The Care and Feeding of Children / A Catechism for the Use of Mothers and Children's Nurses

The approximate composition of these formulas expressed in percentages is as follows:

How should the food be increased during this period?

Beginning with I of this Series, which should usually follow V of the First or Second Series (pages 70, 71), the increase may generally be made in a week or ten days to II; in about two weeks more to III; now more slowly to IV and V. When IV or V has been reached, the same formula may sometimes be continued for three or four months with no other change than an increase in the quantity.

In passing from Formula V of the First Series to Formula I of the Third Series the proportion of fat is at first reduced. Is this necessary or important?

No; it only happens to come so in simplifying the calculation. It may be avoided by taking off at first the upper 13 ounces as top-milk and using 7 ounces of this in a 20-ounce mixture, in place of Formula I; and by using for the next increase the upper 15 ounces as top-milk, taking of this 8 ounces in a 20-ounce mixture in place of Formula II. Then should follow Formula III.

What further addition may be made to the food of the later months?

Usually about the sixth or seventh month, farinaceous food in the form of gruel may be added, this taking the place of part of the water and part of the sugar.

What changes may be made in the food when the infant has reached the age of ten or eleven months?

The proteids may be still further increased, and the sugar and the lime-water reduced until plain milk is given.

How may this best be done?

At first one feeding a day of plain milk and barley gruel may be given; later, two feedings; then three feedings, etc. Let us suppose an infant to be taking such a modified milk as Formula IV or V (page 76), six feedings a day. The plain milk diluted only with barley gruel would at first replace one of these feedings; then two, three, four, etc., these changes being made at intervals of about two weeks. The proportions of the milk and barley gruel should at first be about 5½ ounces milk, 2½ ounces barley; later, 6 ounces milk, 3 ounces barley; still later, 7 ounces milk, 2 ounces barley, until finally plain milk is given to drink and the cereals given separately with a spoon. This is reached with most infants at fourteen or fifteen months; with many at twelve or thirteen months. Other forms of farinaceous food may of course be used in the place of the barley, and in the same proportions.

With some infants the addition of a pinch of bicarbonate of soda may be advantageously made to each milk-feeding when the lime-water is omitted, but with most this is unnecessary.

If the infant strongly objects to the taste of the milk when the milk sugar has been omitted, a small quantity (one fourth to one half teaspoonful) of granulated sugar may for a time be added to each feeding, then gradually reduced.

GENERAL RULES FOR GUIDANCE IN THE USE OF THE FORMULAS GIVEN

It should again be emphasized that these formulas are not intended for sick children nor for those suffering from any marked symptoms of indigestion. For such infants special rules are given later.

What should be the guide in deciding upon a formula with which to begin for a child who is to be artificially fed?

The age and the weight are of some importance, but the best guide is the condition of the child's digestive organs. One should always begin with a weak formula, particularly, (1) with an infant previously breast fed; (2) with one just weaned, as a child who has never had cow's milk must at first have weaker proportions than the age and the weight would seem to indicate; (3) with infants whose power of digestion is unknown. If the first formula tried is weaker than the child can digest, the food can be strengthened every three or four days until it is found what the child is able to take. On the contrary, if the food is made too strong at first, an attack of indigestion will probably follow.

How should the food be increased in strength?

The first essential is that it be done very gradually; abruptly increasing the food usually causes a disturbance of digestion.

It is never wise to advance more rapidly in strengthening the food than from one formula to the next one in any of the series given; with many infants it is better to make the steps of increase only half as great as those indicated (page 72).

How rapidly should the food be increased in quantity?

The increase should not be more than a quarter of an ounce in each feeding; or from one and a half to two ounces in a day.

When should the food be increased?

In the early weeks an increase may be necessary every few days; in the later months sometimes the same formula may be continued for two or three months. It is, however, impossible to give a definite rule as to time. One cannot say with any child that an increase is to be made every week or every two weeks. A much better guide are the conditions present.

The signs indicating that the food should be increased are, that the infant is not satisfied, not gaining in weight, but is digesting well, i.e., not vomiting, and having good stools. One should not increase the food, however, so long as the child seems perfectly satisfied and is gaining from four to six ounces a week, even though both the quantity and the strength of the food are considerably below the average; nor should the food be increased if the child is gaining from eight to ten ounces a week, even if he seems somewhat hungry. The appetite is not always a safe guide to follow.

How can one know whether the strength or the quantity of the food should be increased?

In the early weeks it is well first to increase the strength of the food, the next time to increase the quantity, then the strength again, etc. After the fourth or fifth month, the quantity, chiefly, should be increased.

If a slight disturbance or discomfort occurs after the food has been strengthened, is it best to go back to the weaker formula or to persist with the new one?

