Chapter XXII: Nursing Care of the Average New-Born Baby (2)

_Mother’s Milk._ _Cows’ Milk._
Fats 3.5 to 4. % 3.5 to 4. %
Sugar 6.5 to 7.5% 4.5 to 4.75%
Proteins 1. to 1.5% 3.5 to 4. %
Salts .2% .7 to .75%
Water 87 to 88. % 87. %

It will be remembered that the tissues and bony skeleton are built
by the proteins and salts (lime and phosphorus). Accordingly Nature
supplies these in greater abundance to the calf, who grows so fast
as to double his birth weight in about 47 days, than to the baby who
scarcely doubles his within 180 days. The calf begins life with a
physical need for the abundance of proteins and salts which are
present in cows’ milk, and with digestive organs that can cope with
them, but the baby needs less, can digest less and therefore must be
given less. There are, of course, other and finer differences
between the two milks and an attempt is sometimes made to meet
these. For example, mother’s milk is slightly alkaline and cows’
milk slightly acid and the curd of cows’ milk is larger, tougher and
harder to digest than that formed by mother’s milk. Accordingly some
doctors add lime water to cows’ milk to make it alkaline, and render
the curd softer, finer and more digestible by boiling it.

It is often not possible to give a bottle-fed baby the full 4% of
fat which mother’s milk contains, and some doctors make the protein
of the artificial mixture very much larger in amount than is found
in human milk. The nurse will see that this is a matter which can be
decided only by the physician.

=Articles Needed in Preparing the Baby’s Food.= A complete equipment
for preparing and giving the baby’s milk should be assembled, kept
in a clean place, separate from utensils in general use, and never
put to any other service. A satisfactory outfit for this purpose
comprises the following articles:

One dozen graduated nursing bottles.
One dozen nipples.
Clean, new corks or a package of sterile, non-absorbent cotton
for stoppers.
Bottle brush.
Covered kettle, capacity one gallon, for boiling bottles and
possibly pasteurizing milk.
Pasteurizer or wire bottle rack.
Small kettle, about one quart size.
Graduated pint or quart measuring glass.
Pitcher, two quart size.
Long-handled spoon for mixing.
Funnel.
Measuring spoons—table and tea sizes.
Double boiler.
Thermometer which will register at least 212° F.
Cream dipper (if ordered).
Two small covered jars for sterile and used nipples.
Sugar (lactose, maltose or cane sugar according to orders).
Lime water, if ordered.

Utensils of enamel or aluminum ware are probably the most
satisfactory ones to use as they are easily kept clean, while
bottles with wide mouths and curved bottoms and inner surfaces can
be thoroughly washed more easily than those with small necks and
sharp corners. Nipples that can be turned inside out to be washed
should be selected as it is almost impossible to clean thoroughly
those with tubes or narrow necks. New bottles will be rendered less
breakable if placed in cold water, which is gradually heated,
allowed to boil for half an hour and cooled before the bottles are
removed.

FIG. 168.—Preparing the baby’s milk. (From photograph taken at Johns
Hopkins Hospital.)
]

The bottles should be rinsed with cold water after each feeding and
then carefully washed and scrubbed with the bottle brush in hot
soapsuds or borax water, containing two tablespoonsful to the pint.
They may be kept full of water while not in use or rinsed with hot
water and stood upside down until they are all boiled on the
following morning, preparatory to being filled with the freshly
prepared milk. The baby’s bottles should never be washed in
dishwater nor dried on a towel. The nipples should be rinsed in cold
water, turned inside out and scrubbed with a brush, in hot soapsuds
or borax water; rinsed and placed in a jar ready to be boiled with
the bottles.

=Preparation of Milk.= The full quantity of milk which the baby will
take in the course of twenty-four hours is prepared at one time and
the prescribed amount for each feeding poured into as many separate
bottles as there will be feedings. (Fig. 168.)

The nurse should first boil for five minutes all of the articles
that will come in contact with the milk, including the full number
of bottles and nipples and the jars in which the nipples are kept;
remove them with the long-handled spoon without touching the edges
or inner surfaces and place them on a clean table, dropping the
nipples into one of the sterile jars.

She should wash the mouth of the milk bottle before removing the cap
and pour the amount which the formula calls for into the sterile
pitcher. To this is added the sterile water in which the sugar has
been dissolved in the glass graduate, and the potato or barley
water, the lime water or soda solution as ordered. This mixture is
thoroughly stirred and the amount for one feeding at a time measured
in the graduate and poured into the specified number of bottles
which are then stoppered.

If certified milk is used for the milk mixture it is often given to
the baby without being pasteurized, in which case the bottles are
placed in the refrigerator as soon as they are filled and stoppered.
Very frequently, however, the milk is sterilized or pasteurized. The
nurse will feel surer of keeping the mouths of the bottles clean if
she covers them with squares of gauze or muslin before they are
sterilized, holding the caps in place with tapes or rubber bands.
Pasteurization as applied to infant feeding consists of heating the
milk to 140–165° F. and keeping it at that temperature 20 to 30
minutes.

There are many excellent pasteurizers for home use on the market, or
entirely satisfactory results may be obtained by using a wire bottle
rack (See Fig. 168) and the large kettle already provided. One
method is to place the rack containing the bottles in the kettle
which is filled with cold water to a level a little above the top of
the milk in the bottles, and allow the water to come to the boiling
point. The kettle is removed from the fire, covered tightly and the
bottles allowed to stand in the hot water for twenty minutes. Cold
water is then run into the kettle to cool the milk gradually and
avoid breaking the bottles, after which they are placed in the
refrigerator, well or spring-house and kept at a temperature of 50°
F. until they are taken out one at a time for feedings. If a wire
rack is not available the bottles may be stood on a saucer or a
thick pad of folded newspapers in the bottom of the kettle.

