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Additional Feeding.
For the infants taken out of the incubators additional feeding was necessary; since ou supply of wet nurses was limited these babies had to thrive on mixed feeding. During the service of my predecessor certain proprietary foods had been given, for which he had been criticised, probably unjustly so, since the basis of his feeding was cows' milk. I determined at once to discontinue the use of proprietary foods for reasons well known to pediatrists. Only cows' milk, properly modified, was used. Walker-Gordon modifications were rejected for the simple reason that these mixtures are twenty-four hours old before delivery. Old milk can hardly be found satisfactory with these feeble infants. Hence, I decided on a home modification of the cleanest, freshest milk that could be obtained. Milk was finally obtained from the Walker-Gordon Laboratory. The unchanged milk was sent out to the Incubators by a special messenger. Milk that was drawn the night before reached us about noon; it was, of course, kept cold until delivered. It was allowed to stand on ice for three hours and the lower half removed in the usual way. The top milk was used diluted with whey made from the lower half. In other words, the babies were fed on a whey and milk mixture, as has been advocated by Rotch and Morse in this country, and Monti and others in Europe. The mixtures were usually Pasteurized. Several times we had vomiting and occasionally diarrhea from these mixtures, but in all cases it could be referred to a high bacterial contamination of the milk. During the hot months, especially in times of hot weather and low barometer, the rapid change of milk is too well known to need especial study here.
The following formulae give the directions for mixing and the approximate composition of some of these mixtures. Subjoined is also found the approximate calculated caloric value of the food, on which the quantity of feeding was based. [See Figures]
It would be superfluous to give additional formulae. Altogether we had nine such mixtures, but those given were used mostly. In calculating the composition, the proteids are regarded in the strength of 3.6 per cent, while the fat (one half of all the milk) was computed as 7 per cent. In two mixtures (7 and 8) we employed top milk containing one-third of the whole and which we calculated the fat as 10 per cent in the mixture. The caloric value was calculated from the ordinary rule that one gram of proteid or sugar yields 4.1 large calories, and that each gram of fat gives 9.3 calories.
In feeding these older babies we were again guided by the energy quotient, which, of course, had to be controlled by the digestive power of the infant. It is very difficult to maintain a constant energy quotient when the change is made from human milk (calories, 21 to each ounce) to a milk mixture with only about one-half its caloric strength. It was no wonder, therefore, that most infants lost in weight when this change was made, even though the food was digested perfectly.
While the whey and milk modifications were satisfactory as a food for the older infants, especially when supplemented by one or two breast feedings, it is difficult to understand how such a mixture could be preferred to human milk. To give the infant a proper caloric strength in such dilute foods necessitates the administration of large quantities. I imagine it would be very hard to give a ten-days old baby an energy quotient of 100 in a formula like No. 1.
The Caloric Needs of the Premature Infant.
Heubner has laid down the rule that the food of the infant should have an energy quotient of 100 calories. A quotient of energy which is less than 70 calories is insufficient to sustain the needs of the normal infant. Artificially-fed babies require an alimentation whose energy quotient is 120 calories. Schlossman believes that a higher energy quotient (110 calories) is necessary. [The energy quotient signifies the number of calories in the food given to each kilogram of the infant's weight.]
The subject is comprehensively discussed in an article by J. L. Morse (American Journal Medical Sciences, March, 1904) to which I must refer for more extended reference to the literature.
While it may be admitted that the figures of Heubner are rather too high for large infants, for premature infants their value must stand, since it is a well-known law that the small bodies lose proportionately more heat than large ones. It has, therefore, been assumed that premature infants require more calories per kilo than those born at term. The cases of Beuthner and Schlossman leave the matter still in doubt, although they found a higher energy quotient necessary (113, 119). Morse from his interesting study also reaches the conclusion that the caloric need of premature infants is relatively greater than that of full-term infants.
A further corroboration of this need is found in the very successful method of feeding adopted by Budin, who, calculating on even a low basis of calories in human milk, uses an energy quotient of 120 to 130 calories in alimentation.
I offer this additional evidence of the caloric needs of the premature infant. While I recognize that, as the milk of wet nurses was not analyzed quantitatively, and an average composition was assumed, these figures are by no means absolutely correct. Yet, it is the method usually adopted to calculate the caloric needs. Morse is certainly rather severe in criticising results based on this estimate, when he states that figures based on such an average caloric value per liter of milk can not be of great value. It would be an almost impossible task to analyze each separate food supply of the infant, since it is known that the milk varies in composition on different days and even on different periods of the day. Then it would make a marked difference whether the infant obtained its milk when the breast was overfilled or nearly empty. It will be seen, therefore, that nearly all calculations in regard to the need of the energy quotient when human milk is used must be based on an average caloric value.
We had five wet nurses who furnished the milk, and their milk was emptied into a bottle whence it was fed to the babies. It was often mixed, that is to say, one baby would receive milk from more than one wet nurse on the same day. I feel, therefore, that we are perfectly justified in using an average composition in making calculations.
Then, again, the present purpose is not so much to establish a maximum or minimum line, but to find a practical average which can be used by physicians in the feeding of premature infants. The rule has already been given in the previous section, it remains now to study the individual cases and see if the proper needs have been formulated in the rules for feeding.
It took some little time after I took charge to get the daily weights and quantities sufficiently exact, so that the figures given are the results after September 18th.
In analyzing the record of the food and weight of John Henry (Table 16) several interesting facts may be noticed. In the first place, trying to increase the milk in the first two weeks as rapidly as Budin directs, a severe attack of indigestion was induced. On the fourteenth day with the alimentation having an energy quotient of 120 calories, about what his rule of feeding would give, our patient had frequent green stools showing undigested food. Moreover, he had several attacks of cyanosis and subnormal temperature. On the seventeenth day the food had to be decreased and an additional supply of water given. The dyspeptic symptoms disappeared in about ten days, and he began to have a good daily gain on a quotient energy of about 75 calories. It will be observed that during the ten days (27th to 37th day of life) he gained 162 grams, or an average of 16 grams a day. This record rather supports the assertion of Czerny and Keller (Des Kinder Ernahrung, page 385) that some infants gain 15 grams daily on an energy quotient of 70 calories. During another period (46th to 56th day of life), with an energy quotient of 130 calories, he gained only 112 grams, or an average of 11 grams daily. Of course, the first period was immediately after a period of indigestion and loss in weight; the gain may be probably accounted for by a storing of water. Another period when the quotient energy was near 100 calories (35th to 45th day) gave a daily gain of 18 grams. A much higher quotient energy gave no higher gain. Even later, when on account of supplying his hunger, or putting him to the breast he took a still larger quantity of milk his gain was no greater. Table 17 gives a brief resumé of his subsequent history.
In the case of Bernice (Table 18, Chart 8) I feel sure that our method of feeding was rather too cautious at the beginning. In her case the method of feeding based on the energy quotient had not as yet been adopted. Notice the sharp rise in weight on September 22nd, when the energy quotient on the previous day was near 100 calories. She certainly corroborated the view of Heubner that an infant can not gain on an energy quotient of 70 calories or less. The first good gains are reached when the energy quotient is over 80 calories. During the period of October 11th to 21st (energy quotient near 90 calories) she gained an average of 6 grams daily. During the period of October 22nd to November 1st, with an energy quotient of about 110 calories, she gained 8 grams daily. On the following period of ten days the average gain was 29 grams daily, with an energy quotient of nearly 115 calories.
In the case of Pearl (Table 19) the alimentation had to be reduced on the fifteenth day as dyspeptic symptoms appeared. From the fifteenth to the twenty-fifth day with an energy quotient near 100 calories the average daily gain was about 15 grams. Following this period the food quality was relatively less and the gain in weight was correspondingly less.
Omega (Table 20 - Chart 9) was a large baby and we should expect a larger gain on the same energy quotient, but as a matter of fact we find no great difference. The first period of ten days (15th to 25th day) with an energy quotient of 10 to 130 calories the average daily gain was only about 15 grams. On the following ten days, with a lessened food supply, the gain was about 4 grams daily. This was caused also by slight indigestion superinduced by excessive feeding (17th to 24th day). It only emphasizes the fact that it is dangerous to give an alimentation that exceeds an energy quotient of 120 calories during the first few weeks.
The rapid increase in the food in the case of Margaret (Table 21) did not succeed in producing a rapid gain. Time must always be allowed for the weak digestive apparatus to adapt itself even to mother's milk. She did not stay with us long enough to determine digestive power as the Institute closed and she was sent home in good condition.
The history of St. Louis (Table 22) is exceedingly instructive. By the rapid increase of the food to an energy quotient of 100 calories on the sixth day the initial loss in weight was checked, but an indigestion followed which was treated by a reduction in food, and for twenty days there was no gain in weight. On the twenty-seventh day there was a great improvement in stools and the food was increased to an energy quotient of 100 calories. But pushing the food beyond that again brought on greenish stools. On the forty-first day the infant had not yet regained its original weight, and the stools having improved a forced alimentation was tried, gavage being used at times. Mother's milk was given in increasing quantities so that its energy quotient on the fifty-fourth day reached 195 calories. Probably this was overfeeding -- yet the infant gradually became accustomed to this food and on the following twelve days (48th to 60th day) gained on an average of 19 grams daily. On the following ten days (not shown in the table) he gained 10 grams daily on an energy quotient of 130 calories. His history will be more specifically discussed under "Indigestion."
Annie (Chart 11) illustrates the gradual increase of food, and how the loss in weight is checked when an energy quotient of 70 calories is reached. She gained nicely on an alimentation having an energy quotient of 95 to 100 calories. Chart 12 shows how a larger increase of food does not increase the gain in weight but slightly. An energy quotient of 150 calories was too large. She gained very rapidly (30 grams daily) on a food having an energy quotient of 120 to 130 calories (58th to 64th day). She was a large baby to begin with and her growth was uninterrupted.
Charts 13, 14 and 15 (Leonora, Mag. and Donald) illustrate the growth on mixed feeding. These were graduates, and the curves show their food and weight during certain periods of their life. Again, we notice that an energy quotient of about 120 to 130 calories is most satisfactory. Higher quantities give rise to indigestion. When the energy quotient is the same, and digestion is perfect it is impossible to draw any distinction between modified cows' milk and human milk in these older babies.
1. The use of the energy quotient as a basis of infant feeding is entirely practicable.
2. An energy quotient of 70 calories should be considered the minimum for maintaining the metabolic equilibrium. In many cases a steady growth may be obtained on this alimentation.
3. Most premature infants require human milk having an energy quotient of 100 to 120 calories in order to insure a steady gain in weight.
4. Quantities of human milk having an energy quotient of more than 135 calories should only exceptionally be given, as this favors indigestion and subsequent loss in weight.
5. In older infants there is little difference in growth when human or bovine milk is used, provided the digestion is perfect and the energy quotient the same.
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Formulas I, III, and V. |
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Table 16. |
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Table 17. |
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Table 18. |
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Chart 8. |
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Table 19. |
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Table 20. |
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Chart 9. |
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Table 21. |
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Chart 10. |
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Table 22. |
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Chart 11. |
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Chart 12. |
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Chart 13. |
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Chart 14. |
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Chart 15. |
