Diarrhea in a Newly Immigrated 6-Year-Old
“One in four children live in an immigrant family, meaning that they have at least one parent born outside the US [5]. Besides restrictions to healthcare, these children face life stressors unique to their population group including fear of deportation, family separation, xenophobia, and racism…”
THE CASE
A 5-year-old female with no known past medical history presented to the pediatric emergency department with her family for 8 days of persistent diarrhea. The family speaks Haitian Creole. Using an interpreter, they stated that the patient had been experiencing about 9-12 episodes of non-bloody diarrhea for the last 5 days, and that she has had less urinary output than normal. They were concerned that she may be dehydrated. The patient did not complain of any abdominal pain, nor did she have fever, chills, vomiting, rash, dysuria, or hematuria. The family does report some worsening lethargy over the last 5 days.
The family was unsure of the patient’s vaccination status, as she had not seen a doctor in the last year. Upon further questioning, the father stated that their entire family unit recently arrived to the area from Haiti after traveling for the greater part of the last year. Initially, they took a plane from Haiti to Guatemala, then slowly made their way north until they reached the U.S. border. Their modes of transportation included mostly buses, but sometimes they had to walk great distances. During the last year, each member of the family has had several bouts of diarrhea that usually self-resolved. The parents were able to regularly provide food and water for their family, but at times they drank water from lakes and rivers when necessary.
Vital signs were within normal limits for age, and the patient was afebrile. On exam, the patient was sleeping but easily arousable. Mucous membranes were dry. Capillary refill was <2 seconds. Heart had regular rate and rhythm; lungs were clear to auscultation. Bowel sounds were hyperactive, but the abdomen was soft and nontender.
Given the decreased urinary output, there was concern for dehydration. An IV was placed to administer a bolus of normal saline. Additionally, given the prolonged diarrhea, a basic metabolic panel was obtained to assess electrolyte levels. A Stool GI Pathogen Panel was also sent. This was to differentiate the underlying cause of the patient’s likely gastroenteritis. Given the lack of abdominal pain, there was low suspicion of appendicitis, intussusception, or small bowel obstruction. Given lack of bloody stool, there was low suspicion of inflammatory bowel disease.
The labs returned with electrolytes in the normal range. The Stool GI Pathogen Panel was positive for Cryptosporidium.
DIAGNOSIS
Cryptosporidium infection
DISCUSSION
Cryptosporidium or “Crypto” is a protozoan parasite often found in drinking water in overcrowded areas [1]. Despite being particularly present in low-income countries, it is also relatively common in high-income countries, including the United States [2]. Asymptomatic infections are common; however, diarrhea is the most common symptom. Usually, the disease is self limiting and does not require treatment, lasting 10-14 days in immunocompetent patients [3]. Fatalities in immunocompetent individuals appear to stem from the sequela of dehydration, especially among the elderly population.
Supportive care is the cornerstone of treatment in patients with cryptosporidium [1]. Oral hydration is preferred, but intravenous hydration can be used when indicated, as in this patient. Antidiarrheals such as Loperamide can also be used. In patients with HIV, appropriate antiretroviral therapy should be started immediately. If that has not led to resolution of the patient’s symptoms, Nitazoxanide is the antimicrobial of choice [4]. Nitazoxanide can also be considered in immunocompetent patients with greater than 2 weeks of symptoms. Good hand hygiene should be recommended to the entire family to prevent spreading of the illness.
CASE CONTINUED
The patient felt improved after a bolus of fluids and was given a prescription for Loperamide. Close follow up was advised, but the patient did not have a pediatrician, nor did their family have any direction in obtaining one.
DISCUSSION CONTINUED
The remainder of this discussion will center on the inequalities and difficulties that immigrant children and their families face regarding healthcare.
One in four children live in an immigrant family, meaning that they have at least one parent born outside the US [5]. Besides restrictions to healthcare, these children face life stressors unique to their population group including fear of deportation, family separation, xenophobia, and racism.
Identifying the status of a patient’s family can be awkward and difficult to understand. However, this is important to clarify, as it will help guide the physician, social worker, and/or case manager in developing a plan for further care. A quick but incomplete summary is listed below. As for the sake of this discussion, there are two broad categories:
—“Lawfully present immigrants” are legal permanent residents or green card holders, refugees, and those who have been granted asylum.
