KEEPING THE WELL CHILD WELL
ALAN BROWN, M. B.
What You Should Know About a Child's Feeding. Second of a Series of Six Articles
THE first thing to be remembered before putting a young baby on an artificial food is that there is no real substitute for mother’s milk. Even when a food is compounded of the same ingredients, in the same amounts as nearly as can be determined, still there is a wide difference in its effects.
In order to comprehend the principles which underlie the proper feeding of infants it is well to understand what is involved in the process of digestion and what food elements are needed for the growth, maintenance, and repair of the baby.
Digestion is the process or series of processes by which the food eaten is changed into the forms in which it can be absorbed by the tissues of the body. This is a most intricate operation involving the use of many organs and functions, but one which takes place without difficulty in the healthy human body. But since all the complicated machinery necessary for digestion must be started at once, and since, necessarily, the organs of a newborn baby can be but feeble, it stands to reason that the food presented to them be especially adapted to them. The food must be liquid; also it must contain the essential elements which the human body requires for growth, namely the fats and sugars and starches which furnish the necessary heat and energy; the proteins, or muscle builders; the mineral salts needed for the growth of all the tissues and, lastly a great amount of water. All these are found in milk, and in no other food which the infant is capable of digesting. Therefore, cow’s milk is the one proper food for the artificially fed infant.
A VERY rapid increase in weight is not to be desired.
The ideal in baby feeding is not to produce a fat baby, but rather a proportionately nourished one. It is comparatively easy to grow fat, but it is a harder and slower process to grow muscle, bone, blood and nerve tissue. A perfect baby does not have the outlines of his muscles obliterated by wads and cushions of fat. He is alert, springy, the flesh is hard to pressure, not soft and flabby. His color is pinkish, save when the cheeks have been reddened by the cold or heat. It is practically impossible to put on more than six or eight ounces of good flesh in one week, and very few can put on as much. Artificially fed babies should be watched with particular care as to their weight in summer. It is better to have little or no gain during the excessive heat than to upset the digestion by overfeeding designed to keep the baby gaining.
Wide experience has shown that fresh cow’s milk is the best substitute for breast milk. This milk should be the purest and cleanest possible; it should be the product of a tuberculin tested herd, one that is
healthy, well fed, properly housed and cared for and milked by clean milkers into sterilized utensils. The milk should be bottled and cooled at the dairy and delivered to the consumer in sealed bottles. The milk commonly sold from open cans known as loose milk, should never be given to a baby.
In certain places it is possible to obtain what is known as “certified milk” which is fresh, clean, pure, normal milk of uniform composition and highest quality obtained """"""""""i" from healthy cows and produced and handled under the supervision of a medical'milk Commission with special sanitary precautions. Although the amount of certified milk is as yet far too small, the demand for it is steadily increasing. As soon as mothers become convinced of the infinite advantage of having
a supply of raw milk whose quality is guaranteed, they are quite ready to pay the additional cost, usually from twelve to sixteen cents a quart extra; but compared with the cost of the illness due to the use of unclean milk, this is not to be considered. There can be no doubt but that the use of certified milk has been a factor in the reduction of deaths from infantile diarrhoea in recent years.
Care of Milk in Country
TF ONE is in the country a special arrangement should A be made with the farmer by which he agrees that the cow’s belly, udders and teats should be wiped off with a damp cloth before milking; that the milker’s hands should be washed before milking, that the few jets of the foremilk should be thrown away; and that as soon as the milk is drawn it shall be strained through absorbent cotton into a quart bottle suitably corked and placed in a pail of cracked ice. For the extra trouble the farmer receives from twelve to twenty cents a quart. For those who have country homes the above directions can be carried out to the letter.
Since the sources of contamination of •milk are many and the difficulty of determining the character of milk great, it is
FOUR MORE ARTICLES IN THIS VITAL SERIES
There will be four more articles in the series, dealing with other problems that arise in the successful upbringing of the child. All are as distinctly practical as those that have preceded.
The schedule is as follows :
Nov. 1 5 : What your child should eat after the first year.
