The number of children migrating to the United States has increased tremendously in recent years, and includes temporary visitors, documented and undocumented immigrants, permanent residents, student visa holders, refugees, asylees, and adopted children. Approximately 266,000 children entered the United States as immigrants in 2001,1 and in Minnesota during 1999 more than 50% of refugees entering the state were children under the age of 18 years.2 These children carry a large disease burden, and most of them lack a history of adequate preventive health care. More than 50% of internationally adopted children, regardless of age, sex, and country of origin, will have a previously undiagnosed medical condition, which is identified on initial evaluation in the United States.3 Infectious diseases are the most prevalent conditions identified; of the refugees entering Minnesota in 2000, 53% had positive Mantoux skin test for tuberculosis, 31% had pathogenic parasite infestations, 14.9% had anemia, and 7.5% were hepatitis B carriers.2

Children who are refugees, asylees, immigrants, or international adoptees should all undergo formal medical screening. Additionally, other migrant children should also be considered for screening, for a significant number of immigrants will have persistent, potentially severe medical conditions, which may be uncovered during initial screening.4 This article discusses medical screening of children who migrate to the United States.

The Process of Screening

Preimmigration Screening

The International Office of Migration (IOM) coordinates a required overseas medical examination before legal immigration to the United States. This examination is generally of little assistance to the pediatric practitioner as the child generally receives a very cursory inspection. This examination is done within a year of resettlement and is primarily focused on excluding contagious diseases of public health significance such as active tuberculosis, human immunodeficiency virus, (HIV) infection, syphilis, and severe mental illness. Generally, if a child is less than 15 years of age, no blood work or tuberculosis screening is required, and often only a minimal physical examination is performed. Further, even when performed or required, it is not unusual for persons to purchase false records or normal-appearing chest films to pass the medical requirements. As a result, it is not unusual to encounter active tuberculosis or infections with HIV, hepatitis B, or malaria in children with documented normal results from overseas medical examinations.

The Domestic Health Screen

The purpose of domestic medical screening is to reduce health- related barriers to successful resettlement while protecting the health of the general population. Serious diseases are frequently uncovered during the medical screening, which, if they remain undetected, may significantly impact the child's health and well- being. Beyond the direct implications to the migrant child, the public health interests are served by decreasing the likelihood of untreated infections disease spread to the general population (i.e., tuberculosis, intestinal parasites). In addition, identifying and correcting deficiencies in previous preventive health care (i.e., immunizations) protects the health of the community.

When children enter the United States as refugees the US government recommends that they undergo medical screening within 90 days of resettlement. Although most experts would recommend medical screening for all migrants, everyone does not routinely receive this service (i.e., many immigrants, students, and undocumented individuals). Further, refugees who leave their port-of-entry state (the state they are assigned at immigration) or who move from their declared address within their port-of-entry state before the medical screening are usually lost to follow-up for health department screening. Some states utilize the state or county health departments, or contract with primary care clinics, to accomplish screening, while other states may have medical screenings performed at any local clinic. Despite how a state arranges its screening clinics, the responsibility of medical screening frequently falls to the community pediatrician. In addition, even when screening is performed at a county or state health departments the results are many times sent to the primary care provider. Therefore, the primary care provider must be familiar with the tests performed. It is not infrequent that results are lost and the primary care provider must repeat a medical screen. Conversely, international adoptees uniformly receive medical screening as they are generally brought to an adoption clinic or to their primary care physician by the adoptive parents.

There are many barriers to proper medical screening such as unfamiliarity of primary physicians with medical screening in this population, difficulty in communication, transportation difficulties, lack of financial resources, and cultural and religious differences. Many of these barriers may be adequately addressed through health care provider education, use of culturally and linguistically competent clinic staff and educational materials, creation of an inviting clinic environment (e.g., art work from populations served on display) and an increase in social and outreach services. The financial burden of healthcare is frequently a barrier to screening and ongoing care; however, most children are eligible for financial assistance.

When a refugee is screened most states request health care providers to complete a new arrival domestic health assessment form and return it to the state health department. These forms are not completed for nonrefugee immigrants. Poor health care provider compliance and varying formats among states plague accurate data collection and prevent comprehensive and meaningful data analysis on a national level.

