OH HEYYYYYYY TODAY I PASSED MY RD EXAM! Registered Dietitian right here, hollaaaa! I haven’t wrapped my mind around it yet. So in the meantime, here is a long overdue post about my last internship, in which I interned in the Neonatal Intensive Care Unit (NICU) in a hospital in Winston-Salem, NC.
We’ll start with a lovely photo from the corporate lactation meeting I attended, as one does.
To be clear, corporate lactation= meeting of lactation consultant managers from the various hospitals belonging to one corporation. Not some weird business milk-a-thon.
The meeting was really more of a retreat, at one of the lactation consultant’s lovely lake houses. So interesting to see all the complicated aspects of providing this care- both the science of helping mothers, and the management/business side of things of dealing with billing, charging for nursing supplies, etc.
Because the meeting took place in the South, there were of course complimentary meals. Say what you will about the South (and I have plenty to say, especially about the total nonsense that has been going on in NC), I really love the Southern tradition of hospitality. AKA feeding everyone who comes anywhere near your home/office, anytime resembling a meal time. It reminds me of my family’s Greek tradition 😀
This was chicken chili that was SO SO GOOD. Especially eaten by the lake.
Okay so let’s talk life in the NICU. Here is a bed and an Elmo diaper awaiting a baby!
Working with a NICU dietitian was SO interesting. To review my preceptor:
- Does nutrition assessments on the NICU babies and made recommendations to the medical team about feedings. For example, adding extra protein for a baby whose growth was poor, or adding MCT oil for a baby who seemed to be having trouble absorbing nutrients. Sometimes we had to fight with the doctors because they would “forget” about our policy not to ever use powdered formula in premature babies (here’s why) and do other silly things because doctors are sometimes silly.
- Conducts hospital based research in the NICU, mostly related to breast feeding.
- Serves as a lactation consultant for moms with a baby in the NICU (helping with breastfeeding and pumping).
I was especially lucky because my preceptor was honestly so busy she just let me work independently out of necessity, so I would get to go on rounds with the NICU medical team (attending physician; nurse practitioner and/or resident and/or medical student, who’d present each case; nurses; sometimes pharmacist; sometimes social worker).
Things you worry about in premies (obviously the neonatologists are thinking of a lot more things; managing ventilators and temperatures and crazy things like that. I’m concerned with the nutrition side of things, which is obviously also very important in premies):
- Intake of the right nutrients. Breast is best, and that’s also true (though harder to document) in premature babies. However, premature infants aren’t really supposed to be out of the womb drinking milk- they’re supposed to be in a uterus, drinking amniotic fluid, not having to breathe, etc. So while human milk is the bomb, in the NICU, premature infants have to have their milk mixed with human milk fortifier, aka HMF, which adds extra nutrients, among them protein and bone-building elements like calcium. As someone crunchy it pains me to see HMF, a cow’s milk product going into a premature baby whose mother has abundant breast milk. Which is why it’s so exciting to see that there has now been a HMF developed that’s made using entirely breast milk!
- Immature guts. You want to give them breast milk so they get the immune benefits (and because women’s bodies are amazing and worthy of awe, breast milk produced by mothers of premature infants is higher in protein and calories than the milk of mamas of term babies). However, feeding them too much too early can overwhelm the cells of the developing intestines, which can only absorb so much. Your worst case scenario is necrotizing enterocolitis, in which the cells of the intestines literally start to die. This can result in a baby needing surgery (and potentially getting a lot of their gut removed, resulting in short bowel syndrome or other issues with absorbing nutrients). This can also result in the baby’s death. The good news is that babies who get breast milk instead of formula are much less likely to get it (and in our hospital- and many others- we had the policy that preterm babies who were below the age of highest risk of NEC- about 34 weeks- qualified for donor breast milk if their mama couldn’t provide her own milk).
- Immature brains- it FREAKED ME OUT how routine brain bleeds were. Like, they only treated them if they were severe. Like, wut?!
