PEDIATRIC NURSING THE MACMILLAN COMPANY 
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WlhblAM GjWlbN PEDIATRIC 
NURSING 
Its Principles and Practice 
BY 
BESSIE INGERSOLL CJJTLER, R.N. 
Graduate of Massachusetts General Hospital’ School for Nurses 
Instructor in Pediatric Nursing and Supervisor of Pediatric Department, 
University of Minnesota, Minneapolis ; Formerly Head Nurse in Chil- 
dren’s Department, Massachusetts General Hospital, Boston ; Night 
Supervisor at Children’s Hospital, Boston ; Head Nurse at 
Children’s Hospital, St. Louis, Missouri. 
iBeto gotK 
THE MACMILLAN COMPANY 
1923 
All rights reserved PRINTED IN THE UNITED STATES OP AMERICA 
Copyright, 1923, 
By THE MACMILLAN COMPANY 
Set up and electrotyped. Published June, 1923. THIS BOOK IS 
AFFECTIONATELY DEDICATED 
TO MY PARENTS PREFACE 
No claim to originality is made in this book. It has been 
written primarily for the student nurse. It is simply an 
attempt to correlate into one volume the information which 
experience leads me to believe is necessary for her intelligent 
care of children. The book is not intended to be complete in 
itself, but is to be used as a text on the nursing care of children 
in conjunction with lectures on the diseases of children. It is 
advised that the student be given a list of standard works on 
pediatrics to which she may refer for more extensive study. 
In order to stimulate her interest and to create in her a desire 
to read more, a bibliography has been added which contains 
the references consulted in the writing of the book, also ad- 
ditional interesting material relating to the subjects discussed 
in the text. I have had several years of experience in the ac- 
tual nursing care of children in various parts of the country, 
but in order to present the subject with sufficient emphasis, 
it has been necessary to supplement my knowledge with fre- 
quent quotations from eminent authorities on pediatrics. 
I wish to acknowledge here my indebtedness to Dr. L. 
Emmett Holt, Dr. J. P. Crozer Griffith, and Dr. Julius Hess 
for permission to quote from their text-books; and to Dr. W. 
McKim Marriot for permission to use sections from notes 
compiled by him for nurses. I wish to express gratitude to 
Dr. P. C. Rodda and Dr. E. J. Huenekens of the Pediatric 
Department of the University of Minnesota for their aid; to 
Dr. A. C. Strachauer for reviewing the chapter “Surgical 
Nursing Care of Children”; to Dr. J. C. Litzenberg for re- 
viewing the sections on “resuscitation” and the “care of the 
mother’s breasts”; to Dr. Harry P. Ritchie for contributing 
VII VIII 
PREFACE 
his recent work on the classification of congenital clefts of the 
lip and palate; to Dr. J. C. McKinley for aid in writing the 
section on “Nursing Care of Children with Diseases of the 
Nervous System”; to the Dental Department of the Uni- 
versity of Minnesota for reviewing the section on “Oral 
Hygiene.” I extend my sincere thanks to Dr. A. E. Gourdeau 
of Minneapolis for reviewing and revising the entire manu- 
script ; to Mellie Palmer for assistance in editing it; to Eliza- 
beth Pierce for her many suggestions concerning practical 
nursing and nursing procedures; to Jean Ilirsch for her work 
on the illustrations; to Mrs. Mason Trowbridge the designer 
of the frontispiece; and to all superior officers, friends, and 
co-workers at the University Hospital, Minneapolis, for their 
loyal support and cooperation. The chapter “Mental De- 
velopment of Children” has been contributed by Frederica 
Beard; “The Educational Value of Occupational Therapy 
in the Care of Sick Children” by Susan Tracy; “The Ortho- 
pedic Nursing Care of Children” by Katherine A. Smith. CONTENTS 
CHAPTER PAGE 
I Introduction 1 
II The Growth and Development of the Normal Child 9 
III Hygiene of Infancy and Childhood 17 
IY The Mental Development of Child Life .... 32 
Y The General Conduct of a Hospital Ward .... 49 
VI The Care of the Sick Child in the Hospital ... 63 
VII The Newborn Baby 98 
VIII The Premature Baby 115 
IX Nutrition of Infants and Children 125 
X Maternal Nursing 132 
XI Artificial Feeding of Infants 146 
XII Artificial Feeding of Infants—Continued .... 165 
XIII Artificial Feeding of Infants—Continued .... 180 
XIV Food for the Child 190 
XV Urine and Stool in Infancy and Childhood . . . 206 
XVI Nursing Technique in Minor Surgical Procedures . 225 
XVII Nursing Technique in General Therapeutic Proce- 
dures 258 
XVIII Nursing Technique in General Therapeutic Proce- 
dures—Continued 274 
XIX Nursing Technique in General Therapeutic Proce- 
dures—Continued 287 
XX Special Pediatric Nursing 315 
XXI Infectious Diseases 383 
XXII Nursing Care of Children with Acute Infectious 
Diseases 389 
XXIII Surgical Nursing Care of Children 415 
XXIV The Orthopedic Nursing Care of Children .... 424 
XXV The Educational Value of Occupational Therapy in 
the Care of Sick Children 448 
A Selected Bibliography 460 
Index 463 LIST OF ILLUSTRATIONS 
Frontispiece 
FIG. PAGE 
1. To carry a baby 66 
2. Child wrapped in blanket to restrain him 69 
3. Restraining jacket 83 
4. Cuff to immobilize elbow joint 85 
5. Clove hitch 87 
6. Mouth gag made of tongue blades 91 
7. Method of resuscitation 101 
8. Byrd’s method of artificial respirations. Position for in- 
spiration 102 
9. Byrd’s method of artificial respirations. Position between 
inspiration and expiration 102 
10. Byrd’s method of artificial respirations. Position for ex- 
piration 103 
11. Cord dressings 104 
12. Toothpick applicator used in the bath 107 
13. Wrist band 110 
14. Method of lifting the baby from the table to the bath tub . 112 
15. Position of baby in bath tub 113 
16. Basket for premature baby 118 
17. Flannel cape for premature baby 120 
18. Proper position for breast nursing with mother in recum- 
bent position 138 
19. Method of expressing breast milk 142 
20. Test-tube on a boy to collect urine 210 
21. Test-tube with glove finger for obtaining urine from a boy. 
Test-tube with glove finger for obtaining urine from a 
girl. The distance from a to b should equal distance 
from the rectum to the vagina 211 
22. Test-tube on a girl to collect urine 211 
23. Cotton belt to hold test-tube for collecting urine .... 213 
24. Canvas cover for Bradford frame 215 
25. Frame prepared for collection of 24-hour specimen of urine . 216 
26. Tube for the collection of a 24-hour specimen of urine . . 217 
27. Baby on the frame for the collection of a 24-hour specimen 
of urine 218 
XI XII 
LIST OF ILLUSTRATIONS 
FIG. PAGE 
28. Fosition of baby for puncture of external jugular vein . . 228 
29. A needle with guard for puncture of fontanelle . . . .230 
30. Position of baby for puncture of the fontanelle .... 231 
31. Equipment for giving fluid intravenously, using 3-way stop- 
cock method (b) . 234 
32. Equipment for giving fluid intravenously, using gravity 
method (c) 235 
33. Glass funnel and tubing for giving fluids intraperitoneally 
method (b) 244 
34. Position of child when giving intraperitoneal fluid . . . 245 
35. Position of child for spinal puncture 246 
36. Equipment for thoracentesis 249 
37. Jacket for cold application to the chest 264 
38. Schematic diagram of insolation 271 
39. To fold muslin for poultice 285 
40. Equipment for gavage 288 
41. Position of child for gavage 290 
42. Medicine dropper with tip protected by rubber 295 
43. Toothpick applicator to dry wipe ear 295 
44. Equipment for proctoclysis 310 
45. Method of feeding thick cereal through a hygeia nipple . . 337 
46. Face mask used in treating eczema 377 
47. Plaster casts. Showing method of elevation 428 
48. Bradford frame 438 
49. Tuberculosis of the hip with abscesses and slight flexion 
deformity 439 
50. Pott’s disease, showing posterior shell treatment .... 442 
51. Showing method of head traction sometimes used for cervical 
Pott’s disease 443 
52. The magic circle 449 
53. The finding of Moses 458 PEDIATRIC NURSING CHAPTER I 
INTRODUCTION 
Heaven laughed to find your face so pure and fair, 
And left, 0 little child, its reflex there. 
Canton. 
History of the Treatment of Children. 
Since it is only within the last fifty years that the child and 
his welfare have been given serious consideration, the present 
era has been called the “Century of the Child.” Payne says 
that humanized man has not existed more than a few hundred 
years and that it is only wfithin the last half century that the 
race has been concerned wfith the protection of the child.1 
During this period more has been written on the subject than 
in all previous civilized times. Previously man had more or 
less disregarded his most precious possession, his child, who 
should be looked upon as his sacred pledge to the future.2 To 
be sure, children were not entirely neglected by the Ancients. 
It was during the reign of Trajan, between 110 a.d. and 130 
a.d., that Rome became the home of the greatest obstetrician 
and pediatrician of antiquity, Soranus of Ephesus, the author 
of the work which conforms more nearly with modern stand- 
ards of nursing than any other which appeared before the 
beginning of the last century. Foote says that excluding our 
knowledge of antiseptics, abandoning swaddling and wet 
nursing, and with some editing, the practical instruction is so 
sound that with surprisingly few changes Soranus’s text-book 
could have been used in the education of the nurse and mother 
to better advantage than any similar work up to the time of 
‘ ‘Century of 
the Child” 
Treatment of 
Children in 
Ancient Times 
1 Payne, George Henry, ‘ ‘ The Child in Human Progress. ’ ’ 
3 Foote, John, M.D., “Ancient Poems of Child Hygiene.” Annals 
of Medical History, Vol. II, 1919. 
1 2 
PEDIATRIC NURSING 
Underwood in 1784. Hippocrates and other writers of olden 
days3 make mention of the child as do several medieval 
writers4; but when the perfection of the art and philosophy 
of the early peoples, for example, the cultured Greeks and 
Homans, is compared with their standards of treatment of 
their children, one realizes to what extent the latter wrere 
neglected. History tells us that before the Christian era 
some of the early tribes abandoned and actually slaughtered 
their children without considering it criminal. With the 
spread of the Christian religion and civilization there 
developed parental instinct and a more humane treatment of 
the young. Christ taught that the life and the soul of a child 
were as precious as those of an adult and that to willfully 
destroy an infant was murder in the first degree. He elevated 
and sanctified babyhood and childhood.5 His was the first 
voice raised against a high infant mortality. Payne says: 
“The social, moral, and intellectual condition of women indi- 
cates in an ascending scale the degree of civilization of every 
tribe and nation. It might with equal force be said that the 
attitude of the tribe or nation toward its young is also a 
barometer of human progress.” (See note 1.) 
History of Pediatrics. 
Progress in the treatment of the child from a medical point 
of view has accompanied the slow recognition of the rights of 
the child from the social point of view. The science which 
deals with this progress is called “pediatrics” or “the science 
of healing children.” It is composed of two Greek words, 
“pais,” genitive “paidos,” meaning the child and “iatrike,” 
the science or art of healing. The first printed literature of 
Europe on the subject was by Paolo Bagellardo in 1487 and 
Meaning of 
“Pediatrics” 
3 Foote, John, M.D., “An Infant Hygiene Campaign of the Second 
Century.” Arch. Ped., March, 1919. 
4 Ruhrah, John, M.D., “Walter Harris, a Seventeenth Century Pedi- 
atrist.” Annals of Medical History, Yol. II, 1919. 
5 Shaw, Henry L., M.D., “Hospitals for Babies—Retrospect, Intro- 
spect, and Prospect.” Arch. Ped., Nov., 1921. INTRODUCTION 
3 
by Bartholomews Metlinger in 1473. These were followed by 
other works in the next century. Walter Harris made valuable 
contributions to pediatric literature in 1715 (see note 4). 
Several other publications of similar value appeared about 
the same time. Michael Underwood wrote an ‘ ‘ Essay on the 
Diseases of Children” in 1784 and Edward Jenner in 1798 
produced his work on variolae vaccinas.6 During the nineteenth 
century France, England, and Germany gave to the world 
important works on pediatrics: France by C. Billard, Rilliet, 
and Barthez; England by Cheyne, who wrote “Essays on 
Diseases of Children,” Charles West, and F. Churchill; and 
Germany by Bednar, Saulinge, and others. In the English 
colonies of America the earliest treatise of a medical, in part 
pediatric, subject was a broadside 12 inches by 17 inches 
entitled, “A Brief Rule to Guide the Common People of New 
England How to Order Themselves and Theirs in the Small 
Pocks or Measles.” (See note 6.) It was written by the 
Reverend Thomas Thatcher and bears the date January 21, 
1677-8, a second edition being printed in 1702. 
Dr. Abraham Jacobi (1830-1919) has been called the 
“Nestor of American Pediatrics,”7 and it was through his 
efforts that the first professional teaching of the subject of 
diseases of children was started in 1860 at the New York 
Medical College. He himself occupied the position of teacher. 
He also founded the American Pediatric Society, was its first 
president, and was again president in 1906. He was the prime 
mover in the founding of the section of pediatrics in the New 
York Academy of Medicine and the American Medical Asso- 
ciation.8 The second chair of pediatrics was founded in 1898 
at Harvard. Now there is an ever increasing interest in this 
specialty and there are many eminent pediatricians in all 
civilized countries. This interest has produced much litera- 
Early 
Pediatric 
Literature 
First 
Professional 
Teaching of 
Pediatrics 
8 Jacobi, Abraham, M.D., ‘1 History of Pediatrics. ’ ’ 
’Garrison, Fielding H., M.D., “History of Medicine.” 
8Crandall, Floyd M., M.D., “Abraham Jacobi, An Appreciation.” 
Arch. Ted., June, 1919. 4 
PEDIATRIC NURSING 
ture in America, France, England, and Germany, and pedi- 
atric journals are multiplying and pediatric societies 
increasing. 
The first foundling asylum of which there is authentic 
record was founded in 787 by Archbishop Datheus of Milan. 
It was primarily for the care of illegitimate children w7ho, 
heretofore, had been put to death. The Hospital of the 
Innocents, made famous by the Della Robbia Bambinos, was 
founded in Florence in 1420. (See note 5.) In 1769 the first 
distinct children’s hospital was established in London by 
Dr. George Armstrong. The Kinderkranken Institute, which 
is still in existence, was founded in Vienna by Dr. Marstalier 
a few years later. (See note 6.) The early part of the 
nineteenth century saw the establishment of the Hopital des 
Enfants by the French Republic, a children’s hospital in St. 
Petersburg, another in Vienna, and one in Buda Pesth. The 
great Ormond Street Hospital for sick children was opened in 
London in 1854. Dr. Charles West, called the “Jacobi of 
England,” was the promoter of this institution and its estab- 
lishment was due largely to the efforts of his close friend, 
Charles Dickens, who by his books and in other ways has 
always shown himself a real benefactor to children. (See 
note 5.) The United States was the last country to establish 
children’s hospitals. The first one, containing twelve beds, 
was opened in Philadelphia in 1855. For this reason the city 
has been called the pioneer pediatric city of America. Other 
children’s hospitals were established during the next decade: 
Nursery and Child’s in New York in 1857, a small one in 
Chicago in 1865, the Children’s Hospital of Boston in 1869,9 
and the Thomas Wilson Sanitarium in Baltimore in 1879. 
The Boston Infant’s Hospital was opened in 1881 and was the 
first hospital in this country where only sick babies were 
admitted. (See note 5.) The present Babies’ Hospital of 
New York was established in 1887. Similar institutions have 
First 
Institutions 
for the Care 
of Children 
9“A Half Century of Steady Growth and Usefulness.” Modern Hos- 
pital, Nov., 1919. INTRODUCTION 
5 
increased rapidly in number since these early beginnings, and 
now they are found in nearly all the large cities. 
Comparison of the Child with the Adult. 
The child is not a miniature adult and he cannot be treated 
as such, even though his body has the same general structure 
and contains the same organs as that of the adult. The great- 
est contrast appears in infancy and early childhood. After 
seven years of age children in their diseases resemble adults 
more than they do infants.10 The child is an unfinished 
product; his body and mind are in the process of growth and 
development and great changes are taking place in the differ- 
ent organs and tissues all the time. The relationship of the 
various organ systems of the body to one another shifts, and 
with this process the relationship of each organ system to the 
whole body shifts. For example, in the newborn about 23 per 
cent of the total weight is in muscles; in the adult about 43 
per cent is in muscles. The relative weight of the infant’s 
liver is about 2y2 times that of the adult.11 Because of the 
rapid growth and active changes which are taking place, the 
child lacks reserve vitality and his resistance is lowered. Thus 
he is unusually susceptible to infections, and is more easily 
prostrated by disease, which, because of the instability of his 
nervous system, is often manifested by grave symptoms. He 
is more quickly overcome by disease than is the adult, and he 
is liable to sudden and unexpected death. On the other hand, 
while the child’s organism is less stable than the adult’s, it is 
more plastic; he is very sensitive to outside influences, 
environment, etc., and responds readily to proper treat- 
ment.12 
Children have very little chronic disease or very little 
disease which is evidenced by a degenerative process of one 
form or another. On the whole they tend to recover. Many 
Some 
Differences 
between the 
Child and 
Adult 
10 Holt, L. Emmett, M.D., ‘1 Diseases of Infancy and Childhood. ’ ’ 
u Helmholz, Henry, M.D., “The Use of Drugs in Infancy and Child- 
hood.” Jour. Am. Med. Assn., Oct. 8, 1921. 
u Campbell and Kerr, “Surgical Diseases of Children.” 6 
PEDIATRIC NURSING 
organic lesions which become chronic in the adult may be 
overcome or “outgrown” if the child’s nutrition is unimpaired 
and if he is placed in proper hygienic surroundings. 
The infant or young child cannot express himself to tell 
when he is ill nor is he able to describe his symptoms or sen- 
sations. Information about these can be obtained only by 
skillful and close observation of objective signs. The general 
rule is that the younger the child, the poorer is the prognosis 
in all diseases of childhood. It is for this reason that the 
mortality of the first year of life is so high and that it dimin- 
ishes progressively during the remainder of childhood. 
Statistics show that of all infants born alive approximately 
10 per cent die before the age of 1 year. Twenty-five per cent 
of these deaths occur in the first month from the following 
causes: congenital weakness, 50 per cent; accidents of labor, 
10 per cent; pneumonia, 9 per cent; atelectasis, 8 per cent. 
Of the deaths of all ages 20 per cent occur under 1 year, 5 per 
cent between 1 and 2 years, 4 per cent between 2 and 5 years, 
and 31/2 per cent between 5 and 15 years. The deaths under 
1 year are caused chiefly by the following: gastro-intestinal 
and nutritional diseases, 45 per cent (diarrhea, marasmus, 
etc.) ; acute respiratory diseases, 19 per cent (pneumonia) ; 
congenital malformations, 6 per cent; infectious diseases, 5% 
per cent (1. pertussis, 2. diphtheria) ; tuberculosis and syph- 
ilis, 8 per cent. The principal causes of death in the second 
year occur in the following order: gastro-intestinal diseases, 
acute respiratory diseases, infectious diseases (measles, diph- 
theria, pertussis). The chief causes of death from 2 to 5 years 
occur in the following order: infectious diseases (diphtheria, 
scarlet fever, measles, pertussis), acute respiratory (tubercu- 
losis). The chief causes of death from 5 to 15 years occur in 
the following order: infectious diseases (diphtheria, scarlet 
fever), acute respiratory. There has been considerable reduc- 
tion in infant and child mortality in recent years. The most 
important factors for the first year of life have been better 
natal and prenatal care and better food and hygiene after 
Mortality 
Statistics INTRODUCTION 
7 
birth. After the first year the chief factor has been diphtheria 
antitoxin.13 
Dr. Holt says: ‘ ‘ There is no more promising field in medi- 
cine than the prevention of disease in childhood. The majority 
of the ailments from which children die, it is within the power 
of man, in great measure, to prevent. Prophylaxis should 
aim at the solution of two distinct problems: (1) the removal 
of the causes which interfere with the proper growth and 
development of the child, and (2) the prevention of infection. 
The former can come only through the education of the pro- 
fession and of the general public in the fundamental princi- 
ples of infant feeding and hygiene. This is a department 
which has received altogether too small a place in medical 
education. The latter must come through the profession and 
through legislation, the purpose of which shall be more rigid 
quarantine, more thorough disinfection, and improved sani- 
tation in all departments.” (See note 10.) 
Pediatrics 
Should Be 
Preventive 
Medicine 
Essential Qualifications for a Good Pediatric Nurse. 
Love of 
Children 
The first essential qualification for a good pediatric nurse is 
a love of children, for the child is extremely sensitive to his 
environment. He recognizes intuitively and responds quickly 
to the presence of an unsympathetic person. The nurse must 
be able to win not only his confidence but also that of his 
mother who is always loath to leave him in the care of a 
stranger. Often in her anxiety and ignorance she will doubt 
the nurse’s ability to care for the child. The nurse must 
respect the mother’s feelings and excuse her for her emotion 
and ignorance. She should try to imagine herself in the 
mother’s place, about to entrust her most precious possession, 
her sick child, to the care of some one else, possibly a total 
stranger. 
The pediatric nurse must have a desire to understand the 
child and she must be constantly trying to educate herself to 
better understand him. She must be able to adjust herself to 
Knowledge of 
Mental and 
Physical 
Hygiene of 
Children 
13 Marriot, William McKim, M.D., Unpublished Notes for Nurses. 8 
PEDIATRIC NURSING 
him and to see things from his point of view, participating in 
his joys, his sorrows, his work, and his play. She must be 
able to manage him; this ability is partly instinct and partly 
acquired training. It is essential for her to have special 
preparation in child training and in the mental development 
and hygiene of the child. Her education must contain also 
training in the physical growth and hygiene of the child and a 
knowledge of the child in health and disease, for she must 
know which diseases may affect him and how he may react to 
various affections. 
Since the infant or young child is not able to indicate his 
desires or to describe his symptoms and sensations, the nurse 
must be trained to have very acute powers of observation and 
must be able to recognize and to interpret the signs and 
symptoms which he presents. No other branch of the pro- 
fession demands more exacting or more conscientious work or 
greater faithfulness to minute detail than pediatric nursing. 
If the nurse has a proper love of children together with the 
proper knowledge of the child’s mental and physical de- 
velopment and hygiene, she will be able to see the necessity 
for the exacting detailed work that his care entails, and she 
will have the desire and patience to conscientiously carry it 
out. It has been said that “he who helps a child helps human- 
ity with a distinctness and with an immediateness with wdiich 
no other help given to human creatures at any other stage of 
their lives can possibly be given.” 
Acute 
Powers of 
Observation 
Faithfulness 
to Detail CHAPTER II 
THE GROWTH AND DEVELOPMENT OF THE NORMAL CHILD 
A thorough knowledge of the normal growth and develop- 
ment of the child is an essential equipment for the intelligent 
nurse in order that she may he able to detect abnormalities 
and early signs of disease in children placed under her care. 
The development of the child is divided into 4 definite 
periods of growth: 
1. The term “newborn” applies until all traces of prenatal 
and intra-uterine life have disappeared, usually 3 to 4 weeks. 
2. The term “infant” applies from 3 or 4 weeks to 2 years 
of age. 
3. “Childhood” extends from 2 to 7 years and, 
4. “Youth” from 7 years to puberty. 
The average weight of the full term baby girl is 7 pounds or 
3200 grams and that of the baby boy 7y2 pounds or 3500 
grams. There is an initial loss of weight during the first few 
days of 150 to 300 grams. The causes of this are: 
1. The vernix caseosa is removed at the first bath. 
2. The child begins to urinate and has defecations known 
as meconium. 
3. He obtains very little from the mother’s breasts during 
the first few days, never more than 5 to 10 cubic centimeters 
of colostrum at a nursing and very often nothing at all; he 
therefore burns up body tissue to maintain heat. As soon as 
the mother’s milk comes he should begin to gain weight so 
that in from 10 to 14 days he will have regained his birth 
weight. Some babies regain their original weight in 8 days. 
The average baby does not usually gain weight every day but 
will gain from 30 to 60 grams one day and will lose part of it 
the next, then gain the next or remain stationary for a 
Knowledge of 
Growth and 
Development 
Necessary 
Periods of 
Growth 
Average 
Weight of 
Newborn 
Baby 
Bate of 
Growth 
9 10 
PEDIATRIC NURSING 
day or two. For this reason it is unwise for a young mother 
to weigh her normal baby daily; she will save unnecessary 
worry if she weighs him only once a week. The healthy, 
normal baby will gain 150 to 200 grams every week so that in 
6 months he will have doubled his birth weight; for example, 
if he weighed 3200 grams at birth, he should weigh 6400 grams 
at 6 months of age. The average gain during the second 6 
months is half that of the first 6 months, or 60 to 100 grams a 
week. At 12 to 15 months the birth weight is trebled. The 
gain in weight during the second year is about 6 pounds, 
during the third year about 5 pounds, and during the fourth 
year about 4 pounds. After 4 years of age the average yearly 
gain is 4 to 7 pounds. It is as important that the child follow 
the normal rate of growth as it is for him to actually attain 
the given weight for his age. 
TABLE OF WEIGHTS1 
Table of 
Weights 
Average Weight and Increase in Weight a Year for Boys and Girls 
Age 
BOYS 
GIRLS 
Weight 
in 
pounds 
Increase 
a year 
in pounds 
Weight 
in 
pounds 
Increase 
a year 
in pounds 
Birth 
7.55 
7.16 
6 mo. 
16.00 
16.90 
15.50 
16.68 
1 yr. 
20.50 
9.00 
19.80 
8.60 
2 yr. 
26.20 
6.00 
25.50 
5.70 
3 vr. 
31.20 
4.70 
30.00 
4.50 
4 yr. 
35.00 
3.80 
34.00 
4.00 
5 yr. 
41.20 
4.14 
39.80 
3.87 
6 yr. 6 mo. 
45.20 
4.00 
43.40 
3.60 
7 yr. 6 mo. 
49.20 
4.30 
47.70 
4.30 
8 yr. 6 mo. 
54.50 
5.00 
52.50 
4.80 
9 yr. 6 mo. 
59.60 
5.10 
57.40 
4.90 
10 yr. 6 mo. 
65.40 
5.80 
62.90 
5.50 
11 yr. 6 mo. 
70.90 
5.30 
69.50 
6.60 
12 yr. 6 mo. 
76.90 
6.20 
78.70 
9.00 
13 yr. 6 mo. 
84.80 
7.90 
88.70 
10.00 
14 yr. 6 mo. 
95.20 
10.40 
98.30 
9.60 
15 yr. 6 mo. 
107.40 
12.20 
106.70 
8.40 
16 yr. 6 mo. 
121.00 
13.60 
112.30 
5.60 
Length 
The average length of the newborn baby is 20 to 21 inches 
or 52 centimeters. During the first year the average gain is 
1 Carter, Howe and Mason, ‘ ‘ Dietetics. ’ ’ GROWTH AND DEVELOPMENT 
11 
9 inches; during the second year half as much or 4% inches; 
during the third year and up to 12 years, 2 or 3 inches a 
year.2 
The average circumference of the child’s head at birth is 
13.9 inches or 35 centimeters. The rate of development is 
about 4 inches during the next 3 years. After 5 years the 
increase in circumference is very slow, being at the rate of 
about 1 inch in 5 years. The hair which the baby has at birth 
usually comes out during the first weeks or months and is 
replaced by new. There are two openings or fontanelles in 
the head of the newborn baby. The large or anterior fon- 
tanelle is at the junction of the two frontal or parietal bones. 
It should be about 1 inch in width at the end of the first 
year and should be entirely closed by 18 to 22 months. The 
small or posterior fontanelle is at the junction of the occipital 
and parietal bones. Normally it closes by the end of the 
second month. 
At birth the circumference of the child’s chest is about 
inch less than that of the head, i.e., if the circumference of 
the head is 13.9 inches or 35.5 centimeters, that of the chest is 
13.4 inches or 34.2 centimeters. The circumferences of the two 
remain about the same during infancy. At the end of the 
second year the chest circumference exceeds that of the head; 
at the end of 5 years it is about 1 inch greater than that of the 
head; and at 10 years it is 5 or 6 inches greater. 
During infancy the circumference of the abdomen is about 
equal to that of the chest. At the end of 2 years the measure- 
ments of the head, chest, and abdomen are nearly identical. 
After this age the chest increases more rapidly than either of 
the other two. 
The normal newborn baby wall close his fingers over an 
object, as a rod or fingers placed in his palms, and if raised 
can suspend himself for an appreciable interval of time.3 A 
Head 
Chest 
Abdomen 
Muscular 
Development 
2 Holt, L. Emmett, M.D., ‘ ‘ Diseases of Infancy and Childhood. ’ ’ 
3 Watson, J. B., and Watson, Rosalie R., “Studies in Infant Psy- 
chology.” Scientific Monthly, December, 1921. 12 
PEDIATRIC NURSING 
baby smiles usually at 4 or 5 weeks of age. The muscular 
development varies greatly in different babies; the following 
is an average: at 2y2 to 3 months he will lift his head for a 
short time when placed on his abdomen; he will hold his head 
up when carried at 4 months and will voluntarily grasp for 
objects at about that time; from 7 to 8 months he will sit 
without support for a few minutes at a time; at 9 or 10 
months he will brace his legs and attempt to bear his weight on 
his feet; at 10 or 11 months he will pull himself up on his feet; 
he will change his position and begin to crawl at 9 or 10 
months; at 14 to 15 months he will stand alone and begin to 
walk. 
The newborn baby naturally avoids strong, bright light by 
closing his eyes and by contracting his pupils. Therefore his 
eyes should be protected from a bright, direct light. However, 
do not shut sunlight from the nursery, but protect the baby’s 
eyes. A young baby of a week may follow a light with his 
eyes but the muscles of the eyes do not coordinate, thus 
causing a temporary strabismus. Fixation and coordination 
are established at about 3 months. A child will recognize 
objects at sight at 5 or 6 months, though he notices them 
earlier by instinct. 
The newborn baby is deaf for the first 2 or 3 days because 
the ear drum is collapsed at birth and hearing is not estab- 
lished until the middle ear fills with air. After the first few 
days hearing is quite acute. At 3 months the baby will turn 
his head in the direction from which a noise comes, and at 4 
months will recognize a familiar voice. 
The sense of touch is present at birth but is poorly developed 
except in the lips and tongue, where it is very acute. Because 
of this lack of sensation babies are not sensitive to heat or cold 
and can be easily burned without indicating discomfort. 
Therefore extreme care must be exercised in the use of hot 
water bottles and heaters around them. 
Taste is highly developed from birth. 
Smell is the last of the special senses to be fully developed. 
Special 
Senses 
Sight 
Hearing 
Touch 
Taste 
Smell GROWTH AND DEVELOPMENT 
13 
The time when different children learn to talk varies greatly. 
Girls usually talk from 2 to 4 months earlier than boys. By 
the end of the first year the child will begin to pronounce 
simple words as “Mama” and “Papa.” By the end of the 
second year he will put words together in short sentences, 
consisting of the person or object and the verb to denote action 
as “doggie runs.” From this time on his progress is rapid. 
The use of words is most generally acquired in the following 
order: personal pronoun “me,” names of persons, names of 
objects, verbs, adverbs, adjectives, conjunctions, prepositions, 
articles, and other personal pronouns. A child learns the 
language chiefly through imitation and repetition, therefore it 
is important that adults speak plainly to him. In other words 
avoid “baby talk.” 
The formation of temporary or milk teeth begins during the 
second month of embryonic life. At birth all 20 deciduous 
teeth are completely formed under the gums and the formation 
of the permanent teeth has started. The following is the usual 
order in which the deciduous teeth appear: 
2 lower central incisors 6- 9 months 
4 upper incisors 8-12 months 
2 lateral lower incisors 12-15 months 
4 anterior molars 12-18 months 
4 canines 18-24 months 
4 posterior molars 24-30 months 
At 1 year a child should have 6 teeth 
At IV2 years a child should have 12 teeth 
At 2 years a child should have 16 teeth 
At 21/2 years a child should have 20 teeth 
Appearance of the permanent teeth is as follows: 
First molars 6 years 
Incisors 7- 8 years 
Bicuspids 9-10 years 
Canines 12-14 years 
Second molars 12-15 years 
Third molars 17-25 years 
These permanent teeth replace the deciduous teeth. They 
Speech 
Teeth 14 
PEDIATRIC NURSING 
grow and push outward, causing atrophy of the roots of the 
first teeth, which consequently loosen and fall out. (See Oral 
Hygiene, Chapter VI.) 
The normal temperature of the newborn is 98° F. to 99° F., 
usually about one-half degree higher than his mother’s. The 
heat regulating center in the brain acts imperfectly at first 
and slight causes are sufficient to change the temperature. It 
may become subnormal from apparently slight exposure, or it 
may become very high from some minor disturbance or from 
the application of external heat. Therefore great care must 
be taken not to expose the baby and good judgment must be 
used in the application of external heat. The temperature of 
a child of any age is always higher from similar causes than 
that of an adult. A child also reacts more readily to outside 
influences and may have an elevation of temperature from 
such causes as overexcitement. 
The rate of the pulse and respirations of babies and children 
is greatly increased by a slight disturbance and always by 
crying. Therefore pulse and respirations should be counted 
when the child is very quiet, preferably when he is asleep. 
They should always be taken before the temperature, since the 
insertion of the thermometer often causes excitement enough 
to increase their rate temporarily. 
Temperature 
Average Pulse Rates: 
120-140 in newborn baby 
110 1st year 
100 2d year 
90 5-8 years 
70-80 11-14 years 
Pulso 
Average Rate of Respirations: 
35-40 newborn 
24-36 1-2 months 
20-32 2-6 months 
20-25 1-2 years 
20-23 2-6 years 
18-20 6-12 years 
Respirations GROWTH AND DEVELOPMENT 
15 
The boy is always slightly ahead of the girl in height, 
weight, and muscular development until the change from 
childhood to adolescence or puberty. This occurs usually in the 
eleventh to thirteenth year in the girl, and in the thirteenth to 
fifteenth in the boy. As the girl nears this age she gains more 
rapidly than the boy and is taller and heavier than he is for 
2 or 3 years. Then the boy develops more rapidly and is soon 
ahead of the girl. This difference remains permanent. The 
approach of puberty in the girl is characterized by: (1) the 
gradual enlargement of the breasts, (2) the growth of pubic 
and axillary hair, (3) the beginning of menstruation. This 
function usually starts at the age of 13 or 14 years, sometimes 
earlier, sometimes later. It may be irregular at first, but if the 
child is healthy it soon becomes normal. The approach of 
puberty in the boy is characterized by: (1) change of voice, 
(2) growth of pubic and axillary hair, (3) the development of 
the testes.4 
Puberty brings about mental and psychical changes in both 
sexes. The epoch manifests itself in a variety of ways in 
different individuals.5 Dr. Caroline Hedger has very aptly 
spoken of it as the “difficult age.”5 The child undergoes a 
complete change in disposition. He may suddenly become 
irritable and nervous. He may be unusually shy, awkward, 
self-conscious, or morbid and depressed. Besides being emo- 
tionally unstable, he may have difficulties in adjusting himself 
to his family and home environment, also to society. The 
reason for these inconsistencies is that he is experiencing new 
sensations and desires, before he has developed experience or 
judgment wThich will help him to understand or control these 
emotions.6 It is a dangerous period because the child is laying 
the foundation for the spiritual, mental, and physical develop- 
Puberty 
Changes 
which Occur 
during 
Puberty 
Dangers of 
Puberty 
4 Lucas, William P., M.D., ‘ ‘ Adolescence. ’ ’ ‘‘Oxford Medicine, ’ ’ 
Yol. I. 
5Hedger, Caroline, M.D., “Adolescence.” Public Health Nurse, 
November, 1921. 
®“Child Care and Child Welfare,” issued by Federal Board for 
Vocational Education. 16 
PEDIATRIC NURSING 
Hygiene of 
Puberty 
ment of his future life, and it is essential that he come through 
fit to stand the stress of our modern civilization. Good habits 
should be established in childhood so as to decrease the diffi- 
culties at this time. The child should have his full quota of 
sleep every night. He should have plenty of outdoor exerci.se, 
but not enough to overfatigue him. He should eat simple, 
nourishing food at regular intervals. His bowels should move 
daily. He should continue his school work and usual light 
tasks unless his health is definitely below par. Above all else 
he needs careful and wise supervision in regard to all his 
activities—his manner of living, his work, his play, his choice 
of companions and of literature. This guidance should not be 
a severe restraint; it should not make the boy or girl feel a 
lack of freedom nor should it destroy initiative. Confidence 
and companionship between parent and child are to be sought. 
Both boys and girls must be prepared for these changes by 
having a knowledge of what to expect and of how to conduct 
and to care for themselves. They will enter the period much 
more calmly and they will have less nervous reaction. As soon 
as a child is old enough to understand or is interested enough 
to ask questions about sex and reproduction he should be in- 
formed by his parents. His first questions about the subject 
should be answered in a frank, natural way, making no mys- 
tery or secret of it. He should be told the truth from the first 
in a simple, dignified way and in language that he can under- 
stand. Thus, if a wholesome attitude of mind toward matters 
relating to sex, and if the proper respect and pure ideals are 
instilled in him, they will remain with him throughout his 
life.7 
Blanchard, Phyllis—The Adolescent Girl. 
Guerber, Helene Adeline—You and Your House Wonderful. 
Hall, G. Stanley—The Adolescent. 
Hall, Winfield Scott—From Youth to Manhood. 
Morley, Margaret—Song of Life. 
reading references 
7 Ulrich, Mabel S., M.D., “Mothers of America,7’ “The Girl’s Part,’’ 
*‘ Uncle Sam Needs Teachers. ’ ’ Minnesota State Board of Health. CHAPTER III 
HYGIENE OF INFANCY AND CHILDHOOD 
Proper hygiene and regularity of habits are essential for 
the normal growth and development of the child. The child 
must be taught these principles from the first by hygienic 
environment and absolute regularity in every detail pertain- 
ing to his care. 
A special room or nursery in every home where there is a 
child should be set aside for his exclusive use. This room 
should be above the first floor and should be as large as pos- 
sible, remembering that 1000 cubic feet of air space should be 
allowed every child; it should be reasonably quiet; it should 
have at least two large windows; and it should be so situated 
that the sun shines in a greater part of the day. A corner 
room with southern and eastern exposures is preferable. The 
importance of sunlight in the nursery cannot be overesti- 
mated. The most recent wrork on rickets emphasizes its value 
as a preventive measure.1 A porch or balcony opening from 
the nursery is very desirable. The windows should be screened 
and provided with awnings and bars or some other protection. 
There should be light and dark shades and the simplest of 
washable curtains. 
The air in the nursery must be fresh. A fireplace for either 
coal or wood is the best aid to ventilation. It must be well 
guarded by a high fender or screen which cannot be removed 
by an active child. Ventilators in the window sash are also 
helpful. Direct draughts may be prevented by the use of a 
screen and window boards. Twice a day the baby should be 
taken from the nursery for fifteen minutes while the windows 
Importance 
of Hygiene 
Kegularity 
of Habits 
Ideal 
Nursery 
Sunlight 
Ventilation 
1A. F. Hess, M.D., and L. J. Unger, M.D., “Cure of Infantile Rickets 
by Sunlight.” Journ. Am. Med. Assn., July 2, 1922. 
17 18 
PEDIATRIC NURSING 
Temperature 
are opened and the nursery aired. The temperature should be 
60° F. during the day except during the bath hour when it 
should be 72° F. During the first few months it should be 
65° F. at night. As the child grows older the temperature can 
be lowered gradually so that by the time he is 7 months old it 
may be as low as 40° F.; after he is a year old it can be that of 
the outside air provided it does not go below freezing and 
provided the child is well protected by suitable sleeping gar- 
ments. (See Night Clothes.) It is better to have a current of 
air in the room and constant artificial heat than to have no 
ventilation. The temperature of the nursery should be as low 
as possible during the summer. An electric fan may be used 
in hot weather to change the air but it should not be placed so 
that it blows directly on the child. Since the temperature near 
the floor is lower than that higher up, the thermometer should 
be placed on a level with the baby. Most modern homes are 
heated by steam, hot air, or hot water. The latter is the most 
desirable. Wire screens over the radiators are advised as a 
protection for the child. In addition to the heating plant a 
fireplace is useful in maintaining an even temperature, besides 
being an aid to good ventilation. As it is necessary to have 
the air moist, a hygrometer may be used to test the humidity, 
which should be about 55 per cent. 
Electricity is the best method of lighting the nursery. The 
shades should be adjusted so that the light is indirect. The 
baby should be taught from the first to sleep in a dark room at 
night. 
One should be able to wash everything in the nursery with 
soap and water. The walls should be painted a soft color. 
Pictures may be done away with if a design of Mother Goose 
figures or animals is painted on the walls. The floor may be 
of hard wood (not highly polished) or it may be covered with 
linoleum. Small, light, washable rugs are allowed. The furni- 
ture should be of a simple design and painted white. It 
should include:2 
Method of 
Heating 
Lighting 
Equipment 
2Smith, R. M., M.D., "The Baby’s First Two Years of Life.” HYGIENE OF INFANCY AND CHILDHOOD 
19 
1. A white iron crib. 
2. A bureau or chest of drawers for clothes. 
3. A screen. 
4. A high, large, plain table covered with oilcloth upon which 
to put the baby when changing or bathing him. 
5. Two low chairs, one a rocker without arms. 
6. A footstool. 
7. A platform scale on a separate small table. 
8. A nursery chair and chamber (preferably kept in the bath- 
room). 
9. A covered white enamel pail for soiled diapers (kept in the 
bathroom). 
10. A hamper for soiled linen (kept in the bathroom). 
11. A baby pen (when he is old enough for it). 
12. Small chairs and a small table (when he is old enough for 
them). 
A good bed for the newborn baby in the home is an ordinary 
clothes basket painted "white and with a mattress of hair or 
felt. (A hair pillow may be used for a mattress, but never 
a feather one.) The basket, which is suitable for only a few 
months, is changed for a white iron crib. Curled, live horse 
hair is the best crib mattress, but as this is quite expensive, a 
felt mattress may be used instead. Always cover the mattress 
with a rubber sheet. Never allow the child to sleep with a 
pillow under his head. A down or a feather pillow may be 
kept on the bed during the day. When the baby begins to sit 
up a hair pillow may be put at his back to support him. 
Cotton sheets, wool, or cotton and wool blankets, and a white 
dimity spread complete the bed clothing. 
If possible a bathroom should adjoin the nursery. None of 
the baby’s clothes or diapers should be washed or dried in his 
room. Milk formula? or food of any kind should neither be 
kept nor prepared there. 
All of the above details regarding the nursery and its 
equipment cannot be carried out in every home. Nevertheless, 
one should always have an ideal toward which to strive and in 
this case it should be to make the nursery as nearly perfect as 
existing conditions allow. 
Bed 
Bathroom 20 
PEDIATRIC NURSING 
Visitors 
One or two visitors may be permitted to see the baby during 
the day at a stated time. It is extremely selfish of friends and 
relatives to interfere with the daily routine simply to amuse 
themselves. The baby is not a plaything for adults or an 
object of show for relatives and friends; he is the most 
precious possession ever given to man and should, therefore, 
be guarded accordingly. If possible do not let any one kiss 
the baby; certainly never allow any one to kiss him on the 
mouth. This does not mean that all demonstrations of affec- 
tion must be repressed; for there are other means of showing 
it. 
The newborn baby sleeps most of the time, waking only 
from hunger or discomfort. At first his sleep is deep and 
rather stuporous, but after the first month it is not so pro- 
found and is quiet and peaceful. After 3 years it is the deep, 
sound sleep of childhood. The following is a table for the 
minimum amount of sleep necessary for a child : 
Sleep 
Necessary- 
Amount of 
Sleep 
Age 
Amount of Sleep 
How Divided 
Newborn 
20-22 hours 
6 months 
16-18 hours 
Staying awake to 2 hours 
at a time. 
1 year 
14-15 hours 
11 or 12 hours at night plus 
2 or 3 hours during the day 
(a nap twice a day). 
2 years 
4 years 
6-10 years 
10-16 years 
13-14 hours 
11-12 hours 
10-11 hours 
9 hours 
11 or 12 hours at night plus 
1 or 2 naps during day. 
If regular habits of sleeping and feeding are established from 
the beginning, it will not be difficult to follow them. The new- 
born is fed every 4 hours during the day and 2 or 3 times at 
night; i.e., at 10 or 11 p.m. and at 5 or 6 a.m. The baby sleeps 
nearly all of the time between feedings, if he is dry, warm and 
comfortable. This means that his naps are 2y2 to 3x/2 hours 
long except at night, when he should sleep 6 to 7 hours at a 
stretch. In order to establish this routine the baby must be 
awakened regularly for his feedings. After each feeding HYGIENE OF INFANCY AND CHILDHOOD 
21 
change his position. If he lies on his right side after the 
10 a.m. feeding, he should lie on his left side after the 2 p.m. 
feeding. If he cries between feedings a change of position 
will often quiet him. If this fails try placing him on his 
abdomen. A child must never be rocked to sleep, given a 
pacifier, or any soothing device. See that he is warm, dry, 
and comfortable, and place him on his bed while he is awake 
to allow him to go to sleep by himself. 
A daily nap should be taken until the child is old enough to 
go to school and, if he is suffering from malnutrition, bad 
posture, etc., his school hours should be so arranged that a 
daily nap may still be possible. It should be taken at the same 
hour every day, usually after lunch. His shoes and rompers 
should be removed and he should be made to lie on his bed. 
Open a window to supply plenty of fresh air and draw the 
shades so that sleep may be induced. If the weather permits, 
the child should take the nap out-of-doors on a sleeping porch. 
Do not allow him a strenuous play time just before going to 
bed because as a result he may be too nervous and exhausted 
to sleep or his sleep may be restless. The tendency is to crowd 
more activities into his life than his strength and health will 
permit. There is a close relationship between overfatigue and 
malnutrition.3 The rest period must, therefore, be carefully 
guarded until the time when school interferes with it. From 
this time his activities must be limited to those which do not 
interfere with his normal gain in weight. 
A baby may be taken outdoors for a few minutes when he is 
a week old if the weather is mild. If the time is gradually 
increased he may sleep outdoors during the entire day at the 
end of 2 or 3 weeks. In very cold weather it is best not to take 
the newborn outdoors until he is a month old and then only if 
the temperature is above 60° F. If the temperature is above 
20° F. he may go outdoors when he is 4 or 5 months old. 
When he is older his naps may be taken outdoors except on 
Daily Rest 
Period 
Malnutrition 
and Fatigue 
Time Out 
of Doors 
3Veeder, B. S., M.D., ‘‘Role of Fatigue in Malnutrition of Children.” 
Journ. Am. Med. Assn., Sept. 3, 1921. 22 
PEDIATRIC NURSING 
windy, stormy, or extremely cold days. In other words, he 
should be kept outdoors just as much as the weather permits. 
Plenty of fresh air day and night is as necessary as food for 
the growing organism. Do not wheel the baby when he is out- 
doors but place the carriage in a sheltered spot and leave him 
alone. There is no necessity for wheeling him until he is too 
active to remain quietly in his carriage. 
It is very necessary for the baby to cry as soon as he is born 
in order to expand his lungs and to prevent atelectasis. If 
he does not cry he must be forced to do so 2 or 3 times daily, 
for under normal conditions the lungs do not expand fully for 
several weeks. After that crying is a valuable form of exer- 
cise and the baby should have at least 15 to 20 minutes of loud, 
strong crying every day. Excessive crying is generally caused 
by discomfort, as from soiled napkins, or by hunger, fright, 
anger, or habit. If a baby is crying see that he is dry, that he 
is neither too warm nor too cold, that his clothes do not irritate 
him, and that his position is comfortable. Give him his feed- 
ing if it is time for it and if he is crying from hunger he will 
be satisfied and will sleep afterwards. Make sure that he is 
not crying from pain, possibly from sore buttocks or from 
difficult stool. If he has colic he wall kick his legs and draw 
his knees up over his abdomen and his cry will be loud and 
paroxysmal. If he is crying from fright, comfort him; but if 
he is crying from habit or temper or because he is spoiled, 
start disciplining him at once. 
Exercise is necessary for the child’s development. The small 
baby exercises with every motion he makes with his arms and 
legs and when he cries. The baby’s daily routine in a home 
should include a special exercise time. The room should be 
warmed to 72° P. (as for the bath) and the baby should be 
placed on his bed, dressed only in his shirt and diaper. (See 
note 2.) He should be permitted to kick and exercise in this 
way for 20 to 30 minutes. During the summer he may have 
his exercise outdoors. This is not a practical suggestion for an 
institution because it takes too much time. The small baby 
Crying 
Exercise HYGIENE OF INFANCY" AND CHILDHOOD 
23 
may also obtain exercise if he is held or carried once a day. 
He ought never to be rocked and should be handled only for a 
few minutes at regular intervals; usually the best time is 
before feeding him or before putting him to bed. Be sure that 
his head and neck are well supported when he is being held. 
Intelligent mothering is essential for every baby’s normal 
development, but care must be taken that it does not become 
foolish indulgence. As a rule the baby in the home is held too 
much and the baby in the institution is not held enough. The 
latter needs a certain amount of mothering to prevent him 
from becoming “institutionalized”; therefore special effort 
should be made to pick him up and hold him occasionally. 
As a child develops, his body is in constant motion when he is 
awake and he has sufficient exercise from his normal play. 
His motions should not be restricted by too tight clothing about 
his feet. There are many walkers, rocking horses, and swings 
on the market and, if they are used, care must be taken that 
they are the correct size and constructed so that their con- 
tinued use will not cause deformity, also that they are used in 
moderation. Such devices must be made of plain enameled 
wood with no cushions or upholstering. A baby exercise pen 
is useful after the child begins to crawl about. This is best 
built on a standard or with legs long enough so that the floor 
of the pen is at least 12 inches from the floor of the room to 
prevent draughts from reaching the child. He should never be 
allowed to play on the floor because of draughts and dirt. 
Exercise should be taken outdoors when the weather permits. 
All outdoor sports should be encouraged. The child should be 
permitted to indulge to the point of moderate muscular fa- 
tigue, but not to exhaustion. 
Posture must be carefully watched because incorrect posture 
limits the activities of the growing boy or girl and prevents 
the well-rounded exercise which is necessary for growth and 
development.4 Correct posture is: head up, chest up, shoul- 
Intelligent 
Mothering 
Exercise Pen 
Posture 
4 Dickson, F. D., M.D., 1 ‘ Effect of Posture on Health of the Child. ’ ’ 
Journ. Am. Med. Assn., Sept. 3, 1921, 24 
PEDIATRIC NURSING 
ders up, abdomen in, legs straight, and feet forward. If 
efforts are made to see that the child assumes proper postures 
early in life, sitting and standing, much trouble may be pre. 
vented. Ill-fitting clothing may cause and certainly will 
aggravate postural defects; the weight of the clothes should 
come from the shoulders and they should be made so that their 
weight is evenly distributed.5 Mild postural defects may be 
corrected by proper exercise and periods of rest as prescribed 
by a specialist. 
As soon as a child is old enough to notice his fingers and to 
try to hold objects in them (usually about 6 months), he 
demands something to play with. Since he will put every- 
thing into his mouth, his toys should be made of a material 
which can be washed or preferably boiled. Wooden, rubber, 
or celluloid toys are best; woolen ones are prohibited. They 
should be durable, well made, in good taste as to color, and 
should have no sharp corners, rough edges, or long handles to 
hurt the child. Allow him only one toy at a time, since he will 
be as happy with one as with many, and one will help develop 
his powers of concentration while several will confuse him. If 
he throws his toy on the floor, it may be tied to his crib with a 
piece of tape. Do not allow a child of any age to play with 
money. The purpose of play is not primarily to give pleasure, 
although this should not be lost sight of, but to afford oppor- 
tunities for development, to act as a character builder and an 
assistant to education, to furnish a wholesome stimulus for 
the development of creative instincts, and to supply an outlet 
for mental, physical, and emotional powers. Playthings 
should be selected with the above points in mind.6 No child 
will be happy or contented without occupation; therefore a 
place to play and suitable toys for both indoors and outdoors 
are necessary. These do not need to be elaborate or expensive, 
for simple, homemade contrivances often give more pleasure 
Play Toys 
Purpose 
of Play 
5 Ramsay, W. R., M.D., ‘ ‘ Care and Feeding of Children. ’ ’ 
8 Scott, Miriam Finn, “New Riches of Play.” Good Housekeeping, 
Dec., 1921. HYGIENE OF INFANCY AND CHILDHOOD 
25 
than do the former. (See note 6.) Constructive, meaningful 
toys which bring out the child’s ingenuity, develop his imagi- 
native and creative powers, and produce a desire to concen- 
trate and persist in the task on hand are advisable. Supply 
him with material and encourage him to invent and construct 
things for himself.7 Teach him to always keep his possessions 
in a neat, orderly way and in a place specially provided for 
them. 
(Daily toilet habits discussed in Chapter XV, Urine and 
Stools in Infancy and Childhood.) 
A baby’s clothes should be light, soft, non-irritating, well- 
fitting but not too tight, and warm enough to suit changing 
conditions of climate and season. A baby’s hands and feet 
should be warm but he should not perspire. Dresses and 
petticoats should hang from the shoulders with no extra seams 
or fancy trimming. They should be fastened with tapes or 
very small buttons, as few pins used as possible, for the ‘‘well 
dressed” baby has pins only in his diaper. Clothes for the 
newborn consist of a dress, “gertrude,” shirt, abdominal 
binder, and diapers. The abdominal binder which secures the 
cord dressing may be made of light, part-woolen flannel or old, 
soft, cotton cloth. It should not be hemmed and should be cut 
4 inches by 15 inches. The band is preferably basted, but may 
be pinned with very small safety pins to one side of the front 
midline. It is put on tightly to keep it in place but not 
tightly enough to interfere with respirations or to cause 
discomfort. If it is drawn very tightly around the abdomen 
and the finger slipped under it while it is basted or pinned, it 
will be just snug enough when the finger is withdrawn. The 
binder is not worn after the umbilicus is healed. 
An all-woolen shirt is too irritating for a baby’s skin; cotton 
and wool or silk and wool is better. Plain cotton shirts are 
warm enough when the nursery can be kept at an even tem- 
perature and if the baby’s temperature does not become sub- 
normal. The second size is the most practical as the first size 
Clothing 
Clothes for 
Newborn 
Abdominal 
Binder 
Shirt 
7 Czerny, ‘ ‘ Der Arzt als Erzieher des Kindes. ’ ’ 26 
PEDIATRIC NURSING 
is outgrown very soon. Garments containing wool require 
special laundering. Use Ivory soap and warm soft water 
(hard water softened with pure borax). Wash by squeezing 
the articles with the hands, not by rubbing on a wash board. 
Rinse several times in warm water and hang outside to dry. 
Bird’s-eye cotton is most desirable for diapers because it is 
light and absorbent. Several thicknesses of cheesecloth may 
also be used. Small size diapers (18 inches by 36 inches) are 
best for the newborn and larger ones (26 inches by 52 inches) 
for older children. The meconium of a newborn is very diffi- 
cult to wash from diapers; therefore it is advantageous to put 
a piece of old cotton, 3 to 5 inches square, inside the diaper. 
This can be done for older children also. For the small baby 
the diaper may be folded in the shape of a triangle and two 
corners of the triangle brought around the waist and the third 
corner brought up between the legs. The three ends or corners 
are then pinned together to the shirt in front. The diaper 
may also be pinned to the shirt in back to keep it in place. A 
better way to adjust the diaper when the child is older is to 
fold it in the middle lengthwise, so that it is about 10 or 12 
inches wide and 24 inches long, bring half of it up between 
the baby’s legs in front and half in back, draw it firmly around 
his waist and pin at either side with two safety pins. Do not 
adjust the diaper too tightly, especially over the genitals, 
because it may cause irritation and lead to masturbation. Too 
many thicknesses should not be brought up between the legs. 
When the child is older two diapers (one inside the other) may 
be necessary to absorb the moisture. Rubber pants are unde- 
sirable because the rubber keeps in all the moisture and 
irritates the child’s sensitive skin. They are permitted occa- 
sionally, when traveling or on similar occasions. Change the 
diapers as soon as the child urinates. Always wash them 
before using again. All fecal material should be washed oft at 
once. Wet and soiled diapers should be placed in a covered, 
enamel pail until they are washed. Clothing should never be 
washed or dried in the nursery. Diapers should be washed 
To Launder 
Woolen 
Garments 
Diapers 
Rubber Pants HYGIENE OF INFANCY AND CHILDHOOD 
27 
carefully to prevent red, excoriated buttocks. Use a good 
grade of soap such as Ivory; avoid the use of soda or strong 
washing powders. If the water is hard, soften it with pure 
borax. Rinse thoroughly and hang in the sun to dry. 
The “gertrude” or petticoat is made of light-weight, part- 
woolen flannel, outing flannel, or cotton. It should measure 
27 inches from the shoulder to the hem and should be fastened 
at the shoulder with tiny buttons or tapes. 
. The slip should be made of a fine, soft cotton material, as 
batiste or nainsook; it should be extremely simple with sleeves 
(Bishop sleeves) cut with the body of the dress. Hand work 
or embroidery is allowable but not necessary. It should fasten 
in the back with 2 or 3 tapes. If a tape is run in a small hem 
at the neck and at the bottom of the sleeves the slip will fit 
better. 
The newborn can sleep at night in the clothes worn during 
the day. His outside wraps consist of a cape with hood at- 
tached or a sleeping bag with hood. 
The same style shirt, as given above, in proper sizes, can be 
worn throughout infancy, provided that a normal temperature 
is maintained. As the child grows older and sleeps in a colder 
room, he must wear a sleeping garment which will protect 
him even if he kicks the covers off. A nightgown with draw- 
strings in the bottom of the sleeves and in the hem of the 
gown is best for the first few months. A sleeping bag is also 
satisfactory. It should not be made too large but large 
enough to allow perfect freedom. When the child outgrows 
these, make him a sleeping garment with feet. If a shirt is 
worn at night a different one should be worn during the day. 
A child over a year does not need a shirt at night except in 
cold weather; when he may wear a cap and mittens as well, 
especially if he sleeps outdoors. Clothes may be shortened to 
ankle length when the baby is 3 or 4 months old. The diaper 
is worn until the child is trained, then bloomers, drawers, 
or gauze union suits. The ‘ ‘ gertrude ” is a suitable petticoat 
for all ages. A plain petticoat buttoning to an under waist at 
To Launder 
Diapers 
“Gertrude” 
Dress 
Night 
Clothes 
Clothes for 
Infant 28 
PEDIATRIC NURSING 
the waistline is also good. Simple, dainty dresses are best; 
laces, frills, and tucks should be avoided as much as possible. 
A quilted bib is quite necessary to absorb excess saliva when 
the baby drools. Rompers may be worn as soon as the infant 
begins to crawl about. The infant should wear cotton stock- 
ings after the first two weeks or, if necessary, stockings of 
cotton and wool, then his feet are not encumbered by too 
heavy clothing and he is free to move around as much as he 
pleases. The stockings are pinned to the diaper in front and 
in back. Later they may be attached to an underwaist by 
garters. No shoes are needed until the baby crawls, when he 
should wear soft-soled ones. These should be replaced by 
stiff-soled shoes when he begins to stand. 
A young infant should wear as few clothes as possible 
during hot weather; a sleeveless gauze shirt and diaper only 
are necessary. It is advisable always to keep the abdomen 
covered. The temperature should regulate the amount and 
quality of the clothing. Do not overdress the child as is the 
general tendency; be consistent and dress him according to 
the temperature, seeing that all parts of the body are pro- 
tected. For example, if the room is kept at an even, warm 
temperature, the child may wear the same clothing in winter 
that he wears during the summer, extra heavy wraps being 
added when he goes outdoors. Then, too, do not put a warm 
coat with a fur collar on the child and at the same time have 
his knees exposed by the use of socks instead of stockings. 
The outdoor clothing should consist of a coat sufficiently 
heavy to keep him warm but not heavy enough to restrict 
freedom of motion. Woolen overstockings or leggings, over- 
shoes or rubbers, mittens, and a knitted cap are good 
suggestions. 
The same rule for woolen clothes applies to the child over 
2 years. A union suit may be worn if desired. Drawers 
should have long, ankle-length legs in winter. An underwaist 
must be worn with drawers, the petticoat and garters being 
buttoned to it at the waistline. This underwaist holds the 
In Hot 
Weather 
Clothes 
for Child HYGIENE OF INFANCY AND CHILDHOOD 
29 
weight of the other garments and should be made with broad 
shoulder straps so that the weight is equal upon all points. 
Both boys and girls may wear rompers for play suits until at 
least 5 years old. After that age a boy’s play suit may 
consist of overalls while a girl may wear a dress with 
bloomers to match, thus making a petticoat unnecessary. 
Short stockings are permissible only in warm weather. A 
child should wear shoes sufficiently large and comfortable, 
which conform to the natural shape of the foot. Shoes with- 
out heels should be worn until the boy or girl is 5 or 6 years 
old, and after that shoes with very low heels. 
The child in the home is bathed daily, following the same 
routine for the bath as given under the care of the child in the 
hospital (Chapter VI). The necessary equipment is: 
The Bath 
1. Jar of cotton pledgets made of second grade cotton (size of 
walnut). A covered glass fruit jar may be used. 
2. Jar of cotton eye pledgets made of best grade cotton (size of 
small marble). 
3. Jar of toothpick applicators made of best grade cotton wound 
tightly on small end of toothpick. 
4. Two small glasses or enamel basins, 4 inches in diameter, one 
for oil and one for boric acid. 
5. One large basin to be filled with hot water in which to put 
small basins to heat contents. 
6. One cake pure castile soap (powdered or liquid soap is not 
necessary when caring for only one child). 
7. Paper bag for waste. 
8. Bath thermometer. 
9. One shaker of zinc stearate or boric powder. 
10. Nail scissors, file, orange-wood stick. 
11. Brush and comb. 
12. Tray of safety pins. 
13. One bottle of oil. 
14. One bottle of boric acid solution—2 per cent. (Make a 2 per 
cent boric acid solution out of sterile water and put it ini 
bottle to use as needed.) 
15. Wash cloth and towel. (Old pieces of soft linen make very 
good ones for the small baby. Bird’s-eye linen is also good 
material.) 
Equipment 30 
PEDIATRIC NURSING 
All articles used for the child’s bath in the home should be 
kept for his exclusive use. They do not need to be sterilized 
but should be well washed after use. Cotton pledgets, appli- 
cators, and solutions do not need to be sterilized. Handling 
forceps are not necessary. No highly scented soaps or powders 
are permitted. 
The temperature of the bathroom should be 72° F. A 
kitchen table covered with oilcloth can be kept in the bath- 
room. This makes a convenient place on which to put the 
baby when bathing him as well as when changing his diapers, 
etc. There are on the market folding bath tables with canvas 
tops which take up less room. 
The newborn baby in the home is oiled, as he is in the 
hospital, until his cord comes off and the umbilicus is healed. 
After that time a tub or shower bath may be given, as the 
facilities of the bathroom permit. For the tub bath of the 
small baby a basin or a small enamel foot tub will do. The 
folding rubber tubs which are on the market are very conven- 
ient. A shower may be improvised by attaching a spray to 
the faucet of the bath tub. 
The temperature of the water should be 100° F. for the 
first 6 months. After that it may be gradually lowered until it 
is between 95° and 90° F. by the time the child is a year old. 
After he is 6 months old the healthy infant may have his 
bath followed by a shower of water 80° F. to 70° F. for 15 or 
30 seconds. This is followed by a brisk rubbing of the entire 
body. 
The small baby’s bath is best given in the morning before 
his 10 a.m. feeding. The older child may have a cold sponge 
or shower in the morning and his warm tub bath at night. 
Temperature 
of Bathroom 
Temporature 
of Water 
Time for 
Bath 
Dunn, Charles Hunter, M.D.—Pediatrics. 
Griffith, J. P. Crozer, M.D.—The Care of the Baby. 
Diseases of Infants and Children. 
Holt, L. Emmett, M.D.—The Care and Feeding of Children. 
Diseases of Infancy and Childhood. 
BEADING REFEBENCES HYGIENE OF INFANCY AND CHILDHOOD 
31 
Starr, Louis, M. D.—Hygiene of the Nursery. 
West, Mrs. Max—Child. Care, U. S. Department of Labor, 
dren’s Bureau. 
West, Mrs. Max—Infant Care, U. S. Department of Labor, 
dren’s Bureau. 
Child Care and Child Welfare, issued by Federal Board for 
tional Education, Oct., 1921. 
Chil- 
Chil- 
Voca- CHAPTER IV 
THE MENTAL DEVELOPMENT OF CHILD LIFE 
By Frederica Beard 
Every nurse who has the care of children will do greater 
service to humanity if she be intelligent—rather than igno- 
rant—in regard to the growth, mental and physical, of the 
human beings for which she cares. Her problems in this work 
will be also more readily solved and thereby her burdens grow 
lighter. 
By “mental” we mean all of human nature that is not 
body. One is apt to think simply of the intellect under the 
term mental, reserving that which relates to feeling, emotion, 
and will to the so-called “soul” or “spirit.” But modern 
psychology sees but different phases of one all—a unit of 
consciousness expressing itself in three great activities. 
“ ‘Intellect’ is not a part of the soul but the whole soul, 
predominantly engaged in thinking; ‘sensibility’ is not a part 
of the soul capable only of feeling, but the whole soul pre- 
dominantly engaged in feeling. ‘ Will ’ is not some part of the 
soul capable of choosing, but the whole soul engaged predomi- 
nantly in choosing.”1 
The proper usage of the word “mind” suggests a static 
entity, whereas mental development implies process—an un- 
folding. To speak of “mental states” is in a measure mis- 
leading, because there is nothing fixed, nothing passive, but 
rather a continuous activity of growing experiences. 
Capacities and innate tendencies are the only mental en- 
1 Jones, L. H., “Education as Growth/’ page 28. 
32 MENTAL DEVELOPMENT OF CHILD LIFE 
33 
dowments—capacity to feel, capacity to act, capacity to think, 
and capacity to choose; innate tendencies leading to response 
to certain conditions that serve as stimuli. These capacities 
and tendencies may or may not develop. 
Unfolding means enlargement from within out, and conse- 
quently change. This is the law of growth in all forms of life 
from the lowest to the highest. Human development may well 
be compared to that of plant seed. In both, growth is gradual. 
If a gardener hastens growth, lack of beauty or of strength is 
the result. Change comes often imperceptibly. There is, we 
say, a sudden bursting forth, but an invisible change has been 
going on, and growth means more than difference in size. 
Growth is progressive and orderly. ‘ ‘ First the blade, then the 
ear, and after that the full corn in the ear.” The greatest of 
teachers has also said, ‘‘Consider the lilies of the field, how 
they grow.” Commenting on this, Henry Drummond says, 
‘ ‘ There is but one principle of growth for the natural and the 
spiritual, for animal and plant, for body and soul.” The 
caretaker of the garden makes right conditions for germina- 
tion and fruitage, and that in its widest sense covers the work 
of the gardener of any human life. A leading psychologist 
(see note 1) tells us that to educate is to cause change. Re- 
membering the derivation of the word education—a leading 
out—we must not confine it to the artificial environment we 
call ‘‘school,” but think of it as caused by all that forms a 
part of the environment of the developing being—home and 
the persons within it; natural and social surroundings which, 
of course, include school and all other cultural means. 
“As the plant grows through its own vital power so also 
must human power become great through its own exercise and 
effort,” (Froebel). Professor Edward Thorndike (see 
note 1) says: “But to say that ‘Everything is in the child, 
and education has only to draw it out’ is as true—and as 
false—as ‘Everything is outside the child and education has 
only to put it in.’ ” Plant and child are self-active, but they 
absorb from the environment and in that sense are dependent 34 
PEDIATRIC NURSING 
upon it. In the process of absorption, however, there is selec- 
tion. Next, they project themselves into the environment and 
later, aggressively, gain control over it. 
In the new science of child psychology it has been found 
that there are periods or stages in human development in each 
of which certain tendencies and interests manifest themselves 
more strongly than before or after. To study child life 
through one’s own observations and those of specialists who 
have observed hundreds of children, at these different stages, 
is most essential for intelligent training and wise management. 
To know what to expect at a certain period, how to make 
use of an interest, how to conserve one tendency and let 
another die out; to know that some characteristics are 
transitory and peculiar to a period and that others should be 
permanent—are all possibilities to-day as never before. To 
discriminate between original or innate tendencies and those 
that are acquired through training to habitual exercise, will 
lead to the recognition of what is universal in child life and 
what is peculiar to an individual. 
It is remarkable to find at one period, say, from six to nine 
years, some one interest evident in all children everywhere; 
such an interest expresses itself in various ways under vastly 
differing social conditions. Think, for instance, of the interest 
from three to six years—in play that makes one object serve 
for another according to the imagination of the child: a bundle 
of rags is “dolly,” father’s cane is a hobby horse, a lump of 
mud is a “pie”; of the constructive interest from six to 
twelve years, when to make a real thing is a child’s delight; 
or of the collecting interest which begins at seven or eight 
years in gathering rubbish, and is at its height at ten to twelve 
years in stamps, postal cards, and other collections of value. 
In considering periods of development it is necessary to 
remember three things: 
Age limitations are convenient but not absolute (see note 1) : 
a child of five may belong to the seven-year-old group, while 
a seven-year-old may be in the five-year-old stage. Students MENTAL DEVELOPMENT OF CHILD LIFE 
35 
of childhood make slight variations in these somewhat arbi- 
trary age limits, some dealing with the periods more broadly 
and with fewer variations than others. Suffice it to say here 
that there is remarkable agreement as to the main character- 
istics of each period.2 
Difference in mental powers at varying ages is one of degree 
rather than of kind.3 When it is said that the period under 
six years is a period of impulses, it is not meant that impulsive 
action does not occur later; nor in saying that reasoning and 
reflection belong to the period of the teens does it mean that a 
little child does not exercise a degree of reasoning power, but 
that each of these is most prominent in the period specified. 
In a study of “How to Think,” John Dewey says, “The little 
child generalizes as truly as the adolescent or adult, even 
though he does not arrive at the same generalities. ’ ’ Generali- 
zation means capacity for relating new experiences to old 
ones. An idea that comprehends and unites what was iso- 
lated, involves seeing relations through comparison and judg- 
ment. A little child can do this only in concrete situations and 
in small ways. 
It is also essential, in studying periods, to recognize that 
what is true of nine children out of ten forms a norm or 
standard for understanding child life; the tenth child is 
simply a variation therefrom.4 Universal likenesses under the 
general laws of development are greater than individual dif- 
ferences, yet the latter must always be reckoned with. These 
differences are determined by climatic, racial, social, and 
special educational environment. The immediate experiences 
of a child form the basis on which to lead him to larger ones. 
It is wise to make use of that which he is in touch with, rather 
than to go far afield for subjects by which to enlarge experi- 
ence. A geographic illustration will make clear the effect of a 
particular environment—a child of a fishing village has a 
2 Cabot, E. L‘ ‘ Seven Ages of Children, ’ ’ Introduction, pp. xxv-xxvi. 
3 Cabot, E. L., “Seven Ages of Children.” pp. 115-117. 
4Welton, J., “Psychology of Education,” page 71. 36 
PEDIATRIC NURSING 
very different viewpoint from a child of a mining town. Walt 
Whitman’s poem beautifully suggests this effect, and shows 
also how a young child selects and absorbs from what is about 
him: 
There was a child, went forth every day, 
And the first object he looked upon, and received with wonder, pity, 
love or dread, 
That object he became. 
And that object became part of him for the day, or a certain part 
of the day, or for 
Many years, or stretching cycles of years. 
The early lilacs became part of this child, 
And grass, and white and red morning glories and white and red 
clover, and the song of the phoebe bird, 
And the third month lambs and the sow’s pink-faint litter, 
And the mare’s foal and the cow’s calf, 
And the noisy brood of the barnyard, or by the mire of the pond side 
And the fish suspending themselves so curiously below there—and 
the beautiful curious liquid, 
And the water plants with their graceful flat heads—all became part 
of him. 
Child Life from 1 to 6 Years. 
This poem brings us to the young child’s love of nature and 
to his interest in his immediate environment. His home and 
that which closely relates to it is his world. His ideals—so 
far as he has any—center in father and mother, or those with 
whom he comes in daily contact. He dwells in the present, 
with little time or historic sense. This period has been called 
the play or occupation period, because the child plays for the 
sake of playing. He has no definite purpose in view. The 
above poem suggests also that sense impressions are the most 
permanent. These develop before other mental powers. The 
sense of sight should be appealed to more than the sense of 
hearing at this age. Things ought to have a larger place than 
words. 
If space allowed it would be wise to divide this period into 
two, that of infancy from one to three years, and that of early MENTAL DEVELOPMENT OF CHILD LIFE 
37 
childhood, from three to six years. Here we must consider 
broadly and briefly. 
A child’s actions are now governed by instinct. “An in- 
stinct is a propensity prior to experience and independent of 
instruction” (Paley), such as fear, anger, self-assertion, 
parental love. Some psychologists to-day limit instinct to 
that which involves muscular action. To them instincts of 
love and of hate are more correctly innate tendencies, popu- 
larly termed feelings. Emotions are the manifestations of 
feelings. We often say we do a thing instinctively. That 
means there is a certain tendency within us that makes us act 
that way, for example, to run or jump when frightened. 
The study of instincts shows that some are desirable, some 
are undesirable; under guidance good instincts may be con- 
served and strengthened; while others may die out from lack 
of use. Some instincts mature gradually, others appear late in 
child development. Again, some instincts are the foundation 
of future intelligent action. If these do not lead to action in 
the growing stages, any later attempt to evoke them is likely 
to fail. A child who has not been encouraged to express his 
altruistic instincts in deeds of kindness, is likely, when a man, 
to have no sympathetic emotions strong enough to call forth 
effort for others (See note 4). To cultivate right feelings 
during this period is most important. Self-interest, however, 
precedes interest in others. A child must realize “mine” 
before he can appreciate “thine.” It is well to emphasize the 
sense of possession by “my chair,” “my doll,” and so on, and 
not to expect the unselfishness that a much older child should 
be led to exercise. Ownership must come before a child can 
recognize the rights of ownership. 
We have seen that self-activity is a necessity for growth. 
It expresses itself in a variety of ways. To be busy at some- 
thing—that is, to be self-active—is a primary instinct. But 
desire to do things may die, or it may turn to destructive acts, 
or it may develop into a habit of helpfulness. Froebel says, 
“You can here at one blow destroy, at least for a long time, 38 
PEDIATRIC NURSING 
the instinct of formative activity in your child, if you repel 
his help as childish, useless, of little avail or even as a hin- 
drance. ” “ Let me do it, ’ ’ the child cries, and again ‘ ‘ See me; 
I ‘kin’ do it.” To do for our children rather than let them 
do, will often prove easier, but we lose much for them, and for 
ourselves, in after days. A child of this age investigates and 
tests—projecting himself into his environment; that is how 
he comes to understand himself and it. Investigation may 
degenerate into destruction if provision is not made for right- 
ful exercise of this tendency. Playthings are needed that 
may be opened and taken apart without harm and destruction. 
Curiosity is mental appetite and interest is appetite satisfied. 
“What is it?” is a natural demand. A nurse will find large 
opportunity for making use of the sense of possession, also for 
discriminating in the play objects with which she may amuse 
a small patient. 
Play is the life of a little child. The last twenty years have 
revealed the educational possibilities of play as never before. 
But what is play? Running, jumping, using sand, and blocks? 
It may be one or all of these, but there may be play without 
any of them, or any similar things. It is just the joyous 
expression in any interest that occupies the moment, without 
thought of a result from such occupation. Doing anything 
for a result signifies v?ork. The very young child builds and 
knocks down—testing materials and qualities together with 
his own ability through play, finding what this thing wfill do 
and that will not, wuthout, of course, deliberate or even 
conscious purpose. The older child builds and makes a house 
—often using it in his play, thus showing a definite purpose 
working for a result through play. 
It has already been said that our point of contact is through 
a child’s immediate experience. It follows then that we must 
share the playful spirit ; also, that must use the positive 
rather than the negative from out the environment; the beauti- 
ful and good will bring a spirit of joy, while to dwell in words 
on the undesirable and bad destroys the play spirit. An MENTAL DEVELOPMENT OF CHILD LIFE 
39 
excellent rule in the management of little children is this: 
Do not introduce evil of which they know nothing. A mother 
told her four-year-old not to go across the street to the black- 
smith’s. He had not thought of doing so, but immediately 
went when Mother w’as not looking. A man interested in the 
presentation of bird life talked to first-grade children about 
not robbing birds’ eggs from nests. These little ones had been 
so much interested in bird mothers and their babies, they had 
never thought of doing such a thing! ‘ ‘ Don’t ’ ’ has its place 
when a wrong act has been done, or we know a child is tempted 
to do it. 
If what is lovely is in the environment it will be personified, 
or vice versa. An objective imagination holds sway. Inani- 
mate objects are clothed with life. Spirit rather than form 
attracts; what a person or thing can do rather than what he 
or it looks like; so the moon is the beautiful “lady”; the 
sunbeam ‘ ‘ the birdie on the wall ”; the wood-nymphs are 
“really in the forest,” a bed-post is clothed as “dear dolly.” 
To personify in this way is a strong interest, but imitation of 
doings rather than of doer is noticeable at this time. A child 
is full of faith and the unreal becomes the real; a poetic and 
spiritualizing element enters his imagination. The word 
spiritual is not used here in its highest sense, but in relation to 
life and in contrast to mere material interest—a thing is 
given life—a spirit—in imagination. A child always thinks in 
terms of the human. When he portrays Deity and the angels 
they appear as men. Imaginary, invisible companions are 
quite common; such “fancies” should be treated with sym- 
pathetic consideration by those guiding young children. 
The instinct of fear manifests itself strongly during this 
period, due partly to a lively imagination, partly to inex- 
perience. Fear has its value. It is implanted in every human 
spirit for some purpose. It is a safeguard from danger. It is 
the foundation stone of respect and reverence. Distinction 
needs to be made between normal and abnormal fear. Ex- 
treme fears often come from abnormal circumstances. A 40 
PEDIATRIC NURSING 
child’s fear of darkness may be overcome by suggestion of its 
beneficial character—the restful quiet that comes to flowers, 
birds, and children when the glaring light is gone. A story is 
told of a little girl terrified by a crashing thunderstorm. She 
loved singing, and to soothe and comfort her, her mother sang 
out into the strange voice of the storm, “0 all ye thunders 
and lightnings, praise ye the Lord, Bless Him and magnify 
him forever.” ‘‘The listening child heard a stronger voice 
than that of thunder. She lighted with joy over ‘our new 
song,’ the Psalm of David, four thousand years ago!” A 
nurse may follow the same principles of diversion and em- 
phasis on the beautiful side rather than the terrible, with a 
frightened child. The particular method to be used must 
depend on the particular condition. 
We have but touched on the interest and characteristics of 
this period and hinted at its needs. A more detailed study, 
with careful observation qf children, will give greater insight 
of all three. 
Child Life from 6 to 10 Years. 
Worth-while instincts and impulses must now be trans- 
formed into habits. Constant reaction in the right direction 
strengthens mental control and establishes moral conduct. 
This stage of development is essentially the habit-forming 
period. Some habitual action begins in the earlier period 
(physical habits particularly), but much is not then possible. 
Tendencies crop out now that are to be permanent by constant 
reaction, or to be overcome by habitual response in another 
direction. 
Self is very aggressive and all-absorbing. It is indifferent 
to social claims. It seeks self-advantage and is often revenge- 
ful. This is the period of self-directed physical activity. 
Earlier activity is largely aimless, but now there is purpose in 
view; for example, the younger child runs, the older one runs 
a race. Collecting—a gathering to oneself is a prominent 
interest; through this collecting grows differentiation along MENTAL DEVELOPMENT OF CHILD LIFE 
41 
both intellectual and moral lines. A beginning of scientific 
interest is evident in two ways: collecting things, useful and 
useless, and a frequent questioning as to “how” as well as 
“what.” 
The boy of seven to ten is not spiritistic; his interest is 
materialistic. Objective imagination has become constructive; 
he has ends in view of a concrete nature. His plans for con- 
struction are often too large for attainment. Symbolic interest 
is not in the spiritual symbol but in the sign. Words and 
marks stand for everything; the first reader is loved; the 
mere copying of numerals is a delight; honor rolls, badges, 
etc., are a significant interest in relation to moral valuations. 
Imagination is now keenly realistic. We have seen that the 
younger child gives life to the inanimate; rarely does a child 
of eight years. He responds to the dramatic story of 
realistic wonder and material setting, but cares little for fairy 
stories interesting to his little brother. This child has little 
care for the refinements of life; the cave and the tent satisfy. 
He is lore-ignoring, except as lore is vested in a person. 
External authority is necessary to the growth of valuations. 
A habit of obedience is a basis for control of self; also a habit 
of order and a fulfillment of regulations. 
Is some one asking how wTill this knowledge aid me in my 
daily work? The following illustrations will answer this 
question and should lead the student nurse to make applica- 
tions for herself in other parts of this study. 
A nurse who knows the tendencies and interests of a child 
of eight and contrasts these with those of the four- and five- 
year-old, or again, with those of the eleven-year-old, will treat 
each one differently, when he is ill and when he is conva- 
lescing. For example, she will soothe the youngest by a little 
imaginary play. A kindergartner was traveling one evening; 
a young mother and a sleepy but willful child of three were 
near her in the ‘ ‘ Pullman ’ ’; the mother vainly tried to quiet 
her little one; presently the kindergartner suggested putting 
“the family of fingers” to bed, and while she played “Go to 42 
PEDIATRIC NURSING 
sleep my thumbkin, ’ ’ the child became happy and was ready to 
be undressed. 
If an eight-year-old is restless because he must stay in bed, 
an improvised badge of honor for him who acquiesces to 
requirements will be likely to satisfy for at least one day. A 
group of pictures that may be cut out and classified, perhaps 
as “flower pictures,” “animal pictures,” “engine pictures,” 
etc., will appeal to the collecting interest of this child, while 
the younger one will be content to look at a scrapbook of 
heterogeneous pictures. The latter will like to investigate 
anything that will open and shut, and play for an hour, it 
may be, with trinkets from a box. The older child will find 
satisfaction in being shown how to make a box, an envelope, a 
pinwheel, etc., out of a piece of paper. He will be interested 
in a story of real doings, especially if they are wonderful to 
him; the fable in which animals talk, and the fairy story of 
similar type will appeal to his little brother. 
Repetition is a natural interest; of his own notion a child 
goes over and over a play or a piece of work that becomes 
play through his interest in it. This tendency allows of 
intellectual and moral “set.” Demands made upon a child of 
six to ten years of age show him the requirements and 
expectations of the group in which he is becoming a person. 
Moral habits established by external authority gradually raise 
an individual standard. 
“The Person as a Self” is an interesting study, as Professor 
Baldwin presents it.5 ‘ ‘ Personality is a progressive, never-to- 
be-exhausted thing,” of slow growth; in earliest years the 
individual is not a person in the sense of definitely recognizing 
himself as such. There is first “the receptive self” and, 
second, “the aggressive self,” then follows the rise of the 
ethical sense in recognition of “my ought,” which Professor 
Baldwin names “a dominating self.” Without setting strict 
age limits, the first years of school life are indicated as the 
time when this dawning ethical sense may be educated to 
“Baldwin, Janies, “Social and Ethical Interpretations,” page 33 et al. MENTAL DEVELOPMENT OF CHILD LIFE 
43 
become strong or to be left in its weakness. “Before we pass 
from the family circle to the school socius, before the boy gets 
out of his early imitative stage, we find another incident of 
his growth which is to him of untold importance. I refer to 
the rise and development of the ethical sense.” This ethical 
sense develops in succeeding years until conscience is mani- 
fest. Suppose a boy, suggests Professor Baldwin, who has 
once obeyed the command to let an apple alone, confronts the 
apple again, when no one is present to make him obey. His 
private, greedy, habitual self eyes the apple; there is also the 
suggestible, accommodating, imitative self over against it, 
prompting to do as his father said and let the apple alone; 
and there is—or would be, if obedience had taught him, no 
new thought of self—-the quick victory of the former. But 
now a lesson has been learned. A thought arises of one who 
obeys, who has no struggle in carrying out the behests of his 
father. This may be vague; his habit may be yet weak in the 
absence of persons and penalties, but it is there. It carries all 
the struggle of the first obedience, all the painful protests of 
the private, greedy self. While he hesitates, it is now not 
merely the balance of the old forces; it is the sense of the new 
better obedient self hovering before him. A few such fights 
and he realizes the presence of something in him which repre- 
sents his father, mother, or, in general, the law-giving 
personality. 
If habitual acts become so customary that no effort is called 
forth, no struggle demanded, the final outcome will be intellec- 
tual and moral weakness. Repetitions are deadening unless 
they lead to discovery—it may be of self-power, it may be of 
truth in relation to oneself and others, or of the world in 
which we live. Appreciation must come through a progressive 
mental insight. The self needs opportunity to choose and to 
realize consequences of obedience and disobedience, reverence 
and disrespect, rights of ownership and stealing, truth and 
lying. After many social experiences the “ought” grows out 
of the “must.” According to Aristotle, practice is itself one 44 
PEDIATRIC NURSING 
of the sources of insight. If a child does a certain thing many 
times and every time a satisfying result follows, he not only 
finds out what is best, but he discerns the standard of those 
around him and chooses to act in accordance therewith when 
left to himself. 
Child Life from 10 to 13 Years. 
The third period illustrates the continuity of growth; it 
proves to be a natural result of the preceding period and a 
beginning in certain directions of the marked changes of the 
fourth. Its most prominent characteristic is self-assertion. It 
is an era of will-training. Individuality is increasingly evi- 
dent. Several contrasting types of girls and boys come before 
us, but these are more closely related than at first seems true; 
there is some universal background. 
Sex differences also appear, but many so-called “differ- 
ences” are found to have the same root instinct and interest; 
girls may express in milder form that which is strongly em- 
phasized in boys. Joseph Lee characterizes all boys of this 
age as “Big Injuns” and all girls as “less so.” The fighting 
tendency, evident now as never before nor after, illustrates 
this. Girls do not usually have a “rough and tumble,” but 
they fight in other ways to come out “on top.” There is the 
desire to exert power, to assert oneself, to be a leader. Fight- 
ing is not always in the interest of self-preservation, but from 
motives of justice and altruism in an embryonic stage. Cour- 
age and gentlemanliness, respect for oneself and others, are 
often the result of this tendency. “Crush it and you have 
a coward; if you let it grow wild, you have a bully; if you 
train it, you will have a strong, self-controlled man of will.” 
Actual participation in manual labor will absorb energy that 
often runs to waste in fighting. Games of this age show con- 
test and combat and the individualistic element. Even in 
group games, each man plays for himself and the type of 
game demands a leader or “captain.” Group interest is 
just beginning, and at twelve to thirteen we find the “gang” MENTAL DEVELOPMENT OF CHILD LIFE 
45 
and the “bunch.” This gradual merging of the individual- 
istic into the social interest is a large and important study 
that can be only touched on here. Interest in heroes stands 
out, especially in those of physical prowess. “A symptom 
of the presence in the Big Injun of the coming spirit of mem- 
bership, and perhaps the most important to be recognized of 
all his traits, for those whose business it is to deal with him, 
is his unlimited capacity for hero-w7orship. He cannot as 
yet be loyal to a social group, but he can adore an ideal if 
presented in the concrete form of human personality.6 
Life is intense to our boy and girl and stories of wonderful 
exploits are eagerly devoured. By the testimony of thousands 
of children, reading is the chosen occupation of their free 
hours. This is the period of striking biographies. Interest 
is in persons more than things, and in journeying to the 
outside of the world. Persons are imitated or mimicked ac- 
cording to likes or dislikes. Deeds of daring charm are eagerly 
participated in. Desire for adventure is keen. The outside 
world appeals; love of nature is strong. 
What, how, and why, in relation to concrete affairs (for 
instance, mechanics) are evident. The question “ Why must 
I do it?” shows a seeking after reasons in the struggle to 
adjust one’s will to another’s. Choice of action should have 
a larger place in training now, with always an inevitable 
consequence following; the impersonal law is apt to be recog- 
nized and accepted more readily than the arbitrary personal 
demand. 
Constructive imagination leads to more exact planning and 
more definite fulfillment than before. The making of real 
things, that can be actually put to use, satisfies. Encourage- 
ment is needed for the completion of such undertakings. Co- 
operative service wfill lead to a greater social interest; self- 
absorption and importance pass into thought for others, 
through working for them. Wise consideration is needed here, 
however, for ambition to earn money is characteristic of this 
8Lee, Joseph, “Play in Education,” page 324. 46 
PEDIATRIC NURSING 
age and dislike to sharing in home responsibilities is often 
manifest. Ella Lyman Cabot gives excellent illustrations on 
this subject and wisely says, “Give both the instinct of earn- 
ing and the instinct of spontaneous kindness free play at the 
same time. For example, do not pay for running upstairs 
for a handkerchief or carrying a message. Pay rather for 
work by the hour or job. To pay for not doing a mean or 
disliked thing seems to be bribery; to pay for unneeded, de- 
vised work is pauperism. Pay must be something needed, 
something of market or individual value, and at standard 
rates” (See note 3). To reward moral conduct with money 
is to do a moral injury. 
To sum up this brief outline, one may say this is a period 
of contradictions, of strikingly good and bad traits, terminat- 
ing, as it does, in what has been called the paradoxical age. 
Child Life from 13 to 16 Years. 
The early teens have been beautifully termed adolescent— 
that is, a flowering period. The mental and moral change 
and unrest of this time correspond to the physical change. 
Because of the often peculiar and puzzling character of the 
period, with its contrasts of good and bad qualities, it has 
been termed paradoxical and critical. It is so large a study 
we can but touch the edge of it. 
In the first part of the period a physical awkwardness 
makes a young person self-conscious and often sensitive. 
Added to that the emotional development is such that there 
is more or less upheaval. Feelings are intense, first against 
the opposite sex and then with a great interest for it. Hero- 
worship is strong; some older person is the object of love, 
sometimes of the same and sometimes of the opposite sex. A 
real friend of this kind is worth much to this growing boy 
and girl. They are more different one from the other, in 
their tendencies and interests, than ever before. This is the 
time when a degree of segregation is advantageous. Often 
there are morbid moods, dislikes, and irritabilities. Much MENTAL DEVELOPMENT OF CHILD LIFE 
47 
sympathy and patience are needed from parents and friends. 
Wholesome outdoor activities and work of many kinds are 
good tonics. 
This is a day of judgments, day-dreams, and ideals, ac- 
companied sometimes by admirations, sometimes by discour- 
agements. Ideals are not airy impossibles, but ideas to be 
made real. Strong books—stories setting forth healthy ideals, 
lives of great men, books of travel associated with personalities 
are needed. Historic interest begins; the continuity and 
relationships of people and things; a vision of great move- 
ments will help to overcome too much introspection. A love 
of nature, evident in both girls and boys, makes possible much 
good from genuine farm and camp life. Self and superficial 
externals, with foolish emotional expressions, are forgotten 
in the simplicities and realities of country work and play. 
The “gang” and the “bunch” are at their height in the 
early part of this period, until at fifteen to sixteen years there 
is a “pairing off.” The social interest in groups should lead 
to altruism and to definite service for others. Herein is a 
great opportunity for strengthening development. Intel- 
lectual and moral outlooks are thus more truly balanced. 
The beginning of a critical spirit marks this period. 
“Why,” not in regard to material things—which in the 
previous period occupied attention—but to many problems of 
life. This is a time of questionings and perplexities; these, we 
find, are often not revealed until later years. Both boy and 
girl are apt now to be secretive, and especially the latter. 
Simple explanations from one wTho is trusted, even before 
questions are asked, will be of much help. At this critical 
stage the power to think will be strengthened by opportunity 
to search for and to arrive at conclusions. Many young people 
are stunted in intellectual and moral growth because they 
have been told much that they might discover for themselves 
through suggestive propositions. Judgment should not be a 
haphazard development but one definitely trained. Reason 
may control instinct and impulse, if it has had opportunity 48 
PEDIATRIC NURSING 
to be active. A growing personality must be treated with 
respect, even in its unbalanced condition, if in the end it is 
not to be found wanting, but is to stand true to the needle 
of intellectual and moral integrity. In conclusion, we turn 
back for a moment and think of mental development and the 
growth of the human soul during sixteen years of childhood; 
first, as that of a social being who comes into social con- 
sciousness through self-revelation, then self-direction. These 
are continuing processes which lead finally to the beginning 
of self-realization. The human soul finds his freedom in being 
a part of an ever enlarging social group—first the family, then 
the school, then the community, and lastly, the state. In- 
stinct, emotion, will, judgment, reason, are the mental activi- 
ties by which he arrives; and innate interests are the re- 
sponses he makes to the environment in which he finds himself. 
(Note: A selected bibliography bearing on mental devel- 
opment, elementary psychology and practical child study will 
be found on page 460.) CHAPTER V 
THE GENERAL CONDUCT OF A HOSPITAL WARD 
The Children’s Ward. 
The children’s ward in the general hospital has too often 
been incidental to the rest of the institution. The tendency 
has been to crowd the pediatric department into any space 
that could not be used for other purposes, regardless of its 
suitability. Conditions should have been exactly opposite, 
for if sick children are to be cared for in an institution their 
ward should have the most ideal location which the hospital 
affords. It should be separated from the rest of the hospital 
so as to lessen the danger of infection, for children have a 
lesser degree of immunity than adults. Isolation should be 
adhered to both for the welfare of the children and for the 
comfort of adult patients. 
Infants and children of all ages suffering from medical 
diseases should be separated from those with surgical dis- 
eases. Sick infants under 2 or 3 years should not be in the 
same ward with older children. It is desirable for boys and 
girls over 5 years to be in separate wards, certainly those 
over 8 years should be separated. To include newborn babies 
in the “pediatric department’’ is now becoming customary, 
and this is certainly the most logical arrangement.1 They 
are thus assured the care of a specialist from the beginning. 
They should have a separate nursery and should not be in 
the ward with sick babies. There should also be a special room 
devoted to the care of premature infants. There should be 
several isolation rooms for the use of very ill children or for 
Location 
of Ward 
Arrangement 
of Ward 
1 Sedgwick, J. P., M.D., “Pediatric Control of Newborn Teaching 
Clinic. ’ * 
49 50 
PEDIATRIC NURSING 
those who have contracted contagious diseases. Every isola- 
tion room should have hot and cold running water. The pri- 
vate hospital for children has separate rooms; each one is 
equipped with a crib for the child and a large bed for the 
mother or nurse. 
The diet kitchen from wdtich all the older children’s meals 
are served and where special foods are prepared for the 
younger children should be conveniently located. It should 
be equipped with a gas stove, a sink with hot and cold running 
water, a dish sterilizer, an ice-box large enough to contain all 
the food and fruit, cupboards for kitchen supplies, and all 
dishes necessary for serving the meals. Provide attractive 
dishes for the children’s ward, dishes with Mother-Goose char- 
acters, animals or birds. Tin and enamel dishes crack and 
chip easily, becoming ugly and unsanitary. A convalescent 
child who rebels against food from a plain or ugly plate may 
be beguiled by a “story plate.” Teach little patients to be 
careful, and give them attractive dishes. For convenience 
there should be a chart on which to enter each child’s name 
and his diet and feeding orders. 
A milk laboratory, where all formulas are made and where 
all feedings are heated, is necessary, for milk formulae 
should never be prepared in the general kitchen. The ice- 
box in this room should be large enough to contain all the 
milk used in the department; nothing else should be kept in it. 
A sterilizer for the nursing bottles should be conveniently 
located. If there are enough feedings to justify it, a milk 
sterilizer should be provided. A gas stove, a large sink with 
hot and cold water, and a large table or broad shelf on which 
to work complete the equipment. 
The service room should be near the ward for convenience. 
It should be equipped with a hopper w7ith hot and cold water 
where bed pans may be washed, and where feces may be 
brushed from soiled diapers. A large sink, an electric or 
gas plate, a bed pan sterilizer, a laundry bag frame for soiled 
linen, and one for soiled diapers, plenty of shelves or cup- 
Diet Kitchen 
Milk 
Laboratory 
Service Room GENERAL CONDUCT OF A HOSPITAL WARD 
51 
boards for utensils, a covered trash can, unless there is an 
incinerator, and bed-pan and urinal racks, so that each child’s 
pan and urinal may be kept in a separate compartment marked 
with his name, are other essentials. If possible there should 
be an ice-box for cracked ice with which to fill ice-caps, etc., 
and also a closet with outside ventilation in which to keep 
urine and stool specimens, or else a special ice-box for them. 
The bathroom equipment varies. There may be a shower 
bath for older children and a bath slab and spray for small 
babies. The slab is heated for use by admitting warm running 
water to the closed space in the porcelain under it. The tem- 
perature of the water for the spray may be controlled by a 
central mixing tank or by a storage tank above the slab. 
This tank has a water gauge and a thermometer on the out- 
side. There should be a large bath tub for the older children 
or a high shallow tub—the latter is more convenient for the 
nurse. There should be separate toilet facilities for the boys 
and girls, and the toilet seats should be low. 
The linen room should be furnished with shelves, drawers, 
and cupboards enough to take care of clean linen, children’s 
clothes, and supplies which are used in the department. 
Separate lockers or compartments to contain each child’s 
toilet articles, toys, etc., are useful, and may be built into any 
convenient place in the bathroom, linen room, or service room. 
A dressing room where all treatments and dressings may be 
done is essential. It should contain a sterilizer, an electric or 
gas plate, shelves or cabinets with sufficient space for sterile 
supplies, sterile solutions, dressing trays, and other equip- 
ment. There may be a common dressing table here upon which 
the children are placed for treatments, dressings, etc. If 
this is used the pad on it must be changed after one child has 
been put on it, and the rubber is scrubbed with soap and 
water as in the bathing of a child on a common table. A better 
arrangement is to move each child into the dressing room in 
his bed for dressings, etc. 
The medicine closet must be locked at all times. It should 
Bathroom 
Linen Boom 
Dressing 
Room 52 
PEDIATRIC NURSING 
Medicine 
Closet 
have a basin with hot and cold running water, sufficient shelves 
for all medicines in use in the department, and it should be 
well lighted. 
A warming closet in which to keep blankets always warm 
and ready for use is necessary. Salt, glucose, and sodium 
bicarbonate solutions and camphorated oil may be kept here 
also for emergencies. 
Avoid overcrowding of the children’s ward.2 There should 
be not more than 10 to 15 children in one ward, with a mini- 
mum of 1000 cubic feet of air to every child. There are three 
main factors which enter into the question of cubic space 
for a child in a ward: 1. There should be space to afford 
reasonably pure air for respiration. 2. There should be space 
to allow sufficient separation of the cribs in order to minimize 
air-borne infections. 3. There should be space to avoid over- 
crowding, for the latter lessens the individual care which 
can be given to each infant by a limited number of nurses 
and attendants. Children are much happier in wards than in 
private rooms. If it is possible the ward should have south- 
ern and eastern exposures, with large windows on at least two 
sides. They should be equipped with screens, awnings, and 
dark shades. Each window should have two shades, one which 
may go up, and one down, from the middle of the window 
where they are attached. This allows the shade to be adjusted 
so as to exclude the least possible amount of sun. Shades 
should be lowered only when the sun is shining directly into 
a child’s eyes, or during rest hour. 
The lighting of the ward is important. Overhead lights 
should be shaded so that they reflect the light indirectly, and 
give a soft glow over the whole room. A side light on the 
wall between every two beds will give sufficient light to care 
for the children at night. 
The temperature of the ward should not be over 68° F. 
Warming 
Closet 
Cubic Air 
Space 
Windows 
Lighting 
of Ward 
2 “Ventilation and Cubic Space for Infants in Institutions.” N. Y. 
Medical Journal, Nov. 10, 1917. A report by the Public Health Com- 
mittee of N. Y. Academy of Medicine. GENERAL CONDUCT OF A HOSPITAL WARD 
53 
during the day. If baths are given to the children in their 
beds the temperature of the ward should be 72° F. during the 
bath hour. At night the temperature should not be over 
65° F., but this varies with the age of the children, the nature 
of their complaints, and whether or not it is necessary to 
expose them in the ward during the night for treatments. 
The ward temperature should be noted and should be recorded 
every four hours on a chart which is provided for that purpose. 
The thermometer should hang on a level with the breathing 
zone of the patients. In the summer electric fans are necessary 
to create sufficient motion of air, but should not be so placed 
that they will blow directly upon the children. The essentials 
of good ventilation are: regulation of temperature, moisture 
and motion of air. Any system which fulfills these demands 
is satisfactory.3 Windows which do not cause a direct draught 
should be opened several times a day to keep the air of the 
ward fresh and as free from disagreeable odors as possible. 
Humidity is a factor which is controlled with difficulty and is 
too often disregarded. Ideally, it should be 55 per cent. The 
radiators should distribute heat uniformly to all parts of the 
ward. They should be high enough from the floor to facilitate 
proper cleaning. Wire screens over them protect the children, 
preventing burns. 
The walls of the ward may be painted any warm, cheerful 
color.4 Stencil designs from Mother Goose which are painted 
at a convenient height for the children will amuse them. Make 
the ward as cheerful as possible. Window boxes with flowers 
or separate plants, a small victrola with appropriate records, 
a goldfish or two, or a canary are a few of the many things 
which help to give little patients endless delight and will 
actually hasten recovery. 
The floor may be made of any of the materials in general 
use. It must be durable and easy to clean. The color should 
Temperature 
of Ward 
Ventilation 
Humidity 
Walls 
Floor 
8Kosenau, Milton, M.D., “Preventive Medicine and Hygiene.’’ 
* Ludlow, William, “Color in the Modern Hospital.’’ Modern Hos 
pital, June, 1921. 54 
PEDIATRIC NURSING 
harmonize with the walls. It must be cleaned as often as 
necessary. The method which is employed depends upon the 
material of which the floor is made. Any kind of floor may 
be swept with damp sawdust or sweeping compound to prevent 
dust. Sweeping should be done in the morning after the 
beds are made and it is usually necessary after lunch and 
after supper. 
Cribs may be on one or two sides of the ward. In order to 
minimize the danger of “cross” infection, they should be 
at least 6 feet apart, allowing 100 square feet of floor space 
for each one, or there should be a glass partition between 
every two. Every child’s name must be kept on his bed. There 
are various racks made to hold name cards. In a ward of 
small children these should be hung on a lower round at the 
foot of the bed so that the children cannot reach them. 
There should be a bedside table and straight chair by every 
crib. The type of table depends upon how much has to be 
kept at the bedside. If separate lockers are supplied (which 
is the ideal way) the bedside table can be without shelves. If 
there are no lockers, the table should have one or more shelves 
and possibly a drawer. There should be screens enough to 
screen the beds of older children when baths are given and 
for all other procedures which may expose the child. 
A hand basin with hot and cold running water is necessary 
in a well planned children’s ward. The water faucets should 
be operated by knee adjustments and the soap container by 
a foot pedal. 
A sun porch with roof or awning and which is connected 
with the ward is desirable. This should be arranged so that 
beds may be moved on to it. Whenever the weather permits, 
the children should be there in their beds. An airing balcony 
with direct exposure to the sun, for a part of the day at 
least, is very desirable. Empty beds may be put here in the 
sun for disinfection. This porch may or may not have a 
roof. A sun porch which is enclosed with windows makes 
a good play room for convalescent children. It should be sup- 
Furniture 
Hand Basin 
Sun Porch GENERAL CONDUCT OF A HOSPITAL WARD 
55 
plied with small chairs and tables, also rocking and straight 
chairs, rocking horses, walkers and swings are suggestions to 
amuse the children. A roof may be made into an attractive 
roof garden for convalescent children. Here again window 
boxes have a place. 
A signal or call system is necessary only for older children. 
Any of the systems which qualify for general use are satis- 
factory. The younger child will not understand how to use 
a signal system and should not be provided with it. 
Partitions between the wards and corridor and wherever 
they are possible should have glass inserted in the upper half 
so that the children may be more closely observed. 
