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Our Services :: Post-Adoption Evaluation :: Common Medical Problems

Age Determination in Chinese Orphans
Anemia
Asthma
Dental Health
Development
Eczema and Scabies
Fetal Alcohol Syndrome/Fetal Alcohol Effect
Hearing Screening
Hepatitis B Infection
Hepatitis C Infection
HIV Infection
Hypothyroidism
Iodine Deficiency
Lead Poisoning
Malnutrition, Growth Failure and Rickets
Parasitic and Bacterial Intestinal Infections
Tuberculosis
Vaccines in the Orphanage
Vision Screening
 
 

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 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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Fee Schedule available online.

My office manager will work with you to help you receive the fullest possible reimbursement from your health insurance company, but payment in full is required at the time of service.

iph International Pediatric Health Services, PLLC
Dr. Jane Aronson, FAAP
338 East 30th Street, #1R
New York, NY 10016
P: 212.207.6666
F: 212.207.6665
E: E-mail us

 

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  This page last updated November 13, 2007 11:33 AM EST