The fat is the chief disturbing element in feeding cow's milk. So true is this that fat overfeeding and milk overfeeding are practically synonymous. Vomiting is peculiarly characteristic of overfeeding with too much or too rich milk. Indigestion with vomiting, diarrhea, green or slimy, or curdy, cheesy bowel movements, abdominal distention, and colic due to gas, discomfort and sleeplessness, result from overfeeding with cow's milk much as they do in overfeeding with breast milk, only more readily and disastrously. A very different symptom-complex is the rule, however, in overfeeding with cow's milk. Often the first thing that attracts attention to the child is the fact that it is gaining less rapidly than it did, or is even stationary, and in a baby this is equivalent to a loss in an adult. The food is naturally increased, with perhaps a brief gain, but soon with a greater loss. It will then be recalled that during this time the baby has been more restless, has slept more brokenly, and has cried more than usual. Changes in the bowel movements, too, have occurred that are diagnostic of overfeeding with cow's milk. They have become pale yellow instead of a rich yellow, often grayish, or even nearly white, are harder and dryer. In severe cases the bowel movements closely resemble dry putty in color and consistency and have a strong, cheesy, decomposed odor. The urine is commonly ammo-niacal and irritating. The child later gets pale and flabby, is less playful and active, will not smile. The abdomen becomes soft and somewhat distended with gas. The appetite is lost. Eczemas are brought out in susceptible babies. If the condition is not relieved, or even more milk is taken, there occurs finally either an acute intoxication (see Intoxication), or else the baby settles down into a chronic state of marasmus. In exceptional cases we have seen the gain in weight uninterrupted, even excessive, in spite of gross overfeeding, characteristic bowel movements, etc. That the condition is a fat overfeeding is shown by the fact that the bowel movements are composed largely of insoluble salts of fatty acids - i.e., soaps (soap-stool) - and by the fact that the symptoms are all increased if the milk is increased, and lessened if it is lowered. This disturbance in metabolism is probably an acidosis (Czerny and Keller), due to the withdrawal of alkalies from the body to unite with the fatty acids of the intestines.

The Treatment

The fat must be lessened and the carbohydrates increased to take its place, and the feeding interval must be a long one, preferably four hours. The fat is reduced by using less milk or by removing for a time, depending upon the severity of the condition, a part or all of the cream from the milk. The carbohydrate is increased by adding a gruel and a larger amount of sugar, preferably malt sugar, because it is tolerated in larger amounts, is more easily assimilated, is more fattening, and is more laxative than milk sugar. After some time a very gradual return to a well-balanced food is begun. This is often very difficult because of the continued intolerance for fat. If the difficulties are too great, it is often best, especially after the first half year, not to attempt to increase the fat. The carbohydrates apparently quite take the place of fat in many cases, especially in the latter part of the first year, and their tolerance is much higher. One of the best nourished babies I have seen had practically no milk fat in its food (centrifugal fat-free milk) for about fourteen out of sixteen months of its life. Such a course is adopted only if necessary, because human milk contains four per cent fat, but if it is necessary, the carbohydrates, and to some extent the proteins, can take the place of the fat to an extent that is not commonly appreciated.