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Medical Resources :: General Medical Issues :: International Adoption Medical Issues

This page contains excerpts from a document regarding International Adoption Medial Issues. To access the document in its entirety, click here (a Microsoft PowerPoint Presentation).

International Adoption Medical Issues

Immigration and Naturalization Service 1998 Data
Total intercountry adoptions 15,774:

  • Russia 4,491
  • China 4,206
  • Korea 1,829
  • Guatemala 911
  • Vietnam 603
  • India 478
  • Romania 406

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Immigration and Naturalization Service 1997 Data
Total Intercountry adoptions 13, 621

  • Russia 3,816
  • China 3,367
  • Korea 1,654
  • Guatemala 788
  • Romania 621
  • Vietnam 425
  • India 349

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Medical Diagnoses in Internationally Adopted Children

  • Anemia 30-40%
  • Intestinal parasites 50%
  • Hepatitis B 3-5% China
  • Hepatitis C < 1 %
  • Scabies 25%
  • TB exp Russia 25%
  • TB exp China 9 %

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Medical Diagnoses in Internationally Adopted Children

  • Congenital Syphilis (exp) < 1%
  • Malaria <1%
  • Congenital Heart Disease 3%
  • Craniofacial Abnormalities 3%
  • Kidney abnormalities <1%
  • Lead poisoning (China) 13%
  • Referenced from Dr. Aronson's adoption center and other adoption centers across U.S.

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Laboratory Evaluations

  • CBC with differential, platelets, rdw, retics
  • Liver enzymes (SGOT, SGPT)
  • Alkaline phos, Calcium, Phosphorus (rickets screen)
  • Metabolic screen (thyroid)
  • Hepatitis B,C
  • HIV-1, HIV-2
  • Syphilis serology (RPR, FTA-ABS)
  • Lead (venous)
  • Hemoglobin electrophoresis, G-6-PD
  • Urinalysis with microscopic exam
  • Stools O&P X 3
  • Giardia antigen, Cryptosporidium DFA
  • Stool C&S X 1

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Medical Investigations

  • PPD (mantoux test) within a few months of arrival in the U.S.
  • Hearing evaluation (behavioral audiometry, auditory brainstem evoked potential)
  • Vision screening (pediatric ophthalmologic examination)

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Dental Health in Children Adopted from Abroad

  • Rickets slows primary teeth eruption
  • Enamel abnormalities can occur due to poor nutrition
  • Exposure to sugar in diet causes caries
  • No tooth brushing in orphanages
  • No fluoride in water
  • Recommend Pediatric Dentist to evaluate child within 6 months of arrival in U.S.

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Rickets

  • Screening
  • Calcium
  • Phosphorus
  • Alkaline Phosphatase
  • Knee x-rays for metaphyseal fraying

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Metabolic Screen

  • Thyroxine
  • Phenylalanine
  • Galactose Transferase
  • Biotinidase
  • Sickle Hemoglobin
  • Leucine
  • Methionine

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Lead Screening

  • lead-containing gasoline, coal burning causes lead poisoning
  • 13% of children adopted from China-Aronson et al. 1999
  • Children adopted from abroad need to be screened

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Anemia

  • CBC with differential, platelets,rdw, retics
  • Iron deficiency anemia interferes with normal growth and can be responsible for developmental delay and learning disabilities
  • Hemoglobin electrophoresis for children from Asia, Latin America, Africa, Mediterrranean countries
  • Glucose-6-phosphate dehydrogenase deficiency-children from Asia, Latin America, Africa, Mediterranean countries

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Hepatitis B

  • Prevalence of Hep B carriage varies by country
  • Did the child have Hepatitis B infection and recover?
  • Hepatitis B carrier?
  • Hepatitis B vaccination?
  • Hepatitis B serology
  • Hep B s Ag=hep B surface antigen
  • Hep B s Ab=hep B surface antibody
  • Hep B c Ab IgG=hep B core antibody
  • Hep B c Ab IgM (acute Hep B infec)
  • Hep B e Ag=hepatitis B e antigen
  • Hep B e Ab=hepatitis B e antibody

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Hepatitis B in Videle,Romania November/December 1998

  • 111 children in an institution for the severely handicapped
  • 51 children tested for Hepatitis B
  • 45 children tested for HIV infection
  • 15 children (29%) Hepatitis B sag positive
  • All children HIV negative
  • 8 children prior diagnosis of HIV

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Hepatitis B in China

  • Johnson et al 1998-3.5% of girls adopted from China were Hep B carriers when tested in the U.S.

