A Dietitian’s Experience Working in a Neonatal Intensive Care Unit:

Ideas to

Integrate Holistic Nutrition Principles into the Current Pharmaceutically Based Model

by Kim Rodriguez, RD

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 (a meeting). During rounds, each infant’s plan of care is discussed by the neonatologist, nurse, pharmacist, and dietitian and ultimately approved by the neonatologist. As a dietitian, I analyze intake, output, electrolytes, and acid/base balance and minerals to determine how to feed the infant parenterally (in 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 a good suck and swallow develops. 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 incubators, and medications are often necessary to 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 find that I have a broader outlook on health care than do my coworkers. I immediately recognized 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 that I shared were not well received by my coworkers. Unfortunately, the basis of their understanding involves pharmaceutically based medicine and most seem to only desire this limited understanding. I constantly questioned the resistance to learning about new healing modalities and never grasped why anger was demonstrated when an intervention was introduced 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 that I encountered, with possible avenues to introduce a move to improved care by introduction of holistic nutritional principles. There are hundreds of references supporting my suggestions, which I found overwhelming to list for purpose of this discussion.

A Better Understanding of the Side Effects of Long-Term Antibiotic Use and the Exploration of Nutritional Avenues to Prevent Infection

All preterm infants in the NICU are diagnosed with “possible sepsis” and immediately placed on antibiotics such as ampicillin and gentamicin. 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 be given antibiotics for more than a month.

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

Often the infant 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 would help prevent sepsis, along with a closer look at ionized calcium levels and the dietary history of mother. I would also like to see a more frugal approach to the use of antibiotics dues to their long-term negative implications.

Bovee-Oudenhoven IM, Lettink-Wissink ML, Van Doesburg W, Witteman BJ, Van Der Meer R. Diarrhea caused by enterotoxigenic Escherichia coli infection of humans is inhibited by dietary calcium. Gastroenterology. 2003;125:469–476.

Cardenas-Rivero N, Chernow B, Stoiko MA, Nussbaum SR, Todres ID. Hypocalcemia in critically ill children. J Pediatr. 1989 Jun;114(6):946–951.

Cardenas-Rivero N, Chernow B, Stoiko MA, Nussbaum SR, Todres ID.Desai TK, Carlson RW, Geheb MA. Prevalence and clinical implication of hypocalcemia in acutely ill patients in a medical intensive care setting. Am J Med. 1988 Feb;84(2):209–214.

Myers JT, Swanson JA. Calcium Spikes in activated macrophages during Fcgamma receptor-mediated phagocytosis. J Leukoc Biol. 2002;72:677–684.

Zivin JR, Gooley T, Zager RA, Ryan MJ. Hypocalcaemia: a pervasive metabolic abnormality in the critically ill. Am J Kidney Dis. 2001 Apr;37(4):689–698.

A Better Understanding of Probiotic Therapy and the Continuation of Probiotic Therapy After Antibiotics Are Discontinued

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 when 2000 grams is reached. If diarrhea is present or other opportunistic yeasts cultured, continuance of probiotics is never considered. In this case, the infant is 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.

Cooke J et al. Probiotics in prevention of antibiotic associated diarrhea, meta-analysis Br Med J. June 2002;324(7350):1361.

Kirjavainen PV et al. Probiotic bacteria in the management of atopic disease. J Pediatr Gastroenterol Nutr. Feb 2003;36(2):223–227.

McFarland LV et al. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and disease. Am J Gastroenterol. Apr 2006;101(4):365–372.

Reid F et al. Potential uses of probiotics in clinical practice. Microbiol Rev. Oct 2003;16(4):658–672.

Szajewska H et al. Probiotics in the prevention of antibiotic associated diarrhea in children. J Pediatr. Sep 2006;149(3):367–372.

A Better Understanding of the Importance of Breast Milk and of the Impact Commercial Infant Formula Use Has on Government Programs; Establishing a Goal That No Baby Discharged from the Hospital Is Taking Infant Formula, and Implementation of the Use of Homemade Infant Formula in Cases Where Mother Cannot Breast-Feed or in Problems Tolerating Milk Proteins or Lactose

I conducted my own small study. During my first year working in the NICU, 94% of infants were discharged with a diet of commercial infant formula. Of this 94%, 100% of these mothers could breast-feed and/or pump their breast milk. Of this 94%, 100% were provided with prescriptions to enter the WIC (Women, Infants, and Children) government program, which provides free formula for the infant for the first 6 months of life.

