Chapter XVI
.) As he expresses the milk by a squeezing and suction made possible only when the nipple is well back in his mouth, he must take into his mouth practically the entire pigmented area which surrounds the nipple. To do this he lies in the curve of his mother’s arm as she turns slightly to one side, and holds her breast away from his nostrils in order that he may breathe freely.
Sometimes even when other conditions are favorable, the baby is unable to nurse because of some physical disability. He may be too feeble; have a cleft palate or find suckling painful because of an abrasion of the mucous membrane which occurred when his mouth was bathed just after birth. The manner in which the baby nurses, therefore, may be significant and should be carefully noted and described to the doctor.
There is a difference of opinion among doctors concerning the interval between feedings which is most satisfactory. Some have the baby nurse every four hours and others every three hours during the early months of life. It is believed by some doctors that although a baby who is fed on a four-hour schedule may regain his birth weight more slowly than the baby who is fed every three hours, he suffers less from digestive disturbances and ultimately makes an entirely satisfactory gain in weight. Another point in favor of the four-hour interval is the longer period of freedom which this gives to the mother and this may influence her willingness to nurse her baby. But other doctors, both pediatricians and obstetricians, feel that the four-hour interval is too long for most babies.
Whether the baby shall nurse from one or both breasts at each feeding is another moot question. Some doctors believe that the results are better if both breasts are partially emptied at each nursing, while others feel that the function of the breasts is more satisfactorily promoted by completely emptying one breast at a time, at alternate nursings. Although the baby should pause every four or five minutes to prevent his nursing too rapidly, which is a common cause of colic, neither he nor his mother should be allowed to sleep during the nursing periods. When he has finished, he should be taken up very gently and placed in his crib and left to sleep. If he is nursing satisfactorily, he will be sleepy and contented after nursing and will sleep for two or three hours afterwards; he will seem generally good humored and comfortable while awake; he will have good color; gain weight steadily and have two or three normal bowel movements daily. The normal stool in breast fed babies is bright yellow, smooth and with no evidences of undigested food.
If he is not being adequately nourished, he will present exactly the opposite picture, in some or all of these respects. He will be unwilling to stop nursing after the normal length of time and will give evidence of not being satisfied when taken from his mother. He may be listless and fretful and sleep badly. He will not gain weight as he should, and he may vomit or have colic after nursing.
To ascertain whether or not such a baby is getting enough milk it is customary to weigh him, without undressing him, before and after each nursing. Each fluid ounce of food will increase his weight one ounce. If the baby is not getting a normal amount of milk at each nursing he is often given enough modified milk after each meal to supply the deficit, but at the same time an effort is made to increase the supply of breast milk by improving the mother’s personal hygiene.
The amount which the baby needs at each feeding varies, not only according to his weight and age, but also according to his vigor and
## activity, and must always be figured for the individual baby. A very
general estimate of the amount taken by the average well baby at each feeding, is about as follows:
First week 1½ to 2½ ounces Second and third week 2 to 4 ounces Fourth to ninth week 3 to 4½ ounces Tenth week to fifth month 3½ to 5 ounces Fifth to seventh month 4½ to 6½ ounces Seventh to twelfth month 6½ to 9 ounces
=Artificial Feeding.= There is no entirely adequate substitute for satisfactory maternal nursing, and any other food that is given to the young baby is at best a makeshift. Considering the baby’s delicacy, therefore, and his urgent needs, no pains should be spared to make any artificial food which is given to him as satisfactory as possible. In preparing and giving artificial food it must be borne in mind that normal breast milk:
1. Is exactly right in quantity, quality and proportion.
2. Is fresh, clean and sweet.
3. Is free from bacteria.
4. Tends to protect the baby from infection.
5. Definitely protects him from certain nutritional diseases.
Cows’ milk, suitably modified, is apparently the best available substitute for mother’s milk, but it must first meet certain requirements and then be handled with scrupulous cleanliness and care, if it is to be at all satisfactory.
The requirements are that the milk shall be:
1. Whole milk. It must not be altered by the removal of cream nor the addition of such preservatives as salicylic acid, formaldehyde or boracic acid.
2. Its composition must not vary greatly from day to day.
3. It must be clean and free from disease germs; other organisms should not be present in excessive numbers.
4. It must be fresh: less than 24 hours old when it is delivered.
All of this means that the milk must come from a herd of healthy, tuberculin-tested cows. The milk from a single cow may vary markedly from day to day but that from several cows is nearly constant. The stables and the cows must be kept clean, the udders carefully washed before each milking; the milkers themselves must wear freshly washed clothing, scrub their hands thoroughly and milk into sterile receptacles; the milk must be immediately covered and cooled to a temperature of 45° F. or 50° F. and kept there.
Milk produced under such conditions is usually described as “certified milk” and is often prescribed as infant food without being pasteurized or sterilized. But if there is any doubt about the source of the milk and the method of its handling, it should be strained into a clean receptacle through filter paper or a thick layer of absorbent cotton and subsequently boiled or pasteurized.
