Zeina Makhoul, SPOON’s Nutritionist, is currently in Bangalore, India, training orphanage staff on the implementation of a comprehensive Nutrition Screening System, developed by SPOON in partnership with Holt International Children’s Services.  Zeina sent in this blog post about the initiation of the training at VCT, or Vathsalya Charitable Trust, a 22-year old organization that provides care for orphaned children, places them with foster families, and matches them with domestic and international adoptive families.

Every morning, my ride pulls up to the front of the hotel. VCT’s driver and three little boys, 4, 7 and 9, pick me up. It’s only a 5 minute drive to VCT but we always manage to sing a couple of songs, play a game and make goofy faces.

It’s a different story inside the nutrition screening training room! It’s almost the end of the training and it’s been intense. Thirty-two hours of training in 4 days and counting. I’m so impressed with Team VCT’s endurance and dedication.  Except for the occasional tea and lime juice break, Sylvia, Vineetha, nurse Hema and nurse Deepam did not leave the training room. Neither did I.

Nurse Deepam practicing anemia screening for the first time. It was NOT a success!

It’s Shirley’s turn!

It’s time to take revenge!

So far, we have discussed special health care needs (cleft lip/palate, cerebral palsy, Down syndrome, fetal alcohol syndrome, congenital heart disease, low birth weight, severe malnutrition), fever, diarrhea, constipation, vomiting, iron deficiency anemia and growth.  We practiced measuring hemoglobin using the HemoCue machine by pricking each other’s fingers, measuring weight, length, height, head circumference, and plotting and interpreting measurements on growth charts.  Growth screening was definitely the most challenging section. But after lots of practice and long discussion, I can say with confidence that Team VCT is now a champion of WHO growth charts!

Nurse Deepam practicing measuring head circumference

Nurse Hema and Vineetha calculating BMI

After each day, I asked the team to tell me one new thing they learned and were surprised by. And all of them said, “upright positioning” when feeding children with special needs like CP and cleft palate. The next ones on the list were “small frequent feedings” if an infant is volume sensitive, has reflux or poor appetite and “limiting feeding to 30 minutes or less”.

The nurses, Hema and Deepam, and I stayed one hour longer today and completed the nutrition screening on three little girls who stay at VCT over night.  It was exciting to see the first nutrition screening form being officially completed and filed into the child’s medical chart. Tomorrow, we measure the other 30 kids!

Nurse Hema getting ready to screen a 9 month old for anemia

The first nutrition screening at VCT!

It’s Valentines Day! Finding the perfect gift for a loved one can be tricky. You could celebrate with flowers and chocolates and another dinner out – or you could show your love with a heartfelt gift to SPOON in your Valentine’s honor. (Or both!)

A gift to SPOON ensures that orphaned, fostered and adopted children around the globe will get the nutrition they need to grow and thrive.

When you make a gift of $25, $50, $100 or more in honor of your Valentine, we’ll send a personalized message of love and hope.

Thank you for your love and support for children living without families across the globe.

Happy Valentine’s Day to you and yours from all of us at SPOON!

by Mary Hearst, PhD

After 39 hours of travel, John and I arrived in Dushanbe, Tajikistan. On the way, Raushan met us in Almaty and to our great joy, we saw Kate in the airport heading home from the training in Astana and her time in Karaganda! Sounds like the time in Kazakhstan was successful. In Dushanbe, Raushan, John and I were greeted at the airport by our Open Society partners (OSI) and whisked to our hotel for a quick nap. Our first meeting was that afternoon with the OSI team of Nigora, Zarina and Jamshed.

Smart, articulate, dedicated professionals committed to improving the lives of children. Our agenda was arranged by the OSI team and included meetings with Ministry of Health leaders, city officials, visiting all four baby houses and time with national experts to discuss the results of the desk review – a review of all available data on children in Tajikistan.

Desk Review Team

To our great pleasure, the well-being of children is a high priority nationally. The Ministry of Health official was well aware of the nutritional deficits present in all children in the country and was aware of the additional burden among children living at the babyhouses and in other institutional care situations. Nationwide, the Ministry of Health official told us that 30% of the children are stunted, 30% are anemic, 40% have Vitamin D deficiency and 50% have iodine deficiency. The status of the children in babyhouses was uncertain – better? Worse? It is important to find out. The Ministry of Health official gave his approval for us to visit the babyhouses and gave us his verbal support for carrying out the work of the SPOON Foundation.

