Fetal Alcohol Spectrum Issues

Since prenatal alcohol exposure is a concern that arises so frequently in our preadoption consultations, we've created this page as a resource for families grappling with the alcohol issue. Our experience in this field comes from working at the FAS clinic here at the University of Washington, evaluating and following many alcohol-exposed internationally adopted kids, and volunteering with older orphanage-raised children in Moscow.

Unfortunately, a study found that 60% of pregnant women in Russia reported drinking during pregnancy, with 8% reporting at least one binge drinking episode during pregnancy. Since these were women that were actually receiving prenatal care, the rates and amounts of prenatal alcohol exposures for children in orphanages are likely to be significantly higher, as those pregnancies do not tend to be supervised. The rate of FAS in Russian orphanages have been estimated at 1-10 per 100, and the rate of alcohol-affected kids is even worse. That’s a lot higher than in this country, where it’s thought to be 1-3 per 1000. Alcohol is also a major concern in other former Soviet Union countries, and is an emerging issue in many other countries.

So … what is fetal alcohol syndrome?

FAS is a permanent birth defect syndrome caused by maternal alcohol consumption during pregnancy. The full FAS diagnosis requires all of the following: growth problems before or after birth, a pattern of minor facial anomalies, evidence of altered brain structure or function, and prenatal alcohol exposure. There is an associated increased risk of eye, hearing, heart, and other associated defects, but those aren’t part of the diagnostic criteria.

What about PFAS, AFAS, FAE, ARBD, ARND, ND-PAE etc etc etc? Partial FAS, atypical FAS, fetal alcohol effect, alcohol-related birth defects, alcohol-related neurodevelopmental disorder, and other names have been used to describe children that seem to be affected by prenatal alcohol exposure but are missing one or more of the four FAS criteria. We use the umbrella term fetal alcohol spectrum disorders (FASD) to describe the range of fetal alcohol diagnoses. FASD includes children with FAS as the “tip of the iceberg”, but also alcohol-affected children with fewer or less severe features of FAS.

We know that alcohol can damage the developing fetus, but the effects of alcohol are quite unpredictable – we’ve seen fraternal twins where, given the same mom and alcohol exposure, one has FAS and the other seems fine. There seem to be unidentified protective and risk factors for mom and babies that make predicting the effects of alcohol exposure very hard to do. No amount of alcohol exposure has been proven to be safe, but heavy and repeated binge drinking is highest risk. We also worry more about older moms and later pregnancies, because they seem to produce kids more affected by alcohol, perhaps because alcoholism is further along in those pregnancies. Involuntary termination of parental rights can also be a clue to social dysfunction and alcohol abuse.

Growth

Let’s look at those 4 FAS criteria, starting with growth. Children affected by prenatal alcohol exposure can be unusually small in weight and/or height, at birth or later. Many show some catch-up in growth by adolescence. Of course, many other adverse influences common to adopted children (maternal stress or illness during pregnancy, prenatal tobacco, malnutrition, neglect, orphanage factors) can impact growth as well. We count growth deficiency towards an FASD diagnosis if the growth is not better explained by other factors, and look at the catch-up growth pattern in the first year home to help us tease out environmental versus prenatal causes. Children who are unusually small compared to others raised in similar environments are at higher risk for developmental and behavioral challenges after adoption.

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 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 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 – polaroids aren’t good enough. Take a closeup facial portrait photograph so that the head fills the entire frame (use zoom if need be, but watch the focus), from about 4 feet away. 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!

How Alcohol Affects Brain Structure and Function

Enough about the face … what about the brain? That’s what we really care about, after all. In fact, a lot of young kids with the FAS face are really cute. We can look at the brain structurally by plotting the head circumferences on a growth chart. You should measure the head circumference yourself if there has been any concern – bring a non-stretchable measuring tape, and practice a bit first. Wrap the tape snugly around the widest possible circumference - from the most prominent part of the forehead (often 1-2 fingers above the eyebrow) around to the widest part of the back of the head. Remeasure it 3 times, and take the largest number.

Microcephaly (head circumference less than 3%, or “below the growth chart”) can be evidence of brain damage from alcohol. It’s one of the few things we have to predict later brain function in infants and young toddlers, because meeting early motor milestones does not rule out difficulties later on with learning and behavior. In fact, a lot of the functional disabilities from alcohol damage aren’t apparent before school-age. The lack of concrete predictions about alcohol effects is a constant frustration in this process ... it really is a "time will tell" issue, unfortunately.

“Typical” (in quotes because the outcomes are so variable) functional impacts of prenatal alcohol exposure include problems with inattention and impulsivity (ADHD-like behaviors, sometimes not as responsive to medications), lower IQ scores or mental retardation, math and other specific learning impairments, “executive function” difficulties (the higher-order brain functions that plan and organize how you solve problems), trouble with cause/effect, social and communication challenges, coordination problems, sleep difficulties, and so on. Alcohol commonly affects multiple domains of brain functioning. Teasing this out can require wide-ranging testing by professionals familiar with alcohol effects. Many kids aren’t identified early enough, and are labeled as “difficult”, or “just doesn’t get it”, or other labels that don’t help. Accurate diagnosis as early as possible helps these children.

Raising Children Affected by Alcohol

While these difficulties are usually lifelong, this is not a hopeless diagnosis. Consistent, patient, loving, “industrial-strength” parenting with tons of structure, and appropriate expectations and supports in school can really help kids affected by alcohol reach their full potential. That potential will be limited by alcohol-related brain damage but setting the bar at the right height, and identifying what they CAN’T versus WON’T do can really help them have success in their life, and hopefully prevent some of the “secondary disabilities” of depression, acting out and aggression, victimization, troubles with the law, and especially their own substance abuse potential.

Resources for Caregivers

We have an FASD Resource List with internet and book references that will help give you a better sense of the range of alcohol effects, and what it’s like to parent a child affected by alcohol.

• An FASD Parenting Toolkit is also available from UW

• The CDC has a number of FASD resources

• Making Sense of Fetal Alcohol Spectrum Disorder (FASD) is excellent

• Proof Alliance has a nice 3-page handout on Parenting Children with FASD

• FASD United has many tools and resources for parents

• We also like Parenting Children with Affected by FAS - A Guide for Daily Living

Resources for Educators

Here are 3 free, downloadable PDF guides for educators (also very useful for parents, who often have a lot of advocacy to do at school):

• Alberta Schools guide for teachers and caregivers of child with FASD

• University of South Dakota FASD Education Strategies Handbook

• SAMHSA Reach To Teach - Educating Elementary and Middle School Children with FASDs

Teachers can find more practical strategies in the do2learn Teacher Toolbox.

Trends in Ethiopia Adoption

Thanks to "Mr Personality" and family

A really exciting development we have seen in international adoption in the last few years has been an increasing number of children being adopted from Ethiopia, and wow, are they beautiful! To give you an idea, US government statistics tell us that while there were 42 children adopted in the US from Ethiopia in 1999, the number went up to 2,277 in 2009!

We have definitely felt this trend here at the Center for Adoption Medicine. In addition to our center doing many preadoptive consultations, I have had the pleasure, personally, of taking care of lots of these kids once they have come home. It is an interesting and varied group of children. There seem to be two distinct groups being adopted from Ethiopia. First, the infants who are coming into care soon after birth, and often, coming home even before their first birthdays. Then there are the older kids who come after one or both parents have perished, and these often arrive in sibling groups.  

There is a rumor out there that all the kids coming from Ethiopia are healthy and have no issues, and this simply is not the case.  The variability in health status and medical/developmental issues uncovered both on preadoptive consultation and after they come home is quite large. As with any country of origin, every child is different. There have been a few interesting trends, however. While we see latent tuberculosis (i.e. requiring treatment and infected but not yet sick or contagious) fairly frequently in all of our adopted kids, we have seen quite a bit of active tuberculosis (a life threatening illness, which can be contagious depending upon type of illness and age of the child) in some of our adoptees from Ethiopia. This has ranged from a child who was very obviously ill upon arrival, to a couple of siblings who passed screening in Ethiopia as having latent TB, looked and acted great, but both had active tuberculosis when rechecked in Seattle. Careful scrutiny of in-country testing, and rescreening once home is definitely prudent; and yes, even the kids who come home looking great are subjected to the same battery of tests that we do on most international adoptees, as we pick up all sorts of things that are not apparent on exam or history!

The other illness we are seeing more of is hepatitis A. This is an interesting one in that most young children can have the illness with no obvious symptoms. They do great. The problem is that it is very contagious and it is a more severe illness the older the patient is. This means that unimmunized contacts such as parents, siblings, cousins, grandparents, etc. are at risk. There was recently a  case of a grandma who caught hepatitis A from her totally healthy-appearing 1yo newly adopted grandkids from Ethiopia. She nearly died, and they only found out that the twins had hepatitis A when they were trying to figure out how she became infected. Of note, she did not travel to Ethiopia, she visited them once they got home!  

It is currently recommended that all contacts of internationally adopted kids be vaccinated against hepatitis A, not just those that travel. While we have seen more cases in our Ethiopian kids, we only recently have been widely screening for it, and there is a high rate of hepatitis A in all the coutries from which we typically see international adoptees. HIV is another infection that is seen at a high rate in Ethiopia. We have seen a small number of patients with known HIV positivity, but fortunately have not yet been surprised by an undetected case.

Some other issues to think about in Ethiopian adoptees include female circumcision (or female genital mutilation) and transracial adoptive issues. Female circumcision is still practiced in parts of Ethiopia, especially rural areas. It can vary from some ritual cuts to removal of various structures that can significantly affect sexual and reproductive functioning. I have seen only a few cases and only one which was not known to the patient, her older sisters, or the adoptive family. It takes a pretty complete examination of the external genitalia to see some of these. Many older Ethiopian adoptees are frankly horrified at the idea of being fully examined by a doctor, as this is not something typically done in Ethiopia. Sometimes it takes a few visits before a full exam can be comfortably done. Specialized care by an OB-GYN with some knowledge of this will be important for these girls. 

