A Dietitian’s Experience

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A Dietitian’s Experience in the  Neonatal Care Unit Introducing Holistic Nutrition Principles into the Pharmaceutical Model

Table of Contents
Antibiotics for Sepsis
Formula Feeding
Pre-Natal Nutrition
Drugs for Reflux
Outside Education
My vision

Sidebar
Suggestions for Improvement

As increasing populations of infants are born preterm or with genetic abnormalities, there is a rise in demand for dietitians in the Neonatal Intensive Care Unit (NICU). Additionally, in order to reduce hospital costs, neonatologists are allowing dietitians to prescribe nutrition regimes. I would like to share with you my experience working as a dietitian in a hospital’s NICU.

A normal day begins with gathering information on each infant in preparation for rounds. During rounds, each infant’s plan of care is discussed by the neonatologist, nurse, pharmacist and dietitian, and ultimately approved by the neonatologist. Serving in the capacity as a dietitian, I analyze intake, output, electrolytes, acid-base balance and minerals to determine how to feed the infant parenterally (via the veins).

A neonate’s gastrointestinal tract is underdeveloped and cannot tolerate enteral nutrition (breast milk or formula). As the infant grows older and is stable, enteral nutrition is introduced via a gastric tube until the infant develops a good suck and swallow reflex. As a dietitian, it is my goal to establish advancement in enteral nutrition while decreasing the levels of parenteral solution.

In addition to the use of parenteral solutions and gastric tubes, support such as ventilators, oxygen, warm isolettes and medications are often necessary for the infant’s survival. If the interventions offered in the NICU were not available, many of these infants would not survive.

Armed with a solid understanding of the principles taught by the Weston A. Price Foundation and years of education and exposure to holistic nutrition principles, I found I had a broader outlook of healthcare than my coworkers. I immediately realized that if the care of the infants in the NICU included only a small fraction of these nutrition principles, the infants would heal sooner and more fully while requiring less medical intervention.

While working in an NICU, it was my intention to introduce some of these nutrition principles to fellow health care practitioners, substantiated with available research and testimonials. Many of the testimonials include healing methods used by physicians prior to the widespread use of antibiotics.

The ideas I shared were not well received by my coworkers. Unfortunately, the basis of their understanding involved pharmaceutically based medicine and most seem only to desire this limited understanding. I constantly questioned their resistance to learning about new healing modalities and never grasped why these colleagues became angered when I suggested an intervention that carried the possibility of eliminating or decreasing the need for pharmaceuticals, commercial infant formulas or invasive procedures.

There are numerous examples of the clash between holistic, nutritionally based practice and allopathic pharmaceutically based medicine. Here I will discuss the most obvious I encountered, and suggest possible avenues to introduce a shift to improved care by introducing holistic nutritional principles. There are hundreds of references supporting my suggestions, some of which are provided at the end of this article.

ANTIBIOTICS FOR SEPSIS

All preterm infants in the NICU are diagnosed with “possible sepsis” and immediately placed on antibiotics such as ampicillin and gentamycin. This is done routinely, even if the infant is not truly septic. If a fever persists, antibiotics are often continued for a longer period. It is not unusual for an infant to receive antibiotics for more than a month.

In holistic medicine and in medicine prior to the explosion of pharmaceuticals, the infant’s tissue calcium levels would be closely analyzed for prevention and cure of sepsis. Mother’s calcium level would also often be analyzed to better determine infant stores. In the past, proper nutrition played an integral role in the prevention of sepsis.

These days the infant often receives no calcium or vitamin D for a prolonged period. Given the diets of most of the mothers I interviewed, the infant most likely has poor stores as well. Calcium and vitamin D administered after birth along with a closer look at ionized calcium levels and the dietary history of the mothers, could help prevent sepsis. I would also like to see a more frugal approach to the use of antibiotics due to their long-term negative implications.

Probiotics were administered in our NICU with the initiation of enteral feedings and discontinued when the infant reached 2000 grams. Usually, antibiotics are still administered to the infant at the 2000 gram weight. If diarrhea is present or other opportunistic yeasts found in a culture, continuance of probiotics is never considered. The infant is instead treated with more antibiotics.

Probiotics should be administered throughout the infant’s stay in the NICU and even after discharge until healthy bacterial flora is restored.

FORMULA FEEDING

I conducted my own small study. During my first year working in the NICU, 94 percent of infants were discharged with a diet of commercial infant formula. One hundred percent of the new mothers of these infants were able to breastfeed or pump their breast milk. And 100 percent of these same mothers were provided with prescriptions to enter the WIC (Women, Infants and Children) government program. This program provides free formula for the infant for the first six months of life.

The geographic area of this NICU has the highest teen pregnancy rate in the country. Many young mothers confess their intention for having a baby was a larger government paycheck for the family unit, or the fact that they would receive free health insurance if they were pregnant. Often one would find a teen mother living with her parent or grandparent. The infant’s father was rarely present or involved, and was in fact usually unknown.

