter various vowel sounds when about six months old. By the end of a year these indefinite noises and sounds become distinct words. At about the fourth month, he grasps at objects and smiles and very soon even laughs. He holds up his head at about the third or fourth month; sits up and also begins to creep at six or seven months; while sometime between the ninth and twelfth months he will stand by holding to some one’s hand or the furniture, and will begin to walk with assistance.
These degrees of development at different ages are not to be taken as the only measure of normal progress, for many well babies mature more rapidly and others more slowly than at the rate which is found to be the average.
In addition to these fairly specific evidences of the baby’s condition and progress, such as weight, height and muscular development, there are other and less definite indications of his well-being which the nurse must watch for and accord a very high value.
The baby who is well and is being properly fed in all respects, will have good color; his flesh will be firm; he will take his nourishment with a certain amount of eagerness and seem satisfied afterward. He will sleep for two or three hours after each feeding; will sleep quietly at night, and while awake, unless he is wet or uncomfortable for some other good reason, he will seem contented, good-natured and happy.