CHOC Clinical Nutrition and Lactation Services Director and Registered Dietician Contribute to Infant and Pediatric Feedings Book

We are proud of our clinical nutrition and lactation services team for continuing to advance best practices. Caroline Steele, the department’s director, co-authored Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities (third edition), with CHOC RD Katherine Bennett contributing a chapter. And we’ve just learned more than 2,000 copies of this authoritative guide have been sold in just a couple of months!

This edition of the book addresses the most up-to-date information on human milk and formula storage, handling, and preparation techniques. Five new chapters have been added. Further updates and additions include: both infant and pediatric feeding preparation; guidelines for facilities seeking to implement centralized infant and pediatric feeding preparation for the first time or expand scope of operations; and information on donor human milk along with guidelines for human milk products. The book discusses lactoengineering techniques and current research. There is a chapter on use of blenderized (real food) tube feedings within the hospital setting. In addition, the book contains expanded information on modular components and other additives.

To order a copy, visit

In the Spotlight: Robert B. Kelly, M.D.

A board-certified physician in pediatrics and critical care with clinical interests in pulmonary hypertension, ECMO, pediatric transport, global health, outreach and business has joined CHOC Children’s.

Dr. Robert Kelly is medical director of the cardiovascular intensive care unit (CVICU) and associate division chief and director of research and academics for the division of critical care at CHOC.

In his role, Dr. Kelly enjoys working in the pediatric intensive care unit (PICU) and CVICU, as well as supporting one of CHOC’s goals in guiding research and educational opportunities for physicians and trainees.

“What makes our division special is our incredible diversity,” Dr. Kelly says. “Our group has an excellent mix of new and seasoned physicians from various training programs and prior experiences. From special interest and experience in CVICU and palliative care, to community PICU care and hospital administration, we are a varied group.”

Dr. Kelly attended medical school at Georgetown University School of Medicine, in Washington, D.C. He completed his pediatric residency at Penn State Milton S. Hershey Medical Center, in Hershey, Penn.; and completed his pediatric critical care fellowship at UCLA Mattel Children’s Hospital.

This dedicated physician has been fascinated with science and biology since he can remember, but he found his passion for pediatrics while in medical school.

“Taking care of children is the most rewarding aspect of my job because the challenges of dealing with patients who often cannot communicate their symptoms pushes me to constantly think, question and re-evaluate,” Dr. Kelly says. “I cannot think of anything more satisfying than being able to form a therapeutic relationship with a family, have a direct hand in the progression of their child’s recovery and then see so many of our patients return to visit the unit after discharge.”

One of Dr. Kelly’s goals is to help expand the capacity and capabilities of the CVICU to handle more complex surgical cases. The team recently added an expert CVICU nurse practitioner with excellent leadership and educational experience. Additionally, the team is working on protocolizing sedation and analgesia practices.

“I’m really excited about one of our latest projects, where we will be revamping daily bedside rounding to begin with nurse-led presentations,” Dr. Kelly says. “We believe this practice will make our care even more family-centered, while also empowering nurses to take a larger role in the care of their patients.”

Through the David Geffen School of Medicine at UCLA, Dr. Kelly has participated in several global health missions, including a recent trip to a tertiary academic PICU in Maputo, Mozambique, which he has been working with for many years to bring pediatric resuscitation training to its physicians, nurses and students.

“On the latest trip, I traveled to two referring hospitals to begin instruction on building a local pediatric transport system,” he says. “We plan on future trips to begin analyzing the demographics of pediatric transport among those three hospitals in order to measure the success of our interventions.”

Dr. Kelly is a fellow of the American Academy of Pediatrics and a member of the Society of Critical Care Medicine.

In his spare time, Dr. Kelly likes to spend time with his wife and daughter. He enjoys playing golf and taking vacations with his family to Hawaii, as well as watching the New York Mets and New York Giants.

CHOC Leads the Way in Implementing Food Standards for Dysphagia Patients

CHOC Children’s has emerged as a leader in implementing a new global standard for assessing food and liquid consistencies for patients with swallowing difficulties.

CHOC was one of the first pediatric hospitals nationwide to implement the International Dysphagia Diet Standardization Initiative (IDDSI), which aims to establish a standardized system of measuring and labeling the thickness of food and drink.

The goal is to ensure patient safety and improve treatment outcomes, say Jennifer Raminick and Danielle Monica, two CHOC speech language pathologists who spearheaded the system’s adoption.

Established in 2013 by a group of dysphagia specialists, IDDSI was created to standardize descriptions, consistencies and terminology for diet modifications for patients of all ages, locations and cultures.

The initiative is a marked departure from previous guidelines that relied on ambiguous labels and descriptions that often varied across institutions and providers, and required specialized, arcane equipment to measure food consistency.

IDDSI framework indicators and descriptors.
(c) The International Dysphasia Diet Standardisation Initiative 2016 @

Conversely, IDDSI guidelines are simple and clear; testing is easy and takes 10 seconds or less; and testing tools are easily accessible to providers and at-home caregivers, Danielle and Jennifer say.

Here’s a brief explanation of the flow testing process to assess a liquid’s thickness: Cover the spout of a 10-mL syringe and fill it with the liquid. With a stopwatch in hand, open the spout for 10 seconds, and then stop the flow. The amount of substance remaining in the syringe is then compared to a rubric to gauge its consistency.

If 1 to 4 mL of the substance remains in the syringe, it is considered of “slightly thick”; 4 to 8 mL remaining is considered “mildly thick”; 8 to 10 mL is “moderately thick” or liquidized; and a substance with 10 mL remaining is “extremely thick” or pureed.

Beyond those categories, food is assessed and labeled as, “liquidized” “pureed” “minced and moist,” “soft and bite-sized” or “regular.” These categories are determined by how the food flows off a spoon or fork, or by measuring a food particle against a ruler.

To implement the program house-wide, the rehabilitation services team partnered with several other departments and disciplines.

Jennifer and Danielle worked with CHOC’s Clinical Nutrition and Lactation department as well as the food service team to create a specific menu for dysphagia patients. It included limited options for each level of consistency and easy-to-follow recipes with three ingredients or less. All food is made from scratch.

The rehabilitation services team developed curriculum for multi-level education of current and new dysphagia therapists, physicians, nursing, dietitians, and food service staff members.

Learn more about rehabilitation services at CHOC.