Latest / Nutrition Connection by Dr. Kristen Hicks-Roof / 33: Danielle Fanelle Haller MS, RD, CSR, LD - CLINICAL PEDIATRIC RENAL
Transcript
- Kristen Hicks-Roof PhD, RD: Welcome back to Nutrition Connection, the show where science meets storytelling. I'm your host, Dr. Kristin Xroof, dietitian, researcher, and lifelong advocate of the role of nutrition, health, and wellness. Each episode, I sit down with dietitians and nutrition experts all across the food and healthcare landscape, leaders whose work touches nearly every aspect of our lives. So whether you're a student, a seasoned professional, or someone simply curious about food, nutrition, and health, this podcast is just for you. The views, thoughts, and comments on this podcast do not reflect those of my employer nor the employers of my guests. So let's go ahead and get connected. Y'all, I'm really excited to bring on one of my former students. We have Danielle Finnelli-Haller. She is a pediatric renal dietician with John Hopkins All Children's Hospital. Welcome to the show, Danielle. Danielle Fanelle Haller: Thank you so much for having me. I'm so excited. This is actually my first podcast. Kristen Hicks-Roof PhD, RD: ⁓ well, you gotta love that, right? And it's so cool watching my former students just have these incredible careers and being at Johns Hopkins right there in Tampa, I can't wait for you to really talk about your specialty credential, the CSR, but also what you do in pediatric renal, which is a very niche career. So let's back it up though. What inspired you and made you want to become a nutrition professional? Danielle Fanelle Haller: very much. So dietetics ended up being... kind of like a really natural intersection of a lot of different things that I loved. So to really back up, I grew up in New Jersey and a really stereotypical ⁓ New Jersey Italian household. There was always tons of food. We were always cooking. And from a very young age, I was in the kitchen helping my mom and my grandma cook all kinds of things. So it was just like a, I really just fell into that loving food. I loved grocery shop. I love to watch cooking videos. ⁓ I love talking about food. Anything to do with food. I I absolutely love it. And I always joke that I went from watching Nickelodeon right to Food Network. I kind of skipped the Disney Channel phase. And I started watching Food Network when I was about in fourth grade. And I remember one year for Christmas, all I wanted was the Rachel Ray 30 minute meals ⁓ season on Disney. Kristen Hicks-Roof PhD, RD: No way! Danielle Fanelle Haller: DVD. Yup, that's what I got for Christmas one year was the Rachel Leary 30 minute meal DVDs. So you know, just I just really loved food and then kind of totally separately of that. I grew up as a competitive figure skater. So I started that when I was nine and I skated all throughout, ⁓ you know, my teens and into my early 20s. And one of my skating coaches actually was getting her undergrad in nutrition and dietetics. ⁓ So was, you know, really able to start to make a connection there between how food and how I nourished myself really affected my performance and how I was able to train and things like that. So I took a big interest in food in a very different way throughout that time. So then I really started to look more into nutrition and I thought I wanted to take more of a sports route. ⁓ And then kind of learning more about what a dietitian did, you know, it just kind of was a really natural intersection of these different things that I really love to do. So, you know, I decided to pursue that, pursue the dietitianry. Kristen Hicks-Roof PhD, RD: That's awesome. And I do actually remember, I feel like I was on the review panel that reviewed your application, because I remember you were a competitive figure skater. Now that you say that, I'm like, I totally remember reading that. So it's kind of surprising that you didn't go into that performance route, because nutrition, I know I used to work on University of Arizona gymnastics before dieticians were even part of competitive sports, really at the collegiate level. Danielle Fanelle Haller: Yeah. Yeah. ⁓ Mm-hmm. Kristen Hicks-Roof PhD, RD: I see a lot of crossover between gymnastics and figure skating because you have a lot of aesthetic part of where nutrition plays such a critical role. Yeah. So let's talk about your journey then. You ultimately decided to become a dietician and then how did you ultimately get into a pediatric renal, which is very niche. Danielle Fanelle Haller: very much so. Yeah. It is very niche and I think a lot of it just ends it up, you know I definitely want to back up but I think the moral of the story is you know I just I really went with the flow and I really just rolled with the punches of you know kind of what life brought me but to really back up because it's something that I really want to talk about is that when I was a senior in high school which is very late for this I was actually diagnosed with severe dyslexia and a sensory processing