Medical Evaluation of the Internationally Adopted Child

1
Medical Evaluation of the Internationally Adopted
Child

• Dr. Jane Aronson
• International Pediatric Health Services, PLLC
• Clinical Assistant Professor of Pediatrics
• Weill Medical College

2
International Adoption Statistics

• 1989-2007 265,973 adoptions from abroad (top 20
  countries)
• http//travel.state.gov/family/adoption/stats/stat
  s_451.html

3
Adoptions in 2007 (18,748)

• China 5453
• Guatemala 4728
• Russia 2207
• Ethiopia 1255
• S. Korea 939
• Vietnam 828
• Ukraine 606

4
Adoptions in 2007

• Kazakhstan 540
• India 416
• Liberia 314
• Colombia 310
• Philippines 265
• Haiti 190
• Taiwan 184

5
Adoptions in 2007

• Mexico 89
• Poland 84
• Thailand 67
• Kyrgystan 61
• Brazil 55
• Uganda 54

6
Adoption Statistics 2006

• 6,493 China
• 4,135 Guatemala
• 3,706 Russia
• 1,376 South Korea
• 732 Ethiopia
• 587 Kazakhstan
• 460 Ukraine
• Total 20,679

7
Adoption Statistics in 2005

• 7,906 China
• 4,639 Russia
• 3,783 Guatemala
• 1,630 South Korea
• 821 Ukraine
• 755 Kazakhstan
• 441 Ethiopia
• Total 22,728

8
Adoption Statistics for 2004

• China 7,044
• Russia 5,865
• Guatemala 3,264
• S. Korea 1,716
• Kazakhstan 826
• Ukraine 723
• India 406
• Haiti 356

9
Adoption Statistics 2004

• Ethiopia 289
• Colombia 287
• Belarus 202
• Philippines 196
• Bulgaria 110
• Poland 102
• Mexico 89

10
Adoption Statistics 2004

• Liberia 86
• Nepal 73
• Nigeria 71
• Thailand, Brazil 69
• Romania 57
• Total 22,884

11
Adoptions in 2003

• China(Mainland) 6,859
• Russia 5,209
• Guatemala 2,328
• S. Korea 1,790
• Kazakhstan 825
• Ukraine 702
• India 472

12
Adoptions in 2003

• Vietnam 382
• Colombia 272
• Bulgaria 198
• Haiti 250
• Philippines 214
• Romania 200
• Belarus 191

13
Adoptions in 2003

• Ethiopia 135
• Cambodia 124
• Poland 97
• Thailand 72
• Azerbaijan 62
• Mexico 61
• Total 21,616

14
INS Statistics for 2002

• Top Twenty Source countries for International
  Adoptions for Year 2002 Total 20,099
• China 5,053
• Russia 4,939
• Guatemala 2,219
• S. Korea 1,779
• Ukraine 1,106
• Kazakhstan 819

15
INS Statistics for 2002

• Vietnam 766
• India 466
• Colombia 334
• Bulgaria 260
• Cambodia 254
• Philippines 221
• Haiti 187

16
INS Statistics for 2002

• Belarus 169
• Romania 168
• Ethiopia 105
• Poland 101
• Thailand 67
• Peru 65
• Mexico 61

17
U.S. State Department Data for International
Adoptions in 2001

• Total intercountry adoptions 19, 237
• China 4,681
• Russia 4,279
• S. Korea 1,870
• Guatemala 1,609
• Ukraine 1,246
• Romania 782
• Vietnam 737

18
U.S. State Department Data for International
Adoptions in 2000

• Total Intercountry adoptions 18, 441
• China 5,053
• Russia 4,269
• S.Korea 1,794
• Guatemala 1,518
• Romania 1,122
• Vietnam 724
• Based on immigrant visas issued

19
U.S. State Department Data for International
Adoptions in 1999

• Total Intercountry adoptions 16,369
• Russia 4,348
• China 4,101
• S. Korea 2,008
• Guatemala 1,002
• Romania 895
• Vietnam 712

20
Primary Receiving States for Intercountry
Adoptions

• New York
• Minnesota
• California
• Illinois
• Pennsylvania
• New Jersey
• National Adoption Information Clearinghouse
• http//naic.acf.hhs.gov/

21
Trends in Intercountry Adoption 1989 thru 1999

• 1989 8,102
• 1999 16,363 Doubled in 11 yrs.