When the nurse is in a position to offer advice about the baby’s milk she must explain the importance of always obtaining the freshest, cleanest and purest milk possible, no matter what it costs.
Whether certified or not the milk must always be placed in the refrigerator or some other place at a temperature of 50° F. as soon as it is received and _it must be kept cool and clean_. Mother’s milk, which is being imitated, is clean and sweet and free from disease germs.
Keeping the milk cool means keeping it at a temperature of 50° F. Keeping it clean implies cleanliness of the milk itself, the utensils, the nurse’s hands and the destruction, by sterilization or pasteurization, of disease germs. Those which are likely to be present in infected milk are streptococci, tubercle bacilli, colon bacilli, germs of typhoid, diphtheria and scarlet fever.
The amounts and proportions of the constituents of the substitute feeding will be specified by the doctor, as well as the intervals between feedings and the amount to be given each time. But the doctor’s careful adjustment of the milk formula to the baby’s immediate needs and digestive powers will be set at naught unless the nurse is absolutely _accurate_ in preparing and giving the milk.
The nurse’s invariable responsibility, therefore, is to keep the milk _cool_ and _clean_ and prepare and give it _accurately_.
The nurse will appreciate the necessity and principles of modifying cows’ milk for the human infant if she will consider for a moment, the differences between mother’s milk and cows’ milk, as indicated by the following table, and the reasons for these differences:
_Mother’s Milk._ _Cows’ Milk._ Fats 3.5 to 4. % 3.5 to 4. % Sugar 6.5 to 7.5% 4.5 to 4.75% Proteins 1. to 1.5% 3.5 to 4. % Salts .2% .7 to .75% Water 87 to 88. % 87. %
It will be remembered that the tissues and bony skeleton are built by the proteins and salts (lime and phosphorus). Accordingly Nature supplies these in greater abundance to the calf, who grows so fast as to double his birth weight in about 47 days, than to the baby who scarcely doubles his within 180 days. The calf begins life with a physical need for the abundance of proteins and salts which are present in cows’ milk, and with digestive organs that can cope with them, but the baby needs less, can digest less and therefore must be given less. There are, of course, other and finer differences between the two milks and an attempt is sometimes made to meet these. For example, mother’s milk is slightly alkaline and cows’ milk slightly acid and the curd of cows’ milk is larger, tougher and harder to digest than that formed by mother’s milk. Accordingly some doctors add lime water to cows’ milk to make it alkaline, and render the curd softer, finer and more digestible by boiling it.
It is often not possible to give a bottle-fed baby the full 4% of fat which mother’s milk contains, and some doctors make the protein of the artificial mixture very much larger in amount than is found in human milk. The nurse will see that this is a matter which can be decided only by the physician.
=Articles Needed in Preparing the Baby’s Food.= A complete equipment for preparing and giving the baby’s milk should be assembled, kept in a clean place, separate from utensils in general use, and never put to any other service. A satisfactory outfit for this purpose comprises the following articles:
One dozen graduated nursing bottles. One dozen nipples. Clean, new corks or a package of sterile, non-absorbent cotton for stoppers. Bottle brush. Covered kettle, capacity one gallon, for boiling bottles and possibly pasteurizing milk. Pasteurizer or wire bottle rack. Small kettle, about one quart size. Graduated pint or quart measuring glass. Pitcher, two quart size. Long-handled spoon for mixing. Funnel. Measuring spoons—table and tea sizes. Double boiler. Thermometer which will register at least 212° F. Cream dipper (if ordered). Two small covered jars for sterile and used nipples. Sugar (lactose, maltose or cane sugar according to orders). Lime water, if ordered.
Utensils of enamel or aluminum ware are probably the most satisfactory ones to use as they are easily kept clean, while bottles with wide mouths and curved bottoms and inner surfaces can be thoroughly washed more easily than those with small necks and sharp corners. Nipples that can be turned inside out to be washed should be selected as it is almost impossible to clean thoroughly those with tubes or narrow necks. New bottles will be rendered less breakable if placed in cold water, which is gradually heated, allowed to boil for half an hour and cooled before the bottles are removed.
[Illustration:
FIG. 168.—Preparing the baby’s milk. (From photograph taken at Johns Hopkins Hospital.) ]
The bottles should be rinsed with cold water after each feeding and then carefully washed and scrubbed with the bottle brush in hot soapsuds or borax water, containing two tablespoonsful to the pint. They may be kept full of water while not in use or rinsed with hot water and stood upside down until they are all boiled on the following morning, preparatory to being filled with the freshly prepared milk. The baby’s bottles should never be washed in dishwater nor dried on a towel. The nipples should be rinsed in cold water, turned inside out and scrubbed with a brush, in hot soapsuds or borax water; rinsed and placed in a jar ready to be boiled with the bottles.
