r Digitized by the Internet Arciiive in 2007 witii funding from IVIicrosoft Corporation littp://www.arcliive.org/details/feedcliildrenOOIioltricli r>^^ THE CARE AND FEEDING OF CHILDREN A CATECHISM FOR THE USE OF MOTHERS AND CHILDREN'S NURSES BY L. EMMETT HOLT, M.D., LL.D. PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS (COLUMBIA UNIVERSITY) ATTENDING PHYSICIAN TO THE BABIES* HOSPITAL AND THE FOUNDLING HOSPITAL, NEW YORK iFiftb Edition, C^e^i^eb anb ^Pnlargeti NEW YORr==*3^ffinCDNDON D. APPLETON AND COMPANY 1910 "*%,., % OOPYMGHT, 1894, 1897, 1903, 1906, 1909, by D. APPLETON AND COMPANY Printed in the United States of America TO THE YOUNG MOTHEKS OF AMERICA, TOWARD THE SOLUTION OF WHOSE PROBLEMS THESE PAGES HAVE BEEN DEVOTED, THIS WORK IS RESPECTFULLY DEDICATED BY THE AUTHOR. 214920 >' OF THE UNIVERSITY Of PEEFACE TO THE FIETH EDITIO:^' The constant use of the Catechism as a manual for nursery maids has shown the need of fuller treat- ment of several subjects than was given in the earlier editions. An attempt has been made to meet the needs of mothers and nurses outside of institutions who have made the book a nursery guide, especially in matters relating to older children. The chapters upon infant feeding have been largely rewritten and, it is hoped, simplified for the average reader. Some further details relating to in- fants whose nutrition is difficult have been intro- duced, although the scope of the book makes this part necessarily brief. The author's aim has been not to alarm the mother by acquainting her with all the possible diseases and accidents which may befall her child, but to open her eyes to matters which are her direct and chief concern. It is, therefore, the needs of the well child, not 7 8 THE CARE AND FEEDING OF CHILDREN the sick one, which have been considered. The well child must, in most cases, be left to the care of the mother or nurse for whose guidance and assistance these pages are intended. For directions in matters of illness, however, no mother or nurse should de- pend upon any manual, but upon the advice of a physician. It is hoped that the mothers and nurses who have found the earlier editions of the Catechism helpful in the solution of some of their nursery problems will find even greater assistance from the present volume. New York, 1909. CONTENTS I THE CAEE OF CHILDEEN PAGB Bathing , , , 15 Genital organs 16 Eyes . 17 Mouth 18 Skin • 1^ Clothing 21 Napkins 24 Nursery 25 Airing 27 Weight, growth, and development ...... 30 Dentition 36 n INFANT FEEDING Nursing 42 Weaning from the breast 49 Weaning from the bottle 52 Artificial feeding 54 Selection and care of milk used for infant feeding ... 54 10 THE CARE AND FEEDING OF CHILDREN PAGE Modification of cow's milk 59 Top milk, 63 ; cream, 66. Food for healthy infants 66 Formulas from 7-per-cent milk, 68; formulas from whole milk, 73. FEEDING OP CHILDREN NAPKINS How should naphins he taken care of? They should be immediately removed from the nursery when soiled or wet. Soiled napkins should be kept in a receptacle with a tight cover, and washed as soon as possible. Should naphins which have been only wet he used a second time without washing? It is no doubt better to use only fresh napkins, but there is no serious objection to using them twice unless there is chafing of the skin. Clean napkins, changed as soon as wet or soiled, are of much im- portance in keeping the skin healthy. What are the important things to he ohserved in washing napkins? Soiled napkins should not be allowed to dry, but should receive a rough washing at once ; they should then be kept in soak in plain water until a conven- ient time for washing, — at least once every day, — when they should be washed in hot suds and boiled at least fifteen minutes. Afterward they should be very thoroughly rinsed or they may irritate the skin, and ironed without starch or blueing. They should never be used when damp. NURSERY 25 NURSERY What are the essentials in a good nursery? The furnishings should be very simple, and un- necessary hangings and upholstered furniture should be excluded. As large a room as possible should be selected — one that is well ventilated, and always one in which the sun shines at some part of the day, as it should be remembered that an average child spends here at least three fourths of its time during the first year. The nursery should have dark shades at the windows, but no extra hangings or curtains; about the baby's crib nothing but what can be washed should be allowed. The air should be kept as fresh and as pure as possible. There should be no plumb- ing, no drying of napkins or clothes, no cooking of food, and no gas burning at night. A small wax night-light answers every purpose. How should a nursery he heated? Best by an open fire ; next to this by a Franklin stove. The ordinary hot-air furnace of cities has many objections, but it is not so bad as steam heat from a radiator in the room. A gas stove is even worse than this, and should never be used, except, perhaps, for a few minutes during the morning bath. 26 THE CARE AND FEEDING OF CHILDREN At tvJiat temperature should a nursery he kept during the day? Best, 66° to 68° F., measured by a thermometer banging three feet from the floor, l^ever should the temperature be allowed to go above 70° F. At what temperature during the night? During the first two or three months, not below 65° F. After three months the temperature may go as low as 55° F. After the first year it may be 50° or even 45° F. At what age may the window he left open at night? Usually after the third month, except when the outside temperature is below freezing point. How often should the nursery he aired? At least twice a day — in the morning after the child's bath, and , again in the evening before the child is put to bed for the night. This should be done thoroughly, and the child should be removed meanwhile to another apartment. It is well to air the nursery whenever the child is out of the room. What symptoms are seen in a child who is Tcept in too hot a room? It becomes pale, loses appetite, shows symptoms of indigestion, occasionally vomits, stops gaining in ^^j^.^«hV&*^ AIRINa 27 weight, perspires very mucli, and takes cold easily because of this and also because of the great differ- ence between the indoor and outdoor temperatures. Its condition may be such as to lead one to suspect very serious illness. AIKIITG How early may airing indoors he commenced and how long may it he continued f Airing in the room may be begun, even in cold weather, when the child is one month old, at first for only fifteen minutes at a time. This period may be gradually lengthened by ten or fifteen minutes each day until it is four or five hours. This airing may be continued in almost all kinds of weather. Is there not great danger of a young hahy's talc- ing cold when aired in this manner? Not if the period is at first short and the baby accustomed to it gradually. Instead of rendering the child liable to take cold, it is the best means of pre- venting colds. How should such an airing he given? The child should be dressed with bonnet and light coat as if for the street and placed in its crib or car- riage which should stand a few feet from the win- dow. All the windows are then thrown wide open, 28 THE CARE AND FEEDING OP CHILDREN but the doors closed to prevent draughts. Screens are unnecessary. At what age may a child go out of doors? In summer, when one week old ; in spring and fall, usually at about one month; in winter, when about three months old, on pleasant days, being kept in the sun and out of the wind. What are the best hours for airing out of doors? In summer and early autumn a child may be out almost any time between seven in the morning and sunset; in winter and early spring, a young child only between 10 or 11 a. m. and 3 p. m., although this depends somewhat upon the climate. In Kew York and along the Atlantic coast the early morn- ings are apt to be damp and the afternoons raw and cloudy. On what hind of days should a hahy not go out? In sharp winds, when the ground is covered with melting snow, and when it is extremely cold. A child under four months old should not usually go out if the thermometer is below freezing point; nor one under eight months old if it is below 20° F. What are the most important things to he attended to when the child is out in its carriage ? To see that the wind never blows in its face, that its feet are properly covered and warm, and that the AIRING sun is never allowed to shine directly into its eyes when the child is either asleep or awake. Of what advantage to the child is going out? Fresh air is required to renew and purify the blood, and this is just as necessary for health and growth as proper food. What are the effects produced in infants hy fresh airf The appetite is improved, the digestion is better, the cheeks become red, and all signs of health are seen. 7s there any advantage in having a child take its airing during the first five or six months in the nurse's arms? !N^one whatever. A child can be made much more comfortable in a baby carriage, and can be equally well protected against exposure by blankets and the carriage umbrella. What are the objections to an infant's sleeping out of doors? There are no real objections. It is not true that infants take cold more easily when asleep than awake, while it is almost invariably the case that those who sleep out of doors are stronger children and less prone to take cold than others. 30 THE CARE AND FEEDING OF CHILDREN What can he done for children who take cold upon the slightest provocation? They should be kept in cool rooms, especially when asleep. They should not wear such heavy clothing that they are in a perspiration much of the time. Every morning the body, particularly the chest and back, should be sponged with cold water (50° to 60° F.). Eoiv should this cold sponge hath he given? The child should stand in a tub containing a little warm water, and a large bath sponge filled with cold water should be squeezed two or three times over the body. This should be followed by a vigor- ous rubbing with a towel until the skin is quite red. This may be used at three years, and often at two years. For infants a little higher temperature (65^ to 70°) may be used. WEIGHT, GROWTH, AND DEVELOPMENT Of what importance is the weight of th^ child? !N'othing else tells so accurately how well it is thriving. During the first year a record of the weight is almost indispensable; throughout childhood it is of much interest and is the best guide to the physical WEIGHT, GROWTH, AND DEVELOPMENT 31 condition. It will well repay any mother or nurse to keep such a record. , How frequently should a child he weighed'^ Every week during the first six months, and at least once in two weeks during the last six months of the first year. During the second year a child should be weighed at least once a month. How rapidly should an infant gain in weight during the first year? There is usually a loss during the first week of from four to eight ounces ; after this a healthy child should gain from four to eight ounces a week up to about the sixth month. From six to twelve months the gain is less, usually from two to four ounces a week. Is it to he expected that hottle-fed infants will gain as rapidly as those who are nursed? They seldom do so during the first month ; after that time under favourable circumstances the gain is usually quite as regular, and during the latter half of the first year it is likely to be more con- tinuous than in a nursing infant, because the latter usually loses weight at the time of weaning. Why do they not gain so rapidly at first? It takes a few weeks for the stomach to become accustomed to cow's milk, and until this is accom- 32 THE CAKE AND FEEDING OF CHILDREN plished it is necessary to make the milk very weak or the child's digestion will be upset. For a child of average iveight at hirth (seven to seven and a half pounds) what should he the weight at the different periods during the first year? At three months it should be twelve to thirteen pounds ; at six months, fifteen to sixteen pounds ; at nine months, seventeen to eighteen pounds; at one year, twenty to twenty-two pounds. At Rye months a healthy child will usually double its weight, and at twelve months it will nearly treble its weight. Do all healthy infants gain steadily in weight during the first year? As a rule they do; yet it is seldom the case that one gains every week for the entire year. With most infants there are from time to time periods of a few weeks in which no gain is made. These are more often seen from the seventh to the tenth month and frequently occur when the child is cutting teeth, sometimes during very hot weather. Is it true that every infant who gains rapidly in weight is thriving normally? !N'ot invariably. Some who are fed upon pre- pared infant foods increase rapidly in weight but WEIGHT, GROWTH, AND DEVELOPMENT 33 not in strength, nor in their development in other respects. Is the weight of as much value in the second year as a guide to the child's condition? After the first year, the gain in weight is seldom continuous; there are many interruptions, some de- pend on season, and others often occur without ap- parent cause. At what age should the fontanel close? The average is about eighteen months. It seldom closes earlier than fourteen months, and it should not be open at two years. At what age should a child hold up its head? As a rule during the fourth month, and often during the third month, the head can be held erect when the body is supported. When does an infant first laugh aloud? Usually from the third to the fifth month. When does it begin to reach for toys and handle them? Usually from the fifth to the seventh month. At what age should a child he able to sit and to stand alone? At seven or eight months a healthy child is usu- 34 THE CARE AND FEEDING OP CHILDREN ally able to sit erect and support the body. During the ninth and tenth months are usually seen the first attempts to bear the weight upon the feet, and at eleven or twelve months most children can stand with assistance. When should a child walk alone? The first attempts are generally seen in the twelfth or thirteenth month. At fifteen or sixteen months the average child is able to run alone. What conditions 'postpone these events? Prematurity, a very delicate constitution, any severe or prolonged illness, and especially chronic disturbances of digestion making feeding difficult. A common cause of late sitting, standing, or walk- ing is rickets. Should a child he urged to walk? ^Never; he is usually quite willing to do so as soon as his muscles and bones are strong enough. ]^one of the contrivances for teaching children to walk are to be advised. When do children begin to talk? Generally at one year a child can say " papa " and " mamma '^ or other single words. At the end of the second year the average child is able to put words together in short sentences. WEIGHT, GROWTH, AND DEVELOPMENT 35 // at two years the child makes no attempt to speak, what should he suspected? Either that the child is a deaf-mute or that it is mentally deficient, although this is occasionally seen in children who are only very backward. Table showing the Average Weight, Height, and Cir- cumference of Head and Chest of Boys^ At birth Weight 7| pounds. Height 20^ inches. Chest 13i " Head 14 One year Weight 21 pounds. Height 2^ inches. Chest 18 Head 18 Two years Weight 26^ pounds. Height 32i inches. Chest 19 Head 19 Three years. . .Weight 31 pounds. Height 35 inches. Chest 20 Head 19ir " Four years . . . Weight 35 pounds. Height 38 inches. Chest 20f " Head 19| " ^ Weights for the first four years are without clothes. The weight of girls is on the average about one pound less than boys. They are about the same in height. Charts showing weight curve for the first year, and from one year to fourteen years are given at the end of this book. 36 THE CARE AND FEEDING OF CHILDREN Five years Weight 41 pounds. Heigiit 41^ inches. Chest 2H " Head 20^ " Six years Weight 45 pounds. Height 44 inches. Chest 23 Seven years. . .Weight 49| pounds. Height 46 inches. Chest 23^ " Eight y ars. . .Weight 54^ pounds. Height 48 inches. Chest 24i " Nine years Weight 60 pounds. Height .". 50 inches. Chest 25 Ten years Weight 66i pounds. Height 52 inches. Chest 26 The above weights are with ordinary house clothes. DENTITION" How many teeth are there in the first set? Twenty. What is the time of their appearance? The two central lower teeth are usually the first to appear, and come from the fifth to the ninth month; next are the four upper central teeth, which come from the eighth to the twelfth month. The other two lower central teeth and the four front double teeth come from the twelfth to the eighteenth -jnonth. Then follow the four canine teeth, the two DENTITION 37 upper ones being known as the " eye teeth," and the two lower as the " stomach teeth " ; they generally come between the eighteenth and the twenty-fourth month. The four back double teeth, which complete the first set, come between the twenty-fourth and thirtieth month. At one year a child usually has six teeth. At one and a half years, twelve teeth.^^- At two years, sixteen teeth. At two and a half years, twenty teeth. What are the causes of variation? The time of appearance of the teeth varies in different families; in some they come very early, in others much later. The teeth may come late as a result of prolonged illness and also from rickets. What symptoms are commonly seen with teeth- ing? In healthy children there is very often fretful- ness and poor sleep for two or three nights; there may be loss of appetite, so that only one half the usual amount of food is taken; there is salivation or drooling, and often slight fever; there may be some symptoms of indigestion, such as vomiting or the appearance of undigested food in the stools. In delicate children all these symptoms may be much more severe. 38 THE CARE AND FEEDING OF CHILDREN How long do these symptoms last? Usually only three or four days; but there may be no gain in weight for two or three weeks. What is the cause of most of the other symptoms attributed to teething? IN'early all of them come from indigestion due to bad feeding. PAET II INFANT FEEDING II INFANT FEEDING What is the best infant food? Mother's milk. Of what is mother's milk composed? Thirteen parts solids and eighty-seven water. What are the solids? Fat, sugar, proteids, and salts. What is the fat? The cream. What is the sugar? It is lactose, or milk sugar. What are the proteids? The curd of the milk. Are all these elements necessary? Yes; we cannot expect to rear a healthy infant unless they are all in his food. Of what use is the fat? It is needed for the growth of bones, nerves, the fat of the body, and the production of heat. Of what use is the sugar? It is needed for the production of heat, and to make fat in the body. 41 42 THE CARE AND FEEDING OF CHILDREN Of what use are the proteids? Thej are needed for the growth of the body cells, such as those of the blood, the organs, and the muscles. Of what use are the salts? Particularly for the growth of bone. Of what use is the water? By means of the water the food is kept in a state of minute subdivision or in solution, so that the deli- cate organs of the infant can digest it. It is also necessary to enable the body to get rid of its waste. 2SrURSING Why should mothers nurse their children? First, because there is no perfect substitute for good breast-feeding. Secondly, statistics show that the mortality of bottle-fed infants during the first year is fully three times as great as that of those who are breast-fed. At what period is nursing of greatest importance? During the first two or three months, to give the child a proper start. At this time of life the mor- tality is highest and artificial feeding is most difficult. When should maternal nursing not he attempted? If the mother has or has had tuberculosis or any other serious chronic disease, or is herself in very delicate health, she should not try. She is likely soon NURSING 43 to fail in nourishing her child, and the attempt may do herself much harm as well as injure the child. Hovj often should infants he nursed during the first two days of life? Usually only four or five times daily, since there is very little milk secreted at this time. When does the milk come in abundance f Usually on the third day, sometimes not until the fourth or fifth day. Should the infant he fed anything additional during the first two days? Usually not; if much food were necessary, we m.ay be sure E'ature would have provided it. Water, however, should be given regularly. How frequently should an infant he nursed dur- ing the first week? After the third day, every two hours during the day and twice during the night. The frequency during the rest of the first year is given in the fol- lowing table: Period. Nursings in 24 hours. Interval by day. Night nursings (10 p. M. to 6 A. M.). 1st and 2d day 3 days to 6 weeks 6 weeks to 3 months. 3 to 5 months '. . . 5 to 12 months 4 10 8 7 6 6 hours. 2 " 2i '* 3 « 3 « 1 2 2 1 44 THE CARE AND FEEDING OF CHILDREN How long should the child he kept at the hreasf for one nursing? ISTot over twenty minutes. Should the child take both breasts at one nursing f If the milk is very abundant one breast may be sufficient, otherwise both breasts may be taken. What are the important things to be attended to in nursing? First, regularity; it is just as important as in the case of bottle-feeding. Secondly, the nipples should be kept clean by being washed after every nursing. What should be the diet of a nursing mother? She should have a simple but generous diet with, plenty of fluids; three regular meals may be given, and gruel, milk, or cocoa at bed-time and sometimes between meals. She may take eggs, cereals, most soups, and nearly all vegetables, avoiding sour fruits, salads, pastry, and most desserts. Meat should not be taken more than twice daily, and in many cases but once. She should take but little tea or coffee, and ordinarily no wine or beer. Are fruits likely to disturb a nursing infant? Sour fruits in some cases may do so, but sweet fruits and most cooked fruits are useful. NURSING 45 What else is important in the life of the nursing mother? She should lead a simple natural life; should have regular out-of-door exercise, preferably walking or driving, as soon after her confinement as her con- dition will permit. She should have regular move- ments from the bowels daily. She should be as free as possible from unnecessary cares and worry; her rest at night should be disturbed as little as possible ; she should lie down for at least one hour in the mid- dle of the day. Does the nervous condition of the mother affect the milk? Very much more than her diet; worry, anxiety, fatigue, loss of sleep, household cares, social dissipa- tion, etc., have more than anything else to do with the failure of the modern mother as a nurse. Uncon- trolled emotions, grief, excitement, fright, passion, may cause milk to disagree with the child ; at times they may excite acute illness, and at other times they may cause a sudden and complete disappearance of the milk. Does menstruation affect the milk? In nearly all cases the quantity of milk is less- ened so that the infant is not satisfied and may gain less in weight or not at all. In many cases the qual- 46 THE CARE AND FEEDING OF CHILDREN itj of the milk is also affected to such a degree as to cause slight disturbances of digestion, like restless- ness, colic, or some derangement of the bowels. In a few, attacks of acute indigestion are excited. 