Journal of the Minnesota State Medical Association
and The Northwestern Lancet 28(5):87-91, March 1, 1908
Read before the South Dakota State Medical Association, May 29 and 30, 1907.
The care of premature infants is a subject that has not been given the attention its importance deserves. In countries where the death-rate is falling below the birth-rate the reduction of infant mortality assumes tremendous importance. The medical profession, by improved hygienic methods and by the study of preventive medicine, is constantly trying to lower the death-rate, but when the deaths exceed the births the subject ceases to be one of hygiene and becomes an important question of public concern, and if the relation of births to deaths is not changed the result will be race-suicide. An English writer has recently said that "the birth and care of a child is the object of civilization, and that personal and national morality and success are measured by that standard. Our success or failure with the baby, which is born every eight seconds, will be the measure of our civilization." (Rich.)
It is evident that race-suicide may be avoided by increasing the births or decreasing the deaths, or both, one of which methods the president is trying to do and the other the profession must do; therefore the study of infant-mortality becomes a scientific, social, and political question.
Much has been done to reduce the mortality in infants in children. In the city of New York the infant deaths were reduced 50 per cent by the single measure of improving the milk supply. Much more may be done by other hygienic and dietetic measures, and the care of the premature infant is not the least of these.
A study of the literature shows that between 15 per cent and 20 per cent, or one birth in six, of all births are premature and that 20 per cent of all deaths during the first year of the infant life are due to prematurity. One child in every five that dies during the first year dies by reason of premature birth, and 45 per cent to 50 per cent of the deaths of the new-born are due to prematurity and congenital debility. The chief cause of infant-deaths is diarrhea, yet prematurity kills half as many. Does it receive half the attention? I think not. It certainly seems that these facts are not appreciated, or the care of these babes would not be so generally neglected. We are neglecting the subject, which is second only to intestinal infection in the cause of death in infants.
This paper has a twofold purpose: first, to call attention to a neglected subject and to impress the importance on the profession; and, second, to point out that the principles underlying the care of premature infants are simple and applicable in the country as well as in the cities, and that these babies may be well cared for in the home and many previous lives saved which are now sacrificed on the altar of indifference. I am a thorough believer in the modern incubator and in the employment of trained nurses, but I shall have nothing to say about them, because I am pleading for the premature baby born in the country away from the possibility of scientifically constructed incubators and expert nurses. Because the conditions and equipment are not ideal is no reason for not doing all that is possible under the circumstances.
A well appointed operating room with trained nurses and skilled assistants is undoubtedly the best place to perform an appendectomy, but many of you have obtained perfect results operating in the kitchen of a farm-house. There are three main principles to remember in the care of premature babies:
First. Maintenance of an even temperature.
Second. Proper feeding.
Third. Avoidance of handling and other disturbances.
Because the sweat glands are poorly developed the child is deprived of one of the chief sources of losing heat, therefore it is unable to stand high external temperatures and may suffer heat-stroke. (Morse.) The heat-regulation centers are poorly developed, and they cannot stand low temperature. We see that they must be protected from both heat and cold, which is best done by the incubator or some substitute therefor.
In this paper I shall say nothing about the various types of steel and glass incubators, automatically regulated, but shall confine myself to the consideration of the substitutes for the incubator, because I wish to urge that it is the care, and not the instrument, that saves these babies, and while admitting its value when available, it is not absolutely necessary. Morse of the Harvard Medical School says: "I prefer in private practice at least some substitute for the incubator to the incubator itself," and Dean Richardson says that he prefers the padded crib. If such authorities prefer the substitutes, even when the incubators are available, there certainly is good reasons for their use in the country. The best substitute is the padded crib or clothesbasket; however, any receptacle of proper size may be just as useful, such as a packing-box, a trunk, or even a bureau drawer. The basket may be padded thickly with cotton, but I prefer woolen blankets because the heat is retained and the child is not so liable to be affected by sudden changes in the temperature of the room.
