Major Case Study. Check!

By Sasha B. Bard, MSN

The major case study assignment is the final project of each intern’s main clinical rotation. It is an opportunity to explore an area of clinical interest by researching a chosen patient’s medical condition or disease, the nutritional implications, and appropriate medical nutrition therapy.

I have completed both the main ten-week clinical rotation as well as an elective two-week clinical rotation focused in neonatal intensive care. Because of my strong interest in working with infants, I selected a preterm neonate for my major case study. Specifically, my research explored neonatal abstinence syndrome in preterm infants. Here is the executive summary which encapsulates what I learned:


“Neonatal abstinence syndrome (NAS) refers to a collection of withdrawal symptoms observed in a newborn child including, central nervous system excitability, vasomotor dysfunction, and gastrointestinal distress. NAS is caused by fetal drug exposure secondary to maternal drug use. Since women who abuse drugs often use more than one drug, NAS may result from the combined impact of multiple exposures. Opioids are the most common drugs to give rise to NAS and include illegal drugs, such as heroin, as well as prescription medications including, oxycodone, hydrocodone, and OxyContin.

Maternal drug abuse impacts the fetus directly through drug exposure in utero as well as indirectly through compromised maternal health. For this reason, NAS is not the only health concern for drug-exposed infants. Poor maternal health habits, such as lack of prenatal care, poor nutritional status, exposure to violence, and exposure to infectious disease related to unprotected sex or intravenous drug use, increase the risk of prematurity, low-birth-weight, and fetal demise.

Medical management of a premature, low-birth-weight infant with NAS involves primary and secondary treatment and should always be individualized. Primary treatment is supportive and non-pharmacologic. Pharmacotherapy, with a drug from the same class as that causing the withdrawal, is considered secondary treatment of NAS.

Medical nutrition therapy (MNT) plays an important role in neonatal care for both prematurity and NAS, helping to ensure adequate growth and nutritional status. Nutritional considerations include elevated caloric needs and ability to feed. Preterm infants are prone to feeding difficulties due to developmental delay and fatigue. NAS further compromises feeding ability and therefore nutrition status of an already high-risk patient. NAS symptoms may also increase energy expenditure as well as caloric loss through vomiting and diarrhea.

Close monitoring of feeding and growth are essential components of MNT for the preterm infant with NAS. Human milk is the preferred energy source for all infants. Breastfeeding with regard to maternal drug use is controversial, however it must be considered due to the numerous known benefits human milk provides to the preterm baby. Infant formulas designed to meet the nutritional needs of prematurity are available when breastfeeding is not an option. “


References and full report available upon request, please email sasha.bard@gmail.com .

Resources for Dietitians

With the abundance of information on food and nutrition available both in print and online, it has become increasingly more difficult for nutrition professionals in general - and dietitians in particular - to stay up to date on current research. At the same time, it is essential for today’s dietitians to know where and how to access available resources so that they can find the information they may not have committed to memory. In other words, being a successful and knowledgeable dietitian has evolved from a measurement of “how much information you know” to “how much information you can find.”

In my current rotation at the Food and Nutrition Information Center (FNIC), I am discovering the plethora of resources available, often for free, to nutrition professionals through FNIC’s website. FNIC is “a leader in on-line global nutrition information.” Through their website you can access over 2,500 links to “current and reliable nutrition information.” 

One feature on FNIC’s website that, in my opinion, should be turned into a smart phone app and used by every clinical dietitian is the “Interactive DRI for Healthcare Professionals”: http://fnic.nal.usda.gov/interactiveDRI. This tool quickly calculates macro- and micronutrient needs based on the current dietary reference intakes (DRIs). There’s no shame in utilizing tools like these to save time during clinical nutrition assessments and calculations.

RD411.com is another time saver for dietitians. Making educational handouts can be fun, but for the dietitian whose job it is to help patients, there are better ways to spend that time. RD411 provides evidence-based practice tools that can help nutrition professionals enhance the services they provide. These tools offer information on the latest products, based on the current scientific information available, and resources that can be used both for professional development and to educate a client or the public. It is no longer necessary for nutrition professionals to “reinvent the wheel” by designing from scratch every educational handout, in-service or treatment protocol.

