This occurs if the mother has an inadequate supply of milk, or, more rarely, if it is of poor quality. There is, naturally, no evidence of indigestion, and yet a failure to gain normally in weight, or, what is far more serious, an actual loss. A very suggestive symptom is constipation, that is rarely due to any other cause in breast feeding. The baby is commonly quiet and "good," often "too good," and may become listless and apathetic. If the lack of food is marked, it finally becomes pale, inactive, weak, cool to the touch, emaciated, with soft and sunken abdomen, and depressed fontanelle, and may not nurse or even swallow when food is introduced into the mouth. The bowel movements may become brownish or greenish-brown and slimy-looking, as in infants on a simple water diet. The size and firmness of the breasts are not influenced by nursing as they should be. The baby often nurses quite indefinitely, or only a short time, and then cries because it is not satisfied. Excessive crying and apparent hunger are far more characteristic of overfeeding than underfeeding.

Treatment

The scales will quickly decide whether there is a deficiency, and how great it is. In all but the mildest cases, and especially if the child is losing, other additional food must be given at once, either from another breast or from a bottle. As the child gets stronger and nurses more vigorously, and the mother becomes less worried and stronger in the early cases, the bottles can often be discontinued, or lessened in number. In the severest cases, when the child will no longer nurse or even swallow, the demand for food is urgent, and the use of the stomach tube for feeding will often quickly restore the child to a condition in which it can resume nursing. In the less advanced cases, with simply inadequate gain in weight, we can often wait to see whether improved conditions will not remedy the matter. The mother must be relieved of worry and of lack of sleep. She should be placed in as good physical condition as possible, she should get out of doors, and perhaps take a tonic, that her appetite may be stimulated so that she will take an abundance of milk and other nutritious food. The very common forced feeding beyond the natural appetite, as well as the innumerable "milk producers," such as malt, beer, tea, cocoa, corn meal and oatmeal gruels, sea food, electrical stimulation, massage, and special drugs, are all of doubtful value. The only sure stimulant to milk secretion is the regular thorough emptying of the breast. If another more vigorous baby can also be put to the breast for a time, especially during the first few weeks, it will often establish a free flow. If this is not feasible, we must aim to build up our baby, as indicated, so that he can do this himself. If this is not successful, mixed feeding must be continued, or wet nursing, or gradual weaning, and finally artificial feeding alone is inevitable.

(C) Poor Adaptation To The Mother's Milk

There are, apparently, a few babies who have an idiosyncrasy against their mother's milk, or to that of one wet-nurse, and yet will thrive on that of another. Our knowledge of these cases is very meager. Probably many of them belong in the class of overfeeding, or even underfeeding. If not, a change must be made to another nurse, or to artificial feeding. More evident causes must always be carefully excluded.