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Recommended Screening Tests and Evaluations for child under adoption

     

Kopila- The Well Baby Clinic performs a variety of screening tests for children being considered for international adoption. These tests are essential for the health of adopted child and the family as this provides adoptive parents with an unbiased assessment of the child’s condition, so that a parent can make this crucial decision in the most informed way.

Adoption evaluation

This service consists of two parts:

1. Medical evaluation
2. Neuropsychological screening (developmental screening)

1. Medical: the evaluation consists of a review of all available medical records, physical examination, vision and hearing screening (if age appropriate), laboratory tests and interpretation, and anticipatory guidance about attachment and well child concerns, especially those relevant to the post-institutionalized child.
 

There is consensus among adoption medicine specialists about the screening tests that should be performed on every child adopted from abroad initially. The list below is a more comprehensive list recommended by most adoption medicine specialists and as per guideline recommendations on Redbook of Pediatric Infections, a publication of the American Academy of Pediatrics.

Children adopted from Nepal may have one or more of the illnesses with absolutely no symptoms, namely no cough for TB, no diarrhea for parasites, no jaundice for hepatitis B, and no growth failure for thyroid dysfunction.

These tests are done in state-of-art medical laboratories (in Nepal and abroad) so that these tests need not be repeated when the child arrives at the adopted home country.

It is suggested that families make an appointment with Kopila Clinic as soon as you arrive in Nepal, before or after adoption process begins. This will allow you to have your child examined for any contagious illnesses, evaluated for any conditions that need additional medical referrals (chronic problems), and allow to review the child's immunization status.

 Recommended blood, urine and screening tests

Your child should have several blood tests before or after adoption process begins. If it is done before the process, you can make informed decision on the adoption, and if done after, you will be well prepared to deal with any underlying problems.

  • A Hepatitis B profile is needed to evaluate children for acute or chronic hepatitis B. This should include the Hepatitis B surface antigen , Hepatitis B core antibody and Hepatitis B surface antibody (HBsAg, anti-HBc or HBcAb, and anti-HBs or HBsAb). These basic tests will show if a child has hepatitis B, has been exposed or has had the vaccine, or is a carrier of the disease. If any of the tests are positive, the doctor may recommend further testing to delineate the extent of the illness. It is necessary to do all of the tests listed above (and not just the Hepatitis B surface antigen commonly done by most doctors as a screen), as up to 60 percent of children with Hepatitis B may be missed with only doing the usual blood screen.
  • Hepatitis C has also been seen in some adoptees, and it is recommended that all international adoptees be screened for the antibody to this virus.
  • HIV testing by ELISA for HIV-1 and HIV-2 is recommended for all children. This illness, although not very common in Nepal unlike other Asian countries like Cambodia and Thailand, is recommended for parental peace of mind and for early identification of HIV.
  • A stool examination for ova and parasites, giardia and bacterial infections is recommended for all adoptees from Nepal, not just (but especially) for those with diarrhea. Children living in orphanages in Nepal are at a higher risk, as are children who are significantly malnourished. It is not necessary for children to have diarrhea for them to have illnesses diagnosed by these tests.
  • A complete blood count (including Hemoglobin) to check for anemia, allergies, and/or infection is recommended.
  • A blood test for VDRL (usually syphilis) is recommended to evaluate the child for syphilis, which could have been acquired from his/her birth mother. If this test is positive, further blood tests are necessary. A spinal tap to check for Neuro-syphilis which could cause developmental problems may also be recommended..
  • A screen for hypothyroidism (a TSH) is recommended now for all children adopted internationally.  Some babies are born with thyroid problems not seen at once.  Screening tests are available for hypothyroidism (deficiency of the thyroid hormones), which is extremely essential for the normal brain development of a baby.  Congenital hypothyroidism, a case of inadequate thyroid hormone production in newborn infants, is the most common disorder identified by routine screening. This can occur because of an anatomic defect in the gland, an inborn error of thyroid metabolism, or iodine deficiency.  Iodine deficiency disorders (IDD) affect an estimated 10 million Nepalese nationwide, which is almost half of the entire population and one of the highest in the world.  Congenital hypothyoidism retards growth and brain development.  If it is detected in time, a baby can be treated with oral doses of thyroid hormone to permit normal development.  It is difficult to identify the babies with this problem by just looking at them.  But by doing a blood test on a few drops of blood, this problem can be detected as early as first few days of life.  Most birth children born in the US or other developed countries are screened for this disorder before discharge from the hospital of birth.
  • A PPD test should be placed on a child's arm to screen him/her for tuberculosis. Many children born in hospitals in Nepal receive a BCG vaccine shortly after birth while some are also born at home, thus not getting opportunity for BCG shots. This vaccine is supposed to protect against tuberculosis, and the children may have some reaction to the PPD after receiving this vaccine. However, it is still strongly recommended that all international immigrants, including children from Nepal be screened for exposure to tuberculosis, regardless of whether they have received the vaccine. This test can safely be done on children as young as two months, as long as the BCG scar is not freshly healing. It should be read (looked at to see if it is positive or negative) in 48 to 72 hours by Kopila health care professional, not just a parent. Because these children are children at high risk for disseminated tuberculosis (spreading beyond the lungs, potentially to the kidneys and brain), a positive result is one where the injected area is raised above the skin 10 millimeters or more. The interpretation of this test does not change even if the child had the BCG vaccine.
  • A urinalysis should be done on a urine specimen to evaluate for any blood, protein or infection in a child's urinary system that may need further evaluation.

