Over 30 years ago I was asked by a large church organization in New York City to give a series of lectures on child care to its missionaries, who had come from all parts of the world for a period of retraining. I consented to do this without charge if they, in return, would permit me to interview the missionaries on health practices and child care in their respective areas. This request was granted.
And so the missionaries sat down with me, one by one, and in the quiet of a small classroom transported me to many mysterious and colorful areas of the world - to Nigeria and the Congo, to Indonesia and India, to the South Seas, and even to the reservations of American Indians in the United States.
I questioned these missionaries on many subjects of interest to the pediatrician - among them, the manner of giving birth and the nature of breast feeding. I asked about the position of the baby while being breast-fed, the age of the infant when solid food was added to the diet, the frequency and duration of feedings, when weaning was begun, and in what manner it was attempted. I also inquired about the frequency of thumb sucking, attitudes toward sex, children's exposure to sex, marriage customs, and many other subjects in which I had an interest.
Had I been an anthropologist I'm sure I would have written a book - or at least an article - on this fascinating and unusual experience. But I was only a pediatrician with possibly a little more than average curiosity. Much of the information I obtained has remained vividly in my memory. However, I also recorded the observations of some of these missionaries, and I thought of this experience while reading the article on breast feeding that is being published in this issue of Pediatric Annals. I looked for these booklets in my files and found one, blue-covered and spiral-ringed, in which I had recorded the observations of these misionarles. Today, as then, breast-feeding is essential in many areas of the world where there are no milk cows and no artificial means of refrigeration. Some of the observations I made then may be of interest to the modern pediatrician, so I shall relate a few of them.
The first person I interviewed had spent years in the interior of Nigeria among people called the Yorubas. It was she who described to me the family constellation; a husband usually had a group of wives, each living in her own thatched hut, with the huts all surrounding an open courtyard.
When a pregnant woman was about to give birth she would come out of her hut and squat in the courtyard. Several old women would come near to help her. There was no water and no washing of hands. Dogs were walking around or playing nearby. Anyone, including children, could observe the birth.
The baby was born and placed down in the sand, still attached to the cord. Dogs and sometimes pigs would wander over and smell it. The mother remained squatting until the placenta was forced out. Then one of the women would go to the side of the courtyard and select two large rocks. She would return, place the umbilical cord over one of the rocks, and rub it with the other until the cord was severed. It was next tightly tied with a piece of grass that had been picked nearby. The baby was then rubbed with palm oil and placed on the back of the mother in a cloth tied around her waist.
The baby would be given the breast within the first hours after birth. This was accomplished by the mother through just swinging the infant in the confining cloth around in front so that the baby's face met the mother's breasts. Feedings were self-demand.
I'm sure that many of you were bothered by the method of severing the newborn's cord - and your fears were well founded. A great many of these infants soon developed tetanus and died. One might suppose that in this modern era, when smallpox has finally been conquered, such practices have been relegated to the past. But this is not so. Within the past few years a number of pediatricians from Cornell University Medical College spent many months in Haiti attempting to better the health of the infants and children of that poor and backward country. One fact that attracted their attention was the high infant mortality, due to tetanus. They investigated and found the same practice being followed today in Haiti that was reported to me from Nigeria so many years ago: the umbilical cord was separated by grinding it between two roadside rocks. These pediatricians tried but were unable to convince the natives to change these in-bred tribal customs. So they were attempting to save the infants by immunizing the mothers against tetanus in the hope that they would transmit their immunity to the fetus through the placenta.
One further note from Nigeria. There were no milk cows because of the tse-tse fly. Every mother had to nurse her infant, and all were capable of doing this.
There are other primitive methods of separating the cord. 1 was told by a missionary from an island in the South Seas (Marquesas) that mothers there bit the cord in two, a custom verified by an anthropologist some years later.
So much for this limited anthropological discourse - which, as I mentioned, was brought to mind by the article on breast feeding in this issue. This issue of Pediatric Annals is the last in a symposium on prenatal and neonatal pediatrics. The CoGuest Editors, Dr. Hugh E. Evans and Dr. Leonard Glass, are authors of the textbook Perinatal Medicine, which was published in 1976. The articles in this issue deal with some of the potential difficulties associated with the neonatal period - cardiac problems, withdrawal symptoms related to maternal drug addiction, surgical problems, problems related to the kidneys and genitourinary system, and problems that might arise because of breast feeding. (The subject of the respiratory distress syndrome - a major neonatal problem - was covered in the April, 1978, issue of Pediatric Annals.)
The first article, on neonatal cardiology, is an excellent review of the subject. Its author is Dr. Lorenzo Lavorgna, who has had considerable background in this field. Starting with methods of diagnosis, including echocardiography, Dr. Lavorgna covers the etiology, clinical and laboratory findings, and management of congestive heart failure, acyanotic congenital heart disease, and cyanotic heart disorders. These are problems that are encountered from time to time by all pediatricians. Some have the opportunity to call in a pediatric cardiologist, but many must direct the early care of the child themselves. However, in either case, it is gratifying and often important to be able to make a fairly accurate diagnosis.
Dr. Glass and Dr. Evans have contributed the next paper, "Perinatal Drug Abuse." The authors point out that most attention has been focused on the narcotic drugs but that the use of nonnarcotic agents also poses a very serious problem. They dwell first on heroin and methadone but then write on the effects on the fetus of alcohol, barbiturates, tranquilizers, sedatives, analgesics, cocaine and amphetamines, marijuana, and LSD. The effects of maternal cigarette smoking on the fetus were fully discussed in a previous issue on perinatology (Pediatric Annals, March, 1978). This informative article brings our knowledge of the effects of these various agents on the fetus and newborn up to date.
The third contribution treats of surgical problems in the newborn and is written by Dr. Peter K. Kottmeier, Professor of Surgery and Director of Pediatric Surgery, and Dr. Donald Klotz, Associate Professor of Clinical Surgery, both of the State University of New York Downstate Medical Center. This valuable article deals primarily with the various lifethreatening surgical emergencies of the newborn child. But also included are such gastrointestinal conditions as peritonitis, ascites, necrotizing enterocolitis, Hirschsprung's disease, and the various intestinal obstructions, including atresia.
The fourth article is "Interpreting Urinalysis in the Newborn" and was written by Dr. Abdul J. Khan, chief of Pediatric Nephrology at the Jewish Hospital and Medical Center of Brooklyn. This paper presents a strong case for carefully examining the urine of every newborn child to rule out or detect kidney and urinary-tract abnormalities.
The final paper, also by Dr. Evans and Dr. Glass, reaffirms the advantages of breast feeding but presents various potential problems that may occur. This interesting and informative article presents many possible problems the practicing pediatrician rarely considers, such as the effects oral contraceptives, environmental pollutants, certain dry-cleaning solvents, nicotine, and some pathogenic viruses can have on the breast-fed infant. The paper is very well documented, with a bibliography including several papers written in 1978.