The following is some background on what I look for when watching
a video of an orphan.You should also read "Preparations,
Resources & Expectations for International Adoption"
for more information. Formerly most videos were made in orphanages
abroad by facilitators and were given to the adoption agencies
to forward to the prospective parents. Currently many parents
seeking to adopt from Russia and other countries are making their
own videos. Reading this article will help in understanding what
is considered in a video evaluation.
How to Look at a Video
When I review a video, I first
rate the quality of the video. What is the length of the video?
Is the video blurry and unclear or taken with the child in the
distance? These circumstances may make it difficult to evaluate
the child for Fetal Alcohol Syndrome (FAS) or other syndromes.
If the video is less than 1 minute, assessment of the child's
development may be very limited because the child may not display
enough behavior or development for evaluation.
A good quality video is usually
at least 3-5 minutes in duration and it shows the child in just
a diaper. A good look at the baby without a diaper to affirm gender
is desirable. Viewing the child's skin and extremities for birthmarks
and possible deformities is helpful in diagnosing medical conditions.
If there is a mention of a skin infection or birthmark in the
medical abstract, it makes sense to look at the actual abnormalities
that are mentioned. Muscle tone can be better assessed if one
can look at the extremities, as they are moving. However, there
is no substitute for a hands-on exam. The symmetry of movement
can be observed. If the movement of limbs is asymmetric (one side
moves differently than the other side), I might diagnose a neurological
(brain) abnormality. By looking at the child in a diaper, one
can assess the quality of the child's nutrition.
Development in a Video
The developmental age of the
child can be determined to some extent by looking at a good quality
video. I use the standard Denver Developmental Screening Test
which is a tool used by pediatricians to evaluate personal-social,
gross motor, fine motor-adaptive, and language development (receptive
and expressive) in children under the age of 6 years. Most of
what we are looking at is motor development, since children don't
vocalize too often in an orphanage. Children who are living in
orphanages may be delayed just because they have been living in
an institutionalized setting and their nutrition has been sub-optimal.
Adoption professionals guess that for every 3 months a child resides
in an orphanage there may be a loss of one month of development
(Dana E. Johnson, M.D.). This is probably an over-simplification
of the effect of orphanage life on the development of a child,
but it is a useful guide.
It would probably be very
easy for adoption professionals/facilitators/parents to use the
Denver Developmental Screening Test as a guide in making the video.
Some age appropriate skills could be assessed and filmed. For
example, a four-month-old infant is capable of reaching for toys
or objects slightly out of reach. This could be easily filmed.
A child can sit on his own between 6-8 months. Most kids from
orphanages do not sit on their own between 6-8 months, but it
would be great to be able show sitting when it does occur. Pulling
to a stand, cruising, crawling, and standing alone for a few seconds
is easy to depict in a video. Children follow past the midline
at 2-3 months of age. Kids rake a raisin or a cheerio at 6-8 months
and they have a neat pincer at 8-10 months. Filming a child eating
is a terrific way to assess sucking and swallowing and interaction
with the caretaker. Families who travel to an orphanage to adopt
a child can be instructed to carry out the same tasks so that
a video can be prepared for waiting families. With the advent
of two trips in many countries, the actual adopting family can
make this video and then show it to the adoption medical specialist
on return to the U.S. Photos can be taken as well and a sequence
of photos can depict development almost like a video. These photos
can be emailed to an adoption medicine specialist as "jpg"
or "zip" files and they can be evaluated while families
are in country for the adoption process. "Mpgs" (videos
for the computer) are of limited use at this time.
Recommended Screening Tests and Evaluations
Once
the child has arrived, an initial visit to the doctor
should ideally occur within 10-14 days, unless the child
has an acute illness and then a sick visit is obviously
imperative within 24-48 hours. Once the family knows their
travel dates, they can schedule the adoption consultation
appointment long in advance since the initial visit should
take at least an hour or more.
- Antibody titers for children over one year of age who
have a credible vaccine record from the country of origin:
- diphtheria antibodies
- tetanus antibodies
- polio neutralizing antibodies for type 1,2, 3
- chicken pox antibodies (varicella antibodies)
- measles, mumps, rubella (depends on the country and
reliability of these vaccines)
- HIV-1,2 ELISA
- Hepatitis B serology (Hep B surface antibody, Hep B
surface antigen, Hep B core antibody total)
- Hep C ELISA
- Hep A total with reflex to IgM in case of acute infection
- Syphilis serology (RPR, FTA-ABS)
- lead level (venous)
- Complete Blood count with differential and platelets
- Hemoglobin electrophoresis
- Thyroid screen
- TSH
- Free T4
- Total T4
- Rickets screen
- Alkaline phosphatase
- Calcium
- Phosphorus
- Liver Enzymes
- SGOT
- SGPT
- Kidney Function tests BUN, Creatinine
- Audiology evaluation for all children adopted from abroad
(unknown birth history and possible prematurity).
- Vision screening by a board certified pediatric ophthalmologist
for all children adopted from abroad (unknown birth history
and possible prematurity).
- Dental visit with a pediatric dentist should be done
by 18 months of age (poor nutrition, exposure to sugar
in the bottle).