- Reflux. I know that’s par for the course with term babies and is just an annoyance; but in preterm babies when they reflux they often stop *breathing*. This is obviously a real big problem.
- There were babies on crazy amounts of antibiotics. Obviously an infection can decimate even a term baby’s immature immune system and kill them so so quickly, and premature babies are even more at risk- I am not at all critizing antibiotics use. However, it’s a little scary to think of the effects of removing all bacteria, good and bad, from these babies’ newly developing systems. It’s also scary seeing them on vancomycin and other antibiotics of last resort when they’re this little. What happens if they get older and get sick again and the antibiotics don’t work?!
In other news, I GOT TO SEE A C SECTION.
A team from the NICU is always present during a C section (and also during vaginal deliveries when they see meconium in the amniotic fluid, and I’m sure other higher risk conditions too). Dude, C sections are INTENSE. I was pleased with myself that I still seem to have a solid tolerance for blood, cause it was all graphic! The incision is small (I mean it’s bigger than baby’s typical exit route- and seriously, GO MOMS FOR MAKING THAT HAPPEN) and it is pretty rough process on the baby- I saw one doctor kind of stick her hands behind this bump in the belly from the outside and start shoving HARD and the other doctor dig his hand inside the incision and yank the baby out by the head. After they announce the baby is out, a nurse hits a timer and they wait 30-45 seconds to clamp the cord (I thought delayed cord clamping was just a practice used for premies but they do it for all babies at this particular hospital). Then they bring baby around to see mama for a minute (they have a big sheet hanging up so mom doesn’t see the doctors cutting into her body, just like in the movies) and then they bring the baby over to the warming table. Ordinarily, this would be pretty much the end of the role for the NICU team- they smack the baby on the feet and rub the baby off with some towels and then the baby cries. BUT. This baby had to be revived and wasn’t breathing. It was amazing watching the NICU team at work- one had a stethoscope to the baby’s chest and would hold up her finger in time with the heartbeat, another put an oxygen mask on the baby and started CPAP, and they continued to try to stimulate and annoy the baby enough to start crying and breathing. But it ended up that the baby needed to be intubated! It all happened SO QUICKLY and SO EFFICIENTLY. I was really in awe of this team.
Fortunately, I followed that baby’s case and the baby was fine and was discharged fairly quickly. However, I’m sure it was terrifying for mom and dad (the mother’s first question was “Can I still breast feed?” because WOMEN ARE AMAZING. And she did!)
While there are circumstances you cannot control (as in the case above, in which they ended up thinking the baby had aspirated meconium and that’s why it was so difficult for the baby to start breathing), there are some you can.
How to keep your baby out of the NICU:
- Know your STD status! Seriously. They can be managed beautifully, but only if we know about them and mama does what she needs to do to prevent transmission to her baby. I saw HIV positive mamas do a beautiful job with managing their medication during their pregnancy to prevent disease transmission to baby. However, I also saw babies in the NICU because mama had never gotten a herpes diagnosis. Yes, herpes is a drag as a grownup but if you are a baby delivered when there is an active outbreak, or without mom being treated with an antiviral, you are at HIGH RISK of getting encephalitis and dying. It is scary business. And unfortunately we saw a lot of cases where partners have not been honest about their status, so don’t rely on them for truthful information (isn’t that terrible?!)
- Get your diabetes managed before pregnancy. That means get your sugars tested to make sure you aren’t diabetic before getting pregnant (in general, a pre-conception visit to your medical provider is a really great idea).
- If your sugars are running high during your pregnancy they are going straight to the bebe. That means you can end up with a really really big baby and increased risk of all kinds of dangers at delivery (the baby getting stuck on the way out and getting shoulder dystocia, which can lead to permanent nerve damage; increased likelihood of a C section and all the attendant risks).
- Also, glucose crosses the placenta but not insulin. That means that your baby gets a steady diet of SUGAR SUGAR SUGAR while they’re in the womb and their poor little pancreas has to work overtime to get the sugar out of their blood and into their cells. Then, when the baby is delivered and cut off from their mama’s blood supply, their SUGAR SUGAR SUGAR abruptly ends too, but they still have all this insulin. That leads to hypoglycemia, which can make a baby critically ill and mess up their brain. It also usually ends up with baby in the NICU to be observed, separating baby from mama and making establishment of a good breastfeeding relationship much harder.
- But wait there’s more! Mamas with uncontrolled diabetes also deliver babies with more birth defects (major congenital anomalies occur two to four times more often in infants of diabetic mothers than in infants with non-diabetic mothers- things like mis-formed spinal cords- bad news!) The good news is that a lot of this risk seems to be associated with poor glucose control in the first trimester, so if you can get your diabetes under control before pregnancy, your baby is at much lower risk.
- Be a healthy weight before pregnancy. Being obese increases your risk of all the dangers of a big baby discussed above. But being underweight is also a problem- it’s a risk factor for preterm birth.
A few other non-medical conclusions I came to in the NICU
- Research is horribly difficult and I commend anyone who does it. Obviously it’s no secret that conducting a methodologically sound study requires a lot of attention to detail, but I was kind of blown away at quite how much there was when I helped my preceptor on her manuscript about human milk feeding in the NICU and brain development at 18 months. By the time I came on board the important decisions had already been made about how to track the data, what covariates to analyze, etc., but those decisions had taken relatively little time in the grand scheme of just the lengthy to do list for the project. Sometimes I feel like “Oooh, I’m so fancy, I have a masters degree, I know fancy things about biostatistics” and then I got very humbled doing the actual sausage-making of research. Also, there was a huge capacity for human error! I assume my preceptor will end up submitting spreadsheets we made along with the completed manuscript for publication, but the reviewers basically just have to trust us that we didn’t make up the numbers! That we didn’t make math errors (there is WAY TOO MUCH DATA to check each individual calculation- I did my best to check as I went but I wasn’t about to go back and go through everything!)
- Breastfeeding is also difficult. Premature babies don’t at all have the reflexes to actually nurse at the breast until ~34 weeks gestation but even then, even at full term, it can be very very difficult! It’s a lot to ask of the baby (creating a vacuum with their mouth, which is impossible if there’s an anatomical defect; properly coordinating sucking and swallowing; staying latched on and in the right position; grabbing enough tissue with their mouth to effectively remove milk, etc.) and it’s a lot to ask of the mama (especially deciphering a baby’s hunger and fullness cues, and figuring out whether baby has actually gotten enough since the whole process is basically invisible). It’s amazing and beautiful and we need to give nursing mothers all the support we can. Everyone who wants the Affordable Care Act/”Obamacare” to be repealed- know that you’re taking away insurance coverage for breast pumps and lactation counseling for new moms.
- Mothers still die in childbirth. We saw it happen once and it was awful awful awful. The NICU nurses (obvi amazing human beings) did everything they could to support the father and this new baby. And the hospital waived their usual policy not to give donor milk to older babies and gave this sweet little baby donor breast milk. But it is SO TERRIBLE that it happens. I think about everything my mother has been to me, for all 28 years of my life, and can’t imagine the kind of hole that leaves for the rest of a family to try to fill.
- Watching a family together after the birth of a child gave me All The Feels. You look and you think, God, this should be such a perfect unit. Mama is this amazing baby-grower and milk-provider, and Daddy is there all supportive and anxious on behalf of mama, and they are both so so tired, and so so excited. I would think about how statistically in the coming years many of these unions would not stay intact, and many of these mothers would be left on their own (or fathers, as above). And it made me so, so sad. All these new humans avoided to be surrounded with this safe, protective love. There were lots of extended families at the hospital, which was beautiful and lovely, but honestly there were times I went into a family’s room and there was this exhausted woman who clearly wanted to just pass out and there were scads of relatives sitting on the bed and making noise. There’s something beautiful about just a baby and the two people who made it sharing this little space for awhile. (Caveats: the two people who made it can of course be two men or two women. It’s just so hard for someone to do it all alone, even if they have the support of more distant relatives!)
