CHAPTER X

CARE AND FEEDING OF INFANTS AND CHILDREN IN ABNORMAL CONDITIONS AND IN INFECTIOUS DISEASES

~Digestive Disturbances.~--It is a well-established fact that artificially fed infants are more subject to disturbances due to diet than breast-fed infants, the digestional disturbances of the latter yielding more readily to treatment. As a rule, with the breast-fed baby it is largely a question of adjusting the diet of the mother, of increasing the fluid in her diet, of seeing that she takes the requisite amount of exercise in the open air, and of lengthening the intervals between feedings or of giving the baby water just before putting him to the breast. With the artificially fed infant it is an entirely different proposition.

~Causes in Artificially Fed Infants.~--The digestive disturbances may arise from any one of half a dozen or more causes. The constituents in the milk may be in the wrong proportion. The amount given at a feeding may be too great or too little. The dilution may be too great or too small to meet the needs of the infant. Or the milk may contain the microoerganisms which bring about fermentation or putrefaction. Any or all of these causes may assail the artificially fed baby. Consequently, all the care that can be exercised must be resorted to in the feeding of these babies, not only after digestional disturbances arise, but as a means of their prevention. In the preceding chapter the methods generally used in the feeding of normal infants were discussed. We now proceed to the feeding under abnormal or pathological conditions.

~Errors in Diet.~--The majority of the ills from which the baby suffers can be traced primarily to ~errors in diet~ and in most of these cases the treatment consists chiefly in adjusting the formula to suit the condition. As a rule, these errors may be placed under two heads: those that are brought on by under-feeding and those induced by over-feeding. The pathological conditions arising from under-feeding are due not only to a lack of food, but chiefly to the improper balancing of the different food constituents in the formula. As has already been stated, so much food is required to cover the energy expenditures, so much for maintenance, and so much for storage for the growth and development necessary during the entire period from birth to maturity. These constituents must be regulated to the individual needs of the infant.

~Over- and Under-dilution.~--If the dilution is too great, the infant, while receiving the correct amount of the mixture, may have the necessary food constituents so reduced as to have them fail completely to do their appointed work in the body. Or if the amount of diluent is too small the baby may be receiving too strong a mixture, and develop nutritional disturbances therefrom. Under the first head the child suffers from under-feeding; the appetite is satisfied before enough of the actual food is ingested to meet his various needs. However, it is probable that the artificially fed infant suffers from the results of over-, rather than of under-feeding.

DISEASES DUE TO ERRORS IN DIET

Gastro-intestinal disturbances, colic, enterocolitis, colitis, etc., rickets, scurvy, nephritis, and diabetes are among the diseases most apt to develop from injudicious feeding, and in these cases the dietetic treatment plays the most important part in combating the condition. The disturbances caused by food are recognized by the general symptoms: vomiting, rise of temperature, subnormal temperature, and the stools, the latter being the chief point of observation.

~Fats as Cause.~--When the fats are causing the disturbance, the rise of temperature is apt to be high, but not of long duration. The baby vomits frequently, the vomitus being acid in reaction and odor, the latter due to the presence of fatty acids, butyric acid, etc. Diarrhea often develops in a more or less acute form. In these cases there is a loss of sodium and other alkaline salts in the feces, and a consequent excess of ammonia in the urine, resulting in acidosis. Acid intoxication has been known to develop as a result of this loss of alkaline salts. The chief symptoms of this condition are rapid and deep respiration, stupor or restlessness, and cherry-red lips.[84]

~Symptoms of Excess Fat in Diets.~--The general symptoms in infants receiving an excess of fat in their food take the form of loss of appetite, with more or less loss of weight, or failure to gain. When the cases are not chronic, soft curds may often be seen, which are at times mistaken for casein curds, but may be distinguished from them by their translucent appearance and their solubility in ether. The color of the stools due to the excess of fat under the above-mentioned conditions is shiny and gray. In the majority of cases, especially of a more chronic character, the stools are apt to be large and dry, at times hard and crumbly. The fat in such stools is combined with magnesium and calcium salts, forming the characteristic "soap stools."[85] The combined loss of these salts in the feces has a definite effect on the general metabolism and nutrition, giving rise to rickets.

~Regulating the Fat.~--The treatment consists chiefly of regulating the amount of fat in the formula, and of cutting it out altogether in the beginning when the symptoms show acute acid conditions. In many cases, if the baby is given breast milk, the trouble disappears. At other times it is necessary to substitute a foreign fat such as olive oil for the butter fat. Dr. Ladd in the Children's Hospital in Boston treated many babies who manifested an intolerance for butter fat with "Homogenized Milk," which consisted of skimmed or separated milk and a certain percentage of olive oil, placed in an apparatus which brought about a more complete division of the fat, causing it to mix with the milk as an emulsion closely resembling human milk.

Fat intolerance is most difficult to overcome, the baby being apt to relapse into the acute stage unless the utmost caution is observed in adding the fats to the formula. It is not safe, however, to feed the baby upon a fat-free milk for any great length of time.

