Many new immigrant children may have never had medical screenings or a visit with a health care provider in their country of origin. If children have had prior medical visits, families should be asked to bring all medical records, screening or health histories to the initial visit. Pediatricians should be aware that these records may need to be translated and should be carefully reviewed for accuracy. Immigrant families may be unfamiliar with navigating the health care system as well as standards of practice in the United States. Pediatricians should recognize that US screening and preventive health practices may be an unfamiliar practice in many countries and may need additional explanation. A comprehensive medical evaluation includes asking sensitive questions about issues such as migration experiences, trauma, and family separation. Setting aside adequate time for visits, providing professional interpretation services, and engaging in thoughtful and sensitive inquiry will facilitate a trusting environment that will lead to optimal care for immigrant children8. In screening for trauma, it is essential to incorporate trauma-informed approaches (please see the mental health section of the toolkit for details). If follow-up can be ensured, the comprehensive evaluation does not need to be completed in the first 1-2 visits and some elements can be deferred until a trusting relationship with the family has been established.
Considerations for the Initial Screening of Immigrant Children
- Birth country/ethnicity, country/countries of transit and length of time living in these countries, time in the United States
- Medical records, if available, including vaccine records
- Past medical history, including prenatal serology results of mother/health of mother, birth setting (home/medical facility), gestational age at birth, history of female genital cutting (FGC), other traditional cutting, transfusions, surgeries, tattoos
- Sexual history, including whether history of sexual abuse
- Nutrition history, including foods available, to determine risk for specific micronutrient deficiencies
- Use of complementary and alternative medications
- Environmental hazard exposure history, including possible lead exposure risks
- Tobacco, alcohol, opium/heroin, betel nut24, khat26, other drug use
- Dental history
- Education: last year of school completed and literacy level of patient/parents as applicable, potential learning difficulty and/or need for special education
- Social history—including family structure, support in US, school environment, individuals who live in the same home as the child, primary care taker
- Mental health evaluation (see Mental health section for further details), including use of validated screening instrument (such as the Patient Health Questionnaire PHQ-920, the Pediatric Symptom Checklist PSC21, or the Refugee Health Screener RHS-1522 for those over age 14) and specific screening for trauma
- Developmental screening (including use of age-appropriate screening instrument)
Are some diseases or conditions more prevalent among immigrant children?
The specific health risks of immigrant children depend on the child’s country/region of origin and experiences prior to arrival in the United States. Each child should be evaluated within the context of unique predisposing factors and experiences.
Infectious diseases are among the most common health issues encountered in immigrant children1. Testing for tuberculosis by tuberculin skin testing or interferon gamma release assay (regardless of history of BCG vaccine) should be universally applied in all immigrant children1,8,9. If there is no documentation of prenatal or parents’ lab results, children should also be screened for hepatitis B (regardless of vaccine history), HIV, and syphilis8,11,12,13. Other infectious diseases may be evident with a review of systems (hematuria suggesting schistosomiasis in a child from sub-Saharan Africa), or performance of physical examination (characteristic rash of scabies, or splenomegaly in hyperreactive malaria syndrome) however, some will need specific screening to identify.
Inadequate immunization status (insufficient number, inadequate serologic response due to improper storage of vaccinations, or severe malnutrition) places immigrant children at risk for vaccine-preventable illness1,2,4,8,23. Immunizations should be initiated immediately according to recommended schedules for infants, children, and adolescents.
Specific infectious diseases that should be considered in immigrant children are included in Table 1. (Please refer to the immigrant checklist for an approach to screening). Certain parasitic infections, with which clinicians may be less familiar, are particularly prevalent among immigrant populations and warrant more detailed discussion, below. For more detail about specific infections, refer to the AAP Redbook1 and the CDC Refugee Health Guidelines8.
The most common soil-transmitted helminth infections are Ascaris lumbricoides, whipworm (Trichuris trichiura), and hookworm (Necator americanus, Ancylostoma duodenale). Transmission of Ascaris and whipworm occurs via ingestion of soil contaminated with these helminths in human feces, and infection with hookworm occurs primarily through direct contact between skin (such as bare feet) and contaminated soil. Infections may be asymptomatic or may cause abdominal pain, diarrhea, nausea/vomiting, or anemia due to malabsorption or blood loss. Infections with soil-transmitted helminths may be diagnosed by stool ova and parasite examination, for which, ideally, three samples should be obtained at least 24 hours apart to increase sensitivity. Treatment of choice is albendazole; however clinicians should confirm that patients do not have a history of seizures or other neurologic deficits (which may be indicative of neurocysticercosis*) prior to treatment.
