SCHEME FOR FEEDING NORMAL INFANTS

Gravity cream12 ouncesSkimmed milk18 ouncesLimewater6 ouncesBarley water12 ouncesMilk sugar4 rounded tablespoonfuls

“The barley water is made with two teaspoonfuls of barley flour in a pint of water. The total quantity of the mixture is 48 ounces. Gravity cream contains 16% fat. Twelve ounces of gravity cream in a 48-ounce mixture will give, therefore, 12/48 of 16% of fat, or 4% fat. Both gravity cream and skimmed milk contain 3.20% protein. There are 30 ounces of gravity cream and skimmed milk in the mixture; 30 ounces in a 48-ounce mixture will give 30/48 of 3.20% of protein, or 2.00% of protein. Both gravity cream and skimmed milk also contain 4.50% of sugar. Thirty ounces of gravity cream and skimmed milk in a 48-ounce mixture will therefore furnish 30/48 of 4½ which is the same as 30/48 of 9/2 or almost 3.00% of milk sugar. Four rounded tablespoonfuls of milk sugar are equal to two ounces. Two ounces of sugar in a 48-ounce mixture is equal to 2/48 of 100% or 4%. The total percentage of sugar is, therefore, 7%. Two teaspoonfuls of barley flour in a pint of water makes a 1.50% decoction of starch. Twelve ounces of barley water of this strength in a 48-ounce mixture will give 12/48 of 1.50% or about 0.35% starch. There are six ounces of limewater in the mixture and 30 ounces of gravity cream and skimmed milk. 6/30 of 100% is 20%. Thelimewater is, therefore, 20% of the milk and cream. The mixture thus contains 4% fat, 7% sugar, 2% protein, and 0.35% starch, while the limewater is in the proportion of 20% of the cream and milk.”

If, therefore, the nurse will follow out the plan suggested by Drs. Morse and Talbot, it should be a simple matter to change the percentage of any of the food constituents in any formula.

The following schemes for feeding well babies are included to facilitate the work in the home. A nurse may teach the mother the manner in which these schemes are used, keeping in mind that there can be no iron clad rule for feeding all babies. No nurse should recommend a formula without directions from a physician. And no formula should be changed without his permission.

The following milk formulas are used in the Nathan Straus Pasteurized Milk Laboratories of New York:

Formula No. 1.—Infants from 1st to 4th week, by A. R. Green.

24 ounces of mixture divided into 8 feedings of three ounces each, fed at intervals of 2½ hours:

¾ oz. 16% cream3 oz. full milk19 oz. water1¼ oz. limewater1½ oz. milk sugar

Formula No. 2.—Infants 1st to 3d month, by Dr. R. G. Freeman.

1½ oz. 16% cream3 oz. full milk13 oz. water½ oz. limewater1 oz. milk sugar

Divided into 6 feedings of 3 oz. each, fed 3 hours apart.

Formula No. 3.—Infants 2d to 6th month, by Dr. R. G. Freeman.

18 oz. full milk16½ oz. water1½ oz. limewater1½ oz. milk sugar

Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.

Formula No. 4.—Infants 3d to 7th month, by Dr. A. Jacobi.

18 oz. full milk18 oz. barley water1 oz. cane sugar20 grains salt (less than ¼ tsp.)

Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours.

Formula No. 5.—Infants 7th to 9th month, by Dr. A. Jacobi.

2½ oz. full milk7½ oz. oat or barley water1½ oz. cane sugar30 grains (about ¼ tsp.) table salt

Divided into 5 feedings of 6 ounces each, fed at intervals of 3½ hours.

(First Year)

Scheme based on Holt and Shaw’s “Save the Babies.” Pub. by Am. Med. Ass’n.

