Visiting Obstetrician to Philadelphia Hospital.
Reported by W. A. Edwards, M.D., Assistant Dem. Clin.
Med. University of Pennsylvania.
Arch. Ped. 1:88-95, 1884.
It has been my custom for several years after having brought before the class numerous cases of children's diseases which may our clinic so interesting, to call your attention to an important branch of your life work, infant feeding, a subject that upon superficial thought seems so simple that the majority of medical students are apt to pass it by as pertaining to the nurse and not to the doctor; yet my associations with recent graduates enables me to say that it is the one subject that comes up before them soon after entering their medical career, and often it is not merely a matter which is important for the moment and easily evaded, but because either the portal of entrance to a large practice, or the starting point of embarrassments and disappointments which render their arduous duties even more irksome.
I wish distinctly to state, that though I shall dwell at length upon the feeding of infants with prepared foot, I do not wish to be understood to underrate the value of mother's milk or in its stead that of a reliable and well-developed wet-nurse; there are times when a mother cannot and should not nurse her child, a wet nurse should then be the first thought; then again I may also state, at this point, that a child which has been nursed for a short period can be very much more easily brought up by hand than one who is obliged to be hand-fed from birth.
The great question which has always given rise to so much hesitation and difficulty in its answer is upon what food to place a child. This at times is perplexing; it depends upon various conditions; it depends upon age of child, upon its health, upon its residence, country or city, and upon the circumstances of the family. All these should be taken into consideration; is it to be weaned gradually, or is it necessary that hand-feeding should be its only supply? If you attempt to study this matter from your text-books, you will be dazed with the number of suggestions there presented. It is well that you should form in your own mind the regular course to follow in such cases, and avoid the unfortunate way of answering your inquirer, the fond mother or nurse, by saying, "try this," or "try that." It should not be a matter of trial.
Let me say now that milk should form the basis of all preparations of food. It is not necessary for me to show you the difference between cow's and mother's milk. I will refer you to the physiological tables, and also those of you who read the medical journals of the day to the interesting investigations of Prof. Leeds and Dr. A. V. Meigs, who have studied this matter with great care.
There have been several ways suggested of preparing the food for infants, one taking mother's milk as a guide, and endeavoring to make cow's milk approach the human standard as near as possible by dilution and the addition of sugar of milk. For this purpose Dr. Meigs has suggested the following formula: Order five or six packages of milk sugar, containing seventeen and three-quarter drachms each; the contents of one of these to be dissolved in a pint of water, and each time the child is to be fed let there be mixed together and then warmed, three tablespoonfuls of the sugar solution, two of lime water, two of cream and one of milk. This makes about a gill, and as much of it as the child does not take should be thrown out and a fresh mixture made for the next feeding. The solution of sugar should be kept in a cool place and at once thrown away if it sours, as occurs if kept more than a day or two in warm weather. The dry sugar keeps indefinitely, and is easily dissolved in warm water. A pint bottle should be kept for the purpose of containing the solution, to serve also as a measure of the quantity of water to be used with each package dissolved, and also to save further measuring. The milk to be used should be good ordinary cow's milk, and not the very rich milk of Jersey or some other high-bred stock, and the cream in the same way should be such as is usually sold in the cities, and not too rich, containing about sixteen or seventeen per cent. of fat. The quantity of this food taken by a new-born infant should be two or three fluid ounces every two hours, and if it thrive it will soon take as much as a gill every two hours.
Then there are various preparations in the market of the cereals proper, whose use I shall tell you more of in a few moments, and those of the cereals that have undergone change into dextrine and glucose by malting, and those foods which are composed of milk, either preserved, condensed, or prepared in a more solid form. These preparations are expensive, not to be procured in every drug store, and furthermore are somewhat perishable, so I shall talk to you to-day of the "home-made" foods, to which I advise you to adhere for a time.
