Tuberculosis in International Adoptees

Our international adoption practice includes children from parts of the world where tuberculosis is much more prevalent than in the US, and kids from especially high-risk backgrounds for TB, like institutional care. Research on international adoptees reveals that about 1 in 5 children from these backgrounds will have positive skin tests for tuberculosis (called PPDs) on arrival, or at the retest 6 months later. This brief article gives some background on TB, and rationale for testing and treatment.

Tuberculosis is an infection with Mycobacterium Tuberculosis (TB). While the most common site of infection is the lungs, it can affect many parts of the body. It is an atypical infection and most of the time, infection does not cause any symptoms initially. When an individual is infected by TB but has no symptoms, physical findings, or chest x-ray abnormalities, then they have Latent Tuberculosis Infection (LTBI, or "inactive TB"). Patients with LTBI are not ill appearing, have no symptoms, and are not contagious (i.e. they cannot spread the infection to others).

The reason it is very important to treat LTBI is that if not treated, there is a 5-10% lifetime risk of developing Active Tuberculosis, which is a life threatening illness. Some people have an even higher risk of progression to active disease and these include: infants, adolescents, patients who were infected within the previous two years, patients with compromised immune systems (like HIV), patients with chronic illnesses such as diabetes or kidney disease. LTBI is treated with a medication called isoniazid (INH). It is given once daily for nine months. The liquid preparation is hard to tolerate and often causes bad diarrhea so we generally prescribe a tablet that can be crushed.

Tuberculosis is typically diagnosed using a skin test or a PPD. This should be tested at arrival and again 6 months later, regardless of whether they had BCG (TB immunization) previously or not. A positive PPD reading depends on the risk factors for a particular patient and is sometimes a bit difficult to read, so it is important to have it read by someone who does this often. There are some newer blood tests for diagnosing Tuberculosis that can be used in children over 5 years of age, with some providers using them as young as age 2. .

Frequently Asked Questions:

My child had a negative PPD previously, why is it positive now?

This can be for a number of reasons. Your child may have been newly exposed to TB since the previous test. Also the time from infection until the development of a positive PPD can be between 2 and 12 weeks. There are 10-15% of children with normal immune systems who have had culture proven disease with negative PPDs. Reasons for this include young age, poor nutrition, other viral infections, recent TB infection, and disseminated TB (an overwhelming full body form of the illness). Also kids with abnormal immune systems can have a falsely negative PPD. This is why we repeat a PPD on international adoptees and other children at high risk for TB six months later.

My child was given BCG (an immunization against TB), does this always cause a  positive PPD?

No. BCG is given in many parts of the world to prevent TB and studies find it about 50% effective on average.  It is more effective for preventing some more serious forms of TB in young children and that is why it is given.  Typically it is given soon after birth. While it can cause a positive PPD, for those given BCG at less than 2 months of age, 40% have negative PPD by 1 yr of age and more than 95% have a negative PPD by 5 years of age. It is the young kids with the recent exposures that are at increased risk for developing active disease where it is the most unclear and those are the ones it is most important to treat. There are newer blood tests that may help us with this but not in kids under 5 years of age. Both the Centers for Disease Control and The American Academy of Pediatrics recommend ignoring the history of BCG injection when evaluating a PPD. However, a very recent, actively oozing BCG site is one situation where we may defer the PPD until the BCG site is more healed.

Are there any precautions I should take while my child is taking isoniazid?

Yes, there are, but isoniazid is actually very well tolerated in children.  Adults over 35 years of age are more likely to have some liver inflammation, and are screened with blood tests, but this is not typically needed in children unless they have known liver issues. If your child develops unexplained abdominal pain, vomiting, or jaundice (a yellowing of the skin and eyes) then you should contact your doctor.

Your child may also experience an unpleasant reaction (headache, large pupils, neck stiffness, nausea, vomiting, diarrhea, sweating, itching, and chest pain) if they eat too much tyramine containing food, so those should be avoided or eaten in moderation. These foods include: aged cheeses, avocados, bananas, figs, raisins, beer, ale, caffeine (coffee, tea, colas), chocolate, meats prepared with tenderizer, liver, bologna, pepperoni, salami, sausage, meat extracts, caviar, dried or pickled fish, and tuna, red wine, sour cream and yogurt, soy products, and yeast. Some of those are childhood standbys (bananas & yogurt), some are not (beer). We've not heard many reports of this reaction, so mild-moderate consumption may be OK.

What is the best way to get my child to take the tablet?

A pill crusher will make the medicine into a powder for kids unable to swallow a pill. It is best to mix it in a small amount of something with a very strong flavor such as chocolate syrup or one of the syrups used for Italian sodas. We have a helpful article on "Taking Your Medicine". One clever family opened an Oreo cookie and mixed the powder with the icing in the middle of it, then replaced the top cookie. Their child really enjoyed the daily cookie for nine months!

Is it important to take this medicine every day?

Yes! In fact, some public health departments use "directly observed therapy" (having a nurse watch the patient take the meds) for TB. If a dose is missed, give the missed dose as soon as you remember it. However, if it is  almost time for the next dose, skip the missed dose and continue your  regular dosing schedule. Do not take a double dose to make up for a  missed one.

Isoniazid usually is taken once a day, on an empty stomach, 1 hour before or 2  hours after meals. However, if isoniazid causes an upset stomach, it may  be taken with food. Find a time that works for your family, and set a recurring alarm/reminder.

Will my child need more testing after the isoniazid, or further PPDs?

Not unless they develop symptoms of tuberculosis. Their PPD will likely remain positive, but we will document that they had a clear chest x-ray and completed INH therapy. If TB is suspected later, or needs to be ruled out for job purposes, they can get a chest x-ray.

2019 Update!

There are newer, easier, shorter regimens for treatment of active TB that are currently recommended. These may include daily rifampin for 4 months or once-weekly isoniazid and rifapentine [3HP] for 12 weeks. Please see these WA State Latent TB treatment guidelines for more information.

Links:

• FAQ from the CDC about TB screening for international adoptees

• Waiver options for children diagnosed with TB prior to adoption

Mandarin for the Adoptive Parent

These key words and phrases for the adoptive parent, with Pinyin pronunciation and audio links, are invaluable for parents traveling to China and in the first weeks home.

Here's a Guide to Pronouncing Mandarin in Romanized Transcription.

Another nice resource is Zhongwen.com, an in-depth guide to Chinese characters and culture, with spiffy clickable character definitions and language genealogy.

Some of our families have found the Simple Language for Adoptive Families booklets/CDs helpful as well.

Nutritional Supplements in Adoption

Background

Internationally adopted children tend to suffer more from micronutrient (vitamin and mineral) deficiencies and lack of attuned, stimulating care than from protein/calorie "macronutrient" malnutrition. Basically, most kids in orphanages get enough protein and calories to grow, but don't because of stress, neglect, and, perhaps, some micronutrient deficiencies. Iron and iodine deficiencies are well documented, as are vitamin A and D deficiencies.

The iron deficiencies (+/- anemia) may worsen during the catchup growth period, as children outstrip their limited iron supplies. This makes getting extra iron important for most internationally adopted children, for as long as they're having catchup growth. The constipation angle is overrated, in my experience, and I'd rather manage the constipation than see your child's brain development impaired by lack of adequate iron.

Vitamin and trace mineral deficiencies may also be implicated in the high rate of initial skin and hair symptoms. Zinc deficiency has been linked to stunting, poor healing, diarrhea, and cognitive delays in developing countries. I also wonder about essential fatty acid levels, and if we should be doing something to support the rapid brain growth we so often see. Many of the placing countries in international adoption also have environmental toxin issues (former Soviet Union, India, and China among others), but fortunately the lead issues we saw in years past are better these days.

In general, the research supports prevention and correction of deficiency, but not so much the trendy "giving more of a good thing" supplements industry for children not at risk for deficiency. A varied diet seems better for children at low risk of deficiency, although we still do recommend 600IU per day of supplemental Vitamin D for kids (Ddrops, Carlson D Drops, etc). 

Vitamins and Minerals 

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth.

The ideal supplement for internationally adopted children would contain plenty (100% RDA) of Vitamin's A and D, iodine, iron, zinc, selenium, and other vitamins and trace minerals. I've not yet found the ideal liquid/powder form, and would love to see suggestions in the comments below if you find a good one. Plenty of options in the chewable format, which can be crushed, but that's extra work, and not so dissolvable.

• Enfamil's Poly-Vi-Sol with iron is a basic multivitamin plus iron liquid supplement that is easy to find, but not as complete as the others.
• Novaferrum makes a multi with iron liquid on Amazon that many families feel taste better than Poly-Vi-Sol.
• As for chewables, there are lots of options out there. Flintstone Complete and other drugstore "complete" multivitamins are easy to find, and taste good. Heck, they even make vitamin pixie sticks these days.
• Remember that iron supplements are a frequent cause of accidental overdose in children - the doses we recommend are quite safe, but please keep the tasty vitamins well out-of-reach.