The head nurse’s desk should be in a central place where 
she may have easy surveillance of the entire department.5 
Signal 
System 
Glass 
Partitions 
Cribs and Bedding. 
When selecting a crib from the many different kinds of 
children’s cribs, we must find one which meets the following 
requirements: 1. It must be comfortable and safe for the child. 
2. Convenient for the nurse to handle. 3. Practical and easy 
to clean. 
A size which will be suitable for children of all ages, ex- 
cept the newborn, is 5 by 2y2 feet. Crib sides should be at 
least 24 inches above the level of the mattress so that the child 
can neither climb nor fall over them. Both crib sides should 
be adjustable, i.e., they must move up and down, and must 
have snaps or hooks at each end fastened so that the child 
cannot release them. Crib sides which move up and down 
by means of a foot pedal under the springs of the bed at each 
side are the safest. 
The bars of the sides, head, and front of the crib must not 
be more than 2y2 inches or 3 inches apart at any place, for 
the child might put his head between them and might injure 
himself. The rods must also extend below the springs all 
around, and the frame of the springs must meet the 
Size of Crib 
Construction 
of Crib 
'Stevens, Edward (Architect), “A Modern Hospital of 20th Century.” 56 
PEDIATRIC NURSING 
rods of the head, foot, and sides, so there will be no open 
spaces. 
Cribs should be made of steel, enameled iron, or aluminum 
in order to be as durable, as light, and as strong as possible. 
They should be equipped with large roller casters so that they 
can be easily moved. 
For the convenience of the nurse the top of the mattress 
should be to 3 feet from the floor, and the sides when 
lowered should fall below the bottom of the mattress allow- 
ing room to make the bed and to tuck in the clothes without 
interference from the lowered crib sides. 
Cribs must be practical and easy to clean. There should 
be no extra ornamentation to collect dust and to prevent 
thorough cleaning of the bed with soap and water. 
There is a crib in common hospital use in which the springs 
and mattress can be raised or lowered within the frame, in- 
stead of having adjustable sides. As long as this crib fulfills 
the above requirements it is satisfactory. 
The crib should have a wire spring, tight and firm. The 
mattress should be of horsehair. This is the most comfortable, 
durable, hygienic, and cleanly. It is the most expensive as 
well but can be made over so that it is cheaper in the end. 
The mattress should be covered with a stout linen ticking. 
It should be protected by a washable cover of unbleached 
cotton which fits over it as a pillow case slips over a pillow. 
Pillows are made of hair, feathers, or down. Down pillows 
are expensive and are used only in small sizes. They are 
not practical for use among children in a hospital. Hair 
pillows are advisable for them, as they offer support. Feather 
pillows are in common use. Children should be taught from 
the start to sleep without pillows. A small baby needs none 
until he is old enough to begin to sit up, when a hair pillow, 
protected by a rubber covering, may be placed at his back 
for support a short time each day. A small pillow may be 
placed at the head of the bed to protect the baby from 
draughts. An older child who is confined to his bed will need 
Springs 
Mattress 
Pillows GENERAL CONDUCT OF A HOSPITAL WARD 
57 
pillows during the day, a hair pillow for support and a feather 
one for greater comfort. These must be removed at night 
unless the child’s illness is such that it requires him to be 
propped up all the time. Therefore, a children’s ward should 
be supplied with both hair and feather pillows of various sizes. 
Except when used for older children, all pillows used should 
be protected by rubber slips. These may be sewed on all 
the pillows in the department if desired. This rubber is un- 
comfortable and heating but very necessary for the protection 
of the pillow. A folded towel or pad made for the purpose 
may be kept under the head of a very small baby so that if 
he drools or regurgitates it may be easily changed without 
changing the sheet. 
Sheets are best made of heavy cotton, well shrunken, % 
of a yard longer, and % of a yard wider than the mattress, 
with a 2y2 inch hem at the top and a 1 inch hem at the foot. 
The rubber sheet is best made of double faced silk rubber, 
which may be of white, black, or maroon, and should be 1 
yard longer than the width of the bed and not less than 24 
inches shorter than the length of the bed. 
The draw sheet can be made of single faced, canton flannel 
or cotton drill, large enough to completely cover the rubber 
sheet. 
Blankets of % cotton and Ys wool are the most practical 
for hospital use. All wool are light, warm, and most desirable, 
but expensive and more difficult to launder. 
The spread should be of light weight dimity. 
The pillow slips should be of cotton sheeting in the desired 
sizes for pillows. 
Rubber 
Pillow Slips 
Sheets 
Rubber 
Sheets 
Draw Sbeets 
Blankets 
Spread 
Pillow Slips 
To Make up a Crib. 
To Make up 
Empty Crib 
a. Object: 
1. Cleanliness. 
2. Firmness. 
3. Tightness. 
4. Smoothness. 
Object 58 
PEDIATRIC NURSING 
5. Comfort of patient. 
6. General appearance. 
b. General directions to bear in mind: 
1. Make up on one side first, and then on the other. 
2. Have everything ready before beginning. 
3. Put everything in its place when through. 
4. Let no detail escape notice. 
c. Articles necessary: 
1. Clean linen in the order in which it will be needed. 
2. Laundry bag for soiled linen. 
d. Method of making an empty crib: 
Equipment 
Procedure 
Loosen all bedclothes, remove pillows and place on a chair. 
Remove soiled pillow cases, putting them in the laundry bag. 
Remove every piece of covering separately, keep the upper 
surface inside, fold along creases and drape over the back 
of the chair. Take care not to drag the corners on the floor. 
Put the lower sheet on the mattress right side up, broad hem 
at the top. Tuck it in at the top first, then at the foot and the 
sides, making square corners. The rubber sheet is put on 6 
inches from the top edge of the mattress. Tuck it tightly 
under the sides of the mattress with the middle of the width 
in the middle of the bed. The draw sheet is put on crosswise 
of the bed over the rubber sheet to completely cover it; tuck 
it under the mattress. The upper sheet is put on wrong side 
up, the center fold at the center of the bed, and with the top 
edge 2 inches from the top edge of the mattress. The 
blankets (usually two) are put on 6 inches from the top of 
the mattress. The first blanket is not tucked in at the foot 
but is folded under so that it is level with the lower edge of 
the mattress. The second blanket is tucked in at the foot 
like the sheet. The upper sheet is folded down over the 
blankets at the top and the blankets are tucked in at the 
sides. The spread is put on with the top even with the top 
of the mattress. Tuck in the foot and tuck in the sides, mak- 
ing square corners. Put the pillow cases on the pillows, hair 
and feather, so that the seams of the covers correspond with GENERAL CONDUCT OF A HOSPITAL WARD 
59 
the seams of the pillows. Shake the pillows well into the 
corners of the cases and place them flat on the bed, the hair 
one under the feather one, and with the seam edges of both 
cases and pillows at the head of the bed and the superfluous 
case folded under the pillow at the head of the bed. Place 
them so that the open ends of the pillow cases are on the side 
away from the door. 
e. To make up a crib with a child in it: 
1. Preparation as in preceding procedure. 
2. See that the temperature of the room is 70° to 72° F. 
if the child is to have a bath at the same time. See that he 
is not exposed to any draughts. Do not beat up the pillows on 
the bed while he is in it. All folding of bedclothes is to be 
done at the foot of the bed, not over the patient’s face. Never 
lean on the bed, jerk it, or touch it unnecessarily, for a sick 
child is more sensitive and more irritable than a sick adult. 
A child is never put on another’s bed, nor on a convenient 
empty bed while his bed is being made. If he has permission 
from the doctor he may sit in a chair at the side of the bed 
while it is being made, otherwise he remains in bed. All cover- 
ing, with the exception of one blanket, which is left on for the 
protection of the child, is folded and put over the back of a 
chair as in making an empty crib. The child is turned from 
one side of his bed to the other while the opposite side is being 
made. If he is to sit up in bed arrange the upper bedclothes 
so that they come to his waistline. If he is to lie down in bed 
arrange them so that they come 2 inches below the axilla. 
The spread is turned under the blankets at the head of the 
bed, and the top sheet is turned down over all in a finished 
fold. Always put the crib sides up when leaving a child. 
To Make up 
Crib with 
Child in it 
To Sit a Child up in a Bed. 
There are bed rests made to fit cribs just as for adult beds. 
The back rest is arranged at the desired angle and the pillows 
are adjusted at the patient’s back to make him comfortable. 
A small child who is to sit up in bed can be propped up with 
Back Best 60 
PEDIATRIC NURSING 
2 or 3 hair pillows and a feather pillow at his back. Arm 
supports can be made by placing pillows on both sides of 
the patient as for an adult. He may be kept from slipping 
down in bed, when he is sitting up, as in Fowler’s position, 
by a sling or support under the knees, or by a brace at the 
feet. There is a special knee support—Meinecke, nonslipping 
knee and thigh brace—in common use. This is put under 
the knees and the patient is made comfortable with the use 
of pillows (protected by rubber slips) over it. It may have 
to be tied to the sides of the bed to keep it in place if the 
child is heavy or active. A special knee roll, the proper size 
for a child’s use, can be made of horsehair covered with tick- 
ing and rubber. This is placed in the center of the sheet 
diagonally and is rolled in it. It is put under the child’s 
knees and the corners of the sheet are tied to the head of the 
crib on a level with the mattress. A small pillow covered with 
a rubber case can also be made into a knee roll. Roll the 
pillow lengthwise, tie a bandage around each end to hold it 
and fold it in a sheet diagonally, place it under the patient 
and tie the same as the regular knee roll. A foot sling is made 
by folding a sheet lengthwise in folds about 10 inches wide. 
Tie a piece of bandage at each end and tie the ends of the 
bandage to the head of the bed on either side, level with 
the mattress, and with the center of the folded sheet at the 
patient’s feet to support them. It should be just tight enough 
so that the patient’s feet rest in a sling when his knees are 
extended. An air mattress made of rubber covered with 
ticking or canvas is used for a child, as for an adult, in 
any case confined to the bed for a long time and in which there 
is danger of pressure sores. Small air pillows are useful 
for the prevention of pressure spots. Air rings are made in 
smaller sizes for children. 
Knee Support 
Foot Sling 
Air Mattress 
Air Bing 
To Disinfect a Bed after the Discharge of a Patient. 
Care of 
Bed and 
Bedding after 
Discharge of 
Patient 
When a patient is discharged all bedclothes are removed 
from the bed and are put into the laundry bag. The mat- GENERAL CONDUCT OF A HOSPITAL WARD 
61 
tress and pillows are brushed on both sides with a whisk- 
broom. The bed is scrubbed with soap and water and Bon Ami. 
The rubber is washed on both sides with soap and water and 
is hung over the head of the bed. The bed, mattress, pillows, 
and rubber sheet are exposed to the sun and air as long as 
possible. It is very desirable that they be put on a porch for 
this airing. If the case was infectious or after the death 
of a patient air the bed for 3 consecutive days before using 
it for another patient. If not isolated for infectious disease, 
the minimum length of time to air the bed is 2 hours, but 
wherever possible air any bed for 3 consecutive days in the 
open air and exposed to the sun. Every article which can 
be disinfected by boiling should be boiled after the discharge 
of a patient. Articles which cannot be boiled should be 
scrubbed with soap and water and should be exposed to air 
and sun. 
Rest Hour. 
A definite rest hour should be arranged for children in the 
hospital. Directly after the noon meal seems the most con- 
venient time. During that hour all toys are put aside, the 
shades are lowered, the ward is kept as quiet as possible, and 
every attempt is made to have the children sleep. Even though 
a child cannot sleep, he should not be allowed to talk, read, 
or play with his toys. Under these conditions he will soon 
acquire the nap habit. 
Best Hour 
Visiting Hours. 
Visiting hours are best restricted to once a week in the 
pediatric department. This may Le arranged for at any con- 
venient time. If a child is dangerously ill, his parents must 
be allowed to see him at any time. Never more than two 
people should be permitted to see him at once. No children 
should be allowed under any conditions. (It is wise to ex- 
clude all visitors except parents.) Visitors should remove 
their hats and coats in a special room and should slip on large 
Visiting 
Hours 62 
PEDIATRIC NURSING 
cotton aprons which completely cover their own clothes before 
entering the ward where the children are. Any one with an 
upper respiratory infection or with any infectious disease 
should not be permitted to visit the children’s department. 
Parents or visitors should never be allowed to sit on the cribs; 
the nurse must see that they all have chairs. Visitors must 
never hold or fondle the children. Kissing must be prohibited. 
There should be definite rules about what visitors may bring. 
Toys, games, books, and all such amusements are solicited. 
Food of any kind except fruit should be prohibited. Since 
oranges are about the only fruit that nearly every child may 
eat, it seems wise to have a rule allowing visitors to bring 
only oranges. 
Toys. 
Toys 
Every child’s toys are kept in his table or locker. He 
must not change toys with other patients. There should be a 
central supply of toys in every ward for the use of the chil- 
dren who have none of their own. These should be made of 
material which may be washed, preferably boiled, after the 
use of one child before giving them to another. If a child 
throws his toys on the floor, they must be tied to the side 
of the crib. Books help to amuse older children and a library 
of books should be available for their use. A book should 
be well aired after one child has read it before it is given 
to another. If the child was isolated for an infectious disease, 
the book must be sterilized or destroyed. A child .should never 
be allowed to play with money. Would-be “friends” are 
constantly giving pennies to the child in the hospital. These 
should be taken from him, should be put in an envelope 
marked with his name, and should be kept until he is dis- 
charged. CHAPTER VI 
THE CARE OF THE SICK CHILD IN THE HOSPITAL 
Admitting the Patient. 
Many institutions for children have an admitting ward. 
It should have small rooms or cubicles, each complete for the 
care of one child. Since every child here should be considered 
an infectious case, the equipment should be like that of a 
contagious ward. It would be very desirable to detain every 
new child in the admitting ward until the doctors determine 
that he has no contagious disease, but since the incubation 
periods of all the common contagious diseases vary from one 
day to three weeks, such a ward is of little value unless a 
child may be kept there for three weeks. This is impossible, 
of course, unless there is a special observation ward provided, 
which will allow it. If there is no such observation ward, 
every new child should be kept in the admitting ward until 
the cultures of the nose and throat have been taken and have 
been returned negative, and in the case of a little girl, vaginal 
smears must be taken and must be reported negative for 
gonorrheal vaginitis. If there is a history of recent exposure 
to any contagious disease or if the child presents suspicious 
symptoms he should be kept in the admitting ward and con- 
sidered infectious until it has been proven that he is not. 
The institution, with the exception of the private hospital, 
should furnish all the necessary clothes for the child during 
his stay. Therefore, when he is admitted, all his clothes should 
either be sent home with his parents or should be carefully 
marked and put in a central locker room. All valuables, such 
as rings, jewelry, etc., should be removed and should be 
sent home with the clothes or they must be carefully marked 
and must be put in the hospital safe. 
The 
Admitting 
Ward 
Care of 
Child’s 
Clothes 
Valuables 
63 64 
PEDIATRIC NURSING 
Admission 
Bath 
The new child should have a bath and shampoo in the 
admitting ward. This bath may be a shower or tub bath, 
depending upon the facilities; the usual individual technique 
should be carried out, allowing no child to come into contact 
with anything used by another child. If the new child is very 
ill or if he has a temperature over 101° F. or below 98° F., 
he should have only a sponge bath, unless otherwise ordered 
by the doctor. The shampoo is omitted if he is very ill or 
fatigued. 
Every child under 2 years old who is admitted to the hos- 
pital should be marked or should be tagged in some wray. 
His name and hospital number should be written on a tag and 
should be attached to him in such a way that it will not 
come off. This should be put on him on admission before he is 
taken to the ward. Various methods are employed; a simple 
method is to write the name and hospital number across the 
center of a piece of adhesive, 2 inches long, % inches wide, 
fold this over the middle of a piece of linen tape long enough 
to go around the child’s wrist in a square knot. This must 
be watched, because it will occasionally come off. (See Meth- 
ods of Marking Newborns for Identification, Chapter VII.) 
If there is no admitting ward, the new child can be un- 
dressed and given his admission bath in the ward. Spread 
a sheet over his bed, put him on it, and remove all his clothes. 
The bath depends upon the facilities. A shower or tub bath 
is most desirable. Proper isolation precautions must be 
strictly observed. The child should be treated as an isolated 
case until the nose and throat cultures and vaginal smears 
return negative. Careful isolation and good technique con- 
scientiously carried out will prevent the spread of infection 
or cross-infection. 
To Mark 
Child for 
Identification 
If There Is 
No Admitting 
Ward 
Aseptic Pediatric Nursing Technique. 
Aseptic 
Pediatric 
Nursing 
Technique 
Aseptic nursing has decreased the morbidity and mortality 
among children in hospitals. Every child should have his 
own utensils or toilet articles which should be kept on his CARE OF THE SICK CHILD 
65 
bedside table or preferably in a locker or compartment in the 
bathroom. Here also may be kept the individual articles 
necessary for the care of a child, consisting of: 
1. A white enamel wash basin. 
2. A kidney basin. 
3. A white enamel mug for mouth wash. 
(If there is a convenient utensil sterilizer these articles may 
be boiled after use and do not need to be kept separate.) 
4. Two bath blankets. 
5. Brush and comb in bag for that purpose. 
6. Tooth brush in bag for that purpose. 
7. Towels—bath towel, face towel, wash cloth. 
After touching one child a nurse must wash her hands 
under running water, if possible, before touching another 
child. If running water is not convenient an antiseptic solu- 
tion, as 1 per cent lysol, may be substituted. No article which 
comes into contact with one child should be used on another 
until it has been washed or, if possible, sterilized. If a nurse 
has an upper respiratory infection, she should wear a face 
mask covering her nose and mouth while she is in the depart- 
ment. Doctors, attendants, or any individuals who go near 
the children must observe this rule. When a child is con- 
valescent and is allowed to be up, he must never visit the 
bedside of another child. He may have his chair and toys 
at his own bedside and must remain there or he may be taken 
to a sun porch in a wheel chair. A small child not old 
enough to understand the reasons for such rules must not 
be allowed out of his bed. Older children who have no in- 
fectious diseases and who are out of bed may, with pre- 
cautions, go to the toilet. 
To Handle the Child. 
The handling of the child is greatly minimized by the skill- 
ful nurse when giving him the necessary care. She will think 
ahead enough to make every move count and will do everything 
possible for him while he is in one position. Much harm 66 
PEDIATRIC NURSING 
can be done to a tiny sick baby or a premature by too fre- 
quent or clumsy handling. To lift an infant, place one hand 
and arm under his neck and shoulders with his head in the 
bend of the elbow and the middle of his back resting on the 
To Lift 
Infant 
Figure 1. To Carry a Baby 
To Lift 
Child 
palm. Slip the other arm under his legs. This gives the 
necessary support to the head and back. To lift an older 
child place one hand under each of his arms. To carry an 
infant the nurse puts her right palm under the back of his 
head, with her forearm supporting his neck and back; she 
holds him with his feet toward her, slipping them under her 
To Carry 
Infant CARE OF THE SICK CHILD 
67 
right arm and bracing his buttocks on her right hip. She 
then has her left hand free to open doors, etc. The nurse may 
also carry the baby in her arms with his neck in the bend of 
her elbow and her left forearm supporting his back. If he is 
very heavy, she puts her right arm over his legs and slips her 
right hand under his buttocks. In a hospital when caring 
for many babies the nurse must carry every baby so that 
he comes in contact with her uniform as little as possible by 
holding him away from her. When a child is strong enough 
to sit up, he will sit on the nurse’s arm facing her and will 
brace his body against her chest when being carried. She may 
slip her other hand behind his back for extra support. When 
walking with a small child, help him by holding one hand 
and adjust your gait to his; do not walk so rapidly that he has 
to run to keep up; and do not keep a step or two ahead of 
him so that you are dragging him along by one arm. 
To Carry 
Child 
Physical Examination of Children. 
The physical examination of the child in the hospital may 
be done in the admitting ward on a special examination table, 
a high table covered with a pad and rubber. It may be done 
after the child is admitted to the ward; there it is best to 
have him in his bed for the examination. If done on the table 
the sheet or pad must be changed between children. The com- 
mon examination table gives one more place for a child to 
come into contact with things which may have been in contact 
with other children in the ward, unless good technique is con- 
scientiously carried out. The examination can be just as 
successful if done in the bed, if the beds are properly con- 
structed and high enough to be convenient for the doctor and 
nurse to work over him. Wherever it is done the room must 
be quiet. 
A tray containing the necessary articles for the physical 
examination is convenient. This may be used for all examina- 
tions and may be carried by the nurse when making rounds 
with the staff doctors. Any articles, such as the tape measure, 
Physical 
Examination 
of Children 
Physical 
Examination 
Tray 68 
PEDIATRIC NURSING 
percussion hammer, etc., which may be contaminated by use, 
may be wiped with an antiseptic solution, as 1 per cent lysol, 
or may be put in the sun for 3 or more hours. The tray, 
size, 12 by 18 inches, contai is: 
1. Tongue depressors in a small glass jar. 
2. Flashlight. 
3. Tape measure, marked in centimeters and inches. (Linen 
tape in a metal case; the metal tape is harsh and may 
cut the child if he struggles.) 
4. Percussion hammer. 
5. Paper bags (small) for waste, such as used tongue blades. 
6. Skin pencil. 
7. Scratch pad and pencil. 
8. Glass slides, in box. 
Temperature 
of Boom 
The room in which the child is to be examined should be 
72° F. The examination is much more successful and quicker 
if the child can be kept quiet. This is not always possible, 
for if he has just been admitted he probably will be somewhat 
frightened and homesick and will be crying when the examina- 
tion is started. If he is not crying at the start, careful, tact- 
ful handling may prevent it. The child is to lie on his back 
wTith a pillow under his head. Remove all clothing except the 
diaper, put a blanket over him and turn the bedclothes down 
to the foot of the bed* 
The doctor’s and nurse’s hands should be warm before 
touching the child. Handle him as little as possible during the 
examination, making every move count. Do not use force or 
restraint unless necessary and be careful not to frighten him 
by abrupt, unexpected moves. 
If the child is not crying, the abdomen is usually palpated 
first while he is lying on his back; then the chest and lungs 
are ascultated and percussed. If the end of the doctor’s 
stethoscope is metal, see that it is warmed before it comes in 
contact with the chest. When the back is examined, if he is 
not too sick, the nurse may hold him in a sitting position (by 
holding his hands in hers). If he is too ill to sit up, he may 
Preparation 
of Child 
Order of 
Examination, 
Abdomen 
Chest 
Back CARE OF THE SICK CHILD 
69 
be turned from one side to the other or he may be turned on 
his abdomen. The rest of the examination is done then, leaving 
the nose, throat, mouth, eyes, and ears until the last because 
the child invariably cries when these are done. The small 
baby will have to have his arms wrapped in a blanket and 
pinned tightly to restrain them. 
Figure 2. Child Wrapped in Blanket To Restrain Him 
To examine the throat let the child lie flat on his back in 
bed, hold his head steady while the doctor opens his mouth 
and examines it with the aid of a tongue depressor and a 
flashlight. For the examination of the ears restrain the child’s 
hands in the same wray; if he is a small child and struggles 
violently pin the blanket down over his feet. If an auriscope 
is used for the ear examination, the child may remain in his 
bed; turn his head from one side to the other as each ear is 
examined. The doctor may prefer to use a head mirror and 
reflect the light from it into the throat and ears. In this case 
a drop light, which can be attached to the head of the bed 
at the right angle to reflect the light, is necessary. The nurse 
may hold the child on her lap to have his throat and ears 
examined. If so, she and the doctor sit on two chairs facing 
each other. For throat examination the nurse holds the child 
on her lap, after his hands have been wrapped in the blanket, 
with the back of his head pressed against her chest and 
his head supported by her hand; his body and legs are 
held restrained between her knees. For ear examina- 
tion the child sits sidewise on the nurse’s lap with his head 
Throat 
Ears 
To Use 
Direct Light 
To Use 
Indirect Light 70 
PEDIATRIC NURSING 
pressed against her chest and she steadies it with one hand. 
He is turned on the other side for examination of the other 
ear. The auriseope or the head mirror and drop light may be 
used. (The drop light must be adjusted behind the nurse’s 
shoulder at the proper angle to reflect the light from the 
mirror into the child’s ears.) The ear speculum used for a 
child must be as small as possible and still must have a large 
enough lumen to admit the ear curet or any other instru- 
ment that may be used. A sick child’s ears are examined 
very frequently because otitis media is a common complication 
of almost any disease in childhood. An ear tray, size 12 
inches by 8 inches, is convenient: 
Tray for Ear 
Examination 
Equipment: 
1. Various sizes of sterile ear specula. These should be 
washed and boiled after use and may be kept in a sterile 
covered jar. 
2. Ear curetts—two or three sizes to fit specula of various 
sizes. 
3. Wire applicators. 
4. Paracentesis knife. 
5. Jar of sterile toothpick applicators, made with fluffy ends 
to absorb any discharge from the ear. 
6. Jar of sterile medicine droppers. 
7. Jar of sterile absorbent cotton. 
8. Handling forceps in 5 per cent lysol. 
9. Bottle of alcohol. 
10. Auriscope with extra lights, or head mirror and drop light 
with a cord long enough to reach from the nearest light 
socket to any bed in the ward. 
Eyes 
It is often difficult to hold a child’s head still long enough 
for the doctor to see into his eyes with the opthalmoscope. 
The older child can remain in his bed and the nurse holds 
his head steady and instructs him to hold his eyes open and 
there is little difficulty. A small child who cannot understand 
the procedure will have to be held. Wrap and pin him in a 
blanket, the doctor sits in a chair and the nurse sits in one in 
front of him, placed sidewise of his; she holds the child side- 
wise facing the same direction the doctor does; he then places CARE OF THE SICK CHILD 
71 
the child’s head between his knees and holds it steadily with 
them, while she holds the child’s body quiet during the ex- 
amination. A small baby may cry less if the nurse holds him 
on her lap for the entire examination. The nurse and doctor 
sit on two chairs opposite each other. The baby lies flat on 
his back on her knees to have the abdomen palpated; he lies 
on his abdomen on her knees to have his back examined or 
she may hold him over her shoulder for it. To have the throat 
and ears examined he is held as given above. 
Temperature, Pulse, and Respiration. 
The temperature of a child under 10 years should never be 
taken by mouth. There are two reasons for this: 1. We can 
never be sure that he understands the procedure so that he 
keeps his lips closed enough to insure an accurate registration 
of temperature. 2. A small child not accustomed to a ther- 
mometer may bite off the end and injure himself by swallowing 
the mercury or bits of glass. Therefore, as routine, every 
child under 10 years of age should have his temperature taken 
by rectum, unless there is some disease of the rectum or special 
reason why it should not be irritated by the insertion of a 
thermometer. In such a case the axilla or groin may be used; 
of the two the axilla is more accurate. The temperature by 
rectum registers a little higher (about a degree) and by 
axilla a little lower (about a degree) than it does by mouth. 
When charting a temperature the nurse must indicate how 
it is taken. To take a child’s temperature by rectum shake 
the mercury below 95° F., lubricate the bulb of the thermome- 
ter with vaselin, and insert it gently into the rectum 1 
inch, and hold it there from 2 to 5 minutes, depending upon 
the length of time the special make of thermometer demands. 
The nurse must stand beside a child and hold the thermometer 
in his rectum while it registers, for grave injury may result 
if it should break in the rectum. A child should not be taken 
from his bed to have his temperature taken. He should lie on 
his side when the thermometer is inserted in the rectum, and 
Temperature 
To Take 
Temperature 
by Rectum 72 
PEDIATRIC NURSING 
it should be directed slightly backward. A small child who 
struggles can be better restrained if he lies flat on his abdo- 
men. The thermometer should then be directed downward; 
for the course of the rectum changes with the position of the 
child. 
To take a temperature by axilla, remove all the clothing 
from the shoulder and arm, place the bulb of the thermometer 
in the hollow of the axilla, pointing toward the back; have 
the child cross his arm over his chest, pressing it tightly to 
his side and with his hand on the opposite shoulder. It takes 
10 minutes for a thermometer to register correctly by axilla. 
The nurse must support the patient’s arm to help him to hold 
it in this position. Care must be taken that no folds of cloth- 
ing are between the arm and the side to separate them and 
alter the temperature. 
Every child in the hospital has his own thermometer, kept 
in a glass plainly marked with his name, and filled with sterile 
boric solution, 4 per cent; a thin pad of cotton is put in the 
bottom of the glass to protect the end of the thermometer. 
The solution in the glass must come to within 1 inch of the 
top of the thermometer and it should be changed daily. When 
the child is discharged, the thermometer must be washed with 
soap and water and must be disinfected by soaking for 24 
hours in a 1-1000 bichloride of mercury solution. All the 
thermometers should be tested weekly by comparing them with 
a thermometer which is known to be accurate to see that they 
register correctly. The thermometers of all the children in 
the ward, except those of isolated cases, can be kept on a com- 
mon thermometer tray. This tray should also contain: 
To Take 
Temperature 
by Axilla 
Care of 
Thermometer 
Thermometer 
Tray 
1. A paper bag for waste. 
2. A tube of vaselin. 
3. Tissue paper wipes made of toilet paper, cut in 2-inch 
squares. 
To apply the vaselin to the thermometer squeeze a little of 
it on a paper wipe and lubricate the bulb. After removing CARE OF TI1E SICK CHILD 
73 
the thermometer from the child’s rectum clean it by wiping 
with a paper square before replacing it in the solution. 
A child’s respirations and pulse must be taken when he is 
quiet, preferably, asleep; they should be taken before the 
temperature, since the excitement which may be caused by the 
inserting of the thermometer may increase the rate of the pulse 
and the respirations. In an older child the pulse can be taken 
without difficulty at the radial artery; this is usually impossi- 
ble in a small child; it can be counted more easily at the 
femoral, carotid, or temporal arteries or by placing the fingers 
lightly over the fontanelle. If a child’s pulse is extremely 
weak a stethoscope may be used to count it. 
A child’s respirations can best be counted by placing the 
hand directly over his chest. Many doctors do not care to have 
pulse and respirations taken or recorded routinely for small 
children under a year or two of age. The temperature, pulse, 
and respirations of a child who is ill in the hospital must be 
taken twice a day, in the morning and in the afternoon. If 
his temperature is over 100° F. or below 98° F. it should be 
taken every four hours. Any baby whose temperature is 
below 98° F. should have external heat applied. 
To Take 
Pulse 
To Take 
Respirations 
Weighing. 
The metric system, kilograms and grams, is used for weigh- 
ing a small baby and pounds and ounces are used in weighing 
the older child, although the former may be used for both. 
A balance scale is the most reliable and the most accurate. 
It should be on wheels so that it may be taken from one bed to 
the next; a fresh towel should be put on the scale before a 
child is placed there. When a daily weight is ordered the 
child should be weighed regularly with the same relation to 
the feeding time every day. All the children are weighed upon 
admission. Generally children under two years are weighed 
daily, while children over two years are weighed once a week, 
unless otherwise ordered. If a child is too little or too weak 
to stand or sit on the scale, the nurse may hold him in her 
Scale 74 
PEDIATRIC NURSING 
arms and weigh both herself and him, then subtract her 
weight. 
Bathing of Infants and Children. 
Purpose of 
Bathing 
1. The object and use of a bath: 
a. Cleanliness. 
b. General stimulation—to improve circulation. 
c. To reduce temperature and inflammation. 
d. As a nerve sedative and a nerve tonic. 
e. As a counter-irritant. 
f. Medicated baths in specific cases for local effect on the 
skin and the general action on the skin. 
Temperature 
of Bath 
2. Temperature of the bath:1 
a. Cold bath 33- 65° 
b. Cool bath 65- 75° 
c. Temperate bath 75- 85° 
d. Tepid bath 85- 92° 
e. Warm bath 92- 98° 
f. Hot bath 98-112° 
The temperature of the bathroom or ward where the child is 
bathed should be 72° F. and should be protected from 
draughts. 
3. Frequency of bath—a daily bath is necessary for a sick 
child. 
4. The ideal time for a bath is in the morning before break- 
fast ; this is not possible in an institution. The bath must not 
be given immediately after eating, since the superficial blood 
vessels dilate, diverting the needed blood supply from the 
digestive organs. One hour should intervene between eating 
and bathing unless the meal is of liquids or of a very light 
diet, when half an hour is sufficient. 
Frequency 
Time for Bath 
Kinds of 
Baths 
5. There are three kinds of baths: 
a. Sponge bath. 
b. Tub bath. 
c. Shower bath. 
1 Maxwell and Pope, ‘ ‘ Practical Nursing. ’ ’ CARE OF THE SICK CHILD 
75 
6. The technique for individual isolation must be carried 
out when bathing a child, i.e., prevent one child from coming 
in contact with any other child or with articles used on another 
child. 
a. A sponge bath must be given to a very sick infant or 
child or if the temperature is over 101° F. or below 98° F. 
It may be given to any child of any age or size in his bed and 
seems the most practical and the safest method of bathing a 
child in an institution. 
b. If tub baths are given, the tub must be thoroughly 
scrubbed with soap and water after every child’s bath before 
the next one is bathed in it. The child must also be protected 
from direct contact with other children while he is being pre- 
pared for his bath and while he is being dried and dressed. 
For an infant a table or shelf can be used which should be 
covered with a pad and rubber. A fresh towel is put down 
on this pad before a child is put there; the towel is changed 
and the rubber is scrubbed with soap and water after every 
child. It seems best to undress the older child and prepare 
him for his bath at his bedside, taking him to the tub for his 
bath and then taking him back to his bed to be dried and 
dressed. 
c. Many hospitals are equipped with porcelain bath slabs 
and showers. The bath slab slopes to a sink, a tank over it 
mixes the water to the desired temperature, and a pipe and 
rubber tubing with spray attached convey the water to the 
child. A clean quilted pad should be put on the bath slab 
for every child to protect him from the hard, cold, or con- 
taminated surface. After each child is bathed the slab is 
scrubbed with soap and water and a clean pad put on it for 
the next. The infant is prepared for his bath and is dressed 
after it at his own bed or on the common dressing table, as 
described under the tub bath. 
To give a shower to an older child who is able to stand 
or walk, prepare him for his bath at his bed, put his slippers 
on, and let him walk to the shower wrapped in his bath 
Observe 
Pediatric 
Technique 
Sponge Bath 
for Infant 
or Child 
Tub Bath 
for Infant 
Tub Bath 
for Child 
Shower Bath 
for Infant 
Shower Bath 
for Child 76 
PEDIATRIC NURSING 
blanket. After the shower wrap him in his towel and blanket, 
let him walk back to his bed to be dried and dressed, the same 
as in the tub bath. 
A bath tray containing the necessary articles is used to give 
any kind of bath to a child. A tray for every child is not 
necessary, because with good technique a nurse need not 
contaminate anything on the tray but can use it for one child 
after another. There should be a tray for every nurse, which 
she can use for all the children whom she bathes. Isolated 
cases should have separate trays. Cake soap should never be 
used for children in an institution, since the cakes may be 
confused and infection thus carried. Powdered castile soap 
may be used. This irritates the mucous membranes of the 
nose and causes sneezing if particles of it escape when it is 
being used. Liquid soap may be used. It is prepared by 
adding cake soap to water and boiling it. The bath tray 
includes the following articles: 
Bath Tray 
a. Jar of unsterile cotton pledgets made of second grade 
cotton (size of a walnut). 
b. Jar of sterile cotton pledgets made of best grade cotton 
(size of a marble). 
c. Two small enamel basins—4 inches in diameter, 1 sterile 
for sterile boric solution, 1 unsterile for unsterile oil. 
d. One glass of unsterile toothpick applicators—made of best 
grade cotton wound tightly on the small end of a tooth- 
pick. 
e. One shaker of powdered castile soap. (Large aluminum 
sugar shaker or, if liquid soap is preferred to powdered, 
a bottle of liquid soap.) 
f. One bottle of bathing lotion—50 per cent alcohol. 
g. One bottle of zinc stearate powder. 
h. Nail scissors, file, orange-wood sticks. 
i. Paper bag for waste. 
j. Tray with safety pins, various sizes. 
k. Handling forceps in glass of 5 per cent lysol solution. 
l. Bath thermometer. 
m. One bottle of unsterile oil. 
n. One bottle of sterile boric acid solution, 2 per cent. CARE OF THE SICK CHILD 
77 
Sponge Bath. 
The procedure for giving an infant or a child a sponge 
bath in his bed: Every child has his own basin which is filled 
with water 100° F. and is taken to his bedside with the neces- 
sary clean linen, clothes, bath towel, face towel, wash cloth, 
laundry bag for soiled linen, bath tray, and bath blankets. 
Arrange linen and clothes in the order in which they will be 
needed, place the bath blanket in folds (crosswise) over the 
child’s chest, tuck the upper corners under the mattress on 
both sides to keep it from sliding down, turn the upper bed- 
clothes down, drawing the blanket over the child at the same 
time; a second bath blanket may be used and is slipped under 
him; remove the nightgown. When bathing a small, active 
child it will be necessary to wrap the lower bath blanket 
tightly around him and pin his hands down while his face and 
head are being washed. 
The eyes are cleaned first: To do this remove a sterile eye 
pledget from the jar with the handling forceps, dip it into 
the basin of boric solution then replace the forceps, take the 
pledget in the fingers of the right hand, hold the child’s head 
on the left side with the palm of the left hand, and with the 
left thumb and forefinger hold the lids of his left eye open. 
Do not press the fingers on his eye ball but on the bones of 
the orbit. Wash the left eye beginning at the inner canthus 
and wiping toward the outer so that the secretions of one eye 
will not be carried to the other. If there is much secretion 
in the eye use more than one pledget. Never dip a pledget 
back into the boric after it has been used. Waste pledgets are 
put in the paper bag. The child’s right eye is washed in the 
same way, hold the pledget in the left hand, hold his head 
in position on the right side with the right hand and wipe 
towards the outer canthus. 
The ears are cleaned next; unsterile toothpick applicators 
are used; dip one in the basin of oil and with it wipe around 
the external ear, do not let the toothpick enter the auditory 
canal; use a different applicator to clean the other ear. For 
To Give 
Sponge Bath 
to Infant 
or Child 
Eyes 
Ears 78 
PEDIATRIC NURSING 
older children dip the applicator in the pan of bath water 
instead of the oil. 
The nose is cleaned next with unsterile toothpick applicators 
dipped in oil. Wipe only around the anterior naris and 
use a different applicator for each nostril. 
Wash the child’s face, neck, behind ears, under the chin, 
with clear water without soap and dry by patting with the 
face towel. 
A child should have a shampoo once a week. An infant 
has a daily shampoo with his bath until his hair is so thick 
that it will not dry quickly. To do this the nurse moistens her 
hands in a pan of water and moistens the child’s hair; she 
then sprinkles powdered soap in the palm of her hand and 
rubs it into the hair making a lather. Hold him on the left 
arm with his head in the palm of the left hand and over the 
basin of water and with the right hand squeeze water from 
the wash cloth through his hair until it is thoroughly rinsed; 
take care not to get water into his eyes and ears. 
If the child has been pinned in a blanket, release him. 
His body is next bathed in the following order: right arm and 
hand, left arm and hand, chest, abdomen, back and neck, right 
leg and foot, left leg and foot, buttocks and genitals. Use a 
nail brush if necessary to clean finger and toe nails. Expose 
only the part of the body which is being washed, keep the 
rest covered with the upper bath blanket; dry every part with 
bath towel as soon as it is washed. After drying the child’s 
back and while he is still on his side rub his back with bathing 
lotion and powder it. Turn him as little as possible during the 
bath. When bathing a little girl, separate the labia and wash 
away secretions inside the folds with a boric sponge, wiping 
down away from the urethra toward the rectum. There is 
much difference of opinion among pediatricians regarding the 
care of the prepuce of a little boy. Many authorities do not 
wish the nurse to retract the foreskin to cleanse the glans of 
smegma. Some claim that the dried secretions or smegma 
collected in the genitals will cause irritation which leads to 
Nose 
race, Neck 
Hair 
Body 
Genitals 
Girl 
Boy CARE OF THE SICK CHILD 
79 
harmful habits, as masturbation. Others claim that too fre- 
quent handling of a child’s genitals to clean them will call 
his attention to them to such an extent as to produce bad 
habits. Find out what the doctor’s wishes are in regard 
to this. To clean the glans hold the penis in the left hand 
and retract the foreskin with the thumb and finger and wipe 
away any secretions with a boric pledget held in the right 
hand, then allow the foreskin to slip back. 
Little powder needs to be used on a child and only zinc 
stearate or boric powder if any. Too much cakes in the 
creases and the granules cause irritation. Oil rubbed in 
the folds and creases where two surfaces are in contact is 
usually more satisfactory than the former. The child’s fingers 
and toe nails are cleaned with the flat end of a toothpick and 
are cut when necessary; a small baby’s finger nails must be 
quite short so that he cannot scratch himself. 
After the bath the child is dressed, his hair is combed, the 
blankets are removed, and his bed is made up. 
Use of Toilet 
Powder 
Nails 
Tub Bath. 
The equipment for giving an infant a tub bath is: 
1. Bath tray with contents. 
2. Child’s individual basin of water to wash his face. 
3. Clean clothes arranged in the order in which they will be 
needed. 
4. Bath towel, face towel, and wash cloth. 
5. Bath blankets. 
6. Laundry bag. 
To Give Tub 
Bath to 
Infant 
If a common dressing table is used, take this equipment there, 
put a clean towel over the pad and place the child upon it. 
If no such table is in use, take the equipment to the child’s 
bedside. Proceed as when giving a sponge bath, washing his 
ears, eyes, and nose as in a sponge bath and washing his 
face with clear water in a basin without soap and drying it. 
Then wrap him in his bath blanket, take him to the tub with 
his bath towel, wash cloth, and soap shaker. After he is 
washed, wrap him in his bath towel and blanket and take 80 
PEDIATRIC NURSING 
him back, either to the common dressing table or to his bed 
to dry and dress him. If the common dressing table is used, 
every child can have a separate towel kept at his bedside and 
this may be spread on the table before he is put down there. 
After use, if it is not soiled, it can be folded, clean side inside, 
and can be kept in his locker or at his bed. 
The procedure for giving a child a tub bath: Fill the bath 
tub half full of water 105° F. so that it will be 100° F. when 
ready for use. Spread a bath mat or gray blanket on the 
floor by the tub; place a stool or chair beside the tub, and see 
that the bathroom is 72° F. and free from draughts. The 
equipment is the same as given above for sponge bath. Take 
the child’s basin of wTater to his bedside with the equipment. 
Wash his eyes, ears, nose, and face as when giving a sponge 
bath. If the phild is able to walk, put his slippers on him, 
wrap his bath blanket around him and let him walk to the 
bathroom (if he is not able to walk the nurse carries him). 
Take his bath towel, wash cloth, and soap shaker with him. 
Put him in the tub and give him his bath, using the powTdered 
soap. Do not leave him in a tub of water longer than ten 
minutes unless otherwise ordered. If his condition per- 
mits, give him a general rinsing with water 70° F. after the 
bath, then wrap him in his bath towel and blanket, and take 
him to his bed to dry and dress him. If he is able, let him 
walk back. 
To Give Tub 
Bath to Child 
Shower Bath. 
To Give 
Shower Bath 
to Infant 
To give a shower bath to an infant the equipment is the 
same as for giving a tub bath, without the soap or basin 
of water and it is taken either to the bedside or to the common 
dressing table. The child’s ears, eyes, and nose are wTashed 
the same as in the tub bath. He is wrapped in his blanket and 
is taken to the shower. A clean pad is put on the bath slab. 
He is removed from the blanket and is placed upon it. A 
container of liquid soap may be hung over the bath slab and 
may be connected by a rubber tubing to convey the soap CARE OF THE SICK CHILD 
81 
to the child’s body. Soap his head and body, making a good 
lather. The water for the shower should be 100° F. The 
nurse tests it carefully with her hand before turning it on 
the baby and she keeps her hand over the end of the spray 
so that the water touches her hand before it touches him. 
His head and body are sprayed, taking care not to use too 
much force with the spray, also being careful not to get water 
in his eyes and ears by keeping the hand over them and by 
keeping his face turned away from the spray. x\fter the 
shower wrap him in his bath towel and blanket and take him 
back to his bed or to the common dressing table to be dried 
and dressed. 
To give a shower bath to a child the equipment is the same 
as given above; take it to the bedside; the routine is the same. 
Wash the child’s eyes, ears, nose, and face, wrap him in his 
blanket, put his slippers on and let him walk to the shower, 
since only the children who are able to stand are able to take 
the shower. Make a lather with the soap and soap the child’s 
body; test the temperature of the shower carefully and turn 
it on the child. It should be 100° F. and can be followed by 
a quick shower of 70° F. if the child’s condition will permit. 
Wrap him in his bath towel and blanket, put his slippers on 
and let him walk back to his bed, dry and dress him. 
To Give 
Shower Bath 
to Child 
Clothing for Children in Hospitals. 
The clothing for the newborn in the hospital may be the 
same as for the newborn in the home. The band can be made 
of old cotton cloth torn in strips instead of flannel. Some 
hospitals furnish a complete newborn ’s outfit—shirt, petticoat, 
and slip. Other institutions dress the newborn in a sleeveless 
cape; this is fastened in back with tapes and is made double 
around the top. It takes the place of all other clothing except 
the diaper, but necessitates wrapping the baby in a blanket 
all the time. It has the advantage of saving laundry; it takes 
less time to dress and undress the baby; it costs less to equip 
the newborn’s ward with these capes than with the complete 
Clothing for 
Newborn 
Baby 82 
PEDIATRIC NURSING 
outfits. But its use is limited to the first few weeks of life, 
since it restricts natural motion of arms and legs too much 
to be worn longer than that. 
A sick infant 1 month to 2 years of age should be dressed 
in shirt, stockings, diaper, and nightgown. These should be 
of all cotton material because the usual hospital ward has an 
even temperature. Stockings should always be put on the 
sick child except in very warm weather, until he is old enough 
to know that he should keep his feet under the bedclothes. 
After that he may need them for extra warmth. If a child 
sits up in bed and needs extra clothing, a little wrapper or 
jacket of some bright colored flannel will answer the purpose. 
A red flannel jacket is cheerful and warm, but difficult to 
launder and shrinks easily. The usual hospital nightgown 
for the child of any age opens all the way up the back and 
fastens with tapes. Safety pins should be avoided as much 
as possible in dressing him. 
Hospital diapers are best made of cotton bird’s-eye in 
various sizes to fulfill the need of children of different ages. 
A sick child of any age should wear a shirt and nightgown. 
The shirt should open in front and the nightgown in back. 
The day and night clothing are the same. Stockings or socks 
are worn if necessary for warmth. A wrapper or kimona is 
useful for extra warmth when a child sits up in bed. Pajamas 
may be furnished for little boys if desired. A sick child 
should always sleep between cotton sheets unless his condition 
is such that a blanket next to him is indicated, as in nephritis. 
The ward should be equipped with complete outfits of 
clothing for children of all ages for the use of those who 
are up, for when a child is out of bed he should be fully 
dressed. Therefore underclothes, shirts, drawers, or union- 
suits, underwaists, garters, stockings, and shoes or slippers 
must be supplied. Sandals are very satisfactory for hospital 
use. Rompers can be worn by both boys and girls up to 
6 or 8 years and are very practical for hospital use, both in 
original expense and in laundering. One piece play suits or 
Clothing 
for Infant 
Wrappers 
Nightgown 
Diapers 
Clothing 
for Child 
Necessary 
Clothing for 
Children’s 
Ward Figure 3. Restraining Jacket 
83 84 
PEDIATRIC NURSING 
cover-alls can be used for older boys and dresses or aprons 
with bloomers to match for older girls. The convalescing 
child of from 1 to 3 years is not old enough to understand 
that he should remain quietly in his bed. As he begins to 
feel better he becomes more active, standing up in his bed a 
greater part of the time. If his condition will allow him 
to do this, it is well not to restrain him; make his bed up in 
the regular way, a closed bed; cover the entire top of it with 
a rubber and over that a sheet, tucking it in at the sides. In 
this way his bed will serve as a play pen and the mattress is 
protected; if the bed is properly constructed, he cannot fall 
over the sides or hurt himself. 
Restrainers of all sizes are necessary. An older child, unless 
delirious, will usually remain quietly in bed. But a small child 
under 2 or 3 years, unless he is desperately ill, is very active 
and his condition may be such that it is essential for him to 
be quiet. In such a case a restrainer is useful. A delirious 
child will also have to be restrained. A suitable restrainer 
can be made of heavy material as canvas or unbleached 
muslin. This is made like a sleeveless jacket or child’s under- 
waist and fastens in back with heavy tapes; long heavy tapes 
of webbing iy2 to 2 inches wide are stitched across the front 
so that when the jacket is on the tapes will reach the sides of 
the crib and can be tied to the frame of the bed under the 
mattress and springs. 
Bibs are necessary; turkish toweling is a very suitable 
material. A child can use his bib for several meals unless 
damp or soiled. After use it can be folded and may be kept 
on his bedside table or may be put in his locker or it can be 
kept under his mattress at the head of his bed. 
It is often necessary to keep a sick child’s hands from his 
face for one reason or another, as, for example, after an 
operation for congenital cleft of lip or palate; to prevent him 
scratching his face, as in eczema ; or to prevent thumb sucking. 
Stiff cuffs which immobilize the elbow joint w7ill accomplish 
this; these can be made of heavy cardboard, as mill board or 
Bestrainers 
Bibs 
Cuffs Figure 4. Guff To Immobilize Elbow Joint 
85 86 
PEDIATRIC NURSING 
Bristol board, covered with a soft stout material, as canton 
flannel or twill, and are fastened with one or two heavy tapes 
with buckles, depending upon the size of the cuff. To make 
these cuffs cut two pieces of material in the desired size and 
shape; stitch one or two buckle straps on the front of one 
piece and stitch the two pieces together on the wrong side, on 
three sides only, leaving the fourth side open to slip the 
cardboard in and sew this side by hand. When the cuff is 
soiled, the cardboard can be removed by ripping the stitches 
on the side that is sewed by hand; the cuff is then laundered 
and a new cardboard put in. Cuffs may also be made by 
stitching ordinary wooden tongue blades between two pieces 
of material the right size to go around the child’s arms and 
tying with tapes. 
There are aluminum mittens which can be put on the child’s 
hands to prevent thumb sucking. 
It may be necessary to further restrain a child’s hands by 
tying them to the sides of the bed. To do this protect the 
wrists by wrapping a small piece of sheet wadding around 
them and tie the bandage over it, using the clove hitch. To tie 
the clove hitch make 2 loops forming a figure 8 with both ends 
on top and going in opposite directions; put the loops together 
and pass them over the hands drawing them just tightly 
enough to prevent the hands from slipping through. Make a 
knot in both ends about 12 inches from the arm and tie the 
ends to the frame of the bed under the mattress. (See note 1.) 
A child’s legs are restrained in the same manner. 
A thin muslin cap is useful to hold dressings on the child’s 
head. The department should be supplied with various sizes 
of bonnets. 
Aluminum 
Mittens 
Tn Tia a 
Child’s Hands 
Oral Hygiene of Infancy and Childhood. 
Care of 
Infant’s 
Mouth 
There is no scientific indication for washing the mouth of 
either a breast or artificially fed baby until the teeth have 
erupted. The normal secretions of the mouth are quite 
sufficient to maintain proper cleanliness. The mucous mem- CARE OF THE SICK CHILD 
87 
brane is easily injured and Epstein has conclusively demon- 
strated that washing the mouths of infants causes infections, 
as thrush and stomatitis.2 The mother’s breasts must be kept 
clean (see care of breasts) ; and the nipples and bottles for 
the artificially fed baby must be washed thoroughly and boiled 
before use. A few swallows of w7ater may be given after 
either a breast or bottle feeding. The nurse must see to it 
that the baby puts no unclean objects, as a dirty toy, into his 
Figure 5. Clove Hitch 
month; no one should ever be allowed to put fingers into the 
baby’s mouth to clean it or for any other reason. Since any 
baby may suck his own fingers more or less, his hands must 
always be clean. As soon as he has teeth they must be cleaned 
twice a day; a wooden applicator or toothpick with the end 
wound with cotton is used. It is moistened with (1) normal 
saline, (2) milk of magnesia, (3) boric acid solution 2 to 
F?rrset<Teetii 
2 Marcus, Joseph H., M.D., “Care of Mouth in Early Life.” Amer. 
Journ. of Nursing, Mar., 1922. 88 
PEDIATRIC NURSING 
4 per cent, or (4) sterile water. At 2 years he should be 
provided with a small tooth brush and some simple tooth 
paste or pow’der and should be taught to care for his own 
teeth; they should be cleaned twice a day, in the morning 
before breakfast and in the evening before going to bed. The 
child in the hospital should be supplied with a tooth brush as 
soon as he is admitted and he should use it twuce a day, in the 
morning before breakfast when his face is washed and in the 
evening when he is prepared for bed. The nurse must care 
for the teeth of a small or sick child; the convalescent may 
brush his own teeth but must be taught to do it properly and 
must be supervised. 
The tooth brushes on the market are made soft, medium, 
and hard; the hard brush is preferred. It should be small 
with 1 row of bristles grouped with spaces between for the 
child under 5 years and with 2 rows of bristles for the child 
over 5 years. (Dental Department, University of Minnesota.) 
To brush the teeth, place the powder or paste on the brush 
and start to clean the teeth with the brush dry; the dry 
brush loosens the sordes from the teeth, where the moist one 
would not; there is sufficient saliva to moisten the brush. The 
first step is to place the tooth brush flat on the buccal surface 
of the left upper molar region and turn it with a sweeping 
motion toward the occlusal surface of the teeth; this motion 
cleanses the gum tissue, thereby stimulating it, and it cleanses 
the broad surfaces of the teeth and the intradental spaces. 
Continue the motion around the jaw to the right molar region; 
reverse the position of the brush to the right lower molar 
region and continue around to the left lower molar region, 
using the same sweeping motion. Change the brush to the 
lingual surface of the left lower molar region and continue 
to the right; change the brush to the lingual surface of the 
right upper molar region and continue to the left. In order 
to clean the anterior teeth around the curve of the mouth on 
the lingual surface turn the brush so that the end is in contact 
with them. To complete the cleaning place the brush with the 
Boutine 
Care of 
Child’s Teeth 
Tooth Brush 
To Brush 
Teeth CARE OF THE SICK CHILD 
89 
bristles on the occlusal surface of the left upper molars and 
continue to the right; change the brush to the right lower 
molars, occlusal surface, and continue to the left. The advan- 
tage of this procedure is that all the motions are from left to 
right, right to left, upper and lower teeth, in rotation, thus 
making it easy and simple for the child to remember the 
routine. In order to thoroughly clean the teeth, the stroke 
should be repeated 8 times on the same surface. Rinse the 
mouth with warm normal salt solution. 
To care for the tooth brush after use scrub it with castile 
soap and warm water, rinse it well with warm water, dip it in 
normal salt solution, and sprinkle it with dry salt; let it hang 
or stand in a glass. Before use shake off the dry salt. 
A very sick child or the child with an elevated temperature 
will have to have his teeth and mouth cleaned for him. Sordes 
quickly collect on the teeth and the tongue becomes covered 
with a coating of food particles, epithelial cells, and bacteria 
mixed with secretions of the mouth. The lips become dry and 
cracked. A neglected mouth is a dangerous source of infec- 
tion because (1) it is a source of pollution to the food and 
saliva which is carried to the alimentary tract; (2) the 
collection of bacteria on the tooth surfaces leads to gingivitis 
and pyorrhea; these bacteria can be absorbed by the blood 
stream. 
Care of 
Tooth Brush 
Mouth Wash 
for Sick Child 
Dangers of 
Neglected 
Mouth 
a. Equipment: 
1. Kuroris or forceps. 
2. Pledgets of absorbent cotton (size of walnut). 
3. Two kidney basins. 
4. Glass with solution. 
5. Tongue blade. 
6. Rubber syringe (ear syringe). 
7. Towel. 
8. Cold cream. 
b. Solutions which may he ordered: 
1. Normal saline. 
2. Potassium chlorate. 
3. Listerine 50 per cent. 
Equipment 90 
PEDIATRIC NURSING 
4. Glycerin, lemon, boric (equal parts). 
5. Boric acid 2 to 4 per cent. 
6. Dobell’s 5 per cent. 
7. Myrrh 25 per cent. 
Procedure 
c. Procedure: 
To prepare the tray in the dressing room remove a supply 
of sterile cotton pledgets from a jar with sterile handling 
forceps and place them on the tray. Take the tray to the 
bedside. Place the towel under the patient’s chin and place 
the kidney basin at the side of his face; place a cotton pledget 
in the forceps so that the end of the forceps is well protected 
to avoid traumatizing the mouth; dip it in the solution; hold 
the forceps in the right hand as a pencil; with the left hand 
take the tongue blade. Have the patient hold his mouth 
slightly open, insert the tongue blade to hold the cheek away 
from the teeth, insert the forceps with the cotton pledget and 
clean the buccal surfaces of the teeth and gums, using a 
circular motion. If a large pledget is used, the insides of the 
cheeks are cleaned at the same time. Clean the lingual sur- 
faces of the teeth, the roof of the mouth, and the occlusal 
surfaces, following the same routine as when brushing the 
teeth. Use as many pledgets as necessary to thoroughly clean 
the mouth; put soiled pledgets in the kidney basin on the 
tray. To clean the tongue have the patient hold it out as far 
as he can; if it is very coated and is not too tender to permit, 
clean it with the tooth brush, brushing toward the tip. If it 
is too sore for this use a cotton pledget. Fill the syringe with 
water and rinse the patient’s mouth, letting him expectorate 
into the kidney basin. Apply cold cream to his lips if neces- 
sary. The frequency of the mouth wash depends on the 
condition of the mouth; it may have to be done as often as 
every 2 hours; it should always be done before and after he 
takes nourishment. 
If a child refuses to open his mouth, it can be opened by a 
tongue depressor slipped between the teeth and can be held 
open by a mouth gag. The ordinary wooden mouth gag is CARE OF THE SICK CHILD 
91 
rather large for a small child. Two or three tongue blades 
put together with the end covered with absorbent cotton and 
several thicknesses of gauze held in place with a narrow strip 
Mouth 
Gag 
Figure 6. Mouth Gag Made of Tongue Blades 
of adhesive make a good mouth gag. After it is inserted it 
can be turned sidewise and left in while the child’s mouth is 
being cleaned. 
Care of the Hair and Scalp. 
The infant has a daily shampoo with his bath until his hair 
becomes so long and heavy that it cannot be dried easily. 
Daily washing of the scalp prevents formation of dandruff 
and crusts known by the laity as “cradle cap.” If a baby has 
a seborrheac exudate a little oil or vaselin, lard, or any pre- 
scribed ointment can be rubbed over the scalp at night when 
he is put to bed and is washed off with his shampoo in the 
morning. Seborrhea on a baby’s scalp should always be 
called to the doctor’s attention. 
Every child in the hospital has a separate comb and brush 
kept in his table or locker. These are sterilized after his 
discharge. He has his hair combed twice daily, in the morning 
after his bath and when being fixed for the night. Bright 
colored hair ribbons may be used for little girls; at night these 
must be replaced by pieces of bandage. 
When a child is admitted, he has a shampoo if he is not too 
ill and his head is thoroughly examined for nits or pediculi. 
A shampoo is given every week while he is in the hospital and 
his head is thoroughly looked over then because he can 
contract infections so easily in the institution. 
Routine 
Care of 
Child’s Hair 
Care When 
Admitted 92 
PEDIATRIC NURSING 
To Give 
Shampoo 
to Girl 
Shampooing Long Hair. 
a. Equipment: 
1. Basin of water. 
2. Pitcher of water 110° F. 
3. Small pitcher of water 75° F. 
4. Soap solution in a container. 
5. One bath towel, 2 hand towels, and wash cloth. 
6. Safety pins. 
7. Large rubber sheet or apron provided for the purpose (with 
one end cut to fit, around the neck, and with tapes to tie). 
8. Small rubber. 
9. Soft nail brush. 
10. Hair brush, comb, and fine comb. 
11. Bathing solution. 
12. Foot tub or pail. 
13. Blanket. 
b. Procedure: 
Fold back the upper bedclothes, covering the child with the 
blanket. Remove all but one pillow; bring it over to the side of 
the bed; have the child lie on her side with her back even with 
the edge; place the small rubber covered with a hand towel 
under her head and face. Fold a hand towel over one end of 
the rubber sheet and pin it tightly around her neck, with the 
other end sloping into the pail, which is on a chair at the side 
of the bed or on the floor, depending upon the length of the 
child’s hair. If the rubber apron is used, tie this around the 
neck in the same way. Roll the edges of the rubber sheet to 
form a trough from the head to the pail. Moisten the hair 
and scalp with water and pour the soap solution over them; 
rub the scalp vigorously with the tips of the fingers; pour 
warm water from the pitcher over the head and hair. Rinse 
well by pouring water over the hair, use water 75° F. last, 
squeeze the water from the hair, roll it in a bath towel, unpin 
the rubber from the child’s neck and remove it with the pail. 
Move the child to the middle of the bed, leaving the small 
rubber and towel under her head. Spread her hair out over 
this, rub with the bath towel, and fan until dry; rub bathing 
solution into the scalp when the hair is partly dry. 
Procedure CARE OF THE SICK CHILD 
93 
Shampooing Short Hair, as the Dutch Clip. 
To Give 
Shampoo 
to Boy 
a. Equipment: 
1. Large rubber sheet and small rubber sheet. 
2. Basin. 
3. Wash cloth, bath towel, and 2 face towels. 
4. Nail brush. 
5. Bathing solution. 
6. Brush, comb, and fine comb. 
7. Pitcher with water 110° F. 
8. Pitcher with water 75° F. 
9. Soap solution. 
10. Blanket. 
b. Procedure: 
Fold back the upper bedclothes covering the child with the 
blanket. Move the child down about a foot from the top of 
his bed. Place 2 pillows covered with a small rubber and towel 
under his shoulders to elevate them, place a basin under his 
head above the pillows. Cover one end of the large rubber 
sheet with a hand towel and pin it around his neck; let the 
other end extend under his head over the pillows into the 
basin; wash his hair the same way as given above with soap 
and water, pouring the water from the pitcher over his head 
into the basin below it. Wrap his head in the bath towel 
when thrcfugh, unpin the towel and rubber around the neck 
and remove with the basin, move the pillows back to the head 
of the bed and leave the small rubber and towel under the 
head until the hair is dry; rub as in the above method. 
Treatment for Pediculi or Nits. 
If a child has pediculi kerosene or tincture of larkspur may 
be used to kill them. The treatment is best applied at bed- 
time followed by the shampoo in the morning, 
a. Equipment for applying a kerosene cap: 
1. Kerosene, 1 part with 3 parts of oil in glass container. 
2. (Cotton pledget) gauze square. 
3. Vaselin on cotton pledget. 
4. Safety pins. 
5. Triangular drape or dressing towel. 
6. Kidney basin. 94 
PEDIATRIC NURSING 
b.. Procedure: 
Rub the skin around the edges of the hair with vaselin on 
a cotton pledget. Thoroughly saturate the scalp and hair 
with the kerosene mixture on the gauze square. Pin the tri- 
angular drape or towel around the child’s head, completely 
covering his hair. To put the triangular drape on, place the 
middle of the longest side in the middle of the forehead, bring 
the 2 ends completely around the head and over the third end 
in the back, tying snugly in front in a square knot. Turn the 
edge up over the knot and arrange neatly in back. If the child 
is very active, this may not stay on; to secure it put a piece of 
bandage under the chin and pin it under each ear wTith a small 
safety pin. (Tincture of larkspur, full strength, is applied in 
the same manner. Vaselin is not necessary.) The cap is left 
on until morning. A shampoo is then given; if all the pediculi 
are not dead repeat the cap the next night. If the child has 
many pediculi, keep a cap on his head during the day to 
prevent spreading them. 
If he has nits use hot vinegar and water in equal parts to 
dissolve them. Fine comb the hair, first saturating it with 
vinegar. Separate the hair into small strands and draw each 
strand through a compress saturated with hot vinegar. Repeat 
this every day until the nits are destroyed and follow with a 
shampoo. 
Triangular 
Head 
Bandage 
Treatment 
for Nits 
To Prepare a Child for the Night. 
To Prepare 
Child for 
Night 
Put away all his toys, flowers, etc. Wash his face and hands, 
clean his mouth and teeth (if he is able he brushes his own 
teeth). Loosen the top bedclothes, brush all crumbs from the 
bed with the hand or a folded towel; see that the bed is dry. 
Rub the child’s hack and legs with bathing solution (medi- 
cated alcohol, 50 per cent). Remove the pillows for the night 
unless the child’s condition is such that they are required; 
give him a urinal and a bed pan. Tuck in the lower bed- 
clothes tightly and adjust the upper bedclothes. Have an 
extra blanket folded at the foot of the crib. Give him a drink CARE OF THE SICK CHILD 
95 
of water. Sick children in a hospital should be ready for bed 
and sleep at 7 p.m. The temperature of the ward at night 
can usually be 65° F. to 60° F., unless there are dressings, 
treatments, etc., to be carried out which expose the child. 
Temperature 
of Ward 
at Night 
Charting. 
The pediatric nurse must be able to observe symptoms 
closely in order to ascertain her patient’s condition; she must 
also be able to record these observations on the chart accu- 
rately and in the minutest detail. As in all charting she 
must be able to express her meaning clearly and concisely, 
using as few words as possible to accurately convey her mean- 
ing. Notes of any change in the patient’s condition or un- 
usual symptoms must be made by the nurse as soon as she 
notices them. She must also record the child’s defacations 
and urinations at once, never trusting to her memory or to the 
patient’s word to check up on them at the end of the day. In 
the rush of the present moment it is so easy for the nurse to 
put off such things until a less busy time comes. No careful 
nurse will allow herself to do this, even when caring for 
adults, and when caring for children there is much more 
reason why she should not, since they cannot be expected to 
remember details accurately or to understand their signifi- 
cance. It is usually convenient to have a notebook ruled into 
spaces for recording names of patients, temperatures, pulses, 
respirations, weights, defecations, urinations, etc.; record can 
be made in it of things as they occur and the book can be 
taken into the ward for the more convenient recording of 
temperatures, etc. At the end of the day these records are to 
be copied on the permanent individual charts. To economize 
on space symbols may be adopted to indicate various kinds of 
stools. The children’s charts should be hung on racks or 
should be kept in a special chart container on the head nurse’s 
desk; they should not be kept at the bedside, since the chil- 
dren are apt to destroy them if they are within their reach; 
also parents and visitors will be tempted to read them if they 
Pediatric 
Charting 96 
PEDIATRIC NURSING 
are there. They should be taken to the beds just before staff 
rounds, however, and collected immediately afterwards. 
Care of a Child after Death. 
To Care for 
Child after 
Death 
Whenever a sick child in a hospital is not as well as usual 
the parents should be notified and if they wish they should be 
allowed to remain with the patient. The doctor should be 
notified at once if the child suddenly grows worse. 
As soon as respirations cease, the nurse should close his eyes 
by pressing the lids down with her fingers, should straighten 
his extremities, and should put a roll of bandage under his 
chin. Nothing more is done until the doctor has seen the 
child and has pronounced him dead. If the parents are not 
present, they should be notified at once; if they are present, 
give them a few minutes alone with the child before asking 
them to leave so that the body can be prepared for the morgue. 
The nurse can profitably employ these few minutes in pre- 
paring her equipment to lay out the body, which consists of 
the following: 
1. Child’s individual toilet articles. 
2. Bath tray. 
3. A laundry bag. 
4. Morgue box which contains: 
a. Morgue sheet. 
b. Shrouds. 
c. Boll of bandage, 114 or 2 inches wide. 
d. Boll of bandage, 4 inches wide. 
e. Clothes tags. 
f. Old cotton cloth or compress for diaper. 
g. Adhesive. 
h. Pad of waste cotton covered with gauze 8 or 12 inches 
square. 
i. Common pins. 
Remove all of the upper bed clothing except the sheet, 
remove the child’s clothing, elevate his feet to allow any fluid 
to drain from the mouth and nose. A very small child can be 
held up by the feet. If the eyes do not stay shut, place a piece 
Equipment 
Procedure CARE OF THE SICK CHILD 
97 
of wet cotton over the lids. Leave the roll of bandage under 
the chin to keep the mouth closed. 
Clean the body with soap and water. If there is an open 
wound, remove the dressing, put fresh gauze over it and 
fasten with strips of adhesive. Comb the hair in the cus- 
tomary manner; use a piece of bandage for a hair ribbon 
for the little girl. Tear a piece of old cotton cloth or a 
compress into the right size for a diaper and put it on with 
the waste cotton pad in the center over the rectum and geni- 
tals, turn the edges in and pin neatly in front and on the 
sides at the knees. Tie the knees and ankles together with 
pieces of bandage l1 or 2 inches wide. If it is a small 
baby it is necessary to tie the legs only once. Put the shroud 
on, cross the arms over the chest, and tie the wrists together 
with a piece of bandage. With another piece 4 inches wide 
make a four tail bandage to hold the jaw in place; remove 
the roll of bandage from under the chin; remove the wet 
cotton pledgets from the eyelids. If they do not stay closed, 
insert a piece of wet cotton under the upper lid of each eye 
with the end of a toothpick. 
Make out two tags with the child’s name, ward, date, and 
hour of death; tie one to the child’s wrist. 
The morgue sheet should be large enough to completely cover 
the child. Place him in the center of it, fold the sides up over 
his body, and pin them with common pins, then fold the ends 
over his feet and head and pin them down. The second tag is 
pinned to the outside of the sheet. The nurse accompanies the 
body to the morgue. 
It is the nurse’s duty to see that the child’s personal belong- 
ings are ready for the parents; especially his toys must be 
saved for them, no matter how trivial and worthless they may 
seem, for parents will always treasure them. If the child had 
a communicable disease, disinfect the toys by boiling, if pos- 
sible ; if not possible, wash them with 1 per cent lysol solution 
or put them in the sun from 3 to 24 hours. (Care of bed and 
mattress after death discussed under care of beds.) 
Care of 
Personal 
Belongings CHAPTER VII 
THE NEWBORN BABY 
The hospital nursery for newborn babes should be as ideal 
as conditions permit. The rules given for the selection of the 
home nursery (Chapter III) should be carried out in the 
institution as far as possible, especially in regard to the 
choosing of the room, heating, lighting, ventilation, and tem- 
perature, remembering that 1000 cubic feet of air should be 
allowed to every infant. 
A common hospital crib for newborns is a basket-shaped, 
heavy wire crib about 14 by 24 inches. Six to ten of these are 
suspended from one standard which usually has two rounds, 
an upper and a lower. The cribs are placed alternately, first 
one on the upper round and then one on the lower, so that 
the babies nearest each other are not on the same level. If 
these cribs are used, it is impossible for the nurse to get near 
enough to the baby to do anything for him in his crib. It is 
necessary, therefore, to have a common dressing table equipped 
with a rubber sheet and pad. 
The rules for individual isolation of older children (Aseptic 
Pediatric Nursing Technique, Chapter VI) must be carried 
out for the newborn babes, because the younger the child the 
more susceptible he is to infections. The nurse must wash her 
hands after touching one child before doing anything for the 
next one. A good way to carry out individual technique in 
the nursery is to spread a clean towel on the common dressing 
table and place the baby on the towel when he is to be bathed, 
changed, etc. After he is put back in bed the towel can be 
folded with the clean side inside and hung on the foot of his 
crib. This makes it possible to use the towel several times or 
The Nursery 
Equipment 
Aseptic 
Nursing 
Technique 
98 THE NEWBORN BABY 
99 
until it is soiled. The same technique should be used in 
weighing the baby on the common scale. The ideal nursery 
has a separate little crib and bedside stand for each baby with 
space enough between them so that the nurse can work over 
each baby in his own crib, carrying out every procedure, bath- 
ing, changing, etc., without lifting him from his crib. This 
eliminates the unsafe, common dressing table. Some cribs are 
made with a cupboard under them in which the child’s indi- 
vidual equipment may be kept. If there is not such a place, 
a locker or drawer should be provided for every baby in which 
his towels and basin can be kept. If individual articles are 
not possible, everything coming in contact with one baby 
should be sterilized before being used for the next one. 
A newborn baby is cleaned with oil until his cord comes off 
and the umbilicus is healed and dry. Then water baths, tub, 
sponge, or shower, may be given as for older children. If the 
nursery is equipped with separate cribs and bedside tables, 
the sponge bath can be given the baby in his bed. The bath 
equipment and the necessary linen are taken on a tray to his 
bedside and his individual basin is filled with water. A tub 
bath may be given if a separate bath tub is supplied for each 
baby and if there is space available where the tubs may be kept. 
Sometimes they may be placed on a shelf under the crib. A 
tub bath may be given in a common tub, of course, if it is 
thoroughly scrubbed with soap and water after each baby is 
bathed. Porcelain or marble bath slabs can be used for new- 
borns as for older children. The quilted pad on the slab must 
be changed and the slab must be scrubbed with soap and 
water between baths. If given a tub or a shower bath, the 
babe can be undressed and his eyes, ears, and nose can be 
cleansed and his face can be washed at his bedside, if the 
nursery is equipped with individual cribs and bedside stands. 
Otherwise the child is placed on the common dressing table 
for this. The rubber on the dressing table must be scrubbed 
with soap and water between each bath because more or less 
moisture soaks through to it during a bath. 100 
PEDIATRIC NURSING 
Artificial Respirations. 
As soon as a child is born he should begin to breathe. 
Usually his entrance into the colder air from the birth canal 
will cause him to gasp and to breathe irregularly at first, but 
gradually more regularly. The normal baby will start to cry 
at once, a short, feeble cry, but increasing in strength. It is 
important that he should cry as it helps to expand the lungs 
so that they can properly fill with air. Asphyxia neonatorum 
is that condition of the newborn baby in which primary res- 
pirations are not spontaneously established with sufficient 
force to maintain life. Asphyxia may be due to mucus in the 
air-passages. It is very important to clear the uppermost air- 
passages before the child makes the first gasp. To do this 
hold him up by his heels until the roof of his mouth fills with 
mucus, then tip his head backward to allow it to drain out. 
(See method of resuscitation in Figure 7.) Nothing should 
ever be introduced into the baby’s mouth to wipe it, neither 
cotton nor gauze on the finger nor an applicator, as the mucous 
membrane of the mouth is easily injured and if once abraded 
is subject to such infections as thrush. If the newborn fails 
to breathe, respirations may be stimulated in several ways. 
Whatever the method is, the essential points to bear in mind 
are: 
1. The method must be gentle and simple. Most forms of 
artificial respiration are too strenuous. 
2. The baby must be exposed as little as possible. The 
following methods are recommended by Dr. J. C. Litzenberg of 
the University of Minnesota: 
Method I. Hold the infant so that the neck rests between 
the thumb and forefinger of the left hand, allowing the head 
to fall far backward, the upper portion of the body resting on 
the palm of the hand. With the right hand the knees are 
grasped between the thumb and fingers, the thighs resting 
against the palm of the hand. Expiration is produced by 
folding the baby’s body on itself like a jacknife with the head 
Asphyxia 
Neonatorum 
To Clear 
Mucus from 
Air-Passages 
Essential 
Points in 
Giving 
Artificial 
Respirations 
Method I 
Expiration THE NEWBORN BABY 
101 
downward, thus allowing mucus to drain into the mouth at the 
same time that air is forced from the lungs. (See Figure 
10.) Inspiration is produced by reversing the movement, 
Inspiration 
Figure 7. Method of Resuscitation 
(From DeLee’s “Principles and Practice of Obstetrics,” 
Courtesy of W. B. Saunders Co.) 
unfolding the baby’s body. (See Figures 8, 9.) The body is 
thus alternately folded upon itself and unfolded as move- 
ments are carried out. Repeat 10 or 15 times a minute. The 
movement of expiration should be made first with the body 
Frequency 
of Movement 102 
PEDIATRIC NURSING 
completely inverted. This method is simple, efficient, and not 
overfatiguing to the infant. It is also of great advantage in 
Figure 8. Byrd’s Method of Artificial Respirations. Position 
for Inspiration 
(From Edgar’s “Practice of Obstetrics.’’ Courtesy of P. Blakiston’s 
Sons & Co.) 
that it can be carried out while the child is in a tub of water 
100° F., thus preventing loss of animal heat. 
Figure 9. Byrd’s Method of Artificial Respirations. Position 
between Inspiration and Expiration 
(From Edgar’s “Practice of Obstetrics.’’ Courtesy of P. Blakiston’s 
Sons & Co.) 
Method II 
Method II. Direct inflation of the lungs by mouth-to-mouth 
breathing is another method which may be employed to THE NEWBORN BABY 
103 
resuscitate the child with asphyxia. Place him upon his back 
with his head extended by means of a small pillow under his 
neck; the operator places a piece of gauze (3 or 4 thicknesses) 
over the infant’s mouth and by placing his mouth directly 
over the infant’s and blowing into it, he inflates the lungs. 
The air is expelled by gentle pressure upon the chest, and the 
blowing repeated several times if necessary. The danger of 
the above method is overinflation of the lungs; the blowing 
Figuke 10. Byrd’s Method of Artificial Respirations. Position 
for Expiration 
(From Edgar’s “Practice of Obstetrics.’’ Courtesy of P. Blakiston’s 
Sons & Co.) 
must be very gentle. Do not cover the nose during the process, 
but leave it open as a safety valve. 
In all cases where artificial respiration is used, the first 
movement should be that of expiration to expel, as far as 
possible, mucus or other foreign substances from the air- 
passages. The movements should be made not more than 10 or 
15 times a minute and not too forcibly, the baby being kept in 
a tub of water 100° F. between movements and as much as 
possible during them. Hold the finger over the heart to keep 
check on its action during the process and as long as it con- 
tinues to beat resuscitation is possible. 
The cord is generally tied after pulsations have ceased. A 
General 
Rules 
To Tie Cord 104 
PEDIATRIC NURSING 
sterile linen tape is tied in a square knot y2 to 1 inch from 
skin margin and again y2 inch above that, the cord being cut 
between the two ties. A sterile dressing is put over the 
umbilicus and the ends of the linen tape are tied around it to 
hold it in place. 
Cord 
Dressings 
Cord Dressings. 
No. 1 
A is placed on end of cord, the linen tape is brought 
up through slits on either side and tied over the end 
of the stump. This cannot be changed. B is slipped 
around the stump under A and is changed when 
soiled. 
No. 2 
A is slipped over the stump with the cord through 
the hole. B is tied on the end of the stump with 
linen tape. Neither can be changed. 
Figure 11. Cord 
Dressings. 
Care of 
Umbilicus 
The umbilicus is treated as a surgical wound until the cord 
has fallen off, the wound has cicatrized, and has healed over, 
which takes from 4 to 8 days. The cord should be touched as 
little as possible; the sterile dressing is changed only when 
soiled and the abdominal binder every day after the bath. 
Normally, nothing else need be done to the cord, for the 
original dressing usually stays until the cord drops off. After 
this time a sterile dressing is kept on for several days, until 
the umbilicus is thoroughly healed. Any unusual appearance 
of the cord is reported at once. 
In a normal delivery as soon as the baby’s head is born, 
before the body is delivered, the nurse sponges the eyes with 
4 per cent sterile boric acid, wiping each eye with a separate 
sponge, the motion being away from the nose toward the 
outer canthus. In order to prevent gonorrheal infection of 
the eyes, known as ophthalmia neonatorum, Crede’s method 
is used routinely in most places. Preparation for this method 
consists in having two sterile medicine droppers, or one and 
some sterile pledgets, a solution of 1 to 2 per cent silver 
First Care 
of Eyes 
Crede’s 
Method THE NEWBORN BABY 
105 
nitrate, and normal saline solution. The method is: separate 
the eyelids gently with thumb and forefinger of one hand and 
with the other hand drop 1 or 2 minims of the silver nitrate 
solution from medicine dropper directly into each eye at the 
inner canthus; follow this with a few drops of salt solution, 
using eye pledgets or medicine dropper. Care must be taken 
that the silver nitrate solution is made up fresh every 
few days, otherwise there may be a severe reaction from 
its use. 
The Care of the Newborn. 
The most important point in the care of the newborn baby 
is the maintenance of a normal temperature by keeping his 
body sufficiently warm. His temperature should be takeu 
immediately after birth when it is usually one degree higher 
than his mother’s, but it drops rapidly if there is any ex- 
posure as his heat regulating centers are very unstable. A 
crib with two hot water bottles (115° F. with covers) and 
warm blankets should be prepared for the newborn. As soon 
as he is breathing properly and the cord is tied, he should be 
wrapped in warm blankets, should be put into the crib, and 
should be taken to the nursery. 
The newborn is covered with a thick, white, waxy material 
(the vernix caseosa) which is composed of epithelial cells, 
lanugo, and sebaceous secretions accumulated during the 
intra-uterine life. He may be soiled with meconium, blood, 
and feces. There is less initial loss of heat if the child is not 
exposed for cleaning at this time. Without removing him 
from his bed, quickly anoint him with warm oil as soon as he 
is taken into the nursery. The oil is used at this time only to 
soften the vernix and other material which is on him. Take 
the temperature while giving the bath. Put a diaper around 
his buttocks and see that the cord dressing is held in place by 
a binder; wrap a blanket around his neck and shoulders and 
pin it; put another blanket under him, bringing it up over his 
head so that only his face is exposed; put hot water bottles 
Care of 
Newborn 
Babe 
Temperature 
of Newborn 
First Care 
after Delivery 106 
PEDIATRIC NURSING 
on each side of him and leave him for 6 or 8 hours. The above 
procedure should not take longer than 2 or 3 minutes. Do not 
leave the baby alone but watch him closely because he may 
become cyanotic and may have respiratory difficulties, due 
either to mucus in the throat or improper expansion of the 
lungs. If he is free from respiratory difficulty, he should not 
be touched for at least 6 hours. He must also be watched for 
bleeding from the umbilicus, which must be reported at once. 
Many authorities advise placing the newborn on his right side 
the first 24 hours of life. It was once held that this facilitated 
the closure of the foramen ovale, but this is no longer taught. 
A more plausible reason is that the weight of the liver may 
embarrass the heart in the first hours of life. At the end of 
6 hours the temperature is taken again and 10 minutes is spent 
in giving the baby a cleansing oil bath. At this time he is 
weighed. Weighing him in his blankets and then subtracting 
their weight from the total saves exposure. 
The best oil to use for cleansing is olive oil, but at present it 
is very expensive. Almond oil is also good but nearly as 
expensive. Benzoated lard, too, is very satisfactory and fairly 
cheap. Other oils which may be used are oil of peach kernels, 
cotton-seed oil, plain melted lard, Wesson oil, and Crisco. The 
oil may or may not be sterilized. The bath equipment, which 
consists of the following, may be placed on a tray 15 x 20 
inches: 
Equipment: 
1. Paper bag for waste. 
2. Laundry bag for soiled linen. 
3. Jar of sterile eye pledgets (made from best grade cotton 
the size of a marble). 
4. Jar of sterile cotton pledgets made from second grade 
cotton (size of a walnut). 
5. Jar of cord dressings, sterile gauze, 4 inches square. 
6. Jar of sterile abdominal binders made from old cotton 
torn in strips, 12 x 6 inches, rolled like a bandage. 
7. Jar of sterile toothpick applicators, cotton wound tightly 
around the ends. 
Watch Him 
Closely 
Oils Which 
May Be Used 
Cleansing 
Oil Bath 
Equipment THE NEWBORN BABY 
107 
8. Two small sterile basins, 2 to 4 inches in diameter, 1 for 
sterile boric acid solution (4 per cent), 1 for sterile oil. 
9. One large basin of warm water in which to put small 
basins to warm their contents. 
10. Tray of safety pins. 
11. Handling forceps in glass of 5 per cent lysol solution. 
This tray and equipment can be used for any number of 
babies whether they are bathed in their cribs or upon the 
table. To prepare a newborn for his oil bath wrap and pin the 
blanket around him to restrain his arms. With the handling 
Procedure 
Figure 12. Toothpick Applicator Used in the Bath 
forceps remove an eye pledget from the jar, dip it into the 
basin of warm boric acid solution, then replace the forceps, 
take the cotton pledget in the fingers of the left hand and with 
the palm of the right hand hold the baby’s head to the right 
side, then with the thumb and forefinger of the right hand 
separate the lids of his right eye, holding them open by press- 
ing the lids gently hack against the frontal and maxillary 
bones. Do not make any pressure on the eyeball. With the 
pledget in the left hand clean the eye by wiping from the 
inner canthus toward the outer, thus preventing any dis- 
charge from one eye being carried toward the other. In the 
same manner wash the left eye, reversing hands and using a 
fresh pledget. Put soiled pledgets in the paper bag for waste. 
To clean the nose remove a toothpick applicator from the jar 
with the forceps, dip it into the basin of oil, replace the 
forceps, steady the child’s head with one hand and with the 
other clean the external nares with the applicator. The ears 
are cleaned with toothpick applicators dipped in oil, using a 
separate one for each ear, and cleaning only the external ear. 
The baby’s mouth is not cleaned; the mucous membrane is 
very delicate and if injured is subject to such infections as 
thrush. To clean the baby’s face use a larger cotton pledget 
(made of the second grade cotton). Remove it from the jar 
Eyes 
Nose 
Ears 
Face 108 
PEDIATRIC NURSING 
with the forceps, dip it in oil, take it in the fingers, replace 
the forceps, and sponge the face and head; follow with a dry 
sponge to absorb the oil. Clean the body in the same way, 
dipping the sponges in the oil and wiping with dry ones. 
Only the part of the body which is being cleaned should be 
exposed at a time, the rest should be covered with a blanket. 
Note the order which should be followed: right arm, left arm, 
neck and chest, abdomen around the cord dressing (do not 
touch that), back, right leg, left leg, buttocks, and groin. 
The skin of the newborn is very tender, easily abraded, and 
is subject to infections if it is injured; therefore the nurse 
must not use too much pressure in her attempts to clean the 
vernix from the baby, for if it is not removed at the first bath 
it will be removed at the next, and it will do the baby less 
harm than overexposure and too rigorous rubbing. The origi- 
nal cord dressing is not removed or touched during the first 
bath or at any time unless it is soiled. An abdominal binder 
is put on to protect it and to hold it in place. This is changed 
every day during the bath or whenever it is soiled. If it is 
made of old cotton cloth it may be discarded when it is taken 
off. The binder, which may also be made of flannel, is pinned 
or sewed on the baby to one side of the front midline as the 
newborn usually lies on his side. The nurse should slip her 
finger under the binder when pinning it in order to prevent 
the possibility of pricking the baby or of having the binder 
too tight. 
The shirt is then put on. The nurse puts her fingers through 
the sleeve of the shirt, takes the baby’s fingers and hand in her 
fingers and pulls them through the sleeve. The diaper is 
pinned to the shirt in front and back to keep it in place. 
Stockings are put on and pinned to the diaper at the knees. 
The “gertrude” or petticoat is slipped inside the dress and 
the nurse puts both together over her right arm. With her 
right hand she takes the baby’s legs and with the left hand 
she pulls the dress and petticoat from her right arm over the 
baby. His hands are put through the sleeves as directed 
Body 
Abdominal 
Binder 
Clothing THE NEWBORN BABY 
109 
above; he is turned on his face, the ‘ ‘ gertrude ’ ’ is fastened on 
the shoulders and the dress is fastened in the back. 
To turn a small baby do not drag him into the desired 
position by pulling one leg and arm, but place the right hand 
over his chest, slip the left hand under his shoulders and neck, 
thus supporting the head with the tips of the fingers, and turn 
him quickly. If he has no clothes on, the nurse may turn him 
by placing her right hand in his groin, thumb toward the 
front and fingers behind over the lower back, her left hand 
over his shoulder, thumb in front and fingers behind, support- 
ing his neck with her two first fingers. 
For the first day or two the baby will need an extra blanket 
wrapped around him and if his temperature is below 98° F. 
he should be surrounded by hot water bottles. 
When the baby is put into his crib, fold the dress and 
petticoat up away from his buttocks so that they will not 
become wet or soiled. Another way to prevent the outside 
clothes from being soiled is by the use of stork sheeting (8 x 14 
inches), folded inside a diaper and placed under his buttocks 
under the dress and petticoat. 
In most cases the doctor allows the normal newborn to go to 
breast 6 to 8 hours after birth. On the first day the infant 
obtains the secretion known as colostrum which is composed of 
protein, fat, carbohydrate, mineral matter, and water. There 
is very little of it at first but the amount and character of the 
secretion change, so that by the end of the fourth or fifth day 
the breasts secrete normal breast milk in normal amounts. The 
newborn thrives well if nursed only every 4 hours or on 5 
feedings a day, i.e., 6 a.m., 10 a.m., 2 p.m., 6 p.m., and 10 p.m., 
omitting the 2 a.m. feeding. In order to determine the 
amount taken at breast, the baby can be weighed before and 
after feedings. (See chapter on Breast Feeding.) The new 
baby is weighed regularly before the daily bath. The scales 
are kept on a side table in the nursery and the baby’s towel 
is used on the scales as mentioned in a preceding paragraph. 
The newborn’s temperature is taken twice a day, morning 
To Turn 
a Baby 
Feeding 
Temperature 110 
PEDIATRIC NURSING 
and evening, with his individual thermometer. If it is over 
100° or under 98° F., it should be taken every 4 hours. The 
pulse and respirations are not usually taken. (See Care of 
Thermometers, Chapter VI.) 
Clinical charts should be kept for the newborn baby and on 
them should be recorded the temperature, weight, amount of 
milk taken at breast each time, the total 24 hour amount, and 
any unusual symptoms in regard to the child’s condition. 
Newborn babies and all small children in an institution 
must be marked for identification. There are various methods 
employed. A piece of adhesive 2 inches square upon which is 
written the child’s name and hospital number can be put on 
his back between the shoulders. Since this comes off fre- 
quently it is not a desirable method. A wrist band is often 
used. This is made of linen tape about % inch wide and long 
enough to tie around the wrist; a piece of adhesive is folded 
over the tape at the middle, leaving the ends free to tie. The 
name and hospital number are written on the adhesive. But 
this too comes off, even though it is tied in a square knot. 
Another method is to take a piece of adhesive twice the length 
needed to go around the baby’s wrist; cut and fold half of it 
to make a band to go around the wrist as shown in the dia- 
gram. Place the name on the un- 
folded section of the adhesive and 
fold it around the wrist band. It 
may be sewed on. In many places 
the baby’s foot or thumb print is 
taken immediately after delivery 
or admission and filed with his 
record. This, however, is only for reference and some other 
data has to be combined with it to make it of value. One of the 
most popular methods used at the present time is a bead neck- 
lace with lettered beads spelling the infant’s name strung in 
the center of the chain. Another method is to tie a labeled 
aluminum tag around the baby’s neck with a piece of tape. 
Charts 
To Mark 
Baby for 
Identification 
Figure 13. Wrist Band. THE NEWBORN BABY 
111 
After the newborn’s cord is off and the umbilicus is healed, 
he is ready for a water bath. As stated above, a sponge bath 
given to him in his bed is the most practical and the safest 
method. His individual basin is filled with water (100° F.) 
and together with the bath tray, clean linen, and laundry bag 
is taken to the crib or to the common dressing table, as the 
equipment of the nursery permits. If he is bathed on the 
dressing table a clean towel is put over the pad on the table. 
After bathing each baby the rubber covering on the pad must 
be scrubbed with soap and water. The bath equipment is 
almost the same as for the oil bath; the cord dressings and 
binders are not needed, but the following additional articles 
are necessary: powdered soap, bath thermometer, a wash 
cloth of soft material, as old linen or an old piece of cotton 
which may be discarded after the bath, a linen towel, and 
warm oil to be used in the creases instead of powder. The 
routine for the water bath is the same as for the oil bath. 
The eyes are first washed with boric acid solution; next, the 
ears are cleansed with toothpick applicators dipped in boric 
solution or in bath water; and then, the nose is cleansed with 
applicators dipped in boric solution or in oil if there is any 
nasal secretion. The face is sponged with clear water and 
dried by patting. The nurse wets her hand in the water, 
sprinkles soap in her palm, and lathers the hair. Taking the 
baby on her left arm, with the back of the head held in the 
palm of her hand and his back and neck supported by her arm, 
she holds him over the basin of water and with the right hand 
rinses the hair, being careful not to get water or soap in his 
eyes and ears. (Hold thumb and forefinger over ears.) The 
head may be rubbed briskly except directly over the fontanelle. 
Next, the nurse unpins the blanket in which the baby is 
wrapped, makes a lather in the hand and rubs it over the body. 
The body is sponged in this order: arms, neck, chest, abdomen, 
back, legs, and groin. (See that all the soap is removed, be- 
cause it is irritating to the skin, paying particular attention 
to the folds and creases, as the axilla, groin, and palms of the 
Water Bath 
Sponge Bath 
Equipment 
Procedure 112 
PEDIATRIC NURSING 
hands.) The body is dried by patting it with a towel for the 
baby’s skin is too tender for rubbing. A little oil, instead of 
Figure 14. Method of Lifting the Baby from the Table 
to the Bath Tub 
powder, can be used in the creases and folds where any two 
surfaces rub, for powder cakes and forms little irritating gran- 
ules. If powder is used, only zinc stearate is advised. The THE NEWBORN BABY 
113 
child is dressed according to the preceding directions. A tub 
bath may be given the baby if individual tubs are available. 
The routine is the same as for the sponge up to the time the 
Tub Batb 
Figube 15. Position of Baby in Bath Tub 
baby’s body is soaped. He is then put into a tub of water 
100° F. To do this the nurse places her left hand under his 
shoulders and supports the head and neck; with her right hand 
she holds his feet and lifts him into the tub of water. Still sup- 114 
PEDIATRIC NURSING 
porting him with her left hand, slipping her second finger 
under his left axilla to hold him better if he struggles, she 
bathes him with her right hand. She must be sure that all the 
soap is rinsed off. A shower bath also is used to bathe the baby 
The routine is practically the same as for the tub and sponge. 
A pad is placed on the bath slab to put the baby on. His head 
and body are soaped as before, or a soap container filled with 
soap solution may be hung over the slab and a rubber tubing 
with a stopcock may convey the soap solution to the child’s 
body. The spray may then be turned on, the nurse being care- 
ful to keep her hand on the end of the spray so as to feel the 
temperature of the water before it touches the baby. She must 
also be careful not to spray with too much force and not to 
get water in his eyes and ears. She can turn his head away 
from the spray with one hand and can operate it with the 
other. After the shower, he should be wrapped in his blanket 
and towel and taken to his bed or to his dressing table. 
Shower Bath 
Chapin and Pisek—Diseases of Children. 
Cornell, E. L., M.D.—Means of Identification of Babies in Ma- 
ternity Hospital. S. Clinic of Chicago, Oct., 1919. 
DeLee, Joseph B., M.D.—Obstetrics for Nurses. 
■ Principles and Practice of Obstetrics. 
Dunn, Charles Hunter, M.D .—Pediatrics. 
Edgar, J. Clifton, M.D.—Practice of Obstetrics. 
Griffith, J. P. Crozer—Diseases of Infants and Children. 
Holt, L. Emmett, M.D.—Diseases of Infancy and Childhood. 
Ramsey, W. R., M.D.—Care and Feeding of Infants and Children. 
Smith, R. M., M.D.—The Baby’s First Two Years of Life. 
reading references CHAPTER VIII 
THE PREMATURE BABY 
Premature care should be given: 
1. Any baby weighing less than 2300 grams at birth. 
2. Any baby born prematurely. 
3. Any baby suffering from malnutrition whose weight is 
that of a premature baby. 
4. Any baby whose temperature is subnormal or unstable 
as in cases of athrepsia. 
Essential factors 1 to be considered in the care of the prema- 
ture are: 
1. The maintenance of body heat with a supply of fresh air. 
2. Proper feeding—breast milk. 
3. The prevention of infection. 
4. Control of imperfect respirations. 
The mortality of premature infants is very high. It is 
estimated that 80 per cent of those weighing 1600 grams at 
birth, 40 per cent of those weighing less than 2000 grams, and 
20 per cent of those weighing less than 2500 grams die.2 The 
longer the period of gestation and the larger the infant, the 
better is his prognosis. 
The picture of the premature infant in the early days of life 
is quite characteristic. In addition to his very small size, he 
shows in varying degrees an absence of the life and vigor 
which is seen in the fully developed infant at term. He is 
emaciated, his skin being soft and wrinkled, and showing 
very little subcutaneous fat. His head is large, his abdomen 
is broad and distended, and his limbs are puny. According to 
the stage of his development he may or may not have the 
When 
to Give 
Premature 
Care 
Essential 
Factors in 
Care of 
Premature 
Character- 
istics of 
Premature 
1 Griffith, J. P. Crozer, M.D., ‘ ‘ Diseases of Infants and Children. ’ ’ 
2Sheffield, Herman B., M.D., “Diseases of Children.” 
115 116 
PEDIATRIC NURSING 
remains of hair (lanugo) on his body which was present in 
uterine life; and in like manner his nails may or may not be 
well formed. His face has a senile expression and he is 
torpid and extremely somnolent. His eyes are closed; his cry 
is feeble; the surface temperature is usually cool; the extremi- 
ties seldom move. The respirations are very superficial and 
irregular, often ceasing for a few seconds. The power to suck 
and even to swallow is often slight. These signs evidently 
indicate that the vitality is very low. If the weight is below 
3 or 4 pounds and if the length is less than 18 or 19 inches, it 
indicates that the organs are not developed sufficiently to 
function, and that unless unusual care is taken in the treat- 
ment of such cases, they will die.3 
The premature’s heat regulating center acts poorly, and as 
a result he is very sensitive to external heat and cold. The 
relation between the body surface and the weight is important 
in determining the loss of heat, for the greater the body 
surface in proportion to the weight, the greater the radiation 
of heat. The relation between the body surface and the 
weight of a normal baby is about three times that of the adult, 
and that of the premature is even greater. Therefore it is 
necessary to provide more external heat and more food, more 
calories per kilo to make up for this greater loss. 
The digestive organs are subject to upsets. The child may 
not have the strength to nurse and may not be able to swallow. 
Breast milk is essential. (Dr. J. P. Sedgwick, Minneapolis.) 
The premature’s vitality and resistance are low; he is un- 
usually susceptible to infections, especially respiratory infec- 
tions. No one with any kind of infection should go near him. 
If colds or upper respiratory infections are prevalent, it is 
best for every one who goes near him to wear a mask over the 
nose and mouth. No one except those caring for him should 
be allowed to touch or see him at any time. The premature’s 
room may have the upper half of one partition of glass; 
visitors may observe him through this. 
Poor Heat 
Control 
Digestive 
Organs 
Susceptible 
to Infections 
3Dunn, Charles H., M.D., “Pediatrics.’' THE PREMATURE BABY 
117 
The premature’s lung tissue is often not fully expanded, a 
condition known as atelectasis, so that he is subject to cyanotic 
attacks and difficult respirations. The respirations may be 
shallow and irregular. Therefore it is important that the air 
he breathes should be fresh and should have a full supply of 
oxygen. It may be necessary to furnish oxygen to keep the 
blood supplied. There should be an oxygen tank ready for 
instant use as part of the equipment of the premature room. 
The air which the premature breathes should not be below 
68° or 70° F.; it should be always fresh, with a humidity of 
55 per cent. He should be allowed 1000 cubic feet of air 
space. Incubators were formerly much used; they were found 
complicated and unreliable unless constantly watched; the 
ventilation in them was usually poor and the humidity too 
low. Their use is gradually being abandoned. Many hospi- 
tals have a room especially equipped for prematures. Such a 
room is provided with a heat regulating and ventilating 
apparatus, so that any desired temperature and a generous 
supply of air may be maintained. While the temperature of 
such a room is supposed to be regulated by a thermostat, it 
does not always prove reliable and it means constant super- 
vision. It is difficult also to maintain the desired humidity. 
Also it is unpleasant for a nurse to remain long enough in 
such a warm room to take proper care of the baby. Dr. Julius 
H. Hess of Chicago has designed a special premature bed 
shaped like a large basket, lined with a water chamber which 
is heated by electricity.4 This is safe; it eliminates much of 
the nurse’s work; it is simple to operate; it allows good 
ventilation of fresh air with the humidity a little lower than 
that of the surrounding air. A very simple, cheap, and 
satisfactory premature bed may be made from a clothes basket 
the same size and shape as the above container, about 30 
inches long, 22 inches wide, and 18 inches high. This is ele- 
vated from the floor on a stand. The inside and bottom 
are covered with 2 or 3 thicknesses of newspaper and a large 
Atelectasis 
To Maintain 
Body Heat 
Incubator 
Warm Room 
Premature 
Bed Designed 
by Dr. Hess 
Clothes 
Basket 
4Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” 118 
PEDIATRIC NURSING 
sheet is draped around the inside to cover it. Two large 
sheets, folded crosswise in the middle, are placed over the top 
of the basket with the center fold of each one in the middle 
of the basket, and with a 2-inch opening between the two. 
The ends of each sheet are folded neatly around the outside, 
making square corners and are held in place by safety pins. 
A hair pillow protected by a rubber is put in the bottom of the 
Figure 16. Basket for Premature Baby 
basket for a mattress and a small cotton sheet is put over it. 
The covering over the top of the basket prevents draughts 
from reaching the baby and also prevents droplet infection. 
The opening is large enough to furnish ventilation and to 
allow the nurse to care for the child in his basket. A small 
infant’s crib, much the same size and shape as the clothes 
basket, may be arranged in the same way and is just as satis- 
factory. (See note 3.) An old dry goods box, the same size 
and shape, can be used if a basket cannot be obtained. 
There should be a special room devoted to the prematures. 
Premature 
Boom THE PREMATURE BABY 
119 
This should be quiet; it should have good ventilation and 
plenty of sunlight. The temperature should always be from 
68° to 70° F. and the humidity should be 55 per cent. No 
one but the nurses and doctors who actually care for the baby 
should be allowed in this room, and no one with any upper 
respiratory infection should be admitted. If there is more 
than one premature in the room there should be a screen 
between the baskets, or, better, a glass partition. The room 
must be large enough to allow 1000 cubic feet of air space to 
every baby. 
The premature should have his complete individual equip- 
ment as the normal baby has; this may be kept in a table 
beside his basket. Everything is done for him in his basket 
so that there is no need for a common dressing table. 
The nurse, not the maid, should be responsible for the clean- 
ing of the room when there are babies in it. Once a day the 
floor should be brushed, with a sweeping compound or damp 
sawdust, so that there will be no dust. Dusting should be done 
with a damp cloth. 
Temperature 
Humidity 
Cubic Feet 
of Air Space 
Aseptic 
Nursing 
Technique 
To Clean 
Boom 
Clothing for the Premature. 
1. Flannel band. 
2. Cape made of all wool best grade flannel (illustration). 
3. Piece of old flannel for a diaper with a small piece of 
absorbent cotton inside to absorb the urine. 
4. Flannel wrapping blanket 36 inches square. 
5. Comfort filled with lamb’s wool and protected by an outing 
flannel cover made like a pillow case. 
Clothing 
The baby is dressed in the band which is put on in the 
regular way, the flannel diaper, and the cape which is adjusted 
by the string in the hood and pinned snugly around his 
shoulders. The wrapping blanket is placed under him and is 
brought up over his head and body, leaving only his face 
exposed. A thermometer (bath) is hung inside the basket on 
the same level as the baby; this is to record the temperature of 
the basket which usually has to be between 70° F. and 80° F. 
Temperature 
of Basket Figure 17. Flannel Cape for Premature Baby 
120 THE PREMATURE BABY 
121 
The bath thermometer to record the basket temperature may 
be placed over the baby between his cape and the first wrap- 
ping blanket; here the temperature should be 80° F. to 90° F. 
With both methods it varies with the individual baby; it also 
varies with the same baby as he becomes older and becomes 
better established. It has to be worked out for a new baby, 
the problem being to keep the inside of the basket at the 
temperature which will cause him to have a body heat of 
98.6° to 99° F. This is recorded on the chart with the 
premature’s temperature every 4 hours. This basket tem- 
perature is maintained by the use of as many hot water 
bottles as are necessary. It is advisable to start with 3, at 
115° F. (never warmer), protected by covers. These are 
put one at the feet and one at either side of him outside the 
wrapping blanket. If the bath thermometer is placed in the 
blankets around the child, be sure that the end of it is not 
near a hot water bottle. The wool comfort is spread over all, 
baby and bottles, and is tucked in. The hot water bottles are 
filled as often as necessary; start by refilling one every hour. 
