Description

• 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 international adoption particularly complex.
• Multidisciplinary teams are often necessary for appropriate care. Many parents planning to adopt seek advice from their primary care provider.

Epidemiology

Incidence

• 1,622 children were adopted internationally in 2020. This number has decreased every year since 2004 when international adoption numbers peaked at 22,986.
• 15% of current U.S. adoptions are international.
• In 2020, 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).

Risk Factors

• 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
• Overcrowded or institutionalized living situations (e.g., orphanages)
• History of neglect, deprivation, or abuse

General Prevention

• Prospective adoptive parents are required to have a medical exam, typically performed by a primary care physician, in order to verify sufficient medical and psychological capacity to adopt a child from a foreign country. Exam requirements vary by country.
• A State Department-approved 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 would exclude qualifying for a visa.
• Children should optimally be examined by a physician within 2 weeks of arrival in the United States.
• 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 records (if available).
• A travel medicine visit is encouraged for family members who are traveling to the adopted child’s country of origin.
• A preadoption visit can help clarify medical diagnoses and review available medical records (including photos and/or video) to confirm/refute specific diagnoses.

Commonly Associated Conditions

• 80% of international adoptees have medical or developmental issues; 20% of these are severe (2).
• Infectious diseases:
  • 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 spectrum disorder
• Feeding difficulties, malnutrition, rickets
• Anemia
• 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

History

• Medical records are often limited or difficult to access.
• Review chronic medical conditions, allergies, and medications.
• 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 family history and birth/prenatal history, including exposures.
• Review documented history of emotional or nutritional deprivation and physical, emotional, 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.
• Review laboratory results and screening test results.
• Review testing and treatment of tuberculosis.

Physical Exam

• 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—congenital skin abnormalities, rash, infection, bruises, scars, or signs of prior abuse (2)
  • Genitalia—signs of abuse or ritual cutting
  • Ocular—assess red reflex, extraocular movements, and funduscopic exam
  • Neurologic—sensorimotor skills, coordination, reflexes, strength, and spinal exam
  • Oral exam—tooth development and signs of decay
  • Abdomen—hepatosplenomegaly
• Assess development using a validated instrument, the date of birth may be unknown. 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
  • Formal audiologic exam is recommended for all internationally adopted children.
  • Funduscopic exam is recommended for children with a birth weight <1500 g.

Initial Tests (lab, imaging)

• Based on history and physical exam (3)[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
    • Consider interferon γ release assay in children who have received the BCG vaccine.
    • Consider repeat test after 6 months to rule out exposure prior to leaving country of birth.
  • Three stool specimens from three separate days 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
  • Newborn screening panel
  • Ricket screen if growth delay, institutionalized, or history of limited sunlight or poor vitamin D intake
  • Repeat all testing performed before adoption even if results are normal, as results may be unreliable.
• Consider:
  • Antibody titers depending on veracity of immunization records (4)[C]
  • Stool cultures for bacterial pathogens (diarrhea)
  • H. pylori testing (dyspepsia, abdominal pain, or anemia)
  • Ca⁺⁺, PO₄, alkaline phosphate, and 25-hydroxyvitamin D level (rickets)
  • >12 months of age: for Chagas disease via Trypanosoma cruzi, serologic testing in adoptees from endemic countries (Mexico, Central, and South America)
  • Testing for malaria, typhoid fever, leprosy, and melioidosis if child with unexplained fever, splenomegaly, anemia, or eosinophilia from a country where the disease is endemic

Follow-Up Tests & Special Considerations

• HIV: Confirm antibody positive in children <18 months with DNA PCR (may represent maternal antibody).
• 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 bacillus Calmette-Guérin (BCG) vaccine. Evaluate for active disease; treat latent TB infection (LTBI).
• Test for intestinal parasites if GI symptoms persist.
• Eosinophilia >450 cells/mm³ with negative stool ova and parasites: serologic testing for Schistosoma, Toxocara canis, lymphatic filariasisfor children >2 years old from sub-Saharan Africa, Egypt, Southern Asia, Western Pacific Islands, the NE coast of Brazil, Guyana, Haiti, and the Dominican Republic (4)[A]
  • Add Strongyloides for adoptees from sub-Saharan African, Latin American, and Southeast Asian countries.
• 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.

General Measures

• 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.

Medication

• Immunizations: Catch up vaccines per CDC schedule (http://www.cdc.gov/vaccines/schedules/).
  • No further Hep B vaccine if HBsAg positive, HBsAb and HBcAb positive, or HBsAb positive and HBV vaccine given appropriately
  • MMR for vaccination for mumps and rubella, even if measles antibodies present (4)[C]
• Possible approaches (3)[A]:
  • Repeating questionable vaccinations negates the need to obtain serologic tests.
  • To minimize/avoid vaccine administration, check antibody titers—infants 6 to 12 months: polio; diphtheria; children, >1 year: Hep A; MMR; varicella (4)[C]
• Ensure adoptive parents, caretakers, and household members are up-to-date with Tdap, Hep A/B, and measles vaccines (2)[C].

Issues For Referral

• Time referrals and elective procedures to allow adjustment to new home
• 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.
• 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 one’s native language slows speech development. Speech therapy helps children from non–English-speaking countries.

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 attachment

Diet

• 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.

Patient Education

• 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 (2).

Prognosis

• 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.
• Children may regress in previously acquired skills.
• A desire to search for biologic family is common in adolescence (2).
• American Academy of Pediatrics’ Council on Foster Care, Adoption, and Kinship Care (https://www.aap.org/en/community/aap-councils/council-on-foster-care-adopt...)

ICD-10

• Z02.82 Encounter for adoption services
• Z62.821 Parent-adopted child conflict

ICD-9

• V61.24 Counseling for parent-adopted child problem
• V70.3 Other general medical examination for administrative purposes

SNOMED

• 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)