1. family and parenting
2. children

Abstract:
International adoption has been part
of our society for many years. Each
year, thousands of children are
adopted by families in the United
States, and many of these children
seek emergency care for one reason
or another. Whereas common diseases present commonly, certain
infectious and other diseases affect
international adoptees more commonly than their American-born
peers. A child's country of origin can
sometimes help guide the clinician
toward more likely etiologies of illness. Illnesses uncommon in the
United States or Western Europe
often occupy higher positions on the
differential diagnosis list for these
children. When managing illnesses
in the international adoptee population, it is also important to maintain
a healthy skepticism for the accuracy
of preadoption immunization records
and related health care information.
This accentuates the importance of
considering the child's country of
origin and performing a thorough
physical examination.
Keywords:
international adoption; adoption;
adoptees
Reprint requests and correspondence:
Susan D. Dibs, MD, Clinical Associate,
Johns Hopkins Children's Center, 600
North Wolfe Street, Baltimore, MD 21278.
[email protected]
1522-8401/$ - see front matter
© 2012 Elsevier Inc. All rights reserved.
International
Adoptees: Special
Considerations
Upon
Presentation for
Urgent or
Emergent Care
Susan D. Dibs, MD⁎
B
etween 1999 and 2010, 224 615 children were adopted
internationally to the United States (US). Although the
number of annual foreign adoptions has fallen by more
than 50% during the last 6 years, a substantial number of
children still arrive in the United States from their countries of
origin each year. From October 1, 2009, to September 30, 2010,
11 058 children were adopted internationally by American families. 1 Before their adoptions, many of these children have some
degree of exposure to institutional living, poverty, malnutrition,
social dysfunction, and/or diseases endemic to their home countries.
For these reasons, international adoptees have their own set of
medical concerns and issues that may not be typical of children born
and raised in the US. Presentation of such a child to an emergency
department or urgent care center should elicit some specific
considerations, in addition to the usual components of the differential
diagnosis. This is particularly true of newly arrived adoptees.
CLINICAL CLUES RELATED TO COUNTRY OF ORIGIN
Some historical factors can aid the clinician in the evaluation
and management of these patients' needs. Country of origin is of
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VOL. 13, NO. 1 • SPECIAL CONSIDERATIONS FOR INTERNATIONAL ADOPTEES / DIBS
SPECIAL CONSIDERATIONS FOR INTERNATIONAL ADOPTEES / DIBS • VOL. 13, NO. 1 3
primary concern. Between 2006 and 2010, China,
Russia, Ethiopia, and South Korea have consistently
been among the top 5 sending countries. Until its
adoption program closed in 2008, Guatemala was
also one of the most frequent sending countries. In
addition, Ukraine and Kazakhstan have generally
been among the top 10 source countries.
Children arriving from China have left an area
with a high prevalence of viral hepatitis infections.
In fact, many children are identified as having a
“special need” because of their chronic infection
with hepatitis B or C. Even among those who test
negative for hepatitis B before adoption, approximately 3% to 5% will test positive for hepatitis B
surface antigen upon evaluation in the US. Postarrival screening has also revealed that intestinal
parasite infection and elevated lead levels are not
uncommon in children from China. Although
exceedingly rare in this country, outbreaks of
measles have been documented in adoptees from
China and their close contacts. Because of faulty
immunization practices in most developing nations,
international adoptees (particularly from China)
should be considered at risk for measles.
Rates of alcohol, tobacco, and illicit drug use are
among the highest in the world in Russia and some
other Eastern European countries. Consequently,
fetal alcohol spectrum disorders (FASDs), growth
delay, and developmental delay are, at times, seen
in children from these regions. Although growth
delay is unlikely to be the reason for an emergency
department visit, aggressive or abnormal behaviors
that can be associated with FASD or significant
developmental delay might lead parents to seek
acute care. The prevalence of hepatitis B infection
(20%) and intestinal parasites (33%) are also high in
this area of the world.
Ethiopia has a high prevalence of HIV infection. In
that country, uniform HIV screening of orphans
before adoption is performed. Those rare children
adopted with HIV infection are identified as being
infected before adoption. Their adoptive parents
should know this information. Hepatitis A, B, and C
infections are also common in Ethiopia. Although
children are screened for hepatitis B and C infection
in their home country, a small percentage will initially
screen negative but prove to be infected after
screening in the US. Intestinal parasites are extremely
common in children arriving from Ethiopia. 2
Children from South Korea and Taiwan are
among the healthier international adoptees, and
generally, are developmentally on target. This can
be attributed, in part, to the more developed nature
of these 2 countries and favorable access to
advanced medical care. These children are also
typically raised in high-quality foster care settings,
as opposed to more variable care in orphanages.
Regardless of birth country, most international
adoptees arrive from areas with medium to high
rates of hepatitis A infection. 3 Preadoption screening for this infection is not performed. The risk of a
child arriving with this infection and the need to
immunize all close contacts have been recently
highlighted. Acute hepatitis A infection should be
considered a risk for all new international adoptees.