Symptoms of minor discomfort are seen for a day or two with many infants after an ordinary increase in food; but in most cases an infant soon becomes accustomed to the stronger food and is able to digest it. If, however, the symptoms of disturbance are marked, one should promptly go back to the weaker formula. The next increase should be a smaller one.

Should one be disturbed if for the first two or three weeks of artificial feeding the gain in weight is very slight or even if there is none?

Not as a rule. If the infant does not lose weight, is perfectly comfortable, sleeps most of the time, and does not suffer from any symptoms of indigestion, such as colic, vomiting, etc., one may be sure that all is going well and that the infant is becoming used to his new food. As the child's appetite improves and his digestion is stronger, the food may be increased every few days and very soon the gain in weight will come and will then be continuous. If, however, the scales are watched too closely and, because there is only a slight gain in weight or none at all, the food is rapidly increased, an acute disturbance of digestion is pretty certain to follow.

Is not constipation likely to occur if the child is on a very weak food?

It is very often seen and is due simply to the small amount of residue in the intestine. Under these circumstances, if the bowels move once every day, one should not be disturbed even when the movements are small and somewhat dry. As the food is gradually strengthened, this constipation soon passes off; while if injections, suppositories, or cathartics are used to produce freer movements, the functions of the bowels are likely to be disturbed.

Under what circumstances should the food be reduced?

Whenever the child becomes ill from any cause whatever, or whenever any marked symptoms of indigestion arise.

How may this be done?

If the disturbance is only a moderate one and the food has been made up for the day, one third may be poured off from the top of each bottle just before it is given, and this quantity of food replaced by the same amount of boiled water.

If the disturbance is more severe, the food should be immediately diluted by at least one half and at the same time the quantity given should be reduced.

For a severe acute attack of indigestion the regular food should be omitted altogether and only water given until the doctor has been called.

If the food has been reduced for a disturbance of digestion, how should one return to the original formula?

While the reduction of the food should be immediate and considerable, the increase should be very gradual. After a serious attack of acute indigestion, when beginning with milk again, it should not be made more than one fifth the original strength, and from ten days to two weeks should pass before the child is brought back to his original food, which should be done very gradually. It is surprising how long a time is required with young infants before they completely recover from an attack of acute indigestion, even though it did not seem to be very severe. The second disturbance always comes from a slighter cause than the first one.

THE ADDITION OF OTHER FOODS TO MILK

How long should modified milk be continued without the addition of other food?

This depends upon circumstances; usually, for about six months; but if the infant is thriving satisfactorily the milk may be used alone for ten or eleven months; with some infants who have especial difficulty in digesting cow's milk, it is advisable to begin the use of other food at three or four months or even from the outset.

What is the first thing to be used with milk?

Farinaceous food in some form, usually as a gruel.

How are these gruels made?

They may be made directly from the grains or from some of the prepared flours (page 149). The flours are usually to be preferred as being more simple of preparation.

How should they be used in making the food?

They should be cooked separately, rather than with the milk; when the food is mixed, they take the place of a portion of the water in the formulas given on pages 70 and 71.

How much of the gruel should be used?

If it is prepared as recommended on page 149, it may make according to circumstances from one sixth to one half the total quantity of food.

Which of the farinaceous foods are to be preferred?

Those most used are barley, oatmeal, arrowroot, and farina. There is not much difference in their nutritive value; oatmeal gruel is somewhat more laxative.

What value do these substances possess as infant foods?

Some of the starch is digested and absorbed; but the chief value of gruels is believed to be that when added to milk they render the curd more easily digested by preventing it from coagulating in the stomach in large tough masses. This is certainly true with many infants, but there are others who are not at all benefited, and not a few young infants whose digestion is made distinctly worse by the use of farinaceous food, particularly when employed in considerable quantity. The addition of gruels to milk for all infants is not to be recommended.

What further additions may be made to the diet of healthy infants during the first year?

Beef juice, the white of egg, and orange juice.

How and when may beef juice be used?

With infants who are strong and thriving satisfactorily it may be begun at ten or eleven months; two teaspoonfuls may be given daily, diluted with the same quantity of water, fifteen minutes before the midday feeding; in two weeks the quantity may be doubled; and in four weeks six teaspoonfuls may be given. The maximum quantity at one year should not be more than two or three tablespoonfuls.

With delicate infants who are pale and anæmic, beef juice is more important, and it may often be wisely begun at five or six months in half the quantities mentioned.

When should white of egg be used?

Under the same conditions as beef juice, particularly with infants who have difficulty in digesting the proteins (curd) of milk. At six months half the white of one egg may be given at one time, and soon after this the entire white of one egg. The best in manner of cooking is the "coddled", egg (see page 151).

