JAMA 81:624-627, August 25, 1923
Read before the Section on Obstetrics, Gynecology, and
Abdominal Surgery at the Seventy-Fourth Annual Session of the
American Medical Association, San Francisco, June , 1923.
In this paper I shall attempt to consider only the more important aspects of the care of the new-born in the first few weeks of life. No attempt will be made to cover the entire ground, but stress will be placed chiefly on subjects which have not been sufficiently emphasized in the past, such as physical care of the new-born, congenital defects and injuries, infection, hemorrhage, and feeding.
The physical care includes proper clothing, bathing, external temperature and the administration of fluids.
New-born infants are apt to be kept in rooms in which too high a temperature is maintained. They frequently respond to too high a temperature with fever, just as they respond with a subnormal temperature if they become chilled. Many an obscure fever in a new-born would be diagnosed if the room temperature were more carefully observed. The same applies to the clothing of the infant; chilling must be prevented, but too much clothing makes the baby irritable, and if it is at all thermolabile, it reacts with a fever.
Ramsey advises that, in place of the usual bath, an oil rub be used; his point is well taken, especially for the debilitated infant during the first twenty-four hours.
For the first four days, before the mother's breast milk has begun to flow freely, large amounts of fluid in some form must be administered. If this is not done, the baby may develop a fever, due to dehydration.
Only such congenital defects as demand early treatment will be considered. These include cleft palate, Erb's paralysis and clubfoot. With Erb's paralysis, for the first twenty-four hours the injured arm should be held in a cast or splint over the head, with the humerus at right angles to the body and the forearm at right angles to the humerus, so that all strain may be taken off the deltoid muscle. When the nerves regenerate, the muscle will then be in good condition to function. In order to get the best results, clubfoot should be treated as soon as possible after birth. If the baby's condition permits, treatment for harelip and cleft palate should begin ten days after birth.
Our modern aseptic technique has made cord infections less important than formerly, and the general prophylactic use of silver preparations has done the same for gonorrheal ophthalmia.
Respiratory infections, on the other hand, are becoming increasingly important. The mother or attendant suffering with acute respiratory infection should be required to wear a gauze mask when handling the baby. Pneumonia, meningitis, otitis, and pyelitis in the newborn can often be traced to such a source.
Pemphigus neonatorum has lost none of its dangers. Its high contagiousness means that, in a ward for new-born infants, the slightest suspicion of this disease should cause the isolation of the suspected infant.
Open tuberculosis in the mother is the one sufficient reason against maternal nursing. She not only should not nurse the baby, but, if at all possible, the mother should be separated entirely from the mother, since tuberculosis in the new-born is uniformly fatal.
Congenital syphilis is a very deceptive disease. When the baby is born with clinical evidence of the disease and there is a positive Wasserman reaction, the course to pursue is simple. When, however, as if frequently the case, the infant is born apparently healthy and with a negative Wasserman reaction, but, nevertheless, is in the incubation period of the disease, diagnosis is rendered more difficult, and early treatment is often deferred. In an infant under 3 months of age, a negative Wasserman reaction does not exclude syphilis; but over that age, if carefully and properly performed, it is fairly reliable. In the young infant, when there is any suspicion of syphilis, treatment should be instituted at once until time has made certain of the diagnosis.
Hemorrhage is much more common than was formerly supposed. Warwick  summarizes thus a necropsy report on hemorrhage in the new-born:
1. Cerebral hemorrhage of the new-born is frequently found, occurring in 50 per cent. of thirty-six fatal cases of young infants at the University Hospital.
2. The condition is brought about by trauma in normal or rapid deliveries, by congestion or asphyxiation in slow deliveries, or by disease of the child itself.
3. The so-called "hemorrhagic disease of the new-born" is a much neglected but very important cause of cerebral hemorrhage in infants, occurring in 44 per cent. of the deaths of our series.
4. Forceps deliveries, advanced age of the primipara mother and syphilis probably do not play as important a rôle in the etiology of this condition as was formerly supposed.
