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:

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

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:

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 diarrhoea, with thin, green, acid stools, and much gas and regurgitation, or, sometimes foamy, mucous discharges.

Diarrhoea 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:

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.