TimeMilk OuncesWater OuncesSugarIntervals of FeedingNumber of Feedings1st and 2d days1 to 3 tbs. every 3-4 hours3d and 4th days372 tsp.375th and 7th days483 tsp.378th day5101½ tbs.378th day to end of 3d monthIncrease ½ oz. every 4 daysIncrease ½ oz. every 8 daysIncrease ½ oz. every 2 weeks37-6End of 3d month16164¼ tbs.36Beginning of 4th month to end of 6th monthIncrease ½ oz. every 6 daysReduce ½ oz. every 2 weeks. (Cook barley in water if food disagrees)[76]446-5End of 6th month2412445Beginning of 7th month to end of 9th monthIncrease ½ oz. every week if food is well digested and child seems hungryReduce ½ oz. every 2 weeks445End of 9th month3010 oz. (in which 3 tbs. of cereal is cooked)2 tbsp.45Beginning of 10th month to end of 12th monthIncrease 1 oz. per monthCereal gruel as aboveReduce 1 tbs. per month4-55-4

At the beginning of 7th or 8th month, or earlier if necessary, it is advisable to add orange juice, giving from 1-2 tablespoonfuls between the two morning feedings.[77]

After the 4th month it is well to eliminate the night feeding between 10P.M.and 6A.M.

At end of 11th month add 1-2 pieces of stale bread, toast or zwieback. Part of soft-cooked egg may be given every other day at noon meal by end of 11th month. The orange juice may be increased to 3 tbs. if bowels are not loose.

The strained cereal should be given twice daily by the end of the first year, and the milk should be undiluted at this time unless the digestion of the infant forbids.

Cooled boiled water should be given several times each day between feedings. Babies cry from thirst as well as from hunger.

Scheme based on Dr. Richard M. Smith’s “The Baby’s First Two Years.”

A full-term baby will usually take a formula made as follows:

Cream2 ouncesSkimmed milk2 ouncesBoiled water12 ouncesSugar of milk6 level tsp.

After 3d day increase cream and milk at the rate of 1 ounce each week, and sugar 1 tsp. every other day until at one month the baby will be receiving a formula such as—

Cream5 ouncesSkimmed milk5 ouncesBoiled water22 ouncesSugar of milk3½ level tbs.

At two months—

Cream6 ouncesSkimmed milk6 ouncesBoiled water20 ouncesSugar of milk4 level tbs.

From this point the formula may be increased by adding 2 ounces of skimmed milk each month until the baby is eight months old. For each ounce of milk added, an equal amount of water should be omitted. The sugar in the formula should be reduced one half tbs. every three months.

At six months the baby would be taking—

Cream6 ouncesSkimmed milk14 ouncesBoiled water12 ouncesSugar of milk3½ level tbs.

At eight months—

Cream6 ouncesSkimmed milk18 ouncesBoiled water8 ouncesSugar of milk3 level tbs.

This amount will not be found sufficient in quantity for a twenty-four-hour mixture for children of this age. Increasing the amount of the last formula in the same proportion, it will be—

Cream9 ouncesSkimmed milk27 ouncesBoiled water12 ouncesSugar of milk4½ level tbs.

At this age the formula usually may be changed so as to be made from whole milk instead of cream and skimmed milk. The formula may be made as follows:

Whole milk36 ouncesBoiled water12 ouncesSugar of milk4½ level tbs.

From this point on the formula may be increased by replacing the boiled water with whole milk, two ounces each month up to thirteen months. At this age the boiled water may be omitted from the formula one ounce each week. Beginning at the age of eight months the sugar may be eliminated from the formula, one tablespoonful each month.

Barley Water.—At the age of five months, or at any time thereafter, barley water may be substituted for boiled water in the formula.This should be substituted when the baby is not gaining in weight. It may be substituted in many instances when the movements are not well digested.

Lime Water.—It is frequently found to be advisable to add lime water. It is not necessary in every instance, but should be given if the baby is inclined to spit up, or in cases where the stools are too frequent in number and are slightly green in color.

Determining the Fuel Value of a Formula.—The computation of the fuel value of a formula is very essential since the growth and development of the infant depends largely upon whether or not its energy expenditures are well covered. The method is simple, requiring the same methods used in the computing of other dietaries. Take the formula just calculated, its fuel value would be estimated as follows: Thirty-two ounces are equal to 960 grams. In each 100 grams there would be 3 grams of fat, 2 grams of protein and 6 grains of sugar. Hence in 9.6 one-hundred-calorie portions there would be 9.6 × 3—28.8 grams of fat, 9.6 × 2—19.2 grams of protein, and 9.6 × 6—57.6 grams of sugar, in a thirty-two-ounce mixture.