=Preparation of Milk.= The full quantity of milk which the baby will take in the course of twenty-four hours is prepared at one time and the prescribed amount for each feeding poured into as many separate bottles as there will be feedings. (Fig. 168.)
The nurse should first boil for five minutes all of the articles that will come in contact with the milk, including the full number of bottles and nipples and the jars in which the nipples are kept; remove them with the long-handled spoon without touching the edges or inner surfaces and place them on a clean table, dropping the nipples into one of the sterile jars.
She should wash the mouth of the milk bottle before removing the cap and pour the amount which the formula calls for into the sterile pitcher. To this is added the sterile water in which the sugar has been dissolved in the glass graduate, and the potato or barley water, the lime water or soda solution as ordered. This mixture is thoroughly stirred and the amount for one feeding at a time measured in the graduate and poured into the specified number of bottles which are then stoppered.
If certified milk is used for the milk mixture it is often given to the baby without being pasteurized, in which case the bottles are placed in the refrigerator as soon as they are filled and stoppered. Very frequently, however, the milk is sterilized or pasteurized. The nurse will feel surer of keeping the mouths of the bottles clean if she covers them with squares of gauze or muslin before they are sterilized, holding the caps in place with tapes or rubber bands. Pasteurization as applied to infant feeding consists of heating the milk to 140–165° F. and keeping it at that temperature 20 to 30 minutes.
There are many excellent pasteurizers for home use on the market, or entirely satisfactory results may be obtained by using a wire bottle rack (See Fig. 168) and the large kettle already provided. One method is to place the rack containing the bottles in the kettle which is filled with cold water to a level a little above the top of the milk in the bottles, and allow the water to come to the boiling point. The kettle is removed from the fire, covered tightly and the bottles allowed to stand in the hot water for twenty minutes. Cold water is then run into the kettle to cool the milk gradually and avoid breaking the bottles, after which they are placed in the refrigerator, well or spring-house and kept at a temperature of 50° F. until they are taken out one at a time for feedings. If a wire rack is not available the bottles may be stood on a saucer or a thick pad of folded newspapers in the bottom of the kettle.
Pasteurization does not destroy all germs that may be in the milk, but it kills the more important ones and apparently impairs the nutritive and protective properties of the milk less than boiling. However, pasteurized milk must be kept cold and must be used within twenty-four hours, for the nurse will recall that aging of milk is quite as undesirable as souring.
Scalding is another method of destroying germs in milk. The milk is placed in an open vessel and the temperature raised to about 180° F., or until bubbles appear around the edge and the milk steams in the centre, after which it is cooled and kept at a temperature of 50° F.
Many doctors prefer to have the baby’s milk boiled, since boiling insures absolute sterilization and also renders the curd more digestible. Other changes are produced by boiling, however, which make it important to add an anti-scorbutic and cod-liver oil to the baby’s diet at an early date.
Milk may be boiled directly over the flame for a time varying from three to forty-five minutes, or it may be placed in a double boiler, the water in the lower receptacle being cold, and allowed to remain until the water has boiled from six to forty-five minutes. All of these points are definitely specified by the doctor.
When milk is boiled or scalded the other ingredients are added beforehand, as a rule, after which it is measured and poured into the bottles. Or the milk mixture may be poured into the bottles as for pasteurization and the bottles kept in the actively boiling water for any desired length of time.
=Giving the Baby His Bottle.= At feeding time, the bottle should be taken from the refrigerator, the stopper removed and a nipple taken up by the margin and put on the bottle without touching the mouthpiece. The milk is brought to a temperature of about 100° F. by standing the bottle in a deep cup or kettle of warm water and placing it on the fire. The temperature of the milk may be tested by dropping a few drops on the inner side of the wrist or forearm where it should feel warm but not hot. This dropping will also indicate if the hole in the nipple is of the proper size to allow the milk to drop rapidly in clean drops but not to pour. If the hole is too small, the drops will be small and infrequent and the baby will be obliged to work too hard to obtain it; while if the hole is too large the baby will feed too rapidly and may have colic as a result.
[Illustration:
FIG. 169.—Proper position in which to hold baby and bottle during feeding. ]
The baby’s diaper should be changed if it is soiled or wet before he is given the bottle and he should be held comfortably in a reclining position on the nurse’s arm while she holds the bottle with her free hand. (Fig. 169.) The bottle should be inclined sufficiently to keep the neck full of milk; otherwise the baby may draw in air as he nurses. He should be kept awake while feeding but he should be allowed to pause every three or four minutes in order not to take his milk too rapidly. Not less than ten nor more than twenty minutes is devoted to a feeding, as a rule, and if the baby refuses a part of his milk, it should be thrown away; never warmed over for another time.
[Illustration:
FIG. 170.—Holding the baby upright and gently patting his back to bring up air immediately after feeding. ]
After being fed, the baby should be held upright against the nurse’s shoulder for a moment or two (Fig. 170), and ever so gently patted on the back to help bring up any air which he may have swallowed. He should on no account be rocked or played with after taking the bottle, but should be placed gently in his crib, warm and dry and left alone to sleep. Turning him or moving him about even to the extent of changing his diaper at this time may cause vomiting.
