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Below you will find discussions of the most common medical problems
found in children adopted from abroad.
It is essential to remember that many of the health issues of children
living in orphanages in developing countries are the health issues
of children in general in those countries. With 1.2 billion people
and 23 million births each year in China, there are obviously limited
financial resources; there are common health issues that children
face daily whether in or out of an orphanage. Malnutrition, rickets,
anemia, lead poisoning, asthma, tuberculosis, hepatitis B, bacterial
and parasitic intestinal infections are common medical problems
for children living in institutions and in developing nations.
Medical problems are obviously compounded in the orphanage because
kids are often abandoned as they begin their lives and orphanages
do not have access to modern medical facilities. When a doctor is
involved in the medical care of an orphan, it is a non-university
trained doctor who attends to the child. It would be uncommon for
a university physician to care for a child from an orphanage. Children
are rarely taken to modern medical centers because of lack of geographic
proximity and economics; it is impossible to spare a child care
worker to take a child a long distance for hospital care; the expense
of hospital care is beyond the means of most institutions. In Russia,
children are often hospitalized for minor illnesses, often over-treated,
and kept for long periods of time often exposing them to other respiratory
and intestinal illnesses from other children in the hospital. Daily
medical care is left to the common sense of experienced childcare
workers who staff orphanages. Many orphanages attempt to create
in-house clinics and are equipped to give intravenous fluids, antibiotics,
and other medications right in the orphanage, but without the supervision
of trained medical clinicians. This is very common in China. Children
survive in spite of the limitations of medical care. Their circumstances
are truly a test of their inherent survival capacity. They are truly
hardy!
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Age Determination in Chinese
Orphans
Chinese children who are abandoned in infancy and childhood may
not have an exact date of birth. If an infant has a belly button
with some remains of the umbilical cord from birth, the child was
probably born within a few weeks of the abandonment. Date of birth
is usually assigned based on the date of arrival in the orphanage.
The Chinese adoption administration and institute staff estimate
the year of the birth according to the child's appearance. Occasionally
the date of birth is written on a note pinned on the child at the
time of abandonment.
To accurately determine the age of a child who may have an inaccurate
date of birth is challenging, but feasible. If the child is less
than one year of age, a difference of weeks or even a few months
is not critical to the long-term development and health of the infant.
Children who are pre-school age or beyond require a more intensive
investigation for the assessment of age for appropriate placement
in school. Placement in the proper class in pre-school and beyond
is important for the success of the child socially and academically.
Assignment of an appropriate age is also essential for the child's
sense of self and identity.
Establishing age involves a team approach involving the parents,
the pediatrician, a radiologist, a dentist, teachers, a lawyer,
and developmental specialists in certain cases. It is essential
to allow a transition period after the adoption of about 12 months
before beginning a formal assessment of age. Children can be somewhat
malnourished when they first arrive in the U.S. and this can account
for failure to thrive physically and developmentally. Malnutrition
is by far the most common cause of growth failure. Chronic illness,
family dysfunction, and institutionalized living are other obvious
causes of growth failure. Catch-up is swift, but it may take up
to a year for a consistent pattern of linear growth and weight gain.
Pediatricians evaluate children developmentally using the Denver
Developmental Screening Test (DDST) which assesses children from
birth to six years of age. The DDST uses personal-social, fine motor-adaptive,
language, and gross motor milestones to establish the developmental
level of an infant or a child. It is probably advisable to do the
DDST with each well-child visit and to allow a child 6 months to
a year to adapt and adjust to her new environment. If the child
has delays on the DDST, then early intervention is usually appropriate.
A more comprehensive evaluation is performed by qualified experts
such as language and speech specialists, physical therapists, and
occupational therapists. Children less than three years of age are
entitled to early intervention services all over the U.S. After
the age of three years each school district provides services. A
"bone age" x-ray 12 months after the adoption is recommended. This
involves an x-ray of the left hand and wrist. The "Radiographic
Atlas of Skeletal Development of the Hand and Wrist" by Greulich
and Pyle is used to determine the approximate age of the child There
is alot of variability even in children who are not malnourished.
