Obstetrical Nursing / A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby

An excellent device for protecting the baby’s arms and chest and keeping him generally well covered is the poncho (Fig. 162) devised by Dr. Lucy Porter Sutton of Bellevue Hospital. The poncho is a rectangle made of flannel, outing flannel or an old blanket and cut large enough to tuck well under the head and sides of the mattress and extend below the baby’s feet. The baby’s head slips through an opening, which is almost a right-angled slit, near the centre of the poncho and about 20 inches from the top. The slit is firmly bound and provided with tapes to tie it together after the baby is put in. The poncho should be put on loosely enough to permit the baby to move about at will beneath it. After it is adjusted the bed is made up as usual with additional blankets.

Under all conditions the baby’s airings must be increased gradually, both as to lowering the temperature and lengthening the time, and always adjusted to the vigor and reaction of the individual baby. He must be warm, but not too warm; he must be protected from wind and dust, and his eyes shielded from glare and from flickering light such as may be caused by a tree in a light breeze.

Exercise. Although the baby should not be handled unnecessarily nor tossed about and played with by friends and relatives, it is important that his muscular development be promoted by regular and carefully planned exercise. It is usually considered best for the baby to lie quiet and undisturbed in his crib most of the time during the first three or four weeks. Dr. Griffith begins the baby’s exercise about that time by having the nurse take him in her arms on a pillow and carry him about for a few moments, several times daily. After a week or two of this form of exercise, the nurse carries the baby without a pillow but supports his head and back.

The position of the baby’s body is changed by being carried about in this way, while the movement of the nurse as she walks about causes a certain amount of motion of the baby’s muscles, constituting a gentle exercise.

This exercise, in the form of picking up and carrying about is regarded by many pediatricians as of great importance. There is a possibility that lack of this form of “mothering” is one reason why babies in hospital practice sometimes fail to progress as they should. Certainly lying too long in one position is harmful. The nurse should carry the baby first on one arm and then on the other in order that both sides of his body may be equally exercised. By the third or fourth month he sits up in her arms as she carries him about, and he may be placed on the outside of his crib coverings for a little while every day, to kick and struggle at will. His skirts should be rolled up under his shoulders, or removed entirely, to leave his legs quite free, care being taken that the room is warm and that he has on stockings.

By about the sixth month he will usually begin to make an effort to creep, if turned over on his stomach and helped a little, and he may be propped up in the sitting position, in his crib, for a few moments every day. As he gives evidence of having enough energy to creep farther than the size of his crib permits, he may be put into a creeping-pen, or upon the floor under certain conditions. It must be remembered that the floor is likely to be cold, drafty and dusty. The nurse must assure herself, therefore, that the floor is warm; must cut off all drafts and spread a clean sheet or quilt on the floor before the baby is put down to creep. When the sheet is taken up, it is folded with the upper surface inside in order that when it is again put down the baby will play on the clean side and not on the side that has been next the floor.

A creeping-pen or cariole or some such provision is often more satisfactory than the floor, consisting as it does of a railed-in platform raised about six or eight inches from the floor.

The suggestions for exercise, like those for the baby’s airing, must be very general since it must always be adjusted to the powers of the individual baby and under the doctor’s supervision.

TRAINING THE BABY

Bowels. It is possible to train even a very young baby to have regular daily bowel movements; this training should be started when the baby is about a month old. At the same hour each day he may be laid on a padded table, or taken in the nurse’s lap, a small basin being placed against or under the buttocks, and a soap stick introduced an inch or two into the rectum and moved gently in and out. This slight irritation will usually result in the baby’s emptying his bowels almost immediately. Or he may be held on a small chamber on the nurse’s lap, in a comfortable reclining position (Fig. 163) or with his back supported against her chest, and the desire to empty the bowels stimulated by using the soap stick.