The evidences of satisfactory and unsatisfactory feeding in the bottle-fed baby are about the same as in the baby who is fed at the breast, except that the gain in weight on artificial food may be a little slower and less steady than on maternal nursing; the stools have a characteristic sour odor; are a little lighter in color and may contain white lumps of undigested fat; are usually dryer than in breast-feeding and may be formed in even a very young baby.
It is fairly generally agreed that all babies, whether breast-fed or on the bottle, require a certain amount of cool boiled water to drink between feedings. A small amount is given at first and gradually increased according to the doctor’s instructions, and it may be given from a bottle, a medicine dropper or poured slowly from the tip of a teaspoon.
=Ingredients of the Baby’s Food.= In referring to the ingredients of the baby’s food we cannot use the terms “sugar” or “milk” as though they indicated definite and unvarying materials.
There are three kinds of sugar which are commonly used in modified milk: cane or granulated sugar; lactose or milk sugar and maltose. _Cane sugar_, the one most widely used, is the least expensive of the three and it apparently is satisfactory for most babies. _Lactose_ is fairly expensive and while it causes diarrhea in some babies, others digest it more easily than cane sugar. Lactose is lighter than cane sugar, three spoonfuls being equal in weight to two of cane sugar. The _maltose_-dextrine preparations are easily digested and somewhat laxative. Some babies gain more rapidly when maltose constitutes part of the sugar in their food than when only lactose is used.
The question of milk is somewhat complicated and though the doctor will specify what percentage of fat shall be in the milk which is used in each case, the nurse must know how to obtain it from the milk at her disposal. If the formula is made up with “whole milk,” which contains 4 per cent. fat, the bottle in which it was delivered should be turned upside down and shaken vigorously in order that the cream which has risen to the top may be redistributed evenly throughout the fluid.
If the doctor employs what is termed “percentage feeding,” he may use whole milk, skimmed milk, or top milk. What he is endeavoring to do is to prepare a food which contains definite known percentages of the different ingredients, fat, carbohydrates and protein. Where a mixture is desired which contains more fat than it does protein, the milk to be employed is obtained by discarding a certain amount from the bottom of the jar of milk, the remainder being then called “top milk.” When he wishes the fat to be lower than the protein percentage, he discards some of the top milk in the jar, using the rest, which is then a partially skimmed milk. The upper 2 ounces in a quart bottle of milk contains 24 per cent. fat; the upper 8 ounces is 12 per cent. fat; the upper 16 ounces is 8 per cent. fat and the upper 24 ounces is 5 per cent. fat. If the formula calls for 6 ounces of the upper 8 ounces of milk, therefore, the nurse will see that it is very important that she remove the full 8 ounces and use 6 ounces of the milk which she has removed and not simply take the upper 6 ounces, as this would contain a higher percentage of fat than is ordered. (Figs. 171, 172, Dr. Griffith’s tables of fat percentages.)
Top milk may be removed by tipping the bottle gradually and slowly pouring the designated amount into a measuring glass, or it may be removed by pushing a cream dipper, especially made for this purpose and holding one ounce, down into the bottle until the cream flows in. Another method is to syphon off the lower milk through a bent glass tube, leaving in the bottle the desired amount of top milk.
Many doctors feed the baby according to his caloric needs and prepare the formula from whole milk, sugar and water, determining the amounts of each according to the age and weight of the baby.
Under any condition it is so necessary that the amount and composition of each baby’s food be adjusted to his needs, that it is not considered possible to make out any formulae or feeding schedules which would be safe or satisfactory for general use.