When should orange juice be begun?

Usually about the eleventh or twelfth month; it should be given about one hour before the feeding; two teaspoonfuls at first, then one tablespoonful at a time, and later three or four tablespoonfuls. It is particularly useful when there is constipation. It should always be strained, and care should be taken that it is sweet and fresh.

OVERFEEDING

What is meant by overfeeding?

Giving an infant too much food; either too much at one time or too frequently. Overfeeding is sometimes practised during the day, but is chiefly done at night.

Is not an infant's natural desire for food a proper guide as to the quantity given?

The appetite of a perfectly normal infant usually is; but overeating is a habit gradually acquired and may continue until twice as much food as is proper is taken in the twenty-four hours. This habit is most frequently seen in infants whose digestion is not quite normal; because of the temporary relief from discomfort experienced by taking food into the stomach, they often appear to be hungry the greater part of the time, especially at night.

What are the causes of overfeeding?

The most common one is the habit of watching the weight too closely, and the conviction on the part of the mother or nurse that because a child is not so large nor gaining so rapidly as some other infant of the same age, more food or stronger food should be given.

What harm results from overfeeding?

All food taken in excess of what a child can digest becomes a burden to him. The food lies in the stomach or bowels undigested, ferments, and causes wind and colic. When overfeeding is longer continued, serious disturbances of digestion are soon produced. The infant is restless, fretful, constantly uncomfortable, sleeps badly, and stops gaining and may even lose in weight. Such symptoms may lead to the mistaken conclusion that too little food is given, and it is accordingly increased, when it should be diminished. One of the results of long-continued overfeeding is dilatation or stretching of the stomach.

What should guide one as to the quantity of food to be given to any infant??

(1) The size of the infant's stomach at the different months; (2) the amount of milk which the healthy nursing infant gets; (3) the quantities with which most children do best. The table of quantities and intervals of feeding, on page 108, gives the average figures derived from these sources. It is seldom wise to go beyond the limits there stated; nor should one insist upon giving any fixed amount if it is clearly more than the child wants or can be made to take except by continued coaxing.

LOSS OF APPETITE

What is to be done when without any other signs of illness a child's appetite gradually fails?

This is often the result of a long period of overfeeding or the use of milk too rich in fat. If in all other respects the child seems well and simply does not want his food, it should be offered at regular hours, but not more frequently; on no account should he be coaxed, much less forced, to eat, even though he takes only one half or one third the usual quantity. The intervals between feedings should not be shortened but rather lengthened. Often, with a child a year old, it is necessary to reduce the number of feedings to four or even three in twenty-four hours. Water, however, may be offered at more frequent intervals. The food should be weakened rather than strengthened. No greater mistake can be made than, because so little is taken, coaxing or forcing food at short intervals through fear lest the child may lose weight.

THE CHANGES IN THE FOOD REQUIRED BY SPECIAL SYMPTOMS OR CONDITIONS

Infants with weak digestion and those suffering from various forms of indigestion have often especial trouble in digesting the fat of milk. To meet the needs of such there is required a series of formulas in which the fat is lower than in those already given.

These formulas are obtained from plain milk.

Fourth Series

Formulas from Plain Milk (containing 4-per-cent Fat)

When larger quantities than 20 ounces are required they are calculated in the same manner as described on page 73 in speaking of 10-per-cent milk.

The approximate composition of the formulas of the Fourth Series expressed in percentages is as follows:

Why is it that an infant so often vomits some of its food within a few moments after finishing its bottle?

Usually because the quantity is too large. Sometimes it is due to the fact that the food is taken too rapidly, from too large a hole in the nipple. It may be due to too tight clothing, or to moving the child about in such a way as to press upon the stomach.

What are the principal causes of, and the changes in the food required by habitual vomiting, regurgitation, or spitting up of small quantities of food between feedings, often repeated many times a day?

This is always a symptom of gastric indigestion, and a most troublesome one. In such conditions the fat and often the sugar also should be reduced and the lime-water increased.

Formulas made from rich top-milk or milk and cream are to be avoided. Those made from 7-per-cent milk are less likely to be the cause of trouble than those from 10-per-cent milk; but if the symptoms are at all severe it is better to use instead of these the formulas of the Fourth Series derived from plain milk.

Reduction in the sugar may be made by adding only one half ounce of milk sugar to each twenty ounces of the food; in severe cases the sugar may be omitted altogether.

It is often advisable to double the amount of lime-water—i.e., use two ounces to each twenty ounces of food.

The malted foods and all other foods containing much sugar usually aggravate the symptoms.