22
China and Russia Neck and Neck

• China 67,727
• since 1991
• Russia 54,821
• since 1992
• As of end of 2007

23
Pre-adoption Issues

• Choosing a Country
• Vaccines for travel-start at the beginning of the
  process of adoption!
• CDC http//www.cdc.gov/travel/
• 1-877-FYI-TRIP
• WHO http//www.who.int/ith/

24
Web Sites for Travel Health

• CDC http//www.cdc.gov/travel
• WHO http//www.who.int/ith
• IMAT http//www.iamat.org
• Int Society for Travel Medicine
• http//www.istm.org
• Amer Society for Trop Med and Hygiene
• http//www.astmh.org
• US Dept. of State http//www.state.gov/travel
• Travax http//www.shoreland.com
• CDC Malaria Section http//www.cdc.gov/travel/mala
  riadrugs2.htm
• The High Altitude Medicine Guide
• http//www.high-altitude-medicine.com

25
Vaccines for Travel

• Parents and children traveling abroad need advice
  to keep well and happy!
• Hepatitis A, B, updated dT, IPV?,
  Influenza,Typhoid, Meningococcal
• Rule of 1957 Before and After
• Check Titers for M, M, R,V, diphtheria, tetanus,
  polio and give appropriate boosters
• www.orphandoctor.com/

26
Medical Abstract Reviews

• Countries each have a unique style of presenting
  the medical information about the child-there is
  a standard!
• Russia and Defectology
• Russia and the search for FAS-video, photo
• China-Hep B tests, Syphilis, and HIV, growth
  points, social history, developmental report
• Guatemala-copies of the actual blood work,
  frequent exams, new photos and a weekend with
  your child before adoption

27
Defectology

• Russian philosophy, religion, science
• Perinatal Encephalopathy, Pyramidal
  insufficiency, Spastic tetraparesis,
  Hypertensive-hydrocephalic syndrome, Neuroreflex
  excitability syndrome, Seizure readiness,
  hypotrophy, hip dysplasia, convergent squint,
  dystonia, myotonia, exudative diathesis, open
  foramen ovale, oligophrenia, dysbacteriosis

28
Fetal Alcohol Syndrome

• Worldwide incidence 1.9 per 1,000 Abel et al 1987
• Aronson 1998 FAS incidence based on retrospective
  chart review of Russian medical records-1.53 or
  15 per 1,000 (8 times world incidence)
• FAE is not mild FAS
• Alcohol Spectrum Disorder new term

29
Preparation for Travel Abroad

• Prescriptions Zithromax, Tobrex, Nystatin,
  Elimite 5
• Discussion of URIs, Otitis Media, Reactive
  Airways, Eczema, Diaper rash,Teething,
  Constipation, Gastroenteritis, Hotel and Airplane
  Behavior, Sleep issues, Feeding, and Adaptation
  behaviors of the newly adopted child
• Travel Clinics Abroad SOS/AEA, IAMAT,AMC,
• IMC, EMC, Worldlink, CanAm in Garden Hotel in
  Guangzhou, China
• Stateside Doc availability for phone consultation

30
Medical Evaluation on Arrival

• Newly adopted child should be seen within a week
  of arrival
• Make allowances for a possible initial sick visit
  with a follow-up consultation later
• Physical Exam with attention to diagnoses known
  from prior medical abstracts from the country of
  origin-heart murmur, dysplasia of the hips
• Pediatric Annals April 2000 Aronson