Pasteurization does not destroy all germs that may be in the milk,
but it kills the more important ones and apparently impairs the
nutritive and protective properties of the milk less than boiling.
However, pasteurized milk must be kept cold and must be used within
twenty-four hours, for the nurse will recall that aging of milk is
quite as undesirable as souring.

Scalding is another method of destroying germs in milk. The milk is
placed in an open vessel and the temperature raised to about 180°
F., or until bubbles appear around the edge and the milk steams in
the centre, after which it is cooled and kept at a temperature of
50° F.

Many doctors prefer to have the baby’s milk boiled, since boiling
insures absolute sterilization and also renders the curd more
digestible. Other changes are produced by boiling, however, which
make it important to add an anti-scorbutic and cod-liver oil to the
baby’s diet at an early date.

Milk may be boiled directly over the flame for a time varying from
three to forty-five minutes, or it may be placed in a double boiler,
the water in the lower receptacle being cold, and allowed to remain
until the water has boiled from six to forty-five minutes. All of
these points are definitely specified by the doctor.

When milk is boiled or scalded the other ingredients are added
beforehand, as a rule, after which it is measured and poured into
the bottles. Or the milk mixture may be poured into the bottles as
for pasteurization and the bottles kept in the actively boiling
water for any desired length of time.

=Giving the Baby His Bottle.= At feeding time, the bottle should be
taken from the refrigerator, the stopper removed and a nipple taken
up by the margin and put on the bottle without touching the
mouthpiece. The milk is brought to a temperature of about 100° F. by
standing the bottle in a deep cup or kettle of warm water and
placing it on the fire. The temperature of the milk may be tested by
dropping a few drops on the inner side of the wrist or forearm where
it should feel warm but not hot. This dropping will also indicate if
the hole in the nipple is of the proper size to allow the milk to
drop rapidly in clean drops but not to pour. If the hole is too
small, the drops will be small and infrequent and the baby will be
obliged to work too hard to obtain it; while if the hole is too
large the baby will feed too rapidly and may have colic as a result.

FIG. 169.—Proper position in which to hold baby and bottle during
feeding.
]

The baby’s diaper should be changed if it is soiled or wet before he
is given the bottle and he should be held comfortably in a reclining
position on the nurse’s arm while she holds the bottle with her free
hand. (Fig. 169.) The bottle should be inclined sufficiently to keep
the neck full of milk; otherwise the baby may draw in air as he
nurses. He should be kept awake while feeding but he should be
allowed to pause every three or four minutes in order not to take
his milk too rapidly. Not less than ten nor more than twenty minutes
is devoted to a feeding, as a rule, and if the baby refuses a part
of his milk, it should be thrown away; never warmed over for another
time.

FIG. 170.—Holding the baby upright and gently patting his back to
bring up air immediately after feeding.
]

After being fed, the baby should be held upright against the nurse’s
shoulder for a moment or two (Fig. 170), and ever so gently patted
on the back to help bring up any air which he may have swallowed. He
should on no account be rocked or played with after taking the
bottle, but should be placed gently in his crib, warm and dry and
left alone to sleep. Turning him or moving him about even to the
extent of changing his diaper at this time may cause vomiting.

The evidences of satisfactory and unsatisfactory feeding in the
bottle-fed baby are about the same as in the baby who is fed at the
breast, except that the gain in weight on artificial food may be a
little slower and less steady than on maternal nursing; the stools
have a characteristic sour odor; are a little lighter in color and
may contain white lumps of undigested fat; are usually dryer than in
breast-feeding and may be formed in even a very young baby.

It is fairly generally agreed that all babies, whether breast-fed or
on the bottle, require a certain amount of cool boiled water to
drink between feedings. A small amount is given at first and
gradually increased according to the doctor’s instructions, and it
may be given from a bottle, a medicine dropper or poured slowly from
the tip of a teaspoon.

=Ingredients of the Baby’s Food.= In referring to the ingredients of
the baby’s food we cannot use the terms “sugar” or “milk” as though
they indicated definite and unvarying materials.

There are three kinds of sugar which are commonly used in modified
milk: cane or granulated sugar; lactose or milk sugar and maltose.
_Cane sugar_, the one most widely used, is the least expensive of
the three and it apparently is satisfactory for most babies.
_Lactose_ is fairly expensive and while it causes diarrhea in some
babies, others digest it more easily than cane sugar. Lactose is
lighter than cane sugar, three spoonfuls being equal in weight to
two of cane sugar. The _maltose_-dextrine preparations are easily
digested and somewhat laxative. Some babies gain more rapidly when
maltose constitutes part of the sugar in their food than when only
lactose is used.

The question of milk is somewhat complicated and though the doctor
will specify what percentage of fat shall be in the milk which is
used in each case, the nurse must know how to obtain it from the
milk at her disposal. If the formula is made up with “whole milk,”
which contains 4 per cent. fat, the bottle in which it was delivered
should be turned upside down and shaken vigorously in order that the
cream which has risen to the top may be redistributed evenly
throughout the fluid.

If the doctor employs what is termed “percentage feeding,” he may
use whole milk, skimmed milk, or top milk. What he is endeavoring to
do is to prepare a food which contains definite known percentages of
the different ingredients, fat, carbohydrates and protein. Where a
mixture is desired which contains more fat than it does protein, the
milk to be employed is obtained by discarding a certain amount from
the bottom of the jar of milk, the remainder being then called “top
milk.” When he wishes the fat to be lower than the protein
percentage, he discards some of the top milk in the jar, using the
rest, which is then a partially skimmed milk. The upper 2 ounces in
a quart bottle of milk contains 24 per cent. fat; the upper 8 ounces
is 12 per cent. fat; the upper 16 ounces is 8 per cent. fat and the
upper 24 ounces is 5 per cent. fat. If the formula calls for 6
ounces of the upper 8 ounces of milk, therefore, the nurse will see
that it is very important that she remove the full 8 ounces and use
6 ounces of the milk which she has removed and not simply take the
upper 6 ounces, as this would contain a higher percentage of fat
than is ordered. (Figs. 171, 172, Dr. Griffith’s tables of fat
percentages.)

