THE
CARE AND MANAGEMENT OF PREMATURE INFANTS. BY
Francis J.
Hector, M.D., F.R.C.S.,
Assistant Obstetric Physician and Gyncecologist, Bristol General Hospital.
During the last few years the of premature infants has
care
and management
acquired additional extensively studied importance, in all civilized countries. This has been largely due to the widespread adoption of well-organized ante-natal treatment, and considerably more inductions of labour are now performed in the interests of the mother or and has been
more
the child.
Apart infant, or
from the usual desire to
however
domestic
unpromising
reasons
at
rear
a
premature
birth, various family
may make its survival
a
matter
of supreme importance. The death of the premature infant of an elderly primipara where labour has been induced, shall we say, on account of severe toxaemia, may be in the nature of stark tragedy to its parents. Furthermore, in every case the mother has had perhaps weeks of pregnancy to endure, with all its trials and discomforts, and has every reason to expect a live baby as her reward.
thirty-four
It has been
alleged by
some
that the
rearing
of
premature infants is not, from a purely economic or sociological standpoint, worth the enormous amount 301
302
Dr. Francis J. Hector
entailed, and that such infants grow up weak and rather useless individuals, who may eventually
of
care
become
charge on their fellows. Recent investigations in Germany, however, have shown that premature children, having survived the first few critical weeks, have just as much chance of becoming good workers, a
thinkers
athletes
any other
type of child. The two most important points in the management of premature infants are, of course, temperature regulation and feeding. The regulation of temperature or
as
is the first and constant
infant's
tenacity
difficulty.
of life
must
Even the full-time
sometimes
be
sorely
considering the circumstances which not infrequently obtain at its birth during the winter-time. Projected into a chilly room or labour ward, seized and subjected to even dangerous solicitude, its temperature must often fall to an alarming degree, and this at a time when important anatomical changes and delicate metabolic readjustments are commencingIt may also be pointed out that by reason of its own tested,
metabolic activities the temperature of the foetus in utero is 0-5? higher than that of its mother. Small wonder is it, therefore, that numbers of premature " are certified as dying of prematurity" or
infants "
congenital debility" during the first few days of life, when their deaths were really due to the effects of cold sustained immediately after delivery. Once the
temperature has been allowed to fall for even a very short time in the case of a premature infant, it
unlikely that the effects of such neglect can ever be remedied by any later treatment, however thoroughImmediately after delivery, and before the cord is tied, the infant must be wrapped in a warm blanket. Tying the cord and weighing must be accomplished with the utmost dispatch, and the infant is then
is
Care
Management
and
Premature Infants 303
of
in gamgee, covered with blankets and put into the cot with three rubber hot-water bottles at For 160?, or better still with an electric blanket.
wrapped
hospital
or
nursing home practice the latter is
a
very with
It costs about
desirable article.
thirty shillings, waterproof cover, and It can be can be obtained from any surgical stores. and has a switch used off any voltage for regulator additional six
an
for
shillings
a
The 160? temperatures, 100?, 130?, 160?. be used. The electric blanket is temperature should free from danger, and should be used arched over the three
infant between the
enveloping blanket
covering
Immediately
two years.
past
ordinary
have
been
Queen Charlotte's Hospital during
obtained with it at the
and the
results
Excellent
blankets.
after
reaching
the
ward the rectal temperature must be taken with a subnormal thermometer with a low limit of 88?. All other thermometers are quite useless for premature infants. have
a
great care is taken an infant may rectal temperature of 90? ten minutes after Unless
up quickly in blankets. If the infant is below 4 lb. the rectal temperature should be taken 2-hourly by day and night for a fortnight, and 4-hourly if between 4 lb. and 5 lb. It
delivery, although wrapped
is
absolutely essential
97? and 99?.
to
Failure to
the
temperature between do this must be put down to
keep
part of the nurse. The electric blanket should be kept on at 160? day and night for a
inefficiency
on
the
Good very small baby. results can be obtained with an ordinary cot and The hot-water bottles if sufficient care is taken. in the
fortnight
or a
Below
oiling
or
a
a
should
be
covered
with
of blanket.
layer
birth
bathing
of
bottles
hot-water
rubber flannel
case
weight
of 4
must be made.
lb. No
attempt at premature baby, no
x
Vol. XL1X.
