INFANT FEEDING
In taking up this part of our study on nutrition, there are several
points to be kept in mind by the nurse: (1) that it will be difficult,
if not impossible, to understand the metabolic changes taking place in
abnormal conditions unless those occurring in the normal human body
are understood; (2) that certain diseases are due directly to errors
in diet; (3) that in other diseases, diet plays the chief part both in
the bringing about and in the relieving of the conditions; (4) whereas
there are certain other diseases not affected by diet, save in so far
as well or poorly selected and prepared food always affects the
individual, whether normal or abnormal, and that in the latter
conditions the organism is more susceptible to bad influences.
This being the case it behooves the nurse to examine herself to find
whether or not she understands the fundamental principles underlying
the nutrition of the human body, that she may efficiently deal with
the changes which occur more or less when the body is attacked by
disease.
We include normal infant feeding in this section, because in no other
age is it quite so necessary for care to be observed in formulating
and carrying out a diet. Errors during this period may only appear to
exert a local influence, causing disturbance which may readily be
relieved, but the danger is in laying too little stress upon these
disturbances, forgetting that the delicate organism of a child may be
permanently injured by a constant disregard of nature's mandates. In
the words of the old adage, the pitcher may go once too often to the
well, and an injured digestive apparatus is even more difficult to
mend than the proverbial pitcher.
In this section, then, the metabolic changes due to pathological
conditions and the dietetic treatment thereof will be discussed.
~Age and Weight.~--As has already been stated, there are certain
points to be kept in mind in attempting to provide an adequate diet
for the human machine; _First_, the _age_ and _weight_. The gain
during infancy should be steady--an allowance of 40 calories per pound
of body weight to cover the energy requirements and 4 protein calories
per pound to cover the nitrogen needs. During the second and third
years the energy requirements will be covered by 30 to 40 calories per
pound and the nitrogen needs by 3 to 4 protein calories per pound.
From the fifth to the eighth year the nitrogen needs continue to be
covered by 3 to 4 protein calories per pound and the energy
requirements by 35 to 37 calories per pound during the fifth year; 32
to 34 calories per pound during the seventh year. After the body has
reached its full development its requirements will be met if
sufficient protein is provided to cover its maintenance needs and if
the energy calories are regulated according to the amount of exercise
taken, keeping in mind that the energy requirements of a man at rest
(sitting) will be about 2,000 calories per day and that exercise,
especially that taken in the open air, raises the energy needs of the
body.
~Daily Gain.~--In estimating the relative daily gain in body weight of
children of different ages, Mendel[64] gives the following table:
TABLE
In the first month, about 1.00 per cent
At the middle of the first year 0.30 per cent
At the end of the first year 0.15 per cent
At fifth year 0.03 per cent
Maximum in later years for boys 0.07 per cent
Maximum in later years for girls 0.04 per cent
~Retention of Nitrogen in Infancy.~--When the baby is gaining in
weight and strength there is a retention of both nitrogen and salts,
and when the baby is not gaining there may be a loss of both of these
bodies; when one is retained in the body the other is apt to be
retained.[65]
NORMAL INFANT FEEDING
Much has been written in the past few years on the care and feeding of
infants and children. This is well, since statistics show an alarming
increase in the rate of infant mortality during the early years of
life, and anything which can be done to check this lamentable and
often avoidable waste of valuable life should be resorted to with care
and attention.
~Food for Infants.~--The natural food of all young mammals is the milk
of their own mother. The rate of growth and development differs in
every species; the calf, for example, doubles birth weight much more
quickly than does the baby of the same age. However, the milk of the
cow, which meets the needs of the calf perfectly, falls short of
meeting the requirements of the infant, whose rate of growth is not
nearly so rapid. For this reason if for no other, it would be
advisable to give the baby its natural food rather than to attempt a
substitute which is, at best, a poor one.
~Weight.~--The average infant weighs from six to seven pounds at
birth. This weight should be doubled in the first five or six months
of life and tripled by the end of the first year. The most important
business, then, in the life of the child during the early years is
growth and development. To achieve this properly the baby's habits
must be adjusted to his needs.
~Regularity in Feeding.~--He must have the proper food and enough of
it, and have it given at regular intervals, "by the clock," for
guesswork is fatal in infant feeding. He must be given water between
meals. Babies often cry from thirst when they are thought to be doing
so from hunger or temper, or both. The healthy baby sleeps about
twenty-two hours out of twenty-four during the early months, and even
during the latter six months of the first year more time is spent in
sleeping than in waking.
~The Bowels.~--The bowels should move several times a day, the stools
being smooth and of a yellowish color, of the consistency of pea soup.
After the first month, twice a day is about the normal number of
stools for the healthy baby. The infant should be placed upon a vessel
held in the lap of the nurse at regular times, preferably right before
the morning bath, and in the evening. In this way regularity in
evacuating the bowels is obtained, and a habit formed which will prove
valuable through life.
~The Bath.~--The daily bath is likewise necessary for the health and
comfort of all babies; so, too, are fresh air and sunshine.
As has already been stated, breast milk is much better for babies than
cow's milk or any artificial food. There is something in the mother's
milk which gives strength and resistance to the baby which is
absolutely lacking in any other food no matter how carefully it is
selected and prepared, and for this reason young mothers must be
prevailed upon to nurse their babies whenever it is possible for them
to do so. When circumstances, such as having to be away all day at
work, make it impossible for a mother to nurse her baby at regular
intervals, she can be taught how necessary are two or three breast
feedings a day to the future welfare of her child. When social reasons
or lack of desire on the part of the mother make her unwilling to
nurse her baby, it is the part of the nurse to lay the case before her
and let her judge whether or not she is willing to accept the
responsibility of bringing into the world a life for which she is
unwilling to provide weapons with which to fight the good fight.
