to give small meals frequently rather than the regular meal
three times a day. The feeling of "fullness" which often
occurs during the last two or three months of gestation
makes it more comfortable for tiie pregnant woman to
eat less at a time and oftener. If, for example, she be
given a glass of rich milk or a nutrient beverage, either of
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PREGNANCY AND LACTATION 193
enforced malted milk, albumenized orange juice, butter-
milk, zoolak, or koumiss, at about eleven o'clock in the
morning and again about four o'clock in the afternoon, she
will have taken sufficient nourishment to meet the new
requirements without taxing her digestion or imposing extra
work upon the kidneys.
Abnomial Symptoms. ā The chief point to keep in
mind is any abnormal symptom which may develop. The
chief of these is albumen in the urine. The urine must be
examined frequently and measures taken immediately to
overcome albuminuria should it occur. It is wise, as haa
already been stated, to restrict the meat in the diet, and in
cases where albumen is found in the urine even when the
meats are restricted, it may be necessary to place the patient
upon a milk diet for a time until the urine clears up.
Supplementary Feeding. ā Cereals, especially the whole
cereals, must be used liberally. Gruels made with milk are
often found valuable additions to the dietary. The pro-
spective mother must be urged to take a regular amount of
gentle exercise, not to become overtired, or excited, to eat
sparingly at ni^t, and to drink plenty of water. She must
avoid becoming constipated by eating plenty of green vege-
tables and fruit.
Sample Diet Sheets. ā The following dietary is sug-
gested: Breakfast should consist of thorou^ly cooked
cereals, wheatena, cream of wheat, malt breakfast food,
cracked wheat, rolled or cracked oats, served with cream
or sugar or both, whole wheat bread, muffins, or biscuits,
with butter, raw or stewed fruit, cofifee, tea or cocoa with
milk. Luncheon may consist of milk or vegetable soups,
e^s in any form, boiled potatoes, sweet potatoes, string
beans, greens, or any green vegetables, simple desserts such
as custards, rice or tapioca puddings, bread pudding, etc.,
milk, tea, cocoa, buttermilk, zoolak or koumiss as beverages.
For dinner, if albuminuria is not present, a small piece of
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194 DIETETICS FOR NURSES
meat may be taken, together with green vegetables, rice,
potatoes, simple salads, and a simple dessert, milk or coffee
with milk as a beverage.
Selection of Food. ā The following foods may be used
to formulate the diet sheet: Wheat, oat, or com cereals,
rice, tapioca, made into simple puddings or served as break-
fast foods; fruits, oranges, prunes, apples, raisins, dates,
figs, or grapefuit, stewed or raw. The fruit juices may be
used instead of the whole fruit if the latter disagrees. Vege-
tables: peas (green or dried), beans (string beans or dried
beans), spinach, greens (turnip, mustard, or beet), cabbage,
onions, celery, lettuce, served as vegetables or in soups,
potatoes. Meat: lightly broiled beefsteak or stewed or
boiled meat or chicken served not more than once a day or
three times a week. Eggs, prepared in different ways.
Cheese dishes. Breakfast bacon or ham in moderate quan-
tities, butter, olive oil (or other salad oils) in moderation,
whole wheat, graham or bran bread, Boston brown bread
and crackers, milk, cocoa, chocolate, buttermilk, malted
milk, koumiss, or zoolak; cofifee and tea in moderation.
The diet, as has already been stated, may be supple-
mented by nutrient beverages or milk gruels.
DIET IN LACTATION
The diet of the nursing mother, as has been explained
in a previous chapter, must not only cover her own require-
ments but must likewise be adequate to furnish the extra
requirements imposed by the nursing infant.
Food Requirements of Nursing Infant. ā When the
baby is a month old he should be growing rapidly, and his
food requirements at this period and until he is about three
months old will be approximately fifty calories per pound
of body weight in the twenty-four hours. As he grows older
his requirements grow gradually less in proportion to his
weight. This is because the rate of growth is less, so that
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PREGNANCY AND LACTATION 195
for the next three months the requirements are from 43 to
40 calories per pound of body weight per day, and 35
calories per pound during the last three months, or by the
end of the first year of life.
