Chapter 8

NERVOUSNESS IN EARLY INFANCY

We may now pass back to consider the nervous system of the child in infancy. There, too, from the moment of birth there are clearly-marked differences between individuals. The newborn baby has a personality of his own, and mothers will note with astonishment and delight how strongly marked variations in conduct and behaviour may be from the first. One baby is pleased and contented, another is fidgety, restless, and enterprising. At birth the baby wakes from his long sleep to find his environment completely changed. Within the uterus he lies in unconsciousness because no ordinary stimulus from the outer world can reach him to exert its effect. He lies immersed in fluid, which, obeying the laws of physics, exercises a pressure which is uniformly distributed over all points of his body. No sound reaches him, and no light. After birth all this is suddenly changed. The sense of new points of pressure breaks in upon his consciousness. Cold air strikes upon his skin. Loud sounds and bright lights evoke a characteristic response. A placid child who inherits a relatively obtuse nervous organisation will be but little upset by this sudden and radical change in the nature of his environment. His brain is readily but healthily tired by the new sensations which stream in from all sides, and he falls straight away into a sleep from which he rouses himself at intervals only under the impulse of the new sensation of hunger.

Babies of nervous inheritance, on the other hand, will show clearly by the violence of the response provoked that their nervous system is easily stimulated and exhausted. They will wriggle and squirm for hours together, emitting the same constant reflex cry. The whole body will start convulsively at a sudden touch or a loud sound which would evoke no response from a more stolid infant. The sleeplessness and crying exhaust the baby, rendering the nervous system more and more irritable, while the sensation of hunger which is delayed in other children by twelve hours or more of deep sleep appears early and is of extreme intensity. We must see to it that sense stimuli are reduced to the lowest possible level. True, we cannot again restore the child to a bath of warm fluid, of the same temperature as his body, where he can be free from irksome pressure and from all sensations of sound and light, but we can so arrange matters that he is not disturbed by loud sounds and bright lights, and that he is not moved more than is necessary. Sudden unexpected movements are especially harmful. Jogging him up and down, patting him on the back, expostulation, and entreaties are all out of place and do all the harm in the world. The first bath should be as expeditious as possible, and above all the baby must not be chilled by tedious exposure. Cold irritates his nervous system more than anything else, unless it be excessive warmth. In preserving the proper temperature so that we do not render the child restless by excess of heat or by excess of cold, we too-civilised people have made our own difficulties. We have exaggerated the completeness of the sudden separation of mother and child which nature decrees. It is the function of all mother animals to approximate the unstable temperature of the newly born to their own by the close contact of their bodies, which provide just the proper heat. Labour is nowadays so complicated and exhausting a process for mothers that, all things considered, we are wise in completing the separation of mother and child and in removing the baby to his own cot. But the difficulty remains, and we must arrange that any artificial heating needed is constant and of proper degree.

