THE BULLETIN OF MATERNAL WELFARE

Published by The American Committee on Maternal Welfare, Inc.
116 SOUTH MICHIGAN AVENUE • CHICAGO 3, ILLINOIS

Major Articles in This Issue

JANUARY • FEBRUARY, 1954

<table><tr><td>Psychosomatic Influences in Maternal Care</td><td>7</td></tr><tr><td>Nurse Luncheon Discusses Rooming-in</td><td>10</td></tr><tr><td>The American Committee Looks Ahead to a Big Year</td><td>11</td></tr><tr><td>Obstetrical Facilities</td><td>13</td></tr><tr><td>News of the Auxiliary</td><td>16</td></tr><tr><td>Evaluation of Prenatal Care and Its Social Significance</td><td>17</td></tr><tr><td>Latest Information on Program and Travel for International Congress</td><td>18</td></tr><tr><td>New York Lying-in Believes in Fathers' Classes</td><td>19</td></tr><tr><td>Academy Holds Successful Meeting</td><td>20</td></tr></table>

ACMW Sponsors Nurse Luncheon
Discussion of Rooming-in

On November 6 the American Committee on Maternal Welfare sponsored a luncheon for maternity and pediatric nurses. One hundred sixty-one attended. The principal speaker was Dr. Edith B. Jackson, Associate Clinical Professor of Pediatrics (Psychiatry) Yale University School of Medicine; attending physician, University Service of the Grace—New Haven Community Hospital who spoke on “The Philosophy and Practice of Rooming-in.” Dr. Jackson is pictured above between Dr. Fred H. Falls, president of the American Committee and Miss Ann Kirchner, R.N., secretary of the American Committee.

The luncheon was held in conjunction with the biennial convention of the Illinois State League for Nursing. At the far right of the picture is Miss Anna Fillmore, secretary and general director of the National League for Nursing and featured speaker at the convention, who spoke briefly at the luncheon to emphasize the increasingly close cooperation of the nursing organizations and the American Committee.

The presence of a hospital administrator and a public health worker at the speakers

table personified the four-discipline structure of the American Committee.

Dr. Jackson described rooming-in as a hospital arrangement of maternity patients wherein mother and infant are not left together in a room, but are cared for together in a room. It signifies a certain attitude in the care and certain quality in parental education which runs counter to the procedures of central nursery care for infants which have prevailed during the last three decades. Both this new attitude and principles of education are based on the recognition that people are different and do not always react in the same way at the same time, and that babies as well as mothers are persons.

She went on to emphasize the importance of the attitude of care for the rooming-in nurse. She said the nursing attitude about which mothers have repeatedly expressed appreciation are tact in recognizing and anticipating needs, readiness to meet requests for help and guidance at any time, and willingness to stand by without intrusion while the mother tries her hand at each new procedure.

Page 10

THIRTY-FIRST ANNUAL MEETING

of the

American Orthopsychiatric
Association, Inc.

HOTEL COMMODORE • NEW YORK, N. Y.

March 11, 12, 13, 1954

FRIDAY MORNING, MARCH 12, 1954

problems of pregnancy, the family, and the care of the infant and follows them by films. Holding the greater part of the discussion prior to the film has seemed more conducive to free expression in the group. In addition to group meetings individual consultation is provided for primiparas and other patients having special problems. Examples are given of three such cases, one being self-referred, one referred by the clinic obstetrician, and one by a public health nurse.

Discussant Edith B. Jackson, M.D.

A STATISTICAL ANALYSIS OF 50 CASES FROM THE YALE ROOMING-IN PROJECT, RELATING MATERNAL CHILD CARE PRACTICES TO CHILD BEHAVIOR. Ethelyn H. Klatskin, Ph.D., Edith B. Jackson, M.D.

Fifty records of primiparous mothers including data on the first three years of the child's life were analyzed statistically. A rating scale method of analysis was used. The areas scaled for the mother were: practices in feeding, sleeping, toileting and socialization, and her adjustment to the maternal role. For the child, the areas scaled were: behavior in feeding, sleeping, toileting and socialization, and his evidences of emotional maladjustment. The relationship between the consensus judgments of two groups of raters for mother's practices and child's behavior was analyzed statistically for every area during each of the three years. The statistical results and their relationship to other aspects of the case histories are discussed.

Discussant John A. Rose, M.D.

THE PLACE OF PSYCHODYNAMIC ORIENTATION FOR PROFESSIONAL LEADERS IN A PROGRAM OF PARENT EDUCATION. Gertrude Goller

In recent years parent groups, whose purpose is the improvement of parent-child relations, have had a mushroom growth throughout the country. Leaders are drawn from both lay and professional groups. It is often assumed that training for a particular profession - such as psychiatry, education, social work or psychology - per se carries with it preparation for leadership of parent groups, whose primary goal is education rather than therapy.

This paper places emphasis on the need for the leader's having professional training, with psychodynamic orientation as one of the

Commercial Exhibits Open 9 a.m. to 5 p.m. Through Saturday

[24]

FRIDAY, MARCH 12, 1954 (Continued)

COMMUNITY MENTAL
HEALTH—I

Section B. PARENT EDUCATION OR THE ILLUSION OF OMNIPOTENCE. Hilda Bruch, M.D.

A PILOT PROGRAM UTILIZING GROUP DISCUSSION, FILMS AND MENTAL HYGIENE CONSULTATION IN A PUBLIC HEALTH PRENATAL CLINIC. Sibyl Mandell, Ph.D.

A STATISTICAL ANALYSIS OF 50 CASES FROM YALE ROOMING-IN PROJECT, RELATING CHILD CARE PRACTICES TO CHILD BEHAVIOR. Edith B. Jackson, M.D. and Ethelyn H. Klatskin, Ph.D.

THE PLACE OF PSYCHODYNAMIC ORIENTATION FOR PROFESSIONAL LEADERS IN A PROGRAM OF PARENT EDUCATION. Gertrude Goller.

main essentials, and, along with this, specific additional knowledge if he is to help the members achieve improved relations with their children. Illustrations are drawn from experience with parent groups, to demonstrate the essential contribution made by the leader's knowledge and skills in the several specialized areas that constitute the parent group education experience, particularly those requiring psychodynamic orientation. The leader's use of these skills toward achieving the specific goals of such a program is also discussed.

Discussant Phillip Zlatchin, Ph.D.

SCHEDULE FOR DR. JACKSON'S VISIT

Thursday - March 25 - 12:30 P.M.

Arrival and luncheon with Dr. Margaret B. McFarland

Thursday - March 25 - 3:30 P.M.

Film and lecture for multiple discipline professional group

Thursday - March 25 - 6:30 P.M.

Dr. Margaret B. McFarland's dinner (Dr. Spock, Dr. Marcus, Child Development Residents and Nursery School Teachers)

Friday March 26 - 9:00 A.M. to 10:00 A.M.

Arsenal Nursery School (10:00 to 10:15 coffee)

Friday March 26 - 10:15 A.M. to 12:00 N.

