Best Practices in Care and Treatment of Internationally Adopted Children


Birth records

Prenatal blood and urine test results of biological mother

Exposure to medications, illegal substances, alcohol or tobacco

Maternal age

Gestational age, birth weight, length and head circumference

Apgar scores

Prenatal concerns, neonatal complications

Newborn hearing screens

Newborn metabolic screens

Family history

Maternal illness or death

Vision or hearing deficits

Genetic diseases

Mental health diagnoses

Concerns related to ethnicity such as sickle cell disease

Previous placement(s)

Institutionalization vs. foster setting—reason for placement; timing, and duration of placement

Number of prior placements

Reason for placement into adoptive home

Parental death, economic instability

Nutritional history

Any periods of malnutrition

Nutritional status of other children in the institution

Previous Growth Points

Weight, length/height and head circumference

Plot on WHO growth charts to reveal somatic growth delays (or, less likely, obesity), microcephaly

Trends more helpful than a single point

Often growth measurements out of date

History of abuse or neglect

In the home setting

In any placement setting, such as an institution

Chronic medical diagnoses
 
Reports from previously consulted specialists
 
Laboratory test results, radiographic studies, other studies

Ultrasound results (especially head or abdomen)

Chest x-ray results

HIV, syphilis, HBV, HCV

CBC

Urinalysis

Testing for tuberculosis exposure/infection
 
Immunizations
 
Environmental risk factors

Lead risks

Developmental milestones
 
Behavioral issues
 


A pre-adoption review gives the pediatrician an opportunity to understand the make-up of the adopting family and their specific preferences about the severity of chronic health problems and disabilities of an adoptive child that would be acceptable to them. Some families specifically request children with special health care needs while other families would prefer a relatively healthy child that would be expected to integrate easily into their adoptive family and require little long-term chronic health care. The pediatrician can then interpret the medical information as it applies to the individual family. The pediatrician attempts to provide the family a problem list that includes known diagnoses and potential problems based upon the history, images and country of origin. Parents should be warned that serious medical issues could be present that medical records, photos and videos cannot capture. It is important for families to know that no definitive diagnoses can be made or confirmed based on the limited information typically provided and that more evaluation will be needed once the child arrives in the new home. Even when specific diagnoses are known such as cleft lip and/or palate, spina bifida or a specific congenital cardiac defect, the prognosis for each child will differ and depend upon a number of different factors including the age of the child, past surgical interventions and/or medical treatments. In cases in which no chronic medical condition is diagnosed, parents must be reminded that there is potential for significant medical and emotional morbidity simply based on the child having spent months to years institutionalized or in a neglectful setting. These problems will often include failure to thrive, feeding problems, developmental delays, behavioral or emotional problems, chronic upper respiratory infections, diarrhea, and skin infections. The older the child and the longer that the child has been in an orphanage, for example, the more likely the child is to have these problems.

Parents should be prepared to expect the anticipated follow-up medical evaluations that will be needed as well as the need for ancillary services that might include physical, occupational and/or speech therapies. Often parents are unaware of the significant time commitment that these services will require particularly in the short term until specific diagnoses and plans of treatment are established.

During the pre-adoption consultation parents can be informed of available community support services for specific pre-adoption diagnoses. Local or regional chapters of national organizations can provide parents with educational information that may facilitate preparation for their child’s homecoming.

The pre-adoption visit is also an opportunity to discuss issues that might arise as the child adjusts to life with the adoptive family. These issues, including transition and attachment are discussed in Chapter 3.

Pre-adoption consultation may not be covered by most insurance carriers, but the pediatrician should advise the adoptive parent to seek info from the parents’ employers about benefits covered through an adoption subsidy plan or flexible spending account. For 2013, the maximum federal adoption credit was $ 12,970; depending on the family’s income. Credits would be taken in the year the adoption is final. Allowable adoption expenses include: court costs, attorney fees, traveling expenses (including amounts spent for meals and lodging while away from home), and other expenses directly related to the legal adoption of an eligible child. For more information please see: http://​www.​irs.​gov/​Individuals/​Adoption-Benefits-FAQs or consult a lawyer or tax expert.



