Equation:

(1) Select from the “Layers of Milk” Table the milk which possesses the desired ratio of fat to protein.

(2) Substitute in the equation.

(3) As the sugar-percentage has been reduced equally with that of the protein, add sufficient sugar to raise to the desired percentage.

Example: 20–oz. mixture desired. Percentages desired = Fat 3, Sugar 6, Protein 1. Use upper 8 oz. (fat 12%, protein 4%, viz.: 3:1). Then 20 × 3
12 = 5 oz. of upper 8 oz., with 15 oz. of water in the 20–oz. mixture. The protein necessarily becomes 1%, and the sugar likewise. The mixture already containing 1% of sugar, add 5% of 20 oz., i. e., 1 oz. of sugar to increase this to the 6% desired.

Example: The mother has mixed: Upper 8 oz.; 6 oz.—Lower 8 oz.; 3 oz.—Milk-sugar 3 level tablespoonfuls.—Water 27 oz. Total quantity = 36 oz. The upper 8 oz. contains 12% fat (see Table). Both top and bottom milk contain 4% protein and sugar. Three tablespoonfuls sugar = approximately 1 oz. The fat of the lower 8 oz. may be ignored. Then 6 × 12
36 = 2 = Fat percentage from the top-milk. 3 × 0
36 = 0 = Fat-percentage from the bottom milk. 9 × 4
36 = 1 = Protein and sugar percentages from combined top and bottom milk. The 1 oz. additional sugar divided by 36 = approximately 3% sugar added. There being already 1% sugar derived from the milk, the total sugar = 4%.

Moreover, it does not ordinarily devolve upon the nurse to do more than prepare and give the baby’s food as ordered by the doctor, but situations sometimes do arise when the doctor is not within reach which the nurse must meet as best she can. In such an emergency she might be guided by the following suggestions contained in a pamphlet entitled, “Save the Babies,” prepared by Dr. L. Emmet Holt and Dr. H. K. L. Shaw and published by the American Medical Association, remembering that they are intended for the average, normal baby and are not necessarily suitable for all babies:

“The simplest plan is to use whole milk (from a shaken bottle) which is to be diluted according to the child’s age and digestion.

“Beginning on the third day, the average baby should be given 3 ounces of milk daily, diluted with seven ounces of water. To this should be added one tablespoonful of lime water and 2 level teaspoonfuls of sugar. This should be given in seven feedings.

“At one week, the average child requires 5 ounces of milk daily, which should be diluted with 10 ounces of water. To this should be added 1½ even tablespoonfuls of sugar and one ounce of lime water. This should be given in seven feedings.

“The milk should be increased by ½ ounce about every 4 days.

“The water should be increased by ½ ounce about every 8 days.

“At three months the average child requires 16 ounces of milk daily, which should be diluted with 16 ounces of water. To this should be added 3 tablespoonfuls of sugar and 2 ounces of lime water. This should be given in 6 feedings.

“The milk should be increased by ½ ounce about every 6 days.

“The water should be reduced by ½ ounce about every 2 weeks.

“At 6 months the average child requires 24 ounces of milk daily, which should be diluted with 12 ounces of water. To this should be added 2 ounces of lime water and 3 even tablespoonfuls of sugar. This should be given in 5 feedings.

“The amount of milk should be increased by ½ ounce every week.

“The milk should be increased only if the child is hungry and digesting his food well. It should not be increased unless he is hungry, nor if he is suffering from indigestion even though he seems hungry.

“At 9 months, the average child requires 30 ounces of milk daily, which should be diluted with 10 ounces of water. To this should be added 2 even tablespoonfuls of sugar and 2 ounces of lime water. This should be given in 5 feedings.

“The sugar added may be milk sugar or, if this cannot be obtained, cane (granulated) sugar or maltose (malt sugar).

“At first plain water should be used to dilute the milk.

“At three months, sometimes earlier, weak barley water may be used in the place of plain water; it is made with ½ level tablespoonful of barley flour to 16 ounces of water and cooked 20 minutes.

“At six months the barley flour may be increased to 1½ even tablespoonfuls, cooked in the 12 ounces of water.

“At nine months, the barley flour may be increased to 3 level tablespoonfuls, cooked in the 8 ounces of water.

