International adoption has been a growing phenomenon since the 1950s. After the Korean War, international adoptions started to take place as a relief effort for war orphans. In 1955, Congress passed the Refugee Relief Act to facilitate adoption of these orphans.¹ Currently, about 13,000 children are adopted from abroad each year. The largest numbers of children have come from South Korea, with numbers from other countries waxing and waning in relation to the geopolitical climate. The 1988 Seoul Olympics and the Romanian Revolution in 1989 both affected patterns of adoption from those countries. Table 1 reveals international adoption trends over the past decade. Children from Russia and China have accounted for over 50 percent of international adoptions in the past two years.² Not surprisingly, infants and toddlers (younger than four years of age) comprise the majority of adopted children.³ Female adoptees outnumber male adoptees.^3–5

The prospective parents are generally college-educated, white suburban couples earning approximately $36,000 per year. Parents usually are in their mid-30s, have been married for seven years and have no other children.³ Single-parent adoptions are also becoming more common.

International Adoption Process

The adoption process occurs in three stages: identifying the child, obtaining custody from the host nation and arranging for immigration to the United States.

Identification of a child can be accomplished through adoption agencies, attorneys and adoption facilitators. Parents can also adopt independently by traveling to the host country.

In the second phase, the adoption is completed in the host country and steps are taken to ensure that the child is ready for immigration to the United States.

In the third phase, the parents and child must fulfill specific legal and medical requirements before the child's arrival in the United States. Included in these requirements is a permanent residency visa medical examination, outlined in Table 2.⁶ The child will not be granted a visa until all requirements have been fulfilled.

Each stage has many potential roadblocks; the time from initial notification of availability to “delivery” of the child may be emotionally tumultuous for the prospective parents.

The initial notification includes a package containing a description of the child, a picture and an often incomplete or vague personal and medical history.⁷ South Korea is an exception, providing detailed, legible records and appropriate radiographs.⁶ Parents may ask their family physician to review this history before making a decision to adopt a particular child. Once the child's picture arrives, prospective parents bond quickly and tend to start viewing the child as their own. A pre-adoption visit to the family physician is recommended so parents can learn about well-child care and discuss any specific medical problems noted in the history (i.e., the needs of a child with a cleft palate). It is important to help parents realize that the provided history may be inaccurate and that the child may be a little different than what they imagine. Encouraging parents to maintain an open perspective is important. Phrases such as “oxygen deprivation,”“encephalopathy” or “perinatal asphyxia” may appear in the history and may represent either no appreciable diagnosis or something more ominous.⁸

To help focus expectations, parents with concerns should be encouraged to ask if the workers in the orphanage or foster care system see this child as being any different from others of the same age in the same situation.⁶

Medical Evaluation

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. So that the parents and the child may adapt to each other, it is recommended that the initial medical visit be delayed two to four weeks, unless an acute or unstable medical condition is present. In fact, one half of adoptees require treatment for common pediatric illnesses (e.g., otitis media) within the first month.⁴ Delaying the initial medical visit will allow the parents to spend some time observing the child so they will be able to describe behaviors and define complaints. The physician's goals at this initial visit should include ensuring that the child is free from conditions that would impair the health of the child or the family, evaluating and treating known medical problems and helping parents understand underlying cultural differences.³

In about four out of five cases, the physical examination will not reveal the presence of common medical conditions.⁹ Hepatitis, tuberculosis, parasites, human immunodeficiency virus (HIV) infection and syphilis are examples of problems that may be present although not clinically apparent. Recommended laboratory tests include hepatitis B virus, purified protein derivative (PPD), rapid plasma reagin, HIV, stool for ova and parasites, complete blood count and urinalysis^3,6,10 (Figure 1).⁹

The most common infectious conditions in this population are related to parasites, and these conditions are probably the most alarming to adoptive parents. Case series studying international adoptees have revealed that nearly one third of these children have intestinal parasites on arrival in the United States.¹⁰ Giardia and Ascaris are the most common pathogens discovered. The prevalence of these conditions is highly dependent on the geographic location and setting from which the child originated. Several reports cite the presence of two or more parasites, and in one study,⁵ up to 45 percent of Romanian children were multiply infected. Older ambulatory children and low-birth-weight infants are at higher risk.⁸ Symptoms, which are usually minimal or vague, include bloating, diarrhea, weight loss, lactose intolerance and, in extreme cases, failure to thrive. Such symptoms, however, are not necessarily reliable indicators of ongoing infection.

