NEONATOLOGY ON THE WEB

Historical Review and Recent Advances
in Neonatal and Perinatal Medicine

Edited by George F. Smith, MD and Dharmapuri Vidyasagar, MD
Published by Mead Johnson Nutritional Division, 1980
Not Copyrighted By Publisher

Chapter 4

Neonatal Feeding

Martin H. Greenberg, M.D.

"Infant feeding, a subject that upon superficial thought seems so simple that the majority of medical students are apt to pass it by as pertaining to the nurse and not the doctor."

-Keating, J. M., Archives of Pediatrics, 1:88-95, 1884

"The traditional view of the medical profession has always been that a healthy baby with a healthy mother receives more benefit from breastfeeding than bottle feeding. The advantages to the baby are believed to be both psychological and physical. The harmony of the relationship combines with prophylaxis against infection, especially alimentary, to provide a healthy start to life that most doctors would advocate."

-Editorial-British Medical Journal, No. 5650, London, April 19, 1969, p. 131

INTRODUCTION

It is remarkable that in 1981, at a meeting dedicated to the history and contemporary advances of perinatal medicine, that milk, the prime source of infant nutrition, should remain a significant focus of investigative endeavor and interest in professional and lay publications. Biochemists still search for differences in human milk at varying gestational ages, behavioral scientists still discuss patterns distinct to breast and bottle fed babies, while immunologists and bacteriologists grapple with "protective mechanisms" afforded by breast milk.^[l-5] Breast milk banking^[6] procedures and policies still occupy the thoughts of nursery directors, hospital authorities, and certifying agencies. The politics and safety of infant feeding is even the center of international concern and multi-national industrial enterprise.^[7-10] It seems appropriate, therefore, to reflect on this unique mammalian secretion that has permitted offspring survival, when adult food sources are often remote.

In studying the history of infant feeding, one must assume that the human breast was the sole source of nutrition in man's primitive beginnings. As we "advanced" resourcefulness surely led to alternate methods, from suckling a human breast other than one's mother's to the udder of another animal. Domestication of mammals for food supply made milk and other products available. Delivery of those products to the young was left to man's increasing capability and ingenuity. Tracing this inquisitiveness of man, and the evolution of "artificial" or alternative methods of infant feeding shall be the prime purpose of this chapter. In so doing, it is impossible to disassociate these changes from man's cultural, social, economic, scientific and technological progress.

MAN AS MAMMAL

To begin with, we must first consider man as mammal. Mammals make up less than 0.5% of the more than one million kinds of animals that currently inhabit the Earth. In evolutionary history, they are relative newcomers, but their peak, as represented by number and diversity of kinds, has probably passed. Relatively large animals, some examples of their four thousand species are numerous. In total, they exert a disproportionate influence upon the environment.

In the Phylum Chordata, mammals are grouped with sea squirts, lancelets, fishes, amphibians, reptiles, and birds, unified by distinctive anatomical features that function in support of the body, nervous transmission and breathing. The vertebral column links mammals to fishes, amphibians, reptiles, and birds in the Subphylum Vertebrata.

Much of our information of prehistoric animal evolution is from fossils. However, the main characteristics by which we distinguish modern mammals are not evident in fossils. We describe mammals as lactogenic, hirsute, homeotherms, milk-producing, hairy, warm-blooded animals. Homeothermism is the most important difference between mammals and reptiles. When active, most mammals maintain a body temperature between 95 and 100.4^°F. The hairy body covering serves as insulation. When extremes of temperature arise, other mechanisms intervene to preserve or lower body temperature.

Milk production of mammals for the nourishment of their young is heavily dependent on the body's temperature stability to maintain the required complex glandular relationships. Lower temperatures slow the speed of chemical reactions and temperatures only a few degrees higher than normal body temperature may cause a breakdown of the endocrine system.

Birth is both a beginning and an end. For the newborn mammal, independent life commences and, for the parent, it marks the end of the gestational period. Prenatal care is over and postnatal care begins. The newborn mammal's nutrition, in the form of milk comes from the mother. Rate of growth of the baby is related to the nutritive value of the milk. Mammals that produce milk with high protein content have young that grow faster.