- TB skin test on arrival and again 6 months from the
time of arrival (If the BCG site is not healed wait until
it is healed and if more than a few months is needed for
healing, consider having a chest x-ray; then do the PPD
(TB skin test) when the BCG scar is completely healed.
- Consider repeating HIV, Hep B, C 6 months after arrival
(lengthy incubation periods and exposure just at the time
of departure).
- Full developmental assessment on arrival and every few
months to determine the need for Early Intervention
|
Vocalizations are
Uncommon
The date that the video was
performed helps correlate the developmental age with the chronological
age. Vocalizations are a very key aspect of development. Unfortunately,
most of the children in orphanages do not vocalize. They have
little one-on-one connection with their caretakers. The caretakers
usually do not speak to the children as they change their clothes
or feed the child. When I hear vocalizations in a video, I am
pleasantly surprised and I consider this very encouraging. Receptive
language in toddlers is sometimes seen when a child is asked to
do simple tasks and the child is observed performing those tasks.
This can be inferred from the video without an understanding of
the language used by the orphanage staff. If a person speaking
the language of the country is available to translate the conversation
of the orphanage staff speaking on the video, much can be learned
about the child. If a child is not doing much on a video, this
does not necessarily mean that there is something seriously wrong
with the child. A child may have just awakened from a nap or the
child may have an acute illness, like a cold or just be hungry.
Some children are given sedatives and they appear lethargic. Medications
given in an orphanage can alter a child's mood. The child may
just not be motivated to do much because of lack of stimulation
and lack of experience in interaction and in play. It is better
to assess what is seen and not necessarily to judge what is not
seen.
Social Interaction and Behavior in the
Orphanage
Video should depict the child
interacting with adults and other children if age appropriate.
Toys can be offered to the child to see how the child handles
them. Children often have never seen the toy that they are offered
during the video and their lack of familiarity is not a measure
of intellect. Filming children with other children is enlightening;
how they interact gives us information about the child's ability
to socialize. This is especially valuable for older children,
but not useful for toddlers who normally only exhibit parallel
play. How a child interacts with the caretaker can reveal the
child's comfort with an intimate relationship. It can tell us
a lot about the style of social interaction between children and
staff. This really helps parents understand how difficult life
is in this setting and can explain why a child appears withdrawn
and without much range of emotional response. Eye contact is especially
important to note on the video. If a child averts gaze, looks
away and down, this may mean that the child is feeling shy and
afraid of the video process. If there is a lot of rocking and
gaze aversion, this may reveal withdrawn and depressed feelings.
Attachment disorder cannot be diagnosed from
a video. Lots of children are depressed and bored in orphanages.
Rocking, head-banging, and other self-stimulatory behaviors are
more the norm in an orphanage and these behaviors disappear fairly
quickly after adoption.
Follow-up Videos
Sequential videos are very
helpful in the assessment of a child. Occasionally, agencies can
get tapes of children taken in early infancy with follow-up tapes.
This really is enlightening. If the child has established a consistent
pattern of development even with some delay, this is encouraging.
If the child seems to display a substantial decrease in the developmental
growth with the new video, then this is concerning and may reveal
some underlying medical problem. An infant less than three months
of age has a limited array of behaviors, which makes it difficult
to assess very young infants, but at least we can comment on the
child's alertness, eye contact with the caretaker, and some basic
gross motor development. Children who are six months or more can
be assessed more easily and follow-up video for these youngsters
can be very revealing.
Video of older children should
depict them eating, drinking, playing with friends preferably
outside where the child can run around. Observing children drawing
pictures, identifying pictures that are on cards or in picture
books is especially helpful as long as there is accompanying English
translation. This helps the viewer assess the child's receptive
and expressive language which is really the window into a child's
cognitive development.
Growth Parameters
Plotting the heights, weights,
and head circumferences that appear on the medical abstract is
the most objective data from the medical abstract. How the child
looks on a standard growth curve tells us a lot about the child's
general health. About 50% of children in Russian orphanages fail
to thrive and are found well below the standard growth curve.
A pattern of growth is ideal because it can establish the reliability
of the measurements. One set of points is not that useful. Most
children in orphanages are undernourished and even if they start
out at birth at an average weight and height, they generally do
not maintain that growth velocity due to poor nutrition and institutionalization.
Psychosocial dwarfism or psychosocial growth failure is a well-understood
medical consequence of poor nutrition and institutionalization.
If a child is adopted under the age of two years, there is usually
good rebound with weight gain and linear growth improvement. For
instance, it should also be understood that the birth weights
of children in Russia are well below the average weight of a newborn
in the U.S. The average birth weight in Russia is 2500 grams or
5 ½ pounds. Poor prenatal care, smoking, and drinking,
and congenital infections during pregnancy are quite common in
Russia and are the major causes for low birth weight in newborns.
People assume that when a child is low birth weight that the child
is a premature infant; because of poor pre-natal care, we can
not definitively know whether a child is low birth weight and
full term or low birth weight and premature, or just premature
with appropriate weight for the gestational age.
Measurements can be unreliable.
