Stand back in the shadows of a hospital corridor and spy upon the first meeting between a baby and his family. The blanket is carefully peeled back, and for the first time the child and family meet. The grandmothers loyally out-coo each other, with ‘My, what a darling; it has the cute Smith nose. See the little Jones ears.’ The father, who may have seen his heir for one blurred moment in the recovery room or in one of the corridors, is speechless—not with pride but with anxiety. He has seen advertisements with new babies in them. They were beautiful—but thisl In silent apprehension he waits for the doctor and takes him aside. ‘Frankly, Doctor, what’s wrong with my baby? That’s the funniest-looking thing I ever saw. Why, his head comes up to a point like an egg. When he, his face is all cockeyed, and his nose looks as though Joe Louis had taken a poke at it.’
The doctor brusquely reassures him. ‘Perfectly normal! He’ll be all right. Don’t worry, just a case of primiparous molding with a slight paralysis of the facial nerve. Pressure by the, you know. Oh, the nose! Many of them have that queer appearance at birth. Fortunately all babies improve.’ Off he goes. The dazed father retreats to an armchair to think and worry, worry and think.
In the next several paragraphs I have attempted to answer some of the questions about the new baby which people would like to ask their doctor but do not for fear that they would sound silly to the busy man. This article is in no way intended to act as a guide in baby care after you leave the hospital. There are several excellent books written by highly competent pediatricians which cover this field with distinction, some very moderately priced.
The Molding Head
Molding of the fetal head is a perfectly normal, harmless process, most pronounced in first births. The heads of infants presenting by the breech, or delivered by Cesarean section before labor begins, do not have the opportunity to undergo molding, and are therefore rounded and normal in appearance. The egg-shaped, molded head rounds spontaneously within three or four days.
Swelling beneath the Scalp
In addition to distortion in shape of the head, the child is frequently born with a thick, softish swelling of that portion of the scalp which fitted into the aperture of the cervix when the latter was partially dilated. This swelling, termed caput (Latin: ‘head’), disappears spontaneously with- in a few days. Occasionally after spontaneous births, but more frequently after difficult operative deliveries, there may be a different type of swelling beneath the scalp; in this case a blood clot (cephalhematoma) accumulates between the bone and the attached membrane covering it. Usually a cephalhematoma does not appear for from twelve to twenty-four hours after delivery. It may continue to enlarge for a few days, then remains constant for several weeks, and eventually begins to disappear. A thin layer of new bone grows out from the edges of the fluid-like bump, compressing the clot between it and the old bone beneath. In the end it is merely an inconspicuous irregularity of the head, and when I sit in the balcony at a theater I fancy I can sort out the baldheaded men beneath who had cephalhematomas several decades ago. (May I point out that I have not attempted to prove or disprove this theory.) The clot, being external, outside the bone, of course cannot damage the brain.
Since the baby usually faces back toward the mother’s curved sacrum, it sort of skids out on its nose. At this period the nose is formed of malleable cartilage, the result being that any close resemblance between the nose at birth and the nose a week or two later is largely accidental.
The facial nerve, the nerve which innervates the muscles of expression, makes its exit from the brain on each side at the base of the skull, just below the ear. Not uncommonly one of the forceps blades makes pressure over it, causing temporary paralysis of the muscles it supplies. The infant is unable to close the eye on the affected side, and the paralyzed muscles of the mouth are pulled over toward the normal side, making the face look alarmingly askew. I have never seen a case which did not clear up completely; many within the first twenty-four hours.
Hemorrhage in the White of the Eye
Children are sometimes born with hemorrhages in the white of the eye; these clear up in about ten days. It is not unusual for a child to develop a pussy secretion in one or both eyes within the first twenty-four hours if silver nitrate was instilled in the eye as prophylaxis against gonococcus infection. It does not portend a cold or infection, but is the result of the chemical irritation which silver nitrate often sets up. Within a day or two the condition disappears without treatment.