Nourishment of the young with milk, and the consequent dependence of the young upon the mother, has led to another specialty of mammals, parental care. Such nurture is also typical of birds, but for a much shorter period of the offspring's life. The comparatively long period of dependence of the young of the mammalian mother has paralleled in many their greater cerebral development. The suckling period is a time of learning for many mammals and an important part of their lives. Greater cerebral development and ability to learn further differentiate mammals from other animals. Weaning generally occurs somewhat later than the time when the young actually can eat solid food.

Man is a member of the Primate order, consisting of 166 species in 10 families. Two orders upon which he has become significantly dependent for food, transport, and industry are Perissodactyla, (horses, zebras, asses, tapirs and rhinoceroses) and Artiodactyla, (pigs, peccaries, hippopotamuses, camels, llamas, deer, giraffes, antelopes, cattle, sheep and goats). Domestication has been achieved in many of these species, since man's relationships to his fellow mammals have been largely egocentric.

Early man viewed mammals as a source of food or possibly danger. Advancement of civilization has accentuated this relationship. To make their use more convenient, man has learned to domesticate some of them. This was achieved with most common animals prior to recorded history.

The dog, probably the first domesticated animal at least 9,000 years ago, was used as an aid in hunting, transportation, guarding, herding, protection, food, skin, and sport. Sheep, goats, and pigs were probably domesticated shortly thereafter. Sheep remains in archeological sites predate goat remnants by 1,000 to 1,500 years. Goats were primarily used for meat and hides, sheep for wool and fat. Cattle were domesticated at least 6,000 years ago. They are the most important of domestic mammals as a source of meat, milk, and hides today.

Two important animals domesticated more than 4,000 years ago are horses and camels. Biblical reference to them is about 3,800 years old. Their counterparts in the New World were llamas and alpacas, used by progenitors of the Incas.

In the past 2,000 years, it is evident that man's activities have caused the extinction of mammals at a disproportionate rate. Of the genera of mammals that have existed since this class became distinct, more than two thirds are extinct.

DAIRY FARMING

Man's evolution and eventual ability to dominate and domesticate other mammals for his own use are directly related to his advance and propagation. Dairy cattle are a prime example.

Milk serves as one of the most important sources of food for all civilizations. Milk and dairy products are consumed more by highly developed and prosperous people. Native races of Africa, America and Australia used little milk as food, while primitive races of Europe and Western Asia made use of milk as their descendants have done. Earliest recorded history tells of man's possession of cattle and use of milk and milk products. In Genesis 18:8, Judges 5:25, and Psalms 55:21, mention is made of butter and cheese. The Greeks, from 1000 to 450 B.C., used butter and cheese, as did the Romans, 750 B.C. to 475 A.D., to whom cheese also became an important article of commerce.

No cattle are native to America. All those found in North and South America are descended from animals brought mainly from Europe. They in turn are descended from wild forms that originally lived in Europe and Asia. Some were brought on Columbus' second voyage to the New World, rapidly becoming an important source of nutrition.

From modest beginning in colonial times, the dairy industry became a significant force during the expansion and industrialization of the United States (Table 1). This, in turn, permitted experimentation and widespread availability of artificial means of feeding babies, which will be discussed later.

EARLY MAN

With primitive instincts and basic needs satisfied, man's intellectual growth demanded the search for a meaning to his existence. Codes of morality and ethics for every phase of life were devised. Religion and mythology were intertwined with each of life's functions, vital or mundane. Milk, fundamental to man's existence and essential to procreation, figured significantly in early recorded evidence. The ancient Jews strictly enforced breast feeding and frowned on wet nurses or artificial means of feeding. Interestingly, there are several references to milk in the Old Testament, from Sarah nursing Isaac at age 90, to the Promised Land described as "flowing with milk and honey."

Roman mythology has Remus and Romulus suckling at the teats of the symbolic she-wolf. Goddesses existed for all situations. Rumina caused a woman's breasts to swell, Vaginatus opened the infant's mouth for his first cry and Educa taught the infant to suckle, equating for all time education with nourishment.

Egyptian physicians, most reputed in antiquity, used drugs of animal origin, reading like a witch's pharmacopoeia:

Flesh of lizards
Blood of bat
Womb of cat
Dung of crocodile
Semen and testicle of asses
Vulva of dog
Milk of a lying-in-woman

THE WET NURSE

Human milk was primarily intended for human infants. For many reasons, including illness, death, or need to work, mothers were not always the source of nutrition for their own babies. Necessity demanded resourcefulness. Although frowned upon by the ancient Hebrews, early civilizations utilized the wet nurse.

