Nutritional Supplements in Adoption

Background

Internationally adopted children tend to suffer more from micronutrient (vitamin and mineral) deficiencies and lack of attuned, stimulating care than from protein/calorie "macronutrient" malnutrition. Basically, most kids in orphanages get enough protein and calories to grow, but don't because of stress, neglect, and, perhaps, some micronutrient deficiencies. Iron and iodine deficiencies are well documented, as are vitamin A and D deficiencies.

The iron deficiencies (+/- anemia) may worsen during the catchup growth period, as children outstrip their limited iron supplies. This makes getting extra iron important for most internationally adopted children, for as long as they're having catchup growth. The constipation angle is overrated, in my experience, and I'd rather manage the constipation than see your child's brain development impaired by lack of adequate iron.

Vitamin and trace mineral deficiencies may also be implicated in the high rate of initial skin and hair symptoms. Zinc deficiency has been linked to stunting, poor healing, diarrhea, and cognitive delays in developing countries. I also wonder about essential fatty acid levels, and if we should be doing something to support the rapid brain growth we so often see. Many of the placing countries in international adoption also have environmental toxin issues (former Soviet Union, India, and China among others), but fortunately the lead issues we saw in years past are better these days.

With the following recommendations, I will be paddling a bit out of the main stream of conventional pediatrics and into the duck pond of integrative approaches here, where we find a whole menagerie of promising but less tested ideas, "ancient wisdom", it's-safe-because-it's-natural therapies, and yes, outright quackery.

Sure ... the following supplements may just give you the most expensive septic system on the block, and the nutriceutical industry is turning a tidy profit on fairly unproven claims ... but my sense is that research is starting to demonstrate a benefit to supplementation, especially in nutritionally and developmentally at-risk populations. I'm reviewing this topic for some presentations in the next year, and look forward to sharing the results here on the site.

Vitamins and Minerals 

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth if not beyond.

The ideal supplement for internationally adopted children would contain plenty (100% RDA) of Vitamin's A and D, iodine, iron, zinc, selenium, and other vitamins and trace minerals. I've not yet found the ideal liquid/powder form, and would love to see suggestions in the comments below if you find a good one. Plenty of options in the chewable format, which can be crushed, but that's extra work, and not so dissolvable.

• Enfamil's Poly-Vi-Sol with iron is a basic multivitamin plus iron liquid supplement that is easy to find, but not as complete as the others.
• Schiff Children's Liquid Multivitamin with Iron and Zinc is another decent liquid option.
• My hope is to enlist a quality manufaturer like Kirkman Labs to make a tasty dye-free, zylitol-sugar-based liquid or powdered supplement targeted to the unique needs of children with orphanage backgrounds, to support their nutritional recovery and remarkable catch-up growth.
• As for chewables, there are lots of options out there. Flintstone Complete and other drugstore "complete" multivitamins are easy to find, and taste good. Heck, they even make vitamin pixie sticks these days.
• NSI Synergy Complete Multivitamin Chewables have lots of good stuff, and no artificial colors or sweeteners, which makes them more attractive to me than the typical drugstore vitamins. I've had feedback that taste is an issue here, though.
• Kirkman's Chewable Vitamin and Mineral Wafers have everything but the iron. If we've prescribed additional iron for your child, these would be a good choice. You could also use these and supplement iron in other ways.
• Remember that iron supplements are a frequent cause of accidental overdose in children - the doses we recommend are quite safe, but please keep the tasty vitamins well out-of-reach.

Essential Fatty Acids 

I'm also starting to recommend essential fatty acid supplements like fish oils for older adoptees who aren't getting DHA/ARA from the newer formulas, or as a possible adjunctive therapy for ADHD and other developmental/behavioral concerns. This is another area where conclusive research is lacking, but it seems plausible to me that children from malnourished pregnancies, who weren't breastfed, who were raised on diets poor in healthy omega-fatty-acids, and who are having rapid brain growth may benefit from supplementation in this area. Essential-fatty-acid (EFA) supplementation also shows some promise in certain learning and developmental disabilities, which are more common in IA children. DHA is a type of omega-3 fatty acid that seems important in early brain and vision development, and is a major structural building block in the brain. EPA is another omega-3 fatty acid that may be more helpful in later issues like attention (ADHD) and mental health. Flaxseed oil contains ALA, some of which is converted to DHA/EPA.

The optimum ratios of DHA and EPA have not been fully worked out, but I like to see more DHA early on for infants and toddlers, and more EPA for older children, especially those with ADHD symptoms. Some fish oil products even include some healthy omega-6 and omega-9 fatty acids, for balance. Cod liver oil is a grandma favorite that usually contains natural vitamins A & D - check the labels to make sure you're not overdoing these vitamins, especially if they're in your other supplements and formula. It would be nice to get these healthy fats from diet alone, but sadly, our fish supply isn't safe enough in terms of mercury and PCBs to safely consume enough to meet our target intakes of DHA and EPA.

