FEEDING OF THE HEALTHY INFANT[1]
By E. J. Huenekens, A. B., M. D.Instructor in Pediatrics, University of MinnesotaMINNEAPOLIS
[1]Read before the Hennepin County Medical Society, Nov. 2, 1914.
[1]Read before the Hennepin County Medical Society, Nov. 2, 1914.
The science of infant-feeding has been revolutionized in the last twenty years, and, in the process, it has advanced too radically in many directions. Lately, the pendulum has been swinging backward, so that the most advanced knowledge of today probably represents a middle ground between extreme radicalism and extreme conservatism. In no other direction is this more manifest than in the feeding intervals. The religious adherence to the four-hour feeding interval is giving way to a more rational system. I am one of the firmest adherents of the longer interval: the food is better digested, the stomach has a period of rest, and the general well-being of the infant is better furthered than with more frequent feedings. But there are certain infants who do not receive enough nourishment in this interval, especially young breast-fed infants in whom it can be demonstrated by accurate weighing, before and after nursing, that they receive considerably more milk in twenty-four hours with the three-hour interval. This is the more important in that Rosenstern has demonstrated that a large proportion of infants up to the age of six weeks require more than the usual 100 calories per kilogram of body-weight. One hundred calories represents 150 grams of breast-milk, so that a five-kilo, or eleven-pound, baby should receive a minimum of 750 c.c. of breast-milk in twenty-four hours.
By far the best food for the healthy infant in every way—and this cannot be emphasized too strongly—is mother’s milk. There are certain alimentary disturbances in which it may be advisable to replace breast-milk with certain artificially prepared foods, such, for instance, as albumin milk in alimentary intoxication; but this is never true of the normally healthy infant. While, as regards growth and freedom from digestive disturbances, certain artificially prepared foods may, when used with exceeding care, produce as good results as breast-milk; nevertheless, this is only one function of breast-milk. The other function which can be imparted to no artificial food is the passive immunization of the child against infection. Ehrlich (Zeit. f. Hyg. u. Infectionskr., 1892, xii, 183) has proved that antibodies, antitoxin, and agglutinins are transmitted directly through the milk from mother to child; and it has been shown that the blood of a breast-fed child is considerably more bactericidal than the blood of a bottle-fed infant.
The practice of weaning the baby for trivial reasons has increased in the last decade, and can be laid largely at the door of the medical profession. For all practical purposes the only absolute indication for weaning the baby is open tuberculosis in the mother. For the last few years I have been making a systematic inquiry at the University Dispensary and Infant Welfare Stations as to reasons for weaning young infants; and in nine cases out of ten, the answer has been that “the milk gave out.†In only a very small proportion of cases has an ordinarily well-nourished mother insufficient milk; far oftener the fault lies with the child. Insufficientand late development of the sucking reflex prevents these infants from completely emptying the breast, which in time “dries up.†This period can be tided over by nursing from both breasts, by temporarily increasing the number of nursings, or temporarily employing “allaitement mixte.†In cases in which, after long, patient effort the supply of milk is still insufficient, either supplementary or complementary feeding of cow’s milk can be given. Where this mixed feeding is employed a minimum amount of cow’s milk should be given; and the opening in the nipple should be as small as possible, otherwise the child gets too much cow’s milk, and with too little effort, and gradually refuses the breast.
Another excuse, and one fostered to some extent by physicians, is, that certain breast-milks are “poison for the baby.†This has even less foundation in fact; and here again the fault must be looked for in the baby rather than in the mother. Outside of certain variations in the fat-content, all breast-milks are alike in composition. In proof of this Finkelstein has fed these babies at the breast of tried wet-nurses with absolutely no benefit, while the children of the wet-nurses would thrive at the breast of the “poison-milk mother.â€
Abscess of both breasts may force a temporary cessation of nursing, but the breast should be regularly emptied until the inflammation has subsided; and then the nursing should be re-established. Cracked or sunken nipples may render nursing impossible, but they do not stop the flow of milk. In both these latter conditions the milk may be manually expressed or removed with the breast-pump. In this connection I wish to recommend the improved Jaschke pump, in which, by means of a releasing valve, the sucking movements of the child can be very closely imitated.