It is of greatest importance that the position and method which are adopted, be employed at exactly the same time each day. If this is done, and the baby is being properly fed, it will usually be found that, before he is many months old, his bowels will move freely and regularly without the stimulation of the soap stick and only when he is resting on the small basin or chamber. This establishment of a regular bowel movement not only simplifies the laundry work but is of great moment to the baby’s health.

Thumb-Sucking. It is scarcely necessary to remind a nurse that the baby must not be allowed to suck on an empty bottle or a pacifier nor be permitted to suck his thumb. The habits are very dirty and help to spread infections. The baby may swallow air while practicing them, with colic as a result, and he may so deform the shape of his upper jaw that, later in life, the upper and lower teeth will not meet as they should when he masticates; his front teeth may protrude in a disfiguring manner; and by narrowing and elongating the roof of his mouth the structure of the air passages is altered, with respiratory troubles and adenoids as a frequent consequence. Thumb-sucking may be prevented by the simple procedure of putting stiff cuffs on the baby’s elbows (Fig. 164) which make it impossible for him to reach his mouth with his thumb. These cuffs may be made by covering pieces of cardboard with muslin and attaching tapes with which to tie them on the baby’s arms. His hands may be put into celluloid or aluminum mitts, or little bags made of stiff, heavy material, which in turn are tied to his wrists, or his sleeves may be drawn down over his hands and sewed or pinned with safety pins. It should be borne in mind that a baby sometimes sucks his thumb because he is hungry or thirsty and gives up the practice when his food is increased or when he is regularly given water to drink.

Ear Pulling is not uncommon among young babies and if allowed to continue a long, misshapen ear may result. This may be prevented by using a thin, close fitting cap which ties under the chin, or by using the same kind of elbow splints as for thumb-sucking.

Crying. It is very easy to allow the baby to develop the crying habit, but very difficult to break it up. A baby who is properly fed, kept dry and warm but not too warm, and whose clothes are comfortable will usually cry very little if wisely handled. But a baby may cry because he is hungry, thirsty, wet, cold, over-heated, sick or in pain or simply because he wants to be taken up and entertained and has learned that the way to realize his wish is to cry. By closely observing the baby’s habits and his condition the nurse will usually be able to ascertain the cause of the crying. Very often a drink of fairly warm, sterile water will quiet him, particularly at night. But both the nurse and the mother should refrain from taking the crying baby up and carrying him or holding him when it is discovered that this attention stops his crying. Persistent crying should always be reported to the doctor, as it may have serious significance.

Ruminating. Some babies have the habit, called “ruminating,” of bringing up food; chewing it; moving it about and finally rolling it out of their mouths. Although this habit has not been recognized until comparatively recently, it is now believed to be of fairly common occurrence and often mistaken for vomiting. It is seen as a rule in precocious babies who take more interest in their surroundings than the average, more placid infant, beginning very early to fix their attention upon light, sounds and moving objects. The ruminator begins by bringing up a small amount of his last nourishment, then a little more and a little more until finally he has brought up nearly or quite all of it, apparently deriving a certain amount of pleasure and satisfaction from the procedure. Quite obviously, a continuation of this practice results in undernourishment, sometimes even starvation, since the baby actually retains very little if any of his food. As liquids come up more easily than fluids, the first step toward breaking up this habit is usually to give the baby more solid and concentrated food than he has been taking and to carry him about, talk to him and entertain him for about an hour after feedings, for if his attention is otherwise engaged, he is not likely to ruminate. Another efficacious measure is the use of a cap (See Fig. 165) so constructed and tied under his chin that the baby’s jaws are held tightly together and he is unable to make the movements which are necessary to rumination. (Fig. 166.)

FEEDING THE BABY

Proper feeding is probably the most decisive single factor in the routine care of the baby.

In order that the food be satisfactory it must be not only suitable in composition for the individual baby, but it must be clean, fresh and at the right temperature; given in suitable amounts and at suitable and regular intervals; it must be given properly—not too fast nor too slowly and it must be given under favorable conditions.

