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Our Services :: Assessment of Child's Medical History :: Guidelines for Interpreting Pre-Adoption Medicals From Russia and Other Countries: Syphilis, Hepatitis B and C and HIV, Recommended Screening Tests and Evaluations

This was published in the October 2002 Adoption/Medical News Vol VIII, Nos. 9-10 Newsletter

 

The following is some background on what I look for when watching a video of an orphan.You should also read "Preparations, Resources & Expectations for International Adoption" for more information. Formerly most videos were made in orphanages abroad by facilitators and were given to the adoption agencies to forward to the prospective parents. Currently many parents seeking to adopt from Russia and other countries are making their own videos. Reading this article will help in understanding what is considered in a video evaluation.


How to Look at a Video
      When I review a video, I first rate the quality of the video. What is the length of the video? Is the video blurry and unclear or taken with the child in the distance? These circumstances may make it difficult to evaluate the child for Fetal Alcohol Syndrome (FAS) or other syndromes. If the video is less than 1 minute, assessment of the child's development may be very limited because the child may not display enough behavior or development for evaluation.
      A good quality video is usually at least 3-5 minutes in duration and it shows the child in just a diaper. A good look at the baby without a diaper to affirm gender is desirable. Viewing the child's skin and extremities for birthmarks and possible deformities is helpful in diagnosing medical conditions. If there is a mention of a skin infection or birthmark in the medical abstract, it makes sense to look at the actual abnormalities that are mentioned. Muscle tone can be better assessed if one can look at the extremities, as they are moving. However, there is no substitute for a hands-on exam. The symmetry of movement can be observed. If the movement of limbs is asymmetric (one side moves differently than the other side), I might diagnose a neurological (brain) abnormality. By looking at the child in a diaper, one can assess the quality of the child's nutrition.

Development in a Video
      The developmental age of the child can be determined to some extent by looking at a good quality video. I use the standard Denver Developmental Screening Test which is a tool used by pediatricians to evaluate personal-social, gross motor, fine motor-adaptive, and language development (receptive and expressive) in children under the age of 6 years. Most of what we are looking at is motor development, since children don't vocalize too often in an orphanage. Children who are living in orphanages may be delayed just because they have been living in an institutionalized setting and their nutrition has been sub-optimal. Adoption professionals guess that for every 3 months a child resides in an orphanage there may be a loss of one month of development (Dana E. Johnson, M.D.). This is probably an over-simplification of the effect of orphanage life on the development of a child, but it is a useful guide.
      It would probably be very easy for adoption professionals/facilitators/parents to use the Denver Developmental Screening Test as a guide in making the video. Some age appropriate skills could be assessed and filmed. For example, a four-month-old infant is capable of reaching for toys or objects slightly out of reach. This could be easily filmed. A child can sit on his own between 6-8 months. Most kids from orphanages do not sit on their own between 6-8 months, but it would be great to be able show sitting when it does occur. Pulling to a stand, cruising, crawling, and standing alone for a few seconds is easy to depict in a video. Children follow past the midline at 2-3 months of age. Kids rake a raisin or a cheerio at 6-8 months and they have a neat pincer at 8-10 months. Filming a child eating is a terrific way to assess sucking and swallowing and interaction with the caretaker. Families who travel to an orphanage to adopt a child can be instructed to carry out the same tasks so that a video can be prepared for waiting families. With the advent of two trips in many countries, the actual adopting family can make this video and then show it to the adoption medical specialist on return to the U.S. Photos can be taken as well and a sequence of photos can depict development almost like a video. These photos can be emailed to an adoption medicine specialist as "jpg" or "zip" files and they can be evaluated while families are in country for the adoption process. "Mpgs" (videos for the computer) are of limited use at this time.

Recommended Screening Tests and Evaluations

Once the child has arrived, an initial visit to the doctor should ideally occur within 10-14 days, unless the child has an acute illness and then a sick visit is obviously imperative within 24-48 hours. Once the family knows their travel dates, they can schedule the adoption consultation appointment long in advance since the initial visit should take at least an hour or more.

  • Antibody titers for children over one year of age who have a credible vaccine record from the country of origin:
    - diphtheria antibodies
    - tetanus antibodies
    - polio neutralizing antibodies for type 1,2, 3
    - chicken pox antibodies (varicella antibodies)
    - measles, mumps, rubella (depends on the country and reliability of these vaccines)
  • HIV-1,2 ELISA
  • Hepatitis B serology (Hep B surface antibody, Hep B surface antigen, Hep B core antibody total)
  • Hep C ELISA
  • Hep A total with reflex to IgM in case of acute infection
  • Syphilis serology (RPR, FTA-ABS)
  • lead level (venous)
  • Complete Blood count with differential and platelets
  • Hemoglobin electrophoresis
  • Thyroid screen
  • TSH
  • Free T4
  • Total T4
  • Rickets screen
  • Alkaline phosphatase
  • Calcium
  • Phosphorus
  • Liver Enzymes
  • SGOT
  • SGPT
  • Kidney Function tests BUN, Creatinine
  • Audiology evaluation for all children adopted from abroad (unknown birth history and possible prematurity).
  • Vision screening by a board certified pediatric ophthalmologist for all children adopted from abroad (unknown birth history and possible prematurity).
  • Dental visit with a pediatric dentist should be done by 18 months of age (poor nutrition, exposure to sugar in the bottle).
  • TB skin test on arrival and again 6 months from the time of arrival (If the BCG site is not healed wait until it is healed and if more than a few months is needed for healing, consider having a chest x-ray; then do the PPD (TB skin test) when the BCG scar is completely healed.
  • Consider repeating HIV, Hep B, C 6 months after arrival (lengthy incubation periods and exposure just at the time of departure).
  • Full developmental assessment on arrival and every few months to determine the need for Early Intervention

