by Julius H. Hess, M.D.
The following may be laid down as nursing axioms:
A diet similar to what the mother was accustomed to, with moderate limitations, may be taken.
There should be one bowel evacuation daily.
From three to four hours daily should be spent in the open air in exercise which does not fatigue.
At least eight hours out of every twenty-four should be given to sleep.
There should be absolute regularity in nursing and expression.
There should be no worry and no excitement.
The Diet of the Mother. -- A plain, more or less restricted diet is desirable. This must be enforced in the management of the wet-nurse, but to a less degree with the mother.
Nursing is a perfectly normal function, and a woman should be permitted to carry it out along the natural lines. Inasmuch as there are two lives to be provided for instead of one, more food, particularly of a liquid character, may be taken than the mother may be accustomed to. It is our custom to advise that milk be given freely. A glass of milk may be taken in the middle of the afternoon, and 8 ounces of milk with 8 ounces of oatmeal or cornmeal gruel at bedtime, if it does not disagree with the mother. Our only evidence that a food is disagreeing is the condition of the digestion. When any article of food disagrees with the mother, or if she is convinced that it disagrees, whether or not such be really the case, the food should be discontinued. In a general way, milk (1 quart daily), eggs, meat, fish, poultry, cereals, fresh vegetables and fruits constitute a basis for selection.
For more detailed suggestions see page 122.
The Bowel Function. -- A very important and often neglected matter in relation to nursing is the condition of the bowels. There must be one free evacuation daily. For the treatment of constipation in nursing women we have used different methods in many cases. The dietetic treatment by increasing the whole cereals, rough breads and cooked vegetables with plenty of recreation and exercise promise most. Manipulation of the diet should not be such as to interfere with the milk production. Three other methods are open to use: massage, local measures and drugs. Massage is available in comparatively few cases. Local measures consist in the use of enemas and suppositories. Every nursing woman under our care is instructed to use an enema at bedtime if evacuation of the bowels has not taken place within the previous twenty-four hours. For a laxative in such cases, and in many others, a capsule of the following composition has served well:
Extracti nucis vomicae ... 0.015 gm (1/2 gr.)
Extracti cascara sagradae ... 0.325 gm (v gr.)
Sig. -- To be taken at bedtime.
The amount of the cascara sagrada may be varied as the case may require. In not a few instances we have found it necessary to give two capsules a day in order to produce the desired result. Neither the nux vomica nor the cascara appears to have any appreciable effect on the child.
Air and Exercise. -- Outdoor life and exercise are not only as desirable here as they are under all other conditions, but to the nursing woman, with her added responsibility, they are doubly valuable. In order to get the best results exercise or work should be so adjusted as not to reach the point of fatigue. The mother whose nights are disturbed should be given the benefit of a midday rest of an hour or two. It should be our duty, however, to explain to the mother and to other members of the family that an important element in satisfactory nursing is a tranquil mind.
Care of the Breasts. -- A well-established routine should be instituted for care of the breasts. To facilitate this a readily accessible tray with the necessary utensils should be provided. This should contain a glass-stoppered bottle with a saturated solution of boric acid, a jar of cotton pledgets on toothpicks, to be used as applicators for the boric acid, a graduated glass or beaker. The nipples should be thoroughly washed before and after nursing with a saturated solution of boric acid poured fresh from the bottle for each cleansing, and the surplus thrown away. The boric acid should be applied with the cotton pledgets. The fingers should not come in contact with the nipples if the child is to nurse directly at the breast. If the nipples are tender they should be anointed with a sterile mixture of 5 per cent tincture of benzoin in liquid vaseline.
All utensils, including the breast-pump, if one is in use, should be sterilized by boiling. In case of the breast-pump the rubber bulb may be removed for this purpose. Where the milk is to be expressed the hands must be thoroughly disinfected by washing with soap and water and rinsing before manipulation of the breasts. Under all conditions soap and water should be freely accessible, and their use required before handling the breast of the mother.