Statistical tables which include standard deviations are part of
the bone age assessment and it must be understood that the accuracy
of the test is limited in children less than 4 years of age. Children
can have delayed bone age and it doesn't necessarily mean that this
is their age. Some children who have never lived in an orphanage
and who have been healthy all their lives, may have a delayed bone
age. There are familial /genetic factors which cause the children
in a family to have delayed bone age and delayed puberty. Most children
with delayed bone age catch up later in childhood or adolescence.
They have the potential to grow. It is very important to remember
that people from cultures with a smaller stature do not have delayed
bone age. Their bone age is normal, but they are just smaller.
A set of dental x-rays is also useful (bite wing). It is preferable
to go to a pediatric dentist or at least to a dentist who has a
lot of experience with children and enjoys working with kids. There
is an amazing variability in the numbers of teeth children have
in infancy. Well-nourished children can have no teeth at one year
of age. The average one year old has 4 upper and 4 lower teeth.
Teething usually begins by 5-6 months of age and children teeth
for about 2-2 1/2 years until the 20 primary teeth are all erupted
in the mouth. Nutritional improvement can lead to swift eruption
of her teeth. Dentists are able to consult charts which depict the
appearance of the primary and permanent teeth in the jaw bone at
particular ages. The position of the permanent teeth in the bone
is correlated with age and the disappearance of the root of the
primary teeth is very telling.
Evidence of resorption of the roots of the primary teeth is a particularly
useful way to assess dental age in a young child. Speaking with
the dentist personally is very helpful. Considering the bone age
and the dental age together can give you a better estimate.
Input from teachers is essential. The teacher can pinpoint a child's
age from school performance and social maturity. The team approach
to establishing a child's age also includes a lawyer who then can
present this to family court for actualization. Documentation of
the bone age, dental age, developmental age, and school performance
may result in a legal change of a date of birth.
For more information about age determination in Chinese orphans,
read Age
in Chinese Children in the Medical Resources/Developmental Issues
section of this site, and it's update article, The Conundrum of Age Assignment for Children Adopted from Abroad (2007.10.28), to discern the differences in thinking.
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Anemia
Anemia is widespread in children adopted from abroad. Malnutrition
is the major cause of iron deficiency anemia. It has been documented
in the medical literature of specific countries, like China.25 A
complete blood count (CBC) will uncover anemia. Iron deficiency
anemia can interfere with normal growth and be a cause of developmental
delay and learning problems. With proper nutrition and iron supplementation,
anemia can resolve and medical complications can be minimized.
There are also genetic anemias that are found in children from
specific countries like Vietnam, Cambodia, Thailand, and China.
Children from China can have alpha or beta thalassemia traits genetically.
When there were great waves of immigration of Southeast Asian individuals
during and after the war in Vietnam, physicians gained experience
in the epidemiology, diagnosis, and treatment of anemias indigenous
to this area of the world. This has helped pediatricians enormously
in their understanding of anemia in children adopted from this part
of the world.26 Having a genetic trait for an anemia is generally
not harmful to the individual, but in combination with the same
trait as might occur during reproduction, this can lead to a life
threatening disease in the newborn infant. A CBC and a hemoglobin
electrophoresis test will reveal underlying hemoglobinopathies (anemias
due to abnormal hemoglobin proteins).
For more information about anemia, read Anemia
in the Medical Resources/Dietary Deficiencies and Other Conditions
section of this site.
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Asthma
When a child is adopted from China, it is not uncommon for the
child to have an upper respiratory infection at the time of the
adoption. The orphanages are crowded and infections spread swiftly.
These infections are usually self-limited, but at least 10% of kids
continue to cough and wheeze with each respiratory infection after
adoption. This is called reactive airways disease or asthma. Asthma
is a rapidly increasing medical problem in China today because of
air pollution. Anyone who has traveled to China for business, vacation
or for the adoption of a child will report that their throat hurts
in China and for many weeks after returning home. In the U.S. pollution
has probably been one of the main causes for the increasing incidence
of childhood asthma. There is no evidence that Chinese individuals
have asthma more commonly than persons from other cultures. Without
knowing the family history of a child, it is obviously impossible
to determine the actual cause of the asthma since there is a genetic
role.
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Dental Health
Note that a lot of kids from abroad who have had rickets and malnutrition
may have damage to the primary dentition. Twenty teeth erupt during
the first 2 ½ years of life. Rickets and malnutrition actually can
delay tooth eruption. We commonly see lots of teeth suddenly erupting
with the replenishment of calories and micronutrients during the
early transition after adoption. Existing primary teeth may sustain
enamel damage from bathing in sugar containing feeds in the orphanages
as well as from lack of proper nutrition. Children should be seen
by a general dentist with an interest in children, or a pediatric
dentist, within 6 months of arrival in the U.S. The American Academy
of Pediatrics recommends that children be seen by a dentist by the
age of two years.
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Development
At the April 1999 Joint Council medical institute in Washington,
D.C., Dr. Miller presented her data 28 on the development of 192
children adopted from China The mean age at arrival was 14 months
and 180 children were seen within 3 months of arrival. 74% of children
had at least one area of delay. In a study by Johnson & Traister,
29 136 children examined by a physician for gross and fine motor
skills, tone, strength, language and social abilities, 74% were
abnormal in one or more areas at the time of arrival. About 75%
of the kids evaluated at the International Adoption Medical Consultation
Services in Mineola, New York are referred for early intervention
services within the first few months of their arrival. The vast
majority of the children followed in this practice long-term catch-up
for gross motor, fine motor, and personal-social development within
the first year after adoption. Sustained language delays are more
common. Long-term follow-up data on language delay in children adopted
from abroad is still not available. It is obvious that children
living in orphanages will sustain delays and that these delays will
be less for children who stay for shorter periods of time, but little
is known about long-term outcome. This must be the next step for
research in the next millennium as children mature and become school
age.
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Eczema and Scabies
Another direct consequence of poor nutrition is poor skin condition.
Kids often have rough, red, dry cheeks of the face and the skin
of the rest of the body can peel and have dry, scaly patches. This
is most likely a combination of factors. Kids are rarely bathed.
They are wrapped up in layers of warm clothing all day and the under
layers may be drenched with sweat, urine, and stool. Those insults
rob the skin of its natural oils. Poor nutrition mitigates against
the natural renewal of skin cells. Micronutrient deficiencies such
as zinc deficiency can contribute to poor skin health. Exposure
to food substances that are allergenic can also cause the red, dry,
scaly appearance of a child's skin. This could be eczema. Scabies
can compound the poor condition of the skin. Scabies are microscopic
mites that burrow under the skin and cause rashes and itching about
6-8 weeks after the initial exposure to the mites. It is essential
that pediatricians recognize the many faces of scabies. It is the
great pretender. Empiric treatment with Permethrin 5% cream for
scabies is highly recommended for children with eczema or if there
is any doubt about the diagnosis or if it doesn't get better within
a few weeks after adoption. The whole family needs to be treated
in case of exposure.
For more information about scabies, read Scabies
in the Medical Resources/Infectious Diseases and Parasites section
of this site.
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Alcohol Related Neurodevelopmental
Disorders, Fetal Alcohol Syndrome/Fetal Alcohol Effect
This topic fills chapters and books by Dr. Ann Streissguth 30 and
is far beyond the scope of this survey article on the medical aspects
of international adoption. It is important for the pediatrician
to know that alcohol exposure is common in children adopted from
abroad. Women in Eastern Europe and Russia are not exposed to educational
programs for the prevention of fetal alcohol syndrome. Medical records
rarely reveal that a parent(s) is an alcoholic. Adoption medicine
specialists spend hours reviewing videos and photographs of children
in orphanages in an attempt to recognize the classic features of
fetal alcohol syndrome. It is a difficult diagnosis to make even
with the most experienced and skilled eyes. The classic features
include failure to thrive with a head circumference well-below the
5th%, a long flat philtrum, a thin upper lip, mid-facial hypoplasia,
and smaller than normal palpebral fissures (opening of the eyes).
Children with alcohol related neurodevelopmental disorders may have
ophthalmologic, kidney, cardiac, and skeletal abnormalities. It
is recommended that an adopted child with suspected FAS/FAE should
be seen initially be the following specialists: pediatric cardiology,
pediatric ophthalmology, and a dysmorphologist/geneticist. A renal
sonogram might be useful as well. The vast majority of children
diagnosed with FAS/FAE will have developmental delays, memory and
behavior problems by the time the child is school aged. Diagnosis
is important because there are free services through the social
service system for the family of children with FAS/FAE.
For more information about FAS/FAE, read the articles in the
Medical Resources/Fetal
Alcohol Syndrome section of this site.
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Hearing Screening
All kids coming from abroad should have initial hearing screens
within six months of arrival in the U.S. There is no available medical
history on past ear infections in the orphanage and there may be
a congenital hearing deficit that has not been noticed by the orphanage
staff or doctors. It is very difficult to diagnose subtle hearing
problems in young children and since deafness impairs language acquisition,
hearing evaluations in adopted kids from abroad (audiologic evaluation)
are imperative. The American Academy of Pediatrics has recently
recommended that all newborns be assessed for congenital deafness
in the nursery (policy of uniform newborn hearing screening). Kids
adopted from abroad are at increased risk for language delays and
normal hearing must be demonstrated to provide optimum diagnosis
and treatment of language delays.
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Hepatitis B Infection
Hepatitis B infection has been a stable story over the years. Of
342 children adopted from China from 1/91 to 10/98, 3.5% were hepatitis
B surface antigen positive.20 It is important for prospective parents
to know that these children tested negative for hepatitis B in China.
Their positive test in the U.S. may reflect inaccurate testing in
China, a lengthy incubation period for Hepatitis B infection (6
weeks to 6 months), orphanage exposure from those with acute and/or
chronic hepatitis B infection, blood transfusions, or exposure to
unsterile needles with administration of vaccines or in the drawing
of blood. Children with chronic hepatitis B infection can go many
years without any ill effects. It can be a manageable medical problem.
There is no way to predict when the liver will become inflamed.
Carriers need to have a yearly assessment of their liver enzymes
and they should probably be followed by a children's liver specialist.
Treatment is available for children and adults with active hepatitis
B infection and research is ongoing.21 If a child is diagnosed with
Hepatitis B chronic carriage, other test should be performed including
Hepatitis B e antigen, Hepatitis B e antibody, Hepatitis B DNA,
Hepatitis D antigen, and alpha-feto protein. These tests will be
evaluated by the liver specialist and can help determine whether
there is active liver disease.
For more information about hepatitis B, read Hepatitis
B-C in the Medical Resources/Infectious Diseases and Parasites
section of this site.
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Hepatitis C Infection
All of the adoption doctors across the U.S. are alerted to collecting
their data on Hepatitis C infection in children adopted from abroad.
The incidence is very low in children adopted from abroad. This
kind of hepatitis is associated with blood transfusions, intravenous
drug abuse, and in a very small percentage of cases maternal-to-infant
transmission (5-7%) Two children (2%) of 129 children assessed in
an adoption clinic in Boston between 1989 and 1993 were found to
have active HCV infection.22 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 the past 5 years. 23 The cluster of cases in Yangzhou in Jiangsu
province were children adopted to Canada and according to a parent
who adopted children from Yangzhou in 1995, the children were forced
to have blood tests in Beijing before they left China; all bloods
were drawn with the same needle in the hospital despite protests
from the parents.
For more information about hepatitis B, read Hepatitis
B-C in the Medical Resources/Infectious Diseases and Parasites
section of this site.
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HIV Infection
There have been 6 girls adopted from China between May 1998 and
May 1999 who have tested positive for HIV antibody; none of these
girls have actual HIV infection. When they had polymerase chain
reaction (PCR) tests for actual HIV infection, they were found to
be uninfected. None of these children has HIV infection. They are
currently healthy and thriving. Their mother's were infected and
the antibody from the mother was passed through the placenta from
mother to infant. Only 25% of girls born to infected mothers actually
are infected with the virus. If the mother is treated with AZT during
pregnancy, only about 5% of infants are infected. Unfortunately
this preventive treatment for pregnant women with HIV infection
is not yet available in most developing countries.
