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CLINICAL LECTURES

ON

INFANT FEEDING

"Boston Methods

by

LEWIS WEBB HILL, M. D.

Junior Assistant Visiting Physician, Children's Hospital, Boston; Alumni

Assistant in Pediatrics, Harvard Medical School

Chicago Methods

by

JESSE ROBERT GERSTLEY, M.D.

Instructor in Pediatrics, Northwestern University Medical School; Associate Attending Pediatrician, Michael Reese Hospital, Chicago

PHILADELPHIA AND LONDON

Copyright, 1917, by W. B. Saunders Company

NOV IO-J9I7

PRINTED IN AMERICA

PRESS OF

PHILADELPHIA

Preface

As these lectures represent a somewhat new method of postgraduate medical education in this country, the history leading to their development may be of interest. The plan originated with Dr. W. S. Rankin, Secretary of the Board of Health of the State of North Carolina. He conceived the idea of bringing the medical school, in the person of a traveling lecturer, to the doors of the physician, enabling the latter in this way to continue with his practice instead of being compelled to leave it for several months while he sought postgraduate education in one of the large medical centers. Upon hearing of this scheme, President E. K. Graham, of the University of North Carolina, gave it his enthusiastic support, and courses were arranged under the joint auspices of the University and the State Board of Health. Two sections of six classes each were organized, one in the eastern part of the State, one in the western. Each of us had six towns in his circuit, and traveled each day to a new town, returning to the first one at the beginning of each week.

One of us was trained in the methods used in Boston, the other in Chicago, with postgraduate work in Europe. As a result of this dissimilarity in our training the lectures differ a good deal, and it occurred to us that it might be of value to combine the two sets in one volume, so that the teachings of two somewhat different schools of infant feeding may be compared.

Each of us has prepared and presented his course of lectures independently of the other and without knowledge of the other's methods and plans. It is with a spirit of cooperation rather than rivalry, of construction than destruction, that we offer them to the profession.

Lewis Webb Hill

Jesse R. Gerstley September, 1917

Contents

CLINICAL LECTURES ON INFANT FEEDING (BOSTON METHODS)

By LEWIS WEBB HILL, M.D.

LECTURE I . PAGB

Introduction to Feeding in General 17

Artificial Feeding 27

LECTURE II

LECTURE III

The Proprietary Foods 49

Premature Infants 56

LECTURE IV

Disturbances of Digestion 61

The Various Types of Indigestion 61

The Stools in Infancy 70

Constipation 73

LECTURE V

Nervous Diarrhea 77

Mechanical Diarrhea 77

Fermentative Diarrhea 77

Infectious Diarrhea 83

LECTURE VI

Pyloric Stenosis 91

Pyloric Spasm 93

Intussusception 95

14 CONTENTS

LECTURE VII page

Rickets 104

Scurvy 107

Spasmophilia Ill

CLINICAL LECTURES ON INFANT FEEDING (CHICAGO METHODS)

By JESSE R. GERSTLEY, M.D.

LECTURE I

Introduction 151

Milk 152

LECTURE II

Energy of Foods 176

LECTURE III Modern Conception of Disturbances of Nutrition 178

LECTURE IV Failure to Gain 193

LECTURE V The States of Dyspepsia and Intoxication 205

LECTURE VI Decomposition 224

LECTURE VII Parenteral and Enteral Infections 242

LECTURE VIII Artificial Feeding of the Normal Infant 256

LECTURE IX Breast Feeding 270

LECTURE X

Conclusion 366

Index 369

CLINICAL LECTURES

ON

INFANT FEEDING

Boston Methods

BY LEWIS WEBB HILL, M.D.

CLINICAL LECTURES ON INFANT FEEDING (BOSTON METHODS)

LECTURE I * INTRODUCTION TO FEEDING IN GENERAL

Pediatrics, or the study of diseases of children, is naturally divided into a number of sections, of which the most important is the feeding of infants and the treatment of the diarrheal diseases of infancy.

