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 of Emergency Medicine, UMass Chan Medical School); Brit Long, MD (@long_brit)
Case
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?
Answer
Lead toxicity, 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 ED
- 1 in 4 U.S. children lives in an immigrant family; 3–4% of U.S. children are foreign-born
- 18–33% of foreign-born children are uninsured; 25% live below the federal poverty level
- Foreign-born children experience higher rates of adverse childhood experience than US children
- Examples (non-exhaustive list): Poverty, violence, persecution from host country, difficult/dangerous journeys, acculturation stress on arrival, family separation
- 2026 policy shift: Refugees are no longer eligible for Medicaid, Medicare, CHIP, or ACA — the ED visit may be their only access point
EM 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 Definitions
| Term | Clinical Relevance |
| Refugee | Fled persecution; screened and admitted abroad. Eligible for resettlement services — though these are narrowing. |
| Asylee | Already in U.S.; fewer support services than refugees. |
| Undocumented | Highest 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 Miss
| Category | What to Know | Action |
| Lead Toxicity | #1 consideration, ages 0–16y. Sources: leaded cookware, gasoline, traditional cosmetics | Venous lead level on every non-U.S.-born child |
| Infectious Disease | TB, Hep B/C, HIV, syphilis, Strongyloides, soil-transmitted helminths, H. pylori, STIs in adolescents | See lab table below |
| Nutritional | Iron, Vit D, Zinc, B12/C deficiency; undiagnosed hemoglobinopathies | CBC; hemoglobin electrophoresis if suspected |
| Schistosomiasis | Sub-Saharan Africa exposure | Schistosoma IgG if relevant geography |
| Mental Health | PTSD, depression, anxiety — underreported, often missed | HEADSS (home, education, activity, drugs, sex, safety, suicidality) screen; behavioral health referral |
| Dental / Developmental | Significant dental disease; gaps in newborn screening | Examine teeth; check newborn screen if <12mo |
ED Lab Workup
Core labs (all non-U.S.-born children):
CBC
Blood lead level (ages 0–16y)
IGRA (TB)
HIV Ag/Ab
RPR (syphilis)
Hep B surface antigen
Hep C Ab
Strongyloides IgG
Stool Ova & Parasite
Context-based add-ons:
<6y: TSH/T4
<12mo: Newborn screen if undocumented
Adolescents: Gonorrhea/Chlamydia NAAT, trichomonas, pregnancy test
Sub-Saharan Africa: Schistosoma IgG
Symptomatic: Iron studies, Vit D, BMP
EM Pearl: Vaccines
Accept 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 Populations
Unaccompanied Immigrant Children
- Office of Refugee Resettlement protocol: psych eval within 24h; full history and physical, vaccines, TB test within 48h; HIV if ≥13y
- Insurance coverage as UICS terminates on release to sponsor — only 7 states + DC provide medical coverage regardless of status
- Request ORR records at hhs.gov — often your only prior records
- High index of suspicion for trafficking, abuse, and PTSD
Detention History
- Detention screening = scabies, lice, varicella. Assume unvaccinated.
- Assess for trauma sequelae; connect to mental health before discharge
History & Exam Pearls
Use 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 risk
Circumcision setting: Non-sterile = infection/bleeding risk
History of Female Genital Mutilation (FGM): Ask sensitively; affects exam and OB/GYN management
Journey: Detention? Family separation? Known trauma?
Food insecurity: Drives nutritional assessment and social work referral
EM Pearl: Exam
Treat 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 Do
- Counsel parents to keep copies of: immunization records, birth certificates, Alien Number, SSN, passports — and give a copy to a trusted adult outside the household
- Recommend Power of Attorney designation in case of parental deportation
- Distribute ILRC Family Preparedness Plan at discharge (ilrc.org) — multilingual, printable
- Social work consults if any safety concern before discharge
On ICE Encounters
- Families can refuse entry into their home if authorities do not have a signed judicial warrant. ICE administrative warrants (I-200/I-205) do not authorize home entry without consent.
- Providers are NOT required to share immigration status with law enforcement under HIPAA
- Do NOT document immigration status in the medical record unless legally required (e.g., ORR designation)
Disposition
- Primary care referral — mandatory. Multilingual practice strongly preferred.
- Empiric Rx at discharge: MVI + iron (6mo–6y); albendazole ≥12mo if helminth risk high and O&P pending
- Repeat lead at 3–6 months for all children <6y
- Give family written copy of pending results and what they mean — don’t rely on a follow-up call
- Social work consult for food insecurity, uninsured status, family separation, or any mental health concerns
Clinical Pearls at a Glance
- Lead 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 reasonable with high clinical suspicion while O&P is pending.
- Bridge, don’t just treat: PCP referral + social work = non-negotiable before discharge.
Resources
Clinical
- CDC Domestic Refugee Health Guidance — cdc.gov/immigrant-refugee-health
- AAP: Providing Care for Children in Immigrant Families — Pediatrics 2019;144(3):e20192077
- AAP Immigrant Child Health Toolkit — healthychildren.org
Legal/Safety
- ILRC Family Preparedness Plan — ilrc.org (multilingual, printable)
- ICE Detainee Locator — locator.ice.gov/odls
- ORR records for UICs — acf.hhs.gov
References
- Julie 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. Pediatrics September 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.org
- HHS 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.
