As malnutrition continues to grow among children entering and living in institutions overseas, Holt has begun to explore new ways to address this devastating problem. In one major step forward, Holt has entered into an exciting partnership with the adoption nutrition organization SPOON Foundation. In the coming years, Holt and SPOON will design and implement a wide range of sustainable and affordable nutrition programs to optimize the health and wellbeing of the children in our care overseas. Here, Jennifer Goette reports on the vital importance and potential impact of Holt’s growing work with SPOON.
by Jennifer Goette, Director of Strategic Initiatives
Rajeesh* is a staff favorite at the Vathsalya Charitable Trust (VCT) informal school in Bangalore, India. A 4-year-old charmer with deep brown eyes that gleam with an impish twinkle, Rajeesh bounces around from one activity to the next and often offers to help his teachers in class. He is also quite self-sufficient. On a weekday visit to VCT – Holt’s partnering care center in Banglore – I watch, and giggle, as Rajeesh takes a cup out of the cupboard, helps himself to a drink of water, and then places the unwashed cup back in the cupboard. He flashes a big smile and skips off. One of the cooks shakes her head and smiles as she retrieves the cup and washes it.
Two years ago, Rajeesh was nowhere near the energetic kid that he is today. The sparkle in his eye was dulled by malnutrition. Less than 2-years-old when he was found abandoned and referred to VCT, Rajeesh was quickly diagnosed with severe anemia and moderate cognitive delays. At the time, Rajeesh was not able to speak and could not sit up without assistance. He also had a protruding stomach, often a sign of protein deficiency.
This little guy was immediately given a blood transfusion for anemia and started on iron, zinc and calcium supplements. The staff at VCT balanced his diet and began to regularly monitor his anemia. It still took more than one year in care before the staff noticed significant improvements in Rajeesh’s energy and his iron tests reached normal levels. A few months before his third birthday, Rajeesh was transferred to Bangalore, where he now lives with a loving foster family and has access to speech therapy twice a week. Although Rajeesh continues to struggle with concentration and has some difficulty speaking – signs of the irreversible damage caused by early malnutrition – he has shown vast improvements in his energy level and overall health.
A Growing Problem, A New Challenge
We know malnutrition is a serious problem. Malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths annually among children under 5 around the world. Research shows that mild to moderate malnutrition during a child’s critical early years, particularly iron deficiency, can have significant consequences – such as delayed motor and mental development and reduced resistance to infection. Severe malnutrition during the first few years of life can lead to impaired cognitive functioning and irreversible stunting. We know all of these things. And yet, while there are several global initiatives to address malnutrition and hunger for children living in the care of their families, none of these programs focuses on the most vulnerable children – those living in institutions and care centers, outside of family care.
In many countries where Holt works, our partner agencies are seeing more children like Rajeesh coming into their care. Some partners estimate that as many as 85% of all children now entering care have significant nutrition and health-related problems! This poses a daunting challenge for our staff and partners. Research shows that children with poor nutritional status are less likely to form and maintain healthy attachments with their caregivers or engage in activities that would otherwise advance their development. This could affect their chances to be reunified with their birth family or successfully placed with a foster or adoptive family. Rajeesh is one of the lucky ones. He has not only survived and thrived despite early nutritional deficiencies, but he has also been matched with an adoptive family and will soon start a new life in the United States!
Not every child is so fortunate.
At Holt, our primary goal is to ensure a safe, stable home for every child. To achieve our mission, we must do everything we can to maximize nutrition and health in the children we serve. Our partners have excellent clinical teams on the ground focused on determining the course of treatment and care for each child, but the nutrition issues are complex. Not only are more children entering care undernourished, this issue is confounded by the increasing number of children with special needs. Further complicating the issue are the nutritional risks posed by institutionalization itself. While many children enter care malnourished, children also become malnourished as a result of being in care.
Facing these challenges, we at Holt have asked ourselves: “If nutrition and health are key factors in a child’s development, how can we do more?”
An Exciting New Partnership
The answer became clear last year when Holt began a new collaboration with the SPOON Foundation, a non-profit organization focused on nutrition and feeding for children living outside of family care. About five years ago, Mishelle Rudzinski and Cindy Kaplan started SPOON in Portland, Oregon. Both Mishelle and Cindy adopted children from overseas who came home with growth and/or developmental delays caused by poor nutrition. Moved to act, they founded SPOON – the first organization worldwide to take a specific focus on improving the nutrition and feeding of orphaned, fostered and adopted children. In the years since, SPOON has expanded significantly – collaborating with a renowned team of experts in international development, neonatology, brain development, nutrition, and feeding. The organization has begun initiatives in the U.S., China, Tajikistan, Russia, Kyrgyzstan and, most personally, in Kazakhstan – the country where one of Mishelle’s and both of Cindy’s children were born.
Through our exciting new partnership, SPOON will now be able to reach children in many more countries. Holt and SPOON will design and implement a wide range of sustainable and affordable nutrition programs to optimize the health and wellbeing of the children in our care overseas. Through improved infant and young child nutrition and feeding practices, we aim to strengthen children’s short-term physical and intellectual development – ensuring children have the best chance to reunite with their biological family or find placement with a foster or adoptive family. Our work with SPOON is integral to achieving our ultimate goal – helping children find the loving, stable families they need.