Transracial/transcultural adoption issues come up for most of our international adoptees. In kids of African descent adopted by non-black families, it can be a more prominent issue to society as a whole. Then there is the added level that many of our kids will be perceived to be of African-American descent, which is not how many of them see themselves. We are fortunate in Seattle to have a large Ethiopian community (and growing Ethiopian adoption community), so incorporating Ethiopian culture into one's family life is easier. For those living far out from the big city, reaching out to other adoptive families and Ethiopian communities is thought to be really helpful.

Lastly, let's talk about hair. Yes, hair. The care of African hair seems to be a science onto itself. I do not pretend to be an expert but have heard lots of tips, including saturating the hair with grapeseed or olive oil prior to shampooing and not washing it more than once a week. Many of our families have found support on the Adoption Hair and Skincare Yahoo! Group.

All in all, these kids have been a joy to work with.  The courage and resilience of the older kids never ceases to amaze me.  Every day it seems I think I have seen the most adorable, compeling child ever.

Prenatal Methamphetamine Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Methamphetamine abuse has increased dramatically in the United States in the past decade, especially in the western and midwestern states [105]. In Russia, cheap imported heroin still prevails, but abuse of home-produced ephedrine-based “vint” and other injectable amphetamines is on the rise and already predominates in certain cities, including Vladivostok and Pskov [106]. Methamphetamine abuse is a significant problem in Southeast Asia as well, with 19% of Thai female students using methamphetamine in one school-based study [107]. The UNODC reports large increases in methamphetamine production and abuse in China, Singapore, and Thailand [35]. Because methamphetamine is relatively cheap to manufacture from readily available products, “home labs” are becoming increasingly common in many parts of the world. Unfortunately, the chemicals and byproducts involved are highly toxic and flammable.

Methamphetamine is a CNS stimulant that releases large amounts of dopamine, resulting in a sense of euphoria, alertness, and confidence [108]. It can be injected, smoked, snorted, or ingested orally. Prolonged use at high levels results in dependence and erratic behavior [105]. Evidence on the effects of prenatal methamphetamine use is still emerging, but effects on prenatal growth, behavior, and cognition have been described.

Mechanism

Studies of adult methamphetamine abusers have shown potential neurotoxic effects on subcortical brain structures, namely, decreased dopamine transporters, brain metabolism, and perfusion [108]. Although the impact of methamphetamine use during human pregnancy is currently unknown, animal studies have demonstrated neurotoxic effects of amphetamines and remodeling of synaptic morphology in response to prenatal methamphetamine exposure [109]. One study did describe a smaller putamen, globus pallidus, and hippocampus in methamphetamine-exposed children [108].

Pregnancy

Women using methamphetamine during pregnancy may have an increased rate of premature delivery and placental abruption [110]. Methamphetamine use during pregnancy is linked to fetal growth restriction and, occasionally, withdrawal symptoms requiring pharmacologic intervention at birth [111]. Clefting, cardiac anomalies, and fetal growth reduction have been described in infants exposed to amphetamines during pregnancy. These findings have been reproduced in animal studies [112].

Child Health

Late effects on child health resulting from prenatal methamphetamine use are unknown. Children who live at or visit methamphetamine home labs face acute health and safety hazards from fires, explosions, and toxic chemical exposures, however. The caregiving environments of methamphetamine users are often characterized by chaos, neglect and abuse, and criminal behavior as well as the presence of firearms, contaminated sharps, and other risks [113].

Behavior and Cognition

The scant research describing the outcomes of methamphetamine-exposed children describes possible links with aggressive behavior, peer problems, and hyperactivity [114], [115]. A small recent study found that methamphetamine-exposed children scored lower on measures of visual motor integration, attention, verbal memory, and long-term spatial memory [108]. In rats, even low doses of prenatal methamphetamine exposure can alter learning and memory in adulthood [116].

Selected References

[105]   Anglin M.D.,  Burke C.,  Perrochet B.,  History of the methamphetamine problem. J Psychoactive Drugs (2000) 32 : pp 137-141.
[106]   Rhodes T.,  Bobrik A.,  Bobkov E.,  HIV transmission and HIV prevention associated with injecting drug use in the Russian Federation. Int J Drug Policy (2004) 15 : pp 1-16.  
[107]   Sattah M.V.,  Supawitkul S.,  Dondero T.J.,  Prevalence of and risk factors for methamphetamine use in northern Thai youth: results of an audio-computer-assisted self-interviewing survey with urine testing. Addiction (2002) 97 : pp 801-808.
[108]   Chang L.,  Smith L.M.,  Lopresti C.,  Smaller subcortical volumes and cognitive deficits in children with prenatal methamphetamine exposure. Psychiatry Res (2004) 132 : pp 95-106.
[109]   Weissman A.D.,  Caldecott-Hazard S.,  Developmental neurotoxicity to methamphetamines. Clin Exp Pharmacol Physiol (1995) 22 : pp 372-374.
[110]   Eriksson M.,  Larsson G.,  Winbladh B.,  The influence of amphetamine addiction on pregnancy and the newborn infant. Acta Paediatrica Scandinavica (1978) 67 : pp 95-99.  
[111]   Smith L.,  Yonekura M.L.,  Wallace T.,  Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. J Dev Behav Pediatr (2003) 24 : pp 17-23.
[112]   Plessinger M.A.,  Prenatal exposure to amphetamines. Risks and adverse outcomes in pregnancy. Obstet Gynecol Clin North Am (1998) 25 : pp 119-138.
[113]   Swetlow K.,  Children at clandestine methamphetamine labs: helping meth's youngest victims 2003. Washington, DC: US Department of Justice, Office of Justice Programs, Office for Victims of Crime.  
[114]   Billing L.,  Eriksson M.,  Jonsson B.,  The influence of environmental factors on behavioural problems in 8-year-old children exposed to amphetamine during fetal life. Child Abuse Negl (1994) 18 : pp 3-9.
[115]   Eriksson M.,  Billing L.,  Steneroth G.,  Health and development of 8-year-old children whose mothers abused amphetamine during pregnancy. Acta Paediatr Scand (1989) 78 : pp 944-949.
[116]   Williams M.T.,  Moran M.S.,  Vorhees C.V.,  Behavioral and growth effects induced by low dose methamphetamine administration during the neonatal period in rats. Int J Dev Neurosci (2004) 22 : pp 273-283.

Prenatal Cocaine Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Cocaine has received much attention since the 1980s, when crack cocaine began to plague urban America. Early alarmist predictions about an epidemic of neurologically damaged “crack babies” gave way to guarded optimism with early reports of neurodevelopmental functioning reporting no differences attributable to cocaine exposure. Follow-up studies with more specific measures, however, suggest effects of prenatal cocaine abuse on aspects of neurobehavior and language, as demonstrated with specific developmental tasks.

The rate of prenatal cocaine exposure in the United States ranges from 0.3% to 31% depending on the population surveyed and method of ascertainment [77], [78] and was 10% in the ongoing Maternal Lifestyle Study [34]. In our clinic's experience, reports of cocaine exposure in the international adoptee population are quite rare. The UNODC estimates the lifetime prevalence of cocaine consumption to be approximately 2% to 5% in a study of Guatemalan teenagers; in Russia, China, Korea, and other frequent countries of international adoption, the prevalence seems to be much less [35].

Mechanism

Cocaine and its metabolites readily cross the placenta, concentrating in amniotic fluid, and may produce direct neurotoxic effects, disturb monoaminergic (eg, dopamine, norepinephrine, serotonin) pathways, and cause vascular-mediated damage [91].

Pregnancy

The use of cocaine in pregnancy has been associated with a number of obstetric complications, such as stillbirth, placental abruption, premature rupture of membranes, fetal distress, and preterm delivery [92]. Growth restriction is often reported but may require higher levels of exposure and does not seem to persist after birth [93]. There may be a dose-response effect of cocaine on newborn head circumference [94]. Other CNS lesions (eg, stroke, cystic changes, possible seizures), cardiac defects, and genitourinary (GU) anomalies have also been reported, but the few available large, controlled, population-based studies on cocaine exposure and malformations have reached contradictory conclusions [95].

Behavior and Cognition

Prenatal cocaine abuse may cause specific neurobehavioral and learning problems, although it is not associated with global cognitive deficits [96], [97]. The largest matched cohort study to date found no significant covariate-controlled associations between cocaine exposure and mental, psychomotor, or behavioral functioning through 3 years of age [98]. Infant neurobehavioral abnormalities like irritability or excitability, sleep difficulties, and state regulation difficulty as well as transient neurologic abnormalities like tremor, hypertonia, and extensor posturing have been reported [99], [100]. Heavy prenatal cocaine use has been linked to poor memory and information processing in infancy [101]. At 3 years of age, increased fussiness, difficult temperament, and behavior problems were described [102]. Language delay has also been described, with foster or adoptive caregiving described as a promising protective factor [103], [104].

