Growth in International Adoptees
What factors will affect my child's growth?
A child's growth is affected by a number of factors including prenatal health, nutrititional health, nutritional status, health condition and genetic factors. In addition, institutionalized children suffer from psychosocial growth retardation (abuse dwarfism), falling behind one month of linear growth for each three to four months spent in the orphanage, irrespective of country of origin. After placement in adoptive families, linear growth velocity increases dramatically in almost all children. In fact, if rapid linear growth is not observed during the first twelve months, further investigation is warranted. Despite this growth spurt, three years after arrival 31% of Romanian orphans who had spent eight months or more in institutional care remained below the tenth percentile in height and measured an average of two inches shorter than children raised in their birth families. Ultimately, final height may be shortened in these children by growth retardation and precocious puberty. For this reason it is important to follow the child's height, weight and head circumference measurements closely after arrival.
What are the long-term implications of institutionalization on my child's growth?
Growth failure is the most common medical problem identified after arrival in the adoptive home. The predominant cause of growth failure within institutional care settings is psychosocial short stature. Most children with this problem have an immediate and dramatic surge in growth due to improved nutrition and growth hormone responsiveness when removed from their hostile environment.
This pathognomonic finding of rapid growth following removal from the harsh life of the orphanage was observed in all Romanian children whose heights on arrival were more than two standard deviations below the mean. On follow-up, height velocity was markedly elevated in all children, with a mean z score (the number of standard deviations above or below the mean) of +5.5. Within nine months, 78% of the children 18 months of age or younger on arrival had reached a height in the normal range. Growth velocity in children who were older than 18 months on arrival was virtually identical to that in younger children. However, because more absolute growth was required to exceed the 3rd percentile, none of these had reached a height that fell within the normal range during this nine-month observation.
Longer follow-up confirms that catch-up growth is excellent in most children after removal from an institution. However, the length of time they were within institutional care does have a moderating effect. Benoit et al. observed that, 12 months after arrival, all children adopted at 6 months of age or younger were above the 5th percentile. Growth was also excellent in children adopted at older than six months, but, one year later, 13% and 6% were below the 5th percentile in height and weight, respectively. Rutter found that, despite a high incidence of growth failure on arrival, only 2% and 1% of Romanian adoptees were below the 3rd percentile in weight and height, respectively, at four years old. However, children adopted at six months of age or older were slightly shorter and lighter than control adoptees born in the United Kingdom. Ames also noted that children who had spent eight months or more in institutional care were two inches shorter than their Canadian-born control group and one inch shorter than children institutionalized four months or less when measured at 4.5 years of age or older.
Adult stature in most previously institutionalized children is determined by a combination of factors that positively and negatively affect growth. In general, children removed from an abusive or neglectful environment have striking growth acceleration, and immigrant children have better growth in the United States than in their country of origin. However, many adoptees also have low birth weight or are profoundly stunted at the time of entry into their adoptive family and will enter puberty early.
Psychosocial growth failure is, in part, a state of growth hormone deficiency. Recovery thus involved reconstitution of normal growth hormone secretion. Extrapolation from children who were treated for idiopathic or organic growth hormone deficiency predicts that the age at onset of treatment (i.e., placement in an adoptive home) and height at the onset of puberty are the most important predictors of final stature. Institutionalized children who were appropriate-for-gestational-age, full-term infants and are adopted at an early age have the best prognosis. Low-birth-weight infants adopted at an advanced age who enter puberty early have the worst outlook.
The effect of orphanage confinement on head growth deserves special attention in view of the relationships between brain growth and development. Head circumference correlates well with brain growth in the absence of hydrocephalus. Studies of Romanian adoptees revealed a direct inverse relationship between brain growth, as determined by head circumference, and the length of orphanage confinement during early infancy. This early effect persisted into early childhood.
A cross-sectional analysis of 252 Eastern European adoptees evaluated in the author’s clinic revealed that mean head circumference reached its nadir between 8 and 12 months of age (at a z score of –1.83) and, although recovering some, remained significantly below normal during early childhood. In addition, children who had lived within the Romanian Neuropsychiatric Institutes, the most deprived of child-care settings, had the worst head growth, and those with the poorest head growth had the worst developmental outcomes.
The length of institutionalization appears to have a strong effect on eventual head size. Benoit et al. found that 13% of children institutionalized for more than six months had a head circumference below the 5th percentile an average of 12 months after arrival, whereas all children adopted at six months of age or younger were within the normal range. Rutter made similar observations.
Growth Failure: Neglect or Diet?
Within institutional care settings, children are neglected, abused and nutritionally deprived. Which is more of a factor in their growth failures? These children tend to have weights that are above their heights on growth charts, and higher measures of arm fat with lower measures of arm muscle. At first glance, this abnormal growth pattern suggests a mixed etiology of protein-energy malnutrition and abnormal growth hormone secretion or responsiveness due to psychosocial deprivation. However, in light of the profound stunting, the second etiology appears to be more important.
In some cases, micronutrient deficiencies are more common than macronutrient deficiencies. In a study of Chinese adoptees, serum albumin levels were all within the normal range (suggesting protein intake was not substantially impaired), but 12% to 20% had evidence of iron deficiency, rickets, or iodine deficiency. Iron and iodine are particularly important in brain development, and deficiencies in early life predispose children to cognitive deficits. International adoptees with deficiencies in these two micronutrients deserve close developmental follow-up.
Persistent growth failure
Because psychosocial growth failure is so common and catch-up growth is so prevalent after a well-balanced diet, additional laboratory tests or referral to a specialist is generally unnecessary during the first six to eight months in the adoptive home. However, if catch-up growth does not begin during this time, further investigation is warranted. Chronic infectious diseases and genetic and metabolic conditions may be the cause, and these are frequently overlooked on initial evaluation. However, one of the most common causes of persistent growth failure will be fetal alcohol syndrome (FAS).