~Excess Protein in Food.~--The digestional disturbances arising from too much protein in the food are as a rule readily overcome in breast-fed infants. When it is due to nervousness or worry in the mother, it disappears as soon as the mother ceases to worry or does something to remove the cause of the nervous condition. When the breast milk is high in protein, more exercise in the open air at times adjusts the percentage of protein, provided the mother does not become over-tired, in which case the percentage of protein in breast milk increases.

~Evidences of Excess Protein.~--The symptoms of excess protein in the diet of the breast-fed baby are colic and flatulence, which are often persistent and difficult to overcome. Vomiting is not so common in these babies as in those who are artificially fed. The stools are increased in number, are either brown or green, and generally loose and watery. In artificially fed infants the symptoms are much the same, except that the vomitus often contains large curds which are tough and leathery. The baby suffers from gas formation and colic. The stools are at times normal, except for the presence of large, hard curds; at other times they are increased in number, and are of a watery consistency and alkaline in reaction.

~Regulating the Protein in Formula.~--When the stools are watery and brown and musty in odor as the result of disturbed protein digestion, the treatment consists of taking out the proteins from the formula and of substituting cereal water, to which dextri-maltose or milk sugar is added, the milk being added as soon as possible to prevent too great a loss of body protein. As a rule the whey proteins do not cause the disturbances so often as the casein proteins; and at times it is possible to use whey mixtures with babies who cannot tolerate the casein at all.

Buttermilk also is used in cases of protein indigestion, as is Eiweissmilch and peptonized milk.

~Regulating the Carbohydrates.~--When the disturbances are due to the carbohydrates in the formula, they may be digestional or nutritional. In this form the milk sugar is more apt to be the cause of the trouble than the dextri-maltose preparations which are at times used. In the latter, when the disturbance becomes nutritional, the cause of the trouble can usually be traced to an excess of starch. When the percentage of milk sugar is greater than can be handled by the digestive apparatus of the baby, it is manifested by frequent attacks of colic, with the passage of watery green stools, highly irritating, in character on account of their acidity. In acute cases the loss of weight is often marked, and symptoms of intoxication may develop. The outlook is grave in the very severe cases, but if the baby can survive forty-eight hours after the acute symptoms develop, he is apt to pull through the attack.

~Adjusting the Sugars.~--The treatment in these conditions consists of eliminating the milk sugar from the formula; in less severe cases dextri-maltose may be substituted. As a rule, coincident with indigestion caused by sugar there will be found to be an intolerance for much fat, so that this must be adjusted as well as the milk sugar. Skimmed milk mixtures, containing a certain amount of barley or oatmeal water, are generally found to be suitable in these cases. Dextri-maltose may be added after a few days in order to maintain the fuel needs of the body. Eiweissmilch is at times used, but whey mixtures are contraindicated on account of their high sugar content.

Dextri-maltose also disagrees at times. The baby has colic and flatulence, the stools are usually loose or watery and dark brown in color. The dietetic treatment consists of an immediate withdrawal of the dextri-maltose preparation and a substitution of milk sugar after a few days.

~Evidences of Excess Starch in Formula.~--The disturbances arising from an excess of starch in the diet are, as has already been stated, more apt to be of a chronic than an acute character. Vomiting is not a common symptom under these conditions, although colic is frequent. The stools are at times loose and brown, at other times dry and small. The baby at times suffers from diarrhea and at others from constipation. When the disturbance is acute the starch must be entirely eliminated from the formula. If proprietary foods are being used containing starch, whether it is dextrinized or unchanged, they must be at once abandoned, and a formula made up of protein with sugar and fat.

MODIFIED MILK FORMULAS SUGGESTED BY MORSE AND TALBOT FOR THESE CONDITIONS

Fat 1.00% Fat 2.00% Milk sugar 4.00% or Milk sugar 5.00% Protein 0.75% Protein 1.25%

They likewise advise whey and whey mixtures under these circumstances.

~Fermentation.~--Fermentation is often the cause of infantile indigestion. At times it is acute and may cause a decided elevation of temperature owing to the absorption of the toxic substances formed as a result of the bacterial action. In almost every case of indigestion brought on by fermentation there will be an accompanying diarrhea. As a rule the carbohydrates are more liable to the attacks of bacteria in the stomach than the other food constituents.

~Treatment.~--The treatment consists first of starvation, no food being given for at least twenty-four hours. Then water or weak tea, sweetened with saccharin, may be given, but nothing else. The medical treatment must be left to the discretion of the physician. When the condition warrants a return to food the formula must be made weaker than that which has caused the disturbance. Malt soup mixtures, buttermilk mixtures, whey and albumen water may be added as the condition of the baby improves. In older children the period of starvation may have to exceed that of infants, but a gradual return to normal diet is made. Weak tea and toast may be given after the first twenty-four hours and well skimmed meat broths, soft-cooked eggs, liquid peptonoids, and malted milk added to the diet as the condition of the child improves.

