FOOTNOTES:
[16] Many of the recipes given for fruit beverages are adapted from Practical Dietetics by Alida Frances Pattee, Publisher, Mt. Vernon, N. Y.
[17] Nutrition and Dietetics, by Dr. W. S. Hall, D. Appleton & Co., New York.
CHAPTER XII
INFANT FEEDING
One of the fundamental problems of to-day, as it was of yesterday and will be of to-morrow, is the correct feeding of infants and children.
Every civilized country faces the same problem, largely because the artificial feeding of infants has become so prevalent.
Unfortunately, many women who must labor outside of the home must resort partially, if not entirely, to artificial feeding of their infants. Usually on account of the inconvenience of breast feeding and the strain on the mother, the infant is given artificial food, often improperly prepared. Although infant mortality is high among the poorer classes, it is marvelous that so many of these infants survive.
It is an encouraging fact, however, that women among the well-to-do and educated classes are appreciating the importance of breast feeding and that the number of these who are not only willing but anxious to nurse their infants is increasing.
The mother should be firm in her decision to nurse her child and be encouraged to persevere in efforts to secure the proper development of the breasts before the birth of the child, that the quantity as well as the quality of the milk may be adequate.
The fact that nearly one-fourth of the civilized race dies during the first year of life is astounding. This mortality is due directly or indirectly to nutritional disturbances that could in a great measure be prevented if the babies were properly nursed at the breast or if the artificial feeding was carefully regulated.
Of six hundred and forty-one infants under observation by Dublin, in Fall River, Mass., five hundred and sixty-five were breast-fed and seventy-six bottle-fed. After the first week there were one hundred and six deaths. In seventy-four of these the infants were breast-fed, and in thirty-two, bottle-fed; nearly one-half of the bottle-fed babies died and only 10 per cent. of the breast-fed babies. The breast-fed child, therefore, has five chances to live where the bottle-fed child has one.
One fundamental principle on which all of the leading specialists in the study of the baby agree, is that the milk of the healthy mother is the only ideal baby food. Every mother should be made to realize the importance of nursing her baby for at least nine or ten months, unless circumstances beyond control make it impossible or inadvisable.
Proper care of the breasts and of the general health during the expectant period will usually secure a sufficient flow of milk for the child’s needs.
The mental attitude of the mother has much to do with the secretion of milk; therefore she should cultivate the habit of kindly, cheerful, healthful thoughts. She should keep her circulation and vitality up to par.
She should take regular exercise and be out in the fresh air daily.
During the first two or three days the child receives little nourishment from the breast, simply a few ounces daily of a yellowish substance known as colostrum, which is supposed to have a laxative effect on its bowels.
It is, however, usual to put the child to the breast at regular intervals of about four hours after the first day, to stimulate the milk secretion, which should be quite free on the third day; it, however, may be slow in coming for a day to two longer.
A teaspoonful or two of warm boiled water, or of a five per cent. solution of milk-sugar may be given every few hours, in fact it is considered advisable by some physicians, in order to lessen somewhat the loss in weight which takes place during the first week.
If the free flow of milk is delayed beyond forty-eight hours, some nourishment must be given. A little modified cow’s milk is best. The preparation of this will be taken up under Artificial Feeding.
The mother should not permit herself to become easily discouraged about her ability to nurse her child, for even though the supply at first seems very deficient and it is necessary to give the baby other nourishment, it should be put to the breast at regular intervals, as the sucking by the child stimulates the secretion of milk. The flow of milk often increases when the mother becomes more active.
When the milk flows freely, the contents of one breast is sufficient for one nursing, and the breasts should be used alternately, that is one breast at one feeding and the other at the next.
Nursing should not last longer than from ten to twenty minutes. Too rapid nursing is apt to cause vomiting. If it is necessary to check the flow of milk somewhat, it can be done by pressing the breast slightly between the fingers.
There is a warmth, a purity, and a vitality to the mother’s milk that is impossible to secure in any artificial food no matter how carefully and skilfully prepared. It is also germ-free.
Some women seem unable to nurse their babies for more than two or three months and it is sometimes thought that it is not worth while for a woman to nurse her baby unless she can do so for a considerable time. This, however, is a great mistake, because there is no time in the baby’s life when it is more important for it to have breast milk than in the beginning. This is the time when the baby’s digestion is most easily disturbed and most difficult to correct. Every day or week that a baby gets breast milk gives it a better start.
It has been thought that it is dangerous to use both breast and artificial feeding. This idea is erroneous. The artificial food cannot make the breast milk hard to digest, while the breast feeding seems to make the artificial food digest more readily. This may be due in part to the ferments which the breast milk contains, but more probably is due to the fact that the baby is able to utilize the proteins of human milk to build tissue when it cannot so readily utilize the proteins of the artificial food.
Wet Nursing
Wet nursing is resorted to less frequently now than in the past on account of better methods for artificial feeding.
If the mother is unable to nurse the child herself and the conditions are ideal, that is the wet nurse a healthy, happy woman with a thriving baby of her own, and very particular in the care of her person, this is better than artificial feeding.
Contra-Indications to Nursing
Total absence of milk, after earnest efforts to stimulate its secretion necessitates artificial feeding.
If the mother has chorea, epilepsy, or tuberculosis in any form, it is best to resort to artificial feeding; also if the mother has syphilis and the baby is free from it. In these conditions the child must often be taken from the mother to avoid infection.
If the mother has had serious complications in pregnancy or parturition, the physician must decide on the advisability of natural or artificial feeding.
In case of nephritis, except perhaps in a very mild form, the milk is toxic and therefore nursing from the breast should be prohibited.
Sometimes in acute contagious disease it is safer to nurse the baby than to subject it to the dangers of artificial food. However, when the mother’s temperature exceeds 101 or 102 degrees, the milk will probably possess toxic qualities and disagree with the infant.