To kick off our partnership, the SPOON Foundation traveled to Haiti in September with Holt’s then program director for the region, Sarah Halfman. Here, SPOON’s nutrition scientist, Zeina Makhoul, conducted an initial assessment of the situation and needs at Holt’s partnering care center, Holt Fontana Village. Then last month, Zeina and I traveled to India to talk with our partners there about challenges they face and how we can further enhance and customize their screening and treatment of children in care. While in India, we also had the opportunity to meet and interact with children in care, including Rajeesh.
Zeina is a registered dietitian with a Ph.D. in nutritional sciences. Just listening to Zeina, I realize that childhood nutrition is far more complex than adhering to a food pyramid! While caregivers and staff of our partner organizations provide excellent care, they like me are not nutrition scientists. With all of their responsibilities, they don’t have the time to keep up on the research available or study the nutrition science behind the absorption of vitamins and minerals. That’s where Zeina comes in. Zeina has identified many small changes to care and feeding that can positively impact the health and nutrition of children in our partners’ care.
In India, for example, the standard practice for infants who are not able to breastfeed is to introduce pasteurized cow or buffalo milk after the age of 2 to 3 months. Formula milk is quite expensive, and doctors in India generally believe that families are better equipped to handle cow or buffalo milk than to prepare formula milk. However, this local practice deviates from recommendations by WHO and UNICEF, which both advise waiting until a child is one year old to introduce cow or buffalo milk. Research shows that early introduction of these animal milks has the potential to cause iron-deficiency anemia and other problems in some babies. As children in care are unable to breastfeed, the introduction of animal milks as an alternative is also an example of how institutionalization itself can cause nutritional deficiencies.
As they endeavor to improve nutrition and feeding practices for children overseas, SPOON also recognizes the importance of respecting cultural practices and approaches. They plan to work with our partners to determine culturally appropriate solutions. In the case of the cow’s milk, this may include monitoring children in care for iron deficiency, and providing iron supplements if needed.
Giving Children The Best Start in Life
Personally, I am learning a great deal from the staff at SPOON. Since our partnership began about eight months ago, I have been working closely with Zeina and SPOON co-founder Cindy Kaplan. Both Zeina and Cindy understand and are deeply committed to Holt’s vision to find a permanent, loving family for every child. In fact, they speak passionately about research that shows children in institutions who experience improved growth, development and nutritional status – children who regain the “sparkle” in their eye – are more likely to bond with caregivers and eventually, adoptive parents.
Research from Dr. Dana Johnson at the University of Minnesota shows that in order for a child to grow, the child needs two things: sufficient food/vitamins AND adequate hormones for the body to utilize the nutrition. These hormones are actually stimulated when the child receives nurture and affection – eye and verbal contact, as well as being held, touched and loved by a caregiver. Unlike children in the care of families, children in institutions typically receive far fewer opportunities for attentive, one-on-one interaction with a caregiver. This is another way in which institutional care puts children at far greater risk of malnutrition. As a way to enhance bonding and attachment, SPOON encourages caregivers to hold children and engage with them, especially during feeding times.
What Dr. Johnson’s research tells us is that even with adequate nutrition, a child who goes without love and affection will not thrive. But by providing proper food and nutrition, as well as affectionate, high-quality care, we can really give children the best start in life. Our work together with SPOON is designed to do just that.
During our site visits in India, Zeina and I were able to work with staff to identify areas where knowledge and practices could be enhanced through resources and training. For example, nurses and child development staff use growth charts to track development, but the charts they use need to be updated so that they are appropriate for the age and sex of each child. As part of this initiative, each site will receive new equipment and clinical staff will be re-trained on measuring children. Staff will also learn how to properly track growth and analyze the results using WHO growth charts. Using this new approach, the nurses will be better equipped to catch poor development early and make changes to get the child back on track!
There are also some very practical ways in which SPOON can provide technical support. In India, an initial analysis
of the children’s meals at the care centers suggests that they may not be getting enough iron and zinc. This is because the diet in Bangalore and Pune is mostly vegetarian and primarily based on grains and legumes. Zeina explains that grains and legumes contain a less bio-available form of iron – compared to animal foods – as well as substances that reduce the absorption of iron and zinc in the body. So, if not planned and prepared carefully, it is likely that the children’s diet will not provide adequate amounts of these nutrients. Based on an assessment and a trip to the local market, SPOON can suggest simple, cost-effective, and culturally sensitive solutions that improve the menu without adding costs.
The changes are small, but the potential impact is great.
At Holt, we strive to be innovative in the ways we serve children outside of family care. This partnership with SPOON is a terrific example of how we are combining Holt’s far-reaching programs with SPOON’s technical expertise to give children around the world the chance they deserve to grow and thrive. Once the nutrition screening system is complete, we plan to scale up these efforts to all of Holt’s country programs and partners – and eventually to other organizations focused on orphaned and vulnerable children.
In countries like India, where 46% of all children under five years old are chronically malnourished, there is a tremendous opportunity to make a difference. While we may not be able to counter all of the effects of malnutrition in children coming into care, we want to do whatever we can to give children like Rajeesh the best start in life. Together with the SPOON Foundation, we are taking the first step.
* name changed to protect identity
Click below to hear from nutrition scientist Zeina Makhoul as well as Asha Avadhani, head nurse at Bharatiya Samaj Seva Kendra (BSSK) — one of Holt’s partner care centers in India: