Infant feeding; a handbook for the practitioner

Preface

This series of articles, somewhat elaborated for book form, appeared in the Journal of the American Medical Association from January to May, 1923. The interest they aroused and numerous requests for pub¬ lication in book form, have prompted the issuing of this volume.

Contents

CHAPTER p AGE

1. Breast Milk Feeding. 7

2. Maternal Nursing. 12

Chapter I Breast Milk Feeding

From every standpoint, the ideal mother is one who can nurse her own baby, and thereby furnish it with sufficient milk to meet its needs for normal growth and development. The mother who is not anxious to nurse her infant is a great exception. In fact, most women are greatly disappointed at being unable to meet the full requirements of their baby.

The mother can easily be impressed with the fact that breast milk is the ideal food for a baby. It is always fresh; with a simple technic it remains clean, and it is always available. From the standpoint of economy, it is by far less expensive than other foods. It is the best prophylactic against the communicable diseases and the commoner infections in infancy, and as a curative measure in the presence of nutritional disturbances and infections it has no peer.

Even more important is the fact that the infant is assured a mother’s careful observation, owing to its frequent and intimate contact with her. She soon learns to recognize the earliest manifestations of its illnesses. It must be recognized as a fact that most mothers are capable of nursing their infants.

It cannot be denied that there are mothers whose mental and physical condition makes breast feeding inadvisable, but fortunately they are greatly in the minority. Breasts with an insufficiency of glandular tissue to meet the full needs of the infant, even during the first months of lactation, are encountered more frequently. Far less commonly do we find breasts so poorly developed that all lactation is to be disregarded.

McClanahan, 1 summarizing the opinion of a group of pediatricians whom he interrogated for opinions

1. McClanahan, H. M.: Arch. Pediat. 35: 653 (Nov.) 1918.

BREAST MILK FEEDING as to the relative morbidity among breast and bottle fed infants, concluded:

Breast-fed infants are less susceptible to infection, with possibly two exceptions—influenza and tuberculosis. They resist infection to better advantage and with less after-effect from the disease. Breast-fed infants have less morbidity than properly fed bottle infants, and the advantages are still greater as compared with infants who have been improperly fed.

Studies made in many different countries have demonstrated that the death rate among the artificially fed is at all times higher than among the breast fed; that when breast feeding is the custom, the mortality rate is low in spite of other unfavorable factors; and that when breast feeding is increased in a community, the infant mortality rate is lowered.

In studies made in overcrowded and poverty-stricken districts of London, New York, Chicago and other large cities, the fact is very clearly brought out that where by race or custom it is the practice to feed infants at the breast, the infant mortality rate is lower, even though the environment is highly insanitary.

In our complicated modern society, there must be widespread emphasis among all classes, not only on the importance of breast feeding but also on the ways and means of making it successful. There are many false opinions to be overcome, such as the statement frequently made that the modern woman has lost the ability to suckle her young, and the feeling created, as a result of the emphasis on the importance of pure milk and pasteurization in infant feeding, that this is at least as good as breast feeding and often better.

The reports of Sedgwick 2 of the findings of the Breast Feeding Investigation Bureau of the University of Minnesota confirm the ideas which many physicians

2. Sedgwick, T. P.: Preliminary Report of Study of Breast Feeding in Minneapolis, Am. J. Dis. Child. 21 : 455 (May) 1921.

STIMULATION OF BREASTS have held, that in greater part the inability of the mother to nurse her infant is due to improper instruc¬ tion and insufficient encouragement on the part of the attending obstetrician and those responsible for her nursing care.

Only too frequently when the question is asked, “Why did you wean your child?” the answer is, “Because the doctor advised me to do so.” Knowing how commonly this is true, there is certainly room for missionary work in order that breast feeding may receive further encouragement.

The University of Minnesota breast feeding bureau super¬ vised the care of 2,847 babies during the year 1919. Of these, 96 per cent, were at the breast at the end of their second month, and of 2,022 still under observation at the end on nine months, 72 per cent, were at the breast receiving part or all of their food in this way.

