BJ216 H46 RECAP :iiMM§r Columbia ^Hnibers^itp in tfje €it^ of ^ein Sovk CoHege of ^{jpgician^ anb burgeons; l^eference %ihvaxv Principles and Practice of Infant Feeding BY JULIUS H. HESS, M.D. Major M.R.C., U. S. Army, Active Service. Professor and Head of the Department of Pediatrics, University of Illinois College of Medicine; Chief of Pediatric Staff, Cook County Hospital; Attending Pediatrician to Cook County, Michael Reese and Englewood Hospitals, Chicago. ILLUSTRATED PHILADELPHIA F. A. DAVIS COMPANY, Publishers English Depot Stanley Phillips, London 1918 CONTENTS. Part I. PAGE General Considerations 1 Chapter I. The Anatomy of the Digestive Tract of the Infant 1 Chapter II, The Physiology of the Digestive Tract of the Infant 4 Chapter III. Metabolism; in Infants 7 1. General Considerations 7 2. Composition of Milk and the Metabolism of its Constituents 8 3. Milk Digestion 20 Chapter IV. Bacteria of the Digestive Tract of the Infant. 25 1. The Newborn 25 2. The Nursing Infant 25 3. Artificially Fed Infants 27 4. Significance of the Intestinal Bacteria 28 5. Influence of the Diet on the Intestinal Flora 29 6. Intestinal Bacteria in their Relation to Gastro-in- testinal Disturbances 31 Part II. The Nursing 35 Chapter I. General Considerations 35 Chapter II. Maternal Nursing 39 1. Nursing Axioms 39 2. Hygiene of the Mother 39 3. Conditions Influencing the Breast Milk 42 4. The Nursing Proper 43 Chapter III. Wet-nursing 47 1. The Wet-nurse; Her Selection and Her Baby 47 2. The Hygiene of the Wet-nurse 54 3. The Nursing 58 Chapter IV. The Nursing Infant 64 Chapter V. Mixed Feeding and Weaning 67 Chapter VI. Nutritional Disturbances in the Breast-fed Infant 71 1. Underfeeding 71 2. Overfeeding 76 3. Congenital Debility, with Resulting impairment of Vital Functions 84 4. Intercurrent Parenteral and Enteral Infections .... 85 5. Idiosyncrasy towards Mother's Milk 87 (vii) viii CONTENTS. PAGE Chapter VII. Methods of Feeding Premature Infants 89 1. Infants Nursing at the Breast 89 2. Infants too ^^'eak to Nurse the Breasts 90 3. Proper Time for Beginning Regular Feeding 96 4. Feeding from the Second to the Tenth Day 97 5. Feeding After the First Ten Days 99 6. Number of Feedings Daih' 100 7. The Amount of Each Feeding 101 S. Daily Gains 102 9. Artihcial Feeding 102 10. Conclusions 105 Part III. Artificial Feeding 107 Chapter I. Recent Progress in Artificial Feeding 107 Chapter II. Cow's Milk 110 Chapter III. Adaptation of Milk for Infant Feeding 124 1. Undiluted Whole Milk 126 2. The Percentage Method or System of Feeding .... 126 3. Top Milk Feeding , .'. 127 Chapter IV. Milk Dilutions with the Addition of Carbo- hydrates 129 Chapter V. Feeding in Late Infancy and Early Childhood . . 164 Part R'. Nutritional Disturbances in Artificially Fed Infants 168 Chapter I. Minor Disturbances 168 1. Stationary Weight 168 2. Vomiting 168 3. Colic and Flatulence 169 4. Constipation 170 5. Abnormal Stools 171 6. Milk Idiosyncrasy ■ 173 Chapter II. General Consideration of Nutritional Disturb- ances 175 Chapter III. Disturbed Metabolic Balance 186 Chapter IV. The Stage of Dyspepsia 196 Chapter V. The Stage of Decomposition 207 Chapter VI. The Stage of Alimentary Intoxication 223 Chapter VII. Mixed Forms of Nutritional Disturbances .... 237 Chapter VIII. Nutritional Disturbances Due to Insufficient Food 238 CONTENTS. ix PAGE Chapter IX. Infection and Nutrition 245 1. Susceptibility Influenced by Nutrition 245 2. Course of Infections Influenced by Nutrition 246 3. Infection Influencing Nutrition 247 (A) Parenteral Infections 248 (B) Enteral Infections 254 Appendix. Proprietary Baby P'oods 273 Directions for the Preparation of Infant's Foods 279 Bottles and Nipples and their Care 295 Care of Food During Traveling 297 The Diaper 298 Baby's Daily Bath 300 Cold Bath and Cold Pack 302 Hot Bath 303 Mustard Bath and Mustard Pack 303 Stomach Washing 304 Catheter Feeding by Mouth 305 Catheter Feeding by Nose 306 Irrigation of the Colon and Rectal Feeding ' 306 Saline Solutions 308 Home-made Ice-box 310 Case History 312 Average Weights 314 Measurements 314 General Development 315 Sleep 315 Order and Average Time of Eruption of the 20 Deciduous Teeth 315 Permanent Teeth 316 Closure of Fontanels 316 Average Daily Quantity of Urine in Health 316 Average Rate of Pulse and Respiratio^ 316 Blood-picture in Healthy Children 317 Average White Cell Counts 317 Stool Symbols 317 Urine Symbols 317 Record Sheet 318 Index 325 INTRODUCTION. The dependence of the offspring upon its mother for food to supply its primitive needs can only be realized when we remember that one-fourth of the civilized race die during the first year of life, and' that 60 per cent, of these deaths are due to nutritional disturbances, while a large portion of the other 40 per cent, are primarily de- pendent upon impairment of the infant's constitution by improper feeding. The mortality of the first year is nearly 60 times that of the fifteenth year, and it is not until we approach the 85th year that we meet with such a high percentage death-rate. The problem is not simply to save life during the perilous first year, but to adopt those means which shall tend to healthy growth and nor- mal development. The child must be fed not only to avoid the immediate dangers of acute indigestion, diar- rhea, and marasmus, but the more remote ones — rickets, scurvy, and general malnutrition. These latter three are the most important conditions that predispose to disease in early life. A growing child requires far more food than its weight would indicate. For, in the first place, its intake must exceed its expenditure, so that it may grow. The expenditure of an organism is pretty nearly in propor- tion, not to its mass, but to its surface. The skin surface of a boy from 6 to 9 years, with a body weight of 18 to 24 kilograms (40 to 50 pounds), is two-fifths to one-half that of a man of 70 kilograms (154 pounds), and he should therefore have about half as much food as the (xi) xii INTRODUCTION. man. This disproportion in the needs of the infant as compared with the adult, is even greater than that of the child compared with the adult. By exact measurements it has been determined that an infant from its fourth to the sixth month consumes about twice as much food per kilogram body weight as the adult. Part I. General Considerations. CHAPTER I. THE ANATOMY OF THE DIGESTIVE TRACT OF THE INFANT. Oral Cavity. The salivary glands are well developed at birth, and the active principles of the salivary secre- tion are present, but in small quantities. Teething begins at about the sixth month, and dentition is not completed until about the end of the second year. In most instances this is a normal physiological process, and should cause no disturbances. However, in a considerable number of cases the gastric and intestinal secretions are affected re- flexly, with a diminished activity on the part of these glands ; and if there is any tendency to a general disturb- ance during this period, a reduction in the quantity of the food administered is indicated. However, far too great an importance is usually given by the laity to the process of teething. Stomach. In the newborn the stomach has a more vertical position than in the adult. However, rontgen- ologic examination has demonstrated that it is less ver- tical than has been formerly supposed. The cardiac end is found at the left of the tenth dorsal vertebra. The pylorus lies about midway between the ensiiorm cartilage and the umbilicus. The position of the stomach and its form, due to lack of development of the fundus and lack 1 (1) 2 INFANT FEEDING. of muscular development at tlie cardiac end, account in great part for the frequency of vomiting in the infant. The pylorus also lacks the muscular development of the adult, and is decidedly more patent. Considerable difficulty is experienced in our attempts to gain accurate knowledge of the capacity of the stom- ach. Pfaundler, who measured the size of numerous infants' stomachs, using air under a given pressure, has given us figures which are, in all probability, fairly accurate. He states that the capacity at birth is 2 ounces (60 mils), at one month 2 to 3 ounces (60 to 90 mils), at six months 6 ounces (180 mils), and at one year 9 to 10 ounces (270 to 300 mils). The importance of the stom- ach's capacity in determining the size of the individual feeding is only relative, dependent to a great extent upon the form of diet. With milk as the food, a considerable portion of the water content passes through the pylorus before the meal is finished, if the food is not too rapidly given. When a child is fed by gavage, the size of the meal is of greater importance because of the danger of overdistention by the rapid administration of the food by this method. Notwithstanding the fact that the size of the stomach varies in different babies, we have found it a good working rule in the feeding of normal infants to administer at each feeding a quantity 2 ounces more of the liquid food than the infant is months old. The intestines are relatively larger than in the adult, which applies more especially to the large intestine, and particularly to the sigmoid flexure. - The sigmoid is also more mobile, due to the greater length of the mesosig- moid, and it is extra-pelvic. The musculature is rela- tively thin, and bears an important relationship to the ANATOMY OF THE DIGESTIVE TRACT. 3 frequency of its overdistention and the presence of colic, which is due to the stagnation of large quantities of gas in the intestinal tract. The pancreas shows no special anatomical differences. The liver is relatively two-and-a-half times as large at birth as in the adult, and is easily palpable, and in the nipple-line of the right side usually extends 1 to 1^ inches (2 to 4 cm.) below the costal border. CHAPTER II. THE PHYSIOLOGY OF THE DIGESTIVE TRACT OF THE INFANT. While all the ferments are present in earty life, they vary quantitatively and qualitatively as compared with the older children. Mouth. Ptyalin, which is an amylolytic ferment, is present in the saliva immediately after birth, but is small in amount, and weak in its action. Albumin, water and mucus in saliva vary with the variety of food taken (Pavlow). Stomach. Gastric juice is present in the stomach even in the premature. Its secretion is mainly stimu- lated by the act of sucking and by the presence of the food in the stomach. Free hydrochloric acid is little less than in the adult. It may be stated that the small protein content of human milk, as compared with cow's milk, favors the presence of hydrochloric acid. This is' a point of great importance in the food problem of the infant. Free hydrochloric acid is found in 10 per cent, of cases after 1 hour, and in 33 per cent, of cases after XYi hours on feeding with human milk (Hamburger and Sperck). With cow's milk, free hydrochloric acid is found very rarely, which is due to combination of the hydrochloric acid with salts and proteins. Total acidity is in small part only due to free hydrochloric acid. ^lore important are phosphoric acid, acid phosphates, acid chlorides, fatty acids and acid albumins ( albumoses and peptones). Total acidity is 20 to 60 mils X :10 acid to 100 mils of gastric contents. The (4) PHYSIOLOGY OF THE DJGESTIVE TRACT. 5 action of the hydrochloric acid is as follows: (1) makes protein digestion possible (acid albumins) ; (2) stimu- lates the pancreas; (3) disinfectant and antitoxic action. The following ferments are present in the stomach : (1) Pepsin, which is present at birth, and is active and causes at least partial chgestion of proteins. It increases to the fourth month, then remains fairly constant. More pepsin is present in bottle-fed infants. (2) Rcnnin is also present at birth, and in the presence of hydrochloric acid coagulates milk. Whether this is dependent on pep- sin, or whether it is a specific ferment, is questionable. (3) Lipase, a fat-splitting ferment, is found in the stom- ach in small quantities, and is probably a definite product of the gastric mucosa. Small Intestines. Mucous membrane of the small intestines secretes about 1 liter of juice daily, and this contains all ferments at birth, they being, however, rela- tively feeble at first. The following ferments are pres- ent in the intestinal secretion: (1) erepsin (Cohnheim), which splits casein, albumoses, and peptones to peptids and amino-acids. Other albuminous bodies are not afifected by it. (2) lactase, maltase, invertin; they split disaccharides (milk, malt, and cane sugar) to monosac- charides, and each is stimulated by its own sugar. (3) prosecretin, which is changed to secretin by hydrochloric acid from the stomach, and stimulates the secretion of the pancreas. (4) enterokinase, which activates the pro- teolytic enzyme of the pancreatic juice; and probably (5) diastase. Pancreas. All of the ferments (trypsin, steapsin, and amylopsin) are found in the intestines at birth. The liver possesses the ability to form gtycogen and iirea in the newborn. Bile is present, its emptying from 6 INFANT FEEDING. the gall-bladder being stimulated by chemical action of fats on the duodenal mucous membrane. The functions of the bile are: (Ij to hold fatty acids and fatty acid salts in solution, (2) to stimulate the pancreas, and (3) an antiseptic action. Other functions of the liver are formation of urea, acetone, and formation and storing of glycogen. Large intestines secrete no enzymes, their chief function being absorption of water and throwing off of Ca, P, Xa, K, Fe, Mg. CHAPTER III. METABOLISM IN INFANTS. 1. General Considerations. The term metabolism covers all of the functions of the human body which have to do with the preparation for and assimilation of food. To furnish the body with fuel for its normal activities, the following groups of food elements are necessary : proteins, fats, carbohydrates, salts, and water. Fats and carbohydrates, and to a lesser extent proteins, furnish fuel ; while the proteins and salts more especially form the elements necessary for body growth. It is necessary to distinguish between the activities which take place within the gastro-intestinal tract before absorption of the changed products and the deeper seated metabolism which takes place beyond the intestinal wall, which can be designated as the "intermediary me- tabolism." Under normal conditions in the adults the intake and the products of excretion balance one another, while in the infant there is a positive balance — that is, less is ex- creted than is absorbed — and one may well say that a balance which would be normal in the adult is patho- logical in the child, and would thereupon soon result in a stationary weight, or a loss in weight. Several factors offer difficulties in the study of infant metabolism. First, it is difficult to obtain stools free from urine and with the water content intact. (7) 8 INFANT FEEDING. Secondly, the small volume in which the urine and stools are obtained offers many difficulties in their study. Urine and stool examinations should cover a period of at least three days to be of conclusive value. 2. Composition of Milk and the Metabolism of Its Constituents. The natural food of the infant is human milk, char- acterized by the fact that its quality changes very little, the infant's growth being dependent on the changes of its volume. Milk of different animals varies as to its fuel value, and also in its chemical composition, especially quan- titatively there being marked differences. Protein Fat Sugar Salts Human 1.5 3.5 6 to 7 0.20 per cent. Cow's 3:4 3.8 4 to 5 0.75 " " Human colostrum differs from the milk in that the protein is 5 to 6 times as great in the former ; salts are also higher than in later milk ; sugar is low — 3 to 5 per cent. — and it is low in fats, averaging about 2 to 2.5 per cent., although it varies in different women, and also with the day of puerperium. Colostrum contains also numerous leucocytes and large cells containing fat, these latter probably being epithelial in origin. 1. Proteins. Chemistry of Proteins. Proteins con- tain carbon, hydrogen, nitrogen, oxygen, sulphur, and phosphorus. They are highly complex chemical sub- stances, similar in their chemical composition to proto- plasm and essential to life. Of the proteins milk contains mainly casein and al- bumins, with small amounts of globulins, opalisin, nuclein, etc. Albumin 0.6 Casein 0.8 per cent. 1.2 to 0.3 2.7 to 3.0 " " METABOLISM IN INFANTS. Human milk contains . . . Cow's milk contains 0.2 to 0.3 Casein belongs to the nucleo-albumin group (proteins), which contain phosphorus, are insoluble in water, mod- erately in alkalies, precipitated by acids, not coagulated by boiling, and by pepsin digestion changed to para- or pseudo- nucleins (which are bodies rich in phosphorus). Chemically it is composed of a complex group of amino- acids, the basis of all protein bodies, and a prosthetic group which contains the phosphorus. Amino-acids are characterized by the group COOH, in which an H is re- placed by NH2 group, e.g., acetic acid (CH2HCOOH), amino-acetic acid, or glykokoll (CH2NH2COOH). Human casein contains much less phosphorus than cow's (0.25 to 0.88). This proves that the casein of the human and the casein of the cow's milk are different bodies, although this difference is probably of a quanti- tative nature only. The two caseins differ also in their coagulability, the human casein being more difficult to precipitate with acids, salts and rennin. The soluble albumins are coagulated by heat and weak acids. Metabolism of Proteins. Casein is separated from the so-called whey albumin, and is changed to an insoluble paranuclein. It is unknown whether enzyme causing it is identical with the protein digestive ferment of the gas- tric mucous membrane or not. Pepsin (from the pyloric mucous membrane) changes paranucleins to albumoses and peptones, which then pass into the small intestines. (Erepsin, the ferment of the intestinal juices, works very rapidly on the end products of pepsin digestion.) In the small intestine an intricate splitting takes place. 10 INFANT FEEDING. With the human milk as a food, a very small amount of nitrogenous products of the food appears in the stools, the total being about one-sixth of the intake, and part of this arises from 1. Intestinal juices, 2. Intestinal epithelium. 3. Bacterial activity. After passing through the intestinal wall, proteins have three functions to perform : 1. To replace used proteins (lost through urine, sweat, digestive juices, cell destruction, etc.). 2. To satisfy cell growth which would be impossible without proteins. 3. To furnish fuel for part of the dynamic loss (fats and carbohydrates are the natural fuels, the protein com- bustion being incidental). In feeding with cow's milk, three times as much pro- tein is given as needed for 1 and 2, therefore it is used for 3 (that is, dynamic purpose). The great disproportion as seen in a comparison of the proteins in cow's over human milk is probably due to the needs for cell growth in the calf. ' Within certain limits, however, the excess of protein feeding in the infant does not cause increased retention and cell growth because of the ability of the organism to regulate its functions. End Products of Protein Metabolism in Urine: Urea 60 to 80 per cent. Ammonia 3 to 10 per cent. Oxaluric bodies 1 Uric acid ! ,^. , , . . J- JNitrogenous by-products. Kreatmm j ^ .r f Oxybutyric acid j METABOLISM IN INFANTS. 11 Urea forms 75 to 86 per cent, of the nitrogen con- stituents of the urine. By ammonia coefficient is meant the relation of am- monia to the other nitrogenous bodies in the urine. Influence of the Carbohydrates and Fats on the Nitro- gen Metabolism. 1. Carbohydrates cause (1) Increased retention of proteins. (2) Increased nitrogen in feces. 2. Fats cause J (1) No increased protein retention. (2) Increased nitrogen in feces. 2. Fats. Chemistry of Fats. Human milk fats are esters of palmitic, stearic, and oleic acids with glycerin, the oleic acid ester being present in larger amount in human than in the cow's milk. Human milk fats are de- rived partly from body fat and partly from food fat. Carbohydrates also furnish ingredients for fat making; proteins do not. Metabolism of Fats. 1. Lipase from the gastric mucous membrane causes some splitting of fat. 2. Fats are emulsified in small intestines. 3. Live intestinal cells can change fatty acids to fats. Resorption. 1. Lymph-vessels. 2. Blood-vessels. Disposition. 1. Subcutaneous tissue. 2. Prseperitoneal spaces. 3. Liver. 12 INFANT FEEDING. 4. Burned with resulting end products. (1) Carbonic acid. (2) Water. In stools found normally as unresorbed portion of in- gested fat in the form of 1. Fat (neutral). 2. Lecithin. 3. Cholesterin. 4. Fatty acids representing 1 to 10 per cent, of fat ingested. 5. Alkali soaps. 6. Earthy alkali soaps. In Urine. Fatty acids and glycerin are found in very small quantities, but we cannot say that these are from the fats ingested. Nursing babies always have at least a small amount of fat in their stools. In contradistinction to proteins, the fats in the stools are in greater part only unresorbed fats, only a small amount being due to cell activity. (Proteins greater part). A^arious percentages of fat ingredients normally pres- ent in human stools are, as follows : Neutral fat 29.5 per cent. Fatty acids 10.7 " Combined fatty acids .... 59.8 '' " (18.3 Ca and Mg.) Fat in the Gastro-intestinal Tract and its Relation to Metabolism. Unlike proteins we can nourish the in- dividual without fats, as carbohydrates can replace them. If too long continued, the organism changes, however, m its chemistry through increased absorption of salts and water, which, however, lessens the processes of immunity. METABOLISM IN INFANTS. 13 3. Carbohydrates. Milk sugar formed by the mam- mary glands from material circulating in the blood is a disaccharide (glucose and galactose). Chemistry of Carbohydrates. 1. Monosaccharides. (1) Glucose (dextrose, grape sugatr). (2) Lsevulose (fruit sugar). They ferment and are reducible. (1) Has a right and (2) left polarization. 2. Disaccharides. (1) Lactose — glucose and galactose. (2) Maltose — glucose and glucose. (3) Saccharose — glucose and Isevulose. (1) and (2) are reducible, (3) is not. 3. Polysaccharides (three or more sugar molecules). (1) Flour. (2) Dextrin. (3) Cellulose. Metabolism of Carbohydrates. Monosaccharides are without further change absorbed in the small intestine or fermented. Disaccharides are first reduced to monosaccharides by the intestinal ferments (every disaccharide having its specific ferment) before they can be absorbed. (This is not entirely true of maltose). Polysaccharides are first acted upon by ptyaline in the saliva ; this is continued in the stomach until the stomach content becomes acid, and then by enzymes of intestines and pancreas they are converted to monosaccharides. After absorption into the blood, the carbohydrates serve the following purposes : 14 INFANT FEEDING. 1. Used for energy. 2. Synthetically inverted into glycogen. 3. Fat foundation (probably). Body cells can oxidize only monosaccharides (maltose excepted). Interesting is the storing up of glycogen by the liver and muscles so that the sugar in the blood can be kept constantly at about 0.1 per cent. Glycogen is most easily made from glucose and Isevu- lose; less so from galactose, maltose and starch; least easily from cane and milk sugar. Fat is formed from sugar by the subcutaneous cells, which are especially adapted to this function. Sugar is oxidized to carbon dioxide and water, which can be measured by the respiratory metabolism. Nor- mally, sugar is absorbed from the small intestines, and is not found in the feces. In urine very minute amounts are present, when pass- ing the capacity for assimilation, thereby producing an alimentary glycosuria. This is most easily accomplished in the following order: lactose, galactose, Isevulose, glucose. The assimilation limit for sugars is much greater in infants than in adults. An infant may develop mellituria when milk sugar exceeds 3.1 to 3.6 grams per kilogram body weight ; in the adults at over 1 gram per kilogram. The cane sugar limit is about the same as milk sugar, while that of malt sugar is 7.7 grams per kilogram body weight. The height of the assimilation limit in itself shows that the infant's organism is adapted to a higher carbohydrate metabolism than that of the adult. Carbohydrates in the Tissues. The newborn has a gly- cogen depot. METABOLISM IN INFANTS. 15 Carbohydrates can, in part at least, replace proteins and fats. They cause a rapid increase in weight (very rapid at first), being deposited in the tissues, as glycogen, which latter can absorb two to three times its weight of water. The relation of fats to carbohydrates is as follows : The more carbohydrates present, the greater is the ten- dency on the part of the system to build up body fats. As to oxidation of fats, ''They are burned up in the fire of carbohydrates" (Naunyns). The complete burning of fats into carbon dioxide and water takes place only when the carbohydrate metabolism is normal ; otherwise we get as mid-products the acetone bodies (acetone, aceto-acetic acid, oxybutyric acid, etc.). This occurs also in starvation. (Important in infants' diseases, as seen in diabetes, continued fevers, intoxi- cation, etc.). Acetone bodies can also be formed from protein mole- cules. This occurs in starvation and in meat and fat diets (deficiency of carbohydrates in the latter). Weight becomes stationary or a loss results when car- bohydrates are excluded or insufficient in the diet. Tem- perature falls, and does not rise to normal until they are replaced. 4. Salts. Chemistry of Salts. Salts added to water are relatively split into their "ions" — that is, into either electrically positive or negative bodies. A solution of sodium chloride is a solution in which the NaCl molecule is intact, but the Na (kation) is electro-positive; the CI (anion) is electrically negative. Human milk contains 0.2 Gm. ash in 100 mils. Cow's milk 0.75 Gm. ash in 100 mils. Some exists as inorganic salts, others as important organic compounds. 16 ,, IXFAXT FEEDING. I. Rations (or cations). 1. Calcium. (1) Human 0.42 Gm. per 1000 mils, cow's 1.72 Gm. per 1000 mils, about 1 : 4.5. (2) Excretion is almost entirely through intes- tines, some from unabsorbed food rem- nants, and the rest by tissue metabolism. 2. Magnesium. (1) Human 0.068 Gm. per 1000 mils, cow's 0.2 Gm. per 1000 mils. (2) Its metabolism is very closely related to the calcium. 3. Sodium. 4. Potassium. (Ij Human milk 0.16 Gm. XaoO, cow's 0.465 Gm. Xa20 per 1000 mils, 1 : 3. (2) Human milk 0.69 Gm. KoO, cow's 1.885 Gm. KoO per. 1000 mils, 1 : 3. (3) Excretion mostly through kidneys and stools. 5. Iron. Human milk 0.001 to 0.004 Gm. cow's 0.0007 Gm. per 1000 mils. These figures show considerable variation according to dif- ferent authors. Excreted mainly through the bowels. XL Anions. 1. Chlorine. Human 0.294 Gm., cow's 0.82 Gm. per 1000 mils, 1 : 3. (1) Absorption: 90 to 100 per cent, through the intestine. (2) Excretion: mostly through kidneys. (3) About 0.5 per cent, retained by the system. METABOLISM IX INFANTS. 17 2. Phosphorus is contained in the milk in the fol- lowing forms : (1) Inorganic (calcium phosphate). (2) Organic (casein, nuclein, lecithin, etc.). (3) Total in human 0.294 to 0.418 Gm., in cow's 2.437 Gm. per 1000 mils, 1 : 9. (4) Organic in human 43.3 per cent., and cow's 46 per cent., 1:1. (5) The retention is higher in artificially fed than those fed on human milk. Relation of Salts to Metabolism. The salts are neces- sary in digestion and in every step of metabolism from absorption to excretion and secretion. The role of these salts in both normal and pathological conditions has been given constantly increasing importance in the last few years. Metabolism of Salts in Infants. In the gastro-intes- tinal tract the foods and salts are constantly changing action. A casein product and calcium combine in the stomach to form calcium paracasein. Fatty acids and alkalies and earthy alkalies in the intes- tines form soaps. Casein increases excretion of salt in the intestine (moderate). Fat increases excretion of salts in the intestines (markedly, especially Ca, Na, K). At the same time the phosphorus excretion decreases as the calcium phosphates are changed to calcium soaps by combination of calcium with fatty acids, and the free phosphoric acid unites with sodium and potassium to form easily absorbed salts. Salts are excreted in the urine and stools. The stools are the main source of excretion of calcium, magnesium. 18 INFANT FEEDING. and iron. \Miether these are formed from the tissues or unabsorbed food is difficult to decide. The difference in percentages in human and cow's milk is equalized by the body using only what is necessar)' to its life and growth and not attempting to use it all. Functions of Salts. (1) They furnish building material for new cells. (Rachitis due to lack of absorption.) (2) They are necessary to nerve excitability, muscle contraction, and many other vital functions. (3) Addition of calcium and potassium to normal salt solutions counteracts their poisonous eitects. (4) Life is incompatible with withdrawal of min- erals or even one ion. (5) Life does not so much depend upon the ion as on its chemical combination. Therefore ash alone will not supply the needs. (6) Infants need minerals for growth, as well as for life. Different tissues require different amounts and different salts. (7) Weight drops with withdrawal of salts, even if other ingredients are constant, due to loss of water. Sodium salts are most important in water retention, calcium salts are least. (8) Temperature falls, when salts are withdrawn (sodium). (9) Phagocytosis is increased by calcium salts. Of value in infection. 5. Water. Infants need 105 Gm. of water, and adults 40 Gm. of water, per Kg. Metabolism of Water. Intake is in the food. The outgo from the kidneys, bowels, lungs, and skin. METABOLISM IN INFANTS. 19 Water when ingested quickly passes through the stom- ach to be absorbed by the intestines. The water content of the organism varies with age and food. In the adult 58 per cent, of body is water, and in the newborn infant's body 66 to 69 per cent, is water. Sodium salts have the greatest facility for water retention. Of the anions, CI is the most marked in causing water retention. Excretion of water takes place as follows : kidneys 59 per cent., skin and lungs 33 per cent., intestines 6 per cent. One to 2 per cent, of the water intake is retained. Relation of Water to Metabolism. Approximately two-thirds of the body is water. All cells need it ; it is necessary to different combinations and reactions. In general, it is necessary for young infants on artificial feeding to receive about 140 to 150 mils (4 to 5 ounces) per kilogram (2 pounds) body weight every twenty-four hours. It carries nutritious material in the blood, lymph, cells, etc., and also the material for anabolism and katabolic products. It is also necessary to the function of the lungs and of the skin. It is deeply involved in the question of immunity. 6. Lipoids. Lecithin. Lecithin is the fatty acid ester of the glycerophosphates (glycerin phosphoric acid). Human milk, 0.499 Gm. per 1000 Gm. ; cow's, 0.63 Gm. per 1000 Gm. The organism can apparently live without it in its food. Cholesterin. Human milk, 0.25 to 0.38 Gm. per 1000 Gm. Mainly excreted by the intestines. Lecithin and cholesterin belong to the group of the so- called lipoids, the substances which according to our 20 IXFAXT FEEDIXG. present knowledge play a very important role in the life of the cell. Alice die if their food is made free from all lipoids. This is of interest when we consider that fat- free milk contains but little lipoids. 3. Milk Digestion. 1. In the Mouth. In the mouth milk is mixed with saliva, each 100 mils of milk averaging about 5 mils of saliva (Tobler). The secretion of saliva is stimulated mainly by the act of sucking, but also in part by appetite (psychic reflex). Ptyalin begins its action on the carbo- hydrates of the milk. Saliva may also cause coagulation. 2. In the Stomach. In the stomach the milk is curdled, casein being precipitated by rennin. Human milk coagulates less rapidly and less completely than cow's milk. Therefore in the latter the curds and the whe}' are more quickly separated. Proteins are changed to albumoses and peptones by pepsin, and thus they are prepared for further digestion in the intestine. Albuminous digestive products stimu- late gastric secretion. Of fats 2h per cent, are changed to fatty acids and glycerin by lipase and action of bacteria. Fats at first retard, and later increase, the gastric secretion. Action of ptyalin on carbohydrates is continued during the alkalinity of the stomach. Absorption in the stomach is as follows: (1) salts and sugars, (2) proteins (small amounts), (3) water (none), (4) fats (none). Shortly after beginning of the nursing some of ^he whey content of the food begins to leave the stomach. This is more especially true if the ferments are active. METABOLISM IN IXI'AXTS. 21 The time also varies with tlie (tuahty of the meals. Human milk leaves the stomach in ahout one and one- half to two hours after ingestion, and cow's milk in ahout three hours after ingestion. Two factors have an inijiior- tant bearing on this point: (1) the quantity of the fat, which delays the passage of the food through the pylorus, (2) the size of the curds, the large curds of the cow's milk delaying emptying of the stomach. As previously stated, whey quickly passes out of the stomach, and remaining curd is digested at the surface, and this passes over. Solid masses may pass through. After each passage of food the pylorus again closes. The rapidity of emptying the stomach depends on the action of the pylorus, and this in turn on the chemical composi- tion of the food. Fats and albumins remain long in the stomach, sugars and salts passing through more rapidly. 3. In the Small Intestines. The action of the gastric digestion on the proteins is supplemented by trypsin from the pancreas, and the erepsin of the succus entericus. End products of the protein digestion are amino-acids. Carbohydrates are split into monosaccharides in the small intestines and are absorbed there. Fats which have been split into fatty acids and glycerin are emulsified and absorbed. Absorption of all digested food is almost complete in small intestines. It may be stated that intes- tinal or pancreatic digestion is far more important than gastric digestion in the infant. 4. In the Large Intestines. Absorption of water and excretion of salts are the chief functions of the large intestines in the digestive process. 5. Feces and Urine. Feces is composed of food rem- nants, products of secretory activity of the intestines, products of desquamation of the intestines and bacteria. 22 IXFAXT FEEDING. Composition of feces depends to a certain extent upon the nature of the food ingested. Foods rich in proteins (skim milk, albumin milk, etc.) cause increased intes- tinal secretion, with resulting alkaline reaction, which favors putrefaction and furnishes conditions favorable for development of fat soap stools. Excess of carbohy- drates with acid fermentation gives another picture. Putrefaction and fermentation work antagonistically on the reaction of the stool. There is a balance between the acids derived from fat and sugars by bacterial action and the alkaline intestinal secretion. Proteins in the stool (giving biuret and Millon's tests) are in greater part not derived from food proteins, but they are due to intestinal secretions, desquamated epi- thelial cells of the intestines, and to the bodies of bac- teria. This is especially true of breast-fed infants. The normal infant stool contains no unchanged casein. , Fat has important influence upon the formation of the stool. On feeding with human milk poor in fat the stools are small, containing small quantities of solids and some mucus. On feeding with human milk which is rich in fat, normal stools are produced. ^Microscopically fat is always evident in stools, and is derived partly from food, and in small quantities from the secretion of intestinal juices. Fatty acids and fat soaps are constantly found. Salt excretion is an important function of the large intestine. In the breast fed, ash content of dry stool is 10 per cent., bottle fed 40 per cent. Insoluble calcium salts harden the feces. The following are some tests on constituents of feces : 1. Fat soap easily seen as fatty acid crystals (needles) by heating with acetic acid on the cover glass and allow- ing to cool. METABOLISM IN INFANTS. 23 2. Carbof uchsin in weak solution stains as follows : Neutral fat : no stain. Soaps : faint rose color. Fatty -acids: red. 3. Sudan IIL stains as follows: Neutral fat: orange red. Soaps : crystals do not stain. Fatty acids : stain red or crystals, orange red. 4. Sugar is not demonstrable in any quantity as such, but the character of the fat soap stool seen in milk feed- ing without sugar is changed to a softer, smaller, and normal color by adding sugar. 5. Starch is demonstrable by iodine test microscopic- ally, but care must be exercised in the interpretation of the test, as the starch may be derived from baby powders. The color of the stool is due to bile coloring matter de- rivatives : bilirubin and its reduction products, urobilin and urobilinogen. The smaller the reduction of coloring matter there is present, the more colored the stools. By marked reduction to urobilinogen, the color becomes al- most white. The more milk and cream, i.e., fat, in the diet, the paler the feces. The so-called soap stool is due to excess of fat and overfeeding with milk or cream, and is a firm, grayish, putty-like stool. (See Disturbed Metabolic Balance.) Thin watery stools must always be taken seriously. However, the same cannot be always said of green, curdy stools, which are not infrequently seen in thriving breast- fed infants. These curds are almost invariably due to fatty acids and soaps. Normal stools of breast-fed infants are homogeneous, salve-like, ochre-yellow color, acid, and of sour odor. Microscopically may be seen detritus masses, bacteria, few neutral fat corpuscles, and fatty acid crystals. Normal stools of bottle-fed infants vary with the diet. One can frequently tell the diet by the appearance of the 24 IXFAXT FEEDING. stool. On milk diet: less frequent, usually 1 or 2 daily, firmer and drier, usually pale yellow, alkaline and of foul odor. Constipation is the rule in babies receiving large quantities of milk with a moderate amount of carbohy- drates. Sugars have a laxative tendency (fermentation). Excess of brown color may be caused by excesses of malt sugar. Starches, if well taken, tend to constipate, in large amounts they tend toward an acid reaction and an aromatic odor. Stari'ation of liiinger stool is seen on a very limited diet, as minimum amounts of milk, tea, cereal water. The stool has a dark, greenish-brown color, is soft, and composed in great part of mucus, and appears semi-trans- parent. This mucus may lead to further starvation through mistaken interpretation of its meaning, and re- sult disastrously. In the past it was taught that a study of the stools gave one definite information for the diflierential diagnosis of the gastro-intestinal disease, but experience has taught us that conclusions are of value only when based upon stool examinations in conjunction with a careful study of the diet, and clinical examination of the infant. Urine. A normal infant urinates ten to fifteen times daily, and the urine passed represents 60 to 70 per cent, of the fluids taken as food and drink. It is acid in re- action, and should be free from albumin. However, al- bumin frequently is present in the simple nutritional dis- turbances, and almost constantly in the severe acute ill- nesses. The temporary presence of albumin in the urine of the newborn may be considered physiological, as well as the uric acid during the very early stage. Great de- creases, even to anuria, are common with the intestinal disturbances. CHAPTER IV. BACTERIA OF THE DIGESTIVE TRACT OF THE INFANT* 1. The Newborn. For about one day the meconium passed by the new- born baby is sterile. During this time, however, the bac- teria begin to invade the digestive canal of the infant through the mouth and through the anus. The initial in- testinal flora which thus develops is subject to marked differences, the number and nature of the bacteria de- pending chiefly upon the surroundings of the infant, and exhibits no characteristic constant findings. This period is followed by gradual transition in the nature and in the number of the intestinal bacteria, until about the third day after birth characteristic intestinal flora becomes established, constituting chiefly of Bacillus bifidus (in the nursing infant) and Bacillus coli fin the artificially fed infant), and, besides these, Bacillus acido- philus, ^Micrococcus ovalis, Bacillus lactis aerogenes and others. 2. The Nursing Infant. The principal portal of entry of the intestinal bacteria is the mouth. There is no doubt that a great variety of organisms may from time to time enter this atrium, in- * In the elaboration of this chapter free use has been made of A. I. Kendall's Bacteriology, Lea & Febiger. Philadelphia and New York, 1916. (25) 26 IXFAXT FEEDING. eluding not only the ordinary organisms of the nursling's environments, but pathogenic bacteria as well. A major- ity of these pass to the stomach, and they may pass to the intestinal tract. The flora of the mouth and of the stomach are not well known, but they appear to be of relatively slight importance as a rule. The duodenal flora in health is composed chiefly of coccal forms of the ^Micrococcus ovalis type. Bacillus coli and other members of the colon group are most numer- ous at the ileocecal valve and the cecum, and Bacillus bifidus or similar organisms dominate the large intes- tines from this level to the sigmoid flexure. The re- mainder of the large intestines to the rectum is some- what sparsely populated with living bacteria, partly be- caus,e the fecal mass is relativelv desiccated bv the ab- sorption of water, partly because of the accumulation of waste products of bacterial activity — principally acids re- sulting from fermentation of lactose, formed higher up in the tract — which inhibit the development of bacteria in the lower levels. Bacillus bifidus (Gram positive, blue stain) predomi- nates in the intestinal flora of the breast-fed infant, being acid tolerant and finding favorable conditions for its growth and development, since in digestion of mother's milk lactic acid production from lactose is so great as to inhibit the growth of the Bacillus coli and Bacillus lactis aerogenes in the lower end of the ileum, while the highly acid medium favors the growth of the Bacillus bifidus communis and the acidophile bacteria. Coccal forms and lactose fermenting organisms are present, but scanty ; spore bearers are rare. feACTERlA OF THE DIGESTIVE TRACT. 27 3. Artificially Fed Infants. Escherich directed attention to the striking dissimilar- ity between the intestinal flora of the breast fed and the artificially fed infant. Culturally, morphologically, and chemically the former is more uniform than the latter. The most distinctive features of the dejecta of the arti- ficially fed infants are : the relative increase of Gram- negative bacteria of the coli-aerogenes type, and of coccal forms of the Micrococcus ovalis type, together with a diminution of Bacillus bifidus. Bacillus acidophilus is relatively more numerous, as a rule, in the artificially fed infant than in the nursling. Proteolytic bacteria of several types are also of frequent occurrence, but they are not commonly found in the dejecta of the normal nursling. These organisms are frequently spore-form- ing bacilli, of which two principal groups are recognized — members of the aerobic group, of which Bacillus mesen- tericus is a prominent type, and anaerobic bacteria. Of the latter, Bacillus aerogenes capsulatus is most wndely known; it frequently occurs in small numbers in the feces of artificially fed infants. The reaction of normal feces of artificially fed babies is usually alkaline ; cul- turally and chemically, the evidence of intestinal proteo- lysis of bacterial causation is more marked in these in- fants than in normal nurslings. The general distribution of types of bacteria at the different levels of the intestinal tract is similar to that observed in normal nurslings. The principal differences are found in the cecum and large intestine, where the obligately fermentative bacteria of the bifidus type are replaced to a considerable degree by an extension of 28 INFANT FEEDING. habitat of the Bacillus coli, of Bacillus acidophilus, and the appearance of moderate numbers of proteolytic bac- teria, both aerobic and anaerobic ; many of the latter are sporogenic. The characteristic feature of the normal adult fecal flora as compared with the infantile nursling flora is the very heterogeneous variety of types of bacteria in the former, in sharp contrast to the homogeneity of types of bacteria in the latter. 4. Significance of the Intestinal Bacteria. The striking differences in morphology, chemistry, and in cultural characters between the intestinal floras char- acteristic respectively of nurslings, artificially fed infants and adults suggest at once that nutritional stimuli may be an important factor in determining the dominance of type of bacteria. It is probable that the significance of the intestinal flora lies rather in its potential antagonism to alien bacteria, which certainly gain entrance to the alimentary canal from time to time, than in any specific participation in the normal digestive process of the host. The normal intestinal flora may be regarded as intes- tinal parasites, just as the various bacteria which occur commonly on the skin are regarded as cutaneous para- sites. It is important to realize that the normal intestinal organisms, like the cutaneous organisms, are "oppor- tunists," potentially capable of becoming invasive when- ever the barriers which ordinarily --suffice to limit their development to the lumen of the alimentary canal become impaired, giving rise to endogenous infections. BACTERIA OF THE DIGESTIVE TRACT. 29 5. Influence of the Diet on the Intestinal Flora. Intestinal flora varies greatly, the most important fac- tor in determining its nature being the chemical compo,si- tion of the food. Human milk gives essentially different flora from cow's milk. There are two groups of bacteria possessing an antagonistic action, those causing fermen- tation (saccharolytic), and those causing putrefaction (proteolytic). The representatives of the former are Bac- illus lactis aerogenes and Bacillus bifidus, the latter being the most important organism in the stool of the breast-fed infants. The group exercising proteolytic activity is less clear. We know only that in the processes of putrefac- tion the bifidus flora is replaced by the coli group. De- pending on the predominating group of bacteria, putre- faction or fermentation takes place, causing either firm or soft stools, this rather than the activity of the ferments determining the nature of the stools. The nature of the food and its chemical composition, therefore, determines the nature of the development and activity of the par- ticular bacteria in the intestinal tract. =The human milk, rich in sugar and low in protein, leads to the flora of fermentation, while cow's milk, rich in protein and poor in sugar, to the flora of putrefaction. This phenomenon is nothing specific, but is due to in- dividual components of the milk and their mixture. Carbohydrates lead to the development of the fermen- tative organisms ; the split products of carbohydrates are acetic, butyric, lactic and carbonic acids. The nature of the dominant organisms which develop in diets rich in carbohydrates varies with the carbohy- drate itself. Bacillus bifidus is more commonly predom- inant when lactose is the sugar fed, without an excess of 30 INFAXT FEEDING. protein. If maltose or dextrose is substituted for lactose under the same conditions, Bacillus acidophilus is very frequently the more prominent. •The fermentative action is increased by sodium and potassium salts as found in whey. (This latter probably in part explains the results obtained in feeding malt sugars together with potassium carbonate.) Proteins favor the development of the organisms of putrefaction and lead to formation of indol, skatol, and amino-acids, these being the products of aromatic and fatty series. Gases are also formed by the latter action. The nature of the protein influences the types of pro- teolytic bacteria to a very marked degree. In general, animal proteins other than casein appear to encourage somewhat more active proteolytic flora than vegetable proteins. The processes of putrefaction are favored by calcium salts. The influence of fat in its relation to bacterial proc- esses is not clear. It seems to be able to favor fermenta- tion, if this be already present, and also to increase the intensity of the processes of putrefaction. In breast feeding fermentation outweighs putrefaction. The question whether fermentation or putrefaction in the intestinal canal is desirable, must be answered a priori that the fermentative processes are physiological, since breast feeding always leads to this. By this it must not be understood that the putrefaction in artificial feeding causes injury. Excessive intestinal fermentation in ar- tificial feeding may be the forerunner of disaster, and is to be avoided (dyspepsia, intoxication). Within certain limits, we are able to influence the bac- terial processes in the intestinal tract in the normal infant, BACTERIA OF THE DIGESTIVE TRACT. 31 and thereby change the character of the feces. In a sick infant this is more difficult, and larger quantities of putrefacient food are necessary to overcome pathological fermentation. 6. Intestinal Bacteria in Their Relation to Gastro- intestinal Disturbances. There are many intestinal disturbances of unknown causation, presumably unrelated to bacterial activity. There is a second group of conditions in w^hich bacteria may conceivably play a secondary part; in some of the latter abnormal physiological conditions in the alimentary canal may be justly regarded as the antecedent factors. The boundaries of these two groups are poorly circum- scribed, and they merge through imperceptible or poorly defined limits into a third group of cases in which the activities of endogenous or exogenous bacteria in the alimentary canal may be the causative factor in morbid processes of the gastro-intestinal tract. The symptomatology induced from the products aris- ing from the decomposition of proteins or protein deriva- tives by the action of bacteria in the intestinal tract de- pends largely upon the organism or organisms concerned. It varies from the somewhat insidious, slowly progress- ing, so-called autointoxication, in which a marked in- crease of urinary ethereal sulphates may be a suggestive index, to the acute toxemias characteristic of bacillary dysentery, typhoid, paratyphoid or cholera. Of course, a variety of other bacteria than the few mentioned speci- fically may be concerned, either alone or in symbiosis. Thus streptococci alone, and streptococci in association with dysentery bacilli, may be justly regarded as the etiol- o^ INFANT FEEDING. ogical agents in their respective syndromes. The im- portant factor, from the viewpoint of this discussion, is to reaHze that the formation of nitrogenous products from proteins or protein derivatives, which are being utilized by various types of intestinal bacteria for energy, may be injurious to the host. The other prominent type of abnormal bacterial activ- ity in the alimentary canal — the fermentative type — is of entirely different origin. The essential factor is either a fermentation of carbohydrates, with the formation of products abnormal for the intestine, or of excess of nor- mal fermentative products. The factors leading to an overgrowth of these organisms in the intestinal tract appear to be an excess of carbohydrate and a lack of normal lactic-acid-forming bacteria. It is unfortunate that practically none of the bacteria which incite intestinal disturbances or illnesses produce soluble toxins against which antitoxins can be prepared. Sera likewise have been unsatisfactory. There is little, therefore, that can be accomplished serologically with the present methods in the treatment of intestinal disturb- ances of bacterial causation. Attempts to permanently eliminate or destroy undesirable bacteria with cathartics and intestinal antiseptics have not been productive of re- sults in the past, and prolonged starvation per se does not lead to intestinal sterility or to a significant reduction in the offending bacteria. There are two ways, however, in which direct influ- ence may be applied to bacteria in the intestinal tract : by substituting harmless types of organisms for abnormal types, and by varying the diet of the host in such a man- ner that the intestinal contents at the desired level shall contain nutritive substances that may be reasonably ex- BACTERIA OF THE DIGESTIVE TRACT. 