Pre-travel


Most families will travel to the new child’s country of origin to pick up their child. Some countries require additional visits prior to the formal adoption and some others require a prolonged visit at the time of adoption. Adoptive parents may choose to take along other family members such as siblings, or grandparents of the new child. Each traveler should be thoroughly prepared for the trip including visiting a travel clinic for immunization review and updating. Additional recommendations are based on the family’s destination and expected duration of travel and should include a discussion of





  • management of chronic conditions during travel


  • prevention and management of potential travel-related illnesses


  • other supplies that may be needed


  • food and water safety precautions


  • travel safety

The pediatrician can recommend age-specific items to include in their travel kit. The family should be provided with a list of medications and age- or weight-specific dosing recommendations. This list should include basic first aid materials, nonprescription medications for cough, fever and pain. Often antibiotics are prescribed for the family to have on hand in case of respiratory or gastrointestinal infection for the newly adopted child, Topical anti-parasitic medications may also be prescribed in case the child is found to have an infestation with scabies or lice. Clear instructions for the use of all medications as well as indications requiring consultation with a physician should be provided.

It is becoming increasingly clear that even family members who are not traveling to the child’s country of origin but who anticipate close contact with the child within the first 4–6 weeks of the child being home should prepare by ensuring that their immunizations are up-to-date for specific infections that can be transmitted from the adopted child to his close contacts. These recommendations are based on the possibility of transmission to close contacts and upon documented outbreaks that can be traced back to an internationally adopted child and may include hepatitis A, hepatitis B, pertussis and measles. These vaccines should be given as soon as possible to ensure adequate immunity prior to the arrival of the child. The entire family should be educated on the concept of universal precautions against infectious diseases that may help protect them against infections such as intestinal pathogens.


During Travel


The physical demands of international travel combined with the emotionally-charged experience of meeting their new child can be an overwhelming experience for families. Some countries do not present a child for consideration until the family is present in country in which case the child’s medical record must be reviewed quickly. Occasionally, parents are presented with a child who is seriously ill or is markedly different than described in previous reports. First-time parents have additional challenges that include dealing with the normal demands of a toddler in a foreign setting where communication barriers can exist. In each of these situations parents often find it helpful to get advice from a physician familiar with international adoption . Families should be provided with telephone and dedicated e-mail contact information for contacting a physician while traveling.


Post-adoption


Although a medical examination is required from a US government-approved physician in the child’s country of origin before an adoptee can be issued an entry visa for the United Sates, prospective parents should not rely on this examination to detect all possible disabilities or illnesses. This examination is a formality and is limited to screening for serious physical and mental disorders and used to identify infectious diseases in the child, such as TB and syphilis, which would make the child ineligible for a visa because of public health risks. More information regarding the medcial examination for internationally adopted children can be found at http://​travel.​state.​gov/​content/​adoptionsabroad/​en/​us-visa-for-your-child/​medical-examination.​html.

Once home, adopted children need a comprehensive health evaluation to fully identify and address all of their health and developmental needs (Tables 2.2 and 2.3). The American Academy of Pediatrics (Jones 2011) recommends that a comprehensive medical evaluation be completed soon after placement in an adoptive home to


Table 2.2
Initial physical examination



















































Vital signs

Heart rate, respiratory rate, blood pressure, temperature

Oxygen saturation (O2 sat)

Growth parameters

Weight, length/height, head circumference

Plot on World Health Organization growth charts

Compare to pre-adoption growth records

General appearance

Examine face for features suggestive of genetic disorder, syndromes or congenital anomalies including fetal alcohol syndrome

Note degree of responsiveness and interaction with adoptive parents

Skin

Bacille Calmette-Guerin (BCG) scar (most often on left deltoid)

Infectious diseases, rashes (impetigo, etc.) or infestations (scabies, lice, etc.)

Identify and document any congenital skin abnormalities including hemangiomas, nevi, and blue macules of infancy (Mongolian spots) commonly seen in children of Asian, African and Hispanic ethnicity

Signs of abuse (bruises, burns)

Musculoskeletal

Rickets

Scoliosis

Signs of prior fractures

Genital examination

Ambiguous genitalia

Tanner staging

Any abnormality suspicious for prior sexual abuse or genital cutting

Testing for sexually transmitted infections should be performed if any suspicion of abuse or if patient sexually active

Neurologic examination

Developmental and neurologic abnormalities



Table 2.3
Other screening evaluations









































 
Evaluation

Notes

Hearing

Age-appropriate screening

Screen all children, particularly those with risk factors for hearing loss (recurrent otitis media, microcephaly, meningitis, genetic syndromes) as well as developmental (speech) delays

Vision

Eye examination as appropriate for age

Screening for refraction error starting at age 3 years

Funduscopic exam for children with birth weight < 1500 g, and referral to ophthalmologist

Dental

Dental examination for all children > 12 months or older

Earlier referral for children with dental caries or history of mouth trauma

Developmental Screening

Use standardized validated screening instruments

Screening performed soon after adoption may be influenced by language barriers as well as by the lack of previous exposure to the types of materials used for testing
   