Vocalizations are Uncommon
      The date that the video was performed helps correlate the developmental age with the chronological age. Vocalizations are a very key aspect of development. Unfortunately, most of the children in orphanages do not vocalize. They have little one-on-one connection with their caretakers. The caretakers usually do not speak to the children as they change their clothes or feed the child. When I hear vocalizations in a video, I am pleasantly surprised and I consider this very encouraging. Receptive language in toddlers is sometimes seen when a child is asked to do simple tasks and the child is observed performing those tasks. This can be inferred from the video without an understanding of the language used by the orphanage staff. If a person speaking the language of the country is available to translate the conversation of the orphanage staff speaking on the video, much can be learned about the child. If a child is not doing much on a video, this does not necessarily mean that there is something seriously wrong with the child. A child may have just awakened from a nap or the child may have an acute illness, like a cold or just be hungry. Some children are given sedatives and they appear lethargic. Medications given in an orphanage can alter a child's mood. The child may just not be motivated to do much because of lack of stimulation and lack of experience in interaction and in play. It is better to assess what is seen and not necessarily to judge what is not seen.

Social Interaction and Behavior in the Orphanage
      Video should depict the child interacting with adults and other children if age appropriate. Toys can be offered to the child to see how the child handles them. Children often have never seen the toy that they are offered during the video and their lack of familiarity is not a measure of intellect. Filming children with other children is enlightening; how they interact gives us information about the child's ability to socialize. This is especially valuable for older children, but not useful for toddlers who normally only exhibit parallel play. How a child interacts with the caretaker can reveal the child's comfort with an intimate relationship. It can tell us a lot about the style of social interaction between children and staff. This really helps parents understand how difficult life is in this setting and can explain why a child appears withdrawn and without much range of emotional response. Eye contact is especially important to note on the video. If a child averts gaze, looks away and down, this may mean that the child is feeling shy and afraid of the video process. If there is a lot of rocking and gaze aversion, this may reveal withdrawn and depressed feelings. Attachment disorder cannot be diagnosed from a video. Lots of children are depressed and bored in orphanages. Rocking, head-banging, and other self-stimulatory behaviors are more the norm in an orphanage and these behaviors disappear fairly quickly after adoption.

Follow-up Videos
      Sequential videos are very helpful in the assessment of a child. Occasionally, agencies can get tapes of children taken in early infancy with follow-up tapes. This really is enlightening. If the child has established a consistent pattern of development even with some delay, this is encouraging. If the child seems to display a substantial decrease in the developmental growth with the new video, then this is concerning and may reveal some underlying medical problem. An infant less than three months of age has a limited array of behaviors, which makes it difficult to assess very young infants, but at least we can comment on the child's alertness, eye contact with the caretaker, and some basic gross motor development. Children who are six months or more can be assessed more easily and follow-up video for these youngsters can be very revealing.
      Video of older children should depict them eating, drinking, playing with friends preferably outside where the child can run around. Observing children drawing pictures, identifying pictures that are on cards or in picture books is especially helpful as long as there is accompanying English translation. This helps the viewer assess the child's receptive and expressive language which is really the window into a child's cognitive development.

Growth Parameters
      Plotting the heights, weights, and head circumferences that appear on the medical abstract is the most objective data from the medical abstract. How the child looks on a standard growth curve tells us a lot about the child's general health. About 50% of children in Russian orphanages fail to thrive and are found well below the standard growth curve. A pattern of growth is ideal because it can establish the reliability of the measurements. One set of points is not that useful. Most children in orphanages are undernourished and even if they start out at birth at an average weight and height, they generally do not maintain that growth velocity due to poor nutrition and institutionalization. Psychosocial dwarfism or psychosocial growth failure is a well-understood medical consequence of poor nutrition and institutionalization. If a child is adopted under the age of two years, there is usually good rebound with weight gain and linear growth improvement. For instance, it should also be understood that the birth weights of children in Russia are well below the average weight of a newborn in the U.S. The average birth weight in Russia is 2500 grams or 5 ½ pounds. Poor prenatal care, smoking, and drinking, and congenital infections during pregnancy are quite common in Russia and are the major causes for low birth weight in newborns. People assume that when a child is low birth weight that the child is a premature infant; because of poor pre-natal care, we can not definitively know whether a child is low birth weight and full term or low birth weight and premature, or just premature with appropriate weight for the gestational age.
      Measurements can be unreliable. The staff who measure children in orphanages are well-meaning individuals who have little medical training. It is not unusual for scales to be broken and measuring tapes to stretch. Babies are notorious for squirming and measuring lengths is problematic even in the best circumstances. Taping a staff member or better, yet, the staff physician measuring the child is of particular benefit. We can hear the measurements stated in the video and assess their reliability. Measurements should be kept in the metric system and not be translated into English equivalents unless the metric still appears on the medical abstract. Simple mathematical mistakes are common.