Moreover, the baby himself must be kept in a general condition which will favor the digestion and assimilation of the food that is given to him. Fresh air, suitable clothing, an even body temperature, gentle handling, proper bathing, regular sleep, freedom from excitement, fatigue and irritation, all promote the baby’s ability to use his food to advantage. Reverse influences all work against it.

The character, amount and intervals of the baby’s feeding are definitely ordered by the doctor, but the many factors which influence the baby’s nutrition are so largely a matter of nursing that the nurse has grave responsibilities in connection with his nourishment.

After other conditions have been made favorable, the factors which determine the character of the baby’s food are the kind and amount of food materials which are needed by his growing body and the powers of his digestive organs. If he is given less food than he needs at each stage of his progress he will not be properly nourished; but if he is given food materials in quantities, proportions or character which are beyond the power of his immature alimentary tract to digest, he not only will not be properly nourished but probably will be made ill.

There are three methods of nourishing the baby: breast feeding, artificial feeding and a combination of the two, termed mixed or supplementary feeding.

Breast Feeding. From all standpoints, maternal nursing under normal conditions is the most satisfactory method of infant feeding. If the breast milk is suitable it meets all of the baby’s requirements and the proportion and character of its constituents are exactly suited to his digestive powers.

In order that the nursing be entirely satisfactory, the condition of both mother and baby must be favorable to its success. The preparation and care of the mother have been described: her general condition and state of nutrition; the care and condition of her nipples, flat or retracted nipples being brought out if possible, and if not, the nursing facilitated by the use of a shield. If the baby’s diaper is wet or soiled, it should be changed before he is put to the breast, partly to make him comfortable and partly to avoid disturbing him after his feeding. His mouth is gently swabbed with boric soaked cotton, if this is ordered, he is wrapped in a little blanket and carried to his mother dry and warm and comfortable. (Fig. 167.) Although nursing is an instinct, the baby sometimes has to learn or to acquire the habit which is one reason for putting him to the breast during those first two or three days when he obtains little or no actual food. (See Chapter XVI.) As he expresses the milk by a squeezing and suction made possible only when the nipple is well back in his mouth, he must take into his mouth practically the entire pigmented area which surrounds the nipple. To do this he lies in the curve of his mother’s arm as she turns slightly to one side, and holds her breast away from his nostrils in order that he may breathe freely.

Sometimes even when other conditions are favorable, the baby is unable to nurse because of some physical disability. He may be too feeble; have a cleft palate or find suckling painful because of an abrasion of the mucous membrane which occurred when his mouth was bathed just after birth. The manner in which the baby nurses, therefore, may be significant and should be carefully noted and described to the doctor.

There is a difference of opinion among doctors concerning the interval between feedings which is most satisfactory. Some have the baby nurse every four hours and others every three hours during the early months of life. It is believed by some doctors that although a baby who is fed on a four-hour schedule may regain his birth weight more slowly than the baby who is fed every three hours, he suffers less from digestive disturbances and ultimately makes an entirely satisfactory gain in weight. Another point in favor of the four-hour interval is the longer period of freedom which this gives to the mother and this may influence her willingness to nurse her baby. But other doctors, both pediatricians and obstetricians, feel that the four-hour interval is too long for most babies.

Whether the baby shall nurse from one or both breasts at each feeding is another moot question. Some doctors believe that the results are better if both breasts are partially emptied at each nursing, while others feel that the function of the breasts is more satisfactorily promoted by completely emptying one breast at a time, at alternate nursings. Although the baby should pause every four or five minutes to prevent his nursing too rapidly, which is a common cause of colic, neither he nor his mother should be allowed to sleep during the nursing periods. When he has finished, he should be taken up very gently and placed in his crib and left to sleep. If he is nursing satisfactorily, he will be sleepy and contented after nursing and will sleep for two or three hours afterwards; he will seem generally good humored and comfortable while awake; he will have good color; gain weight steadily and have two or three normal bowel movements daily. The normal stool in breast fed babies is bright yellow, smooth and with no evidences of undigested food.