The ideal incubator should have an abundant supply of fresh, pure air kept at a constant temperature. Morse says he has never seen one that would do this, and that is the reason he prefers the crib, as the baby then has constantly pure, fresh air to breathe if the room is properly ventilated, and he urges that, in addition, advantage may be gained by having the baby breathe air that is slightly cooler than the air of the incubator would be. The basket is kept at a temperature of from 85° to 95° F., according to the age and condition of the baby, and is registered by a thermometer placed within the outer fold of the blanket surrounding the baby, and not hanging in the crib. Great watchfulness is needed to avoid chilling or overheating, which may be partially guarded against by taking the rectal temperature of the baby at regular intervals. When an open basket is used the room must be kept very warm, never being allowed to go below 80° F. The baby must have a room to itself, with good ventilation and the sunniest and quietest in the house. Things which would cause loss of heat must be guarded against, e.g., the baby must never be bathed, but should be oiled at birth and then not oftener than every other day, and this should be done in the basket or incubator and not in the nurse's lap. It should not be dressed in ordinary infant-clothing, but should be wrapped in a soft woolen blanket, the very softest obtainable, or, if fine flannel is not to be had, it may be wrapped about with a soft diaper and then wrapped in a woolen blanket. I cannot understand why the old notion of wrapping these infants in cotton is still tolerated. It is dangerous and costs lives. De Lee says: "The Chicago Lying-in Hospital has received twenty or more infants completely refrigerated even though oiled and wrapped in cotton." It is very difficult to overcome tradition, and it has become a tradition to oil premature infants and wrap them in cotton. Common knowledge ought to teach that woolen clothing will prevent radiation better than cotton, and we apply this principle to mature children and in our own dress. Why then not use better judgment and give these premature ones, who need it infinitely more, the benefit? If it be thought advisable to use any garment at all the bag-dress without sleeves is the best. I prefer a small blanket about a yard square wrapped about the baby and folded up from the feet to the shoulders. The baby is then covered with a light flannel blanket so arranged that a sort of hood is made about the head. Often, even if the incubator be warm, the baby will have cold feet, in which case it is wise to lay a warm-water bag under the feet. It must be remembered, however, that this may elevate the baby's rectal temperature, which must not be mistaken for a true fever.
An attempt to feed a premature infant modified cow's milk will almost surely meet with disaster. Nothing can equal human-breast milk, which must be obtained to get good results. Unfortunately, the premature infant thrives best on the milk of a mother who has nursed her baby for some time, preferably about two or three weeks. Premature babies do not seem to thrive on colostrum, hence it would be better to obtain the milk of another woman, even at the cost of great effort, till the colostrum has disappeared from the mother's breast. Feeding must not be delayed, but must begin soon after the birth, because of the great loss of weight. Every ounce that is lost means a great deal, especially when the baby weighs near two pounds. Very young infants, those weighing less than three pounds, will require that the milk be diluted. The diet-table compiled by Dr. J. B. De Lee, and used at the Chicago Lying-in Hospital, makes the best working basis that I know of. I take the liberty of reproducing it here.
First day, every 30 minutes, 15 drops water 1 part, milk 2 parts.
Second day, every hour and 30 minutes, 15 drops water 1 part, milk 2 parts.
Third day, every hour and 40 minutes, 15 drops water 1 part, milk 2 parts.
Fourth day, every 1 1/2 hours, 1 dram water 1 part, milk 2 parts.
Fifth day, every 1 1/2 hours, 1 dram pure mother's milk.
Sixth day, every 2 hours, 1 1/2 drams pure mother's milk.
Seventh day, every two hours, 2 drams pure mother's milk.
First day, total quantity 2 oz., 1/2 dram, every hour about 45 drops.
Second day, total quantity 4 oz., 1 dram, every hour about 75 drops.
Third day, total quantity 5 oz., every hour about 1/2 dram.
Fourth day, total quantity 6 1/2 oz., every hour about 2 drams.
Fifth day, total quantity 7 oz., 2 drams, every hour about 2 1/4 drams.
Sixth day, total quantity 7 oz., 4 drams, every hour about 2 1/2 drams.
Seventh day, total quantity 8 1/2 oz., every hour about 2 3/4 drams.
Eighth day, total quantity 9 oz., every hour about 3 drams.
Ninth day, total quantity 10 oz., every hour about 3 1/2 drams.
First day, total quantity 4 oz.
Second day, total quantity 5 1/2 oz.
Third day, total quantity 8 oz.
Fourth day, total quantity 9 oz.
Fifth day, total quantity 10 oz.