Head Circumference
      Head circumference is obviously the most important growth parameter in the child's medical profile. The growth of the head correlates with brain growth in early infancy. Heads grow fast and furiously during pregnancy and in the first year of life. The average head circumference of a full term newborn is 35 cm and in the first year of life the infant's head will grow about 10 cm as long as the child is healthy. If you look at a standard growth curve there is a 3rd% and a 97th% line for each age. If the child is somewhere at or between these percentiles, this is considered normal growth. This growth curve allows for the small, medium, and large heads. Head size is considered universal, but without normal data available from other countries it is impossible to state what the normal range of head size is for each country. Sleeping position may alter the shape of the head and the back of the head may have a flat appearance. Misshapen heads are also the result of persistent supine positioning due to lack of stimulation in institutions. This can change if the child's soft spot is still open and there is an effort to have the child sleep on the side and not spend much time during the day lying around. With U.S. efforts to decrease the incidence of sudden infant death syndrome (SIDS), there are a lot of normal healthy children with misshapen or flattened heads from supine positioning during sleep. In some cases a helmet has been used to normalize the shape of the head. Measuring the head properly is not so easy. If the child has rickets and a lot of frontal bossing (forehead is prominent), the head may be spuriously enlarged. The head should be measured over the eyebrows around the largest diameter of the posterior skull. Measure three times for the best assessment. I give parents paper tape to measure head circumference on their trip.

Causes of Microcephaly
      Reasons for small head circumference vary. Some heads are small due to poor nutrition, smoking, drinking, intrauterine infections during pregnancy, and genetic disorders. In some rare cases craniosynostosis (premature closure of the sutures of the cranium) is the cause of poor brain growth after birth. Some kids are born with normal heads, but due to malnutrition and lack of stimulation their heads don't grow. In 1998 and 1999, I sent students (Worldwide Orphans Foundation/Orphan Ranger Program) to work in Russian orphanages in the Udmurtia Republic; 154 children ages ranging from 4 months to 55 months in Izshevsk, Glazov, and Votkinsk were evaluated. 40% of the children had microcephaly (head circumference below the normal growth curve). In orphanages in Borovichi and St. Petersburg, similar data was collected in 1999.
      Those children with head circumferences below the 3rd%, adopted at less than one year of age, may have the potential for rebound growth. When a head circumference is less than the 3rd%, the child's cognitive and intellectual development would be the concern. There is no guarantee that the child will have rebound growth. I am following many newly adopted Russian children in my practice and I am encouraged by how many of the children do catch up even for head growth. A few years ago, I did look at head growth catch-up in 34 children adopted from Eastern Europe and Russia and found that 85% of these kids had head growth catch-up a year after arrival. The children were about one year of age on arrival and then a year later, when the children were around two years of age, follow-up was performed. Cognitive testing of these children was not performed, however. I must reiterate that normal brain growth is essential to the successful development of a child. If a head circumference is below the 3rd%, I first request that parents try to get an updated measurement and then I look at the birth head circumference to determine if this is a pattern that existed at birth or developed during the time in the orphanage. A child who is not a premature infant who has a small head circumference at birth is more of a risk than a child who is born with a normal head circumference and whose head grows slowly while in the orphanage. Many parents ask me about familial microcephaly. There are families with small heads, but we don't have reliable family history for the vast majority of referrals. It would be an error to assume that the small head size of a child is due to familial microcephaly unless this could be absolutely documented with measurements of both parents' heads!

