THE NEWBORN PATIENT

(1)

254

THE

NEWBORN

PATIENT*

By Clement A. Smith, M.D.1

T

BE ENTRUSTED with the honor of

de-livering a lecture named for Doctor

Clifford Sweet is to be handed no easy as-signment. The lecturer’s basic problem is increased by the fact that the assignment comes from Doctor Sweet’s local

profes-sional colleagues. These men, who have

worked side by side with him as the Chil-dren’s Hospital of the East Bay has ex-tended its good influences-and his-not only know Doctor Sweet much better than does your lecturer, but must also know how great is their affection for him. Naturally, they hope I will tell Doctor Sweet some of tilese things for them. Like Myles

Stan-dish long ago on the shores of another and mere eastern bay, they expected their Twentieth Century John Alden to put into graceful words those deep feelings they find themselves unable to express.

I am quite unable to canny out such a

commission. John Alden, with a little gentle prodding, is said to have decided to speak for himself. I shall speak for myself, too,

and for my own colleagues who respect

Doctor Sweet as a doctor first, as a

pedia-trician second, and as a specialized

pedia-tnician third. \Ve say this with admiration

in an age when many 1)ediatnicians have

become so narrowly specialized that their

functions as doctors have become almost vestigial. It has been a great pleasure to spend these few days ill the company of

OD 50 wise in so many aspects of medicine.

I stand before you self-indicted as cne of

those narrow specialists who has allowed himself to be pushed into increasingly

ne-stricted medical territory. But on such

oc-From tile Department of Pediatrics, Harvard

Medical School. and tile Boston Lying-in Hospital afl(l Children’s Medical Center, Boston,

Massachu-setts.

0 The Clifford D. Sweet Lecture, Children’s

Hos-pital of tile East Bay, Oakland, California, May 22

1953.

IADDRESS: 221 Longwood Avenue, Boston 15,

Massachusetts.

casions as this, one should take the broadest

possible view of his particular interest.

Therefore, I wish to consider the newborn

infant simply as a patient, and to talk

mainly about the basic weaknesses and

strengths which modify the requirements

of his care and protection rather than

about specific illnesses which involve

cc-casional infants only. The newborn period

itself is nowadays looked upon as a sort of

malady. Every infant is expected to be

under a doctor’s care, not only during but

immediately after birth. I think this is right.

The newborn period is a dangerous one, as

I don’t need to produce figures to prove.

But it is also a universal disease-and

pen-haps the only one that everyone has to get

over. For this reason, we shall speak mainly

of the ways in which we can best help every

infant during these first days after

birth-the term ones and the premature ones.

Then, if we have time, we may close with

a few remarks on the infant who presents

also the special problems of an added

dis-ease state.

Although birth and the first few days

thereafter are indeed critical occasions, a

surprisingly large number of people

sun-vive them. I think this is in part because

Nature gives the unborn and newborn a

certain physiological resilience, about which

I should like to speak in some detail. A

simple example of the resilience of the

new-born infant is his relative indifference to a

rather wide range of body temperatures.

We have learned to waste little concern

oven rectal temperatures of 97#{176}to 100#{176}F.

in otherwise normal-seeming fuli-teim

in-fants, and even to allow smaller premature

infants to stabilize their temperatures at

levels sometimes so low that we cannot

re-cord them on our standard nurses’

chants-which go down only to 94#{176}F.Certainly

any-one who must cane for many newborn

in-fants soon finds many more important things

(2)

--,- P

P

0

ADULT

/

I

NE WBORN

P P

P Pj

P P

P/

\P\ P /

PREMATURE

If the infant is indifferent to a body

tern-perature of 97#{176}as compared with 99#{176}F.we feel that the physician should be also.

Nevertheless, there are limits beyond

which the infant may not be indifferent to

hypo- on hyperthenmia, and where his own rather feeble temperature regulating de-vices cannot hold his body temperature even within a rather broad normal range.

This is true also of all the other resiliences

of the infant. He may tolerate a widen

bati-tude than the adult, but his body’s

homeo-static mechanisms, which must ultimately

take a stand and resist circumstances of a

truly intolerable nature, are apparently

newborn and, especially, the premature

in-fant, may be normally found. The less

ma-tune the infant, the less one is apt to find

any given measurement falling in the exact

center of physiological range and the more

easily can the already eccentric position of

the infant be made still more eccentric. In

the matter of body temperature, the

cx-ample of the infant whose temperature is

94#{176}F.but on the addition of a few more

blankets becomes 102#{176},is a familiar one.