Useful recipes that will materially help in keeping your child well.
Dentition, exercise, cry, sleep, air—for young children.
Sleep, rest, exercise, play, discipline— for older children.
expedient that all milk (with perhaps the exception of certified and even this is more digestible when boiled) should be properly pasteurized or boiled. We would not think of eating raw meat, and yet it is not nearly
Thi, artide ia from Dr. Alan Brown’* forthcoming book -The Tare »nd Feeding of the Normal Child,’’ to b. poWWhed b, P. D. GoodchUd, earl, in !923.
so fertile a source of contagion as milk. We now know that many of the epidemics of infectious disease, such as scarlet fever, diphtheria, tonsilitis and typhoid fever, are frequently directly traceable to the milk supply.
Pasteurization of milk changes its character very little, and boiling for two or three minutes dóes not change it sufficiently to outweigh its advantage on the side of safety. The occasional case of constipation which is sometimes produced by the boiling of milk may be readily corrected by other means. For infants the milk richness in fat content should not be sought for, but rather milk only moderately rich. Milk from a herd is much preferred to that from one cow.
Care of Milk in the Home
A FTER having secured the best milk possible it is necessary that it be kept pure and cold. All milk for infants at once after milking should be poured into clean bottles which have been sterilized by live steam or by being boiled, and placed upon ice until delivered. As soon as the milk is received at the home it should be prepared according to the formula prescribed. It should then be poured into nursing bottles, one for each feeding during the twenty-four hours, and each stopped with a plug of sterilized cotton wool. These bottles should first be thoroughly cleaned and boiled. The whole feeding may then be pasteurized by, placing the bottles in a water bath until the temperature reaches 145 degrees F. and then allowed to stand at this temperature for. thirty minutes, or the milk may first be brought to the boiling point for a couple of minutes and then poured into bottles. The bottles should be placed in warm water until the milk reaches the proper temperature, namely, blood heat, placed in cold water until cool, ' then on ice, etc.
Milk left in a bottle after feeding should never be used for a second feeding, but should be discarded and the bottle filled with water until it is cleaned and boiled.
The safest, and I am convinced the best, method for the average family in both the city and country is to boil the milk for two or three minutes. Pasteurization under any circumstances does not kill all germs, and if improperly done it is worse than no pasteurization at all. Heating milk to an insufficient temperature merely stimulates the growth of organisms.
Where ice cannot be procured, milk which has been boiled and rapidly cooled, if kept in a cool place, sealed from the dust and flies, will be comparatively safe for twenty-four hours.
Home-made Ice Box
ASIMPLE ice-box can be constructed at a cost of less than one dollar which will keep a baby’s milk cold at an expense of only two or three cents a day. An ice box may be made as follows; Procure a wooden box about eighteen inches square and the same depth; put a layer of sawdust three inches thick in the bottom of the box; fill in with sawdust around a ten-quart pail, which occupies the middle of the box. Inside this pail place another slightly smaller pail, which is to hold the ice and the bottles. This inner pail should be covered, and the outer box tightly closed by a wooden cover lined with several thicknesses of newspaper. The inner pail should be taken out each morning to be emptied and cleaned. When feeding time comes, the box is opened, one bottle is taken out, and the box is quickly closed again. It should be borne in mind that neither pasteurization nor boiling transforms filthy milk into clean milk. It will
however, remove the chances of such epidemics as some of our cities have suffered from during the past years.
Thermos bottles may be employed to keep milk cold, but never to keep milk warm, since germs develop rapidly in warm milk. The milk may be heated rather rapidly by putting the bottle under the hot water faucet. Great care must be taken in the use of alcohol lamps, as frequent accidents happen in this way, especially at night.
The simple graduated bottles are inexpensive and more easily kept clean than most varieties.
The nipple should be of the simple variety which can be purchased at any drug store and selected with small openings, as there is a tendency for infants to get their food too fast. If the opening is small, it can readily be made larger by heating a small sewing needle to a red heat and burning the opening the size desired. Blind nipples may also be purchased and the openings made the size desired. Immediately after feeding, nipples should be cleaned thoroughly with borax and water, then boiled for three minutes and placed in half a glass of water with a heaping teaspoonful of borax in it. Rinse the nipple before using.