33 pected to shift the metabolism of the offending organism, and therefore radically change the character of the products of its metabolism. Diseases Due to Proteolytic Activity of Bacteria. There are a number of conditions of bacterial causation in which available evidence points strongly to the forma- tion of products arising from the metabolism of protein or protein derivatives by specific organism as important etiological factors in the morbid process. Thus, cholera, bacillary dysentery, typhoid, paratyphoid, and many less acute infections are associated definitely with the de- velopment of these organisms within the body, and to some degree at least, at the expense of the body tissues. Available evidence points strongly to the view that cholera vibrios, typhoid, dysentery and paratyphoid bacilli and similar organisms produce their characteristic and harmful effects when they are developing in media free from utilizable carbohydrates ; when utilizable carbohy- drates are added to these media, non-characteristic, harm- less products are formed. In the absence of any definite indication to the con- trary, it would be logical to attempt to maintain a suffi- cient concentration of carbohydrates within the intestinal canal in these infections ag a therapeutic measure. The important effects to be accomplished by a liberal carbohydrate diet in those infections where the decom- position of proteins or protein derivatives by bacterial activity leads to chronic or acute illness of intestinal origin are : a change in the metabolism of the offending organism resulting in the formation of lactic and other acids in them in place of putrefactive products, and a gradual replacement of the proteolytic and pathogenic types by bacteria of the fermentative varieties. 34 INFANT FEEDING. Diseases Due to Excessive Fermentation of Carbohy- drates. Another type of intestinal disturbances depends upon an unusual or an excessive fermentation of carbo- hydrates. This is frequently seen in young infants, in many of whom we have a limited carbohydrate tolerance. (See Nutritional Disturbances.) Part II. The Nursing. CHAPTER I. GENERAL CONSIDERATIONS. Writers on this subject are very prone to state that the abiHty of the mother, particularly among the well-to- do, to fulfil this most important function is decreasing. This may have been a true statement fifteen or twenty years ago. At the present time, however, we are sure it is erroneous. The young mother of to-day is better able to nurse her offspring than was her sister fifteen or twenty years ago. We attribute this to the fact that the youth of the present day are more vigorous, more nearly normal individuals, than were those of an earlier date. Breast-milk during the first two or three weeks of the infant's life is produced under unfavorable conditions, which do not indicate the possiblities of the breast as a secreting organ. Early nursing, following as it does upon the stress of confinement, is not indicative of what may be possible later, when the customary life and daily habits are resumed. Repeatedly we have found a very high fat or a high protein, or both, entirely corrected after the first week or two without interference. This condition at the time was considered sufficiently serious to warrant the discontinuance of nursing on the part of a weakly infant, while in a vigorous infant it would be entirely ignored. A neurotic mother makes the poorest (35) 36 INFANT FEEDING. possible milk-producer. Proportionate to the popula- tion, there are fewer neurasthenics among the young women to-day than there were twenty years ago, and there will be still fewer twenty years hence. At the present time the timid, retiring young woman of the neurasthenic type is not popular in her set. Few functions with w^hich we have to deal are so variable and uncertain as the production of breast milk. Breast milk is one of the most precious substances. It is invaluable, unless we can put value on human life. The most successful nursing age is between the twentieth and thirty-fifth year. Some mothers will be able to carry on the nursing for only two months, others three, five, seven, or nine months. In our experience in both out-patient and in private practice it is extremely rare for the breast milk to be sufficient for the infant after the ninth month. It should be remembered that besides the protein, fat, carbohydrate, salts and water content there are other bodies contained in human milk, which, even though not essential to the infant's life, are of inestimable value to it. These may be divided into two groups : 1. Immunizing bodies — antitoxins, alexins, etc. — which are contained in the mother's blood, and trans- mitted to the baby through her milk. They are of value in protecting the infant against infections. 2. Ferments : lipase, galactase, lactokinase, and dias- tase. Examination of Human Milk. This is rarely of any practical value. The protein rarely causes trouble, and the sugar is usually constant (6 to 7 per cent.). The examination of milk is therefore usually restricted to a determination of the fat content by means of the lacto- GENERAL CONSIDERATIONS. 37 meter. The richest milk, however, will usually agree with the baby, and it is apt to thrive equally well on a milk that shows a small amount of fat. In other words, the baby and not the lactometer is the only practical test. If the milk disagrees, it will be evident clinically. No baby should ever be deprived of its mothei'^s milk only because of the results of a clinical examination of the milk. In making an examination of the mother's milk one must bear in mind that the first milk is very poor, the last very rich in fat, and that an average specimen can be obtained only by mixing the whole amount, or by combining the first and the last, or, better still, by taking only the middle portion after a few drams have been drawn off. This can be accomplished by allowing the in- fant to nurse for two minutes before expressing the sample. Contraindications to Nursing. Tuberculosis when progressive or open is always a contraindication to nurs- ing, because of the danger to the infant and the strain on the mother. With proper precautions, and where the breast is not diseased, and human milk is not obtainable from other sources, it may be well to tide a weak infant over its first weeks by expressing the milk from the mother's breast. Syphilis of the mother, except in freedom from infec- tion on the part of the infant, is not a contraindication. Lack of symptoms on the part of the mother in congeni- tal syphilis is a very common occurrence ; a Wassermann reaction on the mother's blood will quickly clear up any doubt. Any grave constitutional disease in which there is an extraordinary drain on the resources of the body (dia- 38 INFANT FEEDING. betes, heart disease with disturbed compensation, neph- ritis, Basedow's disease, maUgnant neoplasms, epilepsy and psychoses) are contraindications to nursing. Acute diseases should only in exceptional cases be con- sidered as contraindications to nursing, and should in- clude conditions in which there is danger of overburden- ing the mother and infections endangering the infant. CHAPTER II. MATERNAL NURSING. 1. Nursing Axioms. The following may be laid down as nursing axioms : A diet similar to what the mother was accustomed to before the advent of motherhood should be taken. There should be one bowel evacuation daily. From three to four hours daily should be spent in the open air in exercise which does not fatigue. At least eight hours out of every twenty-four should be given to sleep. There should be absolute regularity in nursing. There should be no worry and no excitement. The mother should be temperate in all things. 2. Hygiene of the Mother. The Diet of the Mother. Many times, when con- sulted by nursing mothers because the nursing was un- successful or a partial failure, we have found that their diet had been restricted to an extreme degree. To put on a greatly restricted diet a robust young mother who has always eaten bountifully of a generous variety of foods is one of the best means of curtailing the quantity and lowering the quality of her milk supply. When asked to prescribe a diet, we tell such mothers to eat as they were accustomed to before the advent of pregnancy and motherhood. That this particular vegetable or that particular fruit should be forbidden on general prin- ciples is a fallacy. Food that the patient can digest with- (39) 40 INFANT FEEDING. out inconvenience is a safe food so far as the nursing is concerned, as may readily be determined in any given case. For certain individuals, however, a plain, more or less restricted diet is desirable. This must be remem- bered in the management of the wet-nurse (to be de- tailed later). Nursing is a perfectly normal function, and a woman should be permitted to carry it out along the natural lines. Inasmuch as there are two lives to be provided for instead of one, more food, particularly of a liquid character, may be taken than the mother may be accus- tomed to. It is our custom to advise that milk be given freely. A glass of milk may be taken in the middle of the afternoon, and 8 ounces of milk with 8 ounces of oatmeal or cornmeal gruel at bedtime, if it does not dis- agree with the mother. Our only evidence that a food is disagreeing is the condition of the digestion. When any article of food disagrees with the mother, or if she is convinced that it disagrees, whether or not such be really the case, the food should be discontinued. In a general way, milk (one quart daily), eggs, meat, fish, poultry, cereals, fresh vegetables and fruits constitute a basis for selection. Although occasionally mother can- not take acid fruits, salads and aromatic vegetables, they may be tried and discarded, if they disturb the infant. Eggnogs, thin cereal gruels mixed with milk, cocoa and malted milk and similar drinks can often be taken to advantage between meals. The Bowel Function. A very important and often neglected matter in relation to nursing is the condition of the bowels. There must be one free evacuation daily. For the treatment of constipation in nursing women we have used different methods in many cases. The dietetic MATERNAL NURSING. 41 treatment and plenty of recreation and exercise promise most. Manipulation of the diet should not be such as to interfere with the milk production. Three other methods are open to use : massage, local measures and drugs. Massage is available in comparatively few cases. Local measures consist in the use of enemas and sup- positories. Every nursing woman under our care is in- structed to use an enema at bedtime, if no evacuation of the bowels has taken place during the previous twenty- four hours. For a laxative in such cases and in many others, a capsule of the following composition has served well: I^ Extract! nucis vomicce 0.015 Gm. (J4 gr.). Extract! cascarse sagradse 0.325 Gm. (v gr.). Sig. : To be taken at bedtime. The amount of the cascara sagrada may be varied as the case may require. In not a few instances we have found it necessary to give 2 capsules a day in order to produce the desired result. Neither the nux vomica nor the cascara appears to have any appreciable efifect on the child. Air and Exercise. Outdoor life and exercise are not only as desirable here as they are under all other con- ditions, but to the nursing woman, with her added re- sponsibility, they are doubly valuable. In order to get the best results, exercise or work should be so adjusted as not to reach the point of fatigue. The mother whose nights are disturbed should be given the benefit of a midday rest of an hour or two. It should be our duty, however, to explain to the mother and to other members of the family that an important element in satisfactory nursing is a tranquil mind. 42 INFANT FEEDING. Care of the Breasts. A well established routine should be instituted for the care of the breasts. To facilitate this a readily accessible tray with the necessary utensils should be provided. This should contain a glass-stop- pered bottle with a saturated solution of boric acid, a jar of cotton pledgets on toothpicks, to be used as appli- cators for the boric acid, a graduated glass or beaker. The nipples should be thoroughly washed before and after nursing with a saturated solution of boric acid poured fresh from the bottle for each cleansing, and the surplus thrown away. The boric acid should be applied with the cotton pledgets. The fingers should not come in contact with the nipples, if the child is to nurse directly at the breast. If the nipples are tender, they should be annointed with a sterile mixture of 5 per cent, tincture of benzoin in liquid vaseline. All utensils, including the breast-pump, if one is in use, should be sterilized by boiHng. In case of the breast- pump, the rubber bulb may be removed for this purpose. Where the milk is to be expressed by hand, the hands must be thoroughly disinfected by washing with soap and water, and rinsing with alcohol before manipulation of the breasts. Under all conditions soap and water should be freely accessible, and their use required before handhng the breast or the infant. 3. Conditions Influencing the Breast Milk. The advent of the first menstruation period particu- Tarly, and in some cases the beginning of every men- struation period, is attended with an attack of colic or indigestion in the child. Such attacks, however, rarely necessitate the discontinuance of the nursing even for MATERNAL NURSING. 43 a single day. Not infrequently the quantity of milk is somewhat lessened during menstruation, and this will re- sult in the infant becoming fretful, due to insufficient quantity of the feeding. Under no circumstances should menstruation be considered an indication for weaning. Factors influencing the mental condition of the mother, such as anger, fright, worry, shock, distress, sorrow, or the witnessing of an accident may affect the milk secre- tion sufficiently to cause no little discomfort to the child, and oftentimes the lessening of the flow for a day or two. At times, especially when the mother is under in- fluence of shock or grief, it may be necessary to substi- tute artificial feeding for a few nursings during these periods, until the mother has again resumed her mental equilibrium, her breast being emptied by mechanical means in the meantime. Drugs, alkaloids of opium, hyoscyamus, belladonna, and similar drugs, when given in large quantities, not in- frequently pass into the milk, and should therefore never be administered in large quantities to the nursing mother. Belladonna may cause a decrease in milk secretion, and should be administered with caution during the period of lactation. Mercury, iodides and the newer salts of ar- senic are also secreted in the milk, and may be used to advantage when a luetic mother is nursing a luetic infant. 4. The Nursing Proper. Regularity in Nursing. The breast which is emptied at definite intervals invariably functionates better than does one which is not, not only as regards the quantity, but also the quality, of the milk, thus regular habits in breast-feeding are as essential to milk production as to 44 INFANT FEEDING. its digestion and assimilation. The baby should be wakened to be fed. The average mother will supply the needs of the in- dividual meal with one breast, and the breasts should be alternated in successive feedings. Thorough emptying of the breast should be encouraged under all circum- stances, as this is our best method for increasing the milk supply, and the baby is the only means at hand by which this can be accomplished. This should be en- couraged in every instance. It is most readily thwarted by allowing a lazy baby to partially empty both breasts, and will soon lead to a diminished milk secretion. By this means the mother and the baby soon become adapted to one another, and it will be found that the desired effect is accompHshed both where the milk supply is insuffi- cient or, again, excessive. In the former instance com- plete emptying of the breasts increases the secretion, and, where excessive, incomplete emptying will soon result in a lessened supply. Sometimes, however, it is advisable to give both breasts at each feeding, i.e., under the following conditions: (1) During the first few days, to stimulate secretion, and a little later to relieve the congested breasts; (2) to weak babies when there is an abundance of milk, and they are not strong enough to get the last milk that comes harder ; (3) to overfed babies, where it is desirable to give them only the first and weakest milk, and to lessen the yield of the milk from the breast ; (4) as the milk supplied by one breast fails to meet the needs of the infant, both breasts should be given at each nursing; the first breast should be thoroughly emptied before allowing the baby to take the second breast, and the next nursing started on the second breast given in the last feeding. MATERNAL NURSING. 45 Number of Feedings in Twenty-four Hours. Four- hour intervals at start with six feedings in twenty-four hours, five feedings by the second to the fifth month, ac- cording to the individual needs of the child. Night nursing can often be discontinued by this time, and babies properly fed will go from 10 p.m. to 6 a.m. with- out anything but perhaps a drink of water. Premature and delicate infants and infants with a tendency to vomit are exceptions, and must be fed smaller amounts at more frequent intervals. Length of Nursing. As a rule, a robust baby takes three-fourths of the milk obtained from a good breast in the first five minutes of a twenty-minute nursing. Fifteen to twenty minutes should be the limit for the nursing period. If a baby is doing well on shorter periods, and seems satisfied, let it be its own judge of the nursing time. Weak and lazy babies may require awakening during the nursing period to keep them at work. Very weak babies may require a longer period, with short intervals, in which they rest. Giving of Water. From ^ to 1 ounce of a 1 per cent, solution of cane or milk sugar should be given the infant every three or four hours until the milk appears in the breast. Otherwise there will be unnecessary loss of weight and perhaps a high degree of fever due to inani- tion. A high temperature during the first days of life is more commonly due to ''inanition'' than infection in present-day obstetrics. The best differential test is ad- ministration of water or sugar-water at regular intervals. In a case of inanition plenty of fluid intake results in a critical drop in the temperature. If the child is restless and uncomfortable, it is safe to conclude that it is thirsty. One ounce of the sugar-water 46 INFANT FEEDING. will usually satisfy it. With the commencement of nurs- ing, the baby should be accustomed to getting the food at regular intervals. Even when milk is plentiful, the administration of water, two or three times daily, from a nursing bottle accustoms the baby to taking the food in this way. This makes weaning more easy in case of emergency. CHAPTER III. WET-NURSING. 1. The Wet-nurse: Her Selection and Her Baby. The Problem. When there is a positive inabiUty on the part of the mother to nurse her offspring, either through improper development on the part of the breast or sys- temic disease, we are confronted with the problem of securing human milk from another source, as notwith- standing the numerous reports on successful raising of infants on artificial foods, the statistics of infants fed by artificial foods when compared with those of infants fed on human milk are so strikingly in favor of the latter that the obtaining of human milk must always be con- sidered as an important issue. How Obtained. In our experience, even in a large city, great difficulty has been met in obtaining a regular supply of wet-nurses. On several occasions various charitable and hospital societies have attempted to estab- lish a wet-nurses' registry as a clearing-house for the several maternity and general hospitals of Chicago. These attempts have not been successful for two reasons : (1) because of the irregularity in the demand, and (2) because of the lack of co-operation on the part of the various institutions caring for this class of cases. The Nationality of the Wet-nurse is of considerable significance where the supply allows of a selection. The phlegmatic temperaments as seen in women of Northern and Central Europe of Teutonic and Slavic descent, offer the ideal material, while other nationalities, such as Italians, and the Southern negroes when removed from (47) 48 INFANT FEEDING. their home environment to a Northern dimate, secrete a milk poor in quahty. However, even the latter in an emergency should not be neglected. Requirements of a Good Wet-nurse. 1. She should be in good health, and, especially, free from all con- tagious and infectious diseases, and also from local dis- eases of any kind, such as those involving the nose, throat, skin, etc. 2. Her mammary glands should be of such quality that she can secrete sufficient milk of good quality, and the nipples sufficiently developed to allow of nursing, or proper expression of the milk. 3. Whenever possible, her age should be not less than 18 and not more than 35 years. 4. The age of her baby, as compared with that of the baby she is to nurse, is a matter of indiiTerehce in most instances. However, the first weeks, or if possible the first two months, of lactation should be avoided, because of the presence of colostrum and the rapidly changing quality of the breast milk, which not infrequently causes serious gastric and intestinal disturbances in very suscep- tible infants, as evidenced by vomiting, colic and diar- rhea. Multiparity may be considered an asset, if the nurse has demonstrated her ability to care for and feed previous cases. A multipara is also less likely to be affected by her new surroundings, especially if this be a private home. When the wet-nurse has more or less direct charge of the infant, one wdio has been nursing her own or other infants w411 be more likely to meet the technical difficulties in the care of her charge. Examination of the Wet-nurse. The examination of the wet-nurse should always be made in a systematic manner to insure against overlooking important things. WET-NURSING. 49 First, a careful history should be taken as to the num- ber of her children, miscarriages, and the presence of constitutional diseases in her family. Second, she should be thoroughly examined, all parts of the body being exposed, and the examination should include the skin and hairy parts of the body for the pres- ence of skin lesions and parasites, as well as for old luetic scars. The organs of the chest and abdomen should be subjected to careful examination. Third, the breasts should be examined. Fourth, the genitalia, including the cervix and the urethra, and in all cases a cervical (and where sus- picious, a urethral) smear should be taken and exam- ined for gonococci. As a single smear is often mislead- ing, in cases of the slightest suspicion, where a girl baby is to be nursed, the examination of the cervical and urethral smears should be repeated. • Fifth, an examination and search" should be made for chronic infections', especially for syphilis. A Wasser- mann test should be made in every case, and reported upon before she is allowed to supply milk, as it is well known that a syphilitic mother in a very great number of cases shows no clinical evidence of syphilis. The mouth and pharynx, neck, anus and genitalia, entire skin and lymphatic glands should also be examined for evi- dence of syphilitic lesions. Tuberculosis. The lungs, glands, and osseous system should be examined, and a careful history as to suscep- tibility to colds and to recurring bronchitis elicited. Sixth. Acute infections. She should be questioned as to exposure to contagious disease, and she should be ex- amined for evidence of acute infections of the nose, throat, and ears. 4 50 IXFAXT FEEDING. Seventh. Her teeth should be examined and defects and pyorrhea corrected, if necessary, at the expense of the family. Eighth. The urine should be examined (1) for evi- dence of nephritis, (2) for evidence of diabetes. It should, however, be remembered that a positive reaction for sugar should not be overestimated, unless the sugar is proven to be dextrose, as very commonly in our ex- perience during the early weeks of lactation a lactosuria is present. The kind of sugar can easily be determined by the phenylhydrazine test, followed by a microscopical examination of the crystals. Ninth. Nervous and psychic disturbances, such as epilepsy, insanity, hysteria, should, if found, by all means exclude the subject. Tenth. Her child should be examined for evidence of syphilis. Possibly one of the best arguments for the non-employment of a wet-nurse during the first two months of her lactation is the possibility of a latent syphilis. Where there is the slightest doubt, a Wasser- mann reaction should be made on the infant. The gen- eral condition of the child gives us the best evidence both as to the quantity and to the quality of the maternal milk. Unless the source of the nurse be known, it is well to be certain that she is nursing her own baby. In case of its death or its absence, every effort should be made to obtain its condition at birth and its later development. So far as possible she should not be subjected to an- noying questioning on the part of the family, which is entirely unnecessary, if she has been properly examined by the physician. It has been our experience that such unnecessary questioning has led to nervousness, and not WET-NURSING. 51 infrequently has caused her to decline the position, at a time when she was most needed. Her Place in the Household. She should be treated neither as a guest nor as a menial, but so far as possible should be graded according to her previous station in life. There is a grave danger of mental depression on the part of a woman, well-born and sensitive, who, through misfortune or necessity, is forced to seek this means of employment, and also of an exaggerated estimate of self-importance on the part of a woman but little accus- tomed to the luxuries of life upon her entrance into the home of employment, particularly if attentions are paid to her. As has been previously stated, all instructions and demands should be made by the person best qualified in the individual case. A divided responsibility will always lead to future complications. Her quarters should be well located ; their ventila- tion should be supervised, and she should be held re- sponsible for their general cleanliness. The wet-nurse's baby should always be kept in the room with her, so that she may feel the full responsibility for its health and care. The Quantity of Milk to be Expected from a Good Wet-nurse. The quantity and quality of milk supplied must vary greatly with the glandular development of the individual wet-nurse, the state of her health, and the factors quoted elsewhere which would affect it tempor- arily. The amount and variety of stimulation applied to the breasts, of which the direct n#rsing by a full-term infant is the most valuable (at least for the purpose of stripping the breasts), must be given due consideration. In view of the many emergencies and influencing factors, no absolute standard for quantity and quality can be set for general rule. 52 INFANT FEEDING. A wet-nurse who does not secrete sufficient milk dur- ing the first few days in her new employment should not be discharged until every effort has been made to im- prove her milk production. Frequently the change in environment is sufficient to reduce it temporarily. Cost of Milk. The wet-nurses in Sarah Morris Hos- pital receive their board and room and $8.00 per week. Figuring the former at $5.00 per week, this would total a cost to the institution of $13.00 per week for each nurse. With an average of 30 to 40 ounces of milk per nurse daily, or 210 to 300 ounces per week, the average cost will be about 4.25 to 6.5 cents per ounce, or approxi- mately $1.35 to $2.00 per quart. When milk is dispensed to patients outside of the hos- pital, a charge of 10 cents an ounce is made for it, which is a reasonable price when all of the contending factors are taken into consideration. Number of Nurses Needed. Each good wet-nurse can care for the needs of about two infants, depending upon their weight and development. Length of Lactation. Xo time-limit is placed upon the employment of a wet-nurse as long- as the quality and quantity of her milk is sustained, and she continues in good health. One of our nurses has an infant now thir- teen months old. Such long periods of lactation, how- ever, as a whole are not to be advised. The Wet-nurse's Baby. The presence of the w^et- nurse's baby predisposes to her peace of mind, and wherever possible, she should take it with her. Her baby's state of health is by all means the best indication as to her ability as a nurse, and, with this, the presence of constitutional disease in herself. It may be of im- mense value, if the baby is strong and healthy, to keep WET-NURSING. 53 up the flow of milk, in case the baby to be nursed is a 'weakhng. It may also be used to estimate the functional capacity of a wet-nurse by nursing at regular intervals, and weighing before and after the nursing for twenty- four-hour periods. If in perfect health, it may be put to the breast, after the weakling has taken such milk as it has strength to draw. If this is not practicable, then the weakling should be nursed alternately with the well baby on each breast. It is also of immense value in emptying the breast after the wet-nurse has removed ae much milk as it is possible by expression or by the breast- pump, if this is the means of drawing the milk for the weakling. It is a well-known fact in all institutions where wet-nurses are used, that the greater the degree to which the breasts are stimulated by suckling infants, the greater will be the reward in production. If the milk is insufficient for both babies, partial or entire meals of artificial food may be substituted for the wet-nurse's infant. At the first sign of an acute illness on the part of the wet-nurse's baby, it should be separated entirely from the other baby, and removed from the breast ; its illness should be given the same serious consideration as that of the other infant, so that the mother's anxiety may be re- lieved. It should receive as much of its mother's milk as can be spared. This can be expressed from the breasts and fed from a bottle. Feeding of the Wet-nurse's Baby. When a single infant is to be nursed, the second baby is often a neces- sity in the promotion of the development and stimulation of her breasts. No breast can be developed to its fullest capacity with the breast-pump or hand expressions. It is a well-known fact that the breasts will respond in pro- 54 IXFAXT FEEDING. portion to the demand placed upon then, and in most instances during the first few weeks of the premature's Hfe, when its demands are met by from 4 to 16 ounces of milk, the wet-nurse can supply sufficient milk for both babies. When her supply becomes insufficient to meet the demands, her baby can be put upon partial bottle feedings of the strength as indicated by its age and de- velopment. The progress of the wet-nurse's baby has great influence on her peace of mind, which may spell success or failure in her ability to carry out her work. When the premature infant gives evidence of sufficient strength to be placed upon the breast, we have found the application of the wet-nurse's baby to the other breast a very valuable expedient in aiding the flow of milk into the breast which is to be nursed by the weakling. In many instances we have seen the milk flow from the second breast by this method so freely that but very little efl^ort was required on the part of the weakling to obtain its food. 2. The Hygiene of the Wet-nurse. ■ In general, everything that has been said in the chap- ter on hygiene of the nursing mother applies also to the wet-nurse — of course, with the proper modifications, made necessary by peculiarities of her position. Her clothes should be simple, and in every part washable. As the care of her undergarments is of even greater importance than her outer clothing, it is well that her laundry should be done with the family work, so that the famil}^ laundress who is trusted by the family may be charged with its inspection. To simplify nursing or the drawing of milk, the author has devised two garments for wet-nurses. The WET-NURSING. 55 material used for the outer garment is of yellow gingham, such as is used in the making of hospital uniforms, the yellow color being selected to distinguish the wet-nurse from the blue, as used by the nursing corps. The cor- set-waist is to be made of heavy muslin. The corset, if worn at all, should be of a very low type, so as to avoid all pressure on the breasts. It is best of a cheap quality, so that it can be replaced frequently for sanitary reasons. Each wet-nurse should be supplied with four uniforms and six nursing corset-waists. The Diet of the Wet-nurse. There is danger of the creation of indolent habits through neglect of regular exercise and the lack of regular household duties, but even greater danger lies in the direction of overfeeding with unusual foods. The average wet-nurse is either ob- tained from an institution or a home in which the lux- uries of life are limited, and she has been accustomed to a simple nutritious diet. Every attempt should be made to supply the nursing woman with a well-rounded diet of simple foods, with milk and cereals as the basis, and these supplemented with meats, soups, the common vege- tables, limited amounts of fruits and plain desserts. In so far as possible, the aromatic vegetables, unripe and highly acid fruits, fried meats, and rich pastries are to be avoided. We believe that, on the whole, too great stress has been laid upon the danger of the diet in the mother of a full-term infant, and in most cases the average mother can partake of a very full diet. However, in the case of the woman nursing premature infants, it should become a custom to allow only such foods during the first few days after her installation as can be given with perfect impunity. When a full, free flow of milk is established, other vegetables and fruits can be added, 56 INFANT FEEDING. one at a time, and after each addition to the diet a try- out should be given the milk. We have on numerous occasions seen marked intestinal distention and diarrheal attacks following even seemingly slight indiscretions of the diet on the part of the wet-nurse. It is our hospital practice to furnish each wet-nurse with two quarts of good wholesome milk daily, and at least one pint of cereal gruel, preferably farina or corn-meal. A mixture of milk and cereal gruels makes a very good combination for drinking midway between meals. The remainder of the milk may be taken with the meals, either pure or in the form of cocoa, tea, or weak coffee, in whichever form it is best taken by the individual woman. The latter is of considerable importance, as in the forced diets which are required, where an abundance of milk is demanded, dis- tasteful foods soon become obnoxious in large quan- tities. Beers, malt-extracts, and other rich drinks are not forced upon the nurse, unless she is accustomed to them, and feels their need. It must always be remembered that an excess of fluids would naturally tend to dilute the milk unless the secreting gland be of exceptional develop- ment. Exercise of the Wet-nurse and Her Work. She should be impressed before her engagement with the fact that she will be required to do a moderate amount of work and exercise regularly out of doors. The former will be of service in promoting her general health, and both the work and the exercise will serve as a nerve tonic and prevent her becomnng indolent. This does not mean that she should become a drudge, but that she should at least be required to care for her own room and her own infant's clothes, and should be made to feel that in re- WET-NURSING; 57 turn for her laundry work she would be requested to do some light general work about the house. Her exercise in the open air should so far as possible be at regular times. The question as to the care of the napkins of both babies is open to considerable discussion ; and it may be stated that whenever it becomes necessary for the nurse to express her milk by hand, she should not be subjected to the handling of soiled napkins, whenever this can be averted. Other Conditions Influencing the Quality of the Breast Milk. The nervous and mental state of the nurse is of the utmost importance, and wherever possible an emotional, nervous, erratic v^oman should be excluded, because of the tendency of these influences to suppress the flow of milk. Therefore, whenever possible, a woman of more or less phlegmatic temperament is to be selected. This is especially true in the case of a woman who is to be in close contact with and is to nurse an infant with neu- rotic tendencies. There is also the possibility of the same influence being manifest in time of slight indisposition on the part of her own infant, and such an individual is also more likely to resent the necessity of partial or en- tire artificial feeding of her own child to the advantage of the premature infant, when it has reached such an age when it may make greater demands on her supply. Menstruation rarely produces any serious disturb- ances. It is always a safe procedure to dilute the milk during the first and the second day of menstruation when the nurse suffers considerable pain at these times. Period of lactation may or may not be a considerable factor, depending upon the individual woman. At the 58 INFANT FEEDING. present writing we have in our employ a nurse who has been with the institution for sixteen and a half months, and whose infant is eighteen months old, and who is sup- plying us with the largest quantity and the best quality of milk of the four nurses in the institution.* When possible a nurse should be selected after the first few weeks of lactation, at which time the colostrum has disappeared from the milk, and the quantity and quality of her milk has become established. After the first few weeks of lac- tation, but little or no attention is to be paid to the age of the wet-nurse's baby as compared with that of the infant to be fed, and we have never noted any ill effects following this rule. 3. The Nursing. The Infant's Bedroom. Under ideal circumstances, this should be separated from that of the wet-nurse. This is especially true where a trained attendant has care of the infant. It should under all circumstances also be separated from the wet-nurse when she is of a low de- gree of intelligence and of a type not to be trusted with the care of the infant. * The milk of this nurse was examined in the laboratories of the University of Chicago after seventeen months of lactation with the following result : Protein 1.98 per cent. Casein 0.69 Fat 3.54 " " Lactose 7.025 " " Salts ; 0.1885 " " It must be remembered that this is an exceptional case, and but few women under the stress of ordinary life can properly nurse their infants after the ninth to twelfth month. WET-NURSING. 59 Methods of Drawing Milk. Numerous methods of obtaining milk from the breasts have been described, but only those most practicable of . application will be de- tailed. These should be divided, first, into those in which the baby is placed directly at the breast, and those meth- Fig. 1. — Proper method of holding baby during nursing. ods by which the milk is drawn from the breasts and fed to the infant. Two methods are especially applicable where the baby is fed directly on the breast, and needs assistance because of its weakness. 1. Premature infant is placed at the breast, and is supported there by the nurse's right arm while nursing at the right breast, and the left hand is used to grasp the breast just above the nipple between two fingers (see 60 INFANT FEEDING. p. 59), and the milk is expressed directly into the baby's mouth. In this way the baby is taught to take the breast, and at the same time receives its food with little effort. This method can be continued until the baby has gained sufficient strength to nurse without assistance. 2. Much of the same result can be accomplished by placing the wet-nurse's baby on the opposite breast dur- ing the nursing period, whereupon the simultaneous nurs- Fig. 2. — Author's improved breast milk collector. The pump is made in two types, the first filled with a large rub- ber bulb of a size considerably larger than is ordinarily sold with a breast-pump, and the second with an attach- ment to which the Holz vacuum pump can be fitted. In place of the ordinary collecting bulb at the lower surface, an arm is so constructed as to allow the milk to drain into specially designed graduated 2-ounce milk flasks. ing on both breasts will cause a free flow of milk into both sides. In those methods by which the milk is drawn from the breasts and fed to the infant by hand or by other means. 1. By the breast-pump. The modification of Holz vacuum apparatus, as devised by the author, by which WET-NURSING. 61 means the milk is drawn directly into two graduated 2- ounce flasks, which can be filled to the quantity desired, and stoppered for future use, so that the milk is free from handling, and thereby avoid contamination. Fig. 3. — Direct expression of milk (act 1). Glass grad- uate is held against breast one inch to one inch and a-half back of the nipple, and held in position by the bent fore- finger of the left hand. Thq left thumb gently grasps the upper part of the breast about one inch behind the nipple. The thumb of the left hand gently compresses the breast against the side of the glass with a gentle sweeping move- ment. This is repeated 40 to 60 times per minute. 2. By direct expression, which is performed as fol- lows : A graduated glass is held against the underside of 62 INFANT FEEDING. the lower inch of the breast and nipple by the index and middle finger and a downward sweeping stroke is used to compress the corresponding part of the breast and the nipple against the side of the glass receptacle. The ves- sel can be supported with the other hand. By this means, Fig. 4. — Direct expression of milk (act 2), following a little practice, the nurse can express from 6 to 8 ounces of milk from two good breasts in fifteen to twenty minutes. While drawing, each 2 ounces of milk is poured directly into sterile, stoppered bottles, to prevent the fingers of the nurse coming in contact with the milk by overfilling the glass. It goes without saying that be- fore each expression the breasts must be thoroughly • WET-NURSING. 63 cleansed with a boric acid solution, and the hands thor- oughly washed with soap and water. Daily Number of Expressions. Expression is per- formed six times daily at regular intervals of four hours during the day and night. CHAPTER IV. THE NURSING INFANT. Signs of Successful Nursing. The normal full-term infant shows a gain of not less than 4 ounces weekly. This is the minimum weekly gain which may safely be allowed. When a nursing baby remains stationary in weight or makes a gain of but 2 or 3 ounces a week, it means that something is wrong, and the defect will usu- ally, but not invariably, be found in the milk supply. When the baby is nursed at proper intervals, and the supply of milk is ample and of good quality, it is satis- fied at the completion of the nursing. Under three months of age it falls asleep after ten or twenty minutes at the breast. When nursing period again approaches, it becomes restless and unhappy, crying lustily if the nurs- ing be delayed. When the breast is offered, it takes it greedily. The weekly gain in weight under such condi- tions is usually from 4 to 8 ounces. At the fifth month the baby will have doubled, and at the twelfth month trebled its birth weight. The average gain per week dur- ing the first year is about 4 ounces. The baby increases in length from about 20.5 inches (50 cm.) to 28.5 inches (70 cm.) in the first year. The first tooth appears at about the sixth or seventh month, and at one year there should be six teeth or more. (Age in months minus 6 = number of teeth normally present at that age.) It begins to smile at about the fifth week, grasps objects and holds its head erect in the fourth month, sits alone for a few minutes at seven or eight months, bears its w^eight on its feet at the ninth or tenth (64) THE NURSING INFANT. 65 month, stands with slight assistance at the eleventh or twelfth month, and creeps or walks soon after this (tenth to eighteenth month, average fourteenth month), and says a few words towards the end of the first year. Stools.. The feces of breast-fed babies are strikingly uniform, and are like no other bowel movement in in- fancy. Normally, there are two or three a day, some times only one, or even more than three. They are soft, or mushy, homogeneous, of an egg-yellow or gold color, and have a slightly sour, not at all unpleasant odor. They are never formed, and always cling to the diaper. The nature of the bowel movement, and its uniformity, is due to the "physiological fecal flora" which is brought about by the ingestion of breast milk into the germ-laden in- testinal tract, and which in turn have a fermentative rather than a putrefactive action on the food. The gases normally formed are carbon dioxide and hydrogen, and these are practically odorless. The acidity of the move- ment, its softness, and the mechanical action of the gases present, all insure active peristalsis and ready emptying of the bowels, so that constipation is an exceptional con- dition in a breast-fed baby, and, if present, it nearly al- ways suggests too little food, or abdominal and intestinal muscles too little developed and too weak to force the stool past the anal sphincter. This latter condition is commonly interpreted as constipation by the laity. The dried residue of the feces contains from 10 to 30 per cent, of fat, about 8 per cent, salts, a very large per- centage of bacteria, bile pigments, intestinal secretion (mucus, etc.), epithelial cells, etc. No food proteins or carbohydrates are found. The feces of the breast-fed baby are very frequently not wholly normal; they quite commonly, especially dur- 66 INFANT FEEDING. ing the first 'few months, contain small, soft, white or yellowish fat curds, an excess of mucus, and are often greenish in color, and may be more frequent than nor- mal. Swch a condition is perfectly consistent with a nor- mal growth and zuell-being of the baby, and should never in itself be a cause of worry, or an indication for a change of food. This is a very important point that is very commonly neglected. The condition of the bowel movements is only one factor, and in the breast fed a minor one, in determining a baby's nutrition. CHAPTER V. MIXED FEEDING AND WEANING. Mixed Feeding (allaitement mixte). With a dimi- nution in the amount of milk secreted, the breast milk must, of course, be complemented or supplemented by modified cow's milk. These methods of feeding are usu- ally successful. By complemental feeding we mean the administration of milk from a bottle following a period at the breast at each nursing. By supplemental feeding sub- stitution of a bottle for a breast feeding is meant. Thus, in the former the baby receives as many part bottle as breast feedings, while in the latter it will be supplied with one or more bottle feedings to replace breast feedings. As we know that the breast secretes in proportion to its stimulation, the complementary feeding is far more satis- factory, and not infrequently it is wise to nurse both breasts for a short time, let us say, each one three to five minutes, before the bottle is given. The modified milk strength should be that which is suitable for the average child of the same age (see Artificial Feeding). In beginning the use of cow's milk, however, it must be remembered that at first a weaker strength must be used than the child will require for growth, this weaker food being necessary in order gradually to accustom the infant to the change. If too strong a cow's milk mixture is given at first, it will be very apt to disagree, causing colic and vomiting. Later, when the child has become accus- tomed to the new food, a stronger mixture may be given. When a mother cannot give her infant at least two satis- factory breast feedings daily, it is advisable to wean the (67) 68 INFANT FEEDING. child. The newborn baby is not very discriminating, and will nurse anything equally well. The older baby, how- ever, quickly prefers the easy-flowing bottle to the in- creasingly unsatisfactory breast, and will quite regularly stop nursing at the breast as the milk comes harder and is less abundant. If the bottle is given right after the breast, it is always well to use a nipple from which the milk comes with some difficulty, for the reasons given above. If it is desirable to wean the baby rather quickly, this method of following the breast by the bottle is often to be preferred to the other. Indications for Weaning. Pregnancy is usually an indication for weaning. The mother's milk becomes more scanty, and often poor in quality. This is especially the case if the mother knows she is pregnant, and has been taught that a pregnant woman should never nurse a baby. If the baby continues to thrive at the breast, there is no reason why nursing should not be prolonged. For- tunately a new pregnancy does not often supervene be- fore a time that makes it quite safe to wean the nursing baby, i.e., before the sixth month. In acute infections in the mother, such as pneumonia, and the acute contagious diseases, such as scarlet fever, one must weigh the danger from exposure to infection as against the quality of the artificial food and environ- ment in the individual case. In the milder contagious diseases, such as measles, mumps, it is true that young breast-fed infants are rarely infected. Pertussis is an exception, and has a high mor- tality in the newborn and young infants; and the infant should under all circumstances be protected from ex- posure. In the presence of diphtheria the infant can be immunized with safety. \ MIXED FEEDING AND WEANING. 