The staff who measure children in orphanages are well-meaning
individuals who have little medical training. It is not unusual
for scales to be broken and measuring tapes to stretch. Babies
are notorious for squirming and measuring lengths is problematic
even in the best circumstances. Taping a staff member or better,
yet, the staff physician measuring the child is of particular
benefit. We can hear the measurements stated in the video and
assess their reliability. Measurements should be kept in the metric
system and not be translated into English equivalents unless the
metric still appears on the medical abstract. Simple mathematical
mistakes are common.
Head Circumference
Head circumference is obviously
the most important growth parameter in the child's medical profile.
The growth of the head correlates with brain growth in early infancy.
Heads grow fast and furiously during pregnancy and in the first
year of life. The average head circumference of a full term newborn
is 35 cm and in the first year of life the infant's head will
grow about 10 cm as long as the child is healthy. If you look
at a standard growth curve there is a 3rd% and a 97th% line for
each age. If the child is somewhere at or between these percentiles,
this is considered normal growth. This growth curve allows for
the small, medium, and large heads. Head size is considered universal,
but without normal data available from other countries it is impossible
to state what the normal range of head size is for each country.
Sleeping position may alter the shape of the head and the back
of the head may have a flat appearance. Misshapen heads are also
the result of persistent supine positioning due to lack of stimulation
in institutions. This can change if the child's soft spot is still
open and there is an effort to have the child sleep on the side
and not spend much time during the day lying around. With U.S.
efforts to decrease the incidence of sudden infant death syndrome
(SIDS), there are a lot of normal healthy children with misshapen
or flattened heads from supine positioning during sleep. In some
cases a helmet has been used to normalize the shape of the head.
Measuring the head properly is not so easy. If the child has rickets
and a lot of frontal bossing (forehead is prominent), the head
may be spuriously enlarged. The head should be measured over the
eyebrows around the largest diameter of the posterior skull. Measure
three times for the best assessment. I give parents paper tape
to measure head circumference on their trip.
Causes of Microcephaly
Reasons for small head circumference
vary. Some heads are small due to poor nutrition, smoking, drinking,
intrauterine infections during pregnancy, and genetic disorders.
In some rare cases craniosynostosis (premature closure of the
sutures of the cranium) is the cause of poor brain growth after
birth. Some kids are born with normal heads, but due to malnutrition
and lack of stimulation their heads don't grow. In 1998 and 1999,
I sent students (Worldwide Orphans Foundation/Orphan Ranger Program)
to work in Russian orphanages in the Udmurtia Republic; 154 children
ages ranging from 4 months to 55 months in Izshevsk, Glazov, and
Votkinsk were evaluated. 40% of the children had microcephaly
(head circumference below the normal growth curve). In orphanages
in Borovichi and St. Petersburg, similar data was collected in
1999.
Those children with head circumferences
below the 3rd%, adopted at less than one year of age, may have
the potential for rebound growth. When a head circumference is
less than the 3rd%, the child's cognitive and intellectual development
would be the concern. There is no guarantee that the child will
have rebound growth. I am following many newly adopted Russian
children in my practice and I am encouraged by how many of the
children do catch up even for head growth. A few years ago, I
did look at head growth catch-up in 34 children adopted from Eastern
Europe and Russia and found that 85% of these kids had head growth
catch-up a year after arrival. The children were about one year
of age on arrival and then a year later, when the children were
around two years of age, follow-up was performed. Cognitive testing
of these children was not performed, however. I must reiterate
that normal brain growth is essential to the successful development
of a child. If a head circumference is below the 3rd%, I first
request that parents try to get an updated measurement and then
I look at the birth head circumference to determine if this is
a pattern that existed at birth or developed during the time in
the orphanage. A child who is not a premature infant who has a
small head circumference at birth is more of a risk than a child
who is born with a normal head circumference and whose head grows
slowly while in the orphanage. Many parents ask me about familial
microcephaly. There are families with small heads, but we don't
have reliable family history for the vast majority of referrals.
It would be an error to assume that the small head size of a child
is due to familial microcephaly unless this could be absolutely
documented with measurements of both parents' heads!
Medical Diagnoses and Defectology in Russia
and the Former Soviet Union
The diagnoses found on Russian
medical reports are responsible for a lot of the concern and anxiety
associated with embarking on a Russian adoption. When I first
started reviewing medical abstracts from Russia and Eastern Europe,
I, too was unaccustomed to these medical phrases. With 10 years
of experience in adoption medicine and travel to Russia, Romania,
Bulgaria, and research done by the Orphan Rangers, I can now say
that I am accustomed to these unusual terms, but if you are looking
for a clear-cut interpretation, you will not find this anywhere.
What we know empirically is that physicians in Russia have a unique
perspective of the health of newborn infants. This is the system
of "Defectology" wherein infants are considered inherently
defective and then over time, their "defects" resolve.
Russian physicians believe that young infants and toddlers are
neurologically immature. It is standard for a Russian child to
be evaluated by a pediatric neurologist several times in the first
few years of life. Children who are born to mothers with poor
pre-natal care and any infections during the pregnancy may be
diagnosed as having "prenatal or perinatal encephalopathy".
This diagnosis would be based on pre-natal factors, which led
the baby to be neurologically abnormal. A child who was born to
a mother with syphilis might be diagnosed with prenatal or perinatal
encephalopathy. Conditions that exist at the time of the delivery
such as premature birth or complications at the time of the delivery
like a home birth, might also contribute to the diagnosis of perinatal
encephalopathy. It is a system of potentials.