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Hepatitis C

  • Transmission-blood transfusion, sexual, transplacental/perinatal
  • Potential for chronic liver disease, cirrhosis, cancer
  • Cluster in Yangzhou, China in 1995-reused needles in Beijing
  • 2 Russia, 1 Moldova (Aronson data)

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Hepatitis A

  • Transmission-water, food, fecal-oral
  • High prevalence in all developing nations
  • Very common in daycare, orphanages
  • Usually mild acute viral illness without jaundice
  • No carrier state
  • Usually no complications in normal hosts but can be deadly in Hep B, C carriers
  • HIV Infection
  • Low prevalence in China (4 HIV pos/PCR neg 1998)
  • Increasing prevalence in former USSR, Central America, Southeast Asia (Cambodia 1-2% prev)
  • Rapidly changing epidemiology

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HIV Infection

  • HIV test results from the child's country of origin should not be presumed reliable
  • If HIV ab is negative in U.S. then child is probably negative
  • If HIV ab is positive, need PCR because of transplacental ab

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Tuberculosis

  • Controversial health issue in international adoption
  • Children with prior history of BCG vaccine may have a slightly pos TB test
  • Most internationally adopted children come from countries with high prevalence of Tuberculosis
  • BCG versus actual TB infection????
  • Mantoux test=PPD (purified protein derivative)
  • Health professional interprets PPD at 48-72 hours
  • Guidelines for interpretation found in RedBook 1997 (American Academy of Pediatrics)
  • Most authorities recommend that a positive skin test should be interpreted as indicative of exposure to Mycobacterium tuberculosis
  • Preventive therapy is recommended
  • Induration of greater than or equal to 10 mm in a BCG-vaccinated child from a country with a high prevalence of Tb indicates likely infection/exposure
  • Diagnostic evaluation-Chest X-ray
  • Chest film negative-Treat with INH (isoniazid-10 mg/kg once daily) for 9 months

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Syphilis

  • Etiology-Treponema pallidum bacteria
  • Congenital disease-transplacental
  • Associated with other sexually transmitted diseases-HIV, GC, Hep B
  • Increasing prevalence worldwide in past 20 years
  • Laboratory Diagnosis
  • RPR, VDRL, FTA-ABS (IgG)
  • Clinical manifestations-failure to thrive, microcephaly
  • Skeletal abnormalities-long bone films
  • Chorioretinitis-eye exam by ophthalmologist
  • Deafness-hearing tests(ABR)
  • Developmental delays-Neurodevelop eval
  • Treatment
  • Intravenous Aqueous crystalline Penicillin G for 10-14 days
  • Evaluate medical report for evidence of therapy and follow-up serology
  • Recommend HIV testing

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Giardiasis

  • Worldwide distribution
  • First described in American travelers to Leningrad
  • Common in Daycare and Orphanages
  • Can cause chronic malabsorption and failure to thrive
  • Diagnosis
  • Stools for Ova and Parasites X 3
  • Giardia antigen-increases yield
  • Commercially available stool collection kits in childproof containers
  • For children in orphanages with FTT and growth failure, treatment is a must!
  • Treatment prevents household transmission by toddlers to adults
  • Good handwashing is necessary to prevent transmission to other family members
  • Treatment
  • Metronidazole 95% effective-can be made as a benzoate suspension (Cherry flavor!)
  • 1-800-861-0933 Connecticut pharmacy
  • Furazolidone 70% effective-available in liquid, but lots of treatment failures
  • Follow-up cultures, antigen are a must!

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Helicobacter pylori

  • What is the bottom line on this bacteria in children adopted from abroad?
  • We don't have data as yet to determine whether this is an issue
  • Sxs of failure to thrive w/o appropriate catch-up growth after adoption and chronic recurrent abdominal pain suggest that H. pylori might be a consideraton in the diff.dx

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Scabies

  • Scabies is a contagious skin disorder caused by a mite, Sarcoptes scabiei
  • Mite burrows under skin and deposits dead mite parts and feces causing hypersensitivity reaction
  • Intensely pruritic, erythematous, papulo-vesicular eruption
  • Sites of Predilection
  • Interdigital folds, flexor aspects of the wrists,extensor surfaces of the elbows, anterior axillary folds, belt line, thighs, navel, penis, areolae, abdomen, intergluteal cleft, buttocks
  • Infants younger than 2 years of age
  • The eruption is often vesicular and is likely to occur on the head, face, neck, palms and soles, areas often spared in older children and adults