Medical Diagnoses and Defectology in Russia and the Former Soviet Union
      The diagnoses found on Russian medical reports are responsible for a lot of the concern and anxiety associated with embarking on a Russian adoption. When I first started reviewing medical abstracts from Russia and Eastern Europe, I, too was unaccustomed to these medical phrases. With 10 years of experience in adoption medicine and travel to Russia, Romania, Bulgaria, and research done by the Orphan Rangers, I can now say that I am accustomed to these unusual terms, but if you are looking for a clear-cut interpretation, you will not find this anywhere. What we know empirically is that physicians in Russia have a unique perspective of the health of newborn infants. This is the system of "Defectology" wherein infants are considered inherently defective and then over time, their "defects" resolve. Russian physicians believe that young infants and toddlers are neurologically immature. It is standard for a Russian child to be evaluated by a pediatric neurologist several times in the first few years of life. Children who are born to mothers with poor pre-natal care and any infections during the pregnancy may be diagnosed as having "prenatal or perinatal encephalopathy". This diagnosis would be based on pre-natal factors, which led the baby to be neurologically abnormal. A child who was born to a mother with syphilis might be diagnosed with prenatal or perinatal encephalopathy. Conditions that exist at the time of the delivery such as premature birth or complications at the time of the delivery like a home birth, might also contribute to the diagnosis of perinatal encephalopathy. It is a system of potentials. It is assumed that all babies are defective and that eventually these conditions will resolve with appropriate therapies such as massage and unusual medications not used in Western countries. So if the mother was ill during pregnancy or had no pre-natal care, then the child is considered potentially predisposed to various health conditions and is diagnosed with perinatal encephalopathy. This diagnosis is not based on any scientific research done in Russia or any other country. Russian physicians have had a long tradition of diagnosing serious pathology (disease) in healthy individuals. As I dismiss some of the significance of the confusing terminology on a medical report, I must also state that there may be medical conditions that clearly do exist for a particular child, that are not diagnosed by the physicians in Russia. I look for context when reviewing the medical reports.
      Other diagnoses that are found commonly on medical abstracts are pyramidal insufficiency or deficiency, hypertensive-hyperexcitability syndrome, hydrocephalic-hypertensive syndrome, and neuro-reflex excitability syndrome. When I was in a maternity/infant hospital in Saratov in Russia in 1997, I asked the director of the newborn division about these diagnoses. She asked me to listen to a baby crying in the nursery across the room from where we were standing. She then told me that baby had neuro-reflex excitability. When I approached the infant, I noticed that the bottle which was propped on a rolled blanket had fallen away from her mouth. The child was hungry and irritable. Further, the baby was drinking Kefir, which is a sour, cold liquid yogurt, which is probably not palatable.
      Pyramidal insufficiency refers to the possible abnormality of the corticospinal tracts of the central nervous system that control the movements of the muscles of the body. If the child has even the slightest delay in gross motor development, then this diagnosis is applied. This is often interpreted as cerebral palsy, but this has not been borne out by my clinical experience. Children are often diagnosed with spastic tetraparesis which literally means weakness and spasticity of all four extremities. I see this commonly applied to children who are walking and appear quite normal for gross motor development. Instead of carefully examining a child and then doing investigative studies to confirm actual brain damage, the child is diagnosed as having brain damage because the nervous system appears to be immature. The bottom line is that the doctors are probably looking at normal children who are delayed due to malnutrition and lack of stimulation. They have little formal training in development. It was clear to me after spending many hours discussing the system of diagnosis with staff physicians in orphanages that the diagnoses are based on a belief system, rather than a thinking process based on physiology and anatomy.

Rampant Testing
      Many children get ultrasounds of the organs in the body. For the most part it is unclear why these tests are even ordered and performed. It cannot be assumed that because tests are ordered that there is actually a disease. The findings sound almost poetic, but they are most often not specific to the child and are not useful for medical diagnosis unless there is some clinical correlation. If one sees some abnormality on the video or in person when the child arrives and has a complete physical examination, then further testing should be initiated. When x-rays, sonograms, EKGs, EEGs, and echocardiograms are used to investigate the health of children in orphanages, these tests are performed by untrained individuals and the equipment is often antiquated and in disrepair. It is difficult to assess the reliability of ultrasound evaluations of the various organs. If the child has had a history of a urinary tract infection and has a mention of an abnormal kidney sonogram, I advise parents to have the kidney ultrasound repeated in the U.S. after the adoption. I do not recommend repeat testing in Russia. I have not recommended routine head sonograms even if the head sonogram in Russia has been described as abnormal on the medical. If the child is a very premature or a low birth weight infant with an abnormal neurologic exam or if a full term child has an abnormal neurologic exam during my examination at the time the child arrives in the U.S., I would then recommend a head CT, or MRI in collaboration with a pediatric neurology consultation. I also recommend hearing and eye exams for infants who have a history of prematurity on any medical abstract. Premature infants do have an increased incidence of hearing abnormalities and vision problems in any part of the world. I try to correlate testing in the U.S. with what I find on the physical exam in my office just as I would do for any child.
      Myotonia, dystonia, or dyskinesia, are also favorite terms found on medical reports from Russia. These are terms to describe abnormal muscle tone. Most of the children in orphanages have abnormal muscle tone due to undernutrition, rickets (vitamin D and calcium deficiency), and lack of stimulation. With adequate nutrition and vitamin D supplementation, the muscle tone improves within a few months. In some cases children may benefit from physical therapy through Early Interventions services in their community. Sustained low tone can occur in children who have been in the orphanage for longer periods of time or in children who may have unclear medical problems.
      Another common term found on almost every Russian medical is hypotrophy. When literally translated, it means "less growth". It is sometimes graded (I, II, III). It actually is an appropriately used term to describe the small size of newborns in Russia and then concomitant failure to thrive, which we see in orphanages as a result of poor nutrition and institutionalization. The grading system is subjective and does not appear to be standard from orphanage to orphanage. This grading system is also seen in describing prematurity, but again, is not standardized.

Hip Dysplasia
      At least 10 % of the medical abstracts from Russia will mention this diagnosis; out of about 800 children adopted from Russia who I have evaluated in my office, I have one child with the actual diagnosis, which did necessitate surgery, and she is well and healthy. Developmental dysplasia of the hip (DDH) has a prevalence of less than 1% at birth and can be diagnosed well into the first year of life. It is not completely understood, but in simple terms it is abnormal development of the hip anatomy and if it goes undiagnosed and untreated, it can cause improper growth of the leg and it obviously will interfere with normal gross motor function. It is obviously over diagnosed on Russian abstracts. A good physical exam by a pediatrician upon arrival in the U.S. can easily rule this diagnosis out. If a child has DDH diagnosed late in infancy or childhood, surgery may be required and usually has an excellent outcome.