Top milk may be removed by tipping the bottle gradually and slowly
pouring the designated amount into a measuring glass, or it may be
removed by pushing a cream dipper, especially made for this purpose
and holding one ounce, down into the bottle until the cream flows
in. Another method is to syphon off the lower milk through a bent
glass tube, leaving in the bottle the desired amount of top milk.

Many doctors feed the baby according to his caloric needs and
prepare the formula from whole milk, sugar and water, determining
the amounts of each according to the age and weight of the baby.

Under any condition it is so necessary that the amount and
composition of each baby’s food be adjusted to his needs, that it is
not considered possible to make out any formulae or feeding
schedules which would be safe or satisfactory for general use.

Ready Method for Selecting Amounts to be Employed in Making
Various 20–Oz. Milk-Mixtures, and the Caloric Values Resulting

READY METHOD FOR SELECTING AMOUNTS TO BE EMPLOYED IN MAKING
VARIOUS 20–OZ. MILK-MIXTURES, AND THE CALORIC VALUES RESULTING

┌────────────────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┬─────┐ │ Percentages │Lower│Lower│Lower│Whole│Upper│Upper│Upper│Upper│ │ desired of │8 oz.│ 16 │ 28 │Milk │ 24 │ 20 │ 16 │ 10 │ │ │ │ oz. │ oz. │ │ oz. │ oz. │ oz. │ oz. │ │ │ │ │ │ │ │ │ │ │ ├───┬─────┬──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │Fat│Sugar│Prot’n│ │ │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │0.5│5 │1 │ │ │ 5 │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │0.5│6 │2 │ │10 │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1 │6 │1 │ │ │ │5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1 │6 │1.5 │2.5 │ │ │5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1 │6 │2 │ │ │10 │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1.5│6 │1 │ │ │ │ │ │5 │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │1.5│6 │1.5 │ │ │ │7.5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2 │6 │1.5 │2.5 │ │ │ │ │ │5 │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2 │6 │2 │ │ │ │10 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2.5│6 │1.5 │2.5 │ │ │ │ │ │ │5 │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2.5│6 │2 │ │ │ │ │10 │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │2.5│6 │2.5 │ │ │ │12.5 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │1 │ │ │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │1.5 │2.5 │ │ │ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │2 │ │ │ │ │ │10 │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │3 │6 │3 │ │ │ │15 │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┼─────┤ │4 │4 │4 │ │ │ │20 │ │ │ │ │ └───┴─────┴──────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┴─────┘

┌────────────────┬─────┬─────┬─────┬───────┬────────┐ │ Percentages │Upper│Water│Sugar│Caloric│Calories│ │ desired of │8 oz.│ oz. │ oz. │ Value │per oz. │ │ │ │ │ │ of │ │ │ │ │ │ │Mixture│ │ ├───┬─────┬──────┼─────┼─────┼─────┼───────┼────────┤ │Fat│Sugar│Prot’n│ │ │ │ │ │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │0.5│5 │1 │ │15 │0.8 │175 │ 8.75 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │0.5│6 │2 │ │10 │0.8 │225 │11.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1 │6 │1 │ │15 │1 │225 │11.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1 │6 │1.5 │ │12.5 │0.9 │237.5 │11.88 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1 │6 │2 │ │10 │0.8 │250 │12.5 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1.5│6 │1 │ │15 │1 │250 │12.5 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │1.5│6 │1.5 │ │12.5 │0.9 │262.5 │13.13 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2 │6 │1.5 │ │12.5 │0.9 │287.5 │14.38 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2 │6 │2 │ │10 │0.8 │300 │15 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2.5│6 │1.5 │ │12.5 │0.9 │312.5 │15.63 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2.5│6 │2 │ │10 │0.8 │325 │16.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │2.5│6 │2.5 │ │7.5 │0.7 │337.5 │16.88 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │1 │5 │15 │1 │325 │16.25 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │1.5 │5 │12.5 │0.9 │337.5 │16.88 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │2 │ │10 │0.8 │350 │17.5 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │3 │6 │3 │ │5 │0.4 │375 │18.75 │ ├───┼─────┼──────┼─────┼─────┼─────┼───────┼────────┤ │4 │4 │4 │ │0 │ │400 │20 │ └───┴─────┴──────┴─────┴─────┴─────┴───────┴────────┘

FIG. 171. Table of fat percentages, by permission, from “The
Diseases of Infants and Children,” by J. P. Crozer Griffith,
M.D.

]

* * * * *

─────────────────────────────────────────────────────
TABLE GIVING APPROXIMATE PERCENTAGE-STRENGTHS OF
DIFFERENT LAYERS OF MILK

Per cent. Per cent. Ratio
Fat Protein
and Sugar
Upper 2 oz. 24 4 6 to 1
Upper 4 oz. 20 4 5 to 1
Upper 6 oz. 16 4 4 to 1
Upper 8 oz. 12 4 3 to 1
Upper 10 oz. 10 4 2.5 to 1
Upper 16 oz. 8 4 2 to 1
Upper 20 oz. 6 4 1.5 to 1
Upper 24 oz. 5 4 1.25 to 1
Upper 32 oz. whole milk 4 4 1 to 1
Lower 30 oz. 3 4 .75 to 1
Lower 28 oz. 2 4 .50 to 1
Lower 16 oz. 1 4 .25 to 1
Lower 8 oz. 0.5 4 .0 to 1
─────────────────────────────────────────────────────

* * * * *

TO FIND THE AMOUNT OF ANY LAYER OF MILK TO BE USED TO GIVE
PERCENTAGES DESIRED

Equation:

Total amount of food × Percentage of fat desired Amount of
———————————————————————————————————————————————— = this milk in
Fat-strength of layer of milk used the mixture.

