The nursing of children

Introduction

THIS little volume, dealing mth the nursing of infants and sick children, compiled from a series of articles which originally appeared in The Trained Nurse AND Hospital Review, should have a hearty welcome in training schools and by nurses whose experience in the care of sick children has had to be gained after graduation.

Of books dealing with diseases of children there has been no lack, but our Uterature on the subject of the actual care of the child who has the disease has been scanty, indeed.

In the preparation of these chapters Miss Goodnow's experience as nurse, superintendent, teacher and careful student of methods, has been supplemented by Miss Pasley 's first-hand knowledge of present-day methods in the actual care and management of sick children.

In a book of this size, all matter has necessarily had to be condensed — a condition which should prove an advantage rather than otherwise to the busy nurse. The book has been wTitten by nurses, for nurses.

and for those in the home who are forced by necessity to assume charge of the bedside care of a sick child or an infant. It does not assume to be a treatise on the diseases of children.

We prophesy for the little volume a wide circulation, and trust that it may prove of practical help and value, at some time, to all who may turn to its pages for suggestion.

Charlotte A. Aikens.

PART I Preparation for the Baby

THE nurse who desires to be efficient in her work for children begins her usefulness by helping the prospective mother. She should advise when pregnancy is suspected that the patient visit her physician early, have the fact of pregnancy established or disproven, and keep in touch with him, so that he may direct her physical care during the period.

If the nurse is asked for advice by a pregnant woman she should counsel simple, sensible living, leaving the details to the doctor. She will be called upon, however, to deal with many minor points, as a woman always feels that another woman understands better than a man possibly can and is more sympathetic in this wonderful matter of the entrance of a new Hfe into the world. She will have to answer questions in regard to the traditions which are still current, and should herself know the truth concerning them. The various modes of telling whether the child is to be a boy or a girl are interesting, but all fail more or less frequently, and are not to be taken seriously. The most difficult subject is that of prenatal influence and maternal impressions, with the consideration of birthmarks and deformities. The authorities differ in regard to these matters, and among the medical fraternity one will find equally capable men holding opposite views; but most of the biologists feel that the whole subject and its so-called proofs are merely the result of coincidence. It is a fact that the majority of pregnant women go through experiences which ought, if the traditions held good, to produce marks, deformities, strange tendencies, etc., and yet these things do not occur except in occasional instances. If such matters were cause and eflFect, the effect would not be lacking in nine cases out of ten. It is, however, a matter of common sense and fair play that a prospective mother should be protected from unpleasant occurrences, given cheerful surroundings, and helped in maintaining a calm mental state. In the matter of premature children one constantly hears that eight-months babies do not live, while seven-months do. Such statements not only contradict common sense, but are disproved by facts. The idea doubtless arose from inexact observation and ignorance of the exact amount of prematurity.

When tales of terrible suffering at the time of delivery, blood poisoning, abscessed breasts, etc. are brought to a nurse, she may say simply that modern scientific treatment has practically eradicated nearly all of the old-time complications. She may even use these things as arguments in favor of having skilled care.

Clothing — The nurse is almost always called upon to advise in regard to clothing for the baby, and should know something of the quality and durability of materials. Shopping for the layette should begin about the third month of pregnancy, and any machine stitching should be finished before the sixth month. Embroidery and fine hand work may be reserved for the later months. After the sixth month there should always be a moderate supply of things ready in case of premature birth.

Advise the bu3dng of good flannels, as these, if properly made and cared for, may be used for a long time. All-wool flannel does not launder well; silk-and-wool or linen-and-wool is better. A good quality of either may be obtained for about ninety cents a yard. If the petticoats are made quite full (one or one-and-a-quarter yards at the bottom) they can be used imtil the child is three or four years old. A cheaper flannel (forty cents a yard) may be used for pinning blankets, as these are used but a comparatively short time. For the bands, buy a half yard of forty-cent flannel, leaving it uncut, so that it may be torn into strips of the proper width at the time it is used. Bands should not be hemmed or embroidered, and if made beforehand are apt to be too large or too small. They may be made with darts, but these are easily stitched in. The band should never be pinned on, but sewed or basted. It should be loose enough to admit the nurse's finger as she sews, but snug enough to stay in place.

The shirts which have a double front are undoubtedly best, as they afford more protection where it is needed. They should be fastened by a few stitches or with the tiniest of safety pins. (Imagine yourself with a four-inch blanket pin in the middle of your back and you will have some idea of the reason for omitting pins altogether.) Use the second size of shirts, as the smaller ones shrink or are outgrown very quickly. These may be silk-and-wool or linen-and-wool, and in warm weather cotton or linen mesh.