Let us suppose that you are confronted with a case in which the mother, having nursed her child for some months, finds her milk gone, and it becomes necessary to establish hand-feeding. She tells you that her child no longer receives the amount of nourishment that it should. Convince yourself of this fact before you make any change; take the appearance of the child into consideration, examine its muscles to see if they are firm, and judge whether or not it presents a rosy hue of health. Examine the mother's breast, and if you think that a course of tonics, with outdoor exercise or change of food will increase the supply, by all means have recourse to them before making a change. Remember that the milk does not remain constantly in the mother's breast, and that frequently those who are able to nourish their children with an abundant supply, have, between nursing hours, scarcely any evidence of milk whatever; the application of the child will, however, produce a flow in a few moments.
I give you all these points because frequently mothers wish to wean their child too young, and I firmly believe that encouragement and firmness on the part of the doctor will in many cases give a child a far better chance in after life. If the child is six months old, or thereabouts, and you find it necessary to establish hand-feeding at once, the following would probably be the best plan to adopt: Order nurse or mother to take a quart of morning's milk which is pure and fresh -- better than not from a mixed dairy -- and dilute with a half of a pint of water; put on to boil; take of Robinson's prepared barley, which comes in packages, a heaping dessertspoonful or tablespoonful; rub this to an even paste with a small quantity of milk; then add to it the milk that is boiling, and stir this for twenty to thirty minutes, letting it boil. This should be strained, and a small quantity, say a teaspoonful, of white sugar added to it, the whole to be placed in the refrigerator for the day. When cool a jelly will be formed. Of this the child should take about four ounces, made fluid by heating, and strained in bottle or by spoon, every three or four hours. The last feeding would for a time be about ten o'clock in the evening; after a few months the child will need nothing after usual bed-time until first meal in the morning, at about seven o'clock.
Barley flour seems to hold a position somewhat neutral as regards action on the gastrointestinal tract. Should the bowels become constipated, or should you desired to change the food, a preparation of oat meal known as "Bethlehem Oat Meal" can be used in the same way as the prepared barley. The wheat foods may be used in the same way; they are apt to constipate, however.
At times it may be well in preparing the food to mix these various articles, as a child needs a variety in taste as well as a grown person. If a child is younger than six months, of course it will be necessary to add a larger percentage of water and a smaller amount of cereal. I am satisfied, from investigations made last year (Some Observations on the Salivary Digestion of Starch by Infants, Trans., College of Physicians, Third Series, Vol. VI.), that infants are able in some degree to digest a small quantity of starchy food, and that the starch contained in the above described preparation, is not merely useful in preventing the formation of a heavy curd, but that it also is useful in nutrition. I have found the preparation that I have suggested to you applicable in the majority of cases, and especially in those children who are apt to suffer from indigestion during the summer season, with its unfortunate results. It is also useful when gradual weaning is thought advisable. In such cases the child is nursed from the mother in the early morning; after its bath, say ten A.M., it is to take its bottle or cup of food; nurse again at one or two, a cup of food at six, and again nurse at ten in the evening. As far as condensed milk is concerned, I am satisfied that it is an extremely valuable preparation, but not one upon which it should be attempted to raise a child. It is useful as a bridge to tide over difficulties, and as such can be relied upon, but a child that is brought up on condensed milk alone from an early period is, in my experience, likely to succumb more rapidly to the influence of disorders that other children, either nursed or fed with cow's milk, are able to withstand. Prejudice has frequently interfered with the use of condensed milk, I regret to say. It is certainly nutritious and easy of digestion, and frequently will agree, when properly administered, with a child whose stomach is intolerant of other food. Of the purity of the brand usually used there is no question, and I would advise you to study this matter carefully yourselves, and not throw away a valuable tool because many statements are made against it.
It is easy enough to find some form of diet that will nourish a healthy child. The most difficult problem to solve is the food to be administered to an infant who is delicate from birth and cannot nurse, one who is suffering from some sort of intestinal catarrh, or one whose digestion has been totally upset by a severe attack of summer complaint.
These are in fact the most difficult cases that we have to deal with; in treating such cases we should bear in mind that a child's food should not be made so extremely weak, in order to avoid all irritating qualities, as to make it fail in its object of supplying nutrition, but we must endeavor to make the child's digestive functions meet us half way, and thereby establish an equilibrium; we can either do this by the administration of those drugs which are known to facilitate digestion, such as the various forms of pepsine or pancreatine as the case demands, or we should endeavor by tonic influences to bring about a healthy establishment of the functions of those organs whose secretions are needed for the proper digestion of food.
