CHAPTER XXII

NURSING CARE OF THE AVERAGE NEW-BORN BABY

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.

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.

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.

_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.)

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.

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.

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.

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.

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.

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.

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.

=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.

=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.)

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.

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:

_Mother’s Milk._ _Cows’ Milk._ Fats 3.5 to 4. % 3.5 to 4. % Sugar 6.5 to 7.5% 4.5 to 4.75% Proteins 1. to 1.5% 3.5 to 4. % Salts .2% .7 to .75% Water 87 to 88. % 87. %

It will be remembered that the tissues and bony skeleton are built by the proteins and salts (lime and phosphorus). Accordingly Nature supplies these in greater abundance to the calf, who grows so fast as to double his birth weight in about 47 days, than to the baby who scarcely doubles his within 180 days. The calf begins life with a physical need for the abundance of proteins and salts which are present in cows’ milk, and with digestive organs that can cope with them, but the baby needs less, can digest less and therefore must be given less. There are, of course, other and finer differences between the two milks and an attempt is sometimes made to meet these. For example, mother’s milk is slightly alkaline and cows’ milk slightly acid and the curd of cows’ milk is larger, tougher and harder to digest than that formed by mother’s milk. Accordingly some doctors add lime water to cows’ milk to make it alkaline, and render the curd softer, finer and more digestible by boiling it.

It is often not possible to give a bottle-fed baby the full 4% of fat which mother’s milk contains, and some doctors make the protein of the artificial mixture very much larger in amount than is found in human milk. The nurse will see that this is a matter which can be decided only by the physician.

=Articles Needed in Preparing the Baby’s Food.= A complete equipment for preparing and giving the baby’s milk should be assembled, kept in a clean place, separate from utensils in general use, and never put to any other service. A satisfactory outfit for this purpose comprises the following articles:

One dozen graduated nursing bottles. One dozen nipples. Clean, new corks or a package of sterile, non-absorbent cotton for stoppers. Bottle brush. Covered kettle, capacity one gallon, for boiling bottles and possibly pasteurizing milk. Pasteurizer or wire bottle rack. Small kettle, about one quart size. Graduated pint or quart measuring glass. Pitcher, two quart size. Long-handled spoon for mixing. Funnel. Measuring spoons—table and tea sizes. Double boiler. Thermometer which will register at least 212° F. Cream dipper (if ordered). Two small covered jars for sterile and used nipples. Sugar (lactose, maltose or cane sugar according to orders). Lime water, if ordered.

Utensils of enamel or aluminum ware are probably the most satisfactory ones to use as they are easily kept clean, while bottles with wide mouths and curved bottoms and inner surfaces can be thoroughly washed more easily than those with small necks and sharp corners. Nipples that can be turned inside out to be washed should be selected as it is almost impossible to clean thoroughly those with tubes or narrow necks. New bottles will be rendered less breakable if placed in cold water, which is gradually heated, allowed to boil for half an hour and cooled before the bottles are removed.

The bottles should be rinsed with cold water after each feeding and then carefully washed and scrubbed with the bottle brush in hot soapsuds or borax water, containing two tablespoonsful to the pint. They may be kept full of water while not in use or rinsed with hot water and stood upside down until they are all boiled on the following morning, preparatory to being filled with the freshly prepared milk. The baby’s bottles should never be washed in dishwater nor dried on a towel. The nipples should be rinsed in cold water, turned inside out and scrubbed with a brush, in hot soapsuds or borax water; rinsed and placed in a jar ready to be boiled with the bottles.

=Preparation of Milk.= The full quantity of milk which the baby will take in the course of twenty-four hours is prepared at one time and the prescribed amount for each feeding poured into as many separate bottles as there will be feedings. (Fig. 168.)

The nurse should first boil for five minutes all of the articles that will come in contact with the milk, including the full number of bottles and nipples and the jars in which the nipples are kept; remove them with the long-handled spoon without touching the edges or inner surfaces and place them on a clean table, dropping the nipples into one of the sterile jars.

She should wash the mouth of the milk bottle before removing the cap and pour the amount which the formula calls for into the sterile pitcher. To this is added the sterile water in which the sugar has been dissolved in the glass graduate, and the potato or barley water, the lime water or soda solution as ordered. This mixture is thoroughly stirred and the amount for one feeding at a time measured in the graduate and poured into the specified number of bottles which are then stoppered.

If certified milk is used for the milk mixture it is often given to the baby without being pasteurized, in which case the bottles are placed in the refrigerator as soon as they are filled and stoppered. Very frequently, however, the milk is sterilized or pasteurized. The nurse will feel surer of keeping the mouths of the bottles clean if she covers them with squares of gauze or muslin before they are sterilized, holding the caps in place with tapes or rubber bands. Pasteurization as applied to infant feeding consists of heating the milk to 140–165° F. and keeping it at that temperature 20 to 30 minutes.

