208 Journal of Obstetrics and Gynecology

On the Artificial Feeding of Small and Premature In fan t s.

THE artificial feeding of small and premature infants from birth, on diluted cow’s milk, presents many difficulties at the start owing to the small quantities they are able to take a t each feed, and the gastro-intestinal troubles which are liable to arise.

The former of these two difficulties is probably the harder to contend with, and it is on this ground that I am giving records of a few cases in which the difficulty was overcome.

A premature child from the 3rcl--’7th day of its existence is as a rule only able to take at each feed a quantity varying between 3ss-3i, which, if given two-hourly, works out a t from 3v-3~ of some diluted mixture per diem.

The tendency in the past has been to give such mixturcs as 1 part of milk to 3 parts water, with cream or lactose added, or some s ixi lar very dilute mixture. I have had the opportunity of feeding a small number of premature and small babies on stronger mixtures ( i .~ . , equal parts nf COW’B milk and water with cream, lactose and sodium citrate added), and as the results on the whole hare been satibfactory, and the quantity of food taken provides not only suffi- cient heat to keep the child in equililuriuni but also to allow of a gain in weight, as I will show later, I thought the figures might be of some little value. h child during the first months of its life requires a much larger

quantity of food in proportion to its weight than an adult; this being chiefly due to the fact that the surface of its body from which the chief heat loss takes place, is much larger in proportion to the whole body than in the adult.

Taking the heat values of the various food as

Protein . . . . . . . . . . . . 4 kilocalories C . . . . . . . . . . . . . . . . Fat 9 9 1

Carbohydrate . . . . . . . . . 4 > 7

the child requires 90 C. per kilogram * to keep it in equilibrium, whereas the adult only requires 40 C. per. kilogram of body weight. From these figures one can cdcnlate exactly how much food is

* This quantity is for a full-term child, and should be larger for a preinature child.

Wyatt : Feeding of Premature Infants 209

required to keep a child in equilibrium, and then to this must be added sufficient to allow for a daily increase in weight.

3i of cow's milk has a heat value of 28.4 C. mi of cream 3 9 J > .541 C. 3i of lactose 7 , ,, 14.20 C.

So if a child weighing 4.4 lba. (i.e., 2 kilograms) is taking 10 feeds ct clay containing in each

3ss milk nlx cream 3ss lactose

it mill be getting (1420+5~41+7.10) 10 C. per diem, which works out a t 267 C., a quantity well over the required amount and allowing of a good gain in weight; but if i t is fed on a mixture or 4 this strength i t ~ i l l be getting if anything i iu t suEcient to liecp it in equilibrium, and anyhow not enough to allow of any appreriable gain in weight.

The caqes tabulated have for the most part bccn those in which, owing t(i ronplctc or partial failure of breast swretion, artificial feecling has become necessary; and in sonic of tlieni weak solutions of milk, such as I in 4, have been tried with gradual loss of weight O P the child.

The principle worked upon is to g i w the child after the third day equal parts of cow's milk and water containing cream, lactose and sodium citrate.* The quantity giren varics ; 3i two-hourly is first tiied, and this is then gradually increased, hut in same caws it is not possible to get the child to take more than 3ixr-vi in each feed, and in such cases the feeds are increased by 3i-ii each day.

The preparation of the fceds is done in the following way:- Equal quantities of milk and water are taken, and to each 3i of the mixture, nls of rreain arid 3ss of lactose are added. The whole is put into Soxhlets bottles (each bottle containing su6cient for one feed) and they are put into the special boiler made f o r them. The water is brought t o the boil and then allowed to cool. When the water is just boiling the temperature of the milk is 190"F., and 20 minutes later varies between 150"--165"F. This method does not exactly comply with Pasteur's method of keeping the milk a t 160°F. for 20 minutes, but it is more easily carried out by the nurse, and the result is practically as good. The bottles are sealed with flat rubber discs, and when required, the disc is removed, sodium citrate

* Sir Alinroth Wright showed that this salt when added to cow's milk reacts with the calciuiii salts (necessaiy for coagulation), calcium citratc being fornied, and the resulting calcium caseinogenate formed between this salt, the caseinogen and rennin is in some way renderer1 more flocculent and approaching the ciirtl in human milk, than the ordinary solid clot formed in cow's milk.

21 0 Journal of Obstetrics and Gynzecology

added in proportion of gr. i to each ounce of milk, a teat placed on the neck of the bottle and the child fed straight from it.