It is assumed that all babies are defective and that eventually
these conditions will resolve with appropriate therapies such
as massage and unusual medications not used in Western countries.
So if the mother was ill during pregnancy or had no pre-natal
care, then the child is considered potentially predisposed to
various health conditions and is diagnosed with perinatal encephalopathy.
This diagnosis is not based on any scientific research done in
Russia or any other country. Russian physicians have had a long
tradition of diagnosing serious pathology (disease) in healthy
individuals. As I dismiss some of the significance of the confusing
terminology on a medical report, I must also state that there
may be medical conditions that clearly do exist for a particular
child, that are not diagnosed by the physicians in Russia. I look
for context when reviewing the medical reports.
Other diagnoses that are found
commonly on medical abstracts are pyramidal insufficiency or deficiency,
hypertensive-hyperexcitability syndrome, hydrocephalic-hypertensive
syndrome, and neuro-reflex excitability syndrome. When I was in
a maternity/infant hospital in Saratov in Russia in 1997, I asked
the director of the newborn division about these diagnoses. She
asked me to listen to a baby crying in the nursery across the
room from where we were standing. She then told me that baby had
neuro-reflex excitability. When I approached the infant, I noticed
that the bottle which was propped on a rolled blanket had fallen
away from her mouth. The child was hungry and irritable. Further,
the baby was drinking Kefir, which is a sour, cold liquid yogurt,
which is probably not palatable.
Pyramidal
insufficiency refers to the possible abnormality of the
corticospinal tracts of the central nervous system that control
the movements of the muscles of the body. If the child has even
the slightest delay in gross motor development, then this diagnosis
is applied. This is often interpreted as cerebral palsy, but this
has not been borne out by my clinical experience. Children are
often diagnosed with spastic tetraparesis
which literally means weakness and spasticity of all four extremities.
I see this commonly applied to children who are walking and appear
quite normal for gross motor development. Instead of carefully
examining a child and then doing investigative studies to confirm
actual brain damage, the child is diagnosed as having brain damage
because the nervous system appears to be immature. The bottom
line is that the doctors are probably looking at normal children
who are delayed due to malnutrition and lack of stimulation. They
have little formal training in development. It was clear to me
after spending many hours discussing the system of diagnosis with
staff physicians in orphanages that the diagnoses are based on
a belief system, rather than a thinking process based on physiology
and anatomy.
Rampant Testing
Many children get ultrasounds
of the organs in the body. For the most part it is unclear why
these tests are even ordered and performed. It cannot be assumed
that because tests are ordered that there is actually a disease.
The findings sound almost poetic, but they are most often not
specific to the child and are not useful for medical diagnosis
unless there is some clinical correlation. If one sees some abnormality
on the video or in person when the child arrives and has a complete
physical examination, then further testing should be initiated.
When x-rays, sonograms, EKGs, EEGs, and echocardiograms
are used to investigate the health of children in orphanages,
these tests are performed by untrained individuals and the equipment
is often antiquated and in disrepair. It is difficult to assess
the reliability of ultrasound evaluations of the various organs.
If the child has had a history of a urinary tract infection and
has a mention of an abnormal kidney sonogram, I advise parents
to have the kidney ultrasound repeated in the U.S. after the adoption.
I do not recommend repeat testing in Russia. I have not recommended
routine head sonograms even if the head sonogram in Russia has
been described as abnormal on the medical. If the child is a very
premature or a low birth weight infant with an abnormal neurologic
exam or if a full term child has an abnormal neurologic exam during
my examination at the time the child arrives in the U.S., I would
then recommend a head CT, or MRI in collaboration with a pediatric
neurology consultation. I also recommend hearing and eye exams
for infants who have a history of prematurity on any medical abstract.
Premature infants do have an increased incidence of hearing abnormalities
and vision problems in any part of the world. I try to correlate
testing in the U.S. with what I find on the physical exam in my
office just as I would do for any child.
Myotonia,
dystonia, or dyskinesia, are also favorite terms found
on medical reports from Russia. These are terms to describe abnormal
muscle tone. Most of the children in orphanages have abnormal
muscle tone due to undernutrition, rickets (vitamin D and calcium
deficiency), and lack of stimulation. With adequate nutrition
and vitamin D supplementation, the muscle tone improves within
a few months. In some cases children may benefit from physical
therapy through Early Interventions services in their community.
Sustained low tone can occur in children who have been in the
orphanage for longer periods of time or in children who may have
unclear medical problems.
Another common term found
on almost every Russian medical is hypotrophy.
When literally translated, it means "less growth". It
is sometimes graded (I, II, III). It actually is an appropriately
used term to describe the small size of newborns in Russia and
then concomitant failure to thrive, which we see in orphanages
as a result of poor nutrition and institutionalization. The grading
system is subjective and does not appear to be standard from orphanage
to orphanage. This grading system is also seen in describing prematurity,
but again, is not standardized.