Finally, in our diagram we have drawn

the outsides of the circles as a firm barrier

for the adults, a thinner one for

tue

term

infant, and almost no barrier at all for the

(HIGHLY DIAGRAMMATIC)

FIG. 1. Effectiveness of physiological regulatory mechanisms in the adult (A)

newborn (N), and premature infant (P).

much weaker than those of the adult. Thus

if the infant drifts too near the edge of

the intolerable, he has very little defense

against going right over it. These newborn

patients thus have both the inherent

strength and the inherent weakness of the

pliable but otherwise defenseless

organ-ism.

Once I made a crude diagram to illustrate

this characteristic of newborn and

prema-tune infants as compared with adults

(

Fig.

1). This has been shown elsewhere, and I

introduce it here only in the hope that it

will be new to some of you. The attempt is

to portray how relatively wide is the

physiologic territory (as, for example, the

range of body temperature) in which the

small premature infant whose homeostatic

mechanisms are extremely feeble.

I do not wish to take the whole hour on

this characteristic of newborn patients, but

cannot resist introducing a few further

examples. The levels of any substances

which are carried in the blood of children

at quite narrowly adjusted concentrations

are normally less standardized during the

newborn period and are even more variable

after premature birth. Not only is this lack

of stability noteworthy; the apparent

in-difference of the infant to the abnormal

levels is perhaps more noteworthy still. A

familiar example is that of blood glucose,

which Norval’ found to vary between 15

(3)

life of 50 normal infants who gave no

recognizable sign of hypoglycemic reaction

at the lower levels.

Few factors in the body’s economy are as zealously defended as the hydrogen ion concentration of the blood. The carbon

di-oxide content of the blood and the carbon

dioxide tension in the lungs are important

parts of the system by means of which the

pH is kept stationary. In the older child or

adult, the composition of the urine and the

rate and depth of respiration are varied

con-stantly and considerably so that tile CO2 of

the alveolar air and blood can be

reason-ably steady and the hydrogen ion

concen-tration (pH) of the blood can stand

practi-cally still.

In the full-term infant the recorded data

of Marples and Lippard2 show some

de-parture of blood hydrogen ion content and

CO2 tension from the adult range, and some increase in the area occupied by the normal values. The data obtained by Dr. Wilson’s group from premature infants assumed to

be normal show a still widen scatter and

still greaten departures from the adult range.3

Another example of tolerance is the

well-known ability of the newborn organism to

survive without breathing for much longer

periods than are withstood by the older

members of the same species. The data

pub-lished by Glass, Snyder, and Webster4 on 3

species of mammals show the extensive

pe-nods of enforced anoxia survived by the

youngest of each group. I think from

oh-senvation one may safely say that the

new-born (and, especially, the premature

new-bonn) of the human species behaves

simi-lanly though, of course, the survival may not

be as an intact organism.

These, then, are a few examples of what may well be a basic characteristic of the newborn patient. I wish for convenience’s

sake there was some simple descriptive

word to sum up this combination of

adapta-bility and defenselessness. It is the strength

(and the weakness) of the small boy who

manages to avoid trauma by agreeing with

all the big boys in the gang but is lost once

he gets into a corner where he has to fight.

Or the salvation of those trees so weak that

they bend before every breeze and thus

re-main standing when rigid oaks have been

blown over. A “passive resistance” is almost,

but not quite, the right term.

In any case, this characteristic is in some

ways a distinct disadvantage to the doctor

trying to evaluate and to assist his newborn

patient; in other respects it is a tremendous

source of strength to the infant and,

there-fore, to us who work with him. Perhaps the

greatest clinical disadvantage of this

pas-sive resistance is the resultant concealment

on minimizing of physical signs on

diag-nostic data in this age group. Most of us

are accustomed to patients who have fever

when they acquire an acute infection. The

fever is, presumably, not only a sign of

ac-tive resistance to the infection but a

quanti-tative index of its severity. But in the patient

a day or two in age we are annoyed to find

that the infection may call forth no fever

at all, or even a mild falling off of body

temperature.

