Annually, more than 20 000 children from other countries are adopted by families in the United States. More than 90% of international adoptees are from Asian (China, South Korea, Philippines, Vietnam, and India), Central and South American (Guatemala and Colombia), and Eastern European (Russia, Belarus, Ukraine, Kazakhstan, and Bulgaria) countries. Africa and the Middle East are less common origins for international adoptees, but an increasing minority of children are adopted from Ethiopia, Sierra Leone, Liberia, and other African countries. The diverse birth countries of these children, their unknown medical histories before adoption, their previous living circumstances (eg, orphanages and/or foster care), and the limited availability of reliable health care in some economically developing countries make the medical evaluation of internationally adopted children a challenging but important task.

Internationally adopted children typically differ from refugee children in terms of their access to medical care and Treatment before arrival in the United States and in the frequency of certain infectious diseases. Many refugee children may have resided in refugee camps for months before resettlement in the United States and will have had access to limited medical care and Treatment services. The history of access to and quality of medical care for international adoptees can be variable. Before admission to the United States, all internationally adopted children are required to have a medical examination performed by a physician designated by the US Department of State in their country of origin. However, this examination is limited to completing legal requirements for screening for certain communicable diseases and examination for serious physical or mental defects that would prevent the issue of a permanent residency visa. Information about this required health assessment is available at www.cdc.gov/ncidod/dq/refugee/faq/faq_aliens.htm. This evaluation is not a comprehensive assessment of the child's health. During preadoption visits, pediatricians can stress to prospective parents the importance of acquiring immunization and other health records. The Immigration and Nationality Act of 1996 requires immigrant visa applicants to provide "proof of vaccination" with vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) before entry into the United States. Internationally adopted children who are 10 years of age and younger may obtain a waiver of exemption from the Immigration and Nationality Act regulations pertaining to immunization of immigrants before arrival in the United States (see Refugees and Immigrants). When an exemption is granted, adoptive parents are required to sign a waiver indicating their intention to comply with ACIP-recommended immunizations within 30 days after the child arrives in the United States. However, the child should be seen by his or her pediatrician as soon as possible after arrival in the United States to begin all preventive health services, including immunizations.

Infectious diseases are among the most common medical diagnoses identified in international adoptees after arrival in the United States. Children may be asymptomatic, and therefore, the diagnoses must be made by screening tests in addition to history and physical examination. Because of inconsistent use of the birth dose of hepatitis B vaccine; inconsistent perinatal screening for hepatitis B, syphilis, and human immunodeficiency virus (HIV); and the high prevalence of certain intestinal parasites and tuberculosis, all international adoptees should be screened for these infections on arrival in the United States. Suggested screening tests for infectious diseases are listed in Table 2.16 (see also disease-specific chapters in Section 3). In addition to these infections, other medical and developmental issues, including hearing and vision assessment, evaluation of growth and development, nutritional assessment, blood lead concentration, complete blood cell count with red blood cell indices, newborn screening and/or measurement of thyroid-stimulating hormone concentration, and examination for congenital anomalies (including fetal alcohol syndrome), should be part of the initial evaluation of any internationally adopted child.

Table 2-16

Parents generally will have limited information about a child before the adoption. Parents should obtain any medical information available and meet with the child's physician before their child arrives home to review available information and to discuss common medical issues regarding internationally adopted children. Parents who have not met with a physician before adoption should notify their physician when their child arrives so that a timely medical evaluation can be arranged. Internationally adopted children should be examined as soon as possible after arrival in the United States. A list of pediatricians with special interest in adoption and foster care medicine is available on the American Academy of Pediatrics Web site at www.aap.org/Sections/adoption/SOAFCAdoptionDirectory2.pdf.