Giardia, a protozoan, may be asymptomatic, cause bouts of acute symptoms such as watery diarrhea and abdominal pain, or cause prolonged symptoms including foul-smelling stools, abdominal distention, anorexia, malabsorption, or failure to thrive. Neither stool ova and parasite examination nor eosinophilia are sensitive for Giardiaintestinalis, and clinicians should send giardia specific stool antigen using enzyme immunoassay (EIA) to test for this infection. Treatments of choice are metronidazole, tinidazole, or nitazoxanide.
Strongyloidiasis (Strongyloides stercoralis)
Infections with the nematode roundworm Strongyloides stercoralis primarily occur when larvae penetrate skin after contact with infected soil. Thus, infection usually occurs after children are old enough to crawl or walk. Because Strongyloides can replicate in human hosts, the infection may persist for decades due to autoinfection and once acquired is considered a life-long infection unless treated. The infection is often asymptomatic, but some patients experience skin manifestations (transient pruritic papules at the site of penetration or erythematous tracks, known as larva currens, transient pneumonitis or gastrointestinal manifestations [abdominal pain, vomiting, diarrhea, malabsorption, or failure to thrive]). In the setting of immunosuppression (most commonly associated with corticosteroid use) strongyloides parasites may infiltrate internal organs and unexpectedly manifest as hyperinfection syndrome with associated high rates of morbidity and mortality. Eosinophilia may be present with strongyloides infections, however, its absence does not rule out infection. Ova and parasite testing is very insensitive for detecting strongyloides, given that shedding may occur intermittently and at low levels14. Serology for IgG antibodies against strongyloides is the testing of choice for diagnosis. Ivermectin is the treatment of choice but should not be used in patients from Loa loa-endemic regions unless co-infection has been ruled out28 (see CDC domestic refugee screening guidelines8 for further info).
Schistosoma organisms, the trematode flatworm, are spread via parasites in contaminated fresh water. Schistosoma species are endemic in many areas of Africa16; distribution requires snail vectors, infected human reservoirs, and fresh water sources. Infection, also known as bilharzia, is contingent upon environmental exposure with organisms penetrating skin, therefore, children tend to be at risk of infection only once they are crawling or walking. Acute infection may present with fever, abdominal pain, hepatosplenomegaly, rash, or lymphadenopathy. Skin penetration may cause a pruritic, papular dermatitis similar to “swimmer’s itch.” Infection withSchistosoma haemotobium may lead to bladder inflammation (with associated dysuria, hematuria, secondary urinary tract infections, and pelvic pain), fibrosis, and ultimately, increased risk of bladder cancer or renal failure. Chronic infection with intestinal forms of schistosoma (S. mansoni) may ultimately lead to portal hypertension. Eosinophilia may be present with schistosoma infections, however, its absence does not rule out infection. Ova and parasite testing is also insensitive for diagnosis. Blood schistosoma IgG antibody testing is the diagnostic method of choice. Treatment of choice is praziquantel. If seizures or neurologic deficits of unknown etiology are present, neurocysticercosis* must be ruled out with neuroimaging prior to treatment with praziquantel.
Malaria classically presents with high fevers, chills, rigors, sweats, and headache. Although five species of malaria infect humans, Plasmodium falciparum causes the most significant morbidity and mortality and is hyper- and holo-endemic in some areas of sub-Saharan Africa. For newly arrived immigrants from areas in sub-Saharan Africa where P. falciparum is endemic15, CDC currently recommends presumptive treatment, particularly for specific refugee populations from areas that have greater than 40% endemicity (dark red on the endemicity map) for malaria infection15. For immigrants from regions outside of sub-Saharan Africa as well as immigrants from sub-Saharan Africa who are not presumptively treated, evaluation for malaria should be based on symptoms. Screening with thin and thick blood smears in asymptomatic patients has low sensitivity. Performing daily smears over three days increases sensitivity. PCR testing is available through CDC, particularly in cases of symptomatic infants or pregnant teens and women. A Rapid Diagnostic Test (RDT) is now available in the U.S and offers an alternate way of quickly establishing the diagnosis of malaria infection by detecting specific malaria antigens in blood. Although the use of the RDT does not eliminate the need for malaria microscopy, it can reduce diagnostic delay that may occur in some clinical settings due to challenges in accessing timely microscopic evaluation18. Presumptive treatment for P. falciparum is with atovoquone-proguanil or artemether-lumafantrine.