It may be necessary to change them more often and maybe not 
so often. Every baby’s needs have to be determined indi- 
vidually. 
The premature’s temperature should be 98° F. to 99° F.; it 
is difficult to keep it even as his heat regulating centers are 
very unstable and he quickly responds to slight variations of 
the surrounding temperature. His temperature is taken and 
recorded every 4 hours, never oftener, as he should be handled 
and exposed as little as possible; he is not taken from the 
basket to have this done. 
He is observed every few minutes to see that he is not 
cyanotic. It may be necessary to remove him from the basket 
to resuscitate him. If possible give him artificial respirations 
while he is in the basket. 
He is cleaned daily with warm oil, never water, following 
the routine for oiling given under the care of the newborn 
(Chapter VII). Individual equipment is used; he is oiled 
Hot Water 
Bottles 
Temperature 
Watch for 
Cyanosis and 
Irregular 
Respirations 
Daily Bath 122 
PEDIATRIC NURSING 
without being removed from his basket, here again endeavour- 
ing to expose him as little as possible. The nurse’s hands must 
be warm when she cares for him. All clothes must be warmed 
before they are put on him. His diaper is changed every 4 
hours (at the time his temperature is taken) and his buttocks 
are cleaned with warm oil. He is changed in his basket. He is 
weighed daily; this is the only time in the 24 hours that he is 
taken out of his basket. In the morning before giving him 
his oil bath, the scales are balanced, a clean towel is placed on 
them, and the baby in his soiled clothes is put on them and is 
quickly weighed; he is put immediately into his basket and 
the weight is computed and is recorded. During the oil bath 
the clothes are changed and the soiled ones which he had on 
when he wras weighed are weighed and their weight is sub- 
tracted from the total. 
The premature may be fed by one of several methods: 
Daily Weight 
Method of 
Feeding 
1. By gavage. 
2. With a medicine dropper. 
3. With a Breck feeder. 
4. With a spoon. 
The last three are more commonly utilized but are difficult 
to use, particularly in the younger premature who has little 
or no swallowing reflex. Gavage is quick and accurate, uses 
none of the baby’s energy, and is attended by even less 
retching and vomiting than the other methods. The gag reflex 
is so little developed that he will often not waken when the 
tube is being passed. For this reason all prematures at the 
University Hospital, University of Minnesota, are routinely 
fed by gavage. (See directions for gavaging, use of medicine 
dropper, and Breck feeder, Chapter XIX.) A No. 8 to No. 10 
French catheter is used for the gavage; it is inserted 3 to 5 
inches. A Nelaton catheter is advantageous because it is 
marked in centimeters or inches and its position may be 
estimated at all times. (See note 4.) Breast milk is the only 
food that can be given a premature with safety; it is abso- 
Gavage 
Breast Milk 
a Necessity THE PREMATURE BABY 
123 
lutely necessary for him if he is to survive. Food is generally 
first ordered at the end of 12 to 24 hours after birth; the 
amount depends on his size, usually 5 or 10 c.c. every 4 
hours (Dr. J. P. Sedgwick, Minneapolis) ; it may be diluted 
half with water. At the beginning no attempt is made 
to fulfill his caloric needs but the amount is increased as 
rapidly as his condition will allow. Vomiting is the first sign 
that his tolerance has been exceeded. Ordinarily it may be 
increased 5 c.c. every day or every other day until he is 
having a sufficient number of calories per kilo to fulfill his 
needs. The premature needs more calories per kilo than the 
normal baby; in most cases 120 to 150 are needed to make 
him gain steadily. It may be 10 days to 2 weeks before his 
food can be increased to the required amount. Therefore he 
cannot he expected to gain as soon or as rapidly as the normal 
baby. He usually loses more in proportion to his weight, is 
slower in regaining his birth weight and in starting to gain. 
If he has regained his original weight at the end of 3 weeks he 
is doing as well as can be expected. Water may be ordered 
halfway between feedings; this is always best given by gavage. 
Only water is usually ordered for the first 12 to 24 hours. 
The premature baby must be turned from one side to the 
other every 4 hours after he is fed, as the normal baby is, for 
he lies so quietly and moves so little that his head may grow 
very narrow from lying constantly on one side. He should 
also be made to lie on the back of his head part of the time 
every day. He will not do this unless he is propped in this 
position; 2 pads of cotton can be made and put on either side 
of his head to hold it in this position for a few hours daily. 
According to the above routine the premature ’s temperature 
is taken and he is changed and fed every 4 hours. Everything 
is done for him at one time, then he is left alone until the 
next time they are due. He sleeps in the interval, seldom 
waking or crying. 
The premature is nearly always ready to come out of his 
basket and receive normal care about the time the mother was 
Caloric 
Needs 
Water 
Turn 
Frequently 
Daily Routine 
When to 
Discontinue 
Premature 
Care 124 
PEDIATRIC NURSING 
due to have been delivered if the baby had not been born 
prematurely. For example, if he were born at 7 months, he 
will be ready to come out of his basket in 2 or 2% months 
provided his gain has been satisfactory and his temperature 
has remained stable for at least 2 weeks. As he grows older 
he will not need 3 hot water bottles, and these may be taken 
away one at a time as his temperature permits, until there are 
none left. Also he will be able to suck a nipple and he may be 
accustomed to it by giving him one feeding a day with the 
nursing bottle and gradually increasing until he uses it en- 
tirely. Experience has proved (University Hospital, Uni- 
versity of Minnesota) that little difficulty is met in teaching a 
baby to nurse or suck a bottle when the gavage is omitted, 
even when it has been used for several months. 
The premature’s mother should express her milk according 
to routine after delivery (see Chapter X), that is, every 4 
hours, starting as soon as the milk comes and the engorgement 
is over. This milk may be fed her baby by gavage. When she 
is able to be discharged from the hospital, she may go home 
and send in daily her expressed breast milk to the baby. She 
should receive full instructions regarding the technique of 
expressing regularly every 4 hours, the care of her hands, the 
care of her breasts, the utensils used, and the care of the milk 
(to keep it on ice). When the baby is strong enough to nurse, 
she should come to the hospital once a day at least, and as 
much oftener as possible, to nurse him. If arrangements can 
be made for her to be there at every nursing time it is 
desirable. 
Mother 
Expresses 
Breast Milk CHAPTER IX 
NUTRITION OF INFANTS AND CHILDREN 
A. Proper nutrition is essential for the maintenance of life 
and for the normal growth and development of the child. A 
thorough, accurate knowledge of the principles of nutrition in 
relation to infants and children is the most important branch 
of pediatrics.1 Statistics show us that one-fourth of the 
civilized race die during the first year of life, and that 60 
per cent of the deaths are due to nutritional disturbances, 
while a large proportion of the other 40 per cent is primarily 
dependent upon impairment of the infant’s condition by 
improper feeding.2 
B. Malnutrition3 is the low condition of health and body 
substance often accompanied by disease and for w7hich it 
maintains an open door. It is nature’s danger signal. Any 
child who is 10 per cent underweight for his height and who 
is not gaining at the normal rate is suffering from malnutri- 
tion. The prevalence of malnutrition among children in 
America and other countries is appalling.4 Dr. Wood esti- 
mates that between 15 per cent and 25 per cent of our Ameri- 
can school children are unnecessarily undernourished. It is a 
surprising fact that the children of rich and well-to-do fami- 
lies are quite as defective and underweight as the children of 
the poor. The standard of the children of rural schools has 
been found to be even lower than that of the city schools.5 
Necessity of 
Knowledge of 
Nutrition 
Malnutrition 
Prevalence 
1 Holt, L. Emmett, M.D., ‘ ‘ Diseases of Infancy and Childhood. ’ ’ 
3 Hess, Julius H., M.D., “Principles and Practice of Infant reeding.” 
3 Pearce, N. O., M.D., “Malnutrition, Its Prevalence, Cause, and 
Treatment.” Journal-Lancet, Aug. 15, 1921. 
4Wood, Thomas D., M.D., “War's Emphasis on Health Education.” 
N. Y. Times, April 18, 1918. 
5 Wood, Alice H., Director Elizabeth McCormick Fund of Chicago, 
“Building up the Malnourished Child.” Public Health Nurse, Dec., 
1921. 
125 126 
PEDIATRIC NURSING 
Causes 
The causes of malnutrition as given by Dr. W. R. P. Emerson 
of Boston are: 
1. Lack of home control. 
2. Physical defects, particularly obstruction of the breath- 
ing passages. The removal of these physical defects to make 
the child “free to gain” should precede the work of nutrition 
or health classes. 
3. Overfatigue from lack of sleep or other causes, over- 
stimulation, preparation for classes required after school 
hours, ‘ ‘ movies, ’ ’ and nervous excitement of all kinds. These 
conditions are quite as disastrous in their effect on the children 
of the well-to-do families as are the crowded manner of 
living and the noise of the tenement homes on less fortunate 
children. 
4. Defective feeding. Under this head may be put lack of 
food, improper and faulty food habits, i.e., eating too fast or 
under wrong conditions, eating when overfatigued, etc. 
5. Faulty health habits, for example, insufficient fresh air, 
lack of cleanliness, too little sunshine, or too little playtime 
out-of-doors. 
The treatment of malnutrition consists in finding the cause 
and in eliminating it. As long ago as 1910 Dr. Emerson 
started a nutrition clinic in Boston, and since then nutrition 
or health classes have been established in many other cities. 
Conditions can be remedied only by close cooperation between 
the parents, the school teacher, and the physician, all working 
together for the well-being and interest of the child. 
C. The function of food:6 
1. It furnishes the materials for the growth and repair 
of body tissues. 
2. It furnishes heat and energy by combustion or 
oxidation. 
3. It regulates body processes. 
Food is any material which consists of such elements as can 
be digested and absorbed and thus utilized by the body to 
8 Rose, Mary S., ‘ ‘ Laboratory Hand Book of Dietetics. ’ ’ 
Treatment 
Function 
of Food 
Definition 
of Food NUTRITION OF INFANTS AND CHILDREN 
127 
enter into its structure and growth and to afford energies for 
its activities. The chief elements which food must supply are 
carbon, hydrogen, oxygen, nitrogen, sulphur, phosphorus, iron, 
sodium, potassium, calcium, magnesium, and chlorin. There 
are certain combinations of these elements which are available 
for the welfare of the body. These are: 
1. Protein. 
2. Carbohydrate. 
3. Fat. 
4. Water. 
5. Ash or mineral salts. 
6. Vitamins. (See Note 2.) 
1. Protein contains nitrogen, carbon, hydrogen, oxygen, 
sulphur and phosphorus. It is essential to life because: 
a. It is the only food which contains nitrogen and can 
replace the continuous nitrogenous waste of the 
structures of the body. 
b. It is necessary for cell growth. 
c. It furnishes fuel for part of the dynamic loss. The 
most easily digested form of protein is that supplied 
by milk; the protein of mother’s milk supplies the 
needs of the infant and that of cow’s milk is readily 
digested later on in childhood. 
2. Carbohydrates are composed of carbon, hydrogen, and 
oxygen and are found in compounds known as starches and 
sugars. These cannot replace the nitrogenous waste of the 
body since they are devoid of nitrogen, but they are efficient 
sparers of protein. 
a. They are the most important sources of energy. 
b. They are stored in the liver and muscles as glycogen. 
c. They are partly converted into fat and deposited in 
the subcutaneous tissues, thus causing increase in 
weight. 
3. Fats are composed of carbon, hydrogen, and oxygen. 
a. They may be termed the storehouse of energy. 
b. They help to regulate the body temperature. 
Composition 
Protein 
Composition 
Function 
Carbohydrate 
Composition 
Function 
Fat 
Composition 
Function 128 
PEDIATRIC NURSING 
c. They save the nitrogenous waste and increase the body 
weight. 
4. Water is composed of hydrogen and oxygen. It is 
present in varying amounts in all food materials with the 
exception of a few fats, starches, and sugars. All cells need 
water. 
a. It is necessary for the solution of certain parts of food 
such as sugars, salts, and some of the proteins, and 
for the suspension of other proteins and emulsi- 
fied fat.. 
b. It carries nutritious material into the blood, lymph- 
cells, etc. 
c. It is needed for the elimination of waste products and 
of toxins from the lungs, skin, and kidneys. 
5. The chief mineral salts are compounds of sulphur, phos- 
phorus, chlorin, sodium, potassium, calcium, magnesium, and 
iron. 
a. They are required for growth and normal cell activity. 
b. They are necessary in digestion, and in every step of 
metabolism from absorption to excretion and secre- 
tion. As a rule they are present in sufficient 
amounts in the usual articles of food. 
6. Vitamin (see note 2) is the term applied to those 
accessory food substances whose presence is essential to growth 
and maintenance of normal nutrition. (Term “vitamin” 
coined by Dr. Funk.) Their chemical composition in indefi- 
nite, but it seems probable that they contain basic nitrogen. 
Their mode of action is unknown, but they are of such 
importance that their absence produces definite symptoms and 
the development of certain “deficiency diseases,” as, for ex- 
ample, scurvy and beriberi. There are at least three known 
types of vitamins occurring in different foods.7 They are 
found chiefly in natural foods such as seeds, leaves, tubers, 
edible roots, fruits of plants, fruit juices, animal tissues, such 
Water 
Composition 
Function 
Salts 
Composition 
Function 
Vitamin 
Definition 
Composition 
Function 
7 Hess, Alfred H., M.D., “Newer Aspects of Some Nutritional Dis- 
orders.” Jovrn. Am. Med. Assn., March 12, 1921. NUTRITION OF INFANTS AND CHILDREN 
129 
as muscles and glandular organs, likewise in milk, human 
milk included, butter, eggs, and cheese. Yeast also is rich in 
vitamins.8 
D. It is customary to express the energy value of food in 
heat units or calories. A large calorie is that amount of heat 
energy required to raise 1 liter of water from 0° C. to 1°C.9 
Heat is produced by chemical action, friction, mechanical 
movement, in the utilization of food by the animal organism, 
and by the oxidation of protein, fat, and carbohydrate. It has 
been determined by experiments carried out under properly 
controlled conditions just how much heat is produced by the 
combustion of practically all food substances. 
1 gram of fat yields 9.3 calories. 
1 gram of carbohydrate yields 4.1 calories. 
1 gram of protein yields 4.1 calories. 
The term metabolism covers all the functions of the body which 
have to do with the preparation for and the assimilation of 
food. (See note 2.) 
E. In calculating the total caloric requirement of children 
there must be taken into account:10 
1. Basal metabolism requirement, 
2. Growth needs. 
3. Needs for muscular activity. 
4. Food values lost in excreta. 
1. The basal metabolism of children is higher and more 
intense than that of adults. They, therefore, require food in 
higher proportion to the body weight than the adult. The 
basal requirements (Benedict and Talbot) are highest per kilo 
at about 9 months, and steadily fall from this time up to adult 
life. They are fairly uniform in children of the same weight. 
Calorie 
To Calculate 
Caloric 
Requirements 
of Children 
Basal 
Metabolism 
8 McCollum, E. V., 1 ‘ Part Played in Diet by Food Substances of Un- 
known Chemical Nature,” “Oxford Medicine.” 
8 Bayliss, Professor W. M., ‘ ‘ Physiology of Nutrition. ’ ’ Practitioner. 
July, 1919. 
10 Holt, L. Emmett, M.D., Fales, Helen, ‘ ‘ Food Requirements of Chil- 
dren; I. Total Caloric Requirements.” Am. J. Pis. Child., Jan., 1921. 130 
PEDIATRIC NURSING 
Process of 
Growth 
2. Children are in the process of growth; their bodies are 
daily increasing in size; they demand additional quantities of 
all types of foodstuffs for use in the formation of the increas- 
ing mass of tissue. Since protein contains nitrogen which is 
essential for growth, it is a most necessary part of children’s 
diets.11 The variation of this growth rate is fairly uniform in 
all children. The requirements for growth are greatest during 
the periods when growth is most active, namely, during the 
first year and during adolescence. They are nearly uniform 
from 6 to 12 years. 
3. The muscular activity of children is greater than that 
of adults so the energy requirements are also greater. 
Muscular activity, however, varies enormously with different 
children, but, in general, tends to increase from birth to 
puberty. 
4. The caloric value of foodstuff lost in excreta is subject to 
very little variation in healthy children of the same age living 
under similar conditions. 
F. Caloric requirement of children who are underweight 
is greater per kilo than is that of those who are of average 
weight according to their ages. Children who are overweight 
require fewer calories per kilo. Caloric needs are greatest 
during the periods of greatest growth, during the first year 
and during adolescence. During the latter period more 
calories are required than for an adult. As the growth needs 
end, the calories are reduced to the adult standard. 
Muscular 
Activity 
Foodstuff 
liost in 
Excreta 
Caloric 
Requirements 
of Children 
Following is a table of caloric needs (see note 2): 
Table of 
Calorie Heeds 
Age 
Calories per kilo 
Average infant wilder 2 months of age, 
... 65 to 
100 
Average infant over 2 months of age 
100 to 
120 
Premature infant and thin infant under 2 months... 
... 110. to 
140 
Thin infant over 2 months depending on general 
condition 
... 120 to 
150 
6 months to 12 months 
... 100 
12 months to 24 months 
.. . 90 
11 Holt, L. Emmett, M.D., Fales, Helen, * * Food Requirements of Chil- 
dren; II. Protein Requirements.” Am. J. Dis. Child., Oct., 1921. NUTRITION OF INFANTS AND CHILDREN 
131 
Boys (See note 10.) 
6 years until after growth is complete 
80 
After growth is complete (usually 15 years) 
48 
Girls 
6 years 
76 
10 years 
80 
After growth is complete (usually 15 years) 
44 
Carter, Howe and Mason—Nutrition and Clinical Dietetics. 
Locke, Edwin A., A.M., M.D.—Food Values. 
Lusk, Graham—Fundamental Basis of Nutrition. 
Roberts, Lydia—What Is Malnutrition? U. S. Dep’t of Labor, 
Children’s Bureau. 
READING REFERENCES CHAPTER X 
MATERNAL NURSING 
Importance 
of Maternal 
Nursing 
Maternal nursing should be the keystone of propaganda for 
the prevention of infant mortality and for the foundation of 
good health.1 Breast milk, one of the most precious of sub- 
stances, is the only natural and ideal food for infants.2 It 
contains all the necessary food elements in the proportion best 
suited to them and their developing digestive organs. Sta- 
tistics show that during the first year of life the mortality of 
artificially fed babies is six times greater than that of breast 
fed babies, 80 per cent of infantile deaths occurring among the 
former. The morbidity also of artificially fed babies in 
infancy and in later childhood is many times greater than that 
of breast fed babies. Breast milk confers a certain degree of 
immunity to disease from the mother to the child.3 Therefore 
it is every infant’s right to have breast milk, and it is every 
mother’s duty and privilege to nurse her baby. Authorities 
as Jacobi, Sedgwick, Griffith, and others claim that there is 
no such condition as agalactia, and that at least 95 per cent of 
mothers are able to nurse their babies if they are given proper 
prenatal care and supervision and instruction after delivery. 
A. Some contra-indications to nursing are (see note 3) : 
1. Open tuberculosis in the mother is a contra-indication to 
nursing, because of the danger of infecting the child. If 
breast milk cannot be obtained for him from other sources, the 
mother may express her milk and it can be boiled and fed 
to him. 
2. Any grave constitutional disease in a mother, such as 
Some Contra- 
indications 
to Nursing 
1 Sedgwick, J. P., M.D., “Maternal Nursing.” 
2Holt, L. Emmett, M.D., “Diseases of Infancy and Childhood.” 
3Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” 
132 MATERNAL NURSING 
133 
chronic heart disease, insanity, etc., may demand weaning the 
baby. 
3. a. An acute communicable disease, as scarlet fever, diph- 
theria, typhoid, etc., does not indicate weaning. For a time 
there may not be enough milk and then the temporary addition 
of some milk mixture may be necessary, but the mother’s 
breasts should be stimulated by regular manual expression, 
then, after the acute stage of the disease is over, the baby 
should continue nursing. 
b. If the mother has an upper respiratory infection and 
she is otherwise in good condition, she may continue to nurse 
the baby, but she should wear a mask over her nose and mouth 
while doing so. 
4. Menstruation occurring during lactation is not an indi- 
cation for weaning. 
5. Another pregnancy occurring during lactation usually 
demands weaning, but not necessarily at once if the mother 
and the baby at breast are thriving. 
6. If the mother has mastitis the baby may continue to 
nurse unless he actually draws pus from the nipple, and if the 
abscess is located so that the baby does not come in direct 
contact with it thereby becoming infected by it. In case of 
either of the above conditions the milk should be expressed, 
boiled, and given him from a nursing bottle. 
B. Composition of breast milk: 
The secretion of the first few days of lactation is called 
colostrum. It is less sweet in taste than the later milk and its 
proportions are different. It has a very high content of pro- 
tective antibodies, an even greater proportion than the later 
breast milk. (See note 2.) 
Composition 
of Breast 
Milk 
Colostrum 
Average composition of colostrum 
Fat 2.38% 
Carbohydrate 3.38% 
Protein 8.60% 
Ash 0.37% 
Water 85.27% 
100.00% 134 
PEDIATRIC NURSING 
The composition of colostrum gradually changes, until by the 
end of 5 or 10 days it has assumed the character of normal 
breast milk, which is of a bluish white color, odorless, and 
sweet in taste. (See note 2.) 
Breast Milk 
Average composition of breast milk 
Fat 3.5 % 
Carbohydrate 7.5 % 
Protein 1.25% 
Ash 2 % 
Water 87.55% 
100.00% 
In addition to the above composition, breast milk contains 
immunizing bodies which are contained in the mother’s blood 
and are transmitted to the baby through her milk. They are of 
value for protecting the infant against infections. (See 
note 3.) 
C. Both the quality and quantity of breast milk of different 
women vary greatly. Also the breast milk of an individual 
woman varies considerably at different times during the 24 
hours as well as at different periods of every nursing. The 
quantity secreted by the breast during the first few days of 
an infant’s life is very small. On the first day 10 to 20 c.c. of 
colostrum are secreted, and on the second day 80 to 100 c.c. 
The amount gradually increases. 
Quantity of 
Breast Milk 
Average daily quantity of breast milk, 
At end of 1st week 300 to 500 e.c. 
During 2d week 400 to 550 c.c. 
During 3d week 430 to 720 c.c. 
During 4th week 500 to 800 c.c. 
From 5th to 13th week 600 to 1030 c.c. 
From 4th to 6th month 720 to 1150 c.c. 
From 6th to 9th month 900 to 1220 c.c. 
Hygiene of 
Nursing 
Mother 
D. Hygiene of the nursing mother : 
Nursing should not be made a burden to the mother. It is a 
normal function and she should be permitted to carry it out 
along natural lines. (See notes 1 and 3.) MATERNAL NURSING 
135 
1. Diet (see notes 1 and 3) : 
A nursing mother need not restrict her diet. She should 
have a well balanced diet of plain nutritious food, eating the 
same kinds of food to which she has been accustomed before 
lactation, and the same food that it is proper for any woman to 
eat. There should be an increase in the amount taken, and a 
reasonable addition of fluids to accommodate the loss made by 
the milk.4 (See note 1.) 
2. Bowel function. 
The nursing mother should have one free evacuation of the 
bowels daily. (See note 3.) 
3. Outdoor exercise, work, and sleep (see note 3) : 
The nursing mother may do a reasonable amount of light 
work daily, being careful not to become overfatigued. She 
should spend 3 to 4 hours daily in the open air in mild exer- 
cise. She should sleep at least 8 hours out of the 24, and a nap 
of 1 or 2 hours during the day is advisable. 
4. A nursing mother should avoid worry or excitement, for 
a tranquil mind is an important factor in maintaining suffi- 
cient breast milk. (See note 3.) Anger, fright, worry, shock, 
sorrow, etc., may have a striking effect on the quantity and 
quality of her milk. 
5. The mother should observe absolute regularity in all 
things and especially in nursing the baby. 
6. She should be temperate in all things. 
E. Care of the breasts: 
1. The mother’s breasts should be sponged before and after 
nursing with sterile water 100° F., and should be wiped 
dry. A breast support may be applied loosely.5 This is 
only a support and to hold sterile gauze squares in place over 
the nipples. A breast tray is desirable, especially in a 
hospital. 
Bowel 
Function 
Exercise 
Work 
Sleep 
Worry 
Excitement 
Regularity 
of Habits 
Care of 
Breasts 
Breast Tray 
4Shannon, Ray, M.D., "Demonstration of Food Proteins in Human 
Milk by Anaphylactic Experiments on Guinea Pigs.” Am. J. Dis. 
Child., Sept., 1921. 
5 Larman, C. L., M.D., ‘ ‘ Heavy Breasts as a Factor in the Production 
of Faulty Posture.” Journ, Am. Med. Assn., Jan. 21, 1922, 136 
PEDIATRIC NURSING 
2. It should contain: 
a. Basin of warm sterile water. 
b. Jar of sterile cotton pledgets. 
c. Handling forceps in 5 per cent lysol solution. 
d. Kidney basin or paper sack. 
e. Jar of sterile gauze squares (3 inches square). 
To Sponge 
Breasts 
3. To sponge the breasts, remove a cotton pledget from the 
jar with the sterile forceps, dip it in the jar of water and 
sponge the breast with it, beginning at the end of the nipple 
and sponging away from it and down over the breast. Wipe 
the breast dry with another sponge. After the baby nurses, 
sponge the breasts again and wipe them dry, putting a sterile 
gauze square over each nipple and fastening the breast support 
loosely around them. 
4. If the nipples are cracked or fissured so that the nursing 
is painful for the mother, a shield may help. (Slemon’s 
nipple shield is best—Dr. J. C. Litzenberg.) To use this, fill 
it with expressed milk or warm water and place it over the 
mother’s nipple. There will thus be less difficulty in making 
the baby nurse through it. The shield is undesirable because 
(1) it makes it more difficult for the baby to obtain sufficient 
milk and because (2) the breasts are not sufficiently stimu- 
lated when it is used. It is generally used only for the first 
few minutes of the nursing period until the flow is well 
started. The baby can then nurse directly from the breast 
without causing too much discomfort to the mother. If a 
nipple is cracked so that it bleeds and the baby obtains blood 
with the breast milk, it may make him vomit; then nursing 
from that breast may be discontinued temporarily. It should 
be thoroughly emptied by manual expression at regular inter- 
vals, since this does not cause the pain which the baby’s 
nursing does. The child may continue to nurse from the other 
breast until the fissures are healed, which takes only a day or 
two. A metallic or a lead nipple shield worn over a cracked 
nipple between nursings may give relief. Various medica- 
Cracked 
Nipples 
Nipple Shield 
Lead Nipple 
Shield MATERNAL NURSING 
137 
tions may also be used. Balsam of Peru and castor oil in 
equal parts have been found beneficial. Cracks are sometimes 
touched up with silver nitrate. (Dr. J. C. Litzenberg.) 
5. Inverted nipples cause great difficulty in nursing. 
Proper prenatal supervision may help if the mother is in- 
structed to draw them out by manipulation before delivery. 
During the last three months of pregnancy she may be 
instructed to thoroughly -wash her hands and, using sterile 
olive oil or cocoa butter, to gently massage the nipple to draw 
it out. A breast must not be massaged; there is never any 
indication for it. Ice-caps are given for relief for engorged 
breasts. A nipple shield will also help, but it cannot be used 
over a long period of time. Usually a robust baby who nurses 
vigorously -will draw out the nipple very soon. (Dr. J. C. 
Litzenberg.) 
F. Technique of nursing: 
1. Position: When the mother is in bed, she should lie on 
the side from which the baby is to nurse with her arm under 
her head and not under the baby’s neck. He should be flat 
on the bed on his side and on a level with the breast from 
which he is to nurse. The mother should see that her breast 
does not come against his nose, as a large breast will often 
obstruct the child’s respirations and wrill cause difficult nurs- 
ing. She should be quiet and composed during the nursing 
period. The baby will react to nervousness or excitement, 
often refusing to nurse for no other reason. When the mother 
is sitting up, the child’s head may rest on her knee, which 
is raised by the use of a foot stool. She supports his neck and 
body with her arm and he nurses from the pendulous breast 
of the same side.6 If milk comes too rapidly this way, the 
baby may be held higher on the mother’s arm so that he is on 
a level with her breast. If a normal baby regurgitates after 
nursing, it is often caused by his belching gas. To avoid 
this instruct the mother to hold him up over her shoulder and 
Inverted 
Nipples 
Technique 
of Nursing 
Position 
When Mother 
Is in Bed 
Wien Mother 
Is Sitting Up 
6 Grulee, C. G., M.D., ‘ ‘ Infant Feeding. ’ ’ 138 
PEDIATRIC NURSING 
gently pat him on the back until he belches gas, for when 
he is in an upright position he can do this without causing 
regurgitation. 
2. The first nursing: The normal new baby may go to 
breast 6 or 8 hours after delivery so that he may learn to nurse 
and so that his sucking may stimulate the secretion of milk. 
The First 
Nursing 
Figure 18. Proper Position for Breast Nursing with Mother in 
Recumbent Position 
(From Grulee’s “Infant Feeding,” Courtesy of W. B. Saunders Co.) 
For the first few days he obtains nothing but colostrum in 
very small amounts. Some authorities claim that this is 
wholly insufficient to supply the needs of the child. Addi- 
tional foods may sometimes be ordered during this period to 
prevent (1) too great loss of weight, and (2) dehydration 
Additional 
Food before 
Breast Milk 
Comes MATERNAL NURSING 
139 
from lack of food or fluids, which will in turn cause elevation 
of temperature known as “inanition fever.” A 5 per cent 
sugar solution is also ordered at times by some authorities. 
AVarm sterile water should be given freely during the time 
before the milk comes. As much as 30 c.c. may be given every 
4 hours during the first day, 60 c.c. the second, and 90 c.c. the 
third. The newborn baby does not begin to show signs of 
hunger for about 48 hours. 
3. Regularity in nursing is essential: The fundamental re- 
quirement for stimulation and continuation of milk flow is the 
complete and regularly repeated evacuation of the breasts. 
(Dr. J. P. Sedgwick.) The interval between feedings should 
be determined at once and the baby should be awakened to 
be fed until he has learned regular habits, then he will usually 
be awake at nursing time. 
4. Rotation of the breasts: After the milk supply is estab- 
lished and the baby obtains sufficient milk from one breast at 
a time, he is usually nursed alternately, first at one breast, 
then at the other. If the milk supply is scanty, he may be 
nursed at both breasts every time. Then if they are thor- 
oughly emptied by manual expression after he nurses, they 
will be stimulated to secrete more. If the baby does nurse 
both breasts every time, nursing should be started at alternate 
breasts, because he does his most vigorous nursing during 
the first 5 minutes. 
5. Length of the nursing period: A normal baby takes 
from y2 to % of the milk obtained at a nursing during the 
first 5 minutes at breast. The maximum time for a nursing 
period should be no more than 15 or 20 minutes. He may 
obtain sufficient milk in less time than that. If he is nursing 
both breasts divide the time between them. Do not allow him 
to go to sleep at the breast; if he falls asleep, awaken him. 
6. Intervals between feedings: Experience at the University 
of Minnesota has been that the normal newborn thrives if fed 
at intervals of 4 hours, 5 feedings in 24 hours, i.e., 6 a.m., 
10 a.m., 2 p.m., 6 p.m., and 10 p.m. The 2 a.m. feeding is ad- 
Regularity 
in Nursing 
notation 
of Breasts 
Length of 
Nursing 
Period 
Interval 
■between 
Feedings 140 
PEDIATRIC NURSING 
vised for 2 or 3 months, especially if the baby is at all under- 
weight. The 4-hour interval between feedings is desirable 
because it gives the mother more freedom and prevents much 
of the regurgitating of the baby by allowing his stomach more 
time to rest between feedings. However, many authorities 
advise feeding the new baby much oftener, every 2y2 to 3 
hours. 
7. Amount of milk taken at a feeding: To determine the 
amount of breast milk the baby takes at a nursing period, 
weigh him before and after nursing. To do this, prepare him 
for nursing, see that his diaper is dry, and weigh him with 
all his clothes on. Record the weight and after he has nursed 
weigh him again, changing no part of his clothing even if he 
has urinated or defecated. The difference in grams between 
the two weights is the amount the baby obtained. It oc- 
casionally happens that he weighs 5 to 10 grams less at the 
second weighing than at the first. This means that he obtained 
nothing at breast and that the loss of weight was due to the 
energy used in the sucking. 
G. Water should be given the normal baby even if he has 
sufficient breast milk. Warm sterile water is used and should 
be given from a nursing bottle 2 or 3 times daily between 
feedings. It is very essential that all babies have extra 
water during hot weather. 
H. Complemental feeding is the administration of milk 
from a nursing bottle following the nursing from the breast. 
Supplemental feeding is the substitution of a bottle for a 
breast feeding. (See note 3.) Since we know that the breast 
secretes in proportion to its stimulation, the complemental 
feeding is far more satisfactory, for the baby nurses most 
vigorously during the first of the nursing period, and that 
is the time he stimulates the breasts most. Complemental 
feeding is given only when there is not sufficient breast milk 
to fulfill the baby’s needs after he has nursed both breasts. 
Weigh him before and after nursing, then estimate the amount 
of complemental feeding necessary. The modified milk given 
To Determine 
Amount of 
Breast Milk 
Obtained 
Additional 
Water 
between 
Feedings 
Complemental 
and 
Supplemental 
Feeding MATERNAL NURSING 
141 
should be of a strength which is suitable for the average child 
of the same age. (See Artificial Feeding, Chapter XI.) In 
beginning the use of cow’s milk, however, a lower strength 
must be used than the child will require for growth, and then 
it is gradually increased to the desired strength, thus ac- 
customing him to cow’s milk. If a bottle feeding is given 
directly after the breast, it is always best to use a nipple from 
which milk comes with difficulty, or the baby will quickly 
learn that he can obtain food from the bottle with less effort 
and will refuse to take the breast because the milk comes 
harder. Supplemental feedings are used when it is desirable 
to wean the baby. The premature baby is generally too weak 
to nurse and the effort of sucking uses up too much of his 
vitality. The mother is taught to express both her breasts 
regularly every 4 hours, and the expressed milk is given the 
small baby by gavage. By this complete and regular evacua- 
tion of the breasts they are stimulated and a mother may keep 
her breast milk supply over an indefinite period. 
1. We are told that the fundamental requirement for the 
stimulation and for the continuation of the milk flow is the 
complete and regularly repeated evacuation of the breasts.7 
Therefore manual expression of the breasts by completely 
emptying them will stimulate them to secrete more. To 
express a mother’s breast, the breast should be washed, and 
the nurse’s hands scrubbed thoroughly.8 With the left hand 
a sterile bowl or graduate is held under the breast to be 
expressed, the breast grasped gently but firmly between the 
thumb of the right hand, placed in front, and the remainder 
of the fingers on the under surface of the breast. The thumb 
in front and the first finger beneath should rest just outside 
of the pigmented area of the breast. 
2. A downward pressing motion is made with the thumb 
on the front against the fingers on the back of the breast, 
Manual 
Expression of 
Breast Milk 
Purpose 
Technique 
’Sedgwick, J. Pv M.D., “Establishment, Maintenance, and Keinstitu- 
tion of Breast Feeding.” 
8 ‘ ‘ Breast Feeding. ” U. S. Department of Labor, Children’s Bureau. 142 
PEDIATRIC NURSING 
and the thumb in front and the fingers behind are carried 
downward to the base of the nipple. 
Figure 19. Method of Expressing Breast Milk 
3. This second act should end with a slight forward pull 
with gentle pressure at the back of the nipple, which causes 
the milk to flow out. The combination of these three down- MATERNAL NURSING 
143 
ward movements may be described as “back-down-out.” It 
is not necessary to touch the nipple. This act can be repeated 
30 to 60 times a minute after some practice. 
The baby with an unoperated congenital cleft of lip or 
palate often cannot suck, and the mother can express her 
milk and give it to him by gavage, a spoon, a Breck feeder, 
etc. After operation it is given to him by gavage. Also it is 
occasionally necessary or convenient for the mother to be 
absent at a nursing period. She can express her milk and in 
her absence it can be fed from a nursing bottle at the regular 
time. This makes nursing less of a burden by allowing the 
mother more freedom. If a breast fed baby is admitted to a 
hospital and it is not possible for the mother to be on hand to 
nurse him, she may empty her breasts by expression every 4 
hours at home, keep the milk on ice, and once every 24 hours 
bring it to the hospital for the baby. If possible it is desir- 
able that he should nurse the breast at least once in 24 hours. 
J. Wet nursing is the best substitute for maternal nursing, 
but it presents many difficulties and is often unpractical. 
1. Qualifications of a wet nurse (see note 3) : 
a. She should be in good health and free from tuberculosis, 
syphilis, or other chronic diseases. The baby whom she is 
to nurse must also be free from syphilis because a syphilitic 
baby may infect the woman who nurses it. 
b. She should have sufficient milk for her own baby and 
for another one. This may be determined by weighing her 
baby before and after nursing for 24 hours, and by expressing 
her breasts after nursing. She may either nurse the baby 
directly at her breast or express her milk and then feed it to 
him. 
c. Preferably she should be between 18 and 25 years of age. 
d. The age of her baby compared with the age of the baby 
she is to nurse is insignificant. 
2. To procure a wet nurse is often very difficult. Some 
children’s hospitals, in order to always have the necessary 
breast milk for their sick babies, employ wet nurses, boarding 
Wet Nursing 
Qualifications 
of Wet Nurse 
To Procure 
a Wet Nurse 144 
PEDIATRIC NURSING 
them and their babies. (This is done at the St. Louis Chil- 
dren’s Hospital and at Sara Morris Hospital, Chicago.) Bos- 
ton has a wet nurse directory where women who are willing 
and who are able to qualify to act as wet nurses are regis- 
tered.9 They are then sent out to any one desiring their 
services. Infant welfare societies and social service organiza- 
tions in various localities are always very cooperative in help- 
ing to obtain wet nurses, or to procure milk from them. The 
usual price of breast milk is ten cents an ounce. In any in- 
stance where it is impossible to obtain a regular wet nurse, 
breast milk may be expressed from the breasts of several 
women, collected and fed the baby from a nursing bottle. It 
is advisable to sterilize this mixed milk by boiling for two 
minutes.10 
3. Hygiene of the wet nurse should be governed by the same 
rules as those for the nursing mother. 
4. The wet nurse usually nurses her own baby and she may 
or may not nurse the other baby for whom she is to supply the 
milk. If that baby is too weak to suck, she may sometimes 
express her own milk directly into his mouth. When a 
normal baby is nursing vigorously from one breast, milk will 
very often flow from the other breast at the same time. This 
may be allowed to drip into the other baby’s mouth, or the 
breasts may be expressed either before or after her baby has 
nursed and the milk given the other baby by gavage, if 
necessary, or by some other method. This is usually the most 
satisfactory way and also the most advisable, because the 
expressed breast milk can be sterilized before it is fed the 
baby. (See note 3.) 
K. Weaning: The normal breast fed baby, even though he 
is thriving, has additional food starting at 6 or 7 months of 
age. This is to supply sufficient iron and other food elements 
Hygiene of 
Wet Nurse 
To Give Baby 
Milk from 
Wet Nurse 
Weaning 
8 Talbot, F. B., M.D., Journ. Am. Med. Assn., 1911. Vol. lvi. 
p. 1715. 
Talbot, F. B., M.D., Boston Med. and Surg. Journal, 1911. Vol. 
cliv, p. 290. 
10 Morse and Talbot, “Diseases of Nutrition and Infant Feeding.” MATERNAL NURSING 
145 
necessary to growth. The baby fed exclusively on breast milk 
for a year or two often has anemia and shows signs of rickets. 
Weaning, according to the best authorities, is ordinarily 
started in the last quarter of the first year. It is done grad- 
ually and in the following manner: First one breast feeding 
is dropped and supplemented by artificial feeding. Then 
when the breasts have adjusted themselves to this, a second 
one is dropped, and so on until at the end of about 3 weeks all 
breast feedings are given up. This gradual lessening of the 
demand on the breasts decreases their secretion so that there 
is very seldom any difficulty or discomfort caused. A tight 
breast binder may be applied and a saline cathartic may be 
ordered. Weaning should be avoided during extremely hot 
weather if possible. If it can be arranged, it is advisable to 
delay complete weaning until the cooler weather. The arti- 
ficial food given the infant during and after weaning should 
be a weaker mixture at first than that taken by the infant 
of the same age who has been accustomed to cow’s milk. The 
strength can be increased gradually as the child’s tolerance 
develops. (See Chapter XIV, Food for the Child, for list of 
other foods besides milk which are given at this age.) 
READING REFERENCES 
Carlson, Matilda, R.N.—Breast Feeding in Private Practice under 
Ideal Conditions. Arch. Ped., Sept., 1921. 
Lewis and Wells—Function of Colostrum. Journ. Am. Med. Assn., 
Mar. 25, 1922. 
Reiss, Oscar, M.D.—Institution and Maintenance of Breast Feed- 
ing. Arch. Ped., May, 1921. CHAPTER XI 
ARTIFICIAL FEEDING OF INFANTS 
Definition 
Artificial feeding of an infant is the attempt to feed him 
some other food than breast milk. There is no perfect sub- 
stitute for breast milk, singe that is the food nature intended 
for him. Occasionally, however, maternal nursing is impossible 
and a substitute has to be found for the baby. (See Contra- 
indications to Nursing an Infant, Chapter X.) Since wet 
nursing usually proves unpractical, there have been many 
methods and foods employed in attempting a substitute. These 
attempts have been more or less successful in some but not 
in all cases. Therefore, there is no standard artificial food 
for infants. 
The requirements of an artificial food are: 
1. It must furnish the same food constituents as breast 
milk: 
a. In such proportions as can be utilized by the 
infant. 
b. In sufficient quantities to maintain proper nutrition. 
2. It must be clean, pure, and free from harmful bacteria. 
3. It must be reasonably economical. 
Breast milk contains a combination of food elements—fat, 
protein, carbohydrates, salts, and water—best suited to the 
digestive powers of an infant. The artificial food which most 
nearly fulfills these demands is the milk of some mammal. 
Cow’s milk is the most available, although it is by no means 
a perfect substitute, because the food elements contained 
therein differ in quantity and in chemical composition from 
the elements of breast milk. Therefore, cow’s milk has to 
be modified or altered to better meet the requirements of 
Requirements 
Cow’s Milk 
Most Suitable 
Substitute for 
Breast Milk 
146 ARTIFICIAL FEEDING OF INFANTS 
147 
the infant. Goat’s milk is considered advantageous for arti- 
ficial feeding by some authorities, but it is seldom used 
because it is difficult to obtain. 
If we compare cow’s milk and human milk, we find that 
both contain emulsified fats, carbohydrates, proteins, and 
mineral salts in solution, and that the chemical composition 
of both varies. That of cow’s milk depends upon the breed 
and health of the cows, character of their food, period of 
lactation, season of the year, length of interval between milk- 
ings, the portion of milk withdrawn, and other factors. The 
following table from Hess shows some of the differences be- 
tween cow’s milk and mother’s milk:1 
Comparison 
of Human 
Milk and 
Cow’s Milk 
cow’s MILK 
HUMAN MILK 
Amphoteric or acid 
.Eeaction 
. .Amphoteric or alkaline 
1.029 to 1.034 
.Specific gravity. .. . 
. 1.010 to 1.040 
3.5% 
Protein 
. .1.5% to 2.0% 
3.02% 
Caseinogen 
. 0.5% to 0.75% 
0.53% 
Lactalbumin 
. 1.23% 
Clots in large, lumpy curds 
. Effect of rennin. . . 
. Clots in fine curds 
4.0% 
Fat 
. .3.5% to 4.0% 
4.5% 
Lactose 
. .6.0% to 7.0% 
0.75% 
Salts 
. .0.2% 
13% to 14% 
.Total solids 
. .12% to 13% 
86% to 87% 
Water 
. .86% to 87% 
Never sterile 
. Bacterial contents. 
. Practically sterile 
While cow’s milk may be modified to approximate woman’s 
milk in composition, it can never be just the same or as good 
for infants. In appearance it is much more opaque than 
human milk. There is nearly three times as much protein in 
cow’s milk as in human milk. The reason for this is obvious, 
since the ratio of the growth of the calf to that of the infant 
is about as two to one. The protein in cow’s milk is chiefly 
casein (3.02 per cent insoluble protein) and little lactalbumin 
(0.53 per cent soluble protein), while human milk contains 
casein 0.59 per cent and lactalbumin 1.23 per cent. At- 
tempts have been made to make the curd of cow’s milk more 
Appearance 
Protein 
1 Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” 148 
PEDIATRIC NURSING 
nearly resemble that of the mother’s milk in its physical 
properties by: 
1. Boiling. 
2. Citration. 
3. The addition of cereal water. 
Lactose is the principal sugar in both cow’s and human 
milk, but varies greatly in amount in each, cow’s milk contain- 
ing less than human. The average amount of fat in the two 
milks is about the same, but there is a marked difference in 
the emulsion and composition. The fat of cow’s milk con- 
tains a greater proportion of the volatile fatty acids which, 
it is believed, makes it more difficult to digest. The fat 
globules are larger in cow’s milk also. The differences can- 
not be corrected by any known method of modification. The 
salt in the two milks varies both quantitatively and qualita- 
tively. Calcium and magnesium are in greater proportion in 
cow’s milk, while potassium and sodium bases are in relatively 
greater amounts in human milk. These differences have an 
important bearing upon the infant’s metabolism, but thus 
far no definite conclusions have been drawn. Ferments wrhich 
favorably influence the processes of metabolism and anti- 
toxins which render a certain amount of immunity are con- 
tained in milk which can be utilized by the infant only when 
fed upon human milk, for when contained in the milk of other 
species they do not get into the body fluids of infants. The 
importance of these biological differences is still a matter 
of dispute. Human milk is practically sterile when the baby 
receives it, while the cow’s milk is not and often has a high 
bacterial count, Sterilized, pasteurized, and certified milk 
were the practical results of efforts to obtain germ-free milk 
for infant feeding. The milk for artificial feeding of infants 
must come from healthy cows, must be clean, and must be kept 
in a cool place in order to minimize the bacterial count. It 
must be delivered to the consumer as soon as possible in such 
a way as to prevent any contamination; it must be handled 
cleanly and in sterile receptacles in the home; and it must be 
Sugar 
Fat 
Salt 
Ferments 
Antitoxins 
Production 
of Cow’s Milk ARTIFICIAL FEEDING OF INFANTS 
149 
kept cool and must be covered at all times. The cow from 
which the milk is obtained must be healthy, free from tubercu- 
losis and glanders (tuberculin and mallein tests advisable as 
routine), and must pass a general examination. The cow 
must be kept clean in a clean stable which is well ventilated 
and drained. (No dust, manure, or fodder, except that used 
for immediate feeding, should be kept in the stable.) Dry 
feeding is preferable, since the feces are less liquid, and the 
cow can be kept clean more easily. The milking must be done 
in a clean way. The milker must be free from any com- 
municable diseases and of clean habits. The udders of the 
cows and the hands of the milkers should be scrubbed with 
warm water and soap immediately before milking and an 
antiseptic may be applied afterwards. Milking should be 
done in covered cans through a filter. The cans should be 
cleaned immediately after the milk is poured out, first with 
cold and then with hot water, and rinsed again with hot water 
before milking. The first few ounces should be discarded, 
since this milk contains large numbers of bacteria which are 
washed out from the excretory glands. Milk obtained with 
the preceding precautions should be cooled at once in order 
to prevent the growth and multiplication of bacteria which 
have entered the milk despite precaution. This is accomplished 
by a special cooling apparatus or simply by pouring the milk 
into sterilized bottles and closing with a sterilized cap and 
putting on ice. The bottled milk should be kept iced until 
it reaches the consumer, which should not be later than 24 
hours. 
In the home similar precautions should be taken to pre- 
vent contamination, i.e.: 1. Keep the container covered always. 
2. Keep the milk iced until everything is ready for making 
the feeding. Much good milk is spoiled on the doorstep 
of the home between the hour of delivery and the hour of 
placing the milk in the ice-box. All utensils and vessels used 
in the preparation of the mixture must be clean and sterilized 
by boiling. As soon as the mixture is made it should be 
The Cow 
Care of 
the Cow 
Feeding 
of Cow 
The Milking 
Care of the 
Milk before 
Delivery 
Care of 
Milk after 
Delivery 150 
PEDIATRIC NURSING 
covered and put in the ice-box and should be kept there, 
portions being taken out for individual feedings and warmed 
separately before each feeding. 
Milk is responsible for more sickness and deaths than per- 
haps all other foods combined.2 There are several reasons 
for this: 
1. Bacteria grow well in milk, therefore a very slight in- 
fection may produce widespread, serious results. 
2. Of all the foodstuffs milk is the most difficult to ob- 
tain, handle, transport, and deliver in a clean, fresh, and 
satisfactory condition. 
3. It is the most readily decomposable of all foods. 
4. Finally, milk is the only standard article of diet obtained 
from animal sources which is consumed in its raw state. Al- 
though from a public standpoint there are only two kinds of 
milk, good and bad, the following classification is considered 
most practical by the government: A. Certified milk. B. 
Inspected milk. C. Market milk. 
A. The term “certified milk” was coined by Dr. Henry L. 
Coit of Newark, New Jersey, who, in 1892, needing a good 
milk for his own baby, formulated a plan for the production 
of clean, pure, fresh milk, under the auspices of a medical 
milk commission. The term “certified milk,” then, is a milk 
of the highest quality, of uniform composition, obtained by 
clean methods from healthy cows under special supervision 
of a medical milk commission. It should not contain more 
than 10,000 bacteria per cubic centimeter and should not be 
more than thirty-six hours old when delivered. 
B. “Inspected milk” should be limited to clean, fresh 
milk from healthy cows as determined by the tuberculin test 
and physical examination by a qualified veterinarian. The 
cows are to be fed, watered, housed, and milked under good 
conditions, but not necessarily equal to those conditions pre- 
scribed in the production of “certified milk.” Scrupulous 
cleanliness must be exercised and particular care must be 
Dangers from 
Poor Milk 
Certified Milk 
Inspected 
Milk 
2 Rosenau, Milton, ‘ ‘ Preventive Medicine and Hygiene. ’ ’ ARTIFICIAL FEEDING OF INFANTS 
151 
taken that persons having communicable diseases do not come 
into contact with the milk. This milk must be delivered in 
sterilized containers and must be kept at a temperature not 
exceeding 50° F. until it readies the consumer. There should 
not be more than 100,000 bacteria per cubic centimeter in 
“inspected milk.” This milk should be pasteurized. 
C. All milk that is not certified or inspected in accordance 
with the above regulations, and which is of unknown origin, 
is classed as “market milk” and should be pasteurized. 
The breed of cows from which milk comes makes a differ- 
ence. The milk of Ayreshires and Holsteins is more suitable 
than that of Jerseys and Guernseys for infant feeding because 
of the lesser fat content, the finer division of the fat, and the 
lower proportion of volatile fatty acids. It is better also to 
use, if possible, the milk of a herd rather than that of one 
cow, because the mixed milk is more uniform and stable in 
composition and shows less variation. If milk is obtained 
from one cow and she has some disturbance, the composition 
of her milk changes and may upset the baby, while if the 
milk is obtained from a herd, an upset of one or two cows 
will not be felt by the baby because the milk is so diluted. 
On the other hand, it is, or should be, self-evident that the 
milk of a healthy cow properly fed and cared for, taken in 
the proper way and kept under the proper conditions, is 
better than the mixed milk of a herd which is improperly 
fed and whose milk is not carefully obtained nor carefully 
taken care of.3 
Pasteurization of milk consists in heating it to 150° F. 
and retaining it at that temperature for 15 or 20 minutes, 
then rapidly chilling it. (See note 2.) It is the simplest, 
cheapest, least objectionable, and most trustworthy method 
of rendering infected milk safe. Pasteurization, however, 
cannot atone for filth and should not be used as a redemptive 
process. Only certified milk, or milk of an equally high char- 
acter, can be regarded as reasonably safe and satisfactory 
Market Milk 
Breed of Cows 
Mixed Herd 
Pasteuriza- 
tion of Milk 
* Morse and Talbot, ‘ ‘ Diseases of Nutrition, ’ ’ 152 
PEDIATRIC NURSING 
without pasteurization. Less than 1 per cent of all the milk 
found upon the market comes within the honor class. Pas- 
teurized milk must be handled at least as carefully as raw 
milk. It should be kept cool and delivered promptly. Pas- 
teurization is not a substitute for inspection; it is an adjunct 
to inspection. Inspection gives us a cleaner and better, but 
not necessarily a safer milk, while pasteurization eliminates 
the dangers which inspection cannot see. 
Milk is boiled for two reasons: (1) to sterilize it, and (2) to 
make it more easily digestible. European countries, as France 
and Germany, give only boiled milk to their babies. In many 
places in America boiled milk is used exclusively in infant 
feeding. (See note 1.) Dr. Julius Hess of Chicago says: 
“While we do not believe that feeding with boiled milk should 
be advised as a general measure, (1) when it is possible to 
obtain a good certified milk, (2) when the price is not pro- 
hibitive, (3) when it is well digested by the individual infant, 
and (4) when the latter is to be placed in the hands of mothers 
and nurses who can be depended upon to keep the milk 
clean and wholesome through proper icing and handling; we 
do believe that when these requirements cannot be met, it is 
safer, even for well babies, to be fed a thoroughly sterilized 
milk, and that this can be done without danger of scurvy 
and rickets when these feedings are accompanied by the ad- 
ministration of fruit and vegetable juices, nondextrinized 
cereals, and cod liver oil. ’ ’ Most authorities agree that boiled 
milk is easier to digest, especially for the delicate infant or 
for the one with digestive disturbances. 
Pasteurized milk was first recommended for infant feed- 
ings because it was believed that the process of pasteurization 
destroyed the vitamins or antiscorbutic properties less than 
did boiling.4 A recent work by Dr. Alfred Hess of New 
York tells us that the duration of the heating process is of 
greater importance than the degree of temperature to which 
Boiling 
of Milk 
Reasons for 
Pasteurizing 
Milk 
Disadvan- 
tages of 
Pasteuriza- 
tion 
4Hess, Alfred H., M.D., “Newer Aspects of Some Nutritional Dis- 
orders.” Journ. Am. Med. Assn., March 12, 1921. ARTIFICIAL FEEDING OF INFANTS 
153 
the food is subjected and that milk which has been heated to 
the temperature of 145° F. for 30 minutes has lost more of 
its antiscorbutic potency than has milk which has been raised 
to a temperature of 212° F. for a few minutes. 
Milk never boils (reaches 212° F.) in a double boiler. It 
should be put in a saucepan and placed directly over the flame 
and should be boiled for the length of time ordered, being 
stirred constantly to prevent burning. 
To pasteurize milk in the home, put it in the inside of a 
double boiler, fill the outside with cold water to the level of 
the milk inside, place over the flame and bring the milk to a 
temperature of 155° to 167°. Hold it there for 20 to 30 
minutes, remove from the fire, cool at once, put in a sterile 
receptacle, cover and keep on the ice. (See note 1.) There 
are various pasteurizers on the market; the Freeman pasteur- 
izer is convenient, accurate, and easy to handle.5 
Other materials used in infant feeding are: 
(a) Cool sterile water which is used as a diluent for milk 
in the feeding of the very small baby. 
(b) Carbohydrates, which are added to cow’s milk. The 
sugars used are: 
1. Lactose or milk sugar, which is the natural sugar of 
milk and is quite generally used in formulae. It is most 
rapidly broken down in the stomach and is more slowly ab- 
sorbed, staying in the intestines longer, thus favoring the 
growth of intestinal flora. It is slightly laxative. 
2. Saccharose or cane sugar has the great advantage of 
being cheaper than other sugars. In a large proportion of 
cases it does quite as well as lactose or maltose. It is dis- 
tinctly less laxative and ferments more readily in the stomach. 
3. Maltose is very expensive as a pure product, being 
practically unavailable for infant feeding. There are many 
maltose preparations on the market, however, which contain 
varying proportions of dextrin and maltose; their action in 
the bowels varies accordingly, depending on their maltose, 
To Boil Milk 
To 
Pasteurize 
Milk 
Other 
Materials 
Used in 
Infant 
Feeding 
Water 
Carbohydrate 
Lactose 
Saccharose 
Maltose 
B Griffith, J. P. Crozer, M.D., ‘ ‘ Diseases of Infants and Children. ’ * 154 
PEDIATRIC NURSING 
dextrin, and alkaline content. The proprietary foods contain- 
ing a considerable percentage of dextrin in the absence of 
potassium salts are constipating (Horlick’s Malted Milk, 
Mead’s Dextri-maltose No. 1 and No. 2), while those with a 
higher maltose content together with potassium carbonate 
(Borcherdt’s Dry Malt Soup and Mead’s Dextri-maltose No. 
3) or with potassium bicarbonate (Mellin’s Food) are laxa- 
tive. 
(c) Starch in the form of a cooked cereal solution (3 per 
cent to 6 per cent) is used as a diluent in cow’s milk formula 
after the baby is 2 months old. Barley, rice, or oatmeal (in 
a 5 per cent solution) are the cereals most commonly used. 
It is believed that, besides increasing the total carbohydrate 
intake, the starch solution helps prevent the formation of 
large casein curds by mechanical action due to its colloidal 
nature. 
There are many proprietary foods or so-called “Infant 
Foods” or “patent foods” on the market. When consider- 
ing them, we must remember that there are only certain food 
elements, namely: fat, carbohydrate, protein, and mineral 
salts. (See note 3.) There can, therefore, be nothing in these 
proprietary foods except these elements, all of which can be 
put into simple cow’s milk modifications in any form and in 
any amount desired. As a matter of fact, patent foods are 
composed largely of carbohydrates with relatively small 
amounts of fat and protein. The baby fed on such a food 
very often gains weight rapidly at first, but later suffers from 
nutritional disorders as the result of a poorly balanced diet. 
When such proprietary foods are (1) ordered by the physician, 
(2) with definite indications for their use, and (3) definite 
ends in view, and (4) provided they are to be used in connec- 
tion with milk and (5) their composition is definitely known, 
their chief dangers are eliminated. But what is done is exactly 
the opposite in most instances. In the first place, they are 
often prescribed at random or following the directions on the 
can as offering the line of least resistance; in the second place, 
Starch 
Rice 
Barley 
Oatmeal 
Proprietary 
Foods 
Composition ARTIFICIAL FEEDING OF INFANTS 
155 
parents are sometimes lured by the attractive advertisements 
of the manufacturers and the ease with which these foods are 
prepared and attempt to feed their own babies without con- 
sulting a physician, the results often proving unfortunate 6; 
in the third place, breast feeding is thus discouraged when 
it should be encouraged, and, in the fourth place, these foods 
are costly, being much greater in price than ordinary milk 
mixtures. 
Milk is condensed (1) by evaporation through a vacuum, 
condensed (sweetened) milk and evaporated milk, and (2) by 
drying, dry milk powder. The products of the first class 
retain a considerable quantity of their moisture and depend 
upon canning and sterilization for their preservation, while 
milks of the second class are sufficiently dry to keep for long 
periods of time without further sterilization. The sweetened 
condensed milk when diluted with water gives a poorly bal- 
anced diet because, like proprietary foods, it contains a large 
amount of carbohydrate and relatively small amounts of 
fat and protein. Recent experiments lead us to believe that 
the low protein content of diluted condensed milk is one of 
the most important factors in its failure as a food for infants. 
The baby fed on any of this type of milk will grow fat and 
will seem to thrive for a time, but because of the low fat and 
protein content, his growth and development will be seriously 
interfered with, resulting in nutritional diseases and lowered 
resistance. The unsweetened condensed milk or powdered 
milk can be diluted with water so that it contains reasonable 
amounts of protein and fat, and sufficient sugar can be added 
to fill the individual baby’s needs. These mixtures are of 
definite value for temporary use when clean, fresh milk can- 
not be obtained, as in traveling, or in such countries as 
Labrador, where fresh milk is not available.7 
The modification of milk is the adaptation of milk to the 
Condensed 
Milk 
Sweetened 
Condensed 
Milk 
Unsweetened 
Condensed 
Milk 
Modification 
of Milk 
6 Ramsey, W. R., M.D., ‘1 Care and Feeding of Infants and Children. ’ ’ 
7 Burnett, J., “Disadvantages of Dried Milk in Infant Feeding.” 
Practitioner, March, 1921. 156 
PEDIATRIC NURSING 
nutritive requirements of the individual infant.8 In breast 
feeding there is under normal conditions a certain automatic 
adjustment between the amount of food needed and the 
amount supplied. If too much milk is taken the excess is 
disposed of by regurgitating or vomiting or it passes through 
the bowel in partly digested stools; if digestive disturbances 
do occur they are very slight. If insufficient is obtained by 
the baby he demonstrates hunger and ceases to gain weight; 
in this way the mother’s breasts are stimulated to greater 
production. In artificial feeding, simply because the food 
given is not a normal one for the baby, it becomes even more 
important that the requirements of the infant shall be met as 
nearly as can be determined. With any substitute food both 
an excess and a deficiency are more potent for harm than 
with the natural food of the infant. 
There are several methods of modifying milk: 
1. The percentage method of feeding is frequently spoken 
of as the American or Rotch’s method, since Professor Thomas 
Morgan Rotch of Harvard did much to popularize and sys- 
tematize the method. Prom the above comparisons of cow’s 
milk and mother’s milk, we see that the original attempts were 
to make a substitute for human milk from cow’s milk with 
the same percentage of elements. This, of course, is impossible 
because of the difference in chemical composition of the 
various food elements of the two milks. So-called percentage 
feeding is not a method of feeding; it has nothing to do what- 
ever with the choice of food elements, but is the method 
of determining the composition of an infant’s food by calcu- 
lating in terms of percentage the various elements contained in 
the food, as protein, fat, carbohydrate, etc. This is more 
accurate than estimating the baby’s food in terms of the 
relative ounces of milk, water, etc., in the food. The ap- 
proximate percentage of every food element given the infant 
in his formula is known and these constituents are increased 
or decreased to meet the definite clinical pictures, being guided 
Methods of 
Modifying 
Milk 
Percentage 
Method 
8 Holt, L. Emmett, M.D., “Diseases of Infancy and Childhood.” ARTIFICIAL FEEDING OF INFANTS 
157 
by the knowledge of the mutual relationships which these 
elements bear to one another. Without a knowledge of the 
percentage composition of a formula no scientific feeding is 
possible. (See note 5.) (Morse and Talbot’s “Diseases of 
Nutrition, ’ ’ Chapter XVII, gives a clear and brief method of 
calculating formula according to percentage methods.) 
2. The caloric method of feeding was advocated by the 
German school. (See note 1.) This provides the infant with 
the required number of heat units, the estimation of his need 
being based on his weight. Careful experiments have given us 
the following figures to use as averages: 
Caloric 
Method 
Average infants under 2 months of age 65 to 100 calories 
per kilo. 
Average infants over 2 months of age 100 to 120 calories 
per kilo. 
Premature and thin infants under 
2 months of age 110 to 140 calories 
per kilo. 
Thin infants over 2 months, depending 
on general condition 120 to 150 calories 
per kilo. 
Caloric 
Bequirements 
This check upon the caloric contents is inestimable in de- 
termining the value of mixtures and in avoiding over and 
under feeding. However, it cannot be strictly followed be- 
cause (1) the individual baby has to be considered, the small 
under nourished baby requiring more calories per kilo than 
the well nourished one, (2) the activity of the individual child 
alters the caloric need also, and (3) it is evident that a food 
may contain the requisite number of calories and yet be con- 
structed on an entirely wrong basis. Condensed milk mixture 
is an example of this. The caloric feeding is, therefore, like 
percentage feeding, not a “method of feeding.” It is only a 
method of calculation serviceable in estimating whether or not 
the food answers the infant’s caloric needs. It aids in no 
way in determining how tlie food shall be composed in order 
that these needs shall be met. 158 
PEDIATRIC NURSING 
To Determine 
Caloric Value 
of Milk 
Mixture 
A. To determine the caloric value of a milk mixture: We 
must know, first, the percentage composition in order to esti- 
mate the number of calories in a given milk mixture. 
One gram of fat 9.3 calories 
One gram of carbohydrate 4.1 calories 
One gram of protein 4.1 calories 
Then to determine the caloric value of 1000 c.c. of whole cow’s 
milk: We must know that the percentage composition of 
cow’s milk is approximately: 
Fat ' 4% 
Carbohydrate 4.5% 
Protein 3.2% 
Salts 0.75% 
Water 86 to 87% 
(The salts and water are ruled out as having no food value.) 
Method: 
Multiply 1000 by each of the above figures: 
Fat 1000 X 0.04 = 40 grams in 1000 c.c. 
Carbohydrates 1000 X 0.045 = 45 grams in 1000 c.c. 
Protein 1000 X 0.32 = 32 grams in 1000 c.c. 
Number of calories: 
Fat 40 X 9.3 = 372 calories 
Carbohydrate 45 X 4.1 = 184.5 calories 
Protein 32 X 4.1 = 131.2 calories 
687.7 or approximately 700 
calories in 1000 c.c. of whole milk. 
To Determine 
Caloric Value 
of Breast 
Milk 
B. To determine the caloric value of breast milk: 
Percentage composition is: 
Fat 4% 
Carbohydrate 7% 
Protein 1.6% 
Salts 0.2% 
Water 86 to 88% 
Method: 
Fat 1000 X 0.04 = 40 grams in 1000 c.c. 
Carbohydrate 1000 X 0.07 = 70 grams in 1000 c.c. 
Protein 1000 X 0.016 = 16 grams in 1000 c.c. ARTIFICIAL FEEDING OF INFANTS 
159 
Number of calories: 
Fat 40 X 9.3 = 372 calories 
Carbohydrate 70 X 4.1 = 287 calories 
Protein 16 X 4.1 = 65.6 calories 
724.6 Total calories in 
1000 c.c. of breast milk. 
From the above example we see that 1000 c.c. of breast milk 
has 724.6 calories and that 1000 c.c. of cow’s milk has 687.7 
calories. For practical purposes we may consider that they 
both have 700 calories in 1000 c.c. 
3. Milk dilutions with the addition of carbohydrates. 
Whole milk diluted with water and with the addition of sugar 
in any amount the individual baby requires is a satisfactory 
modification for the majority of babies. But the percentage of 
fat, carbohydrate, and protein in such mixtures has to be esti- 
mated in order to feed the infant scientifically. Also the 
caloric value of the food must be known. 
Practical application of whole milk dilutions with added 
sugar:9 
For even the youngest or most delicate infant it is un- 
necessary to dilute the whole milk to more than % strength 
even during the first week or two of life. After this time 
the concentration of the milk is gradually increased until 
during the second month the baby takes y2 milk and y2 water; 
by 5 months, % milk and % water; and by 9 or 10 months, 
undiluted whole milk. Tt will be seen that in feeding such 
dilutions of milk the proportion of protein is greater than in 
human milk except during the early weeks; this is not a 
disadvantage in normal cases since protein is well tolerated 
by infants.10 (See note 8.) Recent work has proven that 
when cow’s milk is substituted for mother’s milk the protein 
intake should be considerably increased, doubled or even 
trebled. Infants from 1 to 9 months of age can receive from 
Whole Milk 
Dilutions 
with Added 
Carbohydrate 
Application of 
Whole Milk 
Dilutions 
with Added 
Sugar 
Protein 
9 Marriot, Wm. McKim, M.D., Unpublished Notes for Nurses. 
10 Bosworth, Alfred W., “Studies in Infant Feeding.” Am. J. Bis. 
Child., Aug., 1921. 160 
PEDIATRIC NURSING 
15 to 30 grams of protein daily when fed on the usual modi- 
fication of cow’s milk. This increase in protein requirement 
when cow’s milk is substituted for mother’s milk is probably 
due to differences between the two milks in amino-acid con- 
tent. Measures are often taken to help in breaking up the 
curd to aid digestion, as boiling the milk, eitration and the 
addition of cereal waters. The proportion of fat in the diluted 
whole milk mixture is considerably less than that of the human 
milk, but this is advantageous because it has been positively 
established that fat plays an important part in nutritional 
disorders of the artificially fed baby. (See Fat, under Com- 
position of cow’s milk.) The deficiency of fat can usually be 
successfully compensated by the addition of sugar and starch 
to the formula. It is stated by some authorities that the 
optimum amount of whole milk for an average infant during 
the first year is about 1/10 of his body weight in grams, or 
ounces to a pound, and the amount of added sugar is ap- 
proximately 1/100 of his weight in grams. (Dr. Pfaundler’s 
method.) This is another method of checking up on the feed- 
ing of children. 
The diluent used during the first month or 6 weeks of life 
is sterile water. After this a 5 per cent eereal water is pre- 
pared. Rice, barley, or oatmeal are favorite cereals to 
use. (See directions for making cereal Avater, Chapter 
XIII.) 
Carbohydrate, generally in the form of sugar, is added to 
all milk dilutions to bring the percentage up to 7 or 7y2. 
This is the amount of sugar in human milk, and is the optimum 
for the average infant. Those fed on less sugar than this 
are not likely to gain satisfactorily and consistently and those 
fed on more are very prone to gastro-intestinal disturbances. 
(See previous discussion of sugars in relation to infant feed- 
ing.) 
To break up the curd and to assist the digestion of cow’s 
milk (see note 1) : 
Many infants can digest raw cow’s milk but when not well 
Fat 
Dr. 
Pfaundler’s 
Rule for 
Feeding 
Diluent 
of Milk 
Carbohydrate 
To Break 
Up Curd ARTIFICIAL FEEDING OF INFANTS 
161 
taken the tendency to the formation of large protein curds 
in the stools is relieved by boiling the milk 2 or 3 minutes. 
The addition of sodium citrate to the milk mixture prevents 
the formation of hard curds. The proportion of sodium citrate 
used is approximately one grain for every ounce of milk 
mixture. When an alkali, as lime water, is added to the milk 
mixture in sufficient amounts so that the mixture remains 
neutral or alkaline in the stomach, even after the stomach 
has secreted acid, large protein curds do not form because 
casein is not coagulated by rennin when the solution is alka- 
line. Lime water is commonly used in amounts equaling 5 
per cent of the milk mixture. 
Number of feedings in 24 hours: 
The normal newffiorn baby who is breast fed thrives on a 
4-hour schedule. The artificially fed baby can also be fed at 
4-hour intervals to advantage. Many babies will need only 
5 feedings in the 24 hours from the start, 6 a.m., 10 a.m., 
2 p.m., 6 p.m. and 10 p.m. If a baby is under weight and 
sufficient milk for his needs cannot be given him in 5 feedings 
he is given 6 feedings: 6 a.m., 10 a.m., 2 p.m., 6 p.m., 10 p.m. 
and 2 a.m. 
Amount of milk at every feeding: 
The amount of milk given at every feeding period de- 
pends somewhat upon the number of feedings given and upon 
the weight of the baby. Hess gives the following rule: from 
birth to the fifth month the average healthy infant will be 
satisfied with an amount of food approximately 2 ounces 
(60 c.c.) more per feeding than he is months old (1 month— 
3 ounces; 2 months—4 ounces, etc.). Occasionally, infants 
cannot take this amount and if vomiting results the quantity 
may be reduced. Often, however, more than this amount can 
be taken. The average, healthy newborn baby who is breast 
fed takes much larger amounts of milk than was formerly 
supposed possible. This has been demonstrated by weighing 
large numbers of newborns before and after nursing. By the 
end of the second week of life a robust baby is often taking 
Number of 
Feedings 
Amount of 
Milk at Every 
Feeding 162 
PEDIATRIC NURSING 
from 400 to 550 c.c. in 24 hours. After the fourth month the 
average infant wrill take one quart of milk daily. When more 
than a quart is needed to properly nourish him, he has reached 
the stage when a mixed diet should be substituted. By 6 
months, 4 meals of 8 ounces each of milk mixture may be 
given and the fifth meal should be of vegetable soup, cereal 
or vegetable. (See food other than milk to be given during 
the first year, Chapter XIV.) The average infant will take 
very little food during the first 12 hours of life. He is usually 
given nothing but sterile water. After that time, if arti- 
ficial feeding is necessary, 15 to 30 c.c. of a % milk mixture 
with 3 per cent sugar can be given him every 4 hours. 
Table 
Age 
No. of 
feedings 
c.c. per 
feeding 
Dilution 
of milk 
Diluent 
Per cent 
added 
sugar 
24 hour 
intake 
Foods other 
than milk 
2 (la. 
5 
15 
Vs 
Water 
3% 
75 c.c. 
4 “ 
5 
30 
Vs 
< ( 
i 6 
150“ 
lwk. 
5 
60 
Vs 
t ( 
( < 
300 “ 
2 “ 
5 
90 
Vs 
( C 
( l 
450 ‘4 
Orange juice 
1 mo. 
5 
120 
V3-V2 
C ( 
( i 
600 4 ‘ 
U ( ( 
2 “ 
5 
150 
y2 
5% cereal 
c c 
750“ 
(( it 
4 “ 
5 
180 
Water 
i ( 
900“ 
a a 
6 “ 
4 
240 
% 
( ( 
( ( 
960“ 
it a 
8 “ 
4 
240 
% 
( 6 
( ( 
960 “ 
it it 
0 “ 
4 
240 
Whole 
milk 
None 
None 
960 “ 
tc a 
Table to Use 
as Guide in 
Infant 
Feeding 
Disadvan- 
tages of 
Above Table 
This table (see note 9) is not to be too rigidly followed for 
it is merely a guide to the approximate feeding on which one 
might expect an average, normal infant to thrive. Since every 
baby is “a law unto himself,” conditions may arise at any time 
which would be an indication for deviation from this course. 
The object should not be to fit the infant to the scheme, but to 
fit the feeding to the individual infant. This table is com- 
parable to one which would give the average size of shoes or 
clothing worn by children of different ages; it does not guar- 
antee a fit for any individual child, but indicates the general 
range of choice. One of the greatest mistakes made in feeding ARTIFICIAL FEEDING OF INFANTS 
163 
infants artificially is that the individual child is not consid- 
ered, but he is fed according to some scale or table like the 
above, regardless of his individual needs or tolerance. This 
is especially true of babies fed on proprietary foods when the 
“directions on the can” are being followed. When beginning 
to feed an infant on cow’s milk for the first time, one should 
consider the individual baby, taking into account: 
a. His age. 
b. Normal weight for his age. 
c. His present weight. 
d. Number of calories per kilo for the normal baby of his age. 
e. Previous feeding history. 
He is started out on a much weaker formula than his age and 
weight would indicate, additional sugar often being omitted at 
first, because the baby’s tolerance is unknown and until it is 
established great precaution must be used. The formula is 
strengthened gradually, increasing the strength and quantity 
to meet the baby’s demands, being guided by his tolerance 
as manifested by gain or loss in weight, vomiting, diarrhea 
and general appearance of the baby. As long as he gains in 
weight no increase is necessary, but a stationary weight line 
or a continued loss of weight indicates the necessity for an 
increase. Vomiting is one of the first symptoms of overfeed- 
ing; diarrhea is always a danger signal. Only one change in 
the baby’s food should be made at a time, i.e., an increase in 
quantity should not be made at the same time as an increase in 
strength; all changes should be gradual. Usually a y2 ounce 
increase is advisable since abrupt changes may disturb 
digestion. 
Application of the above rules: 
Suppose that we wish to feed a healthy baby of 4 months 
who weighs 5400 grams. According to the above table he 
needs 5 feedings a day, 180 c.c. at a feeding, and is allowed a 
mixture consisting of % whole milk, y3 5 per cent cereal water 
and 3 per cent added sugar, and from 100 to 120 calories 
per kilo. 
Consider 
Individual 
Baby 
Guides When 
Starting 
Artificial 
Feeding 
Make Only 
One Change 
In Feeding 
at a Time 
Application of 
Above Eules 164 
PEDIATRIC NURSING 
Method: 
24 hour amount of feeding is 900 c.e. 
% whole milk is 600 c.e. 
Yz 5% cereal water is 300 c.c. 
3% sugar is 27 grams. 
To check up on the caloric intake of this mixture: 
1000 c.c. whole milk = 700 calories. 
Then 1 c.c. = .7 calories. 
600 c.c. = 420 calories. 
And 1 gram of carbohydrate = 4.1 calories 
Then 27 grams of sugar = 110.7 calories 
And 300 c.c. 5% oatmeal —15 grams oatmeal 
15 x 4.1 = 61.5 calories 
Therefore the total 420 + 110.7 + 61.5 = 592.2 calories 
Since the baby weighs 5400 grams, he is being fed approxi- 
mately 110 calories per kilo, which is about the average 
amount according to the table. 
Another rule for feeding allows the baby whole milk equal 
to 1/10 of his weight in grams or IY2 ounces for every pound 
of weight and carbohydrate equal to 1/100 of his weight in 
grams. By checking up with this method it is found that he 
will be allowed 540 c.c. of milk and 54 grams of carbohydrate, 
which agrees approximately with the above formula. CHAPTER XII 
artificial feeding of infants (Continued) 
Technique for Making Feedings. 
In the well equipped children’s department or hospital 
there is a special kitchen or milk laboratory where only milk 
is kept and only milk formulae are prepared. This room 
should be used for nothing else. The nurse or nurses who are 
preparing formulae should be the only persons who use the 
room and should be responsible for it. The room should 
contain: 
1. A large sink with hot and cold running water and sink 
shelves. 
2. A gas stove with several burners. 
3. An ice-box in which only milk and milk formulae are kept. 
4. A broad shelf or large table on which feedings are prepared. 
5. A cupboard and drawers for utensils, supplies, etc. 
6. A milk sterilizer if large numbers of feedings are to be 
made and if large quantities of milk have to be sterilized. 
7. A bottle sterilizer where all nursing bottles are sterilized. 
(This may be either in the milk laboratory or conveniently 
located in an adjoining room.) 
8. Utensil sterilizer, if possible. 
To save the nurse’s time a trustworthy maid should be on 
regular duty to do the cleaning, wash nursing bottles, dishes, 
etc., under the nurse’s supervision. The nurse who has 
charge of the milk laboratory and who makes the formulae 
should wear a rubber apron to protect her uniform and she 
may wear a cotton apron over that. Some institutions re- 
quire her to wear a large gown to cover her entire uniform 
in place of the small apron over the rubber one; also a large 
cap to completely cover her hair. (While this technique 
Milk 
Laboratory 
Equipment 
Rules for 
Nurse 
165 166 
PEDIATRIC NURSING 
seems very nice it is not necessary.) She should keep her 
hands clean at all times when handling milk and she should 
scrub them well before the preparation of formulae. Rules 
of some hospitals demand that the nurse who makes formulae 
should be considered always ‘ ‘ clean ’ ’; that is, she is not 
allowed to change babies’ diapers, care for isolated patients, 
assist at pus dressings, etc. If there are enough formulae to 
be prepared to take one nurse’s entire time, the above 
technique can be easily worked out. It can often be arranged 
so that she can spend her extra time in heating the feedings 
to be given to the babies, holding the bottles, etc. This is good 
technique but when one considers that the surgeon operates 
on a pus case, then maybe on a clean one, or he visits his other 
patients, does dressings, etc., and we see no bad results, it 
seems only logical that the nurse who makes formulae can, 
by carrying out proper precautions, safely perform other 
duties as occasion arises. If the nurse has an upper respira- 
tory infection she should wear a mask over her mouth and 
nose. 
Supplies 
Standard Supplies Necessary in a Milk Laboratory: 
1. Sugars: 
Cane sugar or saccharose. 
Milk sugar or lactose. 
Dextri-maltose, numbers 1, 2, and 3. 
Karo syrup—blue label brand—brown syrup. 
2. Flours, cereals: 
Rice. 
Pearl barley. 
Rolled oats or oatmeal. 
Barley flour. 
Wheat flour. 
Farina or cream of wheat. 
3. Patent foods: 
Malt soup extract. 
Dry malt soap powder. 
Hoos’ albumin milk powder. 
Powdered milk. 
Unsweetened evaporated milk. ARTIFICIAL FEEDING OF INFANTS 
167 
4. Milk: 
Whole milk. 
Skim milk. 
Buttermilk or skimmed lactic acid milk. 
Whole lactic acid milk. 
5. Sterile water. 
6. Liquid rennet or essence of pepsin: 
Lime water. 
Sodium citrate. 
Culture of lactic acid bacilli. 
1. The above sugars are commonly used in infant feedings. 
The dry sugars, cane sugar, lactose, and dextri-maltose are 
kept in covered glass or enamel jars plainly marked. These 
sugars, especially milk sugar and dextri-maltose, do not dis- 
solve readily in cold liquids; if the formula is to be boiled 
the sugar will dissolve as the mixture begins to heat. If it is 
not to he boiled it is advisable to dissolve the sugar in warm 
water equal to the amount of water to be added to the formula. 
If no water is ordered, dissolve the sugar in the smallest 
possible amount of hot wrnter (30 to 60 c.c.). It should be 
cooled before it is mixed with the milk. It is often more 
convenient to mix the sugar solution for every formula, as 
far as is possible, the day before; pour it into a sterile bottle, 
cover with a sterile square, and keep on ice until ready for 
use the next day. 
Karo syrup (blue label brand or brown syrup) is the only 
kind advised for infant feedings. It is thick and hard to 
measure accurately, therefore it is best to make it into a 
50 per cent solution by adding 55 volumes of water to 45 
volumes of Karo. Since it is impossible to remove it from the 
can without contaminating it when pouring it over the rim 
of the can, it is sterilized after being mixed with the water, 
bottled, covered, and cooled before mixing it with the milk. 
It also can be conveniently made up the day before. 
2. Rice, rolled oats, and pearl barley or barley flour are 
the cereals most commonly used for making cereal water. 
These should always be on hand, kept in covered cans plainly 
Sugars 
Starches 168 
PEDIATRIC NURSING 
marked. Wheat flour may be used in the preparation of malt 
soup, Czerny’s butter-flour mixture, etc. Farina, cream of 
wheat, and other finely milled cereals are used in the prepara- 
tion of thick cereal feedings; they are also kept in covered 
enamel cans. 
3. Malt soup extract or dry malt soup powder may be 
needed. Hoos’ albumin milk powder or some other dried or 
canned preparation of protein milk is convenient for an 
emergency because it takes so long to make protein milk in 
the regular way. Powdered milk and condensed unsweetened 
milk may also be convenient in an emergency. Other patent 
foods may be necessary from time to time. 
4. Certified milk is used if it is possible to obtain it. Whole 
milk is ordered daily in sufficient quantities to cover all pos- 
sible needs. As soon as the milk is delivered, wash the out- 
side of the bottles, dry them, and place them in the refrigera- 
tor. Milk should always be kept covered and removed from 
the ice only when it is necessary to prepare feedings. As soon 
as they are made they are put on ice. (See Care of Milk, 
Chapter XI.) 
Skim milk is ordered from the dairy as needed or it may 
be prepared by skimming the cream from a bottle of whole 
milk with a modified Chapin dipper. This is a small round 
dipper which fits into a milk bottle. To skim milk, let the 
bottle of milk stand until the cream has risen to the top 
and there is a definite cream line, then introduce the dipper 
carefully into the bottle so that the top of the dipper is on a 
level with the contents; the dipper fills with cream, is removed, 
emptied, and again introduced; this is repeated until all the 
cream is removed and only skim milk is left. The modified 
Chapin dipper has a removable bottom which allows the in- 
strument to be pushed down into the full bottle without 
danger of causing it to overflow. There is on the market a 
milk syphon which removes the lower part of a bottle of milk, 
the fat free milk, leaving the top milk or cream in the bottle. 
When opening a bottle of certified milk, remove the outer 
Proprietary 
Foods 
Certified 
Milk 
Skim Milk 
Chapin 
Dipper ARTIFICIAL FEEDING OF INFANTS 
169 
cap, wipe the neck of the bottle, and remove inner cap by 
running the special bottle opener around the edge. 
Buttermilk or skimmed lactic acid milk should always be 
on hand; this keeps several days if not used. Whole lactic 
acid milk may be used for feedings. 
5. Water used for feedings is sterile. A special apparatus 
to sterilize it is most convenient in the milk laboratory and 
economical if large numbers of feedings are to be made. 
Otherwise it is boiled and cooled before being mixed with the 
milk. Large quantities can be boiled at once, poured into 
sterile bottles (5 pint for convenience), covered, and kept on 
ice. In this way cool sterile water is always on band for 
the preparation of formulae and for the babies when it is 
necessary. 
6. Liquid rennet or essence of pepsin is used to coagulate 
milk when making protein milk. Lime water and sodium 
citrate may be ordered in a formula to help break up the 
casein curd of cow’s milk. Lactic acid bacilli culture is used 
in preparing buttermilk or skimmed lactic acid milk and whole 
lactic acid milk. All these above articles should be kept in 
the refrigerator. 
Buttermilk 
Watar 
Other 
Supplies 
Utensils needed. 
Nursing bottles (see description). 
Nipples (see description). 
Bottle brushes. 
Covered glass or enamel jar for sterile nipples. 
Jar or container for unsterile nipples. 
Racks for bottles. 
Dairy thermometer in bottle of 70 per cent medicated alcohol. 
(Before using the dairy thermometer to test the tempera- 
ture of the milk, rinse with sterile water. After use rinse 
clean with sterile water and replace in alcohol.) 
Gram scales—weights. 
Milk bottle opener. 
Can opener. 
Handling forceps—several pair—in bottle of 70 per cent 
medicated alcohol. 
Utensils 170 
PEDIATRIC NURSING 
Can of sterile absorbent cotton (if used to plug nursing bot- 
tles) or can of sterile patent tops or rubber caps. (See 
how to plug nursing bottles.) 
Can of sterile gauze—24 inches square—3 or 4 thicknesses for 
straining protein milk. 
Can of sterile squares—4 inches square—from old cotton cloth 
—to cover milk bottles. 
Elastic bands in box. 
Tags or labels to mark nursing bottles (see how to mark 
bottles). 
Dish towels and dish cloth. 
Graduates—sizes, 1000 c.c., 500 c.c., 30 c.c. 
(Glass breaks easily if boiled and enamel ones are unsatis- 
factory because marks wear off after repeated boiling. 
Porcelain laboratory graduates do not break as easily as 
glass and marks do not wear off with boiling.) 
Egg beater. 
Wooden spoons. 
Modified Chapin dipper. 
Funnels—enamel or aluminum—various sizes with end small 
enough to fit in neck of nursing bottle. 
Strainers, finest wire. 
Double boilers—enamel or aluminum—various sizes (1 quart 
to 3 or 4 quarts). 
Aluminum saucepans—various sizes (1 quart to 3 or 4 
quarts). 
Enamel or aluminum pitchers—various sizes (1 quart to 3 or 4 
quarts). 
Spoons—tablespoons, dessert spoons, teaspoons. 
The above list includes utensils needed for the preparation 
of all ordinary milk mixtures. Any special mixtures may 
demand more elaborate equipment. 
Sterilization 
of Utensils 
Concerning Sterilization of Utensils. 
Utensils may be sterilized by boiling 10 minutes in the 
utensil sterilizer. If only a few feedings are to be made and 
if no sterilizer is convenient, the utensils may be boiled 
over the gas in a large pan for 10 minutes. Utensils do 
not need to be sterile when mixing unsterile feedings, that 
is: ARTIFICIAL FEEDING OF INFANTS 
171 
1. When making ordinary whole milk dilutions, if all 
feedings are boiled routinely after being mixed. 
2. When making cereal water, sugar solutions, Karo solu- 
tions, or such solutions as are boiled routinely after being 
made. 
Utensils do need to be sterile when making sterile feedings, 
that is: 
1. When making whole milk dilutions, if feedings are not 
boiled after being mixed. 
2. When making lactic acid milk mixtures since lactic acid 
milk is a sterile product when completed and cannot be boiled. 
3. When making mixtures from milk powder, evaporated 
milk, etc., the product is considered sterilized in the process of 
manufacturing and preserving and is handled with sterile 
utensils and is mixed with sterile water. 
Nursing Bottles. 
Nursing 
Bottles 
The ideal nursing bottle is constructed so that every por- 
tion can be easily cleaned with a proper brush.1 This neces- 
sitates the avoidance of depressions or angles. The narrow 
cylindrical shaped bottle is most convenient. The Hygeia 
large neck bottle can be used, but it is more expensive and 
the nipples to fit it are usually of hard rubber. The bottle 
should he of a good grade of glass, not easily broken, and 
capable of being boiled without cracking. It should hold 
8 to 10 ounces and should have a series of markings pressed 
into the glass to indicate the number of ounces or cubic centi- 
meters the bottle holds. There should be enough bottles so 
that every baby has as many as he has feedings in 24 hours. 
(Allow 10 bottles per baby in equipping the ward.) Then 
when his 24-hour amount of formula is made, it is divided 
into as many bottles as he has feedings in the 24 hours, 
marked, and kept on ice. When he is to be fed one bottle is 
removed, heated, and the formula fed to him. There should 
be wire racks to hold 4, 5, and 6 nursing bottles so that every 
Kind of 
Bottle 
1 Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” 172 
PEDIATRIC NURSING 
baby’s feedings can be kept in a separate rack marked with 
his own name. Every bottle of feeding should also be 
marked. There are several ways of doing this: 
1. The name may be written on a Dennison gummed label 
and one stuck on every bottle. If the feedings are sterilized 
in the bottles this method cannot be used. 
2. An area 1 or 2 inches square may be glazed or frosted on 
every bottle and the name written with pencil in this area. It 
will not come off when the bottle is boiled. When the bottle is 
washed, rub the name off with sand soap. 
3. Every baby may be given a number and a metal tag 
bearing his number may be attached to every one of his 
bottles; this may be tied around the neck of the bottle with 
a string, an elastic band, or the tag may have a small chain 
fastened to it and this may be slipped over the neck. 
As soon as the feedings are made and put in the bottles 
they should be covered or plugged. (1) Sterile absorbent cot- 
ton plugs may be used. (2) Rubber stoppers which can be 
sterilized are convenient. (3) There are patent caps on the 
market. After use the bottle should be rinsed with cold water, 
washed with soap and water, rinsed, and sterilized before being 
used again. New bottles should be annealed by placing them 
in a container with cold water, bringing the water to a 
boil, boiling for 20 minutes, and then leaving them in this 
water until it becomes cool (see note 1) ; bottles thus treated 
do not crack so easily when hot fluids are poured into them. 
To Mark 
Bottles 
Covers for 
Bottles 
Care of Bottle 
Nipples. 
Nipples 
Kind of 
Nipples 
Nipples should be of soft rubber, of conical or slightly 
bulbous shape, and constructed so that they may be turned 
inside out and easily cleaned. The boles in the nipple should 
be of such size that the milk will drop readily, but will not 
flow out when the bottle is inverted. The new nipple has no 
holes or very small ones. A No. 3 to 5 sewing needle 
heated red hot over a flame makes holes the proper size for 
ordinary use. The blunt end of the needle is inserted into a 
To Make 
Holes la 
Nipple ARTIFICIAL FEEDING OF INFANTS 
173 
cork ; it can then be heated and handled with ease. Three 
holes in a nipple are usually enough. The exact size of the 
holes and the number depend on (1) the consistency of the 
formula (larger holes are required for malt soup, protein 
milk, and other thick mixtures), and (2) the ability of the 
baby to suck. A vigorous baby does not need as large holes 
in his nipple as a weak or lazy baby. 
After use rinse the nipple inside and outside with cold 
water, wash with soap and water, rinse, and boil for 2 minutes. 
All the nipples in use for all the babies in the department 
can be kept in a sterile covered can; keeping them dry length- 
ens the life of the rubber (See note 1). When a nipple 
is needed, it can be removed from the jar with sterile handling 
forceps and fitted on the neck of the bottle. After all the 
babies are fed, all the nipples are boiled together 2 minutes 
and replaced in the sterile jar. 
A mild white soap such as Ivory should be used to wash 
nursing bottles, nipples, feeding utensils, etc. The dish cloth 
and the dish towels should be used for nothing else, 
and should be washed daily and dried outside if pos- 
sible. 
When a baby is nursing a bottle, it should have a cover on 
it to keep the contents warm. An outing flannel bag may be 
made to fit it, with a draw string around the top to adjust it. 
A bottle “cozy” may also be knitted for this purpose. 
Care of 
Nipples 
Nursing 
Bottle Cover 
To Make Sterile Formulae. 
To Make 
Sterile 
Formulae 
The general arrangement of the table is as follows: 
1. Sterile towel on which are placed sterile utensils needed. 
2. Supplies as needed, as sugars, etc. 
3. Scales with weights. 
4. Pitchers in which to mix formulae. 
5. Sterile nursing bottles in racks. 
6. Paper bag for waste. 
Have all necessary supplies within easy reach on the hack 
of the table on which the formulae are to be mixed; this in- 
Equipment 174 
PEDIATRIC NURSING 
eludes sugars, sterile water, handling forceps, jars of sterile 
cotton, sterile squares, etc., as given in the list of supplies 
above. On the upper right hand side of the table spread a 
sterile towel on which are placed sterile utensils, as spoons, 
strainers, funnels, etc. These cannot be kept surgically sterile 
while the formulas are being made, but they are kept as clean 
as possible. Pitchers, graduates, etc., are placed on the table 
after being boiled, as only the inside needs to be kept sterile. 
Have the necessary number of nursing bottles ready in the 
racks marked with the names of the children. A paper bag 
for waste is needed. 
To measure the sugar, flour, etc., on grain scales, place 
on one side of the scales a sterile square of cloth (one of 
tops for milk bottle, 4 inches square is just the right size), 
balance the scales, place the desired weights on the other 
side of the scales, and weigh the ingredient desired by placing 
on the sterile square enough of it to balance the weights. 
After the sugar is weighed it is put into the pitcher in which 
the formula is to be mixed. (Karo syrup, being a solution, 
is measured in the graduate.) Measure and add the other con- 
stituents of the formula as ordered, milk, water, etc. Mix to- 
gether by stirring with a wooden spoon. Bottle the formula 
by pouring into separate nursing bottles (as many as the baby 
has feedings in 24 hours), the amounts to be given at every 
feeding. As the markings on the ordinary nursing bottles 
graduated in ounces are not always accurate, it is more satis- 
factory to measure the feedings in a graduate before pouring 
them into the bottles. Plug the bottles with sterile cotton 
(or whatever method is used) and put on ice until they are 
given to the baby. Utensils, dishes, spoons, etc., used to 
make ordinary milk mixtures do not need to be washed between 
feedings. They may be rinsed with sterile water if desired, 
but by using judgment, and making simple mixtures first, 
leaving until the last any formula, as lactic acid milk, which 
will leave a taste on the dishes, the same utensils may be used 
for making all the formulae. 
Procedure ARTIFICIAL FEEDING OF INFANTS 
175 
To Make Unsterile Formulae. 
Arrange the table as above excepting the sterile articles 
and the sterile towel, for it is assumed that unsterile ingre- 
dients which will later be sterilized are being dealt with. To 
sterilize the formula after it is mixed : 
1. It may be boiled in a saucepan directly over the stove 
for 2 minutes or as long as ordered. Measure and if any 
has boiled away make up the original amount with sterile 
water; after cooling, bottle in sterile bottles and put on ice. 
2. It may be poured into unsterile bottles and sterilized 
in them by placing them in the milk sterilizer for the necessary 
length of time. 
To Make 
Unsterile 
Formulae 
To Sterilize 
Formulae 
Rules for Feeding the Baby: 
To heat the milk to feed the baby, remove from the iee-box 
one of his nursing bottles containing the correct amount of 
milk for the feeding; place it in water 105° F. for 5 minutes 
to heat it. There is a special heater on the market; it con- 
sists of a large round container with a rack inside to support 
the bottles and a thermometer to take the temperature of the 
water. After the feeding is heated, remove the cap or plug 
from the bottle, put the nipple on it, test the temperature of 
the contents by letting a few drops run from the nipple on 
to the back of the hand, put a cover on the bottle, and take 
it to the baby. The nipple should not touch anything, but 
should be uncontaminated until it is put in the baby’s mouth. 
Change his diapers and make him comfortable before feeding 
him; put a*bib under his chin whenever he is fed. He should 
lie on his bed, turned slightly to the right side, since it has 
been found that the stomach empties itself sooner in that 
position. The upper part of his body should be slightly 
elevated by means of a small pillow (See note 1). The nurse 
or attendant should hold the bottle until the baby empties 
it; he should never be left alone with it propped. When hold- 
ing the bottle keep it tilted so that its contents are well up 
over the neck to prevent the child from sucking in air. Re- 
To Feed 
the Baby 
To Heat 
Formula 
position of 
Baby When 
Nursing 176 
PEDIATRIC NURSING 
moving the nipple frequently during the nursing will allow 
the air to escape. 
It should take the child not less than 10 and not more 
than 20 minutes to take his feeding. If it takes longer than 
20 minutes there is something wrong with the baby or the 
nipple, and an investigation should be made. Any milk left 
over after that time is thrown away; never save it or reheat 
it for a later feeding. Do not force a feeding to the point 
of regurgitation. If a baby takes it too fast, again investigate 
the nipple and make the holes to suit his needs; also remove 
the nipple from his mouth several times during the feeding 
period and force him to rest. If he is apt to belch gas and 
regurgitate after a feeding, the nurse should hold him upright 
2 or 3 times during the feeding, and by patting him gently 
on the back help him to belch gas. In this upright position 
he can do so without causing regurgitation. 
The nurse may hold the baby in her arms while feeding him 
if she desires. Some authorities advocate it since it is the 
natural position when nursing from the breast. However, it 
is not always practical in an institution. 
If a baby is regurgitating or vomiting and an estimation 
of the amount is desired, weigh the bib before putting it under 
his chin; leave it there until after his feeding and if he re- 
gurgitates on it, weigh it again. The difference in weights 
will give a rough estimate of the amount of the feeding 
lost. (Of course projectile vomiting cannot be thus 
estimated.) 
Regurgitation is the casting up without much effort of the 
stomach contents soon after it has been taken; it occurs in 
the healthy infant who has taken more food than he can 
comfortably hold, or who has been carelessly handled after 
feeding. 
Vomiting or emesis is the ejection of partly digested con- 
tents of the stomach through the mouth; it is accompanied 
by effort and by evidences of nausea. Projectile vomiting is 
the very forcible ejection of stomach contents, often being 
Time to Be 
Spent at 
Nursing 
Period 
To Estimate 
Amount 
Regurgitated 
Regurgitation 
Vomiting ARTIFICIAL FEEDING OF INFANTS 
177 
forced several feet from the child. It is commonly seen in 
pyloric stenosis or spasm of pylorus.2 
If a Baby Refuses to Take His Feeding. 
A healthy baby may refuse a bottle because he has been 
accustomed to a sweeter mixture and does not like the present 
one. Occasionally saccharin is ordered in his feeding to make 
him take it; this is done only with a doctor’s order. (See 
proportions under forcing water by mouth—Hydrotherapy, 
Chapter XVII.) A sick baby may refuse his feeding be- 
cause he is too weak or too sick to suck a bottle. 
1. He may be gavaged; the catheter can be introduced 
through the nose or mouth. (See directions for gavage, Chap- 
ter XIX.) This is the most satisfactory method of feeding 
babies who cannot nurse. 
2. A Breck feeder is sometimes used; this is a graduated 
tube open at both ends, with a small nipple at one end for 
the baby to suck, and a rubber bulb at the other end to assist 
him in sucking. Its disadvantages outweigh any supposed 
advantages and its use is unsatisfactory because (a) of the 
tendency to too rapid feeding, and because (b) it is difficult 
to keep clean. 
3. A medicine dropper may be used to introduce milk 
into the back part of a baby’s mouth. A piece of rubber 
tubing two inches long should always be put on the tip so 
that the glass will not come in contact with his mouth and 
injure the delicate mucous membrane. The use of the medi- 
cine dropper is also more or less unsatisfactory. 
4. Occasionally milk may be given with a spoon, but it is a 
slow method. When water is ordered, it is best to give it 
halfway between feedings. Sterile water cooled to 100° F. 
is used; it may be given in a nursing bottle, with a spoon, or 
when the child is old enough he may drink it from a cup; 
this is a good way to teach him to drink from a cup. (See 
forcing fluids by mouth—Hydrotherapy, Chapter XVII.) 
If a Baby 
Refuses 
His Feeding 
Gavage 
Breck Feeder 
Medicine 
Dropper 
Spoon 
2Griffith, J. P. Crozer, M.D., "Diseases of Infants and Children.” 178 
PEDIATRIC NURSING 
Water should be offered to all babies several times a day, 
especially in hot weather. A sick baby who has fever should 
usually have as large amounts of water as he will take between 
feedings. 
Home 
Modification 
of Milk 
Home Modification of Milk. 
If a nurse has to prepare a formula in a home, she can 
generally find the necessary utensils in the ordinary kitchen 
equipment. She should select those she needs and see to it 
that they are used for nothing else. They should be boiled 
every day before they are used, and the same technique carried 
out as far as possible as given above for the preparation of 
formulas in the hospital. If the equipment does not allow 
dividing the feeding into bottles (according to previous di- 
rections), the entire 24-hour amount can be put in a sterile 
milk bottle, covered with a sterile square, and placed on ice. 
The necessary amount can be poured out at every feeding time 
into a nursing bottle and heated. (Never heat the whole 
bottle of milk before pouring out the desired feeding.) 
When a baby is discharged from a hospital, the nurse who 
is making formulae should write out full directions about his 
feeding for his mother, and she should explain the various 
steps to her in detail. Some institutions have printed slips 
of recipes of common mixtures, as cereal water, etc., for the 
mothers. Also they have printed forms with general directions 
and blank spaces in which to insert the necessary amounts of 
the various ingredients, etc., for the infant’s formula. The 
mother should be taught to measure the milk, water, etc., in 
ounces, for the average mother does not understand the metric 
system. She should be told to buy an ounce graduate (a medi- 
cine glass with markings will do) to measure the sugar, since 
she would not be expected to have scales, and tablespoons 
vary so in size that one can never be sure just how much sugar 
the child is having if it is thus measured. Instruct the mother 
to fill the glass with sugar and shake it down to the desired 
mark on the glass (not to press it). 
Instructions 
for Mother ARTIFICIAL FEEDING OF INFANTS 
179 
Milk Laboratories. 
There are milk laboratories in some of our larger cities. 
Walker-Gordon laboratories are the best known. The physi- 
cian writes on a printed form the ingredients and the desired 
amounts for the formula, also special directions regarding 
boiling, etc. He sends this prescription to the laboratory 
where it is prepared under the direction of an expert, and 
delivered to the home. This is a very convenient and satis- 
factory method, but the expense must necessarily be con- 
siderably greater than for preparing the formulas at home- 
this makes it prohibitive to many people.3 
Milk 
Laboratories 
3 Morse and Talbot, “Diseases of Nutrition.” CHAPTER XIII 
artificial feeding of infants (Continued) 
Recipes 
Whey. 
Put a pint of skimmed milk into a clean sterile saucepan 
and heat it until it is lukewarm—not over 100° F. Remove 
it from the stove. Add 2 teaspoonfuls of essence of pepsin 
or liquid rennet, or 2 junket tablets. Stir just enough to mix. 
Cover the pan and let it stand until the milk is firm, like 
jelly. Then break it with a fork until it is finely divided, 
strain through a cotton cloth or several thicknesses of sterile 
gauze. What goes through is whey.1 To arrest the action of 
the rennin, heat the whey to 150° F. The composition 2 of 
whey is: 
Whey 
Preparation 
Compositio 
Protein 0.86 (Koenig) 
Fat 0.32 
Sugar 4.79 
Salts 0.65 
Water 93.38 
100.00 
Cereal Water. 
