meal by end of 11th month. The orange juice may be increased to
3 tbs. if bowels are not loose.
The strained cereal should be given twice daily by the end of the
first year, and the milk should be undiluted at this time unless the
digestion of the infant forbids.
Cooled boiled water should be given several times each day between
feedings. Babies cry from thirst as well as from hunger.
SCHEME 2
For Feeding Well Babies
A full-term baby will usually take a formula made as follows:
Cream 2 ounces
Skimmed milk 2 ounces
Boiled water 12 ounces
Sugar of milk 6 level tsp.
After 3d day increase cream and milk at the rate of 1 ounce each
week, and sugar 1 tsp. every other day until at one month the baby
will be receiving a formula such as ā
Cream 5 ounces
Skimmed milk 6 ounces
Boiled water 22 ounces
Sugar of milk 3J level tbs.
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220 DIETETICS FOR NURSES
At two months ā
Cream 6 ounces
Skimmed milk 6 ounces
Boiled water 20 ounces
Sugar of milk 4 level tbs.
From this point the formula may be increased by adding 2 ounces
of skimmed milk each month until the baby is eight months old. For
each ounce of milk added, an equal amount of water should oc
omitted. The sugar in the formula should be reduced one half tbs.
every three months.
At six months the baby would be taking ā
Cream 6 ounces
Skimmed milk 14 ounces
Boiled water 12 ounces
Sugar of milk 3} level tbs.
At eight months ā
Cream 6 ounces
Skimmed milk 18 ounces
Boiled water 8 ounces
Sugar of milk 3 level tbs.
This amount will not be found sufficient in quantity for a twenty
four-hour mixture for children of this age. Increasing the amount
of the last formula in the same proportion, it will be ā
Cream 9 ounces
Skimmed milk 27 ounces
Boiled water 12 ounces
Sugar of milk 4i level tbs.
At this age the formula usually may be changed so as to be made
from whole milk instead of cream and skimmed milk. The formula
may be made as follows:
Whole milk 36 ounces
Boiled water 12 ounces
Sugar of milk 4i level tbs.
From this point on the formula may be increased by replacing the
boiled water with whole milk, two ounces each month up to thirteen
months. At this age the boiled water may be omitted from the
formula one ounce each week. Beginning at the age of eight months
the sugar may be eliminated from the formula^ one tablespobnful
each month.
Barley Water, ā At the age of five months, or at any time there-
after, barley water may be substituted for boiled water in the formula.
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INFANT FEEDING 221
This should be substituted when the baby is not gaining in weight.
It may be substituted in many instances when the movements are not
well digested.
Lime Water, ā It is frequently found to be advisable to add lime
water. It is not necessary in eveiy instance, but should be griven if
the baby is inclined to spit up, or in cases where the stools are too
frequent in number and are slightly green in color.
Determining the Fuel Value of a Formula. ā The
computation of the fuel value of a formula is very essential
since the growth and development of the infant depends
largely upon whether or not its energy expenditures are
well covered. The method is simple, requiring the same
methods used in the computing of other dietaries. Take the
formula just calculated, its fuel value would be estimated
as follows: Thirty- two ounces are equal to 960 grams. In
each 100 grams there would be 3 grams of fat, 2 grams of
protein and 6 grams of sugar. Hence in 9.6 one-hundred-
calorie portions there would be 9.6 x 3 ā 28.8 grams of fat,
9.6x2 ā 19.2 grams of protein, and 9.6x6 ā 57.6 grams
of sugar, in a thirty-two-ounce mixture.
To determine the fuel value of the formula, these results
must be multiplied by their physiological fuel factors, 9 and
4 and 4 respectively. Thus:
29 X 9 = 261 calories from fat
19 X 4 = 76 calories from protein
68 X 4 ā¢= 232 calories from sugar, or a total of
669 calories for the entire mixture.
Scheme for Adding Solids to Infants' Diet. ā
From 9th to 15th month:
6 A.M. ā Milk formula (bottle).
8 a.m. ā Orange juice V^ ounce, or prune pulp or
prune juice.
10 a.m. ā Bottle, cereal (strained) and bread and but-
ter or zwieback.
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222 DIETETICS FOR NURSES
2 p.m. ā Mutton, chicken, or veal soup cooked with
cereal; small portion of baked potato,
small portion of strained spinach or car-
rots; orange gelatin or cornstarch pud-
ding.