~Habits of Mother.~--The mother must be taught how to efficiently
nurse her baby; she must keep in mind that upon her good health and
temperate habits depend the health and comfort of her baby. It
devolves upon her to provide food efficient in quality and quantity.
To do this, her own diet must be simple and wholesome. The nursing
mother must remember that she has to provide, not only for her own
maintenance and energy requirements, but also for the infant whose
fuel requirements are ever demanding more food to provide for its
rapid growth.
~Food and Its Relation to Milk.~--It is believed that two calories of
food extra are necessary to produce one calorie of milk, and since a
month-old baby requires 2-1/3 ounces of mother's milk to every pound
of his body weight, and one ounce of mother's milk will yield 20
calories, it is clearly seen that the mother will have to increase her
diet to cover the requirements of the baby. For example, if the baby
weighed 12 pounds, he would require 28 ounces of milk in 24 hours, or
560 calories. Thus if it requires two calories of extra food to make
one calorie of milk, the mother's diet would have to provide 1,120
calories extra, or about as much food as would fulfill the needs of a
laboring man, 3,000 to 3,500 calories, even if she were doing
practically no actual work; while if she were actively employed and
doing a certain amount of physical labor, her rations would have to
approximate those of a man doing heavy muscular work (about 3,500 to
4,000 calories per day).[66]
~Breast Milk versus Cow's Milk.~--Consensus of opinion shows that
breast-fed infants require less energy than the ones who must be
nourished artificially. This is probably due largely to the fact that
the constituents of human milk are in a more available form than those
in cow's milk, the former requiring a lesser expenditure of energy on
the part of the organism to become available than the latter. Very
active babies, ones who kick and throw themselves about or cry
violently, have a greater energy requirement than the more placid baby
who sleeps more and is more quiet in movement and who cries less when
awake. Breast-fed babies are generally more quiet than their less
fortunate artificially fed brothers. It has been demonstrated that the
artificially fed baby has a much harder fight for existence than the
baby who receives his natural food; hence the necessity of using every
available means to make the food digestible, and to lessen the danger
arising from the additional work put upon the entire apparatus. Cow's
milk contains practically the same chemical elements as are found in
human milk, but these elements are combined in a slightly different
manner, and are not so easily handled by the immature organs. The
proteins of milk consist of casein, which is insoluble, and albumen,
which is soluble. According to Van Slyke the proportion of insoluble
to soluble protein in cow's milk is 3.6:1, while in human milk the
proportion is only 1:1. The ash constituents in cow's milk are in
excess of the needs of the infant organism, but since a great part of
these salts is in an inorganic form they are not retained to the same
extent as those contained in human milk, which are in an organic form.
~Rules and Regulations.~--It is not possible to lay down hard and fast
laws to cover the subject of infant feeding. The food must be adapted
to the individual needs of the baby in question. The nurse must see
that the milk is obtained from a responsible dealer, certified milk
being of course the safest. The bottles of milk should be wiped off
carefully and placed directly on the ice as soon as they are received.
The milk generally used in infant feeding has a fat content of 4%.
That having a higher percentage of fat is technically cream. The
following table showing the fat, sugar, and protein composition of
whole milk, cream, skimmed milk, and whey was arranged by Morse and
Talbot:[67]
TABLE
==========================+============+============+============
| _Fat_ |_Milk Sugar_| _Protein_
--------------------------+------------+------------+------------
Whole milk | 4.00 | 4.50 | 3.50
7% cream | 7.00 | 4.45 | 3.40
10% cream | 10.00 | 4.40 | 2.25
16% cream | 16.00 | 4.20 | 3.05
32% cream | 32.00 | 3.40 | 2.50
Skimmed milk | 1.00 | 5.00 | 3.55
Separated milk (fat-free) | 0.25 | 5.00 | 3.65
Whey | 0.25 | 5.00 | 0.90
==========================+============+============+============
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, 1-1/2 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.
Whey is used with babies who cannot digest the insoluble protein of
cow's milk. This is often the case in premature babies and is
manifested by a persistent vomiting of curd. The energy requirements
are obtained by the addition of cream and lactose to the whey.
~Buttermilk Mixtures and "Eiweissmilch."~--It is often found desirable
to use some other form of milk than whole, top, or even skimmed milk,
and for this purpose lactic acid, milk and the albumen or
"Eiweissmilch" are substituted. In the buttermilk mixtures the
precipitation of the casein is brought about by lactic acid bacilli
(Bulgarian culture). This prevents the coagulation of the casein into
tough curds. Lactose buttermilk or lactic acid milk is used in the
feeding of infants who have persistent green stools, and in cases of
acute toxic diarrhea brought about through the action of gas bacillus.
Buttermilk is more difficult to administer to babies than formulas
made from plain milk by reason of its flavor. However, the results are
remarkable in the above-mentioned conditions.
~"Eiweissmilch"~ is used in atrophic cases where there are bad green
stools.
~"Homogenized Milk."~--Dr. Ladd of the Children's Hospital in Boston
has presented many cases of infants who showed an intolerance for
butter fat. These cases he has treated with formulas containing
foreign fat, usually olive oil. This milk is subjected to a treatment
which brings about a more complete emulsification of the fat than is
possible in cow's milk, causing it to resemble in character the
quality of the mother's milk. Homogenized milk has been used with
success in cases where it was impossible to supply the infant with
breast milk.
The process is accomplished by the use of an apparatus known as an
"homogenizer"[72]; in this machine the fat globule is crushed and so
finely divided as to prevent its re-formation. The greatest drawback
to the use of this process lies in the scarcity of available machines.
