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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


Fourth Edition, Revised and Enlarged


NEW YORK AND LONDON
D. APPLETON AND COMPANY

1907


COPYRIGHT, 1894, 1897, 1903, 1906
By D. APPLETON AND COMPANY


[Transcriber's Note: The text scans did not include a Table of
Contents so the following has been added for the convenience of
the reader.]


CONTENTS

I. THE CARE OF CHILDREN

Bathing
Genital Organs
Eyes
Mouth
Skin
Clothing
Napkins
Nursery
Airing
Weight, Growth, and Development
Dentition


II. INFANT FEEDING

Nursing
Weaning
Artificial Feeding
Selection and Care of Milk Used for Infant Feeding
Modification of Cow's Milk
Food for Healthy Infants--The Early Months
Food for Healthy Infants--The Later Months
General Rules for Guidance in the Use of the Formulas Given
Addition of Other Foods to Milk
Overfeeding
Loss of Appetite
Changes in Food Required by Special Symptoms or Conditions
Common Mistakes in Milk Modification and Infant Feeding
Preparation of Cow's Milk at Home
Directions for Feeding Infants
Intervals of Feeding
Regularity in Feeding
Sterilized Milk
Modified Milk of the Milk Laboratories
Peptonized Milk
Feeding During the Second Year
Feeding During the Third Year


III. THE DIET OF OLDER CHILDREN

Milk and Cream
Eggs
Meats and Fish
Vegetables
Cereals
Broths and Soups
Bread, Crackers, and Cakes
Desserts
Fruits
Indigestion in Older Children
General Rules to be Observed in Feeding
Food Formulas


IV. MISCELLANEOUS

Bowels
Sleep
Exercise
Cry
Lifting Children
Temperature
Nervousness
Toys
Kissing
Convulsions
Foreign Bodies
Colic
Earache
Croup
Contagious Diseases
Scurvy
Constipation
Diarrhoea
Bad Habits
Vaccination
Weight Charts



THE CARE AND FEEDING OF CHILDREN




PART I

THE CARE OF CHILDREN


BATHING

_At what age may a child be given a full tub bath?_

Usually when ten days old; it should not be given before the cord has
come off.

_How should the bath be given?_

It should not be given sooner than one hour after feeding. The room
should be warm; if possible there should be an open fire. The head and
face should first be washed and dried; then the body should be soaped
and the infant placed in the tub with its body well supported by the
hand of the nurse. The bath should be given quickly, and the body
dried rapidly with a soft towel, but with very little rubbing.

_At what temperature should the bath be given?_

For the first few weeks at 100° F.; later, during early infancy, at
98° F.; after six months, at 95° F.; during the second year, from 85°
to 90° F.

_With what should the bath be given?_

Soft sponges are useful for bathing the body, limbs and scalp. There
should be a separate wash-cloth for the face and another for the
buttocks.

_What are the objections to bath sponges?_

When used frequently, they become very dirty and are liable to cause
infection of the eyes, mouth or genital organs.

_Under what circumstances should the daily tub bath be omitted?_

In the case of very feeble or delicate infants on account of the
exposure and fatigue, and in all forms of acute illness except by
direction of the physician. In eczema and many other forms of skin
disease much harm is often done by bathing with soap and water, or
even with water alone.


GENITAL ORGANS

_How should the genital organs of a female child be cleansed?_

Best with fresh absorbent cotton and tepid water, or a solution of
boric acid, two teaspoonfuls to the pint. This should be done
carefully at least once a day. If any discharge is present, the
boric-acid solution should invariably be used twice a day. Great care
is necessary at all times to prevent infection which often arises from
soiled napkins.

_How should the genital organs of a male child be cleansed?_

In infancy and early childhood the foreskin should be pushed back at
least twice a week while the child is in his bath, and the parts thus
exposed washed gently with absorbent cotton and water.

If the foreskin is tightly adherent and cannot readily be pushed back,
the physician's attention should be called to it. The nurse or mother
should not attempt forcible stretching.

_When is circumcision advisable?_

Usually, when the foreskin is very long and so tight that it cannot be
pushed back without force; always, when this condition is accompanied
by evidences of local irritation or difficulty in passing water.


EYES

_How should the eyes of a little baby be cleansed?_

With a piece of soft linen or absorbent cotton and a lukewarm solution
of salt or boric acid,--one half of an even teaspoonful to one pint of
water.

_If pus appears in the eyes, what should be done?_

They should be cleansed every hour with a solution of boric acid (ten
grains to one ounce of water). If the lids stick together, a little
vaseline from a tube should be rubbed upon them at night. If the
trouble is slight, this treatment will control it; if it is severe, a
physician should be called immediately, as delay may result in loss of
eyesight.


MOUTH

_How is an infant's mouth to be cleansed?_

An excellent method is by the use of a swab made by twisting a bit of
absorbent cotton upon a wooden toothpick. With this the folds between
the gums and lips and cheeks may be gently and carefully cleansed
twice a day unless the mouth is sore. It is not necessary after every
feeding. The finger of the nurse, often employed, is too large and
liable to injure the delicate mucous membrane.

_What is sprue?_

It appears on the lips and inside the cheeks like little white threads
or flakes. It is also called thrush. In bad cases it may cover the
tongue and the whole of the inside of the mouth.

_How should a mouth be cleansed when there is sprue?_

It should be washed carefully after every feeding or nursing with a
solution of borax or bicarbonate of soda (baking soda), one even
teaspoonful to three ounces of water, and four times a day the
boric-acid solution mentioned should be used.


SKIN

_How should the infant's skin be cared for to prevent chafing?_

First, not too much nor too strong soap should be used; secondly,
careful rinsing of the body; thirdly, not too vigorous rubbing, either
during or after the bath; fourthly, the use of dusting powder in all
the folds of the skin,--under the arms, behind the ears, about the
neck, in the groin, etc. This is of the utmost importance in very fat
infants.

_If the skin is very sensitive and chafing easily produced, what
should be done?_

No soap should be used, but bran or salt baths given instead.

_How should a bran bath be prepared?_

One pint of wheat bran should be placed in a bag of coarse muslin or
cheese-cloth, and this put in the bath water. It should then be
squeezed for five minutes until the water resembles a thin porridge.

_How should a salt bath be prepared?_

A teacupful of common salt or sea salt should be used to each two
gallons of water.

_How should the buttocks be cared for?_

This is the most common place for chafing, as the parts are so
frequently wet and soiled; hence the utmost pains should be taken that
all napkins be removed as soon as they are wet or soiled, and the
parts kept scrupulously clean.

_If the parts have become chafed, what should be done?_

Only bran and salt baths should be used, and in very severe cases even
these may have to be omitted for a day or two. The parts may be
cleansed with sweet oil and a little absorbent cotton, and the skin
kept covered with a dusting powder composed of starch two parts, boric
acid one part.

_What is prickly heat, and how is it produced?_

It consists of fine red pimples, and is caused by excessive
perspiration and the irritation of flannel underclothing.

_How should it be treated?_

Muslin or linen should be put next to the skin; the entire body should
be sponged frequently with equal parts of vinegar and water, and
plenty of the starch and boric-acid powder mentioned should be used.


CLOTHING

_What are the most essential things in the clothing of infants?_

That the chest shall be covered with soft flannel, the limbs well
protected but not confined, and the abdomen supported by a broad
flannel band, which should be snug but not too tight. It is important
that the clothing should fit the body. If it is too tight it
interferes with the free movements of the chest in breathing, and by
pressing upon the stomach sometimes causes the infant to vomit soon
after swallowing its food. If the clothing is too loose it is soon
thrown into deep folds or bunches, which cause much discomfort. No
pins should be used, but, instead all bands about the body should be
basted. The petticoats should be supported by shoulder straps.

_How should the infant be held during dressing and undressing?_

Nothing is more awkward than to attempt to dress a young baby in a
sitting posture. It should lie upon the nurse's lap until quite old
enough to sit alone, the clothing being drawn over the child's feet,
not slipped over the head.

_Of what use is the band?_

It protects the abdomen, but its most important use is to support the
abdominal walls in very young infants, and in this way to prevent the
occurrence of rupture.

