Cindy Kaplan is improving the nutritional outcomes of children without permanent families. Recognizing that the nutritional needs of children who have suffered from trauma and institutionalized care are drastically different, Cindy is equipping governments and citizen organizations (COs) around the world to protect the orphaned, fostered, and adopted children in their care from the debilitating—yet easily preventable—consequences of malnutrition and improper feeding.
The New Idea
Across the globe, young children are entering orphanages at a severe disadvantage, having been malnourished in utero and without the benefit of early breastfeeding. Sadly, their nutritional intake once in institutionalized care typically continues to be grossly insufficient for children’s brains and bodies to develop normally, particularly given that the nutritional needs of children change when they are in high-stress environments.
Cindy co-founded the SPOON Foundation in 2007 as the first organization worldwide to study, create awareness of, and address the exceptional nutritional needs of children living without permanent parental care. The impetus behind Cindy’s work came after adopting her first son, Jadyn, from Kazakhstan. Jadyn was severally underweight and did not have the strength to lift his own head. She was shocked at the prevalence of malnutrition in orphanages. Even more astounding was the fact that no organization, whether in Kazakhstan or globally, seemed to be paying serious attention to this issue.
Starting in Kazakhstan—and poised to launch in Tajikistan, Russia, Kyrgyzstan, India, Haiti, and China—Cindy is transforming feeding practices and nutrition protocols in orphanages. She is changing the mindsets, attitudes, and behaviors of orphanage workers by equipping them to improve the nutritional outcomes of the children in their care. In this sense, she is helping redefine the roles of caregivers. Where they once saw themselves responsible for ensuring that orphans survive, they now understand and are fully equipped to help them thrive through better nutrition and feeding practices during their first few years of life. Cindy is also the first to have developed nutrition education resources for parents of adoptive children through Adoptionnutrition.org, as well as training programs for foster families in the US and internationally.
Though science proves indisputably that malnutrition in the early years can compromise brain development and physical health, robbing children of the chance to learn, to work, to grow, and to develop meaningful relationships, our world’s most vulnerable children—those living in orphanages, without parental care—are not being included in local and global efforts to fight childhood hunger and malnutrition. Most efforts focus on prenatal nutrition, breastfeeding, and the distribution of therapeutic foods and supplements to children through their families. While this is important and valuable work, it overlooks an entire population of the world’s children living outside of family care—a group so forgotten that there exist no statistics to quantify them.
Recent research has demonstrated that institutionalized children are at far greater risk for malnutrition than children in families (due to multiple factors, including poor prenatal care, lack of breastfeeding, metabolic impacts of stress, institutionalized diets and feeding practices). SPOON Foundation’s own study in Kazakhstan documented rates of under-nutrition as high as 73 percent in orphanages. Once in an institution, caregivers generally feed children diets high in empty carbohydrates and low in the nutrients required for the brain and body to develop normally. They are further handicapped by institutional feeding practices that do not allow for eye contact or extra time for slow feeders. Devoid of key nutrients and appropriate feeding practices, these children’s capacity for social interaction and for learning is significantly hindered in their first two years of life. Under-nourished children are unhealthy children, and unhealthy children in institutions are less likely to be reunified with their birth families and/or placed with adoptive or foster families. The burden on the state is great, yet pales in comparison to the cost of so much lost human potential.
Historically, orphanages have been closed institutions, off-limits to local and international communities. While certain countries, particularly in the former Soviet Union, are slowly opening the doors of their orphanages to outsiders, the countless children residing there remain largely “unseen” by governments, international development agencies, and COs. The exception is religious groups, many of whom are devoted to orphaned children. However, their nutrition support efforts—generally basic food aid only—are generally not guided by an understanding of what type of aid is most needed (let alone the nutritional content of the food distributed), not measured to ensure impact, and not designed with sustainability in mind.
Cindy and the SPOON team are devoted to creating and refining a rigorous process to identify the nutritional needs of institutionalized children, and then working with responsible parties (i.e. governments, international COs, institutions, and families) to ensure those needs are known and met. Given that nutrition most affects brain development when toddlers are between zero and three years old, SPOON focuses its interventions mostly on this population.
