CHAPTER XVII INFANT FEEDING (Part 1)

CHAPTER XVII INFANT FEEDING Nutrition is the most important branch of pediatrics. The question whether a child will be strong and robust or a weakling is often determined by its food in the first three months of its life. The corner-stone of the con- stitution is laid during that period. The largest part of the immense mortality of the first year is traced directly to disorders of nutrition. At times temporary success may mean ultimate failure. This is illustrated in the use of many of the proprietary foods. The results seem to be satisfactory at first, the infant gains in weight remarkably, and the absence of certain vital elements from the food may not be noticed for months. It is finally discovered that the child has rachitis or some allied condition and it starts life handi- capped by an undermined constitution. Another mistake often made is the prolonged use of predigested foods. The child is unable to digest naturally the simplest foods after prolonged use of such methods, this function being undeveloped. Some children with very robust con- stitutions seem to thrive on almost any food, but they are the exception. THE FOOD CONSTITUENTS AND THE PART THEY PLAY IN NUTRITION This is well described by Holt and in part his descrip- tion is given below. " In infancy and childhood, as in 3" 312 DISEASES OF CHILDREN FOR NURSES adult life, the elements of the food are five in number: Proteids, fats, carbohydrates, mineral salts, and water. The forms in which they must be served to a child and the relative quantities in which they are demanded, are different from those required by an adult. One of the reasons for this difference is the delicate condition of the organs of digestion in infancy, and the inability to assimi- late certain forms of food. Another reason is that pro- vision must be made not only for the natural waste of the body, but for its rapid growth, as it nearly trebles in size in the first twelve months. " Proteids.— These are essential to life since they are the only kind of food that is capable of replacing the continuous nitrogenous waste of the cells of the body, upon the healthy condition of which the digestion and assimilation of other elements of food depend. The proteid is furnished by the casein and other albuminoids found in both the woman's and the cows' milk. It is also found in muscle fiber, white of eggs, gluten of wheat, etc. The proteids most easily digested by infants are those of woman's milk. The greatest difficulty in artifi- cial feeding has been to find other proteids to take their place. It is the difference in the digestibility of the proteids which causes most of the trouble in the substitu- tion of cows' milk for woman's milk. The average amount of proteid furnished in a good sample of woman's milk is 1.5 per cent. "Fats.— The uses of fats in the body are intimately associated with those of proteids. Fat possesses the important property of saving nitrogenous waste, so that when this is supplied in the food in proper proportions the entire energy of the proteid may be expended upon INFANT FEEDING 313 growth and nutrition of the cells of the body, without being used up in the production of animal heat. The demands upon the proteid by rapid growth of the body during infancy make it desirable that whenever possible the fats should do the work of the proteid. "In addition to their use as a source of animal heat the fats add to the body weight by storing up fat in the body. They are needed for the growth of the nerve cells and fibers and are essential to the proper growth of bone. Fat also fills the role of a natural laxative. The produc- tion of fat required in infancy is greater than at other periods of life. Probably the most common mistake in artificial feeding is to give too little fat. This is one of the chief reasons for the failure of proprietary infant foods, all being insufficient in fat. Woman's milk of good quality contains from three to five per cent, of fat. "Carbohydrates. — Although these, like the fats, cannot replace the nitrogenous waste of the body, they are impor- tant aids to the proteids, and in this respect they are even more valuable than fats. The carbohydrates are partially changed into fat and may thus increase the body weight. They are capable of replacing the fat waste of the body, and are one of the most important sources of animal heat. The form in which carbohydrates are furnished to infants is milk sugar. "In building up the cells of the body the proteids are first in importance, the carbohydrates second, and the fats third. In production of animal heat the neces- sity to maintain life, the fats come first and the carbo- hydrates second. The proteids should never be called upon for this purpose. In a proper diet all of the ele- ments are represented. 