The Medical Screen

The routine medical screen varies from state to state, community to community, and even from clinic to clinic. The medical screening protocol recommended in this article is based on known risks, extrapolated literature, expert opinion, clinical experience, and perceived cost-effectiveness. Screening examinations should be tailored to the population being screened according to population risk factors, changing epidemiology, cost effectiveness, community resources, payment sources, and available interventions or treatments. For example, sickle cell disease need not be screened for in Somali children because of low prevalence rates, though it may be cost-effective to routinely screen Haitian children.

Medical screening should generally consist of a thorough history and physical examination, screening laboratory tests, and preventive health interventions such as immunizations and well-child care. The child should receive appropriate interventions for any medical or psychiatric illness identified and referral to a specialist as necessary (Table 1).

The clinic staff should be instructed to request caregivers that they bring all health-related documents including immunizations and the IOM forms when making an appointment. Many of these health records are difficult to interpret owing to incorrect data or unavailability of accurate translations of the terms used.5,6 However, occasionally these documents do contain valuable health information on immunizations and previous studies (e.g., tuberculin skin test, chest radiograph). These documents must be interpreted with caution and any valuable data should be noted and recorded in the child's medical record.

History

The initial step in the examination is the taking of a complete medical history including current complaints, past medical history, medications, and allergies, as well as social and family history. The medical history should also include a pregnancy, birth and neonatal history, as well as growth and developmental milestones. Developmental milestones must be taken in a social and cultural context. For example, a child who is carried on the mother's back for the first couple years of life for cultural and practical reasons may have delay in motor development as assessed by ambulation. Because physician visits, diagnostic capabilities, hospitalizations, and treatment vary from country to country, it is important to ask about any major illnesses requiring medications and about details of the disease. Specifically, the clinician may inquire about "yellow jaundice" episodes, typhoid, malaria, exposures to bad or "bloody cough" (TB), or "wasting" or "slim's" disease (HIV/AIDS). Knowledge of the appropriate terms used by an ethnic group or by geographic region can be very helpful. For example, a patient from East Africa who had urinary schistosomiasis will deny it if you ask him if he had urinary schistosomiasis but respond positively if you ask him if he had bilharzia. It must also be noted that many diseases are stigmatized and questions must be asked in appropriate settings and in a culturally sensitive manner to insure accurate responses.

Table 1

RECOMMENDED MEDICAL SCREENING EXAMINATION

The risk of iatrogenic infections such as hepatitis B or C, malaria, and HIV should be assessed by asking past medical history including previous surgical or dental pr\ocedures and blood product transfusions. Many immigrants and refugees have passed through multiple geographic residences between their home country and their final US destination. Therefore it is also important to obtain a thorough history regarding the route of arrival to the United States. Knowledge of previous countries of residence may reveal the potential environmental and infectious disease exposures as well as give the clinician an idea about the quality of previous healthcare and preventive services the patient has received.

In addition to prescriptions and over-the-counter medications, it is important, to inquire about herbal or imported medication usage and traditional health care beliefs and practices. Responses to these inquiries will frequently open a window into the patient's culture and acceptable healthcare framework, which in turn may influence the way healthcare should be provided to the child. Medication history may reveal medications not familiar to the clinician. These may be traditional or herbal, bought over-the- counter, or imported legally or illegally. In a study of 260 Asian medications purchased at local stores in California, 37% had 1 or more undeclared pharmaceutical agents.7 The practitioner may be unfamiliar with these substances. However, many of them may be identified by the regional poison control centers.

When initiating a pediatric family history the clinician should verify that the caregiver(s) are biologically related before inquiring about diseases of concern. It is common for the refugee children fleeing from political strife or famine to be cared for by the extended family members, clan members, or even family friends. In addition to traditional hereditary diseases of concern (e.g., sickle cell disease, diabetes) the clinician should inquire about environmental and geographically acquired diseases (e.g., heavy metal toxicity) affecting family and community members. Positive responses to the inquiries may lead the clinician to expand the medical screen or to search more diligently for specific maladies. The clinician must also take a past social history and learn about current living situations to fully assess environmental and infectious disease risks.

