Our Services :: Pre-Adoption Consultations :: Issues to Consider When Adopting from Abroad

Infections, immunization status and medical history are several of the key issues that physicians must consider when evaluating internationally adopted children, according to Dr. Jane Aronson, Director, International Pediatric Health Services, PLLC in New York City. In this interview, Aronson, who has treated more than 1,300 children adopted from abroad by U.S. parents, tells physicians how to interpret medical records and what health issues to look for in these children.

In your experience, how reliable are the medical records from other countries?

What are some of the key infections that pediatricians should look for in children adopted from abroad?

What role does Hepatitis B play in international adoption?

Do you see a lot of Hepatitis C?

Is HIV something that adoption clinicians should be concerned about?

What types of immunizations should children adopted from abroad receive upon arrival in the United States?

How should families prepare themselves for travel when they are adopting a child from abroad?

Aronson: I don't think of reliability as the issue. Every country creates a medical abstract which is standard for that country; this record reflects cultural and philosophical differences. Physicians from different cultures may have unique medical training and think about health in ways that we might not understand. Adoption medicine specialists learn the characteristics of these records from each country and this helps us explain the information to prospective parents. The information in the records is scanty and reflects social dysfunction. Children are abandoned in hospitals and there is little opportunity to collect prenatal information. The majority of women who abandon children in maternity hospitals do not have prenatal care. The orphanage staff physicians receive incomplete records from these hospitals. Orphanage records may often be quite detailed with regard to feeding, growth, and illnesses, but there is little time or money to translate this information when the pre-adoption medical record is created. Staff in orphanages are not trained physicians and there is little guidance from medical personnel. Measurements of weight, height, and head circumference which are really our signposts of health in a growing child, may be inaccurately recorded because of poor skill and inadequate equipment. It is essential to not judge why the records are poor, but rather to determine which data is useful for parents. Pediatricians who specialize in the review of these rudimentary documents usually provide a list of questions for the parents to present to their agencies to attempt to fill in some of the voids. Current measurements, better photographs, and sometimes if we are lucky, video is requested to enhance the understanding of the child's developmental status.

Let's look at China as a specific example. In China, infant girls are abandoned due to the "One child family policy" and the preference for male heirs who must care for their elderly parents. Thousands of abandoned children are truly "foundlings" and there is no medical history available when they are placed in an orphanage. Prematurity, intrauterine growth retardation, hypoxia and poor Apgar scores, congenital infection, and the type of delivery are conditions that we will not know about.

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Aronson: There are a number of infections that are commonly found in children adopted from abroad. Let me highlight a few.

Tuberculosis

In a recent study of 500 children evaluated in my office, we found that about 8% of children from China and 25% of children from the former Soviet Union (FSU) had positive skin tests for tuberculosis (PPD greater than or equal to 10 mm of induration). All of these skin tests were read by me or other healthcare professionals, not parents. None of these children had active Tuberculosis. Out of over 1,300 children who I have evaluated from abroad, there was only one child with active Tuberculosis. Since kids are adopted from countries (China, FSU, Southeast Asia) where TB is a serious public health issue, we need to be aggressive about testing for TB exposure. Children in these countries receive BCG (Bacille-Calmette Guerin) vaccine, but its efficacy is uncertain. Although BCG certainly must be considered in the equation of how we interpret skin tests, I believe that we should be recommending 9 months of INH preventive therapy for children adopted from abroad who have positive skin tests of greater than or equal to 10 mm and who have normal chest films.

For more information about tuberculosis, read Tuberculosis in the Medical Resources/Infectious Diseases and Parasites section of this website.

Parasitic infections

The big player here is Giardia. Close to 20% of children studied in my office practice had Giardia and because most of these children have failure to thrive, I recommend treatment for Giardiasis even if the child is not particularly symptomatic. Children often have malabsorption because of Giardia and with appropriate therapy, they grow miraculously. Families contact adoption doctors with stories of how the entire family has become infected after an international adoption even if a family member has not traveled abroad. Public health is an important reason why we support treatment of a child with a positive Giardia test (either presence of cysts or antigen positivity). I have been recommending Metronidazole over Furazolidone because of treatment failures with the latter. Specialized pharmacies will prepare very tasty preparations of metronidazole which a child can actually enjoy!

