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Medical Resources Guide
If you have any questions, please contact us for assistance Copyright @ 2003-2012. Great Wall China Adoption dba Children of All Nations. All rights reserved. It is against the law to copy, reprint, store in a retrieval system or transmit any part of this guidebook in any means for any purpose without written permission from Great Wall China Adoption dba Children of All Nations. Table of Contents
Introduction. 1 Health Issues in Adopted Children . 2 Common Medications. 10 Helpful Hints for Adoptive Parents . 15 Age Concerns for Adopted Children . 17 Introduction
Dear GWCA/ CAN Family, The information provided in this packet was obtained through Dr. Jane Aronson. Dr. Aronson is an International Adoption Medical Specialist and a wonderful resource for families preparing to travel abroad for an international adoption. This packet contains information on the most common pediatric medical problems and recommended management strategies. Prescriptions for antibiotics and other medications can be acquired from your pediatrician. We recommend that you find a pediatrician before you travel that can help you understand how to handle simple medical problems while you are far away from home and also give you prescriptions for some simple medications. A preparation list is provided below. Your pediatrician should also be available for consultation by phone while you are abroad. Medical advice when abroad is also available through Dr. Aronson by e-mail or by phone 212-207-6666. If you want on-site medical care while you are abroad, you can consult Dr. She has a section for international medical clinics listed by country. I hope this information will be helpful to each of you. Sincerely, Great Wall China Adoption and Children of All Nations Heath Issues in Adopted Children
It is essential to remember that many of the health issues of adopted children are the same health issues as children in the general public of your child’s placing country. There are very common health issues that children face daily whether in or out of an orphanage. Malnutrition, rickets, anemia, lead poisoning, asthma, tuberculosis, hepatitis B, bacterial and parasitic intestinal infections are common medical problems. Medical problems are obviously compounded in the orphanage because these children are often abandoned as they begin their lives and orphanages do not have access to modern medical facilities. When a doctor is involved in the medical care of an orphan, it may be a non-university trained doctor who attends to the child. It would be uncommon for a university physician to care for a child from an orphanage. Children are rarely taken to modern medical centers because of lack of geographic proximity and economics; it is impossible to spare a child care worker to take a child a long distance for hospital care; the expense of hospital care is beyond the means of most institutes. Daily medical care is often left to the common sense of experienced child care workers who staff the orphanages around the world. Many institutes attempt to create in-house clinics and are equipped to give intravenous fluids, antibiotics, and other medications right in the orphanage, but without the supervision of trained medical clinicians. Children survive in spite of the limitations of medical care. Their circumstances are truly a test of their inherent survival capacity. They are truly resilient! Malnutrition, Growth Failure, and Rickets
Children living in orphanages are malnourished, but the severity of the poor nutrition varies from orphanage to orphanage, country to country. It is impossible to generalize about the health and nutritional status of all children living in orphanages around the world. There are orphanages with more resources than others and even when an orphanage has been reported to have better living conditions, that orphanage can be altered by the economy of the region during different times of the year and in different years. Most kids living in orphanages are fed very dilute formula in infancy. The formula is usually milk-based and resembles standard baby formula used in the U.S. Rice cereal may be added to thicken the feeds. In China, occasionally children will get a steamed egg or a bowl of rice congi. On holidays, sometimes other special foods are available. Feeds are fast and furious and bottles are propped. Children get used to a speedy avalanche of fluid without much nutritional value which can lead to difficulties with coordinating swallowing and the handling of different textures of foods during the transition after adoption (oral aversion). The poor quality of nutrition and lack of exposure to sun leads to vitamin D and calcium deficiency which is called rickets. This is one of the top five medical issues in children living in an institutionalized setting (malnutrition, rickets, anemia, lead poisoning, and asthma). The characteristic "Raggedy Ann" or floppy appearance of many adopted children may be attributed to rickets. With proper nutrition, rickets resolves. The muscles and bones are weak and poorly developed in ricketic kids, but with replenishment with vitamin D and calcium, the body strengthens. Rickets can clearly account for a lot of the gross motor delays that are seen when kids first arrive. Obviously, decreased muscle tone and delayed gross motor development cannot always be attributed to rickets, but the first assumption should be that nutrition is the cause. Proper follow-up with the pediatrician on a regular ongoing basis will allow exploration of other causes as time goes by. Babies and toddlers adopted internationally may also be quite small when they are first adopted by families. The body slows its growth when nutrition is poor in order to conserve energy to meet basic metabolic needs. The under nutrition described above clearly accounts for most failure to thrive that we see in children adopted abroad in general. Typically weight catches up before height. Certainly, genetic characteristics of a particular culture must be kept in mind when evaluating a child for growth failure or failure to thrive. For example, there are Chinese children who are small, but not all Chinese are small people. It is essential that a family’s pediatrician plot the child on a standard growth chart from the child’s country of origin if the child appears to be small to give the child the benefit of the doubt. If the child's anthropometric measurements (height, weight, and head circumference) are found on a standard American growth chart, then Dr. Aronson suggests that the American growth curve is appropriate. If a child is not on either growth curve and catch-up growth is not observed within 6 months, this child needs to be evaluated by the pediatrician more closely for other more complex underlying medical problems. Dental Health
