MOTOoWBS If I WEnB KIKQ Ir I were Else of Engliad, \VIiat lots of (htnes Id do i \niat plans 1 d tnelo, Wliat p(una I d take. To bare thinge mce for 70a Tint I would lasuo orders That, to all Borta and raidca Of gula and boys. All sweets and toys Were sold for * please ** and ' thanks ** Chnstmas would happen onee a month And birthdays once a week, And u the schools They d teach the rules Of naught but hide and seek. l^UTses abould go to bed at six However much they d scream , And you abould dtM At half past nine On strawbemea and cream And I should have great puddles mode In ei>ery single street. Where you could play Tba lireloDg day And eplaeb them with your feet Oh that would be a wondrous tune , For every single thing That ever you had wished were true Would be— if 1 were King (Wntten by Iticbard Francis Kmdersley, October, 1633) MODERN MEDICAL MONOGRAPHS £di(ed HUGH MACLEAN M D D Sc FRCP. MODERN METHODS OF FEEDING IN INFANCY AND CHILDHOOD DONALD PATERSON B A. M D (Edim), FRCP (Lovd) Pfiynnan for Dtstates of Chtldrtn Wesinnnstir IlotpMal Ph^uaan lloi^tal for Stch Chtldrtn Great Orntcrid Strut AMD J. FOREST SMITH fr&p (lov.) Physutan ttt Charge of Chtldrm s Department St Thomas t Hospital SEV£l^TH EDITION LONDON CONSTABLE & COMPANY LTD lo ORANGE 'street LEICESTER SQUARE W Ci ir I XFEBS KINO Ir I tmv Kiog of Bogland AVhat lots of thiogs 1 d do s What plana I d n^dce What paws I <1 talcs To ha^’B things nice for yoa First I mold bsuo orders That to all aorta and ranks Of girla and bojrs All sweats and toM \\ ere sold tor plcaao and thanks ** Chnatinas would happen once a month And birthdojB once a week And in the eaboola They d teacl the rules Of naught but hide and seek Nurses should go to bed at s z However much they d scream And you should d no At half part o no On strawberries and cream And I ebotdd have great puddles mads In every single street Where you eould play The livelong day And splash them with your feet. Oh that would be a wondrous time For every single thing That ever you had w shed were true Would be — if I Were King (Written by Richard Francis Kinderslev October 19r ) MODERN MEDICAL MONOGRAPHS Edited ty HUGH MACLEAN M D D Sc. F R.C P MODERN METHODS OF FEEDING IN INFANCY AND CHILDHOOD BT DONALD PATERSON BX MD (Edis), FRCP (Losd) PAynetan for Bistasts of Chitdten TFesf rtnster HorpUat Physteian IlospilaJfofStckCktldrtn Great OrtTtond Strut AKD I. FOREST SMITH frclp (W) Phyeteiiti tn Charge of 4 Defartmiit St TAemoi s Hatp\tal SEVEf^Tll EDITIOS LONDON CONSTABLE & COMPANY LTD to ORANGE STREET LEICESTER SQUARE WC,a PREFACE TO THE SEVENTH EDITION j The importance of Breast Feeding is once more stEssod in this edition, Tho recent views of H. Waller inbhc establishment of Lactation are given. I The new regulations and designations of the various clsses of nailk are explained. j Where feeding by weight has ‘been adopted the anhors feel that insudlcient consideration has been ginn to the expected weight of the infant. This point is krthcr emphasised. 1 Tho section on Frcmatnre Feeding has been revised, * <«£ Food Tables throughout brought up to dote. Further trcirenccs to recent papers have been given as footnotes. j The latest examination papera in diseases of children boji for doctors and nurses have replaced those of pmouB editions, and the authors hope that this section wu continue to bo os popular aud useful os it appears to lave been in the past. D.P. StfLitr. ms. J. F. S. PREFACE TO THE SEVENTH EDITION The iroportance of Breast deeding is once more stessed m tins edition The recent vjeitfs of H 'W^ler inihe establishment of Lactation are given i The new regulations and designations of the vanona cleses of milk are esplaincd, I Where feedmg by weight has been adopted the atihors feel that insufficient consideration has been gi4n to the expected weight of the mfant This point IB urther cmphosiaed. The section on Frematore Feeding bos been revised, Food Tables throngbont brought np to date Further reirenecs to recent papers have been given os footnotes 1 The latest examination papers in diseases of children boi for doctors and muses have replaced those of prrious editions, and the authors hope that this section wij contmue to be as popular and useful as it oppeare to ave been m the past Sti^btr, 1939 D P. J F.S TABLE OF CONTENTS currsi rios PBETAOE TO THE SEVENTH EDITION . . V 1 BREAST BULK AND NOllUAl. BREAST FEEDINQ 1 H. DITFIOOLTrES IN BREAST FEEDINO . . 21 ni OOW’a AND INFANT FOODS. . . 33 IV. ASTinOIAL FEEDDrO 68 V. THE ABTinOlAL FEEDINO OF THE NORMAL HEALTHT INFANT 86 VI BOSED FEEDINO FOR NOBAIAL ITEAT/my CHILDREN 67 Vn DlABimCEA, VOMETINO AND OONSTIPATIOK (INOLT7DINO INDIOESTION) . . . 108 Vin. WASTINO IN INTAKOY AND THE PBE5IAT0EB INFANT . . .... 128 IS. DIETS FOR 8I0E OHILDBEN. . . . 134 APPENDIX I 152 APPENDIX n 109 INDEX 207 LIST OF ILLUSTRATIONS m 1 BY PBESSUBE OV THE BREAST WITH THE INDEX AND MIDDLE YDiOEBS THE YLOW OP MTT.K IS TO SOME EXTENT CONTROLLED, AND THE BREAST IS KEPT FROM OCOLHDIhO THE INFANT'S NOSE To face page 12 2 SQXHLEt (CPRIOHT) BOTTLE AND BOAT SHAPED BOTTLE . , . . To face page 60 S A VARIETY OF TEATS IN COMMON D8E To face page SI 4 hOTE METHOD OF BOLDINO BABY TO BBINO HP ITS WIND To face page 00 G X RAY SKOWlNa STOMACH DISTENDED XFITH WIND AFTER A FEED . . To face Fig 6, fee page 00 G X-RAY or TICE SAME INFANT SHOWN Dina 5 AFTER HAVTNQ BROUGHT HP ITS IVIND To face Fig 5, eee page 90 7. COMPLETE SOXHLET APPARATUS . To fact page 91 8. TEE PBEMATURE TUBE FEEDER . . Page 130 Wherever fruit juice is mentioned which may be unobtainable during the war, 25 milligrams of ascorbic acid in tablet form, or bottled or tinned fruit or tomato juice should be substituted. It is quite necessary for infants and children to have one or other of these preparations every day to maintain good health. modern methods of feeding IN INFANCY AND CHILDHOOD CHAPTER I breast milk and ' normal breast feeding Mionce an ™ '“otoia'l*]. of tho ortiEciallv ™ “•"f®™ tl>® on of fmluig babies yoonrja't “r It "'til >l>o f«it that to the this Mrir epwMfio and that during newasitv^ttKrj^n*' ttrt‘6c»aJ te©»«ing is a substitute that iiwasitv alone imposes upon u*’—J BRsatNiatANv Ot Feeing The ndenDtages of feeding f,ii e “ markedly demonstrated by the danng the last tnentj jears- owing to the merenso in the number of breast-fed mfants— iTt n ““"''P«®atj to stress the importance of the sub u ,11, 1 fTf"”®* faadmg is still, howerer, too often abandoned tn uttle or no effort to make it a sucee.3 Sreasl mitt ncarhj every child and most women can wholly, or at least Jmrtmlly, breastfeed Ihetr children In the Bret sm Smlly fed‘'’° “‘’’■'“''‘y ® *“'®®'y amaag “““sa who are are to the mother of breast feedmg 1 Breast feeding is cheaper than bottlo feeding - It involves less work, as there are no bottles or ■eats to be cleaned and sterilised or food to bo prepared ei.rK *1 ^ iactation suckling the infant aicis the uterus to involute 4 By keeping the infant in good health, much time, '\ori7 and money arc saved 2 FEEDING IN INFANCnr AND CHILDHOOD Adran/affcs to the Child I Breast milk is a nalaral food, and tio artiGcaal food, even ^nth tlio most claborato modJiications, can approadi its composjtton in proteins, fats and carbohydrates, apart from the fact that it contains almost certainly immune bodies which help the child in Its carl^ struggle for existence 2 It thrives better and has good motions, a good digestion and sleeps vrcll 3 It IS five times less likely to die during the first jear of hf© 4 Being constantly thrown into the company of its mother, it is more hkoly to bo properly cared for than if looked after by some disinterested person The only disadvantago which may ocemo from breast fcechng falls on the mother Breast feeding takes n con- siderable proportion of her time, and she mast therefore bo willing to sacrifice herrelf in this respect Very often tlio calls of social duties aro such that a woman is nniblo to suckle her infant for moro than a short time, and again in other cases a uoman’s employnient hinders her from fulfilling this maternal duty, hoirever willing cho may b© It behoves medical men, therefore, to rccogniso the advantages of this method of feeding ond to pomt it out to theirpatient On the other hand, they must recognise the restrictions which breast feeding jdnees upon the mother and in every way inako it as easy for her as possible It la well to remember at onco that every woman cannot fully breast feed her infant, and that if a woman must shoulder the responsibility of managmg her home and undertake a nomber of social duties this is alivays done to the detriment of breast feeding Many women con only accomplish breast feeding when they exclude most of their other duties and mtcrcsts, and if socially incUned these restrictions are found both extremely irl^omo and often detrimental to their health Breast feeding actuiUy undermines the health of some women, and as it progresses they become thinner and more run down The n eaning of the infant is followed by a resumption of their former ffyod NORSIAL BREAST PEEPING 3 health. This cannot, however, bo said of tho majority of women, as many, on the contrary, seem to thrive and put on flesh during this period. It is esscriital for the doctor to study the individual tcoman vihm adiocating Ireast feeding^ as he loill haie to study the individual child when practising artificial feeding. Contrarindications to Breast Feeding. Probably tho only nnirersal contra-indication to breast feeding is open tuberculosis in the mother, as she runs the risk of infecting her child and at the same rime of weakening herself and allowing tho disease to gain headway. Healed tuber- culosis is obviously no contra-indication in itself, Syphihtio infants should bo nursed by their mothers when possible. These infants are very prone to digestive upsets, and while being treated should bo kept on the breast as far as possible. Since tho mothers of syphilitic infants are themselves infected, there is no need to consider the question of maternal infection from an Infant with condylomata about its mouth. In acute infectious disease, such as pneumonia oc typhoid fever, the mother is as a rule so ill that the infant must be ortiflcially fed, but mild illnesses of non-infectious nature, such as bronchitis, are no contra-indication to breast feeding. With scarlet fever and diphtheria, a here the infant's immunity is high and there is very httle likeli- hood indeed of the child contracting tho disease, nursing may bo continued if the attack bo a mild one. The occurrence of local disease of tho breast-~< g., sore nipples and breast obsce<>s — will be fully discussed under PiiBculties of Breast Feeding. It is sufficient to state that they seldom necessitate moro than temporary weaning hlftb’gnant disease in itself should not be a contra- indication, but if the breast is irtvoivcd, or tho disease is extensive elsewhere, the mother’s health will iireclutle the possibility. In severe constitutional diseases, such as heart disease, nephritis and grave anosmia, the particular extent of the trouble and the moUier's condition must be considered in each case. In themselves, these diseases are not contra-indications to breast feeding. 4 FEEDEfQ IN INFANCT AND CHILDHOOD able £eJected cases, be advised. Core, hou-crer, must be taken to protect the infant from physical violence during a fit or oatbnrst. Vomiting in the case of the breast-fed infant is dfa- ^ cussed on p. 114. It must not be taken aa on indication ‘for veamng. \Vhen menstruation occors during lactation, certain infants at tie onset of each period tend to hare minor (bgeative upsets ; the majority, however, are not affected, and the occurrence of menstruation must never be taken as an indication for weaning. The oceurrence of pregnancy In the lactating mother is somewhat different. If the mother becomes pregnant during the early months of lactation she may bo for some time unaware of her condition. In these cases both mother and child appear to do well. Very often when the mother becomes aware of her condition the secretion of milk lessens and may go altogether. This, we think, is largely duo to worry of the aobsequent early pregnancy Interfering with the good health of the mother. Stimula- tion of the breafifc tends to set up reflex contractions of the uterus, and eucklmg may, in some cases, increase the tendency to abortion. Sforaing vomiting may iaterfero with proper secretion, and the mother may feel the strain of breast feeding too great to continue when she becomes pregnant. We would eoy, then, that lactation need not be Btopped immedmtely on the diagnosis of pregnancy being made, but if the child shows eymptoms of getting an insufficient supply or if tho mother's health is suffering weamng must bo carried out. We have given the contra-indications at the onset in order to emphasise what a sniaU proportion of children miut be brought up on artiffcuil foods. With care near/y eveiy child can be given its natural food ; breast feeding for a month only U better then none at all ; in all cases of doubt decide agatnst waning. Antenatal Measures. For efficient lactation and a In epilepsy and insanity the xaothetmay be physicallv to nurse her offspring, and breast fcediac mar. in NOHaiAL BREAST FEEDING 5 healthy pregnancy a piroper diet is essential This must ho ■vrelJ balanced in the pnnapal foodstuffs, and contain Euffiaent salts and vitamins, not only for tho mother hermlf, but for the growing fcetua At least one hot meat meal is neces'^aiy daily In addibon, a plentiful supply of green vegetable salads and fresh fruit, with eggs and butter, is recommended The calcium or lime requirements for tho bones and teeth of the babj and mother can best be met by the addition of one half to one pint of milk each day Slodem research * * * has shown the wide spread tendency to anamia dunng pregnancy This can be prevented bj an adequate diet, or cored by tlie administration of some yeast preparation, together with on ca'uly assimilated iron salt, e g , Fern et ammon cit gre xv, t d s Antenatal Preparation of Breast and hippies The preparation of both breasts and mpples should be started in the last two months of pregnancy Harold AVollta? * considers that if this is efficiently earned out failure to establish lactation the discomfort of engorged breasts and the nak of breast abscess would bo minimised If the nipples are small and retracted, they sliould be gently pulled upon or squeezed out, using some Lanolin prepantion where nece«5sary Cold water apphcotions will cause the nipples to stand erect In the majority of women a smaU amount of dned secretion, may be seen on the surface of the mpplo towards the end of jingnajxey This should bo constantly removed by frequent bathing after the use of some simple omt ment This dned secretion must not be allowed to block the ducts , if It does tho free outflow which is desirable of colostrum and mature milk will not be jxjssible Blocking of the ducts m the antenatal and early postnatal period 13 suggested rf on palpation of tho breast hard or > Lucy and olhere Ind ifoum JHedieaJ Utaeareh 1930 Aod 103’ * Maey and Bunacber, Amer Jbtim 06sf and Cjm , 1931 ^ ol S7, p 8"8 * Harold Waller ' Ouucsl Slodiea m Laclatioa. Tleuemaan 1030 6 rEEDnsG na iNrA5»cy and childhood painful nodalac ewellmgs can he < In eucfa a case the procedure is as follows the nipples must first be cleansed and by gentle pressorc the ducts thoroughly emptied of any semi coagulated material Now gentlj massage from the base of the breast towards the nipple m an effort to emptj the blocked duct If the function of tho breast tissue to produce milk IS to be established and roamtawed back preouro and engorgement must bo prevented Cracked and blocked nipples TMth. engorged bteasta atn foremmiets of Wast abscess Galaclagogucs Expcnoicntal work m animals baa shown that the pituitary eecretea a hormone which stimulates breast secretion Further work has sho'ni that asttm tends to diminish «?crction m tho breast Espenenco has not > el shown whether tUc«c experimental results may bo safely appbed to human beings The CompesiUon and Quantity of Breast ^lilk Tho percentage comiwaition of breast nulk os given bv different observers a ants to a certain extent Table I shows the figures quoted b> Holt os tlio overage results obtamod from manj samples Tho Fat in human milk shows a variation of from 3 to B percent It diffors from the fat of cow a milk in that it w TABLE I (Holt) vaeiations i> Tire coirrosmoN op ansAST iULK Cov'i mill. j(om« BiiU rtf c«t. espumoo bultlij Ib iicrauin oil £. Water 8&-S7 8805 87 S2-85 50 Fat 4-00 300- 500 Proteins 350 125 1 1-00- 225 Slifk sugar 450 COO- 7-00 Mineral salts 0 75 1 020 1 018- 025 composed largely of olcatc** and further tbo fat plobufes ore smaller or in a state of finer emulsion It has a lower melting point and as a result of its fine 8ub-om. NOHSIAL BREAST FEEDING ‘ II The ExcrcUon of Drugs in MHk. It has been prored that mercury, calomel, amenlo, bromides, sabcylates and iodides are all excreted in the milk. Belladonna and atropin are not excreted in human milk, but these drugs should always ho prescribed with care to the mother who is brcast-fec^g, oaring to their tendency to diminish the eecretiotv of milk. Slorphmo * and quinine aro for prac- tical purposes not excreted in tho breast milk. In the past, some of tho rogetablo aperients wero said to be excreted by the breast, and tho practice of giving an aperient to tho mother in order to correct constipation in the infant nas advised. These drugs are not so excreted, and the fallacy has probably arisen from -the fact that where the mother is suilering from diarrhoea, tho result of some infection, tho child often also has an attack, the result of its having contracted tho infection from its mother. Sulpbonamlde. Noah Alorris states that the eulphon- amide group of drugs is secreted in tho breast milk. Tho authors have found no ill effects on tho breast-fed infant, Salrarsan Js not excreted in human breast miff;, and tho practice of giving this drug to tho mother in order that the congenitally syphilitic infant maybe treated cannot be too strongly deprecated. Even if salvarsan were excreted in tho milk, its action would be ncgbgible when taken into tho stomach of the infant, ond now that congenital syphilis can be adequately treated by early administra- tion of this drug to tho infant itself, this method should never be adopted. Recent icscaTch * shows that the breast fulfils the role of a barncr, maintaining fixity of composition of the milk, even to the detriment of the mother. It will bo seen, then, that tho practitioner can, with ordCnarj’ care, prescribe any Atig which he thinks ncces- sarj' for the treatment of lU-health arising in the mother who is breast-feeding * “Elinsinafwnof MorphmeB«vl Qtnnlne in lIilt-,’'TcrmlligcrBnd Hatolifr, Surg Oynee. and ObtL, 1334, Vol S8 p 823 * •• Passage ol DiSnaiblo SubeUmecnmlo Milk,” Lc«ao tt ol , Aeia retd , 1033, VoL 1C, p. 630. 12 FEEDING TN INFANCY AND CHILDHOOD The Effect of SmoUng on Lactatitfn The pmctico of emoking by the lactatmg mother now so prevnlent tbit a word of warning against excess is neccs’^ary Cbwcal exrpcnenco has shown tliat from time to time cxcc^iio smoking by the mother has had definite toxic cfTccts on tho infant she is nursing The stools tend to become green, the infant may bo fretful and fail to gnui It is ciaimed that up to seven cigarettes a day can be smoked without upsetting the infant * * Establishment of Lactation For tho first tnclre hours after birth tho baby sleeps practically the nhole time The mother is recovering from the cfTccts of labour and it 13 not necessary or desirable to put tlie babj to tho breast A practice is often mode of giving the infant a tcaspoonful of n armed water, m some cases with tho addition of a tnco of sugar every few hours during the first day Wo do not consider that tins is csrential, but It IS in no way harmful At the erul ofiwehe fours the baby tspul to Me breast every ttx hours This teaches tho infant to 8 ucl , provides him v ith colostrum and encourages tho secretion of milk Jt cannot be too strongly emphasised that tie most potent ettmulant to the seorehon of mtV is provided by the eucUng tnfant For the firet feeds tho mother should bo turned half on the side used, and it is most important that a comfortablo position 18 assured Tho baby abould bo placed on the left; arm if the left breast is bemg suckled, and tho head veil supported The nght hand should bo u«cd to guido the nipplo mto the baby s mouth and to keep a gnp on the breast so proventmg an excessive flow of milk or tho tendency in pendulous breasts to mterfere with the baby s respiration When tbo mother is up and about, the feed IS best given from an easy low chair When to give Complementary Feeds After the mother ht^ recovered from tho strain of labour (say in twelve hours) tbo mfant should bo put to each breast at * tv Fmantifil ZeiUeAr / Ktn^erh 1P31 Vol C" p 41 * ^ cotioa in Breast Milk Vt B Thompson Amtr Jovm OhtM omi Oynee„ 1933 Vol 2C p 068 fT*fic(] 1. 14 FEEDING IN INFANCY AND CHILDHOOD as to whether three-hourly or four-hourly feeding gires the best results. With thru-hjiirly feeding the baby ia put to the breast at sir, nine, iicelte, three, six and im o’clock, having the long mtervol at night. Four-hourhj feeds arc best given at six, ten, two, six and ten o'clock. This rigime also allows for the interval at night. The times are emphasised, as it is essential that by three- hourly or four-hourly feeding it is not intended that there should be an ir^tcrval of three or four hours between each feed, but that each feed ahould start at the same time daily. Usually the new-born baby is fed every three hours, but when the weight of 10 lb. ia attamed an attempt should always bo made to institute four-hourly feeding. The advantages of the latter method lie in the fact that it allows complete digestion in the infant's stomach of each feed before the next is given, and it also allows the mother a longer interval for her ordinary duties. A certain number of cases, however, are seen where n^larly a healthy infant will not wait the full four hours. Half an hour, or even an hour, before the nest feed is due the child wakens and continues crying, and it will be found _ that this type of infant does not thrire neH. Ia such cases the three-hourly method of feeding will often give better results if the sarao regularity and feeding by the clock method is adopted. When the baby weighs tO ib. or more at birth it is not likely to be satisfied by the amount of milk secreted by the breasts in the first two weeks aflcr parturition. Such ft baby requires some 26 oz. of breast milk for its needs, and at the start of lactation the breasts n ill not yiefd this quantity. The mother may start four-hourly feeding straight away or the baby may bo fed three-hourly. With either method the baby will at first be underfed, and ft complementary feed of cow's milk and water with added ■sugicr 'do *cfr/cA karwch. 's3k. WsjmrA sufficient for the infant's needs. k-' Time taken over the Breast Feed. If the baby should waken regularly before the 0 a.m. feed, say at 6 a.ro., there is no reason why that feed should not he given at KOBilAL BREAST EEEDINQ 15 an earlier hour, provided tlio next feed is given at the routine hour, namely, 0 or 10 a m., depending on whether three- or four-hourly feeding is being given. Again at night, if the mother b out for the evemng, or it is incon- venient to feed at 10 p m , there is no harm ’nhatever in giving the last feed at 11 p.m , or even later. The baby is put to alternate breasts at each feed and allowed to suckle for fifteen to twenty minutes. The infant gets the buUc of his food in the first five minutes, and in practice fifteen minutes will usually bo found to give him an adequate feed. Care must bo taken to pre- vent his gulping milk at the onset by keeping firm pressuro on the breast. He must never bo allowed to sleep at the breast. The practice of putting sugar solutions on the nipple in order to start the baby sacking is a had one. A httle milk squeezed out of the breast into tho baby's mouth at tho beginning of the feed will usually start the Bucking reflex. Easy Flow of Breast Milk. It should be noted by those lU informed individuals who instruct nm^cs that baby should be made to work for its feed, how easily milk js obtained by tho infant firom the breast. On suddenly removing tho infant from the breast, after a few moments sucking, it will he noted that the milk spurts forth in several jets from the m'pple. In fact, it may be said that the milk almost flows down the child’s throat with httle or no suction at first. At the end of the feed the baby is supported in an upright poiirion to allow air swallow ed to be eructated, and is at once placed in tho cot and allowed to sleep. Too often this simple measure is omitted, and tho cluld after dozing for some minutes wakens up and cries and perhaps vomits a little. In every case soma air is taken into the infant’s stomach at each .and this must always be got rid of before he wU sleep comfortably (see p. 00). The Diet and Hygiene of the Nursing Mother. Wc have already discussed some of the problems of the dtti of the pregnant woman and would again empbause some iu AINU UtUUJtlUUD of tlio points of diet 'when lactation is already establislied. Tbo_ supply of calcium Baltejjjid thejritamins must^bo 'assured, and the half-pint to one pint of milh a day mustjse continued. It may be necessary to add a u'ord of warning about the exccsaire use of milk and milk foods in these cases. So many mothers nill not tolerate milk or milk foods in eicesa without getting digestive upsets, and care must be taken never to push milk to tliis extent. In the case of the working mother it is essential that she should obtain an adequate supply of food as such. One hot meal a day must bo insisted on. Alcohol, especially in the form of stout, enjoyed a considerable reputation as an aid to the secretion of milk. It may be said at once that alcohol has no such effect. On the other hand, it is not true that alcohol is excreted in breast milk unless the amount taken is grossly oiccs&iv'o. If a mother has been in the habit of taking an occasional alcoholic drink, this need not be restricted during htcia« tion. Perhaps thojnost im2>ortaut point to remember is that the mother should secure an adequate supply of fiuid. She must realise that extra fluid is to bo taken each day to supply the needs of the functiomng breort, and, where any doubt exists as to tliis extra fluid being taken, she must bo instructed to drink a glass of aster immediately before she feeds her baby. The doctor will remember the possibility of the occurrence of uhafr may bo termed “ lactation-anaimia.” ^ , Conslipaiion is best treated by the increase in the amount of greenstuO and fruits eaten and by rational exercise.^ If drugs are ncccssaiy, senna pods, cascara or liquid paraflin may bo used. Saline apenents are to be avoided owing to their tendency to diminish secretion by increased loss of flmd. Minor digestive troubles and other forms of ill-health may be treated in the ordinary way and without fear of the baby being affected by drugs uxerett-d itn We have no doubt that o malted milk, such as * '• Human Milk Studies,” 8. S.il’Codi tt ai , Journal 0 / Huinum, 1031, Vol. 7. NORJIAL BREAST FEEDING 17 Hoflick’s Slalted Milk, Oraltine or Lactagol, which has a high content of carbohydrate as malt, has a definitely stimulating action on tho flow of mrik from the breast. Wo suggest two to three glasses may be given in tho day where it agrees with the mother. The effect of sinoking has been discussed on p. 12. Are there any Jemds which should be drfinildy excluded from the diet of a nursing mother t This question cannot bo anancred except by studying each individual case. In the authors* opinion, any food which is digested and appears to agree thoroughly with an individual woman can have no deleterious effect on her milk, and indirectly on her baby. Such an indigestible article of diet as cucumbeis, for example, may upset one woman, causing her to bare abdominal pain, sleeplessness and consequently a faulty supply of milk, whereas another woman, who tolerates tius article perfectly, is undisturbed herself and her baby thrives. Many mid* wives and maternity nurses seem to throw an air of mystery and superstition over tho diet of a nursing mother, dsiming largo numbers of articles as forbidden with no real grounds for doing so. We protest against this pretenco of mystery ' • Weasung and the Commencement of Mixed Feeding. Tho weaning of an infant depends largely on the method of feeding up to the time when weamng becomes desirable or necessary. Some general rules are apphcablo in every case. IVeaning should always take place graduaUy, for by this means the tendency to minor disturbances m tho infant is avoided and the mother’s secretion, lacking the regular stimulation of sucking, is slowly diminished, and painful, engorged breasts are prevented. In order to avoid theso minor upsets of digestion, it is advisable to wean in cold rather than in warm months. At what ago should some addition to tho breast millr be made I Wo think tho addition of vegetable and cereals should not bo delayed beyond tho ago of five months, or when tho baby has reached the weight of 16 lb. When an infant reaches 16 lb. bo requires about 18 FEEDING IN INFANCY AND OHILDHOOD Diet for a Normal Heallby Breast-fed lafaat from Six to Nine Months Old. (Weight 15 to 18 lb.) Feeding Ttmu — 6 am, 10 am. 2pm, 6pm, 10 pm. _ . 6am, Giva both breosta, seren zmsates to each aide . lOoffl 1. Boiled tftinf . . 2 oz. Water . . 1 os Sugar ... 1 level teaspoonful To this add one to three heaped teaspoonfuls of Chapman’s Patire iVbeat Food, Boh/osoa’a Patent Qtoau arParfej or OmoJe’e Cream of Rico or foroN (See footnote r« cooking ) Half a teA venient tuns (or this is between S and 10 azn , or at tea tune To Preeent RKlette Give an eggspoonful of cod bier oil immediately before three of the feeds, or one drop of hahbut bver oil Re Cooking Cereal AH milk thould be brought to lh» boil la makirg np tho cereal tor tbs 10 a m and 6 pun feeds, such as Groats. Cream of Rice, etc . this needs to bo cooked directly (or at least twenty minuter, or from half an hour to an hour in a double saucepan. It may bo added to tho rest of the feed and tho whole cookra for the specified tune, or it may be cooked with water and then stirred Into the rest of tho feed, when it is tboroughly eooked. bf.D Owing to tho thick natoro of this feed, it is necessai? to make m largo hole m tho teat if given from a bottle, but, if pcosible, it is mon desirable to spoon feed from a cop Bone end regetabU Bnfh Take 1 Tb of veal bones or bocl bones, weTl broken Op Cover with water, and «ld one teaspooufol of vinegar Oecasionally, say once a fortnight, add a piece of calves' or ox liA'er (about 2 oz.) Sunrwr for from one to four boors Now add vegetables (carrots, caiih flower, gre e n vegetables and one potato) Simmer for one moro hour, strain and allow to set Civs coo to two UbIe«poonful« in tho 2 pjn. feed (aa directed) (The broth t# best cooked m a double saucepan, and eliould keep for threo days if kept in a cool place ) NOKMAL BREAST FEEBING 19 35 oz of brea$t milk in tbo day Tho majority of motbcra aro not able to secroto moro than this quantity intbout detnmeut to their oirn health Something moro than breast milk 'jccms to be required by mfants after their weight has reached 15 lb The bulk of the milk has become so great that there is a tendency for the stomach to bo overfilled and more concentrated food seems mdicated The tendency is becoming more and moro marked to start mixed feeding in earher months than used to be the common practice, and as a working rule the attainment of the 16 lb standard may be taken ns a guide to tho intro- duction of this mixed feeding The child is given a dinner at 2 p ra of one to two tablespoonfuls of bone and vege table broth Tins may be given before the breast feed, and should be given by spoon rather than from a bottle Shortly after this the soup may bo thickened by tbo addition of potato or some cereal as groats or ground nee The baby is seen to bo more satisfied, and all of tbo breast mill\ is not withdrawn from tbo breast This tlicrefore constitutes the very commencement of weaning, which, by this method, should be an extremely gradual process The second stage is to give a ft.cd of groats (one third to one half teacupful) at the 10 am feed At 0pm one third to one-belfofa teacupful of some starchy preparation, such as Cream of Rice, Robb’s Biscuit, Neave’s or Sister Laura’s or Ridge s, AUenbury No El , or Farox, Robinson’s Patent Groats or Barley, or Chap man’s "WTiole Wheat flour, or Pablum, may slowly bo added The fourth stage is tho addition of two heaped eggspoonfuls of tho yolk of a soft boiled egg to the groats at 10 a m Rusksshouldnofcbegivenexcept at meal tunes, and then only when the lower mci^ors have appeared Each of tho stages desenbed should occupy about one TJaif r^jv.w jdwAd iw* Ahs* xwOtxvf' has cut several teeth, and, round about the age of nine months m a normal healthy child, it can be completely weaned Agam, this should bo done gradually The Technique of Early Weaning It is ollon neces- sary to wean a child m the firetfew months This may be 20 FEEDING IN INPANCY AND CHILDHOOD because of ill health on tho part of the mother, or for social reasons. When this step must be taken, the following technique is recommended : — 1. On tho first day tho mid-daj' breast food should bo replaced by an adequate bottle feed, calculated on the weight of the infant. 2. The second day the 10 a m. feed should bo replaced by an artificial feed. 3. Tho third day tbo G pm. feed is replaced by a bottle feed. 4. The fifth day (tno days later) tho 10 p ra. feed is replaced by a bottle feed. Any breast milk present should be pumped or expressed off. This is most easily done after a hot bath. 6. On the seventh or eighth day tho Gam, feed should he discontinued, depending on how qmcUy the mother’s milk diminishes. If the breasts become full, engorged and painful, a hot bath will relax the nipples, and the mill: can be expressed or pumped off readily, relieving them. The Treatment of the Breasts at Weaning. If acan* ing bos been carried out in a gradual manner as described above, there is little danger of breast trouble in the mother If the mother should complain, rehef may bo given by supporting the breasts by bandaging. Tho mother is instructed to cut down her fluids during the weaning period and tho bowels moy be freely opened by means of ealme aperients each morning. Caro must be taken, how- ever, to avoid excessive purgation. Tho breasts tend to bo most troublesome at night. If this occurs it is a good practice to empty both breasts completely by means of the pump and then to strap securely for the night. At the end of tho weaning period, if the breasts are still secreting, they must be completely emptied and kept continuously bandaged for a few days. Belladonna has often been used as a means of stopping secretion, either given by mouth or applied as a plaster to the breast. It does not socm to have any value unless given in doses which prodiico 83 nnptoms of poisoning. CHAPTER n DIFFICULTIES IN BREAST FEEDING Failure to establish Lactation owing to Defect in the Child. Failuro to estabbah lactation may be due to some defect m the child or in the mother. In the case of (he infant ono of the commonest canscs is by interference with tito respiration of the cluld whilst nt the breast minor conditions may account for this. There may bo some degreo of nasal catarrh, and it is always important to sea that tbo nose is clear before suckling starts ; this may usually bo accomplished by using small pledgets of cotton nool. A second minor obstruc- tion is caused by a pcndulom breast falling over the child’s face ; this is easily controlled by hohliug tbo breast clear on the part of the mother (sec Fig. I, facing p 12). Transient soreness of the infant’s mouth, readily rcoognised on inspection — eg., thnisli—is another cause of failure to take the breast. 'When this occurs tbo infant may be fed for two days on milk expressed into a spoon whilst the local condition is treated with glycerine and borax, after thoroughly cleansing tho mouth several tunes daily. Jloro serious obstacles than these aro tho presence of hare lip and cleft palate malfortnalions. In hare lip, if tho palate is intact, there is little interfereneo irith sucUng. Many surgeons consider that at three montlis the opera- tion of repair may ho carried out. For tho first few days after operation tho baby is fed on expressed milk and it is seldom necessary to w can comjilctely The degree of com- pleteness in cleft palate malformations determines tlie likelihood of successful breast feeding. If tho postenor part only is deficient, suckling is usual IVith greater degrees, there is marked interference with respiration, 22 FEEDING IN INTANCfT AND CHILDHOOD and the mfont mtemipta feeding crcrj few seconds to breathe Itmaj be pos’^ible to suckle successfully in some of these cases, but in many respiration is completely interfered uith, mdk regurgitates through the nose and it IS impossible to continue natural feeding Every effort should be made to express milk and to feed as long as possible on this whilst the question of an early operation must he seriously considered The infant especially the premature infant, maj be bom so weakly that the act of svcking tnlaxU too great a strain This applies still more to tho'o aifants who are suffering froir some organic disease e g , congemtal heart disea'c Such a child should always, if possible bo spoon fed on milk expressed from the mother (eco p 130) and it cannot bo too strongly cmphasiicd that its chance of sumvil depends largely on its obtaining breast milk It IS in many cases qmto po««ible to cstabbsh milk secretion without putting the baby to the breast bj means of ma'sage, manual expression, and the complete empty mg of the breast with a pump As soon as tho weakly infant shows signs of ictuming strength, be should ho placed to the breast and afterwards three hourly feeding will bo found the best method to adopt There is a type of infant who is born healthy, of normal birth weight, and who^c mother has an adequate supply of milk and yet who does not thrive at the breast When observed it wall bo seen that the child "moutlos *' atthebrea‘'t The nipple is never grasped and the infant makes no attempt to suck properly Some of theie cases suggest at once o birth injury, or this failure to suck may bs the first sign of mental defect, but rn the absence of gross disease, this typo of caso can only be accounted for by the failure to establish a suckmg reflex Every effort mustiDemaiieto encoumgo ttie nfforA expreisaiigimlils. from tho breast from time to time and feeding him on this, and care must be taken not to resort, if possible to artificial feeding The successful feedmg of the‘^e ca«es depends almost entirely on tho maternal effort or on the personahty of the nur'e m charge of the case DIFFICULTIES If? BREAST FEEDING 23 Failufe to establish Lactation due to the Mother. In the absence of Bovero illness, this may bo due to lack of ante-natal caro (see p. 5), or 1. Poorly developed breasts. 