The best material for dresses is nainsook, for which one pays 20 or 25 cents a yard. Lawn rumples badly and does not wear or laimder well; other materials are too heavy. If the sKps are made with draw-strings at the neck and wrists and armholes amply large, they will not require making over as the child grows. Nightgowns are best of flannelette, except for summer, when nainsook or longcloth may be used. If they are made of wool flannel, the neck should have a silk or linen binding. The petticoats should be made princess or with a waist, so that they hang from the shoulders. An attempt to fasten clothing about a baby's waist or chest results in its dragging and being always imcomfortable and untidy. None of the clothing should be longer than 24 inches from shoulder to bottom of hem. The regulation 27 inches makes simply

FIGURE I more material to pull and drag and does not aid in keeping the baby warm. Cotton advises instead of the usual slip, lO a sleeveless garment to be made of Scotch flaimel. The neck is finished smoothly and the bottom has a draw-string by which it is drawn up like a bag, keeping the feet warm and making a garment which will stay in place. The arms are of course included in the bag thus keeping the hands away from the face and preventing scratching or infection of eyes. He suggests that a similar slip be worn underneath in cold weather, this one being pro^dded with armholes. A silk-and-wool shirt, diaper and stockings complete the costume. This is advised for only the first six weeks It is particularly good for very small or premature babies.

Soft wool stockings or long bootees should be provided except in summer. They must be pinned to the diaper with tiny safety pins or they will not stay in place. Short jackets are useful to keep the neck and shoulders from chilling when they get uncovered. These may be made of wool, flannelette, or silk.

The diapers may be made of a thin outingflannel. This is soft, absorbent and easy to launder. Canton flannel is clumsy and is not absorbent nor soft until pretty well

II Figure II

worn. Linen is almost too absorbent and soon becomes cold and clammy if wet. Birdseye-cotton is excellent, but is almost sure to become gray after a few weeks laimdering. The Arnold knit diapers are very satisfactory, but are expensive.

The following list of clothing will be found to fit the requirements in most cases:

Three shirts, second size; 4 pairs stockings; 4 flannel petticoats, 4 wool pinning blankets; material for 3 or 4 flannel bands; 10 or 12 dresses or slips,; 3 jackets; 50 diapers, 22 or 24 inches square; 2 or 3 head shawls; 2 soft blankets or small comfortables, washable.

The head shawls should be of very fine soft wool or sUk, as no harsh material should ever come against the baby's face. A coat and a bonnet may be provided later, when the child begins to go out, but are not necessary at the first.

A special hot water bag should be provided, and scales for the daily weighing. The baby basket should contain the following articles:

Two soft towels (old table linen is nice for these); soft old linen or gauze for washcloths; castile soap, (the genuine); bath thermometer; large and small safety pins; boric acid in. powder; boric acid in solution; white vaseline, sterilized; package absorbent cotton, sterilized; package sterile gauze; pair of scissors; plain talcum powder; soft old blanket; full set of clothing for first dressing.

Bed — Some sort of a bed or bassinet should be ready for the reception of the baby. The material and style of this may be left to the taste and purse of the mother. A clothes basket may be used, padded and lined with pink, blue or white, with a deep ruffle of the same covering the outside. One may even use a baby carriage as a bed if it is flat in the bottom. The simplest and most practical thing is a small metal bed; with a hair mattress it will be both comfortable and sanitary. If an ordinary crib be used it will do until the child is six or seven years old. There should be a quilted pad over the mattress and it should be further protected by rubber or waterproof sheeting, preferably double coated. Cambric sheets, light wool blankets and if desired, a light spread make the bed complete. No pillow is needed for some months, though a thin one may be used later on.

The Nurse — ^It ought to be an axiom that no nurse should take an obstetric case, except in an emergency, and thus undertake the care of a young baby, unless she has had good training for this work. Good training means, in most instances, special training, for few general hospitals give more of this work than a mere smattering. The nurse is expected to be a teacher of principles and methods. She must be equipped with both popular and technical knowledge. She must know what things are so and why they are so.

Books — It is well to be able to recommend books from which the young mother may gain information. Holt's ^^ Care and Feeding of Children" is perhaps the most complete work for popular use and is considered an authority. Fischer's ''The Care of the Baby/' Wheeler's "The Baby— His Care and Training," Cotton's ''Home Economics" series and Griffith's "Care of the Baby" are among the best. There are some excellent chapters on the subject in Aiken's "Home Nursing." These are all rehable works and are written for the average intelligent mother. Schinn's "Biography of a Baby" is a scientific study of a child's development, and is told in an interesting manner.