Soranus of Asia Minor, a Greek physician living in Rome, wrote a work on diseases of women for use by mid-wives. In its pediatric section, he catalogued the qualifications of the wet nurse. He taught that an infant may thrive at the breast of one woman and not another. He preferred Greek nurses in order that the suckling infant might become accustomed to the sound of the "most beautiful of languages." He also advocated care of the infant's ills by treating the nurse. If the baby had diarrhea, the nurse was given astringents; for constipation in the baby, it was the nurse who took the laxative.

From the early Christian Era through the Middle Ages, little is found concerning rules of wet nursing." Much of Western medicine was held as "mysterious" and relegated to monks and priests who gradually abandoned "pagan" Greek and Roman concepts. Midwives were firmly in control of the perinatal period. In Talbot's Medicine in Medieval England,^[12] we are told of the midwife's concern for hygienic regulation of an individual's life, beginning with the pregnant mother. This included her food and mode of life before the baby was born, plus preparations for delivery and the immediate needs of the newborn.

If a child refused to suckle, honey was smeared on the nipples. When mother was not able to nurse, it was common to send the baby to a wet nurse and subsequently to a monastery, nunnery or foster home as a servant or a slave. DeMause's History of Childhood (1974)^[13] describes other tragedies of the early Middle Ages. Infanticide was common when inability to care for the newborn occurred. Toward the end of the 13th century, it became generally accepted that children also had souls. However, cruelty to children still was prevalent as babies were used as human frisbees for sport, child labor, or routinely abandoned. Those who were left with a wet nurse were frequently victims of emotional abandonment since one nurse might feed several children, though she suffered from cracked, infected and aching breasts.

In Elizabethan times,^[14] ladies of fashion sent their babies to the wet nurse until two years of age, the usual time for weaning. Rich families would employ a wet nurse and have her live in their homes, often abandoning her own child for a more lucrative life of ease. Where many children were kept, it was not unusual for confusion to occur, and families might find themselves with a child resembling no one in their household.

Thomas Phaire, in 1545, writing the first pediatric text in English, describes choosing the proper nurse, "not of ill complexion and worse manners: but sucke as shall be sobre, honeste, and chaste, well-formed, amyable and cheerefull, so that she may accustome the infant into mirth, no dronkarde, vicious, sluttyshe, for such corrupteth the nature of the chylde."

Red-haired nurses were frowned upon because of their bad temper and passions of the mind. Brown-haired women were considered best.

A 1566 poem by Tansillo (c. 1566) sums up the prevailing feeling toward the wet nurse.

To seek a nurse ye trace the country round
At length the mercenary aid is found:
Some wretch of vulgar birth and conduct frail,
Some known offender, flagrant from the jail.
In mind an idiot, or depraved of life,
A shameless strumpet or impoverished wife;
Or be she brown or black, or fresh or fair,
Or to the mother no resemblance bear,
She brings, it seems, a full and flowing breast,
Enough -- your care excuses all the rest.
Born of high blood, whose work no stain defiles,
Say an ye choose a nurse from brook St. Giles
Heedless what vermin taints the stream she gives
So your stall'd offspring vegetates and lives.

The practice of wet nursing^[15,16] continued for three more centuries, although physicians increasingly condemned it.

Colonial America continued the employment of wet nurses.^[17-19] Radbill,^[20] in a bicentennial symposium, was kinder to this class of nurses, stating that they "took full charge of their infants. They crooned lullabies, knew charms and magic cures, used a variety of simple remedies and possessed a talent for treating cuts, bruises, burns, and the many other minor accidents of children. New Jersey was famous for its prolific women; there the delicate ladies of Philadelphia could find a plentiful supply of wet nurses."

Monumental political, industrial, and social changes that had their roots in the 18th century flowered during the 19th. Characteristic was early Victorian England.^[21] Wet nursing still flourished, but artificial or "handfeeding" began to emerge. Wisdom questioned the continuation of wet nursing. It was suggested that diseases such as syphilis could be transmitted through breast milk and the wet nurse was often incriminated. The practices of wet nursing, artificial feeding, and later, child-farming (to work houses) were condemned in newspapers, medical journals and novels of the period. Dickens voiced his alarm and disapproval in Oliver Twist, Great Expectations, and Dombey and Son.

