Nutritional Supplements in Adoption

Background

Internationally adopted children tend to suffer more from micronutrient (vitamin and mineral) deficiencies and lack of attuned, stimulating care than from protein/calorie "macronutrient" malnutrition. Basically, most kids in orphanages get enough protein and calories to grow, but don't because of stress, neglect, and, perhaps, some micronutrient deficiencies. Iron and iodine deficiencies are well documented, as are vitamin A and D deficiencies.

The iron deficiencies (+/- anemia) may worsen during the catchup growth period, as children outstrip their limited iron supplies. This makes getting extra iron important for most internationally adopted children, for as long as they're having catchup growth. The constipation angle is overrated, in my experience, and I'd rather manage the constipation than see your child's brain development impaired by lack of adequate iron.

Vitamin and trace mineral deficiencies may also be implicated in the high rate of initial skin and hair symptoms. Zinc deficiency has been linked to stunting, poor healing, diarrhea, and cognitive delays in developing countries. I also wonder about essential fatty acid levels, and if we should be doing something to support the rapid brain growth we so often see. Many of the placing countries in international adoption also have environmental toxin issues (former Soviet Union, India, and China among others), but fortunately the lead issues we saw in years past are better these days.

With the following recommendations, I will be paddling a bit out of the main stream of conventional pediatrics and into the duck pond of integrative approaches here, where we find a whole menagerie of promising but less tested ideas, "ancient wisdom", it's-safe-because-it's-natural therapies, and yes, outright quackery.

Sure ... the following supplements may just give you the most expensive septic system on the block, and the nutriceutical industry is turning a tidy profit on fairly unproven claims ... but my sense is that research is starting to demonstrate a benefit to supplementation, especially in nutritionally and developmentally at-risk populations. I'm reviewing this topic for some presentations in the next year, and look forward to sharing the results here on the site.

Vitamins and Minerals 

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth if not beyond.

The ideal supplement for internationally adopted children would contain plenty (100% RDA) of Vitamin's A and D, iodine, iron, zinc, selenium, and other vitamins and trace minerals. I've not yet found the ideal liquid/powder form, and would love to see suggestions in the comments below if you find a good one. Plenty of options in the chewable format, which can be crushed, but that's extra work, and not so dissolvable.

• Enfamil's Poly-Vi-Sol with iron is a basic multivitamin plus iron liquid supplement that is easy to find, but not as complete as the others.
• Schiff Children's Liquid Multivitamin with Iron and Zinc is another decent liquid option.
• My hope is to enlist a quality manufaturer like Kirkman Labs to make a tasty dye-free, zylitol-sugar-based liquid or powdered supplement targeted to the unique needs of children with orphanage backgrounds, to support their nutritional recovery and remarkable catch-up growth.
• As for chewables, there are lots of options out there. Flintstone Complete and other drugstore "complete" multivitamins are easy to find, and taste good. Heck, they even make vitamin pixie sticks these days.
• NSI Synergy Complete Multivitamin Chewables have lots of good stuff, and no artificial colors or sweeteners, which makes them more attractive to me than the typical drugstore vitamins. I've had feedback that taste is an issue here, though.
• Kirkman's Chewable Vitamin and Mineral Wafers have everything but the iron. If we've prescribed additional iron for your child, these would be a good choice. You could also use these and supplement iron in other ways.
• Remember that iron supplements are a frequent cause of accidental overdose in children - the doses we recommend are quite safe, but please keep the tasty vitamins well out-of-reach.

Essential Fatty Acids 

I'm also starting to recommend essential fatty acid supplements like fish oils for older adoptees who aren't getting DHA/ARA from the newer formulas, or as a possible adjunctive therapy for ADHD and other developmental/behavioral concerns. This is another area where conclusive research is lacking, but it seems plausible to me that children from malnourished pregnancies, who weren't breastfed, who were raised on diets poor in healthy omega-fatty-acids, and who are having rapid brain growth may benefit from supplementation in this area. Essential-fatty-acid (EFA) supplementation also shows some promise in certain learning and developmental disabilities, which are more common in IA children. DHA is a type of omega-3 fatty acid that seems important in early brain and vision development, and is a major structural building block in the brain. EPA is another omega-3 fatty acid that may be more helpful in later issues like attention (ADHD) and mental health. Flaxseed oil contains ALA, some of which is converted to DHA/EPA.