The habit which many mothers have of putting the nipple into their own mouths before giving it to the baby should be absolutely prohibited, as this is a frequent source of infec-
Mixing and Care of Food
THE following (as shown in cut on page 20) utensils are usually essential for the modification of milk in the house:
1. Six to eight bottles.
4. Glass graduate (measuring sixteen or twenty ounces.)
5. Granite Pitcher.
6. Glass Funnel.
7. A tablespoon (regulation size.)
8. Enamel saucepan for boiling purposes.
9. Wire bottle rack (not absolutely essential.)
It is far better for the baby and easier for the mother, if she takes a certain time each morning to make up the food for the following twentyfour hours. She then does not have to think qf it again until the next morning. All the utensils for mixing the food are kept in a place by themselves and are not used for any other purpose.
The person whose duty it is to make the food should be responsible for their condition and keep them clean, not trusting to anyone else.
First, the bottles, one for each feeding throughout the day, are attended to. They are all clean and standing full of borax water from the day before. The bottle rack is held over the sink, and the bottles, one at a time, are placed in it upside down to empty the borax water. They are then turned right side up in the rack and filled with hot water to rinse out the borax and again placed upside down to drain and cool while the food is being mixed.
The fresh unopened bottle of milk is then poured into the pitcher so that the cream will be thoroughly mixed in (should the directions call for part removal of the cream, this should be done first before mixing) and then poured back again into the bottle in which it came. Measure the proper amount «f milk in the graduate and
NURSING vs. BOTTLE FEEDING
Every mother, with few exceptions, should at least make an attempt to nurse her infant, because there is no perfect substitute for breast milk, however scientifically concocted or modified. Furthermore, the mortality of breast-fed babies is fully one-third less than that of artificially fed infants. With women properly educated and in good physical condition fully seventy-five per cent, can nurse their in-
HOW BABY LEARNS TO TALK
Girls talk from two to four months earlier than boys; toward end of first year child uses single words; toward end of second year sentences, two to three words; after second year improvement very rapid. This schedule varies greatly, however. Order of Development: (a) Names
of persons; (b)
Names of objects;
(c) Verbs; (d) Adverbs; Adjectives; (f) Conjunctions; (g) Prepositions; (h) Articles; (i) Persony al Pronouns.
pour it into the pitcher. Measure out the proper amount of ice-cold water or gruel as the case may be and pour it into the pitcher. Measure out the sugar with a tablespoon (levelled with a knife) and add to the food. Heaping tablespoons mean all that you can get on the spoon, while a rounded tablespoon is the heaping portion partially removed. Neither of these procedures, however, is as accurate as the first mentioned, viz., levelling. Stir until the sugar is dissolved.
Boiling and Cooking
IF THE directions call for the food to be boiled, proceed as follows: Place the food, as mixed after first measuring the total quantities, in a saucepan and gradually bring it to a boil, stirring constantly. Boil actively for three minutes, then proceed in the usual manner. If the food is to be cooked, it should be placed in a double boiler and cooked for twenty or thirty minutes after food begins to thicken.
Using the funnel, pour into each bottle the amount baby is to have at each feeding. Stop up the bottles with' clean absorbent cotton and put the rack, full, in the ice chest, directly on the ice if possible; wash up the utensils and put them away for the following day.
When feeding time comes all that has to be done is to place one of these bottles in a pan of hot water; the food should be just body temperature when it is fed. It is just as bad to have it too hot as to have it too cold. The temperature should be tested by pouring a few drops upon the forearm and never by putting the nipple in one’s own mouth, or touching the finger to the food itself. In
winter it is well to have a woolen bag or knitted cover, which just fits the bottles, to hold the heat in during the twenty minutes while the baby is feeding.
Cow’s Milk and Mother's Milk
IT WILL be noticed by a comparison of the two kinds of milk that the chief apparent difference is in the amounts of sugar, proteid and salts.