2. Malformation of the nipples. 3. Affections of the nipples. 4. Breast infectione. It has to be recognised that a certain proportion of women who are really anxiona to feed their children have mammary glands which contain little true secreting tissue. The poor breast will, however, often yield a certain proportion of milk if every step is taken to encourage secretion. These methods n tU be discussed later. The care of the malformed nipple, engorged breasts and choked ducts has already been dealt with imder ante-natal treatment (see p. C). MarUdhj retracted mpplea may often be withdrami if the breast pump has been efficiently used in the last two months of pregnancy. If the retraction persists, attempts should bo made to draw oat the nipple before each feed ; if this is not successful, lactation may often be carried out by means of the nipple shield. Special caro roust, in these cases, be taken to see that the infant gets a sufficient supply, and if necessary the breast may be emptied at the^end of a feed by expres- sion or the use of the pump, and the expressed milk given to the child. Sore nipplea often provide an obstacle to efficient breast feeding. If suitable hardening methods have been adopted during pregnancy, this trouble is not hkely to be encountered. During lactation any tendency to soreness may bo treated by means of a spmt lotion, and, if cracl^s should develop. Friar’s balsam may be u'^ed after each feed. A nipple shield is sometimes advisable, esjiecially if the child should prove a very strong sucker. If the cracks persist under treatment tho sound breast only should be used wlulst the affected side is being treated. Callous cracks may be stimulated by touching with silver nitrate, or a lotio hydrarg, pcrchlor 1/1000 may bo pro- 24 TEEDING IN INrANCVT AND CHILDHOOD 8cnbcd The breast must be regularly emptied during this treatment Breast Infections {ae© p 6) Infections of the breast may be seen in the first few days of the puerperium, although true breast abscess is seldom met i\ith till later m lactation It may bo convenient to discuss the subject hero Small tender areas representing a mild degree of mastitis occur not rarely m the functioning breast Heat, in the form of fomentations, n ill usually reheve the pam of these When the infection is more severe a true breast abscess develops The ultimate treatment of this is a surgical evacuation and drainage of the pus For all practical purpoces, breast milk is sterDe, and m cases of breast abscess the tendency of the organism to be excreted m the milk has to be considered Pus, blood stamed fluid and the orgamsms have been foimd m the milk from a breast ^bero an abscess is present The dilflculties nluch we have discussed so iar as causes of failure in the establishment of lactation ore for the most part readily diagnosed, and depend on the examination of the breast and its mpplcs and on the examination of the baby’s mouth and nasal passages Much more diiflcult to recogmso and to treat are those failures which come under the heading of msufficient quantity or quahty of the milk, and it is convement hero to give the methods of mcrcasuig the flow of milk Onfe lactation u eslal/ltshed, the iloxo oj milk ts largdp determined by the demand tehich w made upon the breast Methods of Increasing the Quantity of Breast Milk. The supply can be increased by — 1 hlakmg certain that the infant is completely emptying the breast at each feed, and if not doing so, by expressing the re«idue by hand or the pump The breast must be empty at the end of each feed 2 Improving the mother s general health by attend mg to her diet, sleep and exercise and by excluding domestic womes 3 Addmg to her diet apmt of milk dafly or one of the malted foods NeiTOUs upsets probably do not affect DITFICULTIES IK BltEAST FEEDING 25 tlie milk supply directly, but in^rectly by altering her general habits of eating, sleeping and exercise. 4. Inducing in the mother that desire to nurse her infant v, Inch is so essential to success. This may be done by an exaggerated air of optimism on the part of those about her. 6. SCnssago of the breast with apphcations of hot and cold water alternately have been found xery useful. Breast massage consists of rubbing and kneading the breast between the hands and of squeering the breast toTvards the nipple every three or four hours. This is followed by batliing, where tuo basins of eater are neces- sary. The mother first sponges the breast with cold water and immediately afterwards follows this with water which is as hot as can bo comfortably borne. It cannot be, eircssed too clronglt/, botccier, (hat the vij?oroiw euetion of the infant at the mpple at regular iriter- vaU is the aU’imporiant factor in e^tcihlishing and ntain- taining on adetjuale of bremt irnlL Underfccthog. Obviously, if the infant is underfed, this may be duo either to an insufficient quantity of breast milk or to its poor quahty. Should the quantity bo deficient, the infant fails to gain in weight, tends to bo extremely constipated, or (o pass frequent email greenish (hunger) stools and to ciy incessantly during the day and often at night. Wo hare known some coses, however, of starved infants, here, due to early training, the infant has slept well at night, but has been extremely restless during the day. It is rare that a started infant can be said to be a "good ” child. Often where there is an insufficient supply of breast milk there is tomiling of food. This is, as n rule, duo to air stcalloicing. It is normal for ercry infant to su allow B cuftara nraotmd ct air aJbng’ WTd& rds’ feed. Wlcen, honever, he Is cxcc‘3:ivcly hungry and the supply of milk is maulficicnt, sucking at tlic empty breast soon fills the infant with " wind." It i« in such cases a-* there that the miduifo’s expression of “ windy nulk " lias arisen We do not boUeve that tucli a tiung as ** i^ind^ milic ’’ cxi-ts — 2C FEEDING IN INTANCY AND CHILDHOOD tho explanation too often is not tnovgli »n»7i. A very common history that mothers giro in these cases of under- feeding 13 a desenplion of the baby pa«sing a Bmall green mucus-containing stool with some flatus during the feed, or immediately aflcnvarda. Test Feeds. The diagnosis of insufficient quantity of breast milk ought not to bo difficult. No mother can tell by the size of her broaste, by tho apparent Boning away of tho milk, or by tho tenseness or feel of the breasts, whether they contain httJo or much mdlr. Thero is only one certain way of ascertaining tho amount of milk in the breast, and that is by a “ test feed.” The baby is ircighed before being put to tho breast and IS neighed immediately after the feed irithout altcnug its clothes. If a stool has been passed tho napkin must not lie changed between tho tuo weighings. Tho difference m the weight shons the amount of breast mdk taken. Amount of Breast Milk required lo the Day. It has already been stated that breast feeds vary in their jield during the day, the early morning feeds tend to bo largest, and by noon or early afternoon tho feed has dropped some- times to half the quantity of the first feed. At night again, tho feeds tend to become bigger. The penod of breast secretion thereforo coincides -sMth that part of the day in which the mother’s activity is greatest. It has been C'^tiraated. and is our experience, that the average infant, up to a body weight of 15 lb., requires to oz. of breast milk per pound body weight per day— • e < 7 , an infant weighing 10 lb. will require 22 to 25 oz of breast milk In the twenty-four hours. One i'tolatcd tcpt feed is of no practical value, but tho complete output of ^ tho mother for tho day should be a.scertained to be of real value. Suj)po«irig this infant wreighing 10 lb is fed foiir- ’utnrfiy ^?ivu Vne tninugu 5m ■wnkj. •uxrdri *wb about 6 oz., but in practice some test feeds would be found to he considerably below and some above this amount. Individual requirementsamong babies thlTer very Con- siderably, It is a matter of eommou experience that some DIFFICULTIES IN BREAST FEEDING in^nts from liirtb are nerrous, sleep badly, are easily dis- turbed and often cry. They thrive badly and require la^o feeds to make them get on well. Very often they are boys. Other infants quite the reverse sleep well, are ” good ” babies, and seem Trell nourished on quite email quantities. More often than not these are girls. Wo mention these types to make it quite plain that the estimate of the breast milk requirements given is, and can only be, an approximate one. Wo believe that no rule can ever be laid down which apphes to every infant. The infant itself is the 6nal Judge in thLs most important matter {see p. 85, Chapter V). Complementary Feeding and when it should be used. When the chUd’s failure to gain weight and the appearanco of the symptoms already mentioned as indicating starva- tion suggest that it is receiving a deficient quantity of milk, tost feeds must bo done. If the test feeds confirm the diagnosis of insuiBcient quantity of breast milk the next step is to complement the feeds. Complementary feeds, or the addition of a snail artificial feed after the breast feed, are the best. Supplementary feeds, that is, the giving of a complete artificial feed in place of the breast feed, should never bo resorted to, as weaning will automatically commence. The ideal complementary feed b that of human milk, obtained from some mother who is sccretmg more than is necessary for her own infant. This is given to the infant nbo is not gaining immediatelj’ after it has been to its mother’s breast. Wet nursing, vlierc the infant gets tho whole of its supply from the fcBter-mother, is not so popular in this country as it deserves to bo, largely owing to lack of suitable foster-mothers. With care in selection, and after a preliminary inquiry into tho health of the foster-mother, and the obtaining of a negative Wasser- maim reaction, this practice may at times bo the only method of successfully rearing a weakly infant. Rules for Complementary Feeding. I. Both breasts should be given at each feed, but the breasts should bd pven first in rotation. 28 FEEDIHG IN INFANCY AND CHILDHOOD 2 Tho time the child is left at the breast should he only that sufficient to empty it, -which may be from two to five or BIX mmutea each Sucking at an empty breast fills the child full of wind and only succeeds in further upsetting it 3 The complementatj feed must alwajs be given after the breast feed This ensures that the breasts arc completely empty and that they aro stimulated by the -vigorous sucking of a healthy infant 4 Feeds must never ho made too suect, and there fore sweetened condensed milk is contra indicated The best mixture to u'o os a complementary feed should consist of equal parts of con ’emdkand water, -with no more than a level teaspoonful of sugar to each 2 02 of the mixture Certnm authorities advocate the use of BWeetened oou densed milk given " on the spoon " at the end of the breast feed to augment it This 25 somewhat irrational, as It does not allow for the fact that it is not onl^ a shortage of the solid constituents of milk, but also of the fluid portion 5 Tho ideal to atm at is to test feed all the breast feeds and make up tho deficiency vith a simple milk mixture In actual practice this is not always very practicable, and where test feeding cannot be carried out, the complementary feed should be given after tho tirelve three and six o’clock feeds, or if the infant is fed four hourly at the ten, t-wo and six o’clock feeds, after he has been at tho breast 6 Throughout the period of complementaiy feeding every effort should he made to mamtain and to increase the mother’s supply of milk by the methods already mentioned {p 24) 7 It IS always well to err on tho side of giving a httlo Vt® s. thwi a. hAtVi mmK. out oC tbn qc -will ha found that the breast milk tends to faff progressively Qualify of Milk When the question of the quality of the milk is discu'sed we find many authontie®, on tho one hand, stating that this is never affected to any apprccnble degree, and. on the other hand, u e hear of weamng being DIFFICUr.TIEK IN BRCAST FEKDINT. 20 advised because “ tho milk is blue.” Chemical analysis of milk entails the rolleotion of an average sample from the breast and, apart from the roughest methods, boiuo hours’ investigation in the laboratory. The usual method of collection is to use a breast pump, reject the first ounce or 80 secreted, and take a sample of the next, or so-called “ middle milk,” Investigation of the isolated sample taken in this manner, omng to the daily variation in the constitnenta in hreaet milk, cannot give very reliable information. For a proper estimation of tho con- stituents of tho milk an average sample from four feeds is necessary. Practically, it is found that laboratory results seldom give any true help in a difficult case. We think that in a very small proportion of breast-fed infanta there is some defect in the quality of the breast milk, and vrhero n child is failing to gain vrdght, when the amount of milk pccretcd is ehown by test feeding to bo normal, it w advisable to resort to complementary fecduig. Overfeeding, Whether this is octoally a more common occurrence than underfeeding is a matter of opinion. Certainly a doctor is rcqiuired verj* much oflener in cases ofunder- rather than over-feeding, os Nature tends to correct tho latter fault herself, Tho symptoms by w hich the diagnosis of overfeeding is made are 1. Frequent loose motions. At first these are of a good colour, but later show curds and tend to excoriate tho buttocks. 2. ’Trequent small vomits after fccils not produced by cnictations of wind. 3. Colic, restlessness, disturbed sleep, sweating of the head and flushing of tho face after feeds arc often present. 4. At first there is an excessive gain in weight, often 10 or more ounces licing gained in tho week. Witli increasing gastro-intcstinal disturbances, however, the child’s V tight may rc,adily become stationary. The cliiof cause of overfeeding is too frequent feeding or tho leaving of tho clilld at the breast for too long a ^teriod when there is an over-abundant supply of mill:, os 30 FEEDING IN INFANCY AND CHILDHOOD shown by the test feed. Under these circumstances and despite the smalJ vomits, and the inclination to looseness of the bowels, tlie mother may think the child is bcin<» underfed because of its erjing and restlessness. Trmlmenl. J. Tftd/eeJs should be done to ascertain the extent of the overfeeding. 2. If both breasts have previously been used at each feed, only one breast should be aDowed. 3. The periods between the feeds should be lengthened if a three*hourly feed regime had previously been used, that is, the baby should bo fed every four liburs. Especial caro must be taken to sco that no night feed is given between 10 pm. and G am., or the 10 pjn. feed dis- continued altogether. 4. TIio time at the breast should bo shortened. In the first five to seven minutes the infant’s stomach becomes filled largely with milk, but also with o small amount of swallowed air. After (his there is a pause in the feeding, during n bich the pylorus opens and a considerable portion of the milk enters the duodetmm. Tlie infant then rovses and the stomach is filled a second time. It is then that the overfeeding occurs. By test feeding the child at various stages of the feed a suitable period of time at the breast may be determined. For amount of milk neceaeaiy see p. 26. 5. A little water given immediately before feeds satisfies the infant’s thiret and tends to prevent gulping of milk and overfeeding. This is administered from a spoon a few minutes before the baby b put to the breast. Diarrhoea in Breast-fed Infants. If an infant on the breast develops diarrhoea the questions should be asked — 1. Has the infant developed an infection in the bowel 1 The breast-fed infant is less susceptible to acute gastro-cntentis than an artificjally-fed baby, but such infections do occasionaTCly occur. Tney arc c'nanic- teiised by fever, and blood and mucus in the stools, and the ehnical picture does not differ from a similar infection in an artifitially-fed infant. 2. Is the diarrhcea merely a symptom of infection DIFFICULTIES IN BREAST FEEDING 31 in some other part of tho body {e g., symptomatic diarrhcea seen in acute otitia media) 1 Thia ia a much commoner cause of diarrhcea than that under heading (1). A careful clim'cal examination of the urine, ears, throat and chest will exclude parenteral infections as a cause of this symptom In such cases there is no indication whatever to stop breast-feeding. 3. Is there something wrong in tho mother’s milk wliich has sot up an acute indigestion ? Vanations in tho protein and carbohydrate content of human millc are slight, and give rise to no symptoms (see Table I.). Tho fat or cream content, however, may vary widely, and may set up on acute fat dyspepsia with diarrhcea in an especially sensitive infant. It may bo necessary in a severe case to wean the infant. 4. Has tho infant an intolcranee for normal breast milk, allergy to casein or lactalbumcn t It is a well* recogiused fact that certain infants show allergic sjinp- toms to normal breast milk. These symptoms may appear as eczema, urticaria, diarrhcea, and vomiting. M'here the diarrhcea is severe, weaning may be necessary. 5. Is the quantity of breast milk too much or too httlo ? In both cases diarrhosa may appear os a symptom. Actually m our experience diarrhcea is produced more frequently in the underfed rather than the overfed infant. Test feeds will determine whether tho diarrhcea results from imder- or over-feedmg. Tho treatment of each has already been described. Failure of Ibc Infant to thrive on Normal Breast MUk. The stools of hreast-fed infants are normally acid. This is the result of the relatively high proportion of fat and sugar to tho casein or curd which is present in small amounts only. Each mdlvidual infant reacts in a different way to the food offered, and in some the intestine docs not seem able to tolerate this normal acid stool. The®c infanta require a higher proportion of protein and lower propor- tion of fat and sugar, nhicli produce an alkaline stool, to mamtnin their health and progress. There are a variety of ways of changing the acid stool to one wluch is alkaline. 32 FEEDING IN INFANCY AND CHILDHOOD One of tho best is tho giving of half to one ounce of vholo boiled cow a milk at each feed in addition to the breast Another way is by using one of tho preparations available, such as albulactin powdered casern, or the half cream or skimmed dried miU^, such as Cow and Gate or Trufood, which contain a relativelv high proportion of protem to tho fat CHAPTER ni COW’S MILK AND INFANT FOODS The attitude of medical men towards tho subject of artificial feeding varies. In some there is a complete in- difference, the subject appears too trifling to bother about, and tho feeding of tho infant is left to the mother or nurse to manage, or perhaps the advice is given to use patent foods and to follow tho directions on tho tm Others, con- fused by tho various systems advocated for feeding the baby artificially, and Cndmg that no method will give universally good results, think tho subject too difficult, and wlien tbe need arises refer the “ feeding case ” to tho specialist. A majority of doctors, however, now appreciate tho number of infant lives which can be saved by learning to apply the principles -which underhe all artificial feeding of tho baby, to insist on breast feeding whereier ^Joesj 61 e, and, whero this fails, to modify tho artificial feeds to the individual requiicments of Ifao case. We propose to discuss cow’s milk and point out tbe essential differences in composition between it and breist milk, to state the difficulties encountered in natural feeding and how they may bo overcome so that most infants may be breast-fed, and to mention the symptoms w’hich indi- cate that the artificial feed, if such has been prescribed, is not a suitable one. Milk and Proprietary Foods. For the rational feedmg of the infant by modem methods some knowledge is necessary, not only of the composition of breast milk and cow‘’a uu£k vtifli flioir common variations, ‘but a'lso ol fhe numerous proprietary foods now on the market. In this chapter are pven the main constituents of human milk and cow’s milk, together with the composition of the more commonly used dried milks, and those milk foods to which starch has been added 34 TEDDING IN INTANCY AND CHILDHOOD COW'S MILK Table H Bho^va the arerago composition of milk obtained from different xnammala The proteins ate sboTrn as casein and lactalbumen ohich includes lactglobulin, and together the latter tiro are knoim as the soluble protein of milk TABLE n snowiKQ *1:115: co^rposwiott ot iiixk trom DIFFERENT ilAiUULS (ModiBid /root Abt a P^ixiiatr ei ) Sp« ffls gnTitr 'Utter CaWa. Altin Totil trotclti. FtC Smr 4«h. ToUI foUlf VO-'OS 5S 0 80 121 2 01 R14 6 37 0-30 12 41 10323 fl7 27 ess OS2 3 33 ,7S8 4 04 tS 73 1033 00 12 0 70 100 I 89 1 37 6 19 0 47 9 88 I 0303 SO 88 2 87 0 80 3 70 iOl 4 64 0 8.> 13-12 10347 00 «3 130 0 75 2 05 1 H 5S7 0-36 0 42 Caselo Casein is a pUospbo protein never found any- rrbere except 10 millv Its exact source is doubtful, but it IS suggested that it is made from serum proteins in the roammaiy gland itself It oescurs in milk as cilcimn calcinate, a tnbasic acid, part of i\hjch is colubla and fllterablo and part is not AVhen acted on by dilute acids a Gno curd is formed, when tbe aciditv is mcreased the clot becomes heavy and in the presence of excess of acid the clot re-dissoJves It w solublo in alkalis, and is coagulated by rennet, but not by boilmg Lactalbumen Is closely related to serum albumen having the same physical and chemical properties, but that It IS not identical can be shown by means of immune reactions , Lactglobuhn is identical with serumglobulm and cames mimune properties lActalbumen and glo buhn are coagulated by heat but not by rennet Fat Fat occurring m milk consists of the tngly cendes eholestcrolandaboorbedpigment, it appears that tbe fat occure as a loose oomponnd and not as a mixture Tbe glycendes are tho«e of the non volatile acids, eteanc, * Adn«lp>alsmiIkpowderw*n8debyCew&GftteI.td tmde'th* OAire of CaprolM. INFANT FOODS 35 pabuitic and oleic, and of voiatUc acids, such as butyric, caprylio, etc. The fat readily decomposes under the intiueaco of light, oxygen and iructo-orgatiisms. Sugar. Sugar in miUr occurs only ns lactose, a ’di- saccharide, •which on hyclrolysis aph'ts into dextrose and galactose. Like casein, it is not found in Nature except in milk. Asb. The ash of milk consists of the salts of potas- sium, sodium, citric acid and chlorine. Phosphates are in solution combined ^dth calcium and magnesium, whilst di- and tri-phosphates are In suspension. SIiUc contains circa 0*5 mg. of iron per litre. The normal child requires from 6 to 12 mg. daily (Sherman). An infant who is artificially fed runs a risk of deficiency of iron in its food. This has led some of the more progressive dried milk manufacturers to add iron in some form to their products. Milk absorbs gases from the air, so that a sample ^vill contain oxygen, nitrogen and carbon dioxide. It also absorbs readily noxious gases, and the so-called charac- terUtlo smell of milk is due to the absorption of gases from the farm. Pure milk should be for all practical purposes odourless. Many attempts bare been mode in the past to vaiy the composition of cow’s milk by vaiying the diet of tho animal, but all have failed, provided an adequate diet is being given. The greatest variation in milJt is usually in that of its fat content ; some breeds of cons will give a milk yielding 3'0 to 3T> per cent, of fat, and a good Jersey cow will yield about 6*5 per cent. In fact, tho breed of the cow has moro to do with tho composition of the milk than tlie actual diet which is given to the animal. There ht also a variation in tho differences due to tho season, to ihif isKsJlh sf ihs- .vnimal, f£> Jhn akii} cS lha milker, and to tho relation between tho time of miUdng and tho previous calving of tho animaL It is t\o 11 to note the variations in the percentage composition of cow’s milk, in order to realise that in the methods described for hnmanLdng milk the result of dilution and the addition of fat and carbohydrate gives a mixture tho proportion of 36 FEEDING IN INFANCY AND CHILDHOOD whose constituents varies irith the original composition of tlio ttult used. Bacteriology. Milk contains ceetain enzymes, aggla- tmins and antitoxins The bacterial ooatent offcosh milk is diminished in the first hours after milking by the action of theso bodies, and some of tho immunity to certain infec- tions shown by tho newly bora may be due to these sub- stances in the milk. Colostrum, owing to its rich globulin content, is thouglit to be more effective than milk in conveying immunity to tho young animal. Samples of milk collected from the cow’s udder show micrococci, streptococci and sometimes co?/. Tiiese oiganisms, chiefly by their action on the lactose in mtJIt and to a lesser extent by their proteolytic action, are responsible for the sounng of milk with the production of acid, gas and clots, sucb sourmg being delayed by imme- diate cooling of the collected samples or by the various means nsed in “ sterilising ” milk. The sources of contamination during milking are many. One of tho most fertile is the cow’s coat; dirt diying on this is shed into the milk pail whtati no pre- cautions are taken to clean the animal before milking; infection also comes from the hands and clothes of the milker, especially when "wet milking ’’ is used. Stable dirt and lack of cleanliness m the dairy utensils may cause further infection When the usual methods of transport and rotaibng of milk are considered, it is not surprising that milk bought m our towns is often heavily infected, even when obtained from o healthy herd in the first place In the last twenty years there has been a marked improve- ment m dairy methods, and it is now possible to obtain milk which has been collected from healthy herds under standardised conditions known as certified milk. This will bo discussed later, but sufficient haS been said to indi- _ cate that for practical purpose " raw ’’ milk should not , be given to a baby. Widespread epidemics have resulted from con- taminated milk, such as typhoid and scarlet fevers, and outbreaks of tpidemic sore throat. In this connection the INFANT FOODS 37 possibility of a carrier among the farm servants is to bo remembered. Perhaps rooro important than this is the relation of bovino tuberculo'ds to the human type of disease. Tuberculosis is common among cattle and tubercle bacdli can frequently jbo demonstrated in samples of milk taken at random from various sources. Of recent years the importance of undulant fever (infection by S. Abortis or B. MdUiensis) has been emphasised. Out of 147 cases investigated ^ 141 patients trere found to have been drinking raw milk, that is cow’s millc which had not been boiled or pasteurised. It is claimed that from 20 to 30 per cent, of milk in this country is infected by the organisms of nndnlant fever. The need for clean milk, and for pasteurisation or bofling hefore use, is further emphasised by these facta. It has been suggested that the danger of tuberculosis from milk is rather a theoretical than a practical one ; in fact, the theory is sametimes held that the child by ingesting milk containing these baciUi from time to time has its inunuolty raised for this disease. There are more rational ways of increasing immunity than by the use of infected milk. Whether summer diarrhoea or infective gastro- enteritis is caused by milk-bomo infection has not yet been definitely proved. Perhaps some 10 per cent of cases occurring in London may bo directly attributable to an infected milk, others depending on factors to bo mentioned later. Whertver posstbJe cow's viilh vsed in ariiJiciaX Jixding should be oblained from a mixed herd, and nol from one eoxo onlj/, ns tbo keeping of special cows for invalids and infants increases tho chance of infected miUc if the animals should not bo perfectly healthy. Other miUvS than that obtained from tho cow have been used in the artificial feeding of infants, but they afford no special ndvant.igcs. Of these, perliaps tho commonest has been goat’s milk, which approximates in composition to cow’s milk. It is said tliat the danger 1 Sir Weldon DBlrympleChan>|in«' January 13tb, 1931, p OR ■38 FEEDING IN INFANCY AND CHILDHOOD of tuberculosis is Jess in this a&iinsb bufc the relation of goat 8 milk to lilalta fever m certain countries must bo remembered. ' Graded Milks. Owing to the gross contamination to which 60 much of our milk is exposed, attempts have been made to put on the market a clean milk which is knowm to be of n certain standard of punty, such standard con* forming to that laid down by Order under the Milk and Dairies Act of 1922. These are known as — 1. Tuberculin-festcd Milk * * ® is milk from cows which have passed a veterinary examination and a tuberculin test ; it is bottled on the farm or elsewhere ; and it may be raw, or pasteurised. If it is bottled on the farm, it may be described on the bottle caps or cartons as Tubcrculm-tested 5Mfc (Certified) If it is pasteurised it IS described as Tuberculm4estcd Milk (Pasteurised) It must satisfy certain bacteriological tests. 2. Accredited Milk Is raw mdtf from cows which have passed a veterinary esamination ; it is bottled on the farm or elsewhere. It must satisfy the same bactcrio* logical tests as raw tuberculm*testcd milk. 8. Pasteurised Milk is milk which has been retained at a temperature of 146* to 160* E. for at least thirty minutes ; and does not contain more than 100,000 bacteria per millilitre. . Must Milk be Boiled or Pasteurised 7 This matter has been carefully considered by tJie Royal College of Physicians, and the following resolutions were passed and pubhshed in April 1934 : — “ 1. That a daily ration of is important for the growth and health of children. " 2. That the nsk of tuberculosis and other disease following the consumption of raw milk is considerable. "b. 'TloA Tl^a VUb h/b ♦JjA. ’isn. of 1 SImistry of Health, Memo WT. 2Wfl. roods. Miruatry of Health Statotoiy Rules and Oidere (Milk and Dajnes. England. 10361.1,0 350 BM Stationer? 0©ee • Sliniatry of Health, (MOL and Daincs, England), 1638, ^o -IS H 51 Stationery Office INFANT FOODS 39 milk submitted to low-tempemturc pisteurisation as defined in the official order. “ 4. That such pasteorisation does not materially interfere with the nutritive value of the milk. *' The College, while realising the importance of milk being produced from cows free from infection, and under conditions of cleanliness, recommends *— *' (rt) Tliat local sanitary authorities should be given the power to require that milk sold within their areas should be pasteurised under official control. “ (6) That steps should bo tahen to permit of the pasteurisation and sale, as such, of milk from tubercuhn tested herds. " (c) That, in areas where adequate pasteurisation is at the moment impracticable, milk should be boiled before use.” In short, milk which has not been boiled (scalded) or pasteurised, should not be given to infants or children. VITAMINS The influence of vitamins in nutrition and scientific feeding is now firmly eslabbslicd. From a practical feeding point of view, some knowlwlge is essential of Fat Soluble A, Water Soluble B and Water Soluble C, and most important of all perhaps is Fot Soluble D. Fai Soluble A is essential for adequate grou th, and it has been shown ^ that it also protects against infections. It is found innaturo dissolved m animal fats (see Table TTT.), but Is absent from vegetable oils. Its absence leads to xerophthalmia, keratomalacia, and to an increased susceptibility to bacterial infections, more especially of the bronchi and intestme. It is present in milk, butter and most abundantly m cod- and halibut-liver oil ; it is also possible to got marganno which has had the vitamins added. It is not destroyed by the ordinary scalding of milk, and it is unlilrely that any infant fed on modem * Grecn.H.N ,and MelLiabv.'E.t "Vitamin A as aa Anti infcetive Agent,” Brit Joum .No. 353'4 October 20th, 1028, p 691. ■38 EEEBING IN INTAHCY AND CHILDHOOD of tuteroulosia is less m this ammnl, but the relation of goat’s milk to Malta fever in certam countries must bo remembered ' Graded Milks Owing to the gro«s contanmiation to which Eo much of our milk is exposed, attempts have been made to put on the market a clean milk which is knomi to be of a certam standard of pnnty, such standard con fonnmg to that laid down by Order under the Milk and Dames Act of 1922 These are known as — 1 Tuberculm-testcd Milk * * * is milk from cows which have pa«Eed a veterinary examination and a tuberculin test , it is bottled on the farm or el'enhere , and it may be raw, or pastciiri'sed If it i8 bottled on the farm it may be described on the bottle caps or cartons as Tuberculm tested Milk (Cerlihed) If )t is pasteurised it IS described as Tuberculm tested Milk (Pasteun«cd) It must satisfj certain bactenological tests 2 Accredited Milk is raw irulk from cows which haro pa'sed a veterinary examination , it is bottled on the farm or elsewhere It must satisfy tiie same bacteno logical tests as raw tuberculin tested milk 8 Pasteurised Milk is milk which Las been retained at a temperature of 146® to 150® F for at least thirty mmutes , and does not contain more than 100,000 bacteria per milhUtro Must Milk he Boded or Pasteurised ? 11118 matter has been carefully considered by the Royal College of Physicians, and tbo following resolutions were passed and published in April 1034 — “ 1 That a daily ration of milk is important for the growth and Iiealtb of children “ 2 That the risk of tuberculosis and other disease foUowmg the consumption of raw milk is considerable. “3 That such nsk can bo obviaied by the use of 1 Mmistiy of HeaUli Slemo J87 IC36 roods H M Stationpry Miiustry of HeoUU Btatutoiy Ruloa and Orders (BHIk nnd Dames England IMCI ^o 336 HJJ Stationo^ Office I afimstry of Ifewlli, (iWfcand Dairto England), 1538 I»o .18 IIM Stationery Office INFAKT POODS 39 milk submitted to low-temperature pasteurisation aa defined in the official order. “ 4. That Buell pasteurisation does not materially interfere with the nutntivo value of the milk. “ The College, while realising the importance of milk being produced from cows free from infection, and imder conditions of cleanliness, recommends : — “ (a) Tlmt local sanitary authorities should bo given the power to require that milk sold within their areas should be pasteurised under official control. (6) That steps should bo taken to permit of the pasteurisation and sale, os such, of millc from tuberculin tested herds. " (c) That, in areas where adequate pasteurisation is at the moment impracticable, milli should be boiled before use.” Ih short, milk which has not been boiled (scalded) or pasteurised, should not be given to infants or children. VITAMINS The inilaenco of vitamins in nutrition and scientifio feeding is now firmly establcshed. From a practical feeding point of view, some knowledge is osscutinl of Fat Soluble A, Water Soluble B and Water Soluble C, and most important of all perhaps is Fat Soluble D. Fat Soluble A is essential for adequate growth, and it Las been shown' that it also protects against infections. It is found in nature dissolved in animal fats (seo Table m.), but is absent from vegetable oUs. Its absence leads to xerophthalmia, keratomalacia, and to an increased susceptibility to bacterial infections, more especially of the bronchi and intestme. It is present in milk, butter is cod' ond }}si}ihiitdjTcr od ; }i is also possible to get margarine which has had the vitamins added. It is not destroyed by tbo ordinary scalding of milk, and it is unlikely that any infant fed on modem * Grrcn.H N , ftnd MetliuiW, E. j “ VitarainAason Antj.iafectjve Ascot.'' iltd. Jown . JIo, 0531. October 20th. 1028.9 091. 40 VEEDmG IN INFANCy AND CHILDHOOD methods Tvill suEfer from a deficiency of this ritamin. In the preparation of artificial foods and dried thU vitamin is not entirely destroyed. Water Soluble B has some influence upon growth and weight. There are really two vitamins included under this heading. (1) Tho anti-neuritio factor (Bi)» the absence of which leads to polyneuritis ; (2) the anti- pellagra factor (Bj), tho absence of which in rata leads to a syndrome rescmhlmg pellagra. Vitamm B is found in meat and vegetables, and moat abundantly in yeast preparations hho Sfarmito (ee© Table III,). It is also present in milk, and is not destroyed by scalding. The absence of Vitamin Bj produces beri-bcrl, a disease un- known in tho British Isles. Tho absence of rTatcr Soluble 0 from tho diet result.*! in scurvy. TIus vitamm is present in fresh vegetables and fniits in varying amounts, and also in milk in small quantities {see Table m.). It is partially destroyed by heating and by most of the methods used in preparing artiflcial infants’ foods, the completeness or otherwise of its destruction depending on the temperature used end the exposuro to air and oxidation. The repeated heating of mUk at tho different stages of its transport from the farm to baby’s bottle may result in the complete absence of any antiscorbutic factor m the infant’s diet. "Wberever an infant is fed artificially, it should ho given frosh fruit or turnip Juice, two or three teaspoonfuls daily. Of recent years tho Vitamin “ C ” has been isolated, and is now sold as “ Ascorbic Acid ” (Allen and Hanbury) in tablet form. The dose suggested is 1 tablet (0 OOS gm.) in each feed, or 500 units once dafly. In infants who cannot tolerate fresh fruit jmee, and in an actual ease of scurvy, where a large dose is required over a short period, this form of Vitamin C will be found useful. Vitamin D. It was thought at one time that tho absence of Fat Soluble A from tho diet was responsible, in part at least, for tho production of rickets. It is now known that animal fats contain another vitamin in close association with A, which is called Vitamin D. If this INFANT FOODS 48 DEEDING IN INPANCy AND CHILDHOOD It has been suggested that these preparations are defieient in the vitamin Fat Soluble A and D and Water TABLE V cosmosiriON or the bctter ki^own ruLL- CBIUBI DRIED MILICS }\amn of Prtfd iUUc W»t*r Permt Proleta ' t ,Cuto> brOrM let Cent Calorie lelue olOoe On are RcDUirka. Cloxo (f ill 24 22 9 25 6 42 S U7 Dned milk with crcaco) (Osttrrnilk, No 2J Tratood 15 1 AT fi 20 0 30 0 150 , milk sugar, cream /at, Vits min D and iron added yum dried rodk {full ctcftml ' 2S ' 23 2 2S2 38 35 1 1 ! 