_How long is this band required?_

The snug flannel band, not usually more than four months. In healthy
infants this may then be replaced by the knitted band, which may be
worn up to eighteen months. The band is an important article of dress
in the case of thin infants whose abdominal organs are not
sufficiently protected by fat. With such, or with those prone to
diarrhoea, it is often advisable to continue the band until the third
year.

_What changes are to be made in the clothing of infants in the
summer?_

Only the thinnest gauze flannel undershirts should be worn, and
changes in temperature should be met by changes in the outer garments.
The greatest care should be taken that children are not kept too hot
in the middle of the day, while extra wraps should be used morning and
evening, especially at the seashore or in the mountains.

_Should older children be allowed to go with their legs bare?_

If strong and well there is no objection to this in very hot weather.
In cold weather, however, it is doubtful if any children are benefited
by it, particularly in a changeable climate like that of New York.
Many delicate children are certainly injured by such attempts at
hardening.

_What sort of underclothing should be worn during cold weather?_

Never the heaviest weight, even in winter. Four grades are usually
sold, the next to the heaviest being thick enough for any child.

_Do little children require as heavy flannels as older people?_

Not as a rule. They usually live in a warm nursery; their circulation
is active; and they always perspire easily during their play. When
they go out of doors, the addition of coats and leggings renders thick
flannels unnecessary.

_Are not many little children clothed too thinly for the ordinary
house?_

Very few. The almost invariable mistake made in city homes is that of
excessive clothing and too warm rooms. These two things are among the
most frequent reasons for their taking cold so easily.


NAPKINS

_How should napkins be taken care of?_

They should he 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 napkins which have been only wet be 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
importance in keeping the skin healthy.

_What are the important things to be observed 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 convenient 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 clamp.


NURSERY

_What are the essentials in a good nursery?_

The furnishings should be very simple, and unnecessary 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 plumbing 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 be 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.

_At what temperature should a nursery be kept during the day?_

Best, 66° to 68° F., measured by a thermometer hanging three feet from
the floor. Never 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 be left open at night?_

Usually after the third month, except when the outside temperature is
below freezing point.

_How often should the nursery be 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 kept in too hot a room?_

It becomes pale, loses appetite, shows symptoms of indigestion,
occasionally vomits, stops gaining in weight, perspires very much, and
takes cold easily because of this and also because of the great
difference between the indoor and outdoor temperatures. Its condition
may be such as to lead one to suspect very serious illness.


AIRING

_How early may airing indoors he commenced and how long may it be
continued?_

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 baby's taking 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 preventing colds.

_How should such an airing be given?_

The child should be dressed with bonnet and light coat as if for the
street and placed in its crib or carriage which should stand a few
feet from the window All the windows are then thrown wide open, 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 New York and along the Atlantic coast
the early mornings are apt to be damp and the afternoons raw and
cloudy.

_On what kind of days should a baby 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 be 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 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 by fresh air?_

The appetite is improved, the digestion is better, the cheeks become
red, and all signs of health are seen.

_Is there any advantage in having a child take its airing during the
first five or six months in the nurse's arms?_

None 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.

_What can be 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.).

_How should this cold sponge bath be 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 vigorous
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 the child?_

Nothing 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 condition. It will well repay any mother or nurse to keep
such a record.

_How frequently should a child be 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 be expected that bottle-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
continuous 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 accomplished it is necessary to make the milk
very weak or the child's digestion will be upset.

_For a child of average weight at birth (seven to seven and a half
pounds) what should be 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 five 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?_

Not invariably. Some who are fed upon prepared infant foods increase
rapidly in weight but 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 depend on season, and others often occur
without apparent 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 be able to sit and to stand alone?_

At seven or eight months a healthy child is usually 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
walking is rickets.

_Should a child be urged to walk?_

Never; he is usually quite willing to do so as soon as his muscles and
bones are strong enough. None 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.

_If at two years the child makes no attempt to speak, what should be
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
     Circumference of Head and Chest of Boys_[1]

    At birth        Weight             7-1/2  pounds.
                    Height            20-1/2 inches.
                    Chest             13-1/2   "
                    Head              14       "

    One year        Weight            21     pounds.
                    Height            29     inches.
                    Chest             18       "
                    Head              18       "

    Two years       Weight            26-1/2 pounds.
                    Height            32-1/2 inches.
                    Chest             19       "
                    Head              19       "

    Three years     Weight            31     pounds.
                    Height            35     inches.
                    Chest             20       "
                    Head              19-1/2   "

    Four years      Weight            35     pounds.
                    Height            38     inches.
                    Chest             20-3/4   "
                    Head              19-3/4   "

    Five years      Weight            41 pounds.
                    Height            41-1/2 inches.
                    Chest             21-1/2   "
                    Head              20-1/2   "

    Six years       Weight            45 pounds.
                    Height            44 inches.
                    Chest             23   "

    Seven years     Weight            49-1/2 pounds.
                    Height            46 inches.
                    Chest             23-1/2 "

    Eight years     Weight            54-1/2 pounds.
                    Height            48 inches.
                    Chest             24-1/2 "

    Nine years      Weight            60 pounds.
                    Height            50 inches.
                    Chest         .   25   "

    Ten years       Weight            66-1/2 pounds.
                    Height            52 inches.
                    Chest             26   "

    The above weights are with ordinary house clothes.

    [1] 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.


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 month. Then follow the four canine teeth,
the two 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 teething?_

In healthy children there is very often fretfulness 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.

_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?_

Nearly all of them come from indigestion due to bad feeding.




PART 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 parts 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 the bones, the 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.

_Of what use are the proteids?_

They are needed for the growth of the cells of the body, such as those
of the blood, the various 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 delicate organs of a young
infant can digest it. It is also necessary to enable the body to get
rid of its waste.


NURSING

_Should all mothers attempt to nurse their children?_

As a rule they should do so, but there are many conditions when they
should not.

_What are the most important ones?_

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 to fail in nourishing her child, and the attempt
may do herself much harm as well as injure the child.

_How often should infants be 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?_

Usually on the third day, sometimes not until the fourth or fifth day.

_Should the infant be fed anything additional during the first two
days?_

Usually not; if much food were necessary, we may be sure Nature would
have provided it. Water, however, should be given regularly.

_How frequently should an infant be nursed during 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 following table:

    ------------------------------------------------------------------
    PERIOD.             Nursings in    Interval    Night nursings
                        24 hours.      by day.     (10 P.M. to 6 A.M.).
    ------------------------------------------------------------------
    1st and 2d day          4          6 hours.             1
    3 days to 6 weeks      10          2     "              2
    6 weeks to 3 months     8          2-1/2 "              2
    3 to 5 months           7          3     "              1
    5 to 12 months          6          3     "              0
    ------------------------------------------------------------------

_How long should the child be kept at the breast for one nursing?_

Not over twenty minutes.

_Should the child take both breasts at one nursing?_

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.

_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 condition will permit. She should have regular movements 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 middle 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 dissipation etc., have more than anything else
to do with the failure of the modern mother as a nurse. Uncontrolled
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 lessened so that the
infant is not satisfied and may gain less in weight or not at all. In
many cases the quality of the milk is also affected to such a degree
as to cause slight disturbances of digestion, such as restlessness,
colic, and perhaps some derangement of the bowels. In a few, attacks
of acute indigestion are excited.

_Is regular menstruation a reason for stopping nursing?_

Not invariably; as a rule both functions do not go on together. But if
the child is gaining regularly 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 a good colour, sleeps for 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 steadily
in weight.

_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 playfulness, but is either listless and
indifferent or cross, fretful and irritable, and is apt to sleep
poorly. It grows pale and anæmic and its tissues become soft and
flabby. When the milk is scanty it will often nurse a long time at the
breasts, sometimes three 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 be done when such symptoms appear?_

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 necessary; 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 baby being partly nursed and partly fed?_

None whatever; it is often better from the outset to feed the baby
during the night, in order not to disturb the mother's rest.

_What symptoms indicate that the mother's milk disagrees with the
child?_

The child suffers from almost constant discomfort sleeps; little and
then restlessly, cries a great deal, belches gas from the stomach, and
passes much by the bowels, 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 be 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, endeavouring 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 be made if a nursing infant habitually 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 interrupted by
occasional rests, so that the milk is not taken too fast.

