fields are revealed in either the nursery schools or the neighborhood councils. Referrals of mothers whose children need nursery-school service are often made to the project schools by the council of social agencies.

An over-all intergroup neighborhood council, working closely with the National Conference of Christians and Jews, serves as the policy-making, program-planning, fund-raising body of project. The council operates operates through a series of subcommittees dealing with such subjects as tension situations, program resources, study groups, literature, and fellowship activities.

the

Two simple principles have guided the leaders of the New Haven project at every step. One is: "Start slowly, and build upon genuine interest"; the other, "Don't start anything unless enough people are interested to carry it through." Interest may be expressed by nothing more than the contribution of a book or of a few hours of time, and still be real.

From this kind of neighborhoodrooted interest have grown a number of activities, all having the same underlying motive of building better human relations. One of these is the United Through Books project. This has developed because some of the members of neighborhood councils felt a need to attack ignorance and intolerance through knowledge. A collection of books has been made on interfaith and interracial topics. The exhibit library is set up before meetings of various organizations

such as parent-teacher meetings and veterans groups, and provides material for home-study and discussion groups.

The summer play school is one of the happiest activities carried out under the auspices of the project. This takes in children from 5 to 12 years, divided into two groups. The children bring a picnic lunch and spend the day under the guidance of trained leaders, with mothers helping as volunteers. Hikes, excursions, water sports, story telling, and dramatics fill the hours. Headquarters again is the Day home, its spacious lawns and nearby woods offering shady spots to play and ample room to explore.

Learning to know one another

The play school, too, is a laboratory of adventure and exploration in human relationships. It offers an opportunity for children to find out about one another. A story hour, for instance, may be taken over by a Chinese mother who tells the children stories of China. A Polish or a Negro mother may sing the songs of her people.

Recently it was realized that grandfathers, often neglected, have something to add to the understanding of children. One grandfather, who had been a woolen manufacturer before he retired, was invited to tell a story of how cloth was manufactured in an earlier time. He constructed a miniature loom, which he used to illustrate his story. Thus grandpa became a person of new importance to the youngsters, and a bond

between the old and the young was established.

One visiting the New Haven project naturally asks:

"What kind of difficulties have you met and how do you overcome them?" For of course, in any effort to bring people of different races together you must expect difficulties.

"The way we have gone about this," says the director of the project, "has been to start on been to start on a small scale, getting the endorsement of a few key people who will give moral support. We try to anticipate difficulties and find a way around them and we are content to gc slowly. We find it takes about a year for a sound project to mature into ac tion."

Although the New Haven project re ceives a subsidy of $5,000 a year from the National Conference of Christians and Jews for the 2 years the sponsorship lasts, money is also secured from local sources. This year the funds amounted to $7,500. Individual memberships in the project bring in $1,000. Fees paid to the nursery school, varying for the different schools, the price being set by the parents themselves, also bring in some revenue. Various local organiza tions find ways to raise money. The American Veterans Committee, for instance, through a newspaper drive and other means, raised $1,000.

Closing the nursery-school season this year, a carnival was held to raise funds. More than a hundred persons worked like beavers in the preparation. It proved a spectacular success, brought out more than 1,200 parents and children, was packed with fun, and netted $600. It was unanimously agreed to make the carnival an annual affair.

Not long ago a real-estate dealer in the vicinity of one of the project's centers, who had long held out against sales or rentals to members of one of the minority groups, sold a house to a family in such a group. Asked why he changed his policy he answered: "No use hanging on to that attitude with a place like this in the neighborhood."

The project serves as a kind of visual aid in the community. In several neighborhoods where activities are carried on, institutions have changed their policy and opened their doors to those who

ANGLAND'S first hospital unit for

E

babies born prematurely in their own homes was opened 17 years ago in the City of Birmingham Maternity Hospitals.

For the first 13 years after that, provision in the country as a whole of such special accommodation for premature babies increased slowly.

But in 1944, the Ministry of Health issued a circular to all welfare authorities, recommending that they provide facilities for care of premature babies, both in hospitals and in their own homes, and this circular has stimulated a great deal of interest in such babies. Most welfare authorities have carried out the Ministry's recommendations concerning home care, but lack of building facilities has held up many programs. Efforts have been made, however, to set up units in existing hospitals, such as the unit described in this paper.

