Eastern European Growth Project

PRELIMINARY RESULTS: Neuroendocrine Functions in Post-institutionalized Children

 Internationally adopted (IA) children  from Eastern Europe, ages 6 to 48 months were recruited from the International Adoption Clinics at the University of Minnesota and Inova Fairfax Hospital for Children in Fairfax, Virginia, within three weeks of their arrival in the United States. The children were followed again at 6 months post-adoption.

Risk factors predicting STUNTED PHYSICAL GROWTH in international adoptees (as of December 2005)
Through the willing participation and remarkable cooperation of adoptive families, we have already moved closer to understanding what factors may have a negative impact on physical growth.

Thus far, the information we have gathered supports the existence of several relationships:

• If the child has a history of severe deprivation, it is more likely that they will be of shorter stature at the time of arrival.
• If the child is an older age at adoption, it is more likely that they will be of shorter stature at the time of arrival.
• If the child has a history of prenatal alcohol exposure, it is more likely that they will be of lower weight at the time of arrival.
• If the child has a history of prenatal alcohol exposure, it is more likely that they will have a smaller head circumference at the time of arrival.

Interestingly, we have not found a single risk factor that is able to predict growth stunting in all three growth measures (height/length, weight, and head circumference); also, failure in one area of growth (i.e.: height) can be predicted by more than one risk factor.

These findings further stress the importance of considering and investigating a large variety of risk factors as we attempt to understand growth failure in this population.

DETERMINANTS OF CATCH-UP GROWTH in children following international adoption.
Once removed from a high-risk environment, a child whose growth has been stunted will commonly exhibit an accelerated rate of growth (i.e., catch-up growth) in order to return to a non-stunted growth status. For most IA children, adoption is a dramatic and positive change in environment, and as a result, they demonstrated excellent catch-up growth.

Our results support this observation; height, weight, head circumference, IGF-1 and IGFBP-3 all increased significantly between the initial post-adoption assessment and the six-month follow-up assessment.

The analysis of data for the first 36 children has indicated these factors which are associated with a greater linear (height) growth:

• Female sex seems to predict better linear growth.
• Severity of growth stunting at the initial assessment seems to predict better linear growth.
• An increase in IGFBP-3 between the initial and follow-up visit is associated with better linear growth.
• Changes in IFG-1 levels and weight are not significant predictors of linear growth. Why girls did better than boys, and the role of IGFBP-3 both remain to be studied.

The preliminary results of these findings were presented at two professional conferences.

• The Second International Conference on Adoption Research
  July 17, 2006 - Norwich, United Kingdom
• 2006 Pediatric Academic Societies' (PAS) Annual Meeting
  April 29-May 2, 2006 - San Francisco, CA

Physical growth and health status in post-institutionalized children at high risk of PRENATAL ALCOHOL EXPOSURE (as of March 2007).
One of the main goals of the current project is to explore risk factors such as prenatal alcohol exposure that may contribute to growth and health problems in post-institutionalized children.

 Children coming from institutional care are typically small for their age and have developmental delays, two features that have been associated with a higher risk for prenatal alcohol exposure. Clinicians often do not have reliable information regarding prenatal alcohol exposure from the preadoption medical records. Facial features that are consistent with higher risk for prenatal alcohol exposure can be used to identify high-risk children.

Information gathered within three weeks after arrival in the U.S. and six months post- adoption included:

• anthropometric measurements
• current health status
• facial measurements associated with prenatal alcohol exposure (using the Photographic Analysis Program developed by the University of Washington [Astley, 2003]).

Children at higher risk were diagnosed with more neurological and vision problems, such as strabismus and optic nerve dysplasia. We found that children identified as high risk based on their facial features were more growth delayed at initial assessment. They continue to measure smaller, compared to the lower-risk group, at the six months post-adoption assessment, though we found significant catch-up growth in these children over the six-month period.

IN SUMMARY: early identification of these children will help provide early intervention for these children and their families.

IRON STATUS and growth in post-institutionalized children (as of March 2007).
Children living in adverse environments are at an increased risk for nutrient deficiencies, particularly those important for neurodevelopment. A striking example of this occurs in IA children, many of whom exhibit stunted growth at the time of arrival into the United States. IA children present a unique opportunity to study nutritional effects on neurodevelopment within a controlled situation, given that the time of adoption into a stable environment clearly demarcates the end period of adversity.