Eye Color, Cross-Eyedness, Tears
The eye structure of the newborn is not completely matured. In the first place, the color is not fixed. Most children are born with a gray-blue or transparent liquid blue iris (the colored portion of the eye). The former type of iris usually begins to fleck with brown around the third month and gradually develops into a hazel or dark eye, while the latter is likely to retain its original blue shade. Secondly, new babies are unable to focus the eyes properly; this causes them all to appear cross-eyed, but the vast majority are not. The ability to focus the eyes is gradually acquired, and the infant can progressively maintain a steady gaze for periods of increasing length. If by the end of the first year there is no marked improvement in eye coordination, an eye specialist should be consulted. A third difference between the eyes at birth and the same eyes a few months later is the presence of tears. No matter how lustily the newborn squalls, his cheeks remain dry. The first tears arrive when the child is about three months old, and from then on for several years there is rarely a dry day.
Ability to See and Hear at Birth
The question is frequently asked whether the infant sees at birth. The answer is, yes—at least it discriminates between light and darkness. This can be determined by flashing a light into its eyes. The pupils promptly contract, and when the light is removed they dilate. Furthermore, some infants follow a bright light when they are a day or two old, while others do not acquire this ability for a few weeks or months. There is no question that an infant hears almost immediately. He may appear deaf for a day or two, but soon demonstrates a ‘startle reaction’ at a sudden loud noise such as the slamming of a door.
This formidable name denotes what was a formidable disease. Beginning about twenty years ago, it was observed that 10 to 15 per cent of very small premature infants developed at the age of about a month a tragic eye condition involving the retina, which led to either complete or partial blindness.The conundrum was: why did this new disease suddenly appear? Some thought it was a new kind of viral infection; others thought it was due to some therapeutic agent newly given to these prematures, such as iron; and still others postulated a lack of a vitamin because of alterations in formulae—namely, Vitamin E. Despite all the theories, the baffling curse continued to exact its cruel toll, and institutes for the blind are peopled with its victims. Within the past decade the cause has been found; the villain, man’s unsuspected benefactor, oxygen. It has been demonstrated without question that protracted exposure to oxygen concentration above 40 per cent will produce the lesion in newborn experimental animals. In addition, if the smallest human premature newborn is given oxygen in a concentration less than 40 per cent it does not develop retrolental fibroplasia. To make safety doubly safe, in most premature nurseries they usually wean even tiny babies completely from supplemental oxygen within the first forty-eight to seventy-two hours by gradually diminishing the concentration from under 40 per cent to 0.
With the institution of these precautions, retrolental disease has become a completed and dramatic chapter in the history of medicine.
Sneezing, Hiccuping, and Snorting
Newborn babies sneeze at the least provocation or without any provocation, so that even a series of sneezes does not mean that the child has caught cold. As a matter of fact, it is almost unheard of for a baby less than two weeks old to catch cold.
The hiccuping mechanism seems just as sensitive as the sneezing apparatus, and the hiccup is quite as benign. The infant may snort, grunt, and wheeze in a most disturbing fashion while it sleeps. This is due to a dropping back of the lower jaw, which places the tongue against the roof of the mouth, thus narrowing the airway. It is of no moment.
The skin of the newborn is marvelously sensitive, so that minor lesions are common.
Prickly heat due to overactivity of the sweat glands causes clusters of minute pink pimples surrounded by areas of pink skin. The application of calamine lotion or a weak solution of bicarbonate of soda, a bland powder, and—this should be especially emphasized—lighter clothes and covers, promptly cure the condition. There still seems to be a belief that a new infant must be kept very warm with layers of woolen clothing and several blankets.
This is true only of premature infants, and such warmth is provided them by special heated incubator-cribs. Most small ‘premies’ lie as naked as a jaybird except for a diaper, while enjoying Florida warmth even in the winter.
Alimited to the area covered by the diaper, diaper rash, is quite common, and it usually means poor diaper hygiene. One of two things commonly causes it: either the soap in which the diapers have been rinsed is too strong, or the diapers have not been boiled long enough to kill the bacteria. If bacteria are present, they free ammonia from the urine, which irritates the skin. Stricter attention to the washing of the diapers and temporarily greasing the skin of the affected area with cold cream produce a prompt cure. The diaper should be changed only at each feeding, unless it is obviously soiled by a stool. Changing it more often disturbs the child.