The importance to both mother and child of proper care for the baby during the first few days cannot be overestimated. It is these few days which set the pace for months to come, and it is duriag them often that a nurse makes or immakes her reputation.

Discrimination — Few people, even doctors and nurses, understand that children are born with dispositions, and that these dispositions must be dealt with in one way or another from the hour of birth. The nurse who takes advantage of her opportunities will observe that one child is impatient and wilful and another serene and yielding from the first day of life. It is just as impossible to succeed if one treats all babies alike as it is if one treats all men and women alike. Adaptability nowhere finds a wider application than in the care of young babies.

The Babys Characteristics — What is the baby at birth? Most physicians denominate him '^simply a little animal." The sight is somewhat undeveloped, in that distance is not distinguished at all and only nearby objects are clearly seen. The color sense is non-existent. Taste is not developed, but the baby's mouth is very sensitive to heat and cold or to pungent foods. The sense of smell appears gradually, along with that of taste. The sense of touch is well developed chiefly in tongue, lips and eyes. It is undoubtedly true that ^'a baby's only conscious sensation is in its mouth." The

i6 sensory nerve endings in the skin are little developed, which results in this, that a baby may be badly injured without being itself conscious of it enough to protest. To this are due some of the accidents with hot water bottles, etc. The lungs inhale relatively more oxygen and expel more carbon dioxide than in adults. The sweat glands are not active at birth. Tears do not appear normally until about the third month.

The respiration at birth is about 45 per minute. Rotch says "The breathing is superficial, sometimes quick and again dying away so as to be almost imperceptible." Good authorities say that the temperature of a new-bom baby is from 99 to 100° but it falls two or three degrees within the first hour and fluctuates for several days, being at the end of the first week normally 99°. In actual practice, the average baby tends to record a subnormal temperature for some weeks, and it will rarely be as high as 99 unless there is some functional disturbance. The average height of males at birth is 19^ inches, of females 19^ inches. The average weight of males is 7^ pounds, and that of females 7^ pounds. The ten, twelve and fifteen pound babies of which one hears are exaggerations or guesses, or due to the child being weighed with a considerable amount of clothing. Babies which weigh ten pounds at birth without clothing are very uncommon and a child larger than that is almost never seen.

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PART II Early Care

/^ARE at Delivery — When a child is delivered, the physician is usually there to direct the immediate care.

Most doctors expect the nurse to wash out the child's eyes and mouth. This should be done carefully with warm boric solution. Most doctors prefer to tie the cord themselves; if a nurse is asked to do it, she must see that her hands are sterile. If the child is not breathing properly, the physician will be responsible for the treatment which may be needed, but every nurse should know how to do artificial respiration in order to be of proper assistance and to be prepared to act in case of trouble after the doctor's departure. The nurse should familiarize herself with the different methods of encouraging breathing, and should understand thoroughly the principles involved. This is best learned by actual demonstration, and should precede the regular obstetrical training.

The cord cut, eyes and mouth cleansed and respiration established, the child is given over to the nurse, and thenceforth the average physician pays very little attention to it.

No nurse who has had proper obstetrical training will desire to be left alone at the delivery. If circumstances delay the arrival of the physician and it seems likely that she will have to get on without him, she should sterilize a pair of scissors and two hemostatic forceps (if she has them), or two or three 12-inch lengths of bobbin tape. She should prepare her solutions and get everything within reach. In scrubbing her hands the usual precautions should be taken about thoroughness. Full-strength alcohol or peroxide of hydrogen are rapid and sure disinfectants after the scrubbing.

The actual expulsion of the head should be retarded as much as may be, to prevent laceration. When the chin is delivered, the nurse may feel with one finger to ascertain whether or not the cord is around the baby's neck; if so, it is to be gently slipped off. The shoulders should be delivered carefully. When the cord has ceased pulsating, a clamp may be put upon it, about an inch from the child's navel, the other a greater or less distance from it, toward the placental side. The cord may then be tied, or the clamp left on till a convenient time comes.

The baby, upon delivery, should be received into a warm, sterile towel held in the nurse's hands, and should be laid upon its right side (to insure closing of the foramen ovale), wrapped in a warm blanket, the towel being left to protect the face and eyes from the roughness of the blanket, and the cord from the possibility of infection. The baby may be laid in bed or basket or in a rocker or arm chair which is well padded. In cold weather, it is wise to cover it with a second blanket, and place a hot-water bag in the folds, being careful to avoid possibility of burning.