Two girls are from Anhui province, and one each is from Guangdong,
Yunnan, and Jiangxi provinces. Drug traffic and prostitution in
Southeast Asia probably accounts for the recent spread of HIV into
China. Based on INS statistics, there have been 15, 351 children
adopted from China between 1988 and 1998. Six children testing positive
for HIV antibody results in an overall incidence of 0.04 percent.
For the years 1998 and 1999, the incidence would be slightly increased
at 0.08 percent. There have been a few cases actual HIV infection
in children adopted from Cambodia and Latin America. It is essential
to note that HIV infection is an evolving story all over the world.
It is clear that no country will be spared. The world is small with
the advent of international business and the spread of drug traffic.
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Hypothyroidism
Congenital hypothyroidism has a worldwide prevalence of one in
four thousand births having nothing to do with iodine deficiency.
Congenital hypothyroidism is caused by the improper development
(dysembryogenesis) or complete absence (agenesis) of the thyroid
gland; it is an embryologic defect which can lead to devastating
brain damage if not diagnosed swiftly in the first few months of
life. The U.S. and most industrialized nations perform newborn screens
to assess for hypothyroidism within 48 hours of birth. Children
adopted from other countries may not be born in hospitals where
newborn screens are available. Children may have newborn screens,
but the results may not appear in the medical records and in most
countries in Eastern Europe and Russia, there is no state reporting
system. Newborn screens in Korea are identical to the ones in the
U.S. There have been isolated reports of hypothyroidism in children
adopted from abroad, but too few to consider as higher than the
worldwide prevalence of one in four thousand. Some of these children
have had nutritional deficits which cause transient hypothyroidism.
Since children who are adopted from orphanages may not have the
benefit of hospital screening programs, it may be prudent to perform
the state newborn screen at the time of the initial medical evaluation;
this usually contains the following metabolic tests: thyroxine,
phenylalanine, galactose transferase, biotinidase, sickle hemoglobin,
leucine, methionine, and HIV-1, HIV-2 ELISA. Separate thyroid function
tests (free T4, total T4, and TSH) for older children may be advisable
because the cutoff values for thyroid hormones may differ by age.
For more information about hypothyroidism, read Iodine
Deficiency in the Medical Resources/Dietary Deficiencies and
Other Conditions section of this site.
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Iodine Deficiency and hypothyroidism
An article in the New York Times on June 4, 1996 reviewed the current
status of iodine deficiency in China. It prompted concerns from
all parents who have adopted children from China and those who were
in the process of their adoption.
Iodine is a trace element found in the soil, air, and sea. It is
an essential component of the thyroid hormones, which in turn are
vital to brain development. The most severe from of iodine deficiency
is cretinism, a rare consequence of fetal/infant hypothyroidism.
Iodine is ingested in food, water, and, most commonly throughout
most of the world today, as iodized salt. Most children adopted
from China are from orphanages located within areas where iodized
salt is part of the diet. Infants in Chinese orphanages usually
receive milk-based formula that has enough iodine to prevent severe
deficiency. Only the inaccessible areas of China, such as inland
rural areas, plateau and mountain regions as well as most of Mongolia
and Tibet, have remained iodine deficient. With virtually no adoptions
taking place from these regions, iodine deficiency is not a significant
problem among Chinese adoptees at this point in time. Obviously,
if adoption patterns change or if feeding patterns change radically,
iodine deficiency can cause hypothyroidism and can potentially become
a threat to the health and growth of children anywhere in the world.
This is an ever evolving and changing nutritional issue.
For more information about iodine deficiency and hypothyroidism,
read Iodine
Deficiency in the Medical Resources/Dietary Deficiencies and
Other Conditions section of this site.
