CHAPTER XXIII
COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY
The common ills of early infancy are due largely either to errors in feeding or to infection or both. Of the nutritional disturbances, rickets and scurvy were discussed in the chapter on nutrition, but the obstetrical nurse will sometimes see also, malnutrition, marasmus, inanition, diarrheal diseases, acidosis, colic, constipation and vomiting.
All of these disorders are practically preventable through suitable feeding, good care and hygienic surroundings. The nurse’s part in this prevention consists in giving the painstaking care which was described in the preceding chapter.
The terms _malnutrition_, _marasmus_, and _inanition_ designate different forms and degrees of starvation, and are characterized by loss of weight, prostration, feeble powers of assimilation, general weakness and arrested growth. The temperature is likely to be low, but in acute inanition, a rapid loss in weight may be accompanied by a sudden rise in temperature. (Charts 6, 7, and 8.)
These so-called “wasting diseases” are frequently seen in children who have congenital nervous instability and those born of tuberculous, syphilitic or otherwise delicate parents. The treatment is suitable food; fresh air and sunshine; an abundance of fluid by mouth, rectum, subcutaneously or intraperitoneally; clean surroundings and good nursing care.
THE DIARRHEAL DISEASES
These are among the most frequent and most serious illnesses of early infancy. They may result from mechanical causes, such as a mass of undigested food, which produces increased intestinal secretion and peristalsis; from the action of bacteria, or their toxins, together with the inability of an enfeebled digestive tract to meet the needs of a rapidly growing body; or from such reflex causes as sudden chilling of the body, excitement, fatigue or the prostration resulting from excessively hot weather.
=Acute gastro-enteritis=, the diarrheal disease which is so common and so fatal during the hot months of July and August, is often referred to as “summer complaint” or “summer diarrhea.” It is so largely avoidable through good nursing that the methods of its prevention were described in connection with the care of the baby during the Summer, resolving itself, as it does, into feeding the baby properly and keeping him clean and cool and quiet.
=Symptoms.= While there are different forms of summer diarrhea, the general symptoms are much the same and may develop gradually after some evidence of indigestion, or suddenly with a rise of temperature to 101° F. or 102° F., or even as high as 106° F., accompanied by pain and vomiting. The baby is usually restless, fretful and thirsty and his skin is hot and dry. He gives evidence of pain by shrill crying, drawing up his legs and flexing them on his abdomen. Diarrhea is the conspicuous symptom and there may be anywhere from four to twenty movements in the course of 24 hours. The stools are largely fecal matter at first but they finally become fluid and contain mucus. They may be expelled with a good deal of force and a quantity of gas come with them. The baby grows very weak, thin and hollow-eyed, if the diarrhea persists and unless promptly treated the end may be fatal.
=Treatment and Nursing Care.= The first step is to stop all food and to give water freely. When water is not retained by mouth it is frequently given by rectum, into the tissues or intraperitoneally. The pain may be relieved by applying hot stupes.
Feeding is resumed very gradually and cautiously for one attack of summer complaint predisposes to another and every precaution is taken to prevent a recurrence. Thin barley water or broth is usually given first, followed by whey, protein milk, buttermilk or diluted skim-milk in small amounts and at comparatively long intervals.
The baby should be lightly clad; should be kept quiet and in a cool, shady place out-of-doors as much as possible. During the warmest part of the day, however, he will often be much better off and more comfortable in the house, in a room with the shutters closed. But while keeping the baby cool, the nurse must bear in mind the harm that will be done by chilling him or exposing him to a cold draft or wind. Several tub baths, daily, are often given, at a temperature of 100° F., rather than cool sponge baths because of the baby’s feebleness and inability to react to cool bathing. Packs are also employed, both for high temperature and restlessness and may be cool (80° F.), tepid (100° F.) or hot (105° F. to 108° F.) according to the doctor’s orders; intestinal irrigations; lavage and gavage.