If the child is in good condition, it may be left while the nurse assists in the care of the mother. An occasional look at it in passing is sufficient to assure oneself and the family of its well-being. If the physician wishes the Crede treatment applied to the eyes, he will attend to it before he leaves. This consists of one or two drops of a 2 per cent, solution of silver nitrate put into each eye.

The nurse should see that a clean dropper is ready for the silver solution and another for the sterile water or salt solution, which is usually used after the application. She must provide the salt solution and a sterile glass in which to pour it.

Bear in mind that as soon as the mother is clean and comfortable she will want to see her child. Even though it may not be attractive in its first wrappings, her desire should be granted. After she has really seen the baby, she will be content to have it taken out of the room while she gets some rest.

A new-born baby, if kept well wrapped and carefully watched, may with perfect propriety be left for some time without further attention. The mother, even if asleep, needs strict watching for some hours after delivery, and is less likely to get it if the nurse is absorbed with the baby. Moreover, when one thinks of the radical changes which take place at birth, the establishment of breathing, the change in the blood current, the shock of contact with the outer air and the various hard and soft substances, the lights, movements, sounds, etc., the nervous strain of handling to which the little being is entirely unaccustomed, one finds much to condemn in the customary haste in getting at the bathing and dressing. Give the baby a chance to adjust itself partially at least to the strangeness of the world, before you add many new sensations.

The Nursery — If it is at all possible, every family should arrange for a nursery, however small. It should be a sunny room, but the crib should be set so as to screen the light from the baby's eyes. There should be no carpet, but soft, washable rugs should be provided. The floor is best of hardwood, finished with oil or varnish rather than wax, as it must not be slippery; a highly polished floor is not safe for a nurse with a baby in her arms and certainly not for little feet when they are taking their first steps. There should be no upholstered furniture, no draperies except washable curtains, and no ornaments except pictures which are interesting to children. Provide for the baby's wardrobe a roomy box (such as a shirtwaist box) or a chiffonier. Let cleanliness, simplicity, order and quietness be especially sought for the nursery. Good ventilation should be provided, and this means making a study of that particular room in order to avoid drafts and give an abundance of fresh air. The temperature of the room for the first few days should be nearly 78°, and for a few weeks when the baby is bathed it should be kept very warm, but may gradually be cooled until by the time the baby is a month old it is not more than 70°.

Bathing — As soon as possible after delivery, the child should be well anointed with sterile olive oil or white vaseline, especially in the folds of the groins and about the neck and head. Within a half hour after this application, it will be found that the cheesy material (vernix caseosa) which was present has disappeared. Gentle sponging with not too strong soapsuds at a temperature of 100° to 105° will remove the oil and any foreign matter which may be present. A tub bath is, as a rule, objectionable, because of the danger of infecting the cord; but one may appropriately be given if for any reason the child is blue or chilled.

In giving the bath do not assume the awkward and inconvenient position of sitting in a low rocker with the tub on the floor and the child in your lap. Use a table. In private practice the kitchen or dining-room table is usually the best, and with a folded blanket over it makes a good arrangement. In hospitals an ordinary pine table may be padded and covered with oil cloth. In cold weather it is best to place a hot water bag, not too full nor too hot, between the folds of the blanket upon which the baby is laid.

For a sponge bath have the water at a temperature of 105°, as it cools very rapidly. For a tub bath, make it 100°; by the time the baby is undressed and ready it will have cooled to about blood heat. The temperature should be reduced after a week or two, and the child gradually accustomed to cool water. The softest of wash cloths and towels should be used and the utmost care exercised in drying. If properly absorbent materials are used there is no excuse for rubbing, as the drying can be done by gentle patting. Powder is unnecessary, but may be used sparingly if it does not irritate the skin. Always note carefully what effect powder has, as it may be responsible for things otherwise unaccoimtable.

When a tub bath is to be given, the baby should be wrapped in a diaper or soft towel and lowered slowly into the water. If the water is not exactly the right temperature (blood heat) or the child is thrust into it carelessly or suddenly, a permanent dislike or even fear of baths may result. Special attention should be given to the groins, the folds about the neck and under the arms. The head should be washed at each bath; when this is neglected an eczema sometimes results. If a brown, crusted condition appears on the scalp, several thorough oilings and subsequent bathing will remove it.

The eyes should be sponged off daily with warm boric acid solution. They should not be washed out unless the physician orders it. Any discharge should be at once reported.

