The Kids Are Alright
Michelle Guarnieri
During my time at Children’s National Medical Center (CNMC) in Washington D.C., I 
experienced a lot of change and excitement. After all, I was working with children for the first time! I finished my clinical rotation in December, and thought I knew what to expect at Children’s, but I had no idea of the variety of roles the dietitians fulfilled in this facility. Children’s has both a hospital and several outpatient clinics scattered around the D.C./Maryland area. I was lucky to spend time with three wonderful dietitians in both of these environments and learned more than I could have expected.
For my first week at CNMC, I was in the outpatient gastroenterology clinic. My first day 
consisted of observing the dietitian and how she counseled patients and their families, but I was sent to see patients on my own in the days that followed. Patients presented with problems ranging from Crohn’s Disease to picky eating to breastfeeding difficulties. Prior to this rotation, I hadn’t learned much about baby and child formulas. My preceptor provided education on the basics of infant and child formulas, and this knowledge was extremely valuable when the dietitian had me counsel a mother on how to mix formula for her underweight baby girl. It was a whirlwind of a rotation, but I gained so much knowledge.
Interns are asked to complete a case study while at CNMC, and I chose to work with a child with behavioral eating difficulties. He was highly selective with his foods and became very anxious and scared when other foods were presented to him. Children with issues of this caliber require an entire feeding team to overcome their fears of food. This team consists of a psychiatrist, nurse practitioner, dietitian, and for this specific case, me! My role was to complete a full three-day nutritional analysis and point out nutrients the child wasn’t consuming adequately. His diet was extremely limited, so he was likely deficient in several nutrients. The nutritional analysis I completed confirmed that this boy needed more fiber, vitamin D, and omega-3, to name a few. In addition to completing the nutrient analysis, I was able to observe this patient during a family meal. The clinic uses a double sided mirror, not unlike those in crime shows. During this observation of the child and his parents, we looked at eating patterns, reactions to foods, and anxiety levels. Afterwards, we met with the team and parents to discuss the treatment options. It was so interesting and I was very fortunate to have this as my case study.
On Friday, I spent time in the IDEAL weight management outpatient clinic with a fantastic dietitian. Most of these patients were young teenagers, but there were some even younger children that needed weight management counseling. The dietitian really tried to get to the root of the issues at home and why the child is obese, which was both emotional and highly informative. Just this eight-hour day sparked my interest in weight management, a field I hadn’t even considered before this!
Finally, my second week was spent in the inpatient neurology unit. I was able to learn about a variety of cases, and at times I felt like I could barely keep up. That being said, my preceptor and I mainly worked with children with seizure-causing disorders. We helped start them on a high-fat, low-carbohydrate ketogenic diet, which has been shown to reduce the prevalence of seizures and the advancement of diseases like Glut1 Deficiency. I had always thought of “keto” as a trendy weight loss diet, but I learned that it can be an effective treatment option for several neurological disorders. A ketogenic diet alters energy metabolism, reduces inflammation and modulates neurotransmission. Seeing this first hand at such a renowned hospital was extremely informative and a fantastic opportunity.
All in all, my experience at CNMC was a whirlwind of information, valuable experiences, challenges and enjoyment. I feel very lucky to have spent time at this leading institution, and will use all that I learned in my future career as a Registered Dietitian Nutritionist!