Chapter 4

HYGIENE OF INFANCY AND CHILDHOOD

No characteristic of the Caucasian mind is more marked, and none more universally affects his actions than a constant, gnawing suspicion that the things going on around him are not being done in the proper way, and consequently an irrepressible desire to experiment, and if possible, to change everything. Such a spirit is unquestionably the basis of what we call progress, and, in so far as it conduces to the health and happiness of mankind, is entitled to our most hearty commendation. On the other hand, it cannot be denied that too often we endeavor to bring about changes with but an imperfect understanding of the basic principles at issue, and naturally, under such circumstances, our efforts are crowned with anything but success. In other words, an enlightened investigation of the whys and wherefores of any existing state of affairs may and often does, lead to improvement, while, on the other hand, ignorant meddling is likely to be followed by disastrous consequences.

Nowhere do we see the bad results of false conceptions more marked than in our treatment of infants and children.

Particularly do young infants suffer in this way, as they are pounced upon as soon as they enter the world by every old "granny" and negro "mammy" in the neighborhood, and plied with abominable concoctions that would be productive of homicide if we were to attempt forcibly to administer them to grown men, and whose only effect on the defenseless little sufferer is to cause colic and indigestion. Many times has the writer seen a wee, tiny little mortal, who was too young and weak to even protest, bundled up with a mountain of flannels in the hottest weather of July and August. True to the superstition that the warmer we kept an infant the better, too frequently we see them confined to hot stuffy rooms when they should be out in the sunshine, or under the trees. Instead of being allowed to gain health and strength in the forests, which are the schoolhouses of nature, the miserable little wretch is later sent to a public school as soon as he or she can be trusted to go alone on the streets, and the tiny victim too frequently contracts diphtheria, scarlet fever, whooping-cough, measles, or some other disease as a reward of merit. Truly we see to it that the helpless innocents early realize the truth of the melancholy and hopeless biblical lament that "man's days here are few and full of trouble."

We should rear our children with as little interference as possible, allowing them the utmost freedom compatible with their safety, and permitting them to do those things that nature and instinct demand. Above all let them sleep as much and as long as they will, insist that they live in the open air, and encourage them in every possible way to perfect their physical education by those active amusements that they instinctively prefer. After they have established a sound and rugged constitution ample time will be left for them to develop mentally.

_Feeding of Nursing Infants._--The most important thing in connection with the feeding of infants is to always remember that nature has provided in their mother's milk, when sufficiently abundant and normal in quality, everything in the way of food and drink that they require. During the three days that usually intervene between birth and the coming of the milk in the mother's breast, infants may be given from time to time small quantities of pure water, but under no circumstances should anything else be allowed. During this period the child may be put to the breast four or five times in the twenty-four hours, for, while it gets but little in the way of nourishment, there is even at this time a watery fluid secreted in the breast that goes far towards supplying everything that the infant needs for the time being.

A child should never nurse longer than twenty minutes at one time. It is likewise of importance that the time of nursing be strictly regulated.

Particularly during the first year it is of the utmost importance to watch with an intelligent eye the growth and development of the child. Where the milk agrees with it it has a good color and gains regularly in weight; it cries but little, and is good natured, and thoroughly contented. Should it, on the other hand, lose weight, appear fretful and listless, and sleep badly, there is something wrong, and the mother should at once have her milk examined by a competent physician.

In case the mother does not give sufficient nourishment there is no objection to partially feeding the infant on modified cow's milk--the method of the preparation of which will be considered later on.

Where colic occurs it generally means that the infant is getting a diet too rich in albuminous foods, which should be corrected by advising the mother to take an abundance of out-door exercise, and to avoid all causes of worry so far as is possible.

Vomiting freely is a very common occurrence in small children, and is usually the result of too much food being taken at a time. It also occurs, particularly some time after feeding, as a result of indigestion, which is frequently the consequence of the milk being too rich in fats. Wherever an infant shows signs of trouble it is well to advise the mother to use a diet less rich in meats, and to caution her against over-eating.

Children should be weaned at the end of their first year. This had best be brought about gradually, by, in the beginning, feeding the child once daily, and then gradually increasing the frequency, at the same time proportionately leaving off the nursing. Where children are not thriving, it is often a good practice to wean earlier, in which case modified cow's milk, taken from a bottle, must be substituted.

