A Nourishing Start

After a successful pilot project, Holt and SPOON Foundation secure a four-year grant to implement a nutrition and feeding program for orphaned and abandoned children in five more countries — starting this year in China and Vietnam.

It’s lunchtime at an orphanage in southern Vietnam. Children eat their meals in separate rooms— grouped together by age and degree of special need — and caregivers help feed the youngest and most disabled children. In one room, a caregiver is feeding a boy on a stretcher. He is about 8 years old and has severe spastic cerebral palsy. Many of the other children in this room have cognitive or behavioral delays, and you can hear them screaming or clapping in the background. Some are waiting their turn to be fed. One sits on the floor, feeding herself.

The caregiver is a young woman who wears her hair in a neat bun and little pearls in her ears. She smiles as she spoons congee into the mouth of the boy with CP, who is laying flat on his back with a towel spread across his chest and his arms up around his head. Congee is a watery rice soup common in Vietnam and other parts of East and SE Asia, but it’s especially difficult for a child with CP to swallow. The boy keeps shaking and coughing — sometimes gagging — after each spoonful. Unsure what to do, the caregiver continues feeding him — rubbing his chest as he coughs. Thinking he might have an easier time if flatter on his back, she lowers the stretcher. This only makes it harder for him to swallow, and he shakes as he tries not to choke on his food.

Two years ago, Holt teamed up with SPOON Foundation, a Portland, Oregon nonprofit and truly the first organization worldwide to take a special focus on improving nutrition and feeding for orphaned, fostered and adopted children. After identifying two pilot sites among Holt’s partner organizations overseas, SPOON implemented a nutrition screening system and trained caregivers and staff to properly track the growth and nutrition of children in care. Looking at the diet and feeding practices at each care center, SPOON also suggested small changes that could dramatically reduce malnutrition and improve the overall health and wellbeing of the children.

After implementing the nutrition program in India, anemia prevalence dropped dramatically among children in care.

In India, these changes included introducing cow milk to infants at 6 months instead of 3-4 months; delaying the introduction of cereal to infants to when they are 4-6 months instead of 2-3 months; providing iron supplements with Vitamin C to increase absorption and adjusting the dosage depending on whether the child is anemic; and giving iron at mealtimes but not with milk, which lowers absorption. Although some nutritional measurements such as stunting and head size will take longer to show impact, one outcome was immediate. Just six months after SPOON implemented these changes, anemia prevalence among the children dropped from 45 percent… to nine. At one site, anemia was completely eliminated.

“Anemia is the big issue children face in orphanage care,” says Dan Lauer, Holt’s VP of Africa programs. Dan helped forge Holt’s partnership with SPOON. “If 75 percent of children are anemic, we have a real issue.”

Most commonly caused by a deficiency of iron, anemia can have very severe consequences for a growing child. As Zeina Makhoul, SPOON’s nutrition scientist, explains, “Iron is a very important mineral for brain development. For a child between 0 and 5-years-old — especially between 0 and 2 — this is when their brain is developing at an accelerated rate.  So having a deficiency in iron at that time is really going to impact their brain development.” Long-term studies of anemic children have shown that they have lower IQs and perform more poorly in school. Iron is also very important in disease prevention and immunity. As Zeina explains, “Those who are iron-deficient tend to get sick more easily and for longer periods of time and then those who are sick have poor appetite, and poor appetite means not enough nutrients. Not enough nutrients mean iron- and other deficiencies. It’s an ongoing cycle.”

An added element of iron-deficiency for children living in institutions is its impact on their ability to join an adoptive family. Children who are anemic lose the “twinkle in their eye.” Not only are they cognitively and physically delayed, but they have a harder time forming healthy attachments with adults. These factors are instrumental in a child’s potential for successful placement in a family. Proper nutrition is also vital to the growth and development of children in care temporarily while their parents work to get back on their feet — and will help ease their transition back into their family.

Through the years, some of our partnering orphanages have recognized and tried to address anemia with iron supplements. But, as SPOON taught our partnering staff in India, iron absorption is complex. In the case of one care facility Holt supported, iron levels in children remained low despite iron supplementation. Nutritional deficiencies are often a multifaceted problem and putting a Band-aid on it is not enough.

“Generally, we work in the macro,” Dan says. “We make sure they have the right food and enough food.” As we’ve learned from SPOON, however, nutrition is about providing the right food at the right time in the right way.

Learn more about the pilot nutrition project in India from SPOON’s nutrition scientist:

Holt International and SPOON Foundation in India from Holt International on Vimeo.

With positive outcomes from SPOON’s pilot program, Holt and SPOON have secured a four-year grant from a private foundation to implement the nutrition screening and caregiver training in five additional countries. Earlier this year, Zeina traveled to two sites in China and five sites in Vietnam for initial assessments of nutrition and feeding practices. At each site, she interviewed staff and caregivers, examined measurement tools and techniques, and observed feeding practices.

Caregivers often prop bottles for children to feed, unaware of the potential health consequences.

