Medical Evaluation of the
Internationally Adopted Child
Dr. Jane Aronson
International Pediatric Health Services,
PLLC
Clinical Assistant Professor of
Pediatrics
Weill Medical College
International Adoption Statistics
 1989-2007
265,973 adoptions
from abroad (top 20 countries)

http://travel.state.gov/family/adoption/stats/stat
s_451.html
Adoptions in 2007 (18,748)

China
 Guatemala
 Russia
 Ethiopia
 S. Korea
 Vietnam
 Ukraine
5453
4728
2207
1255
939
828
606
Adoptions in 2007

Kazakhstan
 India
 Liberia
 Colombia
 Philippines
 Haiti
 Taiwan
540
416
314
310
265
190
184
Adoptions in 2007

Mexico
 Poland
 Thailand
 Kyrgystan
 Brazil
 Uganda
89
84
67
61
55
54
Adoption Statistics 2006








6,493
China
4,135
Guatemala
3,706
Russia
1,376
South Korea
732
Ethiopia
587
Kazakhstan
460
Ukraine
Total 20,679
Adoption Statistics in 2005








7,906
4,639
3,783
1,630
821
755
441
Total
China
Russia
Guatemala
South Korea
Ukraine
Kazakhstan
Ethiopia
22,728
Adoption Statistics for 2004








China
Russia
Guatemala
S. Korea
Kazakhstan
Ukraine
India
Haiti
7,044
5,865
3,264
1,716
826
723
406
356
Adoption Statistics 2004

Ethiopia
 Colombia
 Belarus
 Philippines
 Bulgaria
 Poland
 Mexico
289
287
202
196
110
102
89
Adoption Statistics 2004

Liberia
 Nepal
 Nigeria
 Thailand, Brazil
 Romania
 Total
86
73
71
69
57
22,884
Adoptions in 2003

China(Mainland)
 Russia
 Guatemala
 S. Korea
 Kazakhstan
 Ukraine
 India
6,859
5,209
2,328
1,790
825
702
472
Adoptions in 2003

Vietnam
 Colombia
 Bulgaria
 Haiti
 Philippines
 Romania
 Belarus
382
272
198
250
214
200
191
Adoptions in 2003

Ethiopia
 Cambodia
 Poland
 Thailand
 Azerbaijan
 Mexico
 Total
135
124
97
72
62
61
21,616
INS Statistics for 2002







Top Twenty Source countries for International
Adoptions for Year 2002: Total 20,099
China
5,053
Russia
4,939
Guatemala
2,219
S. Korea
1,779
Ukraine
1,106
Kazakhstan
819
INS Statistics for 2002

Vietnam
 India
 Colombia
 Bulgaria
 Cambodia
 Philippines
 Haiti
766
466
334
260
254
221
187
INS Statistics for 2002

Belarus
 Romania
 Ethiopia
 Poland
 Thailand
 Peru
 Mexico
169
168
105
101
67
65
61
U.S. State Department Data for
International Adoptions in 2001








Total intercountry adoptions 19, 237
China
4,681
Russia
4,279
S. Korea
1,870
Guatemala
1,609
Ukraine
1,246
Romania
782
Vietnam
737
U.S. State Department Data for
International Adoptions in 2000







Total Intercountry adoptions 18, 441
China
5,053
Russia
4,269
S.Korea
1,794
Guatemala
1,518
Romania
1,122
Vietnam
724
Based on immigrant visas issued
U.S. State Department Data for
International Adoptions in 1999

Total Intercountry adoptions 16,369
 Russia
4,348
 China
4,101
 S. Korea
2,008
 Guatemala
1,002
 Romania
895
 Vietnam
712
Primary Receiving States for
Intercountry Adoptions
New York
Minnesota
California
Illinois
Pennsylvania
New Jersey
National Adoption Information Clearinghouse
http://naic.acf.hhs.gov/
Trends in Intercountry Adoption
1989 thru 1999
 1989
8,102
 1999
16,363
Doubled in 11
yrs.
China and Russia Neck and Neck