Weight of child : -

CASE I. H.C. ; primipara; child born at the 36th week,

A t birth . . . . . . . . . . . . 5 lb. 32 OC.

3rd day . . . . . . . . . . . . 41b. 11 oz. 5th day . . . . . . . . . . . . 4 lb. 72 oz. 8th day . . . . . . . . . . . . 4 lb. 5: oz. 12th day . . . . . . . . . . . . 4Ib. 4 i o z . 15th day . . . . . . . . . . . . 4 lb. 9 oz. 18th day . . . . . . . . . . . . 5 lb. 1$ oz. 20th day . . . . . . . . . . . . 5 Ib. 5 oz.

The child was breast fed entirely until the 6th day, when the breast secretion became insu5cient. Each breast feed was then supple- mented with fss 1 in 4 (cow’s milk and water). By the 10th day the breast secretion had ceased, and although the quantity of the 1 in 4 mixture had been increased to 3i the child cnntinued io lose weight. On tho 10th day the child was put on 3iss of 1 in 2 mixture two- hourly, which was continued until the child left the Hospital.

CASE 11. A.C.; 2-para. Induction for contracted pelvis at the 38th week. Weight of child : -

At birth . . . . . . . . . . . . 5 lb. 4$ oz. 3rd day . . . . . . . . . . . . 4 lb. 132 oz. 5th day . . . . . . . . . . . . 4 lh. 133 oz.

11th day . . . . . . . . . . . . 41b. 11 OZ.

14th day . . . . . . . . . . . . 4 lb. 15 oz. 17th day . . . . . . . . . . . . 5Ib . 4 4 0 ~ . 19th day . . . . . . . . . . . . 5 lb. 6+ oz.

From the 1st to the 3rd day 3i-3ii of 1 in 6 mixture was given. As there was no secretion from the breast 3i of 1 in 4 mixture was given two-hourly till the 9th day, the child being occasionally sick after the feeds. From the 9th---12th day 3i of 1 in 3 mixture wag given two-hourly, and from the 12th--19th days f i s s of 1 in 2 mixture two-hourly. The child was never sick after it was put on the stronger mixture.

CASE III. G.H.; primipara. Induction fo r albuminuria a t the 35th week.

9th day . . . . . . . . . . . . 4 lb. 11 oz.

Weight of child :- At birth . . . . . . . . . . . . 41b. 9Zoz. 5th day . . . . . . . . . . . . 4 Ib. 3 oz. 8th day . . . . . . . . . . . . 4 lb. 4 0%.

11th day . . . . . . . . . . . . 4lb. 5$ oz. 14th day . . . . . . . . . . . . 4 lh. 6; cm. 18th day . . . . . . . . . . . . 4Ib. 1140~. 20th day . . . . . . . . . . . . 4 lb. 14; oz.

Wyatt : Feeding of Premature Infants 211

In this case there was no secretion from the breast, so the child was fed as follows :-

Hunlan milk from another woman. 1st and 2nd days, 3i %hourly. 3rd day . . . . . . 3ii 1 in 3 mixture "hourly.

5th day . . . . . . 3iv 1 in 2 mixture 2-hourly. 6th day . . . . . . 3vi 1 in 2 mixtiirc 2-hourly. 7th-9th day ... 3 i 1 in 2 mixture 2-hourly. 9th--15th day., . 3iss 1 in 2 mixture 2-hoiirly. 15th-20th day . 3ii 1 in 2 mixture 2-hourly.

4th day . . . . . . 3iv 1 in 3 mixture 2-hourly.

CASE IV. K.11. ; prinlipara. Premature labour at the 30th week. Weight of child : -

At birth . . . . . . . . . . . . 3 173. 0: oz. 3rd day . . . . . . . . . . . . 2 lh. 13 oz. 5th day . . . . . . . . . . . . 3 lb. 15 ox. 8th day . . . . . . . . . . . . 2 lb. 14 ox. 10th day . . . . . . . . . . . . 3 lb. 0 O Z .

13th day . . . . . . . . . . . . 3 Ib. 34 oz. 15th day . . . . . . . . . . . . . 3 Ib. & oz.

lst-3rd day 3i 1 in 8 whey and cream %hourly. The breasts commenced to secrete on the 3rd day, but there was not sufficient to feed the child entirely, so from 3rd-9th days it was given 3i 1 in 3 mixture alternately with both breasts; from 9th-15th days 3iss 1 in 2 mixture alternately with both breasts.

