medical evaluation of the internationally adopted child dr. jane aronson international pediatric...

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


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


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


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


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


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


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


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


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


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


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 [email protected] www.orphandoctor.com

medical evaluation of the internationally adopted child dr. jane aronson international pediatric...

Documents

kazakhstan819 slide

international adoptions

romania895 vietnam712

romania782 vietnam737

total intercountry adoptions

ins statistics

process of adoption

preadoption issues