There are two babyhouses in Dushanbe. They are administered at the city level and because of their proximity, the babyhouse directors meet regularly with other city health-related organizations also administered by the city. This is important for two main reasons. First, there is regular communication and support that exists for the babyhouse directors. And second, the assessment and intervention efforts of the SPOON Foundation will be ‘easier’ and likely similar.

Babyhouse #2  has 100 children between the ages of 0-4 years. As you will see in the photos, the physical environment is wonderful. If fact, the staff have taken it upon themselves to decorate and augment the environment. Children are grouped by ages and live in a sort of suite – they have their beds in one room which is attached to a play room and a dining room. Each suite has the same staff that work in those rooms. The staff of the suites are in a competition to see who can do the most elaborate decorations – paper mache, painting, activities for the children. We were impressed by the artistic abilities of the staff!  There are no children with disabilities at this babyhouse. We got to hold babies, play with children, observe mealtime. It again reminds me of how important this work is – all of those beautiful children.  We also learned that a very high proportion of children are considered ‘social orphans’. They have parents, many of whom visit, but because of poverty of a spouse who migrated for work, the family could not afford to keep the child at home. Those children are not available for adoption. Unfortunately, it also does not mean they eventually go home to their parents.

Babyhouse #1 has 103 children, including children with disabilities and has the Kishti Center attached. Oh, the beautiful children! Again, the environment was pleasant, although not nearly as decorated as Babyhouse #1. The children wanted to be held (we were all willing!). Our friend Ricardo was there to describe the needs of children with disabilities, show the great work of the Kishti Center, and provide support for the SPOON Foundation’s involvement. As we know, the staff work hard to care for the children, but living in an institution is stressful. The children with disabilities are unable to get all the care they need and there is limited to no equipment available. Despite good intentions on everyone’s part, the growth, developmental and social/emotional needs were apparent for children of all abilities.

KISHTI

The next day, we boarded an old Soviet-era plane and flew north over the mountains to Khudjand. The Khudjand Babyhouse is in town, but the Istravshan Babyhouse was 1 1/2 hours south of Khudjand, by car. The situation was different in Khudjand. The babyhouse had 50 children and the physical conditions were not as good. There were more economic challenges present, a greater need to rely on donations from supporters, the building was colder (no central heat), less staff. But the children were no less precious.

Istravshan had several advantages. First, they had a cow who just had a calf! Great for fresh milk! They have fruit trees and grape vines from which they dry the fruit and make compote for the children year round. They also have a vegetable garden that they built for the children to learn and engage as opposed to the Khudjand Babyhouse who needed the garden to supplement their diet. Yet, the 22 children wore hats to stay warm while inside. Many of the younger children had no facial expression or engagement with me, as you would expect from infants or small children.

When we landed back in Dushanbe, we met again with OSI. It is clear, and everyone agrees, that SPOON has an important role to play. There needs to be an assessment of the children’s growth, cognitive and physical development, micro nutrient deficiencies. There needs to be an assessment of staff training needs. There needs to be an assessment of the physical environment and equipment needs. SPOON experts can then provide key recommendations, interventions, training and seek equipment to improve the growth, development and life chances of these 275 gorgeous children.

by Kate Nelson Ward

Some of the children during playtime

Carrie and I visited the Karaganda Bota Goz Baby House three of the five days I was in Karaganda.  Upon arriving the first day, children from several groups were outside playing in the pleasant weather.  They were so precious all bundled-up and running around, playing in the snow with toy shovels. On this day, we brought with us hats, mittens, cloth diapers and clothing that my friends and family from the US had donated.  We, unfortunately, were told we couldn’t take pictures this day, but it was a sight to see.  The children rushed and gathered around the bag of “goodies,” like we were Santa opening his sack of toys.  One of the doctors came in and discussed with the caregivers whether Carrie and I could take some of the children outside.  The caregivers told us that unfortunately, they did not have winter boots for the children in their group so they would have to remain inside.

Botagoz in the blizzard

The next day, Carrie and I braved blizzard-like conditions to visit again.  Carrie termed it, “Extreme Orphanaging”!  This time we brought winter coats from the US and snow suits and boots we found at a local second-hand store.   I spoke with the director, whom I met at the Astana training, and also with the chief pediatrician, Dr. Ludmilla.   They invited me to come the next day to conduct a brief feeding training with their doctors.  How could I pass-up this opportunity?!  Carrie and I trudged home through the snow and wind, where I spent the rest of the day preparing my key words (po-Rooski) for the training.  Thankfully, my friend Stas volunteered to join us at the baby house to help translate the training.