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Lead Poisoning
Scientists and researchers in universities in China have been studying
lead poisoning for the last 25 years.8 Leaded gasoline, coal burning,
smelting, and rapid industrialization especially during the 60s
and 70s during Mao's cultural revolution have all contributed to
a serious health hazard for all Chinese people. Lead poisoning is
found in the urban, suburban, and rural regions of China.9 A published
study by Aronson et al.10 of 301 children adopted from China, revealed
that 13% of these children had elevated lead levels. Only one child
was treated (lead level 48) and she remains healthy and neurodevelopmentally
normal. Lead poisoning, if sustained, can cause damage to the central
nervous system. Lead levels in this study diminished to acceptable
levels within a year of follow-up, except for the one child who
was treated who is only slightly above normal most recently. There
have been very few children from other countries with lead poisoning,
but all children should be screened when they arrive initially.
For more information about lead poisoning, read Lead
Poisoning in Children Adopted from Abroad in the Medical Resources/Environmental
Diseases section of this site.
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Malnutrition, Growth Failure,
and Rickets
Children living in orphanages are malnourished, but the severity
of the poor nutrition varies from orphanage to orphanage and from
country to country. It is impossible to generalize about the health
and nutritional status of all children living in orphanages. There
are orphanages with more resources than others and even when an
orphanage has been reported to have better living conditions, that
orphanage can be altered by the economy of the region during different
times of the year and in different years. Most kids living in orphanages
are fed very dilute formula in infancy if they are fed formula at
all. The formula is usually milk-based and resembles standard baby
formula used in the U.S. Rice cereal is often added to thicken the
feeds. Occasionally children will get a steamed egg or a bowl of
rice congi in China. In Russia, kids are fed "kefir" which is yogurt.
Yogurt placed in cheesecloth to sit over night becomes "vrog", a
kind of cottage cheese, which is also fed to infants and toddlers.
It is low in calcium and has no vitamin D. On holidays, bananas
and oranges are sometimes available for children in Chinese orphanages.
Feeds are fast and furious and bottles are propped. Children get
used to a speedy avalanche of fluid without much nutritional value
which can lead to difficulties with coordinating swallowing and
the handling of different textures of foods during the transition
after adoption (oral aversion and oromotor dysfunction). The poor
quality of nutrition and lack of exposure to sun leads to vitamin
D and calcium deficiency which is called rickets.3,4 This is one
of the top five medical issues in children living in China (malnutrition,
rickets, anemia, lead poisoning, and asthma). It is also common
in Eastern Europe and Russia. The characteristic "Raggedy Ann" or
floppy appearance of many children adopted from abroad can be attributed
to rickets. With proper nutrition, rickets resolves. The muscles
and bones are weak and poorly developed in ricketic kids, but with
replenishment with vitamin D and calcium, the body strengthens.
Rickets can clearly account for a lot of the gross motor delays
that are seen when kids first arrive. Obviously, decreased muscle
tone and delayed gross motor development cannot always be attributed
to rickets, but the first assumption should be that nutrition is
the cause. Proper follow-up with the pediatrician on a regular ongoing
basis will allow exploration of other causes as time goes by. If
the alkaline phosphatase is greater than 500, the child should be
given supplemental vitamin D, x-rays of the knees should be performed,
and consultation with a pediatric endocrinologist should be considered.
Babies and toddlers adopted from abroad may also be quite small
when they are first adopted by families. Greater than 50% of children
living in orphanages are failing to thrive. The body slows its growth
when nutrition is poor in order to conserve energy to meet basic
metabolic needs. The undernutrition described above and lack of
emotional support and stimulation accounts for most failure to thrive/psychosocial
dwarfism that we see in children adopted from abroad in general.5,6
Typically weight catches up before height. Certainly, genetic characteristics
of a particular culture must be kept in mind when evaluating a child
for growth failure or failure to thrive. There are Asian and Latin
American children who are small, but not all children are small
people from these countries.
It is essential that the pediatrician plot the child on a standard
growth chart from the particular country if the child appears to
be small to give the child the benefit of the doubt. If the child's
anthropometric measurements (height, weight, and head circumference)
are found on a standard American growth chart, then the American
growth curve is appropriate. If a child is not on either growth
curve and catch-up growth is not observed within 6 months, this
child needs to be evaluated by the pediatrician more closely for
other more complex underlying medical problems.