Physical Examination

A thorough physical examination is very important and may reveal previously undiagnosed medical conditions such as fungal infections, cardiac anomalies, organomegaly, and congenital anomalies. Vision and hearing evaluation is highly recommended for all children, especially in young infants where hearing and visual deficits may not be readily apparent.8 Nutritional status should be addressed in all patients and an assessment of growth and development parameters is mandatory.9 Particular attention should be paid to weight, height, and head circumference in children from refugee camps and orphanages, since growth is frequently retarded in these children.10

In many cultures age is not counted by the calendar year and is estimated either by the family or by the Immigrant and Naturalization (INS) agent at the time of immigration-leading to the common finding of January first birth dates. Parents may also alter the date of birth of their children to receive benefits from government agencies. For example, the birth dates of children over age 21 may be changed to have them included in the "family unit," since all children under age 21 years are considered part of an INS- approved family unit. Unless the age appears to be different by several years, the child's reported age should be accepted. It is better to wait for at least a year (after arrival) to evaluate these children for chronological age because malnutrition, abuse, neglect, and institutional living may have caused bone or dental age to be retarded.5,6 The child's school performance, maturity, pubertal development, and bone and dental age should be utilized to estimate the age of the child. The growth and developmental assessment must be interpreted with caution given this variance in true versus reported age.

The physical examination may reveal evidence of female genital mutilation (female circumcision) or scars due to cultural scarification, coining, cupping, pinching, burning, and uvulectomy (Figures 1-6). These cultural practices have frequently been misinterpreted by well-meaning health professionals as child abuse and have resulted in some children being removed from their home.11,12 Such physical findings should not be misdiagnosed as child maltreatment, with the possible exception of a newly performed female genital mutilation, which is now illegal in the United States. Specific sites of scarring may actually provide clues to the individual's past medical history (Figure 6).

Preventive Health Interventions

Immunizations. According to the new subsection added to the Immigrant and Naturalization Act (INA) in 1996, a person seeking an immigrant visa for permanent resident status in the United States is required to show proof of having received the recommended vaccines before immigration. Unavailability of a vaccine in the country of origin is one of the exceptions to this rule (e.g., Hib vaccine). Refugees must show proof of immunization at the time they apply for permanent resident status, usually within 3 years of arrival, and are not required, like immigrants, to meet the INA immunization requirements on initial entry into the United States. Overseas immunization is not currently required for adopted children.

In 1999, 87% of all refugees entering Minnesota had either incomplete or absent documentation of immunization (66% of those 0- 5 years old, and 86% of those 6-18 years old.)2 Despite this apparent lack of documentation, a recent seroprevalence survey in more than 600 refugee children aged 0-20 years, from multiple geographic locations, found significant titers for multiple vaccine preventable diseases.13 In this population survey, more than 80% had measles and rubella antibodies and more than 60% were immune to varicella, indicating that a significant number of refugee children have received adequate vaccine series, or had disease, before migration.13 When the immunization is incomplete, it should be completed according to the US immunization "catch-up" schedule established by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC). Antibody testing may be used in older children when it is believed that the child has received a complete vaccination scries in the past. If the child does not have a record of appropriate vaccination, the record is illegible, or the dates do not make sense, the immunization series should be restarted. Note that children from many developing countries are not routinely immunized with Varicella, Hemophilus influenzae type b, mumps, rubella, conjugated pneumococcal vaccines, and influenza, and therefore, these vaccines should be considered for an age-appropriate immigrant or refugee child.

Figure 1. Cambodian adolescent with cupping. Blanching maculopapular rash secondary to dengue fever. Also increased risk of hepatitis; iatrogenic B, C; and HIV secondary to tattoos.

Figure 2. Adolescent Laotian male undergoing pinching therapy.

Figure 3. Somali adolescent female who had uvulectomy as a child.

Figure 4. Facial scarification in a young Sudanese female.

Figure 5. Coining in a Hmong child.

Figure 6. Three burnstick marks over apex of heart, suggestion history of rheumatic fever. Also, positive tuberculin skin test.