(1) Select from the “Layers of Milk” Table the milk which possesses
the desired ratio of fat to protein.

(2) Substitute in the equation.

(3) As the sugar-percentage has been reduced equally with that of
the protein, add sufficient sugar to raise to the desired
percentage.

EXAMPLE: 20–oz. mixture desired. Percentages desired = Fat 3, Sugar
6, Protein 1. Use upper 8 oz. (fat 12%, protein 4%, viz.: 3:1).
Then 20 × 3/12 = 5 oz. of upper 8 oz., with 15 oz. of water in
the 20–oz. mixture. The protein necessarily becomes 1%, and the
sugar likewise. The mixture already containing 1% of sugar, add
5% of 20 oz., i. e., 1 oz. of sugar to increase this to the 6%
desired.

* * * * *

TO DETERMINE THE PERCENTAGES PRESENT IN ANY MILK-MIXTURE ALREADY
IN USE

Quantity of substance used
(milk, cream, or skimmed milk)
× Its percentage-strength
————————————————————————————— = Percentage of element
Total Quantity of Food (F., S. or P. in the mixture.)

EXAMPLE: The mother has mixed: Upper 8 oz.; 6 oz.—Lower 8 oz.; 3
oz.—Milk-sugar 3 level tablespoonfuls.—Water 27 oz. Total
quantity = 36 oz. The upper 8 oz. contains 12% fat (see Table).
Both top and bottom milk contain 4% protein and sugar. Three
tablespoonfuls sugar = approximately 1 oz. The fat of the lower
8 oz. may be ignored. Then 6 × 12/36 = 2 = Fat percentage from
the top-milk. 3 × 0/36 = 0 = Fat-percentage from the bottom
milk. 9 × 4/36 = 1 = Protein and sugar percentages from combined
top and bottom milk. The 1 oz. additional sugar divided by 36 =
approximately 3% sugar added. There being already 1% sugar
derived from the milk, the total sugar = 4%.

* * * * *

FIG. 172. Reverse side of card in Fig. 171.

]

Moreover, it does not ordinarily devolve upon the nurse to do more
than prepare and give the baby’s food as ordered by the doctor, but
situations sometimes do arise when the doctor is not within reach
which the nurse must meet as best she can. In such an emergency she
might be guided by the following suggestions contained in a pamphlet
entitled, “Save the Babies,” prepared by Dr. L. Emmet Holt and Dr.
H. K. L. Shaw and published by the American Medical Association,
remembering that they are intended for the average, normal baby and
are not necessarily suitable for all babies:

“The simplest plan is to use whole milk (from a shaken bottle)
which is to be diluted according to the child’s age and
digestion.

“Beginning on the third day, the average baby should be given 3
ounces of milk daily, diluted with seven ounces of water. To
this should be added one tablespoonful of lime water and 2 level
teaspoonfuls of sugar. This should be given in seven feedings.

“At one week, the average child requires 5 ounces of milk daily,
which should be diluted with 10 ounces of water. To this should
be added 1½ even tablespoonfuls of sugar and one ounce of lime
water. This should be given in seven feedings.

“The milk should be increased by ½ ounce about every 4 days.

“The water should be increased by ½ ounce about every 8 days.

“At three months the average child requires 16 ounces of milk
daily, which should be diluted with 16 ounces of water. To this
should be added 3 tablespoonfuls of sugar and 2 ounces of lime
water. This should be given in 6 feedings.

“The milk should be increased by ½ ounce about every 6 days.

“The water should be reduced by ½ ounce about every 2 weeks.

“At 6 months the average child requires 24 ounces of milk daily,
which should be diluted with 12 ounces of water. To this should
be added 2 ounces of lime water and 3 even tablespoonfuls of
sugar. This should be given in 5 feedings.

“The amount of milk should be increased by ½ ounce every week.

“The milk should be increased only if the child is hungry and
digesting his food well. It should not be increased unless he is
hungry, nor if he is suffering from indigestion even though he
seems hungry.

“At 9 months, the average child requires 30 ounces of milk
daily, which should be diluted with 10 ounces of water. To this
should be added 2 even tablespoonfuls of sugar and 2 ounces of
lime water. This should be given in 5 feedings.

“The sugar added may be milk sugar or, if this cannot be
obtained, cane (granulated) sugar or maltose (malt sugar).

“At first plain water should be used to dilute the milk.

“At three months, sometimes earlier, weak barley water may be
used in the place of plain water; it is made with ½ level
tablespoonful of barley flour to 16 ounces of water and cooked
20 minutes.

“At six months the barley flour may be increased to 1½ even
tablespoonfuls, cooked in the 12 ounces of water.

“At nine months, the barley flour may be increased to 3 level
tablespoonfuls, cooked in the 8 ounces of water.

“A very large baby may require a little more milk than that
allowed in these formulas. A small delicate baby will require
less than the milk allowed in the formulas.”

These formulas may be tabulated as follows:

────────┬────────┬────────┬────────────┬────────────┬────────────── Age │ Milk │ Water │Barley-Water│ Lime-Water │ Sugar ────────┼────────┼────────┼────────────┼────────────┼────────────── │ │ │ │ │ ════════╪════════╪════════╪════════════╪════════════╪══════════════ 3–7 days│ 3 ozs.│ 7 ozs.│ 16 ozs. │ ½ ozs.│2 teaspoons 2d week │ 5 ozs.│10 ozs.│ 15 ozs. │ 1 ozs.│1½ tablespoons 3d week │ 6 ozs.│10½ ozs.│ 14 ozs. │ 1 ozs.│1½ tablespoons 1 month │ 7 ozs.│11 ozs.│ 12 ozs. │ 1 ozs.│2 tablespoons 2 month │11 ozs.│13 ozs.│ 12 ozs. │ 1½ ozs.│2½ tablespoons 3 month │16 ozs.│ │ 11 ozs. │ 2 ozs.│3 tablespoons 4 month │19 ozs.│ │ 10 ozs. │ 2 ozs.│3 tablespoons 5 month │21½ ozs.│ │ │ 2 ozs.│3 tablespoons 6 month │24 ozs.│ │ │ 2 ozs.│3 tablespoons 7 month │26 ozs.│ │ │ 2 ozs.│3 tablespoons 8 month │28 ozs.│ │ │ 2 ozs.│2½ tablespoons 9 month │30 ozs.│ │ │ 2 ozs.│2 tablespoons ────────┴────────┴────────┴────────────┴────────────┴──────────────

