Orphan Nutrition Library
Welcome to the Orphan Nutrition Library – an extensive collection of global orphan health and nutrition research papers.
Learn about the methods for selecting articles used in this extensive review of the literature.
Additionally, read the summary of findings from the literature review.
Browse studies by category to find links to summaries of each article and the full citation. Articles are grouped by the following categories:
- International Orphans
- International Adoptees
- Foster Care in the USA
- International Foster Care
- General Malnutrition
Two different topic areas were reviewed in the literature:
- Nutritional status of children living in institutionalized care and foster care
- General malnutrition
Articles were selected for a review of literature on the prevalence of malnutrition and the risk for malnutrition in children living in institutional care and children living in foster care based on the following criteria:
Searches were completed at pubmed.gov for any original research article on (1) children who were currently living in institutional orphanage care or on children who had recently been adopted from institutional or foster care or (2) children who were currently living in foster care. Studies were excluded if the main selection criterion for participants was children who were abused or neglected rather than selecting for children who were living in foster care.
Papers were included if they reported any nutritional measure, including measures of physical growth, anemia or other micronutrient indicator, or risk factors for malnutrition (such as intestinal parasites). Studies were included even if nutritional assessments were not the main purpose. Any study that reported on children between the ages of 0 and 3 years was included (studies were still included if older children were also assessed).
Articles were selected for a review of literature on malnutrition, including (1) the prevalence of, assessments for, risk factors for, and health consequences of nutrient deficiencies and (2) dietary and intervention recommendations to prevent and treat malnutrition, based on the following criteria:
Only thorough review papers were included, with a priority placed on papers focusing on international nutrition. To meet these criteria, the majority of papers are publications from the World Health Organization (WHO). Also, WHO nutritional guidelines were included in the reviews rather than U.S. guidelines because the WHO guidelines are created to be applied globally and within developing countries.
Although the goal of the literature review was to describe malnutrition in children between the ages of 0 – 3 years, the majority of the publications provided overviews on nutrition in both children and adults. The nutrients reviewed were selected if they met the following criteria: there is a high risk for deficiency in infants or children, there is a high global prevalence of deficiency, and/or there are significant health and developmental consequences of the deficiency in children.
- Nutritional status in institutionalized and newly internationally adopted children
- Nutritional status in children living in foster care
- Micronutrient deficiencies
The majority of research in this population has been completed in newly adopted children coming from institutional care or foster care abroad. Many of the studies describe the health status of these children at the time of adoption. Very few studies focused specifically on nutritional status.
Overall, newly internationally adopted children commonly experience growth failure in height, weight, and head size. Several studies reported greater severity of growth failure associated with more time spent in institutional care, emphasizing the importance of early intervention.
Few studies examined micronutrient status. The main exception is that several studies found anemia to be common. However, numerous studies reported a high prevalence of risk factors for micronutrient malnutrition, including the presence of intestinal parasites, diarrhea, or low birth weight or preterm birth.
Findings from several studies showed that both the social and nutritional environments are important for improving physical growth outcomes, emphasizing that nurturing caregiving needs to be included with health and nutrition interventions to improve child health and well-being.
Although limited, there is some evidence that growth failure is associated with delayed cognitive or motor development.
Finally, one study examined eating behaviors soon after arrival and found that common eating disturbances in this population included food anxieties and the inability to tolerate certain foods.
Read about the specific studies examined:
The majority of research in this population has included children living in foster care within the U.S., and has reported on the children’s health status at the time of entry into foster care.
The only nutritional measure consistently reported by these studies was physical growth. Some studies found that growth failure was common in children under the age of 3 years at entry into foster care; however, other studies did not find much growth failure. On the other hand, several studies found overweight and obesity to be common, but this was most common in children over the age of 2 or 3 years of age.
One study completed in children living in foster care in Bangladesh found infants and children to have poor nutritional status and to be exposed to inappropriate feeding practices (e.g., early introduction of solids).
Read about the specific studies examined:
Malnutrition can occur from being overnourished or undernourished; however, malnutrition due to undernutrition is more prevalent in most parts of the world. The WHO has developed child growth standards which describe how a child should grow, and the growth standards are used to identify children who are undernourished or overnourished. A child is diagnosed as having undernutrition when the child’s height or length (stunted), weight (underweight), or weight-for-height or length (wasted) is well below the mean on the growth standards for his or her age. Approximately 3% of children are severely malnourished, 5% to 15% of children are moderately wasted, and 20 to 40% are moderately stunted. Children are the most vulnerable to becoming malnourished when they live in conditions that provide inadequate food and have a high risk for illness or diarrhea. The feeding practices and recommendations for infants and young children are reviewed for typically growing children, as well for children who have severe or moderate malnutrition.