ENTEROCOLITIS

The dietetic treatment for enterocolitis must be adjusted according to the principal symptom. In some of these cases diarrhea is most prominent, while in others constipation is the most marked symptom. Hence the diet must be such as not only to do no harm to the child, but one that will aid in his ultimate recovery.

DIARRHEA

The treatment for diarrhea, whether it is from fermentation or putrefaction of food, has already been explained. The grave danger in the putrefactive diarrhea is the absorption of the toxic substances which result from bacterial action upon the unabsorbed food material in the small and large intestine. In these cases auto-intoxication may develop and the baby may die before the condition yields to treatment. The entire intestine must be cleansed as a rule. The stomach of the baby may be reached with little trouble by using a small rubber catheter attached to a glass funnel and a solution of bicarbonate of soda. The bowels may be emptied by means of a soapsuds enema. Older children may be given oil, but this of course comes under the jurisdiction of the physician.

CONSTIPATION

Constipation is one of the most frequent troubles visited upon people of all ages. "It is not a disease, it is a condition in which the number of stools is less or the consistency of the stools is greater than is normal for the individual at the given time."[86] It may be caused by neglect of the bowels, which should be evacuated once or twice every day during infancy and once a day after that period. If the habit of emptying the bowels every day is established in infancy it adds much to the health and comfort of the individual during the entire remainder of life. Babies are sometimes constipated as the result of the opium administered in soothing sirups. Others inherit constipation, while still others are constipated by the taking of the wrong kind of food or too little food. In any case it is decidedly bad to resort to drugs, since the habit of taking cathartics is so easily acquired and so difficult to overcome.

~Factors Inducing Constipation.~--With artificially fed babies a formula which contains too high a percentage of diluent and too low a percentage of solids will cause constipation, chiefly because the solids are so completely absorbed that they have no residue to form feces. A formula with too low a fat content in proportion to its protein and carbohydrates may cause constipation because the latter two constituents are almost entirely absorbed, and the feces, which is largely made up of the fat, is correspondingly small. Excess of fat, however, has been proved to be one of the chief causes of constipation in infants, as has also been the case with excess starch. Boiling the milk for the baby at times results in constipation. Hence sterilization is more frequently to blame for the condition than the pasteurization of milk.

~Constipation during Second Year.~--During the second year, if the child is given too much milk and too little solid food, constipation is very apt to be the result. A maximum quantity of from thirty-two to forty ounces may be given. In many diseases brought on by malnutrition, constipation is an obstinate condition to be overcome. This is especially the case in rickets and anemia.

~Use of Laxative Foods.~--After the baby is a few months old, orange juice is given between the morning feedings. Malted foods likewise exert a laxative effect. The higher the percentage of maltose, the more laxative the food. The nurse must keep this point in mind in feeding babies. With older children and adults, the question of diet for constipation is quite as important as it is for infants. Prunes or figs cooked with senna leaves and thoroughly strained furnish an excellent adjunct to the diet under such conditions. The coarse breads such as bran and Graham or wholewheat bread should be used instead of white flour breads. Care should be taken in advising a cereal diet for children, since cereals, with the exception of oats, are apt to be constipating. Fresh fruits, stewed fruits, and fresh vegetables are all good under the above-mentioned conditions. Young children require the vegetables strained or cut fine. Adults should include one coarse vegetable a day in their dietary to obviate the development of constipation. Children should be taught to drink plenty of water, and babies should not be neglected in this respect. As a rule very few adults drink as much water as is necessary for the general welfare of their bodies.

SCURVY

There is probably no disease of infancy which has come in for more study in the past few years than scurvy.

~Cause.~--The disease is believed to be directly due to a deficiency in the diet of the antiscorbutic vitamine, known as "Water soluble C."

~Treatment.~--For many years it was known that lime juice exerted a curative effect upon scurvy. But recently the efficiency of this fruit juice has proved to fall far short of that effected by either orange, or tomato juice.

Feeding experiments have proved that animals, fed upon rations consisting of dry food without the addition of green, will develop scurvy. And that the milk of such animals will show a deficiency in the "C" vitamine which will lead to a development of the disease in infants fed upon such milk.

Milk is, in fact, by no means a perfect food, so far as its vitamine content is concerned. First, because the presence of the vitamine in milk is so dependent upon the diet of the mother or the animal, second, because the pasteurization temperatures used to insure cow's milk of purity from a bacterial standpoint, destroys in it the greater part of its antiscorbutic power. Either of which makes it necessary to supplement the formula of the artificially fed infant, and, in case of the former, the mother's milk of the breast-fed baby, with orange, or canned tomato juice.

The amount of either of the fruit juices which is necessary to insure the child of a freedom from scurvy, is small, ranging from one-half to one ounce of strained juice daily, this amount is increased gradually until the child is taking from one and one-half to two ounces each day. It has been found advisable to administer the fruit juice between the two morning feedings. As a rule, the fruit juices are given at the beginning of the seventh month, but they may be given at a much earlier date, the time being adjusted by the physician.

