International Adoptions: An Overview

International Adoption

McKenzie Pediatrics 2010

What We Do At The Pre-Adoption Visit:

• Review what is known about the child’s medical history, and offer a risk assessment based on that history, including a discussion of potential impact on family and siblings
• Discuss potential health risks to family, which may include exposure to disease such as tuberculosis, and hepatitis A & B
• Review medical plan upon arrival to US
• Discuss travel preparations, including vaccinations
• Expect the unknowns!

Requirements of Permanent Residency Visa Medical Examination:

• Medical history and physical examination to rule out signs of excludable conditions (syphilis, insanity, sexual deviation, some cases of MR, narcotic or alcohol addiction, or any disease, deformity or condition that prevents immigrant from earning a living)
• The decision to grant or deny a visa is made by consular and immigration authorities

Initial Office Medical Evaluation: (Usual Duration 1-1.5 hours)

The “delivery” of international adoptees often involves long airplane flights across multiple time zones in the company of strangers, possibly including new parents, only to arrive in a foreign environment and meet more strangers. It is therefore advised, so that the new parents and the child may adapt to each other, that the initial medical visit be delayed 2-4 weeks, unless an acute or unstable condition is present. Delaying the initial medical visit will also allow the new parents to spend some time observing the child so they will be able to describe behaviors and define concerns.

Initial Blood Tests:

• Hepatitis B Serologies
  • Overall prevalence of hepatitis B virus in internationally adopted children is 4%...1.1% with acute or chronic infection, and 2.9% with resolved infection
  • Overall rate of protective antibodies (resulting from hepatitis B immunization) in international adoptees: 64%
  • Carrier rate for chronic hepatitis B: 20% of adoptees from Romania, 5% from China & Korea, 10% from India, and 1% from Central & South America
• Hepatitis C Antibody
• Measles/Mumps/Rubella Serologies
  • If any of the titers are below protective levels, the child needs fully reimmunized
• Diphtheria & Tetanus Serologies (if >6 months of age)
  • if both titers are less than protective levels, the child needs fully reimmunized
  • if one titer is above and one below protective levels, one dose of vaccine is given and levels rechecked in 1 month
• RPR
  • Rapid Plasma Reagin, for Syphilis, present in <1% of international adoptees
• HIV
  • ELISA screening; Western blot or IFA for confirmation if ELISA positive
• Stool specimen for Ova & Parasites
  • One-third of international adoptees have intestinal parasites, most commonly Giardia, Trichuris, and/or Ascaris)…obtain a series of 3 specimens 1-3 days apart if malnourished, or signs of a GI parasite
• CBC

• Hemoglobin Electrophoresis
  • if from Asia, Latin America, or Africa
• Glucose-6-phosphate Dehydrogenase Assay
  • if from Asia, Mediterranean region, or Africa
• Peripheral Blood Smear for Malaria
  • if from tropical or subtropical region, or if fever of unknown origin
• Lead Screening
• Thyroid Function Tests
• State Metabolic Screen
  • if child <3 months of age

Other Testing:

• PPD
  • Mantoux test for Tuberculosis, even if prior “vaccination” with BCG; office visit to check reaction in 48-72 hours; if reaction >10mm, we will treat for TB
• Urinalysis
• Screening radiographs for rickets
  • if from Asia

Repeat Testing:

• Repeat HIV & Hepatitis B screening in 6 months if initial results negative, to detect individuals who might have been newly infected and in the process of seroconversion during the initial evaluation
• Repeat PPD in 12 months

Medical Evaluation:

• Nutritional status
  • exam & full measurements
• Dental status
• Head Circumference
  • if >2 standard deviations below the mean, child is at above average risk for neurologic dysfunction, including learning disabilities and ADHD; if >3 SDs below the mean, child is at high risk for permanent cognitive deficits
• Developmental status
  • delays are common in international adoptees, especially if spent >12 months in an institution. In children institutionalized >6 months, mean IQ is 15-20 points lower than that of children adopted before 4-6 months of age. Studies show that in 35% of international adoptees, developmental/behavioral concerns resolve, 35% persist though improve with therapy, and 30% remain serious even 3 years after adoption
• Review old medical record and vaccination history
• Look for signs of genetic disorders/congenital anomalies, fetal alcohol syndrome (especially common in adoptees from Eastern Europe or Russia), past physical or sexual abuse
• Hearing and vision screening when possible

Vaccinations:

• All immunizations except varicella (chickenpox) may be given while awaiting the results of HIV screening
• Of the primary countries of origin for international adoptees, only South Korea recommends varicella vaccination. Thus, all new adoptees should receive the first of the two-dose series soon after arrival in the U.S.
• Most international adoptees have NOT been vaccinated against hepatitis A and therefore should receive the first of the two-dose series soon after arrival in the U.S.
• An assessment will be made as to whether the child also needs a HIB vaccination (if <59 months of age) and/or a pneumococcus (PCV-13) vaccination (if <59 months of age, or older with certain risk factors)
• Considerable debate still exists about whether or not to simply re-vaccinate the child as if no previous vaccines given. General consensus is to do so if institutionalized, unless clearly written documentation of dates and doses, and immunizations administered according to international norms

Other Issues:

• Language
• Psychosocial
• Nutritional: expect slow acceptance of our unfamiliar foods and flavors; initially gorging behaviors, however, are common, and should improve gradually
• Sensory Defensiveness: an overreaction or defensive response to ordinary sensations or experiences (grooming, hugging, cuddling, handling materials, common household noises, bright lights et al). Such sensory defensiveness is common in children who have been institutionalized prior to adoption
• Attachment Disorder: The attachment cycle begins when an infant experiences a need such as hunger, thirst, loneliness, or fear. The infant expresses the need by crying, smiling, or some other signal, and the adult intervenes. This cycle, repeated throughout infancy, is crucial to a child’s sense of safety and trust, to the development of a healthy personality, and to higher levels of functioning. Institutionalized children have had attachment cycles disrupted, leaving them feeling unsafe and un-nurtured. Such children may exhibit sensory defensiveness, an inability to give or accept affection from parents, abnormal speech patterns, poor peer relationships, poor impulse control, low tolerance for frustration or change, lack of conscience, lying, stealing, destructiveness, fecal smearing, urinating in unusual places et al

Resources:

1. US Clearinghouse on International Adoption (www.travel.state.gov/adopt.html)
2. National Adoption Information Clearinghouse (www.calib.com/naic/index.htm)
3. National Library of Medicine Medline Plus (www.nlm.nih.gov/medlineplus/adoption/html)
4. Dr. Aronoson, at www.orphandoctor.com
5. The Immunization Action Coalition (www.immunize.org/adoption/)
6. CDC (www.cdc.gov/travel/)
7. Adoption News (www.adoptionews.com)
8. Families with Children from China (www.fwcc.org)
9. American Academy of Pediatrics (www.aap.org/sections/adoption)
10. Adoptive Families (www.adoptivefamilies.com)