In the United States, William H. Parish discussed wet nursing in Keating's 1890 Cyclopedia of Diseases in Children .^[22] He perpetuated the desire for the nurse's moral fitness, stating, "while most probably her milk cannot influence the future moral organization of the growing child, yet her close association with the infant possibly may make a permanent impression on its pliant brain." He added, "If of violent temper, she will furnish during her expositions of temper, milk unfit for the child."

He also felt the wet nurse should be cheerful, active, good-natured, temperate, and of average mental capacity. She must not have syphilis or gonorrhea, which could be transmitted. A scrofulous woman could not furnish good milk, either. Measles and scarlatina exposure also precluded her service, as did all acute illnesses, unless trivial. Her diet was to be proper, avoiding tea and spirits, but encouraging nutritious foods. Beets allegedly procured an abundant flow of milk. In his closing remarks, Parish stated that Prussia had special laws bearing on the relations existing between the employer and the wet nurse, but none existed in this country.

In concluding this section,^[2,3,6] it is noteworthy that in 1981, there is still interest in pooled breast milk, breast milk-banking, and human milk furnished by volunteers, especially members of the La Leche League. Few regulations exist to control human milk supply and handling. In 1956, the World Health Organization published a survey of existing legislation on venereal disease, which included regulations for wet nursing from a number of countries. Have we heard the last of this subject?

ARTIFICIAL FEEDING AND MODES OF DELIVERY

Supplementation of, or substitution for, breast milk probably existed prior to the Stone Age. Evidence of man's creativity in delivering nourishment to helpless infants when the human breast was unavailable, or did not suffice, can be found as early as 2,000 B.C. The British Museum houses the earliest known "feeding cup" discovered in Phoenikas, Cyprus. It looks like a teapot and is of decorated earthenware. Other examples from Babylonian,^[23] Greek, Roman, Etruscan and ancient Judaic periods (Fig. 1) have been found at archeologic sites, particularly in graves of young children. Some vessels resemble oil lamps or miniature wine jugs.

Pottery was employed until the Egyptians developed the ability to blow glass from hollow rods, about 250 to 300 B.C. Perfecting their technique, Romans made clear glass (Fig. 2) at the beginning of the Christian era by removing traces of iron impurities from sand. Interestingly, glass feeding vessels soon lost popularity and did not regain acceptance until the mid-19th century.

The years following the decline of Rome and western civilization are poorly documented. Greek and Roman contributions were rejected, concealed, or just forgotten with the emergence of Christianity. More time was spent in conversion and day-to-day existence than academic pursuit. During the period 700 to 900 A.D., the "intellect of Europe was so clouded by monkish fables that monasteries were buying milk purported to come from the breasts of the Blessed Virgin.^[12]

As Europe descended into its Dark Ages, the Arab became a preserver of Greek science and added his own significant dimension. Infant feeding changed little in content or method of delivery. Knowledge in the fields of hygiene and midwifery were expanded.

European wood-cuts of the 13th and 14th century demonstrate feeding of babies from cow horns to which teats were applied. These were glove-like sewn appendages made from leather or dried cow teats (stuffed with cloth or spongy material). The origin of these practices is unclear, but they were apparently widespread because of availability of material with its convenient shape and the lack of cost. Surion de Vallambert, in 1565, recommended the use of a cow's horn with cow's or goat's milk. At this same time, bottles of wood or leather were introduced in Germany and Italy. They were soon replaced by pewter flasks, during the period when this material was used for many domestic items.

Changes in infant feeding practices necessitated creation of new devices for delivery to the baby. The term "pap,"^[23] allegedly derived from the Scandinavian for the sound made when a baby opens his mouth for nourishment, was probably introduced before its first recordings in literature in the mid 18th century. Recipes for pap usually called for bread, flour and water. A more nourishing mixture, "panada," was a pap base with added butter and milk, or cooked in broth as a milk substitute. Variations on the ingredients included Lisbon sugar, beer, wine, raw meat juices and Castile soap. Drugs were sometimes added to "soothe the baby."

The "pap boat"^[24] was designed to feed the mixture to babies and invalids. Resembling a sauce boat (or sometimes a small bed-pan), they were made of wood, silver, pewter, (Fig. 3) bone, porcelain, (Fig. 4, 5) or glass. They ranged from very plain, for poor families or foundling homes, to highly decorated pieces for wealthier clients. Although intended as a supplemental invalid or post-weaning food, this "dry" form of artificial feeding, often inadequate, became very popular, significantly contributing to the infant mortality of the period.

