'Ibid,
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234 DIETETICS FOR NURSES
show acute acid conditions. In many cases, if the baby is
given breast milk, the trouble disappears. At other times
it is necesary to substitute a foreign fat such as olive oil
for the butter fat. Dr. Ladd in the Children's Hospital in
Boston treated many babies who manifested an intolerance
for butter fat with " Homogenized Milk," which consisted
of skimmed or separated milk and a certain percentage of
olive oil, placed in an apparatus which brought about a
more complete division of the fat, causing it to mix with the
milk as an emulsion closely resembling human milk.
Fat intolerance is most difficult to overcome, the baby
being apt to relapse into the acute stage unless the utmost
caution is observed in adding the fats to the formula. It
is not safe, however, to feed the baby upon a fat-free milk
for any great length of time.
Excess Protein in Food. ā The digestional disturbances
arising from too much protein in the food are as a rule
readily overcome in breast-fed infants. When it is due to
nervousness or worry in the mother, it disappears as soon as
the mother ceases to worry or does something to remove the
cause of the nervous condition. When the breast milk is
high in protein, more exercise in the open air at times ad-
justs the percentage of protein, provided the mother does
not become over-tired, in which case the percentage of
protein in breast milk increases.
Evidences of Excess Protein. ā The symptoms of ex-
cess protein in the diet of the breast-fed baby are colic and
flatulence, which are often persistent and difficult to over-
come. Vomiting is not so common in these babies as in
those who are artificially fed. The stools are increased in
number, are either brown or green, and generally loose and
watery. In artificially fed infants the symptoms are much
the same, except that the vomitiis often contains large curds
which are tough and leathery. The baby suffers from gas
formation and colic. The stools are at times normal, except
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CARE AND FEEDING OF INFANTS 235
for the presence of large, hard curds; at other times they are
increased in number, and are of a watery consistency and
alkaline in reaction.
Regulating the Protein in Formula. ā When the stools
are watery and brown and musty in odor as the result of
disturbed protein digestion, the treatment consists of taking
out the proteins from the formula and of substituting cereal
water, to which dextri-maltose or milk sugar is added, the
milk being added as soon as possible to prevent too great a
loss of body protein. As a rule the whey proteins do not
cause the disturbances so often as the casein proteins; and
at times it is possible to use whey mixtures with babies who
cannot tolerate the casein at all.
Buttermilk also is used in cases of protein indigestion,
as is Eiweissmilch and peptonized milk.
Regulating the Carbohydrates. ā When the disturb-
ances are due to the carbohydrates in the formula, they
may be digestional or nutritional. In this form the milk
sugar is more apt to be the cause of the trouble than the
dextri-maltose preparations which are at times used. In
the latter, when the disturbance becomes nutritional, the
cause of the trouble can usually be traced to an excess of
starch. When the percentage of milk sugar is greater than
can be handled by the digestive apparatus of the baby, it
is manifested by frequent attacks of colic, with the passage
of watery green stools, highly irritating in character on ac-
count of their acidity. In acute cases the loss of weight is
often marked, and symptoms of intoxication may develop.
The outlook is grave in the very severe cases, but if the baby
can survive forty-eight hours after the acute symptoms de-
velop, he is apt to pull through the attack.
Adjusting the Sugars. ā The treatment in these condi-
tions consists of eliminating the milk sugar from the for-
mula; in less severe cases dextri-maltose may be substi-
tuted. As a rule, coincident with indigestion caused by
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236 DIETETICS FOR NTJKSES
sugar there will be found to be an intolerance for much fat,
so that this must be adjusted as well as the milk sugar.
Skimmed milk mixtures, containing a certain amount of
barley or oatmeal water, are generally found to be suitable
in these cases. Dextri-maltose may be added after a few
days in order to maintain the fuel needs of the body.
Eiweissmilch is at times used, but whey mixtures are contra-
indicated on account of their high sugar content.
Dextri-maltose also disagrees at times. The baby has
colic and flatulence, the stools are usually loose or watery
and dark brown in color. The dietetic treatment consists
of an immediate withdrawal of the dextri-maltose prepara-
tion and a substitution of milk sugar after a few days.
