Medical Evaluation of the Foreign-Born Child

More than 210,000 foreign-born children (≤16 yr old) enter the United States each year as asylees (asylum seekers), refugees, and immigrants, including international adoptees (see Chapter 8 ). This number does not include undocumented children living and working in the United States, the U.S.-born children of foreign-born parents, or the approximately 2.7 million nonimmigrant visitors ≤16 yr old who legally enter the United States annually with temporary visas. With the exception of internationally adopted children, pediatric guidelines for screening these newly arrived children are sparse. The diverse countries of origin and patterns of infectious disease, the possibility of previous high-risk living circumstances (e.g., refugee camps, orphanages, foster care, rural/urban poor), the limited availability of reliable healthcare in many economically developing countries, the generally unknown past medical histories, and interactions with parents who may have limited English proficiency and/or varied educational and economic experiences, make the medical evaluation of immigrant children a challenging but important task.

Before admission into the United States, all immigrant children are required to have a medical examination performed by a physician designated by the U.S. Department of State in their country of origin . This examination is limited to completing legal requirements for screening for certain communicable diseases and examination for serious physical or mental problems that would prevent issuing a permanent residency visa. This evaluation is not a comprehensive assessment of the child's health, and except in limited circumstances, laboratory or radiographic screening for infectious diseases is not required for children <15 yr old. After entry into the United States, health screenings of refugees, but not other immigrants, are recommended to be done by the resettlement state. There is limited tracking of refugees as they move to different cities or states. Thus, many foreign-born children have had minimal pre- or postarrival screening for infectious diseases or other health issues.

Immunization requirements and records also vary depending on entry status. Internationally adopted children who are younger than 10 yr are exempt from Immigration and Nationality Act regulations pertaining to immunization of immigrants before arrival in the United States. Adoptive parents are required to sign a waiver indicating their intention to comply with U.S.-recommended immunizations, whereas older immigrants need only show evidence of up-to-date, not necessarily complete, immunizations before application for permanent resident (green card) status after arrival in the United States.

Infectious diseases are among the most common medical diagnoses identified in immigrant children after arrival in the United States. Children may be asymptomatic; therefore, diagnoses must be made by screening tests in addition to history and physical examination. Because of inconsistent perinatal screening for hepatitis B and hepatitis C viruses, syphilis, and HIV, and the high prevalence of certain intestinal parasites and tuberculosis, all foreign-born children should be screened for these infections on arrival in the United States. Table 10.1 lists suggested screening tests for infectious diseases. Table 10.2 lists incubation periods of common internationally acquired diseases. In addition to these infections, other medical and developmental issues, including hearing, vision, dental, and mental health assessments; evaluation of growth and development; nutritional assessment; lead exposure risk; complete blood cell count with red blood cell indices; microscopic urinalysis; newborn screening (this could also be done in non-neonates) and/or measurement of thyroid-stimulating hormone concentration; and examination for congenital anomalies (including fetal alcohol syndrome) should be considered as part of the initial evaluation of any immigrant child. *

* For the most up-to-date guidelines, see: https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html .

Children should be examined within 1 mo of arrival in the United States, or earlier if there are immediate health concerns, but foreign-born parents may not access the healthcare system with their children unless prompted by illness, school vaccination, or other legal requirements. It is important to assess the completeness of previous medical screenings at any first visit with a foreign-born child.

Clinicians should be aware of potential diseases in high-risk immigrant children and their clinical manifestations. Some diseases, such as central nervous system cysticercosis, may have incubation periods as long as several years, and thus may not be detected during initial screening. On the basis of findings at the initial evaluation, consideration should be given to a repeat evaluation 6 mo after arrival. In most cases, the longer the interval from arrival to development of a clinical syndrome, the less likely the syndrome can be attributed to a pathogen acquired in the country of origin.