My lecture today is somewhat of an introductory lecture, taking up breast feeding and a short introduction to artificial feeding. It is my purpose to make these lectures as practical as possible, and to touch upon theory and chemistry only so much as is absolutely necessary — as I am fully aware that you are a practical group of men, dealing every day with sick people, and not with theories, chemical names, and formulae. It is, however, necessary for us to consider a few fundamental chemical facts upon which modern infant feeding is based before we can go on to the more practical portion of the subject.

I am going to teach you " percentage feeding," which is used more in Boston than in any other city. In the old days of infant feeding there was no science of any sort ; a little milk and water was mixed and fed to the baby, without knowing what he was getting of food value; of fat, sugar, and protein. Some babies got along very well on this, but as you know some will get along on almost anything, whereas some need the utmost care.

Dr. T. Morgan Rotch, of Boston, about twenty-five years ago, devised the so-called percentage method. This means that in a baby's milk certain elements have to be recognized. The

* Sixteen lectures were given in the course. The other nine lectures dealt with the general diseases of children. 2 17 food elements of milk are, as you know, fat, sugar, and protein, and it is desirable to know how much of each the infant is getting, because digestive disturbances of all sorts are likely to be due to too much or too little of one element or the other in the milk. These ideas simplify the whole matter of feeding because the physician can tell so easily with what he is dealing. There is no reason why a baby should not have its milk made up in just as accurate a way as a prescription is made up. With adults it is not necessary to regulate the food so carefully, because an adult's digestion is stronger, and small things will not upset it so easily. The percentage method of feeding consists simply in writing a prescription for the baby's milk according to the indications, knowing approximately how much of each food element the prescription contains, the most convenient way of expressing the quantity of these elements being in percentages. As an introduction, I think I cannot do better than to read a few lines written a short time ago by Dr. Ladd, of Boston :

"Now, whatever our method of making a food for infants, in which milk is the basis, we are making a modified milk containing certain percentages of the elements. Percentage feeding presupposes that these alterations have been made by the physician with design and with a definite knowledge of the end-result of his changes. By the old method milk was modified quite as much as by modern methods, but with this fundamental difference : that the physician had not the slightest conception of the composition of his mixture, and hence no check upon his results. Without a knowledge of the percentage composition of the milk it is next to impossible to give a lucid and intelligent expression of its food value. A mixture expressed as so many ounces of cream, milk, lime-water, sugar, and water may exactly fulfil the requirements of an individual infant, but unless I can express such a formula to a student in percentages or calories, or both, my exposition of the principles on which I have acted in prescribing such a formula is vague and indefinite.

"Whatever we may feel about the relative values of fats and sugars and proteins, and the proportions best suited to individual conditions, the percentage method of thinking, writing, and prescribing should not and does not complicate the question. In fact, it simplifies it enormously, for it furnishes us the means for accurate estimation of food values, and only by such knowledge can we intelligently check up our results when struggling with the problem of adapting a food to the individual requirements of an infant.

"If one will grasp this simple idea of percentage feeding, one will disabuse one's mind of the conception, so erroneously held, that percentage feeding is ultra-scientific, very mathematical, complex, and impractical for the average practitioner.

"I wish to emphasize the fact that the purpose of percentage feeding is, on the contrary, to simplify the sometimes very difficult question of finding

Introduction To Feeding In General 19

a food which the infant will digest and upon which it will gain normally in development. The mathematics involved in the calculation of percentages are of the simplest — a. mere matter of proportions. If properly presented, any one of half a dozen in vogue is easily mastered and perfectly practical. It does not matter by whose methods one works to gain this fundamental knowledge of how to calculate the percentage elements of the food, so long as that method is thoroughly mastered. Some methods are simpler to understand than others, and any method requires some study and practice, but this hardly offers an excuse for ignorance of the* subject. Any thirdyear medical student may in two hours be taught a practical way of calculating percentages and estimating the caloric value of any mixture. Such knowledge is rudimentary but fundamental. Any physician who pretends to feed scientifically should not shun the task of acquiring this knowledge, any more than he should avoid the labor involved in grasping the technic of simple surgical or bacteriological procedures, in order to become more skilled in the practice of modern medicine. Too much is written of the difficulties of these methods of calculation by men who have been too lazy or indifferent to learn them; too little has been written about the responsibility of the physician to master them in order to become a more efficient worker along the lines of modern infant feeding."