69 Weaning should always be done gradually, when pos- sible, for the sake of both mother and the child. In cases of sudden weaning, the food must be very much weaker in the beginning than for an artificially fed child of the same age. If weaned at six months, the infant should be put on a mixture suitable for a child of two or three months, and the same rule applies for older infants. When the infant becomes accustomed to cow's milk, the strength can gradually be increased. Rarely should breast feeding be continued beyond the first year. The fear of the laity of the ''second summer" is well founded when dirty milk and other improper foods are fed promiscuously, but with clean, certified, and sterilized milk, and properly prepared soft foods, the dangers of the summer heat are minimized. It should be our rule to underfeed rather than overfeed in hot weather, and during the hot spells the infant's diet may well be re- duced one-half. Care of the Breasts During Weaning. When the breast feeding is carried on the usual length of time (from nine to twelve months), the process of weaning ordinarily causes little or no discomfort. All that is usu- ally required is to press out enough of the milk to re- lieve the patient as often as the breast becomes painful, which may not be more than two or three times a day. When the weaning is necessarily abrupt, no little dis- comfort may result. When the weaning can be accom- plished more gradually, the infant should have one less nursing every second or third day, until only two are given daily. After this has been practised for one week, nursing should be discontinued. In cases of sudden weaning, a saline laxative, such as citrate of magnesia or Rochelle salts^ should be given every day for five days — 70 INFANT FEEDING. sufficient to produce two or three watery evacuations daily. In the meantime the mother should abstain from fluids of all kinds up to the point of positive discomfort. The breasts should be elevated by a firm binder. CHAPTER VI. NUTRITIONAL DISTURBANCES IN THE BREAST-FED INFANT. Breast milk alone furnishes all of the needs for growth and development of the human offspring. The infant will thrive in most instances on breast milk from different sources and different quality, demonstrating the ability of the average infant to assimilate the food which Nature intended for its use, even though the percentage quantity of the various components may vary greatly. Disturbances in the breast-fed baby are dependent upon one or more of several factors. In the order of their fre- quency they may be divided, as follows. 1. Underfeeding. 2. Overfeeding. 3. Congenital debility, with resulting impairment of the vital functions. 4. Intercurrent parenteral (pharyngitis, tonsillitis, bronchitis, pneumonia, pyelitis, etc.) and enteral in- fections. 5. Idiosyncrasy towards mother's milk. While all nutritional disturbances in young infants are of serious import, they are far less dangerous than those of the artificially fed infant, and much more easily cor- rected. They are also much less frequent than nutritional disturbances in artificially fed infants. 1. Underfeeding. Etiology. Two factors of prime importance must be investigated to complete the diagnosis : (71) 72 INFANT FEEDING. (1) The daily quantity of the milk furnished to the infant. (2) The quality of the milk supplied by the mother. The milk may contain the normal percentage of fat, sugar, and protein, but be scanty in amount. Instead of the 4 or 5 ounces to which the child is entitled, it may get but 1 or 2 ounces. Whether or not the quantity is sufficient, may be determined by weighing the baby be- fore and after each nursing for twenty-four hours. (The ordinary spring balance infant scale will not answer, and a simple beam scale with weights and scoop should be supplied.) One ounce of breast milk weighs practically 1 ounce avoirdupois. By nursing for fifteen minutes, a child under one week old should gain 1 to 1.5 ounces; at three weeks of age, 1.5 to 2 ounces; four to eight weeks of age, 2 to 3 ounces; eight to sixteen weeks of age, 3 to 4 ounces ; sixteen to twenty-four weeks of age, 5 to 7 ounces; six to nine months of age, 6 to 8 ounces ; nine to twelve months of age, 8 to 9 ounces. Of course, arbitrary limits cannot be fixed as to the quan- tity. It is not necessary to worry about the quantity taken at individual feedings so long as the infant is mak- ing satisfactory gains in weight, and the general progress is good. Quantity of Human Milk Required by the Nursing Baby. Babies of the same age and weight, under the same conditions, will take nearly the same amount of food. The older and larger the baby, the larger the total quantity of food required, but its energy quotient — that is, the num- ber of calories per kilogram or a pound of weight — lessens steadily with increasing age. The daily amount that nor- mal, thriving babies take from the breast can be stated at about one-sixth to one-fifth of their body weight dur- NUTRITIONAL DISTURBANCES. 73 ing the first month, about one-sixth to one-seventh up to the sixth month, and about one-eighth after the sixth month. Heubner expressed this in terms of energy quotient, as follows : "During the first few months an infant requires 100 calories per kilogram daily of breast milk ; after the sixth month this energy quotient gradually comes down to 80 or 85 at the end of the first year. An energy quotient of 70 is about the minimum amount that an infant can take without losing weight." Human milk can be estimated at 21 calories per ounce, and about 70 calories per 100 Gm. of milk. With these figures in mind, it is easy to determine whether a breast-fed infant gets about the right amount of food, and we have also a valuable standard by which to measure the food of an artificially fed infant. Symptoms. Failure to gain weight properly,, or even a loss in weight, may be the first positive evidence of an insufificient food supply. Usually this is associated with more or less evidence of dissatisfaction on the part of the infant. The infant's sleep becomes disturbed, and it becomes restless, and cries long before the next feeding time. Again, it may manifest its dissatisfaction by nurs- ing greedily for a short time, releasing the breast and crying. It returns to the breast again, but with the same result ; or in other instances the infant will remain at the breast for much longer periods than should be necessary to obtain the food that it needs, which would be accom- plished in from ten to twenty minutes. Usually the stools are normal in appearance, but small in amount, and give little evidence of the cause of the trouble. However, if the food supply be decidedly in- sufficient, we may have a positive evidence of the under- feeding by the appearance of the so-called "hunger 74 INFANT FEEDING. stools," which are of more or less brownish or greenish- brown color, containing little fecal matter and much mucus. If the condition is not corrected, the baby becomes weak and apathetic. The skin loses its turgor, its tem- perature becomes subnormal, it is pale and anemic, the fontanelles become depressed, and the abdomen sunken. Whenever there is room for doubt as to the cause of this group of symptoms, the scale will be the most positive evidence. Treatment. Undue haste in removing the baby from the breast offers the greatest danger in the treatment of underfeeding, and should be resorted to only when other means fail. The ability to increase the quantity of milk secreted by the average woman must necessarily vary directly with the quantity and quality of the glandular tis- sue composing the breast. However, to a certain extent at least, certain factors will more or less 'directly in- fluence the quantity and quality of the secretion, and they are worthy of our attention. Means of Stimulating the Breasts. The surroundings of the mother must predispose to a happy frame of mind ; she must not be overburdened with household cares ; her exercise must be regular, and she must be relieved of worry and lack of sleep. It is well, if possible, to free her from all care of the baby, especially at night. She should be put in as good physical condition as possible; she should get out; of doors. Her appetite should be stimulated, so that she will take an abundance of milk and other nutritious food. The very common forced feeding beyond the natural appe- tite, is of questionable value. The general rules as to the diet previously spoken of should be maintained. It NUTRITIONAL DISTURBANCES. 75 should, however, be remembered that an excessive diet may be assimilated by the mother's body without increas- ing the flow of milk. The fluids given should be palat- able to the nursing mother, and, as previously recom- mended, milk, weak tea, cocoa, farina, oatmeal, and corn- meal gruels as well as milk soups are probably the best. The fat and the protein of the milk can more especially be influenced by the diet. The fats are increased by over- feeding with fats and carbohydrates, with little or no exercise. They are reduced by limiting these articles and substituting vegetables, and by increasing the amount of exercise. The protein is also increased by overfeeding and limited exercise. The carbohydrates are less in- fluenced by the diet, but are also affected by an excess of carbohydrate feeding. Alcohol in the form of malted drinks has a temporary influence in increasing the quan- tity of milk and the amount of fat. The effect on the protein is less constant. We never force a woman to partake of alcoholic liquors unless she desires them, be- cause of the moral as well as of the physical effect. Stimulating massage may be applied to the breast in such a manner as to stimulate the whole gland. This can best be accompHshed by two movements: (1) by gently raising the whole breast from the chest wall and kneading it gently between the fingers, and (2) by hold- ing the breast against one hand and making circular movements around the periphery with the outspread finger tips of the other hand, and gradually working from its base towards the nipple. Baths at a temperature comfortably cool (80° to 90° F.) should be taken daily to promote her general health as well as cleanliness. These should be followed by a brisk rubbing with a coarse towel. • 76 INFANT FEEDING. Steaming the breasts by the application of hot towels covered with oiled silk two or three times daily is of decided benefit. The Bier pump and other means of stimulating an arti- ficial hyperemia can be used to advantage in obstinate cases. The application should be made at regular inter- vals, and not too long continued. A very simple vacuum pump may be made by boring a round hole into a finger- bowl and inserting a piece of rubber tubing and attaching a clamp, which can be opened and closed at will. Galactagogues of any material value for permanent use are unknown. Pituitrin has been recommended for temporary stimulation. We have not had much experi- ence in its use. General tonic will often improve the digestion and tend to overcome the anemia, and in this way improve the general health, and thereby lactation. 2. Overfeeding. This condition is a rare one in the breast-fed baby, and, when present, in all but the very young and pre- mature, nature often provides its own remedy, either by regurgitation on the part of the baby, or by its refusal to nurse longer than to meet its needs, which latter soon leads to a lessened milk secretion. In the first weeks and months it may be of considerable importance, and may cause grave symptoms on the part of the infant — that is, before the mother's breast and the infant have become adapted to one another. Etiology. Although overfeeding in the breast-fed infant is rare when compared with overfeeding on arti- ficial food, yet next to underfeeding it is the most com- mon form of nutritional disturbance in the breast-f^d NUTRITIONAL DISTURBANCES. 77 infant. It is also more commonly present in infants fed by a wet-nurse than in infants nursing the maternal breast. Usually the error lies in too frequent nursing. Rarely it may be due to excessive quantities of milk taken at proper intervals. Occasionally it is due to milk which is excessively rich in fat. Pathogenesis. The normal infant's stomach on breast feeding empties itself in about two hours. When all the food has left the stomach, and is undergoing intes- tinal digestion, free hydrochloric acid is forming in the stomach. Free hydrochloric acid is antiseptic, and it also stimulates secretion of pancreatic juice and secretion of bile, both of the latter products being essential to proper intestinal digestion. For normal digestion it is therefore necessary that the stomach remain empty for some time after all the food has left it. When by too frequent nursings no time is allowed for the above described physiological process, or when by excessive quantities of food at proper intervals too great demands are made upon the hydrochloric acid, and the time of gastric digestion lengthened, with cor- responding shortening of the period of comparative rest, or the gastric secretion diminished by excessive fat, then we may expect disturbance of the normal digestion due to overfeeding. Symptoms. The earliest symptoms are regurgita- tion, diarrhea, and lessened appetite. These three symp- toms are reactions of the organism to excessive intake of food attempting to get rid of the excess. Regurgitation occurs at first occasionally only, imme- diately after nursing, and without any discomfort on the 7S INFANT FEEDING. part of the infant ("spitting"). The regurgitated fluid is often unchanged milk. This is usually the first pre- monitory symptom. Diarrhea follows when overfeeding continues and re- gurgitation becomes insufficient to rid the body of excess of food. The stools are more frequent than normal, and contain undigested particles of food. Lessened appetite, although present in many cases, may be replaced by symptoms suggestive of hunger, the infant taking the breast and nursing greedily. This ap- parent symptom of underfeeding and of hunger may wrongly be interpreted, and lead to additional overfeed- ing by giving the breast at even more frequent intervals to allay the apparent hunger and to quiet the restless infant. In many cases no other symptoms develop, the condi- tion undergoing a spontaneous cure. The breasts lessen their yield, and thus the cause of the condition disap- pears, or, on the other hand, the digestive power of the infant increases to such an extent as to be able to take care of the excess, if not too large. This accounts for the fact that frequently the above-named symptoms are neglected, since they usually produce improvement in the child's condition, and are regarded as passing dis- turbances without much importance. When, however, they are entirely neglected, and excess of the food con- tinued, or even increased, due to wrong interpretation of symptoms, then more serious symptoms develop, and the. condition reaches a stage where spontaneous cure rarely occurs. Vomiting becomes habitual, occurring from a few minutes to half an hour after nursing. It is accom- panied by visible discomfort and straining on the part of NUTRITIONAL DISTURBANCES. 79 the infant. The vomitus consists of curdled milk, mucus, and gastric juice. Between vomiting there is often pain- ful belching. Stomach shows distention, and empties itself only after three to four hours. Free hydrochloric acid is almost or entirely absent, the acid products of fer- mentation being present. The micro-organisms are in- creased in number and variety, due to stagnation and ab- sence of antiseptic free hydrochloric acid. Initial diarrhea is sometimes followed by temporary constipation, diarrhea setting in again. The evacuation is painful, and, with much gurgling and discharge of gases, fluid masses are squirted from the anus. The stools are watery, with white and dark green fragments, and of disagreeable, sour, pungent odor. The irritating feces often causes eczema and intertrigo in the ano- genital region. Abdomen is distended, tense, and often there is visible peristalsis. Intestinal colic causes restlessness and cry- ing; the infant's face gives expression to its pain, and, as the fermentation increases, its agony is increased, due to intestinal paresis. The infant becomes restless ; its sleep is much dis- turbed, and even during sleep its features give evidence of its distress. The weight early becomes stationary, and in severer cases associated with dyspepsia loss of weight becomes marked. Complications. Dyspepsia. Accompanied by the milder evidence of intestinal irritation, evidenced by in- creased peristalsis, with its resultant colic, more or less numerous bowel movements of eight or ten or even more daily, sour and irritating, greenish-yellow in color, and 80 , INFANT FEEDING. containing numerous curds and much mucus. The. but- tocks soon become reddened and intertrigo results. Intoxication, while rare in the breast-fed infant, may result when the dyspepsia is neglected. The baby be- comes drowsy and stuporous, paying little attention to its surroundings, and not infrequently develops a severe anorexia, all associated with more profound intestinal symptoms. In dyspepsia the intestinal findings dominate the pic- ture, while in intoxication they share their prominence with the added nervous symptoms. Pyelitis is not an infrequent complication in neglected dyspepsia and intoxication, and while it undoubtedly is frequently due to an ascending infection, it may re- sult from extension through the blood stream or the lymphatics. Eczema not infrequently results from overfeeding in the breast-fed infant, and is usually seen in the fat type of infant who is otherwise healthy. Pylorospasm, gastric dilatation are not uncommon in the neglected cases. Acidosis may develop in the extreme cases, associated with great loss of weight, but this is rare. Diagnosis. In the presence of symptoms suggestive of overfeeding, positive diagnosis is made by determin- ing exactly the amount of milk taken by the infant, and comparing this amount with what an infant of the same weight and of the same age should get. The method of this determination has been described in detail under the treatment of underfeeding. If, however, the food is found to be quantitatively cor- rect, occasionally information of value may be obtained by examining the quality of the milk chemically, espe- NUTRITIONAL DISTURBANCES. 81 cially as to its fat content. The specimen for examina- tion should be taken under precautions pointed out under Examination of Human Milk. By making proper etio- logical diagnosis, valuable indications for rational treat- ment are obtained. If a careful search is made for the etiological factors lin the common illnesses of infants, which are so fre- quently charged to overfeeding, one will be surprised to find that the error lies in the diagnosis, and that in most cases the condition is not due to overfeeding. This leads us to warn against the only too frequent habit of wean- ing infants without a careful study of the exact cause of the infant's trouble. Treatment. Prophylaxis of this disturbance is of importance, and consists of giving the nursing mother proper instructions as to the nursing, especially as to its frequency, and seeing to it that the rules for nursing, as laid down elsewhere, are observed by the nursing mother In wet-nursing, more caution is necessary, especially in those wet-nurses who have an abundance of milk, which is frequently the case in a wet-nurse whose own child is much older than the infant to be nursed. A very important point to impress both on the mother and also on the wet-nurse is the fact that crying of the infant is not always due to hunger, and that offering the breast should not be used as a means for quieting the child. When the initial or mild symptoms only are present, then correction of the nursing habits is usually sufficient, the infant improving without any special treatment. When the error lies in too frequent nursings, it is best and often completely relieved by lengthening the feed- ing intervals to three or, even better, four hours. 6 82 INFANT FEEDING. It is of equal importance that the infant should not be left too long at the breast. The best average nursing time being about fifteen minutes, with twenty minutes as the maximum. However, when the flow of milk is very free, it may be necessary to reduce the nursing period to even three to five minutes, it being a fact that most infants take about 75 per cent, of their entire meals in the first five minutes at the breast. It is always well at the begin- ning of such an experiment to weigh the baby after a two, three, five, ten, and twenty minutes period to ascer- tain the exact amount which the baby obtains from the particular breast which it is nursing, so that conclusions may be drawn definitely as to the time it is to be left on each breast. If placing the infant at the breast for short periods with long intervals does not give results, it is advisable to express the milk, and feed in small quantities from the bottle. And if another baby be at hand, it may be placed upon the breast to keep up the supply. Or when a wet- nurse is available for temporary use, the babies may be exchanged. Weaning should under all circumstances be considered only as the last resort, after all other methods of adapt- ing the infant to the breast have failed. An excessive amount of fat in the milk is more often due to an excessive intake of food in general on the mother's part than an excess in any one element, and can be diminished best by cutting down the food as a whole, lessening the amount of all food. When the condition has progressed farther, and the symptoms have become more serious, then it is necessary to treat the infant also. The treatment consists in empty- ing the stomach and the bowels of the overload of fer- NUTRITIONAL DISTURBANCES. 83 menting food, and of rest for the digestive apparatus, both these objects being achieved by giving a bland diet, consisting of boiled water or weak tea sweetened with saccharin, for twelve hours, the digestive tract getting rid of its contents spontaneously. If the symptoms improve upon this treatment, the nursing should be gradually resumed by giving two breast feedings in the twenty-four hours following the period of starvation, substituting for the other nursings bland liquids, and increasing cautiously the number of nursings. If on withholding the food, vomiting does not cease, then it is necessary to wash out the stomach. Irrigation of the bowel is often necessary, and aids in removal of fermenting intestinal contents, and allows also the gases to pass, thus relieving the distention and colic. Only when change of diet and irrigation are not sufficient, then the use of purgatives is advisable, castor oil being just as efficient and less harmful than the fre- quently preferred calomel. Colic usually disappears on correction of the diet, and after the intestinal tract has been cleansed of its irritating contents, and of gas. Massage to the abdomen will aid the passage of gases which cause distention, when the bowels tend to become paretic. In severe pain, warm applications to the abdomen give relief. If these meas- ures fail to bring relief, and the pain is such that the in- fant is deprived of sleep, a mild sedative in small doses may be given. Feeding of powdered casein in amounts varying from 6 to ^8 Gm., dissolved in 30 to 60 mils of water, two or 84 INFANT FEEDING. three times daily will relieve colic in many infants, in all probability due to lessening of intestinal peristalsis. There is a class of infants who, although they are gain- ing progressively in weight, cry a great deal, expel a great deal of gas, and perhaps have a green stool now and then. It is almost criminal to take such infants off the breast, although the temptation to do so is very great, because of the worry they cause the mother, and conse- quent harassing of the physician. Such an infant will frequently cry for six, eight, ten, or twelve hours out of the twenty-four, and still make a good gain in weight each week, in which case it is -very probable that the infant is being overfed, and the food supply should be reduced. The mother's diet and general habits should receive attention. 3. Congenital Debility, with Resulting Impair- ment of Vital Functions. Etiology. Premature birth is the most important condition causing debility associated with deficient func- tionating power of the digestive organs. Method of feeding premature infants will be detailed later in a special chapter. Hereditary weakness of the offspring caused by dis- ease in the parents is frequently the cause of deficient morphological and functional development of the diges- tive organs, and thus it is often the underlying cause of nutritional disturbances, which are more commonly chronic in character. Tuberculosis, syphilis, and alco- hoHsm in parents stand at the head of the conditions causing hereditary weakness,, even when the oft'spring does not inherit the disease itself. NUTRITIONAL DISTURBANCES. 85 Malformations of the digestive tract (cleft palate, sublingual tumors, pyloric stenosis, atresias of the intes- tinal tract, Hirschprung's disease, etc.) from any cause compromise its functional capacity usually, but in most cases they cause serious conditions necessitating surgical interventions, and only rarely do they produce simple nutritional disturbances amenable to dietetic means, and therefore they belong to the domain of surgery. Symptoms. As may be expected, symptoms of these so diverse conditions vary. Hereditary weakness may often be suspected when symptoms of nutritional dis- turbances develop even when the infant is given the best care possible, and the milk is quantitatively and quali- tatively correct. Symptoms of underfeeding or of over- feeding, as described previously, may be present, de- pending upon the etiological factor. Diagnosis. Careful examination for malformations, and thorough family history, in cases of suspected hereditary weakness are of chief importance in making the etiological diagnosis. Treatment is usually determined by the pathology, and by the nature of the particular nutritional disturb- ance which developed. 4. Intercurrent Parenteral and Enteral Infections. Etiology. Diseases both in the mother and in the infant are to be considered in etiology of this condition. In the mother the most important are the general infec- tious diseases, e.g., puerperal fever and sepsis, typhoid, pneumonia, etc., and local infections of the breast, and also of the upper respiratory passages. In the infant there are parenteral infections, that is, infections outside the digestive tract, e.g., pharyngitis, tonsillitis, pneu- 86 INFANT FEEDING. monia, pyelitis, bronchitis, and enteral infections, or in- fections of the intestinal tract, which will be discussed under a special heading. Symptoms. In the conditions dependent on the mother's health the symptoms will vary first with the quality and quantity of her milk supply, which will have an effect on the child's general nutrition, and, secondly, may result in direct parenteral or enteral infections of the infant. In those dependent on infections of the infant itself we invariably find evidences of nutritional disturbances, whether the infection be local, systemic, or confined to the intestinal tract. The clinical picture varies directly with the degree of disturbance of the metabolic function. While, as a rule, the enteral infections are more com- monly associated with grave disturbances of the infant's nutrition, it is not uncommon to find the infant severely aft'ected in its ability to m*eet its nutritional needs by the parenteral infections. While any one of the above enumerated etiological factors may give rise to a marked clinical picture, it is to be remembered that this class of disturbances in the breast-fed infants are of minor im- portance as compared with those of the artificially fed (see Nutritional Disturbances in Artificially Fed In- fants). Diagnosis. The diagnosis of the primary seat of in- fection in the infant is of considerable importance in de- ciding the method of treatment. Treatment. Parenteral infections rarely call for re- straint in administration of food because of the asso- ciated anorexia, and the infant should be nursed (if pos- sible without danger to the mother) directly at her breast. NUTRITIONAL DISTURBANCES. 87 In the case of enteral infections it may be necessary to withdraw the maternal milk and replace it by a short period of starvation, to be followed by small quantities of breast milk, either taken directly from the breast during short nursings, or it may be best to feed small quantities of expressed milk to the infant at regular intervals. Not infrequently it becomes necessary to feed these infants by catheter in order to sustain them. And this method of introducing their food should be begun suffi- ciently early to avoid a catastrophe. Under no circumstances should they be placed upon food other than the mother's milk when her state of health and the quality of her milk permit. Inert fluids, such as water, weak tea, broths made from young meats and young fowls, and cereal decoctions should be given between feedings to insure a sufficient intake of water. A careful record should be kept of the twenty-four-hour quantity of all fluids administered, in order to insure the child a sufficient water and food ad- ministration. For conditions in the mother which would justify weaning, see chapter on Weaning and Contraindications to Nursing. 5. Idiosyncrasy Towards Mother's Milk. Etiology. This condition is very rare, although it may not be denied that it exists. The etiology and patho- genesis are as yet little understood. Diagnosis. The diagnosis of this disturbance should be made by exclusion of all other causes that may give rise to a similar symptom-complex. It may be confirmed by the change of the milk either by substituting a wet- 88 INFANT FEEDING. nurse or cow's milk for maternal nursing, whereupon the symptoms improve. Treatment. The treatment depends upon the par- ticular symptom-complex which develops. Change of milk is imperative in cases in which idiosyncrasy is clearly established. The mother's milk should not be al- lowed to dry up during the period of experimentation, because of the possibility of an error in diagnosis. CHAPTER VII. METHODS OF FEEDING PREMATURE INFANTS. 1. Infants Nursing at the Breast. In most cases we do not feed the more developed pre- mature infant on the first day. It may be wise, however, to place the infant on the breast two or three times dur- ing the last half of the first day, after the circulatory and respiratory functions are well established, so that the in- fant may become accustomed to nursing. We are now confronted with two important factors, first, the ability of the infant to nurse the breast; and secondly, sufficient and proper development of the nipples to allow of the infant's properly grasping the same. If the infant is sufficiently developed to take hold of a well-formed nipple, it should be placed at the mother's breast regularly at three-hour intervals on the second day, for two- or three- minute periods, even though there is little hope of the breasts secreting at this time. By this means the infant is trained to expect its food at regular periods, and at the same time the maternal breast is stimulated. When a wet-nurse can be supplied in the home who has her own infant with her, the latter can be used to stimu- late the breasts of the mother, and the new infant can have one of the wet-nurse's breasts set aside for its use. Where the infant is very weak, the breast set aside for it can be made to secrete more freely by simultaneously placing the wet-nurse's baby on the opposite breast dur- ing the period of nursing. (89) 90 IXFAXT FEEDING. We have found this to be a very valuable expedient. However, with this latter method of procedure the quan- tity taken by the premature infant must be accurately measured to prevent overfeeding by weighing the in- fant before and after the nursing period. Nursing di- rectly from the breast has the added advantage of de- veloping the baby's sucking muscles, preventing con- tamination of the milk, and stimulating the breasts by the natural method. It should, however, be remembered that a weak infant may nurse the maternal breast for a considerable time, and yet the amount of food taken may be insufficient. This is especially true of that class of in- fants who are inclined to go to sleep at the breasts. Here, again, weighing is of the utmost importance. When the infant is too weak to nurse sufficiently to satisfy its needs, as ascertained by weighing, the nursing should be followed by substitute feeding with expressed milk, either by the bottle or one of the other methods to be described. These rules do not apply for the first and second day, when only rarely more than four or five meals should be given. In very weak infants, and those subject to re- gurgitation after taking small quantities of milk, it may be necessary to feed more frequently in periods varying from two to two and a-half hours, as may be indicated by the quantity retained, or better results may be obtained by catheter feeding (to be described later) with four- hour intervals. 2. Infants Too Weak to Nurse the Breasts. In this class of infants, wherever possible, they should be fed without being removed from their bed or the in- cubator, if used, so as to avoid all careless exposure of FEEDING PREMATURE INFANTS. 91 the infant. The cause of inability to nurse may be due to several factors: (1) Infants unable to swallow; this is usually because of improper development of the center in the medulla, or lack of co-ordination on the part of the pharyngeal muscles and tongue. This is usually made evident by the milk flowing from the dependent part of the mouth. In such cases it is generally necessary to re- sort to catheter feeding. (2) Those too weak to nurse, and who may appear to be almost dead ; in this class there is great danger in handling the infant, and it is best fed in the bed. (3) Those who will not suck. (4) Those vomiting after every feeding. (5) Those becoming cyanotic after feeding. In the latter cases it may even be necessary to resort to such methods as gentle friction, artificial respiration, best performed by gently compress- ing the thorax, warm baths, oxygen, etc. Methods. One of the following methods can be se- lected for feeding these infants : 1. The nasal spooyi, which can be used either by pour- ing the milk slowly into the nose or into the mouth. The latter is to be preferred, because of the dangers due to decomposition of the milk in the nose and naso-pharynx, with secondary development of rhinitis and pharyngitis. 2. A medicine dropper for mouth feeding. This is possibly one of the best methods for feeding this class of infants, as it is simple of application, and a small dropper is easily obtainable. As in all other methods, the food should be administered very slowly. 3. Nursing From a Bottle. For this purpose the small nipples commonly sold on doll nursing-bottles are of the proper size, and can usually be obtained of proper quality. We have not infrequently perforated the rubber end of a medicine dropper and used it for this purpose. The 92 INFANT FEEDING. bottle to be used can either be an ordinary 1-ounce or 2- ounce medicine bottle, or, better, the special bottle which was designed by the author for this purpose. This bottle -4 — 3 — Z Fig. 5. — Breck feeder for premature infants. holds 2 ounces of milk, is graduated in cubic centimeters, has a ground glass neck which coapts perfectly with the bulb on the special breast-pump, and which after being filled is corked with a ground glass stopper, and which has the added advantage in that the milk is in no way handled after it leaves the breast. FEEDING PREMATURE INFANTS. 93 4. The Breck Feeder. This has the added advantage that the milk can be passed into the pharynx without effort on the part of the child when it is too weak to nurse. This has the one disadvantage of too rapid feed- ing if not properly controlled. 5. A rather slow but satisfactory method of feeding the infants is by expressing the milk directly from the nipple into the infant's mouth during the feeding period. 6. Catheter Feeding by Mouth (gavage). For this purpose a small funnel is attached either directly or by means of a short piece of rubber tubing with a glass connection to rubber catheter. A Nelaton catheter is used (best a No. 14 French), about 25 to 40 cm. long (10 to 16 inches), marked in centimeters or inches, so that at all times its position can be estimated. The in- fant should be fed in the incubator, its crib, or on the dressing table. Its head should be slightly lower than the body. The passage of the catheter is usually effected without difficulty by grasping it as one would a pen, and passing it in the midline to the pharynx, gradually push- ing it into the esophagus. This is usually accomplished without difficulty, because of the poorly developed pharyngeal reflexes, and rarely results in retching or vomiting. In infants who retch during the passage of the catheter, vomiting may be expected because of the fact that these latter infants not infrequently belong to the spasmophilic group. The danger of passing the catheter into the larynx is minimal. It is rarely necessary to pass the catheter more than 10 centimeters (4 inches) beyond the infant's lips, and we have found it equally as practical to limit the passage of the catheter to 7.5 centi- meters (3 inches). In most instances this does not reach the stomach, but has the added advantage of preventing 94 INFANT FEEDING. trauma to the cardiac end of the stomach and the gas- tric mucosa. When a graduated catheter is not at hand, it may be marked at 10 centimeters with indehble ink, and this used as the maximum point for passage. A Fig. 6. — Apparatus for gavage and lavage. (Glass taken from Breck feeder.) When using for small infants the catheter should be attached directly to the funnel without the intervening rubber tube. fairly safe maximum for the passage of the catheter can be ascertained by measuring the distance from the glab- ella to the epigastrium in the individual infant. The de- sired quantity of milk is allowed to flow into the stom- FEEDING PREMATURE INFANTS. 95 ach, slowly, by raising the funnel only very slightly above the level of the body. After feeding, the catheter is firmly compressed to avoid all leakage into the pharynx, and the catheter then removed, but not too rapidly. The Fig, 7. — Introduction of catheter for gavage. milk to be fed should be measured in a graduated glass, and the latter kept close at hand in order that the amount given can at all times be estimated. A complete record of every feeding, both as to the time and the amount, should be kept. This is especially important in institutions where the nurses have a number of infants to observe, and is greatly facilitated by a time- 96 INFANT FEEDING. clock registering the day, hour, and minute of each feed- ing. The nurse records the quantity of milk taken, which in breast-fed infants is obtained by weighing the infant both before and after feeding on an accurate scale, or in infants too weak to nurse by measuring the quantity in a graduated glass before feeding. 3. Proper Time for Beginning Regular Feeding. Due to the tendency toward the rapid development of acute inanition in this class of infants, the greatest dan- ger is that of too long delay in establishing regular feed- ing. Therefore it is often impossible to wait for the mother's milk to appear. We believe that it is, however, unwise in most instances to attempt to feed with milk during the first twelve to twenty-four hours, rather pre- ferring to allow the circulatory and respiratory organs opportunity for proper accommodation to their new en- vironment. During this time the loss of body fluids through evaporation from the skin and respiratory tract due to the warmth of the incubator, and the excretions through the kidneys and bowels, should be recompensed by the regular administration of water or some other inert fluid. We have endeavored to administer about one-sixth of the body weight of water (inclusive of that contained in the milk if given) in twenty-four hours. In smaller infants the first milk is given diluted one to four times during the first four days. After the first twenty-four hours water can be administered partly with the food, and otherwise between feedings. If for any reason the water is not w^ell retained when given by mouth, it can, at least in part, be administered by rectum. FEEDING PREMATURE INFANTS. 97 Example: An infant weighing about 1200 grams should receive 200 mils of water; should this infant receive 50 mils of milk, this can be diluted with 50 mils or more of water or sugar solution, and the remaining 100 mils ad- ministered between feedings. If a stimulant is indicated, a few drops of brandy (6 to 15 in twenty-four hours) may be added to the water or sugar solution during the first twenty-four hours. Half strength of Ringer's solu- tion prepared as follows can be used to good advantage for rectal administration: NaCl 7.5 Gm.' KCr 0.1 " CaCl 0.2 " Water ' 1000.0 mils. We have made it a rule never to start milk feeding until after the first bowel movement. Not infrequently the removal of meconium may be accomplished by the administration of a small quantity of physiological salt solution through a catheter passed one or two inches into the rectum. This is done to remove the meconium before infection of the intestinal tract through the administration of food. Occasionally it is necessary to administer 5 drops of castor oil to obtain slight purgation. 4. Feeding From the Second to the Tenth Day. It must be remembered that the general rules as ap- plied to the feeding of premature infants do not hold for the first ten days of life. The early feedings must necessarily be small, and the increases gradual. Two grave dangers present themselves during the first period of the infant's existence: (1) overfeeding and (2) star- 7 98 IXFAXT FEEDING. vation, the latter usually resulting from an inability to supply sufficient quantity of human milk, following an attempt to await the natural secretion of the mother's breast. Overfeeding results either in vomiting or, more seriously, in stomach distention, which leads to asphyxia and cyanosis. Underfeeding in these weak infants soon leads to inanition. From the second day these infants should be fed regularly day and night, every two or, better, three hours, depending upon the infant's condition and the method of food administration. Not infre- quently where the quantities taken are very small, ten to twelve feedings are required in twenty-four hours. It may even be necessary in very weak infants to feed minimal quantities every hour. The question of the number of feedings will be discussed in detail later. It is practically impossible to formulate definite rules for feeding premature infants during the first ten days, because of their great variation in weight and develop- ment. Therefore it becomes necessary to feed each in- fant indiz'iduaUy. During the first days it is often difficult in infants weighing 1000 to 1200 grams or less to feed more than 20 to 50 mils of milk per day, and it may be necessary to limit the food to this quantity during the first ten days. It is our rule to start feedings in this class of cases with a maximum of 4 mils per feeding, not infrequently using one-fourth or one-half human milk at the start, and the balance water. The feedings should be increased by 1 mil at a time, and with the first evidence of regurgitation the quantity should remain stationary. Even in favorable cases dur- ing this time 30 to 50 calories per kilogram is likely to be the maximum that can be fed with impunity. FEEDING PREMATURE INFANTS. 99 The small feedings which can be assimilated, and the low energy quotient during the first two or three weeks, must be considered physiological, and as we rarely see an increase in weight with feedings of less than 90 cal- ories per kilogram, we are confronted by a rapid loss in body weight during the first days of life. In favorable cases this is usually followed by a stationary weight, or moderate fluctuations after the first four to seven days. Occasionally an infant is seen in whom there is sufficient water retention to avoid most of the initial loss in weight. One should, therefore, remember that even with fre- quent feedings with human milk, either at the breast, by hand, or gavage, it is rarely possible to feed more than the minimum requirements without causing vomiting. 5. Feeding After the First Ten Days. There has been considerable discussion as to the food requirements of premature and underweight infants during the past few years. Budin gives us the rule that premature infants of less than 2500 grams after their tenth day require one-fifth of their body weight (200 Gm. per kilogram of body weight), or 140 calories, while the full-term infant of normal development requires one- seventh of its body weight (140 Gm. per kilogram body weight), or 100 calories per day. On the other hand, Birk believes that the more fully developed premature infant, and those nearing the normal, will thrive on one- sixth to one-seventh of their body weight. Our opinion, based on a series of experiments made on a number of premature infants, is that they require higher food values, or at least the maximum required by normal infants, for the following reasons: (1) the 100 INFANT FEEDING. greater body surface as compared with the body weight; (2) in the normal infant the requirements decrease with the age, and therefore in the premature the quantity re- quired varies inversely with the fetal age after the first weeks of life; (3) the need for body development is relatively greater in the premature than in the full-term infant; (4) a kilogram of body weight in the fat-poor premature infant cannot be taken as parallel in feeding to the well developed full-term infant, with its prepon- derance of fatty tissue. This latter point must also be considered in the feeding of the marasmic infant, to obtain a proper gain in weight as compared with the lower requirements in the fat, full-term infant. 6. Number of Feedings Daily. Our own experience has led us to adopt a conservative position in that we have grouped the infants nursed at the breast or fed from the bottle or by feeders into two general classes: (1) those weighing under 1500 Gm., and (2) those above this figure, based on the tendency of the smaller infants to become exhausted when the feedings are long continued. The former are fed at 2- hour intervals during the day, and 3-hour intervals at night, as follows: 6 a.m., 8 a.m., 10 a.m., 12 m., 2 p.m., 4 P.M., 6 P.M., 9 p.m., 12 P.M., and 3 a.m. — 10 feedings during the twenty-four hours. The larger infants are fed on a 3-hour basis, 8 feedings being given during the twenty-four hours. These figures should in no way be construed as arbitrary. All feedings are more or less dependent upon the general development of the infant in relation to its digestion and metabolism, its retention, and upon the larger quantities of food necessarily given to meet its nutritional requirements, and a careful atten- FEEDING PREMATURE INFANTS. 101 tion to gastric distention, regurgitation, asphyxia, cya- nosis, and other respiratory complications. It has been our personal experience to meet with con- siderable difficulty in attempting to meet the large food requirements in smaller infants without resorting to catheter feeding. In these we have adopted the longer interval between feedings, of four hours with six feed- ings in twenty-four hours, the individual meal in catheter feeding being greater in quantity. Notwithstanding the fact that catheter feeding offers little difficulty and few dangers in experienced hands, this may not be true with those not skilled in its use. A considerable number of our cases have, however, thrived satisfactorily on quan- tities of milk less than one-fifth of their body weight per day, and one should always remember that it is a safe axiom not to force the feeding in these cases as long as their general development is progressing satisfactorily and their weight curve is good. 7. The Amount of each Feeding. The statistics as to the stomach capacity for food in premature infants indicate that this varies within con- siderable limits, even in infants of the same fetal age, as does also their ability to digest and assimilate food. The weight and length, naturally excluding congenital diseases and deformities, will be far more dependable as a guide to stomach capacity than the fetal age. As no definite rules can be established governing the amounts of individual feedings, we begin with what could be considered minimum quantities and gradually increase the amount of feedings as the infant develops an ability to digest it. It is our rule, as previously stated, during the first few days to feed small total quantities varying 102 INFANT FEEDING. from 20 to 50 mils of milk per day, dividing these totals by the number of feedings to be administered (eight to ten), thereby feeding from 2 to 6 mils of milk per feed- ing. The feedings can then be increased by 1 or more mils at a time, and in the absence of vomiting the in- dividual feedings can be increased more or less rapidly until the weight loss ceases or an increase in weight oc- curs. Even in favorable cases, weighing over 1500 Gm., 45 to 75 mils per kilogram weight (30 to 50 calories per kilogram) is likely to be the maximum that can be fed with impunity or safety during the first ten days. 8. Daily Gains. These are not necessarily in proportion to the changing quantity of milk administered, as many factors, such as condition of the bowels, quantity of the urine passed, temperature of the infant's surroundings, will neces- sarily influence the weight. This is more especially noticeable in observations continued during a short period of time. An average greater daily gain than 20 Gm. is unusual when the infant's food is limited to one-fifth of its body weight. An average of from 10 to 20 Gm. daily can in most cases be considered satisfactory. 9. Artificial Feeding. There can be no comparison between the results to be expected in feeding premature infants on human milk, and those to be obtained with artificial food. With human milk taken from a well regulated department for wet-nurses the milk can be obtained fresh, practically sterile ; it is more digestible ; its constituents are of the quality and in the proportions required for the growth and development of the human body; and it is live, and FEEDING PREMATURE INFANTS. 103 contains many of the immunity-conferring properties, as evidenced by the resistance of a breast-fed infant to in- fections and contagious diseases. Most of these proper- ties and advantages are lacking in the dead foods used in artificial feeding. Therefore, if it becomes necessary to resort to artificial feeding, the selection of the food, its preparation, and its adaptation to the infant must all be given the most painstaking consideration. Many varieties of artificial diet have been suggested by various authors, such as simple milk dilutions, cream and top- milk mixtures, skim and buttermilk mixtures, malt soup preparations, condensed and evaporated milk, etc. The results with the various diets are to a great degree de- pendent upon the physician's intimate understanding of and directions for the use of the individual food. Quantity of Food. It must be remembered that the figures quoted for feeding on breast milk are the maxi- mum that can be assimilated, and in most instances these amounts more than fulfil the immediate needs of the infant's existence, and can be considered (and in most instances would be) excessive quantities for artificial feeding in the first few weeks of life, because of the greater difficulty in the digestion of cow's milk. One hundred calories per kilogram is the maximum quantity that can be digested by most premature infants, and in many instances one must be satisfied with a sustaining diet bordering on 70 to 80 calories, and they must at all times be closely watched for evidence of overfeeding, as it is dangerous to exceed the actual food requirements, and the first evidence of digestive disturbances or of in- tercurrent infections should lead to the feeding of human milk. During the first days the same rules for minimal feedings must be observed as in feeding with breast milk. 104 INFANT FEEDING. Quality of Food. Opinions vary greatly as to the best food for an artificial diet. Ordinary milk, water and sugar mixtures are rarely well taken. Pfaundler sug- gests rich fat and low protein milk mixtures ; but in this feeding we have seen fat diarrhea resulting. Budin ob- tained the best results with peptonized boiled milk, using fresh pancreatic extracts for this purpose. Finkelstein, Oberwarth, Birk, Neumann, Von Reuss have obtained their best results through the use of boiled buttermilk mixtures, prepared according to the following formulae: Buttermilk 1000 Flour 10 Sugar 40 The above being used for the first feedings. Buttermilk 1000 Flour 15 Sugar 60 For later feedings. Dextrin-maltose compounds can be substituted for the cane-sugar if desirable. Chymogen or pegnin milk has given us most satis- factory results in the artificial feeding of the premature infants. This latter preparation is little more than a boiled milk in which the curds are precipitated in a fine, flocculent form, about the size of that of human milk, before it is fed to the infant. It is best diluted be- fore use. This preparation should be started with 1 part chymogen milk and 3 parts water, following the direc- tions for increases in quantity and quality as given for human milk. Because of the low carbohydrate content of such mixtures, 0.5 per cent, of lactose should be added after the first few days, and the amount gradually increased to 3 per cent. FEEDING PREMATURE INFANTS. 