INFANT FEEDING
A well fed infant is a happy little animal, who sleeps approximately
twenty-two hours a day, and gains from four to six ounces a week. If
properly fed at the breast, this condition is easily obtained; but if
artificial food is necessary, the resources and skill of the attendants
may be tried to the utmost before the welcome result is brought about.
The feeding of infants may be considered under three heads, (1) the
breast; (2) breast and bottle combined (mixed feeding); and (3)
artificial, which is really modified cow’s milk.
Breast feeding has been taken up elsewhere, but the same care should be
taken in feeding from the bottle as in feeding from the breast, so far
as concerns the intervals between the feedings and the duration of the
same. Since it takes from one to two hours longer for cow’s milk to
digest than it does for mother’s milk the longer interval of three or
four hours between feedings is better for the artificially fed child.
With such an interval there will be less vomiting, less colic, less
tendency to overfeed, and a better natured baby.
One feeding should be omitted at night, and if possible, two.
Length of time for taking the bottle depends somewhat on the child, but
it should not exceed fifteen minutes, as a rule.
=Supplemental Feeding.=—A mother who has too little milk may have it
supplemented by a modified mixture in one of two ways.
First, the quantity furnished by the breast must be determined by
weighing the infant before and after feeding, and then the total amount
for twenty-four hours can be deduced. With this information, it is not
difficult for the doctor to know how much cow’s milk to prescribe. The
supplemental feeding may be given by alternating the bottle and the
breast, or by giving the breast and following it immediately with the
bottle. In the meantime, the mother must be put on tonics with an
abundance of fluids, and a generous diet that will raise the blood
pressure, in the hope that the milk will increase sufficiently to enable
her to feed the child entirely from the breast.
When it becomes necessary to substitute some other food for the breast
milk, it means that the milk of some other mammal must be modified for
the purpose. The most convenient and abundant source of supply is the
cow.
While in many respects cow’s milk is similar to mother’s milk, it is in
reality quite a different product. Mother’s milk is taken, undiluted,
directly from the breast, while cow’s milk is given from a bottle, hours
after milking, and not only must it be diluted, but certain ingredients
must be added to aid its digestibility.
When taken into the stomach in its natural state, mother’s milk is a
liquid, while under the same conditions, cow’s milk forms a semisolid
gelatinous mass.
It is essential that the milk should be as fresh, clean, and free from
bacteria as possible, and this can be approximated only in certified
milk. This milk is required by law to have its constituents definitely
standardized. Thus, there must be 4 per cent of fat, 4 per cent of
protein, and 4 per cent of sugar, and it must be so free from bacteria
that not more than 10,000 per cubic centimeter can be found. The cattle
also are tuberculin tested. The following comparison is from Holt:
_Mother’s Milk_ _Cow’s Milk_
Sp. Gr. av. 1.031 av. 1.031.
Fat 4. % Fat 4. %
Protein 1.50% Protein 3.50%
Sugars 7. % Sugars 4.50%
Salts .2 % Salts .75%
Water 87.3 % Water 87.3 %
Reaction Alkaline Reaction Acid
Bacteria Very few Bacteria Many
Both range from 1.026 to 1.06.
[Illustration: Fig. 130.—Elements of human milk. (Eden.)]
The fats are substantially the same, but the fat of cow’s milk is less
easily digested than the fat of mother’s milk.
The protein of mother’s milk is virtually half lactalbumin and half
casein, which is only slightly coagulated into soft flocculent curds by
the action of rennin and acids, while the casein of cow’s milk is nearly
three times greater in amount than the lactalbumin and is coagulated
into coarse, tough curds.
The sugars in both cases are lactose in solution, but mother’s milk
contains a much higher percentage.
Cow’s milk contains three times the quantity of salts found in human
milk, but the water is the same in both.
So, while the two milks seem in comparison to be much alike, in reality
they are quite different; hence it is necessary to modify cow’s milk in
such a way as to make it not like mother’s milk chemically, but to make
it _act_ like mother’s milk.
It is extremely difficult to bring up an infant on artificial food, and
inasmuch as half the infants that die during the first year, perish from
intestinal disorders, it is imperative that every resource should be
exhausted before the breast feedings are abandoned. It is fallacious to
believe that anyone can feed a baby, or that feeding consists merely in
trying one food after another until one is found to agree. Only a
competent physician should prescribe the food, and he should study his
problem and make his modifications just as he would alter his medicines
for a particular disease.