If the baby is very restless and irritable, too wide awake and too conscious of his surroundings, the all-important task of getting him to the breast and getting him to draw the milk into the breast is apt to be difficult. His sucking is a purely reflex and involuntary act. It can be produced by anything which gently presses down the tongue, and a finger placed in the proper position will provoke the movement without the child's consciousness being aroused. The placid child whose mind is at rest will suck well and strongly. If, on the other hand, the brain is too much stimulated and the child is restless and irritable, the reflex act of suction is inhibited, and it is a difficult matter to get the child to the breast. He is too eager, mouthing, and gulping, and spluttering. Or sometimes his mental sufferings seem too much for his appetite, and though wide awake and crying loudly, he refuses to grasp the nipple, turning his head away and wriggling blindly hither and thither. This effect of mental unrest on the newborn infant is often disastrous, because it is one of the common causes of the failure of women to nurse their children. This is not the place to sketch in detail a scheme for the proper technique of breast nursing, a matter which is much misunderstood at the present day. It will be enough shortly to say that an efficient supply of milk depends upon the complete and regular emptying of the breast. The breasts of all mothers will secrete milk if strong and vigorous suction is applied to the nipple by the child. If anything interferes with suction, the milk does not appear or, if it has appeared, it rapidly declines in amount. The mother's part is to a great extent a passive one, provided that she can supply one essential--a nipple that is large enough for the child to grasp properly. Within wide limits what the mother eats or drinks, whether she be robust or whether she has always been something of an invalid, matters not at all. A frail woman may naturally not be able to stand the strain of nursing for many months, but that is not here the point in question. We are dealing only with the establishment of lactation and with the milk supply of the early days and weeks which is of such vital importance for the child. If the mother is ill, if, for example, she has consumption, we may separate her from the child in the interests of both; but if this is not done, she will continue to secrete milk for a time as readily as if she were in perfect health, and the breasts of many a dying woman are to be seen full of milk. Mothers are too apt to attribute the disappointment of a complete failure to nurse to some weakness or want of robustness in their own health. This is never the reason of the failure, and the fault, if the mother has a well-formed nipple, is generally to be found in some disturbance in the child. Prematurity, with extreme somnolence, breathlessness from respiratory disease, nasal catarrh, which hinders breathing through the nose, infections of all sorts, are common causes of this failure to suck effectively. But perhaps the most common cause of all is the inhibition from nervous unrest of that reflex act of sucking which works so well in the placid and quiet child. It is a point to which too little attention is paid, and mothers and the books which mothers read commonly neglect the nervous system of the child and devote themselves to such considerations as the relative merits of two-hourly and four-hourly feedings--important points in their way, but less important than this.

The matter is complicated in two other ways. In the first place, the nervous baby, just because he is so active and wakeful and restless, is apt rapidly to lose weight and to have an increased need for food. The restlessness is generally attributed to hunger, and this is true, because hunger is soon added to the other sensations from which he suffers, and like them is unduly acute. It is difficult not to give way and to provide artificial food from the bottle. Yet if we do so we must face the fact that these restless little mortals are quicker to form habits than most, and once they have tasted a bottle that flows easily without hard suction, they will often obstinately refuse the ungrateful task of sucking at a breast which has not yet begun to secrete readily. The suction that is devoted to the bottle is removed from the breast, and the natural delay in the coming in of the milk is increased indefinitely. At the worst, the supply of milk fails almost at its first appearance. We must devote our attention to quieting the nervous unrest by removing all unnecessary sensory stimulation from the baby. He must be in a warm cot, in a warm, well-aired, darkened, and silent room, and the necessary handling must be reduced to a minimum. Sometimes sound sleep will come for the first time if he is placed gently in his mother's bed, close to her warm body. If he is apt to bungle at the breast from eagerness and restlessness, it is not wise always to choose the moment when he has roused himself into a passion of crying to attempt the difficult task. So far as is possible he should be carried to the breast when he is drowsy and sleepy, not when he is crying furiously, and then the reflex sucking act may proceed undisturbed.

In the second place, we must guard against the ill effect which the ceaseless crying of these nervous babies has upon the mother. She may be so exhausted by the labour that her nerves are all on edge, and she grows apprehensive and frightened over all manner of little things. The tired mother is apt to fear that she will have no milk, and her agitation grows with each failure on the part of the child. Now the first secretion of milk is very closely dependent upon the nervous system of the mother. We have said that within wide limits her physical condition is of less importance, but her peace of mind is essential. And so it is wise for some part of the day to keep the nervous baby out of hearing of the mother, and so far as possible to choose moments when the child is quiet to put him to the breast. A nurse with a confident, hopeful manner will effect most; a fussy, over-anxious, or despondent attitude will do untold harm. We shall sometimes fail if the nervous unrest is very obstinate either in mother or in child, but we shall fail less often if we diagnose the cause correctly in the cases we are considering. Lastly, it is possible to control the condition in both mother and child by the careful use of bromide or chloral.