7s regular menstruation a reason to stop nursing? !N^ot invariably; as a rule both functions do not go on together. But if the child is gaining regu- larly in weight between the periods, nursing may be continued indefinitely, although it may be well to feed the infant wholly or in part during the first day or two that the mother is unwell. What symptoms indicate that a nursing infant is well nourished? The child has good color, sleeps two or three hours after nursing, or, if awake, is quiet, good- natured, and apparently comfortable. It has normal movements of the bowels and gains weight steadily. What symptoms indicate that a child who is nursing is not properly nourished? It does not gain and may even lose in weight. It no longer exhibits its usual energy and playful- ness, but is either listless and indifferent or cross, fretful and irritable, and is apt to sleep poorly. It grows pale and anaemic and its tissues become soft and flabby. When the milk is scanty it will often nurse a long time at the breasts, sometimes three NURSING 47 quarters of an hour, before stopping. At other times it may take the breast for a moment only, and then turn away in apparent disgust. What should he done in such cases? This depends upon the. severity of the symptoms and how long they have lasted. If the child has made no gain for three or four weeks, or is losing weight, immediate weaning will probably be neces- sary ; in any case, other food in addition to the breast milk should be given at once. One may begin by alternating the nursing and the bottle-feeding and increase the number of bottle-feedings as may be indicated by the results. Is there any objection to a hahy being partly nursed and partly fed? ^one whatever; it is often better from the out- set to feed the baby during the night, in order not to disturb the mother's rest. If the mother has only milk enough for two or three nursings a day, this should be continued so long as her milk agrees with the baby. Even a small amount of breast milk greatly improves a child's nutrition. What symptoms indicate that the mother's milk disagrees with the child? The child suffers from almost constant discom- fort; sleeps little and then restlessly, cries a great 48 THE CARE AND FEEDING OF CHILDREN deal, belches gas from the stomach, and passes much by the bov/els, or if not passed, the gas accumulates and causes abdominal distention and colicky pain. There may be vomiting, but more often the trouble is intestinal. Sometimes the bowels are constipated, but usually the movements are frequent, loose, green, contain mucus and are passed with much gas. What should he done under these circumstances^ If the symptoms have persisted for two or three weeks and the child is not gaining in weight, there is little chance of improvement, and the child should be taken from the breast at once. If there is some gain in weight, one may try for a little longer, en- deavouring to improve the mother's milk by rest, fresh air, careful diet, etc. However, one should always realize that the trouble is with the milk, not with the child. What changes should he made if a nursing infant hahitually vomits? If this occurs soon after nursing, the infant has usually taken too much and the time of nursing should be shortened, or one breast may be given instead of two; the nursing should also be inter- rupted by occasional rests, so that the milk is not taken too fast. If the vomiting occurs some time after nursing WEANING 49 and is repeated, it is a sign of indigestion; often "because the milk is too rich in fat. The intervals Ijetween nursings should then be lengthened; the "breast milk may be diluted by giving one or two tablespoonfuls of plain boiled water, lime-water, or barley-water, five or ten minutes before nursing ; the mother should eat less hearty food, especially less meat. What should he done if the infant has frequent habitual colic? This is usually because the milk is too rich in proteids; the mother should take more out-of-door exercise, eat less meat, and seek to control her emo- tions; all causes of worry should be removed. Can constipation in a nursing infant he con- trolled through the mother s milhf Only to a limited extent. It is important that the mother's bowels be regular and her digestion good. An increase in the meat and milk of her diet is sometimes beneficial. WEAITING At what age should the child he weaned from the hreastf "Usually weaning should be begun at nine or ten months by substituting one feeding a day for one » 50 THE CARE AND FEEDING OF CHILDREN nursing, later two feedings, and thus gradually the child is to be taken from the breast altogether. What is the principal reason for weaning earlier ? The most important one is that the child is not thriving — not gaining in weight and not progress- ing normally in its development. Serious illness of the mother, or pregnancy, may make weaning necessary. At what age should the weaning he completed? Generally at one year. In summer it may some- times be advisable to nurse an infant a little longer rather than wean in warm weather; but even then the dangers of weaning are much less than those of continuing to nurse, as is so often done, after the milk has become very scanty and poor in quality. When should a child who is weaned from the breast he taught to drinJc from the cup, and when to take the hottle? If weaning is done as early as the eighth or ninth month it is better to give the bottle; if from the tenth to the twelfth month the infant should be taught to drink or be fed with a spoon. How may some of the difficulties in weaning he overcome ? By feeding every nursing infant once a day or WEANING 51 by giving it water regularly from a feeding-bottle. It then becomes accustomed to the bottle. This is a matter of great convenience during the whole period of nursing when the mother or nurse is from neces- sity away from the child for a few hours; when more feeding is required at weaning time the child does not object. When should a child he iveaned from the bottle? With children who are not ill, weaning from the bottle should invariably be begun at the end of the first year, and after a child is thirteen or fourteen months old the bottle should not be given except a^ the night feeding. ' 7s there any ohj^xtion to the child's taking the bottle until it is two or three years old? There are no advantages and some serious objec- tions. Older children often become so attached to the bottle that only wdth the greatest difficulty can they be made to give it up. Frequently they will refuse all solid food, and will take nothing except from the bottle so long as it is given, and when finally at three or four years, it is taken away, they will not touch milk during the rest of their child- hood. The difficulty is here that children form the " bottle habit." This habit is troublesome, unneces- sary, and should by all means be prevented. An 53 THE CARE AND FEEDING OF CHILDREN exclusive diet of milk for children of two or three years often results in ansemia and malnutrition. How should one train a child to do without the bottle? This is usually very easy if it is begun at one year. The milk should be poured into a tiny glass or cup and little by little the child is taught to drink ; at first only a small portion of the food is taken in this way, the balance being given from the bottle ; but in the course of a few weeks the average infant learns to drink from a cup without difficulty, and all the food can be so given. If the child is two or more years old, the only effective means of weaning from the bottle is through hunger. The bottle should be taken away at once and entirely, and nothing allowed except milk from a cup until the child takes this willingly. Sometimes a child will go an entire day without food, occasion- ally as long as two days, but one should not be alarmed on this account and yield. This is a matter of the child's will and not of his digestion, and when once he has been conquered it is seldom that any further trouble is experienced. As soon as a child has learned to drink his milk from a cup, cereals and other solid foods may gradually be added to the diet. The educational value of such training is not the least important consideration. WEANING 5» Can a hahy just weaned taJce cow's milk of the same proportions as one of the same age who has had cow's milk from hirth? Very rarely ; to give a baby who has had nothing but the breast from birth, plain cow's milk, or even that milk which a bottle-fed baby of the same age might take, is almost certain to cause indigestion. The change in the food is quite a marked one, and should be made gradually by beginning with a very weak milk and increasing its strength as the baby becomes accustomed to take cow's milk. What would he the proper proportions for an infant weaned at four or five months? About the same as for a healthy bottle-fed infant of two months; the quantity of course should be larger. The food can in most cases be gradually increased so that in two or three weeks the usual strength for the age can be taken. What would he the proper proportions for an in- fant weaned at nine or ten months? About the same as for a bottle-fed infant at four or five months, to be increased as indicated above. Will not a child lose in weight when placed upon, so low a diet? Very often it will do so for the first week or two, but after that wall gain quite regularly; the acute 64 THE CARE AND FEEDING OF CHILDREN indigestion, however, which generally accompanies the use of stronger milk will, in most cases, cause a greater loss. ARTIFICIAL FEEDING What foods contain all the elements 'present in ■mother s milkf The milk of other animals, — cow's milk being the only one which is available for general use. Is it not possible for infants to thrive upon other foods than those containing fresh milk? They may do so for a time, but never perma- nently. The long-continued use of other foods as the sole diet is attended with great risk. What are the dangers of such foods? Frequently scurvy is produced, often rickets, and in other cases simply a condition of general malnu- -trition, — the child does not thrive, is pale, and its muscles are soft and flabby. 'THE SELECTION AND CARE OF MILK USED FOR INFANT FEEDING What are the essential points in milk selected for ihe feeding of infants? That it comes from healthy cows, and that it is clean and fresh. THE SELECTION AND CARE OF MILK 55 Is it not important to select a rich milk? By no means; in fact the very rich milk of highly bred Jerseys and > Alderneys has not been found nearly so satisfactory in infant feeding as that from some other herds, such, for example, as the common " grade cows." Which is the better , milk from one cow or the mixed milk of several cows? The mixed, or " herd milk," is usually to be pre- ferred, since it varies little from day to day; while that from a single cow may vary considerably. How fresh is it important that cow's milk should he for the best results in infant feeding? This depends very much upon the season, and how carefully milk is handled. As ordinarily han- dled at the dairy and in the home, milk should not be used for infants in winter after it is forty-eight hours old; in summer not after it is twenty-four hours old, and it may be unsafe in a much shorter time. When handled with especial care milk may be safe for a longer time. What are the two essentials in handling milk? 1. That it be kept clean and free from contami- nation. This necessitates that cows, stables, and milkers be clean, and that transportation be in sealed bottles ; also that those who handle the milk are them- 56 THE CARE AND FEEDING OP CHILDREN selves healthy and do not come in contact with any contagious disease. All milk-pails, bottles, cans, and other utensils with which the milk comes in contact should be sterilized shortly before they are used, by steam or boiling water. 2. That it be cooled immediately after leaving the cows, and kept at as low a temperature as possi- ble; to be efficient this should not be above 50° F. Milk produced under hygienic conditions and handled with special care is sold in bottles in a num- ber of cities under the name of " certified," " guar- anteed," or " inspected " milk. When available such milk should be used for infants. Of course the extra care bestowed in its production and transportation increases the cost of the milk, but the best will usually be found in the end to be the cheapest. How should milk he handled in the home when obtained fresh from the cows? That to be used for infants should be strained through a thick layer of absorbent cotton or several thicknesses of cheese-cloth into quart glass jars or milk bottles which should be covered and cooled im- mediately, best by placing the bottles quite up to their necks in ice water or cold spring water, where they should stand for at least half an hour. That required for children who take plain milk may now THE SELECTION AND CARE OF MILK 57 be poured into half-pint bottles, stopped with cotton, and put in the ice-chest, or the coolest place possible. This first rapid cooling is very important and adds much to the keeping qualities of the milk. Milk loses its heat very quickly when cooled in water, but very slowly when it is simply placed in a cold room. After standing four or five hours the top- milk may be removed; after twelve to sixteen hours the cream may be removed. Hoio should milk he handled when bottled milk is purchased? It should be cooled as just described, as its tem- perature is usually somewhat raised during trans- portation. If it has been bottled at a dairy, -the cream or the top-milk may be removed after an hour or so. How should milk and cream he handled when they are purchased in hulk? Such milk should never be used for infants when it is possible to obtain bottled milk, as it is much more liable to contamination. Both cream and milk should be poured at once into covered vessels and kept in the coolest place possible. The cream and top-milk will seldom rise upon such milk with any satisfactory regularity. 58 THE CARE AND FEEDING OP CHILDREN What are the important things to he secured in nursery refrigerators ? Absolute cleanliness is essential; hence the inner portion should be of metal. Those made entirely of metal are unsatisfactory as in them the ice melts very quickly. If the ordinary metal refrigerator sold is encased in a wooden box, we have the best form. Another easy way of securing the same result is to make for the refrigerator a covering or " cosey " of felt or heavy quilting, which can be easily re- moved when wet or soiled. The compartments of the refrigerator should be so arranged that the bottles of milk are either in ■contact with the ice or very near it. The supply of ice should be abundant. Often the amount of ice is so small, and the bottles so far away, that the tem- perature of the milk is never below 60° or 65° F. To be really effective a refrigerator should have a temperature where the milk is placed of not over 50° F. The temperature should be tested with the nursery thermometer from time to time to ascertain what results are being obtained. Spoiled milk owing to a faulty refrigerator is to be blamed for many attacks of acute illness among infants. 'Next to the feeding-bottles it is the one thing in the nursery which should receive the closest attention. THE MODIFICATION OF COW'S MILK 59 What is meant by the modification of coiv's milk? Changing its proportions so that it can be more easily digested. Is it 'possible to modify cow's milk so as to make it a perfect substitute for mother's milk? It is not. Although we can modify cow's milk so that the great majority of infants can digest it and thrive on it, it must be remembered that there are differences which cannot be wholly overcome. There are certain peculiar qualities in mother's milk which cow's milk does not contain. How is this milk, whose proportions have been changed, distinguished from the unchanged milk? The changed milk is usually called " modified milk " ; the original unchanged milk is known as " plain milk," " whole milk," " straight milk," or is referred to simply as " milk." What are the principal differences between cow's milk and mother's milk? Cow's milk has only a little more than half as much sugar; it has nearly three times as much pro- teids and salts ; its proteids and fat are different and much more difficult of digestion; its reaction is de- cidedly acid, that of mother's milk is faintly acid or neutral. 60 THE CARE AND FEEDING OF CHILDREN Are there any other important things to he con- sidered ? Yes; mother's milk is always fed fresh and is practically sterile. Cow's milk is generally kept twenty-four hours and sometimes much longer. It is always to a greater or less degree contaminated by dirt and germs, the number of which increases rapidly (1) with the age of the milk; (2) in propor- tion to amount of the dust or dirt which enters it ; (3) with any increase in the temperature at which the milk is kept. It is just as important for success in infant feed- ing that these conditions receive attention as that the proportions of the different elements of the milk are right. Hoiu is the acidity of cow's milk overcome? By the addition of lime-water or bicarbonate of soda. If lime-water is used, one ounce to twenty ounces of food is generally required ; if soda is used, twenty grains to twenty ounces of food. If there is a tendency to constipation the milk of magnesia (Phillips's) may be used; from one half to one teaspoonful being added to each twenty ounces of food. How is the sugar best increased? By adding milk sugar to the food ; one ounce to THE MODIFICATION OF COWS MILK 61 eacli twenty ounces of food will give the proper quantity for the first three or four months. This will make the proportion about the same (between 6 and 7 per cent) as in mother's milk. How should the sugar he prepared? Simply dissolved in boiled water ; if the solution is not clear, or if there is a deposit after standing, it should be filtered by pouring through a layer of absorbent cotton, half an inch thick, which is placed in an ordinary funnel. Will not cane (granulated) sugar answer as well? !N"ot as a rule; however, there are many infants who get on very well when cane sugar is used. It has the advantage of being much cheaper. A good grade of milk sugar is somewhat expensive, costing from twenty-five to sixty cents a pound, and cheap samples are apt to contain impurities. If cane sugar is used, what amount should he added? Considerably less than of the milk sugar. Usu- ally about half the quantity (half an ounce to twenty ounces of food) is as much as most infants can di- gest. If the same quantity is used as of the milk sugar, the food is made unduly sweet, and the sugar is likely to ferment in the stomach and cause colic. 62 THE CARE AND FEEDING OF CHILDREN Is not the purpose of the sugar to sweeten the food in order to make it palatable? Not at all; although it does that, its real use is to furnish one of the essential elements needed for the growth of the body, and the one that is required by young infants in the largest quantity. How do we know that this is so f By the fact that in good breast milk the amount of sugar is greater than that of the fat, proteids, and salts combined. We have seen that pow's milk has nearly three times as much proteids (curd) and salts as mother s milk. How are these to he diminished? By diluting the milk. Will it he sufficient to dilute the milk twice {i. e., add two parts of water to one part of milk) ? 