CISTM16 Wi-Fi Access Medical Considerations in the 1.Choose HILTON - PDF document

6/19/2019 CISTM16 Wi-Fi Access Medical Considerations in the 1.Choose HILTON MEETINGS as your wireless Internationally Adopted Child connection. 2.Open any web browser. Laurie C. Miller, MD 3.When prompted, select “I have a promotion Elaine E. Schulte, MD, MPH June 7, 2019 code” 4.Use ISTM19 code to complete connection. 1 2 Disclosures Objectives 1. Describe the medical, developmental, and behavioral issues that are important to consider in the Drs. Miller and Schulte have nothing to disclose. internationally adopted child 2. Understand the physician's role in preparing the prospective adoptive family (including needed vaccines for family members, preparation for travel, as well as preparing for special needs, "adoption arrival issues") 3. Be familiar with the recommended components of the American Academy of Pediatrics’ initial comprehensive medical evaluation 4. Make informed decisions about immunizing a newly adopted child 5. Explain the appropriate medical follow ‐ up and support of adoptees and their families throughout childhood and adolescence 3 4 What do you say? You’re attending a neighborhood barbeque and friends from across the street approach you because they know you’re an international medicine doctor. They want to adopt a child from overseas because they think the child will be healthier than a domestically adopted newborn, who’s likely to be exposed to opioids. 5 6 1

6/19/2019 Who are the Children? • Orphanage care • Foster Care • Prenatal adversity - Substance/environmental exposures, malnutrition, stress • Postnatal adversity • Malnutrition, abuse, neglect, abandonment • Complex special medical needs - May or may not have received needed care • CHILDREN COME WITH A HISTORY 7 8 Life in an Orphanage Life in an Orphanage • Boring • Growth delays - Wt, then ht, then ofc for young • Lack of individual attention children • Inadequate nutrition - Height most impaired over time • Infectious disease exposure • Developmental delays • Scheduled routine, with no - Language, communication, & variation for individual needs interpersonal skills most impaired 9 10 Foster Care Epidemiology – International Adoption • >307,000 children, from >40 countries have entered US since 1990 • Generally an improvement from institutional care • 1986 ‐ 1990 Korea • Often involves multiple • 1991 ‐ 2008 China, Guatemala , Russia, Korea, Ethiopia placement changes • Inherent separation & loss • 2008 ‐ 2016 China, Congo , Ukraine, Korea, Bulgaria issues • Recent shift to older children 11 12 2

6/19/2019 Number of International Adoptions to the Country representation ‐ 2016 United States – 1995 ‐ 2016 China Ethiopia India Uganda Korea Ukraine Congo Other 1995 2004 2016 Year 13 14 Short and Long ‐ Term Considerations Tolerable Stress • Stress and Trauma • Tolerable stress occurs when the body’s alert systems are activated to a higher degree • loss of a loved one • a fire • a frightening injury • Child experiences significant stress, but has support of loving adults • Adult helps child relax and allows child to recover 15 16 Toxic Stress • Strong, frequent, and/or prolonged adversity that’s not buffered by adequate adult support • Children who are subjected to physical, sexual, or emotional abuse, chronic neglect, exposure to violence, and/or the burdens of family economic hardship experience toxic stress • Children may feel that adults are not to be relied on or trusted • Children experience the world as a dangerous place • Even fetuses can experience toxic stress Nelson, CA, et al. Neural Plast. 2019; 2019: 1676285. 17 18 3

6/19/2019 Using the Live Audience Response System BY INTERNET USING WIFI (preferred) a. Be sure your mobile device or laptop is connected to Wi-Fi Children adopted internationally are at increased risk of: b. Go to the website shown at the top of the slide: a. Developmental delay www.pollev.com/LincolnRoom b. Mental health concerns c. Type or tap your response – that’s it! c. Infectious diseases d. All of the above BY TEXT a. Join by texting “ LincolnRoom ” to 22333 b. You will receive a confirmation text c. Type your answer in text and hit “send” to answer the questions 19 20 Preparing the adoptive family • Pre ‐ adoption counseling • General • Special Needs • Preparation for travel (including vaccines) • The transition • The child and family • Medical issues 21 22 • ~14,000 waiting families • 2018: 615 children arrived 23 24 4

