Eastgate Pediatric Center, Cincinnati, OH
An Open Letter to Pediatricians Regarding Medical Issues Involved in International Adoption
As an adoptive parent of three daughters born in China, I have traveled to this great nation several times. During all three of my adop-tion trips, I saw China and its medical system through the eyes of a mother as well as those of a pediatrician. I have visited the orphan-ages of two of my daughters, and was even able to visit a children's hospital. It was evident to me while in China (as well as the otherdeveloping nations from which many international adoptees come) that medical care is much different from here in the states. Let medescribe to you the conditions from which your future patient may come.
All of my daughters came from orphanages in remote towns. Their rooms had little outside light, no window screens, no central heat orair conditioning, and few toys. Children were fed from a common spoon and bowl. Many of the children had rashes, and several hadhead lice. Contrary to some reports in the media, it was obvious to me that the caretakers tended the children in very loving ways,meeting their basic needs for warmth, food, and fresh diapers. But due to extreme poverty, some of the medical needs of these childrenwere not adequately addressed.
In China, I examined children from my daughters' orphanages, as well as other children. Many of them had ear infections, scabies, lice,and extensive eczema. Some had impetiginized areas on the back of the scalp. Others had perforated eardrums due to delays in startingantibiotics. Out of desperation, one family had taken their child to a Chinese physician, and a Chinese medicine (one not used in thiscountry) had been prescribed to treat the child for otitis media. The child worsened, and we were also able to treat appropriately, once Iexamined her and changed medication to one brought with me from the U.S. All of the children showed significant improvement with“Western” medications, not obtainable in China-Elimite, Nix, hydrocortisone cream, antibiotics-as I prescribed them. It was evident thatthese adopting families, all of whom were first-time parents, had many concerns regarding their children's health, but they had noaccess to reliable medical care.
Since my adoption trips, I have heard of two families from my area whose children became quite ill prior to their journey home. Onehad seizures with fever, due to pneumonia, and the other had bacterial pneumonia. Both had been hospitalized in China. Medical carein these hospitals was not up to standards in the U.S., and a decision to treat with antibiotics was reviewed each day rather than deter-mined in conjunction with the diagnosis. The children received only three days of medication for conditions routinely treated in ourcountry for 10 days. Fortunately for one of the children, a physician (who was in China to adopt) was able to provide additional med-ications (that she had brought for her own child) and prevent worsening of the illness. Both mothers worried that the children wouldcontract illnesses from their hospitalization. There was no assurance that blood and body-fluid precautions were being used.
On my visit to a children's hospital, I met doctors trained in Western medicine, but their efforts were limited by a lack of technologyand the inability to provide medical care as we know it. IV fluids were hanging in open bags, subject to air contamination. Children layin rows in wards, and parents were rarely allowed to be at the bedside to comfort them. At the Children's Hospital, the trauma roomhad little equipment and poor lighting. Even the required physical examination, done on all adoptees before obtaining the visa neces-sary for entrance into the U.S., was limited in its scope. There was no blood work for HIV, Hepatitis B, lead poisoning or syphilis, noPPD, and no monitoring for stool infections. Some children received immunizations prior to adoption, but without the guarantee thatthe vaccines had been stored or administered properly. There were few physicians who could even diagnose otitis media. (Headlampswere used for the immigration physical, and otoscopes were not available.)
Due to language and cultural barriers, emergency room visits in China are quite different than they are in our country. Families may ormay not have an interpreter to take them for a medical evaluation for an ill child. Children are bundled to protect them from cold, evenif they are febrile. Even in major cities in developing nations, there may be no accessible emergency rooms, or even Urgent Care facili-ties. Standards are quite different, sometimes involving a combination of herbs and “Western” medications, if Western medications areavailable. Prescriptions are doled out by a physician, not a pharmacist, with little quality control (and no FDA oversight for safety).
I know that most infections in children are viral in etiology. I am also aware of (and am implementing) the new AAP guidelines for useof antibiotics in treating otitis media, treating pain and not necessarily infection. But I know that international adoptees often have sec-ondary bacterial infections due to poor hygiene in the orphanage, dormitory-style living, and malnutrition. Although such infectionsare unlikely to be fatal, they can seriously interfere with the bonding and attachment process taking place at the time of adoption, aprocess which is vital for long-term mental health. These infections also make for a long and uncomfortable plane ride home.
