Fischer says that with many mothers and nurses the indiscriminate drugging of children to move the bowels is a daily routine. This practice is so common that it is rare to hear of infants or children who function normally. Drugs and correctives are used without rhyme or reason.
The giving of a daily laxative will in time result in a great diminution of bowel movements that are produced by coarse food regularly fed. And the daily use of the warm soap-water enema should also be condemned. While the enema will produce an evacuation, the warm water relaxes the intestines and, if persisted in, will produce a lack of tone in the intestines with a tendency to prolapse, (fall). The proper temperature of such enemas is 60° to 70° and not more than a pint in quantity, usually half a pint at bedtime or about half an hour before the second morning feeding. The cold enema has a stimulating and tonic effect and does not produce any harmful result.
The habit of adding correctives to the infant’s milk daily should be condemned. When large masses of tough, rubbery curd pass through the intestine undigested, due to excess of protein feeding, boiling the milk will soften the curd, and frequently modify the constipation. The condition caused by fat indigestion, known as a calcium-soap stool, results from the formation of fatty acids in the stomach and intestines. In such cases the food must be modified and not calomel and purgatives administered. When the food agrees and there is neither colic nor vomiting, but a gain in weight, the better plan is to continue the formula and if constipation exists add an ounce of buttermilk whey to each feeding. This is made by boiling the buttermilk and straining out the curd. One dram (eighth of an ounce, a teaspoonful) of the malted foods (that can be bought, for instance, malted milk) or a dram of malt soup will modify the constipation.
The importance of water is not sufficiently emphasized. Neither boiled or pasteurized water should be used but pure, filtered, cool water. Invariably when mothers are questioned they admit giving boiled water to their infants. Boiled water is right when traveling or when the purity of the water is in question. Fresh, cool water will aid in eliminating food residue when given between meals, which should be done several times a day. Water added to the food is not sufficient. If refused it can be rendered more palatable by the addition of fruit juices, such as orange, prune or pineapple. Prune juice and spinach juice should also be given for their vitamin content, their anti-scorbutic properties (scurvy, see chapter on Vitamins) and their laxative tendency. Diluents (diluted foods) such as oat-meal, barley water and other starchy gruels, while nutritious and valuable in modifying casein and fat of a given formula, have not been successful in modifying constipation. Their value consists in adding more protein to the food although flatulence and belching usually result.
In the older child the mechanical stimulus to the intestine can be given to food by the addition of bran to cereals or by the use of figs, raisins, whole wheat bread (not fresh) and the coarse cereals such as oatmeal.
Buttermilk or fermented milk can be used to thin the gruel. To sweeten the food, as well as for the food value granulated sugar or malted sugar (dextri-maltose) or malt soup i should be added to the milk. Vegetables such as chopped spinach or chopped string beans, and the green vegetables (rather than the starchy cereals such as potato) should be given. Crackers, wheat bread, biscuit, potato and macaroni are the foods which should rarely be fed unless mixed with a laxative diet. Deficient peristalsis can be stimulated also in older children by colon massage, gymnastics or calisthenics (house muscular exercise). In some instances gentle faradization (Faradic battery, alternating current) applied every other day will aid in stimulating internal functions and promoting peristalsis, (bowel movement).
In subnormal nutrition where rachitic atony of the intestine exists (lack of strength and tone with symptoms of ricketssoftening of the bones, malnutrition, enlargement of the liver and spleen, profuse sweating, great tenderness), there is no drug that will aid nutrition and modify constipation better than cod-liver oil. It must be given pure. To an infant six months of age 3 drops may be added to milk three times a day and the dose increased until 10 drops are given three times a day regardless of the season. It is an anti-scorbutic (useful in scurvy) in summer as well as winter .3
Oil injections can be utilized by means of a glass syringe with a rubber tip attached. One half ounce of oil injected into the rectum or allowed to flow into the colon, will soften feces and in some instances promote nutrition. If left in the colon over night some of the oil will be absorbed. Oil injections should not be used oftener than every second night.
The well-known results of thyroid therapy (utilization of the dried extract of the thyroid gland) in sporadic cretinism (imperfect mental and physical development) and the specific action of the thyroid on the constipation accompanying this disease, needs no emphasis. The administration of 1/4 grain of thyroid’. three times a day, gradually increased until 1 grain is given three times a day has acted beneficially in quite a number of cases. Pituitrin is used for the same purpose. In obstinate cases 2 to 5 minims (drops) may be given hypodermically (under the skin by puncture) and repeated once in 24 hours. Some few cases respond. Interference with normal gland activity and forcing bowel movements continually for months and sometimes for years will lead to intestinal atony (weakness). We must distinguish between acute conditions with fever, in which there is lessened functional activity of the intestinal mucosa (mucus membrane) and the condition of deficient glandular secretion wherein medical assistance is required.
