para>If initially negative, repeat of HIV, Hep B, Hep C, and TB testing are recommended at 6 months; negative tests may represent a "window" period or be falsely negative due to malnutrition in the case of TST (5)[C].
HIV: if antibody positive in children <18 months, confirm with DNA PCR (may represent maternal antibody) (2)[A].
Hep C: confirm positive tests with recombinant immunoblot assay (RIBA) and/or HCV RNA PCR; an initial positive in children <18 months may be due to maternal antibody, repeat after 18 months of age.
Positive TST (TB) must NOT be attributed to bacille Calmette-Gu ©rin (BCG) vaccine and must be investigated; if not active disease, treat latent TB (5)[C].
GI tract signs or symptoms occurring years after immigration: test for intestinal parasites.
Eosinophilia >450 cells/mm3 with negative stool ova and parasites: serologic testing for Schistosoma; add Strongyloides for adoptees from sub-Saharan African, Latin American, and Southeast Asian countries (1)[C].
Developmental screening: repeat at each visit and follow progress; 50-90% of internationally adopted children are delayed on adoption; however, most have normal cognition at long-term follow-up (3)[C].
Social history screening: Behavioral concerns may first present during adolescence, even for children adopted in infancy.
Serial evaluations to age 12 months for children with history of treated congenital syphilis: ophthalmologic, audiologic, neurologic, and developmental (5)[C]
TREATMENT
GENERAL MEASURES
- Regular diet for children who arrive malnourished
- Monitor linear growth.
- If developmental delay is diagnosed, consider early services (e.g., early intervention) or referral to developmental specialist.
- Recommend local support groups for parents.
- Attention to parental interactions: Postadoption depression may occur.
MEDICATION
- Immunizations/Catch-up per CDC schedule (http://www.cdc.gov/vaccines/schedules/)
- No further Hep B vaccine needed if: HBsAg positive; HBsAb and HBcAb positive; or HBsAb positive and HB vaccine given appropriately
- MMR should be used for vaccination for mumps and rubella, even in presence of measles antibodies (7)[C].
- Multiple approaches to children vaccinated outside the United States are acceptable (6)[A]:
- Repeating questionable vaccinations negates the need to obtain serologic tests.
- To minimize/avoid vaccine administration, check antibody titers.
- The following antibody titers can be measured:
- Infants 6 to 12 months of age: polio, diphtheria, tetanus (latter two can serve as marker for DPT)
- Children >12 months: Hep A, measles, mumps, rubella, varicella (7)[C]
- Adoptive parents, caretakers, and household members should be up to date on Tdap, Hep A, Hep B, and measles (2)[A],(4)[C].
ISSUES FOR REFERRAL
- Referrals are often necessary for diagnostic and treatment expertise; however, they should be minimized and planned carefully to ensure adjustment to the new home (1)[C].
- Elective surgical procedures should likewise be deferred until the child has grown accustomed to his or her new home (3)[C].
- Individual or family counseling considered for all adoptive families for adjustment support
- Internationally adopted children may exhibit self-stimulating behaviors (e.g., rocking, head banging); may be related to prior sensory deprivation. These behaviors typically decrease with time, and no treatment is necessary if otherwise developing normally. If in doubt, refer to developmental pediatrics or occupational therapy.
- If a child continues to have disruptive behaviors, or would rather self-soothe than seek nurturing human interaction, consider a thorough developmental evaluation.
- Persistent behavioral issues in the parent-child interactions should be evaluated by a pediatric psychologist or psychiatrist (3)[C].
- Vision (strabismus in 10-25% of previously institutionalized adoptees): refer to pediatric ophthalmology.
- Hearing (higher rates of conductive and sensorineural hearing loss): Refer to audiology and/or ENT for concerns, questionable screening results, or if slow to acquire language skills (3)[C].
- Pediatric dental evaluation by 12 months of age; sooner if signs of dental pathology is present (1)[C].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Regular well-child visits, particularly within first months of entry into the United States
- Close monitoring of developmental milestones, behavior, and individual attachment
DIET
- Regular diet
- Up to 68% fall >2 standard deviations below the mean for one or more growth parameters; most begin to follow a curve <2 deviations from the mean within 9 to 12 months (3).
PATIENT EDUCATION
- Eating: Allow access to as much healthy food as the child wants so the child can learn self-regulatory behaviors of eating that may not have been learned in an institution (hunger, satiety) and can build trust with the parent(s) who feed him or her.
- Toileting: Some children may not be trained yet, others who were may regress and have accidents in their new home. Time, positive reinforcement, and avoiding punishment will resolve this issue as the child becomes comfortable with the new surroundings.
