Description

Adoption of children from foreign countries into the US has tripled in the past 15 years, and the demographics of those children and their homelands have also shifted significantly during that time. The diverse birth countries, disease exposures, and unknown health histories of these children make them a population that requires special attention.

Epidemiology

• >20,000 international adoptions by US families every year
• In 2009, the most common countries of origin for internationally adopted children were, in order, China, Ethiopia, Russia, South Korea, Guatemala, Ukraine, Vietnam, Haiti, India, and Kazakhstan (CDC)

Risk Factors

• Unknown birth history, medical history, and vaccination status
• Possible exposure to toxins and/or inadequate nutrition in utero
• Exposures to infectious diseases not commonly seen in the US
• Previous living conditions:
  • Overcrowding
  • Institutionalization (orphanages)
  • Environmental toxins
• History of neglect, deprivation, or abuse

General Prevention

• Required to be examined by a US State Department physician in their native country before immigration to the US (1).
• Should be examined by a US physician within 3 weeks of arrival.
• A follow-up visit 4–6 weeks after their post adoption appointment is recommended.
• All internationally adopted children should be screened for hearing, vision, growth, and developmental delays.

Commonly Associated Conditions

• Infectious diseases, including (1,2):
  • Hepatitis B
  • Intestinal parasites
  • Tuberculosis
  • Syphilis
  • HIV
  • Helicobacter pylori
• Emotional or behavioral problems
• Developmental delay
• Fetal alcohol syndrome
• Feeding difficulties
• Anemia
• Congenital conditions, including:
  • Cleft lip/palate
  • Orthopedic deformities
• Prematurity or low birth weight
• Malnutrition, rickets
• Inadequate immunizations
• Lead poisoning
• Sensorineural and conductive hearing loss
• Strabismus, blindness

History

• Immunization records and titers (most helpful when dates of administration are included)
• Birth/Prenatal history
• Known family history of birth parents
• Prenatal and perinatal disease or toxin exposures
• Documented history of emotional or nutritional deprivation, or physical or sexual abuse
• Duration of time, if any, spent in orphanage. (Studies have suggested every 3–5 months spent in orphanage is associated with 1 month delay in developmental milestones, although quality of care can vary widely.)
• Growth charts when available: Failure to gain weight appropriately (or weight loss) is the earliest sign of malnutrition, followed by slowed linear growth, and finally lagging head circumference (brain growth).
• Development, behavior, attachment, parent stress, and parent–child interactions should also be routinely monitored.

Physical Exam

• Age-appropriate complete physical exam, with particular attention to growth, evaluation for microcephaly (red flag for fetal alcohol syndrome, genetic disorders, or perinatal brain injury), vision, and hearing
• Evaluate for signs of dental decay and refer for prompt treatment.
• Developmental assessment, especially for those with unknown date of birth
• Skin exam for signs of scabies, pediculosis, and tinea

Diagnostic Tests and Interpretation

• Developmental screening: Denver II Test and/or PEDS parent questionnaire or other 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 screening
• Age-appropriate vision screening

• Obtain (2,3):
  • Hepatitis A (Hep A IgM, Hep A IgG)
  • Hepatitis B (HBsAg, HBsAb, HBcAb)
  • Hepatitis C (enzyme immunoassay [EIA])
  • HIV 1,2 antibody testing/ELISA; consider DNA polymerase chain reaction (PCR) for those <6 months
  • Syphilis: Nontreponemal (RPR, VDRL, or ART) and treponemal (MHA-TP, FTA-ABS, or TPPA)
  • Tuberculin skin test in all ages or interferon-gamma release assay ages ≥5 years
  • 3 stool specimens for ova and parasites, and single specimen for Giardia intestinalis and Cryptosporidium parvum antigens
  • CBC
  • Lead
  • Thyroid-stimulating hormone (TSH)
  • Urinalysis
• Consider based on clinical presentation (2,3)
  • Rapid flourescence spot test to screen for G6PD, Hgb electrophoresis (if anemic, from endemic region)
  • Stool cultures for bacterial pathogens (for children with diarrhea)
  • H. pylori testing (for children with dyspepsia, abdominal pain, or anemia)
  • Ca⁺⁺, PO₄, alkaline phosphate, and 25 vitamin D level (if signs of rickets)
  • >12 months of age: For Chagas disease via Trypanosoma cruzi serologic testing in adoptees from endemic countries (Mexico, Central and South America)
  • Provide age-appropriate immunization if unreliable record of DTaP, polio, measles-mumps-rubella (MMR), or pneumococcal.
  • Conduct serologic testing and immunize for Hep A, varicella. If no record of MMR, can immunize with MMR or check measles, mumps antibodies and if positive give one dose MMR for rubella coverage.