Laboratory evaluation should consist of three separate stool examinations for children who are symptomatic or who are coming from a suspect foster care environment. Asymptomatic, healthy children require only one screening sample.⁶ Immunosuppressed children (including those who are malnourished or who have other serious infections) are at increased risk for parasitic hyperinfection and death; empiric therapy may be a consideration.¹¹ Stool samples should be obtained again after treatment to ensure eradication. Nonintestinal parasites, such as scabies and lice, are common in these children (up to 10 percent) and are treated with topical agents.⁴ Malaria, although uncommon, can be missed because it is not often considered at the time of initial evaluation.

The World Health Organization estimates that the carrier rate for hepatitis B virus (HBV) is 10 to 15 percent in Asia, 1 percent in Central and South America and 0.5 percent in North America.^5,9 Five percent of Chinese and Korean children, up to 10 percent of Asian Indian children and 20 percent of Romanian adoptees are found to have chronic HBV infection.¹² In one study,⁵ 53 percent of adoptees showed serologic evidence of infection with HBV. When acquired in the first year of life, HBV becomes chronic in more than 90 percent of cases.^11,12 Anicteric or asymptomatic infection is most common in young children.¹¹

Complications of chronic HBV infections include cirrhosis and hepatocellular carcinoma. Diagnosis is made by demonstrating a positive HBsAg that persists for six months (Table 3).¹¹ The risk of horizontal transmission is 5 percent. Therefore, all intimate household contacts should be immunized. The Centers for Disease Control and Prevention (CDC) does not recommend routine notification of schools or day care facilities if a child has HBV infection. However, adolescent patients should receive appropriate counseling regarding the risk of sexual transmission. If the child has HBV infection, screening for hepatitis D virus infection is also recommended, especially if the child is from the Mediterranean region or South America.⁸ Many hepatologists recommend annual screening for hepatocellular carcinoma with alphafetoprotein measurements, abdominal ultrasound examinations or both.^12,13

Tuberculosis is a world-wide problem. Children are at higher risk because of poverty, institutional living and poor medical care.¹² In international children younger than 15 years, tuberculosis is at least 10 times more prevalent than it is in a comparable U.S.–born population.¹⁴ In addition, extrapulmonary tuberculosis occurs in 25 percent of untreated children in this age group.¹¹ In Asia, and South and Central America, vaccination with bacille Calmette-Guérin is common and can often complicate evaluation, because the vaccination does not always convey immunity. Underlying malnutrition or inadequate quality controls for the vaccine may prevent some children from developing a sufficient immune response after receiving it. Therefore, all internationally adopted children should have a PPD test. Screening should be performed with the Mantoux test only.^6,11 Definition of a positive PPD test and appropriate treatment are reviewed in Table 4.⁶ Because of the risk of multi–drug-resistant tuberculosis, especially in southeast Asia, it is recommended that cultures be aggressively obtained in patients with active disease; an infectious disease consultation may aid in selection of appropriate drug therapy.⁸

The pandemic of HIV infection, although of great concern, has not proved to be a significant problem in internationally adopted children. Romanian children in orphanages were reported to have a 10 percent seropositive rate, although subsequent U.S. case studies have not confirmed this rate.^4,5,10 Screening for HIV is required before immigration to the United States for children older than 15 years, but testing in some countries of origin may be suspect and may inadvertently increase the risk of transmission (i.e., through the use of reused needles).^3,13 Enzyme-linked immunosorbent assay (ELISA) tests may be inadequate in children who are younger than 18 months of age, because of maternal antibodies. Thus, a Western blot or immunofluorescent antibody test should be used to confirm a positive ELISA.¹¹ The CDC has not reported any cases of seroconversion after adoption.⁶ Considering recent advances in life-prolonging treatment for HIV, routine screening for all adoptees is recommended.