The average taxpayer cost for an infant in the NICU per day is approximately eighty-five hundred dollars. The average stay in our NICU was thirty-two days. The cost to taxpayers for infant formula provided by the WIC government program in 2009 was approximately eight hundred fifty million dollars.

When I asked these moms why they did not want to breastfeed the typical responses were:

“Breastfeeding is gross.” (This was the most common response.)

“My mom did not breastfeed and I want to do as she did.”

“It is easier to use the formula.”

“Why should I take my time? I have other things going on and I get the formula free.”

“The company says the formula is better for my baby.”

“I don’t get enough milk from the breast pump.”

When I asked nurses, other dietitians and physicians why they do not insist on breastfeeding the typical answer was: “It is not my job. That information should have been discussed at their gynecologist’s office before delivery.”

I feel the true reason many caregivers do not encourage breastfeeding is simply in order to feel better about their personal decisions regarding this topic. Many did not breastfeed their own children and seeing other women choose not to breastfeed helps them justify their own choice.

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SIDEBAR SUGGESTIONS FOR IMPROVEMENT 1. Caregivers should gain a better understanding of long-term antibiotic use side effects and explore nutritional avenues to prevent infection. 2. Caregivers should better understand probiotic therapy and the benefits of continued probiotic therapy after antibiotics are discontinued. 3. Caregivers should gain a better understanding of the importance of breast milk, and understand how the collusion of commercial infant formula and government programs discourages breastfeeding. NICUs should establish a goal that no baby be discharged from the hospital with commercial infant formula, and should instead implement the use of homemade infant formula in cases where the mother is unable to breastfeed or the child cannot tolerate milk proteins or lactose. 4. Caregivers should become aware of and ensure proper and effective implementation of the International Code of Marketing of “Breast Milk Substitutes.” Government should begin investigating code violations and impose appropriate sanctions. 5. Caregivers should gain a better understanding of an adequate diet for pregnant and nursing mothers including healthy saturated fats, adequate protein, calcium, vitamin A, vitamin D, and iodine. 6. Caregivers should become familiar with research outside of that conducted and advertised by the pharmaceutical and food industries.

 

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The International Code of Marketing of “Breast Milk Substitutes” is an established set of recommendations to regulate the marketing of infant formulas established by the World Health Organization. The code was designed to contribute to the provision of the safe and adequate nutrition for infants, and advocates breastfeeding for infants. The code states that informational and educational materials should clearly state the benefits and superiority of breastfeeding. There should be no advertising or other form of promotion of a formula, including handouts, coupons or free formula.

In our NICU, each new mother was given a folder and case from the infant formula company and was sent home with a case of free formula, coupons to purchase future formula at a discount, and a medical prescription for the WIC government program to receive free infant formula for six months.

Yet, it is possible to change the pattern of our infant feeding practices, from formula back to breast feeding. I once worked as a dietitian in a large teaching, indigent care hospital. When I started working there, 100 percent of the infant population was funneled into the WIC program for formula at discharge.

We had a young new pediatrician who understood the cost of the WIC formula program to taxpayers. He found it frustrating that we as taxpayers were “feeding” a baby until it was six months old only because mom found breastfeeding to be a burden to her lifestyle, or found it “gross.”

His policy was that no baby was discharged on formula without a valid reason. These reasons were mastitis, HIV, children who were not leaving the hospital with the mother, or the mother was too ill to breastfeed. Furthermore, if they were going to receive formula from WIC, lots of paperwork needed to be completed with the physician’s signature. He made it difficult for nurses to discharge on formula. After this, very few babies were discharged to the WIC program on formula.

PRE-NATAL NUTRITION

In the NICU, the type of diet mother had during pregnancy was never addressed by health practitioners. Many of these mothers had multiple preterm infants and poor dietary habits never changed from pregnancy to pregnancy. These mothers were never instructed on ways to change their diets in order to have a healthy baby.

When I conducted my own dietary history with many of the mothers, I was shocked at how poor their diets were. I estimated that at least 75 percent of their diets consisted of processed and convenience foods. Nearly half (46 percent) of these mothers were obese.

The foods that these mothers believed were nutritious were almost always products that they had heard advertised on television. When I asked them to define a nutritious food, the answers I most often received were: granola bar, nutrigrain bar, cereal, orange juice, oatmeal, and skim milk. The typical proteins these mothers consumed were fried chicken, hamburgers, or other types of processed meats found in fast food sandwiches. All of the mothers routinely consumed sodas. Their breakfasts typically consisted of sugary cereals.

I surveyed one hundred seventy moms regarding their diets and found that 86 percent did not think a poor diet related to preterm labor or an infant’s development; 100 percent did not know that what they ate would affect breast milk production and quality; and 45 percent did not believe that what they ate affected their own health.

DRUGS FOR REFLUX

There are unlimited examples of the clash between what a holistic/ nutritional practitioner would prescribe and what an allopathic physician would prescribe. One example is frequent use of ranitidine (Zantac) for gastro-esophageal reflux in our NICU.