In connection with hemorrhagic disease of the new-born, Rodda  has shown that the coagulation and bleeding time are prolonged, and has suggested this simple method for determining the coagulation time:
The apparatus required consists of a spring lance (a simple scalpel will suffice), two 1 1/2 inch watch glasses and No. 6 lead shot, all of which are easily obtained and transported. Glass and shot should be cleaned, preferably by washing with soap and water, followed by alcohol and ether. Needless to say, the lance should be sterile, which implies freedom from old blood. The heel of the infant is sponged with ether, a puncture is made with the lance blade set (about 0.5 cm) to produce a free flow of blood without the slightest pressure. A clean watch glass containing a No. 6 shot receives the second drop of blood. A second watch glass is inverted over the first. The watch glasses are gently tilted every thirty seconds until the shot no longer rolls, but is fixed in the clot. The end-result is sharply defined; the shot is firmly embedded, so that the glass may be inverted without dislodgement of the shot.
Rodda's work has greatly increased our ability to cope with these cases. Every new-born infant presenting symptoms should have its bleeding and coagulation time tested. Better than this, a prophylactic coagulation test should be done every day for the first three days. The loss of coagulation power usually begins on the second or third day, but may begin during the first six hours of life, and, if no treatment is given, it may last a week or ten days. If the coagulation time is increased, treatment should be instituted at once, even with the absence of any symptoms of hemorrhage. The accepted treatment brings the coagulation back to normal in a comparatively short time, and is so simple that even under the most primitive conditions it can be employed. It consists in injecting, subcutaneously, from 20 to 35 c.c. of whole human blood, once, twice or three times a day, depending on the severity of the symptoms. When given subcutaneously, the blood, of course, need not be grouped. When, as is frequently the case, the hemorrhage is cerebral, the symptoms may be very indefinite; and, unless one has this condition in mind, the diagnosis may be overlooked. Many death certificates signed congenital debility and other meaningless diagnoses are in reality undiagnosed cerebral hemorrhages. Some of these cerebral hemorrhages are due to blood changes which come under the heading of hemorrhagic disease of the newborn; others are due to trauma from either forceps or normal deliveries, or may be due to asphyxia of slow deliveries. In many cases, the hemorrhage is due to a combination of trauma and loss of coagulation power. This can be more readily seen in external trauma, such as forceps or circumcision wounds, in which the hemorrhage may stop entirely for several days, only to begin again as the coagulation time increases.
The common practice of circumcision in the first week of life is undesirable from two standpoints: (1) from the frequent danger of hemorrhage due to increased coagulation time, and (2) because in most infants the normal adhesions of the prepuce at birth can gradually be broken during the early months of life, doing away with the necessity for operation.
The symptoms of brain hemorrhage are often very elusive. Intermittent cyanosis, twitchings, frank convulsions, collapse, and cloudy sensorium are the most common symptoms, but any indefinite symptom which cannot be explained on other grounds should lead to the suspicion of brain hemorrhage. If the coagulation time is increased, blood should be injected at once, and lumbar puncture performed, often with the withdrawal of bloody fluid, an operation which relieves the pressure. If after several days there is no improvement in the symptoms, even though the coagulation time is returning to normal, decompression must be seriously considered. I believe that many cases of spastic paralysis, mental deficiency and epilepsy might be avoided if this operation were more frequently performed. It is a comparatively simple operation, and the mortality is low.
The recognition of hemorrhage of the new-born, especially cerebral hemorrhage, is a most neglected phase of the care of the new-born, and one on which too much emphasis cannot be placed.
Infant feeding divides with hemorrhage the honor of being the most important factor in neonatal mortality. More than 95 per cent. of babies can and should be breast fed, and the care received during the first two weeks of life often determines whether or not the baby will be nursed. The late Dr. Sedgwick once remarked that "the baby is the by-product of obstetrics." To the obstetrician, the mother is the first consideration, and his comparatively slight interest in the infant has caused many large teaching hospitals to place the new-born infants in the care of the pediatrician.