Ready Method for Selecting Amounts to be Employed in Making Various 20–Oz. Milk-Mixtures, and the Caloric Values Resulting
[Illustration:
READY METHOD FOR SELECTING AMOUNTS TO BE EMPLOYED IN MAKING VARIOUS 20–OZ. MILK-MIXTURES, AND THE CALORIC VALUES RESULTING
┌────────────────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┐ │ Percentages │Lower│Lower│Lower│Whole│Upper│Upper│Upper│Upper│ │ desired of │8 oz.│ 16 │ 28 │Milk │ 24 │ 20 │ 16 │ 10 │ │ │ │ oz. │ oz. │ │ oz. │ oz. │ oz. │ oz. │ │ │ │ │ │ │ │ │ │ │ ├───┬─────┬──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │Fat│Sugar│Prot’n│ │ │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │0.5│5 │1 │ │ │ 5 │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │0.5│6 │2 │ │10 │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1 │6 │1 │ │ │ │5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1 │6 │1.5 │2.5 │ │ │5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1 │6 │2 │ │ │10 │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1.5│6 │1 │ │ │ │ │ │5 │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1.5│6 │1.5 │ │ │ │7.5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2 │6 │1.5 │2.5 │ │ │ │ │ │5 │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2 │6 │2 │ │ │ │10 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2.5│6 │1.5 │2.5 │ │ │ │ │ │ │5 │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2.5│6 │2 │ │ │ │ │10 │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2.5│6 │2.5 │ │ │ │12.5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │1 │ │ │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │1.5 │2.5 │ │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │2 │ │ │ │ │ │10 │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │3 │ │ │ │15 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │4 │4 │4 │ │ │ │20 │ │ │ │ │ └───┴─────┴──────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┘
┌────────────────┬─────┬─────┬─────┬───────┬────────┐ │ Percentages │Upper│Water│Sugar│Caloric│Calories│ │ desired of │8 oz.│ oz. │ oz. │ Value │per oz. │ │ │ │ │ │ of │ │ │ │ │ │ │Mixture│ │ ├───┬─────┬──────┼─────┼─────┼─────┼───────┼────────┤ │Fat│Sugar│Prot’n│ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │0.5│5 │1 │ │15 │0.8 │175 │ 8.75 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │0.5│6 │2 │ │10 │0.8 │225 │11.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1 │6 │1 │ │15 │1 │225 │11.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1 │6 │1.5 │ │12.5 │0.9 │237.5 │11.88 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1 │6 │2 │ │10 │0.8 │250 │12.5 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1.5│6 │1 │ │15 │1 │250 │12.5 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1.5│6 │1.5 │ │12.5 │0.9 │262.5 │13.13 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2 │6 │1.5 │ │12.5 │0.9 │287.5 │14.38 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2 │6 │2 │ │10 │0.8 │300 │15 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2.5│6 │1.5 │ │12.5 │0.9 │312.5 │15.63 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2.5│6 │2 │ │10 │0.8 │325 │16.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2.5│6 │2.5 │ │7.5 │0.7 │337.5 │16.88 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │1 │5 │15 │1 │325 │16.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │1.5 │5 │12.5 │0.9 │337.5 │16.88 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │2 │ │10 │0.8 │350 │17.5 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │3 │ │5 │0.4 │375 │18.75 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │4 │4 │4 │ │0 │ │400 │20 │ └───┴─────┴──────┴─────┴─────┴─────┴───────┴────────┘
FIG. 171. Table of fat percentages, by permission, from “The Diseases of Infants and Children,” by J. P. Crozer Griffith, M.D.
]
* * * * *
[Illustration:
───────────────────────────────────────────────────── TABLE GIVING APPROXIMATE PERCENTAGE-STRENGTHS OF DIFFERENT LAYERS OF MILK
Per cent. Per cent. Ratio Fat Protein and Sugar Upper 2 oz. 24 4 6 to 1 Upper 4 oz. 20 4 5 to 1 Upper 6 oz. 16 4 4 to 1 Upper 8 oz. 12 4 3 to 1 Upper 10 oz. 10 4 2.5 to 1 Upper 16 oz. 8 4 2 to 1 Upper 20 oz. 6 4 1.5 to 1 Upper 24 oz. 5 4 1.25 to 1 Upper 32 oz. whole milk 4 4 1 to 1 Lower 30 oz. 3 4 .75 to 1 Lower 28 oz. 2 4 .50 to 1 Lower 16 oz. 1 4 .25 to 1 Lower 8 oz. 0.5 4 .0 to 1 ─────────────────────────────────────────────────────
* * * * *
TO FIND THE AMOUNT OF ANY LAYER OF MILK TO BE USED TO GIVE PERCENTAGES DESIRED
Equation:
Total amount of food × Percentage of fat desired Amount of ———————————————————————————————————————————————— = this milk in Fat-strength of layer of milk used the mixture.
(1) Select from the “Layers of Milk” Table the milk which possesses the desired ratio of fat to protein.
(2) Substitute in the equation.
(3) As the sugar-percentage has been reduced equally with that of the protein, add sufficient sugar to raise to the desired percentage.
EXAMPLE: 20–oz. mixture desired. Percentages desired = Fat 3, Sugar 6, Protein 1. Use upper 8 oz. (fat 12%, protein 4%, viz.: 3:1). Then 20 × 3/12 = 5 oz. of upper 8 oz., with 15 oz. of water in the 20–oz. mixture. The protein necessarily becomes 1%, and the sugar likewise. The mixture already containing 1% of sugar, add 5% of 20 oz., i. e., 1 oz. of sugar to increase this to the 6% desired.
* * * * *
TO DETERMINE THE PERCENTAGES PRESENT IN ANY MILK-MIXTURE ALREADY IN USE
Quantity of substance used (milk, cream, or skimmed milk) × Its percentage-strength ————————————————————————————— = Percentage of element Total Quantity of Food (F., S. or P. in the mixture.)
