(A chapter from Adoption and Prenatal Alcohol and Drug Exposure by Barth, Freundlich and Brodzinsky)
|1. Overview of International Adoption|
|2. Health Status of Children Adopted from Abroad:|
|3. Barriers to Health Assessment and Diagnostic
Dilemmas in Pre-Adoption Referrals for Children Adopted from Abroad
As we come to the end of the twentieth century and begin the new millenium, people all over the world are more connected to one another than in any other time in history. Travel abroad is no longer considered exotic; people vacation in Russia, China, Southeast Asia. American businesses have offices all over the world and joint ventures with other countries are routine. There is a world economy, not just an American economy. What happens in the stock market in Brazil or China has a direct impact on all of us daily. With the exponential growth of personal computer technology that allows us potentially to communicate as if we were intimate friends through the internet, we can no longer hide in our own communities. There is now a world community. Health issues especially as they pertain to the deterioration of the public health of countries abroad due to economic and political changes and environmental pollution in other countries affect us all. Global warming and ever changing weather patterns (El Nino) has certainly brought this issue home. What happens to one country affects all countries. The increasing numbers of children adopted from abroad reflects the concept of a world community. Children in orphanages in countries all over the world are not anonymous anymore. Their plight is an open book and Americans have become leaders in the world's struggle to help abandoned, sometimes homeless children, find families and homes.
When a parent or parents from one country creates a new family by adopting a child from another country, they need to appreciate the specific health issues of the country of origin and the unique medical problems of institutionalized children. Living in an orphanage shapes that child's health and development. This chapter will focus on the very unique health issues of children adopted from abroad and will provide a framework for understanding the impact of these health issues on the potential growth and development of these children.
|Overview of International
In the last 25 years since Roe v. Wade and the legalization of abortion, there have been marked changes in the trends of adoption in the United States. The combination of legalized abortion and easy, available birth control led to the decreased availability of white infants and decreased the numbers of domestically adopted children. [Mansnerus 1998a; Fein 1998a] The highly publicized media reports of a small of number of children adopted and subsequently returned to biologic parents has dramatically pressured Americans to view domestic adoption as risky. The case of 'baby Jessica' frightened many parents away from domestic adoption. [Talbot 1998] (It would be nice to have some original citations from the Times regarding the actual case and court decision; this is only a recent reference to how parents feel about baby Jessica)
The Open Adoption movement, spearheaded by Lee Campbell, a birth mother and the founder of Concerned United Birthparents (CUB) in 1973, although attractive to some families has also shaped how some prospective parents view domestic adoption with caution. [Berry 1991; Brodzinsky & Brodzinsky 1992; Fein 1998b; National Committee for Adoption 1989] The diagnosis of infertility has increased markedly in the last 20 years; the perception of increased infertility is probably due to the explosion and popularization of assisted reproductive technology. [Chandra & Stephen 1998; Te Velde & Cohlen 1999] Access to in vitro fertilization and the new reproductive technology is limited by its expense and lack of health insurance coverage for most families.
International adoption has always been part of the social scheme of life since the beginning of time. When one culture conquered another culture, families were destroyed by the rape and pillage of villages; children who survived were taken in by the conquerors. Many cultures believed that they were strengthened by the assimilation of different cultures through the adoption of abandoned infants and children.
In modern times Americans have adopted children from Vietnam as a result of the Vietnam war. In the early 1950's children were adopted from Korea as a result of the Korean conflict. The Korean conflict and the Vietnam War exposed American soldiers to new cultures and while soldiers lived in those countries, they became part of the lives of the citizens of those countries. They made friends and created new families. Some of the Korean and Vietnamese children who were adopted were Amerasian children and others were children abandoned by the death of parents during the war. The "babylift" [New York Times April 1975] (I don't have the exact reference) from Vietnam in the mid-seventies brought thousands of children to countries all over the world. Within a few years of the end of military occupation in these countries, the numbers of adopted children markedly decreased, but children continued to be adopted as a result of the usual social trends that drive adoption. Lack of access to birth control and legal abortion, poor economic conditions, prostitution, and religious/political/social philosophies control the availability of children for international adoption. In 1999, Koreans still frown upon adoption and consequently, intracountry adoption is rare; single women who have babies are forced to place their children up for adoption due to the absolute disapproval and shame of out-of- wedlock birth. Some women actually have abortions if they find out the fetus is a girl. [WuDunn 1997] Many children are fortunately placed in foster care immediately after birth, rather than being placed in orphanages, and then are adopted by families from other countries.
International adoption has satisfied the yearning of many couples who desire to create families. [Scott 1997a; Mansnerus 1998b] The thousands of miles between Eastern Europe, the Former Soviet Union, Asia, or Latin America and the United States has been appealing to those parents who feel threatened by domestic adoption law. The potential for a child from Eastern Europe and FSU to have a true family resemblance has been a major focus for thousands of American families who would have adopted caucasian American babies if they were available. The revelation that girls in orphanages in China were abandoned due to the "one child family policy" and the preference for male heirs, catapulted many urban socially conscious Americans to adopt girls from orphanages in China. [Johnson 1993; Johnson 1996a; Scott 1997b] According to Kay Johnson, Professor of Asian Studies at Hampshire College and expert in the area of infant abandonment in China, there is a long history of abandonment of infant girls in China that can be traced back to the seventeenth century. There may be as many as one million missing female births each year in China. [Johnson 1996b]
When the reigning dictator of Romania, Nicolae Ceausescu, was assassinated in December 1989, hundreds of thousands of abandoned children living in squalor and degradation in orphanages all over Romania became the focus of outcries from all over the world. [Battiata 1991; Blumenthal 1989; Jamieson 1991; Kifner 1989; Kilton 1990; Nachtwey 1990; Williams 1990] In 1992, 2,552 children were adopted from Romania by Americans and thousands of others were adopted by citizens from many countries around the world. [Immigration and Naturalization Service 1997] Parents beyond reproductive age, single men and women, and gay couples anxious to create a family have all been attracted to international adoption.