Mother’s Milk Cow’s Milk
Fat..........4 per cent. Fat...........3 to 4 per
Sugar.........7 ” ” r Sugar........VA per cent
Proteid........1 ” ” Proteid.......3.5
Mineral Salts % of 1 per
Mineral Salts 1/5 per cent. Water........88 per cent.
Water........88 per cent.
Mother’s milk contains about three per cent, more sugar than cow’s milk and cow’s milk contains over twice as much proteid as mother’s milk. Cow’s milk also contains three times as much mineral salts as mother’s milk.
A study of these percentages has suggested to many in the past the possibility of substituting for mother’s milk a chemically identical modification of cow’s milk. This theory, however, was found to be false, as no amount of modification of the milk of one species can transform it into that of another.
It was, however, found necessary to modify cow’s milk for young infants and the method generally known as percentage feeding was adopted.
The different elements of the food; fat, sugar, and proteid, have definite food value. The food value is measured in units called calories, a calorie being the amount of heat required to raise one litre (approximately a quart) of water one degree Centigrade. The food or caloric value of proteid and sugar are the same, while that of fat is more than twice as much as either of the other elements.
Whole Milk and Cream
WHOLE milk is meant the milk as it comes from the cow, without any modification. By cream is meant the part of the milk which arises to the top of the bottle after standing. It is usually known as gravity cream and has a fat content of above 16 per cent, in contrast to separated cream, which has a fat content of about 32 per cent.
Cow’s milk is usually modified by diluting it with some fluid, such as water or gruel, and then adding sufficient of whatever elements arc to the proper per-
ally the same ounce per ounce as mothers milk, it is apparent that if we dilute cow’s milk we must either give a greater quantity or add something to bring tip its food value.
The usual procedure, therefore, is to dilute cow’s milk and then add a certain percentage of sugar. Since individual infants differ so widely in their tolerance of fat and sugar, it is always advisable to begin with low percentages of these Continued on page 44
Keeping the Well Child Well
Continued from page 21
elements and gradually increase to the proper amount.
The days of complicated formulae for babies’ foods are over. Well babies do not need top milks and creams, whey, lime water and the various foods that are frequently recommended. Such foods or special mixtures should be reserved for sick infants who should be under a physician’s care. Plain dilution of cow’s milk (with all the cream stirred in) to which is added water and sugar, answers all the requirements of a food good until the baby is seven or eight months of age, when some cereal or gruel may be then employed either in place of, or in addition to, the water.
Plain milk mixed with water is easier to digest than cream or top milks and nourishes the baby better. Neither is there the same tendency to constipation when plain dilutions of whole milk are used. Excessive fat in the food, in addition to inducing constipation, frequently tends to make the baby spit up. This, combined with other symptoms, not infrequently produces a loss in weight.
The sugar is added solely for its nutritional value and for its laxative action on the bowels, and not at all for the taste. Sugar is very concentrated nourishment and is therefore one of the most important
ingredients in the food. One ounce of sugar supplies as much nourishment as six ounces of the milk. Sugar, unfortunately, is usually the most difficult part of the food to digest. If too much is given, it may cause either diarrhoea or vomiting; while if too little is given, there will be little if any gain in weight. Milk sugar, which has been so extensively used in the past, should never be used where there is any digestive disturbance. It is not as easily digested as either cane sugar (granulated sugar) or phar-malt dextri-maltose. The latter is the best of all the sugars to use, especially if there is any tendency to looseness of the bowels.
As a routine in feeding normal babies I have been accustomed to use the ordinary granulated sugar, employing milk sugar only in a baby who tends to vomit without looseness of the bowels.
This element of the food is the “curded portion” or casein and never gives us any trouble: on the contrary this element is most beneficial in overcoming or correcting certain forms of diarrhoea.
The Proper Amount of Milk
THE most important points to consider then in deciding upon a well baby’s food are three: the amount of milk, the amount of sugar and the amount
of water to be added to make up the proper bulk and concentration. The quantities of these ingredients depend upon the baby’s weight and age.
