be allowed to cover the energy expenditures of the more
active child, to safeguard it against becoming malnourished.
To facilitate the computation of the food requirements
of children a schedule showing the number of calories per
pound of body per day is included on opposite page.
The food requirements are such as to allow of a steady
increase in the weight and stature of the child ; the rate of
gain for normal children should be as follows:
Average Rate op Gain per
Week, for Normal Children
Age
Average
Age
Average
Boys
gain.
Ounces
Oirls
gain.
Ounces
First year . . .
SVz^V2
First year . . .
3y2-4i/2
Second year . . .
2y2-3
Second year . . .
21/2-3
Third year . . .
l%-2
Third year . . .
l%-2
Fourth to eighth year
Fourth to eighth year
(inclusive) . .
11/4-11/2
(inclusive) . .
W4-'1V2
Ninth to eleventh
Ninth to twelfth
year (inclusive) .
13/4-2
1 year (inclusive) .
iy4-2Vi
Twelfth to thirteenth
Thirteenth to fif-
year (inclusive) .
2%-3
teenth year (in-
Fourteenth to six-
clusive) . . .
2%^y4
teenth year (in-
Sixteenth and seven-
clusive) . . .
3 -4
teenth year (in-
clusive) . . .
1 -2
The averages just given are for healthy children; those
who are underweight for their age and height should show
a more rapid increase in weight with an increased food
allowance. It must also be remembered that a simple
gain in weight is not sufficient evidence of a child's normal-
ity; a freedom from gastro-intestinal disturbances, and a
resistance to disease, are equally essential.
There have been tables arranged to show the proper
weight for height for boys and girls of different ages (see
appendix). These are valuable since, by their use, atten-
tion is called to the child who is not up to the average.
Medical examination of such children frequently shows rea-
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50 DIETETICS FOR NURSES
son for their underweight, and measures may be instituted
which may save the child from a lifetime of poor health.
Dr. Pirquet has arranged a scale (Pelidisi Chart) show-
ing the state of nutrition in children, based upon the sitting
height (in centimeters), to weight (in kilograms). See ap-
pendix.
PROTEIN REQUIREMENTS
There is never a period in life in which protein is not
needed. During the early years it is essential that the pro-
teins, or at least a goodly portion of them, be obtained from
animal sources, milk and eggs in particular; when cereals
and legumes (beans and peas) are used to provide for
the protein requirements, they must be supplemented by
milk or eggs (or both), in order that the growth and de-
velopment of the child may proceed at a normal rate.
Adults require protein for the repair of old tissues and
to furnish material for the building of new cells, and again
it is believed advisable to have at least a portion of this
protein from animal sources, milk, meat or eggs.
MINERAL REQUIREMENTS
Just as energy foods and proteins must be adjusted in
the dietary to safeguard the health of the body, so the min-
eral salts must be adjusted for a like purpose. Studies made
of the dietaries of a number of families brought to light
the fact that the children more often suflFered from a de-
ficiency of calcium, phosphorus and iron in their diets
than they did from too little protein,® proving that it is
quite as essential to adjust the mineral salts in the diet as
it is that of the organic constituents.
According to Sherman the diet of an adult should con-
tain each day per pound of body weight:
•"The Adequacy and Economy of Some City Dietaries," by Sherman
and Gillett.
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FOOD REQUIREMENTS OF THE BODY 61
Protein 0.5 gram or more
Phosphorus 0.01 gram or more
Calcium . 0.005 gram or more
Iron 0.0001 gram or more
These averages, while covering the needs of the mature
body, do not furnish the necessary amount of protein, or
mineral salts to support the growth and development of
the child. Hence, it has been deemed advisable to reckon
the requirements of the latter per thousand calories, in-
stead of per pound of body weight, in this way obviating
some of the danger of protein and mineral deficiencies.
McCollum, Simmonds and Pitz have shown that a de-
ficiency in the inorganic content of a diet may result in a
retarding or suspension of growth. This result has been
overcome on the introduction of the proper mineral salts
into the diet. This salt mixture is such as to make the
total ash, approximate that found in the composition of
milk ash.
The following diagram illustrates this point.
t t ^ ^
Effect upon growth of adding to a diet otherwise adequate a salt mixture
of such composition as to make the composition of the total ash similar
to that of milk ash; immediate resumption after entire suspension of
growth. Courtesy of Dr. E. V. McCollum.