Where artificial feeding must be started early, cow’s milk is almost universally employed. Whenever possible, “certified milk†should be used; the ordinary milk, however, can be boiled with little or no harm. In diluting and preparing this milk, we have the choice of several methods. The so-called percentage feeding, favored in America, is difficult and cumbersome, and has no advantages over its simpler rivals. Pfaundler’s rule may be safely employed. It is as follows: One-tenth body-weight of milk, one one-hundredth body-weight of sugar diluted up to one liter; give 200 c.c. five times in twenty-four hours. Even simpler is the following: One-third milk for the first month, one-half for the second month, two-thirds for the third and fourth months, each with the addition of 4 to 6 per cent sugar. Either milk-sugar or ordinary granulated sugar may be employed. The malt sugars and extracts should be reserved for sick children. After the second month, oatmeal water may be used as a diluent in place of plain water.
Recently Friedenthal, a Berlin physiologist, has attempted an exact imitation of mother’s milk, including that important element, the salt, which had, until recently, been entirely neglected. Langstein is very enthusiastic over this milk as a food for healthy infants; but Finkelstein, in a personal communication, assured me that it has not as yet proved itself. Schloss, dissatisfied with the results of the Friedenthal milk, has modified it in the direction of casein milk by replacing the milk-sugar with the malt preparations, and increasing the protein content. He claims good results, and is supported by Leopold, of New York, who has used it extensively. But we must leave the final word as to both these milks for the future to decide. From the sixth to the ninth month for both breast-fed and bottle-fed babies, cooked cereals, toast, and vegetables should be gradually added to the diet. At the ninth month, unless this is one of the hot summer months, the nursling should be weaned, and a small amount of cow’s milk substituted. The weaning should be gradual by omitting one nursing period each week. The one important exception to the foregoing rules for the first year of life, is the premature infant. In the ninth month of fetal life, reserves of calcium and iron are stored up in the body, which the infant gradually uses up during the first nine months of extra-uterine life. The premature infant lacks this store, and manifests it in different ways. As early as the second or third month a breast-fed premature infant may develop a most extensive craniotabes. This is not due to a true rachitis, i.e., disturbance of calcium metabolism, but to a want of calcium in the body. Small amounts of cow’s milk, which contains much more calcium than human milk, or calcium in the form of calcium lactate or chloride, will remedy this condition. A similar process happens in the case of iron. The premature infant is born with a hemoglobin percentage of 100 to 110; by the third or fourth month this may sink to 40 per cent, and for this reason green vegetables should be added to the diet as early as the fourth month.
The diet of healthy children in the second year should include cooked cereals, vegetables, toast, cooked fruits, and meat-juices; and the quantity of cow’s milk should be limited to one and one-half pints in twenty-four hours. The question of the addition of meat to the diet is important. Some authors have recently advocated the giving of meat as early as the ninth month. During the past year, working in Finkelstein’s laboratory, I have been able to gather some facts which have a direct bearing on this question. (Zeitschrift für Kinderheilkunde, July, 1914.) By means of the new electrometric determination of absolute acidity (that is, the number of H ions), I was able to show that the acidity of the stomach before the eighteenth month of life is insufficient to permit any peptic, i. e., protein, digestion. Solomon, working in the same clinic, in a report not yet published, has shown the same thing from a clinical standpoint. He found that on a meat diet up to the end of the second year large quantities of muscle fibers passed through with the bowel-movement unchanged; but after that age they rapidly decreased in number. It is, therefore, worse than useless to add meat to the diet before the beginning of the third year.