The actual amount of cow’s milk that a baby needs in twenty-four hours in order to maintain weight and proper growth is approximately one-and-a-half to two ounces milk per pound of body weight, provided he can digest one and a half ounces of sugar. The amount of sugar a baby can digest varies with almost every infant but as a rule babies weighing less than twelve pounds can digest one ounce in the twenty-four hours and those over twelve pounds one and a half ounces. However, a great many less than twelve pounds can digest one and a half ounces in the twentyfour hours. The converse may also be
Enough water is added to make the proper amount of food, i. e., the total quantity in twenty-four hours which is determined by the quantity at each feeding and the number of feedings in twentyfour hours.
The rule for the quantity of food at each feeding is one to one-and-a-half ounces more than the months of the baby’s age; at three months give four to four and a half ounces, etc. It is never necessary to give more than eight ounces at a feeding.
As a general rule bottle-fed infants will thrive better through being fed every three hours for the first five or six months and after this every four hours. Up to the third month it is usually wise to continue the 1. a. m. feeding, but after this it should be dropped.
Special Preparations of Milk
PEPTONIZED milk is made by adding a certain amount of pancreatic ferment to cow’s milk and bringing the mixture to the body temperature for a given time. In view of recent knowledge it is extremely doubtful if peptonized milk has any virtues whatsoever. It, however, should never be employed except under the direction of a physician.
Buttermilk is sour milk from which the fat has been almost completely removed. It is usually obtained as a by-product in the process of making butter. It may, however, be made by souring either skim milk or whole milk depending on the amount of fat required.
Buttermilk and sour milk have been used as an article of diet from time immemorial. Its use is mentioned more than once in the Old Testament. It is, however, comparatively recently that it has been used in this country as a food for infants. In Holland, however, buttermilk has been used as a remedy for the summer diarrhoeas of infants for several hundred
In certain conditions, especially where fat is not well tolerated, buttermilk may be given to advantage. In diarrhoea, especially that form produced by overfeeding with fat, the use of buttermilk is often followed by brilliant results. Since buttermilk is usually prescribed for babies who stand fat badly, care should be taken to specify skimmed milk.
Buttermilk should always be made from clean milk and made fresh each day. It is better digested if the milk is first boiled before the lactic acid culture is introduced. Its food value may be increased by adding wheat flour,' or Phermalt Dextri-Maltose or even corn syrup.
Protein milk is a preparation made from cow’s milk and is probably the most effective weapon that a physician has at his disposal for treating cases of diarrhoea, and certain forms of indigestion in infants and young children. Its action depends upon the fact that most of the sugar and a moderate proportion of the fat are removed.
The principle in the preparation of the milk is the curding of whole milk with rennet and then straining off the whey (which contains the sugar) through cheese cloth. The whey is thrown away and the curds mixed with buttermilk, forming a smooth mixture like the original milk. To this is added a certain amount of water and the mixture is réady for use. On account of the many technical difficulties encountered in the preparation of this mixture in the private home a powder has been prepared which with proper dilution with water closely resembles the original formula. The results with the powder
have been found to be just as good as those obtained from the more complicated liquid preparations.
This corrective food should only be employed under the direction of a physician. Infants have been known to gain and thrive on this milk mixture for months and show perfect bone development but under ordinary circumstances it is employed only as a corrective food.
This preparation is known as Protein Milk Powder.
Patent or Proprietary Foods
THE foods on the market prepared for purposes of infant feeding are almost without number. From our knowledge of the composition of mother’s milk we learn whatare thenutritional elementsand approximately in what relative proportions these elements must exist in order to supply the child with the food which Nature intended him to have. The examination of the milk of thousands of nursing women shows that it ranges from two and a half to four per cent, fat; six to seven per cent, sugar and one to one and a half per cent, protein. These figures may be put down as the normal limits of human milk, and they are so, simply because the infant will thrive and grow when the nutritional elements in approximately the above proportions are supplied to him. It is within these limits that the food must be kept in order that there may be normal growth and development; though of course, wide variations from these may be of temporary occurrence. While the child may exist and temporarily do fairly well on a lower percentage of fat he will invariably show defective growth if the protein remains persistently less than one per cent. The chief disadvantage in the infant foods which are used without the addition of cow’s milk lies in the fact that they do not contain the nutritional elements as they exist in normal breast milk, and besides, of necessity, they are all cooked foods and in this heating process all or part of the so-called growth elements are removed.
