Medical Assessment of Immigrant and Refugee Children
- Getting to know a new immigrant or refugee child involves a thorough history, physical examination and appropriate investigations.
- When assessing children and youth new to Canada, be sensitive to and aware of cultural and language differences. You may need to involve trained cultural interpreters.
- Look for chronic illnesses that may not have been adequately treated and diseases not usually seen in Canada.
- Be aware that immigrant and refugee children may present with different problems, both physical and psychosocial.
- It may take several appointments to complete the initial medical assessment.
- This site includes electronic tools to help with medical assessment, and with determining differential diagnoses for common symptoms and laboratory findings.
Most immigrant and refugee children new to Canada have not had a reliable, accurate or valid health assessment. It is vital to diagnose health conditions that could affect a child’s growth and development, including infectious diseases, chronic illnesses and psychosocial issues.
Initial medical assessment
The initial assessment of a young newcomer is no different than that for a Canadian-born child. It includes a detailed and complete history, a full physical exam and appropriate investigations. If symptoms are present, the work-up can be targeted toward specific areas.
Ideally, the first visit should be scheduled as soon as possible after the family arrives in Canada. It occurs more often, however, when a child is sick or has a health problem and after the family has been in Canada for some time.
Meeting a new immigrant or refugee family for the first time can seem overwhelming, especially if they come from an unfamiliar country or culture or if there are several children. Remember:
A sensitive, caring and compassionate health professional can learn a lot about a new child, with a warm smile, calm manner and gentle touch.
- You may need to take considerable time and effort to get background information about a family and to conduct a history and physical exam for each child. Spread this process over more than one visit.
- Ideally, each child in the family should have a separate appointment, though this is not always possible for busy families.
- If a child presents with a specific health concern, you might have to deal solely with that and leave the more general medical assessment until the next visit.
- Some children may need to be admitted to hospital for urgent medical care.
Preparing for the visit: Documentation
The IME is conducted prior to immigration and consists of a medical history, physical examination, age-specific laboratory tests and age-specific chest x-ray. Details on what is covered in the IME are available online from Citizenship and Immigration Canada. It is important to note that a significant period of time may have elapsed between the medical exam and the child's arrival in Canada.
Encourage immigrant and refugee families to bring all health-related documents, including:
- Pre-immigration screening or test results
- Immunization records
- Growth records
- Any medical documents from their country of origin
Make copies for their files and return the originals to the family. Documents may need to be translated. Remember to use previous records with caution, as information may not be accurate.
Communicating effectively with newcomer families
Here are some factors that can affect communication with families, with suggestions for building positive relationships:
- Greet new children and families with a warm smile and use a slow, gentle approach. It may be helpful to learn some greetings in the common languages of families settling in your area.
- Set aside enough time to create a relaxed, open, non-threatening atmosphere.
- Be sensitive to how family members interact and the role each member plays in the family. Typically, you’d obtain most of a history from an older child or adolescent, but in certain cultures it may be more appropriate to address questions to an elder, such as a father or grandparent, even though that person may not always have the correct answers.
- Consider delaying questions about relationships until you are more familiar with the family and their culture. Families may wait to disclose details such as polygamy or common-law relationships until more rapport and trust are established.
- Avoid over-generalizing and stereotyping. While cultural factors may influence how people interact with health professionals, remember that each individual is unique. Being flexible in your communication style and approach is part of providing patient-centred care.
- Families may not wish to 'set the agenda' during this first interaction. You may need to take the lead. Ask the family if they have questions or what they would like from the visit.
- In some cultures, physicians are considered authority figures and are expected to show leadership in determining the course(s) of action.
- Some families are reluctant to reveal their immigration status for fear that a medical illness may become known to authorities and put them at risk of deportation – usually a false assumption. Be clear that information about immigration status is confidential.
- Some families may not return for follow-up appointments if you ask about their immigration status.
- If the family seems reluctant to reveal their immigration status, consider saying something like: “I don't need to know your immigration status, but is there any way that I can help?”
- For billing purposes, whether in a private office or a hospital clinic, it will be important to know whether the family has insurance or health care coverage, and this will usually reveal their immigration status.
Cultural background and migration experience
- Keep in mind that a patient’s background might include war, death, violence, torture, hunger or imprisonment. Such trauma may affect their health as well as whether they trust and respect authority figures.
- Although it is important to have some background knowledge of problems in different parts of this world, do not generalize or make assumptions.
Canada’s health care system
- Give an overview of how the Canadian health care system works. Explain where the family fits within this system.
- Establish what provincial/territorial or federal coverage for health care is available to them.