314 DISEASES OF CHILDREN FOR NURSES "Mineral salts are of greater importance in infancy than later in life, on account of the rapid building up of the bony system which is going on at this period. The most important for this purpose are the phosphate of lime and magnesium. These are furnished in abundance in both woman's milk and cows1 milk. The salts are also necessary for cell growth, forming the mineral con- stituents of the blood and digestive fluids, and facilitating absorption, excretion, and secretion. "Water. — The food of all young mammals consists of from 80 to 90 per cent, of water. This is needed for the solution of certain parts of the food, such as the sugars and some of the proteids and for the suspension of other proteids and emulsified fats. All the food is thus dis- solved and very finely divided, so as to be more readily acted upon by the feeble digestive organs of the infant. Water is also needed in large quantities for the rapid elimination of waste in the body. When the diet of the infant is entirely fluid, additional water between feeding is unnecessary, but when solids are added and the feedings are at longer intervals, water should be given freely between feedings at all seasons, but more especially in summer." WOMAN'S MILK This is the ideal infant food. It is the secretion of the mammary gland. A few drops may be squeezed from the breasts before parturition. Generally speaking, how- ever, it is only present after delivery. During the first two days the secretion is scanty, but usually upon the third or fourth day it becomes established. It is bluish white in color, usually alkaline, sometimes neutral, never acid in reaction. The specific gravity is 1031, and when INFANT FEEDING 315 precipitated it forms light flocculi, never precipitating in large masses, like cows' milk. Colostrum. — The secretion in the first two or three days differs quite markedly from the later milk. It is Fig. 91. — Cremometer: The instrument is filled to the mark o with unskimmed milk and allowed to stand for from eighteen to twenty- four hours at the temperature of the room, when the depth of the layer of yellow cream can be read off in degrees. The num- ber of degrees corresponds to the cream percentage, which in good milk should never fall below 10 per cent, (after Chevalier). of high specific gravity and very rich in proteids and mineral salts. Composition of Woman's Milk. — Proteids are usually present in proportion of one to two per cent. The amount of proteid is larger in the first few days; after the third week it is stationary to the end of lactation, when it falls very markedly. Fat : 4 per cent, is the average. 3i6 DISEASES OF CHILD REX FOR XVRSES Sugar : The ordinary variations are between 6 per cent, and 7 per cent. Fie. 92. — Scheme showing the composition of human and of cows' milk : i, Proteid ; 2, fat; 3,- carbohydrates; 4, salts (Fruhwald and Westcott). Salts : The average proportion is about 20 per cent, or about one-fourth that of cows' milk. EXAMINATION OF MILK The quantity is determined by weighing the baby be- fore and after feeding. The average amount of milk taken at one feeding by a child is an ounce for each month of its age until the eighth month. Reaction is obtained by means of litmus paper; specific gravity is obtained by means of a small hydrometer. Fats. — A cream gauge holding 10 cc. is filled to the zero mark, and allowed to stand for twenty-four hours at the temperature of the room. Then read off the per- centage of cream. The ratio of cream to fat is, woman's 5 to 3. Cows', after eight to ten hours, 4 to 1. The sugar and salts are constant. Proteids can only be approximately determined by the specific gravity and by the percentage of fats. A specific gravity higher than 1031 shows increase in proteids; INFANT FEEDING 317 lower, a decrease, if percentage of fats is normal. In- creased percentage of fats will lower the specific gravity, and a decreased percentage will raise it. Microscopic examination shows the presence of bacteria, etc. COWS' MILK This is the only milk of lower animals practically available for infant feeding. It must be fresh, clean, from healthy animals, preferably of a mixed herd rather than from a single cow. It is then more apt to be uniform, as a single cow is subject to daily variations. Animals should have fresh food and transportation should be as short as possible. For all practical purposes it is necessary that one should know only the amount of fat in the milk being used, as this is the only variable factor. The Difference between Cows' Milk and Woman's Milk. — Cows' milk is more opaque, slightly acid, or neutral, but never alkaline in reaction, as is woman's milk. There is less sugar in cows' milk, and the proteids in cows' milk are not only two or three times as great in amount, but they differ in their character. This latter is best shown by the digestibility of both proteids by the infant's stomach. Cows' milk in the stomach is coagulated into large, firm clots, which dissolve slowly, while woman's milk forms loose flocculent curds which dissolve readily. Cows' milk contains bacteria; woman's milk is sterile. Cream. — A great misapprehension exists as to the composition of cream. It is often spoken of as if it were entirely different from milk. It should be regarded as milk which contains an excess of fat, for the addition of cream to a mixture does not change the proteid percentage, but only the percentage of fat. 3i8 DISEASES OF CHILDREN FOR NURSES In infant feeding it is convenient to make use of cream containing a definite percentage of fat. This may be either 8, 12, or 16 per cent. Sixteen per cent, is most often employed. METHODS EMPLOYED TO KILL THE BACTERIA IN MILK Pasteurized Milk. — The bottles, after having been thoroughly boiled, should be filled with the prescribed quantity of milk and corked with sterilized nonabsorbent cotton. Place the bottles in the cells of the pasteurizer and till the cells with cold water. The cells are then Fig. 93. — Freeman's pasteurizer. placed in the pasteurizer, leaving out the middle set for the convenience of pouring in the boiling water. Next turn the faucet of the pasteurizer so that it will be open; then pour boiling water into the pasteurizer until it reaches the iron rods or until the water begins