The intervals between meals should generally be half an hour longer, and sometimes an hour longer, than when digestion is normal.

The quantity given at a feeding should generally be less than with a normal digestion. Usually a smaller quantity of a strong food succeeds better than a larger quantity of a weak food.

What are the causes of, and food changes required by a constant and excessive formation of gas in the stomach, leading to distention and pain, or eructations (belching) of gas and often of a sour, watery fluid?

This is often associated with habitual vomiting, and is due to similar causes, but particularly to the sugar, which should be greatly reduced or omitted entirely.

What changes should be made when there is habitual colic?

This is generally due to an accumulation of gas in the intestines which forms there because the proteids (curd) of the milk are not digested. They should be reduced by using in the early months a weaker formula—i.e., instead of Formula V of the First or Second Series, IV might be used, or, for a short time, even III. The proteids may be reduced in the middle period by using weaker formulas If we desire to reduce the proteids without reducing the fat, we may change from the Second to the First Series.

Another means of relieving habitual colic is the use of partially peptonized milk (page 115); still another the dilution with barley-water instead of plain water.

What change should be made if curds appear in the stools regularly or frequently?

This is usually associated with habitual colic, and has to be managed exactly like that condition, by the means just described.

How should the milk be modified for chronic constipation?

The constipation of the first weeks of life has been already referred to (page 82); it usually disappears as the food is gradually strengthened in all its proportions.

Habitual constipation at a later period is difficult to overcome by diet alone. It sometimes depends upon the fact that the proteids are too high, and sometimes that the fat is too low. Hence it is more frequent when infants are fed upon plain milk variously diluted (page 90), then when 7-per-cent or 10-per-cent milk is used, and diluted to a greater degree. But it is not desirable to use a top-milk containing more than ten per cent fat for this purpose, nor is it wise to carry the fat in the food above 4 per cent (i.e., 8 ounces of 10-per-cent milk, or 12 ounces of 7-per-cent milk, in a 20-ounce mixture) or other disturbances of digestion may be produced.

In some cases the use, in place of milk sugar, of ordinary brown sugar, in half the quantity, is of assistance; or of some of the malted foods (Mellin's food, malted milk, cereal milk) also in the place of milk sugar.

The substitution of the milk of magnesia for the lime-water as recommended on page 60 will often be found useful.

To infants over nine months old, orange juice may be given.

What special modifications are required during very hot weather?

During the warm season it is well to make the proportion of fat less than during cold weather. During short periods of excessive heat it should be much less. The fat is reduced by using 7-per-cent milk in place of 10-per-cent (i.e., the Second instead of the First Series of formulas, page 71), or plain milk in place of the 7-per-cent milk in the Second and Third Series (page 90). At such times also the usual food should be diluted, and water should be given freely between the feedings.

What changes should be made in the food of a child who, with all the signs of good digestion, gains very little or not at all in weight?

If the child seems hungry the quantity of food may be increased; but if the child will not readily take any more in quantity the strength may be increased by the use of the next higher formula. One should, however, be extremely careful under these circumstances not to coax or force a child; for this plan is almost certain to cause disturbance of digestion and actual loss in weight. A better policy is that of looking after the other factors in the child's life,—the care, sleep, fresh air, etc., for with these rather than with the food the trouble often lies.

What should be done with infants who in spite of all variations in the milk continue to have symptoms of indigestion and do not thrive?

Except inmates of institutions who form a class by themselves, most infants who receive proper care thrive upon milk if the proportions suited to the digestion are given. Still there are some who do not. The nutrition of such is always a matter of difficulty.

If a wet-nurse is available the employment of one is the thing most likely to succeed, particularly if the infant is under four or five months old.

If the infant is older, or if a wet-nurse cannot be obtained, some of the substitutes for fresh cow's milk may be tried. One of the best is condensed milk, Borden's Eagle brand, canned, being preferred. This is more likely to agree if the symptoms are chiefly intestinal (colic, flatulence, curds in the stools, constipation or diarrhoea) than if they are chiefly gastric (vomiting, regurgitation, etc.).

How should condensed milk be used?

For an infant three or four months old with symptoms of indigestion, it should at first be diluted with 16 parts of boiled water, or, sometimes preferably, with barley-water. With improvement in the symptoms the dilution may be made 1 to 14, 1 to 12, 1 to 10, and 1 to 8, these changes being gradually made. The intervals between feedings and the quantities for one feeding are given on page 108.

How long should condensed milk be continued?

In most cases it should be used as the sole food for a few weeks only. Afterward, one feeding a day of a weak formula of modified milk (e.g., No. III or IV of the Second Series, page 71) may be given; later two feedings, and thus gradually the number of milk feedings is increased until the child is taking only modified milk.