Using an interpreter
- Cultural interpreters can help health professionals communicate effectively with families.
- Involving an interpreter can help to establish rapport.
- Interpreters should be professionally trained. They should not be family members. Best practice is to avoid using a child or youth as a family interpreter.
More information on communication and coverage is available on this website:
- How Culture Influences Health
- Barriers and Facilitators to Health Care
- Using Interpreters
- Health Insurance
- Cultural competence
Taking a history
The initial medical assessment involves taking a history for each child and the family as a whole, and probably takes place over more than one visit. Details to be covered when taking a history are summarized below. Additional information on taking a history is available in the pages on cultural competence.
Chief concerns and complaints
- Focus first on a child or family’s chief concerns, complaints, health or medical problems.
- Ask the family if they have questions. Find out what they would like from the visit.
- Verify the child’s full name, with spelling. Mistakes are sometimes made, especially in the order of names or when the child’s surname is different from a parent’s.
- Clarify who the child’s natural birth parents are, and who in the family are regular caregivers.
- A complete family history of parents, siblings and extended family will include:
- Ages (as known), occupations or training both in their country of origin as well as currently, health issues, and specifics that might relate to the child’s complaint,
- Previous illnesses, hospitalizations, operations, accidents and tropical diseases,
- Any history of specific conditions, such as tuberculosis, hepatitis, leprosy, and HIV/AIDS.
- Ask about the family's current setting and whether that will change. For example: Is the entire family united? Is there other family support or extended family in Canada?
- Ask if additional members may join the family in Canada.
- Ask whether travelling back to the country of origin is planned, and how soon.
Birthplace, country where children were raised, travel history
- Assess characteristics of where a child was born and raised (if different from birthplace), especially:
- Climate (e.g., arid, seasonally dry and wet, tropical, temperate),
- Setting, whether rural or urban,
- Housing conditions, water and food sources, and
- Predominant insects and animals (to determine the risk of arthropod-borne infections and zoonoses).
- Whether they lived in a refugee camp, where, and for how long.
- History of travel from their country of origin.
- Countries the family lived in before arriving in Canada.
A list of links to websites providing health information by region or country is available in this guide.
- A child’s date of birth can usually be verified on immigration papers, but be aware that some cultures calculate age differently. Also, newcomer families may not know their child’s precise birth date.
- Ask for a history of pregnancy and perinatal period, including the child’s:
- Birth weight and size, if known.
- Gestational age, if known.
- Neonatal complications.
- Although unusual in sub-Saharan Africa, consanguinity is more frequent among people from the Middle East and West Asian countries such as Pakistan. Consanguinity should be considered if seeing a patient with developmental delay, dysmorphism or neurological symptoms, such as seizures.
Dietary history, growth and development
- Assess dietary history and nutritional status as important windows on growth and development, including:
- Dietary history and food security, pre- and post-arrival.
- Ask if the child has ever exhibited pica or consumed unpasteurized milk.
- Be mindful that refugee and internationally adopted children have high rates of malnourishment and micronutrient deficiencies.
Assess a child’s immunization status, based on:
- The immunization record, including Bacillus Calmette-Guérin (BCG), if available. Note that not all immunization records are accurate and valid. Only accept information from reliable sources. Do not rely on history alone.
- Determine the routine and non-routine immunizations required, either to ‘catch up’ or as a new complete series. Read more about assessing immunization history and developing a catch-up schedule in this resource.
- Ask about previous illnesses, hospitalizations, operations, accidents and tropical diseases (as appropriate), and family history of allergies.
- Ask whether a child has ever passed worms or blood in their stools.
- Assess risk of HIV and other sexually transmitted infections.
- Has this child or a parent ever had surgery, received a blood transfusion or received intramuscular injections with reused needles?
- Has an older child or adolescent been sexually active?
- Ask carefully about specific illnesses, such as HIV or tuberculosis. Remember: A parent may not give the correct response for fear it will jeopardize the family’s care or ability to stay to Canada.
Previous medical care
- Ask what the family usually does when this child is ill.
- Did they consult a local physician in their country of origin or use traditional forms of treatment?
- Ask about past and present medication use, including antimalarials and antibiotics, as well as ‘natural’ remedies and over-the-counter products.
When a child presents with a specific complaint or illness, ask the family about:
- Description/duration/severity of symptoms,
- Current management of symptoms (which may involve traditional treatments),
- Any progress or change in these complaints over time,
- Any specific family concerns about this child’s or other family illnesses.
Review of systems
- This may involve a ‘head-to-toe’ functional inquiry of any symptoms or complaints that have not been addressed.