To determine the fuel value of the formula, these results must be multiplied by their physiological fuel factors, 9 and 4 and 4 respectively. Thus:

29 × 9=261calories from fat19 × 4=76calories from protein58 × 4=232calories from sugar, or a total of569calories for the entire mixture.

Scheme for Adding Solids to Infants’ Diet.—

From 9th to 15th month:

From 15 months to 2½ years:

From 3 to 6 years:

¼ lb. beef, lamb or chicken1 tablespoonful pearl barley1 potato2 tablespoonfuls rice1 carrot2 qts. water2 stalks celery1 pinch salt

Finely divide the vegetables. Add the vegetables, barley and rice to 2 qts. of water. Boil down to 1 qt., cooking 3 hours. Add pinch of salt. Pass through fine sieve.

Morse and Talbot advise baked potato, plain boiled macaroni, rice and wheat germ, bread and butter, baked custard, plain blanc-mange, and plain boiled tapioca to be given when the child is 1½ years old. When the child is nearly two years old they add meat in the most digestible forms, such as the white meat of chicken, lamb or mutton chops, and scraped beef.

The following dietary is suggested for a child two years old:[78]

“Whole milk, butter, mutton broth, chicken broth, beef juice, soft-cooked eggs, dropped eggs, white meat of chicken, lamb or mutton chops, scraped beef, French bread, stale bread, toasted bread, whole wheat bread, milk toast, zwieback, plain white crackers, plain Educator crackers, barley, jelly, oatmeal, cream of wheat, wheat germ, Ralston’s Farina, rice, baked potato, plain boiled macaroni, orange juice, baked apples, stewed prune pulp and juice, junket, baked custard, cornstarch pudding, plain blanc-mange, plain tapioca. It is not advisable, as a rule, to begin green vegetables until the baby is 2½ years old.”

It will be seen in the foregoing dietaries how authorities differ in their beliefs as to the requirements of the child. The dietaries included in this text are selected from those used in different parts of the country by physicians whohave successfully cared for the infants and children under their charge.

The digestion of premature infants is naturally not as strong as that of infants born at term. Very little is positively known, but the consensus of opinion goes to show that in the majority of cases the tolerance for sugar is greater than that of either the proteins or fats. The loss of heat is relatively greater in proportion to its surface area in small than in large bodies. This is a well-known fact, hence the premature baby must require more food in proportion to its weight than the baby who is born at the normal time. Then, too, as the premature infant is thinner he does not keep warm like the older infant, and this must be taken into consideration in feeding him. Breast milk is of course by far the best food for such babies, not only because its constituents are in a more available form for the feeble digestive organs, but because the mother’s milk furnishes a resistance which is lacking in even the most carefully modified of milk formulas.

Energy Requirements of Premature Infants.—Experiments made upon premature infants have proved that the caloric needs of these babies are greater than in the case of full-time babies; that is, they require more per kilogram of body weight. According to Morse,[79]“most premature babies need 120 calories per kilogram of body weight. But there are many exceptions, some thriving on as little as 70 calories per kilogram. No attempt should be made to reach 120 calories per kilogram during the first few days. Thirty calories per kilogram is as much as is wise to give in the first 24 hours of feeding. This amount should be gradually increased each day, watching carefully for symptoms ofindigestion and diminishing it if these appear. One hundred and twenty calories per kilogram can be given in about 10 days.”[80]

Necessary Dilution.—Even breast milk must be diluted with an equal amount of water or a 3% sugar solution. The amount of milk should be increased and the amount of dilution decreased until the undiluted breast milk is given in four or five days. Like older babies, the next best food for premature babies is the properly modified cow’s milk, but the utmost care will have to be observed, as these babies are more easily upset than older and stronger ones.

