Thursday 27th of April 2017

An Open Letter to Pediatricians on Chinese Adoption Medical Issues

Dear Doctor:

As an adoptive parent of three daughters born in China, I have been fortunate to travel to this wonderful nation. During all three of my adoption trips, I viewed China and its medical care delivery system through the eyes of a mother as well as a pediatrician. I have been fortunate enough to visit the orphanages of two of my daughters, and even able to visit a children's hospital. It is my wish to communicate to you the conditions from which your future patient may come.

All of my daughters were from orphanages in remote towns. The orphanage rooms had little outside light, no window screens, no central heat or air conditioning, and very few toys. Children were fed with a common spoon and bowl. Many of the children had rashes, and several had head lice. Despite some reports in the media however, it was obvious that the caretakers cared for the children in very loving ways, meeting the children's basic needs of warmth, food and changing diapers. Due to the conditions of extreme poverty some of the medical needs of these children were not being adequately addressed.

While in China I examined children from my daughters' orphanages, as well as other children. Many of the children had ear infections, scabies, lice, and extensive eczema. Some had impetiginized areas on the back of their scalp. Others had perforated eardrums due to delays in starting antibiotics. Out of desperation, one family had taken their child to a Chinese physician, and a Chinese medicine (one not used in this country) had been prescribed to treat the child for otitis media. The child worsened, and we were also able to treat appropriately once I examined her and changed medications to one brought with me from the US. All of the children showed significant improvement with "Western medications" not obtainable in China, including Elimite, Nix, Hydrocortisone cream and antibiotics as I prescribed. It was evident that these families, all of whom were first-time parents, had many concerns regarding their child's health, but they were unable to obtain appropriate access to reliable medical care.

Since my adoption trips, two families from my local area have had children that became quite ill prior to their journey home. One had seizures with fever due to pneumonia, and the other had bacterial pneumonia. Both were hospitalized at Chinese hospitals. The mothers said that the medical care in the hospitals were not at all similar to standards used in the US, and the decision to treat with antibiotics was a decision reviewed each day rather than determined in conjunction with the diagnosis. Thus, these children received only three days of medication for problems routinely treated in our country for ten days. Fortunately for one child, a physician also adopting a child was able to provide additional medications (that she had brought for her own child) and prevent worsening of the illness. Both mothers were concerned that the children would actually contract illnesses from their hospitalization, as there was no reassurance that blood and body fluid precautions were being used.

My visit to a children's hospital revealed doctors trained in Western medicine, but very limited in the technology and ability to provide medical care as we know it in this country IV fluids were hanging in open bags, subject to air contamination. Children were in ward rooms, and it was difficult for parents to be at the bedside to comfort them. At the Children's Hospital the trauma room had very limited equipment and lighting. Even the required physical examination done on all adoptees before obtaining the visa necessary for entrance into the US was quite limited in its scope, with no blood work for HIV, Hepatitis B, lead poisoning or syphilis, no PPD, and no monitoring for stool infections. Some children had received immunizations prior to adoption, but there was no guarantee that the vaccines had been stored or administered properly. Thus, there were questions as to their efficacy.

It was evident to me while in China (as well as the other developing nations from which many international adoptees come) that medical care is much different from here in the states. There was significantly limited access to physicians who could even diagnose otitis media (headlamps were used for the immigration physical, and otoscopes were simply not available), and the style of medicine practiced there varied from our accepted norms.

Due to language and cultural barriers, emergency visits are quite different than they are in our country. Families may or may not have an interpreter to take them for a medical evaluation for an ill child. Children in many countries are bundled to protect against the cold, even if they are febrile. Even in major cities in developing nations there may be no easily accessible emergency rooms, or even Urgent Care facilities for families to visit. The standards of medical care are quite different, sometimes using a combination of herbs and "western" medications, IF the western medications are even available. The prescriptions are handed out by the physician rather than going to a pharmacy, with little quality control (and no FDA oversight for safety).

I fully recognize that most infections that children have are viral in etiology. I am also fully aware of (and implementing) the new AAP guidelines for judicious use of antibiotics for otitis media, treating pain and not necessarily infection. At the same time, international adoptees often have secondary bacterial infections due to the hygiene in the orphanage, dormitory style living and malnutrition. Although such infections are unlikely to be fatal, they certainly interfere with the bonding and attachment process taking place at the time of adoption, a process which is so vital for long term mental health. These infections also make for a very long and uncomfortable plane ride home prior to the child accessing your medical care.