It has been estimated, as before stated, that the average
infant will take 2% to 2^^ ounces of mother's milk per
day ^ to each pound of body weight and that every ounce
of mother's milk will yield on an average 20 calories. Hence
a month-old baby weighing ten pounds will be taking about
23 ounces a day, yielding 460 calories. Scientists have esti-
mated that for every calorie produced by the milk two
extra calories must be provided by food, so that for the
baby requiring 460 calories per day, to cover his require-
ments the mother will be obliged to consume extra food to
yield 920 calories, or the regular amount to meet her nor-
mal requirements plus the extra food to make sufficient food
for the baby.
Diet of Nursing Mother. ā The diet of the nursing
mother need not be different from that to which she is
accustomed. She should be warned against overwork or
over-fatigue, nervous excitement and worry, since these
factors affect the digestion of the nursing baby. She must
be careful not to eat indigestible foods or foods which
disagree with her, as such things will undoubtedly affect
the digestion of the infant. When an article of food does
cause digestional disturbances in the baby, it should be
carefully omitted from the mother's diet.
Factors Retarding and Stimulating Milk Secretion. ā
Constipation in the mother reacts quickly and unfavorably
upon the secretion of milk. The same has proved to be the
case when she becomes excited, nervous, worried, or over-
tired.
The average diet for the normal woman is safe for the
nursing mother. If her supply of milk is deficient, it may
""Feeding the Family," p. S3, by Mary Swartz Rose.
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196 DIETETICS FOR NURSES
be at times increased or stimulated by the drinking of a
glass of milk between meals or by taking a cup of hot
cereal milk gruel. It was formerly believed that beer, ale,
or stout acted directly upon the mammary glands, stimulat-
ing the secretion of milk, but there is little proof of this
and the drinking of alcoholic beverages need not be en-
couraged on this account, since often more nourishing bev-
erages fulfill the purpose more efficiently and without bad
results.
SUMMARY
Gastric Disturbances. ā The nausea and vomiting so
often a part of early pregnancy is not believed to be the
result of a disordered stomach but primarily a mild form of
poisoning resulting from the incomplete establishment of
the fetal circulation.
Adjusting the Diet. ā The adjustment of the diet to
cover the needs of the prospective mother and those of the
developing child is essential. The amount of food taken
by the mother is not materially changed during the first
three months of gestation. An average normal diet is all
that is necessary. After this time a twenty per cent, increase
in the woman's diet will furnish adequate means both for
her maintenitnce and for the growth and development of
the child.
Type of Food. ā The kind of food which is necessary
for the pregnant woman to take during this period is very
similar to that taken ordinarily. It is necessary to furnish
food materials rich in calcium and phosphorus, with an
adequate supply of proteins in their simplest form in order
to meet the requirement of the growing organism. Milk
and eggs furnish the most efficient foods in this respect and
the prospective mother should see that they form the chief
items of her daily dietary. Milk furnishes calcium in its
most available form for the developing skeleton of the grow-
ing infant, hence it is necessary to provide the mother with
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PREGNANCY AND LACTATION 197
food to replace the mineral which is withdrawn from her
body.
Meat in the Diet ā Meat should be eaten sparingly by
the prospective mother, as it imposes needless work upon
the already taxed kidneys and, if eaten in excess, will give
rise to dangerous complications. Milk and eggs will pro-
vide ample protein for all purposes.
Albumen in the Urine. ā Albuminuria is one of the
most frequent complications in pregnant women. It should
be combated and controlled as soon as possible. The allow-
ance of meat should be cut down or entirely eliminated from
the diet until the urine clears up. When albuminuria is
persistent in spite of efforts to overcome it, the patient must
be placed upon a strict milk diet as used in acute nephritis,
to prevent dangerous complications arising.
LACTATION
Diet of Mother. ā Her dietary need not differ ma-
terially from that to which she is accustomed. She must
avoid indigestible foods or any article which has been proved
to disagree with either the infant or herself.
Factors Regarding Secretion of Milk. ā Constipation,
worry, nervous excitement, and over-fatigue all have an
unfavorable effect upon the secretion of milk and must
therefore be avoided by the nursing mother.
The Bowels. ā Constipation of the mother reacts
quickly and unfavorably upon the health and comfort of
the baby, hence it should be avoided by eating coarse
breads, green vegetables, and fruits, when they do not disa-
gree with the baby, by drinking plenty of water and taking
a certain amount of outdoor exercise to keep her own health
in good condition.