Condensed milk is not to be recommended as a permanent food where good fresh cow's milk can be obtained.

What are the objections to its use?

It is very low in fat and proteids, and high in sugar. This accounts for its easy digestibility, and also explains why children reared upon it often gain very rapidly in weight, yet have as a rule but little resistance. They are very prone to develop rickets and sometimes scurvy.

Are the proprietary infant foods open to the same objections as condensed milk?

They are. What has been said of condensed milk applies equally well to most of those that are sold in the market as substitutes for milk.

What changes in the food are required by slight indisposition?

For slight general disturbances such as dentition, colds, sore throats, etc., it is usually sufficient simply to dilute the food. If this is but for two or three feedings, it is most easily done by replacing with boiled water an ounce or two of the food removed from the bottle just before it is given; if for several days, a weaker formula should be used.

What changes should be made for a serious acute illness?

For such attacks as those of pneumonia, bronchitis measles, etc., attended with fever, the food should be diluted and the fat reduced as described on page 95. It should be given at regular intervals, rather less frequently than in health. Water should be given freely between the feedings. Food should not be forced in the early days of an acute illness, since the loss of appetite usually means an inability to digest much food.

What immediate changes should be made in the food when the child is taken with an acute attack of gastric indigestion with repeated vomiting, fever, pain, etc.?

All milk should be stopped at once, and only boiled water given for ten or twelve hours; afterward barley-water or whey may be tried, but no milk for at least twenty-four hours after the vomiting has ceased. When beginning with modified milk the quantity should be small and the fat low, which may be secured by the use of the Fourth Series of formulas in the place of the First or Second Series. The proportion of lime-water may be doubled.

What changes should be made for an attack of intestinal indigestion attended by looseness of the bowels?

If this is not severe (only two or three passages daily) the fat should be lowered in the manner stated just above, and the milk should be boiled for five minutes. If curds are present in the stools, it may be still further diluted.

If the diarrhoeal attack is more severe, and attended by fever and foul-smelling movements of greater frequency, all milk should be stopped immediately and the diet mentioned just above under the head of acute disturbances of the stomach should be employed.

What changes in the food should be made when the child seems to have very little appetite and yet is not ill?

The number of feedings should be reduced, the interval being lengthened by one hour or even more. No greater mistake can be made than to offer food every hour or two to an infant who is not hungry. Such a course only prolongs and aggravates the disturbance.

What other conditions besides the food greatly Influence the child's digestion?

Proper clothing, warm feet, regular habits, fresh air, clean bottles, and food given at the proper temperature are all quite as important as the preparation of the food; quiet peaceful surroundings and absence of excitement are also essential to good digestion.

COMMON MISTAKES IN MILK MODIFICATION AND INFANT FEEDING

I. In using modifications made from top-milk, much confusion arises from the notion that top-milk is a single definite thing, whereas its composition depends upon a great variety of conditions and, unless all these are known, it is impossible to tell how strong it is. Directions for the removal of top-milk should be explicitly followed (see page 63), or the results will be very different from those expected.

II. In formulas calling for a certain number of ounces of top-milk of any given strength, the mistake is made of removing only the number of ounces needed for the formula. The proper way is to remove the amount required to secure a top-milk of the desired strength and then to take of this the number of ounces needed in the formula.

III. A rich Jersey milk is used as if it were ordinary milk. The formulas given in this book are chiefly calculated on the basis of a good average milk which contains about 4 per cent fat. Many persons have the idea that the richer the milk, the more rapidly the child will gain in weight, and hence the superiority of such milk for infant feeding. While it is true that some children taking a very rich milk may, for a time, gain rapidly in weight, yet sooner or later, serious disturbances of digestion are nearly always produced.

IV. The food is increased too rapidly, particularly after some disturbance of digestion. If, in an infant three or four months old, an attack of somewhat acute indigestion occurs, the food should seldom be given in full strength before two weeks. The increase in the diet should be made very gradually, the steps being made only one half those indicated in the series of formulas on pages 70 and 71. Otherwise it generally happens that the attack of indigestion is very much prolonged and much loss in weight occurs.

V. When symptoms of indigestion occur, the food is not reduced rapidly enough. Indigestion usually means that the organs are, for the time, unequal to the work imposed. If the food is immediately reduced by one half, the organs of digestion soon regain their power and the disturbance is short. In every case the amount of reduction should depend upon the degree of the disturbance.

PREPARATION OF COW'S MILK AT HOME

What articles are required for the preparation of cow's milk at home?

