As parents, we know that good nutrition and normal eating habits are the foundation for lifelong health and that these habits begin in infancy. Due to the cultural differences and situations your child was used to prior to adoption, there will be an understandable period of adjustment when you introduce her to a U.S. diet and to eating in your home. Be prepared to help her make this transition by gathering as much information as you can about her previous food habits. Questions to ask are:
If you'll be visiting your child prior to adoption, observe the feeding practices in the institution or foster care setting so you'll know how children were fed--spoon-fed one-to-one with a caregiver, bottle-fed with the bottle propped on a pillow, or did she feed herself? Was it quiet at meal times, with few opportunities to interact while eating, or a boisterous, social time?
Specific to your child's overall health and well-being, ask:
Did he have any associated feeding problems like choking, difficulty swallowing, or vomiting?
Does he have any food or environmental allergies?
Was he receiving any vitamins, iron or other nutritional supplements?
Your child's feeding experience before adoption will directly influence how he adjusts to his new diet. The manner in which he was fed and his overall satisfaction with his previous mealtime experience will determine how easily he develops normal, healthy eating habits in your home.
Provide a Nurturing, Enjoyable Mealtime Experience
Be conscious and deliberate about the mealtime experience you create for your child. It should be a relaxed, enjoyable time. Additionally, feeding in a loving way is an excellent opportunity to provide nurturing and to promote attachment between you and your child. Through the feeding ritual and routine, she will start to look to you to meet her daily needs. And, as she looks to you to satisfy her physical hunger, her need for security through a trusting, consistent relationship is also met.
Meal time should be an enjoyable, sharing time for families. Mealtime battles should be avoided. You are responsible for providing the food, and your child is responsible for how much and what she eats.
Introducing New Foods
Especially for older children, serve only familiar foods during his first few days and weeks at home--a simple gesture that will bring comfort during this stressful time. He is, of course, dealing with enormous changes in all aspects of his life. Providing familiar foods is also a way you can show that you respect him, because you value his likes and dislikes. After a few days, you can begin to introduce new foods by serving them alongside more familiar selections. Most children tolerate the transition to a new diet fairly well, if you go slowly.
Modeling is another good tool for helping introduce new foods. When you are eating together as a family and you show that you are enjoying a certain food, it is more likely that the child will want to try it. Be patient. What she rejects one week, she will often enjoy eating the next time it is served.
Dealing With Institutional Behaviors
Many children who came from an institutional setting did not get enough to eat. These children are hence often growth delayed and underweight on arrival. They may have learned adaptive behaviors, such as eating as much as they can whenever they can, or eating quickly before the food can be taken away (by caregivers or by other children). These children often will have enormous appetites on arrival home, eating large amounts of food and asking for still more between meals. Some children will eat as much as they can and pocket the food in their mouths. Older children may show hoarding behavior, may hide or steal food.
These are all survival techniques that your child developed as a response to unmet needs. Though these behaviors may be concerning, it is the International Adoption Clinic's experience that they are temporary and will subside within two-three months at home. Your child likely will begin to adjust his intake by himself without your needing to impose limits on his food intake. Self-regulation usually happens once the child understands that food will always be available for him when he is hungry, when he has been assured of your love and support, and when he has done some of the initial catch-up in growth (typically in the first six months post-adoption). Your child's appetite also may vary drastically from day to day--a huge appetite one day and no interest in food the next. This is also normal during the adjustment period.
Make sure that your child knows there will always be enough food for him. It may be helpful to always have a small snack available if he wants more food. Some children actually need to carry around a cracker or other food item in their pocket between meals. For children who eat ravenously and finish their food quickly, it may also be helpful to put smaller portions at a time on their plate. Then when the child asks for more the parent can respond with giving more food and can also say to the child, "Of course you can have more food." In this way you are showing the child your love and care for him in a very concrete way.
It is also normal that your child might regress in his feeding behaviors during the transition time. A younger child who is able to feed himself will want to be fed by you. A toddler who typically would have outgrown the need for a bottle may enjoy being held and bottle-fed like an infant. Hold him, talk to him, smile at him and make eye contact with him during feeding. Don't worry that you are babying your child; meeting his needs at his level of emotional development will only help secure your relationship. Once his needs are met, he will be able to move on to the next level of development.
