John Ruhräh.

A manual of the diseases of infants and children online

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is most frequent in the dependent parts. As it occurs in the
very weak the children often die, but some of them recover.

The edema lasts a week or so and disappears. It may
recur.

Treatment. — Keep the .child warm and stimulate the
heart and circulation. Give digitalis, strychnia, and alcohol.
In the very severe cases citrate of potassium may be given.

INANITION FEVER.

Inanition must not be forgotten as a cause of fever in the
newborn. (See Inanition).



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INFANT FEEDING. 51



INFANT. FEEDING/

There are four methods of feedmg infants : 1. Breast or
maternal feeding. 2. Wet-nursing. 3. Mixed feeding — t. e,,
breast-feeding supplemented by bottle-feeding. 4. Bottle or
artificial feeding.

BREAST-FEEDING*

The milk from a healthy mother is by far the best nour-
ishment for an infant during the first year, and cannot be
fully replaced by any other form of feeding. Infants fed on
breast milk are stronger and better able to resist disease.
While it remains true that babies may be reared on artificial
foods and remain healthy and grow strong, the percentage of
robust bottle-fed babies is much smaller than that of healthy
breast-fed infants. This is particularly true of the lower
classes, who often lack both the time and intelligence re-
quired to rear a healthy infant by bottle-feeding.

Contra-indications to Maternal Nursing. — ^The
following rules, adapted from Holt, will be found a reliable
guide in determining whether or not a mother is fitted to
Durse her child :

1. If the mother has tuberculosis in any form, latent or
active, she should not nurse her child. A tuberculous mother
not only exposes her child to infection, but hastens the prog-
ress of the disease in herself. If the mother has pulmonary
tuberculosis, nursing is almost certain to prove fatal to her.

2. When the mother has had any serious complication,
such as nephritis, convulsions, severe hemorrhages, or septic
infection, during pregnancy or parturition, she should not
nurse her child.

3. If the mother is choreic or epileptic, nursing is contra-
indicated.

4. If the mother is very feeble or has any serious chronic
disease the child will derive little, if any, benefit from breast-
feeding, and the mother will be greatly injured.

* A very complete discussion of this subject will be found in DUt in
Health ana Disease, bj Friedenwald and Buhrah.



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52 DISEASES OF INFANTS AND CHILDREN.

5. Nursing should not be attempted where experience has
shown on two previous occasions, under favorable conditions,
that the mother is unable to nourish her child.

6. Where no milk is secreted nursing is impossible.
Good artificial feeding is to be preferred to poor breast

feeding. If artificial feeding is to be resorted to it is well to
begin early, while the infant's digestive organs are in com-
paratively good condition. The question must always be
carefully considered.

During pregnancy the breasts should be examined, and if
the nipples are short, gentle traction should be made on them
daily. If there is retraction the breast-pump may be needed
to evert them. During the entire nursing period the breasts



Fig. 11.— Breast-pump.

should be kept clean ; they should be washed after each
nursing, preferably with a boric-acid solution.

During the first forty-eight hours the child receives practi-
cally no nourishment from the breast ; the only fluid secreted
during this time is colostrum. This has a laxative eflcct
upon the infant's bowels, emptying them of the dark, brown-
ish material known as meconium, which has accumulated in
the intestinal canal during uterine life. The child should,
however, be put to the breast at regular intervals, so as to
establish a free flow of milk ; this generally begins on the
third day, but is sometimes delayed.

During the first two days of its existence the child gets
about six ounces of colostrum a day, which is all that is



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INFANT FEEDING, 53

needed. It may, however, be given a teaspoonful or two of
warm, boiled water or of a 5 per cent, solution of sugar of
milk. In unusually robust and fretful children, or when
there is fever, a small amount of nourishment may be re-
quired ; this should be given according to the rules for arti-
ficial feeding. If the milk is delayed beyond forty-eight
hours, it becomes necessary to feed the child by the bottle
until the flow is established. The child should be put to
the breast regularly, or the breast-pump may be used to
stimulate the secretion of the milk. Fennel, catnip tea, and
the like should be excluded from the child's dietary.

Many mothers do not nurse
their infants because they have
not been properly instructed
as to the importance of doingit.