'Eol for a very young infant. Although this will give about the quantity of proteids present in moth- er's milk, the proteids of cow's milk are so much more difficult for the infant to digest, that in the beginning it should be diluted five or six times for most infants. If cow's milk is properly diluted and lime-water and sugar added does it then resemble mother s milk? !N^o; the mixture contains less fat. THE MODIFICATION OF COW'S MILK 63 7s it desirable to increase the fat to the proportioyi present in mother s milhf On account of the difference in digestibility it is usually impossible to give to young infants as much fat in cow's milk as is present in good mother's milk. For most infants it is, however, desirable to give more fat than is contained in cow's milk when this has been simply diluted. What is' the easiest way to secure a milJc which contains the proper proportion of fatf By^increasing the fat in the milk before dilution. It may be done by using top-milk or a mixture of milk and cream. What is top-milk? It is the upper layer of milk removed after standing a certain number of hours in a milk bottle, glass jar, or any tall vessel with straight sides. It contains most of the cream and some of the milk just below. The strength of the top-milk is measured by the fat it contains — e. g., 7-per-cent milk contains 7 per cent fat, etc. This is the top-milk of most use in infant feeding. When and how should top-milk he removed? If milk fresh from the cow, or before the cream has risen, is put into bottles and rapidly cooled, the 64 THE CARE AND FEEDING OF CHILDREN top-milk may be removed in as short a time as four hours. In the case of bottled milk it makes little difference if it stands a longer time, even until the next day. The best means of removing it is by a small cream-dipper ^ holding one ounce ; although it may be taken off by a spoon or siphon. It should not be poured off. Does the upper half always contain 7-per-cent fat? "No ; this varies with the length of time the milk has stood, and still more with the richness of the milk used. The richness of the milk depends on several fac- tors : whether it is from a herd or a single cow, also on the breed of the cow and on the manner of feed- ing. In good average milk the cream forms about one-eighth of the whole amount after the milk has stood four or ^ve hours. How can we obtain a 7-per-cent top-milk with the different hinds of cow's milk? From a rather poor milk, by removing the upper eleven ounces from a quart, or about one third. * Obtained from any of the Walker-Gordon milk laboratories, from James Dougherty, No. 411 West 59th Street, New York, and from many druggists. Price, 20 cents. THE MODIFICATION OF COW'S MILK 65 From a good average milk, by removing the upper sixteen ounces, or one half. Erom a rich Jersey milk, by removing the upper twenty-two ounces, or about two thirds. What is cream? Cream is often spoken of as if it were the fat in milk. It is really the part of the milk which contains most of the fat. It differs from milk chiefly in containing much more fat. In what ways is cream now obtained? (1) By skimming, after the milk has stood usu- ally for twenty-four hours ; this is known as " grav- ity cream." (2) By an apparatus known as a sepa- rator ; this is known as " centrifugal cream " ; most of the cream now sold in cities is of this kind. The richness of any cream is indicated by the amount of fat it contains. The usual gravity cream sold has from 16 to 20 per cent fat. The cream removed from the upper part (one fifth) of a bottle of milk has about 16 per cent fat. The usual centrifugal cream has 18 to 20 per cent fat. The heavy centrifugal cream has 35 to 40 per cent fat. 7s cream more digestible than milk? This depends much upon circumstances. For most infants it is much less so; many seri- 66 THE CARE AND FEEDING OF CHILDREN ous disturbances of digestion are caused by cream. What are the important points to he rememhered in modifying cow's milk for feeding during the early months? That of the different ingredients the sugar is most easily digested; for most infants the fat is next; while the proteids are the most difficult of all. There are, however, some infants who have as much difficulty in digesting the fat as they do in digesting the proteids of cow's milk. What relation should the fat hear to the proteids during this period? For most infants Avith good digestion the best results are obtained when the fat is higher than the proteids — e. g., twice as much. However, this is not true of all. There are many healthy infants who are unable to digest this proportion of fat, and who do much better when the fat and the proteids are about equal. * The directions and formulas given in the following pages are intended only for guidance in feeding children who are not suf- fering from any special disturbance of digestion; directions for such conditions are given in a later chapter. FOOD FOR HEALTHY INFANTS 67 Two groups of formulas are therefore useful: (1) Those in which the fats are higher than the proteids, derived from top-milk; (2) those in which the two are about the same, derived from whole milk. How can one ohtain formulas in which the fat is twice the proteids? Bj using for dilution a Y-per-cent milk, for in this the fat is exactly twice the proteids. How can one get the 7-per-cent milk? (1) Most easily as top-milk, as described on page 64; or (2) by mixing three parts of milk and one part of ordinary (16-per-cent) cream; (3) from any of the milk laboratories it may be obtained directly. How should the food he prepared? It is convenient in calculation to make up twenty ounces of food at a time. The first step is to obtain the 7-per-cent milk. Then to take the number of ounces of this that are called for in the formula desired. !N'oTE. — One should not make the mistake of taking from the top of the bottle only the number of ounces needed in the formula, as this may give quite a different result. There will be required in addition one ounce of 68 THE CARE AND FEEDING OF CHILDREN milk sugar ^ and one ounce of lime-water in each tsventy ounces. The rest of the food will be made up of boiled water. These formulas written out would be as follows: Formulas from 7 ■per- cent Milk I. II. III. IV. V. VI. VII. VIII. IX. 7-per-cent milk Milk sugar Lime-water Boiled water Oz. 2 1 1 17 Oz. 3 1 1 16 Oz. 4 1 1 15 Oz. 5 1 1 14 Oz. 6 1 1 13 Oz. 7 1 1 12 Oz. 8 1 1 11 Oz. 9 1 1 10 Oz. 10 1 1 9 20 20 20 20 20 20 20 20 20 The approximate composition of these formulas expressed in percentages is as follows: FoRMrLA. Fat. Sugar. Proteids. I 0.70 1.00 1.40 1.75 2.00 2.40 2.80 3.10 '3.50 5.50 6.00 6.00 6.00 6.50 6.50 6.50 7.00 7.00 35 II 0.50 Ill 0.70 IV 0.87 V 1.00 VI 1.20 VII 1.40 VIII 1.55 IX 1.75 ^ If the milk sugar be measured in the milk-dipper, two scant ■dipperfuls may be calculated as one ounce. If measured in a tablespoon, three even tablespoonfuls may be calculated as one FOOD FOR HEALTHY INFANTS Why is it necessary to make the food so weak at first? Because the infant's stomach is intended to digest breast milk, not cow's milk; but if we begin with a very weak cow's milk the stomach can be gradually trained to digest it. If we began with a strong milk the digestion might be seriously upset. How rapidly can the food he increased in strength from Formula I to II, from II to III, etc. f 1^0 absolute rule can be given. Usually we begin w^ith I on the second day ; II on the fourth day ; III at ten to fourteen days; but after that make the increase more slowly. A large infant with a strong digestion will bear a rather rapid increase and may be able to take V by the time it is three or four weeks old. A child with a feeble digestion must go much slower and may not reach V before it is three or four months old. It is important with all children that the increase in the food be made very gradually. It may be best with many infants to increase the milk by only half an ounce in twenty ounces of food, instead of one ounce at a time as indicated in the tables. Thus from 3 ounces, the increase would be to 3^ ounces; from 4 ounces to 4^ ounces, etc. At least two or 70 THE CARE AND FEEDING OP CHILDREN three days should be allowed between each increase in the strength of the food. The quantities proper for the different ages, and the intervals of feeding, are given on page 105. What general rule can he given for increasing the food? To increase when the infant is not satisfied but is digesting well, and always to wait at least two or three days between each addition to the food. For fuller directions about increasing the food see pages 78 and 79. How does an infant show that he is not satis- fied? He drains the bottle eagerly and cries Avhen it is taken away. He often forms the habit of sucking his fingers immediately after. He begins to fret half an hour or an hour before the next feeding is due. Under such circumstances is it better to increase the strength or the quantity of the food? It is well to alternate; at first increasing the strength, next the quantity, then the strength, and so on. Up to what age should formulas from 7-per-cent milk he continued? Usually up to six or seven months. FOOD FOR HEALTHY INFANTS 71 What formulas should follow these ? The change should gradually be made to those from whole milk. How may this he done f Instead of removing the upper 16 ounces as top milk, one may for two weeks remove the upper 18 ounces as top milk. For the next two weeks remove the upper 20 ounces as top milk. For the next two weeks remove the upper 24 ounces as top milk. After this the bottle may be shaken up and the whole milk used. After these changes should the -number of ounces of milk in the food remain the same ? Only while the upper 18 ounces are used. When the upper 20 ounces are removed as top-milk, each 20 ounces of the food should contain 11 ounces of this milk. When the upper 24 ounces are removed, each 20 ounces of the food should contain 12 ounces of this milk. When the whole milk is used, each 20 ounces of the food should contain 13 ounces of the milk. These formulas written out in full would be as follows ; 72 THE CARE AND FEEDING OF CHILDREN I. II. III. Top-milk Milk sugar Lime-water Gruel 1 1 8 Oz. /Upperl .2 124 0Z./-- ^^ 1 4 3 Oz. /Wholel iQ Imilk /•• 1^ 1 6 Water 20 20 20 Usually by the time ^o. II is reached farina- ceous food may be introduced in the form of gruel, as explained on page 82. How long may No. Ill he continued? If conditions have been such that the schedule could be followed this formula would be reached at seven or eight months. With little or no change this may be continued until the child is nearly a year old, the amount of food given at each feeding being, of course, gradually increased. See page 105. In the series of formulas given in the table the quantities are mentioned for making only twenty ounces of food. How should it he prepared when m,ore than this quantity is needed? It is equally convenient to make up 25 ounces, 30 ounces, 35 ounces, or 40 ounces at a time. FOOD FOR HEALTHY INFANTS 78 To make 25 ounces of any formula add one quarter more of each ingredient. 30 " " " " one half 35 " " " " three quarters " 40 " " " " twice as much " " " Thus, 25 ounces of Formula I would be obtained by using 2J ounces of milk, 1^ ounces of sugar and lime-water, 21 J ounces of water; 30 ounces of the same would require 3 ounces of milk, IJ ounces of lime-water and sugar, and 25^ ounces of water; 35 ounces would require 3^ ounces of milk. If ounces of lime-water and sugar, and 29f ounces of water. The amount of water need not be calculated in any case, but after measuring carefully the other ingre- dients enough water should be added to bring the total up to the amount required. Formulas from Whole Milk Why is such a series of formulas necessary for young infants? Not all children can take as high fats as are given in formulas derived from 7-per-cent milk. How is this shown f Sometimes simply by the fact that they do not thrive properly. Sometimes by marked symptoms of indigestion, such as habitual vomiting, or loose bowels 74 THE CARE AND FEEDING OF CHILDREN with green stools, or constipation with dry crumbly stools. In general the advice may be given that if a child is not doing well upon the first series of formu- las a change to the second should be made. Are there any disadvantages in using this group of formulas? It is certainly true that there is with most chil- dren a greater tendency to constipation than when the formulas from top-milk can be given. It is also true that when the fat is made low the gain in weight is less. Because of this fact other things must be intro- duced to take the place of the fat. What elements can taJce the place of the fat? Principally the carbohydrates — sugar and starch. More sugar should be given and starches should be introduced earlier than when higher fats are used. Formulas from Whole Milk {If-per-cent Fat) I. II. III. IV. V. VI. VII. VIII. IX. X. Milk Oz. 4 1 1 15 Oz. 5 1 1 14 Oz. 6 1 1 11 2 Oz. 7 1 1 8 4 Oz. 8 1 1 5 6 Oz. 9 i 1 4 6 Oz. 10 i 1 3 6 Oz. 11 1 \ 6 Oz. 12 i 1 1 6 Oz. 18 Sugar Lime-water . . W :er ( .el 1 6 20 20 20 20 20 20 20 20 20 20 FOOD FOR HEALTHY INFANTS 75 The approximate composition of these formulas expressed in percentages is as follows: Formula, Fat. Sugar. Proteids. I 0.80 1.00 1.20 1.40 1.60 1.80 2.00 2.20 2.40 2.60 6.00 6.00 6.00 6.50 6.50 6.00 6.00 6.00 6.00 6.00 0.70 II 0.90 Ill 1 00 IV 1.20 V 1.40 VI 1.60 VII 1.80 VIII 2.00 IX 2.10 X 2.30 Gruel for Formulas III, IV, and V should be made, one level tablespoonful of wheat, barley or oat flour to 8 ounces of water. For formulas VI, VII, VIII, IX, and X, two level tablespoonfuls to 8 ounces of water should be used. It will be noted that N^o. X of this series is the same as No. Ill, page 72. How should the food he made up if these formulas are used? The gruel is cooked separately as described on page 147 ; when it has partly cooled the milk, lime- water, milk sugar and water are added and thoroughly mixed. 76 THE CARE AND FEEDING OP CHILDREN How should the strength of the food he increased when this series of formulas is used f The general rules given on pages 70 and Yl may be followed, except that on account of the higher pro- teids in this series the increase after Xo. Ill should be made more slowly ; so that ordinarily ~Eo. V would not be reached until about two months. How rapidly after this time should the food he strengthened? In general the advance from one formula to the next stronger should be made once a month. It is often desirable to make half the increase in the mid- dle of the month. If the schedule is followed ^o. X would be reached at seven or eight months and may be con- tinued for the balance of the first year. GENERAL EULES FOE GUIDANCE IN THE USE OF THE FOEMULAS GIVEN It should again be emphasized that these for- mulas are not intended for sick children nor for those suffering from any marked symptoms of in- digestion. For such infants special rules are given later. GENERAL RULES FOR GUIDANCE 77 What should he the guide in deciding upon a formula with which to begin for a child who is to he artificially fed? The age and the weight are of some importance, but the best guide is the condition of the child's digestive organs. One should always begin with a weak formula, particularly, (1) with an infant pre- viously breast fed; (2) with one just weaned, as a child who has never had cow's milk must at first have weaker proportions than the age and the weight would seem to indicate; (3) with infants whose pow- er of digestion is unknown. If the first formula tried is weaker than the child can digest, the food can be strengthened every three or four days until it is found what the child is able to take. On the contrary, if the food is made too strong at first, an attack of indigestion will probably follow. How should the food he increased in strength? The first essential is that it be done very gradu- ally; abruptly increasing the food usually causes a disturbance of digestion. It is never wise to advance more rapidly in strengthening the food than from one formula to the next one in any of lihe series given; with many in- fants it is better to make the steps of increase only half as great as those indicated (page 69). 78 THE CARE AND FEEDING OF CHILDREN How rapidly should the food he increased in quantity? The increase should not be more than a quarter of an ounce in each feeding ; and not of tener than every three days. When should the food he increased? In the early weeks an increase may be necessary every few days; in the later months sometimes the same formula may be continued for two or three months. It is, however, impossible to give a definite rule as to time. One cannot say with any child that an increase is to be made every week or every two weeks. A much better guide is the condition of the digestion as shown by the child's appetite. The char- acter of the stools, the sleep, and the general disposi- tion. The signs indicating that the food should be in- creased are, that the infant is not satisfied, not gain- ing in weight, but is digesting well, i. e., not vomit- ing, and having good stools. One should not increase the food, however, so long as the child seems perfectly satisfied and is gaining from four to six ounces a week, even though both the quantity and the strength of the food are considerably below the average ; nor should the food be increased if the child is gaining from eight to ten ounces a week, even if he seems GENERAL RULES FOR GUIDANCE 79 somewhat hungry. The appetite is not always a safe guide to follow. There are many infants who will habitually take more food than they are able to digest and there is a danger of increasing the amount of food beyond the normal capacity of the child's stomach. The ultimate results of such overfeeding are serious disturbances of digestion and in some instances dila- tation of the stomach. How can one Jcnoiv whether the strength or the quantity of the food should he increased? In the early weeks it is well first to increase the strength of the food, the next time to increase the quantity, then the strength again, etc. After the fourth or fifth month, the quantity, chiefly, should be increased. // a slight disturbance or discomfort occurs after the food has been strengthened, is it best to go bach to the weaker formula or to persist with the new one ? Symptoms of minor discomfort are seen for a day or two with many infants after an ordinary increase in food; but in most cases an infant soon becomes accustomed to the stronger food and is able to digest it. If, however, the symptoms of disturbance are marked, one should promptly go back to the weaker formula. The next increase should be a smaller one. 80 THE CARE AND FEEDING OF CHILDREN Should one he distuTJjed if for the first two or three weeks of artificial feeding the gain in weight is very slight or even if there is none ? 'Not as a rule. If the infant does not lose weight, is perfectly comfortable, sleeps most of the time, and does not suffer from any symptoms of indi- gestion, such as colic, vomiting, etc., one may be sure that all is going well and that the infant is becoming used to his new food. As the child's appetite im- proves and his digestion is stronger, the food may be increased every few days and very soon the gain in weight will come and will then be continuous. If, however, the scales" are watched too closely and, be- cause there is only a slight gain in weight or none at all, the food is rapidly increased, an acute dis- turbance of digestion is pretty certain to follow. 7s not constipation likely to occur if the child is on a very weak food? It is very often seen and is due simply to the small amount of residue in the intestine. But if the bowels move once a day, one should not be disturbed even when the movements are small and somewhat dry. As the food is gradually strengthened, this constipation soon passes off; while if injections, suppositories, or cathartics are used to produce freer movements, the functions of the bowels are likely to be disturbed. FOR GUIDANCE 81 Under what circumstances should the food he reduced? Whenever the child becomes ill from any cause whatever, or whenever any marked symptoms of indi- gestion arise. How may this he done ? If the disturbance is only a moderate one and the food has been made up for the day, one third may be poured off from the top of each bottle just before it is given, and this quantity of food replaced by the same amount of boiled water. If the disturbance is more severe, the food should be immediately diluted by at least one half and at the same time the quantity given should be reduced. For a severe acute attack of indigestion the regu- lar food should be omitted altogether and only water given until the doctor has been called. If the food has heen reduced for a disturhance of digestion, how should one return to the original formula f While the reduction of the food should be im- mediate and considerable, the increase should be very gradual. After a serious attack of acute indigestion, when beginning with milk again, it should not be 82 THE CARE AND FEEDING OP CHILDREN made more than one fifth the original strength, and from ten days to two weeks should pass before the child is brought back to his original food, which should be done very gradually. It is surprising how long a time is required with young infants before they completely recover from an attack of acute indi- gestion, even though it did not seem to be very severe. The second disturbance always comes from a slighter cause than the first one. THE ADDITION OF OTHEE FOODS TO MILK When should other food he added to the milk? This depends upon circumstances. If formulas from 7-per-cent milk are given, farinaceous food is usually begun at six or seven months. If formulas from whole milk are used it may be given earlier ; a small amount may be added as early as two months, and at three months more may be given. The reason for this has already been mentioned (page 74). What further additions may he made to the diet of healthy infants during the first year? Beef juice, the white of egg, and orange juice. How and when may heef juice he used? With infants who are strong and thriving satis- factorily it may be begun at ten or eleven months; THE ADDITION" OF OTHER FOODS TO MILK 83 two teaspoonfuls may be given daily, diluted with the same quantity of water, fifteen minutes before the midday feeding; in two weeks the quantity may be doubled; and in four weeks six teaspoon- fuls may be given. The maximum quantity at one year should not be more than two or three table- spoonfuls. With delicate infants who are pale and ana?mic, beef juice is more important, and it may often be wisely begun at five or six months in half the quan- tities mentioned. When should white of egg he used? Under the same conditions as beef juice, particu- larly with infants who have difficulty in digesting the proteids (curd) of milk. At six months half the white of one egg may be given at one time, and soon after this the entire white of one egg. The best manner of cooking is the " coddled " Qgg (see page 149). When should orange juice he hegun ? There are many infants whose nutrition is dis- tinctly benefited by giving small quantities of orange juice as early as five or six months, when two or three teaspoonfuls a day may be given an hour before the feeding. By the time one year is reached from two 84 THE CARE AND FEEDING OF CHILDREN to four tablespoonfuls a ^ay may be given. It is par- ticularly useful when there is constipation. It should always be strained, and care should be taken that it is sweet and fresh. OVERFEEDING What is meant hy overfeeding? Giving an infant too much food ; either too much at one time or too frequently. Overfeeding is some- times practised during the day, but is chiefly done at night. 