I’ve mentioned only a few of my favorite sites for finding nutrition resources. Please feel free to comment about resources I’ve missed.

Oh the Places You'll Go...

As we approach the holiday break and the near mid-mark of the internship, I have begun to reflect on what I have been able to accomplish so far during this program, and it’s a lot! I am currently in my last week at the International Food and Information Council in D.C. completing the last of my information management rotations. Through IFIC and FNIC (Food and Nutrition Information Center), I have learned how to communicate to a variety of audiences via the web and have sharpened my researching, presenting, and writing skills. I have completed one of two of my foodservice rotations at College Dining, where I learned about College Park’s dining facilities and their initiative to “go green.” I was able to collaborate with many of the dining services’ team members to learn how they provide nutritious, diverse, and safe food to the university.

Also checked off on my internship list are the majority of my community rotations. I spent two weeks at Food and Friends in DC, a food bank that provides specialized nutritious meals, groceries, and nutrition counseling to people living with HIV/AIDS and cancer. I was able to go on a home visit where I observed the dietitian counsel a cancer patient with an ileostomy bag and spent a day with their delivery driver bringing meals to clients. I spent one week with Maryland’s Food Supplement Nutrition Education program, where I was able to teach the community about general healthy eating practices. My favorite activity was reading a nutrition-related book to elementary school children and making a healthy snack with them. Way back during the first week of the program, I spent a few days with the Montgomery County School Lunch program. I learned about the regulations of school meals on the federal level and how they implement these rules on the county level. I was able to observe several of their school’s kitchens and toured their central production facility.

I already feel like I am well on my way to becoming a dietitian and am looking forward to what’s to come in the New Year. I will be starting my 8-week clinical rotation in January (eek!) followed by 2 weeks each of staff relief, pediatrics, and second clinical experience, which means I should probably use this break to brush-up on my medical nutrition therapy knowledge :)

Until next year,

Rachel

Modified Barium Swallow: a Dietetic Intern's Perspective

By: Angela Farris, MA

During the 6th week of my clinical rotation I was able to participate in a Modified Barium Swallow (MBS) evaluation performed by a Speech Language Pathologist (SLP). In order for a patient to have a MBS performed they must have some sort of dysphagia, aka difficulty swallowing. The first step to determine if a patient has dysphagia is for a SLP to perform a bedside swallow evaluation. During this evaluation the SLP feeds the patient a number of liquids and foods to determine if the patient is at risk for aspiration. Have you ever had a drink or a piece of food "go down the wrong pipe"? If you have, you've aspirated. The problem is that if enough foreign body gets down into the lungs via aspiration bacteria can grown and an infection can spread making a patient very ill.

Below is a video showing a MBS with aspiration:

(aspiration occurs at 0:05 seconds; notice the dark liquid on the left)

The patient I followed failed their bedside swallow evaluation so the next step was to perform a Modified Barium Swallow. A MBS is a definitive way to check for any aspiration risk and determine the appropriate diet modification (i.e. mechanical soft, pureed, regular).

The SLP prepared 5 different test food/drinks for the patient to swallow; a graham cracker, applesauce, water, nectar-thick iced tea, and honey-thick juice. Each item received a barium-powder additive so that it would be easily viewed during the X-ray. Yes, the SLP encouraged me to try the powder -- and I did. Let's just say it makes everything taste like berry-flavored chalk!

I stood behind a protective wall and watched the MBS in real-time. It was amazing to visually see how our bodies have a natural rhythm while swallowing -- more muscles are involved than I could have imagined. It was a great experience and I'd like to see another before my clinical rotation comes to a close.

Here is a further description of modified textured liquids:

• Thin liquids: any regular beverage, ie water, juice, iced tea
• Nectar-thick liquids: easily pourable & are comparable to apricot nectar or thicker cream soups
• Honey-thick liquids: slightly thicker, less pourable, & drizzle from a cup or bowl
• Pudding-thick liquids: hold their own shape; are not pourable & are usually eaten with a spoon

The next time I take a drink or chew a piece of food, I will surely appreciate my ability to swallow!!