- A modified HEADSS interview (touching on home, education/employment, activities, drugs or alcohol, sex, smoking, suicide or depression) may be appropriate, recognizing that most adolescent immigrants or refugees do not have the same experiences as North American children, and may not answer truthfully in the presence of a parent or interpreter.
Assessing psychosocial history
All migrant families come to Canada with hopes of a better life, but they have left their countries of origin for different reasons and take widely different journeys. Newcomers may have experienced violence, extreme hunger, physical and/or emotional deprivation, abuse, and cultural dislocation brought on by war, trauma, the premature death of family members or friends, and neglect. Clinicians should be alert for mental health issues, such as:
- Post-traumatic stress disorder
- Reactive attachment disorders
- Quasi-autistic behaviour patterns
- Sensory processing problems
While taking a psychosocial history is extremely important, you may want to wait until you have established a rapport of comfort and respect with the child and family. Read about specific questions to ask newcomer families when taking a history.
Assess the support system of each newcomer family. They may need to be referred to local community organizations, religious institutions or other support groups that provide assistance. Referral to social services or a social worker is often useful.
When doing the physical exam, be unhurried and gentle. Although the child may not understand, explain what you are doing and leave more uncomfortable parts of the exam until the end. Important clinical signs to assess during a physical exam are summarized below.
- Does a child look well or acutely/chronically ill?
- What is this child’s demeanour? (E.g., happy, depressed, anxious, fearful)
- Begin developmental assessment.
- Look for signs of congenital infections.
- Check temperature, pulse, respiration, blood pressure.
Growth and nutrition
Assessing a child’s growth and nutritional status includes:
- Height, weight and BMI.
- Measuring and plotting head circumference, especially if child is <2 years of age.
- Measuring growth using a standard growth chart. Be cautious when using growth charts, however, because the newcomer child’s correct age is not always known.
- A general nutritional assessment (look for dehydration, anemia, edema, abdominal distension, muscle wasting and signs of rickets, including swelling of the wrists and feet).
- Note size and shape, hair, scalp, lesions, fungal infection or presence of lice.
- Undiagnosed eye disease and vision loss are more common among new immigrants and refugees from developing countries. Assess visual acuity in all immigrant and refugee children after arrival.1
- Check for strabismus, conjunctivitis, uveitis, chorioretinitis and vision abnormalities.
Ear, nose and throat
- Check for lesions, purulent or chronic otitis media, oral thrush, herpetic ulcers, nasal polyps (for possible underlying cystic fibrosis) and hearing abnormalities.
- Children should have their hearing tested before they enter school or any time there is a concern about their hearing or language development. Older children and adolescents also need a hearing assessment if they are having learning difficulties.
- If there is any doubt of a child’s ability to hear, request a formal hearing assessment.
- Make a dental assessment, especially for current dental hygiene and the presence of caries.
- Examine for lymphadenopathy: whether nodes are tender or painless, soft, firm or hard.
- Check for cardiomegaly, pulses (especially femoral pulses), cyanosis, finger clubbing, cardiac rhythm, heart sounds or cardiac murmurs.
- Listen for respiratory difficulties or dyspnea, finger clubbing, crackles or wheezing.
- Look for abdominal distension, jaundice, tenderness, guarding, hepatosplenomegaly or masses.
- Be particularly sensitive with older children, who may be shy, trained not to let anyone touch them, or who may have been abused.
- Determine whether the child wants a parent or anyone else present during this exam. In some cultures it is important to ask for parental consent.
- Apply Tanner staging, if appropriate.
- For males, conduct a testicular exam.
- Check for urethral discharge, genital ulcers, inguinal adenopathy, especially in previously sexually active adolescents.
- Look for signs of female genital mutilation/cutting.
- Check for signs of pregnancy in adolescent girls.
- Arrange appropriate prenatal care, as necessary.
- Look for signs of muscle wasting or weakness.
- Check the spine for scoliosis, spina bifida occulta (i.e., a dimple or tuft of hair) or kyphosis, as well as feet and hips.
- Check focal neurological signs, increased head circumference (for hydrocephaly), fontanels (for flaccid paralysis and the possibility of polio), general muscle power, tone, bulk, coordination and deep tendon reflexes.
- Look for ulcers, areas of hypo- or hyperpigmentation, impetigo, scabies, bruising, subcutaneous nodules or other rashes.
- Be aware that some marks or scars may be cultural in origin or caused by a traditional treatment. A traditional healer’s interpretation of the site of the illness may include ‘coining’ (a coin is rubbed against the skin leaving bruises in a specific pattern), scarification or scarring at site of a physical complaint. Such marks can be misinterpreted as a sign of child abuse.