To give a =pack=, the nurse will cover the bed with a rubber and sheet and bring to the bedside a basin containing a sheet wrung from water of the specified temperature; a basin containing ice and compresses for the baby’s head, and a flannel covered hot-water bottle at 120° F., for his feet. The baby is laid on the upper half of the folded wet sheet, and an upper corner wrapped about each arm (Fig. 177), and the sides folded around his legs. The lower half is brought up between his feet to cover his entire body and tuck around his shoulders. The hot-water bottle is placed at his feet and an ice compress on his head. (Fig. 178.) If the sheets are wrung from warm or hot water, the baby is covered with a blanket after he is put into the pack.
=Intestinal irrigations=, of normal salt solution are often given to babies suffering from intestinal disorders, sometimes once or twice daily to wash out the lower bowel, or a cool irrigation may be given to reduce temperature, the amounts varying from ½ to 2 gallons of solution. The baby should be placed on a pillow and rest on a bed-pan, being protected from chilling as for, an enema (See Fig. 186), and provision made for a two-way flow of the fluid. A small catheter attached by means of a connecting glass nozzle to the tubing on the irrigation bag may be passed into a slightly larger catheter, which is inserted into the rectum about six inches, the fluid flowing in through the small inner tube and out through the larger one which encases it. Or a small catheter for the outflow may be inserted in the rectum alongside the one through which the solution is introduced. Normal salt solution, glucose or bicarbonate of sodium solution are sometimes given by the drip method at the rate of 20 to 40 drops per minute. In this case a glass tube is introduced at some point in the rubber tubing in order that the rate of flow may be watched and regulated by means of a clamp or a stop-cock. The catheter is inserted in the rectum about six inches and held in place by strips of adhesive plaster.
=Lavage= and =Gavage=. Sometimes when the baby vomits persistently the stomach is washed out and a small amount of water or nourishment given before the tube is withdrawn. A tray containing the following articles should be carried to the bedside:
A glass funnel attached to a rubber tubing which connects with a small rubber catheter by means of a glass nozzle.
Basin to receive stomach contents.
Small rubber, towel and curved basin to place under baby’s chin.
Glass graduate containing warm water for washing out stomach.
Food or solution which is to remain in stomach, standing in cup of warm water.
Glycerin to lubricate tube.
Mouth gag, if necessary, or roll of bandage to hold jaws apart.
The baby should be wrapped tightly (Fig. 180) to prevent interference by his struggling and turned slightly to the left side. (Fig. 181.) The catheter is lubricated with glycerin or water and passed back over the tongue and quickly downward until an air bubble is heard as it enters the stomach. The length of tubing which is to be inserted may be anticipated by marking a point on the tube which is the same distance from the end as the baby’s mouth is from its umbilicus. The possibility and the serious consequences of introducing the tube into the trachea instead of into the esophagus must be borne in mind. Although the baby will often choke and struggle when the tube is properly introduced, he will not cough violently and stop breathing as he will if it enters the air passage. Further information is obtained by inverting the funnel in a basin of water after the tube is inserted; if it is in the stomach there will be no result, but if it is in the trachea air will be expelled and bubbles will rise through the water. To wash out the stomach, the funnel is filled with warm water and slightly raised so that the water will run in slowly, after which the funnel is turned upside down into a basin which is lower than the baby’s body, and the stomach contents allowed to run out. This is repeated four or five times, or until the solution returns clear, and the food which is to remain in the stomach is poured in slowly. Before the tube is quite empty it is pinched off with the fingers and quickly withdrawn.
=Acidosis.= The diarrheal diseases are sometimes complicated by acidosis, a condition in which the relative amounts of acid in the blood are so increased that the normal alkalinity is markedly diminished. This condition may result from an excessive intake of acids; an overproduction of acids in the course of normal metabolism; a decrease in the reserve of normal alkali in the body or a failure in the mechanism by means of which excessive acids are usually neutralized or eliminated. Acidosis is a serious complication and often fatal.
