Monday, January 12, 2009

Tests, Tests, and More Tests

So what's the first thing Maritu and Mamush did on their first day in the US? Go to the doctor! Poor kids! Besides a routine check-up with poking and proding, they had an array of lab work:

a. Antibody Titers (children over one year of age) measure the presence and amount of antibodies in the blood to determine immunity developed from previous illness or vaccine. Your pediatrician uses this information to determine which immunizations your child has already received and which are needed. Most Adoption Medicine specialists use titers to measure antibodies in order to avoid re-immunization. Titers are not used for children under 12 months because they are likely to carry antibodies from the birthmother. Titers are used in concert with the immunization record from the country of birth. (You should receive a copy of your child’s medical records from the agency.) You should discuss this further with your pediatrician.
RubellaChicken pox (varicella)

b. Complete Blood Count (CBC) with differentials and platelets counts the number of red and white blood cells, the total amount of hemoglobin, and other data about the red blood cells. For example, a high number of white blood cells indicates infection, and low hemoglobin indicates anemia, which is common in about 25% of children adopted from abroad.

c. Hemoglobin electrophoresis – tests for different types of hemoglobin (including sickle cell disease); unusual hemoglobin levels may indicate anemia, malnutrition, lead poisoning, heart disease and other issues.

d. Lead levels – determines the amount of lead in the blood. Exposure to lead-containing gases from gasoline and the burning of coal are the two most common causes of elevated levels; this appears to be a rare medical issue for Ethiopian adoptees.

e. Hepatitis – Hep A, Hep B and Hep C. Hepatitis is a liver inflammation -- A, B and C are common viruses that cause liver inflammation. The children are tested for Hep B during the intake physical.

f. Liver enzymes – checks the composition of liver fluids

g. Rickets screen – Rickets is a disease involving softening and weakening of the bones, primarily caused by lack of vitamin D, calcium, or phosphate. The Rickets screen tests for these substances. Rickets may also be associated with premature birth.

h. Syphilis – Syphilis is a sexually transmitted disease easily treated with antibiotics. Infants may initially test positive for syphilis if the birth mother was infected.

i. Thyroid screen – Checks the thyroid. A number of parents have reported a slightly enlarged thyroid at the initial exam, but not necessarily an elevated thyroid function test. The enlargement could be related to malnutrition and/or iodine deficiency. This is very common in Ethiopia. Parents have shared that the thyroid was normal size when rechecked after several months of improved nutrition in the U.S.

j. HIV – In addition to an arrival screen, the HIV test should be repeated about 6 months after arrival. The test used could be either an ELISA (tests for HIV antibodies) or PCR HIV DNA (tests directly for HIV presence). The ELISA can be less accurate for children under 24 months because they may test positive for HIV if the birth mother was infected with. The ELISA looks for antibodies, which babies may receive from an HIV-positive birthmother and carry for 18-24 months. The PCR DNA test is more accurate for these children, and also for the few people who have HIV but for some unknown reason do not produce antibodies that can be detected by the ELISA assay. (For more information on these tests, consult your doctor, local Health Department, or one of the online medical resources below.) Due to the prevalence of HIV in Africa and its long incubation period, pediatric infectious disease specialist Dr. Jane Aronson recommends the HIV ELISA with confirmatory Western Blot, followed by a PCR DNA test for all children coming to the US from Ethiopia. NOTE. Within her practice, Dr. Aronson orders an HIV ELISA with reflex Western Blot as well as a qualitative PCR HIV DNA at the initial evaluation.
Note regarding HIV testing in Ethiopia: As of January 2007, the ICL laboratory in Addis recommends children to be tested with the ELISA, with a follow-up PCR. Children under about 18 months should be tested a third time, with the ELISA, prior to traveling to the US. Dr. Jane Aronson believes that PCR HIV testing is the gold standard for HIV testing in youngsters under 2 years of age, which is the standard in the U.S. That said, the resources are limited in countries outside of the U.S. We are indeed fortunate to get any PCR HIV testing outside the U.S. The only countries with international adoption programs where it is available are Ethiopia and VietNam. With this understanding, Dr. Aronson supports the use of a step approach using the HIV ELISA and the PCR as noted in this section. Finally, however, all parents must recognize that there are scientific circumstances wherein a child may have a negative ELISA and turn out to be infected with HIV. This is why Dr. Aronson tests every child on arrival in the U.S. no matter what the age with an HIV ELISA and confirmatory Western Blot as well as a PCR HIV DNA qualitative test.