Evidences of Excess Starch in Formula. ā The dis-
turbances arising from an excess of starch in the diet are, as
has already been stated, more apt to be of a chronic than an
acute character. Vomiting is not a conmion symptom under
these conditions, although colic is frequent. The stools are
at times loose and brown, at other times dry and small.
The baby at times suffers from diarrhea and at others from
constipation. When the disturbance is acute the starch
must be entirely eliminated from the formula. If proprie-
tary foods are being used containing starch, whether it is
dextrinized or unchanged, they must be at once abandoned,
and a formula made up of protein with sugar and fat.
Modified Milk Formulas Suggested by Morse and Talbot for
These Conditions
Fat 1.00% Fat 2.00%
Milk sugar . . . 4.00% or Milk sugar . . . 5.00%
Protein .... 0.75% Protein .... 1.25%
They likewise advise whey and whey mixtures under these
circumstances.
Fermentation. ā Fermentation is often the cause of in-
fantile indigestion. At times it is acute and may cause a
decided elevation of temperature owing to the absorption
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CARE AND FEEDING OF INFANTS 237
of the toxic substances formed as a result of the bacteria]
action. In almost every case of indigestion brought on by
fermentation there will be an accompanying diarrhea. As a
rule the carbohydrates are more liable to the attacks of
bacteria in the stomach than the other food constituents.
Treatment. ā The treatment consists first of starvation,
no food being given for at least twenty-four hours. Then
water or weak tea, sweetened with saccharin, may be given,
but nothing else. The medical treatment must be left to
the discretion of the physician. When the condition war-
rants a return to food the formula must be made weaker
than that which has caused the disturbance. Malt soup
mixtures, buttermilk mixtures, whey and albumen water
may be added as the condition of the baby improves. In
older children the period of starvation may have to exceed
that of infants, but a gradual return to normal diet is made.
Weak tea and toast may be given after the first twenty-four
hours and well skimmed meat broths, soft-cooked eggs,
liquid peptonoids, and malted milk added to the diet as the
condition of the child improves.
ENTEROCOLITIS
The dietetic treatment for enterocolitis must be ad-
justed according to the principal symptom. In some of
these cases diarrhea is most prominent, while in others
constipation is the most marked symptom. Hence the diet
must be such as not only to do no harm to the child, but one
that will aid in his ultimate recovery.
DIARRHEA
The treatment for diarrhea, whether it is from fermenta-
tion or putrefaction of food, has already been explained.
The grave danger in the putrefactive diarrhea is the ab-
sorption of the toxic substances which result from bacterial
action upon the unabsorbed food material in the small and
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238 DIETETICS FOR NURSES
large intestine. In these cases auto-intoxication may de-
velop and the baby may die before the condition yields to
treatment. The entire intestine must be cleansed as a rule.
The stomach of the baby may be reached with little trouble
by using a small rubber catheter attached to a glass funnel
and a solution of bicarbonate of soda. The bowels may be
emptied by means of a soapsuds enema. Olde- children
may be given oil, but this of course comes under the jurisr-
diction of the physician.
CONSTIPATION
Constipation is one of the most frequent troubles visited
upon people of all ages. " It is not a disease, it is a condi-
tion in which the number of stools is less or the consistency
of the stools is greater than is normal for the individual at
the given time."Ā® It may be caused by neglect of the
bowels, which should be evacuated once or twice every day
during infancy and once a day after that period. If the
habit of emptying the bowels every day is established in
infancy it adds much to the health and comfort of the
individual during the entire remainder of life. Babies are
sometimes constipated as the result of the opium admin-
istered in soothing sirups. Others inherit constipation, while
still others are constipated by the taking of the wrong kind
of food or too little food. In any case it is decidedly bad to
resort to drugs, since the habit of taking cathartics is so
easily acquired and so diflScult to overcome.
Factors Inducing Constipation. ā With artificially fed
babies a formula which contains too high a percentage of
diluent and too low a percentage of solids will cause consti-
pation, chiefly because the solids are so completely ab-
sorbed that they have no residue to form feces. A formula
with too low a fat content in proportion to its protein and
'"Diseases of Nutrition and Infant Feeding," p. 307, by Morse and
Talbot.