Selected References

[91]   Chiriboga C.A.,  Fetal effects. Neurol Clin (1993) 11 : pp 707-728.
[92]   Kain Z.N.,  Mayes L.C.,  Ferris C.A.,  Cocaine-abusing parturients undergoing cesarean section. A cohort study. Anesthesiology (1996) 85 : pp 1028-1035.
[93]   Nordstrom-Klee B.,  Delaney-Black V.,  Covington C.,  Growth from birth onwards of children prenatally exposed to drugs: a literature review. Neurotoxicol Teratol (2002) 24 : pp 481-488.
[94]   Bateman D.A.,  Chiriboga C.A.,  Dose-response effect of cocaine on newborn head circumference. Pediatrics (2000) 106 : pp E33-.
[95]   Vidaeff A.C.,  Mastrobattista J.M.,  In utero cocaine exposure: a thorny mix of science and mythology. Am J Perinatol (2003) 20 : pp 165-172.
[96]   Wasserman G.A.,  Kline J.K.,  Bateman D.A.,  Prenatal cocaine exposure and school-age intelligence. Drug Alcohol Depend (1998) 50 : pp 203-210.
[97]   Singer L.T.,  Minnes S.,  Short E.,  Cognitive outcomes of preschool children with prenatal cocaine exposure. Obstet Gynecol Surv (2005) 60 : pp 23-24.  
[98]   Messinger D.S.,  Bauer C.R.,  Das A.,  The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics (2004) 113 : pp 1677-1685.
[99]   Tronick E.Z.,  Frank D.A.,  Cabral H.,  Late dose-response effects of prenatal cocaine exposure on newborn neurobehavioral performance. Pediatrics (1996) 98 : pp 76-83.
[100]   Chiriboga C.A.,  Brust J.C.,  Bateman D.,  Dose-response effect of fetal cocaine exposure on newborn neurologic function. Pediatrics (1999) 103 : pp 79-85.
[101]   Jacobson S.W.,  Jacobson J.L.,  Sokol R.J.,  New evidence for neurobehavioral effects of in utero cocaine exposure. J Pediatr (1996) 129 : pp 581-590.
[102]   Richardson G.A.,  Prenatal cocaine exposure. A longitudinal study of development. Ann NY Acad Sci (1998) 846 : pp 144-152.  
[103]   Delaney-Black V.,  Covington C.,  Templin T.,  Expressive language development of children exposed to cocaine prenatally: literature review and report of a prospective cohort study. J Commun Disord (2000) 33 : pp 463-480.
[104]   Lewis B.A.,  Singer L.T.,  Short E.J.,  Four-year language outcomes of children exposed to cocaine in utero. Neurotoxicol Teratol (2004) 26 : pp 617-627.

Prenatal Marijuana Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Marijuana is a popular recreational drug in many parts of the world. In the United States, 22% of high school students have used marijuana in the past month [76]. Estimates of marijuana use during pregnancy vary between 2% in broad surveys using maternal self-report [77] and 20% to 27% in higher risk populations using urine screens [78], [79]. In the experience of our international adoption clinic, referrals outside North America have not included reports of prenatal marijuana exposure, but the United Nations Office on Drugs and Crime (UNODC) estimates that the annual prevalence of marijuana use is 3.9% in the Russian Federation, 2.4% in Kazakhstan, 0.3% in China, 0.1% in South Korea, and 3.2% in India [35]. In Guatemala, where the rate of drug consumption among young people is on the rise, marijuana consumption by teenagers is at 4% to 6.7% [80].

Mechanism

The principle psychoactive substance in marijuana, delta-9-tetrahydrocannabinol (THC), rapidly crosses the placenta and may remain in the body for 30 days before excretion, thus prolonging potential fetal exposure. THC is also secreted in breast milk. Marijuana smoking produces higher levels of carbon monoxide than tobacco [38], which is hypothesized to be a potential mechanism of action of prenatal marijuana exposure's impact on the developing fetus.

Pregnancy

Marijuana use during pregnancy may have a modest effect on prenatal growth, but the results are inconsistent from study to study and diminish when potential cofounders are controlled [81], [82], [83], [84]. These effects, if any, are not associated with later growth deficiency, although a few studies have suggested an impact on height [81] as well as persistent negative effects on head circumference in the offspring of heavy marijuana users [63]. This review found no consistent link between prenatal marijuana exposure and other adverse pregnancy outcomes or congenital malformations [85].

Behavior and Cognition

Subtle effects of prenatal marijuana exposure on cognition have been observed in two large well-controlled study groups: a predominantly low-risk Ottawa cohort and a higher risk Pittsburgh population. The Ottawa authors argue that although prenatal tobacco exposure is associated with deficits in IQ, impulse control, and other fundamental aspects of performance, prenatal marijuana exposure does not impair IQ or basic visuoperception but influences the application of these skills in problem-solving situations requiring visual integration, analysis, and sustained attention [86]. Marijuana is thus argued to have an impact on higher level executive function and performance in a “top-down” fashion, in contrast to tobacco's “bottom-up” effects [87]. The Pittsburgh study group finds links to inattention and/or impulsivity [88] and subtle deficits in memory and learning [89]. This group also connects prenatal marijuana exposure with academic underachievement, perhaps reflecting less buffering of marijuana's effects by environment in this higher risk population [90].

Selected References

[76]   Grunbaum J.A.,  Kann L.,  Kinchen S.,  Youth risk behavior surveillance—United States, 2003. MMWR Surveill Summ (2004) 53 : pp 1-96.  
[77]   Ebrahim S.H.,  Gfroerer J.,  Pregnancy-related substance use in the United States during 1996–1998. Obstet Gynecol (2003) 101 : pp 374-379.
[78]   Zuckerman B.,  Frank D.A.,  Hingson R.,  Effects of maternal marijuana and cocaine use on fetal growth. N Engl J Med (1989) 320 : pp 762-768.
[79]   MacGregor S.N.,  Sciarra J.C.,  Keith L.,  Prevalence of marijuana use during pregnancy. A pilot study. J Reprod Med (1990) 35 : pp 1147-1149.
[80]   United Nations Office on Drugs and Crime—Guatemala country profile. Available at: http://www.unodc.org/mexico/country_profile_guatemala.html. Accessed June 10, 2005.
[81]   Cornelius M.D.,  Goldschmidt L.,  Day N.L.,  Alcohol, tobacco and marijuana use among pregnant teenagers: 6-year follow-up of offspring growth effects. Neurotoxicol Teratol (2002) 24 : pp 703-710.
[82]   Fried P.A.,  James D.S.,  Watkinson B.,  Growth and pubertal milestones during adolescence in offspring prenatally exposed to cigarettes and marihuana. Neurotoxicol Teratol (2001) 23 : pp 431-436.
[83]   Cornelius M.D.,  Taylor P.M.,  Geva D.,  Prenatal tobacco and marijuana use among adolescents: effects on offspring gestational age, growth, and morphology. Pediatrics (1995) 95 : pp 738-743.
[84]   Day N.L.,  Richardson G.A.,  Geva D.,  Alcohol, marijuana, and tobacco: effects of prenatal exposure on offspring growth and morphology at age six. Alcohol Clin Exp Res (1994) 18 : pp 786-794.
[85]   Shiono P.H.,  Klebanoff M.A.,  Nugent R.P.,  The impact of cocaine and marijuana use on low birth weight and preterm birth: a multicenter study. Am J Obstet Gynecol (1995) 172 : pp 19-27.
[86]   Fried P.A.,  Watkinson B.,  Gray R.,  Differential effects on cognitive functioning in 9- to 12-year olds prenatally exposed to cigarettes and marihuana. Neurotoxicol Teratol (1998) 20 : pp 293-306.
[87]   Fried P.A.,  Adolescents prenatally exposed to marijuana: examination of facets of complex behaviors and comparisons with the influence of in utero cigarettes. J Clin Pharmacol (2002) 42 : pp 97S-102S.
[88]   Goldschmidt L.,  Day N.L.,  Richardson G.A.,  Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol (2000) 22 : pp 325-336.
[89]   Richardson G.A.,  Ryan C.,  Willford J.,  Prenatal alcohol and marijuana exposure: effects on neuropsychological outcomes at 10 years. Neurotoxicol Teratol (2002) 24 : pp 309-320.
[90]   Goldschmidt L.,  Richardson G.A.,  Cornelius M.D.,  Prenatal marijuana and alcohol exposure and academic achievement at age 10. Neurotoxicol Teratol (2004) 26 : pp 521-532.

Prenatal Tobacco Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Tobacco smoking during pregnancy is one of the most ubiquitous prenatal exposures. The prevalence of smoking during pregnancy in the United States is estimated by maternal self-report at 11% and is higher in teens (18%) and women with less than 12 years of formal education (27%) [44]. Fortunately, these rates are declining [45]. In Russia, the prevalence was 16% of pregnant women in one study and seems to be increasing [46]. In Kazakhstan, it is estimated that one third of the adult population smokes [47]. In China, the prevalence of tobacco use among pregnant women has been estimated at 2% but is increasing [48], and 60% of nonsmoking pregnant women in Guangzhou had husbands who smoked [49]. The World Health Organization reports that in South Korea, 7% of women smoke tobacco; in Guatemala, 17% of women smoke [47]. True exposure rates are likely to be significantly higher, because parental self-report routinely underestimates actual exposure. Unfortunately, adoptee tobacco exposure status is often unknown.

Prenatal tobacco exposure has consistently been associated with poor fetal growth and is the single most important cause of LBW in developed countries [50]. Even environmental smoke exposure has been implicated in LBW, fetal death, and preterm delivery [51]. Myriad perinatal complications and child health problems are linked to fetal and childhood smoke exposure. Finally, a growing body of evidence is implicating smoking during pregnancy in a range of adverse behavioral and cognitive outcomes.

Mechanism

Cigarette smoke contains tar, nicotine, and carbon monoxide. Tar contains numerous substances (lead, cyanide, cadmium, and more) known to be harmful to the fetus [52]. Nicotine readily crosses the placenta and distributes freely to the CNS, having direct and indirect effects on neural development [38]. Intrauterine hypoxia, mediated by carbon monoxide and reduced uterine blood flow, is a major mechanism of the growth impairment linked to prenatal tobacco exposure.

Pregnancy

Tobacco smoking during pregnancy has been associated with placenta previa, placental abruption, premature rupture of membranes, preterm birth, intrauterine growth restriction, and sudden infant death syndrome (SIDS) [53]. A dose-dependent association with cleft lip anomalies has also been noted [54].

Tobacco's impact on fetal growth is perhaps the most consistent and concerning, given the range of potential impacts on health and developmental outcomes. Maternal smoking has an impact on fetal growth symmetrically in a dose-related fashion [55] and causes an estimated 5% reduction in relative weight for every pack of cigarettes smoked per day [56]. Because pregnant women who smoke deliver babies weighing 150 to 250 g less than babies of nonsmokers, tobacco smoking essentially doubles the chance of having a LBW baby [57]. Unfortunately, maternal smoking is also associated with a smaller head circumference at birth [58].