Essential Fatty Acids 

We also sometimes recommend essential fatty acid supplements like fish oils for new arrivals, as it seems plausible that children from malnourished pregnancies, who weren't breastfed, who were raised on diets poor in healthy omega-fatty-acids, and who are having rapid brain growth may benefit from supplementation in this area.

Essential-fatty-acid (EFA) supplementation has shown decidedly mixed results in ADHD, which is more common in IA children. DHA is a type of omega-3 fatty acid that seems important in early brain and vision development, and is a major structural building block in the brain. EPA is another omega-3 fatty acid that may be more helpful in later issues like attention (ADHD) and mental health. Flaxseed oil contains ALA, some of which is converted to DHA/EPA.

The optimum ratios of DHA and EPA have not been fully worked out, but I like to see more DHA early on for infants and toddlers, and more EPA for older children. Some fish oil products even include some healthy omega-6 and omega-9 fatty acids, for balance. Cod liver oil is a grandma favorite that usually contains natural vitamins A & D - check the labels to make sure you're not overdoing these vitamins, especially if they're in your other supplements and formula. It would be nice to get these healthy fats from diet alone, but sadly, our fish supply isn't safe enough in terms of mercury and PCBs to safely consume enough to meet our target intakes of DHA and EPA.

Some quality fish oils that are independently tested to have adequate potency and very low levels of contaminants include:

• Nordic Naturals - lots of options here, including flavored oils and small chewable gelcaps
• Pharmax's Finest Pure Fish Oil is one of the less fishy oils out there, and their more expensive Frutol is a fish oil that's emulsified with prebiotics and fruit purees. They even make powdered versions, but I hear those are a bit fishier. Available where their probiotics are found.
• Coromega is another pricey emulsion in orange and chocolate pudding flavors for kids that won't tolerate fish oils straight up, cheaper through VitaCost.
• Carlson's Fish Oils are also easy to find, and available in child-friendly formats.
• Costco Kirkland Brand fish oil softgels are inexpensive option for folks that can swallow pills.
• Tips for taking fish oils - you can often get kids used to taking the oil straight, or try them stirred into a "shot" of juice or water, smoothies, or applesauce.
• Flaxseed oil is a vegetarian option for omega-3's. Refrigerate these oils, as they go rancid pretty easily. Ground flaxseed sprinkled on food or in baked goods is another way to go. While the ALA in flaxseed may be important in its own right, it's not very predictably converted to DHA and EPA.

Probiotics 

Another potentially helpful supplement would be probiotics, which are the good bacteria that live in your digestive tract, and that are found in yogurt. In fact, there's about 3 pounds of these bacteria in your body right now - isn't that a lovely thought? The Europeans have been big fans of probiotics for a while, and pediatricians are just starting to catch on. Probiotics seem to be a safe thing to try, especially for children with loose stools or those taking antibiotics. Since children from orphanages (where antibiotics are overused) are likely to have less-healthy "institutional strains" of these gut bacteria, it may be a reasonable thing to supplement for IA children. We've got lots more info and recommended formulations in our "Probiotics and Prebiotics" article.

Welcome Home Guide

What follows is a list of our typical recommendations at the initial post-placement evaluation. That first visit is a doozy, and much of what we say tends to get lost in the shuffle, so we'll recap many of our suggestions below. We like for folks to have a copy in hand when they leave our office, but you'll also find this article online at www.adoptmed.org/welcome, so that you can follow the links.

Medical Issues

If you are lucky enough to live within driving distance of an international adoption specialist, we highly recommend an initial evaluation 1-2 weeks after homecoming with someone experienced in the unique growth, developmental, infectious disease, and parenting issues that our children tend to bring home with them. A full list of international adoption docs can be found here, and we describe our recommended evaluations in this article, as well as in our travel packet.

Immunizations

Unless you've adopted from Korea (shots trusted), Taiwan (also trusted), or Guatemala (we sometimes trust the shots there), we recommend that you either check titers (blood tests to confirm immunity) or start over on shots.

• Hib and Prevnar (pneumococcal) immunizations are rarely performed in the typical sending countries, so we like to just start those at the first visit. Luckily, you only need 2 each of these if started >12mo, and you only need one Hib if given >15mo.

• It's also rare to see an international adoptee with full immunity to measles, mumps, and rubella, so we'll often start MMR over as well, unless MMR immunization is well-documented at >1yo, in which case we could check titers.

• Many IA children have received multiple DTP (diptheria, tetanus, and pertussis) and Polio immunizations, so those are ones we like to check with titers. However, titers done at less than 12-18mo may reflect transferred maternal antibody, so these may need to wait until the followup blood draw when children have been home ~6 months. If we have to wait to check titers, we will usually give 1-2 DTaP boosters, and perhaps one polio (IPV) booster, both to ensure coverage (lots of tetanus and whooping cough around, not so much polio in this hemisphere though) and to give the titers a good chance of proving immunity. Tdap (tetanus booster with added whooping cough protection) is a good choice for 11-18yo adoptees, and is now allowed earlier for those with uncertain immunization history.

• Hepatitis A and Hepatitis B titers are routinely checked at arrival and 6 months later, so we hold off on those shots until we see what the labs say.

• Varicella (chickenpox, 2 shots) can also be checked with titers, but the extra blood and expense may not be worth it given that we wouldn't save that many shots.

• The oral rotavirus vaccine is not an option, as the first dose must be given at 6-12 wks old, with the last dose not given later than 32 wks old.

I tend to be a "lumper" rather than a "splitter" when it comes to shots. There is no reliable evidence that immunizations "overwhelm" the immune system, and I prefer to have fewer shot visits overall than drag things out by only doing 1-2 shots at a time. 

The Vaccine Education Center at Children's Hospital of Philadelphia is my favorite online source for shot information from the generally pro-immunization perspective, as they link to relevant studies and also specifically address a lot of internet vaccine mythology.

Lab Tests 

• A list of typically performed lab tests is listed here. Yes, that's a lot of tests, but it's the only way to know if many frequently encountered problems are present or not.

• This is standard of care for internationally adopted children, although we get a bit creative in our office with children from Guatemala and Taiwan, and don't perform routine labs for children from Korea.

• Our lab on the 1st floor downstairs, or the lab at Children's, is a good place to get these done. If the draw is not going well, you can certainly decide to try again in a few days.

• It's going to require a lot of blood, typically drawn from the elbow or back of the hand, but your child will make more. Try to be calm, supportive, and resolute during the blood draw, model deep belly breaths, and try to put worries about attachment trauma and other anxieties out of mind, since your child will respond to your emotional state.

• If your insurance company balks at coverage (tsk tsk), you and your pediatrician can adapt this insurance letter by Deb Borchers, MD. Refer them to the AAP Red Book, as well.

• In our office, you can expect a call or letter with all of the lab results in about 2-3 weeks, a bit longer if titers are perfomed. We'll call sooner with any concerning results.

• If you haven't heard by 2-3 weeks, please give the nurses a call at 206-598-3030.

• In 6 months or at 18 months-old, whichever comes later, we need to retest for HIV and hepatitis (to rule out exposures just prior to travel). This is a good time to check additional titers or follow up on earlier abnormal results, if we haven't already. We also retest for anemia and iron deficiency at the followup lab draw, since periods of significant catchup growth may cause children to outgrow their already limited iron stores. A TB followup test is also recommended.

Stool Tests

• You'll need to submit a total of 3 stool samples to check for giardia and other parasites (O&P x3 and 1 stool PCR panel or giardia antigen), collected every other day. This is important, regardless of symptoms - 15-20% of our IA children have a parasite like giardia.

• Until you know the results, be scrupulous about handwashing (Purell and other alcohol-based gels are very handy). 

• Don't let your children bathe together until you know the stools are clear - baths are a great way to share giardia.

• The lab will give you a bag with containers and instructions. Scoop a peanut-sized amount of stool into the preservative-containing vials, and on the day that you're dropping off the stools, submit a fresh (<4 hours old) sample in the screw-top plastic container as well.

• Please make sure your samples are labeled with your child's name, and write in the date and time collected.

• It's easiest for all concerned if you drop them off at our lab on the 1st floor, but you can also drop them off at a local lab, ideally a hospital lab that does this a lot. Have them fax us the results, and call us if you don't hear the results in 1 week.

• It's not unusual for this initial evaluation to miss a parasite - we've had several cases of Ascaris (white roundworm) present several months later ... so have a low threshold to retest for parasites if unexplained abdominal symptoms persist.

• If you have a positive result, we'll explain what to do, but please read our article on giardia and other stool parasites for more information.

TB Tests

•  We test for TB exposure with a skin test called a PPD, on arrival and again in 6 months after arrival. This followup test is crucial - we have a lot of kids who do have latent TB who have false-negative tests on arrival, due to stress/malnutrition.

• This skin test will need to be read by a health care professional in 48-72 hours. Our nurses can do this without an appointment. Just drop in during business hours ... bring your poop samples and drop them off at the lab on your way up.