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Treatment of Scabies

  • Accurate diagnosis is paramount-beware of Scabies Incognito due to steroids
  • Elimite 5% (Permethrin)
  • Leave it on for 8-14 hours and then bathe off
  • Adoption groups should be treated even if only one child is infected

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Fever of Unknown Origin

  • Fever, anemia in a child recently adopted from Asia
  • Think of malaria

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Varicella zoster.Chicken Pox

  • Diagnosis by classic white oval skin lesions/scars and craters
  • Vaccine available in US since March 1995
  • Consider obtaining serology on arrival with other tests depending on cost and numbers of vaccines

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Immunizations

  • Vaccines in other countries may not be protected by quality assurance measures
  • Vaccines may have expired or may be improperly stored
  • NO HIB in China, Russia
  • Hep B is available in China, but not given early enough to prevent infection in abandoned children
  • Children may have a poor immunologic response to the vaccines due to FTT

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Immunization Status of Adoptees from China, Russia, EE

  • Hostetter & Johnson, University of Minnesota, Minneapolis, MN
  • Society for Pediatric Research May 1998
  • "Overall, despite written evidence of age-appropriate immunization, only 35% of Chinese, Russian, and EE adoptees exhibited protective titers to diphtheria and tetanus."

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Immunizations

  • For younger children I recommend repeating vaccines
  • Vaccines are not reliable in Russia, China
  • Vaccines are reliable in Korea, most Latin American countries, India
  • No harm in repeating vaccines for young infants and toddlers who have an unreliable immunization record
  • Us the accelerated immunization schedule as outlined in the Redbook 1997
  • For older pre-school and school age children, check antibodies for diphtheria, tetanus, measles, mumps, rubella
  • If the child has adequate titers, then just give appropriate boosters

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Growth and Development in Internationally Adopted Children

  • Studies suggest that delayed growth and development may be partially or completely reversible by adoption
  • It may depend on how long the child has been in an orphanage

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Growth in Internationally Adopted Children

  • Children adopted under one year of age may catch up in weight within 6 months of arrival in the U.S.
  • Children adopted over one year of age may take longer to catch up for height depending on the extent of their growth delay at the time of the adoption

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Growth Delay

  • For linear growth in children adopted at pre-school and school age there is probably less catch-up because of sustained periods of undernutrition and institutionalization

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Head Circumference

  • Microcephaly is defined as less than the 5th % on a standard growth curve
  • Head circumference is generally universal
  • There are differences in head shapes (brachiocephaly/flattened occiput in China, frontal bossing from rickets)
  • Head circumference in infancy correlates with brain growth
  • Heads grow about 12 cm in the 1st year
  • Microcephaly in the newborn is associated with prematurity, intrauterine infection, chronic intrauterine hypoxia, smoking, alcohol, poor pre-natal care, craniosynostosis (rarely)
  • Children adopted under 18 months of age who have small heads may have rebound growth!
  • Children adopted after two years of age who have small heads may have some rebound, but it is less likely
  • Developmental Delay in Internationally Adopted Children
  • Developmental delays occurred in 3/4 of adopted children in their initial screening-transitional delay (Aronson)
  • 1/4 of the children had more sustained delays requiring ST, OT, or PT
  • Language delay should be the focus especially for kids who are toddlers when adopted

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Fetal Alcohol Syndrome

  • Worldwide incidence 1.9 per 1,000 Abel et al 1987
  • Aronson 1998 FAS incidence based on retrospective chart review of Russian medical records- 1.53% or 15 per 1,000 (8 times world incidence)
  • 1993 # of alcoholics rose by 40.8 % in Russia
  • Girls 15-17 yo-80-94% drink and 17% drink often Environmental and Health Atlas of Russia Murray Feshbach, Editor 1995

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Recommendations

  • Vision and Hearing evaluations
  • Developmental screening with each exam
  • Early intervention after a transition period allowing for catch-up growth and adaptations to a new environment

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Transition issues

  • Feeding
  • Sleeping
  • Siblings
  • Extended family and friends
  • Cultural issues
  • Language delay
  • Language acquisition in older children

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Adoption Transition Mood Disorder

  • Shyness
  • Poor appetite
  • Ravenous appetite
  • Disturbed sleep-early awakening, frequent awakenings
  • Flat affect
  • Attachment difficulties

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Age

  • Dates of birth may not be accurately assigned due to abandonment
  • Bone age and dental x-rays can be helpful one year after the adoption
  • Developmental evaluations over time reveal a pattern
  • Reassigning date of birth may be necessary for proper school placement

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  This page last updated September 17, 2003 8:40 PM EST