Stimulating the Milk Production. ā When the milk
supply is deficient it will be advisable for the mother to
drink a glass of milk or a bowl of cereal milk gruel between
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198 DIETETICS FOR NURSES
meals. Alcoholic beverages are not necessary to insure an
adequate secretion of milk. The milk or milk gruels answer
the purpose more efficiently and without bad results.
Energy Requirements of Infant. ā The average baby
requires fifty calories per day per pound of body wei^t to
cover his energy growth and development needs for the first
three months of life, after which the rate of growth is less
and his requirements decrease from forty-three to forty,
then to thirty-five calories per day per pound by the end
of his first year.
Amount of Milk Needed for Infant. ā Approximately
two and one-third ounces to each pound of body weight per
day covers the needs of the average baby.
Fuel Value of Mother's Milk. ā Each ounce of milk
yields twenty calories.
The Making of Milk. ā It has been estimated that for
every calorie yielded by milk, two extra calories must be
provided by food:
PROBLEMS
(a) Formulate a dietary for a pregnant woman, allowing
for a twenty per cent increase over her normal require-
ments.
(6) Show how the diet may be made to cover the need for
additional iron, calcium and phosphorus.
(c) Formulate a diet for a nursing mother with an infant
two months old and weighing twelve pounds.
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CHAPTER rX
INFANT FEEDING
In taking up this part of our study on nutrition, there
are several points to be kept in mind by the nurse: (1) that
it will be difficult, if not impossible, to understand the
metabolic changes taking place in abnormal conditions
unless those occurring in the normal human body are under-
stood; (2) that certain diseases are due directly to errors in
diet; (3) that in other diseases, diet plays the chief part
both in the bringing about and in the relieving of the con-
ditions; (4) whereas there are certain other diseases not
affected by diet, save in so far as well or poorly selected and
prepared food always affects the individual, whether normal
or abnormal, and that in the latter conditions the organism
is more susceptible to bad influences.
This being the case it behooves the nurse to examine
herself to find whether or not she understands the funda-
mental principles underlying the nutrition of the human
body, that she may efficiently deal with the changes which
occur more or less when the body is attacked by disease.
We include normal infant feeding in this section, because
in no other age is it quite so necessary for care to be ob-
served in formulating and carrying out a diet. Errors dur-
ing this period may only appear to exert a local influence,
causing disturbance which may readily be relieved, but the
danger is in laying too little stress upon these disturbances,
forgetting that the delicate organism of a child may be
permanently injured by a constant disregard of nature's
mandates. In the words of the old adage, the pitcher may
go once too often to the well, and an injured digestive
apparatus is even more difficult to mend than the pro-
verbial pitcher.
199
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200 DIETETICS FOR NURSES
In this section, then, the metabolic changes due to
pathological conditions and the dietetic treatment thereof
will be discussed.
Age and Weight. ā As has already been stated, there
are certain points to be kept in mind in attempting to pro-
vide an adequate diet for the human machine; First, the
age and weight. The gain during infancy should be steady
ā an allowance of 40 calories per pound of body wei^t to
cover the energy requirements and 4 protein calories per
pound to cover the nitrogen needs. During the second and
third years the energy requirements will be covered by 30
to 40 calories per pound and the nitrogen needs by 3 to 4
protein calories per pound. From the fifth to the eighth
year the nitrogen needs continue to be covered by 3 to 4
protein calories per pound and the energy requirements by
35 to 37 calories per pound during the fifth year; 32 to 34
calories per pound during the seventh year. After the body
has reached its full development its requirements will be
met if sufficient protein is provided to cover its mainten-
ance needs and if the energy calories are regulated accord-
ing to the amount of exercise taken, keeping in mind that
the energy requirements of a man at rest (sitting) will be
about 2,000 calories per day and that exercise, especially
that taken in the open air, raises the energy needs of the
body.
Daily Gain. ā In estimating the relative daily gain in
body weight of children of different ages, Mendel ^ gives
the following table:
TABLE
In the first month, about 1.00 per cent
At the middle of the first year . . . 0.30 per cent
At the end of the first year .... 0.16 per cent
At fifth year 0,03 per cent
Maximum in later years for boys . . 0.07 per cent
Maximum in later years for girls . . 0.04 per cent
* "Childhood and Growth," p. 18. by Lafayette Mendel.