The optimum ratios of DHA and EPA have not been fully worked out, but I like to see more DHA early on for infants and toddlers, and more EPA for older children, especially those with ADHD symptoms. Some fish oil products even include some healthy omega-6 and omega-9 fatty acids, for balance. Cod liver oil is a grandma favorite that usually contains natural vitamins A & D - check the labels to make sure you're not overdoing these vitamins, especially if they're in your other supplements and formula. It would be nice to get these healthy fats from diet alone, but sadly, our fish supply isn't safe enough in terms of mercury and PCBs to safely consume enough to meet our target intakes of DHA and EPA.

Some quality fish oils that are independently tested to have adequate potency and very low levels of contaminants include:

• Nordic Naturals - lots of options here, including flavored oils and small chewable gelcaps
• Pharmax's Finest Pure Fish Oil is one of the less fishy oils out there, and their more expensive Frutol is a fish oil that's emulsified with prebiotics and fruit purees. They even make powdered versions, but I hear those are a bit fishier. Available where their probiotics are found.
• Coromega is another pricey emulsion in orange and chocolate pudding flavors for kids that won't tolerate fish oils straight up, cheaper through VitaCost.
• Carlson's Fish Oils are also easy to find, and available in child-friendly formats.
• Costco Kirkland Brand fish oil softgels are inexpensive option for folks that can swallow pills.
• Tips for taking fish oils - you can often get kids used to taking the oil straight, or try them stirred into a "shot" of juice or water, smoothies, or applesauce.
• Flaxseed oil is a vegetarian option for omega-3's. Refrigerate these oils, as they go rancid pretty easily. Ground flaxseed sprinkled on food or in baked goods is another way to go. While the ALA in flaxseed may be important in its own right, it's not very predictably converted to DHA and EPA.

Probiotics 

Another potentially helpful supplement would be probiotics, which are the good bacteria that live in your digestive tract, and that are found in yogurt. In fact, there's about 3 pounds of these bacteria in your body right now - isn't that a lovely thought? The Europeans and naturopaths have been big fans of probiotics for a while, and pediatricians are just starting to catch on. Definitive research is in its infancy, but I feel that it's a safe thing to try, especially for children with loose stools, who're taking antibiotics, or who have allergic predispositions. Since children from orphanages (where antibiotics are overused) are likely to have less-healthy "institutional strains" of these gut bacteria, it may be a reasonable thing to supplement for IA children. We've got lots more info and recommended formulations in our "Probiotics and Prebiotics" article.

Probiotics and Prebiotics

Getting Friendly with Your Gut Bacteria ...

Probiotics, or the use of beneficial bacteria, are an exciting concept in the prevention and treatment of various childhood conditions. Definitive evidence on efficacy and safety is somewhat lacking, but there have been several good studies looking at probiotics like lactobacillus and active-culture yogurts in the prevention and treatment of diarrhea. The weight of the current evidence supports the use of probiotics in acute-onset childhood diarrhea, and their use with antibiotics to prevent antibiotic-associated diarrhea. In addition, the use of probiotic formulas (available in Europe for awhile, and now in the US) may reduce the number of diarrheal illnesses for children in day-care settings. Some small studies suggest that probiotics may also help prevent colds, colic, thrush, yeasty diaper rashes, non-specific tummy aches, and urinary tract infections.

What's especially interesting is the idea that establishing a healthy gut bacterial ecosystem early in infancy may steer the development of the immune system away from hyper-reactive "atopic" conditions like eczema, asthma, and seasonal allergies; this could be very useful in families where there's a family history of these conditions. The research here is early and somewhat conflicting, but this is an area to watch.

The bacteria that colonize your intestines set up shop early on, and the bacteria found in hospital environments don't seem to be the healthiest to be colonized with. It may prove to be wise for pregnant women to consume active-culture yogurt, kefir, or probiotics, and to supplement babies with these healthy bacteria. It should be emphasized that the research on this topic is in its infancy, and that definitive safety and efficacy information is not available.  Furthermore, research has not defined what strains of probiotics work best (or at all!) for various conditions. But so far, we have not seen serious side effects except in significantly immuno-suppressed children.

As far as yogurts are concerned, not all are created equal. In kids from 8mo-2yo and in malnourished adoptees, full fat is the way to go. Stonyfield Organic Yogurts (they make "YoBaby") are well-regarded, tasty, all natural, and have 6 kinds of friendly bacteria, as well as prebiotics (see below). For promotion and maintenance of healthy gut bacteria, serving yogurt daily is a safe, time-tested, granny-approved, and easy-to-find way to go. But for treatment purposes or early in infancy, you might consider probiotic supplements, which can deliver many more of these healthy bacteria than a container of yogurt.