If the vomiting occurs some time after nursing and is repeated, it is
a sign of indigestion; often because the milk is too rich in fat. The
intervals between 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 be done if the infant has frequent or 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 emotions; all causes of worry should be removed.

_Can constipation in a nursing infant be controlled through the
mother's milk?_

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.


WEANING

_At what age should the child be weaned from the breast?_

Usually weaning should be begun at nine or ten months by substituting
one feeding a day for one 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 progressing normally in its development. Serious
illness of the mother, or pregnancy, may make weaning necessary.

_At what age should the weaning be completed?_

Generally at one year. In summer it may sometimes 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 be taught to drink
from the cup, and when to take the bottle?_

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 be overcome?_

By feeding every nursing infant once a day or 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 necessity 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 be weaned 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
at the night feeding.

_Is there any objection to the child's taking the bottle until it is
two or three years old?_

There are no advantages and some serious objections. Older children
often become so attached to the bottle that only with 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 childhood. The
difficulty is here that children form the "bottle habit." This habit
is troublesome, unnecessary, and should by all means be prevented. An
exclusive diet of milk for children of two or three years often
results in anæmia 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, occasionally 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.

_Can a baby just weaned take cow's milk of the same proportions as one
of the same age who has had cow's milk from birth?_

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 be 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 be the proper proportions for an infant 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
will gain quite regularly; the acute 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 milk?_

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 permanently. 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 (see page 141), often rickets, and in
other cases simply a condition of general malnutrition,--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 the feeding of
infants?_

That it comes from healthy cows, and that it is clean and fresh.

_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 preferred 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 be for the best
results in infant feeding?_

This depends very much upon the season, and how carefully milk is
handled. As ordinarily handled 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 contamination. This
necessitates that cows, stables, and milkers be clean, and that
transportation be in sealed bottles; also that those who handle the
milk 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 possible; 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 number of cities under the name of
"certified," "guaranteed," 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 be 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
immediately 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 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.

_How should milk be handled when bottled milk is purchased?_

It should be cooled as just described, as its temperature is usually
somewhat raised during transportation 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 be handled when they are purchased in
bulk?_

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.

_What are the important things to be 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 removed 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 temperature 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

_Can cow's milk be fed to infants without any changes?_

No; for although it contains similar elements to those in mother's
milk, they are not identical, and they are not present in the same
proportions.

_Is this a matter of much importance?_

It is of the greatest importance. There are few infants who can digest
cow's milk unless it is changed. To change cow's milk so as to make it
more nearly resemble mother's milk is called _modifying_ cow's milk.

_How is this milk whose proportions have been changed distinguished
from the original 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 a little more than half as much sugar; it has nearly
three times as much proteids and salts; its proteids are different and
much more difficult of digestion; its reaction is decidedly acid, that
of mother's milk is faintly acid or neutral.

_Are there any other important things to be considered?_

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 proportion 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 feeding that these
conditions receive attention as that the proportions of the different
elements of the milk are right.

_How 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 each 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 be 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?_

Not 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 be added?_

Considerably less than of the milk sugar. Usually about half the
quantity (half an ounce to twenty ounces of food) is as much as most
infants can digest 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.

_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?_

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 cow's milk has nearly three times as much proteids
(curd) and salts as mother's milk. How are these to be diminished?_

By diluting the milk.

_Will it be sufficient to dilute the milk twice (i.e., add two parts
of water to one part of milk)?_

Not for a very young infant. Although this will give about the
quantity of proteids present in mother'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?_

No; the mixture contains too little fat.

_What is the easiest way of overcoming this?_

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.,
a 10-per-cent milk contains 10 per cent fat; 7-per-cent milk contains
7 per cent fat, etc. These are the two strengths of top milk most used
in infant feeding.

_On what does the percentage of fat in top-milk depend?_

1. On the length of time the milk has stood.

2. On the manner in which the top-milk is removed.

3. On the number of ounces removed.

4. On the richness of the milk used.

Unless these are known it is impossible to say even approximately how
strong in fat the top-milk is.

_When and how should top-milk be removed?_

If milk fresh from the cow, or before the cream has risen, is put into
bottles and rapidly cooled, the 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[2] holding one
ounce; although it may be taken off by a spoon or siphon. It should
not be poured off.

    [2] 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.

_How can we obtain a 10-per-cent top-milk with the different kinds of
cow's milk?_

From a rather poor milk (containing 3--3-1/2 per cent fat) by removing
the upper eight ounces from a quart, or one fourth.

From a good average milk (containing 4 per cent fat) by removing the
upper eleven ounces from a quart, or about one third.

From a rich Jersey milk (containing 5--5-1/2 per cent fat) by removing
the upper sixteen ounces, or one half.

_How can we obtain a 7-per-cent top-milk with the different kinds of
cow's milk?_

From a rather poor milk, by removing the upper eleven ounces from a
quart, about one third.

From a good average milk, by removing the upper sixteen ounces, or one
half.

From a rich Jersey milk, by removing the upper twenty-two ounces, or
about two thirds.

[Illustration: The percentage of fat in the different layers of milk
of good average quality.]

_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 usually for twenty-four
hours? this is known as "gravity cream." (2) By an apparatus known as
a separator; 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.


FOOD FOR HEALTHY INFANTS[3]--THE EARLY MONTHS

    [3] The directions and formulas given in the following pages
    are intended only for guidance in feeding children who
    are not suffering from any special disturbance of digestion;
    directions for such conditions are given in a later chapter.

_What are the most important points to be remembered in modifying
cow's milk for feeding during the early months?_

That of the different ingredients of milk the sugar is most easily
digested; the fat is next; while the proteids are the most difficult.

_What relation should the fat bear to the proteids during this
period?_

For most infants with good digestion the best results are obtained
when the fat is three times the proteids. 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 is made only
twice the proteids.

_How can one obtain formulas in which the fat is three times the
proteids?_

By using for dilution a 10-per-cent milk (i.e., milk containing 10 per
cent fat) which serves as the primary formula from which all the other
formulas of this series are derived.

In 10-per-cent milk the fat is just three times the proteids.

_How can one get the 10-per-cent milk?_

(1) As top-milk, as described on page 64; or, (2) by mixing equal
parts of plain milk and ordinary cream (containing about 16 per cent
fat); (3) from any of the milk laboratories it may be ordered
directly.

_Is it better to obtain the 10-per-cent milk by using a mixture of
milk and cream, or as top-milk?_

If one can get milk fresh from the cows, the top-milk is to be
preferred on account of freshness. The food can then be made up when
the milk is but a few hours old. In cities, if one uses bottled milk,
the upper third may also be used. But if one buys milk and cream
separately, it is usually more convenient to mix these, as the cream
will not rise upon milk a second time with any uniformity.

_How can one obtain formulas in which the fat is twice the
proteids?_

By using for dilution a 7-per-cent milk (i.e., milk containing 7 per
cent fat) which serves as the primary formula from which all the other
formulas of this series are derived.

In 7-per-cent milk the fat is just twice the proteids.

_How can one get the 7-per-cent milk?_

(1) 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. As in the
case of 10-per-cent milk, the top-milk is generally to be preferred to
a mixture of milk and cream.

_How should the food be prepared during the early months?_

It is convenient in calculation to make up twenty ounces of food at a
time. The first step is to obtain the 10-per-cent milk or the
7-per-cent milk to be used as the primary formula. Then to take the
number of ounces of this that are called for in the formula desired.

Note.--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 milk sugar[4] and one
ounce of lime-water in each twenty ounces. The rest of the food will
be made up of boiled water.

    [4] 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
    ounce.

These formulas written out would be as follows:

  _First Series_

  _Formulas for the Early Months from 10-per-cent Milk_

  -----------------------------------------------------------
                       I.      II.     III.    IV.     V.
  -----------------------------------------------------------
  10-per-cent milk     2 oz.   3 oz.   4 oz.   5 oz.   6 oz.
  Milk sugar           1 "     1 "     1 "     1 "     1 "
  Lime-water           1 "     1 "     1 "     1 "     1 "
  Boiled water        17 "    16 "    15 "    14 "    13 "
  -----------------------------------------------------------
                      20 oz.  20 oz.  20 oz.  20 oz.  20 oz.
  -----------------------------------------------------------

As the milk sugar dissolves in the water the total in each column
will be exactly twenty ounces. The food is strengthened by gradually
increasing the milk and reducing the water.