Some quality fish oils that are independently tested to have adequate potency and very low levels of contaminants include:

• Nordic Naturals - lots of options here, including flavored oils and small chewable gelcaps
• Pharmax's Finest Pure Fish Oil is one of the less fishy oils out there, and their more expensive Frutol is a fish oil that's emulsified with prebiotics and fruit purees. They even make powdered versions, but I hear those are a bit fishier. Available where their probiotics are found.
• Coromega is another pricey emulsion in orange and chocolate pudding flavors for kids that won't tolerate fish oils straight up, cheaper through VitaCost.
• Carlson's Fish Oils are also easy to find, and available in child-friendly formats.
• Costco Kirkland Brand fish oil softgels are inexpensive option for folks that can swallow pills.
• Tips for taking fish oils - you can often get kids used to taking the oil straight, or try them stirred into a "shot" of juice or water, smoothies, or applesauce.
• Flaxseed oil is a vegetarian option for omega-3's. Refrigerate these oils, as they go rancid pretty easily. Ground flaxseed sprinkled on food or in baked goods is another way to go. While the ALA in flaxseed may be important in its own right, it's not very predictably converted to DHA and EPA.

Probiotics 

Another potentially helpful supplement would be probiotics, which are the good bacteria that live in your digestive tract, and that are found in yogurt. In fact, there's about 3 pounds of these bacteria in your body right now - isn't that a lovely thought? The Europeans and naturopaths have been big fans of probiotics for a while, and pediatricians are just starting to catch on. Definitive research is in its infancy, but I feel that it's a safe thing to try, especially for children with loose stools, who're taking antibiotics, or who have allergic predispositions. Since children from orphanages (where antibiotics are overused) are likely to have less-healthy "institutional strains" of these gut bacteria, it may be a reasonable thing to supplement for IA children. We've got lots more info and recommended formulations in our "Probiotics and Prebiotics" article.

Welcome Home Guide

What follows is a list of our typical recommendations at the initial post-placement evaluation. That first visit is a doozy, and much of what we say tends to get lost in the shuffle, so we'll recap many of our suggestions below. We like for folks to have a copy in hand when they leave our office, but you'll also find this article online at www.adoptmed.org/welcome, so that you can follow the links.

Medical Issues

If you are lucky enough to live within driving distance of an international adoption specialist, we highly recommend an initial evaluation 1-2 weeks after homecoming with someone experienced in the unique growth, developmental, infectious disease, and parenting issues that our children tend to bring home with them. A full list of international adoption docs can be found here and here, and we describe our recommended evaluations in this article, as well as in our travel packet.

Immunizations

Unless you've adopted from Korea (we trust their shots), or Guatemala (we sometimes trust the shots there), we recommend that you either check titers (blood tests to confirm immunity) or start over on shots.

• Hib and Prevnar (pneumococcal) immunizations are rarely performed in the typical sending countries, so I like to just start those at the first visit. Luckily, you only need 2 each of these if started >12mo, and you only need one Hib if given >15mo.
• It's also rare to see an international adoptee with full immunity to measles, mumps, and rubella, so we'll often start MMR over as well, unless MMR immunization is well-documented at >1yo, in which case we could check titers.
• Many IA children have received multiple DTP (diptheria, tetanus, and pertussis) and Polio immunizations, so those are ones I like to check with titers. However, titers done at less than 12-18mo may reflect transferred maternal antibody, so these may need to wait until the followup blood draw when children have been home ~6 months. If we have to wait to check titers, I will usually give 1-2 DTaP boosters, and perhaps one polio (IPV) booster, both to ensure coverage (lots of tetanus and whooping cough around, not so much polio in this hemisphere though) and to give the titers a good chance of proving immunity. Tdap (tetanus booster with added whooping cough protection) is a good choice for 11-18yo adoptees, and is now allowed earlier for those with uncertain immunization history.
• Hepatitis B titers are routinely checked at arrival and 6 months later, so we hold off on those shots until we see what the labs say.
• Hepatitis A immunization (2 shots, >6 months in between) is also a good idea, but not typically my first priority. Ditto for varicella (chickenpox, 2 shots) ... both can be checked with titers, but the extra blood and expense may not be worth it given that we wouldn't save that many shots.
• The new oral rotavirus vaccine is not an option, as the first dose must be given at 6-12 wks old, with the last dose not given later than 32 wks old.

I tend to be a "lumper" rather than a "splitter" when it comes to shots. I've seen no reliable evidence that immunizations "overwhelm" the immune system, and prefer to have fewer shot visits overall than drag things out by only doing 1-2 shots at a time. That said, I'm a flexible guy when it comes to shots ... please share your concerns with us.

The Vaccine Education Center at Children's Hospital of Philadelphia is my favorite online source for shot information from the generally pro-immunization perspective, as they link to relevant studies and also specifically address a lot of internet vaccine mythology.

Lab Tests 

• A list of typically performed lab tests is listed here. Yes, that's a lot of tests, but it's the only way to know if many frequently encountered problems are present or not.
• This is standard of care for internationally adopted children, although we get a bit creative in our office with children from Guatemala and Taiwan, and don't perform routine labs for children from Korea.
• Our lab on the 1st floor downstairs, or the lab at Children's, is a good place to get these done. If the draw is not going well, you can certainly decide to try again in a few days.
• It's going to require a lot of blood, typically drawn from the elbow or back of the hand, but your child will make more. Try to be calm, supportive, and resolute during the blood draw, model deep belly breaths, and try to put worries about attachment trauma and other anxieties out of mind, since your child will respond to your emotional state.
• If your insurance company balks at coverage (tsk tsk), you and your pediatrician can adapt this insurance letter by Deb Borchers, MD. Refer them to the AAP Red Book, as well.
• In our office, you can expect a call with all of the lab results in about 2 weeks, a bit longer if titers are perfomed. We'll call sooner with any concerning results.
• If you haven't heard by 2-3 weeks, please give the nurses a call at 206-598-3030.
• In 6 months or at 18 months-old, whichever comes later, we need to retest for HIV and hepatitis (to rule out exposures just prior to travel). This is a good time to check additional titers or follow up on earlier abnormal results, if we haven't already. We've recently started retesting for anemia and iron deficiency at the followup lab draw, since periods of significant catchup growth may cause children to outgrow their already limited iron stores.