No. 18G.
304
Dr. Francis J. Hector
weight, should be oiled without temperature having first been taken and
whatever the birth the rectal
found to be within normal
oiling
limits, and
be done very rapidly to In the cot the baby should lie
must
of heat.
then the avoid loss
even
absolutely only a soft flat pillow beneath the head. The piling on of many blankets should be avoided, as they may actually weigh down the chest. A hand placed between the blankets and the baby flat with
will
that
ensure
Plenty
of
round the cotton
be
former
baby's head,
wool
tendency to when placed do not
the
air should be
warm
over
are
not
too
allowed which
to a
heavy. circulate
bonnet
of
& placed. There over-clothing and over-blanketing, and or
at
gamgee
the
get enough
is
bottom air.
is
of
a
cot
the infants
The
baby's position may changed occasionally by laying it on the opposite
side. No food should be
given for the first six hours,
sips of water, 5 per cent, glucose, or 5 per cent, glucose in saline, should be offered. To avoid
then small
dehydration sips
of water should also be
feeds.
frequency of experience of extreme
The amount and
important,
and
given between feeds is very variations i11
country and abroad makes important factor is not so much
feeds recommended in this it
probable quality overfeeding
that the
quantity of the feeds. Gross common mistake, and many premature infants are killed by too much food. Twelve hours after delivery begin with one drachm feeds the
as
the
is
the
2-hourly day and night, in the case of infants over 3J lb. Under 3J lb. give \ drachm 2-hourly. Increase the feeds very gradually by J to 1 drachm daily f01 the infant over 3|- lb. and by \ drachm daily fQl the infant under 3J lb. The rate of increase must
Care
and
Management
of
Premature Infants
305
by watching the effects of the feeds the infant. On the slightest evidence of cyanosis
be determined on or
to take the whole feed reduce the amount
refusal
to half and
the feeds
give
to
gradually reverting Suitable feeds for 1.
1 dr.
2. 3. 4.
2
Day
a
hourly 2-hourly
baby
of
1|?
12
2
?
?
12
?
?
12
?
>>
12
?
?
10
?
?
10
6.
3
7.
3
a
short time,
feeds next lb. would be :
3f
day.
?
12 feeds.
2-hourly. ?
5.
for
(omit
two
night feeds).
days the infant can usually be and if the weight is less than got on to ten feeds daily, 3-3, lb. ten feeds daily will probably have to be given for a month. If the weight is over 3^ lb., ten feeds three weeks, then daily should be given for two to eight feeds daily. The exact amount and number of the feeds depends After
seven to ten
on :
(1) The birth weight. taken. (2) How the feeds are the always hungry and takes well, be
increased
cyanosis
are
quite rapidly.
If the infant is amount
Refusal
often
can
of feeds
and
danger signs.
If stationary after, say, (3) The weight curve. ten days, increase cautiously the amount per feed. and this should By far the best food is breast milk,
always
be
given
when
drachms of colostrum the first few
during
even
if
only
a
few
breast milk can be expressed days. The smaller and more
or
premature the infant the In
possible,
maternity hospitals,
more
important this becomes.
where there is
always
a
good
Dr. Francis J. Hector
306
expressed breast milk available, artificial rarely given for the first three to four weeks. private practice every attempt should be made to of
supply feeds In
are
obtain breast milk for the infant for
least
at
one
month. breast
Failing are :
milk,
suitable
artificial
feeds
?
At (1) A modified milk mixture, peptonized. Queen Charlotte's Hospital the mixture is made as follows
:
?
W hole milk
..
..
..
10
Fat
.
.
.
.
10
?
..
..
1
,,
fat)
.
"wliey
Lactose Cream
This to
is
three
decreased
.
..