When you go home from the hospital, keep in mind the fact that the commercial diaper companies do a magnificent job, and using their services is no longer a luxury, it is almost a necessity. Their diapers are uniformly non-irritating, for they are equipped to do better in this department than you can. Furthermore, the physical fatigue their services save the new mother is not inconsiderable.
The susceptibility of the skin to infection at this time makes it obligatory that all nursery linen and clothes be sterilized. For the same reason, the attendants have to wash their hands carefully before touching each child. The most common of these skin infections is impetigo, which takes the form of little isolated, pea-sized blisters, each surrounded by a narrow red ring. When the blister is broken, a moist or dry red scab forms. The lesions appear in crops. Today the condition is most successfully treated with one of the antibiotic ointments. Since the condition spreads, your child may be banished to the isolation nursery.
Small strawberry marks are quite common on the forehead, above the bridge of the nose, on the upper lids, and on the nape of the neck. These pale in the course of months, and many disappear entirely; if they do not, the expert application of radium makes them fade away with the magic of Aladdin’s lamp.
The nails of a small infant should be kept pared to prevent its scratching its face with the purposeless, uncontrolled movements of its hands.
Thrush, a fungous infection, coats the inside of the mouth with a white film resembling curdled milk, which can be peeled off, leaving a few bleeding points and an inflamed area. The infection causes no particular difficulty except in infants already in poor health. A ready cure is effected by swabbing the inside of the mouth three or four times with Mycostatin, an antibiotic specific for the causative fungus, Candida.
Temporary Breast Englargement
It is not unusual for the breasts of both boys and girls to enlarge on the third or fourth day of life. This is due to chemicals () received from the mother during intrauterine existence; these hormones had no effect at that time because they were neutralized by chemicals secreted by the placenta. Usually the enlargement begins to wane in a few days and is gone by the eighth or ninth day. No massage, ointments, ice, or any other treatment is necessary; in fact treatments do more harm than good. Sometimes the growth of breast tissue is so marked that a little secretion can be expressed from the nipple. This is called witch’s milk, and during the medieval period it was accredited with miraculous healing properties. Infrequently one or both breasts become very red and tender. On two occasions I have seen abscesses form which cleared up a few days after incision.
Changes in Sex Organs
Female infants occasionally have a little bloody vaginal discharge toward the end of the first week. It is a form of menstruation, also hormonal in origin, which is of no significance and disappears not to return until pubescence is reached.
In infants which present as frank breeches, buttocks first, marked swelling and discoloration of the scrotum and penis in the male and of the labia in the female may occur during labor and persist for a few days thereafter. Everything clears up without permanent damage.
Circumcision (Latin: ‘Around’ + ‘cut’), the cutting off of the prepuce or foreskin, is probably the oldest surgical operation extant, except for omphalotomy, the severance of the navel cord. Some of the earliest Egyptian sculpture depicts circumcisions. The operation was and still is practiced as a religious rite or tribal custom by peoples scattered all over the world. In some peoples it is practiced as a birth rite, in others as an adolescent ceremony, while in others it is reserved as a premarital ritual to be performed when the individual reaches sexual maturity. In such instances usually both sexes are circumcised; in the female the prepuce or fold of skin surrounding the clitoris is removed. Finally it is practiced by some upon old men as a rite of senescence.
Our chief concern is not its history but its present place in medicine. There are two distinct medical points of view: that which favors its routine use on all male infants, and that which would reserve it for babies in whom the foreskin cannot be drawn back readily. The believers in the first theory say that circumcision makes the care of the male infant a far simpler matter, for, if he is not circumcised the foreskin must be retracted during theand the penis beneath it washed carefully. They fear that this necessary handling of the genitals encourages masturbation. Both infection and cancer of the penis in later life are decidedly less frequent in the circumcised. Those who oppose routine circumcision assert that it is an unnecessary surgical procedure and, even though its danger is slight, it carries with it a minimal risk.
