St. Louis ? When Jennifer Ladage brought home the first of her three adopted children from China, she soon realized the complex medical and emotional issues such children face. Her son had severe rickets, a cleft lip and palate, and difficulty with peer interaction and new relationships.

Where to turn, she wondered.

Out of frustration, Ladage, a pediatrician and assistant professor of pediatrics at St. Louis University School of Medicine, launched a foreign adoption clinic at SSM Cardinal Glennon Children’s Hospital. Since it opened in 2000, she has become an expert on caring for adopted children from foreign lands.

FACES — or Foreign Adoption Clinic and Educational Services — is a place where parents like Yvette and Paul Hubbman of St. Louis can get a read on their Russian daughter Louise’s health issues, and find reassurance.

Ladage is more than a physician. She’s been down this road — three times.

“My first son has been a learning experience,” she said. “These are challenging children.”

The Hubbmans brought 11-month-old Louise to the clinic less than two weeks after bringing her home this month from a state orphanage in St. Petersburg, Russia.

Born prematurely, Louise was relinquished at birth by a mother whose maternal history is unknown. Louise is averse to solid food, sucks her thumb aggressively and has ear infections. She’s also delayed developmentally.

She rocks herself to sleep by kicking her tiny legs and gets upset when her parents leave the room.

“We notice she’s a lot less easygoing than Nicholas,” architect Paul Hubbman said of their 2 1/2-year-old son, also from Russia. “She’s noisy, very vocal.”

Dr. Jennifer Ladage examines 7-month-old Nadia, who was adopted from Russia, as part of her Foreign Adoption Clinic and Education Services (FACES) in St. Louis. Ladage launched FACES in 2000. Since then she has become an expert on caring for adopted children from foreign countries.

Louise screamed when nurse Cindy Debrecht gave her a TB test and vaccinations. “Oh honey,” Yvette Hubbman moaned, holding her daughter tightly.

There’s some concern that Louise may have been exposed to hepatitis C, a worry because it often runs with HIV.

A true specialty

Foreign adopted children often have illnesses and problems that many general practice pediatricians don’t encounter, so a specialty clinic made sense. Ladage says there are roughly 50 such clinics nationwide; they share information with each other by a listserv, an online forum where participants can post comments. The St. Louis clinic draws patients from Missouri, Kansas, Iowa, Nebraska and Illinois.

Each child at the FACES clinic is tested for anemia, rickets, lead, HIV, hepatitis B and C, congenital syphilis and tuberculosis, and is vaccinated and checked for nutrition, growth and development. A routine evaluation takes up to an hour and a half.

Ladage said up to 15 percent of her patients tested positive for latent tuberculosis infections. Many are malnourished, anemic or have stool parasites. Most are developmentally delayed; many are small for their age. Children typically lose one month of development for every three months they’re in an institution.

Problems not just physical

But it’s the behavioral and emotional issues that can be most challenging, she said.

A clinic colleague, child psychologist Barbara Whitman, also a professor of pediatrics at St. Louis University School of Medicine, tests the children for neurological development disorders, and makes referrals for counseling.

The stage is set for problems even before the baby is born. Mothers in impoverished countries may not have had adequate, if any, prenatal care. Some moms may have been malnourished, used illicit drugs or alcohol, or had an infection during pregnancy.

Once born, the babies may spend their first months in orphanages where staff and resource constraints mean the children don’t receive adequate nutrition or stimulation.

Ladage says that can lead to abnormal neurological development, which in turn can result in emotional, behavioral and learning problems.

She said an estimated 5 percent of adopted children had severe behavioral problems, and many had mild emotional issues — and are prone to depression and anxiety.

Such children can be more difficult to raise. They do best with highly committed parents who are willing to make sacrifices to give them consistency and security.

“They’re an extra emotional burden, but they do make progress,” she said.

Her own son, now 9, had an aversion to touch and couldn’t sit through a hair cut. Vaccinations, she said, were a “huge battle.” He still can’t tolerate clothes tags and is picky about fabric touching his skin.

But he’s made “huge progress,” she said, graduating to orthodontic work without incident.

Be prepared

Ladage says orphanages vary, and good adoption agencies will screen for problems that parents may not wish to tackle. “Sometimes you feel like you’re playing God,” she said, in that children with severe problems likely will not be placed.

Even before a child is adopted, Ladage will review any medical records the adoption agency can provide. She also prepares parents for their overseas adoption trips, advising them what medicines to bring.

Ladage says the clinic addresses acute issues such as TB, syphilis and growth in the child’s first six months. She consults with the pediatrician who takes over the child’s care, adding that most of them appreciate the clinic’s fine-tooth-comb approach.

Linda Jo Hauf, 44, who recently adopted her second Russian daughter, 7-month-old Nadia, says she’s been impressed with the FACES clinic. “I have two wonderful and healthy kids,” said Hauf, a St. Louis art teacher.