_Artificial Feeding._--While it is true that children often thrive for a time on the various baby-foods with which the market is so abundantly supplied, it is, nevertheless, the case that where fed in this way they are very apt to develop rickets or scurvy, and not uncommonly show evidences of bad nutrition in loss of weight and strength, becoming peevish and fretful, and sleeping badly.

Much better than any of the artificial foods is properly modified cow's milk, which, with care, may be prepared in such a manner as to take the place of mother's milk in the vast majority of instances. In order, however, that this be successfully carried out, much care and attention is necessary.

At this point it is well to stress the fact that the mother's milk differs from that of the cow in some quite important particulars, and it is only by intelligently taking these differences into consideration that it is possible for us to prepare an artificial food that will be satisfactory. Principal among these differences are that cow's milk contains three times as much albuminous material as that of the human being, and that it is less rich by about half in milk-sugar; furthermore, the former is acid in reaction, while the latter is neutral, or faintly alkaline. It will be seen, then, that in order to prepare a modified cow's milk that will approximate that of the human being it is necessary to dilute it with water sufficiently to cause the albumin to approach in proportion that of mother's milk, and at the same time some alkali must be added to neutralize the excessive acidity. Modified milk prepared, however, from the whole cow's milk, would contain much less fat than is desirable, so that we must use in making it the upper third of the whole milk after it has been allowed to remain undisturbed for a number of hours; in other words, in making modified cow's milk we use a large proportion of the cream, with a less amount of the other constituents.

The following table for calculating the proper proportion of milk to be used at the various periods of the infant's life may be recommended, as it gives quite as satisfactory results as those that are more elaborate; it also gives the frequency of feeding and the proper amounts that should be used. The table was devised by Dr. C. E. Boynton, of Atlanta, Georgia.

Fat Quantity No. of percentage ounces at feedings in Intervals desired. feeding. 24 hours. by day.

Premature 1.00 1/4 to 3/4 12-18 1 to 1-1/2 hrs. 1-4 day 1.00 1 to 1-1/2 6-10 2 to 4 " 5-7 " 1.50 1 to 2 10 2 " 2- week 2.00 2 to 2-1/2 10 2 " 3- " 2.50 2 to 2-1/2 10 2 " 4-8 " 3.00 2-1/2 to 4 9 2-1/2 " 2- month 3.00 3 to 5 8 2-1/2 " 4- " 3.50 3 to 5-1/2 7 3 " 5- " 3.50 4 to 6 7 3 " 6-10 month 4.00 5 to 8 6 3 " 11- month 4.00 6 to 9 5 4 " 12- " 4.00 7 to 9 5 4 " 13- " 4.00 7 to 10 5 4 "

In making calculations from this table it is assumed that the milk from the upper third of the bottle, after it has been allowed to sit for at least four hours, contains 10% of fat, and this is therefore called 10% milk. The calculation is made as follows:--10% milk is to the fat percentage desired, as the amount which we wish to make up is to X. For example, if we wish to prepare twenty ounces of milk for an infant two months old, we will note by referring to the table that 3% is the amount of fat that is desirable for a milk for a child of this age, and the formula will be constructed as follows:--

10:3::20:X. X = 60/10. X = 6.

Six ounces is then the amount of 10% milk that must be used for making twenty ounces of modified milk,--this being mixed with one ounce of lime-water and thirteen ounces of boiled water. It should never be forgotten that while milk modified by the foregoing formula is suitable for most children, it is by no means always satisfactory, and we may, therefore, be compelled to do a considerable amount of experimenting in some cases before arriving at the correct formula.

Suppose the infant is twelve months old, we would get according to the rules just stated the following equation:--

10:4::20:X. X = 80/10. X = 8.

Eight ounces would then be the amount of milk required for preparing twenty ounces of modified milk for an infant of this age.

In preparing modified milk according to the formulas just given, it must be remembered that in all instances only that portion is to be used which collects in the upper third of a bottle of milk that has been allowed to sit undisturbed in a refrigerator for at least four hours. The lime-water is for the purpose of correcting the acidity of the milk.