Anatomy and Physiology of the Infant
Every nursing mother should acquaint herself with the process of the infant’s digestion, as many of the infantile difficulties are caused by overfeeding or underfeeding, due to ignorance on this subject.
The alimentary tract of the new-born infant differs in many ways from that of the adult.
As compared with other mammals, the human infant is the most helpless and undeveloped and therefore the most delicate and easily affected. It is practically dependent on its mother for nourishment which will completely supply its needs.
The capacity of the stomach, after careful study, has been placed at from 1 to 2 ounces at birth, 2 to 3 ounces at the end of the first month, 6 ounces at the 6th month, and from 9 to 10 ounces at the end of the first year. This is simply an average guide, as stomachs vary somewhat in size. Quantities somewhat larger than the foregoing are sometimes fed, but some of the food has passed beyond the pylorus before the last of it is taken. Digestion begins as soon as the food enters the stomach.
The secretion of bile begins within 12 hours after birth, increases rapidly, and is fully established within a week or ten days.
The pancreatic ferments which digest starches and sugar are present in the new-born, although scanty; the sucking movements of the child when nursing exercise the salivary glands so that saliva is secreted; but starch digestion is not completed in the mouth, hence starch and a greater proportion of sugar than is in the mother’s milk are difficult for the infant to digest.
The intestines, when compared with the length of the body, are relatively long in infants, but the muscular coat is comparatively weak; digestion is therefore relatively slow and more subject to derangement by substances that influence peristalsis.
The fact that infants vomit with comparatively little effort, the food overflowing from an overloaded stomach, is due to the relatively feeble closure of the cardiac orifice.
The stomach contents are kept germ-free by the secretion of hydrochloric acid and the upper intestine is nearly free from bacteria in breast-fed infants, because of the antibacterial nature of the intestinal secretion. In some digestive disturbances this safeguard fails and bacteria develop rapidly.
Intestinal Disturbances
Intestinal disturbance in the breast-fed infant is most often caused by overfeeding, the infant often nursing too frequently, thereby emptying the breasts and securing a high fat ratio. Frequent nursing does not give the stomach time to empty and thus digestive disturbances are apt to occur. Therefore, as a means of relieving intestinal trouble in the infant, nursing at regular intervals and not too frequently, is of much importance.
When digestive disturbance has occurred it is best to stop nursing for twenty-four hours, giving the infant weak barley gruel sweetened with saccharin. At the end of twenty-four hours let the infant nurse at the breast for from three to five minutes, this being preceded by a small drink of water.
As the bowel condition improves, the time at the breast may be gradually lengthened.
The mother should watch her diet to avoid too much rich food, and foods that seem difficult to digest, as certain articles of food in the mother’s diet often causes gastric disturbances in the infant.
She should also carefully watch her thoughts, keeping them well poised and upon kindness, love, and peace. Worry or unkind thoughts will affect the mother’s milk and disturb the child’s digestion very quickly.
Fits of temper in the child also disturb its digestion.
Times of Feeding
Regular nursing habits should be insisted on, as indigestion, colic, and diarrhea often result from irregular nursing.
Some authorities discourage night feeding as unnecessary with a normal baby, but most physicians agree that the child should be aroused during the day in order not to miss a feeding, as it will fall asleep again directly after nursing and will soon get into the habit of awakening at feeding time.
The following table from Holt may be used as a guide in breast-feeding:
| Age | Number in twenty-four hours | Intervals during the day hours | Night nursing between 9 P.M. and 7 A.M. |
| 1st day | 4 | 6 | 1 |
| 2d day | 6 | 4 | 1 |
| 3d to 28th day | 10 | 2 | 2 |
| 4th to 13th week | 8 | 21/2 | 1 |
| 3d to 5th month | 7 | 3 | 1 |
| 5th to 12th month | 6 | 3 | 0 |
There may be some slight deviations from this if the child is ill and small for its age. It is a good general rule to feed the child according to the age with which its weight corresponds.
There can be no regular rule followed for all. Some authorities hold that fifteen- to twenty-minute feedings at four-hour intervals during the day, with one feeding at night, are sufficient, but it depends on the child. Some babies’ stomachs are smaller than others, and some do not nurse regularly, but play and are inattentive to the nursing. In either event the child will not get sufficient nourishment at four-hour intervals. The intelligent mother can determine what is best.
Water
In breast-feeding, as well as in most of the formulæ for bottle-feeding, there is an allowance for an amount of fluid that, under ordinary circumstances, satisfies the baby’s requirements. Additional water is often necessary, especially during the hot weather when the body heat is regulated through evaporation from the skin. The most effective means of promoting perspiration is the giving of water. This, however, should not be done to excess. Eight ounces for a 10-pound baby, given in divided doses during the day, will be sufficient.
It is best to give the water when the stomach is nearly or quite empty. It should be boiled and cooled and should be given by the bottle as the child will then take at intervals all that its thirst requires, and the danger of choking as a result of too hasty swallowing is avoided.
Normal Development in the Breast-Fed
The growth and general condition of the child will, of course, be influenced by the quality and quantity of the milk. The birth weight of 7 to 71/2 pounds is usually doubled by the end of the fifth month and trebled by the end of the year. The average gain is from 5 to 8 ounces a week during the first few months and from 2 to 4 ounces a week the last few months of the year.
If the mother’s milk is deficient in any way, the child becomes fretful and loses weight, or the weight remains stationary. In such cases the physician usually examines the milk to determine its quality and advises some means of improving it, or in some way adding to the baby’s food the element in which the mother’s milk is lacking.
The physical condition of the mother often affects the baby’s nourishment, and besides resorting, temporarily, to means for improving the quality of the milk, she should build up her general vitality through regular exercise for the spine and the vital organs, deep breathing of fresh air, and regular rest.
While a scanty food supply will diminish the flow of milk, overloading the stomach at meal time and taking quantities of rich food between meals, as so many nursing mothers, think is necessary, usually does little to increase the quantity or improve the quality of the milk, but often results in an accumulation of superfluous flesh and disturbed digestion, which quickly affects the child.
Sometimes a more restricted diet together with specially directed exercises to relieve any digestive disturbance and correct constipation, and relaxing exercises for the nerves, will do more than anything else to improve the quality of the milk.
Mothers should particularly avoid becoming overtired.
When the milk is good, but the quantity deficient, massage of the breasts three or four times a day for five or ten minutes will increase the supply. One effective means of increasing the secretion of the mammary glands is the mechanical stimulus of suction. If a robust baby can be put to the breast for a time it may develop an ample flow of milk for a puny infant whose powers of suction are feeble.
A good malt extract with meals sometimes tends to increase the flow of milk. When the quality and quantity of the milk are deficient, the physician usually advises a very nourishing diet and a tonic. This nourishment does not of necessity require an excessive amount of liquid.
When the quantity is sufficient, but the quality poor, it is usually necessary to wean the baby, if it is several months old, although mother’s milk, even if below standard in quality, is better for the infant than cow’s milk, at least during the first few months.
Nervousness, sleeplessness, worry, and grief have a decided effect on the milk supply and on the baby. Nervous mothers are apt to have an abundance of milk one day and little the next day; frequently the milk will disappear suddenly.
Weaning
When it is possible, the baby should be weaned gradually. Although there is no set time for weaning, it is not advisable to feed the child exclusively from the breast after the eighth or tenth month. Bunge holds that human milk contains too little iron at this period and the babies are apt to become pale and undernourished.
When additional feeding is decided on, the physician should prescribe the preparation. A bottle a day should be substituted for the breast feeding at first and, gradually, additional bottle feedings, until, after about a month the breast is entirely withdrawn.
After the eighth month and until the age of twelve months, as a general rule, cow’s milk should be diluted and sweetened by mixing eight ounces of barley water and thirty-two ounces of milk, adding an ounce of cane-sugar or milk-sugar, and dividing the whole into five 8-ounce portions.
Additional food may be given to the healthy child after the eighth or ninth month. Orange juice or other fruit juice one or twice a day should be given about an hour before feeding. A teaspoonful may be given at first and the amount gradually increased to about two tablespoonfuls a day.
Orange juice is a specific in conditions of scurvy resulting from improper feeding. The child usually improves rapidly after it begins to take the juice.
Beef juice, meat broths, or strained vegetable soup may be given in increasing amounts up to 5 or 6 ounces daily.
Zwieback and whole wheat or Graham crackers are permissible in small amounts after the ninth month. After nine months the healthy baby should also have a soft-boiled egg occasionally, also baked apple and well-cooked, mashed spinach or carrots.
Food should be given only at regular intervals and nothing but water between feedings.
Starch-digesting ferments are present at birth in sufficient amounts to digest the sugar in milk, but they do not develop sufficiently to digest starches until about the twelfth month, so white bread, crackers made from white flour, potatoes, rice, etc., should not be given the child under a year.
Artificial Feeding
When artificial feeding is necessary, the physician must decide what modification is best for the baby. One can only determine by experimenting upon the actual percentages of fat, proteins, and sugar which each baby needs, following, in general, the proportions contained in mother’s milk, because while many babies thrive on a food of this composition, some do not. The formulæ given are simply a guide, as the proportions may need to be changed, or may need to be made weaker in some cases and stronger in others.
The composition of human milk, however, is a guide to the infant’s digestive ability. This must be determined by a careful study of the individual baby as every baby is a problem by itself.
As previously mentioned, no artificial food is the same as human milk, although it may contain the same proportions of the different elements, and it is often difficult, especially during the first few months, to prepare a combination on which the child will thrive.
Cow’s milk, properly prepared, is the nearest available substitute for human milk. It must be modified, as the digestion of the calf at birth is equal to that of an infant at eight or nine months.
Farmers have in recent years become more particular about the care of their cows and cleanliness in milking because the educational campaign with regard to the danger to human life from tuberculous animals has caused a greater public demand for good, clean milk.
Many infectious diseases are conveyed by milk, and impure milk is a large cause of the extraordinarily high mortality of early infancy. With the improvement of the milk supply, the decline in the infant death-rate has been wondrously gratifying.
Manufacturers have taken advantage of the fact that the public has become a little afraid of cow’s milk and have extensively advertised their prepared foods, claiming them to be the best substitute for mother’s milk. However, experiments have proven that these statements for the most part are misleading, the composition of the foods not being suited to the actual requirements of the infant. Some prominent physicians think that infant mortality has been increasing since prepared foods have been used so extensively.
One leading authority states that “clean, fresh cow’s milk, properly modified, is the best substitute available. It is to be preferred to any prepared food, no matter how sweeping may be the manufacturers’ claim for it.”
The most striking thing about the prepared foods is their tremendous excess of carbohydrates, either cane-sugar or sugar derived from starch by the process of malting. Condensed milk, in particular, contains much too large a percentage of cane-sugar for the child.
Another authority states:
An excess of sugar is likely to damage the organism by the production of poisonous substances in the body. This is particularly true in those infants who are already suffering from indigestion. An excess of sugar in such a baby is likely to render him severely and dangerously sick and result in catastrophe.
Bacteriology
The study of the bacteriology of the alimentary tract of the new-born infant reveals a most interesting fact and explains why artificial feeding is often so difficult and dangerous.
In the intestinal canal at all times many varieties of vegetable organisms (bacteria) are present. These are called floral organisms. Some of these aid digestion while some others increase disturbance in the intestines, particularly if in excess, or if digestive derangements occur.
The flora which predominate are those peculiar to the infant which is properly digesting human milk. This accounts for the uniform action of the bowels in breast-fed infants. As soon as the child gets milk from the breast, the intestinal flora assume this definite form.
When cow’s milk or any other food is given, the intestinal flora change. When the change is made too suddenly, these new flora which live on the digested products of human milk gradually disappear and the action of the new flora often causes intestinal derangements which the infant is not strong enough to overcome.
Composition of Human Milk
If artificial feeding must be resorted to, the composition should resemble mother’s milk as nearly as possible. It is impossible to duplicate it exactly and even though the elements and the proportion of them are the same, the bacterial flora will be different and consequently the effect also.
If the breasts are emptied regularly, human milk varies little in composition after the first few weeks. According to Holt there is an average in mother’s milk of
| Fat | 4% |
| Sugar | 7% |
| Protein | 1.5% |
| Salt | 0.2% |
| Water | 87.3% |
Adaptation of Cow’s Milk
When the baby has been fed at the breast for several months, pure cow’s milk sometimes agrees very well, if overfeeding is avoided.
The amount of milk taken every twenty-four hours by a healthy infant is usually about 11/4 ounces to the pound of the baby’s weight.
A normal infant of twelve pounds would be taking between twelve and eighteen ounces of milk in its twenty-four hour mixture.
Budin recommends one-tenth of the body-weight daily of milk and reports excellent results in infants after the fifth or sixth month, weighing from thirteen to fifteen pounds.
Most infants under the age of nine months are more or less incapable of digesting cow’s milk undiluted. If artificial food is resorted to from the start, practically all physicians agree that the milk should be diluted or otherwise modified during the first few months at least.
Milk diluted with water is often given, one part of milk to two parts of water. This reduces the protein to about the amount found in breast milk.
It is necessary to keep up the proportion of protein, as this alone contains the important food element, nitrogen. From one-half to three-fourths of an ounce of milk-sugar is added to the twenty-four hours’ supply of food to approximate the seven per cent. found in breast milk.
The proportion of milk and milk-sugar is gradually increased and the water decreased, so that at the end of the first or second month the baby gets equal parts of milk and water and about an ounce more of milk-sugar. This process is continued until, near the end of the first year, the child is on whole milk. The sugar is lessened as the water is omitted.
If, after a few months, it is desired to give a baby starch in its food, cereal waters made of barley, rice, wheat, or oatmeal may be used in place of plain water.
As cow’s milk leaves the stomach more slowly than mother’s milk, longer intervals between feeding seem advisable. When the breast-fed infant receives nourishment every two and one-half to three hours, an infant given a cow’s-milk preparation would be fed every three and one-half or four hours.
The most important thing is to prevent both overfeeding and underfeeding as these are often the greatest factors in producing infantile disturbances. A too rapid gain in weight, (from 8 to 12 ounces a week), which often occurs in artificially fed infants, is not a good sign.
Milk prepared according to the formula desired by the physician can now be secured from milk laboratories in all of our larger cities. However, the milk is apt to spoil in transit, and to secure its freshness when one is not in or near a large city, it is best to prepare it at home. Any intelligent mother or nurse can do this very satisfactorily if the physician gives definite instructions.
Its careful preparation is quite as important as the correct formula.
Mineral (calcium) and protein are bone and other tissue builders, and it is a significant fact that cow’s milk contains about twice as much protein and a little more than twice as much of the mineral as mother’s milk, indicating that the growth of the human infant is to be slow. The calf requires about four years for full growth and the human being twenty-one years. Both human and cow’s milk, however, contain an equal amount of fat, the heat-producing element, as Nature intended that the infant should be warm and active.
It seems almost impossible to get milk from the cow as clean and free from bacteria as it should be and therefore sterilization and pasteurization are resorted to almost universally. Various substances such as formaldehyd, boric acid, and salicylic acid are used by dealers to preserve the milk. These all have a deleterious effect on the child. Therefore the safety of the child demands that the mother choose a reliable dairy. The milk may be analyzed occasionally to make sure of its purity.
Top-Milk
A very popular milk preparation and one frequently prescribed by physicians is the top-milk method as originated by Dr. Holt.
Top-milk is that at the top of milk bottles in which milk has been allowed to stand for five or six hours.
The cream at the top contains the most fat. For instance, in a quart of milk that has been permitted to stand, the
| Upper | 4 | ounces contain | 20 | per cent. of fat. |
| ” | 6 | ” ” | 16 | ” ” ” ” |
| ” | 8 | ” ” | 12 | ” ” ” ” |
| ” | 10 | ” ” | 11 | ” ” ” ” |
| ” | 12 | ” ” | 9 | ” ” ” ” |
| ” | 14 | ” ” | 8 | ” ” ” ” |
| ” | 16 | ” ” | 7 | ” ” ” ” |
| ” | 20 | ” ” | 6 | ” ” ” ” |
| ” | 24 | ” ” | 5 | ” ” ” ” |
To remove the top-milk, the first ounce is taken out with a spoon and the remainder with a Chapin milk dipper which contains one ounce.
The following formula is considered a good top-milk mixture, although it is not supposed to meet the needs of all infants and would therefore have to be modified in some cases and made stronger in others.
TOP-MILK MIXTURE
| Top-milk (upper 8 ounces) | 21/2 ozs.; |
| Bottom-milk | 1 oz.; |
| Limewater | 1/2 oz.; |
| Milk-sugar | 1 measure (1/2 oz.); |
| Water, sufficient to make | 8 ozs. |
The sugar is dissolved by boiling it in the quantity of water to be used for the mixture. If not perfectly clear, it is strained through cheesecloth.
The one thing to be particularly guarded against is overloading the stomach with rich food. On account of the high percentage of fat, digestive disturbances often occur when top-milk is used. Some infants can dispose of an abundance of fat from the beginning and most of them can after six or nine months, but many infants have difficulty in digesting fat. The condition called “fat rickets” may exist, though the child may seem to thrive and increase in weight. Its flesh, however, is not hard and firm as it should be in health.
The cream from Guernsey and Jersey cows is usually too rich for infants and therefore the best milk for the baby is that from Holstein or grade cows. The mixed milk from various cows is usually best.
The physician can determine from the stools if the fat ratio is too high, in which case it is best to use top-milk lower in percentage of fat, and lengthen the feeding intervals to four hours.
Certified Milk
If the additional expense of certified milk can be met, it is advisable to use it in preparing the baby’s food, as it is reasonably constant in its composition and is prepared under the most hygienic conditions, in accordance with the requirements of the American Association of Medical Milk Commissions.
All utensils used in preparing the baby’s milk must be absolutely clean. Bacteria develop very quickly in milk and, therefore, the bottles, nipples, etc., should be kept as germ-free as possible by being boiled daily, and the nipples, when not in use, should be kept in a solution of boracic acid (one-fourth ounce boracic acid to one-half pint of water).
The artificially fed baby does not usually thrive as well as the breast-fed infant. It does not gain in weight as fast and the teeth are slower in coming. The general condition of the baby, and a steady, even if slow gain in weight, will indicate whether the food is agreeing.
Every baby, however, is a law unto itself and it sometimes requires considerable study to determine what is the best food. Even with the utmost care a cow’s-milk preparation cannot be made identical with mother’s milk and sometimes an entirely different mixture must be resorted to.
However, no mother should attempt to experiment on her baby or permit herself to be misled by the advertisements of so-called Baby Foods. It is only when these are used in the right proportion and in combination with other ingredients that they can be suited to the requirements of the infant.
Milk Modifications
Malt used in place of milk-sugar or cane-sugar will greatly assist the absorption of fat and decrease the tendency to fermentation and colic. It is being extensively used in milk modifications.
It is best to use the dextrin-maltose preparations that do not contain sodium chlorid, as it is rarely advisable to add this salt to the infant’s food.
Some physicians have been securing very satisfactory results with a preparation containing whey. Whey is a thin, watery fluid, looking very much like skimmed milk; its caloric value is about 300 per quart, 9 per ounce, barely one-half that of whole milk. It is therefore adapted only to temporary feeding, while its low fat content is of great value in cases of fat dyspepsia.
To secure the whey, 5 grams (1 teaspoonful) of rennet should be used to each quart of milk. The mixture must be kept at a temperature of about 100 F. until it separates into a liquid and a solid portion. It is then strained through cheesecloth. Practically all the casein is left on the cloth, the fluid being the whey. The curd should be broken up before straining, in order to obtain, as nearly as possible, the casein. However, about two-thirds of the milk fats remain in the curd. The whey, besides the whey proteins, thus contains only about one-third of the fats, but nearly all of the milk-sugar and salts. The whey still contains the rennet and, to destroy this, the whey must be heated to at least 140 F. for thirty minutes.
The average composition of whey according to Wachenheim is as follows:
| Proteins | 0.8 | per cent. |
| Fats | 1.0 | ” ” |
| Milk-sugar | 4.5 | ” ” |
| Salts | 0.7 | ” ” |
| Water | 93.0 | ” ” |
Sometimes sugar is the primary cause of intestinal fermentation, due to the concentration of the whey and the relative proportions of casein and sugar in the mixture.
According to Finkelstein and Meyer, to prepare a food which will combat intestinal fermentation there must be:
A diminution in the quantity of milk-sugar, a diminution of the salts through dilution of the whey, and an increase in the casein, with varying, and, under certain circumstances, not inconsiderable amounts of fat. After improvement has begun, an easily assimilable and consequently little fermentable carbohydrate should be added.
They developed a food to meet these requirements to which they gave the name of “Eiweissmilch.” This food is prepared as follows:
Heat one quart of whole milk to 100 F.; add four teaspoonfuls of essence of pepsin, and stir. Let the mixture stand at 100 F. until the curd has formed, then strain. Press the mass of curd through a rather fine sieve two or three times by the means of a wooden mallet or spoon. Add one pint of water to the curd during this process. The mixture should now look like milk and the precipitate must be very finely divided. Add one pint of buttermilk to this mixture.
Finkelstein and Meyer used buttermilk in the preparation of this food:
(1) Because of the small amount of milk-sugar which it contains;
(2) To obtain the good effects of the lactic acid;
(3) Because buttermilk can be kept for a longer time.
The composition of this food is:
| Fat | 2.5% |
| Sugar | 1.5% |
| Protein | 3.0% |
| Salts | 0.5% |
One quart of this milk contains about 360 calories.
They call attention to the low caloric value of this food and to the necessity of increasing it as soon as possible by the addition of dextrin-maltose mixtures.
They claim that it is worthy of employment in all the disturbances of nutrition in infants, which are accompanied by diarrhea, of no matter what kind. The use of this food has been extended by others to all sorts of conditions including the feeding of healthy infants and the newly born, and good results are claimed for it.
To use a food low in sugar and salts and high in protein in the fermentative conditions caused by sugar, is rational. In these conditions the substitution of the dextrin-maltose mixtures for lactose is also good.
Not all disturbances of nutrition accompanied by diarrhea, however, are due to the same cause and should not be treated in the same way. No method of feeding can be applicable to both the sick and the well, nor can all babies be given the same food without regard to their individual digestive ability.
The main principles of this method of treating intestinal fermentative conditions may be used and, at the same time, the disadvantages of a routine food may be avoided, by applying the modification of milk by the percentage method as given by Moise and Talbot.
Sterilizing and Pasteurizing
To sterilize the milk it should be heated to 212 F., that temperature being maintained for ten minutes or longer.
Many physicians consider pasteurization the better process. In this the milk is heated to from 150 to 165 F. and kept at that temperature for from twenty to thirty minutes. Boiling produces chemical changes, such as converting the milk-sugar into caramel, etc., while pasteurizing does not.
After pasteurization or sterilization, the milk should be quickly cooled to a temperature of 40 F. or lower and kept, until used, in bottles corked with non-absorbent cotton.
Sterilized or pasteurized milk does not keep as well as raw milk probably on account of the change in the ferments which destroy bacteria; therefore the baby’s milk should be pasteurized fresh every day.
Freeman’s pasteurizer is a very satisfactory and simple device. It consists of a metal pail into which is fitted a rack with a separate cylinder for each bottle. This holds just enough cold water to surround the bottle and keep it from cracking through a sudden change of temperature. The pail, containing a certain amount of water, is placed on the stove, the water is heated to the boiling point, the pail being then removed. The rack of bottles containing the milk preparation, with corks of non-absorbent cotton, is placed in it and the lid applied. The apparatus is placed away from a direct current of air for about forty-five minutes.
As the water in the pail cools, the milk in the bottles grows warm until both are at the same temperature. After forty-five minutes, cold water is turned into the pail to cool the bottles rapidly. They are then kept on ice until again warmed ready for use.
This is the simplest and best way to pasteurize milk and the expense is small.
Improvised apparatus may be used, but it requires much more labor and is not as satisfactory.
All milk should be sterilized or pasteurized before being used as a food for infants.
The following table shows an analysis of milks and infant foods helpful in the selection of a food to supply deficiencies indicated by a chemical analysis of the infant.
COMPARATIVE ANALYSIS OF MILKS AND INFANT FOODS (COMPILED)
(Percentage of Composition of the Dry Substance)
| COMPONENTS | Mother’s Milk | Cow’s Milk | Borden’s Malted Milk | Horlick’s Malted Milk | Borden’s Condensed Milk (Eagle Brand) | Nestle’s Food (Milk Substitute) | Mellin’s Food (Milk Modifier) | Eskay’s Food (Milk Modifier) |
| Protein | 14.00 | 27.00 | 15.10 | 13.83 | 10.10 | 12.40 | 12.10 | 6.82 |
| Fat | 31.00 | 31.00 | 9.20 | 7.90 | 12.10 | 4.15 | 0.25 | 3.58 |
| Cane-Sugar | None | None | None | None | 59.1 | 22.10 | None | None |
| Other Soluble Carbohydrates (Lactose, Maltose, etc.) | 52.00[18] | 36.00[18] | 69.77[19] | 66.56[19] | 16.0[18] | 35.00[19] | 84.00[19] | 56.78[20] |
| Starch | None | None | None | None | None | 25.70 | None | 30.42 |
| Ash (Mineral Content) | 2.00 | 5.00 | 3.46 | 3.42 | 2.4 | 1.62 | 3.78 | 1.00 |
The following table from Holt shows at a glance the comparative average composition of human and cow’s milk:
HUMAN AND COW’S MILK COMPARED
| Human Milk | Cow’s Milk | |
| Fat | 4% | 4% |
| Sugar | 7% | 4.5% |
| Proteins | 1.5% | 3.5% |
| Salts | 0.2% | 0.75% |
| Water | 87.30% | 87.25% |
| Total | 100.00% | 100.00% |
Gruels
Barley, rice, oatmeal, corn meal and soy-bean flour are generally used. If the grains of the cereals are used, they must be cooked from three to four hours.
As a rule, cereal gruels are made by cooking the flour and water for from fifteen to twenty minutes. Two ounces to the quart is about as strong as plain gruels can be made.
Dextrinized gruels may be made as high as eight ounces to the quart. Four level tablespoonfuls of the cereal flour weigh one ounce.
As the soy bean contains no starch, it does not thicken when cooking.
About 1 level tablespoonful to 3 ounces of soy-bean flour are used to the quart. One or 2 tablespoonfuls of barley, oat, or wheat gruel may be added before cooking to increase the nutritive value. One ounce of soy-bean flour, or 2 ounces of barley flour, to 1 quart of water makes a very good standard gruel. It contains 2 per cent. protein, 0.6 per cent. fat, 5.1 per cent. carbohydrates, giving a food value of ten calories per ounce, just one-half the value of milk. In certain forms of intestinal trouble in which cow’s milk is not assimilated, this gruel is valuable used with condensed milk.
Malted gruels are made by adding 1 teaspoonful of good malt extract or diastase to a cereal gruel after it has been cooled. It should be stirred in very thoroughly.
Vomiting
In artificial feeding “spitting” is usually an annoying symptom that does not indicate anything more serious than an overloaded stomach. This condition is usually relieved by lengthening the feeding intervals to four hours.
On the other hand, vomiting usually indicates something more serious in a bottle-fed baby, especially if it is very persistent. It is usually a sign that cow’s milk, or the preparation of it, is not agreeing with the infant. It also indicates a digestive disturbance that should be treated only by the physician, who will probably change the formula.
Occasional vomiting is sometimes due to too rich food and too frequent feeding. Lengthening the feeding hours and decreasing the amount of fat in the mixture will usually eliminate the trouble.
Colic
This is the most common of all of baby’s troubles. It is often due to too rapid feeding either from the breast or bottle, and when there is a tendency to colic, the feeding should be slower. The baby should not be fed while it is suffering from colic, even though it seems that the drinking of warm milk relieves it temporarily. Hot water should be given every half-hour or hour until relieved. If the baby seems cold, hot water slightly sweetened, and a hot bath, should be given at once. A hot-water bottle may be placed near it as well.
In colic there is severe pain in the abdomen, which is swollen and hard. Sudden and violent crying is usually a symptom of colic, which often ceases very suddenly after the emission of gas from the mouth or bowels.
If the baby seems exhausted, the physician should be summoned at once, but these suggestions may be helpful until the physician arrives.
When colic is very frequent in a bottle-fed baby, the food should be modified.
The Stools in Infancy
The character of the stools depends primarily on the composition of the food. They are varied according to the digestive powers of the infant, and according to the amount and rapidity of absorption of the products of digestion. The amount of absorption depends to a considerable extent on the rapidity with which the contents pass through the intestinal tract.
