Welcome Home Guide

What follows is a list of our typical recommendations at the initial post-placement evaluation. That first visit is a doozy, and much of what we say tends to get lost in the shuffle, so we'll recap many of our suggestions below. We like for folks to have a copy in hand when they leave our office, but you'll also find this article online at www.adoptmed.org/welcome, so that you can follow the links.

Medical Issues

If you are lucky enough to live within driving distance of an international adoption specialist, we highly recommend an initial evaluation 1-2 weeks after homecoming with someone experienced in the unique growth, developmental, infectious disease, and parenting issues that our children tend to bring home with them. A full list of international adoption docs can be found here and here, and we describe our recommended evaluations in this article, as well as in our travel packet.

Immunizations

Unless you've adopted from Korea (we trust their shots), or Guatemala (we sometimes trust the shots there), we recommend that you either check titers (blood tests to confirm immunity) or start over on shots.

• Hib and Prevnar (pneumococcal) immunizations are rarely performed in the typical sending countries, so I like to just start those at the first visit. Luckily, you only need 2 each of these if started >12mo, and you only need one Hib if given >15mo.
• It's also rare to see an international adoptee with full immunity to measles, mumps, and rubella, so we'll often start MMR over as well, unless MMR immunization is well-documented at >1yo, in which case we could check titers.
• Many IA children have received multiple DTP (diptheria, tetanus, and pertussis) and Polio immunizations, so those are ones I like to check with titers. However, titers done at less than 12-18mo may reflect transferred maternal antibody, so these may need to wait until the followup blood draw when children have been home ~6 months. If we have to wait to check titers, I will usually give 1-2 DTaP boosters, and perhaps one polio (IPV) booster, both to ensure coverage (lots of tetanus and whooping cough around, not so much polio in this hemisphere though) and to give the titers a good chance of proving immunity. Tdap (tetanus booster with added whooping cough protection) is a good choice for 11-18yo adoptees.
• Hepatitis B titers are routinely checked at arrival and 6 months later, so we hold off on those shots until we see what the labs say.
• Hepatitis A immunization (2 shots, >6 months in between) is also a good idea, but not typically my first priority. Ditto for varicella (chickenpox, 2 shots) ... both can be checked with titers, but the extra blood and expense may not be worth it given that we wouldn't save that many shots.
• The new oral rotavirus vaccine is not an option, as the first dose must be given at 6-12 wks old, with the last dose not given later than 32 wks old.

I tend to be a "lumper" rather than a "splitter" when it comes to shots. I've seen no reliable evidence that immunizations "overwhelm" the immune system, and prefer to have fewer shot visits overall than drag things out by only doing 1-2 shots at a time. That said, I'm a flexible guy when it comes to shots ... please share your concerns with us.

The Vaccine Education Center at Children's Hospital of Philadelphia is my favorite online source for shot information from the generally pro-immunization perspective, as they link to relevant studies and also specifically address a lot of internet vaccine mythology.

Lab Tests 

• A list of typically performed lab tests is listed here. Yes, that's a lot of tests, but it's the only way to know if many frequently encountered problems are present or not.
  
• This is standard of care for internationally adopted children, although we get a bit creative in our office with children from Guatemala and Taiwan, and don't perform routine labs for children from Korea.
  
• Our lab on the 1st floor downstairs, or the lab at Children's, is a good place to get these done. If the draw is not going well, you can certainly decide to try again in a few days.
• It's going to require a lot of blood, typically drawn from the elbow or back of the hand, but your child will make more. Try to be calm, supportive, and resolute during the blood draw, model deep belly breaths, and try to put worries about attachment trauma and other anxieties out of mind, since your child will respond to your emotional state.
  
• If your insurance company balks at coverage (tsk tsk), you and your pediatrician can adapt this insurance letter by Deb Borchers, MD. Refer them to the AAP Red Book, as well.
• In our office, you can expect a call with all of the lab results in about 2 weeks, a bit longer if titers are perfomed. We'll call sooner with any concerning results.
  
• If you haven't heard by 2-3 weeks, please give the nurses a call at 206-598-3030.
• In 6 months or at 18 months-old, whichever comes later, we need to retest for HIV and hepatitis (to rule out exposures just prior to travel). This is a good time to check additional titers or follow up on earlier abnormal results, if we haven't already. We've recently started retesting for anemia and iron deficiency at the followup lab draw, since periods of significant catchup growth may cause children to outgrow their already limited iron stores.
  