Child Health Conference and Round Table

Friday March 26 - 12:15 P.M.

Luncheon at the Arsenal Nursery School with Dr. Marcus, Miss
Lois Waite and Dr. Tomlinson

Friday March 26 - 3:00 P.M.

Conference with members of the Child Development Staff

Friday March 26 - 6:30 P.M.

Dinner with Dr. Kroeger

A room at the College Club has been reserved for Dr. Jackson
for Thursday and Friday, March 25th and 26th.

3. The child has a chance to get acquainted with both the mother and father while still in the hospital.

The fourth panel discussant, the writer, then told about her experience in a Midwest town with the usual type of hospital maternity care. She had had a liberal arts education and did graduate work in history of the theater. Her husband was a graduate student in the School of Fine Arts. Neither of them had had any experience with children at all. She had read with great interest about the possible advantages of rooming-in⁴ and tried in vain to arrange for it before the baby was born. Although she had a sympathetic physician, she found that the hospital experience itself provoked anxiety and fatigue. She felt that a woman and child "living most intimately together for nearly a year can find a rest from each other a shocking ordeal"; and she could not see that the artificial separation prepared either of them, or the father, for life as it is to be lived in the home. It had never occurred to her that she would not nurse; it was accordingly a blow to be told on the third day that she could not do so. Too many visitors tired her. She believed the greatest potential benefits of rooming-in to be: time, interest and help for the mother who wants to nurse her baby, and help for parents when they need it most in being together with their baby as a family unit.

Mrs. O. was the fifth discussant. She was a graduate of State Teachers College in New Jersey and had taught kindergarten, nursery school, and first grade. Her husband was a graduate student in secondary education. Her first baby was with her in the rooming-in unit. She was appreciative of the help given her in nursing her son, the experience of caring for him herself, the opportunity to keep close watch over him and to record his reactions on a daily behavior chart. She was pleased that visitors were limited and that her husband could share in the baby's care.

The last speaker was Mrs. H., chairman of the panel discussion. Her college work had been in zoology. Her husband was a graduate student and instructor in the Department of Economics at Yale. Mrs. H. had had considerable difficulty in nursing her first baby and felt that his care had been taken out of her hands, first by the hospital nursery, then by a practical nurse; she had no trouble with the second baby who was by her bedside in the unit. She commented that in the unit she was never conscious of babies' crying except at night when her own baby was demanding attention.

⁴Gesell, A., and Ilg, F., Infant and Child in the Culture of Today, New York, Harper and Bros., 1943, pp. 81-87.

Questions and discussion from the floor followed the panel presentation.

*Dr. Jackson:* If you could have had your baby in a room by yourself, would you have preferred this to a four bed unit?

Most of the mothers bespoke their preference for the four bed unit because of the companionship, the chance to exchange experiences and points of view about child care with other mothers, and just to see the other babies.

*Dr. Powers:* Is every one of the mothers here in agreement about the four bed unit?

*Mrs. H.:* I, too, say four, and I don't think I would object to having more, though not too many more, maybe eight. But if that were done, there would have to be good soundproofing and provision for privacy, when needed.

*Miss Hyder:* From the point of view of nursing, it would not be possible for one nurse to take care of eight mothers and eight babies. If it were possible to have two rooming-in units, each with four mothers and four babies, one nurse at night with a trained aid could handle eight mothers and eight babies, and two nurses could handle it on other shifts. You have to staff for your busiest moment, not your least busy. If you have five mothers, you may get one mother who needs a great deal more attention than the other four, and the others may suffer, and the quality of nursing will be reduced.

*Mrs. Krementz* (nurse in charge of the rooming-in unit): In the first few days both mother and child need more care than during the last few days.⁵

*Dr. Snoke* (director of the hospital): Would you think it practical to have assembly-line technique? For instance, have the mothers go into a different unit when the babies are new?

*Mrs. O.:* You would lose the sociability.

*Dr. Jackson:* The associations a mother makes when she first comes into the hospital are very important; when we have asked mothers about transfer from the ward to rooming-in, they often prefer to stay where they are for the sake of the associations already made.

The question of the optimal number of beds for a rooming-in unit led naturally into the question of noise and whether the mothers got sufficient rest.

*Mrs. Ol.* (wife of a rooming-in pediatrician, and a rooming-in mother): Some of my friends objected most strenuously to the idea of rooming-in, insisting that by the time they had had more than one baby, they wanted to have a good rest in the hospital, away from the other children. While in rooming-in,

⁵At the time of this discussion, early ambulation had not yet been started. Mothers stayed in bed for six days, were up on the seventh day, and went home on the eighth day.

I was having too good a time to get much rest; but when I got home, I felt more rested than I had when I had my first baby in a private room. I think it was the mental rest that enabled me to do everything when I got up.

*Mrs. H.:* I could sleep any time even if one of the other babies was crying. I knew the nurses would try to quiet him. The noise did not bother me.

*Dr. Snoke (to Dr. Olmsted, rooming-in pediatrician):* You feel that provision ought to be made for the babies to be in a nursery adjacent to the mothers' room?

*Dr. Olmsted:* There are times during the baby's first eight days when he is going to cry, and the mothers will, for a short period, require rest and relief. That has occurred in the rooming-in unit, but it is relatively rare and doesn't last very long.

*Dr. Snoke (to the rooming-in mothers):* How often was the baby put in the small nursery?

*Mrs. W.:* Two nights and three hours. But I got so used to my baby that I felt lonesome when they took him away.

*Mrs. Ol.:* My baby never went into the nursery.

*Mrs. H.:* In the afternoon the babies were taken to the small nursery sometimes. That was when I got a lot of rest.

*Dr. Snoke:* Was the noise subdued enough?

*Mrs. H.:* You could hear the babies occasionally but did not mind, because you knew someone else had the responsibility at that time; although it might be better for some mothers if the nursery were completely soundproofed, and the partition reached to the ceiling.⁶

*Dr. Foord (an assistant director of the hospital):* Is the mother of the crying baby the only one to be disturbed by the crying?

*Mrs. H.:* It depends on whether the other mothers are light sleepers.

*Dr. Foord:* Suppose you have a baby in the unit doing a lot of crying, but the mother doesn't wish it to be moved into the little nursery?

*Mrs. H.:* There was a baby in the unit who did a lot of crying, but we didn't mind it; we didn't feel we had the responsibility for it.

*Dr. Olmsted:* I think it should be pointed out that all of us working this year in rooming-in have come to the conclusion that rooming-in is not going to work for all mothers. There are certain mothers who don't want rooming-in, and for some it could be a traumatic experience.

*Dr. Snoke:* How have you found out about these mothers?

*Dr. Olmstead:* By interviewing mothers in prenatal clinic. Some say they don't want rooming-in.

⁶The partition was incomplete, for the sake of sufficient ventilation in the nursery.