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CARE AND FEEDING OF INFANTS 239
carbohydrates may cause constipation because the latter
two constituents are ahnost entirely absorbed, and the feces,
which is largely made up of the fat, is correspondingly
small. Excess of fat, however, has been proved to be one
of the chief causes of constipation in infants, as has also
been the case with excess starch. Boiling the milk for the
baby at times results in constipation. Hence sterilization
is more frequently to blame for the condition than the pas-
teurization of milk.
Constipation during Second Year. ā During the second
year, if the child is given too much milk and too little solid
food, constipation is very apt to be the result. A maximum
quantity of from thirty-two to forty ounces may be given.
In many diseases brought on by malnutrition, constipation
is an obstinate condition to be overcome. This is especially
the case in rickets and anemia.
Use of Laxative Foods. ā After the baby is a few
months old, orange juice is given between the morning feed-
ings. Malted foods likewise exert a laxative effect. The
higher the percentage of maltose, the more laxative the
food. The nurse must keep this point in mind in feeding
babies. With older children and adults, the question of
diet for constipation is quite as important as it is for infants.
Prunes or figs cooked with senna leaves and thoroughly
strained furnish an excellent adjunct to the diet under such
conditions. The coarse breads such as bran and Graham
or wholewheat bread should be used instead of white flour
breads. Care should be taken in advising a cereal diet for
children, since cereals, with the exception of oats, are apt
to be constipating. Fresh fruits, stewed fruits, and fresh
vegetables are all good under the above-mentioned condi-
tions. Young children require the vegetables strained or
cut fine. Adults should include one coarse vegetable a day
in their dietary to obviate the development of constipation.
Children should be taught to drink plenty of water, and
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240 DIETETICS FOR KURSES
babies should not be neglected in this respect. As a rule,
very few adults drink as much water as is necessary for the
general welfai*e of their bodies.
SCURVY
There is probably no disease of infancy which has come
in for more study in the past few years than scurvy.
Cause. ā The disease is believed to be directly due to
a deficiency in the diet of the anti-scorbutic vitamine, known
as "Water soluble C."
Treatment. ā For many years it was known that lime
juice exerted a curative effect upon scurvy. But recently
the efficiency of this fruit juice has proved to fall far short
of that effected by either orange, or tomato juice.
Feeding experiments have proved that animals, fed
upon rations consisting of dry food without the addition of
green, will develop scurvy. And that the milk of such ani-
mals will show a deficiency in the "C" vitamine which will
lead to a development of the disease in infants fed upon
such milk.
Milk is, in fact, by no means a perfect food, so far as
its vitamine content is concerned. First, because the pres-
ence of the vitamine in milk is so dependent upon the diet
of the mother or the animal, second, because the pasteuri-
zation temperatures used to insure cow's milk of .purity from
a bacterial standpoint, destroys in it the greater part of its
anti-scorbutic power. Either of which makes it necessary
to supplement the formula of the artificially fed infant, and,
in case of the former, the mother's milk of the breast fed
baby, with orange, or canned tomato juice.
The amount of either of the fruit juices which is neces-
sary to insure the child of a freedom from scurvy, is small,
ranging from one-half to one ounce of strained juice daily,
this amount is increased gradually until the child is taking
from one and one-half to two ounces each day. It has been
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CARE AND FEEDING OF INFANTS 241
found advisable to administer the fruit juice between the
two morning feedings. As a rule, the fruit juices are given
at the beginning of the seventh month, but they may be
given at a much earlier date, the time being adjusted by
the physician.
RICKETS
Rickets, like scurvy, is being discussed by scientists both
in America and abroad. The disease is widespread, par-
ticularly in its subacute form, and its effect upon the
health of the child is so serious that no amount of effort
to prevent its development should be considered too great.
Calcium Retention in Rickets. ā The disease is charac-
terized by a failure of the bones to lay down lime salts,
this failure causes a softness and flexibility in the structure
of the bones which permits them to bend into deformities.
Then, too, it is a well established fact that any interfer-
ence with the calcium metabolism in the body, will inevit-
ably bring about disaster. (See Mineral Metabolism,
page 185.)
Factors Inducing Rickets. ā According to Dr. Eddy,
"It is impossible at present to determine whether rickets is
a true avitaminose or a consequence of deficiency in a
series of factors."