Open Oval Window
      This is a diagnosis that is found all too often on Russian medicals and it is again an over diagnosis. It is actually a diagnosis that has no medical significance and is mostly found on autopsy or in some cases during an echocardiogram. All of us have an oval window between the atria of the heart, but it closes early in life. If it remains open, it causes no ill effect.

Intestinal Dysbacteriosis
      This is one of my favorites of the diagnoses; it simply means that there are bacteria in the colon and the harmony of those bacteria may be out of balance. Children with diarrhea or gas are often diagnosed with this condition. Stool cultures are performed and the proof of the diagnosis is that there are bacteria found in the stool. All stools have bacteria, which are necessary to the normal functioning of the intestines. There are only a select number of bacteria that are considered "pathogens" in the colon and some of these are Salmonella, Campylobacter, Shigella, Yersinia, and some Escherichia coli. Intestinal dysbacteriosis is simply the finding of normal bacterial flora with non-specific symptoms. There is no need for treatment although, in Russia, children are often given antibiotics for this condition.

Medications and Therapies
      Children living in orphanages are inevitably treated with an assortment of medications that are commonly not used in the U.S. Medications that are focused on improving blood and cerebrospinal fluid circulation are administered as are sedatives and anti-seizure medications like Phenobarbital (Luminal), carbamazipine (Tegretol), and phenytoin (Dilantin). Children receiving these medications do not necessarily have a diagnosed condition that necessitates treatment with these drugs. Digitalis (Digoxin) has been given to children with simple functional heart murmurs. Vitamins, magnet therapy, paraffin wax treatments, ultraviolet light treatments, electrophoresis, vacuum therapy of the eyes, and massage therapy are all treatments commonly mentioned in medical abstracts. Parental concerns about side effects are common. If a baby appears particularly sluggish or disengaged emotionally, I will often mention that it is possible that the child is on a sedative. We have no long-term studies to answer these concerns scientifically.

Syphilis
      The diagnosis of "exposure to syphilis" or "Lues disease" is very common on Russian medical reports. Probably at least 20% of my pre-adoption reviews include this diagnosis. Of the Eastern European children who I have evaluated in my office, I have had one child from Ukraine with active, acute syphilis just this past year. I have encountered dozens of children with positive FTA-ABS antibodies which is consistent with possible exposure to syphilis which has been treated or is consistent with persistent transplacental antibody. When a mother has syphilis, her body produces proteins in the blood to combat the bacterial infection. These proteins are called antibodies and the baby can then get those antibodies through the placenta during pregnancy. The antibodies are therefore the mother's antibodies, not the baby's. That is what we mean by transplacental antibody. The Russian medical system has done an excellent job in the management of syphilis in newborn infants. They cannot differentiate exposure from actual infection and they treat all children. Children, who are exposed to mothers with even past syphilis, which has already been treated, are given 14-28 days of daily intramuscular injections of penicillin. This is more than adequate therapy for congenital syphilis. It is imperative that parents seek confirmation that the child has been treated with penicillin. I think that syphilis is not an alarming diagnosis on a Russian medical, but it is important to follow-up the child once he/she is adopted. Syphilis serology, including an RPR and an FTA-ABS, an eye exam, and a hearing test are advisable for any child with a history of possible congenital syphilis.

Transfusions
      Transfusions are truly alarming on a medical report. This could mean exposure to Hepatitis B, C, or HIV. I have not personally evaluated any children with HIV infection who have been adopted from abroad, but there have been a few children adopted from Cambodia who were diagnosed with HIV infection. In the past few years there have been a few newly adopted children from China who had positive ELISA tests for HIV, but all of the children had negative PCR tests; this means that their mothers were infected, but they were not infected.

Test Reliability Abroad
      I have a number of children in my practice with Hepatitis B and C infection. In a study published in Pediatrics September 2001, looking at over 500 internationally adopted children who I evaluated in my practice, it was found that 2.6% of children adopted from Russia were carriers of Hepatitis B. Hepatitis C was rare in this population. The children were negative for Hepatitis B and C in Russia and found to be positive after they arrived in the U.S. The lengthy incubation period of up to six months could account for a negative test in Russia and then a positive test upon arrival in the U.S. It must also be understood that the quality of laboratory testing in Russia is not governed by the usual checks and balances that exist in laboratories in the U.S. Some medical abstracts may include lab tests for Hepatitis B and C that are positive and then when retesting is done in Russia, the tests are found to be negative. It would be difficult to rely on these new findings as definitive. All blood tests performed abroad should be repeated when the child is evaluated by their pediatrician in the U.S.