Cod liver oil is now used in many cases where the infant shows a
failure to gain or is in possible danger of developing rickets, with
the homogenizer it is possible to add the oil to the formula, thus
facilitating its use.
~Technique of Milk Modification.~--The absolute necessity for
cleanliness has already been dwelt upon in respect to milk, and in
infant feeding the vigilance which must be observed in the preparation
of the food cannot be too strongly emphasized. The milk itself must be
of known purity. Where there is any uncertainty about its source, it
must be sterilized or pasteurized according to the doctor's orders.
The bottles and nipples should be washed as soon as they are used,
first with plain water to remove the milk, then with soapsuds and a
bottle brush. The bottles should then be filled with boric acid or
bicarbonate of soda solution until needed, when they should be emptied
and placed in a deep pan filled with cold water and allowed to boil
for a few minutes. They should not be taken from the water until they
are to be filled with the milk mixture. The nipples are washed
thoroughly and boiled once a day and dropped into a solution of boric
acid or bicarbonate of soda when not in use. The plain black rubber
nipples are best as they can easily be turned inside out and cleaned.
If the milk drops too slowly from the bottle, the nipple may be
pierced in one or two places with a darning needle.
The morning is the best time in which to prepare the baby's food; the
milk has not stood too long and it is easier to regulate the feedings
if a fresh start is made each morning. Let the bottles and the rubber
corks with which they must be stopped be boiled and cooled while the
milk mixture is being prepared.
~Preparation of Diluents.~--If barley or oatmeal water is to be used
as a diluent, let that be prepared first, that it may be cool before
adding it to the milk. Cover the table with a clean cloth or oilcloth,
upon this place the pitcher in which the milk is to be modified, have
the funnel, milk dipper, and spoon which are to be used boiled with
the bottles, cover the mouth of the pitcher with a clean square of
gauze or cheesecloth, read the formula carefully and measure the
sugar, dextri-maltose, lactose, Mellin's Food, or cane sugar as
directed and place it in a clean glass; now measure the diluent,
water, oatmeal water, barley water, or whey; use part of this diluent
to dissolve the sugar.
~Measuring Milk according to Percentage of Fat.~--Now dip off the
required layer of top milk, that is, the layer containing the desired
percentage of fat and protein. Mix this thoroughly and dip out the
requisite number of ounces into the pitcher. If there is not
sufficient cream in one quart bottle to fill the formula, the cream
must be dipped from a second bottle and mixed with that of the first
before it is measured into the pitcher. The dissolved sugar and rest
of the diluent, together with the correct amount of limewater, are
strained into the pitcher, mixed thoroughly, and strained through the
absorbent cotton lining the funnel into the bottles, allowing the
correct number of ounces for each feeding in every bottle.
~Pasteurizing the Milk.~--The corks are then adjusted, the bottles
placed in the pasteurizer[73] and pasteurized for the desired number
of minutes. The water in the pasteurizer must be cold in the beginning
and the rise of temperature recorded on the thermometer, which is
adjusted at a convenient place in the pasteurizer where the scale can
be read easily. If the temperature of the water is too high, add cold
water and lower the flame beneath the pasteurizer. When the desired
number of minutes has elapsed, lift the bottle rack above the water
for a few minutes and allow a stream of cold water to flow into the
pasteurizer, taking care not to chill the bottles too suddenly or they
will crack. Cool the bottles as quickly as possible and place on ice
until needed, warming the bottle of milk as needed in warm water.
~Amount Given at Each Feeding.~--At birth a baby will usually take
from one half to one ounce at each feeding, this amount is increased
at the rate of a quarter of an ounce each week until the baby is
receiving eight ounces at each feeding. Or the food is measured to
allow of from one ounce to an ounce and a half more than the child's
age in months. For example a baby six months old would receive from
seven to seven and a half ounces at each feeding. Some babies are
bigger and stronger than others and require the maximum amount, while
others are less vigorous and the amount of food which they can handle
at a feeding may fall slightly short of the above amounts, but the
quantities indicated above will serve as a guide in measuring the
formula.
~Method of Calculation of Formula.~--The calculation of a formula
consists in determining the amount (in grams or ounces), of the
various constituents contained in the formula when the percentage of
each is known. Or, in determining its percentage composition when the
amount of fat, protein, carbohydrate and diluent is given. There are
certain inaccuracies in all simple methods of calculation and the use
of the Babcock tester to determine the fat content in the milk to be
used, is advised in all milk or formula rooms. The following method of
calculation has been found satisfactory, and the nurse must master it
in order to intelligently carry out the directions of the pediatrist.
~Determining the Composition of Formula.~[74]--Gravity cream and
skimmed milk are used in this method, the cream is estimated as
containing 16% fat, and consists of the entire cream layer from a
quart bottle of milk which has been allowed to stand without being
disturbed for six hours or longer. The cream must be dipped off with a
cream dipper, or poured off. If there is not a sufficient number of
ounces in one bottle of milk, a second must be used, the entire cream
layer taken, then mixed with that obtained from first bottle, before
the required number of ounces are measured off. Skimmed milk is
estimated as being fat-free (although this is not entirely accurate).
Both gravity cream and skimmed milk are estimated as containing 3.2%
protein, and 4.5% sugar. In this method, one rounded tablespoonful of
milk sugar is estimated as weighing one half ounce (dextri-maltose may
be estimated in the same way). With this brief explanation of the
terms used we will proceed with the method itself.
It is always essential before beginning the calculation of the
formula, to know what percentages of fat, sugar, and protein it is to
contain, and the amount to be given in twenty-four hours; it is also
necessary to know how much lime water is to be added if this substance
is to form a part of the formula.