“A very large baby may require a little more milk than that allowed in these formulas. A small delicate baby will require less than the milk allowed in the formulas.”

These formulas may be tabulated as follows:

Mixed Feeding. Under some conditions the breast-fed baby is given also a certain amount of modified milk, and this combination of natural and artificial feeding is termed mixed or supplementary feeding.

A deficiency in the breast milk, ascertained by weighing the baby before and after each nursing, may be supplied by following each nursing with a bottle feeding; or one or two breast-feedings, in the course of the day may be replaced by entire bottle feedings. In any case the milk mixture to be used as supplementary feeding is prepared with exactly the same painstaking care as is the milk for entire artificial feeding.

If supplementary food is given because of an inadequate supply of breast milk, it is of great importance that the baby be put to the breast regularly, no matter how little food he obtains, for his suckling is the best possible means of stimulating the breasts to secrete more milk and of equal importance is the fact that they will tend to dry up if the baby nurses less than about five times in twenty-four hours. Moreover, even a little breast milk is valuable to him and he should have the benefit of all there is to be had.

An entire bottle feeding is sometimes given to a baby who is nursing satisfactorily at the breast, in order to give his mother an opportunity to take longer outings than are possible between the regular nursings. And sometimes it is to the mother’s advantage, and therefore to the baby’s, to give him a bottle during the night and thus allow her to sleep undisturbed.

COMMERCIAL BABY FOODS

Since the baby’s food is prescribed by the doctor, the nurse has little concern with the various proprietary baby foods and the canned and powdered milks which are so persuasively advertised to young mothers. It is hoped, however, that the discussions on nutrition in general and on baby feeding in particular, have made it clear to the nurse that these foods cannot be expected to be satisfactory if used as a sole article of diet throughout the bottle-feeding period.

There are many times and circumstances, however, when the temporary use of a prepared infant food or canned or powdered milk is advantageous. In some cases of intestinal disturbance, for instance, or while the mother is traveling and is unable to have freshly prepared milk formulas supplied to her along the way; during the summer, while staying at a hotel or boarding house where the freshness, cleanliness or purity of the milk are uncertain; or during a sudden shortage of fresh milk, as may occur during a strike or severe storm when transportation is interfered with, a proprietary food may be a great boon.

If the nurse is confronted with the necessity of choosing and making temporary use of a prepared food she may be guided by considering the general principles of baby feeding and the character of the materials at her disposal.

The Proprietary Foods may be divided into two general groups: one kind contains milk powder and is usually added to water while the other consists largely of sugar and starch and is added to fresh milk before being given to the baby.

Canned Milk is of two kinds; evaporated, which is unsweetened, and condensed, which is sweetened. Evaporated milk is whole milk from which part of the water has been removed, the milk then being canned and sterilized. The addition of water to evaporated milk restores it to the composition of whole milk in many respects, but it is still milk that has been heated. Condensed milk is evaporated milk to which cane sugar has been added to aid in its preservation. Since bacteria do not grow well in highly sweetened foods, it is not necessary to bring sweetened condensed milk to as high a temperature as the unsweetened product, to prevent subsequent bacterial decomposition. The high percentage of sugar in condensed milk quite obviously renders it unsuitable for continuous use as the sole article in a baby’s dietary.

Milk Powders or Dried Milks are prepared by rapidly evaporating the water from whole milk, skimmed milk or partly skimmed milk, leaving the solid constituents in the form of a light, white powder. Milk powder readily dissolves in water, forming a “reconstructed milk” which closely resembles the fresh milk from which it was prepared. But it must not be forgotten that reconstructed milk has been heated. Many doctors consider whole milk powder the most satisfactory form of preserved milk which is available for baby food. Should it be used, however, the importance of keeping it tightly covered and in a cold place must be recognized, for the presence of fat renders it likely to become rancid if not kept cold.