They give a good many reasons; a lot are not valid, and the mothers might change their minds if they knew more about rooming-in and if the idea were not so new to them. They frequently give the reason of needing rest while in the hospital. There are mothers who feel that they will not be able to cope with the nursing, and some are worried or have emotional difficulties. Other mothers show no particular desire for the new baby; it probably would be more traumatic for them to have the baby in the room with them.

*Dr. Powers:* In the past have you had any experience with a mother who didn't want it, and then became a mother in rooming-in?

*Dr. Jackson:* One mother whom Dr. Olmstead decided was not a good candidate came in, and was simply delighted with it.

*Dr. Snoke:* Any mothers who came in and then didn't like it?

*Dr. Olmsted:* We know just from rumor about one mother who wasn't satisfied with rooming-in, and in looking back on it, we might have realized that rooming-in was not advisable for her, that she couldn't cope with it. I don't think the incidence of that will be high.

*Dr. Snoke (to Dr. Jackson):* Are we letting down the bars as far as infection is concerned? Are we letting visitors come and handle the babies?

*Dr. Jackson:* Yes, we encourage the fathers to hold the baby and learn something about its care before mother and baby go home from the hospital. Some fathers are at first embarrassed to show their interest in the baby, but soon succumb to the enthusiasm of other fathers in the unit. It is required that the father wash his hands and put on a clean hospital gown before holding the baby. There has been no cross infection to date.⁷

*Dr. Snoke:* What if mothers want to breast-feed their babies and can't? Do they stay in rooming-in?

*Dr. Jackson:* We keep all mothers who have been admitted to the unit, unless they have to be moved on account of some illness. No mothers have been penalized for their inability to nurse, although some have feared they would be.

*Dr. Powers:* What happens after the hospital stay? Do the mothers keep on nursing their babies?

*Dr. Jackson:* We are gathering material on that at present.⁸

*Mrs. W.:* I will nurse my baby about nine months altogether.

*Mrs. H.:* I have the feeling that obstetricians and

⁷June 1946. This has continued to be true to the present time.

⁸The study, which is in preparation for publication, indicates that rooming-in mothers nurse somewhat longer than mothers whose babies were in the nursery.

pediatricians might weigh a mother's feelings. If they see the slightest hope that a mother might want to nurse her baby, they should try to help.

*Mrs. W.:* Being from Canada, and from a very small community where it is taken for granted that a child should be nursed, I never felt otherwise. I was quite surprised to learn that mothers aren't allowed to nurse the baby more than 20 minutes;⁹ the doctors at home say over 20 minutes.

I have been going to the Child Study Group regularly, where I meet young mothers from all parts of the country, and these girls all say that they were interested in nursing their children, but they just didn't seem to get enough help. The baby was given a bottle, and then, first thing they knew, the child was weaned.

It seems to me that there has not been enough encouragement of nursing by members of the medical profession throughout the country. Some of my friends will not nurse their children; their attitude may be traced to an adverse mental attitude toward this physiologic function, usually conditioned by friends, relatives, or by the family physician.

*Mrs. C.:* From experience with my first child, I was just not prepared to be able to nurse the second. Quite a good deal of the time here with my second baby, I was afraid every day that I would have to start the bottle, but they were patient, and I had great success. I am still nursing the baby, and she will be five months old tomorrow.

*Mrs. B.* (medical student's wife): I had both babies in the New Haven Hospital; the first one was in the nursery, the other was in rooming-in. It was not helpful to me with the first baby to have a different nurse show up each time and try to help me to breast-feed. I don't think I had the same nurse for the same thing at any time. That was the thing I appreciated with rooming-in: Mrs. Krementz was always there.

*Dr. Snoke:* If we find that rooming-in takes more personnel hours in order to give adequate nursing care than the conventional system, it would presumably be a more expensive means of hospitalization. Would it be worth it to you mothers to have the rooming-in type of care rather than the conventional type?

*Mr. O.:* It would be the old man who would have to pay, and in this case willing to pay. I am rather concerned as to how the process of birth alienates the members of the family from each other. The divorce rate and the antiseptic rate go up together.

And I can see where that could happen. Everyone here has been talking about the mother. It goes on at a double rate at the hospital. It is a tough experience for the father who has known and loved his wife and then cannot see either his wife or baby for a while, and then, afterwards, the baby most infrequently. I believe it can be the cornerstone to start differences in the family—where the father is not able to participate, where the baby belongs to the woman alone, where the father is excluded. From my point of view, rooming-in would be worth double the amount to maintain the good relationships.

*Mr. C.:* I don't want to give any ideas about giving double rates, but I think it is more than worthwhile. Dr. Jackson asked me about my own reactions on seeing the baby in the hospital here. The first time I saw the baby, I looked through the glass; I didn't know whether it was ours or not. When I looked through the glass, there was still that feeling of isolation. The minute I was able to hold the baby, we became Dad and Babe.

*Mr. H.:* I think the fathers are willing to pay a moderate amount more for the satisfactions they get in rooming-in.

*Dr. Snoke* (to Dean Bixler of Nursing School): The main thing to meet the demand is personnel?

*Dean Bixler:* I think quantity as well as quality is necessary. We have both graduate staff and students to help in rooming-in.

*Mrs. H.:* The student nurses here are all impressed by it. I don't know whether it is because they have a chance to see the babies and mothers together, but they have all told me they were pleased to be in rooming-in.

*Dr. Thoms:* If the ladies feel they want rooming-in, they are going to get it; so I don't think that we ought to talk about rates.

The discussion for that evening ended there; but it introduced the idea of parental participation for subsequent meetings about rooming-in. The panel method was adopted from this time on for professional meetings about rooming-in as particularly suited to represent its interdepartmental interests; but a panel was considered incomplete without parent representation. Special acknowledgment is due the panel participants, Mrs. Jean Hellmuth, chairman; Mrs. Jane Clayton, Mrs. Jerlean Colley, Mrs. Judith Owen, and Mrs. Rhoda Welt for their organization of the first panel discussion about rooming-in.

⁹The limitation of 20 minutes for a baby at the breast refers to the usual hospital feeding mothers, not to rooming-in mothers.

Reprinted from
JOURNAL OF THE AMERICAN MEDICAL WOMEN'S ASSOCIATION
Vol. 9, No. 3, March 1954, pp. 80-83
Copyright 1954 by American Medical Women's Association, Inc.

1954

SEPARATION OF MOTHER AND BABY

"The practice of separating mothers from their babies in maternity homes is an astounding idea." The Director-General of Army Medical Services (Major-General Kingsley Norris) said this yesterday.

Speaking at the nurses' graduation day at Austin Hospital, he asked: "Whose baby is it?" and added: "Surely the mother has the right to have her baby beside her."

The Director-General, continuing said: "We can see the mother alone in bed, anxious and worried about her child. How can she know how the child is?"

"She can't know unless you go to a place like a snake pit, where the baby is held up for inspection."

"We are informed that the mother does not get enough rest—that is all nonsense. Don't you think the mother would rest with her baby beside her, when she knows the baby is all right?"

"Then they say it is done because of less danger of infection—that also is nonsense."