The treatment is directed toward preventing the production of more acids within the body; restoring the alkali reserve and promoting elimination of the excessive acids and their salts. Solutions of glucose, bicarbonate of sodium and salt are used and are given by mouth, rectum, intravenously and intraperitoneally. Subcutaneous injections are not wholly satisfactory, because of the small amounts which may be given in this way. From 150 to 400 cubic centimetres are given into the peritoneal cavity and as the solution absorbs readily these injections are sometimes repeated every eight or twelve hours, an infusion bottle and short infusion needle being used. From 75 to 300 cubic centimetres of glucose solution (5 per cent. or 10 per cent.) is given intravenously, while as much as 1000 cubic centimetres is sometimes given per rectum in the course of 24 hours by the drip method. Soda solution (4 per cent.) is often given by mouth, if the baby is able to retain it, or intravenously, as frequently as the condition of the urine indicates is necessary. From 75 to 100 cubic centimetres is given at one time to young babies.
In preparing the soda solution it must be remembered that boiling drives off carbonic acid and forms sodium carbonate and that its reconversion into sodium bicarbonate is a complicated procedure. Howland and Marriott[16] say in this connection: “Oscar Schloss has found that sodium bicarbonate in bulk is always sterile. It is probably therefore sufficient to add the bicarbonate with proper precautions to sterile water.”
Since the results of urine tests frequently indicate the treatment in acidosis, it is of very great importance that the nurse be able to obtain specimens from young babies. (Figs. 182, 183, 184 and 185 for methods of obtaining fresh and 24–hour specimens from babies.)
=Colic=, =Constipation=, =Convulsions= and =Vomiting= so frequently seen in young babies are symptoms rather than diseases.
=Colic= usually consists of paroxysms of pain in the stomach or intestines, due to distension or to spasmodic, muscular contractions. The indirect cause may be unsuitable food or food given too rapidly; chilling of the surface of the body, excitement or fatigue. The distension may be due to air swallowed by the baby while nursing or gas formed by carbohydrate fermentation. Excess of protein may form an irritating mass in the intestines and cause a cramp.
While colic frequently accompanies malnutrition and constipation, it is often seen in otherwise well and happy babies, and usually before the fifth month. The attacks are usually sudden and may occur several times a day after feeding, or only in the late afternoon or at night. The baby cries shrilly; his face is drawn and may be flushed, from crying, or cyanotic; his fists are clenched and pressed to his body and his feet and hands are cold. His abdomen is hard and distended and during a pain the baby flexes his thighs upon it and afterward extends them with a jerk. This painful seizure may last only a few moments or it may persist for hours, leaving the baby exhausted.
The chief preventive measures are found in the precautions and attention to detail which have been described, and which should be included in the care of all babies. In a bottle-fed baby it is often found that recurrence of attacks of colic may be averted by a slight change in the milk formula; by giving more water to drink; by lengthening the intervals between feedings; by giving the milk more slowly or by omitting the 2 a.m. feeding, thus giving the baby more digestive rest.
With breast-fed babies, prevention is often accomplished by having the mother nurse her baby more slowly, lengthening the intervals and by improving her own hygiene; particularly by increasing her recreation and out-of-door exercise and relieving constipation. Women who lead sedentary lives and eat rich food very often have colicky babies as do those who are nervous, irritable and inclined to worry. (See chapter on the nursing mother.)
When attacks of colic occur, the pain usually may be relieved by giving half of a soda-mint tablet in a little warm water and an enema of about eight ounces of soap-suds or salt solution at 110° F., given through a small catheter inserted about six inches. The baby will experience almost immediate relief through the expulsion of gas and feces and he may be made still more comfortable by placing a hot-water bag at his cold feet; rubbing his abdomen with vaselin and applying hot stupes. Sometimes the first feeding which falls due after an attack is omitted and a little warm water or barley water is given instead, in order that the digestive tract may rest.
=Constipation= is very common among young infants and may be manifest by the stools being too small, too dry or too infrequent. The commonest causes are:
1. =Faulty diet=—possibly too much protein or too little fat or sugar. 2. =Intestinal atony=, due to undernourishment, rickets or anemia. 3. =Anal fissure= which makes the baby unwilling to empty his bowels because of pain. 4. =Absence of habit= of emptying the bowels regularly.
The prevention of this very troublesome condition lies largely in suitable food; constant fresh air; regularity in the daily routine and training the baby to empty his bowels at the same time every day.