Vaccines in adopted children may be approached slightly differently owing to better population-based knowledge generated through progressive adoption clinic data collection. Studies investigating seroconversion of vaccine-preventable diseases in adopted children have demonstrated that less than half of the adopted children from orphanages in Russia, China, and Eastern Europe have protective antibodies to polio, diphtheria, tetanus, and pertussis despite records of proper immunization.3,14,15 Therefore, all adopted children arriving from Russia, China, or Eastern Europe should have titers checked or, alternatively, the vaccine series should be reinitiated upon arrival to the United States. The vaccination records from Korea, India, Guatemala, Colombia, and the Americas are more reliable and may be accepted, although some experts still recommend checking titers.3,8,15

General Laboratory Tests

It has been estimated that up to 80% of all disease states detected in refugees, the majority of which are infectious diseases, are not evident on history and physical examination alone.16 In addition, many treatable diseases, some of which may pose a public health threat, may be identified through cheap and sensitive screening laboratory examinations. Therefore, most children arriving in the United States should undergo laboratory investigation. The exact protocol may vary from patient to patient based on many factors, but the following tests should be routinely done on most newly arrived children (Table 1).

Complete Blood Count and Differential. Performing a complete blood count and differential may identify many pathologic conditions. Anemia is extremely prevalent in this population and is frequently multifactorial. In addition to nutritional anemia (i.e., iron deficiency), anemia of chronic disease, and lead toxicity, genetic traits such as thalassemia and other hemoglobinopathies are frequently encountered. For example, approximately 40% of persons of Southeast Asian decent carry one or more genes for various red blood cell dyscrasias such as alpha-thalasssemia, beta-thalassemia, hemoglobin E, and glucose-6 phosphate dehydrogenase deficiency.17 Therefore, these conditions should be considered in the differential diagnosis of anemia, especially when the anemia is not responding appropriately to therapy.

Since pathogenic parasites are the most common cause of eosinophilia, asymptomatic eosinophilia in a person coming fr\om a developing country should be thoroughly evaluated. Evaluation for eosinophilia can be quite complex and should be tailored to the patient's country of origin.18 In one study involving Southeast Asian immigrants with eosinophilia, 95% were found to have pathogenic parasites; 55% had hookworm, 38% had Strongyloides, and 2% had amaebiasis.16 These organisms may remain undetected by routine stool ova and parasite examination and can cause ongoing morbidity in children. Since Strongyloides may persist for more than 60 years in a human host, there is a risk of dissemination if the child is immunosuppressed for any reason, including corticosteroid treatment for other conditions.19 Some experts recommend empiric treatment with albendazole when an extensive work-up of the eosinophilia has yielded no clear pathology.20

Hepatitis A and B Serologies. Hepatitis A is extremely prevalent throughout the world. In developing countries, a majority of children have had the infection and have developed immunity by 5 years of age. Some authorities include the hepatitis A serology in the initial medical screening. This is performed to avoid an unnecessary vaccine series, since a number of western states of the United States include hepatitis A as a routine childhood immunization. Also, many immigrant and refugee children subsequently travel back to their home countries, or travel to other international destinations, and may avoid the relatively expensive vaccine series in the future if they are immune.

Hepatitis B is extremely common in many parts of the world, especially Southeast Asia where infection rates range from 5% to 50% and hepatitis B surface anti-genemia exceeds 15%.8,21 Hepatitis B infection can lead to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Hepatitis B screening should include the hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (Anti-HBc), and the antibody to hepatitis B surface antigen (Anti-HBs). The child who is found to be a chronic carrier of hepatitis B should also be screened for hepatitis D infection. Any child with hepatitis B surface antigenemia deserves close monitoring and should be considered for treatment. Although there is some debate in the literature, a reasonable screening protocol for chronic hepatitis B carriers includes serum alpha-fetoprotein (as a tumor marker) every 6-12 months, and right upper quadrant ultrasound annually beginning at 12 years of age.6 Patients who are both antigen and antibody negative for hepatitis B should receive routine vaccination.

