Julian, aged 4, was born at 36 5/7 weeks with gastroschisis and has required home parenteral nutrition (HPN, also known as total parenteral nutrition) and enteral nutrition (EN) since birth. He came home from the hospital at 5 months old and could tolerate only 3 mL/hour of enteral feedings, with the remainder of his nutrition needs supplemented through HPN.
Because his family lives approximately two hours away from our office, I manage Julian’s care remotely and speak with his mom each week to discuss his overall tolerance of EN and HPN as well as his intakes and output before completing a weekly nutrition assessment, which is sent to his gastroenterologist. In addition, I monitor his labs—specifically his electrolytes and liver panel—every other week.
Throughout Minnesota, our team of dietitians at Pediatric Home Service specialize in patients just like Julian who require enteral and/or parenteral nutrition to grow and thrive. To shed more light on the career of a dietitian in the enteral and parenteral fields, I want to share some insights about what I’ve learned.
No Typical Day
While each day varies considerably and can change quickly depending on the needs of my patients, my role generally requires the following:
- Monitoring labs: Each patient differs, as lab frequency is determined by doctor’s orders, but I track results for the children I follow to ensure their numbers are stable.
- Writing formula recipes for both powder and ready-to-feed formulas: Most of my patients don’t follow the recipe on the can, as they require either dilution or concentration that varies from standard preparations.
- Conducting nutrition home visits: In-home visits enable me to conduct nutrition assessments, discuss current feeding plans, and obtain anthropometrics with parents and/or home care nurses. Home visits are important for this patient population, as it can be difficult for patients to travel to hospitals/clinics with all their equipment, and their exposure to potential illnesses outside the home should be limited, given their complex medical condition.
- Communicating with patients’ doctors: I send completed nutrition assessments and growth charts along with order requests/recommendations for adjustments to patients’ EN or HPN feeding regimens.
- Monitoring and assess weight updates: Home care nurses or family members inform me of weight updates for patients. The frequency of updates is determined by the patient’s RD or MD and thus varies, but regardless of frequency this task is pivotal for a home care RD to ensure each patient’s nutrition plan and growth is appropriate.
Interested in getting involved in the pediatric enteral and parenteral nutrition field? The following are tips for getting your foot in the door:
• Don’t overlook applying for temporary or float positions when you’re searching for a job you’re passionate about. When I first found the position I’m in now, it was a temporary role. I was looking for a permanent job but applied because I wanted to work with children and knew this would be a good opportunity to gain experience. The position ended up becoming permanent, so I ultimately landed in the role I was hoping for. While being hired for a full-time position may be your goal, temporary or float positions can be a great way to get experience in pediatric enteral and parenteral nutrition. Many employers recognize that RDs will need specific training in this specialty, so previous EN or HPN experience isn’t necessary to be a strong candidate.
• Pursue additional education. Although you may not already have the experience, increasing your knowledge of pediatric enteral and parenteral nutrition can help you demonstrate a level of understanding and interest in this population—a strong advantage to highlight when applying and meeting with potential employers. You can attend conferences or continuing education events with a pediatric emphasis, each of which is a chance to not only increase your knowledge but also network with like-minded professionals. There are two large annual pediatric-focused nutrition conferences to consider attending: the Neonatal Nutrition Conference at Baylor College of Medicine in Houston, and Assuring Pediatric Nutrition in the Hospital and Community (a project that provides training and resources to community dietitians, as well as conferences and continuing education events nationwide).
Certifications for pediatric or enteral and parenteral nutrition typically come after you have experience within the field. For example, the Commission on Dietetic Registration offers Board Certification as a Specialist in Pediatric Nutrition (CSP); however, before you can sit for the exam, you must provide documentation demonstrating 2,000 hours of practice experience as an RD with the pediatric population. Another certification opportunity offered by the National Board of Nutrition Support Certification is the Certified Nutrition Support Clinician (CNSC), which focuses on nutrition support including parenteral and enteral nutrition. This certification recommends two years of experience in this field before sitting for the exam.
• Take advantage of resources available to you. Organizations like the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics can be beneficial for obtaining more background on current guidelines and resources.
Some resources I’ve found helpful for my role include the following:
- Texas Children’s Hospital Pediatric Nutrition Reference Guide;
- Academy of Nutrition and Dietetics Pocket Guide to Pediatric Nutrition Assessment;
- Academy of Nutrition and Dietetics Pocket Guide to Children With Special Health Care and Nutritional Needs; and
- Webinars provided by formula companies (typically free and found online).
Success in the Pediatric Field
It’s important to remember that all patient families have different educational backgrounds, so it’s necessary to communicate in plain language to help them best understand the information you’re providing (verbal and written) as well as the recipes you offer. Learning how to feed their child through a feeding tube or HPN often is a new skill for these individuals, so being able to answer questions and build confident and competent caregivers (whether it’s by having them demonstrate the training back or slowly reducing the frequency of check-ins) is important for a safe care plan.
My career as a pediatric dietitian at Pediatric Home Service has been both incredibly challenging and rewarding. Challenges occur when my patients continue to lose weight despite efforts toward weight gain, or a patient’s family may disagree with my recommendations, sending me back to the drawing board. Despite the field’s difficulties, the positives always outweigh the negatives. For example, Julian has continued to surpass expectations. He used to receive HPN and EleCare Jr (an elemental formula) seven days per week, and now he receives only HPN four days per week (totaling 11% of his total calories) along with bolus feeds of a home-blended formula recipe of 70% whole foods and 30% Compleat Pediatric formula. Seeing my patients grow, reach milestones, and surpass expectations makes me proud and motivates me as I do my job each day.
— Kayla Skog, RD, LD, is a clinical dietitian at Pediatric Home Service (PHS) in Roseville, Minnesota. She became an RD in 2014 after graduating from Concordia College in Moorhead and has worked as a dietitian for the geriatric population before going to PHS.