> Table of Contents > Adoption, International
Adoption, International
Theodore R. Brown, DO, MPH, FAAFP
image BASICS
DESCRIPTION
Although international adoptions have decreased in the past 10 years, they still represent a significant portion of the roughly 135,000 yearly U.S. adoptions. The demographics of those children and their homelands have shifted significantly during that time. Diverse birth countries, disease exposures, and unknown health histories of these children make them a population that requires special attention. Although specialty clinics are becoming more prevalent, many adoptive parents will look to their primary care provider for their adoption health care needs.
EPIDEMIOLOGY
Incidence
  • 7,092 children were adopted internationally in 2013.
  • Approximately 5% of all U.S. adoptions are international, decreased from 17% in 2004.
  • In 2013, the most common countries of origin for internationally adopted children were the following in descending order: China, Ethiopia, Ukraine, Haiti, Democratic Republic of Congo, Uganda, Russia, Nigeria, Philippines, and Bulgaria.
  • In 2013, 8% of internationally adopted children were <1 year of age, 54% were ages 1 to 4 years, 29% were ages 5 to 12 years, and 9% were ≥ 13 years. 55% were girls.
RISK FACTORS
  • Unknown birth, medical, and vaccination histories
  • Possible exposure to toxins and/or inadequate nutrition in utero
  • Exposures to infectious diseases are not commonly seen in the United States (1).
  • Previous living conditions
    • Overcrowding
    • Institutionalization (orphanages)
  • History of neglect, deprivation, or abuse
  • For adoptive family, risks associated with required foreign travel (2)
GENERAL PREVENTION
  • Required to be examined by a U.S. State Department physician in their native country before immigration to the United States; limited examination targeted at identifying diseases that would exclude qualifying for a visa
  • Should be examined by a U.S. physician within 2 weeks of arrival or sooner if indicated (2)
  • A follow-up visit 4 to 6 weeks after their postadoption appointment is recommended.
  • All internationally adopted children should be screened for hearing, vision, growth, and developmental delays (3).
  • Travel medicine visit for all family members traveling to adopted child's country (2)
  • A preadoption visit between the adoptive family and physician can be helpful in clarifying medical diagnoses, reviewing available medical records, as well as photos and/or video that can help to confirm/refute specific diagnoses (1).
COMMONLY ASSOCIATED CONDITIONS
  • 60% of international adoptees have a mild to moderate medical or developmental issue (4)
    • 20% have no issue; 20% have a severe problem.
  • Infectious diseases, including the following:
    • Hepatitis A/B/C
    • Intestinal parasites
    • Tuberculosis (TB), primarily latent
    • Syphilis, including inadequately treated
    • HIV
    • Helicobacter pylori
  • Emotional or behavioral problems
  • Developmental delay
  • Fetal alcohol syndrome
  • Feeding difficulties, malnutrition, rickets
  • Anemia
  • Congenital conditions (e.g., cleft lip/palate, orthopedic deformities)
  • Prematurity or low birth weight
  • Inadequate immunizations
  • Lead poisoning
  • Sensorineural and conductive hearing loss
  • Strabismus, blindness
image DIAGNOSIS
PHYSICAL EXAM
  • Comprehensive unclothed physical exam, paced to child's comfort; particular attention to
    • Growth parameters
    • General appearance; presence of features suggestive of genetic disorder, syndromes, or congenital defects
    • Skin, for infection or signs of prior abuse (4)[C]
    • Genitalia, for signs of abuse or ritual cutting
    • Neurologic findings
    • May be child's first comprehensive exam; remain sensitive to child's cues and consider translator for older children.
  • Evaluate for signs of dental decay, and refer for prompt treatment.
  • Developmental assessment, especially for those with unknown date of birth (1)[C]
DIAGNOSTIC TESTS & INTERPRETATION
  • Developmental screening: validated developmental screening tools at each visit to screen for potential developmental delay and to assess improvement, decline, and need for additional services
  • Age-appropriate hearing and vision screening
Initial Tests (lab, imaging)
  • Obtain: (1,5)[C],(2,6)[A]
    • Hepatitis A (Hep A IgM, Hep A IgG)
    • Hepatitis B (HBsAg, HBsAb, HBcAb)
    • Hepatitis C (enzyme immunoassay [EIA])
    • HIV 1 and 2 antibody testing/ELISA
    • Syphilis: nontreponemal (RPR, VDRL, or ART) and treponemal (MHA-TP, FTA-ABS, or TPPA)
    • Tuberculin skin test (TST) in all ages or interferongamma release assay ages ≥ 5 years
    • Three stool specimens for ova and parasites, specific request for Giardia intestinalis and Cryptosporidium species testing of one sample
    • CBC with indices and differential
    • Blood lead concentration for ages ≤6 years
    • Thyroid-stimulating hormone (TSH)
    • Urinalysis
    • Hemoglobinopathy/blood disorder screen: sickle cell, thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency
  • Consider based on clinical presentation:
    • Serologic testing for antibody titers depending on the availability/reliability of immunization records (see “MEDICATION”) (7)[C]
    • Stool cultures for bacterial pathogens (for children with diarrhea) (1)[C]
    • H. pylori testing (for children with dyspepsia, abdominal pain, or anemia) (5)[C]
    • Ca++, PO4, alkaline phosphate, and 25 vitamin D level (if signs of rickets) (1)[C]
    • > 12 months of age: for Chagas disease via Trypanosoma cruzi, serologic testing in adoptees from endemic countries (Mexico, Central and South America)
    • >24 months of age: for lymphatic filariasis in those with eosinophilia if from endemic countries (sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Islands, the NE coast of Brazil, Guyana, Haiti, and the Dominican Republic) (6)[A]
Follow-Up Tests & Special Considerations
  • Hep C: confirm positive tests with recombinant immunoblot assay (RIBA) and/or HCV RNA PCR; an initial positive in children <18 months may be due to maternal antibody, repeat after 18 months of age.
  • Positive TST (TB) must NOT be attributed to bacille Calmette-Guérin (BCG) vaccine and must be investigated; if not active disease, treat latent TB (5)[C].
  • GI tract signs or symptoms occurring years after immigration: test for intestinal parasites.
  • Eosinophilia >450 cells/mm3 with negative stool ova and parasites: serologic testing for Schistosoma; add Strongyloides for adoptees from sub-Saharan African, Latin American, and Southeast Asian countries (1)[C].
  • Developmental screening: repeat at each visit and follow progress; 50-90% of internationally adopted children are delayed on adoption; however, most have normal cognition at long-term follow-up (3)[C].
  • Social history screening: Behavioral concerns may first present during adolescence, even for children adopted in infancy.
  • Serial evaluations to age 12 months for children with history of treated congenital syphilis: ophthalmologic, audiologic, neurologic, and developmental (5)[C]
P.31

image TREATMENT
GENERAL MEASURES
  • Regular diet for children who arrive malnourished
  • Monitor linear growth.
  • If developmental delay is diagnosed, consider early services (e.g., early intervention) or referral to developmental specialist.
  • Recommend local support groups for parents.
  • Attention to parental interactions: Postadoption depression may occur.
MEDICATION
  • Immunizations/Catch-up per CDC schedule (http://www.cdc.gov/vaccines/schedules/)
    • No further Hep B vaccine needed if: HBsAg positive; HBsAb and HBcAb positive; or HBsAb positive and HB vaccine given appropriately
    • MMR should be used for vaccination for mumps and rubella, even in presence of measles antibodies (7)[C].
  • Multiple approaches to children vaccinated outside the United States are acceptable (6)[A]:
    • Repeating questionable vaccinations negates the need to obtain serologic tests.
    • To minimize/avoid vaccine administration, check antibody titers.
  • The following antibody titers can be measured:
    • Infants 6 to 12 months of age: polio, diphtheria, tetanus (latter two can serve as marker for DPT)
    • Children > 12 months: Hep A, measles, mumps, rubella, varicella (7)[C]
  • Adoptive parents, caretakers, and household members should be up to date on Tdap, Hep A, Hep B, and measles (2)[A],(4)[C].
ISSUES FOR REFERRAL
  • Referrals are often necessary for diagnostic and treatment expertise; however, they should be minimized and planned carefully to ensure adjustment to the new home (1)[C].
    • Elective surgical procedures should likewise be deferred until the child has grown accustomed to his or her new home (3)[C].
  • Individual or family counseling considered for all adoptive families for adjustment support
  • Internationally adopted children may exhibit self-stimulating behaviors (e.g., rocking, head banging); may be related to prior sensory deprivation. These behaviors typically decrease with time, and no treatment is necessary if otherwise developing normally. If in doubt, refer to developmental pediatrics or occupational therapy.
    • If a child continues to have disruptive behaviors, or would rather self-soothe than seek nurturing human interaction, consider a thorough developmental evaluation.
    • Persistent behavioral issues in the parent-child interactions should be evaluated by a pediatric psychologist or psychiatrist (3)[C].
  • Vision (strabismus in 10-25% of previously institutionalized adoptees): Refer to pediatric ophthalmology.
  • Hearing (higher rates of conductive and sensorineural hearing loss): Refer to audiology and/or ENT for concerns, questionable screening results, or if slow to acquire language skills (3)[C].
  • Pediatric dental evaluation by 12 months of age; sooner if signs of dental pathology are present (1)[C].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Regular well-child visits, particularly within first months of entry into the United States
  • Close monitoring of developmental milestones, behavior, and individual attachment
DIET
  • Regular diet
  • Up to 68% fall >2 standard deviations below the mean for one or more growth parameters; most begin to follow a curve <2 deviations from the mean within 9 to 12 months (3).