That is a very good summing up of the question of percentage feeding. In a nutshell, it is necessary to know, in any milk mixture which is being fed to a baby, approximately how much fat, how much protein, and how much sugar it contains.

In order to do this it is necessary to know the composition of milk.

Human milk contains 4 percent of fat, 7 percent of sugar, 1.6 percent of protein, and about 0.2 percent of salts. Cow's milk contains 4 percent of fat, 4.5 percent of sugar, 3.2* percent protein, and 0.7 percent salts. Now, different specimens of human milk vary a great deal. Different cows' milks also vary a great deal, but these are the average figures.

Besides the quantitative differences, there are also certain qualitative differences. The fat in the milk is in the form of an emulsion; the sugar, protein, and salts are in solution. The globules of fat in cow's milk are much larger than in human milk. The sugars are exactly the same.

In all milks there are two kinds of proteins — casein and albumin or whey protein. In human milk there is more whey protein than casein. The ratio is about three to one. In cow's milk there is more casein than whey, and this is one reason why

* These figures are not absolutely correct, but are near enough for practical purposes.

cow's milk is so much harder to digest, because the casein protein is coagulated in the stomach into tough curds. The whey protein is not. The salts are qualitatively about the same in both milks, the most important being salts of sodium, potassium, magnesium, calcium, iron, phosphorus, and sulphur. The salts are of extreme importance in the nutrition of every baby, but we cannot take them into practical quantitative consideration in feeding a baby, so let us consider the three elements — fat, sugar, and protein. It is very important to bear in mind this composition of milk.

Now I want to run over very briefly the digestion of the different food elements. First, the fat — it is not acted upon to any great extent in the stomach. Chemically it consists of a fatty acid in combination with glycerin, forming a so-called " neutral" fat. After leaving the stomach it enters the intestine, where it is split by the pancreatic juice into glycerin and a fatty acid. The fatty acid combines with an alkali in the intestine, forming a "soap." This is acted upon by the bile, which emulsifies it, and it is then absorbed. The absorption of fat is usually very good. Often 90 or 95 percent of the fat taken in will be absorbed by a well baby. In other cases as little as 30 or 40 percent will be absorbed, and most of the fat will come out in the stool in the form of " soaps."

The sugar is acted upon very little in the stomach. Milk-sugar is what is known as a disaccharid, that is, a complex sugar. In the intestine it is split into simpler sugars and absorbed as such. The absorption of sugar is usually extremely good, and it is very rare to find any in the stools of infants. Sugar may sometimes remain in the intestine, and may be broken up by the bacteria in the intestine into acids, as acetic acid and butyric acid. Fats may also be broken up in this way.

Next comes protein. Protein is partly digested in the stomach, where it is coagulated by the gastric juices. Digestion is carried on further in the intestine by the pancreatic juice and the secretions of the intestine, and the end-products are absorbed as salts of the amino-acids. An important point which I wish to emphasize is that in the intestine of every infant there are always two forces working against each other. That is, the end-products from the breaking down of fat and sugar are acid

Introduction To Feeding In General 21

in reaction; those from the breaking down of protein are alkaline in reaction, from the ammonia which is formed. The normal reaction of a child's stool is slightly alkaline, slightly acid, or neutral, and if there is too great acidity or too great alkalinity, trouble results. It is very important to have such a balance between the fat and sugar and the protein in the food as not to have too great acidity or too great alkalinity in the intestine.