Human Immune Deficiency and Syphilis. Serology for HIV and syphilis should be performed on all children over 15 years of age and on any symptomatic child. It is also reasonable to check any high-risk child under 2 years of age for congenitally acquired disease. For example, children may be considered at high risk if they are adopted from an orphanage or if they originate in refugee camps where excessive rates of HIV or syphilis exist (e.g., many African nations, Haiti). A copy of the IOM records is sufficient for documentation unless the child has ongoing symptoms. When the screening test for syphilis (RPR/VDRL) is positive, a confirmatory fluorescent treponemal antibody absorption test should be performed. False-positive results for RPR/VDRL are common in many populations and are caused by other spirochetal diseases in the immigrant or refugee, such as pinta in individuals from Africa.

When ordering HIV tests in this population, note that many laboratories utilize immunoassay screening and western blot confirmatory tests that reliably detect HIV-1 infection but not always HIV-2 infection. In screening any individual, especially one originating in West Africa where HIV-2 infection is common, immunoassays that are licensed for detection of both HIV-1 and HIV- 2 should be used.22 This may also be true in utilizing polymerase chain reaction (PCR) for typing of HIV viruses in infants where HIV IB is reliably detected, but other subtypes more common in other parts of the world may not be detected by all commercially available tests. In ordering a PCR on a new arrival infant, it is wise to discuss the limitations of the assay with an infectious disease specialist familiar with global HIV epidemiology.

Lead. In most areas of the world lead-based paints and gasoline and industrial waste containing lead are still common. Large numbers of refugee and adopted children are found to have elevated lead levels, though these levels rarely exceed 45 mcg/dL, the current treatment threshold.23,24 Although most children will not exceed a level that mandates chelation therapy, lead levels should still be checked for several reasons. Children may benefit from special services, as many school districts will take excess lead levels into consideration when determining special needs status. In addition, lead levels may actually increase once the child is in the United States, for most will enter substandard housing or they may experience ongoing exposure through use of lead-containing traditional health remedies, medications, cosmetics, and household items (e.g., Mexican ceramics). When the lead level unexpectedly increases, rather than decreases, the ongoing lead exposure must be investigated.

Metabolic Screens

Diseases identified by newborn screening vary by state. Newly arrived children with abnormal growth or development may need broad screening for metabolic diseases, including hypothyroidism or rickets. However, the cost of universal metabolic screening is not justified in older children who manifest normal growth and development. Disease-specific screens may be indicated in high-risk populations, as family counseling may be important in certain diseases such as thalassemias and sickle cell anemia.

Stool Examinatons. A large percentage of immigrants and refugees have gastrointestinal parasites that are easily detected on routine ova and parasite (O&P) examination of the stool.25 Three consecutive morning stools should be collected for analysis. The parents should be given clear and succinct directions in their own language on collection, storage, and delivery of specimens to insure quality and compliance.

It is not uncommon to find multiple organisms in the stool specimen, including those considered nonpathogenic, especially in asymptomatic patients. The presence of Blastocystis hominis, Entamoeba hartmanni, Entamoeba coli, Endolimax nana, and Iodamoeba butschi in the stool indicates poor hygiene (fecal-oral contamination) but does not demand treatment. At least one potential pathogenic intestinal parasite is detected in more that 40% of individuals in some populations.2 Hookworm, Ascaris lumbricoides, Trichuris trichura, Giardia lamblia, Opisthorchis species, Taenia solium, and Strongyloides stercoralis are the most common parasites detected in refugees.20,25

Entamoeba histolytica (E. histo) deserves special mention. The cysts of Entamoeba dispar (E. dispar), a common and nonpathogenic intestinal parasite, are indistinguishable from cysts of E. histo. by microscopy. Treatment for E. histo includes 1 to 3 weeks of antiparasitic medications that commonly cause adverse effects, some of which may be serious. To prevent unnecessary treatment, serum serology and stool antigen for E. histo should be obtained in asymptomatic patients who have cysts in the stool, and only patients with a positive serology or stool antigen for E. histo should be treated.6,26

Some experts have recommended empiric treatment of intestinal parasites with albendazole, as it may be more cost effective and efficient than routine stool evaluation.27 However, albendazole has potential adverse effects, and some pathogens (e.g., E. hislolytica, Schistosomiasis spp) that are common and potentially pathogenic are not adequately treated with albendazole. The use of empiric albendazole in children was not included in the published literature. Therefore, the current recommendation in the pediatric population should be to obtain stool samples to confirm parasitic infestation before treatment.