160 xnththo sdditioa o{ lactose Do > with the 40 22 92 27 0 30 62 148 aJditiOa of iron ililfo Cow and 29 1 20 6 27 3 37 6 151 Pure dnod mOk. Gate (full 1 1 24 20 9 •>7 7 37 5 , 147 CoBtains 314 36 1 26 25 200^ 37 f4 1 1 140 grams of iron and anusoBjum cit rate l>er Ib of dned niJIc. 1 Pure dned ymtl. IS 20 05 20 0 37 64 155 Do do 17 26 4 29 0 37 10 IS5 Do do Mim (foil 1 S 1 20 7 2S0 38 0 103 Do do 2 7 20 6 280 3' 5 156 Cbmpoted of nuU Ferrolao 1 24 0 26 5 38 8 144 extract eggs marrow fat, red bone marrow and the salts of hino andiron with the addition of dried xmlk. A dned milk food / designed for tho treatment of fmtntional ens DUO containing vitamin D and 1 006 parts of iron per imTlioft. Soluble C, It 13 ceri. drying is nfFAKT rOODS 45 TABLE VI DRIED SOLES WITH A DOW PAT COVTCKT Sioia of Dri^iimk wster Per cent Protetn Pereest ^r*t ^ rsrbi^ faidrxe Fercent Cdnrts Valvis of Oas tiuocs lletnukz Cow and , O&Uhalf cream 25 20 0 16 0 j 63 0 — A half-crcam dried milk modified by tho addition of lacto-io Cow and Gate epecial’ 1 hall cream 25 30 3 IG 5 43 S 133 Sio added sugar Cow and Gate (alummed) 30 35 6 08 62 8 103 Glaxo (half cream) 20 31 0 43 0 131 Trufood (!>aU cream) 1 SS 300 13 66 45 1 130 Trufood (slammed) 2S 310 1 1 5185 100 Dryco 30 32 0 46 0 123 Vtfm 26 330 16 600 107 (skunmed) Hnrhek s Slatted Milk. 26 116 8 03 s -0 00 121 Tho product re suiting ft«m Uw drying together o( fresh mdk and the extracts of malted barley Hooker a Malted , llitk 1 15 14 0 02 71 8 120 Do do Alleoburys haU 1 cream ' 30 11 S 73 8 Alleobur) a sweet whej Secway 20 13 0 1-0 76 0 104 Dried wlioy 10 13 0 10 760 100 1 Do do Csfico 550 SSO 2-0 110 1 A calcium casemato product made from milk. Ambrosia (half 2 10 27 0 1"6 45 85 133 Frailao (Cow and Gate) 17 10 8 716 128 m rLVDING m infancy anc childnood It Jias Leea suggested that these preparations aro deficient in the yitamin Tat Soluble A and B and Water TABLE V COMPOSITION of the better ki«own full- OREA3I DRIED httt.tts Curtis of Dried UUk pTriSl Punat. .Cuba* bfdnt* calorie us or Use Kemuki Glaxo (f ill cream) {Oater rrnlk ^o 2) 24 22 9 25 5 42 5 147 Dried milk with raiifc sugar, cream fat, \ ita rain D and iron added Trnfood (lull crenin) 1 2 27 0 26 0 39 0 150 Pure dried rnOk with tbs addition of lactose Dorsella 25 23 2 26 3 3335 160 Do with the additioD of iron e&vo a 4Q 27 0 39 62 US StiUo Cow and S6 20 0 27 3 37 6 151 Gate (full cream) Hnmolao 2 4 '’6 0 27 2 3*5 147 CoBtaica 3U groins of iron and oromoBinm bit rota f«r ]h of dried mile X/Bcta 3C "6 25 20 05 3-64 140 Pnre dried imlk. Milkal 15 20 05 2»0 33 64 163 Do do Ambrotus 1 7 26 4 20 0 37 IJ 155 Do do Klim (full credtn) \ irol ond idUv. 1 6 20 7 26 0 39 0 163 Do do 27 20 S 23 0 37 5 156 Cbmpost^ of malt estrnet, eggs ixiarrour /at nd bono n orroff and the salta of hmo andiron withti s addition of dried lerrolac 24 0 26 5 38 5 144 A dried milk food lies gned for tfis treatment of nutritional atsie mia conlaioing r/fMsJo D and 1 000 parts of iron per ttulHon. Soluble 0, and so their u^e xnay cause riclcts and scurvj It 13 certam, however, that th© destruction of vitarains l» drying is not complete, and the danger is ensilv overcome INTANT rOODS TABLE VI PRIED MILES T^rrH a xow fat cx>>test ■Ntmool Dried UUK 1 vr»t»r jPerwut Pnrtdn. Percent 1 Fat Per teat 1 hribste. Calorie kales ' ofOas ICematbj Cow and Gate half cream 20 0 , luO 68 0 1 A half-crcam dried jndk mod hod by the addition of lactoso Cow and Late epecW liair cream 25 30 3 1C 5 13 8 133 1 Xo added sugar Cow and Gate fakimmed) 30 35 5 08 6“ 8 lOS Glaxo (half creaml 20 310 10 5 430 131 Trufood (half cream) 1 85 32 0 13 86 45 1 130 Trufood (akimmed) 28 34 0 1 1 64 So 100 Oryco 1 30 3*’0 12 0 40 0 l-’S Klim (al^UEuned) 25 38 0 1 0 600 107 Horhck B ' Malted Milk 1 20 U6 803 '0 90 The fiToduct re suiting from (ho drying together of fresh milk and the extracts ot malted barley and wheat Hooker s Malt^ 1 Mill 1 S 14 0 02 71 8 ICO Do do Allenbury e , half cream io^ 30 113 83 73 8 Allenbury a sweet whey 20 ; 13 0 10 '6 0 104 Dried whey I 0 1 13 0 10 "0 0 103 Do do Casco 6 50; SSO 20 J 110 A calcium coseloat o product made Ambrosia flmU cream) 2 10 2-0 17 0 4«r 8■ i 10 8 716 I'S 1 60 FEEDING IN INFANCY ’AND CHUDHOOD by the addition of cod- or hahbut liver oil and fruit juice to the infant’s diet The great disadvantage in prcscnbing dncd milks lies in the fact that ifc is not so economical, and nhere instructions given by the manufacturers are followed out •without any vanation for the mdividual, the result is too often an overfed baby Many of the troubles m the feeding of the infant arise from the difficulty which is often seen in the digestion of fat and of protem We have already said that the diymg of milk is a help in the latter case, and it is now possible to give a dried milk whicli is prepared from a skimmed mtik or from one m which varying proportions of the fat have been removed Tlioso dried milks are mdicated m the presence of fat mtolerance In Table VI will be found the most commonly used dned milks with a modified fat content, together with their composition The question whether it is necessary or desirable to humanise cow’s milk— t e , to modify the composition of the milk to that of breast milk— will be discussed later Several dned milks are now sold which, on tbo addition of 1 drachm of the powder to 1 02 of water, approximate closely to the composition of breast milk The common ones w e give in Table tTI The cost of these prepvirations is, of course, greater than that of ordinary dned milLa Artificial Feeding in the Tropics On the whole dned milk is preferable Tbo elements of the diet which the infant does not readily tolerate under these climatic conditions are (1) fat and (2) sugar This fact has been noted by commercial firms, and they have therefore manufactured a special brand for ©sport to tropical countnes In lookmg at the anal^es, it will ho seen that they are lower in fat content than the usual brand Leas la recyured in these warm chmates than would he required with a higher fat content m the brands sold for use m the Bntisfa Isles Among those firms manufactur- ing a special export or tropical food are the makers of Glaxo and of Cow and Gate, the analyses of which appear on p 62, but any of the dned milks with a low fat content INFANT FOODS 51 TABLE VII SIIO^VINO the comiiovek inniAifiSED BIUED aTTT.KS AKS THEIB COMTOSITlOrr Ximeof 1 Diledilllfc Percent I’rofetn Percent pFat^ Cubc^ nfiliate. Percent. CaloHa Valne cf Ooa OoBce, Aeo&rlj Allenbury’a | ho 1 12 10 3 18 5 63 4 128 A dried milk from wbich eome casein haa been removed, soluble albumen, laetosa and cream added. To be diluted sue times instead of the usual eight AW contains dextrin maltose AUcnbary b Ko 2 1 7 17 6 i 62 7 130 Has some malted Hour added to tho above and coa taina added Vita mjn D (Calciferol) ^o starch present To be diluted sis times instead of the usual ciglit Cow And Cate TTirmum-iw^ 647 1 \ rolLr nullf pow. dcr humanized bp the addition of 1 cream end lactose Lactogeo 633 ^ i HO A dried milk, the 1 protein cemtmt of 1 irbicb bos been ro : ducedby tboeddi : tion of cream and Surwbine Glaxo (Oster Shli.No.!) 20 17 0 20 0 66 0 137 \ modified dried milk, with added lactose. V itaroin D andiron Humanjaed Tmtood 14 2S0 62 3 1 165 Dncd milk in which the ratio of the proteins has been odjosted to the breast milk stan datd with thft aildiiiOB ot f'vv thin and other necessary ingre* duuits McIIm’e Lacto 3 22 17 7 13 86 616 129 Dned milk with the addition of Mcllm’s food. 63 FEEDING IN INFANCY AND CHILDHOOD TABLE VU — eonimued tWedlS^ W»t«r P«T£«lt. Protein. Peretei Pst. Pa teat Cut>»> hr4n,te. Ptf eeat Cslr'rfe Vslos Of Oao ILrsstki. SJIjL 10 SO 280 68 0 156 Humanised Amhrosta 24 ISO 24 0 555 152 fat ftddod Modified dried milk with added cream Ambrosia 20 0 67 0 1 ~ Homamsed Dortella 2D 12 38 25 03 55 62 150 JUodUaQ (Cow and Oat«) 20 ISO ISO 50 3 HlJ as gtrca in Table VI , such as Dryco, woaM bo siutablo for use m tbe tropics Some firms, such as tbo makers of Lactogen, pack their product spcciallj for export, and they are therefor© widely popular in the tropics OJtuo (for Hxport) moisture 2 S per cent Fat 20-0 . Carbabjrdrate 46*0 „ Protein 24 S ,, Ash 6 S Calone >alue of i oz <» 135 Cov and Colt (forUxport) Slouturo 2 5 per cent. Fat ISS Protcina . 27 0 ,» Lactose • 3^ I » Cane sugar C S , Asb > 6*4 • CaloRo value of 1 or 136 " Certified ” milk ond cream for ocean voj ages can be obtained from the Walker Gordon l,aboratone3, 54 Wey- mouth Street, London, W 1, who specialise in the supply of fresh milk for travellers STARCHY PROPRIETARY FOODS Apart from tbe preparations already discussed under tbe headings of dried milks and their modifications, many starchy foods are now oficred as additions to cow’s mflk INFAOT FOODS 53 in the artifickl feeding of infants. The following are some of the common ones in use in this country, the analyses having been obtained from vanous sources, mainly from the manufacturers thmnselves. It tnvsf be understood that Oit analyses represenl (he dried preparation xchich, when made up by the addition of milk and water, is modified so (hat the excess of sugar and starch is not so marled. Tlie protein (P.), fat (F.), and carbohydrate (C.) only are mentioned in percentages, the ash content and moisture supplying the remaining figures. COMPOSITION OF PROPRIETARY FOODS AUenbury’s Malted Food, No. 3. (P,), 9 8 ; (F.), 1 0 ; (C.), 84*2. A mixture of wheat flour and malL When prepared according to directions, it still contains some unaltered starch. Designed for children above the age of six months. One toblespoonful (about 1 oz.), a tea- spoonful of sugar, and tlireo tablcspoonfuls of cold water ; mix, and add ^ pmt of boiling milk and water (equal parts). Calorie value of 1 oz. =115. Allenbury's Cereal. (P.), 13 6; (F.), 6’8; (0.), 75*2. A crisp cereal food, taken with milk or cream contaiiung Vitamins Bj, Bj, and D, with Calcium as CaO, 1«03 per cent., Phosphorus, 1*21 per cent, and Iron 33 parts per million. 1 oz. = 120 calorics. AUenbury’s Milk Food nvltb Additional Iron. This food contains iron equal to 000 parts per milhon. Arrowroot. (P.), 0-1; (F.), 0 02 ; (C.), 84-43.» Hade from the starch of the root of a West Ini'an plant {Maranta arundinacea). Calorie value of 1 oz. = 101. Bengcr’s Food. (P.), 12 2 , (P.), 0 9 ; (C.). 80 3. A mixture of wheat flour and pancreatic extract. When prepared according to directions, most, but not all, of the starch is converted into sohihie forms. The protein is also partially digested as weU as that of the milk used in mixing it. One tablespoonful (about 1 oz.) and four table- spoonfuls of cold milk, then add | pint of boihng milk and i Campbell, Jobo, Laneet, August lOth, 1029 52 TEEDING IN INTANCr AND CHiLDnOOD TABLE VH— coTi/mwei ■N»ineof Dried UUIc ^tUl rrotdiL Peftrat F«t PtreeBt Ctrto- hMnU. ftteeat. Cslorta Vo”* Bemarki 10 80 280 G80 160 Dried milk from w) ich some casein haa been removed; lactose vid apcclal Humanised Amhrteia 24 16 D 210 655 162 Modified dned milk mth added cream No I Ambrosia 164 20 0 67 6 Dned milk with modified cream content with odd! tion of Tjtamin D Humanised Doraello. 20 12 33 25 83 65 62 ISO llodiUc (powaad Gate) 20 186 too 66 3 A full^cream milk pomler cufl taioia; dextrow and dax tnn as given in Table VI , such aa Dryco, would be emtablo for use m the tropics Some firms such as the makers of Lactogen, pack their product specially for evport, and they ore therefore widely popular m the tropics 01079 (for export) Ifoisture S S per cent Fat 20 0 Carbohydrate 46 0 „ Protem 24 5 ,, Ash 6 6 Calorie vatoc of 1 oz « 135 Covr and C’'s Malted Food, No. 3. (P.), 9*8 ; (F.), 1*0 ; (C ), 84'2. A mixture of vheat flour and malt. "iMien prepared according to directions, it still contains some unaltered starch. Designed for children above the ago of six months. One tablespoonfui (about 1 oz ), a tea- spoonful of sugar, and three tablcspoonfuls of cold water , miv , and add | pmt of boibog nulk and water (equal parts). Calorie value of 1 oz. s lltl. AUcabury'j Cereal. (P.), 13'6; (F.), 6 8; (0.), 76-2. A crisp cereal food, taken vith milk or tsream containing Vitamins Bj, B,' Calcium as CaO, 1*03 per cent., Phosphorus, 1'21 per cent, and Iron S3 parts per million. 1 oz. = 220 calorics. Allenbury's Milk Food with Additional Iron. This food contains iron equal to 000 parts per million. Arrowroot. (P.), 0-1; (F.), 0 02; (C.), 84-4oi Made from tho starch of tho root of a West Indian plant (JWaranta arundinacea). Calorie value of 1 oz. = 101. Benger’s Food. 12 2 ; (F.), 0 0 ; (C.), 80-3. A mixture of wheat flour and pancreatic extract. When prepared according to directions, most, but not all, of the starch is converted into soluble forms. The protein is also partially digested as well os that of tho milk used in mixing it. One tablespoonfui (about 1 oz.) and four table- spoonfuls of cold milk, then add J pint of boiling milk and ^ Catopbel], Jobs, Xonert, Augost loth, 1029 64 FEEDING IN INFANCT AND CHILDHOOD water , act aside in a warm place for fifteen minutes, then bring to the boil Calorie value of 1 oz =*113 Betina Builder. (P ), 8 02 , (P ), 0 76 , (C ), 87 31 A preparation consisting of a mixture of dcxtnnised wheat flour and lactose to be added to milk ' Berina Malted Milk Food. (P), 20 36, (F), 16 77, (C) 66 92 Made from whole cream milk, sugar of milk, cream of wheat and extract of malt Prepared with the addition o^ water Chapman’s Whole Wheat Flour (P ), 0 4 , (F ), 2 0 , (C ), 79 3 A finely ground wholemeal flour Not much superior in nutntive value to ordinary “ household ” flour Starch entirely unaltered Calorie value of I oz = 112 Cream of Rice (GrouU’s) (P), C9, (P), 03, (C), 80 0 Tins 13 a patent food containing a high proportion of starch Calone value of I oz = 105 Cream ot Wheat (P) 1181, (T). 2 40, (C), 72 40 Made from the granulated endosperm, or kernel, of wheat Calone value of 1 oz = 108 Daltose (Cow & Gate) A mixture of carbo hydrate containing maltose and dextrose, etc Its composition per cent is moisture 6, maltose and dextrose 60, doxtnns 37, calcium lactate 2, Vitamin D 2000 mtemational units per lb rarer (Glaxo) (P), 146, (F ), 36. (C ) 716 A preparation requiring no cool mg contaimng wheat flour 63 per cent , Midlothian oat flour 18 per cent , maize flour 10 per cent , wbeot germ 16 per cent , dned jeast, bone meal and ntamme concentrates , the whole mixture bemg subjected to a “ solubilising " process to increase the digestibihty of the contents Calone value of I oz = 110 ' Glax-Ovo (P), 18 3, (T), 13 3. (C), G2 2 A preparation conaistmg of milk sohds, malt extract, flavoured with chocolate and contaimng added vitamin D CJalone value of 1 oz = 133 Lacto-Vegma (P), 16, (F), 16, (0), 05 A mdk food combining, m dned form, milk and the juices of vegetables, supplemented by the addition INFANT FOODS 55 of carboliydrates, proteins, and lipoids, and adeqtiate sources oi Vitamins B and D. Maltosan. (P.), 9-1 ; (F.), 0 64 ; (0.), 85*19, A shiny powder, containing iu desiccated form all the elements of malt soup except the milk and the water (t.e , wheat flour, malt extract, with a solution of carbonate of potash). To prepare 1 pint of soup take f pint of water, i pint of cow’s milk, and 2| oz. of Maltosan. Pass through a strainer and heat quickly, stirring all the time. Calorie value of 1 02 . = 116. Mellln’s Food. (P.), 10-3 ; (P.). 0-2 ; (C.), 80-4. A completely malted food. AH the carbohydrate is in a soluble form, hlay be regarded as e desiccated malt extract. Half a tablespoonful, J pint of milk and } pmt of water for a child under the age of three months. Calorie value of 1 02 , as 109. Neave’s Cereal, Food, (P.), 14>50; (F.), 2*13 ; (C.), 78 0. A purely cereal preparation. Calorie value of loz. = 116. NestU’s Milk Food. (P.), 14-5; (F.), 0-16} (0), 77*2. A mixttxre of desiccated Swiss milk, baked wheat flour and cane sugar (27 percent.). Contains about 18per cent, of starch. Calorie value of 1 oz. = 12C. Ovaltine. (P.), 13-2; (F.), 7-0 ; (C ), C7-9. Aeon- centration of the nutritive constituents of malt, milk, and eggs, flavoured with cocoa, and issued in the form of light, readily soluble granules. Contains neither starch fibre nor husks of grain. Calorie value of 1 oz. = 120, Pablum. (P.), 14-8; (F.), 3 00; (0.), 71-4. Com- posed of wheatmeal, commeal, rolled oats, wheat-germ, alfalfa, yeast, and edible bonemeal. Calorie value of 1 02 . s=s 120. Ridge’s Food. (P.), 12-13 ; (P.), 2-71 ; (C.). 79-7^. A baked flour, containing only 3 per cent, of soluble carbo- hydrates, the remainder being starch. Recommended to be made with miik and water. Calorie value of 1 oz. = lie. Robinson’s Patent Barley. (P.), 7-2; (F.), 1'35; (C.), 81-3. Ground pearl barley, poor in every element 60 FEEDING IN INFANCY AND CHILDHOOD except starch and mineral matter Calone value of loz = 109 Robinson's Patent Groats. (P), 12 25, (F), 73, (C ), 72 4 Ground oats u ^ch the husk has been removed Rich in protein and mmcral matter Calone value of I oz = 121 Rjaila Crispbread (P ), 11 0 , (P ), l 3 , (0 ), 74 8 Made m England from crushed whole rye gram Calorie value of 1 oz = 104 Savory and Moore’s Food (P ), 12 0 ; (E ), 1 5 , (C ), 70 8 Composed of wheat flour with the addition of malt and diastase When prepared according to the directions, most, but not all, of the starch is converted into soluble forms (chiefly maltose and malto dextnns) One or two tableapoonfiUs (equals Irom 1 to 2 oz ) to bo mixed with two or three tablcapoonfuls of cold milk or milk and water, and i pint of boiling Tn>ik or milk and water to bo added Catono value of 1 oz « 111 Scott’s Oat Flour. (P), 97, (F), 60, (0), 78 2 A flne oat flour Starch unaltered Calone vMue of 1 oz = 118 Sister Laura’s Food (P ), 20 9G , (F ), 2 04 , (0 ), 76 27 A food prepared from wheat starch, intended to bo added to undiluted milk Calone value of 1 oz = 123 Soya Bean Flour ^ » (P ), 44 ; (F ), 20 , (C ), 14 A flour with a very high food value, especially protein, and a high vitamm content, made from the Soya bean Calorie value of 1 oz = 124 Veguva (P), 9 63, (F), 2 90, (C), 77 24 A lined mixture of spmach, carrots and tomatoes, nch m Vitamins A, B and C (the latter not destroj ed by drying) The vehicle used is a mixture of star^ and its vanous cleavage products obtained by diastatio ih'!integration To be used as a substilnle for borne mado vegetabto broth Calone value of 1 oz =112. I Steam, O vim J X>»# CA , a oL 40. p 7, 1053, Soy# Bean m Inlant Feedmit * . _ » HillandStuart J.A Jlf 4 ,Tol. 03 p 035, lS29,''SoyaBeaa m Slilk Idjosyncrasy ” INFANT FOODS 67 Virol. (P.), 7-50 ; (F.), ll-GO ; (C.), 50*33. Com- I>ose(l of marrow fat, glycerine extract of red bone marrow, eggs, salts of lime, etc., malt extract, and tli6 Juice of Desh lemons. VitaAVeat. (P.), 11-52; (P.), 7*66; (C.), 74-77. Slade in England from wbob wheat. Calorie value of J oz. = 127. When a proprietary food is used the greatest care must be taken that it is not given in excess. If the proportion of starch be too high a dabby pale infant results, with a low resistance to infection (see p- 13G, Starch Dyspepsia). Many of the proprietary foods am deficient in vitamins, and therefore cod-Uver oil and fruit Juice should invariably be added. The baby who will not tolerato sngar when this is given as ^ cane sugar or lactose will often take an adequate amount of carbohydrate when given a preparation cootaiiung a mixture of dextrins and maltose (partly digested starch), or again may fail to gain weight on simple milk mixtures and will Uurve at onco when Eomo starchy food is added to the diet. At the period of wcamng a proprietary food may initiate with success the first attempt to give more than milk. In later chapters wo shall indicate the difficult cases of feeding which may ho expected to improve on the use of proprietary foods. CHAPTER ir artificiaiT^eeding The esfenha! prohltm of (he tohole of ariifcxal feeding w to modify cow'e mill eo that (he infant mil Uint-t on tl ae toell as it does on breast mill * This is not aceompli'lied nece<5‘5anlv by making cow’s milk approiimato to breast milk in Its composition, but the aim is to make it net as adequately as the mother’s milk There are certain fundamento] diSScronces hctrreco cow B milk and breast milk which can never quit© bo OTcrcorao Breast milk is fed ihreclly to tbo infont, wann, and for all practical purposes stenle, and m the quantity demanded by tbo infant’s metabolism itself If the child demands more, the breast is more completely emptied and more u supphed, and if less is demanded tho reverse occurs In artificial feeding on the other band, many hours elapso between the drawing of the milk and its being fed to the infant Bunug this time milk must be cool^ or boiled to preserve it It is no longer stenle, but m many cases teems with bactena , its casein and fat are diflit-ulb to digest and lastly, tho most important difference is tliafc it is supphed to the infant to quantities determined by paternal calculation and not by the infant itself In Table VIII wiD bo found a comparison of tho composition of human milk and of cow’s milk In addition to the above substances pre«ent in tho two milks which show great vonotion*', there are the anfa- mins, Fat Soluble A and D and ^^atc^ Soluble C, which prevent nekets and scurvy respectively Attempts at modifymg con ’s milk by prc-digcsting, healing, boilmg or » Brenoetnana, J s Abt«P**(Latnc9" Vol II. p 023 artificial feeding , TABLEVUI. SHowijra THE co 5 iposrno 27 or cow's aOLK THAT or HOMAK MILK Water . 8C-S7 SS-05 Fat . 400 3 50 Protein. 350 125 Milk sugar . 450 700 Mmeral salts 075 0 20 even diluting must interfcro with the potency of these substances. The question arises in artificial feeding as to whether it is essential to modify the composition of cow’s milk to moke it as near breast milk as possible. The answer to this, shortly, is that all attempts up to the present have foiled to produce a food which the infant metabolises as well os it does breast milk. The primary aim, then, is that the artificial food should be metabolised as efficiently by the infant as breast miUc, and this can often bo accomplished by departing widely from breast miUi standards. It is tbo casern and fat in cow’s milk which tend to cause indigestioo ; this results mechanically from the presenco of nulk clots in the stomach and bowel. On the other band, metabolic disturbances are probably set up by the* fats and salts of the milk. An excess of protein ingested is dealt with by di amination and chmination as urea, excess of carbohydrate by increased oxidation and storage. Fat, however, when in excess, tends to interfere with the general health of the infant, causing ** bUious attacks ” and producing some of the changes known as acidosis. The whole of the three food elements, protein, fat and carbohydrate, are acted upon by bacteria- If the proteins are in exeat's the intestinal Dora is putrefactive, and the stools are said to bo offensive and facal in character. If, on the other hand, fermentative orgamsms predominate, » e., if the protein in the diet is low and the CO FEEDING IN DNEANGY AND CHILDHOOD fat and sugar relatively liigh as in breast milk, the stools are sour-smelling, slightly acid, not ofTensivo, and like those of the breast-fed infant. In the case of minor ailments in the infant the diagnosis of the cause of the upset may be difficult, because the symptoms arising iiom indigestion— the result of increased fermentation in the bowel or from a definite bowel infection by a pathogenic organism — may bo indistinguishable. Again, it may bo ifficult to say in any case of indigestion whiA of the crude elements is primarily at fault. That a balance is necessary between the different food elements becomes obvious early in the experience of the pxdiattician. If much sugar is given little milk may be prescribed. If the milk is largo in amoxmt small amounts of sugar only can be tolerated. High fata and high sugar content should never ho given in the same feed. Finally, alter a bowel infection or an attack of indigestion the tolerance for all food elements is lowered. CLINICAL IMPORTANCE OP POOD ELEMENTS The Fat. We have always believed that tbe fat is the most difficult element in tbe diet to digest. The emulsion of fat in cow’s milk is less complete than in breast milk and its globules are in consequenco much larger. The volatile fatty acids aro eight times more common in cow’s TTiiltf than they arc in human milk, and jxsrhaps this accounts to a certain extent for the tendency of cow’s milk cream to “ sour ” in the stomach. It must bo pointed out that an txcm of fat may produce either diarrheea or constipation — ^the stools may bo loose, add, and contain curds, or pale grey, formed and crumbly. An excess offatmtho feed of what ore commonly called “rich milk mixtures ” is a fruitful sourco of vomiting in infancy. ciJfc-ervur-’ bss Sixtfjin} jvwif ths/ the fat leaves the stomach last and tends to give riso to extremely acid, sour-smclling stomach contents which produce vomiting. By a series of experiments be has 1 Erenneisaxii), J. • ” Abl** Vol. II , p 822 ARTmCIAL FEEDING 61 ehown that the richer the food is in fat, the longer delayed ia the stomach emptying time. We have no methods which are of practical value of making the fat of cow’s milk more digestiblo, and therefore it remains the most difficult food clement to modify and the one which per- haps causes the greatest trouble in artificial feedmg. The Proteins. In breast milk the proportion of soluble proteins (lactalbumen and lactglobnlm) to casein is as two to one, in cow’s milk the proportion of these elements is one to four : in other words, the protein of cow’s milk ia largely made up of Casein. There is no difficulty in digesting the soluble or wboy proteins lactalbumen and lactglobulm. Casein {Curd). Acid and rennet acting on cow’s milk produce a coagulation largely brought about by the <^ein. This is seen, of course, in the making of whey or junket. The breast-fed infant who vomits some time after food brings up soft, fine curds because of the small pro- portion of casein in breast milk. The bottle-fed baby, on the other hand, vomits large hard curds, especially if the feed is one of unboiled milk. Curd formation maybe modified by tarious methods ^ ^ 1. By bringing mitk to the boil m a double saucepan. This modifies the casein, and curd formation in the stomach is greatly diminished. PasteorUation does not inhibit curd formation. Prolonged boiling destroys the vitamin content. 2. Dilution with Water. Diluting the milk with water causes the curds to bo smaller end, since the diges- tion of the curds in the stomach occurs from the periphery, this digestion is aided. 3. Dilution with Cereal Waters. This method is even more effective in retfaemg cuni formation riran &■ dilution with water. The usual cereal water used ia barley or oat water. It is suggested that the colloidal solution of cereal water surrounds the particles of casein and prevents their clotting together to form a large curd 1 “Slilk Curd. Its Mechanism and Jlodiflcatioa," Ketrton Kugel. mass. Arch J)is, ChO^ood, Vol XZI , 1937. p. SS 62 FEEDING IN INFANCT AND CHILDHOOD 4. PcptonUation. This is tho most elleclive method of dealing with the casein, but it is complicated and expensive, and is not neccseary for the modification of cow’s milk in feeding healthy infants. Tho subject of peptonisation of milk will bo referred to later in tho chapter on the feeding of ill infants (see p. 82). 6. By the uso of Dried or Condensed llilka.' In tho process of dTjung or condensing cow’s milk the protein is in some w’ay modified so that tlie curd produced in the infant’s stomach is definitely smaller and softer than when fresh cow’s milk is used. C. By tho use of Alkalies. These may bo giren as lime nater (calcium hj’droxido), sodium citrate, soclinm bicarbonate or magnesium hj-dro-xide (milk of magnesia). It is difficult to explain tlidr mode of action, but it U thought that they displace tho calcium from its combina- tion uitb the ca.«eiD (calciam caseinate), and that tho resulting combination produces curds sober and smaller in size nhen acted on in tho infant’s stomach. The lodications that there is ioo much jitvtein in the diet are ; — 1. Indigestion with marked colic, and the feed vomited contains large hard curds. 2. Coustipatiou. The stools tend to be gfcea or may be yellow in colour. Tlicy contain tho characteristic large, pale amber curds which do not appear greasy in character (see p. 123). 3. The infant fails to gain weight, looks lifeless, u ith a pale, muddy complexion, and the whole picture suggests that the Infant is being poisoned. The Carbohydrate. Svgar. Ijictose or milk sugar is the only carbohydrate present in human or in cow ’s milk. Tho sugar may be reduced in quantity by diluting the milk or by tho removal of the whey, os this contains almost the whole of the , carbohydrate in solution. in Vn practical Jeedint} of cAiWrcn stijar is essential ij the infant is to gain tceight. It will bo found that few infants can take more than 2 oz. (eight heaped tea* spoonfuls) of added sugar in twenty-four hours. ARTIFICIAL FEEDING 63 Tbo ej'mptoms of engar intolerance are those of frequent frothy, acid, scalding stools •vrhich rapidly excoriate the buttocks. As a rule, this indicates an active fermentation of the sugar by the organisms present in the intestine. It is normal in breast-fed infants for fermentative organisms to predominate over putrefactive in the bowel, since tbo protein of breast milk is low and the sugar liigh. Tins accounts for the fact that the stool of the breast-fed infant is slightly acid and not offensive in odour. The artificially-fed infant, on the other hand, is usually pven larger quantities of protein, and so the putrefactive organisms predominate in the intestine. The characteristic stools are more formed, are alkaline, and tend to be offensive in odour. Our aim in artificially feeding an infant is to give a feed which results in no excess of putrefactive over fer- mentative changes in the bowel, and when frequent and fermented stools are passed it should be taken that the sugar is being given to e.vecss in the feeds. On tbo other hand, the infant who is constipated, whose stools are alkaline, and a bo is failing to gain weight, requires the sugar in the feed increased. By increasing the acidity of the bowel content by means of added sugar, the stools tend to become more frequent and constipation is relieved. The question is often asked ; " Is it necessary to use aspecial type of sugar in thenrtificial feeding ofinfants ? We think that for a healthy infant it is not necessary to order a spcdal sugar ; in fact, the ordinary cheap bro^vn sugar mtcy usually be given. Lactose has no special value when added to the feed, and many consider it to bo less digestible than some of the cheaper sugars. ^Mien, how- ever, wo consider the case of the child who is prone to get indigestion, there is no doubt that in these conditions a mixtim) of dextrin and maltose is the most easily tolerated of all the carbohydrates. Such preparations as Mead's Deitrimaltose, Mellin’s Food, Wander’s Kutromalt and Karolac are mixtures of dextrins and C 4 PEEDrXG DC DCFAXCT AND CHILDHOOD maltose, and may be giren as the carbohydrate of cLcdce to the artificially-fcd infant TThere the question of expense docs not arise. Horlich's Malted Milk, in virtue of the dext ri mal t ose it contains, is also useful in cases uhcre there is a tendency to carbohydrate intolerance. PoljEacchari^, e g , starches, are digested in the upper part of the alimentary tract and the greater part of them is absorbed &om the lorrer ileum. Th»a delay in absorption allows some fermentation to take pbce. Monosaccharides, e g^ glucose, are absorbed from the stomach, duodenum and upper part of the ileum. The chance of fermentation is accordingly lessened. “ Dextri- maltore,” however, is tolerated when other carbohydrates produce fermented stools. SiarOi} When a feed with a high sugar content is taken, digestion is rapid and the sugar absorbed qniddy. It is found extremely useful m infant feeding — sometimes at an early age, and certainly when a child reaches 16 lb.— to give a proportion of the carbohydrate m tbo form of starch. The process of starch digestion is slowerthanthat of sugar, and absorption takes pkco tluroughout the interval between two feeds. In many cases this appears to be of considerable advantage. Wo are well aware that some authors state that starch is not digested by an infant under the age of six months That this is a fallacy can readily be shown by following the blood-sugar curve of an infant when starch has been given by mouth. It will be seen that tliero is no essential difference between tbo blood-sugar cuivo so obtained and that after the infant has had a feed of glucose or some other sugar. Some children who are unable to tolerate a full carbohydrate feed where the carbohydrate is present as sugar w iff 60 lonnd* to tolcraie it‘ wden a cerfaiii proponiyir of starch is substituted This fact has long been realised by tlic ni'inuf-vctureri. of proprietary foods, ond such foods as AIlcubuTy’s N<>, HI., Rita’s Food, Robinson’s Patent * IVttwsoM, lX\*siiVti *'Th<* of StAreti in Infant Feeding." ARTmCIAI. FEEDING 65 Greats and Barley, Robb’s Biscoits, Neares’ Food, Sister Laura’s Food, and many others, hare proved successful m virtue of their starch content. A word of must, however, bo given hero. Wo still aro not aware of all the factors in tho production of such disturbances of nutrition in infancy as, for example, rickets, and it is thought that a predominance of starch may be responsible to a certain extent for some of these disorders. When used with care, starch is most helpful in the artificial feeding of infants and it has already been stated, os cereal water, starch performs a valuable function by preventing excessive curd formation (seep. Cl). Salts. Calcium salts in combination with casein are present in larger quantities in cow’s milk than in human milk, whilst the reverse holds true for the salts of potassium and iron. Phosphorus is present in larger quantities in cow’s milk, but less of it is present in an oiganio form, and this may explain its less complete absorption. Iron is present in such minute quantities m cow’s milk and human milk as to bo inadequate for the child’s needs, but during tho last month of intra-uterino life a supply of iron is laid down in tho liver of tho foetus. When pregnancy is interrupted prematurely tho child is deprived of this store of iron and tends to become anaimio. Ono of tho greatest arguments in favour of early mheed feeding is the fact that an iron deficiency exists. Tho giving of bone broth, meat juice and cereals which contain iron at an early ago has thus a rational ba-sis * Since nehets may be produced by an insxtjjicitnt inialc of calcium in tho food of tho child, or, if it is on the breast, of the mother, it is important to sco that the supply of this salt is adequate. This prov ides an argument against tho too rigid humanising of cow’s milk, sinco, by means of marked dilution to reduce tho amount of casein present, tho calcium salts may bo reduced below tho minimum necessary to prevent rickets. There is no doubt that tho * Serna csflaafacturr^ of dnod add iron to Ibwr pwporatioiu (•» FerroUs B&d ilsusotac} 00 FEEDING IN INFAKCT AND CHILDHOOD absorption and utibsation of salts from tho breast milk is mneh more efficient than, from cow’s milk. Watw. Hie normal healthy infant requires about 2J oz. of fluid per pound body eight per day. Part of this he obtains in the form of millg and the remainder must be given as added water. In summer time much more water than this is required for obvious reasons. If an adequate amount of water is not given to a child ho tends to become constipated and to pass only a small quantity of highly concentrated urme, which stains the napkins. In marked cases of dehydration tho infant almost invariably runs a temperature. If water is withheld stiU further the child appears to he poisoned by its feed. As a cure for constipation in breast-fed babies additional water is nsefiil. Feverish and vomiting children and infants witli acute diarrhosa all require additional water. Water with a small amount of salt (i drachm of salt to tho pint), that is, half normal strength saline, when given by tho mouth, is rapidly absorbed and retained. On the other hand, cases have been known where infants have been given too large quantities of water which has kept going an existing diarrhoea, and on the restriction of tho llmd to more normal requirements tho diarrhoea has ceased. hlETnoDs OF Aetifioiai, FEEDISa Many methods of artificial feeding have been advo- cated in the past, and each has proved successful in a pro- portion of cases That no particular method has proved universally successful must bo acknowledged. Wo propose to discuss some common methods which are used, and to suggest one method (C) whoso great merit hes in its simplicity. It must again be emphasised that each indi- vidual case requires consideration and that tho baby is aJirays tho bestjadgoa^to whether it isreceivingadeguate feeds Tho methods of artificial feeding may bo stated to bo— 1. Whole Milk Feeding. This method has been practised successfully in various countries for many years. ARTIFICIAL FEEDING 67 (uid it has oven been shown that premature infants couid ho reared successfully on whole boiled milk. A fact which IS often forgotten is that the infent who is given a full- cream dried milk, such as Glaxo, Cow and Gate, or Ambrosia, when this is made up in the usual proportion, t e., a heaped teaspoonful, or measure, to an ounce of uater, is virtually Bemg fed on whole milk. The arguments in favour of this method of feeding are : — (а) A small concentrated feed of high caloric value can be given. (б) Its preparation is extremely simple. (e) The biological value of the protein is certain to be sufficient for the infant’s needs. The arguments against the use of whole milk are ; — (o) That it lacks the physiological balance of food- stuffs, ».e , the protein is too high and the sugar too low. The latter deficiency, of course, may be easily corrected by adding sugar, and we have already given the methods for modifying the curd formation which would decrease the tendency to protein mdigesUon. (6) When an infant is fed on breast mill: it requires 2 J 02 . per pound body weight per day. When fed on cow’s n^ with sugar added it requires only 3| 02 . per pound body weight and is, thertfoTo, considexahiy short of ftmd. (c) The secretion of hydrochloric acid in the healthy infant’s stomach is sufficient to digest adequately the protein present in breast milk, but is insuffiaent when whole cow’s tnilk is given (see Lactic Add Milk,” p. 76). We consider that in the first three months of life, at least, the disadvantages of whole-milk feeding outweigh its advantages. 