Other recommended evaluations

  • In addition to blood and urine testing, it is strongly recommended that children have other medical screens for problems for which he/she is at high risk. Some of these problems may have no apparent symptoms at the time of his/her adoption, but statistics show that these children are at increased risk for concerns in these areas.
  • A hearing screen is recommended for all children adopted from Nepal. Early intervention with children with hearing impairment is necessary to ensure proper language development and hearing augmentation, so it is helpful to have this screen done soon after you decide to adopt.
  • Likewise, a vision screen and evaluation by an ophthalmologist is recommended. Crossed eyes is a common problem in institutionalized children. As children from orphanage does not have birth history, it is not known if the birth mother had any infections that could compromise the child's vision long term. These infections could include Toxoplasmosis (a parasite infection often passed through cat feces) and Rubella (German measles). Similarly, a family history of eye problems is not known, so the ophthalmologist should screen for any hereditary eye problems.
 

2. Neuropsychological screening (developmental screening)

A developmental screen is recommended to evaluate a child's developmental level of a child. In some countries this information may also be useful in helping a family to qualify for a special needs adoption subsidy. This can be done by a pediatrician at Kopila through a test known as the Denver Developmental Screening Test (DDST). The advantage of having DDST done at Kopila rather than in home country is that this developmental screening ideally should be done in the child’s primary language and such opportunities are rare abroad.

Immunizations

Some children placed at orphanage will have received immunizations prior to their adoption. Others may receive immunizations at the time of their medical evaluation for adoption. Generally, the timing falls into one of three categories:

Immunizations given to children while in orphanages should be repeated. According to multiple adoption medicine specialists, blood testing performed on children in similar institutional care who had received immunization from government hospitals in Nepal demonstrated that the children did not have full antibody protection against the diseases for which they had been immunized, despite records that reflected a full set of immunizations. There are strong questions about the proper storage and administration of the vaccines, as well as whether the records are even accurate reflecting that the shots were even given. All live virus vaccines, such as the MMR (Measles, Mumps, Rubella or German Measles) and Chicken Pox vaccine should be repeated (once the HIV test is shown to be negative). Blood testing should also include testing for the Hepatitis B Antibody (as mentioned earlier), as this will show if a child has antibody to Hepatitis B. Most of the vaccines used these days have such low side effects that it is safe to repeat them, even if a child actually received the vaccines at orphanage.

Immunizations given at Kopila – The Well Baby Clinic are proven to be more reliable, and do not need to be repeated. Vaccines at Kopila comes directly from the International Manufacturers in Lyon, France, Belgium and the United States, maintaining proper cold chain and after it arrives at Kopila, utmost care is taken to insure its shelf life as per the guideline recommended by CDC, USA. Again, it is completely safe to repeat most vaccines, with no risk to a child.

Immunizations given to children at the time of the medical evaluation for the visa are considered to be the safest and most reliable of the vaccines. The record needs to be presented to Kopila staffs so that s/he can then time the administration of future vaccines using that information.

