II.—Present-day methods of infant feeding, including bottle feeding and weaning

PUBLIC HEALTH The symptoms suggesting deficiency are shown by a pale fretful baby, easily infected. Proof of this deficiency may be obtained by estimating the .amount of vitamin C present in the urine ; this may be verified by the administration of a large dose of the vitamin ; if it is lacking in the body it will be retained and will not be excreted in the urine. In nearly all infections, whether acute or chronic, there is a diminished excretion of vitamin C; an infected child needs more of this substance than a healthy child. Vitamin B 1" A deficiency of B 1 has been shown in the U.S.A. to cause impaired growth, constipation, gastric and intestinal stasis. Cows' milk is not a perfect food by any means for the human infant since as well as other deficiencies it is lacking in B v A partial deficiency of B1 is more common in pregnancy than is realised. It causes : Oedema, Tachycardia and breathlessness, Numbness and tingling in extremities, and Enlarged heart, all of which are also seen as early symptoms of beri-beri. Polyneuritis in man may arise from a conditioned deficiency of B x in any gastric or intestinal disorder preventing absorption, e.g., alcoholic neuritis. In this polyneuritis of nutritional origin, the excretion of vitamin B 1 in the urine sinks almost to zero. Vitamin B~ Complex. We have no knowledge of the need for this vitamin in human beings apart from its prevention of pellagra. This is important in the U.S.A. where there are about 7,000 deaths every year from pellagra. Malnutrition. In summing up the problem of a scientific diet, Professor Harris quoted that " the greatest single cause of malnutrition is poverty." He alluded to the incidence of nutritional anemia in 75 per cent. of infants in the London slums; to the 87 per cent. of mild rickets in the children in L C . C . schools. The health returns from ill-fed groups of the population compared with better-fed groups show a striking difference. Improvement in health can be obtained by improving the diet, as has been shown by many experiments the bestknown of which is that of Corry Mann. The difficulty in the assessment of malnutrition is a pity; the only accurate and sensitive tests are, unfortunately, too complicated for general use. A standard is needed, as we are apt to take the average as the normal. To sum up the matter briefly, one would say that the infant needed milk together with cod liver oil and fruit juice; that an expectant mother should be told to take one good body-building meal daily (meat, fish, eggs or cheese) with fruit and vegetables every day and whole-meal bread or a wheat-germ preparation. In conclusion, Professor Harris emphasised the importance of knowing the exact vitamin content of every preparation prescribed, and deprecated the empirical use of certain proprietary preparations, the exact composition of which was unknown. 12

OCTOBER II.--Present-day Methods of Infant Feeding, ineluding Bottle Feeding and W e a n i n g . Summary of Lecture by ALAN ~IONCRIEFF, M.D., F.R.C.P., (Physician, Children's Department, Middlesex Hospital). Dr. Moncrieff has had unusually good opportunities of studying the feeding of infants both at his own clinics, where he deals with normal infants, and in his hospital out-patient department, where he sees the results of the mistakes made in feeding. In a lecture of extreme interest he stressed the importance of a knowledge of elementary essential facts when prescribing an artificial food for a baby. He had come to the conclusion that it was simpler to work out the quantity of the food to be given in terms of ounces of breast milk rather than on a calorie basis. He gave the following thre6 fundamental principles : - (1) 1 oz. undiluted cow's milk = .1 oz. breast milk. 1½ teaspoonfuls sugar = 1 oz. breast milk. teaspoonful fat (not fat emulsion) = 1 oz. breast milk. (2) A baby at birth weighing about 7 lb. should receive ~½ ozs. breast milk or its equivalent per lb. body weight per day. (Smaller babies need more as the body surface is greater). A three months old baby weighing about 10 lb. should receive 9,¼ ozs. per lb. body weight per day. An eight months old baby weighing about 15 lb. should receive 2 ozs. per lb. body weight per day. In dealing with the underweight infant one should take a figure somewhere between the age of the child and the weight ; try a figure midway between these two and see what happens. (8) A normal baby should gain 4½ to 6 ozs. per week. When considering the artificial feeding of an infant, one has to choose between t. Liquid cow's milk. 2. Dried cow's milk. 3. Condensed milk. 1. Liquid milk if not efficiently pasteurised or boiled may be most dangerous, since milk is an excellent culture medium for bacteria. Dr. Moncrieff \vould recommend boiling of all milk used in this country for children under two years of age. He thinks it is safe to tell the mother actually to bring the milk to the boil. The advantages of boiling are that the milk is then safe, it is cooked and therefore more digestible, and the calcium and phosphorus are better absorbed. There are no disadvantages which cannot be got over by adding extra vitamins. Another great advantage of boiling in poor families is that one need not worry about the grading of the milk ; in fact, one might put forward the thesis that dead tubercle bacilli in the milk may be an advantage to the infant in immunising him against tuberculosis; this is a more scientific method of accomplishing immlmisation than the exceedingly dangerous one, still sometimes recommended, of administering live bacilli in the milk. One must remember that the high grades of milk are not always the best for the young infant, since their richness in fat makes them difficult to digest. In deciding what form of cow's milk to give an infant, provided that the home conditions are satisfactory, liquid milk with water and sugars added seems