Eggs frequently produce profound disturbances in young infants, perhaps on account of the absorption of egg albumin, unchanged, in the blood-stream; and they should be kept from the diet-list until the beginning of the fourth year.
These rules for feeding are generalized, and there may be many exceptions. Each child is to some extent a law unto itself, and this is especially true of those children with nervous or exudative diathesis.
In conclusion, I wish to make a plea for greater uniformity in our rules for infant-feeding. Even more than in strictly medical affairs has the public the right to demand information. Heretofore, every new book and every public lecture on infant-feeding has deviated markedly from its predecessors, until the confused laity, and even general practitioners, have turned in disgust to proprietary foods and formulas. Pediatrics is a new science, and as such is bound to undergo rapid changes and conflicting opinions. But that need not hinder us from agreeing on certain fundamental facts which can be given as guides to the general practitioner and to the public.
I believe that the simple rules for infant-feeding here laid down are neither too conservative nor too radical to serve as a basis of agreement upon which the medical profession may show to the public a united front on this important question. Such uniformity of opinion—and the sooner it can be reached the better—will not fail to have a beneficial effect on both the profession and the public.
Dr. Jacob Hvoslof: I would like to ask about the value of lime-water added to the milk. I recently had an experience where I mixed an ounce of lime-water to a pint of milk, as I thought that would improve it. but for some reason or other the baby would not digest his milk. After a while I left the lime-water out, and everything went well. Whether this is a “post†or “propter†I should like to find out.Dr. O. R. Bryant: In case of an exudative diathesis, where you probably will start solids early, you will also be able to use meat earlier. An infant that does well on solids at six months can probably have meat once a day at fifteen months and show a normal stool.Dr. S. R. Maxeiner: I would like to ask Dr. Huenekens where he classes eggs and egg albumin.Dr. C. G. Weston: I have been very much interested in Dr. Hueneken’s paper. I care only for the babies during the three or four weeks after birth; and of late years many of them have passed from me directly into the hands of the pediatrists. I formerly had the babies nursed every three hours, but finding that the baby specialist immediately, on assuming charge, put them on the four-hour schedule, I changed, about a year and a half ago, to that interval; and I thought my troubles would cease, but such has not been the case, and it has been my impression, as well as that of the nurses who have had the care of the infants, that it has made very little difference.The four-hour schedule is not a new thing in Minneapolis. Many of the older members of this Society may remember that twenty years ago Dr. R. O. Beard always fed his babies in this way.It seems to me that we should make no hard and fast rules for the feeding of babies, except the one that mother’s milk should be used whenever possible. We should individualize with the babies. If they do well on the four-hour schedule, follow it, as it makes the care of the child easier for the mother; if, however, the child does not get sufficient milk on this interval to properly nourish it, diminish the latter to three hours.The only way to accurately determine how much milk the nursing infant is getting, is to weigh the baby before and after nursing. One is often surprised at the varying amounts obtained by the same baby at different nursings with no obvious difference in the condition of the breasts. We have had a baby obtain as much as three ounces in the first five minutes of nursing, and at the next feeding take only one or one and a half ounces in twenty minutes.The green and frequent stools, with evidences of colic, etc., are often found to be due to too much milk, or taking it too rapidly; and the weighing method is the only way to determine this.I most heartily endorse what Dr. Huenekens said with reference to the importance of encouraging in every way maternal nursing. Many a mother gives up the attempt to nurse her baby on account of some soreness of the nipples or because she has thought she hadtoo little milk to be of any use. Most of these cases may become, by the means recommended by the reader, good milkers, and many a baby’s life may thus be saved.Dr. E. K. Green: I would like to ask a question in regard to putting babies on cow’s milk. I have adhered very closely to the principle that modified cow’s milk is absolutely the best food for infants, if it is impossible to get mother’s milk, but many times when I have had the opportunity to follow