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The Rearing of Premature Infants
by Means of Incubators.

By H. D. Chapin, M.D., et al

Pediatrics 9(1):34-38, 1900.
A slightly shortened version also appeared in:
Archives of Pediatrics 17:37-39, 1900.

 

Dr. H. D. Chapin opened the discussion of this subject. He said he had records of seventy-three premature children that had been treated in an incubator. Of this large number only two had lived. He then presented the elaborate incubator, devised by Mr. Putnam of Boston, and recommended by Dr. Rotch. Forty prematurely born babies had been in this incubator. All of them had died, although some had lived as long as three weeks. It had seemed to him that one great defect of this complicated incubator was that it did not derive its supply of air from outside of the room. More recently he had saved two infants by putting them in bed, wrapping them in cotton, and keeping up the body warmth by the use of hot bottles. Special attention was directed to the fact that these babies had been breast-fed, and this he believed to be the great essential to success in the rearing of premature infants. Regarding the children that had been treated in the Boston incubator, he would say that one of these infants had weighed only one pound and thirteen ounces, and that the average weight had been about four pounds. These very tiny infants were not even able to swallow, and must be fed by the stomach pump. They had ordinarily been kept at a temperature between 95° and 98° F. Most of them had come from the tenement houses after great exposure, and had indeed been almost moribund at the time of reaching the hospital.

Dr. Allen M. Thomas said that about fifteen years ago, he had begun the use of the incubator at the Emigrant Hospital. The first occupant of the incubator had weighed two and three-quarters pounds, and had been born on the twenty-eighth or thirtieth week. It had been kept in the incubator three months, and had been subsequently reared successfully. His last experience with a premature baby had been in the Lyon incubator. At birth this child had weighed three pounds and eleven ounces. Within twenty-four hours, the temperature of the infant had varied fifteen degrees. Its temperature had risen to 108° F. at first, and the child had gone into collapse. It had then been removed from the incubator, and resuscitated, but in a few hours its temperature had fallen to 93° F. This enormous fluctuation of body temperature was all the more remarkable, because at this time the child had not been given any food, only a little sterile water. The child had gone on well after this, and was now seven months old. It was not uncommon to find great fluctuations of temperature, but not so great as the one just mentioned. He had frequently known the temperature to rise to 105° F. The season of the year had considerable influence over the result, the late spring and summer being especially unfavorable. He had had only six incubator cases in his private practice, but had followed twenty cases occurring in the Nursery and Child's hospital. He had also received certain data concerning forty cases treated by Dr. Adriance. Of this last series, sixteen had recovered. Of the fatal cases, death had been attributed in eleven to prematurity, the others dying later -- perhaps in about a year -- of marasmus or some other trouble. A premature infant, weighing three pounds, or less, was exceedingly hard to save. These infants should not be handled for weighing or feeding. The infant should be placed in a flannel bag, slit down so that the nurse can reach the baby. No incubator would work well at all temperatures. The Lyon incubator was a good one, but was too expensive for general use. Most incubators would require, occasionally at least, a stream of oxygen.

Dr. Edward A. Avers said that his own experience with premature children was represented by forty-one, out of four thousand confinements. The average weight of these children had been four pounds and five ounces. The average period of gestation had been thirty weeks and two days. Seventeen had lived, giving a mortality of 77.2 per cent. Eleven had been treated in incubators, and nine of these had died. All had been fed with breast milk. In his opinion, the air chamber of an incubator should be about six feet square; the air should come from out-doors, and the temperature should be uniform when entering the living chamber. The air should enter from several places away from the child, and should be slightly moist. The water tank should be small. The temperature should not be allowed to go above 95° F. At the present time, he would prefer to place a premature baby in a room by itself, warming and ventilating this room, and making it the incubator. The nurse would have to stand this temperature just as the stokers did on warships.

Dr. J. E. Winters said that his first experience with a premature baby had been sixteen years ago. This baby had been born at the sixth month. That child was living and well, although no incubator had been used. Another child that had been refused at the Lyon incubator place had been brought to him at the medical college, and had been successfully reared on laboratory milk. These infants had been very carefully wrapped and protected from changes in temperature. None of these babies could have suckled at the breast. They had been fed for a long time with a medicine dropper, and all upon milk. The prescription for the milk for the last of these premature infants had been: fat 2, sugar 10, and proteids .25; half an ounce at a feeding. As a result of experience with the Walker-Gordon Laboratory milk, he now believed that no child should be allowed to go even three days after birth without feeding. If this practice of feeding babies immediately after birth were adopted, the children would do better; they would lose less weight at first, and have less temperature changes. At the end of the first week he would use 2.5 per cent. fat, in the second week 3 per cent. fat and .5 per cent. proteids. All of the children had been fed on raw milk, and extreme care had been taken not to give too much, for, if gastric disturbance were excited, it would almost certainly be fatal. He believed that the sterilization or Pasteurization of milk had more to do with the death of these premature infants than had the incubators. If the milk were simply diluted until a low percentage of fats and proteids were obtained, he believed the results would be much better than had been stated this evening.

Dr. Voorhees said that for the past two years incubators had been used at the Sloane Maternity Hospital, chiefly the Lyon incubator. They had preferred, in most cases, to keep the temperature in the incubator at 88° F. One hundred and six babies had been placed in the incubator. Of this number, 29 had died within three days, some of them in a few hours. Of the remaining 77, 13 had died while in the hospital, most of them from atelectasis. He knew that 13 had died out of the hospital, and that at least 25 were alive today, one of them being a little over two years old. This gives a mortality in the hospital of 39 per cent., and the mortality of all the cases followed, 50 per cent. They had been fed hourly at first, beginning with half a drachm to one drachm of a sugar solution, and keeping this up for a few days. After this they had been given breast milk. When this could not be obtained, the premature infants had been fed on modified milk composed of fats 1, sugar 6, and proteids .33 per cent. As these children exhibited a strong tendency to atelectasis, it was well occasionally to tap them and make them cry vigorously.

Dr. Vanderpoel Adriance said that atelectasis was one of the most frequent causes of death. These attacks of atelectasis were the most frequent during the first two or three days. They seldom occurred after the tenth day. Up to the fourth month of intra-uterine life it should be remembered the lungs were composed of bronchi, surrounded by embryonal tissue, and no alveoli were to be seen. It was only after the fourth month that buds appeared and subsequently developed into alveoli. In the prematurely born, these alveoli had not had an opportunity to dilate. Again, the ribs were cartilaginous, and when the child gasped, the ribs sank in, and air was not drawn into the lungs. Another cause was that the respiratory centre was prematurely called upon to perform its function. The popular notion was that the incubator was the sole means of saving the premature infant, but he believed that the feeding was probably the most important. The milk of prematurity contained an excessive amount of proteids, even more than during the colostrum period. This was partly accounted for by the fact, that the lacteal secretion was partly the product of filtration from the blood. The necessity for a low percentage of proteids in the milk was not generally appreciated. When the mother's milk contained so much proteids, the milk could be pumped out of the breast and diluted with water, but a still better plan was to get for a wet-nurse a woman whose child was only about one month old.

Dr. E. Libman said that at one of the Parisian clinics a number of incubator children had died of erysipelas. This had ceased on sterilization of the incubator before using it any further. The reporter of this series of cases of infection had expressed the opinion that a large number of incubator babies died from infection.

Dr. Chapin, in closing the discussion, called attention to the necessity of sharply distinguishing between statistics drawn from private practice, from the better equipped hospitals, and from the wretched infants taken from the tenements.

 


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