Hip Dysplasia
At least 10 % of the medical
abstracts from Russia will mention this diagnosis; out of about
800 children adopted from Russia who I have evaluated in my office,
I have one child with the actual diagnosis, which did necessitate
surgery, and she is well and healthy. Developmental dysplasia
of the hip (DDH) has a prevalence of less than 1% at birth and
can be diagnosed well into the first year of life. It is not completely
understood, but in simple terms it is abnormal development of
the hip anatomy and if it goes undiagnosed and untreated, it can
cause improper growth of the leg and it obviously will interfere
with normal gross motor function. It is obviously over diagnosed
on Russian abstracts. A good physical exam by a pediatrician upon
arrival in the U.S. can easily rule this diagnosis out. If a child
has DDH diagnosed late in infancy or childhood, surgery may be
required and usually has an excellent outcome.
Open Oval Window
This is a diagnosis that is
found all too often on Russian medicals and it is again an over
diagnosis. It is actually a diagnosis that has no medical significance
and is mostly found on autopsy or in some cases during an echocardiogram.
All of us have an oval window between the atria of the heart,
but it closes early in life. If it remains open, it causes no
ill effect.
Intestinal Dysbacteriosis
This is one of my favorites
of the diagnoses; it simply means that there are bacteria in the
colon and the harmony of those bacteria may be out of balance.
Children with diarrhea or gas are often diagnosed with this condition.
Stool cultures are performed and the proof of the diagnosis is
that there are bacteria found in the stool. All stools have bacteria,
which are necessary to the normal functioning of the intestines.
There are only a select number of bacteria that are considered
"pathogens" in the colon and some of these are Salmonella,
Campylobacter, Shigella, Yersinia, and some Escherichia coli.
Intestinal dysbacteriosis is simply the finding of normal bacterial
flora with non-specific symptoms. There is no need for treatment
although, in Russia, children are often given antibiotics for
this condition.
Medications and Therapies
Children living in orphanages
are inevitably treated with an assortment of medications that
are commonly not used in the U.S. Medications that are focused
on improving blood and cerebrospinal fluid circulation are administered
as are sedatives and anti-seizure medications like Phenobarbital
(Luminal), carbamazipine (Tegretol), and phenytoin (Dilantin).
Children receiving these medications do not necessarily have a
diagnosed condition that necessitates treatment with these drugs.
Digitalis (Digoxin) has been given to children with simple functional
heart murmurs. Vitamins, magnet therapy, paraffin wax treatments,
ultraviolet light treatments, electrophoresis, vacuum therapy
of the eyes, and massage therapy are all treatments commonly mentioned
in medical abstracts. Parental concerns about side effects are
common. If a baby appears particularly sluggish or disengaged
emotionally, I will often mention that it is possible that the
child is on a sedative. We have no long-term studies to answer
these concerns scientifically.
Syphilis
The diagnosis of "exposure
to syphilis" or "Lues disease" is very common on
Russian medical reports. Probably at least 20% of my pre-adoption
reviews include this diagnosis. Of the Eastern European children
who I have evaluated in my office, I have had one child from Ukraine
with active, acute syphilis just this past year. I have encountered
dozens of children with positive FTA-ABS antibodies which is consistent
with possible exposure to syphilis which has been treated or is
consistent with persistent transplacental antibody. When a mother
has syphilis, her body produces proteins in the blood to combat
the bacterial infection. These proteins are called antibodies
and the baby can then get those antibodies through the placenta
during pregnancy. The antibodies are therefore the mother's antibodies,
not the baby's. That is what we mean by transplacental antibody.
The Russian medical system has done an excellent job in the management
of syphilis in newborn infants. They cannot differentiate exposure
from actual infection and they treat all children. Children, who
are exposed to mothers with even past syphilis, which has already
been treated, are given 14-28 days of daily intramuscular injections
of penicillin. This is more than adequate therapy for congenital
syphilis. It is imperative that parents seek confirmation that
the child has been treated with penicillin. I think that syphilis
is not an alarming diagnosis on a Russian medical, but it is important
to follow-up the child once he/she is adopted. Syphilis serology,
including an RPR and an FTA-ABS, an eye exam, and a hearing test
are advisable for any child with a history of possible congenital
syphilis.
Transfusions
Transfusions are truly alarming
on a medical report. This could mean exposure to Hepatitis B,
C, or HIV. I have not personally evaluated any children with HIV
infection who have been adopted from abroad, but there have been
a few children adopted from Cambodia who were diagnosed with HIV
infection. In the past few years there have been a few newly adopted
children from China who had positive ELISA tests for HIV, but
all of the children had negative PCR tests; this means that their
mothers were infected, but they were not infected.
Test Reliability Abroad
I have a number of children
in my practice with Hepatitis B and C infection. In a study published
in Pediatrics September 2001, looking at over 500 internationally
adopted children who I evaluated in my practice, it was found
that 2.6% of children adopted from Russia were carriers of Hepatitis
B. Hepatitis C was rare in this population. The children were
negative for Hepatitis B and C in Russia and found to be positive
after they arrived in the U.S. The lengthy incubation period of
up to six months could account for a negative test in Russia and
then a positive test upon arrival in the U.S. It must also be
understood that the quality of laboratory testing in Russia is
not governed by the usual checks and balances that exist in laboratories
in the U.S. Some medical abstracts may include lab tests for Hepatitis
B and C that are positive and then when retesting is done in Russia,
the tests are found to be negative. It would be difficult to rely
on these new findings as definitive. All blood tests performed
abroad should be repeated when the child is evaluated by their
pediatrician in the U.S.