────────┬───────────────┬──────────────── Age │No. of feedings│ Hours ────────┼───────────────┼──────────┬───── │ │ Day │Night ════════╪═══════════════╪══════════╪═════ 3–7 days│ 7 │6–9–12–3–6│10–2 2d week │ 7 │6–9–12–3–6│10–2 3d week │ 7 │6–9–12–3–6│10–2 1 month │ 7 │6–9–12–3–6│10–2 2 month │ 7 │6–9–12–3–6│10–2 3 month │ 7 │6–9–12–3–6│10–2 4 month │ 6 │6–9–12–3–6│10 5 month │ 6 │6–9–12–3–6│10 6 month │ 5 │6–10–2–6 │10 7 month │ 5 │6–10–2–6 │10 8 month │ 5 │6–10–2–6 │10 9 month │ 5 │6–10–2–6 │10 ────────┴───────────────┴──────────┴─────

=Mixed Feeding.= Under some conditions the breast-fed baby is given
also a certain amount of modified milk, and this combination of
natural and artificial feeding is termed mixed or supplementary
feeding.

A deficiency in the breast milk, ascertained by weighing the baby
before and after each nursing, may be supplied by following each
nursing with a bottle feeding; or one or two breast-feedings, in the
course of the day may be replaced by entire bottle feedings. In any
case the milk mixture to be used as supplementary feeding is
prepared with exactly the same painstaking care as is the milk for
entire artificial feeding.

If supplementary food is given because of an inadequate supply of
breast milk, it is of great importance that the baby be put to the
breast regularly, no matter how little food he obtains, for his
suckling is the best possible means of stimulating the breasts to
secrete more milk and of equal importance is the fact that they will
tend to dry up if the baby nurses less than about five times in
twenty-four hours. Moreover, even a little breast milk is valuable
to him and he should have the benefit of all there is to be had.

An entire bottle feeding is sometimes given to a baby who is nursing
satisfactorily at the breast, in order to give his mother an
opportunity to take longer outings than are possible between the
regular nursings. And sometimes it is to the mother’s advantage, and
therefore to the baby’s, to give him a bottle during the night and
thus allow her to sleep undisturbed.

COMMERCIAL BABY FOODS

Since the baby’s food is prescribed by the doctor, the nurse has
little concern with the various proprietary baby foods and the
canned and powdered milks which are so persuasively advertised to
young mothers. It is hoped, however, that the discussions on
nutrition in general and on baby feeding in particular, have made it
clear to the nurse that these foods cannot be expected to be
satisfactory if used as a sole article of diet throughout the
bottle-feeding period.

There are many times and circumstances, however, when the temporary
use of a prepared infant food or canned or powdered milk is
advantageous. In some cases of intestinal disturbance, for instance,
or while the mother is traveling and is unable to have freshly
prepared milk formulas supplied to her along the way; during the
summer, while staying at a hotel or boarding house where the
freshness, cleanliness or purity of the milk are uncertain; or
during a sudden shortage of fresh milk, as may occur during a strike
or severe storm when transportation is interfered with, a
proprietary food may be a great boon.

If the nurse is confronted with the necessity of choosing and making
temporary use of a prepared food she may be guided by considering
the general principles of baby feeding and the character of the
materials at her disposal.

=The Proprietary Foods= may be divided into two general groups: one
kind contains milk powder and is usually added to water while the
other consists largely of sugar and starch and is added to fresh
milk before being given to the baby.

=Canned Milk= is of two kinds; evaporated, which is unsweetened, and
condensed, which is sweetened. _Evaporated milk_ is whole milk from
which part of the water has been removed, the milk then being canned
and sterilized. The addition of water to evaporated milk restores it
to the composition of whole milk in many respects, but it is still
milk that has been heated. _Condensed milk_ is evaporated milk to
which cane sugar has been added to aid in its preservation. Since
bacteria do not grow well in highly sweetened foods, it is not
necessary to bring sweetened condensed milk to as high a temperature
as the unsweetened product, to prevent subsequent bacterial
decomposition. The high percentage of sugar in condensed milk quite
obviously renders it unsuitable for continuous use as the sole
article in a baby’s dietary.

=Milk Powders or Dried Milks= are prepared by rapidly evaporating
the water from whole milk, skimmed milk or partly skimmed milk,
leaving the solid constituents in the form of a light, white powder.
Milk powder readily dissolves in water, forming a “reconstructed
milk” which closely resembles the fresh milk from which it was
prepared. But it must not be forgotten that reconstructed milk has
been heated. Many doctors consider whole milk powder the most
satisfactory form of preserved milk which is available for baby
food. Should it be used, however, the importance of keeping it
tightly covered and in a cold place must be recognized, for the
presence of fat renders it likely to become rancid if not kept cold.

ARTICLES OF FOOD WHICH ARE SOMETIMES INCLUDED IN THE BABY’S DIETARY

=Barley Water=, sometimes used to dilute whole milk, is made by
mixing the barley flour to a smooth paste in cold water, adding
boiling water and boiling for twenty minutes or cooking in a double
boiler for an hour, straining and adding enough water to replace the
amount lost in cooking. The proportions for different ages are as
follows:

Three months, ½ level tablespoonful barley flour to 16 oz. water
Six months, 1½ level tablespoonful barley flour to 12 oz. water.
Nine months, 3 level tablespoonfuls barley flour to 10 oz. water.