Like any unregulated "nutriceutical", it can be hard to find reliable, standardized products, and even harder to get them covered by your insurance. Probiotics, in particular, do not always contain healthy, viable strains of bacteria. One excellent brand of probiotic supplements that's available locally in Seattle is the Pharmax HLC line. Pharmax is involved in a major trial of infant probiotic supplementation, uses human rather than cattle or soil strains, and guarantees high potency. This line is carried at Clark's Pharmacy in Bellevue (425-881-0222), Bastyr Dispensary in Wallingford (206-834-4114), Pharmaca in Madison Valley (206-789-0800), Medicine Man Drugstore in Greenwood (206-789-0800), and online at various resellers.

Pharmax makes an infant powder (HLC Neonate) that's specially formulated for babies, and is easy to give. They also make "toddler straws", where the probiotic is actually inside a straw - nifty, convenient, but not cheap. Their most cost-effective option for children is HLC High Potency Powder, using 1/2 tsp daily for "treatment" dose, and 1/4 tsp daily for "maintenance" dosing. They also just came out with HLC Mindlinx, with additional strains designed to digest casein and gluten, for folks with sensitivites to those, or children with autism that have responded to elimination diets (major unproven claims/controversial issue alert ... but interesting as an example of more targetted probiotic therapy).

Culturelle supplements use Lactobacillus GG, one of the most studied strains, and are easy to find over-the-counter in most drugstores. Lactinex packets are available by prescription in some pharmacies. Nature's Way is another easy-to-find brand that sells a blend of probiotic strains, included lactobacillus reuteri, which was used in the recent infant colic study. The actual Biogaia drops used in that study are not sold here, but the manufacturer does have a US order page.

You'll also want to think about prebiotics - foods and supplements that help these healthy bacteria thrive. These can be found naturally in breast milk, honey (not for use <1yo), garlic, onions, leeks, wheat, bananas, asparagus, artichokes, and chicory root. Supplements of fructo-oligosaccharides (FOS) are also available, and Pharmax includes them in many of their probiotic formulations.

What's fun about this topic from the adoption medicine perspective is that the Eastern European docs love probiotics. "Dysbacteriosis" is a frequently seen diagnosis, often treated with "ferments and enzymes", and while you'll still want to rule out parasites like giardia and other malabsoptive causes of funny poops, I am convinced that children raised in hospitals and institutions have less healthy gut bacteria. In Russia, you can even get yogurt fortified with the power of Cosmonaut intestinal bacteria! Cosmonauts being the pinnacle of Russian health and fortitude, I suppose. Best not to think about how they collect said bacteria ...

Probiotics Resources:

• Fast Facts about Yogurt and Beneficial Bacteria - DrGreene
• Surprising Uses and Benefits of Yogurt - DrGreene
• Full Fat Yogurt for Infants and Toddlers - DrGreene
• Should You Feed "Friendly Bacteria" to Your Infant and Child? - Dr. Parker
  
• The Probiotics Web Page

Updated 7/07

Home Biofeedback

True confessions - both Dr Bledsoe and I have something at home called "Journey to Wild Divine". It's a home biofeedback system and "Myst-style" computer game that uses the same biofeedback technology (finger sensors measuring heart rate variability and skin conductance) that our local hospital's adolescent clinic uses to help with headaches, pain syndromes, self-regulation, and chronic stress.

We think it's an engaging and remarkably effective way to learn self-calming, better emotional control, and alertness, and have been recommending it to our older school-age patients with low frustration tolerance, poor self-regulation, ADHD, anxiety, and stress-related issues like headaches and chronic abdominal pain. The sensors measure signs of your nervous system's balance between sympathetic tone (energized, agitated, "fight-or-flight") and parasympathetic tone (calm, relaxed, "rest-and-digest"). Children who've experienced early stress and neglect tend to be chock-full of the former, with precious little of the latter. With practice, you and your kids can learn to calm yourselves much more quickly and effectively.

In the game, you move through an idyllic landscape, performing various tasks using your developing abilities to become calmer or more alert and energized. Levitating and gently lowering rocks, juggling balls, building stairways, and other nifty activities let you hone these skills until they become effortless. This game is begging for a Star Wars version, since it's really all about the Force, and Yoda would be quite at home with the game's collection of gurus ...

It's not cheap ($159), but that's about what one biofeedback clinic session would cost, and you can do it at home whenever you want. It's actually quite a good deal compared to other home biofeedback devices like HeartMath's emWavePC, handheld emWave (excellent portable device) and StressEraser, which I also like. You will need a fairly modern PC or MAC, since it uses a lot of processing and graphics power. You will also need a modicum of tolerance for SNAG's (Sensitive New Age Guys/Gals) and "what's my mantra?" mysticalisms.