In Boston, the Baby Hygiene Association has had such success, that of 6,000 infants under its supervision only 196 babies less than 6 months old were entirely artificially fed. The statistics of the Starr Center in Philadelphia are equally notable. In 1912-1913, only 48 per cent, of the babies under its care were breast fed. After six years of propaganda for breast feeding, of ninety-two infants whose mothers had been cared for by the prenatal department, ninety were entirely breast-fed at 1 month of age, one was partially breast-fed, and only one was bottle fed.

STIMULATION OF THE BREASTS

The demand which is made on the breast is by far the most important factor in the maintenance of the breast milk supply. Repeated, regular and complete evacuation of the breasts by a vigorous baby is, of course, the natural and best method. When this natu¬ ral stimulus is not obtained, or when the demand on the breast 'is insufficient for any reason, the supply of breast milk decreases gradually until the supply is insufficient to meet the infant’s needs. In these cases, artificial aid is necessary.

BREAST MILK FEEDING

HAND EXPRESSION

Expression by hand is the best method for stimu¬ lating the breasts to secrete, when an infant is not available for this purpose. Wetnurses find it of the greatest advantage to practice expression at regular four hour periods, and when the breast is practically drained to place the wetnurse’s infant at the breasts to empty them completely, both breasts being emptied at each period. The following methods for breast expres¬ sion may well be followed:

The hands and nails should be scrubbed with soap, warm water and a nail brush, for at least one full minute. The nipple is washed with fresh absorbent cotton and boiled water or a boric solution. The hands are dried thoroughly on a clean towel and kept dry. A sterilized graduated glass tumbler or large-mouth bottle should be at hand to receive the milk.

1. The breast is grasped gently, but firmly, between the thumb placed in front, and the remainder of the fingers on the under surface of the breast. The thumb in front and the first finger beneath should rest just outside the pig¬ mented area of the breast.

2. With the thumb, a downward pressing motion is made on the front against the fingers on the back of the breast, and the thumb in front and fingers behind are carried down¬ ward to the base of the nipple.

3. This second act should end with a slight forward pull with gentle pressure at the back of the nipple, which causes the milk to flow out.

The combination of these three movements may be described as “back, down, out.”

It is not necessary to touch the nipple.

This act can be repeated from thirty to sixty times a minute after some practice.

It is advisable to empty both breasts at each expression

The milk should be covered at once by a sterile cloth held in place by a rubber band and kept on ice until used.

Hoobler 3 reports that in the city of Detroit during two succeeding years, 67,000 ounces and 60,000 ounces,

Fig. 2.—Direct expression of milk, first stage.

Fig. 3.—Direct expression of milk, last stage

HAND EXPRESSION respectively, of milk was expressed from the breasts of women in different institutions and from private sources, and distributed throughout the city. Contin¬ ued stimulation of the breasts by expression of the milk resulted in increasing quantities of milk.

Understimulation of the breasts results in a deficient milk supply.

Chapter II Maternal Nursing

The Diet of the Mother .—The first principle of feed¬ ing a nursing mother should be to provide her with an abundance of simple but nourishing food. It should always be palatable and to the mother’s liking. During the first days following labor and while she is still in bed, she should be on a more or less light diet, but one that is varied so that her appetite may be stimu¬ lated ; she may thereby be encouraged to take sufficient food to meet the needs of the infant and herself. Four meals in twenty-four hours are usually all that she will take with comfort, while in bed.

When the mother is up and about, and has resumed her ordinary duties, she may be allowed to eat such foods as she was accustomed to before the advent of pregnancy and motherhood. It is a fallacy to forbid vegetables and fruits on general principles. As a rule, food that the patient can digest without incon¬ venience is a safe food, so far as the nursing is con¬ cerned. Occasionally an infant is seen who reacts to mother’s milk by the development of colic when certain of the aromatic vegetables, such as turnips, cauliflower and onions, are a part of the mother’s diet. Or, again, the same foods, or such additions to the mother’s diet as coffee or salads, may interfere with her digestion and thereby change the quantity and not infrequently also the quality of her milk, all of which may react upon the child. Exceptionally an infant is seen that has become sensitized to one of the animal or vegetable proteins. These cases will be more fully discussed under “Idiosyncrasy to Mother’s Milk.” Restrictions in the mother’s diet are, however, more especially indicated when she is feeding a premature or