31
Developmental Assessment

• Look at the childs development and see them in
  6-8 wks to re-evaluate the development, growth,
  and adaptation to the new home
• Early Intervention referrals should be considered
  for children 12-15 months with delays in
  expressive language, children with oral motor
  dysfunction, and sensory sensitivities,
  self-regulation dysfunction, and obvious gross
  motor and fine motor delays that are more than
  expected for an institutionalized child

32
Head circumference

• Aronson Orphan Ranger Program in Russia
• Stickney 1998 and Holtan 1999-40 of children
  living in orphanages in Russia had microcephaly
• 50 had FTT

33
Head Growth after Adoption

• Catch-up head growth was documented in 85 of
  Eastern European orphans (n34) after arrival
• Mean head circumference increased an average of
  0.67 /- 0.82 SD from arrival (-1.07 /- 0.9SD,
  mean age 13.2 /- 5.2 months, range 5.5-32
  months) to follow-up (-0.40 /- 1 SD, mean age 26
  /- 7 months, range 5.5-32 months)
• P lt 0.01 paired t test (Aronson Johnson,
  unpublished data 1997)

34
Growth Failure

• Psychosocial growth failure or psychosocial
  dwarfism is quite common in children adopted from
  abroad
• Work done by Orphan Rangers (Worldwide Orphans
  Foundation) showed that 50 of kids had growth
  below the 5th (Russian orphanages)
• Kids catch up!
• Please remember that kids may have genetic short
  stature and that short kids can have underlying
  chronic disease

35
Sensory Integration DysfunctionA. Jean Ayres,
Ph.d., OTR 40 years ago

• Children are living in an environment that is
  devoid of normal stimulation
• Children may not be wired to handle the sensory
  input of their new world
• Response to light, sound, taste, touch can
  potentially be unusual and distracting
• Occupational Therapy focuses on retraining
  children to handle sensory input comfortably

36
Sensory Integration Dysfunction (SID)

• Interoceptive
• Tactile
• Vestibular
• Proprioceptive

37
Sleep Disturbances

• Jet lag-give it a week at least for the baby and
  maybe two weeks for you
• Sleep issues of children in general are
  complex-make a family plan and re-evaluate the
  plan in a few months
• Cultural biases-co-sleeping and the family bed
• Night terrors-Are they more common in orphans?

38
Feeding Behavior

• Bottle propping
• Speed feeding
• Rickets and malnutrition
• Lack of heterogeneity of food stuff
• Oral motor dysfunction
• Sensory Integration Dysfunction
• Speech and Language Delays
• Self-regulation dysfunction

39
Age

• Dates of birth may not be accurately assigned due
  to abandonment
• Bone age and dental x-rays are inexact, but
  certainly can be of some use in children who are
  adopted at school age
• Developmental assessments over time are much more
  accurate (teachers and parents know the age of a
  child over time)
• Reassigning date of birth may be necessary for
  proper school placement

40
Attachment is a Process

• Children and parents attach over time and for
• children who know little about intimacy and
• social connection, this is a learning process
• with ups, downs, and plateaus
• Attaching requires a sense of self

41
Attachment Concepts

• Reactive Attachment Disorder is not common
• I see more attachment disorder in parents
• than I see in children Dr. Aronson
• Post Adoption Depression exists!

42
Attachment Theory

• References
• Attaching in Adoption
• Deborah D. Gray

43
More References on Attachment

• Daniel J. Siegel, M.D.
• Parenting from the Inside Out
• The Developing Mind How Relationships and the
• Brain interact to shape who we are
• Allan N. Schore
• Affect regulation and the origin of self The
• neurobiology of emotional development

44
Longterm Follow-up

• What do we know about kids who were
• adopted since the early 90s?
• The vast majority of parents are content with
• their adoptions
• University of Minnesota State F/U study ongoing

45
Follow-up

• Increased incidence of attention deficit
• disorder with and without hyperactivity
• Increased incidence of learning issues