On one particular day we had eighteen out of thirty-one infants dosed with ranitidine. Ranitidine is recommended by the pharmaceutical industry and is indicated in research for gastrointestinal disturbances such as reflux to reduce the amount of acid produced in the gastrointestinal tract. This medication is contraindicated for reflux in holistic and nutritional therapies as it has the potential to create more problems than what it attempts to treat.

OUTSIDE EDUCATION

Physicians, nurses, pharmacists and dietitians must obtain continuing education hours to maintain their license after graduation. This education most often is offered by the pharmaceutical or food industries whose goal is to sell their products. Practitioners will not be exposed to education outside of these industries unless they seek it out themselves.

MY VISION

I envision a hospital’s health care team that encompasses holistic nutritional modalities in the current pharmaceutically based type of care. This team might include a neonatologist, pharmacist, nurse, properly trained nutritionist, and naturopath.

I envision an approach to health care that focuses on the ability of the body to heal when given the right tools (such as proper nutrition) instead of mandating reactions via pharmaceutical therapies.

I envision every infant fed breast milk, healthier babies, and less of my tax money going to those mothers who find it merely inconvenient to breastfeed.

I envision fewer infants requiring NICU services because mom is healthy (eating well).

I envision mothers’ nutrition education no longer coming from the food industry, whose only goal is to sell product, not keep us healthy.

I envision a world where we no longer see bias around anything that takes away from pharmaceutical or health care profits.

I envision a neonatologist who recognizes and analyzes research outside of the research presented by the pharmaceutical industry.

I envision a world where no one values disease as a way to make a profit.

REFERENCES

Calcium in Critically Ill Children. Journal of Pediatric Med 1989 Jun: 114 (6) 946-51.

Prevalence and Clinical Implication of Hypocalcaemia in Acutely Ill Patients in a Medical Intensive Care Setting. American Journal of Med, 1988 Feb: 84(2) 209-14.

Calcium Spike in Activated Macrophages During Receptor Mediated Phagocytosis. Journal of Leukocyte Biology 2002:72:677-684.

Hypocalcaemia: a pervasive metabolic abnormality in the critically ill. Am J Kidney Disease 2001 Apr: 37(4) 689-98.

Calcium inhibits E. coli-induced diarrhea. Gastroenterology, 2003: 125: 469-476.

Reid, F and others. (Oct 2003) Potential uses of probiotics in clinical practice. Microbiol. Rev. 16 (4) 658-72.

Cooke, J and others. (June 2002) Probiotics in prevention of antibiotic associated diarrhea, meta-analysis. British Medical Journal 324 (7350) 1361.

McFarland, LV and others. (Apr 2006) Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and disease. Am J Gastroenterol 101 (4) 365-72.

Szajewska H and others. (Sep 2006) Probiotics in the prevention of antibiotic associated diarrhea in children. Journal of Pediatrics 149 (3) 367-72.

Kirjavainen PV and others. (Feb 2003) Probiotic bacteria in the management of atopic disease. Journal of Pediatr. Gastroenerol Nutr. 36 (2) 223-27.

Oliveria, V. Food assistance research brief-WIC and breastfeeding rates. USDA.gov July 15, 2003.

Samuels, SE and others. (1985) Incidence and duration of breastfeeding in a health maintenance organization population. Am J of Clinical Nutr: 42 504-10.

World Health Organization (1981) Geneva. International Code of Marketing of Breast Milk Substitutes.

Gartner, SM, Greer FR, Section on Breastfeeding and Committee on Nutrition, American Academy of Pediatrics. Prevention of Rickets and Vitamin D deficiency. New guidelines for Vitamin D intake. Pediatrics 2003: 908-10.

Datta S and others. Vitamin D deficiency in pregnant women for a non-European ethnic minority population. GJOG 2002:109:905- 08.

Rasmussen SA and others. (June 2010) “Pre-pregnancy obesity and birth defects. Am J of Clin Nutr 91:1539-40.

World Health Organization (1996). Iodine deficiency disorders. Fact sheet No. 121. Geneva.

Tyler PE, (June 4, 1996). Lacking iodine in their diets, millions in China are retarded. New York Times A1-10.

Hollowell, JG, and others. Iodine nutrition in the United States. Trends and public health implications, iodide excretion data from National Health and Nutrition Examination Surveys (1971-1974 and 1988-1994). J Clin Endocrinol Metab: 1998:83:3401-08.

Morris L Tateman JK (December 2009). The agenda for continuing medical education – limiting industries influence. N. Eng. J Med 361 (25) 2478-82.

Institute of Medicine, Conflict of Interest in Medical Research, Education, and Practice. Washington, DC. National Academies Press 2009.

Children’s Hospital, Boston, MA. Nutrition studies conclusions tied to funding source. Jan 8, 2007.

Tang and others. Relationship between funding source and conclusion among nutrition-related scientific articles Pub Library of Science 2007:4 (2).

 

This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, Winter 2010.

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