Implements for feeding proliferated in the 18th century as new materials and methods of production became accessible. Shapes were clever and varied. Some pap boats were closed, (Fig. 6) others looked like animals, most often a duck (Fig. 7). Feeding cups (Fig. 8, 9) of such design are still manufactured in some countries today (Fig. 10).

Liquid feedings could be administered through sucking pots made of pewter (Fig. 11). These were later replaced by ones made of porcelain (Fig. 12). Some stood upright, others were submarine-shaped and would lie flat.

In 1770, Dr. Hugh Smith invented the "Bubby pot,"^[17] (in some sources, referred to as a "bubbly pot"). It was made of pewter and resembled a gravy pot or tea pot. The bubby pot came at a time when there was a strong move to make artificial feeding safer, and reduce dependency on the wet nurse. The perforated spout was covered with cloth, which served as a nipple. Dr. Smith, in recommending his idea, stated, "Through it, the milk is constantly strained and the infant is obliged to labour for every drop he receives." It is amazing how much this device resembled the previously mentioned Cypriot feeding bottle of 1900 B.C., which Dr. Smith never saw.

Although his pot underwent many variations and existed in porcelain, (Fig. 13) it never replaced the sucking bottle. An American equivalent, the nursing can, used by the Pennsylvania Germans, may have been copied from the bubby pot. This gained little popularity and, by the 19th century, the sucking bottle was almost the rule. Glass rapidly replaced the porcelain successors of pewter. They were now easier to clean and their acceptance coincided with understanding of bacteria, contagion, and improved sanitary conditions. Increasing cleanliness, reliance on milk as the chief "artificial dietary source," and diminished use of pap (Fig. 14, 15) and panada helped to lower the devastatingly high infant mortality rates in urban foundling homes which often approached 100%.

The glass nursing bottle or "the pocket wet nurse" was promoted along with use of milk from non-human sources such as the cow, goat, sheep, ass, and mare. Commercially transported and packaged milk permitted the "liberation" of mother from motherhood to work in factories or mills or as servants to the Victorian gentry.

Charles Windship patented the first glass feeding bottle in the United States. Called a lacteal, it was a deliberate imitation of the human breast. The famous Alexandra Feeder was introduced in England in 1845, and was flat and oval with a curved neck. Almost 200 varieties of this bottle were made and were common in Britain and our country well into the beginning of this century. M. Darbo of Paris introduced his "Biberon" at the same period, receiving great acclaim in the Lancet in 1851. To this day, the baby bottle, in French, is called a "biberon" (Fig. 16).

In 1845, Elijah Pratt of New York, patented the India-rubber nipple. It had a bad taste, and found little favor initially. The Biberon nipple made of cork, was held to be superior because it neither had the repulsive taste of India-rubber, nor was it putrified like calves' teats. Other nipples of the period were made of metal (pewter, silver), glass, ivory or wood. Perfection in manufacturing methods, however, enabled the rubber teat to emerge as the universally accepted nipple (Fig. 17). These changed from the original black (still used in lamb's nipples) to white (containing lead), to red and brown. Later models were adapted to the needs of sterilization, ease of sucking by premature babies and, eventually, "disposability."

In the interim, progress in baby bottle design kept pace with advances in scientific understanding of need for sterility in preparation, handling, and packaging of baby's milk. Demand for artificial feeding grew, along with changes in life style, and was abetted by advertising of commercially available products guaranteed to be safe and perfect for baby. Narrow-necked bottles gave way to the double-ended variety that was more sanitary because of greater ease in washing. The first of its type to be patented was the English Allenbury's feeder, (Fig. 18) in 1894. In the United States, Dr. William Decker of Kingston, N.Y., introduced the first wide-mouth glass nurser in the same year. His invention resulted in a bottle that was easier to clean. He named the new feeder, with corresponding wide nipple, Hygeia, after the Greek goddess of health.

In the early 1900's, the bottle became cylindrical (Fig. 19, 20) to fit into newly invented sterilizers. Automation lowered prices, permitting a mother to have several nursers (Fig. 21) prepared for use and stored in the refrigerator. Portability with bottle holders, reheating with bottle warmers, nipple guards, bottle proppers, and a myraid of appliances to aid the mother and create industrial fortunes, seemed to continue unabated.