From The Age, December 11, 1953, Melbourne, Australia

NEWS FROM NEW ZEALAND

The picture on the following pages was taken at the Wellington, New Zealand, YWCA of a "reunion" group of mothers who had attended the Wellington Parents' Centre classes for expectant mothers which have been held weekly at the Wellington YWCA since August, 1952. As a suggestion and guide to the interested host in the USA and in other countries, Child-Family Digest published a detailed description of these expectant mother classes in its February, 1954 issue, pages 102-05, with some typical comments by the mothers on their experiences.

The Wellington classes provide the comprehensive training for motherhood which Child-Family Digest has publicized for almost five years. C-F Digest feels a special interest in the Wellington Parents' Centre having been a factor in arranging exchanges of information with other sources both in the USA and abroad. The Centre's generous adoption in an annual report of a resolution thanking the editors of C-F D for "aid and inspiration" was deeply gratifying and deeply appreciated. In the January 1954 issue, p. 65, C-F D published a remarkable document, "Joint Submissions to the Consultative Committee on Hospital Reform," prepared by the Parents Centre in association with other New Zealand organizations. This document makes frequent reference to reports and articles published in Child-Family Digest. The world is not too wide for truth so often "crushed to earth" to rise and encompass it.

CANADA

DEPARTMENT OF
NATIONAL HEALTH AND WELFARE

IN YOUR REPLY REFER TO FILE No.

710 Jackson Building,
Ottawa, Canada,
April 21, 1954.

Dr. Edith Jackson,
Department of Pediatrics,
Yale University,
New Haven, Conn.

Dear Dr. Jackson,

May I again express my appreciation for the opportunity I had recently of meeting you and seeing something of the workings of the maternity and newborn departments of your fine new hospital.

It was a real privilege to spend so much of the day with you personally. Thank you for your kindness.

CHILD
FAMILY
digest

VOLUME X, Nnnumber 5

CHILD, PARENT
AND
FAMILY RELATIONSHIPS

May, 1954

Child-Family Digest

May

they do not, you can help change
the situation. For we must realize
that the sickness of the soul which
makes criminals of so many young-
sters cannot be properly treated

with fines or days in prison. One
thing is certain: probation is as
much an arm of correction as Sing
Sing and Alcatraz, and not one bit
less important.

FIRST (?) USE IN U.S.A. OF WOOLWICH SHIELDS

- Letter From a Mother -

"The April, 1953 article "Management of Breast Feeding" was by far the most complete and helpful article I have seen on breast feeding. I have shared it repeatedly with expectant mothers.

"Three friends who had failed previously in breast feeding were able to succeed with the help given in the article. One mother had failed four times before so both of us felt truly triumphant.

"I am especially grateful to the Child-Family Digest for my own recent success in breast feeding. To begin with I had inverted nipples. It was the articles by Dr. Harold Waller of England which led me to send for the shields" and work to reverse the reflexes. Then it was largely the ideas and encouragement in that April issue which enabled me to carry on successfully once the baby arrived.

"You can be sure we are especially grateful when I tell you that our child proved to be allergic to cow's milk."

Mrs. R. M. (Oklahoma)

*Note: A few dozen of the Waller or "Woolwich" double plastic nipple shields were imported into the country. In England they are used routinely by physicians who find that the expectant mother's nipples are inverted. CF-D would appreciate a letter from any other mother in the United States who has used these corrective shields, or the name of any obstetrician who is advising them.

MOTHERS' MILK BANK, INC.

and

BABY HYGIENE COMMITTEE

AMERICAN ASSOCIATION OF UNIVERSITY WOMEN

Invite You to a Discussion of

"ROOMING-IN"

LOIS BROCK, M.D.

Obstetrics and Gynecology.
Children's Hospital

RUTH KEMPE, M.D.

Child Guidance, Children's Hospital
Mental Hygiene Division,
San Francisco Department of Health

Tuesday, September 21, 1954

2:30 P.M.

Nurses' Home Auditorium
3801 Sacramento Street

Children's Hospital
San Francisco

Tea Will Be Served

Mrs. Otto N. Miller, President
Mothers' Milk Bank, Inc.

Connecticut Association for Mental Health, Inc.

## MEETING OF THE BOARD OF DIRECTORS

September 28, 1954 - 12 Noon

New Haven Lawn Club

## AGENDA

1. Report by Secretary Mrs. Selden

2. Report by Treasurer Mr. Bradley

3. Report by President Mrs. Hammersley

4. Report on International Mental Health Congress (Toronto - Aug.) Dr. Edith Jackson

5. Reports by Committees:

Legislative
Education
Personnel
Finance
State-Local Relations
Program Study
Volunteer Services
Mr. Clark
Mrs. Harper
Mrs. Sachs
Mr. Hill
Mrs. Chase
Miss Bixler
Mrs. Selden

6. Report by Executive Director Mr. Doscher

NEONATAL GROWTH IN WEIGHT OF NORMAL INFANTS
ON FOUR DIFFERENT FEEDING REGIMENS

By WILLIAM L. NYHAN, M.D.,* AND MORRIS A. WESSEL, M.D.

New Haven, Connecticut

THE weight of infants during the neonatal period has been the subject of extensive study, and detailed analyses of such studies have been available in the literature for some time.¹,² There is, however, a paucity of material involving concurrent comparison of similar groups of infants on different feeding regimens which afford conclusions as to the effects of different approaches to feeding during this period. Faber and Sutton³ in 1930 reported such a study of breast and bottle fed babies in which it was found that during the first 12 weeks of life the average weekly gain of the breast fed infants was significantly greater than that of the bottle fed infants. Quite recently Paiva,⁴ in a report of a study of a group of breast fed infants, commented that the pattern of growth of these infants did not differ significantly from standard Iowa growth curves⁵ which are based on data from babies predominantly artificially fed. With regard to the manner of feeding, much has been said referable to the theory of self-demand feeding⁶⁻⁹ and to self-demand feeding behavior.¹⁰⁻¹³ Little, however, has been presented to document the physiological effects of this approach to infant feeding.

The present study has involved an analysis of the weight changes of normal newborn infants† on four different feeding regimens in order to ascertain if there were any observable differences that could be related to these different methods of feeding.

## MATERIALS AND METHODS

The weight changes of 400 infants during the first six to eight weeks of life were analyzed. The groupings were as follows: 100 breast-fed on a flexible schedule in rooming-in;¹⁴ 100 bottle-fed on a flexible schedule in rooming-in; 100 breast-fed in the nursery on a 4-hour schedule; 100 bottle-fed in the nursery on a 4-hour schedule. Method of and criteria for selection, and the milk mixture received by the bottle-fed infants during the first week have been described.¹⁵ Following discharge from the hospital, these infants received a mixture of evaporated milk and water with 5% added carbohydrate.‡ Those infants selected had returned for the postnatal check-up between 42 and 54 days of age.