The mental attitude of the
mother has a marked effect on
the milk secretion, and if she
has been properly instructed
and encouraged beforehand,
there is usually no diflBculty.
If, on the other hand, she has
grave • doubts as to her capa-
bility, the milk secretion may

be inhibited. The mental fig. 12.-Colostrum and ordinary milk-

condition of the mother is ^ffiirn'fCmfd)""'' '*'""'^™'"^'"*
often affected as the result

of weighing the child. It is very desirable that the child be
weighed regularly and the weight recorded ; but if the mother
is at all nervous, or if the child is not doing well, the weigh-
ing should not be done by the mother or in her presence.

Breast-nursing often proves a failure because the mother
does not understand how to give the breast to the child. The
child should lie on the right or left arm, according to whether^
the child is to nurse at the right or at the left breast. If the
mother is in a sitting posture, her body should he inclined
slightly forward. With her free hand she should grasp the
breast near the nipple between the first two fingers. If,
owing to the free flow of milk, the child takes the milk too



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54 DISEASES OF INFANTS AND CHILDREN

rapidly, this may be checked by slight pressure of the fingers.
The child should nurse until satisfied. The contents of one
breast are generally sufficient for one nursing, and the breasts
should be used alternately. When satisfied, the infant will
usually fall asleep at the breast. Under ordinary conditions
the nursing should last from ten to twenty minutes. If the
milk is taken too rapidly, vomiting may ensue immediately
after or during feeding. If too much is taken, it is regurgi-
tated almost immediately. If the infant consumes more than
half an hour in nursing, the breast and the milk should be
examined. As the infant grows older it requires and takes
more food, and consequently will require a longer time to
nurse than it did during the early days of life.

The inculcation of good nursing-habits cannot be too
strongly insisted upon. Many attacks of indigestion, colic,
and diarrhea may be traced to improper nursing. When
good habits are once established, there is generally very little
trouble, the success of the training depending largely on the
manner on which it is done. Regular hours for feeding
should be fixed and adhered to ; and if the child is asleep at
the feeding-hour, it may l)e aroused, for it will almost invari-
ably go to sleep after nursing. After the last feeding, which
should usually take place at 9 or 10 o'clock, the child should
be quieted and allowed to sleep as long as it chooses.

During the first month or two the infant will, as a rule,
awaken between 1 or 2 o'clock and again at 4 or 5 o'clock.
After two or three months it will require but one night feed-
ing, and after five months of age the average infant will sleep
all night without nursing.

When the change is being made and the child awakens for
its accustomed nursing it should be given a little warm water
from a bottle and quieted, but not taken up. Regular nurs-
ing habits induce regular bowel movements and sleep, and
the three combined insure health and comfort not only for
the infant, but for the mother as well. A healthy child, if
trained to do so, will sleep without rocking or coddling.
Three things are, however, essential to secure success in this
training : a satisfied appetite, dry napkins, and a quiet dark-
ened room. If it has colic, the warm milk may soothe the



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INFANT FEEDING.



55



child for a time, but later aggravates the trouble, which in
many cases is due to overfeeding or too frequent feeding.

The following table, from Holt, may be used as a guide in
breast-feeding :



Age.



First day

Second day

Third to twenty-eighth day
Fourth to thirteenth week .
Third to fifth month . . .
Fifth to twelfth month . .



Number in

twenty-four

hours.



4

6

10

8
7
6



Intervals

during

day.



6 hours.
4 «

2 «
2i "

3 «
3 "



Night nursini

between 9 P. I

and 7 A. M.



In case of sickness and when the infant is feeble and
below the average, especial rules are required, and directions
should be modified to suit each individual case. A good
general rule is to feed the child according to the age to which
the weight corresponds. The child's weight is the best index
of its nutrition. During the first six months it may be
weighed once a week ; after that time twice a month is suffi-
cient. The average minimum gain for an infant is four
ounces a week. If the weight falls below this for several
weeks consecutively, it is evident that something is wrong.
During illness, of course, there may be no gain or loss ac-
cording to the severity of the condition.

When the breast milk is insufficient for, or unsuited to the
needs of the infant, it becomes fretful, colic occurs, and the
baby appears to be "cross.'' Disturbances of the alimentary
tract, diarrhea with greenish stools containing a large amount
of mucus and undigested curds, takes place at times. At times
the stools are brownish, and contain mucus and numerous
curds the size of a grain of wheat or larger. In other cases
there may be chronic constipation with small, hard, dry stools.

