International adoptions have decreased in the past 10 years. They still represent a significant portion of ~136,000 yearly U.S. adoptions. Diverse birth countries, disease exposures, and unknown health histories of these children require special attention. Multidisciplinary teams are often necessary for appropriate care.
- 5,370 children were adopted internationally in 2016. This number has decreased every year since 2004.
- 5% of current U.S. adoptions are international, down from 17% in 2004.
- In 2016, the most common countries of origin for internationally adopted children were China, Ethiopia, Russia, South Korea, and Ukraine.
- In 2015, 47% of internationally adopted children were <5 years, 38% were ages 5 to 12 years, and 15% were ≥13 years. 50% were girls (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)
- Previous living conditions overcrowded or institutionalized (e.g., orphanages)
- History of neglect, deprivation, or abuse
- For adoptive family, potential risks associated with foreign travel (3)
- U.S. State Department physician must examine the child in their native country before immigration to the United States. This is a limited examination targeted at identifying diseases that exclude visa qualification.
- Should be examined by a U.S. physician within 2 weeks of arrival (3)
- A follow-up visit 4 to 6 weeks after their postadoption appointment is recommended.
- Screen for hearing, vision, growth, and developmental delay.
- Travel medicine visit for all family members traveling to 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. Suspicious records are often “too perfect.”
- Some vaccinations are (e.g., Haemophilus influenzae type B [Hib], pneumococcal, varicella) are not routine in other countries.
- Birth/prenatal history, including exposures
- Available family history
- Documented history of emotional or nutritional deprivation, or physical or sexual abuse
- Time (if any) spent in orphanage or other institution
- Growth charts are critical. The first sign of malnutrition is failure to gain weight, followed by slow linear growth, and lagging 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 the child’s cues and use a translator if necessary.
- Comprehensive physical exam emphasizing:
- Growth parameters
- General appearance; presence of features suggestive of genetic disorder, syndromes, or congenital defects
- Skin—infection or signs of prior abuse (4)[C]
- Genitalia—signs of abuse or ritual cutting
- Neurologic—sensorimotor skills, coordination, reflexes
- Oral exam is important to look for tooth development and signs of decay.
- Developmental assessment using a validated instrument is important, especially if the date of birth is unknown (2)[C]. Developmental screening should be assessed at each visit to identify delay and potential need for additional services. 50–90% of internationally adopted children are delayed on adoption; however, 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-gamma 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)
- 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 vitamin 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 of HIV, Hep B, Hep C, and TB 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.
- HIV: If antibody positive in children <18 months, confirm with DNA PCR (may represent maternal antibody) (3)[A].
- 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): Do not attribute to bacille Calmette-Guérin (BCG) vaccine. Evaluate for active disease; treat latent TB.
- Test for intestinal parasites if GI 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.
- Follow children with history of treated congenital syphilis: ophthalmologic, audiologic, neurologic, and developmental delays with serial exams and/or serologies.
- 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 per CDC schedule (http://www.cdc.gov/vaccines/schedules/).
- Possible approaches (5)[A]:
- Update adoptive parents, caretakers, and household members on Tdap, Hep A/B, and measles (3)[A],(4)[C].
Issues For Referral
- Time referrals and defer elective surgical procedures to allow adjustment to new home (2)[C].
- Individual or family counseling may help adoptive for 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 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 developmental evaluation.
- 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 ENT for concerns, questionable screening results, or if slow to acquire language skills.
- No longer hearing 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 individual attachment
- Regular diet, with specific attention to known nutritional deficiencies in country of origin (www.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.
- 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. Use translator services if available, being 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 openly work through. Provide counseling if needed.
- Encourage families to learn about the 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, & Kinship Care (http://www2.aap.org/sections/adoption/index.html)
- Dawood F, Serwint JR. International adoption. Pediatr Rev. 2008;29(8):292–294. [PMID:18676582]
- Grogg SE, Grogg BC. Intercountry adoptions: medical aspects for the whole family. J Am Osteopath Assoc. 2007;107(11):481–489. [PMID:18057222]
- 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(2):1–64. [PMID:21293327]
- Z02.82 Encounter for adoption services
- Z62.821 Parent-adopted child conflict
- V61.24 Counseling for parent-adopted child problem
- V70.3 Other general medical examination for administrative purposes
- 105430000 Adoption, life event (finding)
- 160864004 Adoption of child (finding)
- 160865003 Request to adopt a child (finding)
- 171382000 Adoption medical examination
- 70849001 Conflict concerning adopted or foster child (finding)
- Internationally adopted children may exhibit self-stimulating behaviors (e.g., rocking, head banging) that usually decrease over time. Refer to developmental or occupational specialist if concerns persist.
- To prepare for child’s arrival, a preadoption visit can identify medical concerns and prepare resources.
- Initial labs: Hep A/BC; 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), 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 adoptive family and caretakers have updated immunizations.
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 July 23, 2017.
- 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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