RICKETS

Rickets, like scurvy, is being discussed by scientists both in America and abroad. The disease is widespread, particularly in its subacute form, and its effect upon the health of the child is so serious that no amount of effort to prevent its development should be considered too great.

~Calcium Retention in Rickets.~--The disease is characterized by a failure of the bones to lay down lime salts, this failure causes a softness and flexibility in the structure of the bones which permits them to bend into deformities. Then, too, it is a well established fact that any interference with the calcium metabolism in the body, will inevitably bring about disaster. (See Mineral Metabolism, page 185.)

~Factors Inducing Rickets.~--According to Dr. Eddy, "It is impossible at present to determine whether rickets is a true avitaminose or a consequence of deficiency in a series of factors."

~Treatment.~--For breast-fed babies it is necessary to adjust the diet of the mother to include more of the vitamine bearing foods, since milk contains vitamines only in proportion to the amount eaten in food. For artificially fed children, the giving of cod liver oil has recently been adopted as the surest and safest method of curing and preventing the development of the disease. Like treatment is used with breast-fed infants if the need arises.

The value of cod liver oil in this respect has only been recently recognized. Mellanby of England claims that the oil owes its curative and preventive properties to the presence of the "A" vitamine. But scientists in this country have not fully accepted this view. Eddy states, "It may be that the power of the oil is due to its 'A' vitamine content, in which it is known to be rich, or it may be due to a new vitamine, but the fact that the oil is a preventive in this respect gives the pediatrist another agent to insure normal growth."

~Sunshine as a Factor.~--It has been found that the disease rickets is more prevalent in winter than in summer; this is believed to be due to the fact that sunshine during the summer months exerts a distinctly beneficial influence over the disease. Dr. Hess's report of the good results which he has found to be derived from the use of the ultra violet rays as a substitute for sunshine in winter, would seem to confirm this view.

MALNUTRITION

~Malnutrition~ is not confined to the children of the poor, though it is more common with infants of parents who have not the means to secure the best milk and give them the benefit of wholesome surroundings and plenty of sunshine. But babies of people in moderate circumstances, and even of wealthy parentage, are at times badly nourished, and require the same exacting care, the same attention to the food, the fresh air, and the sunshine that the poorer babies need in order to survive. Malnutrition may be the result of insufficient food, and it may also be due to the lack of one definite food element. Again, it may be brought on by some deformity of the mouth or stomach, which make it impossible for the baby to get all the food which he requires for his maintenance and growth. He may be born prematurely and his digestive apparatus not be sufficiently developed to care for the amount or type of food necessary for his needs, or he may have some congenital weakness which interferes with the absorption and assimilation of his food. All of these points must be considered.

~Evidences of Correct Feeding.~--If the baby shows a steady gain, both in weight and growth of stature, without digestional disturbances, the food given him is probably correct, but it must be kept in mind that nutritional disturbances, such as rickets and scurvy, are slow in developing, and do not manifest themselves with anything like the rapidity of digestional disturbances. Hence the nurse must take care as far as she is able, not only to prevent the food from causing indigestion, but also to see that it is not given in such a form as to induce those graver and more lasting nutritional disturbances which affect the entire system from infancy throughout the life of the individual.

SUMMARY

~Breast Feeding versus Artificial Feeding.~--There is no doubt about the fact that the breast-fed baby suffers less from digestional disturbances and has more resistance to disease than the baby fed even upon a perfectly prepared artificial food. The majority of diseases manifested by artificially fed infants have their origin in the following errors in diet.

~Over-Feeding.~--Resulting in acute gastro-intestinal disturbances (colic, enterocolitis, colitis, constipation).

~Under-Feeding.~--Resulting in chronic, and acute deficiency diseases (scurvy, rickets, malnutrition).

~Evidences of Dietetic Errors.~--The stools, showing characteristic evidences of excessive quantities of, protein, fat, or carbohydrates in the formula. Loss of weight or failure to gain. The development of deficiency diseases (scurvy, rickets, xerophthalmia, rickets and malnutrition).

~Evidences of Correctness in Feeding.~--Normal gain, freedom from gastro-intestinal disturbances, and deficiency diseases. Rosy cheeks, bright eyes, and a vigorous body.

~Treatment in Abnormal Conditions.~--The treatment consists in adjusting the diet to meet the needs of the particular disturbance manifested. Plenty of fresh air, sunshine and sleep.

~Relapse.~--One danger which the nurse must always be on the lookout for is the relapse into the acute stage. The diet is the chief treatment. In acute gastro-intestinal disturbances rest from food is essential for at least twenty-four hours. Some infants can easily endure starvation for this short period. However, when malnutrition has already been established, it is not wise to carry out the starvation treatment over-long. A cautious return to a normal diet may be made as soon as acute symptoms disappear.