The daily bath is not now considered essential. Some doctors prefer not to bathe the child at all until it is ten days or two weeks old, except so much as is needed for cleanliness. For very small or weak children bathing is always contra-indicated, and oil rubs should be given instead. Use for this purpose albolene, cocoanut oil or benzoinated lard, as olive oil, even if pure, is not readily absorbed. Employ a gentle knead-

The NimsiNG of Children

ing movement for the arms and legs and a circular stroke for chest, abdomen and back.

Even if the bath be omitted, there should be an entire change of clothing twice a day. It is not always necessary to send the garments to the wash, but they should be well aired before being used again. The change of clothing at bedtime is quite as important as in the morning. A baby is no more likely to be comfortable sleeping in its day garments than an older child is. Attention to this small point may save many a sleepless night for both mother and nurse.

Treatment of the Cord — Unless you are familiar with his practice, always ask the physician how he wishes the cord dressed. As a matter of fact, one method appears to be as good as another, providing the materials used are sterile. Dry cotton and powdered boric acid are commonly employed; talcum powder, salicylic acid, bismuth, zinc oxide ointment, etc., are used. If the cord is a little ^^ juicy" or there is any redness about it, pure alcohol will almost invariably check it. After the first dressing, a thorough letting alone is the best treatment. A daily inspection and change of dressing if it becomes soiled are all that is usually necessary.

It is customary in putting on the band to turn the cord to the left, in order to avoid its pressing upon the liver, but no harm is done if this tradition is not observed.

The Excretions — ^The child's bowels should move thoroughly during the first twenty-four hours of life. If they do not of their own accord, an enema should be given. This may be done with a small soft rubber catheter, connected to a funnel, or with an infant's bulb syringe. The syringe is more easily managed, but great care must be exercised in inserting the tip. Plain warm water may be used, or a very weak soap suds if it seems to be needed. The ancient and honorable formula of molasses and water is not objectionable, but is unnecessary.

The first urine voided is usually scanty and high-colored. It may contain a red sediment which can easily be mistaken for blood. The time, quantity and frequency of urination should be made a note of. A child may fail to urinate for the first twenty-four hours without anything being wrong. Sometimes the quantity is very small and is almost colorless, so that it might be overlooked. If the child has not voided after twenty-four hours, a warm normal salt solution enema may be used eflfectively. Water given freely by mouth and moist heat applied over the abdomen and genitals help greatly in the matter. If a child goes over thirty-six hours without urinating, the physician should be called upon to take the matter in hand.

Water — Beginning the first day of life, water should be given regularly. Half an ounce, or even an ounce, every four hours, is not too much. Do not give it from a bottle till after the habit of nursing is established, or the baby may refuse to nurse. Use a spoon in the beginning, but be sure that the baby takes the water and that it is not distributed over its face and clothing in place of being put into its stomach. Feeding a baby water from a spoon takes considerable time, but pays in the end. In ordinary cases it is better not to give water at all until after the baby has once nursed well.

Nursing — The first nursing should take place as soon as the mother is rested and the child washed and dressed. If the mother has any tendency to hemorrhage, the baby should be put to the breast much sooner, as the stimulation of the nipple tends to produce uterine contractions and so stop bleeding. If mother and baby are in good condition some physicians prefer to wait twelve hours. Three or four times during the first twenty-four hours and about five times the second and third day is sufficiently often. There is very little fluid in the mother's breasts during this period, but the first secretion (called colostrum) is laxative and needed by the baby. It is also important that the nursing habit be established.

The mother or some solicitous relative may suggest feeding the baby before the milk appears. One should insist in such a case upon following Nature's suggestions, which very plainly say ''No" to this procedure. The baby is rarely hungry and cannot be induced to nurse often, since the little body contains stored-up sustenance enough to last for a few days; moreover, the very absence of milk in the mother's breasts is in itself a hint that it is not needed.

Remember that a primipara rarely knows how to properly nurse her baby, and that it is the nurse's duty to teach her. Have her lie well over on her side, so that breast will come squarely in front of the baby's mouth. The baby's head may be supported by her arm or a thin pillow, but it is quite as satisfactory to omit either and lay the baby flat upon the bed. The mother should be shown how to support the breast with her hand, holding the nipple so that the baby may be able to get and retain its hold. Much of the difficulty about getting a baby to nurse is due to its being placed in an awkward position so that the child starts out by being discouraged. These matters seem small, but they lie at the root of success. If the milk seems not to flow freely, gentle massage of the breast or warm applications may assist. If it flows too freely the mother may with her first and second fingers near the nipple retard it.