Note that a lot of children who have had rickets and malnutrition may have damage to the primary dentition. Twenty teeth erupt during the first 2 ½ years of life. Rickets and malnutrition actually can delay tooth eruption. We commonly see lots of teeth suddenly erupting with the replenishment of calories and micronutrients during the early transition after adoption. Existing primary teeth may sustain enamel damage from bathing in sugar containing feeds in the orphanages as well as from lack of proper nutrition. Dr. Aronson recommends that children be seen by a general dentist with an interest in children or a pediatric dentist within 6 months of arrival in the U.S. The American Academy of Pediatrics recommends that all children be seen by a dentist by the age of two years. Eczema and Scabies
Another direct consequence of poor nutrition is poor skin condition. Kids often have rough, red, dry cheeks of the face and the skin of the rest of the body can peel and have dry, scaly patches. This is most likely a combination of factors. Kids are rarely bathed. They are wrapped up in layers of warm clothing all day and the under layers may be drenched with sweat, urine, and stool even though the pants are backless. Those insults rob the skin of its natural oils. Poor nutrition mitigates against the natural renewal of skin cells. Micronutrient deficiencies such as zinc deficiency can contribute to poor skin health. Exposure to food substances that are allergenic can also cause the red, dry, scaly appearance of a child's skin. This could be eczema (thirsty skin). Also, scabies can compound the poor condition of the skin. Scabies are microscopic mites that burrow under the skin and cause rashes and itching. It is essential that pediatricians recognize the many faces of scabies. It is the great pretender. At Dr. Aronson’s office, they usually empirically treat it if they have any doubt about skin that doesn't get better within a few weeks after adoption. The whole family needs to be treated in case of exposure. Hearing Screening
Dr. Aronson recommends that all kids coming from abroad have initial hearing screens within six months of arrival in the U.S. We have no available medical history on past ear infections in the orphanage and we also know that a small percentage of children all over the world have congenital hearing deficits. It is very difficult to diagnose subtle hearing problems in young children and since deafness impairs language acquisition we are very aggressive about hearing evaluations in adopted kids from abroad (audiologic evaluation). The American Academy of Pediatrics has recently recommended that all newborns be assessed for congenital deafness in the nursery (policy of uniform newborn hearing screening). Since kids adopted from abroad are at increased risk for language delays, normal hearing must be demonstrated to provide optimum diagnosis and treatment of language delays. Vision Screening
It is recommended that a vision screening be included in the standard screenings and examinations for internationally adopted children, on the same schedule as a child who was born and has received medical care in the US. Because kids from China have epicanthal folds (flat skin fold in the corner of each eye), it is often difficult to distinguish the fold from a lazy eye. An eye can appear to be moving inside, but it actually the fold covers the eye. This is called pseudo-lazy eye or pseudostrabismus. Pediatricians need to be watching this carefully; parents should be aware of times when the eye(s) appear to go in or out and mention this to the health care provider. There is no increased incidence of lazy eye in Chinese kids, but it can be a confusing diagnosis to make. Vaccines in the Orphanage
Vaccines administered in orphanages may be expired, improperly stored, or the malnourished and suppressed immune system may not respond to vaccines, so it is recommended that all vaccines be repeated in kids adopted from abroad in spite of immunization records. It is generally not harmful to re-immunize a young child. The Redbook 1997 published by the American Academy of Pediatrics has charts to guide pediatricians on how to accelerate the vaccine schedule for kids who have been incompletely immunized. A study published from the University of Minnesota adoption clinic in 1998 by Hostetter et al. showed that only 35% of kids with records of vaccines administered, from Eastern Europe, Russia, and China had antibodies to dipththeria and tetanus, but 65% of those kids did not! Older children can have a modified vaccine schedule based on individual titer assessments. Lead Poisoning
Prospective adoptive parents need to be aware that lead poisoning is a possibility when adopting a child internationally. The causes of lead poisoning can include contamination due to a child’s environment, drinking water from specific contaminated containers, the use of certain ceramic or metal dishes for cooking, lead paint exposure, etc. Scientists and researchers in universities in China have been studying lead poisoning for the last 25 years. Leaded gasoline, coal burning, smelting, and rapid industrialization especially during the 60s and 70s during Mao's cultural revolution have all contributed to a serious health hazard for all Chinese people. Lead poisoning is found in the urban, suburban, and rural regions of China. A published study by Aronson et al.1999 of 301 children adopted from China, revealed that 13% of these children had elevated lead levels. Only one child was treated (lead level 48) and she remains healthy and neurodevelopmentally normal. Lead poisoning, if sustained, can cause damage to the central nervous system. Lead levels in this study diminished to acceptable levels within a year of follow-up, except for the one child who was treated who is only slightly above normal most recently. You may find more information on lead poisoning in internationally adopted children through the Centers for Disease Control website at: http://www.cdc.gov/nceh/lead/tips/adoption.htm. Parasitic and Bacterial Intestinal Infections
Not fun for parents are the parasites commonly found in the stools of their newly adopted children. Parasites are identifiable and quite easy to eradicate with medication. To not diagnose parasitic infection could contribute to continued malabsorption and failure to grow. Giardia and ascaris are the most common parasites found in kids adopted abroad. The ascaris worms and giardia cysts can often be missed in the routine ova and parasite stool examination as the parasites do not always shed in every stool. At least three specimens should be obtained. Parents need to be forewarned that the "spaghetti-like" ascaris roundworms may be seen months after adoption in the diaper. There are special pharmacies that now will compound better tasting medicine particularly for the treatment of Giardia. You can contact your pediatrician for the details. For adults who have traveled to China to adopt, please contact your physician if you have symptoms of increased flatulence, diarrhea, abdominal distention, or any changes in bowel habits. This infection is transmitted with the changing of a child's diaper without proper handwashing. Also, it is transmitted by drinking tap water or eating foods contaminated with untreated water. It is best to drink bottled water, boil water, and/or drink canned, sealed beverages. A small group of adopted children will also have bacterial intestinal infections; assessment by performing a bacterial stool culture is simple, easy, and should be a routine part of the initial adoption medical evaluation. Treatment is usually quite successful. Tuberculosis
We need to continue to be very aggressive about testing kids adopted from abroad for TB. The risk for acquiring TB disease within the first few years of exposure is very high. With preventive treatment with a medicine called isoniazid, daily for 9 months, this disease is preventable. It is important to remember that BCG (Bacille Calmette Guerin) vaccine against TB is very ineffective. It is a vaccine designed to prevent TB and is given in China and other countries abroad, but not in the U.S. It may cause the skin test to be slightly positive, but not usually as much as 10 mm. The effect of this vaccine diminishes over time. We cannot afford to attribute a 10 mm TB skin test to past exposure to BCG TB vaccine. If we do this, we will risk having children develop TB because they will not have been given preventive therapy. All TB skin tests should be read within 48-72 hours of placement on the forearm and the test should be interpreted by a health care provider like a physician, physician assistant, nurse practitioner, or nurse. Tuberculosis is a serious health problem all over China. A small percentage of children adopted from China in have tested positive for TB, but their chest x-rays were normal and they do not have TB disease. They have been most likely exposed to TB while living in the orphanage. The adult staff who care for the children have no medical care and they are at great risk for TB disease due to their poor nutrition and crowded living conditions. There actually have been a few children adopted from China over the past ten years who have had TB disease, but so far this is rare. More insight regarding tuberculosis in international adoptees may be found at: http://www.peds.umn.edu/iac/topics/tb/home.html. HIV Infection
Occasionally, children adopted internationally may test positive for HIV upon their return. It is important to note that the initial HIV test is strictly testing for HIV antibodies. In the case of this positive test, a child’s mother was infected and the antibody from the mother was passed through the placenta from mother to infant. Only 25% of children born to infected mothers actually are infected with the virus. If the mother is treated with AZT during pregnancy, only about 5% of children are infected. Unfortunately this preventive treatment for pregnant women with HIV infection is not easily available in all parts of the world. It is essential to note that HIV infection is an evolving story all over the world. It is clear that no country will be spared. The world is small with the advent of international business and the spread of drug traffic. Hepatitis B Infection
A small number of children adopted internationally may test positive for Hepatitis B, either prior to or after the adoption. It is important for prospective parents to know that sometimes children may test negative for hepatitis B in country. Their positive test in the U.S. may reflect prior inaccurate testing, a lengthy incubation period for Hepatitis B infection (6 weeks to 6 months), orphanage exposure from those with acute and/or chronic hepatitis B infection, blood transfusions, or exposure to unsterile needles with administration of vaccines or in the drawing of blood. Children with chronic hepatitis B infection can go many years without any ill effects. It can be a manageable medical condition. There is no way to predict when the liver will become inflamed. Carriers need to have a yearly assessment of their liver enzymes and they should probably be followed by a children's liver specialist. Treatment is available for children and adults with active hepatitis B infection and research is ongoing. (Jenista, JA 1997) You may find more information on Hepatitis B and adoption at: http://www.hepb.org/patients/adoption.htm. Hepatitis C Infection
All of the adoption doctors across the U.S. are alerted to collecting their data on Hepatitis C infection in children adopted from abroad. The incidence is very low. This kind of hepatitis is associated with blood transfusions, intravenous drug abuse, and in a very small percentage of cases maternal-to-infant transmission. You may find more information on Hepatitis C and international adoption at: http://www.peds.umn.edu/iac/topics/hepc/home.html Anemia is widespread in children adopted from abroad. Malnutrition is the major cause of iron deficiency anemia. It has been documented in the medical literature of specific countries. (Chen et al. 1992) A complete blood count (CBC) will uncover anemia. We know that iron deficiency anemia can interfere with normal growth and be a cause of developmental delay and learning problems. With proper nutrition and iron supplementation, anemia can resolve and medical complications can be minimized. There are also genetic anemias that are found in children from specific countries like Vietnam, Cambodia, Thailand, and China. Children from China can have alpha or beta thalassemia traits genetically. When there were great waves of immigration of Southeast Asian individuals during and after the war in Vietnam, physicians gained experience in the epidemiology, diagnosis, and treatment of anemias indigenous to this area of the world. This has helped pediatricians enormously in their understanding of anemia in children adopted from this part of the world. (Glader & Look 1996) Having a genetic trait for an anemia is generally not harmful to the individual, but in combination with the same trait as might occur during reproduction, this can lead to a life threatening disease in the newborn infant. A CBC and a hemoglobin electrophoresis test will reveal underlying hemoglobinopathies (anemias due to abnormal hemoglobin proteins). Iodine Deficiency and Hypothyroidism
Iodine is a trace element found in the soil, air, and sea. It is an essential component of the thyroid hormones which in turn are vital to brain development. The most severe from of iodine deficiency is cretinism, a rare consequence of fetal/infant hypothyroidism. Iodine is ingested in food, water, and, most commonly throughout most of the world today, as iodized salt. An article in the New York Times on June 4, 1996 reviewed the current status of iodine deficiency in China. It prompted concerns from all parents who have adopted children from China and those who were in the process of their adoption. (Aronson 1997) Most children adopted from China are from orphanages located within areas where iodized salt is part of the diet. Infants in Chinese orphanages usually receive milk-based formula that has enough iodine to prevent severe deficiency. Only the inaccessible areas of China, such as inland rural areas, plateau and mountain regions as well as most of Mongolia and Tibet, have remained iodine deficient. With virtually no adoptions taking place from these regions, iodine deficiency is not a significant problem among Chinese adoptees at this point in time. Families should be aware that iodine deficiency can cause hypothyroidism and can potentially become a threat to the health and growth of children anywhere in the world. This is an ever evolving and changing nutritional issue. Hypothyroidism
Congenital hypothyroidism has a worldwide prevalence of one in four thousand births having nothing to do with iodine deficiency. Congenital hypothyroidism is caused by the improper development (dysembryogenesis) or complete absence (agenesis) of the thyroid gland; it is an embryologic defect which can lead to devastating brain damage if not diagnosed swiftly in the first few months of life. The U.S. and most industrialized nations perform newborn screens to assess for hypothyroidism within 48 hours of birth. Unfortunately, children adopted internationally are most often abandoned and do not have the benefit of a newborn screen. Children adopted from other countries may also not be born in hospitals where newborn screens are available. There have been isolated reports of hypothyroidism in children adopted abroad, but too few to consider as higher than the worldwide prevalence of one in four thousand. Some of these children have had nutritional deficits which cause transient hypothyroidism. Since children who are adopted from orphanages may not have the benefit of hospital screening programs, it has been my (Dr. Aronson) protocol to perform the New York State Newborn Screen at the time of the initial medical evaluation; this contains the following metabolic tests: thyroxine, phenylalanine, galactose transferase, biotinidase, sickle hemoglobin, leucine, methionine, HIV-1 ELISA. We also perform thyroid function tests for older children because the cutoff values for thyroid hormones may differ by age. It is not uncommon for the child to have an upper respiratory infection at the time of the adoption. The orphanages are crowded and infections spread swiftly. These infections are usually self-limited, but at least 10% of kids continue to cough and wheeze with each respiratory infection after adoption. This is called reactive airways disease or asthma. Medication placed in a nebulizer which the baby then breathes in effectively manages asthma for children. Asthma is a rapidly increasing medical problem in China today because of air pollution. Anyone who has traveled to China for business, vacation, or for the adoption of a child will tell you that their throat hurt in China and for many weeks after returning home. We know here in the U.S. that pollution has probably been one of the main causes for the increasing incidence of childhood asthma. There is no evidence that Chinese individuals have asthma more commonly than persons from other cultures. Without knowing the family history of a child, it is obviously impossible to determine the actual cause of the asthma since there is a genetic role. What Dr. Aronson has seen in her daily practice is that some kids do potentially have the capacity to grow out of asthma. Development
Many children adopted internationally will exhibit at least one area of developmental delay upon their arrival in the US. This could be a gross motor delay (not walking, or crawling yet), or a speech delay. Dr. Aronson refers 75 % of the children she evaluates at her office during the first few months of arrival from China for early intervention services. The vast majority of the children she follows long-term in her practice catch-up for gross motor, fine motor, and personal-social development within the first year after adoption. Sustained language delays are more common. What we don't know at this point is much about follow-up. It is obvious that kids living in orphanages will sustain delays and that these delays will be less for kids who stay for shorter periods of time, but we know little about long-term outcome. This must be the next step for research in the next millennium as children mature and become school age. Common Medications
Ear Infections and Respiratory Infections
Families should consider taking the antibiotic Zithromax (prescription) as a remedy for ear
infections and respiratory infections. While there are many antibiotics are available overseas, it
is wise to take a drug approved by the FDA. Although 99 percent of colds do not become
complicated, the typical course of respiratory infections in children begins with a cold. A cold
virus in the nose or throat can affect the middle ear, where fluid can accumulate and become
infected. That infected fluid in the middle ear, with an inflamed eardrum, is known commonly as
an ear infection. The eardrum becomes red and swollen and is quite painful. About 20 percent of
children with ear infections actually grab their ears, and about 80 percent will not. Note, that
sometimes children grab their ears for other reasons such as teething pain or sore throats. Some
children grab their ears just because it is a fun activity! The ear infection can affect your child’s
appetite, sleep, mood and may or may not be accompanied by an elevated body temperature. A
child can have a very low-grade temperature with little to no fever and still have an ear infection.