Stool Tests

• You'll need to submit a total of 3 stool samples to check for giardia and other parasites (O&P x3 and 1 giardia antigen), collected every other day. This is important, regardless of symptoms - 15-20% of our IA children have a parasite like giardia.
• Until you know the results, be scrupulous about handwashing (Purell and other alcohol-based gels are very handy). 
• Don't let your children bathe together until you know the stools are clear - baths are a great way to share giardia.
• The lab will give you a bag with containers and instructions. Scoop a peanut-sized amount of stool into the preservative-containing vials, and on the day that you're dropping off the stools, submit a fresh (<4 hours old) sample in the screw-top plastic container as well.
• Please make sure your samples are labelled with your child's name, and write in the date collected.
• It's easiest for all concerned if you drop them off at our lab on the 1st floor, but you can also drop them off at a local lab, ideally a hospital lab that does this a lot. Have them fax us the results, and call us if you don't hear the results in 1 week.
• It's not unusual for this initial evaluation to miss a parasite - we've had several cases of Ascaris (white roundworm) present several months later ... so have a low threshold to retest for parasites if unexplained abdominal symptoms persist.
• If you have a positive result, we'll explain what to do, but please read our article on giardia and other stool parasites for more information.

TB Tests

•  We test for TB exposure with a skin test called a PPD, on arrival and again in 6 months after arrival. This followup test is crucial - we have a lot of kids who do have latent TB who have false-negative tests on arrival, due to stress/malnutrition.
• This skin test will need to be read by a health care professional in 48-72 hours. Our nurses can do this without an appointment. Just drop in during business hours ... bring your poop samples and drop them off at the lab on your way up.
• You may hear that this test is unnecessary in children who received BCG, the TB vaccine performed in many of our placing countries. This is not true. A result of 10mm or greater is a positive result, regardless of BCG status. Our children tend to come from high risk backgrounds as far as TB exposure is concerned.

Followup Visits

• We like to see children for followup visits every 2-3 months after arrival until they've been home 6 months. Our front desk can schedule these for you on the way out.
• We're happy to help you transfer care to a more local pediatrician at any point in the process. Many families stay with us until that 6-months-home visit, when labs, shots, and catchup growth and development are well underway.

Referrals

We see significantly higher rates of visual, hearing, and dental problems in children adopted from orphanages. Prenatal exposures and malnutrition, untreated ear infections, lack of visual stimulation, lack of fluoride and minerals, and poor dental care all contribute. For that reason, we recommend:

• Screening audiology evaluation by a pediatric audiologist in the first few months home. Most of our children are language-delayed on arrival, and audiology is extra important in that scenario. Parents and pediatricians miss significant hearing problems all the time, and ringing a bell next to a child's face is not an adequate test of hearing. We now have an otoacoustic emissions (OAE) gadget in our clinic for easy hearing screens, but it has a really low threshold to refer children to audiologists for further evaluation. If that happens, Children's Audiology (206-987-2000) is a good bet, since they're skilled in behavioral audiology techniques for young children. 
• Screening pediatric opthalmology evaluation in the 1st months home. We see significantly higher rates of strabismus (lazy eye) and other visual problems in IA children. The earlier this is detected, the better. David Epley (206-215-2020) and Mel Carlson (206-526-5222) are two good local pediatric opthalmologists.
• Early dental visit. Pediatric dentists like to see children as young as 1yo. See this article for more about early dental care. We don't have a current list of favorite dentists - check here, and ask other parents in your area.
• If we recommend an early intervention evaluation, you can access the nearest center by calling WithinReach (WA state) at 1-800-322-2588 for a local referral.

Nutrition and Growth

For infants and small toddlers, we recommend an infant or toddler formula with iron and essential fatty acids for the first 2-3 months home, even past the "typical" wean to whole milk at 1yo. Formula is just more nutritionally dense than milk, juice, or water, and contains essential nutrients for rapidly growing children. For more information, see our article on Choosing a Formula. When you do transition to whole milk (>1yo) or reduced-fat milk (>2yo if they've had good growth), try to limit it to under 18 ounces per day, since excess cow milk will fill up their bellies at the expense of other nutrition, and can cause anemia.

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we also recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth if not beyond. Other good sources of essential fatty acids for older adoptees include fish oils and flax seed oil. Probiotics are another supplement to consider. Please see our Nutritional Supplements in Adoption article for more information and specific recommendations.

For other nutrition ideas, start with the following resources on our site ...

