A newly born infant should be put to the breast within a few hours, and afterwards at regular intervals. The quantity of nourishment at first may be small but it is sufficient for the purpose until nature increases the supply. The average amounts of breast milk at different periods of lactation have already been given. In any individual case one must judge by the size of the breasts, the ease with which milk is expressed, and more especially by the satisfaction or otherwise of the infant after a feed as to whether a sufficient amount of milk is present. If the infant fails to gain in weight, and is restless and dissatisfied after a meal, without showing definite signs of indigestion, one will naturally feel doubtful as to whether a sufficient amount of milk is present. The exact amount taken may be ascertained by weighing the infant before and after a feed. The best test as to the quantity at a meal is the infant's appetite, for under regular hours of feeding he will usually take as much as is good for him and no more. If he falls asleep while taking the breast he has had enough, and should not be roused to take more. If vomiting occurs soon after a meal he has probably taken too much. Some infants tend to drink the milk very quickly, a habit that must be checked by limiting the rate of outflow through the nipple. If an infant has been from ten to fifteen minutes at the breast, he should usually have obtained a sufficient quantity. The contents of one breast are usually sufficient for a meal, and the breasts should be used alternately. In the case of bottle-fed babies the amount at a feed must be fixed. Here what we have to fix is the maximum and not the minimum. The minimum amount to be taken is to be decided by the infant's appetite at each meal, which will prove the best guide. When a child has had enough it will usually stop and no coaxing should be employed to make it take more. The painful scenes in which an infant is worried to drink more, has the teat pushed repeatedly into its mouth, and finally in despair of securing rest in any other way, sucks down the surplus milk, should not be enacted in a well regulated nursery. It is especially in the case of sterilized or pasteurized milk, when the amount for each meal is supplied in separate bottles, that this evil prevails. Mothers get the idea that a fixed amount must go down at each meal, irrespective of age, size, strength, illness, hunger or thirst. We hold that there is more scientific accuracy in determining the minimum amount a baby should take in that baby's appetite than in any system of feeding which can be devised. Automatically the various influences referred to above, age, size, strength, and special requirements are brought into play in adjusting the appetite so as to meet the demands of the infant. The maximum amount at a feed must be fixed, not according to any general standard but according to the needs of the infant. The amount which different infants of the same age will take varies greatly. We begin with small amounts at first and gradually increase them as toleration is established. When a proper amount has been reached, which will be determined by having regard to the size of an infant's stomach, its age and weight, and when the infant is growing satisfactorily on this amount and is comfortable after a feed, it is advisable to regard this as a maximum. There is no doubt that many infants, under slight encouragement, will swallow down more food than the capacity of the stomach and the powers of the digestive organs will justify. In practice one will often find that this encouragement is but too readily given by the mother who believes in the feeding up process, and is ignorant of the bad results. It is better to be beforehand in preventing these results by fixing the maximum amount at a meal than to have to adopt a long course of curative treatment later. In the present day many babies find themselves classed among those who "cannot take cows' milk." This class is largely composed of those who have been overfed and have broken down under the process.

One must be able to state the approximate amount of food suitable for infants of different ages. In the following table are given the amount of food at a meal, and the proportion of milk and water in the mixture, the estimates being of an average character.

Amount at each

Meal.

Proportion of Milk and Water.

During 1st month.....

1-1 1/2 oz.

1-3

„ 2nd „ . .

2-3 „

1-2

„ 3rd „ . .

3-4 „

1-2

,. 4th „ . .

4-5 „

1-1

5th „ . .

4-5 „

2-1

6th „ . .

5-6 „

2-1

From 7th to 9th month

6-7 „

3-1

„ 9th to 12th „

8-9 „

All milk.

In the next table are given the total quantities of food material in twenty-four hours, with the proportion of each ingredient.

Quantities Of Food Material In Twenty-Four Hours

Milk.

Plain or Barley-water.

Gravity Cream.

Sugar or Malt Extract.

Oz.

Oz.

Oz.

Oz.

During 1st month

3-6

10-15

1/2-2

1/2-1

„ 2nd „ . .

6-8

12-16

2-2 1/2

1-1 1/4

„ 3rd „ . .

8-10

16-20

2-3

1-1 1/2

„ 4th „ . .

10-15

10-15

2-3

1-1 1/2

„ 5th „ . .