Suppose a thirty-two-ounce mixture is to be made containing 3% of fat,
6% of sugar, 2% of protein, and lime water sufficient to equal 25% of
the cream and skimmed milk in the mixture. The fat in the food must be
derived from cream, since it is the only substance containing fat to
be used in the formula. If the food was composed entirely of gravity
cream it would contain 16% of fat. Since it is to contain but 3% of
fat it is evident that only 3/16 of the mixture must be gravity cream,
3/16 of thirty-two ounces is six ounces. Six ounces of gravity cream
will, therefore, provide the 3% of fat desired in the mixture. The
gravity cream contains protein as well as fat. There are six ounces of
gravity cream in the thirty-two-ounce mixture. The protein content of
gravity cream is 3.2%. The protein content of a thirty-two-ounce
mixture containing six ounces of gravity cream is evidently 6/32 of
3.2% or 0.60%. Two per cent protein is, however, desired in the
mixture. The gravity cream has provided only 0.60%. One and forty
hundredths per cent of protein, the difference between the percentage
of protein desired and that furnished by the gravity cream, must be
obtained in some other way. It must be obtained, moreover, from some
substance which does not contain fat. Skimmed milk is such a
substance. Skimmed milk contains 3.2% protein. In order to get 1.40
per cent in the mixture by the use of skimmed milk, it is evident
that 140/320 of the mixture must be skimmed milk. 140/320 of
thirty-two ounces is fourteen ounces. Fourteen ounces of skimmed milk
will, therefore, provide the additional 1.40% of protein desired.
Both gravity cream and skimmed milk contain 4.50% milk sugar. Twenty
ounces of gravity and skimmed milk are required to furnish the desired
percentages of fat and protein. These twenty ounces in a
thirty-two-ounce mixture must add 20/32 or 4.50% of sugar to the
mixture. Twenty thirty-seconds of 4-1/2 or 20/32 of 9/2 = 180/64, or
practically 3% of milk sugar. It is, however, desired to have 6% of
milk sugar in the mixture. That is, 3% more of milk sugar is required.
This additional sugar must be added in the form of dry milk sugar.
Three per cent of thirty-two ounces is 3/100 of thirty-two. This will
give the amount of sugar desired in ounces. The sugar is to be
measured in rounded tablespoonfuls, or half ounces. If the figures
given above are multiplied by two, the result will be the number of
rounded tablespoonfuls needed. That is, 3/100 of 32 x 2 = 192/100
rounded tablespoonfuls, or for all practical purposes, two rounded
tablespoonfuls.
It is also desired to have the amount of lime water in the mixture
equal to 25% of the cream and milk in the mixture. There are twenty
ounces of cream and milk in the mixture. Twenty-five per cent of
twenty ounces is five ounces. Five ounces of lime water must therefore
be added. The total quantity of the mixture is to be thirty-two
ounces. The milk sugar goes into solution and, therefore, does not add
to this quantity. The difference between thirty-two and twenty-five
ounces is seven ounces. Seven ounces of water must, therefore, be
added to make up the quantity desired.
~Changing the Formula.~--It is often found necessary to change the
formula when using artificial feeding for infants, and under these
circumstances it is necessary to know the percentages of the food
constituents contained in the formula already in use. For this purpose
the following method, quoted from "Diseases of Nutrition and Infant
Feeding,"[75] is included:
~Morse and Talbot's Method.~--Suppose that a baby is taking a food
made up of--
Gravity cream 12 ounces
Skimmed milk 18 ounces
Limewater 6 ounces
Barley water 12 ounces
Milk sugar 4 rounded tablespoonfuls
"The barley water is made with two teaspoonfuls of barley flour in a
pint of water. The total quantity of the mixture is 48 ounces. Gravity
cream contains 16% fat. Twelve ounces of gravity cream in a 48-ounce
mixture will give, therefore, 12/48 of 16% of fat, or 4% fat. Both
gravity cream and skimmed milk contain 3.20% protein. There are 30
ounces of gravity cream and skimmed milk in the mixture; 30 ounces in
a 48-ounce mixture will give 30/48 of 3.20% of protein, or 2.00% of
protein. Both gravity cream and skimmed milk also contain 4.50% of
sugar. Thirty ounces of gravity cream and skimmed milk in a 48-ounce
mixture will therefore furnish 30/48 of 4-1/2 which is the same as
30/48 of 9/2 or almost 3.00% of milk sugar. Four rounded
tablespoonfuls of milk sugar are equal to two ounces. Two ounces of
sugar in a 48-ounce mixture is equal to 2/48 of 100% or 4%. The total
percentage of sugar is, therefore, 7%. Two teaspoonfuls of barley
flour in a pint of water makes a 1.50% decoction of starch. Twelve
ounces of barley water of this strength in a 48-ounce mixture will
give 12/48 of 1.50% or about 0.35% starch. There are six ounces of
limewater in the mixture and 30 ounces of gravity cream and skimmed
milk. 6/30 of 100% is 20%. The limewater is, therefore, 20% of the
milk and cream. The mixture thus contains 4% fat, 7% sugar, 2%
protein, and 0.35% starch, while the limewater is in the proportion of
20% of the cream and milk."
If, therefore, the nurse will follow out the plan suggested by Drs.
Morse and Talbot, it should be a simple matter to change the
percentage of any of the food constituents in any formula.
The following schemes for feeding well babies are included to
facilitate the work in the home. A nurse may teach the mother the
manner in which these schemes are used, keeping in mind that there can
be no iron clad rule for feeding all babies. No nurse should recommend
a formula without directions from a physician. And no formula should
be changed without his permission.
The following milk formulas are used in the Nathan Straus Pasteurized
Milk Laboratories of New York:
~Formula No. 1.~--Infants from 1st to 4th week, by A. R. Green.