k. TB – A tuberculin skin test (TST) is also called a Mantoux or a PPD (Purified Protein Derivative). The test involves injecting a small amount of inactivated – harmless -- TB bacteria under the skin (usually on the forearm), forming a small bubble. The bubble disappears and the skin must be checked for a reaction 48-72 hours later by the person/agency who administered it. It is strongly recommended that your child be re-tested 3-6 months after arrival -- false negatives may occur when the patient is affected by malnutrition or an immunodeficiency of some kind, and there is a possibility of exposure shortly before travel to the U.S. Children may receive a BCG vaccination at the Intake exam if they have not already received one. Be aware that some doctors will not want to do a PPD on a child with BCG, but adoption medicine practitioners and the RedBook on Pediatric Infectious Diseases say the PPD should be given even when the child has a history of BCG vaccine. (See the “Tuberculosis” description below under “Common systemic issues and treatment,” or your health professional for more detailed information.)
NOTE: Dr. Aronson recommends that anyone traveling to Ethiopia have a PPD test 2-3 months before travel, and again about 3 months after travel. Because TB is prevalent in developing countries, travelers could easily be exposed to a contagious individual without being aware of it.

l. Ova and Parasites and Girardia Antigen. You will need to collect stool samples from 3 different bowel movements, each at least a day apart, to check for parasites and other gastrointestinal abnormalities. Three samples are used because there is not always evidence of parasites in every bowel movement – and sometimes parasites are missed even with three samples. Most children from Ethiopia are treated for parasites. Your doctor will check the lab results with medical reference books to determine if your child needs treatment and which medication(s) will be most effective. To avoid spreading parasites to other family members, practice very good hygiene – wash hands well with soap, use antibacterial hand sanitizer when out and about, etc. Some families use the antibacterial or disinfecting disposable cloths to wipe down “public” surfaces, such as toilet seats and levers, sink levers, doorknobs, remote controls, etc.Adoption Medicine specialists generally are very aggressive in treating even the slightest abnormality because there is a high prevalence of bacteria and parasites in the water in developing countries. If a child shows a failure to thrive or lack of growth/weight gain over time, this is an indicator that parasites should still be considered. *Although some parasites are sufficiently common in the U.S. that U.S. children are not treated unless the child is symptomatic, this does not apply to children adopted from Ethiopia *Some parasites are more easily transmitted than others, and some medications cannot be administered concurrently. *Some children may be symptomatic even if their stool samples are negative, so your doctor may choose to prescribe treatment based on the symptoms (i.e. empiric therapy).
Older children. For many children this is a significant source of embarrassment. Be prepared to give positive reinforcement or a special treat for willing compliance. Be alert to times they are likely to defecate – after breakfast is typical.
1. The doctor or lab staff will give you a plastic “bowl” to lay over the toilet for your child to defecate (“kaka” or “arrr”) into and vials with comprehensive instructions. 2. After your child has used the bowl, you will open a vial and use the scoop inside to collect small amounts from different parts of the sample and place them inside the vial. Close and shake – the fluid inside preserves the sample and prepares it for examination. Label accurately.
3. Collect samples for 2-3 vials on each of 3 days, at least 24 hours apart. 4. Take the vials to the doctor or lab – some facilities prefer that you bring all samples in at one time, some allow you to bring them whenever ready. Results may be available within a week, depending on the facility.
Babies and toddlers. If your child is out of diapers, try the procedure above. For children in diapers, your doctor will probably ask you to use plastic wrap to obtain an “uncontaminated” specimen. This is easier if you are able to predict somewhat when a bowel movement will occur. Lay plastic wrap inside the diaper before putting it on your child. Be prepared for mess -- urine will leak out, and if your child has diarrhea, it may not be contained very well. Test of cure (Re-check). After the course of treatment is complete, your doctor may ask you to re-test your child. Also, if your child continues to have symptoms or if any family member begins to show symptoms, your doctor should retest the child and/or family members. A few children have needed a second treatment or different medication to eliminate symptoms. If your child is gaining weight, has formed (if stinky) stools, tests negative for parasites, and otherwise appears healthy, she may simply have bacteria in the colon that is indigenous to Ethiopia, which can take years to change.

m. Malarial test

The Center for Disease Control and Prevention website has a standard immunization schedules as well as a “catch-up” schedule at

We didn't even consider immunizations at this visit because both kids have respiratory issues...

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