If he is not being adequately nourished, he will present exactly the opposite picture, in some or all of these respects. He will be unwilling to stop nursing after the normal length of time and will give evidence of not being satisfied when taken from his mother. He may be listless and fretful and sleep badly. He will not gain weight as he should, and he may vomit or have colic after nursing.

To ascertain whether or not such a baby is getting enough milk it is customary to weigh him, without undressing him, before and after each nursing. Each fluid ounce of food will increase his weight one ounce. If the baby is not getting a normal amount of milk at each nursing he is often given enough modified milk after each meal to supply the deficit, but at the same time an effort is made to increase the supply of breast milk by improving the mother’s personal hygiene.

The amount which the baby needs at each feeding varies, not only according to his weight and age, but also according to his vigor and activity, and must always be figured for the individual baby. A very general estimate of the amount taken by the average well baby at each feeding, is about as follows:

Artificial Feeding. There is no entirely adequate substitute for satisfactory maternal nursing, and any other food that is given to the young baby is at best a makeshift. Considering the baby’s delicacy, therefore, and his urgent needs, no pains should be spared to make any artificial food which is given to him as satisfactory as possible. In preparing and giving artificial food it must be borne in mind that normal breast milk:

1.

Is exactly right in quantity, quality and proportion.

2.

Is fresh, clean and sweet.

3.

Is free from bacteria.

4.

Tends to protect the baby from infection.

5.

Definitely protects him from certain nutritional diseases.

Cows’ milk, suitably modified, is apparently the best available substitute for mother’s milk, but it must first meet certain requirements and then be handled with scrupulous cleanliness and care, if it is to be at all satisfactory.

The requirements are that the milk shall be:

1.

Whole milk. It must not be altered by the removal of cream nor the addition of such preservatives as salicylic acid, formaldehyde or boracic acid.

2.

Its composition must not vary greatly from day to day.

3.

It must be clean and free from disease germs; other organisms should not be present in excessive numbers.

4.

It must be fresh: less than 24 hours old when it is delivered.

All of this means that the milk must come from a herd of healthy, tuberculin-tested cows. The milk from a single cow may vary markedly from day to day but that from several cows is nearly constant. The stables and the cows must be kept clean, the udders carefully washed before each milking; the milkers themselves must wear freshly washed clothing, scrub their hands thoroughly and milk into sterile receptacles; the milk must be immediately covered and cooled to a temperature of 45° F. or 50° F. and kept there.

Milk produced under such conditions is usually described as “certified milk” and is often prescribed as infant food without being pasteurized or sterilized. But if there is any doubt about the source of the milk and the method of its handling, it should be strained into a clean receptacle through filter paper or a thick layer of absorbent cotton and subsequently boiled or pasteurized.

When the nurse is in a position to offer advice about the baby’s milk she must explain the importance of always obtaining the freshest, cleanest and purest milk possible, no matter what it costs.

Whether certified or not the milk must always be placed in the refrigerator or some other place at a temperature of 50° F. as soon as it is received and it must be kept cool and clean. Mother’s milk, which is being imitated, is clean and sweet and free from disease germs.

Keeping the milk cool means keeping it at a temperature of 50° F. Keeping it clean implies cleanliness of the milk itself, the utensils, the nurse’s hands and the destruction, by sterilization or pasteurization, of disease germs. Those which are likely to be present in infected milk are streptococci, tubercle bacilli, colon bacilli, germs of typhoid, diphtheria and scarlet fever.

The amounts and proportions of the constituents of the substitute feeding will be specified by the doctor, as well as the intervals between feedings and the amount to be given each time. But the doctor’s careful adjustment of the milk formula to the baby’s immediate needs and digestive powers will be set at naught unless the nurse is absolutely accurate in preparing and giving the milk.

The nurse’s invariable responsibility, therefore, is to keep the milk cool and clean and prepare and give it accurately.