The World Health Organization estimates that over 2 billion people worldwide have at least one micronutrient deficiency. The three most common deficiencies, iron, iodine, and vitamin A, affect over one-third of the world’s population. The health consequences of micronutrient deficiencies are especially significant for infants and children, affecting growth and development, resistance to infection, and mortality.
Although the risk factors for specific nutrient deficiencies vary, the general risk factors for micronutrient malnutrition include poverty, a limited variety of foods, low intake of animal source foods, low micronutrient density in complementary foods, increased demands due to growth, a lack of knowledge about appropriate dietary practices, a high incidence of infection, malabsorption due to diarrhea or intestinal parasites.
The prevention and treatment for specific micronutrient deficiencies also vary, but the general recommendation to improve micronutrient nutrition is the consumption of a diversified diet. Such diets should be primarily plant-based, including a variety of fruits and vegetables and pulses or legumes, with small amounts of animal and flesh foods. Adequate fats and oils need also to be included for proper absorption of some micronutrients. Education on appropriate dietary practices, food storage, and food preparation is also important in improving micronutrient malnutrition.
The following studies assess the health and development of orphaned children living in international institutions.
- Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster vs ongoing institutional care. (2010)
By Johnson DE, Guthrie D, Smyke AT, et al.
- Medical diagnoses and growth of children residing in Russian orphanages. (2007)
By Miller LC, Chan W, Litvinova A, Rubin A, Tirella L, Cermak S
- Correlates and Barriers to Pediatric Nutrition in Two Orphanages in the Ashanti Region of Ghana: A Surprising Comparison. (2009) By Ribeira, R., Brown, L.B., and Akuamoa-Boateng, A.
- Orphanage Children in Ghana: Are Their Dietary Needs Met? (2010) By Sadik, A.
- Are orphans at increased risk of malnutrition in Malawi? (1999) By Panpanich, R., Brabin, B., Gonani, A. & Graham, S.
The following studies examine the health and nutritional status of internationally adopted children.
Children adopted from Africa
- Health of children adopted from Ethiopia (2008)
By Miller L, Tseng B, Tirella L, Chan W, Feig E.
Children adopted from Asia
- Children adopted from China: a prospective study of their growth and development (2008)
By Cohen NJ, Lojkasek M, Zadeh ZY, Pugliese M, Kiefer H.
- Health of children adopted from China (2000)
By Miller LC, Hendrie NW.
- A longitudinal study on anthropometric and clinical development of Indian children adopted in Sweden. (1992)
By Proos LA, Hofvander Y, Wennqvist K, Tuvemo T.
- Infants’ physical and cognitive development after international adoption from foster care or institutions in China (2010)
By van den Dries L, Juffer F, van Ijzendoorn MH, Bakermans-Kranenburg MJ.
Children adopted from Europe
- Health of Children Adopted From the Former Soviet Union and Eastern Europe. (1997)
By Albers LH, Johnson DE, Hostetter MK, Iverson S, Miller LC.
- Iron deficiency in international adoptees from Eastern Europe (2008)
By Fuglestad AJ, Lehmann A, E. , Kroupina M, G. , et al.
- The health of children adopted from Romania (1992)
By Johnson DE, Miller LC, Iverson SL, et al.
- Determinants of catch-Up growth in international adoptees from Eastern Europe. (2010)
By Miller BS, Kroupina MG, Mason P, et al
- Developmental catch-up, and deficit, following adoption after severe global early privation. (1998)
By Rutter M. & English and Romanian Adoptees (ERA) Study Team
- Iron Deficiency After Arrival is Associated with General Cognitive and Behavioral Impairment in Post-Institutionalized Children Adopted from Eastern Europe. (2012) By Fuglestad, A.J., Georgieff, M.K., Iverson, S.L., Miller, B.S., Petryk, A., Johnson, D.E., Kroupina, M.G.
Children adopted from Central or South America
- Health of children adopted from Guatemala: Comparison of orphanage and foster care (2005)
By Miller L, Chan W, Comfort K, Tirella L.
Children from multiple regions
- Medical evaluation of internationally adopted children. (1991)
By Hostetter MK, Iverson S, Thomas W, McKenzie D, Dole K, Johnson DE
- Serologic prevalence of antibodies to Helicobacter pylori in internationally adopted children. (2003)
By Miller LC, Kelly N, Tannemaat M, Grand RJ
- Developmental and nutritional status of internationally adopted children. (1995)
By Miller LC, Kiernan MT, Mathers MI, Klein-Gitelman M.
- Self-regulation in newly arrived international adoptees. (2011)
By Tirella LG, Miller LC.