There are many excellent pasteurizers for home use on the market, or entirely satisfactory results may be obtained by using a wire bottle rack (See Fig. 168) and the large kettle already provided. One method is to place the rack containing the bottles in the kettle which is filled with cold water to a level a little above the top of the milk in the bottles, and allow the water to come to the boiling point. The kettle is removed from the fire, covered tightly and the bottles allowed to stand in the hot water for twenty minutes. Cold water is then run into the kettle to cool the milk gradually and avoid breaking the bottles, after which they are placed in the refrigerator, well or spring-house and kept at a temperature of 50° F. until they are taken out one at a time for feedings. If a wire rack is not available the bottles may be stood on a saucer or a thick pad of folded newspapers in the bottom of the kettle.

Pasteurization does not destroy all germs that may be in the milk, but it kills the more important ones and apparently impairs the nutritive and protective properties of the milk less than boiling. However, pasteurized milk must be kept cold and must be used within twenty-four hours, for the nurse will recall that aging of milk is quite as undesirable as souring.

Scalding is another method of destroying germs in milk. The milk is placed in an open vessel and the temperature raised to about 180° F., or until bubbles appear around the edge and the milk steams in the centre, after which it is cooled and kept at a temperature of 50° F.

Many doctors prefer to have the baby’s milk boiled, since boiling insures absolute sterilization and also renders the curd more digestible. Other changes are produced by boiling, however, which make it important to add an anti-scorbutic and cod-liver oil to the baby’s diet at an early date.

Milk may be boiled directly over the flame for a time varying from three to forty-five minutes, or it may be placed in a double boiler, the water in the lower receptacle being cold, and allowed to remain until the water has boiled from six to forty-five minutes. All of these points are definitely specified by the doctor.

When milk is boiled or scalded the other ingredients are added beforehand, as a rule, after which it is measured and poured into the bottles. Or the milk mixture may be poured into the bottles as for pasteurization and the bottles kept in the actively boiling water for any desired length of time.

=Giving the Baby His Bottle.= At feeding time, the bottle should be taken from the refrigerator, the stopper removed and a nipple taken up by the margin and put on the bottle without touching the mouthpiece. The milk is brought to a temperature of about 100° F. by standing the bottle in a deep cup or kettle of warm water and placing it on the fire. The temperature of the milk may be tested by dropping a few drops on the inner side of the wrist or forearm where it should feel warm but not hot. This dropping will also indicate if the hole in the nipple is of the proper size to allow the milk to drop rapidly in clean drops but not to pour. If the hole is too small, the drops will be small and infrequent and the baby will be obliged to work too hard to obtain it; while if the hole is too large the baby will feed too rapidly and may have colic as a result.

The baby’s diaper should be changed if it is soiled or wet before he is given the bottle and he should be held comfortably in a reclining position on the nurse’s arm while she holds the bottle with her free hand. (Fig. 169.) The bottle should be inclined sufficiently to keep the neck full of milk; otherwise the baby may draw in air as he nurses. He should be kept awake while feeding but he should be allowed to pause every three or four minutes in order not to take his milk too rapidly. Not less than ten nor more than twenty minutes is devoted to a feeding, as a rule, and if the baby refuses a part of his milk, it should be thrown away; never warmed over for another time.

After being fed, the baby should be held upright against the nurse’s shoulder for a moment or two (Fig. 170), and ever so gently patted on the back to help bring up any air which he may have swallowed. He should on no account be rocked or played with after taking the bottle, but should be placed gently in his crib, warm and dry and left alone to sleep. Turning him or moving him about even to the extent of changing his diaper at this time may cause vomiting.

The evidences of satisfactory and unsatisfactory feeding in the bottle-fed baby are about the same as in the baby who is fed at the breast, except that the gain in weight on artificial food may be a little slower and less steady than on maternal nursing; the stools have a characteristic sour odor; are a little lighter in color and may contain white lumps of undigested fat; are usually dryer than in breast-feeding and may be formed in even a very young baby.

It is fairly generally agreed that all babies, whether breast-fed or on the bottle, require a certain amount of cool boiled water to drink between feedings. A small amount is given at first and gradually increased according to the doctor’s instructions, and it may be given from a bottle, a medicine dropper or poured slowly from the tip of a teaspoon.

=Ingredients of the Baby’s Food.= In referring to the ingredients of the baby’s food we cannot use the terms “sugar” or “milk” as though they indicated definite and unvarying materials.