If a child is so weak and exhausted that it will not digest the mildest form of prepared food, and it is impossible to obtain breast milk, for this should be our first thought, it is useless to weaken the condensed milk, or whatever we use, to such a degree as to make it absolutely valueless as a nutrient; the proper thing to do, under such circumstances, is in my opinion, to give some form of food which requires but little action of the digestive juices, or to prepare the food so that it is partially digested beforehand.
I have used for some time with great advantage, egg albumen dissolved in water, as a food for sick children when the stomach was intolerant of ordinary milk food, also gum arabic water will nourish for a surprisingly long time, and allay irritability.
The barley food as recommended above, would be valueless in a case of this kind, and pure cow's milk diluted to resemble as closely as possible the mother's milk, would be regurgitated; in such cases, and they are very frequent in the summer months, especially if you are called much in consultation practice, the preparation of milk which has undergone partial digestion by the pancreatic ferment, in an alkaline condition, I have found most useful. The preparation is one which must be made with care and according to the following directions: Into a clean quart bottle put a powder of five grains of Extractum Pancreatis and fifteen grains of bi-carbonate of soda, and a gill of water; shake; then add a pint of fresh milk. Put the bottle in a pitcher of hot water, or set the bottle aside in a warm place for an hour or an hour and a half, to keep the milk warm; by this time the milk will become peptonised. When the contents of the bottle acquire a grayish yellow color and a slightly bitter taste, then the milk is thoroughly peptonised; that is to say, the caseine of the milk has been digested into peptone. Great heat or cold will destroy this digestive action, so as to prevent all further action, when you think that the digestion has progressed far enough, at once place the bottle of peptonised milk on ice, or into a vessel of boiling water long enough to scald its contents; it may then be kept like ordinary milk.
I have found from experience that it will be objectionable to the child if the bitter taste is at all well marked; the mother, who should receive your instructions, should be warned to frequently taste the milk during its digestion, and as soon as the bitter taste is the least apparent, the bottle should be placed on the ice for cooling and use, as in these instances it is sufficient to partially peptonise the milk.
I mention these facts particularly, as strange to say, I have always failed with it in hospital practice, whereas in private practice I have had some excellent results, owing, I think, to extra care in its preparation.
Whey is another admirable alternative in these cases; it can be made in the usual way by rennet and afterwards sweetened slightly and given to the child cold or warm as it prefers, in the same manner as ordinary bottle feeding; it may be made with wine and given when there is great weakness, being both nourishment and stimulant. Mothers do not often know how to make wine whey; the proper method is to put the milk to boil and when boiling put a wineglassful of sherry, say to the pint, into it, if the curd does not separate add more wine until it does and as soon as you notice separation of the curd taking place add no more wine, but let the mixture boil for a time, until the whey and curd have been thoroughly separated, consuming about five minutes. This should be then thoroughly strained. It has been recommended to use lime water in the feeding of infants and young children. I am opposed to its indiscriminate use. I have seen children who could not tolerate even the ordinary weak preparation of the pharmacopeia; undoubtedly at times it may arrest vomiting, as we all know, both in children and in adult practice, but I much prefer when it is necessary to use an alkali, and if you use cow's milk raw for a young babe, it is always advisable to see that it is made alkaline, to do it with a small quantity of bi-carbonate of soda.
The food which I have recommended to you above for the weaning of children I am sure that you will find it to work satisfactorily, especially in large cities, where the milk supply is so apt not to be reliable, and on that account so difficult to keep sweet without boiling. I have one word of caution to give you in regard to the use of nursing bottles. They are certainly useful as labor-saving devices in early infancy, and when thoroughly cleaned and carefully watched are no doubt indispensable, but I have long since come to the conclusion that if you can persuade the mother and nurse to take the time and have the patience to feed a child that is old enough to manage by the cup or spoon, the word colic will seldom meet you in your practice. I am convinced that in institutions for foundlings, if it could be possible to discard the bottle, the percentage of death would be very much diminished.