EXAMPLE: The mother has mixed: Upper 8 oz.; 6 oz.—Lower 8 oz.; 3 oz.—Milk-sugar 3 level tablespoonfuls.—Water 27 oz. Total quantity = 36 oz. The upper 8 oz. contains 12% fat (see Table). Both top and bottom milk contain 4% protein and sugar. Three tablespoonfuls sugar = approximately 1 oz. The fat of the lower 8 oz. may be ignored. Then 6 × 12/36 = 2 = Fat percentage from the top-milk. 3 × 0/36 = 0 = Fat-percentage from the bottom milk. 9 × 4/36 = 1 = Protein and sugar percentages from combined top and bottom milk. The 1 oz. additional sugar divided by 36 = approximately 3% sugar added. There being already 1% sugar derived from the milk, the total sugar = 4%.
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FIG. 172. Reverse side of card in Fig. 171.
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Moreover, it does not ordinarily devolve upon the nurse to do more than prepare and give the baby’s food as ordered by the doctor, but situations sometimes do arise when the doctor is not within reach which the nurse must meet as best she can. In such an emergency she might be guided by the following suggestions contained in a pamphlet entitled, “Save the Babies,” prepared by Dr. L. Emmet Holt and Dr. H. K. L. Shaw and published by the American Medical Association, remembering that they are intended for the average, normal baby and are not necessarily suitable for all babies:
“The simplest plan is to use whole milk (from a shaken bottle) which is to be diluted according to the child’s age and digestion.
“Beginning on the third day, the average baby should be given 3 ounces of milk daily, diluted with seven ounces of water. To this should be added one tablespoonful of lime water and 2 level teaspoonfuls of sugar. This should be given in seven feedings.
“At one week, the average child requires 5 ounces of milk daily, which should be diluted with 10 ounces of water. To this should be added 1½ even tablespoonfuls of sugar and one ounce of lime water. This should be given in seven feedings.
“The milk should be increased by ½ ounce about every 4 days.
“The water should be increased by ½ ounce about every 8 days.
“At three months the average child requires 16 ounces of milk daily, which should be diluted with 16 ounces of water. To this should be added 3 tablespoonfuls of sugar and 2 ounces of lime water. This should be given in 6 feedings.
“The milk should be increased by ½ ounce about every 6 days.
“The water should be reduced by ½ ounce about every 2 weeks.
“At 6 months the average child requires 24 ounces of milk daily, which should be diluted with 12 ounces of water. To this should be added 2 ounces of lime water and 3 even tablespoonfuls of sugar. This should be given in 5 feedings.
“The amount of milk should be increased by ½ ounce every week.
“The milk should be increased only if the child is hungry and digesting his food well. It should not be increased unless he is hungry, nor if he is suffering from indigestion even though he seems hungry.
“At 9 months, the average child requires 30 ounces of milk daily, which should be diluted with 10 ounces of water. To this should be added 2 even tablespoonfuls of sugar and 2 ounces of lime water. This should be given in 5 feedings.
“The sugar added may be milk sugar or, if this cannot be obtained, cane (granulated) sugar or maltose (malt sugar).
“At first plain water should be used to dilute the milk.
“At three months, sometimes earlier, weak barley water may be used in the place of plain water; it is made with ½ level tablespoonful of barley flour to 16 ounces of water and cooked 20 minutes.
“At six months the barley flour may be increased to 1½ even tablespoonfuls, cooked in the 12 ounces of water.
“At nine months, the barley flour may be increased to 3 level tablespoonfuls, cooked in the 8 ounces of water.
“A very large baby may require a little more milk than that allowed in these formulas. A small delicate baby will require less than the milk allowed in the formulas.”
These formulas may be tabulated as follows:
────────┬────────┬────────┬────────────┬────────────┬────────────── Age │ Milk │ Water │Barley-Water│ Lime-Water │ Sugar ────────┼────────┼────────┼────────────┼────────────┼────────────── │ │ │ │ │ ════════╪════════╪════════╪════════════╪════════════╪══════════════ 3–7 days│ 3 ozs.│ 7 ozs.│ 16 ozs. │ ½ ozs.│2 teaspoons 2d week │ 5 ozs.│10 ozs.│ 15 ozs. │ 1 ozs.│1½ tablespoons 3d week │ 6 ozs.│10½ ozs.│ 14 ozs. │ 1 ozs.│1½ tablespoons 1 month │ 7 ozs.│11 ozs.│ 12 ozs. │ 1 ozs.│2 tablespoons 2 month │11 ozs.│13 ozs.│ 12 ozs. │ 1½ ozs.│2½ tablespoons 3 month │16 ozs.│ │ 11 ozs. │ 2 ozs.│3 tablespoons 4 month │19 ozs.│ │ 10 ozs. │ 2 ozs.│3 tablespoons 5 month │21½ ozs.│ │ │ 2 ozs.│3 tablespoons 6 month │24 ozs.│ │ │ 2 ozs.│3 tablespoons 7 month │26 ozs.│ │ │ 2 ozs.│3 tablespoons 8 month │28 ozs.│ │ │ 2 ozs.│2½ tablespoons 9 month │30 ozs.│ │ │ 2 ozs.│2 tablespoons ────────┴────────┴────────┴────────────┴────────────┴──────────────
────────┬───────────────┬──────────────── Age │No. of feedings│ Hours ────────┼───────────────┼──────────┬───── │ │ Day │Night ════════╪═══════════════╪══════════╪═════ 3–7 days│ 7 │6–9–12–3–6│10–2 2d week │ 7 │6–9–12–3–6│10–2 3d week │ 7 │6–9–12–3–6│10–2 1 month │ 7 │6–9–12–3–6│10–2 2 month │ 7 │6–9–12–3–6│10–2 3 month │ 7 │6–9–12–3–6│10–2 4 month │ 6 │6–9–12–3–6│10 5 month │ 6 │6–9–12–3–6│10 6 month │ 5 │6–10–2–6 │10 7 month │ 5 │6–10–2–6 │10 8 month │ 5 │6–10–2–6 │10 9 month │ 5 │6–10–2–6 │10 ────────┴───────────────┴──────────┴─────
=Mixed Feeding.= Under some conditions the breast-fed baby is given also a certain amount of modified milk, and this combination of natural and artificial feeding is termed mixed or supplementary feeding.