We strongly recommend that you include taking up adoption package at Kopila in the adoption process because agencies and facilitators are rarely qualified to assess a child’s health. If a child is deemed to be healthy in the host country, an agency will typically accept that assessment. Nevertheless, it is common to identify health issues in the records of these children that should be disclosed to parents. While many conscientious agencies recommend or require comprehensive screening tests, others do not recommend “looking for trouble” or performs tests merely to fulfill formalities.

The process: The medical records and growth data review, physical examination, blood screening tests and developmental tests are carried out by Dr. Anu Amatya at Kopila and then these reports are scrutinized for evidence of conditions that impact long-term health (such as evidence of microcephaly, or prenatal infections, for example). Families will receive a written report as well as consultation over the phone or in person. It is understood that this is a time-sensitive process, so every effort is made to complete the assessment within 7 days.

Background of Anu Amatya, M.D.

Dr. Anu is a Consultant Pediatrician and adoption medicine specialist at the Kopila – The Well Baby Clinic, Pulchowk, Lalitpur, Nepal (00977-1-5542767). She is trained in the USA and has more than 14 years of Pediatric experience in many countries in Asia, Africa and North America including the United States. She provides health evaluations for pre and post adoption. Currently she sees about 200 patients per week which includes 8-10 international adoption per week.

Fees: Complete adoption screening package including follow-up information and conference with your pediatrician in your country –NPR 38,684.00 (equivalent to  US$ 563.00 @ 1 US$ = NPR. 70.00)

This adoption Package include following tests which are in agreement with recommendations by the American Academy of Pediatrics, Committee on Infectious Diseases as well as a consensus of physicians in the US and other developed countries with expertise in international adoption:


 

Adoption  Package

 

  1. Physical Examination 
  2. DDST (Denver Development Screening Test), a developmental exam essential for all international adoptees.
  3. Vision and Hearing Screening Test   
  4. Comprehensive Blood Work

 

a)       Hematology- (To rule out Anemia, Recent infection & Chronic infection)

*      Complete Blood count with differential and platelets

*      Hemoglobin

*      Blood Group

 

b)     Renal Function Test (To assess Kidney Function)

*      Serum Creatinine

*      Sodium                    

*      Potassium

*      Chloride

 

c)      Liver Function Test- (To Asses Liver Function)

*      Bilirubin (total, direct & indirect)

*      SGOT (AST)

*      SGPT (ALT)

*      Alkaline Phosphatase

*      Gamma Glutamyl Transferase

*      Serum Total Proteins

*      Serum Albumin

*      Serum Albumin/Globulin ratio

 

d)       Immunology

*      HIV (I & II)- (ELISA Method)

*      Hepatitis B serology (C.L.I.A Method)

·         Hep B surface antigen (HBs-Ag)-E.L.I.S.A Method)

·         Anti Hep B core antigen-total (AHBc-T)

·         Anti Hep B surface antigen-total (AHBs-T)

·         Anti Hep B core antigen-IgM (AHBc-IgM)

*      Anti Hep C virus- Total (AHCV)-E.L.I.S.A Method)

*       VDRL (Syphilis)

 

*       TORCH  Profile- (E.L.I.S.A. Method)

(Congenital Infection)

 

Ø      Toxoplasma Gondii (TOXO)-IgG

Ø      Toxoplasma Gondii (TOXO)-IgM

Ø      Rubella (RUB)-IgG

Ø      Rubella (RUB)-IgM

Ø      CytomegaloVirus (CMV)-IgG

Ø      CytomegaloVirus (CMV)-IgM

Ø      Herpes Simplex Virus (HSV)-IgG

Ø      Herpes Simplex Virus (HSV)-IgM

 

e)       Thyroid Hormone Test (C.L.I.A. Method)

(To Asses Thyroid Function)

*      Free Tri-idothyronine (FT3)

*      Free Thyroxine (FT4)

*      Total Thyroxine (T4)

*      Total Tri-idothyronine (T3)

*      Thyroid Stimulating Hormone (TSH)

 

f)       Blood Culture

g)   Serum Level for Lead, G6PD and PKU

  1. Miscellaneous

*       Urine Routine

(To assess Urine infection)

*       Urine Culture

*       Stool Routine

(To rule out Worms/Giardia)

 

  1. Immunization

*       Mantoux Test (to rule out Tuberculosis)

*       Recommended Vaccine (not included in the package)

 

   

KOPILA TEAM

 

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