Urinalysis and Conditional Urine Culture. A urinalysis (U/A) is an inexpensive method of screening for many diseases and should be considered for most newly arriving children. In asymptomatic children too young to perform a clean-catch urine specimen, a urine collection bag may be used, as the parameters of interest are generally protein, red blood cells, and sediment and not bacteria. Schistosomiasis hematobium (S. hematobium) is commonly found in some endemic areas of Africa and is the leading cause of squamous cell carcinoma of the bladder. Infection usually presents as intermittent asymptomatic hematuria, and prevalence rates can reach over 90% in some parts of Nigeria and Ghana.28,29 Interestingly, onset of hematuria may be so common that it is considered a sign of maturity in some cultures.30

Tuberculosis Screening

Immigrants and refugees account for roughly 30-50% of the tuberculosis (TB) burden in the United States; an estimated 7 million foreign-born persons living in the United States are infected with tuberculosis.31,32 The risk of tuberculosis is at least 100 times higher in immigrant children than children born in the United States.33,34 Drug-resistant tuberculosis has been rising in the United States, the most important source of drug resistance being imported tuberculosis.35,36

Children are at increased risk of developing disease once infected with the mycobacterium tuberculosis; infants have a 40% risk of active disease without preventive treatment, while adolescents have a 15% risk. This compares with a 5-10% lifelong risk of disease progression in adult immigrants.37 In addition, infants may develop disseminated or meningeal TB before developing a positive tuberculin skin test or abnormal-appearing chest radiograph.

Control of tuberculosis among immigrants and refugees should focus on initial identification o\f infection, followed by preventive therapy and treatment of active disease. All immigrants over 6 months of age should have a tuberculin skin test (TST) with purified protein derivative (PPD). A patient's Bacille Calmette- Guerin (BCG) vaccine status should not be taken into consideration in interpreting PPD test results, despite the objection of many patients and caregivers. A chest radiograph should be performed on any patient with a positive PPD, usually defined as > or = 10 mm of induration, or those patients with symptoms of pulmonary tuberculosis. In young children, an induration of > or = 5 mm warrants a chest radiograph and is considered a positive TST reaction in a child with recent close contact to an active TB case or with chest radiograph findings suggestive of active TB. Note that in young children, hilar adenopathy, best seen on a lateral chest radiograph or computed tomography (CT) scan, is a more common finding for active tuberculosis than the typical adult findings of pulmonary infiltrates or cavitation.

Geographic and Risk Factor-Driven Laboratory Tests

Geography, genetics, and public health conditions all play a role in determining the prevalence of disease in migrating populations. This may be evident for certain diseases where population endemicity is frequently known, such as malaria. However, the prevalence of some diseases may not be known in many populations, and others may not be dependent on countries of origin, but rather on individual risk behaviors. Therefore, each person should receive individualized testing based on estimated pretest probability. The following are examples of commonly performed screening tests that may be reasonable in certain populations.

Malaria Smears. An individual emigrating from a holoendemic malarious region has a greater than 75% chance of having malaria, based on screening of children aged 2-9 years.38 A total of 14% (11 cases) of malaria reported to the Minnesota Department of Health during 1998 were asymptomatic and identified only on screening.39 A small study of Liberian children immigrating to Minnesota found that 28 of 43 (65%) were positive for Plasmodium spp., one third of them being completely asymptomatic and another one third having splenomegaly as their only manifestation of disease.40 It is therefore reasonable to screen asymptomatic refugees for malaria from highly endemic areas.