2. Humanised Milk Method. Sitigh Formula. Tlus method of artificial feeding depends on the use of a single formula, by means of which a mixture is made of cow’s milk which is said to be adequate for all infants at all ages. The total quantity of mixture required for any infant is based on the known fact that a normal healthy infant 68 FEEDING IN INFANOY AND CHILDHOOD reqali;ca 02 of breast milk per pound body weiglit per day, ^ Kno’^^ingthe^eightofaninfant.thototalqnantity of nature for tlie day is calculated, < ? , 1 10-lb baby requires 25 oz. (2^ oz. X 10 02 .) of mixture. This is made up of milk and water equal parts, the dilution bicb brings the protein of cow’a milk to the level of that in human milk (S per cent.). To each pint of tho mbeturo 1 oz. of sugar is added — making the percentage of sugar about 7 per cent. Fat in the form of cream or cod-lIvcr oil is also added to tho mixiuro to make up any deficiency in this component. The disadvantages of tho method lie in tho fact that — 1. By keeping tho percentago of protein low tho bio- logical value of this constituent may fall below tho needs of tho infant, 2. The 60 per cent, dilution may result in giving n mixture which is too low in calcium content. 3. Although suitable for tho first two months of an infant’s life, when older tho amount of mixture calculated as shown by weight requires the addition of so much carbo* hydrate in tho presence of a low protein content that there is a grave nsk of gastro-intcstinal upset from tho excess of sugar given. ThusaI2-lb baby by this method would bo given2j X 12 =30 oz.ofmixture, and to this would have tobeadded IJ oz ofsngar. Most infanta wdl not toJerato carbohydrate m this quaoUty daily unless tlio curd content of the feed bo raised. 3. Percentage Feeding. This method is based on an attempt to modify cow’s milk so that tho percentage composition closely approiimatca to that of human milk. Cow’s milk contaiM 4 per cent, of protein (or four parts per 100), whilst breast milk has onlj two parts per 100. Tho percentage mixture is made by adding water to cow's mi lk to dilute tho protein and tho adding of carbohydrate as milk sugar or as DextnumUoso.” Fat in the fortn of cod-hver oil is also added. Tlie quantity of tho mixture to bo given to tho infant is calculated by cstimatuig tbo number of " calories ” it requires In tho day, and knowing ARTIFICIAL FEEDING 09 the ntnnbcr of calories each ounce of the mixture vrill produce ■when metabolised by tho infant. The Walkor- Gordon Laboratories (S4 Weymouth Street, London, W.!) supply feeds made up to any percentage ordered. The addition of water to cow’s milk may dilute it so that the protein is lowered to the same percentage as that found in humon milk, bnt it la seen thot the proportion of casein to lactalbumen remains unmodified. Again, tho value of a protein depends ulUmately on its ammo-acids, and these obviously arc not affected by the eimplo addi- I tion of water. Cow’s milk protein is not, and never can bo, a true substitute for human protein. When we know uhat amino-acid groupings and what proportions ere essential for tho adequate nutrition of infants, and ■Rhen . starling with cow’s milk, wo can bo modify it that tho amino-acid groupings correspond to those found in human milk, WQ Bhall then havo some reason for calling such a feed “ humanised ” milk. Accepting the fact, however, that humanised milk approximates to human milk in any given sample, can wo alna}s bo sure that by following a given method of dilu« tion and addition of fats and carbohydrate wo always obtain tho same definite composition ! A study of tho variation in the composition of cow’e milk soon shows that to carry out the taethod rsthnaUy elaborate analysis of tho cow’s milk becomes an essential beforo an accurate humanised milk can bo made from tho daily sample. Even if these difficulties bo creomo the question may be asked ; “ Is it necessary or desirable to perform elaborate modifications of tho cow's milk in its prepara- tion for tho infant 1 ” The anmrer is that wo know of nothing in tho baby’s digestive powers which prevents its easily digesting and assimflating a mixture which con- tains a slight increase or decrease in tho proteins, fats or carbohydrates. 4, Caloric Feeding, TJie term “caJono” means a unit quantity of heat One gram of protein or of sugar j iolds about 4 calorics, ubilst 1 gm. of fat jdclde about 0 calorics when utilised 70 FEEDING IN INFANCV AND CHILDHOOD by the body. Stated another way, J 02 . of cow’s milk h equivalent to 20 calories and 1 02 . of sugar is equal to J20 calorics. It has been shown by many obserTcrs that the caloric requirements of infants vary according to llicir age, activity, state of nutrition, and the tcffli>enituw of their environment— in fact, their calorio requirements arc altered by those factors which modify tho infant’s meta* holism. It can readily be understood then that the caloric requirements of infants, even when healthy, are very variable, but it may bo stated that a normal infant in tho English climato requires about 40 to 45 calorics per pound of body weight per day. Some underweight infants may require as much as CO calories. It must bo realised that the estimation of the number of calories required by an infant in tbo day can only bo calcnlatcd roughly, and it is impossible without consideration of tho above factors to use this method as more than a rough guldo to control the artificially-fed infant. It has a use in preventing grow over- or underfeeding (eeo pp. 20 and 25). 5. Simple milk dilution with addition of Carbohydrafe— the method of choice. Four methods of artificially feeding an infant on cow’s milk have been given. Feeding on whole milk ifi simple, but the problem of tho *' casein clot ” makes it undesirable, especially for tbo very young infant. Tho method of using a single formula ihumanised) may result in a gastro-intcstinal upset when tho weight reaped by the baby entails the nso of largo quantities of carlK>- hydrate, and tho calculations depending on the estima- tions of calories and tho use of tables make tho percentage method ratlicr too complicated to cany out in general practice, unless assisted by a nurse who has bad o special training in tho subject. Tho busy practitioner may ask then how h he to know whether an infant is being given too much or too little in its feeds, and are such feeds properly balanced— that is, do they contain approximately tho right proportiona of the mrioas constituents I TTc Mini Me troy to approach 72 FEEDING IN INPAKGt AND GHiEDHOOD baby 2J x 12 =s 30 oz of fioifl, in tbo twenly^four hours. The amount which an infant drinks wiU vary, of cootsq, with the amount of fluid it Ic»es by the bowel, by the kidneys and cspetaally by the skin Infants readily get dehydrated in warm weather owing to increased perspira- tion, and this increased loffl mast be made good by allowing drinlvS of water between the feeds, but these latter must never be allowed to fall below what Nature allows, as shoirn by the amount of breast mill;, Thejluid reguiremenl of a Jieallkf/ injanl in ihe dayis ghen by mvUiplying body weighi in pounds by 2 J o:. CoNv’s Milk. An analysis of a large number of normal infants’ feeds has shown that the baby will thrive well if the basis of ita feeds consists of 1 1 oz. of cow’s rmlt per pound body weight each day. An S-lb. baby would need x 8 oz or 14 ©z. in the twenty-four hours, and aa auch an infant requires 20 oz {2\ x 8) of total TABLE IX.a. itETHOn of ixEDisa on cow’s iolk nv BTUru: WLUTTOK AN1> THE ADDITION OP SDOAB Weluht el rnf»sV In rousdv OuBrtiO? CowiUUk Onset* «f VIMU full sreuEtf 5 8 6 6 0 n 6} 6 0 7 11 6 7 6 8 ' 14 H 8 G t> 1 7 9 C 10 1 17 8 10 5 11 ' 181 0 11 6 12 21 9 12 5 13 221 m 13 6 14 23 12 14 5 16 25 15 6 fiiiii, ft OZ dS wiAm TBoa-t kfi, e-dded. Ddutiou., as we have already noted, also entails the addition of sugar and fat. The latter is best given as one teaspoonful of cod-hver oil or one drop of habbut-Uver oil three times daily before a feed and not mized m the bottle. The additional sugar, as shown to be necessary, consists of ARTiriCIAL TEEDING 73 ono JcTcl tcsspoonful (I diachm) for each pound body v-eight An 8 !b baby then would have ejgbt level tea spoonfuls of sugar added to the day’s feed, which contains 12 02 of cow’s TTtibv And 8 oz of water The feed for a 12 Ib baby would consist of mtlt. 1| x 12 = 21 oz , water 9 oz (12 x 2} ^ 30 oz of total fluid) and sugar twelve level teaspoonfuls The total feed of 30 oz would be divided into five bottles, given at four hourly intervals, and before three of the«e feeds the infant would have a tcaspoonful of cod liver oU, or one drop of hahbut hver oxL Tht milL requirement of a heaWiy tnfant »a the day « pnen 6y inuUiplyinq tfe body tccigJit tn pounds by IJ and, in addition, ti aleo requires one level ieaspoonful of sugar for caefi pound ic^igJ t per day Put another way, the healthy infant requires 2^ oz of a mixture of two parts of milk to one of water, with a level tea«poonful of sugar added for each of Us pounds body weight per day Full cream Dried MiDc (Cow and Gate, Glaxo, Ambrosia, Dor««lIa, Lacta, MilLal etc , Table IX s) It will be remembered that one heaped teaspoonful or measure of a full cream dned milk dissolved in 1 oz of water reconstitutes 1 oz of cow’s milk The amount of TABLE IX B METHOD OP PEEDIXO ON riTIX-CEEAM DSIED MILKS WITH ADDED St/QAE 74 FEEDING IN INFANCY AND CIIIIDHOOD full creattt dried milk necessary for normal progreBS has been determined m a similar manner to cottV milL It la found that the amount xequised is l|^ measutes or drodims per pound -weight daily Aa before, one ht'd teaspoonful (1 drachm) of sugar must be added for each pound, and one half teaspoonful of cod liver oil or one drop of halibut pver od also given three tunes m the day The fluid requirements are -worked out as already given and the amount of dried milk dissolved m this An 11 lb baby needs X 11 oz of water, with Z X 12 level teaspoonfula of sugar m each twenty four hours The drted (fuU-creant) tntlh requirement of a healthy \nfant in the day ts given by wuKiptymg the body iceijjZjt in pounds by one and three fovrlks heaped teospoonfuh, or mcosuTM mrrJi»ra. Tlio symptoms of tliis condition aro given on p. lOS. Tho high protein and low eugar composition of /actio ocid milk prevent io some eatent fermentation in tlie intestine. 3. Acute Oaelr&‘Enterilis may bo treated witli success by this method. A Simple Method of Preparation. TJic use of cultures of lactio acid bacilli render this method somewhat un- practical except in cluldrcn’s hospitals, but it has recently been shown that lactic acid milk may cosily be prepared by tho simpio adthlion of tho acid to stctiUsed milk. Tho results obtained have been comparable with those seen when the older method of fcrmcnlation -was used. Tho method now adopted * is to take 1 pint of skimmed con’s mills, which has been boiled and nllovrcd to cool, and to add to this np to forty-fivo tlrops of hctic add (C r.) drop by drop, sUrring wcU all t!io time. Sugar is added, and tho mixturo may bo given in full strength or after dilution. It must not bo warmed to more than hlood heat before being gireo to tho infant, however, or it will curdle. * itclhdd de«t}bed by ilamatt 78 FEEDING IN INFANCY AND CHILDHOOD During the s umm er weather, and especially if there 18 a long interval between the production of the imll< and tho receipt by the consumer, the natural acidity of the milk increases. Because of this the full quantity of lactic acid cannot be added to the milk without curdling, in fact, sometimes less than one-half or even one-quarter will turn the m i lk sour. It is because of this that up to Jorty-fivt drops per pint is suggested. If any difGculty is experienced in following the above directions, the easiest method of preparing lactic acid milk is os follows : — 1. Make the infant’s feed up from the boded and cooled milk with the necessary water and sugar in the feeding bottle. 2. Warm this to blood heat, then add from one and a half to two drops of lactic acid (B.P.) for each ounce of cow’s milk used in the feed, e p , a 7-oz. feed containing 5 oz. milk and 2 oz. water would have from seven to ten drops of lactic acid added. 3. Beplaco the teat on the bottle and feed immediately without further wanning. Lactic acid milk can bo obtained from the Walkcr- Gordon Laboratories (64 Weymouth Street, I/jndon, W. 1), or from Messrs. L. A. Hmdley, 110 Coniston Road, Broniley, Kent (Bulgolao). Of the dried lactic acid milk preparations the best known are " Lacidao,” made by the Cow and Gate manufacturers (The West Surrey Central Dairy Company, Guildford), and that made by the Merrell-Soule Ojmpany (110 Cannon Street, London, E.C. 4), tho analyses of which are given on p. 77. Hydrochloric Add Milk. In the treatment of infants with eczema or other forms of the allergic diathesis, hydro- chloric acid milk is often considered to be of use. Tho method of preparation is os follows : — 1. Tho milk is boiled, cooled, and the skm removed. This skin is said to consist largely of lactalbnmen, which bos been held to be the constituent in milk responsible for the allergic phenomena. AETHICIAL FEEDING 70 2. Place ia the bottle the required amount of the milk, add water and sugar, to complete the feed, and worm to a suitable temperature. 3. Now add, drop by drop, from one and a half to , two drops of acid hydrochloric dil. (BJ*.) per ormce of cow’s milk in tiio feed, as described under Lactic Acid Feeding. {,"4. Do not warm further, but feed directly to the infant. AUergUac. (F.) 16*15pereent.; casein 24 0 per cent.; lactalbumen 1-0 p* cent. ; ash 6‘7 per cent. ; lactose 49 8 per cent. ; moisture 3 0 per cent. ; acidity value 27* pH value. The Cow and Gate manufacturers now make Aller- gilac— a dried milk contaimng the necessary amount of lactic acid, and with the lactalbumen removed. This is claimed to be suitable in allergic coDditions in infancy and childhood. Buttermilk. In the British J^Ies buttermilk is not widely used, but both on the Continent and in America it is more costly obtainable, and its value is generally recognised. Buttermilk is that doid which is left after the fat has been removed from cream by ebaming in the manufactore of butter, and its sourness is due to the presence of lactic acid. Its compceiiioa is apprccri- mately 2J to 3 per cent, of protein, 0*5 per cent, of fat, , and 3 to per cent, of carbohydrate. Its chief uses are in the diarrheeal diseases of infants, especially in those cases where fermentation has been marked. A very excellent dried brand, “Eledon,” is prepared by NestI6. This is a half-skimmed fresh milk inoculated with lactic acid o^anisms, and, after acidiBcation has proceeded to the desired degree, it is dried by the spray prs5\re^. 31b? es^pc^StxB sf fA\p -diy Is a? follows : butter-fat, 14 per cent. ; protein, 30 per cent. ; lact<»e, 39 per cent. ; mineral matter, 7 per cent. ; actic acid, 6 pet cent.; residual moisture, 4 per cent. 1 oz. of “Eledon” yields 124 calories. For general use the dilation recommended is one part of " Eledon ” so FEEBING m INFANCY ANB CHILBHOOB in 10 parts of water, and the metal measure enclosed with each tin holds -|*oz., of “Eledon,” which is rafficient to prepare 4 fl. oz. of -acid battermilk. Buttermihc is also obtainable fresh from the Walker-Gordon Labora- tories (64 Weymouth Street, London, W.l). Buttermilk Powder. A buttermilk powder is pre- pared by the Glaxo Laboratories which when reconstituted in accordance with the directions, gives a solution having a pH of 6*7. To make half a pint of buttermilk one ounce of Buttermilk Powder G.L. is mixed with sufficient water to make a smooth paste. Hot water is added up to the required volume, and the whole is mixed thoroughly. Analysis ; moisture, 3*6 per cent. ; fat, 6’6 per cent. ; protein, 33*5 per cent. ; lactose, 42 0 per cent. ; ash, 7-5 per cent. ; citrates, etc., 1*6 per cent.*, lactic add, 6 6 per cent. Calorific value per ounce »= 102. High Protein Feeding. Some infants on the breast do badly for no other reason than that the stools are too acid on account of the small amonnts of the alkaline producing protein in breast milk (p. 31). Wien a h’ttle whole boiled cow’s milk is given immediately after the breast feed this upset is corrected. It appears that certain infants require a high protein content in their feeds in order to thrive. This fact has been used as on argument by those who olwa}^ feed on undiluted cow’s milk, but though it is true for some infants, it does not apply to the majority of healthy babies. Both sugar and fat tend to cause fermentation and acidity of the bo^el contents with more frequent stools and, perhaps, scalding of the buttocks. By raising the protein or curd in the feed the stools tend to become more alkaline and the bowels constipated. This explains uso of high protein Aedmg ia issss ©f diarrhma. Whole milk may be given in the treatment of this condition, or even o milk food with a still higher percentage of protein, € Mead’s Protein Milk, Protein and MerreU Soulo Powdered Protein Milk,' the analyses of which are ABTiriOlAL FEUDING SI ' ir«4ii < FioUlaUllk Souls Fo00 lactic acid 30 3-0 Caloric value per ounce I 149 143 1 133 The addition of lactic acid to milk, as already stated, aids in the more complete digestion of the casein in the stomach, and Tvhere it is thought advisable m any case to use a mucturo Tvhich contains an excess of protein it is best given in the form deacnbed above as lactic acid milk The preparation of protein milk is most conveniently earned out by the use of Casec (Mead, Johnson i. Co ), a povrdet Tvhich is ehoivn on analysis to consist of 88 per cent of protein m the form of calcium casemate One packet of this powder oz ) added to a quart of llmd, 1 pint of milk and 1 pint of water, raises the protein content about 1 per cent Two packets increase the pro tern 2 per cent , and so on A high protem milk can also he prepared to any desired protem concentration by the use of a soluble protem (Glaxo Laboratory), a sodiam salt of casein contaimng 91 0 per cent of protem Whey. Whey is made by prccipitatmg the casern m Tnilk A Bimplo method is by adding two teaapoonfuls of rennet to IJ pmts of luke warm milk, and allowmg this to stand until cold If the curd is now etramed through mushn the whey will exude The composition of whey, according to Robert Hutchison,* is os follows — Water . 93 0 % Protein 0 8 % Tat . 0 02% Sugar 4 65% Mineral matter 0 65% 1 HatclUson R Foiid and tl a Principles of D etel ca, Cth ed 82 rCEDING IN INFANCY ^\ND CHILDHOOD A mostconvetucntwayof obtaining ivhey is Iwunng tho -whey powder Secway* (see Table VI, p. 40). which merely requires dilation with water. A glaneo’at Ujc composition will show that, beyond a very small quantity of protein, the chief constUnent of whey is sugar, and where a bland, non-irritating and ehghtly nutritious drink is required whey may bo giren It may be considered useful followmg on an attack of acuto mdigcstion in an infant, and should be replaced by one of tho skimmed dried milks or skimmed lactic acid milk. Peptonised MiDc. There are a number of preparations on the market for pcptomsing (pro digesting) tho protein of cow’s milk. Among those better known aro Bengcr’s peptonising powders and hquor pancrcaticns, but the prmciple of the mnons peptoniang substances is tho same The milk or milk and water is warmed to about blood heat and the active enzyme, cither in powder or fluid form, is added Tho mizturo is then allowed to stand for from twenty to thirty mmutes, a^cr which tho whole IS brought to a bod, the enzyme being in this way destroyed and further peptonisation prevented If the peptomaing process is continued for longer than twenty or thirty mmutes a ehghtly hitter taste is present Peptalacis a preparation made by Cow and Gate Ltd. containmg fuU-crcnm milk and dcxtnniscd starch, which are subjected to the action of pancreatic enzymes for a given penod of time Tho nmturo is then dried, preserv- mg mtact the vitamin content of tho original milk and leaving a powder in which 22 per cent, of tho protein has been peptonised, and 25 per cent, of the starch converted to a soluble and eaady asWilated form. CHOICE OF FOOD When the necessity arises to take the infant off the breast tho practitioner is often asked to choose the best substitute for tho natural food Below aro given some of 1 Made by Tndood lAd^ Lerer E C. 4 ARTIFICIAL FECDLSG S3 the advantages and disadvantages of llic various sub* etitutes for breast milk. 1. Cow's Milk ^ scalded or iiasteuriscsd). Ono of the chief advantages is that cow's mill; is less expensive than any other artificial food. CDio preparation is simple, and it can he freed irom pathogeme organism by boiling, scalding, or pasteurfeing. By so heating, the curd is modified and made much more digestible. The disadvantages lio in the alteration in tho taste, and in the possible destruction of vitamins. The addition of orango or tomato juice, and cod- or hahhut-liver oil, oliminatca tho drawback of a possible vitamin deficiency. 2. Dried Milk (Fuli-crcam Glaxo, Cow and Gate, BorscUa, Lacta, Slilkal, Ambrosia, Khm) Tho old prejudice against ^ving anything hut fresh cow's milk has lately been modified by tho success of modem dried milk. Tho advantages are that it is etcnlo, constant in quality, and, owing to tho diying process modifying the protein, more easily digested. Dried milk is also easy to obtain, to keep, and to mako up. Possible disadvantages aro the nbscnco of vitamins, but it has been shown that tbo ntamhis oro not entirely destroyed, and their deficiency can easily be made up by giving fruit juice and cod- or hahbufc-liver oil each day. Vitamin D is added by some jwal'cre to repair any dcCdency, It is to bo remsmbored that the cost of dried milk is greater than tliat of cow 's milk, A meosuro or drachm of dried milk added to 1 oz. of water reconstitutes 1 oz. of cow's milk. 3. Humanised Dried Milk (Sunahino Glaxo, Allcn- buxy’s No. I., Humanised Trufood, Almata, S MA.). Tho advantages and cUsadvantagea of these foods have already been discussed under heading (2). Ono drachm of these dried milks, when added to 1 oz. of water, approaches ohss-fy iho coropiasOlJnD of breast milk. Their rxist. is greater than that of tho ordinaiy' dried miU: ; and for tlio ndTOntages and dmdvantogcs, boo section on " Singlo Formula Jlixturcs.” * Ocflvie, 8 W., and Tedea. O D.: “<3«tria DigcsHna of IJAir nod BoiImI Milk In JntuiU,'' C.Xf. J, Jul^ liUi, 1631. 86 FEEDING IN INFANCF AND CHILDHOOD tables given are based on tbs assumption that the bab3' has thnved normallj and has reached this normal (espected) weight. If the infant has made appreciably less or more than the normal progress in weight the quantities given wiH require to be modified upwards or downwards. Thus a doctor faced with the problem of feeding an infant of 10 Ib., who by a aimplo calculation should be weighing 12 lb., must base his feeds on the weight of 12 lb. (expected weight), and not on that of 10 lb. (an underweight) He will discover that no satisfactory gam in weight will be achieved until he has done so. Again, if the baby should weigh 14 Ib. when by considera- tion of its normal gain it should be weighing 12 lb. only, he must restrict the feeds to that of the I2-lb. baby. It must again be emphasised that individual babies differ in their food requirements, and that the progress of the infant m healthy gaining is the ultimate test as to whether the quantities that have bees pnsmhcd are the nght ones. Choice of Bottle. The bottle most commonly used is the boal-ihaped bottle, which is manufactured by many firms such as AUenbury and Glaxo. At one end of the bottle is the teat, and on the other end a rubber valve. The advantages claimed for this pattern are that it is readily washed through and cleaned. Air passes through the valve, and thus it is not necessary to remove the teat from the infant’s mouth to prevent a vacuum forming above the tnflb level, which tends to stop the outflow of millf through the teat. A great disadvantage arisw, however, in that unless the valve is most scrupulously clean a small mnig dot may seal the hole in the valve. Th i s will result in the flow of milk diminishing, end repeated suckmg of the infant under such conditions tends to flatten the teat in its mouth. The nurse can readdy recognise when the valve is not working by noting that, on removal of the fium the baby's mouth, a stream of bubbles rushes up through the imlb. She should at once remove the valve andxeplace it by an efficient one. [TfiJmji H(i NORMAL ARTIFICIAL 3?EEDING 87 In tho practical feeding of infanta it is best to remove the valve altogether once the feed has been commenced- Another disadvnnta^ lies in tho' difficulty of steri* Ufimg and transporting feeds in a boat-shaped bottle bccauso of the valve Icaldng. The substitution of a cork for the valve overcomes this difficulty. Tho uprigTil or eoxlHei hoHle is the one commonly used in hospital, and in those nurseries where it is found most convenient to make up in the morning the total feeds for tho day. Tho great advantage of this type is the ease wiih which the feed can bo sterilised in the bottle, and reheated by standing in a jug of warm water before the feed is given. It must be recognised, however, that greater skill is required in the use of an upright bottle, in that at very short intervals the teat must be removed from the baby's month in order to allow air to enter the bottle. If bubbles do not stream up through the milk, a vacuum will form above the surface of the milk, the teat will collapse, and the mPk will cease to flow. Soxhlet bottles cannot be washed through, but can be cleaned efficiently with a good bottle bxuk). What* ever types of bottles are used, extreme care should he taken to see that they are cleaned immediately alter feeds, and kept fully immersed in dean water. Tho authors consider that a boat-diaped bottle without tho valve is best. Choice of Teats. The varieties of teats in common us© ore shown in the illustration (Fig. 3) facing this page. The short stumpy type reeembling the human nipple is exemplified by the Ingram, Gbxo, and AUenhury’s teats. The authors prefer this type for the normal healthy infant, as with this typo there is little chance of the teat shppmg too far back in tho infant’s month, thus causing retching and vomiting. The soxhlet teat is extremely useful in the hands of a skilled nurse who recognises the danger of retching bemg readily induced hy such a long rent being drawn too far into the baby's mouth. 90 FEEDING IN INFANCY AND CHILDHOOD by means of a fine Ecmng needle, the eyo of Tvlnch lias been pressed into an ordinsiy cork Tbo bottle contain- ing tho food IS held teat do\niward, and tho red hot needle is plunged through tho tip of tho teat This should be repeated untii tho required flow (about sixteen drops to the minute) is obtamed Tho practice of making holes with safety pins and tho points of scissors is to bo condemned. Getting up Wind Since every babj swallow’s air normally with its food, this procedure is mranably necea sary , whether a baby be breast or bottle fed, and whatever IS given from the bottle, even water or omngo juice Consideration of the anatomy of tho stomach shoire tho necessity for tho infant to bo held m an upnght position, allowmg tho swallowed air to bo emitted through the gullet Tho more placid and drew^v ■the mCmt is, tlie quicker and more completely this is brought about Sitting upngbt well supported on the nurse’s Lneo, is the method of choice, gently swaying tho baby back and forth from sido to side Some infants bring up their wind best when placed well over tho nurse’s left shoulder Getting op the wind may take up to twenty minutes, and the nurse should never be satisfied until tbreo or four eeparato nfts (wmdy pops) bavo occurred Wmd not brought up will pass through the stomach vuth the food, accumulate in the bowel, and cause bursts of coho and screaming Every infant must be removed from tho cot and held in tho nurse's arms if tho feed is to bo administered properly The practice of propping a bottb on tho pillow and allowing tho infant to feed lying flat in its cot cannot be too strongly condemned Preparing the Feed ^Vbcn the feed of choice is a dned tntlL, it is most convenient to make up each feed separately Tho dried milk is carefully measured by the scoop Eupphed m tbo tin, together with sugar, if pro senbed 3Vaspoons differ enormously m capacity and are Ix^t avoided as measures when possible The dned milk IS mixed to a paste with cold water, in a small measuring jug marked m ounces, and the required amount of hot water is added, and tho whole stirred continuously until r »ionMc)) With wtnU after * fmi. NOIUtAL ARTmCJIAL 3?EEDING 01 it IS completely dissolved. The importance of this hes in the prevention of Email clots, which tend to plug the bole in the teat. Boiling water should not be poured on the dried powder or clots will result. In pouring the milk from the jug to the bottle it is often an advantage to strain through clean butter muslin. This procedure, however, is usually not necessaiy. The food must he given warm, and there is a tendency rather to overheat the bottle before giving it. The optimum temperature is that of the infant, and, without experience, the tempera- ture is seldom guessed with accuracy when the bottle is felt to Bee if it is warm enough. A thermometer should be used at first to eeo that the temperaturo of food approximates to 100* F. Preparing Fresh Cow's MDk Feeds. Occasionally each feed is made up separately, but on the whole the bettor method is to make up the feeds for the whole day. When possible a eoxhlet apparatus should be obtained (see Fig. 7). The requisite amounts of cow’s milk, water and sugar are mixed together in a jug, and the five or six clean soxhlet bottles arc filled equally with the nuxture. These bottles are then firmly stoppered, and placed in tho cruet, and- the whole lowered in the con- tainer, where tliey are heated until the miHc in the bottles just begins to bubble. The bottles are then put m a cool place and used in turn, os each feed becomes due. A bottle is heated by standing in a jog of warm water. The teat is placed on it, and the mixture fed directly to the mfant from this bottle. A simple form of soxhlet apparatus can bo impro- vised by taking five or six 8-oz. medicine bottles, properly sterilised, and pouring an equal amount of tho milk mixture into each — closingeaeh one with a plug of cotton wool The bottles arc then placed in a saucepan of water and heated until tho milk just begins to bubble,* and then putinacool place. Each bottleis warmed np when wanfed. When tho feeds are made separately it is* jjrobably best to sterilisQ tho milk by Just bringing to the boil when it first arrives. If caTcfuUy kept in a cool place, it 02 FEEDING IN INPANCy AND CHILDirOOD need not bo ftirtber steriliced. Where facilities for the caro of the nulk are not good, it is safer to sterilise each individual feed by bringing to the boil Amotutt op Feed asd Fobmues At intervals during the first tTpenty-four hours after birth the infant should be given sips of varm water During the second day 1 02 - feeds of sugar water (one teaspoonful of sugar to 4 oz. of water) should be given at regular intervals from a bottlo. In this way tho infant is taught to suck properly ^ From the second to the fourth day full amounts of feed are offered, but they are made up one half of {lit strength given in the following formula. Commencing on the fifth day, full strength feeds are given. Fbom tot Footts Da.t to Oot Moimi (I.) Humanised Dried Milk Formuls for a Normal Healthy Infant from the Fourth Day to One Month ttefehtel Infant 1 lolouniSi 1 i Iteuorci ec Drtcikfu ot I 1 miti llllk.' 1 WitrriB OsDCU | 1 Ksttlprr orrretfi OnUr P« 0»t 1 Fe(F s 0 13 6 B4 14 5 ,, 7 15 S M 7 QuKk Feedin} See that the hole in the teat is a good aaa, eo that the baby can get tbs feed in ten nuautea easily. BreoXiny TTind Hold baby up for twenty minntes after each feed, until tho wind is bnken twice fruix Juice Give oran» or tomato juico, two to three taaspoonfuls daily throughout the year, diluted with water and eweeteoed with sugar. To PrevttU PitltU A drop of hahhut liver oil, or some cod liver oil preparation, or one of tbs concentrated vitamin I> preparations, such as (HteLn or Radio stolsum, are required before three feeds, except in tbs hottest summer weather (III ) Unsweetened Condensed^ (Evaporated) Milk Formula for a Normal Healthy Infant from the Fourth Day to One Month. Condensed milk . . . 6 oz Water .... 15 oz Brown sugar ... S level tablrspoonfuLi Directions Of this formula pre Uie infant the eama quantities as shown in the table for fivsh cow e milL. above *1110 same directions for quick feeding, breaking wmd, ihut juice and prevention of nekota also apply Feoh Ove MoYni to So: Slovrns Dried Milk. It la the author’s experience that after the first month the mfant thriTcs better on a fuU-cream dried milk rather than on a homamsed dned imlk Ideal, Libbys and Carnation Brand n FEEDING IN INFANCY AND CHILDHOOD (I) Formulze for Feeding on Ful!-crcam Dncd ^Ulk *rom One to Six Months ^ Iclut to PoQDdl FoU-trewa Dried UUt la Drscbmi or Veueree TTiUrla Oraen larti T«iaspnotua.i er 8asw yntoler or Ferde mi Per Dajr Itf Teed. ■1 ■■ mm Bl s S { U 15 24 6 1 G 11 11 174 3 7 K 6 Bl 14 2* 20 34 8 14 ■1 16i 2i 2?4 3i 0 14 10 17 3i 25 6 10 2 5 11 181 3i 274 fil 11 24 12 21 4 30 6 12 2J 13 22* 4* 32J ei 13 2| B 14 23 4f 35 «J 14 24 fi 15 25 C 37* 7 15 3 Nof« "When Ih© uifivnt roachca the of 15 lb , or the o^Q of HUE months, the noxt diet sheet should be convnenced (see No 3) (11) Fresh Cow’s Mflk It will Ic noticed tint tho formula gircn below is considerably stronger than tho ono which was used dunng tho first month Tho niithom think it 13 nercr desirable to change tho strength of tho formuho tooquicUy ThecompotcntandmtclbgentmatcmitynurBo will make tho change gradually from one formula to tho other during the fourth week Formula for Normal Baby from One to Six Months Boiled cow t milL I pint 20 m, \Valcf ipiat-IOot Brown IXsnierarB mgar . 3 level tikVinpoonluu Of thu mixture give o» el 0 a.m , 0 (um 13 noon 3pia,0nm nnllOpm or 6 B m., 10 a-m., 3 pjn., 6pm sad 10 p m » CtowsndGate Glaxo DorsclU, Ucta Mdkid Ambro^U ole NORilAL ARTIFrcIAL FEEDING 95 ^Vl^en baby weighs 10 lb give 5 feeda of 6 os. af Iho above 11 .. 6 .. £| 12 M 5 „ c 13 .. c .. 0| U S n 15 M 6 .. 7 Quick feeding. Seo that the bole m fbe teat ta a good sue, so that the baby can get the feed lo tea cuautes easily Brtaling TTind Hold baby cp for twenty zmsotea after each feed entd the wind u brobeti twi« frutS Jutee Give oranga or tomato juiee. two to three (eaepoonfuls daily, diluted with water and sweeten^ with sugar To Prtttnt Jtieiets A drop of halibat liver od, or tome cod Uver ed pteparation, or cos of the eonee&trated vitamin D pteporationa, such as Ostelin or Iladio* Btolemn, «re required before tlirco feeda, except in the hottest snromer weather. « (111.) Unsweetened Condensed^ (Evaporated) Milk Formula for a Normal Healthy Infant from One Month to Six Months CoQdea»^ milk . 10 oz Water . . . 20 ot Brown sugar . . . 3 leiel lableepooofuls Directions Of this rormuls give the infant the same quantities as shown in the table for freeb cow’s raOk above The samo directions for quick feeding, breaking wmd, fhut juice and p rev e n tion of rickets also apply Measures. Stnee directions aro given m teaspoons and tablespoons, and since there is no umversally accepted standard teaspoon and tablespoon, this causes confusion It is always best to measure fluids in ounces, as very often an ordinary household tablespoon contains from J to J jBiud fi7 Glass juRasnny! «r jopa.'umq^ marked in ounces on the inside, or even a child’s feeding bottle marked in ounces \nJl be found much more accurate In measunng sohds, teaspoons vary enormously. Actually a level measure (ahghtly pressed down) of skimmed, half- * Ide&l, Libia’s and Carontion Brands 06 FEEBIXG EC INFANCST XSX) CHIUJHOOD ' cream, or foil-cream dried milk weighs 1 drachm or i oi A very heaped teaspoon of skimmed, half-cream, or full- cream dried milk also weighs 1 drachm (if measnred in a teaspoon purchased from Woolworth’s). A level tea- spoon, slightly pressed down, is \ drachm. A level table- spoon (Woolworth’s size), slightly pr^cd down, of any of the above is equal to 2 drachms (J oz.). Sugar. This will bo found to bo much heavier than dried milk. One level teaspoon equals 1 drachm. One level tablespoonful equals 4 drachms. A lump of Tale and Lyle’s sugar weighs on the average 1 drachm. The tin measure given in Cow and Gate dried milk, if levelled off and shghtly pressed down with brown sugar, weighs 2 drachms. It should bo noted that an English pint is 20 oz. and an American pint 10 oz. An English tahlcspoonful is exactly twice the size of an American table.«poonful. CHAPTER VI MIXED FEEDING FOR NORAIAL HEALTHy CHILDREN COMMENCEMENT OF MIXED FEEDING WnEJT the child reaches 16 lb. ia weight, ho requires about 25 oz. of cow’s milk. Wo do not believe that any infant or child requires more than this quantity of cow’s milk at any age. It seems logical then to start adding other foodstuffs of a more sohd nature. To balance tho child’s diet, ho requires more carbohydrato, and this is best given as starch. Bone and vogctablo broth can bo added to tho diot with benefit as early os threo months, and since tho cow’s mills as well os breast milk tends to bo deficient in iron, wo consider that early mised feeding is warranted, if for no other reason than this. Cereal Feeding.! Whon sbonld starch be added to the diet 1 To answer this question it is well to understand the uses of starch in infant feeding. 1. Starch forms a colloidal solution with miUc — ^that is, it mixes so thoroughly with tho molecules or particles of casein that these stem incapable of running togetlier and forming largo clots or curds. Put another way, tho curds formed in the stomach after a feed of cow’s inilk and barley water are smaller than tho curds of eoiv’s milk diluted with water only (sec p. Cl). 