disorder And that really flipped my world upside down. And I got in with a educational psychology group that was able to teach me how to learn a lot better. And what came with that is, and we always knew from a young age that I had. severe hearing loss. And so when that all came about, I ended up getting hearing aids when I was 17, which really helped me. So that happened my senior year of high school. So I ended up taking a long break actually after high school and I didn't start college classes until I was 20. And then I didn't start college full time until I was 21. So I was a little bit older by the time that I started college. So it was a little bit of an unconventional path. because by the time I did get to college, I was definitely a little bit older than a lot of my peers. So then when I was about 20, I started taking just some community college classes just to get those basics that I was gonna need no matter what. I was already interested in nutrition at that point, but I just started taking some of those community classes. And then when I was about 21 was when I finally started college full-time when I had stopped skating. You know, and training full time. So that's when I transitioned and started at UNF. ⁓ So I got my degree in nutrition and then for my dietetic internship, I matched at Emory. ⁓ And so I went up there and did my dietetic internship because I knew after undergrad, I knew I really wanted to pursue clinical. You know, thought I, in the beginning, I'd wanted to do more of sports. ⁓ but then once I learned, you know, kind of got into MNT, I was like, this is, I think clinical is more the route for me. So I definitely wanted to do an internship that really focused on clinical and Emory was definitely that place for me. So when I finished, when I graduated my internship. My first job out of internship was at a level one trauma center in Mobile, Alabama. Because my husband lived in Pensacola at the time he was in the military. So that's where he was stationed. So we lived there. And I commuted a little over an hour to Mobile, Alabama every day and worked at a level one trauma center. And I learned a lot. it was quite a job as a brand new RD. And then simultaneously, I was also finishing up grad school. So I actually started grad school on an online program at UNF completely separate from my dietetic internship. So I started that in my internship and then finished that kind of into my first year, year and a half. ⁓ as a practicing dietitian. after we were finished in Pensacola, my husband was getting stationed out in California. I applied for a ton of jobs out there. And one of the jobs that I had applied for was at a home dialysis company. And just in an effort of full transparency, because I think this is something that dietitians do need to talk about more, is that I have to say the only reason I accepted that job was purely because they had the highest offer. ⁓ And I know that that's a little bit taboo to talk about, but I think it's something that we should. And that was the only, really the only reason I wanted to take that job. But I got so lucky because I loved it there. I loved that job. I loved that company. I loved everybody that I worked with. And I really found a passion for renal nutrition. And which is never an area if you had asked me in undergrad or my internship if I'd ever wanted to do renal, I would have been like absolutely not. But I ended up loving renal nutrition. You know, it was very different from what I initially thought it was. You know, it's not just about, you know, you can't have whole wheat products, you can't eat bananas, blah, blah, blah. you know, because a lot of the guidelines had changed in 2020 when brand new guidelines came out and it kind of flipped the renal world on its head and it's very different now. So I really found a passion and a love for it. So then, my husband was getting... Kristen Hicks-Roof PhD, RD: Can we pause? I wanna explore that really fast, right? Renal, back when I was in school, and the diet now for renal are completely different. So how do you manage that, especially, let's say, someone who's nervous to go into renal, because things are always changing. Well, not always changing, but things have drastically changed where maybe what a patient, Danielle Fanelle Haller: Yeah. completely different. Kristen Hicks-Roof PhD, RD: undergoing any sort of care for renal 10 years ago versus what it is now, those recommendations have been different. So how have you been able to balance that as a practitioner as you've really dove a little bit deeper into renal care? Danielle Fanelle Haller: Yeah, and I love that question because there is a large hereditary connection, so you will often see multiple generations in dialysis. So I really just try to be transparent with patients and families and make sure that they understand. know that previously you were told, you know, absolutely cannot, you have to eat white bread and you shouldn't eat oatmeal and things like that, which now to