• Children 2-5 years or older can have a blood test for TB (IGRA) instead; this is off-label but commonly done.

• You may hear that this testing is unnecessary in children who received BCG, the TB vaccine performed in many of our placing countries. This is not true. A result of 10mm or greater is a positive result, regardless of BCG status. Our children tend to come from high risk backgrounds as far as TB exposure is concerned.

Followup Visits

• We like to see children for followup visits every 2-3 months after arrival until they've been home 6 months. Our front desk can schedule these for you on the way out.

• We're happy to help you transfer care to a more local pediatrician at any point in the process. Many families stay with us until that 6-months-home visit, when labs, shots, and catchup growth and development are well underway.

Referrals

We see significantly higher rates of visual, hearing, and dental problems in children adopted from orphanages. Prenatal exposures and malnutrition, untreated ear infections, lack of visual stimulation, lack of fluoride and minerals, and poor dental care all contribute. For that reason, we recommend:

• Screening audiology evaluation by a pediatric audiologist in the first few months home. Most of our children are language-delayed on arrival, and audiology is extra important in that scenario. Parents and pediatricians miss significant hearing problems all the time, and ringing a bell next to a child's face is not an adequate test of hearing. We now have an otoacoustic emissions (OAE) gadget in our clinic for easy hearing screens, but it has a really low threshold to refer children to audiologists for further evaluation. If that happens, Children's Audiology (206-987-2000) is a good bet, since they're skilled in behavioral audiology techniques for young children. 

• Screening pediatric opthalmology evaluation in the 1st months home. We see significantly higher rates of strabismus (lazy eye) and other visual problems in IA children. The earlier this is detected, the better. David Epley (206-215-2020) and Werner Cadera (206-528-6000) are two good local pediatric ophthalmologists.

• Early dental visit. Pediatric dentists like to see children as young as 1yo. See this article for more about early dental care. We don't have a current list of favorite dentists - check here, and ask other parents in your area.

• If we recommend an early intervention evaluation, you can access the nearest center by calling WithinReach (WA state) at 1-800-322-2588 for a local referral.

Nutrition and Growth

For infants and small toddlers, we recommend an infant or toddler formula with iron and essential fatty acids for the first 2-3 months home, even past the "typical" wean to whole milk at 1yo. Formula is just more nutritionally dense than milk, juice, or water, and contains essential nutrients for rapidly growing children. When you do transition to whole milk (>1yo) or reduced-fat milk (>2yo if they've had good growth), try to limit it to under 18 ounces per day, since excess cow milk will fill up their bellies at the expense of other nutrition, and can cause anemia.

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we also recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth if not beyond. Other good sources of essential fatty acids for older adoptees include fish oils and flax seed oil. Probiotics are another supplement to consider. Please see our Nutritional Supplements in Adoption article for more information and specific recommendations.

For other nutrition ideas, you could read following resources on our site ...

• Transitional Feeding Difficulties

• Pediatric Nutrition Resources

• Picky Eating

But I have also been fortunate to collaborate with SPOON Foundation on the content for their most excellent AdoptionNutrition.org web resource. That's the place I'd start.

Development

Our website is chock full of articles, links, and book recommendations on the topic of development in internationally adopted children:

• Stimulating Early Development

• Birth-to-Age-5 Timeline of Development

• Developmental Milestones

• Language Development In Internationally Adopted Children

• Books for Speech/Language Delays

• "Birth-to-Three" Early Intervention

• Sensory Integration and Sensory Processing Disorder

• Recommended Development and Learning Books

Therapeutic Parenting

This topic should probably be listed first, as I believe it's the most important intervention for newly adopted children. Kids who've experienced orphanage caregiving, multiple placements, neglect, abuse, and other trauma do have special needs in the area of parenting and attachment. What you'll read in typical parenting books, and what may have worked with "typical" children is not always the best idea for many of our children.

Please see these excellent resources:

• Top Ten Attachment Tips for the First Year of Placement - great stuff, from Deborah Gray

• Bonding Articles from Adoptive Families magazine

• Sleep and Adoption

• Recommended Parenting Books

• Recommended Attachment Books

• The "Difficult" Child

Choosing a Formula

The topic of what formula to use when breast milk is not an option generates a lot of smoke and heat, and is one of our more frequently-asked-questions ... so here it comes, folks, 2 level scoops of science mixed with 4 ounces of opinion.

I usually recommend a cow-milk-based formula at first. "But aren't all (insert-ethnicity-here) children lactose intolerant?" Actually, inborn lactose intolerance is extremely rare. Since lactose is the main sugar in breast milk, infants are born with the enzymes to digest it. While lactose intolerance may show up earlier in non-Caucasian children, you probably have at least 1-2 years of good ability to digest lactose. Also, an internationally adopted child has most likely already been receiving a cow-milk-based product, quite possibly sweeter, more dilute, and less nutritious than Western formulas. If you really really want to avoid lactose, and stay with a cow milk formula, there are lactose-free formulas, but they swap in corn syrup for the lactose.

Soy formulas are also an option, but in my mind you should have a compelling reason to switch. The long-term effects of a mostly soy-formula diet are not well-described; in the decades they've been in use, we've not seen obvious hormonal impacts from soy's phytoestrogens, and one retrospective study seemed reassuring, but we can't know that there aren't subtle effects. Also, certain minerals may not be as well absorbed from soy products, and children can get constipated on soy formula, neither of which is what you want in the first few weeks. I'm not that anti-soy, and do feel that cow milk itself is a bit overrated as a nutritional source ... but for infants I need a good reason to go with soy. For toddlers, where the soy is just part of a healthy diet, and lactose intolerance is a more real possibility, a soy formula could be fine if they don't tolerate dairy. 

You won't see goat milk on my list of recommended formulas. Goat milk is well and good as a substitute for cow milk, but I've just seen a few too many infants starving on goat milk formulas. Perhaps it's that "make-your-own-formula" isn't the safest way to go, perhaps it's that people don't realize that truly cow-milk-allergic infants are also likely to be allergic to goat milk (and soy) ...

I also never recommend a low-iron formula, but luckily they're hard to find. Adequate iron is essential for cognitive development, and international adoptees are frequently iron-deficient.

As for DHA/ARA, which are omega fatty acids present at varying levels in breast milk that are felt to help brain and eye development, I will say that they make good theoretical sense, but the research outcomes have been more mixed than the advertising would have you believe. For international adoptees, there is no research on this topic, but it would make sense that they'd be deficient in essential fatty acids, so I do have a preference for formulas with DHA/ARA.

You'll be seeing more about probiotic formulas, now that Nestle has introduced an infant formula with probiotic cultures to the US market. I can't say that the verdict is in on probiotics and infants, particularly when it comes to which strains and doses to use, but there is mounting preliminary evidence that this may be a good thing. I don't think everyone should jump on this bandwagon just yet, but something to think about for adventurous early-adopter "natural" medicine type folk. Our article on probiotics has more, including some brands to consider, if you'd like to add your own.

I do recommend that newly adopted infants and young toddlers stay with formula as their drink of choice for about 2-3 months post adoption, and certainly to at least 1 year of age. It's just much more nutritionally dense than milk, juice, etc. Since many adoptees have micronutrient deficiencies (vitamins, mineral, iron), the formula can help. As for "toddler formulas", it's a trade-off: on the good side, they've got more calcium and phosphorus, on the bad side, the sugars are typically from corn syrup (unless you're convinced your child is lactose intolerant, then it's good). Confused yet?

Many parents choose to continue using the familiar local formula when travelling, which makes sense in terms of minimizing transitions. You can gradually switch to a US formula when you get home. However, I do think it's a good idea to bring some US formula too, in case you run out, or for children who don't seem too picky about such things. And for those adopting from China, I would switch promptly to US formula, even though it's likely that melamine is no longer in Chinese formula as of 8/08. For children getting rice cereal in their bottle, I would wean that too when you get home. Rice cereal is for eating, not drinking, and it won't "fill them up for sleep" (sadly).

If you child is refusing formula during your travels, please see our topic on Transitional Feeding Difficulties for some ideas. We also have an article on Nutritional Supplements in Adoption with more advice on vitamins, minerals, and essential fatty acids.

When it comes to specific brands, it's more about your philosophy and pocketbook, and your child's digestion, and less about science. 

One last thing: use bottled water to reconstitute formula in developing countries, and consider doing the same in the US, at least for infants. It doesn't need to be designer water from artesian alpine watersheds, those cheaper jugs will do. Not that our water supply isn't the envy of many countries ... it's just that now the ADA has stated that using fluoridated water for infant formulas may overdo the fluoride. For toddlers, for whom formula is not the mainstay of their diet, I'm not as fussed about the fluoride issue, so filtered or tap water is probably fine. Brita and Pur-type filters remove a bit of the fluoride, but do leave enough for the water to be considered fluoridated.

Updated: 11/2017

How to Take FAS Photos

Excerpted from our Fetal Alcohol Spectrum Issues topic ...

Facial Features of FAS

What about the facial features? An overly long list of features associated with FAS has piled up over the years, but there are only three features that really count – a thin upper lip, a smooth or absent philtrum (vertical groove between the nose and lip), and small eyes. The face of FAS requires all three of these to be abnormal, and the diagnosis of full-blown FAS requires the face. Unfortunately, since that face gets “created” on only 2-3 days in early pregnancy, there are moms who drink heavily whose kids can be quite alcohol-affected but don’t have the face of FAS. Not having “the face” does not rule out alcohol exposure and effects. But having “the face” dramatically increases your risk for FAS and its associated disabilities.

The other things you’ll hear about - big cupped ears, “clown eyebrows”, wide-spaced eyes, epicanthal folds (“asian” eye appearance), flat nasal bridge, short upturned nose, flat midface, small chin, etc - are not necessarily caused by alcohol exposure. They can be developmental (most babies have short upturned noses), ethnic, or just minor anomalies unrelated to alcohol. We do see them more often in alcohol-affected kids but the thin lip, smooth philtrum, and small eyes combination is much more reliable and specific for alcohol damage.

We can often get a decent look at the lip and philtrum from referral photos and videos. That’s two of the three features, and if both are abnormal then we get concerned. If you have a thin lip and smooth philtrum, plus microcephaly (small head), and strong suspicion of alcohol exposure then I’m usually quite worried about damage from alcohol. If we've been relatively happy with the lip and philtrum but have asked to see some trip photos, you might be able to skip the sticker part, but the following photo tips will still be helpful.

FAS Facial Photographic Analysis

In more borderline situations we might need eye measurements. The size of the eyes (measured from the inside to the outside of the visible part of each eye) can only be accurately measured with a specialized photograph, one that you can take on your trip and email to us for computer analysis. Here’s how to take that photo …

The key here is an internal measure of scale – you’ll need a small round sticker 1/2 to 3/4 inches in size, which you can get from an office supply store. Homemade stickers or pieces of tape are not helpful, as they are of variable width. Mark the width in magic marker on the sticker - this is important, as we must know the width of the sticker. Place it on the child’s forehead between the eyebrows … yes, they will look at you funny in the orphanage when you do this, and you want to be sensitive to staff and older children’s feelings. Put some stickers on your own face if you want to goof off, give out extra stickers, and if you can, print/send/bring a nicer smiling photo to the child as a memento. Again, we only need the sticker if the lip or philtrum is worrisome.

Use a digital or 35mm camera – polaroids aren’t good enough. Take a closeup facial portrait photograph so that the head fills the entire frame (but watch the focus). When looking at the face in the viewfinder you should be able to draw an imaginary line from the ear canals through the bony ridge below each eye (lower orbital rim). That makes sure the child isn’t looking up or down. There also should be no left-to-right rotation – make sure both ears are equally visible.

The facial expression is important – smiles or frowns can really distort the features and make a nice thick upper lip and deep philtrum disappear. No smiling! We need a relaxed facial expression with lips gently closed, eyes wide open, and no eyeglasses. For older children, ask them to look at your nose, and breathe through their nose - this often relaxes their expression.

Asking the child to look up with their eyes (“what’s on the ceiling?”) without tilting their head up will help the eyes be wide open; for younger children ask someone to wave something just above your head. It may well be that one photo gives a good look at lip and philtrum, and another one gives us eyes wide open, so keep trying. Please review your photos on the camera screen before packing up, as we get a lot of out-of-focus or otherwise less than useful photos.

A “3/4 view” halfway between frontal and side view is also helpful, especially if you have a centrally mounted flash that can wash out the philtrum in frontal photos. A profile view may also help. One last tip is to use your digital camera’s “video clip” function to capture a brief, very upclose view of the face as it moves through different angles – we can pull frames from this video clip that may capture the true lip/philtrum better than a still photo. If you want more information about the photographic analysis, visit our FAS clinic's website. You can also print out instructions for taking screening "sticker" photos for FAS, and view a video animation of proper camera alignment.

Sounds complicated ... but we do this routinely in our clinic, and have a lot of success even with older infants and toddlers. We've found that parents really are able to do this themselves, especially if they practice a bit in the hotel room. Have fun, and good luck! 

Medical Resources in China

This is a handy list of medical resources in China for travelling families, graciously shared by Todd Ochs, MD. Please note that this list originated in the mid-00s, so many items here may be out of date.

Anhui Province

Hefei - Anhui Provincial Hospital
No. 1 Lujiang Road
0551-2652797
(VIP section for foreigners)
Hu Yunwen, MD

Anhui Provincial Children’s Hospital
No. 39 East Wang Jiang St.
230051 Hefei
Shan Hua, MD
0551-367103-3035 (off.)
13966681963 (cell)
<hua888@mail.hf.ah.cn>

Beijing - International SOS Clinic
No. 1 North Road, Xing Fu San Cun
Chaoyang District
8610-64629117 (clinic)
8610-64629100 (alarm)

Beijing United Family Hospital
#2 Jiang Tai Lu, Chaoyang District
Beijing 100016
8610-6433 3963
8610-6433 2345 (emergency number)
Theresa Horton, MD (pediatrics, USA)
Yan Feng, MD (pediatrics, USA)
Celine Marchand, MD (pediatrics, Canada)

Beijing United Family Hospital and Clinic - Shunyi
Pinnacle Plaza, Unit #818
Tian Zhu Real Estate Development Zone
Shunyi District, 101312
8610-8046 5432
Family Practice

Chongquing - Professor Chen Yuan
Children’s Hospital of Chong Qing Medical University
82623-63632756, ext, President’s Office

Dennis Valdez Gomez, MD - Chongqing Clinic
Room 701 Business Tower
Hilton Chongqing
No.139ZhongShan San Lu
Chongqing, 400015
denis@eglobaldoctor.com

Fujian Province

Fuzhou Lakeside Hotel - Fujian Province
Women’s and Children’s Hospital
Zhao Min Jun, MD, a pediatrician, who speaks English, will come to the hotel.

Xiamen - Lifeline Medical Systems
123 Xidi Villa Hubin Bei Road 361012
0592-532-3168
Mobile 138-5008-2911
<lifelinexiamen@yahoo.com>

Gansu Province

Lanzhou - Jin Yu, MD
Department of Pediatrics
First Affiliated Hospital of Lanzhou Medical University

The Army Hospital, Lanzhou Military Command
International Red Cross Center in Northwest China
Qi Li He
0931-8975114

Guangdong Province

Guangzhou - #1 Affiliated Hospital of Guangdong Medical University
1 Yangjiang Road, Guangzhou 510120
8333-7750 X3046
Emergency hotline 8333-6797

Guangzhou Children’s Hospital
318 Remnin Central Road, Guangzhou 510120
Emergency hotline 8188-6332 X5103

Can Am International Medical Center
5F Garden Tower, Garden Hotel
368 Huanshi Dong Lu
8620-83866988
Western-trained MD’s

International SOS Clinic
Room 152, Dongshan Plaza, 69 Xian Lie
Zhong Road 510095
20-8732-6253
Western-trained MD’s

#1 People’s Hospital (Global DoctorClinic)
1 Panfu Lu 51080
Emergency Hotline 8108-0509, 8333-6797
Mobile 135-7003-5254
Email: <guangzhou@globaldoctor.com>

Sunshine (Kai Yi) Dental Clinic
#2 Tianhe Road
3886-2888 X3111

Guangxi Province

Gulin - Li Xinhui, MD
Department of Pediatrics
Gulin District Hospital

Nanning - (English-speaking pediatrician)
Dr. Liaoning
First Hospital of Guangxi Medical University
6 # Shuang Yong Road
Nanning City, Guangxi China 530027
0771-5356703 (0ffice)
13978812808 (mobile telephone)

Guizhou Province

Guiyang - The Affiliated Hospital, Guiyang Medical College
28 Guiyi Street
0851- 6855119

Hai Nan

Haikou - Hainan People’s Hospital
#8 Longhua Road 570001
0898-6864-2660, 6622-3287 (outpatient)
Emergency hotline 0898-6622-5866/6666/2423

Hebei Province

Guo Zhiliang, MD
Affiliated Hospital of Handan Medical School,
Department of Pediatrics
056002 (86310)3092829

Shi Jia Zhuang
Hebei Number One People’s Hospital
348 West Heping Xi Lu
0311-7046996

Heilong Jiang

Harbin - Harbin Medical University #1 Hospital
#5 Youzheng Street, Nangnang District 150086
0451-3641918, 3607924, 3641563

Harbin #1 Hospital
English-speaking contacts: Dr. Sun Wei Fu
468-3733 X5012, Dr. Chen Mi Bin
(Ultrasound Room)
151 Diduan Street, Daoli District 150010
0451-4683864, 4614606, 4614636