1938 the best to choose. It is not a good plan from the economic point of view to dr9~ the milk first, since the cost of preparation makes the food a more expensive one than is necessary. When one comes to diluting the milk, one has to remember that the protein in cow's milk is mostIy casein. In boiled milk especially the baby tends to lose nearly all the lactalbumin which is in the skin on top of the milk. Casein is a second-rate protei n as far as the human baby is concerned, and it is, therefore, impossible to work out the protein on a percentage basis. It is rare that protein upsets an infant's digestion--what disagrees is the fat, which is much coarser than that in human milk and causes any latent fat intolerance on the part of the baby to become manifest at once. It is in these cases that the value of the half-cream dried milk is so great. The sugar added to the mixture need not be lactose-ordinary brown sugar does perfectly well. Dr. Moncrieff would feed an infant three-hourly for the first two or three months, since the larger feeds necessitated by four-hourly feeding may cause trouble. He gave examples of feeds as follows : - (i) Baby, one month old: 8 lb., six feeds daily. Assume takes 8½ ozs. at each feed. '2 ozs. cow's milk. 1½ ozs. water. 1½ to 2 teaspoonfuls sugar. Don't give the fat in the bottle, but give ¼ teaspoonful crude cod liver oil two or three times a day. Give this before the feed in case it makes the baby sick. One can regulate the calorie value by the amount of sugar ; a baby can take 8 or 9 teaspoonfuls daily. At one or two feeds in the day one can give 4 ozs. instead of 8½ and modify the sugar from feed to feed in the same way. (ii) Baby, three months' old : 10 lb., five feeds daily. 3 ozs. cow's milk. l½ ozs. water. 1½ teaspoonfuls sugar. Half a teaspoonful of cod liver oil three times a day in a spoon ; use a bone spoon for babies as the ordinary metal spoon may hurt their gums. 2. Dried milk. A. Full cream. B. Half cream. C. Humanised. The last variety makes the feeding easier for the mother, and is specially useful for complementary feeds. T h e half cream milks are very useful for the first two or three months of life, but one has to remember that they are less in calorie value than cow's milk, and sugar has to be added to prevent underfeeding. One measure full cream dried milk = 1 oz. cow's milk. One measure half cream dried milk = 4/5 ozs. cow's milk. Example : Baby one month old : 8 lb., six feeds. Three measures half cream dried cow's milk. 4 ozs. water. 1½ teaspoonfuls sugar. Even when one puts the baby on a full cream dried milk larger quantities can be given than in the case