=Potato Water.= One tablespoonful of thoroughly boiled potato is
mashed into one pint of the water in which the potato was boiled and
carefully strained.

=Spinach.= Spinach is carefully washed, steamed for half an hour and
mashed through a fine sieve. It is sometimes started at the sixth
month; one teaspoonful daily, gradually increased to one or two
tablespoonfuls daily.

=Orange Juice.= The orange should be dipped in boiling water and
wiped on a clean towel before being cut and squeezed, to avoid
possible infection of juice. It is usually given to babies getting
heated milk, sometimes as young as one month old. It is carefully
strained and started gradually by giving one teaspoonful in water
once or twice daily between feedings and increasing to ½ or 1 ounce
by the sixth month and 1½ to 2 ounces by the end of the first year.

=Infusion of Orange Peel.= This is sometimes used instead of orange
juice, and is made by boiling one ounce of finely grated orange peel
in two ounces of water, adding a little sugar to counteract the
bitter taste and adding enough sterile water to bring it up to two
ounces.

=Tomato Juice.= Canned tomato strained through a fine sieve, is
sometimes given to a baby a few weeks old, starting with one dram
and gradually increasing to four to six ounces daily.

=Whey.= One quart of whole milk heated to 98° F. or 100° F. and
one-half ounce of liquid rennet or one junket tablet stirred into it
and allowed to stand half an hour or until firm and solid, is poured
into a cheese-cloth bag and allowed to drain for about an hour
without being squeezed.

=Protein Milk.= The curd from one quart of milk, which remains after
the whey is drained, as directed above, is mashed through
cheese-cloth in a fine wire sieve, with a potato-masher or bowl of a
spoon and the curd washed through with one pint of water. A pint of
buttermilk is added and the mixture boiled while being stirred
constantly. This is sometimes given in diarrhea.

=Beef Juice.= One pound of thick round steak, slightly broiled, is
cut into small pieces and the juice expressed with a meat press or a
lemon squeezer, the amount varying from 2 to 3 ounces. It may be
diluted with an equal amount of warm water, or slightly warmed by
being placed in a cup standing in hot water, and salted to taste.

=Broths.= One pound of lean meat, all fat and gristle removed, is
allowed to one pint of water. The meat is cut finely and put on in
cold water, heated slowly and allowed to simmer for three or four
hours, when water is added to replace what was lost in cooking. It
is strained, the fat removed and slightly salted.

=Oatmeal Water.= Two level tablespoonfuls of oatmeal in a pint of
boiling water is cooked in a double-boiler for two hours, strained
and enough boiling water added to replace the amount lost in
cooking.

TRAVELING

FIG. 173.—The baby will travel comfortably in a basket converted into
a bed. (Courtesy of the Maternity Centre Association.)
]

The difficulties of traveling with a young baby may be greatly
lessened by making certain preparations. If the baby is bottle-fed,
the preparations will depend upon the length of the journey and
whether or not it will be possible to have freshly prepared
feedings, for each twenty-four hours, put on the train from
laboratories along the way. If this is not possible and the journey
is not to take more than twenty-four hours, the entire quantity of
food, ice cold, may be carried in a thermos bottle. The requisite
number of sterile nursing bottles may be taken or one bottle which
is boiled before each feeding. Or the milk may be prepared as usual
and the bottles packed in a portable refrigerator. Such a
refrigerator may be bought or one may be improvised. The bottles are
placed in a covered pail and packed solidly in crushed ice; this is
placed in a second pail or a box with a diameter which is at least
two inches larger than the inner pail and the space between the two
packed firmly with sawdust. Several thicknesses of newspapers should
be pressed down over the top and a tight cover fitted to the outer
receptacle.

The sterile nipples may be taken in a sterile jar and a deep cup or
kettle will be needed in which to warm the bottle before each
feeding. It is usually possible to obtain water on the train which
is hot enough for this, or cans of solid alcohol, a stand and a
metal tray may be added to the traveling outfit. If fresh formulae
cannot be delivered to the train, daily, and the journey is to last
more than twenty-four hours, one of the proprietary foods or a
powdered milk will often prove to be a satisfactory solution to the
problem of feeding.

The baby will usually travel more comfortably and sleep better if he
is carried in a basket. A large market basket with a handle or a
small clothes basket will serve. It may be lined with a sheet or a
blanket; have a small hair pillow or folded blanket in the bottom
and be made up like a crib. (Fig. 173.) If this basket stands on the
car seat during the day, and on the foot of the nurse’s berth at
night, the baby will be cleaner, quieter and less exposed to drafts
than if carried in the arms.

THE PREMATURE BABY

All of the precautions and gentleness which are necessary in the
care of the normal baby, born at term, must be greatly increased in
caring for the baby who is born prematurely.

As was explained in Chapter III the premature baby’s prospects of
living increase with the length of his uterine life, and it is often
possible to estimate this by measuring and weighing him. During the
last five months the child’s length in centimetres divided by five
gives the month of pregnancy, according to the following table by
Dr. Williams:[15]

At the fifth month of pregnancy 5×5, fetus is 25 cm. long
At the sixth month of pregnancy 6×5, fetus is 30 cm. long
At the seventh month of pregnancy 7×5, fetus is 35 cm. long
At the eighth month of pregnancy 8×5, fetus is 40 cm. long
At the ninth month of pregnancy 9×5, fetus is 45 cm. long
At the tenth month of pregnancy 10×5, fetus is 50 cm. long

But consideration of the baby’s weight is also of importance when
attempting to forecast his chances of living. A baby weighing less
than 2500 grams or about 5½ pounds should be regarded, and treated,
as premature, unless it is more than 45 centimetres, or about 18
inches long. This length would indicate greater maturity, and
therefore greater viability than would be expected from the weight.
A baby weighing less than 1500 grams (3 pounds and 5 ounces) can
scarcely be expected to live.