The approximate composition of these formulas expressed in percentages
is as follows:

  ----------------------------------------
  FORMULA.   Fat.     Sugar.     Proteids.
  ----------------------------------------
    I.       1.00     5.50       0.33
   II.       1.50     6.00       0.50
  III.       2.00     6.00       0.66
   IV.       2.50     6.00       0.80
    V.       3.00     6.50       1.00
------------------------------------------

  _Second Series_

  _Formulas for the Early Months from 7-per-cent Milk_

  -----------------------------------------------------------
                       I.      II.     III.    IV.     V.
  -----------------------------------------------------------
  7-per-cent milk      2 oz.   3 oz.   4 oz.   5 oz.   6 oz.
  Milk sugar           1 "     1 "     1 "     1 "     1 "
  Lime-water           1 "     1 "     1 "     1 "     1 "
  Boiled water        17 "    16 "    15 "    14 "    13 "
  -----------------------------------------------------------
                      20 oz.  20 oz.  20 oz.  20 oz.  20 oz.
  -----------------------------------------------------------

The approximate composition of these formulas expressed in percentages
is as follows:

  ----------------------------------------
  FORMULA.   Fat.     Sugar.     Proteids.
  ----------------------------------------
    I.       0.70     5.50       0.35
   II.       1.00     6.00       0.50
  III.       1.40     6.00       0.70
   IV.       1.75     6.00       0.87
    V.       2.00     6.50       1.00
------------------------------------------

_How is one to decide whether to use the First or the Second Series of
formulas?_

With a large, strong child, having a good digestion one should use the
First Series. With a smaller, less vigorous child, whose digestion is
not so good, or with one who does not do well upon the First Series,
the Second Series should be used.

_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 be increased in strength from Formula I to
II, from II to III, etc.?_

No absolute rule can be given. Usually we begin with I on the second
day; II on the fourth day; III at one week or ten 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 3½ ounces; from 4 ounces to 4½ ounces, etc. At
least two or three days should be allowed between each increase in the
strength of the food.

_What general rule can be given for increasing the food?_

To increase when the infant is not satisfied but is digesting well.

_How does an infant show that he is not satisfied?_

He drains the bottle eagerly and cries when 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.

_In the series of formulas given in the table the quantities are
mentioned for making only twenty ounces of food. How should it be
prepared when more than this quantity is needed?_

It is equally convenient to make up 25 ounces, 30 ounces, 35 ounces,
or 40 ounces at a time.

  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 2½ ounces of
milk, 1¼ ounces of sugar and lime-water, 21¼ ounces of water; 30
ounces of the same would require 3 ounces milk, 1½ ounces lime-water
and sugar, and 25½ ounces water; 35 ounces would require 3½ ounces
milk, 1¾ ounces lime-water and sugar, and 29¾ ounces water. The amount
of water need not be calculated in any case, but after measuring
carefully the other ingredients enough water should be added to bring
the total up to the amount required.

_How great an increase in the quantity should be made at one time?_

One may make up five ounces additional food; but the first two days
only two or three ounces of the additional amount should be given; the
next two days, four ounces; after two days more, the five ounces may
be given.

The increase in the quantity given at a single feeding should not be
more than a quarter of an ounce.


FOOD FOR HEALTHY INFANTS--THE LATER MONTHS

_How long should the fat be as much as three times the proteids?_

This is seldom of advantage longer than three or four months.

_What changes should then be made in the milk?_

After Formula V of the First Series (6 ounces of 10-per-cent milk in
20 ounces of food) has been reached, the fat should be increased very
slowly for this proportion (3 per cent) is near the limit for most
healthy children. The milk should now be strengthened chiefly by
raising the percentage of proteids.

_How is this accomplished?_

The 10-per-cent milk and the formulas derived from it should now be
discontinued, and those made from 7-per-cent milk used.

  _Third Series_

  _Formulas for the Later Months from 7-per-cent Milk_

  -----------------------------------------------------------
                       I.      II.     III.    IV.     V.
  -----------------------------------------------------------
  7-per-cent milk      7 oz.   8 oz.   9 oz.  10 oz.   11 oz.
  Milk sugar           1 "     1 "     1 "     3/4 "    1/2 "
  Lime-water           1 "     1 "     1 "     1   "    1   "
  Boiled water        12 "     11 "   10 "     4   "    3   "
  Barley gruel         0 "     0 "     0 "     5   "    5   "
  -----------------------------------------------------------
                      20 oz.  20 oz.  20 oz.  20 oz.   20 oz.
  -----------------------------------------------------------

Since the sugar dissolves, the total will be twenty ounces in each
column.

Of any of the formulas, 25 ounces is made by using one quarter more
of each ingredient; 30 ounces, by using one half more; 35 ounces, by
using three quarters more; 40 ounces, by using twice as much, exactly
as described in the First Series on page 73.

The approximate composition of these formulas expressed in percentages
is as follows:

  ----------------------------------------
  FORMULA.   Fat.     Sugar.     Proteids.
  ----------------------------------------
    I.       2.50     6.50       1.25
   II.       2.80     6.50       1.40
  III.       3.15     7.00       1.55
   IV.       3.50     6.00       1.75
    V.       4.00     6.00       2.00
------------------------------------------

_How should the food be increased during this period?_

Beginning with I of this Series, which should usually follow V of the
First or Second Series (pages 70, 71), the increase may generally be
made in a week or ten days to II; in about two weeks more to III; now
more slowly to IV and V. When IV or V has been reached, the same
formula may sometimes be continued for three or four months with no
other change than an increase in the quantity.

_In passing from Formula V of the First Series to Formula I of the
Third Series the proportion of fat is at first reduced. Is this
necessary or important?_

No; it only happens to come so in simplifying the calculation. It may
be avoided by taking off at first the upper 13 ounces as top-milk and
using 7 ounces of this in a 20-ounce mixture, in place of Formula I;
and by using for the next increase the upper 15 ounces as top-milk,
taking of this 8 ounces in a 20-ounce mixture in place of Formula II.
Then should follow Formula III.

_What further addition may be made to the food of the later months?_

Usually about the sixth or seventh month, farinaceous food in the form
of gruel may be added, this taking the place of part of the water and
part of the sugar.

_What changes may be made in the food when the infant has reached the
age of ten or eleven months?_

The proteids may be still further increased, and the sugar and the
lime-water reduced until plain milk is given.

_How may this best be done?_

At first one feeding a day of plain milk and barley gruel may be
given; later, two feedings; then three feedings, etc. Let us suppose
an infant to be taking such a modified milk as Formula IV or V (page
76), six feedings a day. The plain milk diluted only with barley gruel
would at first replace one of these feedings; then two, three, four,
etc., these changes being made at intervals of about two weeks. The
proportions of the milk and barley gruel should at first be about
5-1/2 ounces milk, 2-1/2 ounces barley; later, 6 ounces milk, 3 ounces
barley; still later, 7 ounces milk, 2 ounces barley, until finally
plain milk is given to drink and the cereals given separately with a
spoon. This is reached with most infants at fourteen or fifteen
months; with many at twelve or thirteen months. Other forms of
farinaceous food may of course be used in the place of the barley, and
in the same proportions.

With some infants the addition of a pinch of bicarbonate of soda may
be advantageously made to each milk-feeding when the lime-water is
omitted, but with most this is unnecessary.

If the infant strongly objects to the taste of the milk when the milk
sugar has been omitted, a small quantity (one fourth to one half
teaspoonful) of granulated sugar may for a time be added to each
feeding, then gradually reduced.


GENERAL RULES FOR GUIDANCE IN THE USE OF THE FORMULAS GIVEN

It should again be emphasized that these formulas are not intended for
sick children nor for those suffering from any marked symptoms of
indigestion. For such infants special rules are given later.

_What should be the guide in deciding upon a formula with which to
begin for a child who is to be 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 previously
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 power 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 be increased in strength?_

The first essential is that it be done very gradually; 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 the series given; with
many infants it is better to make the steps of increase only half as
great as those indicated (page 72).

_How rapidly should the food be increased in quantity?_

The increase should not be more than a quarter of an ounce in each
feeding; or from one and a half to two ounces in a day.

_When should the food be 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 are the conditions
present.