PUBLIC HEALTH of liquid milk since the dried milk is cooked and more digestible. 8. Condensed milk has no advantage over dried milk apart from the fact that it makes a better emulsion. Dr. Moncrieff did not think that sodium citrate was needed for infants since the same effect was produced by boiling the milk, which rendered the curd more digestible. Sodium citrate has no effect upon the curd of boiled milk. Lactic acid milk is useful for premature and ill babies, but has no place in the feeding of the normal infant. H~m,,lac is useful in some cases. From one month onwards he would recommend the administration of orange juice in addition to the cod liver oil. He emphasised the importance of the latter and preferred the crude cod liver oil to the more refined substitutes. A year-old baby in winter needed 1½ teaspoonfuls daily as a prophylactic against rickets. He reminded his hearers that cod liver oil and malt as frequently prescribed was useless as a prophylactic against rickets. WEANING The modem tendency is to favour earlier mixed feeding as distinct from weaning, and this is probably a wise move. In animals, and also in savage tribes, one sees the same tendency to commence early in giving small mouthfuls of various foods while persisting with the breast feeding. At the age of six months at the latest the baby should have bone and vegetable broth at his mid-day meal, and by seven months this broth should have become gradually a thick vegetable pur~e, and should replace the mid-day breast feed altogether. Broth is the best food to commence with as the infant becomes accustomed to the taste of meat and vegetables for his dinner from an early age, and also obtains iron from this source. At the same time, porridge should be introduced at the 10 o'clock feed ; the danger of porridge to the teeth has been exaggerated, and if made with milk as it ought to be, it is safe. One cannot feed a family without giving cereals. Groats are unnecessary; a mother should not go to the chemist but to the grocer and buy the finest oatmeal available. She puts this through a sieve and cooks it with 7 ozs. milk. At the age of eight months a baby is having a breast feed when he awakes; at 10 o'clock he has porridge and fried breadcrumbs ; for his dinner broth and some baked apple; a cup of milk for tea with a crust and butter, and a final breast feed at night; the next substitute is orange-juice in the morning f~r the first feed. A little meat should be given directly the first tooth comes through (lamb or liver). Mashed banana is good in the evening sometimes. It is wise to be brave in new items into the diet as the psychological problems connected with weaning are rendered much less acute if mixed feeding is started early. It is possible, and indeed, desirable, for a baby of a year old to be sharing all the ordinary meals of the family without any specially prepared food. When whole cow's milk is givenmwhich it can easily be at about seven months--one finds that it is easier to digest if sugar is added to it. 13

PUBLIC

HEALTH

GCTOBER

Eggs are to be used with caution on account of fat (i) Local Government Superannuation (Transfer intolerance. Value) Regulations, 1988. (Price 8d. net.) Much of the defective development of the jaw, with (ii) Local Government Superannuation (Additional Contributory Payment) Regulations, 1988. the consequent overcrowding of the teeth in bottlefed babies, can be avoided by the use of a very large teat (Price 2d. net.) which the baby is unable to suck but has to milk in the (iii) Local Government Superannuation (Sum in lieu of transfer value) Regulations, 1988. (Price same way as the nipple. Such a teat is made by the Association of Maternity and Child Welfare Centres; ld. net.) (iv) Local Government Superannuation (Reckonone has to he prepared to replace these teats frequently ing of Service on Transfer) Regulations, 1938. as the baby chews through the rubber but the teeth subsequently erupted appear almost as regular and well(Price ld. net.) spaced as those of a breast fed infant. (v) Local Government Superannuation (Mental Hospital, etc., Employment) Regulations, 1988. With regard to the vitamin D administered, Dr. Moncrieff preferred cod liver oil to all substitutes; (Price 2d. net.) he would not give any substance that was unstandardised. Circular 1734 SLll. Price ld. net. By post 1½d. Cod liver oil should be continued until the child is Forwards copy of (~'0 above to Visiting Committees. two years old, after which the danger of rickets has Circular A.S.316. National Health lnsurance. Enquiry passed. into the continued increase of incapacitating illness of Dr. Moncrieff in answering questions as to the long duration. cooking of the bone and vegetable broth said that Memo. 317/X. National Health, Pensions, and Unemone hour's simmering was sufficient. It does not ployment Insurance. Employees of Medical and Dental matter what bones are used in its preparation, he Practitioners. would removethe fat by skimming as it was difficult Cmd. 5801. Price 5s. net. Nineteenth Annual Report for the infant to digest. of the Ministry of Health, 1987-88. P.S.R. & 0 of 1938 No. 775. Price ld. net. By post 1.~d. National Health Insurance (Dental Benefit) Amendment Regulations, 1988.