- Plasticity of growth in height, weight, and head circumference: meta-analytic evidence of massive catch-up after international adoption. (2007)
By van Ijzendoorn MH, Bakermans-Kranenburg MJ, Juffer F
- Serum Choline is Associated with Cognitive and Motor Development in International Adoptees. (2013) By Fuglestad, A.J., Innis, S., Johnson, D.E., Kroupina, M.G., Georgieff, M.K.
The following studies look at the health and nutritional status of children living in foster care in the United States.
- Children in foster care: are they at nutritional risk? (1994)
By DuRousseau PC, Moquette-Magee E, Disbrow D.
- Assessing the health status of children entering foster care (1994)
By Chernoff R, Combs-Orme T, Risley-Curtiss C, Heisler A.
- Comparing the health status of low-income children in and out of foster care (2004)
By Hansen RL, Mawjee FL, Barton K, Metcalf MB, Joye NR
- The medical and psychosocial needs of children entering foster care (1987)
By Hochstadt NJ, Jaudes PK, Zimo DA, Schachter J
- The physical, developmental, and mental health needs of young children in child welfare by initial placement type (2005)
By Leslie LK, Gordon JN, Meneken L, Premji K, Michelmore KL, Ganger W.
- Pediatric health assessments of young children in child welfare by placement type (2011)
By Schneiderman JU, Leslie LK, Arnold-Clark JS, McDaniel D, Xie B
- Medical and mental health of children entering the Utah foster care system (2008)
By Steele JS, Buchi KF
- Unhealthy Weight Being Overlooked in Foster Care? Comparing body mass index of children in out-of-home care with national estimates. (2011) By Helton, J.J.
The following studies look at the health and nutritional status of children living in foster care internationally.
- Catch-up growth assessment in long-term physically neglected and emotionally abused preschool age male children (2003)
By Oliván G.
- Characteristics of young foster children in the urban slums of Bangladesh (2003)
By Sarkar NR, Biswas KB, Khatun UHF, Datta AK.
- Obesity in looked after children: is foster care protective from the dangers of obesity? (2008) By Hadfield, S.C. & Preece, P.M.
- Dietary counseling in the management of moderate malnourishment in children (2009)
By Ashworth, A. & Ferguson, E.
- Maternal and child undernutrition: global and regional exposures and health consequences (2008)
By Black, R.E. et al
- Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6-23 months old and treating moderate malnutrition among 6-59 months old children (2009)
By dePee, S. & Bloem, M.W.
- Proposed recommended nutrient densities for moderately malnourished children (2009)
By Golden, M.H.
- Choice of foods and ingredients for moderately malnourished children 6 months to 5 years of age (2009)
By Michaelsen, K.F. et al
- Nutrition and Growth (2010)
By UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP, and the World Bank
- WHO child growth standards: training course on child growth assessment (2008)
By World Health Organization (WHO)
- WHO child growth standards and the identification of severe acute malnutrition in infants and children: A Joint Statement by the World Health Organization and the United Nations Children’s Fund (2009)
By WHO & UNICEF
- Guiding principles for feeding non-breastfed children 6-24 months of age (2009)
- Antibiotics as Part of the Management of Severe Acute Malnutrition. (2013) By Trehan, I., Goldbach, H.S., LaGrone, L.N., Meuli, G.J., Wang, R.J., Maleta, K.M., and Manary, M.J.
- Failure to Thrive: An Update. (2011) By Cole, S.Z., & Lanham, J.S.
- Failure to Thrive in Childhood. (2011) By Nutzenadel, W.
- Calcium: summary of 2 reports from the World Health Organization (2004 and 2006)
- Folate: summary of 2 reports from the World Health Organization (2004 and 2006)
- Food as a Source of Nutrients: Chapter 17 from Vitamin and mineral requirements in human nutrition. Report of a joint FAO/WHO expert consultation on human vitamin and mineral requirements, Bangkok,Thailand, 21–30 September 1998.
- Concepts, definitions and approaches used to define nutritional needs and recommendations: Chapter 1 from Vitamin and mineral requirements in human nutrition. Report of a joint FAO/WHO expert consultation on human vitamin and mineral requirements, Bangkok,Thailand, 21–30 September 1998.
- Iodine: summary of 2 reports from the World Health Organization (2004 and 2006)
- Iron: summary of 2 reports from the World Health Organization (2004 and 2006)
- Selenium: summary of 2 reports from the World Health Organization (2004 and 2006)
- Vitamin A: summary of 2 reports from the World Health Organization (2004 and 2006)
- Vitamin B12: summary of 2 reports from the World Health Organization (2004 and 2006)
- Vitamin D: summary of 2 reports from the World Health Organization (2004 and 2006)
- Zinc: summary of 2 reports from the World Health Organization (2004 and 2006)
- Guidelines on food fortification with micronutrients (2006). Edited by Allen, LH, De Benoist B, Dary O, Hurrell R.