Hepatitis B Infection
Hepatitis B is a viral infection
which affects the liver. If the person contracts the infection,
it usually resolves within a few weeks and there are no further
medical problems. If the person becomes a carrier of the virus,
the liver can be chronically inflamed. Cirrhosis and possibly
cancer of the liver can develop decades into the future. Natural
history studies of chronic HBV among children are just beginning
to appear in the medical literature. The risk of developing chronic
HBV is correlated highly with the age of initial infection. Approximately
90 per cent of those infected prior to 1 year of age develop chronic
HBV infection, whereas the rate decreases to approximately 40
per cent between 1 and 10 years of age and is less than 10 percent
among adults. Hepatitis B can be transmitted from a mother to
the newborn infant at the time of birth if the mother is infected
and carries the Hepatitis B virus. In China, Hepatitis B is quite
prevalent and 5 to 15 per cent of all those individuals infected
with Hepatitis B can potentially become carriers of the virus
lifelong. Children born to mother's who are carriers are then
exposed to the virus at the end of the pregnancy and at the time
of delivery. Because mother's frequently do not have prenatal
care their carriage status is unknown and when the baby is delivered,
the baby is not given Hepatitis B immune globulin and vaccine
in an effort to prevent the infection in the newborn. Abandoned
children would obviously not be candidates for this intervention.This
is standard procedure in the United States. Many orphanages now
administer Hepatitis B vaccine, but this vaccine is given much
too late to prevent infection from mother to infant at the time
of birth. The vaccine will however at least decrease the transmission
of the virus in the orphanage.
When children are in an orphanage,
they are assessed for Hepatitis B virus with a blood test during
the first few months that they arrive in the orphanage. On the
medical exam, you may see the phrase "Hepatitis B surface
antigen". Usually, you will see the word "negative"
or a symbol "-" to indicate that the baby is not infected
with Hepatitis B virus. Because the incubation period of Hepatitis
B may be as long as six months, these results may not accurately
reflect the Hepatitis B surface antigen status of your adopted
child. Children can also be exposed to Hepatitis B virus in the
orphanage by exposure to blood from staff members or other children
who may be carriers of the virus. This is a blood borne infection
and is transmitted in household settings by exposure to blood
of the individual who is carrying the virus. An orphanage is equivalent
to a household. This virus is not transmitted casually by sharing
food or utensils from time to time. I recommend Hepatitis B vaccination
for all household members when a family member is a Hepatitis
B carrier. If your family consists of other children, they have
probably been immunized as infants because Hepatitis B vaccine
is required for school entry. Parents traveling to adopt a child
abroad should be vaccinated before traveling. The vaccine is a
three vaccine series which can be completed within six months.
If you have two vaccines before you travel, this will probably
afford some protection.
When the child arrives from
abroad, we recommend testing for Hepatitis B which includes Hepatitis
B surface antibody, Hepatitis B core antibody, and Hepatitis B
surface antigen. If the antigen is positive, then we recommend
further evaluation which may include Hepatitis B e antigen and
e antibody.
The prevalence of Hepatitis
B carriage is 3.3% in China and 2.6% in Russia. All of the children
are healthy and most have not required any treatment at this time.
A few children have had elevated liver enzymes indicating some
inflammation of the liver which has necessitated treatment with
interferon. Interferon is a medicine which is injected. There
are many new treatments being studied currently and lots of intensive
research is being devoted to the treatment of children and adults
with chronic Hepatitis B infection. The future looks good for
anyone with chronic Hepatitis B infection.
Hepatitis C Infection
Hepatitis C, formerly non-A,
non-B hepatitis, is fast becoming a worldwide problem. The prevalence
of Hepatitis C in the U.S. is probably as high as 2%. Hepatitis
C infection is the most common cause for liver transplant in the
U.S. 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%-7% although it can
be higher (40%) for children born to women who are co-infected
with HIV.
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 are 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. Out of almost 1800 children evaluated
by me during 10 years doing adoption medicine, there are two children
who are infected with HCV and at this time they are both school
aged and well-appearing with no signs of chronic active hepatitis.
Two children under one year of age who recently arrived from abroad
were initially antibody positive, have turned out to not be infected
and most likely are antibody negative. This cannot be determined
until after the child is at least a year of age. The maternal
antibody can persist that long.
These four children are from
Eastern Europe and the former Soviet Union. Other adoption medical
clinics have also reported cases of HCV. Two children of 129 children
assessed in an adoption clinic in Boston between 1989 and 1993
[Miller et al. 1995] 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 past 5 years. [Traister & Aronson
1998].
The international adoption
medicine group has agreed to continue to screen all children to
better understand the risk factors for HCV in children adopted
from abroad. The complications of HCV are similar to Hepatitis
B Virus (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 United States. 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 treatment regimens available (interferon
in combination with ribavirin) is quite effective. [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;] 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, although
typically the incubation period is 2 weeks to 3 months.