• Transitional Feeding Difficulties
• Pediatric Nutrition Resources
• Picky Eating

... and the following web resources:

Development

Our website is chock full of articles, links, and book recommendations on the topic of development in internationally adopted children:

• Stimulating Early Development
• Birth-to-Age-5 Timeline of Development
• Developmental Milestones
• Language Development In Internationally Adopted Children
• Books for Speech/Language Delays
• "Birth-to-Three" Early Intervention
• Sensory Integration and Sensory Processing Disorder
• Screening for Autism in Toddlers
• Recommended Development and Learning Books
• Development and Learning Links

Therapeutic Parenting

This topic should probably be listed first, as I believe it's the most important intervention for newly adopted children. Kids who've experienced orphanage caregiving, multiple placements, neglect, abuse, and other trauma do have special needs in the area of parenting and attachment. What you'll read in typical parenting books, and what may have worked with "typical" children is not always the best idea for many of our children.

We're hard at work on our own "Parenting Toolbox" for adoptive parents, but in the meantime, please see these excellent resources:

• Top Ten Attachment Tips for the First Year of Placement - great stuff, from Deborah Gray
• Welcome Home - A Guide to Bonding- helpful tips and essays for the 1st year home from Adoptive Families magazine
• Sleep and Adoption
• Recommended Parenting Books
• Recommended Attachment Books
• Parenting and Attachment Links
• The "Difficult" Child

Choosing a Formula

The topic of what formula to use when breast milk is not an option generates a lot of smoke and heat, and is one of our more frequently-asked-questions ... so here it comes, folks, 2 level scoops of science mixed with 4 ounces of opinion.

I usually recommend a cow-milk-based formula at first. "But aren't all (insert-ethnicity-here) children lactose intolerant?" Actually, inborn lactose intolerance is extremely rare. Since lactose is the main sugar in breast milk, infants are born with the enzymes to digest it. While lactose intolerance may show up earlier in non-Caucasian children, you probably have at least 1-2 years of good ability to digest lactose. Also, an internationally adopted child has most likely already been receiving a cow-milk-based product, quite possibly sweeter, more dilute, and less nutritious than Western formulas. If you really really want to avoid lactose, and stay with a cow milk formula, there are lactose-free formulas, but they swap in corn syrup for the lactose.

Soy formulas are also an option, but in my mind you should have a compelling reason to switch. The longterm effects of a mostly soy-formula diet are not well-described; in the decades they've been in use, we've not seen obvious hormonal impacts from soy's phytoestrogens, and one retrospective study seemed reassuring, but we can't know that there aren't subtle effects. Also, certain minerals may not be as well absorbed from soy products, and children can get constipated on soy formula, neither of which is what you want in the first few weeks. I'm not at all anti-soy (I drink it myself), and do feel that cow milk itself is a bit overrated as a nutritional source ... but for infants I need a good reason to go with soy.

For toddlers, where the soy is just part of a healthy diet, and lactose intolerance is a more real possibility, a soy formula would be fine. I do recommend organic brands when it comes to soy products - too much genetically modified "Frankensoy" out there getting doused in Roundup and other pesticides.

You won't see goat milk on my list of recommended formulas. Goat milk is well and good as a substitute for cow milk, but I've just seen a few too many infants starving on goat milk formulas. Perhaps it's that "make-your-own-formula" isn't the safest way to go, perhaps it's that people don't realize that truly cow-milk-allergic infants are also likely to be allergic to goat milk (and soy) ...

I also never recommend a low-iron formula, but luckily they're hard to find. Adequate iron is essential for cognitive development, and international adoptees are frequently iron-deficient.

As for DHA/ARA, which are omega fatty acids present at varying levels in breast milk that are felt to help brain and eye development, I will say that they make good theoretical sense, but the research outcomes have been more mixed than the advertising would have you believe. For international adoptees, there is no research on this topic, but it would make sense that they'd be deficient in essential fatty acids, so I do have a preference for formulas with DHA/ARA.

You'll be seeing more about probiotic formulas, now that Nestle has introduced an infant formula with probiotic cultures to the US market. I can't say that the verdict is in on probiotics and infants, particularly when it comes to which strains and doses to use, but there is mounting preliminary evidence that this may be a good thing. I don't think everyone should jump on this bandwagon just yet, but something to think about for adventurous early-adopter "natural" medicine type folk. Our article on probiotics has more, including some brands to consider, if you'd like to add your own.

I do recommend that newly adopted infants and young toddlers stay with formula as their drink of choice for about 2-3 months post adoption, and certainly to at least 1 year of age. It's just much more nutritionally dense than milk, juice, etc. Since many adoptees have micronutrient deficiencies (vitamins, mineral, iron), the formula can help. As for "toddler formulas", it's a trade-off: on the good side, they've got more calcium and phosphorus, on the bad side, the sugars are typically from corn syrup (unless you're convinced your child is lactose intolerant, then it's good). Confused yet?

Many parents choose to continue using the familiar local formula when travelling, which makes sense in terms of minimizing transitions. You can gradually switch to a US formula when you get home. However, I do think it's a good idea to bring some US formula too, in case you run out, or for children who don't seem too picky about such things. And for those adopting from China, I would switch promptly to US formula, even though it's likely that melamine is no longer in Chinese formula as of 8/08. For children getting rice cereal in their bottle, I would wean that too when you get home. Rice cereal is for eating, not drinking, and it won't "fill them up for sleep" (sadly).