105 When even only insufficient amounts of human milk can be obtained, artificial feeding should be used as a supplement and not as a substitute. 10. Conclusions. 1. The weight, temperature, stools, absence of ab- dominal distention, cyanosis and well-being of the infant should be the guide for increase in the infant's diet. 2. The utmost care is necessary in increasing the diet of the infant during the first days of life. The gastro- intestinal tract offers the best evidence for increases. \^omiting and abdominal distention and associated cya- nosis are the prime indications for stationary or de- creased amounts of feeding. 3. An initial weight loss during the first ten days must be considered physiological. 4. These infants, therefore, should be fed small quan- tities, frequently repeated, every two to three hours dur- ing the day and night. 5. On the first day following the first bowel evacuation the human milk may be fed diluted with one or two parts of water and sugar, with a caloric value approxi- mating 15 to 30 calories (20 to 40 mils, % to 1% ounce of human milk to the kilogram of body weight). 6. From the second day on, in the absence of indiges- tion, the food may be increased by 10 calories daily per kilogram (15 mils daily per kilogram). In the presence of digestive disorders greater care is necessary to main- tain the metabolic equilibrium (120 mils, 4 ounces of milk to the kilogram of body weight). 7. It is of the greatest importance to administer a sufficient supply of water to counterbalance the rapid evaporation due to artificially heated and dried air and 106 INFANT FEEDING. the excessive excreta, more especially during the first few days. About one-sixth of the body weight of water, inclusive of that contained in the milk, should be fed in twenty-four hours. 8. It is to be remembered that a standstill in the weight- curve, and indigestion with bad bowel movements, fre- quently result when 140 calories per kilogram are exceeded. 9. All intestinal disturbances in premature infants should be given the utmost consideration. 10. The method of administration of food in each case varies with the vitality of the infant. 11. In all cases of prematurity, syphilis should be thought of ; and in cases in which there is the slightest suspicion, the infant must not be placed directly on the breast of a wet-nurse. PART III. Artificial Feeding. CHAPTER I. RECENT PROGRESS IN ARTIFICIAL FEEDING. The presentation of the subject of artificial feeding without a review of the progress and evolution which our ideas on this subject have undergone during the past years might easily mislead the student to the belief that the last word in artificial feeding of infants has been said. The men who have given this subject the most con- sideration, we believe, would agree that much is to be hoped for in the future in artificial feeding. It is most difficult to present in a concise manner the best that we have learned in artificial feeding so that it may be practically applied, because of two very important factors which make for success: (1) a careful interpre- tation of the needs of the individual infant, and (2) ex- perience on the part of the feeder to meet those needs. It remained for the American school of pediatrics to do the pioneer work in placing artificial feeding on a scientific basis. Pepper and Meigs, of Philadelphia, gave us the first rational method in milk modification. They more espe- cially attempted to vary the percentages of casein in cow's milk, believing that the excessive quantity con- tained in cow's milk was in great part the cause of feed- (107) 108 INFANT FEEDING. ing difficulties. This was accomplished by diluting the milk and adding milk-sugar and cream to make up the deficiency in energy value. Rotch, of Boston, made further advances in infant feeding in that he taught us that fat and sugar, as well as protein, were important factors in the disturbances of the artificially fed infants. His work on percentage feed- ing, whereby he increased or decreased the various con- stituents of human milk to meet definite clinical pictures, was probably the first epoch-making advance in infant feeding, and his system of feeding has since been known as "the percentage method" of infant feeding. The German school, of which Rubner and Heubner were the chief advocates, gave us the so-called "caloric method" of feeding, by which they sought to provide the number of heat units required by the infant, basing their estimations on the infant's weight. Of this method we will have occasion to speak later. It is sufficient to state that we do not now use this as a method of feeding, but find a check on the caloric contents of the food of in- estimable value in determining the value of our mixtures in avoiding over- and under- feeding. The German school have never attempted the refinements in the per- centage composition of their mixtures as advocated by the American school. More recently Czerny and Finkelstein have taught us the dangers of overfeeding with whole milk, and also its individual ingredients, fat, sugar, and salts, individually and in combination. Their studies have, on the whole, ignored the proteins, in all probability due to the fact that protein disturbances other than those seen in infants suffering from an idiosyncrasy to cow's milk are for the most part limited to infants fed on raw cow's milk, PROGRESS IN ARTIFICIAL FEEDING. 109 while most of the Continental clinics have for several years fed boiled milk. Their studies and conclusions will be more fully discussed under the disturbances of arti- ficially fed infants. During the past few years there has been an increased tendency to boil cow's milk before feeding to the infants in American clinics, based on the desire to render the curd more fragile, and at the same time to destroy the pathogenic bacterial content of the milk. While this has many advantages, it must not be forgotten that it must necessarily cause changes, more especially in the fer- ments, vitamines, and salts, which are of vital importance to human economy. The ferments are believed to be im- portant to the infant, and this importance has been em- phasized especially since the introduction of pasteuriza- tion and boiling of milk, for the reason that a high degree of heat destroys them. , Some of the ferments are normal constituents of milk, such as lipase, galactase, lacto- kinase, and diastase. The absence of ferments in the milk indicates that it has been heated. Hamburger's studies on the biologic differences in human and cow's milk are unquestionably of vast importance, and though there has been a tendency in recent years to neglect this factor in infant feeding, we believe that it will again receive more important recognition in the near future. The changes caused in milk by boiling make it necessary to administer fruit and vegetable juices, non-dextrinized cereals, and other foods, such as codliver oil, to prevent the retarded development on the part of the infant. CHAPTER II. COW'S MILK. No method of artificial feeding can perfectly replace nursing or human milk feeding. This must be admitted, notwithstanding the many advances that have been made in infant feeding during recent years. The best substitute for nursing is feeding with prop- erly modified milk of other animals, and cow's milk, for practical reasons, was found to be the one best suited for this purpose. There are marked chemical, physical, and biologic dif- ferences between the human milk and cow's milk, which account for the superiority of human milk over the cow's milk in infant feeding. How Cow's Milk Differs from Maternal Milk. The differences between these two milks summarized in a table w^hich follows are greater than the table indicates. While cow's milk may be modified to approximate woman's milk in composition, it can never be just the same or just as good for infants. Cow's milk is more opaque than human milk, although the latter may contain a greater percentage of fat. This is due to the opacity of the calcium-casein, which is pres- ent in greater proportion in cow's milk. Cow's milk is faintly acid or amphoteric w^ien freshly drawn, but ordi- narily is distinctly acid in reaction when consumed. Human milk is amphoteric or alkaline. There is three times as much protein in cow's milk as in human milk. The reason for this is obvious, when we recall that the ratio of the growth of the calf to that of (110) COW'S MILK. Ill the infant is about as 2: 1. Furthermore, the protein in cow's milk consists chiefly of casein (3.02 per cent.) and Httle lactalbumin (0.53 per cent.), while human milk con- tains 0.59 per cent, of casein and 1.23 per cent, lactal- bumin. The sugar in the two milks varies greatly in amount, but not in kind. Cow's milk contains almost four times the amount of inorganic salts compared to woman's milk. Of more importance, the salts in cow's milk consist mainly of potassium and sodium bases. These differences have an important bearing upon in- fant's metabolism. There is no great difference in the average amount of fat in the two milks; however, both in human milk and in cow's milk the fat is the most variable constituent. The curd from cow's milk is usually tougher and in larger masses than in human milk. There are also dif- ferences in antibodies, ferments, etc. Cow's Milk Human Milk Amphoteric or acid . Reaction Amphoteric or alk- aline 1.029 to 1.034 Sp. gr 1.010 to 1.040 3.5 per cent Proteins 1.5 to 2.0 per cent. 2.66 per cent Caseinogen 0.5 to 0.75 per cent. 0.53 per cent Lactalbumin 1.23 per cent. Clots in large lumpy curds Effect of rennin .....Clots in fine curds 4.0 per cent Fat 3.5 to 4.0 per cent. 4.5 per cent Lactose 6.0 to 7.0 per cent. 0.75 per cent Salts 0.2 per cent. 13 to 14 per cent. ...Total solids 12 to 13 per cent. 86 to 87 per cent. . . . Water 86 to 88 per cent. Never sterile Bacterial contents ...Practically sterile Biedert, whose theory found many followers at one time, believed that casein of the cow's milk was the dis- turbing factor in artificial feeding. 112 INFANT FEEDING. The large, tough curds forming from the casein of raw cow's milk differ considerably from the fine flocculent curds of the human milk casein. Steps have been taken to make the cow's milk curd resemble the human milk curd in its physical properties, such as boiling the milk, citration and addition of cereal waters, and it was found that this modification considerably improved the results of artificial feeding. The differences in the fat contents of the two milks have less frequently been drawn upon for explanation of frequent nutritional disturbances on artificial feeding, although it has positively been established that fat plays an important part in the nutritional disturbances of the artificially fed infant. The butter prepared from cow's milk contains 10 per cent, of volatile acids, while that prepared from the human milk only 1.5 per cent. And especially the irritant butyric acid glycerid, which is con- tained in 6 per cent, in butter prepared from cow's milk, is contained only in traces in human milk. The fat drops of cow's milk are also on the whole much larger than those of human milk. Lactose is the principal sugar in both cow's and human milk, average human milk containing 6 to 7 per cent., and cow's milk 4 to 5 per cent. This increased sugar contents of the human milk, with its fermentation, ac- counts for the laxative effect of breast milk feeding when the milk is abundant. L. F. Meyer has experimentally shown that salts of the cow's milk, which vary both quantitatively and qualita- tively from those of human milk, have unfavorable in- fluence on children with nutritional disturbances. While we cannot from these experiments conclude that the same holds true for normal, healthy children, yet we have to COW'S MILK. 113 admit that the salt contents of the two milks are of great importance in artificial feeding. Escherich and Hamburger were of the opinion that human milk contained ferments which favorably influ- enced the processes of metabolism. Salge found that tetanus and diphtheria antitoxins could be utilized by the infant only when fed in human milk, while when con- tained in the milk of other species they did not get into the body fluids of the infant. But whether these biologic differences are of great importance to the infant remains to be proven. Although it seems probable, yet it has not been demon- strated that cowl's milk feeding taxes the digestive func- tions of the infant's organism more than human milk feeding. Of great importance is the bacterial contents of the milk, the human milk being either sterile or of low bac- terial contents, while cow's milk is never sterile, and not infrequently its bacterial contents is very high. Steril- ized, pasteurized, and certified milk were the practical re- sults of the efforts to obtain germ-free milk for infant feeding. The milk for infant feeding must come from healthy cow^s, must be obtained in clean manner into clean re- ceptacles, must be cooled very soon after milking in order to keep down the bacterial content, and kept cool after- wards. It must be delivered to the consumer as soon as possible in such a way as to prevent any contamina- tion, and must be handled in the home, cleanly, in sterile receptacles, and at all times be kept cool. The cow from which the milk is obtained must be entirely healthy, and be especially free from tuberculosis and glanders, tuberculin and mallein test being advisable 114 IXFAXT FEEDING. as a routine, besides general examination of the cow. The cows must be kept clean, in a clean stable, which is well ventilated and drained. Xo dust, manure, or fod- der, except that used for immediate feeding, should be kept in the stable. The cows should be kept clean, but even then they should be cleaned again immediately be- fore milking. The milking must be done in a clean way and milk kept clean afterwards, in order that the bacterial count may be as low as possible. Dry feeding of the cows is preferable, since on this feeding the feces is less liquid, and cows can be kept clean with less difficulty. The milkers should be free from any communicable disease, and be of clean habits. The udders of the cows and the hands of the milker should be scrubbed with warm water and , soap immediately before milking, and anti- septic solution may be applied afterwards. Milking should be done into covered cans, and m.ilk made to pass through a filter first. The cans should be always cleaned immediately after the milk is poured out, first with cold and then with hot water, and also rinsed out with hot water before milking. The first few ounces of milk should be discarded, since this milk contains large amoimts of bacteria that are washed out from the ex- cretory ducts. Cooling the milk after it is obtained is a very impor- tant step in the production of clean milk. The milk hav- ing been obtained with the above-described precautions, with as few bacteria as possible, should be cooled at once in order to prevent growth and multiplication of the bacteria that have entered the milk in spite of all the precautions. This is accomplished by special cooling ap- paratuses, or simply by pouring the milk into sterilized COW'S MILK. 115 bottles, closing with sterilized cap, and putting on ice. The milk in bottles should be kept iced until it reaches the consumer, which should not take longer than twenty- four hours. In the home precautions should be taken to prevent additional contamination, and to keep the milk iced to prevent further growth of bacteria, until everything necessary is ready for making the proper mixture for in- fant feeding. Many good milks are spoiled on the door- step of the home between the hour of delivery and plac- ing the milk in the ice-box. All the utensils and vessels used for preparing the mixture must be perfectly clean and sterilized by boiling. As soon as the mixture is made it should be put into the ice-box again and kept there, portions being taken during the day for individual feed- ings, and warmed separately just before feeding. Certified Milk. The term "certified milk" was coined by Dr. Henry L. Coit, of Newark, N. J., who in 1892, needing good milk for his own baby, formulated a plan for the production of clean, fresh, pure milk under the auspices of a medical milk commission. The term "cer- tified m.ilk," then, is the milk of the highest quality, of uniform composition, obtained by cleanly methods from healthy cows, under the special supervision of a medical milk commission. The use of the term "certified milk" should be limited to milk produced in accordance with the requirements of the American Association of Medical Milk Commission- ers. The first requisite in the production of certified milk is to enlist the co-operation of a, trustworthy dairy- man who is willing to enter into a contract with the medical milk commission. In accordance with the terms of this contract, .the dairyman binds himself to comply 116 INFANT FEEDING. with the specifications set forth, and in return his milk is certified. The dairies are subjected to periodic inspections, and the milk to frequent analyses. The cows producing cer- tified milk must be free from tuberculosis, as shown by the tuberculin test and physical examination by a quali- fied veterinarian, and from all other communicable dis- ease, and from all diseases and conditions whatsoever likely to deteriorate the milk. They must be housed in clean, properly ventilated stables of sanitary construc- tion, and must be kept clean and properly fed and cared for. All persons who come in contact with the milk must exercise scrupulous cleanliness, and must not harbor the germs of typhoid, tuberculosis, diphtheria, or other in- fections liable to be conveyed by the milk. Milk must be drawn under all precautions necessary to avoid contam- ination, and must be immediately cooled, placed in steril- ized bottles, and kept at a temperature not exceeding 50° F., until delivered to the consumer. Pure water, as de- termined by chemical and bacteriological examination, is to be provided for use throughout the dairy farm and the dairy. Certified milk should not contain more than 10,- 000 bacteria per cubic centimeter, and should not be more than thirty-six hours old when delivered. Inspected Milk. This term should be limited to clean, fresh milk from healthy cows, as determined by the tuberculin test and physical examination by a quali- fied veterinarian. The cows are to be fed, watered, housed, and milked under good conditions, but not neces- sarily equal to those prescribed in the production of cer- tified milk. Scrupulous cleanliness must be exercised and particular care be taken that persons having communi- cable diseases do not come into contact with the milk. COW'S MILK. 117 This milk must be delivered in sterilized containers, and kept at a temperature not exceeding 50° F. until it reaches the consumer. There should be not more than 100,000 bacteria per cubic centimeter of inspected milk. This milk should be pasteurized. Market Milk. All milk that is not certified or in- spected in accordance with the above definitions, and all milk that is of unknown origin, is classed as "market milk," and should be pasteurized. Frozen Miik. In our own experienc*e we have found that many infants were made ill by feeding of raw frozen milk which has been rapidly thawed, and allowed to stand in a warm room, with resulting vomiting, and not infrequently diarrhea. These symptoms are obviated when the milk is boiled. Pennington and her collabora- tors found very definite changes in milk after freezing. They found that when the milk is held at a temperature of 0° C. there is proteolysis of the casein, which is pri- marily of bacterial origin, and proteolysis of the lactal- bumin, due primarily to the native enzymes of the milk. The action of these two agents together is more rapid than that of either alone. The bacteria and enzymes may break down the true protein and carry the breaking down through to peptones, even to amino-acids. There is a fermentation of lactose with the formation of lactic acid, which is largely, if not exclusively, due to bacterial action. The fat, so far as can be determined, is not affected except by the action of bacteria. Mixed Milk Versus Milk of One Cov^\ It is far bet- ter, other things being equal, to use the mixed milk of a herd in preparing a baby's food than the milk of one cow, because if the milk comes from one cow, and the cow is ill in any way, the baby is almost certain to be dis- 118 INFANT FEEDING. ttirbed, whereas if one or two cows in a herd are ill, the milk from these cows will be so diluted that the baby will probably not notice it. On the other hand, it is, or should be, self-evident that the milk of a healthy cow properly fed and properly cared for, taken in the proper way, and kept under proper conditions, is better than the mixed milk of a herd which is improperly fed, and whose milk is not carefully obtained or carefully taken care of. Boiling, Sterilization, and Pasteurization. Before entering into a discussion of this subject, it is only fair to state that the general teaching in America of feeding with raw milk has led to the production of safe, clean certified milk in the large communities where so many fatalities were experienced through the feeding of un- clean milk. Any methods of handling milk which will in the least interfere with the proper production of clean milk, and lead to the feeling that unclean milk can be made safe for infant feeding by the application of heat or other methods, would be a backward step in infant feed- ing, and would necessarily cause dire results. While the European countries, like Germany and France, have ad- vocated feeding boiled milk for many years without fear of bad nutritional disturbances due to the changes in the milk, in America feeding with raw milk has until re- cently been favored. Increased experience with boiled milk, especially by those who have long used raw milk, leads to the growing conviction that boiled milk is more easily digested than raw milk by dyspeptic infants, ana hence by the well infants. \Miile we do not believe that feeding with boiled milk should be advised as a general measure, when it is pos- sible to obtain a good certified milk, and when the latter is to be placed in the bands of mothers and nurses who cows MILK. 119 can be depended upon to keep the milk clean and whole- some through proper icing and handling, we do believe that when these requirements cannot be met, that it is safer even in well babies to feed a thoroughly sterilized milk, and that this can be done without danger of de- velopment of scurvy and rickets, when these feedings are accompanied by the administration of fruit juices, vege- table soups, and purees and codliver oil. Brennemann suggests that we must answer the follow- ing questions before deciding as to whether we should feed raw, pasteurized, or boiled milk : (1) Does raw milk offer advantages over boiled milk? (2) Does boiled milk offer advantages over raw milk ? (3) Does pasteurization solve the problem? (4) Does certified milk solve the problem? In answer to the first question we must decide whether the changes caused in milk by boiling, such as partial coagulation of lacto-albumin, caramelization of some of the milk-sugar, its action on casein, inhibiting coagula- tion with rennin, etc., lessen the nutritive value of cow's milk as an infant food. We believe that the sentiment of American, German, and French clinics, in which boiled milk has been used for a long period of time, is to the effect that the nutritive value of boiled milk, with its les- ser dangers, are on the whole in favor of boiled milk. Constipation has been suggested as an argument against boiling milk. We believe that constipation in the bottle-fed baby is one of the safest earmarks of the well- being of the infant, and that only that constipation which is due to excessive feeding of fat, and which will be described under Disturbed Metabolic Balance, is an ex- 120 INFANT FEEDING. ception to this statement. While with raw milk digestive disturbances are frequently seen before sufficient milk is given to properly nourish the infant, this is far less com- mon with boiled milk; in fact, it has not infrequently been our experience that we have overfed with boiled milk, because the infant handles it with so much better advantage. In digestive disturbances, with loose stools, it is digested to much better advantage than raw milk, which frequently results in formation of hard casein curds as well as fat curds. The assertion that feeding with boiled milk results in anemia, underdevelopment and rickets, we believe, is not well founded, and these condi- tions, when present, are due to other causes. Scurvy de- veloping during the course of feeding with boiled milk has never been seen in our experience, except when some of the proprietary infant foods have been fed in con- junction with boiled milk. That under certain conditions scurvy should develop in presence of long-continued feed- ing with boiled milk alone, is not to be denied. The dan- gers, however, are very remote, as testified to by the German and French clinicians. When such dangers are feared, they can easily be overcome, as previously sug- gested, by the feeding of fresh fruit juices and vegetable preparations together with the milk diet. Does boiled milk offer advantages over raw milk? Boiled milk when properly handled is relatively free from pathogenic micro-organisms, and if the milk, which has been boiled, was clean milk, also from their toxic products. In raw milk we have a tendency even in clean milk to bacterial growth which causes souring, and which is not pathological, while when the lactic acid organisms are destroyed by boiling, in proper handling of boiled milk it will result in decomposition with its attendant COW'S MILK. 121 dangers. Boiling in the home has the great advantage over commercial pasteurization and boiling in that, if the milk is raw and spoiled before it reaches the home, this can readily be detected by the housewife. While we know that certain pathogenic organisms may de- velop in the milk without giving evidence of their pres- ence, and cause formation of toxic bodies which are not removed by boiling in the home, the latter process still offers every advantage over commercial pasteurization. Boiling milk in the home will most certainly remove the dangers from infection with tuberculosis, scarlet fever, streptococcus sore throat, typhoid fever, dysentery, and many other milk-borne diseases. The advantages of boiled milk in the presence of indigestion and diarrhea have already been mentioned. The small, flocculent curd of the boiled milk is also rapidly and more easily digested than the large, tough casein curds of the raw milk. The hard bean-like protein curds are never seen in stools of the infant fed on milk which has been thoroughly boiled, although we have occasionally seen them in overfeeding with cow's milk which has been heated by the double boiler process. These latter cases, however, are ex- ceptions. Larger amounts and more concentrated mixtures of boiled milk can be fed than in feeding with raw milk. This is a distinct advantage in the beginning of the feed- ing of atrophic infants. This latter advantage is not to be overlooked. While the large percentage of healthy babies will apparently digest equally well raw and boiled milk within therapeutic limits, it will be found that most authors who do not resort to heating milk will, at least in some other way, modify the curd of raw cow's milk, either by simple dilution, by the use of cereal waters or 122 INFANT FEEDING. an alkaline, such as lime water or sodium citrate. We agree with Brennemann in his statements that boiling commends itself as an excellent casein modifier, and that it effectually disposes of the majority of bacteriological problems when the milk is properly handled after boiling. Pasteurization zrrsiis Boiling. Pasteurization was first recommended because of the belief that boiled milk has scorbutic properties, which could not be laid at the door of pasteurized milk. The question of the relation- ship between boiled milk and scurvy has already been touched upon. Pasteurization in the home is not a very satisfactory process. Commercial pasteurization, even though properly carried out, is too distant from the probable time of consumption of the food to be a safe measure, unless the milk is properly handled after pas- teurization. The best argument presented by the advo- cates of pasteurization is that the milk is essentially a raw milk in so far as 'its physiological properties are concerned. Certified Milk I'ersus Boiling. Clean certified milk, properly handled, both before and after it reaches the home, and where the cost is not prohibitive, -when well digested by the individual infant, still remains the ideal food for artificial feeding. When these requirements cannot be met, boiling in the home is the best method for preparation of milk for the infant. Various Methods of Boiling Milk. In our own work we have resorted in most cases to the heating of the milk in a double boiler. This has several advantages in that the milk is heated in a closed vessel, and has then a less pronounced flavor than when heated in open ves- sels, and causes but little pellicle formation, unless we have a very thin column of milk. To overcome this lat^ COW'S MILK. 123 ter, we therefore recommend the smallest double boiler which can be obtained, and which will at the same time hold all of the milk which is to be prepared. The milk mixture is put in the inner receptacle, cold, and the water in the outer vessel also cold. The double boiler is then placed on the stove, and allowed to remain until the water in the outer vessel boils for six to eight minutes. While the milk heated in this manner forms a very much finer and softer curd than that of raw milk, it is not as fine as that of milk boiled directly over the flame. How- ever, in most cases, it answers all purposes, and has the advantages above enumerated. In the presence of gastric and intestinal indigestion and allied conditions, the finer curd of the milk boiled directly over the flame may be more suitable ; and in exceptional cases, when boiling over the direct flame for three to five minutes does not give the desired result, milk boiled for 30 to 45 minutes over the direct flame will offer further advan- tages, and this method is worthy of trial for temporary use. CHAPTER III. ADAPTATION OF MILK FOR INFANT FEEDING. From the foregoing it may be seen that there is no per- fect substitute for human milk in the feeding of the in- fant, and therefore every effort should be made to assist the mother in the nursing of her infant. Since all the attempts made to feed an infant on the food not primarily intended for this purpose are at- tempts at milk adaptation, we necessarily know that no single method can possibly meet the needs of all infants. And therefore it must be our object, first, to formulate our rules so as to make them safe and adaptable to the feeding of the majority of well babies, leaving the dis- cussion of exceptional and sick babies for further study. It must necessarily go without saying that the food recommended will be excessive for some and inadequate for others. Every organism has its individuality and its fixation coefficient, and every infant makes a different use of the food administered to it. All infants cannot, there- fore, be treated according to the same rule. While many excellent results have been reported with the various methods described for artificial feeding of in- fants, and some attempt has been made to place feeding on a scientific basis, we believe that we must concede that the methods are all more or less empirical, and the result will be in considerable degree dependent upon the wide range of food tolerance of the healthy infant. The successful physician must depend on the clinical ob- servation of the individual infant for the success of the (124) MILK FOR INFANT FEEDING. 125 method of feeding which he is using. Every formula with which we start feeding should be looked upon in the light of an experiment, and the reaction of the infant to this feeding should be carefully studied. If these principles are borne in mind, many an ob- stacle to successful infant feeding will be avoided. We believe that the attempts toward ultra refinement of the infant's diet has led to considerable confusion, be- cause of the different conclusions of the various schools undertaking the work. Eventually, however, infant feed- ing will be placed on a thoroughly scientific basis. This, however, does not answer the pressing needs of to-day, which call for a safe and practical solution of the feed- ing problem for the feeding of the everyday baby in everyday life. The baby is so commonly receiving its feeding advice from food manufacturers ; and if feeding on one preparation is not successful, there is a rapid transition from one proprietary baby food to another, with untold detriment to the infant. In advancing the rules for feeding the normal healthy infant, with fur- ther suggestions for the underfed, on simple milk mix- tures zvith carbohydrates added, we desire to state that in our clinical experience we have found them safe for the baby and practical for the physician, which latter is neither to be overlooked nor taken lightly. We claim nothing original for these feeding sugges- tions, as they represent the more common practice of the Continent, and America as well. We have, however, formulated the rules which govern the application of simple milk mixtures, with carbohydrates added, in such a way that their application becomes more practical. Kjtiowing that the feeding advice which we are to receive and advise is founded on clinical experience, and that 126 INFANT FEEDING. similarly good clinical results in feeding have been ob- tained by others by various methods of feeding, we be- lieve it advisable to briefly review the more popular methods of infant feeding as practised today. 1. Undiluted Whole Milk. While undiluted milk has been used with varying degrees of success by some German and French pediatricians (of the latter Budin being the foremost advocate), it may be generally stated that, on the whole, it is not well borne before the fourth month of life. If whole boiled milk is used in the feed- ing of the very young infant, the size of the individual meal must be greatly restricted over that as recommended for diluted mixtures, so that it will not exceed the caloric requirements of the individual. Budin recommended that all whole milk fed to an infant should first be boiled, which causes the protein to be precipitated in the infant's stomach in the form of a fine curd. This can be fur- ther facilitated by the addition of pegnin or chymogen, which causes the formation of the fine curds before it is fed to the infant, with no recoagulation in the stomach.* Alkalinizing milk by the addition of sodium bicarbonate also results in the formation of fine curds. In some forms of vomiting, small quantities of a concentrated food will frequently be found of considerable value. As a routine measure of feeding, whole milk cannot be recommended. 2. The Percentage Method or System of Feeding. This is frequently spoken of as the xAmerican method, or Rotch's method, because of the fact that Rotch, of Bos- ton, did much to popularize and systematize this method of feeding. Not only did he work out a system of * Brennemann, Archives of Pediatrics, 1917, 34, 81. MILK FOR INFANT FEEDING. 127 formulae adapted to infants of varying ages and develop- ment, but he also was the means of establishing the first so-called public milk laboratory. The chief objections to this method, as originally described by Rotch, were its lack of flexibility and the difficulty of remembering the various formulae and their preparation. The followers of the Rotch school state that the percentage feeding, so- called, is not a method of feeding, but merely a method of calculation, and a means of obtaining relative accuracy in the preparation of infants' foods. They have sim- plified the method as originally applied, lengthened the feeding intervals, and, while still retaining some of the original ideas, have made the method far more practical. 3. Top Milk Feeding. In this method a definite number of ounces of the upper part of the milk, which has stood for a number of hours, is used as the basis for preparing the mixture to be fed. To successfully carry out top milk feeding, the per- centages of fat at various levels in 32 ounces (quart) of milk containing 4 per cent, of fat, and which has stood for six hours or longer, must be known: Upper 16 oz. has 7 per cent. fat. 20 " " 6 " a -yA a a r a n a (1) This method endeavors to provide ample caloric values. In this respect the method may be regarded as successful. (2) There is the idea that casein is not very digestible, and that it is advantageous to feed casein in small quantities, making up the shortage in energy value of the mixture with fat. In the light of our pres- ent knowledge, however, we know that the casein of boiled or alkalinized milk, or when mechanically divided 128 INFANT FEEDING. by the addition of cereals, is easily digested. (3) The attempt to produce a formula with the percentage of fat in the same proportion as is found in human milk, as well as larger amounts, which, however, frequently leads to fat indigestion, because of the greater difficulty experi- enced by many infants in handling large quantities of cow's milk fat. (4) The importance of the sugar and salt content of the mixture is underestimated. This method of feeding, nevertheless, has many ad- vocates, and we would advise that the above shortcom- ings of the method as originally described be given full consideration by those adopting this method of feeding. CHAPTER IV. MILK DILUTIONS WITH THE ADDITION OF CARBOHYDRATES. It has been our experience that about 90 per cent, of the infants that come under our observation for artificial feeding will tolerate a wide range of quantitative values in the components of the milk, i.e., fats, proteins, carbo- hydrates, and salts. And the simpler the first formula on which the baby is started, the easier we find it to meet its later needs for growth and development, by in- creasing or decreasing the individual elements in the diet. The first step of this method consists in the dilution of whole milk with water, thereby reducing all the ingredi- ents of the milk. When we compare such a dilution with human milk we find that when protein approximates that contained in breast milk, the fat is considerably reduced below that contained in the latter. This in practical feed- ing we find to be an advantage rather than a disadvan- tage, and if there be an indication for increasing the fat content of the formula this is easily accomplished by the addition of cream, or top milk, which is, however, usu- ally not necessary, as the deficiency in fat can usually be successfully compensated by adding sugar and starch to the formula. As a result of dilution, the salts, which are about three times as great in quantity in cow's milk, are reduced to more nearly the amounts contained in breast milk. We must, however, remember that there are still great qualitative differences in the salt content of the cow's milk dilution and human milk. 9 (129) 130 INFANT FEEDING. In K2O NaO CaO MgO F2O3 P0O5 CI Human milk . 30.1 137 13.5 1.7 0.17 12.7 21.8 % in 100 parts ash Cow's milk . . 22.14 15.9 20.05 2.63 0.04 24.7 21.27% in 100 parts ash Feeding should primarily be formulated to promote normal growth and development, to supply energy for the body functions, to prevent disease; and, although of no lesser importance, feeding in disease shotild be given a secondary consideration in the study of this subject. The food must be given in such form that the infant may be able to digest it easily, to assimilate it, and to utilize its constituents for the purposes enumerated above. The following factors must be considered before esti- mating the composition and quantity of food for infant feeding. 1. The clinical aspects — that is, the general well- being of the infant — must be given equal importance with the percentage and energy value of the food administered. 2. Is there a normal gain in weight w^hich an infant must show as a sign of full health? 3. The qualitative and quantitative chemical composi- tion of the food, the number of calories available from the total administered, and the proportion of the total fixated in the body must be taken into calculation. The normal artificially fed infant should manifest the same cHnical evidences of good health and progress as are seen in the breast-fed infant. It should be com- fortable, which he manifests in a happy disposition. He should be a good sleeper, and awaken regularly for his feedings, and there should be no more occasion for his MILK DILUTIONS WITH CARBOHYDRATES. 131 crying than in the case of the breast-fed baby. His tem- perature should show maximum excursions of 1° to 2° F. daily. He should have large quantities of subcutaneous fat, and his muscular tissue should be well developed. The turgor of his tissues should be normal. The latter can be estimated by the eye and by palpation. The muscles may be taken between the fingers, and their firm- ness or softness estimated in this way. By raising a fold of the skin we may determine whether the panniculus adiposus is well developed. The stools, which of neces- sity must vary with the diet, are firmer and drier and much paler than those of the breast-fed infant, and he should pass one or two daily. Except in the presence of large amounts of carbohydrates, and more especially malt sugars, they are alkaline in reaction, and have a foul odor. Therefore, we see that the criterion of good health for the artificially fed infant depends on many things, which together make up the condition of the infant. And we again desire to emphasize that the impression of the general well-being of the infant is a much safer method of estimating its progress than a study of his weight- curve alone. We have learned to recognize the study of the infant's weight as one of the simplest and most reliable clinical factors in estimation of the infant's progress. And while of necessity the diet of different infants necessary to normal weight increases must vary within very consider- able limits, the scale offers information which is of in- estimable value. The following may be taken as working averages for comparative purposes, and the estimation of over- and under- weight in infants coming under observation. 132 INFANT FEEDING. Average weight at birth 7 pounds (3200 Gm., or about 3333 Gm.). Average initial loss 10 ounces (300 Gm.) or about one-tenth of the body weight at birth. Birth weight regained usually by the fourteenth day. Weight is doubled at the end of the fifth month. Trebled at the end of the first year. Fig, 8. — Scale for weighing infants. Average weekly gain during the first five months) should approximate 5 ounces (150 Gm.), during the remainder of first year 4 ounces (120 Gm.). Yearly gain during the second year 6 pounds (2727 Gm.). Gain during the third year 4.5 pounds (200 Gm.). Gain from the fourth to the eighth year, 4 pounds annually (1800 Gm.). Gain from the eighth to the eleventh year, 6 pounds annually (2700 Gm.). An accurate scale is necessary equipment for proper infant feeding. Parents should be encouraged to pur- chase a balance scale with a large scoop. MILK DILUTIONS WITH CARBOHYDRATES. 133 However, it is not sufficient to base the determination of the amount of food on the weight of the baby alone, since two infants of the same weight may have decidedly different nutritional requirements, dependent upon vari- ous factors. The fat baby requires less food per pound than the thin baby — the overfed less than the underfed infant ; and the sick baby must of necessity be fed within its limits of tolerance during the acute part of its illness, and the body losses must be compensated by increases in the diet beyond those which we have learned to consider as the normal feedings per pound body weight, as its tolerance for food permits during convalescence. A healthy infant should, therefore, show a regular gain within certain limitations. It is not absolutely necessary for an infant to add to its body weight every day, as daily irregularities are rather the rule than the exception. The relation of the time of weighing to the feeding, defeca- tion, and urination are factors which must always be taken into consideration. Therefore under normal condi- tions it is sufficient to weigh the infant once a week. It is especially wise to impress this upon a nervous mother. Further, we must not forget that the weight curve of the nursing infant and that of the artificially fed infant differ widely, so that they cannot be compared directly. The artificially fed infant, although in the beginning gaining less than the breast-fed infant, in the course of a year reaches the same weight as the breast-fed infant, who at first showed larger gains, but later lagged some- what in its gains. Much more important than the weight itself is the rising series of successive weight figures. The clinical aspects, that is, the general zuell-heing of the infant must he given equal importance zvith the per- centage and energy value of the formula. In a consider- 134 INFANT FEEDING. ation of the latter two important factors in successful feeding, the chemical composition must he considered of equal importance zanth the caloric value. Otherwise one meets with profound disturbances due to feeding of in- sufficient or excessive amounts of the components of the diet, difficult of interpretation. It may therefore be stated that the infant must be fed amounts of fat, protein, carbohydrates, and salts and water suitable to its constitution, age, and physical de- velopment, and that these ingredients should be in proper proportion and of sufficient quantity to meet the caloric requirements of its tissues for growth and development. Again, we must not overlook the fact that the constitu- ents of the diet must be in such form as to allow of nor- mal digestion and assimilation. We have spoken of the wide range of tolerance of in- fants to their foods, and have mentioned that this, in all probability, accounts to a very great degree for the fact that so many men have been successful in the feeding of infants on a variety of mixtures which varied greatly both quantitatively and qualitatively. There is in all probability another factor which is important in explain- ing these successes, namely, the fact that to a certain ex- tent fats, carbohydrates, and proteins are interchange- able in their metabolic functions. Proteins. After passing through the intestinal wall proteins have three functions to perform : ( 1 ) to replace used protein (lost through urine, sweat, digestive juices, cell destruction, etc.) ; (2) to satisfy cell growth, which would be impossible without proteins; (3) to furnish fuel for part of the dynamic loss (fats and carbohydrates are the natural fuel, the protein combustion being incidental only). MILK DILUTIONS WITH CARBOHYDRATES. 135 There is three times as much protein in cow's milk as in human milk. The reason for this is obvious, when we recall that the ratio of the growth of the calf to that of the infant is about as 2 to L Furthermore, the protein in cow's milk consists chiefly of casein (3.02 per cent.) and little lactalbumin (0.53 per cent.), while human milk contains 0.59 per cent, of casein and 1.23 per cent, of lactalbumin. The proteins are characterized by containing nitrogen. If the nitrogen is determined in the food eaten during the period of the experiment, it is evident that a balance may be struck which will determine whether the body is re- ceiving in the food as much protein nitrogen as it is metabolizing and eliminating in the excreta. If there is a plus balance in favor of the food, it is evident that the body is laying on or storing protein, while if the balance is minus, the body must be losing protein. During the period of growth, in convalescence, etc., the body does store protein, and under these conditions the balance is in favor of the food nitrogen. It is important also to bear in mind that nitrogen or protein equilibrium may be established at different levels in order to explain the good feeding results with what may be an excessive protein diet. That is, an infant who has been receiving 1.5 Gm. of protein per Kg., and who has excreted the greater part thereof, retaining only such portion as is needed for the body growth, will, upon being fed larger quantities, retain only a similar amount for body growth, excreting the difference in the urine, sweat, and feces. The true cell life does not depend on what has been ingested, absorbed and temporarily fixated, to be eliminated soon afterwards, but on the constant and stable fixation. The body may become adapted to over- 136 INFANT FEEDING. feeding and overfixation, but this is usually of only a short duration, and the excretion of the oversupply is never long delayed. Experimentally, it is found that there is a certain low limit of proteiri which just suffices to maintain nitrogen equilibrium. Rubner found that when 5 per cent, of the total energy intake was in protein that it was sufficient for maintenance, and that even 4 per cent, was sufficient to supply its actual need when amply supplied with carbohydrate. However, 7 per cent, was necessary to keep up the normal growth. Examination of the dietaries of civilized races shows that, on the average, 100 to 120 Gm. of protein are used daily by an adult man. A variable portion of this amount passes into feces in undigested form, but we may assume that about 100 to 105 Gm. are absorbed, and actually metabolized in the body. If we take into account the weight of the body, this amount of protein may be esti- mated as equivalent in round number to 1.5 Gm. of pro- tein, or 0.23 Gm. nitrogen, per kilogram of body weight. Chittenden believes that the daily quota of protein per kilogram of body weight may be reduced to one-half this quantity, from 1.5 Gm. to 0.75 Gm. of protein, or 0.12 Gm. of nitrogen, per kilogram body weight. If the body can be kept in good condition upon 0.75 Gm. per kilogram per day, will an ingestion of more than this (say twice as much) prove injurious or beneficial or indifferent to the body? The full and satisfactory answer to this question must be deferred until more ex- perience is obtained. The newer conceptions in regard to the digestion and nutritive history of the protein foods certainly seem to favor the adoption of a low protein diet. Mankind, when left to the guidance of the natural appe- tites, has always, when possible, adopted the high pro- MILK DILUTIONS WITH CARBOHYDRATES. 