There are three kinds of sugar which are commonly used in modified milk: cane or granulated sugar; lactose or milk sugar and maltose. _Cane sugar_, the one most widely used, is the least expensive of the three and it apparently is satisfactory for most babies. _Lactose_ is fairly expensive and while it causes diarrhea in some babies, others digest it more easily than cane sugar. Lactose is lighter than cane sugar, three spoonfuls being equal in weight to two of cane sugar. The _maltose_-dextrine preparations are easily digested and somewhat laxative. Some babies gain more rapidly when maltose constitutes part of the sugar in their food than when only lactose is used.

The question of milk is somewhat complicated and though the doctor will specify what percentage of fat shall be in the milk which is used in each case, the nurse must know how to obtain it from the milk at her disposal. If the formula is made up with “whole milk,” which contains 4 per cent. fat, the bottle in which it was delivered should be turned upside down and shaken vigorously in order that the cream which has risen to the top may be redistributed evenly throughout the fluid.

If the doctor employs what is termed “percentage feeding,” he may use whole milk, skimmed milk, or top milk. What he is endeavoring to do is to prepare a food which contains definite known percentages of the different ingredients, fat, carbohydrates and protein. Where a mixture is desired which contains more fat than it does protein, the milk to be employed is obtained by discarding a certain amount from the bottom of the jar of milk, the remainder being then called “top milk.” When he wishes the fat to be lower than the protein percentage, he discards some of the top milk in the jar, using the rest, which is then a partially skimmed milk. The upper 2 ounces in a quart bottle of milk contains 24 per cent. fat; the upper 8 ounces is 12 per cent. fat; the upper 16 ounces is 8 per cent. fat and the upper 24 ounces is 5 per cent. fat. If the formula calls for 6 ounces of the upper 8 ounces of milk, therefore, the nurse will see that it is very important that she remove the full 8 ounces and use 6 ounces of the milk which she has removed and not simply take the upper 6 ounces, as this would contain a higher percentage of fat than is ordered. (Figs. 171, 172, Dr. Griffith’s tables of fat percentages.)

Top milk may be removed by tipping the bottle gradually and slowly pouring the designated amount into a measuring glass, or it may be removed by pushing a cream dipper, especially made for this purpose and holding one ounce, down into the bottle until the cream flows in. Another method is to syphon off the lower milk through a bent glass tube, leaving in the bottle the desired amount of top milk.

Many doctors feed the baby according to his caloric needs and prepare the formula from whole milk, sugar and water, determining the amounts of each according to the age and weight of the baby.

Under any condition it is so necessary that the amount and composition of each baby’s food be adjusted to his needs, that it is not considered possible to make out any formulae or feeding schedules which would be safe or satisfactory for general use.

Ready Method for Selecting Amounts to be Employed in Making Various 20–Oz. Milk-Mixtures, and the Caloric Values Resulting

* * * * *

Moreover, it does not ordinarily devolve upon the nurse to do more than prepare and give the baby’s food as ordered by the doctor, but situations sometimes do arise when the doctor is not within reach which the nurse must meet as best she can. In such an emergency she might be guided by the following suggestions contained in a pamphlet entitled, “Save the Babies,” prepared by Dr. L. Emmet Holt and Dr. H. K. L. Shaw and published by the American Medical Association, remembering that they are intended for the average, normal baby and are not necessarily suitable for all babies:

“The simplest plan is to use whole milk (from a shaken bottle) which is to be diluted according to the child’s age and digestion.

“Beginning on the third day, the average baby should be given 3 ounces of milk daily, diluted with seven ounces of water. To this should be added one tablespoonful of lime water and 2 level teaspoonfuls of sugar. This should be given in seven feedings.

“At one week, the average child requires 5 ounces of milk daily, which should be diluted with 10 ounces of water. To this should be added 1½ even tablespoonfuls of sugar and one ounce of lime water. This should be given in seven feedings.

“The milk should be increased by ½ ounce about every 4 days.

“The water should be increased by ½ ounce about every 8 days.

“At three months the average child requires 16 ounces of milk daily, which should be diluted with 16 ounces of water. To this should be added 3 tablespoonfuls of sugar and 2 ounces of lime water. This should be given in 6 feedings.

“The milk should be increased by ½ ounce about every 6 days.

“The water should be reduced by ½ ounce about every 2 weeks.

“At 6 months the average child requires 24 ounces of milk daily, which should be diluted with 12 ounces of water. To this should be added 2 ounces of lime water and 3 even tablespoonfuls of sugar. This should be given in 5 feedings.

“The amount of milk should be increased by ½ ounce every week.

“The milk should be increased only if the child is hungry and digesting his food well. It should not be increased unless he is hungry, nor if he is suffering from indigestion even though he seems hungry.

“At 9 months, the average child requires 30 ounces of milk daily, which should be diluted with 10 ounces of water. To this should be added 2 even tablespoonfuls of sugar and 2 ounces of lime water. This should be given in 5 feedings.