me just sounds so crazy. So I think I really just try make sure that families understand that as we as technology develops and we're able to do better research that the guidelines completely change so that way we're keeping up with really what is best practice Kristen Hicks-Roof PhD, RD: ⁓ so I know before we started recording, I would tell you I got into renal early in private practice with one of my colleagues over in College Station. And I was like, wow, this is one of the most complicated, rigid nutrition prescriptions, right? Of like, it really was a don't eat this, eat this, like from those old school books. But I think you've seen the renal diet be a lot more liberated. Danielle Fanelle Haller: Right. Kristen Hicks-Roof PhD, RD: right, in terms of whether it's the protein recommendations or the different micronutrients and maybe that's better medication control or just the, you know, the way that we understand. And so I think that it's a very important part. So me being in the science realm, we have to understand that science changes and when science changes and we have new science, sometimes that means recommendations change. And so I think it's a good point for all the clinicians who are on the call is be open-minded. especially when you're counseling patients and be up to date on the latest science to be able to support our patients to the best of the ability. So I do think that there's a piece there. So let's talk about your role a little bit. What do you do in your current role? I think one of the things I love the most about being in renal care, especially if you're in dialysis, and I know you work with pediatrics, so I want you to dive into that, is like, I think it's such a good opportunity to actually have good rapport with the patients. Danielle Fanelle Haller: very much so. Yes. Kristen Hicks-Roof PhD, RD: You get so much more time than many clinicians get with their patients. And so let's talk about your role at John Hopkins All Children's Hospital. Danielle Fanelle Haller: Yeah, and that's kind of, you know, to pivot how I got into Peds when we left California. I just so happened to get a job. ⁓ in Peds and I never, didn't think I would transition into Peds, but I just, really liked, I had a great interview and I was really excited about working there and it just so happened that they were, they had a small pediatric dialysis group and the manager, the director at the time was actually covering the dialysis patients and she was the first one to say, worked in every area of Peds, I hate dialysis. So she was very excited when I was, when I, when I was willing to come and take over in pediatrics. And I love what you said about. getting to know your patients very well because that is so true and I think that's something that I love about renal and specifically in pediatrics is you get to know your patients and their families so well because you see them so often. You know our hemodialysis patients are in the facility three days a week sometimes even more if they need to be and we see our peritoneal dialysis patients at least monthly but majority of them need to come back than once a month for either like weight checks or things like that. ⁓ So there really is such a personal connection there that I just feel like is so unmatched in other areas of nutrition. You know if that's something that you really want is that face-to-face and that really strong connection with families. I think Peds and specifically renal even in general is such a great place. for clinicians that just, you know, they are people person. Kristen Hicks-Roof PhD, RD: Yeah, I mean, that's something so I haven't worked with people for a while. mean, I do sometimes, you know, I used to be in corporate wellness and, I love that connection with people. And I in corporate wellness, you actually are able to develop these really strong bonds because you often see them more frequently, depending on the corporate you work with. But I do think that is an asset in terms of renal patients that you you really get to know them. I mean, I remember like, I know their family members who came and brought them to appointments and what car they drove in, what kind of challenges they had at home, beyond just the nutrition information. Danielle Fanelle Haller: for sure, it's, you how was your sister's birthday party this weekend? I remember your aunt was coming to visit you and you guys were going to Disney. You get to know them so well. Kristen Hicks-Roof PhD, RD: Yeah, well, and that's such an important part because we know nutrition is not an isolation, right? It is related to the environment they're in, the family, what's culturally relevant. There's a lot of reasons why people eat the food they do. So let's kind of talk about your day to day. Is it only seeing patients or what else do you do in your role as a pediatric renal dietician? Danielle Fanelle Haller: Yeah. So. I like to say that when you manage renal nutrition is, is really a culmination of managing multiple different diseases. So