Adopting From Distant Countries – PediaCast 062

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The Interview Edition

Dr Dwight Powell, chief of pediatric infectious and director of the International Adoption Clinic at Nationwide Children's Hospital, joins us for a discussion about the growing trend of adopting babies from distant countries.

Transcription

Announcer: This is PediaCast.

[Music]

Welcome to PediaCast, a pediatric podcast for parents, the Interview Edition. And now direct from BirdHouse Studios, here is your host, Dr. Mike.

Dr. Mike Patrick: Hi, everyone, and welcome to PediaCast. It is Episode 62 for Tuesday, October 16, 2007.

Today, we have a special guest. Dr. Dwight Powell is going to be along to talk about the International Adoption Clinic at Nationwide Children's Hospital.

But before we do that, before we get to the interview, I have to do my Steve Carell dance. If you've seen Evan Almighty, you know what I'm talking about.

And why? Why am I so happy that I need [Laughter] to do the funky dance? Well

0:01:00

Flu shots are in, at our office [Laughter]. I tell you, we've been getting so many phone calls. People want to know when they're coming in. And they were kind of late getting in this year. I'm sure I was giving the flu shots at the end of September last year. So here we are mid October, they're finally in.

All of you out there make sure you get your flu shots. We'll have a flu shot show at some point here. But I am definitely pro flu shot and it's a very selfish reason. Actually there's two reasons I'm pro flu shot.

Number one is it makes my job a little bit easier in the winter time because when people don't get their flu shot, now, of course, it's not a 100%. But the more flu that we can prevent, then I'm not going crazy at the office and then too tired to do PediaCast.

So if we have everybody get their flu shot, we have less flu that means I'm less busy. I have more time to get PediaCast done.

0:02:00

We're all happy, OK? Yes, I know. You know, it doesn't pay the bills but I don't wish flu on any one.

The other thing, too, you hear a lot of parents say, "Well, I don't get the flu shots because it gives me the flu." Remember that really is unlikely. With the injection type of flu shot, it's actually impossible because it's not a live viral vaccine. It's not live, so it cannot infect you.

However, remember when your immune system is working, the side effects of an active immune system are going to be the fever, the aches, the pains, and that's just to let you know that shot is working, that your immune system is reacting to it and making antibodies against the flu.

So the fact that you feel a little lousy for a couple of days is fine. It's a lot better than having the real flu where you have a fever for a week and then you get pneumonia as a complication. And next thing, you know, you've been sick for two to three weeks all told.

0:03:02

So I think it is important to get the flu vaccine really regardless of your age so something to think about.

The other reason that I'm pro flu shots is because there was a year, a few years ago, when I was just starting out in private practice that I neglected to get my flu shot. I was around the flu all the time in the office.

I didn't get it from any patients but my daughter got the flu and then I go the flu. Of course, I got pneumonia, missed a week of work. It was just miserable. So from personal experience I can tell you. If the flu shot makes you sick for a couple of days, it's better than I went through the year that I didn't get one.

I should mention if you are having an egg allergy then you should not get a flu shot. Of course, talk to your doctor. And I would encourage you to get your flu shot at your doctor's office, if at all possible. So you can ask him any questions that you have and they can check and make sure that you're all up-to-date on any screenings and things that need to be done, rather than going to a health clinic or a pharmacy or something like that.

0:04:07

Now I don't want "hey email" from the pharmacist out there please. [Laughter] Just understand that.

All right. We better move on or this episode will go on forever. I want to remind you if there is a topic that you would like us to discuss or you have a new story or an interview lead, anything like that, just go to pediacast.org and click on the Contact link.

You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, which is 5437.

Don't forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

0:05:04

And with that in mind, we'll be back with Dr. Dwight Powell to talk about the International Adoption Clinic right after this short break.

[Short Break Music]

All right, welcome back to the program.

Tens of thousands of children from Asia, Europe, South America, Africa and the South Pacific are adopted by American families each year. And every adoption brings uncertainty with regard to the health status of the adopted child.

Many children's hospitals around the country have responded to the increasing numbers of international adoptions by sending up dedicated clinics to address the needs of these parents and children.