The nurse will appreciate the necessity and principles of modifying cows’ milk for the human infant if she will consider for a moment, the differences between mother’s milk and cows’ milk, as indicated by the following table, and the reasons for these differences:

It will be remembered that the tissues and bony skeleton are built by the proteins and salts (lime and phosphorus). Accordingly Nature supplies these in greater abundance to the calf, who grows so fast as to double his birth weight in about 47 days, than to the baby who scarcely doubles his within 180 days. The calf begins life with a physical need for the abundance of proteins and salts which are present in cows’ milk, and with digestive organs that can cope with them, but the baby needs less, can digest less and therefore must be given less. There are, of course, other and finer differences between the two milks and an attempt is sometimes made to meet these. For example, mother’s milk is slightly alkaline and cows’ milk slightly acid and the curd of cows’ milk is larger, tougher and harder to digest than that formed by mother’s milk. Accordingly some doctors add lime water to cows’ milk to make it alkaline, and render the curd softer, finer and more digestible by boiling it.

It is often not possible to give a bottle-fed baby the full 4% of fat which mother’s milk contains, and some doctors make the protein of the artificial mixture very much larger in amount than is found in human milk. The nurse will see that this is a matter which can be decided only by the physician.

Articles Needed in Preparing the Baby’s Food. A complete equipment for preparing and giving the baby’s milk should be assembled, kept in a clean place, separate from utensils in general use, and never put to any other service. A satisfactory outfit for this purpose comprises the following articles:

• One dozen graduated nursing bottles.
• One dozen nipples.
• Clean, new corks or a package of sterile, non-absorbent cotton for stoppers.
• Bottle brush.
• Covered kettle, capacity one gallon, for boiling bottles and possibly pasteurizing milk.
• Pasteurizer or wire bottle rack.
• Small kettle, about one quart size.
• Graduated pint or quart measuring glass.
• Pitcher, two quart size.
• Long-handled spoon for mixing.
• Funnel.
• Measuring spoons—table and tea sizes.
• Double boiler.
• Thermometer which will register at least 212° F.
• Cream dipper (if ordered).
• Two small covered jars for sterile and used nipples.
• Sugar (lactose, maltose or cane sugar according to orders).
• Lime water, if ordered.

Utensils of enamel or aluminum ware are probably the most satisfactory ones to use as they are easily kept clean, while bottles with wide mouths and curved bottoms and inner surfaces can be thoroughly washed more easily than those with small necks and sharp corners. Nipples that can be turned inside out to be washed should be selected as it is almost impossible to clean thoroughly those with tubes or narrow necks. New bottles will be rendered less breakable if placed in cold water, which is gradually heated, allowed to boil for half an hour and cooled before the bottles are removed.

The bottles should be rinsed with cold water after each feeding and then carefully washed and scrubbed with the bottle brush in hot soapsuds or borax water, containing two tablespoonsful to the pint. They may be kept full of water while not in use or rinsed with hot water and stood upside down until they are all boiled on the following morning, preparatory to being filled with the freshly prepared milk. The baby’s bottles should never be washed in dishwater nor dried on a towel. The nipples should be rinsed in cold water, turned inside out and scrubbed with a brush, in hot soapsuds or borax water; rinsed and placed in a jar ready to be boiled with the bottles.

Preparation of Milk. The full quantity of milk which the baby will take in the course of twenty-four hours is prepared at one time and the prescribed amount for each feeding poured into as many separate bottles as there will be feedings. (Fig. 168.)

The nurse should first boil for five minutes all of the articles that will come in contact with the milk, including the full number of bottles and nipples and the jars in which the nipples are kept; remove them with the long-handled spoon without touching the edges or inner surfaces and place them on a clean table, dropping the nipples into one of the sterile jars.