Premature Infant Feeding.—The following method of feeding may be suggested, keeping in mind that it is an easy matter to increase the strength of a mixture if the baby shows the need of such an increase. The premature baby is rarely strong enough to take the breast.

Method of Administering Milk.—The most satisfactory method of administering the food in such cases is by means of the Brick feeder, which consists of a graduated glass tube, open at either end. On the small end is placed a small nipple like those seen on medicine droppers; this one is perforated and goes into the mouth of the baby. A large rubber finger cot is attached to the other end of the tube. The milk is forced into the mouth by pressing the finger cot. In case the infant is too feeble even for this method of feeding, the desired amount is dropped into the mouth from a medicine dropper; 5 c.c. (about 1 dram or 1 teaspoonful) of diluted milk being given at each feeding. This amount is increased gradually from day to day.

Whey Mixtures.—Whey mixtures have been found to meet the needs of premature infants more efficiently than ordinary mixtures. As the proteins in whey are in a more digestible form, they throw less work on the immaturedigestive apparatus. As a rule the casein and whey are in proportion of 1:1.

The following formulas[81]show the amounts in which the food constituents are combined and are suitable for premature babies:

Fat1.00%Milk sugar4.00%Total proteins0.25%Lime water25% of cream and milk mixture

Fat1.00%Milk sugar4.50%Total proteins0.50%Lime water25% of cream and milk mixture

A word as to the use of Proprietary Infant Foods: These prepared foods may be classified under four heads, as follows: (1) condensed milks; (2) malted foods, those consisting chiefly of carbohydrates in the form of maltose and dextrins; (3) those consisting almost entirely of starch, and (4) those composed partly of soluble and partly of insoluble carbohydrates.

(1) Condensed milk may be sweetened or unsweetened. These milks are never given undiluted, the directions calling for one part condensed milk to nine parts water, which gives a mixture containing 0.90% fat, 5.49% sugar, and 0.80% protein if “Eagle Brand” Condensed Milk is used.[82]

(2) Malted Foods: Mellin’s Food and malted milk are examples of this group. These foods contain the carbohydrates in soluble form and when added to milk make an acceptable addition, as they furnish the carbohydrates in the most digestible form. When fed alone, diluted onlywith water, they result in a mixture deficient in both fat and protein.

(3) Imperial Granum is an example of this group, and there are several others with similar compositions. These foods are very much like wheat flour which has been subjected to heat, changing to a small extent the starch to dextrose and dextrin.

(4) Nestlé’s Food, Eskay’s Albumenized Food, and Allenbury’s Food are examples of this group, each containing sugar and a percentage of starch. Upon dilution with water, the amount of fat in the mixture is just a trace.

Incomplete Foods as a Source of Danger.—The ease with which the majority of these foods are prepared and the way in which they agree with the baby constitute the chief danger of their use. If they are added to milk, with the exception of the condensed milk, they result in a modified milk containing the carbohydrates in a more or less digested form. But they are expensive, and give no better result as a rule than a carefully modified milk containing a cereal gruel.

The giving of foods like malted milk alone is dangerous because they are deficient in some of the most necessary constituents, and babies fed in this way, while growing fat, are apt to have soft or brittle bones and muscular tissue higher in fat and water than in protein, so that they do not grow and develop in a normal way, and when they are attacked by the diseases so prevalent in the early years of life, they succumb rapidly, because the resistance given by a properly modified food is lacking.

Condensed milks act in a like manner. That is, in the sweetened milks the carbohydrate content is far in excess of the needs, and the proteins and fats are deficient, so that while the baby fattens he does not receive the building foods commensurate with his body requirements.[83]

Many mothers adopt the use of these foods because they mean less work than in modifying the milk properly, but the nurse should point out the facts just mentioned, explaining that while these proprietary infant foods are undoubtedly valuable at times to fill a place when the milk formula has not proved satisfactory, the use of these foods as a regular custom is expensive, not only from a financial standpoint but from a standpoint of health, since their disadvantages far outweigh their advantages in the long run.

Breast Milk as a Food.—The superiority of breast milk over any other known food cannot be too strongly emphasized.