A deficiency in the breast milk, ascertained by weighing the baby before and after each nursing, may be supplied by following each nursing with a bottle feeding; or one or two breast-feedings, in the course of the day may be replaced by entire bottle feedings. In any case the milk mixture to be used as supplementary feeding is prepared with exactly the same painstaking care as is the milk for entire artificial feeding.
If supplementary food is given because of an inadequate supply of breast milk, it is of great importance that the baby be put to the breast regularly, no matter how little food he obtains, for his suckling is the best possible means of stimulating the breasts to secrete more milk and of equal importance is the fact that they will tend to dry up if the baby nurses less than about five times in twenty-four hours. Moreover, even a little breast milk is valuable to him and he should have the benefit of all there is to be had.
An entire bottle feeding is sometimes given to a baby who is nursing satisfactorily at the breast, in order to give his mother an opportunity to take longer outings than are possible between the regular nursings. And sometimes it is to the mother’s advantage, and therefore to the baby’s, to give him a bottle during the night and thus allow her to sleep undisturbed.
COMMERCIAL BABY FOODS
Since the baby’s food is prescribed by the doctor, the nurse has little concern with the various proprietary baby foods and the canned and powdered milks which are so persuasively advertised to young mothers. It is hoped, however, that the discussions on nutrition in general and on baby feeding in particular, have made it clear to the nurse that these foods cannot be expected to be satisfactory if used as a sole article of diet throughout the bottle-feeding period.
There are many times and circumstances, however, when the temporary use of a prepared infant food or canned or powdered milk is advantageous. In some cases of intestinal disturbance, for instance, or while the mother is traveling and is unable to have freshly prepared milk formulas supplied to her along the way; during the summer, while staying at a hotel or boarding house where the freshness, cleanliness or purity of the milk are uncertain; or during a sudden shortage of fresh milk, as may occur during a strike or severe storm when transportation is interfered with, a proprietary food may be a great boon.
If the nurse is confronted with the necessity of choosing and making temporary use of a prepared food she may be guided by considering the general principles of baby feeding and the character of the materials at her disposal.
=The Proprietary Foods= may be divided into two general groups: one kind contains milk powder and is usually added to water while the other consists largely of sugar and starch and is added to fresh milk before being given to the baby.
=Canned Milk= is of two kinds; evaporated, which is unsweetened, and condensed, which is sweetened. _Evaporated milk_ is whole milk from which part of the water has been removed, the milk then being canned and sterilized. The addition of water to evaporated milk restores it to the composition of whole milk in many respects, but it is still milk that has been heated. _Condensed milk_ is evaporated milk to which cane sugar has been added to aid in its preservation. Since bacteria do not grow well in highly sweetened foods, it is not necessary to bring sweetened condensed milk to as high a temperature as the unsweetened product, to prevent subsequent bacterial decomposition. The high percentage of sugar in condensed milk quite obviously renders it unsuitable for continuous use as the sole article in a baby’s dietary.
=Milk Powders or Dried Milks= are prepared by rapidly evaporating the water from whole milk, skimmed milk or partly skimmed milk, leaving the solid constituents in the form of a light, white powder. Milk powder readily dissolves in water, forming a “reconstructed milk” which closely resembles the fresh milk from which it was prepared. But it must not be forgotten that reconstructed milk has been heated. Many doctors consider whole milk powder the most satisfactory form of preserved milk which is available for baby food. Should it be used, however, the importance of keeping it tightly covered and in a cold place must be recognized, for the presence of fat renders it likely to become rancid if not kept cold.
