FOOTNOTES:

(a) Outline the processes through which a slice of bread and butter must pass, from the time it is eaten until it reaches the blood stream.(b) Outline with a diagram the manner in which the foodstuffs are utilized in the body.(c) Show in the form of a table the effect of the enzymes on proteins, on fats, on carbohydrates.

(a) Outline the processes through which a slice of bread and butter must pass, from the time it is eaten until it reaches the blood stream.

(b) Outline with a diagram the manner in which the foodstuffs are utilized in the body.

FOOTNOTES:[51]“Chemistry of Food and Nutrition,” by Henry Sherman.[52]“Chemistry of Food and Nutrition,” by Sherman.[53]“Chemistry of Food and Nutrition,” by Henry Sherman.[54]Compiled from “Textbook of Physiology,” by Howell, and “Chemistry of Food and Nutrition,” by Sherman.[55]“Chemistry of Food and Nutrition,” by Henry Sherman.[56]This scheme applies to the protein, fat and carbohydrates with quantitative variations only. Courtesy of Dr. A. R. Taylor, Leland Stanford University.[57]“Chemistry of Food and Nutrition,” by Sherman.[58]Herter’s “Bacterial Infections of the Digestive Tract” (1907).[59]“Chemistry of Food and Nutrition,” by Sherman.[60]“Chemistry of Food and Nutrition,” by Sherman.[61]“Newer Points of View Regarding the Part Played by Different Foodstuffs in Nutrition,” by Lafayette Mendel, Ph.D. Read at the Sixty-fifth Annual Meeting of the American Medical Association, June, 1914.[62]See “Bacterial Action in the Body,” p.181.

[51]“Chemistry of Food and Nutrition,” by Henry Sherman.

[52]“Chemistry of Food and Nutrition,” by Sherman.

[53]“Chemistry of Food and Nutrition,” by Henry Sherman.

[54]Compiled from “Textbook of Physiology,” by Howell, and “Chemistry of Food and Nutrition,” by Sherman.

[55]“Chemistry of Food and Nutrition,” by Henry Sherman.

[56]This scheme applies to the protein, fat and carbohydrates with quantitative variations only. Courtesy of Dr. A. R. Taylor, Leland Stanford University.

[57]“Chemistry of Food and Nutrition,” by Sherman.

[58]Herter’s “Bacterial Infections of the Digestive Tract” (1907).

[59]“Chemistry of Food and Nutrition,” by Sherman.

[60]“Chemistry of Food and Nutrition,” by Sherman.

[61]“Newer Points of View Regarding the Part Played by Different Foodstuffs in Nutrition,” by Lafayette Mendel, Ph.D. Read at the Sixty-fifth Annual Meeting of the American Medical Association, June, 1914.

[62]See “Bacterial Action in the Body,” p.181.

There are many traditions in regard to the food requirements of the prospective mother. Many of these have been proved fallacies. As a matter of fact it is the woman more than the developing child who is likely to suffer if the diet is insufficient or badly balanced.

Factors Affecting Diet during Pregnancy.—In formulating a dietary for the pregnant woman, then, not only must the needs of the child be considered but those of the mother also, since the developing embryo draws from the body of the woman materials necessary for its growth, and if these needs are not covered by an increase in the diet, her body and that of the child also will show evidences of lack of nourishment.

Phosphorus and Calcium Requirements.—If, for example, the mother’s diet is lacking in those materials which produce growth, or is deficient in those mineral salts, such as those of phosphorus and calcium, which are requisite and necessary for the growth of bones in the infant, the mother’s bones and teeth will show this loss and in all probability the baby will sooner or later also show a like deficiency. However, it must be remembered that the pregnant woman is under a strain, both physical and mental. She must not be encouraged to eat beyond her needs or the digestion will be disturbed.

Nutritional Disturbances in Early Months.—The nutritional disturbance manifested by nausea and vomiting in the morning is due, not to the stomach or any disturbance therein, but to the fact that a mild form of poisoningoccurs, resulting from the substances produced through the formation of the placenta reaching the general circulation on account of the incomplete establishment of the connection between the embryo and the mother. As soon as this connection is complete and fetal circulation is established this “morning sickness” disappears.

Food Requirements of Prospective Mother.—The food requirements of the prospective mother are not materially affected during the first four months of gestation, and even after this, when the infant is developing rapidly, and up to the date of its birth, the mother’s requirements are only increased about 20%. The amount of food necessary to cover the body needs, for maintenance and energy of a woman living a sedentary or moderately active life, plus 20% for building materials for the growing child, will be adequate for the pregnant woman. Thus, if her needs are ordinarily from 2,000 to 2,400 calories per day, after the fourth month they will probably be increased to 2,400 or 2,800 calories a day and will rarely ever be more than 3,000 calories a day.

