With Special Reference to Feeding and Nursing Treatment

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVI, Issue 2, 1 April 1923, Page 73

With Special Reference to Feeding and Nursing Treatment

The significance of the large number of infants who are unable to survive the first month of life, brings right to the forefront the great necessity for more general widespread knowledge on all matters affecting this infant mortality rate. The outstanding feature of the whole problem is the paramount need for such universal knowledge on general health matters as will enable the mothers-to-be to become strong, resistive, and as independent as possible of the risks which are associated with child birth. Undoubtedly, a large number of these infant losses are associated with prematurity. Usually the term " premature" applies to the infant born between the 7th and 9th month of intra-uterine life. The chance which these infants have for life and good development depends upon many conditions. The one born of syphilitic parents probably has little chance. One born of healthy parents, when the weight at birth exceeds 41bs, has a fairly good chance for Life and normal development, provided the application of heat can be regulated from the beginning, and the baby can receive breast milk. The human young born into the world ahead of its allotted time of nine calendar months within its mother's womb, has to start the battle for its existence handicapped by an immature organism, consequently we know that our efforts for the preservation of the wee mite will be taxed to the limit. Very small premature infants, say, born weighing less than 2£lbs, who cannot receive even a small amount of mother's milk, have a relatively smaller chance of normal growth and development. Signs of Prematurity. These, of course, differ according to the degree of prematurity. If baby is under s lbs, and less than 19 inches in length,

it is best to treat as premature, whether or no, to get satisfactory results. The body is very soft and limp; the skin transparent and downy; the cry very feeble or even absent at first. Pulse and respirations irregular; suction weak, spasmodic, irregular or even absent, and deglutition difficult and prolonged. The first and most difficult problem confronting the organism of the premature newborn is the maintenance of its body heat. It's relative body surface is cosiderably larger even than that of the mature baby, and the chance for giving off heat into its surroundings must therefore be correspondingly larger. At the same time, the amount of protecting fat under its skin is much less and its apparatus for the regulation of heat is entirely inadequate. In fact, we may say that the baby born prematurely is started without the necessary fuel to light its fire, and until can be remedied this deficiency it has to be kept in a very warm medium. Then we add to this that its digestive apparatus is not nearly built up to the demands of independent life, and it can only deal with very small amounts of easily assimilated food, i.e., human milk. There are THREE PROBLEMS to attend to in the correct care of the premature : — 1. To thoroughly maintain and regulate the body heat. 2. To feed baby, supplying both correct food and the necessary amount of fluid. 3. To prevent subjecting the baby to any infection on account of the special lowered resistance (attendants with colds, etc. ) The quicker the prevention of loss of heat from the body lakes place, the better the chance for the baby. Life itself depends on maintaining the required temperature steadily and evenly.

Means of Maintaining the Body Heat. 1. By placing the baby in a warm room and keeping the temperature of the room even (commencing with 65-70 deg. Fahr.) and then gradually lowering as the infant's condition improves. 2. By placing the baby in a cradle especially prepared to prevent any undue escape of heat from the body, and also to supply heat by hot water bags, well protected, these being filled in rotation regularly — one each hour. There should be three hot water bags, one on each side and a third at the foot, if necessary, and filled at a temperature of 166 degrees Fahr. for the sides and 180 degrees Fahr. for the foot bag. 3. By oiling baby (not bathing) and wrapping in cotton wool jacket and light flannel or knitted garments. (All clothing must be light and no special pressure) . Oiling the skin prevents unnecessary loss of heat from the body, and also protects the delicate skin. Keep the room thermometer on the wall near baby's cradle, also room thermometer in the cradle outside baby's cloth-. ing and inside the shawl or blankets. (Temp. 85-95 degrees Fahr.) Guard against overheating the baby by filling the bags with too hot water, or by filling them all at the same time. Take rectal temperature of the baby twice daily, or four hourly, as necessary, and regulate the application of heat and temperature of the room accordingly, i.e., while baby's temperature remains sub-normal the room must be kept at the warmest, and the bottles in the cradle must be filled in rotation, one each hour. Also the baby must be handled and exposed as little as possible to change the position — the latter must be done regularly — at least 4 or 6 hourly. The correct ventilation of the room is essential; the heat should not be raised by excluding all inlets for fresh air. Clothing should be light, no direct pressure, and some freedom of movement (muscular contractions) allowed for. Even the slightest cooling during exposure whilst changed or weighed, etc.,