ARTICLES OF FOOD WHICH ARE SOMETIMES INCLUDED IN THE BABY’S DIETARY

Barley Water, sometimes used to dilute whole milk, is made by mixing the barley flour to a smooth paste in cold water, adding boiling water and boiling for twenty minutes or cooking in a double boiler for an hour, straining and adding enough water to replace the amount lost in cooking. The proportions for different ages are as follows:

• Three months, ½ level tablespoonful barley flour to 16 oz. water
• Six months, 1½ level tablespoonful barley flour to 12 oz. water.
• Nine months, 3 level tablespoonfuls barley flour to 10 oz. water.

Potato Water. One tablespoonful of thoroughly boiled potato is mashed into one pint of the water in which the potato was boiled and carefully strained.

Spinach. Spinach is carefully washed, steamed for half an hour and mashed through a fine sieve. It is sometimes started at the sixth month; one teaspoonful daily, gradually increased to one or two tablespoonfuls daily.

Orange Juice. The orange should be dipped in boiling water and wiped on a clean towel before being cut and squeezed, to avoid possible infection of juice. It is usually given to babies getting heated milk, sometimes as young as one month old. It is carefully strained and started gradually by giving one teaspoonful in water once or twice daily between feedings and increasing to ½ or 1 ounce by the sixth month and 1½ to 2 ounces by the end of the first year.

Infusion of Orange Peel. This is sometimes used instead of orange juice, and is made by boiling one ounce of finely grated orange peel in two ounces of water, adding a little sugar to counteract the bitter taste and adding enough sterile water to bring it up to two ounces.

Tomato Juice. Canned tomato strained through a fine sieve, is sometimes given to a baby a few weeks old, starting with one dram and gradually increasing to four to six ounces daily.

Whey. One quart of whole milk heated to 98° F. or 100° F. and one-half ounce of liquid rennet or one junket tablet stirred into it and allowed to stand half an hour or until firm and solid, is poured into a cheese-cloth bag and allowed to drain for about an hour without being squeezed.

Protein Milk. The curd from one quart of milk, which remains after the whey is drained, as directed above, is mashed through cheese-cloth in a fine wire sieve, with a potato-masher or bowl of a spoon and the curd washed through with one pint of water. A pint of buttermilk is added and the mixture boiled while being stirred constantly. This is sometimes given in diarrhea.

Beef Juice. One pound of thick round steak, slightly broiled, is cut into small pieces and the juice expressed with a meat press or a lemon squeezer, the amount varying from 2 to 3 ounces. It may be diluted with an equal amount of warm water, or slightly warmed by being placed in a cup standing in hot water, and salted to taste.

Broths. One pound of lean meat, all fat and gristle removed, is allowed to one pint of water. The meat is cut finely and put on in cold water, heated slowly and allowed to simmer for three or four hours, when water is added to replace what was lost in cooking. It is strained, the fat removed and slightly salted.

Oatmeal Water. Two level tablespoonfuls of oatmeal in a pint of boiling water is cooked in a double-boiler for two hours, strained and enough boiling water added to replace the amount lost in cooking.

The difficulties of traveling with a young baby may be greatly lessened by making certain preparations. If the baby is bottle-fed, the preparations will depend upon the length of the journey and whether or not it will be possible to have freshly prepared feedings, for each twenty-four hours, put on the train from laboratories along the way. If this is not possible and the journey is not to take more than twenty-four hours, the entire quantity of food, ice cold, may be carried in a thermos bottle. The requisite number of sterile nursing bottles may be taken or one bottle which is boiled before each feeding. Or the milk may be prepared as usual and the bottles packed in a portable refrigerator. Such a refrigerator may be bought or one may be improvised. The bottles are placed in a covered pail and packed solidly in crushed ice; this is placed in a second pail or a box with a diameter which is at least two inches larger than the inner pail and the space between the two packed firmly with sawdust. Several thicknesses of newspapers should be pressed down over the top and a tight cover fitted to the outer receptacle.

The sterile nipples may be taken in a sterile jar and a deep cup or kettle will be needed in which to warm the bottle before each feeding. It is usually possible to obtain water on the train which is hot enough for this, or cans of solid alcohol, a stand and a metal tray may be added to the traveling outfit. If fresh formulae cannot be delivered to the train, daily, and the journey is to last more than twenty-four hours, one of the proprietary foods or a powdered milk will often prove to be a satisfactory solution to the problem of feeding.