Regularity in Feeding.—The absolute need for regularity in feeding—“feeding by the clock” and not by guess or when the baby cries.

Indications of Health.—The normal growth and development to be used as guides as to the physical well-being of the infant; also as an indication of the use of the proper modification of milk for the individual needs of the child.

Dilution.—The amount of dilution necessary—cereal waters, whey, etc.—to increase the digestibility and nutrient values of the formula.

The Addition of Alkali.—The addition of alkalies to milk formulas to accomplish a like purpose.

Milk Sugar, Malt Sugar, Cane Sugar.—The use of the different sugars, namely, dextri-maltose, lactose, or cane sugar under various circumstances as the condition of the infant demands.

Substitutes for Whole Milk.—The substitution of different milk, such as lactic acid milk, Bulgarian culture buttermilk, Eiweissmilch, cream and whey mixtures, as the individual needs of the infant demand.

Technique of Milk Modifications.—The absolute needfor the nurse to understand the technique of milk modification before attempting the care of an artificially fed infant.

Percentage Computation.—A knowledge of percentage, that an accurate computation of a formula may be accomplished.

Preparation of Food.—A sufficient knowledge of food preparation to enable the nurse to prepare any food which may be deemed necessary by the physician for the welfare of the child.

Water.—The importance of giving the baby water aside from that used in modifying the milk. Many babies cry from thirst when they are believed to be crying from hunger or temper.

Increasing the Diet.—The necessity for increasing the amount and strength of the formula with the age, growth, and development of the child by the addition of solid food as soon as the physician deems it advisable.

Feeding Premature Infants.—The method of feeding a premature infant differs from that employed in feeding an infant born at term: (a) because its development has not progressed so far; (b) because its digestive apparatus being more or less immature, food handled with ease by an older baby will be totally unfit for the premature one, both as to quality and quantity.

Wet Nurse.—The advisability of procuring a wet nurse when the mother is unable to nurse the infant, (a) on account of the more digestible character of the food constituents, especially the proteins, in mother’s milk over those of cow’s milk; (b) on account of the resistance furnished by the natural food which has been proved to be very much greater than that furnished by any other food, no matter how carefully the modification of the milk is made.

Premature Infants.—Their caloric needs are greater than in full-term babies, hence their food must be adjusted to meet these needs.

In fact the nurse must have an understanding of the behavior of foods in the metabolism of infancy and the laws which govern their use in the organism of the child.

(a) Write a formula for a two months’ old infant weighing twelve pounds, which contains 3% fat, 2% protein, and 6% sugar.(b) Change this formula so that it will contain 3% fat, 1.5% protein, and 6% sugar.(c) Write a formula for an eight months’ old baby, using whole milk instead of cream and skimmed milk.(d) Write a formula for a premature baby containing 1% fat, 4% sugar, and 0.25% protein (allowing 30 calories per pound of body weight).

(a) Write a formula for a two months’ old infant weighing twelve pounds, which contains 3% fat, 2% protein, and 6% sugar.

(b) Change this formula so that it will contain 3% fat, 1.5% protein, and 6% sugar.

(d) Write a formula for a premature baby containing 1% fat, 4% sugar, and 0.25% protein (allowing 30 calories per pound of body weight).