China
67,727
 since 1991

Russia 54,821
 since 1992

As of end of 2007
Pre-adoption Issues

Choosing a Country
 Vaccines for travel-start at the beginning of
the process of adoption!
CDC http://www.cdc.gov/travel/
1-877-FYI-TRIP
WHO http://www.who.int/ith/
Web Sites for Travel Health
CDC
http://www.cdc.gov/travel
WHO
http://www.who.int/ith
IMAT
http://www.iamat.org
Int Society for Travel Medicine
http://www.istm.org
Amer Society for Trop Med and Hygiene
http://www.astmh.org
US Dept. of State
http://www.state.gov/travel
Travax
http://www.shoreland.com
CDC Malaria Section
http://www.cdc.gov/travel/malariadrugs2.htm
The High Altitude Medicine Guide
http://www.high-altitude-medicine.com
Vaccines for Travel

Parents and children traveling abroad need
advice to keep well and happy!
 Hepatitis A, B, updated dT, IPV?,
Influenza,Typhoid, Meningococcal
 Rule of 1957: Before and After
Check Titers for M, M, R,V, diphtheria,
tetanus, polio and give appropriate boosters
www.orphandoctor.com/
Medical Abstract Reviews





Countries each have a unique style of presenting
the medical information about the child-there is a
standard!
Russia and Defectology
Russia and the search for FAS-video, photo
China-Hep B tests, Syphilis, and HIV, growth
points, social history, developmental report
Guatemala-copies of the actual blood work,
frequent exams, new photos and a weekend with
your child before adoption
Defectology

Russian philosophy, religion, science
 Perinatal Encephalopathy, Pyramidal
insufficiency, Spastic tetraparesis, Hypertensivehydrocephalic syndrome, Neuroreflex excitability
syndrome, Seizure readiness, hypotrophy, hip
dysplasia, convergent squint, dystonia, myotonia,
exudative diathesis, open foramen ovale,
oligophrenia, dysbacteriosis
Fetal Alcohol Syndrome

Worldwide incidence 1.9 per 1,000 Abel et
al 1987
 Aronson 1998 FAS incidence based on
retrospective chart review of Russian
medical records-1.53% or 15 per 1,000 (8
times world incidence)
 FAE is not mild FAS
 Alcohol Spectrum Disorder new term
Preparation for Travel Abroad




Prescriptions: Zithromax, Tobrex, Nystatin, Elimite 5%
Discussion of URIs, Otitis Media, Reactive Airways,
Eczema, Diaper rash,Teething, Constipation,
Gastroenteritis, Hotel and Airplane Behavior, Sleep issues,
Feeding, and Adaptation behaviors of the newly adopted
child
Travel Clinics Abroad: SOS/AEA, IAMAT,AMC,
IMC, EMC, Worldlink, CanAm in Garden Hotel in
Guangzhou, China
Stateside Doc availability for phone consultation
Medical Evaluation on Arrival

Newly adopted child should be seen within a week
of arrival
 Make allowances for a possible initial sick visit
with a follow-up consultation later
 Physical Exam with attention to diagnoses known
from prior medical abstracts from the country of
origin-heart murmur, dysplasia of the hips
Pediatric Annals April 2000 Aronson
Developmental Assessment
Look at the child’s development and see them in
6-8 wks to re-evaluate the development, growth,
and adaptation to the new home
 Early Intervention referrals should be considered
for children 12-15 months with delays in
expressive language, children with oral motor
dysfunction, and sensory sensitivities, selfregulation dysfunction, and obvious gross motor
and fine motor delays that are more than expected
for an institutionalized child

Head circumference

Aronson Orphan Ranger Program in Russia
 Stickney 1998 and Holtan 1999-40% of
children living in orphanages in Russia had
microcephaly
 50% had FTT
Head Growth after Adoption

Catch-up head growth was documented in 85% of
Eastern European orphans (n=34) after arrival
 Mean head circumference increased an average of
0.67 +/- 0.82 SD from arrival (-1.07 +/- 0.9SD,
mean age 13.2 +/- 5.2 months, range 5.5-32
months) to follow-up (-0.40 +/- 1 SD, mean age
26 +/- 7 months, range 5.5-32 months)
 P < 0.01 paired t test (Aronson & Johnson,
unpublished data 1997)
Growth Failure

Psychosocial growth failure or psychosocial
dwarfism is quite common in children adopted
from abroad
 Work done by “Orphan Rangers” (Worldwide
Orphans Foundation) showed that 50% of kids had
growth below the 5th% (Russian orphanages)
 Kids catch up!
 Please remember that kids may have genetic short
stature and that short kids can have underlying
chronic disease
Sensory Integration Dysfunction
A. Jean Ayres, Ph.d., OTR 40 years ago

