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Thursday 30th of March 2017

A letter to Families with Children from China

The majority of the infants coming from China seem to be in excellent condition, far better than their counterparts from Eastern Europe and the former Soviet Union. However, one must remember that the first children to come through adoption programs tend to be the "best babies." As the agencies in the US become more experienced in the process of Chinese adoption and the authorities in China become more familiar with the limits of "acceptability" in an adopted child, we will see children with more severe problems. This has certainly been the experience of long-established adoption programs in other countries such as Korea and India. Thus, families should not presume that adopting a child from China is a guarantee of a "better baby" although I have already heard this opinion from both prospective adoptive families and Chinese governmental officials!

Healthy-appearing infants are usually just that - healthy. However, apparent good condition is never a reason to skip any or all part of the standard evaluation recommended for all international adoptees. This protocol was developed by the American Academy of Pediatrics based on decades of research and experience. The few times in my career when I thought I could skip some or all of the suggested tests in a child or group of children, the child and family have nearly always suffered. Numerous studies from Michign and Minnesota have shown that missed diagnoses only occur when this protocol is not followed.

Recommended by the American Academy of Pediatrics for all international adoptees, regardless of age or of country of origin:

  • Full Hepatitis B Panel
  • Tuberculosis skin test
  • Stool examination for parasites
  • Blood test for syphilis
  • HIV Screen
  • Complete blood count and urinalysis
  • Age-appropriate screening tests, especially for vision and hearing

 

Hepatitis B: There are rumours that Chinese authorities avoid designating known infected children as available for adoption. Thus, the rate of hepatitis B may be lower than in the native Chinese population. Regardless, hepatitis B is a widespread population problem in China and does occur in adoptees. In the past week, I have consulted on two such children, now aged 20 and 36 months.

Because the incubation period for hepatitis is up to 6 months, a child's hepatitis status is usually not clear until he has had two screening tests 6 months apart, or at least one test 6 months after leaving China. Apparent health is the normal condition of hepatitis B chronically infected children. Thus, every child must be fully evaluated.

Tuberculosis is an uncommon problem in international adoptees, at least as compared to refugee children. However, until the AIDS epidemic, almost all tuberculosis in the US was in immigrant children, especially from Asia. Although BCG does partially protect against tuberclosis, it is not 100%. The "old" teaching is that TB skin tests should not be done in the face of BCG vaccine. Longer experience has shown us that the concept is not valid. The centers for Disease Control and Prevention now recommend that all children coming from a high risk environment (such as an orphanage or hospital or China) should be screened for tuberculosis using the PPD (blister under the skin) tuberculosis test. Interpretation of the result is exactly the same as if one had never received BCG. Thus, even your office pediatrician can perform and interpret the test.

The only children who probably should not be tested immediately are those who have a fresh, still-healing BCG scar. Those children should be tested 6 months to a year after the scar has healed, sooner if they develop any suspicious illness.

Intestinal Parasites: Parasites, such as worms, are unusual in infants until they reach the toddler stage when they can and do put anything and everything into their mouths. Infants in most countries are breast-fed for most of their early months and thus, have little or no exposure to parasites. Thus, pediatric textbooks state that parasites do not exist or are very rare in the child less than 12 months old. However, institution-raised children have very different exposures. They are fed formula made with water, they often live in very crowded circumstances with children of varying ages and they are often weaned to solid foods at younger ages than breast-fed babies. Thus, all such children, regardless of age, are at risk for intestinal parasites.

Chronic intestinal parasites may present with few or no symptoms. Good growth, lack of diarhea, young age, etc. are not reasons to skip stool tests for parasites. The parasites most infants acquire are the water-borne types such as Giardia. Unfortunately, these are also the easiest to pass on to their new adoptive families! One stool test for ova and parasites, collected into preservative solution, is probably adequate for the otherwise healthy infant. Older children should have at least three specimens collected at intervals of one week or longer.

Syphilis is an unusual condition in adoptees of the past although we are seeing it more frequently world-wide because of the AIDS epidemic. This screening is one of the few tests often done at the time of the US visa but most parents have no access to the results. Since the test is easy to do and the disease is treatable, it is recommended for all immigrant children.

HIV screening is not routinely recommended but most pediatricians have been testing adoptees. To my knowledge, the only infected children inadvertently adopted to the US have been from Panama and Romania; these statistics will certainly change over the next decade. It's hard to know the epidemiology of HIV in China as wide-spread screening is not practiced. However, for the vast majority of children, HIV is not an issue. The only known highly epidemic areas in China are the provinces bordering India, Myanmar and Vietnam.

What other health concerns do parents of Chinese children have? Questions most frequently raised so far have been about Mongolian spots (normal black and blue birthmarks found over the back of buttocks), lactose intolerance (common as many adult Chinese will assure you!), hemoglobinopathies (unusual but of different types than found in European or black populations), malaria (rare in all but the southern regions of China) and alcohol intolerance (due to the lack of an alcohol-metabolizing enzyme, somewhat common in Asian populations).

The American Academy of Pediatrics recommendations may be found in: 1991 Report of the Committee on Infectious Diseases (also known as "The Red Book"), Evanston, IL: American Academy of Pediatrics, Pages 109-112.

Jerri Ann Jenista, MD, 815 West Jefferson Street, Ann Arbor, Michigan 48103 USA, telephone(313)668-0419, is a pediatrician specializing in pediatric infectious diseases and the medical problems of adoptees and immigrants. She is the mother of four daughters adopted from India and has been very helpful to a number of FCC parents who have called her for advice, some of us from China! Thank you.


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