2 It is necessary in artificial feeding to keep tho carbohydrato side of tho diet at such a level that tho fat ia completely burnt up or metabolised by it, and starch is of assistance in attaining this. It may bo nccessaTy to add to a feed two heaped teaspoonfuls of sugar m order to * Potepwn, Donald i “ The I7«» of Stareb m lufoai Feeding," Pratliliontr, Jane. IMO te »7 » 08 FEEDING IN INTANCTS: AND CHILDHOOD "balance " a feed, and on such an amount of sugar the child may dorelojJ a fenncnCattto chjirrhma On one he »ped teaspoonful of sugar and one of groats, Bcnger’s or other starchy food, the same ob;ect is aciuered, hut the fermenbilivo diarrhoea does not occur Dtspite some evidence to the contmry, from a practical atandpomt it has been found that infants digest and thrive veil on well cooked or split starch granules, if given m email amounts only, from the second month onward It is perhaps better practico, however, os a routine measure to etart adding starch 6cnou^ly to the diet after the child reaches the age of five or six months It IS well at this tune to pdd some form of starch to one feed only m the day — say, the 10 a m feed, then the 2 p ra feed and finally the 6pm feed The form of starch for breakfast or the 10 am feed should be wheat, oat, or barley flour — one heaped tcaspeonful miking about half a teacupful of the cooked product At 2 p m the starch is offered to the infant m the form found m bone and vegetable broth — namely, potato, carrot, parsmps or gieGns(&eep 157) At G p m one of the cercaU mentioned at 10 a m should be given, but not the same cereal Starch must be added to the diet at all times with great care With too small amounts the child fails to gam in weight or thnvo This is frequently seen m tho child fed exclusively on cow's nulh, when tho weight has reached 16 lb On tho other hand if overdone, na is often seen m the children of the poor, the child tends to become soft flabby and pale, lacla energy and tends to become rachitic Only one feed of any one form of starch should be given in the day, for the greater the vanety of starches fed the more success is likely to be achieved There is no objection whatever to the use of one of tho well knowTi proprietary foods (see p 63) provided such is added to tho milk feed with the full knowledge that it is merely a substitute for tho groats or other starchy food \\ ith tho introduction of starch info tho diet, ono of the po^ssiblo causes ol flatulence has been introduced See also Cereal Feeding (p 07) MIXED FEEDING dD Diet for a Normal Healthy Infant from Six to Nine Months Old (Weight 15 to 18 lb ) Feeding Timee 0 ajn., 10 lijn , 2 p m., 0 p m , 10 pan 0 OM 3Iilk . , . . S ox Wafer . • 2 ,, 8u^ar .... 1 heaped toospootiful lOom JfiJftHfft ftji oMve to which has tieen an a Patent Oroata or I'atenl Barley or Parox (See lielow re eonkinc ) Half e lca.4pooiiril of the jolk of a liphtly boiled ettp should be alowly hitroilnml aloni; with this feed, and g^tially increased to two teas{>ooiifuls if well tolerated. 2pm ^fdle Box F isar . . I heaped teaapooriful Add to ih s two lablcspoonfiils of bone and scgetablr broth (see below) One Or two tahlnaponnfuU of Heinz Lihby s or Neatlil s homo^nued vegetable con bo added to this meal with Mvautage 6pm ETBotly oa at 10 a m . but add one to throo heaped teoapoonfuls of a difT^rent corcal from th« one givoo at tliat feed. 10 pm Exactly as at 0 a m Prutf Juice Oranga or tomato J nee, two to threo tenspoonfuls diluted with water and aweetonrd with augnr, should be given daily A eonveiuent tima ' for this IS between 6 and |fl a m .oral tcatime FoprevenlfKieMsa cggspoonful of eod hverod orono drop of halibut liver oil should be gvm immcdatoly before throe of the feeds throughout the year, except m U o hot summer weather Aot« re Coofiny AU mtll^ thotdJ be brought to the t/o*t In making up the ceroal for the 10 a m and 6pm feeds such as Oroato Cream of Itiee, etc , this needs to be cooked directly for at least twenty minutes or from half an hour Co an hour rn a double aarroenan It may bo added Co the rest of tlie feed and the whole cooked for the specifiod time, or it may be cooked with water and then stirred into the rest of the feed when itis thoroughly cooked. y D Owing to the thick nature of this feed it is neerosary to make a large hole in the teat if given from a bottle If possible, it u more desirable to spoon feed from a eup, as a semi •solid Method f>J mating Sone and Vegetable Broth, Take I lb of veal bones or beef bones well broken up Cover with wafer and add one teospoonfiil of vinegar Octsasionally say once a fortnight add a piece of calves' or o* hver (about 2 oz ) Simmer (or from one to four hours how edd vegetables (carrots, caubflower, green Vegetables and one potato) Simmer for one more hour strain, and allow to set Oive one to two tablespoonfiiU in the 2 p ra fnd (aa directed) (The broth is best cooked in a double saucepan, and sftoufi keep for three days if kept fn a oool place ) 100 FEEDING IN INFANCY AND CHILDHOOD Diet for a Normal Healthy Child from Nine Monthr to One Year Old (Wcisht 18 to 22 lb ) i,ou Tho traa-iition from the provioos diet to tJu» one shouU be taking SAT, o foitaJjlit On IToXin^ One tAbl(»spoonful of or*uiso |ii{cr amount. 2. That tho child’s general management as to its sleppit^, catixy!; exercise and fresh-nir habits are such as to provoke a healthy appetite. 3. That tho person who actually offers tho child food docs Fo in a manner condudvo to its being taken, i^., without undue urging, coaxing, bribmg or harassing tho child. 102 rEEDINO IN INFANCT AND aULDHOOD It ehould bo matlo a golden rule that the lose fro- qaen% a child is offered food, the le&s likely it i» (o b© overfed Much more illness is recn in children from the age of one to fire years duo to overfeeding than results &om underfeeding, and this is generally because meals are given at too frequent intervals It has to be rcmtrabcrtd that at tno and n half yeare, when the firit dentition is complete, tho child has as many teeth and is as well able to chew and masticalo its food os it is at the ago of h\o or BIX, and therefore tho composition of tho food at this period IS the Bame, tho amount only of each food bung vaned It 13 C’sontial that tho diet shonld contain fresh foods m Order to supply the necessary vitamins Oranges or tomatoes supply the and scorbutic, wInNt cod or hahbut- hver oil supplies the antirachitic vitamins dunng tba winter months As a rule the tendency among both nch and poor is to overfeed cluldron between tbe ages under considerotiea on starches gmng them too little animal fat and protein Such starchy foods os pomdgo, toast, bread potatoes and milk pudding are given m excels, and ommal proteins, because of their cost and the fact that they need cooking and that they pensh easily, and to some extent becauso of the fallacious idea that tho growing child docs not need meat, are given in far too small quantities On pp 103 and 104 are shown suitable diets for children of from one to two years and from two to seven 3 ears rcsiico tively A complete diet should contain snlBwent (а) Calories A child aged three years should weigh 31 to 35 Ib and needs 45 to 50 calones per pound body weight per day (see Appendix (p 163) for details of tbe various a^es) (б) Food Eleitekts 1 Prolan I 8 gro of protein are required per pound body weight per day (Holt) * * HdU h. E and FnK'^. II L Prtlt«^ n of Chil dreo ’ An, Journ Di* Child- Vol XXlI-4 p 371 MIZED rEEDINQ 103 2 Fat 1 3 gm of fat are reqmrcd per pound body TTejght per day (Holt) ^ 3 Carbohydrata 6 gm of carbobydrato are required per pound body weight per day (Holt) * (c) Esscvhal Salts 1 Pfto/fphoriM Iho needs of a normal child are 1 2 gm daily (Sherman) * 2 Iron The needs of a normal child are G to 12 mg daily (Sherman) ^ 3 Calcium The needs of a normal child are 1 gm daily (Sherman) ® (d) Water Ajm otheb Salts, c g , sodium, potas- sium magnesium, etc (e) VrTAMD,s VitamiM A, B, C and I> (seo p 3D) A wook’s menu, cahulated on such a basis, will bo found m the Appendix, on p 104 How Much Milk should the Child have at this Age ? There is no doubt that mtik should be a staple article of the diet of the growing child at this ago Nevertheless, next to starches there is nothing which tends to bo over done 60 much os cow’s milk Ibe common fault is to giro the child from 30 to 40 or of cow s milk m tho day and tlies bo surprised that sohd food is not taken Loose stools almost invanably result One pint of milk should bo suQicient between the ages of ono and seven years It lias been shown that a mmimum of one half pint of milk IS required per day to provido the growing child’s bones and teeth with tho necessary supply of lime * Holt L E and Foleg ILL » * Fat Bequiremeot, Am Joum £>i» voi \xrrr p 471 * ilolt L E anJ Falcs H L j Corbohydrate Requirement * Am Joum Dx* Chid Vol X\IV p 44 * Il^nry C Shorraitn The ClMmutryof Food and tsutntioo,* (Haenullan hew York) 3rd ed , 102S,pp 30S,31C nod 333. 104 FEEDING IN INPANOT AND CHILDHOOD Diet for a Normal Healthy Child of from One to Two Years On Wahing 1 Tho JUJC8 of half an orango or * dasaertspoonful of tomato Jujcs, with water and aweetaoed with sngar 2 One email nisk Drtakjtul S o m 1 One to two tabl^poonfula of anjr of tho following WcU-cooked groats, cream of wheat, or 'Wheateno, or ruska in miDr; or Jlobha biscuits in milk In warm weather stewed fruit and crisp toast ma g be given m nlaeo of tho above (See that the child a appetite u not satisfied witn this course ) 2 Toast crumbs fried m bacon fat or a small rasher of ensp bacon or halt a soft bolltd egg with bte^cnimba (four da^s m the week) or pounded plaico or aolo or fresh hemng 3 Eight ounces of rmlk (including that used with tho cereal) Dinner 12 30 p m 1 One le>*el tablcspoonfut of any of the following Fish, boiled or steamed or pounded chicken or bmina or sweetbreads or scmpod raw or underdone steak or Irish stew or lightly cooked li\‘er 2 Onetotwoheapedtablespoonfulsofboiled baluMhormashedpolato Sieved sprouts cabbage spinach or greens cauliflower, carrot or parsnip or lettuce (These are all beat steamed ) 3 Milk pudding (Oroult s cream of nee tapioea ete ) with stewed apples prunes junket or eustard Waterto drink. Tta-^pper, 4 30 to If pm 1 Rusks or pulled bread (Zwieback) or ensp toast or thin bread and butter with a little honey seedless jam jelly, custard, junket or stewed fruit and a small piece of sponge cake 2 Once per week half an over npo bsosna may be given if well tolerated (Between one year and eighteen months Robbs biscuits or rusks may be given soaked in wans milk ) 3 Eight ounces of milk (mcludiog any used with biscmts) 6 15 pm It ought not to bo necessary to give anything after tea-supper If the child eats a poor tea however some of tho milk and nu^ inav be kept and oSerod before bo is pat to bed but this should not be done as a routine Mtlt One pmt of nuQc a day should be sulBcient, inelnding that used m cooking Sioeeto riam boiled sweets such os barley sugar (Barley Malts or Barley Bnghts) or fruit drops or Mackintosh a toffco, may be offered after dinner and tea (The teeth sbouM bo cleaned immediately after this) Acte Borne of tho solid constituents m this diet must be introduced slowly during tho period from one to two years the whole diet not being suitable to commence with Rod meat should be introduced slowly and in very siuaU quantities at first To Brevtnf rielels tmd ensure good teeth a teaspoonful of cod hver oil or cold liver oil and malt or halibut Uwir oil one drop should be given three times daily throughout tho year, except m warm summer weather MIXED DEEDING 105 Diet for a Normal Healthy Child of from Two to Seven Years On Wakiiiff The jaice of on orango or graite^t, or tlia jmco of a tomato, diiutod with water and sweoteaod with two Jumpa of sugar, or two teaapocniula of glucose Brtalfatt Sam 1 Porridge, comQakrs Orapcnuta, Shcoddod Wheat, Cream of Wheat, Wheateno, Digestive biscmta, or some dried cerva] or m place of this, lo warm weather, stowed apples, prunes, or figs (Do not satisfy the child s nppctito with this course ) 2 An (three mornings per week), or 3 Tomatoes and roshcra of cnsply fnod bacon (three mornings per week) or i Fub or lightly cooked liver (one iDonuog) S Cri5i) toast or rusk spread with butter fi Fight ounces of milk (including that given with cereal) Dinner, 12 30 p m 1 One to two level tablespoonfuls of any of the foDowing Cutlet mince or stow, li% er, underdone beef or steak finely cut up, or brains Cah, chicken or sweetbreads (Red meat four days m the week, white meat three days ) 2 One to two heaped tahlespoonfulsofbodeiitziiaBhed or baked potato 3 One to two heaped tablrapoonfula of masbod carrots, cauliflower, sprouts peas, beans spinach or greens 4 lulk pudding or stewed iruit, or strained pudding (not suet) or oustara— one heaped tablcspoonlul Water to dnnk. Tea-supper, 4 30 lo fi p m 1 Cnsply toasted wholemeal or brown bread, pulled bread (Zwv* b^) thin bread and butter, rusks and butter, or cream ehe^ sandwiches S. Uoshed overripe banana or stewed fruit, seedless ;am, jelly or honey 3 A small pieco of sponge coko ^ 4 Eight ounces of nulk 0 30pm If tho child has loft some of bis tea, the remnants miy bo offered at 6 30, but as a rule it wiU be found best not to give anything before gome to bed UtL. One pint of milk shoold bo safitrient including that used in eookmg Some cEiildren prefer milk flavoured with cocoa or tea Frutr The child will not lack vitamin C if fruit juice is given on waking it IS dcssirable, however, if well tolerated, that one of the following shoold be given dafly apple orange pear, peach of aeclanae, or banana Unless fnut is thoroughly npe however, it is best given cooked. Sietett Plam boded eweets, such as barley eugar (Barley Malts or Barley JJnghlsJ or fruit drops or kfockintcah « toffee, may bo offered alter dinner or tea (The teeth to be cleaned immediately after tide } To prntnl nrkeU and tnsur* good teeth a tciapoonful of cod hver oil or or balibut-hvcr ofl and malt or a few drops of hahbut-hver oil should bo given three tunes daify throughout the year, except in warm summer weather lOQ FEEDING IN INFANCT AND CHILDHOOD Diet for School Age FrutI Either on waking or to comneiea breakfast fresh fruit is raost blviiaLla A ripe opple orange Juce a few grapes, or hatf a crane fruit should be pvea. Drt'ikjiut 1 Porrjdg" Oropenuts fihrvctded HTieiit Force Puffed Rfce \V \ e tena Cream of VVlirat Oruata Creamed Uurley etc (A sroon helping should be given so tl at tfie ct ild ■ appetite is not 8ati«i]ed ) 2 All egg (sufl billed scrainbt-d or fred> with or without bacon, three n omings in the wei.k. On the oti er momiugs crisply done thin rasf a of bacon with tomatoes or 0s( (sole plaice frvsh herr ng or k piier) Cold I h u eaueages or liver occoaiODaily Brown meal ul jiotatOLS occasionally wiiii tha mam dish, 9 Crisp tQAat butter and n artnslaJa 4 A gloss of milk or weak tea and milk. Dinner 1 Cutlet fresh mince or stew a cut of roast beef steak, tnuttoa (four days in tlie week) and chicken fish sweetbreads liver or ludoey on three days For older children rabbit occasionally 2 Boiled baked, or raash^ potato with carrots cauliflower parsnips or green vegetables such as sj macb sprouts or cabbage or peas or beans 9 Stewed fruit and milk piiddiog or eustard, or sponge or steamed puddings Water to dnnk. Tea eupptf (Soe note below for direetioos wbon tea and supper am given sepa* rately ) 1 Thin bread and butter with fruit such as baked apple or stowed prunes or mashed over npe banana, or Sun maid raUina or rnitk pudding or hooey jam or jelly or cream cheese sandwiches. 2 Sponge cakes Milk or we^ tea or cocoo with milk Hots As the child approaches tbs age of seven or sight, a more snb- stantial tea s ipper is required. Occasionally an egg may be intro duced or vegetablo broth, or fish, or macaroni or spaghetti, or kedgeree or ^ana and toioatocs fried with breodcrumlH or iheese, or a milk pudd ng may bo added to the meal At the age of about nine or ten however it is best to g ve a very Lgbt tea at 4 30 and Buppor should be instituted at G to 6 30 SnuahU Suppert are Elidneys on toast, with rice pudding Ham with salad and hUne mange Fiah oi d potato with baked apple Sausage and potato with fruit or jam tntle Baked eggs done with tomatoes and m Ik jelly or orange aouflld klacaroni and cheese and Caramel pudd ng Tomato or potato so ip at d coffee blane mange Sard ne« on toast with stcweii pears and custard Sweetbreads with stewed apples and cream Muiced chicken on toast with white sauce and Junket. Milk Oiring la lergs nomber of e) ildmj who cannot toJerata much m Ik B go^ atemgv per child a I pwt per day In excoptionai rases wt ere it is well tolerated more may be given with advantage, but it should not la any cifvumetances be pressed Svreu Plain bo led sweet*, such as barley soRAr (Barley Malts or Barley BnghW) or Fruit Drops or Markintoeh a toRce sboiild be oOered after dinner or tea (the teeth to be eloaned Immcdistoly afterwards). mSED FEEDING 107 Diet for Cbjidren of School Age Tho growing child rcqiurca a sulMtantial and mixed diet It shoald contain fresh meat an abundance of fresh vegetables and fruit, butter, milk and occasionally eggs, and it should be properly balanced with sugar and starch The child requires much more food relative to its size than does the adult The authors would draw attention of school masters and others to the old adage, ** You cannot fatten i'Stone mlhotti a supper” We feel strongly that a properly cooked hot supper is necessary from 8 years onwards, t « , throughout the whole “ school *’ age CHAPTER Vn DIARRHCEA, VOMITING AND CONSTIPATION* (INCLUDING INDIGESTION) Aevle di/sj}ep 3 ia or ffoslritte in infants {9 always accompanied by dtarrhcca, or ai least undigested motions. Among tLo commonest symptoms which tho practi- tioner is called upon to deal with in infants aro diarthoea and vomiting. It is of tho utmost importance thot tho doctor should have a clear knowledge of their commoner causes, as they may either bo manifestations of some serious illness or merely of some transient disturbance, often caused by unamtablo feeding. PfAJiancEi. Thb symptom as it occnis in the breast-fed infant has already been discussed on p. 30. Frequent stools may result from — 1. An infection of tho bowel by some pathogenic organism. 2. Acute dyspepsia or indigestion due to overfeeding or to some food indiscretion, and not primarily organismal in origin. 3. Some infection outside the gastro-intestinal tract. This charrhooa may bo termed symptomatic, and is seen in infants with diseases os, e g., middle-car disease, cerebro- spinal meningitis, bronchitis, or more commonly from naso-pharyngitis and colds. Cases from group 1 occasionally, but more commonly from group 2, when the diarrhoea occurs in tho wanner months, are known by tho term “ summer diarrhosa." 1. InleCYive D’raifnma. Tnese inu wvure ■ndwL'ouus 6ot up by organisms such as the streptococcus, Flexncr, Shiga, Sonne, or Y dysentery, or one of the typhoid group. Food poisoning may also give nse to a similar clinical picture. Tho onset is acute, with marked tozaimia, and 108 DIARRHCEA, VOailTING AND CONSTIPATION 109 ft high fever. Blood and mucus in the stools are the rule. Treatment should bo directed against the spcciGc organism. Dietetic measures are discussed later. 2. Dietetic Diarrhcea. In tho second group, due to food indiscrelioTis, tto havo a proportion of those cases of diftrrlima commonly met with in general practice. Probably tho most frequent is tho diarrhcca seen in tho overfed infant, especially when his tolerance for fats is overstepped. This is most bkcly to occur lu warm weather. In tho older child the trouble is often called a " bihous attack.” In the young infant the attack is preceded by certain symptoms. Them is iailuro to gain in weight, a shght temperature, a dirty tongue, lethargy alternating with restlessness, and pale-coloured motions are present. At the onset, an excess of fat may cause pale, constipated crumbly motions ; later, as the tolerance for fat decreases, tho motions arc pale, loose and, finally, acid, green, and contain curds. On tho other hand, excess of carbohydrate may bo the clement in the faulty diet which gives rise to diarrhcca. Whoa this is tho case there is a tendency on tho part of the infant to refuse some of tho feed, and, if ho bo urged, this oicess of sugar is not completely absorbed, and in tho intestzno fatty acids are formed first which irritate the mucous membrane of the bowel, causing increased peristalsis with green, frothy motions (fermenta- tive diarrheea). The buttocks in both fat and carbo- hydrate exoess diarrhoea are severely excoriated. Tho temperature, if raised, is rarely above 100® P. In some of tho older infanta fed on tho starchy proprietaty foods, it may be the starch itself which is giving rise to tho diarrhoea. It cannot be too strongly emphasised that even on a well-balanced diet, such as the ideal food, breast milk, on excess in itself will produce frequent undigested motions, and no one element can bo blamed more than tho other ; tlms the diagnosis of tho offending portion of tho'diefc may bo extremely difficult, and it may bo an excess of all rather than of any one olcmont. DIAEEtiCEA. VOIUTING AND CONSTIPATION 1 1 1 glucose ■« atcr or •tvcnlc tea may bo given alternately by tbo moutb for twenty four or fortj -eight hours (see Appcntlu) This shoulrf bo followed by slimmed hctio acid imlk (sec p 70) or Lncidao (Cow and Gate Ltd ) Other feeds suitahlo arc dried buttermilk made by NestliS, “ Lkdon ' or Glaxo (see p 79) Supposing lactic acid milk is decided upon, then equal parts w itli w atcr, adding a small amount of sugar, should be used to commenco with Graduallj the strength of the mixture should bo increased until tlic child is getting tw o parts of lactif? acid milk to one of water It will also be found useful to tlucl en such feeds with a little starchy fowl such as Savorj and Jlooro’s or Benger s Food at this stage A good plan of campaign is as loUows — For two days alternate dnnks hourly of half strength normal saline and glucose water On the tlnrd day offer lactic acid milk and water (equal parts) and sugar every four hours Make euro that tho feed is not urged Con- tinue to offer altcmoto dnnks of hnlf*strcngth normal sahno and glucose water hourly between feeds day and night The infant will graduatlv wean itself oil the bland dnnl 8, taking only the food and such a result as that given below will probably follow if the infant is allowed to regulate its own food intake Ixrtle »tM mfik DlzUirv tAkto. Sussr v»i«rat>d hill itnuttl) xnmial laUiLt uken let day Kot offered 40 oz 2nd „ l»ot offered 3o „ 3rd „ 2 oz 30 „ 4th „ 6 M 25 „ ID 20 „ 6th „ 18 „ 14 „ 7tli .. 25 „ 10 „ 30 2 , Diarrhma in Older CbOdren When this is duo to dietetic indiscretion or to one of the less tevere infections, u pralirainary dose of castor oil shoul 1 bo followed by a day of starvation Sugar xvater, orange juice, lemon or 112 rEEDEvG ES EJFANCy AND CHtIDHOOD barlei' -rater shoold ba given fre/’ly, mth a gradual return to the normal diet A preliminary step should be the use of a lower fat, or half cream dried milL fseo P 49) A recently introdoced method of treatment of diarrhcea m older infants and children is known as the " apple treatment * ^ This d'*pend» on the presence of mahc acid d^nvativcs normally found in the apple A ample method of preparation consists of finelv gratmg or sieving a fresh npe apple Rom a tea«poonful to several fablespoonfnls should be given at each feed depending on the age of the chOd and fed from a bottle or spoom Additional dnnks of weak tea, bringing the total of 0uid np to 02 per pound body weight per day, are given between apple feeds The whole treatment lasts three to four days ** Aplona ” a dned apple preparation manufactured in the Children’s Ho pital, Homcb, and sold m London by Coates & Cooper Ltd, 94 Clorienwell Hoad, ECl, can be obtame ‘ffceldon. and HaH. M “^ e Appls TtxAOzai. cf InEsaJJo Diarrhea, Arch Drf CTU >cl STT, p 43. DXAERHCEA, VOMITING AND CONSTIPATION 1 1 3 tion, ho drinks increftsed qaantities of water. The diet of an infant is not under its own control, and it is unable to aak for a drink of water. It is offered its feed, and if it leaves some the mother becomes anxious. A httle later the child is again offered food and to quench its thirst, for it too is losing fluid by perspiration, it takes the remainder of its feed and so adds tremendously to the work of its digestive system. After a short time the overjed infant vomits, BO getting nd of the excess of food beyond its requirements. At the same time there may be several loose undigested stools. If at this stage the diet was reduced and more water offered the child, the trouble would probably be averted. Unfortunately, this is too often not rocogoised, the child is again overfed and the B 3 rmptom 8 become more marked. Frequent loss of fluid by vomiting and diarrhma result in acute dehydration, and the picture of summer diarrheea with its intoxication is produced. It is not suggested that overfeeding clone is the only eauso of summer diarrheea, but it is certainly one of the important factors. The prevention of this disease con> eists m reJuctn^ tJic feed during the warmest period of the year and prevention of dehydration by giving the child frequent drinks of water during the hot scoson. The infant must not bo over-urged to take its feed, and such feeds should not contain a high fat mixture. Top milk or added cream mixtures must bo watched carefully in worm weather, so also must the full-cream dried milk mixtures. Oicr-doOiing must be aioided, os it tends to make the child perspire contmuously and produce dehydration. Ho should be kept os cool as possible. The millc should bo carefully guarded against souring either by lactic acid oigan&ms or by more pathogenic bacteria. The question is sometimes asked : “ Is it better to boil the m?IV qs soon as it is brought into the house or is it bettor to boil immediately before giving to the infant ? ” There is httle doubt tiiat the ideal method is to sterilise the whole day’s feeds in separate bottles at one time. For the Soxblet apparatus, see p. 91. Where 114 FEEDING IN INFANCY AND CHILDHOOD ' Buch measures cannot be adopted, a dried or condensed milk is to be recommended. Extreme. cleanUniss on the part of the nurse or other attendants of the child is essential. The exclusion of flies from the nursery, and care in the keeping of the food, must play an important part in the prevention of diarrhcea. The prevention of that great group of diarxhceas in infants, secondary to sore throats, colds, ears and naso- pharyngeal catarrhs, must rest on the isolation of the infant from infections carried into the nursery. No group is more preventable. The wearing of a mask by the mother or nurse, at the shghtest suggestion of a cold, is strongly urged. Rectal Temperature. In small infants, the frequent taking of the temperature rectally may either provoke diarrhma, by acting as a stimulus to the anus, thus causing evacuation of the bowel, or prolong o dianrhceo already estabbshed. In the authors* opinion, the practice of taking the temperature rectally is one which might well bo given up in favour of taiung it in the groin or axilla— the thermometer being left in position for five mmutes. Alternatively, the temperature should not be taken more tUau twice daily if taken rectally, a degree being subtracted from the Cgnro thus obtained, to bring it to the correct one. VoanriNO Nearly every infant is inebned to posset or spit up a few teaspoonfuls of its feed, usually immediately after the feed is finished. This may bo due to a slight overfilhng of the stomach or may occur during the eructation of wind. Vomiting may be divided int<^ 1. Obstructive vomiting. Classical examples of this are achalasia (cardiospasm), duodenal stenosis, congenital pylono stenosis, volvulus and intussusception. (a) (Esophageal Stenosis and Achalasia (cardiospasm or cDsopbagectasia). Generally speaking, the vomiting due to cesophageal stenosis or stricture commences in tho first few months of life, or certainly by tho age of one year, l)IARRH(E.l,VOMrrCfG AND CONSTIPATION 115 when thicker food'ittilTa are introduced into the diet. Tlic?e symptoms persist. In such cases dilatation with bougies may allow thicker feeds, but thm starchy feeds may have to be given for an indefinite period. Using milk Bs a ba^ls, and thickcrung this with vegetables, starchy preparations and beef extract, a balanced diet containing suillcicDt of the mineral elements may bo obtained. Achalasia is as a rule rarely found before eight or nine years of ago. Tlie symptoms are vomiting at or between meals, and failure to gain weight. An X-ray shoirs a spasm of the OD'sophagus, not at the bifurca- tion of the trachea, as in organic cases, but at tho level of the diaphragm. Tho cesoplmgus shows dilatation above this point. Passing a mcrcury-CIlcd storaacli tube before meals rapidly relieves tho spasm. The diet should bo a concentrated one. (ft) Congenital Pyloric SlenosU. This condition starts at or shortly oflcr birth and is cha^>ctcri^ed by largo projectile vomits, marked constipation and failure to gam in weight. Usually tho child Is crying and rcstleas and hungry, The condition is about six times ns frequent in boys os in girls and is most commonly found in the first child. The diagnosis is made on the above history and symptoms and by seeing waves of gastric peristalsis parsing from left to right across the cpiga«tnuni. On careful palpation in tbo upper right quadrant of the abdomen. Just outside the right rectus, a pyloric tumour may bo felt. Tho medical treatment consists of daily gastric lavage (see p 153) and somoUmes It is necessary to give two in the day. Norma! saline (see p 152) is best uccd to wash out tbo stomach, not bicarbonate of soda.' Tlio feed should bo a thick one j>. 110). unless breast milk is obtainable. Ono-thou-yindth of a grain ofntTopin-sulpbatc, or l/500th of a grain of Eumydrin, should be added to each feed. This acts as an anti-spasmodic. Medical treatment is best • 5L, McArtlair, C B , W W. t *' AHuIorlt (n tli» Pjlorio SUaosU ol IcfAnU,** Lanttt, l'«bruftry 8tb, 1030, p SSC z:s t^EDISG IN INFANCY AND CHILDHOOD^ mfants where the diagnosis has not been made tmtil the tenth or twelfth week. As a mlo all symptoms pass off at the sixteenth week, when the pylorus relaxes. If surgically treated, Bammstedt’s operation is tJie operation of choice, in which the muscle of the pylorus is incised in a longitudinal direction. Post-Operalive Feeding Operation. 6 hoars after operation : At hourly intervals 1 drachm of either : 1. Breast milk. S. Humamicd Dried Milk Mixture made up of one measure to each onnee of water. 3. Unsweetened condensed (evaporated) milk nuxture (see p. 84). 4. Laetjo acid milk and wafer miituro (see p. 70). 12 hours after operation : At hourly intervals 2 drachms of the feed chosen. 18 hours after operation : At intervals of one and a half hours, 3 drachms of the feed chosen, gradually incrcosiug until 24 hours after operation : At two'hourly intervals, 1 os. of the feed chosen. Jf breastfed, allow tho infant to nurse at the breast three- hourly from this tii’’ »wardfl. Jf not breast fed : lionrs after oporatio intervals, 2 oz. f the feed chosen. ' ' ^ rs after oporativ mount for the ‘s weight. Vomiting due ' tho ^ be duo or damage food DIABRHCEA, VpiUTINa AND CONSTIPATION 1 17 in the infant is altcays atxotapanied hy dianhoia, or, at hast, undigested motions. Gastritis may bo duo to so-callod gastric influenza, but it ia moro often eecondary to a cold or tonsillitis. In such cases nothing should be offered by the mouth, if tho vomiting is incessant, other than sips of some bland fluid, such aa ftnit juice and irater, well sweetened with sugar or glucose. Barley water, fi^hly brewed weak tea, well-sweetened finiit juice or plain sugar water all are suitable. Should even these sips bo returned, fluid must bo given by the bowel, in tho form of normal saline containmg 5 per cent, glucose. If rectal salines are not ictamed, then tho odrisability of subcutaneous, intrapontoneal or intravenous salmo and glucose should be considered (seo Appendix). In no case are these measures to bo withheld if tho infant has vomited for a period of twenty-four hours. Where vomiting is marked it is best not to give bicarbonate of soda, because of the nsk of alkalosis.' Occasionally, early on, if the infection is not very marked, washing the stomach out gently with normal saline tmtd the zuuous has been completely removed (see Appendix) will cause the vomiting to subside. The bowds should be made to move with some laxative appropriate to tho ago of the child. Kaolin or bismuth carbonate, given in drachm doses, tends to settle the stomach and lessen the retching. lie zotam to full-cfosm diet should ho made very slowly. Skimmed or half-crcam milks (seo p. 49} should be given first, such as Horlick's Malted Milk or Skimmed Cow and Gate, followed later by one of the half-cream dried milks, then by starches in the form of one of tho proprietary starchy foods or finely-ground cereals (seo p. 53), before any fiill-cream milk is introduced. (6) Indigestion (d^pepsia). Protein sndxpestion, ie., inabih^ to manage milk curd or meat, is extremely rare and seldom causes vomit- ing. Should this bo the case, a low protein diet for a few days is indicated, then tho giving of lactic acid milk (sea ' JIaitoU, M., McArthur, 0 B , Payne, W. tV. : ” Alkalosis la th# Pylotio Stanosia of Infants,” Z/aneet, Pobruary 8th. 1930, p. 286 118 PEEDING IN INTiiNCr AND CHUDnOOD p 7C), or dilute lijclrochlonc acid liv the mouth ui doses of from 10 to 30 minims ui & little milk at meal times For methods of modify mg curd, see p 01 / Tat indigestion Louever, is much commoner Rich creamy milk is prone to bnng about a bilious attack, tvhich may culminate m violent vomiting and some- times dnrrhcea uith pale motions Ihe rcmo\at of the fat, in the form of cream, butter, much neb milk and the jolk of egg dnpping olive oil and cod hver od is indicated for the lime being Bland drmUs should bo given, coneicting of sugar nater or well sweetened fruit juice or, if necessary glucose-salino rectally 'iTio fata can later be cautiously re mtroduced For a description of acidosis in older children sec p 134 Carbohytlrale indtgeslton (sugar indigestion) rarely, if ever, causes vomitmg but dianhma may occur Starch indigestion in older cluldren is described on p 137 The general measures taken for the treatment of dyspepsia or indigestion are the same os tbosu for gas tnlia given above 3 Cerebral vomiting Thisiseecnin brain tumourond meningitis In such coses the vomiting occurs irrespective of food or the times of feeding The feeding should not bo altered because of the vomiting 4 Habit vomiting or rumination (mcrycism)* Over- bnght generally female, infoiits from tbo second or third month acquire the habit of being able to strain and regur gitate their food into the mouth, where it is re tasted and re sualloued Each time this is done a small proportion IS wasted so that the pillow is continually uet The result IS that the weight remains stationary, and one sees such infants at six or eight months weighing only 7 or 8 lb Treatment Small concentrated feeds must bo administered so that each ounce contains a large number of calones The greatest pos-uble care should bo taken to get the child to regurgitate its wind and to sleep as much as possible In such cases a gram of chloral hjclrato * Patereon, Donald : ItonunaUoa (llerjeism) in InfanU Praetx-^oner Deceinbcr ID’S DIARRHCEi, VOirrriNOAJJD CO:7STIPATION 119 giren before each feed 13 of adimntage Some of the more u-eful footb are Savory and Moore’s and Bonger’s Food, but any of the starchy foods u>ed to thicken cow’s nuttr mentioned on p 53 can be used Simple directions for mothers for ruminating children are as follows Tho doctor should fill in tho amount of the feed and the times of feeding, m the gaps below • Feed baby at 0, 9, 12, 3, 6 and 10 p m or at 0, 10, 2, 6 and 10 pm At each feed give baby oz of this mixture (see tables on pp 92 and 94) Skimmed boded cow’s radk 1 pint, water | pint, sugar two level tablespoon- fuls Warm this up in a saucepan and to it add two level tablespoonfuls of Savory and Moore’s Food, which has been previously mixed to a paste with cold water Allow the wholo to stand warm for ten minutes, then bring to the bod Two and a half ounces of this mixture should bo offered for each pound body weight per day See that the hole in the teat ts large, so that the baby can get the feed in ten nimutcs easily. Hold baby up for twenty minutes after each feed till thowindis broken twice Givoorangeortomatojuice.two or three teaspoonfuls, diluted with water end sweetened with sugar, daily. This is meant to supply vitamm C for the child's health an cient supply of food for its needs (see pp. 92-05) 2 Offer it this food easily, ao that it does not requiro to struggle, and does not take more than ten minutes at most over the feed. 3. Hold tho infont up carefully so that it may “ break the wind " without at the same time bringing np its feed with It. 4. Give 1 gr of chloral three times in the day until it has got out of the habit of sucking in a frantic, famished fashion. In these cases, as a rule, tho bowels are constipated, but wo have many times known cases in which tho mother states that after each feed the baby has a fluid green motion. CONSHPATIOX Constipation in the Breast-fed Infant. Constipation is extremely frequent in the breast-fed infant, and the common causes and their treatment may bo enumerated as follows : — 1. Jnsuficieni Fluid. This is undoubtedly tho com- monest cause. In warm weather especially, tho quantity of fluid taken is insufScient to keep tho motion moist and allow it to bo passed easily. Tho child should bo given additional drinks of water, and by this is meant that the child should be offered frnm 2 to 4 oz. twice dally end allowed to take what it will of this. Tho giving of fruit jmeo at this’ time is often the custom. DIARRHCEA, YOSHTING AND CONSTIPATION 121 2. OvenodgM, flabbtf infants, \rith no strength in the abdominal muscles, suffer from constipation, and the treatment is to reduce the diet on the whole, mstituting massage and artiffcial sunshme. 3. Irregular aUeniion and bad management on the part of those in charge of tho diild are extremely common. From carhest infancy it should be placed on the chamber at regular times for the purpose of a motion, in addition to the times when placed on merely to pass urine. If there is difficulty in getting tho child to associate the chamber and his motion for the first few days, the anus may require to bo gently stimulated with vaseline on the top of a soft rubber catheter or a glycenne suppository may be used. Once the association between the chamber and defiecatron is established, tho child will then perform as required. 