24 ounces of mixture divided into 8 feedings of three ounces each, fed
at intervals of 2-1/2 hours:
3/4 oz. 16% cream
3 oz. full milk
19 oz. water
1-1/4 oz. limewater
1-1/2 oz. milk sugar
~Formula No. 2.~--Infants 1st to 3d month, by Dr. R. G. Freeman.
1-1/2 oz. 16% cream
3 oz. full milk
13 oz. water
1/2 oz. limewater
1 oz. milk sugar
Divided into 6 feedings of 3 oz. each, fed 3 hours apart.
~Formula No. 3.~--Infants 2d to 6th month, by Dr. R. G. Freeman.
18 oz. full milk
16-1/2 oz. water
1-1/2 oz. limewater
1-1/2 oz. milk sugar
Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.
~Formula No. 4.~--Infants 3d to 7th month, by Dr. A. Jacobi.
18 oz. full milk
18 oz. barley water
1 oz. cane sugar
20 grains salt (less than 1/4 tsp.)
Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.
~Formula No. 5.~--Infants 7th to 9th month, by Dr. A. Jacobi.
2-1/2 oz. full milk
7-1/2 oz. oat or barley water
1-1/2 oz. cane sugar
30 grains (about 1/4 tsp.) table salt
Divided into 5 feedings of 6 ounces each, fed at intervals of 3-1/2
hours.
SCHEME FOR FEEDING NORMAL INFANTS
(First Year)
Scheme based on Holt and Shaw's "Save the Babies." Pub. by Am. Med.
Ass'n.
WHOLE MILK METHOD
-----------+----------+---------------+----------+-----------+---------
| | | |_Intervals_| _Number_
_Time_ | _Milk_ | _Water_ | _Sugar_ | _of_ | _of_
| _Ounces_ | _Ounces_ | | _Feeding_ |_Feedings_
-----------+----------+---------------+----------+-----------+---------
1st and 2d | | 1 to 3 tbs. | | |
days | | every 3-4 | | |
| | hours | | |
| | | | |
3d and 4th | | | | |
days | 3 | 7 | 2 tsp. | 3 | 7
| | | | |
5th and 7th| | | | |
days | 4 | 8 | 3 tsp. | 3 | 7
| | | | |
8th day | 5 | 10 |1-1/2 tbs.| 3 | 7
| | | | |
8th day to | Increase | Increase 1/2 | Increase | 3 | 7-6
end of 3d | 1/2 oz. | oz. every | 1/2 oz. | |
month | every 4 | 8 days | every 2 | |
| days | | weeks | |
| | | | |
End of 3d | | | | |
month | 16 | 16 |4-1/4 tbs.| 3 | 6
| | | | |
Beginning | Increase | Reduce 1/2 | 4 | 4 | 6-5
of 4th | 1/2 oz. | oz. every 2 | | |
month to | every 6 | weeks. (Cook | | |
end of 6th| days | barley in | | |
month | | water if food | | |
| | disagrees)[76]| | |
| | | | |
End of 6th | | | | |
month | 24 | 12 | 4 | 4 | 5
| | | | |
Beginning | Increase | Reduce 1/2 | 4 | 4 | 5
of 7th | 1/2 oz. | oz. every | | |
month to | every | 2 weeks | | |
end of 9th| week if | | | |
month | food is | | | |
| well | | | |
| digested | | | |
| and child| | | |
| seems | | | |
| hungry | | | |
| | | | |
End of 9th | 30 | 10 oz. (in | 2 tbsp. | 4 | 5
month | | which 3 tbs. | | |
| | of cereal is | | |
| | cooked) | | |
| | | | |
Beginning | Increase | Cereal gruel | Reduce 1 | 4-5 | 5-4
of 10th | 1 oz. | as above | tbs. per | |
month to | per month| | month | |
end of | | | | |
12th month| | | | |
-----------+----------+---------------+----------+-----------+----------
At the beginning of 7th or 8th month, or earlier if necessary, it is
advisable to add orange juice, giving from 1-2 tablespoonfuls between
the two morning feedings.[77]
After the 4th month it is well to eliminate the night feeding between
10 P.M. and 6 A.M.
At end of 11th month add 1-2 pieces of stale bread, toast or zwieback.
Part of soft-cooked egg may be given every other day at noon meal by
end of 11th month. The orange juice may be increased to 3 tbs. if
bowels are not loose.
The strained cereal should be given twice daily by the end of the
first year, and the milk should be undiluted at this time unless the
digestion of the infant forbids.
Cooled boiled water should be given several times each day between
feedings. Babies cry from thirst as well as from hunger.
SCHEME 2
FOR FEEDING WELL BABIES
Scheme based on Dr. Richard M. Smith's "The Baby's First Two Years."
A full-term baby will usually take a formula made as follows:
Cream 2 ounces
Skimmed milk 2 ounces
Boiled water 12 ounces
Sugar of milk 6 level tsp.
After 3d day increase cream and milk at the rate of 1 ounce each week,
and sugar 1 tsp. every other day until at one month the baby will be
receiving a formula such as--
Cream 5 ounces
Skimmed milk 5 ounces
Boiled water 22 ounces
Sugar of milk 3-1/2 level tbs.
At two months--
Cream 6 ounces
Skimmed milk 6 ounces
Boiled water 20 ounces
Sugar of milk 4 level tbs.
From this point the formula may be increased by adding 2 ounces of
skimmed milk each month until the baby is eight months old. For each
ounce of milk added, an equal amount of water should be omitted. The
sugar in the formula should be reduced one half tbs. every three
months.
At six months the baby would be taking--
Cream 6 ounces
Skimmed milk 14 ounces
Boiled water 12 ounces
Sugar of milk 3-1/2 level tbs.