When constipation is due to insufficient fat in the food, cod-liver oil is sometimes given, 15 to 30 drops three or four times a day; or a teaspoonful of olive oil two or three times a day. Maltose, malt soup, malted milk, milk of magnesia, liquid petrolatum, oatmeal-water and orange juice are all found among the remedies for constipation; while soap sticks, suppositories and enemata of oil or soap-suds sometimes have to be resorted to.
In giving an enema to relieve constipation, the baby should be protected from chilling, laid on a pillow and the pan so placed that he will be comfortable and not inclined to move, and from 100 to 300 cubic centimetres of soap-suds, at 105° F., given with a small hard-rubber nozzle. (Fig. 186.) When warm olive oil is given at night (1 to 2 ounces through a catheter introduced about 6 inches), it is very often retained and the feces so softened that the baby empties his bowels freely the next morning with little or no assistance.
Abdominal massage will often help to increase the intestinal tone and make peristalsis more vigorous. The abdomen should be rubbed with a circular stroke, beginning in the right groin and following the course of the colon up to the margin of the ribs, across to the left side and down to the groin. This is often given for about ten minutes every day, preferably at night but never just after a feeding.
Constipation is sometimes entirely cured by a suitable dietary; an abundance of drinking water; an out-of-door life; massage, and above all, the unremitting effort to establish a regular habit. The latter is the nurse’s responsibility and she should exercise the greatest patience in trying to accomplish the desired end.
=Convulsions= are a symptom of several disorders of early infancy, which may occur unexpectedly and which the nurse may suddenly be called upon to relieve in the absence of the doctor. Convulsions may be due to brain lesions; to spasmophilia or a special tendency to convulsive disorders; gastro-intestinal disorders; toxemia or syphilis. They may be the initial symptom of an acute infectious disease or may occur on slight provocation in a frail, undernourished baby or one suffering from rickets or tetany. For this reason one sometimes sees convulsions in a baby who is teething or has colic or indigestion.
As convulsions are a symptom of some abnormal condition, the doctor will often prescribe a sustained treatment designed to remove or relieve the cause. But when an attack occurs unexpectedly, and the doctor cannot come at once, the nurse may often terminate the seizure by employing measures that will quiet and relax the struggling baby. The room should be quiet and darkened and the baby handled with utmost gentleness because of the extreme irritability of his nervous system. As a rule, the most satisfactory course is to immerse the baby in water at 100° F., and keep him there for five or ten minutes, supporting his head and shoulders meantime. Someone else should place cold compresses on his head and change them frequently. When removed from the bath, the baby should be wrapped in a blanket, kept very quiet and the cold applications to his head continued.
When it is known that the convulsions are due to indigestion the stomach is often washed out and a high colonic irrigation given before the baby is quieted by the bath. In tetanoid convulsions the baby may take a long deep inspiration and fail to expire. Respirations should be stimulated, in such a case, by spanking him sharply or by dashing cold water on his face and chest. When the attacks are recurrent the nurse may be instructed to terminate them by giving the baby a few whiffs of chloroform, which, with an inhaler is kept in readiness for instant use.
Mustard baths and packs are sometimes given when the need for counter irritation is indicated. For a bath, one ounce, or six level tablespoonfuls of dry mustard is added to one gallon of water at 105° F. and the baby kept in it for about ten minutes, or until the skin is well reddened. He is then wrapped in a warm blanket and surrounded by hot-water bottles, with cold compresses applied to his head. The mustard pack is given in the manner of other packs, with a sheet wrung from mustard water which is possibly a little warmer and stronger than that for the bath, care being taken that the sheet is not cooled before it is wrapped about the baby. He is usually left in the pack for about ten minutes or until his skin is reddened, and then wrapped in warm blankets, with cold compresses to his head.
It is often helpful to the doctor if the nurse is able to describe the onset of the convulsions and tell him where the twitching began, how it progressed and whether or not it was preceded by a cry.
=Vomiting= during early infancy is a symptom of any one of several conditions, the nature of which sometimes may be revealed by the character of the attacks. The commonest causes and varieties of vomiting are as follows:
1. =Too rapid feeding= or =too large amounts of food= given at one time. The vomiting amounts to little more than regurgitation and is often induced by moving or handling the baby immediately after feeding him.