To make 5 per cent cereal water, use (1) rolled oats, (2) 
rice, (3) pearl barley, (4) barley flour. Add 15 grams, y2 
ounce, or 2 rounded tablespoons of dry uncooked oatmeal (or 
pearl barley or rice) to 600 c.c. or 20 ounces of water, and 
salt to taste, about 1 teaspoon to a quart. Boil down one-half 
(or until there are 300 c.c. left). Place the saucepan directly 
over a low flame (do not use a double boiler). It will take 
from 1 hour to iy2 hours for this to boil down. Strain, bottle, 
Cereal Water 
Oatmeal 
Pearl Barley 
or Bice 
1 Morse and Talbot, *1 Diseases of Nutrition. ’ ’ 
2Holt, L. Emmett, M.D., “Diseases of Infancy and Childhood.” 
180 ARTIFICIAL FEEDING OF INFANTS 
181 
and keep on ice. It should be cold before being mixed with 
milk. To make 5 per cent cereal water using barley flour, 
use 25 grams of barley flour to 500 c.c. of water and y2 tea- 
spoon salt. Make the barley flour into a smooth paste by mix- 
ing it with a small amount of water (use part of the 500 c.c. of 
water). Bring the water wuth the salt in it to a boil in a sauce- 
pan placed directly over the flame. Add the barley paste 
slowly, stirring constantly to prevent lumping. Boil for 15 
minutes over a low flame, stirring frequently, strain, make up 
to 500 c.c. by adding water if any has boiled away, bottle, 
and keep on ice. Do not mix with milk until it is cool. 
Barley Flour 
Protein Milk, Known as Albumin Milk, Eiweiss Milch, 
Casein Milk, also Finkelstein’s Milk. 
Method I: Heat 1000 e.c. of raw whole milk to 100° F. and 
stir in 10 c.c. to 15 c.c. of essence of pepsin or liquid rennet. 
Let it stand at 100° F. until it coagulates (about y2 hour) 
and forms a firm curd. Cut in squares with a knife and let it 
stand until the whey separates (about y2 hour). Hang the 
curd in a bag made of 3 or 4 thicknesses of gauze or one thick- 
ness of cotton cloth and let it drain for from 30 minutes to 1 
hour, or until all the whey is drained off. Usually 700 c.c. of 
whey is thus obtained. Do not stir the curd or squeeze it 
while it is draining. Scrape the curd from the gauze into a 
very fine wire strainer and with a wooden spoon force it 
through the strainer 2 or 3 times. Five hundred c.c. of sterile 
water and 500 c.c. of buttermilk or skimmed lactic acid milk 
(see preparation) are added during the process. Beat with a 
Dover egg beater for 1 minute. To sterilize protein milk, add 
1 level tablespoon of wheat flour. Make a smooth paste by first 
adding it to a few tablespoons of the protein milk, then the 
entire amount is added slowly. Boil in a saucepan over a low 
flame 2 minutes or more as ordered. Cut back and forth con- 
stantly with a large wooden spoon while boiling. If any has 
boiled away, make the amount up to a quart by adding sterile 
water. The composition (see note 1) of this food is: 
Protein 
Milk 
Method I 
To Sterilize 
Composition 182 
PEDIATRIC NURSING 
Fat 2.5% (Finkelstein and Meyer) 
Sugar 1.5% 
Protein 3.0% 
Salts 0.5% 
One quart contains about 405 calories 
To Add Sugar 
Sugar in the form of dextri-maltose is usually ordered in pro- 
tein milk as soon as the baby’s condition will allow it. The 
desired amount of sugar is added to the pint of sterile water 
and is dissolved in it by heating. Cool before mixing with the 
curd. 
Method II: (Originated by Dr. C. A. Stewart of Minneapo- 
lis.) 
Boil 1000 c.c. of whole milk for 2 minutes, stirring con- 
stantly. Cool it to below 100° F. and add 5 to 10 c.c. of 
chemically pure lactic acid, which precipitates the curd at 
once. Pour it into a fine wire strainer to drain off the whey, 
which is thrown away. At least 700 c.c. of whey should be 
obtained. This will take only a minute. With a wooden 
spoon force the curd through the strainer 2 or 3 times. Five 
hundred c.c. of sterile water and 500 c.c. of buttermilk or 
skimmed lactic acid milk are added during the process. Beat 
with a Dover egg beater for 1 minute. This method is advan- 
tageous because it is simpler than Method I. The curd is 
softer and thus goes through the strainer more readily. It 
saves several hours of time and the final product is sterile 
if specially prepared skimmed lactic acid milk is added in 
place of commercial buttermilk. The composition is the same 
as that of protein milk prepared by Method I. Sugar may 
be added as directed in Method I. 
Owing to the difficulty in preparation or as the result of 
efforts made at improvement, many substitutes for protein 
milk have been recommended and some of them are produced 
commercially and are on the market.3 Among these are Hoos’ 
milk and Larosan milk. 
Protein Milk 
Method II 
Substitutes 
for Protein 
Milk 
3 Griffith, J. P. Crozer, M.D., “ Diseases of Infants and Children. ’ ’ ARTIFICIAL FEEDING OF INFANTS 
183 
Hoos’ Albumin Milk. 
Hoos’ 
Albumin Milk 
This consists of dried casein milk of a strength and com- 
position to produce, when properly diluted, the original 
formula of Finkelstein. To prepare—pour 1000 c.c. of sterile 
water into a bowd and place 90 grams of milk powder on the 
surface of the water. Mix by beating 1 minute with a Dover 
egg beater, strain, and bottle. 
Larosan Milk. 
Add % of an ounce of Larosan powder to y2 pint of milk 
and mix thoroughly. Another whole pint of milk is heated to 
the boiling point. When it has come to a boil, it is added 
to the Larosan milk mixture and the whole is placed over a 
flame and is allowed to boil for 5 minutes, being stirred all 
the time. This is diluted with water in the proportion of y2 
Larosan milk and y2 water, or % Larosan milk and % water. 
This mixture, because of its high protein content and com- 
parative ease of preparation, can be used as a substitute for 
protein milk in the home. 
Larosan Milk 
Precipitated Casein—Cottage Cheese. 
Precipitated 
Casein 
Method I 
1. Cottage cheese can be made by allowing either skimmed 
or whole milk to become sour. Heat slowly to 100° F. or 
until the whey begins to separate from the curd. Pour it into 
a gauze bag (3 to 4 thicknesses of gauze) to drain off the whey. 
Add salt to taste to the curd. 
2. Casein may be precipitated by the use of liquid rennet or 
essence of pepsin as in making protein milk by Method I. 
Use either raw skimmed or whole milk (1000 c.c.) Heat to 
100° F. and add 10-15 c.c. essence of pepsin or liquid rennet, 
let it stand at 100° F. until it coagulates (about % hour). 
Pour into gauze bag (3 to 4 thicknesses of gauze) to drain off 
the whey. Add salt to taste to the curd. Liquid rennet or 
essence of pepsin will act only in raw milk. 
3. Casein may be precipitated by the use of chemically pure 
lactic acid, as in making protein milk by Method II. Use 
Method II 
Method III 184 
PEDIATRIC NURSING 
either skimmed or whole milk. Boil it 2 minutes, stirring con- 
stantly, cool to below 100° F., and add 5-10 c.c. of lactic acid 
to a quart of milk. The curd is precipitated at once. Pour 
it into a fine wire strainer to drain off the whey. Add salt to 
taste to the curd. This method is advantageous because the 
curd is sterile, since it is made of boiled milk. 
Malt Soup 
Malt Soup (See Note 3). 
1. One and one-half ounces of wheat flour (6 level table- 
spoons) are mixed with 10 ounces of whole milk. Add a few 
tablespoons of milk to the flour and make a smooth paste, 
then add the rest of the milk slowly, stirring to prevent 
lumps and strain. 
2. One and three-quarter ounces of malt soup extract are 
added to 20 ounces of warm water. The two mixtures are 
then added one to the other, and the whole is heated slowly 
to boiling, meanwhile stirring constantly. Enough water is 
finally added to replace that which has evaporated, strain, 
bottle, and keep on ice. The percentage composition of this 
mixture is: 
Composition 
Fat 2.1 % 
Carbohydrate 13.84% 
Protein 2.86% 
It has about 625 calories per quart. 
Mead’s Dry 
Malt Soup 
Stock Powder 
Mead’s Dry Malt Soup Stock Powder. 
Mead’s Dry Malt Soup Powder may be used in place of 
malt soup extract. Mix 9 level tablespoons of the malt soup 
stock powder with water and make formula as given above. 
Buttermilk Mixture. 
Buttermilk 
Mixture 
Buttermilk has been used as a food for infants since at 
least as early as 1770 and good results have unquestionably 
been obtained with it. (See note 1.) 
1. Add 2 level tablespoons of wheat flour to a quart of 
buttermilk. To do this first add a few tablespoons of the ARTIFICIAL FEEDING OF INFANTS 
185 
buttermilk to the flour and stir together until a smooth paste 
is formed, then add the remaining buttermilk. Bring to a 
boil in a saucepan directly over the flame, stirring constantly, 
Remove from the fire for 5 minutes. 
2. Bring to boil the second time, stirring constantly. Re- 
move from fire for 5 minutes. 
3. Add 4 level tablespoons of cane sugar and bring to a 
boil the third time, stirring constantly. Make up to the origi- 
nal quart by the addition of water, bottle and keep on ice. 
Lactic Acid Milk.4 
There are 2 kinds of lactic acid milk: 
1. Skimmed lactic acid milk is made by inoculating skimmed 
milk with a pure culture of lactic acid bacilli. This is what 
is known as commercial buttermilk. 
2. Whole lactic acid milk is whole milk which has been 
inoculated writh a pure culture of lactic acid bacilli. 
Commercial buttermilk is not ordinarily fit for use in infant 
feeding, since it is likely to belcontaminated by undesirable 
germs. If it is boiled the curd forms a tenacious mass which 
cannot be broken up enough to feed through a nipple. Flour 
added to buttermilk will hold the curd in suspension by its 
colloidal action and the buttermilk can be boiled to sterilize 
it. Use 2 tablespoons of wheat flour to a quart of buttermilk. 
Mix an ounce of buttermilk with the flour first to make a 
smooth paste, then add the remainder of the buttermilk, 
stirring until it is wTell mixed. 
A pure lactic acid milk can be made in the following way: 
Sterilize 900 c.c. of whole milk by boiling 2 minutes in a 
saucepan directly over the flame. Pour into a sterile quart 
milk bottle, cover with a sterile square and let it stand until 
it is below 100° F. Then inoculate with culture of lactic acid 
bacilli, about a tablespoon of culture to 900 c.c. of milk. Put 
the bottle in an incubator to keep it at 100° F. for 12 hours 
Lactic 
Acid Milk 
To Boil 
Buttermilk 
To Prepare 
Sterilize 
Milk 
Inoculate 
Incubate 
4 Marriot, Wm. McKim, “Artificial Feeding of Athreptic Infants.” 
Journ. Am. Med. Assn., Oct. 18, 1919. 186 
PEDIATRIC NURSING 
or until the milk thickens. Different strains of culture re- 
quire varying lengths of time. If no incubator is available, 
the milk may be put into a tireless cooker, a thermos bottle, 
or a thermo-pack. It has been successfully coagulated by 
placing the bottle on a warm radiator. When it is thick, re- 
move it from the incubator and place on ice. 
Skimmed lactic acid milk is prepared in the same way, using 
skimmed milk. The properly prepared lactic acid milk is 
thick, creamy, and homogeneous. Too long a period of in- 
cubation, too high a temperature, or contamination of the 
milk results in the separation of the curds and whey. Karo 
syrup is the sugar ordinarily used with lactic acid milk. As 
stated above this is made up into a 50 per cent solution to 
facilitate the handling of it. To make this, mix 45 volumes 
of Karo syrup with 55 volumes of water and sterilize by boil- 
ing, put in a sterile bottle and keep on ice. Do not mix with 
milk until cool. 
To prepare lactic acid milk formulas strain the milk before 
using to break up the curd. Mix with water and Karo syrup 
in the proportions ordered. The use of a Dover egg beater 
will help to thoroughly mix the Karo syrup with the milk. 
Bottle the mixture and keep it on ice. Do not boil lactic acid 
milk unless flour is added and do not heat over 100° F. The 
culture of lactic acid bacilli does not need to be renewed 
oftener than every 2 or 3 weeks if it is carefully handled. 
Skimmed lactic acid milk can be used as a culture, inoculat- 
ing new milk from the old. Bulgarian bacilli cultures are 
the most serviceable, but other lactic acid producing organisms 
may be employed. 
Karo Syrup 
To Prepare 
Formulae of 
Lactic Acid 
Milk 
Culture 
Butter-Flour Mixture of Czerny.5 
Butter-Flour 
Mixture 
Put 7 grams of butter in a saucepan and heat over a slow 
flame until foaming occurs, and until any odor of volatile 
3 Griffith, J. P. Crozer, M.D., Mitchell, A. Graeme, M.D., ‘ ‘ Some Re- 
marks on Diet in Infancy with Special Reference to Employment of 
Czerny’s and Kleinschmidt’s Butter-Flour Mixture.” N. ¥. Med. J., 
Aug. 3, 1921. ARTIFICIAL FEEDING OF INFANTS 
187 
fatty acid has disappeared. This requires from 3 to 5 minutes. 
Seven grams of fine wheat flour are then added and the mix- 
ture is again boiled over a gentle fire with constant stirring 
until the mass becomes thin and of a brownish color (4 or 5 
minutes). One hundred c.c. of warm water and 5 grams 
of cane sugar are added. The whole is again boiled, is rubbed 
through a fine sieve, and is then mixed with the desired 
amount of boiled, cooled milk, and is kept cold until it is 
needed for use. The addition of salt is not necessary, since 
this is contained in the butter. For children under 3000 
grams in weight % milk is added to % of the butter-flour 
mixture. For those of 3000 grams or over % of milk and % 
of butter-flour mixture are employed. 
Percentage composition of stock solution of butter flour 
mixture: 
Composition 
Fat 5% 
Carbohydrate 10% 
Protein 0.5% 
One ounce (30 c.c.) of this mixture contains 
26.6 calories. 
Peptonized Milk. 
Dissolve the contents of a tube of pepsin in 60 c.c. of cool 
water and add to the amount of milk indicated in the direc- 
tions (usually 500 to 1000 c.c.). Allow it to stand at 100° F. 
to 105° F. for 20 to 30 minutes, or a shorter time if the least 
bitter taste is discovered. The mixture is then quickly cooled 
and is kept on ice, or, better, is heated quickly to boiling. 
Peptonized 
Milk 
Thick Cereal Mixture for Infants. 
A thick cereal mixture may be ordered for a baby with per- 
sistent vomiting, especially if the diagnosis is pylorospasm. 
The consistency of the food is the important point in the 
preparation of thick cereal feeding.6 Sauer advises 1 part 
Thick Cereal 
Mixture 
a Sauer, L. W., “Further Contribution to the Study of Pyloric 
Stenosis.” Am. J. Bis. Child., Aug., 1921. 188 
PEDIATRIC NURSING 
of cereal to 7 parts of fluid or a 15 per cent cereal in the 
mixture.7 Measure the desired amounts of milk, water, sugar, 
and salt, and mix them in the inner container of a double 
boiler. Add farina in proportions of 15 per cent of total 
mixture and cook for 1 hour in a double boiler, stirring fre- 
quently. The food should be so thick that it will stick to the 
inverted container. As an example of the usual proportions 
of this thick cereal mixture, Sauer gives the following: 
Skim milk 9 ounces 
Water 12 ounces 
Farina 6 tablespoons 
Dextri-maltose 3 ounces 
Salt 
To Feed 
Thick Cereal 
To feed thick cereal mixture to an infant Sauer says, “A 
satisfactory way to give the food is to have the required 
amount of the prepared food in a cup whichas immersed in a 
shallow saucepan containing hot water. By taking a little of 
the warm, thick cereal on the end of a tongue depressor it can 
very easily be placed far back in the open mouth and scraped 
off with another tongue depressor. A great deal of patience 
is usually required during the first few days since the infant 
will often keep the thick cereal in his mouth some time before 
swallowing it.” 
Experience at the University Hospital, University of Minne 
sota, and elsewhere leads to the recommendation of the use 
of the Hygeia nipple for feeding thick cereal. Cut a very 
large hole in the end, fill the nipple with the cereal mixture, 
and place it in the baby’s mouth. Secure a glass rod which 
will just fit into the tip of the nipple and with it work the 
contents through the hole into the baby’s mouth. His suck- 
ing will also help because this motion initiates the swallow- 
ing reflex. 
7 Chapin, H. D., M.D., “Use of Thick Cereal in Difficult Feeding 
Cases.” Med. Record., Sept. 24, 1921. ARTIFICIAL FEEDING OF INFANTS 
189 
Beef Juice.8 
Take to pound of round steak and broil it slightly. 
Cut into small pieces and then press out the juice with a 
meat press or a potato ricer, and add a pinch of salt. Feed 
fresh or warm slightly before giving, but do not heat suffi- 
ciently to coagulate the albumin. 
Beef Juice 
Scraped Beef. 
Use round steak cut in strips 1 inch in width. With a 
teaspoon scrape off the pulp, being careful not to scrape olf 
the long fibers. 
Scraped Beef 
Agar-agar Jelly. 
2 quarts water 
6 heaping tablespoons of granulated agar-agar 
Sugar—flavoring 
Agar-agar 
Jelly 
Let agar-agar soak in water over night; boil in this water 
for a few minutes, strain, add sugar and the desired flavoring. 
Serve as a dessert with cream and sugar, fruit juice, or stewed 
fruit. 
8 Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” CHAPTER XIV 
FOOD FOR THE CHILD 
Foods Other Than Milk Which Are Given the Infant under 
1 Year Old. 
Orange Juice 
Orange juice can be given any normal baby of 2 or 3 
months. The breast fed baby may have it to advantage; the 
artificially fed baby who has boiled milk must have it. Start 
with % teaspoonful strained and diluted half with warm 
sterile water; give it once a day at first, halfway between feed- 
ings, as at 12 noon or at 4 p.m. ; feed with a spoon or from a 
nursing bottle. Gradually increase the amount so that by the 
end of a month the baby is having y2 ounce of orange juice 
diluted half with water; no sugar should be added. It is be- 
lieved that tomato juice (canned tomatoes) contains the same 
antiscorbutic vitamins as orange juice and may be substituted 
for it; strain and give the same as orange juice is given. 
Prune juice may be given at 3 or 4 months of age or younger 
if necessary to prevent constipation. The same method is used 
as in the giving of orange juice. Cereal water 5 per cent is 
used as diluent of the milk of the artificially fed baby after 
the first 2 or 3 months. Rice, barley, and oatmeal are the most 
commonly used cereals. (See rules for making cereal water, 
Chapter XIII.) 
Both the breast fed baby and the artificially fed one may 
have cereal at 5 or 6 months of age. The finer milled cereals, 
as cream of wheat, farina, or Pillsbury’s wheat cereal, also 
strained oatmeal or a 6 per cent barley jelly, may be prepared. 
The cereal should be mixed with water and salt and cooked 
for 2 hours in a double boiler. It should be very thick. Start 
with 1 teaspoonful of cereal once a day. It may be fed thick 
Tomato Juice 
Prune Juice 
Cereal Water 
Cereals 
190 FOOD FOR THE CHILD 
191 
or it may be mixed with 30 to 60 cc. of the regular formula. 
If the baby is breast fed use a milk mixture, y2 milk and y2 
water (sterile) ; no sugar is used. Feed the cereal with a spoon 
and in this way start to teach the child to eat from a spoon. 
Give the cereal at the regular feeding time before the bottle 
feeding or nursing. Increase the amount so that in 1 month 
the baby is having 3 or 4 tablespoonfuls twice a day, before 2 
feedings, as at 10 a.m. and 6 p.m. 
Vegetables are given to both the breast fed and artificially 
fed baby when 7 or 8 months old. Carrots, spinach, peas, or 
string beans are the best. They should be seasoned with salt, 
well cooked, and mashed through a fine strainer. Save 
the water they have been cooked in because it contains vita- 
mins and should be given to the child with the vegetable. 
Start with 1 teaspoonful once a day, and gradually increase 
so that in 3 or 4 weeks 2 tablespoonfuls are given twice a day, 
or 4 tablespoonfuls once a day. Feed the vegetable with a 
spoon before a regular feeding from the breast or bottle. It 
may be mixed with the cereal and both given at the same time 
if desired. 
Toast or zwieback crumbs without butter may also be given 
at 7 or 8 months; soften the toast with the water the vege- 
tables have been cooked in; start with a small amount and 
increase gradually. 
Vegetable soups and purees may now be started. Broths 
as chicken, lamb, or beef, may be added to the diet, but as a 
general thing a milk and vegetable soup is to be preferred to 
broth. These soups may be fed the child in a nursing bottle, 
from a cup, with a spoon, or used to soften his toast. 
As soon as the baby has learned to take the above-mentioned 
foods satisfactorily, first one entire feeding (breast or bottle) 
should be dropped and should be replaced by some of these 
foods, and gradually other milk feedings should be omitted in 
the same way, so that by the time he is 10 or 11 months old 
he will be entirely weaned from the breast or bottle feedings. 
Drinking from a cup and eating from a spoon should be started 
Vegetables 
Toast 
Vegetable 
Soup 192 
PEDIATRIC NURSING 
when food other than milk is first given, and should be en- 
couraged so that he can carry these on successfully after he is 
weaned. 
At .9 months the following may be added to the diet: 
Stewed celery, beet greens, swiss chard. 
Inside part of baked apple (well cooked with a little sugar). 
Apple sauce Q00ke(j w-^j1 su„.ar make it palatable and strained. 
Prune pulp J 
The breast fed baby, when he is being weaned, is given 
proper milk dilutions, increasing the strength gradually as 
his individual tolerance permits. He should be taught to 
drink this milk from a cup. By the time he is 10 or 11 
months old and is completely weaned from the breast he 
should be having whole milk, not over 1 quart in amount, in 
addition to the above foods. 
The artificially fed baby is gradually weaned from the 
bottle in the same way, teaching him to drink from a cup, and 
gradually increasing the strength of his milk mixture as his 
tolerance permits. Following is a daily schedule for a child 
10 to 12 months old: 
6 a.m. Whole milk, 6-8 ounces, from a cup. 
10 a.m. Fruit juice or apple sauce, etc., cereal with whole 
milk (no sugar), toast or zwieback without butter. 
2 p.m. Vegetable soup or puree. 
Toast, softened with water vegetables have been 
cooked in. 
Generous serving of vegetable. 
Fruit or fruit juice. 
Milk, 4-5 ounces, if necessary. 
6 p.m. Vegetable soup or puree or milk, 8 ounces. 
Cereal with whole milk (no sugar). 
Fruit or fruit juice. 
Piece of zwieback without butter. 
10 p.m. Milk, 6-8 ounces, if necessary. 
Diet at 9 
Months 
To Wean 
from Breast 
To Wean 
from Battle 
Diet at 10 or 
12 Months FOOD FOR THE CHILD 
193 
From 12 to 18 months the following may be added to the 
diet: 
Diet from 12 to 
18 Mouths 
Vegetables (strained) 
Squash (summer). 
Boiled onions. 
Asparagus (fresh). 
Swiss chard. 
Cauliflower. 
Stewed celery. 
Strained tomatoes. 
Beet greens. 
Fruits (strained) 
Ripe bananas (baked). 
Apricots (stewed). 
Pears (stewed). 
Plums (stewed). 
Peaches (stewed). 
Rhubarb (stewed). 
Meat 
Crisp bacon occasionally 
Desserts without raisins 
Junket. 
Bread pudding. 
Tapioca (plain). 
Baked custard. 
Cornstarch (plain). 
Rice pudding. 
Cereals 
Cream of rye. 
Pettijobn’s wheat cereal. 
Rice. 
Spaghetti. 
Macaroni. 
Milk 
24 ounces in 24 hours 
Cottage Cheese 
The number of feedings has been decreased to 3 regular 
meals, 7 a.m., 12 noon, 5 p.m. 
From 18 to 24 months: 
Add meats once a day (small serving) 
Scraped or minced 
Diet from 
18 to 24 
Months 
Beef. 
Lamb. 
Mutton 
Lamb chop. 
Sweetbread. 
Crisp bacon. 
Desserts—Add 
Sugar cookies. 
Ginger snaps. 
Prune whip. 
Apple tapioca. 
Milk 
16 to 24 ounces a day 194 
PEDIATRIC NURSING 
Daily schedule from 18 to 24 months: 
7 A.M. 
Milk, 5-8 ounces. 
Cereal—not strained—no sugar. 
Toast with butter. 
Fruit (stewed). 
12 NOON. 
Soup. 
Baked potato. 
Meat as in list (small serving). 
Vegetable (generous serving). 
Bread with butter. 
Dessert as in list. 
5 P.M. 
Milk, 8 ounces. 
Vegetable soup or cereal. 
Bread and butter. 
Stewed fruit with cookies or dessert. 
From 2 to 4 years: 
Egg—begin by giving egg boiled, poached, or scrambled 
once a week, increasing gradually to a whole egg 2 or 3 
times a week, in place of meat at noon. 
Continue only cooked fruits, not strained, except raw scraped 
apple, orange with pulp, overripe banana. 
Cereals—all kinds, except uncooked, once or twice a day, 
not strained. 
Meat—once a day—scraped or minced or finely cut if the 
child chews properly. 
Vegetables—not strained—once or twice a day. 
Potatoes—boiled or baked—once a day. 
Milk—16-24 ounces. 
Three regular meals. 
Diet list for children from 4 to 10 years: 
Milk—16-24 ounces a day. 
Butter. 
Egg once daily—boiled, poached, or scrambled. 
Cottage cheese. 
Meat once a day—no fried meats. 
Chicken, boiled, baked, broiled. 
Diet from 2 to 
4 Years 
Diet from 
4 to 10 
Years FOOD FOR THE CHILD 
195 
Turkey, boiled, baked, broiled. 
Lamb, roast or chop. 
Beef, minced, roast, or beefsteak. 
Mutton, minced or roast. 
Bacon, crisp. 
White fish, boiled or broiled. 
Sweetbreads. 
Liver. 
Oysters. 
Meat juice as gravy, not thickened with flour. 
Soups—cream soups, purees, vegetable soups. 
Cereals—all cooked cereals, including corn meal, hominy grits, 
wheaten grits, etc., macaroni, spaghetti. No uncooked 
cereals. 
Breads 
Toast—dry or milk toast. 
Stale bread 
Wheat 
Graham. 
Whole wheat. 
Zwieback. 
Plain unsweetened crackers. 
Corn bread. 
No hot breads, fresh breads, muffins, etc. 
Plain educator crackers. 
Vegetables 
Fresh asparagus. 
String beans. 
Peas. 
Carrots. 
Spinach. 
Celery. 
Swiss chard. 
Squash. 
Lettuce. 
Potatoes. 
Lima beans. 
Cauliflower. 
Onions. 
Cooked tomatoes. 
Baked egg plant. 
Beets. 
Turnips. 
Parsnips. 
Fruits—given with meals, never between meals. 
Raw fruits. 
No uncooked berries. 
Orange, including pulp. 
Apples. 196 
PEDIATRIC NURSING 
Grape fruit. 
Grapes without seeds. 
Peaches. 
Pears. 
Baked bananas—not raw. 
Desserts 
Junket. 
Plain rice pudding. 
Plain cornstarch pudding. 
Baked custard. 
Prune whip. 
Ice cream, vanilla—once or twice a week. 
Plain cake. 
Cookies 
Sugar cookies. 
Ginger snaps. 
Tapioca pudding. 
Apple tapioca. 
Bread pudding. 
Plain gelatin. 
Jello. 
Candy—simple kinds after dessert, never between meals. 
It is impossible to follow absolutely any diet list or schedule 
because every child is an individual and all general rules 
must be modified to meet his particular needs. Also eminent 
authorities in all parts of the country disagree upon various 
points in children’s diets. Research is constantly being 
carried out along these lines and the results of investigations 
are daily giving us new facts and are forming new theories. 
(The lists given here have been approved by Dr. E. J. Huene- 
kins of Minneapolis.) 
From such data as is given concerning the energy require- 
ment of children one may assume that it is so high that they 
cannot gain at a normal rate without a good appetite and 
good digestion. One of the special needs of the school child 
as well as of the infant, is to have his diet so selected and 
his meals so arranged that he can ingest day after day from 
one-half to twice the amount of food which wrould suffice for 
Essential 
Points in 
Diets of 
Children FOOD FOR THE CHILD 
197 
an adult of the same size without taxing the alimentary tract 
unduly.1 The diet of school children should emphasize: 
a. Regularity of meals. 
b. An adequate number of meals. 
c. An even distribution of the amount of food. 
d. Bland, simple, and easily digested natural foods, as milk, 
cereals, bread, and potatoes, free from high seasonings. 
e. The quantitative requirement expressed in terms of: 
1. High energy. 
2. Protein sufficient for growth. 
3. A rich and varied supply of ash constituents. 
4. A liberal supply of vitamins. 
5. Foods that demand mastication. 
6. Foods that prevent constipation. 
In addition to the care in the selection of foods and intelli- 
gent education in eating habits, the child must have regular 
hygienic habits in general, including plenty of rest and sleep 
and freedom from overwork and excitement.1 
Dr. Dennett2 says that the foods that do the child the most 
good are: first, milk; second, vegetables; third, cereals; and 
fourth, bread stuffs. 
Milk. 
The same precautions against the contamination of milk 
used for the infant must be followed throughout childhood. 
It has gone out of style to call milk the ‘ ‘ perfect food, ’ ’ since 
no one food is that for the human organism (except breast 
milk during the first year of life) and all foods are good in 
their way. However, milk may be considered the cornerstone 
for the construction of an adequate diet since it tends to make 
good the deficiencies of other foods in a variety of directions. 
It can also be utilized as a carrier of other foods, as cereals, 
eggs, vegetables, bread, etc., in children’s diets. Milk must 
not be given in excess, to the exclusion of other foods. (See 
Milk 
Mary Swartz, “Question of Child Feeding.” Modern Hos- 
pital, Nov., 1919. 
2 Dennett, Roger, M.D., ‘ ‘ Some Dietetic Problems of Infancy and 
Childhood.” Modern Hospital, June, 1921. 198 
PEDIATRIC NURSING 
note 1.) The general opinion is that from a pint to a pint 
and a half is sufficient in 24 hours for the child.3 
Vegetables 
Vegetables. 
Recent scientific knowledge is early (at 7 to 8 months) 
introducing vegetables into the diet of the child because of 
the iron and vitamin content. They are given well cooked 
and strained up to 18 months or 2 years. The water in which 
the vegetables have been cooked is saved because it contains 
many of the valuable properties of the vegetable; it may be 
given with the vegetable; it may be used to soften the toast; 
or it may be made into a vegetable soup with milk. The child 
who has not been accustomed to eat vegetables at an early age 
may refuse them when they are offered to him; this is espe- 
cially true of the poorly trained child often admitted to the 
hospital. In such a case there should be a rule that he can 
have no dessert until he has eaten his vegetables, and he will 
soon learn to eat them. 
Cereals. 
Cereals 
Cooked cereals have a definite place in the daily diet of the 
child; beginning at 2 or 3 months the artificially fed baby 
has cereal water in his milk; the breast fed baby and the 
artificially fed baby both have cereals at 6 months. From 
the first they should be given without sugar and in this way 
the child will never develop the desire for sugar on his cereal. 
(All cereals taste alike if they are sweetened.) Uncooked 
cereals should be avoided. Children like them so well that an 
occasional exception may be made, as on Sunday morning, 
when a spoonful of dry cereal may be sprinkled on top of the 
cooked cereal. 
Fruit. 
Fruit 
Not only do children like fruits, but they are also valuable 
aids in their diet because of the vitamin content, fuel value, 
*Von Der Bogert, Frank, M.D., “Limitations of Milk in the Diet 
of the Older Child.” Albany Med. Annals, May, 1921. FOOD FOR THE CHILD 
199 
and laxative quality. Orange juice because of its antiscorbutic 
properties is given at 2 or 3 months. Prune juice can be added 
soon after, and can be given for constipation at almost any 
age. Only cooked fruits are given to children under 2 years 
(except orange juice) and uncooked fruits are given very 
sparingly until after 4 years. Oranges and scraped raw apples 
are the exceptions. Fruit should be given as part of the 
regular meal, and should not be given between meals. 
Meat. 
There is much discussion as to when the child may be given 
meat. (See notes 1 and 2.) The above outline allows a small 
portion of scraped meat once a day beginning at 18 months. 
A little crisp bacon may be given after 12 months. 
Meat 
Broth. 
Broth may well be replaced by vegetable or milk and vege- 
table soup in the diet of the child.4 
Brotb 
Beef Juice. 
Beef juice has formerly been used in the child’s diet par- 
ticularly to the exclusion of everything else to supply iron. 
Now green vegetables are being largely substituted for it, 
because they are less expensive, easier to produce, and con- 
tain vitamins not contained in the beef juice. The extractives 
of the meat contain stimulating properties which are not 
desirable for the young child. (See note 1.) If beef juice is 
given it should never be heated sufficiently to coagulate the 
albumin. (See directions for preparing.) 
Beef Juice 
Eggs. 
The yolk of egg is rich in iron, but there is considerable 
difference of opinion as to how children tolerate it. Half an 
egg is given at first once a week, gradually increasing the 
amount and frequency until a whole egg is given several times 
a week in place of meat. 
Eggs 
4Leo-Wolf, C. G., M.D., '‘Nursing in Diseases of Children.n 200 
PEDIATRIC NURSING 
Sugar 
Sugar. 
Dr. Dennett says that in his children’s diets he allows them 
no added sugar and that even then they get more than they 
should have. (See note 2.) Certainly no extra sugar need 
be put on cereals or other foods, and if the baby never has 
his food oversweet, he will never develop the taste for it. 
Candy. 
Candy 
Candy, besides tending to cause indigestion, is bad for chil- 
dren’s teeth and should be strictly limited. The desire for 
it is largely a habit started by curious and ignorant parents 
to amuse themselves by watching the child’s reaction to the 
sweet taste. If properly trained, the child may very well do 
without candy. If it must be given it should be limited to a 
piece or two directly after meals and included as part of the 
dessert. It should never be allowed unless all the meal 
including vegetables, etc., has been eaten. 
Ice Cream. 
Ice Cream 
Simple vanilla ice cream may be given as dessert once or 
twice a week, but not often enough to establish a habit. Ice 
cream cones between meals should never be tolerated. 
Foods forbidden to children under 4 years old and avoided 
until 7 or 10 years old (with a few exceptions) :5 
Foods to 
Avoid 
Meats. 
All fried meats, ham, sausage, pork of all kind (except 
crisp bacon), salt fish, corn beef, game, goose, duck, meat 
dressings, meat stews, and gravy made from grease or drip- 
pings. 
Vegetables. 
Fried vegetables of all varieties, raw or fried onions, 
radishes, cucumbers, raw tomatoes, green corn. 
6 Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” 
Holt, L. Emmett, M.D., “Diseases of Infancy and Childhood.” 
Morse, John L., M.D., “Care and Feeding of Children.” 
Griffith, J. P. Crozer, M.D., “Diseases of Infants and Children.” FOOD FOR THE CHILD 
201 
Fruits. 
All dried fruits unless steamed or stewed, bananas unless 
baked, or overripe; all fruits out of season and unripe, sour, 
stale, or wilted fruits; strawberries, gooseberries, blueberries, 
pineapple. 
Breads and Cake. 
All hot, fresh bread, rolls, or muffins; buckwheat and all 
other griddle cakes; all fresh sweet cakes, particularly those 
containing dried fruits and those heavily iced. 
Desserts. 
All nuts, candies, pies, tarts, pastry of every description; 
all heavy, doughy or very sweet puddings; also all salads, 
jellies, jams, syrups, preserves, and other highly seasoned 
foods. 
Drinks. 
Tea, coffee, alcoholic beverages, soda water, and cocoa should 
be avoided. The latter stimulates and also causes the child 
to think he must always have some warm drink and he will 
later substitute tea or coffee as a matter of habit. 
Straining of Food and Mastication. 
The oral hygienist tells ns that in order to prevent dental 
disease foods must be selected which require thorough masti- 
cation, for the use of the teeth is one of the most important 
points in their preservation and development.6 Food, as 
vegetables, fruits, etc., for the small child must be strained; 
but as soon as he has enough teeth, usually 18 months to 2 
years, the straining should be done away with and he should 
be taught to thoroughly masticate his food. Every meal 
should contain a portion of hard or dry bread, as rye crisp, 
which requires chewing. 
Straining of 
Food and 
Mastication 
8 Talbot, F. B., M.D., ‘ ‘ Relation of Diet to Development of Children, 
with Special Reference to the Teeth.” Medical Annals of N. A., March, 
1919. 202 
PEDIATRIC NURSING 
Food Habits. 
Food Habits 
Regularity in eating is absolutely essential to health. This 
regularity should be started at once with the newborn baby 
and should be continued throughout childhood. In this man- 
ner his mind is trained to the idea and he will always continue 
his regular habits. At first the baby has 5 feedings every 
24 hours until he is 9 or 10 months old, when 2 feedings are 
omitted gradually so that by the time he is 12 months old 
he will have 3 regular meals. His heaviest meal should be at 
noon. 
No child under 2 years should be permitted to sit at the 
family table. If possible it is better for the child under 4 
years to have his meals served separately. If this cannot be 
done, he should be so trained that he will take it as a matter 
of course that he has his own food and that the family may 
eat other things. 
Eating between meals is the most pernicious of all dietetic 
habits and should never be tolerated. (See note 3.) Too 
much emphasis cannot be brought to bear upon the importance 
of this, and there should be no exceptions made to the rule. 
Water should be served with all the meals and given be- 
tween meals. The small baby should be offered water once or 
twice daily and oftener in hot weather. Older children should 
be encouraged to drink a considerable amount. When a child 
complains of hunger between meals give him a drink of water. 
Children’s meals ought to be served in an attractive manner, 
both in the home and in the hospital. There are beautiful 
little dishes with blue birds, bunnies, etc., on them which give 
the child great delight. He should be given these dishes from 
the first and should be taught to respect them and to be care- 
ful not to break them. In this way he will soon learn to take 
great pride in them. It is a mistake to give the child unbreak- 
able dishes fearing that he will break the others. Give him 
the others and assume that he will be careful of them. 
Children, especially small ones, do not demand much 
Kegularity 
of Meals 
Eating 
between 
Meals 
Water 
Serve in an 
Attractive 
Manner 
Variety 
of Food FOOD FOR THE CHILD 
203 
variety in their food unless ideas are put into their heads 
by adults. On the other hand a child cannot be expected to 
sit down to exactly the same articles of food every day. A 
reasonable variety is advisable to stimulate his appetite. He 
must be taught to eat any new food without comment. There 
are many articles of diet to which the child of pre-school 
age has to become accustomed; these should be given to him 
gradually, being careful not to express doubt as to his liking 
or eating them. When preparing food see that cold foods are 
served cold, and that warm foods are served warm; but also 
see that the food is not hot enough to burn the child. Pre- 
pare the small child’s food for him; cut his meat, etc., grad- 
ually teaching him to do this for himself when he is able to 
do so, thus developing independence. His eating habits should, 
however, be carefully supervised. At meal time prepare him 
for his meal, teach him to wash his face and hands before eat- 
ing (also after eating) ; put his bib on him and let him sit 
down to his little table in a chair which will bring him to a 
proper level with the table; place his food before him and 
express no doubt as to his eating it. Serve small portions, 
thus teaching him to eat everything on his plate. He should 
be taught to be neat in his eating habits; untidy habits show 
lack of training on the part of the parents. The small child 
just beginning to eat has to be fed, but he must be taught to 
handle a spoon and to feed himself as soon as possible. A 
small spoon with a short handle is much easier for him to 
handle at first; later, after he has learned to use the spoon, 
he should be given a small fork and should be taught the 
different uses of the spoon and fork. He must not be allowed 
to dawdle over his food or to play with it; on the other hand 
he must not eat too fast, but must be instructed to thoroughly 
masticate his food, and he should be given foods that require 
chewing. (See note 6.) If a child of any age persists in 
eating too fast the habit may be overcome : (1) if another per- 
son feeds him every mouthful of food until he learns to eat 
properly (this method will not take many days) ; or (2) he 
Teach Child 
to Eat 
Properly 204 
PEDIATRIC NURSING 
may be given a very small spoon, as a salt spoon, with which 
to eat. 
Never consult a child about what he wants to eat any 
more than he would be consulted about the selection of a new 
coat or shoes. He is no more capable of choosing one than the 
other. Never put notions into his head about food by saying 
that he will not eat this or that, or by discussing the likes and 
dislikes of other people in front of him. Excepting only an 
idiosyncrasy in regard to some special food (which is rare) 
any healthy child should be taught to eat, without question 
or objection, any food that is put before him. Educate him 
as well as train him; tell him ivhy certain foods are good for 
him and others not. A good rule is never to allow a child 
his dessert until he has eaten a sufficient amount of other food, 
including his vegetable. If a normal, healthy child refuses 
his food, and it is simply because of some notion that he does 
not like it, or does not wish for it, do not waste time arguing 
with him, and do not use bribery, threats, deception, or 
force. After he has been given a reasonable amount of time 
in which to eat it, take it away and offer him nothing else. 
Let him go hungry until the next meal time. Then offer him 
the same kind of food he refused before; continue to do this 
until he consents to eat. 
The sick child who refuses to eat is a different problem 
from that of the well child, because going without food may 
do him a definite harm. In such a case the nurse or mother 
must be guided by the baby’s condition and the doctor’s 
orders. The utmost patience and skill, and the greatest pos- 
sible understanding of child psychology is necessary on the 
part of the nurse to win out. Never cater to the whims of 
his appetite, for he often is craving the very foods he should 
not have. Here again deceit must never be used; bribery and 
threats are also avoided and it is seldom necessary to resort 
to force. It is always safe to deprive the child of his dessert 
if he refuses other food. 
Often the sick child should take large quantities of liquids 
If a Child 
Refuses 
to Rat 
The Normal 
Child 
The Sick 
Child FOOD FOR THE CHILD 
205 
as part of his treatment. There may be more or less difficulty 
in making him drink. Sometimes if he is given a straw to 
drink through the novelty will stimulate him to take more 
fluids. The very sick child who cannot sit up to drink has to 
take his fluids through a bent glass drinking tube, a straw, 
or an especially designed feeder. Often a small child or one 
who is delirious will bite the end of the glass tube; in this case 
a small piece of rubber tubing may be substituted. 
The diet of the school boy or girl has to be just as care- 
fully watched as that of the younger child. If he has had 
proper training early in life there will not be much difficulty 
when he is older. See that he gets up early enough to allow 
him to eat his breakfast leisurely; (also to allow him time 
to go to the toilet before going to school). Sufficient time 
must also be allowed him for lunch at noon. Lunches, as a 
drink of milk, etc., at school during the morning or afternoon 
are not necessary for the normal healthy child who eats three 
adequate meals at home. Such lunches should be given only 
with the doctor’s orders, as in cases of malnutrition or if the 
child’s home conditions are poor, not allowing him sufficient 
food. 
The School 
Child 
READING REFERENCES 
Holt, L. Emmett, M.D.—Care and Feeding of Children. 
Ramsey, W. R., M.D.—Care and Feeding of Children. 
Smith, R. M., M.D.—Baby’s First Two Years of Life. CHAPTER XY 
URINE AND STOOL IN INFANCY AND CHILDHOOD 
Care of Buttocks. 
A baby’s buttocks need special care since they are very 
frequently irritated with soiled diapers. In an institution 
diapers should be changed every time the baby has a defeca- 
tion and as much oftener as possible, at least every four hours. 
He should not be taken from his bed to have this done, but a 
buttock tray containing the following articles and a basin 
for soiled diapers may be taken to the bedside (the tray 
may be a basin 12 x 8 inches and 2 inches high) : 
1. A paper bag for waste: 
2. A tray of various sized safety pins. 
3. A bottle of unsterile oil to wash buttocks. 
4. A basin 4 inches in diameter for oil. 
5. A jar of unsterile cotton pledgets—made of second grade 
cotton and made the size of a walnut. 
6. A jar of 5 per cent lysol containing the handling forceps. 
A child’s buttocks are washed every time his diaper is 
changed. Remove the soiled diaper, wiping the buttocks free 
of feces with it; put it in the basin and place a clean diaper 
under the child. Remove a cotton pledget from the jar with 
the handling forceps and dip it into the pan of oil; place the 
forceps back in the antiseptic, take the pledget between the 
fingers, and wash the buttocks with it. It may be necessary 
to use several pledgets to clean the buttocks and genitals. 
Never dip a pledget back into the pan after using it. When 
cleaning a baby girl’s buttocks care must be taken not to in- 
fect the urinary tract with fecal matter; wash the genitals 
first, separate the labia and wash under the folds, sponging 
away from the urethra; then clean the buttocks, wiping down- 
When to 
Change 
Diapers 
Buttock Tray 
To Clean 
Buttocks 
206 URINE AND STOOL IN INFANCY 
207 
ward away from the genitals. Excoriated buttocks may be 
caused by: 
1. Lack of care of the buttocks. 
2. Improper laundering of the diapers. 
3. Frequent acid stools. 
4. Ammoniacal urine. 
If a healthy child’s diapers are changed when he is wet 
or soiled, his buttocks washed with oil and his diapers properly 
laundered, he should have no trouble with excoriated but- 
tocks. No other treatment is necessary. If there is a strong 
odor of ammonia and a dermatitis of the diaper region results,1 
this ammoniacal fermentation can be eliminated by the use of 
antiseptics in the diaper and the dermatitis will disappear. 
After washing the diapers soak them in a solution of mercuric 
ehlorid 1 :5000, wring well and dry before using. (Laun- 
dering of diapers discussed under clothing—diapers, Chapter 
III.) The hospital w7ard should be equipped with a covered 
enamel pail for soiled diapers; they should not be put with the 
general soiled linen. The fecal material should be washed 
from them at once with a brush, holding them under running 
water. Wet diapers are rinsed when removed and all are put 
in the covered pail until laundered. 
If a baby has excoriated buttocks which are due to fre- 
quent diarrheal stools, make every attempt to keep him dry 
all the time. If the stools or urine are strongly acid wash the 
buttocks with sodium bicarbonate solution 5 per cent to neu- 
tralize the acid, then apply any soothing ointment as lanolin 
or a mixture of equal parts of zinc oxid ointment and castor 
oil, or mutton tallow and lard (Dr. F. C. Kodda). Open-air 
treatment sometimes helps; place the child on a Bradford 
frame (details under collection of a 24-hour specimen of 
urine). Instead of using the adhesive method of collecting the 
urine, place a piece of absorbent cotton over the genitals to 
absorb the urine and change this frequently. The stools go 
Cause of 
Excoriated 
Buttocks 
To Prevent 
Ammoniacal 
Odor of 
Diapers 
Care of Wet 
or Soiled 
Diapers 
To Prevent 
Excoriated 
Buttocks 
from Acid 
Stools 
Open-Air 
Treatment for 
Excoriated 
Buttocks 
1 Cook, ,T. V., M.D., “Etiology and Treatment of Ammonia Dermatitis 
of the Gluteal Region of Infants,” Am. J. Bis. Child., Nov., 1921. 208 
PEDIATRIC NURSING 
immediately into the basin below the buttocks and the child 
never has to lie in a wet or soiled diaper. 
Bed Pans. 
Bed Pans 
Separate bed pans should be provided for every child in the 
hospital and urinals for every boy. These can be kept in a 
rack in the service room; they should be cleaned well and 
sterilized once a week and after the discharge of a patient. 
To give a bed pan to a child, screen the bed, warm the 
pan by holding it under warm water, dry it, cover with a 
bed pan cover made of ticking or heavy unbleached cotton, 
and take it with the toilet paper to the patient. Stand on the 
right side of the bed if possible, have the child flex his knees 
with his heels resting upon the bed, place the left hand under 
his buttocks and lower back, raise him up enough to slip the 
bed pan under him with the right hand, and lower him on to it. 
To remove the bed pan, have the child flex his knees, put the 
left hand under his back to raise him from the pan and remove 
it with the right hand. A folded towel or a pad put over the 
part of the bed pan with which the patient’s back comes in 
contact makes it more comfortable for him. After removing 
the pan the nurse must use the toilet paper, for the child 
cannot do it efficiently himself. If he has a defecation and 
cannot be well cleaned with toilet paper he must be 
sponged clean; to do this, fill his basin with warm water and 
bring it to the bedside with pieces of waste cotton and a paper 
bag. Sponge him clean and dry his buttocks. The bed pan 
must be washed thoroughly after use with the hopper brush 
and warm water and dried. 
A specimen of stool is usually routine for every child ad- 
mitted to the medical service and as soon as possible after ad- 
mission. All unusual stools should be saved for the doctor’s 
observation. 
To Give a 
Bed Pan 
Care of Child 
after Use of 
Bed Pan 
Care of 
bed pan. 
Stool 
Specimen 
The Urine in Infancy and Childhood. 
Frequency 
of Urination 
A small baby urinates frequently when awake, 2 or 3 times 
an hour, but much less frequently when asleep. He will often URINE AND STOOL IN INFANCY 
209 
be found dry after several hours of sleep but will urinate 
immediately after waking. It is possible to train a child of a 
year or even younger so that he never, or seldom, wets his 
diaper. Infants of 3 months have been trained to go without 
a diaper except at night. By the time a child is 2 years old 
he should have learned to indicate his desire to urinate; at 3 
years he should have sufficient control of his sphincter muscles 
not to wet the bed at night; if he has not, extra fluids in the 
late afternoon should be restricted; he should empty his 
bladder just before going to sleep, and he should be taken up 
to urinate at 10 p.m. and once or twice after that, as neces- 
sary. 
Average amount of urine passed in 24 hours:2 
Daily Average 
Amount 
of Urine 
Age 
Ounces 
Grams 
1st 24 hours 
0 to 
2 
0 
to 60 
2d 24 hours 
y3 to 
3 
10 
to 90 
3 to 6 days 
3 to 
8 
90 
to 250 
7 days to 2 months 
5 to 
13 
150 
to 400 
2 to 6 months 
7 to 
16 
210 
to 500 
6 months to 2 years 
8 to 
20 
250 
to 600 
2 to 5 years 
16 to 
26 
500 
to 800 
5 to 8 years 
20 to 
40 
600 
to 1200 
8 to 14 years 
32 to 
48 
1000 
to 1500 
The urine of the newborn is usually highly colored. The 
reaction at first is strongly acid; the specific gravity is 1.010 
to 1.012 and it is in proportion to the amount voided. Later, 
as fluids increase, it becomes lighter, almost straw colored, is 
slightly acid or neutral in reaction, the specific gravity is 
lower, 1.004 to 1.016, and remains thus throughout childhood. 
Any unusual appearance of the urine or any unusual odor 
must be noted and reported. The newborn often has a pinkish 
stain on his diaper which may be mistaken for blood; this 
may be due to the urates or uric acid crystals which are de- 
posited in the tubules of the kidney during intra-uterine life. 
As the kidney begins to function they are dissolved and ex- 
creted. The condition, however, should always be reported 
Appearance 
of Urine 
2 Holt, L. Emmett, M.D., 11 Diseases of Infancy and Childhood. ’ ’ 210 
PEDIATRIC NURSING 
as the differential diagnosis demands a microscopical examina- 
tion. 
To collect urine for examination. A single urine specimen 
and a 24-hour amount are collected from the older child as 
from the adult. It is often difficult to collect urine from the 
small child who is incontinent. There are various methods 
employed. 
To Collect 
Urine 
Specimen 
from Child 
To Collect 
Urine 
Specimen 
from a Baby 
Boy 
To collect urine from a baby boy. 
Figure 20. Test-tube on a Boy to Collect Urink 
Equipment: 
Test-tube. 
Adhesive. 
Bandage—2 pieces long enough to tie the legs to the 
crib side. 
Equipment 
Wash the genitals with soap and water and dry. Inspect 
the edge of the test-tube for nicks which might cut the baby. 
It is safer to always bind it with adhesive. Place his penis 
in the test tube and hold in position with narrow strips of 
adhesive from the tube up over the pubis. It is advisable to 
tie his legs to the side of the bed with a bandage so that he 
cannot kick the tube off. A finger cut from an old glove 
and with the tip cut off can be attached to the test tube with Male 
female 
Figure 21.—Test-Tube with Glove Finger for Obtaining Urine from 
a Boy. Test-Tube with Glove Finger for Obtaining Urine from a 
Girl. The Distance from a to b Should Equal Distance from 
the Rectum to the Vagina. 
Figure 22. Test-tube on a Girl to Collect Urine 
211 212 
PEDIATRIC NURSING 
a narrow strip of adhesive and the penis put into the glove 
finger. By this method the test-tube does not come in contact 
with the skin to irritate it. 
To collect urine from a baby girl. 
(1) Adhesive method. 
Equipment: 
Bandage—2 pieces long enough to tie the legs to the 
crib side. 
Adhesive. 
Test-tube or Erlenmeyer flask. 
Wash the genitals with soap and water and dry. Bind 
the top of the test tube with adhesive; take a piece of ad- 
hesive 2 or 3 inches square, depending on the size of the child; 
slit it in the middle in 4 ways making a hole large enough 
to put the tube through; adjust the adhesive to the outside of 
the tube and make it secure with a narrow* strip of adhesive. 
Cut out a triangular piece from the middle of one side of the 
adhesive so that the distance from the tip of the triangle to 
the rim of the test-tube is the same as the child’s perineum. 
Fit this directly over the perineum so that the opening of the 
tube is directly over the meatus and vulva and the triangular 
opening fits over the rectum on either side. Strap the other 
edges of the adhesive around the vulva on the sides and reen- 
force all sides w*ith narrow strips of adhesive. The child’s 
legs are tied to the side of the crib so that she will not kick 
the tube off. If the hips are elevated by a small pillow under 
them there is a downward flow of urine which aids in collect- 
ing it. The test-tube may be prepared with a glove finger as 
for the baby boy; the top of the finger is attached to the center 
of the adhesive square in the same manner. 
(2) To collect urine without adhesive a belt can be made 
of cotton cloth with an opening in the center in which the test- 
tube fits; the rim of the tube must be bound with adhesive. 
The belt fastens around the abdomen and the straps are 
brought around the groin and fastened. The belt can be used 
for boys or girls, but it is more successful for boys. It is 
To Collect 
Urine from 
Baby Girl 
Adhesive 
Method 
Equipment 
Use of 
Cotton Belt URINE AND STOOL IN INFANCY 
213 
especially valuable if the baby’s skin is too sensitive to stand 
the application of adhesive or if a daily specimen has to be 
obtained over a long period of time. 
(3) A specimen of urine can often be obtained by holding a 
child over a basin and making slight pressure over the bladder 
or by putting a cold application over it. This is successful in 
most cases if the child has not urinated for some time, espe- 
cially if awakened after several hours of sleep. 
(4) If other methods fail and the skin is too irritated to 
permit the use of any kind of apparatus, a piece of absorbent 
Make 
Pressure over 
Bladder 
Use of 
Absorbent 
Cotton 
Figure 23. Cotton Belt to Hold Test-tube for Collecting Urine 
cotton may be put in the diaper over the genitals and if the 
child urinates without having a stool, the urine can be squeezed 
from the cotton into a specimen glass. 
(5) Another method is to allow the child to lie on a small 
rubber air cushion with a hole in the center and a basin under 
it. The surrounding portion of the bed is built up with pil- 
lows to the level of the cushion and the infant with diaper 
removed and his legs tied to the sides of the bed is allowed to 
lie with his buttocks over the hole in the cushion until urine 
is passed into the basin. 
There are various kinds of baby urinals (as Spicer Infant 
Urinal) on the market which are more or less successful, but 
Use of 
Rubber 
Ring 
Baby Urinals 214 
PEDIATRIC NURSING 
the adhesive method has been used the longest and seems the 
most satisfactory in the end. 
A specimen of urine must be obtained from the child as 
soon as possible after admission to the hospital. A 24-hour 
specimen, beginning the second 24 hours after admission, is 
usually routine for every child admitted to the medical service. 
In most institutions it is the responsibility of the night nurse 
to obtain these. When a specimen is ordered for a baby it is 
essential that an attempt to collect it be made early in the 
evening; then if the first attempt is not successful there is 
time for a second. It should be one of the duties of the nurse 
on evening duty to put test-tubes on all babies when speci- 
mens are ordered. 
To collect a 24-hour specimen of urine from a baby. 
There are various methods used.3 A satisfactory method is 
the use of the Bradford frame. Select a frame that is longer 
and wider than the child’s body; cover it with a canvas which 
has a hole three-fourths of the distance from the top. (This is 
■where the child’s buttocks wfill come.) Cover the canvas with 
sheets to protect it, pinning them on the under side. Fold 
an abdominal binder to fit the child and pin it on either side 
of the frame where his body will come; place him on the frame 
with his rectum directly over the opening in the canvas and 
hold him in this position by pinning the binder tightly around 
his abdomen. Restrain his legs by tying a piece of bandage 
around each ankle and pinning it to the canvas on either side 
of the frame. In cold weather put stockings on his feet and 
pin them to the abdominal binder or to the canvas; put a 
shirt on him, back side in front, and fasten only the top but- 
ton so that there will be no hard surfaces under his body. 
Elevate the frame on blocks high enough to allow a bed pan 
or basin to be slipped under the buttocks to collect feces. 
Have the frame several inches higher at the head than at the 
Routine Urine 
Specimen 
To Collect 
a 24-Hour 
Specimen of 
Urine from 
Infant 
3 Courtney and Fales, ‘ ‘ Comfortable Arrangement for Separate Col- 
lection of Urine and Feces of Male Infants. ’ ’ Am. J. Bis. Child., Dec., 
1915. Figure 24. Canvas Cover for Bradford Frame 
215 Figure 25. Frame Prepared for Collection of 24-hour Specimen of Urine 
216 URINE AND STOOL IN INFANCY 
217 
foot. Rolls of blanket can be placed at the sides of the frame 
to prevent draughts reaching the child from the open spaces 
under him. In cold weather hot water bottles may be neces- 
sary around him to keep his temperature up to normal. For 
the collection of the urine use the adhesive method (as de- 
scribed above). Instead of a test-tube, use 2 pieces of rubber 
tubing connected by a glass connecting tube; attach a glove 
finger to one end, adjust it to the child, and put the other 
end of the tube in a bottle tied to the side of the crib. A 24- 
Figure 26. Tube for the Collection of a 24-hour Specimen of 
Urine 
hour specimen of urine may be collected from a baby girl in 
this way, but it is more difficult than from the boy; close sur- 
veillance is necessary and the adhesive has to be changed 
several times a day. If the perineum is well covered so that 
the feces cannot contaminate the urine, it is successful. If 
the adhesive is run through a flame to heat it before applying, 
it will stick better. A collodion dressing over the adhesive 
at the perineum will help to keep it in place. If a child is 
kept on a frame for any length of time, his back will need 
special care. To have this done he can be turned on his face 
once or twice daily immediately after he has urinated. 
The Stools in Infancy and Childhood. 
Intelligent observation of a baby’s stools,4 whether he is 
sick or well, is essential because abnormal stools are the first 
Importance 
of Intelligent 
Observation 
of Stools 
* Morse and Talbot, ‘ ‘ Diseases of Nutrition and Infant Feeding. ’ ’ Figure 27. Baby on the Frame for the Collection of a 24-hour 
Specimen of Urine 
218 URINE AND STOOL IN INFANCY 
219 
signs of many illnesses, and much trouble can be forestalled 
by recognizing the first symptoms.5 The stools of all infants 
in a hospital are saved as a matter of routine because they 
furnish valuable aid in judging a patient’s condition. Ab- 
normal stools and stools of older children suffering from di- 
gestive disturbances are saved daily for inspection. Every 
baby whose stools are saved should have a pail marked with 
his name into which the napkins containing them are put. 
This pail should be about 7 inches in diameter; it should 
have a bail or handle and a tightly fitting cover. Every 
child’s pail can be kept on a shelf in the service room (if the 
covers fit tightly there will be no disagreeable odor). If 
possible it is best to keep them in a specially constructed 
cupboard ventilated by an open wdndow. When the doctor is 
expected to make rounds they can be taken to the bedside and 
the napkins can be opened out on the inside of the cover of 
the pail. A tongue blade makes a convenient spatula with 
wdiich to examine them. 
To Save 
Infant’s 
Stools for 
Inspection 
When examining stools note: 
1. The number of stools during 24 hours. 
2. The size of the stool. 
3. The consistency of the stool. 
4. The color of the stool. 
5. The odor of the stool. 
6. The reaction of the stool. 
7. The presence of abnormal material, curds, mucus, blood, 
undigested food (in older children), pus and membrane. 
Points to 
Note 
Regarding 
Stools 
1. The normal breast fed baby has from 3 to 5 stools daily, 
while the artificially fed baby has from 1 to 3 and is more 
subject to constipation. However, individual babies differ; 
some may have only 1 a day and sometimes only 1 every 2 
days and still may be normal. 
2. The size of the stool depends on the number in 24 hours 
and upon the amount of food ingested. If all the stools are 
small the nurse may suspect that the baby is not having 
Number 
of Stools 
Size of Stools 
“Dunn, Charles H., M.D., “Pediatrics.” 220 
PEDIATRIC NURSING 
enough food. If he passes large ones he may not have more 
than 1 a day or 1 every 2 days. 
3. The normal breast fed baby passes soft stools of the 
consistency of pea soup, while the normal artificially fed 
baby passes firmer ones, salve-like in consistency and often 
formed. Constipation causes them to be more firm. Fre- 
quent stools are watery, usually the looser they are the more 
severe is the diarrhea. A loose stool which is foamy or 
frothy when first passed suggests an excess of carbohydrates 
in the diet. 
4. The usual colors are brown, yellow, white, green, black, 
gray, pink, and blue. The color may change, therefore it 
should be examined at once for accurate interpretation. 
Brownish yellow stools are normal for the breast fed baby, 
but are also caused by cereal water, by dextri-maltose, or by 
malt soup mixtures in the diet. Yellow stools are normal for 
the baby who is fed on cow’s milk. White ones are due 
to an excessive amount of undigested fat which is in the form 
of soaps; they are usually quite firm and dry. Green stools 
are the most common abnormal stools; they may be any shade 
from the lightest grass green to a very dark green, the darker 
the green the greater the significance. Occasionally a nor- 
mal looking yellow stool will turn green after exposure to 
air; this has no significance nor are one or two light green 
stools significant in either a breast fed or an artificially fed 
baby. However, frequent green, watery stools are significant. 
Green stools are seen in all types of indigestion and are not 
characteristic of any one form; they do indicate that food 
has passed rapidly through the bowel and that bile has not 
had a chance to undergo a complete change. Black stools are 
due to the presence of undigested blood or to the action of 
some drug as iron, bismuth, or charcoal. The first stool of 
the newborn, the meconium, is dark greenish brown, almost 
black. A starvation stool also is dark green, nearly black 
resembling meconium; it is sometimes constipated and some- 
times watery. Gray stools indicate the absence of bile and 
Consistency 
of Stools 
Color 
of Stools 
Brown 
Yellow- 
White 
Green 
Black 
Meconium 
Gray URINE AND STOOL IN INFANCY 
221 
the excess of fat, the latter generally in the form of soap. 
Both pink and blue stools are seen occasionally and are due 
to an unknown change of bile pigments. 
5. The odor of the stools depends upon the composition of 
the infant’s food, the rapidity of digestion, the absorption, 
and the degree of bacterial activity. The normal stool of the 
breast fed baby has a strong aromatic odor. The odor of fat 
indigestion is that of butyric or lactic acid; that of car- 
bohydrate indigestion is of lactic or acetic acid; and that 
of an excess of protein is a cheesy, fecal odor. Stools com- 
posed mostly of mucus have a peculiar aromatic odor. In- 
fections and ulcerations of the intestines cause stools to have 
a foul, putrefactive odor like decayed meat. 
6. The reactions of stools will be influenced by contamina- 
tion with urine; therefore to test them accurately be sure 
that they are not contaminated. The normal reaction of the 
stool of the breast fed baby is slightly acid and depends 
largely upon the relative quantities of protein, fat, and car- 
bohydrate in the diet. An excess of fat or carbohydrate will 
cause acid and frequent stools while an excess of protein 
will cause alkaline stools. 
7. a. There are 3 kinds of curds found in baby’s stools:— 
(1) The casein curds are found in sizes varying from 
that of a small bean to that of a peanut; they 
are white or yellowish, so tough that they cannot 
be broken up, and so light that they will not sink 
in water. They are found only in the stools of 
babies fed on raw milk. 
(2) Fat curds are small, soft, and the self-same color 
of the stool; they are easily broken up by pressure. 
If they are rubbed on a piece of tissue paper it 
will have an oily appearance when it is dry. 
(3) An excess of mucus in a stool may become dry 
and form in ball-like curds. When broken down 
with a spatula they are more tenacious than fat 
curds. 
Pink 
Blue 
Odor of Stools 
Reaction 
Curds 222 
PEDIATRIC NURSING 
Mucus 
b. Mucus in stools may be recognized by its glistening, 
shiny appearance; it is present in most normal stools but 
should be seen only microscopically. If seen macroscopically 
it is abnormal and is generally seen in large quantities; the 
larger the quantity the more serious is the diarrhea. An 
excess is caused by any condition which irritates the in- 
testine, thus causing an oversecretion of the mucous glands. 
Stools composed chiefly of mucus and blood suggest in- 
fectious diarrhea or intussusception. Undigested starch may 
be mistaken for mucus but may be distinguished by staining 
blue with iodin. 
c. Blood on the outside of a hard, constipated stool in- 
dicates trauma to the rectum. Blood mixed with mucus in a 
watery stool indicates serious inflammation of the intestines. 
Blood and mucus alone are seen in cases of intussusception. 
Scurvy causes blood findings in the stool. Blood in the stool 
of the newborn suggests hemorrhagic disease. Old digested 
blood causes the stool to be black. 
d. Pus findings in a stool indicate an inflammation and 
ulceration of the intestinal wall; it may be yellow or white 
and may look very much like mucus, but is less tenacious. 
e. Membrane in stools indicates severe inflammation of 
the large intestine. It is rarely seen and then only when a 
patient is in a very critical condition. 
f. Undigested particles of food may be seen in the stools 
of older children who are on a general diet. 
Meconium of the newborn is sometimes passed before 
birth, during birth, or directly after birth as is usually the 
case. It is dark brownish green, semi-formed, tenacious, com- 
posed of mucus, bile, intestinal secretions, cells, vernix 
caseosa, epithelial cells, and hairs swallowed with the am- 
niotic fluid. The baby passes 4 to 6 of these stools in 24 
hours. After 2 days they grow lighter, become streaked with 
brown, and gradually change so that in 4 or 5 days they are 
the normal golden yellow stools of the breast fed baby. The 
breast fed baby has 3 to 5 stools in 24 hours which are a 
Blood 
Pus 
Membrane 
Undigested 
Food 
Meconium 
Stools of 
Breast Fed 
Baby URINE AND STOOL IN INFANCY 
223 
golden yellow color, of the consistency of pea soup, slightly 
acid, and of a slightly sour but not unpleasant odor. It 
it not unusual to find soft, fine curds and some mucus in 
the stools of the breast fed baby; if the child seems healthy 
and is gaining in weight they do not have the significance that 
they have for the artificially fed baby. The infant fed on 
cow’s milk will have fewer stools (1 to 3 in 24 hours) which 
are firmer, more formed, salve-like in consistency, lighter, 
more yellowish in color, neutral in reaction, and of a more 
foul, fecal odor. 
Any healthy infant can be taught to have regular bowel 
movements every day. After 1 or 2 months he can be placed 
on a small chamber at regular intervals, once during the 
morning and at bedtime in the evening. This is best done 
after a feeding, since the taking of food stimulates peristalsis. 
The nurse holds the chamber or small basin between her 
knees and holds the baby over it by placing her hands on 
his buttocks and supporting his back and head against her 
chest. In order that he may know what is expected of him 
his rectum may be irritated by inserting a suppository of 
gluten or cocoa butter. Inserting a thermometer or an oiled 
glass rod will often produce a stool with less irritation than 
the suppository.0 Gentle massage of the abdomen may stimu- 
late sufficient peristalsis to produce a stool. In a very short 
time the baby will learn what is expected of him and no 
stimulus will be required. In this way he is helped to 
establish regular habits which will never be outgrown and 
at the same time the nurse or mother is being saved endless 
trouble. There are cases on record where with careful train- 
ing babies as young as 3 weeks of age have been taught never 
to soil their diapers. When the normal healthy child is 5 
or 6 months old he may sit on the nursery chair regularly 
for a few minutes several times a day. As soon as he is 
old enough to understand (about 1 year old) he can be taught 
Stools of 
Artificially 
Fed Baby 
Establishment 
of Regular 
Toilet Habits 
6 Eggleston, C., M.D., “Appliance for Training Infants to Stool. ” 
Journ. Amer. Med. Assn., Jan., 1918. 224 
PEDIATRIC NURSING 
to indicate his desire to urinate. It takes persistent effort 
on the part of the mother or nurse and can hardly be carried 
out in a hospital. Children in a home, however, should be 
trained early. Frequently a well trained child of 1 or 2 
years is admitted to a hospital but by the time he is dis- 
charged he has entirely forgotten his training. This may 
be due to the carelessness of the nurse in answering or in- 
terpreting the child’s calls. In order to prevent this from 
happening the nurse should consult the child’s mother about 
his habits and signs so that the training started by the 
mother can be continued. CHAPTER XVI 
NURSING TECHNIQUE IN MINOR SURGICAL PROCEDURES 
1. To Sterilize Articles Used in Procedures.1 
Tubing, stopcocks, glasses, mixing bottles, beakers, syringes, 
medicine droppers, small basins, needles (with wires in 
them), boil 5 minutes. 
Applicators, pledgets, gauze squares, and towels, keep 
sterile in covered jars in which they have been sterilized in 
autoclave. 
Handling forceps keep sterile in 5 per cent lysol solution. 
Scalpel, paracentesis knife, soak in 95 per cent alcohol 
for 10 minutes. 
To Sterilize 
Articles 
Used in 
Procedures 
2. To Set Up a Sterile Tray. 
Remove the sterile towel from the jar with handling for- 
ceps and with the aid of a second pair of forceps open and 
spread it on the tray. Use 2 towels if 1 is not large enough 
to completely cover the edge of the tray. With the forceps 
place the sterilized articles on the sterile towel. 
To Set Up 
Sterile Tray 
3. To Set Up a Tray, a Part of Which Is Sterile. 
Lift a towel from the jar with the handling forceps; open 
and spread over one-half of the tray with the free end 
hanging from the tray. With the forceps place the sterile 
articles on the towel and turn the free end back over the 
set-up tray. Arrange the unsterile articles on the other half 
of the tray. 
To Set Up a 
Tray, a Part 
of Which Is 
Sterile 
1 University Hospital Routine, University of Minnesota. 
225 226 
PEDIATRIC NURSING 
4. Care of Tubing and Stopcock after Use. 
Care of 
Tubing and 
Stopcock 
after Use 
Drop in cold water at once and as soon as possible rinse 
them by forcing water through with a syringe. Use a small 
brush to clean the stopcocks. Boil in water for 5 minutes or 
force 1 per cent lysol through with a syringe and leave it 
in for 15 minutes. Rinse and dry tubing by stripping. Com- 
plete the drying by forcing air through by means of a rubber 
bulb. 
5. Care of Needles after Use. 
Care 
of Needles 
after Use 
Drop at once into cold water; scrub with Bon Ami and 
ammonia; boil 3 minutes or leave in a 1 per cent lysol solu- 
tion for 15 minutes. To dry needles fill a syringe with 
ether and expel it through the needle several times. With 
a rubber bulb blow out every drop of fluid. When 
dry replace the wire which has been dipped in liquid 
albolene. 
6. Venipuncture. 
Venipuncture 
It is often necessary to obtain blood for diagnostic pur- 
poses. In an adult this is usually taken from (a) one of 
the large veins of the elbow (median basilic or median 
cephalic). In the child, especially under 5 years, this vein 
is often difficult to see or feel and it is impossible to obtain 
blood here. Some other sources from which blood may be 
taken are: (b) External jugular at either side of the 
neck; (c) the femoral vein in the groin; (d) the popliteal 
vein at the back of the knee; (e) in the emaciated child (es- 
pecially the child with congenital syphilis) the large scalp 
veins are very prominent; (f) in the child under 18 months 
the longitudinal sinus in the area of the anterior fontanelle 
may be used.; (g) if all other methods fail and there are no 
contra-indications, the heel may be pricked with the point of 
a sharp scalpel and the blood squeezed into a tube. 
Purpose 
Veins from 
Which Blood 
May Be 
Obtained MINOR SURGICAL PROCEDURES 
227 
Equipment: 
Sterile: 
. 1. Four cotton pledgets. 
2. Two small gauze squares. 
3. One towel. 
4. One medicine glass for 70 per cent alcohol. 
5. One 10 c.c. syringe. 
6. Two needles, 20-26 gauge, inches long. 
Unsterile: 
1. Small rubber square. 
2. Towel. 
3. Tourniquet (rubber tubing inch in diameter, 12 
inches long). 
4. Kidney basin. 
5. Bottle of 5 per cent lysol solution with 2 pairs of 
handling forceps. 
6. Medicine glass with cold water for used needles. 
7. Container for blood. 
8. Collodion. 
9. Blanket and safety pins to restrain child. 
Technique: 
a. If the blood is obtained from the median basilic or 
median cephalic veins, the technique is the same as for the 
venipuncture on an adult. The child lies on his back in the 
middle of his bed with his arm extended toward the doc- 
tor ; roll his nightgown sleeve over his elbow. If he is at 
an age when he will struggle, pin a blanket around him, re- 
straining the other arm and his legs. Place the rubber and 
unsterile towel under his elbow to protect the bed. Place 
the tourniquet in position under his upper arm; sponge a 
4-inch area on the arm at the inner side of the bend of 
the elbow with alcohol. Dry with a dry pledget. Handle 
the sponges with the forceps and drop the soiled ones into the 
kidney basin. The doctor scrubs his hands. Hand him the 
sterile towel to wipe them; he then places the same over the 
child’s lower arm and hand so that he will not come in con- 
tact with them while working. To hold the child’s arm still 
place one hand under his elbow to hold it straight, and the 
Equipment 
To Use 
Median 
Cephalic or 
Basilic Veins 
Position 
of Child 228 
PEDIATRIC NURSING 
other hand over his hand under the sterile towel. After the 
blood starts to flow through the needle loosen the tourniquet. 
The blood is collected in the test-tube or container, which- 
ever is necessary for tests. After the needle is withdrawn 
drop it in the glass of cold water. Apply pressure over the 
Figure 28. Position of Baby for Puncture of External 
Jugular Vein 
puncture with a dry sponge and elevate the arm until bleed- 
ing stops. If it persists, apply a collodion dressing. To do 
this wipe the puncture dry, place a few shreds of absorbent 
cotton over it, paint that with collodion on an applicator and 
keep the arm quiet until it dries. 
b. If it is impossible to obtain blood from the arm the 
external jugular vein may be used. The equipment is 
To Use 
External 
Jugular MINOR SURGICAL PROCEDURES 
229 
the same without the tourniquet. (Figure 28.) The child 
lies with his shoulders elevated on a pillow, his head is 
lowered and turned to one side, where the nurse holds it 
in position. His arms and legs must be wrapped and pinned 
in a blanket. The rubber and unsterile towel are placed 
under his neck. A sterile towel is placed over the side of 
his face with which the doctor’s hands come in contact. 
A 4-inch area over the vein selected is prepared by sponging 
with alcohol and drying. Blood is withdrawn in the usual 
way and the procedure is the same. 
c. If the femoral vein is used, the child lies on his back 
with a pillow under his hips. Restrain him by pinning a 
blanket around his arms and shoulders, also one around his 
legs. 
d. If the popliteal vein is used, the child lies on his face 
and is restrained with the blanket as necessary. The inner 
side of the bend of the knee is exposed. 
e. If the scalp veins are used, the child is restrained as 
necessary and his head is turned and is held to one side to 
expose the vein. 
f. Fontanelle puncture 2 
Equipment: 
Sterile: 
1. Four cotton pledgets. 
2. Applicator. 
3. Two small gauze squares. 
4. One towel. 
5. One medicine glass for 70 per cent alcohol. 
6. One medicine glass for per cent iodin. 
7. One 10 e.e. syringe. 
8. Two needles, 18-19 gauge, 1 y2 inches long with stilets 
and needle guards.3 
Position 
of Child 
To Use 
Femoral Veir 
To Use 
Popliteal 
Vein 
To Use 
Scalp Veins 
Fontanelle 
Puncture 
Equipment 
3 Helmholz, Henry F., M.D., Am. J. Bis. Child., Sept., 1915. 
Fisher, L., M.D., New York State Med. Journal, May, 1919. 
Fisher, L., M.D., Med. Record, Sept. 7, 1918. 
3 Goldbloom, A., M.D., Am. J. Bis. Child., Dec., 1918. 230 
PEDIATRIC NURSING 
Needles 
There are many kinds of needles made for fontanelle punc- 
ture; most of these have a guard. If necessary, an ordinary 
needle, 18-19 gauge, IV2 inches long with 
bevel 0.75 inches long may be used. 
Unsterile: 
1. Small rubber square. 
2. Towel. 
3. Kidney basin. 
4. Bottle of 5 per cent lysol solution 
with 2 pairs of handling forceps. 
5. Medicine glass of cold water. 
6. Test-tube or container for blood. 
7. Collodion. 
8. Razor. 
9. Basin of soap solution. 
10. Blanket and safety pins for restrain- 
ing the child. 
Position of the Child: 
Pin his arms and legs tightly in a 
blanket. Place him crosswise in his crib 
with the top of his head even with the 
side of the bed; the doctor sits on a stool 
at the side of the bed on a level w7ith 
the top of the baby’s head. Have the 
tray on the table at his side. Place the 
rubber and towel under the child’s head. 
Shave the hair from a 3-inch area over 
the posterior angle of the anterior fontanelle; sponge with 
alcohol and dry; with the forceps hand the sterile towel 
to the doctor to wipe his hands and to place under the child’s 
head. The nurse stands on the opposite side of the crib from 
the doctor and grasps the child’s head on either side with 
her hands to hold it absolutely still. The needle is inserted 
into the longitudinal sinus in the area of the anterior 
fontanelle, posteriorly as far as possible. The guard on the 
needle prevents it from slipping. After blood is obtained 
and the needle is withdrawn, drop it in a glass of cold water. 
Position 
of Child 
Figure 29. — A 
Needle with 
Guard for Punc- 
ture of Fonta- 
nel. MINOR SURGICAL PROCEDURES 
231 
Hold the child upright and make gentle pressure over the 
puncture with a dry sponge to stop the bleeding. A collodion 
dressing may be used if necessary. 
There is a “head holder” in use that holds the infant’s 
head in position for fontanelle work; it is very difficult to 
do so with the hands. 
Patent Head 
Holder 
Figure 30. Position or Baby for Puncture of the Fontanelle 
If the child is put on a central dressing table for the 
puncture, he is placed with the top of his head level with the 
end of the table at which the doctor sits. The nurse stands 
at the side of the table and holds the head in the same way. 
7. Ventricular Tap. 
It is often necessary in hydrocephalus to relieve the 
pressure by withdrawing cerebrospinal fluid from the ventri- 
Ventricular 
Tap 
Purpose 232 
PEDIATRIC NURSING 
cles. The needle is inserted through the anterior fontanelle 
to one side or the other of the midline. The equipment is 
the same as for a fontanelle puncture with the addition of a 
graduate to measure the fluid withdrawn. The needles used 
are 18 to 19 gauge, 3 inches long, with plunger (spinal punc- 
ture needles). The position of the child is the same as for a 
fontanelle puncture. Shave a 3-inch area around the spot 
where the needle is to be introduced. Take the child’s pulse 
before starting and watch his condition closely during and 
after the puncture. 
8. Intravenous Infusion. 
Intravenous 
Infusion 
A. It is often necessary to give a child fluid intravenously 
to increase the fluid intake, as in cases of anhydremia; medi- 
cations are often given intravenously. Physiological sodium 
chlorid or glucose solution are the fluids most commonly 
ordered. The same veins may be used as mentioned under 
venipuncture. The vein in the arm can be used without 
difficulty in an older child. One of the other veins is usually 
chosen for a small baby, as the external jugular, a large 
scalp vein, popliteal, or femoral veins. Fluid may be given 
into the longitudinal sinus at the anterior fontanelle, but 
there are dangers connected with this method and it is gen- 
erally used only as a last resort. It is estimated that an 
amount of fluid equal to 1/60 of the body weight can be 
introduced through the veins, but much more can be given 
if there has been an extreme loss of body fluid. (See note 2.) 
Purpose 
Sites of 
Infusion 
Equipment: 
Sterile: 
1. Six cotton pledgets. 
2. Applicator. 
3. Two small gauze squares. 
4. Two sterile towels. 
5. Medicine glass for 70 per cent alcohol 
6. Medicine glass for 3!/2 per cent iodin. 
7. (a) One 30 c.c. syringe, or 
Equipment MINOR SURGICAL PROCEDURES 
233 
(b) Three-way stopcock with 3 pieces of rubber 
tubing 18 inches long attached and syringe, or 
(c) Gravity method—flask and tubing. 
8. Two needles, 20-26 gauge, l1 inches long. 
Unsterile: 
1. Small rubber square. 
2. Small towel. 
3. Kidney basin. 
4. Bottle of 5 per cent lysol with 2 pairs of handling 
forceps. 
5. Medicine glass of cold water. 
6. Flask with solution to be warmed in a basin of water 
105° F. 
7. Collodion (or adhesive). 
8. Tourniquet, if an arm vein is to be used. 
9. Blanket and safety pins to restrain child. 
Three methods may be employed to give intravenous in- 
fusion. 
(a) A 30 c.c. syringe alone may be used if only a small 
amount of fluid is to be given. 
(b) A 3-way stopcock may be used; one rubber on it 
connects with a 20 c.c. syringe; one rubber has an adapter 
for the needle; and the third has a bent glass tube on the 
end and fits into the flask of solution. The procedure is 
the same as for a venipuncture. Air is expelled from the 
tube by turning the valve and by drawing fluid from the flask 
into the syringe, then by turning the valve again to force 
it from the syringe through the tube which is to be attached 
to the needle. The needle is inserted into the vein selected, 
the adapter on the end of the rubber is fitted in it, and the 
fluid is slowly injected by drawing it up into the syringe 
from the flask and then forcing it through the needle. 
(c) The gravity method consists of a graduated flask, 2 
pieces of rubber tubing 12 inches long connected by a glass 
connecting tube with a clamp on one piece; one end of the 
rubber is attached to the flask, the other end has an adapter 
for the needle. The flask with the fluid 100° F. is hung on a 
Methods 
to Use 
Syringe 
Method 
3-Way Stop- 
cock Method 
Gravity 
Method Figure 31. Equipment for Giving Fluid Intravenously, Using 
3-way Stopcock Method (b) 
234 MINOR SURGICAL PROCEDURES 
235 
standard so that it is 2 feet above the child. A 4-inch area 
around the site is cleaned with iodin and alcohol and dried; 
air is expelled from the tube by al- 
lowing the fluid to run through it; 
the needle is inserted into the vein, 
the adapter is attached to it, and the 
fluid is allowed to run in by gravity 
after unfastening the clamp on the 
rubber tubing. Fluid may be given 
by the gravity method using a glass 
funnel in place of the graduated flask. 
This is suspended from a ring ad- 
justed to a standard and has the 
same rubber connections. The fluid 
is measured, poured in, and allowed 
to run in by gravity. 
After withdrawing the needle, drop 
it in a glass of water, make pressure 
over the puncture with a dry sponge, 
and seal it with a collodion dressing 
or with adhesive and cotton. Before 
starting to give fluid intravenously 
take the child’s pulse and apply ex- 
ternal heat if necessary. During the 
procedure watch his pulse and pre- 
vent unnecessary exposure. Leave 
him with hot water bottles if his con- 
dition indicates it and observe him 
frequently. 
B. Antitetanic serum given for re- 
lief of tetanus may be given intra- 
venously. Method (a) is usually em- 
ployed. The serum must he warmed 
to 100° F. 
C. Salvarsan employed in the treatment of syphilis is given 
intravenously. 
Watch Child 
for Reaction 
To Give 
Antitetanic 
Serum 
Figure 32.—Equipment 
for Giving Fluid In- 
travenously, Using 
Gravity Method (c). 
To Give 
Salvarsan 236 
PEDIATRIC NURSING 
Equipment 
Equipment: 
Sterile: 
1. Six applicators. 
2. Eight cotton pledgets. 
3. Two small gauze squares. 
4. Two sterile tow7els. 
5. Three needles, 20-26 gauge, l-l1 inches long. 
6. (a) 3-way stopcock with tubing and 10 c.c. syringe, or 
(b) Graduated flask for the gravity method. 
7. Medicine glass for 70 per cent alcohol. 
8. Medicine glass for per cent iodin. 
9. Mixing bottle. 
10. Graduated beaker. 
11. Pipet. 
12. Stirring rod. 
13. Glass funnel. 
Unsterile: 
1. Small rubber. 
2. Unsterile towel. 
3. Tourniquet, if arm is used. 
4. Kidney basin. 
5. Bottle wTith thumb forceps in alcohol. 
6. Medicine glass with cold water. 
7. File. 
8. Flask of freshly distilled cool sterile water. 
9. Litmus paper. 
10. Tube of salvarsan. 
11. Bottle of sodium hydroxid 15 per cent. 
12. Blanket and safety pins to restrain child. 
To Prepare Salvarsan: 
1. Pour 100 c.c. of freshly distilled water into a mixing 
bottle, to this add % of the salvarsan powder. Shake the 
bottle until it is well mixed. Then add the remainder of 
the powder, shaking the bottle until all the powder is 
thoroughly mixed. 
2. Add 100 c.c. of distilled water and shake well. 
3. Add 10 to 20 drops of 15 per cent sodium hydroxid 
solution or enough to make the solution alkaline. (Test by 
dropping on neutral or red litmus.) 
To Prepare 
Salvarsan MINOR SURGICAL PROCEDURES 
237 
4. Filter the solution through sterile cotton (placed in the 
funnel) from the mixing bottle into the graduated beaker. 
Filter back into the mixing bottle and continue until it 
appears perfectly clear. 
Watch the child for reaction after the injection. Apply 
external heat if necessary. 
D. Neosalvarsan is often given in place of salvarsan in the 
treatment of syphilis.4 
Equipment: 
Sterile: 
1. Six applicators. 
2. Eight cotton pledgets. 
3. Two small gauze squares. 
4. Two sterile towels. 
5. Three needles, 20-26 gauge, inches long. 
6. Medicine glass for alcohol. 
7. Medicine glass for per cent iodin. 
8. Graduate marked in c.c. for mixing salvarsan. 
9. 20 c.c. syringe. 
10. Glass stirring rod. 
Unsterile: 
1. Small rubber sheet. 
2. Towel. 
3. Tourniquet, if arm is used. 
4. Kidney basin. 
5. Bottle of 5 per cent lysol with 2 pairs of handling 
forceps. 
6. Medicine glass with cold water. 
7. File. 
8. Flask of freshly distilled cool sterile water. 
9. Ampule of neosalvarsan. 
10. Blanket and safety pins to restrain child. 
Neosalvarsan is prepared by dissolving the contents of the 
ampule in freshly distilled water; the amount of water de- 
pends on the desired strength of the drug. It may be given 
by any of the 3 methods used to give intravenous infusions, 
Watch for 
Reaction 
To Give 
Neosalvarsan 
Equipment 
To Prepare 
Neosalvarsan 
4Jeans, P., M.D., “Treatment of Hereditary Syphilis,” Journ. 
Amer. Med. Assn., Jan. 15, 1921. 238 
PEDIATRIC NURSING 
Sites to Give 
Salvarsan or 
Neosalvarsan 
but since it is usually given in small quantities, it may easily 
be injected directly with a syringe: method (a). Any of 
the veins where an intravenous infusion may be given may 
be used for giving neosalvarsan. The position of the child 
depends on the vein used. (See directions above.) Watch 
the child closely for reaction after the injection. Apply 
external heat if necessary. 
E. Blood transfusion 5 may be employed in the treatment 
of hemorrhage, various blood diseases, as hemophilia, anemia, 
malnutrition, and many other conditions. The methods are 
described as “surgical” or “citrate,” the latter being the 
one referred to here. Both, however, utilize as an anti- 
coagulant sodium citrate (C.P.) in a solution of freshly dis- 
tilled water varying in strength from iy2 per cent to 3 per 
cent. Twenty c.c. of this solution is used for every 100 c.c. of 
blood which is given. The popular methods of administra- 
tion have already been described under “intravenous in- 
fusions” above. Depending on the choice of the operator, 
these may be: 
(a) Simple syringe. 
(b) Three-way stopcock. 
(c) Gravity. 
The only additional materials needed will be a sterile gradu- 
ate and a flask of sterile physiological saline solution. The 
donor is selected as for the adult with blood in the same 
group as the recipient. An anesthetic does not need to be 
given if the child is sufficiently quiet to allow the procedure 
to be successfully carried on without it. A sedative, as 
chloral hydrate by rectum, may sometimes be ordered a few 
minutes before starting. The very small child can always 
be restrained. The older child, unless he is delirious or too 
sick to be reasoned with, will also lie quiet. The child of 
the active age, between 2 and 6 years, will present many 
Watch for 
Reaction 
Blood 
Transfusion 
Purpose 
‘ ‘Citrate” 
Method 
Methods of 
Giving Blood 
Intravenously 
Additional 
Equipment 
Donor 
* Hoffman and Habein, ‘ ‘ Transfusion of Citrated Blood, ’ ’ Journ. 
Amer. Med. Assn., Feb. 5, 1921. MINOR SURGICAL PROCEDURES 
239 
difficulties and an anesthetic may have to be given. Before 
starting a transfusion take the child’s pulse. Protect the 
body surface from exposure. It is also advisable to apply 
external heat to the lowrer extremities and an ice-bag to the 
head after the transfusion. Any evidence of reaction (chill, 
sudden rise in temperature, etc.) should be immediately re- 
ported. 
Watch lor 
Beaction 
9. Subcutaneous or Intramuscular Injections. 
Subcutaneous 
and Intra- 
muscular 
Injections 
A. Whole blood is sometimes injected subcutaneously or 
intramuscularly; this is especially valuable to check hemor- 
rhage or hemorrhagic disease of the newborn. It is often 
given to older children to relieve various conditions. 
Equipment: 
Sterile: 
1. Two applicators. 
2. Four cotton pledgets. 
3. Two towels. 
4. Medicine glass for per cent iodin. 
5. Medicine glass for 70 per cent alcohol. 
6. Twenty-five c.c. syringe. 
7. Needles, 
Two 18-20 gauge, I-IV2 inches long to obtain blood 
from donor. 
Two 18-20 gauge, l-l1 inches long to inject blood in 
recipient. 
Unsterile: 
1. Two small rubber sheets. 
2. Two hand towels. 
3. One tourniquet. 
4. One kidney basin. 
5. Two pair handling forceps in 5 per cent lysol solution. 
6. Collodion. 
7. Glass of cold water. 
8. Blanket and safety pins to restrain child. 
The blood is taken from any healthy donor. The vein 
(usually in the arm) is prepared as for a venipuncture and 
the blood is withdrawn into the glass syringe. From 10 to 
Whole Blood 
Purpose 
Equipment 
Donor 240 
PEDIATRIC NURSING 
30 c.c. of blood are usually given. 
The sites of injection may be: 
1. Either side of the back. 
2. Either axilla. 
3. Buttocks. 
4. Outer aspect of the thighs. 
5. Outer side of the calves. 
A 4-inch area is prepared with iodin and alcohol and 
dried. Place a sterile towel over the part of the child’s body 
with which the doctor’s hands come in contact. The recipient 
must be ready to have the blood injected immediately that 
it is withdrawn from the donor, before it has time to clot. 
Gently massage the area where it is injected. After the 
needle is withdrawn, drop it into the glass of cold water and 
seal the puncture with a collodion dressing. 
B. Diphtheria antitoxin is given as a prophylactic measure 
and as treatment for diphtheria. 
Equipment: 
Sterile: 
1. Glass of alcohol. 
2. Glass of ether. 
3. Six cotton sponges. 
4. Ten c.c. syringe. 
5. Two needles, 22-26 gauge, l-l1 inches long. 
Unsterile: 
1. Kidney basin. 
2. Jar of lysol with handling forceps. 
3. Antitoxin warmed to 100° F. 
4. Collodion. 
5. Blanket and safety pins to restrain child. 
Antitoxin is injected into the subcutaneous tissues or in- 
tramuscularly. Sites of injection may include: 
1. Muscles of the buttocks. 
2. Outer aspect of the thighs. 
3. Axillas. 
4. Upper arm. 
5. Calf of the leg. 
Sites of 
Injection 
Diphtheria 
Antitoxin 
Purpose 
Equipment 
Sites of 
Injection MINOR SURGICAL PROCEDURES 
241 
The site is cleaned with alcohol, ether, and a dry sponge. 
After the serum is injected, gently massage the area to aid 
absorption. Seal the puncture with collodion. Care for the 
needles, etc., in the usual manner. 
C. Tetanus antitoxin may be given intramuscularly or sub- 
cutaneously. The equipment and the procedure are the same 
as for giving diphtheria antitoxin. The serum must be warmed 
to 100° F. 
D. Hypodermoclysis. 
(1) Subcutaneous injection of fluids is often indicated as 
in case of shock, following hemorrhage, if a child has lost 
fluids from excessive vomiting or diarrhea, or in case of 
dehydration from any cause. Salt solution is usually used; 
5 per cent glucose solution may be used. The usual sites 
for injection are: 
1. Under the breasts. 
2. Either side of the back. 
3. The axillae. 
4. The outer aspect of the thighs. 
5. The outer aspect of the calves. 
6. The upper arm. 
The amount given depends on the size of the child—a small 
baby under a year old can usually take 100 to 300 c.c. at a 
time, sometimes repeated twice a day or in daily injections. 
An older child can have more in proportion to his size. 
Equipment: 
Sterile: 
1. Two applicators. 
2. Four cotton pledgets. 
3. Two towels. 
4. Medicine glass for iodin. 
5. Medicine glass for alcohol. 
6. (a) Graduated flask with 2 feet of rubber tubing with 
glass connecting tube inserted 6 inches from the 
needle end, a clamp on the rubber, and an adapter 
for the needle (as for intravenous infusion). 
Tetanus 
Antitoxin 
Hypo- 
dermoclysis 
Purpose 
Sites of 
Injection 
Amount 
to Give 
Equipment 242 
PEDIATRIC NURSING 
(b) Three-way stopcock with rubber and syringe (as 
for intravenous injection). 
7. Two needles, 18-20 gauge, l1/? inches long. 
If a Y glass connecting tube is used on the end of 
the rubber 2 needles may be used at once. In that 
case include 4 in the equipment. 
Unsterile: 
1. Small rubber. 
2. Small towel. 
3. Kidney basin. 
4. Glass of cold water. 
5. Glass of 5 per cent lysol solution with handling 
forceps. 
6. Collodion. 
7. Flask with solution in pan of water 105° F. (Stand- 
ard on which to hang flask.) 
8. Blanket and safety pins to restrain child. 
Remove the patient’s clothes to expose the area. Restrain 
as much as necessary by pinning in a blanket. Protect the 
bed with the rubber and towel. Prepare a 4-inch area with 
iodin and alcohol and dry it. 
(a) Expel the air from the tube by allowing the fluid 
to run through it. The needle is inserted and the fluid is 
permitted to run in by gravity. Gently massage the area 
where the needle is inserted. As the fluid enters, the needle 
must be partly withdrawn and is reinserted in a slightly 
different direction from time to time. (See gravity method 
(c) for giving intravenous fluid.) 
(b) If the 3-way stopcock is used, the fluid is drawn into 
the syringe from the fla-sk, then is slowly forced through the 
needle. After the needle is withdrawn, drop it in the glass 
of water. Exert pressure over the puncture with a dry 
sponge for a few minutes until the fluid does not ooze from 
it. Seal it with collodion and sterile cotton or adhesive and 
cotton. (See method (b) for giving intravenous fluid.) 
(2) Continuous hypodermoclysis. If the patient is in a 
critical condition and the injection of fluids is very essential, 
a continuous hypodermoclysis may be used, i.e., fluid is 
Position of 
Patient 
Gravity 
Method 
3-Way Stop- 
cock Method 
Continuous 
Hypo- 
dermoclysis MINOR SURGICAL PROCEDURES 
243 
allowed to run in by gravity over a period of hours until the 
desired amount is given. This can be employed only for the 
very small baby who is restrained or for the older child who 
understands the necessity of remaining quiet. It is impossible 
to carry out this procedure on an active child from 1 to 6 
years. When it is used, the nurse must watch the child closely 
every 10 to 15 minutes. Take his pulse before starting the 
hypodermoclysis, place hot water bottles around him if neces- 
sary; expose him as little as possible. Take his pulse and 
watch him carefully during the hypodermoclysis and after- 
wards leave him writh the hot water bottles. 
Watch for 
Reaction 
10. Intraperitoneal Injection of Fluids.6 
Intra- 
peritoneal 
Injection 
of Fluids 
Fluids are often given to an infant directly into the per- 
itoneal cavity to increase the fluid intake in cases of anhy- 
dremia. Physiological sodium chlorid is used in most cases; 
5 per cent glucose has been used. 
Equipment: 
Sterile: 
1. Two applicators. 
2. Four cotton pledgets. 
3. One sterile towel. 
4. Medicine glass for iodin. 
5. Medicine glass for alcohol. 
6. Two needles, 18-20 gauge, inches long. 
7. (a) Graduated glass container with rubber tubing, 
glass connecting tube, clamp, and needle adapter, 
(b) Glass funnel with rubber tubing, glass connecting 
tube, clamp, needle adapter, and graduate to meas- 
ure fluid. 
Unsterile: 
1. Small rubber sheet. 
2. Half sheet. 
* Am. J. Dis. Child., Jan., 1918. 
Aikman, J., M.D., Journ. Amer. Med. Assn., Jan. 24, 1920. 
Gittings, J. C., M.D., Donnelly, J. D., M.D., “Clinical Value of 
Intraperitoneal Injection of Salt Solution,” Am. J. Dis. Child., Feb., 
1922. 
Purpose 
Equipment 244 
PEDIATRIC NURSING 
3. Kidney basin. 
4. Glass with 5 per cent lysol with 2 
pairs of handling forceps. 
5. Collodion or adhesive. 
6. Flask of solution to be used in a 
pan of water 105° F. 
7. Glass of cold water for used needles. 
8. Blanket and safety pins to restrain 
child. 
See that the child’s bladder is not dis- 
tended. Turn his nightgown and shirt back 
over the umbilicus and tuck them under 
him. He should lie flat on his back. Place 
the rubber and half sheet under him to 
protect the bed. If he is large enough to 
struggle restrain his hands by pinning a 
small blanket around his shoulders and 
another one around his knees. As the 
needle is inserted just below the umbilicus, 
prepare a 4-inch area from there toward 
the pubes by painting with iodin and 
alcohol and drying. 
Place a sterile towel 
directly below the pre- 
pared area. Air is ex- 
pelled from the tube; 
the needle is inserted 
and the fluid (100° F.) 
is allowed to run into 
the peritoneal cavity. 
Method (a) may be 
used. The graduated flask is hung from the standard two 
feet above the child. (See Gravity Method for giving 
fluid intravenously.) If method (b) is used the fluid 
is measured and poured into the funnel. From 100 to 400 
c.c. of fluid may be given by this method, depending upon the 
Position 
of Child 
Figure 33.—Glass Funnel and Tubing 
for Giving Fluids Intraperitoneally 
Method (b). 
Methods MINOR SURGICAL PROCEDURES 
245 
size of the child and upon the state of dehydration. The 
wound is sealed with collodion and cotton or adhesive and 
Figure 34. Position of Child when Giving Intraperitoneal Fluid 
cotton. Observe the child’s condition closely during the pro- 
cedure. Expose him as little as possible. Give him hot water 
bottles if his temperature is subnormal. 
watch for 
Reaction 
11. Spinal or Lumbar Puncture. 
Spinal 
Puncture 
A spinal puncture is performed to withdraw cerebrospinal 
fluid from the spinal canal for diagnosis or for therapeutic 
measures in certain diseases, as in cerebrospinal meningitis 
and hydrocephalus, to relieve pressure. 
Equipment: 
Sterile: 
1. Four applicators. 
2. Five cotton pledgets. 
3. Three small gauze squares. 
4. Two sterile towels. 
5. Two spinal puncture needles with plunger, 3 inches 
long, 18-20 gauge. 
6. Three medicine glasses, one for iodin, one for alcohol, 
one for novocain. 
7. Hypodermic needle and syringe for local anesthetic. 
Unsterile: 
1. Small rubber. 
2. Kidney basin. 
Purpose 246 
PEDIATRIC NURSING 
3. Glass of 5 per cent lysol with forceps. 
4. Glass (with cotton in the bottom) with 3 test-tubes 
marked on. 1-2-3. 
5. Alcohol lamp. 
6. Matches. 
7. Flask with sterile novocain. 
8. Collodion or adhesive. 
9. Small blanket—large sheet. 
A large active child may have to have a general anesthetic. 
There is little difficulty in restraining a small child. A seda- 
tive, as chloral hydrate by rectum, % hour before starting, 
Figure 35. Position of Child for Spinal Puncture 
may be ordered. A local anesthetic, as novocain, makes it 
less painful. Remove the child’s shirt and gown, place a 
small blanket over his shoulders, fold the bedclothes back 
over his hips. The temperature of the room should be 72° F. 
Have him lie on his side with his back even with the side 
of the bed from which the doctor is to work. The nurse 
stands on the opposite side. Fold a sheet lengthwise in folds 
of 6 to 10 inches. Place the middle of this under the child’ 
Position 
of Child MINOR SURGICAL PROCEDURES 
247 
body, bringing one end up around the back of his neck, and 
the other up under his knees with his arms caught under 
the sheet. Pull the two ends together with his body bent 
into the proper position, knees drawn up, shoulders and 
body forward, and back arched on a level with the edge of 
the bed. One nurse can easily hold a large child in this way. 
If the doctor wishes to have the child’s body in an upright 
position for the puncture, the nurse standing on the opposite 
side of the bed restrains him with the sheet in the same way, 
supporting him in the sitting position, back bowed and on 
a level with the edge of the bed from which the doctor Avorks. 
The site of the puncture is usually between the third and 
fourth or fourth and fifth lumbar vertebras. Prepare a 4- 
inch area around this site and out over the crest of the ilium 
with iodin and alcohol and dry it. After the doctor scrubs 
his hands, with the forceps hand him a sterile towel to place 
under the patient’s back, and one to place over his hips below 
the site of the puncture. The doctor sits on a level with the 
patient’s back. Local anesthesia is used and the needle is 
inserted. Remove the cotton stopper from test-tube No. 1, 
flame the rim and hold it under the needle to collect the 
cerebrospinal fluid. Usually 1 to 2 fluid drams are with- 
drawn. Collect it in tubes Nos. 2 and 3 also. Seal the wound 
with collodion. 
Site of 
Puncture 
12. Intraspinal Injection of Serum. 
It may be necessary to inject serum intraspinally, as in 
tetanus or cerebrospinal meningitis. The equipment is the 
same as for spinal puncture with the addition of a 30 c.c. 
syringe for injecting the serum (which must be 100° F.), a 
2-inch piece of rubber and a needle adapter, and a graduate 
to measure the fluid which is withdrawn. The amount of 
serum which is given is equal to the amount of fluid with- 
drawn. Gravity method may be used in place of the syringe. 
The equipment for this consists of the regular spinal puncture 
outfit with a sterile glass funnel, rubber tubing, glass con- 
Intraspinal 
Injection 
of Serum 
Purpose 
Equipment 
Methods 248 
PEDIATRIC NURSING 
Watch for 
Reaction 
necting tube, and an adapter to fit the needle. Observe the 
child closely during the injection and afterwards for reaction. 
13. Methods of Surgical Drainage. 
Aspiration 
of Pleural 
Cavity 
A. Aspiration of pleural cavity or thoracentesis (pleuro- 
centesis) is performed for (1) diagnostic and (2) therapeutic 
reasons. 