46
Adoption of the Older Child

• A growing way to create a family
• A child who has been in the orphanage since
• birth
• A child who has had a family, lost a family,
• and found a new family

47
Laboratory Evaluations

• CBC with diff, plts, rdw
• Hemoglobin electrophoresis-Asia, Latin America
• G-6-P D Asia, Latin America
• Rickets screen-alk phosphatase, ca, phos
• Liver enzymes (AST, ALT)
• Thyroid function tests
• Newborn screen for infants lt 12 mos. (includes
  thyroid, PKU, and HIV tests)

48
Laboratory Evaluations

• Hepatitis B, C serology
• Syphilis serology-RPR, TP
• HIV 1, 2, Western Blot, PCR HIV DNA
• Lead (venous)
• Zinc level for skin rash that is unusual
• Stools O P X3
• Giardia antigen, Cryptosporidium DFA
• Stool C S X1

49
Medical Investigations

• PPD (Mantoux test) on arrival and 3 months later
• Hearing evaluation-Audiology
• Vision screening-Pediatric Ophthalmologist
• Dental Care-Pediatric Dentist should see children
  by 18 months

50
Health of Children Adopted From ChinaLaurie C.
Miller and Nancy W. HendriePediatrics 2000
Vol.105 e76

• 452 children
• Chinese adoptees display a similar pattern of
  growth and developmental delays and medical
  problems as seen in other groups of
• internationally adopted children.

51
Prevalence of Infectious Diseases Among
Internationally Adopted Children

• Saiman, Aronson, Zhou et al. Columbia University,
  Winthrop-University Hospital, International
  Pediatric Health Services, Division of
  Tuberculosis Elimination, Centers for Disease
  Control and Prevention
• Pediatrics September 2001 Vol. 108, no. 3
• 608-612

52
Winthrop-University Hospital Internatl Adoption
Medical Consultation Services1997-1998

• 504 children
• Mean Age-1.6 years (range 11 days to 11.7 years)
• 71 female
• 29 male
• 16 countries- China (48), Russia (31),
  Southeast Asia (8), Eastern Europe (8), and
  Latin America (5)

53
Latent TB Infection by Country

• Tuberculosis exposure-404 children tested with
  Mantoux and read by physician
• 75/404 (18.6) greater than or equal to 10 mm
  with negative chest films (LTBI)
• China 21/201 (10.4) LTBI
• Russia 40/133 (30) LTBI
• Other 14/70 (20) LTBI

54
Chronic Hepatitis B Infection

• 14/499 (2.8) were positive for Hep B surface
  antigen
• 8/240 (3.3) from China Hep BsAg
• 4/154 (2.6) from Russia Hep BsAg
• Chronic HBV has decreased markedly over the
  years since this study was done

55
Hepatitis B vaccine

• 175/499 (35) Hepatitis B surface antibody
  positive
• 96/499 (19) received Hep B vaccine
• 42 of 96 received 3 doses and 29/42 (69)
  seroconverted
• 21 received 2 doses and 14/21 (67) seroconverted
• 32 received 1 dose and 8/32 (25) seroconverted

56
What can go wrong with immunizations in
orphanages?

• No cold chain
• Expiration of products
• Poorly produced products in some countries
• Malnutrition and poor immunogenicity
• Country specific schedules
• Given too young
• Intervals too close
• Poor documentation

57
Documentation of Immunizations among
Internationally Adopted Children

• Schulte, Maloney, Aronson et al. Pediatrics
  February 2002109(2) e22
• 34 had documented immunizations in pre-adoptive
  records
• 66 did not have documentation
• Variability of immunizations up to date at 1 yr
• Polio (77) DTP (59) Hep B (29)
• 5 had records of one or more vaccine doses
  administered before birth

58
Update on Immunization Research

• Evaluating Immunizations in Internationally
  Adopted Children Poster Session November 2003 New
  Orleans
• Rosemarie Roque Gordon and Jane Aronson
• In this study of 113 children, the majority
  with written documentation of 3 Hep B, DTP, and
  polio vaccinations given at acceptable intervals
  had protective antibodies

59
Past Immunization Dilemmas

• Hostetter Johnson Society for Pediatric
  Research May 1998 Overall, despite written
  evidence of age-appropriate immunization, only
  35 of Chinese, Russian, and EE adoptees
  exhibited protective titers to diphtheria and
  tetanus.
• Rapid changes in vaccine coverage abroad!