6 P.M. ā Bottle.
From 15 months to 2% years:
8a.m. ā Stewed fruit or orange juice; cereal, crisp
bacon, alternated with soft-cooked or
poached egg; bread and butter or toast,
milk or weak cocoa.
12 or 1 P.M. ā Meat or vegetable soup thickened with
cereal; lamb chop, scraped beef or chicken
or beef juice; baked or mashed potato;
strained spinach; carrots; turnips or
celery; gelatin, custard, or cornstarch
pudding.
3 P.M. ā Crackers and milk.
6 or 7 P.M. ā Bread and milk or cereal; baked apple or
apple sauce.
From 3 to 6 years:
8 a.m. ā Stewed fruit or orange; cereal; bacon or egg
(soft-cooked or poached) ; bread and but-
ter ; milk or cocoa.
12 m. ā Soup ; lamb chop, scraped beef, chicken, or
roast meats; potato; all vegetables; cel-
ery, lettuce; light desserts: custards, gel-
atin, lady fingers.
3 P.M. ā Milk ; fruit and crackers.
6 p.m. ā Milk or cocoa; stewed fruit bread and but-
ter; cereals; eggs.
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INFANT FEEDING 223
Vegetable Soup
1/4 lb. beef, lamb or chicken 1 tablespoonful pearl barley
1 potato 2 tablespoonfuls rice
1 carrot 2 qts. water
2 stalks celery 1 pinch salt
Finely divide the vegetables. Add the vegetables, bar-
ley and rice to 2 qts. of water. Boil down to 1 qt., cooking
3 hours. Add pinch of salt. Pass through fine sieve.
Morse and Talbot advise baked potato, plain boiled
macaroni, rice and wheat germ, bread and butter, baked
custard, plain blanc-mange, and plain boiled tapioca to be
given when the child is U/^ years old. When the child is
nearly two years old they add meat in the most digestible
forms, such as the white meat of chicken, lamb or mutton
chops, and scraped beef.
The following dietary is suggested for a child two years
old: iĀ»
" Whole milk, butter, mutton broth, chicken broth, beef
juice, soft-cooked eggs, dropped eggs, white meat of chicken,
lamb or mutton chops, scraped beef, French bread, stale
bread, toasted bread, whole wheat bread, milk toast, zwie-
back, plain white crackers, plain Educator crackers, barley,
jelly, oatmeal, cream of wheat, wheat germ, Ralston's
Farina, rice, baked potato, plain boiled macaroni, orange
juice, baked apples, stewed prune pulp and juice, junket,
baked custard, cornstarch pudding, plain blanc-mange, plain
tapioca. It is not advisable, as a rule, to begin green vege-
tables until the baby is 2^4 years old." .
It will be seen in the foregoing dietaries how authorities
differ in their beliefs as to the requirements of the child.
The dietaries included in this text are selected from those
used in different parts of the country by physicians who
""Diseases of Nutrition and Infant Feeding/' p. 236, by Morse and
Talbot.
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224 DIETETICS FOR NURSES
have successfully cared for the infants and children under
their charge.
THE FEEDING OF PREMATURE INFANTS
The digestion of premature infants is naturally not as
strong as that of infants bom at term. Very little is posi-
tively known, but the consensus of opinion goes to show
that in the majority of cases the tolerance for sugar is
greater than that of either the proteins or fats. The loss of
heat is relatively greater in proportion to its surface area
in small than in large bodies. This is a well-known fact,
hence the premature baby must require more food in pro-
portion to its weight than the baby who is born at the nor-
mal time. Then, too, as the premature infant is thinner he
does not keep warm like the older infant, and this must be
taken into consideration in feeding him. Breast milk is of
course by far the best food for such babies, not only because
its constituents are in a more available form for the feeble
digestive organs, but because the mother's milk furnishes a
resistance which is lacking in even the most carefully modi-
fied of milk formulas.
Energy Requirements of Premature Infants. ā Ex-
periments made upon premature infants have proved that
the caloric needs of these babies are greater than in the case
of full-time babies; that is, they require more per kilogram
of body weight. According to Morse " most premature
babies need 120 calories per kilogram of body weight. But
there are many exceptions, some thriving on as little as 70
calories per kilogram. No attempt should be made to reach
120 calories per kilogram during the first few days. Thirty
calories per kilogram is as much as is wise to give in the first
24 hours of feeding. This amount should be gradually in-
creased each day, watching carefully for symptoms of indi-
"Moree: "American Journal of Obstetrics," 1905. Hess: "American
Journal Diseases of Children," 1911.