0:06:07

Our guest today, Dr. Dwight Powell, is Chief of the Section of Infectious Diseases and Director of the International Adoption Clinic at Nationwide Children's Hospital. He's also a professor of pediatrics at my alma mater, the Ohio State University College of Medicine.

Now this is normally in the course of an interview where I would say, "Hey, you know, let's join me" and extending a very warm welcome to Dr. Dwight Powell and that sort of thing except that I have to be honest with you. I made a little boo-boo in recording this interview.

And the very, very, very beginning of it where I welcome Dr. Powell and he says, "Thanks for having me on the show. Glad to be here" And that sort of thing is missing. Look, folks, I'm an amateur. What can I tell you?

Again, it's a very short part of the interview that we're missing.

0:06:59

And so he did say, "Thanks for having me" and then I went on to ask him about the history of the International Adoption Clinic model because it is a new thing for children's hospital to have these clinics.

And so, a lot of you may not understand or know that they are available for you to use. So the first question is just asking him about the history of the International Adoption Clinic model. So we're going to join our program "Already in Progress".

I've always wanted to say that. See? Just gave me an excuse. So we're going to join it "Already in Progress". Again, you didn't miss much, maybe 30 seconds or so.

So here we are with Dr. Powell.

Dr. Dwight Powell: I was at the University of Minnesota by Dr. Dana Johnson. And I'm not positive when that clinic started but I think it was like in the early 80s. And since then, there has been a steady accumulation of clinics.

0:08:00

Again, I don't know precise numbers but I know that at least 23 of the 50 states have the availability of at least one International Adoption Clinic.

We're kind of blessed in Ohio because we actually have four standing clinics within major medical centers and then there's a private pediatrician in the Cincinnati area that specializes international adoption. So actually there are five resource centers within our state.

Dr. Mike Patrick: Great. Now what sort of services do you provide? Looking at the website at Nationwide Children's Hospital, it looked like things are geared toward pre-adoption, and then while the parents outside of the United States, and then again when they get back, so let's talk first a little bit about what kind of services these types of clinic usually provide before the adoption takes place.

0:08:59

Dr. Dwight Powell: Most clinics do offer free adoptive evaluation. Now there are a number of folks that specialize, I guess, and are willing to review material by mail, email, and fax and et cetera.

In our clinic, we've tended to ask parents to come in for an actual visit and then to bring material, what they have available.

The focus is really, primarily, to look at what materials the adoption agencies have provided to parents who are interested in adopting a designated child. And generally the adoption agencies will provide the information, and then I ask the parents to give them a yes or no answer on whether or not they're willing to adopt that specific child, generally within 48 to 72 hours.

0:10:04

And so we've tried to be as accommodating as possible as soon as parents are given information to arrange, usually an afternoon, late afternoon, sit down and visit. It takes anywhere from an hour to two hours.

Dr. Mike Patrick: Right.

Dr. Dwight Powell: What we do then is to review the material that the agency had provided and that would include medical information, any issues on any information they have on growth and development and then photographs or best-case scenario videos, which are unfortunately fairly rare.

Dr. Mike Patrick: Right. Now some of the medical materials that you may get on the child that I've come across sometimes are not in English, how do you bridge that gap?

Dr. Dwight Powell: With great difficulty.

Dr. Mike Patrick: [Laughter] Yes.

Dr. Dwight Powell: One of our physicians is fluent in Spanish.

0:11:04

So if there are uninterpreted Spanish data then she can look at that and read it. Most of the Chinese adoption material, there will be at least some English version, often printed, concomitant with the Chinese adoption.

And for instance with immunization, it's kind of want you to see one that's been translated in English and you can begin to get a sense of what the symbols are for this untranslated. The other Russian material, we asked the parents to ask the agencies to translate it. But that doesn't always happen, unfortunately and then you're pretty well stuck.

Dr. Mike Patrick: Right. I'm also interested in exactly what you do to help while the parents are outside of the United States, actually getting the child if questions come up during that time.

0:12:06

It looked like from the description of your clinic that you do have some availability in that situation?