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

The average taxpayer cost for an infant in the NICU per day is approximately $8500. The average stay in our NICU was 32 days. The cost to taxpayers for infant formula provided by the WIC government program in 2009 was approximately $850 million dollars.

When I asked these mothers why they did not want to breast-feed, the typical answers were:

• Breast-feeding is gross (most common answer).

• My mom did not breast-feed 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 that 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 breast-feeding, the typical answer was: “It is not my job. That information should have been discussed at their gynecologist’s office before delivery.”

I think the true reason that many caregivers do not encourage breast-feeding is simply to make themselves feel better. Many did not breast-feed their own children, and seeing other women choose not to breast-feed helps them justify their own choice.

Oliveria V. Food assistance research brief-WIC and breast-feeding rates. USDA.gov.

July 15, 2003.

Samuels SE et al. Incidence and duration of breast-feeding in a health maintenance organization population. Am J Clin Nutr. 1985;42 504–510.

Become Aware and Ensure Proper and Effective Implementation of the International Code of Marketing of Breast Milk Substitutes; G overnment Should Begin Investigating Code Violations and Impose Appropriate Sanctions

This code is an established set of recommendation 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 that infants be breast-fed.

The code states that informational and educational materials should clearly state the benefits and superiority of breast-feeding. 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 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.

World Health Organization. International Code of Marketing of Breast Milk Substitutes. 1981. Available at http://www.who.int/nutrition/publications/code_english.pdf.

A Better Understanding of an Adequate Diet for Pregnant and Nursing Mothers Including Healthful Saturated Fats, Adequate Protein, Calcium, Vitamin A, Vitamin D, and Iodine

In the NICU, the type of diet that mother had during pregnancy was never addressed. Many of these mothers had multiple preterm infants; poor dietary habits never changed and they were never instructed on ways to change their diets to have a healthy baby.

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

The foods that they believed were nutritious were almost always products that they had heard about on television. The answers that I most often received when asking what is a nutritious food were: granola bar, Nutri-Grain bar, cereal, orange juice, oatmeal, and skim milk. The typical proteins consumed were fried chicken, hamburgers, or other types of processed meats found in fast-food sandwiches. All mothers routinely consumed sodas. Breakfast typically consisted of sugar cereals.

I surveyed 170 mothers regarding their diets. This is that I found:

86% did not think that a poor diet related to preterm labor or infants development

100% did not know that what they ate would affect breast-milk production and quality

45% did not think that what they ate affected their own health

Datta S et al. Vitamin D deficiency in pregnant women for a non-European ethnic minority population. BJOG. 2002;109:905–908.

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. 2003:908–910.

Hollowell JG et al. Iodine nutrition in the United States. Trends and public health implications. Iodide excretion data from National Health and Nutrition Examination Surveys I and III (1971-1974 and 1988-1994). J Clin Endocrinol Metab. 1998:83:3401–3408.

Rasmussen SA et al. Pre pregnancy obesity and birth defects. Am J Clin Nutr. June 2010;91:1539–1540.

Tyler PE. Lacking iodine in their diets, millions in China are retarded. New York Times. June 4, 1996;A1–A10.

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

A Better Understanding of Research Outside of the Research Conducted and Advertised by the Pharmaceutical and Food Industry

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

On one particular day, we had 18 out of 31 infants taking 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/nutritional therapies – known to have the potential to create more problems than what it attempts to treat.

Physicians, nurses, pharmacists, and dietitians must obtain continuing education hours to maintain licensure after graduation. This education most always is offered by the pharmaceutical or food industries, whose goal is to sell product. Education outside of these industries is not received unless sought out by the practitioner.

Children’s Hospital Boston. Nutrition studies’ conclusions tied to funding source [online article]. Jan 8, 2007

Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice. Washington, D.C.: National Academies Press; 2009.

Morris L, Tateman JK. The agenda for continuing medical education – limiting industry’s influence. N Eng J Med. December 2009;361(25):2478–2482.

Tang et al. Relationship between funding source and conclusion among nutrition-related scientific articles. PLOS. 2007;4(2).

Conclusion

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 neonatologist, pharmacist, nurse, properly trained nutritionist, and naturopath.

I envision a focus on the ability of the body to heal itself given the right tools (such as proper nutrition) instead of mandating reactions via pharmaceutical therapies.

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

I envision fewer infants’ requiring NICU services because mothers are 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 recognizing and analyzing research outside that presented by the pharmaceutical industry.

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

Kim Rodriguez, RD

“Aiken Nutrition,” offering private nutrition consultations

Chapter leader, Weston A. Price Foundation; Aiken, SC