International adoption has grown rapidly in the last decade with a 50% increase since 1988. There were 13, 621 children adopted from abroad in 1997 according to the Immigration and Naturalization Service and the U.S. Department of State. There were 9,120 intercountry adoptions in 1988 and 13,621 children adopted from abroad in 1997. There has been a steady increase in adoption from countries in Eastern Europe and Former Soviet Union with a greater than ten-fold increase in adoption from Russia with 314 children adopted in 1992 to 3,816 adopted in 1997. Adoption from China has also grown rapidly in the last five years more than doubling from 1994 to 1995 (809 to 2,098) and in 1997 there were 3,637 children adopted from China.
Russian adoption was under threat of complete closure during 1997 and early 1998 as a result of a number of well- publicized incidents wherein children were reputedly abused by American adoptive families (Thorne, Polreis). [Isachenkov 1997; Onishi 1997; Stanley 1997a; Zolotov 1997] New laws have been recently enacted by the Duma (Russian legislature) and Russian adoption is proceeding. Attitudes about adoption from the Russian viewpoint have also been more public in the past few years. Mrs. Shevardnadze, the wife of Eduard Shevardnadze, president of the republic of Georgia, has been very outspoken about her complete disapproval of international adoption in her country. [Stanley 1997b] No children have left Georgia in almost two years because of her opposition.
Adoption in Guatemala has had its ups and downs as well because of the lack of regulation of adoption attorneys and agencies and the subsequent "buying and selling" of babies. DNA testing is now required in Guatemala to ensure that babies are being legally adopted. Countries have either shut down completely over the past few years because of corruption associated with adoption (Paraguay) or devised rigid restrictions of residency (Peru requires adoptive parents to live in Peru for at least 3 to 4 months prior to the official adoption). Few adoptive families can afford the luxury of residing in another country for lengthy periods of time in order to complete an adoption. Intercountry adoption reflects the complexities of cultural and political differences and children desperately needing families potentially can be the victims of unfair governmental policies.
Although there are slow downs and "moratoriums" in international adoption in particular countries from time to time, there is no reason to believe that international adoption will not continue to grow as a way for Americans and other citizens of the world to create families. The history of international adoption during the past 45 years shows us that as countries close, other countries open. On November 4, 1998 the Chinese National Congress voted to make changes in international adoption law. Director General, Mr. Guo of the China Center for Adoption Affairs (CCAA) announced the lowering of the age of qualification for adoptive parents to 30 years of age from 35 years of age and families wanting to adopt second children from China will no longer be placed in the "special needs" category. This will be a boon for adoption from China.
|Health Status of Children
Adopted from Abroad
The health problems of children living in orphanages are complex and clearly related to the subsistence living conditions in institutions. Children in orphanages are often abandoned by their families as infants, toddlers, or even at school age. The political unrest and economic instability of many countries leads to poverty for families living in both rural and urban environments. Prior to abandonment, children may sustain neglect, physical, emotional, and sexual abuse, and undernutrition when they are living with their parents. Prenatal care is most often non-existent for mothers who eventually abandon their children to the state. During the developmentally vulnerable months of an infant's life, the child can sustain enduring damage to the body, the mind, and the soul while living in an orphanage. The depression [Bakwin 1949] and withdrawal that sometimes results from institutionalization leads to immunosuppression and puts children at risk for many infectious diseases. [Sorensen et al. 1993] Malnutrition can result from poor quality and insufficient quantities of food. Infant formulas are sometimes available, but are mixed in very dilute proportions and lose their nutritional value. Children are often fed foods that can cause allergic reactions when introduced prematurely. Spoon feeding of solids is uncommon due to lack of staffing and children do not learn to appropriately chew and handle foods leading to oral aversiveness. Bottle propping is a common way of feeding infants because there just aren't enough staff to feed babies individually. Propping can lead to interrupted feeds if the bottle falls away from the child's mouth, but it can also lead to choking and aspiration pneumonia if the nipple hole is too large and the bottle is propped too steeply. [Brennemann 1932]
We don't have to look too far from our own history to understand the devastating effects of institutionalization. Children who were poorly nourished and depressed, unstimulated, and living in crowded foundling homes, died early in the first year of life from respiratory and gastrointestinal infections. Sometimes up to 75% of children under one year of age died in these circumstances. [Chapin 1908; Chapin 1915; English 1984; Frank et al 1996a]
The specific medical problems diagnosed in children when they first arrive in the United States is at the core of this discussion. Adoption clinics in the U.S. have now begun to spring up all over the country. The first adoption medical clinic, located at the University of Minnesota Medical Center in Minneapolis, Minnesota was actually founded in 1985 by Dr. Dana E. Johnson and Dr. Margaret K. Hostetter. Within the past two years, the number of adoption medical specialty centers has grown enormously as a result of the increasing numbers of children adopted from abroad. There are clinics from coast to coast. On August 13, 1998, adoption medicine specialists met in Cincinnati, Ohio during the annual North American Council on Adoptable Children conference. There were physicians, social workers, nurse practitioners, and adoption professionals all in one hotel conference room sharing their experiences about the specific medical problems of internationally adopted children.
