Study Location: Bucharest, Romania
Type of Paper: Original Article; Randomized Controlled Trial
Purpose: To determine the effects of institutional care on physical growth compared to children living in improved nurturing settings, and to determine the associations between growth and cognitive development. The Bucharest Early Intervention Project was a randomized controlled trial comparing institutional care to foster care.
- Birth weight (medical record review and parental report).
- Physical growth: standard anthropometry [height, weight, head circumference (OFC)]. Z scores for height and weight were calculated using CDC 2000 as a reference and z scores for OFC from data on American children (Roche and colleagues, 1987).
Participants: This study included 51 children assigned to institutional care as usual and 59 children assigned to foster care in Romania. 72 Romanian children who were never institutionalized and who were living with their birth family were also included.
Methods: All children younger than 32 months living in institutions who were free of serious handicapping conditions were assigned to one of the two care conditions and followed until 54 months of age. Physical growth assessments were completed monthly. Cognitive development was measured at baseline, 30, 42, and 54 months of age, and the caregiving environment was measured at baseline, 30, and 42 months of age.
- At baseline (before randomization to care), the children living in institutions were on average smaller than the never-institutionalized children. Baseline data for the children living in institutions were as follows:
- 24% had low birth weight (<2500g)
- Averagez scores were:
- Height for age (HAZ): -0. 84
- Weight for age (WAZ): -1. 23
- Weight for height (WHZ): -0. 67
- Head circumference for age (OFCZ): -1. 10
- Some children were below -2 z scores for growth:
- HAZ (short stature): 9%
- WAZ (underweight): 25%
- WHZ (wasting): 16%; Wasting was more common in infancy. 30% of the children under 12 months of age were wasted.
- OFCZ: 17%
- Predictors of poor physical growth at baseline included:
- HAZ: smaller birth weight, and older age
- WAZ: smaller birth weight
- WHZ: smaller birth weight
- OFCZ: smaller birth weight, and non-Romanian ethnicity
- After randomization (effects of institutional care):
- Children in foster care grew more quickly than children who remained in institutional care. Specifically, children in foster care had rapid improvements in height and weight (for age), but not in weight for height or head circumference.
- In the foster care group, the improvement in growth occurred during the first 12months in foster care. There was no significant improvement in growth after 12 months in foster care. By the end of 12 months, the majority of children in foster care were within the normal range (≥-2 z scores) for height (100%), weight (90%), and weight for height (94%).
- Predictors of improvement in growth for height, weight, and head circumference in the foster care group included being smaller at baseline (lower z score) and being younger than 12 months when placed into foster care. Additionally, higher caregiver quality (i.e., positive regard for the child and sensitivity) was associated with greater improvements in height and weight.
- Larger birth weight and greater improvement in height predicted better cognitive development. Children born low birth weight who were placed in foster care later (after 24 months of age) were extremely vulnerable to impaired cognitive development.
Conclusions & Clinical Implications: Children raised in institutional care have suppressed growth and removal from institutional care results in recovery of height and weight, but not head size, during the first 12 months following removal from institutional care.
This is the first study to show that the quality of the child-caregiver relationship is directly related to catch-up growth. Specifically, improvements in height and weight in the children in foster care were associated with the caregiver being more sensitive and displaying more positive regard for the child. These findings emphasize the interdependence of the social and nutritional environment and that nurturing caregiving needs to be included with health and nutrition interventions to improve child health and well-being.
Being placed in foster care before the age of 12 months was associated with greater improvements in height, . Additionally, greater improvements in height were associated with better cognitive functioning. Together, these findings emphasizing the importance of early intervention (or adoption) for height catch-up growth and better cognitive outcomes.
The findings of this study also emphasize the special needs of low birth weight infants. Children with smaller birth weights had more impaired growth and impaired cognitive development. The authors suggest that these children have special nutritional needs that are likely not met in institutional care where attention to unique nutritional demands is difficult when caring for large groups of children.
Finally, the authors suggest that their findings emphasize that both malnutrition (nutritional quality and intake) and growth hormone/IGF-I alterations are associated with growth suppression in this population. Malnutrition contributes to growth suppression during periods of rapid growth (infancy) and growth hormone alterations later, when growth is slowed, and dietary intake is not so dependent on the caregiver.
Limitations of the Nutritional Results: No significant limitations.
Reference: Johnson DE, Guthrie D, Smyke AT, et al. Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children Randomized to foster vs ongoing institutional care. Arch Pediatr Adolesc Med. 2010; 164 (6): 507-516. http://www.ncbi.nlm.nih.gov/pubmed/20368481