Sixth day, total quantity 11 oz., 2 drams.
Seventh day, total quantity 11 oz., 7 drams.
Eighth day, total quantity 12 oz., 5 drams.
Ninth day, total quantity 13 oz.
Of course experience has taught that milk formulae cannot be followed exactly with mature infants. The same fact holds true with premature infants with even more force, but these tables will be found to be about right, and you can modify them to suit each case. If the child does not get enough food it will lose weight and may seem stupefied and may be subject to attacks of collapse even with quite marked cyanosis. On the other hand, an overfed child will be subject to indigestion, and if it is overfed and regurgitates it may choke, hence each infant must be carefully watched so it may get "just enough." It is usually best not to put the child to the breast even if it can nurse, because the handling might cause too much disturbance, but it is better to give the milk from a small bottle with a very small nipple. It may be fed with a medicine-dropper.
If the baby cannot swallow, it will be necessary to introduce the food through a soft catheter. This method is accompanied by considerable shock. Sometimes one may avoid the use of gavage by giving the milk through the nose by means of a soft catheter inserted a short distance, the milk being allowed to run into the posterior nares and trickle down the throat into the stomach. A child will often be induced to swallow by this method even when all others fail.
The baby should be fed without removing it from the basket or incubator. As soon as the disturbance will not be too great the baby should be put to the breast, for nothing equals nursing. If cyanosis occurs, stimulation is called for in the form of brandy or whisky, 1 or 2 drops, or strychnine, 1-1000 of a grain.
On account of the warm surroundings and the thin skin, evaporation takes place rapidly and the baby literally dries out, therefore plenty of water must be given. I have seen a premature baby that dried up almost like a mummy before it died because the mother neglected this important detail, and the air of the incubator must be kept moist also by a sponge hung in it.
The mother's milk may fail and human milk is unobtainable. Then substitute feeding becomes a necessity. In this case start in with whey diluted with an equal amount of water gradually increasing to pure whey, after which cream may be added in increasing quantities.
I have said before that premature infants should not be bathed because the shock attendant upon the handling may result in collapse. Many authors advise smearing the body of the babe with oil or vaseline. This is also very bad practice, for it causes severe chilling. The pores, instead of being filled with oil, must be kept open, or the baby will fail.
For cleanliness the body may be smeared with oil or sweet lard, which must be completely wiped off with a soft hot towel as quickly and with as little handling of the baby as possible, and the child should be immediately returned to the basket or incubator. This need be done only every other day. The face and nates may be washed with water when necessary. When the baby is stronger it may be bathed by immersion in water at the temperature of 102° F. or 103° F. for a minute and quickly dried in a hot towel. A baby must be quite strong before this method is employed, and as vigorous as a full-term baby before the ordinary bath be given. Although we try to avoid handling the baby as much as possible it needs massage and moving of the joints. In the very young ones a very gentle general massage may be given four times a week, and the older ones every day. The stimulation of the rubbing, if it be not too rough, will do them good. The child should not be allowed to lie in one position too long though, it should be on the right side most of the time for the first few days because of the foramen ovale. The infant should be weighed as often as every other day and must be weighed naked. An accurate record of the weight is necessary, and can be determined only when the baby is naked.
The baby is kept in the basket or incubator until it weighs about four and one-half pounds, depending on its conditions, age, and vigor. The removal must be very gradual and should not be begun until the baby has had a continuously normal temperature for days. The prognosis depends upon the period of gestation, weight, and care the baby receives. Care and attention to the minutest details will do more than high-priced incubators. These babies need a day and a night attendant.
Premature infants run a slightly elevated temperature when they are doing well, and a subnormal temperature is a sure sign that the baby is doing badly.
In conclusion, I want to describe a simple home-made incubator that anyone can make at a very small cost. It consists simply of a box 24 inches long, 20 inches high, and 18 inches wide. Eight inches from the bottom is a false bottom dividing the box into two chambers, the heating apparatus being in the smaller lower chamber and the baby in the upper one. The false bottom is the support for the bed of the baby and does not cover the whole bottom of the box, a space of four inches being left at one end for the circulation of hot air. The top of the box may be fixed on hinges or to slide, which is better. There is a pane of glass in the top so that the baby may be watched, and there are two ventilating holes near the end of the cover opposite the place where the hot air enters. An ordinary pillow is laid on the false bottom for the bed. The incubator is heated by bottles filled with very hot water and placed in the lower chamber through a small door in the side of the chamber. Fresh air enters this door, passes over the hot bottles, is heated, and ascends by the way of the six-inch space at the end of the box to the baby's chamber and out through the ventilating holes at the top, giving a constant supply of warm, fresh air. A thermometer is placed in the incubator beside the baby or, better, beneath the first fold of the enveloping blanket.