7s not an infant's natural desire for food a proper guide as to the qvxintity given f The appetite of a perfectly normal infant usu- ally is ; but overeating is a habit gradually acquired and may continue until twice as much food as is proper is taken in the twenty-four hours. This habit is most frequently seen in infants whose digestion is not quite normal ; because of the temporary relief from discomfort experienced by taking food into the stomach, they often appear to be hungry the greater part of the time, especially at night. What are the causes of overfeeding? The most common one is the habit of watching the weight too closely, and the conviction on the part OVERFEEDING 85 of the mother or nurse that because a child is not so large nor gaining so rapidly as some other infant of the same age, more food or stronger food should be given. What harm results from overfeeding? All food taken in excess of what a child can digest becomes a burden to him. The food lies in the stomach or bowels undigested, ferments, and causes wind and colic. When overfeeding is longer con- tinued, serious disturbances of digestion are soon produced. The infant is restless, fretful, constantly uncomfortable, sleeps badly, and stops gaining and may even lose in weight. Such symptoms may lead to the mistaken conclusion that too little food is given, and it is accordingly increased, when it should be diminished. One of the results of long- continued overfeeding is dilatation or stretching of the stomach. What should guide one as to the quantity of food to he given to any infant? (1) The size of the infant's stomach at the dif- ferent months; (2) the amount of milk which the healthy nursing infant gets; (3) the quantities with which most children do best. The table of quantities and intervals of feeding, on page 105, gives the aver- 86 THE CARE AND FEEDING OF CHILDREN age figures derived f rom.''these sources. It is seldom wise to go beyond the limits there stated ; nor should one insist upon giving any fixed amount if it is clearly more than the child wants or can be made to take except by continued coaxing. LOSS OF APPETITE What is to he done when without any other signs of illness a child's appetite gradually fails? This is often the result of a long period of over- feeding or the use of milk too rich in fat. If in all other respects the chil(J seems well and simply does not want his food, it should be offered at regular hours, but not more frequently ; on no account should he be coaxed, -much less forced, to eat, even though he takes only one half or one third the usual quantity. The intervals between feedings should not be short- ened but rather lengthened. Often, with a child a year old, it is necessary to reduce the number of feedings to four or even three in twenty-four hours. Water, however, may be offered at more frequent in- tervals. The food should be weakened rather than strengthened. !N'o greater mistake can be made than, because so little is taken, coaxing or forcing food at short intervals through fear lest the child may lose weight. CHANGES REQUIRED BY SPECIAL SYMPTOMS 87 THE CHANGES IN THE FOOD EEQUIEED BY SPECIAL SYMPTOMS OR CONDITIONS Why is it that an infant so often vomits some of its food within a few moments after finishing its bottle f Usually because the quantity is too large. Some- times it is due to the fact that the food is taken too rapidly, from too large a hole in the nipple. It may he due to too tight clothing, or to moving the child about in such a way as to press upon the stomach. What are the principal causes of, and the changes in the food required hy habitual vomiting, regurgi- tation, or spitting up of small quantities of food between feedings, often repeated many times a day? This is a symptom of gastric indigestion, and a most troublesome one. In such conditions the fat should always be reduced and the lime-water may be increased. In cases not improved by this change it may be necessary to reduce the fat still further. This is especially true if the whole milk used is very rich. 88 THE CARE AND FEEDING OF CHILDREN Under these circumstances one should remove some of the cream from the top of the bottle before shak- ing it up. How much cream should he removed? At first 4 ounces may be taken off, after which the bottle is shaken and the balance used as in the formulas from whole milk. After a few days if the sjTnptoms improve only 3 ounces of cream may be removed. After a few days longer only 2 ounces are removed, then only 1 ounce and finally the child is brought back to the mixtures from whole milk. How much lime-water may he used? Improvement from this change may follow if the amount of lime-water is doubled. There is rarely any advantage in using more than this ; — i. e., 2 ounces in 20 ounces of food. 7s vomiting often increased hy the sugar? This is not likely with milk sugar if only the quantity mentioned in the formulas is used. How- ever the use of cane sugar often aggravates the vomit- ing, and malt sugar almost invariably does so. There- fore under these conditions the use of any of the malted foods should be carefully avoided. CHANGES REQUIRED BY SPECIAL SYMPTOMS 89 What changes should he made in the intervals of feeding ? Under no circumstances should a vomiting baby be fed oftener than every three hours, and sometimes the intervals should be longer. What changes should he made in the quantity given at a feeding? It is difficult to lay down an absolute rule. Usu- ally a small quantity of a stronger food is better than a larger quantity of a weak food. But one should not give more than is advised in the schedule for the age of the child. To give somewhat smaller quanti- ties is sometimes useful but often this is of no assist- ance. What are the causes of, and food changes required hy a constant and excessive formation of gas in the stomach, leading to distention and pain^ or eructa- tions (helching) of gas and often of a sour, watery fluid? This is often associated with habitual vomiting, and is due to similar causes, but particularly to the sugars mentioned. Besides the measures already described to con- trol vomiting, benefit sometimes follows the use of benzoate of soda, of which half a grain may be added 90 THE CARE AND FEEDING OF CHILDREN to each ounce of food and continued for a few weeks if necessary. What changes should he made in the food when there is habitual flatulence and colic? Flatulence occurs when there is excessive forma- tion of gas in the intestines. If this is readily ex- pelled the child suffers no great discomfort; but if not, some distention of the bowel takes place and colic results. Both these conditions are greatly aggravated by constipation, and to relieve the constipation is often the best means of controlling them. The gas usually arises from faulty digestion of the sugars, starch or proteids, and any of these ele- ments of the food may need to be reduced, particu- larly the starch which in many cases should be omitted altogether. If the proteids are at fault benefit may follow the use of partially peptonized milk. What changes should he made in the food for chronic constipation ? Nothing should be done if the child has one good movement a day. Such a child cannot be called con- stipated. The constipation of the first weeks of life has CHANGES REQUIRED BY SPECIAL SYMPTOMS 91 been already referred to (page 80) ; it usually dis- appears as the food is gradually strengthened in all its proportions. Habitual constipation at a later period is dijfficult to overcome by diet alone. It sometimes depends upon the fact that the proteids are too high, and sometimes that the fat is too low. Hence it is more frequent when infants are fed upon formulas from whole milk, than when formulas from top-milk, or milk and cream are used. But it is not desirable to use a top-milk containing more than 7-per-cent fat for this purpose as other disturbances of digestion may be produced. i^ In some cases a part or all of the milk sugar may be replaced by malt sugar (maltose). This may be used in the form of Trommer's extract of malt, Bor- cherdf s or Loeflund's malt soup extract. Of these from one teaspoonful to one ounce may be added to the food when it is made up for the day. Or some of the foods which contain a large amount of malt- ose (Mellin's food, malted milk, cereal milk) may replace the milk sugar. The substitution of the milk of magnesia for the lime-water as recommended on page 60 will often be found useful. After a short time the amount given each day may gradually be reduced until finally it is discontinued. 92 THE CARE AND FEEDING OF CHILDREN To infants over nme> months old, orange juice may be given. What special modifications are required during very hot weather? During the warm season it is well to make the proportion of fat less than during cold weather. During short periods of excessive heat it should be much less. The fat is reduced by using whole milk in place of the 7-per-cent milk. At such times also the usual food should be diluted, and water should be given freely between the feedings. What changes should he made in the food of a child who, with all the signs of good digestion, gains very little or not at all in weight? If the child seems hungry the quantity of food may be increased; but if the child will not readily take any more in quantity the strength may be in- creased by the use of the next higher formula. (If there is no vomiting the addition of one of the prep- arations of malt as recommended for the relief of constipation may be useful.) One should, however, be extremely careful under these circumstances not to coax or force a child to eat; for this plan CHANGES REQUIRED BY SPECIAL SYMPTOMS 93 is almost certain to cause disturbance of digestion and actual loss in weight. A better policy is that of looking after the other factors in the child's life, — the care, sleep, fresh air, etc., for with these rather than with the food the trouble often lies. What should he done with infants who in spite of all variations in the milk continue to have symp- toms of indigestion and do not thrive? Except inmates of institutions who form a class by themselves, most infants who receive proper care thrive upon milk if the proportions suited to the digestion are given. Still there are some who do not. The nutrition of such is always a matter of difficulty. If a wet-nurse is available the employment of one is the thing most likely to succeed, particularly if the infant is under four or five months old. If the infant is older, or if a wet-nurse cannot be obtained, some of the substitutes for fresh cow's milk may be tried. One of the best is condensed milk, Borden's Eagle brand, canned, being preferred. This is more likely to agree if the symptoms are chiefly intestinal (colic, flatulence, curds in the stools, con- stipation or diarrhoea) than if they are chiefly gas- tric (vomiting, regurgitation, etc.). How should condensed milk he usedf Eor an infant three or four months old with 94 THE CARE AND FEEDING OF CHILDREN symptoms of indigestion^ it should at first be di- luted with 16 parts of boiled water, or, sometimes preferably, with barley-water. With improvement in the^ symptoms the dilution may be made 1 to 14, 1 to 12, 1 to 10, and 1 to 8, these changes being gradually made. The intervals between feedings and the quantities for one feeding are given on page 108. How long should condensed milk he continued? In most cases it should be used as the sole food for a few weeks only. Afterward, one feeding a day of a weak formula of modified milk (e. g., ^N'o. II or III Whole Milk Series, page 74 may be given; later two feedings, and thus gradually the number of milk feedings is increased until the child is tak- ing only modified milk. Condensed milk is not to be recommended as a permanent food where good fresh cow's milk can be obtaiDed. What are the objections to its ttse? It is very low in fat and proteids, and high in sugar. This accounts for its easy digestibility, and also explains why children reared upon it often gain very rapidly in w^eight, yet have as a rule but little resistance. They are very prone to develop rickets and sometimes scurvy. CHANGES REQUIRED BY SPECIAL SYMPTOMS 95 Are the proprietary infant foods open to the same objections as condensed milk? They are. What has been said of condensed milk applies equally well to most of those that are sold in the market as substitutes for milk. What changes in the food are required by slight indisposition ? For slight general disturbances such as dentition, colds, sore throats, etc., it is usually sufficient simply to dilute the food. If this is but for two or three feedings, it is most easily done by replacing with boiled water an ounce or two of the food removed from the bottle just before it is given ; if for several days, a weaker formula should be used. What changes should be made for a serious acute illness? For such attacks as those of pneumonia, bron- chitis, measles, etc., attended with fever, the food should be diluted and the fat reduced as described on page 92. It should be given at regular intervals, rather less frequently than in health. Water should be given freely between the feedings. Food should not be forced in the early days of an acute illness, since the loss of appetite usually means an inability to digest much food. 96 THE CARE AND FEEDING OF CHILDREN What immediate changes should he made in the food when the child has an acute attack of gastric in- digestion with repeated vomiting , fever, pain, etc. f All milk should be stopped at once, and only boiled water given for ten or twelve hours; after- ward barlej-water or whey may be tried, but no milk for at least twenty-four hours after the vom- iting has ceased. When beginning with modified milk, formulas made from skimmed milk as described on page 88 should be used for a few days. The pro- portion of lime-water may be doubled. What changes should he made for an attack of in- testinal indigestion with looseness of the bowels? If this is not severe (only two or three passages daily) the fat should be lowered in the manner stated just above, and the milk should be boiled for five minutes. If undigested milk appears in the stools, it may be still further diluted. If the diar- rhoeal attack is more severe, and attended by fever and foul-smelling movements of greater frequency, all milk should be stopped immediately, and the diet mentioned just above under the head of acute dis- turbances of the stomach should be employed. What changes in the food should be made when the child seems to have very little appetite and yet is not ill? CHANGES EEQUIRED BY SPECIAL SYMPTOMS 97 The number of feedings should be reduced, the interval being lengthened by one hour or even more. 'No greater mistake can be made than to offer food every hour or two to an infant who is not hungry. That only prolongs and aggravates the disturbance. What other conditions besides the food greatly influence the child's digestion? Proper clothing, warm feet, regular habits, fresh air, clean bottles, and food given at the proper tem- perature, are all quite as important as the prepara- tion of the food ; quiet, peaceful surroundings and absence of excitement are also essential to good di- gestion. In many cases in which children suffer fre- quently from indigestion and do not gain properly in weight, the fault is not with the food but with the care that the child receives. Both while the food is being taken and afterwards he should be left quite alone. This is particularly necessary with nervous children. COMMON MISTAKES 11^ MILK MODIFICATION AND INFANT FEEDING I. In using modifications made from top-milk, much confusion arises from the notion that top-milk is a single definite thing, whereas its composition depends upon a great variety of conditions and, un- 98 THE CARE AND FEEDING OF CHILDREN less all these are known, 'it is impossible to tell how strong it is. Directions for the removal of top-milk should be explicitly followed, or the results wall be Terj different from those expected. II. In formulas calling for a certain number of ounces of top-milk, the mistake is made of removing only the number of ounces needed for the formula. The proper way is to remove the amount required to secure a top-milk of the desired strength and then to take of this the number of ounces needed in the formula. III. A rich Jersey milk is used as if it were ordinary milk. The formulas given in this book are chiefly calculated on the basis of a good average milk w^hich contains about 4 per cent fat. Many persons have the idea that the richer the milk, the more rap- idly the child will gain in weight, and hence the superiority of such milk for infant feeding. While it is true that some children taking a very rich milk may, for a time, gain rapidly in weight, yet sooner or later, serious disturbances of digestion are nearly always produced. IV. The food is increased too rapidly, particu- larly after some disturbance of digestion. If, in an infant three or four months old, an attack of some- what acute indigestion occurs, the food should sel- dom be given in full strength before two weeks. The PREPARATION OF COW'S MILK AT HOME 99 increase in the diet should be made very gradually, the steps being made only one half those indicated in the series of formulas found on page 68. Other- wise it generally happens that the attack of indiges- tion is very much prolonged and much loss in weight occurs. V. When symptoms of indigestion occur, the food is not reduced rapidly enough. Indigestion usually means that the organs are, for the time, unequal to the work imposed. If the food is immediately re- duced by one half, the organs of digestion soon regain their power and the disturbance is short. In every case the amount of reduction should depend upon the degree of the disturbance. What articles are required for the preparation of cow's milk at home? Feeding-bottles, rubber nipples, an eight-ounce graduated measuring glass, a glass or agate funnel, bottle brush, cotton, alcohol lamp or, better, a Bun- sen gas burner, a tall quart cup for warming bottles of milk, a pitcher for mixing the food, a wide-mouth bottle for boric acid and one for bicarbonate of soda, and a pasteurizer. Later, a double boiler for cooking cereals will be needed. 7 100 THE CARE AND FEEDING OF CHILDREN What bottles are to he-preferred? A cylindrical graduated bottle with a rather wide neck, so as to admit of easy washing, and one which contains no angles or corners. A single size holding eight ounces is quite sufficient for use during the first year. All complicated bottles are bad, being difficult to clean. One should have as many bottles in use as the child takes meals a day. How should bottles be cared for? As soon as they are emptied they should be rinsed with cold water and allowed to stand filled with water to which a little bicarbonate of soda has been added. Before the milk is put into them they should be thoroughly washed with a bottle brush and hot soap- suds and then placed for twenty minutes in boiling w^ater. What sort of nipples should he used? Only simple straight nipples which slip over the neck of the bottle. Those with a rubber or glass tube are too complicated and very difficult to keep clean, tipples made of black rubber are to be pre- ferred. The hole in the nipple should not be so large that the milk will run in a stream, but just large 'enough for it to drop rapidly when the bottle with the nipple attached is inverted. PREPARATION OF COW'S MILK AT HOME 101 How should nipples he cared for? 'New nipples should be boiled foi' five minutes; but it is unnecessary to repeat this every day as they soon become so soft as to be almost useless. After using, nipples should be carefully rinsed in cold water and kept in a covered glass containing a solu- tion of borax or boric acid. At least once a day they should be turned wrong side out and thoroughly washed with soap and water. What sort of cotton should he used? The refined non-absorbent cotton is rather better for stoppering bottles, but the ordinary absorbent cotton will answer every purpose. Which is better y the Bunsen burner or the alco- hol lamp? If there is gas in the house, the Bunsen burner is greatly to be preferred, being cheaper, simpler, and much safer than the alcohol lamp. If the lamp is used, it should stand upon a table covered with a plate of zinc or tin, or upon a large tin tray. The French pattern of alcohol lamp is the best. Give the directions for preparing the food ac- cording to any of the above formulas. The nurse's hands, bottles, tables, and all utensils should be scrupulously clean. First dissolve the milk sugar in boiling w^ater, filtering if necessary. 102 THE CARE AND FEEDING OF CHILDREN Then add the milk and, cream and lime-water, mix- ing the whole in a pitcher. A sufficient quantity of food for twenty-four hours is always to be prepared at one time. This is then divided into the number of feedings required for the day, each feeding being put in a separate bottle, and the bottle stoppered with cotton. The bottles should then be cooled rap- idly by standing, first in tepid then in cold water, and afterward placed in an ice chest. If the milk is to be pasteurized or sterilized, this should precede the cooling. DIRECTIONS FOE FEEDII^G INFANTS How should the bottle he prepared at feeding time f It should be taken from the ice chest, and warmed by standing in warm water which is deep enough to cover the milk in the bottle; it should then be thoroughly shaken and the nipple adjusted ; the nurse should see that the hole in the nipple is not too large nor too small. How may the temperature of the milk he tested? Xever by putting the nipple in the nurse's mouth. Before adjusting the nipple, a teaspoonful may be poured from the bottle and tasted, or a few drops may be poured through the nipple upon the inner DIRECTIONS FOR FEEDING INFANTS 103 surface of the wrist, where it should feel quite warm but never hot; or a thermometer may be placed in the water in which the bottle stands. A dairy ther- mometer should be used, and the temperature of the water should be between 98° and 105° F. What is a simple contrivance for "keeping the milk warm during feeding? A small flannel bag with a draw string may be slipped over the bottle. In what position should an infant take its bottle ? For the first two or three months it is better, except at night, when it may be undesirable to take the infant from its crib, that it be held on the nurse's arm during the feeding; later it may lie on its side in the crib provided the bottle is held by the nurse until it has been emptied ; otherwise a young infant readily falls into the bad habit of alternately sucking and sleeping, and often will be an hour or more over its bottle. How much time should he allowed for one feeding ? !N^ever more than twenty minutes. The bottle should then be taken away and not given until the next feeding time. Under no circumstances should an infant form the habit of sleeping with the nipple in its mouth. A sleepy infant should be kept awake 104 THE CARE AND FEEDING OF CHILDREN by gentle shaking until the food is taken, or the bot- tle should be removed altogether. Should an infant he 'played with soon after feeding f On no account; such a thing frequently causes vomiting and sometimes indigestion. After every feeding the infant should be allowed to lie quietly in its crib, and disturbed as little as possible, either by the nurse, the parents or visitors. INTERVALS OF FEEDING How often should a haby he fed during the first month? Every two hours during the day and twice during the night, or ten feedings in the twenty-four hours. At what age may the interval he made two and a half hours? Usually at five or six weeks. When may it he increased to three hours? Usually at two months. Why should not a child he fed more frequently? It takes the stomach nearly two hours to digest a meal at two months, and about two and a half hours at five or six months, and if the meals are too near together the second one is given before the first has DIRECTIONS FOR FEEDING INFANTS 105 been digested and vomiting and indigestion result* The meals should be far enough apart to give the stomach a little time for rest just before each feeding. Schedule for Feeding Healthy Infants during the First Year Age. 2d to 7th day 2d and 8d weeks 4th and 5th weeks 6th to Ulh week 9th week to 5th month 5th to 9th month 9th to 12th month Inter- Night No. of val be- feed- feed- Quantity for one tween ings (10 ings in meals. p. M. to 24 feeding. by day. 7 A. M.). hours. Hour.. Ounces. 