It is of much importance to select the milk from a healthy cow in all instances where it is to be fed to infants, and where possible, it should be examined by a competent laboratory man in order to determine if it answers the proper requirements. The writer has often seen milk from apparently healthy cows, which seemed in every way good, that showed on microscopic examination pus cells and a harmful germ (streptococcus).

It is not desirable to have a milk for this purpose that is too rich in fats, and for this reason a cow of the ordinary mixed breed is more satisfactory than the blooded Jerseys or Alderneys.

Not only is it essential to get the proper kind of milk, but the utmost care is necessary in handling it. It should, of course, be as free as possible from every source of contamination, and should be strained thoroughly as soon as milked. It should then be bottled, and chilled at once by being placed in cold water, and after being properly sealed, should be placed in a refrigerator at a temperature of about 50 deg.F., where it should remain undisturbed for four hours before the top portion is skimmed off for making the modified milk.

After the modified milk has been prepared it should be returned to the refrigerator, where it should be kept until required for feeding. It is best not to use milk that has been in the refrigerator longer than twenty-four hours, or at most forty-eight hours, and then only if kept at a proper temperature. The modified milk should be poured directly from the receptacle in which it is kept into the feeding-bottle, and the latter should then be placed in warm water until its content is milk-warm, at which time it is ready to be given to the child.

It is highly necessary in feeding infants by the bottle to remember that cleanliness in everything connected with the process only makes success possible, and in no particular does this apply with greater force than in connection with the proper care of the bottle and nipple. In every case immediately after use they should both be put in water, which should then be brought to a boiling temperature, and both should then be kept in a saturated solution of boric acid. The nipple, after being placed on the bottle, should not come in contact with anything but the infant's mouth. Bottles that have no neck are much to be preferred to others, as they can be readily cleansed. There is on the market at the present time a bottle called the "Hygeia," which possesses the necessary qualifications in a perfectly satisfactory way.

When children who have nursed at the mother's breast reach the age of weaning it is of importance to remember that they cannot eat without digestive disturbances the modified cow's milk of a strength that would otherwise correspond to their age; they should invariably under such circumstances begin with a milk prepared by the formula used for a child several months younger, after which the proportion of milk may be gradually increased until it is used in a pure state.

During very warm weather it is well to reduce the amount of fat by using the whole milk instead of the top portions, as heretofore described. The same precaution should be followed where children have acute diseases, and the total quantity taken should be less than under ordinary circumstances. Where infants have acute indigestion, accompanied by vomiting and diarrhoea, all milk should be for the time withheld,--boiled water being substituted; some hours later barley water may be given, but no milk for at least twenty-four hours. Where children have loss of appetite, it is well to give less cream, and the intervals between food should be increased.

_Sterilized (Pasteurized) Milk._--During epidemics of dysentery, diarrhoea, typhoid fever, scarlet fever, and diphtheria, as well as in those instances where it is suspected that the cow is not healthy, or where the milk has to be kept for considerable periods of time, it is well to sterilize it by heating. The most effective method of accomplishing this is by boiling the milk for an hour or so, but inasmuch as it is believed to be then not quite so wholesome as when less heat is employed, a process known as _pasteurization_ is frequently used; this consists in heating the milk for thirty minutes to from 155 deg. to 160 deg.F.,--such temperatures killing all of the ordinary germs, but not altering the milk so completely as when it is boiled.

_Peptonized Milk._--It now and then happens that children fail to thrive where all of the precautions heretofore referred to have been strictly adhered to, and under such circumstances good results are frequently secured by subjecting the milk to a process known as _peptonization_. This consists in the addition of a digestive ferment, obtained from the pancreas of lower animals, together with ordinary cooking-soda. In carrying out the process the milk, whether whole or modified, is placed in a clean bottle, and the peptonizing powder added after having been rubbed up with a teaspoonful of milk. The container is then placed in a pitcher of water at a temperature of 110 deg.F., which is about as warm as the hand can bear comfortably, and is here left for from ten to twenty minutes if only partial peptonization is desired, or for a couple of hours should it be wished to complete the process. The peptonized milk may be prepared at each feeding, or the whole amount for the day may be made at one time in the morning; in the latter case, where it is desired to have the milk only partially peptonized, the ferment should be destroyed by boiling after it has been allowed to act for from ten to twenty minutes.

