A day in the life of a clinical dietitian
Tuesday 28 January 2020
When you’re feeling unwell, food can often be the last thing on your mind. But have you ever wondered how you would stay nourished if you were too sick to eat for a very long time? What if your digestive system stopped working, or you couldn’t swallow?
Clinical dietitians work in Queensland’s hospitals to provide patients with specialised nutrition support. For many of our state’s sickest kids, dietitians at the Queensland Children’s Hospital (QCH) play a vital role in their treatment and recovery.
We spent a day with Sarah, Melinda, Catherine and Martha at QCH to get the inside scoop on what it’s like to be a clinical dietitian, and the role of nutrition in caring for sick children and young people.
The daily huddle
We join the dietetics team first thing in the morning as they have a brief meeting before heading to the wards. The meeting provides an opportunity to discuss complex cases and triage (prioritise) patients for the day. The team is close-knit and supportive, with staff balancing workloads to assist each other and ensure patients are seen in a timely manner.
After everyone provides a brief update, the team disperses to see the first patients of the day.
Staying nourished when you can’t eat
We head to a ward with Sarah Kane, who specialises in parenteral nutrition – a type of nutrition where patients are fed directly into their bloodstream.
‘It’s a ‘last resort’ method of nutrition support that is used when someone can’t eat or it’s not safe to eat, and they can’t be tube-fed,” says Sarah.
Normally, our digestive system breaks food down into smaller and smaller pieces, until it is so small that it can be absorbed from the gut into the blood stream. This means that when someone is fed with parenteral nutrition, all the proteins, carbohydrates, fats, vitamins and minerals they need must be in their simplest molecular form. Instead of being absorbed through the gut, the liquid solution is delivered into a vein typically in the arm or chest. A pump helps administer the solution at a steady rate.
Sarah’s first patient of the day is a 2-year-old boy who has been on parenteral nutrition for a couple of months. His family is learning how to feed him intravenously so he can return home. Sarah explains that while home parenteral nutrition for children isn’t very common, it’s an area that QCH is leading the way in. Each family receives extensive training before heading home, as well as ongoing support through telehealth services.
Sarah is greeted with a smile from the little boy, who is playing on his hospital bed with his mother and grandmother. As well as supporting his medical recovery, parenteral nutrition has helped him continue to grow, learn and play, while his gut can’t tolerate much food or tube feeds.
Sarah gathers information, answers questions, and adapts the little boy’s nutrition plan for the next 24 hours to ensure his unique needs are met. As she talks with the family and plays with the little boy and his dinosaur toys, it’s clear that being able to work with children and their families is a very rewarding part of the job.
“The atmosphere is very different to an adult hospital. People working in paediatrics really want to work in this space, and you can tell,” says Sarah.
“In my role, I get to look after children and families typically over a long period of time and see the impact of my advice on their health, which is very rewarding.”
Keto, but not as you know it
We head to a nearby ward to see Melinda Ziemann as she checks in on one of her patients. One of Melinda’s specialties is the ketogenic diet.
When used in clinical care, the ketogenic diet can reduce the frequency and severity of seizures for children with epilepsy. Melinda says that around half the kids on the ketogenic diet at QCH receive enteral nutrition, which means food is delivered in liquid form through a tube into the digestive system. Sometimes the tube is short term and goes through the nose and down to the stomach, but if enteral nutrition is needed for a long time, a more permanent tube might be placed, which goes directly into the stomach through the belly.
The ketogenic diet has made a big difference in the life of the 3-year-old boy that we visit with Melinda. He is snuggled into a huge, soft floor cushion in his gently lit room. His mum has brought in blankets, an acoustic guitar, and other personal touches to make the room feel more like home.
Melinda finds out how the little boy went overnight from his mum and nurse. They’ve been working together, along with other members of his medical team, to problem-solve tricky medical challenges as they arise. Melinda discusses a few possible changes to his nutrition plan with mum, outlining the pros and cons of each.
As Melinda explains, while her role is to provide expertise on nutrition, the child and their family are the experts on what is best for them.
“Mum knows her son’s medical needs so well because she is always by his bedside,” says Melinda. “Working with kids, their parents are a big part of the team. We make recommendations but the parents have a big say.”
With input from mum, Melinda outlines a plan that she will take to other members of the patient’s medical team, so that everyone is aware of the new developments.