The proponents of routine circumcision seem to be making wholesale converts, and among the private-patient group more than 75 per cent of newborn boys are circumcised today. In many hospitals it is a routine procedure unless the parents object, while in others it is done only on request or if difficulty in retracting the foreskin necessitates it.
Circumcision is performed at any time within the first week of life, provided the baby is in normal health and of term weight. If he weighs less than six pounds, circumcision is usually postponed until he gains up to this figure. Many obstetricians and surgeons give an intramuscular dose of Vitamin K before the operation, just to make sure the baby’s blood clots well. The child is placed upon a padded Y-shaped board, to which it is secured by towels and safety-pins, each leg being strapped to an arm of the Y. Under sterile precautions—the operative region is prepared with antiseptic solutions, and the operator scrubs as for any other operation—the foreskin is cut off with a knife or scissors, and sutures (stitches) are placed to control bleeding. If the new ‘Gompco’ clamp is used, no stitches are necessary, for post-operative bleeding is controlled by compressing the small blood vessels between two smooth steel surfaces for three to five minutes.
No anesthetic is used. Some pacify the child during the operation with a sponge dipped in wine, whisky, or sugar water. Convalescence is almost always prompt and uninterrupted. If the operation is done by a surgeon or an obstetrician, complications following it are extremely rare; they occur with slightly greater frequency after Jewish ritualistic circumcision, which is usually performed by a man without medical training.
It is noteworthy that the early Jews, who made many interesting observations in both medicine and hygiene, fixed the operation for the eighth day. This was probably arrived at by trial and error. Not an inconsiderable number of those done before the eighth day probably bled dangerously, while those done on the eighth day rarely bled excessively. Modern medicine has found a possible explanation in Vitamin K. This vitamin, produced by bacterial action in the intestinal tract, contributes to the process of blood-clotting. Thedoes not manufacture its own Vitamin K in utero, but some of the mother’s passes across the placenta into the baby’s circulation. At birth the level in the baby’s blood is relatively low, and it drops even lower during the first few days of life, since the child cannot manufacture its own Vitamin K until it swallows a healthy supply of germs. The baby’s intestinal tract then begins to produce its own Vitamin K, and the supply gradually rises until it reaches an adequate level when the baby is a week old.
Until the past decade or two, circumcision of the female was thought occasionally necessary in an adolescent or young woman, but it is never done any more. The pathological behavior for which it was deemed curative is now more wisely handled through psychotherapy.
About half of the mature babies—the figures of different authorities vary from 15 to 80 per cent—and almost all premature babies develop a transitory yellow tint of the skin and eyes on the third or fourth day of life. The depth of color increases for two or three days and then begins to pale, and the normal pink skin color is soon restored. Ordinarily this icterus neonatorum—of the newborn—is of no significance. It can be distinguished from jaundice associated with hemolytic disease (erythroblastosis) because the latter appears on the first day of life; the former not before the third.
Eighty-five per cent of American and European Caucasians, 93 per cent of Negroes, and 99 per cent of Mongols are born with an inherited substance in the blood termed the Rh factor, so termed because its presence was first noted in the Rhesus monkey. (An exception to the usual Caucasian figure is found in Jews, who are 93-per-cent positive.) Such persons are called Rh-positive; the 15 per cent, 7 per cent, and 1 per cent respectively lacking it are called Rh-negative. The Rh substance is transmitted as a Mendelian dominant. If the parents of the husband as well as those of the wife were Rh-positive (homozygous—pure Rh-positive), all the children will be Rh-positive. On the other hand, if both husband and wife had one Rh-positive and one Rh-negative parent, they would be partial positives (heterozygous), and theoretically such a couple would produce, in every four children, one homozygous (pure) Rh-positive child, two heterozygous (partial) Rh-positive children, and one child who was Rh-negative. Possession of or lack of the Rh factor does not make the slightest difference in health, vigor, or longevity.