I also recommend their followup game, "Wisdom Quest", which uses the same software but has 30 new biofeedback activities, which are easy to access through a new "Guided Activity Mode". You should also download a free update for their first game that enables a similar "Chapter Tour", so that you can revisit favorite activities without having to load saved games.

Another device that we have no experience with whatsoever but is appealing to my inner geek is S.M.A.R.T. Brain Games, a home neurofeedback device that uses actual brain wave sensors (instead of heart and sweat sensors) mounted in a bike helmet to help control Playstation (or Xbox) video games with your mental states. They use the ratio of beta to theta brain waves (a measure of focussed alertness and concentration) to control your speed and progress in off-the-shelf Playstation games, especially racing and jumping games.

The cost of this "brain training system"? $600 for the helmet, neurosensors, processor, and modified Playstation controller. Yowzah! But again, possibly cost-effective if you were planning on paying out-of-pocket for actual neurofeedback clinic sessions. For folks desiring neurofeedback treatment for a specific condition (like ADHD), you'd probably be best off starting, at least, with an experienced neurofeedback provider ... EEG Spectrum is a good place to start for general information and local providers.

The research on neurobiofeedback and ADHD is quite promising, if not yet definitive; see this "Play Attention!" article for a favorable take on this particular system, and The Role of Neurofeedback in the Treatment of ADHD for a review of the latest research. My opinion is that neurofeedback may well be a useful adjunct to other medical or behavioral treatments for ADHD. My hope is that it will be more broadly helpful for my patients with anxiety, dysregulation, PTSD, and perhaps even aspects of attachment difficulties. I'll keep you posted as I learn more ...

Coughs, Congestion, and Colds

"There's only one way to treat the common cold - with contempt"

    - the esteemed Sir William Osler, MD

Ah, the common cold. Common, indeed - the average preschooler has six to 10 colds per year, with each illness lasting 10 to 14 days. And the sad truth is, Dr. Osler's 1890s-era wisdom is still largely correct. He went on to say, "... toss the pills into the ocean. So much the better for mankind, so much the worse for the fish"!

For children less than 5, there just isn't any safe, effective treatment available to treat the common cold. None of the common cold medicines can convincingly outperform sugar water, and the FDA has recently warned of a number of serious adverse reactions when used in children under 2 (our advice: don't risk it). But that doesn't seem to keep cold remedies from being a billion-dollar-a-year industry.

We all know what a cold looks and feels like, although we sometimes seem to forget when it comes to our own kids. Signs of something more serious like pneumonia, bronchiolitis, or asthma could be:

• Prolonged or high fever (more than 2-3 days, or >102 degrees)
• Breathing fast (count breaths over one full minute while quiet or asleep; infants should breathe <50-60 times per minute, toddlers <40x/min, older children <30x/min)
• Working hard to breathe (heaving chest, visible rib movement, nasal flaring, grunting)
• Getting dehydrated (not drinking enough, no tears/drool, less than 3 urinations/day)
• Acting really ill or lethargic

If those are happening, please let us know - if you're travelling, we may want to start the zithromax, and possibly find someone to evaluate in person. We do have a lower threshold to start antibiotics when we can't see kids ourselves.

Other Complications:

If nasal congestion and wet cough last more than 2-3 weeks then it may be bacterial sinusitis, which can be helped by antibiotics as well; the color/consistency of the snot doesn't tell us if this is viral or bacterial, unfortunately. Ear infections can be a complication of colds, often marked by new fever and irritability when a cold seems to be running its course. Ear tugging and fiddling is not a reliable sign of ear infection in preverbal children, unfortunately.

Let's review the common medications and treatments for the common cold:

• Decongestants (pseudephedrine, etc) - Somewhat effective for daytime relief in adults and school-age kids, but they just don't work in young kids. Besides, does putting your ill, sleepless child on over-the-counter speed seem like a good idea?
• Decongestant Nasal Sprays (Afrin, Dristan, etc) - These work for short-term congestion emergencies (less than 2 days at a time) but can be nasally addictive, causing "rebound congestion" when you stop using them. Not routinely recommended, and not for infants/toddlers.
  