Adoption is a major intervention in the lives of these children. The majority experience a period of rapid physical catch-up growth post-adoption. Due to the nutritional requirements to support such high growth rates, this catch-up phase may place them at an additional risk to nutrient deficiencies. Stunted physical growth in maltreated populations, including IA children, may be attributed to lack of nutrient delivery coupled with down-regulated growth factors.  In addition to the documented macronutrient abnormalities (stunted physical growth), there is a great need to characterize micronutrient status of IA children. In the current project we are exploring children’s iron status at arrival, and the association between catch-up growth and changes in iron status over the first six months post adoption.

This research will be ultimately result in developing more effective clinical screening and in determining optimal nutritional interventions to support growth and neurodevelopment in this population.

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ORIGINAL RESEARCH PROTOCOL: Neuroendocrine Functions in Post-institutionalized Children

International adoptees from Eastern Europe, ages 6 to 48 months, were recruited to participate in this research study. The children were seen three times: an initial session within three weeks of their arrival into the United States, and follow-up sessions at six and 24 months after their arrival into the United States.

Reason For the Study
Growth of the human body is dependent on countless aspects of a child’s environment and history. When determining the risk (likelihood) that a child will experience difficulties in growth, we must consider as many factors (aspects of the child’s life) as possible. If any aspect of the child’s life is suspected or found to have a negative impact it is called a risk factor.

Research has already shown that the quality and quantity of nutrition isn’t the only risk factor that determines a child’s growth pattern, but the extent to which other risk factors (stress, social interaction, heredity, drug or alcohol exposure, etc.) may contribute is unknown. This knowledge is the basis for our current study, and we know that any attempt to investigate the cause of growth difficulties must take into consideration as many of these risk factors as possible.

Method
We collected a wide variety of information including each child’s age at the time of adoption and quality of pre-adoptive environment.

Because the Eastern European countries require parents to travel to the country for several weeks, adoptive parents are able to see first-hand the conditions of their child’s environment. Based on these observations, we asked parents to rate the quality of their child’s pre- adoptive environment on a 5-point scale (extremely well, well, adequately, poorly, very poorly).

• Current health status
  The number of known medical issues (minor, ongoing, or major) present from the time of adoption to the six-month follow-up assessment is recorded.
  
  Parents have graciously given us access to their child’s medical records including both the pre-adoption medical history given to them by the institution or adoption agency and the medical records compiled after their arrival into the United States. With this access, we are able to gather information from a variety of health professionals who have treated each child including ophthalmologists, audiologists, and endocrinologists.

• Risk that they had prenatal alcohol exposure (based on history and facial feature analysis)
  We ask parents to report their child’s history of prenatal alcohol exposure based on the information that they have received through records, speaking with caregivers at the institution, and other sources.
  
  Our medical team and research staff analyze each child’s facial features to assess whether or not the child has facial features consistent with those found in children with a known history of prenatal alcohol exposure. In order to determine the presence or absence of these features, the medical team utilizes the traditional method of physically measuring various aspects of the face and drawing on experience, while the research staff utilizes the FAS Facial Photographic Analysis Software (FAS Diagnostic and Prevention Network, University of Washington) to analyze a digital photo of each child.

• Physical growth measures: height/length, weight, head circumference (including birth measures if available)
• Stress sensitive system secretion

Cortisol, a stress hormone, can be found in saliva. Under normal conditions, the concentration of this hormone in the saliva is highest in the morning upon awakening and decreases throughout the day. The level is lowest in the evening just before sleep. Incidences of stress during the day should result in a spike in cortisol concentration. Preliminary research has shown that chronic stress, like that experienced by children living in institutions, may alter these rhythmic changes resulting in decreased cortisol concentration in the morning and increased concentration at night. Also, a stressful event results in only a small rise of cortisol concentration. Although this information is not used in diagnostic medicine, researchers associate the degree of rhythm disturbance with the child’s stress level.

For our research, the child’s response to a stressful situation and normal daily rhythm is investigated at each session. To determine the child’s normal daily rhythm, we ask parents to collect their child’s saliva at home (after waking and prior to sleeping) on each of two days, after the child has been in the U.S. for one month and again on two days when the child has been in the country for 6 months. The child’s response (as indicated by production of cortisol) to a stressful situation is investigated by collecting saliva before and after the blood draw that is performed during the medical visit at the initial and follow-up sessions.

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