Hepatitis B Infection
      Hepatitis B is a viral infection which affects the liver. If the person contracts the infection, it usually resolves within a few weeks and there are no further medical problems. If the person becomes a carrier of the virus, the liver can be chronically inflamed. Cirrhosis and possibly cancer of the liver can develop decades into the future. Natural history studies of chronic HBV among children are just beginning to appear in the medical literature. The risk of developing chronic HBV is correlated highly with the age of initial infection. Approximately 90 per cent of those infected prior to 1 year of age develop chronic HBV infection, whereas the rate decreases to approximately 40 per cent between 1 and 10 years of age and is less than 10 percent among adults. Hepatitis B can be transmitted from a mother to the newborn infant at the time of birth if the mother is infected and carries the Hepatitis B virus. In China, Hepatitis B is quite prevalent and 5 to 15 per cent of all those individuals infected with Hepatitis B can potentially become carriers of the virus lifelong. Children born to mother's who are carriers are then exposed to the virus at the end of the pregnancy and at the time of delivery. Because mother's frequently do not have prenatal care their carriage status is unknown and when the baby is delivered, the baby is not given Hepatitis B immune globulin and vaccine in an effort to prevent the infection in the newborn. Abandoned children would obviously not be candidates for this intervention.This is standard procedure in the United States. Many orphanages now administer Hepatitis B vaccine, but this vaccine is given much too late to prevent infection from mother to infant at the time of birth. The vaccine will however at least decrease the transmission of the virus in the orphanage.
      When children are in an orphanage, they are assessed for Hepatitis B virus with a blood test during the first few months that they arrive in the orphanage. On the medical exam, you may see the phrase "Hepatitis B surface antigen". Usually, you will see the word "negative" or a symbol "-" to indicate that the baby is not infected with Hepatitis B virus. Because the incubation period of Hepatitis B may be as long as six months, these results may not accurately reflect the Hepatitis B surface antigen status of your adopted child. Children can also be exposed to Hepatitis B virus in the orphanage by exposure to blood from staff members or other children who may be carriers of the virus. This is a blood borne infection and is transmitted in household settings by exposure to blood of the individual who is carrying the virus. An orphanage is equivalent to a household. This virus is not transmitted casually by sharing food or utensils from time to time. I recommend Hepatitis B vaccination for all household members when a family member is a Hepatitis B carrier. If your family consists of other children, they have probably been immunized as infants because Hepatitis B vaccine is required for school entry. Parents traveling to adopt a child abroad should be vaccinated before traveling. The vaccine is a three vaccine series which can be completed within six months. If you have two vaccines before you travel, this will probably afford some protection.
      When the child arrives from abroad, we recommend testing for Hepatitis B which includes Hepatitis B surface antibody, Hepatitis B core antibody, and Hepatitis B surface antigen. If the antigen is positive, then we recommend further evaluation which may include Hepatitis B e antigen and e antibody.
      The prevalence of Hepatitis B carriage is 3.3% in China and 2.6% in Russia. All of the children are healthy and most have not required any treatment at this time. A few children have had elevated liver enzymes indicating some inflammation of the liver which has necessitated treatment with interferon. Interferon is a medicine which is injected. There are many new treatments being studied currently and lots of intensive research is being devoted to the treatment of children and adults with chronic Hepatitis B infection. The future looks good for anyone with chronic Hepatitis B infection.

Hepatitis C Infection
      Hepatitis C, formerly non-A, non-B hepatitis, is fast becoming a worldwide problem. The prevalence of Hepatitis C in the U.S. is probably as high as 2%. Hepatitis C infection is the most common cause for liver transplant in the U.S. Transmission of Hepatitis C (HCV) infection is through injection drug use and transfusion of blood. In the United States, the major mode of transmission of HCV is via injecting-drug use. [Alter 1997; CDC 1998] Perinatal transmission is 5%-7% although it can be higher (40%) for children born to women who are co-infected with HIV.
      The transmission of HCV infection through breast milk has not been documented. Household contact transmission is very uncommon. The risk factors for HCV infection in internationally adopted children are most likely transfusion, exposure to unsterile needles, and possibly perinatal transmission. Children who are born prematurely may be transfused and there may be no record of this on the medical abstracts that are translated for agencies and families. Out of almost 1800 children evaluated by me during 10 years doing adoption medicine, there are two children who are infected with HCV and at this time they are both school aged and well-appearing with no signs of chronic active hepatitis. Two children under one year of age who recently arrived from abroad were initially antibody positive, have turned out to not be infected and most likely are antibody negative. This cannot be determined until after the child is at least a year of age. The maternal antibody can persist that long.
      These four children are from Eastern Europe and the former Soviet Union. Other adoption medical clinics have also reported cases of HCV. Two children of 129 children assessed in an adoption clinic in Boston between 1989 and 1993 [Miller et al. 1995] were found to have active HCV infection.
      There was a cluster of 5 cases of HCV in children adopted from China in 1995 from an orphanage in Yangzhou, China in Jiangsu province and two children adopted from China were found to be infected with HCV in a large New York City practice where well over 400 children adopted from china have been evaluated over past 5 years. [Traister & Aronson 1998].
      The international adoption medicine group has agreed to continue to screen all children to better understand the risk factors for HCV in children adopted from abroad. The complications of HCV are similar to Hepatitis B Virus (HBV): cirrhosis and liver cancer. At this point in time until we establish the epidemiology in children adopted from abroad it is the consensus of adoption medicine specialists that we screen for hepatitis C antibody using a standard enzyme immunoassay (EIA) during the initial routine medical evaluation when a child first arrives in the United States. Hepatitis C antibody (Enzyme immunoassay/EIA), recombinant immunoblot (RIBA), and the polymerase chain reaction for ribonucleic acid (PCR RNA) are tests used to make the diagnosis of HCV. [Gretch 1997] There are treatment regimens available (interferon in combination with ribavirin) is quite effective. [Camma et al. 1996; Carithers & Emerson 1997; National Institutes of Health Consensus Development Conference Panel Statement 1997; Schalm et al. 1996; Schvarcz et al. 1995;] It might be advisable to repeat the Hepatitis C antibody test six months after arrival in case of exposure to the virus just before leaving the orphanage because there can be an incubation period as long as six months, although typically the incubation period is 2 weeks to 3 months.