Children are living in an environment that is
devoid of normal stimulation
 Children may not be wired to handle the sensory
input of their “new world”
 Response to light, sound, taste, touch can
potentially be unusual and distracting
 Occupational Therapy focuses on retraining
children to handle sensory input comfortably
Sensory Integration Dysfunction
(SID)

Interoceptive
 Tactile
 Vestibular
 Proprioceptive
Sleep Disturbances

Jet lag-give it a week at least for the baby and
maybe two weeks for you
 Sleep issues of children in general are complexmake a family plan and re-evaluate the plan in a
few months
 Cultural biases-co-sleeping and the family bed
 Night terrors-Are they more common in orphans?
Feeding Behavior








Bottle propping
Speed feeding
Rickets and malnutrition
Lack of heterogeneity of food stuff
Oral motor dysfunction
Sensory Integration Dysfunction
Speech and Language Delays
Self-regulation dysfunction
Age

Dates of birth may not be accurately assigned due
to abandonment
 Bone age and dental x-rays are inexact, but
certainly can be of some use in children who are
adopted at school age
 Developmental assessments over time are much
more accurate (teachers and parents know the age
of a child over time)
 Reassigning date of birth may be necessary for
proper school placement
Attachment is a Process
Children and parents attach over time and for
children who know little about intimacy and
social connection, this is a learning process
with ups, downs, and plateaus
Attaching requires a sense of self
Attachment Concepts
Reactive Attachment Disorder is not common
“I see more attachment disorder in parents
than I see in children” Dr. Aronson
Post Adoption Depression exists!
Attachment Theory
References
Attaching in Adoption
Deborah D. Gray
More References on Attachment
Daniel J. Siegel, M.D.
Parenting from the Inside Out
The Developing Mind: How Relationships and the
Brain interact to shape who we are
Allan N. Schore
Affect regulation and the origin of self: The
neurobiology of emotional development
Longterm Follow-up
What do we know about kids who were
adopted since the early 90s?
The vast majority of parents are content with
their adoptions
University of Minnesota State F/U study ongoing
Follow-up
Increased incidence of attention deficit
disorder with and without hyperactivity
Increased incidence of learning issues
Adoption of the Older Child
A growing way to create a family
A child who has been in the orphanage since
birth
A child who has had a family, lost a family,
and found a new family
Laboratory Evaluations







CBC with diff, plts, rdw
Hemoglobin electrophoresis-Asia, Latin America
G-6-P D Asia, Latin America
Rickets screen-alk phosphatase, ca, phos
Liver enzymes (AST, ALT)
Thyroid function tests
Newborn screen for infants < 12 mos. (includes
thyroid, PKU, and HIV tests)
Laboratory Evaluations








Hepatitis B, C serology
Syphilis serology-RPR, TP
HIV 1, 2, Western Blot, PCR HIV DNA
Lead (venous)
Zinc level for skin rash that is unusual
Stools O & P X3
Giardia antigen, Cryptosporidium DFA
Stool C & S X1
Medical Investigations

PPD (Mantoux test) on arrival and 3 months
later
 Hearing evaluation-Audiology
 Vision screening-Pediatric Ophthalmologist
 Dental Care-Pediatric Dentist should see
children by 18 months
Health of Children Adopted From China
Laurie C. Miller and Nancy W. Hendrie
Pediatrics 2000 Vol.105; e76

452 children
 “Chinese adoptees display a similar pattern
of growth and developmental delays and
medical problems as seen in other groups of
internationally adopted children.”
Prevalence of Infectious Diseases
Among Internationally Adopted
Children
Saiman, Aronson, Zhou et al. Columbia
University, Winthrop-University Hospital,
International Pediatric Health Services,
Division of Tuberculosis Elimination,
Centers for Disease Control and Prevention
Pediatrics September 2001 Vol. 108, no. 3
608-612
Winthrop-University Hospital Internat’l
Adoption Medical Consultation Services
1997-1998

504 children
 Mean Age-1.6 years (range 11 days to 11.7
years)
 71% female
 29% male
 16 countries- China (48%), Russia (31%),
Southeast Asia (8%), Eastern Europe (8%),
and Latin America (5%)
Latent TB Infection by Country

Tuberculosis exposure-404 children tested
with Mantoux and read by physician
 75/404 (18.6%) greater than or equal to 10
mm with negative chest films (LTBI)
 China 21/201 (10.4%) LTBI
 Russia 40/133 (30%) LTBI
 Other 14/70 (20%) LTBI
Chronic Hepatitis B Infection

14/499 (2.8%) were positive for Hep B
surface antigen
 8/240 (3.3%) from China Hep BsAg +
 4/154 (2.6%) from Russia Hep BsAg +
* Chronic HBV has decreased markedly over
the years since this study was done
Hepatitis B vaccine





175/499 (35%) Hepatitis B surface antibody
positive
96/499 (19%) received Hep B vaccine
42 of 96 received 3 doses and 29/42 (69%)
seroconverted
21 received 2 doses and 14/21 (67%)
seroconverted
32 received 1 dose and 8/32 (25%) seroconverted
What can go wrong with
immunizations in orphanages?