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INFANT FEEDING 225
gestion and diminishing it if these appear. One hundred
and twenty calories per kilogram can be given in about 10
days." ^^
Necessary Dilution. ā Even breast milk must be di-
luted with an equal amount of water or a 3% sugar solution.
The amount of milk should be increased and the amount of
dilution decreased until the undiluted breast milk is given
in four or five days. Like older babies, the next best food
for premature babies is the properly modified cow's milk,
but the utmost care will have to be observed, as these babies
are more easily upset than older and stronger ones.
Premature Infant Feeding. ā The following method of
feeding may be suggested, keeping in mind that it is an easy
matter to increase the strength of a mixture if the baby
shows the need of such an increase. The premature baby is
rarely strong enough to take the breast.
Method of Administering Milk. ā The most satisfac-
tory method of administering the food in such cases is by
means of the Brick feeder, which consists of a graduated
glass tube, open at either end. On the small end is placed
a small nipple like those seen on medicine droppers; this one
is perforated and goes into the mouth of the baby. A large
rubber finger cot is attached to the other end of the tube.
The milk is forced into the mouth by pressing the finger cot.
In case the infant is too feeble even for this method of
feeding, the desired amount is dropped into the mouth from
a medicine dropper; 5 c.c. (about 1 dram or 1 teaspoonful)
of diluted milk being given at each feeding. This amount is
increased gradually from day to day.
Whey Mixtures. ā Whey mixtures have been found to
meet the needs of premature infants more efficiently than
ordinary mixtures. As the proteins in whey are in a more
digestible form, they throw less work on the immature di-
'"'Diseases of Nutrition and Infant Feeding," p. 238, by Morse and
Talbot.
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226 DIETETICS FOR NUKSES
gestive apparatus. As a rule the casein and whey are in
proportion of 1 : 1.
The following formulas ^^ show the amounts in which
the food constituents are combined and are suitable for
premature babies:
Fat 1.00%
Milk sugar . . . 4.00%
Total proteins . . 0.25%
Lime water . ā¢ . 25% of cream and milk mixture
or
Fat 1.00%
Milk sugar . . . 4.50%
Total protems . . 0.50%
Lime water . . . 25% of cream and milk mixture
PROPRIETARY FOODS
A word as to the use of Proprietary Infant Foods: These
prepared foods may be classified under four heads, as fol-
lows: (1) condensed milks; (2) malted foods, those consist-
ing chiefly of carbohydrates in the form of maltose and dex-
trins; (3) those consisting almost entirely of starch, and (4)
those composed partly of soluble and partly of insoluble
carbohydrates.
(1) Condensed milk may be sweetened or unsweetened.
These milks are never given undiluted, the directions calling
for one part condensed milk to nine parts water, which gives
a mixture containing 0.90 7^ fat, 5.497^ sugar, and 0.80%
protein if "Eagle Brand'' Condensed Milk is used."
(2) Malted Foods: Mellin's Food and malted milk are
examples of this group. These foods contain the carbohy-
drates in soluble form and when added to milk make an
acceptable addition, as they furnish the carbohydrates in
the most digestible form. When fed alone, diluted only
""Diseases of Nutrition and Infant Feeding/' p. 239, by Morse and
Talbot.
" "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.
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INFANT FEEDING 227
with water, they result in a mixture deficient in both fat
and protein.
(3) Imperial Granum is an example of this group, and
there are several others with similar compositions. These
foods are very much like wheat flour which has been sub-
jected to heat, changing to a small extent the stardi to
dextrose and dextrin.
(4) Nestle's Food, Eskay's Albumenized Food, and Al-
lenbury's Food are examples of this group, each containing
sugar and a percentage of starch. Upon dilution with
water, the amount of fat in the mixture is just a trace.
Incomplete Foods as a Source of Danger. ā The ease
with which the majority of these foods are prepared and
the way in which they agree with the baby constitute the
chief danger of their use. If they are added to milk, with
the exception of the condensed milk, they result in a modi-
fied milk containing the carbohydrates in a more or less
digested form. But they are expensive, and give no better
result as a rule than a carefully modified milk containing
a cereal gruel.
The giving of foods like malted milk alone is dangerous
because they are deficient in some of the most necesssary
constituents, and babies fed in this way, while growing fat,
are apt to have soft or brittle bones and muscular tissue
higher in fat and water than in protein, so that they do not
grow and develop in a normal way, and when they are at-
tacked by the diseases so prevalent in the early years of life,
they succumb rapidly, because the resistance given by a
properly modified food is lacking.