—”Undocumented immigrants” are foreign born individuals who are in the US without US government authorization [6].
Even when immigrants are lawfully present, they must meet certain eligibility restrictions to enroll in CHIP or Medicaid, two US government-sponsored healthcare programs. Even after obtaining lawfully present status, there is often a waiting period of 5 years before they may enroll in these programs. As of January 2022, 35 states have allowed lawfully present immigrant children to bypass the five-year wait period. Also, those who are lawfully present who do not qualify for Medicaid or CHIP may purchase coverage through Affordable Care Act (ACA) Marketplaces. Undocumented immigrants are not eligible to enroll in Medicaid, CHIP, or to access coverage through the ACA Marketplaces. This includes those with Deferred Action for Childhood Arrivals (DACA) [6].
California, DC, Illinois, New York, Oregon, and Washington provide comprehensive, state-funded healthcare coverage to all eligible children. Eligibility is mostly determined by family income. Massachusetts provides primary and preventive services. Maine and Vermont plan to extend Medicaid-like state-funded coverage to immigrant children [6].
Even when individuals who are lawfully present are eligible for health insurance, a vairety of obstacles exist—confusion, difficulty navigating the process, language barriers, literacy barriers, transportation difficulties, and fear [5]. Fear is a large driving force in this population, especially for those who are undocumented. This stems from persecution and the idea that seeking healthcare may increase risk of deportation. Given this, it is important for physicians to advocate for their patients. Social work is usually aware of the resources that can be provided to these families, which might include free clinics [5]. It is also important for a physician to learn about the programs in their area that cater to the needs of immigrant families.
Language lines and in-house interpreters are essential to the care of these patients [5]. This is often the first and most important step in caring for these patients. It is also important to enter the patient’s room with cultural humility, as well as with awareness of one's own biases and of the power dynamic between physician and patient.
Not all aspects of immigrant health could be covered in this discussion. A final key aspect that must be attended to in all cases is mental health. When a refugee is fleeing violence, it is imperative to address this stressor’s effect on patients’ mental health [7]. It is advised to screen for anxiety, depression, PTSD, and suicidal ideation. At times, psychiatric diagnoses may present as somatic symptoms, and this diagnosis of exclusion should be considered after a thorough medical work up.
CASE RESOLUTION
The patient in this case improved clinically and was able to follow up with a local free clinic. Social work was also able to connect the family with an immigration lawyer and outpatient case worker.
Resources for Immigrant Families:
Finding Local Free Clinics:
https://nafcclinics.org/find-clinic/
Finding Legal Aid:
https://www.justice.gov/eoir/list-pro-bono-legal-service-providers
AUTHOR: Fahad Ali, MD, is a fourth-year emergency medicine resident at Brown Emergency Medicine. He is also the current resident Chief of Diversity, Equity & Inclusion.
FACULTY REVIEWER: Michelle Myles, MD, is an attending physician and clinician educator at Brown Emergency Medicine.
REFERENCES
Chen, Xian-Ming, et al. "Cryptosporidiosis." New England Journal of Medicine 346.22 (2002): 1723-1731.
Bouzid, Maha, Erica Kintz, and Paul R. Hunter. "Risk factors for Cryptosporidium infection in low and middle income countries: A systematic review and meta-analysis." PLoS neglected tropical diseases 12.6 (2018): e0006553.
Adler, Sara, et al. "Symptoms and risk factors of Cryptosporidium hominis infection in children: data from a large waterborne outbreak in Sweden." Parasitology research 116.10 (2017): 2613-2618.
Clinicalinfo.gov. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/whats-new-guidelines (Accessed on February 22, 2021).
Russell, Eric A., Carmelle Tsai, and Julie M. Linton. "Children in Immigrant Families: Advocacy Within and Beyond the Pediatric Emergency Department." Clinical Pediatric Emergency Medicine 21.2 (2020): 100779.
Health Coverage of Immigrants." Kaiser Family Foundation, 6 Apr. 2022, Kaiser Family Foundation. www.kff.org/racial-equity-and-health-policy/fact-sheet/ health-coverage-of-immigrants/.
(116. Nakeyar C., Esses V., Reid G.J. The psychosocial needs of refugee children and youth and best practices for filling these needs: a systematic review. Clin Child Psychol Psychiatr. 2018;23:186–208.)