No cold chain
Expiration of products
Poorly produced products in some countries
Malnutrition and poor immunogenicity
Country specific schedules
Given too young
Intervals too close
Poor documentation
Documentation of Immunizations
among Internationally Adopted
Children






Schulte, Maloney, Aronson et al. Pediatrics
February 2002;109(2) e22
34% had documented immunizations in preadoptive records
66% did not have documentation
Variability of immunizations “up to date” at 1 yr
Polio (77%); DTP (59%); Hep B (29%)
5% had records of one or more vaccine doses
administered before birth
Update on Immunization Research
Evaluating Immunizations in Internationally
Adopted Children Poster Session November 2003
New Orleans
Rosemarie Roque Gordon and Jane Aronson
In this study of 113 children, the majority with
written documentation of 3 Hep B, DTP, and polio
vaccinations given at acceptable intervals had
protective antibodies
Past Immunization Dilemmas

Hostetter & Johnson Society for Pediatric
Research May 1998 “Overall, despite
written evidence of age-appropriate
immunization, only 35% of Chinese,
Russian, and EE adoptees exhibited
protective titers to diphtheria and tetanus.”

Rapid changes in vaccine coverage abroad!
What to do about Immunizations?

For children under 9 months, I have been
repeating all vaccines, except for children from
Guatemala, South Korea, Thailand, India,
Colombia
 For children greater than 9 months of age, I draw
antibody titers and create an individualized
immunization plan
 Hib, Varivax, Prevnar are easy as they are not
given in most countries outside the U.S.
 Hib is given in some cases in Central America i.e.
Guatemala
More on what to do

If there is a schedule, make sure the
intervals are appropriate and that the
vaccines weren’t given too young
 You may end up removing one vaccine in a
series and salvage others if the titers are
adequate
 Measles cannot be accepted if it is given
less than one year of age
Summary on immunizations for
children adopted from abroad

There is more consensus than before
 Do titers or re-immunize or both
 Negotiate a plan with parent (s)
 Consider cost, risks, benefits
 We need more research to establish
consensus and standard of care
Hepatitis C, Syphilis


No child had these diseases in the study
2/1500 (0.13%) Hepatitis C since 1994
2 new HCV positive children < 1 yo
Both kids lost maternal antibody
One new child with HCV (E +, R+) 10/02
2/1500 (0.13%) Syphilis since 1994
10/478 (2.1%) FTA positive in study

As of 10-29-02





HIV infection in Children Adopted
from Abroad







7299 + children tested in 17 centers in the U.S.
since the early 1990s
12 children with HIV infection (0.16%)
Russia
1
Cambodia
4
Romania
4
Panama
1
Vietnam
2
HIV Infection

Russia 12 month old girl in 1998
 Cambodia all 4 negative in country
 Vietnam 2 negative in country
 Panama 1 negative in country
 Romania 2 negative in country, 2 known to
be infected before adoption
 10/12 negative at time of adoption (83%)
HIV infection in Children Adopted
from Abroad

59 Children HIV ELISA positive
 12 HIV-infected, 47 non-infected
 59 children born to mothers with presumed
HIV infection [59/7299 (0.8%)]
HIV ELISA Positive Children Adopted
from Abroad







Cambodia
China
Russia
India
Romania
Vietnam
Thailand
20
9
9
6
4
3
3





Guatemala
Panama
Ethiopia
Ukraine
S. Korea
1
1
1
1
1
HIV testing in Children





HIV ELISA, Western Blot, PCR, P 24 antigen, HIV
culture
Children under 18 months may still have maternal
antibody
Baby born to mother who is known to be infected gets
HIV ELISA, WB, PCR at birth
F/U HIV testing at one month and then between
4-6 months of age
If the PCR test is negative three times, then the child is
considered to be negative for infection
Dilemmas in HIV Testing of
Orphans

What happens to kids in orphanages who
test HIV positive by ELISA?
 75% of children under 2 yo. who are ELISA
positive are not infected
 How to implement PCR testing? Some
countries just don’t have this kind of testing
as yet
Changing Policies

China Center Adoption Affairs in Beijing issued a
new policy in summer 2002 requesting that all
orphanage directors in China implement HIV
testing for orphans
 Implementation has been swift and all kids are
being tested currently
 There have been no children adopted from China
with HIV infection on arrival in the U.S.
More on HIV for 2007

PCR HIV DNA testing is available in
Ethiopia and Viet Nam
 Recommendation for two PCR HIV DNA
tests for children under 2 yo in Ethiopia due
to high prevalence of 6.4%
 Viet Nam is a low prevalence country for
HIV i.e. 0.3 % so HIV ELISA is acceptable
Gastrointestinal tract pathogens

Giardia infection was common
 117 children with one or more pathogens noted
 87/461 (19%) Giardia lamblia antigen detected
 Being born in EE- Russia, Romania, Moldova,
Bulgaria, and Hungary was a risk factor for the
acquisition of G. lamblia (intestinalis)
Giardiasis

To not treat a child from an orphanage with Giardia
because the symptoms are minimal would be a mistake
 Failure to Thrive is probably universal in this
population and Giardia probably plays its part
 Public Health is a major issue-Kids spread this to
families and friends!
 Treat it with Metronidazole made as a tasty benzoate
suspension 1-800-861-0933 (Connecticut Pharmacy)
 Consider Tinidazole, Albendazole, Quinacrine,
Paromomycin
 Apthorp, Vitality, Miller, Clayton & Edward, Cherry
Gastrointestinal tract pathogens

Campylobacter spp.
 Shigella spp.
 Salmonella spp.
 Cryptosporidia spp.
 Dientamoeba fragilis
 Ascaris lumbricoides
 Hymenolepis nana
5
3
2
4
10
1
3
Gastrointestinal tract
non-pathogens

Blastocystis hominis
 Entamoeba coli
 Endolimax nana
 Chilomastix mesnili
 Entamoeba hartmanni
18
7
4
1
1
Helicobacter pylori Infection

Is this a real player in children with failure to
thrive, reflux esophagitis, diarrhea, and other nonspecific gastrointestinal problems?
 With the new diagnostic stool H. pylori antigen
test, it will probably be diagnosed more often and
may very well be found to be a considerable cause
of poor growth in children from orphanages
 I have increasing numbers of kids with +H.pylori
antigen who do well on treatment
More on H.Pylori Infection






Treatment for symptomatic children is a must
Zantac every 12 hours for three months
Metronidazole benzoate 30 mg per kg per day
divided in 3 doses x 2 weeks
Biaxin 15 mg per kg per day divided in two doses
x 2 weeks
Amoxicillin 50 mg per kg divided in two doses for
two weeks
Test of cure at end of treatment with Antigen test
Skin problems in Orphans





Scabies incognito-Treat with Elimite 5% when in
doubt
Urticaria pigmentosa (mastocytosis)-I see it too
often in little ones from Asia
Acropustulosis of childhood- Is this related to
Scabies? Dapsone works!
Don’t forgot about Fungus!
Eczema could very well be related to Zinc
deficiency
Anemia

We all know iron deficiency anemia
 Bone up on your “Anemias of Asia”
 Know Thalassemia and you will decrease
anxiety
Adoption Support Groups

Families with Children from China
www.fwcc.org
 Families with Children from Vietnam
www.fcvn.org
 Latin American Parents Association
www.lapa.com
Adoption Support Groups

Families for Russian and Ukrainian Adoption
www.frua.org
 Eastern European Adoption Coalition, inc.
www.eeadopt.org
 Adoptive Parents Committee-APC
www.adoptiveparents.org
 Jewish Child Care Association/Ametz Adoption
Program www.jccany.org
Adoption Reading Resources

Adoptive Families Magazine
 Adoption Today
 Parent and Child magazines
 Websites:
www.rainbowkids.org,www.adoptivefamili
es.com, www.aap.org/sections/adoption,
http://naic.acf.hhs.gov/, tapestrybooks.com
International Pediatric Health
Services, PLLC
151 East 62nd St. NYC
 Phone 212-207-6666
 Fax 212-207-6665



Orphandoctor@aol.com
www.orphandoctor.com