“The sugar added may be milk sugar or, if this cannot be obtained, cane (granulated) sugar or maltose (malt sugar).

“At first plain water should be used to dilute the milk.

“At three months, sometimes earlier, weak barley water may be used in the place of plain water; it is made with ½ level tablespoonful of barley flour to 16 ounces of water and cooked 20 minutes.

“At six months the barley flour may be increased to 1½ even tablespoonfuls, cooked in the 12 ounces of water.

“At nine months, the barley flour may be increased to 3 level tablespoonfuls, cooked in the 8 ounces of water.

“A very large baby may require a little more milk than that allowed in these formulas. A small delicate baby will require less than the milk allowed in the formulas.”

These formulas may be tabulated as follows:

────────┬────────┬────────┬────────────┬────────────┬────────────── Age │ Milk │ Water │Barley-Water│ Lime-Water │ Sugar ────────┼────────┼────────┼────────────┼────────────┼────────────── │ │ │ │ │ ════════╪════════╪════════╪════════════╪════════════╪══════════════ 3–7 days│ 3 ozs.│ 7 ozs.│ 16 ozs. │ ½ ozs.│2 teaspoons 2d week │ 5 ozs.│10 ozs.│ 15 ozs. │ 1 ozs.│1½ tablespoons 3d week │ 6 ozs.│10½ ozs.│ 14 ozs. │ 1 ozs.│1½ tablespoons 1 month │ 7 ozs.│11 ozs.│ 12 ozs. │ 1 ozs.│2 tablespoons 2 month │11 ozs.│13 ozs.│ 12 ozs. │ 1½ ozs.│2½ tablespoons 3 month │16 ozs.│ │ 11 ozs. │ 2 ozs.│3 tablespoons 4 month │19 ozs.│ │ 10 ozs. │ 2 ozs.│3 tablespoons 5 month │21½ ozs.│ │ │ 2 ozs.│3 tablespoons 6 month │24 ozs.│ │ │ 2 ozs.│3 tablespoons 7 month │26 ozs.│ │ │ 2 ozs.│3 tablespoons 8 month │28 ozs.│ │ │ 2 ozs.│2½ tablespoons 9 month │30 ozs.│ │ │ 2 ozs.│2 tablespoons ────────┴────────┴────────┴────────────┴────────────┴──────────────

────────┬───────────────┬──────────────── Age │No. of feedings│ Hours ────────┼───────────────┼──────────┬───── │ │ Day │Night ════════╪═══════════════╪══════════╪═════ 3–7 days│ 7 │6–9–12–3–6│10–2 2d week │ 7 │6–9–12–3–6│10–2 3d week │ 7 │6–9–12–3–6│10–2 1 month │ 7 │6–9–12–3–6│10–2 2 month │ 7 │6–9–12–3–6│10–2 3 month │ 7 │6–9–12–3–6│10–2 4 month │ 6 │6–9–12–3–6│10 5 month │ 6 │6–9–12–3–6│10 6 month │ 5 │6–10–2–6 │10 7 month │ 5 │6–10–2–6 │10 8 month │ 5 │6–10–2–6 │10 9 month │ 5 │6–10–2–6 │10 ────────┴───────────────┴──────────┴─────

=Mixed Feeding.= Under some conditions the breast-fed baby is given also a certain amount of modified milk, and this combination of natural and artificial feeding is termed mixed or supplementary feeding.

A deficiency in the breast milk, ascertained by weighing the baby before and after each nursing, may be supplied by following each nursing with a bottle feeding; or one or two breast-feedings, in the course of the day may be replaced by entire bottle feedings. In any case the milk mixture to be used as supplementary feeding is prepared with exactly the same painstaking care as is the milk for entire artificial feeding.

If supplementary food is given because of an inadequate supply of breast milk, it is of great importance that the baby be put to the breast regularly, no matter how little food he obtains, for his suckling is the best possible means of stimulating the breasts to secrete more milk and of equal importance is the fact that they will tend to dry up if the baby nurses less than about five times in twenty-four hours. Moreover, even a little breast milk is valuable to him and he should have the benefit of all there is to be had.

An entire bottle feeding is sometimes given to a baby who is nursing satisfactorily at the breast, in order to give his mother an opportunity to take longer outings than are possible between the regular nursings. And sometimes it is to the mother’s advantage, and therefore to the baby’s, to give him a bottle during the night and thus allow her to sleep undisturbed.

COMMERCIAL BABY FOODS

Since the baby’s food is prescribed by the doctor, the nurse has little concern with the various proprietary baby foods and the canned and powdered milks which are so persuasively advertised to young mothers. It is hoped, however, that the discussions on nutrition in general and on baby feeding in particular, have made it clear to the nurse that these foods cannot be expected to be satisfactory if used as a sole article of diet throughout the bottle-feeding period.