FOOTNOTES:[64]“Childhood and Growth,” p. 18, by Lafayette Mendel.[65]“Diseases of Nutrition and Infant Feeding,” by Morse and Talbot.[66]“Feeding the Family,” by Mary Swartz Rose.[67]“Diseases of Nutrition and Infant Feeding,” p. 218, by Morse and Talbot.[68]“Generally Accepted Methods for Artificial Feeding of Infants with Indicatives and Contra-Indicatives,” by Orville R. Chadwell, M.D. Reprinted from “New England Medical Gazette,” June, 1916.[69]“Mechanical Factors of Digestion,” by Cannon.[70]“Diseases of Nutrition and Infant Feeding,” p. 204, by Morse and Talbot.[71]“New England Medical Gazette,” June, 1916. Reprint by Orville Chadwell.[72]The best substitute for the homogenizer is found in an electric mixer; a formula prepared with a fat other than cream can be made by means of this mixer to approximate very closely that of homogenized milk.[73]There are a number of pasteurizers on the market; one sold by the Walker Gordon Laboratory and one designed by Dr. R. G. Freeman of New York are both satisfactory.[74]Method suggested by Morse and Talbot, “Diseases of Nutrition and Infant Feeding,” pp. 234-235.[75]“Diseases of Nutrition and Infant Feeding,” pp. 225 and 226, by Morse and Talbot.[76]One-half tbs. barley flour may be cooked in the water used as diluent; it should be boiled 20 minutes, strained and cooled before adding to formula.[77]When babies are fed upon pasteurized, sterilized, or dried milk it is advisable to use orange or prune juice earlier than the seventh month. Dr. Hess suggests the use of canned tomato juice as substitute for orange juice.[78]“Diseases of Nutrition and Infant Feeding,” p. 236, by Morse and Talbot.[79]Morse: “American Journal of Obstetrics,” 1905. Hess: “American Journal Diseases of Children,” 1911.[80]“Diseases of Nutrition and Infant Feeding,” p. 238, by Morse and Talbot.[81]“Diseases of Nutrition and Infant Feeding,” p. 239, by Morse and Talbot.[82]“Diseases of Nutrition and Infant Feeding,” by Morse and Talbot.[83]The proprietary foods on the market are many, but those given above as suggested by Morse and Talbot represent the best known infant foods.

[64]“Childhood and Growth,” p. 18, by Lafayette Mendel.

[65]“Diseases of Nutrition and Infant Feeding,” by Morse and Talbot.

[66]“Feeding the Family,” by Mary Swartz Rose.

[67]“Diseases of Nutrition and Infant Feeding,” p. 218, by Morse and Talbot.

[68]“Generally Accepted Methods for Artificial Feeding of Infants with Indicatives and Contra-Indicatives,” by Orville R. Chadwell, M.D. Reprinted from “New England Medical Gazette,” June, 1916.

[69]“Mechanical Factors of Digestion,” by Cannon.

[70]“Diseases of Nutrition and Infant Feeding,” p. 204, by Morse and Talbot.

[71]“New England Medical Gazette,” June, 1916. Reprint by Orville Chadwell.

[72]The best substitute for the homogenizer is found in an electric mixer; a formula prepared with a fat other than cream can be made by means of this mixer to approximate very closely that of homogenized milk.

[73]There are a number of pasteurizers on the market; one sold by the Walker Gordon Laboratory and one designed by Dr. R. G. Freeman of New York are both satisfactory.

[74]Method suggested by Morse and Talbot, “Diseases of Nutrition and Infant Feeding,” pp. 234-235.

[75]“Diseases of Nutrition and Infant Feeding,” pp. 225 and 226, by Morse and Talbot.

[76]One-half tbs. barley flour may be cooked in the water used as diluent; it should be boiled 20 minutes, strained and cooled before adding to formula.

[77]When babies are fed upon pasteurized, sterilized, or dried milk it is advisable to use orange or prune juice earlier than the seventh month. Dr. Hess suggests the use of canned tomato juice as substitute for orange juice.

[78]“Diseases of Nutrition and Infant Feeding,” p. 236, by Morse and Talbot.

[79]Morse: “American Journal of Obstetrics,” 1905. Hess: “American Journal Diseases of Children,” 1911.

[80]“Diseases of Nutrition and Infant Feeding,” p. 238, by Morse and Talbot.

[81]“Diseases of Nutrition and Infant Feeding,” p. 239, by Morse and Talbot.

[82]“Diseases of Nutrition and Infant Feeding,” by Morse and Talbot.

[83]The proprietary foods on the market are many, but those given above as suggested by Morse and Talbot represent the best known infant foods.

Digestive Disturbances.—It is a well-established fact that artificially fed infants are more subject to disturbances due to diet than breast-fed infants, the digestional disturbances of the latter yielding more readily to treatment. As a rule, with the breast-fed baby it is largely a question of adjusting the diet of the mother, of increasing the fluid in her diet, of seeing that she takes the requisite amount of exercise in the open air, and of lengthening the intervals between feedings or of giving the baby water just before putting him to the breast. With the artificially fed infant it is an entirely different proposition.