The baby will usually travel more comfortably and sleep better if he is carried in a basket. A large market basket with a handle or a small clothes basket will serve. It may be lined with a sheet or a blanket; have a small hair pillow or folded blanket in the bottom and be made up like a crib. (Fig. 173.) If this basket stands on the car seat during the day, and on the foot of the nurse’s berth at night, the baby will be cleaner, quieter and less exposed to drafts than if carried in the arms.

THE PREMATURE BABY

All of the precautions and gentleness which are necessary in the care of the normal baby, born at term, must be greatly increased in caring for the baby who is born prematurely.

As was explained in Chapter III the premature baby’s prospects of living increase with the length of his uterine life, and it is often possible to estimate this by measuring and weighing him. During the last five months the child’s length in centimetres divided by five gives the month of pregnancy, according to the following table by Dr. Williams:^[15]

• At the fifth month of pregnancy 5×5, fetus is 25 cm. long
• At the sixth month of pregnancy 6×5, fetus is 30 cm. long
• At the seventh month of pregnancy 7×5, fetus is 35 cm. long
• At the eighth month of pregnancy 8×5, fetus is 40 cm. long
• At the ninth month of pregnancy 9×5, fetus is 45 cm. long
• At the tenth month of pregnancy 10×5, fetus is 50 cm. long

But consideration of the baby’s weight is also of importance when attempting to forecast his chances of living. A baby weighing less than 2500 grams or about 5½ pounds should be regarded, and treated, as premature, unless it is more than 45 centimetres, or about 18 inches long. This length would indicate greater maturity, and therefore greater viability than would be expected from the weight. A baby weighing less than 1500 grams (3 pounds and 5 ounces) can scarcely be expected to live.

The premature baby is not only small, but in general is imperfectly developed, having slenderer powers than the full-term baby and at the same time much greater needs. His respiratory and digestive organs are less ready to function than in the full-term baby; his muscles and nerves are feeble; his heat-producing mechanism is unstable and yet there is an excessive radiation of body heat through the relatively large area of skin.

Accordingly, the baby who has been deprived of those valuable last weeks of growth and development is small and limp; lies quietly most of the time and moves very feebly if at all. He is often too weak to nurse at the breast and may swallow with difficulty. His temperature is low, his respirations irregular and he is frequently cyanotic.

The care of this frail little body practically resolves itself into:

• 1. Maintaining a normal body temperature.
• 2. Promoting and maintaining normal respirations.
• 3. Supplying adequate and suitable nourishment.
• 4. Conserving his strength.
• 5. Preventing infection.

To maintain a normal body temperature it is necessary to give special thought to the baby’s clothing, bed and room. He should be oiled with warm olive oil and entirely wrapped in cotton batting or flannel or enveloped in a quilted garment, with hood attached, made of cheese-cloth or flannel and cotton batting. (Fig. 174.) Diapers are often omitted in caring for very feeble babies, a pad of cotton being slipped under the buttocks instead as this may be changed with less disturbance to the baby than a diaper.

His bed consists of a box or basket, with the bottom well padded with several inches of cotton, a small pillow or a soft blanket folded to the proper size, covered with rubber or oiled muslin and a cotton sheet. The sides of the basket should be lined with heavy quilted material (Fig. 175), to shut out drafts and help to preserve an even temperature of the air immediately around the baby. A flannel covered hot-water bag at 110° F. may be placed beside the baby, or two, three or four glass bottles, each holding about a pint, containing water at 100° F. and securely stoppered, may be hung in the corners of the basket. (Fig. 176.) A thermometer should hang in the basket also, and the temperature kept between 80° F. and 90° F. It is easier to keep the temperature even if the bottles are filled in rotation instead of all at the same time.

The amount of heat needed around the baby is decided by taking his temperature (by rectum) at regular intervals; supplying more heat if the temperature is low and less if it is at or above normal. Some doctors have the temperature taken every four hours; others twice daily. As the baby grows able to maintain a temperature of 98° F. to 100° F., unassisted, the surrounding heat is gradually reduced and finally removed, and flannel clothing replaces the quilted robe.