However, it is necessary for the nurse to know how to carry out the
doctor’s orders intelligently and how to report to him the conditions
present.
In prescribing for the child, the doctor usually has some definite
outline in his mind, such as
Age and weight. _Example_: 3 months old; weight 10 pounds; 7
feedings; 1 every 3 hours.
Interval, three hours.
Amount in each bottle, four ounces.
Formula:
Milk, 12 oz.
Diluent, 16 oz. (Cereal water or plain water.)
Sugar, ½ oz.
Flour ball, if any, ½ oz.
Boil if ordered.
The infant should not take more than two ounces of milk to a pound of
weight in each twenty-four hours.
=Proprietaries.=—Baby foods are not to be recommended nor condemned.
They are placed on the market as substitutes for mother’s milk with
definite instructions as to preparation. They are also very expensive.
They are not to be condemned, because many of them are invaluable when
used in connection with cow’s milk. Sometimes a child will not tolerate
anything but malted or condensed milk, or Nestle’s food, for example.
The malt sugars, such as Horlick’s and Mellin’s, are easily assimilated,
fattening, and laxative.
All foods in the modification of milk should be of the best. The
standard sugars are Merck’s milk sugar, Mead’s Dextri Maltose,
Nährzucker, cane sugar, and Mellin’s and Horlick’s foods. Robinson’s
barley flour or Johnson’s are the best known. Imperial granum is a
partially dextrinized flour and corresponds to the home-made “flour
ball.”
FOOD PREPARATION
=Buttermilk Made from a Culture.=—Bring two quarts of milk to a boil,
cool to the temperature required for inoculation (80° to 100° F.,
depending on the culture employed). Introduce the culture, and allow it
to stand at the temperature of the room until a solid clabber forms.
Place on ice, whip with an egg beater or break up with a churn before
using. If a fat-free buttermilk is desired, use skimmed instead of whole
milk.
There are many kinds of buttermilk cultures on the market, but Hansen’s
is considered one of the best, because it is not too acid, besides
which, it has a good flavor, and the culture can be utilized over and
over for a week or ten days.
In preparing a subsequent portion, it is only necessary to use two or
three ounces of the first buttermilk, which may be reserved for the
purpose. This amount is introduced into the freshly boiled milk, instead
of the original powder, and the preparation is continued exactly as
described for the mother culture.
In every case the mixture must be placed on ice as soon as the clabber
forms, as it becomes too sour otherwise.
=Eiweiss Milk.=—Heat one quart of whole milk to 145° F. and coagulate
with pepsin, rennin, or chymogen, which is 10 per cent rennin. Let it
stand until clabbered, which takes about ten minutes. Pour into a gauze
bag and let it stand until all the whey is drained off. To the dry curd,
add ½ ounce of flour ball, and one pint of skimmed buttermilk, the whole
to be rubbed through a very fine wire mesh sieve (as fine as a
tea-strainer, at least), three separate times; or, it may be ground
twice through a special mill to break up the curd as minutely as
possible. Add a pint of water and measure. There should be a quart and
three or four ounces over. Place upon a slow fire and bring to a boil
while stirring constantly. Boil two minutes, then cool, strain, measure,
and add water to make up for evaporation. Shake well before measuring,
as the curd is heavy and settles to the bottom.
=Peptonized Milk.=—(See p. 338.)
=Whey.=—To a pint of fresh, warm cow’s milk, add rennin as pepsin, or
chymogen, and stir until mixed. Let it stand until coagulation is
complete. Then the curd should be broken up with a fork, and the whey
drained off through coarse muslin. This removes the coagulable proteins
from the milk. A ten per cent cream can be had at home by allowing a
quart of milk to stand for six hours and then using the upper
one-fourth.
=Whey-Cream Mixture.=—Make whey as described and mix with cream, in the
proportion of whey 1½ ounces to cream, 1 dram for each feeding.
=Barley Water. No. 1.=—Use one ounce of barley pearls to a quart of
water. Wash thoroughly, put on a slow fire and boil for six hours. Add
water to make up for evaporation, and add a pinch of salt. Strain and
cool rapidly.