Working in a big hospital can be busy and demanding, but Melinda really enjoys what she does.
“The best part is knowing that you’re making a difference to children and their families.”
Navigating tricky feeding issues together
We journey to one of the many outpatient units to join metabolic and respiratory dietitian Catherine Bonifant, who is in a specialist outpatient clinic called the aerodigestive clinic. It’s for children with health issues that impact their respiratory system and upper digestive tract, many of whom have had multiple surgeries, have faltering growth, and require tube feeding.
Catherine explains that the aerodigestive clinic aims to reduce the appointment burden often experienced by families whose children have complex health needs.
“Instead of attending many separate appointments, the patient attends just one – they stay in a single room, and the specialists visit them one after the other,” says Catherine. “It’s much easier for families.”
In this appointment, a mum and her one-year-old bub are meeting with Catherine and a speech pathologist. They’re working together to navigate some tricky feeding issues while the little boy explores the room with curiosity.
Catherine shows mum a new phone app to help her track bub’s food options and intake, answers questions, and sets a clear plan for the next review appointment. Catherine’s expertise and warm approach help to ease mum’s concerns, and together they confirm the next steps in baby’s nutrition care.
Having worked as a paediatric dietitian for 20 years, Catherine knows that nutrition can make a big difference in the lives of children and young people.
“It’s extremely gratifying to see the significant impact nutrition interventions can have on the young person’s and their family’s life,” says Catherine.
“I like being able to support children and their families, and to work as part of a team to achieve positive outcomes.”
Preparing for a life-changing surgery
Catherine heads into her next appointment while we venture to a new ward and meet with Martha Churchett, a dietitian specialising in renal care, cystic fibrosis, and weight management. It’s a very special day for Martha’s patient, a 14-year-old boy on the renal ward.
“He’s getting ready for a kidney transplant – he just found out this morning,” says Martha. “Usually we’d catch up about how he’s going with his food and fluid restrictions, but now we’ve started to talk about how his diet will change post-transplant.”
We say hello to Martha’s patient, who responds with a huge smile; it’s a reflection of just how important today is for him. Martha chats with her patient while he receives dialysis, a process which uses a machine to filter the blood of waste products instead of the kidneys.
“There are many potential dietary restrictions for people with renal conditions, including limits on sodium (salt), phosphate, potassium, and fluid. It all depends on their individual situation,” says Martha. “We know it can be really hard for patients to manage these restrictions—imagine a diet with limits of meat, dairy, fruit and vegetables—so it’s helpful to have a dietitian to problem solve with.”
Martha checks in with the patient’s father and the nursing staff and confirms a few details that will inform her nutrition care plan moving forward. As there’s a lot for the patient and his family to take in today, she keeps her visit short. She will see him again soon after the transplant surgery.
“The best part of my job is definitely seeing the impact that nutrition can have and the positive changes in kids’ lives – whether it be weight gain, weight loss, improving symptoms, or feeling better and having more energy.”
It’s not always about eating your greens
A day in the life of a clinical dietitian can take all different shapes and forms, and it can sometimes surprise people to learn just how life-saving nutrition intervention can be.
“People are often unaware of the complexities of our role and the areas in which we’re involved,” says Catherine. “For example, the management of the metabolic disorder phenylketonuria (PKU) is purely diet. Poor adherence to diet long-term can cause brain damage. Therefore the diet is hugely important.”
“It’s so different from what people expect,” adds Melinda. “It can surprise people to learn that we often feed through tubes and use special feeds to match a child’s medical condition. And they don’t realise just how much maths is involved.”
Dietitians aren’t the food police – they’re not judging your plate at the family BBQ – and they aren’t spending their days spruiking unproven diet supplements on social media. Instead, they are supporting people from different walks of life on their journey to better health and wellbeing.
“There’s much more to being a dietitian than getting people to eat their fruit and veg,” says Sarah.
“For me, it’s about working with both kids and their families to help them becomes the healthiest and happiest they can be,” reflects Martha. “And no, I don’t have an Instagram account!”
Thank you to Sarah, Melinda, Catherine, Martha and the Dietetics and Food Services team at the Queensland Children’s Hospital, Children’s Health Queensland Hospital and Health Service, for their time and insights, and to the families who generously allowed us to share their stories.