The signs indicating that the food should be increased are, that the
infant is not satisfied, not gaining in weight, but is digesting well,
i.e., not vomiting, 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 somewhat hungry. The
appetite is not always a safe guide to follow.

_How can one know whether the strength or the quantity of the food
should be 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.

_If a slight disturbance or discomfort occurs after the food has been
strengthened, is it best to go back 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.

_Should one be disturbed 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 indigestion, 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 improves 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, because there is only a slight
gain in weight or none at all, the food is rapidly increased, an acute
disturbance of digestion is pretty certain to follow.

_Is 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. Under these circumstances, if the bowels move once
every 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.

_Under what circumstances should the food be reduced?_

Whenever the child becomes ill from any cause whatever, or whenever
any marked symptoms of indigestion arise.

_How may this be 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 regular food should be
omitted altogether and only water given until the doctor has been
called.

_If the food has been reduced for a disturbance of digestion, how
should one return to the original formula?_

While the reduction of the food should be immediate and considerable,
the increase should be very gradual. After a serious attack of acute
indigestion, when beginning with milk again, it should not be 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 indigestion, 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 OTHER FOODS TO MILK

_How long should modified milk be continued without the addition of
other food?_

This depends upon circumstances; usually, for about six months; but if
the infant is thriving satisfactorily the milk may be used alone for
ten or eleven months; with some infants who have especial difficulty
in digesting cow's milk, it is advisable to begin the use of other
food at three or four months or even from the outset.

_What is the first thing to be used with milk?_

Farinaceous food in some form, usually as a gruel.

_How are these gruels made?_

They may be made directly from the grains or from some of the prepared
flours (page 149). The flours are usually to be preferred as being
more simple of preparation.

_How should they be used in making the food?_

They should be cooked separately, rather than with the milk; when the
food is mixed, they take the place of a portion of the water in the
formulas given on pages 70 and 71.

_How much of the gruel should be used?_

If it is prepared as recommended on page 149, it may make according to
circumstances from one sixth to one half the total quantity of food.

_Which of the farinaceous foods are to be preferred?_

Those most used are barley, oatmeal, arrowroot, and farina. There is
not much difference in their nutritive value; oatmeal gruel is
somewhat more laxative.

_What value do these substances possess as infant foods?_

Some of the starch is digested and absorbed; but the chief value of
gruels is believed to be that when added to milk they render the curd
more easily digested by preventing it from coagulating in the stomach
in large tough masses. This is certainly true with many infants, but
there are others who are not at all benefited, and not a few young
infants whose digestion is made distinctly worse by the use of
farinaceous food, particularly when employed in considerable quantity.
The addition of gruels to milk for all infants is not to be
recommended.

_What further additions may be made to the diet of healthy infants
during the first year?_

Beef juice, the white of egg, and orange juice.

_How and when may beef juice be used?_

With infants who are strong and thriving satisfactorily it may be
begun at ten or eleven months; 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 teaspoonfuls may be given. The maximum quantity at one year
should not be more than two or three tablespoonfuls.

With delicate infants who are pale and anæmic, beef juice is more
important, and it may often be wisely begun at five or six months in
half the quantities mentioned.

_When should white of egg be used?_

Under the same conditions as beef juice, particularly with infants who
have difficulty in digesting the proteins (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 in manner of cooking
is the "coddled", egg (see page 151).

_When should orange juice be begun?_

Usually about the eleventh or twelfth month; it should be given about
one hour before the feeding; two teaspoonfuls at first, then one
tablespoonful at a time, and later three or four tablespoonfuls. It is
particularly 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 by overfeeding?_

Giving an infant too much food; either too much at one time or too
frequently. Overfeeding is sometimes practised during the day, but is
chiefly done at night.

_Is not an infant's natural desire for food a proper guide as to the
quantity given?_

The appetite of a perfectly normal infant usually 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 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 continued,
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 be given to any
infant??_

(1) The size of the infant's stomach at the different 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 108, gives the average figures
derived from 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 be done when without any other signs of illness a child's
appetite gradually fails?_

This is often the result of a long period of overfeeding or the use of
milk too rich in fat. If in all other respects the child 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
shortened 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
intervals. The food should be weakened rather than strengthened. No
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.


THE CHANGES IN THE FOOD REQUIRED BY SPECIAL SYMPTOMS OR CONDITIONS

Infants with weak digestion and those suffering from various forms of
indigestion have often especial trouble in digesting the fat of milk.
To meet the needs of such there is required a series of formulas in
which the fat is lower than in those already given.

These formulas are obtained from plain milk.

  _Fourth Series_

  _Formulas from Plain Milk (containing 4-per-cent Fat)_

  ---------------------------------------------------------
                I.   II.  III. IV.  V.    VI.   VII.   VIII.
  ---------------------------------------------------------

  Plain milk    5oz. 6oz. 7oz. 8oz. 9oz.  10oz  12oz.  14oz.
  Milk sugar    1 "  1 "  1 "  1 "  3/4 "  3/4 " 1/2 "  1/2 "
  Lime-water.   1 "  1 "  1 "  1 "  1 "    1 "   1 "    1 "
  Boiled water 14 " 13 " 12 "  7 "  6 "    5 "   2 "    0 "
  Barley gruel  0 "  0 "  0 "  4 "  4 "    4 "   5 "    5 "
    ---------------------------------------------------------
               20   20   20   20   20     20    20     20
               oz.  oz.  oz.  oz.  oz.    oz.   oz.    oz.
    ---------------------------------------------------------

When larger quantities than 20 ounces are required they are calculated
in the same manner as described on page 73 in speaking of 10-per-cent
milk.

The approximate composition of the formulas of the Fourth Series
expressed in percentages is as follows:

  ----------------------------------------
  FORMULA.   Fat.     Sugar.     Proteids.
  ----------------------------------------
     I.      1.00     6.00       0.90
    II.      1.20     6.00       1.00
   III.      1.40     6.50       1.20
    IV.      1.60     6.50       1.40
     V.      1.80     6.00       1.60
    VI.      2.00     6.00       1.80
   VII.      2.40     5.50       2.10
  VIII.      2.80     5.50       2.50
  ----------------------------------------

_Why is it that an infant so often vomits some of its food within a
few moments after finishing its bottle?_

Usually because the quantity is too large. Sometimes it is due to the
fact that the food is taken too rapidly, from too large a hole in the
nipple. It may be 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 by habitual vomiting, regurgitation, or spitting up of small
quantities of food between feedings, often repeated many times a day?_

This is always a symptom of gastric indigestion, and a most
troublesome one. In such conditions the fat and often the sugar also
should be reduced and the lime-water increased.

Formulas made from rich top-milk or milk and cream are to be avoided.
Those made from 7-per-cent milk are less likely to be the cause of
trouble than those from 10-per-cent milk; but if the symptoms are at
all severe it is better to use instead of these the formulas of the
Fourth Series derived from plain milk.

Reduction in the sugar may be made by adding only one half ounce of
milk sugar to each twenty ounces of the food; in severe cases the
sugar may be omitted altogether.

It is often advisable to double the amount of lime-water--i.e., use
two ounces to each twenty ounces of food.

The malted foods and all other foods containing much sugar usually
aggravate the symptoms.

The intervals between meals should generally be half an hour longer,
and sometimes an hour longer, than when digestion is normal.

The quantity given at a feeding should generally be less than with a
normal digestion. Usually a smaller quantity of a strong food succeeds
better than a larger quantity of a weak food.

_What are the causes of, and food changes required by a constant and
excessive formation of gas in the stomach, leading to distention and
pain, or eructations (belching) 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 sugar, which should be greatly reduced
or omitted entirely.

_What changes should be made when there is habitual colic?_

This is generally due to an accumulation of gas in the intestines
which forms there because the proteids (curd) of the milk are not
digested. They should be reduced by using in the early months a weaker
formula--i.e., instead of Formula V of the First or Second Series, IV
might be used, or, for a short time, even III. The proteids may be
reduced in the middle period by using weaker formulas If we desire to
reduce the proteids without reducing the fat, we may change from the
Second to the First Series.

Another means of relieving habitual colic is the use of partially
peptonized milk (page 115); still another the dilution with
barley-water instead of plain water.

_What change should be made if curds appear in the stools regularly or
frequently?_

This is usually associated with habitual colic, and has to be managed
exactly like that condition, by the means just described.