Cindy’s approach is medically sound, evidence-based, and emphasizes assessment before action. SPOON begins every project with a thorough assessment to ensure all stakeholders clearly understand the needs, barriers to improvement, and best opportunity for impact. The team spends time understanding the national context (i.e. national nutrition policies, cultural beliefs pertaining to food and nutrition, and standard dietary practice), as well as the institutions they partner with (i.e. food prep and feeding observations, focus groups with caregivers, and clinical care and systems), and the health of the children (i.e. growth measurements, blood tests, and developmental evaluations). The assessment phase is also an important step to get buy-in and support from key constituents, including local government, COs, partners, and donors. Whenever possible, they collaborate with local governments and the citizen sector to design and implement preliminary assessments, so that results are unlikely to be disputed or ignored.
Once SPOON completes the assessment, the team shifts to developing evidence-based interventions created with the intention to shift standard policy and practice in orphanage and/or foster care systems, often on a national scale. Common interventions include optimizing diets, ensuring adequate equipment, introducing nutrition-screening systems, and conducting training-of-trainers on best nutrition and feeding practices. Cindy is adamant about piloting and refining programs before taking them to scale, so that they can leverage the evidence-base to garner the support of all stakeholders.
The interventions focus as much on what children are eating as they do on how children are being fed. Medical research has shown that while food is necessary for children to grow healthily, nutrition alone is not sufficient to produce growth—certain hormones, which are secreted in response to positive human interactions, must also be present. Given that infants interact most with their caregivers during meals, changing feeding practices represents a unique opportunity to support healthy development. In addition, some of the feeding practices used can be life threatening. For example, rapid feeding through an enlarged nipple hole in a bottle can lead to choking and aspiration, which is a common cause of pneumonia. Children in orphanages are seven times more likely to die of pneumonia than children in families. Cindy, and SPOON, understood early on that they would have to address both the environment in which children are fed, as well as the nutrient content of the food they are provided.
Interventions must take into account that orphanages are typically resource-strapped. Most of SPOON’s recommended changes and activities implemented through partners require awareness and education, not necessarily financial resources. For example, tea inhibits the absorption of certain essential nutrients. Yet in many countries, tea is routinely served to infants during meals (both as a cultural practice, and as way to keep kids full). Cindy’s approach is not to convince orphanages that they should stop giving kids tea, but rather that they should serve tea at least one hour after a meal.
In 2009, SPOON formed a collaboration with the influential Kazakh Academy of Nutrition and its nonprofit arm, the Kazakh Children’s Nutrition Fund. Together with these local partners, SPOON Foundation completed the first-ever worldwide study of the nutritional and developmental status of young, institutionalized children. Beginning with a comprehensive baseline assessment, SPOON conducted blood tests and measured the growth and development of children in ten of the country’s baby houses. SPOON then implemented an intervention pilot to measure the impact of dietary changes and/or supplementation on the children’s nutritional status. High rates of attrition limited intervention results, but baseline data alone was enough to catalyze national change. Results from the baseline assessment were worse than anticipated, with 73 percent of the children testing positive for one or more condition of under-nutrition. Well over one-third of the children were stunted, had iron-deficiency anemia, and/or a vitamin D deficiency. In direct response to SPOON’s study and advocacy efforts, the Government of Kazakhstan issued a new national policy stipulating improved nutrition norms and menus for every baby home across the country. SPOON is now following up, in collaboration with a leading Kazakh CO, to provide feeding training to baby home caregivers so that all children will benefit from the new and important nutrition offered.
Cindy knows that her idea has global relevance and she is pursuing several strategies to expand the reach of her work. On one hand, she plans to continue to find like-minded local organizations (like the Kazakh Children’s Nutrition Fund), interested in partnering with SPOON and having the credibility to introduce them to local networks of orphanages. With the example of Kazakhstan in her back pocket, Cindy now has the track record she needs to attract the interest of neighboring Central Asian countries. She organized a dissemination conference in the spring of 2012 to bring baby home directors together to learn about the new Kazakh policy and provide them with training. The goal was also to help those directors network for the first time with each other and to start sharing lessons learned. In addition, Cindy also invited COs from neighboring countries. As a result, SPOON was invited to collaborate with governments and the citizen sector in Russia, Tajikistan, and Kyrgyzstan to create similar reforms in those countries.
