Refugee & Immigrant Child Health - emDocs
A 7-year-old male recently arrived from the Democratic Republic of Congo presents for a "wellness check" from a resettlement agency. No U. S. medical records. His mother reports fatigue, poor appetite, and one episode of bloody stool. Vaccinations are unverified. On exam he is pale and has a mildly distended abdomen and scattered excoriated papules on trunk and extremities. What is on your differential? What makes the differential and workup for this patient different than the average pediatric patient?
Author: Zain Talukdar, MD (Pediatrician, Riverside Healthcare, Graduate of University of Chicago) //Reviewers:Sophia Görgens, MD (EM Physician, Yale University, CT); Cassandra Mackey, MD (Assistant Professor ofEmergency Medicine, UMass Chan Medical School); Brit Long, MD (@long_brit)CaseA 7-year-old male recently arrived from the Democratic Republic of Congo presents for a “wellness check” from a resettlement agency. No U. S. medical records. His mother reports fatigue, poor appetite, and one episode of bloody stool. Vaccinations are unverified. On exam he is pale and has a mildly distended abdomen and scattered excoriated papules on trunk and extremities. What is on your differential? What makes the differential and workup for this patient different than the averagepediatricpatient?AnswerLeadtoxicity, intestinal parasites (helminths, Strongyloides), iron deficiency anemia, scabies, latent TB. There are unique concerns for recently immigrated pediatric patients that can affect your differential/workup. Why This Matters in the ED1 in 4 U. S. children lives in an immigrant family; 3–4% of U. S. children are foreign-born18–33% of foreign-born children are uninsured; 25% live below the federal poverty levelForeign-born children experience higher rates of adverse childhood experience than US childrenExamples (non-exhaustive list): Poverty, violence, persecution from host country, difficult/dangerous journeys, acculturation stress on arrival, family separation2026policyshift: Refugees are no longer eligible for Medicaid, Medicare, CHIP, or ACA — theEDvisit may be their only access pointEM Pearl:Comprehensive medical screening is supposed to occur for refugees/asylees within 90 days of arrival per CDC — it often does not. The ED may be the first encounter. Key DefinitionsTermClinical RelevanceRefugeeFled persecution; screened and admitted abroad. Eligible for resettlement services — though these are narrowing. AsyleeAlready in U. S. ; fewer support services than refugees. UndocumentedHighest uninsured rates; most limited care access. Do NOT share information with immigration authorities. Unaccompanied Immigrant Child (UIC)Minor without parent/guardian. Office of Refugee Resettlement (ORR) custody — special clinical and legal rules apply. Conditions Not to MissCategoryWhat to KnowActionLead Toxicity#1 consideration, ages 0–16y. Sources: leaded cookware, gasoline, traditional cosmeticsVenous lead level on every non-U. S. -born childInfectious DiseaseTB, Hep B/C,HIV, syphilis, Strongyloides, soil-transmitted helminths, H. pylori, STIs in adolescentsSee lab table belowNutritionalIron, Vit D, Zinc, B12/C deficiency; undiagnosed hemoglobinopathiesCBC; hemoglobin electrophoresis if suspectedSchistosomiasisSub-Saharan Africa exposureSchistosoma IgG if relevant geographyMental HealthPTSD, depression, anxiety — underreported, often missedHEADSS (home, education, activity, drugs, sex, safety, suicidality) screen; behavioral health referralDental / DevelopmentalSignificant dental disease; gaps in newborn screeningExamine teeth; check newborn screen if <12moED Lab WorkupCore labs (all non-U. S. -born children):CBCBlood lead level (ages 0–16y)IGRA (TB)HIV Ag/AbRPR (syphilis)Hep B surface antigenHep C AbStrongyloides IgGStool Ova & ParasiteContext-based add-ons:<6y:TSH/T4<12mo:Newborn screen if undocumentedAdolescents:Gonorrhea/Chlamydia NAAT, trichomonas, pregnancy testSub-Saharan Africa:Schistosoma IgGSymptomatic:Iron studies, Vit D, BMPEM Pearl: VaccinesAccept valid foreign records. If unavailable, start CDC catch-up schedule. Send measles, mumps, rubella, varicella, and Hep B titers if records are unclear rather than re-administering blindly. Special PopulationsUnaccompanied Immigrant ChildrenOffice of Refugee Resettlement protocol: psych eval within 24h; full history and physical, vaccines, TB test within 48h; HIV if ≥13yInsurance coverage as UICS terminates on release to sponsor — only 7 states + DC provide medical coverage regardless of statusRequest ORR records athhs. gov— often your only prior recordsHigh index of suspicion for trafficking, abuse, and PTSDDetention HistoryDetention screening = scabies, lice, varicella. Assume unvaccinated. Assess fortraumasequelae; connect to mental health before dischargeHistory & Exam PearlsUse a certified interpreter — not a family member, not Google Translate. It changes your diagnostic yield. Tell families explicitly: medical information is not shared with immigration authorities. Say it out loud. It reduces what they withhold. History elements often missed:Birth:Facility delivery? Prenatal labs? Newborn screen?Blood transfusions:Hep B/C, HIV riskCircumcision setting:Non-sterile = infection/bleeding riskHistory of Female Genital Mutilation (FGM):Ask sensitively; affects exam and OB/GYNmanagementJourney:Detention? Family separation? Known trauma?Food insecurity:Drives nutritional assessment and social work referralEM Pearl: ExamTreat the exam as if the child has never been fully examined. Vision, hearing, teeth, goiter, skin, musculoskeletal, genitalia — all at first opportunity, regardless of age. Legal & Safety — What the ED Can DoCounsel parents to keep copies of:immunization records, birth certificates, Alien Number, SSN, passports — and give a copy to a trusted adult outside the householdRecommend Power of Attorney designationin case of parental deportationDistribute ILRC Family Preparedness Planat discharge (ilrc. org) — multilingual, printableSocial work consults if any safety concern before dischargeOn ICE EncountersFamilies can refuse entry into their home if authorities do not have a signed judicial warrant. ICE administrative warrants (I-200/I-205) do not authorizehomeentry without consent. Providers are NOT required to share immigration status with law enforcement under HIPAADo NOT document immigration status in the medical record unless legally required (e. g. , ORR designation)DispositionPrimary care referral — mandatory. Multilingual practice strongly preferred. Empiric Rx at discharge:MVI + iron (6mo–6y); albendazole ≥12mo if helminth risk high and O&P pendingRepeat leadat 3–6 months for all children <6yGive family written copyof pending results and what they mean — don’t rely on afollow-upcallSocial work consultfor food insecurity, uninsured status, family separation, or any mental health concernsClinical Pearls at a GlanceLead level on every non-U. S. -born child under 16. #1 missed diagnosis. Don’t assume domestic screening happened. Many never complete the 90-day eval. Certified interpreter every visit. No exceptions. State explicitly:we don’t share records with immigration authorities. Adolescents:Screen privately for PTSD, depression, and trafficking risk. UICs:High-risk. Request ORR records, screen for trauma and trafficking. Empiric antiparasitic is reasonablewith high clinical suspicion while O&P is pending. Bridge, don’t just treat:PCP referral + social work = non-negotiable before discharge. ResourcesClinicalCDC Domestic Refugee Health Guidance — cdc. gov/immigrant-refugee-healthAAP: Providing Care for Children in Immigrant Families —Pediatrics2019;144(3):e20192077AAP Immigrant Child Health Toolkit — healthychildren. orgLegal/SafetyILRC Family Preparedness Plan — ilrc. org (multilingual, printable)ICE Detainee Locator — locator. ice. gov/odlsORR records for UICs — acf. hhs. govReferencesJulie M. Linton, Andrea Green, COUNCIL ON COMMUNITY PEDIATRICS, Lance A. Chilton, James H. Duffee, Kimberley J. Dilley, J. Raul Gutierrez, Virginia A. Keane, Scott D. Krugman, Carla D. McKelvey, Jacqueline L. Nelson; Providing Care for Children in Immigrant Families. PediatricsSeptember 2019; 144 (3): e20192077. 10. 1542/peds. 2019-2077American Academy of Pediatrics. Providing Care for Children in Immigrant Families. Pediatrics. 2019;144(3):e20192077. UNHCR Global Trends Report 2024. CDC. Guidance for the U. S. domestic medical examination for newly arriving refugees. Updated 2024. Jordan G, et al. Exploitation, Labor and Sex Trafficking of Children and Adolescents. Pediatrics. 2023;151(1):e2022060416. Immigrant Legal Resource Center. Family Preparedness Plan. 2024. ilrc. orgHHS Office of Refugee Resettlement. Care Provider Standards for Unaccompanied Children. 2023. Geltman PL, et al. Lead poisoning among refugee children resettled in Massachusetts. Pediatrics. 2001;108(1):158-162. Talukdar Z. Refugee and Immigrant Health Part 2. [Lecture]. UI Health / UIC. 2025.