Stool Tests

• You'll need to submit a total of 3 stool samples to check for giardia and other parasites (O&P x3 and 1 giardia antigen), collected every other day. This is important, regardless of symptoms - 15-20% of our IA children have a parasite like giardia.
• Until you know the results, be scrupulous about handwashing (Purell and other alcohol-based gels are very handy). 
• Don't let your children bathe together until you know the stools are clear - baths are a great way to share giardia.
  
• The lab will give you a bag with containers and instructions. Scoop a peanut-sized amount of stool into the preservative-containing vials, and on the day that you're dropping off the stools, submit a fresh (<4 hours old) sample in the screw-top plastic container as well.
  
• Please make sure your samples are labelled with your child's name, and write in the date collected.
• It's easiest for all concerned if you drop them off at our lab on the 1st floor, but you can also drop them off at a local lab, ideally a hospital lab that does this a lot. Have them fax us the results, and call us if you don't hear the results in 1 week.
  
• It's not unusual for this initial evaluation to miss a parasite - we've had several cases of Ascaris (white roundworm) present several months later ... so have a low threshold to retest for parasites if unexplained abdominal symptoms persist.
• If you have a positive result, we'll explain what to do, but please read our article on giardia and other stool parasites for more information.
  

TB Tests

•  We test for TB exposure with a skin test called a PPD, on arrival and again in 6 months after arrival. This followup test is crucial - we have a lot of kids who do have latent TB who have false-negative tests on arrival, due to stress/malnutrition.
• This skin test will need to be read by a health care professional in 48-72 hours. Our nurses can do this without an appointment. Just drop in during business hours ... bring your poop samples and drop them off at the lab on your way up.
• You may hear that this test is unnecessary in children who received BCG, the TB vaccine performed in many of our placing countries. This is not true. A result of 10mm or greater is a positive result, regardless of BCG status. Our children tend to come from high risk backgrounds as far as TB exposure is concerned.

Followup Visits

• We like to see children for followup visits every 2-3 months after arrival until they've been home 6 months. Our front desk can schedule these for you on the way out.
  
• We're happy to help you transfer care to a more local pediatrician at any point in the process. Many families stay with us until that 6-months-home visit, when labs, shots, and catchup growth and development are well underway.

Referrals

We see significantly higher rates of visual, hearing, and dental problems in children adopted from orphanages. Prenatal exposures and malnutrition, untreated ear infections, lack of visual stimulation, lack of fluoride and minerals, and poor dental care all contribute. For that reason, we recommend:

• Screening audiology evaluation by a pediatric audiologist in the first few months home. Most of our children are language-delayed on arrival, and audiology is extra important in that scenario. Parents and pediatricians miss significant hearing problems all the time, and ringing a bell next to a child's face is not an adequate test of hearing. We now have an otoacoustic emissions (OAE) gadget in our clinic for easy hearing screens, but it has a really low threshold to refer children to audiologists for further evaluation. If that happens, Children's Audiology (206-987-2000) is a good bet, since they're skilled in behavioral audiology techniques for young children. 
• Screening pediatric opthalmology evaluation in the 1st months home. We see significantly higher rates of strabismus (lazy eye) and other visual problems in IA children. The earlier this is detected, the better. David Epley (206-215-2020) and Mel Carlson (206-526-5222) are two good local pediatric opthalmologists.
• Early dental visit. Pediatric dentists like to see children as young as 1yo. See this article for more about early dental care. We don't have a current list of favorite dentists - check here, and ask other parents in your area.
• If we recommend an early intervention evaluation, you can access the nearest center by calling WithinReach (WA state) at 1-800-322-2588 for a local referral.
  

Nutrition and Growth

For infants and small toddlers, we recommend an infant or toddler formula with iron and essential fatty acids for the first 2-3 months home, even past the "typical" wean to whole milk at 1yo. Formula is just more nutritionally dense than milk, juice, or water, and contains essential nutrients for rapidly growing children. For more information, see our article on Choosing a Formula. When you do transition to whole milk (>1yo) or reduced-fat milk (>2yo if they've had good growth), try to limit it to under 18 ounces per day, since excess cow milk will fill up their bellies at the expense of other nutrition, and can cause anemia.

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we also recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth if not beyond. Other good sources of essential fatty acids for older adoptees include fish oils and flax seed oil. Probiotics are another supplement to consider. Please see our Nutritional Supplements in Adoption article for more information and specific recommendations.

