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BUFFALO MEDICAL JOURNAL

Yearly Volume 74

NOVEMBER, 1918

ORIGINAL ARTICLES

Number 4

The right is reserved to decline papers not dealing with practical medical and surgical subjects, and such as might offend or fail to interest readers. Contributors are solely responsible for opinions, methods of expression and revision of proof.

Dietetic Malnutrition in Infants and Its Treatment.

FRANK BRUNDAGE, M. D., Asst. Pediatrist,

University of Buffalo.

In presenting for your consideration the subject of malnutrition I do not wish to disappoint your expectations for something new, either in regard to the diagnosis or treatment of the condition but rather to emphasize some important truths.

The recent contributions to our knowledge of this subject, particularly those of Finklestein and Meyer, have made a new classification of the disorders of digestion and malnutrition as described by the name of decomposition; but for the present, the term malnutrition will answer our purpose. Its occurrence is so common and its treatment so varied that a momentary review of the subject will, I hope, be productive of some good. Malnutrition is a secondary condition and not a disease, the degree of severity depending upon its cause and duration. It is characterized by a stationary or decreasing weight, a sensitive digestion, more or less anemia and an unbalanced nervous system. It occurs in both breast and bottle infants; in the former usually mild in degree but the latter running a more severe course. The primary causes are many, foremost among them being lues, tuberculosis, infectious diseases, and digestive disorders of the severe type. Of infantile malnutrition due to specific diseases it is not my intention to speak of at present but only of the malnutrition due entirely to faulty diet.

Owing to the prolonged use of proprietary foods or the unskilled use of cow's milk, by far the greater number of cases occur in the bottle fed. In the breast fed, malnutrition

occurs in about half as many cases as in the bottle fed and is here due to a diminished quantity or quality of breast milk or a disproportion of its constituents. The matter of environment, too, is often a contributary factor yet in some of the worst cases, the environment may be all that could be desired but the degree of malnutrition is severe-due entirely to diet. Further, the food may be good but its preparation bad; the quantity may be sufficiently scientific and the intervals badly judged. It is clear therefore that this malnutrition may be the result of bad quantity of milk, either a deficient or over great quantity, bad timing of feeding or ignorant methods of food preparation; or a combination of these factors. And the perplexing question is always, which of these causes or combinations has produced this condition, and again if the result of one factor, what particular element in its make up is to be suspected.

Out of 200 babies registered at one of our milk stations, 17 we classed as suffering from malnutrition, 11 of these being bottle fed and six breast fed. This includes only those cases due to dietary causes. No special food was at fault, condensed milk and Horlick's however were the worst offenders. Mellin's and Eskay's were noticeably absent, due to the fact that these are generally used with cow's milk. Cow's milk had been tried in most cases but the method and strength had been out of all proportion to the digestibility of the child; consequently the food was unsuccessful. We cannot emphasize this too strongly. Where there is a failure charged to cow's milk, the suspicion must be strong that its strength was at fault.

Heretofore we considered that the top milk method was the last word in the feeding of babies, but this is now a thing of the past and only used in special cases. Today we are convinced that simplicity is the key note; therefore the reason for giving the proprietary foods, that their preparation was easy, is no longer a justification for either use. We must admit, however, that there are many cases fed successfully on the proprietary mixtures and at times are valuable as a temporary food, but I have yet to see a dissatisfied mother after her babe has been changed to cow's milk.

There are three gradations of this condition of dietary malnutrition which I will divide clinically for the sake of clearness. First class, mild malnutrition in the breast fed. The weight is about two pounds under the average; the muscles are somewhat flabby; there is mild anemia; the child is restless and irritable. It usually occurs at three periods; at two months of age when the mother has tried to nurse and is unsuccessful, at six months of age when the breast supply naturally begins to diminish in quality and quantity and at

the 14th or 15th month when the nursing is prolonged. Many of these cases develop the early symptoms of rickets, and we should constantly be on the watch. In 15 cases of rickets entered at one of our milk stations 7 were in the breast fed, due to nervous stations well predominating. The early stages of rickets in all of these cases occurred within the above periods. Therefore, it is important that we should keep this fact in mind.