Weighings were performed in all cases by the regular nursing staff utilizing standard nursery balance scales. In the nursery, weighings were performed just prior to the first morning feeding at 7:00 a.m. In the rooming-in units the time of weighing tended to be more flexible, waiting upon the baby's time of spontaneous waking. However here, too, babies were weighed just prior to feeding and the times of morning feeding were generally similar. In all cases the babies were weighed nude and following brief cleansing procedures. Since all weighings were performed in the morning the first weight period represented a partial day. The data for all subsequent periods represent full 24-hour intervals.

## RESULTS

The mean daily weights during the pe-

† The milk mixture given in the home to infants artificially fed was a mixture of evaporated milk and water in the proportions of 1:1.5 to which 5% carbohydrate was added in the form of corn syrup. In this milk mixture approximately 16% of the total calories is in protein, 45% in carbohydrate and 39% in fat. The caloric value is approximately 0.7 Cal/cc.

From the Yale Rooming-In Project, Department of Pediatrics, Yale University School of Medicine, New Haven, Conn.

This Project has been supported by grants-in-aid from: (1) Mead Johnson and Company; (2) The George Davis Bivin Foundation, Inc.; (3) The Field Foundation, Inc., and (4) National Institute of Mental Health, of the National Institutes of Health, Public Health Service.

(Received for publication April 20, 1954.)

* Address: 789 Howard Avenue, New Haven, Connecticut.

† On the Maternity Division of the Grace-New Haven Community Hospital (University Service).

442

444

NYHAN-NEONATAL GROWTH

TABLE II

SIGNIFICANT DIFFERENCES (t VALUES) IN AVERAGE WEIGHT CHANGE AND MAXIMAL LOSS FROM BIRTH WEIGHT AMONG 4 GROUPS OF BABIES ON 4 DIFFERENT FEEDING REGIMENS

<table><thead><tr><th>Day</th><th>2</th><th>3</th><th>4</th><th>5</th><th>6</th><th>7</th><th>Maximal Loss</th><th>6 Wks.</th></tr></thead><tbody><tr><td>Breast-fed nursery</td><td>4.56</td><td>8.20</td><td>8.00</td><td>7.20</td><td>5.27</td><td>5.00</td><td>8.32</td><td>2.43</td></tr><tr><td>Bottle-fed nursery</td><td>(p&lt;.001)</td><td>(p&lt;.02)</td></tr><tr><td>Breast-fed rooming-in</td><td>2.10</td><td>2.81</td><td>3.55</td><td>2.06</td><td>—</td><td>—</td><td>3.60</td><td>—</td></tr><tr><td>Bottle-fed rooming-in</td><td>(p&lt;.05)</td><td>(p&lt;.01)</td><td>(p&lt;.01)</td><td>(p&lt;.05)</td><td>—</td><td>—</td><td>(p&lt;.001)</td><td>—</td></tr><tr><td>Breast-fed nursery</td><td>3.56</td><td>7.44</td><td>5.99</td><td>5.20</td><td>3.50</td><td>3.52</td><td>6.32</td><td>—</td></tr><tr><td>Breast-fed rooming-in</td><td>(p&lt;.001)</td><td>—</td></tr><tr><td>Bottle-fed nursery</td><td>—</td><td>2.28</td><td>2.20</td><td>—</td><td>—</td><td>—</td><td>2.11</td><td>—</td></tr><tr><td>Bottle-fed rooming-in</td><td>—</td><td>(p&lt;.05)</td><td>(p&lt;.05)</td><td>—</td><td>—</td><td>—</td><td>(p&lt;.05)</td><td>—</td></tr></tbody></table>

In each comparison the figures are presented opposite the group having the greatest initial loss or 6 wk. gain.

the breast-fed babies highly significant differences occurred on each day. The maximal losses among the breast-fed nursery babies were likewise quite significantly greater than those of the breast-fed rooming-in babies. Among the bottle-fed babies the differences were all in the same direction. There were, however, many fewer significant differences, and they were of consistently smaller magnitude. Significant differences in this comparison occurred only on days three and four. The maximal loss of the bottle-fed rooming-in babies was significantly less than that of the bottle-fed nursery babies. Differences in this last comparison were significant at the 5% level of confidence.

By the time of the six-week check-up, the breast-fed nursery group had gained significantly more than had the bottle-fed nursery group. Other differences among the four groups at this time were not significant statistically.

The possibility arises that some of the observed differences during the first week might be related to the fact that the bottle-fed babies received food from the first day of life while the breast-fed babies waited for a comparable caloric intake for the onset of lactation somewhat later. The day of lowest

weight for each baby was therefore determined. The means for the various groups and the standard deviations of these means were determined. An analysis of mean differences was then performed. These data are presented in Table III. This analysis gives a precise estimation of the average duration of weight loss in the four groups which was not possible from the data presented in Chart I, where simply the average daily weights were determined. The day of lowest weight occurred significantly later in the group of breast-fed nursery babies than in either of the bottle-fed groups. Differences otherwise among the groups were

TABLE III

DAY OF LOWEST WEIGHT FOR 4 GROUPS OF 100 BABIES EACH ON 4 DIFFERENT FEEDING REGIMENS

<table><thead><tr><th></th><th>Day</th><th>Standard Deviation</th></tr></thead><tbody><tr><td>Breast-fed nursery</td><td>3.6</td><td>1.0</td></tr><tr><td>Breast-fed rooming-in</td><td>3.4</td><td>1.1</td></tr><tr><td>Bottle-fed nursery</td><td>3.2</td><td>1.3</td></tr><tr><td>Bottle-fed rooming-in</td><td>3.1</td><td>0.9</td></tr></tbody></table>

Low day occurred significantly later in the first group than in the last two groups: t=2.8 (p&lt;.01) and t=3.62 (p&lt;.001) respectively. Differences otherwise among the groups were not significant statistically

446

NYHAN-NEONATAL GROWTH

strictly schedule-fed during the first months of life at home. These considerations in all probability account for the paucity of significant differences at this time. Certainly it is evident that there were few differences at this time which one could likely relate to the type of food ingested. Possibly the philosophy of flexible feeding schedules might have been particularly appealing to the nursing mothers. Certainly under any type of schedule it is relatively easy to regulate the amount of food a bottle-fed receives at a feeding while this is much more difficult in the case of a breast-fed baby. It may be that these factors account for the fact that the breast-fed nursery babies gained significantly more than their bottle-fed nursery counterparts. Precise analysis of these latter factors was impossible because of the nature of the data available. The most striking aspect of the analyses of these neonatal gains was the close similarity among the various groups at the time of the six week check up. It is evident that by this time the end results of different feeding regimens as measured by weight gain are really very little different even though the differences noted in the first week of life are quite marked.