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52 DIETETICS FOR XUESES
The following outline will serve as a guide in making
the estimates for the food requirements of children:
The Diet of a Child Should Contain for Evert 1000 Calories
Furnished by the Foodstuffs,
Protein 25.00 grams or more
Phosphorus 0.48 gram or more
Calcium 0.25 gram or more
Iron 0.005 gram or more
Vitamine Needs. — We have seen the manner in which
the energy and protein foods have been adjusted in the
diet, but these can not alone assure the body, and especially
the growing body of a normal maintenance and repair of
its tissue, or support the growth which is essential at this
time. This function is believed to belong to the vitamines,
since feeding experiments have demonstrated the fact that
animals soon cease to grow, develop deficiency diseases, and
finally die, when deprived of the essential constituents.
Gillett advises, as a safe rule, the use of one, and preferably
two foods known to be rich in the fat soluble vitamine, in
each day's food allowance, milk and leafy vegetables, for
example. If the foods containing phosphorus, calcium, and
iron are taken in suflBcient quantity, the second, or "B"
vitamine needs, will probably be adequately covered, but
the presence of the "C" vitamine must be carefully at-
tended to; some fresh fruit or vegetables (see table) is
obligatory each day to insure the individual against the
development of scurvy.
Factors Affecting the Food Selection. — The estima-
tion of the energy needs of the body, and the selection of
the foods to furnish the fuel for this purpose, depend
largely upon the individual. The digestion of the fats, as
well as the way in which the body utilizes them, makes the
use of this foodstuff more or less limited according to the
ability of the individual to take care of them, the minimum
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FOOD REQUIREMENTS OF THE BODY 53
allowance for children being between 2 and 3 ounces per
day. According to Gillett, 'If boys and girls get at least this
amount from butter and its substitutes, cream, bacon, fat
meat and oils, additional amounts from their food will
provide a margin of safety, without overtaxing the digestive
system."
After determining the amount of fat required in each
day's food allowance, it is a simple matter to adjust the
carbohydrates. It is safer from a health standpoint, to
obtain the greater portion of this foodstuff from starchy
foods rather than from the sugars, many foods rich in
starch, likewise contain appreciable amounts of protein and
fat, whereas sugar is practically one hundred per cent, car-
bohydrate. The ease, too, with which this substance fer-
ments in the stomach, and the manner in which it destroys
the appetite for other foods, makes the use of much of it
in concentrated form unadvisable, especially in the diet of
children.
The amount of sugar allowed each day, should be lim-
ited to an ounce or ounce and a half (2 to 3 tablespoonfuls),
and a less quantity is desirable. In order to obtain the
best results, with the least deleterious effect on the body,
it is advisable to give sugar in dilute form. A piece of pure
candy after a meal may not harm the child; but just
before, or between meals, as well as the habit of making
the breakfast cocoa and cereal of syrup-like sweetness is
deplorable, and should in all instances be discouraged.
The American Red Cross recommends the following
method for estimating the amount of sugar in the dietary:
Add one-half the weight of such foods as jellies, jams and
preserves, and three-quarters the weight of such foods as
candy, honey and syrup, to the weight of sugar used."
The amount of sugar consumed, as such, by the adult each
day, ia not of such paramount importance as it is in the
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64 DIETETICS FOR NURSES
case of ehildren, but even for adults an excessive amount of
carbohydrate in this form is not considered advisable from
a health standpoint.
In order to assure each member of the family of getting
all of the materials needed for the growth, repair and regu-
lation of their bodies, as well as the necessary fuel material
with which to run the engine and to maintain the proper
body temperature, the following practical method is sug-
gested for the planning of the daily dietary.
The Diet Each Day Should Contain:
1. Milk:
One quart for each child under two years of age. From 1 pint
to 1 quart for each child from two to five years of age. (M. S.
Rose of Teachers' College advises at least a quart for every child
of six years and under, at least 1 'pint for children from six to
sixteen, and one half of a pint thereafter.
2. Cereals and Breadstuffs:
(Activity of person determining the amount.)
For children under two years of age . . . 1- 3 oz. a day
For children from two to five years . . . . 2- 5 oz. a day
For children from five to twelve years . . . 5- 9 oz. a day
For all over twelve years .of age 9-16 oz. a day
3. Meat or its Substitute:
For children under five years no meat is needed.