Kate demonstrating oral-motor techniques

We arrived promptly at 10am on Thursday and were ushered to the special needs room.  Surprisingly, the children in this room had relatively mild special needs, but culturally/linguistically, children with special needs are typically referred to as deytey-invalidov (invalids).   I spent the next hour and a half going over techniques for positioning and feeding with four doctors and two caregivers; working with an infant with Down syndrome and a child with cerebral palsy – both sweet little girls!  The doctors were very receptive, but I honestly think the caregivers got more out of the training.  After we were done, the doctors left, but we stayed in the room talking with the caregivers and playing with the children.  We finished our time at the baby house by going upstairs and playing with another group of children.  I then boarded the train to begin my long journey back to the US.

Leaving Kazakhstan is always bittersweet for me.  I am sad to leave my friends, colleagues and all the beautiful children.  However, this trip was incredibly productive and successful, and I have high hopes for SPOON’s work there in the future.

by Kate Nelson Ward

…I lived in Karaganda.  For those unfamiliar with Kazakhstan, Karaganda is the fourth largest city in Kazakhstan located about 200 kilometers south of the capital, Astana.  I worked there as a volunteer English teacher with a group of other Americans.  My roommate at the time was a wonderful woman from Maine named, Carrie.  While I left Karaganda after about a year, Carrie returned and has lived in Kazakhstan (mostly Karaganda) for the past seven years.

Carrie with two children at the Karaganda baby house

Several years ago, Carrie began volunteering at one of the baby homes in Karaganda.  I loved hearing her stories and seeing pictures of her time with the children.  One such story came my way in the summer of 2010.  Carrie met a woman named Cindy Kaplan, who was in Karaganda to adopt her daughter.  Cindy had recently founded a non-profit organization dedicated to improving the nutritional status of children living in Kazakhstan’s baby homes.   And in fact, they had begun their work by introducing a new menu and multivitamins to several baby homes, including those in Karaganda.

Anyone who meets Cindy can’t help but be inspired.  At that point, I hadn’t met Cindy and I was inspired!  Carrie recently told me that during that summer, Cindy said something to her that forever changed her perspective on how she views her time at the baby house:

Many of these children live lives void of a stable, loving adult figure.  Any eye contact, touch, play, affection and interaction can make a world of difference.

Carrie continues to visit the baby house every week with this in mind.  She pours love onto these kids and has built rapport with the caregivers.  She has inspired countless people in the US to send cloth diapers, toys, and winter clothes for these children (myself included).

At SPOON Foundation, we recognize that nutrition and feeding are just a piece of the puzzle in terms of healthy social, emotional, cognitive and physical development in orphaned children.  And so, we are so thankful for people like Carrie who are doing their part to make a difference.

I’m so excited to spend the next few days in Karaganda with Carrie and visit the baby home this week.

Children at the Karaganda baby house

by Kate Nelson Ward

Thank you, spasibo, and rakhmet to everyone who supports SPOON’s work in Kazakhstan!  We share our success with you.

Thank you to all of our supporters!

Saturday was my last day in Astana, lavishing in the post-training calm.  My luggage finally arrived bearing the adaptive feeding equipment we had intended to demonstrate during the training.  Though we were not able to use it, I left it with Raushan, SPOON’s Central Asia Program Manager, as a kit to keep for other Central Asian trainings.

Aside from all of the wonderful comments we received from the chief doctors, a highlight of the training for me involved distributing the training toolkits SPOON developed.  The toolkit is a booklet of curriculum for training caregivers and materials for preparing and documenting training.  I was proud to hold a hard copy (translated into Russian) in my hand.

SPOON’s Feeding Training Toolkit

Raushan and I leave Astana with happy hearts.  Raushan continues onto Almaty and then Tajikistan and Kyrgyzstan next week.  I am headed to Karaganda for a few days (more on that later).

By Zeina Makhoul

Tuesday morning, I met with the nurses and the child development workers to learn about the clinical care at BSSK. Children are measured regularly (weight, height and head circumference). Growth charts, similar to the ones used at VCT, are used to track growth. Hemoglobin is measured every 3 months. All children at BSSK, whether anemic or not, receive iron supplements and a calcium/vitamin D/B12 supplement. When needed, the child development workers conduct an evaluation of the motor and mental development of infants and young children and an IQ test for older children.