Certainly, fever can be a sign of underlying disease because it means the body is fighting
infection, but generally, kids can have ear infections without displaying dramatic signs.
Zithromax may also be taken for respiratory infections which can affect either the upper or
lower respiratory tracts. Upper respiratory infections are usually viral and do not require
antibiotic therapy. The cough from a cold is most likely a postnasal drip and sounds worse than it
really is. Saliva from teething can cause a little cough from time to time as well. If the virus
moves into the lower section of the respiratory tract and causes inflammation of the airways, it is
pneumonia. Symptoms include high fever, a productive-sounding cough, and fast breathing. As
with an ear infection, the child usually starts off with a cold. After a few days, a high fever
develops and breathing becomes very, very rapid. This combination undoubtedly disrupts eating
and sleep patterns and the child is diagnosed with pneumonia. It is very important to distinguish
the difference between an upper and lower respiratory tract infection.
Dr. Aronson recommends taking Zithromax as a powder when traveling abroad. It is dosed once
daily and does not require refrigeration. Do not reconstitute the powder until the antibiotic is
needed. Directions for adding the appropriate amount of water are written on the bottle by the
pharmacist. For ear infections, children take the medicine once a day for five days. For
pneumonia, the course is 10 days of Zithromax. It is advisable to take enough Zithromax to last
for 10 days. The dosage is weight-dependent and should be determined by a physician before
traveling. To ensure that the child receives a full dose of medicine, give the medicine from a
medicine dropper, not in the feeding bottle. Some medicine applicators look just like a nipple, so
the baby will suck the medicine down easily. Other medicine applicators resemble eyedroppers.
A syringe without a needle may also be used.

*Please note that if a child has a high fever, is breathing very fast, unable to eat, drink, or
sleep, the child should be seen by a physician urgently or brought to an emergency
department of a hospital.
Cuts and Scrapes
Physicians commonly recommend taking an antibiotic ointment such as Bacitracin, Neosporin
or triple antibiotic ointment for cuts, scrapes, and scratches.
Pink Eye or Conjunctivitis
A prescription for Tobrex drops can be used in treating pink eye, also known as conjunctivitis.
The symptoms of an eye infection involve yellow discharge from one eye or both. Often times
the eyes will be closed shut, practically glued together in the morning, and there may be
intermittent discharge throughout the day. Use a cotton ball with a little bottled water to wipe the
eyes clean. In order to prevent the spread of eye infection, wash the child’s hands and your hands
frequently throughout the day. Apply Tobrex drops simply by placing a drop near the inner
corners of the eyes and moving the child’s head slightly to that side. The drop will go in the
direction the head is tilted by capillary action and it will end up in the conjunctival sac. Dr.
Aronson recommends putting two drops in each eye, three times a day, for one week even if only
one eye is infected. Adults should each have their own prescription for Tobrex eye drops, as
conjunctivitis is highly contagious.
Skin Problems
Most children living in orphanages are not getting enough calories or the proper proportions of
various nutrients. Poor nutrition can affect the immune system and/or the skin. Eczema is quite
common and identified by very dry, rather scaly, red skin. Bathing in very hot or cold water can
also contribute to dry skin. Hydrocortisone 1% cream or ointment, Aquaphor, or Cetaphil
cream may be used to treat eczematous skin. Use Aquaphor or Cetaphil twice a day as a
maintenance regimen to keep the skin moist. Applying cream for dry skin is a nice way to
introduce the child to tactile stimulation via massage. Steroid cream can be used judiciously to
manage more angry and red areas of skin especially on those sweet little faces. You may
substitute any emollient that you already have in your treasure trove of creams at home; avoid
using perfumed creams. Unscented Dove soap is the least allergenic soap and good for all-
purpose body washing for adults and children. Don’t use a rough washcloth to wash the baby; a
soft sponge will do.
Scalp
Malnutrition and poor hygiene may also affect the child’s scalp. If a child is not bathed regularly,
an excess amount of oil on the scalp may plug the pores of the skin, leading to an inability of the
hair follicle to function normally. The result is severe dermatitis or cradle cap. Cradle cap can
look very similar to adult dandruff as the layer of oil that is on the scalp becomes brownish-
yellow and then flakes off. The scalp may appear red in some areas. A good way to treat cradle
cap is with T-gel Shampoo by Neutrogena. It is a coal tar extract, and a tiny amount can be used
every other day to remove the scales and oil until the scalp looks cleaner. This will also improve
the scalp’s ability to grow hair.