Secretion. -- Spontaneous failure of lactation is extremely rare and probably always occurs in consequence of an incomplete emptying and an insufficient stimulation of the breasts. This is especially true in the feeding of premature infants, and nursing must be supplemented by other methods of emptying the breasts, such as expression, pumping, or the nursing of a second infant.
The ability to restore the milk supply in breasts which have not been nursed for days and even weeks, when proper stimulation is applied is the best proof of this assertion.
When the milk supply is temporarily insufficient the necessary complemental feedings should be obtained from some other source and only as a last resort should mixed feeding be instituted.
Fissures. -- Fissures offer serious difficulties to nursing because of the severe pain and danger of mastitis.
Relief of the pain is frequently accomplished by elevation of the breasts by a binder. Among the best local applications are silver nitrate solution 5 per cent, followed by an ointment. Balsam of Peru 1, castor oil 30; or silver nitrate 1, balsam of Peru 2 and petrolatum 30.)
The nipples must be thoroughly cleansed before each nursing.
Simple Engorgement. -- The first essential to relief is the restriction of fluids by mouth and the administration of laxatives. In our experience compound jalap powder in teaspoonful doses once or twice daily is best. Saline laxatives are effective but more likely to pass into the milk. Citrate of magnesia is least likely to do this. The breasts are tightly bandaged and an ice-bag is applied to each, external to the bandage. If this does not relieve the breasts massage and expression should be practised and the bandage and ice-bags reapplied.
If the cold applications produce discomfort as they occasionally do, hot boric dressings, protected by oil silk may be used, a compression bandage being applied external to the dressings. These should be repeated at hourly intervals.
The infant should be put to breast regularly at four-hour intervals if able to take them. The wet-nurse's baby may be used for this purpose if at hand.
Mastitis. -- Ice-bags are best applied early. Later, warm moist applications are more useful. When incision is necessary, it should be radial and must not enter the mammilla. This should be performed as soon as pus is localized and is to be followed by expression through the incision. In order to prevent further congestion of the breasts gentle expression should be practised at regular intervals. This not only relieves the congestion, but, in a very large percentage of cases, it tends to localize infection and a normal secretion is maintained after the healing of the incision.
Menstruation. -- The advent of this physiological function is frequently attended by a lessened milk secretion which leads the infant to become fretful due to underfeeding. Occasionally menstruation is attended by attacks of colic or indigestion in the infant, but, under no circumstances, should the advent of menstruation be considered as an indication for weaning, as all of the symptoms disappear within two or three days.
Factors influencing the mental condition of the mother, such as anger, fright, worry, shock, distress, sorrow, or the witnessing of an accident may affect the milk secretion sufficiently to cause no little discomfort to the child, and oftentimes the lessening of the flow for a day or two. At times, especially when the mother is under the influence of shock or grief, it may be necessary to substitute artificial feeding for a few nursings during these periods, until the mother has again resumed her mental equilibrium, her breast being emptied by mechanical means in the meantime.
Asthenia and Anemia without a definite underlying organic pathology must not be considered sufficient causes for weaning. Most of such women receive benefit to their own health, increasing in weight and strength and often overcoming their anemia. This is probably due to the more complete involution during the puerperium and stimulation of the glands of internal secretions and blood-making organs.
Drugs. -- Alkaloids of opium, hyoscyamus, belladonna and similar drugs, when given in large quantities not infrequently pass into the milk, and should therefore never be administered in large quantities to the nursing mother. Belladonna may cause a decrease in milk secretion, and should be administered with caution during the period of lactation. Mercury, iodides and the newer salts of arsenic are also secreted in the milk, and may be used to advantage when a luetic mother is nursing a luetic infant.
Regularity in Nursing. -- The breast which is emptied at definite intervals invariably functionates better than does one which is not, not only as regards the quantity, but also the quality, of the milk, thus regular habits in breast-feeding are as essential to milk production as to its digestion and assimilation. The baby should be wakened to be fed.