2. =Acute gastric indigestion.= Sour stomach contents may be vomited immediately after feeding, or not until several hours later and may be followed by mucus and bile. The baby is usually pale, particularly about the mouth; he may perspire about the forehead and give evidence of pain, being relieved by the vomiting.
3. =Stenosis of the pylorus.= The vomiting from this cause is projectile in character and may occur immediately after food is taken into the stomach, or, some time later without apparent cause, a larger amount of fluid may be expelled than was given at the preceding feeding. The vomiting may begin a few days after birth or several weeks afterwards in a baby who has been well previously.
4. =Intestinal obstruction= due to congenital obstruction, which causes persistent vomiting from birth; or due to intussusception of the intestines, when vomitus consists first of stomach contents which later becomes bile stained and sometimes contains fecal matter, blood and mucus. It is attended by prostration, and after fecal matter is passed at the beginning, there is frequent evacuation of blood and mucus.
5. =Chronic= or =habit vomiting=, sometimes occurring in early infancy, may be difficult to control because of being incited by such slight causes as laughing, crying or being moved.
In addition to being caused by the above mentioned conditions, vomiting in young babies may usher in an acute infectious disease, as a chill does in an adult, or it may accompany such diseases as peritonitis, meningitis, brain tumors and toxic conditions such as uremia.
INFECTIONS
The infectious diseases which the obstetrical nurse is most likely to see in her baby patient are ophthalmia neonatorum; syphilis; impetigo; pemphigus and vaginitis.
=Ophthalmia Neonatorum=, inflammation of the eyes of the new-born or “babies’ sore eyes,” is one of the common diseases of infancy and certainly one of the most dreaded because of the tragedy of lifelong blindness which may follow in its wake. In the early days of organized work for the prevention of blindness the term “ophthalmia neonatorum” implied a gonorrheal infection, but it is now known that inflamed eyes and subsequent blindness may result from infection of innocent origin. Accordingly, in those states where it is required that the disease be reported, ophthalmia neonatorum is defined as inflammation of the eyes of new-born babies, irrespective of the cause. The disease is frequently due to the gonococcus, the baby’s eyes being infected from the mother during passage through the birth canal or infected later by her hands or clothing. Or the inflammation may be caused by the streptococcus, pneumococcus or the colon, diphtheria, or influenza bacilli while very frequently the infection is mixed.
It is estimated that about 20 out of every 1000 new-born babies have sore eyes, and though many of the infections are mild, between 5 and 8 of these 20 cases are capable of becoming serious and causing blindness if not speedily and skillfully treated. The number of cases which are neglected is suggested by the fact that about 10 per cent. of all blindness, the world over, is due to infant ophthalmia and that about 20 per cent. of the inmates of schools for the blind in this country are sightless from this cause. This does not take into account the unnumbered army of those who are partially blind, or blind in one eye, and thus seriously handicapped, as a result of this disease.
=Symptoms.= The first symptoms are redness and swelling of the lids, usually accompanied by a discharge of pus from the beginning, and they ordinarily appear during the first few days of life, but sometimes develop as late as the second or third week. The disease may run a very rapid course and cause blindness in 48 hours from the time the first symptoms appear, or it may persist for weeks. Ulceration of the cornea is the dreaded consequence of the inflammation as ulcers are followed by scars. When the scar is small, or to one side of the pupil, there may be little or no impairment of vision, but if it is large and centrally located it forms an opaque screen and causes blindness by shutting out the light, although the interior of the eye behind the scar is sound and uninjured. Sometimes the ulcer causes a perforation of the cornea through which the lens and vitreous humor are discharged.
Attempts have been made to remove the scar following a centrally located ulcer and replace it with a clear cornea from some such animal as a guinea pig, but the operation apparently has not been perfected. When it is, many blind persons may have their sight restored to them.