I managed, I'd like to say I manage a multitude of different diseases, but just to kind of like talk a little bit about our patient population, see anywhere from pre-mes and the NICU all the way up to 21 years of age. And I personally see anywhere from pre-dialysis, CKD patients, I'd say the majority of my patients are dialysis. and then I do also see post-transplant patients as well. And then I also see some non-CKD ⁓ nephrology stuff. like ⁓ nephrogenic diabetes insipidus and things like that that aren't necessarily gonna always go the dialysis route, but definitely still have renal nutrition implications and things like that. ⁓ So I'd say a large majority of our patients do have ⁓ feeding tubes, ⁓ usually G tubes. our kids have DJs because we see a lot of renal. or kidney failure associated gastroparesis. So a lot of our kids need GJs. And we do a large combination of oral feeds and tube feedings. And then I work very, very closely with the rest of my nephrology team. So I probably work closer with my nephrology team than I do the other dieticians. So on our team, we have a nurse practitioner, our nephrologists, the dialysis nurses, and then we also have a social worker. child life specialist and a hospital school teacher. And there is there's always good reasons for us to all need to collaborate together all the time because we always all have the common goal of you know wanting the kid to be happy, healthy, normal. growth development as much as we can and to know the end goal of hopefully seeing them on the other side of transplant, ⁓ living just like a normal, happy, healthy life. Kristen Hicks-Roof PhD, RD: That's awesome. Yeah, I think one of my favorite parts is that you're talking about like, this is the dietician on the interprofessional care team, right? Like this is how all clinical procedures and clinical healthcare plan should be. And that's one, again, another perk of being in renal care is it's so integrated, especially in PEDs. mean, PEDs, the dieticians are... Danielle Fanelle Haller: Yes. Yes. Kristen Hicks-Roof PhD, RD: really integral, which you don't always see in adult populations. I'm sure you know as you know, ⁓ Danielle Fanelle Haller: I completely agree with that. feel like as pediatric dieticians, we are very well respected. can only, I've only worked in pediatrics at my facility and I remember. ⁓ My director at the time when I interviewed for this job, remember her saying that, our dietitians here are very well respected. ⁓ You know, it's very common, I'd say majority of the time for our physicians to really make sure that they get the final okay from the dietitian before they're discharged. you know, a lot of times I sometimes in adults, the dietitian's recommendations, their notes aren't always read as thoroughly as one would hope, but at least for at least for us in pediatrics, and I know I can speak specifically for our renal team, ⁓ our notes are always read and our recommendations are always taken very seriously. So it's a great area to be in because we are very well respected. Kristen Hicks-Roof PhD, RD: Yeah, that's super nice. So what else do do besides day-to-day patient care? Are there any other responsibilities that you have in this type of role? Danielle Fanelle Haller: Yes, so there is a lot of care coordination. ⁓ I'd say there's more care coordination, you know, that's not just face to face than any other. area. I say, I know for me, I kind of talked about the team that I work on. So, you know, I may work with our hospital school teacher, we like to plan events. So, you know, we made to a, we just recently did a carnival day. So I worked with her to plan, ⁓ you know, compliant foods that we could have to celebrate carnival day. Or I may be working with our social worker, ⁓ you know, ⁓ if there could be like a complex social situation. ⁓ know there's something that maybe sadly this is something that you see in pediatric CPS involvement to a certain degree. I may be working with our social worker you know kind of figuring out where my expertise may be needed on that front. So it's a lot of you know You do have to be a little bit of a jack of all trades because you have to be able to support the rest of the interdisciplinary team in their roles outside of just that patient facing clinical work. Kristen Hicks-Roof PhD, RD: Yeah, we talked previously a little bit about science and how science has really changed the renal diet. But how does science and scientific evidence really fuel your day to day? And is that integral to your day to day? Danielle Fanelle Haller: I love this question. So I always like to start by saying that I don't believe in the term renal diet. ⁓ I think that needs to be eliminated from every textbook and everything because I feel very strongly about we need to have an individualized approach. And I know for such a long time, it was just, you are CKD stage four. you have these recommendations and you are dialysis and you have these recommendations. It was just a sweeping diet. But if