• Hep B: Repeat at 6 months.
• HIV: Transplacentally acquired maternal antibody may be present in uninfected infants up to 18 months: If antibody positive, confirm with DNA PCR for children <18 months.
• Hep C: Positive tests should be confirmed with recombinant immunoblot assay (RIBA) testing and/or HCV RNA PCR. Transplacentally acquired maternal antibody may be present in uninfected infants up to 18 months, so if positive <18 months, repeat after this age.
• Tuberculosis (TB): Positive tuberculin skin test should NOT be attributed to bacille Calmette-Guérin (BCG) vaccine, and must be investigated. Give preventive therapy if known exposures. Repeat testing at 6 months, as poor nutrition may result in false-negative (anergic) skin test. No chest x-ray (CXR) indicated.
• GI tract signs or symptoms occurring years after immigration: Test for intestinal parasites.
• Eosinophilia: Eosinophilia >450 cells/mm³ with negative stool ova and parasites, serologic testing for Schistosoma; and add Strongyloides for adoptees from sub-Saharan African, Latin American, and Southeast Asian countries
• Developmental screening: Repeat at each visit and follow progress. 50–90% of all internationally adopted children are delayed upon adoption; however, most of them have normal cognition at long-term follow-up.
• Social history screening: Behavioral concerns may first present during adolescence, even for children adopted in infancy (4).

Medication (Drugs)

• Immunizations per Centers for Disease Control and Prevention schedule with catch-up as needed: http://www.cdc.gov/vaccines/recs/schedules/
• If no records, or records do not comply with the US or WHO guidelines, treat as unimmunized.
• Adoptive parents, caretakers, and household members should be up to date on TdaP and Hep A

Additional Treatment

• 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: Post adoption depression may occur.

• Individual or family counseling considered for all adoptive families for adjustment support.
• Many internationally adopted children show sensory-seeking behaviors early on thought to be related to the sensory-depriving orphanage experience. These behaviors typically improve without treatment. Child may appear similar to autistic-like features (e.g., hand-flapping, rocking), but if child is otherwise developing normally (socially, emotionally), no action needed (1).
• 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.
• Vision (higher rates of strabismus): Refer to pediatric ophthalmology (1).
• Hearing (higher rates of conductive and sensorineural hearing loss): Refer to audiology and/or ENT (1).
• Pediatric dental evaluation by 12 months of age, sooner if signs of dental pathology.

Follow-Up Recommendations

• Regular well-child visits, particularly within first months of entry into the US
• Close monitoring of developmental milestones, behavior, and individual attachment

Diet

• Regular diet
• Weight catch-up will occur with a normal diet, barring other medical conditions, and eating habits should normalize using parenting methods discussed below (5).

Patient Education

• Eating: The recommended approach is to allow access to as much healthy food as the child wants, as often as he or she wants it, so that the child can learn the important 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: While some children may simply not be trained yet, others may have accidents in their new home because of regression. Time and positive reinforcement and avoiding punishment will resolve this issue as the child becomes comfortable with his or her new surroundings.
• Sleeping: Children must learn to trust their new home and parents, and thus this is not a time for aggressive sleep rules (i.e., ferberization). Parents should be present, physically and emotionally, just enough to let the child know he or she is safe, establish a bedtime ritual upon arrival, and then gently reinforce this ritual.
• Language: As the child experiences a myriad of changes, it may be helpful for the adoptive family to have learned some key phrases in the child’s native language for the first few weeks post-adoption. Depending on the child’s age and language proficiency, an interpreter may also be useful in the home and at medical appointments until English becomes more comfortably understood and familiar (1).
• Adopted children may experience grieving of lost family, relationships, and culture, which is common and expected behavior; encourage parents to acknowledge and work through this loss with their children, and consider formal counseling, if needed.
• At 3–4 years of age, adopted children will begin to recognize physical differences between themselves and adoptive family if they are of different racial origin.
• Children and families should be encouraged to learn about the culture of the birth country and the ethnic group of origin.
• Relationships with others of the same racial or ethnic group may be very helpful to the adopted child.

Prognosis

Long-term issues include (5,6):

• Children who experienced early neglect, deprivation, or loss prior to adoption are more likely to have developmental delay or behavioral or attachment problems.
• These issues decrease with time the child has spent within the adoptive family, although those with significant histories of deprivation are at risk for difficulties that may persist for life.
• Although most adopted children are healthy, as a group, they have been found to have higher rates of moderate to severe physical and mental health problems, hearing and visual impairment, learning disability, developmental delay, and special health care needs when compared with biologic children of the same parents.
• Developmental delay, in particular, is found to be more likely in an internationally adopted child than in his or her nonadopted peers. However, recent studies show marked catch-up development reported after living in adoptive homes, with many children achieving normal-range development later in life (depending on length of time spent in an institution prior to adoption).
• Fortunately, international adoption pairs some of the most vulnerable, potentially high-risk children with the lowest-risk parents (usually financially stable, well educated, with relatively extremely low divorce rates).
• Most families have found the process of international adoption deeply rewarding, while acknowledging the potential challenges.

ICD-9

V70.3 Other general medical examination for administrative purposes

ICD-10

• Z02.82 Encounter for adoption services

SNOMED

• 171382000 Adoption medical examination