=Prevention.= It may be stated almost without qualification that ophthalmia neonatorum is a preventable and curable disease, and accordingly that blindness from this cause is inexcusable. Prevention lies first, in wiping the baby’s eyes immediately after birth and instilling a drop or two of a silver salt, such as nitrate of silver, argyrol or protargol, or bathing them with boracic acid solution; and second, in close watching for early symptoms and giving speedy treatment when they appear. This is urgent because there is no way of determining in the beginning whether the infection is mild or virulent. Nitrate of silver solution, 1 per cent., is the prophylactic most commonly employed and its use is now routine in most hospitals and in the practices of many physicians in this country. The solution is sometimes dropped between the baby’s lids, immediately after the birth of the head, and before the birth of the entire body, and sometimes immediately after delivery is completed. Many doctors follow the silver drops with normal salt solution to prevent the slight silver catarrh which so frequently occurs otherwise, and which may be confused with early symptoms of ophthalmia. Still others prefer simply to bathe the eyes with boracic acid solution (unless they know that the mother has gonorrhea) and to watch them closely for the slightest redness, swelling or discharge and give prompt treatment if these appear.
The Credé method, made famous by the Viennese obstetrician who introduced it in 1881, was to drop from a glass rod, a single drop of nitrate of silver, 2 per cent., into each eye immediately after birth. The routine use of this prophylaxis reduced the occurrence of ophthalmia in Credé’s clinics from 10 per cent. to .1 per cent. among the new-born babies.
Since it is now believed that close vigilance and subsequent care are equally as important as the prophylactic drops, the Credé treatment has been variously modified and other and weaker silver solutions are frequently used, and with satisfactory results. The dropping of a germicide into the baby’s eyes kills the organisms which may be present at the time, but it does not protect against subsequent infection. For this reason the nurse cannot be charged too earnestly to watch the baby’s eyes closely for the first evidence of infection, and report it to the doctor immediately, day or night, for the late infections are as destructive of sight as those which occur before or during birth.
=Treatment and Nursing Care.= The treatment and nursing care in ophthalmia frequently require the greatest skill. There may be merely an application of silver and sponging with boracic acid solution or a gentle irrigation with a blunt nozzle (Fig. 187), or the preservation of the baby’s sight may necessitate dressings and treatment which will require elaborate preparation (Fig. 188), and may also require some form of treatment every quarter- or half-hour, day and night and occupy the entire time of two or three special nurses. The nurse’s duties in caring for the eyes will be explicitly defined by the doctor, but in general she must remember that she is nursing a baby suffering from an acutely infectious disease, who should be strictly isolated, and that as a rule she should wear a gown, rubber gloves and protective goggles while caring for him. All of her attentions to the inflamed eyes must be given with the _greatest gentleness_ in order to avoid abrasion of the conjunctiva or injury of the cornea. Moreover, the baby with suppurative conjunctivitis is a sick baby often fighting for his life as well as his sight, and every effort must be made to preserve his strength and increase his resistance. Fresh air and careful feeding are imperative. Breast-fed babies have a distinct advantage over bottle-fed babies and for this reason the mother should always accompany the nursing baby if he is taken from his home to a hospital to be treated for ophthalmia neonatorum, unless there is a wet nurse available at the hospital.
It is of interest to nurses that the effort to safeguard the eyes of babies through preventive treatment and early care was developed into a national movement by one who also was influential in starting the training of nurses in this country, Miss Louisa Lee Schuyler. The lay work for the prevention of blindness, which is now country-wide, was started by the New York State Committee for Prevention of Blindness, which was organized by Miss Schuyler in 1908. She was its first Chairman and skillfully directed the work of the Committee for ten years. During the Civil War Miss Schuyler was a member of the Sanitary Commission and afterwards was one of the group which was responsible for starting at Bellevue Hospital, in New York City (in May, 1873), the first training school for nurses in this country, planned in accordance with Miss Nightingale’s standards for the organization and conduct of a school for nurses. Later, in 1911, the Bellevue School for Midwives was established as a result of the combined efforts of the Hospital Trustees and Miss Schuyler’s Committee for Prevention of Blindness, the course of training being outlined by a sub-committee composed of Miss Lillian D. Wald, Dr. J. Clifton Edgar and myself. So far as it is possible to learn this school was the first in this country to be conducted along the lines of a school for nurses, or after the manner of the midwife schools in England.
=Syphilis=, which ranks high among the scourges of mankind, is seen with distressing frequency among young babies. It may be contracted during uterine life, when it is said to be “inherited,” or it may be “acquired” after birth by kissing a syphilitic person or coming in contact with contaminated articles, such as clothing, or nursing from a diseased breast.