At eight months--
Cream 6 ounces
Skimmed milk 18 ounces
Boiled water 8 ounces
Sugar of milk 3 level tbs.
This amount will not be found sufficient in quantity for a
twenty-four-hour mixture for children of this age. Increasing the
amount of the last formula in the same proportion, it will be--
Cream 9 ounces
Skimmed milk 27 ounces
Boiled water 12 ounces
Sugar of milk 4-1/2 level tbs.
At this age the formula usually may be changed so as to be made from
whole milk instead of cream and skimmed milk. The formula may be made
as follows:
Whole milk 36 ounces
Boiled water 12 ounces
Sugar of milk 4-1/2 level tbs.
From this point on the formula may be increased by replacing the
boiled water with whole milk, two ounces each month up to thirteen
months. At this age the boiled water may be omitted from the formula
one ounce each week. Beginning at the age of eight months the sugar
may be eliminated from the formula, one tablespoonful each month.
_Barley Water._--At the age of five months, or at any time thereafter,
barley water may be substituted for boiled water in the formula. This
should be substituted when the baby is not gaining in weight. It may
be substituted in many instances when the movements are not well
digested.
_Lime Water._--It is frequently found to be advisable to add lime
water. It is not necessary in every instance, but should be given if
the baby is inclined to spit up, or in cases where the stools are too
frequent in number and are slightly green in color.
* * * * *
~Determining the Fuel Value of a Formula.~--The computation of the
fuel value of a formula is very essential since the growth and
development of the infant depends largely upon whether or not its
energy expenditures are well covered. The method is simple, requiring
the same methods used in the computing of other dietaries. Take the
formula just calculated, its fuel value would be estimated as follows:
Thirty-two ounces are equal to 960 grams. In each 100 grams there
would be 3 grams of fat, 2 grams of protein and 6 grains of sugar.
Hence in 9.6 one-hundred-calorie portions there would be 9.6 x 3--28.8
grams of fat, 9.6 x 2--19.2 grams of protein, and 9.6 x 6--57.6 grams
of sugar, in a thirty-two-ounce mixture.
To determine the fuel value of the formula, these results must be
multiplied by their physiological fuel factors, 9 and 4 and 4
respectively. Thus:
29 x 9 = 261 calories from fat
19 x 4 = 76 calories from protein
58 x 4 = 232 calories from sugar, or a total of
----
569 calories for the entire mixture.
~Scheme for Adding Solids to Infants' Diet.~--
From 9th to 15th month:
6 A.M.--Milk formula (bottle).
8 A.M.--Orange juice 1/2 ounce, or prune pulp or prune
juice.
10 A.M.--Bottle, cereal (strained) and bread and butter
or zwieback.
2 P.M.--Mutton, chicken, or veal soup cooked with
cereal; small portion of baked potato, small portion
of strained spinach or carrots; orange gelatin or
cornstarch pudding.
6 P.M.--Bottle.
From 15 months to 2-1/2 years:
8 A.M.--Stewed fruit or orange juice; cereal, crisp
bacon, alternated with soft-cooked or poached egg;
bread and butter or toast, milk or weak cocoa.
12 or 1 P.M.--Meat or vegetable soup thickened with cereal;
lamb chop, scraped beef or chicken or beef juice; baked
or mashed potato; strained spinach; carrots; turnips or
celery; gelatin, custard, or cornstarch pudding.
3 P.M.--Crackers and milk.
6 or 7 P.M.--Bread and milk or cereal; baked apple or apple
sauce.
From 3 to 6 years:
8 A.M.--Stewed fruit or orange; cereal; bacon or egg
(soft-cooked or poached); bread and butter; milk or
cocoa.
12 or 1 P.M.--Soup; lamb chop, scraped beef, chicken, or roast
meats; potato; all vegetables; celery, lettuce; light
desserts: custards, gelatin, lady fingers.
3 P.M.--Milk; fruit and crackers.
6 P.M.--Milk or cocoa; stewed fruit; bread and butter;
cereals; eggs.
VEGETABLE SOUP
1/4 lb. beef, lamb or chicken
1 potato
1 carrot
2 stalks celery
1 tablespoonful pearl barley
2 tablespoonfuls rice
2 qts. water
1 pinch salt
Finely divide the vegetables. Add the vegetables, barley and rice to 2
qts. of water. Boil down to 1 qt., cooking 3 hours. Add pinch of salt.
Pass through fine sieve.
Morse and Talbot advise baked potato, plain boiled macaroni, rice and
wheat germ, bread and butter, baked custard, plain blanc-mange, and
plain boiled tapioca to be given when the child is 1-1/2 years old.
When the child is nearly two years old they add meat in the most
digestible forms, such as the white meat of chicken, lamb or mutton
chops, and scraped beef.
The following dietary is suggested for a child two years old:[78]
"Whole milk, butter, mutton broth, chicken broth, beef juice,
soft-cooked eggs, dropped eggs, white meat of chicken, lamb or mutton
chops, scraped beef, French bread, stale bread, toasted bread, whole
wheat bread, milk toast, zwieback, plain white crackers, plain
Educator crackers, barley, jelly, oatmeal, cream of wheat, wheat germ,
Ralston's Farina, rice, baked potato, plain boiled macaroni, orange
juice, baked apples, stewed prune pulp and juice, junket, baked
custard, cornstarch pudding, plain blanc-mange, plain tapioca. It is
not advisable, as a rule, to begin green vegetables until the baby is
2-1/2 years old."
It will be seen in the foregoing dietaries how authorities differ in
their beliefs as to the requirements of the child. The dietaries
included in this text are selected from those used in different parts
of the country by physicians who have successfully cared for the
infants and children under their charge.