=Barley Water. No. 2.=—Use one heaping teaspoonful of Robinson’s patent
barley flour to each pint of cold water. Boil twenty minutes and add
water to make up for evaporation. Add a little salt, strain and cool
rapidly.
=Other cereal waters=, like rice and oatmeal, are made like barley water
No. 1, and in the same proportion.
=Flour Ball.=—Take four cups of ordinary wheat flour and wrap it in a
piece of muslin, and tie it tightly. Drop the mass into boiling water
and boil six hours. Then take it out, cool it and remove the outer
peeling with a sharp knife. Break into small pieces, the size of an
English walnut, and dry thoroughly in a slow oven. Pulverize in a mill
or meat-grinder, sift and keep in a dry place.
=Milk= may be sterilized, pasteurized, or boiled.
_Sterilization_ kills both germs and spores, but it is not nearly so
necessary as it is to have the right proportion of sugar and fats. Place
in an autoclave and keep at a temperature of 160° F. for an hour.
_Pasteurization_ is desirable when a good, clean milk is not attainable.
It kills the germs, but not the spores. The process must be carefully
attended to, or the milk will sour more easily. Heat a quart of milk to
160° F. for twenty minutes. Cool rapidly to 40° F.
_Boiling milk_ for two minutes kills all bacteria, and renders the
casein more easy of digestion and prevents the formation of curds.
PUTTING FOODS TOGETHER
=Whole milk= contains 4 per cent fat, and must be thoroughly shaken
before it is measured, for otherwise one child will get all the fat and
another all the skimmed milk.
=Fat-free, or skimmed milk=, contains about 0.1 per cent fat. The cream
has been removed by a siphon or centrifuge. If unable to get a fat-free
milk from a dairy, the cream can be removed from a quart of whole milk
quite easily with a siphon.
=Sugars and flours= should be weighed when used, for they vary greatly
in volume.
In using flour ball or imperial granum, the flour must be mixed with
water or cereal water, to make a smooth paste and brought to a boil. If
the milk is to be boiled also, add the milk to the paste and boil all
together. Cool and strain.
All baby feedings should be strained, as tiny lumps of food will clog
the rubber nipple and the nurse may think the baby is not taking its
feedings well. The following is a typical formula:
Whole milk 15 oz. }
Barley water 15 oz. }
Sugar ½ oz. } 5×6×4
Flour ball ½ oz. }
Boil two minutes. }
Weigh the sugar and flour ball and make a paste with the barley water.
Shake the whole milk, measure out 15 oz. in the graduate, and add the
barley water mixture. Boil two minutes. Cool in running water, strain
bottle and put on ice. The figures at the side mean that five feedings
of six ounces each are to be given at four-hour intervals.
It is necessary to cool all feedings as soon as modified, and keep them
on ice for preservation until used.
The only accurate way is to make up the whole quantity for twenty-four
hours, put into separate bottles the exact amount of each feeding and
give at the time ordered, after the bottle has been properly warmed. In
warming the food, care must be used to get it neither too hot nor too
cold; 100° F., or when it feels warm to the back of the hand, is about
right. The child should be held in the arms while taking the bottle.
A buttermilk feeding must not be heated to more than 100° F. because it
curdles and can not be used.
=The rubber nipples= should be washed thoroughly after use, boiled once
a day, and kept in boric acid solution.
=The necessary articles= for home modification of milk can be obtained
anywhere. One set of utensils should be kept for this purpose
exclusively and boiled each time before the food is prepared. A list is
convenient:
A 16 ounce glass graduate.
One tablespoon and one teaspoon may be used for measuring purposes, if
unable to get a satisfactory scale.
1 2–quart aluminum cooking dish.
1 long-handled aluminum spoon.
1 fine wire mesh strainer, thirty holes to the inch.
1 dozen bottles, 5 ounce size if the child is small, and 10 ounce if
the child takes large feedings.
The bottles should have wide mouths, straight sides, and round bottoms,
which clean easily. Paper caps or corks that fit tightly should be used
instead of cotton stoppers. Close rubber caps are best, for, as the milk
cools, a vacuum is created, the rubber is drawn in and the milk remains
air-tight until opened. If infants are kept on a milk diet alone for too
long at a time, they do not thrive so well, hence as early as six
months, other things may be given. At this stage, the most desirable
additions to the food would be cereal, farina or cream of wheat, orange
juice, vegetable broth, toast crumbs, etc. The administration of orange
juice should be started when the child is only a few weeks old.