4. Fear of Vie act of defecation due to an anal fissure is an infrequent cause. Tho anus is sometimes tom or split whilst passing a large constipated motion, and the association of pain on defecation is so fixed in the infa nt's mind that no effort is made, ^e application of a weak, half-strength hamamelidls ointment (BP.) before each act, and keeping the motion soft by means of hquld paraffin emulsion should right this. 5. Congenital anal etenosis is more common than is generally supposed. Some children require very careful dilatation of the onus, beet dono with a well-vaselined httle finger. A httle Semprolin, Nujol, Virolax or Petrolagar Emulsion, given as a rontine night and morning, with occasionally some mflk of magnesia first thing m the morning, is helpful to induce good habits. If tho breast-fed infant is under-nourished, con- stipation may bo the first sign that the supply of milk is dftficiant. A sariaa of teat fceda will qjmMy ahnw if this be so, and small complementary feeds of cow’s milk following tho breast feeds will both correct constipation and at tho same time cause the infant to thrivo. Constipation in the Artificially-fed Infant On the whole, tho remarks regarding constipation m the breast- 122 FEEDING IN INFANCY AND CHILDHOOD fed apply to those artmdally fed, but in addition tbcfo are other Factors. It is usual for crery infant who li fed on cow’» milk to be BHj>htly consUpated, os judged by the normal brc»son. Donald t “Tho and Llmitfttleni of Cwaa In Infant Focding ” Lanett, April 23rd. 1927. p blO. DIABRHCEA, VOIIITINQ AND CONSTIPATION 123 three monungs in the week will also aid in getting the child Into tight habits. Uquid parafHn emulsion, as Semprohn EmuUion, Nujol, Sagradol, Angler’s, or Petrol- agar, given night and morning, is most useful, and also the addition of orange, tomato, or prune juice to the daily diet. In older children any error in the management of the child over the movement of its boa els is followed by a greater or le‘ound body weight. No appreciable gain of weight will bo noted until the intake of food has reached 3 oz. of breast milk for each pound weight. It will be reeoj then, that a prematuro infant of 4 lb , a fortnight obi, requires 12 (4 X 3) oz. of breast milk in the day, a quantity sufBcient for a strong, healthy, full-torm infant weighing G lb at the same age. Artificial Feeding. The relatively large quantities ©f food required by premature infanta increases tho difficuhy of findmg a suitable artificial feed for them, and emphasb-es tho necessity of establishing lactation in tho mother by tho means already described (Chapter IT.) or ohtataieg breast milk from other sources. Because of the larre difficult digestion of cow’s milk protein, relatively saay quantities must be fed to tho infant, with consequent l» 2 j chance of gain in ireight. They usually tolerate rjjjj 132 FEEDING IN INFANCY AND CHILDHOOD . well, and, although the curd digestion may bo overcome to Bomo extent by peptonisation, as a practical measure, it will usually be found that a condensed (evaporated) milk — low in protein and high in sugar — offers one of the best substitutes for breast Tnillf in feeding premature infanta. The unsweetened condensed (evaporated) milks may be “humanised*’ by taking one part of condensed (evaporated) milk to three parts of water and adding one slightly rounded teaspoonfu! of sugar to each 4 oz. of the mixture. This can besubstituted for breast milk, allowing as before that each pound body weight requires 3 oz. of breast milk per day or Soz.ofthia unsweetened condensed (evaporated) milk mixture. A 4-lb. premature infant would theoretically require 12 (4 x 3) oz. of this humanised milk m the day, but in practice it may be found that Bucb an amount causes some mdigesfiou, and it is better to give the 4-Ib. baby 10 oz. of such a mixture rather than to upset it by giving the full tbeorotiral requirements. If cow’s milk is used as the artificial feed, it will give better results when converted into lactic acid milk (see p. 76). As in full-term infants, dried milks appear to be more easily digested than raw milk, and many premature babies can be successfully reared on one of the dried milks. These ehould preferably be “ humanised ” when used to feed a premature infant, and there are now Beveral humanised dried milks on the market, such as Frailac, SnnsHno Glaxo, Humanised Trufood, Humanised Cow and Gate, which, on the addition of 1 oz. of water for each raeasuro of the dried milk, make up a mixture similar in composition to breast milk. The choice of an artificial feed for the premature infant a/fer off er 2 Potato eauhfiocper, turnips, parsups, carrots, peas, beans, or green vegetables (including etearo^ lettuco) 3 tliik padding and stewed frmt, or steamed pudding (without suet] 4 Water to dnnk Tm 4 30 to 8 p m 1 Thio bread and butter, cnsp toast or pulled bread (Zwioback), with stewed fruit, jam, treacle, boney. golden 8>nip and a sponge cake 2 Drinks The same as at hroakfast (In winter, a bowl of broth or a little milk pudding may be given at tins meal ) Etditme, 0 30 lo 7 p m. Nothing more than a plain biscuit or some glucoso ehoold be given, the teeth being carefully cleaned after this Swets Plain boiled sweets such as barley sugar (Barley Slalta or Barley Bngbr*) or fruit drops or Msckintosb a toBee, should bo offered after dinner or tea, the teeth to be cleaned immediately afterwards Afifk This should have the cream removed (skuamed) and not more than, three quarters of a pint la to be given in the day, including that used in cooking Clueo*9 (potnfersd) This IS the best form for cbild^ and should be given at intervals, when required Cod Iirer OIL This should be avoided as tt fends to produce liverish attacks Plain mall, or malt and iron, shontd bo substituted, together with one drop of halibut liver oil tbrea times daily, or a fow drops of Ost«>tin or Bodiostoleum is indieated. jrfitnsa to be taken wfiA caution because of tbeir high /at eonient Milk, butter, eggs, cream, pastry, suet pudeung chocolate or cocoa. 13C r^EPIiVG l^CFAKCY AXD CiULDHOOP Treatment. The vomiting nttncljj can oalv bo prevented by rcmovjng Infection^. The quantity of fat readily tolerated in health becomes grossly cxcesslre in the presence of an infection, and results in ketosw with excretion of acetone in the urine. By dropping temporarily the moderate amounts of fat, rrhich the child normally tolerates, to the lowest possible level, at tbe least sign of infection, the formation of acetone and consequent vomiting is minimised. Tlio diet recommended as a tempomry inta%vrt only, is as above. Great attention must always bo given to the bowels, grey pou der, milk of magnesia, or rhubarb and coda being tho most useful aids for this purpose. The treatment of Acute Acidosis Attacks. Tho child prone to have a poor tolerance for fat gets, at intervals, an infection ttIucIi is accompanied by acute vomiting. Tho onset la very often extremely sudden, and tbe prostration great If an attack is suspected, one to two tcaspoonfub of sodium bicarbonate con bo given, spread over tbo day, in various dnnks. It is useful, therefore, as a prophylaxis. Onco the vomiting has commenced, how- ever, It is wrong to giro sodium bicarbonate. The proper treatment then is tbo administration of sugar?, especially glucose It is very often best for a few* hours to cease fluids by mouth altogether, giving normal saline with 10 per cent, glucose rcctally, or saline with 2 per cent, glucose beneath tho skin. In very severe cases intravenous sahne and gluco'c (2 per cent.) slioutd bo given at once, as this condition may prove fatal. It is safe to give up to 2 oz. of gluco'o in tho first twenty- four hours. To keep the mouth moist, barley sugar may bo sucked. Occasionally, a little syrup or honey, together with thick cereal (made with water) is kept down, and if so tho formation of acetone fa quickly checked. Feeding. Onco the voimting has cca«cd, ns much fluid as possible should bo given, but milk and other fats should be witlilield for a day or more One of the DIETS FOR SICK CHILDREN 137 Bkimmecl dned milks, or malted nulka such ob Horbck’s, should bo commenced Trith Starches such as porridge, potatoes, and nco pudding should next bo given, and Cnally tlie ordinary normal diet slowly resumed (ir ) Starch Djspcpsia In tho child with carbo- hydrate indigestion or starch dyspepsia, the abdomen is seen to bo distended and pendulous, and all the muscles are extremely flabby, but ho is well covered Such children are wind^, sleep badly, and are mchned to have bouts of constipation alternating with diarrhcea The motions when passed aro frothy and acid, tending to burn the child An examination of tho stools under tho microecope inll show much undigested starch present, nliich readily stams blue with iodine It is charactenstio that these children have voracious appetites at times and eoldora chew their food properly They ate soft and flabby and have been named by Scotch pxdiotncians “ bread and butter ” children Tho chief points in eorreeitnQ the dttt are tho reduction of tho total quantity of starches, and ollenng such starches to tho child in a more readily digestible form Any cereal given should bo cooked for from ono to tivo hours in a doiiblo saucepan, thus ensunng that all the starch granules aro properly split Bread should bo given os pulled bread (Zwieback), Byvita enspbread, stale white bread, which has been baked and toasted, or ell crisped rusks Potato must bo given sparingly and the green vegetables given m pur& form only Floured nco (cream of nco) is the best form of nco to bo given TOth this rigwit the latgo distended abdomen tends to disappear steadily Drxnka Such children aro molmed to dnnk much water between mcal<5 Tlua practico should be discon- afiVwnig' tfccaj at meals oaJy , and then la e&re^aUy considered quantities One of the commonest sights, especnlly among tlic M ell to do, who are often attracted by tho cult of a no red- meat diet, is a child with hiod, knee andfial/cct Tliese children have been rachitio as infants, and when older J36 FEEDmG IN INFANCy AND CHILDHOOD Treatment. The vomiting attacks can only lio prevented by removing infections. The quantity of fat readily tolerated in health hccomea grossly excessive in the presence of an infection, and results in ketods with excretion of acetone in the tirino. By dropping temporarily the moderate amounts of fat, -which the child normally tolerates, to the lowest possible level, at the least sign of infection, the formation of acetone and consequent vomiting is minimised. Tlio diet recommended as a temporary rmasurt only, is as above. Great attention must always be given to tbo bowels, grey powder, millc of magnesia, or rhubarb and soda being the most useful aids for this purpose. The treatment of Acute Acidosis Attacks. The child prone to have a poor tolerance for fat gets, at intcr^TiIs, an infection which is accompanied by acute vojniting. The onset is very often extremely sudden, and the prostration great. If an attack is suspected, one to two tcaspoonfuls of sodium bicarbonate can be given, spread over the day, in various drinks. It is useful, therefore, ns a prophylaxis. Once the vomiting has commenced, how- ever, It is wTong to give sodium bicarbonate. The proper treatment then is the administration of sugars, especially ylucosc It is very often best for n few houra to cease fluids by mouth altogether, giving normal saline ^vith 10 per cent, glucose xcctally, or saline with 2 per cent glucose beneath tho skin. In very severo cases intravenous saline and glucose (2 per cent.) should be given at once, as this condition may prove fatal. It is safe to give up to 2 oz. of glucose in the iirst twenty- four hours. To keep the mouth moist, barley sugar may bo sucked. Occasionally, & Jittlo synip or honey, together Avith tliick cereal (made with water) is kept down, and if so tho formation of acetone is quickly checked. Feeding. Once tho vomiting has ceased, as much fluid ns possible should be given, but milk and other fats should be witliheld for a day or more. One of the PIETS JOB SICK CHILDREN 137 skimmed dried null s, or malted milks such as Horhck’s should bo commenced with Starches such as poradge, potatoes and nee pudding should next be given and finally the ordinary normal diet slowly resumed (II ) Starch Dyspepsia In the child with carbo hydrate indigestion or starch dyspepsia, the abdomen is seen to be distended and pendulous, and all the muscles are extremely flabby, but he is well covered Such children are windy, sleep badly, and are mchned to have bouts of constipation altematmg with diarrhffia The motions when parsed are frothy and acid, tending to burn the child An examination of the stools under the imcroscopo wiU show much undigested starch present, which readily stains blue with iodine It is characteristic that thc®e cluldren have voracious appetites at times and seldom chew their food properly They are soft and flabby and have been named by Scotch pa?diatncianB “ bread and butter ’ children The chief pomts in contcting (ht diet are the reduction of the total quantity ofstarches and oflenngsucb starches to the child m a more readily digestible form Any cereal given should bo cooLed for from one to tiro hours on a double »anccpan thus ensuring that nil the starch granules are properly spbt Bread should bo given as pulled bread (Zwieback) Ryvita enspbread, stale white bread, which has been baked and toasted, or well crisped rusLs Potato must be given sparingly and the green vegetables given in purfe form only Floured nee (cream of nee) is the best form of rice to be given With this rigme the largo distended abdomen tends to disappear steadily DnnXs Such children oro inclined to drink much water between meals This practice should be discon tinned allowing fluid st meals otHy, and then in carefully considered quantifies One of the commonest sights especially among the well to do, who are often attracted by the cult of a no red meat diet, is a child with htocL knee and fiai feet These children hove been rachitic as infants, and when older 138 FEEDING IN INFANCY AND CHILDHOOD have been kept on an extremely lo^ protean r^iTne Breakfast has been purely a starchy one, and the only protean given at dinner has been gravy or fish or on egg This low protein diet necessarily entails a high carbohydrate intake, and invariably results m a large, beautiful, very soft and flabby child From the ago of one year onrvard, children can manage protem at both break fast and dinner ivith great benefit to themselves, and in this way their starch intake can be rigorously curtailed ^ Diet In Scurvy The treatment of a case of scurvy consists of giving adequate quantities of Vitamin C As scurvy does not occur under the ago of six months a mixed diet is always to be recommended A pint of scalded cow’s milk is given per day m place of any patent or dned food which the child is having An attempt should bo made to get the child on to the diet sheets on pp 00-100 the diet for a normal child of the appropnate age Two to three tablespoonfuls of orange or tomato juice should bo given durmg the twenty four hours, well diluted and sweetened, for a penod of three days After this the amount should be reduced to one tablespoonful per day Potato cream, that is, well boiled mashed potato, to which has been added a httle milk and the whole stirred into a cream, is useful It can bo added one or two teaspoonfuLs to each bottle for three or four days The baby should be handled ns httle as possible until the scorbutic lesions are healed by the givmg of a diet nch in water soluble vitamin C, such as the above Diet in Rickets The diet plaj’s an important, but not an exclusive, part m the treatment of rickets It should be a well balanced diet containing all the food elements A pmt of mdk should bo given daily to ensure a sufficient amount of calcium, and for children above mne months two to three eggs per week ensures a sufficient quantity of phosphorus Great care should be taken that the child is not bemg overfed on the diet as a » Tlw Hj-potomc (Flabby) Child Donald Paterson, Bnt Med Joum February 14th 192o DIETS FOR SICK CHILDREN 139 whole, and is not OTorweight, soft and flabby because of this. Some form of cod- orholibut-lirer oU should bo given, either as cod- or habbat-Hvor oil and malt, plain cod- or balibut-Uvcr oil, cod-Uver oil emulsion, such ns Scott’s Emulsion, or ono of tho crg«»terol preparations, such as Radiomalt, Radiostol, Vigantol, Ostelin, Ostamalt or Vitamalt or Calciferol. In addition to tho diet, tho child should have light clothing, and plenty of exercise is absolutely necessary, the child being allowed to kick and move its Umbs freely. It should not bo cooped up in a cot or pram many hours daily because of its condition. Direct exposure of tho skin to the sun’s rays, so that tho faco, arms and legs are brown, and in tho summer months tho whole body, is most beneficial. In winter a CQurso of artificial sunhgbt takes the place of the natural sun. General massago to all the musdes will hurry tho cure. Diet In Nephritis, In aeuU k nner 1 A 1 bcral quantity of red or white meat of any sort or fish may be p%*en 2 bresh vegetables may bo given in abundaneo such ns Lett ice spinach cobbage caiiltl1o«er asparagus ce “ry onions iomatocfl norsniis and carrots lotato must bo taken witli groat caution Try to manage with a piece not larger t( an an egg 3 Fresh or atowed fruit anpice pears grapes peaches plums clomea pineappto and rbuoarb uned fruits prunes figs rftteins and dates (Avoid rojlky and suet puddinga and custards ) 4 ^V&ter to dnnk. Tta 1 lettuce or tomato eondwieb or two or three Coergen digestive bisciuts 2 Cup of tea Supjoer 1 Salads or so ma (excepting \‘egotable soups) 2 A tittle Gsh (bail'd sCcamed or baked) or fish mayoosa so or cold tongi e 3 One HKk or a email portion of Ityvita enspbreod or Fnergeo whole meal bread or bran biscuits 4 Dnnka os fit bmakfast Art\cUi cf Jood trKicA ehould b« pirm uuS eaut cn on ateount of (Aeir tendti cj Jo/a«en • — Suyar (including all sweets chocolates sweet jams honey and syrups) £/orckj foods (such aa pomdge bmod potato and rice pudding) FoUj Foodt (such os butUr cream and eggs) Dnnka Cocoa Ovaltine and dried nulka should bo avo ded Keep to plain water or weak tea, or cow a milk (a pmt a day) FovietfaiarenotfaUrntn^ Sleat Feb soups (oieept vcgefabla soups) saledt jjeu) gnva /not /raw and atawid.) jwthnut miicb sugar Ryvita enspbtead and Fncrgca nod CaUonla food products (with vcfyliltJo butler) Af ilk In a growing child despite tho tendency to overwe cht a pint of milk should bo given daily to ciuiira good tooth and adequate bony growth U4 FEEDING IN INF.AKCi* AND CfllEDHOOD The authors ha% e not found it necesMij* to give ^yroid or pituitaiy in the ordinary cape of adiposity, which is eo often exogenous in origin. Endocrine therapy should bo reserved for Ihoso cases which show definito evidence of changes in tho ductlces glands. Diet in Ceeliac Disease, In this condition tho priniuw fault is on inabihty on the part of tho ciiild to utQIso its fat. The fault does not Uo in the splitting or digestion of the fats, which is carried out quite nelJ, but tho split fat is passed in large quantities in the stool Tlio lined stool should normally contain about S5 per cent, of split fat, but in ccoliao disease from CO to 15 per cent is common. Tho proper diet should bo one low in fat, high in protem, which is well tolerated, and modcratelj high in carbohydrate htilk should bo given ns sUmmed dned milk or utU skimmed cow's milk or Horlick’s dialled Milk, a total of J to j pint of skimmed milk per day being the maximum. The yolk of egg is not well tolerated, since it is almost entirely fat end must bo given with great caution. No cream, of course, should be ^vcn. Butter in scrapmgs only is tolerated, and in place of this fish pastes and scrapings of jam may bo given. Skimmed con- densed (evaporated) milk, spread on bread or biscuits, is both pabtablo and useful. Smeo all fats, and therefore the fat-soluble vitamma, have been removed, it is ^ ell to replace them by one of the concentrated eigostorol preparations (see p 138). One tablespoouful of orange juice and one tcaspoonfu! of Harmlto should bo included in tho diet daily As mucli liver extract os uiU lie on a siipcnco should bo given (hreo times doily in tho early stages. Four c.c. of Carapolon (Bayer) given intra- muscularly, per week, is indicated. Such foods as scraped meat, fean crisp bacou, the white of egg, cold tongue, lean ham, underdone beef, aro all most smtable, and should bo introdured at tao at least of tbe child's meals. Groats, twice or thrice cooked rice, Plasmoii propira- DIETS rOR SICK CHILDREN 14u tions, aro well tolerated A Uttle potato only should be given and green vegetables m moderation Over npo brown banana is extremely well tolerated and useful m certain cases In each ease an attempt should be made to give banana m large quantities, as those in which it is tolerated progress rapidly Ccdiac Diet (For ehtUnn crer ll t o^e cf one yeor) On iroXniM^ A glass of oruigo juic« grapefruit or tomato juice aveotened n tb sugar BreaL/aet aay 8 fr ed < cry thin nahera of bacoa (fned untD the fat has been suuoly removed, and then allowed to drip eo that the minimum of greaso remains) Fish abould be given os one or two mornings, also 1 ghtly grilled I ver Cnsp toast aad butter and one cupful only of well skiromed wuUt complete the meal iltd mommy A plain bueiut or acme fru t such as an orange or orange ju eo may bo given. D nnrr eaj at I® 30 Underdono beef steak stew cutlet chicken, Csh or bmns or occas anally a little lightly gr lied hscr potato CAuUdower tumipa paren ps carrots peas bmus or green vegetables (including steained lettuce) olt rery tesU sirred or Heuu.'Lbby a or bomogemaed vegetal lea would bo s ery suitable 5rcond Cen rn SISk pudding and a eved stewed fruit or steamed pudding (without suet) or preferably orer nps banana if this is well tolerat^ (see not® below) Tea 4 30 to 6 p m. Thin "bread and butter crisp toast or pulled bread (zwieback) with sieved stewed fru t or a vety I ttle jam, treacle honey or golden syrup and a sponge cake Dnnks the same as at breakfast Jn mnter a bow] of broth or a Uttle milk pudd ng may be given at this meal (Orover npo banana may bo given at this meal also if preferred ) Bedims OSOtoVpm If the ch Id has left some of his tea these remnants may be offered Bgam et thu time Foods TTcH ITofmifsd Scroptd raw or underdone steak pounded eh cken fiah raw or lightly cooked liver and weU.8kimmed broth 1.0 140 FEEDING IN INFANOy AND CHILDHOOD A put bottio of milk should ba sIIdTed to stand for two hoars and thn ere^ then poured or dipped off A skimmed dned or separat“d mEUr such B3 Cow Bad Gate may be given instead in equivalent auantitics These chUoreada beat on from J2to20oz ofmilk p^dsy VegttahUi These are best mven very finely eiered. Avoid «a eveesa of croon vegetables as they are boU^ and tend to produce gas rotatoM, cauliflower parsnips, turnips eod cairofs are most snitabJo Ueiaz, Libby a or hiestia a homogenised vegetables aro partieululy suitable f/vif Over npo bananaa are often especially suitable hut not tolerated in all esaea AVhere they ora well tolerated four or even aix bananas should bo given ra the day Orange tomato or grapftfhnt julee should be given daily All aleuia/ruit should ba sirred /Jreatl Thisis best given asensp toastorruska and later as brown bread Articles eontoininj; Fot tchuh should ba Avoided or Talen tcilA Caultoa Yolk of egg (give the white only at first) cream, btnter fried foods Small doses of eod or halibut liver o3 together with or artificial sunlight will make up for the deficient vitam ns Diet in Catanbal Jaundice The diet m this condi* tJon should be lotf in fat and lugh ui sugar dunng ilio acute stage As carbohydrate throws no work on tho hver, and both fat and protein do this, the latter two should be as far as possible aTOidcd Well diluted skimmed milk (not more than J pmt in tho day*) and a sufBcient allowanco of starchy foods at each of tho tlireo meals should be continued until the motions regam their brown colour No attempt to push along with fats (cream) or proteins (meat other than a little tongue or bacon) should bo made for some time No eggs or cream should be given and butter must bo avoided for the tune bemg Vegetable broth with crisp toast will bo found most u««ful for dmner, and cereal foods, both cooked and dry, for breakfast and tea Stewed fruit may bo served with these in place of milk or cream Fever Diet (m Colds. Influenza, TonsiUitis, Bron* chitis, Pneumonia and Infectious Diseases such as Measlea, Scarlet Fever, etc ) Donng a febrile illnc<»s m childhood DIETS FOR SICK CHILDREN 147 thoi-o is u tendency for acetone and diacetic acid to appear in the urine ; the child is in a state of acidosU Sneh is responsible, to some extent, for the drou^iness and initabiUty of the patient. It results fiom the faulty burning up of the fat in the body, and the diet must therefore be planned to give the following : — 1. A minimum of fat (fata ar© found in butter, milk, cream and eggs). 2. A high proportion of carbohydrate (sugar, starch and glucose) in order to help the complete metabohsm of fat. 3. Little or no protein foods (proteins are red and white meat, milk curd, egg white, etc ), so that the diges- tive and assimilative powers aro not overtaxed. The following suggestions moy prove helpful in constructing a suitable diet m the presence of fever : — 1. Timts of Feeding. The child is best fed at its regular feeding times, namely, breakfast, dinner, ond tea-supper, with one feed in the night. Bland drinks, mentioned under 2, should bo offered freely bcti% een feeds. Shoi^Id the child be taking its food extremely badly, however, more frequent feedings moy be necessary, but should on no account bo pressed 2. Fluids. Water, barley water, orongo or lemon uater (well sweeteued with sugar or glucose) should bo given freely. Add a little bicarbonate of soda to any of these prepared fluids occasionally, and soda water might also bo given. 3. Sugar. Try to get the child to take powdered glucose, two heaped teaspoonfuls three times daily, especially if there is a tendency to vomiting. This may be given dry or dissolved in fruit Juice, or along with one of the starchy foods. 4. Starches. To increase the caloric value of the food, and at the same time prevent oeidosis, the addition of starches and sugars is very useful. Patent groats or barley, made irith ^\ater, Chapman's Entire Wheat Food, Cream of Rice, arrowroot, and cornflour, Bengor’s and Savory and Moore’s Foods, aro all to be recommended 150 FEEDING IN INFANCY AND CHILDHOOD 13 successfully emplojrd in the treatment of ccrcma Dned Goat s SUk, manufactured Lj Cow and Gate i8 sold imder tho trade name of Caprolac Its composition IS protein 27 1 per cent , licto»e 47 2 per cent , tat H S per cent , mmeral matter 7 5 per cent , moisture 3-4 per cent Apart from these dietetic measures, it h essential that the child should bo prevented from rcratch mg by means of cardboard arm splmU— the finger noih bemg clipped short The application of Calammo Lotion where the okin is dry, or Resorem omtment where it is broken, is to bo recommended I7yiifar«i (I/eal Ziehen Vrticalus (Uriieana papulosa) Tho exact causation of this common slan condition is not known It would appear, however, tliat beat mduces attacks, and great care should bo taken, m hot weather especially, that children are not o\er clothed either by day or mght Undoubtedly fat, such as bacon fat or dnppmg oils and fned food, will produce heat spots in some coses And fruits appear to cause attacks m other children All raw fruit should bo stopped, such ns oranges apples grapefruit, and stone fruit (excepting tangerines, which aro not and), until tho spots have disappeared A tcaspoonful of bicarbonate of soda, spread over tho day (a pmch m all tho drinks) is indicated Tho total diet is best reduced a little Diet m Anxtaui It is usnally found that tho diet of an anwmic child has been oxccssivelj high m starch and low in protem Tins should bo corrected and tho stirchj foods decreased and the protems incrca-xrd Tlie yolfc of tho egg contains much phosphorus and iron and an attempt should bo made to give a little on three or four mornings m tho week A Iittlo cnip lean bncon or tish at breakfast prevents this meal from being too starchv At midday scraped ran or underdone steak or muttori or lightly cooked liver sliould bo given on four days in tho week I'egetnbles, such as spinach or greens, especially when steamed rather than boiled ha^-o mucli nvodablo iron Raw meat joice maj bo given with llarmito at 11 a m , or poured o\ er tho mlddaj meal as gra\*5 DIETS rOR SICK OHILDREN 151 The mo'st smtabb forms of iron to bo given medi anally to littlo children are Fern Garb Sacch , os much os TPiil he on » sixpence three times daily after meals, or Pamsh’a Chemical Pood, half a teaspoonful three tunes daily after meals, or iron and ammomura atrato,^ 3 gr three times daily after meals Traces of copper and man ganese have been Bhovm to be essential for successful iron therapy Mormite should be given daily Some of the propnctaiy hver extract preparations are extremely successful Among these are Allen and Hanhury’s ** Byno Hepol, ’ ‘ Nco Bovimn© 20,’ made by the Petrolagar Laboratories Ltd , “ Hepa Simplex ” (Bencard), and Livron (Boots), and other vaneties of dned hver extract made by the largo firms of manu factunng chemists Wanders “Veguva,” a mixture of dned spinach, carrots and tomatoes, has a high iron content and is most suitable for amemio infants and children Syrup Minadex (Glaxo) is a popular and useful tome in anamiia * Jiutnlional AnimiainlnfMcy with special nfewnce to Iroa Deflueacy Helen Mockay B a Majesty b Btationery OlDce 1031 APPENDIX I SALINE SOLUTIONS NorTTial saline is made by dissolving 1 drachm (a heaped teaspoonful) of salt in a pint of ^ater and steri- lising by boihng. It h used to replace fluid lost by the infant in cases of marked diarrhoea and in shock. It may be given intravenouslif, though this is a matter of extreme difficulty in infants or small children. The subeutantoui route, the injection of the salmo into the subentaneons tissues over the chest or abdomen, is the best method. The amount given (after the saline has been raised to the body temperature) trill depend on tho size of the patient, but is seldom more than 0 to 8 oz. at a time. Caro must be taken not to over-distend tho tissues, as in the debihty trblch accompanies dehydration the skin over tho bite of injection has been known to ebugh when an attempt was made to give too much salmo. Salino has been given directly fn/o the peritonecd cavity by pinching up a fold of the lax abdominal wall and inserting a ncedJo parallel to tho surface. This method is certainly not devoid of the risk of infection and of puncturing tho underlying gut. HalJ-slrength normal saline is made by dissolving i drachm (a level teaspoonful) of salt in a pint of a ater and sterilising as before by boding. It is unsuitable for sub- cutaneous injection, but is of marked value when given by mouth. In cases of dehydration half-strength ealine appears to be more readily retained by and absorbed from the infant’s stomach. It may be freely given as a drink from time to time, or sovcral ounces may be left in the stomach after gastric lavogo. Saline and Glucose. In giving subcutaneous or rectal V lines, it is well to give glucose with it, ns this acts not IIS APPENDIX only B3 food, but also combats accompanying acidosis The strength of glucose giren mth subcutaneous saline 15 from 2 to 6 per cent , and Tnth rectal salmo from 6 to 10 per cent GASTRIC LA.VAGE Washing out the baby’s gtomach is bften an essential for the -treatment of cases of dyspepsia or vomiting, and IS not a difficult matter The necessary apparatus consists of a soft, small, red robber cesophageal tube, to the open end of ahich is attached a gloss funnel The barrel of a 20 c c synnge may be used as a substitute for the latter There is no difficulty m passmg the tube into the baby's stomach, and it is not necessary to use any lubncant if the outside of the tube has been wetted at the onset Water may beu^^ed or a solution ofeodinm bicarbonate (one tea- spoonful to the pint) may bo helpful if much mucus is present The liquid must bo given worm, and care must be taken not to over -distend the infant’s stomach by using more than a few ounces at a time By alternately raising the funnel above and then depressing it below the level of the infant, fimd may bo run into or out of the stomach The lavage sboidd bo continued until the washings return clear, » e , imaccompamed by food dftrw or mucus, and, finally, if considered necessary, some fluid may be left m the stomach at the end of the operation If much vomiting has occurred, bicarbonate of soda should not be used, but normal saline only * COLONIC LAVAGE For washmg out the rectum and lower few mchea of the colon, an apparatus similar to that described for gastric lavoge may be used Warm saline should be preferred to ordinary water The buttocks are on a pillow covered with macluntosh sheeting aud the well grea'^ed tube gently inserted to a dishmoe of 2 to 2 inches The level of the funnel should not be more than 18 mehes above * Mattols IL Meirthjr C B.Tajoe W “ Alkalosis la the Pylonc Blcaos 9 of If fonts, Lan tt February 8th 1930, p 2S5 APPENDIX IS5 pliosphoras and iron, and In the fat <;olublo vitamins A and D Tho cluef consUtuonts of tho egg are fat m the yolk and protein m the ■white, and the calorie value is about 70 Eggs should he cautiously introduced into the diet at breakfast, or occasionallj at tho midday feed from six mouths onward If there is any hesitation over takmg the jolk of a soft boiled egg, minute quantities only should be added and a month should bo taken to reach a quantity of a tcaspoonful, or more if necessity Between the ages of six months and a jear tho yolks of two eggs may be given during tho week Prom one j car onn arf this maj bo increased to three eggs per week, when tho child can tolerate so much Thero are very few children below the age of mne or ten years wbo succoasfully tolerate more than three or four egga in the week, numbers being shghtly hvcnsh because too many are given Meats MvUon and buj are equally digestible, but “ital IS an immature meat and much more di£5cult to digest than either Pork is also mdigestible, because of tho fat between the fibres, taking half as long again to digest as beef or mutton Bacon, however, is very easy to digest, and bacon Jat is of all fats the most digestible The more fat there is interspersed with tho meat fibres, the more mdigcstiblo it is The most digcs tible of 1 11 meats is the breast of cAtcIcn or gamt Kidnty is very compact, and because of this is inclmed to bo indigestible It contains more nncleo proteins than ordmarv meat, and is therefore inclined to be gouty Siottibreads or pancreas are mo'^t digestible, but they alao contain much nucleo protem and should not be given more than once per fortnight at most if there is a fsaiihsl gouty iuadouey Xtso’, A»sb or hss hees shown to contain a substanco which is most beneficial ra the treatment of penucious anaunia in adults and secondary anicmia in childhood It is well for fried ox or sheep’s hver to be present in the diet of the child once per week It undoubtedly stimulates the appetites of APPENDIX 157 tolerated, but, of course, they can be recognised in the siooh Spinach, sprouts or carrots cannot be mistahen in the hght yelloi’nsh milky motion, but they should not be abandoned because of their presence m it Vegetables vary m thear/ood talue Green vegetables have a high vitamin content, containing much irater- Boluble C and fat soluble A and D. Those contammg much cellulose, such as beans, asparagus and fumips, may bo given partly for their food value and partly as roughage, to promote peristalsis Among the vegetables nchest m protein are the pulses (peas, beans and lentils), green vegetables, such as savoys, tumip tops, spmach and cauh- flower. Those richest m carbohydrate are the pulses, savoys, turnip tops, tomatoes and cabbage, and tubers and root vegetables, such as potatoes, beetroot's, carrots and parsnips Vegetables are also vatnablo for their salt content, some of them havmg a high proportion of calcium, mag nesium and sodium, which the body requires These salts (or mineral matter) are highest m the pul-ms, next highest in green vegetables, and a moderate proportion is to be found in the root vegetables or tubers Watercress, lettuce, tomato, cabbage and turnip are especially valu- able for their vitamin content, as they contain much fat- soluble A and D and water soluble C In cooking regelables steaming is much to bo preferred fo boiimg, as a largo proportion of the carboiiydrafe'’, protems and salts are wasted m the process of boilmg By steaming with a small quantity of fluid only, this waste IS almost completely eliminated Vegetables should only be cooked for suIBcient timo to mako them thoroughly soft Steaming them with a httle butter, or feervmg them With butter, adds to tbeir taste and food value Fruit and Fruit Juice There are several reasons why raw fruit or fruit juico is valuable m feeding all infants and children Besides the high vitamm content (see p 42), especially water soluble 0, they are a means of providing carbohydrate in a pleasant form They also supply certain salts and water In some fruits there is 168 APPENDIX also a largo amoant of cellulose, and by virtuo of this they tend to combat constipation. Orange juice, tomato juice or grajpe/ruit juiu, ' Itco or three teaspoonfule diluted with water and sweetened with sugar, should be commenced at once with all ariificiallg-Jcd babies, mcapectivo of the fact that scurvj’ does not develop in children under sis months of age. In breast-fed infants there is no. need to start fruit joico before the ago of tlireo or four months. The kind of frait juico given must be adjusted to the bahiea themselves. Orange juico is cheap and Suita most infants, but occasionally it oppeare to bo badly tolerated, and in these cases tomato juice or grape- fruit juice must be substituted. In a constipated infant betrreen six and nine months old h little strained stowed prune or stewed fig juice is permissible and useful. Baked apple or apple eauu can be given from nine months onward. After a year prune pulp and even fig juice con- taining some of the seeds are quite well tolerated. WoBimro. Some mothers or nurses disconlinus the use of fridt juico when artificially feeding a child, because of a tendency to looseness in the bowels. It must be remembered that fruit juice is given for its vitamin content, and although it may be necessary to dificontinuo its use for a day or two, it must bo recommenced or scurvy will result. Raw apple produces looseness in tho majority of cliildren under two years, and should theroforo bo given with great care. There is no very great advantage in giving the apple raw, and on that account it would Bccm unnecessary to insist on it. Bananas contain a high pro- portion of carbohydrate end banana oil. Tho over-ripe, brown or black banana is roost suitable for infant feeding, and in such conditions as cceliac disease bananas aro well tolerated. The average child tolerates only small quanti- ties at long intervals, say half a banana uell mashed up at tea time once a week, to bo commenced betueen one and two years, Qrapejruit and orange, including the pulp, can be given with safety from two years of age. Peaces and apricots contain little nourishment, but can be given APPENDIX 169 stowed quite safely after the age of one year and raw after two years. Pears must rank among the more indigestible fruit, and should not he given raw or stewed before the firat dentition is complete at about two and a half years of ago. Seed fhiit, such as strateherries and raspberries, are innch better given coohecl, and then not before tbe age of two years. Eaw fruit may bo pven to very young children with care and in moderation with advantage, but in large qoantities and without discrimmaiion it can do a great deal of harm. Jfany mothers too readily exploit the idea that fruit is good for children, and give in to their demands bj’ heaping fruit upon them Excessive raw fruit, besides producing looseness, is conducive to the production of urticarial and other rashes (see p IGO). There is some evidence that this is duo to the addity of the fruit. Both apples and bananas contain much acid and tend to produce urticaria in some children. Tanrjerines, which are bland and non*ncid, will readily take the place of oranges as a source of ntamm in those children who show an intolerance for acid fruit. Melons cannot be said to be a suitable food for infants or young children, and are among the most indigestible of all taw fruits. The giving of melon at any age should bo coiaidered an experiment, and its effect carefully watched. Cereals (see p. 63). A very largo proportion of the diet of the human infant cod child is made up of starchy food. It may bo given in a great many appetising forms. On page 160 is a table quoted from Sherman,^ show- ing the quantities of coxbohydrato, protein ond fat in some of the more common cereals. Bfellanhy * has shown that tho form of starchy food given to a puppy matters profoundly. Oat flour is much more nei^ets-proukeing tfian wiieaiS ifbur Ihr some yt;< undetermined reason. Clinically, it has been noted for • Sfcomum . “rood Prodnrt* ** Kew York • Jlacirullan, 1C20 • llellArby, K. • J/erf itwrorelk Council Jleport, Ko 03, “ Erpen zucotal RickaU “ 160 APPENDIX Ptf tfat. CubcbMnU rmciB Perwat tfU Oatmeal 67-5 16-1 7’3 Bice . 7D0 8-0 03 NVbolemeai Hour . 71*& }3 8 1>9 While flour. 76-4 7-D M Barley 77*8 83 M Bye . . 78-7 68 09 many years that a diet rrith aa cxeessiva pcoporttoti of starch in it tends to produce rickets. ‘That the “ balance ” of ft diet is of itnportaneo there is no manner of doubt. Wheat floor is least prodnctiTo of rickets, rico flour, rrholemeal flour and barley flour como next in that order, and oat flour is tho coreal most produetiro of rickets. Provided that cereals oro accompanied by a eufiicltnt quantity of milk (in the arerago child from six months to two years this is about I pint per day), and the child is having some anti-raebitio vitamin in the form of cod'llver oU, starcbes can be given with perfect safety in teasonable quantities. Some of the corcalfl in common uso aro pomugo, Cream of llTJoat, groats or IVheateno, fho dried cereals, such as Shredded Wheat or Grape-nuts, bread and toast, rusks and puUcd bread (Zwieback), Ityvita crisphread, ground rice, tapioca, sago, macaroni, spaghetti and vcnniceUi. The patent cereals will bo found on p. C3. The value of cereals depends not only on their carbo- hydrate content, hut also on their vitamin, salt and pro- toin content. Ono of our chief sources of vitamin B U to bo found in cereal foods. Polished rico is, however, lackmg in this respect. DigeslibtUiy. The starch grains of diflerent ccrcala vary in their digestibaity, some requiring much more cooking than others to split them open. Some more cefluloso and have moro residoo on account of im. Tho great majority absorb a quantity of water dunng cooking and swell to thteo or more times Ihctf ongmal APPl!NDl:t Idi size For example, a teaspoonful of groats makes half a teaoupFul of pomdge. ■Wholemeal flour produces bread contammg more vitamia B than nhit© flour, but, on the other hand, because of its cellulose content, much less of the n hole- meal bread is absorbed than bread made from white flour This fact IS taken advantage of where a residue is required in the intestine to combat constipation Cooking Cer&als It is almost impossible to imagme an over cooked cereal food The common mistake is to under cook it, and the starch granules are offered to the child unsplit, so that indigestion results Half an hour’s direct cooking, or from one to two hours m a double saucepan, is most desirable Cream of Htce Take one heaped teaspoonful of GtquIVb “Ctfeme do Riz” (cteam of iico agents, liuzonby & C!o ), mix to a paste with cold water, add a teacupful of milk, place in a double saucepan, and simmer for fortj minutes to one hour, sturmg frequently This should produce about half a teacupful of a consistency smtablo to bo spoon fed to the infant Croats Robinson’s Patent Groats for breakfast Take a heaped tcaspoonful of groats, mix to a paste with cold water and add a tcaOupful of warm water to this. Place m a double saucepan Boil for from thirty minutes to one hour Stirring will prevent lumps forming After mixing 'with cold woter and before cookmg this may be added to the infant’s bottle of milL and cooked with it, thus stenhsing the milk at the same time As a rule, however, it is more convement to feed the semi- fluid groats and milk wi& a spoon Cream of Wheal Bring a pmt of water or milk and water to the boil m a small double saucepan To this add two level tablespoonfuls of cream of wheat and stir till the pomdge thickens Then allow this to cook for at least an hour This amount of cream of wheat is sufficient for three or four children for one meal Ice Cream In certain febrile illnesses plam loe cream will be found most useful For example, m typhoid appendix U 2 fi vcr, wljwi tho Uinpcnlurt u jiJuii water uxsi help to reduce thts Icmperature, and nt the iwmo Ura« add a httlo carbohydrate to the day V food, thug cooihating acidosis Icc cream it'^elf contaminp creamy: milk and yolk of egg js more nourishing and has a much higher fat Content In making this, therefore, the egg yolk ehould ho reduced to a minimum and the niilk rhouM be wall skimmed In this form it is extremely pahlahlo and u«eful after tonsiUecloroy Broadly gpcnking ices may bo divided into two cla£J^c'^, cream ices and antcr iccs The former aro some times composed almost entirely of cream awcclenwl, flavoured and elaborated in a number oT wb\b, but more frequently llio so called cream leo consists of custarik more or less nch according to respective requirements, niUi the adtbtjon of /labouring ingrcihenfs (Sira Breton) II aler icm are usually prepared from the juicts of fresh fruit, mixed with fruit errups nr |im A simple rcapo is the following — Lemon I'HUc. One quart of milk, tv,-o cops of sugar and half a cup of lemon or orange jmcc Allou to froero in an ordinary freezer, or Krigidaire \Miero fat is tolerated tlio following w an excellent ICO one cup of nulk, half o cup of cream, half a cup of sugar, one egg salt and Vanilla to taste Alloa to freexe Prlnnpal Food Sources of the Vitamins ^ \ 1 TA«TV A XIX I^carolo (a gwn l«Jy vegetable), apitincli, Alfalfa. Carrots Animal fats ajul oils glan InUr orgaiiH, rjfg*. milk Hutfrr Cod hal but an I oil er fWi oili XX Artichoke given string beans bnts-wU sprout* tclwy leaver lettuce, g’vco pens lumpkin sweet potatoes grein drierf poi*. Tomato, banana, date drieil jiruiie water melon (mw on 1 tinntsl) • TaVoj from The Mwmms Shennw a-wl SmilU tud Ul, 1531 ilocmiiUft Sewlork APPENDIX 103 X Cabbage, cauliflower, ctcumber Tunup, boot, lentil, onion, parsnip rrosh apples, cooking figs, fresh grapw, oraoga juice, prapefniJt, lemons, peaches parley, bran, conuncrcul bread, cottomoed Nuts almoniN, Barcelona nuts, Brazil nuts, walnuts and peanuts Seed oQa Animal museto tisuea VlTAJIDi B, XXX Yeast, cereals (particularly wheat germ), beans, peas and seeds, spmach. Laic, mustard greens Tomato mdk, e^, nuts Asparagus (green) XX Heart, liver and kidney Hog muscle Wheat (whole), rye, barloy, oatmeal, maize, brown nee Potatoes carrots, turnips Oranges, lemons grapefruit, fresh prunes, apples and peam, bananas X Moata (ordinary) Jlflled wheat, maize, nee VlTAJOK B, xjx. Cereal products, yeast, milk, lean meat, green leaves Liver xz Tomatoes, eggs mdk, fish X ilaize, butter VlTAMU? C XXX Lemon juice, orange juice, tomato juice (fresh or tinned), swedes turnip, spinach, watercress XX Luno juice raspbcmesnndcloudbwics fresh chemes fresh appli-s, carrots, potatoes, onions cabbage germinated seeds, watermelon X Oropo juice, poors, apricots, peaches, plums Raw mflk VrrASf» D XXX Tish liver od (goose Osh In er, hemng, sardmo oU and cod and halibut liver 0(1) PulTcr (Uh Incr oil Egg yolfc, butterfat, whole milk XI Green leafy foods VlTAUDf E XXX Lettuce leav cs, wlient embiyo XX Seed oils and vegetable oils. X Baiiaims and oranges Animal tissues. m APPENDIX SICAI.S FOR OKE DAY FOR A OHtU> OF ABOUT THREE TEARS (WEIQITE 31 TO 35 LB.) AJOVDAY i o h w £v 53 Is i II 3^ P s 4 li u 3 1 a > On TTsHit; Or*p(fnUt ]alce. 2 UU». tpoOtiin]* . , Slcu' lamps , HHotJiUt Ssm ■ Ith 4 or otmllk tvoUblesponohdi Sigkr. oc« (eupoaniui BmoiIi tvo eilip fuben . Tout two tuLit lUea , ... UIUe to drfDk Xllixwr It-SOpm Trfili stow wRb pcuto, two Ubl«027 'i'i 178 623 3«7 •002 -Oil •003 180 ■CJI «oi ■007 1£3 •003 ■0-3S •003 Sit A ii.r,i> A iCn v A,0 A,B.C.a A.B.atl Ji.t,c,x> A.V.C. A.t A. l> B. “ A,I),R,D 222 807 1,080 l-OOl lotos ■879 TUESDAY 1 o ll „r ll a ll II .1 ti fl 1 p On WaHnf Onoeolaief SUmspoonrol) 1 - - 14 41 14 41 •OOB 0B9 010 A It.C. ' Bam yorrtde^. 4*0 totlfsnxufuli Sogiir, one (eupooniol » 9 19 W « 80 ■M9 ■031 A,B. a.bTd BronbKad, two ball illcte t S3 93 93 •002 323 W7 ■002 A,B M»v Incladloa ttiAt fflTen wltU the porrida* • .ptiinfr 12.30 pn. itotcc toattoa, oee Uas- »po«)nlnJ . SplBMh. on* UbJwpooo 10 41 93 .7 IBl 233 «SS 331 A.B,C.D 19 _ 80 1B2 t2->a 009 A, B.D _ to 13 ■013 2239 •012 A.H,C.D MMhed.rot»to“. 1 *4W». 34 SB •018 1-030 •on A, B.C 1-nilt »ltl* erniP. o“« lu-nc^od ttUeepoonfo] . 8 S - lot 103 •912 •SM .012 A. B.C 7>nao<7nfotj B«nr on* tf«*pnonfal (ttiSlixV os* t4MM{«o:t.i]t Tout two bnU il m natttr ^ UUk InclnilnS that tiraa with ronro ClnofT llSOjim. IJTFr one pl>w« 11*0)0 tworr* *1 rvhss Kutied potiloea 1 tatle* tpoontul CBnot* A n r o 166 APPENDIX FRIDAY -APPENDIX 167 SUNDAY TKB BNEROY P.EQUIRCMEKT AT TIU: DirTERENT AGES (SHERMAN) i Under 1 year 100 Calones calories jjer Jb } 2- 5 . flO-SO M 40-36 „ 6— 0 ,> . 80-70 „ 36-32 10-13 M . 75-65 „ 34-30 „ 14-17 . 65-50 „ 30-23 „ 18-25 „ . 65-40 „ 25-18 „ ALLOWANCES IN CALORIES PER DAY AT DIFFERENT AQES (SHERMAN) * Children of 1-2 yeare . 1,000-1,200 Calories per day Children of 2-5 •. . 1,200-1,500 „ Children of 0-9 ,, . 1,400-2,000 „ „ Girls of 10-13 . 1.800-2,400 „ „ Boj’S of 10-13 „ . 2,300-3,000 „ „ Girls of 14-17 „ . 2,200-2,600 „ Boys of 14-17 „ « . 2,800-4,000 „ „ * I’rom “Hio CbczniBiry of Food and Nutntjon,” Henry 0. Sherman Macmillan (New York), 3nl Ed,, 1928. ■08 APPENDIX FOOD ALLOTVAKOES FOR TIEALTnY OltlLDBEK (OIM.ETT) 1 Ctkaict per D«r Te«n Bor* Ctris Under 2 000-1,200 000-1,200 2-3 1,000-1,300 080-1 280 3-4 1,100-1,400 1 £)6O-],360 4r-6 1,200-1,500 1,140-1,440 6-6 1,300-1.600 1,220-1,620 1 300-1,600 6-7 1.400-1,700 7-8 1,500-1,800 1 380-1,680 8-0 1 600-1.000 1 400-1,760 0-10 1,700-2 000 1 560-1 860 10-11 1.900-2 200 1,050-1 050 11-12 i 2,100-2 400 1.750-2 050 12-13 2,300-2,700 J 850-2,160 I 050-2 250 13-14 ' 2 500-2 000 14-16 2,600-3,100 2.050-2 350 16-16 2.700-3,300 2.160-2 460 16-17 2 800-4 000 S,S5(f-S,m TABLE SnOWINO ^VEIOnX, nEIOIIT, XJfD OIROUilFEnENOE OP THE DEAD AI«D OIIEST FROM BIBTE TO TUB SDl- TEEhTIt IEAH (holt) EXAMINATION PAPERS APPENDIX n INFANT CARE IN HEALTH AND DISEASE AND MEDICAL AND SURGICAL DISEASES OF CHILDREN THE GENERAL NURSING COUNCIL FOR ENGLAND AND WALES t mat Slate Examii\/Ui{m for the SupplemeTttary Pari oj the Pegieler /or Stcl Children s Nurses ^TEOVBSDAY, octOBnp 14Tn, 1D36 Infant Gan tn Health atid Disea«e,ttnd Vtdx-eal Diseases of Cl tldren (First Paper) StORHIKO (TJiroo Questions m all aro to bo Answcral Questions 1 and 2 nro CoreiuiUory Tune atlo%red — One and a half lioun ) 1 A breast fed baby gams weight m{>idly» has much flatulence and tnquont largo green atooh State irhat is ItTely to bo the cousQ of this condition and gi% o ) our managomont of such a COSO 2 Giva the common causes of constipation in on infant and state wliat 3 ou na a nurse might do to remedy tins 3 Stato what you understand b> (a) rught terrors (b) habit spasm ^Vliat would your management be of tho child in each caso f 4 Say what types of meningitis you know Describe the courso of one t}po Surffteal Dueascs of Children (Second Paper) 1 Wliat ore the principles of tho treatment of a fracture of the tlugh t Deacribo briefly how this condition wouhl bo ds&U watJb ja a- rJtidd nf tfto yeojs 2 A cluld 13 brought to Caiuolty with lustory of bleeding from the anu3 Wliat conditions aro likely to causo^this ! 3 WTiat are tho three vanetics of wounds and tho particular dangers ossoemtod with each } 189 170 nXAMINATION PATERS 4 Stnfa briefly what you understand by (а) Ecchyniosia, (б) CoUapso, (e) Embolus, (li) Hydrocolo, (e) Septicaiinio ARERMOOK Oentral iJurtttuj of Sick Ohtldren 1 Sfention (IiO cfuef i>ouits to bo ob«orvod £a nursing a cbiW with oeuto endocarditie giving reasons for tho treatment tliat you would adopt 2 hat would bo your immcdiato nursing treatmijnt of a so'-ero acald of the chc:it in a young child f What complications, immedioto and remote nr® likely to occur T 3 Give (he nursing cdro of a child suffering from mucopurulent eonjUQctivitia What precautions must be taken in his treatment t 4 Wliafc do you understand by normal salmo solution t llav would you prepare it in a pnrste house ? Describe the various methods by which it may bo given to a patient wEDVEspay, rssavAJty Stts, ]&37 InfarU Care and Uedieat Dueasu c/ Children (Questions 1 and 2 aro Compulsory) 1 Besenbo in detail tho day's diet for s normal infant of cme year old 2 Desenbo how Sad may be given to an infant othermso than by the mouth Stat« under what circumstances this may be necessary 3 Describe briefly the course and nursing management of a COSO of entono (tyjdioid) fever 4 Say what you know of impetigo tVhat steps would you take to prevent it from spreading to other children f 5urpicof Jhstaace oj Children 1 What 13 talipes equmo varus I Describe tho troatmeiit of such a cose 2 What are the causes of cemcal adenitis T Desonbe shortly tho treatment usually adopted 3 What 13 a hernia I Give the eigns and symptoms of ostrangu lated hernia EXAJONATION PAPERS 171 4 What do you understand by — (o) Immunity, (&} Separation of an epiphysis (c) General onasthosia (d) NecTMis, {«) Polypus’ General Nttntnff oj SteL CAUdren 1 Wliat nro tho symptoms and signs that you would tooh for machildsuiT ring from savcronnsmia 1 Ooothonursing can? and ehet of such a ease 2 A rluld 13 brought to tho Casualty Departm«nt by 1 ( r mother who states she tlunlws lias swallowed lysol Gi\o signs and symptoms that would make you think her statement 13 correct What would jou do before tlio arrival of tl o doctor 1 3 Alcnticn points to be eoasiderod in tho general caro of tl o operating thofttro W’hat caro do you gii o tho mstrumenta after an operation 1 4 How will you instruct a probationer in tho caro and in tho method of gmng a fe«l to a norma! infant at four moiithx of ago and how will you toaoh her to clean tho utonsib after use 1 THtntSDAT, UA\ 20ni, 1037 In/ani Care in UeiiUk and Duttue and Medical Diseoits aj Children {First Paper) MoaNTva (Tliroe Questions m all are to be Answered Questions 1 and 2 aro Compulsory Time allowed — One and a linlf hours ) 1 You are asked to show a young mother with her first babj oxacily how to manage breast feeding Give m dctaib your instruction 2 ZTcscribe briefly the coxieso of hroncho-paonmonm in a child State where the dangers to life anso and what y ou as a nurse may do to lessen tho risk 3 Slontion one typo of coso m which tnbe feeding may bo pro scribed for on infant Deecnbo in detail how you would perform this 4 Dftionba in detail the diet which you might expect to bo presenbod for a child of three years old suflenng from cmliac disease ^uryicol I>i«o»« oJ OhiUlrtn {Second Paper) ajoiurcro 1 Wluit IS empyema of tho thorax t Dceonbo how it would bo Ireaw 172 EXAJIINATION PAPERS 2 FoUowmg an operation for the removal of tonsils and adenoids a child 13 noticed to becomo increasingly palhd and Iho pulse rate nsoe ^Vhat is occurring ! Dosenbo how the case should be treated 3 State briefly what is — (а) Aranuln (б) Fliimosts (e) Haunaturia (d) Scrmoid cyst fe) Proctoscope 4 What 13 a n-evus 1 How would it be treated • General ^urain^ o/ Stdt Children AVTEBHOON 1 IVhst special cars would you take in the feeding of a child for the first five days after each of the following operations (q) Ilepair o! hare lip ^ (6) Tracheotomy (e) Homoval of tonsils and adenoids Id) Excision of glands of neck t 2 What do you understand by anterior pobomyebtis (mfantilo paralysis! f Describe folly tho nursmg oaro in the acute and the convalescent stages of a child aged eight years 3 Qivo a careful account of the nursmg of a cluld suffering from tuberculous meningitis 4 Describe bnofly the rashes associated with the following conditions (o) 'Measles (b) Inattention to the itygienio management of a young infant (c) Tho giving of eerum (d) Congenital syphilis. IVEOnnSDAY OCTOBEB 13 tb 1037 Infant Care xnHealthaTid Dnease andMedtealDiBiaetsof Children (First Paper) uomnt^a (Three Questions in all are to bo Answered Questions 1 and 2 are Compulsoij Time allowed— One and a half hours ) 1 Give detailed instructions suitable for the guidance of a woman about to woan her infant How would you then feed such a child T 2 Discuss tl 0 commoner causeo of vomiting m infancj and cluldhooil and the treatment of such coses 3 Dasenbo a case of cJ icken pox How would you nurse it ! EXAJONATION I»APERS 173 1 How would you look After a child — (o) flulTcnng from threadworms , (6) Safienns from fioro buttocks t Surgical Di^ea^r# aj ChUlrtn [Second Paper) aoKAxsa 1. Doscnbo how jou would prepare o case for an operation on tho obdomeiu 2. Oivo tho symptoms of tubercle of tho lup joint Wiat are tlio prmciplcs of treetmeot of this disease ? 3. StAto briefly wliat is trachootoiny, Actiesectioni melaina, an ulcer, ioxsmia 4. Wiat IS oeuto mastoiditis t \Vliat is tho usual treatment ’ General A'urnny oj Siet Children , ArrEBKOON 1. You arnvo at a private houso at 5 pm. to undortoko the caro of A boy aged eix years who is to have his tonsils and adenoids removed at 0 a.m next morning Give full details as to } our duties between tbeso tunes 2. \\'hnt IS meant by tho term a balanced diet t Discuss some of tho ill effects on tho nutrition of a child which may bo caused by an til balanced diet 3. For what purpose in auramg arc tho following used : (a) Ico bag , (b) Cradle; (c) Flatus tube ; (d) Fomontntion ; («) Oxjgcn; (/) Sandbag 1 4. Give tho nursing caro end nvmsgemont of a baby six months old sufformg from whooping cough vrEDVzspav, tlbiiuarv 2'n), 1038 J»i/ant Care tn i7eakA and Ducaee, nnd Medical Discaeet of Children [Firet Paper) KO^irxSO (Tluoo Quwlioiia m all arc to bo Answered Questions 1 and 2 nto Conipulaory. Time allowed— One and o half hours ) 1. How would you nurw n case of chorea t What complicalioiiB may result from thia disease 1 174 DX^illNATION PAPERS 2 Wat would lead jou to 8up| in a cose of % agtnal discliarge } *l 'What are the a gns of a calculus m the duct of the submaxillar} gland ? How would it be treated ! 4 Give the definition of — (а) Hyposp&dios (б) Celluhtis (e) Pcs ploQUi (d) Immunity (t) Meningocele <7en«raf o/ Std, Children ATTEESOO'? 1 "UTiat instructions would you Rivo a junior nurse regarding the giving of medicmes f IVhat rules would you yourself observe in the giving of dangerous drugs and the core of the poison cupboard T 2 Give an account of the nursing caro wluch should bo gn cn to a child of sevon years of age eufTcnng from catarrhal jaundice Arrmige o diet and write a report for the doctor 3 Describe briefly how you would prepare for tl o following treatments (а) Bladder Isv’age (б) CEsophageal feed (c) Blood transfusion , (d) Obv e oil enema ? 4 How can the nursing staff aid the hosp fal authont os m ward economy T rX^UIINAaiON PAPERS 175 \VXD'rE3I)A\, JIAY IllH 1038 Infant Cart tn HealUi and Disease and Medical Diseasa of Children ( Afrt Paper) AtonKiso Tliroo Queations m all nro to be Answered Questions 1 end 2 aro Compulsory Time allowed — One ond a half hours.) 1 \Vliat are the advantages of, and contra indications to, breast feeding t How would you feed artificially a normal baby of ono month old t 2 TMiat aro the climcal features of rickets and what stops should bo token to prevent a child da\'eloping tins disease T 3 \Vliat 13 meant by • — (a) Complementary feeding , (b) Teat feeding , (e) Coma , (d) Carpo pedal spasm , {«) Tic t 4 Describe the s^ptoma of ocute bronchitis How would you nurse a oiiild of five years of age suQoring from this complamt 1 Surgical Diseases of CAddreii (Second Paper) MOSKIKa 1 Desertbo the treatment of bow legs in a child of three years of ago Wliat instructions should bo given to the mother of sucli a child attendmg an Out patient Department T 2 IV’hot are the TOnous degrees of burning f ITescnbo — (a) Tirst aid troatment {b) Final treatment in a hospital 3 Wliat 13 myringotomy ? For what is it performed T Describe the after caro of a case 4 Gito the definition of — (n) ConjUDCtivitia , (fi) \ slough , (c) Teno synovitis , (d) A wheal , («) An cmbolas General ^irrsinji of Stet Cf \ldrm ATTEBNOOV 1 ^Vluit, in your opuuon are tlie tssontml qualifications and ntlnbutcs of a good eick chitdren’s nurse t 176 EXASIINATION PAPERS 2 "iou nro >n cl arfioof a nur<«CTVof rf Jldren under ISmoatliso/ ago Olio child has bad three lowso stools iii 12 hour? btotc fully ^rhat you would do — (а) As regards obtaining medical advice, (б) Beforoyou received an^ orders 2 IIow would you prepare and ppply — (а) A starch poultice , (б) A turpentmoetupo, (c) A I otuet pack, (d) An ICO bag ? 4. How would you nurse a case of German measles m a private house and wliot steps would you take to proient the spread of infection 1 WEDVSSDAY OCTODEB 12X11 1938 Injant Cart inUeahhand Diaeate and HedicaJDueaatsof Children (First Paper) MOKNC>Q (Tlirco Questions m all ore to Iw Answered Questions 1 and S ore Com( ulsory Tune allowed— Ono and a half hours.) 1 Discuss tho eoQunoner causes of persistent crying m a young infant 2 Doscnboepdeptieattacksoccumngmchndhood How would a cluld suffering from this disease best be handled f 3 Gne the dimcal features of scurvy How con this condition bo prevented and treated t 4 would lead you to suppose tiiat on infant was prematurely born ? How would you nurso such an infant T Surgical Dtseatea of Cl ildren ^ (.Second Paper) uoiuanous forms of pre medication that may be ordered 2 How would you deal with a ^uld suffering from a severe lacerated wound, prior to the arrival of a medical oSIcer 7 EXAMINATION PAPERS 179 3 Give the dft&Qition of — (o) Infection {&} Scpticffioua (c) Ecchymosie {d) Synovitis , (e) An abrasion 4 What 13 fissure in ano f How hareyou seen it treated 7 General Nursing oj Stet Cl ildrtn AyEEENOOV 1 For what condition i3 goatno lavage performed 7 Describe the procedure m detail 2 What 13 aspiration 7 For what reason is it performed 7 What signs and symptoms most be watched for during the process 7 3 Describe in detail the care and sterilisation of infants feedmg bottles What particular attention si ould bo paid to tho teats 7 4 What effect may a prolonged period in hospital have upon a child 8 nund 7 How may any possible ill effect be pro vented by tl o nurse 7 180 PAPERS HOSPITAL FOR SICK CHILDREN, GRtAT ORMOND STREET iSetiior ifurtes' JUedtail Eiaminaiton (Five Questions only to bo onswered Tunoftlloxvctl— Slicnrs) Amn^ lost (Qu^tions 1 and 2 oro Coup iljo>j ) 1 (a) Give the quantities of fooil requirwl for aii mf mt ncj Jnn? 81b »ff^(tit With complications, of u cluld sufforuig fn^m cdca^ *3 3 In tbo COSO of a child of seven yeors suflenng from diabetn* wliat symptoms would you exppct t Deecnbo the dii't and treatment and stoto wliat complications should be looked for 4 How would you nurse a sovero caso of rhetimatio nrthntis and what complications would you look Out for 7 5 A child of one year is suffonng from cercbro-spjnnl meningitis Dcecnbo tho clinical picture, and narsmg> care and freot ment of sucb a rose G Give in detail t!io clinical picture and nursing with feeding of n caso of congenital pyloncsti-nosis treated (a) medically, and (6) surgically UA&cn, 1035 (Q icstions 1 and 2 are Compulsorj ) 1 OutUno tho feedmg of an infant from birth until nine months usmg fn«h cow s milk. 2 Enumerate the causes of stnlor during childhood and give tho treatment of any one of tlicao 3 Give tho nursmg care and treatment of o bahy of nix montls suffering from broncho pneumonia 4 IVhat an? the symptoms of acuto pyoht«> Indjeofo Iho treatment 6 WTiat do 3 ou understand by tho following terms •— Cyclical vomitmg Tenesmus Tetany Lcueopenia. lx«ino phiho. Interstitial kentiUs. Functional olbummuna. EXAMINATION PAPEKS 181 0 Gi\o tbs incobation period of, and describe ibo symptoms of scarlet fever Give the nniemg care and treatment of this disease %Vliat complications may arise t UAiLcn, 1036 1 Describe in detail the care of the premature baby 2 'Unto out a day’s diet sheet for the following children — (а) A healthy baby nine montlie old (б) A child of threo years with oocliac disease (c) A child aged seven with diabetes mcllitus jd) A child aged ten grossly overweight 3 Winch skin diseases are infections t Describe the treatment of any two of them 4 Wliat steps may be taken to prevent the following diseases — (a) Congenital syphilis (b) Measles (e) Diphtheria (d) Tuberculosis ? 5 What are the vanous causes of stndor m childliood Give full details mcludmg treatmeot of any tno of them OECEMPEB, 1037 1 Compare the relative merits of breast feeding and feeding on fresh cow s milk, dned cow’s milk, and conden^ cow's sulk 2 Dnder what circomstancee is oxygen likely to be ordered ? How may it be odmioisteted 7 3 Write out a day’s menu for (1) a boy aged ten years grossly overweight , (2) a boy aged four y ears with catarrhal jaundice , (3) a healthy child aged fifteen months 4. What would lead you to suspect mental deficiency in a hohy nine months old T Describe any two types of mentally defective children B Describe the symptoms and give the nutsmg details, of a cose of infantile scurvy Senior Afaficaf Hxa>i»nafiou know of meftsles, its complications, and the nur*jng of such a case fi How would } ou treat (o) Knureals. (6) Thread worttvf:, (e) Soobics. in a child of Cv oy ears 6 On whftt would rmt the diagnosis of pjlonr Btenosis, and wlmt would the treat ment and niimng consist of f EXAlUNAirOK PAPERS IS6 SOCIETY OF APOTHECARIES OF LONDON Mastery of Midin/ery ExaiMnahim in Pecdtatnes KOrmiBEB 21 st, 1034 (Question S is Compulsoiy) J Abreast /odiofaat.tbKezQontiisoM isiosmgn-eigbt Describe the steps you would take to investigate such a case and give m detail any treatment you might adopt 2 Discuss the significance of mabena m the infant 3 Givo the di^ereotial diagnosis and treatment of rasbea m the ** napkin area " of an infant of three months 4 ^Vbat precautions do you consider necessary for the prevention of tubereulous infection m the infant t 5 On what evidence would you base on opinion that a child of twelve months is m a state of perfect health t UAY 22kd, 1035 (Question 6 is Compulsory) 1 Give the differential diagnosis and treatment of vonutmg in an infant under the age of eix months 2 Discuss the causes and treatment of fever occumsg m an infant m the first four weeks of life 3 What specific measures are available to protect a child from any of the acute infectious fevers t 4 What disturbances may you find in the infant of a '‘highly strung " mother T 6 A normal, newly bom baby has to be artificially fed Give in detail your diet for such an infant, and the reasons for your choice of food NOVEMBEB 20tB, 1035 (Question 5 a Compulsory) 1 Give an account of the symptoms and signs of acute polio myelitis 2 Discuss “physiological jaundice” in the new bom. 3 A young child has laryngeal obstruction Give the differential diagnosis and treatment EXAMIKATION PAPERS 187 4. Describe tbe Bigns ojid sjaptoma o! overfeedins; in a breast- fed infwt. What iteps wouid yon take to deal with this condition T 6. tVliat are the fluid roquirementa of the infant T WTiat ore the clinical manifestations of (o) too little flcld, (&) too mucii fluid, tn the infant’s diet 7 HAT 2flTn, 1930 (Question 6 b Compolsory) I. What are the causes of chronic dianhea in a child seed three years 7 5. Discuss tho etiology of nutntioniil antemia in infancy. How may such a disorder bo prerented 7 3. Describo the clinical features and dbeuss tbs prognosis of intre cranial injury in tho new-born. 4. Oivo in detail tho management and feeding of a premature infant weighing threo pounds at birth. 6. DIscusa tlie common causes of failnre on the part of fiio mother to hreost-fecd her child. ttovcuBtnt Utn, 1036 (Quretioo 6 is Compulsory) 1. Discuss tho etiology of “fils” in infnnej'. Outline your ' treatment of “ fits.” S. Describothoderclopment of tbo infant in rclationto a diagnosis of mental deficiency. 3 What are tho clinicat features and complications of pyelitis ininfancy 7 Gn-eindelailyourtrcatmentofthisdisorder. 4. Describe tho Turioties of stomatitb that may occur in infancj'. How may such disorders bo — (n) rrovented. (6) Treated. 5, Giro in detail the instructions you would supply to tiio mother of a normal breoot-fed infant to enable her to Institnto “ mixed feeding.” At wliat ago sliould “ mixetl feeding ” bo begun 7 UAT 19ni. 1037 (Qacstioii.& b Compulsory) 1. Describe tho physiology of lactation and state what stejM you would toko to inercoao a failing supply of breast milk. 2. Give* tho etiology, clinical features anti troiitment of birth injuries to tho bnichial ploxus. 188 EXAMINAHON PAPERS 3 Discuss tlie causes of fever in the newly bom Infant 4 Compare the advantages and disadvantages of raw boiled pasteurised and dried tnilk for the feeding of mfonta 6 ^Vhat directions would yon give for the ar^fficjal feeding of an infant dunng the first two weeks of life r * NOvrstBZtt (to, 1937 (Queetion 6 is Compulsory) I 1\Tiat evidence would lead yon to diagnose mental deficiency m a child aged two years t 5 Give the clinical features and treatment of hoonorrhegio disease of the newly bora 3 Discuss the etiology and prevention of ncketa 4. Describe briefiy the methods that are in use to protect children from tho acute specific fevers 6 Give the difiercntial diagnosis of vormtmg in art mfant under one year of age iur Uxn 1938 (Question 3 is Compulsory) 1 Give in detail the treatment you would adopt for diarrhma and vonutiDg ut on infant oged six months 2 Discuss ^anosis m the newly bora VTbot ar® your views with regard to the prognosis m this condition ? 3 A breast fed infant three months old, is losing weight , desciibe tho steps you would take to m% csti^to and treat snob a case, 4 What are your vnewa concerning the compulsory pasteurisation of milk 7 5 Discuss tho etiology and treatment of mfantllo eczema >.ovzniBEB 16x31, 1933 (Question S is Cbmpulsorj ) 1 Describe the clinical features of congenital syphiiia ^ infancy 2 Give the causes and treatment of constipation in the infant 3 A mother brings her infant to you with a iiiatoiy that the child has not moved tbo right leg for twenty four hours Discuss the diBerential dis^oais in this ease EXAJaNATION PAPERS 189 4 Discosa jaundico m tiio ocwiy bom. B On e m detoO your treatment of n rremaluro mfsnt weiglung 31 lb UA.V lOru. 1939 (Question 5 13 Compulsory) 1 Giro tho clinical features anti treatment of coeliac disease 2 Discus tho etiology of the cerebral paUics of childhood 3 Dcacribo m detail j our treatment of pneumonia m infancy 4 are tho clinical features of intussusception f Discuss tho differential diagnosis of this condition 5 Giro tlio principlos on which jou would food an infant artificially Illustrate your remarLi by reference to a normal infant aged two months, weighing 10 lb 100 exajunation papers THE HANBURY PRIZE EXAMINATION IN DISEASES or CHILDREN Westmlaster Hospital runs 25TB, 1934 (Time aUowed — Two nourB) 1 Gi%e an account of the aymptoniatology and treatment of mfontOe scurvy 2 (a) You are consulted by tho father as to the feeding of o healthy infant agod tiireo months, whose mother has just died The baby is to bo m charge of a sensible, but m expenonecd woman Oivo your written instructions (6) State a suitable dose for each of the followmg drugs admuuatered to a patient aged five years — . Cliloral hydrate Hczomine Santonin 3 What maxufestations may be encountered during the course of juvemle rheumatism T 4 Give on account of tho symptoms and clisieal signs of one onfy of the following — Erythroidemo polyneuritica (Pink disease) Cerebellar neoplasm rnriE 27x0, 1035 (Tune allowed — Three Houra) ^ 1 You are asked to see a breastfed mfant who is failing to gam weight How would you investigate and treat such on infant 1 2 Tell what you know about ndsets 3 What forms of meningitis aro there ? State briefly the differ encd in the cerebro spuial fluid m each typo and some ol the differentiating points between them 4 A girl of seven years has acute chorea Tell wliat you know of this condition, and how you would treat it, giving tho possible complications nnsDAV, JUNE 23 bd, 1030 (Time allowed— Two Hours) 1 Give the symptoms and signs of pleuri^ with effusion How would you treat a young patient so affected T EXiVDUNATION PAPERS 191 2 Dsscnbo the rteogmtion of ecttvity m rhmimahe canJjtH and the treatment m nn actne plKuw of tlio condition 3 Gi\ o an outhns of the vonelioa and causes of mental deficioncv m infancsy and childhood r TDESDAT, JOT.T IStH, 1037 (Time alloned — ^Two Hours} 1 In making a rapid examination of an ill child, what oro the salient points of tho examination and irhy t 2 Give bnefly tho diagnosis, investigation, and treatment of a modorately severe taisa of bronclucctasis in a child aged five 3 ears 3 Give an account of the etiology of the motor paralv^es of infancy and childhood 4 Define shortly — Spasmus nutans IsephrosLS Spasmophilia Metungisro DEOESinEIt, 103S 1 State brielly irhat > ou know of thodifferent types of meningitis, givmg tho etiology, pathology, clinical picture, and treat meat 5 An infant was bom weighing 7 lb At the end of 3 months the weight was 8 1b (s) Give Its expected weight and the directions you would give to tho mother about its feeding if it were fed on cow s milk mixture or humomsed dried nulk mixture (6) What are the chief errors m the technique of infant feeding which one would meet with in goncrol practice T 3 How would you investigate a girl ogod three yoars with pyrexia of unknown ongm, and what would be the commoner causes of fever at tlus age T 4 State what 3 ou know about ordinaiy measles, and how you would look after a boy aged six years, with this complaint rci»E, 1939 1 Give briefly the four chief vitamins, telling what you know of each 2 (a) Define the following *' Expected weight. Tost feed. Com plementary feed. Supplementary feed ” {b) Howwould 3 ou feed a normal infant of ton weeks, weighing 10 Ib , on cow’s milk or on a dned milk T State m detail the directions you would giv*e to the mother 3 What are tho indications for tonsillectomy T State what symptoms and complications follow on dioeased tonsils and ^enoids 4 Tell what 3 ou know of the clmical picture, differentia] dtagnosos, and treatment of mumps, with Its compheations 192 EXAMINATION PAPERS THE RO^AL SANITARY INSTITUTE IN CO-OPERA- TION WITH THE ASSOCIATION OF NURSERY TRAINING COLLEGES Examtnatum/or Nursery Sfuries uvEsrooi^ vovEMDm crn a**© Oni 1937 (Firit Paper) rRn>A\ uoiun>a Four Questions onJy to Ixj Ansnered Timo aUovred — Two hoari 1 Write a short descnption of tho cligostirc system, statui^ tho various organs tl rough which tho food peuscs and the mma cliangos which toko ploco m tlio procetu of digniloii 2 \Vhat aro tho odvantogos of suiBcient rest ond sleep 1 Dosenbe the condttioo }ou night find m a child sullenng from the oOrcts of tech of sleep 3 ZTow would 70 U undertake the elconiog of vour nurscr) (a) daily {b) weekly T 4 li It essential tlint Titnmin C slioul 1 be present in tl 0 diot 7 Row can it ho ensured that it ts obtain^ hj a bottle fed mfont 7 u ^Vhat IS a protein T In wliat foodstuffs does it occur t Discuss I! 0 importnnco of protein m tho diet of an mf&nt C ^rimt are tho common causes of soro buttocks and how vsould vou flcol with them ? (Second Paper) nUOAY AlTEBSOOt lour Questions only tohoAnswered Time allowed— Tiro hour* 7 Row does a very young baby get cierciso J Wlij is excrewe necessary for it 1 8 ^Vliy 13 it so important tluit children should liAv e the com panionship of other ctuldren T 0 IV'l at 13 tho value to tho joung child of pointing cx}>Cr}wce 1 ^\'hat material would jou j rovndo and nlcng what Iinea would you guide Jus work I 10 If a breast fed baby of aii weeks was ' screaming nIgV t and ttej and tho father augpistod weaning what would } ou suggest for tho hnppmeae of tho hoavohold } EXA5IIKATI0N PAPERS 1^3 1 1 is diplithena a scnoos dioease I What t!o you know < f its pmention and trcatmeat m its carlj stogos T 12 A cliild has put its arm through a plas? wmdow and lias cut the artcrj at tho wnat Dc«cnbo the steps \ou would take for first aid treatment LOVDOV, 3A?ITAB\ 7XH ASTD SlH, 103S {Firtt Paper) rB.TDS\ MOPSU.O Four Questions only to bo Answered Time allowed — ^Two hours 1 Describe the process of respiration 2 ^Tiat are the benefits of the direct rays of the sun to a child ? In what circumstances may they pro^e dangerous or harmful ? 3 Gi\ 0 a description of a nursery which m j our opinion would be hj giemeally perfect 4 Stats what you know of tbs t'aliis of eggs m tho diet At what ago would vou first pv© eggs and how nr© they best cooked t 5 For wliat purposes u woter essential in the human body t 6 \7hat wonld you consider suitable elotlung for (a) a baby of fire months, (6) a chfld of five years, on a worm July doy ! (Seemd Paper) ramaY AnEB>ooN Four Questions only to bo Answered. Tune allowed — ^Two hours 7 VVliBt are tho ad%anfages of regular phj'S cal erercises for cliddrcn and what form of exercise would you ndvocate for children under six years of ago ? 