If the infant is getting too little milk, it is fretful and gains
slowly or not at all, but there is rarely any disturbance of
the stomach or bowels. In these cases the nursing is con-
tinued for over thirty minutes without satisfying the child,
or it may nurse a minute or two and then refuse because
the supply is so scanty. When the breast milk is nearly



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56



DISEASES OF INFANTS AND CHILDREN.



normal in quantity and in quality, certain measures, which will
be discussed, may be taken to augment the supply and enrich
the quality, or it may be supplemented by artificial feeding.
When the milk is very jx)or in quality, as, for example, when
the specific gravity is from 1.015 to 1.025 and when only 2
or 3 per cent, of cream is present, the child should be weaned
at once, for the condition is not amenable to treatment.

Mother^s milk may easily be tested by means of Holt's
milk set, which consists of a lactometer and a cream gaugc.^
With this the specific gravity and the amount of cream may
easily be estimated. Estimated with this instrument the
cream is to the fat as 5 is to 3. The following table will
help in estimating the quality of human milk :



Normal averag;e . . .
Healthy variations . .

Healthy variations .

Unhealthy variations

Variations

Variations

Variations

Variations

Variations



Specific

gravity,

70° F.



1.031
1.02&-1.029



1.032-1.033
Below 1.028



Below 1.028
Below 1.028



Above l.C



Above 1.033
Above 1.033



Cream, twenty-four
hours.



7 per cent.
9-12 per cent

5-6 per cent.

High (above 10 per cent.).

Normal (5-10 per cent.).
Low (below 5 per cent.).

High.

Normal.
Low.



Proteins.



1.5 per cent.
Normal (rich

mUk).
Normal (fair

milk).
Normal or slightly

below.
Low.
Very low (very

poor milk)
Very high (very

rich milk).
High.
Normal or nearly

so.



When the mother^s milk is found not to agree with the
infant, it may often be modified by the following means :

1 . If the milk is too rich, the diet should be limited, espe-
cially as to the amount of meat taken. All alcoholic and
malted drinks should be prohibited. With plenty of fresh
air and exercise, such as walking, the desired effect will gen-
erally be brought about. The exercise should be carried to
the point of fatigue.

2. When the milk is good, but deficient in quantity, the
supply may be augmented by massage of the breasts three
times a day for from five to ten minutes. A good malt ex-
tract may be given with the meals, and fresh air and exercise
prescribed. Sufficient fluid should be given, preferably milk.

^ This may be obtained from Eimer & Amend, New York.



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INFANT FEEDING. 57

3. When the milk is deficient in quantity and poor in
quality, improvement may be brougnt about by various
means ; massage, malt, and iron are to be prescribed if there
is anemia. An alcoholic malt extract combined with pep-
tonate of iron, or of iron and manganese, is a good combina-
tion, and may be had in very palatable form. The diet should
be ample and contain sufficient nitrogenous fo<Kl. Milk
should be taken with the meals, during the intervals between
meals, and at bedtime.

4. When the quantity is sufficient, but the quality is poor,
little can be done, and the child must generally be weaned.
The forgoing measures may be tried, but not for too long a
period, as the child may suffer in consequence.

After the second month the child may be given a bottle
once a day. The child learns to take its milk from the bottle,
which facilitates weaning when the time comes ; it also allows
the mother greater liberty.

Wet-nursing. — Some infants will thrive on nothing but
breast milk. If the mother cannot nurse her child a wet-
nurse should be chosen according to the following rules :

The woman should be healthy and of good habits. The
absence of syphilis, tuberculosis, alcoholism, and other dis-
eases should be determined by careful examination. The
nipples should be carefully examined for fissures and ulcera-
tion. The breasts should be examined before and after nurs-
ing, and the milk tested as previously described. The size
of the breast alone is not a good guide as to the amount or
quality of the milk it secretes. The quantity may be judged
by the size of the breast before and after nursing or by
weighing' the baby before and after nursing. This latter
method, although a good one, is not usually resorted to.
The wet-nurse should always be one who has nursed her
own child successfully for at least a month. If possible she
should be a primipara between twenty and thirty-five years
of age. Younger or older women should not, as a rule, be
employed. If the infant's condition permits, the nurse should
be given at least a week's trial, for often the change in her
mode of living may cause a scanty flow of milk or render it
otherwise unsatisfatory. When she has become accustomed



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58 DISEASES OF INFANTS AND CHILDREN.

to her surroundings, the milk may become perfectly normal.
Owing to idleness and a too abundant diet the milk may
become too rich. In these cases the rules previously laid
down may correct the condition.

