Best practice sharing to support paediatric dietitians

30 March 2020

The PSG are aware that many paediatric dietitians up and down the country are facing difficult decisions on how to operate as a service in light of the COVID-19 outbreak and diversion of resources. During these unprecedented and uncertain times, it is important we all come together.

The PSG would like to share some useful best practice insights gathered from various paediatric dietetic departments. The suggestions below will not suit all departments, but we hope they serve as options to consider. The PSG would like to request that all paediatric dietitians share any best practice ideas, or concerns by emailing us [email protected]

1. Contingency plans for the operation of paediatric dietetic services with staff shortages

Some departments (acute) are operating as split teams, where the majority work from home and a minimum of 2-4 dietitians are based in the hospital (depending on number of beds), to cover essential patient reviews on the wards. Some departments operate this with weekly rotations to ensure all staff share hospital and home working.
Most departments and trusts have started changing all outpatient clinics to telephone reviews to avoid unnecessary patient contact. Where remote working is available with access to electronic patient records, healthcare professionals self-isolating are able telephone review patients from home.
For joint-consultant-led clinics with ad-hoc dietetic input is required, ensure medical teams liaise via secure email to refer patients for dietetic follow up. If joint consultant-dietetic video calls are possible from hospitals please refer to your Trusts policy for suitable, secure, platforms to use.
- This University of Oxford document provides a useful guide for clinicians on how to perform video consultations.
Safeguarding lists are also being generated to ensure that vulnerable patients are visible and prioritised by all staff
The PSG are aware that staff may be asked to work on adult wards and intensive care units. To ensure the tools available are utilised to assist this transition and upskill staff who may not be familiar with dietetics in adult settings, please see the BDA Critical Care Group page for guidance and links to resources and Irish Nutrition and Dietetic Institute.

2. Working from home

The PSG are aware that working from home may be challenging for some Trusts that do not have remote working platforms set up.
For those Trusts that do have remote working, ensure that you use secure video call platforms and emails to keep patient data confidential
The PSG recommends that you stay connected with your teams regularly, if not by regular calls, by setting up instant messaging groups to discuss issues and concerns (remember to make time for non-work-related discussions too)
Utilise the resources provided by your Trust to help maintain your wellbeing. The BDA Mental Health Group are also working on some guidance which will be available shortly.
Mind, the mental health charity, have a dedicated section on their website on ways to deal with the anxieties, worries and concerns due to the COVID-19 outbreak. Take the time to read and implement some of the ideas.

3. Dealing with lack of anthropometry data

The PSG are aware that there is a variation in the number of local healthcare centres open and able to carry out infant/child monitoring weight and length/height.
The PSG suggests that home scales can be used, and where infants need to be weighed, caregivers hold the infant whilst standing on the scales, then deduct their own weight to obtain the infant’s weight. More information here.
Mid-upper arm circumference can be readily performed by caregivers at home with a tape measure to also monitor growth. Please follow this guidance on how to perform measurements.
Estimations on weight can be made by visually assessing growth with caregivers e.g. if there are changes in clothes or nappy size, etc.
Where accurate weights are essential to deduce appropriate medication doses and implement specialised diets (particularly in those with inherited metabolic disease), some departments are arranging with GP, health visiting or community nurses to weigh patients as the above suggestions are not accurate particularly for infants who are very small.
Dietitians at Southampton Children's Hospital have created videos on how to measure height, length and upper arm circumference at home, see section 7. Guidelines for remote dietetic consultations for the links.

4. Hospital meal provision

The PSG are aware that some hospitals are dealing with reduced levels of catering staff and consequently meal services are being reduced, which will have implications for those requiring special diets. If any Trusts are dealing with this, please share your experiences and insights.

The BDA's Food Services Group would also appreciated feedback.

5. Supporting families with limited access to special foods

The PSG are aware that many caregivers are struggling to access certain foods to implement or continue specialised diets for the management of a multitude of medical conditions including drug-resistant epilepsy, food allergies, coeliac disease and inherited metabolic diseases. The Food Allergy Specialist Group of the BDA are looking at producing a template letter for caregivers of infants and children on special diets to give to supermarkets to allow priority access. The BDA are also working closely with supermarkets to raise this concern and have produced a letter template patients with specialist diets.

6. Supporting breastfeeding on neonatal wards and mothers with COVID-19

The PSG supports UNICEF guidance on breastfeeding for mothers with COVID-19 and ongoing provision of breastmilk and donor milk to infants on neonatal wards. Please use the following links for more information:

7. Guidelines for remote dietetic consultations

Guidelines for remote dietetic consultations produced by Rosan Meyer and Lusie Marino, reviewed and endorsed by the BDA PSG

This document provides paediatric dietitians with an excellent, comprehensive tool to conduct both inpatient and outpatient nutritional assessment and reviews remotely.

The document includes;

Considerations and tips to conducting remote dietetic consultations including information families need to know before a remote appointment
Information on remaining GDPR compliant
Nutritional assessment templates
Guides on calculating energy, protein and fluid requirements
Food diary templates
Calculating drip rates for gravity feeding
How to perform remote weight, length, height and MUAC measurements in infants and children

Alongside the document, information sheets for caregivers have been produced to support performing remote anthropometric measurements

Dietitians at Southampton Children's Hospital have created videos on how to measure height, length and upper arm circumference at home. These methods should only be used during the current COVID-19 period as they have limited accuracy

Dr Rosan Meyer has produced a handy video guide on offering remote practice during the pandemic