137 tein level of 90 to 100 Gm. per day. That mankind has made a mistake in adopting the higher protein level can hardly be claimed on the basis of our present knowledge. The chief demands for protein are to compensate for wear and tear, and to provide for growth. Sugars and starches, when added to a diet sufficient to meet an infant's needs, will, temporarily at least, cause a greater nitrogen retention. Fats have little or no such influence. Nitrogen to be retained must be built up into living protoplasm, and to accomplish this salts must be available. Unless they are present, the nitrogen is again excreted. Approximately 1.7 Gm. of ash are retained for each 1 Gm. of nitrogen (Howland), or 0.3 Gm. of ash for each 1 Gm. of protein. Hoobler believes that the protein needs of the infant are supplied when 7 per cent, of its caloric needs is fur- nished in protein calories, and states that three-fourths of a;n ounce of whole or skim milk, or 0.6 Gm. of protein per pound body weight is sufficient to meet these needs. To make up the deficiency in the caloric needs, he adds for each ounce of whole milk one-third of an ounce of sugar or cereal. Rubner was able to promote normal growth when 0.7 per cent, of the total energy intake was in proteins. Cowie finds the protein requirement in a two- to twelve- months infant to average 1.1 Gm. per pound. Dunn states that 1.0 Gm. to 1.5 Gm. of protein daily per kilogram of body weight is necessary for the nor- mal infant. Camerer states the following requirements for each kilogram of body weight in a child between 2 and 4 years of age: proteins, 3.6 Gm. ; fat, 3.1 Gm. ; carbohy- drates, 9.2 Gm. ; and water, 75.3 Gm, 138 INFANT FEEDING. It has been our custom to feed approximately 1.5 ounces of milk to a pound of body weight to the healthy normal infant, which would represent 1.5 Gm. of protein per pound of body weight. Notwithstanding what has been said on theoretical and experimental studies of the protein needs of the arti- ficially fed infant as compared with the amount of pro- tein as received by the breast-fed infant, it must be granted that casein, the chief protein of cow's milk, as given in ordinary dilutions to the infants is sufficient to cover entirely the protein needs of the infant, and that its excess rarely causes nutritional disturbances when the tendency to large curd formation is prevented by boiling or alkalinizing the milk. We have therefore continued to use the protein as contained in 1.5 ounces of milk per each pound of body weight of the normal infant, and in the underfed we have not hesitated to increase this quantity to an amount equal to 2 or even 2.5 ounces per pound, thereby approxi- mating 1.5 ounces per pound of what the baby should weigh for its age. Increases of milk in the diet must be gradual, the additions being guided by the child's ability to handle the food. From what has been stated, it may be inferred that it is wise to establish the protein content in a diet which may then be supplemented by fats, carbo- hydrates, and salts, because protein is the tissue builder and must necessarily be a basic constituent of all diets. Fats. Fats are necessary to normal growth and nutrition of the human body. But they to a greater ex- tent than the other food elements can be replaced by proteins and sugars, more especially the latter. This ex- plains the fact that infants fed on low fat mixtures, more especially proprietary foods, such as condensed milk, will MILK DILUTIONS WITH CARBOHYDRATES. 139 continue to gain in weight. However, such development cannot be considered as normal. Fats furnish part of the heat energy necessary to main- tain the body temperature. They are stored as a reserve food. The fat is a protein saver, and when supplied in proper amount but little protein is used for the produc- tion of animal heat, thereby allowing for greater protein retention for the growth of the body tissues. . Under normal conditions, the average infant will digest from 2 to 3.5 per cent, of fats. However, some infants digest fat badly, and when a fat intolerance is once estab- lished it is overcome only with great difficulty. In such cases it is necessary to throw the burden of furnishing the extra food necessary on the carbohydrates; and car- bohydrates in large quantities are unsafe food for the infant. Such a catastrophe should be avoided, as infants receiving an insufficient amount of fat rarely thrive satis- factorily. We should therefore aim to stay within safe limits. And it has been our experience that most infants will thrive well on the amount of fat furnished by the use of 1.5 to 2.0 ounces of whole milk per pound body weight. When moderate quantities of fat are fed, we avoid the acute clinical picture of fat overfeeding asso- ciated with vomiting and diarrhea, and not infrequently a high temperature, and occasionally convulsions. On the other hand, the moderate quantity of fat contained in the diet necessitates a high percentage of carbohydrate feed- ing, which in turn avoids the so-called fat-soap stools, with their tendency to rob the body of an excessive amount of calcium and magnesium. For the formation of a fat-soap stool it is necessary that we have an insuffi- ciency of carbohydrates and a relative excess of proteins, as putrefaction is necessary for the production of these 140 INFANT FEEDING. stools, while fermentation opposes their formation. And in the presence of excessive fermentation the putrefac- tion is limited. It may therefore be stated that while the tolerance for fat of cowl's milk varies greatly in different individuals, most infants, however, will digest and assimilate 1.5 to 2.0 Gm. of fat per pound body weight daily, which is the quantity represented in 1.25 to 2.00 ounces of average cow's milk. This quantity will also supply the body needs for growth and development, when associated with a sufficient carbohydrate content in the food. Carbohydrates. They are used chiefly to supply heat and energy, to supply in part material for fat foun- dation, thereby replacing in part the fat waste. Because of their high caloric value they supply a large amount of energy. They are efficient sparers of protein, and will supply energy in case of fat insufficiency in the diet. Synthetically, they are converted into glycogen in the body. Fat is formed from sugar by the subcutaneous cells, which are especially adapted to this function. Sugar is reduced to CO2 and water, which may be meas- ured by the respiratory metabolism. Normally, sugar is absorbed from the small intestine in greater part, and is not found in the feces. If absorbed in sufficient quantity, they will cause a rapid increase in weight. When insuffi- cient carbohydrate is supplied to the body, it is obtained by breaking down the body protein. In general, infants have a very high carbohydrate tol- erance — much higher than the adult — and even infants suffering from certain forms of nutritional disturbance may retain their ability to metabolize sugar, even though it may have been reduced for fat and proteins. Some infants do not handle sugar well, and among these MILK DILUTIONS WITH CARBOHYDRATES. 141 are certain forms of gastro-intestinal disturbances, eczema, etc. During recent years much has been written on the superiority of one form of carbohydrate over the other. We can practically exclude the monosaccharides in the consideration of the subject, and speak only of the di- saccharides, of which lactose, saccharose (cane-sugar), and maltose are the ones used in infant feeding, of the polysaccharides, as represented by the cereal flours and dextrin, and last, of the mixture of disaccharides and polysaccharides, together with other substances, these mixtures being represented by the various infant foods on the market. Sugars. Of recent years there has been a consider- able discussion on the comparative nutritive value of milk-sugar (lactose) and cane-sugar (saccharose). In our own experience we have found little to recommend one over the other in so far as their nutritive value and the limit of tolerance is concerned, except as we have seen a laxative effect from the use of lactose, which is usually not present with the same quantities of sac- charose. This is, however, not seen in all infants. Mal- tose is not used pure, but as previously stated, in the form of various compounds in infant feeding. It may therefore be stated that cane-sugar will answer all re- quirements for most cases, but should rarely be used in amounts larger than 3 to 4 per cent, of the total mixture, because of its intense sweetness. It may be also recom- mended from the standpoint of economy. In the presence of extreme colic, it is often wise to change the form of sugar that the infant is receiving, as the individual infant may show an intolerance for one or the other sugar. 142 INFANT FEEDING. Quantities. Cane- and milk- sugar may be added to the diet in the following quantities : Infants under 6 pounds — 0.5 ounces in twenty-four hours. Infants between 6 and 10 pounds — 0.75 to 1.00 ounces in twenty- four hours. Infants between 10 and 14 pounds — 1.00 to 1.25 ounces in twenty- four hours. Infants over 14 pounds — 1.5 ounces in twenty-four hours. Approximately, therefore, about 1 ounce of sugar is added in twent}-four hours for each 10 pounds of body weight, or about %oo of the body weight in twenty-four hours. Including the sugar contained in the milk, and exclu- sive of the cereal, the infant should average from 4.0 Gm. to 6.0 Gm. of carbohydrates per pound body weight to furnish its needs. Dextrin and maltose compounds can frequently be added to the diet to advantage in the presence of sta- tionary weight. It must, however, be remembered that their relationship to constipation varies greatly, depend- ent upon their malt, dextrin, and potassium carbonate content. Thus we find that those of the proprietary foods containing a considerable percentage of dextrin, in the absence of potassium carbonate, are constipating (Horlick's malt food. Mead's dextrimaltose) ; while those with a higher maltose content, together with potas- sium carbonate (Borcherdt's dri malt soup and Mellin's food), are laxative. Cereal Flours. They can be added to the diet of most infants early in life in quantities varying from 1 to 2 per cent, of the total quantity of the milk mixture to good advantage. Such an addition to the food fre- quently results in rapid weight increases, and general MILK DILUTIONS WITH CARBOHYDRATES. 143 improvement of the infant. In older infants, cooked cereals may be used in place of the starch solutions. We have reason to believe from clinical experience that the flours made from cereals have a decided advantage over the dextrinized flours on the market. Whether this is due to vitamines contained in the former or to some other distinctive property we are unable to state. The cereals also have a decided influence on the calcium and magnesium balance. The cereals cause retention of these salts, which may have a favorable influence on the weight. Salts. Salts are necessary in digestion, and in every step of metabolism, from, absorption to excretion and secretion. The role of salts in both normal and path- ological conditions has been given constantly increasing importance in the last few years. Human milk contains 0.2 Gm. of ash in 100 mils, and cow's milk 0.78 Gm. of ash in 100 mils. The difference in percentage in the human and in the cow's milk is equalized by the body using only what is necessary for its life and growth. The salts are absolutely necessary for the life of the organism. While all the salts are in larger percentage in cow's milk than in human milk, the relative proportions of the different salts differ greatly. In general, cow's milk con- tains relatively a very large amount of calcium phosphate, while the proportion of potassium salts and iron in cow's milk as compared with human milk is relatively small. There is a great difference in the form in which phos- phorus is present in human and in cow's milk. In human milk three-quarters of the phosphorus is in organic com- bination, while in cow's milk only one-quarter is in or- ganic combination. The iron in neither human milk nor 144 INFANT FEEDING. in cow's milk is sufficient to meet the demands in the first year of Hfe; the infant must depend on the iron stored during fetal life. The following table gives per- centages of different salts in 100 parts of ash of the human and of the cow's milk. K2O NaO CaO MgO F2O3 P2O5 CI Human milk . . 30.1 13.7 13.5 1.7 0.17 12.7 21.8 Cow's milk ... 22.14 15.9 20.05 2.63 0.04 24.7 21.27 The inorganic salts in human milk consist mainly of the alkaline bases, potassium and sodium, while in cow's milk the calcium and magnesium account in greater part for the difference in the total mineral content of the two milks. From the preceding table it becomes evident that in higher dilutions of cow's milk the potassium and sod- ium content must suffer most. Such a long-continued feeding of an insufficient amount of potassium and sodium may affect the infant's development to a serious extent. Human milk also contains about four times as much iron as cow's milk, and dilution of cow's milk re- sults in a decrease in the iron content, which must not be carried too far unless supplemented by other iron-con- taining food. "Therefore the mineral metabolism of the artificially fed infant differs greatly from that of the breast-fed in- fant. The infant receiving cow's milk, with its greater salt contents, lives on a higher plane of mineral metab- olism than does the one receiving the breast milk. He absorbs 60 per cent, of the total ash, and retains only about 15 per cent., while the breast-fed infant utilizes to the full his opportunities, and absorbs 80 per cent, of the ash, and retains 40 to 50 per cent. In the majority of infants this excessive salt intake undoubtedly does no harm ; the surplus is not absorbed, or is merely eliminated. MILK DILUTIONS WITH CARBOHYDRATES. 145 "Sodium and potassium are usually well retained, un- less severe diarrhea is present, or there is an excess of fat or of sugar in the diet. Under such circumstances they are lost, and the loss is badly borne, and cannot in- definitely be continued. When all available alkalies have been drawn on, the infant breaks down his own tissue to furnish more of these substances, which is an explana- tion, for a part at least, of the excessive nitrogen excre- tion under such conditions. When diarrhea ceases, and the intake is sufficient, a positive balance is rapidly instituted. 'The metabolism of calcium has been largely studied, on account of its close relationship to rickets and tetany. Calcium is so largely excreted by the bowel that it is im- possible to say how much is absorbed, plays part in the organism, and is then excreted by the intestine, either be- cause it is in excess, or because (as in the case of rickets) the body cannot utilize it. This is also true of mag- nesium, and to a much less extent of sodium and potas- sium" (Howland). The salts are necessary for building up of the body tis- sue, and each gram of protein retained and built into body tissue requires approximately one-third of a gram of ash. Water. The quantity of water necessary for the in- fant is not only of theoretical, but also of vast practical importance. There are many breast-fed infants who ob- tain a food which is very rich in other nutritive sub- stances, but contains only a small amount of water. These infants may not gain well in weight unless water is added. And, besides that, in sick infants it is occa- sionally necessary to feed them (especially in cases of vomiting, anorexia, infections) with concentrated food, 10 146 - IXFAXT FEEDING. and in these cases the total water intake necessary must not be lost sight of. In regard to water retention Meyer* found three classes of cases: (1) those in which there was a de- crease in weight when the food was concentrated, and the weight increased only after addition of water; (2) those where the weight remained the same on a concen- trated food, and there was an increase after the addition of water; and (3) those in which the addition of water made no difference, but who did well on a concentrated food. He found that the water need decreased with in- creasing age — that on artificial food the water needs were 89 Gm. per Kg. body weight in twenty-four hours at the beginning, and 80 Gm.. at the end of the first year ; while in breast-fed infants the water need amounted to 134 Gm. to 140 Gm. per Kg. in twenty-four hours. Water is absolutely necessary for life, and manifesta- tions of life are impossible without w^ater. The lack of or inadequacy of water are much more dangerous to the infant than a corresponding deficiency in the food. Ex- cess of water, however, exerts also an unfavorable influ- ence on the organism. Immunity is considerably de- pendent on the physiological water content of the body. Estimation of the Caloric Contents of the Food as a Check on Over- and Under- feeding. Calorimetric estimations of the diet must be considered only as a check on under- and over- feeding, and not as a method of feeding. In the infant whose diet usually consists of milk or its constituents and sugar and cereal flours, this is a very simple matter. It should, however, be remem- bered that there are considerable variations in the caloric '^ L. F. Meyer, Zschrft. f . Ivhlk. 1912, 5, 1. MILK DILUTIONS WITH CARBOHYDRATES. 147 requirements of normal babies. The fat and well-nour- ished infant will require less food to maintain its body heat than the emaciated one. The sick baby will rarely be able to digest its full needs as estimated by its body weight. Therefore as in every other phase of infant feeding, the individual infant must be given primary consideration. It must be remembered that the nutri- tion of the baby depends upon the quantity of the food assimilated, and not upon the quantity ingested. Less food is being absorbed and utilized in the infant with a deficient power of digestion, and overfeeding will re- tard the infant's progress. A comparative estimate of the infant's diet, with a theoretical minimum, is of special value in cases of doubt as to whether the retarded prog- ress is due to insufficient food or defective digestion and assimilation. Under this system the physician reckons the minimum daily caloric requirements, either from the present weight of the baby or what it should weigh in health, and then chooses the food necessary to meet this re- quirement, bearing in mind that the fat, carbohydrate and protein contents of the diet must not only meet the caloric requirements, but also be properly proportioned, so as to contain the proper number of grams of each of the constituents to meet the infant's needs for growth and development. Heubner and Rubner gave us the first definite estimates as to the caloric needs. They found that the average healthy infant after birth requires on the average 100 calories per kilogram body weight, from six months to the end of the first year — approximately 85 calories per kilogram body weight — and that 70 calories per kilogram body weight is the energy quotient on which a baby would maintain a weight equilibrium. 148 IXFAXT FEEDING. Dunn places this minimum caloric requirement for artificially fed infants as follows : Birth to 6 months , . . 120 cal. per Kg. (55 cal. per pound) 6 to 12 months 100 " " " (45 " " " ) 12 to 24 months 90 " " " (40 " " " ) Dennett^ gives the following figures : Fat infants over 4 months of age . . 40 to 45 cal. per pound Average infants under 4 months of age and moderately thin infants of any age 50 " 55 " " Emaciated infants (varying with the degree of emaciation) 60 " 65 " " " Bradyt gives the following figures as his experience with ii)stitutional children: 50 to 55 calories for each pound during the first 6 to 8 months of life. Our own experience coincides with those of Dennett and Brady in that we find that the figures of Heubner do not meet the requirements of any except the well-nour- ished infants. Underfed infants not suffering from de- composition (marasmus) must be fed food of a higher caloric value per pound body weight than the normal in- fants, and while such infants must be fed minimal quan- tities when first seen, for a proper gain in weight their normal weight must be estimated and their diet gradually approximated to the needs of the weight that they should normally have. Average infants under 2 months of age . . 30 to 45 cal. per lb ( 65 to 100 per Kg.) Average infants over 2 months of age . . 45 " 55 " " " (100 " 120 . " " ) * Infant Feeding, J. B. Lippincott Co., Philadelphia, page 58. t J. M. Brady, Institutional Care of Infants, Archives of Fed., 1917, 34, 356. MILK DILUTIONS WITH CARBOHYDRATES. 149 Premature and thin infants under 2 months of age 50 to 65 cal. per tb (110 to 140 per Kg.) Thin infants older than 2 months, de- pending upon their general condition . 55 " 70 " " " (120 " 150 " " ) During the first few weeks of life of the artificially fed infant it is usually difiicult to approximate these figures (see p. 159). Increases in quantity of food should always be gradual, especially in the presence of malnutrition, and the infant carefully observed, and increases made only as the toler- ance for food permits. Estimation of the caloric contents of the food is not a feeding method and should be used only as a check on over- and under- feeding, the scale, stool, and general condition, and particularly the disposition of the infant, being the ultimate guide for dietetic changes. Energy quotient is the number of calories which the infant is getting per pound or per kilogram of body weight. To determine the energy quotient of the diet multiply the number of ounces of each food ingredient of the food mixture by their caloric values, add the products and divide the sum by the number of pounds or kilo- grams of the baby's weight. Caloric Values of 1 oz. (30 Gm.) of Various Foods. Calories Cow's milk 21 Human milk 21 16 per cent, cream 54 Skim milk 11 Buttermilk 11 150 IXFAXT FEEDING. Calories. Buttermilk mixture .- 21 Albumin milk 12 Chymogen milk 21 Keller's malt soup 25 Cane-sugar (by weight ) 120 Maltose-dextrin compounds (average) 110 Malt-soup extract, dry, by weight 90 '' " " by measure 132 Flour, by weight 100 Cereal waters (1 oz. cereal to quart) 3 The following table gives equivalents of 1 ounce by weight and the domestic measures of carbohydrates used in artificial feeding of infants : Cane-sugar .... By weight . 1 OZ. By measure 1.00 oz. Table- Dessert- spoonfuls spoonfuls leveled with a 2 3 Tea- spoonfuls knife. 6 Milk-sugar .... 1 '' 1.50 i< 3 4.5 9 Dextri-maltose 1.50 a 3 4.5 9 Flour (wheat) - 2.25 <( 5 7.5 15 Flour (barley) 1.50 a 3 4.5 9 Barley (pearl) 2.50 '•' 5 8 15 Oats (rolled) . 2.50 a 5 8 15 1 tablesboon ful = 1.5 dessert' spoonfuls = 3 teaspoonfuls. Practical Application of Milk Dilutions with Addi- tion of Carbohydrates in Infant Feeding. In the appli- cation of the rules for the feeding of normal, healthy infants, it must be remembered that each infant must be fed to meet its individual requirements, and the rules modified so as to meet the demands of the individual baby. If milk dilutions, with the addition of carbohy drates are used, the simplest and most natural standard would be one that would tell us how much milk and car- bohydrates per pound or per kilogram body weight the baby should get. To be exact we should express, or at least be aware, of the number of grams of proteins, fats, MILK DILUTIONS WITH CARBOHYDRATES. 151 carbohydrates and salts that the infant is receiving for each pound of its body weight. We beHeve that if statis- tics on infant feeding were collected on this basis rather than in percentages of the ingredients in the milk mix- tures (the total mixture being of such variable quantity) the collected data would be far more valuable as a basis for future work in infant feeding. In every instance the general health of the infant is of the greatest importance in estimating its capacity for as- similating the diet. To meet protein and fat requirements, the average nor- mal infant will require each day a minimum of ly^ ounces (45 mils) of cow's milk per pound of body weight, exclusive of the sugar and starch which are added in preparation of the mixture. Practical experience has taught us that infants under five months of age will frequently require amounts ap- proximating 2 ounces (60 mils) of cow's milk per pound body weight, except during the first few weeks of life, when smaller quantities of whole or skim milk are indi- cated (see p. 159). With the institution of a mixed diet, the infant thrives with less milk per pound body weight. In beginning feeding with cow's milk, mixtures must always be started as weak formulae, more often using only 1 ounce (30 mils) of cow's milk to a pound body weight, gradually increasing the strength to meet the infant's needs. Underweight infants should at first be fed according to their present weight, gradually increasing the strength of the mixture as rapidly as consistent with the baby's ability to handle the diet, and thus approximating the needs of a full weight baby of the same age. These 152 INFANT FEEDING. babies will frequently take over 2 ounces (60 mils) of milk per pound body weight. Number of Feedings in Twenty-four Hours. Three- hour intervals at the start, with 7 feedings in twenty- four hours, for the first month (6-9-12-3-6-10-2), 6 feed- ings during the second and the third month (6-9-12-3- 6-10), 5 feedings by the fourth to the fifth months (6-10- 2-6-10), according to the individual needs of the child. Premature and delicate infants with a tendency to vomit are exceptions, and may be fed smaller amounts at more frequent intervals, even two hours, if indicated. Catheter feeding may be necessary, in which case the longer interval will usually answer. Amounts at Each Feeding. From birth to the fifth month the average healthy infant may be satisfied with an amount of food approximating 2 ounces more per feed- ing than the infant is months old ( 1 month, 3 ounces ; 2 months, 4 ounces; 3 months, 5 ounces; etc.). Exception- ally, infants cannot take this amount at each feeding, and when vomiting is the result of overfeeding, the quantity can be reduced and an extra meal substituted. After the fourth month the average infant will take daily 1 quart of the food mixture. When more than 1 quart of milk mixture is needed to properly nourish the infant, we have reached the age when a mixed diet should be instituted. By the sixth month four meals of 8 ounces each of milk mixture may be given, and a fifth meal of broth and vegetables (see rules for mixed diet, p. 155). Water to be Added. In our o^vn experience we have found that a concentrated milk mixture does not disturb the infant's digestion when the milk is boiled or alkalin- MILK DILUTIONS WITH CARBOHYDRATES. 153 ized by sodium citrate, sodium bicarbonate, or lime- water. The amount of water is calculated by multiplying the number of feedings by the amount of each feeding, and subtracting the milk to be given. Example: Baby aged 3 months should receive 5 feed- ings of 5 ounces each (age in months plus 2) or a total of 25 ounces for the day. Subtracting 16.5 ounces (11 pounds body weight and 1.5 ounces of milk for each pound) gives us 8.5 ounces as amount of water to be added. Carbohydrates toi be Added. Having the necessary amount of mElk and water, we ascertain the carbohy- drates to be added. Cane-sugar answers our requirements for most cases. Milk-sugar acts as a laxative in many infants. Unless the laxative effect is desirable, it has no advantage. Maltose and dextrin compounds are acceptable to the infant's digestion in relatively larger quantities. They are not as sweet as cane-sugar. Because of the high dextrin content, some of the prod- ucts on the market (Horlick's malt food, Mead's dextri- maltose) may be constipating. Others which have a higher maltose content (Borcherdt's dri malt soup, Mel- lin's food, both of which also contain potassium carbo- nate) are laxative. Cane- and milk- sugars are added in such quantities that the final mixture contains 3 to 5 per cent, of sugar in addition to the sugar in the cow's milk. Cane-sugar is much sweeter than milk-sugar, and the infant will occasionally refuse a mixture containing over 3 per cent, of cane-sugar. Starch may be added to the diet in quantities of 1 to 2 per cent, of the whole mixture in the form of cereal 154 INFANT FEEDING. waters. We do not hesitate to add cereal water to the diet after the infant is one month old, and find it espe- cially valuable in those cases in which Ave are feeding 3 per cent, or more of cane-sugar, and in which the infant takes a dislike to its food because of the intense sweet- ness of the mixture. Maltose and dextrin compounds may be added in quan- tities up to 6 per cent, of the total mixture. Roughly, the following quantities of cane- or milk- sugar will answer the carbohydrate needs of the infant: Infants under 6 pounds — 0.5 ounce in twenty-four hours (2700 Gm.— 15 Gm.). Infants 6 to 10 pounds — 0.75 to 1,00 ounce in twenty-four hours (2700 to 4500 Gm.— 22.5 to 30 Gm.). Infants 10 to 14 pounds — l.OO to 1.25 ounces in twenty-four hours (4500 to 6400 Gm.— 30 to 37.5 Gm.). Infants over 14 pounds — 1.5 ounce in twenty-four hours (over 6400 Gm.-45 Gm.). To Break the Curd to Assist Digestion of Cow's Milk. Many infants can digest raw cow's milk. When not well taken, the tendency to formation of large protein curds is relieved by boiling the milk from two to three minutes over the flame, or, better, by putting in a double boiler and heating until the water in the outer vessel boils eight minutes. Although the curd is less finely divided by the use of the double boiler, as compared with boiling on the direct flame, it answers the purpose of most infants, and causes fewer changes in the milk. Addition of sodium citrate to the milk mixtures also prevents formation of hard protein curds. Bosworth and \''an Slyke have shown that increasing amounts of sodium citrate added to the milk increases the coagulation time up to the point when 1.7 grains (0.1 Gm.) per ounce (30 MILK DILUTIONS WITH CARBOHYDRATES. 155 mils) is added, after which the milk does not coagulate at all. Sodium which is added replaces some of tlie cal- cium in the caseinate, and forms sodium caseinate of cal- cium-sodium caseinate, and when rennin is added this double salt is changed to calcium-sodium-paracaseinate, which in the presence of sufficient quantity of sodium does not curdle. Sodium citrate may be prescribed either in 5-grain tablets, adding approximately 1 grain for each ounce of milk in the mixture, or a prescription may be written in such form that each teaspoonful will contain sufficient sodium citrate for the day's food. When lime-water is added to cow's milk until it is neutral or faintly alkaline to phenolphthalein, a basic cal- cium casein is formed which is not acted upon by rennet, and will not form a curd, even in the presence of lime salts (Van Slyke). Casein is not coagulated by rennin when the solution is alkaline. When a sufficient amount of an alkali is given, the milk mixture remains neutral or alkaline in the stomach, even after the stomach has secreted acid, and large protein curds do not form then. Lime-water is commonly used in amounts equaling 5 per cent, of the milk in the mixture (1 ounce to 20 ounces of milk). Not infrequently we have found the adding of citrate of soda or lime-water to boiled milk of advantage in the difficult feeding cases, and in the presence of vomiting. Mixed Diet for Young Infants. As early as the second or third month, 1 or 2 teaspoonfuls of orange juice may be given daily. This in part at least counter- acts the effect of boiling. Start with 5 drops diluted with water, twice daily, and increase gradually. Fifth month, a little well cooked cereal may be added to one of the meals (begin with 1 teaspoonful), adding 156 INFANT FEEDING. part of the bottle of milk to it, the meal being finished by the remainder of the bottle. At sixth month, infants readily take a broth and vege- table meal as a substitute for one of the milk feedings, in the form of a vegetable and meat soup. Begin with 1 ounce, and follow by a second bottle containing the milk mixture with 1 ounce less than full feeding. Gradually replace an entire milk feeding. Ninth month, a vegetable soup or a clear broth (chicken, lamb, or veal), and toast or zwieback crumbs, with an additional portion of stewed fruits (apples, prunes) or a strained vegetable (spinach, carrots, or tur- nips). The broth is usually given in the same quantity as the bottle, if given alone, or somewhat less if either the tablespoon of vegetable or fruit is given in addition. Caloric Values of Foods. Amount Cal. Apple sauce 1 ounce 30 Bacon (slice) % ounce 30 Bread average slice, 33 Gm 80 Butter 1 pate (M ounce) 80 Cereal (cooked) 1 heaping tablespoonful (1 ounce) 50 Carrots (cooked) 1 ounce 13 Crackers (soda or Graham) 1 ounce 100 Cream (16 per cent.) .... 1 ounce 54 Custard 1 ounce 60 Egg 1 (1.5 ounces) 80 Egg (white) 1 30 Egg (yolk) 1 50 Gelatin 1 ounce 50 Malt extract 1 ounce! 89 Meat 1 ounce 50 to 70 Milk (whole) 1 pint • 350 Milk (whole) 1 ounce 21 MILK DILUTIONS WITH CARBOHYDRATES. 157 Amount Cal. Potato (whole) 1 medium sized 90 Potato (mashed) 1 heaping tablespoonf ul 70 Rice (boiled) 1 tablespoonful 60 Soup (vegetable) 1 ounce ". • 15 Soup (chicken) 1 ounce 8 Toast average slice 80 Vegetables (peas, beans, carrots) 1 heaping tablespoonful 30 Vegetable (cooked spin- ach) 1 heaping tablespoonful 16 These caloric values are approximate for the most part, but are sufficiently accurate for practical purposes. Thus the caloric value of a particular menu can be easily figured. Feeding Example No. 1. Infant age three months should weigh '11 pounds (average birth-weight 7 pounds, plus 4 pounds, representing a gain of 5 ounces weekly for thirteen weeks). Estimating 1.5 ounces of milk per pound body weight, give 16.5 ounces of milk (346 cal- ories). Now, figuring that the infant should receive 25 ounces of food daily, 5 ounces at each feeding (age in months plus 2 ounces) for 5 feedings, and adding 4 per cent, cane-sugar, or 1 ounce (120 calories), a total of 466 calories, or about 42 calories to the pound body weight. To this 8.5 ounces of water should be added to make the total mixture 25 ounces. For practical purposes the cow's milk may be con- sidered as averaging : Proteins 3.5 per cent. Fat 4.0 " '' Carbohydrates 4.0 Thus, in the milk mixture in feeding example No. 1 ordered for a 3-months-old infant, weighing 11 pounds, we have 42 calories per pound, and we will now calculate 158 INFANT FEEDING. the percentages of the various ingredients in the mixture, and the grams of each ingredient per pound body weight. Milk, 16.5 ozs. = 495 mils Water, 8.5 " =255 " Sugar, 1.0 oz. = 30 Gm. Protein uaroo- Fat hydrate Salts Cal. . 17.3 19.8 19.8 3.46 Gm. (I 346 .... 30.0 a 120 Total mix- ture, 25.0 ozs. =750 mils ... 17.3 19.8 49.8 3.46 Gm. 466 2.3 2.64 6.6 0.46 per cent. For each pound body weight . 1.575 1.8 4.5 0.31 Gm. 42 We thus find that the infant fed on the prescribed diet receives 25 ounces of the mixture containing Protein 1.575 Gm. per pound body weight Fat 1.8 " " " - ' . " Sugar 4.5 ^ " the mixture containing Protein 2.3 per cent. Fat 2.64 " Sugar 6.6 " " and 42 calories per pound of body weight, all of which may be considered as a safe minimum. The mixture may readily be strengthened to meet indications for more fat and protein by the addition of milk, and more carbohy- drate by the addition of flour and sugar. Feeding Example No. 2. Child age eight months should weigh 17.25 pounds (average birth- weight, 7 pounds) which should be doubled in the first five months (14 pounds), plus a gain of 4 ounces a week for the re- maining thirteen weeks (3.25 pounds). The following mixture will be prepared: 1.5 ounces of milk per pound body weight equals 26 ounces (546 calories) ; water to make one quart, equals 6 ounces; sugar, 3 per cent.. MILK DILUTIONS WITH CARBOHYDRATES. 159 equals 1 ounce (120 calories) ; starch, 1 per cent., equals 0.3 ounces (30 calories) ; the total being 696 calories, or approximately 40 calories per pound. This is to be fed in four feedings of 8 ounces each, and the fifth may be re- placed by a soup and vegetable meal. A small cereal feeding (1 tablespoonful) can also be given with 1 or 2 of the bottles, pouring part of the bottle of milk over it, and finishing the meal on the remainder of the bottle. (See also Mixed Diet.) Milk, 26.0 ozs. = 780 mils . Protein .. 27.3 Fat 31.2 Carbo- hydrate 31.2 Salts 5.46 Gm. Cal. 546 Water, 6.0 " =180 " . • • • > • . • « * • . • (I • • • Sugar, 1.0 oz. = 30 Gm. . • . . • 30.0 • • . . K 120 Starch, 0.3 " = 9 " . • • « • 9.0 • • • • ii 30 Vegetable soup, 8.0 " =240 mils , ... 2.0 4.5 8.0 2.4 it 144 Cereal, one heaping tablespoon- ful, 1.0 oz. = 30 Gm 15.0 .... " 50 Total mixture 29.3 35.7 93.2 7.86 Gm. 890 For each pound body weight . 1.7 2.1 5.5 0.46 " 52 Further needs of the individual case can be supplied by concentrating the milk until whole milk is given, the carbohydrates in the mixture being gradually decreased and given in another form, as gruel, custard, etc. Artificial Feeding During the First Weeks of Life. The rules as given for infant feeding are hardly appli- cable for feeding during the first one or two to three weeks of the infant's life. The infant's first feedings should consist of higher dilutions of either whole or skim milk, should be boiled, and sugar added in smaller per- centages than suggested for the older infants. Such mix- tures must of necessity show a lower caloric value than 160 \ INFANT FEEDING. will meet the infant's needs for growth and development, but, as suggested, the mixture for the newborn should be composed of weak formulae, and increased according to the infant's tolerance. The following table of mixture will act as an outline for average cases : Diet for Newborn Infants During the First Four Weeks of Life. 1st 48 3-4 5-6 7-8-9 10-11-12 13-14 3d 4tli Milk (whole), ozs. . hours days days days 3 days 4 days 6 week week 8 11 Milk (skim), ozs. . . . . 6 8 5 4 4 2 ... Sugar (cane), dr. . . .. 1 1 2 2 2 3 4 6 Water (boiled), ozs. .. 16 10 8 8 8 8 8 10 Calories in mixture .. 15 81 118 148 158 215 250 321 Feedings : Amount in ozs. . . .. 1 1 1.5 1.5 2 2 2.5 3 Number daily .... .. 7 7 7 7 7 7 7 7 Intervals in hours .. 3 3 3 3 3 3 3 3 The above mixtures should be boiled for three minutes over the direct flame or in a double boiler. If the latter is used, the water in the outer vessel should be boiling for eight minutes. Add boiled water to make up the original quantity. Method of Feeding a Baby from the Bottle. Babies should be fed while they are lying on their beds, the upper part of the body being somewhat elevated by means of a pillow of proper thickness. The baby should be turned slightly on the right side, as it has been found that the stomach empties itself sooner in that position. The bottle should always be held by the nurse or at- tendant, until it is empty. From fifteen to twenty minutes should be occupied with the meal. MILK DILUTIONS WITH CARBOHYDRATES. 161 Do the above rules furnish mixtures of a quality and quantity proper to meet the infant's needs? If proper mixtures they should (1) Contain approximately Protein 1.5 to 2.0 Gm. for each pound of body weight Fat 1.5 " 2.0 " Carbohydrates .. 4.0 " 6.0 " " " " " " (2) Calories per pound body weight for normal infant : Under 2 months of age 30 to 45 calories Over 2 months of age 45 " 55 (3) Percentages in the mixtures. It is well to know the percentages of the various ingre- dients in the diet, as they will assist in the proper inter- pretation as to the etiology of food disturbances. Fat. Infants, according tO' their age, under normal conditions, digest from 2 to 3.5 per cent, of fat. Some infants digest fat badly, consequently in some cases it is necessary to give skim milk. Proteins. In the average feeding mixture for in- fants under 10 months, 2 to 3 per cent, of proteins are well taken. Carbohydrates. They should,, as a rule, not exceed 6 to 7 per cent., the average amount in human milk, in- cluding the sugar contained in the milk before its modi- fication. Summary. I. Preparation of the mixture. 1. Calculate the baby's normal weight. 2. Calculate the amount of cow's milk to be used in the preparation of the mixture, taking 1.5 ounces of cow's 11 162 INFANT FEEDING. milk per pound of normal body weight at that age, which is a safe minimum for a healthy infant. 3. Calculate the total daily amount of the mixture by multiplying the amount of each feeding (age in months plus 2 ounces) by the number of feedings. 4. Add water to make the mixture up to this total amount. 5. Add 3 to 5 per cent, of sugar, and later 1 per cent, of starch. 6. Make the curd more digestible by boiling or alkalin- izing the mixture. II. Checks on the above mixture. 1. Number of grams per pound body weight of each food ingredient in the mixture. 2. Percentage of each ingredient in the mixture. 3. Total caloric value of mixture and caloric value per pound body weight. III. Remember that — 1. Orange juice or codliver oil additions to the diet should be started by the second or the third month. 2. When more than 1 quart of milk mixture is needed to properly nourish the infant, the age is reached when a mixed diet should be instituted. 3. These amounts are relative, and must be increased or decreased according to the infant's progress and in- dividual needs, the above rules furnishing a safe minimum for a healthy infant. 4. The above amounts are usually insufficient for the underfed infant after it has become accustomed to the diet. Frequently it is necessary to approximate the re- quirements of a normal baby of that age. 5. Premature and underfed infants must at first be fed smaller amounts. MILK DILUTIONS WITH CARBOHYDRATES. 163 6. The food formula of a baby clinically healthy and making a satisfactory gain in weight should not be changed without a well-defined indication. Explanatory Note. For practical purposes we have used pounds for weight, and ounces for measuring fluids, because of the common use in the home of avoirdupois scales, and bottle and measuring glass graduated in ounces. We have also calcu- lated 1 oz. = 30 Gm., and 2.2 lbs. = 1 Kg. CHAPTER V. FEEDING IN LATE INFANCY AND EARLY CHILDHOOD. Feeding During the Last Quarter of the First Year. The following diet list will serve as an example for feed- ing during this period : Nine to twelve months diet. 6.00 A.M. Milk mixture, 8 ounces. Milk, 6 ounces; water, 2 ounces; sugar, 2 level teaspoonfuls. 8.30 A.M. Orange or prune juice, ^ to 1 tablespoonful (0.25 to 0.5 02.). If preferable, this may be given with the 10 a.m. or 2 p.m. meal. 10.00 a.m. Milk mixture, 8 ounces. Cereal (farina, oatmeal, etc.), 1 to 2 tablespoonfuls. 2.00 p.m. Vegetable soup or a clear broth (chicken, lamb or veal), with an additional portion of a strained vegetable (spinach, carrots, potatoes, etc.). Vegetables can be started by the ninth month. The broth is usually given in the same quantity as the bottle, if given alone, or some- what less if a vegetable is given in addition. When starting the soup feeding, first replace 1 ounce of the 2 p.m. bottle by 1 ounce of soup in another bottle; then give 7 ounces of the milk mixture. Gradually increase soup and diminish milk until an entire bottle of milk iz replaced by soup. Gradually cut water and sugar out of the milk mixture until full milk is given by the tenth or eleventh month. 6.00 p.m. Milk mixture, 8 ounces, and bread, zwieback crumbs or cereal. 10.00 P.M. Milk mixture, 8 ounces, if needed. (164) FEEDING IN INFANCY AND CHILDHOOD. 165 A slice of crisp bacon may be given to advantage dur- ing the eleventh and the twelfth months, probably best with the mid-morning meal. Four feedings a day are usually sufficient during the early part of the second year. In such a diet the fruit juices which may be given once or twice a day should not be considered as meals, and may be given b^ween the regular feedings. Whole milk is now fed, and should not exceed 1 quart daily. The sugar and water are de- creased gradually. Twelve to fourteen months diet. 6.00 A.M. Milk, 8 ounces. 8.30 A.M. Orange juice, prune juice, or apple sauce (1 oz.) If preferred, this may be given with the 10 a.m. or 2 p.m. meal. 10.00 a.m. Milk, 8 ounces, and cereal (farina, oatmeal, etc.) 1 or 2 tablespoonfuls, slice of crisp bacon. 2.00 P.M. Vegetable or cream soup and zwieback, toast, etc., or a clear broth (chicken, lamb or veal), with an additional portion of 1 tablespoonful of a strained vegetable (spinach, carrots, potatoes, etc.). The broth is usually given in the same quantity as the bottle, if given alone, but some- what less if a vegetable is given in addition. A little scraped beef or beef juice may occasion- ally be added to the vegetable. 6.00 P.M. Milk, 8 ounces, and bread, zwieback or cereal, custard or pap. 10.00 P.M. Milk, 8 ounces, if needed. Fourteen to eighteen months diet. 6.00 A.M. Milk 8 to 10 ounces 8.30 A.M. Fruit juice (orange juice, prune juice, or apple sauce) 1 to 2 ounces. 166 INFANT FEEDING. 10,00 A.M. Cereal, 2 to 3 tablespoonfuls, with 2 ounces of milk or cream, followed by 6 to 8 ounces. of milk. Toast, zwieback, crackers, or wafers may be alternated with bacon. 2.00 P.M. (1) Vegetable or cream soup and zwieback or toast, or (2) a clear brotli (chicken, lamb or veal), with an additional portion of one table- spoonful of a strained vegetable (spinach, car- rots, potatoes, etc.). The broth is usually given in the same quantity as the bottle, if given alone, but somewhat less if the vegetable is given in addition. Part or whole of a coddled egg with toast, zwieback or cracker crumbs can now be added to the above soup and vegetable meal. Thei egg may be alternated with beef juice or scraped beef. 6.00 P.M. Cereal, 2 tablespoonfuls, farina, cream of wheat, oatmeal, arrowroot, custard or pap, with 8 ounces of milk. Part of the milk may be given over the; cereal, or as bread and milk, or milk toast. 10.00 P.M. Milk, 8 toi 10 ounces. (Can usually be left out by this time.) Eighteen months to three years. 7.00 A.M. Stewed fruit or orange juice ; cereal ; crisp bacon, alternate with soft boiled or poached egg; Bread and butter or toast ; milk or weak cocoa. 12 or 1p.m. (1) Broth: meat or vegetable soup thickened with cereal. (2) Meat : lamb chops, scraped beef, chicken or beef juice. (3) Vegetable: baked or mashed potatoes; strained spinach, carrots, turnips or celery. (4) Dessert : gela- tine, custard, cornstarch or rice-pudding, or other simple dessert. 6.00 P.M. Cereal and bread or cracker, with milk. Baked apple, apple sauce or other stewed fruit. FEEDING IN INFANCY AND CHILDHOOD. 167 Other Foods Permitted at Three Years. Meats. Broiled or boiled fish, roast or stewed poultry, raw or stewed oysters, broiled beefsteak, roast or broiled beef or mutton — all in moderate quantities. Eggs. Soft boiled, poached or scrambled, 1 or 2 daily. Cereals and Breads. Oatmeal, hominy grits, wheaten grits, cornmeal, barley, rice, macaroni, etc. Light and not too fresh wheat and Graham bread, toast, zwieback, plain unsweetened biscuit. Soups. Plain soup and broth of nearly every kind, preferably vegetable broth. Vegetables. White potatoes, boiled onions, spinach, carrots, peas, asparagus (except the hard part), stewed celery, young beets, arrowroot, tapioca, sago. Fruits. Nearly all, if stewed and sweetened. Of raw fruits, peaches are the best; pears, grapes freed from seeds, oranges. Desserts. Light puddings, as rice pudding without raisins, bread pudding, plain custard, pap, wine jelly, ice cream, junket. Foods to be Taken with Considerable Caution. Mufifins, hot rolls, sweet potatoes, baked beans, turnips, parsnips, cabbage, egg plant, stewed tomatoes, fresh corn, cherries, plums, raw apples, huckleberries, gooseberries, currants, preserved fruits. Foods to be Avoided. Fried foods of any kind, griddle cakes, pork, sausage, highly seasoned food, pastry ; all heavy, doughy, or very. sweet puddings; unripe, sour, or wilted fruit; bananas, cucumbers, nuts, coffee, alco- holic beverages. PART IV. Nutritional Disturbances in Artificially Fed Infants. CHAPTER I. MINOR DISTURBANCES. 1. Stationary Weight. Stationary weight may be reheved by the addition of : (1) One to 2 per cent, of starch (0.25 to 0.5 ounce, 8 to 15 Gm.), in the form of wheat, barley, or rice flour, or oatmeal or barley water to the day's feeding, or (2) Addition of more sugar, if insufficient. (3) One or 2 per cent, of fat (cream, 1 to 4 ounces, 30 to 120 mils), or (4) Skim milk. The ingredients to be added vary with the individual requirements and the preceding diet. 2. Vomiting. The young infant vomits easily, and without effort. The weak sphincter at the cardia predisposes to regurgi- tation. Regurgitation of only small portion of the meal is designated as "spitting." This latter symptom has be- come less common since the introduction of the longer feeding interval, which allows the stomach to empty itself thoroughly before the next feeding. Other than too fre- quent feedings, too large an individual meal, and food (168) MINOR DISTURBANCES. 169 too rapidly taken, are the most common causes of vomit- ing. These conditions can easily be remedied. Excessive handling and abdominal bands that are too tight are fre- quently causes of vomiting. Excessive feeding with fat, such as is frequently seen in formulae made from cream mixtures and top milk mixtures, are common causes of vomiting, and should lead to reduction of the fat con- tent of the food by replacing the contents in part by whole or skim milk. Excessive quantities of sugar in the diet may also cause vomiting. Vomiting due to the large tough protein curd of the raw milk can be obviated by boiling or alkalinizing the milk. 3. Colic and Flatulence. Constipation is very frequently associated with colic and flatulence, disappearing with the institution of a proper diet. More commonly the habitual colic, as seen in the young infant, may be taken as an evidence of gastric or intes- tinal indigestion, and may be due to one of several causes : (1) too much milk at proper intervals, (2) too frequent feedings, and (3) mixture too rich in fat, or (4) exces- sive in carbohydrates. Regurgitation and vomiting are commonly associated, and not infrequently diarrhea re- sults. By careful study of the diet and observation of the stools the offending factor can in most instances be eliminated. Excessive flatulence can frequently be eliminated by reduction or change in the kind of sugar and cereal gruels. A reduction in all the elements of the food may be necessary temporarily in the presence of severe symptoms. 170 INFANT FEEDING. Feeding of powdered casein in amounts varying from 4 to 8 Gm., dissolved in 30 to 60 mils of water, two or three times daily, will relieve colic in many infants, in all probability due to lessening of intestinal peristalsis. Not infrequently the crying due to underfeeding may be interpreted as colic. Reduction of the diet of these infants is a source of danger. If the stools are good, and there is no vomiting, and the baby is gaining in weight, one should be convinced that it is not the cry of habit before making changes in the diet. The constant solicitude of nurses because the baby has "gas on the stomach" is unwarranted. All bottle-fed babies have gas in the stomach. They swallow it with their meals in the form of air. If the baby is gently raised in the sitting posture the gas will usually "come up." This may be done in the middle of a feeding if the stomach seems unusually distended. Occasionally severe attacks of colic may be relieved by a saline enema. 4. Constipation. In breast-fed babies, and not infrequently in infants fed on boiled milk, we frequently find a sluggish rectum, which is evacuated to better advantage by the use of simple mechanical means than by the use of physics. A lubricated catheter, a simple suppository, made from glycerin or soap, or 1 to 2 ounces of a saline enema or sweet oil injection can be recommended. If properly used, they are not harmful, nor do they create bad habits which are often ascribed to them. A regular hour for their use, with proper training, creates regular habits, and in most instances the condition improves to such an ex- tent that they can be discontinued. Most infants can be trained to regular evacuations by the fourth or fifth MINOR DISTURBANCES. 