(a) Meat:
For children from five to ten years . . 1-2 oz. (no more) a day
For children from ten to fourteen years 2-4 oz. (no more) a day
of meat or fish.
For individuals over fourteen years . 2-6 oz. should be the
maximum for the day.
(h) Eggs:
For children under two years ... no eggs are given.'
For children from two to five years . 3-5 eggs may be given
each week, being sub-
stituted for part or all
of the meat.
'Part of soft cooked egg may be given at the beginning of eleventh
month; this must be given at the noon meal, and should not be included
in each day's meal (two or three times a week is sufficient).
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4.
FOOD REQUIREMENTS OP THE BODY 55
(c) Beans, Peas, Cheese :
For children it is necessary to use milk abundantly when beans
or peas are substituted for the meat or egg proteins.
Vegetables :
For children under six months * .
For children from six to nine months
no vegetables need be
given.
1 oz. gradually in-
creased to 6 oz. of
strained vegetable soup
(see formula, page 223).
For children from twelve to fifteen
months 1 small baked potato
may be added, and
such vegetables as peas,
string beans, carrots,
spinach, squash, lima
beans (strained).
Two vegetables, one of which should be potatoes (white), should
be given each day. A leafy vegetable (spinach greens, string
beans, kale, lettuce) should be given from three to four times each
week and oftener if possible.
5. Fruit:
For children from six months
(earlier if physician approves) .
For children from first to second year
For children from two to ^ye years .
1-2 tablespoons orange
or prune juice a day.
1-3 tablespoons twice
daily.
3-4 tbsp. or more, twice
daily (amount gov-
erned by health of
child).
All children should be given fresh fruit three or four times a
week; some fruit given every day. Adults may be served dried
fruit most days, but some fresh fruit should be given each week.
Desserts:
One sweet dish (custards, cereal puddings, junkets) once or twice
a day, but little if any clear sugar should be given (cereals
should be served with very little if any sugar).
7. Fats :
For each person over five
. . . 2-3 oz. of fat (pur-
chased as such) a day,
depending upon the
age and ability of the
individual to digest
fats.
* Dr. Hess advises the use of canned tomato juice as a substitute for
orange juice when the latter is unobtainable.
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66 DIETETICS FOR NURSES
Suggestions for Serving Meals. — After reckoning ihe
number of calories needed for the day, it is well to remem-
ber that the protein must be adequate in type and amount;
that there should be an abundant supply of vitamines and
iron in each day's ration; that milk should always be in-
cluded in order to make sure of having a sufficient amount
of calcium in the diet; that th^-e should be only one
heavy protein dish at any one meal, and that it is unwise
to serve a meal in which the fluids predominate on account
of their deficiency in energy and proteins.
If a meal is made up of the right kind of foods, in the
proper proportion, and each individual eats sufficient to
assure the maintenance of the normal weight, is free froni
gastro-intestinal disturbances, and shows a normal resist-
ance to disease, it is more than probable ihsit a sufficient
quantity is being consumed each day.
All foods should be carefully selected, and properly pre-
pared in order to derive the maximum benefit therefrom, and
the regularity and attractiveness with which the meals are
served have almost as much to do with the health and hap-
piness of the individual, as the character of the foods in-
cluded in the day's dietary.
PROBLEMS
(a) Calculate the dietary requirements of a nurse weighing
125 pounds, who spends 8 hours sleeping, 8 hours on
duty, 2 hours at meals, 2 hours brisk walking, 2 hours
in the class-room, and 2 hours reading or studying.
(6) Calculate the diet for a child of ten years of age, weigh-
ing 65 pounds, showing the number of calories, the
amount of protein, calcium, phosphorus and iron neces-
sary to make this diet cover the requirements of the
child.
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SECTION II
LABORATORY OR DIET KITCHEN WORK
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CHAPTER IV
METHODS OF FEEDING IN NORMAL AND
ABNORMAL CONDITIONS
There are several methods of feeding which have been
adopted to meet the needs of the individual under various
conditions: Feeding by mouth, gavage or forced feeding,
rectal feeding (nutrient enemata), and inunction.