Beat Stress in the Workplace

While at my University of Maryland College Dining rotation, I had the opportunity to attend a stress management workshop with members of the National Association of College & University Food Services (NACUFS). Each year members of NACUFS gather for their annual Mid-Atlantic sub-regional meeting to learn fresh ideas that serve their mission and promote exceptional dining services within their facilities. Luckily, this year's meeting was held at the University of Maryland, College Park campus, which allowed my partner, Marion, and me to attend. Even more exciting was that the topic involved stress management. Professional speaker and organizational motivator, Julie Gaver lead the workshop and provided humorous ways to beat stress in the workplace. 

In a high-energy foodservice environment, skills to manage stress are necessary to overcome adverse situations. When stressed, Gaver challenged participants to define the situation, rather than let the situation define them. As one might guess, the first step to the defining a situation starts with an individual’s attitude. Though one may be stuck in a “down” mood, Gaver provided helpful tips to take back one’s attitude before letting the situation rattle one’s day. First, she suggested improving your attitude by the way you start your morning routine. Knowing what makes you happiest in the morning, whether it is certain music or making time for breakfast, sets the stage for the rest of the day. Her next tip is to make a conscious effort to smile throughout the day. It’s the easiest thing to change about yourself, and people notice when you show your positive attitude. In addition to wearing a smile, it is important that you speak with a positive tone in your voice. Gaver explained that speaking with an exclamation at the end of your sentence is the best way for your positive attitude to shine through one’s voice. She went on to tell us that if you’re around pessimistic people, it’ll eventually rub off on you.  Surround yourself with positive people and your attitude will go up as well.  And lastly, if all else fails—fake it. Giving off a positive outlook can only make things better.

The next phase of Gaver’s presentation explored ways to find humor in the workplace. Not only does humor improve mental health by reducing stress, but it also leads to higher job satisfaction and better workplace morale. Gaver provided various anecdotes recounting her own stressful moments at work and how she overcame them.  The common factor was humor.  Being able to make light of a situation at your own expense and laugh at yourself is a great way to bring humor to the workplace.  Knowing your coworkers and what’s considered appropriate humor is tricky, so directing humor towards yourself is always the most harmless.

While this conference was directed toward foodservice professionals, the concept applies to everyone: keep a positive attitude and foster good relationships with those around you.  As a dietetic intern, I am constantly changing rotations and getting acclimated to new work environments.  In the past three months, I have interned at the Food and Nutrition Information Center, the International Food Information Council, the Food Supplement Nutrition Education program, and University of Maryland Dining Services.  With seven more months of rotations to go, Gaver’s stress management workshop was exactly what I needed.  A little humor can make all the difference.

 

Left to right: UMCP Vice President of Student Affairs: Linda Clement, Keynote Speaker: Julie Gaver, UMD Interns: Marion Viglietta and Lauren Hogan, UMCP Director of Dining Services: Colleen Wright-Riva

How Food-Safe is Your Kitchen?

By Joyce L. Hornick

Would you get food from a salad bar that didn’t have a sneeze guard? How about eat at a restaurant that didn’t clean their dishware properly? Or at a place that served week old food? Yuk! Definitely not! Luckily, laws are in place preventing the above scenarios from happening, but do you follow the basic rules of food safety at home?

The FDA, USDA, and the CDC all work together to ensure our commercial food supply is safe. State and local governments have standards for food safety that restaurants, food manufacturers, grocery stores, and other food-related commercial establishments are required to follow. Many jurisdictions require restaurants to have food service employees trained via the ServSafe® method and take an exam to be certified. The system isn’t perfect. Foodborne illnesses still occur, but the US has one of the safest food supply systems in the world. At home, we can continue with safe food handling practices to keep our food safe. We have many resources about food safety at our fingertips. Web sites such as foodsafety.gov, fightbac.org, cdc.gov, and fda.gov all have a lot of useful information.

The five most common risk factors that cause foodborne illnesses as reported by the CDC are:

1. Purchasing food from unsafe sources.
2. Failing to cook food adequately.
3. Holding food at incorrect temperatures.
4. Using contaminated equipment.
5. Poor personal hygiene.

These risk factors have been identified, with protocols in place, to help minimize foodborne illnesses within our commercial food supply.

