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International adoption: Looking beyond infectious diseases
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From 1999 to 2012, more than 200,000 international adoptions occurred, according to the Bureau of Consular Affairs at the US Department of State’s Intercountry Adoptions website.
“The numbers have been going down, but there seems to be a number of committed and involved parents who are still looking at international adoption,”
Infectious Diseases in Children spoke with several experts who have both personal and professional experience with international adoptions about preparing families for international adoption and the care that follows when a child comes to the United States.
Pre-adoption counseling
Physicians, especially from international adoption centers, are usually contacted once a family receives information about a child for possible adoption. This information typically includes medical and social information, along with photographs and, sometimes, video of the child.
“What we’re looking at is if the child is healthy or does the child have a medical special need that we need to discuss,”
Margaret Hostetter, MD, director
of infectious diseases at Cincinnati
Children’s Hospital, said the
demographics of international
adoption has shifted since the
early 1970s.
Photo courtesy of Marsland M.
Printed with permission from Yale
University
“For instance, if a child has heart disease, I would have our cardiologist review the records to see if it’s something beyond a simple hole in the heart,” she said. “I might then have another specialist look at it to see if there might be a genetic condition associated with the heart condition so the parents have a complete evaluation and a reliable expectation.”
Besides looking at the medical records, developmental records also are reviewed to determine whether the child is where he should be developmentally.
“Almost always, the children are a few months behind,” Staat said. “They typically catch up quickly if they’re otherwise healthy.”
Early in the process, Staat said it is important to understand the parents’ expectations to help them decide if the child is the “right fit” for their family.
“Families don’t always understand all that’s involved with adopting a child with special needs,” she said. “Some kids will have things that cause them to have a shortened lifespan, and some families may not want to adopt someone who won’t live past childhood. It’s about understanding what the family is hoping for and helping them decide what child is best for their family.”
At the International Adoption Center at Cincinnati Children’s Hospital, Staat said an interpreter is present for children aged at least 18 months at the initial visit so they can help translate and possibly help with the developmental assessment as well.
Staat said it is important that pediatricians continue working with the families throughout the adoption process. They should also be readily available for the family members who travel to the country of adoption to bring home the child.
“We also make recommendations to make sure that the family travels safely,” she said. “We recommend that they are immunized for any diseases endemic to the country where they are going. We give travel advice as well. For instance, they need to have medicine for traveler’s diarrhea and often need to take malaria prophylaxis for travel to certain countries in Africa.”
Common infectious diseases
Hepatitis B virus, hepatitis C virus, syphilis, HIV and tuberculosis are the most commonly seen infectious diseases in internationally adopted children.
“If a child is identified as having an infectious disease, the first thing we do is explain exactly what it is to the families,” Chambers said. “Most parents don’t know that these diseases can have an acute and chronic form. We look at the child’s lab work and try to best describe where the child is in the disease process; if they’re in the acute form or already in a chronic form and considered to be a carrier. We sometimes recommend that parents ask for more follow-up labs to give additional recommendations that might be helpful to further delineate the child’s condition.”
Children are seen 2 to 3 weeks after arrival into the United States to take care of any medical issues and check for any developmental issues.
According to findings of a study published in Pediatrics, about 2% to 5% of internationally adopted children are infected with HBV. The prevalence reinforces the need for repeat serologic testing every 6 months after initial testing. It is possible that children were infected or vaccinated shortly before entrance into the United States and, therefore, would not have serological evidence during initial testing.
In the cases of HBV and HCV, follow-up tests are needed to determine whether the child has an acute or chronic infection. The management for each virus is then discussed with the parents.
Krilov said at one time US laws forbade parents from bringing internationally adopted children with HIV into the United States. However, the rule has since been changed.
When testing for HIV, physicians try to determine whether the child, especially when young, is truly HIV positive or the positive test result is from maternal antibodies. Before the adoptive parents bring the child to the United States, Krilov recommended the parents make an appointment with an HIV clinic.
