In the United States, generalized routine laboratory screening of healthy children is not the standard of care. In children who are internationally adopted, extensive screening tests are performed for a multitude of reasons. These screening tests are recommended by the Pediatric Red Book of Infectious Disease and the Academy of Pediatrics. It is only through extensive laboratory testing that a physician may:
- Uncover a medical condition that has not yet presented itself clinically.
- Rule out a diagnosis or condition that was reported on the pre-adoption evaluation.
- Help to confirm the adequacy of treatment of a particular ailment or document cure.
Some parents feel that maybe they do not need to test their children because they had some blood work performed by the orphanage, and that the child was already seen by a physician in order to qualify for a visa. While these are all good things to have done for your child, they are not enough. The visa medical examination focuses primarily on detecting certain serious, contagious diseases that would make the child ineligible for entry in the United States. The procedure usually consists of a very brief physical examination and review of the child’s medical history. A chest x-ray is performed to look for active tuberculosis, and blood tests are performed to screen for HIV infection and syphilis. These tests are performed only if the child is older than 15 years of age; in those younger than 15 years, they are only performed only if there is a suspicion of medical illness. Chances are, since adoptees don’t really have much available medical history, the visa examination only consisted of documenting that the child was breathing at the moment of the examination and was not terribly ill with any contagious disease. As for testing done by the orphanage, caution should be used when interpreting it. While these tests are important in the pre-adoption evaluation process in order to help the family make their decision, the validity of these tests needs to be confirmed and they should only be considered as a screening tool. Confirmation of a medical diagnosis should never be made solely on these test results. Because there is a wide variation in the geographic regions where children are placed for international adoption, different medical problems can be encountered depending on the region origin. Screening is also important because of the unknown medical background of the child, inadequacy of health care, and poor living conditions encountered in the institutional care setting. A physician should see an internationally adopted child within two weeks of arrival in the United States. A child who is ill upon arrival with either an acute or chronic medical condition should be evaluated for that problem immediately. In the case of seemingly healthy children, the parents and child need time to get to know one another after arrival. The process of attachment and bonding needs to progress. The best way to accomplish that bonding is to spend time with the child and put them under as little stress as possible. Some parents may feel the need to have large family gatherings and parties, go on elaborate vacations to Disneyland, and buy everything at Toys ‘R’ Us for the child. While their intentions are good, this will only overstimulate the child and stress him or her out. Just like these painless examples, an immediate visit to a doctors office and multiple visits to the blood laboratory are other types of excursions that do not need to be made immediately unless the child is acutely ill. The initial post-adoption evaluation will include the following:
- A thorough review of the child’s medical history and concerns discovered on the pre-adoption evaluation
- A complete physical examination
- An evaluation of developmental milestones (using the Denver Developmental Screening test)
- An evaluation of the child’s immunization status confirmed with vaccine titers. (There is no harm in a child’s receiving an extra vaccine, but there may be harm if the child remains susceptible to these childhood illnesses. The doctor will use the same catch-up schedule that would be used if the child was born in the United States and was behind in the vaccines.)
- A laboratory screening for a multitude of medical concerns
I would like to try to explain what each lab test generally screens for.
- CBC (complete blood count): Provides information on the health status of the child’s blood cells, pertaining to anemia, which can be caused by a multitude of reasons: sickle cell disease, thalasemia, anemia of chronic illness, or just iron deficiency anemia.
- Lead Screen: Lead can cause anemia and developmental delay if untreated. Internationally adopted children often have high lead levels because lead is frequently found in old institution walls, water supply (pipes), and the overall environment as a pollutant.
- G6PD Deficiency: An enzyme deficiency common in Asia, Africa, and the Mediterranean region. Screening of children from these areas needs to be performed prior to prescribing medications that may cause hemolytic (blood cell breakdown) anemia in persons lacking this enzyme.
- Hemoglobin Electrophoresis: Screening in Asian children to look for thalasemia anemia.
- HIV Elisa: Tests for the AIDS or HIV virus.
- VDRL: Tests for syphilis. Frequently transmitted from the mother to child.
- Hepatitis B panel: Should be performed prior to hepatitis B vaccination. It tests for acute chronic illness as well as vaccine status.
- Hepatitis C: For hepatitis C
- Calcium, Phosphorous, Alkaline Phosphatase: Screens for Rickets.
- Urinalysis: Checks the overall kidney function.
- Stool sample: Looks for intestinal parasites. Giardia is common in institutions.
- Stool cultures: Looks at intestinal bacteria.
- Comprehensive metabolic panel SMA-20: Checks on overall body function, liver, and kidney.
- TFT: Screens for thyroid disease.
- PPD: Provides tuberculosis status.
- Immunization Titers: Checks to see if the child mounted an immune response in order to continue with the current vaccine schedule or restart all vaccines from the beginning.
- State Newborn Screen: Performed only in children less than 12 months. Checks for metabolic disorders routinely tested at birth (PKU, Biotinidase, Sickle cell).
- Hearing and vision tests
As you can see, that there is going to be a lot of blood drawn in order to perform these test. It is a stressful time for both child and parent. I generally recommend that the parents perform these tests on two visits spread at least one week apart.