15-20

7-10

2-3

l

„ 6th „ . .

20-25

10-12

1-2

l

7th to 9th „ . .

25-30

8-10

1-2

l

9th to 12th „ . .

30-40

-

1-2

-

Necessarily these are but approximate estimates, but enough has been said above to show that other factors than age must be taken into account. A premature infant will require smaller and more dilute feeds than a full term child. Another point to be considered is the variation in the amount and quality of the food at different seasons. Less food is required during the hot months than in cold weather, as will be indicated also by the infant's appetite. Without reducing the amount of diluent, it will be found advisable in hot weather to reduce the amount of milk and cream, as given above.

It may be said that the amount of proteins in the milk feeds is steadily increased up to the ninth month by a diminution of the amount of diluent, and that in this respect nature's method is not followed. Chemical analysis shows that the proteins of breast milk do not increase in amount as the infant grows; it is only the amount of milk which becomes greater. This criticism may be admitted as correct. If from any reason breast-feeding were suddenly stopped at eight months, one would not put the infant at once on to milk diluted with one-third water. The food would probably be too strong, and a weaker dilution would be ordered. On the other hand when the infant has been fed from the early months with cows' milk of gradually increasing strength, the stomach becomes accustomed to it and digests the food. The difficulty is met by increased digestive action on the part of the stomach which can be carried out, as a rule, without any sign of distress. If the dilution of the early months were kept up, the total amount of fluid required would be in excess of an infant's requirements and would produce dilatation of the stomach.

Bottles And Bottle-Feeding

The dangers of the milk are frequently added to by those of the bottle. The old-fashioned flat bottle with long india-rubber tubing attached has now been reformed out of existence. It has been replaced by one of oval shape, with at least two openings, and with a rubber nipple attached at the end. While the cleaning is thus rendered easier it still requires a good deal of skilled attention. The question as to whether all feeding bottles may not be reformed out of existence can be answered in the affirmative. At Paddington Green Children's Hospital, and probably in other hospitals, no bottles are used but the infants are fed out of ordinary feeding cups with rubber teats attached to the end of the spout. The advantages of these over any form of bottle are very great. They can be cleaned with the greatest ease simply by running boiling water through them in a shorter time and with more thoroughness than any form of bottle. In order to allow of cleaning, there should not be a strainer in the neck of the cup. These feeders require, as is right, that the nurse should hold the cup and attend to the feeding throughout the meal. The nipples are of a larger size than were formerly used for feeding bottles. At first sight it might appear likely that some deformity of the mouth might follow from the use of these larger teats, but they really seem to reproduce more exactly nature's method, in which an infant's mouth is filled with the nipple and part of the breast. The rubber teat is removed after feeding, turned inside out, and cleaned in hot water; it is then kept in cold water until required again. The teats must not be kept too long in use as they soon begin to show small cracks. The feeding cups should be made of china, and not of any porcelain-lined metal, as the lining of the latter tends to chip off and leave an uneven surface which renders thorough cleaning impossible. By these means the risk of the milk becoming contaminated with organisms in the feeding apparatus is reduced to a minimum.

The Palatability Of The Milk Mixture

One desires to make the food palatable to an infant and as varied as possible. The addition of milk sugar or malt extract or cane sugar will usually give the sweet taste which is most appreciated. Some infants will take one of these flavouring agents more readily than either of the others, and this can be found out by actual trial. An infant will have a distinct preference for one flavouring, to which it has been accustomed, and show clearly if that flavouring is not present. It is not advisable to over-sweeten the milk at times or the less sweetened milk may be refused. Although custom has prescribed the use of warm milk for infants, there is no harm, especially in hot weather, in trying a feed of cold milk, and if the child prefers it in continuing the same. Naturally one will not try iced milk or milk just off the ice. Even with the sweetening added there must be a monotonous sameness about an infant's diet, and if any such flavouring as cinnamon water or dill water is liked, there is no harm in mixing a little of one or other of these with the milk. Barley-water as a drink will often be taken better if one of these flavouring waters is added. A slight variety in the diet may be secured by giving one or two cream feeds in the day in place of the ordinary milk mixture, as follows : Gravity cream, 1/2 oz.; malt extract, 1 drm.; barley-water, 2 1/2 oz. This also varies the work to be done by the stomach inasmuch as the fat digestion is here tested in place of the casein digestion of the ordinary mixture.