EPSDT Care for Kids Newsletter

HEALTH CARE ISSUES IN
INTERNATIONALLY ADOPTED CHILDREN
Dianne M. McBrien, MD, Assistant Professor, Pediatrics
Division of Developmental Disabilities, University Hospital School
The University of Iowa Hospitals and Clinics
Winter 1999

An increasing number of Americans are choosing to build their families through international adoption. In 1978, American families adopted just over 5,300 children; in 1995, the number rose to nearly 9,800. In the 1960s, the typical adoptee was a war orphan from Korea. In 1995, however, about one-fourth of all adoptees in the U.S. were from Romania and the countries of the former Soviet Union; a fifth were from China; and most of the remaining children were from Korea, South America, Thailand, India, and Africa.

Families preparing to travel to a foreign country to receive a child may ask their health care provider about what medical supplies to bring for the child. If the family is traveling to a remote area, amoxicillin powder may be taken along, and the family should also be advised to seek medical advice -- either via telephone call to the United States or to a local physician identified by orphanage officials -- in the event the child becomes ill. Families should also pack liquid acetaminophen and diaper rash ointment. Families adopting Asian children may believe they need to pack lactose-free formula; however, true lactose intolerance is rare in healthy Asian children under 4 years of age. Parents should gradually transition the child from her accustomed feedings to a new formula; powdered formula should be made with boiled water while traveling.

Children should be evaluated by their local health care provider within 48 hours of arrival in the United States. Most newly arrived adoptees appear much smaller than their chronological age; this may be due to malnutrition, recurrent infection, or genetic factors. National Center for Health Statistics growth charts may not be appropriate for some international adoptees, particularly Asian children. The Families with Children from China website (http://www.fwcc.org/) has gender-specific growth charts based on data from southern Chinese children; however, these may not be suitable for children from other regions of China or other Asian nations.

Inaccurate referral information can present problems. For example, children may have been weighed in the birth country while bundled in multiple layers of clothing, and thus appear to have lost weight when initially assessed in this country. The reported birth date may be inaccurate, especially for abandoned children; if there are questions about a child’s chronological age, assess bone age of the left hand and wrist.

Developmental assessment, including hearing and vision screening, should be done at the initial visit and repeated at a 4-6 month follow-up. New adoptees often show some delay (Miller et al.); the majority of these children recover from delays in the months after their adoption. Children with persistent delays should be referred as soon as possible for early intervention services.

CONDITION	SCREEN
Anemia	Complete blood count with differential.
Cytomegalovirus (CMV)	Routine urine CMV culture is not generally recommended, as a positive result does not differentiate asymptomatic carriage from active infection.
Dental disease	Older children may need extensive restoration.
Glucose-6-phosphate dehydrogenase deficiency	G6PD assay.
Hepatitis B	Get hepatitis B surface antigen and antibodies to hepatitis B surface and core antigens. Follow-up testing for surface antigen is recommended 6 months after the initial test (in rare cases, infection may have been at a stage too early to detect with initial screen). Children who test positive for surface antigen should be assessed for "hepatitis B antigen" and elevated transaminase levels. Children with significant transaminase elevation, clinical evidence of hepatic dysfunction, failure to thrive, or abnormalities on hepatic ultrasound should be referred to a pediatric gastroenterologist.
HIV	HIV infection in adoptees is rare but has been reported in adoptees from China and Eastern Europe. Since the ELISA in children under 18 months often reflects maternal infection status rather than the child’s, use both ELISA and culture or PCR.
Hematuria, proteinuria	Urinalysis
Hemoglobinopathies	African and Asian children are at increased risk of hemoglobin disorders.
Lead poisoning	Include a serum lead level, as children have often lived in dilapidated buildings, and may be from large industrial areas with few environmental controls.
Metabolic screening	Newborn metabolic screening is not routine in many countries; all new adoptees should undergo the state screen, regardless of age.
Parasites	Stool ova and parasites. Risk factors for parasitic infection include ambulation, history of abandonment, abnormally low weight, and origin in country other than Korea. Complete blood count with differential; the presence of eosinophilia supports parasitic infection.
Syphilis	VDRL and fluorescent treponemal antibody (FTA-abs) where history or physical findings raise concerns.
Tuberculosis	All adoptees should have a Mantoux test, even if there is documentation of prior TB testing. Children who have received bacille Calmette-Guerin vaccine (BCG) should also be tested (see 1997 Red Book for interpretation guidelines).

Written documentation of vaccinations is often acceptable, if immunizations were given in the order recommended in the United States. Immunization dates should be carefully reviewed, as clearly false or inaccurate dates may have been provided. Most vaccines used worldwide come from reliable manufacturers, and are effective. However, live virus vaccines requiring cold storage should generally be repeated. The 1997 Red Book provides guidelines for "catching up" incompletely immunized children.

Children often have trouble adjusting to their new homes at first. Sleep issues are common, and some children may have difficulty with new foods. Confusion, grief, and language difficulties can contribute to problem behaviors in older children. Parents may find it helpful to meet with other parents of international adoptees; support groups are available in most metropolitan areas and on most major online services. Two helpful magazines for adoptive parents are Roots and Wings, and Rainbow Kids (online at http://www.rainbowkids.com).

As these children join their adoptive families, health care providers, with their knowledge of common medical issues arising with international adoptees, have a unique opportunity to help them get a healthy start in their new life. Some useful resources on this topic include: