Dietetics for Nurses

by Fairfax T. Proudfit

Seven per cent. (7%) cream is obtained from the upper 16 ounces of a quart bottle of milk which has been allowed to stand undisturbed for six hours. The upper third of the bottle contains 10% fat, while the whole fat layer from the quart bottle, regardless of the number of ounces, contains about 16% of fat.

Methods of Artificial Feeding.—The use of whole milk, top milk, or skimmed milk, diluted with water, and either milk sugar, malt sugar, or sucrose (cane sugar) added, is the method of feeding most commonly used, and upon it are based the formulas universally advised by infant specialists. There are cases in which simple dilution is not advisable. In premature or very young infants, for example, the whey mixtures have been found to give the best results. In toxic diarrheas, where the putrefactive bacteria make the use of all but the minimum amount of protein inadvisable, the above method is contraindicated, as it is likewise in cases where vomiting of casein curd is a prominent feature.[68]

The Use of Alkalies.—There are many cases in which the physician deems it advisable to add an alkali to the milk mixture. The one generally selected is limewater. However, sodium citrate and sodium bicarbonate are also used. The reasons for adding alkalies to the milk mixtures are: (1) to check the coagulation of the casein, (2) to hasten the emptying of the stomach, or (3) to chemically change the formation of the curd. In certain cases it is only necessary to delay the coagulation of the casein in the stomach, in which case a certain amount of limewater is used. Its action is to swell the protein of the milk and in this way effect the precipitation of the casein. In other cases it is found advisable to prevent the formation of curd and hasten its departure from the stomach. Cannon[69] claims that milk before it coagulates leaves the stomach quickly like water in gushes. Hence, if an alkali like limewater, bicarbonate or citrate of soda is added to the milk this coagulation will be checked and the digestion be facilitated.

Amount and Type of Alkali Used.—The amount of alkali[70] necessary to bring about any change in the general effect of the formula must be determined by the amount of milk and cream in the mixture, since these constituents alone determine the acid content. However, it is impossible to judge exactly the amount of alkali to add, but an approximate estimate is made from the work done by the various investigators. It has been estimated that from 25 to 50% of limewater must be added to milk to change it to any marked degree. In using bicarbonate of soda, a much less quantity brings about the desired result, 1½ grains of bicarbonate of soda being equal to one ounce of limewater. The action of these two alkalies is different. The soda acting upon the milk causes the curds to be more porous, and therefore more easily acted upon in digestion.

Sodium citrate likewise tends to prevent the formation of tough curds. It is added in amounts of 1 to 2 grains to each ounce of milk or cream in the mixture whenever it is found necessary to use it at all.

The addition of any alkali to the formula is resorted to if the symptoms indicate the need for it, but the type and quantity is entirely within the province of the physician, not the nurse.

The Addition of Sugar.—Lactose is the form in which the carbohydrates are found in milk, and it has been a general rule to employ this sugar in making up the sugar content of a formula, using from 6 to 7% of the mixture in this form to cover the necessary energy requirements of the infant. Other sugars are used, however; and of late years malt sugar has been widely employed for this purpose. The form now generally accepted is known as dextri-maltose, which is a combination of dextrin and maltose, both of which are readily acted upon by the sugar-splitting enzymes of the digestive juices. In digestion, lactose or milk sugar is split to dextrose and galactose and utilized in the body, both as a source of energy and as a food for the lactic acid bacteria which are active in the small intestine.

Malted Foods.—The addition of malted foods or malt sugar to the food of infants tends to bring about a more rapid gain, both in energy and in body weight, than is generally the case where other sugars are used. This sugar is used as a substitute for milk sugar in many formulas, especially in those cases in which the casein of cow’s milk needs to be made more digestible in form. Malt sugar is indicated in the following conditions:[71] (1) in severe atrophies, (2) in cases of fat indigestion before the atrophic stage is reached, (3) in cases where there is slight curd indigestion, indicated by some vomiting and slow gain in weight, (4) in cases where excessive intestinal fermentation is manifested by gas and colic.

Malt sugar (dextri-maltose) is contraindicated to a slight degree in cases “of simple acute diarrhea where lactose, by supplying fermentative media, more easily restores the normal bacterial balance.”

Diluents.—Barley and oatmeal water are used as diluents to the amount of one-fourth or more of the mixture. Oatmeal water or jelly is used more during the winter months than in the hot summer months. As the fat content of the oatmeal gives it a more laxative effect, it is undesirable to use it at the season in which the summer diarrheas are prevalent. Barley water has something of a colloidal action upon the casein, causing the curds to be finer and less tough in character. Both barley and oatmeal water are used in place of plain water for babies when this colloidal effect upon the curd of the milk is desired, also where the weight of the infant shows a disposition to remain stationary, especially where there are no other symptoms to account for the lack of gain.