NICU, Genetics, and ketogenics

​So far I have loved the site I’m at. All of the Registered Dietitians (RD’s) are kind and willing to help you learn. At this particular site the interns are scheduled to change services (area’s in the hospital, eg. ICU, GI, Renal, etc.) every weeks with the exception of staff relief. Which means, I still don’t feel like I have a handle on things yet, but I’m off to my next rotation. 

Week four is in the Neotatal Intensive Care Unit (NICU) or you may also header it called the ICN for intensive care nursery. This is one of the rotations I was most nervous for. I was extremely worried that it would get to me, seeing all the tiny babies hooked up to tubes and machines all over the place. It turned out better than I thought. Due to the need for sedation with this vulnerable population many of the babies are sleeping a majority of the time you are there. Seeing all of the tubes can be a little off putting but you generally aren’t up close and personal with these patients for too long. Additionally, its a great opportunity to see NG-Tubes and G-Tubes up close. 

My week in the NICU was definitely a learning experience. Being at a teaching children’s hospital there are a ton of other students that you’ll come in contact with. This was my first week where I was on a team that rounded. Rounding was a different experience, but it also help me realize how grateful I am that I’m not a Med Student! The team I was working with was comprised of the attending physician, a resident physician, a medical student, a pharmacist, a pharmacy student, a social worker, the dietitian, and me. While we were rounding the attending would ask the medical student question realating to the physiology that supported her medical recommendations. That was the moment that made me so thankful that the RD’s I work with are happy to explain everything and don’t expect you to know everything in their specialized area’s because it takes practice. Many of them are extremely knowledgeable in their practice areas because they did it everyday and, not always but, often only have to focus on one disease state. 

My biggest take away from my NICU experience is the stark contrast between pediatric nutrition and adult nutrition. You can see this in other services as well, but in the NICU where disease management and growth are the top priorities, especially with a population that has an insane growth rate without disease, I have learned that the biggest focus with pediatrics is GROWTH. When working with adults you can focus on a set number for calories, protein, and fluid with minor fluctuations, because you are typically looking for weight maintenance and mild weight loss is generally not a big problem if they were previously healthy. However, with pediatrics, especially neonates, they need to be growing or a least maintaining weight for proper development. 

On to week 5, this was my first week that I traveled to a different site. I actually split the week between two different services. I go to class on Monday’s, leaving Tuesday through Friday for my clinical practice. On Tuesday and Wednesday, I was working in the Metabolic Clinic, this clinic specializes in kiddos with genetic disorders, mainly PKU. Then I traveled to the south hospital on Thursday and Friday to work in the Ketogenic clinic. 

During my undergrad we briefly discussed PKU, although it’s rare, it’s one of the more common genetic disorders. However, I learned more about PKU in these two days than in all of my undergraduate. PKU or Phenylketonuria is a genetic disorder where the amino acid phenylalanine can not be broken down into the amino acid tyrosine. Some phenylalanine is necessary for protein building and growth, however, too much phenylalanine build up can cause damage to the brain and lead to a severely diminished mental status. As phenylalanine is  found in protein, it is important for those with PKU to avoid large quantities of protein in the diet. 

My short two days in genetics, I learned about the need for Phenylalanine (Phe) free foods and formula. As most people are diagnosed with PKU shortly after birth, they begin a Phe restricted diet, and require a Phe free formula, usually costing an arm and a leg, and it can be very difficult to get insurance to cover it. As they grow older and can manage their own diets, they may still require Phe free formula to meet their protein requirements, however they learn a more lenient way to “count” Phe in their diet, making it easier to eat socially. In fact, the clinic I was in was even treating an elite athlete, so as you can imagine, the quality of life for those with PKU is increasing, although it is still difficult to manage. Additionally, many people slack off of their diet in their teens and early twenties because they want to eat what their friends are eating and other related issues. 

Overall, I learned so much in the genetics clinic, and not just about PKU, but other metabolic disorders as well. The RD’s I worked with were also very involved in research and showed me some of the papers they were working on. To me this is always interesting to see the dietary recommendations evolve, especially in a population that can have a difficult life. As a student, getting a glimpse at emerging research is also beneficial because I now have an idea of what to expect to see change as I go into practice. 

Like I said, I finished the week in the ketogenic (keto) clinic. However, there was actually a mix up with the scheduling so I did not actually get to see patients on a keto diet face to face, but I learned so much about this under-taught diet. When we typically think of keto, our minds generally jump to a “fad-diet” for weight loss, revolving around a high protein, high fat, low- carb diet, that focuses on putting yourself in a ketogenic state, usually monitored by finding ketones (a byproduct of fat metabolism) in the urine. THAT IS NOT WHAT I AM TALKING ABOUT RIGHT NOW! 

The real ketogenic diet is currently being used to help treat and potentially even cure epilepsy. How the keto diet is created for patients is based on ratios. The true ketogenic diet is a 4:1 ratio. This means that there are four grams of fat to every 1 gram of protein and carbs. Some people find success on a 3:1 ratio or maybe even a 2:1 ratio. While I was in the keto clinic, I got to adjust keto recipes changing the ratios for a patient who was being weened off the diet and needed a lower fat to protein and carb ratio. Although this task was more about adjusting the numbers, my biggest take away is what it looks like to have one of these recipes sitting in front of you.

The chef who develops the keto recipes let me create my own recipe and order up a tray to see what it actually looks like. I decided to make a chicken salad. When I was adjusting the recipes I noticed that they all had a lot of mayonnaise in them, so I thought that it would be good to change it up and add a little more flavor, so I decided to use ranch. No. This was a terrible idea on my part. Although, many of the other 4:1 recipes probably weren’t much better. My chicken salad ended up being about a 1/2 cup of ranch dressing, with two carrots and four chunks of chicken. I really just made a ranch dressing soup. This is a valuable lesson. Always try what you are asking your patients to do. One, you’ll be a better practitioner because you can come up with ideas to make the diets you’re recommending more practical. Two, you’ll have a greater empathy for what you’re asking your patients to do.

The RD’s I worked with were great. One was currently working on her PhD with a focus on the ketogenic diet and was very knowledgeable. She explained to me that there could be other applications for the ketogenic diet because it appears that it may play a role in actually healing the brain rather than just treating the symptoms.  This was another great example of learning from others research, and another thing for me to look for when I am a practitioner. 
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Like I said at the beginning, there was a scheduling mix up and I did not actually see keto patients, but I did have the opportunity to see other patients in the hospital. One of the keto RD’s is also the inpatient dietitian for this site, so I was able to see patients with her and help her with her charting. I even got to see an inpatient with an eating disorder, which I was not expecting but I was an awesome experience. I want to point this out because you’re internship is a lot of what you make it, not just what you are scheduled to do. The way I learn is by asking questions, not necessarily from studying the books. This week they ran out of ketogenic things for me to do but I was given the option to get more inpatient experience. Take the experiences that are offered to you. Sometimes they’ll say you can go home or do a little extra work. Do the work, it will pay off. Sometimes you’ll do the work and still go home early, but your internship is yours, learn what you can.