(The American Academy of Pediatrics Provisional Section on Adoption (PSOAD) was formalized on July 1, 2000. PSOAD can be reached by calling 1-800-433-9016, by fax 1-847-434-8000 and on the web at http://www.aap.org.)
Rickets, lead poisoning, anemia, syphilis, tuberculosis, hepatitis B and C infection, HIV infection, intestinal parasitic infections, scabies, impetigo, malnutrition and failure to thrive, psychosocial short stature, developmental delay, iodine deficiency, hypothyroidism, and incomplete immunizations, are some of the most common medical concerns. [Barnett & Miller 1996; Frank et al. 1996b; Hostetter & Johnson 1996a; Miller et al. 1995a; Mitchell & Jenista 1997a; Mitchell & Jenista 1997b] Some of these medical problems will be further delineated in the next section of this chapter.
Rickets is a disease of the bones and muscles and is due to vitamin D and calcium deficiency. [Barness & Curran 1996] It was first described in the 17th century [Smerdon 1950] and causes delayed growth, weakening and bowing of weight- bearing bones, ineffective tooth enamel formation, and muscle weakness due to low levels of calcium. It is a prevalent health problem in children all over the world, not just for children living in orphanages. [Chen et al. 1992a]Children living in orphanages do not get enough calcium and vitamin D in their diet and they lack exposure to sunlight, decreasing the skin's ability to produce adequate vitamin D. [Aronson 1998a; Jenista 1997a] The muscle weakness (hypotonia) due to the lack of calcium can cause the child to appear floppy. [Torres et al. 1986] When the child arrives in the U.S., the child may appear developmentally delayed as a result of the decreased muscle tone [Aronson 1998b] and weakness of the bones due to rickets. Lack of stimulation and lack of exercise can also contribute to muscle weakness, especially muscles of the abdomen. When a baby lies in the supine position chronically, the abdominal muscles are weak and malnutrition can cause muscle wasting. Positioning on the belly improves this condition swiftly. Improved nutrition with vitamin D and calcium supplemented foods and vitamins, exposure to sunlight, and exercise rapidly improve the child's muscle tone and bone strength. A dentist should be consulted regarding the integrity of the primary teeth to prevent later damage to the secondary dentition.
For more information about rickets, read Rickets in the Medical Resources/Dietray Deficiencies & Other Conditions section of this site.
Lead poisoning (plumbism) has become a serious problem all over the world. Lead-containing gasoline, coal burning, smelting factories, and lead-containing paints are responsible for most of the lead contamination of the air, water, soil, and food. Adopted children in China appear to have the highest risk of lead poisoning of any adoptive group due to coal burning and lead-containing gasoline.[Shen et al. 1996] Between 1994 and 1998, 184 girls adopted from China were evaluated at the International Adoption Medical Consultation Services on Long Island and 11.4% of the girls had elevated lead levels. One child was treated for lead poisoning, but had no apparent ill effects from the elevated lead in her body. [Aronson 1998c] Lead poisoning can interfere with the function of the brain and kidney; [Piomelli 1996] it can affect learning and cause neuro-developmental deficits. [Bellinger et al. 1991; Needleman et al.1979; Schwartz 1994] With time, lead dissipates from the body and as long as there is no additional exposure, children can be well and healthy.
For more information about lead poisoning, read Lead Poisoning in Children Adopted from Abroad in the Medical Resources/Environmental Diseases section of this site.
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. [Chen et al. 1992b] A complete blood count (CBC) will uncover anemia. Forty children (31%) out of a population of 129 who were screened in an adoption clinic in Boston were anemic. [Miller et al. 1995b] We know that 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. 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. [Glader & Look 1996] 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). Another unusual abnormality of red blood cells is a deficiency of an enzyme, glucose-6- phosphate dehydrogenase; this genetic enzyme deficiency can be found in southern Chinese, Southeast Asians, Filippinos, Greeks, Italians, Sephardic Jews, and African Americans and can cause anemia when there are particular exposures to certain medications and infections. [Segel 1996]
For more information about anemia, read Anemia in the Medical Resources/Dietary Deficiencies & Other Conditions section of this site.
Human immunodeficiency virus (HIV) is an evolving issue in international adoption. Drug trafficking has been reported in every corner of the world and with it comes HIV. Sexually transmitted diseases and prostitution are part of the drug culture. Children are born to prostitutes often as there is usually no birth control or abortion available; these children are at high risk for abandonment. The prevalence of HIV in an investigation in two children's hospitals in Phnom Penh in Cambodia was 1-2%. [Richner et al. 1997] Although this is a low prevalence, it is essential that parents be aware of the risks and have their children tested for HIV infection when they return to the U.S. One child adopted from Cambodia in the past couple of years had tested negative for HIV antibody in Cambodia, but when retested in the U.S. was found to be infected with HIV.[Altwies & Aronson 1998] There was no serologic evidence of HIV infection in 56 children adopted from Eastern Europe and the Former Soviet Union who were evaluated in two international clinics from 1991-1995. [Albers et al 1997a]
Until the summer of 1998, no one had seen a child with a positive test for HIV antibody from China. At the meeting of adoption medicine specialists in Cincinnati on August 13, 1998, Dr. Jane Aronson, director of International Adoption Medical Consultation Services, reported that during an eight week period in the summer of 1998, three little girls newly arrived from China had tested positive for HIV antibody. Two of the children were from Anhui province in central eastern China and one was from Guangdong province in southern China. The girls were 12, 16, and 17 months of age. All three girls were immediately evaluated for actual viral infection and they were all negative. Their mothers were infected, but they only carried their mother's antibodies and were not truly infected.