THE FEEDING OF PREMATURE INFANTS
The digestion of premature infants is naturally not as strong as that
of infants born at term. Very little is positively known, but the
consensus of opinion goes to show that in the majority of cases the
tolerance for sugar is greater than that of either the proteins or
fats. The loss of heat is relatively greater in proportion to its
surface area in small than in large bodies. This is a well-known fact,
hence the premature baby must require more food in proportion to its
weight than the baby who is born at the normal time. Then, too, as the
premature infant is thinner he does not keep warm like the older
infant, and this must be taken into consideration in feeding him.
Breast milk is of course by far the best food for such babies, not
only because its constituents are in a more available form for the
feeble digestive organs, but because the mother's milk furnishes a
resistance which is lacking in even the most carefully modified of
milk formulas.
~Energy Requirements of Premature Infants.~--Experiments made upon
premature infants have proved that the caloric needs of these babies
are greater than in the case of full-time babies; that is, they
require more per kilogram of body weight. According to Morse,[79]
"most premature babies need 120 calories per kilogram of body weight.
But there are many exceptions, some thriving on as little as 70
calories per kilogram. No attempt should be made to reach 120 calories
per kilogram during the first few days. Thirty calories per kilogram
is as much as is wise to give in the first 24 hours of feeding. This
amount should be gradually increased each day, watching carefully for
symptoms of indigestion and diminishing it if these appear. One
hundred and twenty calories per kilogram can be given in about 10
days."[80]
~Necessary Dilution.~--Even breast milk must be diluted with an equal
amount of water or a 3% sugar solution. The amount of milk should be
increased and the amount of dilution decreased until the undiluted
breast milk is given in four or five days. Like older babies, the next
best food for premature babies is the properly modified cow's milk,
but the utmost care will have to be observed, as these babies are more
easily upset than older and stronger ones.
~Premature Infant Feeding.~--The following method of feeding may be
suggested, keeping in mind that it is an easy matter to increase the
strength of a mixture if the baby shows the need of such an increase.
The premature baby is rarely strong enough to take the breast.
~Method of Administering Milk.~--The most satisfactory method of
administering the food in such cases is by means of the Brick feeder,
which consists of a graduated glass tube, open at either end. On the
small end is placed a small nipple like those seen on medicine
droppers; this one is perforated and goes into the mouth of the baby.
A large rubber finger cot is attached to the other end of the tube.
The milk is forced into the mouth by pressing the finger cot. In case
the infant is too feeble even for this method of feeding, the desired
amount is dropped into the mouth from a medicine dropper; 5 c.c.
(about 1 dram or 1 teaspoonful) of diluted milk being given at each
feeding. This amount is increased gradually from day to day.
~Whey Mixtures.~--Whey mixtures have been found to meet the needs of
premature infants more efficiently than ordinary mixtures. As the
proteins in whey are in a more digestible form, they throw less work
on the immature digestive apparatus. As a rule the casein and whey
are in proportion of 1:1.
The following formulas[81] show the amounts in which the food
constituents are combined and are suitable for premature babies:
Fat 1.00%
Milk sugar 4.00%
Total proteins 0.25%
Lime water 25% of cream and milk mixture
or
Fat 1.00%
Milk sugar 4.50%
Total proteins 0.50%
Lime water 25% of cream and milk mixture
PROPRIETARY FOODS
A word as to the use of Proprietary Infant Foods: These prepared foods
may be classified under four heads, as follows: (1) condensed milks;
(2) malted foods, those consisting chiefly of carbohydrates in the
form of maltose and dextrins; (3) those consisting almost entirely of
starch, and (4) those composed partly of soluble and partly of
insoluble carbohydrates.
(1) Condensed milk may be sweetened or unsweetened. These milks are
never given undiluted, the directions calling for one part condensed
milk to nine parts water, which gives a mixture containing 0.90% fat,
5.49% sugar, and 0.80% protein if "Eagle Brand" Condensed Milk is
used.[82]
(2) Malted Foods: Mellin's Food and malted milk are examples of this
group. These foods contain the carbohydrates in soluble form and when
added to milk make an acceptable addition, as they furnish the
carbohydrates in the most digestible form. When fed alone, diluted
only with water, they result in a mixture deficient in both fat and
protein.
(3) Imperial Granum is an example of this group, and there are several
others with similar compositions. These foods are very much like wheat
flour which has been subjected to heat, changing to a small extent the
starch to dextrose and dextrin.
(4) Nestle's Food, Eskay's Albumenized Food, and Allenbury's Food are
examples of this group, each containing sugar and a percentage of
starch. Upon dilution with water, the amount of fat in the mixture is
just a trace.
~Incomplete Foods as a Source of Danger.~--The ease with which the
majority of these foods are prepared and the way in which they agree
with the baby constitute the chief danger of their use. If they are
added to milk, with the exception of the condensed milk, they result
in a modified milk containing the carbohydrates in a more or less
digested form. But they are expensive, and give no better result as a
rule than a carefully modified milk containing a cereal gruel.
The giving of foods like malted milk alone is dangerous because they
are deficient in some of the most necessary constituents, and babies
fed in this way, while growing fat, are apt to have soft or brittle
bones and muscular tissue higher in fat and water than in protein, so
that they do not grow and develop in a normal way, and when they are
attacked by the diseases so prevalent in the early years of life, they
succumb rapidly, because the resistance given by a properly modified
food is lacking.
