Symposium on International Adoption
Reviewed by David R. Hill, MD, DTM&H
Sources: S8.1 Pre-adoption review of medical records. Jenista JA, Adoption/Medical News, St. Joseph Mercy Hospital, Ann Arbor, MI; S8.2 Travel issues for internationally adopting families. Miller L, International Adoption Clinic, Department of Pediatrics, The Floating Hospital for Children at New England Medical Center, Tufts University School of Medicine, Boston, MA; S8.3 Post-arrival evaluation of international adoptees. Johnson DE, International Adoption Clinic, Department of Pediatrics, University of Minnesota, Minneapolis, MN.
Travel for international adoption is increasing. There were nearly 16,000 children adopted from foreign countries in 1998. A symposium that addressed this topic was led by three speakers who are recognized as leaders in the field. Dr. Jenista from the St. Joseph Mercy Hospital in Ann Arbor, MI, spoke on preadoption review of medical records, Dr. Miller from New England Medical Center, Boston, MA, spoke on travel issues for the adopting family, and Dr. Johnson from the University of Minnesota concluded with information on evaluation of adopted children after return to the United States. The subject of international adoption was recently reviewed by Travel Medicine Advisor Update.
Jenista discussed the country of origin of adopted children, which has changed over the last decade; now, more than 50% originate from China or the states of the former Soviet Union. Many children up for adoption are living in orphanages rather than foster care and they may be older (mean age, 22 months), leading to a higher frequency of developmental and medical problems. Medical records are sometimes provided and parents may request a review of them by health care providers in order to make informed decisions about their potential children. These records can include medical information, photographs, and video clips. Jenista presented information on more than 2800 records, primarily from countries in eastern Europe, the former Soviet Union, and China. Records from the former Soviet Union described children with a high risk of maternal drug or alcohol use, neglect, prematurity, low birth weight, developmental delays, and frequent neurologic diagnoses. However, many data were lacking or inaccurate, such as the immunization history, and many of the diagnoses were unsubstantiated after arrival in the United States. Similar problems were seen with records from China, and up to 50% of the time they did not even represent the adoptive child. In the final analysis, records frequently had misinformation and the absence of important information; thus, the child could not be accurately assessed from them. If a video was included, it often raised concern about previously unrecorded diagnoses. This leaves prospective parents with a high degree of uncertainty about their potential child, and caused up to 50% of parents not to adopt the child. Jenista stressed that the records she reviewed probably represented only 10% of all adoptive children. Nevertheless, there should be a process to provide more accurate information.
Miller focused on the actual adoption and the preparations that should be undertaken by parents and family members. The goal is to have families informed, realistic, and medically prepared. Those persons who are traveling to adopt the child should receive the appropriate pretravel advice, immunizations, and medications. Parents, siblings, and other caregivers should consider initiating hepatitis B vaccine if their child originates from an endemic country. Parents need to be aware of the conditions in which they may find their child, and they need to be realistic about the health of the child. In addition to infectious diseases, growth, developmental, and emotional delays are most prominent, particularly among institutionalized children. About 50% of children will be delayed in height, 30% in weight, and 37% in head circumference. Developmental delays may be seen in 90-100%, and 60% of children aged 2 years may lack any language skills.
Johnson concluded the symposium by describing the health of children after they have been adopted and returned to the United States. Physical examination and laboratory testing are critical to proper evaluation of children. The prevalence of infectious disease depends upon the child’s country of origin. As examples, 28% of children from Romania were hepatitis B carriers in 1998, children from eastern Europe had a high prevalence of intestinal parasites, primarily giardiasis and ascariasisis, and 25% of children from Russia in 1998 were PPD positive, compared with 5% positivity in children from China. Congenital syphilis seems to be uncommon. Elevation of blood-lead levels and iodine deficiency were seen in children from China. In terms of growth, catchup usually occurred, particularly if children were adopted at younger than 20 months of age, but there were long-term emotional, developmental, and intellectual effects of institutionalization. Many of these were not apparent for years after adoption, so ongoing testing is important. Johnson summarized by stating that after a few years in the United States, 35% of children have made great progress, 35% are left with few serious problems, and about 30% may have serious issues. Adoptive families will need ongoing support and should enter the process with realistic expectations about the future capabilities of their children.
Suggested Readings
1. Samuel BU, Barry M. The pregnant traveler. Infect Dis Clin NA 1998;12:325-354.
2. Moss PJ, Beeching NJ. Provision of health advice for UK medical students planning to travel overseas for their elective study period: Questionnaire survey. BMJ 1999;318:161-162.
3. Gamester CF, et al. Medical students’ risk of infection with bloodborne viruses at home and abroad: Questionnaire survey. BMJ 1999;318:158-160.
4. Fischer PR. HIV precautions for traveling medical personnel. Trav Med Advisor Update 1999;9:10-12.
5. Wilkinson D, Symon B. Medical students, their electives, and HIV (editorial). BMJ 1999;318:139-140.
6. Hill DR. The health of internationally adopted children. Trav Med Advisor Update 1998;8:17-20.
Persons traveling overseas for medical electives or service projects should be aware:
a. that HIV may be prevalent in the countries of travel.
b. of the modes of transmission of HIV.
c. of the use of post-needlestick or mucosal exposure prophylaxis with anti-retroviral therapy.
d. All of the above
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