If you child is refusing formula during your travels, please see our topic on Transitional Feeding Difficulties for some ideas. We also have an article on Nutritional Supplements in Adoption with more advice on vitamins, minerals, and essential fatty acids.

When it comes to specific brands, it's more about your philosophy and pocketbook, and your child's digestion, and less about science. But to reward you for making it this far through the article, I can tell you that I did have a wee bit of a slight preference for Similac Organic Infant Formula with Iron, since it comes from a longtime formula company, is organic, and includes DHA/ARA. But other excellent, and considerably less expensive options are available. 

Update: A recent kerfuffle in the NYT points out that this formula now contains cane sugars instead of lactose, and is thus perceptibly sweeter. While I do prefer lactose (the natural sugar in breast milk), for adoptees who are used to sweeter formulas, this is not such a disadvantage at first. Still, I expect to see Similac move back towards lactose (more expensive in organic form). And the other organic formulas have now added DHA/ARA, so they're looking more appealing. For a list of formulas with commentary, please see below ...

One last thing: use bottled water to reconstitute formula in developing countries, and consider doing the same in the US, at least for infants. It doesn't need to be designer water from artesian alpine watersheds, those cheaper jugs will do. Not that our water supply isn't the envy of many countries ... it's just that now the ADA has recently stated that using fluoridated water for infant formulas may overdo the fluoride. For toddlers, for whom formula is not the mainstay of their diet, I'm not as fussed about the fluoride issue, so filtered or tap water is probably fine. Brita and Pur-type filters remove a bit of the fluoride, but do leave enough for the water to be considered fluoridated.

One more one last thing: if you have yet to buy your baby bottles, consider buying a brand that is free of Bisphenol-A (BPA). This is a chemical you may have heard of by now that can leach out of certain plastics, especially at high heat or with older bottles. There's not enough data in humans yet to know what it does, but in animals it doesn't seem to be a good thing (it's an "endocrine disrupter"). Thus for young developing infants who get most of their nutrition from bottles, why not pick something that may be safer? Yes, there's currently a price premium, but it's not awful compared to brands like Avent (still using BPA) that have been the thus-far faves of the best-for-my-baby set. See the Z Report for an exhaustive guide to brands that do and don't have BPA, some bottle reviews, and this guide to Smart Plastics (pdf). We've had good luck with the Born Free bottles at our house ...

Updated: 10/08

Bottle-feeding and Formula Links:

Growth Charts

It's hard to be "ethnically correct" when assessing growth in international adoption. Many of the available country-specific growth charts are out-of-date, from a small sample size, drawn from ethnic groups that may not represent your child's ethnicity, based on malnourished populations, or all of the above. US growth charts aren't perfect either, but they are drawn from large population surveys, and were recently revised to better reflect the racial-ethnic diversity and combination of breast- and formula-feeding in the US.

In 2006, the WHO (World Health Organization) released new international birth-5yo charts based on 8,500 children from Brazil, Ghana, India, Norway, Oman and the USA. Their unique approach was to select children whose care meets recommended health promotion standards (breastfeeding, standard pediatric care, anti-smoking, etc) so that the charts would represent how children should grow, not necessarily how they are growing. Their big finding was that "child populations grow similarly across the world’s major regions when their needs for health and care are met."

However, most international adoptees are bottle-fed and often do not receive ideal or even adequate care. Our default charts are still the revised CDC/NCHS (US) growth charts published in 2000, if only because we by now have years of experience following ethnically diverse children pre- and post-adoption on these charts. Still, it can be interesting to plot children on country-specific growth charts, so here's a smörgåsbord of US, premature, and country growth charts.

For more information, see our articles on Evaluating Growth in Adoptees and Head Circumference Issues ... 

US Growth Charts

• START HERE - CDC growth charts for boys and girls, birth to 20 years
• Nellhaus male and female head circumference charts for children over 3 years old (I don't love these charts, as the pooled data is from 1948-1965, and is not as "interracial" as advertised, but we don't have many other options for older children).
• These 2010 United States head circumference growth reference charts: birth to 21 years, by Rollins et al., look better than Nellhaus for plotting head size in kids older than 2-3yo.

WHO Growth Charts

• Weight-for-age, 0-5yo
• Height-for-age, 0-5yo
• Head circumference-for-age, 0-5yo

Charts for Premature Infants

• 26wks to 1year chart, for boys and girls
• Fetal-infant growth chart for 22wk-2mo preterm infants from a meta-analysis of published reference studies
• Charts based on birthweight categories (for when gestational age is unclear). LBW (low birthweight) is for birthweights from 1500g to 2500g. VLBW (very low birthweight) is 1000g to 1500g at birth.
  
  • LBW Premature Girls
  • LBW Premature Boys
  • VLBW Premature Girls
  • VLBW Premature Boys

Chinese Growth Charts

The widely available China growth charts are from a sample of Southern Chinese children in Hong Kong in the 1960s, and thus quite out of date and not necessarily ethnically appropriate. These can be found on the Families with Children from China (FCC) site.

Also available online are Hong Kong boy and girl growth charts, which do include weight, height, and head circumference. More information about these charts is here.