Dietetic Treatment of Normal Pregnancy.—The peculiar conditions surrounding the woman at this particular time must be taken into consideration in arranging her diet. The building foods which are necessary for the developing child must be given in the simplest form, milk and eggs being used liberally and meat sparingly to obviate any unnecessary tax being placed upon the kidneys. The use of fruit and green vegetables to supplement the milk and eggs is urged. It has been found advisable at such times to give small meals frequently rather than the regular meal three times a day. The feeling of “fullness” which often occurs during the last two or three months of gestation makes it more comfortable for the pregnant woman to eat less at a time and oftener. If, for example, she be given a glass of rich milk or a nutrient beverage, either ofenforced malted milk, albumenized orange juice, buttermilk, zoolak, or koumiss, at about eleven o’clock in the morning and again about four o’clock in the afternoon, she will have taken sufficient nourishment to meet the new requirements without taxing her digestion or imposing extra work upon the kidneys.

Abnormal Symptoms.—The chief point to keep in mind is any abnormal symptom which may develop. The chief of these is albumen in the urine. The urine must be examined frequently and measures taken immediately to overcome albuminuria should it occur. It is wise, as has already been stated, to restrict the meat in the diet, and in cases where albumen is found in the urine even when the meats are restricted, it may be necessary to place the patient upon a milk diet for a time until the urine clears up.

Supplementary Feeding.—Cereals, especially the whole cereals, must be used liberally. Gruels made with milk are often found valuable additions to the dietary. The prospective mother must be urged to take a regular amount of gentle exercise, not to become over-tired, or excited, to eat sparingly at night, and to drink plenty of water. She must avoid becoming constipated by eating plenty of green vegetables and fruit.

Sample Diet Sheets.—The following dietary is suggested: Breakfast should consist of thoroughly cooked cereals, wheatena, cream of wheat, malt breakfast food, cracked wheat, rolled or cracked oats, served with cream or sugar or both, whole wheat bread, muffins, or biscuits, with butter, raw or stewed fruit, coffee, tea or cocoa with milk. Luncheon may consist of milk or vegetable soups, eggs in any form, boiled potatoes, sweet potatoes, string beans, greens, or any green vegetables, simple desserts such as custards, rice or tapioca puddings, bread pudding, etc., milk, tea, cocoa, buttermilk, zoolak or koumiss as beverages. For dinner, if albuminuria is not present, a small piece ofmeat may be taken, together with green vegetables, rice, potatoes, simple salads, and a simple dessert, milk or coffee with milk as a beverage.

Selection of Food.—The following foods may be used to formulate the diet sheet: Wheat, oat, or corn cereals, rice, tapioca, made into simple puddings or served as breakfast foods; fruits, oranges, prunes, apples, raisins, dates, figs, or grapefruit, stewed or raw. The fruit juices may be used instead of the whole fruit if the latter disagrees. Vegetables: peas (green or dried), beans (string beans or dried beans), spinach, greens (turnip, mustard, or beet), cabbage, onions, celery, lettuce, served as vegetables or in soups, potatoes. Meat: lightly broiled beefsteak or stewed or boiled meat or chicken served not more than once a day or three times a week. Eggs, prepared in different ways. Cheese dishes. Breakfast bacon or ham in moderate quantities, butter, olive oil (or other salad oils) in moderation, whole wheat, graham or bran bread, Boston brown bread and crackers, milk, cocoa, chocolate, buttermilk, malted milk, koumiss, or zoolak; coffee and tea in moderation.

The diet, as has already been stated, may be supplemented by nutrient beverages or milk gruels.

The diet of the nursing mother, as has been explained in a previous chapter, must not only cover her own requirements but must likewise be adequate to furnish the extra requirements imposed by the nursing infant.

Food Requirements of Nursing Infant.—When the baby is a month old he should be growing rapidly, and his food requirements at this period and until he is about three months old will be approximately fifty calories per pound of body weight in the twenty-four hours. As he grows older his requirements grow gradually less in proportion to his weight. This is because the rate of growth is less, so thatfor the next three months the requirements are from 43 to 40 calories per pound of body weight per day, and 35 calories per pound during the last three months, or by the end of the first year of life.

It has been estimated, as before stated, that the average infant will take 2⅓ to 2½ ounces of mother’s milk per day[63]to each pound of body weight and that every ounce of mother’s milk will yield on an average 20 calories. Hence a month-old baby weighing ten pounds will be taking about 23 ounces a day, yielding 460 calories. Scientists have estimated that for every calorie produced by the milk two extra calories must be provided by food, so that for the baby requiring 460 calories per day, to cover his requirements the mother will be obliged to consume extra food to yield 920 calories, or the regular amount to meet her normal requirements plus the extra food to make sufficient food for the baby.

Diet of Nursing Mother.—The diet of the nursing mother need not be different from that to which she is accustomed. She should be warned against overwork or over-fatigue, nervous excitement and worry, since these factors affect the digestion of the nursing baby. She must be careful not to eat indigestible foods or foods which disagree with her, as such things will undoubtedly affect the digestion of the infant. When an article of food does cause digestional disturbances in the baby, it should be carefully omitted from the mother’s diet.

Factors Retarding and Stimulating Milk Secretion.—Constipation in the mother reacts quickly and unfavorably upon the secretion of milk. The same has proved to be the case when she becomes excited, nervous, worried, or over-tired.