Condensed milks act in a like manner. That is, in the
sweetened milks the carbohydrate content is far in excess
of the needs, and the proteins and fats are deficient, so that
while the baby fattens he does not receive the building
foods commensurate with his body requirements.^Ā®
" The proprietary foods on the market are many, but those given above
as suggested by Morse and Talbot represent the best known infant foods.
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228 DIETETICS FOR NURSES
Many mothers adopt the use of these foods because they
mean less work than in modifying the milk properly, but
the nurse should point out the facts just mentioned, ex-
plaining that while these proprietary infant foods are un-
doubtedly valuable at times to fill a place when the milk
formula has not proved satisfactory, the use of these foods
as a regular custom is expensive, not only from a financial
standpoint but from a standpoint of health, since their dis-
advantages far outweigh their advantages in the long run.
SUMMARY
Breast Milk as a Food. ā The superiority of breast milk
over any other known food cannot be too strongly em-
phasized.
Regularity in Feeding. ā The absolute need for regu-
larity in feeding ā " feeding by the clock " and not by guess
or when the baby cries.
Indications of Health. ā The normal growth and de-
velopment to be used as guides as to the physical well-being
of the infant; also as an indication of the use of the proper
modification of milk for the individual needs of the child.
Dilution. ā The amount of dilution necessary ā cereal
waters, whey, etc. ā to increase the digestibility and nu-
trient values of the formula.
The Addition of Alkali. ā The addition of alkalies to
milk formulas to accomplish a like purpose.
Milk Sugar, Malt Sugar, Cane Sugar. ā The use of the
different sugars, namely, dextri-maltose, lactose, or cane
sugar under various circumstances as the condition of the
infant demands.
Substitutes for Whole Milk. ā The substitution of dif-
ferent milk, such as lactic acid milk, Bulgarian culture but-
termilk, Eiweissmilch, cream and whey mixtures, as the
individual needs of the infant demand.
Technique of Milk Modifications. ā The absolute need
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INFANT FEEDING 229
for the nurse to understand the technique of milk modifica-
tion before attempting the care of an artificially fed infant.
Percentage Computation. ā A knowledge of percent-
age, that an accurate computation of a formula may be
accomplished.
Preparation of Food. ā A sufficient knowledge of food
preparation to enable the nurse to prepare any food which
may be deemed necessary by the physician for the welfare
of the child.
Water. ā The importance of giving the baby water
aside from that used in modifying the milk. Many babies
cry from thirst when they are believed to be crying from
hunger or temper.
Increasing the Diet ā The necessity for increasing the
amount and strength of the formula with the age, growth,
and development of the child by the addition of solid food
as soon as the physician deems it advisable.
Feeding Premature Infants. ā The method of feeding
a premature infant differs from that employed in feeding an
infant born at term: (a) because its development has not
progressed so far; (b) because its digestive apparatus being
more or less immature, food handled with ease by an older
baby will be totally unfit for the premature one, both as to
quality and quantity.
Wet Nurse. ā The advisability of procuring a wet nurse
when the mother is unable to nurse the infant, (a) on ac-
count of the more digestible character of the food con-
stituents, especially the proteins, in mother's milk over
those of cow's milk; (b) on account of the resistance fur-
nished by the natural food which has been proved to be very
much greater than that furnished by any other food, no
matter how carefully the modification of the milk is made.
Premature Infants. ā Their caloric needs are greater
than in full-term babies, hence their food must be adjusted
to meet these needs.
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230 DIETETICS FOR NURSES
In fact the nurse must have an understanding of the
behavior of foods in the metabolism of infancy and the
laws which govern their use in the organism of the child,
PROBLEMS
(a) Write a formula for a two months' old infant weighing
twelve pounds, which contains 3% fat, 2% protein, and
6% sugar.
(6) Change this formula so that it will contain 3% fat,
1.5% protein, and 6% sugar.
(c) Write a formula for an eight months' old baby, using
whole milk instead of cream and skimmed milk.
(d) Write a formula for a premature baby containing 1%
fat, 4% sugar, and 0.25% protein (allowing 30 calories
per pound of body weight) .