With all of this information available, what are the most important things you can do as a consumer to keep your food safe at home?

1. Only buy perishable foods from grocery markets you trust. Look at the packaging of meats and poultry to make sure it is sealed properly and the meat looks fresh. Check the sell buy date to make sure it isn’t expired. Try to buy meat and other perishables last while at the grocery store and put them in the refrigerator first once you get home.
2. Always make sure food is cooked to the proper temperature. It’s the best way to lower your risk from bacterial contamination. An instant read thermometer is a must for every kitchen. For a quick list of proper cooking temperatures, look at or print out this chart.
3. Put leftovers in the refrigerator right after finishing your meal. Put the food in shallow containers with a loose fitting lid to allow heat to escape. Seal tightly once they have cooled. Don’t let leftovers sit out on the counter to cool off.
4. One of the easiest ways to prevent cross-contamination of foods is to have different cutting boards for different tasks. Always clean knives and other utensils thoroughly after using for one task before using for another. Thoroughly clean work surfaces after working with raw meat, poultry, and fish. Never put cooked food on a plate that had raw meat on it.
5. Wash your hands, wash your hands, wash your hands. Mom knows best on this one! This is the easiest way to prevent cross-contamination, reduce the spreading of bacteria and viruses, and is just good hygiene!

Food service establishments are required to follow these guidelines to keep their food safe. Following these guidelines will help make your home “restaurant” kitchen safe as well. As we head straight into the holiday season, think about the large number of people you may be cooking for and make sure your kitchen and your food is safe for everyone.

Farewell "Dumb Phone, I Got An iPhone

I was nervous coming into the UMD internship program,which has a technology emphasis, because I didn’t have a smart phone. My trusty red phone that looked like it survived a stampede could only call and text; it had no apps, no web browsing, no touch screen. I thought how am I going to survive this program when I can’t even send an e-mail or get directions on my phone?
Admittedly, at first I wasn’t excited to get a smart phone. I didn’t want to learn all the ins and outs of a complicated phone. Trusty red and I had a long history together and I knew how to use it well. But recently the time came for me to upgrade phones, so I finally said goodbye to my little red phone and upgraded to a shiny new iPhone.

I felt pretty clueless in the store surrounded by all the smart phone options. The clerk spoke highly of the iPhone, so I thought sure I’ll take that one! I got it home and spent the entire weekend playing with all the features and functions of the phone. It wasn’t always smooth sailing because of my smart phone learning curve. But after about a week I’m happy to report I am successfully using my iPhone for things I never knew I could!

My favorite part so far has been taking pictures and being able to e-mail them and upload to twitter or facebook right from my phone. I was amazed at how easily I was able to take a picture at a rotation and upload it to a powerpoint presentation within a few minutes. I used to not even use the camera on my old phone because it was such as hassle. I’m also really enjoying all the apps. There are some really cool nutrition related apps I never knew about, like the MyDS dietary supplement app from the Office of Dietary Supplements.

I’m still getting used to using my new smart phone but overall I’m happy I upgraded. When I had my “dumb phone” I was blissfully unaware of all I was missing by not having a smart phone. I used to think all I needed a phone for was to call and text; who needs all that other stuff? But all that other stuff is useful technology that can help me be a better dietitian. Now, if given the option to go back to the old trusty red phone, I think I’ll stick with my iPhone.

This is posted on behalf of Emily Izer, Dietetic Intern

Food Sensitivities: Hocus Pocus or the Secret Weapon?

The newest craze among people, especially professional athletes, is the IgG Antibody testing for food sensitivities and the coinciding food elimination diets. While at my elective/second hospital rotation in Arizona, I got to work alongside many professional and collegiate athletes. As a performance nutrition professional, my preceptors are often asked, “if I am already eating right for my body, what else can I do that will provide me with that edge?” or if they are a rehabilitation client, “what will aid in a faster recovery time?”.

There has not been a lot of research on the significance of IgG testing and food elimination diets. However, I myself, have seen a great difference in those who have followed their tailored food sensitivity list and have heard comments of those who have changed their eating habits around this idea.