The era of plastic and the age of disposability are the most recent advances in the saga of artificial feeding. Resurgence of breast feeding appears to have diminished this activity somewhat, but new products appear on the market with almost predictable frequency.

Proprietary or artificial infant foods^[17] became available on a commercial basis, thanks to pioneering efforts of Justus von Liebig, who marketed his "perfect" infant food in 1867. His "formula" was a mixture of wheat flour, cow's milk and malt flour cooked with bicarbonate of potash to reduce the flour's acidity. It was first sold as a liquid but later marketed as an entirely farinaceous powder. "Patent" or "instant" baby foods manufactured by Nestle's and Horlick's contained dried cow's milk with starch or malt and Mellin's Food was made with desiccated malt extract. A final group of foods of pure cereal origin was represented by brands such as Imperial Grain, Eskay's Food, and Robinson's Patent Barley.

Medicine made strides that would have overwhelming effects on health and nutrition. Advances in bacteriology by Pasteur, Koch and their contemporaries made milk handling safer for infant consumption. Milk chemistry and modifications for its improved digestability were studied .^[25] Meigs in Philadelphia and Biedert in Germany, in the 1890's, studied milk composition. Finklestein devised "protein milk," one with low fat, low carbohydrate and high protein, to "counteract with harmful effects of carbohydrate fermentation in the intestines." Czerny in Austria developed a butter-flour mixture because he felt infant diarrhea was due to fat intolerance.

The term "formula" was derived from Thomas Morgan Botch's approach to "percentage feeding." Complexity in formula construction reached its zenith. Careful attention was paid to exact percentages of fat, carbohydrate and protein. The protein was often split to alter the proportion of whey and casein. A common basic formula, at the time, at Infant's Hospital in Boston was 2-6-2, meaning 2% fat, 6% carbohydrate, and 2% protein. Dr. Lee Forest Hill^[25] commenting on his training in Boston said, "One of my duties was examining each day the stools of some 20 infants for neutral fat, fatty acids and soaps. Although I have long since abandoned using carbofuchsin and Sudan 111, nevertheless, I have never overcome the habit of visual and olfactory inspection of stools of sick infants -- "stool gazing" is the present term -- much to the amusement of my house staff." Indeed, pediatric texts of the era were never without several pictures of stool types, adding vivid color when available.

Other important advances were Henry Coit's^[26] artificial milk, acidified milk, and the concept of "curd tension" by Marriott of St. Louis and Chicago's Brennemann. In New York, Jacobi strongly supported breastfeeding, stating that "No matter how beneficial boiling or sterilization or pasteurization may be, they cannot transform cow's milk into woman's milk." He denounced the giving of "top milk" resulting in high fat intake for babies. L. Emmett Holt,^[27] in 1895, published the highly influential The Care and Feeding of Children, the first book for parents.

In 1915, Gerstenberger^[28] and his colleagues developed an artificial milk "formula" achieved by adding homogenized vegetable and animal fats and oils to skim cow milk to approximate the fatty acid content of human milk. By 1919, Gerstenberger and Ruh had fed about 300 infants successfully on their S.M.A., Synthetic Milk Adapted. Other companies continued the quest for a closer synthetic approximation of human milk or formula modification for various medical indications. Franklin Infant Food introduced, in 1923, a powdered formulation, later to be called Similac. Enfamil, by Mead Johnson, was a late comer in 1959, but the company, established in 1905, pioneered vitamin research in the 1920's with the first cod liver oil of standardized potency in 1924 and pure solution of Vitamin D in 1929. In 1934, Pablum was introduced as the first precooked vitamin and mineral enriched cereal for infants. That began a fruitful collaboration between E. Mead Johnson and Dr. T. Drake of Toronto. Both men later began extensive and world-famous collections related to the history of infant feeding.

CONCLUSION

It is difficult, with the limitations of time and space to mention all the important events and people contributing to the evolution and understanding of infant feeding. It is interesting to speculate on the future of this basic element of life. We have seen a dramatic shift from breast to bottle feeding and back again. Artificial formula acceptance paralleled the growth of pediatrics as a special medical discipline. A close relationship was built between infant food manufacturers and the medical profession. The pediatrician was given a place of prominence in prescribing the baby's formula with resultant close doctor-parent relationship. Issues of concern to pediatricians today include the resurgence of nurse-midwives, prevalence of pediatric nurse practitioners, expanding family medicine, lay self-help groups, consumer advocates, and politically charged issues centering on breast versus bottle feeding in the Third World.