The nature of the food, of course, influences the character of the stools. The examination of the stools is of the greatest aid in determining whether or not any given food element is properly digested and assimilated, and, in many diseased conditions, in telling what element is at fault. This, however, can only be determined by analysis, but a little information on this subject will be of value to the mother or nurse.
During the first few weeks or months of life, the breast-fed infant has three or four stools daily. These are of about the consistency of thick pea soup and are golden yellow. The number of stools gradually diminishes to two or three in the twenty-four hours, and the consistency becomes more salve-like.
It is not uncommon for thriving breast-fed babies to have a large number of stools of diminished consistency and of a brownish color; in such instances, the examination of the breast milk will show that the proteins are high.
It is best not to pay too much attention to the stools if the baby is gaining in weight and appears well. It is not unusual to find many soft fine curds and sometimes mucus in the stools of healthy breast-fed babies.
It is not only unnecessary, but decidedly wrong to wean a baby simply because the stools are abnormal, if it is doing well in other ways. The breast-fed infant will often go weeks or months without a normal stool and yet thrive perfectly. On the other hand, if a baby has such stools when it is taking cow’s milk it is a decided evidence of malnutrition.
Infants that are thriving on cow’s milk have, as a general rule, fewer movements in the twenty-four hours than do breast-fed babies and these movements are firmer in consistency.
Constipation
Constipation seems to be the chief difficulty in artificial feeding, due usually to the poor absorption of fat, or the low percentage necessary to prevent indigestion. If the constipation is not severe, the substitution of oatmeal for barley water in the mixture will usually relieve the trouble.
If the constipation is severe, causing occasional attacks of colic or straining at stool, it is sometimes advisable to give a little higher percentage of fat in the mixture, but this should be done very cautiously and usually on the advice of the physician.
If, however, this does not relieve the trouble, the best plan is to substitute one of the dextrin-maltose mixtures for milk-sugar or cane-sugar. The malt itself is not especially laxative but it prevents the excessive fermentation which usually occurs when the bowels are very costive.
Diarrhea
Two, three, or more green and loose evacuations, even though they may contain whitish particles of undigested fat, are of no great significance in the breast-fed infant, but should be regarded as danger signals in bottle-fed babies.
Even a mild attack of diarrhea is usually a symptom of fat-dyspepsia which, if taken in time, may usually be promptly checked.
A dose of castor-oil at the beginning of the attack may relieve any irritation that might have caused the trouble.
It is best to omit all food for at least twenty-four hours. Plain water should be given very freely and occasionally barley water, if the baby is hungry. After that it is best to start with a mixture low in fat. Skimmed milk or boiled milk free from all fat, diluted with cereal water, may be given at regular intervals.
Should slight diarrheal attacks continue, or should the stools be of a diarrheal character, the wisest plan is to substitute a dextrin-maltose mixture for the sugar, as malt decidedly favors fat absorption.
In almost every case of infantile diarrhea it is advisable to consult the physician, especially if there is considerable restlessness and rise in temperature.
Diarrhea is more frequent in summer among bottle-fed babies, as the heat often promotes the growth of germs in the milk. Therefore to sterilize or pasteurize milk during the heated months is especially necessary.
A chill, due to insufficient clothing, will sometimes cause diarrhea. The abdomen, arms, and legs should be kept warm by close-fitting garments of soft wool.
Anemia
In treating anemia in infants, as in adults, the cause should be removed by correcting any errors in diet and treating any other physical deficiencies.
The cause of infantile anemia is an insufficient absorption of iron from the food.
The amount of iron in both human milk and cow’s milk is small and is insufficient for the needs of the growing infant. However, Nature has deposited enough iron in the liver of the new-born infant to last until it can digest foods which contain iron in sufficient amounts. The iron in human milk is apparently more easily retained than that in the milk of animals.
The iron content of human milk is dependent on the general condition of the mother. It is higher in healthy individuals and lower in those under par.
Anemia in infants is apt to become severe and often take on a pernicious form. A prolonged intestinal disturbance often brings on anemia, and not infrequently anemia is due to a deficiency of protein in the food.
The treatment consists largely of additions or changes in the diet, depending on the age of the infant. Purées of vegetables that contain much iron, such as spinach and carrots, and also fruit juices, are valuable and in proper proportions can be added to the diet after the age of six months. It is best that the physician decide on the advisability of this as it will depend on the general condition of the infant.
Rickets
Rickets, a chronic impairment of nutrition, affects not only the bones, but all of the tissues of the body, particularly the nervous system. Artificial feeding is the chief cause of rickets on account of the poor absorption of fats, and often because of protein starvation.
Prepared foods, on account of their large percentage of starch and their lack of protein and butter-fat are frequently the cause of rickets.
In addition to its fuel value, milk-fat contains the elements which promote growth.
As previously stated, the infant requires a certain percentage of protein, fat, and mineral for the blood and tissue building and the growth of the bones. In artificial feeding, the preparations given are often deficient in these important elements.
Climate and poor hygienic surroundings sometimes cause rickets in breast-fed babies, probably on account of the lowered vitality of the mother and the child and consequently poor digestion and assimilation, but it is most frequently found in babies improperly fed.
Dr. Winfield S. Hall says:
Fresh milk, appropriately modified and in proper amount, together with such other food as is indicated for the age and weight, is the important point in the treatment of rickets. Fresh air, day and night, sunshine and outdoor life, are only next in happiness. Cod-liver oil, especially with the addition of phosphorus, is a very valuable addition to the treatment.
Scurvy
Rickets is a chronic condition, while scurvy is an acute disease.
This difficulty is considered as entirely due to improper feeding and therefore must be overcome by a change of diet. Recovery is usually very rapid when the child is properly fed.
Pains and tenderness about the joints, particularly of the legs, are the usual symptoms, causing the baby to cry when it is lifted or moved about. The gums sometimes become swollen and bleed. In almost every case it is found that infants suffering from scurvy have been on a continuous diet of prepared foods like malted milk, condensed milk, or boiled milk which Dr. Hall terms “dead food,” presumably on account of a lack of the life-giving proteins and butter-fat.