Feeding-bottles, rubber nipples, an eight-ounce graduated measuring glass, a glass or agate funnel, bottle brush, cotton, alcohol lamp or, better, a Bunsen gas burner, a tall quart cup for warming bottles of milk, a pitcher for mixing the food, a wide-mouth bottle for boric acid and one for bicarbonate of soda, and a pasteurizer. Later, a double boiler for cooking cereals will be needed.

What bottles are to be preferred?

A cylindrical graduated bottle with a rather wide neck, so as to admit of easy washing, and one which contains no angles or corners. A single size holding eight ounces is quite sufficient for use during the first year. All complicated bottles are bad, being difficult to clean. One should have as many bottles in use as the child takes meals a day.

How should bottles be cared for?

As soon as they are emptied they should be rinsed with cold water and allowed to stand filled with water to which a little bicarbonate of soda has been added. Before the milk is put into them they should be thoroughly washed with a bottle brush and hot soap-suds and then placed for twenty minutes in boiling water.

What sort of nipples should be used?

Only simple straight nipples which slip over the neck of the bottle. Those with a rubber or glass tube are too complicated and very difficult to keep clean. Nipples made of black rubber are to be preferred. The hole in the nipple should not be so large that the milk will run in a stream, but just large enough for it to drop rapidly when the bottle with the nipple attached is inverted.

How should nipples be cared for?

New nipples should be boiled for five minutes; but it is unnecessary to repeat this every day as they soon become so soft as to be almost useless. After using, nipples should be carefully rinsed in cold water and kept in a covered glass containing a solution of borax or boric acid. At least once a day they should be turned wrong side out and thoroughly washed with soap and water.

What sort of cotton should be used?

The refined non-absorbent cotton is rather better for stoppering bottles, but the ordinary absorbent cotton will answer every purpose.

Which is better, the Bunsen burner or the alcohol lamp?

If there is gas in the house, the Bunsen burner is greatly to be preferred, being cheaper, simpler, and much safer than the alcohol lamp. If the lamp is used, it should stand upon a table covered with a plate of zinc or tin, or upon a large tin tray. The French pattern of alcohol lamp is the best.

Give the directions for preparing the food according to any of the above formulas.

The nurse's hands, bottles, tables, and all utensils should be scrupulously clean. First dissolve the milk sugar in boiling water, filtering if necessary. Then add the milk and cream and lime-water, mixing the whole in a pitcher. A sufficient quantity of food for twenty-four hours is always to be prepared at one time. This is then divided into the number of feedings required for the day, each feeding being put in a separate bottle, and the bottle stoppered with cotton. The bottles should then be cooled rapidly by standing, first in tepid then in cold water, and afterward placed in an ice chest. If the milk is to be pasteurized or sterilized, this should precede the cooling.

DIRECTIONS FOR FEEDING INFANTS

How should the bottle be prepared at feeding time?

It should be taken from the ice chest, and warmed by standing in warm water which is deep enough to cover the milk in the bottle; it should then be thoroughly shaken and the nipple adjusted; the nurse should see that the hole in the nipple is not too large nor too small.

How may the temperature of the milk be tested?

Never by putting the nipple in the nurse's mouth. Before adjusting the nipple, a teaspoonful may be poured from the bottle and tasted, or a few drops may be poured through the nipple upon the inner surface of the wrist, where it should feel quite warm but never hot; or a thermometer may be placed in the water in which the bottle stands. A dairy thermometer should be used, and the temperature of the water should be between 98° and 105° F.

What is a simple contrivance for keeping the milk warm during feeding?

A small flannel bag with a draw string may be slipped over the bottle.

In what position should an infant take its bottle?

For the first two or three months it is better, except at night, when it may be undesirable to take the infant from its crib, that it be held on the nurse's arm during the feeding; later it may lie on its side in the crib provided the bottle is held by the nurse until it has been emptied; otherwise a young infant readily falls into the bad habit of alternately sucking and sleeping, and often will be an hour or more over its bottle.

How much time should be allowed for one feeding?

Never more than twenty minutes. The bottle should then be taken away and not given until the next feeding time. Under no circumstances should an infant form the habit of sleeping with the nipple in its mouth. A sleepy infant should be kept awake by gentle shaking until the food is taken, or the bottle should be removed altogether.

Should an infant be played with soon after feeding?

On no account; such a thing frequently causes vomiting and sometimes indigestion. After every feeding the infant should be allowed to lie quietly in its crib, and disturbed as little as possible.

INTERVALS OF FEEDING

How often should a baby be fed during the first month?

Every two hours during the day and twice during the night, or ten feedings during the twenty-four hours.

At what age may the interval be made two and a half hours?

Usually at five or six weeks.

When may it be increased to three hours?

Usually at two months.

Why should not a child be fed more frequently?