Henan Province

Sheng Guangyao, MD
First Hospital of Henan Medical Hospital,
Department of Pediatrics
40053, Henan (86371)6913382

Zhengzhou - Professor Sheng Guanyao
President, First Hospital of Henan Medical University
Henan Provincial People’s Hospital
No. 7 Wei Wu Road, Jin Shui District 450003
0351-595-1056/2183, 588-0011

Hong Kong- International SOS Clinic
16/F World Trade Center
280 Gloucester Road
Causeway Bay
852-25289900 (alarm)

Hong Kong Adventist Hospital
40 Stubbs Road
852-2574-6211

Hubei Province

Wuhan - #1 Affiliated Hospital to Hubei Medical University
238 Jie Fang Lu, Wu Chang District, Wuhan 430060
027-8804-1919, 8806-6234

Xie He Hospital Affiliated to Tong Ji Medical University
1095 Jie Fang Da Dao, Wuhan 430030
027-364-6230, 363-459

Hunan Province

Hunan Children’s Hospital
BP. 127-5259097 Tel. 0731-5600965
Liu Zhiqun, born in the year of 1972, has gained Bachelor of Medicine after a five-year study in the Clinical Medicine Department of Hunan Medical University since 1990. Upon graduation he starts to work with the Emergency Center of Hunan Children’s Hospital, concentrating on emergency cases in the Department of Pediatrics. Now he has been the physician-in-charge in the Emergency Center.

Changsha - Hunan Province People’s Hospital
28 Dong Mao Jie, Jie Fang Xi Lu 410002
0731-222-4611 X3333/2210

Inner Mongolia

Hohhor - Inner Mongolia Autonomous Hospital
N0. 20 Zhao Wu Da Road
0472-4964477

The Affiliated Hospital to Inner Mongolian Medical College
1 Tong Dao Bei Jie, Hui Min District 010050
0471-696-5931/ 3300 x6804

Baotou - Zhiang Jianmei, MD
Department of Pediatrics
General Hospital of Baotou Gantie Company

Jiangsu Province

Nanjing City - Jiangsu Provincial People’s Hospital
#300 Guangzhou Road, Nanjing City
025-371-4511

AEA Nanjing Clinic
Nanjing Hilton Hotel
Zhong Shan Dong Lu
319 Hao Ground Floor
8625-4802842

Jiangxi Province

Nanchang - Zhao Jian, MD (speaks English)
No.1 Municipal Hospital, Nanchang, Jiangxi, PRC
Appointed Head of Dept of Cardiology. Promoted as Chief Doctor and Professor of Medicine.

Jianxi Province People’s Hospital
152Al GuoLu, 330006
(0791) 681-3352/3124 x 358

Jilin Province

Changchun - Norman Bethune Medical University #2 Hospital
#18 Zhiqang Street, Nanguan District 130041
Emergency hotline 0431-897-4612 X621

Liaoning Province

Shenyanag - Liaoning Province People’s Hospital
#33 Wenyi Road, Shenhe District 110015
Emergency hotline 024-24810136, 24147900
English-speaking contact:
Dr. Zheng Zhong Xin at X8479, or mobile 13002490807.
Hospital designed for foreigners, with English-speaking MD’s.

#2 Hospital of China Medical University
26 Wenhua Road, Heping District, 110003
024-2389-3501
Dr. Xie Hui Fang speaks English, ext. 6640
Mon & Fri., 6540/6549 Tues- Thurs.
024-2389-1476 (home)
Mobile 13609827551

American Medical Cernter (Global Doctor)
54Pangjiang Road, Dadong District
024-2433-06778/ 2342-6409
Emergency 024-2432-6409

Ningxia Autonomous Region

Yinchuan - Yinchuan No. 1 Renmin Hospital
No. 2 Li Qun West Street
0591-6192067, 6192235

Ningxia Hui Autonomous Region People’s Hospital
Huai Yuan Lu, Xin Shi District 750021
0951-202-1154/1491 X335/361

Qinghai

Xining - Qinghai Province People’s Hospital
2 Gong He Lu 810007
097-817-7911 X215

Shanxi

Taiyuan - Shanxi Medical University #1 Hospital
85 Jie Fang Nan Lu 030001
0351—404-4648, 404-4111 X25463/26706

Shaanxi Province

Xi’an - Xi Jing Hospital,
affiliated with People’s Liberation Army Number Four Medical University
No. 17 West Changle Road
029-3375548 (foreigner service section)
029-3374114 (operator)

Shaanxi Provincial People’s Hospital
You Li Lu
029-525-1331 X2079 (pediatrics)
Jiao Fu Yong, MD (head of pediatrics dept.)

Shangdong Province

Jinan - Shangdong Province Qianfoshan Hospital
66 Jing Shi Lu, 250014
0531-296-8900/ 3647 x2224/2082

Jinan - Wang Yi, MD
Depatment of Pediatric Cardiology
Shangdong Provincial Qianfoshan Hospital
66Jing Shi Lu, Jinan 250014
0531-296-8900/3647 X2224/2082

Wang Yali, MD,
The Affiliated Hospital of the Weifang Medical College,
Department of Pediatrics

Shanghai - Shen Xiaoming, MD
Shanghai Children’s Medical Centre
1678 Dongfang Road, Pudong District 200092
(021)58732020

Shanghai United Family Hospital and Clinics
#1139 Xian Xia Lu,
Changing District, 200336
021-6291 0917

Sichuan Province

Chengdu - Jinka Hospital
affiliated with Huaxi Medical University
No. 37 Guo Xue Xiang
028-5422408

Sichuan International Medical Center & Foreigners Clinic
028-524-2408 (M-F 0830- 1730), 542-2777
(M-F nights and weekends)

Chengdu Children’s Hospital
137 Taishengnai Road
Emergency hotline 028-662-4791

Tianjin - General Hospital of Tianjin Medical University
154 An Shan Da, He Ping District, Tianjin 300450
022-2781-3159

Xi Zang

Lhasa - Tibet Autonomous Region #1 People’s Hospital
Emergency Medical Facility
#18 North Lin Kuo Road 85000
Emergancy hotline 0891-120
English-speaking contact: 0891-632-2200

Xin Jiang

Urumqi - Xinjiang Uigur Autonomous Region
People’s Hospital
91 Tian Chi Lu 830001
0991-282-2927 X3120/2209

Yunnan Province

Kunming - First attached Hospital of Kunming Medical University
153 Xichang Road, Kunming
0871-532-4888
Emergency hotline 0871-532-4590

Yunnan Provincial Maternal and Child Hospital
#20 Gu Lou Road, Kunming 650051
871-517-7000

Zhejiang Province

Hangzhou - Sir, Run Run Show Hospital
#3 Qing Chun Dong Road, Hangzhou City
0571-8609-0073

Du Lizhong, MD
Children’s Hospital of Zhejiang Medical University,
310003, Hangzhou

List compiled with help of:

Jian Chen, Holt International
Du Junbao, MD, Beijing
Aina Ling, MAPS
Snow Wu, Great Wall Adoptions
U.S. Embassy, Beijing (hospital listing)
Adoptive parents

For additions or subtractions, contact Todd J. Ochs, MD in Chicago, and please let us know as well.

Sleep and Adoption

"People who say they sleep like a baby usually don't have one." - Leo J. Burke

The Problem ...

Dr. Sears: "Thou shalt cosleep, unless you don't really want that special bond we like to call attachment."

Dr. Ferber: "Thou shalt let them cry, unless you don't really want that thing we like to call a good night's sleep."

Dr. Dobson: "Good night's sleep? Have you considered a good night's spanking?"

Dr. Weissbluth: "If you don't sleep train them now, there's a 92% chance they'll be huffing paint behind the Quik-E-Mart by age 16."

That neighbor whose kid would have slept well even if raised by wolves: "Really? Our precious Tyler slept through the night since he was 2 months old ..."

Attachment therapist: "Never let their feet touch the ground ..."

Movement therapist: "But if she doesn't learn to crawl soon, her left brain will never talk to her right brain!"

Mother-in-law: "You're spoiling that child - she needs to cry it out."

APmom on your 4am chat group: "Cherish these magical middle-of-the-night bonding opportunities - not ever sleeping is a glorious gift!"

Dad: "Honey, the baby's crying ..."

Mom: "Honey, why don't you go cherish this particular magical moment ..."

Too many experts, not enough left brains talking to right brains. Too much opinion, not enough research. Too much crying, not enough sleeping. What's an adoptive parent to do? Read on, my sleepless friend, as we tiptoe through the too-often tendentious topic of SLEEP.

What is this thing you call sleep?

So much depends on adequate, restful sleep. We've got important work to do at night, from physical growth (80% of growth hormone is secreted while we sleep), to mental growth (integrating themes and memories of the day), to recharging cellular batteries, and other functions that we just haven't understood yet.

