Post on 23-Dec-2015
Medical Evaluation of the Medical Evaluation of the Internationally Adopted ChildInternationally Adopted Child
Dr. Jane Aronson
International Pediatric Health Services, PLLC
Clinical Assistant Professor of Pediatrics
Weill Medical College
International Adoption StatisticsInternational Adoption Statistics
1989-2007 265,973 adoptions from abroad (top 20 countries)
http://travel.state.gov/family/adoption/stats/stats_451.html
Adoptions in 2007 (18,748)Adoptions in 2007 (18,748)
China 5453Guatemala 4728Russia 2207Ethiopia 1255S. Korea 939Vietnam 828Ukraine 606
Adoptions in 2007Adoptions in 2007
Kazakhstan 540India 416Liberia 314Colombia 310Philippines 265Haiti 190Taiwan 184
Adoptions in 2007Adoptions in 2007
Mexico 89Poland 84Thailand 67Kyrgystan 61Brazil 55Uganda 54
Adoption Statistics 2006Adoption Statistics 2006
6,493 China 4,135 Guatemala 3,706 Russia 1,376 South Korea 732 Ethiopia 587 Kazakhstan 460 Ukraine Total 20,679
Adoption Statistics in 2005Adoption 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
Adoption Statistics for 2004Adoption Statistics for 2004
China 7,044 Russia 5,865 Guatemala 3,264 S. Korea 1,716 Kazakhstan 826 Ukraine 723 India 406 Haiti 356
Adoption Statistics 2004Adoption Statistics 2004
Ethiopia 289Colombia 287Belarus 202Philippines 196Bulgaria 110Poland 102Mexico 89
Adoption Statistics 2004Adoption Statistics 2004
Liberia 86Nepal 73Nigeria 71Thailand, Brazil 69Romania 57Total 22,884
Adoptions in 2003Adoptions in 2003
China(Mainland) 6,859Russia 5,209Guatemala 2,328S. Korea 1,790Kazakhstan 825Ukraine 702India 472
Adoptions in 2003Adoptions in 2003
Vietnam 382Colombia 272Bulgaria 198Haiti 250Philippines 214Romania 200Belarus 191
Adoptions in 2003Adoptions in 2003
Ethiopia 135Cambodia 124Poland 97Thailand 72Azerbaijan 62Mexico 61Total 21,616
INS Statistics for 2002INS 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
INS Statistics for 2002INS Statistics for 2002
Vietnam 766India 466Colombia 334Bulgaria 260Cambodia 254Philippines 221Haiti 187
INS Statistics for 2002INS Statistics for 2002
Belarus 169Romania 168Ethiopia 105Poland 101Thailand 67Peru 65Mexico 61
U.S. State Department Data for U.S. State Department Data for International Adoptions in 2001International 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
U.S. State Department Data for U.S. State Department Data for International Adoptions in 2000International 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 724Based on immigrant visas issued
U.S. State Department Data for U.S. State Department Data for International Adoptions in 1999International Adoptions in 1999
Total Intercountry adoptions 16,369Russia 4,348China 4,101S. Korea 2,008Guatemala 1,002Romania 895Vietnam 712
Primary Receiving States for Primary Receiving States for Intercountry Adoptions Intercountry Adoptions
New YorkMinnesotaCaliforniaIllinoisPennsylvaniaNew Jersey
National Adoption Information Clearinghousehttp://naic.acf.hhs.gov/
Trends in Intercountry Adoption Trends in Intercountry Adoption 1989 thru 19991989 thru 1999
1989 8,102
1999 16,363 Doubled in 11 yrs.
China and Russia Neck and NeckChina and Russia Neck and Neck
China 67,727 since 1991
Russia 54,821 since 1992
As of end of 2007
Pre-adoption IssuesPre-adoption Issues
Choosing a CountryVaccines 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/
Web Sites for Travel HealthWeb 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/malariadrugs2.htm
The High Altitude Medicine Guide
http://www.high-altitude-medicine.com
Vaccines for TravelVaccines 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 AfterCheck Titers for M, M, R,V, diphtheria,
tetanus, polio and give appropriate boosterswww.orphandoctor.com/
Medical Abstract ReviewsMedical 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
DefectologyDefectology
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
Fetal Alcohol SyndromeFetal 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 FASAlcohol Spectrum Disorder new term
Preparation for Travel AbroadPreparation 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
Medical Evaluation on ArrivalMedical 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
Developmental AssessmentDevelopmental Assessment
Look at the child’s 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
Head circumferenceHead circumference
Aronson Orphan Ranger Program in RussiaStickney 1998 and Holtan 1999-40% of
children living in orphanages in Russia had microcephaly
50% had FTT
Head Growth after AdoptionHead Growth after Adoption
Catch-up head growth was documented in 85% of Eastern European orphans (n=34) 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 < 0.01 paired t test (Aronson & Johnson, unpublished data 1997)
Growth FailureGrowth 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
Sensory Integration DysfunctionSensory Integration DysfunctionA. Jean Ayres, Ph.d., OTR 40 years agoA. 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
Sensory Integration Dysfunction Sensory Integration Dysfunction (SID)(SID)
Interoceptive TactileVestibularProprioceptive
Sleep DisturbancesSleep 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?
Feeding BehaviorFeeding 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
AgeAge
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
Attachment is a ProcessAttachment 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
Attachment ConceptsAttachment 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!