In December 1998 another toddler from Yunnan province in China was found to be HIV antibody positive, but her actual viral test is negative, again confirming maternal transfer of antibody; this mother was HIV-infected! The Chinese government has done its best to minimize the issue of the spread of AIDS in China, but these four children with maternal antibody clearly indicates that HIV exists in China. The sale of blood has probably contributed to the spread of HIV in China as well as drug traffic from Southeast Asia. Drug traffikers in the 'Golden Triangle' of southeast Asia moved into Yunnan province during the 1970s. Illicit drug trade flourished in the 80s and AIDS is spreading; in 1997 8,307 people tested positive for HIV and two-thirds of them were infected by the sharing of needles. [Mo 1998; The New York Times 1998] Parents must test their children when they arrive in the U.S; the HIV-ELISA should be the initial test and if it is positive, then a polymerase chain reaction (PCR) for HIV is performed to detect the actual virus; it is a low risk, but it is essential that children be tested.
According to an article in the New York Times, "Russia stands on the precipice of an AIDS epidemic every bit as explosive as the one that swept through Europe and the United States 15 years ago." According to the Health Ministry in Russia, there were 1,500 new HIV cases reported in 1996. Officials predicted that by the end of 1997 there would be 100,000 infected individuals. [Specter 1997] Drug addiction is so widespread in Russia that it reaches into the smallest cities and towns. People are desperate and depressed. With the fall of communism, hospitals closed and treatment for addiction was no longer available. Sharing needles is the only way people take injection drugs. [Garrett 1997a] Though we do not know the prevalence of HIV in orphanages in Russia, it would be prudent to have all children tested for HIV when they arrive in the U.S.
Hepatitis B (HBV) carriage has always been an issue in international adoption because of the prevalence of Hepatitis B in Asia. Hepatitis B infection in orphans is probably acquired as a result of maternal to infant transmission at the time of birth, but over time children can acquire this infection horizontally from exposure to blood of those carrying the virus in the orphanage (children, staff), from re-used, unsterile needles used for administration of antibiotics and vaccines, and in some circumstances transfusions.
According to the World Health Organization, the carriage rate for Hepatitis B is about 10% in Asia and 1 % in Latin America. [Sobeslavsky 1980; Hostetter & Johnson 1996b] With the aggressive administration of Hepatitis B immunization in Korea, the prevalence has decreased markedly, but this is not the case in China or Southeast Asia where the vaccine is not that readily available. Children adopted from Asia are at the greatest risk for Hepatitis B (5%) . [Hostetter et al. 1991a] Children currently adopted from Eastern Europe and Russia are at lower risk for Hepatitis B infection (2%). [Albers et al. 1997b] At the beginning of this decade, there was an explosion in adoption from Romania due to the fall of Ceausescu. As mentioned earlier in this discussion, 2,552 children were adopted by Americans in 1991 and 5,000 more by other countries abroad. [Johnson et al. 1992a] Transfusions of unscreened blood were used routinely to treat children for malnutrition in Romanian orphanages and as a result many became infected with HIV and Hepatitis B. At the adoption medicine clinic in Minnesota, 65 Romanian children brought to the U.S. during 1990-1991, were evaluated for Hepatitis B. Twenty percent of the children were carriers of Hepatitis B. [Johnson et al. 1992b] In an adoption clinic in Boston eight (6%) children out of 129 screened, had active hepatitis B. [Miller et al. 1995c] A group of pediatricians from the United States traveled to Romania in December 1998 and examined 52 children in an orphanage for severely handicapped children in Videle; 29% of the children were found to be carriers of Hepatitis B infection. [Aronson et al. 1998d]
Hepatitis B carriage or chronic hepatitis B infection can lead to cirrhosis and/or cancer of the liver at some point in time, but we cannot predict when or if this will happen. Dr. Jerri Ann Jenista has written a very complete and understandable article for parents looking at the practical aspects of this medical issue. As Dr. Jenista states, "For most families and children hepatitis B is a long-term commitment to educating oneself and assuring good medical care. Only a few children face drastic intervention. Like high blood pressure or high cholesterol, you manage hepatitis B; don't let it manage you." [Jenista 1997b] There is active and aggressive research in the treatment of chronic hepatitis B infection [Hoofnagle & Di Bisceglie 1997] and the Hepatitis B Foundation, American Liver Foundation, and the CDC are comprehensive resources for information on the diagnosis, management and treatment of this infection. [American Liver Foundation 1999; CDC's Hepatitis website 1999; Hepatitis B Foundation 1999; Immunization Action Coalition 1998-1999] The long term prognosis for children with hepatitis B chronic infection is unknown at this point in time. When a child is initially medically evaluated after adoption Hepatitis B surface antibody, Hepatitis B surface antigen, and Hepatitis B core antibody should all be ordered as part of the screening tests for a child adopted from abroad. [American Academy of Pediatrics 1997a] It is probably prudent to repeat these tests six months after the child arrives because of possible exposure to the virus just before leaving the orphanage and an incubation period as long as six months.