_How should the milk be modified for chronic constipation?_

The constipation of the first weeks of life has been already referred
to (page 82); it usually disappears as the food is gradually
strengthened in all its proportions.

Habitual constipation at a later period is difficult 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 plain milk variously diluted (page
90), then when 7-per-cent or 10-per-cent milk is used, and diluted to
a greater degree. But it is not desirable to use a top-milk containing
more than ten per cent fat for this purpose, nor is it wise to carry
the fat in the food above 4 per cent (i.e., 8 ounces of 10-per-cent
milk, or 12 ounces of 7-per-cent milk, in a 20-ounce mixture) or other
disturbances of digestion may be produced.

In some cases the use, in place of milk sugar, of ordinary brown
sugar, in half the quantity, is of assistance; or of some of the
malted foods (Mellin's food, malted milk, cereal milk) also in the
place of milk sugar.

The substitution of the milk of magnesia for the lime-water as
recommended on page 60 will often be found useful.

To infants over nine 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 7-per-cent milk in
place of 10-per-cent (i.e., the Second instead of the First Series of
formulas, page 71), or plain milk in place of the 7-per-cent milk in
the Second and Third Series (page 90). At such times also the usual
food should be diluted, and water should be given freely between the
feedings.

_What changes should be 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 increased by the use of the next higher formula. One should,
however, be extremely careful under these circumstances not to coax or
force a child; for this plan 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 be done with infants who in spite of all variations in
the milk continue to have symptoms 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, constipation or diarrhoea) than if
they are chiefly gastric (vomiting, regurgitation, etc.).

_How should condensed milk be used?_

For an infant three or four months old with symptoms of indigestion,
it should at first be diluted 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 be 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.,
No. III or IV of the Second Series, page 71) may be given; later two
feedings, and thus gradually the number of milk feedings is increased
until the child is taking only modified milk.

Condensed milk is not to be recommended as a permanent food where good
fresh cow's milk can be obtained.

_What are the objections to its use?_

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 weight, yet have as a rule but little
resistance. They are very prone to develop rickets and sometimes
scurvy.

_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, bronchitis measles, etc.,
attended with fever, the food should be diluted and the fat reduced as
described on page 95. 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.

_What immediate changes should be made in the food when the child is
taken with an acute attack of gastric indigestion with repeated
vomiting, fever, pain, etc.?_

All milk should be stopped at once, and only boiled water given for
ten or twelve hours; afterward barley-water or whey may be tried, but
no milk for at least twenty-four hours after the vomiting has ceased.
When beginning with modified milk the quantity should be small and the
fat low, which may be secured by the use of the Fourth Series of
formulas in the place of the First or Second Series. The proportion of
lime-water may be doubled.

_What changes should be made for an attack of intestinal indigestion
attended by 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 curds are present in the stools, it may
be still further diluted.

If the diarrhoeal 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 disturbances 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?_

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.
Such a course 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 temperature are all quite as important as
the preparation of the food; quiet peaceful surroundings and absence
of excitement are also essential to good digestion.


COMMON MISTAKES IN 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, unless all
these are known, it is impossible to tell how strong it is. Directions
for the removal of top-milk should be explicitly followed (see page
63), or the results will be very different from those expected.

II. In formulas calling for a certain number of ounces of top-milk of
any given strength, 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 which contains about 4 per cent fat. Many persons
have the idea that the richer the milk, the more rapidly 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, particularly after some
disturbance of digestion. If, in an infant three or four months old,
an attack of somewhat acute indigestion occurs, the food should seldom
be given in full strength before two weeks. The increase in the diet
should be made very gradually, the steps being made only one half
those indicated in the series of formulas on pages 70 and 71.
Otherwise it generally happens that the attack of indigestion 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 reduced 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.


PREPARATION OF COW'S MILK AT HOME

_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 Bunsen 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.

_What bottles are to be 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 water.

_What sort of nipples should be 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. Nipples made of black rubber are to be
preferred. 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.

_How should nipples be cared for?_

New nipples should be boiled for 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 solution 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 be used?_

The refined non-absorbent cotton is rather better for stoppering
bottles, but the ordinary absorbent cotton will answer every purpose.

_Which is better, the Bunsen burner or the alcohol 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 according 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 water,
filtering if necessary. Then add the milk and cream and lime-water,
mixing 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 rapidly 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 FOR FEEDING INFANTS

_How should the bottle be prepared at feeding time?_

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 be tested?_

Never 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 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 thermometer 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 be allowed for one feeding?_

Never 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 by gentle shaking until
the food is taken, or the bottle should be removed altogether.

_Should an infant be played with soon after feeding?_

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.


INTERVALS OF FEEDING

_How often should a baby be fed during the first month?_

Every two hours during the day and twice during the night, or ten
feedings during the twenty-four hours.

_At what age may the interval be made two and a half hours?_

Usually at five or six weeks.

_When may it be increased to three hours?_

Usually at two months.

_Why should not a child be 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
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.        Interval     Night      No. of   Quantity   Quantity
                   between    feedings    feedings  for one     for 24
                    meals,    (10 P.M.     in 24    feeding.    hours.
                   by day.   to 7 A.M.).    hours.
---------------------------------------------------------------------
                    Hours.                          Ounces.     Ounces.
2d to 7th day         2          2           10      1 -1-1/2   10-15
2d and 3d weeks       2          2           10   1-1/2 - 3     15-30
4th and 5th weeks     2          1           10   2-1/2 - 3-1/2 25-35
6th to 8th week       2-1/2      1            8      3 - 5      24-40
3d to 5th month       3          1            7      4 - 6      28-42
5th to 9th month      3          0            6      5 - 7-1/2  30-45
9th to 12th month     4          0            5      7 - 9      35-45
---------------------------------------------------------------------

This schedule gives the averages for healthy children 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 will 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.

_When should the interval between the feedings be lengthened?_

When there is gastric indigestion as shown by 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 be 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.


REGULARITY 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 putting 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 required long, for with regular
feeding an infant soon wakes regularly for its meal, almost upon the
minute.

_Should regularity in feeding be kept up at night as well as during
the day?_

Only 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 baby go without food from 10 P.M. to 6 or 7
A.M.?_

Usually at four months, and always at five or six months. Night
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, diphtheria scarlet fever, cholera, tuberculosis, and
many forms of diarrhoea.

_Under what circumstances is it necessary to sterilize milk?_

1. In warm weather when it cannot be obtained 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 considerable 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 known as _sterilizing_, in which the milk is heated to
212° F. for one hour or one hour and a half; the second is known as
_pasteurizing_, in which the milk is heated to 155° or 170° 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 indefinitely?_

No; 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. for two or
three days.

_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 that 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 way as milk which has not been heated.

_Is milk in any way injured by heating to 212° F. for an hour?_

There is abundant evidence that milk is rendered 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 upon two successive days, without removing
the cotton stoppers from the bottles.

_Is milk in any way injured by 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 be pasteurized?_

A convenient form of apparatus is that known as Freeman's
pasteurizer[5]; another is the Walker-Gordon pasteurizer.[6]

    [5] 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.

    [6] Obtained at the same prices from any of the Walker-Gordon
    milk laboratories.

_How should milk be 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.

_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 laboratories?_

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 prepared 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 feeding only by one who is
somewhat familiar with this method of ordering milk.


PEPTONIZED MILK

_What is peptonized milk?_

Milk in which the proteids (curd) have been partially 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?_

None, if peptonizing is continued for only ten minutes, but at the end
of twenty minutes it begins to be bitter, when the process of
digestion has gone further.

_How is the bitter taste avoided in partially peptonized 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 be peptonized at once, or each bottle
separately just before the feeding?_

Either plan may be followed. If the former, it is better to raise the
milk to boiling point after peptonizing; if the latter, it should not
be peptonized more than ten minutes, for it will continue to peptonize
while it is being taken by the child.

_Is not the bitter taste of completely peptonized milk a great
obstacle to its use?_

Not 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.

_How much of the peptonizing powder should be 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 usually put up in a single tube or tablet. In the formulas
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 milk?_

Partially peptonized milk is useful for young infants 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 be continued?_

Completely peptonized milk may be used for a few days, or at most a
few weeks; partially peptonized 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 YEAR

_How many meals are required during the second year?_

It is usually better to continue five meals throughout the second
year. 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 be prepared at the time it is given, or all
feedings at one time, 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. If it is to be modified by adding cream,
water, etc., it is done as during the first year.