2 2 10 1 -U 2 2 10 li-3 2 1 10 2i-3i 2ir 1 8 3 -5 3 1 7 4-6 3 6 5-7i 4 5 7 -9 Quantity for 24 hours. Onncet. 10-15 15-30 25-35 24-40 28-42 30-45 35-45 This schedule gives the averages for healthy chil- dren. The smaller quantities are those required by small children whose digestion is not very vigorous. The larger quantities are those required by large children with strong digestion; in very few cases Avill it be advisable to go above these figures. The interval is reckoned from the beginning of one feeding to the beginning of the next one. ^Yhen should the interval between the feedings he lengtheried? When there is gastric indigestion as shown by 106 THE CARE AND FEEDING OF CHILDREN habitual vomiting or the - regurgitation of food long after the bottle is finished ; also when the appetite is very poor so that the infant regularly leaves some of its food. When should the interval between the feedings he shortened? This is done much too frequently; it is rarely advisable to feed any infant, except one seriously ill, oftener than the time put down in the schedule. EEGULAEITY IN FEEDING How can a baby be taught to be regular in its habits of eating and sleeping? By always feeding at regular intervals and put- ting to sleep at exactly the same time every day and evening. When should regular training be begun? During the first week of life. Should a baby be wakened to be nursed or fed if sleeping quietly? Yes, for a few days. This will not be re- quired long, for with regular feeding an infant soon wakes regularly for its meal, almost upon the minute. STERILIZED MILK 107 Should regularity in feeding he kept up at night as well as during the day f Onlj up to nine or ten o'clock ; after that time a baby should be allowed to sleep as long as it will. At what age may a well hahy go without food from 10 p. M. to 6 or 7 a. m. f Usually at four months, and always at five or six months. E'ight feeding is one of the most frequent causes of wakefulness and disturbed sleep. STERILIZED MILK What is meant by sterilizing milk? Heating milk for the purpose of destroying germs. Does all cows* milk contain germs? Yes; even when handled most carefully, milk contains many germs; but when carelessly handled, and in summer, the number is enormous. While most of these are harmless or cause only the souring of milk, others are occasionally present which may produce serious diseases such as typhoid fever, diph- theria, scarlet fever, cholera, tuberculosis, and many forms of diarrhoea. Under what circumstances is it necessary to ster- ilize milkf 1. In warm weather when it cannot be obtained 108 THE CARE AND FEEDING OP CHILDREN fresh; hence always in cities and towns during the summer. 2. When one cannot be certain that the cows are healthy, or that the milk has been carefully handled. 3. When the milk is to be kept for any consider- able time (i. e., over twenty-four hours), especially if no ice can be had. 4. During epidemics of typhoid fever, scarlet fever, diphtheria, or any form of diarrhoeal disease. What are the two methods of heating milk? The first is kno^vn as sterilizing, in which the milk is heated to 212° F. for one hour or one hour and a half; the second is kno^vn as pasteurizing, in which the milk is heated to 155° or 160° F. for thirty minutes. A temperature of 155° F. continued for thirty minutes is sufficient to kill the germs of the diseases above referred to. Will milk which has been thus treated keep in- definitely ? ji^o; for although all the living germs may be killed, there are many undeveloped germs, or spores, which are not destroyed, and which soon grow into living germs. Milk heated to 212° F. for an hour will keep upon ice for two or three weeks ; that heated to 155° F. should be used within 24 hours. STERILIZED MILK 109 Is milk which has been sterilized always a safe food? 'No; for the reason that the milk may be so old, so dirty, and so contaminated before sterilizing thai it may be still unfit for food, though it contains no living germs. Is cow's milk rendered more digestible by being heated in this way? Sterilizing milk does not improve its digestibility but rather the contrary. Sterilized milk should be modified for infant feeding in the same v^ay as milk which has not been heated. Is milk in any way injured by heating to 2V2^ F. for an hour? There is abundant evidence that milk is ren- dered less digestible by such heating; also that it is more constipating, and that for some children its nutritive properties are interfered with, so that it may cause scurvy ; this, however, is not seen unless it is continued as the sole food for a long period. These objections are of so much importance that this plan of heating milk is not to be recommended for general use. When is it advantageous to heat milk to 212^ F. ? For use upon long journeys, such as crossing the ocean. Milk should then be heated for one hour 110 THE CARE AND FEEDING OF CHILDREN iipon two successive days; without removing the cot- ton stoppers from the bottles. 7s milk in any way injured hy heating to 155° F, for thirty minutes? This point is not yet definitely settled. Such heating does not affect the taste of milk and does not render it more constipating. The unfavourable effects, if there are any, are so slight that they need not deter one from the use of pasteurized milk, even for long periods. The preference, however, should always be given to milk which is so clean and so fresh as not to require any heating. How should milk he pasteurized? A convenient form of apparatus is that known as Freeman's pasteurizer ^ ) another is the Walker- Gordon pasteurizer.^ How should milk he cooled after 'pasteurizing? Always by placing the bottles in cold water, so as to cool them rapidly ; never by letting them stand at the temperature of the room, or by placing them, when warm, in an ice box. ^ This can be obtained at 411 "West Fifty-ninth Street, New York, with bottles and full directions ; a tin one, at a cost of $3.50, and a copper one, which is much more durable, for $7.00. 2 Obtained at the same prices from any of the Walker-Gordon milk laboratories. MODIFIED MILK OF THE MILK LABORATORIES 111 Why is this precaution necessary? Cooling in the air or in an ice box requires from two to four hours, and during that time a great many of the undeveloped germs may mature and greatly injure the keeping properties of the milk. In the cold water, milk can be cooled in from ten to twenty minutes if the water is frequently changed, or if ice is added to the water. MODIFIED MILK OF THE MILK LABORATORIES What is " modified milk " of the milk labora- tories ? It is milk containing definite proportions of the fat, sugar, proteids, etc., put up usually according to the prescription of a physician, who indicates how much of the different elements he desires. The most reliable are the laboratories of the Walker-Gordon Company, which has branches in many of the large cities of the United States. This is an excellent method of having milk pre- pared, since it can be done with greater care and cleanliness than are possible in most homes. It is besides a great convenience if circumstances make it impossible to prepare the milk properly at home. The laboratory should be used for infant feed- ing only by one who is somewhat familiar with this method of ordering milk. 112 THE CARE AND FEEDING OF CHILDREN PEPTONIZED MILK What is peptonized milhf Milk in which the proteids (curd) have been par- tially digested. How is this accomplished? By the action of a peptonizing powder which is composed of a digestive agent known as the extractum pancreatis and bicarbonate of soda, which is added to the plain or diluted milk. This is sold in tubes or in tablets, and it is the active ingredient of the peptogenic milk powder. Describe the process. The plain or modified milk is placed in a clean glass jar or bottle, and the peptonizing powder, which is first rubbed up with a tablespoonful of the milk, is added and the bottle shaken. The bottle is then placed in a large pitcher or basin containing water kept at the temperature of about 110° F., or as warm as the hand can bear comfortably, and left for ten to twenty minutes if the milk is to be partially peptonized; for two hours if it is to be completely peptonized. What taste has partially peptonized milk? INone, if peptonizing is continued for only ten minutes, but at the end of twenty minutes it begins PEPTONIZED MILK 113 to be bitter, when the process of digestion has gone further. How is the hitter taste avoided in partially pep- tonized milk? At the end of ten or fifteen minutes the milk may be placed in a saucepan and quickly raised to boiling point; this kills the ferment, so that the milk will not become bitter when warmed a second time. Or, the milk may be rapidly cooled by placing the bottles first in cool and then in ice water; in this way the ferment is not destroyed, and the milk may become bitter when warmed for feeding. Should the whole day's supply he peptonized at once, or each hottle separately just hefore the feeding ? Either plan may be followed. If the former, it is better to raise the milk to boiling point after pep- tonizing; if the latter, it should not be peptonized more than ten minutes, for it will continue to pep- tonize while it is being taken by the child. Is not the hitter taste of completely peptonized milk a great ohstacle to its use? E'ot in the case of young infants ; one under four or five months old will usually take it without any objection after two or three feedings; but it cannot often be used for those who are much older. 114 THE CARE AND FEEDING OF CHILDREN How much of the peptonizing powder should he used? There are required for one pint of plain milk, five grains of the extractum pancreatis and fifteen grains of bicarbonate of soda. This quantity is usu- ally put up in a single tube or tablet. In the formu- las previously given, less than this will be required ; for the weaker formulas, one half or one third of the powder mentioned will be sufficient for one pint of food. For a single feeding of four ounces, one may use one eighth of a tube with a weak formula, or one sixth of a tube with a stronger formula. What are the advantages of peptonized milh? Partially peptonized milk is useful for young in- fants who have great difficulty in digesting the curd of milk, sometimes even when diluted as already described; completely peptonized milk, during acute attacks of indigestion. For how long a period may the use of peptonized milk he continued? Completely peptonized milk may be used for a few days, or at most a few weeks; partially pepto- nized milk may be used for two or three months, but not indefinitely; it should be left off gradually by shortening the time of peptonizing, and lessening the amount of the powder used. FEEDING DURING THE SECOND TEAR 115 FEEDING DURING THE SECOND YEAR If the general directions given in previous pages have been followed, the infant will be taking at eleven or twelve months "^ve meals, at four-hour intervals, 8 or 9 ounces at a time. Of this, about two-thirds should be milk and one-third gruel — i. e.. Formula III, page 72, or Formula X, page 74. Besides this he will probably be receiving orange juice one or two ounces a day, and beef juice, one ounce a day. How many meals are required in the second year? Usually five meals. Some children will sleep from 6 p. M. to 6 A. M. without waking, but unless there is a feeding at 10 p. m. children are apt to wake very early in the morning. Should each feeding he prepared at the time given^ or all feedings together, as during the first year? During the second and third years it is better to prepare the milk for the entire day at one time. Later, when only plain milk is used, the quanti- ties needed for the different feedings should be put into one or into two bottles, which then may be pas- teurized or not as may be necessary. In this way the different feedings are kept separate, and the day's supply of milk is not disturbed every time the child is fed, as otherwise is unavoidable. The food 8 116 THE CARE AND FEEDING OF CHILDREN should be prepared as soon as possible after the daily milk supply is delivered in the morning. What changes may now he made in the food? The proportion of milk in the food may be in- creased ; the lime water and milk sugar may be grad- ually omitted ; broth may be added to one of the feed- ings. The child should begin to take at least part of his food from the cup. Give a proper diet for an average healthy child of twelve months. 6.30 A. M. Milk, six to seven ounces ; diluted with barley or oat gruel, two to three ounces; after the thirteenth month, taken from a cup. 9 A. M. Orange juice, one to two ounces. 10 A. M. Milk, two parts ; oatmeal or barley gruel, one part ; from ten to twelve ounces in all may be allowed ; it should be given from a cup. 2 P. M. Beef juice, one to two ounces ; or, the white of one egg, slightly cooked ; later the entire egg ; or, mutton or chicken broth, four to six ounces. Milk and gruel in proportions above given, four to six ounces. 6 p. M. Same as at 10 a. m. 10 p. M. Same as at 6.30 a. m., except that the milk may be given from the bottle. How long may this schedule he followed? Usually until the fourteenth or fifteenth month. After this time the cereals may be given much thicker and fed from a spoon. FEEDING DURING THE SECOND YEAR 117 May any other fruit juices he given at this period 9 Orange juice is the best; next to this the juice of fresh ripe peaches, red raspberries or strawberries. All these should be strained very carefully through muslin to make sure that the child gets none of the pulp or seeds, either of which may cause serious disturbance. Of the orange or peach juice, from one to four tablespoonfuls may be allowed at one time; of the others about half the quantity. The fruit juice is best given one hour before the second feeding. When should a child he weaned from its bottle? Most children can and should be taught to take their food from the cup or spoon by the time they are thirteen months old ; but it is convenient to give the 10 p. M. feeding from the bottle during the greater part of the second year (see page 52). Give a proper diet for an average child from the fourteenth to the eighteenth month. The bottle should not be given except at night. Cereals may now form an important part of the diet. They should be very thoroughly cooked, usually for three hours, and strained. 118 THE CARE AND FEEDING OF CHILDREN The daily schedule should be about as follows : 6.30 A. M. Milk, warmed, eight to ten ounces, given from a cup. 9 A. M. Fruit juice, one to three ounces. 10 A. M. Cereal : one, later two or three, tablespoonfuls of oat- meal, hominy or wheaten grits, cooked for at least three hours and strained ; upon this from one to two ounces of thin cream, or milk and cream, with plenty of salt, but without sugar. Crisp dry toast, one piece ; or, unsweetened zwieback ; or, one Huntley and Palmer breakfast biscuit. Milk, warmed, six to eight ounces, from a cup. a P.M. Beef juice, one to two ounces; and one egg (soft boiled, poached or coddled) ; and boiled rice, one tablespoonf ul ; or, broth (mutton or chicken), four ounces ; one or two Huntley and Palmer breakfast biscuits, or zwieback ; and (if most of the teeth are present) rare scraped meat, at first one teaspoonful, grad- ually increasing to one tablespoonful. 6 P. M. Cereal : two tablespoonfuls of farina, cream of wheat, or arrowroot, cooked for at least one half hour, with milk, plenty of salt, but without sugar. Milk, warmed, eight to ten ounces, given from a cup. 10 P. M. Milk, warmed, eight to ten ounces, which may be given from a bottle. Give a proper diet for an average child from the eighteenth month to the end of the second year. The same order of meals as for the months just preceding should be followed. For most children milk at 10 p. m. is desirable. There are many, how- ever, who sleep regularly from 6 p. m. until 6 a. m. FEEDING DURING THE SECOND YEAR 119 without food; for such the night feeding should, of course, not be insisted upon. The daily schedule should be about as follows : 6.30 A. M. Milk, warmed, ten to twelve ounces, given from cup. 9 A. M. Fruit juice, two to three ounces. A. M. Cereals : similar to those given from the fourteenth to the eighteenth month ; they need not be- strained although they should be cooked and served in the same way. Crisp dry bread, zwieback, or Huntley and Palmer biscuits, without butter. Milk, warmed, one cup. 2 P. M. Beef juice and one egg ; or, broth and meat; care being taken that the- meat is always rare and scraped or very finely divided; beefsteak, mutton chop, or roast beef may be given. Very stale bread, or two pieces of zwieback. Prune pulp or baked apple, one to two tablespoonful& Water ; no milk. 6 P. M. Cereal : farina, cream of wheat, or arrowroot, cooked for at least one half hour, with milk, plenty of salt, but without sugar, or, milk toast or stale bread and milk, 10 p. M. If required, ten to twelve ounces of plain milk. What fruits may he given at this period? If the child has a feeble digestion, only the fruit juices previously allowed ; strong children may have^ in addition prune pulp, baked apple, and apple- sauce. The prune pulp is prepared by stewing the dried prunes without sugar until they are very soft^ 120 THE CARE AND FEEDING OF CHILDREN and removing all the skin by putting the fruit through a strainer; of this from one to two table- spoonfuls may be given at one time. The baked apple should be given without cream, and the apple- sauce should have very little sugar. How and when should water he given f Throughout the second year water should be given freely between the feedings, especially in warm weather; from one to three ounces may be given at one time, either from a spoon, a glass, or a bottle. The water should be boiled daily and then cooled. It should not be allowed to stand in the room, but fresh water should be put into the bottle each time. FEEDING DURING THE THIRD YEAR What changes may he made in the diet during the third year? The night feeding at 10 p. m. should be omitted. A greater quantity of solid food may be allowed, particularly at the mid-day meal. It is not advisable to begin potato and other vegetables until this age is reached. Three regular meals should be given and milk once besides, either between the breakfast and dinner or dinner and supper, whichever is the longer interval. Water should be allowed freely between meals. FEEDING DURING THE THIRD YEAR 121 What would he a proper schedule for an average child during the third year? 7.30 A.M. Cereal: cooked (preferably over night) for three hours, although a somewhat larger variety may be given than during the second year ; given as before with milk or thin cream, salt, but very little sugar. "Warm milk, one glass. A soft egg, poached, boiled or coddled. Bread, very stale or dry, one slice, with butter. 10 A. M. "Warm milk, one cup, with a cracker or piece of very stale bread and butter. 