Hepatitis C. Certain populations, particularly Egyptian, have extremely high rates of hepatitis C and deserve routine screening, even in children.41 It has been estimated that the overall adult prevalences of hepatitis C in Africa, China, and Southeast Asia are 5%, 3%, and 2.5%, respectively.42 As mother-to-child transfer is uncommon, the prevalence of hepatitis C in children is very low. It is therefore unnecessary to routinely screen migrant children for hepatitis C unless they are from a highly endemic area (e.g., Egypt), the parents are known to have hepatitis C, or the child has known iatrogenic risk factors (e.g., history of blood transfusion). One exemption is children adopted from orphanages in China and Russia where relatively high rates of hepatitis C infection have been found.8

Sexually Transmitted Infections (STI). For most sexually active adolescents, rapid urine antigen testing for Gonococcus and Chlamydia should be considered. Some immigrants and refugees are at risk for lymphogranuloma venereum, chancroid, granuloma inguinale, and donovoniasis, which are not commonly encountered in the United States. The clinician should also be alert for the possibility of past sexual exploitation or assault and therefore a need for testing for STI and pregnancy.43

Referral to Other Specialties

All immigrants are under tremendous stress, having left their homelands, and possibly being separated from their families. They have settled in a foreign culture with a significant language barrier, and often are at the lowest end of the socioeconomic spectrum. Additionally, many have experienced war atrocities, violence, starvation, or premature death from disease inflicted on family members and friends.44-50 Referral for culturally appropriate social and psychological care should be made for all individuals who express difficulty in coping with these stresses. Children often respond to stress with behavioral changes such as sleep disruption, restlessness/anxiety, appetite change, weight loss, and regressive behaviors.47,48,51-53 Frequently these children are misdiagnosed with attention deficit disorder/attention deficit/hyperactivity disorder (ADD, AD/HD) and inappropriately treated. Referral to behavior specialists who have experience with immigrant and refugee populations and post-traumatic stress disorder (PTSD) is indicated. Children from some orphanages may have developmental and psychological difficulties due to profound social and psychological neglect and deprivation. It is important that all adopted children receive a thorough developmental and, when old enough, psychiatric evaluation, both of which may require a comprehensive evaluation by experts.

Many immigrant children have poor oral hygiene, and dental diseases are prevalent. Most children over 3 years of age should be referred to a dentist for evaluation and education.

Finally, many ophthalmologic and otolaryngologic abnormalities may be detected and treated in newly arrived children, including vitamin A deficiency keratitis, trachoma, and chronic otitis media/ mastoiditis with associated hearing loss. If hearing and vision screens cannot be performed in the clinic setting, or if abnormalities are detected on screening, these children should be referred for further evaluation and management.

Conclusion

The number of children migrating to the United States has increased tremendously. The majority of these children have undiagnosed medical conditions, and it is imperative that these children receive a comprehensive medical evaluation. Unfortunately, the guidelines and recommendations available for primary care providers vary extensively and frequently are not evidence-based. The screening evaluation should include a routine screen with special testing for unique population and individual risk factors. The routine screen for newly arrived children should include a detailed history, physical examination, and screening laboratory tests. Preventive services must be offered including updating of immunizations; well-childcare; dental, hearing, and ophthalmologic screening; and education. Many of these children are under extreme stress, and PTSD is very common and often remains undiagnosed or misdiagnosed-these children should be referred to an appropriate mental health professional for evaluation and treatment. The screening visit should assist the new immigrant in successful relocation by reducing health-related barriers, and simultaneously protect the health of the general population.

Acknowledgment

We would like to thank Elizabeth Raduege, MD, Pat Walker, MD, DTM&H, Robert Levin, MD, and Ann O'Fallon and colleagues at the Minnesota Department of Health.

Clin Pediatr. 2003;42:763-773

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William M. Stauffer, MD, MSPH, DTM&H1

Stacene Maroushek, MD, PhD2

Deepak Kamat, MD, PhD3

1 Pediatric and Medicine Faculty. Regions Hospital/ Healthpartners, Center for International Health and International Travel Clinic; and Adjunct Faculty, Division of Infectious Diseases & International Medicine, Department of Internal Medicine, University of Minnesota; and Division of Emergency Medicine, Department of Pediatrics, University of Minnesota; Assistant Professor of Pediatrics, Hennepin County Medical Center and Division of Pediatric Infectious Diseases, University of Minnesota; 3 Director, Institute of Medical Education, Children's Hospital of Michigan, Detroit, Michigan.

Reprint requests and correspondence to: Deepak Kamat, MD, PhD, Professor of Pediatrics, Director, Institute of Medical Education, Children's Hospital of Michigan, Detroit, MI 48201.

2003 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.

Copyright Westminster Publications, Inc. Nov/Dec 2003