The Health of Internationally Adopted Children
SPECIAL COVERAGE
Approximately 10,000 children are adopted from foreign countries each year by United States families. The health of these children has been the focus of several studies over the last decade. Two centers with extensive experience in the medical care of international adoptees, Tufts New England Medical Center and the University of Minnesota, have examined the accuracy of preadoptive medical records.1 Do these records correlate with the findings once the child has arrived in the United States?
All study children were adopted from Eastern Europe and the former Soviet Union; 47 of the 56 children had preadoptive medical records. Records were reviewed for maternal medical and obstetric history, birth history, and the child's medical history. Only a few listed information about the birth mother, and only 14 of 47 (30%) indicated birth Apgar scores. Gestational age was indicated in 34 (72%) and birth weights in 42 (89%). Twenty-seven (57%) of the children had appropriate weight for gestational age, 11 (23%) were small, and the comparison could not be made for four. Developmental findings were only briefly described, but delays were reported in 26 (55%). Most children had multiple other medical diagnoses. These diagnoses were usually made by specialists; however, the dates were rarely recorded, and almost never were there supporting laboratory or other tests.
The most frequently recorded category of medical illness was central nervous system pathology in 43 (91%) of 47. Perinatal encephalopathy was the most common of these and was diagnosed in 25 instances. Other neurologic diagnoses accounted for 21 cases, congenital anomalies for 13, cardiac disease for four, nutritional disorders (such as failure-to-thrive) for 15, infections (such as pneumonia or bronchitis) for 39, and miscellaneous for 29. No child had been vaccinated in accordance with World Health Organization recommendations, and 24 (43%) of 56 had no vaccines recorded. No child had received vaccines against rubella, hepatitis B, or Haemophilus influenzae. When laboratory testing was recorded, all hemoglobin levels were reported to be normal, and all testing for HIV, hepatitis B, syphilis, and tuberculosis was negative.
After arrival in the United States, each child was evaluated with a history, physical, and developmental exam. Laboratory testing included a complete blood count, urinalysis, RPR, hepatitis B and HIV serology, and a stool for ova and parasites. Anthropometric measures were standardized. Significant growth delays were recorded for 44% of the children in weight, 68% in height, and 43% in head circumference. Growth lag correlated with duration of confinement in the orphanage; one month of growth delay corresponded to five months of confinement. Developmental delays were documented in 70% for gross motor skills, 82% for fine motor, 53% for social and emotional skills, and 59% in language skills.
Despite preadoptive records that indicated multiple instances of unfamiliar neurologic abnormalities, no child had severe neurologic problems. In addition, while many of the other diagnoses were not confirmed, 11 of 56 (20%) children did have significant medical problems, most of which were not previously documented. These included chronic hepatitis B infection, optic nerve hypoplasia, severe hearing loss, renal calculi, spastic diplegia, and strabismus. Previous hepatitis B infection was found in 14%, tuberculosis in 5%, and intestinal pathogens in 51%. No child had HIV infection or syphilis.
COMMENT BY DAVID R. HILL, MD, DTM&H
International adoptions by U.S. citizens are steadily increasing. There were 6472 adoptions in 1992 and 11,340 in 1996.2 The most frequent source countries, accounting for more than 90% of adoptions, are in Asia, Central and South America, and Eastern Europe. (See Table 1.) As is illustrated by this article and others,1,3,4 the health status of these children is poorly documented and often at variance to what is found on initial examination in the United States.
Table 1
Top 15 Source Countries for International Adoptions, 1992-1996*
| Country | Number of Adoptees | % of Total Adoptions |
| Korea | 8592 | 19.9 |
| Russia | 6950 | 16.1 |
| China | 6786 | 15.7 |
| Guatemala | 2242 | 5.2 |
| India | 1846 | 4.3 |
| Colombia | 1786 | 4.1 |
| Paraguay | 1716 | 4.0 |
| Philippines | 1558 | 3.6 |
| Romania | 1247 | 2.9 |
| Vietnam | 1024 | 2.4 |
| Brazil | 697 | 1.6 |
| Peru | 602 | 1.4 |
| Bulgaria | 594 | 1.4 |
| El Salvador | 578 | 1.3 |
| Honduras | 561 | 1.3 |
| There were 43,201 internationally adopted children from 35 countries during this time.2 | ||
The reasons for the poor information are multiple. The children are from diverse origins, they often have unknown backgrounds, including the backgrounds of their parents, and their health care has frequently been inadequate. Further compounding the problem, some referral agencies will falsify or provide inaccurate documents in order to facilitate adoption. Although all internationally adopted children are required to have an examination in their country of origin by a physician designated by the U.S. Embassy or consulate, this exam is limited to screening for certain communicable diseases and for serious physical defects that would prevent the issue of a residency visa. The bottom line is that the records cannot be relied upon to provide the necessary information. Thus, health care providers who will evaluate the adopted child need to take a defined approach.
This approach has been outlined in several sources.5-7 (See Table 2.) More than 50% of children will be found to have at least one important medical condition, and as many as 60% of these are infectious diseases.3,4,8-11 The adopted child does not need to be seen immediately, unless they are acutely ill, but can wait for 2-4 weeks after arrival. At the initial visit, all children should undergo a complete physical and developmental exam. The physical exam will pick up most congenital abnormalities, such as craniofacial anomalies and dislocated hips, and detect ectoparasites, such as scabies and lice (parents should check children immediately for these). While many children are found to be undernourished or developmentally delayed, as indicated in this study and others,1,4,6,10,11 most will catch up in time.7,11 Nevertheless, some children who are developmentally delayed at adoption will have ongoing difficulty with learning and will benefit from periodic assessment throughout childhood. Hearing and vision testing should also be performed.
