"Food for Thought": Dr. Dana Johnson's Webinar on Nutrition and Adoption

Yesterday I watched with great interest a webinar conducted by Dana Johnson,M.D., and organized by Adoption Learning Partners. Entitled “Food for Thought: The Impact of Poor Nutrition in Early Development”, this presentation focused on the nutritional histories of internationally-adopted children, on their nutritional needs after adoption, and on developmental outcomes that appear to be related to diet.

Dr. Johnson was careful to emphasize the difficulty of disentangling nutritional from social factors in development. Infants and toddlers in orphanage settings are likely to be deprived both in their diets and their experience of normal social interactions. For the family child, or for the child in high-quality foster care, mealtime involves far more than simply the ingestion of nutritious substances. It is a “cue-based” process in which the baby’s signals of hunger or satiety are responded to by caregivers. This process involves talking and listening, social communication by facial expressions, turned heads, or open mouths, and anticipation of what another person is about to do (a feature of “theory of mind”). Feeding in the family also involves the pleasures of taste and texture and a sense of gradual mastery of self-feeding, achieved in graduated steps as sensitive caregivers provide food a baby can handle.

In an institution, however, as Dr. Johnson noted, feeding is not cue-based but efficiency-based. Bottle-fed babies have their bottles propped so staff members do not have to sit with them-- thus removing all possibility of social interaction during feeding. Institutional caregivers spoon food into babies’ mouths as rapidly as they can, then go on to the next baby without taking time to socialize or play. Feeding can thus become an unpleasant experience rather than the pleasurable, playful, self-regulated one it ideally should be. By the toddler period, institutional children are expected to be able to feed themselves, and although they eventually become competent at this, months may go by during which they do not have the motor skills to ingest much food. All these problems are intensified for children who have malformations of the mouth or whose motor control is problematic, as might be the case when cerebral palsy is present. Babies who were of low birth weight are particularly affected because of their greater need for calories and trouble absorbing fats and carbohydrates. Fetal alcohol syndrome is another factor determining special needs.

The result of time spent in an institution is very commonly growth failure. Children adopted from institutions are generally undergrown in both height and weight, and may have smaller head circumferences than family children. One of the tasks of the first year after adoption is the fostering of catch-up growth, which is usually rapid when circumstances are good. (However, the tragic news reports of abuse deaths of internationally-adopted children generally note malnourishment of the child; it is hard to know whether this condition is due to failure of catch-up growth to begin with, whether it is part of a pattern of neglect and abuse, or even whether it is due to ill-judged attempts to use food to control the child’s behavior [see, for example, www.ncids.org/Brief%20Bank/Briefs/Salvetti,%20Paul%20J.doc].)

In his webinar, Dr.Johnson recommends a thoughtful approach to the re-feeding of growth-retarded adoptees. First, he suggests establishing a nurturing feeding environment, where eating together can be pleasurable socially and otherwise. As in so many aspects of child development, in the beginning, the relationship between the child and the caregiver is more important than the calories ingested or the parent’s “feeding skills”. A second suggestion is that the adoptive parent begin with foods familiar to the child. The Internet site www.spoonfoundation.org provides information about what children from specific countries may be accustomed to eating and recipes for indigenous foods. Although many adoptive families cook such foods as a way to celebrate the child’s origin, Dr.Johnson’s point is that initially these should not be special holiday foods. They are what the child is accustomed to and therefore will have the greatest appeal for him or her. (And while you might intuitively think that an undergrown child will be famished and ready to eat anything, this is not the case. Chronic underfeeding leads to apathy and lethargy, and these children need to be tempted and encouraged to eat.) This is, by the way, not a time to correct the child’s table manners or make a point of discipline by demanding that the child eat.

Once a child is eating well of a family’s version of familiar foods, other appealing, easy-to-eat foods may be gradually introduced. It’s a good idea to remember that toddlers, even those with excellent care histories, are reluctant to try new things (this is sometimes called neophobia), and will often try foods only after they have seen them a number of times without eating them. Parents should keep an eye on whether a child can handle lumps or other textural differences; if not, a feeding clinic or a speech and language pathologist may be of help in teaching the child to use the mouth and tongue better, which may also minimize later speech problems.

Dr. Johnson also referred to concerns about over-eating and hoarding of food, and recommended treating these issues with sensitivity. A very helpful piece about hoarding is at www.spoonfoundation.org, along with information on other related topics.