Dr. Dwight Powell: We do. And it's pretty much the same kind of approach we do when we meet, in a pre-adoptive meeting with parents. And I fail to mention that one of our goals is to really help parents understand what kind of medical problems, psychological problems, learning and developmental problem based on the information that's available to us, the child may face.

And we actually are upgrading that composite group of issues as the child has mild, moderate or severe risks. That's never "no risks" obviously.

Dr. Mike Patrick: Right.

0:13:01

Dr. Dwight Powell: You know in parents, we are seeing unfortunately an increasing number of what I call "blind adoptions," particularly in Eastern Europe like Kazakhstan where no information is provided to the agencies and parents are simply told "You come to Kazakhstan. You'll be presented a child" and then you have that kind of "magic" window to make a decision, whether you adopt this child or not.

They often are given a sparse amount of information, which they can usually email back to us about medical records, and obviously, digital photographs. So we try to make the same kind of assessment and help them, just as we would in the pre-adoptive situation.

The second component of our availability when parents are in the foreign country, we've had number of folks where the child may be ill or having problems that weren't forecast and there just really isn't any kind of medical back up available in the country.

0:14:10

So we do have our infectious disease physicians and two of us that work in International Adoption Clinic, our ID doctors. We're on call, of course, 24/7 and we take those calls and try to do the best we can to help parents get through what medical problems may have surfaced.

Dr. Mike Patrick: Right. Now once they get home with the child, then obviously, you have an initial visit. What kind of things do you do at that time?

Dr. Dwight Powell: We try to see all the children within two weeks of their return to the U.S. Our clinic meets on Friday morning. And we tell parents and obviously if you don't have an identified primary care provider, by the time you get back and the child's ill, we'll try to see them sooner.

0:15:04

And obviously, they're really ill, we're going to make them I'm going to strongly suggest they go right to either one of our urgent care or centers, or to the emergency department. But most of the time we're able to see them in two weeks.

And we do fairly extensive battery of evaluations that takes cumulative of about four hours, usually two to three hours on Friday and another one to two hours on Monday morning.

We have working with us, there's always a work physician in the clinic. There's three of us have to share that responsibility. One of us is always available in the clinic. We have a full time nurse practitioner who's always in the clinic, Monday and Friday. We have developmentalist, a nutritionist and a psychologist.

0:15:59

And so, the children undergo, obviously, a complete physical exam by the physician. The developmentalist spends anywhere from half an hour to an hour to try to determine major motor deficits and decide whether the parents really need to be referred typically to "Help Me Grow," which is a state-wide program available in every county.

And it got resources to do occupational therapy, physical therapy, speech therapy, et cetera. And we can expedite the referrals that help me grow network through our developmentalist evaluation.

Dr. Mike Patrick: It's really a multidisciplinary approach.

Dr. Dwight Powell: Yes.

Dr. Mike Patrick: That's great.

Dr. Dwight Powell: Yes. The nutritionist really tries to help these folks transition from the diet. A lot of these kids have been on, which is very foreign to us, the diet the parents will be comfortable with.

0:16:59

And then our psychologist spends a good half hour to hour just talking about some of the issues that are going to crop up. It's an absolute given that are going to be issues, in terms of attachment, in bonding and some psychosocial problems because the child has different nationality in the family and the community.

Dr. Mike Patrick: Right. Now when you do see these kids in terms of health issues, what are some of the more common problems that you encounter. Obviously there's the development and the psychosocial. But in terms of medical issues, what sort of things are you most concerned about?

Dr. Dwight Powell: Well, they all get screened for basic nutrition obviously growth parameters and virtually all of these kids are to a degree developmentally delayed, and often nutritionally delayed.

They get standard CBCs and protein and screen for rickets, calcium, phosphorous.

0:18:05

They all get hemoglobin electrophoresis, looking for any kind of problems that would set them up for hemolytic anemia. They get thyroid screen. They go through a battery of tests for infections that are common stool, parasites. They get skin test for tuberculosis.