- Now for a briefly horribly depressing note. One day I was taking the elevator upstairs to the NICU and sharing it with me were a pregnant woman in a prison uniform and the police officer accompanying her. My sincere hope was that she was there for a prenatal appointment and would be out of jail by the time she delivered. It still upset me- but that wasn’t even the part that I’m writing about. I told my preceptor how I’d winced seeing the woman. She said, “Yeah, what we see is typically that women who are victims of abuse are the ones who get in trouble with the law. They are in abusive situations and try to get out but don’t do a very good job.” Then she shared a horrifying story with me which you have permission to skip. So two new parents went and visited their brand new, preterm baby in the NICU. Then they walked back to return to the mother’s room in Mother Baby. As the mother walked through the door with her back to the father, he pulled out the gun he had brought to the hospital and shot and killed first her and then himself (story about the case here). I have actually struggled to talk to anyone about how much this upset me. At this point, my preceptor began explaining to me about the new safety precautions the hospital was taking since that incident (the NICU will be a locked unit, people will have to present their ID each time they want to come in, people with a criminal record will be banned. Though I heard no talk of metal detectors or anything preventing guns coming in, *sigh*). As my preceptor wisely pointed out, people in hospitals are VULNERABLE. They’re sick, they’re weak, they may have been hospitalized because they’d already been victimized in some way. I have unfortunately witnessed in my personal and professional life that domestic violence may come to a head during a pregnancy. When I was at Wake Forest (more on that later), there was a baby born with a brain bleed that was attributed to the physical abuse inflicted on his mother. SO. Public service announcement. Those of us who are RDs, or RNs, or anyone in health care, we come into contact with vulnerable populations EVERY DAY. Regardless of your setting, think of who you encounter: Older adults. Children. Pregnant women. People who are poor. People who are homeless. People with disabilities. If nothing else, we need to have the statistics in the back of our mind and we have to be aware that if it’s that common, we should be looking out for it. 1 in 3 women and 1 in 4 men are victims of some form of physical violence from a partner in their lifetime. In the last year tracked, there were 108 cases of domestic violence related homicide in North Carolina. The NC Coalition Against Domestic Violence has some warning signs to look for here. Let’s be real- it’s probably fairly easy to miss domestic violence in many patients. Yes, most hospitals work some kind of screening into the questions they ask a patient on admission (i.e. “Do you feel safe at home?”) but a bored looking CNA asking this question to someone who’s likely in physical pain and just wants to get to a doctor is not likely to elicit the most meaningful information (especially if the abusive partner has accompanied the victim to the hospital). Once the medical team gets to a patient, they’re very focused on the “Problem List” of physical ailments. Hopefully the nurses can catch something- Lord knows, they seem to know everything about patients! But I still maintain that if we’re going in to patients, we’re asking open-ended questions and coming across as sympathetic and like we may have more time to listen to someone than the average doctor who zooms in and out of their room, that we should pay attention if we end up getting a cry for help from a patient. However small. I’m not suggesting any of us go in and try to save the day, but a well-timed phone call to social work tipping them off that you got a weird vibe may be helpful. Other settings may have other things RDs can do which could help protect victims of domestic violence. Arranging for a ride for someone who has no car, who has been socially isolated by an abusive partner, who just wants to get to her mom’s house (which my preceptor did for a WIC mother last summer at the health department). Providing information on safety planning ( <— this site has really good information for pregnant women) for someone who may not be ready to leave an abusive relationship today but wants to maybe start taking steps toward doing it in the future (and needs to protect him/herself as much as possible in the meantime). Finding a pretense to get a patient alone to make sure there isn’t something that they want to say but are afraid to have an abusive partner witness.