The average mother will supply the needs of the individual meal with one breast, and the breasts should be alternated in successive feedings. Thorough emptying of the breast should be encouraged under all circumstances, as this is our best method for increasing the milk supply, and the baby is the best means at hand by which this is accomplished. This should be encouraged in every instance. It is most readily thwarted by allowing a lazy baby to partially empty both breasts. This will soon lead to a diminished milk secretion. Expression or the nursing of a second baby will usually prevent the loss of milk supply. Massage will often be of great assistance in retaining the milk flow. It should be carefully and gently applied at regular intervals.
Sometimes, however, it is advisable to give both breasts at each feeding, i.e., under the following conditions: (1) During the first few days to stimulate secretion, and a little later to relieve the congested breasts; (2) to weak babies when there is an abundance of milk, and they are not strong enough to get the last milk that comes harder; (3) to overfed babies, where it is desirable to give them only the first and weakest milk, and to lessen the yield of milk from the breast; (4) as the milk supplied by one breast fails to meet the needs of the infant, both breasts should be given at each nursing -- the first breast should be thoroughly emptied before allowing the baby to take the second breast, and the next nursing started on the second breast given at the last feeding.
When to Begin First Feedings. -- Little is to be gained by placing a premature infant to the mother's breast during the first twenty-four hours and as they do not stand starvation the limited supply of milk needed should be obtained from some other mother. Water should be administered four or five times during the first twenty-four hours. When the premature is unable to take the breast, massage and expression should be begun on the second day and continued at first four, and later six, times daily. When a wet-nurse's baby is available it should be left to suckle the mother's breast at stated intervals.
Number of Feedings in Twenty-four Hours. -- During the second, third, and fourth days the infant may be placed at the breast at four- to six-hour intervals, and if strong enough to nurse these may be increased so that it will be nursed every three to four hours. If it does not obtain sufficient food by this means it may be given hand feedings of expressed milk between nursings.
Length of Nursing. -- As a rule, a robust baby takes three-fourths of the milk obtained from a good breast in the first five minutes of a twenty-minute nursing. Fifteen to twenty minutes should be the limit for the nursing period. If a baby is doing well on shorter periods and seems satisfied, let it be its own judge of the nursing time. While premature infants may nurse well during their first three or four days, frequently when they become intensely jaundiced they develop a marked apathy and under such circumstances they must be awakened during the nursing period to keep them at work. At such times they must at least be partially hand fed. It may also be necessary to feed them more frequently.
Administration of Water. -- At least one-twentieth to one-twelfth of the body weight of the infant, in the form of inert fluids, should be fed daily during the first two days. A 1 per cent milk-sugar solution (boiled) will answer. For further fluid intake needed see Tables I, II and III, pages 181 and 182. Otherwise there will be unnecessary loss of weight and perhaps a high fever due to inanition. A high temperature during the first days of life is more commonly due to "inanition" than infection in present-day obstetrics. The best differential test is administration of water or sugar water at regular intervals. In case of water inanition sufficient fluid intake results in a rapid drop in the temperature.
Nursing in Difficult Cases. -- When the weight curve remains stationary or the gain is less than should be expected the possibility of underfeeding as the cause must not be lost sight of. The estimation of the twenty-four hour secretion of milk is of first importance because of the relationship between demand and supply. The quantity taken by the infant at each nursing should be measured by weighing before and after each feeding at the breast, and also by measuring the amount of milk fed by hand. Conclusions should be made only after such estimation for a period of at least twenty-four to forty-eight hours. Expression of both breasts after each nursing may be of advantage to the mother even though the baby is only nursing on one breast. Expression when thoroughly and properly applied will, in itself maintain a full and free milk supply without placing an infant at the breast. In some instances this may be continued for many months. It may be stated that the small flat breast offers greater difficulties to proper manipulation than the full conical breast. For details as to the method of expression see page 126.
The classes of cases which are most likely to necessitate hand feedings are those suffering from cleft palate and harelip and those in which there is a deformity of the mother's nipples. We have recently had an opportunity to observe some of the cases being treated by the Minneapolis Breast Feeding Bureau. Among these a very severe case of harelip and cleft palate, nine months of age, and a case of congenital absence of nipples in the mother, whose infant was five months of age. Both of these infants had been fed exclusively on expressed milk and had attained the average weight and development of breast-fed infants of their respective ages.