(50
per cent,
peptonized weeks
for
the
by twenty
.
three
After two
is
subsequent
on
(2) Whole milk diluted with
?
hours.
days. an
5 per cent, cane sugar. Should any of the numerous
water
\
.
peptonization
minutes
oz.
gradually alternate
equal quantity of
plus
proprietary articles
be
used, they should be made up in the proportions recommended on the container ; but the amount of the feeds must not be
as
recommended, but
as
stated
above.
technique of feeding varies with the birth weight, the general condition of the child and its ability to suck well. The child must not be put to the breast for the first few weeks of life, especially if it lS a very small. A bottle with a large hole in the teat, spoon, a medicine dropper, or a nasal catheter may With small premature infants one would be used. generally begin with a medicine dropper or pipette. The infant is not to be taken out of the cot. The hand of the nurse is placed behind its head and back and The
Care
and
the infant
Management
of
Premature Infants
307
raised up a little way from the The feed must be given at the temperature
pillow.
gently
of 100? and between the
given slowly, allowing plenty sips for the infant
to swallow.
and the
is
of time When
to suck well without
ability strength gained, getting tired, use a bottle, the teat having a large hole so that the milk flows easily. Should the child be lethargic and suck badly the feeds should be given with a nasal catheter. Rigid asepsis is necessary for this as for all methods of feeding. premature infant is extremely susceptible to infection, and nobody with the slightest sore throat In private practice or cold must be allowed near it. The
it is better to exclude everybody from the infant's room, and allow only the parents to see the child for a very short time daily for the first month, if it is very
develop a cold, she should wear a face mask while attending to the child, or ?better still?another nurse should take her place small.
Should the
nurse
until the cold has gone. The injection of whole blood
or serum
often
saves
life, apparently by conferring upon the child those antibodies which it lacks, and this especially applies Excellent results have to the very premature child. this treatment. The with been obtained in Germany blood is
Any healthy donor need to group the blood. of injection 2cc. are given, 3cc. 011
given intramuscularly. and there is
may be used, On the first day the third
day, 5cc.
subsequent have been
alternate
given.
on
no
the fifth
day give
5
cc.
The strictest
day,
and
until ten
on
each
injections
aseptic precautions
must, of course, be taken. In conclusion, it may be stated that 95 per
cent,
of the credit for the survival of a small premature infant is due to its nurse, and a great deal has been
308
Care
and
Management
accomplished by
a
nursing
of
Premature Infants
staff imbued with sufficient
enthusiasm and determination to
unpromising
infants.
save even
Incredibly
the most
small infants have
some clinics with survived, premature children weighing between one and two
thus
pounds
and the
success
has been remarkable.
of
CARE AND MANAGEMENT OF PREMATURE INFANTS. BY
Francis J.
Hector, M.D., F.R.C.S.,
Assistant Obstetric Physician and Gyncecologist, Bristol General Hospital.
During the last few years the of premature infants has
care
and management
acquired additional extensively studied importance, in all civilized countries. This has been largely due to the widespread adoption of well-organized ante-natal treatment, and considerably more inductions of labour are now performed in the interests of the mother or and has been
more
the child.
Apart infant, or
from the usual desire to
however
domestic
unpromising
reasons
at
rear
a
premature
birth, various family
may make its survival
a
matter
of supreme importance. The death of the premature infant of an elderly primipara where labour has been induced, shall we say, on account of severe toxaemia, may be in the nature of stark tragedy to its parents. Furthermore, in every case the mother has had perhaps weeks of pregnancy to endure, with all its trials and discomforts, and has every reason to expect a live baby as her reward.
thirty-four
It has been
alleged by
some
that the
rearing
of
premature infants is not, from a purely economic or sociological standpoint, worth the enormous amount 301
302
Dr. Francis J. Hector
entailed, and that such infants grow up weak and rather useless individuals, who may eventually
of
care
become
charge on their fellows. Recent investigations in Germany, however, have shown that premature children, having survived the first few critical weeks, have just as much chance of becoming good workers, a
thinkers
athletes
any other
type of child. The two most important points in the management of premature infants are, of course, temperature regulation and feeding. The regulation of temperature or
as
is the first and constant
infant's
tenacity
difficulty.