She should wash the mouth of the milk bottle before removing the cap and pour the amount which the formula calls for into the sterile pitcher. To this is added the sterile water in which the sugar has been dissolved in the glass graduate, and the potato or barley water, the lime water or soda solution as ordered. This mixture is thoroughly stirred and the amount for one feeding at a time measured in the graduate and poured into the specified number of bottles which are then stoppered.

If certified milk is used for the milk mixture it is often given to the baby without being pasteurized, in which case the bottles are placed in the refrigerator as soon as they are filled and stoppered. Very frequently, however, the milk is sterilized or pasteurized. The nurse will feel surer of keeping the mouths of the bottles clean if she covers them with squares of gauze or muslin before they are sterilized, holding the caps in place with tapes or rubber bands. Pasteurization as applied to infant feeding consists of heating the milk to 140–165° F. and keeping it at that temperature 20 to 30 minutes.

There are many excellent pasteurizers for home use on the market, or entirely satisfactory results may be obtained by using a wire bottle rack (See Fig. 168) and the large kettle already provided. One method is to place the rack containing the bottles in the kettle which is filled with cold water to a level a little above the top of the milk in the bottles, and allow the water to come to the boiling point. The kettle is removed from the fire, covered tightly and the bottles allowed to stand in the hot water for twenty minutes. Cold water is then run into the kettle to cool the milk gradually and avoid breaking the bottles, after which they are placed in the refrigerator, well or spring-house and kept at a temperature of 50° F. until they are taken out one at a time for feedings. If a wire rack is not available the bottles may be stood on a saucer or a thick pad of folded newspapers in the bottom of the kettle.

Pasteurization does not destroy all germs that may be in the milk, but it kills the more important ones and apparently impairs the nutritive and protective properties of the milk less than boiling. However, pasteurized milk must be kept cold and must be used within twenty-four hours, for the nurse will recall that aging of milk is quite as undesirable as souring.

Scalding is another method of destroying germs in milk. The milk is placed in an open vessel and the temperature raised to about 180° F., or until bubbles appear around the edge and the milk steams in the centre, after which it is cooled and kept at a temperature of 50° F.

Many doctors prefer to have the baby’s milk boiled, since boiling insures absolute sterilization and also renders the curd more digestible. Other changes are produced by boiling, however, which make it important to add an anti-scorbutic and cod-liver oil to the baby’s diet at an early date.

Milk may be boiled directly over the flame for a time varying from three to forty-five minutes, or it may be placed in a double boiler, the water in the lower receptacle being cold, and allowed to remain until the water has boiled from six to forty-five minutes. All of these points are definitely specified by the doctor.

When milk is boiled or scalded the other ingredients are added beforehand, as a rule, after which it is measured and poured into the bottles. Or the milk mixture may be poured into the bottles as for pasteurization and the bottles kept in the actively boiling water for any desired length of time.

Giving the Baby His Bottle. At feeding time, the bottle should be taken from the refrigerator, the stopper removed and a nipple taken up by the margin and put on the bottle without touching the mouthpiece. The milk is brought to a temperature of about 100° F. by standing the bottle in a deep cup or kettle of warm water and placing it on the fire. The temperature of the milk may be tested by dropping a few drops on the inner side of the wrist or forearm where it should feel warm but not hot. This dropping will also indicate if the hole in the nipple is of the proper size to allow the milk to drop rapidly in clean drops but not to pour. If the hole is too small, the drops will be small and infrequent and the baby will be obliged to work too hard to obtain it; while if the hole is too large the baby will feed too rapidly and may have colic as a result.

The baby’s diaper should be changed if it is soiled or wet before he is given the bottle and he should be held comfortably in a reclining position on the nurse’s arm while she holds the bottle with her free hand. (Fig. 169.) The bottle should be inclined sufficiently to keep the neck full of milk; otherwise the baby may draw in air as he nurses. He should be kept awake while feeding but he should be allowed to pause every three or four minutes in order not to take his milk too rapidly. Not less than ten nor more than twenty minutes is devoted to a feeding, as a rule, and if the baby refuses a part of his milk, it should be thrown away; never warmed over for another time.