The possibility that factors other than the differences in feeding regimen might have influenced these neonatal weights in the various directions observed was considered. The adverse effects of illness on weight gain were controlled by selection of the patients studied. There were no significant differences among the groups with regard to birth weight or sex of the baby. It is of interest with regard to the former that the breast-fed nursery group which had the lowest birth weight had, nevertheless, the greatest losses during the first week of life. Postnatal weight losses have uniformly been found to be greater in infants heavy at birth than in those with small birth weights.², ¹⁸ It was noted that there were more Negroes in the nursery groups than in the rooming-in groups. In the earlier literature¹, ¹⁶ it is stated that Negro infants gain weight more slowly than do white infants. More re-

cently, Bakwin and Patrick¹⁷ found no significant differences in the weight gain of Negro infants as compared with white infants. It appears likely that the observed differences in the present study were not related to color differences among the groups studied.

With regard to maternal parity, there were more primiparae among the rooming-in groups than among the nursery groups. Also there were more primiparae among the rooming-in mothers who fed their babies at breast than among those who used bottle feedings. Among the nursery babies the breast-fed group did not differ from the bottle-fed group with regard to maternal parity. In the older literature which has been reviewed by Griffith and Gittings¹⁸ and in their own series on the subject, infants of primiparous mothers have been noted to lose more weight initially and later to gain more slowly than infants of multiparae. Meredith's² more recent observations on the effect of birth order on neonatal weight changes showed a less consistent trend. In the present series the rooming-in groups, though containing a greater number of primiparae than the nursery groups, had the smaller losses. As this trend is in the opposite direction to the expected effects of differences in parity, it is unlikely that the observed differences could be related to this disparity in the composition of the groups. Among the rooming-in babies the greater losses in the breast-fed group than in the bottle-fed group were in the direction one would expect from the observed differences in parity between the two groups. However, the fact that significant differences between these two groups occurred only during the first few days of life would seem to indicate that differences in food intake were operating.

## SUMMARY

Neonatal weight changes of 400 normal infants were studied statistically. The series was composed of 200 infants fed on a flexible schedule of which 100 were breast-fed and 100 were bottle-fed; and 200 infants fed

422

WESSEL—PAROXYSMAL FUSSING

mind. When picked up, he was quiet, contented, and dozed.

"(Age 6 days) The baby is increasingly unmanageable and more puzzling. Babies never annoy me, but this one does. I have never seen a baby act like this before. It seems that nothing satisfies him but holding him. It was suggested that I'd just have to hold him in one arm and work with the other until he fell asleep. How well I knew that sleep was no guarantee. At nine this evening, Dr. Cobb saw the baby, held him, fed him, burped him, tried putting him in different positions in bed ... but the baby cried as vigorously as ever. He was taken to the nursery, now not always quiet even when being held. In fact, his cries gradually became deafening and impossible. It was then that I asked Dr. Cobb if this was what you call colic. The doctor ordered 1 cc. of spiritus frumenti in 30 cc. of 5% glucose. The baby took this fairly well and quieted down considerably, but he still seemed miserable and uncomfortable. He sputtered and whimpered. Within 20 minutes, he burst forth, again in full force. Picked up, patted, almost lulled to sleep he was replaced in his crib. He went to sleep, was quiet, but woke up shortly and suddenly started crying again; dropped off to sleep, and soon again awoke crying; off and on, until midnight when a second dose of spiritus frumenti was given. He took this and it just seemed as if a wave of relaxation swept over him. He seemed momentarily content at last. I picked him up, placed him on his stomach over a hot water bottle wrapped in a towel, with his head down. Soon he stopped crying, went to sleep, and slept for three and one-half hours."

The purpose of this paper is to review the literature and to report observations in relation to paroxysmal fussing from a series of 98 infants observed in the course of a parent-child relationship study (The Yale Rooming-In Project).

## REVIEW OF LITERATURE

There have been four main points of view from which physicians have considered the etiology of colic, or paroxysmal fussing, namely, that of congenital hypertonicity, of allergy, of immaturity of the intestinal tract, and of transfer of tension from the adults to the infant.

## The Concept of Congenital Hypertonicity

The concept of congenital hypertonicity presupposes a "hypertonic infant" with a congenital imbalance of the autonomic nervous system. Some observers feel that this is a very definite entity.³ Thus Haas⁴ has stated, "It is characterized by hypertonicity of all the skeletal muscles, as shown by the ability to raise the head and grasp objects even in the early days of life, and by general spasticity. The hollow viscus shows increased activity of smooth muscle fibers. There is marked psychic irritability, expressed by insomnia, general restlessness and crying." This concept is closely allied to the clinical entity of "Vagotonia," described by Eppinger and Hess⁵ in 1915. It is postulated that because of abnormal sensitivity of the central nervous system, minimal stimuli which are usually without effect lead to the development of fussiness in certain infants. Neff⁶ represented this point of view. He suggested that the "colicky" spells are an outgrowth of the startle reflex and may be considered as a prolonged reflex reaction during what he describes as the "hyperactive period of infancy." Atropine and phenobarbital are the recommended treatment for these infants.

Further support of constitutional factors is presented by Jorup⁷ who, in 1952, in a detailed comprehensive study described a condition of *Colonic Hyperperistalsis in Neurolabile Infants*. This author presents a picture of hyperactive infants who, in addition to having frequent stools, are extremely sensitive to sound and light, who sleep lightly and awaken easily, and in general are quite similar to the infants described as hyperactive in the American literature.

## Allergy

The possible relationship of allergy to the etiology of "colic" was referred to as early as 1901 by Zahorsky.⁸ He stated, "The cause must usually be assigned to excessive proteins in the (breast) milk. These proteins, like those of the bean, very readily undergo gaseous decomposition and the gas causes

424

WESSEL-PAROXYSMAL FUSSING

PER-CENT
45 -
40 -
35 -
30 -
25 -
20 -
15 -
10 -
5 -
0 -
12 | 11 | 10 | 9 | 8 | 7 | 6 | 5 | 4 | 3 | 2 | 1 | 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12
A.M. NOON P.M.

FIG. 1. Hourly incidence of fussiness of 68 infants at time of post-natal check.

which inhibit normal propulsion of material
are accompanied by the abdominal pain of
"colic."

Parental Influence

The fourth point of view stresses the pa-
rental influence. Spock²² states that it is
more common in the first born. Brenne-
mann² and Spock²² report that this condi-
tion is more common in breast-fed infants.
Anderson²³ suggests that infants on a de-
mand schedule are relatively free of this
"fussiness." Some physicians have described
a characteristic anxious, nervous and tense
parent. They have, however, not clarified
whether this parental picture is the cause
or result of the infant's difficulties.

SOURCE AND CLASSIFICATION OF DATA

The authors' interest in "fussiness" or
"colic" was stimulated by an unpublished
study made by Kleeman and Cobb (1948)
when affiliated with the Rooming-In proj-
ect. At the seven weeks post-natal exami-
nation of 78 consecutive rooming-in babies,
the mothers were questioned as to whether
their infants had any special "fussy" period,

and, if so, at what hours. Only 10 of the 78
mothers reported no special "fussy" period.
Of the remaining 68 mothers, 50 reported a
"fussy" period for the infant sometime dur-
ing the late afternoon or evening, and 12
during the morning hours; three infants
were reported to have fussy periods both in
the morning and afternoon, and three were
said to be fussy all day. The hourly inci-
dence of fussiness among these 68 infants
as reported by their mothers is shown in
Figure 1. It will be seen that 42% of these
infants were reported to be fussy from
7:00 to 8:00 P.M., while the periods of
least fussiness were reported to be between
3:00 and 4:00 A.M., and between 1:00 and
2:00 P.M.