For the sake of your future patient, please give contact information to be used by a family if they have medical concerns about their child. Although I admit this is controversial, please also consider giving the family two prescriptions for travel. With my patients, I often give them prescriptions with the promise that they will contact me (via e-mail or phone) or seek care from a western trained physician prior to starting the medication. With this promise in place for over 8 years of caring for adoptees, no one has ever started antibiotics inappropriately. It needs to be clear that if the child is ill appearing (suggestive of a more serious infection), urgent medical care should be sought, regardless of concern about the available health care facilities.

For antibiotic coverage I prescribe Zithromax for most international adoptees, as children are rarely allergic to this medication. Zithromax covers ears, skin and lungs, does not require refrigeration, and will not promote "super-bug" overgrowth. I also give parents a list of symptoms that may require antibiotics so that they know when to call. These may include three days of a fever less than 103 degrees, irritability with fever and pulling ears, skin infections with scabs, or a general feeling of discomfort. I review with families that upper respiratory infections and "bronchitis" are NOT bacterial in nature, and will not require antibiotics. Upon prescribing, I call into the pharmacy a prescription for the dry powder (under the child's name), requesting that the correct amount of liquid be put into a separate bottle to be reconstituted (only if necessary).

For scabies, I prescribe Elimite for travel. Prompt treatment of scabies prevents the spread throughout the family, and this medication is low in toxicity. If multiple children from a given orphanage have similar rashes, the likelihood of scabies is higher. Other medications that should be packed by the family are acetaminophen and/or ibuprofen, nasal saline drops, glycerin suppositories, lice medication, hydrocortisone 1% cream, a diaper barrier cream, and diphenhydramine (to be used for plane sedation if necessary).

As for the malpractice issue (treating a patient you have never seen), I have been honest with families about this issue and my discomfort. I also inform them that this WILL NOT happen again while the child is under my care. It is a requirement of our office that all families receiving travel prescriptions have a post adoption medical evaluation appointment set up prior to traveling for adoption. I also require that I have a copy of the medical records provided by the orphanage to review for other medical concerns. This initiates the physician-patient relationship.

Please weigh your hesitancy to prescribe medications for a child you have not yet seen with the risks encountered in a delay in obtaining appropriate medical care. If you are unwilling to give medications please at least assist the family in locating (in advance) resources in the country of their child's adoption to seek appropriate medical care, as well as giving them a plan to obtain necessarily medications. Having such a plan in place will be very helpful at alleviating the anxiety of parents who are already anxious about making the transition into parenting.

It is also important for you, as a physician, to realize the scope of health problems that may be present in these children, even though the child may not have any symptoms. When children are handed to their parents in a developing nation, it is obvious that the children have been living in conditions of extreme poverty. Seeing them at that moment, no physician would hesitate to evaluate them for illnesses including hepatitis B and C, HIV, tuberculosis, parasites, syphilis, lead poisoning, anemia, developmental delay and other medical conditions related to living in poverty. By the time you see the child s/he will look much more like the rest of their middle class family. Please still be thorough in the diagnostic tests you order (repeating all those done in the country of birth). Failure to diagnose diseases that may be asymptomatic could have far reaching health consequences for this child and his/her family. A full listing of medical testing recommended is in the Red Book, the Report from the Committee on Infectious Diseases from the American Academy of Pediatrics.

Finally, many studies have shown that these children have demonstrated negligible antibody titers to many vaccines, despite immunization records that indicate that the vaccines were given. With few exceptions, it is recommended that vaccines be repeated or that antibody titers be checked 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 also have a PPD done. Any test that is 10 mm is considered positive (again, please see the Red Book).

The adoption of a child is a very special time for a new family, and the transition is made worse by having a sick child for whom the family cannot obtain adequate medical treatment while abroad. Parents are becoming more educated about adoption issues, and will want a thorough evaluation of the potential medical problems with which their child may be faced. Many of these families have already dealt with the issues of infertility and disrupted adoptions. Their helplessness in feeding, sleeping and emotional concerns, as well as concern about potential medical problems, will only worsen their own feelings of inadequacy.

Please contact me if you have any questions about this information or the medical conditions of children adopted from China and other countries.

Sincerely yours,

Sincerely yours. Deborah A. Borchers, M.D., F.A.A.P.
Eastgate Pediatric Center,
Cincinnati, OH
513-753-2820; fax 513-753-2824; This email address is being protected from spambots. You need JavaScript enabled to view it.

Revised May 29, 2005. Reprint permission is not necessary for parents, social workers or physicians. Please contact me for permission prior to placing on a website.

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