Condensed milks act in a like manner. That is, in the sweetened milks
the carbohydrate content is far in excess of the needs, and the
proteins and fats are deficient, so that while the baby fattens he
does not receive the building foods commensurate with his body
requirements.[83]
Many mothers adopt the use of these foods because they mean less work
than in modifying the milk properly, but the nurse should point out
the facts just mentioned, explaining that while these proprietary
infant foods are undoubtedly valuable at times to fill a place when
the milk formula has not proved satisfactory, the use of these foods
as a regular custom is expensive, not only from a financial standpoint
but from a standpoint of health, since their disadvantages far
outweigh their advantages in the long run.
SUMMARY
~Breast Milk as a Food.~--The superiority of breast milk over any
other known food cannot be too strongly emphasized.
~Regularity in Feeding.~--The absolute need for regularity in
feeding--"feeding by the clock" and not by guess or when the baby
cries.
~Indications of Health.~--The normal growth and development to be used
as guides as to the physical well-being of the infant; also as an
indication of the use of the proper modification of milk for the
individual needs of the child.
~Dilution.~--The amount of dilution necessary--cereal waters, whey,
etc.--to increase the digestibility and nutrient values of the
formula.
~The Addition of Alkali.~--The addition of alkalies to milk formulas
to accomplish a like purpose.
~Milk Sugar, Malt Sugar, Cane Sugar.~--The use of the different
sugars, namely, dextri-maltose, lactose, or cane sugar under various
circumstances as the condition of the infant demands.
~Substitutes for Whole Milk.~--The substitution of different milk,
such as lactic acid milk, Bulgarian culture buttermilk, Eiweissmilch,
cream and whey mixtures, as the individual needs of the infant demand.
~Technique of Milk Modifications.~--The absolute need for the nurse
to understand the technique of milk modification before attempting the
care of an artificially fed infant.
~Percentage Computation.~--A knowledge of percentage, that an accurate
computation of a formula may be accomplished.
~Preparation of Food.~--A sufficient knowledge of food preparation to
enable the nurse to prepare any food which may be deemed necessary by
the physician for the welfare of the child.
~Water.~--The importance of giving the baby water aside from that used
in modifying the milk. Many babies cry from thirst when they are
believed to be crying from hunger or temper.
~Increasing the Diet.~--The necessity for increasing the amount and
strength of the formula with the age, growth, and development of the
child by the addition of solid food as soon as the physician deems it
advisable.
~Feeding Premature Infants.~--The method of feeding a premature infant
differs from that employed in feeding an infant born at term: (a)
because its development has not progressed so far; (b) because its
digestive apparatus being more or less immature, food handled with
ease by an older baby will be totally unfit for the premature one,
both as to quality and quantity.
~Wet Nurse.~--The advisability of procuring a wet nurse when the
mother is unable to nurse the infant, (a) on account of the more
digestible character of the food constituents, especially the
proteins, in mother's milk over those of cow's milk; (b) on account of
the resistance furnished by the natural food which has been proved to
be very much greater than that furnished by any other food, no matter
how carefully the modification of the milk is made.
~Premature Infants.~--Their caloric needs are greater than in
full-term babies, hence their food must be adjusted to meet these
needs.
In fact the nurse must have an understanding of the behavior of foods
in the metabolism of infancy and the laws which govern their use in
the organism of the child.
PROBLEMS
(a) Write a formula for a two months' old infant weighing twelve
pounds, which contains 3% fat, 2% protein, and 6% sugar.
(b) Change this formula so that it will contain 3% fat, 1.5% protein,
and 6% sugar.
(c) Write a formula for an eight months' old baby, using whole milk
instead of cream and skimmed milk.
(d) Write a formula for a premature baby containing 1% fat, 4% sugar,
and 0.25% protein (allowing 30 calories per pound of body weight).
FOOTNOTES:
[64] "Childhood and Growth," p. 18, by Lafayette Mendel.
[65] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.
[66] "Feeding the Family," by Mary Swartz Rose.
[67] "Diseases of Nutrition and Infant Feeding," p. 218, by Morse and
Talbot.
[68] "Generally Accepted Methods for Artificial Feeding of Infants
with Indicatives and Contra-Indicatives," by Orville R. Chadwell, M.D.
Reprinted from "New England Medical Gazette," June, 1916.
[69] "Mechanical Factors of Digestion," by Cannon.
[70] "Diseases of Nutrition and Infant Feeding," p. 204, by Morse and
Talbot.
[71] "New England Medical Gazette," June, 1916. Reprint by Orville
Chadwell.
[72] The best substitute for the homogenizer is found in an electric
mixer; a formula prepared with a fat other than cream can be made by
means of this mixer to approximate very closely that of homogenized
milk.
[73] There are a number of pasteurizers on the market; one sold by the
Walker Gordon Laboratory and one designed by Dr. R. G. Freeman of New
York are both satisfactory.
[74] Method suggested by Morse and Talbot, "Diseases of Nutrition and
Infant Feeding," pp. 234-235.
[75] "Diseases of Nutrition and Infant Feeding," pp. 225 and 226, by
Morse and Talbot.
[76] One-half tbs. barley flour may be cooked in the water used as
diluent; it should be boiled 20 minutes, strained and cooled before
adding to formula.
[77] When babies are fed upon pasteurized, sterilized, or dried milk
it is advisable to use orange or prune juice earlier than the seventh
month. Dr. Hess suggests the use of canned tomato juice as substitute
for orange juice.
[78] "Diseases of Nutrition and Infant Feeding," p. 236, by Morse and
Talbot.
[79] Morse: "American Journal of Obstetrics," 1905. Hess: "American
Journal Diseases of Children," 1911.
[80] "Diseases of Nutrition and Infant Feeding," p. 238, by Morse and
Talbot.
[81] "Diseases of Nutrition and Infant Feeding," p. 239, by Morse and
Talbot.
[82] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.
[83] The proprietary foods on the market are many, but those given
above as suggested by Morse and Talbot represent the best known infant
foods.