We are also-most of us-used to seeing

patients with any degree of metabolic

acidosis attempt to set matters right by the

active compensatory mechanism of

hy-perpnea. The more severely the disease

cm-cumstances threaten to reduce the pH of

the blood, the more marked is the Kussmaul

type of breathing. And we are accordingly

disconcerted to find that many a moderately

dehydrated infant whose respiration

ap-pears but barely perceptibly increased has

a blood pH of 7.2 on even below. There is

something vaguely uncooperative (and

al-most disloyal to the rules of the game played

between doctor and patient) about a

pa-tient whose spinal fluid is loaded with

bac-teria and pus cells but whose fontanel

scarcely bulges, who is not stiff and

con-vulsing but merely a little cold and

unne-sponsive. On an infant who behaves quite

normally even though his blood glucose is

only 25 mg./100 ml. Finally, the doctor is

apt to find newborn patients often

some-what unresponsive (or variously responsive)

(4)

be sufficient for the infant in terms of body

weight, or even in those more academic

terms of surface area, are often ineffective.

This may well be another example of the adaptability of newborn life, and another

way in which their failure to follow the

rules of the game disturbs the doctor who sees these newborn patients infrequently.

On the other hand, I believe that the

positive advantages of this passive

resist-ance are enormous, granted we understand

their limitations enough to take the proper

advantage of them. Provided we find means

of keeping the infant within the feeble

boundary of what he can tolerate, the lange

degree of his tolerance is a powerful ally to

the physician working with him. It may

well be that this is how the race is kept

go-ing through the regularly recurring hazards

of birth. Elsewhere in nature one finds

many other examples of the same tenacity

of young organisms to life. I regularly tell

our students-none of whom would be in

this audience-that the newborn infants

they care for with us are like recently

trans-planted trees. If one wishes to move a tree,

he will be wise to select the youngest and

smallest tree he can find. A big tree is

sel-dom able to survive any but the most expert

transplantation; a 2-foot sapling will live

through almost any handling, and a seed is

sure fire. Similarly, a 3-pound premature

in-fant may cling to life with even more vigor

under many circumstances than would a

7-pound mature infant.

To sum up our first generalization then,

tile newborn patient-especially if

prema-tuneiy born-has a surprising passive adapta-bility to unfavorable circumstances but

shows few defense mechanisms against

them. Yet only under relatively severe

in-suit does the meager degree of his

de-fenses result in his downfall.

Now let us consider a second broad

characteristic of newborn patients, which

seems to me too often forgotten by those

taking cane of them. This may be summed

up in the statement that the first few days

after birth are normally a time of negative

balances.

Perhaps this seems too self-evident to

deserve notice. But pediatricians are

doe-tons whose patients are, almost by

defini-tion, normally not just in equilibrium but in

positive balance-except for this small but

highly important group of neonatal ones.

No wonder the temptation arises to

ad-minister more calories, or more fluid on,

pen-haps, more electrolytes than are needed by

the newborn patient unless we constantly

remind ourselves of his reduced

require-ments. The tendency to give too much and

too early is usually more dangerous than

any possible error toward feeding on

pre-scribing too little and too late. Especially

is this true of the prematurely born infant,

whose negative balances, if not more

marked, may certainly be more prolonged

than those following full-term birth.

The simplest example of negative balance

is post-natal weight loss. So far as I know,

no one nowadays tries to correct this brief

dependence of the infant on capital rather

than on income. Unlike the economists,

we know that a period of barge income is to

follow, and therefore do not attempt to

avoid this temporary oven-expenditure. The

newborn temporarily expends not only

weight, but also calories, nitrogen, sodium,

chloride, potassium, and other electrolytes

fasten than he can store them. I think this

same status of temporarily negative

bal-ance may be normally true of body water;

indeed it is true of hemoglobin and true of

inherited antibodies. If the infant were an

adult who had just undergone a surgical

operation, few would deny him the

relaxa-lion of a short period of negative balance

thereafter. Just because the newborn

pa-tient is smaller than the adult, and because

he has not been put through something

im-portant bike a surgical operation but merely

asked to re-adjust his whole physiology

from a dependent to an independent

ex-istence, should we not also respect his

need for a negative balance period and

re-strain

our attempts

to force

him

to gain

at

once in weight, water, nitrogen,

hemo-gbobin, or other items?