The need for special care of premature babies is as great in Britain as it

is in the United States. In Birmingham, England, 6 percent of all the babies born alive are prematurely born (that is, they weigh 51⁄2 pounds or less at birth).

Prematurity accounts for approximately three-fifths of the deaths of infants during their first 4 weeks of life, and one-third of the deaths up to the end of the first year.

The Ministry of Health circular suggests that for every infant weighing 52 pounds or less at birth the weight should be recorded on his birth-notification card, and as a result country-wide figures for the incidence and mortality of premature babies will soon be available.

What causes prematurity?

Various investigations have been carried out recently in Britain in order to discover the causes of the premature births. These are most conveniently divided into known and unknown causes.

Known causes.-In different investigations, maternal ill-health was re

ported for 32 to 48 percent of the premature babies, toxemia being the greatest single cause of prematurity. It was found that in 12 to 16 percent of the cases the pregnancy was multiple. Fetal deformity occurred in 3.4 to 5.9 percent of the premature babies studied.

Unknown causes.-In the previously mentioned investigations no cause for the onset of premature labor was determined in 32 to 51 percent of the cases.

More attention is now being given to the effect of social conditions on prematurity; and Prof. Dugald Baird has demonstrated three important facts concerning premature infants born in Aberdeen:

(1) The incidence of prematurity is twice as high among the poorer people as among the richer.

(2) Among the poorer people, over 50 percent of the prematurity is unexplained; among the richer, a very small percentage.

(3) Proportionally more of the smaller premature babies are born to the poorer people.

(4) Among the poorer people the premature babies in every weight group have higher mortality than among the richer. In other words, premature babies born of poor mothers have a lower vitality.

An experiment carried out by the Peoples' League of Health showed that an adequate diet during pregnancy can reduce the incidence of prematurity.

What causes death in the premature baby?

Among premature babies in Great Britain the principal causes of death in the first month of life are: (1) Prematurity, (2) intracranial birth injury, (3) infection, and (4) fetal deformity.

In Birmingham, a premature baby is 22 times as likely to die during the first 4 weeks of life as a baby weighing over 511⁄2 pounds at birth, and the risks of death from infection and from birth injury are each nine times as great for prematures as for other babies.

The risk of death between the ages of 4 weeks and 1 year is approximately twice as great for premature babies as for other babies, and it is interesting to find that the increased risk of death from infection still exists after the first 4 weeks of life; it is more than twice that for babies that are not premature.

How can we reduce mortality due to prematurity?

As steps toward reducing the high mortality due to prematurity, efforts are now being made to reduce the incidence of premature birth by improving social conditions, ensuring an adequate diet during pregnancy, improving prenatal care, and providing more hospital beds for pregnant women with complications likely to lead to premature labor.

In addition, efforts are being made to reduce the mortality among premature babies by ensuring better care for them during and after delivery.

A program including all these efforts has been in effect in Birmingham for a number of years, and the deaths among all premature babies in the city during the first 4 weeks of life were reduced from 26 percent in 1938 to 18 percent in 1946; the deaths among such babies in the first year of life were reduced from 34 percent to 23 percent.

These figures can be still further reduced, as is shown by the results obtained in the City of Birmingham Maternity Hospitals, to which the premature-baby unit described in this paper is attached. In 1946 the incidence of prematurity in this hospital was 8.5 percent, and the neonatal mortality among the 188 premature babies born there was 10.1 percent.

When Birmingham's premature-baby unit was opened, in 1931, it consisted of one large nursery for 10 infants and 6 single rooms for mothers. It soon became obvious that smaller nurseries, and more of them, were required.

Thereupon the large nursery was divided into two smaller nurseries, and some of the single rooms were also used as nurseries. This, however, limited the accommodation for mothers and therefore lowered the incidence of breast feeding.

Recently it was decided to take over the second floor of the building, and the unit will now accommodate 26 babies and 8 mothers.

The first floor consists of two warm nurseries, four cool nurseries, two isolation nurseries, a milk room, a ward kitchen, utility rooms, and a nurses' toilet.