For other nutrition ideas, start with the following resources on our site ...

• Transitional Feeding Difficulties
• Pediatric Nutrition Resources
• Picky Eating

... and the following web resources:

Development

Our website is chock full of articles, links, and book recommendations on the topic of development in internationally adopted children:

• Stimulating Early Development
• Birth-to-Age-5 Timeline of Development
• Developmental Milestones
• Language Development In Internationally Adopted Children
• Books for Speech/Language Delays
• "Birth-to-Three" Early Intervention
• Sensory Integration and Sensory Processing Disorder
• Screening for Autism in Toddlers
• Recommended Development and Learning Books
• Development and Learning Links
  

Therapeutic Parenting

This topic should probably be listed first, as I believe it's the most important intervention for newly adopted children. Kids who've experienced orphanage caregiving, multiple placements, neglect, abuse, and other trauma do have special needs in the area of parenting and attachment. What you'll read in typical parenting books, and what may have worked with "typical" children is not always the best idea for many of our children.

We're hard at work on our own "Parenting Toolbox" for adoptive parents, but in the meantime, please see these excellent resources:

• Top Ten Attachment Tips for the First Year of Placement - great stuff, from Deborah Gray
• Welcome Home - A Guide to Bonding- helpful tips and essays for the 1st year home from Adoptive Families magazine
• Sleep and Adoption
• Recommended Parenting Books
• Recommended Attachment Books
• Parenting and Attachment Links
• The "Difficult" Child

Giardia and Other Stool Parasites

Giardia is the most common parasitic infection in international adoptees, and is also frequently implicated in day-care center diarrhea outbreaks. Studies have shown that it is found in up to 20% of international adoptees, particularly older adoptees from Eastern Europe; in our experience it seems to come in clusters, averaging around 10-20% of our adoptees, and we do see it from China as well.

It's a microscopic flagellated protozoan parasite that is quite infectious (it can take as few as 10 cysts to cause infection), and it is typically spread by drinking contaminated water or fecal-oral transmission. So ... wash hands scrupulously after diaper changes, toilette, and before meals/food prep until giardia is ruled out, and don't have new arrivals share baths with other children at first.

Giardia can be asymptomatic, but symptoms often include loose, watery stools, with a certain foul-smelling greasy, floaty, frothy je ne sais quoi. Flatulence, cramps, bloating, and malaise can also be present. Chronic giardia may be associated with significant weight loss and failure-to-thrive. It also can cause secondary lactase deficiency - interfering with the intestine's ability to digest lactose. Even after successful treatment, loose stools can persist for a month or two. Cutting back on lactose, and supplementation with probiotics (unproven but likely to be safe) may help during this time period.

To diagnose giardia and other intestinal parasites, we recommend submitting 3 stool samples collected 2-3 days apart (preserved promptly after passage in a polyvinyl alcohol kit) for ova and parasite (O&P) examination, and one fresh (<1hr old) sample for Giardia antigen. Some refugee centers treat empirically with albendazole on arrival; we don't, because we prefer to know what we're treating, and because albendazole is ineffective against some of the common parasitic infections in adoptees. If the initial stool tests (remember, collect them 2-3 days apart to increase the chances of finding something) are negative but symptoms consistent with intestinal parasites persist, consider rescreening the stool; initial stool examinations miss infections in some children.

It's also important to do a "test-of-cure" giardia antigen test 1-2 months after treatment to confirm treatment success. If an adoptee tests positive for giardia, we treat, regardless of symptoms. You may not realize until later that the giardia was in fact causing symptoms, including malaise and poor growth; we also do this for the "public health" of the adoptive family.

Folks who don't see a lot of giardia often prescribe flagyl (metronidazole); in our experience this has an unacceptable failure rate. A better choice is Tinidazole, which was recently FDA approved for this indication, but has been in off-label use for some time, even in children <3yo. A convenient one-time 50mg/kg dose (max 2g) is what we use. It's mighty bitter, so mix with espresso syrup or other intensely sweet/flavorful option. See our medication tricks and tips for other ideas. Clark's Pharmacy in Bellevue, WA (425-881-0222) has it available in convenient dosing, is giardia savvy, and does mail order. Alinia is another recently approved medication for giardia that seems to be a reasonable alternative.

We don't automatically test or treat family members if giardia is promptly diagnosed in a new arrival, but if the child has been home awhile, if there are other young children around, or if anyone else is symptomatic then they should get checked as well.