So identified major problems probably infections are the most common, with intestinal parasites being the number one probably in 20% to 25% of children will have particularly GERD. And about 15% to 20% are going to have been infected with tuberculosis and will require treatment.

Unfortunately, almost of them have latent tuberculosis, but we've seen some active TB as well.

0:19:02

Dr. Mike Patrick: Now some of these kids received BCG, vaccine to protect them from tuberculosis. If you see kids that have that and they have theirs this is a little beyond what most parents are looking for but we also have some listeners who are physicians that maybe interested in this.

So if you have a positive skin test and they have a history of having the BCG vaccine, do you still treatment as if they have tuberculosis?

Dr. Dwight Powell: Unfortunately, we have to, at this point. I mean the good news is BCG vaccine probably protects young children if they are infected from progressing to widespread, what we called Millard tuberculosis, where it involves the brain and liver and bone marrow and spleen and lymph nodes.

It's not a very good vaccine however in protecting against infection. And once you're infected with TB germ, if you're very young, you're a high risk of developing active disease.

0:20:06

And if you are able to keep the organism from spreading, you develop what's called "latent" tuberculosis. The body can wall it off and put it into a dormant state.

But as a child if you're infected you have a good 15% lifetime risk that the germ will someday reactivate.

Dr. Mike Patrick: See, you always have to be on the lookout for that.

Dr. Dwight Powell: Yes. When people hear about tuberculosis, the adult that's coughing and spreading it to other people, that's reactivation from childhood latent TB that wasn't picked up and treated.

So unfortunately, I've no way, at this point, of differentiating BCG from actual TB infection. The guidelines from the American Academy of Pediatrics and the Centers for Disease Control are "totally disregard BCG."

0:20:58

And I'll just tell you one kind of quick scenario where a physician in an outside community, who is screening an adopted child, thought well. The child received BCG. He's protected and I can't screen with a TB skin test anyway.

Within two months of coming to this country, the child presented to children with widespread disseminated tuberculosis involving the brain, stayed in the hospital a month, had to be treated with multidrug therapy for a year, and ends up with paralysis on one side of the body.

Dr. Mike Patrick: Right.

Dr. Dwight Powell: So, yes, all children absolutely must be screened. Again, 15 to 20% of adopted children are going to be infected with TB.

Dr. Mike Patrick: And if they have that positive skin test and history of BCG vaccine, we're not going to say that it was the BCG vaccine that caused it.

Dr. Dwight Powell: Absolutely not.

Dr. Mike Patrick: Right.

Dr. Dwight Powell: We're going to treat it as if it's tuberculosis.

Dr. Mike Patrick: Now speaking of vaccines, what's the quality of the vaccines that children do receive in other countries?

0:22:05

Dr. Dwight Powell: It varies both the quality of the vaccines and the accuracy and reporting of records of receiving the vaccines. We think some of the countries like, particularly Guatemala, South Korea and China seem to be pretty accurate.

Their records are very detailed in terms of the age in which the child received the vaccine. Other countries such as Russia, they're very poorly documented. They'll say child received three doses of something but they don't give you the age or the date, or the time, or any other information.

So our approach is, we don't routinely read vaccinate all children. If they have a record saying that they've, for instance, three diphtheria-tetanus-pertussis vaccinations, we can do tests for antibodies to make sure that they in fact have responded to the vaccines.

0:23:11

If they have then we get them credit for those three. We do the same for polio. We do the same if they received Haemophilus vaccine.

We generally don't measure measles because most of the children will have received only measles and not mumps and rubella. So they have to get caught up on those anyway.

And so we do often duplicate if they've had measles. They're going to get another actual to measles combined MMR vaccines.

Dr. Mike Patrick: Great. Now when you come up then with this customized vaccine schedule based on what they seemed to be immune to or not have immunity to, then do you do these vaccines yourself in the clinic and have them come back or do you communicate this information with whoever they're primary care doctor is going to be, or is it just so after the parents?

0:24:07

Dr. Dwight Powell: In our clinic, we do not do primary care. And so our job really is to, number one, help parents identify a primary care provider within the community where they reside.

