Finding Your Way in Clinical Dietetics

I felt like I had to write a blog post on this topic of clinical dietetics, because it has been where I have been working for the last 9 years. Plus being in a hospital was not a place I thought I would be. For those of you that aren’t as familiar with the world of dietetics a vast number of RDs work at hospitals and are clinicians. These RDs see inpatients and outpatients and provide nutrition recommendations/education on various disease states. Throughout school you learn that there are variety of jobs and places where RDs can work, but you are prepared that you will most likely find yourself working at hospital, some where along the line. I didn’t think that was where I would end up, but now we are 9 years later and I found that I love NICU nutrition and I really hate not being in that specialty area.

I share this with you, because there are lots of RDs who are on the flip side of this coin and worked in clinical and hate it and are unhappy in that area. That is ok, but I wanted to take a moment and try to encourage/prepare you … if you are a RD who has found a specialty area that you love in clinical dietetics … don’t give up and fight like hell for that dream you have.

So let’s say you find that you enjoy working at a hospital. Lots of RDs enjoy working to care different types of patients in different areas of the hospital. You tend to have two groups of clinical RDs - adults and pediatrics. Then within those age groups you have different disease states where people start to specialize. Clinical dietetics managers are under pressure to staff these various areas of the hospital with the minimum number of staff possible, because helps the bottom line. So more often then not you are asked to cover multiple areas/units/or populations within the hospital. So you are pushed towards being a “jack of all trades” and that is ok for some people. For some of us that is not what we want. For some of us, we have very specific goals and aspirations. I wanted to write this post to push you to never stop fighting for that specific dream you have. If you have a niche and an area within dietetics you love … do everything you can to put yourself in that dream job. I was feeling compelled to write this, because I haven’t heard this enough. Instead I have heard “oh well I have to be flexible and do something else for awhile” or “you need to sometimes do things you didn’t originally expect” or “we all need to be part of the team.” And I do agree with those statements, but not when those statements are used to keep me from my clearly stated objective. I have worked too hard towards a specific goal to be derailed from that dream. So never apologize for having a passionate dream and knowing where you want to go. No one should make you feel that your drive should be something you apologize for, but instead should be harnessed to propel you forward.

With all that being said …if you find yourself working towards a dream you have (if it is in clinical dietetics or not) … never let anyone stand in your way. Go after that dream with all that you have and don’t let people who lack that drive make you feel bad for your desire to succeed.

Working In A Formula Room

It has been awhile since I have spoken about my day job here on the blog. As you may recall, I work in a Neonatal Intensive Care Unit (NICU) and I am a pediatric dietitian. I work with newborn babies and I calculate their nutrition needs to help them grow appropriately since most of our patients are born early. Another part of the job, is helping to oversee our Formula Rooms. This is the part of the NICU where all of the feedings are put together/made for our patients in 24 hour batches. We help to schedule, oversee and hire the Formula Room Technicians that work in those mixing rooms. Sometimes the dietitians fill in those shifts as well if we don't have enough techs to fill the spots on a particular weekend. 

This last week I have had the opportunity to work in our Formula Rooms a couple of times. I am always impressed with our system and how we so accurately get all of our babies fed ~ 8 times a day. It is truly a well oiled machine and is so neat to be a part of that. 

I thought it might be neat to address some of the Frequently Asked Questions that I get about our Formula Room/NICU and how nutrition plays a role in that environment. Most people are surprised to learn that there are dietitians in the NICU and that we have a mixing room for feedings. 