You have all probably heard a good deal of discussion about "calories." What is a calorie? Of course, all food is fuel. The different elements of food have different fuel value, and we measure this fuel value by calories. A calorie is the amount of heat that is necessary to raise one liter of water one degree centigrade. This is a " large" calorie, which is the one we use in infant feeding. The average baby needs about 50 calories per pound of body weight in order to thrive. The different food elements. produce different amounts of these calories. Fat produces 9.3 calories per gram; protein and sugar each produce 4.1 calories per gram.

That covers the bare essentials of the theoretical part of our subject, and although it may sound rather complicated and not very practical, it is necessary to understand the scientific groundwork upon which rests the practical superstructure of our ideas of infant feeding.

In regard to breast feeding, it is an axiom that every baby should be fed upon the breast if possible. Of course, there are a good many women who cannot nurse their babies, but it should be insisted upon that every woman who is able should nurse her baby through the first year. Breast milk produces the big, robust babies, and babies who are breast fed have very little chance of developing the gastro-intestinal troubles of various sorts which bottle-fed babies are so likely to have, especially in the summer. Of course, in some cases a baby must be weaned, but these cases are comparatively few. Persist in breast feeding, and do not take the baby off the breast merely because it perhaps vomits once or twice or does not gain on the breast milk. If a mother has not enough milk, try to find out why. Look after her habits, see that she leads a reasonable, quiet life, that she is not worried or nervous about anything, and that she gets a proper diet.

Another thing : sometimes the milk is late in coming into the breast. Normally, after a baby is born it comes into the breast in from twenty-four to forty-eight hours. Sometimes it is delayed for four or five days. However, don't take the baby off the breast because the milk is late in coming.

How is a new-born baby to be fed? It may be put to the breast six hours after birth. This may not furnish much nourishment, but it teaches the baby to suck, and it stimulates the breast to produce milk. For the first twenty-four hours the baby should be nursed every six hours ; for the next day, every four hours; for the first few weeks after that, every two hours.

There is a great deal of discussion in all the pediatric centers about the intervals between nursings, but I really think most of the intervals — that is, two, two and one-half, three, or four-hour intervals are reasonable. Most normal babies get along well on any of those intervals. Personally, I think it is best to have a normal baby nursed every two hours during the first month ; for the next three months every two and one-half hours ; after this, every three hours. It is a good thing to have the baby take one bottle a day. This gives the mother more time to get out and take exercise than if it has to be nursed every time.

If the bowels of a new-born baby have not moved well soon after birth, it is wise to give a small dose of castor oil, because the meconium may undergo decomposition and make the baby ill from toxic absorption, so it is important to clean it out artificially if it has not cleaned itself out naturally.

It is important to have the baby nursed regularly, and not every time it cries. Have this distinctly understood by the mother. If the baby is asleep at the time of nursing, it should be waked. It is better to give the baby alternate breasts each feeding rather than a little out of one and a little out of the other, for if one is used for each nursing it will be emptied, and thus stimulated to the production of more milk.

An average baby will empty the average breast in about fifteen minutes; of course this time may vary, but that is usually the average. A baby does not take the same amount of milk from a

Introduction To Feeding In General 23

breast at each nursing, and at some feedings it will take only one or two ounces, at others six or seven. This is not very important, however, because most babies get the same amount every twenty-four hours. If little is taken at one feeding, it will be made up at another. The twenty-four-hour amount is the important thing to consider. Sometimes it is important to know if a baby is getting enough milk in a day, and the best way to learn this is to weigh the child before and after each nursing. Take the difference between the weights before and after nursing, add them all together, and the result will be the number of ounces the baby is getting in a day, as an ounce of milk weighs about an ounce.