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INFANT FEEDING 201
Retention of Nitrogen in Infancy, ā When the baby
is gaining in weight and strength there is a retention of
both nitrogen and salts, and when the baby is not gaining
there may be a loss of both of these bodies; when one is
retained in the body the other is apt to be retained.^
NORMAL INFANT FEEDING
Much has been written in the past few years on the care
and feeding of infants and children. This is well, since
statistics show an alarming increase in the rate of infant
mortality during the early years of life, and anything which
can be done to check this lamentable and often avoidable
waste of valuable life should be resorted to with care and
attention.
Food for Infants. ā The natural food of all young mam-
mals is the milk of their own mother. The rate of growth
and development differs in every species; the calf, for ex-
ample, doubles birth weight much more quickly than does
the baby of the same age. However, the milk of the cow,
which meets the needs of the calf perfectly, falls short of
meeting the requirements of the infant, whose rate of
growth is not nearly so rapid. For this reason if for no
other, it would be advisable to give the baby its natural
food rather than to attempt a substitute which is, at best,
a poor one.
Weight ā The average infant weighs from six to seven
pounds at birth. This weight should be doubled in the
first five or six months of life and tripled by the end of the
first year. The most important business, then, in the life
of the child during the early years is growth and develop-
ment. To achieve this properly the baby's habits must be
adjusted to his needs.
Regularity in Feeding. ā He must have the proper food
and enou^ of it, and have it given at regular intervals,
'''Diseases of Nutritioo and Infant Feeding," by Morse and Talbot,
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202 DIETETICS FOR NURSES
"by the clock," for guesswork is fatal in infant feeding. He
must be given water between meals. Babies often cry from
thirst when they are thought to be doing so from hunger
or temper, or both. The healthy baby sleeps about twenty-
two hours out of twenty-four during the early months, and
even during the latter six months of the first year more
time is spent in sleeping than in waking.
The Bowels. ā The bowels should move several times
a day, the stools being smooth and of a yellowish color, of
the consistency of pea soup. After the first month, twice a
day is about the normal number of stools for the healthy
baby. The infant should be placed upon a vessel held in
the lap of the nurse at regular times, preferably right before
the morning bath, and in the evening. In this way regu-
larity in evacuating the bowels is obtained, and a habit
formed which will prove valuable through life.
The Bath. ā The daily bath is likewise necessary for
the health and comfort of all babies; so, too, are fresh air
and sunshine.
As has already been stated, breast milk is much better
for babies than cow's milk or any artificial food. There is
something in the mother's milk which gives strength and
resistance to the baby which is absolutely lacking in any
other food no matter how carefully it is selected and pre-
pared, and for this reason young mothers must be pre-
vailed upon to nurse their babies whenever it is possible
for them to do so. When circumstances, such as having to
be away all day at work, make it impossible for a mother
to nurse her baby at regular intervals, she can be taught
how necessary are two or three breast feedings a day to the
future welfare of her child. When social reasons or lack of
desire on the part of the mother make her unwilling to
nurse her baby, it is the part of the nurse to lay the case
before her and let her judge whether or not she is willing
to accept the responsibility of bringing into the world a
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INFANT FEEDING 203
life for which she is unwilling to provide weapons with
which to fi^t the good fight.
Habits of Mother. ā The mother must be taught how
to efficiently nurse her baby; she must keep in mind that
upon her good health and temperate habits depend the
health and comfort of her baby. It devolves upon her to
provide food efficient in quality and quantity. To do this,
her own diet must be simple and wholesome. The nursing
mother must remember that she has to provide, not only
for her own maintenance and energy requirements, but
also for the infant whose fuel requirements are ever demand-
ing more food to provide for its rapid growth.