the patients on peritoneal dialysis, they don't always have the same issues with potassium that a hemodialysis patient might have. So I really, I avoid using the term at all costs because I don't think we should have a sweeping renal diet for patients that may not need it. So I just like to to impose restrictions only when it's needed. ⁓ So kind of what goes into that is being, and we talked about this a little bit earlier, is that you have to keep up with the evidence and it's always gonna keep changing. And I think specifically to PEDS renal, it's a relatively small patient population. So what comes with that, unfortunately, is there is not the vast amount of literature and data out there as there would be for say like NICU babies or like intestinal rehab or CdICU babies because this is a relatively new-ish area. ⁓ So sometimes it's hard to necessarily extrapolate the information to all of your kids. And kind of what goes hand in hand with that is that there's a really big difference between a one-year-old that was a 25-weeker versus an 18-year-old that lost their kidney function when they were 16. So. There's just a lot of being able to interpret the data and figure out how it's relevant to your patient. ⁓ So something that I love to utilize is the listservs out there ⁓ because, you know, like I said, there's not the vast amount of studies. So sometimes there really isn't guidelines on exactly what you need to do for this patient. Something that I like to say over and over again about renal dialysis, when renal dialysis kids in general is, you will never see the same patient twice, ever. Every patient is completely different. And you know, I think a lot of times in adult dialysis when I did that, I think if you see about 300 adult dialysis patients, you've kind of seen them all. ⁓ You see a lot of, there's a lot more overlap, but there's never been two PEDS renal kids that have ever been the same. So I think there's a huge amount of being able to interpret data, look at how the study was done, and figure out how is this actually applicable to this kid in this very specific situation. And you know, also with that... understanding that most of the studies that are done are on relatively small patient populations because there's not, relatively speaking, there's not a lot of kids on dialysis. So I think it's crucial to be able to interpret studies and really look at them analytically and understand how does this apply in this situation. Kristen Hicks-Roof PhD, RD: feel like I would love this job. It's like a medical mystery every day. I do like that. And I love the way you talked about like, I just wish we got rid of the word diet. I do not like a Mediterranean diet and paleo diet and all these other things. I'm like, what happened to just like every food fits in different ways, right? And I think that is the future of personalized nutrition care. You're right though, especially in peeds. Danielle Fanelle Haller: It is. you Mm-hmm. Kristen Hicks-Roof PhD, RD: You just don't have the data to be able to synthesize to make a uniform decision. And I think we've bucketed people so much to the point where we've lost embracing foods that they like, foods that they have access to, foods that they normally cook, right? And like, and how do you have research looking at every different type of food? If I go over to the, you know, African ⁓ local grocery store, those foods are going to be so different than if I go over there to Kroger. Danielle Fanelle Haller: Exactly. Kristen Hicks-Roof PhD, RD: Right? And so like there's, it's so complex. Danielle Fanelle Haller: And with kids, you know, we deal with a lot of... severely picky eaters. And you know, like I said, a lot of our kids are on tube feedings, but the goal is always to get them to eating orally as much as we can. So you have to find a happy balance because you may have a severe picky eater and you know, you may have a kid that really struggles with super high phosphorus, but the only thing that they're willing to eat by mouth is frozen macaroni and cheese. So we do have to find a place for that. ⁓ So that way we can work towards getting them to eat by mouth. It may not be ideal, but you have to be willing to find a way to make that food fit. ⁓ Because looking at the big picture and looking at long term, that's important. Kristen Hicks-Roof PhD, RD: I mean, macaroni and cheese is probably one of my favorite foods, so I'll sign up to be a test case any day. So, video, what is something that is your most favorite or that you're most proud of in your career so far? Danielle Fanelle Haller: you ⁓ that's a really good question. I would have to say, you know, especially in this role, taking a kid that I had when I kind of first started that was just out of the NICU. He was a preemie failure to thrive, you know, recently discharged all the way through transplant. He got transplanted probably about a year ago and he is thriving. ⁓ you know, to the point where he's gained a little too much weight, post transplant