The baby should be put to the breast within six hours after birth, and then regularly every four hours, five or six times a day, until the milk begins to flow freely. The practice introduced by Schick of feeding the infant large amounts of carbohydrate solution and other artificial mixtures to do away with the initial weight loss is permissible in a large, well organized hospital; but under other circumstances it may be very undesirable, for it may be the entering wedge for the complete weaning of the baby. A better general practice is to give the baby large quantities of water, and if at the end of a week there is not sufficient breast milk, small amounts of artificial food may be given. However, before this is done, it is usually wiser to nurse both breasts, instead of one; to nurse every three hours, instead of four, and to begin the manual expression of the mother's breasts after each nursing. The religious adherence to the four-hour schedule in the face of a shortage of breast milk is a serious mistake. I am one of the firmest adherents of the four-hour schedule when there is a normal supply of breast milk, but otherwise a temporary placing on a three-hour schedule is frequently of great benefit. One of the most frequent causes of an insufficient supply of breast milk is the fact that the infant's sucking reflex is poorly developed, and, as a consequence, the mother's breasts are not thoroughly emptied. Manual expression of the breasts after each nursing stimulates the supply. The technic is as follows: The breast is grasped firmly between the thumb and index finger just back of the areola, the fingers pressed firmly together, and then, with a sudden "stripping motion" toward the nipple, the milk is ejected in a stream. The method requires practice until a good technic is developed. The increase in the breast milk by this method is often surprising. If, in spite of these methods, artificial food is necessary, it should be complemented, that is, given after each nursing, instead of replacing a nursing, and should be given in minimal amounts. If given ad libitum, the baby soon stops nursing completely to wait for the easier bottle. The quantity of the artificial food given is more important than the kind; the simple milk dilutions with carbohydrate additions, the Holland buttermilk formula or casein milk may be used.
The method of manual expression is also of great value in malformations of the breasts or nipples, as well as in acute mastitis and abcesses of the breast. In malformation, if necessary, the entire breast milk supply may be expressed for the baby for a period of nine months (personal case). In acute conditions of the breast, the secretion of milk may be kept up until the inflammatory process has subsided. In acute generalized disease of the mother, such as the exanthems, in which it may at times be inadvisable to have the baby nursed, the milk may be expressed in this manner and fed to the baby.
It is surprising in how many otherwise efficient hospitals these simple methods are neglected, and in an offhand manner the babies are placed on a bottle because the mother has not enough breast milk.
It should be obvious from the foregoing statement that the interest in the health of the infant should not cease with the first few weeks of life, as is too frequently the case. With our increased knowledge of pediatrics, and especially of infant feeding, the continued health of the infant demands that as a prophylactic measure the baby be seen by a physician at least once a month during the first year of life.
The purpose of this paper has been served if it brings to the obstetrician the realization that the new-born infant has a claim on his time and skill equal to that of the mother.
538 La Salle Building.
Dr. Henry F. Helmholz, Rochester, Minn.: Dr. Sharpe's paper is of great importance because it suggests a method of preventing disease. Anything that we can do to reduce the number of cerebral palsies is clear gain. When they have reached the chronic stage there is practically nothing that can be done for them in a medical way. The matter of routine lumbar puncture in cases of suspected cerebral hemorrhage is of great importance. I disagree with him only in a minor point: that the symptomatology of cerebral hemorrhage is a very difficult one and that many conditions may give rise to exactly the same symptomatology described but in which at necropsy no cerebral hemorrhage is found. In one other matter, too, I would emphasize the fact that these hemorrhages occur not only on the surface but also in the depth of the cerebral tissues. I think this is a point that is frequently overlooked and, unfortunately, in my experience, is more frequent than is usually described. Unquestionably, the milder hemorrhages are, as a rule, superficial, but even in this connection it is well to realize that hemorrhage at the time of birth, due to rupture of a small vessel, may light up again because of the hemorrhagic tendency in the new-born. During the last year we have made it a routine procedure, in cases of more severe labor and forceps delivery, to give infants at delivery a prophylactic injection of blood. The father is usually available, and it can be carried out very simply. It seems to me that the slight hemorrhage occurring immediately after birth can be controlled in this way and should prevent the lighting up of the hemorrhage due to the hemorrhagic tendency that one sees so frequently. With regard to the pathology and possible etiology of pressure or encephalitis, it has been my experience that there is usually considerable involvement of the brain substance, and that exceptionally there may be an element of pressure. Dr. Huenekens has so completely covered the field that it seems useless to attempt to say anything more than just emphasize again the three most essential points: the temperature, guarding the infant against infection, and breast feeding.
