Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster vs ongoing institutional care

Abstract

Objectives: To determine effects of improved nurturing compared with institutional care on physical growth and to investigate the association between growth and cognitive development.

Design: A randomized controlled trial beginning in infants (mean age, 21.0 months; range, 5-32 months), with follow-up at 30, 42, and 54 months of age.

Setting: Institutionalized and community children in Bucharest, Romania.

Participants: One hundred thirty-six healthy institutionalized children from 6 orphanages and 72 typically developing, never-institutionalized children.

Intervention: Institutionalized children were randomly assigned to receive foster care or institutional care as usual.

Outcome measures: Auxology and measures of intelligence over time.

Results: Growth in institutionalized children was compromised, particularly in infants weighing less than 2500 g at birth. Mean height and weight, though not head size, increased to near normal within 12 months in foster care. Significant independent predictors for greater catch-up in height and weight included age younger than 12 months at randomization, lower baseline z scores, and higher caregiving quality, particularly caregiver sensitivity and positive regard. Baseline developmental quotient, birth weight, and height catch-up were significant independent predictors of cognitive abilities at follow-up. Each incremental increase of 1 in standardized height scores between baseline and 42 months was associated with a mean increase of 12.6 points (SD, 4.7 points) in verbal IQ (P < .05).

Conclusions: Foster care had a significant effect on growth, particularly with early placement and high-quality care. Growth and IQ in low-birth-weight children are particularly vulnerable to social deprivation. Catch-up growth in height under more nurturing conditions is a useful indicator of caregiving quality and cognitive improvement.

Trial registration: ClinicalTrials.gov NCT00747396.

Figures

Figure 1

Group status at age 54 months for children living in Romanian institutions who were assigned to usual care or foster care.

Figure 2

Growth in the foster care group (FCG) vs care as usual group (CAU) at baseline, 30 and 42 months of age. a) Mean growth rates (s.e.) from random effects linear growth models for height (cm/mo), weight (kg/month) and OFC (cm/month) * p F(1, 50) = 100.6, p < .001, partial η2 = .67] and weight z-scores [F(1, 50) = 94.0, p = < .001, partial η2 = .65]. CAU weight z-scores [F(1. 50) = 10.3, p < .01, partial η2 = .17] At 42 months, height-z in FCG vs. CAU 0.06 ± .97 (s.d.) vs −0.62 ± 0.99, t(1,108) = −3.65, * p < .001 and weight-z −0.31 ± 1.05 vs −0.75 ± 1.17, t(1,108) = −1.98, † p = .05 c) Comparison of υ weight-for-height σ and ofc z-scores (s.e.).

Figure 3

Growth in the foster care group (FCG) vs care as usual group (CAU) at baseline, 6, 12 and 18 months post-randomization. a) Comparison of ν height and λ weight z-scores (s.e.m.) in CAU and FCG from baseline (n=51, 54) 6 ((n=46, 57), 12 (42, 51) and 18 (21, 50) months post-randomization. ANOVA FCG height [F(1, 43) = 57.32, p < .001, partial η2 = .57] and weight z-scores [F(1, 43) = 63.65, p = < .001, partial η2 = .60]. * p ≤ .001, † p

Figure 4

Full Scale IQ ± SE at 54 months vs. age of randomization and birthweight. ν ≥ 2.5 kg, λ t(21) = 3.84]