with all those steroids, which is very common. ⁓ But I think it's just remarkable to see this little teeny tiny baby off of the growth chart, you know, on like 28 calorie per ounce formula. And, you know, now he's eating and running around and it's just... awesome to see that and really understanding what a huge role nutrition played in that. To be able to get him to the point where he met weight criteria for transplant. Kristen Hicks-Roof PhD, RD: Yeah, you know, I remember when I used to do clinical work, it's hard, right? Clinical work is really hard. People aren't feeling well, you're trying to help them with diet, which is like an uncomfortable conversation sometimes. Some people are open to it and some people aren't, but there are those cases that you're like, I know that these clinical recommendations made a tremendous impact, whether whatever the outcome might be. And like, I always remember it was such a feel good feeling. Like you're like, Wow, I mean, I literally made a difference in a person's life. Now, is it gonna happen with everyone? No, if you're listening and you've never practiced in clinical, no, you will not impact everyone, but you can make the difference and dieticians can play such integral roles in that. And I just think that is really special. Danielle Fanelle Haller: And I love that you say that because that's something that I think that I really took hold of when I got into just renal in general, both in adults and pediatrics, is that I think you can see the change. almost tangibly in renal because you know if you really do good education on you know say you're on the other end of the spectrum and you have a kid who's really struggling with low ⁓ potassium and we do a lot of work to figure out how we can get more potassium into this diet and then you know you're slowly starting to see things improve and you're you're Tangibly, you know your interventions at work and you know same thing you know if you have a kid who's has issues with weight gain and growth. And you see them start off as failure to thrive and not even on the chart. And then, you you implement these interventions and you see them come back every couple of weeks and you're like, wow, I'm actually, doing something here. I'm seeing a change. And I think, I think that's one of the best parts about renal nutrition. Kristen Hicks-Roof PhD, RD: I mean, I can agree with you and it is such a good feeling. And I think really for many dieticians, that is our calling. We want to truly help people. And sometimes it's challenging if you're in places where, you you see a patient one time and they never come back and you just don't know what happened to them or you have not an, I hate the term non-compliant patient because I think everyone's compliant. Maybe our recommendations don't align with why they're there or what they value. So I think it's us bridging and working with patients to ultimately get the best care plan for them. So, Danielle, what suggestions would you have for someone who's interested, let's say in renal in general, but then also renal pediatrics? Like what tips would you have for them to be able to land that type of role in their career? Danielle Fanelle Haller: think with renal in general, you have to be flexible. ⁓ you have to be willing to pivot constantly because there will be times where you're going to be just kind of like pounding, you know, we've got to get this calcium under control. We've got to get this calcium under control. And then there may be times when you're giving the complete opposite recommendation and education to the same exact patient. So you have to be willing to pivot and then kind of along with that. And I would almost say that this could be you know just clinical in general is that most of the time when you are seeing a patient whether it's in the dialysis clinic or in a hospital you always have to remember that you are probably seeing the worst version of them they are not they are not feeling they're they're not feeling their best self they're not acting their best self so you have to have empathy and I cannot stress that enough for renal is that this is a full, it is a full-time job managing their, just their kidney disease, let alone other medical issues that they have. So you have to be able to empathize and understand that they are at their worst self. So that would. Kristen Hicks-Roof PhD, RD: I it sounds good in theory, but so what suggestions or tips would you have? I know many dieticians who work in clinical practice, they're burnt out. They have, you know, it's a lot of patient caseload and maybe all your patients don't actually change behavior, right? Like we want to. So what suggestions would you have to be able to harness the empathy and really... feel good about what you're doing because we really do make a difference in the clinical care, but sometimes it's hard to see that when it's so gray and cloudy. Danielle Fanelle Haller: I think especially from a mental health standpoint for the clinician is you have to