The most conspicuous symptoms are the familiar “snuffles;” the scaling, fissures or eruption on the soles, palms, buttocks and about the mouth; shrill, hoarse crying; swollen painful joints; partial paralysis and a general feebleness and inanition. Some or all of these symptoms may be present when the baby is born or they may develop any time within the first two or three months of life.
Babies of syphilitic mothers are often given mercurial inunctions immediately after birth, even though they have no symptoms of the disease as it is very likely to be present in a latent form. This is one reason for the routine inspection of the placenta, since in it is sometimes found the only indication for treating the baby. An infant who is known to have syphilis is given mercurial inunctions or baths, the ointment being rubbed into the groin, axilla, back and abdomen in rotation on successive days, to prevent irritation of the skin. The nurse should protect herself with rubber gloves, wash the area with warm water and soap and thoroughly rub in the ointment. Sometimes the ointment is put on the inside of the back of the baby’s binder, by which means he rubs it in himself. The syphilitic baby should be isolated and should not be put to the breast of an uninfected woman, but he may nurse from a syphilitic woman without harm to either her or himself. Good general care, including fresh air and sunshine are important to the baby suffering from syphilis.
=Thrush= or =Sprue= is a highly communicable disease of the mouth of new-born babies, due to one of the fungi. It is common among sickly, undernourished babies and those living in unhygienic surroundings, but it is seldom seen in healthy babies who are cared for with absolute cleanliness. The disease is characterized by small raised, white spots in the baby’s mouth, frequently on the back of the tongue and inner surface of the cheeks.
Prevention lies in good care and in cleanliness of the mother’s nipples, or the bottles and nipples for artificially fed babies, and of all other articles coming in contact with the baby, particularly his mouth. Some doctors have the baby’s mouth bathed before each feeding, as a preventive measure, while others feel that a gentle swabbing once daily is sufficient, if the nipples are kept clean, since an abrasion of the mucous lining is easily caused and is favorable to the development of thrush.
Treatment consists in cleanliness and in gently swabbing the spots, three or four times a day, with sterile cotton wet with an alkaline solution such as borax (10%), bicarbonate of sodium (6%) and sometimes with formalin (1%) or a weak solution of permanganate of potassium.
=Impetigo= and =Pemphigus= are highly infectious skin diseases of early infancy which are seen more often in hospitals than in patients’ homes. The treatment of the raised blisters that appear on different parts of the body is entirely a medical question, but in caring for the patients suffering from either of these infections the nurse must take every precaution to avoid extending the trouble on the skin of the infected baby, himself, and of communicating it to other babies in the ward. Strict isolation is imperative; gentle handling and frequent changing of the underclothing to prevent extending the disease to uninfected areas.
=Vaginitis.= This highly infectious malady is considered troublesome rather than serious, as a rule, though it may be complicated by ophthalmia or arthritis. Gonorrheal vaginitis is the commonest form seen in early infancy and may be due to infection which the baby acquired during its passage through the birth canal or later from the mother’s hands or clothing. The symptoms are a vaginal discharge, which may be thin and serous or thick and yellow and purulent and it may be scanty in amount or abundant; a reddened, swollen condition of the vagina and vulva and sometimes redness and excoriation of the inner surface of the thighs. The nurse’s chief responsibilities are to be constantly on the alert to detect evidences of the disease and report them promptly to the doctor, and to observe strict isolation in caring for the baby while carrying out the doctor’s orders for douches or suppositories.
COMMON ABNORMALITIES OF THE NEW-BORN
=Icterus= or =Jaundice=, which is so frequently seen in new-born babies, is occasionally a symptom of some septic condition; of syphilis or congenital cirrhosis of the liver or obstruction of the bile ducts, but as a rule it is without any serious significance. The jaundiced appearance usually begins on the second or third day and may continue for two or three weeks or it may subside in three or four days. The depth of the color varies, being very pale in some cases and almost green in others. When this discoloration of the skin is unaccompanied by other symptoms, no treatment is given.