The second floor consists of eight small wards (each for one mother and baby), a demonstration room, a day room for the mothers, a ward kitchen,

a utility room, a bedpan room, and a bath and toilet for the mothers.

All nurseries are entered from a central corridor, where the nurses and doctors put on masks and gowns and wash their hands.

Traffic into the nurseries is strictly controlled. The only persons who enter are the nurse on duty in each nursery, the nursing superintendent of the unit, the senior medical officer, and the pediatric resident physician. Visiting doctors, nurses, medical students, and so forth, are only allowed to observe the nurseries from the corridor.

The smallest infants, requiring the most individual care, are placed in a nursery with four bassinets, as four is believed to be the maximum number of

such infants that can be cared for by one nurse per shift.

The somewhat larger infants (under 41⁄2 pounds, but not requiring so much. individual care as the smallest ones) are placed in a nursery with six bassinets, as one nurse per shift is able to care for this number.

As there are no cubicles in these nurseries, a floor area of 50 square feet is allowed for each bassinet, and the bassinets are placed 6 feet apart. This arrangement has proved most successful in preventing spread of droplet infection from one baby to another.

The two warm nurseries are kept at a temperature of 70° to 75° F. Higher temperatures are avoided because of the bad effect on the staff. (English doctors and nurses are not accustomed to the high temperatures commonly found in America.)

The

Luckily, experience has shown that even the smallest babies thrive well in a nursery kept at this temperature, provided the bassinets are heated. nursery temperature becomes detrimental to the smaller babies only when it falls below 70° F. We have found that babies over 41% pounds usually do better in a temperature of 65° F. after the first few days of life.

Each of the four cool nurseries on the first floor accommodates two bassinets. These nurseries are kept at 60° to 65° F., according to the need of the infants. Two isolation nurseries accommodate two cots each, and these nurseries can be kept at any temperature or humidity desired.

The eight wards on the second floor

are kept at 60° to 65° F. A baby is only transferred to his mother's room when he is sufficiently well developed to cope with the relatively cool atmosphere and when he is able to feed from the mother's breast.

The provision of accommodation for breast-feeding mothers has proved an important factor in promotion of breast feeding.

Heating the nurseries

All nurseries are heated by hot-water radiators and gas fires. Natural means of ventilation are used (windows and ventilators) and the required humidity is obtained by heating pans of water on gas rings.

nurseries is 60 to 65 percent; it is measThe relative humidity in the warm

ured by wet- and dry-bulb thermometers provided in each nursery.

No air-conditioning plant has been installed because the unit is a training school for nurses who will go into homes to care for premature babies, and it is important to teach these nurses how to obtain the necessary conditions by simple means available in an ordinary, English home.

Each nursery has a lavatory for hand washing, a diaper can with a lid, and a receptacle for soiled linen.

Each bassinet has a locker containing toilet articles and a thermometer, also a shelf for the nurse's gown.

The milk room is equipped for sterilization of bottles and preparation and sterilization of breast milk and milk mixtures. Nurses enter this room only if they are wearing cap, gown, and mask.

The kitchen on the first floor is chiefly for the use of the staff, but it is also available for washing used bottles and nipples, so as to avoid taking soiled utensils into the clean milk room. The kitchen on the second floor is for the use of the mothers.

A large utility room on the first floor contains a small electric sterilizer for instruments, small bowls, and receivers. and a large sterilizer for the bathing bowls. (Bathing bowls are used for the larger and older infants, to avoid the use of common baths.) A smaller utility room on the same floor is used for collection of diaper cans until they are removed from the unit. A utility room on the second floor is used for sterilizing.

A day room is provided for mothers who are up and about. A mother is accepted for admission when her infant is 3 days old, after the period of greatest mortality is over and the infant is likely to survive.

Mothers usually remain in the unit for 3 weeks; they then return home and come to the hospital daily to supply breast milk. As soon as the baby is strong enough to suck, the mother breast-feeds him once a day.

A demonstration room is provided for the use of mothers who are living at home and coming to the unit each day for the purpose of breast feeding. In addition, this room is used to teach mothers how to care for their babies before the babies are sent home.

