JAMA 63:1758-1760, Nov. 14, 1914
Read before the Section on Diseases of Children
at the Sixty-Fifth Annual Session of the American
Medical Association, Atlantic City, N.J.,
The premature or delicate infant has an equal right to life with the robust. Indeed, its frail condition should insure it every possible care, since because of its feebleness its life's prospect is not nearly so good. While I have no available data, such at least is my personal experience. The fact that I have seen several striking examples of the possibilities of saving the lives of some of these cases and believe that not sufficient care in their management is practiced, is my excuse for presenting this brief paper.
The two general requirements in the care of premature infants are the maintenance of body heat, and proper nourishment.
In order to sustain life, body heat must be maintained and also the rapid dissipation of heat prevented. Heat is given off from the body by the excretions and feces and urine, by the lungs in the form of vapor, and from the skin. Vierordt states that 73 per cent. of body heat is eliminated by radiation and conduction from the skin. This heat loss can be greatly limited. My experience in a number of cases with the modern incubator has not been satisfactory. The infants live a few days and then die even when they are not losing weight. For the last several years I have adopted the following method. It is not at all original and the method is described in some of our modern text-books.
I direct that an ordinary clothes-basket 24 inches long be procured. This can be purchased in any village. The bottom is padded so that the basket has a depth of 8 inches. It is then lined with white oilcloth and over this a layer of cotton batting held in place by being stitched through the sides of the basket. This in turn is covered with white flannel. The flannel covering for the basket is fastened over the top by means of safety-pins so that the upper portion can either be turned back or fall about the neck of the infant, leaving the body surrounded by an air-space.
Heat is maintained by means of hot-water bottles. I always direct that these be covered by flannel. The 12-ounce citrate of magnesia bottle is convenient, as it has a rubber cork and a wire fastener that insures against leaking. Five of these bottles are sufficient to maintain proper temperature. A thermometer is kept in the basket and the heat maintained at from 90 to 95 degrees. During the night when the room temperature is lower it may be necessary to cover the basket with a rubber sheet in order to maintain the temperature. It will be noted that while the body is in a warm atmosphere the face is exposed so that the infant breathes the atmosphere of the room. As the room can be well ventilated it breathes, I think, a better air than when confined in an incubator.
The body of the infant is anointed with olive-oil, wrapped in a layer of cotton batting -- loosely applied -- and this in turn in a soft flannel basket. The infant can be fed in the basket without being removed. Indeed, it need be taken out only when it is necessary to oil the body. Absorbent cotton pads can be used for napkins.
As soon as the infant begins to gain in weight the temperature of the basket can be lowered and in my experience in from two to three weeks the hot-water bottles can be dispensed with.
This is vitally important because of the caloric needs of the infant. Breast-milk of course is the best food, but as emphasized by Drs. Holt and Morse, breast-milk should be diluted. Many of these infants are not strong enough to draw milk from the breast and there is no doubt in my mind that physicians and attendants are frequently deceived in believing that because the infant takes the breast it is getting nourishment. Only recently I was able to demonstrate to the attendant by weighing the infant before and after a breast-feeding that there was no appreciable gain in weight. In these cases the milk should be pumped from the breast regularly, diluted with an equal quantity of water, and fed to the infant. If it does not retain this dilution then the milk should be further diluted. Whatever dilution the infant takes, the food should be rapidly increased in strength. There are cases in which the infants are not strong enough to nurse from the bottle and in these cases some other method must be adopted. In these cases I have found the Breck feeder a lifesaving appliance. At the Child-Saving Institute this method of feeding is frequently employed with normal infants who refuse to take the bottle. It seems to me superior to the medicine dropper and certainly requires less skill than gavage.
For the first two or three days at least, food should be given every hour; after this the feeding interval should be lengthened. When it is not possible to procure breast-milk, then the feeding becomes very important. In two recent successful cases I began with the following:
In one of the two cases the infant vomited this food. I directed that the whey be made from skimmed milk, when it retained its food. As soon as it retains this formula nicely, the strength should be increased by the addition of either milk or cream.
1. The premature or delicate infant may develop into a strong individual. I have in mind three of these cases. One patient was normal in weight at 5 months. The other I had the privilege of examining at the age of 3 years. It was in every way a normal child. The third is now a young man in his twentieth year. He is normal physically and above normal in his intellectual attainments.
2. Among dangers to be guarded against are the regurgitation of food in the throat and the suction into the larynx. I have seen one fatal case from this cause. Temperature should be taken in order to guard against fever. In a recent case that I saw with the physician, the temperature reached to 105, due as I believe to the excessive external heat. In every case a thermometer should be kept constantly in the basket. The most frequent mistake, however, is letting the infant take the breast and assuming that it is actually getting food, or if it vomits assuming that the breast-milk does not agree with it.
3. Finally, the hopeful symptoms are a gain in weight and normal yellow stools.
Dr. Henry Dwight Chapin, New York: I wish to emphasize what Dr. McClanahan has said concerning incubators. I treated about 150 babies in different incubators and almost all of them died. While we gain in one factor, that is, heat, we lose in a vital factor, and that is fresh air. Most of them do not deliver sufficient fresh air to the infant, and these premature infants are unusually susceptible to lack of air. I think incubators should be abandoned entirely. I have used such appliances as Dr. McClanahan suggests. In the hospital I have two modern incubators but I do not use them. These premature infants have great difficulty in swallowing. Some of them are so difficult to feed I have been obliged to resort to gavage. I have saved one or two that I am sure would have otherwise been lost, by feeding in this way. One or two have died suddenly. Necropsy showed food had gone into the larynx. The nurse must be warned about slow feeding with any kind of a feeder.