There are many times and circumstances, however, when the temporary use of a prepared infant food or canned or powdered milk is advantageous. In some cases of intestinal disturbance, for instance, or while the mother is traveling and is unable to have freshly prepared milk formulas supplied to her along the way; during the summer, while staying at a hotel or boarding house where the freshness, cleanliness or purity of the milk are uncertain; or during a sudden shortage of fresh milk, as may occur during a strike or severe storm when transportation is interfered with, a proprietary food may be a great boon.

If the nurse is confronted with the necessity of choosing and making temporary use of a prepared food she may be guided by considering the general principles of baby feeding and the character of the materials at her disposal.

=The Proprietary Foods= may be divided into two general groups: one kind contains milk powder and is usually added to water while the other consists largely of sugar and starch and is added to fresh milk before being given to the baby.

=Canned Milk= is of two kinds; evaporated, which is unsweetened, and condensed, which is sweetened. _Evaporated milk_ is whole milk from which part of the water has been removed, the milk then being canned and sterilized. The addition of water to evaporated milk restores it to the composition of whole milk in many respects, but it is still milk that has been heated. _Condensed milk_ is evaporated milk to which cane sugar has been added to aid in its preservation. Since bacteria do not grow well in highly sweetened foods, it is not necessary to bring sweetened condensed milk to as high a temperature as the unsweetened product, to prevent subsequent bacterial decomposition. The high percentage of sugar in condensed milk quite obviously renders it unsuitable for continuous use as the sole article in a baby’s dietary.

=Milk Powders or Dried Milks= are prepared by rapidly evaporating the water from whole milk, skimmed milk or partly skimmed milk, leaving the solid constituents in the form of a light, white powder. Milk powder readily dissolves in water, forming a “reconstructed milk” which closely resembles the fresh milk from which it was prepared. But it must not be forgotten that reconstructed milk has been heated. Many doctors consider whole milk powder the most satisfactory form of preserved milk which is available for baby food. Should it be used, however, the importance of keeping it tightly covered and in a cold place must be recognized, for the presence of fat renders it likely to become rancid if not kept cold.

ARTICLES OF FOOD WHICH ARE SOMETIMES INCLUDED IN THE BABY’S DIETARY

=Barley Water=, sometimes used to dilute whole milk, is made by mixing the barley flour to a smooth paste in cold water, adding boiling water and boiling for twenty minutes or cooking in a double boiler for an hour, straining and adding enough water to replace the amount lost in cooking. The proportions for different ages are as follows:

Three months, ½ level tablespoonful barley flour to 16 oz. water Six months, 1½ level tablespoonful barley flour to 12 oz. water. Nine months, 3 level tablespoonfuls barley flour to 10 oz. water.

=Potato Water.= One tablespoonful of thoroughly boiled potato is mashed into one pint of the water in which the potato was boiled and carefully strained.

=Spinach.= Spinach is carefully washed, steamed for half an hour and mashed through a fine sieve. It is sometimes started at the sixth month; one teaspoonful daily, gradually increased to one or two tablespoonfuls daily.

=Orange Juice.= The orange should be dipped in boiling water and wiped on a clean towel before being cut and squeezed, to avoid possible infection of juice. It is usually given to babies getting heated milk, sometimes as young as one month old. It is carefully strained and started gradually by giving one teaspoonful in water once or twice daily between feedings and increasing to ½ or 1 ounce by the sixth month and 1½ to 2 ounces by the end of the first year.

=Infusion of Orange Peel.= This is sometimes used instead of orange juice, and is made by boiling one ounce of finely grated orange peel in two ounces of water, adding a little sugar to counteract the bitter taste and adding enough sterile water to bring it up to two ounces.

=Tomato Juice.= Canned tomato strained through a fine sieve, is sometimes given to a baby a few weeks old, starting with one dram and gradually increasing to four to six ounces daily.

=Whey.= One quart of whole milk heated to 98° F. or 100° F. and one-half ounce of liquid rennet or one junket tablet stirred into it and allowed to stand half an hour or until firm and solid, is poured into a cheese-cloth bag and allowed to drain for about an hour without being squeezed.

=Protein Milk.= The curd from one quart of milk, which remains after the whey is drained, as directed above, is mashed through cheese-cloth in a fine wire sieve, with a potato-masher or bowl of a spoon and the curd washed through with one pint of water. A pint of buttermilk is added and the mixture boiled while being stirred constantly. This is sometimes given in diarrhea.

=Beef Juice.= One pound of thick round steak, slightly broiled, is cut into small pieces and the juice expressed with a meat press or a lemon squeezer, the amount varying from 2 to 3 ounces. It may be diluted with an equal amount of warm water, or slightly warmed by being placed in a cup standing in hot water, and salted to taste.

