Adventures in Pediatrics

By: Rachel Coury

This week marks the end of my 2-week clinical pediatric rotation at Children's National Medical Center (CNMC) in DC. Children's is world-renowned for the innovative and extensive services they provide in treating kids who are sick. During my rotation, I had the opportunity to gain insight into a variety of unique specialities that their dietitians take part in. My first week was spent with an RD covering general pediatric medicine, neurosurgery, burns, and trauma units. I was able to learn about the ketogenic diet and how it is used as a treatment method for children with epilepsy. This diet is high in fat and very low in carbohydrates with a modest amount of protein. It is designed to keep the body in a prolonged state of ketosis, which has been shown to have a therapeutic effect in preventing seizures in this population, although the exact mechanism of its effect is still unknown.

I was able to see a young girl with Pica (a disease I thought only existed in textbooks) who preferred eating her hospital bracelet to an actual meal of food and performed an initial and follow-up assessment on an adolescent female with a redundant colon. This patient had been suffering from chronic constipation since age 4 prior to the discovery that she had extra loops of bowel in her large intestine making it more difficult for waste to pass through. She came to CNMC to get a colectomy and is hopeful that post-op her constipation issues will be a thing of the past.

My second week at Children's provided just as many interesting experiences. My preceptor covered the intestinal rehab, bowel/liver transplant, and home TPN services. I was impressed by her ability to whip out a TPN faster than I could whip out my calculator. She was part of a unique team who work with children who have short gut. Some of the kids have as little as 10 cm of their bowel remaining (compared to a normal bowel length of ~400 cm), which puts them at severe risk for malabsorption, dehydration, and poor growth. The intestinal rehab team works to ween these kids off TPN as they slowly advance their enteral feeds (we're talking 1 ml per week here if they're lucky). Their goal is to get the kids' short gut to function as closely as possible to a bowel of regular length and maintain adequate hydration as these kids' can suffer from extensive intestinal losses.

As you can see, my experience at Children's was very enriching and exciting. I'm sad to call tomorrow my last day here but am excited to move on to my next site and continue my progression towards becoming an RD.

Until next time!

Comparing Adult with Pediatric Nutritional Assessment

By Joyce L. Hornick

In the fall, I worked at a community hospital as a clinical dietitian helping adult patients. In January, I got the opportunity to work as a clinical dietitian at a children’s hospital helping pediatric patients. Even though we’re all humans, the nutritional care of these two populations is completely different.

Estimating energy and protein needs of an adult follows systematic scientific equations. The energy and protein needs of most adults do not vary widely, from person to person or from day to day. The primary goal of calculating energy needs is typically to maintain current nutritional status if well-nourished, and to prevent loss of lean body mass. Even with chronic illness, needs estimation is relatively easy to achieve. Specific dietary and food recommendations are made depending on the diseases a patient may have and how they can use food to help improve their condition or prevent further progression of the illness.

In infants, the estimation process is much more complex, especially if the infant has a chronic illness or was born with a congenital or genetic defect. In older children and adolescents, the estimation process is still complex, though the rate of growth is typically at a slower pace. The primary goal of energy and protein estimation is to continue with a consistent upward growth pattern. It is very important to prevent trends toward a negative growth curve which could lead to Failure to Thrive. Depending on the type of illness a child has, their energy needs could be double what a healthy infant needs.

The energy needs of pediatric patients are based on their physical body weight. For a newborn, whose weight should be increasing typically by 25-30 grams per day, their energy needs will need to be evaluated every month to month and a half. If the chronic condition they have increases their metabolism, they may need twice as many calories to have optimal weight gains and their energy needs may need to be evaluated more often. Specific dietary and food recommendations are made much the same way they are made with adults. Though, since children tend to be pickier eaters than adults, there is a higher risk of malnutrition.

I was quite naïve upon starting my clinical pediatric rotation. I thought to myself, how hard could it be? Children are smaller than adults, but how much different can their nutritional needs be? In reality, their needs are much different than an adult. It was eye opening to see how detailed some pediatric patients needed their nutritional needs planned out. Children with special dietary needs due to illnesses need individualized care plans, just like adults, but the risk of malnutrition is much greater, making the care plan that much more important and even more detailed.