these cases carefully I have had all sorts of stomach and bowel disturbances on cow’s milk until someone would suggest some other food, such as malted milk, or Mellin’s Food, or even condensed milk, which seems to be the farthest from the natural food, and then the babies would get along fairly well. Is this a common experience, or is there something wrong with my method? We have in our own home two children brought up on the bottle, one with malted milk and the other with Mellin’s Food. In both these cases I tried, not only once, but several times to use the modified cow’s milk, but failed absolutely. I would like to know if you consider the fault usually with the modified milk, or does the individual have considerable to do with the case?Dr. A. S. Fleming: I would like to ask if in the case of the healthy infant the mother’s diet would modify the constituents of the milk otherwise than in the facts stated. For instance, will it modify the character of or the percentage of the sugar, or will any of the aromatic constituents disturb the infant’s digestion?Dr. M. J. Jensen: Dr. Huenekens dealt with the feeding of the healthy infant only. I would like to ask if it is not true that nearly all infants born alive, are born as healthy and sound as any infant ever is, so far as the functions of its organs and tissues are concerned? Nature frequently decides on producing premature births and “stillâ€-births, rather than running the risk of producing a sick or sickly infant. In young infants it is very often difficult to determine when to classify them as healthy or unhealthy, realizing the conditions of their environment and usual care that is given in the homes.In regard to the sterilization or boiling of cow’s milk: I do not think that children fed on pasteurized or boiled milk develop as well as those who are fed upon raw milk as it comes from the cow. Dr. Palmer, of Chicago, fed seven hundred children on raw milk during the midsummer months and only lost three of the number. The miserable, atrophied children began to live the moment treatment with raw milk was begun. If the process of milking was carried out in a sanitary manner, or by means of a suction apparatus, then cooled, and placed in sterilized bottles, I believe we would prohibit the development of bacteria, and save the food which exerts so marked a protective influence upon the infant’s organs.When raw milk free of all objections cannot be obtained, it is sometimes advisable to use another milk product namely, buttermilk.Dr. S. Marx White: There is just one point I have been thinking about in the discussion on the question of infant-feeding, and that is whether Dr. Huenekens really means us to believe that in practically all cases the mother can furnish sufficient milk for the child. He passed that over in saying that in nine out of ten cases the mother gave as a reason for discontinuing the milk that the milk gave out. Is it not true that in a good many instances the mother needs treatment quite as much as the infant? I do not mean medical treatment, but management. Is it not true that an overworked, tired, nervous, worrying mother is unable to supply sufficient milk for the child? It has been my impression from a very limited experience in this field, that the mental and nervous and physical state of the mother is a very large factor in the production of the milk. When upset and under deleterious influences she is really not a proper producer for the child; and the management of the mother is often quite as important a factor as any other.Dr. W. H. Aurand: In such cases as Dr. White just mentioned, what are we going to do to increase the supply of milk? Also, I would like to ask Dr. Huenekens if he means to feed to the new-born baby 200 c.c. at a feeding?Dr. Huenekens(closing): As regards lime-water: I cannot recommend its use. Wherever there is a specific demand for calcium, as in premature infants or spasmophilic cases; or where it may help to produce a firm stool; or, as in diarrheal disturbances, it may be of great value, but in the normal healthy infant it is of no benefit whatever.Dr. Bryant mentioned the giving of meat in exudative diathesis: His statement that such infants can probably have meat once a day at fifteen months, and show normal stools, is beside the question. A normal macroscopic stool does not necessarily mean that the meat has been digested. However, I am now working on this problem, that is, to determine whether an early solid diet produces an earlier digestion of meat.I would classify eggs and egg albumin as proteins, and therefore not digestible until the beginning of the third year: but, over and above this, there is danger of anaphylaxis from the absorption of the unchanged egg albumin into the blood-stream.What Dr. Weston says of the feeding intervals is very interesting. I do not want to be considered an enemy of the four-hour