Clinical Nutrition

Cleft Lip/Palate

This week I was at the Center for Excellence in Disabilities for my dietetic internship. The dietitian at the CED sees children with various disabilities and diagnoses that can affect nutritional status, growth, and feeding/mealtime routine.  Examples of diagnoses include cerebral palsy, autism, cleft lip/palate, Treacher Collins syndrome, stickler syndrome, Pierre Robin Sequence, children with developmental delays, down syndrome, Prader-Willi syndrome, and more.

Although I didn’t see any patients with cleft lip/palate that week, I was able to read quite a bit about it and watch a few educational videos about how to feed infants with cleft lip/palate, and I thought I’d share a bit what I learned!

Cleft lip or palate both occur in the first 10 weeks gestation.  In these first 10 weeks, the left and right sides of the face and the roof of the mouth join together.  When these sides fail to join correctly, it results in an opening of the lip or the roof of the mouth.  These can be “unilateral” – just on the right or left side of the face or palate — or “bilateral” — on both sides of the face.  Cleft lip/palate can occur separately or together, and are present in 1 in 700-800 births.

Complete unilateral cleft lip and palate.

Complete unilateral cleft lip and palate.

Children born with cleft lip or cleft palate or both, will almost always need surgery to correct this condition.  Cleft lip can be repaired in the first 3 months of a child’s life, and cleft palate  can be repaired after the first year of life, at about 12-18 months of age.  Surgery for cleft lip generally follows the “rule of 10” : The child must weigh at least 10 pounds, have a hemoglobin of at least 10, and be at least 10 weeks old.

Besides surgery to close the opening in the lip or palate, children may also need to see a team of professionals in order to get help with their eating, teeth, speech, ears and hearing (fluid buildup can lead to ear infections and hearing problems), and social/psychological development as the years go by. A team of professionals may include ENTs, pediatricians, orthodontists, oral and maxillofacial surgeons, plastic surgeons, prosthodontists, pediatric dentists, speech pathologists, audiologists, nurses, genetic counselors, psychologists, social workers, and dietitians.

Nutritionally, children born with cleft lip/palate at most at nutritional risk at 0-4 months of age.  It can be difficult for a child to be able to breastfeed, especially in those with cleft palate. Formula can spurt out the child’s nose, and the child can have difficulty forming a seal around a baby bottle and having proper suction.  These difficulties with feeding can lead to failure to thrive if not taken care of.

There are tips and tools that parents can use with their infants with cleft lip/palate to make sure their child is getting enough calories.  Holding the child in an upright/45 degree angle position can help limit the amount of formula that enters the nasal passage and comes out the nose.  Special baby bottles that are squeezable are a great aid for infants that need some extra help.  Formula can be squeezed into the baby’s mouth via a “pulse squeeze” pattern.  Babies with cleft lip/palate will also need to be burped more often because they swallow more air during feedings. In more serious cases, such as infants with exceptionally wide cleft palates, a G tube may be needed (feeding tube that delivers nutrition directly into the stomach).

Special bottles that can aid in successfully feeding an infant with cleft lip or cleft palate.

Special bottles that can aid in successfully feeding an infant with cleft lip or cleft palate.

With the help of special feeders and appropriate care via a team of medical professionals, the child should grow normally and go on to lead healthy, happy, productive lives.

Sources:

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Rehabilitation Hospitals

This past week I have been interning at Health South, a rehabilitation hospital here in town. Health South not only operates in West Virginia; it also has rehabilitation hospitals, outpatient rehabilitation satellite clinics, and home care in 27 states as well as Puerto Rico.

What makes a rehabilitation hospital different from a “normal” hospital?  Rehab hospitals provide care for patients who are ready to be discharged from the hospital, but are not yet able to function safely at home.  Many patients leave their stay at the hospital to return to a skilled nursing facility or nursing home, but rehab hospitals are for those that have the goal of returning to a certain level of independence at home.  Rehab hospitals assist in bridging that gap.

A patient’s progress at a rehab hospital is measured by a FIM (Functional Independence Measure) which is a scale that measures physical and cognitive disability.  The scale is made up of 18 components which are ranked from a scale of 1 to 7.  A score of 1 means that the patient contributes to <25% of the task or is unable to contribute (total dependence), and a score of 7 represents total independence. Scores can then range from 18 to 126, with the higher number denoting a higher level of physical and cognitive independence.  The FIM scale includes assessing self-care (eating, grooming, bathing/showering, dressing upper body, dressing lower body, and using the toilet) as well as mobility (transfers from bed to chair/wheelchair/toilet, stairs, walking/using a wheelchair), sphincters (bowel and bladder management), communication (expression and comprehension), and cognition (problem-solving and memory).

Who would be a good patient for a rehab facility? According to Health South’s website, “Anyone who is limited functionally from an injury or illness can benefit from rehabilitation. As a next step in the continuity of care, rehabilitation hospitals restore function and strength so patients can return to their highest level of independence.”  This could be someone who has a traumatic brain injury from a motor vehicle accident, recovering from a stroke/CVA (cerebrovascular accident), a recent amputation, spinal cord injury, pulmonary issue (COPD – chronic obstructive pulmonary disease), or someone recovering from an accident such as a bad fall.

What I’ve noticed in the past week is that you see a lot less tube feedings and parenteral nutrition in rehab hospitals. That is not to say that patients have no troubles with eating, however! Many patients have chewing and swallowing difficulties due to esophageal strictures, dysphagia from a recent stroke, and may have no teeth or use full/partial dentures.  I was able to be in the room and witness 2 barium swallow tests that assessed the patients’ level of swallowing and chewing function in front of an x-ray.  Thin liquids, nectar-thickened, and other foods were tested to see what patients are able to safely swallow.  The National Dysphagia Diets (NDD) have three levels, all of which I have seen on diet orders at the rehab facility:

  • NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
  • NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
  • NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
  • Regular (all foods allowed).

A dietitian at a rehabilitation hospital will assess and evaluate patients when a physician orders a diet consult, or when the patient triggers for another reason. General questions to ask the patient during the assessment include questions about the patient’s appetite, bowel function, any chewing/swallowing difficulties, changes in weight and other questions that apply to the individual patient.  There may be recommendations for a diet change, the addition of an evening snack, or the addition of a nutrition supplement such as Glucerna or Ensure to promote weight gain, weight maintenance, or protein intake.

In addition to dietitians, rehab hospitals also employ a multitude of different health professionals, including physical therapists, occupational therapists, speech language pathologists, x-ray technicians, doctors, nurses, case managers, and pharmacists.  There really is a multitude of different professions working together to help patients regain their strength, endurance, and independence.

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Clinical Case Study

The final project for my 5-week clinical rotation was a case study on a patient of my choosing. I probably saw close to or over 100 patients during this rotation, and the patient I chose was a 5-month old diagnosed with failure to thrive (FTT). The reason I chose this patient because it was in an area I was not so familiar with (pediatric nutrition), and I found the social/environmental cause of it interesting to learn about.  Roanna and I presented our case studies today in front of an audience of 10 Registered Dietitians. I learned a lot from her case study, which was focused on a 25-year old anorexic patient with multiple health issues.  Here is my powerpoint presentation for my case study below.

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November: American Diabetes Month

November is American Diabetes Month, and check out the facts:

  • 25.8 million Americans live with diabetes (8.3% of the population)
  • Approximately 79 million Americans have prediabetes
  • 1.9 million new cases of diabetes were diagnosed in people aged 20 years and older in 2010

And check out this powerpoint I made earlier this year that covers medical nutrition therapy and carbohydrate counting for those with diabetes.

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Lab Value of the Day: BNP

In my clinical rotation, I see different lab values and results every day. Most people probably don’t realize how many lab values Registered Dietitians come across on a daily basis in the clinical world.  Most of these I was already very familiar with, such as glucose, triglycerides, cholesterol, sodium, chloride, potassium, and albumin. But today I came across “BNP” and thought I’d share what I learned.

BNP stands for B-type-Natriuretic Peptide and is secreted by the ventricles (lower chambers in the heart) in response to pressure changes in the heart.  BNP is a predictor of the severity of congestive heart failure, or CHF.  So when heart failure worsens, the level of BNP in the blood increases.  When heart failure is stable, BNP decreases in the blood.  However, those with stable heart failure still have higher BNP levels than those patients with no heart failure.

Levels of BNP in the blood indicate different degrees of severity of the heart failure:

  • BNP levels below 100 pg/mL indicate no heart failure
  • BNP levels of 100-300 suggest heart failure is present
  • BNP levels above 300 pg/mL indicate mild heart failure
  • BNP levels above 600 pg/mL indicate moderate heart failure.
  • BNP levels above 900 pg/mL indicate severe heart failure.

The patient I saw today had a BNP of slightly over 300 pg/mL, which indicates mild heart failure.  I spoke to a dietitian today who said she has seen patients with a BNP level of over 9000 pg/mL (yes, over nine thousand!), indicating severe heart failure.

A study has shown that the BNP blood test accurately predicts CHF 81.1% of the time, while physician’s judgement alone (without looking at BNP levels) is accurate 74% of the time.   While BNP testing isn’t a substitute for years of a physician’s medical experience and knowledge, it is still a helpful diagnostic tool that is also quick and inexpensive.

Sources:

Krause’s Food & Nutrition Therapy, 12th Ed., L. Kathleen Mahan & Sylvia Escott-Stump

http://my.clevelandclinic.org/heart/services/tests/labtests/bnp.aspx

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