Equipment: 
Sterile: 
1. Six applicators. 
2. Six cotton pledgets. 
3. Two small gauze squares. 
4. Two towels. 
5. Twenty c.c. syringe. 
6. Needles, 18-19 gauge, 3 inches long, (a) spinal punc- 
ture needles, or (b) venipuncture needles, 18-20 
gauge, 3 inches long. 
7. Medicine glass for iodin. 
8. Medicine glass for alcohol. 
9. Medicine glass for novocain. 
10. Hypodermic syringe and needle. 
11. (a) Syringe, rubber, clamp, adapter for diagnostic 
thoracentesis. 
(b) Y tube, rubbers, adapters, 2 clamps, syringe for 
therapeutic thoracentesis. 
Unsterile: 
1. Small rubber. 
2. Kidney basin. 
3. Bottle of 5 per cent solution with 2 pairs of handling 
forceps. 
4. Graduate to measure fluid withdrawn. 
5. Collodion or adhesive. 
6. Glass with 2 sterile test tubes. 
7. Alcohol lamp. 
8. Matches. 
9. Flask of 1 per cent novocain. 
10. Small blanket. 
If the child will remain quiet, the position is the same as 
for an adult; support him in the sitting position with his 
Purpose 
Equipment 
Position 
of Child MINOR SURGICAL PROCEDURES 
249 
back to the side of the bed. Remove the sleeve of his shirt 
and gown on the affected side. Bring the gown around to 
the opposite side and pin it. This makes a holder for the 
rubber sheet and sterile towel. Place the child’s hand of 
the affected side on the opposite shoulder. Cover the shoulders 
Figure 36. Equipment for Thoracentesis 
with a small blanket. Place the rubber in the holder which 
was made by pinning the gown. Prepare a 4-inch area 
around the site of the puncture, paint with iodin and 
alcohol and dry it. Place a sterile towel over the rubber 
sheet. 250 
PEDIATRIC NURSING 
Diagnostic 
Thora- 
centesis 
(1) When a thoracentesis is performed for diagnostic pur- 
poses only a small amount of fluid is withdrawn. Use equip- 
ment (a). The area of the puncture is anesthetized with 
novocain, using a hypodermic syringe and needle. The fluid 
is withdrawn into the syringe. Light the alcohol lamp. Re- 
move the cotton stopper from one of the test-tubes, flame the 
rim of the tube before using it (fluid may be put in 2 test- 
tubes). Seal the wound with a collodion dressing. Watclj 
the child carefully for reaction during the procedure. 
(2) When a larger quantity of fluid is to be withdrawn 
for therapeutic, reasons several methods are available but 
the following is the common one. Use equipment (b). Close 
both clamp no. 1 and no. 2, insert the needle. Make nega- 
tive pressure with the syringe. Open clamp no. 2 and with- 
draw the fluid from the chest. Close clamp no. 2; open clamp 
no. 1 and expel the fluid into the graduate. Close clamp 
no. 1, open clamp no. 2, and repeat. The child may struggle 
violently during this procedure so that he cannot be held 
in the desired position. In this case remove his clothes, 
restrain his arms and legs by the use of a folded sheet 
as for a spinal puncture, hold him by pulling the ends of 
the sheet together until he is in the desired position and 
support him thusly. 
B. Pericardial effusion may demand an aspiration for re- 
moval of the fluid. The equipment is the same as for the 
pleural aspiration. 
Needles, 19-19 gauge, 3 inches long with plunger, or 
18-19 gauge, 3 inches long without plunger 
20 c.c. syringe. 
Position of the child: Place him on a head rest, restrain 
him as necessary; remove the sheet and gown. The usual 
area of the puncture is near the left margin of the sternum 
between the fourth and fifth ribs. Observe carefully the 
child’s condition during the procedure. 
C. Abdominal paracentesis is employed to withdraw fluid 
for diagnostic and therapeutic purposes. 
Therapeutic 
Thora- 
centesis 
Aspiration of 
Pericardial 
Cavity 
Purpose 
Equipment 
Position 
of Child 
Watch for 
Reaction 
Aspiration of 
Abdominal 
Cavity 
Purpose MINOR SURGICAL PROCEDURES 
251 
Equipment: 
Sterile: 
1. Five Applicators. 
2. Five cotton pledgets. 
3. Four small gauze squares. 
4. Sterile towel. 
5. Sterile fluff. 
6. Sterile pad. 
7. Small scalpel. 
8. Needles, 3 inches long, 18-19 gauge with plunger, or 
3 inches long, 18-20 gauge without plunger. 
9. Medicine glass for alcohol. 
10. Medicine glass for iodin. 
11. Medicine glass for novocain. 
12. Hypodermic syringe with 2 needles. 
Unsterile: 
1. Small rubber sheet. 
2. Dressing basin. 
3! Bottle of 5 per cent lysol solution with 2 pairs of 
handling forceps. 
4. Flask of 1 per cent novocain. 
5. Collodion. 
6. Glass (cotton in bottom) with 2 sterile test-tubes. 
7. Alcohol lamp. 
8. Matches. 
9. Blanket and safety pins. 
10. Adhesive. 
See that the child’s bladder is empty. 
Position : 
1. The child may sit in a straight chair if possible. 
2. He may sit on the side of his bed with his legs hanging 
over the edge, feet resting in a chair. 
3. He may sit up against the pillows and head rest with 
legs extended. 
If necessary, restrain him by pinning his arms and legs 
in a blanket. Fold the gown up over his abdomen; place 
the small rubber sheet over his lap and against the lower 
abdomen below the site of the puncture. Prepare the skin, 
a 4-inch area, with iodin and alcohol and dry it. Place 
Equipment 
Position 
of Child 252 
PEDIATRIC NURSING 
a sterile towel over the rubber sheet. The area to be punc- 
tured is anesthetized, an incision is made with a scalpel, and 
the needle is inserted. The basin is held ready to collect 
the fluid. A small amount of it is first collected in 1 or 2 
sterile test-tubes (flame the rim before collecting it). Watch 
the patient’s condition during the procedure. After the 
needle is withdrawn, clean the wound with a pledget. If it 
is dry, seal it with collodion; if it is oozing, dress it with a 
pad and adhesive. 
D. Paracentesis of Tympanic Membrane—Myringotomy. 
Myringotomy is performed to drain fluid or pus from the 
middle ear in otitis media. 
Equipment: 
Sterile: 
1. Ear curet. 
2. Ear applicator. 
3. Curved ear forceps. 
4. Paracentesis knife. 
5. Toothpick applicators. 
6. Cotton pledgets. 
7. Ear specula—various sizes. 
Unsterile: 
1. Kidney basin. 
2. Handling forceps in jar of 5 per cent lysol solution. 
3. Head mirror with indirect light or auriscope. 
4. Blanket and pins. 
Wrap the child in the blanket to restrain him; hold him 
as directed under “examination of the ear.” 
Watch for 
Beaction 
Paracentesis 
of Tympanic 
Membrane 
Purpose 
Equipment 
14. Von Pirquet Test for Tuberculosis. 
This test is usually done routinely on all children ad- 
mitted to institutions as an aid in diagnosing tuberculosis. 
It is much more significant in childhood than in adult life. 
The younger the patient the more significant is a positive 
von Pirquet reaction. 
Equipment: 
1. Alcohol in medicine glass. 
2. Ether in medicine glass. 
Purpose 
Equipment MINOR SURGICAL PROCEDURES 
253 
3. Cotton sponges in a jar. 
4. Scarifier, tip sterilized in alcohol, wiped dry. 
5. Koch’s Old Tuberculin. 
6. Handling forceps in glass of 5 per cent lysol solution. 
7. Normal saline in a medicine glass. 
8. Kidney basin. 
The child’s forearm is the most convenient place to apply 
the test. The skin is prepared with alcohol and ether and 
dried. Three scarifications are made about 1 inch apart. 
Koch’s Old Tuberculin is dropped on 2 of the scarifications, 
normal salt solution on the third as a control. Hold the 
arm until the skin is dry. If there is a reaction, it usually 
occurs in 12 to 24 hours and consists of a reddened area 
around the inoculations and none around the control. 
Site to 
Apply Test 
15. A Mantoux Test may also be employed to aid in making 
the diagnosis of tuberculosis. This consists of the introduc- 
tion of a small amount of Koch’s Old Tuberculin intra- 
dermally. 
Equipment: 
Sterile: 
1. Tuberculin syringe. 
2. Alcohol in a medicine glass. 
3. Ether in a medicine glass. 
4. Fine hypodermic needle, 26-28 gauge. 
5. Two sponges. 
Unsterile: 
1. Koch’s Old Tuberculin. 
2. Kidney basin. 
Clean an area on the forearm with alcohol and ether and 
dry it. 
Mantoux Test 
Purpose 
Equipment 
16. Phenolsulphonephthalein Test. 
Phenolsulpho- 
nephthalein 
Test 
Phenolsulphonephthalein is a dye which, when injected 
into body tissues, is excreted by the kidneys. By injecting a 
definite amount and estimating the amount excreted within 
Purpose 254 
PEDIATRIC NURSING 
a certain time the kidney function is tested. Have the child 
empty his bladder immediately before the injection. The 
dye in salt solution is given as a hypodermic injection into 
the lumbar muscles. The child must drink at least 1 glass 
of water just after the injection so that he will be able to 
urinate at the desired time. Collect the urine in exactly 1 
hour and 10 minutes and again in 2 hours and 10 minutes 
after the injection. Keep the urine specimens separate and 
mark clearly, indicating the time. Medications or liquids 
which have been previously ordered may be given during the 
test, but solid food is withheld until its completion. 
To collect urine from a small baby for a phenolsulphoneph- 
thalein test put a test-tube over his genitals (as for collect- 
ing a urine specimen) just after the injection of the dye and 
leave it on for 2 hours and 10 minutes, taking care that no 
urine leaks around the edges. Give him as much fluid as 
he will take. At the end of the time remove the test-tube 
and catheterize him for the remainder of the urine to complete 
the specimen. In this case it is not possible to keep the 
specimens separate. 
To Collect 
Urine from 
Child 
To Collect 
Urine from 
Infant 
17. Schick Test for Diphtheria.7 
Schick Test 
Purpose 
When a ease of diphtheria occurs, all persons who may 
have been exposed in any way should have a Schick test done 
to indicate whether or not they are susceptible. A minute 
amount of diphtheria toxin is injected intracutaneously. If a 
reaction occurs, it indicates absence of natural antitoxins and 
susceptibility to disease. If there is ao reaction, it indicates 
the presence of natural antitoxin. 
Equipment: 
Sterile: 
1. Glass of alcohol. 
2. Glass of ether. 
3. Four cotton sponges. 
Equipment 
7 Holt, L. Emmett, M.D., “Diseases of Infancy and Childhood.” MINOR SURGICAL PROCEDURES 
255 
4. Tuberculin syringe. 
5. Two needles, 28 gauge, U/2 inches long. 
Unsterile: 
1. Kidney basin. . 
2. Jar of 5 per cent lysol solution with 2 pairs of 
handling forceps. 
3. Toxin to be injected. 
18. Vaccination. 
Vaccination is the inoculation of man with virus of vac- 
cinia or cow-pox to cause that disease, since it will produce 
a permanent or partial immunity to small-pox.8 
Equipment: 
Sterile: 
1. Scarifier (needle or scalpel). 
2. Two flat toothpicks. 
3. Two gauze squares. 
Unsterile: 
1. Rubber to blow virus from the tube. 
2. Tube of virus. 
3. Adhesive. 
Site of vaccination: 
Outer aspect of upper arm. 
Outer aspect of upper third of calf of leg. 
Several scratches at right angles to each other are made 
with a scarifier. They are made just deep enough to draw 
serum hut no blood. The virus is blown from the tube to 
this area and is rubbed in with the flat end of a toothpick 
for a minute, then is allowed to dry. Cover with gauze and 
adhesive or a specially designed cap of isinglass. 
19. To Determine the Coagulation Time of the Blood of the 
Newborn.9 
Vaccination 
Purpose 
Equipment 
Site of 
Vaccination 
To Determine 
Coagulation 
Time and 
Bleeding 
Time 
(Employed at University Hospital, University of Minnesota.) 
8 Morrow, A. S., M.D., ‘ ‘ Diagnostic and Therapeutic Technique. ’ ’ 
* Rodda, F. C., M.D., ‘ ‘ Studies with a New Method for Determining 
the Coagulation Time of the Blood of the Newborn,” Am. J. Bis. 
Child., April, 1920. 256 
PEDIATRIC NURSING 
Equipment 
Equipment: 
Sterile: 
1. Glass for alcohol. 
2. Glass for ether. 
3. Six cotton sponges. 
4. Spring lance or scalpel. 
Unsterile: 
1. Handling forceps in glass of 5 per cent lysol solution. 
2. Two watch crystals, inches in diameter. 
3. No. 6 lead shot. 
4. Two squares of blotting paper. 
5. Kidney basin. 
The watch crystals and a shot are cleaned by sponging 
with alcohol and ether. The infant’s heel is sponged with 
alcohol and ether. It is punctured with a lance to cause a 
free flow of blood without the slightest pressure. The sec- 
ond drop of blood is caught on one of the watch crystals con- 
taining the no. 6 shot. The second glass is inverted over 
it and the two are gently tilted every 30 seconds until the 
shot no longer rolls but is fixed in the clot. The average 
coagulation time is 7 minutes; if it is over 10 minutes, it 
indicates a prolonged coagulation time and an abnormal con- 
dition. The length of time the blood flows from the punc- 
ture determines the bleeding time. The normal is 2 to 5 
minutes. The blotting paper is used to absorb the blood until 
bleeding stops. 
Significance 
Protein 
Sensitization 
Test 
20. Protein Sensitization Test. 
In certain types of asthma, hay fever, and urticaria it has 
been shown that the organism is sensitized to proteins whether 
of food, pollens, or animal emanations. This phenomena is 
termed aniphylaxis. The identification of the offending pro- 
tein is achieved by introducing a solution of the protein in 
hydroxid intracutaneously. 
Equipment: 
1. Bottle of sodium hydroxid—Vio normal solution. 
2. Foreign proteins desired. 
Purpose 
Equipment MINOR SURGICAL PROCEDURES 
257 
3. Glass of alcohol. 
4. Glass of ether. 
5. Two sterile medicine droppers. 
6. Sterile toothpicks. 
7. Sterile cotton pledgets. 
8. Sterile cataract knife. 
9. Paper bag for waste. 
Procedure: 
1. The skin, usually of the back, is cleaned with alcohol 
and ether. Superficial incisions of the skin are made with 
the cataract knife. Sodium hydroxid is placed on the incisions 
with the medicine dropper and the proteins are put on with 
the flat end of the toothpick and are mixed with the hydroxid. 
2. Another method of doing this is to make the super- 
ficial skin incisions with a scarifier like the one used in doing 
the von Pirquet test. 
3. Proteins may be introduced intracutaneously with a 
syringe and fine needle as in doing the Schick test. 
Procedure CHAPTER XVII 
NURSING TECHNIQUE IN GENERAL THERAPEUTIC PROCEDURES 
A. Hydrotherapy is the science which deals with the treat- 
ment of disease by means of water.1 
1. Internal use of water: 
The sick child in most cases needs large quantities of water: 
a. By mouth. If he has been vomiting or has had ex- 
cessive diarrhea he will quickly develop acidosis from lack 
of body fluids. Fever may also accompany this condition. 
When attempting to force the fluid intake give measured 
amounts at regular intervals. 
The child of 6 months can take 700 to 1500 e.c. in 24 hours. 
The child of 1 year can take 1500 to 2000 c.c. in 24 hours. 
The child of 2 years can take 1500 to 2500 c.c. in 24 hours. 
(Dr. F. C. Rodda, Minneapolis.) 
The baby may be given water from a nursing bottle 
as he is given his feeding; if he is breast fed it may be 
easier to give him additional fluids with a spoon. The water 
given to a child under 1 year old should be boiled and cooled 
to 100° F. Ice water should never be given. An older 
child may drink water from a cup. Sometimes fluids may 
be given to a very sick patient with a rubber ear syringe; 
fill it with the fluid, insert the tip well into the child’s 
mouth, press the bulb, slowly squeezing in the contents as 
he SAvallows; care must be taken not to choke him. The addi- 
tion of saccharin (with a doctor’s orders) to water is justi- 
fiable if it will increase the fluid intake. Use it in the pro- 
portions of Yg grain to 8 ounces of water; dissolve in a little 
hot water first, then add the remainder. If a child’s condi- 
tion will permit, the addition of fruit juices, as orange juice, 
Internal 
Use of 
Water 
By Mouth 
Amounts 
Which 
May Be 
Given 
How to 
Give to 
Infant 
and Child 
1 Parker, L. A., R.N., ‘ ‘ Materia Mediea and Therapeutics. ’ ’ 
258 GENERAL THERAPEUTIC PROCEDURES 
259 
will often be helpful in forcing fluid; a small amount of 
sugar may be added to make it palatable; the addition of 
sugar may be indicated in some instances, as in acidosis. If 
in spite of all efforts the child still refuses to take fluids they 
are usually ordered by gavage, i.e., by the introduction of 
the tube through the nose or the mouth. (See description 
of gavage, Chapter XIX.) In this way desired quantities of 
fluid may be given at stated intervals. Sometimes fluids by 
mouth cannot be retained even when gavaged, as in the case 
of pyloric stenosis. In such cases fluids may be given: 
b. By rectum (1) either in small quantities injected at reg- 
ular intervals or (2) by continuous Murphy drip method. 
(See directions under enemata, Chapter XIX.) Glucose 
solution 5 per cent or normal salt solution are frequently 
used. (3) Colon flush may be employed to relieve nervous 
irritability and to reduce the temperature. (Described under 
enemata, Chapter XIX.) 
c. Fluids, as normal saline, are also given under the skin. 
(See hypodermoclysis, Chapter XVI.) 
d. Fluids may be given intravenously. (See description, 
Chapter XVI.) 
e. They may be given directly into the peritoneal cavity. 
(See description, Chapter XVI.) 
2. External use of water in the treatment of disease: 
The therapeutic action of the external use of water de- 
pends largely on the temperature of the water; it must be 
sufficiently hot or cold to produce some effect, but we must 
constantly bear in mind that in treating the child extreme 
degrees of temperature are to be avoided. Extreme heat may 
cause severe depression, and extreme cold may produce 
shock.2 
a. Cold applied to the surface of the body causes con- 
traction of the blood vessels followed by a reaction which 
dilates them, and a general stimulation and tonic action re- 
sult. (See note 2.) 
Rectum 
Under the 
Skin 
Into Peri- 
toneal Cavity 
External 
Use of 
Water 
Effect of 
Cold 
2Sheffield, Herman B., M.D., “Diseases of Children.” 260 
PEDIATRIC NURSING 
Effect of 
Heat 
b. Heat applied to the surface of the body dilates the super- 
ficial blood vessels, causing diaphoresis, and increased elimi- 
nation, thus congestion is relieved. The body temperature 
is at first increased and later decreased. (See note 2.) 
Temperatures 
Temperatures 3 
Effect 
Cold, 40°-60° F. 
Overstimulation followed by fatigue 
or even collapse. 
Hemostatic. 
Cool, 65°-75° F. 
Tepid, 85°-95° F. J 
Stimulation. 
Warm, 9r)°-100° F. 
Sedative. 
Hot, 100°-110° F. 
Stimulation. 
Very hot, 110°-120° F. 
Hemostatic. 
Use of Cold 
Cold Pack 
a. Use of cold: 
(1) Cold pack is employed to relieve nervous irritability, 
to produce sleep, and to lower an elevated temperature. 
Equipment: 
Hot water bottle (and cover) 115° F. 
Ice-cap with cover. 
Two blankets. 
Sheet large enough to envelop child. 
Tub of water 100° F. 
Rubber sheet. 
Bath thermometer. 
Pan of ice in large pieces. 
Bath towel. 
Face towel. 
Fold the bedclothes to the foot of the bed, at the same time 
replacing them with a blanket; place the rubber sheet covered 
with a blanket under the child; remove all his clothes but 
his diaper; place the hot water bottle at his feet and the ice 
cap at his head; apply friction to the entire body by rubbing 
for two or three minutes; the sheet is wrung from water 
100° F. and placed under the child crosswise with the ends 
Purpose 
Equipment 
Procedure 
3 Hinsdale, Guy, M.D., ‘ ‘ Hydrotherapy. ’ ’ GENERAL THERAPEUTIC PROCEDURES 
261 
brought up over his body and under his arms to completely 
envelop him, and in such a way that one surface of the 
body does not come in contact with another; fold back the 
upper blanket and rub ice upon the outer surface of the 
sheet, first in front, including the arms, then back and legs, 
so that his entire body is included. (Hold the piece of ice 
in a towel while doing this.) The upper blanket is again 
put over the child and he is left wrapped in the sheet about 
one hour if his condition will permit. Watch him for cyanosis 
and take his pulse frequently; repeat the ice rub once during 
the interval. At the end of the hour remove the sheet; dry 
his body; remove the blankets and rubber. If the child seems 
cold leave the hot water bottle at his feet. Take his tempera- 
ture, pulse and respirations in y2 hour. (See note 2.) If 
he is asleep do not awaken him for the temperature but take 
and record the pulse and respirations.4,5,6 
(2) Sponge bath (University Hospital Routine, University 
of Minnesota) is given to improve the circulation and respira- 
tions, to increase elimination, to relieve restlessness, to make 
the patient more comfortable, and to reduce an elevation of 
temperature. 
Equipment: 
Large rubber sheet. 
Small cotton sheet. 
Hot water bottle (with cover) 115° F. 
Ice-cap with cover. 
Bath thermometer. 
Bath blanket. 
Gauze sponge. 
Bath towel. 
Basin of water, unless otherwise ordered 90° F., at first, 
then gradually lowered to 80° F. 
Pitcher of cracked ice and water. 
Fold the upper bedclothes to the foot of the bed, replacing 
them with the blanket; fold the rubber and sheet together in 
Watch for 
Reaction 
Sponge 
Bath 
Purpose 
Equipment 
Procedure 
4Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” 
5 Holt, L. Emmett, M.D., * ‘ Diseases of Infancy and Childhood. ’ ’ 
6 Dunn, Charles H., M.D., ‘ ‘ Pediatrics. ’ ’ 262 
PEDIATRIC NURSING 
folds lengthwise and slip them under the child; remove all 
his clothes but his diaper; place the hot water bag at his 
feet and the ice-bag at his head. Apply friction to the 
entire body for 2 or 3 minutes by rubbing. Fold the bath 
blanket to the center of the trunk exposing y2 of the bodjq 
then proceed to sponge with one hand, follow with the other, 
using long even strokes. Dip the sponge in the basin of 
water, leaving enough on it to run down over the body after 
the sponging. Begin at the hair line of the neck and sponge 
down over the shoulder and outer arm, keeping the arm 
separated from the body; turn the sponge in the hand, begin 
at the hair line and sponge over the shoulder and the inner 
arm. Dip the sponge; sponge over the chest and trunk, outer 
leg and inner leg to the foot. Continue, dipping the sponge 
every second stroke until the exposed surface of the body 
has been covered. At intervals mop the wrater from the bed 
with the sponge. Keep the water in the basin at the desired 
temperature. Note the pulse frequently and watch the patient 
for cyanosis. Continue sponging for 5 minutes. Fold the 
bath blanket over the sponged surface and expose the other 
half of the body. Proceed in the same way, sponging for 
5 minutes if the child’s condition will allow it. Cover him 
with the blanket and turn him on his side to expose his back; 
sponge it for 5 minutes, beginning at the neck and working 
down to the feet. To remove the patient from the bath, mop 
the water from the bed; roll the rubber and sheet close to 
the back; dry the back and turn him on the dry bed, re- 
moving the rubber and sheet. Dry his entire body, put his 
clothes on, remove the blanket and fold up the bedclothes. 
Take the temperature, pulse, and respirations in y2 hour if 
he is awake; if not, take only pulse and respirations and 
record them. 
(3) Alcohol sponge is given for the same purpose as the 
sponge bath. (University Hospital Routine, University of 
Minnesota). 
Watch for 
Reaction 
Alcohol 
Sponge 
Purpose GENERAL THERAPEUTIC PROCEDURES 
263 
Equipment: 
Two bath blankets. 
Iee-eap with cover. 
Hot water bottle (with cover) 115° F. 
Gauze sponge. 
One pint 25 per cent alcohol. 
One bath towel. 
Fan fold the upper bedclothing to the foot of the bed, 
covering the child with the bath blanket; slip the other 
blanket under him; remove all his clothes but the diaper; 
unpin that and leave it under him; place the ice-cap at his 
head and the hot water bottle at his feet. Apply friction 
to the body by rubbing for 2 or 3 minutes. Expose of 
the body and sponge as in the sponge bath. Squeeze the solu- 
tion from the sponge so that none will drip on the bed; 
keep the arm separated from the body while sponging. Con- 
tinue 10 to 15 minutes as ordered, or as the child’s condition 
will permit. Dry him; dress him; fold up the bedclothes 
and remove the blankets. Take his temperature, pulse and 
respirations in % hour. If he is asleep take only the pulse 
and respirations and record them. 
(4) Cold wet applications are used for all forms of local 
irritation, to relieve pain, swelling, heat, or redness; they 
may be put on the throat, as in tonsillitis or croup, or to the 
chest to relieve nervous irritability, and to reduce an elevated 
temperature. 
(a) Cold wet application to the neck is made of light weight 
cotton material; use several thicknesses and cut it to fit the 
child; wring it from water 90° to 80° F. (or as ordered) ; 
cover this with a piece of old flannel and pin it in place with 
safety pins. Protect the bed and pillow with a rubber sheet 
and rubber slip. 
(b) Cold wet application to the chest is also made of 
some light weight cotton material cut into a sleeveless jacket 
to fit the chest; cut another one from old flannel about 2 
inches longer all around. Put a rubber and a pad under the 
Equipment 
Procedure 
Watch for 
Reaction 
Cold Wet 
Applications 
Purpose 
Cold Wet 
Application 
to Neck 
Cold Wet 
Application 
to Chest 264 
PEDIATRIC NURSING 
child’s neck and shoulders to protect the bed. Wring the 
cotton jacket from water 90° to 80° F. (or as ordered) ; fit 
it inside the flannel one, slipping both under his back and 
over his chest; pin on the shoulders and under the arm. Put 
his night dress on and leave the application on his chest, 
changing it every % to 1 hour, or as necessary to keep it con- 
stantly moist. 
Figure 37. Jacket for Cold Application to the Chest 
Use of Heat 
b. XJse of heat: 
(1) Hot pack is used to produce diaphoresis. 
Equipment (University Hospital Routine, University of 
Minnesota) : 
Three large woolen blankets. 
One large rubber sheet. 
One small rubber sheet. 
Two cotton bath blankets (1 for a small child). 
One bath towel. 
One face towel. 
Bath tub with water 100° to 110° F. 
Bath thermometer. 
Ice-cap with cover. 
Hot water bottle with cover (115° F.). 
Put the large rubber sheet between 2 of the woolen blankets 
and warm them with the third woolen blanket in the blanket 
warmer; fan fold back the upper bedclothes, replacing them 
with the third woolen blanket; put the rubber sheet (between 
the two woolen blankets) under the child; remove all his 
clothes but the diaper; wring the two cotton blankets from the 
Hot Pack 
Purpose 
Equipment 
Procedure GENERAL THERAPEUTIC PROCEDURES 
265 
tub of water, 100° F.-llO0 F., and place them under him, 
one lengthwise and one crosswise of the bed; fold them around 
him to completely envelop his body and in such a way that 
no two surfaces of the body are in contact; put a hot water 
bottle at his feet and an ice-cap at his head. Tuck the dry 
blanket over him down well over his sides and fold the blankets 
and rubber under him up over his body; put a small rubber 
sheet over all and tuck it in. Draw the bedclothes up for 
greater warmth. Take the child’s pulse at the temple every 15 
minutes. Do not leave him alone in the pack; give him hot 
and cold drinks during the procedure, as much as he will 
take (unless his liquids are restricted). Leave him in the 
pack 20 minutes after perspiration has started if his condi- 
tion will permit. Remove the wet blankets and rubber sheet, 
leaving him between dry woolen blankets. After hour dry 
his body, give him an alcohol rub, and remove the blankets. 
(2) Mustard bath is given in cases of sudden shock, heart 
failure, collapse, convulsions, or great prostration from any 
cause. 
Equipment: 
Two bath blankets. 
One bath towel. 
One face towel. 
One hot water bottle (115° F.) with cover. 
One ice-cap with cover. 
Bath thermometer. 
Tub large enough for the child—a foot tub is used for 
the small baby. 
Mustard—use in proportions of 1 tablespoonful to a 
gallon of water. 
First mix all the mustard with a little cool water to make 
a smooth paste, then add the remainder of the water at a 
temperature of 100° F., gradually increasing to 105° F. The 
duration of the bath is 10 minutes; it may be necessary to 
repeat it in 1 hour. Remove the child from the tub, place him 
in bath blankets, dry his body, dress him, and leave him with 
Watch for 
Reaction 
Mustard 
Bath 
Purpose 
Equipment 
Procedure 266 
PEDIATRIC NURSING 
the ice-cap at his head and the hot water bottle at his feet. 
(3) Mustard pack is used for the same conditions as the 
mustard bath; it is less efficient but less disturbing to the 
patient. 
Equipment: 
Large rubber sheet. 
Two bath blankets. 
Large sheet. 
Tub of water 105° F. 
Bath thermometer. 
Ice-cap with cover. 
Hot water bottle (115° F.) with cover. 
Mustard—use 1 tablespoonful to a gallon of water. 
Fan fold the upper bedclothes to the foot of the bed, re- 
placing them with a blanket; place the rubber sheet and 
blanket under the child; remove all his clothes but the diaper; 
put the hot water bottle at his feet and the ice-bag at his 
head. Wring the sheet from the tub of mustard water; place 
it under the child crosswise of the bed and completely envelop 
his body with it; bring the under blanket and rubber up over 
him and tuck the upper blanket down around his sides; 
leave him in the pack 15 to 30 minutes, or until there is a 
notable redness of the skin. Remove him, dry and dress him, 
and leave him with the hot water bottle at his feet and the 
ice-cap at his head. 
(4) Hot wet applications are used to promote local cel- 
lular activity and to aid drainage. 
Equipment: 
Several thicknesses of woolen material as old blanket. 
Oiled silk or muslin large enough to cover the application. 
Binder or bandage to secure the application. 
Safety pins. 
Stupe wringer and handles. 
Two pairs of handling forceps in glass of 5 per cent 
lysol solution. 
Sterile pad for dressing over an open wound. 
Kidney basin. 
Round basin. 
Mustard 
Pack 
Purpose 
Equipment 
Procedure 
Hot Wet 
Applications 
Purpose 
Equipment GENERAL THERAPEUTIC PROCEDURES 
267 
Use several thicknesses of old woolen material (as old 
blanket) large enough to completely cover the area; fold it 
in the canvas part of the stupe wringer in the basin and bring 
to a boil over a flame; use the wringer handles to wring the 
application dry; take it to the bedside on a tray with the 
rest of the equipment. Remove the application from the can- 
vas with the forceps and place it over the desired area. If 
there is an open wound, first cover it with a sterile pad. 
Cover all with a dry piece of flannel and oiled silk, holding 
them in place with a binder or bandage as necessary. Change 
the application every 1 or 2 hours, depending on its size; it 
must be changed often enough to keep it constantly moist and 
warm. 
(5) Hot air bath is given as a diaphoretic and to increase 
elimination, i.e., as in nephritis with impending uremia. 
Equipment: 
Ice-cap with cover. 
Hot water bottle (115° F.) with cover. 
Four or 5 blankets. 
Two large rubber sheets. 
Bed cradle long and wide enough to completely cover the 
child’s body. 
Bath thermometer with a long string tied to the handle. 
Hot-air stove and elbow pipe covered with asbestos. 
Bunsen burner or alcohol lamp. 
Drinks. 
Alcohol for rub after bath. 
Cover the child with a blanket; remove the upper bed- 
clothes, folding and placing them in a chair; leave one pillow 
under his head; put one large rubber sheet and a blanket 
under him; remove all his clothes but the diaper. If he is 
very restless, delirious, or active enough to interfere with the 
procedure, restrain him by wrapping and pinning the blanket 
which is under him tightly around him and use the one over 
him to cover the cradle; otherwise leave him between the 
blankets, put the ice-cap at his head and the hot water bottle 
at his feet; place the cradle over his body; put the bath 
Procedure 
Hot Air 
Bath 
Purpose 
Equipment 
Procedure 268 
PEDIATRIC NURSING 
thermometer under it and over the child’s body leaving the 
string outside to facilitate the removal when it is necessary 
to read it. Arrange the stove on the support at the foot of 
the bed and run the pipe covered with asbestos 3 or 4 inches 
under the cradle; tie it to the cradle so that it is 4 inches at 
least above the child’s feet. Draw the ends of the rubber and 
blanket which are under him up over the sides of the cradle, 
and under the blankets which are put over it; use two to four 
blankets over it, as necessary to produce the desired tempera- 
ture ; tuck them in well around the child’s neck and shoulders, 
around the pipe and under the mattress at the foot of the bed, 
and under the cradle at the sides. Cover all with a second large 
rubber sheet, tucking it in over the blankets in the same way. 
Put the lamp or burner in the stove and light it. Give the 
child as much fluid as he will take, unless restricted. Watch 
his pulse, taking it frequently at the temporal artery. Do not 
leave him alone in the hot air bath. Unless otherwise ordered 
the temperature of the bath is 110° F. to 115° F.; leave him 
in it 15 to 20 minutes after the desired temperature has been 
reached, unless his condition indicates immediate removal. 
After removal leave him in the blankets for an hour; wrap 
the one directly under him around him and leave the ones 
which covered the cradle over him. Make up the bed. At the 
end of an hour wipe his body dry; give him a vigorous 
alcohol rub; dress and leave him between dry blankets, or at 
least with one directly over him. He should be carefully pro- 
tected from exposure or draughts. 
Watch for 
Reaction 
B. Heliotherapy. 
History 
As early as 490 B.C. the beneficial effects of the sun’s rays 
were recognized by the Greeks, but not until recently have 
they been utilized as definite therapeutic agents. Shortly 
before 1800 sun treatment was practiced by the French, and 
through the nineteenth century was employed by several 
eminent physicians. In recent years, Dr. Rollier of Leysin, 
Switzerland, has been the greatest exponent of heliotherapy. GENERAL THERAPEUTIC PROCEDURES 
269 
In dealing with surgical tuberculosis he saw that in spite of 
great skill and excellent technique, poor results were obtained 
by the surgeons. Dr. Rollier realized that these infections 
must be treated not as purely local lesions, but as general 
constitutional diseases. The J. N. Adam Memorial Hospital 
of Perrysburg, New York, a municipal institution of the 
City of Buffalo, was the first hospital built for this purpose in 
the United States. Dr. John Pryor adapted Dr. Rollier’s sys- 
tem of solar radiation to the needs of this hospital and 
wonderful results have been obtained. 
System and a careful application of it are essential. 
Solar rays, when applied to the skin, must be used as cau- 
tiously as any other therapeutic agent; an overdose can be very 
definitely harmful. The best results will be obtained only by 
strict regulation of the process together with careful observa- 
tion of the patient. 
This treatment can be carried out all the year around and 
in almost all altitudes and climates. Institutions adopting 
this method of treatment should have wide sheltered terraces, 
where the beds may be rolled out into the sunshine. 
Heliotherapy is valuable in all cases wdiere resistance is 
below normal, including tuberculosis, anemia, rickets, perito- 
nitis, undernutrition, and during convalescence from acute 
infectious diseases. It is with tuberculosis that the most 
work has been done. Of equal interest and importance is 
the work of Hess and others with rickets.7 This is the com- 
monest nutritional disorder among infants, yet little has been 
known about it. Some have believed the main cause to be 
dietetic, while others held that it resulted from faulty hygiene. 
Its occurrence during winter and spring and disappearance 
during summer called attention to the possible effects of di- 
rect sunlight. Hess exposed babies to the direct rays of the 
sun for from fifteen minutes to one hour daily and found that 
they not only improved in general vigor and nutrition but also 
Process of 
Insolation 
Therapeutic 
Value 
7 Hess, A. r., M.D., Am. J. Pub. Health., Feb., 1922. 270 
PEDIATRIC NURSING 
that without exception the signs of rickets rapidly disap- 
peared. While cod-liver oil is a specific for this disorder and 
should be used, we find from this work that sunlight is an 
extremely important prophylactic agent. 
The patient should never be subjected to sudden insolation, 
but should become accustomed gradually to fresh air and 
sunshine. The first day or two have him sleep with open 
windows. Then in two or three days wheel his bed out on 
the porch for an hour, increasing this period until he can 
stay out-of-doors all day. In a week or ten days direct ex- 
posure may be started. Sun baths should not be given later 
than one-half hour before the noon meal, and not earlier than 
two hours after eating. During insolation the eyes should be 
protected by a folded cloth, colored glasses, or an umbrella. 
The patient should rest in bed, warmly covered except for 
the exposed area. The feet are insolated first, and the rest 
of the body gradually included, as clearly shown in the dia- 
gram. Sinuses and ulcers are protected by wire screening, 
which permits free circulation of air and admission of sun 
rays. When the discharge is profuse, a light gauze dressing 
may be changed frequently, These lesions are the last to 
receive direct exposure. During the treatment, close watch 
must be kept of the temperature, pulse, urine, and blood. 
The exposure should not be long enough to cause dermatitis, 
rise in temperature, headache, nausea, or other constitutional 
symptoms. Feeble patients with high temperatures should 
have shorter insolation than that indicated on the diagram. 
It is most important that no breeze strike the body. Screens 
or wind-breaks may be used for protection. As soon as a 
patient seems chilly, he should immediately be wheeled back 
into a warm room. In the summer the sun has a fatiguing and 
depressing effect during the middle of the day, and must be 
avoided. When the weather is warm, the children wear only 
a loin cloth all day, whether eating or playing out-of-doors. 
During the winter months, when the sun’s rays are weak, 
the children are allowed to exercise in the snow for an hour 
Technique  
DAYS 
1st 
2nd 
3rd 
4th 
5th 
6th 
7th 
8th 
9tn 
10th 
From the 10th to the 
15th day, increase ac- 
cording to the same scale. 
From the 15th day, 
all the previously exposed 
portions of the body 
should receive the same 
amount of insolation as the 
longest exposed part,— 
increasing the time 5 
minutes daily, till a bath 
of from 3 to 4 hours is 
taken. 
5 
Min. 
10 
Min. 
15 
Min. 
20 
Min. 
25 
Min. 
30 
Min. 
5 
Min. 
10 
Min. 
15 
Min. 
20 
Min. 
25 
Min. 
30 
Min. 
35 
Min. 
5 
Min. 
10 
Min. 
15 
Min. 
20 
Min. 
25 
Min. 
30 
Min. 
35 
Min. 
40 
Min. 
5 
Min. 
10 
Min. 
15 
Min. 
20 
Min. 
25 
Min. 
30 
Mm. 
35 
Min. 
40 
Min. 
45 
Min. 
5 
Min. 
10 
Min. 
15 
Min. 
20 
Min. 
25 
Min. 
30 
Min. 
35 
Min. 
40 
Min. 
45 
Min. 
50 
Min. 
THE PROGRESSION BY WHICH THE PATIENT IS EXPOSED TO THE SUN 
Figure 38. 
DR. ROLLIERS SCHEMATIC DIAGRAM OF INSOLATION 
271 272 
PEDIATRIC NURSING 
or two on pleasant days. Socks, shoes, and a loin cloth are 
the only clothes worn at this time. Recumbent patients who 
have completed their exposure are given four or five hours 
of insolation daily, when the weather permits. On cloudy 
days air baths may be given for an hour. Although not an 
adequate substitute for insolation, air exposure is beneficial 
to the patient. 
The beneficial effects of solar radiation are attained mainly 
by the short length waves, of which the ultra-violet is per- 
haps the most valuable. Special lenses are sometimes used to 
enhance these. Artificial light produced by special lamps has 
proved useful.8,9 The quartz lamp and carbon arc lamp 
have both been used with excellent results in rickets.10 In 
tuberculosis the results are inferior, but still very much worth 
while in the absence of direct sunlight. Window glass, on the 
other hand, is impermeable to some rays and patients receiv- 
ing treatment through it enjoy only about one-fourth of the 
benefit of fresh air exposure. 
Insolation has three distinct effects upon the skin: it 
causes a latent hyperemia, a pigmentation, and a thickening 
of the epidermis. The hyperemia promotes absorption of the 
rays; the pigmentation increases their penetrability so that 
they are more completely absorbed; and the thickened epider- 
mis affords the body increased protection against abrasions 
and bacterial invasion. Apart from the effects on the skin, 
there have been shown to be distinct changes in the whole 
metabolism. The cellular elements of the blood are influenced, 
as is the phosphorous content of the blood serum. 
Pain usually disappears within ten days after treatment 
is begun, fever drops, chills cease, appetite returns, weight 
and strength are regained, and the condition of the blood 
improves. Hemoglobin and red cells increase, while leuco- 
Solar 
Rays 
Effects 
upon the 
Body 
8 Lasch, W., and Wertheimer, W., ‘ ‘ Effect of Artificial Heliotherapy 
on Metabolism,” Monatschr. f. Kinderh., Nov., 1921. 
9 Hess and Unger. Journ. Amer. Med. Assn., May 27, 1922. 
10 Kramer, Casparis and Howland. Am. J. Bis. Child., Sept., 1922. GENERAL THERAPEUTIC PROCEDURES 
273 
cytosis, if present, decreases. In peritonitis with effusion, the 
fluid slowly but steadily absorbs. In surgical tuberculosis 
sequestra are painlessly discharged, the sinuses have a pro- 
fuse discharge followed by sloughing and the formation of 
healthy granulation tissue, and there is abundant recalcifica- 
tion. If treatment must be interrupted at any time, it should 
he resumed at a stage somewhat earlier than that at which 
it was discontinued. After exposure a gentle rub with spirits 
of camphor will harden the skin, give it a velvety texture, and 
refresh the patient. This application is not essential and 
may be omitted when the expense is too great. For a sensi- 
tive skin an oil rub may precede the sun bath. As pigment 
increases, the skin becomes first tanned, then bronzed, and 
finally a deep chocolate color. The texture is velvety and 
there is great resistance to bacterial infection. These patients 
are not subject to the usual winter infections of the respiratory 
tract, including influenza. The degree of pigmentation is in 
direct proportion to the favorable progress of the cure. Dr. 
Rollier considers this an index to prognosis. 
general references 
Caille, Augustus, M.D.—Postgraduate Medicine, 
Griffith, J. P. Crozer, M.D.—Diseases of Infants and Children. 
Jamme, Anna, R.N.—Nursing Procedures 
Maxwell, Anna, R.N., and Pope, Amy E., R.N.—Practical Nursing. 
Morrow, Albert S., M.D.—Diagnostic and Therapeutic Technique. 
Pope, Amy E., R.N.—Manual of Nursing Procedures. 
Rollier, Auguste—La Cure de Soleil. 
Sanders, G. J., R.N.—Modern Methods in Nursing. 
Wheeler, Mary C., R.N.—Nursing Technique. CHAPTER XVIII 
NURSING TECHNIQUE IN GENERAL THERAPEUTIC PROCEDURES 
(Continued) 
Use of 
Drugs 
for 
Children 
C. Drug’s are not used as much in the treatment of disease 
in children as in adults. They are given only when the child’s 
condition presents some clear and definite indication for their 
use. Dr. Jacobi has said that most conditions in childhood 
tend to right themselves without any medication.1 A large 
proportion of the acute illnesses of infancy and childhood are 
due to disturbances of the gastro-intestinal tract; any disease 
tends to manifest itself by gastro-intestinal symptoms. Since 
the use of drugs also tends to derange digestion, it is important 
not to allow their continued use to still further interfere 
with this function.2 
1. The relative dosage is another difficulty in administer- 
ing drugs to children. The child cannot be treated as a 
miniature adult and cannot be given a fraction of the adult 
dose. When calculating the proper dose, it is necessary to 
consider the peculiarities of infants and children, and also 
the fact that certain drugs are well tolerated by them while 
others are not. There are various formulae to calculate the 
proper dose; these are based on wreight or age, or weight and 
age. Clark’s rule gives the most exact results. Multiply 
the adult dose by the weight of the child (in pounds) and 
divide by 150 (the weight of the average adult). 
Dosage 
Clark’s Rule 
1Holt, L. Emmett, M.D., “Diseases of Infancy and Childhood.” 
2 Helmholz, Henry F., M.D., ‘ ‘ The Use of Drugs in Infancy and 
Childhood.” Journ. Amer. Med. Assn., Oct. 8, 1921. 
274 GENERAL THERAPEUTIC PROCEDURES 
275 
2. Methods of giving drugs: 
a. By mouth. 
By gavage—inserting the tube through the (a) nose or 
(b) mouth. 
b. By rectum. 
c. Intravenously. 
d. Intraspinally. 
e. Intramuscularly. 
f. Subcutaneously. 
g. By inunction. 
h. By inhalation. 
a. By mouth: Powders, capsules, and pills have a limited 
use except for the older child. As a general thing drugs 
should be given in as simple a form as possible, preferably in 
solution. If it can be avoided a child should not be forced 
to take any particularly nauseous or bitter medicine; it should 
be made as palatable as possible; follow it always with a 
drink of water and with orange juice if possible. 
Sweet syrups and elixirs which are sometimes used to dis- 
guise disagreeable tastes are also nauseous and they quickly 
upset digestion. The small baby, as a rule, will take almost 
any medicine. The older child who is well trained if 
tactfully approached and reasoned with will offer little diffi- 
culty ; explain to him the necessity for it, appeal to his better 
instincts and sense of honor by asking his cooperation; do not 
antagonize him from the first by using force or by expecting 
unreasonable things of him. Do not tell him his medicine is 
“good” if you know very well that it is distasteful. The 
so-called “spoiled” child, who has always listened to mean- 
ingless threats or bribes and who has been constantly permitted 
to have his own way, will present many difficulties. A child 
can always be made to take any medicine by using restraints 
and force, but this should be done only as a last resort when 
other methods have been tried and have failed. If it has to 
be done pin his hands in a blanket, place him on his back in 
bed, and put the spoon containing the medicine on the back 
of his tongue and hold it there, allowing the medicine to run 
Methods 
of Giving 
By Mouth 276 
PEDIATRIC NURSING 
in until swallowing takes place; in this way he cannot regurgi- 
tate but has to swallow. Medicine may also be given by 
gavage, introducing the tube through the mouth or nose. 
(See technique for procedures, Chapter XIX.) Suggestions 
for giving some of the common medications: 
For the small baby, whenever possible, put the medicine 
with his milk; as for example, (1) calcium lactate or calcium 
chlorid (given for spasmophilia) are very bitter, but mixed 
with the feeding are usually well taken. Avoid giving par- 
ticularly nauseous medicines near a meal. 
(2) Cod liver oil may cause digestive disturbances when 
given over a long period of time. It should be given halfway 
between feedings or between meals, and if mixed with orange 
juice it is much more palatable. A cod liver oil emulsion can 
be given without producing nausea. Special glasses or spoons 
should be set aside for giving it, since it causes them to smell 
and taste. 
(3) Castor oil is made more palatable if given ice cold and 
mixed with orange or lemon juice. To prepare: squeeze 2 
or 3 ounces of orange juice in a glass; take it with the meas- 
ured oil and dram of sodium bicarbonate to the bedside; 
mix the three together, stir, and give while it is effervescing; 
follow with a drink of orange juice or let the patient hold a 
piece of ice in his mouth. A thin chocolate syrup will dis- 
guise the taste of many disagreeable medicines if the child’s 
condition wTill warrant its use; it is particularly valuable when 
giving quinin or powdered animal charcoal. A little square 
of milk chocolate may be given after a medication. 
(4) Cascara sagrada is best taken in the form of aromatic 
fluid extract. 
(5) When giving digitalis drop it on some sugar in a spoon. 
(6) Atropin sulphate is a drug frequently given very 
young children (see pyloric stenosis). The nurse who does 
pediatric work must know the toxic symptoms of this drug. 
They are:3 
Calcium 
Lactate 
Cod Liver 
Oil 
Castor Oil 
Cascara 
Sagrada 
Digitalis 
Atropin 
Sulphate 
3 Bloomgarten, A. S., M.D., “ Materia Medica for Nurses.” GENERAL THERAPEUTIC PROCEDURES 
277 
1. Dryness of the mouth and throat. 
2. Excessive thirst. 
3. Difficulty in swallowing. 
4. Hoarseness. 
5. Flushed, dry skin, especially on face and neck. 
6. Very rapid pulse and breathing. 
7. Pupils widely dilated. 
When starting to give atropin 1 minim of a 1-1000 solution 
is usually ordered several times a day, and increased 1 minim 
every day or every other day until signs of atropinism appear. 
The nurse must watch the patient closely and must be able to 
distinguish these signs at once. In the small child dilatation 
of the pupils and flushed skin, especially of the face and neck, 
are the most characteristic early symptoms. 
b. By rectum: Certain drugs, such as chloral hydrate, are 
very irritating to the stomach and are successfully given by 
the rectum. (See directions for giving a small enema, Chapter 
XIX.) 
c. Intravenously: The intravenous method of giving medi- 
cations, as antitetanic serum or diphtheria antitoxin, has al- 
ready been discussed. (See intravenous infusion of fluids, 
Chapter XVI.) 
d. Intraspinally: The intraspinal method has been dis- 
cussed; cerebrospinal meningitis serum may be given this 
way. (See intraspinal injection, Chapter XVI.) 
e. Hypodermically or subcutaneously: Many drugs, as 
morphin sulphate or atropin sulphate, are given in this way. 
Hypodermic tray should contain: 
Equipment: 
1. Flask of sterile distilled water. 
2. Alcohol lamp. 
3. Matches. 
4. Forceps. 
5. Jar of sterile cotton pledgets. 
6. Paper bag for waste. 
7. Bottle of alcohol 70 per cent. 
8. Tablespoon in which to boil the needle. 
By Rectum 
Chloral 
Hydrate 
Intravenously 
Intraspinally 
Hypo- 
dermically 
Equipment 278 
PEDIATRIC NURSING 
9. One c.c. hypodermic syringe. 
10. Needles y2 to % inches long, 26-28 gauge. 
11. Medicine glass of alcohol in which to sterilize syringe. 
12. Drug in tablet form. 
13. Rubber bulb. 
Remove the wire from the needle, put it on the syringe 
and test for leakage, replace the wire, wrap the needle lightly 
in cotton, and sterilize by boiling in water in the large spoon 
over the alcohol flame for 1 minute. Flame the forceps and 
with them place the needle on a sterile cotton pledget. Steri- 
lize the syringe by drawing alcohol up into it and expelling it 
several times; let it soak in the glass of alcohol while the 
needle is boiling; then rinse it by drawing up sterile water 
from the spoon and expelling it. Then draw up a quantity 
sufficient to dissolve and dilute the tablet. Expel it into the 
empty spoon; pick up the tablet with the sterile forceps and 
put it in the measured water in the spoon; dissolve it by 
stirring with the tip of the syringe; draw it up into the 
syringe; pick up the needle with the sterile forceps, remove 
the wire and attach it to the syringe; expel the air by hold- 
ing the syringe with the needle pointing up and force out 
1 or 2 drops of the solution. Enfold the needle in an alcohol 
sponge and with a second alcohol sponge carry it to the patient. 
Replace the drug and lock the medicine closet before leaving. 
Place the syringe in the sponge on the bedside table while 
preparing the patient. If he struggles while the hypodermic 
is being given, restrain him by pinning a blanket around him. 
It may be given in any fleshy part of the body and not over 
any bony portion. The usual sites are: 
1. Outer aspect of upper arm. 
2. Inner aspect of thigh. 
3. Calf of leg. 
4. Buttocks. 
Cleanse the area well by rubbing with an alcohol sponge. 
Raise and hold between the thumb and forefinger of the left 
hand a fold of tissue around the area of injection; hold the 
Sites for 
Injection GENERAL THERAPEUTIC PROCEDURES 
279 
syringe in the right hand and quickly insert the needle; 
slightly withdraw it, then inject the fluid by making pressure 
on the piston of the syringe with the thumb ; quickly withdraw 
the needle; knead the area gently with a sponge in order 
to aid in the absorption of the drug. If the drug is in solution 
instead of in tablet form, prepare the needle and the syringe 
in the same way, rinse the syringe, attach the needle, remove 
the cork from the bottle, lower the needle into it and draw the 
desired amount of the drug up into the syringe. Give as 
before. 
f. Intramuscularly: For intramuscular injection the 
equipment and procedure are the same as for subcutaneous 
injection except for the needle, which is 24 to 26 gauge, 1 to 
inches long and the drug is given deeper by inserting 
the needle vertically into the muscle; the gluteal region is 
preferable. Press over the puncture with a sponge and 
massage it gently to aid the absorption of the drug. 
A special syringe and needle should he kept separate for 
giving camphorated oil; the needle should screw on the syringe 
and it should be 22 to 24 gauge. 
Care of articles used: Clean the syringe and needle by 
drawing up alcohol and expelling it. Leave the syringe with 
the plunger out and absolutely dry. Dry the needle by 
blowing out all moisture with a rubber bulb. Dry the wire; 
dip it in liquid petroleum and replace it in the needle. Leave 
the tray in order and ready for immediate use. 
g. Inunction: Drugs, as mercury, are often given a child by 
inunction. Wash the site of the inunction with soap and 
water to soften the skin.4 The nurse puts a rubber glove on 
her right hand, takes the desired amount of ointment in her 
fingers, and rubs it all into the child, using the tips of her 
fingers and the heel of her hand with a rotary motion. The 
site for inunction is changed daily in the following routine: 
Intra- 
muscularly 
Needle 
Inunction 
Mercury 
Sites for 
Routine 
Inunction 
4 Ramsey, W. R., M.D., and Groebner, O. A., M.D., “Further Progress 
in the Study of Relative Efficiency of Different Mercurial Preparations, ’ ’ 
Am. J. Dis. Child., Sept., 1920. 280 
PEDIATRIC NURSING 
1st day, inner right arm. 
2d day, inner left arm. 
3d day, inner right thigh. 
4th day, inner left thigh. 
5th day, chest. 
6th day, back. 
7th day, rest. 
After use wash the glove with soap and water, then rinse, dry, 
and remove it, using it for this purpose daily. Sometimes, 
in the case of a baby, instead of rubbing the mercury oint- 
ment in with the hand, the desired amount is ordered to be 
put under the adbominal binder and is allowed to rub itself 
in as the child moves about. 
h. Inhalation: (1) Inhalations, as of steam or benzoin, 
may be given to the child as to the adult. 
Method 1: 
Equipment: 
1. Pitcher of boiling water containing the desired drug. 
2. Bath towel. 
3. Paper bag large enough to go over the pitcher. 
Cut a hole (large enough for the patient to put his nose 
and mouth through) in the bottom of the bag and put it over 
the pitcher with the bottom up. If the child can sit up, 
hold the pitcher in front of him; have him hold his nose and 
mouth over the hole in the bottom of the bag to inhale the 
steam; cover his head and the pitcher with a large bath towel 
or blanket to prevent the escape of the steam. The child must 
not be left alone for an inhalation because he may burn him- 
self. Continue it for 10 to 20 minutes and repeat every 2 or 3 
hours as ordered. If he cannot sit up, place the pitcher on 
a chair at the side of his crib; have him lie on the edge of his 
bed on his side; adjust the paper bag over the pitcher (with 
the bottom up) so that it will convey the steam from the 
pitcher to the child. Throw a large bath towel or blanket 
over his head. 
Inhalation 
For Child GENERAL THERAPEUTIC PROCEDURES 
281 
Method 2: 
Equipment: 
Electric plate on asbestos mat. 
Tea kettle. 
Rubber tubing to fit over spout of kettle. 
Funnel. 
The electric plate is placed on the bedside table; the kettle 
of water, with the drug as ordered, is placed on it. One end 
of the rubber tubing fits over the spout of the kettle; the 
funnel is attached to the other end. Steam is conveyed to 
the patient through the rubber tubing and the funnel which 
is held over the patient’s nose. If a cheap tin funnel is used 
it can be bent to fit quite closely over the nose. Care must be 
taken not to burn the patient. 
A croup tent may be arranged to give inhalations to an 
infant. 
Equipment: 
Electric plate on asbestos mat. 
Croup kettle with long nozzle—containing water and drug 
as ordered. 
Screen with 3 panels. 
4 blankets. 
Have the infant lie in his crib; fit the screen around the 
head and sides; cover the top and sides of the screen with 
blankets to make a closed tent over his head; secure them 
with safety pins at the sides. If a screen is not obtainable, 
sticks (like an old broom handle) can be tied to the head and 
the foot of the crib and blankets suspended from them over 
the head, foot, and sides to make a closed tent. Place the 
electric plate and the asbestos mat on a chair at the side of 
the bed and after the water in the croup kettle is boiling, run 
the spout under the tent at the corner where the blankets 
come together. The spout should be at least 2 feet above the 
patient and the steam should be directed upward and away 
from him. If he is very active, restrain his hands. The 
nurse must stay with him constantly while he is having the 
inhalation. Unless otherwise ordered continue it for % hour; 
For Infant 282 
PEDIATRIC NURSING 
it may be repeated 3 to 4 times daily. After the removal 
of the steam wipe the child dry, change his clothes if they 
are damp, and leave him between blankets. The room should 
be 68° and he should be protected from draughts or exposure; 
do not take him outdoors for several hours after the treat- 
ment. 
If a regular croup kettle is not available a tea kettle can 
be used with rubber tubing fitted over the nozzle for a 
spout or one may be made of a roll of newspaper inserted 
into the nozzle. 
If the child can be put in a small room, sufficient steam 
may often be obtained by opening the radiator valve. 
(2) Chloroform is often given for relief of convulsions; it 
is given on a mask covered with gauze which is held over 
the child’s nose and mouth. Both chloroform and a mask 
ready for use should be kept in the pediatric medicine closet 
for an emergency. 
(3) Oxygen may be given in cases such as sudden collapse, 
shock, heart failure, croupous pneumonia, etc.5 An oxygen 
tank ready for use should be part of the equipment of a 
pediatric department and of the room devoted to the care 
of prematures. Compressed oxygen is furnished in tanks of 
various sizes; a rubber tube should be attached to the oxygen 
outlet on the tank to convey the gas to the bottle of water 
which hangs on the side of the tank; another rubber tube 
writh a funnel on the end of it conveys the gas to the patient. 
The bottle of water acts as a gauge for the amount of oxygen 
given, since the bubbles may be counted as they pass through 
it; unless otherwise ordered allow 10 bubbles a minute. Hold 
the funnel about 2 inches from the child’s nose and mouth. 
If it is to be given over a long period of time and if he is 
quiet, a bandage from one side of the crib to the other may 
be arranged to support the funnel in the desired position over 
his nose. 
Chloroform 
Oxygen 
6Caille, Augustus, M.D., “Postgraduate Medicine.” GENERAL THERAPEUTIC PROCEDURES 
283 
D. Counterirritants. 
1. Purpose: 
a. To dilate blood-vessels of the skin. 
b. To relieve pain and inflammation. 
2. Turpentine stupe is applied to the abdomen for relief of 
abdominal pain and distention. 
Equipment: 
1. Basin. 
2. Two pieces of soft flannel for stupe cloth. 
3. One piece of dry flannel. 
4. One piece of oiled silk or muslin a little larger than 
the flannel. 
5. Binder and safety pins. 
6. Turpentine in a medicine glass, 1 part to 10 parts of 
oil (unless otherwise ordered). 
7. Applicator to apply turpentine. 
8. Two pairs of handling forceps in a glass of 5 per cent 
lysol solution. 
9. Kidney basin. 
10. Blanket. 
11. Canvas stupe wringer and handles. 
12. Towel. 
The canvas stupe wringer, containing one piece of flannel, 
is suspended by the handles across the basin; cover it with 
boiling water to saturate it; gather it up by the handles and 
wring it dry; remove the sticks; pour the water from the 
basin, replace the canvas and flannel, cover it with a towel and 
take it with the rest of the equipment to the bedside. Turn 
down the bedclothes to expose the abdomen. With the appli- 
cator paint it with turpentine and oil mixture. With the 
forceps remove the flannel from the canvas and apply it; use 
great care not to bum the child, since his skin is extremely 
tender. As a prevention the nurse keeps her hand under the 
stupe and over his abdomen until she is certain it will not 
burn. Cover the moist flannel with a dry piece and the oiled 
muslin; hold all in place with an abdominal binder. Change 
the stupe every 15 to 30 minutes as necessary to keep it warm, 
Counter- 
irritants 
Turpentine 
Stupe 
Purpose 
Equipment 284 
PEDIATRIC NURSING 
or as ordered; reapply turpentine and oil every 8 hours if the 
skin is not reddened by it. After the removal of the stupe 
wash the skin with soap and water and apply vaselin; leave a 
dry flannel over it for several hours. If there is an abdominal 
wound apply the stupe over the sterile gauze dressing which 
covers it. 
3. Flaxseed poultice: 
Equipment: 
1. Poultice board or 
newspaper. 
2. Poultice pan and 
spoon. 
3. Spatula or knife. 
4. Gas burner. 
5. Water. 
6. Flaxseed. 
7. Muslin—double the size of the completed poultice and 
large enough to allow 2 inches to fold under on all 
sides, shape it to fit the area to be poulticed. 
8. Binder, safety pins. 
9. Oiled muslin. 
10. Piece of flannel. 
11. Vaselin, tongue blade. 
12. Paper bag. 
13. Towel. 
14. Needle, thread. 
Spread the muslin on the poultice board; put the pan con- 
taining the desired amount of water over the flame; when it is 
boiling add the flaxseed by sifting it in slowly with one hand 
and stirring constantly with the other. Continue until the 
batter is just thick enough to drop from an inverted spoon; 
remove from the flame and beat it vigorously 3 to 5 minutes. 
Pour it on % of the muslin (a), with the spatula spread it 
evenly so that it is % to inch thick; leave a 2-inch margin 
on the edges to turn in; cover with the other half (b) and 
turn 2 inches under on 3 sides. If the child is very active 
baste the edges together. Take it to the bedside folded in a 
Flaxseed 
Poultice 
Equipment GENERAL THERAPEUTIC PROCEDURES 
285 
bath towel on a tray with the rest of the equipment. Anoint 
the skin over the area to be poulticed with vaselin; apply 
the poultice, using great 
caution not to burn the 
child. The nurse must 
test the poultice carefully 
with her hand before ap- 
plying it. Cover it with 
the flannel and oiled mus- 
lin and hold it in place 
with the binder pinned 
loosely. Change as or- 
dered or every 1 or 2 hours as necessary to keep it con- 
stantly warm. As soon as the poultice pan is emptied it 
should be filled with water and should be washed after the 
poultice has been applied. After the removal of a poultice 
scrape the flaxseed from the muslin; wash and use it over 
again. 
4. Mustard poultice: Mix 1 part of mustard with 12 parts 
of flaxseed; add it to the boiling water following the above 
directions. 
5. Mustard paste: 
1. Poultice board or newspaper. 
2. Bowl, spoon, knife. 
3. Mustard, 1 part. 
4. Flaxseed, 12 parts. 
5. Pitcher of water, 100° F. 
6. Muslin—twice the size of the area, over which it is to be 
applied. Crease in the middle and turn in a 2-inch 
margin on all sides. (See illustration for flaxseed 
poultice.) 
7. Towel. 
8. Binder, safety pins. 
9. Vaselin, tongue blade. 
10. Paper bag. 
11. Needle, thread. 
Spread the muslin on the poultice board; mix mustard, 1 
part, with flaxseed, 12 parts, in a bowl; mix with a little cool 
Figure 39. To Fold Muslin for 
Poultice 
Mustard 
Poultice 
Mustard 
Paste 286 
PEDIATRIC NURSING 
water and add warm water to make a thin paste which can be 
easily spread. With the knife spread it on half of the 
muslin (a) following the creases; fold the other half (b) 
over it and turn 2 inches in on 3 sides; baste the edges to- 
gether. (See illustration of flaxseed poultice.) Carry it to 
the patient folded in a warm towel on a tray with the rest 
of the equipment. With the tongue blade spread the vaselin 
over the area to which the mustard paste is to be 
applied; apply the paste, cover with the folded towel and 
hold it in place with a loose binder; leave it 5 to 15 min- 
utes, watching it frequently, and remove it as soon as the 
skin becomes reddened; it may be applied several times a day. CHAPTER XIX 
NURSING TECHNIQUE IN GENERAL THERAPEUTIC PROCEDURES 
(Continued) 
E. Other Therapeutic Procedures. 
1. Hot water bottles: A hot water bottle for a child should 
never be filled with water over 115° F. Always take the tem- 
perature accurately with a bath thermometer ; fill the bag 
half full of water; expel the air and screw on the top; hold it 
upside down to see that it does not leak. Always have a 
cover on it and never let it come in direct contact with the 
child. Outing flannel made into a bag, 18 by 10 inches, with 
a drawstring in the top makes a good cover. Put the bottle 
in the bag, neck first, and close the bag by drawing the string. 
Too much care cannot be exercised in the use of hot water 
bottles around the child since his skin is extremely tender 
and sensitive and burns very easily. After use drain all 
water from the hot water bottle, inflate it, screw on the top, 
and wipe the outside dry. 
2. Electric heating pads of various sizes are in common 
use; unless the nurse is extremely vigilant they are unsafe 
because of the danger of burns from them. There is on the 
market an asbestos lined copper receptacle to cover the 
electric beater, which lessens this danger. The nurse should 
never leave the child alone in the room with an electric heater 
turned on. 
3. The ice-cap is useful treatment for many conditions in 
infancy and childhood; it may be applied to the head to relieve 
pain and to reduce temperature; it may also be used on other 
Hot Water 
Bottle 
Temperature 
Cover 
Electric 
Heating 
Pad 
Ice-Cap 
287 288 
PEDIATRIC NURSING 
parts of the body to relieve pain. Applied to the precordia it 
gives the child with heart disease much relief. But as a 
general thing extreme cold 
applications, especially ice, 
must be used with caution 
around young and delicate 
infants. To fill an ice-cap: 
with a spoon fill it half full 
of ice chopped into pieces 
the size of small hickory 
nuts; expel the air and 
screw on the top. Cover it 
with a special ice-bag cover 
or a square piece of gauze 
with the corners- tied over 
the top. After use the ice- 
cap should be wiped dry in- 
side and outside, should be 
inflated with air, and the 
top should be screwed on. 
To disinfect a hot water bot- 
tle or an ice-cap, scrub the 
outside with Bon Ami and 
water and soak in a 1 per 
cent lysol solution for 15 
minutes. If rubber goods 
are put away for a long 
time, sprinkle them with tal- 
cum powder to preserve the 
rubber. 
4. Gavage is the introduc- 
tion of food into the stom- 
ach by means of a tube passed through the mouth or the nose.1 
a. To pass the tube through the mouth: 
Care of 
Rubber 
Goods 
Gavage 
Figure 40. Equipment for Gavage 
To Pass Tube 
through 
Mouth 
1 Morrow, Albert S., M.D., “Diagnostic and Therapeutic Technique.” GENERAL THERAPEUTIC PROCEDURES 
289 
Equipment: 
Equipment 
1. Glass or enamel funnel 
2. Glass connecting tube 
3. Rubber connecting tube 
4. Catheter. 
Boil 2 minutes, place in a 
sterile towel, take to the 
bedside with the rest of the 
equipment on a tray. 
5. Food in bottle or graduate heated to 100° F. 
6. Bib. 
7. Blanket—safety pins. 
The size of the catheter depends on the size of the child and 
the nature of the food to be introduced. 
For the premature baby use a catheter no. 10 French. 
For the child 6 months use a catheter no. 12 to no. 14 French. 
For the child 1 year use a catheter no. 16 French. 
For the child 18 months use a catheter no. 16 to no. 18 French. 
For the child over 2 years use a catheter no. 20 French. 
If the food is very thick, as buttermilk mixture, protein 
milk, etc., or if the baby has much mucus to obstruct the 
lumen of the tube, one or two holes may be cut in the catheter 
above the one already in the end, or if necessary the end of 
the catheter may be cut off "entirely. Thick food may also be 
forced through the catheter with a syringe. Dr. Julius Hess 
recommends the use of a Nelaton catheter as it is marked in 
centimeters or inches and its position at all times can be 
estimated.2 A ring screwed to the round at the head of the 
bed 1 foot above the child is convenient to hold the funnel so 
that the nurse may use both hands and thus may do the 
gavage alone. 
The child lies on his back in the crib. If he struggles, 
restrain him by pinning him in a blanket. Put the bib under 
his chin. Open his mouth by depressing his chin; a mouth gag 
between the lips may be necessary to prevent an older child 
from biting the tube. A good substitute for a mouth gag for 
gavage is an empty spool held between the teeth with the 
tube run through the hole in it.3 Hold the catheter in the 
Size of 
Gavage 
Tube 
Nelaton 
Catheter 
Position 
of Child 
2 Hess, Julius, M.D., “Principles and Practice of Infant Feeding.” 
3 McCombs, “Diseases of Children for Nurses.” 290 
right hand like a pen; moisten the end by dipping it into 
the bottle of milk; pass it rapidly through the mouth, through 
the pharynx into the esophagus. There may be a good deal 
of gagging as it passes the pharynx, therefore it is passed 
PEDIATRIC NURSING 
Figure 41. Position of Child for Gavage 
rapidly; then slowly push it down the esophagus; resistance 
will usually be felt and there will be a' second gagging as it 
passes the cardiac opening of the stomach.4 It is passed a 
little beyond this point. In an infant the distance from the 
alveolus to the cardia is 6% inches; at 2 years it is 9 inches; at 
4 Dunn, Charles H., M.D., ‘ ‘ Pediatrics. ’ ’ GENERAL THERAPEUTIC PROCEDURES 
291 
10 years it is 11 inches. (See note 1.) Hess recommends that 
the catheter be inserted only 3 or 4 inches for the infant. 
(See note 2.) A fairly safe maximum can be ascertained by 
measuring the distance from the glabella to the epigastrium 
in the individual infant. The entrance of the tube into the 
stomach may be indicated by a gush of air through it or by 
the presence of curdled milk in it. After the tube is in the 
stomach a small piece of adhesive may be put around it at 
the point where the lips come (or it may be marked with 
indelible ink) and inserted to this point every time. After 
the tube is in the stomach raise the funnel as high as possible 
to allow the escape of gas; then lower it to the ring on the 
head of the bed and pour the milk into it. Use one hand to 
steady the child’s head and the other to hold the tube at his 
lips; do not let an ordinary feeding enter the stomach in less 
than 5 minutes; pinch the tube to check the flow. To remove 
the tube pinch it off tightly and quickly withdraw it; leave 
the child comfortable and if he is subject to vomiting leave 
the bib under his chin and turn him on his right side. Rinse 
the tube by allowing cold water to run through it; wash it 
with soap and water; rinse and boil it 2 minutes; put it away 
in a sterile towel. 
b. To pass the tube through the nose: 
If passing the tube through the mouth for gavage is con- 
tra-indicated, as in the case of lesions or an operation wound 
about the mouth or after intubation, nasal feeding may be 
substituted. The equipment is the same as for gavage only 
the catheter is about 2 sizes smaller for the child of corre- 
sponding age. The tube is lubricated with petrolatum and 
several drops of it are instilled into the nostril, through which 
it is inserted and passed into the stomach, as when it is passed 
through the mouth. 
5. Duodenal feeding consists in giving the food through a 
tube passed through the stomach into the duodenum. It is 
indicated if the food given by gavage is not retained, as in 
cases of pylorospasm. The position of the child is the same 
Distance 
to Insert 
Tube 
To Pass Tube 
through Nose 
Equipment 
Size of 
Tube 
Duodenal 
Feeding 292 
PEDIATRIC NURSING 
as for gavage; the equipment is the same; the catheter is about 
2 sizes smaller for the child of corresponding age. The tube 
is passed as for gavage only it is inserted 3 to 5 inches farther 
after it has passed the cardiac opening. Obstruction is met 
as it passes the pylorus, then the passage is easier and there 
may be another gush of air through the tube; the fluid 
aspirated from the duodenum is alkaline in reaction. The 
fluoroscope may be used to determine the presence of the 
tube in the duodenum. 
6. Gastric lavage consists in washing out the stomach by 
introducing water or other fluid through a catheter and then 
siphoning it off; it is a very valuable therapeutic measure. 
(See note 1.) 
Equipment: 
Same as for gavage with the addition of: 
1. Graduate with fluid to be used for lavage. 
Solutions which may be used are: 
Sodium bicarbonate, 1 to 5 per cent. 
Boric acid, 1 to 4 per cent. 
Sterile water. 
Amount, 1-4 pints. 
Temperature, 100° F. 
2. Large rubber sheet to protect clothing and bed. 
3. Basin into which to siphon fluid. 
Position of child: (1) Pin him in a blanket; place him on 
his right side on the edge of the crib with the rubber sheet 
and bib under his chin and the side of his face; put the basin 
on a chair or a stool at the crib side. 
(2) If there are two nurses to do the lavage, one may sit 
in a chair and hold him in an upright position on her lap 
with the back of his head pressed against her chest; the basin 
is on a stool in front of her. The other nurse sits on a chair 
facing him and does the lavage. This position may be neces- 
sary when dealing with an older child who struggles. The 
catheter is inserted as for gavage; after it is in the stomach 
and the air is expelled, fill the funnel with fluid and just 
Size of 
Tube 
Distance 
to Insert 
Tube 
Gastric 
Lavage 
Equipment 
Position 
of Child GENERAL THERAPEUTIC PROCEDURES 
293 
before it has all gone in lower the funnel over the basin and 
siphon back the solution. Repeat this until it returns clear; 
1 to 4 pints may be necessary. 
7. Removal of Gastric Contents. It may be necessary to 
remove the contents of the stomach for diagnostic purposes. 
This may be done by (a) expression, (b) aspiration or ex- 
traction. (See note 1.) 
a. Gastric expression: Equipment is the same as for gavage 
with the addition of a graduate for the gastric contents. The 
position of the child is the same as for lavage, (1) on his right 
side on the edge of the crib or (2) sitting upright on a nurse’s 
lap. The tube is inserted as for gavage and after it is in 
attempts are made to express the gastric contents by making 
pressure over the stomach and holding the funnel below the 
level of the stomach over the graduate. If the child is old 
enough to cooperate, ask him to strain as if at stool and to 
bend the body forward while pressure is made over the 
stomach. If the stomach contents are fluid, there will be no 
difficulty. 
b. Gastric extraction or aspiration: The equipment is the 
same as for gavage with the addition of a rubber aspirating 
bulb on the end of the tubing and a graduate for stomach 
contents. The position of the child is the same as for lavage. 
The catheter is inserted as directed above. The aspiration 
bulb on the end of the tube is compressed and released, thus 
drawing out the gastric contents. 
8. Ear. Examination of the ear is discussed under exami- 
nation of the child, Chapter VI. 
Paracentesis of the ear drum is discussed under “Nursing 
Technique in Minor Surgical Procedures,” Chapter XVI. 
a. Ear irrigation purpose: To remove cerumen, purulent 
material, or a foreign body from the external auditory canal. 
Method 1: 
Equipment: 
1. Rubber and sheet. 
2. Blanket and safety pins. 
Amount of 
Fluid 
Eemoval 
of Gastric 
Contents 
Gastric 
Expression 
Equipment 
Gastric 
Extraction 
Equipment 
Ear 
Examination 
Myringotomy 
Irrigation 
To Use 
Irrigating Can 
Equipment 294 
PEDIATRIC NURSING 
3. Basin. 
4. Irrigating can with rubber tubing, clamp on it, and 
glass connecting tube. Sterilize by boiling 5 minutes. 
5. Rubber catheter no. 10 French. Sterilize by boiling 
5 minutes. 
6. Standard on which to hang irrigating can. 
7. Solution as ordered. 
The following may be used: 
(a) Normal saline. 
(b) Boric acid, 2 to 4 per cent. 
(c) Sterile water. 
Amount, 1-5 pints. 
Temperature 100° F. 
8. Toothpick applicators. 
The position of the child: He lies on his back completely 
wrapped and pinned in a blanket from his neck to his feet; he 
may remain in his bed or he may be taken to the common dress- 
ing table. Put the rubber and sheet under his head and 
shoulders and the basin under the ear to be irrigated. The 
irrigating can with the solution is hung on a standard 1 foot 
above his head. Expel the air from the tube by allowing 
solution to run through it. With the left hand pull the lower 
lobe of the ear down and out (directly opposite from posi- 
tion of adult ear) to straighten the auditory canal; with the 
right hand introduce the catheter into the external canal so 
the tip rests against the superior wall, thus allowing space for 
the solution to wash out cerumen, etc. Irrigate until the 
solution returns clear; 1 to 5 pints may be needed. After the 
irrigation dry wipe the canal thoroughly by means of tooth- 
pick applicators. 
Method 2: A rubber syringe may be used in place of the 
irrigating can. The position of the child is the same; the 
bulb is filled with solution, the tip is inserted into the ear, 
and the contents are expelled, using the same technique as in 
method 1. 
b. Instillations of medication into external auditory canal. 
Medications may be ordered instilled into the outer ear. 
To do this use an ordinary medicine dropper and protect the 
Position 
of Child 
Amount of 
Fluid 
To Use 
Rubber 
Syringe 
Instillation 
of Medication GENERAL THERAPEUTIC PROCEDURES 
295 
child from injury from the glass tip by fitting a small piece 
of rubber tubing iy2 inches long on the end of the dropper. 
Sterilize by boiling. Straighten the auditory canal by pulling 
the lower lobe of the ear down and out; draw up the medica- 
tion into the medicine dropper; insert the end of the rubber 
tube into the external auditory canal and instil a few drops 
Figure 42. Medicine Dropper with Tip Protected by Rubber 
of the medication as ordered. In place of ear irrigation the 
child with a suppurating otitis media may have an order to 
have his ear dry wdped: for this, toothpick applicators are 
used; these should be made wdth the cotton at the extreme 
end loose and fluffy to better absorb moisture. The ear should 
be wiped frequently enough to keep the canal free from dis- 
To Dry 
Wipe Ear 
Figure 43. Toothpick Applicator to Dry Wipe Ear 
charge; in severe cases it may have to be done as often as 
every 5 to 15 minutes; in other cases every 1 to 2 hours is 
often enough. A special nurse is necessary to give the child 
with suppurating otitis media proper care. 
9. Nose. a. Nasal irrigation. Purpose: To clean the nasal 
passages of purulent or profuse discharge. 
Equipment: 
1. Rubber and sheet. 
2. Blanket and safety pins. 
3. Basin. 
4. Irrigating can, rubber tubing, clamp, glass connecting 
tube, boiled 5 minutes. 
5. Catheter no. 10 French, boiled 5 minutes. 
C. Solution. 
Nose 
Irrigation 
Equipment 296 
PEDIATRIC NURSING 
The following may be ordered: 
(a) Normal saline. 
(b) Boric acid, 2 to 4 per cent. 
(c) Sterile water. 
(d) Dobell’s solution. 
(e) Potassium permanganate. 
Amount, 1-3 pints, or as ordered. 
Temperature 100° F. 
Position of child: Wrap and pin him tightly in a blanket 
to restrain him; place him in the ventral position crosswise 
of the bed with his head hanging over the edge so that it is 
lower than his shoulders; place the rubber sheet and pad 
under his head and shoulders; place the basin on a chair 
beneath his head. The irrigating can hangs on a standard so 
that it is 1 foot above him. The nurse supports the child’s 
head with one hand and with the other she introduces the 
catheter into first one nostril and then the other. He will 
breathe through his mouth and the irrigating solution 
will drain from the other nostril, very little of it getting 
into his mouth. The advantage of this method is that 
the Eustachian tube being above the irrigating fluid, will 
not become infected. Further there is less unpleasant 
gagging. 
b. Medications may be ordered instilled into the nostrils; 
use a medicine dropper with the tip protected by a piece of 
rubber tubing l1 inches long; sterilize it by boiling for 2 
minutes. Insert the rubber into the nostril and instil a few 
drops of the medication, as ordered. 
10. Mouth and Throat. Examination of the mouth and 
throat discussed under physical examination of the child, 
Chapter VI. 
a. A gargle may be used for an older child as for an adult, 
using the solution ordered. The temperature should be 
105° F. The very young child cannot gargle. In place of it 
(b) a spray may be ordered, or (c) irrigation. 
b. For the spray of the nose and throat any satisfactory 
Position 
of Child 
Instillation 
of Medication 
Mouth and 
Throat 
Gargle 
Spray atomizer may be used with the medication ordered. Re- 
strain the child if necessary. 
c. Irrigation of the mouth and throat: 
Equipment: 
1. Blanket and pins. 
2. Sheet and rubber. 
3. Basin. 
4. Irrigating can, rubber tubing, clamp, glass connecting 
tube. Boil 5 minutes. 
5. Catheter no. 10 French. Sterilize by boiling 5 minutes. 
6. Solution as ordered. 
The following are sometimes used: 
(a) Normal saline. 
(b) Boric acid, 2 to 4 per cent. 
(c) Sterile water. 
Amount, 1-5 pints. 
Temperature, 100° F. 
Position of child: Wrap and pin him in a blanket; put the 
rubber and sheet under his head; turn him on one side and 
hold him with his face well over to the side; place the basin 
under his mouth and nose. Insert the tip of the catheter 
into the mouth, which should be held open to allow the solu- 
tion to run in and out freely and into the basin. A mouth 
gag may be necessary. 
11. Eye. Eye examination discussed under physical ex- 
amination, Chapter VI. 
a. Eye irrigation. Purpose: To cleanse the eye of puru- 
lent discharge, as in ophthalmia neonatorum. 
Equipment: 
1. Blanket and safety pins. 
2. Rubber and sheet. 
3. Kidney basin. 
4. Cotton pledgets and basin for solution. (Sterile.) 
5. Handling forceps in glass of 4 per cent boric acid 
solution. 
6. Solution as 'ordered. 
GENERAL THERAPEUTIC PROCEDURES 
297 
Irrigation 
Equipment 
Position 
of Child 
Eye 
Irrigation 
Equipment 298 
PEDIATRIC NURSING 
The following may be used: 
(a) Normal saline. 
(b) Boric acid, 2 to 4 per cent. 
Amount, 1 to 2 pints. 
Temperature, 90° F. 
Position of child: Wrap and pin him in a blanket; place 
him crosswise of the bed, the nurse standing at his head. Put 
the rubber and sheet under his head; to irrigate the right 
eye turn his head on the right side; put a dry pledget over 
the left eye; place the kidney basin under the right side of 
his face. The nurse holds his head in position with the palm 
of her left hand and holds his eyelids open with the thumb 
and finger of that hand, making pressure on the bones of the 
orbit and not on the eyeball. With the forceps she dips a 
cotton pledget in the basin of solution, then takes it in the 
fingers of her right hand, holds it at the inner canthus of the 
right eye, squeezing the solution from it over the eyeball. 
The stream must not be directed on the eyeball, but must 
flow indirectly over it. Repeat until the eye is free from 
discharge, using a clean pledget every time. To irrigate the 
left eye, turn the child’s head on the left side, put a dry 
pledget over the right eye, and proceed as before; use solution 
enough to cleanse the eyes, 1 to 2 pints may be necessary in 
severe infections, as gonorrheal ophthalmia; the irrigation 
may have to be repeated every 15 minutes to every 2 hours. 
After the irrigation wipe each eye with a separate dry sponge, 
beginning at the inner canthus and wiping toward the outer. 
There is danger of corneal ulcer in most eye conditions, 
therefore avoid (a) pressing on the eyeball when holding the 
lids open, (b) dropping the solution directly on the eyeball, 
(c) letting the discharge from one eye run into the other. 
b. To instil drops in the eye: 
Medications of various kinds, as argyrol, may be ordered. 
Use a medicine dropper, protecting the tip with a small piece 
of rubber tubing. To instil drops into the left eye hold the 
child’s head on the left side; hold the eye open and drop the 
Position 
of Child 
Amount of 
Fluid 
Dangers 
to Be 
Avoided 
Instillation of 
Medications GENERAL THERAPEUTIC PROCEDURES 
299 
desired amount of medication at the inner canthus, allowing 
it to run over the eyeball toward the outer canthus; press 
the lids together, holding them a minute, and wipe them with 
a dry sponge; always wipe away from the nose. Instil drops 
into the right eye in the same manner with the child’s head 
on the right side. 
c. Cold applications to the eyes: 
Purpose: To relieve inflammation, as in gonorrheal oph- 
thalmia. 
Equipment: 
1. Cotton y2 inch thick, the shape and size of the eye. 
2. Basin with a large piece of ice. 
3. Basin with boric acid solution, 2 to 4 per cent. 
4. Paper bag for waste. 
Dip the cotton pledget in the boric acid solution and place 
it on the ice until it is thoroughly cold, then apply it to the 
eye; use a separate one for each eye and do not use the same 
one twice; put the discarded ones in a paper bag. Do not 
let the pledget from either eye come over the bridge of the 
nose. Applications are changed as ordered; usually they 
are put on for 15 minutes out of every hour and during 
that time they should be changed every 1 to 2 minutes. 
12. Vagina, a. A vaginal douche may be ordered for a 
little girl who has a gonorrheal vaginitis. 
Equipment: 
1. Blanket. 
2. Half sheet. 
3. Rubber and pad. 
4. Bed pan or douche pan. 
5. Rubber catheter no. 10 to no. 15 French. 
6. Irrigating can with rubber tubing, clamp, and glass 
connecting tube. 
7. Sponges in basin of 4 per cent boric acid solution. 
8. Bath thermometer. 
9. Handling forceps in glass of 5 per cent lysol solution. 
10. Kidney basin. 
11. Paper bag. 
12. Standard on which to hang irrigating can. 
Cold Appli- 
cations 
to Eye 
Vaginal 
Douche 
Equipment 300 
PEDIATRIC NURSING 
Solutions which may be ordered are: 
Bichloride of mercury, 1 to 10,000. 
Boric acid, 2 to 4 per cent. 
Normal saline. 
Potassium permanganate, 1 to 2000 to 1 to 5000. 
Amount, 2 quarts unless otherwise ordered. 
Temperature, 100° F., unless otherwise ordered. 
The irrigating can, rubber tubing, catheter, and kidney 
basin are boiled 5 minutes. The irrigating can with the solu- 
tion, covered with a towel, and the kidney basin containing 
the sterile catheter are put on a tray with the rest of the 
equipment and carried to the bedside. Fan fold the upper 
bedclothes to the foot of the bed; put a blanket over the 
child’s shoulders; use a half sheet to drape her (see method 
under catheterization) ; place the rubber and pad under the 
hips. She lies on her back with her knees flexed and one 
small pillow under her head; put the douche pan under her 
so that her buttocks are even with the opening of the pan; 
make her comfortable by placing a folded blanket or small 
pillow under her back at the top of the pan. (A bed pan, 
if it is large enough to hold the fluid, may be used in place 
of a douche pan.) Hang the irrigating can on the standard 
1 foot above the child; attach the catheter to the end of the 
tube. Expel the air from it and warm it by allowing the 
solution to run through it for a minute into the douche pan. 
Clean any discharge from the vulva with boric sponges, 
wiping downward toward the rectum; separate the labia 
majora with the right hand, insert the catheter into the 
vagina, down and back, 1 to 3 inches depending upon the size 
of the child. Hold it in place while the solution is flowing and 
turn it around in the vagina so that every part is irrigated 
equally, clamp off the tube and remove the catheter before 
the douche can is entirely emptied; put the soiled catheter 
into the kidney basin; remove the blanket and the half sheet. 
If the douche is given as a regular treatment at stated inter- 
vals, the half sheet used for draping may be folded away in 
Position 
of Child 
Distance 
to Insert 
Tube GENERAL THERAPEUTIC PROCEDURES 
301 
the child’s locker and may be used every time; or it may be 
used for a draw sheet the next time her bed has to be 
changed. 
b. Medications, as argyrol, may be instilled in the vagina 
with a medicine dropper. To do this fit a piece of rubber 
tubing 2 inches long on the tip of it and insert only the rubber 
into the vagina; this will prevent possible injury to the deli- 
cate mucous membrane from the glass tip. To inject oint- 
ment into the vagina fill a small triumph syringe with oint- 
ment ; protect the glass tip with a piece of rubber tubing 2 
inches long; insert it into the vaginal orifice, squeezing in the 
ointment. This syringe may be placed on a clean towel and 
is used only for the treatment because it is too difficult to 
clean after every medication. Applications, as silver nitrate, 
may be made with a swab through a speculum. A nasal 
speculum answers very well for little girls. 
To give a vaginal suppository, the patient lies on her back 
with her knees flexed; the nurse puts a rubber glove on her 
right hand, takes the suppository, separates and holds the 
labia with the left hand and inserts the suppository into 
the vaginal opening as far as it will go. 
13. Rectum. 
(a) An enema is given: 
1. To cleanse the lower bowel and empty it of feces. 
2. To give nourishment. 
3. To give medications as sedatives for: 
a. General effect. 
b. Local effect. 
4. To give stimulation or extra fluids. 
5. To reduce an elevation of temperature. 
(1) Cleansing enema: 
(a) Purpose: To cleanse the lower bowel and to empty it of 
feces. 
(b) Equipment: (To be carried to the bedside on a tray.) 
1. Irrigating can and tubing 18 inches long with glass con- 
necting tube. 
2. Clamp on tube. 
Instillation of 
Medication 
Vaginal 
Suppository 
Enema 
Purpose 
Cleansing 
Enema 
Equipment 302 
PEDIATRIC NURSING 
3. Standard on which to hang can. 
4. Solution ordered, 100° F., never over 105° F. 
5. Kidney basin. 
6. Yaselin or oil, square of paper for applying it. 
7. Small rubber sheet and pad. 
8. Bed pan and cover. 
9. Bath thermometer. 
10. Toilet paper. 
11. Blanket and safety pins. 
12. Catheter for rectal tube. 
Size no. 10 to no. 12 French for child up to 6 months. 
Size no. 12 to no. 15 French for child up to 1 year. 
Size no. 15 to no. 18 French for child up to 2 years. 
Size no. 18 to no. 20 French for child over 2 years. 
(A funnel attached to the tubing and a pitcher for the 
solution may be used in place of the irrigating can and 
standard.) 
(c) Solutions for cleansing enema. 
For a child under 2 years plain warm water or normal salt 
solution will usually produce the desired results and should 
be used unless otherwise ordered. If soap is ordered use a 
plain castile soap in proportions of 1 tablespoon of soap jelly 
to a pint of water. Yellow or laundry soap may be very 
irritating and should not be used. Skim the foam from the 
top of the solution. 
(d) Amount of solution necessary: 
This depends upon the size of the child and upon the pur- 
pose of the enema. For a cleansing enema for catharsis: A 
child under 6 months should have a pint at least; a child 
over 6 months should have a quart. The solution is expelled 
as soon as it is given, in most instances, so that the enema is 
really a colonic flushing. 
(e) Procedure: 
1. Have room 70° F. 
2. Screen the child’s bed. (One nurse should be able 
to give a baby or child an enema without 
help.) 
Solutions 
Amount of 
Solution GENERAL THERAPEUTIC PROCEDURES 
303 
3. Position of the child: 
I. Under 6 months: 
Place rubber and pad under his buttocks to pro- 
tect the bed, remove diaper, fold his clothes back to 
the waist, and put the blanket over his shoulders. He 
is placed on a warm bed pan or douche pan covered 
with a pad and is placed with his buttocks over the 
edge of the hole. The nurse holds his two ankles in 
her left hand, elevates his feet, and uses her right 
hand to give the enema. 
II. Child from 6 months to 5 years: 
Restrain his hands by pinning them in a blanket. 
Protect the bed with a rubber and pad; place the 
warm bed pan under his buttocks with a folded 
diaper over the part which comes in contact with his 
back; if the pan is so constructed that there is a 
hollow at the back, fill it with a small pillow or a 
folded blanket (covered with rubber). (Any child 
under 5 years or any sick child will expel the fluid 
while the enema is being given.) If a marble or 
porcelain bath slab is a part of the equipment, the 
small child may be placed here for his enema, first 
covering the slab with a pad—following out the same 
rules for individual technique as given under the 
directions for bathing. 
III. Child over 5 years: 
As soon as the child is old enough to understand, 
he should not be put on a pan while the enema is 
being given. His position may then be the same as 
for an adult, i.e., left lateral with hips elevated, no 
pillow under head; or in dorsal position, no pillow 
under head, and knees flexed. 
(f) Method of giving enema: 
Place standard at side of crib, hang irrigating can on it 
not more than 1 to feet above the child. Attach catheter 
to tubing, expel air from tube, warm it by permitting solution 
Position 
of Child 
Under 
6 Months 
Six Months 
to 5 Years 
Over 
5 Years 
Procedure 304 
PEDIATRIC NURSING 
to flow until tube is filled with warm solution; close clamp, 
vaselin the tip of the catheter l1 to 3 inches. Insert it care- 
fully into the anus, guiding it by the right hand, in which it is 
held; use a slight boring motion, keeping in mind the position 
of the anal canal. If the child is on his back direct the tube 
first upward and then downward and backward. If he is in 
the left lateral position direct the tube upward, backward 
and toward the left. If there is difficulty in inserting the tube 
it may be : (1) Obstruction by feces, (2) a nervous contraction 
of the sphincter, or (3) the point of the tube may be caught 
in a fold of mucous membrane. Wait a moment, then with- 
draw the tube slightly and again advance it; by opening the 
stopcock after the tube is inserted the flow of fluid may re- 
move the obstruction. Insert the rectal tube 2 inches in the 
small baby, 3 inches in the older child, but never insert more 
than 4 inches.5 Give the fluid slowly, for rapid distention of 
the colon stimulates peristalsis with the consequent desire to 
evacuate. Stop the flow temporarily if severe pain seems to 
be caused. Quickly withdraw the tube and if the child has 
not already started to expel the fluid, hold a folded towel 
over the anus making pressure until the desire to expel the 
enema has passed. Leave the older child on a pan until all 
the fluid is expelled. The small baby who has been expelling 
the fluid as the enema is being given can be removed from 
the pan at once. 
(g) The cleansing of tubing, etc.: 
Disconnect the catheter and place it in the kidney basin. 
Wash the irrigating can and tubing, dry the can and return 
it to the shelf. Dry the tubing by stripping and draining, coil 
it with the stopcock open. Wash the rectal tube or catheter 
in cold water, then in warm water and soap and boil for 3 
minutes. The use of sodium chlorid, 1 teaspoon to 1 quart 
of water, is supposed to lessen the damage to the tubing by 
boiling. 
Distance 
to Insert 
Tube 
Care of 
Tubing 
s Mills, H. B., M.D., Bird, G. C., M.D., Penn. Med. Journal, March, 
1919. GENERAL THERAPEUTIC PROCEDURES 
305 
(2) The small enema: 
(a) Purpose: Medications, nourishment, or other solutions 
to be retained for absorption are given this way. The bulk 
of fluid should not be large enough to distend the walls of 
the intestine. 
(b) Equipment: carried to bedside on a tray: 
1. Basin of water 105° F. in which is placed a small pitcher 
containing the solution to be injected. 
2. Catheter, the smallest size that the solution will run 
through. 
3. Funnel, rubber tubing, 18 to 24 inches long, clamp on tube, 
glass connecting tube. 
4. Kidney basin. 
5. Yaselin—paper square to apply it. 
6. Small rubber sheet and pad. 
(c) Procedure: Screen the bed; jdace the child in the 
dorsal position, with the pillow removed from under his head, 
and his hips elevated by a pillow protected by a rubber and a 
pad. Attach the catheter to the tubing, lubricate the end, and 
insert it as far as for the cleansing enema, 2 to 4 inches. Give 
solution, pouring it on the side of the funnel to prevent the 
forcing of the air in the tube into the colon; raise the funnel 
from 8 to 12 inches above the child as the fluid flows in. After 
the fluid has been introduced, pinch off the tube, hold the 
buttocks together with the hand leaving the tube in for 3 
minutes, then withdraw it slowly, pressing the child’s but- 
tocks together with the hand, holding them this way and ele- 
vating them for 5 minutes or so. 
A. ,Suds and Glycerin Enema: 
Water, 1 quart. 
Soap jelly, 2 tablespoonfuls. 
Glycerin, 2 ounces. 
B. M. G. W. Enema: 
One ounce magnesium sulphate. 
One ounce glycerin. 
Small Enema 
Purpose 
Equipment 
Procedure 
Suds and 
Glycerin 
Enema 
M. G. w. 
Enema 306 
PEDIATRIC NURSING 
Two ounces water. 
Dissolve magnesium sulphate in hot water, stirring until dis- 
solved, then add glycerin. 
C. Sedative Enema: 
Chloral hydrate or bromids may be given by rectum; dis- 
solve in 15 c.c. to 30 e.c. of hot water, milk, or starch, as or- 
dered. Before giving a sedative enema always make the 
patient as comfortable as possible so that he may have an 
opportunity to be benefited by it. Clean the rectum of feces 
by giving a cleansing enema y2 to 1 hour before giving the 
sedative. (Give according to the directions under “Small 
Enema.”) 
D. Nutritive Enema: 
To give the patient nourishment if he cannot take it by 
mouth. 
When giving a nutritive enema over any length of time 
give a cleansing enema of normal saline or soap suds once a 
day. A concentrated food must be given, the amount depend- 
ing upon the size and the age of the child, usually 2 to 6 ounces 
every 4 to 6 hours. 
The materials generally used are: 
1. Peptonized milk. 
2. Peptonized beef juice. 
3. Peptonized beef extracts. 
4. Egg albumen. 
5. Gruels. 
6. Dextrose. 
(The nutritive enema has a limited use for small children 
because, as a rule, they retain fluids by rectum poorly. 
As a temporary expedient or adjunct to natural feedings, 
it is most useful, but for permanent feeding quite imprac- 
tical. See note 1.) 
E. Shock Enema: 
Two ounces salt solution. 
One to 2 ounces brandy. 
Two ounces black coffee or 5 gr. caffein citrate. 
Sedative 
Enema 
Nutritive 
Enema 
Purpose 
Materials 
Used 
Shock Enema GENERAL THERAPEUTIC PROCEDURES 
307 
F. Stimulating Enema. 
For general stimulation and to increase fluid intake. 
1. Normal saline solution, .9 of 1 per cent (1 teaspoonful to 
1 pint). 
2. Glucose 5 per cent in normal saline solution or in water. 
Give every 2 to 6 hours. 
Amounts vary with the age of the child. 
A child under 2 years, 30 to 90 c.c. 
A child 2 to 4 years, 90 to 120 c.c. 
A child over 5 years, 120 to 180 c.c. 
(A small child will usually retain fluids by rectum better 
by this intermittent method than by continuous proctoclysis 
or “Murphy drip method.” However, the latter is often used 
and sometimes is retained very satisfactorily.) 
G. Oil Enema: 
To soften feces in severe constipation. 
One to 4 ounces of oil (Cottonseed or Wesson). 
Warm it, insert rectal tube and give very slowly. 
This is to be retained and followed by a suds enema in from 
2 to 6 hours. 
H. Milk and Molasses Enema: 
To relieve fermentation and distention. 
Three ounces warm milk and 3 ounces warm molasses well 
mixed, give slowly and follow in one hour with warm 
water enema. 
I. Turpentine Enema: 
Add 10 to 30 minims to 1 quart of soap suds solution. 
J. Starch Enema: 
To relieve local irritation, to check diarrhea or to intro- 
duce drugs. 
One-half tablespoonful of starch dissolved in cold water, add 
slowly 6 ounces of hot water and boil, avoid too thick 
consistency. When it is cooled to body temperature it is 
ready for use. If it is used to introduce a drug, give 
only 15 c.c. to 30 c.c. of starch, and add drug to it after 
it has cooled to 100° F. 
Stimulating 
Enema 
Oil Enema 
Milk and 
Molasses 
Enema 
Turpentine 
Enema 
Starch Enema 308 
PEDIATRIC NURSING 
Enteroclysis 
b. Enteroclysis or colon irrigation: 
(1) Purpose: 
1. To cleanse the bowel. 
2. To reduce temperature. 
(2) Solutions used: 
1. Plain water. 
2. Saline or whatever solution ordered. 
100° F. (If to reduce temperature start with 100° F. and 
cool gradually to 75° F. by adding cold water.) 
(3) Equipment : Same as for cleansing enema. 
(4) Procedure: 
Position of child: On his side or on his back, with the but- 
tocks elevated on a pillow covered with rubber and no pillow 
under his head. 
The irrigating can is hung on the standard so that it is 
not more than 8 to 12 inches above the child; the rectal tube 
is inserted 1% to 3 inches in the rectum. A pint of fluid is 
given at a time, the tube is clamped off, and when that is ex- 
pelled another pint is given; this is continued until the fluid 
returns clear; 1 to 4 quarts are usually necessary. A child, 
especially a small one, will usually expel the fluid all the time 
it is being given. 
c. Proctoclysis, known also as rectoclysis, seepage and 
Murphy drip: 
(1) Purpose: Continuous instillation of fluid. 
(2) Equipment: 
1. Irrigating can with solution of 100° F. 
2. Rubber tubing. 
a. One piece 26 inches long. 
b. One piece 16 inches long. 
c. Two pieces 8 inches long. 
3. Glass connecting tube. 
4. Glass Y connecting tube. 
5. Catheter, as small as possible. 
Purpose 
Solutions 
Position 
Procedure 
Distance 
to Insert 
Tube 
Proctoclysis 
Purpose 
Equipment GENERAL THERAPEUTIC PROCEDURES 
309 
6. Narrow piece of adhesive. 
7. Rubber with pad or diaper. 
8. Standard upon which to hang the irrigating can. 
9. Murphy drip bulb. 
10. Clamp to adjust flow. 
11. Two hot water bottles. 
12. Towel. 
13. Safety pins. 
14. Yaselin. 
15. Paper square to apply it. 
(Apparatus: The irrigating can hangs on the standard. 
The piece of rubber 16 inches long fits on the lower part of 
the Y connecting tube and connects with the rectal tube with 
a glass connecting tube. One end of the 8-inch rubber tubing 
fits on one branch of the Y tube; the other end fits one end 
of the Murphy drip bulb which is connected with the irrigating 
can by the other 8-inch tube on which is adjusted the clamp 
to regulate the flow of the fluid. The other piece of rubber 
tubing 26 inches long fits on the other branch of the Y tube 
and is fastened to the outside of the irrigating can to allow 
a means of escape for air expelled by the patient.) 
(3) Procedure: The bed under the patient is protected by 
a rubber and pad. Expel the air from the tubing and warm it 
by allowing the solution to run through it until it is warm; 
clamp the tube; lubricate the end of the catheter and insert 
it in the rectum 3 to 5 inches. A narrow strip of adhesive 10 
inches long is put around the catheter where it enters the 
rectum and is strapped on to the buttocks on either side to 
hold the tube in place. A sick child or a small child not old 
enough to understand the procedure will pull the tube out 
of his rectum. It may be necessary to tie his hands. 
The rate of flow is gauged by adjusting the clamp on the 
rubber tubing and observing it through the Murphy drip bulb. 
It is safe to start at 10 drops per minute for a child under 5 
years, and 15 to 20 drops for a child over that age. The rate 
of flow may be increased if the child can tolerate it. It should 
be allowed to flow as rapidly as possible, but not so rapidly 
Apparatus 
Procedure 
Distance 
to Insert 
Tube 
Bate of 
Flow Figure 44. Equipment for Proctoclysis 
310 GENERAL THERAPEUTIC PROCEDURES 
that the rectum will be worn out in a few hours. Proctoclysis 
is usually ordered for 2 or 3 hours and then off for 2 or 3 
hours to give the rectum a rest so that it can retain and can 
absorb fluid over a longer period of time. Proctoclysis is more 
successful if a cleansing enema is given a short time before it 
is started and once a day as proctoclysis is continued. 
The fluid in the irrigating can is 100° F. when proctoclysis 
is started. Experiments at the University Hospital, Uni- 
versity of Minnesota (by Miss E. Pierce), have shown that 
by the time the fluid reaches the rectum it is room tempera- 
ture, no matter at what temperature it was started. If efforts 
are made to keep the fluid in the can at 100° F. by the use 
of a thermos bottle or by an electric light bulb immersed 
in it, it still is at room temperature when it reaches the 
rectum. The only way to keep the fluid at 100° F. when it 
enters the rectum, if the above apparatus is used, is to have 
the tube between 2 hot water bottles 135° F., placed about 
12 inches from where it enters the rectum. It is not safe to 
put hot water bottles at this temperature in a child’s bed 
unless there is some one there to watch him closely and then 
the bottles must be entirely covered by wrapping a bath towel 
around both and pinning the corners together to hold them 
in place. 