• Antihistamines (Benadryl, etc) - A good treatment for allergies, but colds are caused by a viruses; useful only for their sedative effect in desperate sleepless situations. Beware - 1 in 5 kids gets LOOPY on benadryl.
• Cough Suppressants (dextromethorphan, codeine, etc) - It sure is tricky suppressing that cough reflex without putting your child in a coma. Safe doses of codeine and it's synthetic cousin, dextromethorphan, don't seem to be that effective at suppressing this vital reflex. That said, in older children with a lingering, nagging, non-productive cough, you might try some Delsym (long-acting dextromethorphan).
• Expectorants (guaifenesin) - These don't work in young children, who don't need any help making copious secretions. In older kids and adults, they may make phlegm thinner, but so does drinking lots of fluids. Mucinex is a single-ingredient, extended release form of this for older kids and adults.
• Tylenol or Ibuprofen - IF your child is uncomfortable from fever, or in pain, these can help. Otherwise you may be suppressing the body's immune response.
  
• Antibiotics - No. Nyet. Bu.
• Zinc - Yuck. Zinc lozenges and zinc up the nose have not shown to be effective in kids. But zinc deficiency is associated with poor immune function (and many adoptees are zinc deficient). There's lots of zinc in high-protein foods like meats, seafood, milk, and fortified breakfast cereals. A "complete" multivitamin with minerals can also help.
  
• Vitamin C - Controversial. Large doses may shorten symptoms in adults, but megadoses are not clearly safe in kids, and can cause diarrhea. Like zinc, let's make sure you're getting enough, and some extra at the first signs of a cold may help.
  
• Echinacea - Recent study done here found no clear benefit at reducing symptoms in kids. Bummer.
• Probiotics - Lactobacillus milks, active culture yogurts, and probiotic supplements are emerging as a good thing, although definitive studies are still pending, and it's not at all clear that they treat colds. They may be effective at preventing colds, allergies, and diarrhea, with a host of other potential benefits.
  
• Andrographis (Kan Jang) - Herbal remedy that's all the rage in Scandinavia. Some smaller studies showing benefit in colds and flu. Promising, but larger studies may sink this ship as well.
• Umcka drops - Ancient Zulu Homeopathic Geranium-ness. Germans love this stuff, available here through Nature's Way. Some promise for sinus, throat, and bronchial infections. Who knows, really? If you enjoy taking the latest natural remedies, give it a try.
• The Stuff That Teacher Invented Who Never Ever Got Another Cold (Airborne) - It was on Oprah, so it must work. This contains Lonicera, Forsythia, Schizonepeta, Ginger, Chinese Vitex, Isatis Root, Echinacea, along with vitamins, zinc and magnesium. Phew. Feels a bit faddish to me, with a few too many ingredients.
• Whiskey - Dr. Osler's preferred cold remedy: "hang your hat on the bedpost, get into bed, start drinking whisky. When you see two hats stop!" Not an option for the kids, but what you do with the colds they give us is entirely up to you.
  
• Humidification - Unclear benefit from humidifiers and vaporizers, but they feel good for many, and may keep nasal secretions easier to clear. If you use these, clean them obsessively, as they are effective at aerosolizing molds and bacteria.
  
• Menthol, Eucalyptus, VapoRub - Studies show that people think these are working even if they aren't. You can put them in the vaporizer, plug a gizmo into a wall outlet, or rub them onto your child. That may be the key ... with the massage, you get the healing power of relaxation and parental tender loving care.
  
• Chicken Soup - Yup, studies and grandmothers actually agree on this one.
  
• Nasal Saline Drops/Sprays and Bulb Suction - This really can help infants and toddlers, who can't effectively blow their nose. Infants, in particular, have tiny nasal passages that they depend on for sleeping and eating. You can buy nasal saline or make it with 1/2 tsp salt in 1 cup warm water. Put 1-2 drops in each nostril before suctioning to help clear dry nasal secretions. A bulb syringe is most effective if you squeeze it, put the tip in one nostril, and pinch the nose to get a good seal on the side you're suctioning and close off the side you're not, and SLUUURP. Don't go too crazy with this, as you don't want to overly irritate the nasal mucous membranes.
  
• Plenty of Rest and Plenty of Fluids - Yes. Da. Shi.
• and finally ... Tincture of Time - The ONLY cure for the common cold. Support the immune system in its good work with rest, fluids, love, and attention, and otherwise stay out of the way.
  

Additional Resources:

• Colds - Kidshealth.org
• Colds - DrGreene.com
• The Difference Between Colds and Allergies - DrGreene.com

Updated 8/07

Integrative Medicine Links

Relaxation Links

Here's a collection of links to help with relaxation and self-regulation, for both kids and parents (do these together!). You can also print out our "Meditation Menu" of links and resources.