CHAPTER XVIII ARTIFICIAL FEEDING (Part 1)

CHAPTER XVIII ARTIFICIAL FEEDING The various elements necessary for proper food in infancy, the difference between mother's milk and cows' milk, the various ways of preparing cows' milk to render it sterile or more easily digestible, and the various other preparations that may be used as substitutes for milk were discussed in the previous chapter, so that it is in order to discuss the subject of infant feeding proper. The different methods of feeding which are available are breast-feeding, either by the mother or by a wet- nurse; mixed feeding, or a combination of artificial feeding and nursing; and artificial feeding exclusively. The first choice should always be maternal nursing. This is nature's food for the infant and nature cannot be improved upon. " While recent advances in artificial feeding have greatly diminished the necessity for wet-nursing, there are still many instances where, objectionable though they may be, they are indispensable for saving the life of the child, as the perfect substitute for good breast-milk is as yet un- discovered" (Holt). By mixed feeding is meant a combination of breast and artificial feeding. This may be resorted to when the milk supply of a mother is insufficient, or when the strain upon her health is unduly great. The same care must be 33° ARTIFICIAL FEEDING 33 I exercised to keep the nipples clean and to have the feeding 1 at regular intervals in breast feeding as in artificial diets. Weaning should always be done gradually, when possible, for the sake of both mother and child. "While there are many women, especially of the lower classes, who are able to nurse their children advantageously throughout the first year, the number of such among the better classes is certainly very small. By the latter nursing can rarely be continued beyond the ninth, and often not beyond the sixth month, without unduly draining the vitality of the mother and at the same time harming the child. Weaning in hot weather is usually to be avoided. " In cases of sudden weaning the food must be very much weaker in the beginning than for an artificially fed child of the same age. If weaned at six months the child should be put on a mixture suitable for a child of one month of age; if at nine or ten months, upon a food appropriate for a child of three or four months. If this is done the change can be made without causing much disturbance. When the infant has become somewhat accustomed to cows' milk, the strength can be gradually increased" (Holt). ARTIFICIAL FEEDING In artificial feeding there are several fundamental principles which must be constantly borne in mind; they are well described by Holt and his work is quoted, in part, below: ''The food must contain the same con- stituents as mother's milk: namely, fat, proteid, sugar, inorganic salts, and water; the constituents must be pres- ent in about the same proportions as in good mother's milk; as nearly as possible the different constituents should 332 DISEASES OF CHILDREN FOR NURSES resemble those of mother's milk both in their chemical composition and in their behavior in the digestive fluids; the addition to foods of very young infants of substances not found in mother's milk, like starch, is unnecessary, contrary to the best physiology, and if used in consider- able quantities may be positively harmful. " In the artificial feeding of infants, cows' milk is selected because it furnishes all the necessary elements, although not in proportions required by young infants. In feeding infants according to this plan the attempt is made so to modify cows' milk as to make it conform in composition to woman's milk, and so to adjust the proportions of the various constituents to meet the individual cases. "In modifying cows' milk for infant feeding our calculations are based upon the composition of good breast milk, as determined by the latest analyses: Woman's milk, Cows' milk, per cent. per cent. Fat 4 3.5 to 4 Sugar 7 4.5 Proteids 1.5 4 Salts 2 .7 Water 87.3 87.3 (Holt.) "In cows' milk there is an excess of proteids and salts, too little sugar, and about the quantity of fat required. Other conditions which must be considered are the pres- ence of bacteria in cows' milk, its acid reaction, and the fact that its proteids are more difficult of digestion. " Fats. — The average amount of fat that an infant can digest varies from 2 to 4 per cent. It is rarely necessary in health to go above or below these proportions. Be- ginning with the 2 per cent, in the early days of life, this can be increased to 3 per cent, in a month, and to 4 per ARTIFICIAL FEEDING 333 cent, at the age of five or six months. No other mod- ification in the fat is necessary. " Sugar. — In woman's milk the percentage of sugar is constant in all instances, between 6 and 7 per cent. In feeding cows' milk it is seldom necessary to have the sugar less than 5 per cent, and never more than 7 per cent. It should be distinctly understood that the purpose of adding sugar to milk is not to sweeten it, but to furnish the proper proportion of soluble carbohydrate necessary for the infant's nutrition. However, when good milk sugar cannot be obtained, cane sugar may be used. The amount added must be but little more than half that of milk sugar on account of its sweeter taste and its greater liability to