Pre-Adoption Reviews from Other Countries
Guatemala
The amount of information
on babies adopted from Guatemala varies widely. There may be some
social history, but for the most part the story of a child's life
begins with the birth and there are usually measurements (height,
weight, and head circumference) which are included with the birth
certificate and tests for HIV, syphilis and Hepatitis B. The tests
may have been done on the mother, the baby, or both. Over the
last few years I have begun to advise families to include Hepatitis
C in their requests for other tests on the baby. I also now mail
a New York State newborn screen to families and they bring it
to the doctor who examines the baby in Guatemala on regular basis
until the finalization of the adoption in Guatemala City. This
blotter paper includes HIV, sickle cell screening, hypothyroidism
and other enzymes deficiency diseases. All children born in the
U.S. are assessed in nurseries in hospitals at birth for these
diseases, but this is not the case in Guatemala. I then send the
blotter paper to the Albany lab and the results are available
to parents within a few weeks. I have good collaboration with
the physicians in Guatemala for this process.
I also coach parents to visit
their new baby in Guatemala before the final adoption process.
After the DNA homology test is cleared, the baby is officially
assigned to the family and I encourage the family to go to Guatemala
City to spend a weekend with their baby. It is an opportunity
to meet the foster family and to bond with the child. During that
time, a video can be made and new photographs can be taken. I
review the video and photos when the family returns to the U.S.
I also encourage the family to accompany the baby to the pediatrician's
office in Guatemala for the well check which is performed usually
every month in Guatemala. The newborn screen can be performed
at the office visit. The visit can be taped and I can get a lot
from that physical exam. I can see the entire baby and I can see
the baby measured. The development can also be assessed. Parents
get a sense of the social development of the child and feel closer
to their baby when they do this pre-adoption visit. There are
adoptions from orphanages in Guatemala and the medicals are brief;
testing for HIV, Syphilis and Hepatitis B is routine, but there
is no opportunity to do much more than this.
Korea
The medical abstracts prepared
for babies in foster care in South Korea are the most detailed
of all the medicals for children adopted from abroad. The children
are seen regularly by pediatricians and measurements are quite
accurate. Social histories are quite detailed. It is not uncommon
for birth mothers to smoke and drink during pregnancy in South
Korea and women are quite honest about their lives during the
pregnancy. The reliability of the social history prior to birth
is reliable. Babies are tested for HIV, syphilis, Hepatitis B
and a Guthrie test is done to rule out PKU (phenylketonuria).
These tests are quite reliable.
Medical conditions are identified in children and Korean physicians
are quite involved in the diagnosis and management of all medical
conditions. For example, if a child has a heart murmur, it is
quite common for the child to have a chest x-ray, an EKG, and
an echocardiogram. All of this information can be obtained upon
request through the adoption agency if it has not been performed.
Adoption doctors/pediatricians in the U.S., prepare letters requesting
further tests and evaluations and this letter is then faxed to
the Korean agency through the American adoption agency. It can
take a few weeks for the tests to be performed, but the system
is quite collaborative. If a child has been admitted to a hospital
for an illness, the discharge summary is made available to parents.
If there are developmental issues, a request for further exams
by a neurologist can be made. I often request video to be made
at the time of that exam. This is quite useful. The Korean adoption
process is ideal in my opinion.
China
The medicals from China have
improved drastically over the past few years. When I started doing
adoption medicine 10 years ago, there was one perfunctory paragraph
written about the child's social history and a 1 inch by 1 inch
photo. Parents blew the photograph up and put it everywhere in
the house. Now, the medical includes a detailed account of how
the child was found, with a discussion of the child's daily eating
and sleeping pattern. A new developmental inventory has been constructed
as well. This developmental tool is far from ideal. It appears
to be quite generic in fact, but in time it will improve as the
process becomes more mature. The medical contains a lot of medical
tests including complete blood counts, liver enzymes or TTT (Thymol
Turbidity Test), and hepatitis B tests. The Chinese characters
for negative and positive are quite distinctive and should be
examined and compared to the English translation.
Every referral from China
includes a Chinese version and an English translation. The Chinese
medical is followed by the English translation usually within
a few days or at most a week.
The reliability of the blood
tests is always a question. Now children are tested for syphilis
(TRUST test) and HIV. China Center Adoption Affairs has directed
all social welfare institutes (orphanages) to test orphans for
HIV, but implementation of this directive will take time so not
all children are tested. Also, the reliability of local laboratory
HIV testing in China is clearly an issue. Please note that an
HIV ELISA test done on a child under 18 months of age does not
diagnose the child's infection. The child may be antibody positive
for HIV, but in 75% of the cases, the child is not infected.
Currently, children are measured
for their height, weight, and head circumference at the time of
the initial medical exam which is usually within a few months
of admission to the orphanage. There may be measurements performed
on the date of admission to the orphanage. What is particularly
useful these days are the updated measurements which are fairly
common in this process. Updated photos are also more and more
the rule. The photos may actually depict the baby sitting in a
chair or in a walker. About 1% of children adopted from China
are in foster care and parents are in some cases able to meet
the foster family. Videos are rarely used in this process; when
they are available, they are for children with special needs i.e.
cleft palate/cleft lip. Getting a child who has some medical condition
examined by a university physician is difficult in China, but
not impossible. The medical care is rather perfunctory in general.