Since many of the infectious diseases are asymptomatic, use of screening tests is often the best way to detect them. (See Table 2.) Markers for hepatitis B can be found in 5-50% of children, and 1-15% will be chronic carriers.4,10,12,13 Children from Asia and certain European countries, such as Romania, have the highest rates. Many children have already had hepatitis A. Hepatitis C and D can be found, but routine screening is not recommended.
HIV infection depends upon the child's country of origin and the presence of certain risk factors. Since adoptees may come from subgroups at high risk for HIV (such as drug abuse in the biologic parents, prostitution in the mother, a history of transfusion, and high HIV prevalence in the country of origin), screening should be considered for all children. Horizontal transmission of HIV was a problem for children in orphanages in Romania in the early 1990s because of the frequent use of blood transfusions and contaminated needles.14,15 Congenital syphilis is not common but, if present, frequently has not been diagnosed, and, if the diagnosis has been made, treatment may have been inadequate. All children should be tested for syphilis.
Table 2
Evaluation of International Adoptees
Hepatitis B virus serology-HBsAg, anti-HBc, anti-HBs
HIV-1 serology
Syphilis serology
Stool examination for ova and parasites
Mantoux intradermal skin test
Complete blood count with red blood cell indices
Vision, hearing, and developmental testing
Nutritional assessment
Immunization status
Cytomegalovirus is excreted in about one-half of adopted children,3,4,7 but routine screening is not recommended because of the high prevalence in children in the United States, particularly in day care centers. Rather, adoptive families should be instructed in careful handwashing after contact with urine, diapers, and respiratory secretions, especially if an adoptive mother is non-immune and is contemplating pregnancy.
A stool for ova and parasites is likely to be positive in 15-35% or more of children.4,9,10 The most common pathogens are Giardia, Ascaris, and whipworm. One stool is usually sufficient for screening unless there are symptoms that persist. Since the child will be remaining in the United States, it is prudent to treat any positive patients. Some recommend follow-up screening at six months. In the case of diarrhea, stools should also be cultured for enteric bacteria.
Tuberculosis is less common in adopted children than in refugee children.4,16 Nevertheless, the risk is approximately 50 times the risk in U.S.-born children,17 and all adoptees should be screened with intradermal Mantoux testing according to current guidelines.18 Although some children will have received BCG vaccine, this does not preclude proper screening for tuberculosis.
Children should have a complete blood count to screen for anemia and hemoglobinopathies. Anemia could be secondary to dietary deficiency, intestinal nematodes, particularly hookworm, and other chronic diseases. Hemoglobinopathies, such as sickle cell trait, can be found in children from India, Africa, and countries in the Mediterranean, and ß-thalassemia in children from Southeast Asia, among other countries.
Children who are acutely ill can have a variety of infectious diseases; many of them will be routine childhood diseases, but some will be more exotic imported diseases. A finding of fever, splenomegaly, rash, anemia, or eosinophilia should prompt an appropriate work-up that will take into account the country of origin and the incubation period of the infectious disease being considered.
Finally, children will need to be assessed for the routine childhood immunizations. It is likely that many children will either have received no immunizations or have been underimmunized; vaccine records may also be inaccurate. Albers et al indicated that no adopted child had received vaccines against rubella, hepatitis B, or Haemophilus influenzae.1 Children should be brought up to date with currently recommended vaccines.19 If there is any question as to whether immunizations were given, or whether the children were immunogenic because of illness or malnutrition, the best course is to repeat them.
Travel medicine professionals will see increasing numbers of parents traveling to adopt a child. We should be familiar with the health problems of adopted children so that we can help to counsel parents prior to their trip. Because many children will be hepatitis B virus carriers, consideration can be given to starting vaccination in family members before adoption. An informed parent will be better able to deal with the challenge of adopting a child in an international setting.
References
1. Albers LH, et al. JAMA 1997;278:922-924.
2. Bureau of Consular Affairs, Department of State. Significant Source Countries of Orphans Immigrating to US (FY '89-'96). 1997.
3. Hostetter MK, et al. Pediatrics 1989;83:550-563.
4. Hostetter MK, et al. N Engl J Med 1991;325:479-485.
5. Committee on Early Childhood, Adoption & Dependent Care. Pediatrics 1991;88:642-644.
6. Hostetter M, Johnson DE. Am J Dis Child 1989; 143:325-332.
7. Jenista JA. The immigrant, refugee, or internationally adopted child. In: Pediatric Infectious Diseases: Principles and Practice. Jenson HB, et al. (eds.) Norwalk, CT: Appleton and Lange; 1995:1493-1508.
8. Lange WR, Warnock-Eckhart E. Pediatr Infect Dis J 1987;6:447-450.
9. Jenista JA, Chapman D. Am J Dis Child 1987;141: 298-302.
10. Johnson DE, et al. JAMA 1992;268:3446-3451.
11. Miller LC, et al. Arch Pediatr Adolesc Med 1995;149: 40-44.
12. Hershow RC, et al. Pediatr Infect Dis J 1987;6:431-437.
13. Centers for Disease Control. MMWR Morb Mortal Wkly Rep 1991;40:784-786.
14. Patrascu IV, et al. Lancet 1990;335:672.
15. Rudin C, et al. Lancet 1990;336:1592-1593.
16. Hayani KC, Pickering LK. Adv Pediatr Infect Dis 1991;6:91-110.
17. Lange WR, et al. Pediatr Infect Dis J 1989;8:625-629.
18. Committee on Infectious Diseases. American Academy of Pediatrics. Pediatrics 1996;97:282-284.
19. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1998;47:8-12.
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