By watching this thermometer a fairly constant temperature can be maintained by frequent filling of the bottles. This is the method usually advised for heating the incubator, but practically it does not work satisfactorily, so I have devised a hot-air radiator made of ordinary 3-inch eaves-spouting, which I have used with success. A temperature varying not more than two or three degrees is easy to maintain. I have kept this simple incubator with this radiator at the temperature desired for weeks and with not an unusual amount of watching. The heat from the chimney of an ordinary lamp enters the spout-radiator through an elbow an inch or two above the chimney. This elbow curves upward toward the box, which it enters by way of a hole in one end of the chamber where the spout divides into two parts to give more radiating surface. These two branches unite at the other end of the box, and the warm air passes out through a hole in that end, without entering the chamber in which the infant is. Thus the products of combustion in the lamp do not enter to injure the baby. The air to the baby enters by the door in the side of the box described before, is heated by the hot pipes and ascends to the baby. Over the discharging end of the radiator is a cap with a hole one inch in diameter. This discharge hole, being very small, keeps the hot air from rushing through without radiating its heat. Any one can build the box, or you can use a packing-box, and a tinner can put the radiator together in a few minutes from the spouting he has on hand in his shop. The whole thing costs but a dollar or two, and I can assure you it will be a surprisingly satisfactory incubator and, to my mind, much better than the crib or basket. This box can easily be made collapsible so that the whole thing can be slipped under the seat of the buggy and can be set up complete in less than five minutes. Specifications for making the incubator are as follows:
Get a board an inch and a half thick, ten inches wide, and twenty-one feet long. From this cut six pieces two feet long and one piece 18 inches long. On four of the two-foot pieces nail a small cleat, the full width of the board, one inch from each end. Eight inches from the edge of two of the two-foot pieces nail a cleat parallel to the long way of the piece and on the same side of the piece as the small cleat. IN the center of the 18-inch piece cut a hole 3 1/4 inches in diameter. Now set the pieces with the long cleats on edge. The cleats will face each other and be eight inches from the floor. Place one of the 18-inch pieces with the hole in it against the end cleats of the two side pieces and fasten them there by means of two hooks screwed into the short edge of the side pieces, the hook fastening in a staple or ring in the 18-inch piece. Fasten the other end in the same manner, and then place the radiator in the two holes at the end. Now lay two of the 18-inch pieces on the long cleats, and you have the false bottom or bed support. The other two-foot pieces with the cleats are now put together with the two remaining 18-inch pieces, with hooks arranged as described, and when put together they are placed on top of the first set and securely fastened, thus making a box 18x20x24 inches. There now remain two of the two-foot pieces, which are fastened together with several cleats to make a top. A hole about 8 by 10 inches is cut near one end of the top for a window for observing the child, and still nearer the end are cut two ventilating holes about two inches in diameters.
Dr. D. W. Craig (Sioux Falls): I had the great pleasure a few years ago of seeing Dr. B. DeLee demonstrate his new incubator in the Chicago Medical Society. It is very useful for city practice, but not at all practical for the country.
This one before us certainly will fill a long-felt want, and for my part I am going to have one if I have to make it myself.
While listening to this paper I thought of one or two cases that I have had the pleasure of observing. One was a case of Cesarian section in which the baby had to be placed in an incubator, and it was kept there for a number of weeks before it was strong enough to live outside of the incubator. Then there was a case that I had in Sioux Falls that died on account of not having an incubator. If we had had one of these incubators it would have had a much better chance to live.
Dr. Litzenburg (Essayist): This is simply a substitute for the more elaborate incubator, for use in the country, and I can assure you it works because I have used it, and have kept it at a temperature not varying more than four degrees for weeks at a time.
The principles that underly the care of premature infants are simple, and anyone can apply them. All they require is care. I thank you.