Milk procured and kept under favorable conditions will remain sweet for many days. The essential points in procuring a milk that is safe for infants are the following:

(a) Utmost cleanliness, asepsis and antisepsis about milking, stable, cows, udders, hands, pails, bottles, nipples, etc.

(b) Rapid cooling of the milk to a low point, and keeping it constantly on ice, thereby inhibiting the growth of bacteria.

(c) The interval between milking and final consumption should be the shortest possible.

(d) The cows should be healthy, and tuberculosis should be excluded by the tuberculin test.

Sterilization

If milk can be obtained that meets all of the above requirements, we commonly give it raw. If not, the question of sterilization arises. This can be either fairly complete by boiling for five minutes or longer, or partially by pasteurizing - i. e., heating the milk from 150° to 165° F. for twenty to thirty minutes. Boiling produces chemical changes, such as a partial coagulation of lactalbumin, conversion of some milk sugar into caramel, etc., and destroys ferments, and possibly other living properties, and so is thought by some to lessen the nutritive value of the milk. Pasteurization kills practically all pathogenic germs, and nearly all others, and does not bring about such chemical changes. The latter, therefore, seems the preferable method, but it is more complicated, and is less safe in other than intelligent hands. There is very little, if any, conclusive evidence that boiling the milk lessens or changes its nutritive value, except that in a very small percentage of cases scurvy will occur (see Infantile Scurvy). Even this is open to question, because in France, for example, practically all milk is boiled for a long time, and yet scurvy is almost unknown (Budin). In many cases boiling the milk seems to make it more easily digested. That it favors the production of rickets is hardly tenable. Until we are better convinced that sterilization is more injurious, and as long as we are taught that it is quite possible that a good deal of our tuberculosis is acquired through milk in infancy, it would seem a wise precaution to boil, or pasteurize, all milk that is not safe from that standpoint - i.e., from cows that have recently given negative tuberculin tests.

3. Growth And Development On Artificial Food

Under favorable conditions this may be in no way inferior to that of breast feeding. Usually, however, progress is less rapid and sure, and serious digestive and nutritional disturbances are more frequent. In many, serious difficulties are encountered throughout, especially during the first few months. Gain in weight is apt to be slower at first, and more rapid toward the end of the first year than on breast milk. Symptoms of rickets are more frequently present, and dentition is commonly delayed.

4. Feces

One must never expect to see the gold-yellow, mushy, slightly acid bowel movement of the breast-fed child. The movements are always less frequent - one, or at most two, a day; are harder and dryer, commonly "formed," alkaline in reaction, and of a paler yellow color, with a stronger, more cheesy odor. An acid odor with increased frequency is pathological. Carbohydrates, especially malt sugar, give the bowel movement a browner color. The bowel movement of fat-free milk is homogeneous, smooth, brownish, like hard vaselin. When other food is added late in the first year, the bowel movements approach in every way those of the adult.

5. Feeding During The Second Year

During the early part of the second year four feedings a day, later three, are a sufficient number with fruit juices before one or two of the meals. Milk should be given at each meal, not to exceed a quart a day, and often a less amount is preferable. The rest of the food may be made up during the first few months of rusk, zwieback, dry toast, vegetable soup and broth, well-cooked cereals, fruit juices, baked or scraped raw apple, an occasional soft-boiled or poached egg, well-cooked and mashed spinach, carrots, and cauliflower. From these a well-balanced diet may be chosen to suit the circumstances, all new additions being made very cautiously. Later in the second year scraped beef or finely divided rare roast beef, steak, lamb chop, or chicken, a little baked or mashed potatoes, a little of some of the heavier vegetables, such as peas, lima beans, head lettuce, asparagus tips, cornstarch pudding, custards, etc., may be added to the diet. Milk may be given from a cup, if it is well taken. This is frequently not the case, and there is no objection to the child's taking its bottle throughout the year, either directly before or after, or with the other food. He will commonly take more milk from a bottle and fall off to sleep better than if it is given from a cup.

6. Other Substitutes

"Baby Foods." - The very extensive use of these so-called "foods" warrants their brief discussion. For our purpose they may be divided into two classes:

I. Those that are advertised as complete foods in themselves and contain milk.

II. Those that are to be used only in conjunction with fresh milk, and are so advertised.

In the first class are the sweetened condensed milks, the malted milks, Nestle's food, etc. Condensed milk is milk evaporated to about one fourth of its volume with the addition of about forty per cent of cane sugar. In the others the milk is evaporated to dryness, and sugar and partially or completely dextrinized flours are added. In the malted milks the predominant carbohydrate is malt sugar; they are all deficient in fat and fresh animal proteids, and contain an excess of carbohydrates. Many infants apparently thrive on them alone for some time, but are always less immune and resistant to infections, and practically invariably, if fed on these alone for a long time, will show decided evidence of rickets, often of scurvy, and other nutritional disturbances.

In the second class belong such malted foods as Mellin's and Horlick's, that are composed chiefly of dextrins and maltose, especially the latter; the farinaceous foods, such as imperial granum, Ridge's food, Robinson's patent barley flour, etc., that are composed largely (about 75 per cent, Holt) of unchanged starch; Es-kay's albuminized food, made up largely of dextrins, dextrose, and lactose (67.81 per cent, Holt); and starch (21.21 per cent, Holt). They take the place of the simpler carbohydrates, barley, oatmeal, sugar, etc., over which they have few or no advantages. The malt preparations are useful when malt sugar is desired rather than milk sugar or cane sugar. The farinaceous preparations form a convenient transition either in the milk, or as a porridge, to the cereals. The chief objections to these "foods"are the price; the use of the word "food," that leads the uninformed to think of it as the important part of the mixture and not the milk; the questionable claim that they have some special virtues as milk modifiers; and the directions which go with them that assume that all babies of a certain age are alike, and that the mother (for they are advertised to the laity) and a printed page alone can meet one of the most complex problems in medicine.