The present study was conceived and
planned by one of the authors (J. C. C.)
who from clinical experience had formed
the impression that allergy was an impor-
tant contributing factor in the causation of
"paroxysmal fussing." Records of families
observed in the Rooming-In Project provide
most of the data for this report. The details
of data collection have been presented else-
where.²⁴ Between July 1, 1948 and January
1, 1950, 180 mothers were selected in pre-
natal clinic for follow-up observations. The

° Dr. James A. Kleeman was a Rooming-In
Fellow July 1947-July 1948.

426

WESSEL-PAROXYSMAL FUSSING

YALE UNIVERSITY DEPARTMENT OF PEDIATRICS - NEWBORN FAMILY HISTORY OF ALLERGY

To be filled in by Baby's Mother, Mrs.

Delivery Date:

ALLERGY is unusual sensitivity to such things as dusts, pollens, or other substances in the air; clothing, cosmetics, or other things coming in contact with our skin; or food, medicines, or other things we swallow.

PLEASE USE THE FOLLOWING DEFINITIONS to fill in the kinds of allergy in the form below:

HAY FEVER, runny nose or eyes at certain times of year or in certain localities.

ASTHMA, choking up of the lungs with wheezing.

ECZEMA, itching or burning skin irritation, sometimes with redness, swelling, blisters, crusting, scaling, and/or thickening of the skin. Lasts more than a week.

HIVES, puffy red itching blotches on the skin which come and go within a few days.

DERMOGRAPHIA, sensitive skin which swells up and gets red when scratched even lightly.

GASTRO-INTESTINAL ALLERGY, any of various forms of indigestion such as heartburn, bloating with gas, colicky cramps, vomiting, or diarrhea. Usually lasts a day or two.

MIGRAINE HEADACHES, throbbing aches usually on one side of the head, lasting more than a day, not helped by aspirin.

<table><thead><tr><th></th><th>Age now<br>approx.</th><th>Little or<br>No Allergy</th><th>Mild Allergy<br>State what kind</th><th>Severe Allergy<br>State what kind</th><th>Not sure<br>(Remarks)</th></tr></thead><tbody><tr><td>✓ Myself</td><td>26</td><td>*</td><td>HAY FEVER</td><td></td><td></td></tr><tr><td>My Mother</td><td>DECEASED</td><td>✓</td><td></td><td></td><td></td></tr><tr><td>My Father</td><td>DECEASED</td><td></td><td></td><td></td><td>✓</td></tr><tr><td>My Brothers 1<br>and/or<br>Sisters<br>(If more<br>than 5,<br>use the<br>back of<br>sheet)</td><td>31<br>33<br>35<br>37<br>39</td><td></td><td>HAY FEVER<br>GASTRO-INTESTINAL<br>ECZEMA<br>AS A CHILD</td><td></td><td></td></tr><tr><td>My Husband</td><td>35</td><td>✓</td><td></td><td></td><td></td></tr><tr><td>His Mother</td><td>65</td><td></td><td>ASTHMA</td><td></td><td></td></tr><tr><td>His Father</td><td>DECEASED</td><td>✓</td><td></td><td></td><td></td></tr><tr><td>His Bros. &<br>Sisters<br>(If more<br>than 5,<br>use the<br>back of<br>sheet)</td><td>39<br>41<br></td><td>✓</td><td></td><td></td><td></td></tr><tr><td>Our Children 1<br>2<br>3<br>4</td><td>34mos.<br>21mos.<br></td><td>✓</td><td>ECZEMA DISAPPEARING</td><td></td><td></td></tr></tbody></table>

FIG. 3. Newborn family history of allergy questionnaire.

healthy and well-fed, had paroxysms of irritability, fussing or crying lasting for a total of more than three hours a day and occurring on more than three days in any one week. If an infant had no such paroxysms or if the paroxysms were less than the above in total duration, he was classified as "contented." The "contented" group thus includes some mildly fussy babies. Each

of the records was read independently by two authors in relation to specific items which are listed below. In case of disagreement, the record was re-read jointly, and agreement was usually reached. In the few instances where agreement was not reached, the items in question were not counted. In 19 records there were insufficient data regarding the age of onset and disappearance

428

WESSEL-PAROXYSMAL FUSSING

the majority of which occurred in the late afternoon or evening hours. Twenty-one infants had a daily fussy period with no regularity of time. Thirteen infants were reported to have no period of fussiness. The time distribution and frequency of diurnal regularity are similar for the mild fussy periods of the "contented babies," and for the more prolonged periods of the "fussy infants."

*Duration:* Figure 4 shows the duration of the complaint for the 29 infants on whom sufficient data were available. Three of the infants were noted to be fussy in the first week of life, while still in the hospital; 17 began their fussiness during the second week; six during the third week; one during the fourth week; and one each during the seventh and eighth weeks. Symptoms usually diminished to a point where the infant would no longer be considered "fussy" by the end of the second month of life, although in six instances the fussing extended beyond the end of the third month.

*Intercurrent Physical Phenomena:* Five of the "fussy" infants had concurrently a waxy papular rash on the face. Mucoid diarrhea accompanied the "paroxysmal fussing" in three. Seven mothers commented that periods of rapid and congested or "snuffly" breathing often preceded the paroxysms of "fussing."

*Hyperactivity of Infant:* Ten of the 98 infants studied were noted to be more than usually active at the time of the neonatal examination at seven weeks of age, and nine these infants were in the "fussy group."

*Allergic Condition of Infant:* There were six infants whose "paroxysmal fussing" was markedly reduced by the removal of specific foods, either by limiting the mother's diet in the case of breast-fed infants, or by changing the protein in the artificially-fed infant. The "fussiness" promptly returned when the food was again ingested. This seemed to indicate an allergic etiology in the case of these six infants.

*Type of Feeding:* There was no significant difference in the incidence of "fussi-

ness" in relation to the type of feeding. However, the great majority of the infants were breast-fed: 67 were wholly breast-fed; 23 were breast-fed with some cow's milk mixture; and 8 were fed completely on cow's milk mixture.⁹ Orange juice on a few occasions appeared to cause fussiness, but there was no higher incidence in the group fed orange juice as compared to the infants maintained on multivitamin drops or ascorbic acid.

*Weight and Weight Gain:* There were no significant differences between the "fussy" and "contented" groups of infants as regards average birth weight, average weight gain, and average per cent weight gain during the neonatal period. The infants gained an average of 46% of their birth weight by the time of the neonatal check-up visit, at about seven weeks of age.

*Sex:* The incidence of "paroxysmal fussing" was equally divided between male and female infants, and there was no significant difference in the duration of symptoms between the two sexes.