The amount of fluid taken by proctoclysis is measured and 
is recorded. First measure the amount put into the irrigating 
can. Record the amount put in, if refilled. If discontinued 
before all is taken, measure the amount remaining and sub- 
tract it from the amount put into the can. If intermittent, 
measure the amount when started and the amount remaining 
when discontinued. Record the amount taken. 
d. To give a rectal suppository: 
(1) Position: Left lateral. 
(2) Procedure: The nurse puts on a rubber glove or a 
finger cot, lubricates the end of her finger and the tip of the 
suppository, and passes it into the rectum, pushing it with 
her finger as far as it will go. 
311 
Temperature 
of Solution 
Amount 
of Fluid 
Rectal 
Suppository 312 
PEDIATRIC NURSING 
To 
Catheterize 
Girl 
14. Bladder. 
a. To catheterize a girl: (University Hospital Routine, 
University of Minnesota.) 
Equipment: 
1. Two sterile catheters no. 8 to no. 10 French (rubber 
catheters only are used) in a basin. 
2. Basin of warm sterile boric acid 2 per cent solution with 
sponges in it. 
3. Kidney basin. 
4. Sterile handling forceps in basin with catheters. 
5. Sterile basin, or 
6. Sterile bottle for urine. 
7. Rubber and diaper. 
8. Bed pan for an older child. 
9. Blanket. 
10. Half sheet. 
Boil the catheters (1) and handling forceps (4) for 5 min- 
utes; sterilize the boric acid solution, the sponges (2), and 
the bottle for the specimen (6) by boiling in a small round pan 
(2) covered with a pan (5). It is desirable to have two 
nurses to catheterize a small active child, because one has to 
hold her in position while the other catheterizes her. While 
one nurse drapes the patient and arranges the equipment at 
the bedside, the other one scrubs her hands. If it is im- 
possible to have two, one nurse can do it alone if she ties 
the child’s legs to the side of the crib, arranges her equipment, 
and then scrubs her hands. The child lies on her back with 
her knees flexed and separated; a rubber and diaper are put 
under her buttocks; an older child may be placed on a bed 
pan. A blanket is placed over her shoulders; the upper bed- 
clothes are fan folded to the foot of the bed. A half sheet 
is used to drape her; place it over her crosswise, twist one 
lower corner around each foot, tuck the ends of the sheet 
under her hips on either side, bring the center of it in folds 
up over the pubis exposing the vulva. It is not possible to 
drape a small child who struggles. 
The nurse who is to do the catheterization scrubs her hands 
Equipment 
Position 
of Child 
To Scrub 
Hands GENERAL THERAPEUTIC PROCEDURES 
313 
for 4 minutes; she uses a brush and soap and hot water, 
rubbing them well, and cleans her nails with an orange wood 
stick, then rinses her hands under hot running water for 1 
minute. One nurse stands on the left side of the bed and 
holds the patient in position; the other stands on the right 
side with the equipment tray on a table at her right. The 
basin for urine is put on the bed between the patient’s feet. 
With the right hand the nurse takes the handling forceps from 
the basin; with them she removes a sponge from the basin 
of boric solution and cleans the outside of the labia, wiping 
down toward the rectum. Separate the labial folds with the 
thumb and finger of the left hand and clean the introitis first 
on one side and then on the other, using a fresh sponge every 
time, and as many as necessary. Clean the meatus with a 
fresh sponge, wiping away from it on all sides. Soiled sponges 
are put in the kidney basin. Hold a warm sponge over the 
meatus to dilate it, thus allowing the easier passage of the 
catheter. Place a sponge below the labia over the rectum. 
Remove the catheter from the basin with the right hand, tak- 
ing hold of it about 3 inches from the tip with the thumb 
and forefinger, and supporting it with the other fingers; 
place the other end in the sterile basin between the child’s 
feet; separate the folds of the labia with the left hand and 
introduce the tip of the catheter into the meatus until urine 
flows—usually % to 3 inches, depending on the size of the 
child. 
It is often difficult to find the meatus of a baby girl; the 
vaginal opening may be mistaken for it, as it may be a blind 
opening in what seems to be the vaginal orifice. In this case 
insert the extreme tip of the catheter into this opening and 
then take a turn up and back to find the meatus. Before at- 
tempting to introduce the catheter determine the exact loca- 
tion of the urethra. Do not grope blindly around searching 
for it, thus contaminating the catheter. If an obstruction is 
met when inserting the catheter, wait a minute before push- 
ing it further because it may be a nervous contraction of the 
To Clean. 
Genitals 
Distance 
to Insert 
Catheter 314 
PEDIATRIC NURSING 
sphincter and, if so, it will pass away in a minute. If the 
urine stops flowing before the expected amount is obtained, 
withdraw the catheter a little to the level of the urine in the 
bladder. When withdrawing the catheter pinch it off and 
draw it out quickly. The sheet used for draping can be folded 
away in the child’s locker and used for a draw sheet when 
it is necessary to change the bed. 
b. To catheterize a boy: 
The nurse is frequently required to catheterize a boy. The 
equipment is the same as given above. 
Two nurses are desired; one can do it alone in an emergency. 
The child’s position and draping are the same and the ex- 
ternal genitalia are cleaned in the same manner. Hold the 
penis at an angle of about 60° from the body with the left 
hand; retract the prepuce and hold it back by wrapping a 
piece of gauze around it; sponge the glans clean. Take the 
catheter in the right hand and introduce it into the urethra 
as far as it will go. If it meets an obstruction, which is a 
nervous contraction, wait a minute or more and this will dis- 
appear and the catheter can be passed easily into the bladder. 
To 
Catheterize 
Boy CHAPTER XX 
SPECIAL PEDIATRIC NURSING 
The object of this chapter and the next one, “Infectious 
Diseases/ ’ is to emphasize the points that differ in the nursing 
care of the sick child from that of the adult and such points 
as experience has shown will be helpful to the pediatric nurse. 
It is taken for granted that she has had one or two years of 
training in the care of adults, including lectures and classes 
in medical and surgical nursing. No attempt has been made 
to go into the details of the etiology, pathology, lesions, symp- 
toms, course of the disease, diagnosis, or prognosis, etc., of the 
diseases mentioned, except as they may influence the intelli- 
gent nursing care of children suffering from such diseases. 
The nurse should obtain her information of the above diseases 
from lectures by the medical staff and by additional reading 
of works on pediatrics. “Diseases of Infancy and Childhood” 
by L. Emmett Holt, M.D., Sc.D., LL.D., and John Howland, 
M.D., A.M., and “Diseases of Infants and Children,” by J. P. 
Crozer Griffith, M.D., Ph.D., have been consulted and quoted 
from freely; and the points brought out in the nursing care 
of children with various diseases follow more or less closely 
the treatment advocated by these authorities. 
1. Diseases of the Newborn Baby. 
Prematurity demands the most expert nursing care. (See 
care of the premature, Chapter VIII.) 
Asphyxia is taken up under the care of the newborn and 
methods of resuscitation are discussed there. (Chapter VII.) 
Congenital atelectasis is the failure of the lungs to fully 
expand and to function properly; it is usually associated with 
asphyxia directly after birth, but may not develop until later. 
Prematurity 
Asphyxia 
Congenital 
Atelectasis 
315 316 
PEDIATRIC NURSING 
Cyanosis is the most characteristic symptom. Artificial respir- 
ations are generally employed in the treatment of atelectasis 
but causing the infant to cry is the best treatment. He should 
be made to cry loudly and strongly several times a day for 
from 15 to 30 minutes. To do this the alternate use of hot 
and cold baths (100° F. to 70° F.) may be employed, also 
spanking or other procedures which will produce lusty crying. 
The cyanosis will then disappear. The cyanosis of the new- 
born due to congenital heart disease will become worse if the 
child cries. The child with atelectasis must have his posi- 
tion changed frequently, and he should be picked up and 
carried around at regular intervals. He may also need ex- 
ternal heat to maintain his body temperature. 
Congenital malformations and anomalies must be looked for 
in the newborn during his first bath. A few of the common 
ones are: 
1. Cleft lip. (See classification under diseases of digestive 
system.) 
2. Cleft palate. 
3. Epstein’s pearls are little whitish epithelial masses on 
the palate of the newborn; they are probably embryonic cell 
rests which follow the ventral closure of the embryo. They are 
observed in a large majority of cases and have no significance. 
No attempt must ever be made to remove them. After a few 
days they spontaneously drop off and disappear. 
4. Spina bifida. (Discussed under diseases of nervous 
system.) 
5. Hydrocephalus. (Discussed under diseases of nervous 
system.) 
6. Hernia. (Discussed under diseases of digestive system.) 
7. Congenital malformations of bones, as club-feet, poly- 
dactylism, etc. 
8. Congenital malformations of urogenital organs. 
Phimosis. 
Hypospadias. 
Epispadias. 
Congenital 
Malformations SPECIAL PEDIATRIC NURSING 
317 
Extrophy of bladder. 
Undescended testicle. 
Hydrocele. 
Imperforate hymen. 
Imperforate vagina. 
Imperforate uterine canal. 
9. Malformations of rectum. 
Atresia or stenosis of rectum. 
10. Stenosis of esophagus. 
These malformations when noted should be reported at once. 
Nearly all of them are very evident if present, except the con- 
genital atresias, as of the rectum, urethra, or esophagus. They 
occur frequently enough for the nurse to have in mind always 
the possibility of their presence in every newborn babe until 
she has had opportunity to rule them out. Therefore, it is 
essential that she watch for the first urination and defecation 
and the absence of either by the end of 12 hours should be 
reported. Excessive vomiting after nursing should also be 
reported. The only treatment for any of these conditions is 
surgical. 
Icterus neonatorum is a yellowish discoloration of the skin 
of the newborn; it appears from the third to the sixth days 
over the whole body, varying in intensity; it is noticed in 
about 40 per cent of newborn babies. The baby’s general 
condition is not usually influenced and the condition disap- 
pears without any treatment. The exact cause has never been 
satisfactorily determined. The nurse must always report 
the condition to the doctor; she may also assure the 
mother that her baby is not ill and that the color will 
disappear. 
Hemorrhages occur quite frequently during the first days 
of life. They may be divided into two groups: 
I. Traumatic or accidental which depend upon causes con- 
nected with delivery. 
1. Cephalematoma. 
2. Visceral hemorrhage. 
Icterus 
Neonatorum 
Hemorrhages 
of Newborn 318 
PEDIATRIC NURSING 
II. Spontaneous hemorrhage—hemorrhagic disease of the 
newborn. 
1. Hemorrhage from intestines, or melena. 
2. Hemorrhage from stomach. 
3. Hemorrhage from mouth. 
4. Hemorrhage from nose. 
5. Subcutaneous hemorrhage. 
6. Hematuria. 
7. Hemorrhage from conjunctiva. 
8. Hemorrhage from female genitals. 
9. Hemorrhage from umbilicus. 
Any signs of hemorrhage, even the slightest, should be re- 
ported at once. Hemorrhage of the newborn is often accom- 
panied by prolonged bleeding and clotting time; so these are 
usually determined routinely on all newborn babies. If they 
are exaggerated, treatment is generally started at once; this 
consists in subcutaneous or intramuscular injection of whole 
blood.1 (See description of method, Chapter XVI.) Bleed- 
ing from the umbilicus must always be watched for during 
the first few hours of life; this may be due to faulty tying of 
the cord, as well as to hemorrhagic disease. Baby girls often 
have a slight bloody discharge from the vagina during the 
first few days. This may indicate hemorrhagic disease or it 
may be without significance; it must always be reported at 
once. 
Engorgement of the breasts is frequently seen in the first 
few days after birth, usually about the time the mother’s milk 
comes; it is believed to occur more often in boys than in girls. 
The breasts contain milk which the old German midwives 
called “Hexanmilch” (Witches’ milk). This engorgement 
disappears without treatment and, in fact, the breasts must 
not be massaged or handled and should be protected from 
pressure. The condition must be called to the doctor’s atten- 
tion. A complication occasionally seen is a true mastitis. The 
1Rodda, F. C., M.D., “Studies in a New Method of Determining the 
Coagulation Time of Blood in Newborns. ’ ’ Am. J. Bis. Child., April, 
1920. 
Engorgement 
of tne 
Breasts 
Mastitis SPECIAL PEDIATRIC NURSING 
319 
breast, generally only one, grows uniformly larger, red, hot, 
and painful on pressure. Ice may be ordered as a prophy- 
lactic measure. A small soft rubber ice collar about 6 inches 
long makes a suitable ice-cap. If an abscess does form, the 
treatment is surgical. 
Infections of the Newborn: The newborn may suffer from 
any of the infectious diseases, as measles, mumps, etc. They 
rarely do occur, however. If the baby contracts an infectious 
disease, it is usually wdien the mother has the disease and in- 
fects the child before birth through the circulation or after 
birth from contact. Pertussis in the newborn and in young 
infants has a high mortality. The newborn must always be 
protected from the possibility of any infection whenever it is 
known to be present in the mother or in the household or 
institution. (See contraindications to nursing, Chapter X.) 
Sepsis is no longer common in the modern nursery, though 
there are rare cases. Aseptic nursing technique is a certain 
prophylactic measure. 
Infection of the umbilicus, or omphalitis, does not occur as 
frequently as it once did. It is caused by uncleanliness and 
lack of aseptic care of the umbilical cord after birth. The skin 
around the umbilicus becomes red, hot, shiny, and frequently 
the subcutaneous tissue is infiltrated and hard. The treat- 
ment is, first of all, prophylactic, and if the nurse carries out 
aseptic technique in the care of the umbilicus infection will 
not occur. Any redness or any unusual appearance around 
the cord must be reported. (See care of umbilicus, Chapter 
VII.) 
Gonorrheal infection of the newborn occurs in the eyes and 
in the vagina of baby girls. Ophthalmia neonatorum is a 
gonorrheal infection of the eyes of the newborn, contracted 
from the mother during the passage of the child through an 
infected birth canal, or after birth from contact with infected 
clothing or other articles. It does not usually manifest itself 
before the third day, and is extremely virulent from the 
onset. The symptoms are: swelling of the lids, or chemosis, 
Infections 
of the 
Newborn 
Infection 
of the 
Umbilicus 
Gonorrheal 
Infection 
Ophthalmia 
Neonatorum 320 
PEDIATRIC NURSING 
profuse purulent discharge, sometimes hemorrhages from the 
lids, ulceration, and there may be sloughing of the cornea. 
Loss of vision follows severe cases if treatment is not started 
at once. The first treatment is prophylactic. This is known as 
Crede’s treatment of the eyes of the newborn and consists in 
the instillation of silver nitrate, 1 or 2 per cent, 1 or 2 drops 
in each eye, immediately after birth, followed by salt solu- 
tion. Even though this is generally carried out, in fact it is 
compulsory in most states, infections do sometimes occur. 
Complete isolation of the patient is necessary since the disease 
is highly infectious, and the nurse must protect herself as 
well as the other patients. If the infection is in one eye only, 
efforts must be made to prevent the infection of the other eye. 
The patient should lie only on the affected side; a shield may 
be put over the non-affected eye. If the patient is a girl, 
care must be taken not to infect the mucous membrane of the 
vagina. The hands should be restrained; it is advisable to 
keep the infant’s arms pinned in a blanket constantly. The 
treatment consists in irrigating the eyes frequently enough 
to keep them free from pus. Owing to the copious discharge, 
this may have to be done every 10 to 20 minutes (see methods 
of irrigating eye). A special nurse is necessary. The use of 
cold is employed in the form of ice packs applied to the lids. 
These, too, may have to be changed at frequent intervals, as 
often as once every minute for 15 minutes out of every hour, 
or even oftener as the case may demand. Atropin sulphate 
may be ordered to keep the pupils dilated. Argyrol drops are 
used and sometimes silver nitrate. This is a serious condition 
and great emphasis must be put on the isolation of the child, 
especially in the institution, to prevent the spread of the dis- 
ease. Expert nursing care is necessary and shows gratifying 
results. Great patience is demanded, for the disease may 
persist over a period of weeks. Although gonorrheal in- 
fection of the eyes usually manifests itself on the third or 
fourth day, there are many cases on record where it has 
developed later, after a week or 10 days. Any discharge SPECIAL PEDIATRIC NURSING 
321 
from the eyes of a newborn baby must be reported to the 
doctor at once so smears may be taken. Discharge from the 
eyes of whatever nature is reported to the State Board of 
Health. Gonorrheal infection must always be suspected and 
the baby must be isolated until it has been ruled out by 
repeated negative smears. It is quite common to see a 
more or less profuse, purulent discharge from the eyes of 
the newborn immediately after birth; this is due in some 
cases to the silver nitrate instilled at birth. It may, of 
course, be due to any of the pyogenic organisms and the 
condition should always be reported, the eyes should be kept 
clean by frequent irrigation, and the case should be isolated 
until the cause is determined. 
Gonorrheal vaginitis occurs in newborn babies; like 
ophthalmia it is contracted from the mother at birth or soon 
after and manifests itself by profuse, purulent, vaginal dis- 
charge. Any vaginal discharge which may be noticed should 
be reported; gonorrheal infection should be suspected and the 
child isolated until repeated smears have proved negative. 
(See technique of treatment of vagina, Chapter XIX; also 
care of vaginitis under diseases of genito-urinary system.) 
The newborn baby girl often has a mucous vaginal discharge 
which is insignificant, but in order to rule out the possibility 
of a gonorrheal infection, it must be reported at once. 
Bloody vaginal discharge is not uncommon, usually only 
a few stains on the diaper, but this also must be reported. 
The skin of the newborn is intensely red at first; this fades 
gradually to a healthy pink color by the end of a week. There 
may be desquamation for several days. In the care of the 
newborn, especially in the care of large numbers of babies 
in an institution, skin rashes of various types are too fre- 
quently seen. Very often these rashes are miliaria or ‘ ‘ prickly 
heat.” The use of cotton clothing prevents much of it. The 
most insignificant skin lesion noticed on a baby must be 
reported and such infectious conditions as impetigo con- 
tagiosa, syphilis, etc., must be ruled out. Isolation should be 
Gonorrheal 
Vaginitis 
Skin 
Infections 
of Newborn 322 
PEDIATRIC NURSING 
carried out until a diagnosis is determined. Routine aseptic 
nursing care of the newborn will prevent much of the diffi- 
culty met with from skin lesions. 
An elevation of temperature occurs in a certain percent- 
age of infants during the first few days of life before the 
mother’s milk comes. It is believed that this elevation of 
temperature comes with peculiar frequency at the time when 
the weight is at the lowest point, and also in those infants 
whose weight loss is most marked, thus suggesting a close 
connection between the rise of temperature and the con- 
dition of starvation or inanition. The administration of 
food and the forcing of fluids cause the temperature to fall 
rapidly, proving that there is some definite relation between 
the taking of food and the fall of temperature.2 
The hyperexcitability, increased reflexes, and slight flexor 
contracture of the extremities observed in most newborn 
babes are probably due to the incomplete development of 
the motor center of the cortex. This tremor has no sig- 
nificance and the mother who notices it and thinks that her 
baby is a particularly “nervous baby” should be reassured. 
Inanition 
Temperature 
2. General and Nutritional Diseases. 
Rickets is a chronic disease of nutrition, affecting the bones 
most strikingly, but general in its nature and involving as 
well the ligaments, muscles, mucous membranes, nervous 
system, and other parts of the body. It is a very widely 
spread disease in all civilized countries, although its prev- 
alence varies greatly with the locality and the season. It 
is almost universal among the poor in large cities and is 
less frequent generally during the summer months and in 
rural districts. The cause of rickets is still a matter of dis- 
pute, but recent investigations are proving that improper diet, 
lack of sunlight, and poor hygiene (see Heliotherapy, Chap- 
Rickets 
2 Grulee, C. G., M.D., and Bonar, B. E., M.D., ‘ ‘ Some Observations on 
the So-Called Inanition Temperature of Newborns,” Am. J. Dis. Child., 
July, 1921. SPECIAL PEDIATRIC NURSING 
323 
ter XVII) are important predisposing factors. Therefore, 
a suitable diet, much direct sunlight, and the best possible 
hygienic living conditions are essential points in the prophy- 
laxis as well as in the treatment of children with rickets.3 
These cannot be overemphasized. Cod liver oil is always given 
for rickets and is of unquestionable value in the prophylaxis 
and the cure of the disease.4 Massage is employed to cor- 
rect deformities and to strengthen feeble muscles; postural 
treatment also helps in a corrective way. Further develop- 
ment of deformities must be guarded against and properly 
regulated exercise which does not directly increase the de- 
formity is to be encouraged. After the ossification of the 
bones operative treatment or special orthopedic procedures 
may be necessary to correct the deformities. (See Chapter 
XXIV.) 
8curvy is a nutritional disorder brought about by inade- 
quacy of diet and falls in the group of so-called “deficiency 
diseases.” It is characterized by anemia, loss of appetite, 
irritability, and later swelling of limbs, tenderness and 
severe constant pain, hemorrhages of the gums, subperiosteal 
hemorrhage, hematuria, and other hemorrhagic manifesta- 
tions occur. The nursing care calls for correction of the 
diet to supply the necessary vitamins, the lack of which 
caused the disease; orange juice or the juice of some fresh 
fruit is always given. Good hygiene is a necessary part of 
the care. Because of the extreme tenderness and pain of 
the limbs, the child is hypersensitive and apprehensive, so 
that he will often scream through fear of being touched when 
any one approaches him. Gentle, skillful handling is im- 
portant. Everything should be done for him at one time, 
and all procedures, as bathing, etc., must be made as brief 
as they can be, causing him as little discomfort as possible 
Scurvy 
* Powers, Park, McCollum, Simmons, ‘ ‘ Prevention of Development of 
Rickets in Rats by Sunlight. Studies in Experimental Rickets,” Journ. 
Amer. Med. Assn., Jan. 31, 1922. 
4 “More About Cod Liver Oil in Therapy,” Journ. Amer. Med. Assn., 
Dec. 31, 1921. 324 
PEDIATRIC NURSING 
while the acute symptoms last. As the weight of the bed- 
clothes on his body may increase the pain, a cradle may be 
put over him to support them. 
The nutritional disturbances of infancy are caused by 
many factors seemingly non-related and which are difficult 
to correlate.5 These causative factors are classified by Hess 
as follows: 
1. Overfeeding of a well balanced dietary or of a single 
food element. 
2. Underfeeding, either, 
a. Quantitatively, as in pyloric stenosis, or 
b. Qualitatively, by a poorly balanced diet or one lack- 
ing in proper proportion the essential food ele- 
ments. (Including vitamin deficiency.) 
3. Secondary causes 
a. Heat—with resulting systemic depression and often 
associated with spoiled food. 
b. Infection within the intestinal tract. (Dysentery, 
paratyphoid, etc.) 
c. Systemic parenteral infection. (Otitis media, 
pyelitis, pneumonia, etc.) 
4. Inherent abnormal metabolism, causing disturbance by 
food qualitatively and quantitatively proper for a 
healthy infant. (Exudative diathesis, spasmophilia, 
etc.) 
There is no generally accepted classification or terminology 
or the nutritional disturbances of infancy.6 The older 
terminology spoke of dyspepsia (acute and chronic), catar- 
rhal enteritis, ileocolitis, etc. This Avas an attempt at a 
pathological classification but was inadequate because the 
majority of nutritional disturbances show little if any 
Nutritional 
Disturbances 
of Infancy 
Causes 
Various 
Classification 
5Hess, Julius H., M.D., “Principles and Practice of Infant Feeding.” 
6Grulee, C. G., M.D., “Infant Feeding.” 
Hill and Gerstley, “Clinical Lectures in Infant Feeding.” 
Porter and Carter, ‘ ‘ Management of the Sick Infant. ’ ’ SPECIAL PEDIATRIC NURSING 
325 
anatomical change at postmortem. Czerny and Keller formu- 
lated a classification based on etiology. This was an important 
contribution but its use is limited because the etiology of 
many of these conditions has not been clearly worked out 
and because it is a more or less cumbersome vehicle for the 
busy clinician. The classification of Finkelstein, while not 
accepted in toto to-day, still remains the simplest classifica- 
tion which at all answers the purpose. It is based entirely 
on clinical observation and divides these disturbances into 
syndromes, more or less clear cut, and each due to a rather 
wide variety of etiological factors. Finkelstein divides these 
conditions into the following types: 
1. Disturbed metabolic balance (fat constipation, mal- 
nutrition, early atrophy). 
2. Dyspepsia (sugar indigestion, fat indigestion). 
3. Decomposition (marasmus, athrepsia, atrophy). 
4. Intoxication (ileocolitis, catarrhal enteritis, summer 
diarrhea, cholera infantum). 
5. Inanition (primary). 
The first and second of these are the milder types, and 
reveal no destructive lesions at autopsy. The principal com- 
plaint in the first condition is failure to gain in weight. In 
dyspepsia the outstanding symptoms are diarrhea and fail- 
ure to gain. A carefully made, accurate weight curve is of 
inestimable value in the regulation of these cases. Other 
than this they present no particular nursing problems beyond 
a scrupulous carrying out of the dietary prescribed. This 
will probably be breast milk if obtainable, otherwise malt 
soup, lactic acid milk, protein milk, or simpler whole milk 
dilutions. (See preparations of foods, Chapter XIII.) It 
must be remembered that these milder disturbances can go 
over quickly into the other, severe types. 
Decomposition or athrepsia7 (the term popularized by 
Marriot) in a baby means an extremely sick patient who re- 
Disturbed 
Metabolic 
Balance 
Dyspepsia 
Athrepsia 
1 Marriot, Wm. McKim, M.D., ‘ ‘ Some Phases of the Pathology of 
Nutrition in Infancy.” Journ. Amer. Med. Assn., Dec., 1920. 326 
PEDIATRIC NURSING 
quires an unusual amount of intelligent conscientious nursing 
care. Skillful nursing is in fact an absolute requisite for 
a good prognosis and an appreciation of this should en- 
courage the constant, often difficult care these patients require. 
The infant with athrepsia must have breast milk to survive. 
He is often too weak to suck and must be gavaged; extra 
fluids must be given him by mouth, also by other routes, as 
salt solution or glucose, intravenously, intraperitoneally, etc. 
He usually cannot maintain his own body heat, so if his 
temperature is subnormal he must be given routine premature 
care (see premature care, Chapter VIII) including the oil 
bath instead of a water bath, woolen clothes, and the appli- 
cation of heat to maintain an even, normal temperature. Like 
the premature, while he is very ill, he should be handled as 
little as possible, all nursing procedures being carried out at 
one time. He is very susceptible to infections, hence the 
great necessity for aseptic nursing care. He is subject to 
sudden collapse or sinking spells and must be carefully 
watched for symptoms of these. The cure of athrepsia usually 
takes several months and it is a well known fact that the 
child who has to stay in a hospital over such a long period 
will not continue to thrive in most cases. He is said to 
become “hospitalized” or “institutionalized.” It is also a 
recognized fact that the child who is picked up and “played 
with” or handled a reasonable amount gains more rapidly 
than the child who is not. Therefore, as the infant’s condi- 
tion will permit, he should be picked up and “mothered” 
several times a day as part of his routine treatment. In- 
telligent mothering is good for the child, but it must not be 
foolish indulgence which will lead to the establishment of 
bad habits. Fresh air and sunlight are important factors in 
the care of the athreptic child; as his condition and the 
weather permit he should go outdoors daily. (See Helio- 
therapy, Chapter XVII.) 
Intoxication is another extremely grave condition in which 
Intoxication SPECIAL PEDIATRIC NURSING 
327 
the clinical picture is one of collapse with fever, vomiting, 
diarrhea, and extreme loss of weight. The nervous symp- 
toms are marked later, but when seen early the child 
is apathetic and drowsy, in contradistinction to athrepsia, 
where there is little sleep, the sensorium clear, and the patient 
fretful. The treatment will probably be initiated by a period 
of starvation during which glucose or saline will be given 
intravenously and saline solution intra-abdominally, sub- 
cutaneously, etc. The nursing care will be essentially 
the same as in athrepsia except that the fever present 
will call for tepid packs, sponges, or other methods of 
relieving nervous irritability and of reducing tempera- 
ture. 
Diabetes mellitus does not occur as frequently in childhood 
as in adult life, but the prognosis is particularly poor when 
it does. The course of the disease is much more rapid than 
in adults. The treatment is the same, but usually the diet 
which will render the child’s urine sugar free is far below 
his caloric requirements and the requirements for growth, 
or even for maintenance of life. He must, therefore, be kept 
in bed and as quiet as possible. He should be isolated also 
to remove from him the temptation of all forbidden food; 
he cannot understand the reason for his diet, and the child 
who was formerly the most truthful and honest will practice 
astonishing methods of deceit to obtain the food he craves. 
The most constant surveillance is therefore necessary. If 
he does obtain carbohydrate and exceed his tolerance, the 
carbohydrate mechanism becomes less and less capable and 
tolerance sinks, while the child’s condition becomes more 
critical. 
Acidosis is the condition in which the acid substances are 
present in the blood in a quantity relatively so increased 
that the normal excess of alkali is diminished. This occurs 
frequently in children and may accompany almost any ill- 
ness in which there is a rapid or profuse loss of body fluid, 
Diabetes 
Mellitus 
Acidosis 328 
PEDIATRIC NURSING 
as from diarrhea or vomiting, or if the child goes without 
food or liquids for a short time. The treatment should be 
largely prophylactic. Whenever a child has excessive 
diarrhea or vomiting, liquids should be given him at once 
to make up the loss from the system. (See methods of 
giving fluids, Chapter XVII.) It is the fear of acidosis 
which prevents purgation of the child before operation (see 
preoperative care of children, Chapter XXIII) and it 
is the reason why he must be given fluids as soon as 
possible after operation. Whenever the condition is 
suspected an alkali, as sodium bicarbonate, may be 
given. 
Rheumatism can be roughly classified as acute or chronic. 
The latter is similar to chronic progressive polyarthritis of 
adult life and is often known as “Still’s Disease” in child- 
hood. It is fortunately not a common condition and the 
care of the patient is essentially an orthopedic problem. A 
much more common form, and more important because amen- 
able to therapy, is acute rheumatic fever. This is usually 
ushered in wdth a high temperature and is soon accompanied 
by reddened, painful, and swollen joints. It may or may 
not follow an attack of tonsillitis. It is frequently associ- 
ated with chorea and with cardiac complications. The im- 
portant consideration from the nursing standpoint is pro- 
phylaxis. The etiology in the vast majority of cases is 
mouth infection, and the school nurse, particularly, will have 
abundant opportunity to teach proper hygiene and to lessen 
the frequency of this disease. Carious teeth, infected tonsils, 
or even the simple history of frequent attacks of tonsillitis 
demand proper medical attention. 
In the care of the attack itself, the important items are: 
1. Forcing of fluids (if no cardiac complications exist). 
2. Protection and immobilization of the affected joints. 
3. The insurance of absolute rest in bed. 
The child should not be allowed to do anything for himself. 
Rheumatism SPECIAL PEDIATRIC NURSING 
329 
3. Diseases of the Digestive System. 
Congenital 
Cleft of 
Lip or 
Palate 
Congenital cleft lip and palate. 
Group I. 
Prealveolar (process) cleft (lip cleft—alveolar process 
normal). 
(a) Unilateral. 
(b) Bilateral. 
(c) Median. 
Group II. 
Postalveolar (process) cleft (palate cleft—alveolar 
process normal). 
(a) Soft palate. 
(b) Hard palate. 
Group III. 
Alveolar (process) cleft. 
(a) Unilateral. 
1. Alveolar process. 
2. Lip. 
3. Palate. 
(b) Bilateral. 
1. Alveolar process. 
2. Lip. 
3. Palate. 
(c) Median. 
1. Alveolar process. 
2. Lip. 
3. Palate. 
This classification is based on the following propositions: 
1. Disuse of the term “hare lip.” 
2. Consideration of the subject from the standpoint of con- 
genital clefts, thereby correlating all cases. 
3. The alveolar process forms the foundation for a surgical 
grouping. 
4. Development of generic surgical terms for the groups. 
5. All anatomical descriptions subsidiary to these terms 
Classification 330 
PEDIATRIC NURSING 
which give the opportunity to describe alveolar process, lip, 
and palate separately. 
Time and sequence of operations. 
Group I, from a surgical point of view, can he operated 
upon the first day or the first week or later in life with equal 
facility, but owing to the better control of the baby, it is 
advisable to do this as early as possible, say within the first 
month. 
Group II demands much more of an operation than Group I. 
There is no reason for doing it until the baby begins to talk. 
Owing to the risk involved, it is suggested that the proper 
time for the operation is at 1 year, or when the baby is 
well established, or weighs about 15 pounds. 
Group III demands that the closure of the alveolar process 
be done as early as possible, surely before the baby is 3 
weeks old. Otherwise the line of the face becomes fixed and 
as he grows older this closure is accomplished with increasing 
difficulty. It is within the judgment of the operator in this 
group to select whether the process shall be first brought 
together with a wire and plates, or whether the first repair 
of the lip will accomplish this necessary step. Therefore 
the surgeon selected should have the opportunity of decision 
as early in the baby’s life as it is possible to have him see 
the case. 
(This classification has recently been made by Dr. H. 
Ritchie of St. Paul, Minnesota, who has kindly contributed 
the above.) 
Since the only treatment of the above conditions is surgical, 
it is essential that the nurse be able to recognize the dif- 
ferent groups and know when surgical treatment should be 
started. Before the baby is ready for surgery, whatever 
group he may be in, he should be in the best possible condi- 
tion. As a result of the malformation he usually has more 
or less difficulty in nursing and may be suffering from mal- 
nutrition. He needs several weeks of the very best aseptic 
nursing care to improve his general condition so that he will 
Time of 
Operation 
Group I 
Group II 
Group III 
Importance of 
Recognition 
of Groups 
by Nurse 
To Prepare 
for Surgical 
Treatment SPECIAL PEDIATRIC NURSING 
331 
be able to stand surgery. Since the baby with an alveolar 
cleft or cleft lip has to be gavaged after operation, it is 
advisable to begin to feed him this way before operation. 
Experience has shown that it is the most satisfactory method. 
Postoperative care of child with congenital cleft of lip 
or palate: The baby with cleft lip is usually operated on 
during the early days or weeks of life. After operation he 
must be kept reasonably quiet. Since crying is a strain on the 
tissues of the lip, it should be reported to the surgeon. A 
sedative, as chloral hydrate, may be ordered. The child’s 
hands must be restrained to keep him from rubbing his lip 
or sucking his fingers. Cuffs should be worn over his arms 
and it is wise to take the added precaution of tying his 
hands to the sides of the crib. The lip should be kept as 
clean as possible. Some surgeons do not wish the nurse to 
clean the lip, so this is done only when ordered. The tray 
to clean a postoperative cleft lip should contain: 
Jar of sterile gauze pledgets. 
Jar of toothpick applicators, sterile. 
Paper bag for waste. 
Pair of handling forceps in 5 per cent lysol solution. 
Tube of sterile vaselin. 
Jar of antiseptic solution as ordered to clean the lip. 
Post- 
operative 
Care of Child 
with Cleft 
Lip 
Kestrain 
Hands 
Post- 
operative 
Tray 
One-half 4 per cent boric acid' 
solution 
One-half 70 per cent alcohol^ 
May be used unless 
otherwise ordered. 
With the sterile handling forceps remove a gauze pledget 
from the jar and dip it into the solution and with it gently 
pat the lip clean; do not rub it. Toothpick applicators 
which are dipped in the antiseptic are used to clean the 
nostrils. Extreme care must be taken in cleaning the lip after 
it has been repaired. 
The feeding and method of feeding must be established 
before the operation so that the child will be accustomed 
to it, and the same food and method are continued afterwards. 
The baby with a lip that has just been operated on cannot 
To Clean 
Lip 
Feeding PEDIATRIC NURSING 
332 
nurse either his mother’s breast or a nipple. His mother 
should express her milk, which is given to him by gavage. 
This method saves all strain on the lip and allows the baby’s 
mouth to be kept as clean as possible. After the gavage 
tube is removed put 15 to 30 c.c. of sterile water into the 
baby’s mouth with a sterile medicine dropper, the end of 
which should be protected with a rubber tube. 
The child with cleft palate is usually operated on after 
he is a year old. He, too, should be kept quiet and should 
not be allowed to strain his stitches by talking or crying. 
In order to prevent him from injuring his wound, his hands 
must be restrained by cuffs and by tying if necessary. The 
usual routine is to feed him sterile liquids with a sterile spoon 
for at least 10 days after operation. Follow all food with 
15 to 30 c.c. of sterile water. This liquid diet will not give 
him adequate food. He should have nourishment every 2 
hours and all liquids should be made as concentrated and as 
nourishing as possible by the addition of carbohydrate. Since 
his food is not sufficient for his needs, he must be kept in 
bed as quietly as possible during the time he is taking only 
liquids and after that time until he has regained his weight. 
Oral hygiene as already discussed under the care of the 
mouth and teeth (Chapter VI) must be preached by the 
nurse wherever she may be and she holds it in her power 
to do much missionary work along this line. Dental caries is 
universal in its distribution, but is essentially a disease of 
childhood. Most of the conditions which require the atten- 
tion of the dentist in adult life have had their origin in 
childhood.8 Recent investigations furnish abundant proof of 
the fact that the sordes which causes dental caries may also 
be the cause of cardiac disease, acute rheumatism, mental 
backwardness, malnutrition, and a host of other evils. Since 
babyhood and adolescence are the periods of greatest sus- 
ceptibility to dental caries, the prevention of them becomes 
a matter of vital importance for the health of the child. 
Post- 
operative 
Care of Child 
with Cleft 
Palate 
Restrain 
Hands 
Feeding 
Oral 
Hygiene 
Importance 
of Oral 
Hygiene 
8 Fones, Alfred, D.D.S., ‘ ‘ Mouth Hygiene. ’ ’ SPECIAL PEDIATRIC NURSING 
333 
While scrubbing of the teeth is essential, it alone cannot pre- 
vent their decay. Proper diet is another necessary prophy- 
lactic measure. This consists: 
1. In the elimination of sugars, as candy, between meals, 
and in the elimination of excess sugar with meals. 
2. In the elimination of an excess of the finely ground 
white flour foods, and in the substitution of coarser foods. 
3. In the introduction of roughage which scours and 
cleanses the teeth, as for example, rye crisp, celery. 
4. In the introduction of foods which require mastication 
to develop the function of the teeth, to develop the jaws 
and the salivary glands. 
(Approved by Dental Department, University of Minne- 
sota.) 
Stomatitis of various types calls for cleanliness of the 
mouth (see mouth wash, Chapter VI). The young child who 
cannot understand how to rinse his mouth will have to have 
medications applied with a swab or by irrigations (see method, 
Chapter XIX). Potassium chlorate is considered a specific 
remedy for ulcerative stomatitis and is usually used. Any 
swabbing of the mouth or application of medications must 
be done very gently because of the extreme soreness. 
Thrush is a parasitic form of stomatitis characterized by 
the appearance upon the mucous membrane, usually of the 
tongue and cheeks, of small white flakes and large white 
patches. It occurs most frequently (1) in infants suffering 
from protracted, exhausting diseases, (2) in infants with 
deformities of the mouth, as alveolar cleft, and (3) among 
sick or poorly nourished infants crowded together in institu- 
tions under poor hygienic conditions. It does not develop 
on healthy mucous membrane. An abrasion, such as may 
be caused by frequent or careless cleaning of the baby’s 
mouth, offers a favorable field for the growth of thrush. The 
infection spreads from one child to another unless careful 
isolation is observed The nursing care is largely prophy- 
lactic. It can be avoided to a certain extent (1) if the mucous 
Stomatitis 
Thrush 334 
PEDIATRIC NURSING 
membrane is not injured by cleaning it; (2) if aseptic nursing 
care is practiced; and (3) if all nipples and bottles are 
sterilized after use. There are various treatments used for 
thrush. Medications should not be applied with a swab 
since they only increase the danger of injury to the mucous 
membrane and prolong the infection. After nursing, sterile 
water, 15 to 30 c.c., may be dropped into the child’s mouth 
with a medicine dropper, the tip of which is protected by a 
rubber. Any medication is best made in the same way. Irri- 
tation caused by sucking the nipple may prolong the dis- 
ease ; it may also cause so much pain that the baby wrill 
refuse to suck. He often has to be gavaged unless there 
seems to be danger of spreading the disease down the esopha- 
gus by the passage of the tube. 
Retropharyngeal abscess is quite common in children. It 
is characterized by difficulty in swallowing, noisy, difficult 
respirations and mouth breathing; the head may be drawn 
backward. Before the abscess is opened there is always danger 
that it may break and that the child may be choked by the 
purulent discharge, or that he may inhale it. He must be 
carefully watched for this, and if his dyspnea will permit, 
he should lie on his face with a pillow under the chest to 
make his head lower than his shoulders and facilitate drain- 
age from the nose and mouth in case the abscess does erupt. 
This position must always be assumed after operation to aid 
drainage. The child can be restrained if necessary. Swallow- 
ing is difficult, often impossible before the abscess is opened, 
afterwards there is little difficulty in the usual case. 
Adenoidal growths whenever noticed by the nurse must be 
reported and arrangements must be made for their removal. 
This is another splendid opportunity which the nurse has 
to influence and educate the public and to do constructive 
prophylactic work. She should be able to recognize the 
child with adenoidal growths by the so-called adenoid facies, 
the mouth breathing or sometimes simply by the history of 
repeated “colds.” 
Retro- 
pharyngeal 
Abscess 
Adenoidal 
Growths SPECIAL PEDIATRIC NURSING 
335 
Tonsillitis calls for isolation of the patient. In fact when- 
ever a child has a sore throat he should be isolated, since 
that symptom ushers in so many contagious diseases. Throat 
cultures should be taken because of the possibility of diph- 
theria. The child should be kept quietly in bed, should be 
given a fluid or semi-solid diet, and his fluid intake should 
be forced. Local applications, either hot or cold, may give 
relief. An astringent gargle may be ordered if he is old 
enough to gargle, if not, an irrigation of the mouth may take 
its place. A cleansing spray may be used. Removal of the 
tonsils should be advised if the child has hypertrophied 
tonsils or recurrent attacks of tonsillitis. After tonsillectomy 
he should be kept in a lateral or ventral position and should 
be turned frequently. He should be kept absolutely quiet for 
3 days to prevent hemorrhage. It is advisable, however, to 
keep him in bed for a week. 
Cicatricial stricture of esophagus in the child occurs very 
frequently and is caused by the accidental swallowing of a 
caustic solution, such as lye.9 The immediate treatment con- 
sists in giving the child dilute acid drinks, as lemon juice or 
vinegar. Do not pass a gavage tube, since it may cause a 
perforation of the corroded wall of the stomach or esophagus. 
Medical aid must be called quickly. General measures, such 
as stimulants, warmth, etc., are taken.10 Often the child dies 
at once from the irritant poison, acute inflammation, burns, 
sloughing, perforation, etc. If these do not occur he gradually 
improves. The healing of the burns by granulation and 
cicatrization takes place, the contraction of the cicatrix grad- 
ually narrowing the lumen of the esophagus until a stricture 
is produced. It is usually several weeks or months (sometimes 
years) after the original trouble before the symptoms of 
stricture begin. There is an increasing difficulty experienced 
in swallowing solid food, which often is regurgitated after 
Tonsillitis 
Stricture 
of 
Esophagus 
Cause 
Immediate 
Treatment 
Cicatrix 
Causes 
Stricture 
Symptoms 
9 Jackson, Chevalier, M.D., ‘ ‘ Esophageal Stenosis Following the Swal- 
lowing of Caustic Alkali.” Journ. Amer. Med. Assn., July 21, 1921. 
10 Cushney, Arthur, M.D., “Pharmacology and Therapeutics.” 336 
PEDIATRIC NURSING 
the attempt is made, and finally even liquids are regurgitated. 
The child becomes much emaciated, often almost moribund, 
from starvation. The treatment in such cases is surgical and 
usually consists in a systematic and careful use of bougies 
of a progressively increasing size. Sometimes gastrotomv be- 
comes necessary to save life. Food may be given by rectum, 
but the child’s rectum will not tolerate long continued rectal 
feedings. Fluids may be given in other ways, by hypo- 
dermoclysis, by intravenous and by intraperitoneal routes. 
After the dilatations the child usually takes liquid food or 
solid food by mouth, if well masticated, with more or less 
success. Such children should be given as concentrated food 
as possible every hour or two. They should be kept in bed 
to conserve energy and they may need external heat and 
extra warm clothing to maintain normal body temperature. 
The cure takes many months of patient, persistent treatment. 
The very best rules of hygiene must be carried out to aid 
recovery. Often, as the child begins to recover, the vomiting 
of food may become more or less psychic, for he has acquired 
the habit of regurgitating most of his food. If this is be- 
lieved to be the case, do not give him a basin in which to 
vomit and assume that there is no possibility of his doing 
so. This psychic vomiting may cause as much difficulty and 
be quite as hard to overcome as the original trouble. 
Pyloric stenosis is a congenital hypertrophic stenosis of 
the pylorus. It usually manifests itself in infants from 2 
to 8 weeks of age, and occurs more often in the child who 
previously has had no signs of gastric disorder and more fre- 
quently in the male than in the female child. The disease 
is characterized by vomiting, which is very forceful and pro- 
jectile in type. It may occur directly after the taking of 
food or several hours later, and the amount vomited is 
often more than that just taken in. There is progressive loss 
of weight, the stools are starvation stools, and the urine is 
scanty. The treatment is (1) medical or (2) surgical. 
Usually, (1) medical treatment is tried first. This consists of 
Treatment 
Nursing 
Care 
Pyloric 
Stenosis 
Symptoms 
Treatment SPECIAL PEDIATRIC NURSING 
337 
lavage before feedings, followed by gavage. The food is 
usually breast milk or a thick cereal mixture which must be 
so thick that it will stick to an inverted spoon. (See rules 
for preparing, Chapter XIII.) 11 To be successful the medical 
therapy must be carried out with all faithfulness to detail. 
The baby is in poor condition and needs expert nursing care. 
He often has to be treated as a premature. Fluids are given 
Medical 
Treatment 
Nursing Care 
Figtjre 45. Method of Fefding Thick Cereal Through a 
Hygeia Nipple 
him in other ways besides by mouth (see methods described, 
Chapter XVII). He should lie on his right side to favor 
the passage of food through the pylorus. Relief of the con- 
dition by medical treatment may take many months of the 
most patient, exacting nursing care. Clinical opinion varies 
widely on the length of time that medical therapy should be 
followed. (2) Surgical treatment usually consists in the per- 
Surgical 
Treatment 
“Sauer, L. W., M.D., “Use of Thick Cereal in the Treatment of 
Pyloric Stenosis.” Arch. Ped., July, 1918. 
“Further Contribution to the Study of Pyloric Stenosis.” Am. J. 
Dis. Child., Aug., 1921. 338 
PEDIATRIC NURSING 
forming of the Ramstadt operation.12 The preoperative care 
outlined under surgical care of children is followed (Chapter 
XXIII). The postoperative nursing care is practically the 
same as that demanded by medical treatment before operation. 
Breast milk is essential and is given as ordered, usually as 
soon as the effect of the anesthetic has passed. 
Vomiting (Griffith) is a frequent symptom in early life 
which is due to varied causes. Simple regurgitation, without 
effort, of food which is little changed, if any, occurs in the 
case of healthy infants who have taken more milk than they 
can comfortably hold, or who have been carelessly handled 
after feeding. True vomiting is accompanied by more effort 
and by evidences of nausea, such as pallor of the face and 
perspiration. It is very common at the beginning of (1) acute 
febrile diseases in early life. When acute and of brief dura- 
tion, accompanied by nausea and coated tongue, and per- 
haps followed by diarrhea, it is generally the sign of 
(2) acute gastro-intestinal disturbance. Very obstinate vomit- 
ing, frequently with much mucus, occurs in (3) chronic 
gastric indigestion and gastritis in infancy and in cases of 
stenosis of pylorus. Vomiting may be the evidence of a 
(4) toxic state, as seen, for instance, in uremia and acute 
milk poisoning. If repeated frequently for days, and at- 
tended by retracted abdomen, headache, moderate fever, and 
some degree of constipation, it is very suggestive of (5) men- 
ingitis, or, in the absence of fever, (6) of brain tumor. 
(7) Recurrent vomiting is a disorder not to be forgotten. 
Vomiting is (8) common with paroxysms of coughing, es- 
pecially in pertussis and severe bronchitis. Very obstinate 
vomiting with distention of the abdomen and some degree 
of constipation occurs in (9) peritonitis. When obstinate 
Regurgita- 
tion 
Vomiting 
Causes 
13Kerley, C. G., M.D., “Ramstadt Operation.” Journ. Amer. Med. 
Assn., Jan. 14, 1919. 
Goldbloom, Alton, M.D., and Spence, Ralph C., M.D., “Prognosis in 
Operated Cases of Hypertrophic Stenosis of the Pylorus.” Am. J. Bis. 
Child., April, 1920. SPECIAL PEDIATRIC NURSING 
339 
constipation is combined with obstinate vomiting the existence 
of (10) obstruction of the bowels, sometimes congenital, may 
be suspected. The extreme ease with which vomiting is 
brought about in infants and children must be borne in mind. 
This is especially true when once the tendency to vomit has 
been developed. Thus, in many infants, slight moving of 
the body after a meal is sufficient to cause the loss of it. 
The mere taste of food may occasion vomiting, both in in- 
fants and in older children, everything being ejected the 
taste of which is not liked. This is probably the reason why 
nourishment given to infants by gavage may be retained when 
that entering the mouth in the usual way may be vomited. 
A child can, with sufficient practice, vomit whenever he de- 
sires, and he will often use this power to produce a desired 
reaction from his mother. 
Rumination is habit vomiting; after taking milk the infant 
immediately regurgitates without any effort, spits out some, 
holds some in his mouth, and after going through a chewing 
process with it re-swallows it; he does this constantly, re- 
gurgitating his milk and re-swallowing it. Thick cereal feed- 
ing is often given, since it cannot be readily regurgitated. 
This is the only condition in which a pacifier is ever indicated; 
here occasionally it helps, for the child constantly sucking a 
pacifier will forget to ruminate. Another device to prevent 
ruminating is the use of a 4-tailed bandage of the jaw, 
or a specially designed mask to hold the mouth shut and 
immobilize the lower jaw.13 
The swallowing of foreign bodies is common in childhood. 
The child of almost any age may have more or less of a 
habit of putting objects into his mouth. Careful training will 
overcome the habit to a great extent and should be emphasized 
because of the danger of swallowing such objects. The size 
and shape of the foreign body swallowed largely determines 
the result. Symptoms are indefinite and vary according to 
Rumination 
Swallowing 
of Foreign 
Bodies 
“Kerley, C. G., M.D., and Lorenz, E. J., M.D., “Failure to Gain; 
Rumination.” Arch. Ped., May, 1921. 340 
PEDIATRIC NURSING 
conditions. It may lodge in the esophagus and the removal 
of it is a surgical procedure. It may pass into the stomach 
and remain there for a varying length of time, or it may 
pass directly into the intestines and be expelled without 
event. An x-ray will determine its progress. Whenever it 
is known that a child has swallowed a foreign body a physician 
should be called to determine the seriousness of it. Efforts 
should be made to aid the exit of the body and to protect the 
gastric mucous membrane. This is best accomplished by the 
administration of abundant food which will coat the object, 
such as potatoes, bread or cereals. No purgatives or emetics 
should be given. Surgery is the last resort if other measures 
fail. 
Diarrhea like vomiting is only a symptom, but is of such 
importance that the nurse must have some knowledge of it. 
It is one of the most frequent and often the most serious of 
the disorders of childhood, and especially of infancy. Over 
25 per cent of the deaths of children under 10 years old 
are due to diarrhea from one cause or another. It is seen 
more frequently in summer than in winter. It may be due 
to (Griffith) : 
1. Irritation of the gastro-intestinal tract by: 
a. Improper food. 
b. Drugs, etc. 
2. Toxic origin, acute gastro-enteric intoxication. 
3. Nervous origin. 
a. Hot weather. 
b. Chilling of body. 
c. Emotional excitement. 
d. Fatigue—and a variety of like causes. 
4. Acute intestinal indigestion—functional disturbance of 
the intestine. 
5. Metabolic origin—acute infectious diseases, parenteral 
infections. 
6. Inflammatory origin—ileocolitis, tuberculous enteritis. 
It is a matter of concern when any child has frequent watery 
Diarrhea 
Significance 
in Children 
Causes SPECIAL PEDIATRIC NURSING 
341 
stools, and if they persist over 24 hours a physician should 
be called to determine the cause. 
Acute intestinal indigestion occurs in a mild form and if 
untreated develops into the severe type known as cholera 
infantum or the “intoxication” of Finkelstein. It occurs 
more frequently in summer than in winter. The treatment is 
first prophylactic. If the child who begins to vomit or to have 
diarrhea is taken at once to a physician much grief can be 
avoided. The nursing care of the child with intestinal in- 
digestion calls for hygiene, proper regulation of the diet, 
and correction of the dehydration. He should be kept out- 
doors as much as possible. The city child should be taken 
to the country if possible. 
Ileocolitis (dysentery, enterocolitis, enteritis, inflammatory 
diarrhea) is a pathologic process seen more frequently in 
summer months and in the warmer climates. It occurs most 
often in children under 2 years old. Proper hygiene, fresh 
air, and regulation of the diet are essential. Forcing of fluids 
in various ways is necessary. A change of air is advisable. 
Isolation must be carefully carried out for the disease is 
highly infectious, especially among children in institutions. 
Chronic intestinal indigestion, often called celiac dis- 
ease, or Hiirter’s infantilism, occurs most frequently in 
children from 1 to 5 years and in children in the middle or 
upper classes. The disease is usually characterized by the 
child’s intolerance for carbohydrate and fat, thus making the 
diet largely protein. The stool is very characteristic, almost 
pathognomonic. It is extremely large, foul, unformed, greasy, 
and almost colorless. The nursing care consists in carrying 
out a carefully regulated diet to suit the tolerance of the 
child, hygienic care, general management and training. There 
are frequent discouraging relapses and the same careful treat- 
ment has to be continued over a period of years. There is 
a marked dilatation of both the large and the small in- 
testine. A firm, well fitting abdominal binder often gives 
relief. 
Acute 
Intestinal 
Indigestion 
Chronic 
Intestinal 
Indigestion 342 
PEDIATRIC NURSING 
Colic 
Colic is the term applied to paroxysmal pain in the in- 
testines from various causes.14 It is essentially a symptom of 
indigestion, and is often associated with flatulence, some- 
times with constipation. Colic of infancy is caused by spasm 
of the muscular wall of the intestines, and is usually due 
to (1) too much food, (2) too frequent feeding, (3) improper 
food. Gas or flatulence which accompanies colic may be pre- 
vented to a certain extent in both bottle fed and breast fed 
babies: if the child is raised to a sitting posture several times 
during the nursing and is gently patted on the back until the 
gas is belched. Relief is sometimes obtained if the baby with 
colic is allowed to lie on his face with a hot water bottle (115° 
F.) under his abdomen. A saline or plain water enema may 
also give relief by starting peristalsis and causing expulsion 
of gas. 
Hirschsprung’s disease, or congenital enlargement of the 
colon demands no special pediatric nursing care except the 
constant struggle with severe constipation, which means re- 
peated enemata, drugs, diet, etc. (See treatment of con- 
stipation.) Surgery is sometimes employed. 
Intussusception is a disease of childhood. Whenever a child 
has severe abdominal pain, vomiting, and bloody mucous 
stools, this condition should be suspected. Unless operation 
is performed within a few hours, the prognosis is extremely 
poor. The nursing care involves no special technique beyond 
that of other postoperative abdominal conditions. The im- 
portant part is to recognize the symptoms early so that the 
child may be operated on at once. 
Hernia: 
1. Umbilical hernia is either congenital or acquired. The 
acquired type occasionally results after the separation of 
the cord. The condition is usually remedied by an adhesive 
strap inches by 6 or 8 inches. This is drawn tensely, is 
applied, and is fastened over the ribs on both sides so that 
14 Grulee, C. G., M.D., “Treatment of Colic in Breast Fed Infants.” 
Journ. Amer. Med. Assn., Dec. 18, 1920. 
Hirschsprung’s 
Disease 
Intussus- 
ception 
Hernia 
Umbilical 
Hernia 
Adhesive 
Strap SPECIAL PEDIATRIC NURSING 
343 
a longitudinal fold of the abdominal wall is drawn over the 
hernia. This may have to be used for several months. The 
adhesive should be changed every week or 10 days and the 
skin should be cleaned with benzin. If the skin is much 
irritated, it may be necessary to apply sterile gauze over the 
irritated places and to make the adhesive strip longer, thus 
relieving tension in any one place. 
2. Inguinal hernia is congenital or acquired. It is often 
treated by means of a yarn truss. A skein of soft woolen 
yarn of the proper length is passed around the body just above 
the iliac crests, and a slip noose formed in front so that 
the knot comes directly over the external inguinal ring. The 
free end is then passed between the thighs and along the line 
of the gluteal fold and is tied or pinned behind and somewhat 
to one side. The truss may be protected from the discharges 
by means of a piece of oiled muslin rolled around the yarn 
where it passes between the thighs. Several skeins of yarn 
should always be on hand so that the soiled one may be 
removed and replaced. These should be worn night and 
day for several months at least. Before the truss is applied 
the hernia should be carefully reduced. This can usually 
be done with the child in a recumbent position, the pelvis 
being somewhat elevated and the thighs being flexed on the 
abdomen. If the hernia cannot be reduced readily and if 
there are signs of strangulation, as evidenced by pain or 
shock, a physician should be summoned at once as surgical 
intervention may be necessary.15 
Postoperative care of hernia: The small child who has 
not yet learned to express his desires to go to the toilet and 
who is still wearing a diaper often has to be operated on for 
hernia. This means that his wound will be constantly sat- 
urated with urine. To prevent this the following dressing 
is applied: 
The hernia wound is covered with a thick collodion dress- 
ing in the operating room and no other dressing and no 
Inguinal 
Hernia 
Post- 
operative 
Care of 
Hernia 
15 Ramsey. W. R., M.D., ‘ ‘ Care and Feeding of Children. ’ ’ 344 
PEDIATRIC NURSING 
abdominal binder are put on. When the child returns to his 
bed, a restrainer is put on him to keep him flat on his back 
and a small cradle is placed over his body. His legs are 
tied to the cradle on either side with a piece of bandage. 
His nightgown is brought up over the cradle and is pinned 
to it on all sides with safety pins so that he cannot get his 
hands under it to touch his wound. If he is particularly 
active or naughty, his hands may have to be tied also. A 
diaper is placed under his buttocks but not brought up around 
his body to fasten it. It is changed whenever it is wet or 
soiled. With this arrangement the child’s abdomen is kept 
entirely uncovered and exposed and nothing touches it 
to infect it. He should be picked up, keeping him in a re- 
cumbent position, several times daily to change his position. 
The scrotum is often edematous after operation, causing con- 
siderable discomfort. Relief may be obtained by supporting 
it in a sling made of a diaper placed under it and pinned up 
to the sides of the cradle. 
Appendicitis and peritonitis in children are usually treated 
by surgery. After operation the child may be ordered on a 
back rest or in Fowler’s position to aid drainage (see direc- 
tions for adjusting head rest, knee roll, etc.* Chapter V). 
He may be too little to understand that he should maintain 
this position or he may be delirious or too sick to be reasoned 
with. He may also remove his dressings or may pick at his 
wound. In such a case a special nurse is necessary. Even 
if he is under constant surveillance restraints may often be 
necessary. It is better to avoid them if possible. After any 
abdominal operation there may be difficulty with the small 
child who may soil his dressings with urine or feces. This 
necessitates some arrangement similar to the one described 
above for postoperative care of hernia. The details have 
to be decided for every separate case, as the difficulties pre- 
sent themselves. If the child’s condition will permit, he 
may be strapped to a Bradford frame with his buttocks over 
the opening in the canvas and a tube over his genitals to SPECIAL PEDIATRIC NURSING 
345 
collect the urine and convey it to a bottle at the side of the 
crib. (See method for collecting 24-hour urine specimen, 
Chapter XV.) 
Intestinal parasites or worms do occur in childhood but 
do not occur nearly as frequently as the laity believe. 
1. Ascaris lumbricoides or round worms are the most com- 
mon intestinal parasites found in children in this country. 
They often cause no symptoms. Sometimes there are signs 
of digestive disturbance, restlessness, irritability, tympanites, 
colic, gritting of the teeth, picking of the nose, and various 
nervous manifestations. Their presence is determined only 
by the actual finding of the worms or ova in the stools. They 
occur often enough for the nurse to consider them a possibility 
whenever a child first comes under her observation and she 
should examine the stools closely. The treatment consists in 
a short period of starvation, the administration of a vermi- 
fuge, as santonin followed by some cathartic. This may have 
to be repeated in 2 weeks. 
2. Oxyuris vermicularis or pin worms are frequently found 
in children. They cause severe itching around the anus, 
usually worse at night. They may be observed in the stools, 
around the anus, and occasionally around the genitals. The 
treatment calls for daily rectal irrigations. Infusion of 
quassia is a favorite remedy. Some vermifuge, as santonin, 
is given by mouth. The child’s anus and genitals must be 
kept clean and are sponged with an antiseptic, as bichlorid 
of mercury, every 2 to 4 hours and after a defecation. Some 
soothing ointment may be applied to the anus to relieve the 
irritation. The clothing, including night clothes and bedding, 
should be changed daily. The disease is contagious and the 
child in the home or in the institution should be isolated 
from others. He may also reinfect himself unless his hands 
are restrained so that they cannot come in contact with the 
anus. 
3. Taenia saginata is the most common type of tapeworm 
found in children. There may be no symptoms or there may 
Intestinal 
Parasites 
Ascaris 
Lumbricoides 
Oxyuris 
Vermicularis 
Taenia 
Saginata 346 
PEDIATRIC NURSING 
be vague digestive disturbances. The diagnosis is made only 
after finding segments of the worm in the stools. The treat- 
ment consists of a short period of starvation, a rectal irriga- 
tion, and a saline purgative, followed by some vermifuge. 
Male fern or pumpkin seed are common remedies. Another 
purgative is given in an hour or two after the administration 
of the vermifuge. When the child is about to have a 
defecation it is suggested that he be seated on a vessel full 
of water so that his buttocks are in contact with the fluid. 
The water will help support the worm while it is being ex- 
pelled and there seems less danger of the head breaking off. 
Children stand catharsis very poorly and the treatment for 
these above conditions, especially for trenia saginata, is par- 
ticularly exhausting and should not be started unless the child 
is in good physical condition. He should be kept quietly 
in bed for a few days before the treatment is started, while 
it is being given, and afterwards until he has regained his 
strength and weight. 
Prolapse of the rectum is common in children, occurring 
usually with the act of defecation. It can be easily reduced 
in most cases by laying the child on his face with his hips 
elevated, and by making gentle pressure upon the tumor with 
oiled fingers. A glove should be worn when doing this. The 
application of cold, either of ice or cold cloths is of assistance 
oftentimes. An adhesive strip, 2 or 3 inches wide strapped 
tightly across the rectum over the buttocks, helps to prevent 
prolapse. The child should lie quietly on his back for at 
least an hour after the reduction of the prolapse, and his 
activities should be restrained for a period of weeks to pre- 
vent recurrence. Straining at stool should be avoided by 
regulation of the diet, non-irritant laxatives, and suppositories. 
Operation is sometimes necessary. 
Constipation is usually due to: 
1. Habit. 
a. Lack of proper training in regular toilet habits. 
Prolapse 
of Rectum 
Constipation 
Cause 2. Faulty diet. 
a. Improper balance of food principles. 
b. Too little food from (1) excessive vomiting or 
(2) underfeeding. 
c. Irregular habits of eating. 
3. Abuse of cathartics. 
4. Anomalies of the gastro-intestinal tract. 
5. Constitutional disease. 
The healthy child trained in infancy to regular habits of 
eating and regular times for defecations will have little diffi- 
culty with constipation as he grows older (Chapter XV). 
Occasionally a baby will have only one stool a day or maybe 
one every other day. If this stool is copious and normal in 
character and if the baby is thriving, there is no cause to 
worry. It is best to interfere as little as possible because 
this interference produces a habit and chronic constipation 
may result. 
The breast fed baby is seldom troubled with constipation, 
if he has regular feeding hours and if he is trained to regular 
habits of defecation. Constipation of the mother and irregu- 
larity of her habits may produce constipation in the baby. 
The artificially fed baby is more subject to constipation. 
Normally he has fewer stools in 24 hours and they are firmer 
and more formed than those of the breast fed baby. To treat 
constipation in a baby (1) he should be trained to regular 
habits at once ; (2) the diet should be regulated and the proper 
balance of food principles should be brought about; (3) he 
should have plenty of water. A small baby can take 30 
to 60 c.c. of boiled water 2 or 3 times daily halfway between 
feedings. This is increased as he grows older until, by the 
time he is a year old, he may have 180 to 240 c.c. several 
times a day between meals. (4) Fruit juices are beneficial. 
A baby over 6 weeks can generally have prune juice, start- 
ing with 1 dram once a day, diluted half with water, and 
gradually increasing so that in a few weeks he is having y2 
to 1 ounce twice a day, diluted half with water. (5) Massage 
SPECIAL PEDIATRIC NURSING 
347 
Prevention 
Breast Fed 
Baby 
Artificially 
Fed Baby 
Treatment 348 
PEDIATRIC NURSING 
of the abdomen will sometimes help. It should be given for 
10 minutes twice a day. 
Irregular habits are the greatest single cause of constipa- 
tion in the older child. The condition here, together with 
that found in constitutional disease and anomalies of the 
gastro-intestinal tract is usually due to an atonia of the mus- 
culature of the colon. A faulty dietary and the abuse of 
cathartics on the other hand results usually in hypertonicity 
of the intestinal musculature. Therefore, the two general 
conditions are approached differently. It can be said with 
safety, however, that the modern tendency in the treatment 
of constipation is away from reliance on drug therapy toward 
the attempt at correction of the underlying cause. (1) Reg- 
ular times to go to the toilet cannot be overemphasized. Often 
constipation is the result of the child not taking time to go 
to the toilet. He should be taught to go soon after breakfast, 
and this meal should be early enough to allow him ample 
time before his day’s activities begin. If he realizes from the 
start that he has to stay in the toilet until he has a stool, 
he will soon form the habit of having one at this time. 
(2) Regulation of the diet is necessary. Coarse cereals, coarse 
breads, vegetables with a good deal of fiber, and fruits are 
essential at meal hours. Agar-agar jelly is beneficial (see 
rules for making, Chapter XIII.) (3) Water between meals 
should be given and a glass of either hot or cold water be- 
fore breakfast is helpful. (4) Massage of the abdomen may 
be employed. (5) Well rounded exercise is necessary, es- 
pecially exercises which tend to develop the abdominal mus- 
cles. (6) Proper posture should be established. Enemata 
should not be employed regularly. Occasionally an enema 
is necessary for immediate relief wdien the bowels have not 
moved for a day or two. Suppositories, as a gluten supposi- 
tory or soap stick, are helpful to irritate the lower bowel, at 
times, to produce a stool. Neither enemata nor suppositories 
will cure constipation and if they are to be resorted to their 
use should be alternated, so that the constant use of one 
Child 
Treatment SPECIAL PEDIATRIC NURSING 
349 
or the other will not produce a habit. Drugs are the last 
resort and they are given only if ordered. Castor oil is 
never given for constipation. Liquid petrolatum (liquid 
albolene, Russian oil, mineral oil) which is given several times 
a day will help by increasing the bulk of the intestinal con- 
tents and by acting as a lubricant. It is not absorbed and 
has no systemic action. The dose should be gradually de- 
creased as the desired results are obtained. Milk of magnesia 
or cascara sagrada may be ordered. They are usually given 
in small doses several times a day and the dose is gradually 
decreased. 
4. Diseases of the Respiratory System. 
Diseases of the respiratory system are among the com- 
monest of the disorders of early life, being exceeded in infancy 
only by digestive disturbances and in early childhood even 
surpassing these in number. 
Coughing (Griffith) is an important respiratory symptom. 
There are different types. A short suppressed cough followed 
by a facial expression of pain is observed in pneumonia and 
pleurisy; a peculiar barking, brazen cough in spasmodic 
croup or the early stage of laryngeal diphtheria; a tight, 
hoarse cough in laryngitis and tracheitis. Long hard parox- 
ysms of dry coughing, sometimes causing pain in the chest, 
occur in the early stages of severe bronchitis, and a loose 
rattling cough in bronchitis after secretions have been estab- 
lished. The long paroxysms of rapid, short, expiratory 
efforts, continuing until suffocation seems impending and fol- 
lowed by a crowing inspiration, are characteristic of pertussis. 
A peculiarly severe, ringing, brazen cough, in some respects 
resembling that of croup but often paroxysmal, is some- 
times caused by the presence of glandular or other tumors 
or abscesses within the thorax, or by the presence of a foreign 
body in the wind pipe. An annoying “tickling,” or hacking 
cough occurs in pharyngitis. When the pharyngitis is severe 
the cough causes pain in the throat. A hard dry cough, often 
Coughing 350 
PEDIATRIC NURSING 
severe, is heard in passive congestion of the lungs produced 
by disease of the heart. Indigestion is frequently attended 
by a hacking cough, the so-called “stomach cough.” Asthma 
has a short dry cough, not paroxysmal. Voluntary expectora- 
tion of sputum following coughing does not, as a rule, take 
place in any disease until the child is 6 or 7 years old. Sputum 
for examination may be obtained by introducing a catheter or 
a cotton applicator to the base of the tongue. This irritation 
causes coughing and sputum may be aspirated by the catheter 
or caught on the applicator. Most every type of cough is ex- 
aggerated at night. The treatment depends on the cause. 
Drugs as sedatives or expectorants are sometimes necessary. 
A variety of “home remedies,” as syrups, etc., to relieve the 
irritation are usually given, with varying success. Cold 
applications to the throat may help, also steam inhalations 
or a croup tent are sometimes beneficial. (See method of 
giving, Chapter XVIII.) 
Epistaxis occurs frequently in children; it is often seen 
in nasal diphtheria and may be an early symptom of some 
other infectious disease. Repeated epistaxis without other 
symptoms is usually due to the fact that the child picks 
his nose or to the presence of a foreign body. Any child 
who picks his nose or has a habit of introducing objects 
into the nostrils should be broken of the habit. The im- 
mediate treatment to check the hemorrhage consists in com- 
pressing the nose between the thumb and finger. Ice may 
be applied over the nose and sometimes small pieces of ice 
may be introduced into the nostrils or may be held in the 
mouth. Cold applications can be put on the back of the 
neck. If the hemorrhage persists, a physician should be 
called; it may be necessary to plug the anterior nares and 
sometimes the posterior nares as well. Further treatment 
consists in hygienic and general tonic measures. 
Upper respiratory diseases occur too frequently in children. 
A child who “takes cold” repeatedly should have a thorough 
medical examination. All his habits, as of eating, sleeping, 
To Obtain 
Sputum 
Epistaxis 
Upper 
Respiratory 
Infections SPECIAL PEDIATRIC NURSING 
351 
exercise, time out-of-doors, and clothing should be carefully 
looked into and mistakes should be remedied. He should 
have the benefit of hygienic surroundings and proper modes 
of living. He should be outdoors as much as possible, and 
should sleep in a well ventilated room with a moderate 
amount of covering. Cold sponging of the chest or cold 
showers are helpful. His clothing should be heavy enough to 
protect him, but not too heavy; it will be governed entirely 
by the circumstances, as the heating system of the home and 
the climate. Upper respiratory infections spread rapidly 
among children in an institution. This is especially true of 
sick infants, who are very susceptible to them. What seems to 
be a simple cold often quickly develops into otitis media, 
bronchitis, or pneumonia; even death may result. Therefore, 
all children suffering from even the mildest infections should 
be carefully isolated. Many such infections can be avoided if 
nurses, doctors, and others working with the children wear 
masks over the nose and mouth if they themselves are suffer- 
ing from upper respiratory infections, or better yet, if they 
stay away from the children entirely. When treating an 
infant with coryza, the general rules of hygiene should be 
observed; his nose should be cleaned out frequently, at least 
every two hours, to help him to breathe and to nurse. Warm 
oil, as liquid petrolatum, dropped into the nostrils is 
helpful. 
Spasmodic laryngitis or croup is frequent in children from 
6 months to 3 years old, occurring more often in the well 
nourished child. The attack always comes at night. The 
child seems as usual during the day except for a little hoarse- 
nes and cough or possible coryza or slight fever toward 
evening. These symptoms increase until about midnight when 
the child has an attack of croup. The treatment consists 
in giving an emetic, since vomiting from any cause will re- 
lieve laryngeal spasms. Syrup of ipecac is most commonly 
used for this purpose. An enema is given if the child is 
constipated. Antipyrin in suitable doses is usually ordered 
Croup 352 
PEDIATRIC NURSING 
as a prophylaxis. Steam inhalations or a croup tent are valu- 
able remedies. (See croup tent, Chapter XVIII.) Warm or 
cold applications over the larynx help. The child should 
be kept indoors for several days after an attack; the attacks 
are apt to be repeated for several consecutive nights. Pro- 
phylactic treatment consists in giving the child general tonic 
and hygienic treatment and plenty of fresh air. Avoid every- 
thing which is known to bring on an attack and ihsist on a 
thorough physical examination. 
Hay Fever and Asthma. There is no essential difference 
between these two conditions; in the first the nasal mucosa 
is involved, in the second the bronchial mucosa or both. The 
condition is defined by Osier as a reaction of an anaphylactic 
nature in sensitized persons, in others possibly a reflex neuro- 
sis, characterized by swelling of the nasal or respiratory 
mucosa, increased secretion, and, in asthma, spasm of the 
bronchial muscles with dyspnea, chiefly expiratory. In in- 
fancy there is a very close association of asthma with 
bronchitis, but in the older child the condition resembles the 
adult form above described. 
The condition is often hereditary. It is particularly fre- 
quent in children who had eczema in infancy. Local sources 
of irritation in the throat and pharynx, such as hypertrophied 
tonsils, adenoids, chronic hypertrophic rhinitis, sinusitis, etc., 
are recognized as predisposing causes. Contact with animals, 
such as a pet cat or dog, horses, domestic fowl, etc., may 
initiate an attack. The pollens of various plants, such as 
ragweed, golden rod, timothy, etc., have a similar action. 
Schloss and Talbot showed that certain foods, particularly 
milk, eggs, cereals, and many others when contained in the 
diet will give rise to asthmatic attacks. All of these latter 
causes, i.e., susceptibility to animals, plants, or foods, evidently 
due to a sensitization against the particular protein, resemble 
the phenomenon of anaphylaxis very closely. (See protein 
sensitization tests, Chapter XVI.) Shannon has recently 
shown that in cases of eczema in infancy, so frequently a 
Hay Fever 
and 
Asthma SPECIAL PEDIATRIC NURSING 
precursor of later asthmatic tendencies, the offending pro- 
tein can be carried in the breast milk. 
These patients are seldom hospitalized except during an 
acute attack. Measures employed at this time are various. 
Among the drugs used are stramonium leaves (used as an 
inhalant), potassium ioclid, and atropin. One of the most 
efficient in giving immediate relief is the intramuscular in- 
jection of epinephrin. Tonics, such as cod liver oil, are 
frequently prescribed following the attack. The cooperation 
of the nurse is invaluable in seeking out the offending food 
when the asthma is of that type and in keeping that protein 
out of the diet thereafter. In the case of an infant the nursing 
care is usually identical with that of acute bronchitis. 
Aspiration of a foreign body into the larynx is not un- 
common. It very often happens because the child attempts 
to laugh or cry when he has something in his mouth. The 
foreign body entering the trachea may be expelled immedi- 
ately, remain impacted, or pass on into the bronchi, depend- 
ing on the size and shape of the object. The first thing to 
do is to help the child expel the object by inverting him; 
he may cough and bring it up without further difficulty. But 
if attempts are unsuccessful, immediate surgery is usually 
necessary. If the foreign body cannot be removed by bron- 
choscopy, a tracheotomy may have to be done. To prepare 
the child for this wrap him tightly in a blanket to restrain 
him, with his hands down to his sides and legs straight. 
Place him on his back on a padded table with a hair pillow 
under his shoulders and his head hanging down, exposing 
his throat. One person steadies his head, holding it straight 
with his body while another person holds his feet during the 
operation. Every children’s department should have a com- 
plete sterile tracheotomy outfit for emergency use. The tube 
is held in the child’s trachea by means of a tape around his 
neck, fastened in back. He needs constant watching; a special 
nurse is necessary until he becomes accustomed to the tube. 
A piece of gauze should be put between the child’s neck 
353 
Foreign 
Body 
in Larynx 354 
PEDIATRIC NURSING 
and the flange of the tube to protect his skin; a piece of 
moist gauze (several thicknesses) is kept over the opening of 
the tube constantly and changed frequently. The inner 
tube is cleaned frequently, at least every 2 hours. To do 
this it is removed and a pipe cleaner, feather or small brush 
is run through until it is free from mucus; it should be 
boiled twice a day. The air the patient breathes should be 
warm and moist. An extremely serious complication is 
bronchopneumonia. 
Pneumonia. Bronchopneumonia is seen most frequently 
in children under 2 years old; it may be primary or secondary 
to some infectious disease or to almost any illness of infancy. 
The mortality is high. The disease runs no definite course ; 
often it lasts over a period of weeks. The nursing care con- 
sists in hygienic treatment. Warm moist air (not cold air) 
is necessary. Antipyretics in the form of cold baths, sponges, 
etc., may be indicated to allay nervous irritability and to 
reduce temperature. Fluids should be forced in all possible 
ways and the diet is usually light but nourishing. Special 
attention must be given to the care of the mouth. Inhalations 
may be helpful. The child should be picked up and held 
for a few minutes several times a day, for a frequent change 
of position is essential. Never allow the baby with broncho- 
pneumonia to lie in one position for hours. Isolation must 
be carried out. 
Lobar pneumonia occurs at any age, but most frequently 
after 3 years; it is usually primary. The mortality is not 
so high as from bronchopneumonia. It runs a definite course 
with a crisis in typical cases as in the adult. Hygienic treat- 
ment is necessary. The patient is sometimes ordered to be 
put in a warm room with plenty of fresh warm air. Some- 
times he is ordered to a cold room with the windows open 
or, if possible, outdoors. In the latter case he must be well 
protected with shirt, stockings, nightgown, flannel wrapper, 
and a cap on his head; he should have a woolen blanket 
directly over him and have hot water bottles at his feet. The 
Pneumonia 
Broncho- 
pneumonia 
Lobar 
Pneumonia SPECIAL PEDIATRIC NURSING 
355 
small child who will not keep his hands covered can be put 
in a sleeping bag with a hood. He usually has less dyspnea 
if he can sit up. It is difficult to keep a small child comfort- 
able and in proper position when he is sitting up. The pillows 
must be arranged so that he is not doubled over on himself, 
but so that his head and shoulders are bent backward enough 
to allow him the fullest possible breathing space or his 
dyspnea will not be helped by the upright position. The 
nurse must visit him every few minutes to rearrange his 
pillows and to keep him in the proper position, for he is 
very restless. Isolation technique is carried out. Cold sponges, 
etc., are often necessary to allay nervous irritation and to 
reduce temperature. Fluids must be forced in all possible 
ways; the diet may be liquid or light. The mouth needs 
special nursing care to keep it clean; apply cold cream to 
the lips (see care of mouth, Chapter VI). Even after the 
child is over the crisis he must be kept quiet to avoid strain 
on the heart ahd the development of heart complications. 
Dry Pleurisy. In this condition the pleura is covered 
with an exudate composed mainly of fibrin. The symptoms are 
sharp, localized pain increased on respiration and a short, 
teasing cough. The pain, particularly in childhood, is often 
referred to the abdomen. 
The condition is seldom seen in childhood as an isolated 
clinical disease. It is almost invariably a complication of 
bronchopneumonia and occasionally of tuberculosis. It is a 
frequent cause of the “growing pains” described by the 
laity. 
The treatment, apart from that of the underlying con- 
dition, consists of counterirritation achieved by painting the 
affected area with tincture of iodin or by applying a mustard 
poultice. Immobilizing the affected side by strapping it 
with a wide band of adhesive plaster will often relieve the 
pain. 
Pleurisy with Serous Effusion. This condition often suc- 
ceeds that just described. In addition to the fibrinous exudate 
Dry Pleurisy 
Pleurisy 
with 
Effusion 356 
PEDIATRIC NURSING 
upon the pleura found in the “dry” pleurisy, there is an 
effusion of serum from the blood vessels into the pleural 
cavity. This, when at all extensive, can cause serious 
embarrassment from pressure upon the heart and lungs so 
that cyanosis may be seen and dyspnea is common. It may 
go on to an empyema. 
This condition in early childhood is generally seen as a 
complication of pneumonia, although later pulmonary tuber- 
culosis may be the cause. It is also seen in nephritis, in acute 
rheumatic fever, scarlet fever, or any of the acute infectious 
diseases. 
The treatment, other than symptomatic, is directed to the 
underlying condition. It may be necessary to do a thora- 
centesis to relieve cardiac or respiratory embarrassment. Pro- 
longed rest in bed, even in the absence of any acute symptoms, 
is very important. 
Empyema is an inflammation of the pleura in which true 
pus is formed and collects in the pleural cavity. There may 
or may not be any dyspnea, although respirations are ac- 
celerated. Cough is present in most cases. There is marked 
anorexia with consequent loss of weight, which in the pro- 
longed cases goes on to emaciation. 
In 90 per cent of the cases occurring in children under 
5 years there is a pneumonia present or initiating the con- 
dition. In later childhood tuberculosis may be the under- 
lying cause. More rarely, it is found complicating any of 
the acute infectious diseases and is found in pyemia from 
whatever cause. 
Empyema is always serious and particularly in the first 
two years has a very high mortality. On the other hand, it is 
an extremely satisfying condition to treat when seen early 
and intelligently handled. The treatment is always surgical 
and there are many methods in vogue at the present time. 
However, whatever the method, whether it be simple tube 
drainage, irrigation with Dakin’s solution, or tube drainage 
combined with some suction apparatus, or rib resection, the 
Empyema SPECIAL PEDIATRIC NURSING 
357 
aim is always the same, i.e., the constant and complete evacua- 
tion of the pus in the pleural cavity. Asepsis in the changing 
of dressings, cleansing of tubes, etc., is very important. Gen- 
eral hygienic measures with especial care of the diet will 
influence greatly the ultimate prognosis. Blow bottles to aid 
in expanding the lung are indicated later in the course. 
Abscess of the Lung. This rather rare condition may occur 
as the unusual complication of a pneumonia or as a local 
inflammatory reaction to a foreign body in the lung. The 
treatment is similar to that of empyema, i.e., surgical, and 
the nursing care is identical. 
Bronchiectasis or chronic interstital pneumonia is a chronic 
pneumonia with the inflammation usually confined to the 
connective tissue framework of the lung and accompanied 
by dilatation, i.e., bronchiectasis of the smaller bronchi. It 
may often follow repeated attacks of acute bronchitis; in 
later childhood it frequently complicates tuberculosis. 
There is no specific therapy. A change of climate may help. 
The general regime advised is the same as for tuberculosis. 
The nursing care does not differ. 
Lung 
Abscess 
Bronchiec- 
tasis 
5. Diseases of the Genito-urinary System. 
The nurse who is responsible for the care of a child, es- 
pecially of a sick one, must watch him closely for any dis- 
orders of urinary secretion. Congenital malformations have 
been discussed. Various urinary disturbances, as anuria, re- 
tention of urine, suppression of urine, polyuria, frequent 
micturition, or incontinence of urine, must be reported when- 
ever they are observed, since they are all significant. 
Nephritis occurs frequently as a complication of infectious 
febrile diseases. Here as in so many of the diseases of 
childhood prophylaxis is the most important point. When a 
child is suffering from any infectious febrile disease, the 
kidneys should be spared as much as possible by rest in 
bed, prevention of exposure or chilling, a diet low in pro- 
tein and the forcing of fluids to increase the elimination of 
nephritis 358 
PEDIATRIC NURSING 
toxins. The skin must be kept active by frequent sponging 
and warm baths. The bowels should be kept open by laxa- 
tives. The treatment of nephritis follows the same rules 
as the prophylactic measures. The child should have the 
benefit of hygienic surroundings. lie must be kept quietly 
in bed and all chilling or exposure must be avoided. He 
should wear a shirt at least part wool, stockings, nightgown, 
and a flannel wrapper, and he should have a woolen blanket 
directly over him. Warm fresh air is necessary. The diet 
must be regulated to meet his tolerance for protein, it being 
remembered, however, that he should, if possible, be allowed 
enough food for his needs of growth. If he has edema, 
his fluid intake is usually limited and salt is restricted. Both 
his daily fluid intake and output, including liquid stools as 
well as urine, must be carefully measured and recorded. A 
specimen of urine is saved for daily examination. Elimina- 
tion through the skin is increased by frequent sponging and 
warm baths. Hot air baths and hot packs may also be needed. 
(See method of giving, Chapter XVII.) The desire for salt 
and water and the long confinement to bed may make the 
child extremely unhappy and irritable. The nurse must use 
her influence to keep his mind from his own discomforts and 
she should keep his hands occupied wflth such amusements 
as his condition will permit. 
Pyelitis is a frequent complication of many diseases of 
childhood; occasionally it is primary. It occurs alone or with 
cystitis (pyelocystitis). It is more frequent in females than 
in males. Whenever any child has an unexplained elevation 
of temperature, a specimen of urine should be obtained to rule 
out the possibility of pyelitis. The child with pyelitis is 
usually quite irritable and demands patient, tactful manage- 
ment. Fluids must be forced to the limit (see methods of 
doing this and amounts to be forced at various ages, Chap- 
ter XVII). Drugs may be given, hygienic care, fresh air, 
sunlight, proper diet, and rest in bed are necessary. 
Tuberculosis of the kidney occurs rarely in childhood ex- 
Pyelitis 
Tuberculosis 
of Kidney SPECIAL PEDIATRIC NURSING 
359 
cept as a manifestation of general tuberculosis. The treat- 
ment and nursing care must be directed toward general 
hygienic measures. The child should be treated as any patient 
with tuberculosis. There may be a complication of pyelitis 
calling for the forcing of fluids. Some cases are benefited 
by surgery. 
Morbid growths of the kidney are more frequent in early 
life than later, especially in the first 5 years. The great 
majority are malignant in nature. The growth of the tumor, 
particularly if it is sarcoma, is rapid so that it soon fills a 
considerable portion of the abdominal cavity. The child 
suffers from a variety of symptoms which are due to pressure 
and metastasis. He develops marked emaciation and anemia. 
The only treatment is surgical. The prognosis is very un- 
favorable. The nursing care before or after operation is the 
same as that of any very sick child. It is largely symptomatic. 
The nurse should do everything in her power to keep the 
child comfortable. Narcotics or sedatives for the relief of 
pain seem justifiable. 
The child has often been known to introduce foreign bodies 
into the bladder through the urethra. The nurse must watch 
closely the child who frequently handles his genitals and 
if he does not stop after being reprimanded or if he is not 
old enough to understand, his hands will have to be re- 
strained to break him of the habit. 
Enuresis is incontinence of urine or bed wetting.16 If a 
child over 3 years is troubled with it, he should be examined 
by a doctor to see that there is no deformity or disease causing 
it. It may be a habit due to lack of training, and if so, 
strict discipline must be exerted at once. If the child’s con- 
fidence can be gained, he will often be very cooperative in 
his endeavors to overcome the habit, since he will be very 
much ashamed of it. Although there are a great many 
methods of treatment prescribed, the following indicates the 
usual line of approach: the child should be allowed no 
Morbid 
Growths 
of Kidney 
Enuresis 
16 Carter, William, M.D., “Enuresis.” Arch. Ped., May, 1920. 360 
PEDIATRIC NURSING 
liquids after 4 p.m. and his evening meal should consist of 
no highly seasoned foods. He should urinate before retiring 
at night; he should be taken to the toilet again at 10 p.m., 
and once or twice after that during the night if necessary, 
always at regular intervals. Thoroughly awaken him so that 
he will know what he is about and make him w7alk to the 
toilet himself, because if conditions are made too easy for 
him, he wTill never overcome this habit. Do not allow him 
to become overtired for fatigue may be a factor in enuresis. 
Elevating the foot of the bed at night may help. 
Male genital organs. Malformations have been discussed 
under diseases of the newborn. Whenever the nurse notices 
'phimosis, she must report it to the doctor and follow his 
wishes in regard to retracting the foreskin. There is much 
difference of opinion on the subject. If circumcision is per- 
formed, the child should be kept quietly in bed for a few days 
and the penis should be covered with a sterile vaselin dress- 
ing. This can be held in place with a T binder and should 
be changed after every urination. Efforts should be made 
to prevent the penis from becoming infected with feces. 
Hydrocele occurs in small children. The nursing care 
involves nothing special. If it is aspirated, care must be taken 
to prevent infection. 
Undescended testicle calls for the same sort of postopera- 
tive nursing as hernia. However, it is not usually operated 
on until the child is old enough to have control of the bladder, 
and so offers no difficulties. 
Female genital organs. Gonorrheal vaginitis is frequently 
found in little girls of all ages and epidemics have been 
common in hospitals and children’s institutions. It is ex- 
tremely infectious and the mucous membrane of the vagina 
seems peculiarly susceptible. Therefore, the utmost pre- 
cautions are necessary to isolate the infected cases. Infection 
is transmitted (1) by the use of a common toilet seat; (2) by 
improperly laundered napkins; and (3) by the use of common 
articles, improperly sterilized, between children; (4) by 
Male 
Genital 
Organs 
Phimosis 
Hydrocele 
Undescended 
Testicle 
Female 
Genital 
Organs 
Gonorrheal 
Vaginitis SPECIAL PEDIATRIC NURSING 
361 
nurses’ hands; and (5) by careless technique of various kinds. 
To prevent the spread of the infection it should be routine 
to take vaginal smears from every little girl who is admitted 
to an institution and she should be isolated until these smears 
are reported negative. Every sign of a vaginal discharge, 
or inflammation of the genitals, no matter how long the child 
has been in the hospital, should be reported at once. The care 
of gonorrheal vaginitis calls for strict isolation, a separate 
bed pan, separate toilet articles, and sterilization of all 
articles used by the child. She should be instructed not to 
put her hands near the genitals because there is danger that 
she may infect her eyes. If she is not old enough to under- 
stand the importance of this, her hands must be restrained 
by cuffs or by tying. The nurse must exert care not to 
infect herself, particularly her eyes, when caring for a case 
of gonorrheal vaginitis. Whatever the treatment employed 
the genitals must be kept clean by frequent sponging, and 
a soft pad of absorbent cotton and gauze should be worn 
over the genitals and should be destroyed when soiled. (Tech- 
nique of vaginal treatments discussed, Chapter XIX.) Some 
of the various treatments wThieh may be used include: 
(1) medicated vaginal suppositories; (2) antiseptic douches; 
(3) silver nitrate or some antiseptic injected into the vagina 
with a medicine dropper; (4) antiseptic in the form of an oint- 
ment injected into the vagina; (5) dry dusting powders over 
the genitals. In carrying out any line of treatment the im- 
portant part for the nurse to bear in mind is the necessity for 
extreme care and gentleness, in order not to injure the very 
delicate mucous membrane. 
To Prevent 
Isolation 
Restrain 
Child’s 
Hands 
Clean Genitals 
Various 
Treatments 
6. Diseases of the Nervous System. 
(The following section on Diseases of the Nervous System 
has been approved by Dr. J. C. McKinley, University of 
Minnesota.) 
Convulsions occur more frequently in infancy than in any 
other period of life, and the frequency of their occurrence 
Convulsions 362 
PEDIATRIC NURSING 
diminishes steadily during early childhood so that they are 
relatively uncommon after 7 years. A convulsion is a symp- 
tom of trouble, not a disease.17 The child who has a con- 
vulsion, even a slight one, must have medical attention. Con- 
vulsions in infancy and childhood may be caused by or as- 
sociated with such conditions as: 
Causes 
1. Acute infectious diseases. 
2. Toxemia from asphyxia, uremia, poisoning, etc. 
3. Disease or injury to the brain, meningitis, polio- 
myelitis, hydrocephalus, tumors, embolism, throm- 
bosis, intracranial hemorrhage of the newborn. 
Organic 
origin 
Functional 
origin 
[ 1. Idiopathic (so-called) epilepsy. 
2. Emotional disturbances, as fright, anger, violent cry- 
ing, etc. 
"1. Acute and chronic gastro-intestinal disorders. 
2. Hyperpyrexia—heat stroke. 
3. Terminal convulsions. 
A- Spasmophilia. 
Other 
pauses 
Symptoms 
Convulsions are usually sudden in onset and are initiated 
by facial pallor, fixation, and sometimes a rolling or crossing 
of the eyes and a general stiffness of the body. Twitching 
then begins in some part of the body, the face or an ex- 
tremity. The twitching increases in severity and extends 
so that all parts of the body are involved. Consciousness is 
lost. The head is held backward, the back is arched, the 
arms are flexed, the hands are made into fists with thumbs 
in palms. There are clonic to and fro movements of the ex- 
tremities, quick and jerking. Similar movements in the 
face cause a series of grimaces. The spasm includes the 
muscles of respiration so that breathing is suspended or 
irregular or ineffectual. Cyanosis appears, especially about 
the lips. There may be frothing at the mouth and rattling 
in the larynx. The pulse is weak and often irregular. After 
17 Morse, J. L., M.D., ‘ ‘The Convulsive Disorders of Childhood.” 
Journ. Amer. Med. Assn., Jan. 21, 1922. SPECIAL PEDIATRIC NURSING 
363 
several minutes the convulsive movements become weaker and 
less frequent and finally cease. The body relaxes, conscious- 
ness returns, and the child cries, or if the convulsion is severe 
he remains somewhat stuporous. The convulsion may not be 
repeated or it may occur frequently over a period of several 
days. All convulsions are not as severe as the above descrip- 
tion indicates. They may be lacking in several of the described 
features and may be of very short duration. 
The type of convulsions previously referred to might be 
spoken of as the cortical type. An infrequent variety is the 
spinal type, which is usually predominantly tonic in character 
and is not associated with loss of consciousness, as is the 
cortical type. The spinal type is seen in cases of strychnin 
poisoning and in the infection, tetanus. The treatment is 
the same for the spinal as for the cortical type.18 
The convulsions caused by “Jacksonian epilepsy” are quite 
definite; the first movements are likely to be seen in the region 
presided over by the portion of the brain affected, therefore 
it is important to notice where these movements begin. Other 
portions of the same side of the body may become involved 
in the attack. Consciousness is often retained and when lost 
is lost late in the attack. 
Since the nurse and not the doctor is usually present to see 
the first of the attack she should carefully observe all symp- 
toms to relate them to him, as they are all most significant in 
determining the cause of the convulsion. 
The first duty to the child having convulsions is to bring 
the convulsion under control and to see that he does not 
injure himself; if he has teeth a mouth gag should be put 
between his jaws. Relaxation may be produced by the applica- 
tion of counterirritants to the surface of the body, heat to 
the feet, and cold to the head. The child is sometimes put in 
a hot bath (100° F.), a mustard bath may be given (see direc- 
tions) or a mustard pack. Since he should be disturbed as 
little as possible, the mustard pack has an advantage over a 
Treatment 
18 Harriot, Wm. McKim, M.D., Unpublished Notes for Nurses. 364 
PEDIATRIC NURSING 
hot tub, as the former can be given with less disturbance. It 
is evident if the convulsion is due to the action of a high 
temperature, as in heat stroke, that a hot bath will do harm, 
and that a cold bath is indicated to reduce the temperature. 
A colon flush may be given. There is nothing more a nurse 
can do for immediate relief of a convulsion without a doctor’s 
orders. The latter should be called immediately, as a neu- 
rological examination made, if possible, during or following 
a convulsion may be a deciding factor in establishing the 
diagnosis. Chloroform may be given the child; oxygen is 
sometimes beneficial. Sedatives may be ordered, as morphin 
sulphate, bromids, chloral hydrate, etc. Magnesium sulphate 
subcutaneously is often given. If indicated the stomach may 
be lavaged or a cathartic may be given. Attempts must be 
made to determine the cause of the convulsion in order to re- 
move it, if possible, and measures must be taken to guard 
against the repetition. The nurse’s accurate observation of 
the early symptoms before the doctor arrives will be of in- 
estimable diagnostic value to him. 
Infantile tetany or spasmophilia is a disease characterized 
by extreme irritability of the nervous system to mechanical 
stimulation. It is usually associated with rickets and seems 
to be closely connected with changes of calcium metabolism. 
During the acute attack the patient should be kept quiet, 
away from noise and excitement. Warm baths may be given 
to relieve the convulsions. Further nursing care calls for the 
correction of the diet and hygienic care, including sunlight 
and fresh air. Calcium chlorid or calcium lactate are usually 
given. 
Epilepsy occurs in childhood as in adult life. During the 
seizure the nurse must see to it that the child does not injure 
himself; place him in a comfortable position, loosen the clothes 
about his neck and waist and put a mouth gag (a cork or a 
rubber) between his teeth to prevent him from biting himself. 
The child subject to epileptic attacks must have constant 
supervision because of the danger of an attack, and he must 
Spasmophilia 
Epilepsy SPECIAL PEDIATRIC NURSING 
365 
lead a quiet life free from mental or physical strain. Fur- 
ther regulation of his activities should be in the hands of a 
physician. 
Chorea is a nervous disease characterized by aimless, irregu- 
lar movements of any or all voluntary muscles. It is closely 
associated with rheumatism, tonsillitis, and heart disease. 
During the acute attack of chorea the child must be in bed 
and must be isolated from any possible excitement or noise; 
visitors must be excluded. If the movements are violent the 
sides of the crib must be padded or the child will injure him- 
self. Restraints should not be used. Sedatives may be or- 
dered to control the child. General hygiene and proper diet, 
etc., must be emphasized in the care of the child with a 
tendency to chorea. Fresh air should be obtained, but exer- 
cise must be prescribed with great caution, and its effects must 
be carefully watched. The child must be removed from any 
disturbing influences and should be placed under the care of 
some one who understands him and who can manage him 
wisely, without causing friction and so that scolding or pun- 
ishment will not be necessary. School work is allowed only 
with the doctor’s permission and under careful supervision. 
He must never be pushed in his studies; his outside activities 
as music, dancing, etc., must be eliminated, and his athletic 
activities must be restricted. Chorea has a strong tendency 
to recur. The present role of mouth infection as an etiological 
factor necessitates examination for the removal of possible 
foci. 
Speech defects in children are significant and should be 
recognized and attempts should be made to correct them at 
an early age.19 Dr. Blanton says that speech disorders are 
early and valuable symptoms of anomalies of intellectual and 
emotional growth as well as organic difficulties of the nervous 
Chorea 
Speech 
Defects 
19 Blanton, Smiley, M.D., “Medical Significance of the Disorders of 
Speech.” Journ. Amer. Med. Assn., July 30, 1921. 
Gifford, Mabel F., ‘ ‘ Speech Disorders and Defects. ’ ’ Arch. Fed., 
May, 1920. 366 
PEDIATRIC NURSING 
system. They are due to lack of ability on the part of the 
child to adapt himself emotionally to social situations, or to 
a faulty sensory or motor speech mechanism either hereditary 
or acquired. 
Injurious habits of childhood are many and various; they 
are closely connected with the disturbances of the nervous 
system. The tendency is too frequently to disregard them 
and pass them by with the remark that the “child will out- 
grow” them. This is wrong: the first time it is noticed that 
a child is developing a habit measures should be taken to 
arrest it. At that early stage it can be done with little diffi- 
culty. In the case of thumb sucking the child’s hands should 
be restrained so that he cannot put them in his mouth; alumi- 
num mittens may be put on; cuffs can be put around the 
elbow; or his hands can be tied to the sides of the crib. Often 
a child forms a habit of stroking or sucking some soft wooly 
object when going to sleep, and after a short time will refuse 
to go to sleep without it; such notions should not be tolerated. 
Nail biting is a habit which must not be allowed. As this 
occurs in older children restraints are not usually possible; 
punishments do no good; rewards sometimes help. Win the 
child’s confidence and try to explain to him in terms that he 
can understand why he should not continue the habit. Grit- 
ting of the teeth may sometimes be observed in a sleeping 
child, and often in a very sick child, as with peritonitis, etc. 
Masturbation is the habit of irritating the genitals; the 
child may do this with his hand, by rubbing the thighs to- 
gether, with some object, or with his clothing. This habit is 
seen in children of all ages and in both sexes; it has even 
been observed in infants under 1 year. It is commonly prac- 
ticed by the mentally defective of any age. The habit may 
be caused by any local irritation which makes the child rub 
the genitals; a pleasant sensation results and then a habit is 
begun. Lack of cleanliness of the genitals, highly acid urine, 
adhesions, vulvovaginitis, eczema of the labia, or tight cloth- 
ing are some of the predisposing causes. An older child may 
Injurious 
Habits of 
Childhood 
Masturbation SPECIAL PEDIATRIC NURSING 
367 
be taught the habit by some associate. The small child usually 
masturbates by rubbing the thighs together. The older 
child seems to know instinctively that he is doing a forbidden 
thing when he masturbates, therefore he will do it in secret 
and the utmost vigilance is necessary to discover him in the 
act. 
Treatment consists in finding the cause and removing it. A 
small child can be restrained; if he is using his hands they 
must be tied. If he is rubbing his thighs together his legs 
must be tied to the sides of the crib or a padded splint adjusted 
between the knees to keep the legs apart. An older child 
cannot be restrained easily. In the first place he will not 
masturbate when he is being watched, but will do it after he 
has gone to bed and early in the morning after he wakens. 
Constant watchfulness is necessary to break him of the habit. 
Punishment will do little good, in fact it usually makes him 
worse by teaching him to practice deceit. Many different 
methods will have to be resorted to to reach the individual 
child. General hygiene, as proper living conditions, diet, ex- 
ercise, sleep, and clothing should be looked into. If he is old 
enough to understand win his confidence and appeal to his 
sense of honor. Keep him well occupied during the day; 
watch him in his play, and especially watch him with other 
children to see that he does not teach them the habit. Keep 
him under close observation at night. Do not let him realize 
he is being watched. Do not instruct the older children or 
the parents that masturbation leads to insanity, etc., as this 
is frequently the basis of a neurosis far more troublesome 
to deal with than the habit (Dr. J. C. McKinley, 
Minneapolis). 
There are a great variety of other harmful neurotic habits 
which are met with in children. They should all be handled 
in the same general way. Find the cause if possible and re- 
move it; make attempts to early break the habit and look into 
the general hygienic care. 
There are other symptoms which may be manifested by the 368 
PEDIATRIC NURSING 
so-called “nervous child”; these include hysteria, insomnia, 
habit spasm, and many others. They usually indicate the 
maladjustment of the child to his surroundings and the pres- 
ence of some irritating influence. The cause must always be 
sought and removed if possible. If the parents aggravate the 
condition, the child may have to be separated from them 
for a short time and may have to be placed under the care of 
some one who understands child psychology well enough to 
manage him wisely and exercise firm but kind control over 
him. The nervous child should have the benefit of the best 
possible hygienic surroundings and modes of living; his diet, 
his sleep, his exercise, his play, etc., may all have a bearing 
on his condition. 
Disorders of the brain and meninges. The child with mal- 
formations of the brain and meninges, as anencephaly or 
porencephaly, etc., lives only a short time and no special 
nursing care is indicated. 
Cerebrospinal or epidemic meningitis occurs usually in 
epidemics. The infection is carried in the discharges of the 
nose and mouth. Isolation of the child is necessary. He 
should be in a quiet room away from all noise and should be 
disturbed as little as possible. The treatment of the disease 
consists in the administration of Flexner’s serum, usually 
intraspinally. A spinal puncture is done, the spinal fluid is 
drained off and an equal amount of serum is injected. Fur- 
ther treatment is symptomatic. The nursing care of the 
child calls for no special pediatric technique, not elsewhere 
described. It, too, depends largely on the presenting symp- 
toms. 