Babies are brought to the unit by the ity ambulance service, in special baskets, each heated by three hot-water bottles. These baskets are kept at the ambulance station.

Each time an infant is brought to the nit in one of these baskets, a clean basket is handed to the ambulance nurse En exchange, thus ensuring a supply of elean baskets at the ambulance station. The ambulance nurse is provided with a flashlight so that she can watch the baby's color. A mucus catheter is available, and also a supply of oxygen, which is given by means of a rubber mask.

On arrival at the unit, the baby is adnitted to a warm nursery, if newly born

and free from exposure to infection. If he is admitted later than a few hours after birth, or if he has been exposed to infection, the baby is placed in an isolation nursery until proved to be free from infection.

On admission, the baby's general condition is noted, his rectal temperature taken, and the cord inspected for bleeding. The infant is then transferred to a heated bassinet and allowed to remain undisturbed (except for emergency treatment, such as suction to remove mucus from his throat, or administration of oxygen) until he has recovered from his journey. Weighing and dressing are delayed until the condition of the child warrants the handling involved.

The resident physician examines each baby for signs of abnormality or disease as soon as possible after admission. During this examination, the child remains in the bassinet and is handled and exposed as little as possible. Vitamin K (2 milligrams) is given routinely to each baby.

Up to the present time no incubators have been used. Open bassinets, with three hot-water bottles, are used for even the smaller infants. Each bassinet is fitted with a washable lining, in which there are three pockets, for hot-water bottles, one at each side and one at the foot.

For a small baby, additional heat is supplied by means of an electric pad

placed under him. To prevent contamination of the pad, or electric shock, or overheating of the baby, the pad is covered by two layers of rubber sheeting, separated by four layers of blanket. The hot-water bottles are changed, in rotation, every hour, in order to keep the heat of the bassinet as uniform as possible.

Thermometers inspected regularly

Each heated bassinet is provided with a thermometer, which is placed between the blankets on top of the baby. This thermometer should never rise above 95° F. if overheating is to be avoided. Each electric pad is provided with a red "telltale" light, which reminds the nurse at regular intervals to inspect the ther

mometer.

The baby's clothing is made of "union flannel" (wool with a small percentage of cotton to prevent shrinkage). A set of clothing consists of a vest, a hooded gown, a diaper, and a bib. As the air in the nurseries is relatively cool, the baby's loss of heat from his head may be considerable unless the head is covered, and, for very small babies, head shawls are used in addition to the hooded gowns.

In the rather cool English nurseries, it is important to avoid unnecessary exposure during such nursery procedures as changing the diaper or the clothes, oiling, and temperature taking. The smaller babies are cleaned with oil. A soap-and-water bath is not given until a weight of 4 pounds is reached.

In healthy babies, the rectal temperature is taken twice daily and it is allowed to stabilize between 96° F. and 99° F.; the smaller the baby, the lower the level of stabilization within this range.

The baby is kept lying on his side (on the right side after feedings and on the left side between times) because of the danger of his regurgitating food and inhaling it. The smaller the baby, the less he is handled; and any necessary handling takes place before a feeding, not after.

Oxygen is given by means of a soft rubber face mask. Nasal catheters are avoided because of the danger of injury to the baby's nasal membrane and the possibility of subsequent infection.

Feedings are started after 12 to 24

23

hours of life. At first small amounts are given; these are gradually increased until, at the age of 7 days, the baby is receiving daily 2 ounces per pound of body weight, and at 14 days, 3 ounces per pound of body weight. At this latter time the daily caloric value of the food is usually 50 to 60 per pound of body weight.

Breast milk is used whenever possible, the protein content being increased by the addition of 1-percent or 2-percent hydrolyzed casein. If breast milk is not available, evaporated milk is used, in increasing strengths from 1 to 12 to 1 to 5, with 1-percent or 2-percent added hydrolyzed casein and added sugar.

Babies not strong enough to be put to the breast are fed by bottle if they can suck well. A medicine dropper is used if the baby sucks poorly but can swallow, and for babies with poor swallowing ability feedings are given by stomach tube. The baby is fed every 2 hours until he can take a sufficient amount at each feeding to be fed only every 3 hours.