feeding, for I use it wherever possible, and I think it the best interval; but when the infant cannot get enough in that period, we have to choose between two evils. I think the lesser evil is to give the child more milk at shorter intervals, and take the risk of a slightly poorer digestion. We should, also, wherever possible, control the amount of breast-milk by weighing the child before and after nursing. It is highly important to determine whether the baby is getting too much or too little.As to Dr. Green’s statement, “Modified milk†is a very general term. What is usually meant is milk with a high percentage of fat and a low percentage of sugar, while malted and condensed milk have a high percentage of carbohydrate. In my opinion, if he had used cow’s milk without the addition of cream and with large amounts of cane sugar, he would not have had this trouble. But a large number of children will not do well on this diet. We have special rules for abnormal children with exudative and nervous diathesis.In reply to Dr. Fleming’s question regarding the mother’s diet and its effect on her milk: What the mother eats has absolutely no effect on the composition of the milk in any way whatever, except perhaps in the percentage of fat. Now-a-days we do not advise any particular foods for the mother’s diet,—anything she likes, and can digest, plus large quantities of fluid;—otherwisethere is no single food we advocate—none that will make the milk richer or better, or increase the quantity.I cannot agree with Dr. Jensen that raw milk is so far superior to boiled milk. Of course, wherever it is possible, we should use certified milk, which does not require boiling; but, if we have inferior cow’s milk contaminated with bacteria, we can boil the milk with very little harm. It is just as well digested, and the food value just as great. There is of course slight danger of scurvy; but that is very easily diagnosed, and very easily cured by a little fresh milk or small doses of orange juice. Where we have inferior milk, it should be boiled in every case.Dr. White brought up a very interesting point in regard to nervous mothers. Their milk supply is subject to wide fluctuations; but, if the breasts are well emptied at each nursing, they will secrete sufficient milk. I will admit that these cases are difficult to handle, for the infants usually have nervous diathesis, and do not respond well to ordinary food. The one important point is to completely empty the breasts; and that is the only measure we can take to increase the supply of milk.In reply to Dr. Aurand: I would feed a new-born infant 200 c.c. at a feeding if the milk is sufficiently diluted. The liquid part of the food passes very quickly into the duodenum, so that, before the infant has finished feeding, a part of this quantity has already left the stomach.In conclusion: We have an opportunity in our infant-feeding to practice the really scientific prophylactic medicine of the future. We can do more in preventing infant-mortality by proper feeding than by any other single measure; and we should encourage mothers to bring their new-born infants to the physician for advice on feeding, and to continue to consult him at longer or shorter intervals during the whole of the first year of life.
Dr. Jacob Hvoslof: I would like to ask about the value of lime-water added to the milk. I recently had an experience where I mixed an ounce of lime-water to a pint of milk, as I thought that would improve it. but for some reason or other the baby would not digest his milk. After a while I left the lime-water out, and everything went well. Whether this is a “post†or “propter†I should like to find out.
Dr. O. R. Bryant: In case of an exudative diathesis, where you probably will start solids early, you will also be able to use meat earlier. An infant that does well on solids at six months can probably have meat once a day at fifteen months and show a normal stool.
Dr. S. R. Maxeiner: I would like to ask Dr. Huenekens where he classes eggs and egg albumin.
Dr. C. G. Weston: I have been very much interested in Dr. Hueneken’s paper. I care only for the babies during the three or four weeks after birth; and of late years many of them have passed from me directly into the hands of the pediatrists. I formerly had the babies nursed every three hours, but finding that the baby specialist immediately, on assuming charge, put them on the four-hour schedule, I changed, about a year and a half ago, to that interval; and I thought my troubles would cease, but such has not been the case, and it has been my impression, as well as that of the nurses who have had the care of the infants, that it has made very little difference.
The four-hour schedule is not a new thing in Minneapolis. Many of the older members of this Society may remember that twenty years ago Dr. R. O. Beard always fed his babies in this way.