Referrals to early intervention programs for children 0–35 months of age

Referrals through school system for children 36 months and older with establishment of Individualized Educational Plan (IEP) when appropriate

Speech/language evaluation

When possible, a speech evaluation within a few weeks of arrival home by a speech therapist fluent in the child’s native language is optimal to identify gaps in articulation and language processing skills

Physical or occupational therapy evaluation

When indicated if any physical developmental delays





  • confirm and clarify existing medical diagnoses


  • assess for any previously unrecognized medical issues


  • discuss developmental and behavioral concerns


  • make appropriate referrals


  • determine immune status and determine potential need for immunization

The initial medical evaluation of newly adopted children includes a detailed review of past medical history, a comprehensive physical examination and laboratory screening using a panel of tests for medical disorders and for diseases prevalent in the countries from which the child is adopted. The physical examination should be comprehensive. Table 2.2 lists findings that may be seen in international adoptees.

The most common medical problems identified in internationally adopted children will be infectious in nature. However, these children may have hematologic and metabolic issues as well. Most problems are what have been termed as “silent” or asymptomatic in nature and would not have been identified from the medical history or physical examination (Hostetter et al. 1991). For this reason, comprehensive medical screening for all children adopted abroad has become the standard of care regardless of age, sex or country of origin (Hostetter et al. 1991; Murray et al. 2005). This screening includes laboratory testing for hematologic, metabolic and infectious processes. Additionally, other recommended screens include hearing, vision and dental evaluations as well as developmental and mental health assessments. Table 2.3 lists other recommended tests.

A visit scheduled at 10–14 days of coming home is ideal for both the adoptive family and the child, unless the child has a known unstable or critical condition. Within the first 2 weeks of being home, parents and child will have had a time to recover from international travel. Issues with sleep cycle and eating will have begun to normalize. Parents may then have the opportunity to consider the child within the context of the home routine and have more specific questions about helping the child adjust to the home environment. The child will have had the opportunity to settle into a predictable daily routine. They will be more comfortable with their new families and a visit to the doctor’s office will not be as anxiety provoking.

During this initial post-adoption evaluation, the pre-adoption medical record will be reviewed. If a pre-adoption evaluation has been performed for the child, then any additional medical records should be reviewed. Occasionally additional growth points and laboratory testing results will be provided to parents at the time of picking up the child in the country of origin. Whenever possible, parents should be asked to forward medical records so that the records can be reviewed prior to the visit. Table 2.1 lists the information to be sought from the child’s history. In addition, a complete physical examination and comprehensive laboratory screening based on environmental, nutritional, ethnic and infectious disease risks should be performed.

This initial post-adoption visit is critical for assessing the child for medical and mental health issues. This visit also provides adoptive parents an opportunity to ask questions about their own observations from the weeks spent with the child. It is important to have an interpreter available during the visit for older children to give them a chance to ask and answer questions.

Issues to address at this first visit include not only eating, sleeping and elimination but also behavioral and emotional issues that can arise in the immediate post-adoption transition (Schulte and Springer 2005).


Hearing and Vision


Hearing and vision screens are recommended by the AAP as part of routine post-adoption work-up. Hearing and vision screening not only allows early detection and treatment of deficits, it also may prevent associated outcomes such as speech and language disorders, reduced school performance, behavioral problems, decreased psychosocial well-being and poor adaptive skills (Table 2.4).


Table 2.4
Post-adoption diagnostic screening for hematologic, nutritional and metabolic disorders








































 
Diagnostic test

Note

Anemia

Complete blood count (CBC) with red blood cell indices and white blood cell differential
 

Hemoglobinopathy and blood disorders

Sickle cell disease—hemoglobin electrophoresis

Thalassemia

G-6-PD concentrations

Toxin exposure

Blood lead concentration
 

Rickets screening

Calcium, phosphorus, alkaline phosphatase, 25(OH) vitamin D

If children receive vitamin D supplementation a few weeks to months before testing, 25(OH) vitamin D levels may be normal

Radiographs of long bones

Metabolic screen

Newborn screen
 

Thyroid stimulating hormone and Free T4

Urinalysis

The prevalence of hearing and vision problems among international adoptees is not known. Among children adopted from Eastern Europe, as many as 78 % had abnormal ocular findings including subnormal visual acuity, amblyopia, refractive errors, strabismus, congenital malformations and optic nerve hypoplasia (Gronlund et al. 2004). According to surveys of parents of international adoptees who had received immediate post-adoption care in Minnesota, 24.7–31 % of children had later received a diagnosis of or treatment for vision problems, 11.9–12.8 % of children had had diagnosis or treatment for hearing problems. Chronic ear infections were reported for 14.6–17.6 % and speech disorder or language delay was reported for 19.4–26.0 % of children whose parents were surveyed (Eckerle et al. 2014). In this study, hearing problems were associated with increased risk of developmental, learning, cognitive and speech problems. Vision problems were associated with increased risk of developmental problems and among children with combined hearing and vision problems there was an increased risk of social and attention problems (Eckerle et al. 2014).