_Feeding after the First Year._--As the infant is weaned other food should be gradually added; this should still consist largely of milk, to which some time later may be added gruels prepared from well-cooked oats or barley, beef-juice, or the white of an egg slightly cooked. The various broths may also be allowed. Children relish very much all fruit-juices, and they may be given in moderation without harm, and even with benefit in many cases. As the child grows older, the various cereals should form a greater and greater proportion of its diet, but due care should be exercised in always seeing to it that they are thoroughly cooked; in order to be digestible for children such substances should be cooked at least three or four hours before eaten.

_General Hygiene of Infant Life._--In order for children to be healthy, the greatest regularity is necessary in their habits. They should arise at a certain hour in the morning and go to bed at a fixed time at night. Their clothing should be loose, and not too tight fitting, and should at all times correspond to the state of the weather. Nothing is more common, and nothing produces irritability, loss of sleep, and even serious general disturbances in infants, more frequently than too much clothing. It is generally customary to use from the time of birth and during the period of infancy a flannel band around the child's abdomen. Just how this acts is not clear, but there seems good reason for the belief that in some unexplained way the practice has the effect of warding off intestinal disturbances, and is, therefore, to be recommended.

Napkins should be changed when soiled, and then should be immediately placed in water, in which they should remain until washed out; under no circumstances should they be left lying around the nursery.

When the weather permits, the child should be kept as much out-of-doors as is possible. For the first few days of the infant's life, particularly if the weather be cool, it should, of course, be kept indoors, but even then free access of air should be allowed. There is no objection whatever to the infant sleeping out-of-doors--in fact, where this is feasible, it generally shows improvement as soon as the practice is commenced. When out-of-doors, it is of course necessary to see that the sun does not shine directly into the infant's face, and wetting should, of course, be avoided; also the hood of the carriage should be arranged to prevent strong winds from blowing on the child.

The nursery should be well aired, a window being left up at night except during severe weather.

_Sleep._--Nothing is more important for the proper development of a child than for it to have an abundance of sleep. During the first few months of its life it sleeps practically all of the time--the period becoming gradually lessened as it grows older. Infants should be suffered to sleep just as much as is possible, it being not only unjustifiable but absolutely criminal to interfere with them in this particular in the slightest degree. Not only is it necessary that infants have all the sleep that they desire, but it is true throughout childhood, a fact to which many foolish parents seem utterly oblivious. How often do we see a child scarcely more than an infant aroused in the morning and sent off to school, and how frequently do we hear misguided parents boast of their inflexible rules in enforcing such evil practices. Truly man comes hard by the knowledge that nature is much wiser than he, and the vast majority never learn the fact at all.

As soon as the child is able to crawl, it should be placed on a clean quilt or blanket on the floor, and allowed to move about to its heart's content. When it is able to walk, allow it to run about and play to its full capacity--as in such exercises consists the great school of its physical being, the school upon which will depend its strength and health in after life. Allow the child to keep up his play as long as he has any inclination to do so, and never be so foolish as to confine him in the house when he wishes to be out under the blue heavens, for here only will it be possible for him or her to develop into a real man or woman. Allow this to go on until the child of its own accord comes and asks to be taught other things, for not until then is its outside education nearing completion, and not until then is it possible for him to take interest in and learn things connected with books. No boy should ever be sent to school before he is twelve or fourteen years of age; girls, on account of their maturing earlier, may begin a couple of years sooner.

The whole science and art of properly raising children consists in feeding them good clean food in proper amounts, in never allowing them to be awakened, and in permitting them to play in the open air to their hearts' content.