ARTICLES OF FOOD WHICH ARE SOMETIMES INCLUDED IN THE BABY’S DIETARY
=Barley Water=, sometimes used to dilute whole milk, is made by mixing the barley flour to a smooth paste in cold water, adding boiling water and boiling for twenty minutes or cooking in a double boiler for an hour, straining and adding enough water to replace the amount lost in cooking. The proportions for different ages are as follows:
Three months, ½ level tablespoonful barley flour to 16 oz. water Six months, 1½ level tablespoonful barley flour to 12 oz. water. Nine months, 3 level tablespoonfuls barley flour to 10 oz. water.
=Potato Water.= One tablespoonful of thoroughly boiled potato is mashed into one pint of the water in which the potato was boiled and carefully strained.
=Spinach.= Spinach is carefully washed, steamed for half an hour and mashed through a fine sieve. It is sometimes started at the sixth month; one teaspoonful daily, gradually increased to one or two tablespoonfuls daily.
=Orange Juice.= The orange should be dipped in boiling water and wiped on a clean towel before being cut and squeezed, to avoid possible infection of juice. It is usually given to babies getting heated milk, sometimes as young as one month old. It is carefully strained and started gradually by giving one teaspoonful in water once or twice daily between feedings and increasing to ½ or 1 ounce by the sixth month and 1½ to 2 ounces by the end of the first year.
=Infusion of Orange Peel.= This is sometimes used instead of orange juice, and is made by boiling one ounce of finely grated orange peel in two ounces of water, adding a little sugar to counteract the bitter taste and adding enough sterile water to bring it up to two ounces.
=Tomato Juice.= Canned tomato strained through a fine sieve, is sometimes given to a baby a few weeks old, starting with one dram and gradually increasing to four to six ounces daily.
=Whey.= One quart of whole milk heated to 98° F. or 100° F. and one-half ounce of liquid rennet or one junket tablet stirred into it and allowed to stand half an hour or until firm and solid, is poured into a cheese-cloth bag and allowed to drain for about an hour without being squeezed.
=Protein Milk.= The curd from one quart of milk, which remains after the whey is drained, as directed above, is mashed through cheese-cloth in a fine wire sieve, with a potato-masher or bowl of a spoon and the curd washed through with one pint of water. A pint of buttermilk is added and the mixture boiled while being stirred constantly. This is sometimes given in diarrhea.
=Beef Juice.= One pound of thick round steak, slightly broiled, is cut into small pieces and the juice expressed with a meat press or a lemon squeezer, the amount varying from 2 to 3 ounces. It may be diluted with an equal amount of warm water, or slightly warmed by being placed in a cup standing in hot water, and salted to taste.
=Broths.= One pound of lean meat, all fat and gristle removed, is allowed to one pint of water. The meat is cut finely and put on in cold water, heated slowly and allowed to simmer for three or four hours, when water is added to replace what was lost in cooking. It is strained, the fat removed and slightly salted.
=Oatmeal Water.= Two level tablespoonfuls of oatmeal in a pint of boiling water is cooked in a double-boiler for two hours, strained and enough boiling water added to replace the amount lost in cooking.
TRAVELING
[Illustration:
FIG. 173.—The baby will travel comfortably in a basket converted into a bed. (Courtesy of the Maternity Centre Association.) ]
The difficulties of traveling with a young baby may be greatly lessened by making certain preparations. If the baby is bottle-fed, the preparations will depend upon the length of the journey and whether or not it will be possible to have freshly prepared feedings, for each twenty-four hours, put on the train from laboratories along the way. If this is not possible and the journey is not to take more than twenty-four hours, the entire quantity of food, ice cold, may be carried in a thermos bottle. The requisite number of sterile nursing bottles may be taken or one bottle which is boiled before each feeding. Or the milk may be prepared as usual and the bottles packed in a portable refrigerator. Such a refrigerator may be bought or one may be improvised. The bottles are placed in a covered pail and packed solidly in crushed ice; this is placed in a second pail or a box with a diameter which is at least two inches larger than the inner pail and the space between the two packed firmly with sawdust. Several thicknesses of newspapers should be pressed down over the top and a tight cover fitted to the outer receptacle.
The sterile nipples may be taken in a sterile jar and a deep cup or kettle will be needed in which to warm the bottle before each feeding. It is usually possible to obtain water on the train which is hot enough for this, or cans of solid alcohol, a stand and a metal tray may be added to the traveling outfit. If fresh formulae cannot be delivered to the train, daily, and the journey is to last more than twenty-four hours, one of the proprietary foods or a powdered milk will often prove to be a satisfactory solution to the problem of feeding.
The baby will usually travel more comfortably and sleep better if he is carried in a basket. A large market basket with a handle or a small clothes basket will serve. It may be lined with a sheet or a blanket; have a small hair pillow or folded blanket in the bottom and be made up like a crib. (Fig. 173.) If this basket stands on the car seat during the day, and on the foot of the nurse’s berth at night, the baby will be cleaner, quieter and less exposed to drafts than if carried in the arms.
THE PREMATURE BABY
All of the precautions and gentleness which are necessary in the care of the normal baby, born at term, must be greatly increased in caring for the baby who is born prematurely.
As was explained in