When we get all of the information back, by the way, we also arrange for vision and hearing screen, and of course we detect any problems in the initial adoption clinic screening that requires a subspecialist evaluation, we take care of arranging for that and making certain that the child gets cared for very quickly cleft palate, heart murmur, undescended testicles all of those kind of things require subspecialist evaluation and possibly intervention.

And we take care of all of that before we turn all that over to the primary care provider.

0:25:05

We filled out a very detailed assessment of what has been found and what problems the child had and have been taken care of, what problems the child may have or may need for their care, along with recommendations for catch-up vaccines and all that, hopefully within two weeks of seeing the child to the primary care provider.

Our only current follow up after that is at six months and we do that for two reasons. We want to give parents a chance to go over some of the behavioral issues that may have developed. We have a psychological testing that our developmentalists go through with the parents to see how things are going.

0:26:02

We always repeat the TB skin test for children that were negative initially because they may have been infected shortly before coming to the United States and it can take up to two months before the skin test becomes positive after infection.

Similarly, we retest for HIV and hepatitis, in those children that were negative initially.

Dr. Mike Patrick: Sure. And then all that information obviously continues to go back to their regular doctor.

Dr. Dwight Powell: Absolutely.

Dr. Mike Patrick: Now what if there are physicians who are interested in doing this kind of workup on their own, particularly if it's in a rural area and it is a hardship for the parents to, let's say, go to a large children's hospital.

Are there any support resources for primary care doctors that you are able to provide?

Dr. Dwight Powell: It's difficult. And we started this whole business so that it's really time consuming.

0:27:09

Dr. Mike Patrick: Right.

Dr. Dwight Powell: And it does require multiple resources. And most primary care providers just don't have those resources and they don't have the time to do what we do.

Again, certainly in our state, I think we've clinics in Cleveland, Akron, Columbus and Cincinnati. There's absolutely no reason that a parent can't come to one of those specialized clinics.

Dr. Mike Patrick: Right.

Dr. Dwight Powell: My personal view is, it would be extremely difficult for the primary care provider to do all that is recommended to be done with these children.

Dr. Mike Patrick: Right. So this is really a great service. And I think that there's probably a lot of parents out there who have not heard of this and so hopefully will just get a little more business your way. [Laughter]

0:28:05

Dr. Dwight Powell: Great. We're certainly here to help. And I think, I love a quote that comes Dr. Johnson, who is again the originator of all these. And basically this is kind of a letter that's on their website to adoptive parents and he's answering the question "What are the chances that my child will be normal on arrival?"

He says, "Let me be blunt. The chances of an institutionalized child being completely normal are zero."

Dr. Mike Patrick: [Laughter] Right.

Dr. Dwight Powell: And so there are always, always issues that have to be addressed in these children.

Dr. Mike Patrick: Yes.

Dr. Dwight Powell: And they tend to be different than children that are born in the United States.

Dr. Mike Patrick: Great. We appreciate you stopping by and letting us know a little bit more about the clinic.

0:29:03

Dr. Dwight Powell: All right. It's been my pleasure.

Dr. Mike Patrick: Great.

Dr. Dwight Powell: For having me.

Dr. Mike Patrick: Sure. I'm sure there'll be some other infectious disease-type issues in the future that come up. So I'm sure we'll have you here again.

Dr. Dwight Powell: No problem.

Dr. Mike Patrick: All right. Bye-bye.

Dr. Dwight Powell: All right. Bye-bye.

[Music]

Dr. Mike Patrick: All right, of course, thanks go out to Dr. Powell for making time in his busy schedule to stop by and talk to us about the International Adoption Clinic at Nationwide Children's Hospital.

0:30:02

Also thanks go out to Vlad over at Vladstudio. He is, of course, the artist who takes care of us and provides the pictures that we used at the website and also in the feeds. So please support Vlad at vladstudio.com.

Also the Poster Page is available at pediacast.org so you can print out posters and hang on bulletin boards to tell other parents about the show.

Tomorrow, we're going to answer more of your questions. So until then, this is Dr. Mike saying, stay safe, stay healthy and, of course, stay involved with your kids.

So long, everybody!

[End Music]