=Broths.= One pound of lean meat, all fat and gristle removed, is allowed to one pint of water. The meat is cut finely and put on in cold water, heated slowly and allowed to simmer for three or four hours, when water is added to replace what was lost in cooking. It is strained, the fat removed and slightly salted.

=Oatmeal Water.= Two level tablespoonfuls of oatmeal in a pint of boiling water is cooked in a double-boiler for two hours, strained and enough boiling water added to replace the amount lost in cooking.

TRAVELING

The difficulties of traveling with a young baby may be greatly lessened by making certain preparations. If the baby is bottle-fed, the preparations will depend upon the length of the journey and whether or not it will be possible to have freshly prepared feedings, for each twenty-four hours, put on the train from laboratories along the way. If this is not possible and the journey is not to take more than twenty-four hours, the entire quantity of food, ice cold, may be carried in a thermos bottle. The requisite number of sterile nursing bottles may be taken or one bottle which is boiled before each feeding. Or the milk may be prepared as usual and the bottles packed in a portable refrigerator. Such a refrigerator may be bought or one may be improvised. The bottles are placed in a covered pail and packed solidly in crushed ice; this is placed in a second pail or a box with a diameter which is at least two inches larger than the inner pail and the space between the two packed firmly with sawdust. Several thicknesses of newspapers should be pressed down over the top and a tight cover fitted to the outer receptacle.

The sterile nipples may be taken in a sterile jar and a deep cup or kettle will be needed in which to warm the bottle before each feeding. It is usually possible to obtain water on the train which is hot enough for this, or cans of solid alcohol, a stand and a metal tray may be added to the traveling outfit. If fresh formulae cannot be delivered to the train, daily, and the journey is to last more than twenty-four hours, one of the proprietary foods or a powdered milk will often prove to be a satisfactory solution to the problem of feeding.

The baby will usually travel more comfortably and sleep better if he is carried in a basket. A large market basket with a handle or a small clothes basket will serve. It may be lined with a sheet or a blanket; have a small hair pillow or folded blanket in the bottom and be made up like a crib. (Fig. 173.) If this basket stands on the car seat during the day, and on the foot of the nurse’s berth at night, the baby will be cleaner, quieter and less exposed to drafts than if carried in the arms.

THE PREMATURE BABY

All of the precautions and gentleness which are necessary in the care of the normal baby, born at term, must be greatly increased in caring for the baby who is born prematurely.

As was explained in Chapter III the premature baby’s prospects of living increase with the length of his uterine life, and it is often possible to estimate this by measuring and weighing him. During the last five months the child’s length in centimetres divided by five gives the month of pregnancy, according to the following table by Dr. Williams:[15]

At the fifth month of pregnancy 5×5, fetus is 25 cm. long At the sixth month of pregnancy 6×5, fetus is 30 cm. long At the seventh month of pregnancy 7×5, fetus is 35 cm. long At the eighth month of pregnancy 8×5, fetus is 40 cm. long At the ninth month of pregnancy 9×5, fetus is 45 cm. long At the tenth month of pregnancy 10×5, fetus is 50 cm. long

But consideration of the baby’s weight is also of importance when attempting to forecast his chances of living. A baby weighing less than 2500 grams or about 5½ pounds should be regarded, and treated, as premature, unless it is more than 45 centimetres, or about 18 inches long. This length would indicate greater maturity, and therefore greater viability than would be expected from the weight. A baby weighing less than 1500 grams (3 pounds and 5 ounces) can scarcely be expected to live.

The premature baby is not only small, but in general is imperfectly developed, having slenderer powers than the full-term baby and at the same time much greater needs. His respiratory and digestive organs are less ready to function than in the full-term baby; his muscles and nerves are feeble; his heat-producing mechanism is unstable and yet there is an excessive radiation of body heat through the relatively large area of skin.

Accordingly, the baby who has been deprived of those valuable last weeks of growth and development is small and limp; lies quietly most of the time and moves very feebly if at all. He is often too weak to nurse at the breast and may swallow with difficulty. His temperature is low, his respirations irregular and he is frequently cyanotic.

The care of this frail little body practically resolves itself into:

1. Maintaining a normal body temperature. 2. Promoting and maintaining normal respirations. 3. Supplying adequate and suitable nourishment. 4. Conserving his strength. 5. Preventing infection.

To maintain a normal body temperature it is necessary to give special thought to the baby’s clothing, bed and room. He should be oiled with warm olive oil and entirely wrapped in cotton batting or flannel or enveloped in a quilted garment, with hood attached, made of cheese-cloth or flannel and cotton batting. (Fig. 174.) Diapers are often omitted in caring for very feeble babies, a pad of cotton being slipped under the buttocks instead as this may be changed with less disturbance to the baby than a diaper.