In the case of syphilis, Chambers said it is important to know what treatment the child received prior to adoption, including the date of diagnosis, drugs and dosages used.
“Sometimes, the records just say ‘was treated for syphilis,’ and that’s not going to be helpful for us once the child gets home,” she said. “If we can get a discharge summary, it helps for decision-making and treatment once they’re here.”
Staat cited a 2008 study conducted at her adoption center which found 21% of children with an initial tuberculin skin test had evidence of latent TB infection. Of the 46.9% of children who were tested initially, 20% had latent TB infection at retest.
“Not very many kids have active TB, but we have some kids coming from Africa with active TB,” she said. “It’s always important to keep that in your mind.”
Staat said most tests done in the child’s native country are reliable.
“If they tested negative there, they test negative here, for the most part,” she said. “We have had some kids who tested negative there but test positive here. That’s why it is important to test the children again once they arrive in the US, because there are effective therapies for some of these diseases and you certainly wouldn’t want to miss that.”
Beyond bacteria and viruses
Krilov said intestinal parasites are another common infectious disease seen in children adopted from outside the US.
In another study conducted in Cincinnati and published in Pediatrics, researchers examining 1,024 children for intestinal parasites found that 27% had at least one pathogen. The most common was Giardia intestinalis (19%), followed by Blastocystis hominis (10%), Dientamoeba fragilis (5%), Entamoeba histolytica (1%), Ascaris lumbricoides (1%) and Hymenolepis species (1%).
“As soon as the children come for their first visit, they get three sets of stool tests,” Chambers said. “We definitely recommend doing three sets; people have gotten into the habit now of doing one set in general pediatrics and very often we will see two negative and one positive.”
Mary Allen Staat, MD, MPH, who is director of the International Adoption Center at Cincinnati Children’s Hospital, seen here with her three adopted children, said she often has a specialist look at any questionable documentation from potential adoptees..
Source: Staat MA
Chambers said doing three tests would diminish the possibility of a false-negative result.
“One important thing with the international adoption population is that they could have no symptoms because they’ve had the parasite for so long,” Chambers said. “We definitely check every child regardless of symptoms. We also recommend that families be extra careful in regards to bathing, toilet habits, etc., until all of the parasite test results are returned.”
After the initial visit, Staat said the children at her clinic are seen for follow-up 3 months after adoption if any specific issues are present or at 6 months if they were generally healthy. Some of the tests performed at the initial visit that came back negative, such as tuberculosis testing and other tests, are repeated at the 6-month visit.
“We’ll repeat HIV, HCV and HBV,” she said. “They could have been exposed right before they left and didn’t have an immune response when we first saw them. We just go over where they are, how their growth is, where they are developmentally and see how everyone in the family is adjusting. We also make referrals if we feel like the child needs extra help in any areas.”
Immunization and documentation reliability
According to Chambers, most children have been vaccinated and often have proper documentation. “That’s one thing we coach in our pre-adoption seminar. We remind them to ask for the child’s vaccination records if they’re not already provided in the medical packet. If we can get their documentation, that’s helpful once they get home.”
However, both Chambers and Staat said they always check antibody titers to be sure of immunity.
“We’re doing a bunch of blood work anyway, so we just check those,” Staat said. “Then we know what the child has immunity to, if they don’t have immunity we vaccinate them.”
Staat said immunization of children is a priority all over the world, especially in orphanages where immunization is slightly more regimented.
“Once kids are institutionalized, they actually get vaccinated if they weren’t before,” she said. “The time you might have a problem is if the child has been abandoned and wasn’t in the orphanage very long, so there wasn’t time for immunizations. However, that’s not the case most of the time.”
“We generally make an assessment on each case as to whether to trust the history and documentation sufficiently to recommend revaccinating or not,” he said. “This is not a simple ‘yes’ or ‘no’ question, but takes some deliberation.”