For the sake of your future patient, please give contact information to an adopting family if they may have medical concerns about theirchild. I admit this is controversial, but please consider also giving the family two prescriptions for travel. With my own patients, I oftengive prescriptions as long as they promise to contact me (via e-mail or phone) or seek care from a Western-trained physician, prior tostarting the medication. With this promise in place, in more than eight years of caring for adoptees, no family I've counseled has ever
Eastgate Pediatric Center, Cincinnati, OH
started antibiotics inappropriately. It must be clear that if the child is ill-appearing (suggestive of a serious infection), urgent medicalcare should be sought, regardless of any concern about local health care facilities.
For antibiotic coverage, I prescribe Zithromax for most international adoptees, as children are rarely allergic to this medication. Zithromax treats ears, skin, and lungs; does not require refrigeration; and does not promote “super-bug” overgrowth. I give parents alist of symptoms that may require antibiotics, so that they know when to call. Symptoms on my list include: three days of a fever lessthan 103 degrees, irritability with fever, pulling ears, skin infections with scabs, and a general feeling of severe discomfort. I tell familiesthat upper respiratory infections and so-called “bronchitis” are NOT bacterial in nature, and will not require antibiotics. Upon prescrib-ing, I call in to the pharmacy a prescription for the powder (under the child's name), requesting that the correct amount of liquid beput into a separate bottle, to be reconstituted (if necessary).
For scabies, I prescribe Elimite during travel. Prompt treatment of scabies prevents the spread throughout the family, and this medicationis low in toxicity. If several children from a given orphanage have similar rashes, the likelihood is that they have scabies. Other medica-tions that should be carried by the family are acetaminophen and/or ibuprofen, nasal saline drops, glycerin suppositories, lice medica-tion, hydrocortisone 1% cream, a diaper barrier cream, and diphenhydramine (to be used for sedation on the plane, if necessary).
As for the malpractice issue (treating a patient you have never seen), I have been honest with families about my discomfort with suchpractices. I also inform them that I WILL NOT do this again while the child is under my care. It is a requirement of our office that allfamilies receiving travel prescriptions have a post-adoption medical evaluation appointment set up PRIOR TO traveling for adoption. Ialso require that I get a copy of the medical records provided by the orphanage to review for any other medical concerns. Compliancewith these requirements initiates a physician-patient relationship.
Doctor, please weigh your hesitancy to prescribe medications for a child you have not seen against the risks encountered by a delay inobtaining appropriate medical care. If you are unwilling to give medications, at least assist the family in locating (in advance) medicalresources in the country of their child's adoption, as well as providing a plan to obtain necessary medications. Having such a plan inplace will alleviate the anxiety of parents, who are anxious enough about making the transition into parenting.
It is also important for you to realize the range of health problems that may be present in these children, even though they may notexhibit any symptoms. When children are handed to new parents in a developing nation, it is usually obvious that they have been livingin conditions of extreme poverty. If you could see them at that moment, you would not hesitate to evaluate them for illnesses, includinghepatitis B and C, HIV, tuberculosis, parasites, syphilis, lead poisoning, anemia, developmental delay, and any other medical conditionrelated to living in poverty. By the time you see the child, he or she will look much more like the rest of his middle-class family. Regardless, you must still be thorough in the diagnostic tests you order (repeating all those done in the country of birth). Failure todiagnose diseases that may be asymptomatic could have far-reaching consequences for this child and his family. A full listing of recom-mended testing is in the Red Book, the report from the Committee on Infectious Diseases, from the American Academy of Pediatrics.
Studies have shown that many of these children have demonstrated negligible antibody titers to many vaccines, despite immunizationrecords indicating that the vaccines were given. With few exceptions, I recommend that vaccines be repeated or that antibody titers bechecked to document a child's immunity. Children may not react due to malnutrition, a temporarily compromised immune system,improper storage of vaccines, or even falsified records. All children, regardless of whether they were given the BCG vaccine, should alsohave a PPD done to test for TB. Any test that is 10 mm is considered positive (again, please see the Red Book).
The adoption of a child is a special time for a family, and the transition is made worse by having a sick child for whom the family can-not obtain adequate medical treatment. Parents are becoming more educated about adoption and health concerns, and they want a real-istic evaluation of the potential medical problems their child may face. Many adopting families have already dealt with infertility anddisrupted adoptions. They may feel unsure of themselves in terms of feeding, sleeping, and emotional problems. Don't let them worryabout potential medical problems, too.
Please contact me if you have any questions about this information or about the medical conditions of children adopted from China orother countries.
Deborah A. Borchers, M.D., F.A.A.P. Eastgate Pediatric Center, Cincinnati, OH 513-753-2820; fax 513-753-2824; firstname.lastname@example.org
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