Dr. John Zahorsky, St. Louis: Most of us who have had experience with expensive apparatus for warming babies have discontinued its use. One method is valuable in the ordinary home; that is, to use an ordinary soap-box, and an ordinary steam or hot-water radiator, and put the box with one side to the radiator so the heat from it will pass into the box. The heat can be regulated by putting the box nearer or farther away from the incubator. This method can be used with the ordinary stove, with which, of course, someone will have to see that the fire is uniform. The distance will regulate the amount of heat the baby gets. Especially are mistakes made in the amount of heat to which the baby is subjected. Some nurses seem to think the warmer the baby is kept the better. The most common injury to the baby is from too much heat, which will produce injury that it may take a few days to overcome. It often produces cyanosis and death. A good rule is not to keep the temperature over 90. From 86 to 88 is usually sufficient. Watch the baby's rectal temperature, and if it goes lower than 96 degrees do not heat the incubator but warm the baby with a hot bath. Heating by hot air is a slow process. Most premature babies that are not sickly in any way die of exhaustion because they are not sufficiently fed. After the third or fourth day they get attacks of cyanosis, which means exhaustion of the respiratory center. In some way the baby must get enough food or it will die. The premature baby should have one-fifth of the body weight in mother's milk daily. Commence on one-twentieth of the body weight the first day -- do not wait three days as we do with the normal baby, but commence to feed at once. It has no reserve store to sustain life. Every day the amount should be increased until it reaches one-fifth of the body-weight. It is best given with a dropper, a spoon, or, as Dr. Chapin has emphasized, with a catheter. One may get it down in six feedings, or it may take ten, twelve, or even twenty-four, but the baby must receive one-twentieth of its body-weight during its first twenty-four hours.
L. R. DeBuys, New Orleans: The principal problem we have is to maintain the body temperature, and in doing this we have to be careful not to get it too high. A plan I have used is to make a gown of two layers of Canton flannel with one layer of cotton batting between. The baby is put in this and the warmth put externally -- either hot bottles or hot-water bags. Covering all is a blanket. Another point that has not been mentioned is the placing of a thermometer inside the top covering and external to the baby's gown, to which it is pinned. You can tell then whether you are giving the baby enough or too much heat.
Dr. S. M. Hamill, Philadelphia: I, also, protest against the use of the older type of incubator, and emphasize one point in Dr. McClanahan's paper that seems to me important in the case of the premature infant, namely, supplying a sufficient amount of fresh air. I have not used an incubator for some years. I have been following much the same course that Dr. McClanahan has outlined. I had an experience a year and a half ago, which demonstrated that at least one premature infant was able to breath an air of low temperature without detriment. I had the infant forced on me in the children's ward of the Polyclinic Hospital. None of the small rooms in the hospital were then available. Being an advocate of fresh air, I keep the windows open constantly, winter and summer. Having had this child brought into the ward it became necessary either to rob the children in the ward of their usual amount of fresh air, or to keep the windows open and endeavor to maintain the body-heat of the premature infant while at the same time letting it breath the cold, fresh air of the ward. On the principle of doing the greatest good to the greatest number, I chose the latter course, and put the baby in a specially prepared clothes-basket close to a radiator. I succeeded in maintaining the heat about the body of the baby at from 90 to 95° F., whereas the temperature of the ward often fell as low as 50 or 55 F. at night. That baby did better than any premature baby I have ever seen. I have had experience in keeping these babies in room temperature of from 65 to 70 degrees for a short time, but never before at such a temperature as that above indicated. I am not advocating this as a proper procedure, but it illustrates the fact that these babies can breathe an air at low temperature without harm.
Dr. F. B. Talbot, Boston: Concerning the conservation of energy in the new-born, the new-born baby maintains his own body-heat after birth by using up the glycogen that has been deposited in the liver. In a certain number of circumstances when all the glycogen is used up, the body-fat is converted into sugar, and is used in this form. If the mother's milk comes in on the third day, and often later, they may not use their own body-fat at all. Under these circumstances they do not lose weight. If it does not come until five or six days they lose a great deal of body-fat and weight. The obvious conclusion to draw from this is that if the baby has not much fat, is not well developed, is a weak baby, it must be fed early to give it energy to keep its life, and to maintain its body-heat. This discussion goes with accurate scientific measurements of heat and determination of the respiratory quotient.
Dr. F. N. Rogers, Manchester, N.H.: One point I would bring out that Dr. McClanahan mentioned in his clothes-basket arrangement is that the weight a child would lift by respiration is simply the displacement of air. When cotton batting and pads are put about the child, there is apt to be more or less weight to be displaced, which takes energy.
Dr. Henry F. Hemlholz, Chicago: In those cases with syncopial attacks during the first or second day, I have used in two cases 6 per cent. dextrose with excellent results. The child in one instance was practically moribund but responded quickly to an ounce of 6 per cent. dextrose solution. That was kept up at five-hour intervals. There was no breast-milk available and the child from that time on did very well. The following day we were able to obtain some breast-milk, and the child recovered. The dextrose was administered hypodermatically.
Dr. H. M. McClahanan, Omaha: Some years ago I bought what I thought was a model incubator, and all of the premature babies died about the fifth or sixth day, until I became discouraged. In all the cases I cited in my paper I was called to the home. Gavage is not as convenient there as in the hospital. The infant should not go too long without food. I believe a thermometer should be constantly present in the basket, and the temperature of the basket should not go about 90 or 95. Secondly, I emphasize, also, the danger of letting a baby's temperature go to 104, 105, or 106. In the last child I lost, I saw an hour before it die the temperature was 106, I believe due to the carelessness of the nurse in letting the temperature of the basket get too high. The temperature should be taken as a routine measure every twenty-four hours at least.