Pre-Adoption Reviews from Other Countries
      Guatemala
      The amount of information on babies adopted from Guatemala varies widely. There may be some social history, but for the most part the story of a child's life begins with the birth and there are usually measurements (height, weight, and head circumference) which are included with the birth certificate and tests for HIV, syphilis and Hepatitis B. The tests may have been done on the mother, the baby, or both. Over the last few years I have begun to advise families to include Hepatitis C in their requests for other tests on the baby. I also now mail a New York State newborn screen to families and they bring it to the doctor who examines the baby in Guatemala on regular basis until the finalization of the adoption in Guatemala City. This blotter paper includes HIV, sickle cell screening, hypothyroidism and other enzymes deficiency diseases. All children born in the U.S. are assessed in nurseries in hospitals at birth for these diseases, but this is not the case in Guatemala. I then send the blotter paper to the Albany lab and the results are available to parents within a few weeks. I have good collaboration with the physicians in Guatemala for this process.
      I also coach parents to visit their new baby in Guatemala before the final adoption process. After the DNA homology test is cleared, the baby is officially assigned to the family and I encourage the family to go to Guatemala City to spend a weekend with their baby. It is an opportunity to meet the foster family and to bond with the child. During that time, a video can be made and new photographs can be taken. I review the video and photos when the family returns to the U.S. I also encourage the family to accompany the baby to the pediatrician's office in Guatemala for the well check which is performed usually every month in Guatemala. The newborn screen can be performed at the office visit. The visit can be taped and I can get a lot from that physical exam. I can see the entire baby and I can see the baby measured. The development can also be assessed. Parents get a sense of the social development of the child and feel closer to their baby when they do this pre-adoption visit. There are adoptions from orphanages in Guatemala and the medicals are brief; testing for HIV, Syphilis and Hepatitis B is routine, but there is no opportunity to do much more than this.

      Korea
      The medical abstracts prepared for babies in foster care in South Korea are the most detailed of all the medicals for children adopted from abroad. The children are seen regularly by pediatricians and measurements are quite accurate. Social histories are quite detailed. It is not uncommon for birth mothers to smoke and drink during pregnancy in South Korea and women are quite honest about their lives during the pregnancy. The reliability of the social history prior to birth is reliable. Babies are tested for HIV, syphilis, Hepatitis B and a Guthrie test is done to rule out PKU (phenylketonuria).
      These tests are quite reliable. Medical conditions are identified in children and Korean physicians are quite involved in the diagnosis and management of all medical conditions. For example, if a child has a heart murmur, it is quite common for the child to have a chest x-ray, an EKG, and an echocardiogram. All of this information can be obtained upon request through the adoption agency if it has not been performed. Adoption doctors/pediatricians in the U.S., prepare letters requesting further tests and evaluations and this letter is then faxed to the Korean agency through the American adoption agency. It can take a few weeks for the tests to be performed, but the system is quite collaborative. If a child has been admitted to a hospital for an illness, the discharge summary is made available to parents. If there are developmental issues, a request for further exams by a neurologist can be made. I often request video to be made at the time of that exam. This is quite useful. The Korean adoption process is ideal in my opinion.

      China
      The medicals from China have improved drastically over the past few years. When I started doing adoption medicine 10 years ago, there was one perfunctory paragraph written about the child's social history and a 1 inch by 1 inch photo. Parents blew the photograph up and put it everywhere in the house. Now, the medical includes a detailed account of how the child was found, with a discussion of the child's daily eating and sleeping pattern. A new developmental inventory has been constructed as well. This developmental tool is far from ideal. It appears to be quite generic in fact, but in time it will improve as the process becomes more mature. The medical contains a lot of medical tests including complete blood counts, liver enzymes or TTT (Thymol Turbidity Test), and hepatitis B tests. The Chinese characters for negative and positive are quite distinctive and should be examined and compared to the English translation.
      Every referral from China includes a Chinese version and an English translation. The Chinese medical is followed by the English translation usually within a few days or at most a week.
      The reliability of the blood tests is always a question. Now children are tested for syphilis (TRUST test) and HIV. China Center Adoption Affairs has directed all social welfare institutes (orphanages) to test orphans for HIV, but implementation of this directive will take time so not all children are tested. Also, the reliability of local laboratory HIV testing in China is clearly an issue. Please note that an HIV ELISA test done on a child under 18 months of age does not diagnose the child's infection. The child may be antibody positive for HIV, but in 75% of the cases, the child is not infected.
      Currently, children are measured for their height, weight, and head circumference at the time of the initial medical exam which is usually within a few months of admission to the orphanage. There may be measurements performed on the date of admission to the orphanage. What is particularly useful these days are the updated measurements which are fairly common in this process. Updated photos are also more and more the rule. The photos may actually depict the baby sitting in a chair or in a walker. About 1% of children adopted from China are in foster care and parents are in some cases able to meet the foster family. Videos are rarely used in this process; when they are available, they are for children with special needs i.e. cleft palate/cleft lip. Getting a child who has some medical condition examined by a university physician is difficult in China, but not impossible. The medical care is rather perfunctory in general. If your child is ill during the adoption process, agencies have identified local physicians to help families. I usually recommend using the established western-style medical clinics such as the SOS system which are frequently located in the larger cities in China. There are also university medical centers in some cities in China where physicians have become medical resources for families adopting in China i.e. Hefei Children's Hospital and Anhui University Medical Center. The consulate exam on Shamian Island is not detailed. The White Swan Hotel medical care is sub-optimal and injectable antibiotics such as amikacin are commonly prescribed and ill-advised for children.