Diaper Rash
Two basic kinds of diaper rash will be discussed. Mechanical breakdown of the delicate skin
around the genitals and anus is caused by frequent exposure to urine and stool. The skin may
become red, dry, and wrinkled (prune-like). This is best handled by using preventative measures
discussed below. Occasionally, a child develops a fungal diaper rash, from yeast, which is
commonly found in the stool. As it remains in contact with the skin, it causes a splitting of the
cells of the skin and a very painful, fiery rash develops around the buttocks, genitals, the inner
parts of the thighs, the grooves of the groin, and on the skin up to the belly button. For fungal
diaper rash, apply Nystatin cream (100,000 U/gm; prescription) three times a day for seven
days. Remove the diaper during naps and at bedtime and have the child sleep on a layer of towels
instead of just a sheet in the crib. Exposure to air keeps the skin dry and aids significantly in the
healing process.
Preventative measures for Diaper Rash
Sometimes the skin around the genitals will appear a little red and maybe even prune-like, from
repeated exposure to urine and stool. In this case, Desitin, A&D Ointment, or Balmex would
work as a barrier to the moisture in the diaper. Any of these products works rapidly and
facilitates healing. Apply product with each diaper change or as needed.
Any commercial baby wipe brand is fine as long as it is unscented and lacks alcohol. Since
disposable diapers are ultra-absorbent, baby wipes are usually unnecessary after urination. Be
careful not to overuse wipes, as their tendency is to strip the skin of its natural oils, increasing the
risk of diaper rash.
Scabies
Scabies are microscopic mites that burrow under the skin. Scabies exist in the United States and
all over the world, but they are particularly common in a crowded setting like an orphanage or
school. Approximately 10 percent of internationally adopted children come back with scabies.
Scabies will cause a reaction about 6 to 8 weeks after the mite has burrowed under the skin. It
may be a local reaction where the burrowing occurred, or it might be a rash on the whole body.
Scabies organisms tend appear mainly at the soles of the feet and the palms of the hands, but
may also be found around the armpits and belly button. Manifestations of this include little red
raised bumps on the palms of the hands and the soles of the feet, with possible scaling, or even
blister-like spots. It is recommended that each person traveling abroad as well as the child have a
prescription for Elimite cream 5%. Elimite cream 5% is one brand of permithrin that is used to
treat Scabies. It is not necessary to treat the child or yourselves preventively without a diagnosis
of actual scabies. If scabies is diagnosed in the child, then everyone on the trip should be treated
preventively. Apply the cream, which is odorless, to the skin, from the neck down, covering the
whole body. Leave it on for 10 hours overnight and shower it off in the morning. Putting socks
on the baby’s hands will keep the baby from scratching the rash, rubbing the medication into the
eyes, and eating the medication. Only one application is required, but it may take weeks or
months for the skin to rejuvenate completely. Be sure to use a good moisturizer to aid in the
skin’s healing. Benadryl may be necessary for a few nights to keep the itching under control.
Remember that adults will not manifest signs of scabies while in the orphanage because it takes 6
to 8 weeks. If a child has scabies, the scabies reaction may be avoided in the parents by using a
single application of the Elimite cream. It is recommended that you change sheets and towels the
morning after the treatment.
Antipyretics (anti-fever) and Analgesics (pain relief)
Acetaminophen
Acetaminophen is a good product for the treatment of fever and pain. It comes in a variety of
brands and fruity flavors and has a medicine applicator inside the bottle marked with 0.4 ml and
0.8 ml. It is best to take a couple of bottles overseas. Acetaminophen works great for relieving
the pain of teething, which is commonly demonstrated by excessive drool, fingers or fists in the
mouth, and/or fretful behavior. Teething is associated only with very low-grade temperatures of
less than 100 degrees. If the baby has a cold or a viral infection, a dose of acetaminophen will
relieve muscle aches and discomfort, which usually occur with a temperature of 101.5 degrees
and above. Acetaminophen may also be used to relieve the painful inflammation of an ear
infection for the first 48 hours after initiation of antibiotic therapy. Note: acetaminophen and
ibuprofen are medications for fever and/or pain for teething, colds, and ear infections.

One may substitute ibuprofen for any of the following:

Ibuprofen (Motrin, Advil) (100mg/5ml) Doses are based on the weight of the child Dose: 10 mg per kg of weight every 4 hours Dose: 5mg per kg of weight every 6-8 hours i.e. child weighs 8 kg; multiply 8 X 10 =80mg which is one infant dropper of acetaminophen i.e. child weighs 10 kg; multiply 10 X 5 =50 mg, which is 2.5 cc of ibuprofen To convert pounds to kilograms, divide the pounds by 2.2 i.e. 22 pounds divided by 2.2 equals 10 kilograms. Allergy and Itching Medication
Hives are recognized as red skin with an elevated, itchy, white area or welt. Benadryl
(diphenhydramine is the generic) is usually found in a concentration of 12.5mg per 5cc and may
be used to treat both hives from allergies and the itchy rash of scabies. It is available now as a
clear, bubble gum-flavored liquid without dyes. The dose is 1 mg per kilogram of weight, given
as often as every 6 to 8 hours. Thus, for a 6kg child: 6kg x 1mg per kg equals 6mg which equals
2.5ml (1/2 teaspoon) of Benadryl. Please remember that antihistamines commonly cause
sleepiness. About 3 percent of children and adults do have an idiosyncratic reaction of
hyperactivity. This reaction can occur even after the medication has been used and has caused no
reaction at all. This medication is not recommended to control behavior on airplanes!