We all sleep in cycles, but children have unique sleep patterns. As infants, they have many sleep periods through a day, and a greater proportion of active (REM) sleep - about 50%, with the other half being "quiet sleep", a precursor to more developed Stages 1-4 of non-REM sleep. By 3-4 months, melatonin turns on, and infants organize their sleep into more of a day/night pattern. This is why it's silly to expect children to sleep through the night before 4 months.

By 6 months, the full cycle of non-REM and REM sleep is happening, but infants can get into Stages 3 and 4 (deep sleep) much faster than adults, and still spend more time in REM sleep. Deep non-REM sleep is important, since it's the most restorative phase of sleep, and is also when growth hormone is released. REM sleep seems to process and organize new memories and events, and is crucial to mental wellbeing.

By 3-4 years of age, children's sleep finally resembles adult sleep in quality, with 4-6 sleep cycles. The first half of the night has more non-REM sleep, with more REM sleep in the second half.

Image from SleepForKids.org, an excellent resource from the National Sleep Foundation

You'd think with something this important we'd be born good at it ... but we're not. Not even close. Just like walking and talking, the ability to fall asleep and stay asleep is something that is learned at developmentally appropriate times. How and when to help your child learn is the hard part.

Why bother? Sleep deprivation is being increasingly linked to emotional and behavioral problems, poor concentration, impulsivity, ADHD misdiagnoses, impaired learning, reduced physical performance, poor growth, headaches and bellyaches, and decreased immune function, not to mention family stress.

Sleeping through the night?

As for "sleeping through the night" ... nobody does. We all wake up to some degree several times a night, often when our sleep cycles from deep to lighter sleep. Arousals after REM sleep also occur, and tend to leave you more awake and alert. You may not be up long enough to remember it (that takes 3-5 minutes), but you do wake up, even without the "help" of your less sleep-skilled child. Our goal, thus, is not to "sleep through the night", but to promote healthy sleep associations and self-soothing skills so that your kids will fall back asleep when they wake 5 times every night.

How common are night wakings that you'll notice? By 4-6 months, babies are physiologically capable of sleeping through without feeding, but according to the 2004 Sleep in America poll, 70% of these infants still wake up and need help or attention, with 47% of toddlers, 36% of preschoolers, and 14% of school-age children also with notable wakenings. The numbers seem considerably higher in new adoptees, for reasons we'll address below. As far as other sleep difficulties go, the same poll revealed that 69% of all children experience one or more sleep problems, including stalling, bedtime resistance, and daytime sleepiness.

How much sleep does my child need?

The following table is based on sleep surveys and recommendations from the National Sleep Foundation:

While each child is unique, it's rare for kids to need much less sleep than these recommendations. However, there does seem to be individual variation in amount of needed sleep, as well as "night owl" vs "early bird" variation; these patterns are present from early childhood and are fairly stable. As for the naps, children who nap are happier, have better attention spans, may learn better, and arrive at bedtime without being overly tired. Good naps lead to good night-time sleep, and vice-versa. "Sleep begets sleep." Just try to keep naps from lasting into the later afternoon. For a great discussion of the how and why of naps for one and all, see Sleepless in America.

Special Concerns in New Adoptees

Sleep disturbances are far and away the biggest initial concern for the new adoptive families that come to our clinic. Most new international adoptees sleep well enough on the trip home - quite possibly because they're thoroughly overwhelmed and emotionally exhausted by this transition. When you arrive home, 1-2 days of jet lag per time zone crossed is typical, but children often recover before grownups.

Learning as much as possible about the prior sleep environment and bedtime routines can be very helpful. But since orphanages can have unnaturally long naps and early bedtimes (often aided by medication, sadly), you may not want to follow their timetable precisely. Remember that children from orphanages may never have been alone in a room, and will need a prolonged transition to sleeping by themselves. Children in foster care may have quite evolved bedtime routines, transitional objects, and sleep habits ... such as cosleeping, which is common in Korea and many other countries. Even the clothes they came in have reassuring smells and associations, so keep them around ...

If the "cry-it-out" methods work as advertised, then why do kids from orphanages who've unfortunately been crying-it-out their whole lives sleep so poorly at first? Well, since almost every aspect of bedtime and your child's new sleep environment is different and thus "wrong" at first, it's natural that new adoptees have difficulty falling asleep and falling back asleep during night arousals. Your child's grief at the loss of familiar caregivers may erupt at night, and when you come to console them they may be expecting someone else.

New adoptees are usually so overstimulated (we call it "Disneyland syndrome") that they may blow right through sleepytime into an adrenaline-addled second or third wind. Also, your child is experiencing dramatically more love and stimulation, is having rapid catchup development, and we know that children working on new skills often obsessively practice or at least cogitate upon these new milestones. Nightime is no exception, and it's not unusual to find children happily or unhappily attempting new feats in the crib.

Children experiencing parental love and attention for the first time are understandably reluctant to give it up because someone says it's "bedtime". The early stages of a new attachment have an insecure, "velcro" quality, so it's normal for new adoptees to be anxious and insecure around bedtime. If they won't even let you have a bathroom break, how are they suppose to handle the big kahuna of daily separations - bedtime in their own crib? Add to that the fact that it's developmentally normal for kids to have a flareup of separation anxiety at around 18 months, and you got quite an anxious child on your hands.

Plus ... it's scary in the dark, even for many "home-grown" kids. On top of that, think of all the negative associations with nighttime your adoptive child may have had. Being cold, soaked through the rags that served as diapers, in a hard metal crib, with no one answering your cries, and waking up to a different shift of caregivers is not a good memory. Neither is hearing your first parents yell and hurt each other late at night.

Finally, children with histories of prematurity, prenatal substance exposures, lack of early responsive, regulating caregiving, and stressful/traumatic experiences can literally be wired differently, with real neurologic differences in sensory processing and self-regulation. Children with oversensitivities to sound, light, or touch are more likely have difficulty filtering these inputs out at night. Children with poor emotional and self-regulation experience their emotions more intensely, and have difficulty self-soothing. The process of "attunement" (a powerful emotional connection in which the caregiver recognizes, connects with, and shares the child’s inner states) with a responsive caregiver is necessary to help your child identify, organize, and work through their emotions. That attunement, more than "crying-it-out", is what will rewire your child so that they develop genuine self-soothing skills. Try to see initial nightime wakenings with empathy for where they're coming from and what they're now experiencing.

For all of these reasons, most adoption professionals do not recommend sleep training that involves prolonged crying in the first few months home. You may have brought home an 18-month-old, but he/she may be emotionally younger in many ways, and your relationship itself is a bouncing brand new baby ... one that will keep you up more than you might like in the first few months. Plan on being more emotionally and physically available at night, and try to think of these nightime interactions as an opportunity for bonding, and a way to repeatedly show your new arrival that she is loved, safe, and well-cared for.

But keep your eyes on the prize - restful restorative sleep for all. It's never too early to set up good sleep habits, and help build self-soothing skills. You'll probably want to have both a transitional sleeping plan, and a longterm plan. Get the The No-Cry Sleep Solution for Toddlers and Preschoolers or Sleepless in America, and one of the "sleep training" books (Sleeping Through the Night is my favorite, but see our list of recommended Sleep Books), and get down to learning and soul-searching about what's going to work for your family in the short and long-term. Pantley's questionnaires can help guide the discussion, and the National Sleep Foundation's Children's Sleep Diary (pdf) can help analyze a school-age child's sleep patterns (or use this simpler sleep log for younger kids) ...

While the transitional plan should probably involve some parental presence during sleep onset and night arousals, the longterm plan is up to you. It's a emotionally loaded powder-keg of competing sleep philosophies out there, and I'm not going to light the fuse. If you are loving, attentive, and attuned during the day, and have been responsive to transitional sleep issues in the first months home, you do have my permission to move into some modified "gentle" sleep training if that's what you need to do (prolonged hysterical crying does feel traumatizing to many of us, though). You also have my blessing to cosleep 'til the cows come home, as long as you're all cosleeping and not cosleepless.

Bottom line - know thyself, and know thy children. If they have histories of trauma or neglect, you don't want to reinforce those stress-forged neuro-endocrine pathways by retraumatizing them. If a method feels like torture, or just isn't helping your child, then try something else. Sleep training is not a one-size-fits-all solution; some children may settle quickly after a brief fuss that blows off some of the stresses of the day. Some will cry for HOURS and devolve into a sweaty, snot-smeared, how-dare-you-do-this-to-me, too-frantic-to-sleep zombie. And they'll do this every time the routine gets off and you have to "re-sleep-train". Weigh the risks and benefits for your family. What's worse, lonely frantic crying and loss of loving, attuned care at night, or having a dangerously sleep-deprived, depressed, not-so-attuned parent during the day? There's no right answer to that ... you need to trust your instincts here. That said, I do think Mary Sheedy Kurcinka's Sleepless in America is the closest I've read to "the right answer", since she skillfully walks you down the path of what underlies your child's sleep issues, and helps you adjust your approach to your child's temperament. Very very highly recommended.

Let's get practical ...

After all this sleep theory, I know that you wanna get practical, so let's get into practical:

Zeitgebers

But first, more theory. Ha. Just kidding. Zeitgebers are the "time-givers", the environmental cues that set or reset our biological clocks. Because we run on a 25-hour clock, and the world runs on a 24-hour clock, we need daily cues to continually set our circadian rhythms. And trust me, you need these right now, especially if you just got off the plane.

• Light is the major zeitgeber - keep things dim in the hour before bedtime, dark at night except for a dim nightlight if necessary, and brightly lit through the day. A sunny breakfast first thing in the morning is ideal.
• Physical handling and eye contact are potent stimuli that can boost adrenaline levels. Keep the physical play and long intense gazes for daytime ... but soothing contact like rocking and gentle backrubs work well at night.
• Food routines can help maintain circadian rhythms, so try for consistency in your meal/snack/bottle schedule.
• Vigorous physical activity during the afternoon can make a big difference at night as well. Go for a big hike or playground session - your new arrival may have more energy than you think.

Bedtime Routines

Even if you're a free spontaneous spirit, your child is gonna need a bedtime routine. Young children thrive on predicability and routine, and that goes double for post-institutionalized children. How long should it be? How about 30-40 minutes ... sound too long? Well, how long does your child take to actually fall asleep after you "put them to bed"? Either you've just found some time that could be better spent on a cozy, bonding bedtime ritual, or you've won the sleep jackpot (don't tell the other parents). When things are going well is when it makes sense to trim it back to 20 minutes or so. Here are some ideas for your bedtime routine ...

• The whole hour before bedtime should be free of TV, computer games, vigorous play, or other stimulating activities.
• Sleepy-time snacks. Preempt the "I'm still huuuungry" calls with a healthy and even sleep-inducing bedtime snack. Complex carbohydrates, as well as turkey, peanut butter, bananas, soy and dairy products (which all contain tryptophan) can help you get your sleep on. Best eaten half an hour before bed.
• Review a pictorial sleep routine story that you wrote/drew together to reinforce the prebed ritual, and to confidently anticipate sleep successes. These sorts of personalized picture stories can really help in any anxious situation.
• Baths. Who doesn't love a bath? Well, the kids who got stuck under a cold faucet during diaper changes don't love the bath so much at first, but usually quickly warm up to the concept. Try not to make it a wet 'n wild play session, though. Remember - "you're getting sleeeeepy ..."
• Brush the teeth. Battery-powered toothbrushes are fun. So are tasty toothpastes. "Should I brush your teeth ... or your bellybutton?" Riff on your routine with absurd suggestions - they like it, and it builds language in the younger child or new English speaker. My niece likes to "teach the cat how to brush".
• Change into PJs ... and don't forget to change out of PJs in the morning - helps them be a more powerful sleep association.
• Bedtime bottle? The dentists just can't seem to win on this one ... but certainly no caloric beverages in the crib/bed, and it's nice to finish feeding 15 minutes before sleep to let saliva wash out some of those sugars, and to avoid setting up drinking as a sleep association that won't be there in the night. Milk, formula, and breastmilk are all soporrrific!
• Take a tour of the room, saying goodnight to all the favorite toys. Doubles as a language lesson for the English learners.
• A bedtime prayer is part of many bedtime rituals ... think about the content though. "If I die before I wake" might not be your best sleepytime thought.
• Put your child in his bed or crib and take up your station next to him. Oh look, was there a nice little not-too-stimulating surprise waiting in bed? Maybe a sticker? Or a new book? Isn't going to bed dandy?
• Do consider a gentle, soothing back massage or foot rub. Massage can work magic at bedtime, unless your child is overly sensitive to touch or ticklish ...
• Bookreading. Let your child choose 2-3 books. The lights should be really dim by now, so it's not about the pictures, it's about your soothing voice. If your voice needs a rest, try a tape of you reading, or an audiobook.
• "Goodnight, you princes of Maine, you Kings of New England ..." What will you leave your child with each night?

Bedtime Itself

It's earlier than you think. In fact the ideal toddler bedtime is often somewhere between 6:30 to 8pm.

• Use your sleep logs to keep track of when your child shows signs of sleepyness, and when he actually falls asleep.
• If you miss it, poof goes the easy sleepy bedtime - tired cranky adrenaline-addled children don't fall asleep well.
• If you get home from work late, you may need to rejigger that or make early mornings your quality time.
• If you're having sleep issues, you're well advised to keep sleep schedules the same 7 days a week. Which means keeping the bedtimes the same, but also not letting them sleep in much past their usual/appropriate wakeup time (ouch).
• That said, sometimes your child's current circadian rhythms has him going to bed later than you think. Try letting the bedtime start out later but inch it backwards by 10-15 minutes per night.

Falling Asleep

This here is the key, folks ... the associations your child has with that golden moment of falling asleep will be the ones she needs each time she wakes in the middle of the night. Do everything in your power to let that moment be on her own. No feeding, no rocking at that moment, if you can. Stay in the room at first, by all means, stay next to the bed or even in it if you must ... you can wean that later if you want. Falling asleep is hard to do if you are anxious and having difficulty letting go ... Here are some ideas to help with the weaning process, which may take weeks to months.

• Does your child have a "lovey", or transitional object, that can represent the emotional security she's building with you? If she didn't arrive with one, have an array of dolls, stuffed animals, and blankies around for a few days and see if she gravitates to one. Several of my patients swear by the Slumber Bear that plays womb sounds when jostled.
• When she settles on one, experienced parents keep backup loveys on hand, and even rotate them so they're equally worn and stinky.
• Maybe there are a few nonsense "errands" you need to do, in the room or out of it? But you'll be right back.
• In fact, you can set a silent timer like an hourglass egg timer or visual timer and tell her that you'll be back in 3 minutes when the timer is done. Come back, check on her briefly, and repeat. Make sure you do come back.
• Even if you're not doing the timer thing, coming back in for brief checkins when your child is not screaming for you is reassuring and rewards good bedtime behavior.
• Successes with independent falling asleep are often followed by fewer night wakings in 1-2 weeks.

Night Wakings

Remember the sleep study statistics - 70% of infants, 47% of toddlers, 36% of preschoolers, and 14% of school-age children wake and need help at least once per night - these are normal, folks.

• What's going on? Illness, teething, soaked diapers, recent stresses, new developmental milestones, night fears, night terrors, nightmares?
• Again, be more responsive at first than you might eventually plan to be ...
• But be as brief, boring, and minimalist in your interventions as possible.
• And give brief fussing a chance to subside on it's own - your child may be having one of those night arousals that doesn't involve fully waking up.
• Before you approach your wide-awake-and-screaming-at-4am child, take several slow, deep breaths, in through nose, out through mouth, focussing on a happier parenting moment or image of your child. Then go in.
• Keep the "deep cleansing breath/find your happiness" thing going while you're in there. Seriously - breathing and a calm, affectionate approach is SO helpful, day or night; HeartMath's "Quick Coherence technique" is one way to get there. 
• Review your child's sleep associations - is there anything he falls asleep to that isn't there in the night?
• Is there something your child could do for himself that's self-soothing? Some of my older adoptees have cassette/CD players in bed with calming stories or music. If you played music at bedtime, can your child turn it back on easily?
• Pantley has several great suggestions - giving your older child one or two Get-Out-Of-Bed-Free cards, a "Sleep Fairy" that leaves stickers under the pillow when children have had a successful night (depending on what they're working on - reward incremental successes), and even wrapped prizes in the morning for kids that have a good quiet night.
• If you suspect night terrors, do less. They're more distressing for you than your child, and sleep experts discourage waking a child while they're having one. I've also heard that limiting fluids before bed may help, as full bladder might provoke night terrors.

Cozy Sleep Nooks

First things first - if there's a TV or computer in your child's room, banish it forthwith. They are the anti-sleep.

• Ideally the sleep area is for sleeping and quiet resting ONLY, and perhaps separated by curtains or other dividers from the rest of the room.
• Lots of stuffed friends can be reassuring, as are pictures of loved ones.
• Climb in and spend some time in it yourself. Is the mattress comfortable enough? Audible household or outdoor noises? Lights shining in from the hallway or street?
• Is there a place for you? Because that's the ultimate safe, secure "cozy sleep nook", at first. I think the ideal transitional solution is with one parent sacked out next to the child, since that will maintain a consistent sleep environment for the child when you eventually wean the parental presence.
• If you're not there during the night, something that explicitly reminds her of you is also very important - since smell is one of the most powerful shortcuts to our primitive brain, where our senses of anxiety and security come from, perhaps an aromatic worn t-shirt or pillowcase of yours? And some photographs of you together in a loving, calm moment can be reassuring in the night.
• Other options are having the crib or for an older child, a futon, next to your bed.
• Cosleeping is also a popular option at first. Some adoptive parents report that their child was easily weaned after a few months to their "big girl bed", but in general, once you start cosleeping it's the hardest to wean.

Light

• Seattle in the summer is brutal for sleep. Try creative window treatments like "blackout curtains", cardboard, aluminum foil (also adds a certain "blocking the alien mind control rays" touch to your decor) or whatever it takes to get that room dark.
• If you do use a nightlight, keep it as dim as possible to avoid vernichten das zeitgeber, ja?  If you know what I mean ...

Sound

• White noise can be a godsend for sleep, and is one of the first things I recommend for light sleepers.
• A fan or aquarium pump running all night long can help drown out other intrusive noises.
• Ocean wave noise generators, womb noises, and heartbeat lullabies are other favorites.

Smell

• That lovey smells funky for a reason. Wash it at your peril.
• Something that smells like you can be soothing too. See above ...
• Aromatherapy - lavender and chamomile scents are felt to be relaxing as well. Try some "Badger Sleep Balm" ...

Touch

• Being wet in the night is trouble, so limit fluids in the 1-2 hours before bed, use diaper doublers, and consider a nice layer of protective diaper paste before bedtime.
• For children that seem to crave that snug-as-a-bug-in-a-rug sensation, often winding up wedged in the corner, perhaps a smallish sleeping bag or sleepsac would feel good. Grembo, LittleBigFoot, and others make zipup sleep bags for infants and toddlers. Tucking in the the sheets extra-tight may help at first, but they come undone; some parents have used a lycra sleeve around the mattress that the child slips into. Weighted blankets are available for older children with sensory issues as well.
• Many orphanage-raised children will have pronounced self-stim/self-soothing habits like rocking, head shaking or banging, ear fiddling, or sucking on lips or fingers. These do fade with time, but may still show up in time of stress.

Temperature

• The body tends to cool off at night, and people sleep better in a cooler environment.
• Warm baths followed by cool bedroom may help this process along.

Does my child have a sleep disorder?

Courtesy of Dr Mindell, the following list of sleep problems may indicate that your child has a sleep disorder. If these issues are present, if sleep issues are getting worse not better, or if you're at the end of your rope, please talk to your health care provider.

1. Loud snoring, noisy breathing, or breathing pauses while sleeping
2. Breathing through his mouth while sleeping
3. Appearing confused or looking terrified when he awakens during the night
4. Frequent sleepwalking
5. Rocking to sleep or head banging when falling asleep or during the night (ed: actually very common in orphanage raised children, and thus only a problem for them if severe or persistent)
6. Complaining of leg pains, "growing pains", or restless legs when trying to fall asleep at night
7. Kicking his legs in a rhythmic fashion while sleeping
8. Sleeping restlessly
9. Frequent difficulty falling asleep or staying asleep
10. Sleep difficulties leading to daytime behavior problems or irritability

Additional Sleep Resources

• Our favorite Sleep Books
• babysleep.com - most excellent advice and videos from pediatric sleep experts 
• drcraigcanapari.com - my favorite online pediatric sleep doc (and college bestie)

Acknowledgements

Thanks to New Hope Child and Family Agency for the impetus, Elizabeth Pantley for many fab ideas, Drs. Mindell and Weissbluth for others, Dr. Greene for the zeitgebers, and our sleepless families for the inspiration.

Giardia and Other Stool Parasites

Giardia is the most common parasitic infection in international adoptees, and is also frequently implicated in day-care center diarrhea outbreaks. Studies have shown that it is found in up to 20% of international adoptees, particularly older adoptees from Eastern Europe; in our experience it seems to come in clusters, averaging around 10-20% of our adoptees, and we do see it from China as well.

It's a microscopic flagellated protozoan parasite that is quite infectious (it can take as few as 10 cysts to cause infection), and it is typically spread by drinking contaminated water or fecal-oral transmission. So ... wash hands scrupulously after diaper changes, toilette, and before meals/food prep until giardia is ruled out, and don't have new arrivals share baths with other children at first.

Giardia can be asymptomatic, but symptoms often include loose, watery stools, with a certain foul-smelling greasy, floaty, frothy je ne sais quoi. Flatulence, cramps, bloating, and malaise can also be present. Chronic giardia may be associated with significant weight loss and failure-to-thrive. It also can cause secondary lactase deficiency - interfering with the intestine's ability to digest lactose. Even after successful treatment, loose stools can persist for a month or two. Cutting back on lactose, and supplementation with probiotics (unproven but likely to be safe) may help during this time period.

To diagnose giardia and other intestinal parasites, we recommend submitting 3 stool samples collected 2-3 days apart (preserved promptly after passage in a polyvinyl alcohol kit) for ova and parasite (O&P) examination, and one fresh (<1hr old) sample for Giardia antigen. Some refugee centers treat empirically with albendazole on arrival; we don't, because we prefer to know what we're treating, and because albendazole is ineffective against some of the common parasitic infections in adoptees. If the initial stool tests (remember, collect them 2-3 days apart to increase the chances of finding something) are negative but symptoms consistent with intestinal parasites persist, consider rescreening the stool; initial stool examinations miss infections in some children.

It's also important to do a "test-of-cure" giardia antigen test 1-2 months after treatment to confirm treatment success. If an adoptee tests positive for giardia, we treat, regardless of symptoms. You may not realize until later that the giardia was in fact causing symptoms, including malaise and poor growth; we also do this for the "public health" of the adoptive family.

Folks who don't see a lot of giardia often prescribe flagyl (metronidazole); in our experience this has an unacceptable failure rate. A better choice is Tinidazole, which was recently FDA approved for this indication, but has been in off-label use for some time, even in children <3yo. A convenient one-time 50mg/kg dose (max 2g) is what we use. It's mighty bitter, so mix with espresso syrup or other intensely sweet/flavorful option. See our medication tricks and tips for other ideas. Clark's Pharmacy in Bellevue, WA (425-881-0222) has it available in convenient dosing, is giardia savvy, and does mail order. Alinia is another recently approved medication for giardia that seems to be a reasonable alternative.

We don't automatically test or treat family members if giardia is promptly diagnosed in a new arrival, but if the child has been home awhile, if there are other young children around, or if anyone else is symptomatic then they should get checked as well.

Other stool parasites like Ascaris lumbricoides, Blastocystis hominis, Dientamoeba fragilis, Entamoeba histolytica, Trichuris trichiura, hookworms, and pinworms are also commonly identified in international adoptees. O&P results will often include non-pathogens, or commensals, which are not felt to cause illness and do not require treatment. However, they can be a sign that other parasites are present, and you should make sure that all 3 stool samples are evaluated. Links with good information about these and other, less familiar parasites are listed below.

Other Stool Parasite Resources:

• CDC Giardia Fact Sheet
• eMedicine Giardiasis Overview
• CDC Alphabetical Listing of Parasitic Infections (so many parasites to choose from, including Amebiasis, Ascariasis, Blastocystis hominis, Chilomastix mesnili, Cryptosporidium, Dientamoeba fragilis, Entamoeba coli, Enterobiasis (pinworms), Head Lice Infestation, Intestinal Roundworms, and Nonpathogenic Intestinal Amebae Infections)
• eMedicine Intestinal Protozoal Diseases (detailed medical overview of many common parasites, free registration required)
• A Field Guide to Emerging Enteric Protozoa - Contemporary Pediatrics (covers Dientamoeba fragilis, Blastocystis hominis, Entamoeba coli, and Cyclospora cayetanensis)
  

Language Development In Internationally Adopted Children

Initial delays in speech and language are almost universal in children adopted from institutions, with expressive language (talking) usually more delayed than nonverbal social interaction skills. Those of us who work with a lot of adopted children develop a rough sense of what are "typical" orphanage delays, but fortunately, we're also seeing some useful research data on what actually is "normal" language development in internationally adopted children.

The thing to remember (and remind your pediatrician, school district, mother-in-law, etc ...) is that this is not just an ESL or bilingual issue. Internationally adopted children from backgrounds of neglect or inadequate stimulation are usually delayed in their native language.  When they are adopted, they have "arrested" development of that 1st language (unless you happen to be fluent in Russian, Mandarin, etc). They then rapidly lose what abilities they had in their native language, before their "new first language" (English) has time to develop. This leaves them in the "language lurch" for awhile, without functional abilities in either their 1st or 2nd languages.  Not an easy place to be ... this may be partly responsible for those "the honeymoon is over!" behavioral issues that many families experience several months post-adoption.

Sharon Glennen, Ph.D., CCC-SLP, has done a lot of the research on this topic, including a longitudinal study of language development in children adopted as infants and toddlers from Eastern Europe. On her website, she reviews the effects of orphanage care on language development, presents some very useful tables of typical language development in international adoptees, as well as pre-adoption language questions for parents to ask.

Other Resources:

• Our Favorite Books for Speech/Language Delays
• Article from Adoptive Families Magazine on Language in Toddler Adoptees
• Harvard Study of Language Development in Internationally Adopted Children (ongoing)
• Study of Language Development in Children Adopted from China (ongoing)
• RUSH Into English, a CD for Russian children 4-5 years and up to help them learn English