2 P. M. Soup, four ounces ; or, beef juice, two ounces. Meat : chop, steak, roast beef or lamb or chicken. A baked white potato ; or, boiled rice or spaghetti ; both cooked five hours. Green vegetable : asparagus tips, string beans, peas, spinach ; all to be cooked until very soft, and mashed, or preferably put through a sieve ; at first, one or two teaspoonfuls. Dessert : cooked fruit — baked or stewed apple, stewed prunes. Water ; no milk. 6 P. M. Cereal : farina, cream of wheat, or arrowroot, cooked for at least one half hour, with plenty of salt, but without sugar ; • ■ or, milk toast ; or, bread and milk ; or, stale or dry bread and butter and a glass of milk. PAET III THE DIET OF OLDER CHILDREN Ill THE DIET OF OLDER CHILDREN (FOURTH TO TENTH YEAR) Throughout this period the largest meal should always be in the middle of the day, and a light sup- per given, very much like that described for the third year. During the first half of this period, milk may be allowed once either between breakfast and dinner or dinner and supper ; no other eating between meals should be permitted, but water should be allowed freely. MILK AND CREAM What part of the diet should milk form during childhood? It should form a very important part up to the tenth year; nothing can take its place. There are comparatively few children who cannot take and digest milk if it is properly fed. Why is milk so advantageous'^ Because no food that we possess has so high a ixutritive value as milk, for the amount of work re- 125 126 THE CARE AND FEEDING OF CHILDREN quired of the organs of digestion. It is, therefore, peculiarly adapted to the diet of the child. What are the essential joints in the use of milhf It should be clean and fresh, but not too rich. It is a mistake to select for any children the rich milk of a Jersey herd and use it as though it were an ordinary milk. For children who have difficulty in digesting milk, it should be somewhat diluted, i. e., one part of water to four parts of milk, or salt or bicarbonate of soda should be added. It is also im- portant not to give milk at meals when fruits, espe- cially sour fruits, are allowed. How much milk may advantageously he given? The average child with good digestion should take from one and one half pints to one quart of milk daily, this including not only what the child drinks but what is served upon cereals and in other ways. It is seldom wise to allow a child to take as much as two quarts daily, as a more mixed diet for most children is better. To what extent may cream he used? Older children do not require so large a propor- tion of fat in their food as do infants, and the use of cream, especially very rich cream, often results in disturbances of digestion. The use of too much or too rich cream is a common cause of the coated THE DIET OF OLDER CHILDREN 127 tongue, foul breath and pale gray stools, often called " biliousness." Is not cream useful in overcoming the constipa- tion of children? With infants it is valuable to a certain point, but mth older children only to a limited degree, and if such symptoms as those above described are present, cream should not be given. EGGS To what extent may eggs he used in the diet of this period? They form a most valuable food. It is essential that they should be fresh and only slightly cooked, soft boiled, poached or coddled; fried eggs should never be given and all omelets are objectionable. Which is more digestible, the white or yolk of the egg? For the great majority of children, the white of the egg. This forms one of the most digestible pro- teids we possess, and can be used, even in the latter part of the first year, with advantage. Is it not true that eggs often cause ^' bilious- ness ''? Very seldom, if fed as above advised. This is an old prejudice but has little basis in fact. 138 THE CARE AND FEEDING OF CHILDREN How often may eggs he given f Most children from four to ten years old will take one egg for breakfast and another for supper for an indefinite period with relish and benefit. There are, however, some few who have a peculiar idiosyncrasy as regards eggs and cannot take them at all. MEAT AI^D FISH What meats may he given to young children? The best are beefsteak, mutton-chop, roast beef, roast lamb, broiled chicken and certain delicate fish, such as shad or bass. What are the important 'points to he considered in giving meat to children? Most meats should be rare and either scraped or very finely divided, as no child can be trusted to chew meat properly. Meats are best broiled or roasted, but should not be fried. How often should meat he given? At this period, only once a day, at the mid-day meal. 7s not the excessive nervousness of many modern children due to the giving of meat, or at least aggra- vated hy its u£e? There is little ground for such a belief, unless an excessive amount of meat is given. Certainly THE DIET OF OLDER CHILDREN 129 cutting off meat from the diet of nervous children seldom produces any striking benefit. What meats should he forbidden to young chil- dren? Ham, bacon, sausage, pork, liver, kidney, game and all dried and salted meats, also cod, mackerel and halibut; all of these are best withheld until the child has passed the tenth year. Are not gravies beneficial and nutritious? The beef juice, or so-called " platter gravy," from a roast is exceedingly nutritious and desirable, but many of the thickened gravies are much less diges- tible and are too often given in excess ; only a small quantity should be allowed. They should not form an important part of the meal. VEGETABLES What vegetables may be used at this period? White potatoes may be given first. These should preferably be baked or boiled and mashed, but never fried. They should be served with beef juice or with cream rather than with butter. Of the green vegetables, the best are peas, spinach, asparagus tips, string beans, stewed celery, young beets, or carrots, and squash. Baked sweet potato, turnips, boiled onions and cauliflower, all well cooked. 130 THE CARE AND FEEDING OF CHILDREN may be given after the sixth or seventh year in mod- erate amount. The principal trouble in the digestion of vege- tables is due to imperfect cooking. It is, in fact, almost impossible to cook them too much ; they should also be very finely mashed. They form a valuable addition to the diet after three years, although the amount at first given should be small, one or two teaspoonfuls. They greatly aid in securing regu- larity of the bowels. Because small particles are seen in the stools, it is not to be inferred that they are causing disturbance and should, therefore, be stopped, but only that they should be more thor- oughly cooked and more finely divided before being given. 7s it safe to use canned vegetables for chil- dren f Many of the best brands of canned vegetables are quite safe and some, such as peas and asparagus, can be used with advantage. They are frequently better than stale green vegetables often sold in the markets. What vegetables should not he given to young children? None of those which are eaten raw, such as celery, radishes, onions, cucumbers, tomatoes or let- THE DIET OF OLDER CHILDREN 131 tuce. Certain others, even when well cooked, should not be allowed; as corn, lima beans, cabbage, egg plant. E'one of these should be given until a child has passed the age of ten years. Are vegetable salads to he given? As a rule salads of all kinds should be omitted until a child has passed the tenth year. Salads are difficult to digest and a cause of much disturbance in children of all ages. CEREALS What are the most important points in selecting and preparing cereals? The important things are that they are properly cooked and not used in excess. The ready-to-serve cereals should never be chosen for children, nor should a child, because he is fond of cereals, be allowed to make his entire meal of them, taking two or three saucerfuls at a feeding. Many of the partially cooked preparations of oatmeal and wheat are excellent, but should be cooked for a much longer time than is stated upon the pack- age, usually three or four times as long. Digesti- bility is chiefly a matter of proper cooking. Most of the grains, — oatmeal, hominy, rice, wheaten grits, — require at least three hours' cooking in a double boiler 9 132 THE CARE AND FEEDING OF CHILDREN in order to be easily digested. The prepared flours, • — corn starch, arrowroot, barley, — should be cooked at least twenty minutes. I know of no preparation in the modern market which requires no cooking, "which is to be recommended for children. How are cereals to he given? Usually with milk or a mixture of milk and cream; always with an abundance of salt and with very little or no sugar, one half teaspoonful on a eaucerful of cereal should be the limit. Cereals should not be served with syrups or but- ter and sugar. BROTHS AND SOUPS What broths and soups are to he recommended? Meat broths are generally to be preferred to vegetable broths, — mutton or chicken being usually most liked by children. INTearly all plain broths may be given. Those thickened with rice, barley or corn starch form a useful variety, especially with the addition of milk. Vegetable purees of peas, spinach, celery or asparagus may be used for children over seven years old. Tomato soup should not be given to young children. THE DIET OF OLDER CHILDREN 133 BREAD, CRACKERS AI^D CAKES What forms of hreadstuffs are best suited to young children? Fresh bread should not be given, but stale bread cut thin and freshly dried in the oven until it is crisp is very useful, also zwieback, the unsweetened being preferred. Oatmeal, graham or gluten crack- ers, and the Huntley and Palmer breakfast biscuits, stale rolls, or corn bread which has been split and toasted or dried till crisp, form a sufficient variety for most children. What hreadstuffs should he forhiddenf All hot breads, all fresh rolls, all buckwheat and other griddle cakes, all fresh sweet cakes, especially those covered with icing and those containing dried fruits. A stale lady-finger or piece of sponge cake is about as far in the matter of cakes as it is wise to go with children up to seven or eight years old. DESSERTS What desserts may he given to young children? Mistakes are more often made here than in any other part of the child's diet. Up to six or seven years, only junket, plain rice pudding without rai- 134 THE CARE AND FEEDING OF CHILDREN sins, plain custard and, not more than once a week, a small amount of ice cream. What should he especially forbidden? All pies, tarts and pastry of every description, jam, syrups and preserved fruits; nuts, candy and dried fruits. Does " a little " do any harm ? Yes, in that it develops a taste for this sort of food, after which plainer food is taken with less relish. Besides the " little " is very apt soon to he- come a good deal. Does not the child's instinctive craving for sweets indicate his need of them? That a child likes or craves sweets is the usual excuse of an indulgent parent. Every child likes his own way, but that is no reason why he should not be trained to obedience and self-control; a child's fondness for sweets can hardly be considered a nor- mal instinct. As a matter of fact, supported by everyday experience, no causes are productive of more disorders of digestion than the free indulgence in desserts and sweets by young children. It is a con- stantly increasing tendency, not easily controlled as a child grows older; and in early childhood, the only safe rule is to give none at all. THE DIET OF OLDER CHILDREN 135 FEUITS Are fruits an essential or important part of the diet? They are a very important part and should be begun in infancy. They are particularly useful for the effect they have upon the bowels. It is important that they should be selected with care and given with much discretion, especially in cities. In the country where fruit is absolutely fresh, a somewhat greater latitude may be allowed than is given below. What fruits may safely he given to children up to five years old? As a general rule, only cooked fruits and the juices of fresh fruits. What fruit juices may he used? That from sweet oranges is the best, but the fresh juice of grape fruit, peaches, strawberries and rasp- berries may also be used. What stewed fruits may he given? Stewed or baked apples, prunes, pears, peaches and apricots. What raw fruits are to he particularly avoided with young children? The pulp of oranges or grape fruit, also cherries, berries, bananas and pineapple. 136 THE CARE AND FEEDING OP CHILDREN What precautions should he emphasized regard- ing the use of fruits? That they should be used with greater care in hot "weather and with children who are prone to attacks of intestinal indigestion. What symptoms indicate that fruits should he avoided P A tendency to looseness of the bowels with the discharge of mucus, or frequent attacks of abdominal pain or stomach ache. Is there any special choice of meals at which fruit should he given? The fruit juice given early in the morning, upon an empty stomach, works more actively upon the bowels than if it is given later in the day. It is not, as a rule, wise to give cream or milk with sour fruits. Usually the fruit is best given at the mid-day meal, as a dessert, at a time when no milk is taken. It is in all cases important that the quantity of fruit should be moderate. What hesides water and milk should a child he allowed to drinh and what should he forhidden? Tea, coffee, wine, beer and cider in all quantities and in all forms should be forbidden to young chil- dren below puberty. Cocoa which is made very weak, i. e., almost all milk, is often useful as a hot INDIGESTION IN OLDER CHILDREN 137 drink. Lemonade, soda-water, etc., should if pos- sible be deferred until the tenth year. A free in- dulgence in things of this kind should never be per- mitted with children of seven or eight years. INDIGESTION IN OLDER CHILDREN What are the different ways in which indigestion shows itself in children'^ First, in acute disturbances which last for a few days only; and, secondly, in chronic disturbances which may continue for weeks or months. Which of the two forms of indigestion is more likely to impair seriously the health of the child? Chronic indigestion; for since the cause is not recognized it often goes on for months and even years unchecked. What are the symptoms of acute indigestion? These are familiar and easily recognized. They are vomiting, pain, undigested movements from the bowels, often fever and considerable prostration. Such attacks are usually traceable to their proper cause, the removal of which is followed by prompt recovery. VdS THE CARE AND FEEDING OF CHILDREN What are the common causes of acute indi- gestion? This is frequently due to overeating, to indul- gence in some special article of improper food, or to eating heartily when overtired. Acute indigestion often marks the beginning of some acute general illness. How should acute indigestion he managed? One should bear in mind that for the time being the digestive organs have stopped work altogether. The important thing, therefore, is to clear out from the intestines all undigested food by some active cathartic, such as castor oil. The stomach has usu- ally emptied itself by vomiting. All food should be stopped for from twelve to thirty-six hours, accord- ing to the severity of the attack, only water being given. At the end of this time is it safe to begin with the former diet? No; for such a procedure is almost certain to cause another attack of indigestion. At first only broth, thin gruel, very greatly diluted milk, or whey should be given. The diet may be very slowly but gradually increased as the child's appetite and diges- tion improve, but in most cases a week or ten days should elapse before the full diet is resumed. INDIGESTION IN OLDER CHILDREN 139 What are the symptoms of chronic indigestion? These, although familiar, are not so easily dis- tinguished and are very often attributed to the wrong cause. There are usually general symptoms such as indisposition, disturbed sleep, grinding of the teeth, fretfulness, languor, loss of weight and anaemia. There are besides local symptoms : flatulence, abdom- inal pain, abdominal distention, constipation, or looseness of the bowels with mucus in the stools, foul breath, coated tongue, loss of appetite, or an ab- normal, capricious appetite. Such symptoms are often wrongly ascribed to intestinal worms. What are the common caiLses of chronic indi- gestion f This is generally the result of a bad system of feeding, either the prolonged use of improper food or of improper methods of feeding. Examples of bad methods of feeding are, coaxing or forcing to eat, rapid eating with insufficient mas- tication, eating between meals, allowing a child to have his own way in selecting his food, as when he lives largely upon a single article of diet. Things to be considered under the head of improper food are, indulgence in sweets, desserts, etc., the use of imper- fectly cooked foods, especially cereals and vegetables, and of raw or stale fruits. 140 THE CARE AND FEEDING OP CHILDREN Is it not true that a diet or a special article of food which does not make a child ill is proof that such a diet or such a food is proper for a child? By no means; with many people the only guide in feeding children is that the article in question did not make the children sick, therefore it is allowable. This is a very bad principle. A better one is to adopt such a diet as will nourish the child's body with the least possible tax upon his digestive organs ; in other words, to exclude articles which experience has shown to be injurious to most children. How should chronic indigestion he managed? This is a much more difficult matter than the treatment of acute indigestion, for, as it is usually the result of the prolonged use of improper food or of an improper method of feeding, a cure can be accomplished only by a discovery and removal of the cause. 7s chronic indigestion curable? In the vast majority of cases it is so, but only by faithfully observing for a long period the rules for simple feeding laid down elsewhere. One of the greatest difficulties in the way of recovery is that parents and nurses are unwilling to follow a re- GENERAL RULES TO BE OBSERVED IN FEEDING 141 stricted diet long enough to secure a complete cure, or to change radically their methods of feeding, but expect the child to recover by simply taking medicine. For how long a 'period is it necessary to continue very careful feeding'^ In any case it must be done for several months ; with most children for two or three years ; with some, throughout childhood, for with them the slightest deviation from established rules is sure to provoke a relapse. 7s not medicine useful? It is undoubtedly of assistance for the relief of some symptoms, but the essential thing .is proper feeding, without which nothing permanent can be accomplished. ' GENERAL RULES TO BE OBSERVED IN FEEDING Bad habits of eating are readily acquired but difficult to break. Young children should not be allowed to play 142 THE CARE AND FEEDING OF CHILDREN with their food, nor should the habit be formed of amusing or diverting them while eating, because by these means more food is taken. Older children should not be permitted to make an entire meal of one thing, no matter how proper this may be. Children who are allowed to have their own way in matters of eating are very likely to be badly trained in other respects ; while those who have been properly trained in matters of eating can usu- ally be easily trained to do anything else that is important. Learning to eat proper things in a proper way forms therefore a large part of a child's early edu- cation. If careful training in these matters is begun at the outset and continued, the results will well re- pay the time and effort required. Whether the child feeds himself or is fed by the nurse, the following rules should be observed: 1. Food at regular hours only; nothing between meals. 2. Plenty of time should be taken. On no ac- count should the child bolt his food. 3. The child must be taught to chew his food. Yet no matter how much pains are taken in this respect, mastication is very imperfectly done by all children; hence up to the seventh year at least, all GENERAL RULES TO BE OBSERVED IN FEEDING 143 meats should be very finely cut, all vegetables mashed to a pulp, and all grains cooked very soft. 4. Children should not be continually urged to eat if they are disinclined to do so at their regular hours of feeding, or if the appetite is habitually poor, and under no circumstances should a child be forced to eat. 5. Indigestible food should never be given to tempt the appetite when the ordinary simple food is refused; food should not be allowed between meals because it is refused at meal-time. 6. One serious objection to allowing young chil- dren highly seasoned food, entrees, jellies, pastry, sweets, etc., even in such small amounts as not to upset the digestion, is that children thus indulged soon lose appetite for the simple food which pre- viously was taken with relish. 7. If there is any important article of a simple diet such as milk, meat, cereals, or vegetables, which a child habitually refuses, this should always be given first at the meal and other food withheld until it is disposed of. Children so readily form habits of eating only certain things and refusing others that such an inclination should be checked early. 8. If an infant refuses its food altogether, or takes less than usual, the food should be examined 144 THE CAKE AND FEEDING OF CHILDREN ^ to see if this is right. Then the mouth should hj. inspected to see if it is sore. If neither of these things is the cause, the food should be taken away and not offered again until the next feeding time comes. 9. In any acute illness the amount of food should he much reduced and the food made more dilute than usual. If there is fever, no solid food should be given. If the child is already upoiL a milk diet, this should be diluted, and in some cases partially pep- tonized. 10. In very hot weather the same rules hold, to give less food, particularly less solid food, and more water. FOOD FORMULAS Beef Juice. — One pound of rare round steak, cut thick, slightly broiled, and the juice pressed out by a lemon-squeezer, or, better, a meat-press. From two to four ounces of juice can generally be ob- tained. This, seasoned with salt, may be given cold, or warmed by placing the cup which holds it in warm water. It should not be heated sufficiently to coagulate the albumin which is in solution, and which then appears as flakes of meat floating in the fluid. FOOD FORMULAS 145 Beef Juice hy the Cold Process. — One pound of finely chopped round steak, six ounces of cold water, a pinch of salt; place in a covered jar and stand on ice or in a cold place, five or six hours or overnight. It is well to shake occasionally. This is now strained and all the juice squeezed out by placing the meat in coarse muslin and twisting it very hard. It is then seasoned and fed like the above. Beef juice so made is not quite as palatable as that prepared from broiled steak, but it is even more nutritious, and is more economical, as fully twice as much juice can be obtained from a given quantity of meat. Beef juice prepared in either of these ways is greatly to be preferred to the beef extracts sold. Mutton Broth. — One pound of finely chopped lean mutton, including some of the bone, one pint cold water, pinch of i4lt. Cook for three hours over a slow fire down to half a pint, adding water if neces- sary ; strain through muslin, and when cold carefully remove the fat, adding more salt if required. It may be fed warm, or cold in the form of a jelly. A very nutritious and delicious broth is made by thickening this with cornstarch or arrowroot, cook- ing for ten minutes and then adding three ounces of milk, or one ounce of thin cream, to a half pint of broth. 146 THE CARE AND FEEDING OF CHILDREN ChicheUy Veal, and Beef Broths. — These are made and used in precisely the same manner as mut- ton broth. Scraped Beef or Meat Pulp. — A rare piece of round or sirloin steak, the outer part having been cut away, is scraped or shredded with a knife; one teaspoonful to one tablespoonful may be given, well salted, to a child of eighteen months. Scraping is much better than cutting the meat fine. Tor this on a large scale, as in institutions, a Hamburg-steak cutter may be employed. Junket, or Curds and Whey. — One pint of fresh cow's milk, warmed; pinch of salt; a teaspoonful of granulated sugar; add two teaspoonfuls of Fair- child's essence of pepsin, or liquid rennet, or one junket tablet dissolved in water; stir for a moment, and then allow it to stand at the temperature of the room for twenty minutes, or until firmly coagu- lated; place in the ice box until thoroughly cold. For older children this may be seasoned with grated nutmeg. Whey. — The coagulated milk prepared as above is broken up with a fork and the whey strained off through muslin. If some stimulant is desired, sherry wine in the proportion of one part to twelve, or brandy one part to twenty-four, may be added. FOOD FORMULAS 14T Whey is useful in many cases of acute indiges-^ tion. Barley Water. — One level tablespoonful of Eob- inson's patent barley, or the prepared barley flour of the Health Food Company, is thoroughly blended with a little cold water and added, stirring, to one pint of boiling water containing a pinch of salt. This is cooked for thirty minutes in a double boiler and then strained. As much boiled water should then be added as has boiled away. Barley Gruel or Barley Jelly. — This is made in the same manner as the above but from two to four level tablespoonfuls of the flour are used. Either barley water or barley jelly may be made from the grains. For barley water, use one heaping tablespoonful of pearl barley which has been soaked four or five hours, or overnight, one pint of water, a pinch of salt. This is boiled steadily for four hours, adding water from time to time to keep the quantity up to one pint. It is then strained through muslin. For barley gruel or barley jelly use from two to four tablespoonfuls of pearl barley. Ricey Wheat, or Oat Water. — These are made from rice, wheat, or oat flour exactly as barley water^ above described. Like the barley water they may also be made from the grains using the same proportions. 