_Teething._--Teething is a subject which has at all times interested both doctor and layman, and in its supposed relation to all kinds of disorders of infancy has undoubtedly exercised an influence over the popular imagination out of all proportion to its real importance. Too often it has happened that this perfectly normal, and usually by no means serious, process, has been held responsible for grave diseases in children--diseases which in reality were the consequence of neglect and mismanagement in the far more serious matters of food, sleep, out-of-door exercises, and general hygiene. It cannot, however, be denied--particularly in respect to nervous children--that teething appears occasionally to induce unpleasant disturbances, such as fretfulness, broken sleep, digestive disorders, and occasionally fever; as a rule such symptoms persist only for a few days, if the infant be properly looked after. The treatment should consist in lancing the gums should they become much swollen, and the withholding of the usual amount of food, particularly where intestinal disturbances occur. The ages at which the teeth usually come are as follows:

2 Middle Lower Teeth 5 to 9 months. 4 Upper Front Teeth 8 to 12 months. Remaining Lower Front Teeth 12 to 18 months. 4 Front Jaw Teeth 12 to 18 months. Stomach Teeth (Canine) 18 to 24 months. Eye Teeth (Canine) 18 to 24 months. 4 Back Jaw Teeth 24 to 30 months.

_Bowel Diseases._--Digestive disturbances, accompanied by diarrhoea, are the bane of infancy, and are responsible for a very large part of the frightful mortality among babies. The subject, therefore, is one of tremendous importance, but is so complicated that the limits of this little volume will only permit its being touched upon.

As already mentioned, indigestion accompanied by looseness of the bowels may be and often is the result of milk being used from diseased cows, or it may be the consequence of such carelessness in handling it that disease-producing bacteria are later allowed to contaminate it. It should also never be forgotten that where children are eating artificially prepared food improper mixing of the different components may result in serious disturbances, and we should, therefore, exercise the utmost care always in seeing to it that the food is prepared strictly according to the table which has already been given--not forgetting that in a certain number of instances we can go by no rule, and will have to experiment until we ascertain the proper proportion of the ingredients.

After a diarrhoea begins we should at once reduce the quantity of fat in the milk that is being given to the infant, and if the trouble be at all severe it is best to take it off of all food for twenty-four hours, and substitute boiled water or barley-water. As soon as the trouble is checked we may then begin to feed cautiously with largely diluted milk, and, gradually increasing its strength, in the course of a few days return to the food that was being given before the disturbance occurred. A dose of calomel or castor oil in the beginning of diarrhoeal troubles often has a very salutary effect; the parent should not hesitate to administer this if a doctor is not at hand.

In warm climates during the time of teething children very commonly develop chronic diarrhoeal conditions which often end fatally; wherever possible the parent should under such circumstances at once remove the little sufferer to a colder climate where recovery is generally rapid and complete. Even the most careful nursing under the most competent physician is often fruitless in combating disorders of this character as long as the infant remains in a warm climate.

_Colic._--Colic is always due to indigestion, and is the result of the food undergoing fermentative changes, with the production of gases. This goes on even under normal conditions to a certain extent, but when it is excessive the intestines become greatly distended, and pain of a severe or even agonizing character is produced.

In the treatment of this condition warm applications should be made to the abdomen, and as quickly as possible an enema (injection), consisting of a few ounces of warm solution of salt water should be given; the salt should be in the proportion of a level teaspoonful to the quart of water. Parents will find the little ear syringe, which may be purchased at any drug store, a most satisfactory instrument for giving enemas to infants, as they do not hold too much, and being soft, are incapable of tearing the delicate tissues of the child. It is of the utmost importance to remember that the salt solution should be tepid, yet not sufficiently hot to scald the infant. As the water when given in this way is expelled very quickly the enemas may be repeated any number of times desired.

Where these measures fail, a physician should be sent for at once, but in the meantime if it be evident that the infant is suffering very much, a small dose of paregoric may be given; it should not however be forgotten that opiates are exceedingly hurtful to nervous children, and that soothing syrups and other mixtures containing drugs of this class should be avoided.

_Constipation._--Constipation among very young children generally passes off as the food becomes richer, but should it occur at a later time, the trouble may be more difficult to remedy. Of first importance is having the bowels of the infant move at a certain time each day, which may be quickly accomplished in many little children by placing them upon a small chamber daily at a given hour; usually the baby very quickly learns what this procedure means, and in this way a regular habit is established which is of the utmost value to the child throughout its infancy, and every effort, therefore, should be made to bring it about as quickly as possible.