Child Health

It is difficult to differentiate the impact of prenatal smoking and environmental tobacco smoke on childhood health problems, such as respiratory and ear infections, pulmonary function, asthma, and SIDS. Postnatal smoke exposure increases the incidence of middle ear disease, asthma, wheeze, cough, phlegm production, bronchitis, bronchiolitis, pneumonia, and impaired pulmonary function, and it has also been associated with snoring, adenoidal hypertrophy, tonsillitis, and sore throat [59]. Smoking during pregnancy does cause poor lung growth, affecting pulmonary function in infancy and childhood [60], [61], and seems to confer additional risk to postnatal smoke exposures [62].

With respect to tobacco-associated growth impairment, children generally demonstrate “catch-up” with their weight and height percentiles during their first few years of life, with less catch-up noted in head circumference [63], [64]. In fact, a trend toward obesity is noted [65].

Behavior and Cognition

Dose-effect impacts of prenatal tobacco exposure on behavioral and cognitive outcomes of children have been reported, even after controlling for confounders like socioeconomic status, parental education and mental health, prenatal growth, other prenatal exposures (eg, alcohol), and postnatal disadvantages [66].

Infants born to mothers who smoke tobacco display higher rates of impaired neurobehavior, with reduced habituation, lower arousal, hypertonicity and tremors, sucking difficulties, worse autonomic regulation, and altered cries [67]. Nursery evaluations suggest a withdrawal effect as well [68]. The international adoptee population seems less likely to have these dysregulations repaired by consistent and regulating caregiving while residing in a hospital or orphanage.

There is a consistent association described between prenatal exposure to tobacco and attention deficit hyperactivity disorder (ADHD)–like symptoms [67] and externalizing behavior problems [69], [70]. Antisocial traits like disruptive behavior, conduct disorder, and later delinquency have been linked to prenatal tobacco exposure as well [71]. Although these associations are clear, proving the causal relation is challenging, because not all these studies control for confounders, such as prenatal alcohol exposure.
There is a stronger link between prenatal smoking and behavioral outcomes than that described with impaired cognition. Smoking during pregnancy was associated with decreased IQ scores for children by an average of 4 points [72], however, which was prevented by smoking cessation [73]. Other studies are inconsistent but have suggested persistent deficits in auditory-related tasks like verbal memory, language, and auditory processing [74].

It is unclear if these outcomes can be attenuated by nurturing and regulating home environments and to what extent the effects of tobacco interact with other biologic, prenatal, and postnatal risk factors. For internationally adopted children, the potential interaction of these developmental modifiers seems particularly complex, with tobacco-associated risks (eg, LBW and microcephaly, infant neurobehavior, toddler negativity [75], childhood attention and/or impulse control deficits, antisocial behavior) occurring within a trajectory of caregiving moving from early institutional neglect to later nurturing and stimulating family environments.

Selected References

[44]   National Center for Health Statistics Health. United States, 2004, with chartbook on trends in the health of Americans 2004. Hyattsville, MD: National Center for Health Statistics.  
[45]   Hamilton B.E.,  Martin J.A.,  Sutton P.D.,  Births: preliminary data for 2003. Natl Vital Stat Rep (2004) 53 : pp 1-17.
[46]   Grjibovski A.,  Bygren L.O.,  Svartbo B.,  Housing conditions, perceived stress, smoking, and alcohol: determinants of fetal growth in Northwest Russia. Acta Obstet Gynecol Scand (2004) 83 : pp 1159-1166.
[47]   World Health Organization Tobacco or health. A global status report. Available at: http://www.cdc.gov/tobacco/who/. Accessed June 10, 2005.
[48]   Lam S.K.,  To W.K.,  Duthie S.J.,  The effect of smoking during pregnancy on the incidence of low birth weight among Chinese parturients. Aust NZ J Obstet Gynaecol (1992) 32 : pp 125-128.  
[49]   Loke A.Y.,  Lam T.H.,  Pan S.C.,  Exposure to and actions against passive smoking in non-smoking pregnant women in Guangzhou, China. Acta Obstet Gynecol Scand (2000) 79 : pp 947-952.
[50]   Kramer M.S.,  Intrauterine growth and gestational duration determinants. Pediatrics (1987) 80 : pp 502-511.
[51]   Kharrazi M.,  DeLorenze G.N.,  Kaufman F.L.,  Environmental tobacco smoke and pregnancy outcome. Epidemiology (2004) 15 : pp 660-670.
[52]   Lee M.J.,  Marihuana and tobacco use in pregnancy. Obstet Gynecol Clin North Am (1998) 25 : pp 65-83.
[53]   Andres R.L.,  Day M.C.,  Perinatal complications associated with maternal tobacco use. Semin Neonatol (2000) 5 : pp 231-241.
[54]   Chung K.C.,  Kowalski C.P.,  Kim H.M.,  Maternal cigarette smoking during pregnancy and the risk of having a child with cleft lip/palate. Plast Reconstr Surg (2000) 105 : pp 485-491.
[55]   Macmahon B.,  Alpert M.,  Salber E.J.,  Infant weight and parental smoking habits. Am J Epidemiol (1965) 82 : pp 247-261.
[56]   Kramer M.S.,  Olivier M.,  McLean F.H.,  Determinants of fetal growth and body proportionality. Pediatrics (1990) 86 : pp 18-26.
[57]   Samet J.M.,  The 1990 report of the Surgeon General: the health benefits of smoking cessation. Am Rev Respir Dis (1990) 142 : pp 993-994.
[58]   Kallen K.,  Maternal smoking during pregnancy and infant head circumference at birth. Early Hum Dev (2000) 58 : pp 197-204.
[59]   DiFranza J.R.,  Aligne C.A.,  Weitzman M.,  Prenatal and postnatal environmental tobacco smoke exposure and children's health. Pediatrics (2004) 113 : pp 1007-1015.
[60]   Stick S.M.,  Burton P.R.,  Gurrin L.,  Effects of maternal smoking during pregnancy and a family history of asthma on respiratory function in newborn infants. Lancet (1996) 348 : pp 1060-1064.
[61]   Gilliland F.D.,  Berhane K.,  McConnell R.,  Maternal smoking during pregnancy, environmental tobacco smoke exposure and childhood lung function. Thorax (2000) 55 : pp 271-276.
[62]   Jedrychowski W.,  Flak E.,  Maternal smoking during pregnancy and postnatal exposure to environmental tobacco smoke as predisposition factors to acute respiratory infections. Environ Health Perspect (1997) 105 : pp 302-306.
[63]   Fried P.A.,  Watkinson B.,  Gray R.,  Growth from birth to early adolescence in offspring prenatally exposed to cigarettes and marijuana. Neurotoxicol Teratol (1999) 21 : pp 513-525.
[64]   Vik T.,  Jacobsen G.,  Vatten L.,  Pre- and post-natal growth in children of women who smoked in pregnancy. Early Hum Dev (1996) 45 : pp 245-255.
[65]   Wideroe M.,  Vik T.,  Jacobsen G.,  Does maternal smoking during pregnancy cause childhood overweight?. Paediatr Perinat Epidemiol (2003) 17 : pp 171-179.
[66]   Weitzman M.,  Byrd R.S.,  Aligne C.A.,  The effects of tobacco exposure on children's behavioral and cognitive functioning: implications for clinical and public health policy and future research. Neurotoxicol Teratol (2002) 24 : pp 397-406.
[67]   Olds D.,  Tobacco exposure and impaired development: a review of the evidence. MRDD Research Reviews (1997) 3 : pp 257-269.  
[68]   Law K.L.,  Stroud L.R.,  LaGasse L.L.,  Smoking during pregnancy and newborn neurobehavior. Pediatrics (2003) 111 : pp 1318-1323.
[69]   Williams G.M.,  O'Callaghan M.,  Najman J.M.,  Maternal cigarette smoking and child psychiatric morbidity: a longitudinal study. Pediatrics (1998) 102 : pp e11-.
[70]   Fergusson D.M.,  Horwood L.J.,  Lynskey M.T.,  Maternal smoking before and after pregnancy: effects on behavioral outcomes in middle childhood. Pediatrics (1993) 92 : pp 815-822.
[71]   Wakschlag L.S.,  Pickett K.E.,  Cook E., Jr,  Maternal smoking during pregnancy and severe antisocial behavior in offspring: a review. Am J Public Health (2002) 92 : pp 966-974.
[72]   Olds D.L.,  Henderson C.R., Jr,  Tatelbaum R.,  Intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics (1994) 93 : pp 221-227.
[73]   Olds D.L.,  Henderson C.R., Jr,  Tatelbaum R.,  Prevention of intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics (1994) 93 : pp 228-233.
[74]   Fried P.A.,  O'Connell C.M.,  Watkinson B.,  60- and 72-month follow-up of children prenatally exposed to marijuana, cigarettes, and alcohol: cognitive and language assessment. J Dev Behav Pediatr (1992) 13 : pp 383-391.
[75]   Brook J.S.,  Brook D.W.,  Whiteman M.,  The influence of maternal smoking during pregnancy on the toddler's negativity. Arch Pediatr Adolesc Med (2000) 154 : pp 381-385.

Prenatal Opiate Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

In the United States, 2.3% of pregnancies in the Maternal Lifestyle Study involved heroin or methadone exposure [34]. In international adoption, the most commonly reported prenatal opiate exposure is heroin. Heroin use has made a resurgence in recent years, particularly in Eastern Europe and the former Soviet Union. The United Nations Office for Drug Control and Crime Prevention reported that the number of known heroin addicts rose by 30% in Russia in 1999 and had quadrupled since 1995, with a current prevalence of heroin abuse at 2.1% [11], [35]. In Kazakhstan, the prevalence of heroin abuse is estimated at 1.3% [35]. Opiate use is also prevalent in the countries of Southeast Asia and parts of China, particularly near areas where opium is grown and in more urban areas. Although there are no official reports from China, unofficial estimates say that there could be up to 12 million total heroin users [36]. Pregnant women who enter drug treatment programs for addiction receive another opiate, methadone, as a substitute for heroin or opium. Because drug treatment programs are on the rise in Russia and China, prenatal exposure to methadone may also occur [36], [37].