10 148 THE CARE AND FEEDING OF CHILDREN Gruel or Jelly from :Rice, Wheat, or Oats. — These are made from the flours or grains as has been described for barley gruel. For the wheat preparations, ordinary wheat flour may be used or HubbelFs prepared wheat flour; or wheaten grits may be employed. For the rice preparations the ordinary rice grains or rice flour may be used. For the oat preparations, either the oat flour of the Health Food Company may be used, or any of the commonly employed forms of oatmeal. When any of these farinaceous foods are to be mixed with milk, the milk should be added directly after removing the gruel from the fire, and stirred two or three minutes. Imperial Granum. — This is prepared and used in precisely the same way as the barley flour above mentioned. Albumin Water. — The white of one fresh egg-, half a pint of cold water ; pinch of salt ; teaspoonf ul of brandy. This should be shaken thoroughly and fed cold either with a spoon or from a bottle. It is useful in cases of vomiting, and can sometimes be retained by a very irritable stomach. Lime-Water. — One heaping teaspoonful of slaked Jime ; one quart boiled or distilled water ; place in a FOOD FORMULAS 149 corked bottle and shake thoroughly two or three times during the first hour. The lime should then be allowed to settle, and after twenty-four hours the upper clear fluid carefully poured or siphoned off for use. Dried Bread. — Either stale or fresh bread may be used ; it is cut in thin slices and placed in the oven, with the door open, and quickly dried until it is crisp, but not browned. It is in many respects preferable to crackers for little children. Coddled Egg. — A fresh egg, shell on, is placed in boiling water which is immediately after removed from the fire. The egg then cooks slowly in the water, which gradually cools, for seven or eight min- utes, when the white should be about the consistency of jelly. For a delicate digestion the white only should be given, with salt ; it can be easily separated from the yolk. PAET IV MISCELLANEOUS IV MISCELLANEOUS THE BOWELS How many movements daily should an infant have during the first few weeks of life? Usually two or three a day for the first week, and then one or two each day. How many after a child is a month old? A healthy child should have at least one move- ment each day; many have two and some more than two ; but it is the character of the stools rather than their number which is to be taken as the evidence of perfect digestion. What is the appearance of a healthy movement of a child who is taking nothing hut milk? It is soft, yellow, and smooth, containing no lumps. When are the stools dark brown or hlack? While taking bismuth, iron, and sometimes when taking much meat or beef juice; also while taking 153 154 THE CARE AND FEEDING OF CHILDREN many of the prepared foods. They may be dark brown or black from blood. This last is a condition which may indicate serious illness. How may a child he trained to he regular in the action of its howels? By endeavouring to have them move at exactly the same time every day. At what age may an infant he trained in this Usually by the second month if training is begun early. What is the hest method of training? A small chamber, about the size of a pint bowl, is placed between the nurse's knees, and upon this the infant is held, its back being against the nurse's chest and its body firmly supported. This should be done twice a day, after the morning and afternoon feedings, and always at the same hour. At first there may be necessary some local irritation, like that pro- duced by tickling the anus or introducing just inside the rectum a small cone of oiled paper or a piece of soap, as a suggestion of the purpose for which the baby is placed upon the chamber; but in a surpris- ingly short time the position is all that is required. With most infants, after a few weeks the bowels will move as soon as the infant is placed on the chamber. SLEEP 155 What advantage has such training? It forms the habit of having the bowels move regularly at the same hour, which is a matter of great importance in infancy and makes regularity in childhood much easier. It also saves the nurse much trouble and labour. SLEEP Should a child sleep in the same hed with Us mother or nurse f Under no circimistances, if this can possibly be avoided. Very young infants have often been smoth- ered by their mothers, by overlying during sleep. If the infant sleeps with the mother, there is always the temptation to frequent nursing at night, which is in- jurious to both mother and child. Older children also should, if possible, have separate beds; many contagious diseases and bad habits are contracted by children sleeping together. How should an infant's hed he prepared? The mattress should be firm but soft, the pillow very thin, and the covering not excessive. A baby should not be allowed to sleep always in the sam© position, but should be changed from side to side. Hair pillows are useful in summer and for children who perspire very niuch. 156 THE CARE AND FEEDING OF CIlILDItEN How much sleep is ^natural for a newly horn hahy? A baby with a good digestion and proper food will usually sleep at this period about nine tenths of the time. How much should a hahy sleep at six months? About two thirds of the time. Up to what age should an older child take a nap during the day? Always until four years old, and if possible longer. At what age may an infant go all night without feeding? At five months a child should not be fed or nursed between 10 p. m. and 6 a. m. At two years a child can easily go from 6 p. m. to 6 a. m. without feeding. How should a hahy he put to sleep ? The room should be darkened and quiet, the child's hunger satisfied, and the child made gen- erally comfortable and laid in its crib while awake. 7s rocking necessary? By no means. It is a habit easily acquired, but hard to break, and a very useless and sometimes in- SLEEP 157 jurious one. The same may be said of sucking a rubber nipple, or "pacifier/' and all other devices for putting children to sleep. What are the principal causes of disturbed sleep ? As quiet peaceful sleep is a sign of perfect health, disorders of sleep may be produced by al- most anything which is wrong with the child. 1. Habitual disturbance of sleep in infants is most frequently associated with the food or feeding. It may be from the discomfort of chronic indigestion due to improper food. In bottle-fed infants it is often the result of overfeeding; in those who are nursed it is often due to hunger. A common cause is frequent night feeding ; an infant who is fed three or four times during the night is almost invariably a bad sleeper. 2. Disturbed sleep or sleeplessness may be due to causes purely nervous. Such are bad habits ac- quired by faulty training; as when the nursery is lighted and the child taken from its crib whenever it wakes or cries; or when some of the contrivances for inducing sleep have been used. Any excitement or romping play just before bedtime, and fears aroused by pictures or stories, are frequent causes. Children who inherit from their parents a nervous 158 THE CARE AND FEEDING OF CHILDREN constitution are especially likely to suffer thus. 3. There may be physical discomfort from cold feet, insufficient or too much clothing, or want of fresh air in the sleeping room. 4. Interference with breathing due to obstruc- tion from large tonsils or adenoids. These cause great restlessness and lead a child to assume many different postures during sleep, often lying upon the face or upon the hands and knees. 5. Chronic pains or frequently recurring night pains may be causes of disordered sleep, when a child wakes with a sudden sharp cry. In infants this is most often due to scurvy, sometimes to syphilis. In older children it may be the earliest symptom of dis- ease of the hip or spine. 6. Sleeplessness and disturbed sleep are frequent whenever the general condition falls much below a healthy standard ; e. g., in infants who are not thriv- ing and in children suffering from marked anaemia. How are children who sleep too little, or whose sleep is constantly disturbed, to he treated? ITever by the use of soothing sirups or other medicines. Successful treatment consists in the dis- covery and removal of the cause. Do children ever sleep too much? It is doubtful if healthy children ever do. Ex- EXERCISE 159 cessive sleep is an important symptom of some dis- eases of the brain. Otherwise it seldom if ever oc- curs unless soothing sirups or other drugs have been given. EXERCISE 7s exercise important for infants? It is as necessary for them as for older children. How is it obtained? A young baby gets its exercise by screaming, waving its arms, kicking, etc. The clothing should not be so tight as to make these movements impos- sible. At least twice a day the infant should be allowed for fifteen or twenty minutes the free use of its limbs by permitting it to lie upon a bed in a warm room, with all clothing except the shirt, stock- ings, and napkin removed. Later, when in short clothes, the baby may be put upon a thick blanket or quilt laid upon the floor, and be allowed to tumble about at will. A nursery fence two feet high, made to surround a mattress, is an excellent device and makes a convenient box stall for the young animal, where it .can learn to use both its arms and legs with- out the danger of injury. Only by exercise such as this do the muscles have an opportunity to develop properly. 160 THE CARE AND FEEDING OF CHILDREN THE CEY When is crying useful? In the newly born infant the cry expands the lungs, and it is necessary that it should be repeated for a few minutes every day in order to keep them well expanded. How much crying is normal for a very young hahy? From fifteen to thirty minutes a day is not too much. What is the nature of this cry? It is loud and strong. Infants get red in the face with it; in fact, it is a scream. This is neces- sary for health. It is the baby's exercise. When is a cry abnormal? When it is too long or too frequent. The ab- normal cry is rarely strong, often it is a moan- ing or a worrying cry, sometimes only a feeble whine. What are the causes of such crying? Pain, temper, hunger, illness, and habit. .What is the cry of pain? It is usually strong and sharp, but not generally continuous. It is accompanied by contraction of the THE CRY 161 features, drawing up of the legs, and other symptoms of distress. What is the cry of hunger? It is usually a continuous, fretful cry, rarely strong and lusty. What is the cry of temper? It is loud and strong and accompanied by kick- ing or stiffening of the body, and is usually violent. What is the cry of illness? There is usually more of f retfulness and moaning than real crying, although crying is excited by very slight causes. What is the cry of indulgence or from habit ? This is often heard even in very young infants, who cry to be rocked, to be carried about, sometimes for a light in the room, for a bottle to suck, or for the continuance of any other bad habit which has been acquired. Hoia can we he sure that a child is crying to he indulged f If it stops immediately when it gets what it wants, and cries when it is withdrawn or withheld. What should he done if a hahy cries at night ? ' One shouJd get up and see that the child is com- 163 THE CARE AND FEEDING OP CHILDREN fortable — the clothing smooth under the body, the hands and feet warm, and the napkin not wet or soiled. If all these matters are properly adjusted and the child simply crying to be taken up, it should not be further interfered with. If the night cry is habitual some other cause should be sought (see page 118). How is an infant to he managed that cries from temper, hahit, or to he indulged? It should simply be allowed to " cry it out." This often requires an hour, and in extreme cases, two or three hours. A second struggle will seldom last more than ten or fifteen minutes, and a third will rarely be necessary. Such discipline is not to be carried out unless one is sure as to the cause of the habitual crying. Is it nicely that rupture will he caused from cry- ing? ]^ot in young infants if the abdominal band is properly applied, and not after a year under any circumstances. LIFTITTG CHrLDREN How should a young hahy he lifted from its hedf The right hand should grasp the clothing below the feet, and the left hand should be slipped beneath THE TEMPERATURE 163 t the infant's body to its head. It is then raised upon the left arm. What is the advantage of this? The entire spine is supported, and no undue pres- sure is made upon the chest or abdomen, as often happens if the baby is grasped around the body or under the arms. How should a child old enough to run about he lifted? Always by placing the hands under the child's arms, and never by the wrists. What injury may he inflicted hy lifting the child hy the wrists or hands? Often serious injury is done to the elbow or shoulder joints. THE TEMPEEATUKE What is the normal temperature of an infant? The normal temperature varies more than in adults. In the rectum it usually fluctuates between 98^ and 99.6° F. ; a rectal temperature of 97.5° F. or of 100; 5° F. is of no importance whatever un- less it continues. Where should the temperature of infants and young children he tahen? 11 164 THE CARE AND FEEDING OF CHILDREN The rectum is altogether the best place, and next to this the groin. The rectal temperature is from half a degree to a degree higher than that in the groin. How long should the thermometer he left in place to take the temperature? Two minutes in the rectum, and five minutes in the groin. Is the temperature of a young child a good guide as to the severity of its symptoms in illness? As a rule it is. A temperature of 100° to 102° F. commonly means a mild illness, and one of 104° F. or over a serious one. The duration of the fever is, however, even more important than the height of the temperature. It should be remembered that in all young children slight causes often produce a high temperature which lasts for a few hours ; one should not therefore be unduly alarmed unless the tempera- ture continues high, or is accompanied by other im- portant signs of illness. Is not a high temperature a more serious symp- tom in a young child than in an adult? The opposite is rather the case. Young children are extremely sensitive to conditions which produce fever, and the thermometer often gives an exagger- ated idea of the severity of the symptoms. A cause NERVOUSNESS 165 which in an adult might produce a temperature of 102° F. or 103° F., in a young child would very likely be accompanied by a temperature of 104° or 105° F. NERVOUSNESS What are the principal causes of excessive nerv- ousness in infants and young children, and what can he done to prevent this? The most important cause is the delicate struc- ture of the brain at this time, and its rapid growth. It grows as much during the first year as during all the rest of life. This requires quiet and peaceful surroundings. Infants who are naturally nervous should be left much alone, should see but few people, should be played with very little, and should never be quieted with soothing sirups or the " pacifier." At what age may playing with hahies he hegun? Babies under six months old should never be played with; and the less of it at any time the bet- ter for the infant. What harm is done hy playing with very young hahies? They are made nervous and irritable, sleep bad- ly, and suffer from indigestion and in many other respects. 166 THE CARE AND FEEDING OF CHILDREN When may young children he played with? If at all, in the morning, or after the midday nap; but never just before bedtime. TOYS What points should guide one in selecting toys and playthings for an infant? The instinct in a baby to put everything into the mouth is so strong that nothing should be given that cannot be safely treated in this way. Hence one should choose things which are smooth, those which can be easily washed, and those which cannot be swallowed. One should avoid (1) toys with sharp points or corners; (2) those with loose parts that might be de- tached or broken off and swallowed; (3) small ob- jects which might be swallowed or pushed into the nose or ear, such as coins, marbles, and safety-pios, also beads and buttons unless strung upon a stout cord; (4) painted toys; (5) those covered with hair or wool. Infants have often been severely injured by swallowing what they have pulled off from their small toy animals. What points are to he considered in selecting the toys and playthings of a child over two years old? It should be remembered that toys are not mere- TOYS 167 ly a source of amusement, but that they have an educational value as well. Those are therefore to be preferred the use of which develops the child's imagination, and with which he can be taught to amuse himself. For boys nothing can surpass blocks, toy soldiers, balls, engines, and cars; and for girls, dolls and housekeeping sets. The complicated Ine- chanical toys now so much in vogue give only a momentary pleasure, and as soon as the wonder at their operation has worn off, they have lost interest for the child except that which he gets in breaking them to see how the thing worked. What important things can he taught children with their toys and how may this he done? The imagination may be developed, and children may be trained to habits of neatness, order and regu- larity, and to concentration of mind. To this end toys should be kept in an orderly way upon a shelf in the nursery or in a closet, never piled in a miscellaneous heap in the corner of the room. Children should select their toys and play with one thing at a time, which they should be taught to put away in its place before another is given. They should never be allowed to have a dozen things strewn about the room at one time, with none of which they are occupied. 168 THE CARE AND FEEDING OF CHILDREN KISSIKG Are there any valid objections to kissing in- fants? There are many serious objections. Tuberculo- sis, diphtheria, and many other grave diseases may be communicated in this way. The kissing of in- fants upon the mouth by other children, by nurses, or by people generally, should under no circumstances be permitted. Infants should be kissed, if at all, upon the cheek or forehead, but the less even of this the better. CONVULSIONS What should he done for a child in convulsions before a doctor arrives f Keep the child perfectly quiet with ice at the head, put the feet in a mustard bath, and roll the entire body in large towels which have been dipped in mustard water (two heaping tablespoonfuls of mustard to one quart of tepid water), and have plenty of hot water and a bath tub at hand, so that the doctor can give a hot bath if he thinks it advis- able. When is a hot bath useful? If the convulsions have continued until the pulse is weak, the face very pale, the nails and lips blue, FOREIGN BODIES 169 and the feet and hands cold, the hot bath will be useful by bringing blood to the surface and relieving the heart, lungs, and brain. How should the hath he given? The temperature should not be over 106° F. ; this should always be tested by a thermometer if one can be obtained. Without this precaution, in the ex- citement of the moment, infants have frequently been put into baths so hot that serious and even fatal burns have been produced. If no thermometer is available the nurse may plunge her arm to the elbow into the water. It should feel warm, but not so hot as to be at all uncomfortable. One half a teacupful of powdered mustard added to the bath often adds to its efficacy. FOEEIGlSr BODIES What should he done if a foreign hody has been swallowed? First, examine the throat with the finger. If it has lodged there remove it. If it has passed from the throat it has usually gone into the stomach. Next be sure that the thing has actually been swallowed. Often needless alarm is allayed by finding in the child's crib or elsewhere the thing supposed to have been swallowed. The stools should be examined daily to see if the foreign body passes the bowel. 