The addition of malted milk or Mellin's Food may also have the effect of diminishing constipation;--the result being brought about by the maltose contained in these preparations. The same thing may be accomplished by substituting for a part of the milk sugar in the baby's food a similar quantity of maltose. Milk of magnesia may be used in preparing the baby's food in the place of lime-water, with the result oftentimes of relieving a tendency to constipation.

_Croup._--By croup is meant a spasmodic condition which usually affects children at night, and is in no way to be confounded with that really dangerous disease, membranous croup, or diphtheria, to which so many children fall victims.

Spasmodic croup is a condition which has as its basis digestive disturbances, and is almost always relieved as soon as the stomach is emptied. Vomiting may be brought about by making the child swallow a small quantity of mustard stirred up in water, or by the use of ipecac. Such severe and extremely unpleasant remedies are rarely necessary, however, since the disease may be in almost all instances at once relieved by placing around the victim's throat a cloth wrung out of cold water, which may itself be covered by a dry bandage to prevent the bed from getting wet. Children will usually go to sleep in a few minutes after the cold cloth is applied, and suffer no ill consequences as a result of its remaining around their throats throughout the night. Where the croup is very severe the little sufferer's feet may be placed in hot water, in addition to the cold cloth around the neck--the combination practically always resulting in the rapid relief of the unpleasant symptoms.

Great care should be exercised in the diet of children who are subject to croup, as by intelligent supervision the tendency to this very annoying trouble may be in a short time entirely overcome.

_Nervousness._--Children of neurotic parents, particularly where they are reared in cities, are exceedingly prone to nervousness in one form or another. The condition is undoubtedly often due to heredity, but may be induced in otherwise healthy children by unhygienic surroundings and improper food. Infants exhibiting symptoms that indicate trouble of this kind should not be played with, and every care should be exercised to so direct their lives that the trouble may be gradually overcome. In all cases where nervousness persists an intelligent physician should be consulted.

_Vaccination._--The only safe method that we possess of preventing small-pox is by means of vaccination. Its great value has been so thoroughly tested that the writer does not deem it necessary to go into a discussion as to its merits. A child should be vaccinated in at least three places during its early infancy,--there being no danger in doing the operation immediately after birth. Persons ignorant of aseptic surgery should not do this operation, but should always call in the services of some person prepared to do the work in a cleanly manner. Either the leg or the arm may be selected; and children should be revaccinated whenever small-pox breaks out in the community.

_Kissing Babies to be Avoided._--Kissing infants in the mouth is a very bad practice, as in this way disease may be quite innocently conveyed to them. The public should be taught to understand that it is not infrequently the case that bacteria may be present in the mouths of individuals who are quite immune to their ill effects, and who are, therefore, perfectly well, but who may, by conveying them to others, particularly children, induce in them serious disease. When caressed in this way at all children should be kissed upon their necks or feet, and never in their mouths or on their hands.

_Juvenile Contagious Diseases._--Children are peculiarly prone to a class of highly contagious diseases, the exact nature of which is not yet understood, and we possess therefore little knowledge as to the proper means of preventing their spread. Practically all that is known about them is that they are conveyed by contact, or even by the air, particularly where a child suffering from one of them is placed in a confined place with another who is susceptible; these diseases likewise may be carried by means of clothing and other articles that have been in close contact with a child suffering with any of them. The lesson of importance to be learned, therefore, is that if we wish our children to escape maladies of this class we should not permit their indiscriminate association with others. As these diseases cease to be a serious menace after children have passed through their earlier years it does not at a later time matter so much as to whether they are exposed to them or not. As a general thing children develop these affections in from ten to fifteen days after having been exposed, though one of the most severe of them, scarlet fever, may make its appearance as early as twenty-four hours after it is contracted. These diseases are usually ushered in by a severe headache, pains in the head, back, and limbs, high fever, and oftentimes a chill. As soon as a child develops such symptoms the advice of a competent medical man should be at once sought, and the little sufferer should be at once completely isolated.

In concluding, the writer would particularly exhort parents to obey to the letter the instructions of their physicians, and never under any circumstances to dose their helpless off-spring with patent or proprietary medicines, which contain no man knows what, and which unquestionably are often highly injurious, especially to children.