OTHER CONTRIBUTING FACTORS
In addition to country of origin and living
conditions (orphanage vs foster home), other
historical factors that should be considered are
diet, dates of travel, areas visited while in country,
onset of symptoms, chronicity of symptoms, ill contacts, recent illnesses, and any treatments administered. The clinician should be cautious when
considering the preadoption immunization history,
written or otherwise. In children arriving from
underdeveloped countries, the immunization record should be considered unreliable. The one
exception to this rule would be vaccines administered at the time of a child's exit examination at the
US Citizenship and Immigration Services supervised clinic in his or her home country.
Overall, when developing an approach to the
diagnosis of illness in an internationally adopted
child, clinicians need to remember that common
illnesses are encountered frequently in children
from all around the world. It is probably most
prudent to initially develop a differential diagnosis
irrespective of country of origin and adoption history and, subsequently, refine the list of possible
etiologies based on a child's specific history.
SPECIFIC ETIOLOGIES BASED ON
CHIEF COMPLAINT
Fever
In addition to the common viral agents that often
cause fever in children, several unusual etiologies
should be considered during the evaluation of fever
in children recently adopted internationally. Since
2007, at least 15 clusters of hepatitis A infection
in new adoptees have been identified upon arrival
in the United States. All involved spread of the
infection to close personal contacts of the child.
Although many children are asymptomatic during
their infection, some may present with fever. Anorexia, nausea, vomiting, malaise, and jaundice may
also be present. The incubation period can be as
4
VOL. 13, NO. 1 • SPECIAL CONSIDERATIONS FOR INTERNATIONAL ADOPTEES / DIBS
long as 15 days, and duration of symptoms can
reach 2 weeks. Therefore, any adoptee with fever,
particularly when accompanied by symptoms of
liver inflammation, should illicit concern for acute
hepatitis A infection.
Although children do arrive after adoption with
hepatitis B or C infections, most have previously
been identified as having the infection. The overwhelming majority acquired the infection perinatally and are asymptomatic. However, the same
signs and symptoms of liver inflammation listed
above for hepatitis A can reflect the rare case of
acute infection with hepatitis B or C. Such a clinical
presentation can also reflect a phase of more active
viral replication in a child chronically infected with
one of these viruses.
Measles is another increasingly recognized risk in
international adoptees. Although rarely seen in the
US, measles virus is more common in developing
nations where immunization rates are significantly
lower. In 2001 and 2004, 2 separate outbreaks of
measles were identified in children recently adopted
from China and their close contacts. 4 After the
latter outbreak, adoptions from the Hunan province
were temporarily suspended. In affected children,
fever, cough, coryza, conjunctivitis, an erythematous maculopapular rash, and Koplik's spots follow
an incubation period of 8 to 12 days. Any new
adoptee, particularly from China, with this clinical
picture should be suspected to have measles and
managed accordingly.
Rarely, malaria can present in a new international
adoptee. Risk of this infection is highest in children
from sub-Saharan Africa, intermediate in those
from India, and low in those from southeast Asia
and Latin America. 5 Symptoms of fever with chills,
headache, rigor, and sweats may be cyclical in
nature. Diagnosis and treatment before exit from the
child's birth country should not exclude the diagnosis. Relapse can occur weeks to years after initial
infection, especially if inadequate initial treatment
was administered. If suspected, workup of possible
malaria infection should proceed with both thin and
thick blood smears for identification of the Plasmodium parasite upon staining. Treatment is based on
the particular species, possible drug resistance, and
severity of disease.
GASTROINTESTINAL SYMPTOMS
Although diarrhea in children residing in the US is
often associated with self-limiting viral illnesses,
intestinal parasites should be suspected as likely
culprits in international adoptees. When infection
has been present for some time, diarrhea may not be
a reported symptom. Rather, abdominal pain,
abdominal distention, or foul-smelling flatulence
and stool may be the primary complaints. The
prevalence of this parasitic illness varies with
country of origin. One recent study indicated a
wide range of occurrence, with South Korea (0%) at
the lowest end and Ethiopia (55%) and the Ukraine
(74%) at the upper end. 6 Giardia intestinalis is the
most common parasite detected, but Trichuris
trichiura, Ascaris lumbricoides, Strongyloides stercoralis,
Blastocystis hominis, Dientamoeba fragilis, Entamoeba
histolytica, Hymenolepis species, and Cryptosporidium
species have all been seen. 6,7 An increase in
sensitivity of diagnosis occurs, with a collection of
3 total stool specimens (1 collected every other day
for 3 collections). Tests for ova and parasites, Giardia
antigen, and Cryptosporidium antigen should be
performed. Less commonly, gastrointestinal complaints may be the result of Helicobacter pylori
colonization of the gastric mucosa, bacterial gastroenteritis, or lactose intolerance.
RESPIRATORY ILLNESS
The crowded conditions often present in institutional settings lead to the spread of many typical
upper respiratory tract viral illnesses. These viruses
are certainly the most common agents causing acute
respiratory illness in children worldwide. However,
it must be kept in mind that children from Africa,
Southeast Asia, and parts of Eastern Europe are
coming from areas where tuberculosis is endemic. 8
Although positive tuberculosis skin testing performed on an internationally adopted child will
generally reflect latent tuberculosis, a minority will
have active disease. 9 Therefore, respiratory symptoms in an international adoptee who has not had
negative skin testing after immigration, and again
6 months later, warrants consideration and workup
for Mycobacterium tuberculosis infection.
PALLOR/ANEMIA
Two sources of anemia are commonly seen in
the international adoptee population. Iron deficiency anemia is one of the most frequently
encountered medical problems affecting children
worldwide. Internationally adopted children can be
even more susceptible because of lack of prenatal
care, iron-deficient diets, and blood loss secondary
to intestinal parasites. Because of excessive lead
exposure and the lack of widespread screening
programs for lead toxicity, many sending countries
have higher levels of lead toxicity than what we see
in the US. This has been particularly evident in
SPECIAL CONSIDERATIONS FOR INTERNATIONAL ADOPTEES / DIBS • VOL. 13, NO. 1 5
Chinese adoptees, with prevalence reaching 14% in
one study.
RASHES
Certain skin conditions and infections are commonly noted in new international adoptees. Eczema, scabies, molluscum contagiosum, tinea capitis,
and tinea corporis very frequently affect children
when they initially arrive home. The nature of an
institutional setting facilitates the spread of those
rashes with an infectious etiology.
AGGRESSIVE OR UNUSUAL BEHAVIOR
Certain risk factors in an internationally adopted
child's background can place him or her at risk for
unusual or undesirable behaviors, at least temporarily after arrival to their home. Time spent in an
institutional setting may be characterized by lack of
nurturing contact, sensory and social deprivation,
and resultant developmental delays. These can all
contribute to “quasi-autism” or acquired institutional
autism. 10 Withdrawal, lack of communication and
eye contact, and repetitive movements (ie, hand
flapping, rocking, and head banging) can be seen in a
newly placed adoptee. This can be quite disturbing to
the new parents. Because these quasi-autistic behaviors most often disappear or improve over time, care
should be taken to distinguish these from true autism
spectrum disorders. Close observation over the first
several months at home is warranted.
Aggression is another behavior that can be noted
either soon after placement or later. New adoptees
may have come from a poorly supervised institutional setting where adoptees were exposed to
aggression between children or even between caregivers and children. Fear and the lack of communication skills with a new family may lead a child to
respond aggressively. In addition, underlying FASD,
at times undiagnosed, can also be a contributing
factor to any observed aggression.
OTHER ISSUES
It is also important to note that a number of
comorbid conditions common to international
adoptees can exist. For example, some degree of
growth delay and developmental delay is often
present when a child initially arrives home. Similarly,
microcephaly might be evident. However, these are
unlikely to bring a child to urgent or emergent
medical care.
SUMMARY
International adoption has been part of our
society for many years. International patients,
adopted or otherwise, are likely to continue to be
part of the population who seek emergency care. In
general, common diseases present commonly to
acute care settings. However, certain infectious and
other diseases affect international adoptees more
commonly than their American-born peers. When
managing illnesses in the international adoptee
population, it is important to maintain a healthy
skepticism of the accuracy of preadoption immunization records and related health care information.
A child's country of origin can sometimes help guide
the clinician toward more likely etiologies of illness.
Illnesses uncommon in the US or western Europe
often occupy higher positions on the differential
diagnosis list for these children.
REFERENCES
1. Bureau of Consular Affairs, US Department of State. Intercountry adoption. Statistics—2010. Available at http://
adoption.state.gov/about_us/statistics.php. Accessed 10-7-11.
2. Dinkins R, Aronson J. Medical issues common to Ethiopian
adoptees. Available at http://www.orphandoctor.com/medical/
regional/Ethiopia/index.html. Accessed 10-7-11.
3. Committee on Infectious Diseases, American Academy of
Pediatrics. Recommendations for administering hepatitis
A vaccine to contacts of international adoptees. Pediatrics
2011;128:803-4.
4. Staat DD, Klepser ME. International adoption: issues in infectious diseases. Pharmacotherapy 2006;26:1207-22.
5. Pickering LK. Malaria. Red book: 2009 report of the Committee on Infectious Diseases. Elk Grove Village (IL):
American Academy of Pediatrics; 2009.
6. Staat MA, Rice M, Donauer S, et al. Intestinal parasite screening in internationally adopted children: importance of multiple
stool specimens. Pediatrics 2011;128:e613-22.
7. Miller LC. International adoption: infectious diseases issue.
Clin Infect Dis 2005;40:286-93.
8. Pickering LK. Tuberculosis. Red book: 2009 report of the
Committee on Infectious Diseases. Elk Grove Village (IL):
American Academy of Pediatrics; 2009.
9. Murray TS, Groth ME, Weitzman C, et al. Epidemiology and
management of infectious diseases in international adoptees.
Clin Microbiol Rev 2005;18:510-20.
10. Miller LC. The handbook of international adoption medicine.
New York (NY): Oxford University Press; 2005.