Cindy is also partnering with established international orphan care organizations that can help her introduce her approach in many new countries without having to build the entire infrastructure herself. For example, she is partnering with Holt International and Joint Council on International Children’s Services. These two renowned orphan care organizations contracted SPOON (in a fee-for-service model) to assist them in addressing under-nutrition in orphanages in the countries they serve, such as China, Haiti, and India (2014). Through these established partners alone, SPOON expects to reach children in up to 20 countries in the next 10 years. Before partnering with any organization, Cindy ensures that they have a sound reputation with orphanages on the ground, networks to reach children in the foster care system, a capacity to execute and sustain the work long-term, and credibility with other local partners and governments.
Cindy knows she must influence those organizations focused on nutrition to start paying attention to the needs of children raised outside of family environments. She has had initial success influencing USAID to prioritize orphan nutrition and is targeting other agencies and leading humanitarian organizations to extend their efforts to children in, exiting or threatened by institutional care. In addition, Cindy has attracted a powerful medical advisory, focused on advancing and publishing research about SPOON’s work in order to give it more credibility in the field.
In addition to international work, Cindy is developing resources for parents of adopted and fostered children nationally, to help them bring their malnourished toddlers back to health. It is important to note that SPOON supports deinstitutionalization. The organization is working to improve child health and nutrition within institutions to heighten chances for placement with a family; to prevent children with special needs from entering institutional care, and to prevent fostered and adopted children from circling back to institutions.
SPOON is a 501c3. Roughly 30 percent of SPOON’s budget is earned income and the rest comes from corporations such as Nestle, Pfizer, General Mills, and foundations such as Margaret A. Cargill Philanthropies. Cindy currently employs six part-time staff and roughly ten contractors.
Growing up with a brother impacted by significant emotional and learning challenges, Cindy quickly learned what it was to be an underdog. She spent recess protecting him from bullies and went on to spend her childhood and adolescence watching out for those less fortunate, babysitting for kids with disabilities, and working in shelters for runaway and throwaway youth.
Then, as a young woman, Cindy became the vulnerable one, barely able to eat anything without feeling ill. It took her ten years to be properly diagnosed with Celiac disease, but in the interim, she knew enough to connect how she felt to what she ate. Cindy quickly became a self-taught expert in all things wellness and nutrition, and true to her “helper” nature, felt compelled to spread her knowledge. Cindy left her job in a fast-paced advertising agency to start a corporate wellness consulting firm, helping companies to identify and meet the health needs of their employees. Cindy loved the challenge of building something from scratch and getting others to see the value and share the vision. After building a successful organization, she eventually sold it and went on to join a startup company making allergen-free foods as their first hire. After three years, their brand became a national success, and she experienced once again the thrill of building an entrepreneurial vision. Cindy was hooked. Yet, in the big picture of her life, she felt something was missing.
When Cindy and her husband set out to adopt a baby, they learned about an adoption program in Kazakhstan. During the process of adoption, Cindy met Mishelle, a neighbor who was also in the process of adopting from Kazakhstan. Her child-to-be was a five-year-old girl diagnosed with Cerebral Palsy, so severely disabled that she could barely walk. Nine months later, Cindy received a referral for a “healthy baby boy.” Within minutes of meeting Jadyn, they knew he was not healthy. At six months, he weighed ten pounds and did not have the strength to lift his own head. He was being fed too rapidly to keep up and could not digest the inadequate amounts of formula he was being given. He was diagnosed with failure to thrive and Cindy’s whole life became immediately dedicated to saving his. Meanwhile, Mishelle’s little girl, Bakha, did not have Cerebral Palsy, but vitamin D deficiency-related disabilities, which were easily resolved. Cindy and Mishelle could not help but wonder “what if” for their kids. Cindy started looking for volunteer opportunities but could not find any organizations working to address the critical problem of malnutrition for orphaned children. She co-founded SPOON at that moment, and has directed the organization since.