In recognition of Nutrition Awareness Month, I was delighted to interview two Registered Dietitians at Connecticut Children’s about the ins and outs of their clinical nutrition program in the Milk Room, NICU and Pediatrics floors. Thank you to Jennifer Zarrilli, MS, RD, CD-N and AnnMarie Spizzoucco, RD, CD-N for the insightful and candid interview!
1. What do you wish providers & staff knew about what you do?
JZ: The work of the dietitian goes beyond healthy eating. Instead, we are really in there with the medical team making suggestions for medical nutrition therapy to treat chronic diseases. Some diseases have specific nutrition therapy that is the treatment for the disease.
We are also prescribing parenteral nutrition and tube feedings that keep children alive. A lot of people don’t realize, as nutritionists, we do these things along with all the other things we do to promote health throughout the child’s life to ensure proper growth and development, as well as disease management.
AS: As NICU dietitians, we have an integral role in the interdisciplinary team. We round with the teams each day and provide nutrition recommendations. We assess patient growth, which is known to have such a significant impact on neurodevelopmental outcomes. We work with our nurses and lactation consultants very closely to assess when patients are ready to start oral feedings and what would be the best plan. We’re involved in developing a discharge plan and following some of our patients in the NICU follow-up clinic.
2. Now that you’ve had a milk room for over a year, what advice do you have for other hospitals looking to implement one?
AS: I am very excited about the milk room. I have been a NICU dietitian for over 15 years and this has been one of our goals since I started. We are excited because we know it increases our safety standards. It is so important to verify you are feeding the right milk to the right baby and that you are preparing the milk with aseptic techniques. I do love the barcode scanning system. We know once we give our labels to moms, they take them home to scan the milk, and one they bring milk back in so we can verify and validate we are using the correct milk for the correct baby. We also scan our fortifiers so we know we are not adding an incorrect fortifier.
Some of our babies have allergies or intolerances and it is really important they receive the correct additive to prevent any type of anaphylaxis, reaction or intolerance so I am very excited about that. I think it is great to prepare the milk outside of the NICU to decrease the risk of infection and knowing it is a safe environment. Also, now we are using the milk in the correct time frame as we know there is an expiration linked to that specific feeding. Our milk techs are preparing every 12 hours so we are able to make changes to the feedings. In the past we mixed milk on the unit and sometimes mixed for 24 hours, so we had to wait to make the adjustment. But now the techs are able to make the change at the next 12-hour prep.
JZ: Having our own room has helped us reduce waste, especially using the Keriton systems. When we have our monthly calls, we can see how many near misses of feeding expired milk or formula there were. It is so good to see the scanning system in place to prevent that. In the past, they could have received an expired feed or the wrong feed. It has been really helpful to have that double check with breastmilk and formula. We have had great communication with our nurses and our milk techs. I think the nursing team really appreciates all the work the milk techs do. I think it is a more accomplished position just from when we were preparing formulas. We are able to provide fortification for smaller volumes. We are really able to meet the needs of the sickest infants that way.
AS: The benefits of having the milk room along with the barcode scanning system is ideal. I love the ‘view inventory’ feature. In the past we didn’t know what we had in our freezer. We wouldn’t know when moms were pumping. We wouldn’t know what their volumes were. It is optimal to have the capability to look, and to see what moms’ inventories are. It helps guide me even when I am on rounds. If the nurses report the babies are having really watery stools, I can go into the app and see what mom is pumping. One of our moms was pumping 16oz every 3 hours, and that is an optimal situation for mom to pump to hind milk. I wouldn’t have known that if I didn’t have the app.
If we are talking about a mom with low supply, we can look at the app and see that she is only pumping a few times a day. We can decide to get Lactation involved. Sometimes our milk techs will let us know we only have enough milk in inventory to prep for the next 12 hours, and ask us if we can reach out to mom. So now we can. I think having the milk techs and the barcode scanning application is optimal for our moms and our babies.
JZ: When you go live with a milk room it is important to have a barcode scanning system. It was helpful to have connections with other facilities to find out what worked well and what didn’t, and what suggestions they have. You could always wish for a bigger site for your room, so we could produce more clean feedings or store more milk. We are lucky to have a lot of storage on the unit. That is why it is so important to be able to see the inventory and where it is located. It has worked out nicely for us. Even for the moms who didn’t bring the milk to the milk room, it has worked out nicely to be able to go onto the unit. In the future we would love to be able to use the milk lab for lacto-engineering. An opportunity for the future to analyze the milk and adjust the nutrients for each patient.
3. What metrics do you use to measure the success of your nutrition program?
JZ: Every month we have a business review and look at our budget and expenses for the department. We look at how many patients we have seen outpatient. The number of assessments inpatient and if we screen every patient within 24 hours. We look at our near misses with patients, who were at risk for getting the wrong feeds. We look at occurrences of allergy misses in food, high priority recommendations, chart audits and patient satisfaction surveys.
AS: We are looking into first feed and decreasing our feeding time to less than 12 hours, and we have seen success so far. I use Klassify a lot to track our moms pumping and I use it for mom who are having challenges. Klassify helps us to help moms be successful. Expiration is a big area of focus for us, and specifically working through why mom’s milk is expired. We do a safety review and find out why it happened. We use it as an opportunity to educate our staff if we find an area that is lacking. So we can really emphasize to the staff why it is so important to manage volumes during preparation so milk is wasted or expired.
4. What have been some of the successes of the formula room?
JZ: I think that Keriton was a huge success for the formula room. We always wanted that two-person verification that the correct formula was used for the correct patient. That was really key to success. Space is a limitation. I think that was one of the biggest successes when we went live with the barcoding system for our formula room. It is nice we are open later into the evening if a patient is admitted late in the evening we can get them the formula they need. I feel like dietitians over the years are more engaged in ensuring the orders are correct and building relationships with the techs and building collaboration that way.
AS: I think it is important that we are able to verify that we are mixing the right formula. There are so many formulas that have similar names and look the same. We were always trying to come up with ways in the Epic to emphasize the formula name and make sure we are picking the right product, but with the scanning system it is a great double check you are mixing the correct formula for the correct patient.
5. What are some of the biggest challenges facing NICU nutrition management?
AS: I think our biggest challenge in optimizing nutrition for NICU patients is tolerance. I am going to promote moms milk and use of donor human milk. Babies tolerate moms milk better. We are able to tolerate the feeds much better and we are able to advance and fortify their feedings to ensure optimal growth. The biggest opportunity would be basing our fortifications on analyzed breastmilk.
6. What are some of the biggest challenges facing pediatric nutrition management?
JZ: Right now we are fighting for Medicaid coverage for our outpatient visits. Nutrition is not covered in Connecticut by Medicaid services. We are currently working on legislation to get that passed. Without that, children on Medicaid services do not have the access that everyone else does and that puts them at a disadvantage. Overall there could be better for children access to dietitians, whether that be in schools or hospital based clinics.
Jennifer Zarrilli, MS, RD, CD-N, current Clinical Nutrition Manager at Connecticut Children’s. Graduated with an BS in nutrition from the University of Connecticut in 2008 and MS in nutrition from the University of Saint Joseph in 2019. She has been a pediatric dietitian for about the past 13 years, entirely at Connecticut Children’s.
AnnMarie Spizzoucco, RD, CD-N is a Registered Dietitian with 15 years experience in a Level IV NICU at Connecticut Children’s Medical Center. She works to support the Milk Room: developing policies, competencies, and workflows related to preparation, distribution and storage of breastmilk and formula. AnnMarie serves on multiple multidisciplinary teams involving NICU Research, Lactation, and Nutrition Support.
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