Wet-nursing is now largely replaced by correct artificial
feeding.

MIXED FEEDING*

The child is fed partly on the breast and partly on the
bottle. This method is indicated when the mother's milk is
poor or scanty, owing to some intervening illness, or when,
owing to deficient quantity, the mother cannot entirely nurse
the child ; it is also useful in weaning. Weaning is accom-
plished with less discomfort to mother and child if done
gradually. If the mother is nursing the child but once or
twice a day, her milk may become very poor, and conse-
quently should be examined from time to time. In these
cases the child is usually satisfied after a bottle, but not after
the breast-feeding.

ARTIFICAL OR BOTTLE-FEEDING.

When it becomes necessary to feed the child artificially
the physician must understand the nature of the milk mix-
ture that he prescribes, so that he may vary it to suit the
child's digestion and modify it to meet the requirements of
the growing infant.

In the United States the only milk available for infant
feeding is cows' milk. To insure success by artificial feeding
an accurate knowledge of the composition of the milk and in
how much it differs from mother's milk is essential. A
knowledge of the methods for overcoming these differences is
also necessary. It should constantly be borne in mind that,
while general deductions may be made and average figures
given, the element of personal equation enters largely into
the problem, and each infant must be considered a law unto
itself. Children living in the country and in the smaller
towns, where there is no overcrowding and where an abun-
dance of fresh air can be had, seem to thrive on cows' milk
that has been modified but little, perhaps merely by the addi-



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INFANT FEEDING. 59

tion of water in various proportions. In the larger towns,
where overcrowding is frequent and fresh air and sunlight
are not easily secured, the question is a more difficult one.
Children with these environments require a more exact milk
mixture and additional care. City milk is often stale and
preserved by the addition of chemicals.

The first requisite in artificial feeding is a pure, fresh milk.
This can be obtained only by having the dairy farms, cattle,
milk production, and distribution under competent sup€?rvision,
and by cleanliness and care in the handling and transportation
of the milk. Clean cows, clean stables, clean milkers, sterile
milk pails and utensils are necessary, and the milk should be
cooled rapidly after milking and kept cold until used. Pas-
teurization and sterilization should be necessary only under
unusual conditions. They are often necessary now, because
the milk is impure to start with and improperly cared for.
No coloring matter or preservatives should be allowed. In
the home the milk should be kept in closed jars or bottles
until used, and it should be kept cold. Pure milk is best
secured by having the supervision of the dairies and market-
ing under the same management. Bacteriological and chemical
analyses are necessary from time to time to control the work.

In order to adapt cows' milk to the infant's digestion
several changes must be made in it. These become apparent
by studying the nature and composition of the milk.

Composition of Cows' Milk. — ^The proteins differ not
only in amount, but also in character. In human milk the
proteins consist of lactalbumin and casein, in the proportion
of two-thirds of the former to one-third of the latter. In
cows' milk one-sixth of the protein is lactalbumin and the
remainder is casein. The protein of human milk precipitates
in fine flakes ; that of cows' milk, in heavy curds. The total
amount of protein material also varies, being from 1.5 to 2
per cent, in human milk and, on the average, 3.5 per cent,
in cows' milk. The modification consists in diluting the
milk until the protein is from 0.6 per cent, or more, accord-
ing to the age of the infant and its digestive ability. In some
cases of difficult feeding the lactalbumin and casein may be
separated and added in the required amounts. This is not,



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60 DISEASES OF INFANTS AND CHILDREN

however, usually necessary. The proteins may be prevented
from forming large curds by the addition of lime-water or of
barley-or oatmeal-gruel. With the smaller percentages this
is not ordinarily required. When necessary, as during ill-
ness, the proteins may be predigested.