It is not, of course, suggested that these drugs should be given freely or as a routine to every hungry baby wailing for the breast, or that we can hope to combat or ward off an inherited neuropathy by a few doses of a sedative. There are, however, not a few babies in whom there develops soon after birth a sort of vicious circle. They can suck efficiently and digest without pain only when they sleep soundly. If they are put to the breast after much crying and restlessness, each meal is followed by flatulence, colic, and renewed crying. The only effective treatment is to secure sleep and to carry a slumbering or drowsy infant to the breast. Then the sucking reflex comes to its own again, the breast is drained steadily and well, and digestion proceeds thereafter without disturbance and during a further spell of sleep. Two or three times in the day we may be forced, as meal-time approaches, to cut short the restlessness of the child by giving a teaspoonful of the following mixture:

Pot. brom., grs. ii. [2 grains]

Chloral hydrate, gr. i. [1 grain]

Syrup, M x. [10 minims]

Aq. menth. pip., ad 3 i. [1 dram]

After this has been taken the child should be laid down for a quarter of an hour until soundly asleep. Then very gently he can be carried to his mother and the nipple inserted. If in this way a few days of sound sleep and less disturbed digestion can be secured, the difficulty will in most cases permanently be overcome. The steadier suction and more efficient emptying of the breast will promote a freer flow of milk, and the deeper and more prolonged sleep will lower greatly the needs of the child for food. Most of the babies who show this fault are thin, meagre, and fidgety, and with some increase of muscular tone. The head is held up well, the limbs are stiff, the hands clenched, the abdomen retracted, with the outline of the recti muscles unusually prominent. If we can relax this exaggerated state of nervous tension, if we can help them to become fatter and to put on weight, the dyspepsia will disappear with the other symptoms.

It is a question still to be answered whether the rare conditions of pyloric spasm and pyloric hypertrophic stenosis are not further developments of the same disturbance. Certainly these grave complications appear most commonly in infants with a pronounced nervous inheritance, and, as might be expected, they are more commonly found in private practice than among the hospital classes.

In passing, we may note that there are babies who exhibit the opposite fault, and in whom the contrary regimen must be instituted. Premature children, children born in a very poor state of nutrition, and children born with great difficulty, so that they are exhausted by the violence of their passage into the world, are apt to show the opposite fault of extreme somnolence. They are so little stimulated by their surroundings, and they sleep so profoundly, that the sucking reflex is not aroused. Put to the breast they continue to slumber, or after a few half-hearted sucking movements relapse into sleep. We must rouse such children by moving them about and stirring them to wakefulness before we put them to the breast.

Once the child has been got to the breast, once the milk has become firmly established, we have overcome the first great difficulty which besets us in the management of nervous little babies, but it is by no means the last. Restlessness and continual crying must be combated or digestion suffers, and may show itself in a peculiar form of explosive vomiting, which betokens the reflex excitability and unrest of the stomach.

The sense of taste is as acute as all other sensations. If the child is bottle-fed, the slightest change in diet is resented because of the unfamiliar taste, and the whole may promptly be rejected. The tendency to dyspeptic symptoms is apt to lead to much unwise changing of the diet, and everything tried falls in turn into disrepute, until perhaps all rational diets are abandoned, and some mixture of very faulty construction, because of its temporary or accidental success, becomes permanently adopted--a mixture perhaps so deficient in some necessary constituent that, if it is persisted with, permanent damage to the growth of the child results. We must pay less attention to changes of diet and explore our management of the child to try and find how we can make his environment more restful.