PATIENT EDUCATION
  • Eating: Allow access to as much healthy food as the child wants so the child can learn self-regulatory behaviors of eating that may not have been learned in an institution (hunger, satiety) and can build trust with the parent(s) who feed him or her.
  • Toileting: Some children may not be trained yet, others who were may regress and have accidents in their new home. Time, positive reinforcement, and avoiding punishment will resolve this issue as the child becomes comfortable with the new surroundings.
  • Sleeping: Children must learn to trust their new home and parents, and thus, this is not a time for aggressive sleep rules. Parents should be present, physically and emotionally, just enough to let the child knows that he or she is safe; establishing and then gently reinforcing a bedtime ritual on arrival.
  • Language: Adoptive family should learn key phrases in the child's native language prior to adoption. A translator should be available for school-aged children for the first few weeks; avoid the perception on the child's part that a translator's presence signifies potential return to his or her country.
  • Adopted children may experience grieving of lost family, relationships, and culture, which is common, expected, and healthy behavior; encourage parents to acknowledge and work through this loss with their children, considering formal counseling, if needed (3).
  • Children and families should be encouraged to learn about the culture of the birth country and the ethnic group of origin, including forming relationships with others of the same racial or ethnic group (4).
PROGNOSIS
  • Degree of recovery of developmental delays is likely dependent on duration of time spent in an institution
    • Likelihood of long-term developmental, behavioral, or academic problems increases with adoption age.
    • Rate of recovery appears to exceed rate of normal development over a period of years and continues indefinitely (2).
  • Some children may regress in previously acquired skills (1).
  • When the child reaches adolescence, a desire to search for his or her biologic family is common (4).
  • Adoption medicine is an evolving specialty, with an ever-increasing number of resources available, including the American Academy of Pediatrics' Council on Foster Care, Adoption, & Kinship Care (http://www2.aap.org/sections/adoption/index.html).
REFERENCES
1. Jones VF, High PC, Donoghue E, et al. Comprehensive health evaluation of the newly adopted child. Pediatrics. 2012;129(1):e214-e223.
2. Centers for Disease Control and Prevention. CDC Health Information for International Travel 2014. New York, NY: Oxford University Press; 2014.
3. Schulte EE, Springer SH. Health care in the first year after international adoption. Pediatr Clin North Am. 2005;52(5):1331-1349.
4. Barratt MS. International adoption. Pediatr Rev. 2013;34(3):145-146.
5. Miller LC. International adoption: infectious diseases issues. Clin Infect Dis. 2005;40(2):286-293.
6. American Academy of Pediatrics. Medical evaluation of internationally adopted children for infectious diseases. In: Pickering LK, ed. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
7. Feja KN, Tolan RW Jr. Infections related to international travel and adoption. Adv Pediatr. 2013;60(1):107-139.
Additional Reading
  • Dawood F, Serwint JR. International adoption. Pediatr Rev. 2008;29(8):292-294.
  • Grogg SE, Grogg BC. Intercountry adoptions: medical aspects for the whole family. J Am Osteopath Assoc. 2007;107(11):481-489.
  • Kroger AT, Sumaya CV, Pickering LK, et al. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(RR02):1-60.
  • U.S. Department of State, Bureau of Consular Affairs. The Hague Convention on Intercountry Adoption: a guide for prospective adoptive parents. http://travel.state.gov/content/dam/aa/pdfs/PAP_Guide_1.pdf.
  • Weitzman C, Albers L. Long-term developmental, behavioral, and attachment outcomes after international adoption. Pediatr Clin North Am. 2005;52(5):1395-1419.
Codes
ICD10
  • Z02.82 Encounter for adoption services
  • Z62.821 Parent-adopted child conflict
Clinical Pearls
  • Initial labs: Hep B, Hep A, Hep C, HIV 1 and 2, syphilis, CBC, TSH, lead, G6PD deficiency, hemoglobin electrophoresis; PPD/TST (or IGRA ages ≥5 years), ova and parasites (three stool specimens, including single specimen for Giardia and Cryptosporidium antigens), urinalysis
  • If initially negative, repeat of HIV, Hep B, Hep C, and TST testing are recommended at 6 months; negative tests may represent a “window” period or be falsely negative due to malnutrition in the case of TST.
  • Immunizations per CDC schedule with catch-up (http://www.cdc.gov/vaccines/schedules/), as needed; ensure that adoptive family and caretakers are current on Tdap, Hep A, Hep B, measles.
  • Internationally adopted children may exhibit self-stimulating behaviors (e.g., rocking, head banging), will typically decrease with time, and do not require treatment if otherwise developing normally; refer to developmental pediatrics or occupational therapy if there are concerns.
  • Adoption medicine is an evolving specialty, with an ever-increasing number of resources available, including the American Academy of Pediatrics' Council on Foster Care, Adoption, & Kinship Care (http://www2.aap.org/sections/adoption/index.html).