Mechanism

Despite the detrimental effects of opiates on the user, including the risk of addiction and exposure to the hazards of intravenous drug use (hepatitis B and C and HIV), opiate exposure to the developing fetus is not considered teratogenic. There is no known congenital malformation associated with prenatal opiate exposure. There have been harmful fetal effects described with heroin and methadone use, however, and infants born to addicted women can suffer withdrawal in the newborn period. Any child referred for international adoption with a maternal history of intravenous drug use should be considered at increased risk for HIV and hepatitis B and C.

Pregnancy

LBW and symmetric intrauterine grown retardation have been reported in the offspring of heroin abusers [38]. Pregnant heroin addicts also have a statistically significant increased risk of preterm delivery. Methadone use seems to have less effect on fetal growth and has not been shown to increase the risk of premature birth. For children born after a pregnancy complicated by opiate use, prenatal growth may be affected by maternal malnutrition and comorbid infections as well as by opiate exposure.

Neonatal Abstinence Syndrome

Neonatal abstinence syndrome (NAS) has been well described in infants born to opiate-dependent mothers. The symptoms of NAS include CNS symptoms (eg, hyperirritability, tremors, convulsions), gastrointestinal distress, respiratory distress, and autonomic disturbances [39]. It has been reported that the infants of methadone-addicted mothers experience more severe symptoms for a longer time, partly because of the longer half-life of this opiate. Treatment of symptomatic infants generally consists of providing children with a tapering schedule of tincture of opium, morphine, or phenobarbital while monitoring clinical symptoms. During the withdrawal period, infants may dramatically influence normal caretaker interactions because they are often resistant to cuddling or soothing and have a decreased ability to respond normally to auditory or visual stimuli. The long-term impact of these early alterations in socialization may be detrimental, particularly in an orphanage setting, where nurturing caretaking may already be less frequent.

The onset of withdrawal symptoms is usually between 48 and 72 hours after birth. It is highly unlikely that a child born overseas is going to be available for adoption at this point; thus, most families adopting internationally do not directly encounter NAS. Clues to NAS may be present in the preadoption record, however, and should alert families and professionals to the possibility of prenatal opiate exposure and other risks associated with injection drug use in birth mothers (HIV and hepatitis B and C).

Behavior and Cognition

In some early studies, concerns about prenatal opiate exposure and poor developmental outcome were described. Reported neurodevelopmental problems included a short attention span, hyperactivity, and sleep disturbances in prenatally exposed children assessed at the age of 12 to 34 months [40]. More recent studies also suggest mild memory and perceptual difficulties in older children, but overall test scores are still within the normal range [41]. In general, it is difficult to differentiate the impact of a poor postnatal environment and prenatal heroin exposure on children's long-term outcome. One study suggests that opiate-exposed children have increased susceptibility to adverse environmental influences compared with nonexposed children [42]. Conversely, a study from Canada suggests that drug-exposed infants adopted out at birth were equivalent to Canadian matched controls in terms of educational achievement and IQ. The adopted children did, however, have increased rates of early adult depression [43].

Selected References

[34]   Lester B.M.,  El Sohly M.,  Wright L.L.,  The Maternal Lifestyle Study: drug use by meconium toxicology and maternal self-report. Pediatrics (2001) 107 : pp 309-317.  
[35]   UNODC Research and Analysis Section United Nations Office on Drugs and Crime—World Drug Report 2004. Available at: http://www.unodc.org/unodc/world_drug_report.html. Accessed June 10, 2005.
[36]   Kulsudjarit K.,  Drug problem in southeast and southwest Asia. Ann NY Acad Sci (2004) 1025 : pp 446-457.  
[37]   Somlai A.M.,  Kelly J.A.,  Benotsch E.,  Characteristics and predictors of HIV risk behaviors among injection-drug-using men and women in St. Petersburg, Russia. AIDS Educ Prev (2002) 14 : pp 295-305.  
[38]   Chiriboga C.A.,  Fetal alcohol and drug effects. Neurologist (2003) 9 : pp 267-279.  
[39]   Finnegan L.P.,  Effects of maternal opiate abuse on the newborn. Fed Proc (1985) 44 : pp 2314-2317.  
[40]   Rosen T.S.,  Johnson H.L.,  Long-term effects of prenatal methadone maintenance. NIDA Res Monogr (1985) 59 : pp 73-83.  
[41]   Lifschitz M.H.,  Wilson G.S.,  Patterns of growth and development in narcotic-exposed children. NIDA Res Monogr (1991) 114 : pp 323-339.  
[42]   Marcus J.,  Hans S.L.,  Jeremy R.J.,  A longitudinal study of offspring born to methadone-maintained women. III. Effects of multiple risk factors on development at 4, 8, and 12 months. Am J Drug Alcohol Abuse (1984) 10 : pp 195-207.  
[43]   Lipman E.L.,  Offord D.R.,  Boyle M.H.,  Follow-up of psychiatric and educational morbidity among adopted children. J Am Acad Child Adolesc Psychiatry (1993) 32 : pp 1007-1012.  

Glossary of Russian Medical Terms

Original list of terms by Jerri Jenista, MD; some drug definitions from Karen Hauff, Pharm.D; updates and intro by Julian Davies, MD

Big thanks to the original authors for their gracious permission to adapt and publish this list, for the pioneering work of Dr Jenista and the staff of the International Adoption Center, and the counsel of our colleagues in Russia and on the Adoptmed listserv of adoption medical professionals.

It should be noted that we are not Russian doctors, nor were we trained in the mysterious art of Russian neurology, so take this for what it is: a glossary of medical terms found in Russian (and Ukrainian, and Kazakh, and other former Soviet Union) medical charts based on the interpretations we've collected over the years. Other definitions for many of these terms exist, they are not always used consistently (or translated accurately), and the degree of concern over these diagnoses will vary based on other factors in a child's history.

We would urge you to discuss the specifics of a particular referral with an international adoption specialist who can incorporate these medical terms into the context of a child's growth, development, physical features, and signs of more familiar Western medical conditions.

Why so many neurologic diagnoses in Eastern European referrals? Some possible reasons:

• Russian medicine tends to list issues that we might consider "risk factors" or "things to watch for" as diagnoses (thus, lack of prenatal care can become "risk for intrauterine infection")

• many diagnoses are provided by specialists and hospitalists, notoriously the neurologists, many of whom seem to have "favorite diagnoses", and incentives to overdiagnose in general

• a persistent Soviet-era pessimism about the birth process; even with a (to us) healthy delivery they are quite worried about interruptions of blood and oxygen to the baby's brain, kinking of the spinal cord, and so on ... their descriptions of the birth process (and occasional interpretations of newborn spinal xrays) can leave one marvelling that babies are born with their heads still attached

• a tendency to interpret what to us are normal, immature newborn behaviors (startle reflex, trembling chin, mottled skin, belching, etc) as signs of neurologic damage

• and a subsequent tendency to ascribe what we might call normal infant maturation to recovery from neurologic illness, thanks to massage, medications, supplements, and other typical treatments

• when it comes to orphanage-raised children (who, admittedly, do come from higher-risk backgrounds), there may be a bit of cultural pessimism about outcomes

Or, on the 'flip' side:

• "Sometimes they diagnose just to show they care ..."

• "It's all just a big jobs program for Russian neurologists."
  

• "This diagnosis, in Western terminology, means that the child was born in Russia."

• "It's the 'shotgun' approach to diagnosis - if you label all the children with neurologic impairments, you can rest easy that you haven't missed any of the actual diagnoses."
  

An article just published in Lancet sheds some light on the practice of pediatrics in Russia, Kazakhstan, and Moldova in a systematic review of hospitals. Essentially, the pediatricians are found to be dedicated and proud of their work, but hampered by antiquated, unproven protocols that over-diagnose, over-test, and over-medicate young children, not to mention the outdated or missing diagnostic equipment and treatment supplies. Kids languish in hospitals far too long for minor illnesses, and in the case of orphans, typically receive very little stimulation (we've found that children often do worse in hospitals than orphanages). Children are routinely prescribed "large numbers of ineffective or dubiously effective treatments" (avg of 5 at a time in Kazakhstan) for vague indications, without adequate monitoring of potentially dangerous side effects.

Medical anthropology aside, orphanage doctors naturally have a good deal of experience with orphanage-raised children, and it can be very helpful to seek their opinion on how a child is doing. Sometimes they are stuck with diagnoses from other medical settings (see above) that they are not as concerned about, or can provide useful information on trends over time.

A brief note on cerebral palsy: It's remarkable how much time we spending talking and thinking about and trying to rule out CP in Russian referrals ... when in fact we haven't had more than a few Russian (and Kazakh and Ukrainian) children that arrived here in the past few years that turned out to have significant CP.

Not that we're going to stop asking followup questions about muscle tone trends, and rate of development, and if there are current concrete neurologic concerns, or flat-out "does this child have CP?" ... but I think it probably deserves much less anxiety than it gets. The Russian docs seem to do a good job recognizing cerebral palsy, or we do, or it's just not that common, compared to orphanage-related delays, transient dystonia (periods of higher or lower muscle tone in infancy that resolve), low tone and strength from lack of stimulation or mild rickets, and other issues that get better with time, stimulation, and nutrition.

Not that we don't see kids with neurologic and developmental issues ... but we see a lot more language delay, poor motor planning, sensory issues, fetal alcohol spectrum concerns, insecure attachments, learning problems, ADHD, etc than we do cerebral palsy. And CP can certainly be a milder disability than some of the above.

On that note, without further ado ... here it is, the evolving glossary of Eastern European medical terms and treatments:

Abnormal chordae (trabeculae): Extra muscle tissue in the wall of the heart, usually the left ventricle (lower chamber). Typically found by routine echocardiogram of the heart. This is an "incidental finding" - it does not cause symptoms or disease.

Abominum: Antispasmodic used in the treatment of gastritis and colitis.

Abstinence syndrome: Newborn withdrawal syndrome (or NAS), usually from narcotics.

Actovegin: Calf's blood extract used by Russian doctors and Tour de France cyclists to improve oxygen-carrying capacity.

Adiposogenital syndrome: Freohlich's syndrome, i.e., truncal obesity with hypogonadism and short stature in boys. Sometimes used (incorrectly) to describe obese boys with delayed sexual maturation.

Alcoholic fetopathy: Fetal alcohol syndrome.

Alienist: Psychiatrist.

Alimentary subnanism: Short stature due to malnutrition, illness or other medical problems past the first year of life. Also called hypostatura in younger children.

Alpha tirroxinum: Thyrotropinum, thyrotropin or TSH.

Aminalon (gamma aminobutyric acid): An antihypertensive medication to decrease pressure in the brain.

Ampiox: Antibiotic combination of ampicillin and oxacillin.

Anamnesis: Medical history.

Ankyloglossia: Tongue-tied.

ARVI: Acute respiratory viral illness (a "cold").

Asparkam: Potassium-magnesium combination used for cardiac arrhythmia.

ATP: Adenosine triphosphate, a coenzyme to improve muscle contraction.

Australia antigen: Also written as HbsAg. Hepatitis B surface antigen, marker for current infection.

Baclofen (Baclon): Drug used to treat spasticity such as that seen with cerebral palsy or spinal cord trauma.

Baktysutil (?): see Orobicin

Bendazol (dibasol or tiabendazole): A vasodilator.

Bilary dyskinesia: Functional problem with the motility of the biliary tract, often (over)diagnosed from ultrasound examinations. 

BL: Test for the causative bacterium of diphtheria.

Brulamycin (tobramycin): Aminoglycoside antibiotic.

Calcium orotate (calcium salt of orotic acid): Used in the treatment of hyperuricemia and hypercholesterolemia; also used to treat liver disorders.

Cardiopathy: Any functional condition of the heart, e.g., rapid or slow or irregular heartbeat, heart murmur, poor heart function. Often transient and nonspecific.

Catarrhal otitis: Middle ear inflammation (redness only) without pus, accompanied by an upper respiratory tract infection. The condition American pediatricians call otitis media (redness of the ear drum with pus) is called "purulent otitis."

Cavinton (vinpocetine): Used to treat cerebrovascular and cognitive disorders.

Cefamezin (cefazolin): First-generation cephalosporin antibiotic.

Cefamid (cephradine): Semisynthetic cephalosporin antibiotic.

Cerebro-asthenic syndrome: Same as neurasthenic syndrome.

Cerebrolysin: Porcine brain extract used to treat nervous system disorders.

Cinnarizine (Sturgeron, Midronal): An antihistamine drug used to control vomiting by decreasing pressure in the brain, also to selectively dilate brain blood vessels.

Citral solution, citric acid solution: Used to relieve flatulence and pain; ingredient found in herbal remedies used for a variety of disorders.

COE: ESR - erythrocyte sedimentation rate (a marker for inflammation of infection).

Colpitis: Inflammation of the cervix or vagina.

Corvalol: Phenobarbital-containing OTC medication.

Complamin (xanthinol nicotinate): Used to treat hypercholesterolemia, peripheral arterial disorders; cerebral circulatory and metabolic disorders; retinal vascular disorders; Ménière’s disease and hearing disorders.

Coprogram: Stool examination.

D=S: Dexter=Sinister, that is, the right equals the left. Usually referring to muscle tone or reflexes in the extremities.

Diamox (diacarb, fonurit, acetazolamide): Diuretic drug (carbonic anhydrase inhibitor) used to decrease pressure in the brain, sometimes to help control seizures.

Diaphanosopy: Examination of any body part by transillumination (shining a light through or against it).

Dibasol (bendazol): Vasodilating drug.

Dropsy of the testicles: One of my favorite "lost in translation" diagnoses. It means hydrocele, which is a benign fluid collection in the scrotum that resolves with time.

Dysbacteriosis: Loose or diarrheal stool following lack of breast-feeding, illness or a course of antibiotics. Due to changes in the normal bacterial flora of the intestine. Treated first with an antibiotic to decontaminate the gastrointestinal tract and then with "ferments and enzymes," similar to our treatment with lactase (milk sugar enzyme) or probiotics (live cultures found in yogurt).

Dysmetabolic nephropathy: Secondary impairment of kidney function following a insult such as malnutrition. There is no structural damage to the kidney. Most cases are reversible once the underlying disease is taken care of.

Electrophoresis: Method of giving medication. Substance is applied to the skin, usually over the affected part, and then a mild electric current is run through is.

Encephabol (pyritinol): Used to treat rheumatoid arthritis, cerebral insufficiency, organic brain disorders, migraine and trigeminal neuralgia.

Epicrisis: The word means "time period." It is used in two different ways.

*When a patient is admitted to the hospital. Written summaries of the condition and progress are made at admission, at about 10 days and at discharge. These are referred to as epicrisis.

*Developmental progress is codified by the skills which are typically achieved in a certain time period or epicrisis. In the first year of life there are well child check-ups at 1, 2, 3, 6, 9 and 12 months of age. Each visit encompasses an epicrisis from the previous point. As the child gets older, the epicrisis periods are longer usually 6-month intervals. Thus a 9 month old who is "delayed 1 epicrisis" has the expected development of a 6 month old.

Euphyllin (aminophylline): Bronchodilator, for wheezing or asthma.

Exudative diathesis: Skin rash usually attributed to feeding problem, especially food allergy, or a drug reaction. The skin is usually red and dry; the child may scratch until it oozes or bleeds. If the rash persists for months or is very severe, it may be considered eczema.

Ferrimed (vitamin B substances, iron polymaltose, folic acid): Used in the treatment of iron-deficiency anemia.

Furagin (furazidin): An anti-infective agent.

Furanthril or Furantral (furosemide): Loop diuretic.

Gestosis: Morning sickness. Sometimes the term is used (incorrectly) to refer to toxemia or pre-eclampsia manifest in the mother during pregnancy by protein in the urine, edema (swelling), high blood pressure and, rarely, other neurologic problems.

Glutamic acid: A dietary supplement.

Grefe symptom: "Sundowning" of the eyes (sclera is visible above the iris when the eye is open but relaxed) sometimes indicating hydrocephalus.

Growth: Classified by percentile as on North American growth charts. Average or normal growth is considered to be between the 25th and 75th percentiles for age and sex. Growth patterns:

Harmonic: Height, weight and chest circumference are all at or near the same percentile.
Dismarmonic: One of height, weight or chest circumference is markedly different in percentile from the other parameters.
Mesosomatic: Height, weight and chest circumference are all average.
Microsomatic: Height, weight and chest circumference are all low.
Macrosomatic: Height, weight and chest circumference are all high.

Gypotrophy: Same as hypotrophy.

Health group : Classification of children's health condition. Groups I-III are considered basically healthy children, although treatment may be necessary. Sometimes an A or B is appended; certain diseases belong to these A or B subgroups. These health groups are pretty vague and inconsistent, in our experience.

Group I: Absolutely healthy (unusual to see on orphans records or any records, for that matter)
Group II: Minor problems such as enlarged tonsils or a mild chronic condition such as gastritis with no symptoms.
Group III: A chronic condition with frequent exacerbation, for example, asthma under poor control.
Group IV: Severe health condition with some degree of disability.
Group V: Physical handicap such as a missing extremity

Hyalase, Wydase (hyaluronidase): Adjuvant to increase the absorption and dispersion of other injected drugs or for hypodermoclysis.

Hyperexcitability (neuroexcitablity, neuro-reflex irritability) syndrome: Similar to muscular dystonia but diagnosed within the first 3 months of life. Noted when the infant has marked reactions to stimuli (such as being moved or disturbed), especially if tremor, increased newborn reflexes, trembling chin or frequent belching is present. It may result in "movement disorder" at an older age.

Hypermetropia: Far-sighted.

Hypertension syndrome: Same as hypertension-hydrocephalic syndrome.

Hypertension-hydrocephalic syndrome: Clinical diagnosis based on one or more criteria alone or in combination:

• Seizures

• Increased muscle tone

• Brisk reflexes

• Firm or tense fontanel (soft spot)

• Pulsation of the fontanel Tremor

• Jitteriness

• Large head circumference

• Dilated blood vessels over the scalp

• Prominent or bulging eyes

• "Sundowning" of the eyes

• Bluish discoloration over the bridge of the nose.

May be "confirmed" by ultrasound of the brain looking for dilation of the ventricles (fluid-filled spaces in the brain) or changes in the blood flow pattern. Considered in most children to be a transient condition secondary to the birth process. Treated with certain vitamins, diuretics, and/or other drugs to improve blood flow to the brain. Surgical shunting is very rare. It is not equivalent to the Western term "obstructive hydrocephalus".

The condition is considered to be "subcompensated" when the child still has some minor signs or symptoms but is doing okay. It is "compensated" when there are no clinical signs except perhaps for a head slightly out of proportion with the rest of the body: at this point, the child expected to be normal.

Hypometropia: Myopia, near-sighted.

Hypostatura: Short stature due to malnutrition, illness or other medical problems. Past the first year of life, it is called alimentary subnanism.

Hypothyrosis: Hypothyroidism, treated with oral thyroid replacement. Screening for hypothyroidism is usually carried out at the first well-child check-up at one month of age.

Hypoplasia: Short stature with no other problems, usually genetic or "constitutional". Also used to refer to under-development of any organ such as a limb, the testis, an eye, etc.

Hypotrophy: Weight lower than expected for age. May be further described as mesosomatic or microsomatic, harmonious or disharmonious, depending on changes from previous growth and the relationship to the height and chest circumference.

Hypoxia of the newborn: Lack of oxygen at or before delivery, usually diagnosed if it was a difficult pregnancy, labor or delivery, if the baby needed a lot of resuscitation at birth or if specific abnormalities are noted in the placenta (afterbirth). When severe oxygen deprivation was felt to occur, the word "asphyxia" is used, although this seems to have a loose definition over there. "Prenatal hypoxia"" is a vague term, sometimes used with the wording "non-specific intrauterine infection" to explain away low weight or asymmetric reflexes or tone in a full-term baby.

Hypoxic (metabolic) cardiopathy: A clinical diagnosis, sometimes confirmed by "metabolic changes in the EKG." This refers to any number of mild changes in circulation such as perioral cyanosis (blueness around the lips and nose), irregular heartbeat, mottled skin, anemia or rickets. This is a transient condition, which resolves when the underlying condition is treated. Term may be also used for more serious conditions such as myocarditis.

Increased seizure readiness syndrome: When a child has an evaluation for suspected seizures or some other problem, an EEG of the brain may be done. The term is used to describe the finding of an abnormal focus on the EEG or when a child has increased muscle tone not related to cerebral palsy. Usually no treatment is given.

Intrauterine pneumonia:  Applied broadly when a newborn has respiratory distress or "rule-out sepsis" (signs of infection).

Ischemia of the newborn: Usually referring to lack of blood flow to the brain, used in the same way or as a synonym to "hypoxia of the newborn."

Lambliosis (lambliasis): Giardia infection.

Lidaza: A very popular enzyme drug, bovine hialuronidase extracted from testicles. Given by injection or electrophoresis to decrease scarring form chronic inflammation, for example, after abdominal surgery.

Limonal: Light magnesium carbonate used to treat constipation.

Little's disease: Cerebral palsy.

Logopedist: Speech therapist.

Lues, Luis: Syphilis.

Luminal (phenobarbital): An anticonvulsant, unfortunately used in many children who do not have epilepsy.

Midronal: Same as cinnarizine.

Minimal brain dysfunction: Used variably to describe transient neurology signs such as hyperactivity or short attention span, or as a followup diagnosis to "perinatal encephalopathy".

Mixed genesis: A health condition with more than one contributing or underlying causes.

Movement (motor) disorder: This is one result of delayed motor skills. For example, a 10 month old who cannot crawl has a movement disorder. This is not considered a serious diagnosis in contrast to more pronounced forms, like spastic tetraparesis. It is sometimes used when a child is not "perfect" but no other diagnosis can be made.

Mucoviscidosis: Cystic fibrosis.

Muscular dystonia: Muscle tone is considered to be dependent on the emotional condition of the baby. A normal child should be calm with appropriate relaxed tone. Muscular dystonia is present when the tone is very high (jittery or irritable) or is labile (changes rapidly). This is not a permanent condition but changes over brief time periods (an hour) as the baby's state changes (from sleepy to alert, etc.)

Myodocalm (tolperisone or mydeton): Centrally acting muscle relaxant.

Myotonic syndrome: Vague terminology used to describe changes in muscle tone, especially low tone (hypotonia).

Narcomania: Drug addiction.

Natal trauma of the spinal cord: Diagnosis made at the time of delivery based on the process of the delivery itself and the state of the newborn. Risk of this condition is considered to be present if the delivery was difficult, i.e. the baby had to be rotated, the head turned, etc. or if the baby has certain signs such as abnormal tone, tremor, irritability, mottled discoloration of the skin, pallor or sweating. This is a functional condition; that is, it will resolve with treatment (massage, application of mild electrical current to the skin over the affected part, etc.) Even when the condition has resolved, the diagnosis is often kept until the age of 1 year. It is frequently used as a contraindication to giving immunizations, with the thought that vaccinations may exhaust the immune system and prevent complete resolution of the spinal trauma. May be accompanied by xray "findings" of "subluxation of C1-C3 vertebrae." Scarier-sounding than it typically turns out.

Nephropathy: Generalized term used to describe any past or present abnormality in kidney function, usually used for conditions thought to be transient.

Neurasthenic syndrome: Condition when a child gets tired very easily or irritated for little or no reason. Manifests in many ways, e.g., irregular or fast heart beat, poor sleeping habits, becoming very red or very pale with vegetative functions (feeding, burping, passing stool) in infants.

Nicospan (nicotinic acid): B-complex vitamin.

Nootropyl (nootrops, piracetam): Drugs used to treat strokes, vertigo, learning disability and other brain disorders. Occasionally used in Down's Syndrome and sometimes in difficult births.

Obstructive bronchitis: A viral respiratory infection with wheezing. This can be wheezing from the inflammation and airway mucous of viral bronchiolitis, or a wheezing tendency that may evolve into asthma. Roughly speakly, 1/3 of infants and toddlers who wheeze for the 1st time won't wheeze again, 1/3 will have wheezing with colds and such but outgrow it by school-age, and 1/3 will continue to have asthma symptoms into later childhood and beyond.

Oligophrenia: Functional mental impairment, meaning the person is not operating at the expected level, usually not diagnosed until older than 4 years. Vague and frustrating "diagnosis" for us, that may be caused by any number of inheritable or environmental influences such as genetic syndromes, learning disabilities or mental retardation of unknown cause, fetal alcohol spectrum issues, head trauma, infection, orphanage care, social chaos, poor schooling, and other adverse experiences, etc ...

Could refer to an adult that would be cognitively "normal" if tested but has had a hard-knock life and is seeking disability pension, or an orphan unfairly labeled as "debil" by a cursory examination at 3-4yo, or a person with mild mental delay, or severe mental retardation. Not unusual to hear that a birth parent has this label, very hard to know whether this is an inheritable condition in any given case. It does not refer to schizophrenia, although it is useful to ask about mental health concerns. Nor does it refer to a rock opera by the Who.

Onanism: Masturbation.

Open oval window: Patent foramen ovale, the normal embryological connection between the two upper chambers (atria) of the heart, typically detected on routine newborn heart ultrasound. Is not considered a heart defect, and usually closes on its own. Not the same as an atrial septal defect (ASD).

Panagin (aspartic acid): A dietary supplement.

Panangin: Hungarian-made equivalent of Asparkam.

Pancreatin: Pancreatic enzymes with protease, amylase and lipase activity used to treat pancreatic insufficiency associated with CF and pancreatitis.

Pantogen (calcium pantothenate): A component of coenzyme A which is essential for the metabolism of carbohydrate, fat and protein; B complex vitamin.

Pantogar (calcium pantothenate; thiamin nitrate; medicinal yeast; cystine; keratin; aminobenzoic acid): Used to treat disorders of the hair and nails.

Pantotene: Vitamin B5.

Papaverine: Synthetic analog of an antispasmodic substance found in the opium poppy. Used to relax involuntary muscles (blood vessels, intestine, etc.)

Pentagin: Pentazocine, narcotic analgesic.

Perinatal (prenatal) encephalopathy : Variably translated as "perinatal lesion or affectation of the central nervous system," "encephalopathia," and many others. One or more risk factors present in the history of the mother or the baby, which may allow, or not, for a poor neurological outcome (see table that follows). Some variation of this on >90% of Russian referrals, thus has very little, if any, predictive value for any particular child. Best to look for more concrete information in the referral.

Maternal Factors
Lack of known medical history
Drug, alcohol or cigarette use
No prenatal care
Anemia
Past miscarriages, abortions or premature deliveries
Young or old maternal age
High number pregnancy
Chronic health problems
Infections
Poor social situation
Difficult or complicated delivery
Abnormal placenta
And many others

Infant Factors
Low Apgar scores
Abnormal muscle tone or reflexes
Jaundice
Seizures
Irritability or depression
Tremor
Poor suck, feeding problems
Abnormal ultrasound of brain or other parts of body
Intrauterine or perinatal infections
Prematurity
Abnormal prenatal growth
Abnormal laboratory tests
And many others

Perinatal trauma (affectation) of the CNS (central nervous system): Synonym for perinatal encephalopathy. Also called perinatal lesion, cranio-cerebral trauma of the newborn and other variations.

Phthisiologist: Specialist in the management of tuberculosis.

Piloecstacy of the kidneys: Dilatation of the collecting system just next to the kidneys, considered to be "pre-hydronephrosis."

Piracetam: see Nootropyl

Positive dynamics: Continuous improvement or in the recovery phase in any condition, but especially in growth and development. A child with positive dynamics is expected to be normal.

Prematurity: Determined by maternal history, birth weight, and/or a scoring system such as the Dubowitz (same as used in North America). Described as stage or degree (terms not used in US), see table below.

Stage or Degree

Gestational Age

Weight

1

36-37 weeks

2001-2500 grams

2

32-35 weeks

1501-2000 grams

3

28-31 weeks

1000-1500 grams

4

<28 weeks

<1000 grams

Psycho-affective respiratory attack: Breath-holding spells.

Pyramidal insufficiency: Infant considered to be at risk of cerebral palsy because of adverse perinatal history (e.g., extreme prematurity or low birth weight) and/or because of abnormal physical examination (e.g., increased tone or reflexes, asymmetry of reflexes, delayed development). Usually cannot be confirmed as cerebral palsy until after 12 months of age as most children will improve before then. Usually is apparent by 6 months of age and, if it is going to resolve, disappears by 1 year. This is a commonly encountered diagnosis.

Pyridoxine (pyridoxal phosphate): Vitamin B6, often used with other B vitamins to treat brain disorders.

Rachitis: Rickets, bone disease due to lack of vitamin D (see table below).

Stage or Degree

Time to develop

Clinical signs

1

Weeks

Minimal or nothing at all.

2

2-3 months

Delayed development due to bone pain and weakness.

3

Many months

Marked developmental delay, bone deformation (bowed legs), abnormal skull shape or size (boxy forehead), poor muscle tone and strength.

Relanium (diazepam): Long-acting benzodiazepine used as a sedative, anxiolytic and anticonvulsant.

Retrobolin (nandrolone): Anabolic agent.

RIF: "Immuno-fermentation reaction" - a test for syphilis.

RIT (or RIBT): "Immobilization Treponema Pallidum Reaction" - another syphilis test.

Rudotel (medazepam): Long-acting benzodiazepine with uses similar to diazepam, such as anxiolytic, sedative, anticonvulsant, etc.

Sana-Sol: Multivitamin and mineral supplement.

Seduxen (diazepam): Long-acting benzodiazepine used as a sedative, anxiolytic and anticonvulsant.