Another useful reference could be "Infant feeding and growth of Chinese infants: birth to 2 years", which tracked growth in healthy, fullterm, formula-fed infants in 1985 Hong Kong and found that at 2 years old, infants were -0.6 standard deviations (SDs) lighter and -0.4 SDs shorter than US growth data, even with similar protein/calorie intake to Caucasian infants.

An article called "Updated gestational age specific birth weight, crown-heel length, and head circumference of Chinese newborns" based on preterm and term births in Hong Kong has weight, height, and head circumference charts.

Guatemalan Head Circumference Charts from Dr. Montiel

Note - these are unofficial charts based on his personal experience

• Guatemala - Head circumference graph for infant girls, ages 0-9mo
• Guatemala - Head circumference graph for infant boys, ages 0-9mo

Indian Growth Charts

The Indian Academy of Pediatrics has recently published new recommendations for growth monitoring of children from India, including growth charts based on "affluent urban children from all major zones of India measured between 1989-91"; this is actually an advantage, as they are more likely to reflect how Indian children can and should be growing:

• India - Girls, 0-3yo
• India - Boys, 0-3yo
• India - Girls, 2-18yo
• India - Boys, 2-18yo

The following Indian growth charts are older, and are presumed to reflect more malnourished populations:

• South India - Girls, 0-12yo 
• South India - Boys, 0-12yo

Korean Growth Charts

These are from the International Adoption Clinic at UMN:

• Korea - Female Growth Charts
  
• Korea - Male Growth Charts

Nepalese Growth Charts

An article with weight, height, and head circumference data for relatively healthy, higher socioeconomic status Kathmandu term infants:

• Nepal - Article describing growth in Nepalese Infants, Birth-1yo
• Nepal - Infant Growth Charts, which I adapted from the article above

Russian Growth Charts

From Dr. Tsepkova, via Karen's Adoption Links. Of unknown sample size and quality ... we prefer the CDC growth charts for Russian children.

• Russian Girl Growth Charts, 0-17yo
• Russian Boy Growth Charts, 0-17yo

Taiwan Growth Charts

From a parent who lives in Taiwan. These are the growth charts that seem to be a part of children's shot records. The less-than-smooth percentile lines does make me wonder whether the sample size or statistical techniques were adequate. I'm told they were in use from 1999-2009, when they switched to the WHO charts above.

The 1st page top left has head size in centimeters, by age in months. The rest of the 1st page is weight in kg by months and then by year. The 2nd page is height in cm by age. Percentile lines are in the legend.

• Taiwan Girl Growth Charts
• Taiwan Boy Growth Charts

Vietnamese Growth Charts

Adopt Vietnam has links to a few Vietnamese growth charts; however, they are not easy to interpret and are of unknown date and sample size.

Probiotics and Prebiotics

Getting Friendly with Your Gut Bacteria ...

Probiotics, or the use of beneficial bacteria, are an exciting concept in the prevention and treatment of various childhood conditions. Definitive evidence on efficacy and safety is somewhat lacking, but there have been several good studies looking at probiotics like lactobacillus and active-culture yogurts in the prevention and treatment of diarrhea. The weight of the current evidence supports the use of probiotics in acute-onset childhood diarrhea, and their use with antibiotics to prevent antibiotic-associated diarrhea. In addition, the use of probiotic formulas (available in Europe for awhile, and now in the US) may reduce the number of diarrheal illnesses for children in day-care settings. Some small studies suggest that probiotics may also help prevent colds, colic, thrush, yeasty diaper rashes, non-specific tummy aches, and urinary tract infections.

What's especially interesting is the idea that establishing a healthy gut bacterial ecosystem early in infancy may steer the development of the immune system away from hyper-reactive "atopic" conditions like eczema, asthma, and seasonal allergies; this could be very useful in families where there's a family history of these conditions. The research here is early and somewhat conflicting, but this is an area to watch.

The bacteria that colonize your intestines set up shop early on, and the bacteria found in hospital environments don't seem to be the healthiest to be colonized with. It may prove to be wise for pregnant women to consume active-culture yogurt, kefir, or probiotics, and to supplement babies with these healthy bacteria. It should be emphasized that the research on this topic is in its infancy, and that definitive safety and efficacy information is not available.  Furthermore, research has not defined what strains of probiotics work best (or at all!) for various conditions. But so far, we have not seen serious side effects except in significantly immuno-suppressed children.

As far as yogurts are concerned, not all are created equal. In kids from 8mo-2yo and in malnourished adoptees, full fat is the way to go. Stonyfield Organic Yogurts (they make "YoBaby") are well-regarded, tasty, all natural, and have 6 kinds of friendly bacteria, as well as prebiotics (see below). For promotion and maintenance of healthy gut bacteria, serving yogurt daily is a safe, time-tested, granny-approved, and easy-to-find way to go. But for treatment purposes or early in infancy, you might consider probiotic supplements, which can deliver many more of these healthy bacteria than a container of yogurt.

Like any unregulated "nutriceutical", it can be hard to find reliable, standardized products, and even harder to get them covered by your insurance. Probiotics, in particular, do not always contain healthy, viable strains of bacteria. One excellent brand of probiotic supplements that's available locally in Seattle is the Pharmax HLC line. Pharmax is involved in a major trial of infant probiotic supplementation, uses human rather than cattle or soil strains, and guarantees high potency. This line is carried at Clark's Pharmacy in Bellevue (425-881-0222), Bastyr Dispensary in Wallingford (206-834-4114), Pharmaca in Madison Valley (206-789-0800), Medicine Man Drugstore in Greenwood (206-789-0800), and online at various resellers.