After being fed, the baby should be held upright against the nurse’s shoulder for a moment or two (Fig. 170), and ever so gently patted on the back to help bring up any air which he may have swallowed. He should on no account be rocked or played with after taking the bottle, but should be placed gently in his crib, warm and dry and left alone to sleep. Turning him or moving him about even to the extent of changing his diaper at this time may cause vomiting.

The evidences of satisfactory and unsatisfactory feeding in the bottle-fed baby are about the same as in the baby who is fed at the breast, except that the gain in weight on artificial food may be a little slower and less steady than on maternal nursing; the stools have a characteristic sour odor; are a little lighter in color and may contain white lumps of undigested fat; are usually dryer than in breast-feeding and may be formed in even a very young baby.

It is fairly generally agreed that all babies, whether breast-fed or on the bottle, require a certain amount of cool boiled water to drink between feedings. A small amount is given at first and gradually increased according to the doctor’s instructions, and it may be given from a bottle, a medicine dropper or poured slowly from the tip of a teaspoon.

Ingredients of the Baby’s Food. In referring to the ingredients of the baby’s food we cannot use the terms “sugar” or “milk” as though they indicated definite and unvarying materials.

There are three kinds of sugar which are commonly used in modified milk: cane or granulated sugar; lactose or milk sugar and maltose. Cane sugar, the one most widely used, is the least expensive of the three and it apparently is satisfactory for most babies. Lactose is fairly expensive and while it causes diarrhea in some babies, others digest it more easily than cane sugar. Lactose is lighter than cane sugar, three spoonfuls being equal in weight to two of cane sugar. The maltose-dextrine preparations are easily digested and somewhat laxative. Some babies gain more rapidly when maltose constitutes part of the sugar in their food than when only lactose is used.

The question of milk is somewhat complicated and though the doctor will specify what percentage of fat shall be in the milk which is used in each case, the nurse must know how to obtain it from the milk at her disposal. If the formula is made up with “whole milk,” which contains 4 per cent. fat, the bottle in which it was delivered should be turned upside down and shaken vigorously in order that the cream which has risen to the top may be redistributed evenly throughout the fluid.

If the doctor employs what is termed “percentage feeding,” he may use whole milk, skimmed milk, or top milk. What he is endeavoring to do is to prepare a food which contains definite known percentages of the different ingredients, fat, carbohydrates and protein. Where a mixture is desired which contains more fat than it does protein, the milk to be employed is obtained by discarding a certain amount from the bottom of the jar of milk, the remainder being then called “top milk.” When he wishes the fat to be lower than the protein percentage, he discards some of the top milk in the jar, using the rest, which is then a partially skimmed milk. The upper 2 ounces in a quart bottle of milk contains 24 per cent. fat; the upper 8 ounces is 12 per cent. fat; the upper 16 ounces is 8 per cent. fat and the upper 24 ounces is 5 per cent. fat. If the formula calls for 6 ounces of the upper 8 ounces of milk, therefore, the nurse will see that it is very important that she remove the full 8 ounces and use 6 ounces of the milk which she has removed and not simply take the upper 6 ounces, as this would contain a higher percentage of fat than is ordered. (Figs. 171, 172, Dr. Griffith’s tables of fat percentages.)

Top milk may be removed by tipping the bottle gradually and slowly pouring the designated amount into a measuring glass, or it may be removed by pushing a cream dipper, especially made for this purpose and holding one ounce, down into the bottle until the cream flows in. Another method is to syphon off the lower milk through a bent glass tube, leaving in the bottle the desired amount of top milk.

Many doctors feed the baby according to his caloric needs and prepare the formula from whole milk, sugar and water, determining the amounts of each according to the age and weight of the baby.

Under any condition it is so necessary that the amount and composition of each baby’s food be adjusted to his needs, that it is not considered possible to make out any formulae or feeding schedules which would be safe or satisfactory for general use.