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CHAPTER X
CARE AND FEEDING OF INFANTS AND CHILDREN
IN ABNORMAL CONDITIONS
Digestive Disturbances. ā It is a well-established fact
that artificially fed infants are more subject to disturbances
due to diet than breast-fed infants, the digestional disturb-
ances of the latter yielding more readily to treatment. As
a rule, with the breast-fed baby it is largely a question of
adjusting the diet of the mother, of increasing the fluid in
her diet, of seeing that she takes the requisite amount of
exercise in the open air, and of lengthening the intervals
between feedings or of giving the baby water just before
putting him to the breast. With the artificially fed infant
it is an entirely different proposition.
Causes in Artificially Fed Infants. ā The digestive dis-
turbances may arise from any one of half a dozen or more
causes. The constituents in the milk may be in the wrong
proportion. The amount given at a feeding may be too
great or too little. The dilution may be too great or too
small to meet the needs of the infant. Or the milk may
contain the microorganisms which bring about fermentation
or putrefaction. Any or all of these causes may assail the
artificially fed baby. Consequently, all the care that can be
exercised must be resorted to in the feeding of these babies,
not only after digestional disturbances arise, but as a means
of their prevention. In the preceding chapter the methods
generally used in the feeding of normal infants were dis-
cussed. We now proceed to the feeding under abnormal or
pathological conditions.
231
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232 DIETETICS FOR NURSES
Errors in Diet. ā The majority of the ills from which
the baby suffers can be traced primarily to errors in diet and
in most of these cases the treatment consists chiefly in ad-
justing the formula to suit the condition. As a rule, these
errors may be placed under two heads: those that are
brought on by underfeeding and those induced by over-
feeding. The pathological conditions arising from under-
feeding are due not only to a lack of food, but chiefly to the
improper balancing of the different food constituents in the
formula. As has already been stated, so much food is re-
quired to cover the energy expenditures, so much for main-
tenance, and so much for storage for the growth and devel-
opment necessary during the entire period from birth to
maturity. These constituents must be r^ulated to .the
individual needs of the infant.
Over- and Under-dilution. ā If the dilution is too great,
the infant, while receiving the correct amount of the mix-
ture, may have the necessary food constituents so reduced
as to have them fail completely to do their appointed work
in the body. Or if the amount of diluent is too small the
baby may be receiving too strong a mixture, and develop
nutritional disturbances therefrom. Under the first head
the child suffers from underfeeding; the appetite is satisfied
before enough of the actual food is ingested to meet his
various needs. However, it is probable that the artificially
fed infant suffers from the results of over-, rather than of
under-feeding.
DISEASES DUE TO ERRORS IN DIET
Gastro-intestinal disturbances, colic, enterocolitis, colitis,
etc., rickets, scurvy, nephritis, and diabetes are among the
diseases most apt to develop from injudicious feeding, and
in these cases the dietetic treatment plays the most impor-
tant part in combating the condition. The disturbances
caused by food are recognized by the general symptoms:
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CARE AND FEEDING OF INFANTS 233
vomiting, rise of temperature, subnormal temperature, and
the stools, the latter being the chief point of observation.
Fats as Cause. ā When the fats are causing the disturb-
ance, the rise of temperature is apt to be high, but not of
long duration. The baby vomits frequently, the vomitus
being acid in reaction and odor, the latter due to the pres-
ence of fatty acids, butyric acid, etc. Diarrhea often de-
velops in a more or less acute form. In these cases there is
a loss of sodium and other alkaline salts in the feces, and a
consequent excess of ammonia in the urine, resulting in
acidosis. Acid intoxication has been known to develop as
a result of this loss of alkaline salts. The chief symptoms
of this condition are rapid and deep respiration, stupor or
restlessness, and cherry-red lips,^
Symptoms of Excess Fat in Diets. ā The general
symptoms in infants receiving an excess of fat in their food
take the form of loss of appetite, with more or less loss of
weight, or failure to gain. When the cases are not chronic,
soft curds may often be seen, which are at times mistaken
for casein curds, but may be distinguished from them by
their translucent appearance and their solubility in ether.
The color of the stools due to the excess of fat under the
above-mentioned conditions is shiny and gray. In the ma-
jority of cases, especially of a more chronic character, the
stools are apt to be large and dry, at times hard and crum-
bly. The fat in such stools is combined with magnesium
and calcium salts, forming the characteristic " soap stools." *
The combined lose of these salts in the feces has a definite
effect on the general metabolism and nutrition, giving rise
to rickets.
Regulating the Fat. ā The treatment consists chiefly
of r^ulating the amount of fat in the formula, and of cut-
ting it out altogether in the beginning when the ssonptoms
^''Diseases of Nutrition and Infant Feeding/' by Morse and Talbot.