of life
must
Even the full-time
sometimes
be
sorely
considering the circumstances which not infrequently obtain at its birth during the winter-time. Projected into a chilly room or labour ward, seized and subjected to even dangerous solicitude, its temperature must often fall to an alarming degree, and this at a time when important anatomical changes and delicate metabolic readjustments are commencingIt may also be pointed out that by reason of its own tested,
metabolic activities the temperature of the foetus in utero is 0-5? higher than that of its mother. Small wonder is it, therefore, that numbers of premature " are certified as dying of prematurity" or
infants "
congenital debility" during the first few days of life, when their deaths were really due to the effects of cold sustained immediately after delivery. Once the
temperature has been allowed to fall for even a very short time in the case of a premature infant, it
unlikely that the effects of such neglect can ever be remedied by any later treatment, however thoroughImmediately after delivery, and before the cord is tied, the infant must be wrapped in a warm blanket. Tying the cord and weighing must be accomplished with the utmost dispatch, and the infant is then
is
Care
Management
and
Premature Infants 303
of
in gamgee, covered with blankets and put into the cot with three rubber hot-water bottles at For 160?, or better still with an electric blanket.
wrapped
hospital
or
nursing home practice the latter is
a
very with
It costs about
desirable article.
thirty shillings, waterproof cover, and It can be can be obtained from any surgical stores. and has a switch used off any voltage for regulator additional six
an
for
shillings
a
The 160? temperatures, 100?, 130?, 160?. be used. The electric blanket is temperature should free from danger, and should be used arched over the three
infant between the
enveloping blanket
covering
Immediately
two years.
past
ordinary
have
been
Queen Charlotte's Hospital during
obtained with it at the
and the
results
Excellent
blankets.
after
reaching
the
ward the rectal temperature must be taken with a subnormal thermometer with a low limit of 88?. All other thermometers are quite useless for premature infants. have
a
great care is taken an infant may rectal temperature of 90? ten minutes after Unless
up quickly in blankets. If the infant is below 4 lb. the rectal temperature should be taken 2-hourly by day and night for a fortnight, and 4-hourly if between 4 lb. and 5 lb. It
delivery, although wrapped
is
absolutely essential
97? and 99?.
to
Failure to
the
temperature between do this must be put down to
keep
part of the nurse. The electric blanket should be kept on at 160? day and night for a
inefficiency
on
the
Good very small baby. results can be obtained with an ordinary cot and The hot-water bottles if sufficient care is taken. in the
fortnight
or a
Below
oiling
or
a
a
should
be
covered
with
of blanket.
layer
birth
bathing
of
bottles
hot-water
rubber flannel
case
weight
of 4
must be made.
lb. No
attempt at premature baby, no
x
Vol. XL1X.
No. 18G.
304
Dr. Francis J. Hector
weight, should be oiled without temperature having first been taken and
whatever the birth the rectal
found to be within normal
oiling
limits, and
be done very rapidly to In the cot the baby should lie
must
of heat.
then the avoid loss
even
absolutely only a soft flat pillow beneath the head. The piling on of many blankets should be avoided, as they may actually weigh down the chest. A hand placed between the blankets and the baby flat with
will
that
ensure
Plenty
of
round the cotton
be
former
baby's head,
wool
tendency to when placed do not
the
air should be
warm
over
are
not
too
allowed which
to a
heavy. circulate
bonnet
of
& placed. There over-clothing and over-blanketing, and or
at
gamgee
the
get enough
is
bottom air.
is
of
a
cot
the infants
The
baby's position may changed occasionally by laying it on the opposite
side. No food should be
given for the first six hours,
sips of water, 5 per cent, glucose, or 5 per cent, glucose in saline, should be offered. To avoid
then small
dehydration sips
of water should also be
feeds.
frequency of experience of extreme
The amount and
important,
and
given between feeds is very variations i11
country and abroad makes important factor is not so much
feeds recommended in this it
probable quality overfeeding
that the
quantity of the feeds. Gross common mistake, and many premature infants are killed by too much food. Twelve hours after delivery begin with one drachm feeds the
as
the
is
the
2-hourly day and night, in the case of infants over 3J lb. Under 3J lb. give \ drachm 2-hourly. Increase the feeds very gradually by J to 1 drachm daily f01 the infant over 3|- lb. and by \ drachm daily fQl the infant under 3J lb. The rate of increase must
Care
and
Management
of
Premature Infants
305
by watching the effects of the feeds the infant. On the slightest evidence of cyanosis
be determined on or
to take the whole feed reduce the amount
refusal
to half and
the feeds
give
to
gradually reverting Suitable feeds for 1.
1 dr.
2. 3. 4.
2
Day
a
hourly 2-hourly
baby
of
1|?
12
2
?
?
12
?
?
12
?
>>
12
?
?
10
?
?
10
6.