Causes in Artificially Fed Infants.—The digestive disturbances may arise from any one of half a dozen or more causes. The constituents in the milk may be in the wrong proportion. The amount given at a feeding may be too great or too little. The dilution may be too great or too small to meet the needs of the infant. Or the milk may contain the microörganisms which bring about fermentation or putrefaction. Any or all of these causes may assail the artificially fed baby. Consequently, all the care that can be exercised must be resorted to in the feeding of these babies, not only after digestional disturbances arise, but as a means of their prevention. In the preceding chapter the methods generally used in the feeding of normal infants were discussed. We now proceed to the feeding under abnormal or pathological conditions.

Errors in Diet.—The majority of the ills from which the baby suffers can be traced primarily toerrors in dietand in most of these cases the treatment consists chiefly in adjusting the formula to suit the condition. As a rule, these errors may be placed under two heads: those that are brought on by under-feeding and those induced by over-feeding. The pathological conditions arising from under-feeding are due not only to a lack of food, but chiefly to the improper balancing of the different food constituents in the formula. As has already been stated, so much food is required to cover the energy expenditures, so much for maintenance, and so much for storage for the growth and development necessary during the entire period from birth to maturity. These constituents must be regulated to the individual needs of the infant.

Over- and Under-dilution.—If the dilution is too great, the infant, while receiving the correct amount of the mixture, may have the necessary food constituents so reduced as to have them fail completely to do their appointed work in the body. Or if the amount of diluent is too small the baby may be receiving too strong a mixture, and develop nutritional disturbances therefrom. Under the first head the child suffers from under-feeding; the appetite is satisfied before enough of the actual food is ingested to meet his various needs. However, it is probable that the artificially fed infant suffers from the results of over-, rather than of under-feeding.

Gastro-intestinal disturbances, colic, enterocolitis, colitis, etc., rickets, scurvy, nephritis, and diabetes are among the diseases most apt to develop from injudicious feeding, and in these cases the dietetic treatment plays the most important part in combating the condition. The disturbances caused by food are recognized by the general symptoms:vomiting, rise of temperature, subnormal temperature, and the stools, the latter being the chief point of observation.

Fats as Cause.—When the fats are causing the disturbance, the rise of temperature is apt to be high, but not of long duration. The baby vomits frequently, the vomitus being acid in reaction and odor, the latter due to the presence of fatty acids, butyric acid, etc. Diarrhea often develops in a more or less acute form. In these cases there is a loss of sodium and other alkaline salts in the feces, and a consequent excess of ammonia in the urine, resulting in acidosis. Acid intoxication has been known to develop as a result of this loss of alkaline salts. The chief symptoms of this condition are rapid and deep respiration, stupor or restlessness, and cherry-red lips.[84]

Symptoms of Excess Fat in Diets.—The general symptoms in infants receiving an excess of fat in their food take the form of loss of appetite, with more or less loss of weight, or failure to gain. When the cases are not chronic, soft curds may often be seen, which are at times mistaken for casein curds, but may be distinguished from them by their translucent appearance and their solubility in ether. The color of the stools due to the excess of fat under the above-mentioned conditions is shiny and gray. In the majority of cases, especially of a more chronic character, the stools are apt to be large and dry, at times hard and crumbly. The fat in such stools is combined with magnesium and calcium salts, forming the characteristic “soap stools.”[85]The combined loss of these salts in the feces has a definite effect on the general metabolism and nutrition, giving rise to rickets.

Regulating the Fat.—The treatment consists chiefly of regulating the amount of fat in the formula, and of cutting it out altogether in the beginning when the symptomsshow acute acid conditions. In many cases, if the baby is given breast milk, the trouble disappears. At other times it is necessary to substitute a foreign fat such as olive oil for the butter fat. Dr. Ladd in the Children’s Hospital in Boston treated many babies who manifested an intolerance for butter fat with “Homogenized Milk,” which consisted of skimmed or separated milk and a certain percentage of olive oil, placed in an apparatus which brought about a more complete division of the fat, causing it to mix with the milk as an emulsion closely resembling human milk.