Feeding by Mouth. — The first method is the one used
in health and in the majority of abnormal conditions. In
cases where there is a certain abnormal development of the
mouth or throat, and in some cases of insanity or uncon-
sciousness, where for some reason it is impossible for the
individual to swallow, this method cannot be used.
Forced Feeding. — With very young children and babies
gavage or forced feeding is found at times to be necessary.
In these cases a small rubber catheter is introduced into the
stomach through the nostrila and the milk or other fluid
poured through the tube. In unconscious or insane patients
it is often found necessary to insert a gag (a cork will serve
the purpose) between the teeth to prevent the biting of the
tube when it is inserted through the mouth into the
stomach.
Food Used for Forced Feeding. — The food in these
cases consists of reenforced soups, milk gruels, or nutrient
beverages, not more than six or eight ounces given at one
time. Finely chopped meat and vegetable purees have
been given in this way when the digestion of the patient
was not impaired, but when conditions rendered it neces-
sary to resort to this method of feeding.
59
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60 DIETETICS FOR NURSES
Technique of Gavage. — The apparatus used m gavage
consists of a moderate sized soft rubber tube to which is
attached a rubber or glass funnel and a "pinch cock." The
tube should be filled with water to prevent air entaing the
stomach and causing pain or discomfort. In certain cases
the patient refuses to swallow the tube and it will be found
necessary to use some means to force the passage if the
throat is shut oflf. By closing the nostrils the patient will
be obliged to breathe through the mouth, thus opening the
passage into the throat through which the tube may be
quickly slipped. In certain abnormal conditions the gastric
organ is so badly impaired as to render it impossible for
the patient to retain food taken in by way of the mouth.
It is often found that food introduced into the stomach by
means of the "stomach tube" will be retained and utilized
which otherwise would be rejected. It is disagreeable, how-
ever, and should only be used when it is impossible to feed
otherwise.
Rectal feeding is used when the other organs of diges-
tion are impaired to such an extent as to render the need of
more food obligatory. Many investigators believe that
rectal feeding is absolutely useless, while others have firm
faith in its efficacy.
Technique of Rectal Feeding. — The rectum should be
cleansed by flushing with a soapsuds enema one hour before
the nutrient enema is given. This should be done once a
day, in the morning. The cleansing enema may.be either
soapsuds, a solution of bicarbonate of soda, or boric acid (1
teaspoonful to the pint), or a saline solution. When there
is much mucus, or if the rectum is inflamed, the soda or
boric acid solution may be more soothing than the saline or
soapsuds enema. After one hour's rest the patient should
be given a nutrient enema.
The method of administering nourishment through the
rectum is important.. A autri^nt en^^ifl^ injected only intQ
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METHODS OF FEEDING 61
the lower bowel not only does no good, but may a€tually
cause a good deal of unnecessary discomfort to the patient.
Temperature of Enema. — Care must be taken not to
have the temperature of the nutrient enema too hot or
too cold or it will be promptly rejected. The patient is
placed on the side with one knee flexed; the solution is
poured into a fountain syringe bag or an enamel con-
tainer (heat the container before pouring the solution into
it or the latter will be chiDed). The bag or container has
attached to it a rubber tube with a cock adjusted so
that only a small stream will flow in at a time. To
the end of this tube a rubber rectal tube or catheter — I cm.
(about ^ inch) — is attached. This should be well greased
(do not use glycerin as this substance is irritating
to the mucous lining of the rectum). The liquid should
be allowed to fill the tube before it is inserted into the rec-
tmn, to prevent any air passing in with it. The tube should
be inserted with a gentle twisting movement, using very
little force or the tender mucous membranes wiD be injured.
Insert the tube twelve or more inches, since the solution
is more completely absorbed if given high up in the bowel.
The bag containing the solution should be held only a few
inches higher than the rectum, thus allowing only a small
stream to pass in and allowing an air space above the
stream for tiie passage of gas which may be accumulated in
the upper part of the rectum. The tube should be allowed
to remain in the rectum for fifteen or twenty minutes, then
very gently withdrawn to prevent the liquid from being
rejected. A pad of gauze may be pressed against the anus
to assist the patient in retaining the enema. It is well to
divert the attention of the patient also, to further assist her
in retaining the liquid.
