The Nutritional Status of Individuals Adopted Internationally as Children: A Systematic Review

Since 1955, international adoption has been a way of finding homes for children who have been orphaned or abandoned. We aimed to describe the nutritional status of individuals adopted internationally and their long-term nutritional and health outcomes. We searched four databases for articles published from January 1995 to June 2020, which included information on anthropometric or micronutrient status of children adopted internationally (CAI). Mean Z-scores on arrival to adoptive country ranged from −2.04 to −0.31 for weight for age; −0.94 to 0.39 for weight for height; −0.7 to 0 for body mass index; −1.89 to −0.03 for height for age; −1.43 to 0.80 for head circumference for age. Older children, those adopted from institutionalized care or with underlying disability, were more likely to be malnourished. Though long-term data was scarce, mean Z-scores post-adoption ranged from −0.59 to 0.53 for weight for age; −0.31 to 1.04 for weight for height; 0.39 to 1.04 for body mass index; −1.09 to 0.58 for height for age; −0.06 to 1.23 for head circumference for age. We conclude that though CAI are at high risk of malnutrition at baseline, marked catch-up growth is possible, including for those older than two years of age on arrival. This has implications not only for CAI but for the wider population of malnourished children worldwide. Research on how to optimize catch-up growth is a priority.


Rationale
3 Describe the rationale for the review in the context of what is already known.

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Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number. 4 Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

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Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.

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Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.

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Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

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Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

Risk of bias in individual studies
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.

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Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means).

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Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I 2 ) for each meta-analysis.

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Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).

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Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.

Study selection
17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

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Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.

DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).

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Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).  19 or 20 will be used for the search.