The quantity of all these foods may be increased as the child gets
older, and by the end of a year the diet is broadened still further.
Beside a quart of whole milk, it may have thickened soups, vegetables,
such as cauliflower, spinach, carrots, creamed celery and a little baked
potato. Fruits, orange juice, grape fruit juice, prune sauce, apple
sauce and scraped apple may be given, but no bread. In place of bread,
use toast, Huntley and Palmer wafers and biscuits, and soda or oatmeal
crackers. Sweet desserts should be avoided, but flavored junket or
simple custard is unobjectionable.
No meats are permitted until the child is eighteen months old, except,
perhaps, a little crisp bacon, or a bone to suck.
None of these supplemental foods should be given between meals, but
always at the feeding hour. The above list supplies a dietary so varied
that no child will tire of it.
In reporting the condition of the infant to the physician, the following
form may be used to advantage. It is a clear cut, concise summary of
what he wishes to know.
Infant’s Daily Report
1. _Food_: Does baby take it all? Is he satisfied?
2. _Bowel movements_: How many in last 24 hours? What is the color?
Are they hard, soft, or watery? Any odor? Any curds? Any slime?
Any blood? Any colic? Much gas?
3. _Does baby vomit?_ When? How much?
4. _Does baby sleep well?_ _Is he good natured?_
5. _Any fever?_ _What is the weight?_
=Significant Symptoms and Conditions.=—In an artificially fed baby, the
normal condition of the bowels is constipation. The stools are formed,
alkaline in reaction, rather hard, and usually only one a day.
The stools should have a characteristic color, according to the food
taken. Thus:
_Sugar or starch_ will color the movement a dark brown, like vaseline.
_Too much fat_ gives a pale yellow stool, almost white, like putty.
_Eiweiss_ feedings show as a pale yellow, somewhat like the fatty
stools, but constipated.
_Barley water_ gives a brown liquid stool.
_Starvation stools_ are thin, slimy, dark brown or green.
_The consistency_ of the movements is also important.
Too much sugar or starch means diarrhœa, with thin, green, acid stools,
and much gas and regurgitation, or, sometimes foamy, mucous discharges.
_Diarrhœa_ may also be due to indigestion. Mucus in the stools usually
signifies intestinal irritation.
_Constipation_ may exceed the normal limits of the artificially fed
child when the food contains too much fat.
_Bad odors_ of the stools result from putrefaction.
_Colic_ means imperfect digestion with gas. There is less colic when the
intervals between the feedings are lengthened.
_Curds_ are of two kinds. The soft friable ones due to fat, and the hard
bean-like masses of protein. Curds occur with feedings of raw milk only,
and though associated with symptoms of indigestion, they signify
overfeeding. If the sugar content of the food is low, the child will
gain very slowly.
_Vomiting_ is an important phenomenon. It may be due to overfeeding, to
excess of sugar or fat in the food, or to pyloric stenosis. Excess of
fat is shown by vomiting and regurgitation of small quantities of food
one or two hours after feeding. It may be associated with constipation.
If vomiting occurs immediately after feeding, it is probably due to the
taking of an excessive amount, or to the too rapid ingestion of the
regular bottle. If the vomiting takes place later than twenty minutes
after feeding, it is probably pathological. It may be the result of
indigestion, meningitis, or of pyloric stenosis (q. v.).
For the first weeks of life, mother’s milk should be obtained at all
hazards, if possible, but if this is not to be had, the artificial
feedings may be started.
A desirable milk modification for the first weeks of life should begin
with a low food value. For example, a child one week old weighing seven
pounds, should start on a formula like this:
Whole milk 7 oz.
Water 7 oz.
Cane sugar ½ oz.
Boil two minutes.
This will make seven feedings of 2 oz. each, and one is given every
three hours with one feeding omitted at night.
Cane sugar is _less_ liable to produce colic than sugar of milk.
Lime water, or sodium citrate may be added, if the child vomits, or if
other indications arise. Both are alkalies.
The strength of the mixture, as well as the quantity, must be increased
as the child gets older and it is seen that the formula will agree.
The percentage of protein is kept down by dilution, with plain or cereal
water, while fats (as cream) and sugars are added to make up the
strength lost by the dilution.