For more information about giardia, read Giaridiasis in the Medical Resources/Infectious Diseases and Parasites section of this website.

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Aronson: 3.3% of children from China and 2.6% of children from FSU are hepatitis B carriers from a study of my practice. Most of these cases are reflective of maternal-infant transmission. Children from China cannot benefit from vaccine at birth because they are abandoned and in other countries the vaccine is not readily available. Most children are tested in the first few months of life which may not reflect the lengthy incubation period of Hepatitis B infection (6 weeks-6 months). The quality assurance commonly found in labs in the U.S. may not be available in countries abroad which may also explain inaccurate testing.

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Aronson: Out of 1, 300 children who I have tested for Hepatitis C, I have two infected children and they are both asymptomatic; they have negative PCR RNA tests and are considered "immunotolerant". I think that we need to continue testing children for Hepatitis C infection because epidemiology changes over time. The story is evolving.

For more information about hepatitis B and C, read Hepatits B-Cand Hepatitis C in Children in the Medical Resources/Infectious Diseases and Parasites section of this site.

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Aronson: This is an unfolding story. Each country has its own story which we must follow closely. There are always reports of increasing prevalence of HIV in different countries. There have been a few children who have been found to be HIV-infected after they were adopted by American families. This may reflect inadequate laboratory technique in the country of origin. As adoption specialists we advise families about how to interpret HIV tests.

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Aronson: Most of us are basically redoing the entire immunization schedule for children adopted from abroad, except for children from Korea and some in foster care from Guatemala. This approach is based on what we have experienced when we study the immunization records from abroad. Intervals are not appropriate, expiration dates are not honored, and vaccines may even be dated before the child was born. We also know that vaccines are not kept refrigerated and that children who are malnourished may not respond to vaccines. For older children, checking antibody titers may allow for the creation of an individualized schedule to meet the unique needs of the child.

For more information about care for your child when you arrive back in the States, read Recommended Screening Tests in the Our Services/Post-Adoption Evaluation section of this site.

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Aronson: All families need to be prepared for travel and this involves a three-prong approach:

	1.		Assess vaccine records for adults and children traveling abroad and make a plan for updating the record with your family physician/pediatrician/travel or infectious diseases specialist; should be planned at least 6 months in advance
	2.		Update health records for families so that appropriate medications for each family member are renewed
	3.		Check health insurance policies for international travel coverage and make a list of accredited medical facilities located in the cities of travel

I have created a section on this web site called International Medical Clinics which includes a list of most accredited clinics in cities where families commonly travel for adoption. Individual web sites for these clinic systems are also available on the internet. I am also available to my families for calls from abroad for trouble- shooting. Vaccines which are baseline for travel abroad for adoption include: Hepatitis B, A, updated tetanus/diphtheria (once every ten years), measles, mumps, rubella for those born in 1957 or after, chicken pox vaccine for those with no documented history, influenza vaccine during the winter season, and cholera and typhoid as dictated by CDC recommendations. If you have the primary polio series you probably do not need a booster, but if you cannot get your records, one dose of inactivated polio vaccine is recommended. Note that checking antibody titers for measles, mumps, rubella, and chicken pox is an alternative if you would like to avoid shots! Malarial prophylaxis recommendations should be the province of an infectious diseases specialist.

For more information about preparation for travel abroad to pick up your child, read the Preparation for Travel section of Our Services in this site.

The American Academy of Pediatrics has established a Provisional Section on Adoption (PSOAD) as of July 1, 2000 and it is an excellent resource for physicians and parents. Contact Eileen Casey at 1-800-433-9016 ext. 7937 or visit their website http://www.aap.org.

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