Table 1: Infectious diseases to consider in immigrant children (Please refer to Medical Screening and Treatment Checklist for tiered approach to appropriate work-up)
- M tuberculosis
- M Bovis
- HIV 1, 2
- Viral hepatitis
- Hepatitis A
- Hepatitis B
- Hepatitis C (overseas surgery, transfusion, female genital mutilation, traditional cutting, tattoos, sexual abuse)12
- Hepatitis D (chronic carriers of Hepatitis B)
- Parasitic infections
- Soil-transmitted helminths
- Roundworm (Ascaris lumbricoides)
- Whipworm (Trichuris trichura)
- Hookworm (Necator americanus, Ancylostoma duodenale)
- Strongyloides stercoralis (nematode)
- Entamoeba histolytica
- Giardia intestinalis
- Taenia solium (cysticercosis, pork tapeworm)
- Toxocara canis and visceral larva migrans
- Typhoid fever (Salmonella Typhi) among recently arrived febrile patients
- Geographically specific infections:
- Schistosoma spp. (trematode)
- Opisthorchis species
- Chagas Disease—(Trypanosoma cruzi)
- Lymphatic filariasis
- Loa loa
- Chikungunya virus
- Dengue fever
- Sexually Transmitted Infections
- Skin infections
- cutaneous larva migrans
- Helicobacter pylori
Immigrant children may present with under-nutrition and malnutrition, including wasting and stunting8
. Overweight and obesity are increasingly prevalent concerns among immigrant children8
. A detailed dietary history, complete physical examination, and thoughtful laboratory evaluation can help clinicians to detect particular nutritional issues.
Throughout the world, iron deficiency is the most common nutritional issue. Among immigrant children with anemia, it is important to also consider undiagnosed hemoglobinopathies, particularly for children of African, Southeast Asian, East Asian, Hispanic or Mediterranean ethnicities1,2,4
. Vitamin D deficiency is also common among immigrant children, particularly in those with growth delay, poor vitamin D intake or limited sun exposure due to geography, veiling, or institutionalization2,8
. Other micronutrients that may be deficient among immigrant children in resource-limited settings include vitamin A, zinc, vitamin B12, iodine, vitamin B3 (niacin), tryptophan, vitamin B1 (thiamine) or vitamin C8
. Refer to AAP Pediatric Nutrition handbook3
or CDC domestic refugee screening guidelines8
with further details regarding signs, symptoms and regional risks for specific micronutrient deficiencies.Toxic and Environmental Exposures
As a result of living conditions in home countries and/or impoverished living conditions in the United States, toxin exposure is common among immigrant children. Lead exposure is the most widespread toxin exposure among immigrant children. Exposures prior to arrival in the U.S. may include leaded gasoline, contaminated home remedies or traditional cosmetics, leaded ceramic glazes, the use of car batteries as a domestic power source, leaded cookware, or air pollution4,8,27
. After arrival in the U.S., exposures may include many of the same items, in addition to lead paint in older homes in the US8,27
. A number of culture-specific exposures have been associated with elevated blood lead levels in children; see Table 1
in the CDC refugee guidelines8
for further detail regarding lead exposure. The CDC offers comprehensive guidelines6
and a Toolkit10
regarding prevention of lead poisoning among refugee children.
A comprehensive medical history may reveal other potential hazardous environmental exposures. Prenatal exposure to alcohol may be associated with fetal alcohol syndrome that was not previously diagnosed1,2
. It is important to inquire about the use of non-prescribed medications as well as traditional treatments or herbal remedies obtained overseas or locally. Migrant children are also at particular risk for health problems related to workplace injuries4
.Other General Health Issues
Many immigrant children may have lacked access to pediatric medical care and their mothers may have had home births without prenatal medical screenings, including testing for hepatitis B, HIV, and syphilis. Dental problems, including dental caries or more serious dental diseases, are pervasive in immigrant children, given scant, if any access to dental preventive care and treatment in their countries of origin2,4,8
. Undiagnosed vision and hearing problems may be present1,2
. Other medical issues, such as thyroid disease, congenital defects, or genetic conditions, may be present and require subspecialty care1,8.