(5)

6

.4.

Kg

2

I.

2 3 4 5

FtaI agt #{149}months Agc #{149}rnov*ks

3 4 S 6

to re(iuce significantly, the phase of negative

balances in the newly born patient, we

should not only ask ourselves whether this

relatively brief resting phase between rapid

intra-utenine and rapid extra-uterine growth

is a bad thing; we should also consider

whether we can devise feeding methods

capable of quantitatively replacing the

placenta.

To show how far we fall short of

replac-ing placental function after premature birth,

I have combined 2 charts of human growth

ilito a third. The first of these charts is

Mc-Cance and Widdowson’s representation of

weight gain by the average human fetus

and infant from gestation until 6 calendar

months after term birth

(

Fig. 2). For broad

in detail the average growth following birth

at appropriate intervals between 750 and

2500-gm. birth weights

(

Fig. 3). These

lines showing the average losses and gains

of weight during the first 50 days after

birth are quite like those followed by our

infants of comparable birth weight at the

Lying-in Hospital. I must say that we have

questioned the inclusion by our Bellevue

colleagues of the lowest line, showing the

average performance of infants weighing

just oven 1% pounds at birth. The subtle

implication that such infants survive as

regularly in New York as do the larger ones

charted is not lost upon us. Certainly that is

not the case in Boston. However, when we

have been able to make such a tiny infant

FIG. 2. Growth of the fetus and newborn infant (from McCance and Widdowson5).

portrayal, the post-natal dip and rise has

been smoothed out of this curve. Note that

the curve is inflected at the line signifying

term birth, from a fasten and fasten rise to

a slower and slower one. Normally, then,

the infant is not asked by Nature (and

our-selves) to grow as fast after birth as it did

as a fetus before.

If we interrupt the usual intra-utenine

circumstances by premature birth, the

de-gree of effect upon growth will differ,

de-pending upon the degree of prematurity.

We are grateful to Doctors Dancis,

O’Con-nell, and Holt6 for another chart indicating

live, its growth was about that here shown.

And in later publications, the 750-gm.

in-fant line has quietly become a dotted one.

Now, in Figure 4, we have taken these

same curves of premature infant growth

and plotted them from where they take off

from Dr. McCance’s and Miss Widdowson’s

smoothed curve for normal weight gain

be-fore and after term birth. This blending of

data from 2 sources is something no one

should dare to do. There is, however, some

precedent for an easterner behaving

out-rageousby in California. To quote the words

(6)

325”

3

273

23C

#{149},223

2

‘p

AVZRAGE WKIfT CURVES PRL&!1VRE INFANTS

(B.llvu. Nosptta1, N.Y.C.)

..

.5!

. 0

21

1!

40 :i Lb.

10 20 30

. 1ec

FIG. 3. Average weight gain of premature infants, Relievue Hospital.’

Lane Lectures7 at Stanford in 1949, “This

is an example of an unrighteous

determina-tion to have a chart come out the way you

want it to. And, as you see, the wages of

sin are-as they so often

are-delight-ful.”

In any case, the upper line on this

corn-bined chart shows what fine positive

hal-ances would have been achieved by our

premature infants had they remained in

utero. We have also included our Lying-in

Hospital experience as to the expected

survival rate in relation to birth weight

and-thus-roughly to prematurity.

Not only does life outside the uterus

seemingly have to begin by a few days of

negative balance, but once the infant starts

to gain again, the gain is seldom as good as

that achievable in utero. Only at that

de-gree of prematurity which is almost, by

definition, full-term birth (i.e., 2500-gm.

birth weight) does the growth shortly at-tamable outside the uterus parallel that

which would be attained within. At more

premature births, the rate of gain attained

during the first 50 days ex utero rises much

less rapidly than that which would have

been expected in utero. Of course we all

know that ultimately the line describing the

weight of the average small premature

in-fant turns more steeply upward, while the

line of the average term infant is curving

downward. The lines will ultimately tend to

come together as the premature infant

catches up to the usual stature of the term

one. So that in time the lost ground is

regained, and this is how I think it should

be regained-by allowing time.