It is essential that all parents considering adoption abroad, understand the possibilities of adopting a child with hepatitis B infection. The tests performed in the country of origin are not reliable or may reflect the lengthy incubation period of this infection. Because in household transmission of hepatitis B is possible, all parents should be vaccinated against Hepatitis B, ideally before completing the adoption. [Aronson 1998e; Christenson 1986; Friede et al. 1988; Vernon et al. 1976]
For more information about hepatitis B, read Hepatitis B-C in the Medical Resources/Infectious Diseases & Parasites section of this site.
Hepatitis C, formerly non-A, non-B hepatitis, is fast becoming a worldwide problem. 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%-6% although it can be higher (14%) for women who are coinfected with HIV. [Ohto 1994] 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 is 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. There is no established epidemiology of HCV for internationally adopted children as yet.
Three children evaluated at the International Adoption Medical Consultation Services at Winthrop-University Hospital have tested positive for HCV infection out of well over 500 children screened in the last three years. All three are from Eastern Europe and FSU. The children are well and healthy at this point in time and are being followed yearly by pediatric liver specialists. Other adoption medical clinics have also reported a few cases of HCV. Two children (2%) of 129 children assessed in an adoption clinic in Boston between 1989 and 1993 [Miller et al. 1995d] 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 the past 5 years.[Traister & Aronson 1998]. 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.[Johnson 1998]
The international adoption medicine group has agreed to establish a data base to better understand the risk factors for HCV in children adopted from abroad. The complications of HCV are similar to 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 U.S. 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 limited numbers of treatment regimens available (alpha-interferon alone or in combination with ribavirin) with limited efficacy. [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;] Newer therapies are under investigation (pegylated interferon, beta interferon, thymosin-alpha 1, n-acetyl cysteine, glutathione, agents to inhibit HCV protease enzyme and helicase, antisense RNA) [Norton 1998]. 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.
When appropriate treatment regimens become available for children with Hepatitis C infection, we can inform those who have tested positive in the future. This is actually the model recently adopted by the Surgeon General of the United States, Dr. David Satcher. Letters will be sent by blood banks and hospitals to those most at risk of having received tainted blood transfusions before 1992 when testing for HCV in blood banks first began. [Groopman 1998]
For more information about hepatitis C, read Hepatitis C in Children in the Medical Resources/ Infectious Diseases & Parasites section of this site.
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. [Report of the Working Group on Tuberculosis Among Foreign-Born Persons 1998] 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 making them more susceptible to tuberculosis. The incubation period can be weeks and even months. 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 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).[American Academy of Pediatrics 1997b] The skin test is placed on either forearm and should be read by a medical professional between 48 and 72 hours. 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.[Miller et al. 1995e] 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. [Hostetter et al. 1991b] 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. 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 6-9 months of preventive therapy with isoniazid. [American Academy of Pediatrics 1997c] 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. [Hendrie 1999]
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. [American Academy of Pediatrics 1997d] 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 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. [CDC 1997; Lifschitz 1965; Nemir 1983; Otten 1997]
For more information about tuberculosis, read Tuberculosis in the Medical Resources/Infectious Diseases & Parasites section of this site.
Syphilis is on the rise in Eastern Europe and the Former Soviet Union. According to statistics provided by the Russian government in 1996, there were ten million people in Russia with some sexually transmitted disease. Russia had 217 cases of syphilis per 100,000 people, a rate that is more than 50 times those in the United States or Europe. In 1990, the figure for Russia was only 6 cases per 100,000. [Specter 1997b] A reference to the possibility of congenital syphilis (lues disease) was found on at least 25 percent of the pre-adoption medical abstracts from Eastern Europe and the Former Soviet Union reviewed at the International Adoption Medical Consultation Services at Winthrop-University Hospital. Congenital syphilis can occur in babies whose mothers contract syphilis during their pregnancy. Syphilis in a newborn infant can be completely asymptomatic or it may have multisystem manifestations including anemia (low hemoglobin), thrombocytopenia (low platelets), hepatosplenomegaly (enlarged liver and spleen), inflammation of the retina of the eye, osteochondritis (long bone inflammation), and abnormalities of the skin and teeth; it can also interfere with normal brain growth and cause severe developmental delays and mental retardation. [American Academy of Pediatrics 1997e]
The physicians in Eastern Europe and the Former Soviet Union cannot distinguish between maternal transfer of antibody from acute infection in the baby and prudently, they tend to treat all babies born to mother's with positive syphilis serology. Women are tested at the time of their arrival in maternity hospitals; if the test is positive, the mother is treated and the infant is treated with a month of daily intramuscular penicillin. This is more than adequate therapy, but treatment failures can occur if the treatment is not completed or the penicillin has expired. When a child's medical abstract from abroad reveals possible exposure to maternal syphilis, efforts should be made to document treatment in the country of origin. The record of treatment can usually be found with a little bit of effort. Exposure to syphilis on a pre-adoption report should not automatically preclude adoption of the child because there is a very low prevalence of actual acute infection. When the child is medically evaluated after adoption, two tests for syphilis should be performed. Any one of the three tests for acute syphilis can be used. A rapid plasma reagin (RPR), Venereal Disease Research Laboratory (VDRL), or automated reagin test (ART) is used to assess acute, active syphilis. The fluorescent treponemal antibody absorption (FTA-ABS) test is the second test that should be performed; it is a more specific test for syphilis and helps confirm the diagnosis. [American Academy of Pediatrics 1997f] Out of more than 500 children screened at the International Adoption Medical Consultation Services at Winthrop-University Hospital, about 8 children have had positive FTA-ABS tests, but none of these children had acute syphilis requiring treatment. On follow-up, most of these children no longer tested positive. One child who was over 4 years old when first tested, was considered to have had syphilis as a newborn and was appropriately treated.