The same author says in his Diseases of Infancy and Childhood that casein (the chief protein constituent of milk and occurring nowhere else), can be fed to very sick infants and will be assimilated in either small or large doses. It stimulates alkaline secretion hence is antagonistic to acid fermentation. Casein is therefore indicated to combat diarrhea. This teaching based on experimental feeding reverses our former theories on the danger of giving large percentages of such protein. This form of food, recommended by Finkelstein, has gained a strong foothold in many clinics abroad. He has used it success-fully in cases of intestinal disturbance, enteritis (associated with dyspepsia), atrophy associated with decomposition, and cholera infantum (summer complaint). Fever, if present, does not contra-indicate the use of this food. It has a low sugar and low salt content, and is prepared as follows:
Heat 1 quart of milk to 100° F. Add 4 teaspoonfuls of the essence of pepsin and stir. Let the mixture stand at about 1000 F. until the curd has formed (about half an hour). Filter the whey from the curd through a linen cloth and discard the whey (a thin fluid). The curd is then removed from the cloth and pressed through a fine sieve by means of a paddle or spoon. Add 1 pint of water during this process. The fluid should now look like milk and the precipitate must be finely divided. To this mixture 1 pint of buttermilk is added. The composition is now
Protein (casein) 3 per cent Fats 2.5 per cent Sugar 1.5 per cent Food Salts 0.5 per cent Water 95.2 per cent
Casein milk should be given in small quantities of 2 to 4 ounces in catarrhal diarrhea, 6 to 8 ounces in wasting, (atrophy), every 3 or 4 hours, depending on the age of the infant.’
Sugar should not be added until the stools are homogenous (uniform). Either malt or cane sugar can be used. This method of feeding should be continued for months, always used as a corrective for gastro-intestinal (stomach-intestinal) disturbance. It should be used as a substitute diet if the artificial diet in use disagrees or deranges the digestive tract .2
Hess 3 in making a comparison between cow’s milk and human milk says that while cow’s milk may be modified to approximate woman’s milk in composition it can never be just the same or just as good for infants. Cow’s milk is more opaque, due to the opacity (non-transparency) of the calcium-casein (lime-protein) which is present in greater proportion in cow’s milk. The latter is faintly acid or amphoteric when freshly drawn but ordinarily is distinctly acid in reaction when consumed. Human milk is amphoteric or alkaline. There is three times as much protein in cow’s milk as in human milk. The reason for this is obvious when we recall that the ratio of growth of the calf to that of the infant is about 2 to 1. Furthermore the protein in cow’s milk consists chiefly of casein (3.02%) and little laetalbumin (0.53%) while human milk is credited with 0.59% of casein and 1.23% of lactalbumen (albumin of milk). The sugar in the two milks varies greatly in amount but not in kind. Cow’s milk contains almost four times the amount of inorganic salts as mother’s milk. In the former, calcium and magnesium are in greater proportion, while in mother’s milk potassium and sodium bases are in relatively greater amounts. These differences have an important bearing on the infant’s nutrition. There is no great difference in the fat of the two milks but in both human and cow’s milk the fat portion is a variable factor. The curd of cow’s milk is usually the tougher while there are also differences in the antibodies (antagonistic to disease germs), ferments, etc. Cow’s milk is never sterile (free from germs), while human milk is practically so.
Hess further says that constipation is frequently associated with colic and flatulence, disappearing with a proper diet. It may be due to too much milk at proper intervals, too frequent feedings, too much fat, excess in sugars and starches. Excessive flatulence can frequently be eliminated by reduction or change in the kind of sugar and cereal gruels. Feeding powdered casein in amounts varying from 4 to 8 grams (about 1/2 to 1/4 of an ounce) dissolved in 30 to 60 mils 3 of water two or three times a day will relieve colic in many infants in all probability due to lessening of. peristalsis (movements of intestine). The constant solicitude over gas on the stomach is unwarranted. All bottle-fed babies have gas on the stomach. They swallow the air in feeding (as many adults do). If the baby is raised to a sitting position the gas will usually come up.
In breast-fed babies and not infrequently in infants fed on boiled milk, the colon is often sluggish. One or two ounces of a saline enema 2 or sweet oil injection can be recommended. If properly used they are not harmful, nor do they create bad habits which are often ascribed to them. A regular hour for their use, with proper training, creates regular habits and in most instances the condition improves to such an extent that they can be discontinued. Most infants can be trained to regular habits by the fourth or fifth month. In the presence of fat-soap stool it may be necessary to substitute skimmed milk temporarily with increase of sugar. In the presence of constipation where the maltose-dextrin compounds have been used, a change to milk sugar or cane sugar, or one of the dextrin-maltose compounds (see subsequent footnote) containing a high percentage of maltose and potassium carbonate, is often beneficial. Occasionally the addition of cereal water to the diet is of benefit. The reverse, however, may be the case. When the infant is old enough constipation is best relieved by the addition of vegetables, fruits or fruit purees (pressed through a sieve). When the above fail the addition of 1 or 2 teaspoonfuls of milk of magnesia to the day’s feeding answers well for temporary use or 1 or 2 tablespoonfuls of dry or liquid malt soup extract added to the day’s dietary, acts equally well. In infants where constipation is distressing and other dietetic changes fail, a week or two on Keller’s malt soup usually works wonders. Underfed infants frequently suffer from constipation. Such stools are small, dark in color and contain much mucus and are associated with stationary weight. Increase in the bulk of the diet relieves the constipation. Where there is a predisposition against milk, which causes vomiting and diarrhea, the symptoms speedily subside upon the use of castor oil. This class of cases offers great difficulty in feeding during the first year as carbohydrates (sugar and starches) must of necessity form a considerable portion of the diet. Broths, cooked cereals and vegetable purees should be gradually added to the diet as soon as they can be digested.