Fostering Better Care

When a child enters foster care, he or she receives a full medical evaluation, including laboratory testing of hemoglobin and lead levels and screening for hepatitis B and C, syphilis, tuberculosis, HIV, and (in sexually active adolescents) gonorrhea and chlamydia. But is all this testing really necessary – and is it worth the cost to the foster care system? New research suggests not (1).

Children entering foster care currently undergo laboratory testing based on recommendations developed by an expert panel in New York, which were last endorsed in 2005 by the American Academy of Pediatrics. “At the time, expert opinion was the highest level of evidence available, as there was very little scientific literature on children in foster care,” explains lead author Mary Greiner, who goes on to say that research is paying increasing attention to this underserved population and opinion is shifting.

But if a one-size-fits-all approach to laboratory testing for these children is not cost-effective – what is the alternative? Greiner and her colleagues propose a more targeted approach. “Targeted screening would involve looking at the community and the individual being tested,” she says. “Each community may have different prevalence rates of infections and each individual may have their own risk factors, such as exposure to high-risk activities or a history of sexual abuse that would confer increased risk for specific infections.”

The study revealed, for instance, that chlamydia screening in sexually active populations provides a good return on investment; 7 percent of adolescents tested positive, meaning that it’s more cost-effective to screen everyone than to miss existing infections. For diseases like syphilis or tuberculosis, however, the opposite is true – fewer than 1 percent of children are infected, so screening an almost entirely healthy population is unnecessary and expensive. “In the future, algorithms will likely account for infection prevalence rates in a given community and an individual patient’s risk factors for specific infections,” says Greiner.

Nonetheless, the researchers were somewhat surprised to find infection rates as low as they were. “Our biggest surprise was that the risk for infectious disease was quite low in this population, at least in our area of the country. Youth in foster care are at high risk of medical problems and come from environments where they are in contact with adults known to be at high risk for infectious disease issues like HIV and hepatitis C.” The assumption was that foster youth would also be at high risk – but that is evidently not the case. In the future, then, perhaps they can be spared the extensive testing current guidelines recommend in favor of more optimized screening for the diseases most likely to affect them.

“Despite our article’s focus on infectious disease findings, youth in foster care continue to be high risk for other medical problems, including developmental delay and mental health concerns – and they certainly warrant ‘early and often’ health care surveillance, as recommended by the American Academy of Pediatrics,” concludes Greiner.