In a study of 56 children adopted from Eastern Europe and the Former Soviet Union in two international adoption clinics, no child had serologic evidence of syphilis.[Albers et al. 1997c] Two (2 percent) children out of one hundred and twenty-nine internationally adopted children screened in Boston had congenital syphilis. [Miller et al. 1995f] In a group of sixty-five children adopted from Romania between 1990 and 1991, one child had congenital syphilis with inflammatory changes in the long bones and retina (eye), enlarged liver and spleen, and microcephaly (head circumference less than 5th%). [Johnson et al. 1992c] For adopted children possibly exposed to syphilis, it would be prudent to have a pediatric ophthalmologic evaluation (eye exam), as well as an audiologic screening (hearing evaluation). Hearing, vision, and brain development can be affected by syphilis infection. Acute syphilis can cause inflammation (osteochondritis) of the long bones (femur, tibia, fibula) and long bone films can be useful in the evaluation of acute congenital syphilis. At this point in time, physicians in Eastern Europe and the Former Soviet Union are very aggressive in treating babies with possible exposure to syphilis and the data accumulated thus far supports low prevalence.
For more information about syphilis, read Syphilis in the Medical Resources/Infectious Diseases & Parasites section of this site.
The public water supply of developing countries is often contaminated by human and animal waste products. Human feces are also used as fertilizer to cultivate crops. Before the twentieth century and even at the turn of this century, people in the U.S. died of typhoid and cholera because there was no understanding of how infection was spread. Once scientists understood that the contamination of the water supply with feces was the cause of epidemics of diarrheal disease, public laws were enacted to protect people from fecal contamination of the water supply. Sewers were installed in towns and cities; water treatment plants spread to every part of our country. Unfortunately, children living in orphanages in Eastern Europe, the former Soviet Union, China, Southeast Asia, India, and Latin America, are exposed to water contaminated with feces everyday of their lives. Water sanitation is expensive to construct and maintain. Some of the most common intestinal parasites that children encounter in orphanages are divided into the following groups [American Academy of Pediatrics 1997 g]: intestinal protozoa- Blastocystis hominis, Cryptosporidium parvum, Dientamoeba fragilis, Entamoeba histolytica, and Giardia lamblia; nematodes (round worms)-Ascaris lumbricoides, Enterobius vermicularis (pin worms), Necator americanus and Ancylostoma duodenale (hookworms), Strongyloides stercoralis,Trichuris trichiura (whipworm); Cestodes (tapeworms)-Hymenolepis nana (dwarf tapeworm). The prevalence of intestinal parasites in children adopted from abroad varied in four different studies from 14 percent to 51 percent. [Albers et al. 1997d; Hostetter et al. 1991b; Johnson et al. 1992d; Miller et al. 1995g]
Chronic or acute infection with intestinal parasites potentially causes malabsorption of whatever limited nutrients are available, exacerbating malnutrition and failure to thrive. Children are often infected with multiple organisms and in household transmission is not uncommon, especially with Giardiasis; Parents and siblings may be infected with parasites when they travel abroad to adopt the child. All of these parasites are easily treated once they are diagnosed. At least three stool specimens should be collected for ova and parasite analysis and giardia antigen and cryptosporidia direct fluorescent antibody tests should be requested as well. "Ping ponging" of giardia is not uncommon in households and sometimes treating the entire family simultaneously may be required. Treatment failures are not uncommon for Giardiasis with the use of furazolidone or because of lack of compliance due to the lack of palatability of the metronidazole tablets which are crushed and flavored in many pharmacies. The International Adoption Medical Consultation Services at Winthrop-University Hospital recommends treating children with metronidazole benzoate which is a more palatable product. It comes in at least twenty flavors. (The dose is calculated slightly differently and these instructions can be obtained directly by calling the Prescriptions Specialty Compounding Pharmacy in Cheshire, Connecticut at 1-800-861-0933 or 203-250-0445).
For more information about giardisas, read Giardiasis in the Medical Resources/Infectious Diseases & Parasites section of this site.
of Children Adopted from Abroad
A small pilot study undertaken at the University of Minnesota International Adoption Clinic recently revealed that only 35 percent of Chinese, Russian, or Eastern European adoptees exhibited protective titers to diphtheria and tetanus despite written evidence of age-appropriate immunizations. [Hostetter & Johnson 1998] Some of the suggested reasons why children appear to be unprotected in spite of documented vaccines are expired vaccine lots, improperly stored vaccines, a poor immunologic response due to malnutrition and the complex effects of institutionalization, and in some cases just inaccurate documentation by untrained orphanage staff.
Anecdotal experience with inadequate antibody titers obtained at the International Adoption Medical Consultation Services at Winthrop-University Hospital supports the conclusions of the Minnesota pilot study. Over the past six years this center has recommended repeating vaccines for very young children adopted from abroad. Repeating vaccines has few untoward effects in young infants and toddlers.
For older children (older than three years) a modified approach might be considered because of the possibility of hyperimmunization syndrome. It is not uncommon for children in Eastern Europe and the Former Soviet Union to have an immunization record with greater than the usual prescribed numbers vaccines. Checking diphtheria, tetanus titers may be useful. This can be discussed in more detail with an infectious diseases consultant or adoption medicine consultant. The Redbook 2000 is also an excellent resource for immunization guidelines for children not immunized completely. [American Academy of Pediatrics 1997h]
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. This issue was addressed in the January 1997 issue of the Families with Children from China newsletter. [Aronson 1997a]
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. Murray Feshbach has reported on iodine deficiency in the Georgian Republic of FSU [Feshbach 1998]. 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, read Iodine Deficiency in the Medical Resources/Dietary Deficiencies & Other Conditions section of this site.