It is true that every baby should be fed on the breast, but it is also true that there is abnormal breast milk — bad breast milk. There are four kinds of bad breast milk. The first kind is too rich — it has too much of every food element. This type of milk is found in certain women of the upper classes usually, who eat too much rich food and who do not take enough exercise. The second type is one in which the fat and sugar are low and the protein high. This sort of milk is seen in the poorer classes of women who do not get enough to eat and who have to work too hard. The third type of milk is one in which the fat and sugar are very low and the protein very high. This type of milk is usually found in excessively neurotic women. The fourth type of milk is that in which, by repeated chemical analyses, it is found that every one of the elements is in perfect proportion ; but which, for some reason or other, the baby cannot take. I do not know the cause, but it is unquestionably true that in the milk of some nursing women a toxic substance is secreted, and this upsets the baby. In one case I analyzed the milk three times and found it perfectly normal, but the baby could not take it at all and had to be weaned. Of course, in considering this type of milk it must be taken into account that the trouble may be in the baby and not in the milk, and that the milk might be perfectly suitable for some other baby.

This type of milk is not common, but it is certainly seen sometimes. It ought not to be assumed, however, that a milk is of this sort until the nursing mother has been given a very thorough trial and until the milk has been analyzed, if possible. Never give up nursing until every means has been tried of modifying the mother's milk and making it better.

How may the chemical composition of a nursing mother's milk be modified?

When a woman has too rich milk, the important things are to take her outdoors, — make her exercise, — keep her bowels open, cut down on her diet, and make her drink plenty of water. In the other type, where the milk is too thin, ease up the woman's home life, have her arrange to get some one to do part of her work, and have her eat more, especially fatty and starchy food. If the quantity of milk, on the other hand, is too little, have her drink plenty of fluid. I have many of my nursing mothers take corn-meal gruel at night before going to bed. It is of no use, however, to give more than three or four pints of fluid a day; anything over this does more harm than good. Another thing, and probably the most important of all : use the breast. There is nothing which will stimulate milk production so well as a complete emptying at each nursing. If the baby is. weak and small and does not empty the breast, pump it out. There is no drug with which I am familiar that will increase milk secretion.

As to the diet of the mother: I think the best thing to tell a nursing mother in average circumstances is to eat exactly what she would if she had no baby at all, provided she is taking a reasonable diet. Undoubtedly there are certain things which may be eaten by a nursing mother that will influence the milk and upset the baby. Cabbage, strawberries, and certain other fruits and vegetables sometimes do this. Babies generally get on well, however, if the mother is healthy and eats an average ordinary diet.

How much should a normal breast-fed baby gam? It should be weighed every week, so that its progress can be followed, and the food corrected, if necessary. The normal breast-fed baby should gain six to eight ounces a week for the first five months of its life. For the rest of the first year it should gain four to six ounces a week. If it does not gain as much as this, there is something wrong. The weight of a baby is one of the best indices we have to determine whether or not it is thriving, and the weighing of babies is neglected in altogether too many cases.

Introduction To Feeding In General 25

The breast-fed baby usually has three or four rather loose, golden-yellow, sour-smelling movements a day. Those fed on cow's milk usually do not have so many.

Certain babies may have more than others and the stools may be green in color and smell bad. The baby may vomit a little. But if it is getting on well in every other way and is gaining weight, it is best not to pay too much attention to this.

Let us take up the abnormal breast-fed baby, the baby who is not gaining on the breast, who has a good deal of colic, who does not sleep at night, who vomits often, who has bad movements; and the thin, poorly nourished, breast-fed baby who does not get enough to eat. These troubles may be due to a number of causes. If a baby does not gain, but has no symptoms of indigestion, the milk may not be rich enough or there may not be enough of it. In cases like this substitute feedings should be given after a trial has been made to increase the amount and richness of the milk. Modified cow's milk can be given after each breast feeding, or it can be substituted in alternate feedings with the breast. It is a little better to give it after each breast feeding, because cow's milk is better taken care of in the stomach when it is mixed with human milk.