Sexual crisis: Bloody discharge from the vagina of the newborn or breast swelling, with or without milk discharge. Normal finding, noted in the first two weeks of life, due to withdrawal of maternal hormones.

Sonne Dysentery: Lower intestinal infection with Shigella bacteria, causing loose/watery to bloody/mucoid stools, occasional neurologic symptoms like seizures and lethargy, treated with antibiotics and fluids.

Spastic tetraparesis: This is a potentially more serious form of movement disorder in children less than 12 months of age, graded from mild to severe, involving all 4 limbs. In the worst case, the child barely moves at all. If treatment (massage and physical therapy) is started early, this is usually easily correctable but some children have persistent neurological findings. When we see this diagnosis, we make sure to ask about trends of muscle tone and development over time, and if the child is felt to be showing signs of cerebral palsy.

Specialized Schools: Courtesy of Dr Gordina, here's a list of Russian specialized ("correctional") schools:

• Type 2 - For children with hearing problems

• Type 3 - For children with significant vision problems (legally blind)

• Type 4 - For children with poor vision

• Type 5 - For children with significant speech/language delays

• Type 6 - For children with motor and orthopedic problems (mostly CP)

• Type 7 - For developmentally delayed children

• Type 8 - For children with intellectual disabilities (mental retardation)
  

Squint: Crossed eye.

Stage of condition: The progression of a disease:

Recuperation or rehabilitation - Improving but still requiring treatment.
Subcompensated - Abnormal, clinically unstable may deteriorate.
Compensated - Abnormal but stable.
Recovery - Condition or illness completely resolved.

Stigma: Any one or more minor congenital abnormalities such as low set or posteriorly rotated ears, high arched palate, epicanthal folds, broad thumb, etc... When no particular syndrome is identified, North American physicians sometimes refer to such as child as a "funny looking kid," or to use a more technical term, "mildly dysmorphic". A child with 3 or more minor congenital anomalies is at increased risk for a broader syndrome.

Stomatologist: Dentist.

Sugeron: Same as cinnarizine.

Sumamed: Azthromycin (Zithromax), a macrolide antibiotic.

Thymomegaly: Enlarged thymus, "diagnosed" from the normal thymic shabow on infant xrays, and of no clinical significance.

Toxicosis: The same as gestosis when used for pregnant woman. Also used in any severe acute disease, usually an infection, to describe a very ill looking patient (same as North American description "toxic-appearing.")

Trental (pentoxifylline): Used in the treatment of intermittent claudication associated with peripheral vascular disease.

Triampur: Combination diuretic containing triamterene and hydrochlorthiazide.

Umbilical hernia: We use the same term ... for some reason seems more common over there. Benign protrusion of the bellybutton caused by lax umbilical fibrous ring. Can look impressive, but is common, painless, easily reducible, and the majority resolve without intervention in a few years. Large, "elephant trunk" hernias are less likely to close on their own, but it's an easy day-surgery to fix. Does not need taping or any other "treatments".

Valerian: Dried rhizome and roots of valeriana officinalis, which is used as a sedative.

Vegeto-vascular syndrome: Symptoms thought to be associated with blood flow to internal organs, for example, frequent headaches or migraines in an older child or mottled skin in the infant.

Verospiron (spironolactone): Diuretic, aldosterone antagonist.

Vertizine (meclozine): Used in the prevention and treatment of nausea, vomiting and vertigo associated with motion sickness.

Vicasol: Synthetic vitamin K.

Viferon: Anti-viral, immunomodulating medication containing interferon and vitamins.

Wassermann test: Also written as RW. Screening test for syphilis.

Wydase: see Hyalase

Growth Charts

It's hard to be "ethnically correct" when assessing growth in international adoption. Many of the available country-specific growth charts are out-of-date, from a small sample size, drawn from ethnic groups that may not represent your child's ethnicity, based on malnourished populations, or all of the above. US growth charts aren't perfect either, but they are drawn from large population surveys, and were recently revised to better reflect the racial-ethnic diversity and combination of breast- and formula-feeding in the US.

In 2006, the WHO (World Health Organization) released new international birth-5yo charts based on 8,500 children from Brazil, Ghana, India, Norway, Oman and the USA. Their unique approach was to select children whose care meets recommended health promotion standards (breastfeeding, standard pediatric care, anti-smoking, etc) so that the charts would represent how children should grow, not necessarily how they are growing. Their big finding was that "child populations grow similarly across the world’s major regions when their needs for health and care are met."

However, most international adoptees are bottle-fed and often do not receive ideal or even adequate care. Our default charts are still the revised CDC/NCHS (US) growth charts published in 2000, if only because we by now have years of experience following ethnically diverse children pre- and post-adoption on these charts. Still, it can be interesting to plot children on country-specific growth charts, so here's a smörgåsbord of US, premature, and country growth charts.

For more information, see our articles on Evaluating Growth in Adoptees and Head Circumference Issues ... 

US Growth Charts

• START HERE - CDC growth charts for boys and girls, birth to 20 years

• Nellhaus male and female head circumference charts for children over 3 years old (I don't love these charts, as the pooled data is from 1948-1965, and is not as "interracial" as advertised, but we don't have many other options for older children).

• These 2010 United States head circumference growth reference charts: birth to 21 years, by Rollins et al., look better than Nellhaus for plotting head size in kids older than 2-3yo.

WHO Growth Charts

• Weight-for-age, 0-5yo

• Height-for-age, 0-5yo

• Head circumference-for-age, 0-5yo

Charts for Premature Infants

• 26wks to 1year chart, for boys and girls

• Fetal-infant growth chart for 22wk-2mo preterm infants from a meta-analysis of published reference studies

• Charts based on birthweight categories (for when gestational age is unclear). LBW (low birthweight) is for birthweights from 1500g to 2500g. VLBW (very low birthweight) is 1000g to 1500g at birth.

• LBW Premature Girls

  1. LBW Premature Boys

  2. VLBW Premature Girls

  3. VLBW Premature Boys

Chinese Growth Charts

The widely available China growth charts are from a sample of Southern Chinese children in Hong Kong in the 1960s, and thus quite out of date and not necessarily ethnically appropriate. These can be found on the Families with Children from China (FCC) site.

Also available online are Hong Kong boy and girl growth charts, which do include weight, height, and head circumference. More information about these charts is here.

Another useful reference could be "Infant feeding and growth of Chinese infants: birth to 2 years", which tracked growth in healthy, fullterm, formula-fed infants in 1985 Hong Kong and found that at 2 years old, infants were -0.6 standard deviations (SDs) lighter and -0.4 SDs shorter than US growth data, even with similar protein/calorie intake to Caucasian infants.

An article called "Updated gestational age specific birth weight, crown-heel length, and head circumference of Chinese newborns" based on preterm and term births in Hong Kong has weight, height, and head circumference charts.

Guatemalan Head Circumference Charts from Dr. Montiel

Note - these are unofficial charts based on his personal experience

• Guatemala - Head circumference graph for infant girls, ages 0-9mo

• Guatemala - Head circumference graph for infant boys, ages 0-9mo

Indian Growth Charts

The Indian Academy of Pediatrics has recently published new recommendations for growth monitoring of children from India, including growth charts based on "affluent urban children from all major zones of India measured between 1989-91"; this is actually an advantage, as they are more likely to reflect how Indian children can and should be growing:

• India - Girls, 0-3yo

• India - Boys, 0-3yo

• India - Girls, 2-18yo

• India - Boys, 2-18yo

Korean Growth Charts

• These historical charts are from the International Adoption Clinic at UMN.

• These 2017 Korean National Growth Charts look higher quality.

Nepalese Growth Charts

An article with weight, height, and head circumference data for relatively healthy, higher socioeconomic status Kathmandu term infants:

• Nepal - Article describing growth in Nepalese Infants, Birth-1yo

• Nepal - Infant Growth Charts, which I adapted from the article above

Russian Growth Charts

From Dr. Tsepkova, via Karen's Adoption Links. Of unknown sample size and quality ... we prefer the CDC growth charts for Russian children.

• Russian Girl Growth Charts, 0-17yo

• Russian Boy Growth Charts, 0-17yo

Taiwan Growth Charts

From a parent who lives in Taiwan. These are the growth charts that seem to be a part of children's shot records. The less-than-smooth percentile lines does make me wonder whether the sample size or statistical techniques were adequate. I'm told they were in use from 1999-2009, when they switched to the WHO charts above.

The 1st page top left has head size in centimeters, by age in months. The rest of the 1st page is weight in kg by months and then by year. The 2nd page is height in cm by age. Percentile lines are in the legend.

• Taiwan Girl Growth Charts

• Taiwan Boy Growth Charts

Vietnamese Growth Charts

Adopt Vietnam has links to a few Vietnamese growth charts; however, they are not easy to interpret and are of unknown date and sample size.

Developmental Milestones

Here are some resources to help understand the order and timing of typical developmental milestones. Remember that institutionalized children are often delayed by up to 1 month for every 3 months in that setting, that there's a wide age-range of "typical" even in family-raised children, and that it's usually more useful to focus on the sequence and tempo of developmental achievement rather than strict timing of milestones. If you do have concerns about your child's development, please share them with your child's providers, and consider an Early Intervention evaluation.

• The Talaris Institute has a lovely Timeline of Development that illustrates how children develop in the first five years in social/emotional, cognitive, language, sensory, and motor domains
• Pathways Chart of Birth-15mo Developmental Milestones
• In-depth review article from Pediatrics in Review on birth-2yo growth and development, with detailed motor, cognitive & speech, and psychosocial charts. Written for pediatricians, but accessible enough for parents.
• The same journal has another review article on toddler development (1-3yo), with 18mo, 24mo, and 36mo developmental charts
• The excellent Talking with Toddlers website/book has a nice checklist of expressive words and signs that your child may be using, as well as a Language Log for the refrigerator door. Since caregivers reliably underestimate how many words a child uses, these will help you add them up and keep track of new words if you have any concerns about expressive language.
• When it comes to language development in orphanage-raised children, Sharon Glennen has some very useful pre-adoption language questions for parents to ask, as well as tables of typical post-adoption language development in international adoptees.