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 swifty 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. Unfortunately, children adopted from China are most often abandoned and do not have the benefit of a newborn screen. Children adopted from other countries may also not be born in hospitals where newborn screens are available. Newborn screens in Korea are almost identical to screens in the U.S. Thyroid screens are sometimes seen on medical abstracts Eastern Europe and the Former Soviet Union, but the reliability of these tests is unknown. There have been isolated reports of hypothyroidism in children adopted abroad, but too few to consider as higher than the worldwide prevalence of one in four thousand. Since children who are adopted from orphanages may not have the benefit of hospital screening programs, it has been the protocol of the International Adoption Medical Consultation Services to perform the New York State Newborn Screen at the time of the initial medical evaluation; this contains the following metabolic tests: thyroxine, phenylalanine, galactose transferase, biotinidase, sickle hemoglobin, leucine, methionine, HIV-1 ELISA. We also perform thyroid function tests for older children because the cutoff values for thyroid hormones may differ by age.
to Thrive, Psychosocial Short Stature, Microcephaly, and Developmental Delay
Many children who are adopted from abroad are failing to thrive and developmentally delayed when they arrive in their new homes. [Miller et al 1995h] In the orphanage children move into a survival mode and cannot grow; they struggle to survive and they literally fall off their growth curves (see growth curve). When this author visited Siret, Romania in November 1997, sixteen children ranging in age from 3 ½ to 17 years were examined. The mean age was 12 years; there were 7 girls and 9 boys. Seven (44 percent) children were microcephalic (head circumference < 5th%); twelve (75%) children had short stature (height < 5th%); ten (62.5 percent) children were failing to thrive (weight < 5th%). [Aronson et al. 1997b] Short stature secondary to deprivation and malnutrition have been well-described in the literature. Recovery occurs with adequate calorie intake in kids under two years of age who are adopted from orphanages. Unusual behaviors are not uncommon in children with psychosocial short stature. These behaviors include pain agnosia, bizarre eating and sleep disorders, self-destructive behaviors like head banging, over friendliness, apathy and depression. [Blizzard & Bulatovic 1996; Money 1977; Money et al. 1983; Powell et al. 1967a; Powell et al. 1967b] There are still many unanswered questions about the pathophysiology of short stature in the context of deprivation, but many children under two years of age can grow and recover; without knowing the parental heights, we can never truly know whether a child has reached his genetic potential.
Ninety-three children from Eastern Europe and Russia were evaluated at the International Adoption Medical Consultation Services at Winthrop-University Hospital between November 1996 and December 1998; thirty-three (35.5%) children had head circumferences below the 5th% (microcephalic) on arrival to the U.S. Thirty-five children's head circumferences were measured at birth and nine (26 percent) children were microcephalic at birth. [Aronson et al. 1998f] These children were probably suffering the effects of maternal malnutrition (poor prenatal care) and intrauterine growth retardation. It could also be from exposure to alcohol or drugs. This is impossible to determine.
Worldwide Orphan's Foundation in New York awarded a research fellowship to Lydia Stickney during the summer of 1998. The student was fluent in Russian and lived in the homes of Russian families in Udmurtia Republic in the Ural mountain and worked in three orphanages in the cities of Izshevsk, Votkinsk, and Glazov. This was arranged through the Ministry of Education in the Udmurtia Republic. She was taught how to weigh and measure the lengths and head circumferences of children at the International Adoption Medical Consultation Services at Winthrop-University Hospital in the Spring of 1998. The range of ages was 4 months to 55.5 months. Sixty out of 147 (41 percent) children had microcephaly (HC < 5th %); 61 out of 153 (40 percent) children had short stature; 40 out of 153 (26 percent) children were failing to thrive. [Aronson et al. 1998g]
We have already referred to the profound undernutrition, intermittent nutrition, bottle propping and inappropriate offerings (potatoes, kefir (yogurt), and milk instead of infant formula) in orphanages abroad. Growth failure is due to malnutrition and emotional deprivation and lack of stimulation. There must be an interplay of both. The timing, duration, and severity of malnutrition are clearly operating in concert to produce growth failure and finally developmental delay. Understanding why some children actually grow in the same environments where other children are failing is truly a mystery. [Galler & Ross 1993a] Growth failure can obviously interfere with normal mental development because the brain is robbed of essential nutrients during very critical periods of growth especially in the first two years of life.