will not only subject them to a fall in temperatm-e, but will also cause a standstill or loss in weight, because the abstraction of heat will deprive the system of the small surplus energy which could have been used for a gain in weight. HOW LONG should these babies be kept in a warm room? As soon as a regular gain in weight is established and the baby's temperature remains normal, the room temperature may be reduced very gradually under a continuous control of the baby \s weight and temperature . Abrupt changes must be carefully avoided. An initial loss in weight during the first week or ten days of baby's life must be expected. Feeding of Premature Infants. With the feeding of premature babies it must always be remembered that the digestive apparatus is not built up to the demands of independent life, and consequently it can at first probably only deal with small amounts of the most easily assimilated food — i.e., Mother's Milk — and it may be necessary even to dilute this in the first instance. It is somewhat difficult to lay down any hard and fast rules regarding the feeding of these infants, as their natural adaptability and certain other compensating factors differ so in individual cases. Some infants are several days, or even weeks probably, before they learn to suck consistently, while others may commence comparatively good suction in a day or two. In the case of the former, it may be necessary to use a good pipette with a soft tubing (about two inches) attached, and to give the food carefully and slowly by this method. This method may be used until it is noted that the babe attempts to suck, when a small teat and bottle should be quickly substituted (if artificially fed) . Great patience and understanding is necessary on the part of the nurse when feeding these premature babies. One mother or nurse will succeed where another fails entirely to get the desired result. Seven months' babies seldom manage to obtain their full requirement direct from the breast for

the first few weeks even if they seem to suck well, and in practice, we have found it necessary to express the mother's milk every three or four hours, and then to feed the baby as afore mentioned, putting it direct to the breast, say, two or three times daily only. Constant lifting is not good for these weaklings and interferes with the regulation of the heat application, so necessary to their progress. No pains should be spared to secure mother's milk for the baby, and the usual means to establish a good milk supply should be pursued with even greater vigour and zest, as the necessity is so great. At the Infants Hospital (Dr. Emmet Holt) in New York City, this was considered such a necessity for their premature cases, that arrangements were made whereby they collected and bought breast milk from healthy nursing mothers, for their infants in hospital . One worker was employed just especially to supervise the homes and to assure and collect the milk in a thoroughly clean way. At Karitane Hospital, when a premature baby is admitted, they always endeavour to get into touch with the mother or nurse immediately, and ask them to persevere with the methods for establishing the milk supply, also to arrange for the mother to come into residence as soon as she is able to travel, if at all possible. This is done in order to assure Natural Feeding whenever possible, and thus gives the baby the very best chance. Frequency of Feedings and Amount The amount and frequency of feedings depends on the size of the infant and the degree of prematurity. If the baby is able to take from Joz to loz at each feedig during the first week, it is usually not necessary to feed oftener than every three hours, with one feed during the night, that is, 7 feedings daily. The total amount able to be taken at one time, without exhaustion, usually decides the number of feedings necessary in 24 hours . Consequently, a careful record of the actual amount taken should be kept. The night feed (7th feeding) is usually discontinued when the baby is able to take the required amount for growth and de-