3
7.
3
a
short time,
feeds next lb. would be :
3f
day.
?
12 feeds.
2-hourly. ?
5.
for
(omit
two
night feeds).
days the infant can usually be and if the weight is less than got on to ten feeds daily, 3-3, lb. ten feeds daily will probably have to be given for a month. If the weight is over 3^ lb., ten feeds three weeks, then daily should be given for two to eight feeds daily. The exact amount and number of the feeds depends After
seven to ten
on :
(1) The birth weight. taken. (2) How the feeds are the always hungry and takes well, be
increased
cyanosis
are
quite rapidly.
If the infant is amount
Refusal
often
can
of feeds
and
danger signs.
If stationary after, say, (3) The weight curve. ten days, increase cautiously the amount per feed. and this should By far the best food is breast milk,
always
be
given
when
drachms of colostrum the first few
during
even
if
only
a
few
breast milk can be expressed days. The smaller and more
or
premature the infant the In
possible,
maternity hospitals,
more
important this becomes.
where there is
always
a
good
Dr. Francis J. Hector
306
expressed breast milk available, artificial rarely given for the first three to four weeks. private practice every attempt should be made to of
supply feeds In
are
obtain breast milk for the infant for
least
at
one
month. breast
Failing are :
milk,
suitable
artificial
feeds
?
At (1) A modified milk mixture, peptonized. Queen Charlotte's Hospital the mixture is made as follows
:
?
W hole milk
..
..
..
10
Fat
.
.
.
.
10
?
..
..
1
,,
fat)
.
"wliey
Lactose Cream
This to
is
three
decreased
.
..
(50
per cent,
peptonized weeks
for
the
by twenty
.
three
After two
is
subsequent
on
(2) Whole milk diluted with
?
hours.
days. an
5 per cent, cane sugar. Should any of the numerous
water
\
.
peptonization
minutes
oz.
gradually alternate
equal quantity of
plus
proprietary articles
be
used, they should be made up in the proportions recommended on the container ; but the amount of the feeds must not be
as
recommended, but
as
stated
above.
technique of feeding varies with the birth weight, the general condition of the child and its ability to suck well. The child must not be put to the breast for the first few weeks of life, especially if it lS a very small. A bottle with a large hole in the teat, spoon, a medicine dropper, or a nasal catheter may With small premature infants one would be used. generally begin with a medicine dropper or pipette. The infant is not to be taken out of the cot. The hand of the nurse is placed behind its head and back and The
Care
and
the infant
Management
of
Premature Infants
307
raised up a little way from the The feed must be given at the temperature
pillow.
gently
of 100? and between the
given slowly, allowing plenty sips for the infant
to swallow.
and the
is
of time When
to suck well without
ability strength gained, getting tired, use a bottle, the teat having a large hole so that the milk flows easily. Should the child be lethargic and suck badly the feeds should be given with a nasal catheter. Rigid asepsis is necessary for this as for all methods of feeding. premature infant is extremely susceptible to infection, and nobody with the slightest sore throat In private practice or cold must be allowed near it. The
it is better to exclude everybody from the infant's room, and allow only the parents to see the child for a very short time daily for the first month, if it is very
develop a cold, she should wear a face mask while attending to the child, or ?better still?another nurse should take her place small.
Should the
nurse
until the cold has gone. The injection of whole blood
or serum
often
saves
life, apparently by conferring upon the child those antibodies which it lacks, and this especially applies Excellent results have to the very premature child. this treatment. The with been obtained in Germany blood is
Any healthy donor need to group the blood. of injection 2cc. are given, 3cc. 011
given intramuscularly. and there is
may be used, On the first day the third
day, 5cc.
subsequent have been
alternate
given.
on
no
the fifth
day give
5
cc.
The strictest
day,
and
until ten
on
each
injections
aseptic precautions
must, of course, be taken. In conclusion, it may be stated that 95 per
cent,
of the credit for the survival of a small premature infant is due to its nurse, and a great deal has been
308
Care
and
Management
accomplished by
a
nursing
of
Premature Infants
staff imbued with sufficient
enthusiasm and determination to
unpromising
infants.
save even
Incredibly
the most
small infants have
some clinics with survived, premature children weighing between one and two
thus
pounds
and the
success
has been remarkable.
of