Children are very resilient and have the potential for catch-up growth. Their recovery for weight, height, and even head circumference can be stunning. [Aronson et al. 1999] Thirty-four children adopted from Eastern Europe and Russia were evaluated for catch-up head growth by measuring the head circumference at arrival and at follow-up. The mean age at the time of arrival was 13.2 months and the mean age at the time of follow-up was 26 months. Eighty-five percent of the children increased their z-scores for HC after arrival. What we can't predict is how initial or early microcephaly even with catch-up will affect a child's long-term development. [Winick & Rosso 1969]
It is essential to note that cognitive assessments are much more sensitive than physical growth as a measure of recovery. [Galler & Ross 1993b] For a review of research on malnutrition and developmental delay refer to the following resources.[Agarwal et al. 1989; Chase & Martin 1970; Colombo et al. 1992; Cravioto et al. 1966; Galler & Ross 1993a; Grantham-McGregor et al. 1987; Lien et al. 1977; Miller et al 1995i; Richardson et al. 1978; Stoch & Smyth 1976; Winick et al. 1975]
For more information about developmental delays, read Growth in Children Adopted from Abroad in the Medical Resources/Developmental Issues section of this site.
|Barriers to Health Assessment
and Diagnostic Dilemmas in Pre-Adoption Referrals for Children Adopted from
Thousands of pre-adoption medical abstracts from Russia and Eastern Europe are reviewed by adoption medicine specialists in the United States each year. Many diagnoses found on these medical abstracts are not confirmed when the children are finally evaluated in the U.S. after adoption, but other diagnoses are identified. [Albers et al 1997e] Many of these diagnoses are not well-understood because they do not conform to American medical research and beliefs. [Jenista 1997c; personal communication Downing et al.1998]
Past medical history for children placed in orphanages particularly in Eastern Europe and Russia, can be vague and subject to the cultural biases of the medical practice of the particular country. Although detailed records are kept in some orphanages, they are hand-written and filled with the usual medical abbreviations; the translation of these records is compromised by the lack of staff, non-medical translators, and the exorbitant cost of translation. Dates of birth are sometimes recorded incorrectly simply because the day and month were transposed. Parents can often be presented with updated translations of their child's medical records when they arrive in Russia, that do not quite resemble the initial records that were used in the pre-adoption process. Just before parents embark on their journey abroad a new medical can even be faxed from Russia to the adoption agency to the parents for final review adding intense pressure to this already agonizingly, complex process.
In Russia and Eastern Europe, physicians subscribe to a system based in pathology (disease). All children are considered to be neurologically immature at least for the first few years of life. Terms such as "perinatal or prenatal encephalopathy of hypoxic genesis or mixed genesis", "pyramidal deficiency or insufficiency", "hypertension-hydrocephalic syndrome", "hyperexcitability or neuro-excitability syndrome", "spastic tetraparesis", "muscular dystonia", " myatonic syndrome", and "hypotrophy" are commonly found as "boiler plate/generic diagnoses on the medical abstracts in Russia. Recently the terms enuresis (bedwetting) and encopresis (soiling) were diagnoses found on the medical abstract of a seven month old infant. Infants are by their very nature bedwetting and soiling! These medical diagnoses cannot be used in infancy! It is clear to adoption medicine specialists who review these adoption files in the United States, that these terms cannot help guide us in understanding the true medical status of orphans abroad.
Dr. Marina Melnikova, a family physician, who works at the International Medical Clinic (IMC), a prestigious privately owned and operated ambulatory medical center in Moscow, spent the month of April 1998 doing collaborative research with Dr. Jane Aronson, director of the International Adoption Medical Consultation Services at Winthrop-University Hospital. Dr. Melnikova was a great source of invaluable information about Russian orphanages and medical care of Russian children because IMC does pre-adoption and post-adoption medical evaluations for families adopting from Canada and the U.S. She recently gave birth to a healthy baby boy, Dmitriy, on October 4, 1998 and he was diagnosed with perinatal encephalopathy and neuro-excitability syndrome. His mother understands the medical system of her country and knows that although her child is considered abnormal by Russian medical standards, that Dmitriy is thriving by his last medical evaluation at IMC as performed by the Chief Medical Officer, Dr. Eric Downing.
Medical abstracts from China, Southeast Asia, Russia, Romania, and Latin America vary with regard to the completeness of past medical history and the reliability of anthropometric measurements (height, weight, head circumference). Children adopted from Korea are usually in foster care homes and visits to local pediatric clinics result in excellent pediatric care including reliable immunizations and growth and developmental assessments. When children are born prematurely in Korea, there can be excellent documentation of the hospital course and there is some responsiveness to follow-up requests made from other countries when there have been complications in the medical course of the child's hospitalization. Children adopted from Guatemala and Mexico are commonly in foster care homes and are often also evaluated by competent physicians in the local communities. This is in direct contrast to children living in orphanages in Eastern Europe, Russia, and China who receive either no medical care, intermittent medical care, or care from inadequately trained physicians.
Measurements of children in orphanages are performed by staff members who are not medically trained personnel. Scales are old, in disrepair, and go unbalanced. Children are often weighed with many layers of clothing (China) or weighed in the arms of a well-meaning caretaker. Head circumferences may be measured with string or cloth which over time can stretch or shrink. Where the measuring device is placed around the head may also result in inaccuracies. Head circumferences are often completely ignored as a necessary part of the child's ongoing medical care. Chest circumferences are often mixed up with head circumferences when the records are translated. Metric measurements are sometimes converted into English measurements incorrectly when the records are typed and distributed in the U.S. There is every attempt to perform these measurements accurately, but without proper training the measurements are inevitably inaccurate. In a retrospective chart review performed at the International Adoption Medical Consultation Services at Winthrop-University Hospital, of 93 children adopted from Russia and Eastern Europe, only 35 (37.6 percent) of the medical abstracts had birth head circumferences recorded on the medical report. This is clear evidence of the incompleteness of the records, either because the measurements were never recorded, or more likely, they were missed in the translation of the documents; translators are usually not physicians and they do not appreciate the relevance of a child's measurements.
For more information about medical abstracts, read the Assessment of Child's Medical History in the Our Services section of this site.
|This page last updated November 26, 2007 8:59 PM EST|