Later, when only plain milk is used, the quantities needed for the
different feedings should be put into one or into two bottles, which
then may be pasteurized 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 should be prepared as soon as possible after the
daily milk supply is delivered in the morning.

_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 be followed?_

Usually until the fourteenth or fifteenth month. After this time the
cereals may be given much thicker and fed from a spoon.

_May any other fruit juices be given at this period?_

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 be 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.

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 oatmeal
               hominy or wheaten grits, cooked for at
               least three hours; 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.

   2 P.M.  Beef juice, one to two ounces; and one egg (soft
               boiled, poached or coddled); and boiled rice, one
               tablespoonful;
             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, gradually
               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, however who sleep regularly from 6 P.M. until 6 A.M. 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.

  10 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 tablespoonfuls.
           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 be 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 applesauce. The prune pulp is prepared by stewing the dried prunes
without sugar until they are very soft, and removing all the skin by
putting the fruit through a strainer; of this from one to two
tablespoonfuls may be given at one time. The baked apple should be
given without cream, and the applesauce should have very little sugar.

_How and when should water be given?_

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 be 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.

_What would be 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.
           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.




PART III

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 supper 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 nutritive value as milk,
for the amount of work required of the organs of digestion. It is,
therefore, peculiarly adapted to the diet of the child.

_What are the essential points in the use of milk?_

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 important not to give milk at meals when fruits, especially
sour fruits, are allowed.

_How much milk may advantageously be 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 be used?_

Older children do not require so large a proportion 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 tongue, foul breath and
pale gray stools, often called "biliousness."

_Is not cream useful in overcoming the constipation of children?_

With infants it is valuable to a certain point, but with 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 be 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 proteids 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 "biliousness"?_

Very seldom, if fed as above advised. This is an old prejudice but has
little basis in fact.

_How often may eggs be given?_

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 AND FISH

_What meats may be 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 be 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 be given?_

At this period, only once a day, at the mid-day meal.

_Is not the excessive nervousness of many modern children due to the
giving of meat, or at least aggravated by its use?_

There is little ground for such a belief, unless an excessive amount
of meat is given. Certainly cutting off meat from the diet of nervous
children seldom produces any striking benefit.

_What meats should be forbidden to young children?_

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 digestible 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, may be given after the sixth or seventh year in moderate
amount.

The principal trouble in the digestion of vegetables 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 regularity 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
thoroughly cooked and more finely divided before being given.

_Is it safe to use canned vegetables for children?_

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 be given to young children?_

None of those which are eaten raw, such as celery, radishes, onions,
cucumbers, tomatoes or lettuce. Certain others, even when well cooked,
should not be allowed; as corn, lima beans, cabbage, egg plant. None
of these should be given until a child has passed the age of ten
years.

_Are vegetable salads to be 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 package, usually three or four times as long. Digestibility
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 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 be 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 saucerful of cereal should be the limit.

Cereals should not be served with syrups or butter and sugar.


BROTHS AND SOUPS

_What broths and soups are to be recommended?_

Meat broths are generally to be preferred to vegetable broths,--mutton
or chicken being usually most liked by children. Nearly 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.


BREAD, CRACKERS AND CAKES

_What forms of breadstuffs 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 crackers 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 breadstuffs should be forbidden?_

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 be 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 raisins, plain custard and, not more than once a week,
a small amount of ice cream.

_What should be 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 become 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 normal 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 constantly increasing
tendency, not easily controlled as a child grows older; and in early
childhood, the only safe rule is to give none at all.


FRUITS

_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 be 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 be used?_

That from sweet oranges is the best, but the fresh juice of grape
fruit, peaches, strawberries and raspberries may also be used.

_What stewed fruits may be given?_

Stewed or baked apples, prunes, pears, peaches and apricots.

_What raw fruits are to be particularly avoided with young children?_

The pulp of oranges or grape fruit, also cherries, berries, bananas
and pineapple.

_What precautions should be emphasized regarding 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 be avoided?_

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 be 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 besides water and milk should a child be allowed to drink and
what should be forbidden?_

Tea, coffee, wine, beer and cider in all quantities and in all forms
should be forbidden to young children below puberty. Cocoa which is
made very weak, i.e., almost all milk, is often useful as a hot drink.
Lemonade, soda-water, etc., should if possible be deferred until the
tenth year. A free indulgence in things of this kind should never be
permitted 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.

_What are the common causes of acute indigestion?_

This is frequently due to overeating, to indulgence 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 be 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 usually emptied itself
by vomiting. All food should be stopped for from twelve to thirty-six
hours, according 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 digestion improve, but
in most cases a week or ten days should elapse before the full diet is
resumed.

_What are the symptoms of chronic indigestion?_

These, although familiar, are not so easily distinguished 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 anæmia. There are
besides local symptoms: flatulence, abdominal pain, abdominal
distention, constipation, or looseness of the bowels with mucus in the
stools, foul breath, coated tongue, loss of appetite, or an abnormal
capricious appetite. Such symptoms are often wrongly ascribed to
intestinal worms.

_What are the common causes of chronic indigestion?_

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 mastication 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 imperfectly cooked foods, especially cereals and
vegetables, and of raw or stale fruits.

_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 be 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.

_Is 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 restricted 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.

_Is 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 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 usually 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 education. If careful training in these
matters is begun at the outset and continued, the results will well
repay 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 account 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 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 children 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 previously 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 to see if this is right. Then the mouth
should be 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 be 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 upon a milk diet, this should
be diluted, and in some cases partially peptonized.

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
obtained. 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.

_Beef Juice by 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 salt. Cook for three
hours over a slow fire down to half a pint, adding water if necessary;
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, cooking for ten minutes and then adding three
ounces of milk, or one ounce and a half of thin cream, to a half pint
of broth.

_Chicken, Veal, and Beef Broths._--These are made and used in
precisely the same manner as mutton broth.

_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.

For 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 Fairchild'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 coagulated; 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. It is best given cold.
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. Whey
is useful in many cases of acute indigestion.

_Barley Jelly from the Grains._--Three tablespoonfuls of pearl barley;
soak overnight, then place this in one quart of fresh water; add pinch
of salt, and cook in double boiler steadily for four hours down to one
pint, adding water from time to time; strain through muslin. When cold
this makes a rather thick jelly. If a thinner gruel (barley water) is
desired, one half the quantity of barley should be used.

_Oat, Wheat, or Rice Jelly._--These are prepared from oatmeal, wheaten
grits, and rice grains in the same manner as the barley jelly.

_Barley Jelly from the Flour._--Either Robinson's patent barley or
prepared barley flour of the Health Food Company may be used. One
rounded tablespoonful of the flour, thoroughly blended with a little
cold water, is added, stirring, to one pint of boiling water
containing a pinch of salt; cook for twenty minutes in a double
boiler, and strain. This makes a jelly of about the consistency of
that made from the grains as above. It is essentially the same in
composition, and much less trouble to prepare. A thinner gruel (barley
water) is made by using half the quantity of flour.

When this is to be mixed with milk, it is well to add the milk to the
barley gruel before removing from the fire, and stir two or three
minutes, or until the milk has nearly reached the boiling point, when
it should be removed and bottled.

_Oat or Wheat Jelly from the Flour._--These are made from the prepared
oat flour of the Health Food Company or Hubbell's prepared wheat
flour. They are used like the barley.

_Imperial Granum._--This is prepared and used in precisely the same
way as the barley flour above mentioned, the gruel being mixed with
milk before it is removed from the fire.

_Albumin Water._--The white of one fresh egg; half a pint of cold
water; pinch of salt; teaspoonful 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 lime; one quart
boiled or distilled water; place in a 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
minutes, 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.




PART 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 movement 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 but milk?_

It is soft, yellow, and smooth, containing no lumps.

_When are the stools dark brown or black?_

While taking bismuth, iron, and sometimes when taking much meat or
beef juice; also while taking 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 be trained to be regular in the action of its
bowels?_

By endeavouring to have them move at exactly the same time every day.

_At what age may an infant be trained in this way?_

Usually by the second month if training is begun early.