Overweight/obese immigrant children may be increasingly at risk for chronic conditions such as hypertension, diabetes, and cardiovascular disease8
It is important to inquire about history of female genital cutting (also known as female genital mutilation, female circumcision) and parents’ beliefs regarding this practice19
, particularly if a child is from Africa (where female genital cutting is practiced in over 27 countries) or parts of the Middle East19,25
. Using a culturally sensitive and non-judgmental approach, pediatricians should discuss the illegality of female genital cutting in the US with families, including the illegality of sending children back to country of origin for the procedure (sometimes referred to as “vacation cutting”) educate families about significant morbidity and mortality associated with this practice8,19
Developmental delays may be undetected or detected at a later age among immigrant children17
. Pediatricians who care for immigrant children should conduct careful developmental surveillance and screening at regular intervals as recommended by the AAP. Developmental screening requires consideration of important issues by families, medical providers, interpreters, and school/child care personnel. Questionnaires and screening tools should be administered using validated translations or with the help of trained interpreter staff when possible. Appropriate referral for early intervention services and/or psychoeducational evaluation should be initiated as soon as a concern is identified.
Mental health merits particular attention in immigrant populations. Stressful experiences may take place prior to departing from one’s country of origin, during transit or upon arrival to the United States. Sensitive and trauma-informed approaches to care are essential. In addition, immigrant children and families may experience discrimination and fear within the United States8
, and acculturation may place stress upon children, adolescents, and families. Immigrant children may also have mental health conditions that are prevalent among the general U.S. population, such as depression, anxiety, posttraumatic stress disorder, somatization, sleep disturbance, and substance abuse2,8
. Mental health services should be sought for the entire family when appropriate. See Immigrant Health Toolkit Mental Health Section for further details
*Cysticercosis is a parasitic tissue infection caused by larval cysts of Taenia solium, also known as the pork tapeworm. These cysts can infect the brain (neurocysticercosis), which may present as seizures or neurologic deficits in children. It may also manifest as cysts in the muscles and other tissues, Presumptive treatment with praziquantel or albendazole in the setting of neurocysticercosis is contraindicated without concomitant anti-epileptic and steroid pre-treatment because these drugs may provoke significant brain inflammation and seizures. If child has history of seizures or neurologic deficits of unknown cause, do not treat with praziquantel or albendazole until the presence of neurocysticercosis has been eliminated through neuroimaging.
AAP Academy of Pediatrics. Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.
American Academy of Pediatrics Committee on Early Childhood, Adoption, and Dependent Care. Comprehensive health evaluation of the newly adopted child.Pediatrics. 2012;129(1):e214-e223
American Academy of Pediatrics Committee on Nutrition; Pediatric Nutrition Handbook, 7th Edition. Kleinman RE, Greer FR, eds. Elk Grove Village, IL. American Academy of Pediatrics 2014.
American Academy of Pediatrics Council on Community Pediatrics. Providing care for immigrant, migrant, and border children. Pediatrics. 2013;131(6):e2028-e2034.
Cappellini MD, Fiorelli G. Glucose-6-phosphate dehydrogenase deficiency. Lancet 2008; 371: 64-74.
CDC. CDC Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children. Available at: http://www.cdc.gov/nceh/lead/publications/refugeetoolkit/pdfs/cdcrecommendations.pdf. Accessed June 5, 2015.
CDC. Elevated blood lead levels in refugee children --- New Hampshire, 2003—2004. MMRW. 2005;54(02);42-46. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5402a4.htm. Accessed June 5, 2015.
CDC. Guidelines for the U.S. Domestic Medical Examination for Newly Arriving Refugees. Available at: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html. Accessed June 5, 2015.
CDC. Implementation of new TB screening requirements for U.S.-bound immigrants and refugees – 2007-2014. MMWR, March 21, 2014, 63(11): 234-236.
CDC. Lead poisoning prevention in newly arrived refugee children: tool kit. Available at: http://www.cdc.gov/NCEH/lead/Publications/RefugeeToolKit/Refugee_Tool_Kit.htm. Accessed June 5, 2015.
CDC. Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection. MMWR. September 19, 2008 / 57(RR08);1-20. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5708.pdf. Accessed June 5, 2015.