The premature baby is not only small, but in general is imperfectly
developed, having slenderer powers than the full-term baby and at
the same time much greater needs. His respiratory and digestive
organs are less ready to function than in the full-term baby; his
muscles and nerves are feeble; his heat-producing mechanism is
unstable and yet there is an excessive radiation of body heat
through the relatively large area of skin.

Accordingly, the baby who has been deprived of those valuable last
weeks of growth and development is small and limp; lies quietly most
of the time and moves very feebly if at all. He is often too weak to
nurse at the breast and may swallow with difficulty. His temperature
is low, his respirations irregular and he is frequently cyanotic.

FIG. 174.—Quilted robe, with hood, for the premature baby.
]

The care of this frail little body practically resolves itself into:

1. Maintaining a normal body temperature.
2. Promoting and maintaining normal respirations.
3. Supplying adequate and suitable nourishment.
4. Conserving his strength.
5. Preventing infection.

FIG. 175.—Premature baby in basket lined with quilted pad; wearing
quilted robe and being fed from a Boston feeder. The blanket is
turned back showing hot-water bag. (From photograph taken at Johns
Hopkins Hospital.)
]

To maintain a normal body temperature it is necessary to give
special thought to the baby’s clothing, bed and room. He should be
oiled with warm olive oil and entirely wrapped in cotton batting or
flannel or enveloped in a quilted garment, with hood attached, made
of cheese-cloth or flannel and cotton batting. (Fig. 174.) Diapers
are often omitted in caring for very feeble babies, a pad of cotton
being slipped under the buttocks instead as this may be changed with
less disturbance to the baby than a diaper.

FIG. 176.—Model of improvised bed for premature baby: closely woven
clothes basket with padded bottom and four, flannel-covered bottles
of hot water attached to the sides. Thermometer and feeder are shown
in basket. (By courtesy of Dr. Alan Brown, Hospital for Sick
Children, Toronto.)
]

His bed consists of a box or basket, with the bottom well padded
with several inches of cotton, a small pillow or a soft blanket
folded to the proper size, covered with rubber or oiled muslin and a
cotton sheet. The sides of the basket should be lined with heavy
quilted material (Fig. 175), to shut out drafts and help to preserve
an even temperature of the air immediately around the baby. A
flannel covered hot-water bag at 110° F. may be placed beside the
baby, or two, three or four glass bottles, each holding about a
pint, containing water at 100° F. and securely stoppered, may be
hung in the corners of the basket. (Fig. 176.) A thermometer should
hang in the basket also, and the temperature kept between 80° F. and
90° F. It is easier to keep the temperature even if the bottles are
filled in rotation instead of all at the same time.

The amount of heat needed around the baby is decided by taking his
temperature (by rectum) at regular intervals; supplying more heat if
the temperature is low and less if it is at or above normal. Some
doctors have the temperature taken every four hours; others twice
daily. As the baby grows able to maintain a temperature of 98° F. to
100° F., unassisted, the surrounding heat is gradually reduced and
finally removed, and flannel clothing replaces the quilted robe.

In many hospitals there are special rooms for premature babies,
which are divided by glass partitions into cubicles so that each
baby is in a three-sided enclosure. The rooms are usually darkened
to save the baby from the needless irritation of light, and are
supplied with constantly changing fresh, moist, filtered air, the
temperature being kept at from 80° F. to 90° F.

In a patient’s home or in a hospital where there is no special room
for premature babies, a cubicle may be improvised by placing the
basket in which the baby lies, in the corner of a room and placing a
screen parallel with one of the walls. Such a room should be
darkened, well ventilated and have in it a large open vessel of
water.

Since the premature baby’s lungs are not fully expanded,
respirations are likely to be shallow and irregular, thus failing to
supply the amount of oxygen which he sorely needs. As crying
inevitably involves deep breathing, it is a common practice to make
the premature baby cry at regular intervals during the day in order
to promote the respiratory function. Dr. Griffith further recommends
plunging the baby into a mustard bath at 100° F. or 105° F. if
necessary to make him cry vigorously. It is also important to turn
the premature baby from side to side, several times a day to prevent
fluid from collecting in the lowermost part of the lung, a condition
favorable to the development of pneumonia.

In feeding premature babies, breast milk is ordinarily the most
desirable food. If the baby is too feeble to nurse, as frequently
occurs, the milk may be expressed from the breast of his mother or a
wet nurse, by stripping or pumping, into a sterile receptacle, and
if not used immediately it should be covered and placed in the
refrigerator. Breast milk is sometimes used whole and sometimes
diluted with water, and is given by gavage if the baby is very
feeble; from a medicine dropper or a special feeder. Such a feeder
consists of a glass tube with a small nipple on one end and a rubber
bulb on the other, by means of which the milk may be gently
expressed into the baby’s mouth, thus minimizing his effort to
obtain it. (See Fig. 175.)

The amount and intervals for feeding the premature baby have to be
adjusted to the individual with even greater care than for a normal
baby, for he needs more fuel and building material, because of his
imperfect development and yet because of that same imperfect
development his digestive powers are feebler than those of the
full-term baby. During the first day or two, he is sometimes given
nothing but water or sugar solution, the milk being started
gradually when the baby is from thirty-six to forty-eight hours old.
He may be given a very small quantity every two hours, or he may be
fed at three- or four-hour intervals, depending entirely upon his
condition and progress. It is usually considered very important for
the premature baby to have sterile water or sugar solution to drink
between feedings, and this is given in the same manner as his milk.

Unlike the normal baby he is not taken from his bed to be fed,
unless he nurses at the breast.

The premature baby is weighed as often as is safe for him, since the
suitability of his food is largely indicated by changes in his
weight. But sometimes very young and feeble babies are weighed only
once or twice a week because of the inadvisability of disturbing
them more frequently.

Avoidance of fatigue and the conservation of the premature baby’s
limited strength and energy are accomplished through reducing his
muscular activity to the minimum, by very little and very gentle
handling; and by minimizing his loss of energy in the form of heat
by keeping the little body warm and quiet.