His bed consists of a box or basket, with the bottom well padded with several inches of cotton, a small pillow or a soft blanket folded to the proper size, covered with rubber or oiled muslin and a cotton sheet. The sides of the basket should be lined with heavy quilted material (Fig. 175), to shut out drafts and help to preserve an even temperature of the air immediately around the baby. A flannel covered hot-water bag at 110° F. may be placed beside the baby, or two, three or four glass bottles, each holding about a pint, containing water at 100° F. and securely stoppered, may be hung in the corners of the basket. (Fig. 176.) A thermometer should hang in the basket also, and the temperature kept between 80° F. and 90° F. It is easier to keep the temperature even if the bottles are filled in rotation instead of all at the same time.

The amount of heat needed around the baby is decided by taking his temperature (by rectum) at regular intervals; supplying more heat if the temperature is low and less if it is at or above normal. Some doctors have the temperature taken every four hours; others twice daily. As the baby grows able to maintain a temperature of 98° F. to 100° F., unassisted, the surrounding heat is gradually reduced and finally removed, and flannel clothing replaces the quilted robe.

In many hospitals there are special rooms for premature babies, which are divided by glass partitions into cubicles so that each baby is in a three-sided enclosure. The rooms are usually darkened to save the baby from the needless irritation of light, and are supplied with constantly changing fresh, moist, filtered air, the temperature being kept at from 80° F. to 90° F.

In a patient’s home or in a hospital where there is no special room for premature babies, a cubicle may be improvised by placing the basket in which the baby lies, in the corner of a room and placing a screen parallel with one of the walls. Such a room should be darkened, well ventilated and have in it a large open vessel of water.

Since the premature baby’s lungs are not fully expanded, respirations are likely to be shallow and irregular, thus failing to supply the amount of oxygen which he sorely needs. As crying inevitably involves deep breathing, it is a common practice to make the premature baby cry at regular intervals during the day in order to promote the respiratory function. Dr. Griffith further recommends plunging the baby into a mustard bath at 100° F. or 105° F. if necessary to make him cry vigorously. It is also important to turn the premature baby from side to side, several times a day to prevent fluid from collecting in the lowermost part of the lung, a condition favorable to the development of pneumonia.

In feeding premature babies, breast milk is ordinarily the most desirable food. If the baby is too feeble to nurse, as frequently occurs, the milk may be expressed from the breast of his mother or a wet nurse, by stripping or pumping, into a sterile receptacle, and if not used immediately it should be covered and placed in the refrigerator. Breast milk is sometimes used whole and sometimes diluted with water, and is given by gavage if the baby is very feeble; from a medicine dropper or a special feeder. Such a feeder consists of a glass tube with a small nipple on one end and a rubber bulb on the other, by means of which the milk may be gently expressed into the baby’s mouth, thus minimizing his effort to obtain it. (See Fig. 175.)

The amount and intervals for feeding the premature baby have to be adjusted to the individual with even greater care than for a normal baby, for he needs more fuel and building material, because of his imperfect development and yet because of that same imperfect development his digestive powers are feebler than those of the full-term baby. During the first day or two, he is sometimes given nothing but water or sugar solution, the milk being started gradually when the baby is from thirty-six to forty-eight hours old. He may be given a very small quantity every two hours, or he may be fed at three- or four-hour intervals, depending entirely upon his condition and progress. It is usually considered very important for the premature baby to have sterile water or sugar solution to drink between feedings, and this is given in the same manner as his milk.

Unlike the normal baby he is not taken from his bed to be fed, unless he nurses at the breast.

The premature baby is weighed as often as is safe for him, since the suitability of his food is largely indicated by changes in his weight. But sometimes very young and feeble babies are weighed only once or twice a week because of the inadvisability of disturbing them more frequently.

Avoidance of fatigue and the conservation of the premature baby’s limited strength and energy are accomplished through reducing his muscular activity to the minimum, by very little and very gentle handling; and by minimizing his loss of energy in the form of heat by keeping the little body warm and quiet.

In this connection the daily bath is of considerable importance. It almost always consists of sponging the baby with warm olive oil as he lies in his bed, and with the least possible exposure and turning. It is given every day or every second or third day according to his condition. The eyes are wiped with boric pledgets and the nostrils with spirals of cotton dipped in oil. The buttocks are wiped with an oil sponge each time the diaper is changed.

The premature baby is very susceptible to infection and strongly predisposed to pneumonia. Infection in general is guarded against by having everything that comes in contact with the baby scrupulously clean; protecting him from drafts, chilling and dust; allowing no one with a suspicion of a cold to come near him and by the nurse’s wearing a clean gown and protecting her nose and mouth with a gauze mask while attending him.

