- Although international adoptions have decreased in the past 15 years, they still represent a significant portion of ~135,000 yearly U.S. adoptions.
- Diverse birth countries, disease exposures, and unknown health histories make them particularly complex.
- Multidisciplinary teams are often necessary for appropriate care. Many adoptive parents seek advice regarding adoption health needs from their primary care provider.
- 4,058 children were adopted internationally in 2018. This number has decreased every year since 2004.
- 5% of current U.S. adoptions are international.
- In 2018, the most common countries of origin for internationally adopted children were China (~40%), India, Ukraine, Colombia, South Korea, Nigeria, and Ethiopia.
- In 2018, 52% of internationally adopted children were <5 years, 33% were ages 5 to 12 years, and 15% were 13 to 17 years. More females than males were adopted internationally (52% vs. 48%) (1).
- Unknown birth, medical, and vaccination histories
- Possible in utero or postnatal toxin exposure
- Inadequate nutrition (before or after birth)
- Exposures to infectious diseases not commonly seen in the United States (2)
- Overcrowded or institutionalized living situations (e.g., orphanages)
- History of neglect, deprivation, or abuse
- Potential risks associated with foreign travel for the adopting family (3)
- A State Department–approved physician must examine the child in their native country (“panel evaluation”) before immigration to the United States. This is a limited examination targeted at identifying diseases excluding visa qualification.
- Children should be examined by a physician within 2 weeks of arrival in the United States (3).
- A follow-up visit 4 to 6 weeks after their postadoption appointment is also recommended.
- Screen for hearing, vision, growth, and developmental delay.
- Review immunization record (if available).
- A travel medicine visit is encouraged for family members who are traveling to the adopted child’s country of origin (3).
- A preadoption visit can help clarify medical diagnoses; review available medical records (including photos and/or video) to confirm/refute specific diagnoses (2).
Commonly Associated Conditions
- 80% of international adoptees have medical or developmental issues, 20% of these are severe (4).
- Infectious diseases:
- Hepatitis A/B/C
- Intestinal parasites
- Tuberculosis (TB), primarily latent
- Syphilis, including inadequately treated
- Helicobacter pylori
- Emotional or behavioral problems
- Developmental delay
- Fetal alcohol syndrome
- Feeding difficulties, malnutrition, rickets
- Congenital anomalies (e.g., cleft lip/palate, orthopedic deformities)
- Prematurity or low birth weight
- Inadequate immunizations
- Lead poisoning
- Sensorineural and conductive hearing loss
- Strabismus, blindness
- Medical records are often limited or difficult to access.
- Review immunization records carefully. Records that are “too perfect” should raise suspicion.
- Some vaccinations (e.g., Haemophilus influenzae type B [Hib], pneumococcal, varicella) are not routine in other countries.
- Review birth/prenatal history, including exposures.
- Review available family history.
- Review documented history of emotional or nutritional deprivation and physical or sexual abuse.
- Review time (if any) spent in orphanage or other institution.
- Growth charts are critical—review carefully. The first sign of malnutrition is failure to gain weight, followed by slowed linear growth, and a lag in head circumference.
- Review or observe (as able) data regarding developmental milestones, behavior, attachment, parent stress, and parent–child interactions.
- This may be the child’s first comprehensive exam; be sensitive to cues the child is providing and use a translator as necessary.
- Comprehensive physical exam. Highlight:
- Growth parameters
- General appearance; presence of features suggestive of genetic disorder, syndromes, or congenital defects
- Skin—infection or signs of prior abuse (4)
- Genitalia—signs of abuse or ritual cutting
- Neurologic—sensorimotor skills, coordination, reflexes
- Oral exam—tooth development and signs of decay
- Assess development using a validated instrument; the date of birth may be unknown (2). Assess development at each visit to identify delay and potential need for additional services. About 50–90% of internationally adopted children are delayed on adoption; most have normal cognition at long-term follow-up.
Diagnostic Tests & Interpretation
- Developmental screening
- Hearing and vision screening
Initial Tests (lab, imaging)
- Based on history and physical exam (2)[C],(3,5)[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 interferon-γ release assay ages ≥5 years
- Three stool specimens for ova and parasites, specific request for Giardia intestinalis and Cryptosporidium species testing of one sample
- Complete blood count (CBC) with indices and differential
- Blood lead concentration for ages ≤6 years
- Thyroid-stimulating hormone (TSH)
- Hemoglobinopathy/blood disorder screen—sickle cell, thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency
- Antibody titers depending on veracity of immunization records (6)[C]
- Stool cultures for bacterial pathogens (diarrhea) (2)[C]
- H. pylori testing (dyspepsia, abdominal pain, or anemia)
- Ca++, PO4, alkaline phosphate, and 25-hydroxyvitamin D level (rickets) (2)[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: Review CBC for eosinophilia to consider lymphatic filariasis in children from sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Islands, the NE coast of Brazil, Guyana, Haiti, and the Dominican Republic (5)[A].
If initially negative, repeat HIV, Hep B, Hep C, and TB testing is recommended at 6 months; negative tests may represent a “window” period or be falsely negative due to malnutrition (in the case of TST).
- HIV: Confirm antibody positive in children <18 months with DNA polymerase chain reaction (PCR) (may represent maternal antibody) (3)[A].
- Hep C: Confirm positive tests with recombinant immunoblot assay (RIBA) and/or hepatitis C virus RNA PCR; an initial positive in children <18 months may be due to maternal antibody, repeat after 18 months of age.