171 month. The infant should be well supported on the mother's lap, over a chamber, which she may hold be- tween her knees. This is done to best advantage after a feeding, and a suppository may be used until the infant realizes that the operation is undertaken for a purpose, In the presence of fat-soap stool it may be necessary to reduce the whole milk, substituting skim milk tempor- arily, and increasing the sugar. In the presence of constipation, where the maltose-dex- trin compounds have been used, a change to milk-sugar or cane-sugar, or one of the dextrin-maltose compounds con- taining a high percentage of maltose and potassium car- bonate, is often beneficial. Occasionally, the addition of cereal water to the diet is of benefit. The reverse, however, may be true. When the infant is old enough, constipation is best re- lieved by the addition of vegetable or fruit purees. When the above fail, the addition of 1 or 2 teaspoon- fuls of milk of magnesia (magma magnesiae, N. F.) to the day's feeding answers well for temporary use, or 1 or 2 tablespoonfuls of dri or liquid malt soup extract added to the day's feeding acts equally well. In infants where constipation is distressing, and other dietetic changes fail, a week or two on Keller's malt soup usually works wonders. Underfed infants frequently suffer from constipation. Such stools (hunger stools) are small, dark in color, and contain much mucus, and are associated with stationary weight. Increasing the diet relieves the constipation. 5. Abnormal Stools. (1) Curds. Curds are seen as undig'ested masses, and may be formed from fat or protein, or a combina- tion of the two. 172 INFANT FEEDING. Fat curds are far more common than protein curds, and are usually seen as small, soft, whitish or yellow masses, either sprinkled throughout the stools or not in- frequently making up a large part of the stool. They are usually intermixed with mucus, which is present in ex- cess. The chemical composition can easily be demon- strated by the usual tests for fat. Breast-fed infants very commonly show curds of this type, and usually they have very little pathological significance in these infants. Protein curds are far less frequent, and present quite a different appearance. They are also seen only in the presence of feeding with raw milk. They appear as smooth, hard masses, of a yellowish-brown color, with white center when broken, and are usually larger than the fat curds. They are also smaller in number, and may be found mixed in feces which otherwise appears noniial. The laboratory test (ether), which causes the fat curds to go into solution, results in hardening and toughening of the protein curds. This is an easy method of differen- tiation. Such stools have usually an offensive odor. Treatment. The fat curds, if numerous, call for a considerable reduction in the fat percentage. The protein curds, if numerous and persistent, should lead one to re- duce the protein, at least temporarily, or also to boil- ing or citrating the milk, which causes their disappear- ance. In a dyspeptic infant with hard curds in the stools, removing the sugar from the raw milk mixture, thereby lessening the frequency of stools and slowing peristalsis, may cause the hard curds to disappear — that is, a sugar diarrhea that caused a non-digestion of the casein has been remedied. (2) Loose, green stools with a sour odor may be due to a high percentage of sugar, more commonly milk-sugar. MINOR DISTURBANCES. 173 or, again, they may be due to an excess of fat. Such stools are usually frequent, and, if the dietetic error is not corrected, may lead to nutritional disturbances. Stools of similar appearance, which are not infrequently seen in breast-fed infants, have far less significance, and should not lead to weaning if the child is making at least a fair progress. In the artificially fed, the treatment con- sists in the careful study of the diet, with removal of the cause, when found. (3) Fat-soap Stools. These are light-colored, large, dry stools, which do not adhere to the napkin, and are seen in feeding in which cream or cow's milk is in excess. They are described more fully under Disturbed Metabolic Balance. (4) Starvation stools have already been described. (5) Blood in Stools. This may be associated with many different conditions, and the character of the stool differs with the source of the hemorrhage into the intes- tinal tract, and may vary from a tarry stool to one con- taining bright blood. 6. Milk Idiosyncrasy. A few infants show a true idiosyncrasy to cow's milk, which is overcome only with great difficulty, even when the milk is carefully modified. The true cause of this condition is still in dispute. However, it may be said that some of these cases are undoubtedly due to anaphy- laxis. On the other hand, some of them are undoubtedly not explained on this basis. Infants suffering from such idiosyncrasy will usually refuse the milk, and when it is forced upon them it results in vomiting, diarrhea, and frequently an urticario-erythematous rash. Cow's milk feeding in these cases is often associated with a low- 174 INFANT FEEDING. grade fever. The symptoms speedily subside upon the administration of castor oil and the withdrawal of milk. This class of cases offers great difficulty in feeding during the first year of life, as carbohydrates must necessarily form a considerable portion of their diet. Broths, cooked cereals, and vegetable purees should be gradually added to the diet as soon as they can be digested. CHAPTER II. GENERAL CONSIDERATION OF NUTRITIONAL DISTURBANCES. Our ideas on this subject have undergone considerable change during the past few years. Older authors viewed the nutritional disturbances as conditions limited to the stomach and bowel, and likened them to similar condi- tions in the adult, with the exception that more serious results were to be expected in the infant because of the slight physiological resistance. The infant's body is more favorable to a severer course. For many years the classification of Widerhofer, of the Vienna school, first published in 1880, and based on an anatomico-pathological basis was the one in general use. These he grouped as follows : 1. Functional disturbances, as acute and chronic dys- pepsias. 2. Enterocatarrhs, with more or less marked histo- logical changes and clinical findings. 3. Follicular enteritis, with deep-seated inflammatory and ulcerative changes, especially in the large intestine. 4. Cholera infantum (this latter, a severe type of en- terocatarrh, was classed as a distinct clinical entity). Clinical observation soon convinces one that the cases do not follow the distinct types in the above classification, mixed and progressive types being the rule. In many in- stances far-reaching after-effects remain, and, again, in others of the severest types few if any anatomical lesions were demonstrable at autopsy. Especially in young in- fants we find marked and often general disturbances f ol- (175) 176 INFANT FEEDING. lowing in the wake of what seemingly were localized gas- tro-intestinal lesions, with the result that the systemic and not the intestinal symptoms were of more serious import. Again, we know that many findings formerly attributed to invasion of bacteria or their toxins can now be at- tributed directly to improper metabolism of the food ingested. To avoid confusion in our discussion of this vast field of nutritional disturbances, we will first consider the food injuries, and speak only of the infections incidentally as they affect the former, and at a later period discuss the infections more directly. Food Injuries. The nomenclature covering this sub- ject has also changed, and we now^ adopt the term "Nutritional Disturbances" in place of "Gastro-intestinal Diseases," the former covering the functional and ana- tomical disturbances, as well as the bacterial and food traumas. It is, however, necessary in order to justify the newer nomenclature to. look upon nutritional disturb- ances not as localized in the gastro-intestinal canal, but as general affections involving the whole organism in one of the most vital of its functions. The gastro-intestinal symptoms form only a part of the clinical picture ; there- fore, in its fullest conception the mental state, changes in the temperature, pulse, respiration, etc., may become as important in their interpretation as the diarrhea. Two schools of pediatrics have given us the nucleus for our present view^s on nutritional disturbances and their classi- fication — those of Czerny and Finkelstein. Czerny's work antedated that of Finkelstein by several years, and he based his classification on what he considered injuries due to overfeeding with individual food elements. These he called ''food injuries," and described them as due to NUTRITIONAL DISTURBANCES 177 fat, starch, sugar, protein, and salts, individually or in combination, either when given in excess, or when given to an infant with lowered tolerance for these food elements. Finkelstein viewed the nutritional disorders from a broader standpoint. He considered them '^as the gradual development of an increasing intolerance for food" — step by step, from the mildest disturbances, in which the only striking symptom is failure to gain in weight, through the severer dyspepsia, up to the final stage of intoxication, when the infant is in a state of "metabolic bankruptcy" In his classification we see one increasing process, the important factor of which is found in the fact that the infant can tolerate less and less food, until finally any food in any amount acts harmfully. The stages of the various disorders under the Finkelstein classification must therefore necessarily merge gradually into one another, and lack in definiteness, and at times present a picture so complicated that an exact diagnosis as to the stage be temporarily impossible. Etiology in General. Before entering upon a gen- eral discussion, it may be wise to review some of the theories promulgated for the advantages of human over cow's milk in infant feeding. Biedert believed that the decomposition products of protein digestion were the im- portant factors. This idea has not been substantiated clinically. Hamburger advanced the idea that the albu- mins foreign to the human body contained in cow's milk were important factors. Tl"»s also has not been proven. Czerny believes that the fat, and, again, the sugar, are the important factors. L. F. Meyer believes that the whey content, and more especially the high salt content of whey (0.75 per cent, as compared with 0.2 per cent. 12 178 INFANT FEEDING. in human milk), predisposed to intestinal injury, follow- ing which trauma fats and sugars play an important part. Marfan, Escherich, Pfaundler, and others believed that specific protective bodies of unknown nature were con- tained in raw human milk, which are of vast importance as immunizing bodies. Of greatest importance as etiological factors, as viewed by. Finkelstein, are the fermentation products of the fats and carbohydrates, which result in the formation of the lower fatty acids (lactic acid, butyric acid, etc.). Protein decomposition is evidenced only by its causing increased intestinal secretion, a very bad odor of the stool, and a tendency to constipation, except in the presence of large, raw curds, with their tendency to mechanical irritation. The acids formed by fat and carbohydrate metabolism when in excess result in increased peristalsis, increased secretion of mucus, etc. They may also interfere directly with intestinal digestion, or cause irritation of the in- testinal wall itself. In mild cases this may result only in impaired growth and progress, but in the severer types of nutritional disturbances there is breaking of the nor- mal relation between intestinal digestion and the paren- teral cellular metabolism, whereby the whole body func- tion may be impaired, due to toxic products escaping through the intestinal wall into the general circulation, or, again, products necessary to normal growth may be lost into the intestinal tract. We know that bacteria and their toxic products, as encountered in the food administered, are less often the offending factor than formerly supposed, and that improper food either quahtatively or quantitatively are of equal or greater importance in the causation of nutri- tional disturbances. Food injuries can therefore be due NUTRITIONAL DISTURBANCES 1/9 to : ( 1 ) underfeeding by a generally restricted or an im- properly balanced diet, (2) overfeeding with a food of proper or improper proportions, (3) lessened tolerance for food. 1. Nutritional Disturbances Following Underfeeding. We recognize two types: (1) qualitative and (2) quanti- tative. Sooner or later the results are similar. The former diets, qualitatively wrong, are frequently seen where theoretically the caloric requirements are met, but one or more of the necessary food elements are in excess and the mixture short in the required amounts of others. An example of this is seen in feeding of carbohydrate- rich foods as condensed milk, malted milk, etc. When the minimum requirements for growth and development, at least for both organic and inorganic salts are met in such a diet, the organism may be able to overcome the excess of one ingredient, but if this is not true, sooner or later some grave complications will result. When we feed less than a sustaining diet of 32 calories per pound body weight, or 70 calories per kilogram, we soon have the results of a quantitative inanition, with all of its un- desirable results. 2. Nutritional Disturbances Due to Overfeeding. This is probably the most important of all etiological factors, and may be due to a diet of correct proportions, but quan- titatively too great for the individual case, or a diet with an excessive amount of one or more constituent ingred- ients. To judge such errors in diet, each individual infant must be studied as a distinct entity. 3. Nutritional Disturbances Due to a Primary Lessen- ing of Tolerance to Food. Many factors can cause such a state of affairs : 180 IXFAXT FEEDING. (a) Intercurrent illness, with impairment of the digestive function. Bacterial infections are probably the most common, and may be either general or localized infections. (&) Heat of summer, with its depressing influence on the organism. (c) Spoiled milk, due either to bacteria contained or their products. (d) Improper hygienic conditions, with their result- ing depression. General Symptomatology. The varied symptoma- tology of the nutritional disturbances can only be realized when we consider the numerous factors involved in the process of nutrition. We must, therefore, consider the digestion of foods in, and their absorption from, the in- testinal tract, the replacing and upbuilding of the body tissues, heat production and regulation, and the con- trol of the functions of all organs and tissues. That nutrition influences all of these functions is evidenced by the disappearance of the so-called alimentary fever, by the withdrawal of food. This is also true of certain forms of albuminuria. AVe also find cerebral and spinal symptoms as well as cardiac and respiratory changes, which readily disappear with a corrected diet. By the development of the foregoing symptoms in their various phases, and under varied conditions, we can ex- pect the most divergent clinical pictures. The individual type varies directly with the general condition of the infant, as well as with the predominating dietetic ele- ments. All infants suffering from nutritional disturb- ances have a lessened food tolerance. This has a far- reaching effect, even to the involvement of the most re- NUTRITIONAL DISTURBANCES 181 mote tissues and cells, which, again, is evidenced by a general weakening of all body functions. The end re- sult is a paradoxical reaction to food intake, which is evi- denced by loss of weight, irregularities in the tempera- ture curve, etc., on food administration beyond the point of tolerance. These evidences of disturbed metabolism vary directly with the variety and quantity of food intake, and with the degree of metabolic disturbance which. has preceded. A good example of this reaction is seen in the following series of cases : Three infants each are fed 30 Gm. of sugar daily, added to their ordinary diet. The first baby, a well one, gains in weight somewhat more rapidly than previously; the second develops diarrheal stools, a slight irregularity in the temperature curve, and its weight remains stationary; while the third infant, which was more deeply involved, develops a temperature of 101° and over, very frequent stools, and loses 100 Gm. in weight in twenty-four hours. Lowered resistance is not alone evidenced in the reaction to food, but also are lessened immunity to infection, and marked depression by hot weather. All of these may be followed by severe systemic infections, and markedly retarded convalescence. The normal healthy infant with a well-balanced metab- olism reacts to food as follows : 1. An elastic, pink skin, a well-developed panniculus adiposus, well colored mucous membrane. Its tissues should feel firm. 2. One should expect certain muscle and bone develop- ment according to the age of the infant. 3. A uniform rectal temperature (98° to 99° F.), almost a monotheria. Any considerable deviation is abnormal. 182 INFANT FEEDING. 4. It should show a regular, steady gain in weight. 5. The bowel movements should be regular, and should vary with the food ingested. 6. Its disposition should be happy, and its nervous functions normal. It should sleep well, and be satisfied with feedings at three- to four- hour intervals. 7. It should show a wide tolerance for food, both as to the diet as a whole, and to the individual food element. 8. Renal, circulatory, and respiratory functions should be normal. Bearing in mind the attributes of the healthy infant, we are now in a position to review the factors leading to and influencing our present conceptions of the* nutritional disturbances, based on an ascending series of pathological stages in those infants whose tolerance for food has been overstepped either because of overfeeding or because of diminished or abnormal tolerance on the part of the baby itself. Classification of Nutritional Disturbances. The older classification into acute and chronic dyspepsia, entero- catarrh, ileo-colitis, and cholera infantum must be dis- carded in the light of our new knowledge, and the whole reclassified, with the view in mind that the gastric and intestinal symptoms are only local evidences of a general systemic involvement, with the clinical picture varying as to the predominating food elements, the preceding gen- eral condition of the infant, and the knowledge that changes are rapidly seen from one type to another through the influence of various exogenic factors. For our purposes we will combine the essentials of the Czerny and Finkelstein classifications into a working basis. NUTRITIONAL DISTURBANCES 183 Group I. Nutritional disturbances (food injuries) due to overfeeding (overstepping the infant's food tolerance). (a) Light forms, without destructive lesions. (1) Disturbed metabolic balance. (2) Dyspepsia. (b) Severe forms, with destructive lesions and gen- eral disturbances of the whole organism. (3) Decomposition. (4) Intoxication. The reaction to food administration is the basis of this classification, and the degree of reaction depends directly upon the preceding food injuries. It must also be re- membered, as previously stated, that one form leads rapidly into the next, if the errors in the diet are not remedied, or when secondary infections complicate the picture. Group II. Nutritional disturbances due to underfeed- ing. (Insufficient food. Inanition.) (a) Quantitative inanition. (Pyloric stenosis, pylorospasm, etc.). {b) Qualitative inanition. (1) Excessive starch (flour) feeding. Not due to excess of starch alone, but to the lack of other ingredients in the diet. (2) Scorbutus. (3) Rachitis. Group III. Secondary nutritional disturbances, follow- ing lowered resistance and lessened food tolerance, due to 184 INFANT FEEDING. (a) Heat J resulting in systemic depression, and often associated with spoiled foods (milk, etc.). (b) Infections from within the intestinal tract (enteral). (1) Non-specific intestinal infections (ileocolitis, etc.). (2) Specific intestinal infections (typhoid, para- typhoid, dysentery, etc.). (c) Systemic infections (parenteral). Otitis, pyelitis, pneumonia, etc. Group IV. Nutritional disturbances due to congenital debility, anomalies or idiosyncrasies, with resulting ab- normal metabolism. Food qualitatively normal. (a) Exudative diathesis (eczema, etc.). (b) Psychoneuropathic diathesis. (1) Neuropathic (strict sense). (2) Spasmophilia (tetany, convulsions, etc.). (3) Habitual vomiting. (4) Pylorospasm. The following scheme may be used for classifying the main types : Dis. Met. Balance Dyspepsia Decomposition Intoxication Lessened fat Lessened fat and Tolerance lowered Follows other tolerance. Food carbohydrate to all food forms, especially of sufficient tolerance. Rel. elements. when a diet rich caloric value. excess of sugar in whey and in the food. sugar is not corrected. Stationary Stationary weight Rapid loss of Rapid loss of weight. or moderate weight. weight. loss. Slight variations Moderate fever. Subnormal High fever. in temperature. temperature. NUTRITIONAL DISTURBANCES 185 Dis. Met. BAXiANCE Dyspepsia Constipation with Diarrhea, green, fat-soap stools. mucus, curds, acid. Absence of acute Acute symptoms, gastro-intestinal general loss of symptoms, turgor. Sensorium not involved. Sensorium not involved. Favorable reaction to reduction of fat and increase of carbohydrates in the diet. Rapid repair on withdrawal of improper food. Decomposition Intoxication Often history of diarrhea. May be constipated. Weak, slow, small pulse. Hunger. Vomiting. Sensorium not involved. Starvation dangerous, also great danger in overfeeding. Diarrhea, watery, blood, etc. Rapid, weak, small pulse. Rapid, pauseless respiration. Hunger. "Vomiting. Collapse. Glycosuria. Albuminuria. Anuria. Leucocytosis. Sensorium markedly involved. Nervous symptoms may outweigh Intestinal symptoms. Improvement on withdrawal of food. CHAPTER III. DISTURBED METABOLIC BALANCE. Syjiouyms. Weight disturbance, disturbed balance, fat constipation, malnutrition, atrophy of moderate de- gree, Bilanz-Stoerung (Finkelstein), Milchnaehrschaden (Czerny-Keller). This represents the mildest stage of nutritional dis- turbances, and results from administration of food be- yond the infant's limits of tolerance, resulting in retarda- tion of development, both qualitatively and quantitatively, however, without marked • general symptoms of disease. This condition is clinically characterized by pallor, rest- lessness, disturbed sleep, constipation, usually associated with fat-soap stools, and stationary weight. Fortunately, this clinical picture is less frequently seen than formerly, when cream and top milk mixtures were more extensively used. Etiology. It is seen under a variety of conditions : 1. Most cases are caused by a relatively high fat con- tent of the food, i.c.^ a relative overfeeding with whole milk, in the presence of moderate amounts of carbohy- drates ; therefore we have improper proportions of carbo- hydrate and fat. In the presence of excessive amounts of carbohydrates we are more likely to see a dyspepsia. Proteins also play an important role in the causation of the clinical picture of this disease, in that in the presence of a relative overfeeding with proteins an alkaline intes- tinal reaction necessary to the production of fat-soap stools is brought about. The svmptoms usually follow a (186) DISTURBED METABOLIC BALANCE. 187 period of good progress, which ceases more or less abruptly. 2. Cases in which the milk mixture is theoretically quantitatively correct, but in which the infant suffers from a congenital idiosyncrasy to milk. Many of this class of cases are associated with exudative diathesis. 3. Following lowered food tolerance due to intercur- rent infections, either parenteral or enteral. Artificially fed infants are almost exclusively affected, probably because of the high carbohydrate and low pro- tein content in the breast-fed infant's food. This con- dition was first described by Czerny under the name of Milchnaehrschaden, having been first noticed in those infants who received large quantities of fat in the food. This may be due to an absolute excess of fat, as seen in the first group, or a relative excess of fat, as seen in the second group of infants having an idiosyncrasy toward milk. Fortunately, in these infants the tolerance for car- bohydrates has in most cases not been reduced, and there- fore the fat in the food can to a great degree be replaced by sugar and cereals. Pathogenesis. As fat-soap stools are so frequently regarded as the basic symptom in the diagnosis of dis- turbed metabolic balance, we will first emphasize then- significance. The fat-soap stool must be viewed as an effect, and not as the cause, of this intestinal disturbance. The condition is not a fat indigestion, but a disturbance in salt metabolism, based on a relative overfeeding of fat in the presence of a relative carbohydrate underfeeding, and enhanced by a relative excess of protein. There is an increased excretion of the alkalies by in- creased combining of alkalies with fatty acids, and through loss of alkalies by increased intestinal secretion. 188 INFANT FEEDING. The alkalies most involved in the formation of the fat- soap stools which are so commonly seen in this condition are calcium and magnesium. There is, however, also a (iecreased sodium and potassium retention, as evidenced more especially by increased excretion in the urine. This loss of calcium and magnesium through the stools, and inability to retain sodium and potassium, and thereby secondarily a loss in water retention, soon leads to weight loss. The fat-soap stools as stated, contain an excess of calcium and magnesium soaps, and less fatty acids and neutral fats than seen in the normal stools. To obtain such a stool, there must be a strong alkaline reaction in the large intestine, and the food elements of the diet are important factors in the production of this reaction. Fats. An excess of fats in the food leads to an ex- cess of fatty acids in the intestine, with a tendency to the formation of an acid reaction of the intestinal con- tent. To combine with these, alkalies are withdrawn from the body, if insufficient in the intestinal tract. Proteins cause secretion of a large quantity of intes- tinal juice which is alkaline. This in time tends to pro- duce an alkaline intestinal reaction, if not counteracted by excessive fermentation, the former being favorable to the formation of fat-soap stools. In all probability the great calcium content of cow's milk (4 to 1), as com- pared with breast milk, also offers another factor in the tendency to formation of calcium soaps. Carbohydrates. In the presence of sufficient ferment- able carbohydrates (disaccharides) in the diet, the intes- tinal reaction becomes acid, the products of fermentation counteracting the tendency to alkaline reaction, and thus preventing the formation of fat-soap stools. DISTURBED METABOLIC BALANCE. 189 The withdrawal of excessive amounts of alkalies from the system disturbs the acid-alkaline equilibrium, creating a relative excess of acids, i.e., the formation of an acid- osis. This is evidenced by the increase of the ammonia coefficient in the urine, i.e.^ the relation between the am- monia and the total nitrogen products. In disturbed metabolic balance we find a striking ex- ample of a paradoxical reaction, namely, increasing the" food (milk or fat) makes the condition worse, and causes weight loss, diminishing the food, a return to normal, and if properly changed, even though lessened, a gain in weight. The clinical picture is due to: 1. Excessive withdrawal of salts from the body tissues, due to fat and protein overfeeding. 2. A relative insufficiency of carbohydrates. The stools are dependent upon overfeeding with milk, with insufficiency of carbohydrates. To be considered pathological, they must be accompanied by systemic manifestations. The same stool may be seen under normal conditions in high protein and low fat feeding, more especially in the feeding with boiled milk, as a strong alkaline intes- tinal reaction is the paramount condition upon which their formation is dependent. Symptoms. There is a retarding of development qualitatively and quantitatively, the infants frequently be- ing undersized, without showing marked general symp- toms of disease. 1. Weight. Notwithstanding proper or even excessive caloric intake, there may be no gain in weight, or an irreg- ular increase, however, under the normal. (Stationary weight or insufficient gain in the infant corresponds to a 190 INFANT FEEDING. loss in weight in the adult. Stationary weight in an in- fant alone leads to the picture of malnutrition and marasmus.) 2. Temperature. Usually we find daily oscillations from 1° to 2°, with a tendency toward subnormal. 3. The child is restless. 4. Sleep is disturbed. 5. The skin is pale, with loss of elasticity and turgor. Intertrigo and eczema are frequently seen. 6. Muscles are soft and flabby. 7. Regurgitation and vomiting are frequent. 8. Abdomen tympanitic. 9. Stools. In excessive milk feeding the common type is the fat-soap stool, which is foul-smelling, dry, light in color (gray to white), friable, and does not stick to the napkin. The pale color is due to the reduction of bili- rubin to urobilinogen. The odor, in part at least, is due to the decomposition of protein. In the presence of ex- cessive carbohydrates this stool may be lacking, due to the presence of a slight dyspepsia. 10. Immunity is lessened with resulting furunculosis and susceptibility to respiratory, gastro-intestinal, and genito-urinary infections. 11. Urine is usually ammoniacal, and contains an ex- cess of sodium and potassium salts. Diagnosis must be based on the clinical pictiu'e and feeding history, as follows: sufficient caloric intake (100 calories per kilogram), with relative excess of fat and protein, and insufficiency of carbohydrates, absence of diarrhea, stationary weight, and lack of proper develop- ment, all in the absence of any other causative factor. DISTURBED METABOLIC BALANCE. 191 d "1 Q .< > iS i ^^ .__ °^o V .____L O 5 •• !£ to a 12 pi III! it^ \ > - - J 'si T_ • 3;<^ f 5 •: — < ^ ^N L- >A 5 ^ f . ; T — ( ^ ■ oi 5> 5 1 i 6 cS "■o -J ^. = ( - JW -__ s \ -^ CC K TS ../O). 1 \ "k- X N 4 + ^ = ( „ ^ ~ -__-_ -___^_,- »^rO / ' 1 a u 1- D C ^ s — -e-— r 5 -J :» i^ '1^ .' r ^ P s h o 1- q: ^ \ '* "^ \ _i£a -—\L \\ iv t c 'i a a H o ooc § L K s ___.p\_ 'i 1^ ''lO / ";"~"5. c c <- + c 4 C IT H □ h ^ < i IS n MIS ^ Ugn:l m >S M rf J T Q NouvoiaaK SWOXdWAS S a 5t is y a| 2 zty - o > ll ^ s S Doijn H 1 1 M ^ s ^ ^ ^ = ; § s ^ s g s § O §5 S S 1 5 S 2 "> - o 'i' 'r '<^' '4 1 1, 1 1 4- o ft! g 11 |£ pstimci il!I»nf) pas aoo. [TOO I 192 INFANT FEEDING. Underfeeding and all past illnesses which might retard development must be excluded. Prognosis is very favorable in uncomplicated cases, with a properly instituted diet. In the average case two to three weeks is required to overcome the constipation, and to obtain a gain in weight. Occasionally a severe type is seen which is difficult to overcome, most com- mon in infants with an idiosyncrasy to cow's milk. Complications. Because of the lowered immunity, infections are common, especially of the nasopharynx, lungs, middle ear and skin and gastro-intestinal and genito-urinary tract. Exudative diathesis is not an un- common associated condition. Sequellae. Disturbed metabolic balance is often the forerunner of the more serious nutritional disorders, such as dyspepsia, decomposition, and intoxication. Chronic constipation frequently results, due to the atony of the intestinal wall and abdominal muscles. Rickets frequently develops in these infants. Treatment. To institute a proper treatment, we must remember that the clinical picture is not dependent on gastro-intestinal findings only, but also on an abnor- mal intermediary metabolism (therefore the designation rvisturbed Metabohc Balance), and that fat overfeeding primarily, and a carbohydrate insufficiency secondarily, are causative factors, and that protein overfeeding may be an important element. 1. Diet with Human Milk. This is by all means the best treatment, especially in young infants. Weight in- crease may be slow at first, probably due to low salt and protein content of human milk. A loss of more than 6 to 10 ounces over a period of three or four days is fre-. DISTURBED METABOLIC BALANCE. 193 quently seen. More than this should lead one to suspect an error in diagnosis. This loss may be due, as stated, to stopping of a food rich in proteins and salts, and sub- stituting one low in the same. This stage is passed in about four days, when the system adapts itself to the new food ingredients. Temperature and pulse do not change, and the stools assume a breast-milk-stool character. If the stage of reparation is slow, and the child does not gain in weight, the substitution of one meal rich in pro- tein and salts daily will frequently help (buttermilk or skim milk). Mother's milk also helps to increase the immunity. 2. Diet with Artificial Foods. In pathogenesis of this condition the milk fat plays the most important role, and this is best counteracted by replacing it with well-toler- ated carbohydrates. Protein tolerance is usually little im- paired, so that high percentage may be retained in the diet in the presence of increased carbohydrates. ( 1 ) In simple cases reduce the quantity of milk and add carbohydrates in the form of sugar and starches. (2) In severer cases (a) Malt soup (Keller's) is exceedingly valuable. Malt soup is indicated in the presence of fat-soap stools which soon become pasty and of mahogany-brown color ; the best re- sults with malt soup are obtained in infants from three to six months of age. After six months more milk than given in the original formula must be added to increase the protein content of the diet. (b) Buttermilk or skim milk mixtures (contain- ing two carbohydrates, i.e.^ sugar and 13 194 INFANT FEEDING. flour). The action of both is the same. Occasionally it is necessary in young in- fants to reduce the sugar recommended in the original formula (see Buttermilk Mix- ture, p. 284). (c) Brady's buttermilk mixture No. 1 (p. 284). Change of the diet is followed by better sleep, im- proved turgor, skin becomes less pale, less variation in temperature. Stools change from soap stools to (1) yel- low-brown, alkaline' and fair consistency, when butter- milk mixtures are fed, (2) acid, softer, mahogany- brown color when malt soup is fed. These results of treatment are due to the fact that the tolerance for carbohydrates is high, and protein toler- ance is little impaired. Each case should be watched to see if an excess of carbohydrates is not being given in the new diet, which is indicated by (a) restlessness, (&) stopping of weight increase after an early rise, (c) ali- mentary fever (irregular), (d) too frequent stools. If the cow's milk mixtures are not well tolerated, human milk is indicated. The above mixtures should be gradually replaced by ordinary milk mixtures after two to eight weeks. In infants over six months of age one of the most con- stant and brilliant therapeutic results follows the use of a limited amount of milk (boiled or citrated) and the free administration of toast, zwieback, rusk, and cooked cereals given in increasing quantities up to amounts that will bring on a steady gain of 6 to 8 ounces a week. To this diet broth or vegetable soup and orange juice should be added soon. In other words, if a baby of six or seven months does not gain on ordinary milk mixtures, it should be fed like a normal baby of nine or ten months, With. DISTURBED METABOLIC BALANCE. 195 the single exception that the milk should be kept rather low, or at least given cautiously, and preferably boiled or citrated, or both. In many cases this can be done even in the fifth month. CHAPTER IV. THE STAGE OF DYSPEPSIA. Synonyms. Stadium dyspepticum, indigestion, Zuck- ernaehrschaden. Etiology. Dyspepsia may develop either primarily in a healthy child or as a sequel of disturbed metabolic balance, when the insufficiency of the intestine has be- come such as to make it impossible to avoid development of pathological fermentation. This may be due either to absolute or relative overfeeding, or because of pri- mary influence, which tends to decrease the food toler- ance. The products of fermentation cause increased peristalsis, which leads to the chief symptom of dyspep- sia, diarrhea. The nlost important factors may be enumerated as follows : 1. Errors in diet with milk of good quality: (a) over- feeding with diet of normal proportions (too frequent and too much) ; (b) feeding with a diet of improper pro- portions (excess of sugar, etc.) ; (c) excess of raw milk, with resulting mechanical irritation, due to large, hard protein curds. 2. Extremes of temperature, heat of summer and cold of winter, with resulting systemic depression. 3. Feeding with infected milk (decomposition products of milk and bacterial toxins). 4. Infections of the gastro-intestinal tract {enteral in- fections) . (196) THE STAGE OF DYSPEPSIA. 197 5. Systemic infections (otitis, pharyngitis, pyelitis, etc.), associated constantly with a lessened tolerance for food (parenteral infections). 6. Congenital lowered tolerance to cow's milk. In practice, especially in young infants, frequently we do not observe the stage of disturbed metabolic balance, because dyspepsia develops directly, due to a relative ex- cess of sugar in the food. Pathogenesis. We will discuss in detail the second group of cases, those due to feeding with a diet of im- , proper proportions. The symptoms of dyspepsia are brought about by in- creased acid fermentation, which causes increased peris- talsis, and increased intestinal secretion, with resulting loss of body fluids. Pathological breaking down of car- bohydrates (sugars, flour) is to be regarded with great- est probability as primary. It is probable that the fat in most cases is involved only secondarily, as a result of the increased peristalsis, fermentation, etc. The same amount of fat is commonly tolerated perfectly if the sugar is lessened sufficiently. It is also probable that the fat has an unfavorable influence on the sugar toler- ance. That the decomposition products of casein do damage to the intestines could not be demonstrated. On the contrary, it was found that by sufficient doses of casein the pathological fermentation could be combated, and thus the casein has a directly curative influence, as seen in the tendency to formation of fat-soap stools. By reduction or complete withdrawal of carbohydrates the pathological fermentation can in almost all cases be de- creased, and also the peristalsis, and this seems to prove that the carbohydrates are the primary cause of this 198 INFANT FEEDING. condition. The different carbohydrates show different tendency to fermentation. Milk-sugar ferments most easily, less easily the cane-sugar, and least the dextrin- maltose preparations. By clinical experiments it was found that the toler- ance of even the same intestine towards carbohydrates is not always the same, and that it also depends to a cer- tain extent upon the quality of the fluid in which they are dissolved or suspended. The same amount of sugar given with large quantities of whey produces much more easily dyspeptic symptoms than the same amount of sugar administered in less whey or in water. From this it fol- lows that in pathogenesis of dyspepsia of artificially fed infants the whey is also of importance, this being in all probability due to the quality and quantity of the whey salts. Symptoms. Dyspepsia is characterized clinically by acute gastro-intestinal symptoms, the most marked of which are the stools, which are increased in number, and of an abnormal quality. The organism does not show signs of any deep-seated general changes; weight loss is moderate or the weight remains constant. Temperature is moderately increased, and repair is rapid with the withdrawal of improper food. Several general symptoms are usually absent in the early stages. The mind is clear. The heart action is not rapid. Respirations are not greatly increased. The baby is restless and fretful, cries a great deal of the time, sleeps brokenly, and sucks its hands and other objects as if hungry. The face soon becomes drawn, and the tis- sues more or less flabby through loss of body fluids. The skin shows little change. Temperature is moderately increased. THE STAGE OF DYSPEPSIA. 199 Weight. The weight loss varies directly with the loss of body fluids through the increased intestinal peristal- sis and consequent diarrhea. Year1 . Q 1Q ^BflRV DiagnosisJlYSPiESlA^ R. Case No — _^ Complications — I^LOJ^l % Age _fl J^oriius. gj Weight LS^DAmDs a I Condition Poor g Date^SeJCUSiO § Age 8-^3 MoriTH^ £J Weight I5lbs6ozi 2 [ Condition (^000 . Fig. 10. — Chart showing hospital record of an infant with dyspepsia. Gastro-intestinal Symptoms. The appetite is poor. The mucous membrane of the mouth is red, and may be the seat of thrush (due to decreased immunity). Vomit- 200 ' INFANT FEEDING. ing may be present, and usually occurs long after feed- ing. Volatile fatty acids may be detected in the stomach content by their odor. The abdomen is distended, and peristalsis increased, and is visible or can be heard by aus- cultation. Restlessness is marked. Stools. The clinical diagnosis is usually made from the stools. They are 'increased in frequency, and they also differ from the normal. They are thinner, contain more mucus, and are either watery or hashy. There is abnormal odor, either that of decomposition or that of acid fermentation. The reaction is variable, mostly acid. The color of the stool is often green, this being due to transformation of bilirubin to biliverdin by oxidizing ferments. The increased peristalsis results in impairment of ab- sorption, which may easily be determined by metabolic experiments, and also estimated by macroscopic, micro- scopic, and chemical examination of the stools. Fatty acids appear in the stools in the shape of white or yellowish lumps (milk curd), and, by addition of strong acids and slight warming, fatty acid needles may be crystallized from them. Neutral fat is present in the form of smaller or larger drops. If flours are in excess, the stools are frequently paste- like and foamy. By iodine solutions the unchanged starches are stained blue, and the erythrodextrin is stained red. Of especial interest has been for some time the ques- tion whether in stools undigested casein was found. The yellowish lumps, the so-called milk-curds, in the hashy stools, seen even in feeding with boiled milk, have erron- eously been regarded as casein curds, which were sup- THE STAGE OF DYSPEPSIA. 201 posed to escape digestion on account of their being diffi- cult of digestion. Today we know positively that these so-called "casein curds" are composed chiefly of fatty acid salts and bacteria. Only in feeding with raw milk frequently large, tough, bean-like casein curds pass through the intestine without being digested. Even in the presence of true casein curds, however, one must not conclude that they are the primary factors in the patho- genesis of this nutritional disturbance unless we are cer- tain that an excess of raw milk has been fed. Varieties. First, the acute dyspepsia, which begins with a definite acute onset, usually in infants who have been previously well, and second, a chronic dyspepsia, which begins less acutely, or follows acute attacks, and which recurs even in the presence of a carefully regu- lated diet. It soon becomes evident that in the latter cases there is a definite lessening of the food tolerance. Diagnosis. The diagnosis can be made only by a careful consideration of the feeding history and the clin- ical and functional symptoms. It is first necessary to differentiate dyspepsia from the milder forms of enteral and parenteral infections. The latter are frequently associated with intestinal irritation. One must remember that the infections, especially in young infants, are frequently associated with a second- ary nutritional disturbance, and vice versa, that secondary infections commonly follow in the wake of nutritional disturbances. An infection should be suspected when the temperature remains high after the withdrawal or reduction of the food (especially of the carbohydrates), and when albumin and hyaline casts appear in the urine, and the mucus continues in excess in the stools, present- ing the picture of a secondary enterocolitis. If jnfeQ- 202 INFANT FEEDING. tions are not recognized, there is a great danger of con- tinuing the starvation diet (which has been inaugurated for the treatment of dyspepsia) too long, and thereby reducing the vitahty of the infant to the stage of decom- position. It is also of importance to note whether the dyspepsia is primary or an acute exacerbation in the course of a decomposition, as on this diiiferentiation to a great extent depends the prognosis and the therapy. Here, again, a careful history is of vast importance, and one should carefully note the presence of repeated dys- peptic attacks, with recurring fluctuations in weight, the occurrence of previous infection, both enteral and paren- teral, as all of these indicate a tendency to decomposition. Prognosis. In infants previously health}^ and with a proper dietetic treatment, the prognosis is good. Re- peated attacks should always be seriously considered. Dyspepsia in very young infants is always more serious than in the older and better developed ones. Treatment. Human Milk. The best treatment of all forms of dyspepsia consists of feeding human milk. The younger the infant, the more the indication for human milk. This is especially true of infants under two months of age. In severe cases it may be necessary to place the infant on a starvation diet for six to twelve hours, and then administer the breast milk in restricted amounts. Artificial Feeding. In artificial feeding the treatment of acute dyspepsia is somewhat different from the treat- ment of chronic dyspepsia. Acute Forms. In the acute form, where the child was previously well and its tolerance good, the simple unload- ing of the intestine may allow it to resume its normal function. The following treatment is recommended : THE STAGE OF DYSPEPSIA. 203 1. Starvation or Hunger Diet. Short (six to twelve hours, rarely longer) starvation, only liquids being ad- ministered, tea with saccharin being the best (saccharin, 1 grain [0.065 Gm.] to 1 quart [1000 mils]). They should be given freely, up to amounts of the total fluids needed. This permits the stomach and the intestines to empty themselves, and to assume their normal functions. Laxatives are usually not indicated. If temporary star- vation is inaugurated, the intestinal tract soon empties itself of its irritating contents. 2. Indifferent Diet. During the second day in young infants, one-third whole milk (best boiled or citrated) plus two-thirds thin oatmeal gruel, without sugar, may be fed, such a diet being low in food value and salts. Buttermilk or skim milk may be used in place of the whole milk in severe cases. The total daily quantity of the milk mixture on the second day should not exceed 6 to 12 ounces, divided into six feedings of 1 to 2 ounces each. To this, 20 to 25 ounces of tea, plus saccharin, may be added, making a total of about 1 quart of fluid for the day. This will usually answer. Further treatment de- pends on the reaction to the above. Upon this treatment the general condition improves, also the disposition, etc., and the weight loss ceases in two or three days. When this is not the case, decomposition or infection should be suspected. 3. Sustaining Diet. Gradually, and as rapidly as pos- sible, the food should be increased, the increase to be made at least every other day, in order to limit the under- feeding to minimum. By the third day the quantity of the milk mixture should be increased, the quality may be left unchanged, giving water or tea to the necessary quantity of fluids between the feedings. Weight increase 204 INFANT FEEDING. should not be expected because of the low sugar content and low caloric value of the diet, but a decrease in weight should always be considered serious. The stools are at first small and contain mucus, later less frequent, and often on milk mixtures without sugar there are fat-soap stools which are a good indication. 4. Ordinary Diet. In mild cases, the ordinary milk mixtures proper for the given infant may usually be re- sumed by the end of a week. In more severe cases, re- turn to a full diet should be slower. In these mixtures, the carbohydrates should be started with 1 per cent, of the whole mixture, and gradually increased to 5 per cent. The carbohydrates most suitable for this purpose are the maltose-dextrin compounds, especially those with a high dextrin content and no potassium carbonate. In older in- fants cereals in the form of flour ball, barley flour, farina, zwieback, can often be added to advantage, as well as clear broths. At first there is a rapid increase in weight, later on a slower one. Avoid underfeeding too long, even if the stools look bad, if the temperature and weight curves improve, be- cause of the danger of decomposition. It should be borne in mind, therefore, that it is undesirable to underfeed for a long period, and more especially dangerous to inaugu- rate starvation repeatedly, or to keep an infant for days on a starvation diet, such as cereal waters or very weak milk mixtures. It is also necessary to know and recognize the stools of an underfed infant (hunger stool). This is greenish-brown in color, composed chiefly of mucus, and small in amount, and sometimes frequent. They should not be mistaken for the curd-containing frequent stools of dyspepsia, as the former is an indication for the re- sumption of food, while the latter indicates starvation, THE STAGE OF DYSPEPSIA. 