6/19/2019 Understanding (limitations of) the medical record Understanding (limitations of) the medical record Prenatal alcohol exposure Prenatal alcohol exposure Special needs Special needs Preparation for travel Preparation for travel Risk of infectious diseases Risk of infectious diseases The transition The transition Growth and developmental delays Growth and developmental delays “Baggage” from early life experiences “Baggage” from early life experiences Risk of neurobehavioral disorders Risk of neurobehavioral disorders Long ‐ term follow ‐ up needs Long ‐ term follow ‐ up needs 25 26 Understanding (limitations of) the medical record 27 28 Understanding (limitations of) the medical record Lab results Growth measurements Photo Hepatitis B HIV Syphilis 29 30 5

6/19/2019 Limited information, sometimes “unusual” 31 32 Special needs Special needs 47% Any condition that makes it more difficult to find an adoptive Any condition that makes it more difficult to find an adoptive family family USA 25% (2013) USA 25% (2013) • Age (Age >5 yrs) • Age (>5 yrs) Hague Convention on Hague Convention on Netherlands 31% (2013) • Sibling group • Sibling group Intercountry Adoption Intercountry Adoption Netherlands 31% (2013) • Medical condition Sweden “most” (2013) • Medical condition Sweden “most” (2013) France 70% (2018) France 70% (2018) THIS DOESN’T INCLUDE SPECIAL NEEDS DIAGNOSED AFTER ARRIVAL 33 34 Special needs Special needs Obvious Physical Findings: YES NO Premature Overlooked implications Undescended testicle The Infernal List! Umbilical hernia Cleft lip Cleft palate Visual problem Strabismus Deformed ears Heart murmur Sample from 5 page document Cardiac anomaly G6PD deficiency Thalassemia Other blood problems Hepatitis B Other infection Malformed hand, legs or feet Smith ‐ Lemli ‐ Opitz Syndrome Russell ‐ Silver Syndrome Difficulty moving (autism, severe developmental (poor growth, renal Autism delay, many organ malformations) malformations, GI problems) Behavior problem Prior possible abuse 35 36 6

6/19/2019 Special needs Special needs Missed diagnoses “Inapparent” special needs • Behavioral disturbances • Attachment disorder • School or learning problems (ADHD ~2 ‐ 4x increased risk) Astley & Clarren J Peds 129:36, 1996 Various studies 2005 ‐ 2014 37 38 Risk of infectious diseases HEPATITIS B HEPATITIS A TUBERCULOSIS PARASITES SYPHILIS HEPATITIS C HIV 39 40 Risk of infectious diseases Risk of infectious diseases Preparation for travel Preparation for travel HEPATITIS B HEPATITIS A TUBERCULOSIS MEASLES 41 42 7

6/19/2019 Risk of infectious diseases Risk of infectious diseases Preparation for travel Preparation for travel 27 cases Adoptee Measles Outbreak Hepatitis A Traveler Non ‐ traveling contact 15 adoptees Contact of NTC 19 26 54 families 7 9 states 48 Consulate staff Hotel personnel Flight attendants & passengers on many flights Clin Infect Dis 2008, 47(6): 812–4 Extended family members and family visitors MMWR . 2007; 56:144 ‐ 6 43 44 Risk of infectious diseases Preparation for travel Preparation for travel Parents and other close contacts: recommended vaccines • Parents also need general travel advice Measles Varicella DTP HAV HBV Polio • Accompanying children – vaccines and general safety and Born Document immunity Document before or 2 doses of MMR prior Tdap 1990 health ( ≥ 28 days apart) if born after 1956 Document immunity IPV if prior vaccine and travel to risk Document disease or area prior vaccination ( 2 doses ≥ 3 months apart) https://wwwnc.cdc.gov/travel/yellowbook/2018/international ‐ travel ‐ with ‐ infants ‐ children/international ‐ adoption 45 46 The transition Preparation for travel The visa exam • Physical exam • Vaccine catch ‐ up (or waiver) • TB screening >2 years *(TST/IGRA if positive, CXR) • VDRL (not required if <15 unless infection suspected) Inadmissibility criteria: communicable disease of public health significance*, inadequate vaccine record, physical or mental disorder with associated harmful behavior, drug abuser or addict *TB, syphilis, GC, Hansen’s, Quarantinable diseases, or public health emergency of international concern (PHEIC) 47 48 8

6/19/2019 The transition The transition 49 50 The transition The transition 51 52 The transition The transition 53 54 9

6/19/2019 The transition The transition Transition behaviors • Eating • Sleeping • Potty • Play • Sensory 55 56 The transition The transition 57 58 The transition 59 60 10

6/19/2019 The transition 61 62 The transition The transition 63 64 Finally, the arrival medical exam! The arrival medical exam Wow, he looks great! And he was already tested for Hepatitis B, HIV, and syphilis in Peru! 65 66 11