_What is the best 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 produced 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 surprisingly 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.

_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 bed with its mother or nurse?_

Under no circumstances, if this can possibly be avoided. Very young
infants have often been smothered 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 injurious 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 bed be 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 same position, but should be changed from side to side. Hair
pillows are useful in summer and for children who perspire very much.

_How much sleep is natural for a newly born baby?_

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 baby 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 baby be put to sleep?_

The room should be darkened and quiet, the child's hunger satisfied,
and the child made generally comfortable and laid in its crib while
awake.

_Is rocking necessary?_

By no means. It is a habit easily acquired, but hard to break, and a
very useless and sometimes injurious 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 almost 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 acquired 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 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 obstruction 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 disease 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 thriving and in children suffering from marked anæmia.

_How are children who sleep too little, or whose sleep is constantly
disturbed, to be treated?_

Never by the use of soothing sirups or other medicines. Successful
treatment consists in the discovery and removal of the cause.

_Do children ever sleep too much?_

It is doubtful if healthy children ever do. Excessive sleep is an
important symptom of some diseases of the brain. Otherwise it seldom
if ever occurs unless soothing sirups or other drugs have been given.


EXERCISE

_Is 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
impossible. 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,
stockings, 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 without the danger of injury. Only by exercise such as
this do the muscles have an opportunity to develop properly.


THE CRY

_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 baby?_

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 necessary for health. It is the baby's
exercise.

_When is a cry abnormal?_

When it is too long or too frequent. The abnormal cry is rarely
strong, often it is a moaning 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 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 kicking or stiffening of the
body, and is usually violent.

_What is the cry of illness?_

There is usually more of fretfulness 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.

_How can we be sure that a child is crying to be indulged?_

If it stops immediately when it gets what it wants, and cries when it
is withdrawn or withheld.

_What should be done if a baby cries at night?_

One should get up and see that the child is comfortable--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 121).

_How is an infant to be managed that cries from temper, habit, or to
be 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 likely that rupture will be caused from crying?_

Not in young infants if the abdominal band is properly applied, and
not after a year under any circumstances.


LIFTING CHILDREN

_How should a young baby be lifted from its bed?_

The right hand should grasp the clothing below the feet, and the left
hand should be slipped beneath 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 pressure 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 be lifted?_

Always by placing the hands under the child's arms, and never by the
wrists.

_What injury may be inflicted by lifting the child by the wrists or
hands?_

Often serious injury is done to the elbow or shoulder joints.


THE TEMPERATURE

_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 99.5° F.; a rectal temperature of
97.5° F. or of 100.5° F. is of no importance whatever unless it
continues.

_Where should the temperature of infants and young children be taken?_

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 be 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 temperature
continues high, or is accompanied by other important signs of illness.

_Is not a high temperature a more serious symptom 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 exaggerated idea of the severity of the symptoms. A cause
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 nervousness in infants and
young children, and what can be done to prevent this?_

The most important cause is the delicate structure 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 babies be begun?_

Babies under six months old should never be played with; and the less
of it at any time the better for the infant.

_What harm is done by playing with very young babies?_

They are made nervous and irritable, sleep badly and suffer from
indigestion and in many other respects.

_When may young children be 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 detached or broken off and swallowed; (3)
small objects which might be swallowed or pushed into the nose or ear,
such as coins, marbles, and safety-pins, 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 be considered in selecting the toys and playthings
of a child over two years old?_

It should be remembered that toys are not merely 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
mechanical 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 be taught children with their toys and how
may this be done?_

The imagination may be developed, and children may be trained to
habits of neatness, order and regularity 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.


KISSING

_Are there any valid objections to kissing infants?_

There are many serious objections. Tuberculosis, diphtheria, and many
other grave diseases may be communicated in this way. The kissing of
infants 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 be done for a child in convulsions before a doctor
arrives?_

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
advisable.

_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, 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 bath be 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 excitement 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.


FOREIGN BODIES

_What should be done if a foreign body has been swallowed?_

First, examine the throat with the finger to see if it has lodged
there, and if so remove it. If it has passed from the throat it has
usually gone into the stomach.

_What should be done in this case?_

Give the child plenty of dry food, like bread, potato, etc., but under
no circumstances either an emetic 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; otherwise it becomes coated with
fecal matter and passes the intestine usually without doing injury.

_What should be done if a child gets a foreign body into the ear?_

Unless this can easily be removed with the fingers 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 be done if there is a foreign body in the nose?_

The child should blow his nose strongly while the empty nostril is
compressed. Unless this removes 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 suddenly and returns every
few minutes. With this 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 be done for a baby 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 injected 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.

_How should a child with earache be 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 several 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 laudanum in the ear is not to be
recommended.


CROUP

_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 becomes
difficult.

_What is the dangerous form of croup?_

Membranous croup, which is the same thing as diphtheria of the larynx.

_How does this develop?_

Gradually; very rarely does it come on suddenly.

_What should be done for a baby who has spasmodic croup?_

The room should be very warm, hot cloths or poultices 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 beneath the tent. If the
symptoms are urgent, ten drops of the sirup of ipecac should be given
every fifteen minutes until free vomiting occurs. Whenever the
symptoms reach a point where breathing becomes 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 ordinary cold in the head. The eruption appears
after three or four days, first upon the face and neck as small red
spots, and spreads slowly over the body.

_Is 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 accompany 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 fever, and sore
throat. The eruption usually appears 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 contagious 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 vomiting 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 scattered 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, with white patches upon the
tonsils, or a free discharge which may 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 five days, rarely later than a week;
in measles in from nine to fourteen days, occasionally as late as
twenty days; in whooping-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 very close exposure is not
necessary in the case of either of these diseases, and whooping-cough
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 diseases be 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 be done when a child shows the first symptoms of serious
illness?_

The child should be put to bed. If it is an infant 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
temperature If the bowels are constipated, give a teaspoonful 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.


SCURVY

_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 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 be 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 before
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 recognised, or untreated, it may cause death.


CONSTIPATION

_When it is necessary to move the bowels immediately, 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. None of these
should be continued excepting under the physician's directions.

_What sort of a syringe is to be preferred for giving 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 156).

_What is the best hour?_

In most cases immediately after the first meal in the morning.

_What are some simple means by which constipation may be relieved?_

The best are diet, suppositories, and massage.

The changes to be made in the milk of constipated 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 particularly 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 vegetables 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, usually in about
two hours. In obstinate cases one may also be used at bedtime.
Glycerine suppositories act more quickly, but are too irritating for
regular 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 accustomed to it. The second method is by
rubbing the deeper parts with a circular movement--the fingers not
moving upon the skin--making a series of small circles, beginning at
the right groin and following 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.


DIARRHOEA

_In case a child is taken with diarrhoea, what should be 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 aggravates
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.

_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 treatment mentioned.


BAD HABITS

_What are the most common bad habits of young children?_

Sucking, nail-biting, dirt-eating, bed-wetting, and masturbation.

_What do children suck?_

Most frequently the thumbs or fingers, sometimes the clothing or
blanket; often the "pacifier" or rubber 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 sucking habit a harmful one?_

When persisted in it may produce a misshapen mouth or fingers. It
constantly stimulates the flow 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 putting children to sleep, or of quieting them
while restless from dentition or indigestion.

_How is the sucking habit to be 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-biting and dirt-eating seen, and how are they to be
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 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 be 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
habitual bed-wetting is abnormal.

_How should a young child addicted to bed-wetting be managed?_

At three or four years of age, punishments are sometimes useful,
especially when it seems to depend more upon the child's indifference
than anything 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 supper 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 means mentioned are
successful 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 rubbing 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 be treated?_

Masturbation is the most injurious of all the bad habits, and should
be broken up just as early as possible. Children should especially be
watched at the time of going to sleep and on first waking. Punishments
and mechanical restraint are of little avail except with infants. With
older children they usually make matters worse. Rewards are much more
efficacious. It is of the utmost importance to watch the child
closely, to keep his confidence, and by all possible 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

_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 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.

[Illustration: Weight chart for the first year; the curved line
indicates the average rate of gain.]

[Illustration: Weight chart, one to fourteen years. The upper line
indicates the average for boys; the lower (dotted) line that for
girls.]





End of Project Gutenberg's The Care and Feeding of Children, by L. Emmett Holt