By: Candice Danielson
Belly aches, vomiting, constipation, or diarrhea are experiences most kids endure from time to time growing up. Unfortunately for some kids, this is a daily nightmare that causes significant distress and requires reaching out to medical professionals for help. Once diagnosed, dietitians can really help those kids. In early December, I had the opportunity to shadow an outpatient gastroenterology dietitian at Children’s National hospital for two days in the gastrointestinal (GI) clinic and another two days remotely via telemedicine. I felt excited to start because I previously never worked or shadowed anyone in an outpatient setting or with a pediatric population, so it was a little out of my comfort zone. I could tell immediately that the team values the dietitian and the patients she counsels appreciate the recommendations she provides. The patients she sees are typically referred from another provider, and they often see her shortly after an inpatient visit in Children’s Hospital. The dietitian sees a variety of conditions, such as inflammatory bowel disease (IBD), celiac disease, eosinophilic esophagitis, GERD (reflux), allergies and patients struggling with their weight just to name a few.
I learned how to evaluate a child’s nutrition status by studying growth charts, calculating the rate of growth, and determining the calories, protein and fluid needs for optimal growth. Additionally, as part of the assessment, I learned to ask about the child’s development, behavioral patterns with eating, and the child’s social environment during meal time. One of the biggest concerns in the GI clinic was difficulty gaining weight or growing slowly. The malabsorption, inflammation, and abdominal pain can lead to decreased food intake and therefore nutrient deficiencies and weight loss as a result.
Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the digestive tract and one of the main disease states treated in the clinic. There is no cure for IBD, but it can be treated with medication, nutrition therapy, and sometimes surgery. Those with this diagnosis often experience weight loss, anemia, slow growth, vitamin/mineral deficiencies, and avoiding certain foods. Nutrition therapy can be used to either manage the disease and induce remission or it can improve symptoms. I was given an assignment to create a handout to show patients the difference between primary diet therapy and nutrition support for IBD. The primary diet therapy to manage IBD is either exclusive enteral feeding or strict therapeutic diets, such as the Specific Carbohydrate Diet or the Crohn’s Disease Exclusion Diet. One of the patients I saw during the rotation completed the Specific Carbohydrate Diet protocol in the past and successfully went into remission. Although it was difficult and it required her whole family to change their diet for some time, she was happy she followed through with it. I learned there are more liberalized diet options that may not manage the disease, but may still improve symptoms and provide the nutrients needed to prevent deficiencies, weight loss, and malnutrition. This type of nutrition support for IBD includes the Mediterranean diet, Low FODMAP diet, Lactose-free/dairy-free/gluten-free diets, general healthy eating, and identifying and avoiding trigger foods. I previously learned about IBD in my undergraduate coursework, but it was really eye-opening to see how much this disease can affect the growth of a child.
Along with the IBD clinic day, there is a Celiac clinic day, where the multidisciplinary team has visits with celiac patients exclusively. I learned how a specific lab value, the TTG IGA antibody, is used to determine if the patient is accurately following the diet. If the test comes back too high after being on the diet for a few months, it means gluten is still entering the body. In one of the celiac sessions, the dietitian helped a family uncover possible suspects of gluten in the child’s diet, such as school lunches and meatballs. Cross contamination is a main concern the dietitian must cover in these sessions. Additionally, I learned to cover nutrients of concern including fiber, iron, and B vitamins and to educate families on sources of high fiber gluten-free grains.
I also learned about a disease called Eosinophilic Esophagitis (EOE) during this rotation. EOE is a chronic, immune-mediated inflammatory disease of the esophagus. It usually results from a food allergy and if left untreated, can cause difficulty swallowing. One way to treat this disease is to eliminate potentially allergenic foods from the patient’s diet. I was able to see a patient in the process of the “6 Food Elimination Diet” – this patient completely eliminated dairy, eggs, wheat, soy, peanuts, and tree nuts. The mother was understandably frustrated about the large number of changes in the diet in a small period of time, but by the end of our session with her, she was confident and reassured they would be successful.
Overall, I learned about a dietitian’s role in an outpatient setting, how counseling sessions are conducted and I expanded my knowledge of nutrition interventions in GI disorders such as IBD, celiac disease, and EOE. I learned how to assess children for malnutrition and adequate growth and, also, how to calculate nutrition needs in the pediatric population. I enjoyed this setting because of the increased time available to talk in depth with patients about their nutrition and provide solutions to optimize their growth. It seems like a rewarding path working with a pediatric population and I can tell the parents, as well as the kiddos, are quite appreciative of the service. I can definitely envision myself working in this setting in the future and I truly valued my experience at the outpatient GI clinic.