Pediatric Hospitals: A Whole New Ball Game

Before my rotation at Children’s National Medical Center, I completed 10 weeks at the Baltimore VA Medical Center.  I felt pretty confident in my clinical skills and ready to try a different type of hospital.  I knew that that CNMC was going to be different, but I don’t think I really knew what to expect.  Here are what I think are the top differences between working with the adult population and pediatrics.

1.      Parents over Patients

When gathering information traditionally, you can just ask the patient how they have been feeling and so on.  When your patient is 18 months old, that becomes a less realistic scenario.  As a clinical practitioner, you need to direct your questions to the family members, usually parents, and work with them to provide the best care for your patient.  Usually, they are fully aware of feeding behaviors, symptoms and general habits so you still get all of the information you need. 

      A pediatric hospital can serve patients from birth through their 20’s so there is a wide range.  You need to develop your own clinical judgment to determine at what point the child is included in the conversation. 

2.      Calculating Needs and Evaluating Values

The calculations are different, which is something that I had not thought of ahead of time.  Rather than calculating needs in total calories or grams of protein, everything is presented in relation to the patient’s weight.  For example, the needs of an infant that weighs 3.73kg would be documented as 102kcal/kg/day rather than 380kcal.  Weight is constantly fluctuating so this is a more appropriate method. 

The reference ranges also differ depending on age.  At different stages of development the body has changing needs, so a value that is in range for a baby could be outrageously high for an 18 year old and vice versa.  Practitioners need to be tuned into these differences to give the most accurate assessments.

3.      Growth

Growth can be the main reason you are seeing this patient.  During my rotation, I was on the GI and General floors so many of our patients were underweight and came in for Failure to Thrive.  In adults, changes in weight can be important in addressing an acute condition while weight changes in a child can impact their development and affect them lifelong. 

My impression is that nutrition in the pediatric population can do more good by preventing these problems long term and setting a child up for a healthy life.

I learned a great deal during this rotation and these are only some of the highlights.  Pediatric nutrition is fascinating and I loved being able to work with this population.  If you ever find yourself in a pediatric population, just remember some of these differences to improve your understanding and hopefully the quality of care you are able to provide.

The Implications of Food Allergies in College Dining Services

By Nikki Bolduc

UMD South Campus Dining Hall 

As part of our University of Maryland Dining Services rotation, Maria and I recently had the opportunity to attend a food service meeting at Penn State University.  This regional meeting took place as part of the National Association of College & University Food Services (NACUFS) organization and included food service professionals from five different colleges.  Topics for the meeting focused on specific issues that dining services face as they relate to food allergies (i.e. gluten-free, dairy-free, nut-free) as well as vegetarian, vegan and kosher food preferences. 

Each college shared information about some of their biggest challenges when dealing with food allergies and food restrictions.  Some of the subjects that were discussed in the meeting included best practices when dealing with food allergy signage, how to effectively market special events, the future of healthy menu trends, the use of social media outlets, and green initiatives.  It was interesting to hear what each school was doing to tackle some of these challenges as well as their future plans.  The meeting was very productive and demonstrated how effective peer collaboration can be. 

Overall, I learned a lot about the obstacles registered dietitians face when dealing with food allergies and food restrictions in a food service establishment.  Schools are extremely concerned with keeping their students safe.  Finding the best method to reach students who have food allergies, keep foods separated, communicate which foods are safe, and provide a variety of safe foods can be a huge challenge.  Each school used a different method to do each of these things and while there are no best practice guidelines for schools dealing with such issues, it will remain interesting to see exactly where the future of food allergies and food restrictions in food service go.

A Modified Barium Swallow

Today I had the opportunity of observing a modified barium swallow study on one of my patients. A modified barium swallow is a type of procedure used to investigate the coordination of muscles and structures in the mouth and throat. The purpose of this study is to identify patients who are at risk for aspiration (when matter enters the lungs). It also serves as a tool for identifying safe food/liquid consistencies for patients to consume. 

How it works:

• Barium sulfate, an opaque substance when viewed by X-ray, is added to liquids of different consistencies
• Types of liquid consistencies:
• Thin – non-restrictive
• Nectar – some liquids require thickening, consistency is most similar to tomato juice
• Honey – all liquids require thickening, liquids become very slow to pour
• Pudding – liquids must be spooned
• The patient sits or stands in front of a fluoroscopy machine (X-ray) while swallowing the prepared liquids
• Fluoroscopic images are taken simultaneously, capturing the bolus as it travels from the oral to the pharyngeal phase
• The speech language pathologist views the fluoroscopic images and can then determine the safest consistency for the patient

Unfortunately, my patient suffered from silent aspiration, meaning her epiglottis was delayed in blocking the trachea (passageway to the lungs), allowing thin liquids to enter into her lungs. Nectar thick liquids however did not cause her to aspirate so for the time being, her nutritional needs must be met entirely by a nectar thickened liquid diet, and that’s where the dietitian’s job begins! 

If you want to see a barium swallow check out this short clip.

The Beginning of the End

My partner and I are entering into our last section of the internship - Food Service.  It's only about another 9 weeks and we'll finally graduate from the UMD internship program.  I really can't believe how fast time flies.  It feels like it was only the other day we were all sitting together in orientation wondering about what was to come in our program.

Now that we are nearing the end of the program, many of us interns, including myself, are looking towards the near future - what jobs should we apply for and when should we take the exam.  As exciting as graduation is, applying for jobs and writing up resumes can be quite stressful.  Plus, most of us are planning on taking the exam as soon as we can.  So that's a lot of studying on top of that resume writing.

In order to stay focused and keep the stress at bay, I've come up with a few good tips on how to get ready for the internship graduation, jobs and the RD exam.

• Resumes and cover letters.  Dig up your resume and start tweaking!  Add in all of the experiences and activities you've completed thus far in the internship.  This will take a while to complete, so give yourself enough time to build out a well rounded resume.  Also, write up a cover letter template that you can change with each job you apply for.
• When to look for jobs.  Each preceptor or internship director will give you a different answer.  But I've found that beginning to get an idea of WHERE to find jobs and WHAT they require in their applications is a good thing to know.  Start scoping out the scene about 3 months prior to graduation.
• Network!  Much of this internship is about networking, making connections and finding great friends in this field.  Reach out to your preceptors, friends or other colleagues that may be able to help you get a foot in the door.  Most are more than happy to help you out!
• Know when you want to take the exam.  Keep a plan in mind when you're thinking about when you should take the RD exam.  This will help you determine a good study schedule.
• Study, study, study.  There are a lot of great resources out there to help you study and ace the RD exam.  Pick one, or two and get down to business.  A lot of money can be spent on special study guides.  However, a copy of the Inman CD's and book is a great and cost-effective way to go.  You may even be able to borrow a copy from past interns (hint, hint!).

So, wish us all luck as we get nearer to graduation, the RD exam and the real world.  Keep these tips in mind as you progress through the internship next year.  That way, you'll have a somewhat stress free end of the internship!  Good luck!

Gaining a Better Understanding of Pain Management

 

Today we had the opportunity to attend the Maryland's Dietetics in Health Care Communities annual spring workshop.  Presentation topics included how to better manage glucose levels in sub-acute facilities, the basics of parentral nutrition, electronic medical/health records, renal failure nutrition therapy and practical pain management for dietitians.  While all the presentations were informative, I found the pain management discussion especially thought-provoking and interesting.  How many times have we as dietitians heard patients complain that their low po intake was directly related to their high pain level? It had never occured to me that dietitians could help improve both appetite and intake through better pain management.  During the talk, I learned that with the right tools, dietitians can play an active role in a patient's pain management regimen to improve mealtime outcomes.  Below are a few tips on how to assess a patient's pain level and the basic information needed to initiate a conversation within the health care team regarding pain management. 

 

1) Have a dialogue with your patient if pain is impacting their intake

 

   - Use the universal pain scale (seen below), but ask follow up questions.  For example, if a patient gives you a 10/10 for pain, follow up by asking, is this the worst pain imaginable, could you imagine the pain getting worse?

 

 

2) Know the basics

 

  - All opioids are created equal at equal doses i.e. no medication is stronger than another

 

 - All opioids are metabolized in the liver and cleared in the kidneys

 

 - Short acting oral opioids and IV opioids have different onset times but around the same average duration (3-4 hours)

 

3) Work with the inter-disciplinary team to modify pain dosage or timing to improve patients mealtime intake.