Marriages between Rh-positive people—whether they are pure or partial positives—marriages between Rh-negative people, and marriages between Rh-positive women and Rh-negative men never develop any reproductive difficulty in regard to the Rh factor. The only mating which can potentially cause trouble is the marriage of an Rh-negative woman to an Rh-positive man. Even then, in over 90 per cent of such unions, no Rh difficulty ever arises. In less than 10 per cent, the woman becomes sensitized to the Rh factor, a substance foreign to her body—just as foreign as typhoid bacilli or polio virus. Sensitization expresses itself by the creation of antibodies, chemical substances which attack the specific foreign substance against which an individual has become sensitized. In the case of typhoid bacilli or polio virus, when an individual has been sensitized (immunized) by either having contracted typhoid fever or infantile paralysis, or having been previously injected by a properly prepared vaccine, when live organisms enter his body a kind of alarm bell rings which marshals the specific antibodies against the specific invader. In the case of an Rh-negative individual previously sensitized against the Rh factor, antibodies are ready and on the alert to be marshaled against any Rh-positive cells which may gain temporary access to his body.
How does an Rh-negative woman become sensitized? It is by either the previous transfusion or injection of blood from an Rh-positive donor or pregnancy with a fetus that has Rh-positive blood cells. A transfusion of Rh-positive blood given an Rh-negative seven-year-old girl at the time of tonsillectomy left her severely sensitized. A five-year-old child was given an injection into the buttock of a small amount of blood from her father to transfer immunity to measles. Seventeen years later she came to me in her first pregnancy, already significantly sensitized.
However, most women are first sensitized during pregnancy. When the husband is homozygous (pure) Rh-positive all his fetuses will be Rh-positive; if he is heterozygous (partial) and his wife Rh-negative, half of the fetuses will be Rh-positive and half Rh-negative. For sensitization by pregnancy, Rh-positive red blood cells from the fetus must enter the maternal circulation. Such a transfer from fetal to maternal circulation must be infrequent during pregnancy, for it is rare for an unsensitized Rh-negative woman to become sensitized during the course of pregnancy. She is far more likely to be sensitized at delivery, when apparently a shower of fetal cells may be squeezed into her circulation with the delivery of the placenta. The conundrum is: why is only one Rh-negative woman in ten, married to an Rh-positive man, sensitized by pregnancy?
What are some of the practical points from all this theory?
The main one is that if you are just plain Jane Doe about to marry Joe Doaks, and neither knows his Rh, you have approximately one chance in four hundred of bearing a child with erythroblastosis. So don’t worry about the Rh. If you do know that yours is the unwelcome Rh combination —you Jane, are negative, and Joe positive—there are ninety-nine chances in a hundred that you will not have the slightest difficulty with the Rh factor in your first pregnancy, and ninety chances out of a hundred that no Rh problem will develop if the two of you have a dozen children. Furthermore, even if you become sensitized, by the combination of good obstetrics, good pediatrics, and the liberal use of exchange transfusions you have better than a 75 per cent chance of having a fine healthy baby.
What is the routine procedure in regard to Rh in modern prenatal care?
Early in pregnancy a specimen of blood is drawn from an arm vein; half is used to test for syphilis (the ‘Wassermann’) and half to determine the Rh. If the Rh test returns positive, no more need be done about it. If it is negative, the husband’s blood is drawn and his Rh determined. If it is also negative the matter of the Rh factor can be dismissed. When he is Rh-positive it should be determined by appropriate tests whether the wife is already sensitized. Additional sensitization studies are run on blood samples drawn at midpregnancy and again about the thirty-fifty week.
If a woman is sensitized, the degree of sensitization is determined. It is expressed in terms of titre. If the patient’s blood serum is diluted twice and still yields a positive test, but when diluted again with an equal volume is negative, the titre is read as 1:2. And so if the response is positive at a dilution of 1:128 but negative at 1:256, the titre is 1:128. A titre below 1:16 is considered low; up to 1:32 is moderate, and 1:64 and above high. Usually the titre rises during pregnancy if the unborn fetus is Rh-positive. The height of the titre is roughly correlated with the degree of involvement of the newborn. Yet one sees exceptions in both directions. I have attended women with high titres in which there is little fetal involvement, and vice versa.