Food Aversions and Under-eaters
Some children do continue to have feeding difficulties and will reject food, no matter what food you provide or what environment you provide to eat it in. Food rejection may be the result of traumatic feeding experiences in the past. For example, in some institutions children were fed quickly with a large spoon, not allowed time to chew and swallow. Some were fed from bottles with large nipples where the hole was too big, which resulted in choking. Sometimes the milk was too hot and burned the baby's mouth. Mealtime may not have been a pleasant experience.
Another reason for food rejection may be the result of sensory issues, typically of unfamiliar textures. Most institutional food is bland, liquid or pureed. The child may not have received a gradual introduction of solid foods when she started chewing. These children need a very slow progression from purees to chunkier, solid foods.
Some children do not eat well due to the digestive problems associated with intestinal parasites such as Giardia lamblia, which can cause diarrhea and cramping, or Helicobacter pylori (H. pylori), which is a common bacterial infection that can cause poor appetite due to chronic abdominal pain and vomiting. Severe feeding difficulties may be the result of decreased muscle tone in the mouth. These children often drool and hold their mouths open. It is easy for them to choke. Children who are at especially high risk for these specific problems include premature infants and children with neurological problems. Every child who has feeding difficulties should receive a thorough medical evaluation to try to identify the causative factors, and will probably be referred to a speech pathologist for specific oral motor function difficulties.
Feeding Your Infant
If your child has been receiving formula in his foster home or institution, do not bring along new formula purchased in the U.S. when you go abroad to get him. Instead, wait to buy formula in his country of origin, and purchase enough of the same brand to last until he gets home. Transition to a U.S.-brand formula after you arrive home so you can consult with your primary care provider if there are problems tolerating the new formula. Most infants do well on a regular milk-based formula. There are minor differences among brands, but the nutritional values will be about the same.
If your child was receiving soy-based formula in the orphanage or foster care setting, find out why the soy formula was being used (instead of milk-based formula). Lactose intolerance is typically an adult-onset condition (and a higher incidence occurs in Asian and African populations), and therefore true lactose intolerance is unusual in infants and young children. If your child was receiving a soy-based formula due to gastrointestinal symptoms such as diarrhea, vomiting, constipation, bloating or abdominal pain, you should have these symptoms re-evaluated when you arrive home. These symptoms should not be automatically attributed to lactose intolerance but may instead be caused by intestinal or parasitic infections*, hereditary diseases like cystic fibrosis, celiac disease or severe protein malnutrition.
Nutritional Considerations
Children coming from a situation of nutritional deprivation or malnutrition will need extra iron and vitamins during the period of catch-up growth--up to six months post-adoption. To detect signs of anemia, your child's iron status should be checked soon after her arrival and again over the next six months. Iron supplementation is the typical treatment for this condition. It is beyond the scope of this article to discuss all the nutritional considerations that can inform planning a diet for a child. Please see the list of resources below.
"Normal' Eating
In her book How to Get Your Kid to Eat, But Not Too Much, Ellyn Satter describes normal eating as "being able to eat when you are hungry and continue eating until you are satisfied. It is being able to choose food you like and eat it and truly get enough of it. It is being able to use some moderate constraint in your food selection to get the right food, but not being so restrictive that you miss out on pleasurable foods. It is three meals a day, most of the time, but it can also be choosing to munch along. It is leaving some cookies on the plate because you know you can have some again tomorrow, or it is in eating more now because they taste so wonderful when they are fresh. Normal eating takes up some of your time and attention, but is only one important area of your life."
Additional Resources
Child of Mine: Feeding With Love and Good Sense. Ellyn Satter, R.D.
How To Get Your Kid To Eat, But Not Too Much. Ellyn Satter, R.D.
The Handbook of International Adoption Medicine. Laurie C. Miller, M.D.
Parents' Survival Guide to Transitional Feeding. The Institute of Pediatric Nutrition
http://partners.lmedem.com/html/Ross/RossPVfeedingguide.pdf
*Some children do develop a temporary intolerance to lactose from parasitic infections, which can injure the mucosa of the intestines. Once the infection has resolved, the child will become able to tolerate milk again.