Attachment TheoryAttachment Theory
References
Attaching in Adoption
Deborah D. Gray
More References on AttachmentMore 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
Longterm Follow-upLongterm 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
Follow-upFollow-up
Increased incidence of attention deficit
disorder with and without hyperactivity
Increased incidence of learning issues
Adoption of the Older ChildAdoption 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
Laboratory EvaluationsLaboratory 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 < 12 mos. (includes
thyroid, PKU, and HIV tests)
Laboratory EvaluationsLaboratory 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
Medical InvestigationsMedical Investigations
PPD (Mantoux test) on arrival and 3 months later
Hearing evaluation-AudiologyVision screening-Pediatric OphthalmologistDental Care-Pediatric Dentist should see
children by 18 months
Health of Children Adopted From ChinaHealth of Children Adopted From ChinaLaurie C. Miller and Nancy W. HendrieLaurie C. Miller and Nancy W. Hendrie
Pediatrics 2000 Vol.105; e76Pediatrics 2000 Vol.105; e76452 children“Chinese adoptees display a similar pattern
of growth and developmental delays and medical problems as seen in other groups of
internationally adopted children.”
Prevalence of Infectious Diseases Prevalence of Infectious Diseases Among Internationally Adopted Among Internationally Adopted
ChildrenChildrenSaiman, 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. 3608-612
Winthrop-University Hospital Internat’l Winthrop-University Hospital Internat’l Adoption Medical Consultation ServicesAdoption Medical Consultation Services
1997-19981997-1998
504 children Mean Age-1.6 years (range 11 days to 11.7
years)71% female29% male16 countries- China (48%), Russia (31%),
Southeast Asia (8%), Eastern Europe (8%), and Latin America (5%)
Latent TB Infection by CountryLatent 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%) LTBIRussia 40/133 (30%) LTBIOther 14/70 (20%) LTBI
Chronic Hepatitis B InfectionChronic 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
Hepatitis B vaccineHepatitis 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
What can go wrong with What can go wrong with immunizations in orphanages?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
Documentation of Immunizations Documentation of Immunizations among Internationally Adopted among Internationally Adopted
ChildrenChildren Schulte, Maloney, Aronson et al. Pediatrics
February 2002;109(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
Update on Immunization ResearchUpdate 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
Past Immunization DilemmasPast 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!
What to do about Immunizations?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
More on what to doMore on what to do
If there is a schedule, make sure the intervals are appropriate and that the vaccines weren’t 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
Summary on immunizations for Summary on immunizations for children adopted from abroadchildren adopted from abroad
There is more consensus than beforeDo titers or re-immunize or bothNegotiate a plan with parent (s)Consider cost, risks, benefitsWe need more research to establish
consensus and standard of care
Hepatitis C, SyphilisHepatitis C, Syphilis
No child had these diseases in the study 2/1500 (0.13%) Hepatitis C since 1994 2 new HCV positive children < 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
HIV infection in Children Adopted HIV infection in Children Adopted from Abroadfrom 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
HIV Infection HIV Infection
Russia 12 month old girl in 1998Cambodia all 4 negative in countryVietnam 2 negative in countryPanama 1 negative in countryRomania 2 negative in country, 2 known to
be infected before adoption10/12 negative at time of adoption (83%)
HIV infection in Children Adopted HIV infection in Children Adopted from Abroadfrom Abroad
59 Children HIV ELISA positive 12 HIV-infected, 47 non-infected59 children born to mothers with presumed
HIV infection [59/7299 (0.8%)]
HIV ELISA Positive Children Adopted HIV ELISA Positive Children Adopted from Abroadfrom Abroad
Cambodia 20 China 9 Russia 9 India 6 Romania 4 Vietnam 3 Thailand 3
Guatemala 1 Panama 1 Ethiopia 1 Ukraine 1 S. Korea 1
HIV testing in ChildrenHIV 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
Dilemmas in HIV Testing of Dilemmas in HIV Testing of OrphansOrphans
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 don’t have this kind of testing as yet
Changing PoliciesChanging 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.
More on HIV for 2007More 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
Gastrointestinal tract pathogensGastrointestinal 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)
GiardiasisGiardiasis
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
Gastrointestinal tract pathogensGastrointestinal tract pathogens
Campylobacter spp. 5Shigella spp. 3Salmonella spp. 2 Cryptosporidia spp. 4Dientamoeba fragilis 10Ascaris lumbricoides 1Hymenolepis nana 3
Gastrointestinal tract Gastrointestinal tract non-pathogensnon-pathogens
Blastocystis hominis 18Entamoeba coli 7Endolimax nana 4Chilomastix mesnili 1Entamoeba hartmanni 1
Helicobacter pylori InfectionHelicobacter 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
More on H.Pylori InfectionMore 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
Skin problems in OrphansSkin 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!
Don’t forgot about Fungus! Eczema could very well be related to Zinc
deficiency
AnemiaAnemia
We all know iron deficiency anemia Bone up on your “Anemias of Asia”Know Thalassemia and you will decrease
anxiety
Adoption Support Groups Adoption Support Groups
Families with Children from China www.fwcc.org
Families with Children from Vietnam
www.fcvn.orgLatin American Parents Association
www.lapa.com
Adoption Support Groups 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
Adoption Reading ResourcesAdoption Reading Resources
Adoptive Families MagazineAdoption TodayParent and Child magazinesWebsites:
www.rainbowkids.org,www.adoptivefamilies.com, www.aap.org/sections/adoption, http://naic.acf.hhs.gov/, tapestrybooks.com
International Pediatric Health International Pediatric Health Services, PLLCServices, PLLC
151 East 62nd St. NYC Phone 212-207-6666 Fax 212-207-6665 Orphandoctor@aol.com www.orphandoctor.com