Food and Its Relation to Milk. ā It is believed that
two calories of food extra are necessary to produce one
calorie of milk, and since a month-old baby requires 2y^
ounces of mother's milk to every pound of his body weight,
and one ounce of mother's milk will yield 20 calories, it is
clearly seen that the mother will have to increase her diet
to cover the requirements of the baby. For example, if the
baby weighed 12 pounds, he would require 28 ounces of milk
in 24 hours, or 560 calories. Thus if it requires two calories
of extra food to make one calorie of milk, the mother's diet
would have to provide 1,120 calories extra, or about as much
food as would fulfill the needs of a laboring man, 3,000 to
3,500 calories, even if she were doing practically no actual
work; while if she were actively employed and doing a cer-
tain amount of physical labor, her rations would have to
approximate those of a man doing heavy muscular work
(about 3,500 to 4,000 calories per day).*
Breast Milk versus Cow's Milk. ā Consensus of opinion
shows that breast-fed infants require less energy than the
ones who must be nourished artificially. This is probably,
due largely to the fact that the constituents of human milk
are in a more available form than those in cow's milk, the
ā¢"Feeding the Family," by Mary Swarta Roee.
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204 DIETETICS FOR NURSES
former requiring a lesser expenditure of energy on the part
of the organism to become available than the latter. Very
active babies, ones who kick and throw themselves about
or cry violently, have a greater energy requirement than
the more placid baby who sleeps more and is more quiet in
movement and who cries less when awake. Breast-fed
babies are generally more quiet than their less fortunate
artificially fed brothers. It has been demonstrated that the
artificially fed baby has a much harder fight for existence
than the baby who receives his natural food; hence the
necessity of using every available means to make the food
digestible, and to lessen the danger arising from the addi-
tional work put upon the entire apparatus. Cow's milk con-
tains practically the same chemical elements as are found in
human milk, but these elements are combined in a slightly
different manner, and are not so easily handled by the
immature organs. The proteins of milk consist of casein,
which is insoluble, and albumen, which is soluble. Accord-
ing to Van Slyke the proportion of insoluble to soluble pro-
tein in cow's milk is 3.6:1, while in human milk the propor-
tion is only 1:1. The ash constituents in cow's milk are in
excess of the needs of the infant organism, but since a great
part of these salts is in an inorganic form they are not re-
tained to the same extent as those contained in human milk,
which are in an organic form.
Rules and Regulations. ā It is not possible to lay down
hard and fast laws to cover the subject of infant feeding.
The food must be adapted to the individual needs of the
baby in question. The nurse must see that the milk is
obtained from a responsible dealer, certified milk being of
course the safest. The bottles of milk should be wiped oflf
carefully and placed directly on the ice as soon as they are
received. The milk generally used in infant feeding has a
fat content of 4%.. That having a higher percentage of
fat is technically cream. The following table showing the
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INFANT FEEDING
205
fat, sugar, and protein composition of whole milk, cream,
skimmed milk, and whey was arranged by Morse and
Talbot: *
TABLE
Fat
Milk 8v^ar
Protein
Whole milk
4.00
4.50
3.50
7% cream
7.00
4.45
3.40
10% cream
10.00
4.40
2.25
16% cream
16.00
4.20
3.05
32% cream
32.00
3.40
2.50
Skimmed milk ....
1.00
6.00
3.56
Separated milk (fat free) .
0.25
5.00
3.65
Wh^
0.25
5.00
0.90
Seven per cent (7%) cream is obtained from the upper
16 ounces of a quart bottle of milk whick has been allowed
to stand undisturbed for six hours. The upper third of the
bottle contains 10% fat, while the whole fat layer from the
quart bottle, regardless of the number of ounces, contains
about 16% of fat.
Methods of Artificial Feeding. ā The use of whole milk,
top milk, or skimmed milk, diluted with water, and either
milk sugar, malt sugar, or sucrose (cane sugar) added, is the
method of feeding most commonly used, and upon it are
based the formulas universally advised by infant specialists.
There are cases in which simple dilution is not advisable.
In premature or very young infants, for example, the whey
mixtures have been found to give the best results. In toxic
diarrheas, where the putrefactive bacteria make the use of
all but the minimum amount of protein inadvisable, the
above method is contraindicated, as it is likewise in cases
where vomiting of casein curd is a prominent feature.*^
The Use of Alkalies. ā There are many cases in which
* "Diseases of Nutrition and Infant Feeding/' p. 218, by Morse and
Talbot.
'"Generally Accepted Methods for Artificial Feeding of Infants with
Indicatives and Contra-Indicatives," by Orville R. Chadwell, M.D. Re-