to run from the faucet; then turn off the faucet. Place in position the center cells and put the cover on securely. In a half hour remove the cover. Attach a hose to cold water faucet over the sink and another one to the faucet of the pasteur- izer. Place the hose from the cold-water pipe inside the INFANT FEEDING 319 pasteurizer between the cells and the sides, turn on the cold water, and at the same time turn on the faucet of the pasteurizer, so that the water will run out at the bottom at the same time that it is running in at the top, thus causing a sudden cooling of the bottles, which is very important. After the bottles are thoroughly cold remove and place in the ice-chest. The pasteurizer should then be emptied by the hose attached to the faucet. Three important facts must be remembered in pas- teurizing milk. First, that the pasteurizer must stand on wood or on some other nonconductor of heat. Second, that the water poured into the pasteurizer must be boiling hot so that the temperature of the milk will be raised to 167 ° F. in ten minutes. Third, that the bottles must be rapidly cooled. Sterilized Milk. — Prepare and fill bottles the same as for pasteurizing. The bottles are then set on a block of wood about one inch thick which is placed in a boiler so that the bottles do not touch the bottom. The water in the boiler should be then closely covered and allowed to. steam for one hour. The bottles should then be removed, cooled, and put on ice. RECEIPTS FOR THE PREPARATION OF INFANT FOODS Barley Water. — Cover two tablespoonfuls of pearl barley with boiling water, let it boil five minutes, drain, and throw water away. Cover with two quarts of boiling water and simmer gently until reduced about one quart, which takes about two hours. Then strain through four thicknesses of gauze. The prepared barley flour of the "Health Food Com- pany of New York" or Robinson's Barley, two drams to 320 DISEASES OE CHILDREN FOR NURSES each twelve ounces of water, and cooking for fifteen minutes is almost identical with the ordinary barley water (Holt). Starch 1.63 Fat 0.05 Proteid 0.09 Inorganic salts 03 Water 98.20 contained in barley water (Holt). Total 100.00 Rice and Oatmeal Water.— Cover two tablespoonfuls of rice or oatmeal with boiling water. Let it boil five minutes, drain, and throw water away. Cover with two quarts of boiling water and simmer gently until reduced about one quart. Then strain through four thicknesses of gauze. If used alone, add a little salt. Rice Milk.— Wash a tablespoonful of the best rice and boil it one and a half hours in a pint of new milk. Rub it through a fine sieve. Add two tablespoonfuls of granulated sugar, heat, and serve. Albumin and Milk.— Put the white of one egg into eight ounces of cold milk. Pour the whole into a fruit jar, screw on the top and shake vigorously for half a minute. It is then ready to serve. It should be light and smooth. Albumin Water.— Put the white of one egg into eight ounces of cold water. Pour the whole into a fruit jar and shake vigorously for half a minute, when it is ready to serve. Whey.— Heat one pint of milk to ioo° F. (no higher), add one teaspoonful of rennet and stir gently, stand aside to set, but not on ice. After the milk has been thoroughly coagulated, stir up the curds with a fork or spoon, and strain through a flannel cloth. One quart of milk will make about two-thirds or three-fourths of a quart of whey. INFANT FEEDING 32 1 In acute indigestion whey will often be retained when other foods are rejected. Whey and White of Egg. — To every 7 oz. of whey add the beaten white of one egg. Whey and Milk or Cream. — In adding milk, cream, or a milk mixture to whey, the whey should be made as directed above and after all the curds have strained off the whey should be heated to a temperature of 1500 F. and the milk, cream, or milk mixture must have been pasteurized before adding. Whey, Milk, or Cream and White of Egg.— Add the quantity of pasteurized milk or cream at the temperature and in the manner stated above; then the mixture must be cooled or quite cold before adding the beaten whites of the eggs, the number of whites being one to every seven ounces of whey used, and not one to every seven ounces of the mixture. Wine Whey. — Heat a half pint of milk in a saucepan, and when steaming hot add, quickly, four tablespoonfuls of sherry wine. Let the mixture stand for a few minutes on the stove, then take from the fire, break up the curds, and strain through flannel or four thicknesses of gauze. It may be served with or without sugar. Fully Peptonized Milk. — One pint of milk, 4 oz. of cold water, 1 peptonizing powder (5 gr. extract of pan- creatis, 15 gr. soda bicarbonate). Dissolve the powder in 4 oz. of water and to each bottle of milk of 4 oz. (previously pasteurized) add 1 oz. of the mixture. Stand the bottle in a pan of water i20° F. and allow it to remain there for a half hour, when it should be used at once. Peptonize each bottle to be used just before il is time for the feeding. Milk, 322 DISEASES OF CHILDREN FOR NURSES fully peptonized, should only be given by garage or by the rectum on account of its bitter taste. All milk ordered peptonized and given by gavage or rectum must be fully peptonized. Partially Peptonized Milk. — One pint of milk, 4 oz. of cold water, i peptonizing powder (5 gr. extract of pancreas, 15 gr. soda bicarbonate). Dissolve the powder in 4 oz. of water and to each bottle of milk of 4 oz. (previously pasteurized) add 1 oz. of the mixture. Stand the bottle in a pan of water, 1200 F., and allow