~Fevers in General.~--It requires very little deviation from the normal to raise the temperature of a child. A slight attack of indigestion, a slight soreness of the throat, will bring up the temperature of some children out of all proportion to the seriousness of the disorder.

~Diet in Fevers of Short Duration.~--As a rule, in the fevers of short duration, such as intermittent fever, malarial fever, etc., the diet is a simple matter. Milk is given when it agrees, with buttermilk, koumiss, broths, and albuminized beverages to vary the diet.

~Diet in Infectious Diseases.~--When, however, the fever is induced by specific bacteria, such as in the case of typhoid and scarlet fever, the diet is a different matter altogether. The disease may be one in which the diet is the chief item of importance; such is the case with typhoid and scarlet fever, with the former because of its long duration, the increased rate of metabolism due to both the fever and the action of the bacteria making it necessary to increase the normal amount of food to meet the new requirements of the body; and with the latter on account of the kidney complications which must be guarded against, and which can only be handled by regulating the diet.

~Infant Feeding.~--The feeding of infants under febrile conditions resolves itself into an adjustment of the milk formula to meet the existing state of affairs. The digestion is always more or less disturbed by fever, especially during the early stages.

~Restricting the Food.~--It is not always possible to diagnose the disease immediately, so that the safe thing to do is to lengthen the intervals between the feedings for the breast-fed baby and to stop food entirely for twelve to twenty-four hours for those who are artificially fed, when there is any doubt as to the cause of the rise of temperature. Some mothers find it difficult, if not impossible, to institute this period of starvation. In these cases barley water or albumen water may be given at stated intervals. Many physicians give very weak tea, slightly sweetened, under the above conditions; it does no harm to the baby and relieves the mother from the belief that her child is being starved to death. In twenty-four hours, if the fever arises from disturbed digestion, some manifestation of the condition will be observed.

~Bacterial Activity.~--In cases of intestinal putrefaction the fever is apt to rise at an alarming rate and is controlled only by removing the cause. The proteins which have escaped digestion and absorption in the intestines furnish the best medium for the growth of putrefactive bacteria. Hence this food constituent must be given in its most digestible form.

~Dietetic Treatment.~--Milk in most instances is the best form in which to give protein food, especially to young children and babies. At times, however, it will be found that milk disagrees; it must be peptonized, or one of the fermented milks, such as buttermilk (Bulgarian culture), Eiweissmilch, or koumiss must be substituted. In cases where the putrefactive bacteria make it unwise to use milk at all, for a time the proteins should be furnished in the form of cereal gruels, and the juice of an orange strained and diluted given once or twice a day between the morning and evening feedings.

~Whey~ is contraindicated in cases where the fever is brought on by putrefaction in the intestine, chiefly because it furnishes one of the best mediums known for the growth of the offending bacteria.

Patience is required in handling the diet for fevers in infancy. As has already been stated, it requires a very slight cause to raise the temperature of a child, but for this very reason especial care must be observed that no enlightening symptom escapes the notice of the nurse.

~Complications.~--Tuberculosis or scurvy may be in an incipient stage, and may be overcome if recognized in time. The nurse has a better opportunity for observing changes in an infant or child under her care than the physician who comes once a day or less. The nurse should make note of these changes, that the physician may have a chance to regulate the diet accordingly.

~Fluid Diet.~--With children, as with adults, the energy output in fever is greater than in health, hence the need for plenty of fluids to help eliminate the waste products due to the increased metabolism. These fluids may consist of water, fruit beverages, cereal water, whey, and broth. It is well for the nurse to remember that when the child is confined to bed, he will not need so much food as he would if he were up and about, but that if the fever is of long duration, as in typhoid, the increased rate of metabolism must be met by an increased amount of food, as the ordinary requirement standards for a child in health cannot be applied to the diet of a child under these conditions.

SCARLET FEVER

Scarlet fever is an acute infectious disease, characterized by high fever, sore throat, a red rash, and a tendency to nephritis. The disease usually begins suddenly with an attack of vomiting; the temperature rises to 104 deg. or 105 deg. and on the first or second day a rash appears, first on the chest and neck, and spreads over the entire body. This lasts from three to seven days, desquamation begins soon after the rash disappears and lasts from two weeks to six, the palms of the hands and soles of the feet peeling last. The appearance of the tongue is very characteristic, being coated, and through this coating are seen a few bright red points, producing the well-known strawberry tongue. After a few days the coating disappears, leaving the tongue bright red. In mild cases the tonsils are enlarged and the throat very red. In severe cases there may be difficulty in distinguishing the disease from diphtheria without a culture being taken. The tendency of the child to develop nephritis during the second or third week makes the treatment largely dietetic in character.

~Dietetic Treatment.~--Milk is the chief diet for the first three weeks. If it disagrees, it should be modified or peptonized to suit the condition. Koumiss and buttermilk may be substituted when it is impossible to prepare the milk so that it will not cause digestional disturbances. This, however, is seldom found to be the case during infancy. Malted milk and even condensed milk, or some of the dextrinized and malted foods at times prove valuable when whole milk disagrees. But the nurse must remember that a baby runs a risk of developing nutritional diseases of a grave character if fresh milk is eliminated from the diet for any great length of time.