CARE OF THE BABY DURING THE SUMMER

The dangers of infancy are greatly increased in summer, more babies dying during the hot months than any other time during the year. The cause of these deaths is variously termed summer complaint, summer diarrhea, acute gastro-enteritis and cholera infantum, and is due to infected or decomposing food or both.

Clearly this malady is practically preventable through care.

Although such care as has been described in the preceding pages largely constitutes the prevention of the much-to-be-dreaded summer diarrhea, there are a few extra precautions and safeguards with which the nurse must surround her little patient during the warm weather.

She must bear in mind the character of the illness to be avoided: indigestion associated with infection.

It becomes almost a matter of life or death, then, to give the baby clean, suitable food and avoid deranging his digestion.

Babies suffer from the heat more than adults do and are often excessively irritated and exhausted on warm days. And this overheating, exhaustion and restlessness are of themselves enough to affect his digestion.

Accordingly the scourge of summer diarrhea is prevented by giving the baby proper food and keeping him clean, cool and quiet.

The baby should have maternal nursing if possible, for breast-fed babies fall victim to summer diarrhea much less frequently than bottle-fed babies. He should be fed with absolute regularity, and as a rule, no matter what the nature of his food, it is reduced one-quarter to one-third in amount during very warm weather and he is given an increased amount of cool boiled water to drink. His weight may increase very slightly, or even stand still for a short time, as a result of his decreased food, but this is not usually deplored, if he keeps well, for the important thing is to avoid digestive disturbances while the weather is warm.

Cleanliness, as at other times, applies to the baby’s food, clothing and surroundings. Many doctors think it safer to have all milk boiled during the summer, and of course require flawless technique in its preparation and administration. The baby’s soiled napkins should be placed immediately in a covered receptacle containing water, and not left for even a moment where they can be reached by flies. They should be washed, boiled and dried in the open air and sunshine as promptly as possible.

The baby should be protected from flies and mosquitoes by screens in the windows and netting over his crib and carriage, both because they make him restless and irritable and because flies particularly are carriers of filth and disease—the kind of disease that kills so many babies during the summer. Accordingly the nurse must always regard flies with a deadly fear.

The baby should be kept away from dusty places and from cats and dogs. And since babies will put their fingers in their mouths it is a wise precaution to wash their hands several times a day.

The baby should be in the country, in the mountains or at the seashore if possible during the warmest part of the summer at least, but if he is in town there is much that the nurse can do to keep him cool and comfortable. His clothing at this time must be adjusted to his condition and the temperature of the moment just as it is in cold weather. A thin shirt, band, diaper and cotton slip will usually be enough for out-of-door wear, while in the house he may often dispense with the slip and sometimes with everything but his diaper.

During excessively hot days, the baby should have two or three cool sponge baths, in addition to the soap and water bath, one of the sponges being given before he is put to bed for the night. He should sleep on a firm mattress, preferably curled hair but never feathers, and in the coolest, best ventilated room available. During the day it is usually best to take him out-of-doors early in the morning and late in the afternoon, but to keep him indoors during the warmest part of the day, when it is likely to be cooler indoors than out, particularly if the blinds are closed. Quite naturally the nurse will have to take into consideration the size, arrangement and location of the baby’s home in her effort to keep him in cool, quiet, shady places and out-of-doors as much as possible.

He must not be played with, held on hot laps nor subjected to the entertainment and attention which misguided but well-meaning mothers and friends are so eager to lavish on a hot, fretful baby.

Very often during warm weather a fine rash known as “prickly heat” appears on the back of the baby’s neck and spreads over his head, neck, chest and shoulders. This rash is due to too warm clothing or to the hot weather or to both. Less clothing and frequent baths will often give relief, but if the baby is very uncomfortable, he may be greatly soothed by being immersed in cool baths containing soda, bran or starch in the following proportions:

=Soda bath.= Two tablespoonfuls of baking soda to one gallon of water.

=Bran bath.= A cheese-cloth bag about six inches square, partly filled with bran, is soaked and squeezed in the bath water until it is milky.

=Starch bath.= About eight ounces of cooked laundry starch to one gallon of water.

No soap should be used while the baby has prickly heat and after the bath he should be patted thoroughly dry and powdered with some such soothing powder as the following:

Powdered starch one ounce Oxide of zinc one ounce Boracic acid powder 60 grains

As we look back over these pages of somewhat detailed description of the case of the baby, it is borne in upon us that the nursing of this unfailingly delightful and interesting little patient has special adjustments and adaptations for different seasons and circumstances; but that on the whole the care of all babies the year around resolves itself into the observation of a few general principles, namely: proper feeding; fresh air; regularity in his daily routine; cleanliness of food, clothing and surroundings; maintenance of an equable body temperature and conservation of his forces.

If the nurse fixes these principles firmly in her mind and acts upon them, she will do a great deal to give her baby patient a fair start on his life’s journey.