Example of breast fed malnutrition. Chas Bell, weight at birth 7 pounds and 8 ounces. Admitted to the milk station

at ten weeks of age, weight 7 pounds and 14 ounces. Mother complained that the child cried constantly, was never satisfied and wanted to nurse continually. The stools were green and there was occasionally vomiting. We gave cow's milk, starting with one ounce of milk and 3 ounces of water, with the addition of one-half teaspoonful cane sugar. In two weeks the food was increased to two and one-half of milk and the same of water, with one teaspoonful sugar to each feeding. The vomiting ceased, the stools became better and we had a contented baby. At the present time the baby has gained on an average of 8 ounces each week. If this mother had given a proprietary food the result might have been disastrous. These cases tolerate milk well because there has been no great damage to the digestive system.

The second class is the moderate degree of malnutrition in the bottle fed. These babies have been fed on one or two foods for a considerable length of time, usually months. The first food not producing a satisfactory weight another is tried. with the same result. The foods are ordinarily well digested and the child is fairly comfortable, yet the weight is stationary or the gain is very slight. The addition of cow's milk to the dietary of these cases is all that is necessary to get the desired result. But we must again urge the caution that all amounts be at the beginning conservative and increased as the toleration indicates. A baby moderately hungry for a day or two is far better off than one almost killed by kind

ness.

The third class is characterized by a constant loss of weight, anemia, flabby muscles, vomiting or diarrhoea and constant crying. Many of these cases are either luetic or tubercular but give no definite symptoms or positive reactions. These are the cases more annoying and vexing to the physician than many a contagious disease. Some do not thrive on any food but become anaemic.

Example-Baby Ford, admitted to the milk station at two months of age, weight 5 pounds and 6 ounces. The weight at birth was seven pounds. All kinds of foods had been tried.

Cow's milk was given at one month of age, half milk and half water, six ounces in all. We could not expect this strength and quality to be successful considering the digestibility of the child. It vomited the milk and had green stools, so another food was tried. There was no clinical evidence of lues, Wassermann was refused, VonPirquet was negative. Scurvy was suggested because of the apparent pain in handling the baby, especially when the diapers were changed. The treatment consisted in giving skim milk, boiled and peptonized. Later the cream was added and the peptonizing was omitted. Cane sugar was used in one-half teaspoonful to each bottle.. Curds would appear in the stools and the baby showed symptoms of being distressed. The cream was removed and there was a cessation of the symptoms. When the cane sugar was increased the stools became more frequent. Dextromaltose was given in place of cane sugar but was immediately vomited. 2% cane sugar solution was then added for the regular diluent. The cereal gruels either plain or dextrinized were not tolerated, water being the most satisfactory diluent. It must be remembered, however, that in many of these cases the gruels are of great benefit and should always be tried in a slow growing infant. One teaspoonful of beef juice was given in every bottle and one teaspoonful orange juice given three times daily. This baby weighs now 12 and one-half pounds, a gain of one pound a month, in spite of its many upsets and diet of skim milk which was given probably half of the time. It evidently had an intolerance to fats as well as sugars. This is a type of case which is far too common and the treatment is discouraging but with a careful study of the child's tolerance, the final outcome is usually successful. I could cite many other cases of this class where the gain was more rapid and the treatment more satisfactory.

The treatment of malnutrition is dietary and general.. Breast feeding should always be encouraged and every effort made to maintain it where there is normal growth. When the breast is not satisfactory, one should not be too conservative in putting infants on the bottle. When breast milk is good, it is better than good artificial feeding, but good artificial feeding is always better than poor breast milk. We now believe that longer intervals in the breast fed are conducive to better health. Most breast cases do better on 3 or 4 hour intervals when previously we advised 2 or 3 hour intervals. I am not satisfied about the efficacy of these intervals in the bottle fed. When commencing on cow's milk, it is well to give a cathartic, a bowel wash and a 12 hour hunger diet. of saccharin tea solution. We have recognized recently that too long a starvation period is actually injurious to the child. In the mild cases it may only be necessary to add cow's milk