DIET OF THE MOTHER sick infant, because such infants are more readily affected by qualitative changes in the breast milk. More commonly, the error in the mother’s diet lies in the nature of underfeeding and overfeeding. A greatly restricted diet in a robust young mother who has always eaten to her own satisfaction of a generous variety of foods is one of the surest means of curtailing the quantity and lowering the quality of her milk supply. On the other hand, overfeeding leads to revulsion to food, and sooner or later indigestion results. When the mother is convinced that any article of food disagrees with her, even though there may be doubt about it, the food should be discontinued. In a general way, milk, eggs, meat, fish, poultry, cereals, fresh vegetables and fruits should constitute the basis for selection. The acid fruits, salads and aromatic vegetables may be tried, to be discarded if they seem to distress the infant. Eggnogs, cereal gruels with milk, cocoa with milk, malted milk, and similar drinks can be given with the meals; or, when the mother desires, she may take them between meals. The day’s diet should include 1 quart of milk in some form, and at least 1 quart of water. Tea and coffee in moderate amounts may be permitted.

Number of Meals .—Most mothers are better satisfied when eating only four times daily, the fourth meal being supplied at bedtime. The latter should consist of a dish of cereal and milk, or some other simple and easily digested food.

Air and Exercise .—From two to four hours daily should be spent in the open air, weather permitting. During this outdoor period, she should take moderate exercise, but never to the point of fatigue. It is well to divide the time of recreation into a morning and an afternoon period.

Sleep .—At least eight hours out of every twenty-four should be given to sleep. If her nights are disturbed,

MATERNAL NURSING she should have the benefit of an hour or two rest period during midday. In case the infant has been accustomed to a feeding during the night, this should be withdrawn as soon as possible so that there will be only one nursing period between 6 p. m. and 6 a. m. This is most easily accomplished when the infant sleeps in a room separated from the mother and is under another’s care during the night. Under all circum¬ stances, the infant must sleep in its own crib.

To Avoid Constipation .—One free evacuation daily should be insisted on. As the excessive use of cathartics may result in diarrhea in the baby, efforts should be made to regulate the bowel function through food and exercise. A glass of cold water on arising in the morning, combined with a diet containing coarse cereals, sufficient vegetables and fruits, is usually all that is necessary. If this regimen does not have the desired effect, abdominal massage and local measures, such as an oil enema or a suppository, may prove effec¬ tive. When these measures do not prove effective, it may be necessary to administer mild laxatives, such as liquid petrolatum, magma magnesiae or cascara sagrada. If no evacuation of the bowels has taken place during the previous twenty-four hours, an enema should be administered at bedtime.

Care of the Breasts .—During the latter months of pregnancy, a small amount of clear fluid is secreted by the breasts. Toward the end of pregnancy, and for the first few days after labor, colostrum is secreted. By the third or fourth day the character of the secretion is changed so that it resembles the later milk in both its physical and its chemical properties. The specific factor or factors which stimulate milk secretion are as yet unknown, but it is not unlikely that it may be in the nature of an enzyme. Two important results follow continued stimulation of the breasts by the infant: (1)

Fig. 4.—Breast tray and its contents: tray, boric solution, liquid petro¬ latum, gauze in jar, cotton in jar, glass, applicators in jar.

CARE OF THE BREASTS contraction and involution of the uterus, and (2) increased secretion of breast milk. In the average breast, feeble stimulation results in a minimal milk supply, while stimulation by a strong infant or regular expression will be followed by a supply varying directly with the demand made on the breasts.

In the presence of small nipples, slight traction night and morning during the last months of pregnancy has a beneficial effect in lengthening the nipple.