*Birth Order:* Analysis of birth order revealed that of the 76 first-born infants, 42 or 55% were "fussy," while of the 22 who had older siblings, only 6 or 27% were "fussy." This difference is significant at the .05 level (Chi square 4.26).

Of the individual factors, the only three which appear to have a significant relationship to the incidence of fussing are hyperactivity, allergic reaction, and order of birth.

## Familial Factors

*Family History of Allergy:* The frequency and degree of allergy among the known members of the families of the 95† infants is shown in Table 1. There appears to be

⁹ The frequency and amount of feedings were determined by the mother on the basis of the infant's apparent needs. The standard milk mixture was 2 parts of evaporated milk, 3 parts of water, and 5% added carbohydrate, usually in the form of corn syrup.

† Three of the 98 questionnaires returned were inadequately filled out.

430

WESSEL-PAROXYSMAL FUSSING

FIG. 5. Proportion of allergy and family tension in family history of 48 fussy infants.

morning nausea even before her marriage. Four months after her baby was born, she sought psychiatric help again, complaining of her insecurity in handling the baby and of her fears of drowning him.

C. According to the record of Mrs. C, there was marked friction in the relationship between her husband and her parents. During pregnancy, this became so strained that Mrs. C's mother refused to enter the house unless Mr. C apologized. Therefore Mrs. C visited with her mother only at the bus station. Both Mr. and Mrs. C were in conflict about their relationships to their own parents, and struggled desperately to maintain their independence. Mrs. C displayed a great deal of tension as she talked about the family relationships.

D. A 29-year-old southern society girl on a trip abroad met and married Mr. D, a foreign medical student. In spite of his aristocratic birth, he was not accepted by her family. Political upsets had cut him off from home, and her parents refused to help financially. The couple who had been used to much luxury were forced to work and pinch every penny so that he could finish medical school. The pregnancy was emphatically not planned and meant even greater hardship. A male child was of greatest importance to the D family to perpetuate the family name; but a girl was born.

Mrs. D made the interesting observation that when she and her husband had fights and she "blew off at him," then she was able to nurse the baby without trouble. On the contrary, however, when she got annoyed by her own parents who were visiting, and was unable to blow off steam, she got tense and nervous; then, after nursing, the baby would fuss and vomit.

There were 13 records which were in-

adequate for evaluating the family tension, either because the one-year interviews were lacking or because the notes were too brief or not clear. Six of these were for infants who were "fussy" and seven were for infants in the "contented" group. Of the 85 remaining records, 43 were classified as showing "family tension."

In the 43 families whose records revealed "family tension," 31 (72%) of the infants were "fussy." In the 42 families in whose records "family tension" was not prominent, there were only 11 "fussy" infants (26%). This difference is statistically significant (Chi Square 17 - p < 0.001).

Of the factors associated with paroxysmal fussing in the 48 infants, family tension alone or together with allergic reaction of the infant stands out most prominently. In 22 of the 31 "fussy" infants with a tense family background, the family tensions were judged to be the predominant factor in the infant's "fussiness." In nine infants, the "fussyiness" seemed to be due in part to family tensions and in part to an allergic reaction, since the removal of specific food substances provided some relief. In addition, there were six infants (see above) whose "paroxysmal fussing" was thought to be due predominantly to allergy, because of the definite relief after removal of specific foods. For the remaining 11 "fussy" infants, there was no obvious contributory cause. These data are presented in Figure 5. It is of interest that of the nine babies described as hyperactive, who were also "fussy," six were in the family tension group and three in the group where both family tension and allergy seemed to be etiologically important.

## TREATMENT

Since no controlled study was made, it is only possible to report the various methods of treatment which were used with some success. In most cases, several forms of therapy were used concurrently, so that the relative value of any one was difficult to assess. The number of infants whose "paroxysmal fussing" seemed to respond to various types of treatment was as follows:

432

WESSEL-PAROXYSMAL FUSSING

DISCUSSION

The authors recognize that there are probably various factors related to the development of "paroxysmal fussing." In this study, allergy and family tension stood out as important contributing factors. The high correlation of the presence of fussiness in the infant and tension in the family were the most surprising of the findings. It is important to consider some of the ways in which these results may have been influenced.

First, the mothers in this study were a select group. Two-thirds of them were college graduates, but "fussy" babies appeared as frequently among the mothers who had no college degree.⁹ It is true that there is a bias in terms of the selection based on the interest of mothers who returned the allergy questionnaire. How this bias may effect the results is unknown. Second, all of the infants started life on a flexible feeding schedule. Comparison with infants fed on a rigid schedule is therefore lacking. The authors' definition of "fussiness" ruled out the babies who fussed simply because of hunger alone and were relieved by feeding. Hunger seemed to contribute to the fussiness of only four infants in the group. Overfeeding did not appear to be a contributing factor. Third, the authors were obviously interested in the occurrence of "fussiness" or "colic." Thus some of the mothers may have been inclined to stress the "fussiness" of their babies, because they were gratified by the interest shown in their problem. On the other hand, the authors have noted some mothers have the feeling that "fussiness" in infants is not a disease and is therefore not to be discussed with the doctor.

Fourth, the question may legitimately be raised whether the individuals reading the

records for evidence of family tension were unduly influenced by their knowledge of whether or not the infant was "fussy." It will be remembered that the original direction of the study was toward an evaluation of the importance of allergy as a cause of "colic." Family tension, however, with no prior bias in its favor, forced itself on the readers of the records as a matter for consideration. In view of these influences, the authors feel that their results are inconclusive, but strongly suggest that the relationship between "family tension" and "fussiness" of the infant merits further study.

The higher incidence of fussiness toward the end of the day suggests a physiological contributing factor. Kleitman,²⁵ Jorup,⁷ and Brennemann² have reported similar findings. Perhaps fatigue increases the kind of tension which is sensed by infants. The onset of "paroxysmal fussing" usually in the second or third week of life also suggests a physiological factor. Glaser²⁶ has interpreted this period as the time required for allergic sensitization to take place. It might equally well be interpreted as the time required for the infant to develop his sensitivity to stimuli resulting from "family tension." These stimuli probably have to do with the way the mother handles and talks to the baby. It is sometimes observed that "paroxysmal fussing" or "colic" ceases when the baby is hospitalized or cared for by a different person.

Of those cases where the "family tension" seemed to contribute to the "paroxysmal fussing" of the infant, it might well be asked why the "fussing" stops at about two months of age when the "family tension" continues in full force. Many mothers have told the writers that as the infant grows older, the evening "fussy" period yields to a play period, or a period when the child seems restless and demands extra attention, but does not actually cry as if in pain. The cessation of the "paroxysmal fussing" may be related to the achievement of a certain level of motor and social development. When the infant begins to be able to use

⁹ One of the authors (J. C. C.) who is currently working with medically indigent families in Baltimore has formed the clinical impression that "paroxysmal fussing" is just as common in the infants of this group as is was among the much better educated group in New Haven.