When boiled milk has been used, the change should be made to pasteurized milk or raw milk if it can be secured clean and fresh. If prepared foods have been given, the amount should be greatly decreased and replaced by a cow’s-milk preparation in which a small percentage of the prepared food may be included, or, better still, omitted entirely, if a cow’s-milk preparation including a good substantial gruel will agree.
In scurvy, orange juice or other fruit juices should be given, from 1 to 4 ounces a day, according to the age. Orange juice is particularly valuable, 2 or 3 teaspoonfuls being given before each feeding.
A lack of fresh air often aids in producing scurvy.
Feeding during the Second Year
After the baby has reached the age of one year, we often feel that it is not necessary to be so careful of its diet. However, the number of deaths due to digestive disturbances caused by improper feeding during the second year is significant.
After the child is a year old it should be given solid food very gradually to develop its digestive functions as well as its teeth. A soft-boiled egg or a little beef juice may be added to the diet. Until the appearance of the anterior molar teeth, however, the child’s diet should be confined largely to milk. A thin slice of buttered bread or a little plain rice or rice pudding, a soda cracker or bread crumbs in milk may be given. The year-old child may also begin to drink cow’s milk. One or two glasses a day may be given, until the child is at least 13 or 14 years old.
Good judgment should be used in feeding children, as habits and tastes are being formed, and whether they are normal or abnormal will depend on the kind of food given and when.
Four meals a day, at regular intervals, and nothing but water between these intervals, is considered the best plan.
Dry toast, zwieback, and crackers may be gradually added to the diet, also well-cooked cereals, like cream of wheat, rice, and oatmeal. The oatmeal should be strained the first few months it is given. Very little sugar should be added to the cereals, as children very quickly cultivate a desire for sweets, rejecting other more nourishing foods, and too much sugar is apt to disturb the digestion. It is best during the first few months that no sugar be added to cereals.
The amount of whole milk, or milk diluted with barley or oatmeal gruel, should be limited to one quart when the other foods are given.
Beef juice (from one to two ounces), mutton broth, chicken broth, and cereal broths may be given after the age of one year; not more than two ounces at first, gradually increasing in a few months’ time to four ounces. This is best given at the beginning of the noon feeding. These broths have little nutritive value, but usually stimulate the appetite for other foods.
The child must build muscle, bone, and sinew, and more protein is required as soon as he begins to walk. Milk, eggs, and cereals will furnish this. The heavier protein diet is best given at eighteen months to two years, in eggs, cooked soft. An egg may be given every other day, soft boiled for about two minutes, or coddled for four minutes. At the age of two years an egg may be given every day. These soft-cooked eggs are best when mixed with broken dry toast or broken whole wheat or Graham crackers, because if dry food is served with them they will be better masticated, hence more saliva be mixed with them.
The habit of thorough mastication should be cultivated at this period.
Oatmeal, thoroughly cooked, and shredded wheat, with cream and sugar, ripe fruit, bread and butter, milk, soft-cooked eggs (poached or boiled), constitute a rational diet at this age.
Bread is better broken in milk because the chewing movements mix the saliva with the milk and smaller curds are formed as the milk enters the stomach.
Custard may after two years be added to the diet, also baked or mashed potato, plain boiled macaroni, also a little butter on the potato, toast, or bread.
Also after the age of eighteen months, a small quantity of very lean meat, like scraped or chopped beef or lamb, or finely minced chicken, may be given once a day.
Also well-cooked and mashed vegetables like peas, spinach, carrots, and asparagus tips. For the first few months these should be strained.
Some fruit should also be given each day, orange juice, apple sauce, or the pulp of stewed prunes; the latter especially is valuable when the bowels are inclined to be constipated.
Tea, coffee, and cocoa are absolutely objectionable, and before the age of two years no kind of candy should be given.
One of the most important things to teach the child, when it is taking foods other than milk, is thorough mastication, not only to assist the proper growth of the teeth, but to prevent the digestive disturbances that invariably occur from the bolting of food, and children are especially liable to do this.
Dry toast and zwieback compel mastication and strengthen the gums. These should be given in the hand, a piece at mealtime and occasionally between meals, if the child seems hungry. The child will then gradually get into the habit of chewing other solid foods when they are given.
If the child is hungry between meals, he should be fed at a regular period, midway between breakfast and luncheon and between luncheon and the evening meal. The food should be dry (toast or a dry cracker) to induce thorough and slow mastication.
Many object to “piecing” between meals, but if this piecing be done at hours as regular as his meal hour, and the food be dry and well masticated, it will readily digest and will not interfere with his meals. The growing child needs more frequent meals than the adult. His stomach is not so large, he is active in outdoor exercise, and eliminates waste freely. He also requires much heat and energy. The active child at outdoor play uses almost as much energy as the laboring man.
Many mothers are in doubt as to whether the baby’s food should be salted. It is necessary to add a very little salt to the food for the baby; broths should be seasoned slightly and a pinch of salt added to potatoes and eggs. Cereals and vegetables are cooked in water to which a little salt has been added.
Experienced observers of children and their ailments and diseases have said that more babies are killed by overfeeding than by underfeeding. Especially in summer, when the child’s condition reflects that of the mother, too much food will cause indigestion, irritation of the stomach, and diarrhea.
Often the child is fretful because it is too warm or is thirsty. It will often be benefited by giving it less food and more water. This fretful mind affects the child’s digestion just as it affects the digestion of the mother.
If a healthy child refuses good, wholesome food because it wishes some other than what is offered it, it is not hungry and doesn’t need the food.
The growing child craves sweets, but a child should not be given candy whenever it wants it during the day. Candy or sugar is quickly converted into heat and is best eaten immediately following a meal. Sugar may be spread on bread for the four o’clock lunch or a little candy may be eaten at this time. Two or three pieces of candy an inch square are sufficient.