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

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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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