ferment in the stomach. " Proteids. — The modification of the proteids is the most important change necessary in cows' milk, for it is the proteids which give the greatest difficulty in infant digestion. In ordinary cases in health, a reduction in the amount of proteids present is all that is necessary. The normal amount of proteids in woman's milk is 1.5 per cent. In very young infants it is necessary to reduce it even more than this, sometimes to .75 per cent, and even to .50 per cent. By the end of the first month the average child can take 1 per cent, and by the fourth month 1.5 per cent, and by the sixth month 2 per cent. The reduction of the proteids is effected by dilution with water." The meaning of such terms as 3.6.1. mixtures etc., is 3 per cent, fat, 6 per cent, sugar and 1 per cent, proteid mixture. Mixtures should always be expressed in the sequence of fat, sugar, proteid. " Inorganic Salts. — These, like the proteids, are exces- DO 4 DISEASES OF CHILDREN FOR XCRSES sive in cows' milk and to nearly the same degree. There- fore, when milk is diluted as required by the proteids, the salts will be nearly in their proper proportion and they may be dismissed from separate consideration. " Reaction. — The acidity of cows' milk may be over- tome by the addition of either lime-water or bicarbonate of soda. Of the former, 5 per cent, of the total quantity is required; of the latter, one grain to each ounce of food." The subject of heating milk for the destruction of bacteria was considered on page 318. Fat is furnished by cream; proteid by milk. Cream containing 16 per cent, fat is taken as a working basis, and a standard solution of milk sugar of 20 per cent. strength should be used. CREAM The cream in an ordinary quart bottle of milk is: Upper 2 oz 24 per cent. Upper 6 oz 20 " " Upper 8 oz 10 " " Upper 10 oz 8 " " This is obtained not by pouring off the top milk, but by siphoning off from the bottom of the jar all but the amount for the desired percentage of cream. For instance, to get a 24 per cent, cream 30 oz. of the bottom milk would be siphoned off, leaving 2 oz. of' 24 per cent, cream. If 4 oz. of 24 per cent, cream is needed, then two bottles of milk would have to be used. To make 12 per cent, cream, take two parts of 16 per cent, cream and one part of whole milk. Example: To make 9 dr. of 12 per cent, cream take 6 dr. of 16 per cent, cream and 3 dr. of whole milk. Eight per cent, cream contains one part 16 per cent. cream and two parts of whole milk. ARTIFICIAL FEEDING 335 Example: To make 8 per cent, cream, take 2 oz. of 16 per cent, cream and add 4 oz. of whole milk to make 6 oz. Fats. Sugars. Proteids. 16 per cent, cream. 16 4 3.60 12 per cent, cream 12 4.20 3.80 8 per cent, cream 8 4.20 3.90 When one is thoroughly conversant with these facts it is easy to modify cows' milk. There are several for- mulae to expedite this work, but while not as accurate as some (Westcott's for instance), for all practical purposes the best is Baner's. Baner's Formula. — Q = Total quantity to be used in twenty-four hours. F = The per cent, of fat desired in the mixture. S = The per cent, of sugar desired in the mixture. P = The per cent of proteid desired in the mixture. M = milk. C = cream. L. W. = lime-water. Qx(F-P) -. = cream. percentage ot cream — 4 QxP — the cream = milk. 4 5 per cent, of the total quantity = lime-water. Q - M - C - L. W. = sterile water. Qx(S-P) ... =rmlk sugar. 100 Example. — A 4.7.2. mixture is ordered, 40 oz. to be given in twenty-four hours. The percentage of the cream used is 16. Q = 4o. F = 4. s = 7. P = 2. 4Q,x(4-2) 40x2 = 6f oz. cream. oz. milk. ne-water. r8 oz. of sterile water. 2 oz. milk sugar. I 6-4 1: 40 > 2 A2 E3i 4 6f~ Too 40- of 40 2 6| i3i oz. hr 40 (7 2) 40 s 3 $6 DISEASES OE CHILDREN FOR NURSES The proper proportions for a 4.7.2. mixture, 40 oz. to be given in twenty-four hours, based upon 16 per cent, cream are: Cream 6§ oz. Milk i3§ " Sterile water 18 " Lime-water 2 " 40 " Two ounces of dry milk sugar are dissolved in this mixture. Short Cuts. — In a 3.6.1. mixture the cream equals one-sixth of the total quantity, if 16 per cent, cream is used; and the milk equals one-fourth of the total quantity. In a 3.6.1. mixture if a 12 per cent, cream, both the fat and the proteid are furnished by the cream and the addition of milk is unnecessary. Example. — Total quantity 32 oz., a 3.6.1. mixture made with 12 per cent, cream. MX(j~l) 32X2 „ * J ' = *—— = 8 oz. cream. 12-4 32 ■ 1 4 8=0 = milk. In a mixture where citrate of soda is used the powder is added in the proportion of 1 gr. to each ounce of milk or cream. The 5 per cent, of lime-water is not used in such a mixture, the citrate of soda giving the necessary alkalinity. In using a solution where 2 gr. = 1 dr., or any other solution, the amount of water used to dissolve the necessary number of grains should be subtracted from the total quantity of sterile water. ARTIFICIAL FEEDING 337 METHODS FOR DETERMINING THE PERCENTAGES OF VARIOUS MIXTURES Whole cows' milk contains 4 per cent, of fat, 4.5 per cent, of sugar, and 4 per cent, of proteid. Milk and Lime-water, 5 to 1. — f of the mixture is milk. % of 4 per cent. =-\° =3-3 per cent, of fat. f of 4§ per .cent. =ff = 3l Per cent- °f sugar, f- of 4 per cent. =-%°- = 3J per cent, of proteid. Therefore, this mixture contains 3! per