It is wise to accustom a nervous child from a very early age to take a little water or fruit juice from a spoon every day. Otherwise when breast-feeding or bottle-feeding is abandoned one may meet with the most formidable resistance. Infants of a few months can be easily taught; the resistance of a child of nine months or a year may be difficult to overcome. The difficulty of weaning from the breast recurs with great constancy in nervous children. By this time the influence of environment has become clearly apparent. The child is often enough already master of the situation, and is conscious of his power. Such children will sometimes prefer to starve for days together, obstinately opposing all attempts to get them to drink from a spoon, a cup, or even a bottle. When this happens, sometimes the only effective way is to change the environment and to send the baby to a grandmother or an aunt, where in new surroundings and with new attendants the resistance which was so strong at home may completely disappear. When weaning is resented, and difficulties of this sort arise, it is clear that the mother, whose breast is close at hand, is at a great disadvantage in combating the child's opposition.

For nervous infants, alas! broken sleep is the rule. What, then, is to be done? It is astonishing to me that any one who has studied the behaviour of only a few of these nervous and restless infants should uphold the teaching that the crying of the young infant is a bad habit, and that the mother who is truly wise must neglect the cry and leave him to learn the uselessness of his appeals. It is true that the youngest child readily contracts habits good or bad. Either he will learn the habit of sleep or the habit of crying. Mercifully the inclination of the majority is towards sleep. But to encourage habits of restlessness and crying there is no surer way than to follow this bad advice and to permit the child to cry till he is utterly exhausted in body and in mind. It is unwise _always_ to rock a baby to sleep; it is also unwise to allow him to scream himself into a state of hysteria. A quiet, darkened room, the steady pressure of the mother's hand in some rhythmical movement, will often quiet an incipient storm. The longer he cries, the more trouble it is to soothe him. Sleep provokes sleep, so that often we find restlessness and sound sleep alternating in a sort of cycle, a good week perhaps following a bad one. The nurse who is quick to cut short a storm of crying and to soothe the child again to sleep is helping him to form habits of sleep. The nurse who leaves him to cry, believing that in time he will of his own accord recognise the futility of his behaviour, is making him form habits of crying. A rigid routine in sleep is a good thing, but the routine belongs to the baby, not to the nurse. The child must be educated to sleep, not taught to cry. A baby has but little power of altering his position when it becomes strained or uncomfortable. He cannot turn over and nestle down into a new posture. If we watch him wake, the first stirring may be very gradual, and in a moment he may fall again to sleep. A few minutes later he stirs again more strongly, and is wider awake and for longer. It may only be after a third waking, by a summation of stimuli, that he is finally roused and breaks into loud crying. The nurse who is on the watch, who, sleeping beside him, wakes at the slightest sound and is quick to turn him over and settle him into a new position of rest, will probably report in the morning that the baby has had a good night. The nurse who lets the child grow wide awake and start crying loudly, will spend perhaps many hours before quiet is again restored. Of the voluntary, purposive crying of infants a little older I am not here speaking. Infants in the second six months are quite capable of establishing a "Tyranny of Tears" and feeling their power. Fortunately it requires no great experience to distinguish one from the other, and to adopt for each the appropriate treatment.

Again, in elementary teaching upon the management of infants stress is laid, rightly enough, upon the importance of regularity in the times of feeding, and on the observance in this respect also of a very strict routine. But in the case of the very nervous infant a certain latitude should be allowed to an experienced nurse or mother. We may wreck everything by a blind adhesion to a too rigid scheme, which may demand that we leave the child to scream for an hour before his meal, or that, when at length he has fallen into a sound sleep after hours of wakefulness, we should proceed to wake him.

Symptoms of dyspepsia which are due to continued nervous excitement demand treatment which is very different from that which would be appropriate to dyspepsia which is due to other causes, such as overfeeding or unsuitable feeding. The temporary restriction of food, which is commonly ordered in dyspepsia from these causes, is very badly supported by the nervous infant. Hunger invariably increases the unrest, and the unrest increases the dyspepsia.

The difficulties of managing a nervous infant are very real, and call for the most exemplary patience on the part of the mother and the clearest insight into the nature of the disturbance.