- Positive TST (TB): Do not attribute to bacillus Calmette-Guérin (BCG) vaccine. Evaluate for active disease; treat latent TB infection (LTBI).
- Test for intestinal parasites if gastrointestinal symptoms persist.
- 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 (2)[C].
- Behavioral concerns may first present during adolescence, even for children adopted in infancy.
- For children with history of treated congenital syphilis, follow with ophthalmologic, audiologic, neurologic, and developmental screening.
- Regular diet for children who arrive malnourished
- Monitor linear growth.
- Consider early intervention for children with suspected delays.
- Involve parents in local and online support groups.
- Postadoption depression may occur in parents.
- Immunizations: Catch up vaccines per Centers for Disease Control and Prevention (CDC) schedule (http://www.cdc.gov/vaccines/schedules/).
- Possible approaches (5)[A]:
- Ensure adoptive parents, caretakers, and household members are up-to-date with tetanus, diphtheria, and pertussis, Hep A/B, and measles vaccines (3)[A],(4)[C].
Issues For Referral
- Time referrals and elective procedures to allow adjustment to new home (2)[C]
- Individual and/or family counseling does help adjustment.
- Internationally adopted children may exhibit self-stimulating behaviors (e.g., rocking, head banging) related to prior sensory deprivation. These behaviors typically decrease with time, and no treatment is necessary if the child is 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 intervention.
- Persistent behavioral issues in the parent–child interactions merit further evaluation.
- Refer to pediatric ophthalmology for strabismus (seen in 10–25% of previously institutionalized adoptees).
- Refer to audiology and/or ear/nose/throat for concerns, questionable screening results, or if slow to acquire language skills.
- No longer hearing one’s native language slows speech development. Speech therapy helps children from non–English-speaking countries.
- Pediatric dental evaluation by 12 months of age; sooner if signs of dental pathology is present (2)[C]
Follow-up RecommendationsPatient Monitoring
- Regular well-child visits, particularly within first months of entry into the United States
- Close monitoring of developmental milestones, behavior, and attachment
- Regular diet, with specific attention to known nutritional deficiencies within country of origin (http://adoptionnutrition.org)
- Up to 68% of international adoptees fall >2 standard deviations below the mean for one or more growth parameters; most begin to follow an appropriate growth curve (<2 deviations from the mean) within 9 to 12 months of arrival to the United States.
- Allow ad lib access to healthy foods to promote self-regulatory eating behaviors.
- Toileting: Some children may not be trained yet; others may regress in their new home. Time, positive reinforcement, and avoiding punishment often resolve this issue as the child adjusts to new surroundings.
- Sleeping: Children must learn to trust their new home and parents. Avoid aggressive sleep rules. Parents should be present physically and emotionally to establish safety and promote bedtime ritual.
- Language: Adoptive family should learn key phrases in the child’s native language prior to adoption. When using translator services, be careful to avoid perception of translator use equating to potential return to native country.
- Adopted children may grieve lost family, relationships, and culture; encourage parents to acknowledge this and openly work through it. Provide counseling if needed.
- Encourage families to learn about the child’s culture and ethnicity of origin (4).
- Recovery from developmental delay correlates with time spent in institutional setting.
- Risk of long-term developmental, behavioral, or academic problems increases with adoption age.
- Rate of recovery exceeds rate of normal development (3).
- Children may regress in previously acquired skills (2).
- A desire to search for biologic family is common in adolescence (4).
- American Academy of Pediatrics’ Council on Foster Care, Adoption, and Kinship Care (http://www2.aap.org/sections/adoption/index.html)
- Barrat MS. International adoption. Pediatr Rev. 2013;34(3):145–146. [PMID:23457203]
- National Center for Immunization and Respiratory Diseases. General recommendations on immunization—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(2):1–64. [PMID:21293327]
- Z02.82 Encounter for adoption services
- Z62.821 Parent-adopted child conflict
- Internationally adopted children may exhibit self-stimulating behaviors (e.g., rocking, head banging) that usually decrease over time. Refer to developmental or occupational specialist when concerns persist.
- A preadoption visit can identify medical concerns, ensure travel safety for prospective parents, and prepare resources prior to a child’s arrival.
- Initial labs for internationally adopted children include Hep A/B/C, HIV 1/2, 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), and urinalysis.
- If initially negative, repeat HIV, Hep B/C, and TST at 6 months.
- Catch up immunizations per CDC schedule (http://www.cdc.gov/vaccines/schedules/).
- Ensure that appropriate immunizations are up-to-date for adoptive family and caretakers.
R. Aaron Lambert, MD, FAAFP
- U.S. Department of State, Bureau of Consular Affairs. Intercountry adoption. https://travel.state.gov/content/adoptionsabroad/en.html. Accessed September 22, 2019.
- Jones VF; and Committee on Early Childhood, Adoption, and Dependent Care. Comprehensive health evaluation of the newly adopted child. Pediatrics. 2012;129(1):e214–e223. [PMID:22201151]
- Centers for Disease Control and Prevention. CDC Health Information for International Travel 2014. New York, NY: Oxford University Press; 2014.
- Barratt MS. International adoption. Pediatr Rev. 2013;34(3):145–146. [PMID:23457203]
- 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; 2012:239–240.
- Feja KN, Tolan RW Jr. Infections related to international travel and adoption. Adv Pediatr. 2013;60(1):107–139. [PMID:24007842]
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