When a baby has colic, when it is fussy most of the time and does not gain, the milk is probably too rich, or too much is taken at a feeding. It may contain too much fat or protein. The sugar in human milk gives very little trouble. The symptoms of fat indigestion are vomiting of creamy, thick, sour-smelling material, diarrhea, failure to gain, and fussiness. The symptoms of protein indigestion are the same, except that the vomitus is not quite so thick and creamy.

Treat these conditions by treating the mother in the first place, by taking her outdoors, having her walk, take exercise, and by getting her to drink plenty of water. In the second place, keep the baby quiet after each nursing. Do not let the mother shake it up and down, as so many do. Also, it is a very good idea to give a tablespoonful of boiled water to dilute the milk. Again, it is well not to let the baby nurse too long. It may be getting too much milk. Sometimes if the intervals between nursings are increased, it will help these cases.

As to colic, the treatment is to prevent it, if possible, by regulating the feeding. The best thing to do during the attacks is to give a suds enema, hot applications to the abdomen, half a sodamint tablet, a few drops of gin or aromatic spirits of ammonia, or peppermint water.

A very common cause of disturbance in breast-fed babies is irregular feeding intervals. Many mothers nurse their babies every time they cry, and thus they are fed sometimes every half-hour, sometimes every three hours. Such feeding as this is bound to cause trouble; the usual symptoms are failure to gain, fussiness and sleeplessness, colic, vomiting, and the passage of an increased number of loose stools, which may be green. Oftentimes it is surprising to see how much may be done for babies of this sort simply by regulating the nursing periods.

Many babies have the same sort of symptoms because the mother is upset or worried about something or because the household is in confusion. A nervous mother and a nervous household make a nervous and unstable baby, and many babies may have severe symptoms of indigestion and may fail to gain in weight for a number of weeks until calm and quiet conditions are restored in the household. The mother should be in a quiet room, without any noise or confusion around if possible, when she is nursing her baby; and after the nursing, it should be put into its bed and left alone for half an hour. Some babies may swallow a good deal of air when they nurse, and with these babies it is a good idea for the mother to interrupt the nursing every two or three minutes and hold the baby up against her shoulder, slapping its back gently, to give it a chance to get rid of this swallowed air, which may cause colic.

There are certain indications for weaning. Many mothers have the idea that if menstruation starts the baby should be weaned. This is not so. Sometimes menstruation in the mother does upset the baby temporarily, but it will probably be right again in a day or two. If a nursing mother becomes pregnant, however, the baby should be weaned immediately in most cases. Women with any wasting disease, such as tuberculosis, cancer, or chronic nephritis, in most cases should not be. allowed to nurse their babies. It is also best to wean the baby if the mother develops any severe acute illness, such as typhoid fever or pneumonia. If the mother has a "cold" or

Introduction To Feeding In General 27

slight tonsillitis, it is best to discontinue nursing for a day or two, or perhaps in some cases not to discontinue it entirely, but to substitute bottle feedings for half of the breast feedings.

If a mother cannot nurse her baby, it is often a very great advantage to get a wet-nurse. What are the qualifications of a wet-nurse? In the first place, how is the wet-nurse's own baby? If it is doing well, the chances are that the other baby will do well. No one should be taken whose own baby is over eight or nine months old, because after this period the milk becomes thin and poor in quality. Every nurse should have a thorough physical examination to exclude tuberculosis and syphilis. A Wassermann should be done on the blood of every wet-nurse if possible.

ARTIFICIAL FEEDING

In artificial feeding, what kind of milk is to be used? There is another axiom in pediatrics, and that is that no milk is too good for a baby. Get the very best milk possible. Get it from a good dairy, from a farmer who takes care of his barns and his cattle and who is interested in producing good milk. There is nothing that causes so many babies to die as unclean milk. Milk is really one of the dirtiest things in the world, because of the conditions under which it is produced and the ease with which bacteria grow in it.