cent, of fat, 3f per cent, of sugar, and 3^- per cent, of proteid. Milk and Lime-water, 3 to 1. — The percentages are determined in the same way, three-fourths of the whole quantity being milk. Whey, 5 oz. + 1 oz. of a 16 Per Cent. Cream. — Whey contains 0.32 per cent, of fat, 4.79 per cent, of sugar, and 0.86 per cent, of proteid. Cream contains 16 per cent, of fat, 4 per cent, of sugar, and 3.6 per cent. of proteid. In this mixture one-sixth of the total quantity is cream. \ of 16 per cent. = -^-=2.66 per cent, of fat contained in cream. f of .32 per cent. = — = .26 per cent, of fat contained in whey. 2.92 per cent, of fat contained in mixture. \ of 4 per cent. = f = 0.66 per cent, of sugar contained in cream. \ of 4.79 per cent. = ?3l9S = 3.99 per cent, of sugar contained in whey. 4.65 per cent, of sugar contained in mixture. \ of 3.60 per cent. = '' - .60 per cent, of proteid contained in cream. \ of .86 per cent. = 4''?° = .71 per cent, of proteid contained in whey. 1 .31 per cent, of proteid contained in mixture. The mixture contains 2.02 per cent, of fat, 4.65 per cent, of sugar, and 1.31 per cent, of proteid. Rule for Determining the Percentage of Fat in a 338 DISEASES OE CHILDREN FOR NURSES Mixture. — Add the quantities of the ingredients together. Multiply the percentage of the fat in the cream by the quantity of cream in the mixture and divide by the total quantity. Multiply the percentage of fat in the milk by the quantity of milk in the mixture and divide by the total quantity. The sum of the two results gives the percentage of fat in the mixture. Example. — In a mixture containing 5 oz. of a 16 per cent, cream, 11 oz. of milk (4 per cent, fat) and 24 oz. of water, the total quantity is 40 oz. 16 X 40 ^ |4} = 2 per cent, of fat in the cream. - = M = 1.1 per cent, of fat in the milk. 40 3.1 per cent, of fat in the mixture. Therefore, the mixture would contain 3.1 per cent. of fat. BOTTLES AND NIPPLES The best style of bottle is that which can be most easily cleaned. On no account should bottles with any complicated apparatus be allowed. The cylindric bottles with wide mouths are generally preferred. The best nipples are those of plain black rubber which slip over the neck of the bottle. Those with long rubber tubes going to the bottom of the bottle should not be used, as it is practically impossible to keep them clean. The hole in the nipple should be large enough to allow the milk to drop rapidly when the bottle is inverted, but not so large as to permit the milk to run through in a stream. The bottles should be thoroughly cleansed and sterilized before each feeding, and when not in use the nipples should be immersed in boric acid. ARTIFICIAL FEEDING 339 RULES FOR FEEDING A child should not be more than twenty minutes taking its food, and should not be allowed to sleep with the nipple in its mouth. The bottle should be placed so that the child sucks milk, and not air. Usually the child's food in health should be increased in strength just as fast as the child's digestion will permit. An infant much above the average in weight must have its food graded accordingly. With this knowledge artifi- cial feeding in health resolves itself into an easy problem. Indications for Varying Mixture. — In regard to the exact indications when the fats, sugar, and proteids of milk are to be varied in infant feeding, much is yet to be learned; however, the following are the chief points: Sugar. — If the sugar is too low, the gain in weight is slower than when it is furnished in proper amounts. Excess of sugar is shown by colic, or thin, green, and very acid stools, which cause irritation of the buttocks. Sometimes eructations and regurgitations of small quan- tities of food take place. Fat. — -Excess of fat is shown by vomiting or regurgita- tion of food in small quantities, usually one or two hours after feeding; sometimes by frequent stools which are almost normal. There may be fat lumps in the stools. Too little fat causes constipation, and dry and hard stools. Proteids. — Excess of proteids is shown by the presence of curds in the stools, by colic, constipation, and vomiting. Excess in quantity of milk given at a feeding causes immediate regurgitation. 1 1 is not practicable to modify the milk so as to meet 340 DISEASES OE CHILDREN FOR NURSES every temporary symptom of discomfort an infant may have. The general rules are: If the}' are not gaining in weight without special signs of indigestion, increase the proportions of all the ingre- dients. If there is habitual colic, reduce the proteids. For frequent vomiting, soon after eating, reduce the quantity. For the regurgitation of sour masses of food reduce the fat and also sometimes the proteids. For obstinate constipation increase both fat and proteid. THE USE OF FOODS OTHER THAN MILK DURING THE FIRST YEAR The addition of other foods should be deferred until after the eighth or ninth month. Starch can then be added, usually in the form of barley. As starch is added, sugar should be gradually withdrawn. The only other thing to be advised during the first year is beef juice; this may be given after the tenth or eleventh month to weak infants; at first only \ oz. daily; later 3 oz. In difficult cases of feeding the problem is essentially the same: that the food must be adapted to an infant whose powers of digestion are