Syphilis is encountered in international adoptions in fewer than 1 percent of cases.^7,10 A screening rapid plasma reagin test is recommended because of the availability of efficacious treatment and the severe complications of untreated disease. False-positive tests may occur as a result of other spirochete infections (e.g., pinta, yaws), usually in children from endemic tropical regions. A positive rapid plasma reagin test should be confirmed with a fluorescent treponemal antibody or microhemagglutinin test for Treponema pallidum. A positive maternal history of syphilis should strongly suggest the possibility of congenital syphilis and prompt closer evaluation of the child, including lumbar puncture for a cerebrospinal fluid VDRL test.¹¹ Children presenting with acquired syphilis should indicate to physicians the possibility of past sexual abuse.¹¹ Evaluation and treatment regimens that were initiated in other countries are often inadequate (for example, single-dose, short-acting penicillin) and suspect.⁸ Follow-up treatment should be continued until serology is negative.

In addition to the issue of infection, routine health maintenance and well-child care are easily addressed at the initial visit. Missing immunizations, and abnormal hearing and vision screening test results are noted in more than 33 percent of adoptees.⁴ HBV, Haemophilus influenzae, measles-mumps-rubella and varicella vaccinations are the ones that are most commonly missing.⁶ Ineffective vaccination may occur when severe malnutrition causes a blunted or absent immune response.^6,10 A high index of suspicion and a low threshold for revaccination are important in reviewing immunization records in these patients. If the record is “too perfect,” it should be considered suspect, and revaccination should be considered.¹⁰

Dental problems are also prevalent (20 percent) but are usually amenable to repair. If the child is younger than three months of age, a phenylketonuria screening test should be performed.⁶ Growth curves are also important, with the caveat that many of these children will not follow a standard American growth chart. “Catch-up” growth is not uncommon during the first year of adoption as a result of better nutrition. As mentioned, failure to thrive may indicate occult parasitic infection.

Developmental delay is a common problem. The International Adoption Clinic in Boston has reported that 33 percent of adoptees demonstrated gross motor delays, 40 percent had fine motor delays and 16 percent had cognitive and language delays.¹⁵ These numbers were significantly higher when adoptees from the former Soviet Union and Eastern Europe were studied.⁷ Cultural and language differences may also hamper initial efforts to evaluate the child, possibly delaying the detection of developmental problems; this is a frequent complaint of adoptive parents.¹³ Establishing a baseline assessment of development at the initial visit and following the child's progress over the next three months is warranted. Isolated gross motor delay is often associated with caloric deprivation.⁸ Accelerated or “catch-up” development is common, but early intervention and special needs programs may help the child reach his or her development potential. Older children may take longer to exhibit development and growth “catch up.” Language proficiency should be assessed at an early stage, and English as a second language services should be sought.¹³

During the initial examination, it is important to document all scars, bruises and evidence of past sexual or physical abuse. The psychologic trauma associated with such events may not be fully evident until months or years later.⁶ Maladaptive behaviors, including episodes of anger and unprovoked acting out (often diagnosed as attachment disorder) may be severe and can be detrimental to a child's integration into a new family. These behaviors, often rooted in institutional experiences, may require more than understanding and patience; intensive mental health support may be necessary.² Fetal alcohol syndrome is a particular concern to parents who adopt children from Eastern Europe and the former Soviet Union. In one study,⁷ investigators reported that only one of 56 children had overt fetal alcohol syndrome; however, problems attributable to fetal alcohol syndrome may not be apparent at the initial visit and may manifest as the child gets older. Also reported were unpublished data from records reviewed for children from these regions, indicating a 19 percent maternal alcohol use, so these parental fears may be justified.⁷

Other common medical problems include iron deficiency anemia and thalassemia. If a suspected iron deficiency anemia does not respond to iron therapy, lead poisoning should be considered.¹³ Congenital anomalies have been noted to range from 2 to 10 percent, including such conditions as cleft lip, hypospadias, single limb defect and ventricular septal defect.^4,9 Accurate age determination can be a problem with older children. Radiographs and level of sexual maturity can be helpful, but no specific test can pinpoint a child's age. “Catch-up” growth confuses the situation even more. Every effort should be made to help parents determine a “birthday,” but frequently a “best guess” approach may be required.¹⁶ Circumcision is frequently requested and is the most common elective surgery in the first two years after adoption.^3,4