Other stool parasites like Ascaris lumbricoides, Blastocystis hominis, Dientamoeba fragilis, Entamoeba histolytica, Trichuris trichiura, hookworms, and pinworms are also commonly identified in international adoptees. O&P results will often include non-pathogens, or commensals, which are not felt to cause illness and do not require treatment. However, they can be a sign that other parasites are present, and you should make sure that all 3 stool samples are evaluated. Links with good information about these and other, less familiar parasites are listed below.

Other Stool Parasite Resources:

• CDC Giardia Fact Sheet
• eMedicine Giardiasis Overview
• CDC Alphabetical Listing of Parasitic Infections (so many parasites to choose from, including Amebiasis, Ascariasis, Blastocystis hominis, Chilomastix mesnili, Cryptosporidium, Dientamoeba fragilis, Entamoeba coli, Enterobiasis (pinworms), Head Lice Infestation, Intestinal Roundworms, and Nonpathogenic Intestinal Amebae Infections)
• eMedicine Intestinal Protozoal Diseases (detailed medical overview of many common parasites, free registration required)
• A Field Guide to Emerging Enteric Protozoa - Contemporary Pediatrics (covers Dientamoeba fragilis, Blastocystis hominis, Entamoeba coli, and Cyclospora cayetanensis)
  

Coughs, Congestion, and Colds

"There's only one way to treat the common cold - with contempt"

    - the esteemed Sir William Osler, MD

Ah, the common cold. Common, indeed - the average preschooler has six to 10 colds per year, with each illness lasting 10 to 14 days. And the sad truth is, Dr. Osler's 1890s-era wisdom is still largely correct. He went on to say, "... toss the pills into the ocean. So much the better for mankind, so much the worse for the fish"!

For children less than 5, there just isn't any safe, effective treatment available to treat the common cold. None of the common cold medicines can convincingly outperform sugar water, and the FDA has recently warned of a number of serious adverse reactions when used in children under 2 (our advice: don't risk it). But that doesn't seem to keep cold remedies from being a billion-dollar-a-year industry.

We all know what a cold looks and feels like, although we sometimes seem to forget when it comes to our own kids. Signs of something more serious like pneumonia, bronchiolitis, or asthma could be:

• Prolonged or high fever (more than 2-3 days, or >102 degrees)
• Breathing fast (count breaths over one full minute while quiet or asleep; infants should breathe <50-60 times per minute, toddlers <40x/min, older children <30x/min)
• Working hard to breathe (heaving chest, visible rib movement, nasal flaring, grunting)
• Getting dehydrated (not drinking enough, no tears/drool, less than 3 urinations/day)
• Acting really ill or lethargic

If those are happening, please let us know - if you're travelling, we may want to start the zithromax, and possibly find someone to evaluate in person. We do have a lower threshold to start antibiotics when we can't see kids ourselves.

Other Complications:

If nasal congestion and wet cough last more than 2-3 weeks then it may be bacterial sinusitis, which can be helped by antibiotics as well; the color/consistency of the snot doesn't tell us if this is viral or bacterial, unfortunately. Ear infections can be a complication of colds, often marked by new fever and irritability when a cold seems to be running its course. Ear tugging and fiddling is not a reliable sign of ear infection in preverbal children, unfortunately.

Let's review the common medications and treatments for the common cold:

• Decongestants (pseudephedrine, etc) - Somewhat effective for daytime relief in adults and school-age kids, but they just don't work in young kids. Besides, does putting your ill, sleepless child on over-the-counter speed seem like a good idea?
• Decongestant Nasal Sprays (Afrin, Dristan, etc) - These work for short-term congestion emergencies (less than 2 days at a time) but can be nasally addictive, causing "rebound congestion" when you stop using them. Not routinely recommended, and not for infants/toddlers.
  
• Antihistamines (Benadryl, etc) - A good treatment for allergies, but colds are caused by a viruses; useful only for their sedative effect in desperate sleepless situations. Beware - 1 in 5 kids gets LOOPY on benadryl.
• Cough Suppressants (dextromethorphan, codeine, etc) - It sure is tricky suppressing that cough reflex without putting your child in a coma. Safe doses of codeine and it's synthetic cousin, dextromethorphan, don't seem to be that effective at suppressing this vital reflex. That said, in older children with a lingering, nagging, non-productive cough, you might try some Delsym (long-acting dextromethorphan).
• Expectorants (guaifenesin) - These don't work in young children, who don't need any help making copious secretions. In older kids and adults, they may make phlegm thinner, but so does drinking lots of fluids. Mucinex is a single-ingredient, extended release form of this for older kids and adults.
• Tylenol or Ibuprofen - IF your child is uncomfortable from fever, or in pain, these can help. Otherwise you may be suppressing the body's immune response.
  