Dr. Edward L. Cornell, Chicago: I want to call attention to the importance of brain hemorrhage following rapid normal delivery. I think too many of us overlook the fact that a baby delivered less than two hours after labor is started is frequently subject to brain hemorrhage. Within the last three years I have had three or four cases following short deliveries, one patient having the baby in thirty-five minutes after the first pain. The baby died on the fourth day, and at the necropsy hemorrhage was present throughout the brain, even involving the lower brain structures. For the last year and a half it has been my caution to use some form of hemostatic preparation as a prophylactic measure to combat, if possible, the impending hemorrhage following rapid normal deliveries, a very difficult forceps delivery or long drawn out labor cases. Regarding circumcision early in the baby's life, I feel that Dr. Huenekens' remarks are necessarily true. I have used circumcision on the eighth or ninth day for the last ten years, and, with few exceptions, have had no trouble with hemorrhage afterward. We favor the four hour feeding and have used it since 1917 at the Chicago Lying-in Hospital, with very satisfactory results save for a few exceptions. I agree that we should use three hour feeding in cases of shortage of milk. I wish to call attention to the electric breast pump. This pump was developed by Dr. Abt. We are using it with great satisfaction in cases of shortage of milk or engorged breasts.
Dr. Earnest Sachs, St. Louis: I agree with Dr. Huenekens and Dr. Sharpe that this question of hemorrhage is a very vital one. I agree with Dr. Huenekens in contradistinction to what Dr. Sharpe has said that the diagnosis is extremely difficult. I have had the good fortune in the last year to see all such cases in the pediatric service of Dr. Marriott, and we have all been greatly troubled in making the diagnosis, believing that we had a birth hemorrhage when none was present. I wish to protest strongly against what Dr. Sharpe has advocated for many years, namely, that increase in the spinal fluid was evidence of disturbance or increase in the intracranial pressure. Through the kindness of Dr. Marriott, I had the opportunity of having the spinal pressure measured as a matter of routine in a large number of cases in which the spinal puncture was done for diagnostic purposes, and found that the pressure varied anywhere from 4 to 60 mm. None of these cases were traumatic or tumor cases. If this is so, then this argument that a rise in the intraspinal pressure is per se evidence of increased intracranial pressure must fall.
Dr. William Sharpe, New York: In this series of 100 consecutive new-born children it was, indeed, frequent to find a mild frontal and intracranial hemorrhage, as was indicated by bloody cerebrospinal fluid. I agree that, if we attempt to diagnose extensive intracranial hemorrhage or intracranial hemorrhage of varying degree, unless we use early lumbar puncture before the blood clots, it is very difficult to diagnose intracranial hemorrhage. I, too, feel that in these cases intracranial hemorrhage occurs much more frequently than we have any conception of, and that the only method of diagnosing extreme cases of intracranial hemorrhage is the lumbar puncture. I agree with Dr. Helmholz that the signs produced by mild intracranial hemorrhage may be absent entirely or, at least, not recognized, and it is only by means of lumbar puncture that such a diagnosis can be made. By repeated lumbar puncture producing drainage it is possible to lessen the number of spinal palsy cases later in life. In these nine cases in which we found blood in the cerebrospinal fluid, forceps had not been used and labor was in one case a breech with version and extraction, and in one case the cord was about the neck, but otherwise the labors were normal, so that intracranial hemorrhage can occur without labor difficulty. The coagulation time was taken in each one of the nine cases in which blood was found in the cerebrospinal fluid, and it was normal. As to the so-called normal pressure in new-born babies, in adults a pressure of from 6 to 8 mm. is considered normal, but it may be as high as 10. In children with open fontanel and with elasticity of the dura, the pressure was universally 7 or 8, rarely above that. Then we were considering that 6 was normal pressure for new-born babies. When we again made the test at the time they left the hospital, three or four weeks later, the pressure was usually 4, sometimes 5. Whether more cerebrospinal fluid escapes at the time of birth to protect the brain or whether this cerebrospinal edema is the result of trauma at birth, I do not know.
Dr. E. J. Huenekens, Minneapolis: I agree with Dr. Sharpe on the advisability of frequent lumbar puncture with cases of cerebral hemorrhage, but I wish to emphasize more than he has the necessity of ascertaining the coagulation time. I am surprised that in his nine cases he found no increase in coagulation time. Dr. Warwick found that intracranial hemorrhage occurred in 44 per cent. of deaths in a large series, and in all of these 44 per cent. there was an increase in the coagulation time. That is an important point in the treatment of these cases.
 Warwick, Margaret: Cerebral Hemorrhage of the New-Born, Am. J. M. Sc. 158:95 (July) 1919.
 Rodda, F.C.: Studies with a New Method for Determining the Coagulation Time of the Blood in the New-Born, Am. J. Dis. Child. 19:268 (April) 1920.