In summation, we might agree with Dermond MacCarthy^[29] who said that perhaps the best reason for advocating breast feeding is "the poetry." A deep understanding is expressed by it and it is with poetry that life ought to begin.

REFERENCES

1. Berger R. L.: When Should One Discourage Breast Feeding. Pediatrics 67:300-302, 1981.

2. Gusler J. D., Breismeister L. H.: The Insufficient Milk Syndrome: A Biocultural Explanation. Medical Anthropology 4:1980.

3. Anderson S. A., Chinn H. I., Fisher K. D.: A Background Paper on Infant Formulas. February, 1980. Prepared for Bureau of Foods, Food and Drug Administration, Department of Health, Education, and Welfare, Washington, D. C. , 20204.

4. Guthrie H. A., Guthrie G. M.: The Resurgence of Natural Child Feeding. Clin. Pediatr. 5:481-484, 1966.

5. Leo J.: Down With Motherhood. Time July 28, p. 78, 1980

6. Pittard W. B., Bill K.: Human Milk Banking. Clin. Pediatr. 20:31-33, 1981.

7. Jelliffe D. B.: Breast Milk and the World Protein Gap. Clin. Pediatr. 7: p. 96, 1968.

8. A Boycott Over Infant Formula. Business Week April 23, pp. 137-140, 1979.

9. Corporate Strategies. Business Week February 2, pp. 56-58, 1981.

10. Seib G. F.: How Two Mothers Took on Bureaucracy in Fight to Toughen Infant-Formula Rules. Wall Street Journal Friday, August 8, p. 13, 1980.

11. Robinson V.: The Story of Medicine. New York: New Home Library, 1943.

12. Talbot C. H.: Medicine in Medieval England. London: Osbourne Book Co. Ltd., 1967.

13. Schwab M. G.: The Rise and Fall of the Baby's Bottle. J. Hum Nutr. 1979, August; 33 (4): 276-282.

14. Fildes V.: The Elizabethan Wet Nurse. Nurs. Times, 1978, 16 Mar.: 74 (11): 472-473.

15. Prince J.: Infant Feeding Through the Ages. Midwives Chron. 89: (1067): 283285, Dec., 1976.

16. The Neonate: A Day in the Life of a Wet Nurse. Nurs. Mirror 1979, 11 Jan., 148 (2): XIV-XV.

17. Cone T. E., Jr.: History of American Pediatrics. Boston: Little Brown and Company, 1979.

18. Cone T. E., Jr.: 200 Years of Feeding Infants in America. Columbus, Ohio: Ross Laboratories, 1976.

19. Lowenberg M. E., Lucas B. L.: Feeding Families and Children-1776 to 1976. A Bicentennial Study. J. Am. Diet Assoc. March 76; 68 (3): 207-215.

20. Radbill S. X.: Medicine in 1776; Colonial and Revolutionary Medicine in Philadelphia. Trans. Stud. Coll. Physicians. Phila. 76; 44 (2): 1-8.

21. Phillips V.: Children in Early Victorian England: Infant Feeding in Literature and Society. J. Trop. Pediatr. 1978, August 24 (4): 158-166.

22. Keating J. M.: Cyclopaedia of the Diseases of Children Vol. I. Philadelphia: J. B. Lippincott, Co. 1890.

23. Leibowitz J. D.: Oriental Feeding Cups at the L.A. Mayer Memorial Institute for Islamic Art, Jerusalem. Bull. Cleve. Med. Library Assoc. 22 (3): 64-65, July, 1976.

24. Drake T. G. H.: Antiques of Pediatric Interest. J. Pediatr. 2: 68, 1933.

25. Hill L. W.: Infant Feeding: Historical and Current. Pediatr. Clin. N. Amer. 14:255, 1967.

26. Coit H. L.: Certified Milk: Arch. Pediatr. 14-824, 1897.

27. Holt L. E.: Observations upon the Capacity of the Stomach in Infancy. Trans. Amer. Pediatr. Soc. 2: 168, 1890.

28. Gerstenberger H. J. et al.: Studies in the Adaptation of an Artificial Food to Human Milk. Amer. J. Dis. Child. 10:249, 1915.

29. Editorial: Brit. Med. J. 1969, April 19 (5650) pp. 131-132.