Tuberculous meningitis is the most frequent sporadic form 
of meningitis seen in small children. Recovery seldom takes 
place. Isolation is advisable, since the child usually has other 
tuberculous lesions. The disease may last over a period of 
weeks with frequent relapses. The patient is usually un- 
conscious for some time before death. Feedings may be 
gavaged to prolong life. The nursing care is the same as 
Disorders of 
Brain and 
Meninges 
Epidemic 
Meningitis 
Tuberculous 
Meningitis SPECIAL PEDIATRIC NURSING 
369 
for any very sick child. Repeated spinal punctures may be 
done to relieve pressure. 
Acute meningitis occurs from other causes, as, for example, 
pneumococcus meningitis. The nursing care of any type is 
the same. 
Meningismus or pseudo-meningitis is a term frequently 
heard by the nurse and it is used to describe symptoms re- 
sembling those of meningitis occurring in the course of many 
different affections of infants and children, especially acute 
infectious fevers, marantic states, pyelitis, etc. It is a toxic 
non-infeetive meningitis. 
A baby with hydrocephalus must be carefully handled; 
whenever he is carried his head must be carefully supported. 
He cannot turn himself, so the nurse must do this for him and 
it must be done frequently as the great weight of the head 
produces pressure spots very quickly. Every effort should 
be made to prevent them. A thick pad of the finest grade 
of absorbent cotton has been found helpful to use as a pillow. 
Pressure of the fluid is sometimes relieved by tapping the 
ventricles. (See directions for ventricular tap.) 
There are many types of idiocy of childhood. The nurse 
must be well acquainted with the mental as well as the physi- 
cal development of the normal child to be able to recognize 
the abnormal. If she suspects that a child is abnormal 
mentally, she must see to it that he has medical care. A 
mental test is an aid in determining the degree of abnormality. 
Some mentally deficient children can be handled very well at 
home, but the vast majority are better off in institutions, 
homes, or schools for feebleminded. There, if possible, they 
are taught clean habits, etc., and are given instruction as their 
mental condition will permit. In caring for a mental de- 
fective the nurse must at all times accommodate herself to 
the child, always bearing in mind his handicap and always 
making efforts to help him by teaching, proper training, etc. 
Disorders of the spinal cord: 
,Spina bifida is a malformation of the vertebral canal with 
Acute 
Meningitis 
Meningismus 
Hydrocephalus 
Idiocy 
Spina 
Bifida 370 
PEDIATRIC NURSING 
the protrusion of some part of its contents in the form of a 
fluid tumor. There are different types of spina bifida. In 
any type the tumor must be protected from pressure ; the child 
must lie on his face or on one side or the other, well propped 
so that he cannot turn and thereby injure the tumor. If 
there is no skin over it, a sterile gauze dressing must be kept 
over it, which is held in place with a loose binder. Opera- 
tion is often performed. In a large majority of these cases 
the tumor is in the lower spine and because of this the wound 
is very apt to become infected from urine or feces. To avoid 
this the baby may be put on a frame covered with canvas 
which has an open space where the baby’s buttocks come. 
Hold him on the frame by passing a binder loosely around his 
body and legs; turn him on his face and place him so that 
he will urinate and defecate through the opening of the canvas 
into a pan under the frame. The baby boy can easily have 
a tube strapped to the penis to collect the urine and convey 
it to a bottle hung at the side of the crib (Chapter XV) ; in 
this way he can be turned on his side occasionally. This pro- 
cedure can be carried out on girls but offers more difficulties. 
There is often paralysis of the lower extremities and of the 
sphincter muscles as a result of pressure from the spina 
bifida; therefore, the child is always wet with urine and soiled 
from feces. Additional precaution must be taken in dress- 
ing the wound. Cover the sterile gauze dressing with a piece 
of oiled muslin or silk a little larger than the gauze, and strap 
it on with adhesive. Strap the lower edge of the silk tightly 
to the baby’s buttocks and change this as often as neces- 
sary to keep the dressing well protected. A cOllodin dressing 
over the wound is an added precaution. The baby is turned 
on his back to be fed and he should be picked up carefully 
to rest him and change his position. Hydrocephalus is a fre- 
quent complication following an operation for spina bifida. 
Acute poliomyelitis (infantile paralysis) is essentially a 
disease of childhood, usually occurring epidemically. No spe- 
cific remedy is yet known and the treatment is symptomatic, 
Acute 
Poliomyelitis SPECIAL PEDIATRIC NURSING 
371 
so there is no definite course to be followed in the nursing 
care. Absolute rest is essential, even in the mildest cases, and 
should be continued for an average period of two weeks, or 
longer if symptoms persist. Pains in the affected limbs 
during the acute stage may be lessened by the application of 
splints to insure immobilization, and also at times by wrap- 
ping the limbs in cotton. There should be as little handling 
as possible. It is important to support the limbs so as to 
lessen the chances of deformity, such as foot drop. After all 
acute symptoms have subsided treatment will be begun for the 
development of paralyzed muscles. Massage and passive 
movements are usually ordered as soon as hyperesthesia has 
gone, and are continued over a period of years. Active volun- 
tary movements carried out under trained supervision are 
necessary. Mechanical applications are used to prevent de- 
formity, also to furnish support to the limb to enable the 
child to walk. (See Chapter XXIV.) 
There are many other diseases of the nervous system and 
various types of paralysis which occur in children. The care 
of such cases, as a whole, offers no unusual difficulties from a 
pediatric point of view. Since in all these cases there is more 
or less danger of the development of pressure spots, this seems 
a fitting place to discuss the prevention and care of decubitus. 
Wherever there is continual pressure the skin deserves special 
attention. The first essential is to keep the child dry; this 
means free from perspiration and urine. Often the case of 
paralysis is incontinent of urine or feces or both and a Brad- 
ford frame is a very valuable aid, for the child may be put 
on it so that defecations go through the opening in the canvas, 
and if the patient is a boy a tube may be put over the penis 
to convey the urine to a bottle beside the bed. He must be 
turned frequently and must have all points of pressure 
rubbed with alcohol. The scales of old skin around the af- 
fected areas should be cleaned off with benzin and the skin 
should be rubbed with alcohol several times a day to stimulate 
circulation. All pressure should be removed if possible by 
Paralysis 
Pressure 
Spots 
Prevention 
Treatment 372 
PEDIATRIC NURSING 
the use of rubber rings and other measures as the condition 
indicates. A pneumatic or water bed, if obtainable, is of help. 
The sheets under the patient must be kept free from all 
wrinkles, crumbs, etc. If the skin is broken various medica- 
tions are applied in the effort to heal it. A sterile dressing 
may be kept over the area, but adhesive must not be used to 
hold it in place, for the use of it may make more abrasions 
on the tender skin. 
7. Diseases of the Circulatory System. 
Congenital 
Heart 
Disease 
Congenital heart disease is a frequent cause of death in 
the first few hours of life. The symptoms are usually mani- 
fested soon after birth. Cyanosis is one of the most striking 
and characteristic of them. Atelectasis of the newborn will 
also cause cyanosis, but the baby with a congenital heart dis- 
ease will become more cyanotic after crying, while atelectatic 
cyanosis disappears after crying. The prognosis depends on 
the type of the anomaly, but over 50 per cent of the cases die 
before 5 years and a majority between the first and second 
month. Some, however, reach puberty or even adult life. 
The patient is usually subject to attacks of cyanosis, dysp- 
nea, etc., due to the congenital anomaly. Treatment is not 
specific but is symptomatic. The individual has a lowered 
resistance and is very susceptible to all infections, especially 
pulmonary, and almost any acute illness may prove fatal. He 
will have to lead a quiet life with exercise, play, and all 
activities limited to his endurance. Because he is more or 
less of an invalid he is apt to become somewhat neurotic unless 
he is very wisely handled. Do not discuss his disease in front 
of him by saying he cannot do this or that because he has 
“heart trouble.” 
Other usual types of heart disease are caused by infections, 
as infected tonsils, carious teeth, or following acute infectious 
diseases, as diphtheria or scarlet fever, etc. It is the nurse’s 
duty, if she knows the child has enlarged tonsils or decayed 
teeth, to see that he has medical attention. In caring for a 
Other 
Types of 
Heart 
Disease SPECIAL PEDIATRIC NURSING 
373 
child with any acute infectious disease, the importance of 
rest and a quiet room with limited activity even after he feels 
perfectly well cannot be overemphasized because of the large 
number of cases that develop heart complications. Much 
serious heart disease can be thus prevented. Tonsillitis and 
chorea are frequent concomitant diseases. Rheumatism, al- 
though seen, is a less frequent complication than in the adult. 
In the nursing care of a child with heart disease the most 
important point in every case is as complete rest as possible 
during the acute stage and for several weeks or months after- 
wards. The muscle walls of the child’s heart are less resistant 
than those of the adult and dilatation occurs much more 
rapidly. The consequences are grave indeed. Hygienic sur- 
roundings, including fresh air, outdoors when possible, a light 
nutritious diet that fulfills the child’s needs are necessary. 
If there is respiratory difficulty 5 small meals instead of 3 
may be advisable to give him adequate calories for growth. 
The skin deserves special attention because of the danger of 
decubitus. An ice-bag to the precordia often gives relief. 
It may be necessary to prop him up in bed because of dysp- 
nea, but unless he has respiratory difficulty he can be better 
controlled if he is lying flat. The nurse is obliged to use 
every means within her power and much patience, ingenuity, 
and tact in keeping the child properly restrained and quiet. 
He must be in a quiet, isolated room away from all disturb- 
ing influences and excitement. After the acute attack is over 
he may be given simple games, toys, etc., that do not require 
too much exertion. Exercise can be started with the doctor’s 
orders and as the child’s condition permits. All exercise 
must be given regularly and systematically and carefully regu- 
lated to the child’s endurance. The child convalescing from 
heart disease can be better controlled in regard to activity if 
with other children with the same condition, not with normal 
children or with those who are allowed to be more active.20 
20 Morse, J. L., M.D., "Children’s Heart Hospital at Brookline, Mass.’’ 
Mod. Hospital, June, 1919. 374 
PEDIATRIC NURSING 
After he has recovered, all his activities, including his school 
work, his outdoor sports, etc., must be restricted and all com- 
petitive athletic games will have to be eliminated. Here again 
the child with heart disease must not be allowed to become 
neurotic by being constantly reminded of his condition. It 
is always necessary to use caution in discussing a child’s con- 
dition before him. Even a very young child who does not 
seem to understand, or a sick child who seems too ill to under- 
stand, will hear and remember much more than it seems 
possible. 
8. Diseases of the Blood. 
Anemia 
There are various types of anemia which occur in childhood. 
The first step in the treatment is to find the cause and remove 
it if possible. The nursing care should lay particular stress 
on hygiene. The patient should be kept quiet, usually in bed. 
Fresh air and sunshine are necessary and he should live out- 
of-doors as much as possible. The diet should be simple, 
nutritious food, rich in iron. The skin must be kept in good 
condition and the bowels must be regular. The child with 
anemia is unusually susceptible to infections and must be 
guarded from damp and cold or undue exposure. Blood trans- 
fusions are frequently indicated. Iron in some form is given 
in most cases. 
The nursing care of the child with leukemia is, in a gen- 
eral way, the same as that outlined above. The patient is 
usually very ill and every effort is made to keep 
him comfortable. The treatment is directed toward the 
relief of symptoms as they occur. The prognosis is very 
grave. 
Hemophilia is an inherited, constitutional tendency to re- 
peated, severe, and even uncontrollable hemorrhage produced 
by the slightest trauma or occurring spontaneously. The pa- 
tient is known to the laity as a “bleeder.” True hemo- 
philia is a disease of the males transmitted through the fe- 
males. If there is a family tendency to bleeding, this con- 
Leukemia 
Hemophilia SPECIAL PEDIATRIC NURSING 
375 
dition should be watched for in the child and if the slightest 
hemorrhage occurs, the physician must be notified. The 
same surgical means, especially compression, are employed 
to arrest the hemorrhage in a child as in an adult. Blood 
transfusion is usually indicated and repeated transfusions are 
often given. After the hemorrhage he must be kept quietly 
in bed until he has fully recovered from loss of blood; and 
general hygienic measures are observed. The child with 
hemophilic tendencies must be protected from trauma, for 
even the slightest bump or bruise may have disastrous results. 
It is very difficult to thus guard and protect a child and still 
allow him to develop normally either mentally or physically. 
Care must be taken that he does not become neurotic. 
9. Diseases of the Lymph-Nodes. 
Enlargement of the lymphatic glands is common in infancy 
and childhood. This may be secondary to some infection else- 
where, occurring in the glands into which the lymphatics from 
the diseased regions drain. Often enlarged glands occur in 
a child who is in a general poor state of health. Tuberculosis, 
Hodgkin’s disease, and the leukemias are considered in the 
differential diagnosis, but the commonest cause is simple ade- 
nitis. The treatment depends on the cause; surgical drainage 
is often necessary in adenitis. It may be unavoidable in tu- 
berculosis. The nursing care calls for general hygienic meas 
ures. 
Adenitis 
10. Diseases of the Ductless Glands. 
Cretinism or hypothyroidism is brought about by the ab- 
sence of the internal secretion of the thyroid gland. The con- 
dition is generally first noticed during the second half of the 
first year, sometimes later, and rarely earlier. Failure to 
grow and to develop mentally are the first symptoms. The 
only treatment is the administration of thyroid extract and 
if begun early enough this gives spectacular results. Here 
again the nurse may help to determine the prognosis if she is 
Cretinism 376 
PEDIATRIC NURSING 
able to recognize the early symptoms so that treatments may 
be started early. 
Hyperthyroidism (Graves’ disease, exophthalmic goitre), 
occurs in childhood, usually in girls between 8 and 5 years. 
The treatment demands complete mental and physical rest, 
removing the child from all excitement or contact with other 
children. Measures are taken to allay the nervousness and to 
induce relaxation and sleep. Surgery may be advisable in 
persistent cases. 
Other diseases of the ductless glands are present in chil- 
dren, but the nursing care deserves no special attention. 
Hyper- 
thyroidism 
11. Diseases of the Skin. 
Miliaria 
Miliaria (heat rash, or prickly heat) is a term applied to 
the rash caused by obstruction of the sweat-glands, occurring 
with or without inflammation. This condition can usually be 
prevented by the use of lighter clothing, preferably clothing 
of all cotton, by frequent bathing, and by the use of plain 
castile soap and good toilet powder, as boric and starch. The 
skin must also be kept dry and the temperature of the nursery 
must not be over 68° F. 
Seborrhea is a functional disease of the sebaceous glands. 
The term is commonly applied to the dirty yellow crusts seen 
in the scalps of infants and known by the laity as “cradle 
cap.” Cleanliness of the scalp is necessary to prevent the 
disease, and to cure it. The crusts are softened with oil at 
night and washed off with soap and warm water in the morn- 
ing. This is repeated until the scalp is clean, then apply an 
ointment as prescribed. A daily shampoo must be given. 
Intertrigo is the term applied to any eruption which de- 
velops where two moist surfaces are in contact, as in the folds 
of the groin, axillge, behind the ears, etc. The areas should 
be kept clean, dry, and a powder or ointment should be 
applied as ordered. 
Eczema is a most frequent skin disease in early life. To 
treat it the areas must be freed from crusts; warm oil should 
Seborrhea 
Intertrigo 
Eczema SPECIAL PEDIATRIC NURSING 
377 
be used to do this, and preferably it should be used to clean 
the child’s entire body. The treatment ordered is then ap- 
plied to the area. A generous amount of the ointment (or 
whatever medication is ordered) must be put on, and covered 
with a dressing. If the lesions are on the body the dressings 
can be held in place by binders or bandages. If the scalp is 
affected the hair should be shaved and the dressings should be 
Figure 46. Face Mask Used in Treating Eczema 
kept on by a thin, tightly fitting cap or bonnet which ties un- 
der the chin. If the face is involved the ointment is spread on 
a cotton mask, with slits cut for eyes, nose, and mouth, and 
this is tied in place. (See Figure 46.) Dressings must be 
changed as frequently as necessary to keep the affected areas 
constantly in contact with the ointment or medication. In- 
tense itching accompanies eczema and the child makes his con- 
dition much worse if he is allowed to scratch. This must be 
prevented by restraining his hands. Cuffs may be put around 
the elbows and his hands usually will have to be tied to the 378 
PEDIATRIC NURSING 
crib sides. Constant supervision is necessary to see that he 
does not learn new methods of scratching himself. He should 
be picked up several times a day to change his position, since 
the constant restraints and intense itching make him very 
miserable. A sedative, as chloral hydrate, may be justified to 
give relief. This is a persistent disease to treat and the re- 
straints are necessary long after the skin lesions seem to be 
healed because the irritation may persist and scratching will 
cause a recurrence. Recent work on eczema shows a possible 
relationship to food sensitization in the infant affected.21 
Impetigo contagiosa occurs frequently in children and may 
be a very serious condition. It is extremely infectious and 
strict isolation must be maintained to prevent the spread 
of the disease. The treatment and nursing care are the same 
as for skin conditions in general. Pemphigus neonatorum is 
another extremely serious skin affection of the newborn which 
resembles impetigo contagiosa in its manifestations. Strict 
isolation must be observed. 
Many other skin conditions occur in children. The treat- 
ment is the same as for adults with the same diseases. Isola- 
tion is observed as necessary. Most treatments, as ointments, 
etc., stain linen, so that special linen, usually the oldest, should 
be kept separate for the use of children with skin conditions. 
In most skin affections the child’s hands must be restrained to 
prevent scratching. 
Furunculosis is often seen in children, especially in the 
athreptic infant, or one who has been in the hospital for a long 
time and who has become “hospitalized.” There are many 
methods of treatment. Surgery may be necessary. If open- 
air treatment is desired all the child’s clothing is removed, 
only a diaper is placed under his buttocks, not pinned, and a 
tent lined with electric light bulbs is placed over his body 
with only his head exposed. The bulbs are turned on as 
necessary to keep him warm. He is turned frequently, avoid- 
ing pressure on the parts affected. His bed must be kept dry. 
Impetigo 
Contagiosa 
Pemphigus 
Neonatorum 
Other Skin 
Conditions 
Furunculosis 
21 Shannon, W. R., M.D., Am. J. Dis. Child., Sept., 1921. SPECIAL PEDIATRIC NURSING 
379 
If there is no such apparatus available, as the one mentioned 
above, the child may be put in a deep basket, as a premature 
basket, all his clothes are removed, a diaper is placed under 
his buttocks; a cradle is placed over his body and this is cov- 
ered with blankets so that only his head is exposed; hot water 
bottles are put under the cradle to keep him warm. His posi- 
tion must be changed frequently and he should be picked up 
several times a day to rest him. His hands must be restrained 
by tying them to the cradle. Whatever the treatment em- 
ployed for furunculosis, the child’s hands must be restrained. 
Autogenous vaccine therapy is occasionally combined with 
other therapeutic measures. 
Burns or scalds are frequent injuries in childhood.22 They 
are due (1) to the child’s ignorance and helplessness; (2) the 
carelessness of attendants; (3) and to the fact that the child’s 
skin is much more delicate than the adult’s, and is injured 
by a lesser degree of heat and in a shorter time. The prognosis 
is governed by many factors, but is always more grave in the 
child than in the adult. If over one-third of the body surface 
is burned death will probably ensue. There are different 
methods employed in the care of burns, but whatever method 
is used the.wound is thoroughly cleaned first. This may be 
so painful that an anesthetic will be necessary. 
1. Dressings may be applied to the burned areas with the 
medication, as an ointment or picric acid solution, etc. These 
dressings are held in place by light binders or bandages. 
They must be changed frequently enough to keep the burned 
areas constantly in contact with the medication. 
2. The child’s whole body may be immersed in a tub of 
water which must be kept at a constant temperature of 100° 
F. His body rests in a canvas hammock suspended from the 
sides of the tub and he is placed so that no pressure is made 
over the burned areas. A special nurse is necessary to watch 
him constantly. 
3. Paraffin dressings may be used. The paraffin is melted 
Burns 
or Scalds 
22 Kelly, Samuel, M.D., ‘ ‘ Surgical Diseases of Children. ’ 380 
PEDIATRIC NURSING 
in a container. The area to which it is to be applied is thor- 
oughly dried and the paraffin is put on with a brush or a spray. 
This treatment excludes the air, thus giving relief from pain, 
and does a great deal toward preventing accidental infection. 
The paraffin container must be tightly closed when not in use 
and is heated preferably over a direct flame, for if any water 
is allowed in the paraffin mixture, its application will be at- 
tended with more pain. A thermometer is essential since the 
paraffin mixture should be used at a certain degree of heat, 
usually specified by the physician making the application. 
4. The child’s body may be exposed—open-air treatment. 
Here the treatment is the same as for the open-air treatment 
of the child with furunculosis. A tent with electric bulbs in- 
side is placed over his body, or a plain cradle covered with 
blankets, and hot water bottles are used. 
Surgical asepsis must be observed in caring for burns to 
prevent infection. Oftentimes extreme pain is caused by 
the changing of the dressing, cleaning the wound, etc. An 
anesthetic may be indicated. All handling or manipulation 
must be done as gently as possible to avoid unnecessary pain. 
Formation of cicatrices must be guarded against. Shock must 
be watched for in the early care of the child with burns. 
Fluids must be forced to the limit to prevent absorption of 
toxins. General hygienic care is necessary. 
12. Diseases of the Eye. 
(Methods of irrigating eyes, instilling drops, holding of the 
child for such treatments, etc., have already been discussed, 
Chapter XIX.) 
Gonorrheal ophthalmia has already been discussed under 
“Diseases of the Newborn,” although it may occur at any age. 
Children are subject to many other eye diseases. Whenever 
the nature of the disease demands it, the child should be 
isolated. The child of almost any age may rub his eyes, so it 
is a pretty safe rule to restrain the hands of any child suffer- 
ing from a disease of the eyes. There are exceptions in in- 
Gonorrheal 
Ophthalmia SPECIAL PEDIATRIC NURSING 
381 
dividual cases. It is often necessary for children to wear 
glasses and it is surprising to observe how quickly a small 
child will adjust himself to them. 
13. Diseases of the Ear. 
Inflammation of the ear in some of its forms is of extreme 
frequency in early life and is associated with many condi- 
tions. It may be secondary to almost any illness of infancy 
or childhood. Routine examination of the ears should be 
done: (1) On every sick child coming under medical observa- 
tion for any reason; (2) whenever a child has an unexplained 
elevation of temperature. 
There are many different ways of treating otitis media, 
sometimes irrigations are ordered (see method of irrigating 
ears, Chapter XIX). Drops may be instilled into the canal 
(see method, Chapter XIX). From a nurse’s point of view 
the most important point is to keep the external auditory 
canal free from discharge and dry. This means that in the 
case of severe otitis media the ear may have to be dry wiped 
with a toothpick applicator (see method) every 15 or 30 min- 
utes. A special nurse is necessary to give the child proper 
care. Isolation of the patient is necessary since the disease 
spreads rapidly among children in the hospital. Hygienic 
care, sunlight, etc., are beneficial. 
Mastoiditis is the most frequent complication of otitis media. 
Proper early treatment will often prevent this. The treat- 
ment of mastoiditis is surgical. The nursing care involves 
no special pediatric technique not already described. There 
is always more or less difficulty in keeping a dressing or 
bandage on a child’s head, if he is at all active. A muslin 
cap which fits snugly and ties under the chin may be put on 
over the dressing and bandage and will help to hold them in 
place. The child’s hands will have to be restrained if he 
continues to pick at the dressing. 
A foreign body in the auditory canal is a frequent occur- 
rence. A variety of objects are discovered there. They some- 
Routine 
Examination 
of Ears 
Otitis 
Media 
Mastoiditis 
Foreign Body 382 
PEDIATRIC NURSING 
times enter by accident, but more often they are pushed in 
by the child. The nurse should ascertain the nature of the 
object if possible. Unless it is a pea, a bean, or some seed 
which will swell when it comes in contact with water, she may 
safely try to remove it by irrigating. (See method of irrigat- 
ing ear, Chapter XIX.) If not successful after two or three 
attempts, she should summon medical aid. 
GENERAL REFERENCES 
Griffith, J. P. Crozer, M.D.—Diseases of Infants and Children. 
Holt, L. Emmett, M.D.—Diseases of Infancy and Childhood. CHAPTER XXI 
INFECTIOUS DISEASES 
Infectious diseases are those which are caused by micro- 
organisms (bacteria, protozoa), which are specific for every 
disease. When an individual is infected by such specific or- 
ganisms he reacts in a rather uniform manner for every type 
of organism. The diphtheria bacillus produces only diph- 
theria, and the virus of measles produces only measles. All 
infectious diseases are capable of being transmitted from one 
individual to another. In the case of a few (malaria, typhus, 
yellow fever, etc.) transmission by contact does not occur. 
In these the specific virus is not on any exposed part of the 
body, and, though it is brought to the surface by means of a 
wound, is not a menace until conveyed into a wound of a 
susceptible person. Conveyance in these diseases is by means 
of biting insects. Other diseases (measles, small-pox, vari- 
cella) are highly infectious and may be transmitted often by 
the slightest contact, or by early indirect contact (by means 
of a third person). In all of the highly infectious diseases 
the virus has an easy and constant exit from the body of the 
infected person. In most of these this exit, as well as the 
portal of entry, is the respiratory tract. Natural transmission 
takes place most commonly by the inhalation of droplets of 
secretion which are coughed, are sneezed or otherwise are ex- 
pelled from the respiratory tract of a diseased person. This 
mode of transmission is spoken of as droplet infection. 
Direct contact of the afflicted with the susceptible individ- 
ual is the most common means of transmission. A source 
of contagion difficult of control because it is so often un- 
recognized is the human “carrier,” who is a person, having 
Definition 
Means of 
Transmission 
383 384 
PEDIATRIC NURSING 
been exposed to the virus of disease, who continues to harbor 
this virus in an infectious form without showing clinical evi- 
dence of the disease. In most, if not all instances, the carrier 
either is immune to the virus which he harbors, thus account- 
ing for the absence of clinical evidence, or he suffers from the 
clinical disease in such a mild manner that its nature is un- 
recognized. The carrier state has been recognized in cases 
of diphtheria, typhoid fever, and others. In hospitals where 
many children are housed together other means of transmis- 
sion than by direct contact with the disease or carrier, assume 
a more important role than they do in ordinary home life. 
That certain diseases may be air borne was formerly believed, 
but this is true only in a limited sense. Some of the diseases 
in which virus is harbored in the upper respiratory tract are 
accompanied by coughing and sneezing (measles, pertussis) so 
that droplets of secretion are expelled a number of feet. A 
favorable air current carries them further. Such droplets 
are not carried around corners, or out of one room into an- 
other, except under most unusual circumstances. The stir- 
ring up of the contaminated dust and fine dirt by improper 
sweeping or otherwise is another means of air transmission 
more important in certain diseases than droplets, because of 
the greater distance to which dust may be carried. Any dis- 
ease transmissible by contact can, under favorable circum- 
stances, be carried to a susceptible individual by a third person 
or by contaminated articles (dishes, clothing, toys, etc.). The 
shorter the time occupied by the journey the more likely is 
the successful transmission. The virus of certain diseases 
(measles) is very short-lived and but brief exposure to day- 
light and drying causes its death. The virus of other dis- 
eases (scarlet fever, diphtheria) is tenacious and long-lived, 
and therefore more likely to be transmitted by indirect con- 
tact after a long interval.1 
With proper precautions patients with different contagious 
diseases may be cared for in neighboring rooms by the same 
To Care 
for Patients 
with 
Contagious 
Diseases 
1 Marriot, Wm. McKim, M.D., Unpublished Notes for Nurses. INFECTIOUS DISEASES 
385 
nurses, attendants, etc., without cross-infection. In such 
cases the application of common sense based upon knowledge 
should suffice. But a rigid set of rules is the only method 
that is “fool-proof.” The proper technique is, in certain 
ways, the reverse of that used in the surgical procedures. In 
the case of a contagious disease the patient and everything 
with which he comes in contact is contaminated or “dirty,” 
and must be sterilized before being used for another patient. 
He must be cared for in such a way that the attendant upon 
leaving the room is “clean” and ready to care for another. 
Every children’s hospital or department should have sepa- 
rate rooms where it is possible to carry out isolation on those 
who may develop contagious diseases or who show symptoms 
suspicious of a contagious disease. Much trouble and many 
epidemics with resulting quarantine can be avoided if the chil- 
dren’s hospital has an observation ward. When a child is 
admitted he is kept there over a period of two weeks at least, 
preferably three weeks, until the presence or absence of in- 
fectious disease is proved. The ideal observation ward should 
have separate rooms or cubicles for every child. Since all are 
considered infectious to others until it has been proven that 
they are not, complete isolation is carried out. However, few 
hospitals are thus ideally equipped.2 If there is no observa- 
tion ward, every child newly admitted to the general ward 
must be isolated there as much as conditions will permit. 
The arrangement and facilities of every hospital must de- 
termine the details to be followed in isolation technique, but 
there are a few essential principles which must be observed, 
whatever conditions may be. 
A gown must be worn by the nurse for any work which 
involves intimate contact with the patient. To put on the 
gowm, the nurse removes her cuffs, rolls up her sleeves, and 
slips it from the hook in such a way as not to contaminate 
herself; she holds the gown by the neck band and slips one 
Isolation 
Booms 
Observation 
Ward 
Essentials 
of 
Isolation 
Technique 
Gown 
a Doane, J. C., M.D., ‘ ‘ Prevention of Cross Infection in the Children’s 
Ward of a General Hospital,” Mod. Hospital, May, 1920. 386 
PEDIATRIC NURSING 
arm, then the other into the sleeves and ties the tapes in back. 
To take off the gown the nurse washes her hands under run- 
ning water (basin in the room), slips the gown off, creasing 
it down the center, with the clean side inside, and hangs it on 
the hook in such a way that the inside is kept clean, and that 
it can be slipped off the hook again without contamination; 
she then scrubs her hands again. If no gown is worn the 
nurse must be careful that none of her clothing touches the 
bed or anything in the room, and that she contaminates only 
her hands or forearms, which can be scrubbed. Gowns are 
changed whenever necessary. If caring for more than one 
patient with the same infection, the gown need not be changed 
between patients. Avoid wearing the gown outside the room. 
In caring for the patient the nurse should collect everything 
needed, then put on the gown and care for him. 
To care for the bed linen, place a clean sheet or clothes bag 
on a clean newspaper spread on the floor. If a bag is used, 
before the nurse contaminates her hands, she should turn back 
a cuff 3 or 4 inches deep. As each piece of linen is taken from 
the bed it is placed in the bag or on the sheet. When the linen 
is all collected the nurse washes her hands, closes the bag, and 
puts a tag on it marked “to boil.” 
The room should be dusted daily with a damp cloth, ac- 
cording to directions. Place the dust cloth in the bag with the 
linen to be boiled. Door knobs must be scrubbed with soap 
and water daily. To sweep the floor sprinkle it with sweeping 
compound; collect the dust on a paper and place it in the 
waste pail; a separate broom is used in infected and unin- 
fected areas. The broom is scalded under the hopper faucet 
after use. A separate mop is used for infected and uninfected 
areas and it, too, is scalded after use. 
Excreta may be boiled in a specially designed hopper, or 
it may be disinfected with some such solution as chlorid of 
lime, 5 per cent. Use twice as much of the solution as there is 
excreta; break up the feces with a spatula; expose one hour 
or longer if ordered. Empty pans or urinals are rinsed and 
Bed Linen 
The Room 
Excreta INFECTIOUS DISEASES 
387 
are washed under running water, then are sterilized by boiling 
for 15 minutes. 
A paper bag should be attached to the bed or table. Gauze 
squares (cotton cloth or paper) are used for wiping away 
secretions and are dropped in the bag after use. A rubber 
pillow slip is put on under the cotton slip if secretions are 
profuse. All pads, as those worn by cases of vaginitis, are 
destroyed at once. 
To serve meals the nurse puts a bib on the child and takes 
his tray to the bedside. He feeds himself if possible; if not 
she puts on a gown and feeds him. Refuse food is scraped 
from the dishes into a paper bag which is put into the waste 
pail. Dishes are boiled for 15 minutes. The same technique 
is carried out when giving the child water, nourishment, medi- 
cine, etc. 
Every child has his own thermometer which is kept on his 
bedside table or in the room. The nurse wears a gown when 
taking the temperature, pulse, and respirations; she removes 
it and washes her hands before recording them. 
Playthings must always be tied to the bed. 
Charts or records must be kept outside the room, and must 
never be put down inside the infected area; they must be 
handled only by “clean” persons. 
All utensils used in the care of the child for carrying out 
treatments, bathing, etc., must be boiled after use. 
The doctor, when examining the child, etc., must observe 
the same technique as the nurse. Articles used by him in 
examinations, as the stethoscope, must be washed with soap 
and water after use. 
Visitors should be allowed only if the child is critically ill; 
only parents should ever be permitted. The visitor must 
wear a gown when he enters the patient’s room and the nurse 
must stay with him during the entire visit, except under spe- 
cial conditions when the visitor is known to be intelligent and 
can be trusted to follow instructions. The visitor may observe 
the child from the corridor without wearing a gown. 
Secretions 
To Serve 
Meals 
Thermometers 
Playthings 
Charts 
The Doctor 
Visitors 388 
PEDIATRIC NURSING 
When the patient is out of isolation his clothes are removed. 
He is wrapped in a clean sheet, is taken to the bathroom and 
is given a soap and water bath and shampoo, is dressed in 
clean clothes and is taken to a clean bed and room. The bed, 
table, chair (all furniture), window ledge, door knob, curtain 
cords, and every article or part of the room touched by the 
patient are scrubbed with soap and water and the room is 
aired for a least one day. All linen is cared for as directed 
above. Mattress and pillows may be sent to the sterilizing 
room, and should be sent after cases of small-pox and typhus; 
in other cases they can be aired (in sun if possible) for one 
day. Rubber goods, as ice-caps, hot water bottles, sheets, etc., 
are scrubbed with soap and water and aired (in open air) for 
one day. If possible books, letters, etc., are destroyed; if not 
they may be pinned in a towel and sent to the sterilizing 
room. Toys are preferably destroyed; if possible they are 
scrubbed with soap and water, or aired for a day. 
To scrub the hands in caring for isolated cases the nurse 
turns on the warm water (with knee or foot adjustment on 
basin), scrubs her hands with liquid soap (in a container 
worked by the foot) and a stiff brush under the warm run- 
ning water for two minutes. She rinses them well under run- 
ning water and wipes them dry, discarding the towel after 
use. 
(The above rules for isolation have been taken from those in 
use for many years at the University Hospital, University of 
Minnesota, which in turn were adopted from the “Manual of 
Aseptic Technique,” published by the Providence City Hos- 
pital, Providence, Rhode Island.) 
The city and state quarantine rules vary and the nurse 
should acquaint herself with the rules of the locality in which 
she is working. 
To Remove 
Patient 
from 
Isolation 
Care of 
Nurse’s 
Hands CHAPTER XXII 
NURSING CARE OF CHILDREN WITH ACUTE INFECTIOUS DISEASES 
1. Scarlet fever is an acute, contagious disease usually 
ushered in by vomiting, fever and sore throat and character- 
ized by an erythematous rash, appearing first upon the neck 
and spreading rapidly over the entire body; it is followed by 
desquamation. The incubation period is 1 to 7 days. 
The chief complications are otitis media and adenitis; the 
more important sequalae are otitis, causing little or no pain, 
and nephritis. The constancy of the throat infection in scarlet 
fever strongly points to the pharynx as the point of entry of 
the infection. The disease seems to be most infectious dur- 
ing the height of the febrile period, i.e., during the first 3 
to 5 days; the infectiousness gradually lessens after that 
time. It is generally believed to be spread by the secretions 
of the nose and throat rather than by the desquamating scales. 
If complicated by otitis media, mastoiditis, etc., the patient 
is infectious as long as discharges from these lesions continue. 
The usual quarantine in uncomplicated cases is about five 
weeks. The mortality is roughly estimated at 10 or 15 per 
cent, although it is much less in uncomplicated cases. In 
general the younger the child the greater the danger of death. 
There is no specific treatment for scarlet fever; the most im- 
portant points in the treatment are (1) establishing proper 
quarantine and carrying out adequate means of disinfection; 
(2) the hygienic care of the child; (3) directing of the diet; 
(4) watching for complications, especially otitis and nephritis. 
The child must be kept in bed until his temperature has been 
normal for at least a week. He should have a warm, well 
ventilated, sunny room. Nervous symptoms and high tem- 
perature can be controlled by hydrotherapy. The sore throat 
Definition 
Characteristic 
Symptoms 
Incubation 
Period 
Complications 
Epidemiology 
Mortality 
Treatment 
Nursing 
Care 
389 390 
PEDIATRIC NURSING 
may be treated by hot saline irrigations (temp. 105°), gargles, 
sprays, etc.; cervical adenitis may often be abated by applica- 
tion of ice or cold. Itching may occur during the eruptive 
stage and can often be relieved by application of sodium bi- 
carbonate, 15 per cent solution, or treatment may be pre- 
scribed. The diet is preferably liquid during the febrile 
stage, then low protein until at least 3 w7eeks after the onset, 
because of the tendency to nephritis. Plenty of fluids should 
be given and the urine output, as well as fluid intake, should 
be measured and recorded. The mouth requires special care. 
Desquamation may be aided by daily rubs with oil, vaselin or 
petrolatum. Even the mildest complaint of discomfort or pain 
in the ears must be reported by the nurse, since a severe otitis 
may develop and cause little pain. 
2. Measles is a highly contagious disease, more widely prev- 
alent than any other eruptive fever; the incubation period 
is 11 to 14 days; there is a gradual invasion of 3 or 4 days 
with symptoms of acute coryza; a maculopapular eruption 
appears first upon the face and spreads slowly over the 
entire body, lasting from 4 to 6 days and followed by a bran- 
like desquamation which is complete in about a week. The 
most characteristic feature about the exanthem is the appear- 
ance of small, pin point size, bluish white spots surrounded 
by a red areola on the mucous membrane of the mouth; 
these are known as Koplik’s spots and are very important 
aids in the early diagnosis of measles before the rash appears 
on the skin. The mortality is low except among infants 
and young children. Bronchopneumonia is the most serious 
complication. The infectiousness of measles is greatest 
during the time of the acute catarrhal symptoms. It is 
infectious from the very onset of these symptoms and before 
the appearance of the rash. In most instances the catarrhal 
symptoms have entirely ceased within 10 days from the onset, 
and the infectiousness diminishes gradually with their sub- 
sidence. The period of quarantine is arbitrarily set at 2 
to 2Y2 weeks for the very mild cases, and 3 weeks or more 
Definition 
Incubation 
Period 
Characteristic 
Symptoms 
Mortality 
Epidemiology ACUTE INFECTIOUS DISEASES 
391 
for cases of moderate severity. The presence of discharging 
ears, or other similar complications, prolongs the period of 
quarantine. The desquamating scales of skin are probably 
not of themselves infectious. There is no specific therapy. 
The child is kept in bed as long as there is fever or other 
symptoms. Diet is chiefly liquid during the febrile stage, 
then a light, easily digestible one is given. Because of 
photophobia the eyes should be protected from light until 
it is no longer unpleasant. The use of a screen or dark 
glasses is preferable to darkening the room. Nervous symp- 
toms and elevated temperature may be controlled by hydro- 
therapy. The mouth must be kept clean. Itching during the 
eruptive stage may be treated as has been suggested for scarlet 
fever (sod. bicarb, sol. 15 per cent). Complete isolation of 
the patient is necessary. Since pneumonia is a frequent com- 
plication the child should be given an abundance of fresh 
air, without exposing him to cold air; in addition to being 
fresh the air should be warm and moist. 
3. German Measles or rubella is a contagious, eruptive 
fever; the incubation period varies from 7 to 22 days. 
It is characterized by a short period of invasion, with 
mild indefinite symptoms usually lasting but a few hours, 
and an eruption which is generally well marked but of variable 
appearance. Swelling of the post-cervical glands is one of the 
most constant features. The constitutional symptoms are 
very mild and the disease is not serious. There are no com- 
plications of importance. Rubella is contagious at any time 
during its course, but it is most highly contagious during the 
early stages. Quarantine is observed until the rash has faded 
and symptoms have disappeared. There is no treatment 
except isolation and treatment of individual symptoms as 
they arise; the child should be in bed and on a light diet as 
long as the symptoms are present. 
4. Varicella or chicken-pox is one of the most contagious 
diseases. The incubation period is from 14 to 21 days. The 
disease is characterized by a cutaneous eruption of papules 
Treatment 
Nursing 
Care 
Complication 
Definition 
Incubation 
Period 
Characteristic 
Symptoms 
Complications 
Epidemiology 
Treatment 
Nursing 
Care 
Definition 
Incubation 
Period 392 
PEDIATRIC NURSING 
Characteristic 
Symptoms 
and vesicles and by mild constitutional symptoms; serious 
complications are rare. The disease is often confused with 
variola because of the nature of the rash. The contagium 
of the disease is contained in the vesicles and is communicated 
by inoculation with their contents. The patient should be 
isolated and considered contagious as long as crusts are 
present. Treatment consists of isolation and treatment of 
symptoms as they present themselves; itching may be allayed 
by sponging with sodium bicarbonate solution, 15 per cent. 
Oil or vaselin may be applied to the crusts. Scratching must 
be prevented. The bath may be given with bichlorid of 
mercury 1 to 10,000 solution in place of water. 
5. Pertussis or whooping-cough is a contagious, respiratory 
disease, which prevails epidemically and in all large cities 
endemically. The incubation period is 7 to 14 days. The 
disease is characterized by catarrhal and nervous symptoms; 
the catarrh affects the mucous membrane of the respiratory 
tract; the most pronounced nervous manifestation is a 
peculiar spasmodic cough which occurs in paroxysms and 
which is often accompanied by vomiting. In later childhood 
it is ranked as one of the milder infectious diseases, but in 
infancy it is one of the most fatal. The most serious compli- 
cation is bronchial pneumonia. Hemorrhage is occasionally 
encountered and may be due to the intense congestion incident 
to severe paroxysms. Pertussis may be communicated from 
the beginning of the catarrhal stage. It is more contagious 
at this period than later, but it is contagious throughout the 
spasmodic stage; however, the infectiousness of the disease 
is slight after the first few weeks. The quarantine is usually 
6 weeks to 2 months. Pertussis vaccine may be used in the 
treatment and is of value as a prophylaxis; otherwise the 
management is entirely symptomatic. Mild cases require no 
treatment; the child need not be kept in bed unless complica- 
tions arise which demand it. He should have plenty of fresh 
air and sunlight and should be kept outdoors if the weather 
permits; damp or night air should be avoided. If vomiting is 
Complications 
Epidemiology 
Treatment 
Nursing 
Care 
Definition 
Incubation 
Period 
Characteristic 
Symptoms 
Mortality 
Complications 
Epidemiology 
Treatment 
Nursing 
Care ACUTE INFECTIOUS DISEASES 
393 
frequent it is often desirable to refeed him immediately after 
vomiting because in most instances it is not due to gastro- 
intestinal derangement. Various drugs, etc., may be ordered 
to control the paroxysms of coughing: a simple method, which 
sometimes helps to cut short the paroxysm, is to forcibly push 
the lower jaw forward. (Marriot.) 
6. Mumps, epidemic parotitis, is a contagious disease, the 
incubation period being 2 or 3 weeks. It is characterized 
by swelling of the parotid, and sometimes of the other 
salivary glands, with constitutional symptoms which are 
usually mild. Pain usually precedes and accompanies the 
swelling of the jaw, which may be on one or both sides. 
Complications are not common; occasionally orchitis occurs, 
and in the female a similar inflammation of the ovaries, uterus, 
breasts, and external genitals. Mumps is contagious from 
the beginning of the symptoms and isolation is usually main- 
tained for one week after the swelling has disappeared, about 
three weeks in all. The virus is unquestionably present in 
the saliva of the patient. If constitutional symptoms are pres- 
ent the child should be kept in bed. The glands may be 
protected by flannel or absorbent cotton and heat may re- 
lieve pain. Diet is liquid, because of pain produced by 
mastication. The mouth should be kept clean by the use of 
antiseptic mouth wash and frequent cleaning. 
7. Diphtheria is a specific infectious disease, characterized 
by a local fibrinous exudate usually upon the mucous mem- 
brane of the throat and by constitutional symptoms due to 
toxins produced at the site of the lesion. The presence of 
the Klebs-Loffler bacillus is the etiological criterion by which 
true diphtheria is distinguished from other forms of mem- 
branous inflammation.1 Lesions may occur on any part of the 
surface of the body and are frequently found on other parts 
of the respiratory tract than the throat; very commonly sev- 
eral of these sites in the respiratory tract are involved at 
the same time. Large cities are never entirely free from 
Definition 
Incubation 
Period 
Characteristic 
Symptoms 
Complications 
Epidemiology 
Treatment 
Nursing 
Care 
Definition 
Characteristic 
Symptoms 
Site 
of 
Lesions 
Prevalence 
of 
Disease 
1 Osier, Sir William, M.D., ‘ ‘ Principles and Practice of Medicine. ’ ’ 394 
PEDIATRIC NURSING 
diphtheria but the incidence increases very noticeably, often 
to the extent of an epidemic, with the coming of winter; 
summer brings a very marked decline in the number of cases. 
Diphtheria occurs at any and all ages, but with by far the 
greatest frequency between 2 and 6 years. One attack 
does not protect against subsequent attacks. 
Faucial diphtheria, a diphtheria of the tonsils and tonsillar 
region, is the most common variety which is encountered, and 
may be considered the ordinary type. Incubation period is 
1 to 4 days. The constitutional symptoms of the acute 
stage are the same as those of acute tonsillitis which is caused 
by other organisms. There is fever, soreness of the throat, 
malaise, and often headache. There is at first a redness of 
the throat. Very quickly there appears a grayish white de- 
posit, which coalesces, becoming a dirty gray. The breath 
becomes foul. The membrane may be peeled off with some 
difficulty, leaving a bleeding surface; it tends to spread 
from the original site. Very frequently the uvula and soft 
palate may become involved, and, less frequently, the hard 
palate. It may also extend to the pharynx, larynx, and nose. 
There is usually some, and there may be marked involvement 
of the cervical lymph-glands so that the neck becomes greatly 
swollen. When the disease becomes advanced there is marked 
prostration. When untreated with antitoxin it progresses 
until the death of the patient, or until sufficient immunity is 
established to overcome it. A certain number will recover 
without treatment, but the mortality under such circumstances 
is exceedingly high. The damage caused by diphtheria 
consists of local destruction of tissue and the effects on the 
body of toxin which is absorbed from the local process. The 
local destruction of tissue is relatively unimportant. If the 
amount of absorbed toxin is great the patient dies early in 
the disease with little or no localizing manifestation of the 
effect of the toxin appearing. The absorption of smaller 
amounts of toxin produces lesions (degeneration) which be- 
come manifest late in the disease, usually after all local signs 
Faucial 
Diphtheria 
Incubation 
Period 
Characteristic 
Symptoms 
Mortality 
Complications ACUTE INFECTIOUS DISEASES 
395 
have disappeared. The extent of the degeneration depends 
upon the amount of the toxin absorbed, which, in turn, de- 
pends upon the extent of the local process and the length of 
time it has been present. Degeneration of the kidney is 
shown by albumin and casts in the urine, and sometimes by 
symptoms of nephritis. Degeneration of the heart muscle 
(myocarditis) is manifested by dilatation of the heart, rapid, 
irregular pulse, and often by signs of cardiac incompetence, 
ending in death. Degeneration of the nerves results in loss 
of function (paralysis) of the parts supplied by the affected 
nerves. All degenerative processes tend to recover ultimately 
if the patient lives. Involvement of the vital organs (heart, 
respiratory muscles, kidney) often does not allow the patient 
to live long enough to accomplish local regeneration. 
Of the diphtheretic paralysis that of the soft palate is 
most frequent and the earliest, usually occurring during the 
second week of the disease. The symptoms are a nasal 
voice and difficult swallowing. The attempt to swallow 
liquids results in regurgitation through the nose. Food is 
sometimes aspirated into the lungs with resulting pneumonia. 
Heart symptoms usually make their appearance in the third 
week, and various paralysis (extremities, etc.) after this time. 
The diagnosis of diphtheria is made in part by the clinical 
features and by the finding of the bacillus in the material from 
the site of the local disease. 
The injection of serum from an immunized animal into 
another animal or into a human patient confers immunity 
to the injected individual, with the result of curing diph- 
theria if present or of preventing the individual from acquir- 
ing clinical diphtheria as long as the antitoxin remains in 
the body. 
Antitoxin may be given subcutaneously, intramuscularly 
or intravenously, depending upon the purpose to be accom- 
plished. Subcutaneously antitoxin is slowly absorbed over 
a relatively long period (several days). For this reason this 
route is the one of choice when it is desired to immunize for 
Diphtheria 
Paralysis 
Diagnosis 
Use of 
Serum 
To Give 
Antitoxin 396 
PEDIATRIC NURSING 
the protection of those exposed to but not suffering from 
diphtheria. When a patient has the disease it is desirable 
to obtain a high concentration of antitoxin in the blood at 
the earliest possible moment. This is most rapidly accom- 
plished by intravenous administration, and this route should 
be used in all cases of severe or long-standing diphtheria. 
Very frequently a severe reaction, accompanied by a chill, 
high fever and headache, follows intravenous administration. 
Consequently this route is not advisable in early or mild cases 
in which there is ample time to allow for absorption from 
intramuscular injection. Absorption from a muscle is much 
more rapid than from subcutaneous tissue. In the treatment 
of diphtheria often both intravenous and intramuscular routes 
are used. 
In treating diphtheria the administration of antitoxin in 
sufficient amount at the earliest possible moment, with the 
exception of the operative treatment of laryngeal diphtheria, 
is more important than all other therapeutic measures com- 
bined. The child should preferably be kept in bed for at 
least two weeks after he is afebrile. Where there are cardiac 
complications, confinement to bed should be maintained until 
these are no longer present. Cleansing gargles, sprays and 
swabbings decrease discomfort and aid healing of the local 
process. The diet should be lightened in proportion to the 
prostration. For severe diphtheria only liquids should be 
given. The child with laryngeal diphtheria should breathe 
warm, moist air. There should be a steam room in every 
contagious hospital, for after intubation or tracheotomy the 
steam room is a necessity. 
Insertion of a tube into the trachea through an incised 
opening in the neck allows a patient with laryngeal stenosis 
to breathe freely—this is called tracheotomy. Special tubes 
are made for this purpose. (See details of care of patient 
after tracheotomy under diseases of respiratory tract, Chap- 
ter XX.) Tracheotomy is not the method of choice for 
relief of obstruction, but it is sometimes necessary when in- 
Treatment 
Nursing 
Care 
Steam Boom 
Tracheotomy ACUTE INFECTIOUS DISEASES 
397 
tubation of the larynx for any reason is impossible. The 
air the patient breathes after tracheotomy should be warm 
and moist. Pneumonia is a frequent complication. 
Hollow tubes of special shape to fit the larynx, and of a 
size suitable for the age of the patient, may be inserted 
by way of the mouth into a stenosed larynx with complete 
relief of respiratory difficulty. This operation is preferable 
to tracheotomy because of its simplicity. It also allows the 
patient to warm and moisten his own respired air. Pneumonia 
is much less frequent. 
In preparing for either tracheotomy, or intubation, the 
patient is firmly wrapped and pinned in a blanket in order 
to minimize the struggle.2 Intubation may be performed 
with a patient in a sitting posture in the lap of the assistant; 
or it may be done with the patient recumbent and the head 
and gag held by an assistant. The recumbent position is 
preferable because one less assistant is required and the 
patient is in the position for tracheotomy should this become 
necessary. Every children’s department should have an 
intubation set with various sizes of sterile tubes ready for 
immediate use, also a complete sterile tracheotomy set for 
emergency use. During intubation a silk thread is attached 
for convenience to the top of the tube. After the tube is in 
place this thread is usually removed. If, for any reason, 
it is left attached, the other end is secured to the cheek 
by adhesive tapes. The child’s hands then must be restrained; 
any restraint employed must not embarrass respiration. 
Whenever intubation is attempted there should be at hand 
all instruments required for emergency tracheotomy. Stenosis 
may be below the tube or the tube may push ahead of it a 
plug of detached membrane which completely and immediately 
blocks all passage of air. It is also advisable to have 
emergency stimulants at hand and ready to use. After in- 
tubation and removal of the string the restraining blanket is 
Intubation 
Procedure 
Position 
of Child 
Care of 
Child after 
Intubation 
3 Jennings, Hazel L., R.N., “Equipment and Procedure for Intuba- 
tion,” Am. J. Nursing, Nov., 1921. 398 
PEDIATRIC NURSING 
removed. With a proper sized tube correctly placed in the 
larynx the epiglottis should close effectively on swallowing 
so that no food enters the larynx. In some patients, however, 
the drinking of liquids causes such choking and coughing 
that especial care must be taken with the manner of feed- 
ing. Various positions may be tried to find the one best 
suited to comfortable swallowing. Placing the patient on 
his back with his head lower than his shoulders may help. 
Lying face down with his head over the edge of the bed and 
sucking through a tube may prove satisfactory. Sometimes 
gavage is necessary. The gavage tube may be inserted through 
the nose. If the tube is coughed up the physician should be 
notified immediately. 
When the tube has been properly retained it usually is 
removed after four days. If it then must be replaced it is 
left in another four days. In the majority of instances the 
larynx is sufficiently patent at the end of eight days so that 
the tube may be dispensed with. 
Some individuals are naturally immune to diphtheria toxin; 
others are not. Those who are immune have antitoxin in 
their blood. When a small dose of toxin is injected into the 
skin of an immune person there is produced no local reactive 
lesion because the injected toxin is quickly neutralized. A 
similar injection of toxin into the skin of a non-immune 
person causes a very marked local reaction with swelling, 
redness and later pigmentation. This is known as the Schick 
test and is an excellent clinical means of distinguishing those 
who are susceptible to diphtheria from those who are not.3 
Any person with a negative Schick test has sufficient antitoxin 
in the blood to protect him against diphtheria. Such a per- 
son can come into repeated contact with diphtheria patients 
without fear of acquiring the disease. 
Passive immunization (injection of antitoxin) is an emer- 
gency measure of inestimable value, but the protection it 
affords is of short duration, sometimes as short as two or 
Extubation 
Schick Test 
Passive 
Immunization 
3 Kilduffe, R. A., M.D., “The Schick Test and Its Practical Applica- 
tion in the Control of Diphtheria.” Am. J. Nursing, Jan., 1922. ACUTE INFECTIOUS DISEASES 
three weeks. Active immunity may be produced by in- 
jections of a mixture of toxin and antitoxin. No serious 
effects attend the injection and often no local discomfort. 
After a short series of such injections an active immunity 
slowly develops, which lasts for a number of years. It is 
advisable for those coming in frequent contact with diph- 
theria, if found to be non-immune by the Schick test, to be- 
come actively immunized by this method. The recent work 
of Dr. Zingher on this subject is recommended to every 
pediatric nurse.4 
Any one who harbors the diphtheria bacillus, without at 
the same time having clinical evidence of its presence, is a 
carrier. Carriers are themselves immune, otherwise they 
would have the disease. They are as much a menace to others 
as those having clinical diphtheria and should be kept in 
quarantine until the upper respiratory tract is free from 
virulent bacilli. 
Every pediatric nurse should be thoroughly familiar with 
the principles of immunity, at least to the extent of under- 
standing clearly the rationale of diphtheria therapy. An 
additional point which bears emphasis here is the opportunity 
of the welfare and school nurse, in their examination of 
sore throats, of making possible early diagnosis of this 
condition. 
8. Variola or small-pox5 is a highly contagious disease 
which occurs endemically and epidemically in those localities 
in which vaccination is not in vogue. The incubation period 
is usually 12 to 14 days. The first symptoms are malaise, 
dullness, headache, backache, loss of appetite. The onset 
is sudden and is ushered in by vomiting, high tempera- 
ture—often 104°—rapid pulse and respirations and prostra- 
tion. There may be convulsions, delirium and chills. The 
rash appears in 3 or 4 days and goes through definite stages 
of (1) macule, (2) papule, (3) vesicle, (4) pustule, (5) 
399 
Diphtheria 
Carrier 
Definition 
Incubati 
Period 
Characteristic 
Symptoms 
4Zingher, Abraham, M.D., “Diphtheria Prevention Work in the Pub- 
lic Schools of New York City.” Arch. Fed., June, 1921. 
6 Emerson, Charles P., M.D., ‘ ‘ Essentials of Medicine. ’ ’ 400 
PEDIATRIC NURSING 
crusts, (6) scar, and is followed by desquamation. After 
the rash appears the temperature falls and symptoms im- 
prove. When the pustular stage of the rash occurs the tem- 
perature is again elevated, also pulse and respirations are 
more rapid for a few days. There is a characteristic, un- 
mistakable odor to the skin rash. The most frequent compli- 
cations are affections of the respiratory apparatus, as 
laryngitis, edema of the glottis, bronchitis, bronchopneu- 
monia, otitis media, multiple cutaneous abscesses, bed sores, 
and adenitis. The mortality of unmodified small-pox is 25 
to 40 per cent or more. The disease is transmitted by direct 
contact. Infection certainly resides in the pustules and 
crusts. It is also readily communicated in some way before 
the eruption appears. It ceases to be infectious by the time 
the crusts have fallen and the skin has become smooth. Isola- 
tion must continue until every vestige of the disease has dis- 
appeared. This varies from 4 to 6 weeks from its onset. 
Owing to the intense infectiousness of small-pox any sus- 
pected case should be isolated absolutely and immediately. 
The extreme diffusibility of the poison renders the quarantine 
in private homes very difficult, and treatment in special hos- 
pitals is highly recommended. Every one exposed to the dis- 
ease should be promptly vaccinated, since by its more rapid 
development vaccination may modify or even prevent the 
action of the small-pox infection. 
The treatment of the disease is purely symptomatic. The 
patient is kept in bed in a well ventilated room. The diet 
is liquid during the febrile stage, light nourishing diet after 
that. Water is forced. Hydrotherapy may be indicated to 
allay nervous symptoms and relieve high temperature. Cold 
wet applications which are changed frequently may alleviate 
che itching of the skin. Bichlorid of mercury, 1 to 10,000 
solution, may be used for the bath. Crusts may be moistened 
with oil, vaselin or petrolatum. Scratching must be pre- 
vented. The patient’s mouth and eyes demand special care 
to keep them clean. 
Complications 
Mortality 
Epidemiology 
Treatment 
Nursing 
Care ACUTE INFECTIOUS DISEASES 
401 
Vaccination, or the human inoculation of cow-pox virus, 
is carried out to prevent small-pox. Every one should be 
vaccinated against it. Vaccination is compulsory in many 
states before a child is allowed to attend public schools. It 
is safer if this is done several times during the lifetime. It 
should be done first during the early months of infancy, as 
soon as it is certain that the infant is thriving. The con- 
stitutional disturbance is much less at this time than later. 
It should be repeated at 12 or 14 years of age and again 
at 25 or 30 years. One vaccination may protect for a life- 
time, hut it cannot be depended upon to do so. (Technique 
for vaccinating described in Chapter XVI on minor surgical 
procedures.) The treatment of the complications is not dif- 
ferent because of the small-pox present and their nursing care 
is therefore the same, except for the addition of the isolation 
technique employed. 
9. Typhoid fever is an acute infectious disease due to a 
specific organism, Eberth’s bacillus. Typhoid fever in child- 
hood is not infrequent, but it is rare in infancy. It is almost 
invariably contracted by drinking water or milk which con- 
tains the organisms. The infrequency of typhoid fever in 
infants who are artificially fed is explained, in part at least, 
by the fact that most of the water and a large part of the 
cow’s milk taken have been previously boiled or heated in 
some manner. The incubation period is indefinite, usually 
1 to 2 weeks. In general the lesions resemble those of the 
disease as it occurs in adults. In a considerable number 
of cases the pathological process in the intestines does 
not go on to ulceration; when ulcers do form they are seldom 
large or deep and perforation is very rare in childhood. 
Cases of typhoid seen in children under ten years old may 
be described as fever characterized more often by nervous 
symptoms than by intestinal symptoms. The onset is usually 
sudden; fever, prostration, vomiting, diarrhea and headache 
may usher it in. Symptoms are often more suggestive of 
acute indigestion. There is enlargement of the spleen as 
Vaccination 
Definition 
Incubation 
Period 
Characteristic 
Symptoms 402 
PEDIATRIC NURSING 
in adults; but the eruption is less constant, less abundant 
and less characteristic in childhood, and appears earlier. The 
temperature usually rises more rapidly than in adults. The 
remittent character is less marked and the average duration 
is shorter. 
Complications of typhoid in early life are infrequent and 
mild, however, bronchitis, pneumonia and otitis media do 
occur. The mortality in children over 3 years old prob- 
ably does not exceed 3 or 4 per cent, death usually occurring 
not from the disease but from some accident or complica- 
tion. Since the typhoid-producing bacilli may be found in 
the patient’s blood, stools, and urine, or in rose spots, all 
secretions must be carefully disinfected and complete isola- 
tion of the patient must be maintained until repeated tests 
prove the absence of the bacilli. The child with typhoid 
fever must stay in bed during the febrile period and a 
few days beyond it. He should have a warm, sunny, well 
ventilated room. The diet usually consists of liquids which 
are given frequently. Plenty of water must be given. Solid 
food is usually allowed after the temperature has been nor- 
mal several days. There may be diarrhea or there may be 
constipation. Tympanitis may be relieved by stupes or by 
the use of a rectal tube. Hydrotherapy may be employed to 
allay nervous symptoms and reduce an elevation of tempera- 
ture. Intestinal hemorrhage and perforation must be watched 
for even if they do rarely occur. As in adults the mouth 
demands special nursing care. 
Immunizing treatment for typhoid consists in giving injec- 
tions of cultures in which the germs have been killed by 
heat. The results are encouraging. (Griffith.) 
10. Tuberculosis. Infection with the tubercle bacillus is 
exceedingly common in childhood. By the age of 6 years 
practically 25 per cent of all children have been infected at 
one time or another. By the age of 14 years from 40 to 
50 per cent, and in some localities apparently 90 per cent 
have been infected. It is probable that every adult living 
Complications 
Mortality 
Epidemiology 
Treatment 
Nursing 
Care 
Immunization 
Definition 
Prevalence ACUTE INFECTIOUS DISEASES 
403 
in a large community would show evidence of a former focus 
if sufficiently examined. Very fortunately relatively few 
children who have been infected show clinical evidence of 
the disease. Frequently at necropsy foci of infection are 
found, cured, latent or active, which are in such a location 
or of such limited extent as not to be demonstrable during 
life. The frequency of infection may be shown by the 
cutaneous tuberculin or von Pirquet test (Chapter XVI). 
Such a test when positive means that the individual either 
has or has had a tuberculous infection. Obviously such a 
reaction is of greater significance in early childhood than in 
later life. A positive reaction in a young infant would 
mean the presence of an active infection at the time of 
the test. It is necessary to make a distinction between those 
who have clinical tuberculosis and those who have been in- 
fected but do not develop clinical disease. It may be that 
the difference between merely infection and the active clinical 
disease is chiefly the massiveness of the dose of tubercle 
bacilli. The younger the child the more likely is the dis- 
ease to follow infection. Also the younger the child the 
more likely is the disease to progress rapidly to death. In 
later childhood there is a greater tendency to resist the dis- 
ease. When freely exposed to the infection the infant acquires 
the disease rather readily. Among adults, on the contrary, 
tuberculosis manifests so little the characters of a con- 
tagious disease that its infectious character was at one time 
a matter of dispute. Tuberculosis of adults is very likely 
to be the result of exacerbation of a former infection instead 
of an entirely new infection. 
The chief source of infection is constant association with 
a tuberculous individual, such as occurs in home life when 
a member of the family has the disease in an active form. 
Milk from tuberculous cattle is an infrequent source. In- 
fection may occur by means of coughed droplets directly 
or by means of dust which has been contaminated by means 
of droplets or dried sputum. If protected from sunlight 
Von Pirquet 
Test 
Source 
of Infection 404 
PEDIATRIC NURSING 
tubercle bacilli withstand drying and the hottest summer heat 
for long periods. Tubercle bacilli gain entrance to the body 
either by way of the respiratory or the alimentary tract. They 
may gain a foothold in the throat, lungs, or bowel. There 
may or may not be a lesion at the point of lodgement (lesions 
of the lung are described below). The bacilli are taken up 
by the lymphatics and are carried to the nearest lymph- 
glands (cervical, bronchial or mesenteric). In the glands an 
inflammation is set up of a character similar to tuberculous 
lesions wherever they may occur elsewhere. If allowed to 
run its course the inflammatory process goes slowly through 
the stages of cellular infiltration and caseation (softening). 
In the cervical glands the clinical course is more easily ob- 
served. Here there is swelling, increasing over a relatively 
long period, some tenderness, finally softening, eventually 
involving the skin of the neck through which the caseous 
contents of the focus are discharged. Such a tuberculous 
sinus tends to continue to discharge over a period of months 
or even years. If the resistance of the patient is sufficient 
the described process may be arrested in any stage and may 
remain latent or may become clinically cured. A latent 
focus in the glands or elsewhere may have its activity re- 
newed by some other illness, or any other factor which 
greatly lowers the resisting power of the individual. Measles, 
pertussis and influenza are especially prominent in this 
respect. Crowded tenements with insufficient light and fresh 
air, and scanty and improper nourishment are predisposing 
causes. 
Other body structures may be involved by continuity from 
the above-mentioned lesions, or bacilli may be distributed 
from these lesions by way of the lymph-channels and the 
blood stream. Swallowed sputum containing material from a 
lung focus may also be a further source of infection by 
causing intestinal lesions. 
Although any type of lesion may be found at any age, 
certain types are more frequent at certain ages. In the ACUTE INFECTIOUS DISEASES 
405 
first 2 years the most frequent sites of infection are the lungs 
and bronchial glands. Meningitis is very frequent and 
miliary tuberculosis is common. From the third, to the sixth 
year involvement of the lungs and bronchial glands remains 
the most common form. General tuberculosis and meningitis 
remain common. Involvement of the cervical and mesenteric 
glands, and of the intestine, peritoneum, bones and joints 
increases in frequency. In later childhood pulmonary tuber- 
culosis is common but begins to assume the adult type 
(see below). General tuberculosis and meningitis are less 
frequently observed. Involvement of the bones, joints, 
peritoneum and cervical glands remains common. 
In the above tabulation there is to be observed a certain 
degree of increasing resistance to the tuberculous infection 
as the age increases. In infancy there is a great tendency 
for the disease to become widespread, as evidenced in part 
by the frequency of disseminated tuberculosis and of men- 
ingitis. In adults lung infection is the most frequent man- 
ifestation of tuberculosis, and lesions elsewhere are relatively 
uncommon. In children, on the other hand, pulmonary dis- 
ease, though common, is only one of the many forms to be 
found with almost equal frequency. These differences con- 
stitute further evidence of the tendency to dissemination in 
early life. In childhood the individual focus shows less 
tendency to heal than later. Later the formation of fibrous 
tissue about a tuberculous focus is a great aid in limiting 
its extent, or in bringing about its clinical cure. Such fibrosis 
is almost unknown before '2 years and is rare before the 
age of 7, while in adult life it is the rule. In infancy pul- 
monary tuberculosis occurs as a bronchopneumonia, which 
differs but little from pneumonia which is due to other 
organisms. It affects impartially all parts of the lungs. This 
type of pulmonary tuberculosis is uncommon in adults and 
when it does occur has been spoken of as galloping con- 
sumption. Death after a few weeks or months is the usual 
but not invariable result. Pulmonary tuberculosis of adults 
Sites 
of Lesions 406 
PEDIATRIC NURSING 
is a chronic disease, often running a course of 3 to 5, or 
even 10 to 20 years. It affects chiefly the apices of the 
lungs. In infancy and early childhood any focus of tuber- 
culosis affects markedly the lymph-glands which drain the 
affected region. In adults such an event is unusual, the in- 
fection tending to remain limited to its original site, or if 
the glands are affected it is to a mild and unimportant 
degree. It seems highly probable that the increased re- 
sistance of the older child and adult to tuberculosis does not 
depend upon the age of the individual but rather upon the 
protection and partial immunity afforded by previous in- 
fection with tuberculosis. The adults of primitive races 
which have not previously been exposed to tuberculosis react 
to the infection just as do infants and young children. The 
disease of the lung involves all parts of the lungs, pursues a 
rapid course, involves the regional lymph-glands and is often 
disseminated throughout the body as a miliary tuberculosis. 
Tuberculous bronchopneumonia has already been partially 
described. The onset may be more gradual and often the 
course is more chronic than ordinary bronchopneumonia. 
There is a cough, irregular or continued fever and wasting. 
Bronchial gland tuberculosis is a very common form in mid- 
dle and late childhood. It arises in connection with the 
tracheobronchial glands at the hilus or root of the lung. The 
onset is insidious and the symptoms are usually vague. The 
patient is likely to be anemic and below par generally. Such a 
lesion may break down to cause pulmonary or general tuber- 
culosis. It runs the same chronic course as in the lymph- 
glands. In a sense these cases represent a middle ground 
between active clinical tuberculosis and those who are 
merely infected without showing any clinical evidence of 
the disease. 
Chronic ulcerative tuberculosis of the lungs (phthisis) is 
the type more common than any other in adult life. This 
form is rare in infancy and early childhood and is infrequent 
in late childhood. When it does occur cough and dyspnea 
Tuberculous 
Broncho- 
pneumonia 
Bronchial 
Gland 
Tuberculosis 
Chronic 
Ulcerative 
Tubercu- 
losis ACUTE INFECTIOUS DISEASES 
407 
are less prominent than in adults and hemoptysis and in- 
volvement of the larynx are rare. 
Miliary tuberculosis is the result of dissemination of 
tubercle bacilli throughout the body, or a large portion of 
the body by way of the blood stream. There arise multiple 
foci of infection which by the time death occurs have attained 
the size of a millet seed (hence the name). Bacilli may 
be distributed exclusively to the lungs by way of the pul- 
monary artery, to the entire body except the lungs by 
way of the general circulation, or both circulatory systems 
may be involved in the distribution. Slightly different symp- 
toms arise, depending upon the distribution. In general the 
initial symptoms are vague and are those of general im- 
pairment of health (loss of appetite, strength and weight). 
A moderate irregular and a typical fever develops. All the 
above signs continue and increase. There is apathy, dull- 
ness, and finally coma and death about three weeks from 
the onset. The diagnosis is frequently quite difficult be- 
cause of the lack of characteristic and definitely localizing 
symptoms. If the lungs are involved there is a cough and 
the diagnosis may be made by an x-ray examination. When 
there is general involvement of the body the spleen is usually 
enlarged and the illness in many respects resembles typhoid 
fever. Ophthalmoscopic examination may reveal tubercles 
in the choroid of the eyes. In case the meninges become 
involved in the general distribution the symptoms of men- 
ingitis are marked enough to greatly or entirely obscure 
the symptoms of the disease elsewhere. 
Tuberculosis may involve the bones or joints and it then 
demands orthopedic care. Infection of the kidney or 
genito-urinary organs is quite rare in children. Skin mani- 
festations, as tuberculides, are not uncommon. Phlyctenular 
conjunctivitis is another rather common complication. 
The prognosis of tuberculosis in childhood has already been 
considered in a general way. The mortality is high in in- 
fancy and decreases with the increasing age of the child. 
Miliary 
Tubercu 
losis 
Prognosis 
Mortality 408 
PEDIATRIC NURSING 
Tuberculosis of lymph-glands, bones and joints has a rela- 
tively low mortality. Tuberculous peritonitis frequently 
terminates favorably. 
The treatment of tuberculosis is largely hygienic. If the 
predisposing causes previously mentioned can be reversed 
or prevented much will be accomplished toward the re- 
covery of the patient. What is needed is abundance of rest, 
clean fresh air, wholesome food, sunlight and pleasant sur- 
roundings. A change to a higher and drier climate may 
be of benefit. The removal from contact with a continued 
source of infection is essential. If possible an infant should 
be removed cofnpletely from a tuberculous mother whether 
or not he has been infected. If this is not possible the mother 
should be instructed how to protect her infant most care- 
fully. The use of cod liver oil, in combination with creosote, 
iron or arsenic, is often of great benefit as a tonic. 
11. Syphilis. Syphilis is an infectious disease of a chronic 
course with acute or subacute manifestations. It is caused 
by a spirillum which is known as the spiroeheta pallida. It 
is subject to the same rules for transmission as is diphtheria 
or other contagious diseases. The organism is unable to 
withstand drying, and is easily killed by mild antiseptics. 
Dry surfaces (door knobs, toilet seats, etc.) do not long harbor 
the virus. Mere washing of contaminated linen renders it 
safe. The disease is transmitted only by intimate contact 
between moist surfaces and of course only when the virus 
is present on one of those surfaces. The normal dry, healthy, 
intact skin is not attacked. Microscopic breaks in continuity 
of the skin of which one may be unaware may become in- 
fected. For this reason the nurse caring for a child with 
congenital syphilis should wear rubber gloves. The disease 
is often spoken of as a venereal disease but in a large pro- 
portion of instances the infection is innocently acquired and 
the primary lesion is elsewhere than on the genitalia. 
Syphilis may have its onset at any age from early 
intra-uterine life onward. No individual is immune. When 
Treatment 
Nursing 
Care 
Definition 
Sources of 
Infection the onset is before birth it has been customary to speak of 
the disease as hereditary or congenital, and when after birth 
it is spoken of as acquired. Acquired syphilis in childhood 
is quite uncommon, while the inherited disease affects about 
6 per cent of the infant population of the “dispensary” 
class. It is the present belief that in all instances of heredi- 
tary syphilis the virus has been transmitted from a syphilitic 
mother to the fetus by way of the placenta. Doubt has 
been cast upon this belief because the mother is so often, 
in fact usually, quite unaware of her disease and shows no 
clinical evidence of it, while the father ordinarily entertains 
no doubt as to at least the former presence of his infection. 
It has been the opinion of many, and is still that of a few, 
that syphilis may be transmitted to the offspring by a 
syphilitic father without the mother acquiring the disease. 
However, with a few easily explained exceptions, all mothers 
of syphilitic children give a positive Wassermann reaction 
with their serum. Syphilis is a chivalrous disease in that 
in women it rather uniformly causes less disturbance than 
in men. 
Miscarriages, premature labors, and stillbirths occur in 
syphilitic families with notable frequency. The excess of 
these occurrences over those in non-syphilitic families is to 
be ascribed to the harmful effects of the spirochete upon the 
fetus. The earlier the fetus becomes infected the less likely 
it is to be carried to term or to be born alive. The more 
active the infection in the mother the earlier is the fetus 
infected. Since syphilis has a great tendency in many in- 
dividuals to become clinically inactive with the lapse of time, 
there is very likely to occur a certain succession of effects 
upon a series of offspring of a syphilitic mother. The early 
pregnancies result in early miscarriages, later ones result 
in stillbirths, and still later pregnancies result in living births, 
the children being first marked syphilitic and dying early, 
and later being but mildly infected and living. After a still 
further lapse of time the infection in the mother may have 
ACUTE INFECTIOUS DISEASES 
409 
Prevalence PEDIATRIC NURSING 
410 
become quiescent to such an extent that no transmission of 
the disease takes place and the child is born in a healthy 
and non-syphilitic state. Anti-syphilitic treatment of a syph- 
ilitic mother through her pregnancy, and often only during 
the latter half of her pregnancy, will result in the birth 
of a non-syphilitic infant. The treatment of the mother 
during one pregnancy does not protect subsequent pregnancies 
unless the treatment has been carried to the point of cure. 
When syphilis is acquired after birth the onset is char- 
acterized by a lesion of the mucous membrane or skin known 
as the “primary sore” or “chancre.” The initial sore is 
the portal of entry of the spirochete into the body. The 
spirochetes quickly become disseminated throughout the body. 
The external lesions which are produced by the disseminated 
spirochetes become manifest in the course of about 3 months, 
and are known as “secondary” lesions. These eventually 
subside, the disease becomes quiescent (“latent stage”), 
and after a period of months or years lesions of a different 
type from those formerly existing make their appearance. 
These are known as “tertiary” lesions. The inherited dis- 
ease goes through precisely the same stages with the excep- 
tion of the primary sore which is lacking because the infec- 
tion occurred by way of the placenta. Because the initial 
sore is lacking, the secondary and tertiary stages are fre- 
quently referred to as the “early” (or infantile) and “late” 
stages respectively. The hereditary disease in early childhood 
and the acquired disease in adult life differ somewhat in 
their symptomatology and effects, but not because of any 
biological difference in the behavior of the spirochete. The 
clinical manifestations differ in the early stages because in 
infancy the rapidly developing structures are more pro- 
foundly affected than are the same structures when fully 
developed. They also differ for the reason that certain parts, 
merely because of rapid growth, are highly vascular, and 
such vascular areas are more likely to be affected or are 
affected more severely. Later in childhood, when the develop- 
Primary 
Stage ACUTE INFECTIOUS DISEASES 
411 
ment is slower or more nearly completed, the manifesta- 
tions of syphilis approach much more closely the types found 
in adults with acquired syphilis. The differences that are 
observed are chiefly: the high mortality of infantile syphilis 
as compared to the adult mortality of practically zero in 
the secondary stage, certain changes in bodily development, 
notably in the teeth, which cannot occur in adults because 
they are already fully developed, the tendency to secondary 
skin lesions of greater severity in infancy, the almost con- 
stant involvement of the growing portion of the long bones 
(epiphysis) in infancy, the frequent occurrence of inflam- 
mation of the cornea of the eye (keratitis) as a late or 
tertiary manifestation in childhood. The frequency of 
syphilitic cardiovascular changes in adults is compared to 
their almost complete absence clinically in childhood. 
The secondary phase of hereditary syphilis usually ex- 
hibits itself some time between the third and eighth week 
of life. Rather uncommonly lesions may be apparent at birth 
or may first appear in the third month. The more severe the 
infection the earlier the appearance. Since a syphilitic baby 
may show any combination of a fairly large number of 
individual types of lesions, it is scarcely possible to describe 
a “typical case.” The most frequent lesion and usually the 
earliest is a rhinitis (snuffles), which frequently causes com- 
plete occlusion of the nose and is accompanied by a serous 
or serosanguineous (bloody) discharge. The untreated 
condition becomes chronic and in occasional instances sec- 
ondary necrosis of the nasal bones causes the falling in of 
the bridge of the nose (saddle nose). The occurrence of 
skin lesions is second in frequency. A common type is a 
maculopapular, copper-colored eruption involving any or 
all parts of the body. In severe infections there is often an 
inflammation of the . skin about the mouth extending deeply 
into the skin, which is marked by slightly bleeding fissures 
which radiate in all directions from the mouth. Unless 
treated early, these fissures leave permanent scars (rhagades) 
Secondary 
Stage 412 
PEDIATRIC NURSING 
which are pathognomonic of early syphilis. Similar involve- 
ment of the palms and soles without fissures but with 
desquamation is common. Third in frequency is enlarge- 
ment of the spleen. This, however, is but a minor aid in 
diagnosis, because of its frequent occurrence from other 
causes. Slight fever may be present in severe cases. 
A severely infected infant is very likely to show marked 
wasting and loss of strength. He is fretful and cries if 
handled. The cry is hoarse, high pitched, and is persistent, 
especially at night. The nutrition becomes a matter of grave 
concern, and death from progressive malnutrition is a fre- 
quent result. In the general dissemination of spirochetes 
over the body there is involvement, or opportunity for in- 
volvement, of every organ or structure. It is the involve- 
ment of the viscera, which, though exhibiting little or no 
localizing evidence, is the case of the serious malnutrition 
and death. In contrast to the serious picture above is the 
infant who is so mildly infected that at the time of examina- 
tion he may show no signs whatever of his infection and may 
seem in perfect health. 
Though involvement of the epiphysis of the long bones 
is almost constant, the lesion is but seldom severe or ex- 
tensive enough to cause clinical symptoms. The symptoms 
when they occur are pain and swelling, because of which 
the part is not used (pseudoparalysis). Lesions of lesser 
importance, because of lesser frequency, are iritis, choroiditis, 
optic neuritis, meningitis (hydrocephalus, convulsions) and, 
as later secondary lesions, condylomata and mucous patches. 
The period of secondary manifestations is followed by a 
period of latency of the infection during which there may 
be no external evidence of the disease. After the age of 
6 or 7 years (occasionally before) the disease again becomes 
evident with increasing frequency. The lesions assume a 
somewhat different type from those of the secondary period. 
These tertiary lesions may involve any part of the body. 
The parts which are most commonly affected and in the order 
Tertiary 
Stage ACUTE INFECTIOUS DISEASES 
413 
of their frequency are the eyes, the nervous system, the 
bones, joints, and the mucous membranes. 
The most common lesion of the eyes is an inflammation of 
the cornea (keratitis). Fully one-third of all older syphilitic 
children have this disorder in one or both eyes at some time 
or other. An increasing cloudiness of the cornea occurs 
which is associated with impaired vision, photophobia and 
injection (prominence and fullness) of the conjunctival 
blood vessels about the cornea. Syphilitic keratitis tends to 
become chronic and even with treatment the patient is 
fortunate to have the cornea again clear at the end of a 
year. Inflammation of the retina and choroid of the eye 
(retinochoroiditis), causing impairment of vision, is not 
uncommon. 
About one-third of all syphilitic children have a syphilitic 
infection of the nervous system. The infection occurs dur- 
ing the disseminative or secondary period, but in most in- 
stances remains latent until middle childhood or later. Such 
infection is diagnosed by examination of the cerebrospinal 
fluid. Various clinical manifestations are observed of all 
degrees of severity. Of these the following are most com- 
mon : changes in pupillary reflexes, atrophy of the optic nerve, 
hemiplegia or paraplegia, dementing processes or milder 
grades of mental retardation. In late childhood or early 
adult life tabes dorsalis and general paresis are encountered. 
Epilepsy is not uncommonly the result of syphilitic changes 
in the brain. 
Of the bones the tibia is most frequently affected. The 
most common lesion is an inflammation of the periosteum and 
outer layers of bone causing a swelling, chronic in character 
and more painful at night. Not infrequently the deeper 
layers of bone are involved, resulting in a clinical course 
almost identical with a low grade, chronic osteomyelitis from 
other causes. 
Of the joints the knees are most frequently affected. There 
may be acute trouble with swrelling and pain, or a chronic 414 
PEDIATRIC NURSING 
synovitis may result with greatly increased fluid in the 
synovial cavities and with little or no pain or disability. 
Gummatous ulcers may appear upon the skin or the mucous 
membrane. The breaking down of these lesions is the cause 
of the perforations of the palate and nasal septum which are 
occasionally observed. 
Treatment,G The treatment differs in no essential man- 
ner from the treatment of syphilis of adults. The same drugs, 
arsphenamin, mercury and iodin, are used but in a dose pro- 
portionate to the age or weight of the child. Especial de- 
pendence is placed upon arsphenamin and mercury, which 
are given in courses over a period varying from one to three 
or more years and until negative Wassermann reactions are 
repeatedly and persistently obtained. The earlier in the 
disease treatment is started, the shorter is the period of 
necessary treatment and the easier is the cure. In young 
infants intensive treatment may be found to interfere with 
the nutrition, and as a consequence the method and dosage 
must be modified accordingly. In certain instances in which 
the central nervous system is affected, intraspinal administra- 
tion of minute amounts of arsphenamin is found to hasten 
the recovery. 
(With the kind permission of Dr. Wm. McKim Marriot of 
St. Louis, the above work on syphilis, that on tuberculosis, 
and part of that on diphtheria have been taken from notes 
compiled by him for the use of nurses.) 
Treatment 
0 Jeans, P. C., M.D., “Treatment of Hereditary Syphilis,” Journ. 
Amer. Med. Assn., Jan. 15, 1921. CHAPTER XXIII 
SURGICAL NURSING CARE OF CHILDREN 
Preoperative and Postoperative Care of the Infant. 
Every surgical case is a case by itself and every infant 
must be individualized, but there are certain fundamentals 
concerning the preoperative and postoperative care that 
have to be considered as a whole. The infant varies from 
the adult quantitatively and qualitatively; that is, he is 
not only a smaller organism than the adult but he also pre- 
sents certain peculiarities. 
1. The infant’s body differs from the adult’s anatomically, 
histologically, and even chemically, the water content of the 
newborn being 75 per cent as compared to 67 per cent in 
the adult. 
2. It is an organism peculiarly susceptible to extreme 
metabolism disturbances, such as dehydration and acidosis. 
3. It is an unstable organism as evidenced by lack of 
temperature and central nervous system control. 
4. The infant possesses little resistance and practically 
no immunity to infectious diseases. 
As a result of these peculiarities, he demands the most 
skillful preoperative, operative, and postoperative care. The 
essential points to be considered are: 
1. Prevention of dehydration. 
2. Maintenance of body heat. 
3. Prevention of infection. 
1. Prevention of dehydration: It has long been known 
that from lack of food and water or as a result of vomiting, 
purging, or diarrhea, a child will rapidly lose weight and 
will soon fall into a precarious state. This is due to the loss 
Preoperative 
and 
Post- 
operative 
Care of 
Infant 
Some 
Differences 
between 
Infant 
and Adult 
Essential 
Points 
in Operative 
Care 
Prevent 
Dehydration 
415 416 
PEDIATRIC NURSING 
of body fluids known as dehydration or anhydremia. The 
disease which the infant is suffering from, the loss of blood 
during operation, and the anesthetic which is given, all com- 
bine to increase this condition which rapidly results in acidosis 
and intoxication. The object of the preoperative and post- 
operative care must be to prevent such conditions. Some of 
the methods of prevention are: 
Catharsis is avoided before operation. The infant is given 
the regular amount of food just as long as possible, usually 
up to 3 hours before the operation. Fluids should be forced 
in every way for several days before it. They may be given: 
a. By mouth, if possible, unless the child vomits. 
b. By rectum, if possible, if the child will retain them. 
c. Intravenously, if necessary, if other methods fail. 
d. By hypodermoclysis, if necessary, if other methods fail. 
e. Intraperitoneally, if possible, unless it interferes with the 
site of operation. 
The postoperative care demands that the infant be given 
suitable food (usually breast milk is indicated) as soon as he 
can retain it, and all efforts to supply fluids in other ways 
are continued after operation. 
2. Maintenance of body heat: An infant’s heat control 
is poor, showing wide variations of temperature due to the 
surrounding temperatures. Therefore, the operating room 
should be warm, 70° to 76° F.; the infant should be sur- 
rounded by hot water bottles during the operation, and should 
be exposed as little as possible. Wrap his arms and legs and 
as much of his body as possible with cotton; put warm blan- 
kets over him. Only the site of operation should be exposed. 
After the operation he should be placed in a warm bed and 
heaters should be applied as necessary to keep his temperature 
up to normal, for chilling is conducive to shock. 
3. Prevention of infection: Since the infant possesses 
practically no immunity to infection, he may readily contract 
disease. Therefore, isolation and aseptic nursing technique 
are important for as long as possible before operation and 
Avoid 
Catharsis 
To Maintain 
Body Heat 
To Prevent 
Infection 
Aseptic 
Nursing SURGICAL NURSING CARE OF CHILDREN 
417 
afterwards until he has completely recovered. This isola- 
tion is also beneficial because it keeps him quiet and away 
from disturbing influences.1 
Preoperative Care of the Child 
The same general principles regarding the preoperative 
care as given for the infant hold true for the child. The 
person who is caring for the child tries to: 
1. Prevent dehydration. 
a. By avoiding catharsis. 
b. By forcing fluids. 
c. By feeding up to the time of operation if possible. 
2. Prevent infection by carrying out aseptic nursing. 
Catharsis is avoided before operation to prevent dehydra- 
tion and acidosis. See that the child has a normal, free 
evacuation of the bowels daily for several days previous to 
operation and catharsis will not be necessary. If the nature 
of the case permits, in order to clean the lower bowel an 
enema may be ordered 4 hours before operation. Fluids are 
forced by mouth or, if necessary, in other ways as enumer- 
ated above for several days before operation; water by mouth 
may be given up to 1 hour before the operation is scheduled. 
Unless the nature of the operation forbids, the child is given 
his usual diet up to the day of the operation; 4 hours pre- 
ceding a light meal is given, consisting of some high carbo- 
hydrate food, as cereal with milk and sugar. To prevent 
acidosis some authorities advise sodium bicarbonate and glu- 
cose in suitable doses 15 minutes before operation.2 
A child of any age and especially the sick one lacks im- 
munity and is very susceptible to disease; therefore, isola- 
tion and aseptic nursing are necessary. Several days before 
operation he should be given a separate room, if possible, 
where he may be isolated from danger of contracting dis- 
Preoperative 
Care of Child 
Prevent 
Dehydration 
Prevent 
Infection 
Avoid 
Catharsis 
1Eodda, F. C., M.D., "Abdominal Surgery in Infaney from a Pediatric 
Viewpoint.” Journal-Lancet, Sept. 18, 1921. 
lJourn. Amer. Med. Assn., June 11, 1921. 418 
PEDIATRIC NURSING 
ease, and where he may be quiet, as the latter is an essential 
factor. A specimen of urine must be collected the night 
before operation and examined carefully. 
It is seldom necessary to shave the field of operation on 
a child, especially if he is under 6 or 8 years of age. If 
there is hair around the site, shaving is, of course, indicated 
and it may be ordered routinely for all extensive orthopedic 
operations, etc. With tact and patience it is generally pos- 
sible to shave a child without serious difficulty. In most 
cases if the procedure and its necessity are explained to him 
before starting, he will cooperate. The nurse may make a 
game of it which will highly amuse him. If he is too active 
or irritable it may be wiser to wait and shave him after 
he is under the anesthetic. The individual case decides the 
details of this question as of all others discussed here. 
To shave a child: 
1. Safety razor with blades (straight razor unsafe for use 
on a child). 
2. Basin of soap solution. 
3. Sponges. 
4. Paper bag for waste. 
5. Tissue paper squares to clean razor blade. 
6. Hand towel. 
Shave not more than 12 hours before operation, usually the 
evening before. The area should be definitely indicated in 
a written order. Special permission must always be obtained 
from the parents if the child’s head has to be shaved, or if 
even a small amount of his hair has to be cut off, as for a 
mastoid operation, etc. 
Preoperative medication is given as ordered and is re- 
corded on the child’s chart. Atropin sulphate is ordered in 
most cases. Morphin is seldom used but chloral hydrate 
by rectum is sometimes ordered as a sedative. 
The child should urinate within y2 hour before going to 
the operating room; if he does not it should be reported and 
he may have to be catheterized. 
To Prepare 
Field of 
Operation 
To Shave 
a Child 
Equipment 
Preoperative 
Medication 
To Urinate 
hefore 
Operation SURGICAL NURSING CARE OF CHILDREN 
419 
The child is given his routine morning bath, being sure 
that his nails are clean and that his head is clean and free 
from pediculi. He should be dressed in a shirt, stockings, 
nightgown, and diaper if necessary; a three-cornered drape 
is tied around his head to completely cover his hair. (See 
how to put on cap for treatment of pediculosis, Chapter VI.) 
His body is wrapped and pinned securely in a blanket; this is 
to restrain him and it is usually better to put it on before he 
leaves his bed since it has to be put around him as soon as 
he reaches the anesthetizing room. See that he has nothing 
in his mouth. Record on his chart the time he leaves for 
the operating room and accompany him there. 
A warm etherizing room and operating room, 70° to 76° F., 
and external heat during the operation are important factors 
for the successful postoperative recovery of any child. The 
nurse must see to these details, also that he is protected by 
warm blankets and that only the field of operation is ex- 
posed. Local anesthesia as well as general may be used for 
children.3 
To Restrain 
before Giving 
General 
Anesthetic 
Prevent 
Unnecessary 
Exposure 
Postoperative Care of the Child.4 
While the child is absent his room and crib are prepared 
for his return; strip the crib and air the room well. 
To make an ether bed: In addition to the regular equip- 
ment for making a bed add: 
• One blanket. 
Rubber pillow slip or a piece of rubber the size of a pillow 
slip. 
Two emesis basins. 
Tongue depressor. 
Squares—gauze or old cotton cloth for mouth wipes. 
Postoperative record sheet. 
Pen and ink. 
Paper bag. 
Post- 
operative 
Care of 
Child 
Ether 
Bed 
3 Farr, R. E., M.D., ‘ ‘ Local Anaesthesia in Surgery in Infancy and 
Childhood.” Tr. Sect. Dis. Child., A.M.A., p. 162, 1920. 
4 Bartlett, W., M.D., ‘ ‘ After Treatment for Surgical Patients, ’ ’ 420 
PEDIATRIC NURSING 
Glass and drinking tube. 
Two face towels. 
Three safety pins. 
Bandage. 
Make the bottom part of the crib in the usual manner; put 
the blanket on over the draw sheet; fold up the two lower 
corners so that it may be pulled out easily without dis- 
turbing the rest of the bed; place the upper sheet, blankets 
and spread on the bed, not tucking them in at the foot or on 
the sides. Adjust the top of the upper bedclothes as for 
an open bed, fold them all back together in a roll even with 
the foot; at the side from which the patient will be returned 
to his bed roll all of them (including the extra blanket) 
even with the edge of the mattress. Remove the pillow slip 
from the feather pillow; place a rubber of the same size 
inside it and spread it at the head of the bed where the 
patient’s head comes; hold it in place by pinning the two 
upper corners to the mattress at the head. (Do not pin 
through rubber.) Stand the hair pillow at the head of the 
bed and hold it in place by slipping a piece of bandage 
around it and the bars at either end. Fold a face towel 
over the upper edge of the bedclothes to protect them. Fill 
two hot water bags and place them in the crib, one near 
the head and one near the foot. Pin the paper bag to the 
head of the bed on the side nearest the table. On the bed- 
side table place 2 emesis basins, tongue blade, mouth wipes, 
postoperative record sheet, and pen and ink. 
As the child returns from the operating room, the nurse 
who precedes him into the room quickly prepares the bed 
for him by rolling back the upper bedclothes and removing 
the hot water bottles. If any of his clothing is damp or 
soiled, it must be changed, exposing him as little as possible. 
Tuck in the upper bedclothes at the foot and the sides of 
the crib as usual. The extra blanket is left over him for 
24 hours unless he is too warm. He should lie on his side. 
Postoperative care after general anesthesia should always 
After 
Operation SURGICAL NURSING CARE OF CHILDREN 
421 
include prophylactic measures against so-called ether or as- 
piration pneumonia. This means keeping the child on his 
side or in the ventral position with no pillow until he is 
completely conscious. This should be done from the start, 
beginning with the stretcher which carries him from the 
operating room. During the following days his position 
should be changed frequently, not allowing him to assume 
the dorsal position except when unavoidable. The above 
caution applies particularly to the postoperative care of a 
child following tonsillectomy. When vomiting occurs the 
vomitus may be received in the kidney basin. After vomiting 
the patient’s mouth is wiped out. The nurse must stay 
with him constantly until he is fully recovered from the 
anesthetic, i.e., until he is rational. She must watch the 
site of operation for hemorrhage, must take and record the 
pulse and respirations every 10 minutes for 1 hour, or until 
he is fully recovered, then must take them every 20 minutes 
for 3 hours. The temperature, pulse, and respirations must 
be taken and recorded every 4 hours for at least 3 days. 
The room should be 70° F. for 24 hours, then the usual 
temperature; it must be well ventilated, avoiding direct 
draughts. It must be quiet, no unnecessary talking should 
be allowed, and visitors and avoidable coming in and out are 
forbidden. The child’s face and eyes must be shaded from 
direct light, either sun or artificial light, but sunlight must 
not be shut out. Aseptic nursing care must be carefully 
observed. If the nature of the operation permits, the child 
is usually given water by mouth as soon as nausea ceases and 
in as large quantities as possible. Milk is given as soon after 
that as it can be tolerated. Fluids in other ways, as by 
rectum, by hypodermoclysis, etc., are very often necessary 
to prevent dehydration or acidosis. Sugar solutions in place 
of plain water may be ordered or extra corbohydrate, as 5 per 
cent sugar in the milk. Sodium bicarbonate and glucose 
in regular doses are also given after as well as before opera- 
tion by some authorities. (See note 2.) Light diet is given 
Keep Child 
on Side 
Change 
Position 
Frequently 
Vomiting 
Watch for 
Hemorrhage 
Take Pulse 
and 
Bespiration3 
Quiet 
Aseptic 
Nursing 
Force Fluids 422 
PEDIATRIC NURSING 
as soon as possible. All these details depend entirely upon 
the nature of the individual case and must be considered as 
guides only. A record of the fluid intake and the urine 
output should be kept for at least 48 hours; the first urina- 
tion after operation should be noted and the time is re- 
corded. If the child does not void urine within 8 hours, 
it should be reported. A specimen of urine is secured 
routinely. The first defecation must also be watched for, 
and if normal bowel function is not established, it too should 
be reported. 
Surgical Dressings. 
Surgical 
Dressings 
The dressing over the wound is never changed until ordered; 
efforts must be made to keep it sterile and if it becomes 
soiled it must be reported. The usual surgical technique is 
observed in changing it. If the child has an abdominal in- 
cision, as after an appendectomy, lie must wear an abdominal 
binder or swathe; this is best made of some light, firm 
material, as outing flannel, canton flannel, or twill; there 
should be various sizes to fit all ages. The abdominal binder 
should extend from just over the symphysis pubis up over 
the wound, but not high enough to bind the thorax; it should 
be pinned firmly in front; the slack at the sides is taken 
up with safety pins. The binder is held in place by perineal 
straps; these are straps 12 to 15 inches long, 1 to l1 inches 
wide, made of outing flannel. Pin the 2 straps with 1 
small safety pin at the middle of the lower edge of the 
binder in back, bring them around to the front through the 
groins and pin one strap on either side of the midline of 
the lower front of the swathe with small safety pins. If a 
chest binder is worn, it is also held in place by straps over 
the shoulders; the 2 straps are pinned with 1 small safety 
pin to the upper edge of the swathe at the middle of the 
back, one strap being brought over either shoulder and 
pinned to the upper edge of the binder on either side of the 
midline of the front. 
Abdominal 
Binder 
Straps SURGICAL NURSING CARE OF CHILDREN 
423 
Elevation of the foot of the bed may be ordered after 
operation, for instance, if the child is in shock. It is raised 
the desired height by means of (1) a mechanical adjust- 
ment, (2) by placing blocks of wood under the legs, or (3) 
by putting the foot of the bed on a protected table or chair. 
If the head of the bed is to be elevated for Fowler’s position, 
it also is done by one of the above methods. A head rest and 
two or more pillows are adjusted behind the child’s back 
and he is held in the correct position by the use of a knee roll 
or a foot sling. (See head rest, foot sling, knee roll, already 
discussed, Chapter V.) A cradle is used to keep the weight 
of the bedclothes from any part of his body. If necessary, 
it may be held in place by a piece of bandage or string around 
the cradle and under the springs of the crib. (The post- 
operative care of any particular diseases follows the descrip- 
tion of these conditions in Chapter XX.) 
(Note: This chapter has been read and approved by Dr. 
A. C. Strachauer, University of Minnesota.) 
To Elevate 
the Foot of 
the Bed CHAPTER XXIV 
THE ORTHOPEDIC NURSING CARE OF CHILDREN 
KATHERINE A. SMITH 
Introduction: 
Modern Orthopedic Surgery has been well defined by 
Berry as “the surgery of the deformities and disabilities 
of the apparatus of locomotion; the phrase, apparatus of 
locomotion, being used in a broad sense to include, not only 
the lower extremities, but also the trunk and upper ex- 
tremities. ’ ’ 
This subject occupies a vast field, and one of very great 
and general interest. Its most distinctive advance in recent 
years has been toward the prevention of deformity. 
Every intelligent nurse with keen powers of observation 
is an important factor in this prophylactic movement. Her 
work offers countless opportunities for early recognition of 
conditions, which, if disregarded, develop into serious and 
permanent deformities. 
The object of this chapter is to enable the nurse to rec- 
ognize in the child any significant symptoms, so that she 
may refer the patient to proper medical authority at an early 
stage. Since limited space does not allow detailed discussion 
of all orthopedic affections, tuberculous disease of the hip and 
spine have been selected, since their favorable prognosis 
depends largely upon the skillful, conscientious handling by 
the nurse, through long years of treatment. 
Orthopedic affections may be divided into two main classes: 
Congenital, and acquired. Congenital orthopedic affections 
are present at or before birth. They may be caused by 
424 ORTHOPEDIC NURSING CARE OF CHILDREN 
425 
undernutrition, pressure, or heredity, although for many 
congenital malformations no cause can be determined. Ex- 
amples of this class are club-foot, congenital dislocation of 
the hip or other bones, torticollis or congenital wry neck, 
and missing or supernumerary hones. Acquired orthopedic 
affections develop after birth, and follow disease, injury, 
faulty hygiene, undernutrition, or strain upon the body 
framework. In this group are included acute osteomyelitis, 
tuberculous disease of the bones and joints, arthritis, in- 
fantile paralysis (anterior poliomyelitis), spastic paralysis, 
poor posture, wreak feet, and the various deformities following 
rickets or contractures due to burns or other injuries. 
General Nursing Care: 
Mental attitude of child. In the first place, to attain the 
best possible results the child himself must be made to co- 
operate by keeping the right mental attitude. If he has 
learned the curse of self-pity from indulgent friends or 
thoughtless attendants, teach him the satisfaction of being 
treated not as a cripple, but as a healthy individual, with a 
normal mind. Ignore his physical handicap, treat him with 
respect, and help him to develop his own resources. Happi- 
ness is relative, and a crippled child who is utterly miserable 
in a household of romping brothers and sisters, will be per- 
fectly happy with a group of other convalescents. Any vis- 
itor in the orthopedic ward of a children’s hospital will 
notice with great surprise the happy faces, the bursts of 
song, and the general air of contentment. For those cases 
whose treatment extends over many months or years the 
orthopedic hospital school, a recent institution where super- 
vised treatment can be given while the child’s mind is oc- 
cupied with educational school work, is the ideal environ- 
ment. Indeed the knowledge of occupational therapy is 
invaluable in the care of individual cases. 
Care of the skin. The nurse is responsible for the con- 
dition of the skin of her patients. It is not always pos- 426 
PEDIATRIC NURSING 
sible to remove apparatus for cleansing purposes, but the 
utmost vigilance is necessary to prevent the formation of 
pressure spots, which are not only a great source of dis- 
comfort, but which sometimes suspend other treatment for 
weeks. 
These most frequently appear under a point of constant 
friction or pressure, such as the edge of a plaster cast, or 
under the weight of traction or any bony prominence like 
the knee or the ankle, or on the back of the heel. The foul 
odor of pus coming from underneath a plaster cast should 
always be investigated, and is sometimes the first indication 
of a pressure spot. The treatment obviously consists mainly 
in removing all pressure. The physician should be notified, 
and will direct treatment. Plaster casts may be trimmed, 
or have windows cut in them, while metal or other malleable 
materials may be slightly bent, readjusted, or padded with 
felt or cotton wadding. 
Careful observation will prevent the development of a pres- 
sure spot beyond the point of redness, and further progress 
is usually a direct reflection upon the care of the nurse. The 
treatment of tissue injury may be indicated in outline form. 
Treatment of Pressure Spots : 
Stage 
Treatment 
I. 
Redness. 1. 
Removal of pressure. 
2. 
Friction to restore circulation. 
3. 
Application of alcohol or other 
hardening lotion. 
II. 
Redness with broken skin. 1. 
Removal of pressure. 
2. 
Drying powder such as aristol, 
dermatol, boric acid, or zinc 
stearate. 
III. 
Dark bruise. 1. 
Removal of pressure. 
2. 
Friction around discolored area 
to restore circulation and pro- 
mote absorption. 
3. 
Hot and cold applications to 
stimulate the blood supply. ORTHOPEDIC NURSING CARE OF CHILDREN 
427 
IY. Deep discharging sore. 