=A Cephalhematoma= is a tumor of blood between the periosteum and the bones of the skull of the new-born baby. It is often due to some injury sustained during birth and is most frequently seen after prolonged labors. Cephalhematoma is sometimes confused with a caput succedaneum, but whereas the caput disappears in a few days the cephalhematoma may not be entirely absorbed for two or three months. Although certain conditions sometimes indicate the advisability of surgical treatment, the nurse’s care consists solely of protecting the tumor from injury.
=Club foot= is one of the commonest deformities of the extremities of young babies, occurring once in about every 1000 births. It may be congenital or caused by injury or it may be due to such diseases as cerebral paralysis or poliomyelitis. The nurse should watch for any abnormality in the structure or position of the feet, for the earlier treatment is started, the better is the prospect of a cure.
=Engorgement of the Breasts.= Not infrequently the breasts of new-born babies are engorged, in which state they are easily infected by being rubbed or squeezed. Since the greatest care must be taken to avoid bruising swollen breasts, they are sometimes protected by the application of a pad of sterile cotton. Hot compresses are sometimes applied when there is redness with the swelling, or a tiny ice-bag, made by tying off the fingers and thumb of a rubber glove, and partly filling it with finely crushed ice, after which the wrist is tightly tied.
=Hare Lip.= The fissured lip, which is not infrequently seen in new babies, may consist merely of a small notch or it may amount to a deep cleft reaching up into the nostril. It is due to a non-union of the frontonasal plate with the lateral processes and may occur on one or both sides, thus forming a single or double hare lip. An extensive fissure will usually interfere with suckling and the nurse may need both ingenuity and patience in feeding such a baby, for the prospect of successful treatment, which is surgical, increases with the baby’s age and improved nutrition. The longer she can feed the baby successfully, therefore, the better his chance of recovery.
=Cleft palate=, a common congenital abnormality, consists of a fissure of the soft, and sometimes of the bony, palate; it may be on one or both sides and may be continuous with a hare lip. The problem of feeding the baby with a cleft palate is very grave since the fissure may make it impossible for him to form the vacuum in the back of his mouth which is necessary for suckling. He is sometimes fed with a medicine dropper or by gavage or by means of a special nipple provided with a flap which fits into the roof of the mouth and closes the opening into the nasal passages. Even more than in the care of the baby with a hare lip is it important to nourish the baby with a cleft palate, and build him up for as long as possible before he is subjected to the strain and shock of the inevitable operation.
=Hernia.= Umbilical and inguinal hernias are both seen in young babies.
=Umbilical hernia= is the commoner type and is not uncommon in thin babies and those with indigestion and distension and in babies who cry violently. Such hernias are not regarded as serious if prompt measures are taken to reduce them as they usually respond very readily to treatment. But since neglect may have serious consequences, the nurse should watch for protrusions and report them promptly. She will often be instructed to reduce the hernia and apply adhesive strapping, in which case the following observations by Dr. Griffith will be helpful:
“Usually it is quite sufficient to draw the skin into two folds, one on each side of the hernia and meeting over it; holding these in place by straps of adhesive plaster crossing over the navel, or by a broad horizontal band of adhesive plaster reaching to the lumbar regions. Another method is the following: A silver quarter of a dollar is laid upon the adhesive surface of a piece of rubber plaster about two inches square; over this is placed the broad strap referred to, with its adhesive surface next to that of the smaller piece. After reducing the hernia and pressing the sides of the abdominal walls slightly together the band is applied with the quarter dollar directly over the position of the navel. My own preference is for a simple adhesive band without the use of the coin. The dressing should be worn constantly, changing it from time to time as the old one loosens. The dressing must, of course, not be removed during the bath. Several months are required before the opening is permanently closed. Occasionally the plaster produces a great deal of cutaneous irritation, especially in the first few months of life. The employment of zinc oxid plaster tends to avoid this difficulty.”[17]
=Inguinal hernia= is less common in very young babies but it should be watched for since it usually may be easily reduced by the use of a truss, if discovered and treated early, but may be serious if neglected.
In general, the new baby who is ill, needs the same thoughtful, gentle, painstaking care that the nurse gives to the well baby, but these must be shaped to his immediate requirements and the doctor’s special instructions.