If your child is ill during the adoption process, agencies have
identified local physicians to help families. I usually recommend
using the established western-style medical clinics such as the
SOS system which are frequently located in the larger cities in
China. There are also university medical centers in some cities
in China where physicians have become medical resources for families
adopting in China i.e. Hefei Children's Hospital and Anhui University
Medical Center. The consulate exam on Shamian Island is not detailed.
The White Swan Hotel medical care is sub-optimal and injectable
antibiotics such as amikacin are commonly prescribed and ill-advised
for children.
Cambodia
and Vietnam
These medical reports are
quite limited. There is a nice social history report for most
children adopted from Vietnam, but not from Cambodia. There is
an official physical exam from both countries done by a physician
from a western-style clinic like the SOS system in Phnom Penh
in Cambodia or in other cities in Vietnam or the Family Medical
Centers directed by Rafi Kot, M.D. in both Hanoi and Ho Chi Minh
City. Measurements are sparse in both countries. The photos are
usually sent by e-mail and are quite tiny and because the children
have been traditionally adopted at such a young age, the photos
are limited in their usefulness. Updates can be obtained, but
it is like pulling teeth. Reliability of measurements is certainly
an issue. If the child has a disability or medical condition,
agencies can arrange for children to be examined at the above
clinics.
Blood testing is done for Hepatitis
B, HIV, and syphilis. A lot of the testing is done at the Pasteur
Institute in both countries. This is a superb laboratory. If the
testing is not done at Pasteur, it is important to know that and
to understand the limitations of that testing quality.
India
The children adopted from
India are often premature and/or low birth weight. There is almost
no social history on the medical referral, but there is usually
a decent physical exam done by a pediatrician although it is rarely
current. There are usually a few sets of measurements and descriptions
of the child's eating habits and development are common. Childhood
illnesses are reported in detail; vaccines are reported with dates.
Updates can be gotten through the written requests, but feedback
is slow. Having other tests and blood work done is possible, but
takes a lot of persistence.
Bulgaria
The children are referred
at about one year of age, but the adoption usually doesn't occur
for another year. The medical is rather slim in content and resembles
a Russian medical. Similar diagnostic terms are found on Bulgarian
medical reports. There is usually a birth weight and height or
an orphanage admission weight and height, but rarely will you
find a head circumference. Getting current measurements takes
forever, but eventually happens. Pictures are often poorly composed
by facilitators. Video has been discontinued by the government
this past year. We hope that it will come back. Parents travel
to Bulgaria to see their child and they can make video and bring
it home. The children are tested for HIV, syphilis, and Hepatitis
B, but you won't see that mentioned in writing. The agency will
report this to parents verbally. It is "understood"
that if the child is made available for adoption, then the tests
are negative. Not something adoption doctors like very much. Some
children in orphanages in Bulgaria are involved in "Granny
programs" to improve stimulation. Two children are cared
for by one volunteer granny a few hours each day, a few days a
week. The kids who are in these programs have an easier transition
after adoption.
Hungary
The referral process has changed
a lot in the last year actually. We used to have a paragraph and
a photo that required a magnifying glass to be seen. Now we get
a one page medical with some limited medical information and growth
points. We rarely know where the child is from or any social history.
This is usually conveyed to parents verbally. Video is more and
more common. Children are in foster care from time to time. Medical
referrals will improve a lot over time in this country.
Romania
No adoptions are currently
going on in Romania officially. The country has been closed for
a year and a half, but slowly adoption is opening. Those folks
who had filed papers before the closing are first in line. Special
needs kids are a priority. The referral medical is very similar
to the Russian medical referral. Romanian is easy to read because
it looks like Italian and French. The medicals are brief, but
usually contain some social history and growth points at birth
and current ones as well. It always mentions where the child is
located. Feedback from the agency is slow, but does occur. There
are doctors in Bucharest to contact for independent exams. Kids
are commonly in foster care through foundations. Some of this
foster care is a family with the one child, but a lot of it is
an apartment with caretakers and 10 babies. Parents should know
that tests and other medical interventions are difficult and unreliable.
Miscellaneous
Countries
Children are adopted from
many other countries like Azerbaijan, Belarus, Philippines, Thailand,
Brazil, the Republic of Georgia (foster care infants), Sierra
Leone, and Ethiopia. Countries close and new countries open. It
takes at least a couple of years until the process in new countries
is stable and predictable.
We have come a long way over
the years that I have been doing adoption medicine and hopefully
with the implementation of The Hague treaty, full disclosure of
medical information about children being adopted will be made
available.
Risk Assessment
I do not tell parents whether
or not to adopt a child. I put the referral in a risk category:
average, mild, moderate, and extreme, depending on the number
of medical issues. Average risk is if the child has no medical
diagnoses that are of concern. This does not mean that there are
no medical issues for this child. It just means that there are
no issues that are apparent. It has been demonstrated that children
who are living in orphanages have many health issues such as failure
to thrive, malnutrition, anemia, parasitosis, exposure to TB,
elevated lead levels, hepatitis B carriage, and other issues that
may not be apparent in the pre-adoption record. Mild risk is if
the child has one medical issue, moderate risk is 2, and extreme
risk is 3 or more.
 International Pediatric Health Services, PLLC
Dr. Jane Aronson, FAAP
128 Maplewood Avenue
Maplewood, NJ 07040
P: 917-538-5217
E: E-mail
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