For more information about rickets, read Rickets
in the Medical Resources/Dietary Deficiencies & Other Conditions
section of this site.
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Parasitic and Bacterial
Intestinal Infections
Not fun for parents are the parasites commonly found in the stools
of their newly adopted children. Parasites are identifiable and
quite easy to eradicate with medication. Failure to diagnose parasitic
infection can contribute to continued malabsorption and failure
to thrive. Giardia is the most common parasite found in kids adopted
from abroad. Giardia can often be missed in the routine ova and
parasite stool examination because the parasites do not always shed
in every stool. The Giardia antigen test should be ordered for each
specimen to increase sensitivity. At least three specimens should
be obtained. Parents need to be forewarned that "spaghetti-like"
Ascaris roundworms may be seen months after adoption in the diaper
of children from Asia and Latin America. There is a special pharmacy
in Connecticut called Prescription Specialties that now will compound
better tasting metronidazole (Flagyl) for the treatment of Giardia.
The pharmacy is located in Cheshire, Connecticut and the phone number
is: 1-800-861-0933. They will send the medication to the family.
Metronidazole is the drug of choice for chronic Giardia, but it
must be prepared homogenously and tasty for the child to adhere
to the regimen. Adults who have traveled abroad to adopt should
consult their primary care physician if they have symptoms of increased
flatulence, diarrhea, abdominal distention, or any changes in bowel
habits. This infection is transmitted with the changing of a child's
diaper without proper handwashing. Also, it is transmitted by drinking
tap water or eating foods contaminated with untreated water. It
is best to drink bottled water, boil water, and/or drink canned,
sealed beverages. A small group of children from abroad will also
have bacterial intestinal infections; obtaining one bacterial stool
culture is simple, easy, and should be a routine part of the initial
adoption medical evaluation. Treatment is usually quite successful.
For more information about giardia, read Giardiasis
in the Medical Resources/Infectious Diseases and Parasites section
of this site.
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Tuberculosis
The epidemiology of Tuberculosis abroad is well-understood. The
high prevalence countries are Mexico, the Philippines, Vietnam,
Cambodia, India, China, Haiti, South Korea, and the former Soviet
Union.11 Children living in orphanages abroad are the unwitting
victims of this disease. They are exposed to adult caretakers with
active tuberculosis who are living and working in the orphanage
and have no access to medical care. Caretakers in orphanages are
often ill for weeks and months without any medical attention making
the spread of TB easy. Orphans have poor nutrition leading to inevitable
immunosuppression (decreased ability to fight infection) making
them more susceptible to tuberculosis. The incubation period can
be weeks, months, and even years. A child arrives in the U.S. well-appearing
and can begin to have symptoms over time. The symptoms in a newly
adopted children can be very subtle. The child may present to a
pediatrician's office with a fever, cough, weight loss, or with
a gradual change in mood and loss of developmental milestones. There
may be no symptoms at all, in fact, as the disease is just beginning.
There may just be a fever and no other symptoms. Unless the doctor
is aware of the increased risks of tuberculosis in orphanages, the
diagnosis of TB can be easily missed.
It is recommended that a child who is adopted from abroad be tested
with a Mantoux skin test (PPD or purified protein derivative). 12
The skin test is placed on either forearm (under the skin so that
there is at least a tiny blister formed initially that resorbs within
a few minutes) and should be read by a medical professional between
48 and 72 hours. Multiple puncture skin tests are no longer considered
appropriate for TB skin testing because of a high percentage of
false negative and false positive results. A positive PPD means
that the diameter of the (induration) raised skin is greater than
or equal to 10 mm. In an international adoption clinic at the Floating
Hospital in Boston, one hundred and twenty-nine children were medically
evaluated between 1989 and 1993. Four (3 percent) children had positive
Mantoux skin tests. 13 Two hundred ninety-three children adopted
from 15 countries were evaluated between April 1986 and June 1990
at the University of Minnesota adoption clinic and ten (3 percent)
children had positive Mantoux skin tests, and four of these had
active pulmonary tuberculosis.