In many hospitals there are special rooms for premature babies, which are divided by glass partitions into cubicles so that each baby is in a three-sided enclosure. The rooms are usually darkened to save the baby from the needless irritation of light, and are supplied with constantly changing fresh, moist, filtered air, the temperature being kept at from 80° F. to 90° F.

In a patient’s home or in a hospital where there is no special room for premature babies, a cubicle may be improvised by placing the basket in which the baby lies, in the corner of a room and placing a screen parallel with one of the walls. Such a room should be darkened, well ventilated and have in it a large open vessel of water.

Since the premature baby’s lungs are not fully expanded, respirations are likely to be shallow and irregular, thus failing to supply the amount of oxygen which he sorely needs. As crying inevitably involves deep breathing, it is a common practice to make the premature baby cry at regular intervals during the day in order to promote the respiratory function. Dr. Griffith further recommends plunging the baby into a mustard bath at 100° F. or 105° F. if necessary to make him cry vigorously. It is also important to turn the premature baby from side to side, several times a day to prevent fluid from collecting in the lowermost part of the lung, a condition favorable to the development of pneumonia.

In feeding premature babies, breast milk is ordinarily the most desirable food. If the baby is too feeble to nurse, as frequently occurs, the milk may be expressed from the breast of his mother or a wet nurse, by stripping or pumping, into a sterile receptacle, and if not used immediately it should be covered and placed in the refrigerator. Breast milk is sometimes used whole and sometimes diluted with water, and is given by gavage if the baby is very feeble; from a medicine dropper or a special feeder. Such a feeder consists of a glass tube with a small nipple on one end and a rubber bulb on the other, by means of which the milk may be gently expressed into the baby’s mouth, thus minimizing his effort to obtain it. (See Fig. 175.)

The amount and intervals for feeding the premature baby have to be adjusted to the individual with even greater care than for a normal baby, for he needs more fuel and building material, because of his imperfect development and yet because of that same imperfect development his digestive powers are feebler than those of the full-term baby. During the first day or two, he is sometimes given nothing but water or sugar solution, the milk being started gradually when the baby is from thirty-six to forty-eight hours old. He may be given a very small quantity every two hours, or he may be fed at three- or four-hour intervals, depending entirely upon his condition and progress. It is usually considered very important for the premature baby to have sterile water or sugar solution to drink between feedings, and this is given in the same manner as his milk.

Unlike the normal baby he is not taken from his bed to be fed, unless he nurses at the breast.

The premature baby is weighed as often as is safe for him, since the suitability of his food is largely indicated by changes in his weight. But sometimes very young and feeble babies are weighed only once or twice a week because of the inadvisability of disturbing them more frequently.

Avoidance of fatigue and the conservation of the premature baby’s limited strength and energy are accomplished through reducing his muscular activity to the minimum, by very little and very gentle handling; and by minimizing his loss of energy in the form of heat by keeping the little body warm and quiet.

In this connection the daily bath is of considerable importance. It almost always consists of sponging the baby with warm olive oil as he lies in his bed, and with the least possible exposure and turning. It is given every day or every second or third day according to his condition. The eyes are wiped with boric pledgets and the nostrils with spirals of cotton dipped in oil. The buttocks are wiped with an oil sponge each time the diaper is changed.

The premature baby is very susceptible to infection and strongly predisposed to pneumonia. Infection in general is guarded against by having everything that comes in contact with the baby scrupulously clean; protecting him from drafts, chilling and dust; allowing no one with a suspicion of a cold to come near him and by the nurse’s wearing a clean gown and protecting her nose and mouth with a gauze mask while attending him.

CARE OF THE BABY DURING THE SUMMER

The dangers of infancy are greatly increased in summer, more babies dying during the hot months than any other time during the year. The cause of these deaths is variously termed summer complaint, summer diarrhea, acute gastro-enteritis and cholera infantum, and is due to infected or decomposing food or both.

Clearly this malady is practically preventable through care.

Although such care as has been described in the preceding pages largely constitutes the prevention of the much-to-be-dreaded summer diarrhea, there are a few extra precautions and safeguards with which the nurse must surround her little patient during the warm weather.

She must bear in mind the character of the illness to be avoided: indigestion associated with infection.

It becomes almost a matter of life or death, then, to give the baby clean, suitable food and avoid deranging his digestion.