205 Fats can be added in place of sugars, but this should be done with care. CodHver oil has given us the best re- sults. It should be given in small quantities at first, be- ginning with 1 mil twice daily, and increased to 4 mils per dose. In some infants the above-described treatment is un- successful. In one group of these cases the loss of weight is not favorably influenced, while the stools im- prove; and in a second group the loss continues with continued diarrhea. In these cases there is either infec- tion or they are cases of grave nutritional disturbances on transition to decomposition. It would be a very great mistake to continue starvation longer, with the idea that by giving the digestive tract longer rest, it may still re- cover. This may kill the child. In these cases treatment as recommended for decomposition or infection must be instituted. Therefore, it is advisable to use routine treatment as described above, and, if not successful, the underfeeding should not be continued under any circum- stances, but the treatment for decomposition (described later) or infection (see Infections) should at once be in- stituted, if human milk is not obtainable. It is in these cases that Finkelstein's albumin milk is indicated. (See p. 292, for preparation, and p. 236, for method of administration.) Chronic Cases. In treatment of chronic forms there is no indication for underfeeding. Since here there is no transitory weakness, but a chronic weakness of tolerance, the additional trauma of starvation would have an un- favorable influence. Carbohydrates are to be reduced to the amounts absolutely necessary (about 2 to 3 per cent), and the less easily assimilable carbohydrates are to be replaced by those that are more easily assimilated 206 INFANT FEEDING. (maltose-dextrin mixtures). If this does not improve the stools, then nursing on the breast or albumin milk feeding is necessary. If both of the latter are not avail- able, then the quantities of foods should be carefully measured, with the hope that when the child becomes older the tolerance will become physiologically increased, and the condition thereby undergo spontaneous healing. Medicinal Treatment. This is unnecessary in most cases. For the treatment of irritative conditions which persist even after the dyspepsia proper (loose stools in presence of gain in weight), astringents are of use. Tannigen or tannalbin 1 to 5 grains (0.065 to 0.325 Gm.) four to five times daily will answer, or calcium lactate in doses of 10 to 15 grains (0.65 to 1 Gm.) may be pre- scribed in a 10 per cent, solution to be added to each milk feeding. CHAPTER V. THE STAGE OF DECOMPOSITION. Synonyms: Marasmus, atrophy, pedatrophy. The third stage of impaired nutrition in the classifica- tion of Finkelstein, called by him decomposition, is recog- nized by him as what has been described in pediatric literature as marasmus or atrophy. The clinical picture may be viewed as the end result of repeated nutritional disturbances or constitutional factors. The past history is of the utmost importance, and a careful search reyeals improper diets, with resulting disturbance of nutrition, or a nutritional disturbance following enteral or paren- teral infections, each leaving in its wake evidence of im- paired nutrition, until after weeks or months we have reached the stage of deep-seated tissue starvation. The chronic infections, such as syphilis and tuberculosis, may also result in a similar picture, but must be differentiated to clear the classification for therapeutic purposes. During this stage it becomes increasingly difficult for the infant to assimilate a sustaining diet, with resulting extreme loss of weight, and great lack of resistance of the organism to infections and other injurious external influences (heat, cold), this general weakening of the vitality of the infant being due to perverted metabolism, consisting of breaking down of the body substance, and change in the composition of the cells (abnormal kata- bohsm), and of deficient and improper assimilation of the food (abnormal anabolism). Etiology. Disturbed metabolic balance may be the (207) 208 INFANT FEEDING. direct forerunner of decomposition, if the dietetic error is not corrected ; likewise all factors leading to dyspepsia and intoxication may also be forerunners of decomposi- tion. At what moment this change takes place we have no means of telling, but we know that deep-seated organic changes are necessary to its development; these changes which produce such an intolerance toward nourishment may have developed previously to the preceding illness, or during its course. Premature infants are especially predisposed, also young infants with previous dietetic errors and diarrheal attacks, also those fed on a one- sided diet, excessive in carbohydrates, especially cereal waters, and gruels, as seen in too long continued hunger diet. Especially to the very young does the statement as to cereal waters and gruels apply. All of the preceding reduce the tolerance toward assimilation of a full and normal diet. The tendency to decomposition, and there- fore to the narrowing of tlie nutritional sphere increases with each dyspeptic attack. Czerny's internal hunger, or, as he commonly calls it, ''cell hunger," is the cause of de- composition. The above term is used in contradistinc- tion to hunger as usually thought of, which is due to a lack of food to appease the appetite. Pathogenesis. In the older literature the terms marasmus and atrophy were used to describe the clin- ical picture as presented by this condition. And it was assumed that destructive changes in the intestinal glands following chronic inflammation, with a secondary impair- ment of the functions of absorption and excretion, were the underlying pathological conditions, which resulted in an inanition. This, however, has been found to be erron- eous, since repeatedly the intestine of the atrophic infants was found to be normal. THE STAGE OF DECOMPOSITION. 209 The great and sudden fluctuations in weight as seen in this condition must in the first place be due to loss of water and salts, while the disintegration of the body sub- stance, including the cells, furnishes only a smaller quota to the loss of weight. The researches of Czerny on metabolism have thrown considerable light on this condition. The abnormal split- ting of sugar and fats contained in the food produces ex- cessive amounts of acids in the intestines, which results in the loss of alkali salts, first, through neutralization of the acids formed in the intestinal tract from the food, and secondly, through salt losses due to excessive intes- tinal secretion, as seen in this condition. These abnormal processes result in a relative acidosis, an acidosis of en- teric origin. And as a result of such, enteral loss of salts and markedly increased NH-excretion takes place, which is evidenced clinically by increase of ammonia in the urine. To cover these losses, salts deposited in the tis- sues are in part withdrawn, and finally the cells them- selves are destroyed through being deprived of their salt content (mineral hunger). It should be remem- bered that an abnormal fat metabolism is frequently the essential factor in the etiology of this condition, due to an overstepping of the fat tolerance. And further that fermentative changes in the carbohydrates produce in- creased acidity of the contents of the intestinal canal, and so enhance the action of fats. While there is usually an excess of protein loss over protein assimilation, the tolerance for proteins is usually less affected. Because of the loss of nitrogenous substances due to a relative excess in excretion of NH, proteins must be utilized in the diet to counteract these losses. 14 210 INFANT FEEDING. Increased peristalsis in diarrheal conditions results in further inanition, due to the passing of undigested food through the intestinal tract. The ''decomposition" of the organs essential to life finally leads to an alteration of the condition of the cells and of their functions, which results in the death of the organism. Symptoms. The cardinal symptoms of decomposi- tion are intolerance to food and great loss of weight. 1. Lack of ability to assimilate food is pathognomonic of this condition. The paradoxical reaction to food, Fig, 11. — Infant with decomposition. mentioned in the two preceding stages of nutritional dis- turbances, becomes here a striking and serious phenom- enon. Starvation or the institution of the hunger day as a therapeutic measure in these infants not infrequently results in an inanition which is fatal to the infant. Again, too rapid increases in the diet are equally serious, and not infrequently precipitate alarming and fatal symp- toms. When the condition has progressed to this degree, human milk alone offers hope of recovery. 2. Loss in weight is the second cardinal symptom of decomposition, due, as the name of this condition sug- gests, to disintegration of the body substance. This may be slight in the beginning, and in the light cases ; in the THE STAGE OF DECOMPOSITION. 211 ^ i Q •< ^ O O IS < 1 a rli liii o Z < Z c c p- d c a: .0 .2 "a 1 & Q a >■ It a _ii^ -_;^ ^ ^! ' I' ~ iC< r— i .; ' -aJ ^^ ^ \ ^i 4 + ^ 1^ :::::r:::::?^ '^f- V .^ "'^^vr""i^ «-'t£, J / f^ a: = \ 1 ^0 / 'v I \ r~^ _ J _s - ..^ \ ? ..___.;:5::::j '^(V __._- \ \-; ^ t 4q 3^ t ^^ f^ ■'■ , ooc lOl. " 3 yO^l ua^.g-oj Z7(S^ —ica. ' 1 X T 1 1 : .^< ! _-.. .'?' i-^ s 'K ^^ 1 : ^11 i — -.i--.:.___5^ ^^ ShH 7l*/U2 go )S JlJ^d :> / (lP'\yd?i diiro Z fix gXii gxo: ^""3 yiHf5f ET"H0IIfB'35""C;D: ^ 1 ^ / n ^ ^ — - J / -t-^s s / i . -J Z |X^ -__.::::"" 2 ' h 7 o u IKI. |:^ gr.). Camphor 0.05 to 0.10 gram (1 to 2 gr.) dissolved in sterile oil may be injected subcutaneously in emergency. Special symptoms and conditions arising during the course of the disease, as are high fever, excessive vomit- ing, symptoms of ner^'ous excitation, or extreme depres- sion, are to be treated as detailed under Intoxication (p. 232). Injections of silver ■nitrate are of value in some cases where blood and pus persist in the stool even after the subsidence of acute symptoms, and especially in dysen- tery. Before an injection is given, the colon should be irrigated first with sterile water (not saline). One per cent, silver nitrate solution is then injected in a suit- able quantity. If it causes any pain or irritation, it should be washed out with saline solution. It should not be repeated more often than once a day, and if three injections do not result in marked improvement it is better to discontinue them. Dietetic Treatment. Human Milk. The ideal treat- ment for all cases of intestinal infections would most naturally be best accomplished by feeding with human milk, and whenever obtainable, more especially in the severe types, it is by all means the diet of choice. Feeding with human milk, especially in young infants, produces ver\' good results, because it retards the INFECTION AN.D NUTRITION. 269 complicating nutritional disturbance, and thus favors healing. Artificial Feeding. From the great number of food mixtures that have been advised for enteral infections, we may judge as to the lack of any specific action. It is probable that success may be obtained with any feeding which prevents the aggravation of nutritional disturb- ance, and favorably influences the nutritional disturb- ance which may exist. Feeding with albumin milk, skim and buttermilk, and cereal mixtures and whey-cereal mixture (Frank) offer the least risk. Prolonged starvation by insufficient diet or by refusal on the part of the infant to take the prescribed diet is always disastrous, and must be avoided. After six, or at the most twelve, hours on the tea diet the infant is placed on cereal water (barley, rice, or flour ball), using 1 tablespoonful of the flour to a pint of water in young infants, and 2 tablespoonfuls to the pint of water in infants over 1 year. After twenty-four to forty-eight hours on the above diet an ounce of clear chicken or lamb broth can be added to the above cereal w^aters, seasoning with a small amount of salt. If the child will take the food, it may be given in the same quantities to which the child has been accustomed, or smaller quanti- ties at more frequent intervals. By far the best results obtained in our private and hos- pital work have been by instituting feeding with albumin milk of Finkelstein after the first twenty-four hours on an inert diet. The value of the albumin milk may be explained by the fact that it is easily digestible, contain- ing moderate quantities of fat and sugar and finely divided casein, which is easily digested in this form. The rules to be followed in the feeding with albumin milk are described under Decomposition. This diet is also to 270 INFANT FEEDING. be recommended in home practice, wherever it is pos- sible to obtain it, either from a neighboring hospital or by instruction of the nurse or of the mother. Feeding with albumin milk should be begun after twenty-four hours on the tea and cereal water diet. Sufficient quan- tity of inert fluid, either in the form of water, tea, or cereal water should be given with or between the small feedings of albumin milk. One of the gravest dangers in the severe infections is that the infants are likely to take too. little rather than too large quantities, and are especially prone to vomit when the food is forced upon them. Boiled skim buttermilk or skim milk with starch or flour ball added (1 tablespoonful to the pint) may be used as substitute, if albumin milk cannot be obtained. They are, however, not so efficacious. They should be fed in small quantities, as recommended for albumin milk. Chymogen milk (either made from the whole milk, or in severe types from skim milk), either diluted or in small quantities, if given full strength, is frequently re- tained when the stomach is very irritable, and where the child objects to the less palatable albumin milk and but- termilk mixtures. The whey-cereal mixture therapy of Frank deserves a special mention. It is administered as follows : 1st day: Initial starvation period on tea for not longer than twelve hours. 2d day : Feed five times 50 grams whey and 50 grams cereal gruel prepared from crushed grain. 3d day : Increase to 60 grams whey and 60 grams cereal gruel. 4th day: 75 grams whey and 75 grams gruel. INFECTION AND NUTRITION. 271 5th to 8th day: Not later than on the fifth to eighth day of treatment replace a tablespoonful of whey by tablespoonful of milk. Increases of milk to be guided by the infant's progress and needs. 9th to 11th day: Increase the addition of milk gradually. 12th to 14th day : Even in the grave case 400 grams of milk and 400 grams of cereal gruels and 200 grams of meat broth must be given, and not later than in this time the broth is to be prepared with strained rice or farina. In infants over 1 year, beginning with the tenth day, finely scraped beef may be added. A careful record should be kept of the exact amount of milk and other fluids taken in each twenty-four hours, and, where possible, the child should be weighed daily to ascertain the loss in weight. The dietetic therapy has never such a prompt result as in alimentary nutritional disturbances. Even in favor- able cases the disease (purulent and bloody stools, fever) continues for one week; in unfavorable cases, several weeks. Strict adherence to the food regime once insti- tuted is desirable. In these cases no greater mistake could be made tham to change diet with introduction of repeated hunger days, or to remain on small quantities of food. Thus, an infant suffering from infection succumbs often not to the infection, not to the nutritional disturb- ance, but to inanition. Diet in Convalescence. The problem of nutrition offers great difficulties, even after the- subsidence of the fever, and following the improvement in the number and character of the stools, as it is frequently necessary to keep the infant on a restricted diet for from one to three weeks. Only rarely it is possible to feed sufficient caloric 272 INFANT FEEDING. units for the maintenance of weight during the first and the second weeks of the illness. Where possible, the albumin milk, buttermilk, skim milk, and chymogen milk and cereal gruels should be gradually increased, and these increases in quantity should be maintained even in the presence of moderately bad stools if vomiting is ab- sent, unless one becomes convinced that one or the other of the food elements is absolutely detrimental to the infant's welfare. It is our desire to impress that possibly the gravest dan- ger to the infant during the period of convalescence is that of underfeeding. Upon the return to milk mixture small quantities of boiled milk, low in fat (albumin milk, buttermilk, skim milk) should at first be used. This may be accomplished by adding it to the cereal gruels. Dur- ing this stage beef juice broths, ^gg albumin, coddled tgg (prepared as for typhoid fever patients), zwieback crumbs, pap, custards, and junket may be added. Under conditions where ideal milk and milk preparations can- not be obtained, we have found that not infrequently the better brand of evaporated milk, as obtained on the open market, are useful, when properly diluted. The use of condensed milk should be avoided. The obstinate constipation which is sometimes seen during convalescence should be treated with the utmost conservatism, along the lines as laid down for constipa- tion. The infant should have at least one evacuation of the bowels daily. A saline enema is usually sufficient to produce this result. Appendix. PROPRIETARY BABY FOODS. It should be borne in mind that the average daily cost of many of the proprietary baby foods is in excess of twenty-five cents. For practical purposes the baby foods may be classed as follows : Group I, Prepared from cow's milk. 1. Condensed milk without added sugar. 2. Condensed milk with added sugar (Borden's Eagle Brand) (F., 8.85; P., 7.34; milk-sugar, 11.61; cane-sugar, 42.9; ash, 1.77; water, 27.53). 3. Evaporated milk (St. Charles) (P., 9.0; P., 7.82; milk-sugar, 11.19; ash, 1.71; water, 69.91). 4. Peerless Brand unsweetened evaporated milk (F., 9.27; P., 7.28; milk-sugar, 9.99; ash, 1.51; water, 71.82). 5. Carnation Brand. 6. Lacta Praeparata (powder). 7. Mammala (powder) (F., 12.12; P., 24.35; milk- sugar, 55.34; ash, 5; moisture, 3.19). 8. Honor Brand powdered milk (F., 12.0; P., 34.0; milk-sugar, 44.0; ash, 7.0; moisture, 3.0). 9. Merrill-Soule powdered modified milk (F., 18.0; casein, 8.6; albumin, 7.5; milk-sugar, 57.8; ash, 7.Z\ moisture, 1.2). Calories, 133 per ounce. To be used 1 part food to from 4 to 10 parts of water. 18 (273) 274 INFANT FEEDING. Group II. Foods prepared from dried cow's milk and modified cereals. To be diluted with water only. (A) Containing much unchanged starch. 1. Nestle's Food (milk-sugar, 7.4; maltose, 15.6; cane-sugar, 24.77; starch, 17.31; protein, 10.92; dextrin, 13.51; fat, 5.63; ash, 1.49; water, 3.37). 2. Anglo-Swiss. (B) Starch largely converted into soluble carbohy- drates, such as maltose and dextrin. 1. HorHck's Malted Milk (F., 8.5; P., 16.3; mal- tose and dextrin, 18.80; lactose, 49.15; ash, 3.8; water, 3.0). 2. Allenberry's I and II. (No. I, F., 17.2; P., 10.6; maltose, 14.0; dextrin, 10.0; lactose, 42.0; ash, 3.0.) (No. II, F., 15.88; P., 9.90; maltose, 20.0; lactose, 36.0; dextrin, 13.0; salts, 3.71.) Group III. Foods prepared from modified cereals to be used wnth fresh cow's milk. (A) Starch unchanged. 1. Flours of barley, wheat, rice, corn, oats, soy beans, etc. (Barley flour, 1 level tablespoonful (98 grains) to 12 ounces water equals 1.27 starch or 1.8 calories per ounce.) 2. Arrowroot. (B) Starch partially dextrinized. 1. Robinson's patent barley flour. 2. Imperial Granum (F., 1.4; P. 14.0; carbohydrates (sol.), 1.8; carbohydrates (insol.), 73.5; ash, 0.39; water, 9.0). APPENDIX. 275 3. Eskay's Food (contains a small amount of egg albumin) (F., 1.0; P., 6.7; carbohydrates (in- sol.), 21.21; carbohydrates (sol.), 67.81; ash, 1.3). 4. Denno's Baby Food (F., 1.79; P., 11.0; cane- sugar, 15.2; starch, 64.6; ash, 1.12; water, 6.2). 5. Allenberry's No. Ill (malted) (F., 1.05; P., 10.23; carbohydrates (sol.), 25.00; maltose, 16.5; dextrin, 8.5; carbohydrates (insol.), 60.01; ash, 0.60). (C) Starch completely changed to dextrin and maltose : 1. Borcherdt's Dri-Malt Soup Extract (maltose, 71.10; dextrin, 13.50; protein, 8.66; ash, 2.94; moisture, 3.80). Calories per ounce by weight equals 110. It is a laxative, and is easily di- gested because of the high maltose and potas- sium carbonate (1.1 per cent.) contents. 2. Borcherdt's Malt Soup Extract (protein, 6.40; maltose, 57.57* dextrin, 11.70; ash, 2.54; mois- ture, 21.79). It contains 1.1 per cent, potas- sium carbonate. 3. Borcherdt's Dri-Malt Soup Extract with Wheat Flour. Semi-liquid malt soup extract, to which gelatinized wheat flour has been added, and the whole dried. One ounce equals 110 calories. 4. Borcherdt's Malt Sugar (dry) (maltose, 87 per cent.; dextrin, 5 per cent.). The following table will give a comparative idea of the rela- tive value by weight and measure of Bor- cherdt's liquid and dri-malt soup extracts: 276 INFANT FEEDING. 16 Fluid oz. equal 19.5 oz. dry malt powder by measure. 1 Fluid oz. equals 1.2 oz. dry malt powder by measure. 1 oz. of liquid by weight equals 0.83 oz. of powder. 1 Fluid oz. represents 90 calories. 1 Ounce of powder by weight represents 110 calories. 5. Horlick's Malt Food (contains no milk) (F., 1.4; P., 12.06; maltose, 17.86; salts, 2.6). Calories, 109.29. 6. Mellin's Food (F., 0.16; P., 10.35; maltose, 58.88; dextrin, 20.69; carbohydrates (sol.), 79.57; salts, 4.3; water, 5.6). Calories, 91.43. 7. Dextri-maltose (Mead's No. 1) (maltose, 52; dextrin, 41; water, 5; sodium chloride, 2). No. 2 (maltose, 53; dextrin, 42; water, 5). No. 3 (maltose, 52; dextrin, 41; water, 5; potassium carbonate, 2). 8. Nahrzucker (Sohxlet) (R, 0.03; P., 0.13; mal- tose, 41.0; dextrin, 53.3; ash, 1.7; water, 2). . Group R^. Foods prepared from casein. 1. Larosan (casein plus calcium). 2. Xutrol (sodium compound of casein). 3. Plasmon (from casein by action of CO2 and NaHCOs). Group V. Diastatic ferments. 1. Diastoid (Horlick's, powder). 2. Diazyme (Fairchild, liquid), a good product. Group VL Peptonizing powders. 1. Peptogenic milk powder (Fairchild's). 2. Pepsin. Group VII. Rennet powders (precipitating curd in a finely divided form). 1. Chymogen (rennin and milk-sugar). 2. Pegnin (rennin). APPENDIX. 277 It will be noticed that there are two great classes of proprietary infant foods : The First. (Groups I, II). Those containing cow's milk. Sweetened Condensed Milks. These are advertised as complete infant foods. All of them are quite similar in composition. All contain large amounts of cane-sugar. It is impossible to make, by simply adding water, a properly balanced food for an infant's continuous diet. A dilution to give a rational amount of proteins and fats has a large excess of sugars, and one to contain any amount under 7 per cent, total sugar would be so weak in both protein and fat that the baby's proper growth would be very seriously interfered with. Eagle Brand condensed milk contains: fat, 8.85; pro- teins, 7.34; milk-sugar, 11.61; cane-sugar, 42.90; ash, 1.77; water, 27.5. TABLE. A Well-known Condensed Milk, Showing the Content of Various Dilutions. Fats and Proteins Deficient. Full 6 parts 12 parts 18 parts strength water water water Per cent. Per cent. Per cent. Per cent. Fat 6.94 .99 .53 .36 Proteid 8.43 1.2 .65 .44 Cane-sugar ... 50.69 7.23 3.90 2.67 Salts 1.39 .17 .10 .07 Water 31.30 90.49 94.80 96.46 The Unszveetened Evaporated Milks. They were made by heating the milk to 200° F., and then transferring it to vacuum pans, where it is maintained at a temperature of 125° F., until sufficient water is evaporated to bring the product to the required condensation. In most products this milk is about double strength. 278 INFANT FEEDING. The sugar content not being in excess, these milks can be so diluted that a reasonable amount of fat and protein can be obtained, with, however, a considerable deficiency in sugar; this relatively low amount of carbohydrate can then be made up by adding sugar (cane or maltose-dex- trin compounds), much the same as is done with cow's milk. \Miere it is impossible to obtain clean, fresh milk, evaporated milk can be used with good success as a tem- porary diet in traveling, etc. A fresh can should be opened daily. It can be diluted with three to six or more parts of water, or cereal water and sugar in some form as indicated; however, the carbohydrates contained in the formula should rarely exceed 7 per cent. One part of milk to two parts of diluent plus carbohydrates is the strongest formula in which it is ever necessary to feed infants, as this equals the strength of whole milk with carbohydrate added. Occasionally, infants with a very weak digestion will thrive on the evaporated milk where all other methods fail, if the food is started in high dilution, the quantity be- ing increased as the infant shows improved capacity. Because of the repeated heating and the low salt con- tent, the food necessarily loses some of its vital require- ments, and an early attempt to change to fresh milk should be made in order to avoid constitutional disorders as rachitis, scurvy, etc. The tendency to become very fat on this class of foods is proverbial, but this is not usually associated with high resistance or immunity to infections, and these infants succumb rapidly to- the respiratory and intestinal infections. Unless the mother is forewarned, it is often with reluctance that she can be made to foresee the necessity of taking her baby off the food which agrees with it, and experiment with a new and occasionally uncertain formula. APPENDIX. 279 The Pozcdcred Milk Foods. Mammala, Honor Brand, and Merrill-Soule Brand are fresh milk dried. In the two former, part of the cream has been removed. All have some lactose added. They find their most impor- tant indication as an occasional substitute feeding in breast-fed infants — first, for the mother's convenience, to allow her recreation ; secondly, where the milk of the mother is insufficient, and one or two regular feedings are indicated temporarily until a formula of fresh milk is advisable, or while traveling, when the milk supply is uncertain; and thirdly, those containing large amounts of maltose (Horlick's) can be given once daily in breast- fed infants in need of a laxative. The Second Class. Those to be used in conjunction with fresh cow's milk. In this class belong Groups III and IV. These give us a far more rational infant food. Group III. (A) The unchanged or partially dextrin- ized starches are especially to be used in solution in place of boiled water as diluents, best after the second month. A number of good cereal flours can be purchased on the market. (B) In this group are found most of the highly ad- vertised and detailed baby foods. They have little or no advantage over the plain cereal flours. (C) These are especially valuable where maltose and dextrin are better taken than cane- or milk- sugar. Dex- tri-maltose (Mead's No. 1 and 2) and Nahrzucker. DIRECTIONS FOR THE PREPARATION OF INFANT'S FOODS. Tea. To a small half-teaspoonful of fennel, chamomile, or ''green" tea add 1 pint of boiling w^ater, cover with a 280 INFANT FEEDING. clean dish, and steep for two o^r three minutes, or till the tea is of a light yellow color ; then pour through a clean sieve or muslin. It should be weak. If used for thirst only, in diarrheal cases, one-fourth of the above amount is sufficient. Barley Water. Soak 1 tablespoonful of washed barley (pearl) in water overnight; pour off water, add 1 quart of fresh water, and boil down to 1 pint (2 hours). Add boiled water to make 1 pint, if necessary. Strain through fine cloth. Keep in ice-chest. Oatmeal and Rice Water. They are prepared in the same manner, only boiled •more slowly. They may be made from barley, oatmeal, or rice flours by using 1 rounded tablespoonful to 1^ pints of water, and boiling for 20 minutes down to 1 pint, in an open stew-pan, stirring constantly. (Ap- proximates 3 calories per ounce.) Oatmeal, Barley, and Wheat Jelly. Use twice the quantity of cereal and same quantity of water. To Dextrinize Barley or Oatmeal Water. Cool to 105° F., add 1 teaspoonful extract of malt, cereo, liquid taka-diastase or diazyme, stir, allow to stand for 15 minutes, when the gruel becomes thin and watery. Add a pinch of salt, stir, only to mix, cool, strain, and put in ice-chest. APPENDIX. 281 Flour Ball. Tie 2 pounds of wheat flour in a cheese-cloth bag, and boil in 2 quarts of water for five hours. Remove from water; place in oven until quite brown on the outside. This will require from two to three hours slow baking. Break open and throw away the brown shell; the re- mainder, the baked flour, must then be grated into a powder, or may be ground in a mill. Albumin Water. To Yz cup of cold boiled water add the white of 1 fresh ^%g and a pinch of salt. Stir very thoroughly. A piece or two of artificial ice may be added before stirring. One-half teaspoonful of sugar and orange juice may be added, if not contraindicated. Barley water may be used. Albumin Water with Beef Extract. One-quarter teaspoonful of beef extract may be added to the cold water before adding the tgg albumin. White of Egg and Digested Gruel. Whites of 2 eggs may be added to 1 pint of dextrin- ized barley, oatmeal, etc., gruels. Stir thoroughly. Pasteurized Milk (double boiler). Place milk in cold water bath, having water to level of milk; bring milk to temperature between 155° and 167° F. for 15 to 20 minutes. Sterilized Milk (double boiler). The milk mixture is put into the inner vessel cold, and the water in the outer vessel is also cold, The double 282 . INFANT FEEDING. boiler is then placed on the stove and allowed to remain until the water in the outer vessel boils for 6 to 8 min- utes; the whole process requires 10 to 15 minutes. While the milk heated in this manner forms a much finer and softer curd than that of raw milk, it is not as fine as the milk boiled directly over the flame. Whey. Heat 1 quart of clean raw milk to 104° F., and add 1 level teaspoonful of chymogen or fresh essence of pep- sin (Fair child's-). Allow it to stand for one-half hour, pour off the free whey, pour the curd into a straining cloth for one-half hour, and collect the remainder of the whey. Chymogen Milk. Boil milk for five minutes, cool to 104° F., and add 1 full teaspoonful of chymogen to each quart of milk, and stir for one-half minute. Let it come to a clabbard by allow- ing it to stand for 15 minutes; then beat it well until the curd is finely divided. Do not heat above 100° F., when preparing individual bottles for feeding, otherwise curds will clump, and will not pass through the nipple. Indications for chymogen milk : ( 1 ) Vomiting in in- fancy; (2) indigestion due to the large curd formation. Buttermilk in the Home. A pure culture of lactic acid bacilli is added to raw, pasteurized, or boiled milk in an earthenware dish, and allowed to stand at about 80° F. for 15 to 20 hours, or until the casein is coagulated. Stir vigorously in a churn, or with a spoon or egg-beater until the curd is very small, and then push the contents through a fine wire strainer APPENDIX. 283 with a spoon. If the buttermilk is too thick, add a small amount of water. When the buttermilk is once made, a small portion (about 4 ounces) may be used as the in- oculating agent for the next supply to be made. In this way the original culture may be made to last from six to eight weeks. The quality and action of the product made will vary but little. Add 4 ounces of buttermilk to 1 quart of fresh milk, incubate, and follow the above outline. Sometimes the milk will not coagulate, although it may smell sour. Stirring with a spoon will often pro- duce coagulation in a few minutes. The fat present will rise to the top, and when coagulated appears as a brown- ish-yellow scum, which may be removed before the curd is broken up. At the present time the market is flooded with tablets for the preparation of buttermilk, but one must hesitate before using them to prepare milk for a baby. A pure culture should be used, or one recom- mended by the physician. Whole or skim milk is to be used as indicated in each individual case. Startoline. Carefully pasteurize 2 quarts of fresh whole milk to a temperature of 180° F. for one hour, or boil for five minutes ; cool quickly to about 80° F., and add 1 ounce of Hanson's Lactic Ferment Culture, and let it stand un- disturbed until well curdled, which should be in 15 or 20 hours, at a temperature of 75° F. Then place on ice. When ready to use, beat curd up with a spoon until it is of a creamy consistency. Buttermilk for Hospital Feeding. Pasteurize whole sweet milk to a temperature of 180° F. for one hour ; then place in cold water until cooled to 284 INFANT FEEDING. 80° F. Add 1 ounce of startoline to every quart of milk, stir with a spoon, and cover; allow to stand from 15 to 20 hours, then churn for one hour ; then add a little cold sterile water to break butter away from milk; and strain buttermilk. Buttermilk and Skim Milk Mixture. To a few tablespoonfuls of buttermilk add 2^ level tablespoonfuls of f^our (flour ball or dextrinized barley flour), to make a paste. ]\Iake up to 1 quart with but- termilk. (1) Bring to a boil, withdraw from fire. (2) Bring to a boil, withdraw from fire a second time. (3) Add 4 level tablespoonfuls of cane-sugar, and bring to a boil for the third time. (^Maltose-dextrin preparations are best in all diarrheal conditions.) (1, 2, and 3 should require about twenty minutes time.) Make up to 1 quart with boiled water, if it has boiled away; put on ice. It is well to start with one-half the amount of sugar, and increase as indicated. Brady's Buttermilk Mixture No. 1. Dr. Jules Brady, of St. Louis, has suggested the two buttermilk mixtures following, which contain less car- bohydrates than the above buttermilk mixture, and which he has found especially valuable in the feeding of infants in institutional practice. Mixture No. 1, which is used for young infants during the first two months, contains 11 calories in 'each ounce; the young infant receives 4 ounces of this mixture for every pound of bod}^ weight as soon as it will take it. The baby weighing 6 pounds at birth is allowed to take 24 ounces in twenty-four hours, or 3.S ounces every three APPENDIX. 285 hours, 7 feedings in twenty- four hours. The average in- fant at three or four days will take 1 ounce; at eight days, 1 to 2 ounces; at fourteen days, 1^ to 2 ounces; at three weeks, 2 ounces ; at six weeks, 3 ounces ; at eight weeks, 4 ounces. Mixture No. i. Ya, quart skim milk. Ya^ quart barley water (thick). 1 ounce by measure, Mellin's Food. Yz ounce granulated sugar. The ingredients are mixed together in the following manner: To the barley gruel is added the cane-sugar and the Mellin's Food, and then the buttermilk is slowly added, and the mixture strained. Note that the butter- milk is not boiled. The mixture is rather thick, and has the sour taste of buttermilk. As a rule, the milk is acidi- fied with lactic acid bacilli twelve hours before being made up, having first agitated it. Brady's Buttermilk Mixture No. 2. On reaching a weight of 8}^ to 9 pounds, infants re- ceive the mixture No. 2, which contains 18 calories for every ounce. The babies are allowed 3 ounces of the mixture No. 2 for every pound of body weight. Mixture No. 2. % quart whole milk. % quart barley water (thick). 1 ounce granulated sugar. Indications for buttermilk and skim milk mixtures : 1. Fat indigestion. 2. Loose bowels (it may be necessary to reduce the amount of sugar. The high protein contents tends to constipate). 3. Malnutrition, with stationary weight. 286 INFANT FEEDING. Keller's Malt Soup. To 11 ounces (330 Gm.) of warm milk gradually add 1% ounces (50 Gm.) of flour, stir constantly, then pour through a clean sieve or muslin. In another dish dis- solve 3 ounces (100 Gm.) by weight, or 2}4 ounces or tablespoonfuls by measure, of Borcherdt's malt extract with potassium carbonate in 20 ounces (600 Gm.) of boiled warm water. Then mix both solutions, put on fire, stir continually, and boil for two or three minutes. IndicaHons for Keller's Malt Soup : 1. Fat indigestion. 2. Disturbed metabolic balance (fat-soap stools). 3. Chronic constipation (often relieved by simple addition of malt soup extract to ordinary milk mixture in place of part of sugar). C ontvaindications : 1. Before the third month, if the stools are loose. 2. For a period of more than four to eight weeks (to be followed, where possible, by ordinary milk mixtures, the strength of the latter being gradually increased). Cream Soups. Cream soups may be made from vegetable pulp, using 1 tablespoonful of cooked potatoes, peas, or asparagus to ^ cup of water in which the vegetables were cooked, ^ cup of sweet milk, and Yz teaspoonful of flour, with a little butter and salt. Cook another minute or two. Strain if necessary. Serve. Corn or tomatoes may be used in the same manner, using 2 tablespoonfuls of strained vegetables, with about one-third water and two-thirds milk. When APPENDIX. 287 tomatoes are used, add a small pinch of soda to tomatoes before adding other ingredients. Vegetable Soup. One-fourth pound lamb stew, cut into pieces, 1 potato cut into pieces, 1 carrot cut into pieces, 2 stalks of celery cut into pieces, 1 tablespoonful of pearl barley, 2 table- spoonfuls rice, 2 quarts water. Boil down to 1 quart; boil three hours. Add pinch of salt, and strain before feeding. Lamb, or Veal Broth. Lean meat chopped fine, 1 pound ; cold water, 1 quart ; a pinch of salt ; cook slowly two or three hours to 1 pint. Add water from time to time, so that when finished there will be 1 pint of broth. Strain; when cold, skim off fat. Chicken Broth. Small chicken, or one-half of large fowl, with all skin and fat removed ; chop bones and all into small pieces ; add 1 quart boiling water and a little salt; cover closely, and allow to simmer over a slow fire for two hours. After removing allow to stand one hour; then strain. Add water, if necessary, from time to time, so that there will be 1 pint when finished. Farina Soup. To 1 pint of meat broth, gradually add, while stirring, 1 even tablespoonful of farina, and boil down to 1 cup (^ pint) in about twenty minutes. It is a good plan to boil the farina for from fifteen to twenty minutes before adding it to the broth ; then broth and farina need to be boiled together for but ten minutes. 288 INFANT FEEDING. Dried Fruit Soup. Wash thoroughly 1 cup of dried apricots and 1 cup of prunes. Cook in 1 quart of cold water until very soft. Strain and press out all juice. Sweeten to taste. Thicken with a tablespoonful of rice flour to 1 quart of the liquid. Cook twenty minutes to remove the raw taste of the flour. Soy Bean and Condensed Milk (Ruhrah). Add a level tablespoonful of soy bean flour to 2 level tablespoonfuls of barley flour, add a pinch of salt, and mix to a paste with boiled water, adding further water to 1 quart. Boil for twenty minutes, and add water to make up for the loss due to evaporation during boiling, so that total mixture is 1 quart. Condensed milk is now added, varying in quantity from y^ to \ dram of condensed milk to each ounce of the mixture, depending upon the age and the condition of the infant. Double the quantity of soy bean and barley flours may be used for older chil- dren. Each ounce of soy bean gruel contains 10 grams of protein and 102 calories. Two ounces of soy bean gruel in a quart of water contains 0.56 per cent, protein, 0.62 per cent, fat, and 3.31 per cent, sugar. The quantity of the feedings may be varied according to the condition and needs of the infant, varying from 1 to 8 ounces per feeding. It is indicated whenever fresh clean milk is not ob- tainable, in infants with marasmus, in some intestinal disturbance associated with diarrhea. Beef Juice. Take % to ^2 pound round steak, broil slightly, cut into small pieces, and then press out the juice with a meat APPENDIX. 289 press or potato ricer, and add a small pinch of salt. Feed fresh, or warm before giving, but do not heat sufficiently to coagulate albumin. Potatoes. Boil potatoes in salt water in the ordinary way until they are thoroughly done. Then mash through a very fine sieve, and add a little butter. Spinach. Cook' spinach in salted water until tender. Pour cold water over it, and drain. Chop fine, or rub through a coarse sieve. To 2 tablespoonfuls of spinach add 1 tea- spoonful of fine breadcrumbs, y^ teaspoonful melted but- ter, and a little salt. Reheat and serve. Asparagus. Cook one-half of a bunch of asparagus in about a pint of slightly salted water. When tender, remove stalks one by one. Place on a warm plate, and remove pulp by taking hold of the firm end of the stalk, scraping lightly with a fork towards the tips. Use pulp only. Make a sauce with one-fourth of a cup of water in which asparagus was cooked, one-fourth of a cup of milk, 1 teaspoonful flour, a little butter and salt. Dip a small piece of toast in the sauce. Take what is left of the sauce and mix with 2 tablespoonfuls of asparagus pulp. Reheat. Place on toast and serve. Carrots. Cook ^ pound of young carrots in a pint of fat-free soup stock or slightly salted water, adding more if it 19 290 INFANT FEEDING. cooks away before they are done. Rub through a sieve ; add 1 teaspoonful of bread-crumbs, a Httle butter and salt. Reheat and serve. Beans. Soak 2 ounces or 4 tablespoonfuls of beans, and cook them slowly in a good deal of water until they are soft, but not broken. Rub through a sieve, add 1 cupful of soup stock, and let them cook for one-half hour, adding more stock if it boils away. Mix a little butter and flour, about a teaspoonful of each, and a little salt. Add to soup. Return to fire, and cook for a few minutes. Green Peas. Cook a cupful of green peas in boiling salted water until they are done. Drain, saving the water in which they are cooked. Rub through a coarse sieve. Make a sauce of 2 tablespoonfuls of water in which the peas were boiled, 2 tablespoonfuls of sweet milk, i^ teaspoon- ful flour, ^ - teaspoonful fine bread-crumbs. Mix all together. Reheat and serve. Fruits. (a) Orange Juice: Take sweet orange, cut into halves, and squeeze out juice by hand or with a lemon squeezer; strain, put on ice, and use as ordered. (b) Prune Juice: Take ^ pound of prunes, wash thoroughly, cover with cold water, and soak overnight. In the morning place on stove in the same water, and cook until tender. Add 1 teaspoonful of sugar, and strain. (c) Prune Jelly: Cover 1 pound of prunes with 1 quart of water; cook slowly until tender; pit, and press APPENDIX. 291 pulp through a sieve. Add sugar to sweeten (2 tea- spoonfuls) and Yz box of gelatin dissolved in a pint of water, and boil. Strain, cool, and keep covered. (^) Apple Sauce: Take 6 apples and peel, core, and cut them into quarters. Place them in an enameled dish ; sprinkle over them 1 tablespoonful of sugar; add 1 cup of cold water; put the dish on the stove, and boil the apples to a mush (about thirty minutes). {e) Orange Gelatin: Soak ^ box of shredded gelatin in cold water for thirty minutes. Add 2 cupfuls of boil- ing water, and dissolve. Then add 1 cupful of sugar, the juice of 1 lemon, and a cupful of orange juice. Strain through a fine strainer (or a cloth) into moulds, and set away to harden. Eggs. Use only soft-boiled or poached eggs. Be sure that the eggs are fresh. Drop tgg in boiling water; imme- diately turn flame out, and allow to stand for five minutes. Pap. Put 1 pint of milk on to boil; add butter the size of a walnut. Beat 1 tgg thoroughly. When milk boils, add the beaten ^gg, stirring constantly. Mix 1^ tablespoon- fuls flour into a paste and add to mixture, stirring con- stantly. Allow mixture to boil ten minutes. Just before taking from the fire add a pinch of salt. May be taken plain, or with milk and sugar as directed. Cornstarch Pudding. Take 1 pint of milk and mix with 2 tablespoonfuls of cornstarch; cane-sugar, 1 tablespoonful. Flavor to 292 INFANT FEEDING. taste; then boil the whole eight minutes. Allow to cool in a mould. Custard Pudding. Break 1 tgg into a teacup and mix thoroughly with sugar to taste. Then add milk to nearly fill the cup. Mix again, and tie over the cup a small piece of linen. Place the cup in a shallow saucepan half full of water, and boil for ten minutes. If it is desired to make a light batter pudding, a tea- spoonful of flour should be mixed in with the milk be- fore tying up the cup. Infant's Gelatin Food. About 1 teaspoonful of gelatin should be dissolved by boiling in ^ pint of water. Toward the end of the boil- ing, ^ pint of cow's milk and 1 teaspoonful of arrow- root (made into a paste with cold water) are to be stirred into the solution, and 1 to 2 tablespoonfuls of cream added, just at the termination of the cooking. It is then to be moderately sweetened with white sugar, when it is ready for use. The whole preparation should occupy about fifteen minutes. Albumin or Eiweiss Milk (Finkelstein). One quart. Take fresh whole milk, bring to a tem- perature of 98° to 100° F. Then add 2 level tablespoon- fuls of chymogen powder to a quart of milk; place in a water bath of 107° F., for fifteen to twenty minutes, until coagulated. Then hang in a sterile muslin bag for one hour to drain. To the curd of 1 quart of milk add 1 pint of buttermilk, and rub through a copper gauze strainer three times. APPENDIX. 293 Then add 2 level tablespoonfuls of wheat flour, flour ball, or imperial granum, rubbed to a paste with 1 pint of water. Boil ten minutes, cutting back and forth con- stantly, not stirring, with a large wooden spoon, other- wise large curds will form. If needed, water should again be added, when directed by the physician. Finkel- stein advises the early addition of 3 per cent, of carbohy- drate in the form of a maltose dextrin compound. This is best done by dissolving the sugar in a moderate quan- tity of water, and adding while the mixture is being boiled. It must not be heated above 100° F. before feed- ing, otherwise it will clump. Albumin milk contains : protein, 3 per cent. ; fat, 2.5 percent.; milk-sugar, 1.5 per cent.; starch, 1.0 per cent.; salts, 0.5 per cent. Caloric value is 450 calories per liter, or 12 calories per ounce. Indications for albumin milk (Finkelstein) : 1. Diarrheas and all cases of abnormal intestinal fer- mentation (sugar). 2. Fat indigestion with low sugar tolerance. 3. Gastro-intestinal infections associated with fre- quent stools. 4. Systemic infections with intestinal complications. Albumin Milk (Miiller and Schloss). Use 1 quart of water and 1 quart of buttermilk, and boil for three minutes. Set aside for thirty minutes, and then pour off the upper 36 ounces of the whey. Boil the upper 4.5 ounces of a quart of fresh milk for three min- utes. Add 1 ounce of dextri-maltose to the boiled top milk, and to this add the curds from the first mixture, which would equal 27.5 ounces, making 1 quart of the milk mixture. 294 INFANT FEEDING. Larosan Milk. Two-thirds of an ounce of Larosan powder (p. 276) is added to 5^ pint of milk, and mixed thoroughly. Another whole pint of milk is heated to the boiling point. \Mien it has come to a boil, it is added to the Larosan milk mixture, and the whole is placed on the flame and allowed to boil "for five minutes. This may be diluted with water in the proportion of one-half Larosan milk and one-half water, or two-thirds Larosan milk and one- third water. Fig. 16.— Utensils needed for artificial feeding : Double boiler (small)-, pan, funnel, bottle-brush, 250-mil (8 oz.) graduated glass or pitcher, 6 nursing bottles and rack, paper caps for bottles (sterile), nipples, milk, sugar, flour, milk magnesia, citrate of soda, tablespoon, dairy ther- mometer, \-egetable mill. This mixture, because of its high protein content and comparative ease of preparation, can be used as a substi- tute for albumin milk in the home. Meats. Raw or slightly cooked beef, scraped and seasoned, can be fed in amounts equaling a tablespoonful at eighteen months or sooner, once daily. APPENDIX. 295 Take meat, preferably from the round, free from fat. Place on a board and scrape with a silver spoon. When you have the desired amount of meat pulp, shape into a pat and broil on a hot, dry spider. Do not cook too long. When done, season with a little salt and butter. Serve. A few drops of lemon juice may be added. Later, lamb, beefsteak, roast beef and chops are the best, and should be broiled. By no means fry any meat for the baby. Soup meat, well cooked, may also be given. All meats should be very finely cut before giving them to children. BOTTLES AND NIPPLES AND THEIR CARE. The nursing bottle should be of such a construction that every portion of it is easily reached with a proper brush. This necessitates the avoidance of sharp corners and angles, and makes the smooth stream 'lines in its construction desirable. It should be made of good glass, not easily broken, capable of being boiled repeatedly without cracking, and should hold about 8 to 10 ounces. Several nursing bottles should be kept on hand, and, if possible, as many bottles as there are nursings in a day should be available, so that the whole day's feeding may be prepared according to the particular formula, and the mixture then iced, and the individual bottles warmed on a water-bath whenever necessary. New bottles should be annealed by placing them in a vessel with cold water, and then bringing the water to a boil, boihng for twenty minutes, and then leaving the bottles in this water until it will cool off again. Bottles thus treated do not crack so easily when hot fluids are poured into them. After nursing, the bottle should immediately be rinsed with cool water, and then washed with hot water and soap 296 INFANT FEEDING. suds by means of a bottle brush. Afterwards the bottle should be set aside, inverted, so as to drain. Before use, the bottles should be boiled for five minutes. To avoid cracking, they must be placed in cold water and heated slowly. After the food has been prepared, the individual Fig. 17. — Good and bad nursing bottles. 1. Ordinary small-neck nursing bottle as sold in drug stores (8-ounce). 2. Improved large-neck nursing bottle (made in 5- and 10- ounce size). 3. Hygiea nursing bottle. bottles may be filled and stoppered with sterile cotton, or, better, sterile paper caps, which are sold for this purpose. Nipples that can be turned inside out and easily cleansed should be selected. The conical shaped nipple is preferable. The hole in the nipple should be of such size that the milk will drop rapidly and not flow when the bottle is inverted. New nipples should be boiled before APPENDIX. 297 they are used. After using, every nipple should imme- diately be washed with soap and water, being turned in- side out, boiled and finally dropped into a sterile jar, where it is to be kept dry until ready for use again. Keeping the nipples dry lengthens the life of the rubber. Several nipples should always be kept on hand. Fig. 18. — A milk station consisting of three rooms. Room 1. For all used bottles, bottle washers, and steam bottle sterilizers. Room 2. A clean room for preparation of for- mulae. This room also contains milk separator, fat-test- ing apparatus and butter churn. Room 3. Pasteurizing and sterilizing apparatus. CARE OF FOOD DURING TRAVELING. Whenever possible, the baby should be kept on its usual diet during the long journey. This is usually ac- 298 INFANT FEEDING. complished without much difficulty when the baby is on boiled milk. If it has been fed on a raw milk mixture, the milk must be boiled before starting. When for any reason it is impractical to carry the milk mixture, evap- orated milk or powdered milk may be used. (See Pro- prietary Infant Foods, p. 273.) In the use of evaporated milk, a fresh can must be opened at least once daily. When it is known that the baby's formula is to be changed, it should be tried out on the new food before starting on the journe}'. As soon as possible, the pre- vious diet should be re-established. All water given to the baby while traveling must be boiled. The infant's food, after boiling for at least ten minutes, should either be placed in individual nursing bottles, or in bottles holding not more than 1 pint, so that not more than two or three feedings should be given from a single bottle. The bottle should be packed in ice, using care so that none of the ice reaches the top of the bottle. Upon reaching the train they should be placed in the ice-box of the dining or buffet ca,r, unless a private ice-box is available. The baby's bottle can be warmed on the train by setting in a dipper of warm water, which may be carried hot in a thermos bottle, if the journey is to be a short one. Care must be taken that the water be not too hot, otherwise the cold bottles will be cracked. The nipples may be carried in a wide-mouthed, well-corked bottle, sufficient to cover the individual feedings. The nipples and bottles should be cleansed immediately after use. THE DIAPER. The diaper should be made of soft, Hght, and ab- sorbent material, such as cotton diaper cloth, which can be purchased for this purpose. Cotton-flannel is too little APPENDIX. 