Two hundred and eighty-six children were tested for TB at the International
Adoption Medical Consultation Services in Mineola, New York between
1994 and 1998 and 50 (17.5 percent) children had positive Mantoux
skin tests with induration (raised skin) of greater than or equal
to 10 mm. All of the children had negative chest films and have
had no signs of active disease. The positive skin test tells us
that the child has probably been exposed to an adult individual
with active tuberculosis. If the skin test is positive (greater
than or equal to 10 mm of induration), then the child should have
a chest x-ray performed. If the child's chest x-ray is negative,
then the child does not have disease, but rather has been exposed
to TB and is not contagious, and will require 9 months of preventive
therapy with isoniazid. In a recent e-mail communication from Dr.
Nancy Hendrie, a pediatrician who travels abroad and evaluates children
for adoption in orphanages in Cambodia, it was revealed that there
were three children adopted from Cambodia recently with active tuberculosis
disease.
Children in all countries, except the U.S. and the Netherlands,
are given a vaccine (Bacille-Calmette-Guerin or BCG) to prevent
tuberculosis. The vaccine has very limited efficacy in the prevention
of TB; some physicians are concerned about the interpretation of
the PPD skin tests for children with a history of BCG vaccine. The
current recommendations for interpretation of the PPD skin test
are found in the Redbook 2000 from the American Academy of Pediatrics.
It is this author's experience that since internationally adopted
children come from countries with a very high prevalence of tuberculosis,
the PPD must be regarded as an essential tool for the diagnosis
of TB in children. There have been a number of studies designed
to assess the effect of BCG vaccine on the PPD test (cross-reaction
to BCG) and it is this author's considered opinion and the consensus
of the adoption medical group, that cross-reaction to BCG plays
a minimal role in the assessment of TB exposure for children adopted
from abroad. A skin test of greater than or equal to 10 mm of induration
is positive regardless of BCG status, and is consistent with TB
exposure; it warrants a chest film and 9 months of preventive therapy
with isoniazid. Vaccination with BCG does not preclude testing for
TB with a PPD.
If the BCG scar appears to be newly healed, a delay of the PPD
skin test until complete healing, is probably prudent. Parents should
be apprised of the subtle symptoms of TB during the waiting period
until a skin test is performed. If there is the slightest suspicion
of TB, a chest x-ray should be performed. There is also the possibility
of anergy (no immune response to a PPD skin test) at the time the
child first arrives in the U.S. due to poor nutritional status;
it is recommended that a PPD be repeated six months after the initial
PPD when the child is better nourished to avoid the possibility
of a falsely negative skin test.
For more information about tuberculosis, read Tuberculosis
in the Medical Resources/Infectious Diseases and Parasites section
of this site.
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Vaccines in the Orphanage
Vaccines administered in orphanages may be expired, improperly
stored, or the malnourished and suppressed immune system may interfere
with response to vaccines, so it is recommended that all vaccines
be repeated in kids adopted from abroad in spite of immunization
records. It is generally not harmful to re-immunize a young child.
The Redbook 2000 published by the American Academy of Pediatrics
has charts to guide pediatricians on how to accelerate the vaccine
schedule for kids who have been incompletely immunized. A study
published from the University of Minnesota adoption clinic in 1998
by Hostetter et al.7 showed that only 35% of kids with records of
vaccines administered, from Eastern Europe, Russia, and China had
antibodies to diphtheria and tetanus, but 65% of those kids did
not! Older children can have a modified vaccine schedule based on
individual titer assessments.
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Vision Screening
Kids from Asia have epicanthal folds (flat skin fold in the corner
of each eye), and it is often difficult to distinguish the fold
from a lazy eye. An eye can appear to be moving inside, but actually
the fold covers the eye. This is called pseudo-lazy eye or pseudostrabismus.
Pediatricians need to be aware of this; pediatricians should ask
parents to be aware of times when the eye(s) appear to go in or
out and discuss this with the next interval visit. A pediatric ophthalmologic
consultation is advisable. There is no increased incidence of lazy
eye in Chinese kids, but anecdotally, Russian and Eastern European
children have a high incidence of true strabismus. Again, resultant
amblyopia secondary to untreated strabismus in older adopted children
will interfere with learning.
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