Child development worker demonstrating IQ test

The staff kindly translated their menus from Marathi (language spoken in Pune) to English.  They had a menu for each of season, winter (October-February), summer (March-June) and rainy (June-September), because of the seasonality and therefore market availability of the fruits and vegetables. For example, summer is the season for mangos and sugar cane so the menu included fresh mango, mango juice and sugar cane juice for snacks. During the summer, children are also given buttermilk (yogurt drink) instead of curd (yogurt) in an attempt to replenish fluid lost in the very hot summer months. Winter is the best season for most vegetables. As for fruits, oranges, grapes, papayas and strawberries are in season. During the rainy season, the staff avoids serving leafy greens as they hard to digest and tend to harbor bacteria because of the rain. All seasons and every single day, children are served dhal and rice, chapatti (or a variation) and most times a vegetable (such as cabbage, green peas, okra, carrots, spinach) for lunch and dinner. The diet is for the most part vegetarian, except for certain Sundays when chicken or egg curry is served. The menus need to be further analyzed to determine if children are receiving nutrients in amounts that are adequate for their growth.  It’s important to keep in mind that certain factors may increase the risk for undernutrition even if dietary intake is adequate.

Infants waiting patiently to be fed

I headed to the infants’ room and found many of them lying on a mattress on the floor waiting patiently for their turn to be fed. Caregivers sat on the floor with crossed legs and a pillow under one side of their body to get in feeding position.  They picked up the children one by one, fed them, burped them and put them in their cribs. With some help from a couple of the nurses, at least 8 infants were fed and burped in less than an hour. The children with cleft lip/palate were fed with a spoon. I asked whether they had ever used cleft bottles, the nurses said that they used to have them but not anymore. The caregivers seemed to be comfortable using the spoon.

Sister Ashaa helping caregivers with feeding

Caregiver feeding a child with a cleft lip

After an extensive discussion with the nurses around the medical charts, growth charts, and the use of supplements, the staff gathered in the conference room for a presentation on the nutrition screening tools that we plan to pilot test at BSSK among other sites.  The staff had very helpful and important feedback.

Explaining the Nutrition Screening Form to nurses

As Jennifer and I were wrapping up for the day, Roxana and the staff surprised us with a cake celebration and beautiful hand-made gifts by women in their community center program. The celebration was really in honor of Jennifer. As part of her new job, as Holt’s initiative director, she will not be involved with BSSK and VCT in the same capacity and so will be not be traveling as frequently, or not at all L, to India. The staff wanted to say thank you and not goodbye but “see you later”! I will definitely miss her the next time I’m in India. I set the timer on my camera and we all gathered for what might be a last photo with Jennifer at BSSK.

Roxana presenting Jennifer with a gift

The next morning, we joined the children and staff for morning prayers, 3 OMs and a number of spiritual songs. I couldn’t help but smile when I heard the children’s sweet voices.

I joined the cooks in preparing lunch. I observed as they pressure-cooked the dhal, chopped the tomatoes and cilantro using a traditional, dangerous looking, chopping knife. When I asked if I can help, they brought me a regular knife and a cutting board! Chapattis were freshly made right before lunch. Right next to the kitchen, in the storage room, there were canisters of whole wheat, homemade infant cereal, cracked wheat, several types of lentils, ghee, and a 4-foot pile of sugar bags.

Traditional chopping knife

Cook making cabbage dish

That’s a lot of sugar!

Every Wednesday afternoon, a group of foster moms bring their children to BSSK to be examined by Dr. Sarda, another pediatrician at BSSK. The foster moms reported whether or not they had concerns about the child’s health or feeding. I asked again about feeding practices in India and Dr. Sarda confirmed that the introduction of rice cereal and cow or buffalo milk at 2-3 months is a common practice. Cow milk is usually recommended because it resembles breast milk, he said, but when it’s not accessible, buffalo milk is used instead. Dr. Sarda and I exchanged business cards and he promised to send me a book on nutrition that he has written.