velopment in 6 feeds instead of 7, that is to take and deal with a larger amount each time. In practice we find this usually occurs when the baby is between 51bs and 61bs in weight. The intake of fluid is very important and it is no guide to wait for the usual signs of hunger or 1 hirst in an infant, as a premature baby will sleep on and soon suffer for lack of fluid. A good average guide as to the minimum amount of fluid necessary is— to endeavour to give three ounces of fluid for each pound of body weight (i.e. in the case of an infant weighing three pounds, endeavour to get it to take 9oz.s of fluid daily, at least as soon as possible). When the baby's sucking ability increases rapidly, it usually takes over this amount, but considerably under the amount for age. Kind of Food. First. — Baby's own mother's milk. It may be necessary to dilute this at first, but soon give it undiluted. There is no comparison between the progress of a premature baby breast fed and a premature baby artificially fed — the one is soon weeks head of the other in general progress. Secondly. — Another healthy mother's milk, diluted at first and later undiluted (sometimes this is procurable temporarily) . Thirdly . — Even a small amount of breast milk daily, say, 2oz to 3oz, and complemented with an easily digested artificial food, cow's milk modified to the human standard, peptonised, and diluted, and with a low fat percentage. The extra diluent is carefully reduced daily. Fourthly. — If mother's milk is absolutely impossible to obtain, and we have to depend on artificial food only, we find in practice that the best is Humanised Milk No. 1, made with the unset milk and Plunket Emulsion gradually introduced to bring the fat percentage up to say 3 per cent. The milk is usually peptonised for from half an hour to one hour for a week or two. The fat is kept at a very low percentage and extra dilu-

cut is added. The average two months premature baby shows definite signs of inability to deal with any full strength artificial food (i.e., food yielding about 19 or "20 calories per ounce) under six weeks of age at least. To repeat what has been said previously: All feedings are more or less dependent upon the general development of the infant in relation to its digestion and retention of food. Careful attention has to be paid to such points as — abdominal distention, vomiting, character of motions etc. Begin with what are considered minimum quantities and gradually increase the strength and amount of food as able, i.e., as the infant develops the ability to deal with the food. It is best to give water only, or weak Sugar of Milk solution until there is some indication of the first bowel movement. 1 1 the baby is totally unable to take a sufficiency by mouth and suction, one must resort to catheter feeding (lavage) giving larger amounts at longer intervals for the lime, or until the baby commences to suck and swallow properly. The following are brief summaries of some of the cases which have been cared for in Karitane Hospital, Dunedin. Many people think that these wee things are not worth working with, but we have so often proved that a weakling premature baby may (if correctly cared for from the beginning) develop into a bonny, sturdy youngster, that we feel the most we can do for these handicapped babies is the very least we should do. Baby Ruth, admitted when four hours old, weight 2^lbs, premature 2| months, artificially fed for 10 days Avith dilute breast milk, then mother came to the hospital and we developed and established her milk supply; baby was fed with mother's milk diluted at first, and later undiluted. Baby was a vvvy poor sucker, and could not suck direct at the breast until about six weeks old, and even then had to be fed with expressed milk afterwards for several weeks. Mother and baby left hospital when baby was seven weeks old and weighed 51bs 2iozs, Baby

was breast fed until one year old and then weighed 16£lbs, and developed well in every way. She was seen again at two years old; was up to the normal standard in all ways regarding- weight, height, mental development and physical activities; in fact, was a real "live wire" and had splendid health . 2. Baby Patsy, admitted when 5 hours old, weight 31b 15oz, 2 months premature. Baby was born while the mother was dangerously ill with pneumonia. She was igiven the usual treatment for a premature baby and fed three hourly, the food being, to begin with, peptonised whey with equal parts of water, followed later by Humanised Milk No. 1 mixture with a low fat percentage. Baby progressed vsteadily and well, and now weighs Bibs 7|ozs at three months. She is small, but \ery firm and well developed in every way, also has a good colour. 3. Baby Mavis, admitted when 32 hours old, having been brought by train journey in Mid-winter. Condition to precarious to weigh on admission, but birth weight was stated to be 2-}lbs in cotton wool. Baby weighed lib. 13ozs when two weeks old, and general condition was not good. Routine treatment was pursued with, and her condition gradually improved; at four months of age baby was discharged, weighing just under 51bs. — was veiy vigorous, with good muscular tone and colour and treated as a normal baby. Baby seen again at 8 months, weighing lOlbs., small-framed, but plumpexcellent colour, and general deveopment quite up to standard, head being held erect, and baby smiling and alert, and grasping for her toys. She had gamed -^ 1 lbs. the previous 6-J weeks. One might go on instancing case after case, having knowledge of a large number of premature infants who were primarily treated in Hospital, and whose mothers kindly report progress (^'vvy six months. The main fact emphasised in one's mind is — that these handicapped babies must be given the best possible chance to attain normal growth and development in every way. A.P.