Anyone who seriously questions the

(7)

post-G.

survIvol 97%

87%

60%

500

Fetal oqe.months Age.months

INTRA-UTERINE VS EXTRA-UTERINE GROWTH

Doto of McConce and of Dancis ef of

FIG. 4. Growth lines of premature infants from

Figure 3#{176}plotted to scale under line of average

fetal and neonatal growth in Figure 2.’

natal period should consider whether we

have clean evidence that it would be a good

thing for the infant to gain as rapidly after

birth as if he still had the maternal

organ-ism and the placenta working to provide

his nourishment. If a few days or a week

of negative balances were a real threat to

the infant, we might expect to find the

largest number of neonatal deaths occurring

on the fourth on fifth day, just before the

machinery of independent extra-uterine life

shifted into gear and started forward.

Actually, this is not, of course, the time

when we do lose many infants. Most of our

losses, premature and term, occur on the

very first day after birth8 when one can

scarcely argue that so brief a period of

squandering capital can have exhausted

all the infant’s resources.

You may object that the only moral which

can be drawn from this chart concerns the

futility of hurrying weight gain as a whole,

and that there is no argument here against

providing large amounts of specific

sub-stances such as iron, electrolytes, vitamins,

and-did we but know which

ones-hor-mones, during the early post-natal days. My

answer would be that if we are unable to

prevent these gross general losses by

con-structing circumstances which will keep

the infant a sort of extra-uterine fetus, I

doubt that we should attempt to prevent the

other more specific negative balances

temporarily incidental to readjustment of life.

Both of the points which I have been

try-ing to establish-that the newborn patient is

characteristically a flexible rather than a

rigid organism, and that he is an organism

normally expending more than his

income-both of these characteristics, and others,

deeply affect our management of him.

Neither of these characteristics nor any

others justify the least element of

negli-gence toward him. Any such negligence

might well be described by the adjective

“criminal.” On the other hand, the

underby-ing physiological status of the newborn

pa-tient does argue strongly for a good deal

of observant inactivity on the part of the

physician-inactivity which, properly

ap-plied, may be described by the adjective

“masterly.”

Actually the only proper alternative I see

to a policy of masterly inactivity toward

newborn patients would be one of equally

masterly activity. The infant refuses to

reg-ubate things in his own behalf, as we spent

some time earlier in pointing out. So, if we

are to assume this task for him, we must be

masterly to the point of omniscience. It is

possible to give the adult patient who needs

repair of electrolyte structure a relative

oversupply of several electrolytes on the

premise that his kidney will adjust the

hal-ance by excreting whatever we have

intro-duced in excess. It is not safe to do this for

the infant, so that one must know exactly

the right amounts to give if one gives

any-thing. We have never felt that we could be

masterly in that fashion. Our tendency has

been to do little beyond establishing those

simple general circumstances within which

the infant can most safely work things out

best for himself, watch closely, and leave

practically all the rest to the infant.

To describe safe general routines for the

newborn patient is very simple; to go into

all details of every possible contingency in

(8)

is impossible. As one of a committee now

in its second year of work revising the

Academy’s “Manual on Hospital Care of

Newborn Infants” I can tell you that there

are still a good many fine details which ilave to be settled by telling people to use their heads and do the best they can. But broadly speaking, we have found’#{176} that

in-fant mortality and morbidity are low and

nurses’ time is efficiently used when hospital and medical policy are designed to provide the following main items:

1. Obstetrical and pediatric interest and

responsibility for the fetus and infant jointly -not obstetrical interest and responsibility nierely until the infant is born and pedi-atric interest and responsibility only after birth. One of the best ways of promoting this joint interest is by regular fetal mortal-ity conferences employing good autopsy studies of both stillborn and neonatally

dead infants, and never evading the

ques-tiofl: ‘How could we have done better?”

2. A recorded physical examination of

the infant within the first 24 hours after birth. Similarly, a second recorded physical

examination done within 48 hours before he leaves the hospital. With us, this is at the seventh or eighth day. Dr. Clifford is trying

to find enough time in the hospital’s busy

sciledule so that this discharge examination can be done while the baby lies undressed

on the mother’s bed-an excellent step

toward bringing the baby, mother, and doctor together early and often.

3. Simple nursery routines which require the least handling and the least congrega-tion of infants. We have given up any

bath-ing or inunction of the skin. We have

given up all central “treatment” or examin-ing” tables. Examination is done in the in-fant’s bassinet or incubator-treatments

similarly except those so elaborate that a small table must be set up for the purpose.