It seems to me that we should make no hard and fast rules for the feeding of babies, except the one that mother’s milk should be used whenever possible. We should individualize with the babies. If they do well on the four-hour schedule, follow it, as it makes the care of the child easier for the mother; if, however, the child does not get sufficient milk on this interval to properly nourish it, diminish the latter to three hours.
The only way to accurately determine how much milk the nursing infant is getting, is to weigh the baby before and after nursing. One is often surprised at the varying amounts obtained by the same baby at different nursings with no obvious difference in the condition of the breasts. We have had a baby obtain as much as three ounces in the first five minutes of nursing, and at the next feeding take only one or one and a half ounces in twenty minutes.
The green and frequent stools, with evidences of colic, etc., are often found to be due to too much milk, or taking it too rapidly; and the weighing method is the only way to determine this.
I most heartily endorse what Dr. Huenekens said with reference to the importance of encouraging in every way maternal nursing. Many a mother gives up the attempt to nurse her baby on account of some soreness of the nipples or because she has thought she hadtoo little milk to be of any use. Most of these cases may become, by the means recommended by the reader, good milkers, and many a baby’s life may thus be saved.
Dr. E. K. Green: I would like to ask a question in regard to putting babies on cow’s milk. I have adhered very closely to the principle that modified cow’s milk is absolutely the best food for infants, if it is impossible to get mother’s milk, but many times when I have had the opportunity to follow these cases carefully I have had all sorts of stomach and bowel disturbances on cow’s milk until someone would suggest some other food, such as malted milk, or Mellin’s Food, or even condensed milk, which seems to be the farthest from the natural food, and then the babies would get along fairly well. Is this a common experience, or is there something wrong with my method? We have in our own home two children brought up on the bottle, one with malted milk and the other with Mellin’s Food. In both these cases I tried, not only once, but several times to use the modified cow’s milk, but failed absolutely. I would like to know if you consider the fault usually with the modified milk, or does the individual have considerable to do with the case?
Dr. A. S. Fleming: I would like to ask if in the case of the healthy infant the mother’s diet would modify the constituents of the milk otherwise than in the facts stated. For instance, will it modify the character of or the percentage of the sugar, or will any of the aromatic constituents disturb the infant’s digestion?
Dr. M. J. Jensen: Dr. Huenekens dealt with the feeding of the healthy infant only. I would like to ask if it is not true that nearly all infants born alive, are born as healthy and sound as any infant ever is, so far as the functions of its organs and tissues are concerned? Nature frequently decides on producing premature births and “stillâ€-births, rather than running the risk of producing a sick or sickly infant. In young infants it is very often difficult to determine when to classify them as healthy or unhealthy, realizing the conditions of their environment and usual care that is given in the homes.
In regard to the sterilization or boiling of cow’s milk: I do not think that children fed on pasteurized or boiled milk develop as well as those who are fed upon raw milk as it comes from the cow. Dr. Palmer, of Chicago, fed seven hundred children on raw milk during the midsummer months and only lost three of the number. The miserable, atrophied children began to live the moment treatment with raw milk was begun. If the process of milking was carried out in a sanitary manner, or by means of a suction apparatus, then cooled, and placed in sterilized bottles, I believe we would prohibit the development of bacteria, and save the food which exerts so marked a protective influence upon the infant’s organs.
When raw milk free of all objections cannot be obtained, it is sometimes advisable to use another milk product namely, buttermilk.
Dr. S. Marx White: There is just one point I have been thinking about in the discussion on the question of infant-feeding, and that is whether Dr. Huenekens really means us to believe that in practically all cases the mother can furnish sufficient milk for the child. He passed that over in saying that in nine out of ten cases the mother gave as a reason for discontinuing the milk that the milk gave out. Is it not true that in a good many instances the mother needs treatment quite as much as the infant? I do not mean medical treatment, but management. Is it not true that an overworked, tired, nervous, worrying mother is unable to supply sufficient milk for the child? It has been my impression from a very limited experience in this field, that the mental and nervous and physical state of the mother is a very large factor in the production of the milk. When upset and under deleterious influences she is really not a proper producer for the child; and the management of the mother is often quite as important a factor as any other.
Dr. W. H. Aurand: In such cases as Dr. White just mentioned, what are we going to do to increase the supply of milk? Also, I would like to ask Dr. Huenekens if he means to feed to the new-born baby 200 c.c. at a feeding?
Dr. Huenekens(closing): As regards lime-water: I cannot recommend its use. Wherever there is a specific demand for calcium, as in premature infants or spasmophilic cases; or where it may help to produce a firm stool; or, as in diarrheal disturbances, it may be of great value, but in the normal healthy infant it is of no benefit whatever.
Dr. Bryant mentioned the giving of meat in exudative diathesis: His statement that such infants can probably have meat once a day at fifteen months, and show normal stools, is beside the question. A normal macroscopic stool does not necessarily mean that the meat has been digested. However, I am now working on this problem, that is, to determine whether an early solid diet produces an earlier digestion of meat.
I would classify eggs and egg albumin as proteins, and therefore not digestible until the beginning of the third year: but, over and above this, there is danger of anaphylaxis from the absorption of the unchanged egg albumin into the blood-stream.
What Dr. Weston says of the feeding intervals is very interesting. I do not want to be considered an enemy of the four-hour feeding, for I use it wherever possible, and I think it the best interval; but when the infant cannot get enough in that period, we have to choose between two evils. I think the lesser evil is to give the child more milk at shorter intervals, and take the risk of a slightly poorer digestion. We should, also, wherever possible, control the amount of breast-milk by weighing the child before and after nursing. It is highly important to determine whether the baby is getting too much or too little.
As to Dr. Green’s statement, “Modified milk†is a very general term. What is usually meant is milk with a high percentage of fat and a low percentage of sugar, while malted and condensed milk have a high percentage of carbohydrate. In my opinion, if he had used cow’s milk without the addition of cream and with large amounts of cane sugar, he would not have had this trouble. But a large number of children will not do well on this diet. We have special rules for abnormal children with exudative and nervous diathesis.
In reply to Dr. Fleming’s question regarding the mother’s diet and its effect on her milk: What the mother eats has absolutely no effect on the composition of the milk in any way whatever, except perhaps in the percentage of fat. Now-a-days we do not advise any particular foods for the mother’s diet,—anything she likes, and can digest, plus large quantities of fluid;—otherwisethere is no single food we advocate—none that will make the milk richer or better, or increase the quantity.
I cannot agree with Dr. Jensen that raw milk is so far superior to boiled milk. Of course, wherever it is possible, we should use certified milk, which does not require boiling; but, if we have inferior cow’s milk contaminated with bacteria, we can boil the milk with very little harm. It is just as well digested, and the food value just as great. There is of course slight danger of scurvy; but that is very easily diagnosed, and very easily cured by a little fresh milk or small doses of orange juice. Where we have inferior milk, it should be boiled in every case.
Dr. White brought up a very interesting point in regard to nervous mothers. Their milk supply is subject to wide fluctuations; but, if the breasts are well emptied at each nursing, they will secrete sufficient milk. I will admit that these cases are difficult to handle, for the infants usually have nervous diathesis, and do not respond well to ordinary food. The one important point is to completely empty the breasts; and that is the only measure we can take to increase the supply of milk.
In reply to Dr. Aurand: I would feed a new-born infant 200 c.c. at a feeding if the milk is sufficiently diluted. The liquid part of the food passes very quickly into the duodenum, so that, before the infant has finished feeding, a part of this quantity has already left the stomach.
In conclusion: We have an opportunity in our infant-feeding to practice the really scientific prophylactic medicine of the future. We can do more in preventing infant-mortality by proper feeding than by any other single measure; and we should encourage mothers to bring their new-born infants to the physician for advice on feeding, and to continue to consult him at longer or shorter intervals during the whole of the first year of life.