Treatment. ā For breast-fed babies it is necessary to
adjust the diet of the mother to include more of the vita-
mine bearing foods, since milk contains vitamines only in
proportion to the amount eaten in food. For artificially
fed children, the giving of cod liver oil has recently been
adopted as the surest and safest method of curing and pre-
venting the development of the disease. Like treatment
is used with breast-fed infants if the need arises.
The value of cod liver oil in this respect has only been
recently recognized. Mellenby of England claims that the
oil owes its curative and preventive properties to the pres-
ence of the "A" vitamine. But scientists in this country
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242 DIETETICS FOR NURSES
have not fully accepted this view. Eddy states, "It may be
that the power of the oil is due to its 'A' vitamine content,
in which it is known to be ridi, or it may be due to a new
vitamine, but the fact that the oil is a preventive in this
respect gives the pediatrist another agent to insure normal
growth."
Sunshine as a Factor. ā It has been found that the dis-
ease rickets is more prevalent in winter than in summer;
this is believed to be due to the fact that sunshine during
the sunmier months exerts a distinctly beneficial influence
over the disease. Dr. Hess's report of the good results which
he has found to be derived from the use of the ultra violet
rays as a substitute for sunshine in winter, would seem to
confirm this view.
MALNUTRITION
Malnutrition is not confined to the children of the poor,
though it is more common with infants of parents who have
not the means to secure the best milk and give them the
benefit of wholesome surroundings and plenty of sunshine.
But babies of people in moderate circumstances, and even
of wealthy parentage, are at times badly nourished, and re-
quire the same exacting care, the same attention to the
food, the fresh air, and the sunshine that the poorer babies
need in order to survive. Malnutrition may be the result
of insuflScient food, and it may also be due to the lack of
one definite food element. Again, it may be brought on by
Some deformity of the mouth or stomach, which makes it
impossible for the baby to get all the food which he requires
for his maintenance and growth. He may be bom prema-
turely and his digestive apparatus not be sufl&ciently devel-
oped to care for the amount of type of food necessary for
his needs, or he may have some congenital weakness which
interferes with the absorption and assimilation of his food.
All of these points must be considered.
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CARE AND FEEDING OF INFANTS 243
Evidences of Correct Feeding. ā If the baby shows a
steady gain, both in weight and growth of stature, without
digestional disturbances, the food given him is probably cor-
rect, but it must be kept in mind that nutritional disturb-
ances, such as rickets and scurvy, are slow in developing,
and do not manifest themselves with anything like the
rapidity of digestional disturbances. Hence the nurse must
take care as far as she is able, not only to prevent the food
from causing indigestion, but also to see that it is not given
in such a form as to induce those graver and more lasting
nutritional disturbances which aflfect the entire system from
infancy throughout the life of the individual.
Summary
Breast Feeding versus Artificial Feeding. ā There is
no doubt about the fact that the breast-fed baby suffers less
from digestional disturbances and has more resistance to
disease than the baby fed even upon a perfectly prepared
artificial food. The majority of diseases manifested by arti-
ficially fed infants have their origin in the following errors
in diet.
Over-Feeding. ā Resulting in acute gastro-intestinal
disturbances (colic, entero-colitis, colitis, constipation).
Under-Feeding. ā Resulting in chronic, and acute
deficiency diseases (scurvy, rickets, malnutrition).
Evidences of Dietetic Errors. ā The stools, showing
characteristic evidences of excessive quantities of, protein,
fat, or carbohydrates in the formula. Loss of weight or fail-
ure to gain. The development of deficiency diseases
(scurvy, rickets, xerophthalmia, rickets and malnutrition).
Evidences of Correctness in Feeding. ā Normal gain,
freedom from gastro-intestinal disturbances, and deficiency
diseases. Rosy cheeks, bright eyes, and a vigorous body.
Treatment in Abnormal Conditions. ā The treatment
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244 DIETETICS FOR NURSES
consists in adjusting the diet to meet the needs of the
particular disturbance manifested. Plenty of fresh air, sun-
shine and sleep.