We ilave recently reduced

temperature-taking after the third day from every 4 to every 8 hours and wish we had made this change long ago. I think of numerous other means by which nurses’ time might be saved, and hurried, careless contacts of

nurses and infants reduced. Infants who

ap-pear in normal general condition don’t need

weighing more than once after birth

cx-cept perhaps on day 3 and at discharge on

day 7 or 8. Certainly we have still much to learn about the amount of nursing cane

which the one person yearning to take it

all oven-the infant’s mother-might give.

4. Nursery routines should, however, be

such as will protect the relatively few

in-fants in whom morbidity may develop. In

our experience, almost all of them will be

drawn from the group of premature

in-fants, from those born by Cesanean on other

operative delivery, those with any difficulty

of resuscitation on with major congenital

anomalies; those born to mothers with

toxemia, diabetes, on significant grounds for

suspecting incompatibility disease, and all

infants born more than 21 days after

cx-pected date. In our hospital, all of these

go from delivery to special nurseries, where

they may have extra observation.

Some infants among those just

enumen-ated-the small prematures, for

example-may have to stay in such a special nursery

for months. Most of the others, such as

those operatively delivered, may only

re-quine a few hours of extra watching and a

second physical examination before being

taken to the regular nursery on the mother’s

floor. The premature nursery and the special

nursery for these nonpremature infants re-quining special observation are visited every

morning by the Visiting Pediatrician.

Infants in whom we feel the threat of

p0-tential morbidity to be that of maternal

in-fection are isolated in one or more

observa-lion nurseries until 48 hours without diffi-culty, and negative cultures, have relieved our fears.

We have been pleased with the control

such a system gives the Visiting

Pedia-trician and house staff over the 150 to 200

infants in our hospital at any one time. But

we would not think of giving up one other

check-the early morning visit of the head

nurse to every one of the 7 regular nurseries

(

besides the observation and premature

(9)

daily written report to the Visiting Pedia-tnician of any symptom, sign, or problem

in any infant anywhere, no matter how

trivial the symptom nor how important the

infant’s family in the local aristocracy. It

then becomes the Visiting Pediatrician’s

responsibility to look into any of these

re-ports which suggest the possibility of

infec-tion, and it is understood to be within his

authority to transfer the infant with actual

-on strongly suggested-infection to another

nursery or even another hospital. He

obvi-ously must accomplish this with tact. The

important thing, however, is that his

author-ity to accomplish it is understood. By these

means, the Visiting Pediatrician, when he

leaves the hospital at 10 in the morning knows that although he has only seen a few

of them, all of the newborn patients are

relatively safe for another 24 hours.

This general plan of reducing

non-essential items of nursing attention and

medication to a minimum, of respecting the

ability of most infants to do well if left

rela-lively undisturbed, on focusing the most

at-tention on that minority of infants who are

most likely to require it, and of keeping 1

pediatrician constantly informed of change

in status of every infant in the hospital,

private and public-this plan has made our

hospital a safer place for newborn patients.

It has not prevented premature birth, nor

the respiratory difficulties often

superven-ing after premature birth, or after fetal

dis-tress at term birth-those states now called

“hyaline membrane disease,” yet scarcely

better understood under that name than

when they were called “intra-uterine anoxia

with aspiration of amniotic sac contents.”

We cannot prevent the birth of infants with

congenital abnormalities, nor with Rh or

other incompatibility disease. We have

seen a decline-if not a disappearance-of

the old picture called “hemorrhagic disease”

with spontaneous bleeding on the second

on third day, notably from the bowel and

umbilicus, and into the skin. This change

does not seem to be entirely related to

vita-mm K administration. We still see infants

who bleed, but most commonly in the

terminal phases of infection, or perhaps in

association with anoxic damage to the

capillaries.