There are three forms of erythroblastosis. In the least frequent and most serious, the fetus dies in utero at some time during the last third of pregnancy, or is born alive with tissues grossly waterlogged (fetal hydrops) and succumbs a few hours later. In the milder and more common forms the infants may be born seriously anemic or with a normal amount of hemoglobin that is rapidly destroyed postnatally. These two forms are almost always completely cured by one or several exchange transfusions.
In an exchange transfusion a catheter (plastic tube) is threaded deep in the umbilical vein and 20 cubic centimeters (2/3 ounce) of the infant’s Rh-positive blood are withdrawn and then 20 cc. of the Rh-negative donor blood are injected; 20 cc. are withdrawn and 20 cc. injected, until the infant has received at least 500 cc. (V/a pints) of Rh-negative blood. By this time 85 per cent of the infant’s cells have been replaced. At frequent intervals for the next thirty-six hours following transfusion, blood samples are checked to determine whether the hemoglobin is falling rapidly and whether the bilirubin, the end-product of red-cell destruction, which causes the jaundice in this disease, is rising precipitately. In either instance a second—or, if necessary, a third—exchange transfusion is given. At the end of forty-eight hours the infant has used up or excreted all of the antibodies its tissues received in the uterus from the mother, and since it does not form new antibodies the Rh-positive cells which its own bone marrow is forming go unmolested.
The salvage of such children to normal health is another dramatic triumph in the history of recent medicine.
Not infrequently in moderately or highly sensitized patients the doctor will see fit to induce labor at the thirty-sixth to thirty-eighth week of pregnancy to forestall the possible death of the undelivered fetus. Occasionally, when induction is not feasible, he may consider termination of pregnancy sufficiently urgent to justify Cesarean section. Delivering the baby before the thirty-sixth or thirty-seventh week has proved useless, since premature babies withstand the postnatal effects of erythroblastic disease very poorly.
Many methods have been tried to desensitize already sensitized women, or to prevent increased sensitization during another pregnancy, but to date all have been uniformly valueless. There is no known effective treatment of the condition.
There are other blood factors besides the Rh to which a mother may become sensitized. If she is group O and the fetus A or B, she may develop antibodies against the blood type the fetus possesses, also against the so-called Kell factor, as well as a large number of other subgroupings. Ordinarily this type of erythroblastosis is mild, not requiring exchange transfusion.
Whether or not a woman should attempt another pregnancy after a fatal outcome to the fetus from erythroblastosis is difficult to answer. There are too many individual factors in each case to attempt to generalize an answer. The patient’s physician is in a much better position to advise. One factor which would weigh in such a decision is whether the husband is homozygous (pure) or heterozygous (partial) Rh-positive. This can be determined by testing his parents, or by a special laboratory test on his blood. If he is heterozygous and by good fortune the sperm which fertilizes the egg transmits the Rh-negative factor, no difficulty will arise, no matter how severely the wife is sensitized.
Successful pregnancies have been accomplished in highly sensitized women who have had a series of erythroblastotic stillbirths, by artificial insemination. The semen of an Rh-negative donor is substituted by injection for the semen of the Rh-positive husband, of course with his knowledge and enthusiastic approval. Not many couples are emotionally attuned to this procedure, but when they are it offers one feasible solution.
Bone fractures are uncommon at delivery; when they occur they heal rapidly and perfectly. The clavicle or collarbone is the most frequent site; clavicular fracture is particularly common when difficulty is encountered in delivering the shoulders of excessively large infants. These fractures are often so benign that they go unrecognized until several weeks after birth, when the mother unexpectedly feels a bony ridge or stripe across the collarbone. Even when they are diagnosed at birth, usually no treatment is required.
Of the long bones, the thigh and upper arm bone are the most frequently fractured. Such accidents were more common when version was a popular obstetrical operation.
Occasional skull fractures are met, usually after difficult forceps or breech deliveries. If promptly diagnosed and treated by lifting up any bony fragments compressing the brain beneath, complete recovery may be anticipated.