60
What to do about Immunizations?

• For children under 9 months, I have been
  repeating all vaccines, except for children from
  Guatemala, South Korea, Thailand, India, Colombia
• For children greater than 9 months of age, I draw
  antibody titers and create an individualized
  immunization plan
• Hib, Varivax, Prevnar are easy as they are not
  given in most countries outside the U.S.
• Hib is given in some cases in Central America
  i.e. Guatemala

61
More on what to do

• If there is a schedule, make sure the intervals
  are appropriate and that the vaccines werent
  given too young
• You may end up removing one vaccine in a series
  and salvage others if the titers are adequate
• Measles cannot be accepted if it is given less
  than one year of age

62
Summary on immunizations for children adopted
from abroad

• There is more consensus than before
• Do titers or re-immunize or both
• Negotiate a plan with parent (s)
• Consider cost, risks, benefits
• We need more research to establish consensus and
  standard of care

63
Hepatitis C, Syphilis

• No child had these diseases in the study
• 2/1500 (0.13) Hepatitis C since 1994
• 2 new HCV positive children lt 1 yo
• Both kids lost maternal antibody
• One new child with HCV (E , R) 10/02
• 2/1500 (0.13) Syphilis since 1994
• 10/478 (2.1) FTA positive in study
• As of 10-29-02

64
HIV infection in Children Adopted from Abroad

• 7299 children tested in 17 centers in the U.S.
  since the early 1990s
• 12 children with HIV infection (0.16)
• Russia 1
• Cambodia 4
• Romania 4
• Panama 1
• Vietnam 2

65
HIV Infection

• Russia 12 month old girl in 1998
• Cambodia all 4 negative in country
• Vietnam 2 negative in country
• Panama 1 negative in country
• Romania 2 negative in country, 2 known to be
  infected before adoption
• 10/12 negative at time of adoption (83)

66
HIV infection in Children Adopted from Abroad

• 59 Children HIV ELISA positive
• 12 HIV-infected, 47 non-infected
• 59 children born to mothers with presumed HIV
  infection 59/7299 (0.8)

67
HIV ELISA Positive Children Adopted from Abroad

• Guatemala 1
• Panama 1
• Ethiopia 1
• Ukraine 1
• S. Korea 1

• Cambodia 20
• China 9
• Russia 9
• India 6
• Romania 4
• Vietnam 3
• Thailand 3

68
HIV testing in Children

• HIV ELISA, Western Blot, PCR, P 24 antigen, HIV
  culture
• Children under 18 months may still have maternal
  antibody
• Baby born to mother who is known to be infected
  gets HIV ELISA, WB, PCR at birth
• F/U HIV testing at one month and then between
• 4-6 months of age
• If the PCR test is negative three times, then the
  child is considered to be negative for infection

69
Dilemmas in HIV Testing of Orphans

• What happens to kids in orphanages who test HIV
  positive by ELISA?
• 75 of children under 2 yo. who are ELISA
  positive are not infected
• How to implement PCR testing? Some countries just
  dont have this kind of testing as yet

70
Changing Policies

• China Center Adoption Affairs in Beijing issued a
  new policy in summer 2002 requesting that all
  orphanage directors in China implement HIV
  testing for orphans
• Implementation has been swift and all kids are
  being tested currently
• There have been no children adopted from China
  with HIV infection on arrival in the U.S.