We have certainly reduced, if not

corn-pleteby removed, the problem of infections

late in the neonatal period-those beginning

after 3 or 4 days of age-and we have been

much less troubled by skin infections with

today’s absence of attention to the skin than

under yesterday’s over-attention. But to our

dismay, we have not as yet been able to

prevent the death of an occasional infant

from pneumonia, sepsis, or meningitis

ap-parently contracted on the day of birth, if

not before. These very early and almost

silent infections were the cause of 12 per

cent of our neonatal mortality at the Boston

Lying-in Hospital last year. This is,

per-haps, not a very large proportion of not a

very large total mortality, but one feels it

should be no proportion at all. To this

diffi-cult problem of the insidious and rapidly

progressing infections acquired within a

brief interval on either side of birth, we

have not yet found the complete answer in

antibiotics and chemotherapy. Some

corn-binations of these drugs-usually penicillin

and sulfadiazine or streptomycin-we now

routinely administer to all infants whose

mothers had ruptured membranes for 24

hours or more before delivery. Perhaps we

will have to give such drugs routinely to

certain rather barge groups of mothers as

well as to their infants. In any case, we find

it interesting that even the problem of

in-fection-bike so many other threats to the

newborn patient-is more and more a

prob-bern of maternal-fetal relationship than a

result of the infant’s defenselessness when

cast forth into a hard world. Again, the

matter becomes a field for joint

obstetrical-pediatric responsibility and activity.

Thus, we, like yourselves, not only have

our larger responsibility to provide

maxi-mum protection to every newborn baby,

but also have our occasional newborn

pa-tients presenting special diagnostic and

(10)

these newborn patients, we have learned to act slowly and only on very clean reasons. Thus, we do not feed or give fluids to such infants IlITitil they are 2 or 3 days of age,

lifllC55 we have evidence of unusual deficits

-as i)y diarrhea or vomiting-to be restored.

If we find ourselves forced to give fluids by

needle, we increasingly tend to use solu-tions ratiler dilute in electrolyte content, and proportionately smaller amounts pen

Ullit of body weight than might be used for

the older patient.

If the question of endocrine therapy is

raised for any newborn patient, as it often is, we have learned to go more slowly and to

(lemand better evidence for such a program than in older patients.

If temperature instal)ility on an unusual

biochemical measurement in blood or spinal fluid is presented to us as grounds for thera-peutic or diagnostic activity, we are in-dined to ask whether the condition to be corrected is necessarily harmful and whether the proposed correction is itself entirely harmless.

Thus, we feel, one should approach one’s newborn patients gently, watchfully, and above all, repeatedly-but always consider-ing whether what we observe may not be within normal limits for them. If we ask

ourselves first, “May this not be acceptable

neonatal behavior?” and, second, “Am I

sure I can correct it any better than the

in-fant can if left to himself?” we will be

making wilat seems to me the proper

ap-proach to the newborn infant.

REFERENCES

1. Norval, M. A., Kennedy, R. L.

J.,

and

Berkson,

J.

: Blood sugar in newborn infants.

J.

Pediat., 34:342, 1949.

2. Marples, E., and Lippard, V. W. : Acid base balance of newborn infants, II, Consideration of the low alkaline re-serve of normal newborn infants. Am.

J.

Dis. Child., 44:31, 1932.

3. Wilson,

J.

L., Reardon, H. S., and

Mura-yama, M. : Anaerobic metabolism in the newborn infant, I, On the resistance of the fetus and newborn to oxygen lack.

PEDIATRICS, 1:581, 1948.

4. Glass, H. G., Snyder, F. F., and Webster,

E. : Rate of decline in resistance to anoxia. Am.

J.

Physiol., 140:609, 1944. 5. McCance, R. A., and Widdowson, E. M.:

The chemistry of growth and develop-ment. Exhibit Guide, Sixth International Congress of Pediatrics, Zurich, 1950. Brit. M. Bull., 7:297, 1951.

6. Dancis,

J.,

O’Connell,

J.

R., and Holt,

L. E. : A grid for recording the weight of premature infants.

J.

Pediat., 33:570,

1948.

7. Gamble,

J.

L. : Lane Medical Lectures,

Companionship of body water and dee-trolytes ill organization of body fluids. Stanford University, California, Stanford

Univ. Press, 1951.

8. Smith, C. A. : The valley of the shadow of birth. Am.

J.

Dis. Child., 82:171, 1951. 9. American Academy of Pediatrics,

Commit-tee on Fetus and Newborn: Standards and Recommendations for Hospital

Care of Newborn Infants, Full Term

and Premature. Evanston, Illinois, Amen-ican Academy of Pediatrics, 1954. 10. Smith, C. A. : Safeguarding the

newborn-The pediatrician’s responsibility. Am.

(11)

1955;16;254

Pediatrics

Clement A. Smith