Administration of vitamins B and C is commenced on the third day, and of A and D on the seventh day. A preparation containing calcium and phosphorus is started on the fourteenth day because of the low mineral content of breast milk and the relatively great requirements of the premature baby. Administration of iron is begun at 4 to 6 weeks.

To prevent infection

Measures for prevention of infection, such as limiting the number of bassinets in each nursery, spacing of bassinets, free ventilation, and limitation of traffic into the nursery, have already been mentioned.

Parents are allowed to see their babies from the corridor through viewing windows. Other relatives and friends are not allowed to visit.

The members of the staff are medically examined before being allowed to take up duty in the unit and must report if sick.

Absorbent and impervious masks are used by everyone working in the unit, including the mothers when feeding or caring for their infants and the workers who clean the floors of the nurseries.

Floors are treated with oil to reduce the risk of dust-borne infection.

Direct infection is prevented by the

use of gowns, by careful hand washing, by care with laundry and in preparation of feedings, and by providing individual equipment for each baby. Bedside care has replaced the use of common changing tables, and sterilized bowls have replaced the common bath. All pieces of necessary common equipment, such as stethoscopes and measuring tapes, are carefully sterilized before use, and weighing scales are draped with a fresh piece of paper for each baby.

Any baby showing the slightest sign of infection is immediately removed to an isolation nursery, and no new baby is admitted to the affected nursery until the nursery has been proved free from infection.

The nurse responsible for preparation of feedings is never allowed to undertake duties that involve changing of diapers. With this one exception. "task-nursing" is not favored; in fact, one nurse is responsible for the complete care of all babies in her nursery, and she does not enter other nurseries.

The senior medical officer in charge of the unit visits it twice weekly, seeing each baby and discussing current problems, and she is also available day and night for consultation. This medical officer is responsible for the plan of care, which is available in writing for the use of the medical and nursing staff.

In addition, the pediatric resident physician visits the unit daily, examines

each infant on admission and before discharge, and is available day and night for emergency calls.

Before a baby is discharged, his home is visited by a public-health nurse, to ensure that everything is ready for him. In addition, his mother is given demonstrations on the care of her baby (bathing, dressing, handling, preparation and giving of feedings, protection from infection, and so forth) before he is sent home.

Arrangements are made for the baby to be taken to the special "small baby" session at the well-baby clinic, and to return to the unit for special follow-up examinations at stated intervals.

The unit is recognized by the Ministry of Health as a training center for nurses in the care of the premature baby. Medical students from the University of Birmingham are given demonstrations in the unit and many postgraduate courses for doctors, nurse-midwives,

public-health nurses, and so forth, are held at the unit.

Many aspects of prematurity are being studied in the unit; for example, the effects of high-protein feeding, the incidence of rickets, the prevention of anemia, and the rate of mental and physical development of the baby. It is of interest that retrolental fibroplasia has not occurred in the Birmingham premature babies.

Hospital care is obviously best for premature babies with poor homes. I is also best for all those weighing les than 41⁄2 pounds at birth, because these small babies are likely to regurgitat food and inhale it and so require a whole-time nursing service. But re sults can be very satisfactory for the larger babies treated in good homes with good equipment and a good nurse In some parts of England no special hospital accommodation is available for premature babies, and home care be comes important.

When the baby goes home

Health circular for home care are: Recommendations in the Ministry of

A separate room for the mother and baby, provision of equipment on loan by the local health authority, a supply of expressed breast milk when necessary. the advice of a pediatrician, and the services of a homemaker to care for the

family while the mother is unable to do

it herself.

Nurse-midwives and public-health nurses with special training and experience in the care of premature infants are recommended as suitable persons to give attention to premature infants born at home.

The suggested equipment for loan includes a bassinet, clothing, hot-water bottles, an electric pad, a feeding bottle, a thermometer, and a mucus catheter. It is doubtful, however, whether an elec tric pad should be included, because of its possible dangers, especially from overheating, when in unskilled hands

In Britain we realize that reduction of mortality due to prematurity can only be achieved if there is full realization of the dangers associated with prematurity and if full cooperation exists between the hospital staff and the home attendants. This entails special education of the various persons concerned. Reprints available in about 3 weeks