170 THE CARE AND FEEDING OF CHILDREN What further treatment is needed? Give the child plenty of dry food, like bread, po- tato, etc., but under no circumstances either an emet- ic or cathartic. An infant may have its usual food. What harm would a cathartic do ? It is likely to hurry the foreign body too rapidly through the intestine and in this way do harm ; other- wise it becomes coated with faecal matter and passes the intestine usually without doing injury. What should he done if a child gets a foreign body into the ear? IJnless this can easily be removed with the fin- gers it should not be meddled with, for it is likely to be pushed farther into the ear. The child should be taken to a physician. What should he done if there is a foreign hody in the nose? The child should blow his nose strongly while the empty nostril is compressed. Unless this re- moves it a physician should be called. Meddlesome interference is always harmful. COLIC What are the symptoms of colic? There is a strong, hard cry, which comes sud- denly and returns every few minutes. With this EARACHE 171 there is drawing up of the feet, contraction of the muscles of the face, and other signs of pain. The abdomen is usually tense and hard. What should he done for a hdby with colic? First, see that the feet are warm. Place them against a hot-water bag, or hold them before an open fire; apply a hot flannel to the abdomen, or let the child lie upon its stomach across a hot-water bag. If the colic continues, a half teacupful of warm water containing ten drops of turpentine may be in- jected into the bowels with a syringe; at the same time the abdomen should be gently rubbed so as to start the wind. If the gas is in the stomach, half of a soda mint tablet may be given in a tablespoonful of very warm water. EARACHE What are the symptoms of earache? The pain is generally severe and accompanied by a sharp scream ; the child often puts the hand to the affected ear, or cries whenever it is touched. The pain is likely to be prolonged and continuous. Hoiu should a child with earache he treated? The ear should be irrigated with a solution of boric acid (twenty grains to the ounce) as warm as can be borne. Dry heat may then be applied in sev- 172 THE CARE AND FEEDING OF CHILDREN eral ways. The ear having been first covered with cotton, a small hot-water bag or one filled with hot salt or bran, may be bound over it with a bandage ; or a small butter plate heated in hot water may be used in the same way. The hot-water bag may be held against the ear or the child may lie with his head upon it. The use of such substances as oil and lau- danum in the ear is not to be recommended. CBOTJP What are the symptoms of croup? There is a hollow, dry, barking cough, with some difficulty in breathing. When is this likely to come on? Usually at night. Is simple croup dangerous? The ordinary croup of infants is spasmodic croup, and is very rarely dangerous, although the symptoms seem very alarming. What are the symptoms? In a mild attack there is simply noisy breathing, especially on drawing in the breath, with a tight, barking, or croupy cough. In a severe attack the child's breathing is more noisy and be^-omes diffi- cult. CONTAGIOUS DISEASES 173 What is the dangerous form of croup f Membranous croup, which is the same thing as diphtheria of the larynx. How does this develop? Gradually; very rarely does it come on sud- denly. What should he done for a hahy who has spas- modic croup? The room should be very warm, hot cloths or poul- tices should be applied over the throat, and either a croup kettle or an ordinary tea-kettle kept boiling in the room. This is more efficacious if the child is placed in a tent made by a raised umbrella with a sheet thrown over it, and the steam introduced be- neath the tent. If the symptoms are urgent, ten drops of the sirup of ipecac should be given every fifteen minutes until free vomiting occurs. When- ever the symptoms reach a point where breathing be- comes difficult, a doctor should be summoned without delay. CONTAGIOUS DISEASES What are the first symptoms of measles? Measles comes on rather gradually with cough, sneezing, watery eyes and nose, much like an ordi- nary cold in the head. The eruption appears after 174 THE CARE AND FEEDING OP CHILDREN three or four days, first upon the face and neck as small red spots, and spreads slowly over the body. 7s measles a serious disease'^ In infants and during the winter season it is likely to be very serious on account of the danger of bronchitis and pneumonia, which frequently ac- company it. In children over four years old it is generally not severe. No child should be voluntarily exposed to this disease, and particularly one who is delicate or prone to disease of the lungs should be protected against it. When and how is measles contagious? Measles may readily be conveyed from the very beginning of the catarrh, two or three days before any eruption is present. It is not often carried by healthy persons. Its poison does not cling long to a sick room. What is German measles? German measles, or rubella, is a distinct disease and has nothing to do with ordinary measles. It is extremely rare for a child to be much sick with it. There is usually a very extensive eruption which may cover the body, but few other symptoms. What are the first symptoms of scarlet fever? Generally it comes suddenly, with vomiting, high CONTAGIOUS DISEASES 175 fever, and sore throat. The eruption usually ap- pears within twenty-four hours as a red blush, first upon the neck and chest, and spreads rapidly. When and how is scarlet fever contagious? Scarlet fever is only slightly contagious for the first one or two days of the attack. It is most con- tagious at the height of the disease and during desquamation. It may be carried by healthy persons and by the clothing or bedding from the sick room. How does whooping-cough begin? For a week or ten days it cannot be distinguished from an ordinary cold on the chest. Then the attacks of coughing gradually become more severe and vom- iting may follow. After a severe coughing fit the breath is caught with a peculiar noise known as the " whoop." How does chicken-pox begin? It usually comes out gradually, as widely scat- tered pimples over the scalp, face, and body, many of which soon become small vesicles, resembling tiny blisters. There is itching and local discomfort but little fever, and the child rarely seems to be very ill. How does diphtheria begin? Sometimes suddenly, but usually gradually, with sore throat and swelling of the glands of the neck, 176 THE CAEE AND FEEDING OF CHILDREN with white patches upon the tonsils, or a free dis- charge, which maj be bloody, from the nostrils. How does mumps begin? As a swelling upon the jaw, beneath the ear. As it increases it extends forward upon the cheek and backward behind the ear. It affects one or both sides. Mumps is not very common in young children, and in them it is usually mild. After twelve or thirteen years it is likely to be more severe. How long after exposure do the first symptoms appear in the different diseases? In scarlet fever in from three to -Q.ve days, rarely later than a week ; in measles in from nine to fourteen days, occasionally as late as twenty days; in whoop- ing-cough in from one to two weeks ; in chicken-pox in from fourteen to sixteen days ; in German measles in from ten to sixteen days. In diphtheria the time varies much ; it may be only one day, and it may be one or two weeks. In mumps it is usually a little less than three weeks, the average being twenty days. Which of these diseases are most contagious? Measles and chicken-pox are very contagious, and very few children who have not had them can come near a person suffering from either disease without taking it. Whooping-cough is almost as contagious as measles, and for young babies even more so. A CONTAGIOUS DISEASES 177 very close exposure is not necessary in the case of either of these diseases, and whooping-congh can undoubtedly be contracted in the open air. Scarlet fever and diphtheria are much less contagious; for both of these a pretty close exposure is necessary. How long should a child with any of these dis- eases he kept away from other children? With measles, for two weeks after the rash has gone ; with scarlet fever, for at least four weeks after the rash has gone, and longer if the peeling is not over or if the ears are running; with whooping- cough, for two months, or so long as the paroxysmal cough continues; with chicken-pox, until all crusts have fallen off, or for about three weeks after the eruption appears ; with German measles for one week after the eruption has faded; with diphtheria, at least ten days after the throat is well in a very mild case, and four weeks if the case has been severe; with mumps for one week after the swelling has gone. What should he done when a child shows the first symptoms of serious illness? The child should be put to bed. If it is an in- fant, the food should be diluted to one half the usual strength; if an older child, only fluid food should be given. If the child seems feverish, take the tem- perature. If the bowels are constipated, give a tea- 178 THE CARE AND FEEDING OF CHILDREN spoonful of castor oil, but no other medicine without the doctor's orders. Send for the doctor at once, and until he comes carefully exclude all other children from the room. By what nursery training may the examination and treatment of sick children he made much easier? By teaching all children to gargle, to show the throat, to take pills, and by constantly teaching them to regard the doctor as the child's best friend, and his visits as a great treat. On no account should a child be frightened into obedience by threats of what the doctor will do. With care and patience most children may be taught to gargle and take pills at four or five years, and to show the throat willingly at two or three. All these matters should be made a part of the child's education. SCUEVY What is scurvy and how is it produced? Scurvy is a disease of general nutrition, usually caused by the long-continued use of improper food. Most of the cases come from the use of the prepared infant's foods sold in the stores, especially when they are given without fresh milk; occasionally the use of condensed milk and of sterilized milk is followed by scurvy ; sometimes it is seen when, owing to feeble SCURVY 179 digestion, it has been necessary to make cow's milk very weak for a long time. What symptoms are seen in an infant with scurvy ? At first there is only indefinite and occasional soreness in the legs so that the child cries out when handled. As this soreness becomes more severe the child is often thought to have rheumatism. The gums swell and are of a deep purple colour. There may be bleeding from the gums, nose, bowels, or black-and-blue spots may be seen upon the legs. The ankles and knees may swell. The child grows very pale, loses appetite and weight, and sleeps badly. What should he done when an infant shows signs of scurvy? The diet should at once be changed to fresh milk, properly modified according to the child's digestion, but not sterilized or pasteurized. The juice of a sweet orange should be given, best about an hour be- fore the feeding. At first one or two teaspoonfuls, four or five times a day; later, more may be given if the symptoms are not improved. Properly treated an infant with scurvy generally recovers promptly and completely. If not recog- nised, or untreated, it may cause death. 12 180 THE CARE AND FEEDING OF CHILDREN CONSTIPATION When it is necessary to move the towels imme* diately, what are some of the easiest methods? An injection of one tablespoonful of sweet oil may be given, or half a teaspoonful of glycerine in one tablespoonful of water, or a teacupful of tepid soap and water, or a glycerine suppository. Xone of these should be continued excepting under the physi- cian's directions. What sort of a syringe is to he 'preferred for giv- ing an injection to an infant? The bulb syringe is the simplest ; this consists of an oval bulb of soft rubber and a soft rubber or a hard rubber tip. It holds one or two ounces. What is the most essential thing in preventing or overcoming constipation ? The formation of the habit of having the bowels move every day regularly at the same hour, and proper early training (see page 154). What is the test hour? In most cases immediately after the first meal in the morning. What are some simple means hy which constipa- tion may he relieved? The best are diet, suppositories, and massage. CONSTIPATION 181 The changes to be made in the milk of consti- pated infants have been mentioned on page 82. The addition to the milk of some of the malted foods, such as Mellin's food or malted milk, is sometimes useful. For little children the fruit juices are par- ticularly beneficial when given half an hour or more before the first morning feeding, with half a glass of water. For older children the amount of white bread, toast, and potato, should be reduced, and green vege- tables, oatmeal, and Graham bread given, with plenty of fruit twice a day. Raw scraped apples are sometimes of more value than any other fruit. The best suppositories for continuous use are probably the gluten suppositories of the Health Food Company. One should be given the first thing in the morning. They act rather slowly, usu- ally in about two hours. In obstinate cases one may also be used at bedtime. Glycerine suppositories act more quickly, but are too irritating for regu- lar use. Massage consists in rubbing the abdomen, which may be done in one of two ways: Beginning at the right groin, the hand is carried up to the ribs, then across to the opposite side, then around to the left groin. The abdomen is stroked gently at first, and afterward deeper pressure used as the child becomes 182 THE CARE AND FEEDING OF CHILDREN accustomed to it. The second method is by rubbing the deeper parts with a circular movement — the fin- gers not moving upon the skin — ^making a series of small circles, beginning at the right groin and fol- lowing the same course as described above. Either method should be employed for six or eight minutes twice a day, at almost any regular time, except soon after a meal. DIAEEHCEA In case a child is taken with diarrhoea, what should he done? \ With a moderate looseness of the bowels in an older child, solid food should be stopped, and boiled milk given diluted with gruel; the child should be kept perfectly quiet, as walking about always aggra- vates such a disturbance. If the symptoms are more severe and attended by fever and vomiting, all milk should be stopped at once, and only broth, barley water, or some thin gruel given. Some cathartic, usually castor oil, is required with a severe attack. If the patient is an infant, the milk should be diluted and especially should the fat be reduced (see page 76). In severe attacks with vomiting or frequent foul stools, all. food should be stopped for at least twelve hours and all milk for a longer time, and the bowels freely moved by a cathartic. BAD HABITS 183 Why is a cathartic necessary if the movements are already frequent? Such movements are nearly always due to an irritation in the bowel, set up by the fermenting food which has not been digested. The diarrhoea is Nature's effort to get rid of the irritant. Nothing to stop the movements should be given until the bowels have been thoroughly cleared by the treat- ment mentioned. BAD HABITS What are the most common had habits of young children? Sucking, nail-biting, dirt-eating, bed-wetting, and masturbation. What do children such? Most frequently the thumbs or fingers, sometimes the clothing or blanket; often the " pacifier " or rub- ber nipple. When is this habit most frequently seen ? It begins in quite early infancy, and if not broken may last until children are six or seven years old. Is the sucTcing habit a harmful one? When persisted in it may produce a misshapen mouth or fingers. It constantly stimulates the flow 184 THE CARE AND FEEDING OF CHILDREN of saliva and certainly aggravates disturbances of digestion during which the sucking habit is likely to be practised. It may lead to thrush or other forms of infection of the mouth. It is not necessary as a means of quieting a child, though it may in some degree cover up the consequences of bad feeding or bad training. On no account should the habit of sucking the " pacifier " be allowed as a means of put- ting children to sleep, or of quieting them while rest- less from dentition or indigestion. How is the sucking habit to he controlled? One should be sure in the first place that the constant sucking of fingers is not due to hunger from insufficient food. Sucking of the hands may often be controlled by wearing mittens or fastening the hands to the sides during sleep. In more obstinate cases it may be necessary to confine the elbow by small pasteboard splints to prevent the child from bending the arm so as to get the hand to the mouth. When are nail-hiting and dirt-eating seen, and how are they to he controlled? These habits belong especially to children over three years old. They are seen particularly in those who are excessively nervous or whose general health is below par ; sometimes in those who develop serious nervous diseases later in life. Children with such BAD HABITS 185 tendencies should be closely watched, and every means used to break up these habits early. Dirt- eating is a morbid craving which is rarely seen in a normal child. At what age may a child generally he expected to go without wetting the bed during the night? Usually at two and a half years, if it is taken up late in the evening. Some children acquire control of the bladder at night when two years old, and a few not until three years. After three years habit- ual bed-wetting is abnormal. How should a young" child addicted to hed-wet- ting he managed? At three or four years of age, punishments are sometimes useful, especially when it seems to de- pend more upon the child's indifference than any- thing else. They are of no value in older children, rewards being much more efficacious. In all cases one should give a child plenty of milk and water early in the day, but no fluids after 4 p. m., the sup- per being always of solid or semi-solid food. The child should be taken up regularly at ten o'clock or thereabouts. It often happens that the formation or continuance of the habit is due to the child being in poor general condition, to some irritation in the urine, or in the genital organs. Unless the simple 186 THE CARE AND FEEDING OF CHILDHEN means mentioned are snccessfnl the child should be placed under the charge of a physician. What is masturbation? It is the habit of rubbing the genital organs with the hands, with the clothing, against the bed, or rub- bing the thighs together. Sometimes the child sits upon the floor, crosses its thighs tightly and rocks backward and forward. Many of these things are passed over lightly and are regarded for months as simply a " queer trick " of the child. It may be seen at any age, even in those not more than a year old, and in both sexes. How should such a child he treated? Masturbation is the most injurious of all the bad habits, and should be broken up just as early as pos- sible. Children should especially be watched at the time of going to sleep and on first waking. Punish- ments and mechanical restraint are of little avail ex- cept with infants. With older children they usually make matters worse. Rewards are much more effi- cacious. It is of the utmost importance to watch the child closely, to keep his confidence, and by all pos- sible means to teach self-control. Some local cause of irritation is often present, which can be removed. Medical advice should at once be sought. VACCINATION 187 VACCI]SrATIO]S" Nowadays when small-pox occurs so seldom is it necessary to have every child vaccinated? It should by all means be done. It is only by the practice of general vaccination that small-pox is kept down. In countries or in communities where vaccination is neglected, frightful outbreaks of small- pox occur every now and then just as in olden times. What is the best time for vaccination? The time usually selected is from the third to the sixth month. It may be deferred in a very delicate child who is not likely to be exposed to small-pox, or in a child suffering from any form of skin disease. Which is preferable for vaccination, the arm or the leg? The part which can be most easily protected and kept at rest is to be chosen. In infants who do not yet walk or creep, the leg is to be preferred ; in older children, in most circumstances, the arm. If older children are vaccinated on the leg, they should not be allowed to walk much while the vaccination is active. When should vaccination be repeated? An unsuccessful vaccination proves nothing and should be repeated in two or three weeks. If success- 188 THE CARE AND FEEDING OF CHILDREN fully vaccinated in infancy, a child should invariably be revaccinated before puberty. If exposed or likely to be exposed to small-pox at any time vaccination should be repeated. CHART I CHART II CO ""^ cc S\ Vs ^\\ \ Vs. \ \ \ \ \\ \ \ V \ \ V \ \ A w \ [ \ ^ \ \ \ \ % \^ ^^ \, ^ \\ saimod 190 Of INDEX Airing, 27. Albumin water, 148. Appetite, loss of, 86. Barley water and barley jelly, 147. Baths, 15-16. bran, 19. cold sponge, 30. salt, 20. Bed-wetting, 185. Beef, scraped, 146. Beef juice, preparation of, 144. use of, 83. Bowel movements, 153-155. Bread, crackers, and cakes, 133. Broth, mutton, chicken, veal, beef, preparation of, 145, 146. Broths and soups, uses of, 132. Cereals, for infants, 75. for older children, 131. Chest, table, 35. Chicken-pox, 175.' Circumcision, 17. Clothing, 21-23. Colds, prevention of, 30, Colic, changes in food for, 90, 93. in breast-fed infants, 49. symptoms and treatment of, 170. Condensed milk, 93. Constipation, diet for, 91. general treatment of, 180. in breast-fed infants, 49. Convulsions, 168. Cream, for older children, 126. how obtained, 65. Croup, 172. Cry, 160. Dentition, 36-38. Desserts, 133. Development, 30-36. Diarrhoea, changes in food for, 96. general treatment of, 182. Diet (see Feeding). Diphtheria, 175. 191 193 THE CARE AND FEEDING OF CHILDREN Earache, 171. Eggs, 127, 149. for infants, 83. Exercise, 159, Eyes, 17, 18. Feeding, of infants, 42-121. artificial, 54-121. modification of cow's milk in, 59-76. formulas from 7 per cent, milk, 67-73. formulas from whole milk, 73-76. nursing, 42-54.* of older children, 125-144. Fever, 163-165. Fish, 128. Fontanel, closed, 33. Foods, proprietary, 95. Foreign bodies, in the ear, 170. in the nose, 170. swallowed, 169. Foreskin, 17. Fruits, 117, 119, 135. Genital organs, 16, 17. German measles, 174. Granum, Imperial, 148. Gruels, preparation of, 147. uses of, 82. Head, measurements of, table of, 35. supported, 33. Height, table of, 35. Indigestion, in infants, 96. in older children, 137-141. Junket, 146. Kissing, 168. Lime water, 148. Lifting children, 162. Masturbation, 186. Measles, 173. Meat, 128. Menstruation, effect of, on breast milk, 45. Milk, cow's, modification of, 59-76. selection and care of, 54. top, 63-65. mother's, 41-^2. , Modification of cow's milk (see Feeding), 59-76". Mouth, 18. Mumps, 176. Napkins, 24. Nervousness, 165. Nipples, 100. Nursery, 25. Nursing (breast feeding), 43. diet during, 44. indigestion during, 47, 49. intervals, 43. when not attempted, 42, 48. Nursing bottles, 100. IXDEX 193 Oat water and gruel, 147, 148. Orange juice, 83. Overfeeding, 84. "Pacifier," 184. Pasteurized milk, 110. Peptonized milk, 112. Prickly heat, 20. Refrigerators for nursery, 58. Rice water and gruel, 147. Scarlet fever, 174. Scurvy, 178. Seven per cent, milk, formulas from, 68, 75. Skin, 19. Sleep, 155-159. Speech, 34. Sprue, 18. Sterilized milk, 107. Stomach indigestion, changes in food in, 96. Stools, 153-155. Sugars, in infant feeding, 61. for older children, 134. Teeth, 36-38. Temperature, 163-165. Top-milk, 63-65. Toys, 166. Vaccination, 187. Vegetables, 129. Vomiting, 88. in breast-fed infants, 48. Walking alone, 34. Water, for infants, 92. for older children, 120. Weaning, 49-54. from bottle, 117. Weight, 30, 31. chart, 189, 190. table of, 35, 36. Whey, 146. Whole milk, formulas from, 73-76. Whooping-cough, 175. (36) THE END /Demoranba. /ei^<:)ran©a> jflDempranOa* ADemoranba. AemorauDa. Aem<>ran5it; n&emoran^ilR iDcmoranba. A5 AW INITIAL FINE OF li ^^ cVsS^SED FOR FAIUURE WIL.L BE ASSESSED ^^^ ^^ THIS B°°^ ^r'jTo 5° ^^^""^ °'' ' WIUU INCREASE TO 5 ^^ ^^^ ^^ DAY AND TO $10" OVERDUE. ^__^===== lolt,h.^.