Older children may have plain vanilla ice cream and plain junket, oyster or clam broth made with milk, the oysters and clams carefully strained out. Lemonade and orange juice may be given, but no meat broths or albumenized beverages or egg dishes can be admitted to the dietary.

~Development of Nephritis.~--Nephritis must be guarded against. The skin, being covered with a rash, is put out of commission as an excretory organ; in consequence all of the work of this description is placed upon the kidneys. In the first part of this text the work of the kidneys was defined; it was found that they were the chief organs for the excretion of the end-products of protein metabolism. It can be readily understood that when these organs are given not only their own work but that of the other organs to perform, unless the food requiring the greatest amount of effort on the part of the kidneys is confined to those types which can be most easily taken care of, such as milk, the kidneys stand a great chance of becoming impaired. Such is the case in nephritis.

~Convalescent Treatment.~--The return to normal diet must be made with the greatest caution. Specimens of urine must be taken often, for in this way alone can the development of nephritis be reckoned with.[87] Should nephritis develop in spite of efforts to prevent it, a farinaceous diet[88] such as is given in these conditions must be resorted to.

After three weeks, if the patient shows no disposition toward nephritis, and if convalescence is progressing satisfactorily, the diet may be increased day by day, adding milk toast, cereals, cream soups, rice, baked potato, then custards and soft eggs, the soft part of oysters, broiled or baked fish, broiled breast of chicken, and, still later, rare beef and lamb chops. Meat, however, must not be given until all danger from nephritis has passed.

DIPHTHERIA

~Diphtheria.~--The feeding in diphtheria follows the regime given in acute fevers. The body must be kept in good condition. At the same time it is necessary to understand the complications which make the dietetic treatment of this disease assume a place of importance.

~Complications.~--It may be complicated by broncho-pneumonia, albuminuria, carditis, endocarditis, and dilatation of the heart. Anemia must be combated, but care should be used not to push the diet to such an extent as to impose too great a tax upon the already weakened heart.

~Dietetic Treatment.~--While the fever lasts the diet must be fluid, milk, buttermilk, malted milk, and some of the proprietary infant foods such as Mellin's Food, Eskay's Food, and like preparations. Milk gruels, made with milk and some cereal such as farina, barley flour, fine cornmeal, arrowroot, strained oatmeal, etc., are at times more easily swallowed than the unthickened liquids. Liquid beef peptonoids, panopeptone, and like predigested beef preparations prove valuable in many cases.

~Convalescent Diet.~--As convalescence progresses, or in cases where the patient finds it easier to swallow a semi-solid than a liquid, soft custards, gelatin, well-cooked cereals, and ice cream may be given. Eggnog and milk punch are at times given, but only upon the advice of the physician in charge.

~Rectal Feeding.~--When the condition of the patient makes it necessary to nourish in other ways than by mouth, nutrient enemas[89] may be given. In certain cases of diphtheria, young infants can be fed more successfully through a tube inserted by way of the nose into the stomach than by feeding in the ordinary way. The formula is prepared in the same way as for bottle feeding, and is poured into a glass funnel and through the soft rubber catheter into the stomach. Care must be observed to prevent the patient struggling on account of the heart weakness which invariably complicates this disease.

WHOOPING COUGH

In the early months of life it is probable that whooping cough is one of, if not the most fatal of the diseases to which the infant is subjected. The period of incubation of this disease is from one to two weeks, the cough at first not appearing different from those accompanying colds of all sorts. However, in from ten days to two weeks the characteristic whoop occurs, differentiating this disease from all others. The symptoms aside from the whoop are the difficulty of taking breath and the great prostration after the paroxysm and the frequent vomiting of the food, brought on by the violent coughing.

In very young infants the whoop does not always occur. But the child coughs and holds its breath until it is blue in the face. At times young babies may have convulsions. The so-called spasmodic stage, during which the child may have from a few to a great number of paroxysms of coughing a day, lasts from a month to six weeks, and in some cases even longer. As the disease declines the cough gradually disappears and the child appears to be suffering with ordinary bronchitis. The characteristic whoop may return at any time during the ensuing six months or year if the child has an attack of bronchitis and is inclined to cough.

~Complications and After-effects.~--The complications and after-effects of whooping cough give it a serious character. Hemorrhage may occur from the nose. According to Ruhraeh: "Paralysis may follow from meningeal hemorrhage, broncho-pneumonia, acute emphysema, and collapse of the lung may occur. Diarrhea, convulsions, and albuminuria are also met with. Tuberculosis and chronic bronchitis may follow."[90]

~Dietetic Treatment.~--The diet plays an important part in whooping cough. The serious complications and after-effects of this disease upon children necessitate a rigid observance of dietary laws. With infants it is always best, when it is possible, to give breast milk. As this is the natural food it requires less effort on the part of the digestive apparatus to become available. It has been proved that even during the time when the baby is nursing the milk is projected in spurts into the duodenum without waiting to be attacked by digestive enzymes in the stomach, and for this reason the breast-fed infant is more apt to be efficiently nourished than the artificially fed baby, who loses his dinner by vomiting before absorption has had a chance to occur.