It takes the stomach nearly two hours to digest a meal at two months, and about two and a half hours at five or six months, and if the meals are too near together the second one is given before the first has been digested and vomiting and indigestion result. The meals should be far enough apart to give the stomach a little time for rest just before each feeding.

Schedule for Feeding Healthy Infants during the First Year

This schedule gives the averages for healthy children The smaller quantities are those required by small children whose digestion is not very vigorous. The larger quantities are those required by large children with strong digestion; in very few cases will it be advisable to go above these figures.

The interval is reckoned from the beginning of one feeding to the beginning of the next one.

When should the interval between the feedings be lengthened?

When there is gastric indigestion as shown by habitual vomiting or the regurgitation of food long after the bottle is finished; also when the appetite is very poor so that the infant regularly leaves some of its food.

When should the interval between the feedings be shortened?

This is done much too frequently; it is rarely advisable to feed any infant, except one seriously ill, oftener than the time put down in the schedule.

REGULARITY IN FEEDING

How can a baby be taught to be regular in its habits of eating and sleeping?

By always feeding at regular intervals and putting to sleep at exactly the same time every day and evening.

When should regular training be begun?

During the first week of life.

Should a baby be wakened to be nursed or fed if sleeping quietly?

Yes, for a few days. This will not be required long, for with regular feeding an infant soon wakes regularly for its meal, almost upon the minute.

Should regularity in feeding be kept up at night as well as during the day?

Only up to nine or ten o'clock; after that time a baby should be allowed to sleep as long as it will.

At what age may a well baby go without food from 10 P.M. to 6 or 7 A.M.?

Usually at four months, and always at five or six months. Night feeding is one of the most frequent causes of wakefulness and disturbed sleep.

STERILIZED MILK

What is meant by sterilizing milk?

Heating milk for the purpose of destroying germs.

Does all cows milk contain germs?

Yes; even when handled most carefully, milk contains many germs; but when carelessly handled, and in summer, the number is enormous. While most of these are harmless or cause only the souring of milk, others are occasionally present which may produce serious diseases such as typhoid fever, diphtheria scarlet fever, cholera, tuberculosis, and many forms of diarrhoea.

Under what circumstances is it necessary to sterilize milk?

1. In warm weather when it cannot be obtained fresh; hence always in cities and towns during the summer.

2. When one cannot be certain that the cows are healthy, or that the milk has been carefully handled.

3. When the milk is to be kept for any considerable time (i.e., over twenty-four hours), especially if no ice can be had.

4. During epidemics of typhoid fever, scarlet fever, diphtheria, or any form of diarrhoeal disease.

What are the two methods of heating milk?

The first is known as sterilizing, in which the milk is heated to 212° F. for one hour or one hour and a half; the second is known as pasteurizing, in which the milk is heated to 155° or 170° F. for thirty minutes. A temperature of 155° F. continued for thirty minutes is sufficient to kill the germs of the diseases above referred to.

Will milk which has been thus treated keep indefinitely?

No; for although all the living germs may be killed, there are many undeveloped germs, or spores, which are not destroyed, and which soon grow into living germs. Milk heated to 212° F. for an hour will keep upon ice for two or three weeks; that heated to 155° F. for two or three days.

Is milk which has been sterilized always a safe food?

No; for the reason that the milk may be so old, so dirty, and so contaminated before sterilizing that it may be still unfit for food, though it contains no living germs.

Is cow's milk rendered more digestible by being heated in this way?

Sterilizing milk does not improve its digestibility but rather the contrary. Sterilized milk should be modified for infant feeding in the same way as milk which has not been heated.

Is milk in any way injured by heating to 212° F. for an hour?

There is abundant evidence that milk is rendered less digestible by such heating; also that it is more constipating, and that for some children its nutritive properties are interfered with, so that it may cause scurvy; this, however, is not seen unless it is continued as the sole food for a long period. These objections are of so much importance that this plan of heating milk is not to be recommended for general use.

When is it advantageous to heat milk to 212° F.?

For use upon long journeys, such as crossing the ocean. Milk should then be heated for one hour upon two successive days, without removing the cotton stoppers from the bottles.

Is milk in any way injured by heating to 155° F. for thirty minutes?

This point is not yet definitely settled. Such heating does not affect the taste of milk and does not render it more constipating. The unfavourable effects; if there are any, are so slight that they need not deter one from the use of pasteurized milk, even for long periods. The preference, however, should always be given to milk which is so clean and so fresh as not to require any heating.

How should milk be pasteurized?

A convenient form of apparatus is that known as Freeman's pasteurizer^[5]; another is the Walker-Gordon pasteurizer.^[6]

How should milk be cooled after pasteurizing?