The average diet for the normal woman is safe for the nursing mother. If her supply of milk is deficient, it maybe at times increased or stimulated by the drinking of a glass of milk between meals or by taking a cup of hot cereal milk gruel. It was formerly believed that beer, ale, or stout acted directly upon the mammary glands, stimulating the secretion of milk, but there is little proof of this and the drinking of alcoholic beverages need not be encouraged on this account, since often more nourishing beverages fulfill the purpose more efficiently and without bad results.

Gastric Disturbances.—The nausea and vomiting so often a part of early pregnancy is not believed to be the result of a disordered stomach but primarily a mild form of poisoning resulting from the incomplete establishment of the fetal circulation.

Adjusting the Diet.—The adjustment of the diet to cover the needs of the prospective mother and those of the developing child is essential. The amount of food taken by the mother is not materially changed during the first three months of gestation. An average normal diet is all that is necessary. After this time a twenty per cent. increase in the woman’s diet will furnish adequate means both for her maintenance and for the growth and development of the child.

Type of Food.—The kind of food which is necessary for the pregnant woman to take during this period is very similar to that taken ordinarily. It is necessary to furnish food materials rich in calcium and phosphorus, with an adequate supply of proteins in their simplest form in order to meet the requirement of the growing organism. Milk and eggs furnish the most efficient foods in this respect and the prospective mother should see that they form the chief items of her daily dietary. Milk furnishes calcium in its most available form for the developing skeleton of the growing infant, hence it is necessary to provide the mother withfood to replace the mineral which is withdrawn from her body.

Meat in the Diet.—Meat should be eaten sparingly by the prospective mother, as it imposes needless work upon the already taxed kidneys and, if eaten in excess, will give rise to dangerous complications. Milk and eggs will provide ample protein for all purposes.

Albumen in the Urine.—Albuminuria is one of the most frequent complications in pregnant women. It should be combated and controlled as soon as possible. The allowance of meat should be cut down or entirely eliminated from the diet until the urine clears up. When albuminuria is persistent in spite of efforts to overcome it, the patient must be placed upon a strict milk diet as used in acute nephritis, to prevent dangerous complications arising.

Diet of Mother.—Her dietary need not differ materially from that to which she is accustomed. She must avoid indigestible foods or any article which has been proved to disagree with either the infant or herself.

Factors Regarding Secretion of Milk.—Constipation, worry, nervous excitement, and over-fatigue all have an unfavorable effect upon the secretion of milk and must therefore be avoided by the nursing mother.

The Bowels.—Constipation of the mother reacts quickly and unfavorably upon the health and comfort of the baby, hence it should be avoided by eating coarse breads, green vegetables, and fruits, when they do not disagree with the baby, by drinking plenty of water and taking a certain amount of outdoor exercise to keep her own health in good condition.

Stimulating the Milk Production.—When the milk supply is deficient it will be advisable for the mother to drink a glass of milk or a bowl of cereal milk gruel betweenmeals. Alcoholic beverages are not necessary to insure an adequate secretion of milk. The milk or milk gruels answer the purpose more efficiently and without bad results.

Energy Requirements of Infant.—The average baby requires fifty calories per day per pound of body weight to cover his energy growth and development needs for the first three months of life, after which the rate of growth is less and his requirements decrease from forty-three to forty, then to thirty-five calories per day per pound by the end of his first year.

Amount of Milk Needed for Infant.—Approximately two and one-third ounces to each pound of body weight per day covers the needs of the average baby.

Fuel Value of Mother’s Milk.—Each ounce of milk yields twenty calories.

The Making of Milk.—It has been estimated that for every calorie yielded by milk, two extra calories must be provided by food.

(a) Formulate a dietary for a pregnant woman, allowing for a twenty per cent. increase over her normal requirements.(b) Show how the diet may be made to cover the need for additional iron, calcium and phosphorus.(c) Formulate a diet for a nursing mother with an infant two months old and weighing twelve pounds.

(a) Formulate a dietary for a pregnant woman, allowing for a twenty per cent. increase over her normal requirements.

(b) Show how the diet may be made to cover the need for additional iron, calcium and phosphorus.

FOOTNOTE:[63]“Feeding the Family,” p. 93, by Mary Swartz Rose.

[63]“Feeding the Family,” p. 93, by Mary Swartz Rose.

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, theageandweight. 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:

In the first month, about1.00 per centAt the middle of the first year0.30 per centAt the end of the first year0.15 per centAt fifth year0.03 per centMaximum in later years for boys0.07 per centMaximum in later years for girls0.04 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]

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 alife 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 2⅓ 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, theformer 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 thefat, sugar, and protein composition of whole milk, cream, skimmed milk, and whey was arranged by Morse and Talbot:[67]

FatMilk SugarProteinWhole milk4.004.503.507% cream7.004.453.4010% cream10.004.402.2516% cream16.004.203.0532% cream32.003.402.50Skimmed milk1.005.003.55Separated milk (fat-free)0.255.003.65Whey0.255.000.90

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 whichthe 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, 1½ 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.—Lactoseis 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 asdextri-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, indicatedby 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 ofacute 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, itmust 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 layercontaining 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 fromseven 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 theuse 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 4½ 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 × 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 forinfants, 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—

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