299 absorbent, and soon becomes hard as a result of washing. A second diaper may be folded into a square, and be laid under the hips to prevent the moisture from reach- ing the clothes, or instead of this arrangement, which is rather heating and bulky for summer use, a small diaper may be folded two or three times to form a square of about nine inches, and this may be placed inside of the larger diaper to receive the urine and feces. About four dozen diapers are needed for an average baby. A rubber or waterproof cover should never be applied outside the diaper. It is very heating, and liable to pro- duce chafing and eczema. Diapers should be changed as soon as soiled, except at night, when they should be changed when the child is awakened for feeding, or when it is awakened by its own discomfort. Soiled diapers are always a somxe of discomfort, and not infre- quently the cause of severe irritation of the skin, as well as of infections of the genital and urinary tracts. This is especially true in the case of female infants. No diaper should be applied a second time without first being washed. All diapers which have been soiled by dis- charges from the bowel should have the bulk of the feces removed from the diaper, and should be immediately washed with soap not too alkaline in character, and later boiled for twenty minutes, and thoroughly rinsed, so that all alkali may be removed. They should then be aired thoroughly. Soda and washing-powders should be avoided because of the danger of irritating the child's buttock's, after being moistened by the urine. The diapers of an infant ill with an intestinal infection should be cared for separately from those of other chil- dren. After changing the diapers, the nurse's hands and nails should be scrupulously cleansed with brush and file. 300 INFANT FEEDING. BABY'S DAILY BATH. The baby should be bathed at least once a day, and on hot days even as many as three sponge-baths may be given. In the first six months the temperature of the bath should be 100° F., and in the second half of the year from 90° to 95° F. The room in which the bathing is done should have a temperature of at least 70°, and not more than 75° F. Toward the end of the first year the infant may be sprayed for 15 to 30 seconds with water at 75° to 80° F. This should be followed by brisk rubbing of the entire body. In young infants the bath is most conveniently given before the mid-morning feeding, and the face and hands may be sponged before the 6 o'clock feeding. In older infants, a cool sponge and massage may be given in the morning, and the warm bath at bedtime. Before the umbilical cord has separated, sponge-bath only should be given, and never a submersion bath, for the fear of infection of the umbilical stump. Sponge- bath may be given on a towel, and when a tub-bath is given, the child should be allowed to rest upon the at- tendant's left arm, which is slipped under its back from the baby's right side. By grasping the baby under the armpit with the left hand a good hold is secured, which prevents slipping. The right hand is left free for wash- ing the baby. A special wash-cloth, preferably of cheese- cloth, should be provided for washing the baby's face and head. A pure, bland, white soap should be used. Very little soap is needed for cleansing the baby's skin, and it is most important that the skin should be thoroughly rinsed. If the skin is sensitive and easily irritated, soap should be avoided, and the bran-bath (made by putting a handful APPENDIX. 301 of bran in cheese-cloth bag and soaking this in the water until milky) should be used. After the bath the baby should be wrapped in a large soft towel and dried by sponging, and not by rubbing. Special attention should be paid to folds and creases of Fig. 19. — Hospital bathroom. Located between two small wards for infants, showing two metal water jackets rest- ing on a porcelain sink. These can be filled with water, and have a registering thermometer for indicating the tempera- ture before giving the bath. They are covered with a clean towel for each baby. Baby is showered from an automatic mixing tank, which registers temperature of the water in the tank. The room further contains a scale and a low dressing table, with the various dressings, powders and ointments to be used. Also low nursery chairs, collapsible bags for soiled linen, and waste basins. 302 INFANT FEEDING. the skin, and these should be well powdered after being thoroughly dried. Only warm baths should be used in infants who be- come pale and cyanotic when a cooler bath is used. Care should be taken in bathing all children suffering from coughs. Great care should also be used while bath- ing a child suffering from vulvovaginitis, to avoid infec- tion of the eyes. COLD BATH AND COLD PACK. Cold bath is an efficient antipyretic and nervous de- pressant in cerebral irritation, but it is a somewhat severe procedure for the infant, and is less frequently indicated than in the adult. It is to be used only in infants who react well. The bath is started with water at 100° F., and the temperature is then gradually lowered by the addition of ice-water, down to about 80° F. The infant should be continually rubbed while in the bath. The bath should not be longer than five to ten minutes, and should be discontinued at once, if any cyanosis appears. The infant must be dried quickly, and then wrapped in a dry blanket, without dressing, and put to bed. In most cases, however, a cold pack is preferable to cold bath, especially in young infants, as the former is a somewhat milder procedure. Cold pack is one of the best antipyretic procedures in infancy and childhood. The naked child is wrapped in a blanket wrung out of water at a temperature of about 100° F., and is then rubbed with ice through the blanket for about five to ten min- utes. Ice-bag to head and hot-water-bag to feet are very useful — often necessary. After rubbing with ice, the child is left in the blanket, and covered well. The blanket may be removed, the child dried, and put into a dry blanket after about one hour. APPENDIX. 303 HOT BATH. Hot bath is indicated in cases of collapse or shock as a stimulating procedure, and prolonged hot bath as a dia- phoretic procedure. It should be started with water at a temperature of 100° F., and the temperature gradually raised to about 105° F. by addition of hot water. An ice-cap or cold cloth should be applied to the head. A thermometer should always be used while giving a hot bath. The infant should be well rubbed during the bath, which should be continued for about ten minutes. After the hot bath the infant should be well dried, until the skin is red, and then wrapped in a blanket and put to bed. MUSTARD BATH AND MUSTARD PACK. Mustard bath and mustard pack are indicated for their stimulating effect in cases of shock or collapse, and in acute congestion of internal organs, and also in con- vulsions. The amount of mustard used and the temperature of water is the same in both procedures. Powdered mus- tard, in quantity of about 1 level tablespoonful to each gallon, or 1 teaspoonful to each quart, when smaller quantities are sufficient, should be used. Full quantity of mustard powder is first dissolved in about a gallon of warm water, and to this the rest of the water is added, while preparing the bath. For giving the pack, a smaller quantity of water is usually required. The temperature of the water should be about 100° F., and it may be raised to about 105° F. by addition of hot water. Cold applications should be made to the head. The bath should be continued for about ten minutes, accompanied by rubbing the skin, and followed by ablu- 304 INFANT FEEDING. tion with lukewarm water, rapid drying, wrapping in a blanket, and rest. Mustard pack is somewhat less efficient than mustard bath, but it is also less severe and less disturbing to the infant. The naked child is wrapped in a blanket which has been wrung out of water prepared as above stated. The infant is left in the pack until the skin is well red- dened — about ten to twenty minutes — then washed off with warm water, followed by lukewarm water ablution, dried, and put to bed without dressing. STOMACH WASHING. The apparatus for stomach washing consists of a soft rubber catheter, 20 to 24 French, or infant stomach-tube, a small funnel, attached to a rubber tube, and a glass connection between the catheter and the tube. The infant is wrapped with the arms confined, and is held in the sitting position, wath a large basin at the nurse's feet. The tongue is depressed with the forefinger of the left hand, and the right hand passes a catheter rapidly backwards into the pharynx and down into the oesophagus. Gagging is aggravated by passing this catheter slowly. After the catheter is part way in the oesophagus, it should be passed more slowly. As the cardiac orifice is passed, and the catheter enters the stom- ach, gagging again becomes more evident. This can be used as a sign that the catheter is entering the stomach. A good rule to follow in passage of the catheter is to measure the distance from the root of the nose to the tip of the ensiform cartilage, which approximates the distance from the teeth to the cardiac end of the stom- ach, and then pass the catheter about an inch farther. The passage into the stomach is usually marked by the APPENDIX. 305 appearance of curdled milk in the glass connecting tube. The funnel should now be raised as high as possible, to facilitate the escape of any gases from the stomach, and should then be lowered, in order to siphon any fluid con- tents. The funnel is then raised, and warm water at a temperature of about 100° F. is poured into the stomach, quickly. The amount of water passed into the stomach at any time should about equal the quantity of the feed- ing to which the child is accustomed. The funnel is then lowered, just before all of the water leaves the tube, and the water siphoned out. This procedure is repeated a number of times, until the fluid comes back clear. Dur- ing withdrawal, the tube must be compressed carefully to prevent leakage into the larynx. The washings should be collected and measured, so that the quantity remaining in the stomach may be estimated. Sterile water or one-half strength normal saline, Ringer's solution, or a solution containing sodium chlo- ride 5 Gm., sodium bicarbonate 5 Gm., and water 100 mils, may be used. It is frequently advisable to allow part of the solution to remain in the stomach. Stomach washing is indicated in vomiting due to pylo- rospasm, hypertrophic pyloric stenosis, all forms of gas- tric irritation, chronic indigestion, acute dilatation of the stomach, and food and drug poisoning. CATHETER FEEDING BY MOUTH. The same apparatus is used as in stomach washing, the same technic being used for the introduction of the catheter, except that its tip should not be made to pass the cardiac end of the stomach, the food being allowed to enter the oesophagus just above the cardia. This is accomplished by passing the catheter about one-half inch 20 306 INFANT FEEDING. less than the distance from the root of the nose to the tip of the ensiform cartilage. The infant should be lying on its back, and not in sitting posture, as recommended in stomach washing. When the feeding is finished, the catheter should be tightly pinched between fingers and rapidly withdrawn, to prevent any food from trickling into the larynx. It is often advisable to wash the stom- ach before the food is introduced. Catheter feeding is indicated in the feeding of pre- mature infants, infants refusing their diet, those too weak to nurse, in the presence of persistent vomiting, and in all cases of delirium and coma. CATHETER FEEDING BY NOSE. This is not indicated in young infants. In older chil- dren it is often impossible to pass the catheter through the mouth, without undue struggling. It is also indicated in throat paralysis following poliomyelitis and diphtheria, and after throat operations and intubation. The method is similar to that described in catheter feeding by mouth, except that a smaller catheter (No. 15 French) is to be used. IRRIGATION OF THE COLON AND RECTAL FEEDING. The apparatus varies somewhat with the purpose to be accomplished. Where large quantities of fluids are to be introduced, it is necessary to use a douche-can or fountain syringe, 4 to 5 feet of tubing, and a flexible rectal tube or soft rubber catheter (size 20 to 24 French). When small quantities are to be introduced, a glass fun- nel may be used in place of the douche-can. When large quantities of fluid are used, the can must not be raised APPENDIX. 307 more than 2 feet above the child's body. The child should be turned upon its side, with the lower limb ex- tended, and the upper thigh flexed upon the abdomen. The catheter should be well oiled, and introduced for about 3 to 4 inches when large quantities are to be given, and further introduction of the catheter may be made while the solution is flowing into the rectum. Indications. 1. To produce evacuation of the bowel. A salt solution containing a level teaspoonful of salt to a pint of tepid water or weak soap-suds solution, or a teaspoonful of glycerin in an ounce of water; or in the presence of large fecal masses, 2 or 3 ounces of sweet oil may be used. 2. To reduce temperature. At least 1 to 4 quarts of a salt solution or weak soap-suds enema at about 95° F. should be used, allowing about ^ to 1 pint to enter the rectum, and repeating after expulsion. 3. Rectal feeding. A normal salt solution or nutrient enemata containing 2 level tablespoonfuls of dextrose to the pint of normal saline solution may be used. It is indicated in cases of acidosis, and also in the presence of vomiting, intoxication, and decomposition where the body is in need of water. It is usually necessary that only a small amount (2 to 6 oz.) of this solution be introduced at a time, or that it be given by the drop method. Other- wise it will not be retained. It should be repeate'd at regular intervals of from two to four hours. It may be necessary to compress the buttocks for twenty minutes after administration, when the fluid is not well retained otherwise. 4. Medication. There are two indications for rectal medication : ( 1 ) For the systemic effect. The drugs most commonly used for this purpose are chloral hydrate 308 INFANT FEEDING. and the bromides, more especially in the presence of convulsions or coma. They should be diluted in small quantities of water or salt solution, not over 1 ounce, and ma}' be administered in about four times the oral dose for the given age. (2) For local effect. Enemata are indicated for their local eft"ect in the presence of marked tenesmus, inflammation, ulceration and hemor- rhage. Not infrequently the tincture of opium (3 to 5 drops) and tincture of belladonna (3 to 5 drops) are administered, probably best in a 10 per cent, starch solu- tion, for their sedative eft'ect. In the presence of in- flammatory processes, 1 per cent, silver nitrate solution may be used. SALINE SOLUTIONS. 1. For subcutaneous use. They are especially indi- cated in the presence of considerable loss of body fluids through vomiting, refusal of diet, and diarrhea, and in the presence of acidosis. Rectal administration should first be tried, and, in case that suflicient fluids cannot be administered to meet the infant's needs in this way, hypo- dermoclysis should be instituted. In infants 2 to 4 ounces can usually be administered, and in older children 4 to 6 ounces. This can be repeated every four hours, if necessary, or until fluids can be supplied by another route. Fluids can be administered beneath the skin of the abdomen, chest, or lumbar region. There is some shock accompanying the administration of large quanti- ties of fluids subcutaneously, probably due to the pain, and it is frequently necessary to give a child in collapse some subcutaneous stimulation of camphor in oil (10 per cent. 1 mil), or adrenalin solution (1:1000, about 5 drops), before administration. The stimulating injection APPENDIX. 309 is to be made in regions of the body other than where the saHne injection is made. The best solutions for this purpose are (a) NaCl 7.5 grams. KCl 0.1 CaCl 0.2 Water, q. s. ad 1000.0 mils. (b) Dextrose may be added to the above solution in proportion of 50 grams to the liter (5 per cent.). All solutions used for subcutaneous administration should, if possible, be made from fresh distilled water, and re-sterilized shortly before use. 2. Intravenous injections. The same solutions as in- dicated for subcutaneous use may be administered intra- venously. Sodium bicarbonate, 30 Gm. to the Hter, being added in the presence of acidosis and dextrose, 50 Gm. to the liter in cases of malnutrition and decomposition. Either direct or indirect transfusions of blood are also of extreme value in the presence of marked marasmus. Technic. In older infants and children the injection may be made into the external jugular or median basilic or median cephalic veins. In young infants with open fontanelle, the longitudinal sinus is the most convenient point for administration. However, in the use of the latter method extreme care must be used, because of the ease with which the sinus wall can be punctured. All apparatus used in the intravenous administration must be thoroughly and freshly sterilized before use. Where a moderate quantity of fluid is to be administered (2 mils, 10 mils, or 20 mils) all glass Record or Luer syringes can be used. In injection of fluids into the longitudinal sinus a short bevelled needle, about 0.75 inch in length, should be introduced at the posterior angle of the fontanelle. 310 INFANT FEEDING. The region of the fontanelle is sterihzed, and the first syringe is three-quarters filled with the fluid to be in- jected. The syringe is now connected with a needle by means of a short piece of rubber tubing to allow flexibil- ity in case of movements on the part of the child, and the needle is passed into the sinus, its entrance being recog- nized by a sudden lessening of the resistance. Helmholz* suggests that the question of negative pressure within the sinus is one that must not be overlooked* and it is always well in entering the sinus to have the syringe attached, and before injection to withdraw blood, to make sure that the needle is in the sinus. Unless a head-clamp, as described by Helmholz is available, two assistants are required, one to hold the child's head firmly, and the second to manage the syringe, while the physician steadies the needle. From 100 to 200 mils of either a saline, dex- trose solution or citrated or fresh blood can usually be administered without difficulty. Ungerf has described an apparatus whereby large quantities of fresh blood can be transfused. HOME-MADE ICE-BOX. The following home-made ice-box described by Holt and Shaw will answer, if a more elaborate refrigerator is not available. Get from your grocer a deep box about 18 inches square, and put 3 inches of sawdust in the bottom. Place two pails in this box — one a smaller pail, inside the other * Helmholz. H. F. : The longitudinal sinus as the place of preference in infanc}- for intravenous aspirations and injections, including transfusion. Am. Jour. Dis. Child., 1915, x, 194. t Unger, J. J. : A new method of syringe transfusion. Jour. Am. Med. Ass'n., 1915, Ixiv, 582. APPENDIX. 311 — and fill the space between the outer pail and the box with sawdust. The nursing bottles filled with milk are placed in the inner pail. This pail is then filled with cracked ice, which surrounds the bottles. The inner pail should have a tin cover. Nail several thicknesses of newspaper on the Imder surface of the cover of the box. This ice-box should be kept covered, and in a shady, cool place. The water from melted ice should be poured off, and the ice renewed at least once each day. Fig. 20. — An asbestos-lined copper receptacle for electric heating pads for use in the care of premature and debili- tated infants (Hess). To avoid the danger of fire from short circuits in electric heating pads, a copper receptacle is used,. 16 inches long, 13 inches wide, and V/i inches high, into which a 12 x 15-inch heating pad is laid. To allow of a maximum radiation from the lid or upper surface of the same, the floor and sides are lined with asbestos sheeting, while the lid is not lined. The cord passes through a small rubber insulator at the side to prevent contact with the metal and injury to the cord. This simple device can be used temporarily in wards and homes where better facili- ties for the care of this class of infants are lacking. It is to be placed in the bottom of a basket or crib, under the mattress or pillow. 312 INFANT FEEDING. CASE HISTORY. (A) Present Illness. 1. Complaints: Mother's or patient's own statement. 2. Get history of present illness in detail : onset, course and duration. Fever. Vomiting. Stools. Urine. Eruptions. Sleep, etc. 3. Previous treatment, if any. (B) Previous History. 1. Birth: Para, nature and complications. 2. Development: Teeth (time of eruption), sat erect, walked, talked, mentality. 3. General Health : Robust or delicate, appetite, colds, fevers, coughs, bowels, convulsions, mouth- breathing, running ears, bed-wetting, etc. 4. Illnesses: Diseases similar to the present. Kind, date, duration, severity, recurrences, complica- tions, careful history of acute infectious diseases. 5. Feeding: In detail in every infant. (a) Breast feeding: How long, intervals, condition of the baby, why discontinued. (b) Artificial feeding: Kind of food, intervals, how prepared, how much at each feeding, total quantity, how long used, effect on baby and on bowels, why discontinued. (C) Family History. Parents, brothers and sisters. (Constitutional diseases: Tuberculosis, syphilis, mis- carriages (order of), rheumatism, nervousness or insan- ity, alcoholism). (D) Examination. , Examine patient fully. APPENDIX. 313 1. General appearance and zveight: Nutrition and gen- eral development, facial expression (intelligence, pain, etc.), amount of prostration, pallor, cry, nervous condition, posture, respiration. 2. Skin : Eruptions, turgor. 3. Temperature: Pulse and respiration (in infant omit temperature until 11). 4. Head: Size, shape, fontanelles (size, tension), cranio-tabes, eyes, nose (mouth, tongue, teeth under 12). 5. Neck: .Goiter, glands, rigidity. 6. Chest: Shape, deformities, inequalities, expansions, kings and heart in detail. 7. Abdomen: Size, distention, retraction, tenderness, rigidity, liver, spleen, bladder, kidney, fluid and tumors. 8. Spine : Deformities, rigidity. 9. Genitalia and genital region : Phimosis, vaginal dis- charge, fissures, inflammation, eruptions, hemor- rhoids, pin-v^orms, etc. 10. Extremities: Glands, deformities, paralyses, at- rophy, muscle tone, reflexes, athetosis, swell- ing, tenderness, discoloration, joints, gait. 11. Temperature : In child under 3 years always rectal, and often in older children. 12. Mouth: Teeth, tongue, stomatitis, enanthemata, pharynx, tonsils, adenoids. 13. Middle ear. 14. Special examinations: Urine, blood, sputum, cul- tures, feces, vaccinations, serum reactions, etc. 314 IXFAXT FEEDING. AVERAGE WEIGHTS. Girls Pounds Boys Age Pounds Birth 7.55 7.16 Six months 16.50 15.50 Twelve months 20.50 19.80 Eighteen months 22.80 22.00 Two years 26.50. Three years 31.20. Four years 35.00. Five 3-ears 41.20. Six 5'ears 45.10. Seven years 49.50. Eight years 54.50. Nine years 60.00. Ten years 66.60. Eleven years 72.40. 79.80. 88.30. 25.50 30.00 34.00 39.80 43.80 48.00 52.90 57.50 64.10 70.30 81.40 91.20 99.30 100.30 Twelve years Thirteen 3'ears Fourteen years Fifteen vears 110.80 108.40 Sixteen vears 123.70 113.00 MEASUREMENTS. Age Height Chest in. in. Birth 20.5 . 13.25 6 months 25.0 16.0 1 year 29.0 18.0 2 years 32.5 19.0 5 vears 41.5 21.0 Head in. 13.75 17.0 18.0 18.75 20.5 Head at birth. 13.75 inches. First year, gain 4 inches; second year, gain 1 inch; 2 to 5 years, gain 1.5 inches for the 3 years. Large head and small chest suggests rickets. The head is larger than the chest until second year, normally. APPENDIX. 315 GENERAL DEVELOPMENT. A healthy infant speaks single words toward the end of the hrst year, uses short sentences at the end of the second year; sits erect at the seventh month; stands with assistance at ninth or tenth month; attempts to walk at twelfth or thirteenth month, and walks freely at the' fourteenth or fifteenth month. SLEEP. The healthy infant sleeps practically all the time ex- cept when being fed. Hours per day At birth 20 to 22 At end of 1st year 16 " 1.8 During 2d and 3d years 12 " 13 During 4th and 5th years 10 " 11 During 12th and 13th years '. 8 " 9 ORDER AND AVERAGE TIME OF ERUPTION OF THE TWENTY DECIDUOUS TEETH. Months 2 lower central incisors 6 to 9 4 upper incisors 8 " 12 2 lower lateral incisors and 4 anterior molars 12 " 15 4 canines 18 '' 24 4 posterior molars 24 " 30 At 1 year should have 6 teeth. At 1 year 6 months should have 12 teeth. At 2 years should have 16 teeth. At 2 years and 6 months should have 20 teeth. 316 INFANT FEEDING. PERMANENT TEETH. Years 1st molars . . • 6 Incisors 7 to 8 Bicuspids 9 " 10 Canines 12 " 14 Second molars 12 " 15 Third molars 17 " 25 CLOSURE OF FONTANELS. Posterior fontanel usually closes b}^ the end of the second month. Anterior fontanel at the end of the first year is about 1 inch in diameter, and usually closes at the eighteenth month. Normal variations, from fourteen to twenty-two months. AVERAGE DAILY QUANTITY OF URINE IN HEALTH. Ounces 1st 24 hours to 2 2d 24 hours % " 3 3 to 6 days 3 " 8 7 days to 2 months 5 "' 13 2 to 6 months 7 " 16 6 months to 2 years 8 " 20 2 to 5 years . . ' 16 " 26 - 5 to 8 years 20 " 40 8 to 18 years Z2 " 48 AVERAGE RATE OF PULSE AND RESPIRATION. Pulse Respirations Birth 140 35 to 40 1 month ...120 25 " 40 6 to 12 months 105 to 115 25 " 30 2 to 6 years 90 " 105 25 7 to 10 years 80 " 90 22 " 25 11 to 14 years 75 " 80 20 APPENDIX. 317 BLOOD-PICTURE IN HEALTHY CHILDREN. Newborn Infants Older children HcTmoglobin 110 percent. 70 to 95 per cent. 65 to 95 per cent. Erythrocytes 5 to 8 millions 4.5 to 5.5 millions 4 to 4.5 millions. AVERAGE WHITE CELL COUNTS. 1. Healthy children between 1 and 15 years of age average between 7000 and 15,000 leucocytes, approxi- mately the same as adults. 2. Polymorphonuclear neutrophiles increase gradually from 30 per cent, in the first year to about 70 per cent, in the fifteenth year. 3. Lymphocytes decrease from 60 per cent, in the first year to about 30 per cent, in the fifteenth year. (This represents combined (large and small) lymphocytes). 4. The reversal of the percentages of neutrophiles and lymphocytes occurs usually about the sixth year. 5. Eosinophiles average between 4 to 6 per cent., but vary greatly in different children at the same ages. 6. Transitional cells average approximately 2 to 3 per cent., not varying greatly at the different ages. 7. Mast-cells, about 0.3 to 0.6 per cent. Frequently absent. 8. Large mononuclear neutrophiles, 1 to 3.3 per cent. About the same at different ages. stool symbols Urine symbols N = normal. A ^albumin. S = soft. S = sugar. W = watery. Ac = acetone. F = fat-soap. D = diazo. M = mucus. I = indican. Bl = blood. C=: casts. C = curds. P = pus. G = green. Bl = blood. Ep = epithelium. 318 INFANT FEEDING. RECORD SHEET. A brief description of the clinical sheet used in our wards mav be of value, as it answers both the needs of a histor}^ sheet and of a daily chart as well. The points illustrated by it are : a graphic relationship between the temperature, weight, quality, and quan- tity of food taken, and the end-results on the stools and urine. Also separate spaces are provided for complications which may influence the preceding under the heading- of symptoms, together with spaces for treatment other than dietetic, energy value of foods, vomiting, blood examinations, tuberculin re- actions, etc. The small figures 1-10 are used to make an electrical reaction curve in cases showing a spas- mophilic diathesis. APPENDIX. 319 SARAH MORRIS HOSPITAL FOR CHILDREN o a i auou •3' a 9 it o o C/3 O d o § o o P P ? ? F ? 1 ; 1 1 1 1 1 1 1 'i 1 1 1 *1 9 ? p O O O c i f SWIPTOMS MtDlCATION f - > a. B &> 5 - j t z l d I z 2 ?• 2 :r o =■ 2 a 2 ^ 2 2 ?■ PI S > ?~fT ~o ^ 1 •• ^ .* - n > PI ??? c T i 1 ^ J ._ J = "= 320 INFANT FEEDING. DEPARTMENT OF PEDIATRICS UNIVERSITY OF ILLINOIS — COLLEGE OF MEDICINE e Z Address Date Sex Aae Race Diagnosis • a Z Doctor History of Patient. Duration, progress, onset, eariiest symptoms and later developments Previous History. BIRTH: Para? Natare and Complications- DEVELOPMENT: Teeth Mentality GENERAL HEALTH: APPENDIX. 321 PREVIOUS ILLNESSES FEEDING HISTORY No. of Months Why di^TOniinueg ARTIFICIAL FEEDING. In Detail FAMILY HISTORY PHYSICAL EXAMINATION 21 322 INFANT FEEDING. TEMPERATURE P R Weight Height 1 LABORATORY EXAMINATIONS I f TREATMENT ASSIGNED TO APPENDIX. 323 SUBSEQUENT TREATMENT AND REMARKS 1 Date Weight ' 1 INDEX. Abdomen, distended in over- feeding on the breast, 79 Acetone bodies, 15 Acid, aceto-acetic, 15 amino, 9, 30 fatty, 178 fatty in stools, 12 hydrochloric^ fmiction, 5 in stomach, 4 lactic, 32 oxy butyric in urine, 10, 15 uric, 10 Acidity of the stomach, 4 Acidosis, decomposition, 209 disturbed metabolic balance, 189 intoxication, 226, 227 overfeeding on the breast, 80 Age of nursing mother, 36 Albumin milk, caloric value, 150 decomposition, 218 recipe, 292, 293 v^ater, 281 with beef extract, 281 Albumins, in milk, 8 in urine, 24 Albumoses, 9 Alcoholism, hereditary weak- ness, 84 Alexins in milk, 36 Alkali soaps in stools, 12 Allaitement mixte, 67 Allenberry's I, II, 274 III, 275 American Association of Medi- cal Milk Commissioners, 115 American school of pediatrics, 107 Ammonia coefficient, 11 in urine, 10 Amylopsin, 5 Anemia, boiled milk, 120 Anglo-Swiss, 274 Anions, 16 Anorexia, enteral infections, 260 Antitoxins in milk, 36 Anuria, 24 Apnea in decomposition, 215 Appetite lessened, overfeeding on the breast, 78 Apple sauce, caloric value, 156 recipe, 291 Arrowroot, 274 Artificial feeding, 107 adaptation of milk, 124 amount at each feeding, 152 caloric contents, 146 caloric method, 108 carbohydrates, 140, 153 cereal flours, 142 cow's milk, 110 curd breaking, 154 dextrin and maltose com- pounds, 142, 154 energy quotient, 149 example No. 1, 157 example No. 2, 158 fats, 138 first weeks of life, 159 milk dilutions with addition of carbohydrates, 129 mixed diet for young in- fants, 155 number of feedings in a dav, 152 nutritional disturbances, see Nutritional Disturbances in Artificially Fed In- fants, objects to be attained, 130 percentage method, 126 (325) 326 INDEX. Artificial feeding, proteins, 134 salts, 143 starch, 153 sugars, 141 quantity, 154 summary, 161 top milkj 127 undiluted whole milk, 126 water, 145, 152 Asparagus, 289 Assimilation capacity for car- bohydrates, 14, 140 Atresias of the intestinal tract, 85 Atrophy, 207 moderate degree, 186 Autointoxication, 31 Bacillus acidophilus, 25, 27, 28, 30 aerogenes capsulatus, 27, 255 bifidus, 25, 26, 27, 29 coli, 25, 28, 255 dysenterise, 31, 255 lactis aerogenes, 25, 29, 255 mesentericus, 27 paratyphosus, 255 pyocyaneus, 255 typhosus, 255 Bacon, caloric value, 156 Bacteria of the gastro-intes- tinal tract of the arti- ficially fed infant, 27 diet influencing, 29 gastro-intestinal disturbances, 31 newborn infant, 25 nursing infant, 25 proteolytic, 29 causing disease, 33 saccharolytic, 29 significance, 28 Barley, dextrinization, 280 jelly, 280 water, 280 . _ Basedow's disease, contraindi- cation to nursing, 38 Bath, bran, 300 cold, 302 Bath, daily, 300 hot, 303 mustard, 303 room, hospital, 301 Beans, 290 Beef juice, 288 Biedert, 111, 177 Bier pump, 76 Bile, functions, 6 Blood in healthy children, 317 Borcherdt's dri malt soup, 142 extract, 275 with wheat flour, 275 laxative, 153 malt soup extract, 275 sugar, 275 Bosworth, 154 Bottles, nursing, 295 Brady, 148 buttermilk mixture No. 1, 284 No. 2, 285 Bread, caloric value, 156 permitted at three years, 167 Breast, Bier pump, 76 care during weaning, 69 care in nursing, 42 massage, 75 pump, 60 steaming, 76 stimulation, 74 Breck feeder, 93 Brennemann, 119, 126 Bronchitis in breast-fed infant, 86 Bronchoenterocatarrh, 255 Broths, recipes, 287 Budin, 126 Butter, caloric value, 156 Buttermilk and skim milk mix- ture, 284 caloric value, 149 mixture, Brady's No. 1, 284 No. 2, 285 caloric value, 149 recipe, 282, 283 Calcium, excretion in stools, 17 metabolism, 145 INDEX. 327 Calcium, milk, 16 paracasein, 17 phosphate in milk, 17 salts and water retention, 18 fat-soap stools, 188 phagocytosis increased, 18 putrefaction favored, 30 Caloric contents of the food, 146 intake in disturbed metabolic balance, 190 method of artificial infant feeding, 108 needs of infants, 147 values of foods, 149, 156 Camerer, 137 Carbohydrates, 13 artificial feeding, 153 bacteria influenced, 33 chemistry, 13 colic and flatulence, 169 disturbed metabolic balance, 188 fat formation, 140 relation, 15 fermentation, 32 fermentative organisms, 29 functions, 14, 140 insufficient, disturbed metab- olic balance, 190 metabolism, 13 nitrogen metabolism, 11 quantities in artificial feed- ing, 142, 161 replacing proteins and fats, 15 stomach digestion, 20 stools, 22 tissues, 14 tolerance limited, 34 high in infants, 140 weight increase, 15 Carrots, caloric value, 156 recipe, 289 Case historv, 312 Casein, chemistry, 9 , curds, 201 metabolism, 9 Casein, powdered, in colic and flatulence, 169 in overfeeding on the breast, 83 salt excretion, 17 varying percentages, 107 Catheter feeding by mouth, 93 technic, 305 nose, 306 "Cell hunger," 208 Cereal, caloric value, 156 flours, 142 permitted at three years, 167 waters, caloric value, 150 Chittenden, 136 Chlorine in milk, 16 Cholera infantum, 223 Cholesterin, 19 in stools, 12 Chymogen, 276 milk, caloric value, 150 recipe, 282 Cleft palate, congenital de- bility, 85 Cohnheim, 5 Coit, Dr. Henry L., 115 "Colds," parenteral iafections, 249 Colic and flatulence, 169 change of sugar, 141 overfeeding on the breast, 79 Colitis, membranous, 257 ulcerative follicular, 257 Collapse, intoxication, 223, 230 Colon, irrigation, 306 Coma, intoxication. 230 Complemental feeding, 67 Congenital debilitv, with re- sulting impairment of vital functions, 84 Constipation, 170 boiled milk, 119 chronic, disturbed metabolic balance, 192 dextrin and maltose com- pounds, 142 disturbed metabolic balance, 186 excessive milk diet, 24 328 INDEX. Constipation, fat, 186 nursing woman, 40 Convulsions, intoxication, 230 Cow producing milk for infant feeding. 113 Cowie, 137 Crackers, caloric value, 156 Cream, caloric value, 149, 156 Curds, breaking, 154 cow's milk, 112 delaying food in stomach, 21 digestion in stomach, 22 fat, in stools, 172 protein in stools, 172 in dyspepsia, 196 vomiting, 169 Custard, caloric value, 156 Cyanosis, decomposition, 213 Cvstitis. parenteral infections, 249 Cystopvelitis, enteral infections, 261 Czerny, 108, 176, 177, 182, 186, 187, 208, 209, 223, 231, 240 Day, 249, 255, 256 Death in decomposition, 215 Debility, congenital, with re- sulting impairment of vital functions, 84 Decomposition, 207 death, 215 diagnosis, 214 differential, 185 disturbed metabolic balance, 192 etiology, 207 pathogenesis, 208 prognosis, 214 proteins, 31, 33 symptoms, 210 S3monyms, 207 treatment, 215 Dennett, 148 Denno's baby food, 275 Development, general, 315 Dextrin and maltose com- pounds, 142 Dextrose, B. acidophilus fav- ored, 30 Kahlbaum's, 233 Diabetes, contraindication to nursing, 38 Diaper, 298 Diarrhea, 196 dyspepsia, 196 enteral infection, 258 overfeeding on the breast, 78 summer, 223 Diastase, 5 milk, 36 Diastatic ferments, 276 Diastoid (Horlick's), 276 Diathesis, exudative, 184 disturbed metabolic bal- ance, 192 psychoneuropathic, 184 Diazyme (Fairchild's), 276 Diet, hunger, 203 intoxication, 234 intestinal flora, 29 nursing mother, 39 starvation, 203 7 to 12 months, 164 12 to 24 months, 165 14 to 18 months, 165 18 months to 3 years, 166 Disaccharides, 13 Disturbed metabolic balance, 186 artificial food diet, 192 complications, 192 diagnosis, 190 differential, 185 etiolog}^, 186 human milk diet, 192 pathogenesis, 187 prognosis, 192 sequellse, 192 S3^mptoms, 189 synonyms, 186 treatment, 192 Domestic measures, carbohy- drate equivalents, 150 Drugs influencing production of milk, 43 Dunn, 137, 148 INDEX. 329 Dysentery, 257 Dyspepsia, 196 diagnosis, 201 differential, 185 disturbed metabolic balance, 185 etiology, 196 overfeeding on the breast, 79 pathogenesis, 196 prognosis, 202 symptoms, 198 synonyms, 196 treatment, 202 Earthy alkali soaps in stools, 12 Eczema, disturbed metabolic balance, 190 overfeeding on the breast, 80 Edema, decomposition, 213 flour injury, 242 Egg, caloric value, 156 permitted at three years, 167 recipe, 291 white and digested gruel, 281 Eiweiss milk, 292 Energy quotient, 12, 149 Enteritis, catarrhal, 223 Enterokinase, 5 Epilepsy, contraindication to nursing, 38 Erepsin, 5 action on end products of pepsin digestion, 9 Escherich, 27, 113. 178 Eskay's food, 275 Excretion and intake, 7 Expression of milk, 61 Fat, Fats, 11 bacteria influenced, 30 chemistry, 11 carbohydrates, 11 colic and flatulence, 169 constipation, 186 delaying food in stomach, 21 disposition, 11 disturbed metabolic balance, 188 Fat, excessive, causing vomit- ing, 169 disturbed metabolic bal- ance, 190 formation from carbohy- drates, 14, 140 . functions, 138 intolerance, 139 intoxication, 226 metabolism, 11 niilk, 112 nitrogen metabolism, 11 overfeeding, 186 phosphorus excretion, 17 quantity in artificial feeding, 139, 161 requirements, 140 resorption, 11 salts excretion, 17 soap stools, 139, 171, 173, 186 stomach digestion, 20 stools, 12 urine, 12 Feces, color, 23 composition, 21 reaction in artificially fed in- fants, 27 tests on constituents, 22, 200 Feeding, artificial, see Artificial Feeding. complemental, 67 increases, 149 mixed, 67 quantity at different ages, 2 rectal, 306 supplemental, 67 too frequent, colic and flatu- lence, 169 Fermentation, 22, 29, Z2 excessive, 34 dyspepsia, 197 sodium and potassium salts increasing, 30 Ferments, diastatic, 276 milk, Z6 mouth, 4 pancreas, 5 small intestine, 5 stomach, 5 330 INDEX. Fever, enteral infections, 260 intoxication, 228 Finkelstein, 108, 176, 177, 178, 182, 186, 207, 218, 225, 226, 227, 292 Flatulence and colic, 169 Flour, ball, 280 barley, 274 caloric value, 150 injury, 240 diagnosis, 243 etiology, 240 pathogenesis and metab- olism, 240 prognosis, 243 prophylaxis, 243 treatment, 243 Flours, 274 Fontanelles, closure, 316 Food elements necessary, 7 injuries, 176 intolerance, 177 decomposition, 210 tolerance lessened, 180 Foods, avoided at three vears, 167 given with caution at three years, 167 permitted at three vears, 167 Frank, 269, 270 Fruits permitted at three years, 167 recipes, 290 Galactase in milk, 36 Galactagogues, 76 Gastric juice, 4 Gavage, 93 apparatus, 94 Gelatin, caloric value, 156 food, 292 orange, 290 General development, 315 German school of pediatrics, 108 Gerstley, 249, 256 Glanders in cow, 113 Globulin in milk, 8 Glycocoll, 9 Glycogen, 14 Glycosuria, 14 intoxication, 231 Gram, neeative bacteria, 27 positive bacteria, 26 Gruel, digested and white of egg, 281 Hamburger, 4, 113, 177 Heart disease, contraindication to nursing, 38 Heat causing nutritional dis- turbances, 180 intoxication, 224 Heating pad, receptacle, 311 Helmholtz, 213, 310 Hereditarv weakness, 84 Heubner, '73, 108, 147 Hirschprung's disease, 85 Holt, 223, 310 Honor brand powdered milk, 273, 279 Hoobler, 137 Horlick's, malt food, 276 malted milk, 274 constipating, 142, 153 Howland, 145, 227 Hunger, cell, 208 decomposition, 212 internal, 208 mineral, 209 Hj'pertonia, flour injury, 242 Ice-box, home-made, 310 Idiosvncrasv, cow's milk, 173, ' 187 mother's milk, 87 Immunity, flour injury, 242 Immunizing bodies in milk, 36 Imperial granum, 274 Inanition, qualitative, 240 quantitative, 238 Indigestion, 196 Indol, 30 Infant, artificiallv fed, normal, 130, 181 ^ breast-fed, nutritional dis- turbances, 71 INDEX. 331 Infant foods, proprietary, 273 infections, 85 nursing, 64 premature, see Premature In- fant, underweight, feeding, 151 Infections, breast-fed infants, 85 enteral, 254 complications, 260 dyspepsia, 196 diagnosis, 261 etiology, 254 pathology, 256 prognosis, 264 symptoms, 258 treatment, 265 intoxication, 223, 227 nutrition, 245 parenteral, 248 diagnosis, 250 dyspepsia, 191 etiology, 248 symptoms, 250 treatment, 252 susceptibility, decomposition, 213 weaning, 68 Intake and excretion, 7 Intermediary metabolism, 7 Intertrigo, disturbed metabolic balance, 190 Intestines, anatomy, 2 bacteria, 26 functions, 21 milk digestion, 21 physiology, 5 Intolerance, food, 177 Intoxication, 223 alimentary, 223 definition, 223 diagnosis, 232 differential, 185 disturbed metabolic balance, 192 etiology, 223 gastro-enteric, 223 overfeeding on the breast, 80 pathology, 22il Intoxication, pathogenesis, 225 prognosis, 232 symptoms, 228 treatment, 232 Intravenous saline injections, 309 Invertin, 5 Ions, 15 Iron, excretion in stools, 18 milk, 16 Irrigation of the colon, 306 Rations, 16 Keller, 186, 216, 223, 231, 240 Keller's malt soup, caloric value, 150 constipation, 171 contraindications, 286 disturbed metabolic balance, 193 indications, 286 recipe, 286 Kendall, 249, 255, 263 Kreatinin in urine, 10 Lacta prseparata, 273 Lactase, 5 Lactokinase in milk, Zd Lactometer, 36 Lactose, bacillus bifidus fav- ored, 29 laxative tendency, 153 saccharose compared, 141 Larosan, 276 milk, 294 Lavage, apparatus, 94 Lecithin, 19 in stools, 12 Leucocytosis, intoxication, 231 Lime water to break curds, 155 Lipase, 5 in milk, 36 Lipoids, 19 Liver, anatomy of, 3 enlaro-ement, intoxication, 231 physiology of, 5 Longitudinal sinus, injections, 310 2>2,2 INDEX. Magnesium excretion in stools, 17 in milk, 16 salts, fat-soap stools, 188 Malformations of. digestive tract causing congenital debility, 85 Mallein test in cows, 113 Malnutrition, 186 Malt soup, extract, caloric value, 150, 156 Keller's, caloric value, 150 Maltase, 5 Maltose and dextrin com- pounds, 142 caloric value, 150 favoring B. acidophilus, 30 Mammala, 273, 279 Marasmus. 207 Marfan. 178 McClure, 249 Mead's dextrimaltose, 142, 276, 279 constipating, 153 Measurements, 314 Measures, domestic, carbohy- drate equivalents, 150 Meat, caloric value, 156 permitted at three years, 167 recipes, 294 Meconium, 25 Medicine dropper in feeding premature infants, 91 Mehlnahrschaden, 240 Meigs. 107 Mellin's food, 142, 276 laxative, 153 Menstruation influencing pro- duction of milk, 42 Merriet, 227 Merrill-Soule powdered modi- fied milk, 273, 279 Metabolic bankruptc}^, 177 intoxication, 227 calcium, 145 Metabolism, definition of, 7 difficulties in study, 7 intermediary, 7 Metabolism, mineral in arti- ficially fed and breast- fed infant, 144 nitrogen influenced by carbo- hydrates and fats, 11 of proteins, 9 sodium and potassium, 145 Meyer, L. F., 112, 146, 177, 250 Micrococcus ovalis, 25, 26, 27 Milchnahrschaden, 186, 187 Milk, albumin, caloric value, 150 bacteria, 113 caloric value, 156 chymogen, caloric value, 150 recipe, 282 coagulation differences, 20 composition, 8 digestion, 20 excessive, colic and flatu- lence, 169 fat, 112 for nursing mother, 40 lactose, 112 overfeeding, 186 sahs, 112 station, 297 breast, human, mother's, cal- oric value, 149 conditions influencing pro- duction, 42 examination, 36 expression, 61 ferments, 36 idiosyncrasy, 86 immunizing bodies, 36 influencing intestinal flora, 29 quantity obtained by nurs- ing infant, 72 stomach digestion, 21 value, 36 cow's, adaptation for infant feeding, 124 boiling, changes, 109, 119, 121 constipation, 119 methods, 12^ INDEX. 333 Milk, sterilization and pasteur- ization, 119 caloric value, 149 , certified, 115 vs. boiling, 122 condensed, 273, 277 and soy bean, 288 cooling, 114 curds, methods of break- ing, 154 evaporated, 273, 277 frozen, 117 home care, 115 idiosyncrasy, 173, 187 infected, dyspepsia, 196 inspected, 116 intestinal flora, 29 larosan, 294 market, 117 maternal compared, 110 milking, 114 minimal requirements, 151 mixed vs. milk of one cow, 117 pasteurization (double boil- er), 281 pasteurization vs. boiling, 122 powdered, 273, 279 quantities to be fed, 151 raw, excessive, dyspepsia, 196 skim, caloric value, 149 spoiled, intoxication. 223 nutritional disturbances, 180 sterilization (double boil- er), 281 stomach digestion, 21 Milking, 114 Mixed feeding, 67 Monosaccharides, 13 Mother, neurotic, 36 nursing, age, 36 air, 41 alcoholic drinks, 75 appetite, 74 baths, 75 breasts, care, 42 Mother, nursing, breast infec- tions, 85 constipation, 40 diet, 39 drugs, 43 exercise, 41 general infectious diseases. 85 menstruation, 42 mental condition, 43 Wassermann reaction, ^7 Mouth, bacteria, 26 milk digestion, 20 physioloev, 4 M tiller, 293 Multiparity, wet nurse, 48 Nahrzucker, Sohxlet, 276, 279 Nasal spoon feeding of prema- ture infants, 91 Nationality, wet-nurse, 47 Naunyns, 15 Neoplasm, malignant, contrain- dication to nursing, 38 Nephritis, contraindication to nursing, ZS enteral infections, 261 Nestle's food, 274 Nipples, 295 Nitrogen equilibrium, 135 retention, 137 Nuclein in milk, 8 Nursing, 35, 43 ability, 35 axioms, 39 both breasts, 44 contraindications, 2)7 early, 35 length, Z6 length of each period, 45 maternal, 39 night, 45 number in a day, 45 one breast, 44 proper method of holding the baby, 59 regularity, 43 signs of successful, 64 time, 82 334 INDEX. Nurse, wet-, see Wet-nursing. Nutritional disturbances, arti- ficially fed infants, 168 breast-fed infants, 71 classification, 182 congenital debility, 184 diagnosis, alimentary from those due to infections, 248 differential, 185 etiology in general, 177 general consideration, 175 general symptomatology, 180 insufficient food, 238 mixed forms, 237 overfeeding, 179, 183 secondary, 183 tolerance lessened, 179 underfeeding, 179, 183 Nutrol, 276 Oatmeal jelly, 280 water, 280 Opalisin in milk, 8 Orange, gelatin, 290 juice, 155 recipe, 290 Otitis, parenteral infections, 249 Overfeeding, artificiallv fed in- fant, 179 breast-fed infant, 1^ dyspepsia, 196 Oxaluric bodies in urine. 10 Pack, cold, 30^ hot, 303 Pain, abdominal, enteral infec- tion, 258, 260 Pallor, disturbed metabolic bal- ance, 186 Pancreas, ferments of, 5 Pap, 291 Paradoxical reaction, 181 decomposition, 210 disturbed metabolic balance, 189 Paranuclein, 9 Paratyphoid, enteritis, pathol- ogy, 257 Pavlow, 4 Peas, green, 290 Pedatrophy, 207 Pegnin, 276 Pepper, 107 Pepsin, 5, 276 action on paranucleins, 9 digestion of casein by, 9 Peptogenic powder (Fair- child's), 276 Peptones, 9 Peristalsis, visible, overfeeding on the breast, 79 Pfaundler, 2, 178 Phagocytosis increased by cal- cium salts, 18 Pharyngitis, breast-fed infants, 85 Phosphorus, excretion de- creased by fats, 17 in milk, 17 Plasmon, 276 Pneumonia, breast-fed infant, 85 enteral infections, 261 nursing mother, 85 parenteral infections, 249 Polysaccharides, 13 Potassium and sodium metab- olism, 145 in milk, 16 salts favoring fermentation, 30 Potato, caloric value, 157 recipe, 289 Pregnancy as indication for weaning, 68* Premature infants, amount of each feeding, 101 artificial feeding, 102 daily gains, 102 decomposition, 208 methods of feeding, 89 number of feedings daily, 100 Prematurity, congenital debil- ity, 84 Prosecretion, 5 INDEX. 33: Proteins, chemistry, 8, 135 decomposition, 31, 33, 173, 177 disturbed metabolic balance, 186, 188 equilibrium, 135 excessive, disturbed metab- olic balance, 190 feces, 22 foreign to human body, 177 functions, 10, 134 metabolism, 9 putrefaction favored, 30 quantities in artificial feed- ing, 136, 161 requirements, 136 stomach digestion, 20 stools, 22 sugars and starches, 137 Prune jelly, 290 juice, 290 Psychoses, contraindication to nursing, 38 Ptyalin, 4 polysaccharides, 13 Pudding, cornstarch, 291 custard, 292 Puerperal fever, nursing mother, 85 Pulse, average rate, 316 slow^, decomposition, 213 small, irregular, intoxication, 231 Purpura, decomposition, 213 Putrefaction, 22, 29, 30 calcium salts, 30 Pyemia, enteral infections, 261 Pyelitis^ breast-fed infant, 86 overfeeding on the breast, 80 parenteral mfections, 249 Pylorospasm, 184 Pylorus, overfeeding on the breast, 80 stenosis, 85 Pyodermatoses, enteral infec- tions, 261 Quest's figure, 214 Rachitis, boiled milk, 120 disturbed metabolic balance. 192 salts absorption deficient, 18 Record sheet, 318 Rectal feeding, 306 medication, 307 Regurgitation, overfeeding on the breast, 77 Rennet powder, 276 Rennin, 5 Reparation stage, 216 Respiration, average rate, 316 Cheyne-Stokes, decomposi- tion, 213 rapid, decomposition, 213 toxic, 231 Restlessness, disturbed metab- olic balance, 186 dyspepsia, 198 Rice, caloric value, 157 water, 280 Ringer's solution, intoxication, 232 Robinson patent barlevflour, 274 Rosenstern, 216, 226 Rotch, 108, 126 Rubner, 108, 136, 137, 147 Ruhrah, 288 Saccharose, caloric value, 150 lactose compared, 141 Salge, 113 Saline solutions, 308 Saliva, secretion, 20 Salivary glands, 1 Salts, 15 chemistry, 15 excretion by large intestine, 6 functions, 18, 143 human and cow's milk, 143 metabolism, 17 nitrogen retention, 137 solutions, 308 withdrawal influencing weight, 18 Saner, 249 Schloss, 293 336 INDEX. Sclerma in intoxication, 231 Scurvy, boiled milk, 120 "Second summer," 69 Sensorium, decomposition, 213 intoxication, 230 Sepsis, nursing mother, 85 Shaw, 310 Skatol, 30 Sleep disturbed, 186 length, 315 Smillie, 254 Smith, 263 Soaps, intestines, 17 stools, 12 Sodium and potassium metab- olism, 145 citrate to break curds, 154 in milk, 16 salts and water retention, 18 favoring fermentation, 30 Sohxlet-Nahrzucker, 276 Solutions, saline, 308 Soup, chicken, caloric value, 157 cream, 286 dried fruit. 288 farina, 287 Keller's malt, caloric value, 150 recipe, 286 permitted at three 3'ears, 167 vegetable, caloric value, 157 recipe, 287 Soy beans and condensed milk, 288 Spasmophilia, 184 Spinach, 289 '•Spitting," 78, 168 Stadium dvspepticum, 196 Starches, addition, 153 constipating tendency. 24 nitrogen retention, 137 Startoline, 283 Steapsin, 5 Steinitz, 240 Stomach, absorption, 20 - acidity, 4 anatomj^, 1 bacteria, 26 Stomach, capacity, 2 ferments, 5 gas, 170 milk digestion, 20 physiolog}^, 4 washing, 304 Stools, see also Feces. abnormal, 171 blood, 173 composition, 21 curds, 171 decomposition, 213 diagnostic value, 24 disturbed metabolic balance, 189, 190 dyspepsia, 200 enteral infections, 259 examination, 8 fat-soap, 139,171, 173 pathogenesis, 187 fats in, 12 flour injur}^, 242 hunger, 24, IZ, 171, 243 intoxication, 230 Keller's malt soup, 171 loose, green, 172 nitrogenous bodies in, 10 normal, 23 nursing infant, 65 starvation, see Hunger. sj^mbols, 317 underfeeding on breast, IZ Strabismus, intoxication, 230 Streptococcus, 31, 254 enteritis, 255 Stupor, intoxication, 230 Subcutaneous saline solutions, 308 Sublingual tumors, congenital debility, 85 Sugar, cane, see Saccharose. excessive, dyspepsia, 196 intoxication, 226 laxative tendency, 24 malt causing brown color of stool, 24 milk, see Lactose. nitrogen retention, 137 INDEX. 337 Sugar, quantities in infant feeding, 142 vomiting, 169 Summer diarrhea, 223 etiology, 249 Supplemental feeding, 67 Syphilis, contraindication to nursing, 37 decomposition, 207 hereditary weakness, 84 Tea, recipe. 279 Teeth, deciduous, 315 permanent, 316 Teething, 1 Temperature, carbohydrates, 15 extremes, dyspepsia, 156 salts, 18 subnormal, decomposition, 212 Tenesmus, enteral infection, 258, 260 Tetany, flour injury, 241 Therapeutic dietetic test, 250 Thrush, dj^spepsia, 199 Toast, caloric value, 157 Tobler, 20 Tonsillitis, breast-fed infant, 85 parenteral infections, 249 Toxemias, acute, 31 Traveling, care of food, 297 Trypsin, 5 Tuberculin test, cow, 113 Tuberculosis, contraindication to nursing, 37 cow, 113 decomposition, 207 hereditary weakness, 84 Turgor of the tissues, 131 Twitchings, intoxication, 230 Typhoid, epteritis, pathology, 257 nursing mother, 85 Underfeeding, breast-fed in- fant, 71 nutritional disturbances, 179 Underdevelopment due to boiled milk, 120 Unger, 310 Urea, 10 Uric acid in urine, 10 Urine, 24 ammonia increased, in in- toxication, 227 daily quantity, 316 decomposition, 213 disturbed metabolic balance, 190 end products of protein me- tabolism, 10 ethereal sulphates increased, 31 examination, 8 fat, 12 intoxication, 231 sugar, 14 symbols, 317 Van Slyke, 154, 155 Vegetable, caloric value, 157 permitted at three years, 167 Vomiting, artificial feeding, 168 decomposition, 212 dyspepsia, 200 enteral infections, 260 habitual, 184 intoxication, 230 overfeeding on the breast, 78 Wassermann reaction,, mother's blood, 37 wet-nurse, 49 wet-nurse's infant, 50 Water, 18, 145 absorption by large intes- tine, 6 artificial feeding, 152 content of the organism, 19 excretion, 19 function, 146 metabolism, 18 nursing infant, 45 retention. 146 weight, 146 Weakness, hereditar}-, 84 \\>aning, 67 care of breasts, 69 22 338 INDEX. Weaning, indications, 68 method, 69 overfeeding on the breast, 82 Weigert, 240 Weight, artificially fed infant, 131 average, 314 carbohydrates, 14 disturbance, 186 disturbed metabolic balance, 189 failure to gain in breast-fed, 1Z fluctuations, flour injur\', 241 gain, flour injury, 241 infections, 250 successful nursing, 65 loss, decomposition, 210 disturbed metabolic bal- ance, 188 dyspepsia, 199 enteral infections, 258 infections, 250 intoxication, 230 salt withdrawal, 18 stationary, 168 disturbed metabolic bal- ance, 186 artificial feeding, 168 overfeeding on breast, 79 water, 146 Wet-nurse, 47 age, 48 baby, 50, 52 clothes, 54 cost of milk, 52 diet, 55 examination, 48 exercise, 56 hygiene, 54 length of lactation, 52 menstruation, 57 mental state, 57 multiparity, 48 nationalit}', 47 number needed, 52 period of lactation, 57 place in household, 51 quantity' of milk, 51 quarters, 51 requirements, 48 selection, 47 urine, 50 Wassermann reaction, 49 work, 56 Wheat jelly, 280 Whey, dyspepsia. 198 recipe, 282 Widerhofer, 175 Zuckernaehrschaden, 196 1 DUE DATE 1 MAR 1 "^^ I^Ol i ^PR 3 F» t ' 94 # 201-6503 Printed in USA V\'