CASE v. A.B.; primipara. Full term. Weight of child:- At birth . . . . . . . . . . . . 6 lb. 52 OZ.

3rd day . . . . . . . . . . . . 51b. 13$ OZ.

8th day . . . . . . . . . . . . 5 11). 13$ oz. 11th day . . . . . . . . . . . . 5Ib. 14a OZ.

15th day . . . . . . . . . . . . 6 lb. 5 f o z . The child up to the 6th day was breast fcd, but then the secretion began to fail, so it was given 3iss 1 in 3 alternately with both breasts %hourly. By the 7th evening the breast secretion had ceased, so from 7-10 days 3iss 1 in 3 twa-hourly was given; 10th-15th days Si i 1 in 2 two-hourly was given.

CaSE VI. A.S.; 2-para. Premature labour at the 34th week. Weight of child : -

5th day . . . . . . . . . . . . 5 lb. 148 oz.

At birth . . . . . . . . . . . . 4 lb. 13;oz. 3rd day . . . . . . . . . . . . 4 lb. 6 OC.

5th day . . . . . . . . . . . . 4lb. 7: oz. 10th day . . . . . . . . . . . . 4lb. 11 oz. 12th day . . . . . . . . . . . . 41b. 124 oz 14th day . . . . . . . . . . . . 4 lb. 152 oz.

212 Journal of Obstetrics and Gynxxxdogy

1st day . . . . . . . . .

3rd day . . . . . . . . .

5th day . . . . . . . . .

9th and 10th clays ... Ilth-l.4th days ...

2nd day . . . . . . . . .

There was no breast secretion. 4th day . . . . . . . . .

6th and 7th days ... 8th day . . . . . . . . .

3i 1 in 6 3i 1 in 4 3ii 1 in 4

3iv 1 in 2 3vi 1 in 2 3i 1 in 2 3x 1 in 2 3iss 1 in 2 3ii 1 in 2

3-hourly. 2-hourly. 2-hourly.

2-hourly. 2-hourly. 2-hourly. 2-hourly. 2-hourly . 2-hourly.

CASE VII. K.Y. ; primipara. Casareaa section for contracted pelvis. Weight of child :-

At birth . . . . . . . . . . . . 6 lb. 12 OZ.

3rd day . . . . . . . . . . . . 6 Ib. 5 02;.

5th day . . . . . . . . . . . . 6 lb. 9 OZ.

8th dag . . . . . . . . . . . . 7 lb. 13 O Z .

14th clay . . . . . . . . . . . . 7 Ib. 7 O Z .

21st day . . . . . . . . . . . . 8 lb. 3 O Z .

28th day . . . . . . . . . . . . 8 lb. 9 oz. I n this case there was no breast secretion, so the child was fed on the 1 in 2 mixture from the 3rd day. It dar ted with 3i %hourly, and was gradually worked up, so that by the time it left the ITospital it was taking 3iii 2-hourly.

CASE VIII. R.G.; primipara. Premature labour a t the 36th week. Weight of child : -

At birth . . . . . . . . . . . . 5 lb. 2; 01;.

3rd day . . . . . . . . . . . . 41b. 142 oz,

10th day . . . . . . . . . . . . 4 Ib. 169 oz.

5th clay . . . . . . . . . . . 4 lb. 124 oz. 8th day . . . . . . . . . . . . 4 Ib. 13 O Z .

14th day . . . . . . . . . . . . 5 Ib. 6 O Z .

The baby was breast fed until the 6th day, but on the 5th day the motions became green and watery and the child was sick after every feed. It was given Hyd. c Cret. gr. 8 , followed in two hours by 01. Ricini and 01. olivae aii ~ S S , and the next day Sod. Salicyl. gr. i Aq. ad. 3i t.d.s. to t ry and improve the intestinal trouble. The milk was found to contain 2 per cent. fat. But the child did not improve, so it was entirely taken off the breast fo r a time and was given 3i 1 in 2 two-hourly, the breast secretion being exhausted and thrown away. On the 8th day the sickness had nearly ceased and the stools were much improved, so it was placed on alternate feeds of breast milk and 3i of 1 in 2 two-hourly. This treatment was carried out till the 14th day, when the child was put back entirely on the breast, there being no longer any sickness and the motions being normal.