In this connection the daily bath is of considerable importance. It
almost always consists of sponging the baby with warm olive oil as
he lies in his bed, and with the least possible exposure and
turning. It is given every day or every second or third day
according to his condition. The eyes are wiped with boric pledgets
and the nostrils with spirals of cotton dipped in oil. The buttocks
are wiped with an oil sponge each time the diaper is changed.

The premature baby is very susceptible to infection and strongly
predisposed to pneumonia. Infection in general is guarded against by
having everything that comes in contact with the baby scrupulously
clean; protecting him from drafts, chilling and dust; allowing no
one with a suspicion of a cold to come near him and by the nurse’s
wearing a clean gown and protecting her nose and mouth with a gauze
mask while attending him.

CARE OF THE BABY DURING THE SUMMER

The dangers of infancy are greatly increased in summer, more babies
dying during the hot months than any other time during the year. The
cause of these deaths is variously termed summer complaint, summer
diarrhea, acute gastro-enteritis and cholera infantum, and is due to
infected or decomposing food or both.

Clearly this malady is practically preventable through care.

Although such care as has been described in the preceding pages
largely constitutes the prevention of the much-to-be-dreaded summer
diarrhea, there are a few extra precautions and safeguards with
which the nurse must surround her little patient during the warm
weather.

She must bear in mind the character of the illness to be avoided:
indigestion associated with infection.

It becomes almost a matter of life or death, then, to give the baby
clean, suitable food and avoid deranging his digestion.

Babies suffer from the heat more than adults do and are often
excessively irritated and exhausted on warm days. And this
overheating, exhaustion and restlessness are of themselves enough to
affect his digestion.

Accordingly the scourge of summer diarrhea is prevented by giving
the baby proper food and keeping him clean, cool and quiet.

The baby should have maternal nursing if possible, for breast-fed
babies fall victim to summer diarrhea much less frequently than
bottle-fed babies. He should be fed with absolute regularity, and as
a rule, no matter what the nature of his food, it is reduced
one-quarter to one-third in amount during very warm weather and he
is given an increased amount of cool boiled water to drink. His
weight may increase very slightly, or even stand still for a short
time, as a result of his decreased food, but this is not usually
deplored, if he keeps well, for the important thing is to avoid
digestive disturbances while the weather is warm.

Cleanliness, as at other times, applies to the baby’s food, clothing
and surroundings. Many doctors think it safer to have all milk
boiled during the summer, and of course require flawless technique
in its preparation and administration. The baby’s soiled napkins
should be placed immediately in a covered receptacle containing
water, and not left for even a moment where they can be reached by
flies. They should be washed, boiled and dried in the open air and
sunshine as promptly as possible.

The baby should be protected from flies and mosquitoes by screens in
the windows and netting over his crib and carriage, both because
they make him restless and irritable and because flies particularly
are carriers of filth and disease—the kind of disease that kills so
many babies during the summer. Accordingly the nurse must always
regard flies with a deadly fear.

The baby should be kept away from dusty places and from cats and
dogs. And since babies will put their fingers in their mouths it is
a wise precaution to wash their hands several times a day.

The baby should be in the country, in the mountains or at the
seashore if possible during the warmest part of the summer at least,
but if he is in town there is much that the nurse can do to keep him
cool and comfortable. His clothing at this time must be adjusted to
his condition and the temperature of the moment just as it is in
cold weather. A thin shirt, band, diaper and cotton slip will
usually be enough for out-of-door wear, while in the house he may
often dispense with the slip and sometimes with everything but his
diaper.

During excessively hot days, the baby should have two or three cool
sponge baths, in addition to the soap and water bath, one of the
sponges being given before he is put to bed for the night. He should
sleep on a firm mattress, preferably curled hair but never feathers,
and in the coolest, best ventilated room available. During the day
it is usually best to take him out-of-doors early in the morning and
late in the afternoon, but to keep him indoors during the warmest
part of the day, when it is likely to be cooler indoors than out,
particularly if the blinds are closed. Quite naturally the nurse
will have to take into consideration the size, arrangement and
location of the baby’s home in her effort to keep him in cool,
quiet, shady places and out-of-doors as much as possible.

He must not be played with, held on hot laps nor subjected to the
entertainment and attention which misguided but well-meaning mothers
and friends are so eager to lavish on a hot, fretful baby.

Very often during warm weather a fine rash known as “prickly heat”
appears on the back of the baby’s neck and spreads over his head,
neck, chest and shoulders. This rash is due to too warm clothing or
to the hot weather or to both. Less clothing and frequent baths will
often give relief, but if the baby is very uncomfortable, he may be
greatly soothed by being immersed in cool baths containing soda,
bran or starch in the following proportions:

=Soda bath.= Two tablespoonfuls of baking soda to one gallon of
water.

=Bran bath.= A cheese-cloth bag about six inches square, partly
filled with bran, is soaked and squeezed in the bath water until it
is milky.

=Starch bath.= About eight ounces of cooked laundry starch to one
gallon of water.

No soap should be used while the baby has prickly heat and after the
bath he should be patted thoroughly dry and powdered with some such
soothing powder as the following:

Powdered starch one ounce
Oxide of zinc one ounce
Boracic acid powder 60 grains

As we look back over these pages of somewhat detailed description of
the case of the baby, it is borne in upon us that the nursing of
this unfailingly delightful and interesting little patient has
special adjustments and adaptations for different seasons and
circumstances; but that on the whole the care of all babies the year
around resolves itself into the observation of a few general
principles, namely: proper feeding; fresh air; regularity in his
daily routine; cleanliness of food, clothing and surroundings;
maintenance of an equable body temperature and conservation of his
forces.

If the nurse fixes these principles firmly in her mind and acts upon
them, she will do a great deal to give her baby patient a fair start
on his life’s journey.