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.

[Illustration:

FIG. 174.—Quilted robe, with hood, for the premature baby. ]

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.

[Illustration:

FIG. 175.—Premature baby in basket lined with quilted pad; wearing quilted robe and being fed from a Boston feeder. The blanket is turned back showing hot-water bag. (From photograph taken at Johns Hopkins Hospital.) ]

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.

[Illustration:

FIG. 176.—Model of improvised bed for premature baby: closely woven clothes basket with padded bottom and four, flannel-covered bottles of hot water attached to the sides. Thermometer and feeder are shown in basket. (By courtesy of Dr. Alan Brown, Hospital for Sick Children, Toronto.) ]

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.

##