A well established routine should be instituted for the care of the breasts during the period of lactation. To facilitate this, a readily accessible tray with the necessary utensils should be provided. This should contain a glass-stoppered bottle with a saturated solu¬ tion of boric acid, a jar of cotton pledgets on tooth¬ picks, to be used as applicators for the boric acid, and a graduated glass or beaker. The nipples should be thoroughly washed before and after nursing with a saturated solution of boric acid poured fresh from the bottle for each cleansing, and the surplus thrown away. The boric acid should be applied with the cotton pledgets. The fingers should not come in contact with the nipples, if the child is to nurse directly at the breast. If the nipples are tender, they should be anointed with a sterile mixture of 5 per cent, tincture of benzoin in liquid petrolatum.

In some cases, when the milk first comes in, the breasts may become engorged and painful. Usually this rights itself without difficulty as soon as the rela¬ tion between the supply and demand is established. During this period of adjustment, besides limiting the fluids taken, the discomfort from engorgement may be relieved by elevating the breasts and keeping them partially under pressure by the use of a supporting breast binder. If a binder is used in time and the mother takes little fluid in her diet for a few days, it is rarely necessary to empty the breast by expression or

MATERNAL NURSING with a breast pump. If left alone, mild cases of caked breast will disappear without treatment. Unnecessary handling of the breasts should be avoided. Besides limiting the fluid intake, laxatives are indicated. The vegetable cathartics are less likely to pass into the milk than are the salines. An icebag applied externally to a thin binder often will be of assistance. If the cold application produces discomfort, as occasionally it does, hot boric dressings protected by oiled silk may be used. These should be repeated at hourly intervals. The infant should be put to the breast regularly.

Fissures .—These offer serious difficulties to nursing because of pain and the danger of mastitis. Nursing through a nipple shield should be tried in order to minimize the danger of infection. When the infant cannot or will not use the shield, expression should be practiced. Failure to empty the breasts by these methods may make it necessary to risk the danger of infecting the breasts by allowing the infant to nurse directly from the breasts. When a nipple shield is used, it is imperative that it be cleaned thoroughly after nursing and reboiled before using. Among the best local applications are silver nitrate solution, 5 per cent., followed by an ointment, such as balsam of Peru, 1 part, and castor oil, 30 parts; or silver nitrate, 1 part, balsam of Peru, 2 parts, and sufficient petrolatum to make 30 parts.

Mastitis .—This is of frequent occurrence, even dur¬ ing the week following delivery, manifesting itself by headache and circumscribed pains in the mammary gland. The disease is usually confined to one of the lower quadrants. Tenderness, swelling, surface red¬ dening and hard nodular points follow. The course of these mastitides, most of them parenchymatous, is favorable.

Much more serious are those cases which occur later, usually about three weeks after delivery. They

MASTITIS begin more violently, with high fever, headache, vomit¬ ing, reddening of the skin and tumor formation which is painful to pressure. The pain is exhibited both at the seat of the trouble and in the axilla. With improper treatment, abscess formation quickly occurs and is often followed by repetitional relapses. In these cases we have often to deal with an interstitial mastitis.

Great care should be taken in differentiating between a simple engorgement (caked breast) and mastitis. As in the former, there is every indication for keeping the child at the breasts, in order that they may be emptied at regular intervals. Further indications for treatment in caked breast are met by a dry diet and purgation. When a diagnosis of mastitis is established, the infant should be removed from the breast and a tight binder applied. Two large icebags should be applied to each breast, kept half full so that they may not be too heavy. The binder should be thin, so that the icebags are not separated from the skin by enough cloth to prevent the cold from reaching the gland. The skin must feel cold to the touch; otherwise, no good will be derived from the ice. A saline cathartic may be given, and the liquids in the diet are restricted. The icebags may be removed one at a time after the patient has had a normal temperature for twelve hours. The infant is put back to the breast twenty-four hours after the temperature becomes normal.

If an abscess develops, the pus should be evacuated through radiating incisions. Even in the presence of abscess formations it is only exceptionally necessary to wean the infant. Usually by the end of the first week, even though the wound is still open and draining, the infant can be returned to the breast, after the first milk at each nursing is expressed and discarded. This will be found to have a favorable influence on healing. In most cases the breast function is soon reestablished.