- Check for sign of Bacillus Calmette-Guérin (BCG) immunization, which may be on one forearm, in the deltoid or upper arm region, or (sometimes) on the sole of a foot or over the upper scapulae.
Screening lab tests
Laboratory tests should be ordered based on clinical indications. For example, when the family is from an area of high prevalence for a suspected disorder, when there is a positive family history, or if the child has suggestive clinical signs.
How much screening and diagnostic work should be done?
There are different opinions about the extent of screening or diagnostic work-up for children and youth new to Canada, particularly if they have no symptoms. A primary consideration is the country of origin and route taken to Canada, which may place them at higher risk of some diseases. Families who come from countries that have medical services and cultural practices similar to Canada’s may not require an extensive approach, especially if there are no clinical problems. A number of organizations provide up-to-date health information by region or country. A list of links is available in this guide.
Potential screening lab tests for a child or youth new to Canada
- Complete blood count (CBC) with differential; an elevated eosinophil count may indicate parasitic diseases.
- Ferritin or serum iron studies.
- Sickle cell preparation.
- Hemoglobin electrophoresis, if sickle cell screen is positive or α- or β-thalassemia suspected.
- G6DP (glucose-6-phosphate dehydrogenase) screening if the child is from Africa, China/Asia or the Mediterranean.
- Malaria smear.
- Hepatitis: Hepatitis A serology, hepatitis B surface antigen and antibody, hepatitis C antibody.
- HIV in patients from endemic areas, after counselling and with informed consent.
- Stool analysis: For culture and sensitivity and for ova and parasites. If intestinal parasites are clinically suspected and if diarrhea or abdominal pain are present, 3 stool tests for ova and parasites may be necessary.
- Syphilis serology (e.g., venereal disease research laboratory [VDRL] or rapid plasma reagin [RPR]), as indicated. This testing is required by law for all immigrants ≥ 15 years of age and in younger children when sexual activity or sexual assault is suspected, or in cases of suspected congenital syphilis.
- Serology for schistosomiasis and strongyloidiasis, depending on the country of origin.
- A tuberculosis skin test (e.g., Mantoux test) is recommended for all children from endemic areas, regardless of history of BCG immunization.
- Chest X-ray, if clinically indicated. This is required for all immigrants ≥ 11 years of age, before arrival.
- Urinalysis (dipstick): Check for glucosuria, proteinuria, hematuria.
- Ferritin or serum iron studies.
- Thyroid function: Thyroid stimulating hormone (TSH), thyroxine (T4).
- Liver enzymes: Alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP).
- Serum creatinine and urea.
- Serum lead (Pb).
When to order lab tests for children and youth new to Canada?
Generally, most centres will do or arrange for diagnostic tests at the first visit, particularly if test results might influence possible treatments or management. Health care providers should not only individualize the type but also the timing of lab tests. When children are asymptomatic and there is no danger to public health, some tests may be requested later, once the family has adjusted to their new environment, rapport has been established and they have been counselled.
There may also be a number of psychosocial factors to take into consideration. Children new to Canada, like other children, might fear needles and new experiences. If test results do not have immediate consequences, consider delaying them to the second or third visit. It is helpful to do all blood tests at the same time to avoid multiple blood sampling.
At the second visit
The second visit with a young newcomer and the family may take place as soon as 2 to 7 days after the first, depending on whether the Mantoux test for tuberculosis needs to be read at 48 to 72 hours.
At this second visit, try to complete any unfinished histories, physical examinations or other investigations, with particular focus on:
- Developmental assessment: If necessary, this should continue over several visits, allowing the child to become accustomed to you and to their new surroundings.
- Behavioural/psychological problems: Determine whether the child has demonstrated any behavioural or psychological problems, both in the past and now that they are coping with immigration.
- Tuberculosis: Results of the tuberculosis skin test (TST, Mantoux test), should be read and documented. If positive, a chest X-ray should be requested. If the TST result and/or chest X-ray is positive, arrange referral to a respirologist or infectious diseases specialist for prophylaxis against tuberculosis and follow-up.
- Stool specimens: lf requested at the first visit, send the returned bacterial culture, ova and parasite bottles to the microbiology lab for processing.
By their second visit, the newcomer family may better understand the Canadian health care system and have more questions. In general, however, new immigrants and refugees tend not to question authority figures and often don’t have a lot of questions.
Optimally, the third visit should be scheduled for approximately 1 month after the first one, and may include:
- Further developmental assessment.
- Ethnic or genetic medical issues.
- A closer review of mental health issues.
- Ongoing anticipatory guidance about nutrition, education, injury prevention, schooling, language learning, cultural and social issues.