~Diet under Ten Years of Age.~--For children under ten years, a fluid diet is necessary, at least in the beginning of the disease while there is a fever, and later, if the vomiting is persistent. Milk, buttermilk, koumiss, broths, albuminized beverages, and cereal gruels such as barley and oatmeal gruel and arrowroot gruel can be given. Later, if the fluids are retained, cream of wheat, farina, junket, soft custards, and soft-cooked eggs may be added. Care must be taken in giving toast, unless it is softened with milk or broth, for the crumbs may bring on a paroxysm of coughing and vomiting. The best results in feeding with whooping cough are obtained by giving the food in small quantities and oftener. A few ounces given every two hours are less apt to be vomited than a larger quantity. It is also easier for the child to take the small amount after an attack of coughing and vomiting than it would be for him to attempt a larger meal.

~Use of Stimulants.~--In many cases where weakness is great, it has been found advisable to add some stimulant to the diet. With infants this is best given in albumen water, a small amount of good brandy acting better than other stimulants. With young children some of the predigested liquid beef preparations, such as liquid peptonoids, are found valuable. These foods are given alternately with the other fluid foods.

~Hygiene and Sanitation.~--Infants and children suffering with whooping cough require plenty of fresh air and sunshine. They must be kept out of doors as much as possible and sleep in well-ventilated rooms or sleeping porches. They must be protected from drafts and excitement, and never allowed to become over-tired. In this way the anemia which so often results from prolonged attacks of whooping cough is in a measure held in check. At times it is found necessary to give some kind of an iron tonic, but this comes under the jurisdiction of the physician instead of the nurse. When bad effects do occur in spite of all the care exercised during the attack of whooping cough, they must be accorded the treatment especially devised to meet the situation.

MEASLES

This is an acute, infectious disease characterized by a red eruption which appears on the fourth day. Measles is one of the most contagious of all the diseases of childhood. It may be acquired by direct contact with another case or by being in the room with a case. The infection may also be carried through the air and occasionally by a third person. Measles is more prevalent in the winter than in summer. In cities it often occurs in epidemics. The period of incubation is from ten days to three weeks, occurring generally at about two weeks after exposure.

The attack may begin with the child showing a languid attitude, complaining of headache. Then a cough develops, with nausea and fever at times. The fever is often high, reaching 104 deg. F. on the second day. As a rule the fever gradually falls after the second day and becomes normal in almost a week. However, the temperature varies in different cases.

~Complications.~--Measles is not considered dangerous in itself, but the after-effects sometimes prove fatal. This is especially the case in broncho-pneumonia, which frequently develops during or after the attack.

The gastro-intestinal, as well as the respiratory, tract is attacked in measles, diarrhea being especially common. Very weak children have been known to develop gangrenous stomatitis; paralysis and tuberculosis[91] likewise develop in some cases as the direct result of measles.

Thus it is demonstrated that measles is not to be lightly treated. Even if it is not in itself fatal, the results of the disease are so dangerous that the care of the nurse is especially necessary. The great trouble is that so often a nurse is not in attendance and the child suffers through ignorance of the mother.

~Dietetic Treatment.~--The dietetic treatment of measles is important. For infants milk is the exclusive diet, the formula for bottle-fed babies having to be weakened on account of the catarrhal condition of the gastro-intestinal tract. For older children it is necessary to confine the diet to fluids as long as the fever lasts, and at times longer if the stomach gives evidence of digestional disturbances. Milk is the chief food, with milk soups, buttermilk, and koumiss used to vary the diet. Orangeade and lemonade may be given to allay thirst. A return to normal diet must be made gradually, giving cereal gruels, milk toast, and broth before the more solid articles of diet suitable to the age of the child. When there are complications they must be treated, as in whooping cough, according to their symptoms.

SUMMARY

~Gastro-intestinal Disturbances~ are responsible for much of the fever manifested during infancy and childhood.

~Infectious Diseases~ are all more or less accompanied by an elevation of temperature.

~Incipient Diseases~, especially tuberculosis and scurvy, may likewise cause a rise of temperature. The relief of either disease or the fever depends largely upon how quickly the conditions are discovered and the means instituted to overcome them.

~Metabolism in Febrile Conditions~ of children, as well as of adults, is rapidly increased, hence the energy output is greater, and for this reason the fluid intake must be augmented in order to eliminate the toxic substances produced as a result of the rapid breaking down of the body tissues.

~The Kidneys~ are more or less strained to eliminate the products of the increased metabolism and for this reason it is especially necessary to adjust the diet in order to limit, as far as possible, the foods which add to the burden already imposed upon the organs of excretion.

