Last summer, news reports captured the public's attention with stories about thousands of Central American children crossing the Mexican-American border. Although these stories have faded from the front page, nurses like Cathy Woodward, DNP, RN, PNP-AC, began wrestling with questions about the future healthcare needs of these children.
Woodward, an Associate Professor in the Department of Pediatrics at the University of Texas Health Science Center in San Antonio, has been volunteering at a portable health clinic in McAllen, at the southern tip of Texas in the Rio Grande Valley.
"When I first began treating these children, there were certain questions I had about immunizations and TB testing, and I had to do research to find the answers," said Woodward, who is a chairperson of the Global Health Care Special Interest Group for the National Association of Pediatric Nurse Practitioners (NAPNAP). "I thought it would be useful to share this information with other healthcare providers."
Guidelines address issues
Woodward and three other NPs from the Global Health Care Special Interest Group developed guidelines for primary care providers for the care of newly immigrated children.
The guidelines were released in March at the NAPNAP annual conference in Las Vegas. The two-page poster covers TB screening, immunizations, mental health, developmental needs, nutrition, and growth.
TB screening is recommended for children who have symptoms of tuberculosis, emigrated from countries with a high burden of TB disease, or had close contact with someone with the disease, according to the poster.
Guatemala is the one Latin American country that is a moderate risk, according to the Centers for Disease Control and Prevention. The states with the most unaccompanied children released to sponsors are Texas, New York, California, and Florida, according to the Office of Refugee Settlement.
While volunteering, Woodward also learned how to handle immunizations for this patient population, and the guidelines address this issue.
"If patients have written records of immunizations, then clinicians can start from where the children left off rather than re-immunizing," Woodward said. "If they do not have records, then they should restart or draw blood to see if antibodies are present, but the latter is very expensive."
The guidelines also cover the specific mental health issues children may be facing — such as depression, anxiety, isolation, exposure to violence, and post-traumatic stress disorder — and provide tools for evaluating and treating behavioral health.
Life in the states
According to data from the U.S. Department of Homeland Security, border protection agencies encountered more than 67,000 children from Guatemala, El Salvador, Honduras, and Mexico in 2014, compared with about 38,000 the previous year. Data from the first quarter of 2015 suggest the numbers are dropping significantly as a result of government efforts to decrease illegal immigration.
Although the numbers are decreasing, most of the children Woodward saw in Texas had slim prospects of receiving health insurance in the near future because they were not legal citizens, she said.
As these children start their new lives in the U.S., nurses may have an opportunity to treat them in emergency rooms, school systems, free health clinics, or other settings. In fact, community-based nurses are well trusted in Central America, which gives American nurses a unique opportunity to help these children, said Allison Squires, PhD, RN, an assistant professor in the College of Nursing at New York University, who has conducted health research in Latin America.
"What you find in Latin America is a greater emphasis on community-based preventive care," Squires said. "The governments there depend on this because these countries have fewer resources to treat illnesses if they are not prevented."
Joyce Yoshimizu, RN, PNP, a nurse who works in a school-based health clinic in the Los Angeles Unified School District, said the clinic experienced a large influx of children in the last three months of the 2013 to 2014 school year, and the majority of those children were unaccompanied minors from Central America.
As a result of the influx, the clinic treated more than 2,600 students during the 2013 to 2014 school year — a 13% increase compared with the previous year. New foreign students undergo a complete health assessment, which includes a health history; physical examination; laboratory tests for anemia and lead; and developmental, nutritional and dental assessments. The students also are given vision and hearing tests.
Care with dignity
"The most common [health concerns] we see are obesity, dental cavities, vision problems, anemia and asthma, but we do find other defects such as scabies, atopic dermatitis and tinea," Yoshimizu said. Many students from Central America do not have immunization records, and as a result they receive the standard vaccines in the school health clinic, which is part of the School Enrollment Placement Assessment Center.
Although the district no longer requires TB testing for students, international students new to the district are given a TB risk assessment with questions about whether they have been in a high-risk country or have a family member with the disease. Many of the new students who enter the clinic answer "yes" to one of the questions in the assessment and are therefore given the Mantoux TB skin test, but very rarely do they test positive for the disease, Yoshimizu said.
Emergency department (ED) nurses also may encounter immigrant children — particularly those with chronic medical conditions that have worsened due to delayed treatment, said Elda Ramirez, PhD, RN, FNP-C, FAANP, a clinical professor in the School of Nursing at the University of Texas who has worked as an emergency nurse for 25 years.
"We see children with upper respiratory infections as a result of asthma, but they do not usually come in unless they are really sick," Ramirez said. "The relatives may take the child to a sobadora (massage healer) or other type of healer before seeking help through Western medicine."
Ramirez also watches for signs that help is needed beyond the immediate physical symptoms that prompted the visit to the ED. Nurses can assess whether patients are growing properly, communicating in a way that is developmentally appropriate, receiving dental care, and wearing clean clothes.
"If you see signs that there is not enough support for this child, then go through the hospital to request a social work assessment because there are resources for families," she said.
Although nurses may encounter cultural and language differences and opposing political opinions surrounding the children who enter this country, Ramirez believes it is imperative to rise above these factors to facilitate the best healthcare for this patient population.
"There are a lot of people who are on one side or the other in the immigration debate, and this can be a very uncomfortable place for healthcare providers," Ramirez said. "It is really important not to have any bias or judgment. The bottom line is that we need to treat these children with dignity and ask ourselves whether there is anything we can do to make this child healthier."
The impact of violence
The children who emigrate from Central America seem to be in fairly good physical health when they arrive, but nurses on the frontlines of border healthcare are concerned about a different issue: the impact of the psychological trauma these children encounter before they arrive.
"It is critical that nurses are informed about the factors that led to the children's migration so we can respond to issues such as violence and separation from family," said Marylyn McEwen, PhD, PHCNS-BC, FAAN, an Associate Professor in the College of Nursing at the University of Arizona and President of the Border Health Nurses chapter of the Arizona Nurses Association.