Relapse. ā One danger which the nurse must always be
on the lookout for is the relapse into the acute stage. The
diet is the chief treatment. In acute gastro-intestinal dis-
turbances rest from food is essential for at least twenty-
four hours. Some infants can easily endure starvation for
this short period. However, when malnutrition has already
been established, it is not wise to carry out the starvation
treatment over-long. A cautious return to a normal diet
may be made as soon as acute symptoms disappear.
PROBLEMS
(a) List the evidences of errors in the diet of infants; show
how they may be corrected in the formula.
(6) Outline the processes in the preparation of Eiweissmilch
(protein or albumen milk). What constituent is par-
ticularly low in this milk, and how was its reduction
accomplished?
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CHAPTER XI
THE FEEDING OF ADULTS IN DISEASES OF THE
GASTRO-INTESTINAI, TRACT
ACUTE AND CHRONIC GASTRITIS
Predisposing Factors. ā The majority of diseases af-
fecting the stomach have as their predisposing factors, and
owe their development to, one or all of the following condi-
tions: (1) errors in diet; (2) disturbed secretory processes;
(3) disturbed motility and tone.
It is probable that in the beginning the first factor was
the chief offender in the case, bringing about the develop-
ment of one or both of the other conditions. The other
factors to be considered in this respect are heredity, occupa-
tion, poverty, and diseases which involve to a greater or
lesser degree the digestion of the stomach and intestines. A
child may inherit a weakened organism through excesses or
disease on the part of the parent. If this weakness is not
overcome while the child is growing, the probabilities are
that the digestion steadily declines until in adult life it be-
comes a pathological condition. Lack of fresh air, poor
and dirty food, unwholesome surroundings, crowded and
badly ventilated sleeping rooms, insuflScient water, and
overwork, all act in making the digestion bad. These must
be overcome if permanent good is to result.
Errors in Diet. ā Errors in diet arise more often through
ignorance than from any other cause. A child may be
allowed to eat any and all kinds of unwholesome and un-
suitable food. When the stomach rebels, showing the serious
danger signals of nature, medicines are given but the diet
is unheeded; until the time comes when even the medicines
245
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246 DIETETICS FOR NURSES
fail to give temporary relief, and the organs of digestion are
in some instances permanently impaired.
Disturbed Secretory Processes. ā Consensus of opin-
ion goes to show that the majority of cases of acute and
chronic gastritis (catarrhal) and gastric ulceration are due
primarily to a disturbance of the secretory processes, while
the impaired motility and lack of tone in the stomach prob-
ably influence their development and aggravate the disease
already present.
Composition of Gastric Juice. ā In a former chapter
the processes of gastric digestion were explained. The gas-
tric juice, composed of from 0.2 to 0.3% free hydrochloric
acid and several important enzymes and lipases, which act
upon the proteins and emulsified fats, must be suflScient in
quantity to assure good digestion, and when anything arises
to interfere with the secretion of this fluid a deviation from
the normal is bound to occur.
Disturbed Motility and Tone. ā Again, it has been
proved that good gastric digestion, like good intestinal di-
gestion, depends more or less upon the way in which the
food mass is mixed with the digestive juices and moved
along the alimentary canal. Anything which interferes
with the secretion of the juices or delays the food over its
normal length of time in the stomach surely exerts unfavor-
able influences on the general metabolism of the food, for
while, as we have already found, gastric digestion is not
essential to the final utilization of the food in health, in dis-
ease it undoubtedly exerts a marked influence upon the gen-
eral nutrition of the individual.
HYPOCHLORHYDRIA
The lack of hydrochloric acid in the gastric juice lowers
the resistance to bacterial action, for this constituent exerts
a decided germicidal influence in gastric digestion, prevent-
ing fermentation with the production of organic acids and
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FEEDING IN GASTRO-INTESTINAL DISEASES 247
probably alcohol. In conditions due to hypochlorhydria
(lack of hydrochloric acid) foods which leave the stomach
quickly must be given with enough of the other necessary
constituents in their simplest and most easily digested form
to balance the diet and prevent the occurrence of the other
disorders as troublesome as the original disorder.
Dietetic Treatment. ā The following points must be
kept in mind in formulating a dietary for patients suffering
from a deficiency of hydrochloric acid: (1) boil the drinking
water to destroy any bacteria which may be present; (2)
use carbohydrates in the form of starch rather than sugar,