Chapter III

CONDITIONS TEMPORARILY AFFECTING THE QUANTITY AND QUALITY OF BREAST MILK

In many women the return of the menstrual period is associated with changes in the breast milk. This is especially true of the first menstrual period. In some instances they may occur with each menstruation. They may be both quantitative and qualitative. In cases of simple reduction in the food, the infant will frequently show signs of hunger. At other times, when there are also qualitative changes, colic and indigestion, the latter associated with frequent stools, occurs.

Menstruation is never an indication for weaning, and only rarely should any of the feedings be discon¬ tinued at these times, even though they cause minor disturbances in the infant. Disturbances are most frequently seen either before or during the first menstrual period.

The mental condition of the mother may have a direct influence on the milk, secretion. These changes are, however, usually only temporary. When the infant is distressed at these times, it may be wise temporarily to remove it from the breast for one or two days, until the mother has recovered from the under¬ lying cause, such as grief, shock, fright or anxiety. Expression should be practiced in the interim.

Drugs .—Alkaloids of opium, hyoscyamus, belladonna and similar drugs not infrequently pass into the milk and should therefore never be administered in large quantities to the nursing mother. Belladonna may cause a decrease in milk secretion and should be admin¬ istered with caution during the period of lactation.

CONTRAINDICATIONS TO NURSING

Mercury, iodids and the newer salts of arsenic are also secreted in the milk and may be used to advantage when a syphilitic mother is nursing her infant.

Contraindications to Nursing. —Tuberculosis, when progressive or open, is always a contraindication to nursing, because of the danger to the infant and the strain on the mother. With proper precautions, and when the breast is not diseased and human milk is not obtainable from other sources, it may be well to tide a weak infant over its first weeks by expressing the milk from the mother’s breasts. It must be boiled before it is used.

Syphilis of the mother, except in freedom from infection on the part of the infant, is not a contra¬ indication. Lack of the symptoms on the part of the mother in congenital syphilis is a very common occur¬ rence ; a Wassermann reaction on the mother’s blood will usually clear up any doubt.

Any grave constitutional disease in which there is an extraordinary drain on the resources of the body, such as diabetes, heart disease with disturbed compen¬ sation, nephritis, exophthalmic goiter, malignant neo¬ plasms, epilepsy and psyphoses are contraindications to nursing. *

Acute diseases should only in exceptional cases be considered as contraindications to nursing. Only con¬ ditions in which there is danger of overburdening the mother and infecting the infant should lead to its removal from the breast.

In acute infections in the mother, such as pneu¬ monia, and the acute contagious diseases, such as scar¬ let fever, after considering the condition of the mother, one must weigh the danger from exposure to infection of the infant, as against the quality of the artificial food and environment in the individual case.

20 CONDITIONS AFFECTING BREAST MILK

In the milder contagious diseases, such as measles or mumps, it is true that young breast-fed infants are rarely infected. Pertussis is an exception and has a high mortality in the new-born and young infants, and the infant should under all circumstances be protected from exposure. In the presence of diphtheria, the infant can be immunized with safety.

Pregnancy .—Only under exceptional circumstances, such as congenital weakness or illness on the part of the infant, should a mother be called on to prolong lactation after she becomes aware of her condition. First, she should not be called on to undergo the strain of nourishing her infant, the fetus and herself. Sec¬ ondly, conception rarely occurs during the first months of lactation, the infant thereby having had the benefit of a good start on the breast, and bottle feeding can usually be instituted without great danger.

EXAMINATION OF HUMAN MILK

No baby should be deprived of its mother's milk because of the results obtained on chemical analysis. The baby, and not the laboratory, offers the practical test for judging the quality of breast milk. It is well known that the composition of milk, more especially in its fat and to a lesser degree in its protein and sugar content, varies greatly in the same individual, not only from day to day, but also at different periods of the same nursing. An analysis, therefore, to be of value, should be made from a specimen obtained from several expressions during the twenty-four hours, and each specimen should consist of the milk of an entire expression or the middle portion. The latter can be accomplished by allowing the infant to nurse for two or three minutes before the sample is expressed. A safer method would be to collect samples at all of the regular nursing periods. It is also essential for any

COMPOSITION OF BREAST MILK conclusion that the total amount of the milk obtained in twenty-four hours be known through weighing the baby before and after each feeding. It is also to be remembered that the quality of the milk cannot be gaged by simple chemical analysis, because of the impossibility of estimating some of its most vital contents. Repeated examination of the milk from different wetnurses secreting about the same average quantities has shown marked variations in the chemical composition, notwithstanding which fact the infants under observation made equally good progress on the different milks. Again, normal chemical averages may be found in milk lacking essentials for the proper growth of the infant.