Always by placing the bottles in cold water, so as to cool them rapidly; never by letting them stand at the temperature of the room, or by placing them, when warm, in an ice box.

Why is this precaution necessary?

Cooling in the air or in an ice box requires from two to four hours, and during that time a great many of the undeveloped germs may mature and greatly injure the keeping properties of the milk. In the cold water, milk can be cooled in from ten to twenty minutes if the water is frequently changed, or if ice is added to the water.

MODIFIED MILK OF THE MILK LABORATORIES

What is "modified milk" of the milk laboratories?

It is milk containing definite proportions of the fat, sugar, proteids, etc., put up usually according to the prescription of a physician, who indicates how much of the different elements he desires. The most reliable are the laboratories of the Walker-Gordon Company, which has branches in many of the large cities of the United States.

This is an excellent method of having milk prepared since it can be done with greater care and cleanliness than are possible in most homes. It is besides a great convenience if circumstances make it impossible to prepare the milk properly at home.

The laboratory should be used for infant feeding only by one who is somewhat familiar with this method of ordering milk.

PEPTONIZED MILK

What is peptonized milk?

Milk in which the proteids (curd) have been partially digested.

How is this accomplished?

By the action of a peptonizing powder which is composed of a digestive agent known as the extractum pancreatis and bicarbonate of soda, which is added to the plain or diluted milk. This is sold in tubes or in tablets, and it is the active ingredient of the peptogenic milk powder.

Describe the process.

The plain or modified milk is placed in a clean glass jar or bottle, and the peptonizing powder, which is first rubbed up with a tablespoonful of the milk, is added and the bottle shaken. The bottle is then placed in a large pitcher or basin containing water kept at the temperature of about 110° F., or as warm as the hand can bear comfortably, and left for ten to twenty minutes if the milk is to be partially peptonized; for two hours if it is to be completely peptonized.

What taste has partially peptonized milk?

None, if peptonizing is continued for only ten minutes, but at the end of twenty minutes it begins to be bitter, when the process of digestion has gone further.

How is the bitter taste avoided in partially peptonized milk?

At the end of ten or fifteen minutes the milk may be placed in a saucepan and quickly raised to boiling point; this kills the ferment, so that the milk will not become bitter when warmed a second time. Or, the milk may be rapidly cooled by placing the bottles first in cool and then in ice water; in this way the ferment is not destroyed, and the milk may become bitter when warmed for feeding.

Should the whole day's supply be peptonized at once, or each bottle separately just before the feeding?

Either plan may be followed. If the former, it is better to raise the milk to boiling point after peptonizing; if the latter, it should not be peptonized more than ten minutes, for it will continue to peptonize while it is being taken by the child.

Is not the bitter taste of completely peptonized milk a great obstacle to its use?

Not in the case of young infants; one under four or five months old will usually take it without any objection after two or three feedings; but it cannot often be used for those who are much older.

How much of the peptonizing powder should be used?

There are required for one pint of plain milk, five grains of the extractum pancreatis and fifteen grains of bicarbonate of soda. This quantity is usually put up in a single tube or tablet. In the formulas previously given, less than this will be required; for the weaker formulas, one half or one third of the powder mentioned will be sufficient for one pint of food. For a single feeding of four ounces, one may use one eighth of a tube with a weak formula, or one sixth of a tube with a stronger formula.

What are the advantages of peptonized milk?

Partially peptonized milk is useful for young infants who have great difficulty in digesting the curd of milk, sometimes even when diluted as already described; completely peptonized milk, during acute attacks of indigestion.

For how long a period may the use of peptonized milk be continued?

Completely peptonized milk may be used for a few days, or at most a few weeks; partially peptonized milk may be used for two or three months, but not indefinitely; it should be left off gradually by shortening the time of peptonizing, and lessening the amount of the powder used.

FEEDING DURING THE SECOND YEAR

How many meals are required during the second year?

It is usually better to continue five meals throughout the second year. Some children will sleep from 6 P.M. to 6 A.M. without waking, but unless there is a feeding at 10 P.M. children are apt to wake very early in the morning.

Should each feeding be prepared at the time it is given, or all feedings at one time, as during the first year?

During the second and third years it is better to prepare the milk for the entire day at one time. If it is to be modified by adding cream, water, etc., it is done as during the first year.

Later, when only plain milk is used, the quantities needed for the different feedings should be put into one or into two bottles, which then may be pasteurized or not as may be necessary. In this way the different feedings are kept separate, and the day's supply of milk is not disturbed every time the child is fed, as otherwise is unavoidable. The food should be prepared as soon as possible after the daily milk supply is delivered in the morning.

Give a proper diet for an average healthy child of twelve months.