Fat intolerance is most difficult to overcome, the baby being apt to relapse into the acute stage unless the utmost caution is observed in adding the fats to the formula. It is not safe, however, to feed the baby upon a fat-free milk for any great length of time.

Excess Protein in Food.—The digestional disturbances arising from too much protein in the food are as a rule readily overcome in breast-fed infants. When it is due to nervousness or worry in the mother, it disappears as soon as the mother ceases to worry or does something to remove the cause of the nervous condition. When the breast milk is high in protein, more exercise in the open air at times adjusts the percentage of protein, provided the mother does not become over-tired, in which case the percentage of protein in breast milk increases.

Evidences of Excess Protein.—The symptoms of excess protein in the diet of the breast-fed baby are colic and flatulence, which are often persistent and difficult to overcome. Vomiting is not so common in these babies as in those who are artificially fed. The stools are increased in number, are either brown or green, and generally loose and watery. In artificially fed infants the symptoms are much the same, except that the vomitus often contains large curds which are tough and leathery. The baby suffers from gas formation and colic. The stools are at times normal, exceptfor the presence of large, hard curds; at other times they are increased in number, and are of a watery consistency and alkaline in reaction.

Regulating the Protein in Formula.—When the stools are watery and brown and musty in odor as the result of disturbed protein digestion, the treatment consists of taking out the proteins from the formula and of substituting cereal water, to which dextri-maltose or milk sugar is added, the milk being added as soon as possible to prevent too great a loss of body protein. As a rule the whey proteins do not cause the disturbances so often as the casein proteins; and at times it is possible to use whey mixtures with babies who cannot tolerate the casein at all.

Buttermilk also is used in cases of protein indigestion, as is Eiweissmilch and peptonized milk.

Regulating the Carbohydrates.—When the disturbances are due to the carbohydrates in the formula, they may be digestional or nutritional. In this form the milk sugar is more apt to be the cause of the trouble than the dextri-maltose preparations which are at times used. In the latter, when the disturbance becomes nutritional, the cause of the trouble can usually be traced to an excess of starch. When the percentage of milk sugar is greater than can be handled by the digestive apparatus of the baby, it is manifested by frequent attacks of colic, with the passage of watery green stools, highly irritating, in character on account of their acidity. In acute cases the loss of weight is often marked, and symptoms of intoxication may develop. The outlook is grave in the very severe cases, but if the baby can survive forty-eight hours after the acute symptoms develop, he is apt to pull through the attack.

Adjusting the Sugars.—The treatment in these conditions consists of eliminating the milk sugar from the formula; in less severe cases dextri-maltose may be substituted. As a rule, coincident with indigestion caused bysugar there will be found to be an intolerance for much fat, so that this must be adjusted as well as the milk sugar. Skimmed milk mixtures, containing a certain amount of barley or oatmeal water, are generally found to be suitable in these cases. Dextri-maltose may be added after a few days in order to maintain the fuel needs of the body. Eiweissmilch is at times used, but whey mixtures are contraindicated on account of their high sugar content.

Dextri-maltose also disagrees at times. The baby has colic and flatulence, the stools are usually loose or watery and dark brown in color. The dietetic treatment consists of an immediate withdrawal of the dextri-maltose preparation and a substitution of milk sugar after a few days.

Evidences of Excess Starch in Formula.—The disturbances arising from an excess of starch in the diet are, as has already been stated, more apt to be of a chronic than an acute character. Vomiting is not a common symptom under these conditions, although colic is frequent. The stools are at times loose and brown, at other times dry and small. The baby at times suffers from diarrhea and at others from constipation. When the disturbance is acute the starch must be entirely eliminated from the formula. If proprietary foods are being used containing starch, whether it is dextrinized or unchanged, they must be at once abandoned, and a formula made up of protein with sugar and fat.

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