Sugar. — The milk-sugar of human milk is present in a
very constant proportion — from 6 to 7 per cent. In cows'
milk it averages about 4.5 per cent. Diluting the mUk, of
course, decreases the proportion, and the amount must be
made up by adding either milk-sugar or cane-sugar. The
former, being that normally present in the milk, seems the
most suitable. Cane-sugar has, however, many advocates,
among them being Jacobi. Cane-sugar, owing to its excess-
ive sweetness, is used in just half the quantity of milk-sugar.
As it is inexpensive, it is useful in practice among the poor.

During the first few days of life sugar may be given in
the proportion of 5 to 5.5 per cent. ; from the second week
to the third month, 6 per cent. ; and from that time until the
eleventh month, 7 per cent, may be used. At the eleventh
month it may be reduced to 5, and a few months later to
4.5 per cent. There is no advantage in giving over 7 per
cent., and it may give rise to symptoms of excessive sugar-
feeding.

Fat. — The fat of human milk averages 4 per cent. ; that
of cows' milk is the same. When the milk has been diluted
the amount must either be made up by adding cream or by
using the upper one-third or upper half of the milk after the
cream has risen. It is preferable to use fresh cream that has
risen by the gravity method or the top-milk method.

There are objections, based on theoretic grounds, to the
use of centrifugal cream ; these are of less practical interest
in infant-feeding than was formerly supposed.

The amount of fat to be given varies with the age, weight,
and digestive ability of the infant. For an average infant 2
per cent, the first week, 2.05 per cent, the second, and 3
per cent, the third week are the amounts usually prescribed.
At four months the amount may be increased to 4 per cent. ;
after that time this amount must not be exceeded, or the



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INFANT FEEDING. 61

Infant is apt to develop indigestion, with the large whitish
stools giving off the characteristic odor of the fatty acids.

Salts. — The mineral constituents of human milk make up
about 0.2 per cent, of its entire bulk ; those of cows^ milk
are three or four times greater. These inorganic salts vary
in about the same proportion as the proteins. When the
milk is modified for the purpose of increasing or diminishing
the percentage of proteins, it is, at the same time, modified
for the salts.

Reaction. — The reaction of human milk is always alkaline.
Since cows' milk is usually acid or neutral, this acidity must
be corrected by adding either 5 per cent, of lime-water or
sodium bicarbonate. The sodium salt is used in the propor-
tion of 1 grain to the ounce. As the lime precipitates at the
higher temperatures, when the milk is to be boiled it is better
to add the bicarbonate. For young infants, when there is a
hyperacidity of the stomach or acute illness, larger quantities
than those just mentioned may be used. Coit recommends
the use of potassium bicarbonate.

MILK MODBFICATION*
(Methods of Practical Value in Modifying Milk.)
There are a number of methods of milk modification that
may be used with good results in the artificial feeding of
infants. A practical knowledge of these methods is a de-
sideratum in the rearing of bottle-fed infants. Those most
in use are :

1. Laboratory feeding.

2. Top-milk method.

3. Materna graduate.

4. According to Maynard Ladd's table (after Rotch).

5. Bauer's method.

6. According to Louis Starr's table.

1. I/aboratory Feeding. — In cities the best substitute
for breast-feeding is furnished by milk laboratories, where
modifications are made according to the physician's prescrip-
tion. The Walker-Gordon laboratories, now established in



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62



DISEASES OF INFAJ^TS AND CHILDREN.



many cities, supply an ideally clean railk, unsterilized, pas-
teurized, or sterilized at any temperature desired. The milk
is supplied in nursing-bottles, each bottle holding enough for
one feeding and being ready for use. Beyond warming the
bottle and putting on a nipple no further preparation is
necessary. In winter the milk is delivered in baskets, and
in summer in small refrigerators. When economy must be
l>ractised, the milk may be obtained in larger jars and
divided into the requisite number of feedings by the mother
or nurse. Blank forms on which to write prescriptions are
furnished physicians. The following is an example of such
a prescription :



^-



Per Cent.



Fat

Milk-sugar . . . .

Proteins

Lime-water . . . .
Other Diluent -
Heated at 167'' F.



Jfumberof \ ^

feedings • • ^
Amount at

each feeding
Infant's age
Infant's weight



}•



7 ounces.



Ondcncd for..



Date,



SlQNATUNC,



..M. D.



These prescriptions are filled at the laboratory by mixing



Online LibraryJohn RuhrähA manual of the diseases of infants and children → online text (page 4 of 29)