Babies suffer from the heat more than adults do and are often excessively irritated and exhausted on warm days. And this overheating, exhaustion and restlessness are of themselves enough to affect his digestion.

Accordingly the scourge of summer diarrhea is prevented by giving the baby proper food and keeping him clean, cool and quiet.

The baby should have maternal nursing if possible, for breast-fed babies fall victim to summer diarrhea much less frequently than bottle-fed babies. He should be fed with absolute regularity, and as a rule, no matter what the nature of his food, it is reduced one-quarter to one-third in amount during very warm weather and he is given an increased amount of cool boiled water to drink. His weight may increase very slightly, or even stand still for a short time, as a result of his decreased food, but this is not usually deplored, if he keeps well, for the important thing is to avoid digestive disturbances while the weather is warm.

Cleanliness, as at other times, applies to the baby’s food, clothing and surroundings. Many doctors think it safer to have all milk boiled during the summer, and of course require flawless technique in its preparation and administration. The baby’s soiled napkins should be placed immediately in a covered receptacle containing water, and not left for even a moment where they can be reached by flies. They should be washed, boiled and dried in the open air and sunshine as promptly as possible.

The baby should be protected from flies and mosquitoes by screens in the windows and netting over his crib and carriage, both because they make him restless and irritable and because flies particularly are carriers of filth and disease—the kind of disease that kills so many babies during the summer. Accordingly the nurse must always regard flies with a deadly fear.

The baby should be kept away from dusty places and from cats and dogs. And since babies will put their fingers in their mouths it is a wise precaution to wash their hands several times a day.

The baby should be in the country, in the mountains or at the seashore if possible during the warmest part of the summer at least, but if he is in town there is much that the nurse can do to keep him cool and comfortable. His clothing at this time must be adjusted to his condition and the temperature of the moment just as it is in cold weather. A thin shirt, band, diaper and cotton slip will usually be enough for out-of-door wear, while in the house he may often dispense with the slip and sometimes with everything but his diaper.

During excessively hot days, the baby should have two or three cool sponge baths, in addition to the soap and water bath, one of the sponges being given before he is put to bed for the night. He should sleep on a firm mattress, preferably curled hair but never feathers, and in the coolest, best ventilated room available. During the day it is usually best to take him out-of-doors early in the morning and late in the afternoon, but to keep him indoors during the warmest part of the day, when it is likely to be cooler indoors than out, particularly if the blinds are closed. Quite naturally the nurse will have to take into consideration the size, arrangement and location of the baby’s home in her effort to keep him in cool, quiet, shady places and out-of-doors as much as possible.

He must not be played with, held on hot laps nor subjected to the entertainment and attention which misguided but well-meaning mothers and friends are so eager to lavish on a hot, fretful baby.

Very often during warm weather a fine rash known as “prickly heat” appears on the back of the baby’s neck and spreads over his head, neck, chest and shoulders. This rash is due to too warm clothing or to the hot weather or to both. Less clothing and frequent baths will often give relief, but if the baby is very uncomfortable, he may be greatly soothed by being immersed in cool baths containing soda, bran or starch in the following proportions:

Soda bath. Two tablespoonfuls of baking soda to one gallon of water.

Bran bath. A cheese-cloth bag about six inches square, partly filled with bran, is soaked and squeezed in the bath water until it is milky.

Starch bath. About eight ounces of cooked laundry starch to one gallon of water.

No soap should be used while the baby has prickly heat and after the bath he should be patted thoroughly dry and powdered with some such soothing powder as the following:

• Powdered starch one ounce
• Oxide of zinc one ounce
• Boracic acid powder 60 grains

As we look back over these pages of somewhat detailed description of the case of the baby, it is borne in upon us that the nursing of this unfailingly delightful and interesting little patient has special adjustments and adaptations for different seasons and circumstances; but that on the whole the care of all babies the year around resolves itself into the observation of a few general principles, namely: proper feeding; fresh air; regularity in his daily routine; cleanliness of food, clothing and surroundings; maintenance of an equable body temperature and conservation of his forces.

If the nurse fixes these principles firmly in her mind and acts upon them, she will do a great deal to give her baby patient a fair start on his life’s journey.