8 What is habit T How would you load a cbild to form the imbit of obedience t 0 In tlio light of } our experience of c) ildrcn ot plav , discuss tbe wisdom of proTidir^ them with educational toys 10 WTiat symptoms in a child of fourwould lead you to suppose enlarged adenoids and tonsils were present 1 Describe whei© tVite* ctTgatia Wo 1 1 Wliat do you understand by on mfcctiovw disease ’ 12 IVliat 13 a fomentation ’ How would you mako one t WHiat ar© Iho difference^ between a fomentation and a poultice ? WTuch do you prefer and why t 194 EXAMINATION PAPERS tovDOV ATOn, 22 sd asd SSrd 1033 (First Paptr) TRIXIAY MOa^rt^O Four Qucptiona onlj to bo Ansrrored Tirao allawwl — Two liours 1 Wiat are tlio functioaf of (a) tlio skin (fc) tbo laclno\’s ? 2 Write a sliork essay on the managoment of a child tlireo j oars old and a baby six montlis old at tiie seevnde, 3 l^Tiat are tlio means by which a nursery may bo vontiIate f "Tiy is it bettor for a child to play with other chiJ l«n mtJ cr than with his parents or other adults 1 0 How far is it possible to use suggestion m tho training of \ oung children ? Give eramplcs of harmful suggestion Id \\Tiat do you know of the conditions commonly known an (а) mastoid (6) ncLets (c) “St Vitus Dance and (d) discharge from tlw eyo of a baby t In hcato the unportanco and significanco of each II Gisothonamesof someusefol choraicaUlisinfootants Ifow are woollens best purified and disinfected f Quote tho incubation penal (in days) of moasles and tho quacaiatino ^in. dayal after exposure to infection of *mea$]es ^Mien does the penod of infection cn I In this disease f 12 ior what purposes in tho nursery would vou use (a) loflino, (б) olive oil (c) Fnara Balsam (i) castor oil (e)bicir bonate of soda 7 trvEBpooL JUNB I7 th asd 18x11 1033 (First Paper) TIIIDAV 3tOBKD.O Four Questions only to bo Answered Time allowed — ^Two hours 1 Giv e a brief outline of tlio bones forming the skeleton. 2 Describe m detail how and where you would bath a baby nine months old EXAMINATION PAPERS 195 3 Whatcotwouldyouclioosoforttbaby T How would you fumiah the cot t 4 Whftt la the difference between boded and pa3touri«od miltf ? TVluch do you prefer for young cliildrcn t State your reasons 5 Diacuss the causes of loss of appetite m a child between tlie ages of one and two years 6 What principles would gmdo you in selecting footwear for a child aged three years for indoor and for outdoor use T (Steond Paper) ramw AITEEMOO*? Four Questions only to be Answered Timo ollowcfl — ^Two hours 7 Why la it bad for a \eo young child to be too long on its feet especially walking on pavements ! S How would you tram a cluld (o) to honesty, (6) to indo pendenco (e) to self control (d) to obcdicnco t 0 ^Vhat do wo mean by irrational fears t Eowwould you deal with a child who was afraid of (a) having her hair waaltod (6) being loft alone in o room, (c) going through a tunnel ■■tn atnim t 10 What action would you take m the coso of a constipated child * 11 Describe m detail tho mcosuros you would taho for the treat meat of o slight discharge of tho o> e. IS Describe first aid for (a) a bum (&} a bleeding nose and (o) a fit in a child XO'TPOv, JCTL^ 22 nd and 23 itD, 1033 (FtrH Paper) FBIDAV UORNINO Four Questions onlj to bo Answered Tune allowed — ^Two hours 1 hat is tho normal temperature of the body t How would you take and record tbo temperature of (a) nn infant {6) tho nursery t 2 How would you dcalwith what are generally known as “ bad habits’ T Gi\o oxomplce 3 How would jou heat and \entilatoasickroom T Setouttho advantages and disadvantages of an open fire 4 Wliat would luul you to behjvo that a breast fcxl infant was being oTOrfed 1 Outlmeyour nnnogementof a ease of ov orfeoding at tho breast 6 Wlint 13 meant by tho terma (a) protective and (t) energy giMi g foods t Nome the mo«t important of each type 190 E^U^IINAnON PAPERS 6 Of wl at nsaf enal wo»iM j ou mahe infanta naplaca nni] haw many wonld ^ ou allow for one clnld t JIow woul J j on wash impkuw ! WI at soop would you use 1 How wouj I yon whiten them if they become stained J (Second Paper) TRIOiV ATECajfOOS Four Questions onl; to bo Answered Time allowed— Tiro hours 7 How would yon ensure that a child m jonr care dovelopedn good carriage ! 8 ^Tiot would make you think that a chil 1 two years old wo* abnormally backward t \^T]at IS tongue-tio t 0 TOiyshouldchddrenboencouragedtokeeppetsf ttTiatpcts would it bo posslblo to keep with children under etmai years of ago (a) if living in the eountrj , (b) if living in a largo town ? 10 If a child recently put into } our charge complnins frequently of fatigue how would you proceed to find tl o cause f 11 What particular symptoms would lead \eii to suspect timt a child was sufionng from (o) scarlet fever (6) mcASlca (c) whooping cough 1 12 State briefly how you would arrange a nursery medieuseeun board Howarobottleseontainingpoisonsdistinguidim 1 uvEnrooL, novembeb 4Tn akd 5tu 1038 {FtrsT Paper) nUDA) MORNINO Four Questions only to bo answered Tunoallonwl— Two I ours 1 TThat IS the composition of human blood f Hoamerato its various functions 2 Give reasons for and ogainst cold batlia for children and discuss tJioir possible ad%antagcs and dtsadvantagon 3 What aretl o chief pointa to look for whonsolectmg a suitable place for a summer holiday with young cluldreii t 4 State the dangers of giving ordinary raw cows milk to on infant and describe how tl eso dai gere may bo overcome 5 Describe how you would keep Iho food in hot weather In a smaU flat if ll ere were no lefr^nitnr 6 ^Wiat clothing would you adnso for a Uby nged tlirco montl 3 f Deserdotho ganncnls anl the material of which tl ev si ould bo made Give tl o numbe r required EXA'VnNATIOX PAPKES 197 (Seem t Paper) niiDA\ akcersoov I our Questions only to bo Anspnjred Tuno alloTvcd — ^IS to hours 7 \Vliat rulca should bo observed so that a cluld may lin\o fKirfect milk teeth T AVhea do tho permanent teuth begin to appear ? 8 Trnco the ovidcncca of the growth of imngmatton in n child daring tho first fl\ e yonra of Ufe 0 "tVliat IS tho special \aluo of naturo stody m the trammg of the young efufd * Show how jou coufd help the town child to a true study of Nature 10 ^Vhat ore the commoner cansca of (a) diarrhcea, (6) fevonsh- nceamAbAbyagedse\cnTnon*hs T II IMiat 13 “itch " Wiat precautions would be necessary in • dealuig with a case in a house whoro there were other cluldroa t 12 If you were asked to make up a first aid outfit for use in emergencies m tho nursery, what would the contents of It bo ’ LOKDOV, JANUailT 13tn ANP 14Tn, 1639 (2 «wt Paper) rflTOAY MOBSINO Four Questions only to be Answered Tune allowed— Two hours 1 Deectibo tho structuro of tho mouth Explain how bod tcoth may aHcct tho health and describe how a child can bo liolpod to lia\ 0 good tooth 2 ^Vllat suggestions would you moko ton young mother cs regards heod-co^ erings for a young child in winter and summer T Give reasons 3 What do you consider tho most important points in the soleciioa and making up of a cot for a cluld from nmo montlis of ago onnards ? 4 How would you prepare wIksj, beef too, steamed custard and brotli containing calcium for a baby sufforing from rickets? IVliat legefahlai would you put uito tho broth 1 6 \Miat are tho best moans to employ in cooking foot! for cluldren T Gi\ o your reasons. C IVlint typo of bedding do you consider to bo b^t for (a) a young baby, (b) children up to Gvoy cars of ago ? 193 EXA5IINATI0X PAPERS {Seeoivi Paper) * mnjAT AJTETlsrOOV i our Quosiioaa only to Lo Answered l^mo allowed— Two lioura 7 When should a child Iwim to walk T Wiat art* tbo dancers of walking loo early 7 8 How would 5 ou 1 elp an lataut to grow up mdepondeot and self -controlled I 9 Imogmo a morning iT>cnt m a nurserj with two children aged two jeara aiul four }cara» wliat part would jou plaj m tho arrangement of tl o momxng 5 ectfrjtKis f 10 Write short notes on (a) German moaslca, (J) ndcnoiUi* (c) ringworm (d) thrmdworms. 11 Wliat la meant by impetigo t Wbnt procaulion* would you take with regard to tbo other children m a fnmjly of children ono of whom dovetoped tins afTcctian f 12 \Vhore ^ould you keep tour raodicino cupboard and with what would jou stock It t W^lat would >ou use w applying first aid on account of (a) a scraps elbow, (b) a wcisp stiog. and (e) aspromed ankle } LOVtkOM Iran. 20ni asto 21 bt, 1039 (Special Paper for Jewtth Candidates) Four Questions only to bo Answered Tiro© ollowed—Two houn Tinm90A'\ A7TCB^00^ Four Questions onlj to b© Answered Tun© allowed — ^Two lioun 7 \Vliy 13 exercise nccc^ry T How si ould an infant of fiix months obtam sufficient exorcise t 8 Suggest some x>ossib!e causo© of debtructiToness m cldldreu Is this quality nocoasarily liarmful T How would you deal with a destructive cluld aged four jeors T 9 Discuss tbo value and tbo danger of liablt forming os it n0> to bo Answered Tuno allowed — ^Two hours 1 'n’Latsrothoiunctjonaof tboaLmT Wiatare tbocharaoter ii>tic9 of a healthy altm 7 2 What aro tho chief causes of (o) constipation (&) dianrhcca in on infant 7 How would you deal with tboso conditions 7 3 Gi\o an account of how you would furnish and decorate tho ideal day nursery for a child aged three years 4 Wliat sobstitiitei} for breast feeding are most commonly used 7 Stato briefly and concisely tho advantages and disadvantages of each. 5 What are vitamins 7 Tnumemte the principal % itomins. ou render to a child who hod been bmlly bitten by a dog t Livinipooi. Jtr^ JOtH AND ITxn 1039 (first Paper) miDAY >tonNI^o Tour Questions only to bo Answered Tima allowed — ^Two hours 1 Describe the structure of the kidno}*s ond their function 200 EXASnNATION PAPIIRS - Wiat nuaouroh i«bo«)Jd bo taken to ensure lltal llio mill, leoth keep liealtliv ? 3 State the dangers which ought occur when exposing a child to bright sunliglit and describo the precautions jou would take t o pi c\ ent lh«n ' 4 ■Wnteouteuitablamenusforod^ forocbild aged ISmonths and for one aged three years 0 Dcocnbohowyouwouldprcpareadned miDsfeodandhowyou would clean tho feeding bottle and teat afterwards 6 Wiat ill effects may result from tho uso of bodlj fitting foot wear? How may Iheao bo avoided or trcatccl r {Second Paper) rniDAT ATTEHSOOV Four Questions only to bo Answered Tune allowed — ^Two hours 7 ^Miy are proper rest and suitable exereise necessary for a child 7 8 Discuss the relative merits of free play and otganised plaj 9 ^Vliat are tho values of story telling t ^That kind of stones would you choose and why t 10 Say what you moan by a ‘ perfectly healthy cluld ” 11 Describe the onset of (a) measles, (b) scarlet fover, and (e) diphtheria 12 Describo what emergency nursing treatment you would imtitute in tho homo before tho am\al of tho doctor for a cluld who has just suffered from a “ fit ” the nature of which 13 unknown lONDOv, JULY 20in, 21 st A^D 22vn, 1039 (First Paper) m O B SPAY ATtEEilOOS Four Questions only to be Answered Time allowed — ^Two hours 1 Give a brief descnption of the arteries veins and capflianes and the circulation of the blood tlirough thenu 2 What are the chief pomtsto remember m bathing a t my baby t 3 In a countiy cottage without ‘‘modem convoniences,’ what steps would yon take to protect and preserve your charges* milk supply from the moment it is dehvered nt the house T 4 Whatgradeof nulkwould>oarecoinmendforacluld t If tho grade you xecominend is not available what would bo 3 our next choice 1 State your reasons EXAJUNAHON PAPERS 201 5 HoTP would jou prepam tnpe swc«tbr«id loinato pur^o bobcd n| pie pnino piiroo and bnrley water for cUildron two years of ago t 6 Desenba methods of woshuig and cl^^ mg a flaimel iughtgo%ni, a 6ilk and wool \ eat, a blueailk frock white woollen socks a woollen cardiian and ft while coflon pillow case (.Second Paper) FBlDftT UOBKD.a Four Questions only to be -Answered Time allowed — ^Two hours 7 Sug^t suitable handwork for a convalescent child aged five 3 ears 8 TOmt do you consider ore tlio essential types of toys winch should bo selected for a child aged four y ears in any nursery! Give reasons. 0 Too much rigidity lo nursery routine is not desirable Dis cuss this proposition fully 10 If a child of tlixec years were constantly catching cold what might be tha causes t 1 1 What conditions or diseases may affect a child b head ! How may they be prevented f 12 What would y ou do if a BoiaU boy w your clinrge, on jumping downstairs fell and on being picked up was imablo to stand on hta nght foot t 202 EXAMINATION PAPERS NATIONAL SOCIETY OF DAY NURSERIES AND THE NATIONAL ASSOCIATION FOR THE PRE- VENTION OF INFANT MORTALITY Adixmcetl Creche WorLere* Cxamrnalton SATUUDAr JOKE 23 rd, 1034 (Tuno aUoned — Two liours) 1 nto an essay on teellung giving its possible troubles 2 How would you feed a healthy baby of four montlis on orduinry rml& ! Gi\ o quantities and method of preparation 3 ^Vhat must 3 ou bear in muid when planning a diet shott for the toddler t 4 ^Vhat are the fldvantoge» of breast feeding t a Say what you know about 1 Thrush 2 Thpcadworms (giving treatment) 3 The care of baby a scalp .,4£fvomta would jou pov q)Ccial attention t 2 How would you rendoi 1 ell to a child (1) will n burnt band (2) on an attack of croup (3) with o bad cut at the wrist ? 3 \\Tiat do 5 ou know about rickets and what steps should bo taken to prevent their devolopmv.nt T 4 A eluld cornea out m spots W at points must you obsorro and const ler to find out wl at illness might bo beginning 5 Outhuo a twenty fo ir I oura programmo for a 1 ealthy child of two years old — what go^ Imbits do you wwh to encour ge ut thia age t 6 Write an account of tho qualities tl at make a good ‘ cliild nurse special Adraneed £iommah<>i»/<>r A urwy Nurscf 8aTi7aDA\, SErTEirnEn IDtd 1D3G Five Questions only to be Answered Time allowed — Two 1 ours 1 hy IS Onto natal care so important 1 How can it help in improving the health of the race t 2 Give a brief account of tho new duties tlini every bab> I as to leom after birth 3 j b 1 oiild every babj bo breast fed ! 4 Giv^e on account of the symptoms s gns and treatment of nekets 5 How V ould you look after » prenioiiire baby during the first month of its life 1 C W at dai gors may anso from b ims and scalds T How would } ou treat a cose of extensive bums in a baby of six montbsf Adt'anced Examtnal on Jor Nvreery AwrsM SATuitDAy suBcn 20Tn 1037 Question 1 mw( be answered and fo ir oti ers Time allowed — Two J ours 1 Wl y 13 sleep important to a bab> T Howwouldjonertablish good sleeping habits in a young infant and low much sleep does a baby need dunng its first year of life t 201 ISAMINATION PAPERS 2 Winfc substitute? for brRiat m Ik aro mailablot DoiCribo tho preparation of a somplo fowl for n 1 aby of threo •wcpIcs of ono of tho substitutes j ou deocnbo 3 IIoi7 would jou cor© for tho akin of o bob^ wl o w liable to develop napkin rash t 4 Describe the preparations you would tnnko to prepare for a prematuro baby 6 How would jou alicinpi to deal with (a) tho child (b] tbs child who tells lies t C in ftt do j ou know of tl o emergency treotmont of (a) Falla on the head ' (b) Drowning (c) Dog Bites J ildfaiiccd Examinalion for Nursery A wrj«.f SATTODAY, SnFTEUBEB UtO 1937 Fj\ 0 Questions onlj to bo Answered Time allowed— Tivo 1 ours 1 Wliat aro tho aigas and symptoms of an morfed bat^ ! How would j ou prove that any particular baby jraa being overfed t 5 Qivo a brief descriptioa of a prematuro baby How would you treat such an infant 7 3 Wliat clothing wovid )ou put on a baby of sis montlui (1) In winter (2) In summer Eow much sleep and exercise should he require f 4 Give an account of vitamin C How would you make up any deficiency of this vitamin m tho diet f What reaulta might follow feodmg without vitamin C t 5 Wbot are the signs symptoms and treatment of BronchitU T 6 What IS the isolation period of (1) Scarlet Fever (2) Measles jS) Mumps (4) Cliicken Pox How would you disinfect ofler o co'm of Scnrlct Fever T Part J1 {Advanced) Ezammaitm uTAttm 26x11 1933 Question 1 Ptust be answered and four other questions Time allowed — Two hours 1 Wliat common difficulties aro met with in broOsfc feeding 7 How can you help to avoid them and how would you dooi with them when they occur ! EXAMINATION PAPERS 205 2 MTiat precautions would j ou take la tho care of in artificially fed babv of five montba dnnng the hot period of an Engbsh aumroer 7 3 What do 3 ou know about Mtamins f Descnbohow jouwould take core that your charge receives sufficient of those matenals 4 Describe bow }ou would deal with (а) Gravel rash on knc) no, 160, 106 Vitamins in, 42, 103, 164 Barcelona outs, ntomtos in, JSt Barley, ICl Dour. 07. ICl Titanuns in, 42, 104 water, 6], 110, 115, 140 Barley sugar, 103-106, 135 Boons, 153 viCaminain, 42, 163, I6( Beef. ISO. 183 caiono value of. 140 vitamins in, 42 Dectruots, 168 vitamins in, 42, 164 DcUadonna, narsmg mothers and, 10,20 Bemax, 42 Beng-r’e Food, 110, 117, 147 compoeitlon of, 63 peptoniaing ponders, S2 Uorf ben, 40 Beriaa Builder, rornpositjon of, 54 Malted Milk rood, 61 Berna milk composition of, 45 Bifsrbo'iato of soda, f2. 1 1 1, I i**, 135. 146 151 BBe. 123, 121 Bilious attack, 106, 116, 113 208 INDEX Biscuits, U2. U7, 105 Bismuth carbonftte, 110 Blue Butterfly nulk, composition of, 45 Bottle, choice of, 85-87, 00, 129, *Itusiraiuma, facing p 86 Bottle feeds, 87-05 Bovnl, l48 Bowel, catarrh of the, 123 ' Brain tumour. 117 Brains, 09, 103 Titamins in, 43 Bran, Titamins in, 164 Brazil cuts, vitamuia w, 42, 164 Bread. 101, 143 161, 165 I calonc value, 140 fried in bacon fat, calonc value of, 140 pul]f^ (Zwieback), 103, 104, 136, 161 vitamins IQ, 43. 162 164 Breast, abscess of tbe. 34 dmtnng nulL from the, by artiSciat means. 10, 30 feeding Su Feeing breast infoctioQS of the, 23 massage, 25 milk. See MiUi, breast Qipplo fbielcl, 33 nipples, preparation and cote of. 5, 13 23 poorly developed, 23 treatment at weanug SO tuberculous disease o( the, 0 Breek Feeder, 129 Bronchi, baetenal infection of, 40 Bronchitis, 107 diet in, 140 Broth, bono and vegetable, 17,65, 96, 07, 08, 157 making of, 18. 03 Bmsscls sprouts, 153 Titamms in, 163 Butter, caloric value of, 140, 165 vitamins in, 40, 42, 163 Butterfat vitamins in, 161 Buttermilk 79 dried, 110 powder, SO vijaminain. 42 Byno Hepol, 152 Cabbsqe, 103, 163 10$ vitamms m, 42, 164 Calamine lotion 151 Calciferol. 42, 133 Calcium hydroiido, 62 in tbe diet, 62, 65, 105 CaU‘8 brain 157 CallanU' bread or biscnils, 142 Calonc feedmg, 60 requirements of chililren, €9, tot, 16S, 169 value of common cticlcs of diet, 140, 1CS-16S sralue of dried miU., 48-62 valns of starchy foods, 53-57 Caprolac 151 Carbohydrates, nmoont required, 102 effect of excess of, on motions, i09 high carbohydrate diet, 131, 137. 146 Sn artiflcial feeding, 7, 62, 64, 06 m breast milk, S, 7, 8 in cereals, 161 in condKDsed (evaporated) milk, 45, 46 m cow's imQc, 69 in dned milk, 49, 49, 61, 62 in fruit, 168 m propnetory foods. 63 m vegetables, I58 indigestion. 64. 116, 136 Cardiospasm 113 Carnation milk, coranositiOJi of, 45 Carrots 07, 103, 157, 158, 166 calorie sttlue of, 140 vitemuis in, 42, 163, 164 / Casec. 40, 81 Casein m rmik, C, 7. 31. 59, Cl powdered 32 Castor oil, 109, 121 Catarrhal jaundice, diet is, 245 Cauliflower, 103 153 Titamms in, 42, 104 Celery, vitamina ui, 42, 163 CercaJ water, 6f, 65 CereaU, 17, 65. 00, 159-161 cooking of, 19, 03 136, 162 digestibibty of, 16t vitamins in. 161, 164 Chapman's Bntire Wheat Fowl, IB. 51 BS. 09. 147 Cheese, 156 Titamms m, 42 Chemee, Titamins m, 164 Chest circumference, 169 CbestnoU Titamms in. 42 Chicken. 99. 103, 156, IDO Chloral hydrate, 117, 113 Cliocolate. 134 Cleft palate malformations, 21 Cloudberries, vitemins in, 164 Cocoa, 134 mDEX 209 Cocoajiut, vit&mii^ m, 4^ Cocoanut oil, rttaiaina la, 43 Cod, 151 Cod Uver oU, C, 60, 57, 02, 101, 131 emulsion, 18, 4fl, 72, 08, 125, 132, 133 140 oso ol, in Mt deEcieaey, 8 vitimuns m, 40, 41, 43, 163, iG4 Ckehso disease, djot la, 143-145 Btoola in, 1S4 Coffee, calonc value of, 140 Colds, 103, 115 diet In, 146 Coin:, 30 Colitis, mucus, 135 Colonio lavage, I63 Coloatrum, 10, 36 Condensed sulk Sm HiU., con densed (evaporated) Constipation m artiScial feeding 00, 02, 63, 121-133 u brt^t feeding 16.66 120 ux nuniQg mothers, 16 Com, Titanuns 10, 43 ComSakM, 142 Cornflour, 147, 148 Coreaet milk, oompositioa of. 46 Cottonseed, vitamins in, ICl Cow and Grate fuU^omUQ, 48, 07. 73, 83 for i^ort uao CO, 62 lialf mam, 32, 40, 147 bumamsed 5l, 74 131 * skiuimed, 33, 42 116 apocja] b^f cream, 40 100 Cow's milk hlllk, cow s Cronberry vitamins in, 43 Cream. 0, 84, 121. 134 calonc value of, 140 certified for ocean voyages, 62 Vitamins in, 43 Cream of Bice, IB, 19 5i, 98 99. 130. 147, 102, 160 cooking of, 170 Cream of Wiwat, 99, 103, 142, 161, 167 composition of, 64 cooking 0I, Cress vitamins In, 43 Cucumber, vitamins in, 43, 181 Curd formation, 34, OS, 90 in tbo Btools, 124 modification of, 61 Custard 99, 103 Qranotie attaeVs, 131 tc Dalxosb, 54 i>ates, vimmina in, 203 Dehydration, 06, 72, 100, 112, 131 Daxtrfmaltoae, 7, 03, 04 Dextrm, 63 Dcitfosc, 35 Diabetes diet in 130-142 Dianhcea, 108-114 dietetic, 69 60, 100 dnnka in, 110, 111 feeding in, and provention of, 79, 80. UO-114 /ermeotaCiva, 77, 79, SO, 97, 124 10 breast fed infants, 30 10 ^atnCia, 115 infective, 107 salxfie solutions, 163 sumnier, 37, 207. 113 symptomatic, 107, 109 treatment of, 109 water use of, 60 109-113 Dnt. common articles of, 154- 162 Diets, from eix to mco months «Id, 18 from mne months to eno year old, 99. 100 from one to two years, 103 from one to seven years, 100 from two to seres yean, 104 for a child of about tbreo years, 165-108 for children of school age, 105, 100 for sick children, 234-251 Diptoms milk, ooroposition of, 45 Dor8'*Ila dned milk, 73, 83 composition of, 48 Dned milk See Milk, dried Drug excretion m raitk, 10 Dcyco. 109 composition of, 49 emtabis for use in the Tropica, 63 Duodenal stenosis 117 Dysentery, 107, 125 Dyspepsia, 116 acuto, 107, IIB carbohydrate (or sugar), 110 fat, 6 60, 116 133 tn artificial feeding, 69-62 protein, 62 116 starch, 110, 136 sugar to bo used in cases of, 63 whey, for coses of, 82 210 INBex Ear trouble, 109 Eczema, 31 diet in, 78, U9, ISO Eggs. 09, 103, 134, 137, 138, 160 calonc value of, 140 their food value and constt tuents, 164, 163 vitamins m. 43. 16G 163, 164 yoDwOf, 134, 143, 161 Elcdon butterrmlk, 79 Endive, vitamins m, 43 Endocrine therapy, 144 Enci^n cereal products and bread J-U Energy renuircnaent at different flg«r. IC7 Epstem’a diet, 139 i Ergosterol, 41, 140, 143 I Es^rato, Vitamins in, 163 ! Evaporated milk («e< Milk), 45 | Everyday milk, composition of, 45 ' Examination papers. 160-205 ' Expression of breast tmlk, 22, 166 Fasez.IO. 64, 08 Fat amount r^uired per day, 102 animal, vitamins in. 41 deficiency of, in diet, best method of orercoming 6 dyspepsia, G 60,116 diet for, 133 excess of in diet, effects of, 00 109 ISl. 123. 224 135 high fat content foods, 134 in cereals, IGl in condciucd (evoporated) milk. 45 4fl IR cow's and breast milk 2. 5 C 8, 9, 31. 34. 35 60, CO in dri^ milk, 48-52 in proprietary foods, 63-57 m tbs stools, 143 m the diet, 102, 146 low fat diet 135 Fattening and non fattening foods, 143 Feeding artificial, 33, 68-90 amount of food required, 71- 76 01 bottle feeds, 87-95 bowel disorders in 69, 60, 03 calonc feeding 69 carbohydrate in 7 50, 62-64 choice of food, 82-84 clinical importance of food elements, 60 cod liver oil, uscof, 72, 84 92 Feeding, artificial— continued constipation in. 62, C3, 120, 123 fruit jmee, nso of, 40, 02 how to fe^ the baby, 89 in cases of diarrhica, 79, 80 in the tropics, 60 iron deficiency tn, 65 night bott^. 89. 100 of prematnro infants, 67, 77, 130 proteins in, 60, Cl-64 nekets, prevention of, 92 fslUta, SS starch tn, 64. 65 sugar fa, 7, 63-64. 72. T3 tunes of feeding, 87, 02, 04 vomiting in, 60-82 wind, to brook Uie. 89, 02, 04 with buttermilk, 79 with condensed (ersporated) milk, 76, 76. S3 with cow’s milk, 0{k>72 83,02 am oon t req innd pe r day, 67, 6S, 72, 76, 06 boiled 83. 92 curd fonsotion, modifi cation of, 61 difficulties of, 63 diJution of isnk to modify its eorsposi tioD.fiO, 61, 62, 63, 69. 72, 79 dilution, with oddition of carbohydrate, 70 fat. reaults of axcces of, 60.61 faumanised milk method. 67, CD indigestion in, 60-62 lactose, QM of, 63 metabobo disturbances resulting from. 69 pcrccnfsm feeding, 63 proparatron of feeds, 90- 06 sugar, use of. 63 tunes of feeding, 02, 94 unboiled. 30 whole milk feeding, 08 tnth d/vd mdk. 73. 75, 83, 03 preparing ilio feed, 89 with humanised lined nnlk, 74-76 83 01 with hydrochlonc scid milk, 78 with lactic aod milk, 7C-78 INDEX 211 Fcwljas breaat, 1-32 ob.i«9a o{ tba breast, veaniag ID, 2-1 ftclmatagea of, 1-4, 8, C3 oloohol, U90 0f, IS amount of mtUi requirwl daily, 14.*26, 27. C7, 71 anto oaial mca^uTfS, 4 co’crfltrum, Sts fnnetiomi, 18 eompl'imailAry feeding. 8 12, 27, 28 constipation in, 18, Q6. 110 contra tadicationa to, 3 dvaTibosaln, 31 diet and hygieno of mother, 5. 8, 15, 15. 23 diQlcuItSca in, 21-33 diseases of tUo mother, wlion tiioy do or do not present nunloff, 3, 4, 0 drugs, thoir effect on milk, 10 faiium to tbnre on, 22, 25, 20, 32 ilret feeds 13, 14 flow o! nUU, 14, 16. 24 conttolling the Cow, ffofs 12 {nsudeiect supply of milk, £5-27 ictetation, esCablishmese of, failure to cstabtuti, 21-24 malted milk stimulatea Oow of milk. 10 mcostmation and. 4 nerroiw upsets, their effect oa, 23 night feeding 13,14 nipplee, preparation and eoro of, 8. 13. 23 ' of premature infanla, 32, 129 os'orfaeding, 28. 31 pregnancy and, 4 (juolityot milk, 27 28 quantity of railk, mcrcastog the, 25 and composition of milk, I tunatlona in. 8 secr»tion of ml^, d"lay in Iho. 12 MtaUished viihont put ting bnby to Ibo breast. •limulant to, 11 should he done it fx^nihle, 33 smokmg, effect of, 1 1 Feeding, hreut— continued Buckhng, bmUon. 13-15, 21 supply of milk. “ test fe^s ” for ascertaining, 20, 2S, 30 syphditio infanta should h« nursed by their mothers, 3 time baby U olkwcd to suckle, II, tunes of feeding, 13 tuberculous mothers ontl, 3, 0 underfeeding, 25, 31 Toimting in, 2C, 38, 3 1 vratcr, use of, 30 weantos as-d ttA comrw^ic*- ment of muted feeding, 17, io weight of baby, log of, in flnt few days, 12 wet nursing, 23 Feeding, complementar}, 8, 12, 27-29 Feeding, mhred, 07-107 eomals, 87 commencement of, 00 (Let from six to luno mooths old. 18, 08 from nioo months to one year old, 180 from one to two yean, 104 from two to sc\cn yten, 105 for children of school age, 100, 107 failuro to gnm weight, 87 feeding from ono to itosTa years, ICO food clcro^nta needed, 101 how much milk docs a child of ©no to 6a>ea years reriulro, 102-105 proteins in. 101 •tarch in, 86 Foeds. nictltod of malting, 80-85 FemCarb harcb ,151 Ferri «t emmon , 5 Ferrolac, 4^, 65 n Fever diet, 146-143 1 Figjulco, 121, 161 Figs, Vitamins in, 101 Filberts, ntamiru in, 43 Finger sucking, 110 Fish. 103, r.Q vi'aminain. 43, 41. 164 Fwb'Cakcs. 156 rubti\«.ron. vitamins in, 1C3 Flat feet. 130 Hour. 161 Titaminsin 43,162 212 INDEX Dmd, insufficiency See Water Food allowances for healthy ohil drea, 1C8 elonietits needed in the diet, 101 Foods, composition of, 140. 165- 168 Foice, 144, 1C6, 1G7 caloric Taluo of, 140 Frailae, 49 Freali air, 128 Fnara balsam, 23 Fruit drops, 103-105 juices. 18, 40. 41, 4G. 60. 67, 98. 99, 109, Jiff. JffS 169 Fruits, 121, 187-169 raw^, 169 stowed. 09, 103-105, 142 vitamins in, 42-44, 163. 164 GSLACTAGOOtrEa, 6 CSalactono 35 Game, 166 Gases, absorbed in tailk, 35 Gastric influcnta 110 lavofo, 116 163 Gastritis, 116 Qastro cntentis, 9, 31. 37, 77 Gaatro intestinal upset. 24, 30, 08 100, 132 Glaxo, full cream dncd, 43, 67, 73, hflU^crcara dned, 49. 109. 147 Sunshine, 61, 74, 83. 131 for export use, 60, 62 Glox Ovo, composition of, 64 Globulin, 10 Glucose, 64, 134, 135 powdered, 134 146 saline, 116, 163 vitamins in 43 water, 109, 110 Goat's milk, 34, 37 Goose fish liver vitonuns in, 164 Grapefruit, 169 juice, 99, 134, 159, 166 vitoEiunB in 43, 164 Grape nuts. 105, lOl Grapes, 105 vitamins in, 43, 164 Great OTmond Street. Hospital for Sick Children, oxammatron papers, 180 Green Butterfly milt, composition of, 45 Green leaves, vitamins in, 163, 164 vegetables 163 vitamins in, 163, 164 Greens, 07, 103 Grey powder 130 Groats, 17, 00, 103, 148, 161 coolang of, 162 Groult'a Cream of lUec, 13, 64, 93. 103. 102 Growth, vitamms and, 39, 40 Uaodoce, 165 Ibetnolae, 48, 05 n Hako, 167 Halibut hver oil, ff, J8, 48 60, 72, 8i, 02, 08, 101, J28, 152, 134, 136 vitamins in, 40. 41, 43, 163, 184 Hail), vitamins m, 43 Hamamebdis ointment, 120 Hanbury pnzo examination in diseases of children, 14 fst minster Hcapital, papers, 191 Hare bp. 21 Head circumfeKnco, 169 Heart disease, 22 Heart, vitamtAS in, 43. 164 Heatspots, diet in, 160 Height table 168 Be^ Simplex, ICI Hemngs, 103. 167 vjtaauns in, 164 Bindley, hlcssrs 1/ -A , 78 Hog musele, vitamins la, 16t Hooey, 105, 167 vitamms in, 43 Hooker’s Plaited Milk, coisposi tion of, 40 Horhek's Malted Milk. 16, C4, 116, 134 143, 147 composition of, 49 Humanised Ambrosia, compoat tion of, 62 condensed milk. 46 131 cow 6 culk, 7, 35, 69 dned milks, 60-52, 74, 76, 87, 01. 131 Trofood, 74, 83 131 Hydrochionc neid, 118 milk, 78, 149 Icin, 148. 149 I«l vitamins in, 43 IdealcondcnBedfevaporated) milk, 45. 76 Indigestion. St* Dyspepsia. Infections, immunity of the re* cently bom to vflnons 9 Zttfectioas diseosea, diet m 146 INDEX !13 (oflucQza, diet in, 146 gcutnc, 116 InCiissuswpCion, 114, 127 Iron in milL, 35. OS, 06 in tbo diet, 6S, 103 mcwt snjtabla forms of, JSJ Iron end aminoniiua citmte 132. 162 Iron ealt, 6 Jau, 100 Junket, 100, 104 Kale vitaimiu in, 43, 104 Kaolin, 117 Karalac. 63 Keratomalacia, 30 Ketosia, 130 Ividney, 160 vitauiuui in, 43, IC4 KidnajB polyevstic, 128 Klim luU cream dri^, 4Q, 33 flkimmed dried, 40 Knock knee, 137 laensAO, 77, 78, 111 Lacta dried milk 49,73,33 Lactagol 10 LaeUlbupien, 0 7. 34, 0l Lactation, cstabluhment of, 1 1 falluro to eelabluh, Sl-34 LactelobuLn, 0 7,34,01 Lactio acid milk 67, 70>70 81. 110. 110, I3l method of niakins, 77 Lacto 61 Lacto<\ eguva, 64 Lactogen. 61 Lactose, 7, 30, 67, 02, 03 Lard, vitamins in, 43 I Lemon milk 163 I Lemons, vitamins m, 43, 104 I Juice of, 110 water, 140 Lentils, 153 vitamins m, 43, 164 Lottuco, 103 adtamiosio 43, 15S, J03 104 Libby's condensM (evaporat^l milk 45 75 * Lichen nrtlcatis, l&l Limes, vitamins in, 43 134 Liqiud porafOn emulston, 120,121 Liver, 160, 160 vitamins in, 43, 104 Liver extract preparations, 151 Zavron, 102 fitacAfiosi, I6I ihtgaesiam hydroxtda, 62 61aite, vitamins in, 104 Stalautntion, 128 Midt, 135 and Iroa, 13S Malted foods, 25 milks, 10, 49, 147 Afaltoaan. composition of, 05 Maltoso, 63 64 klamsmuB, 128 3Iaro a milk, 37 Marganno, vitamins in, 40, 43 Marmito, 143. 145, 152 vitamins iii, 40, 42 Mead s ^xtnmaltose, 63 Protein 31ilk, 60 SI hleals, tunes of, 13, 87, 03 94 Set alto Diets Measles, diet in 146 Mcasunng fluids and solids 05 Meat m the diet, 101, 130. 138, 142 165 jujco, 65, 162 viiamins in, 4D, 42 43 104 Molo^na neonatorum, 125 MeUin'e Food, 66, 03 Lacto. 61 Melons. 160, 163, 164 Meningitis, IDS, HB Menstruation and breast feeding, 4, 8 MemsU Soulo Company, 77, 78 Powdered Protein 51ilk, 60, 81 hleryeism 117 MickleSeid s irradiated tnilk, 41 n MiddlO'«ar disease, 103 Uidwtlcry axammation in Pa?dia tncs o{ Socioty of Apotliccanes papers 186 Alilk, ass's its composition, 34 breast, amount Secreted, vana tions in. 0 bactonology of, 0 carbobydrates in, 8, 0 casein in, 0. 7, 34 compositiOD of, 0*0, 3J, 34, 60 curd of, 61 diet, and composition of tlia milk, 8 digestibility of, 7, 0 drugs in, excretion of, II expression of, 23, 151 214 INDEX Uilk— «&n^triua} brcaBt— eoniiRued /at In, 6. 6, 8. 0, 31, 34, 60 firat portion of milk dr&mt used m cases of ** fat dyspepsia,” C tnlection (ram, 3 iron ID, 05 lactalbumen in, 6, 7, 34 lactglobalm in, 0, 7 lactose in, 7 menstruation, effect of on, 8 phosphoma in, 8, 05 pregnancy, effect of on, 8 proteins in, 6-0, 34, 61 quality of, 25, 20 quantity of, znotkods of in creasing, 25 variations in, 8 salts m, G. 8. 05 sugar in. 0, 7, 34, 02 vitamins in, 40 certified for ocean voyages, 62 condensed (evaporated), 45 composition of better known brands, 46. 46 humamsatiao of, 40, 131 sweetened full cream, 45, 46 slummed, 45, 40 UDswoetened full cream, 46, 46 use, fo artificial feeding. 75. 83 uss of, m tbe feeding of prcmstiuvinfaats 40,130 vitamins in, 43, 46, 40 cow’s, absorbs gases from tbe OIF, and nonous gases. 35 advantages and di^van. tagcsin its use, 83 amount to give a normal child. 102 bacteriology of, 36 boiling or scalding of, 36-^1, 43 112 calono vohia of, 60, 140 166 casein m, 34, 69 certified milk, 33 composition of, 34 36 59 contamination of, 30-39 dilution of, in artificial feed mg, 76 with cereal waters, result of, 61 with water, result of, 61 disease resulting from tha use of. 36 fat content of, 34, 35, 59, 60 61tli, eonttnunf i cow’s — eoRfinurd n poded, 38 ^ humamsation of, 7, 35, GO iron in, 35, 65, 90 lactalbumen in, 34 lactoso m, 35 pasteurisation of, 38, 59 poptonlsation of, 62,82, 132 phosphorus in, 8. 65 preparation of feeds, 90, 92. 93 pcDteins in, 6, 7, 34, 69. Cl pun) Dulk should be ^out less, 35 raw '• milk should not be given to n baby, 30 ealu in, 6. 35, 65 skimmed lioded, IIS eounngof, 36, 113 stcnlisalion of, 30 sugar in, 7, 34, 35, 62 tnboTclo baeilh in, 37-39 vitamin content of. 39, 40, 4 1, 43, 163, 1C4 dnrd, 46 odvantagea of, 47 brands with a low fat eon tent, 47 composition and calond value of the bettor known brands, 48-02 curd In, 47 ibgestibility of, 47, OO diMd vantages of, 60 fulltilk pudding 102, 104 Milkal dried milk. 43, 73, 83 tfinadex B^rup, 152 Mixed feeding 5ee rccdiag, mixed Modilac dned milk, 52 Monosaccliandes, C4 Meonraker milk, composition of, 45 Mortality, and tke feeding of babies, 1 Mother, diet and hygiene of, 6. 8, IS. 10. 55 Motiona Set Stools Mucus colitis, 127 Mulbcrnea. vitamins m. 43 Mushrooms, vitamins in, 43 Mustard greens, vitamins in, 161 Mutton, 156. 165 vitacoins in, 43 TfASO VBABTTIOmS. 103 National Societr of Day Nor 8<.nce and ttie National Assocta tioa for the Prevention of In fast Mortabty examination papers. 202 Keave’a Cereal Food, 19, 61 compoaitjon of, 65 Milfo, composition of, 48 Neo Bovuune. 162 Nephritis, 128 diet la. 139 Nervous type of child, 134 diet for, 135 Ncstl4 s milk, 45 Milk Pood, es Night feeding, 87, 101 Nipples See Breast Nujol, 121, 122 Nursery ‘Jkoining Colleges cx aminatiOQ papers, 192 Nurses exommatioo papers for, 169-205 Nutromatt, 63 Nuts, Yitaimiu in, 42->44, 164 Oi-T flour, 97, 100, lOi water. Cl Oatmeal, 161 %'itamins in, 43, 104 Ocean voyages, ccrtifled cufk and cream for. 62 (Esophageal stenosis, 114 Oils, animal, vitamins in, 39 aegolable, vitamins fn, 30 Qltvo oil. 121 Mtomica in, 43 Omons, Yitonuos m, 43, 44, 164 Oranges, 169 caloric value of, 140 juiCQ, 18, 41, 93-100, 103, 104, 110, 121, 128, 134, 137, 169, 16S vitamins in, 41, 164 Ostamalt, 138 Ostclio. 42, 92, 23J, 139, 140, 145 OsUrmilk, 4S Ovaltme, 16, 65 Ovcrclotiung, 113 Overfeedmg, 29, 31, 102, 109, 113 129 Overweight child, diet of, 142 Ousters, vitamins m, 44 Pablcu, 10, 65 Pcsdiatncs, Master of llidmfery examination m, 186 Papnks, 40 m Pomsh's diezaical Pood, 162 Parsley, vitamms in, 44 Parsnips. 07, 103, 163 Titamins m, 44, 104 Pas(eunp*d nulk, 3$, SO Pastry, 154 Patent foods, composition of, 63-57 masy ora dcSeieut in vitamins, 67 ' must not bo given in excess, 67 storcli in, 64 Fcactm. ISO Titomms in, 44, 164 Peanut^ 44 Fears, ICO caloric value of, 140 vitamins in, 44, 16-1 Peas, 158 vitamins m, 44, 103, iC4 Pellagra, 40 Pcplalac, 82 Peptoai^d milk, 62, £2. 132 Peristalsis, 114, 124. 163 Pet milk, composition of. 46 PetrolBgar Emulsion, 121. 122 Phosphates in milk, 35 INDEX Fliosphorus m eggs, 137 m miltc, 8. 63 m tho (iict. 102 Pineapple, vitamins in 44 Plaice, 09. 103, 157, 163 Flaamoa oats, 142, 143 Plums, vitamins in, 1C4 Pneumofua diet in, 146 Polyneuritis, 40 Polj-saccliandea, 6 1 Pork, 150 vitamins in, 44 Porridge, 101. 142, ICl, 165 Potato cream, 137 Potatoes, 17. 07, 00, 101, 103, 130, 142, 14S, 157, 158, 165-163 sweet, vitamins in 44, 163 vitaxnina in, 44, 161 Pregnancy and breast feeding, 4. 6 ansmia in, 5 Promatufo infant, feeding of. 22, 130 PrematuTO Tuba Feeder, 130 Protein, deficiency of, la diet, 102, 183 exc«i3 of, indications of, 62, 63 high protein feeding, 80 m%re(Ut milk, 2, 6-0, 34, 69, 61 m cereals, 101 ]Q conilansed milk, 43, 46 in cow’s milk, 6, 34, 66, 61 in dried milks, 43-62 in proprietary foods 63-67 in the diet, 102 146 in vegetables. 163 indigestion, 62, 117 utllks, 80, 81 > S M.A . 80. 81 Prunes, 103 juice of, 121, 169. 107 vitamins in, 44 163, 164 PuCed nce, 105, 142 Puffer fish liver oil, vitamios in, 164 Pulse rate 168 Pulses 18 S Pumpkin vitamins in, 44, 163 Pylono stenosis, 1I3-1I6, 12S Rabbit, 105 Radiomalt, 42, 138, 145 Radiostol, 138, 140 Rodiostoleum, 42, 92, 134 Radish, Vitamins in, 44 Raums, vitamins m, 44 Rammslcdt’s operation, 1 14 Raspberries 160 vitamins m, 44, 161 I Rectal poljpi, 125 Btd Butterdy mlJk. coinposition Regal milk, composition of 45 Register for sick children's nuriM), examination papers, 170 Reime^, 61 Resorcin ointment. 151 Respiration rate, 1C3 Rliutmrb vitamins in, 44 and soda, 135 Rice, 161 ground, 17. 143, J61 colono value of, 140 potislied, 161 podding, 163 vitamins in, 44. l6f Rico flour. I6I Rickets, 40, 43, 6a, 132 diet to, 137, 160, 161 prevention of. IS, 41, 92. 98 Ridge’a Food, 64 composition of, 55 Robb’s Biscuits, ID. 64, DU, 107 Robmaon’s Patent Barley, IS, 61 03 composition of, 65 Oroats, 18, 64, 93, 162 composition of, 60 Roe, llsh, vitamins m. 44 Rojal Sanitary Institute ex oinmotion papers, 192 Rumination, 118 Rushs 19,104, IGl Rye. 161 ntonuns in, 44 RyAitaCnspbreod, J3C 101 coin}>oeition of, 66 S yiA dried imlk, S2, 83 Saco, 09. 101 Sagradol. 121 Salmo solutions 115, 136, 152 water, 119. Ill Salmon, vitamins in, 44 Sails in milk. 6. 7. 35. 69, 67 in the cLct, 103 In vegetables, 163 Salvarsan, nursing xnotliers and, 10 Sardine oil, vitamins m. J 64 Sanssges, 167 Savory and Moore’s Fooil, 110, 117, 147 composition of, 66 Savoys, 163 INDEX 217 Sc^Iet lover, dit t in. 14C Soott's Emulsioa, 138 Scott’a'Oat nour, C6 Sourvy, 4S diet in, 133 Seeway, driod whey, 40 S2 t^cd oib, vitamins in, 164 ^oevU. ^^tamina in, 164 Scmolma, 99 Semprobn Emaisjon, 1£0, 1^1 Serum nIbnmoA 34 Sorumglo'bulm, 34 Shredded Wheat, 104, 103, 131. ICl Shrimp, vitamina m, 44 birk children, diets for. 131-151 Sister Laura’s Food, IS, 6f, 08 composition of SC Smohuig. efioct of on lactation, 12 Sodium citrate, 02 Solo, 103, 157 Sore throat, 110 Soxhiet apparatas, 36. 00 . tllnt