understand that if the patient isn't taking your recommendations, it's not personal. They're not doing it as a personal attack to you. So, and I think that's, you know, where, where, that empathy really ties in is being able to understand where they're coming from. If there is a struggle with being able to take their binders, which is a huge, to a lot of renal patients is really understanding and trying to meet them where they're at of where is the disconnect here? Is it ⁓ we just forget to bring them with us or ⁓ are the pills too big or do you just forget? Is it not important to you? ⁓ And you have to meet that patient where they are. ⁓ Kristen Hicks-Roof PhD, RD: Yeah, you know, I used to do some research when I was at UNF actually with a few faculty, Dr. Jen Ross and Dr. Andre Arikawa, which you may remember them as your former faculty. Danielle Fanelle Haller: ⁓ she was probably my favorite undergrad. She was fabulous. I learned so much from Kristen Hicks-Roof PhD, RD: Yeah. So we were we were doing and we were doing some research on empathy in the classroom, actually, and how empathy both on the teacher and the student side could change the output and the student satisfaction and the teacher satisfaction. So I think the concept you're talking about is not just for those who are in clinical. I think it's for many, many different areas. ⁓ You know, one of my favorite books that I used to talk about and I still do, it's called Self-Compassion by Dr. Ashley Neff. And it's really talking about how we can be compassionate about ourselves and to ourselves, but then that also helps us to build empathy for other people. And if we are in the people jobs, right, like we are helping people for a living, no matter what you do as a dietitian. we have to be able to foster and embrace that empathy because that's how we're gonna ultimately get our recommendations across. And I think you gave some really good examples, especially in clinical, people are not feeling great. That's why they're there to see you, right? Danielle Fanelle Haller: Exactly. ⁓ I did kind want to just jump back though when you talked about like what advice I would have because I would love to give a little bit of advice on people that were interested in peas specifically because we always need more pediatric dietitians. ⁓ So just a couple of things I wanted to touch on with that is if you were interested in pediatrics, I would highly, highly, highly recommend trying to shadow in a pediatric hospital to kind of understand that it's very different from an adult hospital. Because I think it's really important to understand, and this can kind of circle back to a little bit of the scientific evidence, ⁓ in that kids are not little adults. We like to say that a lot in pediatrics. little adults. They are a completely separate patient population so you really have to understand that a lot of the stuff that you learn from adults may not be applicable to kids. And then this is also something I feel very passionate about. is that you have to be able to look a family and a parent in the face and say, I don't know to a question. Because I think sometimes there's a lot of pressure when you come out of your internship or finish your RD exam to have to know such a wide range of things. But I think nothing builds rapport with a family quite like saying, I don't know to a question. Because if you say, don't know to something, what you do know, they're going to fully trust in you. And I think that's one of the most powerful things that you can do is be able to say, I don't have an answer to that question. So. Kristen Hicks-Roof PhD, RD: mean, if anyone who's listening has ever gone through a doctoral defense, this is what they try and break you because a lot of PhDs and doctors are supposed to be know-it-alls in a way. And what they try and do in doctoral defense is try and get you to admit that you don't know, but you can critically think of the science that you do know and be able to apply it. Because I do think you're right. We have to be able to build trust and rapport. And especially today in a world of information, they're coming to you as a credible source of information. And so we need to remain and hold on to that credibility. Okay, my final question as we wrap up here, Danielle, is if you had a crystal ball, what do you think is coming next in nutrition? Danielle Fanelle Haller: Okay, I love this question. So I kind of have two answers to this and I have to say I actually watched Jenna Braddock's episode a couple weeks ago and I love that she kind of gave two different answers for that. So I'm kind of stealing her idea. So I kind of want to give an answer for the field of nutrition in general and then PEDS renal specific. So just for overarching field of nutrition in general, I think it's going to be AI is coming. I mean, it's here. AI is here. So I think we really have to be able to understand how we can utilize AI and not work against it. I know it can be very controversial right now, but the reality of the situation is that parents are going to be using ChatGPT and Gemini. They're just going to. Just today. I got off the phone maybe two hours ago with a mom who was using ⁓ chat GPT and Gemini to try to figure out a different formula situation. So it's coming. So I think what we need to do is be able to guide parents on one, what might be the best AI source for them? And then two, how can we best utilize prompts and what keywords can we enter into prompts to make sure that we are getting an evidence-based, reliable answer? So I think that's really important. And then something for PEDS renal specific, and this is more of, if I could just wave a wand and make something happen, this is what I would love to see. I would love to be able to see compounded enteral formulas in the same way that we have compounded parenteral nutrition for the home setting, because there's so many times when I kind of talked earlier about, you know, in such an individualized approach. And unfortunately, so many formulas, you know, kind of have that sweeping renal diet, you know, idea in mind where it's low in calcium, phosphorus, potassium, things like sodium, but. a lot of, like I said, no two renal patients or no two P's renal patients are ever the same. So they may not need all of those. So at that point, you know, we may be, we may need this formula for this nutrient, but then we're needing to supplement this formula and it kind of becomes this really, you know, difficult balancing act to kind of manage all of these things. So think if we could compound formulas, that would be, that would lead to the best outcomes. I think in a way we've kind of laid some grassroots for that. because as home blended formulas kind of start to become a little bit more popular, there isn't a lot of evidence for renal specific. ⁓ immunocompromised patient population, where they lie with that. There's a little bit of evidence, but not necessarily super strong. I think we've laid some grassroots there as far as being able to take that individual approach. at the same time, when you say you take like an avocado, say if you're a patient with hypokalemia and you want to do a home blended formula and you have, we'll say, okay, we're going to increase the avocado. We're going to use the USDA numbers. But at the same time, that's just an average based on a large amount of data. We don't know that the avocado that they picked up necessarily has that amount. So it's a step in the right direction, but if it could be more standardized and compounded where we know exactly how much is in it, I think that would absolutely change the game. Kristen Hicks-Roof PhD, RD: It's super fascinating. mean, I have so many ideas going through my head. I'm not in this space, but it's almost like the TPN for Ian, right? Like because we can craft orders specific for micronutrients and calculations and carb fat protein, right? ⁓ That I could see that wave actually going there, especially you see a lot of these like food first blenderized type formulas that people are moving towards versus just like completely manufactured. Danielle Fanelle Haller: Exactly. Exactly. Kristen Hicks-Roof PhD, RD: So it'll be interesting almost those two converging together because the big thing is what will be the regulatory practice, right? To make sure that we have clinical management and it's not just like making my own formula at home, right? It's like, okay, maybe that's not the best thing, but how can we go that direction? Danielle Fanelle Haller: Thanks. Exactly. Yeah. Exactly, exactly. think, you know, I hope one day that we see that. ⁓ I think that would be absolutely game changing for not not and you could make an argument for any area of nutrition that being absolutely game changing. But I know specifically for these pediatric renal kids, that is something if I could wave a wand, that would be the first thing I would wish for. Kristen Hicks-Roof PhD, RD: Well, maybe someone listening is in the formula, ⁓ in the formula industry, and they have this great idea. Reach out to Danielle if you want more information. So thank you so much for coming on the show and telling us your story and your career. And I love talking with clinical dietitians as well. I know I bring on guests in a lot of different niches. And sometimes people say I don't give enough love and attention for the clinical, but you know, it's really all about. Danielle Fanelle Haller: Yes. Kristen Hicks-Roof PhD, RD: look at there's dieticians in every nation sector and we each play our role in patient care and being able to help, whether that's on the individual patient, all the way to the community or the population level. So I appreciate you telling your story and if you liked the episode, make sure you like, subscribe, leave a review, but most importantly, check out the next episode because every episode I bring out a different dietician and nutrition expert to share their story and give you tips about how to get the role. Thanks again. Danielle Fanelle Haller: Exactly.