For those of you who have not heard about these “food elimination diets” or want some further clarification on what they are, let me explain. It first starts out with a blood draw. Your blood samples are then tested against a panel of different food antigens to see if your body reacts to any of the additives. If there is a sensitivity present, your body produces an antibody (IgG) and then each of those receive a grading of a +1, +2, +3, or +4 in regards to the strength of the sensitivity (remove from the diet for three months, six months, nine months, or one year, respectively). Immunoglobulins G (IgG) are found in all body fluids, they are the smallest and most abundant of the antibodies in the body. They are the most important antibodies for fighting bacterial and viral infections. Since these antibodies are so prevalent in our bodies you might wonder what kind of a reaction you might get when for example consuming some items you show a sensitivity to. Anywhere from the obvious signs/symptoms such as a stomach ache, delayed digestion, and heartburn to a slower reaction time or mental clarity.

While in Arizona, I got to analyze many of these results just as a nutrition professional would for their client. Once the lab results are received, I would go through the food items that elicited a reaction, then determined if there were any similar food families present, most commonly: Bovine (cow’s milk, goat’s milk, eggs, beef, dairy products, etc.), Nightshade (peppers, potatoes, tomatoes, etc.), Legumes (all beans, peas), Grains/Grasses (rice, wheat, oats, corn, etc.), and Fungi (baker’s and brewer’s yeast, cheese). Many foods fall into “families”, this means that they have a similar structure and make-up, therefore, also causing a similar “reaction”. These foods are then eliminated from their meal plans and substitutions are made when necessary (almond or coconut milk instead of cow’s milk). After the allotted time for elimination foods are then cycled back in (one at a time) so the individual can try and read how their body feels upon reintroduction.

Many of the athletes found this plan difficult and hard to follow at first, then you would start hearing the responses about how they “cheated” and for instance, ate a wheat product when they weren’t supposed to and how they felt so slow and sluggish the rest of the day. This is when you start believing that some of this really might make a difference even on a smaller level.

There still needs to be a lot of research done to prove the significance of eliminating foods that your body shows a higher sensitivity to from the diet. You must remember that this testing does not prove you have a full-blown allergy, but that your body shows sensitivity. However, I believe that the ideas behind the diet are good. If you eat the same items over and over again, your body will most likely show sensitivity to them due to overexposure. It probably is a smart idea for everyone to start cycling food items most often consumed and add some variety into your refrigerator and pantry. Stay tuned for more information!

Location, Location, Location

You don’t have to be in the realty business to have heard this one: Location, location, location. It’s the right place at the right time. Things just happen to fall into place. Lauren and I just completed our second of three weeks at UMD Dining Services and we’re thankful for (just in time for Thanksgiving!) our timing there. On top of the standard assignments and experiences throughout this rotation, we’ve been lucky enough to take part in extra programs and events solely due to timing in the internship. On our second day, we were invited to attend a stress management workshop held at College Park for the Mid-Atlantic region of the National Association of College & University Food Services (NACUFS). Anyone can benefit from this program: students, employees, management, and of course, dietetic interns. Our keynote speaker, Julie Gaver, said it’s all about choosing your attitude by keeping a smile on your face and bringing humor to the workplace.

Now that we were both feeling stress-free and energetic, we were invited to work at the Student Government Association sponsored UMD Crab Fest. WOW. I don’t know if these students know how lucky they are to have an event like this on campus. They had everything there. Potato salad: check. Macaroni salad: check. Adorable single-serving butterballs: check. The list goes on. Dining services purchased sixty-six bushels of crabs. (I’ll admit, to me that meant “a lot” so I had to dig further for a number). At an average of sixty-seven crabs per bushel, that turned out to be a whopping 4422 crabs ordered for about 900 students. That’s a lot of crabs! I’m not even a student and I had a blast.

After our much-needed Thanksgiving break, we’ll be entering our third and final week at this rotation just in time to see the pilot launch of the “OZZI” reusable to-go containers in the dining hall. This program is an effort to reduce not only waste, but costs associated with disposable containers used in the dining hall. If we had left before the holiday we wouldn’t have been able to see this happen! Like I said; it’s all about location. It’s those extra things we were fortunate enough to experience that made this rotation all the more special to me. We got lucky!

Until next time,
Marion