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 deg. and 105 deg. 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 deg. F. for one hour or one hour and a half; the second is known as pasteurizing, in which the milk is heated to 155 deg. or 170 deg. F. for thirty minutes. A temperature of 155 deg. 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 deg. F. for an hour will keep upon ice for two or three weeks; that heated to 155 deg. 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 deg. 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 deg. 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 deg. 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 deg. 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 anaemia. 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 anaemia.

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 deg. and 99.5 deg. F.; a rectal temperature of 97.5 deg. F. or of 100.5 deg. 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 deg. to 102 deg. F. commonly means a mild illness, and one of 104 deg. 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 deg. F. or 103 deg. F., in a young child would very likely be accompanied by a temperature of 104 deg. or 105 deg. 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 deg. 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.

THE END