- Referral to local community agencies and social services, as needed.
- Referral to a dentist.
After extensive screening and work-up, clinicians may find previously undetected medical diseases or conditions that require close follow-up or referral to a specialist. However, many young newcomers are healthy and do not require extensive follow-up. The number and timing of subsequent visits should therefore be arranged according to individual needs.
At follow-up visits, clinicians may be required to:
- Answer more family questions.
- Ensure completion of primary series and ‘catch-up’ immunizations.
- Check compliance with prescribed treatments or medications.
- Monitor growth and development.
- Identify and advocate for children with school problems or families under psychosocial stress.
- Arrange appropriate consultations for identified problem areas.
How much anticipatory guidance and counselling should clinicians do?
- Canadian climate, appropriate clothing, skin care, frostbite prevention, etc.
- Babies’ nutritional needs and breastfeeding, as appropriate.
- Nutrition, choosing foods and balancing meals based on Canada‘s Food Guide, taking into account the family’s cultural eating habits. Canada’s Food Guide is available in many languages (English, French, Arabic, Chinese, Farsi, Korean, Punjabi, Russian, Spanish, Tagalog, Tamil and Urdu. Order for free or download from Health Canada.
- Education for school-age children, especially when additional assessment is needed for appropriate program placement.
- Injury prevention and the mandatory use of seat belts and car seats in Canada.
- Child discipline, especially what is considered appropriate – and inappropriate – in Canada.
- Travel plans to visit friends and relatives abroad. Children of immigrants who travel to visit friends and relatives (VFRs) are at risk for travel-related illness.
Visit Caring for Kids to download and print parent handouts on a range of health promotion topics.
Referrals to community agencies
At follow-up visits, check on the psychological well-being and ongoing adaptation of the child and family to life in Canada. On an ongoing basis, determine whether:
- Their housing is adequate.
- They have accessed all appropriate and available financial resources, such as child or disability allowances.
- They have applied for provincial/territorial health care coverage.
- They are learning English or French.
- Children are experiencing school problems.
- There are psychological stresses, particularly evidence of post-traumatic stress disorder or depression.
Consider partnering with and referral to community organizations when ongoing support is needed to reinforce specific counselling. If appropriate, ensure the family has ongoing social service assessment for these and other social issues. It’s important to be aware of agencies and services – both general and for specific groups – located in your area.
- Centers for Disease Control and Prevention. Growth charts.
- Centers for Disease Control and Prevention. Guidelines for the U.S. domestic medical examination for newly arriving refugees.
- Citizenship and Immigration Canada. Refugees: Health care.
- Health Canada. Eating well with Canada’s food guide.
- Kamat DM, Fischer PR, eds. Textbook of Global Child Health. Elk Grove, Ill: American Academy of Pediatrics, 2011. See especially section 1 in chapter 4: “Cultural sensitivity, awareness, and competency in pediatric practice”, and section 2 in chapter 19: “Care of Immigrants”.
- Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011;183(12):E824-925.
- Public Health Agency of Canada, 2012. Canada immunization guide: Evergreen edition.
- University of Washington Medical Center. EthnoMed: Integrating cultural information into clinical practice. See especially culture clues tip sheets.
- World Health Organization. The WHO child growth standards.
- Screening Children and Youth New to Canada: Practical Resources June 10, 2015
- "The next patient is from where in Africa? What am I supposed to do?" The Initial Medical Assessment of a New Immigrant or Refugee Child, October 22, 2014
- Pottie K, Greenaway C, Feightner J, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011;183(12):E824-925.
Other works consulted
- DuPlessis HM, Cora-Bramble D, American Academy of Pediatrics Committee on Community Health Services. Providing care for immigrant, homeless, and migrant children. Pediatrics 2005;115(4):1095-100.
- Beiser M. The health of immigrants and refugees in Canada. Can J Public Health 2005;96(Suppl 2):S30‑44.
- DesMeules M, Gold J, Kazanjian A, et al. New approaches to immigrant health assessment. Can J Public Health 2004;95(3):122-6.
- Juckett G. Cross-cultural medicine. Am Fam Physician 2005;72(11):2267-74.
- McDonald JT, Kennedy S. Insights into the ‘healthy immigrant effect’: Health status and health service use of immigrants to Canada. Social Sci Med 2004;59:1613-27.
- Stauffer WM, Maroushek S, Kamat D. Medical screening of immigrant children. Clin Pediatr (Phila) 2003;42(9):763-73.
- Walker P, Barnett E, eds. Immigrant Medicine. Philadelphia, PA: Elsevier Press, 2007.
- Robert Hilliard, MD
Last updated: May, 2016