Pharmax makes an infant powder (HLC Neonate) that's specially formulated for babies, and is easy to give. They also make "toddler straws", where the probiotic is actually inside a straw - nifty, convenient, but not cheap. Their most cost-effective option for children is HLC High Potency Powder, using 1/2 tsp daily for "treatment" dose, and 1/4 tsp daily for "maintenance" dosing. They also just came out with HLC Mindlinx, with additional strains designed to digest casein and gluten, for folks with sensitivites to those, or children with autism that have responded to elimination diets (major unproven claims/controversial issue alert ... but interesting as an example of more targetted probiotic therapy).

Culturelle supplements use Lactobacillus GG, one of the most studied strains, and are easy to find over-the-counter in most drugstores. Lactinex packets are available by prescription in some pharmacies. Nature's Way is another easy-to-find brand that sells a blend of probiotic strains, included lactobacillus reuteri, which was used in the recent infant colic study. The actual Biogaia drops used in that study are not sold here, but the manufacturer does have a US order page.

You'll also want to think about prebiotics - foods and supplements that help these healthy bacteria thrive. These can be found naturally in breast milk, honey (not for use <1yo), garlic, onions, leeks, wheat, bananas, asparagus, artichokes, and chicory root. Supplements of fructo-oligosaccharides (FOS) are also available, and Pharmax includes them in many of their probiotic formulations.

What's fun about this topic from the adoption medicine perspective is that the Eastern European docs love probiotics. "Dysbacteriosis" is a frequently seen diagnosis, often treated with "ferments and enzymes", and while you'll still want to rule out parasites like giardia and other malabsoptive causes of funny poops, I am convinced that children raised in hospitals and institutions have less healthy gut bacteria. In Russia, you can even get yogurt fortified with the power of Cosmonaut intestinal bacteria! Cosmonauts being the pinnacle of Russian health and fortitude, I suppose. Best not to think about how they collect said bacteria ...

Probiotics Resources:

• Fast Facts about Yogurt and Beneficial Bacteria - DrGreene
• Surprising Uses and Benefits of Yogurt - DrGreene
• Full Fat Yogurt for Infants and Toddlers - DrGreene
• Should You Feed "Friendly Bacteria" to Your Infant and Child? - Dr. Parker
  
• The Probiotics Web Page

Updated 7/07

Pediatric Nutrition Resources

Update:

This page has largely been replaced by our new expanded Food & Nutrition Books page.

Ellyn Satter is my favorite authority on pediatric feeding issues. All of her books emphasize a healthy division of responsibility: you're responsible for what is served and when you serve it, and your kids decide what and how much they eat. In general, childrens' bodies know better than we do how much they need to eat for appropriate growth, and this division of responsibilities helps you avoid mealtime battles, and promotes healthy eating choices. However, while her advice on feeding issues is great, her nutritional advice does leave something to be desired for folks making for progressive diet choices (organic, veggie, etc) for their family. These are some of her books ...

• Child of Mine - Feeding with Love and Good Sense - "A warm, supportive, and entertaining book for parents about basic nutrition for infants and young children, and a solid nutrition reference for professionals. Covers breast feeding, bottle-feeding, learning to eat grownup food, and normal growth from infancy through preschool."
• How to Get Your Kid to Eat ... But Not Too Much - "This is the book about feeding dynamics. Based on a solid understanding of child development and parent-child relationships, firmly builds the bridge between nutrition and feeding. Offers specific advice on feeding children from infancy through adolescence, including feeding the sick child, eating disorders, childhood obesity, and poor growth."
• Your Child's Weight - Helping Without Harming - "This groundbreaking book gives clear evidence that children gain too much weight because of how, not what they are fed. Satter's calming, practical and carefully documented voice empowers readers to feed well, parent well, and let children grow up to get bodies that are right for them. Packed with Satter's ever-popular feeding stories, Your Child's Weight offers clear guidance for professionals as well as parents."

Another good book is Feeding Your Child for Lifelong Health: Birth Through Age Six featuring research-based concepts of "metabolic programming" - how what we eat early on can influence influence cellular functions in ways that affect intelligence, personality, immunity, strength, and, of course, growth patterns. 

Anemia and Iron Deficiency

We'll update this soon with our take on this VERY common issue in international adoption, but for now, here are some good resources on the topic. A quick reminder: liquid iron supplements can cause temporary staining of the teeth - squirt towards the back of the mouth, and have the child drink some OJ afterwards (vitamin C boosts iron absorption).

Anemia and Iron Deficiency

• Anemia - KidsHealth
• Excellent tips on boosting iron intake from DrGreene

Thalassemias

• "What Is Thalassemia?" - Cooley's Anemia Foundation
• Comprehensive Thalassemia Resource from Children's Hospital in Oakland
• Thalassemias - KidsHealth

Transitional Feeding Difficulties

While many international adoptees have no trouble eating & drinking & growing & gaining, some children from orphanage or neglectful backgrounds have initial trouble with age-appropriate foods. Feeding difficulties are some of the hardest to cope with emotionally, since feeding your likely malnourished child gets at the core of parenting.

