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.

Comparing Inpatient with Outpatient Nutritional Counseling

By Joyce Hornick, Dietetic Intern

My most recent rotations during my dietetic internship were acting as a clinical dietitian in a large community hospital, followed by observing dietitians in semi-clinical outpatient settings in cardiac care and diabetes care. This gave me the opportunity to see Registered Dietitians (RD) performing similar interactions with patients in two completely different settings.

In the hospital setting, patients are seen for various nutritional issues, many times at the request of the medical staff. The biggest advantage of inpatient counseling is the captive audience. The patient can’t choose to be elsewhere. The immediate needs of the patient can be focused on. For example, if a patient is in the hospital for hyperglycemia (high blood sugar), the immediate nutritional needs to help control their blood sugar can be addressed, along with how to prevent future events of hyperglycemia through an appropriate diet. Sometimes the patient has never been given the proper nutritional information or had received incorrect information. Many patients are appreciative of the information and are grateful for the time you give them to answer their questions.

Unfortunately, the hospital room isn’t always the best place to talk to a patient about their nutritional needs. Many different staff members are in and out of a patient’s room, giving minimal time to spend with a patient without being interrupted. A hospital RD may have more than a dozen patients to see in a day, so time must be used efficiently. Patients can be on many medications while in the hospital, which may make them drowsy and not conducive to listening to new dietary information. The patient may not understand what caused them to be ill, especially if it is a new diagnosis. They may be in denial they need help managing a chronic illness. For example, one patient I tried to talk to about how to manage his diet to control his blood sugar denied any need for help despite his being in the hospital to have a below the knee amputation due to complications from his diabetes.

In the outpatient setting, everything seems to be just more relaxed, less hectic, and at a slower pace. Most sessions are scheduled to take an hour, but most appointments went a little longer. Patients are usually referred to an RD by their doctor, which may or may not occur after a hospitalization for their illness. Typically, these patients are motivated to change how they manage their illness through diet. They’re tired of not feeling well and want to learn how they can change their eating habits to feel better. They want to change, but may not know how or just need reassurance from a professional that they can make the changes. A lot of patients have a family member come with them to the session for moral support. Fortunately, the point of outpatient counseling is to help you find your barriers to change and to help you remove those barriers. They help you set realistic goals that you want to achieve for yourself. They don’t set goals for you that they want you to achieve. They help you realize your self-empowerment potential.

The biggest negative of outpatient counseling is the No-Show. Many patients have good intentions when making an appointment, but sometimes just can’t follow through. Maybe they thought they were ready to talk about their nutritional and/or health problems, but get cold feet. It can also just be the fear of the unknown. If they’ve never been to a nutritional counseling session with an RD, they may think they are just going to be given a list of foods they can’t eat anymore. They may feel another person will be scrutinizing what they eat and judging them for their habits. From what I observed, this is definitely not the case. Any of the RD’s I worked with were non-judgmental. They listened to the patient and asked them questions. They did not reprimand.

Neither of these types of counseling is necessarily better than the other. They can complement each other. All RD’s in these settings want to be able to help people understand how nutrition plays a role in their health. As a prospective dietitian, I feel it is more important to see where I will feel more comfortable and best able to help people. Each setting takes a particular type of personality to do the job, placing the importance on fit rather than setting.