      Cambodia and Vietnam
      These medical reports are quite limited. There is a nice social history report for most children adopted from Vietnam, but not from Cambodia. There is an official physical exam from both countries done by a physician from a western-style clinic like the SOS system in Phnom Penh in Cambodia or in other cities in Vietnam or the Family Medical Centers directed by Rafi Kot, M.D. in both Hanoi and Ho Chi Minh City. Measurements are sparse in both countries. The photos are usually sent by e-mail and are quite tiny and because the children have been traditionally adopted at such a young age, the photos are limited in their usefulness. Updates can be obtained, but it is like pulling teeth. Reliability of measurements is certainly an issue. If the child has a disability or medical condition, agencies can arrange for children to be examined at the above clinics.
     Blood testing is done for Hepatitis B, HIV, and syphilis. A lot of the testing is done at the Pasteur Institute in both countries. This is a superb laboratory. If the testing is not done at Pasteur, it is important to know that and to understand the limitations of that testing quality.

      India
      The children adopted from India are often premature and/or low birth weight. There is almost no social history on the medical referral, but there is usually a decent physical exam done by a pediatrician although it is rarely current. There are usually a few sets of measurements and descriptions of the child's eating habits and development are common. Childhood illnesses are reported in detail; vaccines are reported with dates. Updates can be gotten through the written requests, but feedback is slow. Having other tests and blood work done is possible, but takes a lot of persistence.

      Bulgaria
      The children are referred at about one year of age, but the adoption usually doesn't occur for another year. The medical is rather slim in content and resembles a Russian medical. Similar diagnostic terms are found on Bulgarian medical reports. There is usually a birth weight and height or an orphanage admission weight and height, but rarely will you find a head circumference. Getting current measurements takes forever, but eventually happens. Pictures are often poorly composed by facilitators. Video has been discontinued by the government this past year. We hope that it will come back. Parents travel to Bulgaria to see their child and they can make video and bring it home. The children are tested for HIV, syphilis, and Hepatitis B, but you won't see that mentioned in writing. The agency will report this to parents verbally. It is "understood" that if the child is made available for adoption, then the tests are negative. Not something adoption doctors like very much. Some children in orphanages in Bulgaria are involved in "Granny programs" to improve stimulation. Two children are cared for by one volunteer granny a few hours each day, a few days a week. The kids who are in these programs have an easier transition after adoption.

      Hungary
      The referral process has changed a lot in the last year actually. We used to have a paragraph and a photo that required a magnifying glass to be seen. Now we get a one page medical with some limited medical information and growth points. We rarely know where the child is from or any social history. This is usually conveyed to parents verbally. Video is more and more common. Children are in foster care from time to time. Medical referrals will improve a lot over time in this country.

      Romania
      No adoptions are currently going on in Romania officially. The country has been closed for a year and a half, but slowly adoption is opening. Those folks who had filed papers before the closing are first in line. Special needs kids are a priority. The referral medical is very similar to the Russian medical referral. Romanian is easy to read because it looks like Italian and French. The medicals are brief, but usually contain some social history and growth points at birth and current ones as well. It always mentions where the child is located. Feedback from the agency is slow, but does occur. There are doctors in Bucharest to contact for independent exams. Kids are commonly in foster care through foundations. Some of this foster care is a family with the one child, but a lot of it is an apartment with caretakers and 10 babies. Parents should know that tests and other medical interventions are difficult and unreliable.

      Miscellaneous Countries
      Children are adopted from many other countries like Azerbaijan, Belarus, Philippines, Thailand, Brazil, the Republic of Georgia (foster care infants), Sierra Leone, and Ethiopia. Countries close and new countries open. It takes at least a couple of years until the process in new countries is stable and predictable.
      We have come a long way over the years that I have been doing adoption medicine and hopefully with the implementation of The Hague treaty, full disclosure of medical information about children being adopted will be made available.

Risk Assessment
      I do not tell parents whether or not to adopt a child. I put the referral in a risk category: average, mild, moderate, and extreme, depending on the number of medical issues. Average risk is if the child has no medical diagnoses that are of concern. This does not mean that there are no medical issues for this child. It just means that there are no issues that are apparent. It has been demonstrated that children who are living in orphanages have many health issues such as failure to thrive, malnutrition, anemia, parasitosis, exposure to TB, elevated lead levels, hepatitis B carriage, and other issues that may not be apparent in the pre-adoption record. Mild risk is if the child has one medical issue, moderate risk is 2, and extreme risk is 3 or more.

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Dr. Jane Aronson, FAAP
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  This page last updated February 26, 2010 1:43 AM EST