CDC. Screening for hepatitis during the domestic medical examination for newly arrived refugees. 2014. Available at: http://www.cdc.gov/immigrantrefugeehealth/pdf/domestic-hepatitis-screening-guidelines.pdf. Accessed June 5, 2015.
CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR. December 17, 2010 / 59(RR12);1-110. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm. Accessed June 5, 2015.
Dreyer G, Fernandes-Silva E, Alves S, Rocha A, Albuquerque R, Addiss D. Patterns of detection of Strongyloides stercoralis in stool specimens: implications for diagnosis and clinical trials. Journal of clinical microbiology. 1996;34(10): 2569-71.
Gething PW, Patil AP, Smith DL, Guerra CA, Elyazar IRF, Johnston GL, Tatem AJ, Hay SI. A new world malaria map: Plasmodium falciparum endemicity in 2010. Malaria Journal 2011, 10:378 doi:10.1186/1475-2875-10-378. Map available at: http://www.map.ox.ac.uk/browse-resources/endemicity/Pf_class/africa-plus/. Accessed June 5, 2015.
Hürlimann E, Schur N, Boutsika K, Stensgaard AS, Laserna de Himpsl M, Ziegelbauer K, Laizer N, Camenzind L, Di Pasquale A, Ekpo UF, Simoonga C, Mushinge G, Saarnak CF, Utzinger J, Kristensen TK, Vounatsou P. Toward an Open-Access Global Database for Mapping, Control, and Surveillance of Neglected Tropical Diseases. PLoS Negl Trop Dis. 2011; 5(12): e1404. Available at: http://openi.nlm.nih.gov/detailedresult.php?img=3236728_pntd.0001404.g002&req=4. Accessed June 5, 2015.
Martin-Herz SP, Kemper T; Brownstein M, McLaughlin JF. Developmental Screening with Recent Immigrant and Refugee Children: A Preliminary Report (November 2012). Available at: http://ethnomed.org/clinical/pediatrics/developmental-screening-with-recent-immigrant-and-refugee-children. Accessed June 5, 2015.
Mouatcho JC & and Dean Goldring, JP. Malaria rapid diagnostic tests: challenges and prospects. J Med Microbiol October 2013; 62 (10): 1491-1505. Available at: http://jmm.sgmjournals.org/content/62/Pt_10/1491.full. Accessed June 5, 2015.
Nour NM. Female genital cutting: clinical and cultural guidelines. Obstetrical and Gynecological Survey 2004;59(4): 272-279.
Patient health questionnaire (PHQ) screeners. Available at: http://www.phqscreeners.com/overview.aspx?Screener=02_PHQ-9. Accessed June 5, 2015.
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Refugee Health Screener (RHS-15). http://www.refugeehealthta.org/files/2012/09/RHS15_Packet_PathwaysToWellness.pdf. Accessed June 5, 2015.
Rytter MJH, Kolte L, Briend A, Friis H, Christensen VB. The immune system in children with malnutrition – A systematic review. PLOS ONE. 2014;9(8):e105017.
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A comprehensive medical evaluation should be available to all immigrant children, either within the medical home or coupled with referral to a medical home. Many aspects of this evaluation are routinely recommended per Bright Futures13 guidelines for evaluation of all children but have nuances specific to immigrant children. The Centers for Disease Control and Prevention (CDC)7 and the American Academy of Pediatrics (AAP) Red Book1 offer resources with detailed discussions and/or checklists regarding screening of refugees and international adoptees. However, there has been little detailed guidance about post-arrival medical screening for other new immigrants; this generally has been extrapolated from published experience of screening of refugee and international adoptees.
The following checklist provides general medical screening recommendations for unaccompanied minor, undocumented immigrant, asylee, refugee, and other immigrant children from low resourced countries, especially if from low socioeconomic circumstances. These recommendations are consistent with current CDC domestic refugee screening guidelines7, and this document will be updated periodically in effort to maintain consistency with existing guidelines. Although the AAP defines “immigrant children” as children who are foreign-born or children born in the United States who live with at least 1 parent who is foreign-born2, these recommendations are specific to foreign-born immigrant children. For all patients without legal access to health insurance (such as unaccompanied minors and other undocumented children), providers must balance the medical needs of individual patients with the reality of patient/institutional costs for laboratory evaluations and prescribed medications.