M I N I S T R Y OF H E A L T H P U B L I C A T I O N S

The subjoined notes regarding recent Ministry of Health circulars, memoranda and reports are made R E C E N T A P P O I N T M E N T S IN T H E available by courtesy of the Ministry. Readers are reminded that priced documents should be obtained PUBLIC H E A L T H SERVICE not from the Ministry but from H.M. Stationery Office, The following are some recent appointments in the Adastral tIouse, Kingsway, W.C.2, who will open deposit accounts and receive subscriptions for the public health departments of various local authorities. The Editor will be grateful if members of the Society regular supply of publications of a specialised nature. Documents which are not priced in the following list will notify him at once of any new appointments. are not available from the Stationery Office, and if Bexley M.B. : A.M.O.H., Dr. Mary Love. any reader wishes for a copy of one of these, it is open Board of Control: Commissioner, Dr. R. G. to him to apply to the Ministry direct. Anderson. Circular 1718 (encloses Form H16a). Local Financial Hampshire C.C. : A.C.M.O.H. and M.O.H. (FareStatistics, 1987-88. Requests Clerks to Rural District ham U.D.), Dr. A. R. Graham. Councils to forward a Return of Receipts and ExpendiLancashire C.C. : A.C.M.O.H., Dr. Alexander T. ture of the Council for the year ended March 31st, 1938. Elder (A.M.O.H., Dewsbury C.B.). Salary Circular 1720 (encloses Form H47 and Memo. H58). £800, rising by £50 to £1,000. Local Financial Statistics, 1987-38. Requests Town Rochester M.B. : A.M.O.H., Dr. Wm. Hall Clerks of Metropolitan Borough Councils to furnish an (A.S.M.O., Derbyshire C.C.). Epitome of the Accounts of the Council for the year Warminster and Westbury R.D. : M.O.H., Dr. ended March 31st, 1938. I. B. Lawrence, A.M.O.H., Wilts C.C. (late Circular 1727. Price ld. net. By post 1½d. Public M.O.H., Calne Boro'). (This corrects the note Health (Imported Food) Regulations, 1937. Notifying as to Dr. Lawrence's appointment given in our Port Health and certain Sanitary Authorities of the last number.) recognition of Official Certificates under the Public Health (Imported Food) Regulations, 1987, for meat and meat products from Chile and Norway. A SESSIONALMeeting of the Royal Sanitary Institute Circular 1732. Price ld. net. By post 1½d. Air Raid Precautions. Circular addressed to Clerks of County will be held in the Royal Pavilion, Brighton, on Friday, Councils and County Borough Councils on the Pro- October 21st, 1938, when discussions will take place on " School Exclusion in Infectious Disease," to be opened vision of Hospital Accommodation. Circular 1735 S/12. Price ld. net. By post 1½d. by Duncan Forbes, M.B.a.., M.D., B.SC., D.P.H. (M.O.H., Local Government Superannuation Act, 1937. Forwards Brighton), and on " The Repair of Working Class to local authorities copies of the undermentioned draft Dwelling Houses," to be opened by A. Howard Holt. Regulations made by the Minister under the Local The chair will be taken at 5 p.m. by Thomas Orr, M.D., B.SC. (Chairman of Council). Government Sup. Act 1937. 14