71
More on HIV for 2007

• PCR HIV DNA testing is available in Ethiopia and
  Viet Nam
• Recommendation for two PCR HIV DNA tests for
  children under 2 yo in Ethiopia due to high
  prevalence of 6.4
• Viet Nam is a low prevalence country for HIV i.e.
  0.3 so HIV ELISA is acceptable

72
Gastrointestinal tract pathogens

• Giardia infection was common
• 117 children with one or more pathogens noted
• 87/461 (19) Giardia lamblia antigen detected
• Being born in EE- Russia, Romania, Moldova,
  Bulgaria, and Hungary was a risk factor for the
  acquisition of G. lamblia (intestinalis)

73
Giardiasis

• To not treat a child from an orphanage with
  Giardia because the symptoms are minimal would be
  a mistake
• Failure to Thrive is probably universal in this
  population and Giardia probably plays its part
• Public Health is a major issue-Kids spread this
  to families and friends!
• Treat it with Metronidazole made as a tasty
  benzoate suspension 1-800-861-0933 (Connecticut
  Pharmacy)
• Consider Tinidazole, Albendazole, Quinacrine,
  Paromomycin
• Apthorp, Vitality, Miller, Clayton Edward,
  Cherry

74
Gastrointestinal tract pathogens

• Campylobacter spp. 5
• Shigella spp. 3
• Salmonella spp. 2
• Cryptosporidia spp. 4
• Dientamoeba fragilis 10
• Ascaris lumbricoides 1
• Hymenolepis nana 3

75
Gastrointestinal tract non-pathogens

• Blastocystis hominis 18
• Entamoeba coli 7
• Endolimax nana 4
• Chilomastix mesnili 1
• Entamoeba hartmanni 1

76
Helicobacter pylori Infection

• Is this a real player in children with failure to
  thrive, reflux esophagitis, diarrhea, and other
  non-specific gastrointestinal problems?
• With the new diagnostic stool H. pylori antigen
  test, it will probably be diagnosed more often
  and may very well be found to be a considerable
  cause of poor growth in children from orphanages
• I have increasing numbers of kids with H.pylori
  antigen who do well on treatment

77
More on H.Pylori Infection

• Treatment for symptomatic children is a must
• Zantac every 12 hours for three months
• Metronidazole benzoate 30 mg per kg per day
  divided in 3 doses x 2 weeks
• Biaxin 15 mg per kg per day divided in two doses
  x 2 weeks
• Amoxicillin 50 mg per kg divided in two doses for
  two weeks
• Test of cure at end of treatment with Antigen test

78
Skin problems in Orphans

• Scabies incognito-Treat with Elimite 5 when in
  doubt
• Urticaria pigmentosa (mastocytosis)-I see it too
  often in little ones from Asia
• Acropustulosis of childhood- Is this related to
  Scabies? Dapsone works!
• Dont forgot about Fungus!
• Eczema could very well be related to Zinc
  deficiency

79
Anemia

• We all know iron deficiency anemia
• Bone up on your Anemias of Asia
• Know Thalassemia and you will decrease anxiety

80
Adoption Support Groups

• Families with Children from China www.fwcc.org
• Families with Children from Vietnam
• www.fcvn.org
• Latin American Parents Association
• www.lapa.com

81
Adoption Support Groups

• Families for Russian and Ukrainian Adoption
• www.frua.org
• Eastern European Adoption Coalition, inc.
• www.eeadopt.org
• Adoptive Parents Committee-APC www.adoptiveparents
  .org
• Jewish Child Care Association/Ametz Adoption
  Program www.jccany.org

82
Adoption Reading Resources

• Adoptive Families Magazine
• Adoption Today
• Parent and Child magazines
• Websites www.rainbowkids.org,www.adoptivefamilies
  .com, www.aap.org/sections/adoption,
  http//naic.acf.hhs.gov/, tapestrybooks.com

83
International Pediatric Health Services, PLLC

• 151 East 62nd St. NYC
• Phone [phone]
• Fax [phone]
• Orphandoctor_at_aol.com
• www.orphandoctor.com