Colds & Coughs

Over-the-counter decongestants can cause infants and children to become either overly active or
quite sleepy so they are not recommended for traveling kids. Echinacea can be very useful for
the treatment of a cold especially as the cold first begins. A child’s dose varies with age; consult
a physician for proper dosing. Usually children under one year of age can take 5 drops twice a
day and toddlers can take 10 drops twice a day. No particular brand is recommended over any
other, but some products are flavored and are tastier for children. Echinacea is available at health
food stores.
The mainstay of treating a cold is saline nasal drops. They go in each nostril every few hours.
Recommended brands include Ocean, Nasal, and Ayr. Saline gel is now available and is quite
comforting. After using the saline nose drops, a bulb aspirator effectively removes the mucus.
Many types of bulb aspirators are available. They are available at local pharmacies. Saline nose
drops are great for adults to avoid excessive drying of the nasal mucus while flying on a very
long trip.
Vomiting & Diarrhea

If the child just has diarrhea, continue to feed her/him formula in order to provide sufficient
nourishment. Use plain, bubble gum, or grape Kaolectrolyte packets that are reconstituted with
8 oz of bottled water between feeds. Pedialyte is available in small containers for travel, but is
less convenient. If the baby has nausea or vomiting, dispense with feedings for 4 to 8 hours and
use the electrolyte solution every 5 to 10 minutes. Since the baby cannot tolerate large amounts
of fluids, use an eyedropper to drop the electrolyte solution down the sides of the mouth. If the
baby consumes too much fluid all at once, s/he will become nauseous and vomit back whatever
was just consumed. So go slowly. If the diaper is too absorbent and the parent has difficulty
checking whether or not the child has urinated, put tissues in the diaper. Babies usually urinate
every hour or two. Decreased activity and poor urine production should also signal a need for
urgent medical attention.
Helpful Hints for Adoptive Parents

Teething
Teething begins about 4-6 months of age, but there may be no teeth until after one year! When a child’s mood changes and they are inserting their fingers or fist, mouthing everything in their environment, or drooling to beat the band, think of teething. A dose of acetaminophen or ibuprofen at bedtime for the obviously teething infant is a gift to the baby. Remember that the fever of teething is low grade and is rarely above 100 degrees. Constipation This is the nightmare for new parents, especially when traveling in their child’s placing country. The change in the diet usually causes a hard and painful bowel movement. Prevention of constipation is really a priority. Using more fluids and fiber in the diet and having that 6-pack of Sunsweet prune juice could save a baby a lot of discomfort. Fruits, vegetables, and diluted juices can prevent constipation. It is best to get a baby regulated from above and not from below. Many families rely on glycerin suppositories. In a pinch it is okay, but not as a long-term solution. Plane Ride and Ear Pressure Parents frequently ask about the management of ear pain from the changes of pressure in the airplane especially if a child has a cold or an ear infection. Having the child sucking on a bottle or a sippy cup on take off and landing can be helpful. A dose of acetaminophen or ibuprofen before the take off or before landing is also useful. Decongestants have not been proven to be effective. As mentioned above, it is not advisable to use antihistamines to control or prevent changes in behavior on an airplane. Good old-fashioned distraction with walking up and down the aisles, a visit to the bathroom, snacks, drinks, and play are in order. Some parents claim that inserts for the ear canals called “earplanes” are useful; they are available for adults and children. Sleeping and Jet Lag It is recommended that when you arrive home after a very long trip (greater than 8 hours time difference) that you and the baby just sleep as needed for a few days regardless of the time schedule. This will provide the needed rest after a very arduous trip. Then, sleep deprive a few hours at a time for the next few days until you are back in your time zone. Go out for walks and do simple errands, but keep the baby awake. Drink plenty of fluids and don’t go back to work. It helps to have a select friend or family member to watch the baby so you can grab a nap here and there. Babies less than one year of age should be fed formula with iron, either milk or soy. There are many opinions about whether babies should have soy or milk. Baby food is heavy and inconvenient, but some families do like to take some along. Babies eat 3 meals and 2 snacks aside from their bottles. It is suggested that the infant can do fine just on the formula while you are traveling and food can be added on arrival at home. But… if the child has teeth and an appetite to match, table foods will be fine as long as you prepare the food as mashed or in small pieces. Any food will be fine, except for some obvious restrictions like nuts, chocolate, and peanut butter. As mentioned above, the formula should contain iron. Development of intellect is based on good nutrition and iron is necessary for intellectual growth. Introducing more fluids, fruits, and vegetables and having a handy supply of prune or fruit juice can prevent constipation. Toddlers clearly can be fine on a regular assortment of table foods. Many families often have questions about transitioning their baby from the formula the baby was fed in the country of origin to formula in the U.S. There are as many ways to do this as there are parents adopting. As long as the baby appears to be getting enough calories, it doesn’t matter how you transition the child. Most formulas from abroad are quite similar to American formulas. Nipples can differ so bring along a variety and you will find the magic nipple for your baby. Oral Motor Dysfunction Beyond the scope of this discussion is oral motor dysfunction, which is quite common in babies adopted from orphanage due to a complex set of circumstances including bottle propping, malnutrition, rickets, and under stimulation. Your baby may have difficulty sucking and swallowing so be patient and feed the child slowly with a lot of close holding and attention to the body language of the baby. Also some children appear to “know” instinctively, that drinking fluids like water, leads to increased urination and they don’t want to be wet so they don’t drink. They are used to not being changed for hours at a time in the orphanage so this is a practical response to a sad situation. Age Concerns for Adopted Children