Table 1 . — Composition of Mature Breast Milk

Reaction.

Specific gravity

Fat .

Sugar .

Protein .

Salts .

Water .

Amphoteric or alkaline ..From 1.010 to 1.040 ...3.0 to 4.0 per cent. ....6.0 to 7.0 per cent. . ... 1.5 to 2.0 per cent.

.0.2 per cent.

The average composition of mature breast milk approximates the figures given in Table 1.

On the addition of rennin it clots in fine curds. Oppenheimer 4 says:

In general, variations in quality determined by analysis fall into three types:

1. All elements too high: This type is most frequently found in women who do too little and eat too much and too rich food.

2. Fat and sugar low, proteins high: This type is usually found in women of the poorer classes who are overworked and underfed.

4. Oppenheimer, E.: Pub. 83, Breast Feeding Children’s Bureau, Washington, D. C.

22 CONDITIONS AFFECTING BREAST MILK

3. Fat and sugar very low, proteins very high: This type is usually found in the highly strung, overeducated and highly civilized women of the larger cities, but may be found in neurotic women of any class or community.

In recent years variations in the nutritional proper¬ ties of human milk have been shown to be due to its vitamin content. The vitamins of human milk are supplied from the food taken by the mother; if they are not present in sufficient quantities in her food, the milk suffers. The effect of an insufficient amount or absence of these substances is exhibited in the child. Scurvy, for example, in the breast fed has been shown to develop because of the deficiency of the antiscorbutic factor in the mother’s food. The development of rickets in the breast fed has also been shown to be due to a deficiency in the mother’s diet, reflected in the quality of her milk.

CHAPER IV

THE NURSING PROPER

Regularity in Nursing .—The breast that is emptied at definite intervals invariably functions better than does one which is not, as regards not only the quantity, but also the quality of the milk. Thus, regular habits in breast feeding are as essential to milk production as to its digestion and assimilation. The baby should be wakened to be fed.

The average mother will supply the needs of the individual meal with one breast, and the breasts should be alternated in successive feedings. Thorough emptying of the breast should be encouraged under all circumstances, as this is our best method for increasing the milk supply, and the baby is the only means at hand by which this can be accomplished. This should be encouraged in every instance. It is most readily thwarted by allowing a lazy baby partially to empty both breasts, as this will soon lead to a dimin¬ ished milk secretion.

Sometimes, however, it is advisable to give both breasts at each feeding, e. g., (1) during the first few days to stimulate secretion, and a little later to relieve the congested breasts; (2) to weak babies when there is an abundance of milk and they are not strong enough to get the last milk, which comes harder; this is to be followed by expression; (3) to overfed babies, when it is desirable to give them only the first and weakest milk and to lessen the yield of milk from the breast; (4) as the milk supplied by one breast fails to meet the needs of the infant. The first breast should be thor¬ oughly emptied before the baby is allowed to take the second breast and the next nursing started on the second breast given in the last feeding.

NURSING

Number of Feedings in Twenty-four Flours .—Four-hour intervals should be observed at the outset, with either five or six feedings in twenty-four hours, accord¬ ing to the individual needs of the child. Night nursing can often be discontinued by the second month, and babies properly fed will go from 10 p. m. to 6 a. m. without anything but perhaps a drink of water.

A three-hour nursing period is more especially indi¬ cated when the mother’s breasts are small and poorly developed, as the more frequent stimulation will result in a larger twenty-four hour quantity. The same is true of a small and weak infant who finds it difficult to remain at the breast through the entire nursing period.