The trouble you may have likely has little to do with you or your feeding skills. If you just received the child, they may be scared, stressed, grieving, and just not that hungry. Also, their past experiences with feeding have a large influence on your early mealtime issues.  Prior feeding practices may have including bottle-propping with wide-open nipples (chug-chug-chug passive feeding with little active sucking involved), uncomfortably hot or cold foods, sweeter formulas thickened with cereal, and limited or no introduction of solid foods. These practices can lead to markedly immature oral-motor-feeding skills, aversions to feeding, fear of novel food experiences, and taste/temperature sensitivities. Some kids have the feeding ability, but just want things the familiar way, so if you get the opportunity, do ask their caregivers what that way is.

The immediate focus in children with marked feeding difficulties or refusal should be on keeping up hydration; that said, it is VERY unusual for a child to refuse himself into severe dehydration. Solid foods can wait until you get home. Formula is still the drink of choice, as your child will need the calories. If your child is refusing the bottle, you might try some of the following tweaks:

• try the familiar local stuff, in a local bottle (straight bottle, big open nipple)
  
• experiment with various formula brands (see Choosing a Formula)
  
• add in 1 tsp of sugar per 6-8oz bottle if the local stuff is sweeter (but wean this over the next 1-2 weeks)
• try a slightly more dilute formula (not for more than a day or so)
  
• mix in some rice cereal to the formula (I don't love this practice but they're often used to it)
• play with temperature (from cooler to warmer than you'd think, but test it on your wrist first)
• and definitely try different nipple styles or open up the nipple you do have
  

The massive transition you're going through together may also contribute to your child's energy level and interactivity. Keeping as much routine as possible around meals/snacks/sleep, nesting in your hotel room, and avoiding crowded and overwhelming spaces can help.

The solid foods can happen at their pace ... oral defensiveness is certainly something that we see. What these children need is a gradual, persistent, and consistent approach to introducing textures (simple to more complex) and tastes (bland to more stimulating). The same approach should be used for children with difficulty making transitions from one feeding stage to the next (pureed to junior textures, bottle to cup). If they don't progress in the next few weeks then visiting a feeding/speech/oral-motor therapist on return would be a good idea.

Things that also may contribute - any painful-looking mouth sores or teeth (emerging or decayed)? Any painful reflux behaviors (sour face, arching back)? Any cough/sputter with eating? Vomiting/diarrhea, or bad constipation? Other concerning signs of illness? If so, let us or your doctor know.

Head Circumference Issues

Why we care about head circumference issues ...

Dr. Dana Johnson's review article on head size - "Does Size Matter, Or Is Bigger Better?" - says it best. Highly recommended for parents considering referrals with head growth concerns. Growth charts are available here.

How to measure a proper head circumference ...

Bring a non-stretchable measuring tape, and practice a bit first. Wrap the tape snugly around the widest possible circumference - from the most prominent part of the forehead (often 1-2 fingers above the eyebrow) around to the widest part of the back of the head. Try to find the widest way around the head. Remeasure it 3 times, and take the largest number.

Evaluating Growth in Adoptees

Almost every medical report has at least one set of growth measurements. It is always advisable, and usually possible, to request an updated series of measurements on a newly referred child. Growth is an objective measure of the child’s nutritional and medical status and may be the most reliable information available prior to adoption. However, weight errors can occur from measuring children in winter clothes versus unclothed, and height and head circumference seem especially susceptible to erratic measurements, due to technique or old stretched-out measuring tapes. Growth charts specific to children from certain countries are available, but these measurements are usually plotted on the revised United States growth charts (see below). It is generally the pattern of growth over time, rather than growth indices at a specific age, that is of greatest value.

Unfortunately, an orphanage is far from the ideal environment for childhood growth. Many children exhibit evidence of malnutrition and psychosocial dwarfism. Most are stunted in linear growth (height). Generally, we expect children to lose about 1 month of linear growth for every 3 months in institutional care. Although most children who are malnourished and poorly stimulated maintain brain growth, over time even head circumference may not be spared. Microcephaly is a red flag. Children who have microcephaly that is extreme or present from early in infancy may have medical diagnoses other than malnutrition or deprivation, such as fetal alcohol syndrome, a genetic disorder, or a perinatal brain injury. Although most orphans exhibit dramatic catch-up growth after adoption, even in head circumference, it is not yet known whether this recovery of brain mass means that the brain will function normally.

We recommend that you download the revised CDC growth charts for tracking weight, height, and head circumference along with us. These are what we use for children from Eastern Europe, as well as most children from other regions. While there are some ethnic differences in growth, many of the country-specific growth charts are problematic – for example, the China growth charts date from the early 1960s, and may be “normalizing” malnutrition.

For children from China or Korea with borderline growth it may be reasonable, however, to give them the benefit of the doubt. Growth charts for these populations and for premature infants can be found in our Growth Charts section.

If percentiles are confusing at first, think of it this way - a child at the 10th percentile for height is 10th in line of a hundred kids of the same age and gender lined up by height. 50th in line, or 50th percentile, is average. The broad definition of "normal" is from the 3rd percentile to the 97th percentile, or "within 2 standard deviations of the mean", for the engineers out there. But again, trends of growth over time are usually more meaningful than the percentile at any given moment .