Frequently Asked Questions

1. What does a dietitian do in a NICU?
   • This is a great question. The role of a dietitian in a NICU varies, but the main role is to help provide nutrition care to this specialty population. The RD serves as the nutrition expert on the medical team and provides guidance/advice to the neonatologist about  the best feeding recipe for each patient. Each week the RD sees every patient in the NICU and writes up a nutrition note about their plan of care that week. The RD would suggestion what feeding option might be best for that patient, the avenue of administering the feeding, when start vitamins, how feedings might change based on lab values and monitor growth velocity and tweak the nutrition plan as needed. 
2. Do you just mix formula in the Formula Room?
   • No. In our Formula Room we prepare ALL of the feedings for ALL of our patients and they are stored in a refrigerator in that room. The RN will come in and out of the Formula Room to get the feedings and take that aliquot to the bedside and feed the baby. Each patient has their own bin in the refrigerator and their feeding is in that bin for the RN to grab anywhere from 6-8 times per day.
3. How do you feed your patients?
   • In the NICU, since our patients are normally premature, our most common form of administering nutrition is via a feeding tube or via TPN. We prefer to use the GI tract and will try to give feedings via the feeding tube and we work to wean TPN support as soon as possible due to line infection risk and liver damage. Infants do not have their swallow/feeding reflex developed until ~34 weeks gestation and so that would be the point that with cues, we might start some bottle feedings. 
4. Do you feed your patients breast milk? 
   • Yes. Our goal is to use maternal breastmilk whenever possible. That is the gold standard for all of our babies, because it has so many protective properties. Some times there are medical diagnoses that prevent the use of breastmilk, but those cases are limited. Premature babies also need higher calories, more fat and more protein. They are born early and their nutrition needs are higher compared with a term infant. This means that unfortified breastmilk won't meet their nutrition needs so in the NICU we use different formula/fortifier to add to the breastmilk to increase the calories, protein, fat and other vitamins the infant is receiving. We have recipes that we use to mix these feedings and that is the primary role of our formula room technicians. They are the ones that will mix up these recipes for each baby in 24 hours batches and those feedings will be used throughout the day by the nursing staff.
5. How much do you prepare each day in the Formula Room?
   • Our technicians make 24 hour batches for all the babies that we are mixing for that day. Our NICU holds 90 babies and our nursery unit holds an additional 10 babies. There is the potential that we could mix for all 100 babies, but that is normally not the case. It is inevitable that there is a baby or two who are NPO (nothing by mouth). Our average census is ~70-80 patients at a time. 
6. Why do you have technicians mixing feedings compared with nursing staff? 
   • Nursing staff in some hospitals do mix feedings and they have at our hospital in the past. With this creation of a Formula Room space it is more conducive to having one person mixing up feedings compared with each RN mixing their feedings. It decreases the number of people in the room and would decrease risk of errors/infection risk. We work hard to make sure that our technicians are trained well and mix the feedings appropriately. This helps give the RNs more time at the bedside to do what they do best, provide that direct care for our babies. 

Hopefully this has given you a little better idea about what we do in the NICU and how we provide top-notch nutrition care to our patients. We have some of the sickest babies in the state at our hospital and I am so proud of our medical staff for the level of care that we provide each and every day! 

Being a clinical dietitian in the NICU

I have been thinking about writing a blog post about my job as a Registered Dietitian in a Neonatal Intensive Care Unit. I know some people have no idea what I do on a daily basis and even some of my family may be confused. 

But to start off this explanation we need to go back to high school. I met with a Dr Fadley who was a therapist of sorts. He meets with people, has you take a test and that then determines future occupation based on your interests/skills. He told me that I could go into dietetics, but it would be tough (and it was), but I would be best suited for special education and being a teacher. I kind of blew him off and thought that was ridiculous. 

Well here looking back about 10 years later ... I think Dr Fadley spoke some truth. I have a passion for helping those that can't always help themselves. I love working with people who have faced challenges in their lives - mental, emotional or physical. I have a special place in my heart for being that care giver and helping people. Looking back I can see that displayed in many ways, but I think in my current job it helps to sums up what I do every day. I help to provide care for the littlest of babies who aren't suppose to be born yet. All of us in the neonatal world, work to help them beat the odds and have a chance at life. Being able to be part of that team, who works to give each of these babies a fighting chance is amazing. I love it! 

My specific role as the dietitian is to calculate the nutritional needs for our neonates. I work with a team of neonatologists, speech therapists, nurses and dietary technicians to make sure that our babies are getting the best recipe for feedings to meet their  unique needs.  More goes into these calculations than just crunching numbers. As the dietitian, I have to be aware of various medical conditions that could have an impact on their nutrient absorption/metabolism. This can be a complicated process if you have a baby with renal failure, a cardiac condition or a GI issue. Each of our patients, is like a puzzle that we are working on figuring out during their hospital stay. 

In addition to charting on each of these patients, I help to oversee the formula room. This is the place in our hospital where all the feedings are made by dietary technicians. We make 24 hours worth of feedings for all of our patients and we help to make sure that these techs are doing their job right. These techs are valuable part of our team and help ensure that the nutrition plan the dietitian comes up with is put into action. 

I wanted to share my job with you, because it is different. Hopefully this is a helpful little snap shot into the world of neonatology through the eyes of the dietitian. It is an amazing place to be and I enjoy being able to play a small role in so many children's lives.