Initial Health Care
for Internationally Adopted Children
Shannon Sullivan, MD, Department of Pediatrics
Children’s Hospital of Iowa, University of Iowa Hospitals and Clinics
Winter 2005

American families adopt more than 20,000 children from more than 100 different countries each year. These children represent an estimated 14% to15% of all adoptions. Primary care providers can play an important role in getting these children, and their new families, off to a good start. Before adoption International adoption raises a number of special, sometimes unique, challenges. The primary care provider can help identify these issues, offer guidance to parents, particularly if this will be the family’s first child; and inform them about resources, support services, and other assistance they can use.

The National Adoption information Clearinghouse (http://naic.acf.hhs.gov/) recommends that providers talk with prospective parents about:

The child’s medical history Risk assessment, based on this history, and potential effects on the family Sibling issues Travel preparations, if the parents will be traveling to the child’s country of birth Community supports available to the family

Each year, American families adopt more than 20,000 international children, from more than 100 different countries.

Medical History. Parents usually receive some medical information about a child they are thinking of adopting. These records may be complete and useful, or little more than a name, date of birth (sometimes estimated), and gender. Sometimes health information is inaccurate or difficult to interpret. However, families often receive photos and even videos that can provide information about a child’s health and development.

A cautious interpretation of the child’s lab study results may be needed, as quality control varies from place to place. Contact information for international adoption clinics that can help with the interpretation of medical information and assessment of risk is online at www.comeunity.com/adoption/health/clinics.html, or at the American Academy of Pediatrics website, www.aap.org/sections/adoption/links.htm.

When the child arrives

Children who are acutely ill should receive a medical exam immediately upon arrival. Other international adoptees should be examined within two weeks of joining their new families in the United States. This exam should include a careful review of the child’s medical history, repeat lab studies, and immunization.

Whether or not a child had lab tests in the county of birth, it is important to test for TB, hepatitis, HIV, parasites, lead poisoning, and such nutritional disorders as anemia, rickets, and iodine deficiency. A child’s vision, hearing, and development should also be assessed as soon as possible, and referrals made for early intervention services if needed. For more information on lab tests and screening, see page 5.*Mike

Referral for early intervention services is especially important for children who have, or are suspected of having:

• Head circumference more than two standard deviations below the mean
• Cerebral palsy; hypertonia, hypotonia, hyperreflexia, athetoid movement
• Down syndrome
• Fetal alcohol syndrome (FAS)
• Deficits of vision, hearing, or other senses
• History of abuse
• Attachment disorders
• Behavior disorders

Immunization. The American Academy of Pediatrics (AAP) recommends re-immunization of all internationally adopted children, particularly infants who may have received only one or two immunizations. This is because of concerns about outdated or improperly stored vaccines, and because malnutrition can result in a poor immune response following vaccination.

The Immunization Action Coalition suggests that vaccinations administered in the child’s birth country may be considered effective if administered in accordance with the CDC Guidelines (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5102a1.htm). Another way to clarify immune status is to do serologic testing. If titers indicate immunity, give the remaining immunizations based on the child’s age, following CDC guidelines. If no immunity is indicated, begin the sequence of immunizations all over again.

If there are uncertainties about whether a child has been vaccinated, re-immunization is usually considered safe. However, there are exceptions:

• No immunizations - An acutely ill child should not be immunized
• DTP (diphtheria, tetanus, pertussis) – Children younger than 7 years old should not receive more than 6 doses of DTP
• No varicella – Children awaiting the results of HIV screening shouldn’t be immunized for varicella

Lab tests

Tuberculosis. TB is common in the majority of countries that provide most of the children for international adoption. Children who have TB may produce a false-negative result to a Mantoux test because of prior immunization to TB using bacilli Calmette-Guerin (BCG) vaccine, or because the child has incubation-stage TB, other infections, or malnutrition.

The BCG vaccine is used with many children from Asia, Latin America, and Eastern Europe. The usual vaccination site is the right upper shoulder, where you may find a scar resembling one left by smallpox vaccination. BCG does not always provide protection against TB, and can prevent accurate TB testing. As a result, it is important to screen these children with a purified protein derivative (PPD) test. If the BCG scar appears to be recent, wait until the scar is completely healed before administering the PPD. If PPD testing produces a reaction (induration) of 10 mm in diameter or greater, the child should have a chest radiograph and further evaluation.

All internationally adopted children should have follow-up skin testing 6-12 months after arrival. Children do not need a chest radiograph if they have neither symptoms nor a positive PPD.

Hepatitis. Hepatitis B is endemic in the countries of origin of many international adoptees. To identify current infection, resolved infection, or chronic carrier status, do serologic testing for:

• Hepatitis B surface antigen (HBsAg) – A positive test calls for evaluation by a pediatric gastroenterologist
• Hepatitis B surface antibody (anti-HBs) – A negative test calls for immediate hepatitis B immunization, unless serologic testing shows immunity

Retesting should be performed 6 months after arrival to detect infection that was in the incubation phase at the time of the first test. For information on other important lab tests for internationally adopted children, see page 5*Mike.

Growth

When charting the growth curves for the child’s height, weight, and head circumference, it is important to use growth charts appropriate to the child’s ethnic group. These growth charts are online at www.comeunity.com/adoption/health/growth.html.

Internationally adopted children who have been institutionalized frequently show growth retardation of about 1 month loss of growth for every 2 to 3 months of institutionalization. Catch-up growth should occur in the first 6 to 12 months after adoption. If this doesn’t happen, or growth is slow, arrange for immediate consultation and evaluation. Girls with significant growth retardation who show dramatic catch-up growth may experience precocious puberty.

Conclusion

The entry of a child into a family, whether through birth or adoption, is a significant and complex event. Primary care providers have a key role to play in helping the family address medical, developmental, and psychosocial issues.

Resources

The authors thank Contemporary Pediatrics for allowing us to use information from our article, “Promoting a Healthy Tomorrow Here for Children Adopted from Abroad” (2003; 20(2): 69-86.

Other helpful resources include:

Iowa Healthy Families Line 1-800-369-2229
Referrals to key EPSDT and other services and resources

International Adoption Clinics
www.comeunity.com/adoption/health/clinics.html

National Adoption Information Clearinghouse
naic.acf.hhs.gov/

U.S. Clearinghouse on International Adoption
http://travel.state.gov/family/adoption/adoption_485.html

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