More intense business: I also got an opportunity to spend a few days at Wake Forest’s hospital because they have a Level IV NICU. That means I got to see babies with more serious conditions such as:
- Babies with congenital abnormalities that are beyond what can be addressed at a smaller hospital (there was a baby who they were wondering could’ve been affected by Zika aaagh!)
- Babies who need ECMO. I did my case study on ECMO this summer and it’s crazy- like dialysis but it’s doing the job of your lungs and/or heart instead of the job of your kidneys.
- Babies who needed surgery. Sometimes due to congenital abnormalities, sometimes due to complications they’ve suffered due to prematurity (like necrotizing enterocolitis, brain bleeds, retinopathy of prematurity etc.) Look at this gorgeous diagram below!
Seeing the RD in action at Wake Forest was AMAZING. She was definitely practicing at the top of her field and they actually had HER teaching the MEDICAL RESIDENTS how to do things (this is a big deal; if you work in health care or know anyone who does you are probably aware of the many God Complexes on display in the medical field).
However, it was really intense seeing how sick these babies were. When trying to feed the babies, the dietitian and doctors have a LOT they are working against- fluid restriction is common with the lung complications many babies have, many of the babies end up fat restricted (we saw one baby whose triglycerides were over A THOUSAND- normal is 150 or less- so they quickly had fats removed from their IV for a few days), many end up dextrose restricted (because they end up with crazy high blood sugars and insulin in neonates doesn’t tend to support lean body mass growth, only the growth of fat cells; so they tend to try to restrict the dextrose rather than adding insulin), they have all kinds of acid-base imbalances which can only be addressed so much with manipulating the oxygen-carbon dioxide exchange in the ventilator and also involves manipulating what’s added to the IV. All of these things result in babies getting LESS nutrition, and it’s horrifying seeing these shrinking babies (there was one baby who did not gain any weight for a MONTH- the prognosis was very poor).
In the long run, I don’t know if it would be too sad working with these sick babies with such limitations in their recovery. But I know it was really energizing being in a teaching hospital where amazing research takes place. Seeing all the medical teams bustling around was really exciting (and let’s be honest, there were some extremely good looking surgical residents. Greys Anatomy in real life!)
Something else that stuck out to me about Wake Forest was their AWESOME cafeteria. Stealth health at its finest- check out this gorgey burrito bowl!
So it looks pretty standard buttttt…
- It contained a ton of veggies (I chose butternut squash and asparagus), lean protein (black beans and shrimp), tasty but heart-healthy toppings (hot peppers, corn salsa, and guacamole; and no cheese!), and portion controlled fatty stuff (just a wee bit of the chip strips was enough to give a satisfying crunch)
The hospital where I was most of the rest of the time was much less exciting, and expensive, cafeteria-wise.
So I mostly went to the Starbucks and got too many pumpkin spice lattes and (SO GOOD, why had I not known about these before?!) bean chips.
As for the ol’ social life, as I did this summer, I joined a gym just for the duration of my internship. Working out is so so good for mental health. Also, honestly, in a town with not that much to do in the vicinity of my housing, I might as well do something life-affirming (exercise) instead of something self destructive (watch Netflix every day from 6pm til I go to sleep).
Sometimes my legs die and I have to sit like this for awhile.
I didn’t super socialize with my roommates in my student housing- I was lucky enough to not have to share a bedroom the whole time, which was SO NICE and SO not a guarantee- I just got lucky. I did, however, learn that one of my roomies had a birthday two days apart from mine so we and our other roomie at that time embarked on an Italian cuisine adventure at Di Lisio’s.
I got the gnocchi with pesto which was BOMB and lasted me two delicious meals.
Then one other night my friends Kyle and Shaylen were in town (Kyle was looking at Wake Forest Law School) and we met up for dinner. They asked me for a recommendation and I was like “Er, I mean the only place I’ve really gone is Krankie’s but I know it’s delicious and a fun hipster scene.” So I went again!
This was a hoppin’ john esque creation: rice, black eyed peas, greens, and YUMMY chow chow (kind of a tangy/sweet onion relish?) on top. Plus cornbread.