Dental


Dental examination is recommended for all international adoptees. Dental disease may be more common in international adoptees because of poor hygiene, fluoride deficiency or feeding practices such as “bottle propping”. Malnutrition and/or nutritional deficiencies can lead to serious dental complications. Vitamin D deficiency results in tooth enamel mineralization defects and increased propensity for dental caries. Vitamin D deficiency during gestation and infancy affects primary teeth and during early childhood through age 8 years affects permanent teeth. Dental abnormalities may also reveal hereditary vitamin D deficiencies, other vitamin deficiencies such as hypovitaminosis A, C and E or mineral deficiencies such as phosphorus, magnesium and calcium (Davit-Beal et al. 2014).


Age Determination


For some international adoptees, questions may arise with respect to the accuracy of the child’s documented age. For younger children a difference of weeks or months is not likely to be significant in the long term. For older children age determination may be more important particularly with respect to practical issues such as placement in school or eligibility for special education services but can also be important when assessing the timing of pubertal development.

There are no accurate or reliable tests for age determination. Malnutrition and deprivation may affect assessments using standard measurements including radiographic bone age and dental eruption. Onset of puberty may be advanced as a child’s nutritional status rapidly improves. It is usually best to delay changing a birth date until at least 12 months after adoption to allow for catch up growth and prolonged observation of a child’s physical and emotional development.


Developmental Screening


In international adoptees , developmental screening soon after adoption may be complicated by language barriers and the fact that the child may have not had exposure to the tools and materials used for testing. Therefore in these children, early scores may not be predictive of later functioning. Children adopted internationally nearly always demonstrate delays in at least one area of development. Referral to a Behavioral and Developmental specialist may be indicated if children continue to demonstrate developmental delays after a reasonable period of adjustment.


Mental Health Review


Children adopted internationally are at increased risk of mental health disorders including socioemotional problems. The risk for mental health disorders among this group of children may be heightened by pre-adoption factors including prenatal drug and alcohol exposure, prolonged institutionalization, history of multiple placements or with a history of previous abuse and neglect.

In-office assessments may be helpful for identifying children with mental health problems





  • Pediatric Symptom Checklist


  • Brief Infant Toddler Social Emotional Assessment


  • Ages and stages questionnaire: Social-Emotional


Screening for mental health disorders should take place at all medical visits particularly at the time of regular health assessments. Referral to a pediatric mental health specialist is indicated if abnormalities are identified through in-office screening.


Laboratory Evaluations—Hematologic, Nutritional and Metabolic Disorders


Internationally adopted children are at risk for medical disorders that may be caused or exacerbated by pre-adoption living situations that deprives children of adequate nutrition and physical, emotional and intellectual stimulation. In addition, children are at risk for having had prenatal and childhood exposures to environmental toxins and infectious diseases. Many of the medical problems common to internationally adopted children are diagnosed not by physical signs or symptoms but by deliberate screening examinations. Therefore all children should be screened routinely as a part of the medical evaluation of internationally adopted children regardless of age, sex and country of origin (Hostetter et al. 1991) .


Rickets


Inadequate Vitamin D levels have been found to be common among international adoptees . They are at risk for inadequate prenatal nutrition that may result in inadequate vitamin D stores. Additionally, many children have inadequate caloric and/or vitamin D intake prior to adoption. Institutionalized children may not spend much time outdoors and may lack adequate sun exposure. Results from a prospective cohort study of children evaluated shortly after adoption revealed low levels of vitamin D (vitamin D insufficiency) in 27 % and vitamin D deficiency in 7 % of adoptees. Vitamin D insufficiency was correlated with lower BMI and longer length of time in an institution, but was not found to be associated with birth country, giardia, tuberculosis or parasitic infections (Gustafson et al. 2013).

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Jun 23, 2017 | Posted by in OBSTETRICS | Comments Off on Best Practices in Care and Treatment of Internationally Adopted Children

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