• Antibiotics - No. Nyet. Bu.
• Zinc - Yuck. Zinc lozenges and zinc up the nose have not shown to be effective in kids. But zinc deficiency is associated with poor immune function (and many adoptees are zinc deficient). There's lots of zinc in high-protein foods like meats, seafood, milk, and fortified breakfast cereals. A "complete" multivitamin with minerals can also help.
  
• Vitamin C - Controversial. Large doses may shorten symptoms in adults, but megadoses are not clearly safe in kids, and can cause diarrhea. Like zinc, let's make sure you're getting enough, and some extra at the first signs of a cold may help.
  
• Echinacea - Recent study done here found no clear benefit at reducing symptoms in kids. Bummer.
• Probiotics - Lactobacillus milks, active culture yogurts, and probiotic supplements are emerging as a good thing, although definitive studies are still pending, and it's not at all clear that they treat colds. They may be effective at preventing colds, allergies, and diarrhea, with a host of other potential benefits.
  
• Andrographis (Kan Jang) - Herbal remedy that's all the rage in Scandinavia. Some smaller studies showing benefit in colds and flu. Promising, but larger studies may sink this ship as well.
• Umcka drops - Ancient Zulu Homeopathic Geranium-ness. Germans love this stuff, available here through Nature's Way. Some promise for sinus, throat, and bronchial infections. Who knows, really? If you enjoy taking the latest natural remedies, give it a try.
• The Stuff That Teacher Invented Who Never Ever Got Another Cold (Airborne) - It was on Oprah, so it must work. This contains Lonicera, Forsythia, Schizonepeta, Ginger, Chinese Vitex, Isatis Root, Echinacea, along with vitamins, zinc and magnesium. Phew. Feels a bit faddish to me, with a few too many ingredients.
• Whiskey - Dr. Osler's preferred cold remedy: "hang your hat on the bedpost, get into bed, start drinking whisky. When you see two hats stop!" Not an option for the kids, but what you do with the colds they give us is entirely up to you.
  
• Humidification - Unclear benefit from humidifiers and vaporizers, but they feel good for many, and may keep nasal secretions easier to clear. If you use these, clean them obsessively, as they are effective at aerosolizing molds and bacteria.
  
• Menthol, Eucalyptus, VapoRub - Studies show that people think these are working even if they aren't. You can put them in the vaporizer, plug a gizmo into a wall outlet, or rub them onto your child. That may be the key ... with the massage, you get the healing power of relaxation and parental tender loving care.
  
• Chicken Soup - Yup, studies and grandmothers actually agree on this one.
  
• Nasal Saline Drops/Sprays and Bulb Suction - This really can help infants and toddlers, who can't effectively blow their nose. Infants, in particular, have tiny nasal passages that they depend on for sleeping and eating. You can buy nasal saline or make it with 1/2 tsp salt in 1 cup warm water. Put 1-2 drops in each nostril before suctioning to help clear dry nasal secretions. A bulb syringe is most effective if you squeeze it, put the tip in one nostril, and pinch the nose to get a good seal on the side you're suctioning and close off the side you're not, and SLUUURP. Don't go too crazy with this, as you don't want to overly irritate the nasal mucous membranes.
  
• Plenty of Rest and Plenty of Fluids - Yes. Da. Shi.
• and finally ... Tincture of Time - The ONLY cure for the common cold. Support the immune system in its good work with rest, fluids, love, and attention, and otherwise stay out of the way.
  

Additional Resources:

• Colds - Kidshealth.org
• Colds - DrGreene.com
• The Difference Between Colds and Allergies - DrGreene.com

Updated 8/07

Hepatitis B

Quick bottom line - we're seeing fewer and fewer Hepatitis B "surprises" in our clinic, although they still rarely happen. The future for children with Hep B is felt to be bright, with promising ways to manage, if not cure, what is generally a chronic infection in children who acquire this at birth.

Our detailed thoughts coming soon ... in the meantime, some good links to get you started:

Hepatitis B Resources:

Infectious Disease and Immunization Links