Foster moms waiting to talk to Dr. Sarda

It was time to say goodbye to the children, the staff and Roxana and take the 3-hour drive to Mumbai and then a 27-hour trip back to Seattle. Sigh! In the next few months, I will be processing all the information that I learned at the Village in Haiti and VCT and BSSK in India and using it to customize a nutrition screening system that works for all sites. I’m hoping to return to Haiti and India around May to launch the pilot phase. When I return, I will not see many of the children I met, a bitter but sweet feeling as I know they will have joined a loving family.

by Kate Nelson Ward

“We’re at our baby homes everyday and we become blind to the needs and problems that actually exist.  Our job is more than just calculating nutrients and calories.  It’s important to recognize the process [of caregiving and feeding].  This training has prompted me to begin walking through my baby house and observe first hand the feeding practices.”

“After this training I feel inspired to work more closely with my staff and take a team approach to addressing the feeding needs [of children in the baby house].  I now feel confident that I can lead and facilitate my team!”

These quotes are just a small reflection of the candid feedback we received from participants at the end of today.  Today I witnessed many “aha” moments during the training activities.

Introduction by Almaz Sharman

We were fortunate to have SPOON’s newest board member, Almaz Sharman, introduce Day 2 of the training.  We then followed-up on yesterday’s experience at the baby house by discussing some videos captured of caregivers feeding children with special needs.  Many of the doctors were surprised at the very simple techniques that can be employed to improve the feeding experience for children with special needs.

Tanya reviewing the video from the previous day’s trip to the babyhouse

To simulate a child with cerebral palsy, Tanya and Slava asked the doctors to tilt their heads back, straighten their legs and put their hands behind their back.  Then, doctors spoon-fed and offered cups of water to each other while in this strained position.  There were many outbursts of discomfort when they realized how difficult it is to swallow.  We discussed low-cost, practical ways to address positioning needs for children with cerebral palsy, such as providing head, neck and jaw support and using pillows and blankets to provide stability to the torso and align hips.  Doctors were also interested in higher-cost options such as specialty chairs and equipment, and said they are now considering reallocating money in their budget to purchase adaptive equipment.

Baby House directors experiencing being fed and drinking as a child with Cerebral Palsy (with improper positioning)

We then discussed feeding needs for “typical” children.  Doctors had the experience of being fed with very large spoons and being fed with their eyes closed.  We heard comments of “it’s very difficult” or “why are you feeding me so quickly?” which told me these were “aha” moments for many.

Other parts of the training included a brief documentary on attachment, discussion on stages of feeding and screening for nutrient deficiencies.  It was a day packed-full of information and it seemed to pass all too quickly.  I was thankful for several minutes at the end of the day to reflect as a whole group on the training experience.  I can’t give enough praise to Tanya and Slava – they are incredible partners in training!  They have been doing such trainings for over half my life, so I have much to learn from them!

Here’s some more of the feedback we received:

“I appreciate the practicality of the training.  In our medical training we learned all the theory, but now we have the practical skills.”

“I see now the different nutritional needs of children with cerebral palsy [from typical children].  I now recognize the importance of adaptive feeding equipment, especially for children with cerebral palsy.  I think I may make purchasing this type of equipment a priority and request this from sponsors.”

“I like this practical teaching method.  It will be very useful for my baby house staff.  I hope to replicate some of these activities with my staff.”

“We need more conferences like this!”

by Kate Nelson Ward

I arrived in Astana, Kazakhstan safe and sound early this morning.  Unfortunately, my bag didn’t make it, but the show must go on.  “And what exactly IS that show?” you might ask.  On this trip, we’re building on the foundation we’ve laid over the past few years and addressing the feeding piece of the orphan malnutrition puzzle.

The project, called Kazakhstan Infant Nutrition & Feeding, Nurturing Together (KZ INFaNT), is a collaboration of USAID, The Women’s League with Creative Initiative, SPOON Foundation and the Kazakhstan Ministry of Health.  Through it, I have the privilege of working with two of our favorite colleagues and child development experts, Tanya Morozova and Slava Dovbnya, in training head doctors from baby houses in Kazakhstan.

Tanya and Slava working with a child with cerebral palsy

Today was day 1 of our training conference.  The day started with welcomes and introductions from representatives of the Kazakhstan Ministry of Health and Department of Sanitary Epidemiology and the chair of the “Women’s League.”  We had a packed training schedule today, including:

• Overview of the Kazakhstan Orphan Nutrition Project
• The importance of nutrition and feeding for children living in institutional settings
• The unique nutritional needs of children with special needs
• Baby House visit: practical feeding techniques for children with cerebral palsy
• Training-the-trainer: how to facilitate a training

Captive audience

Slava discusses feeding children with cerebral palsy