Duration of Rectal Feeding. — Rectal feeding cannot
be substituted for a great length of time, first, because the
patient cannot absorb sufficient nourishment in this way to
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62 DIETETICS FOR NURSES
fully covCT the body requirements, and, second, because the
rectum becomes more or less sensitive and will reject the
liquid before it has an opportunity to be absorbed. PVom
three to four nutrient enemas a day is about the limit for
the average patient. Between the nutrient enemas it is
advisable to give one of saline solution.
The following regime is practiced during the "Total Ab-
stinence Period" in the treatment of gastric ulcer: 7 a.m.,
cleansing enema; 8 a..m, nutrient enema; 1 p.m, nutrient
enema; 3 p.m., saline enema; 6 p.m., nutrient enema.
One saline and one nutrient enema may be given during
the night if the patient is very weak. She should not be
wakened, however, to be given the enema.
Feeding by Invmction. — This method consists in the
rubbing into the body of certain nutrient oils, such as olive
oil, cocoanut oil, cocoa butter, etc. It is of little value, but
is occasionally resorted to with very much emaciated and
underfed infants, when digestional disorders make it im-
possible to introduce enough food by mouth to cover the
needs of the body.
SPECIAL DIETS
There are a number of diets formulated to meet the
various normal and abnormal conditions. In hospitals these
are classified as follows, for the convenience of both nurse
and doctor:
House Diet. — That which is served to the hospital
staff, the nurses, and those patients not requiring special
diets.
Liquid or Fluid Diet. — Consisting of milk, nutrient and
other palatable beverages, broths, and thin gruels.
Light, Semi-solid or Convalescent Diet. — Composed
of thick or cream soups, eggs, toast, cereals, custards, jellies
and ice cream, and later vegetable purees, broiled birds,
chicken, lamb chops, and rare beefsteak.
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METHODS OF FEEDING 63
Mixed Diet. -. — The diet used in normal conditions and
for those not affected by any special food.
Special Diets. — Those designed to be used for certain
pathological conditions, such as scarlet fever, nephritis, etc.
These diets are classified as follows:
Milk Diet. — A diet in which milk is the sole article of
food.
Carbohydrate-free Diet. — One in which the sugars and
starches are eliminated.
Purin-free Diet. — One in which the foods rich in purin
bases are eliminated. This is used in gout, arteriosclerosis,
etc.
Salt-free Diet. — Diet in which sodium chloride (salt) is
as far as possible excluded. It is used in certain cases of
nephritis when edema is present.
Nephritic Diet. — A diet used in nephritis and diseases
complicated by nephritis (scarlet fever). In this diet the
protein foods, meat in particular, are restricted, milk being
the exception.
Diabetic Diet. — A diet in which the carbohydrates are
restricted or eliminated.
"Allen Treatment of Diabetes*' consists chiefly of
"starvation" for a given period and a re-education of the
organs to a toleration for carbohydrates.
Emaciation Diets. — Those containing a high per-
centage of fat-forming foods, such as milk, cream, eggs,
cereals, potatoes, etc., olive oil.
Obesity Diets. — Those containing as few of the fat-
forming foods as possible, such as cream, olive oil, potatoes,
white bread, etc., pastry and desserts, candy and soda water,
and containing lean meats, fish or shellfish cooked and served
without butter or other fats, fresh or stewed fruit without
sugar, green vegetables and salads served without oil or
other fats; one ^g a day two or three times a week, coffee
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64 DIETETICS FOR NURSES
and tea without sugar or cream, toasted gluten bread (1
slice) without butter, saccharine substituted for sugar.
There are a number of other diets, but they come more
or less under the above heads.
THE TRAT
As the patient's tray assumes an important part of the
daily regime, it is necessary to give close attention to the
arrangement and serving of it. There are certain definite
rules to observe: (1) The linen, silver, glassware, china, and
food must be absolutely clean. (2) The tray must be suflB-
ciently large not to appear crowded. (3) The arrangement
of the obligatory articles, such as salt and pepper, silver,
water glass, napkin, etc., must be alike at every meal; this
not only facilitates the service by making it easy for the
nurse to see whether any of these necessary articles are
left oflf, but it also enables the patient to find them without
trouble.
The Linen. — The linen cover of the tray must be clean
and uncreased. The napkin likewise must be clean and un-
wrinkled. The china must be free from chips and cracks.
Care must be taken not to put a collection of odd pieces on
the tray as it gives an untidy appearance.
The Silver. — The silver must be bright and in cold