~The Skin~ is an organ of excretion which, under normal conditions, shares the work of the kidneys. In infectious conditions, accompanied by eruptions which more or less cover the entire surface of the body, this organ is temporarily out of commission, hence its work, as well as their own, must be accomplished by the kidneys.

~Dietetic Treatment~ in the majority of infectious diseases may be divided into three periods: Starvation, Fluid Diet, and Convalescent Diet.

Starvation, during which time no food is given for twenty-four hours or longer, in order to allow the digestive apparatus to rest and to give time for any substance which may be causing the elevation of the temperature to pass from the body. This treatment is also wise because it furnishes an opportunity for the symptoms of the disease to manifest themselves; Fluid Diet, given when acute symptoms subside, and Convalescent Diet when danger from relapse is over.

~Scarlet Fever~ is treated with two main ideas in view--preventing the development of nephritis and relieving the condition should it develop.

~Dietetic Treatment~ is logically the only means of treating or relieving nephritis. For the first three weeks, during which time this complication is apt to develop, a milk diet is necessary. This may be in the form of whole milk, milk soups, malted milk, etc. At the end of this time, if there are still no symptoms of nephritis, a convalescent diet, beginning with cereals and soft toast and progressing through the simple digestible foods such as rice, baked potatoes, soft eggs, etc., may be given. This is continued until the patient is well on the road to recovery. Meat should not be added until practically all danger of nephritis is passed.

~Nephritis.~--If, during the course of the disease this complication, should develop, the treatment described for acute nephritis on page 336 should be immediately instituted.

~Diphtheria.~--Dangerous complications at times develop as a result of diphtheria, making the treatment of this disease of the utmost importance. Heart symptoms, pneumonia, albuminuria, and anemia are among the complications to be dreaded and combated.

~Dietetic Treatment~ in diphtheria is most important. It consists of a fluid diet made up of milk, malted milk, or buttermilk. At times the condition of the throat makes a slightly thickened mixture more easily swallowed than one which is distinctly fluid in character, and for this purpose farina, arrowroot, or barley flour may be used.

~Increasing the Diet.~--As convalescence advances the semi-solids, soft toast, soft custards, gelatin, and cereals may be given. Should the heart show symptoms of being affected, the intake of fluid must be restricted.

~Gavage and Rectal Feeding~ are at times necessary. Infants may be successfully fed by passing a small rubber tube through the nose into the stomach and administering the milk formula to which they are accustomed. Rectal feeding is likewise valuable in cases of extreme anemia accompanying diphtheria.

Care must be observed by the nurse in giving gavage to babies, since any struggling on the part of the child may result in death from heart disease.

~Whooping Cough.~--On account of the character of the disease and the proneness of the stomach to eject the food during paroxysms of coughing, dietary measures are more or less necessary in order to enable the child to receive sufficient food to cover his daily needs.

~Complications.~--Hemorrhage, pneumonia, albuminuria, diarrhea, and convulsions may occur during the disease, while tuberculosis and chronic bronchitis may follow as after-effects.

~Dietetic Treatment.~--Breast milk is by far the best food for the baby, in this as in all conditions. In whooping cough the fact that this fluid leaves the stomach almost as soon as it enters lessens the chances of the baby losing its meal by vomiting it.

~Older children~ do well with frequent small meals, since they are not so apt to give rise to pressure which brings on the paroxysms of coughing and vomiting. When the meal is vomited, a second should be given in order to keep the child from suffering from malnutrition.

~Stimulation~ is found to be necessary in certain cases. Albumen water containing a spoonful of brandy or some of the prepared beef preparations, such as liquid peptonoids, may prove valuable under the circumstances.

~Measles.~--Complications and after-effects developing as a result of measles make the dietetic treatment of this disease important. Gastro-intestinal disturbances, especially diarrhea, are apt to occur, and tuberculosis has been known to develop as a result of measles.

~Dietetic Treatment.~--The fluid diet as used in any acute febrile condition is used as long as the temperature is elevated. Milk, buttermilk, malted milk, and milk soups constitute the chief items in the diet. Orangeade and lemonade are found valuable in relieving the thirst.

PROBLEMS

(a) List the evidences of errors in the diet of infants; show how they may be corrected in the formula.

(b) Outline the processes in the preparation of Eiweissmilch (protein or albumen milk). What constituent is particularly low in this milk, and how was its reduction accomplished?

FOOTNOTES:

[84] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot.

[85] _Ibid._

[86] "Diseases of Nutrition and Infant Feeding," p. 307, by Morse and Talbot.

[87] See chapter on Urinalysis, p. 323.

[88] Consisting of cereal gruels, rice, and other starchy foods.

[89] See Nutrient Enemas, p. 145.

[90] "Diseases of Infants and Children," p. 326, by Ruhraeh.

[91] "A Manual of Diseases of Children," p. 319, by Ruhraeh.