He said some foreign vaccines lack the potency of those given in the United States, and improper storage also can decrease their effectiveness.
“Attempting to determine vaccine status by antibody testing can be ineffective because the simple presence of antibody cannot confirm how many doses of vaccine the child has received,” Chusid said. “Our routine recommendation, especially for younger children, is to restart immunizations as if the child is vaccine-naive. There is no significant risk to extra vaccinations, and this is the safest course to take. The ‘catch-up’ schedule in the Red Book can be utilized.”
However, in cases where records are exemplary and there is confidence in the overseas medical provider, Chusid said the physician can accept the records and just pick up where they leave off to fill any gaps that may be present in the child’s history.
“For instance, varicella, meningococcal and hepatitis A vaccine are not routinely given in many countries,” he said.
Developmental, behavioral and emotional problems
According to
“If we go back to the mid-1980s to the Korean foster home system, there were these wonderful foster parents who gave the children love and developmental support until their adoption into the United States,” Hostetter said. “Fast forward to 30 years later to children from war-torn countries, children who are forced to live in camps because they might have been displaced, children whose parents might have been killed in war, all of these children are going to be in need of psychological help.”
Krilov echoed Hostetter’s thought on the shift.
“The emphasis on international adoption is moving away from infectious diseases because the bigger problem is becoming growth and development,” Krilov said. “Unlike some infectious diseases that are somewhat easily treated, nutrition is something that isn’t a quick fix. Brain development and potential behavioral issues are things that aren’t so straightforward and are outside of the comfort zone for many pediatricians.”
Staat said that a major part of her institution’s program is mental health and learning services for internationally adopted children.
“We have a mental health and learning team to help out internationally adopted children and their families throughout their lifetime,” she said. “The child’s background of institutionalization, malnutrition and trauma places them at high risk for these issues.”
Chambers said her experience also has shown her that developmental and behavioral issues are becoming especially important.
“When I started this clinic, I thought it was going to be mostly infectious diseases that I was going to be treating, but it’s not,” Chambers said. “It ends up being about one-third medical, one-third emotional and one-third developmental. One of the biggest things that I didn’t know is that there are so many emotional and developmental needs; they have just as many of those needs as they do infectious diseases. The further I’ve gotten into it, and the longer that my kids have been home, their medical issues are long in the past, but their cognitive and emotional issues are not.” — by Amber Cox
References:
Staat MA. Pediatrics. 2013;doi:10.1542/peds.2010-3032.
Stadler LP. Pediatrics. 2013;doi:10.1542/peds.2007-2559.
Trehan I. Pediatrics. 2008;doi:10.1542/peds.2007-1338.
US Department of State. Intercountry Adoption. Available at: www.adoption.state.gov. Accessed Dec. 2, 2013.
For more information:
Jennifer Chambers, MD, can be reached at UAB International Adoption Clinic, CPPI 310, 1600 7th Ave. South, Birmingham, AL 35233; email: adoption@peds.uab.edu.
Michael J. Chusid, MD, can be reached at Pediatric Infectious Diseases, Children’s Hospital of Wisconsin, Suite C450, 999 N. 92nd Street, Wauwatosa, Wisconsin 53226; email: mchusid@mcw.edu.
Margaret Hostetter, MD, can be reached at Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 7017, Cincinnati, OH 45229.
Leonard R. Krilov, MD, FAAP, can be reached at Winthrop University Hospital, 120 Mineola Boulevard, Suite 120, Mineola, NY 11501; email: lkrilov@winthrop.org.
Mary Allen Staat, MD, MPH, can be reached at Cincinnati Children’s Hospital Medical Center, International Adoption Center, Division of Infectious Diseases, 240 Albert Sabin Way, MLC 7036, Cincinnati, OH 45229; email: mary.staat@cchmc.org.
Disclosure: Chambers, Chusid, Hostetter, Krilov and Staat report no relevant financial disclosures.