1. 
Removal of pressure. 
2. 
Friction of surrounding area. 
3. 
Heliotherapy. 
4. 
Drying powder or hot antiseptic 
dressing. 
5. 
Healing ointment such as com- 
pound tincture benzoin, aristol 
ointment or balsam of Peru. 
Care of apparatus. The apparatus used for protection, 
fixation, and correction is of various kinds. It is strictly 
essential that the nurse understand the exact purpose of 
such apparatus, since in her daily care of the patient she 
is frequently called upon to readjust it. Misplaced splints or 
braces can undo, in an incredibly short time, the progress 
of tedious weeks. Splints and braces worn by growing chil- 
dren must be constantly watched and kept in good condition. 
The special shoes worn by children with weak feet need fre- 
quent repair; crutches are outgrown and need replacing; 
splints require occasional extension, and straps need mending. 
Deft readjustment of apparatus, slight loosening of a strap, 
or shifting of the affected limb will often relieve pain. These 
measures may be employed only with the permission of the 
surgeon, but should always be tried before resorting to drugs 
in acute cases. 
Care of plaster casts. To avoid the necessity of frequent 
changing of plaster casts, a process which is painful and 
expensive for the patient, and is often harmful, several simple 
measures may be employed. 
In the first place, to ensure an enduring cast, great care 
is needed while it is drying. This process requires from 
48 to 72 hours, depending upon the thickness of the cast. 
During this time, the cast should be kept absolutely still, 
and all pressure on the heel or other prominences avoided. 
After application of a cast, the utmost care must be used 
in lifting patients on and off the stretcher. Casts are not 
infrequently ruined by cracking at this time. Figure 47. Plaster Casts. Showing Method op Elevation 
428 ORTHOPEDIC NURSING CARE OF CHILDREN 
429 
If any blood stains through the bandage, this discolored 
area is usually painted with tincture of iodin, to prevent 
possible infection. 
With small children especially, the spica casts should be 
trimmed away as far as possible around the genitals, and 
these edges bound with oiled silk or rubber tissue, which is 
easily cleansed, and may be changed when necessary. Rubber 
wet with concentrated urine will scald delicate skin and 
must be kept clean. If the cast becomes stained, it may 
be washed with chlorinated soda, 1 to 64 solution, which 
is also a valuable deodorant. 
As soon as the cast is entirely dry, the edges may be 
trimmed and bound with 1 y2 or 2 inch adhesive plaster, 
snipping the edges to fit smoothly around all curves. If 
stockinet has been used under the cast, it may be finished 
nicely by facing back on the outside of the plaster and 
binding down with adhesive. 
Some surgeons have the cast painted with white woodwork 
enamel, to form a protective coat which is impervious to 
moisture, is easily cleaned, and prevents the crinoline edges 
of the bandage from fraying. 
Postoperative care. Following operation or manipulation, 
there is usually swelling of the injured tissues. Plaster 
bandages, when employed for immobilization or protection, 
are applied before this swelling develops, and the child must 
be watched closely. When there is considerable swelling of 
an extremity inside the cast, this pressure restricts the circu- 
lation, and in toes or fingers at the end of the bandage we 
find hard swelling, and even cyanosis. On pinching the toes, 
if the blood returns almost immediately, there is no cause 
for alarm, but when the toes are cold and dusky, and the 
circulation very sluggish, there is danger from too much 
pressure, and this should be reported to the surgeon without 
delay. The nurse should elevate the afflicted part if possible, 
and keep it warm. If necessary, the doctor, or in emergency 
the nurse under his direction, w7ill release pressure by bi- 430 
PEDIATRIC NURSING 
valving the sides of the cast with a sharp-pointed, curved 
plaster knife, or plaster shears. The two halves of the cast 
are bound together by wide bands of adhesive plaster, or 
webbing straps. The greatest care must be taken not to cut 
the patient during this procedure. When it is necessary 
to bivalve or remove a dry cast, the plaster may be 
slightly softened with warm water containing peroxid 
or vinegar, and applied with a bulb syringe or small 
pitcher. 
Congenital Orthopedic Affections 
Congenital torticollis. This is a distortion of intra-uterine 
origin caused by painless shortening of the tissues on one 
side of the neck. The sternomastoid muscle is primarily 
involved, although the trapezius also may be contracted 
especially in acquired torticollis. 
Early treatment by manipulation will often effect a cure. 
Posture should, as far as possible, favor the correction of 
deformity. Extreme or neglected cases usually require opera- 
tive treatment. Subcutaneous tenotomy and open incision 
are followed by fixation in an overcorrected position by 
means of a plaster support. This is removed at the end of 
from 4 to 8 weeks, and massage, manipulation, and gymnastic 
training are begun. In those cases when intelligent manipula- 
tion cannot be obtained, a brace may be worn for several 
months with advantage. 
Congenital dislocation of the hip. This is by far the most 
common and the most important of all the congenital dis- 
locations. It is a deformity in which the head of the femur 
is partially or completely displaced from the acetabulum. 
It may be present on one or both sides of the body, and 
is more common in girls than in boys. 
The deformity is seldom recognized until the child begins 
to stand and walk. The leg on the affected side is short, and 
there is unusual prominence of that hip, causing a limping 
walk. In double congenital dislocation of the hips the child ORTHOPEDIC NURSING CARE OF CHILDREN 
431 
walks with a characteristic waddle. X-ray pictures confirm 
the diagnosis. 
Early treatment while the bones are soft and ligaments 
more elastic, is of the utmost importance in the prevention 
of permanent deformity. The hip is usually reduced by 
forcible manipulation, called Lorenz bloodless operation, al- 
though occasional open reduction is necessary. Operative 
treatment is followed by fixation in an overcorrected position 
in a plaster spica, and the patient is sometimes allowed 
to walk while wearing this bandage. Massage may 
follow the removal of the cast. Recurrence is not 
uncommon. 
Talipes. This deformity is commonly known as club-foot. 
There are 4 simple varieties, and various combinations of 
these 4 types: 
1. Talipes equinus. The foot is turned downwards, and 
the patient walks on the heads of the metatarsal bones. 
2. Talipes calcaneus. The foot is turned upwards, and 
the patient walks on his heel. 
3. Talipes varus. The inverted foot, which shifts the weight 
to the outer border. 
4. Talipes valgus. The everted foot, which bears the weight 
on the inner border. 
Talipes should be recognized at birth, and treatment be- 
gun at once. In no other congenital malformation are early 
diagnosis and treatment more important. A perfect cure 
both as to form and function is possible when early, efficient, 
prolonged treatment is given, while untreated talipes grows 
progressively worse. 
The extent of the deformity and the age of the child de- 
termine the method of treatment to be employed. Manipula- 
tion, plaster casts for overcorrection, forcible reduction fol- 
lowed by plaster casts, special shoes, braces, and even open 
operation, may be necessary. There is a tendency to re- 
currence, and treatment should be continued until the de- 
formity is overeorrected, and growth completed. 432 
PEDIATRIC NURSING 
Acquired Orthopedic Affections 
Deformities following rickets. Rickets, or rachitis, is a 
constitutional disease of infancy caused by defective nutri- 
tion, of which the most marked effect is distortion of the 
bones. The most common deformities in the order of their 
appearance are craniotabes, rachitic rosary and enlargement 
of other epiphyses, rachitic bowing of the spine from lack 
of muscle tone, bow-legs, knock-knees, pigeon-breast, and 
Harrison’s groove. 
The prognosis depends upon the age of the patient, the 
severity of the disease, and the treatment employed. Proper 
dietetic treatment begun when the child is under one year 
of age will usually eradicate all traces of deformity within 
a few years. In older children, deformities of the trunk tend 
to disappear with age, wdiile those of the lower extremities 
increase with weight bearing and activity. 
Treatment is dietetic, hygienic, medicinal, and corrective, 
according to the age of the patient. (Prophylactic, dietetic, 
and medicinal treatment have already been discussed in 
Chapter XX.) Mild deformities, such as craniotabes, en- 
largement of the epiphyses, including rachitic rosary, rachitic 
kyphosis, and mild bowing of the extremities, usually respond 
promptly to this treatment. Slight bowing of the legs in 
infants is normal and disappears with growth. Abnormal 
bowing, especially when rachitic, should be recognized in 
the early months of life, and manipulation begun. The bone 
is grasped firmly by placing a hand at each end close to 
the joint. Gentle but firm pressure is exerted to bend the 
bone to a straight, and later to an overcorrected position. 
This exercise should be repeated several times, twice daily. 
With more extreme cases, braces may be used to hold the 
bones in an overcorrected position, and if this is not effective, 
operative treatment is necessary. The closed method of 
fracture, called osteoclasis, is usually employed, followed by 
fixation in a plaster cast. In older children, or any case of ORTHOPEDIC NURSING CARE OF CHILDREN 
433 
extreme anterior bowing, an open osteotomy, with removal of 
a wedge of bone, is advisable. The bowing may be of vari- 
ous types, but the treatment is similar. 
Deformities following anterior poliomyelitis. Anterior 
poliomyelitis, or infantile paralysis as it is commonly called, 
is an acute infectious disease. It is frequently seen in epi- 
demic form, but the mode of transmission has not been de- 
termined. It is caused by a minute germ which attacks the 
central nervous system, causing inflammation, followed by 
injury or destruction of the cells. Changes are most marked 
in the anterior portion of the cord. Primarily, the paralysis 
is widespread because of interference with function caused by 
congestion and edema. Eventually the area is determined by 
the actual damage to the nerve cells and conducting tracts. 
As in other acute infectious diseases, there is usually a 
sudden onset with elevation of temperature and general 
malaise, with possible vomiting or convulsions. Early symp- 
toms often resemble those of an acute coryza. Paralysis of 
the flaccid type usually follows within 24 hours, and is accom- 
panied by tenderness and pain on motion. In small children 
paralysis may be the first symptom noted. Fever and other 
acute symptoms disappear within a few days. After that 
time the pain gradually subsides, until by the end of 6 weeks 
only the paralysis remains. 
The prognosis as to function depends upon the extent of 
cell injury or destruction, and the subsequent treatment of 
the weakened or disabled part. 
Treatment during the acute stage does not come within 
the orthopedic range, but the importance of prophylactic 
measures at this time cannot be overestimated. Most author- 
ities agree that while there is any muscle tenderness, absolute 
rest in bed is indicated. The position of the affected part 
may be changed, but the extremities should be supported in 
such a way as to relieve all unnecessary strain. Toe drop 
caused by the weight of the feet or bedclothes is a serious 
deformity, and may be prevented by supporting the toes 434 
PEDIATRIC NURSING 
on a sand bag or firm pillow. After all pain has disappeared, 
massage, electrical treatments, and exercise will restore much 
of the lost power. Ultimately it may be necessary to resort 
to braces or operative treatment for correction of deformity. 
Spastic paralysis (Little’s disease). This disease is char- 
acterized by motor weakness, by stiffness and loss of con- 
trol, rather than by paralysis. It is followed by contraction, 
atrophy, and deformity. Mental deficiency is a common 
sequel. There are four types: Spastic hemiplegia, involving 
one side of the body; paraplegia, involving lower extremities 
only; diplegia, involving both upper and lower extremities; 
and monoplegia, where the spasticity is limited to one ex- 
tremity. By far the most common cause in children is cerebral 
hemorrhage at the time of birth. 
The significance of early symptoms is rarely appreciated. 
Cerebral hemorrhage does not come within the orthopedic 
province, but its early recognition and the prevention of 
spastic paralysis should be included. Its frequent occurrence 
without death is attested to by the thousands of cases of 
mental deficiency, spastic palsies, epilepsy, blindness, and 
varying degrees of amentia. Infants born after instrumental 
or protracted labor, or any newborn baby showing some de- 
gree of asphyxiation or delayed spontaneous respiration, 
should be watched for symptoms of cerebral hemorrhage. 
Inequalities of the pupils, ocular palsies, hyperactivity of 
the reflexes, and twitching or convulsions may be present. 
Lumbar puncture is of great diagnostic and therapeutic 
value. Early decompression may relieve all symptoms and 
prevent the resulting brain injury and muscular spasticity 
which become apparent when the child is a few months of 
age. These children are restless, and repeatedly throw their 
arms and legs outward, and turn their heads in characteristic 
athetoid movements. They drool a great deal, and instead 
of normal sounds, the extreme cases make animal-like noises. 
Marked contraction of the adductor muscles is common, and 
causes the so-called “scissors gait.” ORTHOPEDIC NURSING CARE OF CHILDREN 
435 
The prognosis of cerebral hemorrhage is good, if diagnosed 
soon after birth and skillfully treated. The prognosis of 
neglected cases is poor. Patient care, mental and physical 
exercises, and special measures for building up the general 
nutrition are rewarded by slight improvement. In those rare 
cases where mental faculties are unimpaired, the cooperation 
of the child may be secured, and more accomplished for the 
relief of spasticity. 
Treatment of spastic paralysis consists in building up 
the general condition, special mental and physical training, 
and operation to relieve the muscle contraction. 
Obstetrical paralysis. Obstetrical paralysis of the shoulder 
and arm is caused by injury to the brachial plexus. This is a 
comparatively common result of difficult or protracted labor. 
It may be induced by direct pressure on the brachial plexus, 
but most often follows traction on the body or head, with 
violent twisting of the neck. There may be only hemorrhage 
due to bruising, but frequently the nerve roots are torn apart. 
During the first month there may be local swelling and pain 
on motion. If the nerves are torn, control of the muscles is 
impaired, and atrophy is common. In extreme cases the arm 
hangs in an attitude of inward rotation with pronated fore- 
arm. 
For mild cases receiving prompt treatment the prognosis is 
excellent. Function may be greatly improved although rarely 
completely restored when the birth injury was excessive. 
Treatment consists in immobilization of the arm and 
shoulder by means of a cotton or plaster bandage. When 
the primary tenderness has subsided, simple massage should 
be started, and all strain on the deltoid relieved by a sling, 
splint, or cast. Operative treatment may be employed for 
the stretching of capsule and muscles, or for nerve repair. 
Tuberculosis of the Hip. 
Etiology. This disease may occur at any age, but it is most 
common among children. The tubercle bacilli usually enter 436 
PEDIATRIC NURSING 
the body through the mouth, and become active when the re- 
sistance of the child has become lowered by illness, under- 
nutrition, constant fatigue, or unhygienic surroundings. 
Trauma following a fall or blow is frequently the localizing 
cause. 
Symptomatology. The bacilli usually attack the epiphysis 
of the neck of the femur, and gradually work through the 
head. As the infection spreads, the first symptoms to appear 
are a limping gait, pain on motion, muscular spasm, and dis- 
tortion. X-ray examination at this stage frequently shows 
bone atrophy and destruction, and confirms a diagnosis of 
osteomyelitis, which from the absence of high temperature, 
and other symptoms of acute infection, is diagnosed tubercu- 
lous. Acute osteomyelitis of the bone is usually in the shaft, 
while tuberculosis is in the epiphysis. 
If the first symptoms are disregarded, the infection burrows 
steadily through the head, resulting in joint involvement, 
which is very much more serious. There is now marked pain 
on motion, and the muscles around the hip are contracted, 
holding the thigh in a slightly flexed position to prevent 
strain. This muscle spasm sometimes relaxes suddenly during 
deep sleep, and the friction of the inflamed surface of the 
head against the acetabulum causes intense pain, so that the 
child gives a sharp piercing cry known as a “night cry.’’ 
This wakens him, and with the return of consciousness, the 
muscles immediately contract again, protecting the joint, and 
the child drops off to sleep. 
Before hip disease was diagnosed and treated in the earlier 
stages, the infection often ate away part of the head and 
neck of the femur, and spread to the acetabulum. As a re- 
sult, the two opposing diseased surfaces healed together, form- 
ing a stiff hip, with more or less deformity, depending upon 
the position in which the leg was held by the contracted 
muscles. The most common deformity is flexion and adduc- 
tion, although abduction is also occasionally seen. 
Complications. (1) “Cold” abscess, so called because of ORTHOPEDIC NURSING CARE OF CHILDREN 
437 
the absence of inflammation usually present in abscesses caused 
by other organisms, is the most common complication of tu- 
berculosis of the hip. It causes little pain, unless there is 
great tension on the surrounding tissues. Unless the pain 
is severe, or the resistance of the body very low, the abscess 
is allowed to absorb. In opening a tuberculous abscess there 
is great danger of cross-infection, which is very serious. For 
this reason, many surgeons wish to withdraw the fluid by 
aspiration rather than incision when evacuation is necessary. 
The incision into a cold abscess must be dressed with the 
most perfect surgical technique. (2) Involvement of the sec- 
ond hip is not uncommon. (3) Meningitis occasionally occurs 
in those cases where the resistance of the.child has been greatly 
undermined, and the absorption from diseased bone or abscess 
is great. (4) In adults, pulmonary tuberculosis is present in 
a large percentage of these cases, although rarely seen in 
children. 
Prognosis. The object of treatment is to restore normal 
function and prevent deformity. This is accomplished when 
diagnosis is made early, and proper treatment carried out. 
In advanced cases, there is usually some permanent shortening 
of the leg on the affected side, and more or less limitation of 
motion. In extreme cases, complete ankylosis of the hip with 
shortening usually results. Complete cure is seldom effected 
in less than 3 or 4 years. 
General Treatment. As in all tuberculous cases general 
hygienic measures are of supreme importance. A simple lib- 
eral, nourishing diet, and a regular daily program including 
much rest and fresh air, are essential. The efficiency of the 
treatment may be judged by the local comfort and general 
constitutional improvement. 
The last few years have proved the great value of helio- 
therapy in surgical tuberculosis. The greatest benefit is de- 
rived from general body sun baths, although localized ex- 
posure with the use of special lens is valuable, especially in 
cases with discharging sinuses. The most remarkable result 438 
PEDIATRIC NURSING 
of heliotherapy in joint tuberculosis is the preservation of 
motion, and even restoration of motion when partial ankylosis 
has taken place. 
Local Treatment. The first step is to protect the joint from 
all motion or jar. This is accomplished by applying traction 
in the line of deformity. If muscle spasm is present, and 
holds the thigh slightly flexed, traction must be made in this 
line. If the existing deformity is disregarded, and the leg 
is pulled in a line parallel to the body, the contracted 
muscles will only increase their tension, and defeat the object 
of traction. 
Figure 48. Bradford Frame 
Undivided Cover for Diaper Children. 
Divided Cover Permitting the Use of the Bed Pan. 
The common deformities in acute tuberculosis of the hip 
are flexion, with adduction or with abduction. To determine 
the amount of flexion, raise the extended leg until the spinal 
column rests flat on the bed. Traction must be applied with 
the leg supported at this angle. To determine the amount 
of ad- or ab-duction, swing the extended leg toward or away 
from the median line, until the crests of the ilia are directly 
parallel with the foot of the bed. Adjust the traction appa- 
ratus to pull at this angle. A small pad placed under the 
popliteal space is a comfort to older patients. ORTHOPEDIC NURSING CARE OF CHILDREN 
439 
During the acute stage it is necessary for the child to re- 
main in bed. Traction is most successfully secured by means 
of a Bradford frame, an adhesive extension, a pulley attached 
to the foot of the bed, and weights. The measurements of the 
frame are very important, since traction depends upon the 
fixation of the pelvis. The frame should be 4-6 inches longer 
than the patient, and the width between the crests of the ilia, 
the width of the frame. For older children the frame cover is 
divided, and the upper and lower pieces separated 6 inches 
to permit use of the bed pan. The lower edge of the upper 
and longer cover should come just to the edge of the buttocks. 
Figure 49. Tuberculosis of the Hip with Abscesses and Slight 
Flexion Deformity 
A firm pelvic band fixes the pelvis to the frame, and a second 
narrower band is placed around the frame and over the well 
leg for restraint. The trunk is fixed by a muslin apron reach- 
ing from the pubic bone to the sternum, and extending to 
the edge of the frame on each side. This is held in place by 
2 straps from the top center buckled under the corners of 
the frame to 2 side straps inserted in the apron just below 
the axillae. The lower part of the apron is secured by means 
of straps buckled underneath the frame. 
The adhesive extension is applied in spinal fashion, and 
attached to a footpiece from which a cord rolls over the 
pulley and is attached to the weights. The general rule for 440 
PEDIATRIC NURSING 
weight is to put on as many pounds as the age of the child 
plus one. Traction correctly applied brings great relief. 
As muscle spasm decreases, the leg may be lowered, and 
gradually reduced to a more normal position. This reduc- 
tion is accomplished slowly, for if attempted too rapidly 
muscle spasm will immediately increase. 
Avoid all jar of the injured joint. Turn the child off the 
frame by rolling him gently onto the well side, to bathe, rest, 
and rub his back. Never allow him to sit up, and see that 
the cord does not slip off the pulley. Move him as little as 
possible. 
After all acute symptoms, i.e., muscle spasm, night cries, 
and elevation of temperature, have disappeared, the child may 
be put into a traction hip splint, the ones most commonly used 
being the Bradford abduction splint, the long traction brace, 
or a plaster spica. A high sole is attached to the shoe on the 
well foot, and with crutches for support the child is allowed 
up and around. 
When all acute symptoms subside quickly, the parents are 
inclined to be too optimistic; they remove the apparatus just 
to see if the child can walk, and, finding he can, leave it off. 
The inevitable result is a recurrence, with increased bone 
destruction. The importance of prolonged conscientious 
treatment cannot be overemphasized. 
Pott’s Disease, or Tuberculosis of the Spine. 
Etiology. Identical with that of tuberculosis of the hip. 
Symptomatology. Pain, stiffness, weakness, awkwardness, 
and deformity, as the disease progresses. Guarded motion of 
the spine in walking; stooping by flexing knees and hips rather 
than back; when sitting, the weight of head and shoulders is 
supported by the hands, which grasp the chair. The tubercle 
bacilli attack the body of any single vertebra and destruction 
slowly spreads. If early symptoms are disregarded, the inter- 
vertebral disks and adjacent vertebrae become involved, and 
there is a buckling of these joints under the weight of the ORTHOPEDIC NURSING CARE OF CHILDREN 
441 
upper part of the body, forming a kyphos. This is accom- 
panied by a marked decline in the general condition of the 
patient. Due to pressure on the nerves coming from the 
spinal cord, abdominal or chest pain is often present. As in 
tuberculosis of the hip, there is muscle spasm over the dis- 
eased joint. 
Complications. (1) Abscess is a frequent complication in 
Pott’s disease. This is a serious complication, which may 
greatly prolong the duration of the disease for two main 
reasons. The resistance of the patient is lowered by the 
absorption from the abscess. Mechanical treatment must fre- 
quently be suspended because of local swelling. The abscess 
seldom appears immediately over the infected vertebra, but 
follows the line of least resistance, usually working its way 
along some muscle sheath until it finds room to expand. When 
the cervical vertebrae are involved, the abscess may be retro- 
pharyngeal, or deep cervical. In dorsal Pott’s disease, the 
abscess often manifests itself in the mediastinum, causing 
dyspnea, coughing, and considerable discomfort. This is the 
most dangerous location for an abscess in Pott’s disease. In 
Pott’s disease of the lumbar region, the abscess usually fol- 
lows the sheath of the psoas muscle, appearing in the 
lower abdomen, or it may be lumbar, iliac, or gluteal. 
(2) Paralysis of the lower extremities may result from 
pressure on the cord in the case of a sharp kyphos. 
(3) Meningitis is occasionally seen when the resistance 
of the child is low, and the bony destruction extensive. 
(4) Lung involvement is not uncommon in tuberculosis of 
the spine. 
Prognosis. The object of treatment is to restore normal 
function and prevent or correct deformity. With prolonged 
efficient treatment, this is possible in early cases. When there 
is a large kyphos involving several vertebrae, the deformity 
can be greatly reduced, although not entirely removed. With 
the most efficient, persistent treatment, this disease is rarely 
cured in less than 3 or 4 years. 442 
PEDIATRIC NURSING 
General Treatment. This is of the utmost importance. See 
tuberculosis of the hip, General Treatment. 
Local Treatment. The fact that the spine is a weight bear- 
ing column, makes the treatment difficult. The principles of 
treatment are protection, hyperextension and immobilization. 
These can best be provided by recumbency in a posterior 
plaster shell, on a Bradford frame. To prevent further de- 
formity, all pressure must be removed. Correction of the 
existing deformity is accomplished by hyperextension of the 
spine, using the angle of the kyphos as the pivot. The ad- 
vantage of the posterior shell lies in the fact that it provides 
Figure 50. Pott’s Disease, Showing Posterior Shell Treatment. 
a firm, comfortable support, allowing almost no motion of the 
trunk, which would jar the injured vertebae. This is also 
one of the most efficient means of securing hyperextension. 
The child in the shell is strapped to a Bradford frame to 
stabilize the shell, and restrain the child. In handling these 
delicate cases, the nurse must be deft, firm, and gentle. The 
back, and especially the skin over the kyphos, needs special 
care. There is great danger of a pressure spot over the bony 
prominence, and this may be avoided by cleanliness, harden- 
ing of the skin, and adjusting of the shell padding, so that the 
Aveight comes just each side of the spinous process, rather than 
directly over the point. The pads, over Avhich the column is ORTHOPEDIC NURSING CARE OF CHILDREN 
443 
hyperextended, are usually fixed 1 inch apart, to relieve all 
pressure over this prominence. The child should be moved 
as little as possible, but it is usually necessary to turn him out 
of the shell at least once a day. The most satisfactory method 
is to apply the anterior half of the shell, strqp it into place, 
turn the child upon his face, and remove the posterior shell. 
This gives a minimum of jar and motion, and exposes the back 
for bathing, rubbing, restful change of position, and sun treat- 
ment. If there is no anterior shell, the child is turned in the 
following way: Loosen all straps and clothing. Raise the 
Figure 51. Showing Method of Head Traction Sometimes Used 
for Cervical Pott’s Disease 
child’s hands over his head. Tell him your purpose, and in- 
struct him to hold his body stiff and straight. Grasp him by 
the knee and shoulder, and slowly turn him upon his face. 
When acute symptoms are absent, ambulatory treatment 
in a leather or plaster jacket or a steel back brace is some- 
times advised. 
To shorten the period of convalescence two operations may 
be performed. They are more successful in adults than in 
children. Dr. Albee’s operation is the one most frequently 
employed, and consists in providing the affected part of the 444 
PEDIATRIC NURSING 
spine with a natural, permanent splint. The spinous processes 
are divided, and a long splinter of bone from the tibia is in- 
serted. When the graft is healed, this portion of the back is 
stiff. 
A second operation, used more for adults than for children, 
is Dr. Hibb’s. The spinous processes are bent down, one over 
the other, forming with the periosteum a bony ankylosis in the 
region of the kyphos. 
Weak Feet. Every nurse realizes the value of strong, 
normal feet. Much of the foot trouble in adults may be 
traced directly to improper shoes, incorrect walking habits, 
and untreated weak feet during the early years of life. 
In young children, the most common cause of weak feet 
is poor muscle tone due to general undernutrition. With 
relaxation of tendons and muscles, the arch drops, and it is 
the abnormal contour of the foot, described by the term “flat 
foot,” which first attracts the mother’s attention. 
The arch should be supported in the normal position by 
means of inner sole pads, or building up of the outer sole 
of the shoe. At the same time the general condition of the 
child is improved by dietetic and hygienic measures, and 
within a few months the original tendency to weak feet has 
entirely disappeared. 
When a child begins to walk he should have the support of 
broad, firm soles. If the ankles are weak, high shoes are 
indicated until these muscles have been strengthened. 
Sudden onset of foot trouble in older children is commonly 
caused by improper shoes, faulty position in walking, and 
undernutrition. 
The first symptoms are pain in the arch, ball, ankle, or 
in the leg. On examination the foot may be apparently 
normal, but observation shows an improper walking attitude, 
or cramped and ill-fitting shoes. There may be sagging of 
the ankle, eversion of the foot, and later actual displacement 
of the bones of the arch. 
Shoes should be broad enough to allow ample room for the ORTHOPEDIC NURSING CARE OF CHILDREN 
445 
toes to grasp the ground in walking. This strengthens the 
arch muscles, and is the normal function of the foot. The 
heel should be broad and low, and the length of the shoe be- 
tween % to % inch beyond the great toe when the child is 
standing. 
The fact that the comparatively small foot surface bears 
the weight of the entire body many hours each day makes 
the study of this part of the body especially interesting. The 
anatomy of the foot is intricate, and it is easy to understand 
why slight shifting of body weight or crowding of the bones 
can cause so much distress. 
The normal attitude of the foot in walking is slight ad- 
duction as the step is taken. This throws the weight of the 
body to the outer side of the foot, and back onto the ball. In 
walking with the toes turned out, the weight of the body is 
shifted from the outer side of the foot to the inner, which 
is not prepared for this added strain and breaks down. When 
standing, the feet should be slightly everted, since both feet 
are on the ground at once, and a more perfect balance is 
maintained. Confusion of these two attitudes is the cause 
of a great deal of foot trouble. 
“Pigeon-toe” is usually a symptom of weak feet, and the 
treatment is the same as that given above. This attitude is an 
involuntary effort to avoid deformity. 
Alternating hot and cold douches, one minute each, for 
five or ten minutes twice daily, will stimulate the circulation 
and improve the muscle tone. A set of simple exercises which 
should be practiced twice daily are very beneficial. 
Exercise for Weak Feet: 
1. Walk across the room and back, in the proper attitude, 
10 to 20 times. 
2. Stand with the feet straight ahead, and parallel to each 
other; slowly raise to the tiptoe position, shifting the 
weight to the outer border of the foot; slowly lower 
the heels to the floor. Repeat this 20 times. 
3. Have the patient lie flat on his back. Bend the toes 446 
PEDIATRIC NURSING 
downward, then upward, then in a circular motion. 
Repeat 20 times. 
4. Raise the child to a sitting position on a bed or table. 
Stand facing the child, and place the palms of your 
hands against the balls of his feet. Have him press 
slowly against the resistance of your hands. Repeat 
20 times. 
5. Stand on one foot. Try to grasp the round rung of a 
chair with the toes of the other foot. Repeat 20 times. 
Lateral Curvature of the Spine (Scoliosis). Lateral curva- 
ture of the spine is an habitual or fixed deformity in which 
the spine is more or less inclined to one or the other side of 
the median line. It may occur at any age, but the majority 
of cases are first noticed about the age of puberty. 
The most common causes of scoliosis are general weakness, 
fatigue, habitual posture, occupation, rachitis, or scoliosis 
secondary to disease or deformity. Ill-fitting school desks 
are a contributing cause in many instances. 
Prognosis is excellent in early cases due to habitual posture, 
weakness, and fatigue. Lateral curvature in a young child 
is of far greater importance than in an older subject because 
of the probability of an increase of deformity. Incipient de- 
formity may be cured and cure is not impossible even when 
deformity is more advanced, but in this more than in any 
other postural deformity absolute cure implies early diagnosis 
and prevention rather than the correction of fixed distorfion. 
The first and most important preventive measure is the 
discovery of deformity or the tendency to deformity at an 
early age. Children should be stripped for all physical 
examinations. 
Principles of treatment include all measures for the im- 
provement of general nutrition; avoidance of overfatigue; 
the prevention of predisposing postures, and the correction 
of existing deformity. 
The methods of local treatment, prescribed according to the 
requirements of the individual case, are as follows: ORTHOPEDIC NURSING CARE OF CHILDREN 
447 
1. Corrective exercises. 
2. Gymnastic training. 
3. Support of weakened muscles by means of a light brace 
or leather or plaster jacket. 
4. Corrective jackets under which increasing pressure is 
brought to hear over the bony prominence of the de- 
formity. 
Operative treatment is not very successful and is seldom 
advised. 
Postural Kyphosis (Round Shoulders). This is a common 
deformity, and in childhood its etiology is similar to that of 
lateral curvature. Clothing which restricts free motion may 
be a predisposing cause. 
Round shoulders are frequently accompanied by flat chest 
and prominent abdomen. Habitual deformity may cause 
serious and permanent displacement of the viscera. Many of 
the digestive disorders of later life may be traced directly to 
this cause. 
Treatment is identical with that for mild cases of lateral 
curvature. Improvement of the general nutrition, assumption 
of a soldier-like erect attitude in both walking and sitting, 
and corrective exercises are the most important measures. 
Conclusion. One chapter on the nursing care of orthopedic 
conditions will prove quite inadequate to those students who 
are especially interested in orthopedic surgery. The follow- 
ing list of books will be found useful for further study. 
READING REFERENCES 
Albee—Orthopedic and Reconstruction Surgery. 
Berry—Orthopedic Surgery for Nurses. 
Calot—-Indispensable Orthopedics. 
Jones—Orthopedic Surgery of Injuries. 
Lovett—The Treatment of Infantile Paralysis. 
Scudder—Treatment of Fractures. 
Soutter—Operations on Muscles, Bones, Joints, etc. 
Tubby—Textbook of Orthopedic Surgery. 
Whitman—Orthopedic Surgery. CHAPTER XXV 
THE EDUCATIONAL VALUE OF OCCUPATIONAL THERAPY IN THE 
CARE OF SICK CHILDREN 
Susan E. Tracy, r.n, 
When a child is overtaken by an illness it is usually felt to 
be an interruption to his education. If by education is meant 
only that process which goes on inside the schoolroom this is 
doubtless true, but a far greater truth is that it is really im- 
possible to interrupt his education. Educated he will and 
must be by any and all agents which call out from his own 
mind that which is there to respond. Wherever a child finds 
himself, there he finds his education. If the aim be to con- 
form to the accepted methods of the schools the education 
of the sick child must be supervised by teachers from these 
schools and the practice of sending to the bedside of such 
children teachers who will keep them along with class wrork 
is in force in many cities. Much good work has resulted from 
this method. In the case of the youngest children this teach- 
ing becomes true occupational therapy since the kindergarten 
has always been a powerful help in treating the little ones. 
The employment of this method with older children and even 
with adult patients is far more advantageous than is generally 
supposed. This may be credited to the fact that “man is 
always and everywhere a motor animal; his normal reaction 
being a motor reaction.”1 
Formerly disease was vanquished by various “charms.” 
There has been found in all primitive peoples that which has 
responded to this form of treatment and we shall do well to 
revert to ancestral types. It matters not whether the child 
1 Crile, George, M. D., “The Origin and Nature of the Emotions.” 
448 EDUCATIONAL VALUE 
449 
be a hospital patient or a private home case, rich or poor, as 
he may be called, we may draw around him a magic circle; 
his own mind the center of this circle while the teacher marks 
the sixteen points of its circumference. The charm in the 
process lies largely with the teacher. The education of the 
Figure 52. The Magic Circle 
sick child may be most unhappily developed or it may be a 
constantly increasing joy. 
Let us suppose that the magic circle be started with a 
lesson on Light. A true light-treatment. The fear of dark- 
ness is often very great with little children. A lesson on light 
will help to dissipate this fear. Candle-making is a charm- 450 
PEDIATRIC NURSING 
ing occupation. Molds may be made of cement or even sand 
or earth. A small box of earth can serve for this purpose. 
The melted paraffin and a soft string for a wick is all that 
is needed. From candles the step may be made of modeling a 
crude little oil lamp such as is used by the dwellers in 
arctic huts. This lamp is formed of clay. Many charming 
lanterns can be designed, very thin sheet brass being a good 
material for these. What becomes of the darkness? This is 
a successful treatment if the child learns that it is quite 
in his own power to abolish it. 
The second point in the magic circle is the study of perfect 
Form. Here one is happily provided with a wonderful series 
of balls. To teach appreciation of the sphere, mix a pure 
white salt-bead paste. This is done by using one part corn- 
starch to two parts table salt. Mix thoroughly while dry and 
heat very hot without scorching. To this add one part boil- 
ing water, mixing quickly and thoroughly. Knead smooth 
and mold into uniform balls. Let these harden, after which 
they may be used as marbles or pierced before quite hard to 
form beads. To be able to make a dozen or more of these 
beads of equal size and shape is a good test of sense of form 
and judgment. 
Next in the circle comes Color. Mix a second lot of salt 
and starch paste adding to this, in the boiling water, a little 
coloring matter. This may be had from a scrap of crepe 
paper or pigment of any sort. If time and interest warrant, 
divide the dry salt and starch into several lots, using a 
different color with each portion. This results in a charming 
series of plastic lumps which furnish much entertainment. 
The whole world loves a ball. Why? Possibly because all 
live upon the surface of one. Men, women, and children all 
play ball. A series of some twenty-odd balls have been de- 
signed and worked out by nurses in different hospitals. In one 
institution in the middle west a lesson in nursery astronomy 
was developed from these balls. Over a round table was hung 
a small umbrella from which the handle had been cut away. EDUCATIONAL VALUE 
451 
The whole top and under side were covered with deep blue 
paper. From the center was suspended a great golden sun- 
ball made of fluffy wool with rays of different lengths. After 
this the earth-ball was made with white poles, green temperate 
zones, and red and orange tropics. Jupiter with his many 
moons, Venus, Mars, and Saturn with his wonderful ring, 
were fashioned. Wooden beads were used for the moons. 
These, all hung with well-nigh invisible threads from the blue 
dome, formed a fascinating solar system. Now, to the music 
of some simple little hymn sing— 
Smooth and round, smooth and round, 
Rolling all along the ground, 
Spinning high in upper air 
Go the bright balls everywhere; 
From my hand I send you free, 
Soon returning unto me— 
Wondrous spheres of light and shade! 
Perfect form which God hath made. 
Round and round, round and round, 
Turns the earth without a sound, 
In the bright skies near and far 
Shines the light of many a star, 
Balls of beauty and of light, 
Swinging clear in God’s own sight, 
Star with star they each and all 
Are forever playing ball. 
Harmony follows the Form and Color lessons. The string- 
ing of colored beads, the decoration of the sphere, the showing 
of light through colored shades, the mixing of a series of 
colored waters in tiny phials which can be arranged variously, 
the blowing of soap-bubbles and observation of their colors— 
all these occupations help to answer the questions—“What 
does light do to color?” and “What does color do to light?” 
The prism “Jack-o’-lanterns” on the wall, the “Broken Sun- 
light” game, teach harmony and prove the truth of the ex- 
pression that “Beauty lies in harmony and not in contrast; 
and harmony is refinement.”2 
3 Montessori, Maria, ‘ ‘ Montessori Method. ’ ’ 452 
PEDIATRIC NURSING 
A lesson on Water will be a delight. Pure, colorless watei 
first. How good it tastes to the little sick child! Then water 
yellow with orange juice, pink with raspberry juice! The 
difference between an empty cup, a full cup and an over- 
flowing cup is interesting. Catching rain-water, melting snow, 
watching ice melt, asking ourselves the question—“Why do 
we not get a cupful of water from a cupful of ice?” helps to 
vary the lesson. Think about still water, then running water, 
making wells, canals, and rivers, water-wheels, water-falls, 
and then boats. At first the boat is only a floating chip, a 
raft, a quickly folded paper boat made from the wax paper 
lining the biscuit-box and so able to really float, later it be- 
comes more elaborate, made from wood and metal. Whenever 
possible finish this subject with a swimming lesson. 
Plants come sixth in the circle. Seeds to be planted and 
tended, bulbs to blossom, cuttings from bouquets to be rooted 
in water or sand, trees to be drawn, painted, cut out or made 
from twigs or wire, flowers to be studied and copied in all 
sorts of materials, this will open up the plant-world to any 
child. A lovely little greenhouse can be made by cutting 
down a small wooden box to a slant-roof top and tacking on a 
strip of wood along the lower edge on which a piece of window- 
glass rests. The box holds a layer of plain sand in which is 
set all sorts of bits of growing things. A piece of geranium, 
or any scrap of plant which comes to hand. When rooted, 
these must be potted off into tiny pots of earth. Do not keep 
the sand too moist. 
Animals come next. Our world is expanding rapidly. 
These animal toys are the delight of every child. Modeled 
from clay or salt-bead mixture, which is warmer and more 
comfortable, cut from paper, made from cloth and stuffed, 
quickly contrived from fruits, vegetables, or seeds, drawn, 
painted, or impersonated by the child himself, in any case, the 
charm holds. The fuzzy kitten and the curly dog keep the 
first place in the child’s affections. 
People ! The crowning creation. Dolls of all nations, times, EDUCATIONAL VALUE 
453 
and events now enter. Paper dolls, rag dolls, improvised dolls, 
dolls from ‘ ‘ Mother Goose ’ ’ and Hans Andersen, loved, recog- 
nized, and imbued with life by the little patient. No child 
need ever be shut away from people for the butcher doll calls 
at his bedside, the fisherman takes him out in his dory, Mother 
Hubbard finds a bone for his dog, and little Puck whisks him 
around the world. 
And now that the child’s world is peopled we may give a 
little time to sense-training. No more beautiful example of 
such a lesson will be found than that given by Madam Montes- 
sori on “The Silence.” She writes: “I have established sev- 
eral games of silence. ... I call the children’s attention to 
myself, telling them to see how silent I can be. I assume 
different positions; sitting, standing, and maintain each pose 
silently, without movement. A finger moving can produce 
noise, even though it be imperceptible. We may breathe so 
that we may be heard. But I maintain absolute silence, which 
is not an easy thing to do. I call a child and ask him to do as 
I am doing. He adjusts his feet to a better position and this 
makes a noise! He moves an arm, stretching it out upon 
the arm of his chair; it is a noise. His breathing is not 
altogether silent, it is not tranquil, absolutely unheard as 
mine is. 
“During these manoeuvers on the part of the child, and 
while my brief comments are followed by intervals of im- 
mobility and silence, the other children are watching and 
listening. Many of them are interested in the fact, which 
they have never noticed before ; namely, that we make so many 
noises of which we are not conscious, and that there are de- 
grees of silence. There is an absolute silence where nothing, 
absolutely nothing moves. They watch me in amazement when 
I stand in the middle of the room, so quietly that it is really 
as if ‘I were not.’ Then they strive to imitate me, and do 
even better. . . . When the children are trying in this way 
there is established a silence very different from that which 
we carelessly call by that name. It seems as if life gradually 454 
PEDIATRIC NURSING 
vanishes, and that the room becomes, little by little, empty, as 
if there were no longer any one in it. Then we begin to hear 
the tick-tock of the clock, and this sound seems to grow in 
intensity as the silence becomes absolute. From without, from 
the court which seemed silent before, there come varied noises, 
a bird chirps, a child passes by. The children sit fascinated 
by that silence as by some conquest of their own. ‘ Here, ’ says 
the directress, ‘ Here there is no longer any one; the children 
are all gone away.’ Having arrived at this point, we darken 
the windows, and tell the children to close their eyes, resting 
their heads on their hands. They assume this position and in 
the darkness the absolute silence reigns. ‘Now listen,’ we say, 
‘a soft voice is going to call your name.’ Then, going to a 
room behind the children, and standing within the open door, 
I call in a low voice, lingering over the syllables as if I were 
calling from across the mountains. This voice, almost occult, 
seems to reach the heart and to call to the soul of the child. 
Each one as he is called, lifts his head, opens his eyes as if 
altogether happy, then rises, silently seeking not to move the 
chair, and walks on the tips of his toes, so quietly that he is 
scarcely heard. . . . Having reached the door, with a joyous 
face, he leaps into the room, choking back soft outbursts of 
laughter. ’ ’ 
Naturally following this a lesson on Sound will be ex- 
pected; sounds of wind, water, rain, music. What is the 
difference between noise and music ? The simplest instruments 
can be tried. A row of glasses of different sizes, partly filled 
with water, give varied notes. A willow whistle made at the 
bedside is a good example. A choice little concert was given 
by a hospital engineer with no other instrument than a lilac 
leaf. On this he played familiar, sweet old songs, and charmed 
a whole ward. 
Feeling or touch-sense is taught to defective children by a 
game which is good for all. A cloth bag is partly filled with 
bits of different substances, little form being permitted. The 
child’s hand is thrust into this bag and the string is drawn EDUCATIONAL VALUE 
455 
up around the wrist. He is then asked to name the contents by 
the sense of touch alone. 
In the lesson on Motion a pendulum is of value, also an 
old clock taken from its case and set to running, waterwheels, 
the muscles of the child’s own body, and even a motor. Teach 
the difference between absolute quiet and motion and practice 
these. 
The Sense of Rhythm develops as we watch waves, cradles, 
drums, woodpeckers and dancing. Relate this back to form 
and find in any picture or design, the lines that rime. 
And now, being surrounded by creatures of sense, we must 
provide them with Food, Clothing, and Shelter. These last 
three lessons are played by every child. Marketing, cooking, 
making of dishes, doll-dressing, sewing and weaving; last of 
all, tents or houses. No pasteboard box but has the possibility 
of a house, no scrap of cloth or leather but may form a wig- 
wam. One of the best things which a nurse can learn is to be 
able to take exactly what lies within reach and from these 
things create new and attractive models. The nurse who 
sits beside a surgical case may easily shape from absorbent 
cotton, animals, dolls, or snow-scenes, with charming results. 
If, after forming, a bit of color be applied (even coffee can 
be used), and when dry, brushing the toys over with shellac, 
there will be permanent value realized. 
By this time some one is asking, “Where is the therapeutics 
in all this?” Lessons are planned but therapy means the ap- 
plication of remedy to disease. We live in a thought-world; 
when one is ill his thought is not well-directed, it strays into 
unwholesome paths. To direct thought into wholesome chan- 
nels is the first great office of occupational therapy. Physical 
changes follow as thought leads and it is logical to expect 
improved conditions throughout the body. Corrective ex- 
ercises may be illuminated by being given in the form of 
occupations. It is far more inviting to exercise muscles with 
a visible, tangible result than to do so on abstract principle. 
Every piece of work is a witness to power. This is a prized 456 
PEDIATRIC NURSING 
possession. To know that illness has not deprived one of 
power even though that power be manifested in new and 
heretofore unvalued activities, raises one at once from the 
ranks of those “laid on the shelf.” The more creative the 
work the greater the power manifested. Man, woman, or 
child will bow before one who can express beauty with that 
which has formerly been accounted worthless. 
Two years ago a series of tests were made in the pneumonia 
and empyema wards in the children’s department of the Bos- 
ton City Hospital. All the cases w7ere of the acute type. No 
child was well enough to be sent to the Convalescent Home. 
Children with miserable ashen faces, with little breath, 
propped up with slow-discharging wounds, coughing children, 
nauseated children, children with temperatures high and 
low, a truly abject set of little ones they were. In all cases 
of severe illness a sense of insecurity is experienced. Even 
a delirious patient may be helped just here by occupational 
therapy. The simplest manual labor is to hold something. 
The person who feels insecure wants to hold on to something. 
This impulse may be utilized to good purpose, for the sickest 
child will often hold a thing placed in his hands. Sometimes 
a sick baby will hold a wilted flower all day long. A pretty 
paper-fold is of much value here. The sickest child in this 
ward, a boy who had no breath to use up in words, held out 
his hand for a flying bird. The next step was to make the bird 
fly which called for slight finger-action only. From this he 
went on making the folds for a house, then the other forms of 
work and, as his powers increased slowly, he made balls, 
pocketbooks, baskets, etc. These children made Indian splint 
baskets, stuffed soft toy animals, made several friezes telling 
the “Noah’s Ark” story and others by this means. They 
stenciled mats, made cork and pin furniture, knit, sewed, 
did simple leather work and turned out so many pieces that 
three cases were filled for exhibition at “The Children’s 
Museum. ’ ’ 
It was interesting to see how the children themselves be- EDUCATIONAL VALUE 
457 
came teachers. When a new case was brought in they would 
say, “Now you begin with just the easiest things. We’ll show 
you how, and then you will soon do the harder things. ’ ’ They 
begged for more hours of teaching and were themselves won- 
derful demonstrators. Not one case was found wThere work 
had to be taken away because of unfitness for so sick a child. 
If these children could be helped by occupational treatment 
it would surely indicate its use in acute conditions. 
The mistake is sometimes made of blaming a patient for 
lack of interest. This is never wise since different substances, 
mankind included, kindle at different temperatures. A hos- 
pital ward presents all sorts from hard coal temperaments 
to gasoline, or even sulphur types. At times the latter seem 
to predominate and an enthusiastic following is quickly gath- 
ered, but more often considerable time must be spent on the 
part of the teacher in merely raising the temperature to 
kindling point. The aids to this are first a true good nature. 
To be just as much interested in the child who does not and 
apparently will not work, requires real devotion. Good models 
freely shown and of much variety, are of great assistance. 
Quietly working in the sight of the patient without asking 
him to participate will many times bring about the desired re- 
sult. Sometimes half the period must be spent in this way, 
but at a given point the interest blazes up. 
Off from a large ward filled with cardiac cases was a 
smaller room for a few patients. In this small ward were two 
little girls. The only thing which they saw or could see 
through the always open door was a third child who was ap- 
parently dying and suffering greatly. Suddenly another ob- 
ject crossed the field of vision. A “Berkshire Bird” flew in. 
Just one little canary in a ring but what a wonderful change 
he wrought! The attention of the two little girls was held 
captive and soon three more canaries were in sight. All the 
conversation in the room turned to bird-making and love and 
admiration were lavished on the newcomers. Here, indeed, 
was kindling temperature quickly reached. Figure 53. The Finding of Moses 
(Courtesy of the Bartlett Sisters and the Home of Truth, Boston, 
Massachusetts) 
458 EDUCATIONAL VALUE 
459 
In another room five children are telling the story of “The 
Finding of Moses.” These are not sick children but are 
banded together as “ Help-one-anothers. ” The first part of 
the play is silent. We all close our eyes and go to Egypt. 
Then each one tells what she saw in Egypt. One saw the 
great stretch of brown, sandy desert and the sky, nothing 
more. The next saw the pyramids and the sphinx; the next 
saw the winding river Nile, the next a part of a temple and 
some little people far off with water-jugs on their heads. And 
then came one who saw Pharaoh’s daughter with her maids, 
and little Moses in his basket. All these characters were made 
and dressed, just rag dolls, but Egyptian rag dolls. The chil- 
dren posed for the group and the patterns were made as they 
posed. Then came a great picture-building of the scene which 
was to cover a dingy wall. All that the children saw in 
Egypt went into this background while the dolls were grouped 
on the shelf in front and the baby Moses lay in a cunning 
basket made by one of the children from a few corn-husks. 
Moses himself was made of absorbent cotton tied with sewing 
thread. The walls of any child’s room might be made more 
interesting by such a play. This method of teaching is just 
as well suited to ward patients. It is group work of a de- 
lightful type. It needs only loving cooperation to make the 
dullest wall express history, geography, study of form, color, 
harmony, proportion, perspective, grouping, sewing, basketry 
and unity which binds all in One. 
Dunton—Occupation Therapy for Nurses. 
Fisher, Dorothy Canfield—A Montessori Mother. 
Hickman—Soft Toys and How to Make Them. 
Sage and Cooley—Occupations for Little Fingers. 
Tracy—Rake Knitting. 
Studies in Invalid Occupation. 
READING REFERENCES A SELECTED BIBLIOGRAPHY 
Frederica Beard 
Bearing on Mental Development, Elementary Psychology, 
and Practical Child Study 
Baldwin, James Mark—Mental Development in the Child 
and the Race. A valuable discussion including reference 
to habit, accommodation, and volition. 
Social and Ethical Interpretations in Mental Develop- 
ment. Especially helpful in regard to the developing 
personality. 
Beard, Frederica—The Beginners’ Worker and Work. 
While written especially for the religious teacher of little 
children, it shows their tendencies, interests and needs to 
all parents and helpers. 
Cabot, Ella Lyman—Seven Ages of Childhood. Fascinat- 
ing, original, full of illustrations with scientific back- 
ground. 
Coe, George Albert—A Social Theory of Religious Educa- 
tion. As title implies, this book emphasizes the social 
element in education and is a most valuable contribution 
to this end. 
Cope, Henry F.—The Parent and the Child. 
Dewey, John—How We Think. An original analysis of the 
thinking process. 
DuBois, Patterson—Reckonings from Little Hands. A 
sympathetic insight of the nature of little children by a 
father who writes about his own children. 
The Natural Way. Full of practical helpfulness. 
The Point of Contact in Teaching. Also written for the 
religious teacher, the book has received wide recognition 
for the principle it enunciates, and has been recommended 
to, and read by, day school teachers. 
460 A SELECTED BIBLIOGRAPHY 
461 
Fiske, George W.—Boy Life and Self-Government. See 
especially the chapter, “Jimmie, Jim, and James.” 
Forbush, William—The Boy Problem. Written with an 
understanding of boy life. 
Griggs, Edward Howard—Moral Education. A most val- 
uable dissertation on this phase of education. 
Gruenberg, S. M.—Your Child and Mine. 
Hartshorne, Hugh—Childhood and Character. An interest- 
ing insight with a moral and religious emphasis. 
Horne, Herman—Psychological Principles of Education. 
Clear, practical, and strong. 
James, William—Principles of Psychology (Brief Edition). 
Strong and suggestive on fundamentals, including an 
illuminating study on habit. 
Talks on Psychology and Life’s Ideals. Practical ap- 
plications of psychology to education and life. 
Johnson, George E.—Education by Plays and Games. 
Jones, L. H.—Education as Growth. Enlightening to the 
general student who is not a specialist. 
King, Irving—Psychology of Child Delevopment. Studies of 
periods with emphasis on continuity of growth. 
Kirkpatrick, Edwin A.—Individual in the Making. This 
book is suggestive in accordance with its title. 
Lee, Joseph—Play in Education. A most helpful study of 
child life beyond the limits of the title. 
McDougall, W.—An Introduction to Social Psychology. As 
title implies this book emphasizes the social elements in 
education and is a most valuable contribution to this end. 
Moxcey, Mary E.—Girlhood and Character. Both scientific 
and practical for every leader of girls. 
Puffer, J. Adams—The Boy and His Gang. Helpful on the 
particular subject of the title. 
Ribot—Psychology of the Emotions (English Translation). 
An important study along its particular line. 
Slattery, Margaret—The Girl in Her Teens. Popular in 
style and suggestive. 
Stoner, Winifred Sackville—Natural Education. 
Swift, Edgar J.—Mind in the Making. This book is sug- 
gestive in accordance with its title. 462 
A SELECTED BIBLIOGRAPHY 
Taylor, A. R.—Study of a Child. Suggestive on the develop- 
ment of conscience. 
Weigle, Luther A.—The Pupil and the Teacher. Written, 
primarily for the church school teacher, it contains a 
scientific study of the child in a form easily understood. 
Wilton, J.—Psychology of Education. A discriminating 
study of mental development, especially as regards in- 
stinct and experience. INDEX 
Abdomen, average development of, 
11 
Abdominal binder, 25 
description of, 422 
Abdominal paracentesis, perform- 
ance of, 250-252 
Abscess of the lung, 357 
Acidosis, 327 
prevention of, 417 
Adenitis, 375 
Adenoidal growths, 334, 335 
Admitting ward, value of, 63 
Adolescence, 15, 16 
meaning of, 46 
Agar-agar jelly, preparation of, 
189 
Age limitations, grading of, 34 
Aikman, Dr. J., on intraperitoneal 
injection of fluids, 243 
Air mattress, use of, 60 
Air ring, use of, 60 
Albee, Dr., operation by, for tu- 
berculosis of spine, 443, 
444 
Alcohol sponge bath, 262 
Altruism, development of, 47 
Aluminum mittens, use of, 86 
American Pediatric Society, found- 
ing of, 3 
Anemia, 374 
Anhydremia, prevention of, in in- 
* fant operations, 415, 416 
Anterior poliomyelitis. See Polio- 
myelitis 
Antitetanic serum, 235 
Antitoxin, diphtheria, as factor in 
mortality decrease, 7 
use of, 395, 396 
in injections, 240, 241 
tetanus, in infusions, 235 
in injections, 241 
Apparatus, care of, in orthopedic 
nursing, 427 
Appendicitis, 344, 345 
Aristotle, on practice, 43, 44 
Armstrong, Dr. George, first Lon- 
don Children’s Hospital 
founded by, 4 
Arthritis, as acquired orthopedic 
affection, 425 
Artificial feeding, caloric method 
in, 157-159 
condensed milk in, 154 
Dr. Pfaundler’s rule on, 160 
lactose in, 153 
maltose in, 153 
modified milk in, 156-161 
of infants, 146 
percentage method in, 156, 157 
proprietary foods in, 154, 155 
recipes in, 180-189 
rules for checking up quantities 
in, 163, 164 
saccharose in, 153 
sign posts in, 163 
starch in, 154 
Artificial respiration, methods in, 
100-104 
Artificially fed baby, stools of, 
223 
Ascaris lumbricoides, 345 
Aseptic nursing, after operation, 
420, 421 
in infant operations, 416, 417 
of newborn, technique of, 98, 
99 
pediatric, technique of, 64, 65 
Asphyxia neonatorum, 101 
nursing in, 315 
Aspiration, of pericardial cavity, 
249, 250 
of pleural cavity, 248, 249 
Asthma, 352, 353 
Athrepsia, 325, 326 
Atropin sulphate, 276 
Authority, external, necessity of, 
41 
Axilla, taking of temperature by, 
72 
Babies’ Hospital of New York, 
opening of, 4 
Baby urinals, description of, 213, 
214 
Back rest, for crib, 59, 60 
Bagellardo, Paolo, first printed 
European pediatric litera- 
ture by, 2 
Baldwin, James, on development 
of ethical sense, 43 
463 464 
INDEX 
Barthez, contributions to pedia- 
trics by, 3 
Bartlett sisters, work by, for oc- 
cupational therapy, 458, 
459 
Basal metabolism, of children, 129 
Bath, admission, need of, 64 
alcohol sponge, purpose of, 262 
bathroom temperature during, 
30 
equipment for, 29 
hot air, procedure in, 267, 268 
mustard, 265, 266 
oil, of newborn, 106-108 
procedure in, 29 
sponge, 260, 261 
temperature of water in, 30 
time for, 30 
water, of newborn, methods of, 
111-114 
Bath tray, equipment of, 76 
Bathing, of infants and children, 
procedure in, 74-81 
of newborn, procedure in, 106, 
108 
pediatric technique in, 75 
Bathroom, equipment of, 51 
ideal, 19 
temperature, during bath, 30 
Beard, Frederica, ‘ ‘ The Mental 
Development of Child 
Life,” 32-48 
Bed, elevation of foot of, 423 
ether, making of, 419, 420 
ideal, for the baby, 19 
Bed linen, care of, in infectious 
diseases, 386 
Bed pans, use of, 208 
Bedding, disinfection of, 60, 61 
Bednar, contributions to pediatrics 
by, 3 
Beet, scraped, preparation of, 189 
Beet juice, in children’s diets, 199 
preparation of, 189 
Benedict, on basal metabolism of 
children, 129 
Berry, on orthopedic surgery, 424 
Bibs, 84 
Billard, C., contributions to pedia- 
trics by, 3 
Bladder, in nursing procedure, 
312-314 
Blankets, 57 
Blood, diseases of, 374, 375 
Blood, whole, in injections, 239, 
240 
Blood transfusion, intravenous 
method of, 238, 239 
Body heat, maintenance of, in in- 
fant operations, 416 
Bones, missing or supernumerary, 
425 
tuberculous disease of, 425 
Boston city hospitals, experiments 
with occupational therapy 
in, 456-458 
Boston Infants’ Hospital, opening 
of, 4 
Bradford frame, use of, in collec- 
tion of 24-hour urine 
specimen, 214-216, 218 
in tuberculosis of hip, 439 
in tuberculosis of the spine, 
442 
Brain, disorders of, 368 
Breast-fed baby, stools of, 222, 
223 
Breast feeding and complemental 
feeding, 140, 141 
Breast food, additional food before 
coming of, 139 
Breast milk, average daily quantity 
of, 134 
comparison of, with cow’s milk, 
147, 148 
composition of, 133, 134 
determination of caloric value 
of, 158 
manual expression of, technique 
in, 141, 142 
Breasts, care of, 135, 136 
Bronchiectasis, 357 
Bronchopneumonia, 354 
tuberculous, 406 
Broths, in children’s diets, 199 
Buda Pesth children’s hospital, 
opening of, 4 
Burns, treatment of, 379, 380 
Butter-flour mixture of Czerny, 
preparation of, 186, 187 
Buttermilk mixture, 184, 185 
Buttock tray, equipment of, 206 
Buttocks, care of, 206, 207 
excoriated, cause of, 207 
prevention of, 207 
Byrd’s method of artificial respi- 
rations, positions in, 102, 
103 
Cabot, E. L., on rewards, 46 
Calcium lactate, 276 
Caloric method of feeding, 157- 
159 
Caloric requirements, of children, 
129 
of underweight children, 130 INDEX 
465 
Caloric requirements, tables for, 
130, 131 
Caloric values of foods, 129 
Carbohydrates, 127 
in infant feeding, 153 
in milk dilutions, 159, 161 
Carrier, diphtheria, 399 
Cascara sagrada, 276 
Casein, precipitated, preparation 
of, 183, 184 
Casparis, on effect of heliotherapy 
on rickets, 272 
Castor oil, 276 
Casts, plaster, care of, 427-429 
Catharsis, avoidance of, in infant 
operations, 416 
in pre-operative child care, 
4, 7 
Catheterization, routine in, 312-314 
of a boy, 314 
of a girl, 312-314 
Cereal, thick, feeding of, Sauer 
on, 188 
Cereal mixture, thick, preparation 
of, 187 
Cereal water, in milk dilutions, 160 
preparation of, 180 
Cereals, in artificial feeding, 154 
in children’s diets, 198 
in infant feeding, 190, 191 
Cerebrospinal meningitis, 368 
Chappin dipper, use of, 168 
Chest, average development of, 11 
Child, handling of, 65-67 
mental attitude of, in orthopedic 
cases, 425 
postoperative care of, 419-423 
pre-operative care with, 417-419 
procedure in preparing of, for 
operation, 418 
shaving of, equipment for, 418 
Child development, ‘ ‘ gang ’ ’ in- 
stinct in, 44, 45 
individuality in, 44 
self-assertion in, 44 
Child education, avoidance of nega- 
tive in, 38, 39 
constructive imagination in, 45 
development of ethical sense in, 
43 
development of personality in, 42 
experience as point of contact 
in, 38 
instinct in, 37 
moral habits in, 42 
obedience in, 41 
practice in, 43 
repetition in, 42 
Child education, stress upon posi- 
tive in, 38, 39 
value of play in, 38 
Child hygiene, knowledge of, as 
pediatric nursing essen- 
tial, 8 
Child life, emphasis of personifica- 
tion in, 39 
from one to six years, 36-40 
power of impressions during, 
36 
from six to ten years, 40-44 
self in, 40 
from ten to thirteen years, 44-46 
from thirteen to sixteen years, 
46-48 
mental development of, 32 
Child organism, differences in, 
from adult, 5 
Child psychology, knowledge of, 
as pediatric nursing es- 
sential, 7 
Child treatment by ancients, 1 
Childhood, years of, 9 
Children’s Hospital, Boston, open- 
ing of, 4 
Children’s ward, accessory rooms 
to, 50-52 
arrangement of, 49 
cubic air space of, 52 
floor of, 54 
furniture of, 54 
heating of, 53 
lighting of, 52 
location of, 49 
necessity for signal system with 
older children in, 55 
need of hand basin in, 54 
need of sun porch with, 54, 55 
size of, 52 
value of glass partitions in, 55 
wall decoration of, 53 
windows in, 52 
Chloroform, use of, 282 
Chorea, 365 
Christ, on infant destruction, 2 
Churchill, F., contributions to 
pediatrics by, 3 
Cireulatorv system, diseases of, 
372-374 
Cleft lip, 316 
Cleft palate, 316 
Clothing, 25 
for the child, 28, 29 
for infant, 27, 28 
hospital, description of, 82, 83 
for the newborn, 25, 81, 82 
in hot weather, 28 466 
INDEX 
Clove hitch, diagram of, 86 
Club foot, congenital, 425, 431 
Coagulation time of blood of new- 
born, determination of, 
255, 256 
Cod liver oil, 276 
in therapy, 323 
Coit, Dr. Henry L., on certified 
milk, 150 
Cold, effect of, 259 
Cold applications to eye, 299 
Cold pack, use of, 260, 261 
Cold wet applications, use of, 263, 
264 
Colic, 342 
Collecting, beginning of instinct 
for, 40 
Color, lesson on, for children, 450 
Colostrum, composition of, 133 
Condensed milk, in artificial feed- 
ing, 154-155 
Congenital atelectasis, 315 
Congenital cleft palate and lip, 
329-333 
operative procedure in, 330- 
332 
oral hygiene in, 332, 333 
Congenital heart disease, 372 
Congenital malformations, 316 
of bones, 316 
of urogenital organs, 316 
Congenital orthopedic affections, 
430-432 
Constipation, 346-349 
treatment of, 348, 349 
Constructive imagination, in child 
education, 45 
Contacts, in infectious diseases, 
387 
Contagious’ diseases, care of 
patients with, 384, 385 
Convalescing children, diversion 
of, 41, 42 
Convulsions, 361-364 
causes of, 361 
symptoms of, 362, 363 
treatment of, 363, 364 
Cord, dressings for, illustrations of, 
104 
tying of, 103, 104 
Cottage cheese, preparation of, 
183, 184 
Coughing, 349, 350 
Counterirritants, use of, 283-286 
Cow’s milk, as substitute for breast 
milk, 146, 147 
comparison of, with human milk, 
147, 148 
Cow’s milk, for infants, require- 
ments concerning, 148, 
149 
Crede, method of, for care of eyes 
of newborn, 104, 105 
Cretinism, 375 
Crib, construction of, 55 
empty, procedure in making up, 
57-59 
size of, 55 
wfith child in it, procedure in 
making up, 59 
Croup, 351, 352 
Croup tent, use of, 281, 282 
Crying, infant’s, 22 
Cuffs, necessity for, 84-86 
to immobilize elbow joints, pat- 
tern for, 85 
Curds, in stools, 220 
methods of breaking up of, 160, 
161 
Daily rest period, 21 
Datheus, Archbishop, founder of 
Milan foundling asylum, 4 
Death, care of child’s body after, 
96, 97 
equipment for, 96 
care of personal belongings 
after, 97 
Deformity, movement toward pre- 
vention of, 424 
Dehydration, prevention of, in 
pre-operative child care, 
417 
infant operations for, 415, 
416 
Dennett, on children’s diets, 197 
Dewey, John, on child’s generali- 
zation, 35 
Diabetes mellitus, in childhood, 
327 
Diapers, 26 
care of, 207 
laundering of, 26, 27 
Diarrhea, 340, 341 
Dickens, Charles, as children’s 
benefactor, 4 
Diet, at nine months, 192 
at twelve months, 192 
from 12 to 18 months, 193 
from 18 to 24 months, 193, 194 
from 2 to 4 years, 194 
from 4 to 10 years, 194-196 
Diet kitchen, equipment of, 50 
Diets, children’s, beef juice in, 
199 
broths in, 199 INDEX 
467 
Diets, children’s, cereals in, 198 
drinks to be avoided in, 
201 
eggs in, 199 
essential points in, 196, 197 
foods to be avoided in, 200, 
201 
fruits in, 198, 199 
importance of good food 
habits in, 202 
importance of good eating 
habits in, 202, 203 
meat in, 199 
milk in, 197, 198 
sugar in, 200 
vegetables in, 197, 198 
for sick children, importance of 
fluids in, 204, 205 
of school children, need of care 
in, 205 
Digestive system, diseases of, 329- 
334 
Digitalis, 276 
Diphtheria, extubation in, 398 
faucial, 394, 395 
intubation in, 397, 398 
nursing of, 393-399 
Schick test in, 398 
performance of, 254, 255 
tracheotomy in, 396, 397 
Diphtheria antitoxin, 395, 396 
as factor in mortality decrease, 7 
in injections, 240, 241 
Diphtheria carrier, 399 
Diseases, infectious, precautions in 
care of, 383-388 
of blood, 374, 375 
of circulatory system, 372-374 
of ductless glands, 375-376 
of ear, 381, 382 
of eye, 381, 382 
of genito-urinary system, 357 
of lymph-nodes, 375 
of respiratory tract, 349-357 
of skin, 376-380 
Donnelly, Dr. J. D., on intraperi- 
toneal injection of fluids, 
243 
Dress, description of, 27 
Dressing room, equipment of, 51 
Drinks, improper, in children’s 
diets, 201 
Drugs, Clarke’s rule for dosage on, 
274 
for children, 274-283 
methods of administering, 275- 
283 
by inhalation, 280-283 
Drugs, methods of administering, 
by inunction, 279, 280 
by mouth, 275-277 
by rectum, 277 
hypodermically, 277-279 
intramuscularly, 279 
intraspinally, 277 
intravenously, 277 
subcutaneously, 277-279 
Drummond, Henry, on universality 
of principle of growth, 
33 
Dry pleurisy, 355 
Ductless glands, diseases of, 375, 
376 
Duodenal feeding, 291 
Dyspepsia, 325 
Ear, diseases of, 381, 382 
examination of, equipment- of 
tray for, 70 
in nursing procedure, 293-295 
irrigation of, procedure in, 293, 
294 
medication of, 294 
Eczema, 376-378 
Eggs, in children’s diets, 199 
Electric heating pads, use of, 
287 
Emerson, Dr. W. E. P., on malnu- 
trition, 126, 127 
Empyema, 356, 357 
Enema, M. G. W., 305, 306 
method of giving, 301-305 
milk and molasses, 307 
nutritive, 306 
oil, 307 
sedative, 306 
shock, 306, 307 
soap suds and glycerin, 305 
starch, 307 
stimulating, 307 
turpentine, 307 
Engorgement of breasts, 318 
Enteroclysis, procedure in, 308 
Enuresis, 359, 360 
Epilepsy, 364, 365 
Epistaxis, 350 
Epstein’s pearls, 316 
Esophagus, stricture of, 335, 
336 
Ether bed, making of, 419, 420 
Ethical sense, development of, 42, 
43 
Excreta, care of, in infectious 
diseases, 386, 387 
Exercise, necessity of, 22, 23 
Exercise pen, description of, 23 468 
INDEX 
Experience, immediate, as point of 
contact in child education, 
38 
Extubation, procedure in, 398 
Eye, cold applications to, 299 
diseases of, 380, 381 
first care of, 105 
in nursing procedure, 297-299 
irrigation of, 297, 298 
Fat, in milk dilutions, 160 
Fatigue and malnutrition, 21 
Fats, as food, 127, 128 
Fear, value of, as educational safe- 
guard, 39, 40 
Feeding, by gavage, 122, 288-291 
of newborn, 109 
Feedings, amount of milk in, 161, 
162 
numbers of, 161 
table for guidance in, 162 
Feeling, early lessons in, 454, 455 
Feet, weak, acquired, 425 
orthopedic precautions against, 
444-446 
Female genital organs, diseases 
of, 360, 361 
Femoral vein, use of, in vein punc- 
ture, 229 
Finkelstein, on protein milk, 181, 
182 
Fisher, Dr. L., on fontanelle punc- 
ture, 229 
Flaxseed poultice, use of, 284, 285 
Floor, of children’s ward, 53, 54 
Fluids, importance of, in sick 
children’s diets, 204, 205 
Fontanelle puncture, equipment 
for, 229, 230 
procedure in, 229-231 
Food, ash or mineral salts as, 127, 
128 
caloric values of, 129-131 
carbohydrates as, 127 
composition of, 127 
definition of, 126 
fat as a, 127 
function of, 126 
protein as, 127 
vitamins as, 127, 128 
water as, 127, 128 
Food habits, good, importance of, 
202 
Foods,, improper, in children’s 
diets, 200, 201 
Foot sling, use of, 60 
Foreign body, in ear, 381, 382 
in larynx, 353, 354 
Foreign body, swallowing of, 339, 
340 
Form, lesson on, for children, 450 
Formulas, of lactic acid milk, 186, 
187 
sterile, equipment for making of, 
173, 174 
procedure in, 173 
unsterile, making of, 175 
Froebel, on growth, 33 
Fruit, in children’s diets, 198, 199 
Fruit juices, in infant feeding, 190 
Furniture of a children’s ward, 
54 
Furunculosis, 378 
Games, value of, 455, 456 
Gang instinct, growth of, 44, 45 
Gardner, on inunction method of 
administering drugs, 279 
Gastric contents, removal of, pro- 
cedure in, 293 
Gastric lavage, procedure in, 292, 
293 
Gavage, as method of feeding 
premature, 122 
by mouth, 288-291 
by nose, 291 
description of, 288-291 
Genital organs, female, diseases 
of, 360, 361 
male, diseases of, 360 
Genito-urinary system, diseases of, 
357-361 
German measles, nursing of, 391 
‘ ‘ Gertrude, ’ ’ measurements of, 27 
Gitt.ings, Dr. J. C., on intraperi- 
toneal injection of fluids, 
243 
Goldbloom, Dr. A., on fontanelle 
puncture, 229 
Gonorrheal infection of the new- 
born, 319 
Gonorrheal ophthalmia, 380, 381 
Gonorrheal vaginitis, 360, 361 
of the newborn, 321 
Gritting of teeth, 366 
Group interest, educational ideal 
of, 47 
Growth, rate of childhood, 9 
of infant, 9 
table of, 10 
Habits, eating, good, importance 
of, 202, 203 
formation of, 40 
good food, importance of, 201 
of childhood, injurious, 366-368 INDEX 
469 
Habits, regular toilet, establish- 
ment of, 223, 224 
regularity, importance of, 17 
Hair and scalp, care of, 91 
Hand basin, in children’s ward, 54 
Harmony, lesson on, for children, 
451 
Harris, Walter, contributions to 
pediatric literature by, 3 
Harvard, second chair of pediat- 
rics, 3 
Hay fever, 352, 353 
Head, average development of, 11 
Hearing, development of, 12 
Heart disease, 372, 373 
Heat, body, maintenance of, in 
infant operations, 416 
effect of, 260 
use of, 264-268 
Heating of ideal nursery, 18 
Heliotherapy, 268-273 
effects of, 272, 273 
history of, 268, 269 
technique of, 270, 272 
therapeutic value of, 269, 270 
Helmholz, Dr. Henry F., on fon- 
tanelle puncture, 229 
Hemophilia, 374, 375 
Hemorrhages of newborn, 317, 318 
spontaneous, 318 
traumatic, 317 
Hernia, 316, 342-344 
inguinal, 343 
Hess, Dr. Julius H., on value of 
heliotherapy, in rickets, 
269 
premature bed designed by, 117 
Hess and Unger, on artificial light, 
272 
Hip, congenital dislocation of, 425, 
430, 431 
tuberculosis of, 435-440 
Hirschsprung’s disease, 342 
Holt, Dr. L. Emmett, on pediatrics 
as preventive medicine, 7 
IIoos’ albumin milk, 183 
Hopital des Enfants, founding 
of, 4 
Hospital of the Innocents, found- 
ing of, 4 
Hospital ward, conduct of, 49 
Hot air bath, procedure in, 267, 
268 
Hot pack, procedure with, 264, 
265 
Hot water bottles, use of, 287 
Hot wet applications, use of, 266, 
267 
Howlind, on effect of heliotherapy 
in rickets, 272 
Humidity of children’s ward, 53 
Hydrocele, 360 
Hydrocephalus, 316, 369 
Hydrotherapy, definition of, 258 
Hygiene, importance of, 17 
Hyperthyroidism, 376 
Hypodermic injection of drugs, 
277-279 
Hypodermoelysis, continuous, 242, 
243 
methods of, 241-243 
Hypothyroidism, 375, 376 
Tce-cap, use of, 287 
Icterus neonatorum, 317 
Identification, mark for, 64 
tags for newborn, 110 
Idiocy, of childhood, 369 
Impetigo contagiosa, 376 
Inanition temperature, 322 
Incubator, abandoning of, 117 
Indigestion, acute intestinal, 341 
chronic intestinal, 341 
Individuality, development of, 44 
Infant, and adult, operative dif- 
ferences between, 415 
application of term, 9 
pre- and postoperative care of, 
415-417 
Infant feeding, artificial, cow’s 
milk in, 146-153 
water in, 153 
caloric requirements of, 157 
carbohydrates in, 153 
cereals in, 190 
fruit juices in, 190 
overcoming of difficulties in, 176, 
177 
rules for, 175-177 
toast in, 191 
vegetables in, 191 
Infant foods, in artificial feeding 
of infants, 154 
Infantile paralysis, as acquired 
orthopedic affection, 425 
Infantile tetany, 364 
Infants, surgical nursing with, 415- 
417 
Infection, avoidance of, in pre- 
operative child care, 417 
prevention of, in infant opera- 
tions, 416 
Infections of the newborn, 319-322 
Infectious diseases, 315 et seq. 
care of bed linen in, 386 
care of excreta in, 386, 387 470 
INDEX 
Infectious diseases, care of secre- 
tions in, 387 
contacts in, care regarding, 387 
definition of, 383 
nurses ’ precautions in care of, 
388 
precautions in care of, 383-388 
transmission of, 383, 384 
Inguinal hernia, 343, 344 
Inhalations, methods in use for, 
280-282 
Injurious habits of childhood, 366- 
368 
Instinct, cultivation of, 37 
definition of, 37 
Institutions, for the care of chil- 
dren, first, 4, 5 
Intelligent mothering, necessity of, 
23 
Intertrigo, 376 
Intestinal indigestion, acute, 341 
chronic, 341 
Intestinal parasites, 345, 346 
Intoxication, 326, 327 
Intramuscular injections, of diph- 
theria antitoxin, 240, 241 
equipment for, 240 
purpose of, 240 
sites for, 240 
of drugs, method in, 279 
of whole blood, 239 
donor of, 239 
equipment for, 239, 240 
purpose of, 239 
sites of, 240 
Intraperitoneal injection of fluids, 
243 
equipment for, 243, 244 
methods of, 244 
purpose of, 243 
Intraspinal injection of serum, de- 
scription of, 247, 248 
Intravenous blood transfusion, 
238, 239 
donor for, 238 
equipment for, 238 
gravity method in, 238 
simple syringe method in, 238 
three-way stopcock method in, 
238 
Intravenous infusion, 232 
equipment for, 232 
gravity method in, 233, 235 
sites for, 232 
of antitetanic serum, 235 
of neosalvarsan, 235 
of salvarsan, administration of, 
235 
Intravenous infusion, syringe 
method in, 233 
three-way stopcock method in, 
233, 234 
Intubation, procedure in, 397, 398 
Intussusception, 342 
Inunction, method of, 279, 280 
Irrigation, ear, 293, 294 
eye, 297, 298 
mouth and throat, 297 
nose, 295, 296 
Isolation, rules regarding, 383- 
388 
Isolation room, 385 
Jacobi, Dr. Abraham, first profes- 
sor of pediatrics, 3 
Jenner, Edward, work on small- 
pox vaccination, 3 
Joints, tuberculous, 425 
Judgment, developing of, 47 
Jugular vein, external, use of, for 
vein puncture, 228, 229 
Kerosene cap, equipment for ap- 
plying, 93 
Kidney, morbid growths of, 359 
tuberculosis of, 358, 359 
Kinderkranken Institute, found- 
ing of, by Dr. Marstalier, 
4 
Kramer, on effect of heliotherapy 
on rickets, 272 
Lactic acid milk, 185, 186 
preparation of, 186, 187 
Lactose, in artificial feeding of 
infants, 153 
Larosan milk, 183 
Laryngitis, spasmodic, 351 
Larynx, foreign body in, 353, 354 
Lateral curvature of spine, ortho- 
pedic nursing in, 446, 447 
Length, average increase in, 10,11 
Leukemia, 374 
Light, lesson on, for children, 448- 
450 
Lighting of children’s ward, 52 
of ideal nursery, 18 
Linen room, arrangement of, 51 
Little’s disease. See Paralysis, 
spastic 
Litzenberg, Dr. J. C., on care of 
cracked nipples, 136, 137 
on inverted nipples, 137 
Lobar pneumonia, 354, 355 
Love of children, as pediatric nurs- 
ing essential, 7 INDEX 
471 
Lumbar puncture. See Spinal 
puncture 
Lung, abscess of, 357 
Lymph-nodes, diseases of, 375 
M. G. W. enema, 305, 306 
McKinley, Dr. J. C., on diseases of 
the nervous system, 361- 
372 
Male genital organs, diseases of, 
360 
Malnutrition, and fatigue, 21 
causes of, 126 
prevalence of, 125 
treatment of, 126 
Malt soup, preparation of, 184 
Maltose, in artificial feeding of in- 
fants, 153 
Mantoux test for tuberculosis, 253 
Marriot, Dr. William McKim, on 
syphilis, 414 
Marstalier, founding of Vienna 
Kinderkranken Institute 
by, 4 
Mastication, importance of, 201 
Mastitis, 319 
Mastoiditis, 381 
Masturbation, 366, 367 
Maternal nursing, 132 
contraindications for, 132, 133 
importance of, 132 
Mattress, description of, 56 
Mead’s dry malt soup stock pow- 
der, use of, 184 
Measles, nursing of, 390, 391 
Meat, in children’s diets, 199 
Meconium, in stools, 222 
Median basilic veins, use of, for 
vein puncture, 227, 228 
Median cephalic veins, use of, for 
vein puncture, 227, 228 
Medicine closet, location of, 52 
Meninges, disorders of, 368 
Meningismus, 369 
Meningitis, acute, 369 
cerebrosphinal, 368 
tuberculous, 368, 369 
Mental, meaning of, 32 
Mental powers, variations in, 35 
Mercury, method of administering, 
279, 280 
Metabolic balance, disturbance of, 
325 
Metlinger, Bartholomeus, first 
printed European pedi- 
atric literature by, 2 
Meyer, on protein milk, 181, 182 
Miliaria, 376 
Miliary tuberculosis, 407, 408 
Milk, boiling of, reasons for, 152 
certified, 150 
condensed, in artificial feeding, 
154, 155 
cows ’, comparison of, with breast 
milk, 147, 148 
dilutions, carbohydrates in, 159, 
161 
fat- in, 160 
protein in, 159 
scientific application of, 159, 
160 
water in, 160 
Hoos’ albumin, 183 
in children’s diets, 197, 198 
‘ ‘ inspected, ’ ’ meaning of, 150, 
151 
laboratories, in cities, 179 
equipment of, 165 
necessity for, 50 
standard supplies necessary 
to, 166-169 
utensils in, 169-171 
Larosan, 183 
market, 151 
mixture, determination of caloric 
value of, 158 
modified, 156-161 
caloric method of feeding 
with, 157-159 
home preparation of, 178 
percentage method of feeding 
with, 156, 157 
molasses and, enema, 307 
pasteurization of, disadvantages 
of, 152 
process of, 151, 152 
reasons for, 152 
peptonized, preparation of, 187 
poor, dangers of, 150 
protein, preparation of, Method 
I, 181, 182 
Method II, 181, 182 
substitute for, 182, 183 
supplies, for milk laboratory, 
168, 169 
Minor surgical procedures, nursing 
technique in, 225 
Mittens, aluminum, use of, 86 
Modified milk, 156-161 
Moral habits, in child education, 42 
Morrow, Dr. A. S., on smallpox 
immunity, 255 
Morse, on percentage method of 
feeding, 156 
Mortality statistics, chief causes 
of death, of first year, 6 472 
INDEX 
Mortality statistics, chief causes of 
death, of second year, 6 
of two to five years, 6 
of five to fifteen years, 6 
chief factor in decrease of, after 
first year, 7 
of first year, 6, 7 
Motion, lesson on, for children, 455 
Mouth, care of, equipment for, 
89, 90 
procedure in, 90, 91 
in nursing procedure, 296, 297 
method of feeding by, 288-291 
method of giving drugs by, 275- 
277 
neglected, dangers of, 89 
Mouth wash, 89 
Mumps, nursing of, 393 
Muscular development, rate of, 11, 
12 
Mustard bath, procedure in, 265, 
266 
Mustard pack, procedure in, 266 
Mustard paste, 285, 286 
Mustard poultice, 285 
Nail biting, 366 
Nasal instillation method of medi- 
cation, 296 
Nasal irrigation, procedure in, 295 
Needles, care of, after use, 226 
Negative, avoidance of, in child 
education, 38, 39 
Neosalvarsan, intravenous ad- 
ministration of, 237 
equipment for, 237 
preparation for, 237, 238 
reaction from, 238 
sites for, 238 
Nephritis, 357, 358 
Nervous system, diseases of, 361- 
372 
“Newborn,” application of term, 
8 
aseptic nursing technique with, 
98 
care of, 98-114 
clothing for, 81, 82 
coagulation' time of blood of, 
determination of, 255, 256 
diseases of, 315-322 
feeding of, 109 
first bath of, equipment for, 106 
first care of, after delivery, 105, 
106 
first water bath of, 111-114 
infections of, 319-322 
tight clothes of, 27 
“Newborn,” rate of growth 
of, 9 
temperature of, 109, 110 
weight at birth, 9 
New York Medical College, first 
chair of pediatrics at, 3 
Night, preparation of child for, 
94 
temperature of ward during, 94, 
95 
Nipples, care of, 172, 173 
cracked, care of, 136, 137 
inverted, 137 
Nits, treatment for, 93, 94 
Norm, in child psychology, mean- 
ing of, 35 
Normal child, growth and develop- 
ment of, 9 
periods of growth of, 9 
Nose, in nursing procedure,- 295, 
296 
Nursery, ideal, description of, 17 
Nursery and Child’s Hospital, 
New York City, opening 
of, 4 
Nurses’ precautions, in care of in- 
fectious diseases, 388 
Nursing, maternal, 132-145 
orthopedic, 424-447 
routine in, 139, 140 
special pediatric, 315-423 
special surgical, with children, 
225-257 
surgical, with infants, 415-417 
technique of, 137-140 
therapeutic, 258-314 
with vocational therapy, 448- 
459 
Nursing bottles, care of, 172 
covers for, 173 
description of, 171, 172 
Nursing care, general, in ortho- 
pedic cases, 425-430 
Nursing mother, hygiene of, 134, 
136 
Nutrition, necessity of knowledge 
of, 125 
Nutritional diseases of infants, 
322-327 
Nutritional disturbances of in- 
fancy, 323 
Hess on, 324 
Obedience, in child education, 
value of, 41 
Observation ward, 385 
Occupational therapy, value of, 
448-459 INDEX 
473 
Oil bath, for premature, 121, 122 
of newborn, procedure in, 106- 
108 
Oil enema, 307 
Omphalitis, 319 
Operation, aseptic nursing after, 
420, 421 
Ophthalmia neonatorum, 319-321 
Oral hygiene, after operations for 
congenital cleft palate 
and lip, 332, 333 
of infancy, care of first teeth 
in, 87 
care of mouth in, 87 
Ormond Street Hospital, opening 
of, 4 
Orthopedic affections, acquired, 
432-435 
classification of, 425 
congenital, 430-432 
classification of, 424 
Orthopedic nursing, after anterior 
poliomyelitis, 433, 434 
after rickets, 432, 433 
care of apparatus in, 427 
care of plaster casts in, 427- 
429 
care of skin in, 425, 426 
for weak feet, 444-446 
general rules for, 425-430 
in cases of lateral curvature of 
spine, 446, 447 
in postural kyphosis, 447 
in tuberculosis of the spine, 440 
Katherine A. Smith on, 424-448 
mental attitude of child in, 425- 
426 
of anterior poliomyelitis, 433, 
434 
of congenital dislocation of hip, 
430, 431 
of congenital torticollis, 430 
of obstetrical paralysis, 435 
of spastic paralysis, 433, 434 
of talipes, 431 
of tuberculosis of hip, 435-440 
post-operative nursing in, 429, 
430 
Orthopedic surgery, definition of, 
424 
Osteomyelitis, 425 
Otitis media, 381 
Out of doors, time, 21, 22 
Oxygen, use of, 282 
Oxyuris vermicularis, 345 
Pack, cold, procedure with, 260, 
261 
Pack, hot, procedure with, 264, 
265 
mustard, procedure with, 266 
Paley, on instinct, 37 
Paracentesis, abdominal, perform- 
ance of, 250-252 
of tympanic membrane, per- 
formance of, 252 
Paralysis, in children, 371, 372 
obstetrical, orthopedic nursing 
in, 435 
spastic, 425 
orthopedic nursing in, 434- 
435 
Parasites, intestinal, 345, 346 
Partitions, glass, in children’s 
ward, 55 
Payne, on child treatment as 
barometer of human 
progress, 2 
Pediatric charting, instructions re- 
garding, 95, 96 
Pediatric nursing, essentials and 
qualifications for, 7 
faithfulness to detail, 8 
knowledge of child hygiene, 7 
knowledge of child psychol- 
ogy, 8 
love of children, 7 
technique of, aseptic, 64, 65 
Pediatric teaching, pioneer work 
in, at Harvard, 3 
at New York Medical College, 
3 
Pediatrics, history of, 2-4 
early literature in, 3 
meaning of, 2 
Pediculi, treatment for, 93 
People, lesson on, for children, 
452, 453 
Pemphigus neonatorum, 378 
Peptonized milk, preparation of, 
187 
Percentage method of feeding, 156, 
157 
Morse and Talbot on, 156 
Rotch on, 156 
Peritonitis, 344, 345 
Personality, development of, 42 
Personification, emphasis of, in 
child life, 39 
Pertussis, nursing of, 392, 393 
Petticoat, 27 
Pfaundler, Dr., rule of, on arti- 
ficial feeding, 160 
Philadelphia, first children’s hos- 
pital at, 4 
Phimosis, 360 474 
INDEX 
Physical examination of children, 
procedure in, 67-71 
Physical examination tray, equip- 
ment of, 67, 68 
Pillow slips, rubber, necessity of, 
57 
Pillows, description of, 57 
Plants, lesson on, for children, 452 
Plaster casts, care of, in ortho- 
pedic nursing, 429 
Play, educational possibilities of, 
38 
purpose of, 24, 25 
Play toys, for infants, 24 
Pleurisy, 355 
dry, 355 
with serous effusion, 355, 356 
Pleurocentesis, performance of, 
248, 249 
Pneumonia, 354, 355 
bronchial, 354 
chronic interstitial, 357 
lobar, 354, 355 
Poliomyelitis, acute anterior, 370, 
371 
an orthopedic affection, 425 
deformities following, nursing 
of, 433 
Popliteal vein, use of, in venipunc- 
ture, 229 
Positive, stress upon, in child edu- 
cation, 38, 39 
Postoperative care, in orthopedic 
nursing, 429, 430 
of infant, 415-417 
of young child, 419-423 
Postural kyphosis, orthopedic 
nursing in, 447 
Posture, 23 
poor, an orthopedic affection, 
425 
Pott’s disease, 440-444 
Powers of observation, as pediatric 
nursing essential, 8 
Practice, value of, 43, 44 
Premature baby, bathing of, 121, 
122 
bed for, 117, 118 
designed by Dr. Hess, 117 
breast milk for, need of, 116, 
123, 124 
characteristics of, 115, 116 
clothing for, 119, 120 
flannel cape, design for, 120 
expressed breast milk for, 141 
feeding of, by gavage, 122 
methods in, 122, 123 
Sedgwick on, 116, 123 
Premature baby, nursing procedure 
with, 115-124, 315 
temperature of, 121 
Premature care, discontinuance of, 
123, 124 
Premature room, 117, 118, 119 
Pre-operative care of child, 417- 
419 
of infant, 415-417 
Prolapse of rectum, 346 
Proprietary foods, for infant feed- 
ing, 154-155, 168 
Protein, as a food, 127 
in milk dilutions, 159 
Protein milk, preparation of, 
Method I, 181, 182 
Method II, 181, 182 
substitutes for, 182, 183 
Protein sensitization test, 256, 257 
Protoclysis, procedure in, 308-311 
Providence City Hospital, isolation 
rules of, 388 
Pubertv, changes occurring during, 
15 
dangers of, 15, 16 
development of children at age 
of, 15 
hygiene of, 16 
Pulse, average rates, 14 
procedure in taking, 73 
Pyelitis, 358 
Pyloric stenosis, 336-338 
Ramsey, on inunction methods, 
279 
Rectal suppository, method of 
using, 311 
Rectum, in nursing procedure, 301- 
312 
malformation, 317 
method of feeding by, 306 
method of giving drugs by, 
277 
prolapse of, 346 
taking of temperature by, 71 
Repetition, as a natural interest, 
42 
Respiration, average rate of, 14 
procedure in taking, 73 
Respiratory tract, diseases of, 349- 
357 
Rest hour, enforcement of, 61 
Restraining jackets, description of, 
84 
pattern for, 83 
Restraining of child’s hands, 
method of, 87 INDEX 
475 
Restraining of child’s legs, method 
of, 87 
Resuscitation, methods of, 100 
Byrd’s method, 102, 103 
Retropharyngeal abscess, 334 
Rheumatism, in childhood, 328 
Rhythm, lesson on, for children, 
455 
Rickets, 322, 323 
deformities following, nursing 
of, 432, 433 
Rilliet, contributions to pediatrics 
by, 3 
Rodda, Dr. F. C., on care of ex- 
coriated buttocks, 207 
Rollier, Dr. Auguste, schematic 
heliotherapy diagram of, 
271 
Rotch, Prof. Thomas Morgan, on 
percentage method of 
feeding, 156 
Round shoulders, 447 
Rubber goods, care of, 288 
Rubber pants, undesirability of, 
26 
Rumination, 339 
Saccharose, in artificial feeding of 
infants, 53 
Salts, mineral, as a food, 127, 128 
Salvarsan, intravenous adminis- 
tration of, 236 
equipment for, 236 
preparation of, 237 
reaction in, 237 
Sauer, Dr. L. W., on feeding of 
thick cereal, 188 
Saulinge, contributions to pedi- 
atrics by, 3 
Scalds, treatment of, 379, 380 
Scalp veins, use of, in venipunc- 
ture, 229 
Scarlet fever, nursing of, 389, 
390 
Schick test for diphtheria, 398 
performance of, 254, 255 
School, right interpretation of, 33 
Scientific feeding, 159-161 
Scoliosis. See Lateral curvature 
of spine 
Scurvy, 323, 324 
Seborrhea, 376 
Secretions, care of, in infectious 
diseases, 387 
Sedative enema, 306 
Sedgwick, Dr. J. P., on feeding of 
the premature, 116, 123 
Self-activity, necessity for, 37 
Self-assertion, development of, 44 
Self-realization, process of, 48 
Sense-training, early lessons in, 
453-455 
Serum, intraspinal injection of, 
247, 248 
Service, development of idea of, 
47 
Service room, equipment of, 50 
Shampoo, for long hair, equipment 
for, 92 
for short hair, equipment for, 93 
method of giving, 92, 93 
Shannon, Dr. W. R'., on eczema, 
378 
Shaving of child, equipment for, 
418 
Sheets, description of, 57 
rubber, description of, 57 
Sheffield, Dr. Herman B., on effect 
of cold, 259 
on effect of heat, 260 
Shirt, for infants, 25, 26 
Shock enema, 306, 307 
Shower bath, method of giving, 75, 
80, 81 
Sight, appeal to, in early years, 
36 
development of, 12 
Signal system, necessity for, with 
older children, 55 
Silence, lesson on, 453, 454 
Skin, care of, in orthopedic cases, 
425, 426 
diseases of, 376-380 
Skin infections of the new-born, 
321, 322 
Sleep, necessary amounts and divi- 
sion of, 20 
Small-pox, nursing of, 399-401 
Smell, development of, 12 
Solar system, lesson on, for chil- 
dren, 451 
Soranus of Ephesus, pediatrician 
of antiquity, 1 
Sound, lesson on, 454 
Spasmodic laryngitis, 351, 352 
Spasmophilia, 364 
Spastic paralysis. See Paralysis, 
spastic 
Special senses, development of, 
12-13 
Speech, defects of, 365, 366 
development of, 13 
Spicer infant urinal, use of, 213, 
214 
Spina bifida, 316, 369, 370 
Spinal cord, disorders of, 369-700 476 
INDEX 
Spinal puncture, 246, 247 
equipment for, 245, 246 
position of child in, 246 
site of, 246 
Sponge bath, method of giving, 
75, 77-79, 260-261 
Springs, description of, 56 
St. Petersburg, first children’s hos- 
pital of, 4 
Starch, in artificial feeding of in- 
fants, 154 
Starch enema, 307 
Starches, for infant feeding, 167, 
168 
Stenosis of esophagus, 317 
Sterilization of articles, procedure 
in, 225 
Stimulating enema, 307 
Stomatitis, 333 
Stool specimen, importance of, in 
medical examination, 208 
Stools, blood in, 222 
color of, 220, 221 
consistency of, 220 
curds in, 221 
examination of, points to note 
in, 219 
in infancy and childhood, im- 
portance of observation 
of, 217 
meconium in, 220, 222 
membrane in, 222 
mucus in, 222 
normal number of, 219 
normal size of, 219, 220 
odor of, 221 
of artificially fed baby, 223 
of breast-fed baby, 222, 223 
pus in, 222 
undigested food in, 222 
Stopcock, care of, after use, 226 
Strachauer, A. L., on pre- and 
postoperative surgical 
nursing, 415-423 
Subcutaneous injections, hypoder- 
moclysis, 241-243 
amount in, 241 
continuous, 242, 243 
equipment for, 241, 242 
methods for, 242 
reaction in, 243 
of diphtheria antitoxin, 240, 241 
equipment for, 240 
purpose of, 240 
sites for, 240 
of tetanus antitoxin, 241 
of whole blood, 239, 240 
donor in, 239 
Subcutaneous injections, of whole 
blood, equipment for, 239, 
240 
purpose of, 239 
sites of, 240 
Suds and glycerin enema, 305 
Sugar, in children’s diets, 200 
in infant feeding, 167 
Sun porch, necessity for, with chil- 
dren’s ward, 54, 55 
Sunlight, in ideal nursery, 17 
Surgery, orthopedic, definition of, 
424 
Surgical drainage, 248-252 
abdominal paracentesis, 250-252 
aspiration of pericardial cavity, 
249-250 
aspiration of pleural cavity, 248, 
249 
paracentesis of tympanic mem- 
brane, 252 
Surgical dressings, 422-423 
Swallowing of foreign bodies, 339, 
340 
Syphilis, 408-415 
prevalence of, 409 
primary stage of, 410, 411 
secondary stage, 411, 412 
sources of infection of, 408 
tertiary stage of, 412-414 
treatment of, 414 
Taenia saginata, 345 
Talbot, on basal metabolism of 
children, 129 
on percentage method of feed- 
ing, 156 
on wet nursing, 144 
Talipes, congenital, nursing of, 
431 
Taste, development of, 12 
Teeth, children’s, routine care of, 
88 
deciduous, order of appearance, 
13 
first, care of, 87 
permanent, order of appearance, 
13, 14 
preservation of, through masti- 
cation, 201 
Temperature, bathroom, during 
bath, 30 
child reactions in, 14 
of children’s ward, 53 
of newborn, 109, 110 
of nursery, 18 
of premature, 101 
procedure in taking of, 71 INDEX 
477 
Temperature, water, for bath, 30 
Test, Mantoux, 253 
phenolsulphonephthalein, 253, 
254 
protein sensitization, 256, 257 
Schick, for diphtheria, 398 
performance of, 254, 255 
von Pirquet, in tuberculosis, 
403 
performance of, 252, 253 
Testicle, undescended, 360 
Tetanus antitoxin injections, 241 
Thatcher, Reverend Thomas, treat- 
ise on pediatrics by, 3 
Therapy, made attractive, 455, 456 
Thermometer, care of, 72 
Thermometer tray, equipment of, 
72 
Thomas Wilson Sanitarium, Balti- 
more, opening of, 4 
Thoracocentesis, performance of, 
248, 249 
Thorndike, Edward, on growth, 33 
Throat, in nursing procedure, 296, 
297 
Thrush, 333, 334 
Thumb sucking, 366 
Toast, in infant feeding, 191 
Toilet powder, use of, 79 
Tongue depressor, diagram of, 91 
Tooth brush, description of, 88. 89 
Toothpick applicator, for use with 
newborn, 107 
Torticollis, congenital, 425, 430 
Tonch, development of, 12 
Touch-sense, early training of, 454, 
455 
Toys, care of, 62 
Tracheotomy, procedure in, 396, 
397 
Tracy, Susan E., on education 
value of occupational 
therapy in the care of 
sick children, 448-460 
Tray, part sterilized, setting up of, 
225 
sterilized, setting up of, 225 
Treatment of the child, in ancient 
times, 1 
Tub bath, equipment for, 79 
method of giving, 75, 79-80 
Tuberculosis, 402-408 
chronic ulcerative, 407 
Mantoux test for, 253 
miliary, 407 
nursing care in, 408 
of bones and joints, as acquired 
orthopedic affection, 425 
Tuberculosis, of hips, 435-440 
of kidney, 358, 359 
of spine, Albee’s operation for, 
443, 444 
Hibbs’ operation for, 444 
orthopedic nursing of, 440- 
444 
sites of lesions in, 405, 406 
sources of infection in, 403, 404 
von Pirquet test in, 403 
performance of, 252-253 
Tuberculous bronchopneumonia, 
406 
Tuberculous meningitis, 368, 369 
Tubing, care of, after use, 226 
Turpentine enema, 307 
Turpentine stupe, use of, 283, 284 
Tympanic membrane, paracentesis 
of, 252 
Typhoid fever, nursing in, 401 
linger, on artificial light, 272 
University Hospital, University of 
Minnesota, isolation rules 
in, 383-388 
routine of, 225 
in alcohol sponge bath, 262 
in sponge bath, 261 
regarding catheterization, 312- 
314 
regarding hot pack, 264 
technique of, for determining 
coagulation time of blood 
of newborn, 255, 256 
Urinals, baby, description of, 213, 
214 
Urination, daily amounts of, 209 
frequency of, 208, 209 
Urine, appearance of, 209, 210 
collection of, equipment for, 210, 
211 
for examination, 210 
methods in, 210-213 
of 24-hour specimen, from a 
baby, 214-218 
use of test-tube in, 210-212, 
217 
with baby boy, 210, 211 
with baby girl, 212 
routine specimen, need of, 214 
Utensils, for milk laboratory, 169, 
170 
sterilization of, 170, 171 
Vaccination, for prevention of 
small-pox, 401 
process of, 255 478 
INDEX 
Vagina, in nursing procedure, 299- 
301 
Vaginal douche, procedure in, 299- 
301 
Vaginal suppository, procedure in, 
301 
Variation, in child psychology, 
meaning of, 35 
Varicella, nursing of, 391, 392, 
398-401 
Vegetables, in children’s diets, 198 
in infant feeding, 191 
Venipuncture, equipment for, 227 
procedure in, 226-229 
use of external jugular vein in, 
228, 229 
of femoral vein, 229 
of median basilic veins, 227, 
228 
of median cephalic veins, 227, 
228 
of popliteal veins, 229 
of scalp veins, 229 
veins available for, 226 
Ventilation of children’s ward, 52, 
53 
of nursery, 17 
Ventricular tap, purpose of, 232 
Vienna children’s hospital, open- 
ing of, 4 
Visiting hours, arrangement of, 
61, 62 
Visitors, baby’s, 20 
Vitamins, as a food, 127, 128 
Vomiting, 338-339 
von Pirquet test, for tuberculosis, 
403 
performance of, 252, 253 
Walls, decoration of, in children’s 
ward, 53 
Warm room, for use with prema- 
ture, description of, 117 
Warming closet, necessity for, 52 
Water, as a food, 127, 128 
external use of, in disease, 259- 
268 
for the breast-fed infant, 140 
in milk dilutions, 160 
internal use of, 258, 259 
by mouth, 258, 259 
by rectum, 259 
into peritoneal cavity, 259 
intravenously, 259 
under the skin, 259 
lesson on, for children, 452 
sterile, in infant feeding, 153 
temperature of, for bath, 30 
Weaning, method of, 144, 145 
processes in, 192 
Weather, hot, proper clothes for, 
28 
Weighing, procedure in, 73 
Weight, at birth, 9 
childhood, 9 
infant, 9 
Weights and increases, average, 
table of, 10 
West, Dr. Charles, contributions to 
pediatrics by, 3 
work by, for children’s hospital, 
4 
Wet applications, cold, 263-264 
hot, 266, 267 
Wet nursing, 143, 144 
Whey, preparation of, 180 
Whitman, Walt, on child’s power 
to absorb, 36 
Whooping cough, nursing of, 392, 
393 
Woolen garments, laundering of, 
26 
Wry neck, as congenital orthopedic 
affection, 425 
Youth, years of, 9