It is not well to put too much reliance on the analysis published by some proprietary food manufacturer.
This type of food is decidedly weak in animal fat, for the reason that there is no means of keeping more than a small percentage of it in food without its becoming rancid. When considerable percentages are indicated in the analysis it is certain that it does not exist as butter fat. The quantity of animal milk protein is likewise deficient and what is present has been cooked, thus detracting materially from its value in infant nutrition. Both scurvy and rickets are not an infrequent result of the exclusive use of these foods.
These products are prepared by a special process in which the water is removed from the cow’s milk and it has been fairly well proven that the growth elements are present in full force. Dried whole milk is therefore a satisfactory food for infants, if given in proper dilutions under the supervision of a physician. They are especially useful as a temporary measure in cases of acute illness or in travelling. Some brands of whole milk powder (C. M. P.)may be employed along with solid food in feeding older children when fresh clean milk is not obtainable.
Not Really Foods
are not foods in the accepted meaning of the term, and if they are used alone independent of milk the patient will soon present a sorry spectacle. They are sugars largely, being composed of maltose and dextrin, which are derived from starch. Some contain a considerable quantity of unconverted starch. When added to the water and milk mixture, they furnish the soluble and insoluble carbohydrates in the form of maltose and free starch, and thus they fulfil this function in the food with as good results as, but usually no better than, would milk sugar and a cereal gruel. Maltose is a laxative sugar. In cases of constipation in the bottle-fed child it may replace the milk sugar in equal quantity and as such may be used with decided benefit in some cases. In other cases this change to maltose is without effect. The claim that when added to cow’s milk these proprietary foods increase the liability to scurvy is without foundation. If the milk is given uncooked, the child will not have scurvy, regardless of the nature of the sugar; if the
milk is heated to 160 degrees or 175 degrees F, the child may have scurvy regardless of the sugar.
The exploiting of photographs of crowing, fat, red-cheeked babies which are used to illustrate the supposed virtues of this or that manufacturer’s food, composed principally of maltose, is not a very high-minded procedure on the part of the manufacturer who thus stoops to steal the credit which belongs to a cow.
Giving the Baby Its Bottle
WHEN it is time to feed the baby take the cold bottle from the ice, do not pour out the milk, but place the bottle, still corked, in a vessel of warm water, having the water cover the bottle above the milk line, and allow the water to heat. Do not allow the water to boil, as that will make the milk too hot. To test the temperature of the milk, open the bottle and drop a little milk on the inner surface of the arm. If it feels comfortably warm to the mother’s skin, it will be right for the baby. If it has been made too hot, cool the bottle under running water. The mother should never put the nipple in her own mouth to test the temperature of the
milk, as an infection, such as a “cold” might easily be conveyed in this way from mother to baby. Put on one of the sterilized nipples from the jar. Handle the nipple only by the neck and do not touch the part that is to go into the baby’s mouth.
Hold the baby on the left arm in the same position as for breast feeding. The bottle should be held by the mother or nurse throughout the feeding and never propped on a pillow. It must be presented to the baby at such an angle that the neck of the bottle is kept continually filled and the baby is able to grasp the nipple squarely. The feeding should be finished in twenty minutes. If the baby eats greedily, withdraw the nipple for a moment several times during the feeding or, better still, make the hole in the nipple smaller. If he is sleepy, keep him awake until the bottle is finished. If, in spite of this, he falls asleep, remove the bottle and do not give another until the next feeding time. Babies like to nurse a little, then sleep a little, then take the bottle again but this should not be allowed as it unduly prolongs the feeding.
(Article No. 3 will appear in the Nov. 15 issue. It will deal with child's feeding after one year.)