Children who are abandoned in infancy and childhood may not have an exact date of birth. If an infant has a belly button with some remains of the umbilical cord from birth, the child was probably born within a few weeks of the abandonment. Date of birth is usually assigned based on the date of arrival in the orphanage. The placing country’s adoption administration and institute staff estimate the year of the birth according to the child's appearance. Occasionally the date of birth is written on a note pinned on the child at the time of abandonment. To accurately determine the age of a child who may have an inaccurate date of birth is challenging, but feasible. If the child is less than one year of age, a difference of weeks or even a few months is not critical to the long-term development and health of the infant. Children who are pre-school age or beyond require a more intensive investigation for the assessment of age for appropriate placement in school. Placement in the proper class in pre-school and beyond is important for the success of the child socially and academically. Assignment of an appropriate age is also essential for the child's sense of self and identity. It has been Dr. Aronson’s experience that establishing age involves a team approach involving the parents, the pediatrician, a radiologist, a dentist, teachers, a lawyer, and developmental specialists in certain cases. It is essential to allow a transition period after the adoption of about 6-12 months before beginning a formal assessment of age. Children can be somewhat malnourished when they first arrive in the U.S. and this can account for failure to thrive physically and developmentally. Malnutrition is by far the most common cause of growth failure. Chronic illness, family dysfunction, and institutionalized living are other obvious causes of growth failure. Catch-up is swift, but it may take up to a year for a consistent pattern of linear growth and weight gain. Pediatricians evaluate children developmentally using the Denver Developmental Screening Test (DDST) which assesses children from birth to six years of age. The DDST uses personal-social, fine motor-adaptive, language, and gross motor milestones to establish the developmental level of an infant or a child. It is probably advisable to do the DDST with each well-child visit and to allow a child 6 months to a year to adapt and adjust to her new environment. If the child has delays on the DDST, then early intervention is usually appropriate and a more comprehensive evaluation is performed by qualified experts such as language and speech specialists and physical therapists. Under the age of three years, children in New York State are provided with free early intervention services in each borough. After the age of three years each school district provides services. If a family has a question or concern regarding their child’s age, Dr. Aronson usually recommends a "bone age" X-ray between 6-12 months after the adoption. This involves an X-ray of the left hand and wrist. The radiation exposure is minimal. A radiologist, a physician who specializes in the interpretation of X-rays, compares your child's X-rays to the X-rays of children with established ages in a textbook called "Radiographic Atlas of Skeletal Development of the Hand and Wrist" by Greulich and Pyle. The X-ray plates in this atlas are representative of thousands of healthy children relating the child's bone development to chronological age. There is alot of variability even in children who are not malnourished. Statistical tables which include standard deviations are part of the bone age assessment and it must be understood that the accuracy of the test is limited in children less than 4 years of age. Children can have delayed bone age and it doesn't necessarily mean that this is their age. Some children, who have never lived in an orphanage and who have been healthy all their lives, may have a delayed bone age. There are familial/genetic factors which cause the children in a family to have delayed bone age and delayed puberty. Most children with delayed bone age catch up later in childhood or adolescence. They have the potential to grow. It is very important to remember that people from cultures with a smaller stature do not have delayed bone age. Their bone age is normal, but they are just smaller. Next she recommends a set of dental X-rays. It is preferable to go to a pediatric dentist or at least to a dentist who has a lot of experience with children and enjoys working with kids. There is an amazing variability in the numbers of teeth children have in infancy. Well-nourished children can have no teeth at one year of age. The average one year old has 4 upper and 4 lower teeth. Teething usually begins by 5-6 months of age and children teeth for about 2-2 1/2 years until the 20 primary teeth are all erupted in the mouth. One baby who was eight months old at the time her family arrived to meet her in China had no teeth, but she was actively teething. Within two weeks of her arrival in the U.S., she had five teeth. It is quite possible that her recent nutritional improvement led to swift eruption of her teeth. Dentists are able to consult charts which depict the appearance of the primary and permanent teeth in the jaw bone at particular ages. The position of the permanent teeth in the bone is correlated with age and the disappearance of the root of the primary teeth is very telling. We encourage you to consult a local pediatrician or an International
Adoption Clinic and/or Specialist for any concerns or questions you
have regarding the health and development of your child.

Source: http://childrenofallnations.com/documents/2013/08/medical-resources-guide.pdf