“It’s not easy to let outsiders come in and observe and point out problems,” says Jian Chen, Holt’s VP of China programs. “But China has a great desire to help children.” Over the past 20 years, China has made dramatic strides in the care provided to orphaned and abandoned children living in the country’s social welfare institutes. The government has significantly increased support and resources for children in orphanage care — to the point where Holt has primarily shifted our focus to children living in poverty outside the social welfare system. But as we have seen in other countries — including our own — nutrition is a complex problem, and even if they have enough to eat, children may still become malnourished.

In both China and Vietnam, Zeina observed similar problems with feeding. Given limited staff and time — and sometimes just out of habit — caregivers often prop bottles rather than hold the babies while they feed, unaware of the consequences bottle-propping can have on a child’s health. When children drink from bottles propped to their mouths, they sometimes inhale some of their milk, which can cause upper respiratory problems. Bottle-propping can also cause choking and ear infections. In some care facilities, caregivers may force-feed children if they aren’t hungry or won’t eat — causing them to “pocket” food in their mouths. An hour later, the caregivers may still find rice still stuck in the corners of their cheeks.

For children older than 4 months, some sites had begun mixing cereal in with their formula — cutting the nipples on their bottles to help the milk flow easier. This is considered “age-inappropriate feeding,” and is one of the problems SPOON corrected in India. “If they’re ready to eat cereal,” Zeina says, “they need to be spoon-fed, not bottle-fed.” Age-inappropriate feeding can cause delayed motor development, as children don’t learn to use the muscles in their mouth. One 4-year-old Zeina met didn’t know how to scrape the food from her upper lip, and relied on Zeina to do it for her.

During her trip to Vietnam, Zeina observed as the 8-year-old boy with CP struggled to swallow his food while laying flat on a stretcher. “Feeding kids with special needs was the most obvious need of training,” she says. When they sit upright instead of laying horizontally, it’s easier for them to swallow. Many would also have an easier time swallowing food thicker than the watery congee commonly fed to children in Vietnam and China.

Not only is it hard for children with special needs to swallow, congee is not particularly nutritious. “It makes babies look fat, but no one has any idea if the baby is healthy or not,” says Jian. Although it’s convenient and easy to make and serve, congee decays teeth and gums because it doesn’t require children to chew. “The digestive system is undermined as well,” Jian says.

While in China, Zeina could see the positive impact of the government’s investment in the orphanages — including sophisticated equipment and resources, and good hygiene and sanitation. In Vietnam, the institutions she visited had varying quality and diversity in diet, depending on resources provided by the government and/or Holt. Not all of the sites she visited in Vietnam received support from Holt. Those that did had a significantly better diet, with more fresh fruits and vegetables. Milk is also considered a luxury item in Vietnam.

“With more funding,” says Thoa Bui, Holt’s senior executive for programs in S.E. Asia, “we can support more orphanages and completely change the way children are cared for.” In the meantime, SPOON will work to find cost-effective and culturally appropriate solutions to the nutritional deficiencies they discover — much as they did in India.

Nutrition scientist Zeina Makhoul shares about her recent visits to Vietnam and China:

Holt International and SPOON Foundation in China and Vietnam from Holt International on Vimeo.

“Caregivers really want the best for children in care,” says Dan Lauer, VP of Africa programs. “They’re like sponges.”

Over the coming year, SPOON will return to China and Vietnam to implement the nutrition screening system and also to India to expand the training to three additional care centers. To build local capacity, SPOON aims to “train the trainers” — equipping resident caregivers and staff with the skills and resources they need to accurately measure and track health indicators in children, much the same way as Holt strives to give families in our family strengthening programs the tools and resources they need to independently care for their children. This approach creates self-reliance and a knowledge base to build upon. As Holt CEO Phil Littleton says, “It’s important these orphanages are getting the knowledge they need to give children a healthy start.”

Through the years, China and Vietnam have welcomed Holt’s assistance and partnership in strengthening in-country care and finding loving adoptive families for orphaned and abandoned children. When Holt approached the governments of China and Vietnam, they again welcomed our support and partnership in serving children. “They said, ‘We have training for sterilizing equipment,” Jian says of the China Center for Children’s Welfare and Adoption, “but never a feeding training.”

So far, orphanage staff and caregivers have embraced the training and are eager partners in our mission to ensure every child has the best chance in life. “Caregivers really want the best for children in care,” Dan says. “They’re like sponges.”

Through 2017, Holt and SPOON plan to expand the program to Ethiopia, the Philippines and Mongolia. Working with local governments, Holt is also hopeful that we can scale up the program on a regional or national scale in the countries where we work. In China, the government hopes SPOON and Holt will expand the training to other orphanages throughout the country and has offered funding to support the program.

“I thought the problem would automatically resolve after 20 years, but despite great effort by caregivers and the government to strengthen nutrition, there’s still a gap in feeding,” Jian says. “When there’s one egg in a huge pot of noodles for 30 children, the problem is not solved. China sees that too and is willing to step in and help.”

 Robin Munro | Managing Editor

In addition to our work with SPOON, Holt is in a tremendous position today to impact the lives of 2,600 children with more food and better care in 11 countries where we’re working.… Click here to help children receive the proper nutrition they need to thrive!

To read more about our work with SPOON, click here and here

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