- Sleeping: Children must learn to trust their new home and parents, and thus, this is not a time for aggressive sleep rules. Parents should be present, physically and emotionally, just enough to let the child knows that he or she is safe; establishing and then gently reinforcing a bedtime ritual on arrival.
- Language: Adoptive family should learn key phrases in the child's native language prior to adoption. A translator should be available for school-aged children for the first few weeks; avoid the perception on the child's part that a translator's presence signifies potential return to his or her country.
- Adopted children may experience grieving of lost family, relationships, and culture, which is common, expected, and healthy behavior; encourage parents to acknowledge and work through this loss with their children, considering formal counseling, if needed (3).
- Children and families should be encouraged to learn about the culture of the birth country and the ethnic group of origin, including forming relationships with others of the same racial or ethnic group (4).
PROGNOSIS
- Degree of recovery of developmental delays is likely dependent on duration of time spent in an institution
- Likelihood of long-term developmental, behavioral, or academic problems increases with adoption age.
- Rate of recovery appears to exceed rate of normal development over a period of years and continues indefinitely (2).
- Some children may regress in previously acquired skills (1).
- When the child reaches adolescence, a desire to search for his or her biologic family is common (4).
- Adoption medicine is an evolving specialty, with an ever-increasing number of resources available, including the American Academy of Pediatrics' Council on Foster Care, Adoption, & Kinship Care (http://www2.aap.org/sections/adoption/index.html).
REFERENCES
11 Jones VF, High PC, Donoghue E, et al. Comprehensive health evaluation of the newly adopted child. Pediatrics. 2012;129(1):e214-e223.22 Centers for Disease Control and Prevention. CDC Health Information for International Travel 2014. New York, NY: Oxford University Press; 2014.33 Schulte EE, Springer SH. Health care in the first year after international adoption. Pediatr Clin North Am. 2005;52(5):1331-1349.44 Barratt MS. International adoption. Pediatr Rev. 2013;34(3):145-146.55 Miller LC. International adoption: infectious diseases issues. Clin Infect Dis. 2005;40(2):286-293.66 American Academy of Pediatrics. Medical evaluation of internationally adopted children for infectious diseases. In: Pickering LK ed. Red Book: 2012 Report of the Committee on Infectious Diseases. 229th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.77 Feja KN, Tolan RWJr. Infections related to international travel and adoption. Adv Pediatr. 2013;60(1):107-139.
ADDITIONAL READING
- Dawood F, Serwint JR. International adoption. Pediatr Rev. 2008;29(8):292-294.
- Grogg SE, Grogg BC. Intercountry adoptions: medical aspects for the whole family. J Am Osteopath Assoc. 2007;107(11):481-489.
- Kroger AT, Sumaya CV, Pickering LK, et al. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(RR02):1-60.
- U.S. Department of State, Bureau of Consular Affairs. The Hague Convention on Intercountry Adoption: a guide for prospective adoptive parents. http://travel.state.gov/content/dam/aa/pdfs/PAP_Guide_1.pdf.
- Weitzman C, Albers L. Long-term developmental, behavioral, and attachment outcomes after international adoption. Pediatr Clin North Am. 2005;52(5):1395-1419.
CODES
ICD10
- Z02.82 Encounter for adoption services
- Z62.821 Parent-adopted child conflict
ICD9
- V70.3 Other general medical examination for administrative purposes
- V61.24 Counseling for parent-adopted child problem
SNOMED
- 171382000 Adoption medical examination
- 70849001 Conflict concerning adopted or foster child (finding)
- 160864004 Adoption of child (finding)
- 105430000 Adoption, life event (finding)
- 160865003 Request to adopt a child (finding)
CLINICAL PEARLS
- Initial labs: Hep B, Hep A, Hep C, HIV 1 and 2, syphilis, CBC, TSH, lead, G6PD deficiency, hemoglobin electrophoresis; PPD/TST (or IGRA ages ≥5 years), ova and parasites (three stool specimens, including single specimen for Giardia and Cryptosporidium antigens), urinalysis
- If initially negative, repeat of HIV, Hep B, Hep C, and TST testing are recommended at 6 months; negative tests may represent a "window" period or be falsely negative due to malnutrition in the case of TST.
- Immunizations per CDC schedule with catch-up (http://www.cdc.gov/vaccines/schedules/), as needed; ensure that adoptive family and caretakers are current on Tdap, Hep A, Hep B, measles.
- Internationally adopted children may exhibit self-stimulating behaviors (e.g., rocking, head banging), will typically decrease with time, and do not require treatment if otherwise developing normally; refer to developmental pediatrics or occupational therapy if there are concerns.
- Adoption medicine is an evolving specialty, with an ever-increasing number of resources available, including the American Academy of Pediatrics' Council on Foster Care, Adoption, & Kinship Care (http://www2.aap.org/sections/adoption/index.html).