I noticed on the schedule that I was going to see a new patient, an 11-month-old boy named Justin. I wondered if his family was new to Southern California, or if the family’s insurance had recently changed. As I entered the examining room to meet them I was surprised by what I saw. Mr. Brown appeared to be in his late 40’s and was well dressed. His light brown hair was slightly graying around the temples and he carried himself like the business executive that he was. Mrs. Brown, who had almost platinum blond hair, was smartly dressed and looked much younger that her 42 years. She was a successful attorney. Both she and Mr. Brown felt that it was now time for her to cut back and start their family. Little Justin was sitting apprehensively on his dad’s lap, clinging to dad’s shirt as I spoke with the parents. His jet-black hair provided a stark contrast to the parents’ fair hair, as did the almond shape of his eyes. Justin, it turned out, was Eurasian. The Browns had just adopted him from Russia, and this was his first medical visit in the United States.
When I started to gather some medical history, Mr. Brown interrupted and said, “Before you go any further, we know very little about Justin’s past other than we were told he was healthy with the exception of a number of ear infections.” He then produced a crumpled and wrinkly piece of onionskin paper with Russian writing on one side. On the other side was a grid that obviously was an immunization schedule of some sort. The dates and stamps were impossible to read or they simply did not coincide. The immunizations that were legible were names that didn’t make any sense to me. “I’m really sorry, but this is all we were given from the orphanage before we left,” Mr. Brown said apologetically.
This scenario was played out in my office, and the offices of pediatricians throughout the country, at an increasing rate over recent years. International adoption is a phenomenon carrying with it a host of issues and problems that must be addressed and properly dealt with. The fall of the former Soviet Union has greatly changed the landscape of international adoption, and has brought with it a whole new set of issues and problems that must be confronted by the medical community in the United States.
In the 1970’s and 1980’s most of the adopted children coming to the United States were from Asia and Latin America. The majority of these children was under one year of age, and had spent their lives in foster care or small orphanages. Most of these adoptions were arranged by non-profit agencies, and were relatively inexpensive to process. This changed dramatically with the fall of the former Soviet Union and the geopolitical changes that have taken place in Asia.
In 1990 American families adopted nearly 8,000 babies from other countries, mostly from Korea and Latin America. By 1999 that number had swelled to over 16,000. Over two-thirds of these babies were from China and the former Soviet Union. The mean age of these adoptees was two years of age, and the average cost of the adoption was approximately $20,000. Many of these adoptees spent their two years in large institutions with poor supervision, little physical interaction and social deprivation. A large number of these children were products of high-risk pregnancies and complicated deliveries.
When a child is adopted some sort of record is to be provided. This may include a whole and detailed medical history, complete with lab results, x-rays and immunization card--or, it may simply be a Polaroid picture of the child and a verbal assurance from the adoption attorney that the child is “healthy”. As a rule, children adopted from Korea and Guatemala do have good medical records. Unfortunately, children from other countries often times have very poor records. Those records that are provided are inaccurate, hard to interpret or believe, or simply do not fit with the child’s condition. This poses the biggest challenge to the physicians in the United States who are going to be the primary caregivers of these new citizens. It can also be a heartbreaker to the parents who have such high expectations for their new child.
When a child is brought to this country for adoption, the parents should bring him to the doctor for his first visit within 10-14 days. That is assuming there are no known medical problems that warrant a sooner evaluation, such as a heart defect, etc. This will allow both parents and child to recover from whatever jet lag they may be experiencing, and will provide time for all parties to become acquainted. This visit is important, as it will give the doctor a chance to learn as much as he or she can about the baby’s past, and perform a thorough physical examination.
The examination should include plotting the baby’s growth parameters on the growth curve. These parameters are height, weight and head circumference. The information gives an idea about the child’s general nutritional status. A detailed examination should follow with documentation of any old injuries or fractures. If a child comes into this country with a known medical diagnosis, it is the duty of the new doctor to reconfirm that diagnosis so that there is absolutely NO question about it. Although these children are “medically” screened by United States Immigrations before entry into this country, the process is far from complete. One recent study showed that 67% of children evaluated and cleared in an international adoption clinic had a medical condition that was missed and picked up only at the first examination by the United States physician. In addition to a complete examination these children should be screened for hearing and vision, and should have a dental evaluation.
There is a consensus among the medical specialists as for routine labs that should be performed on an internationally adopted child. These include:
Prior to 1990 the incidence of syphilis in newly adopted children from Russia was 0.3 - 1.6%. A recent study of medical records from Russia indicated that more than 30% of the deliveries of adopted children mention a diagnosis of maternal syphilis. A recent study shows that as many as 50% of adopted children are infested with intestinal parasites. Exception to this is children from foster homes in Korea where parasites are quite rare. Lead poisoning is a significant health problem in some areas of China. One study of 301 children adopted from China revealed that 13% had elevated lead levels by United States standards.
One area of consternation for doctors in the United States who treat international adoptees is the immunization status. The American Academy of Pediatrics and the Center for Disease Control have long suggested that immunizations from other countries are acceptable and efficacious. The main problem, however, is that the records are usually sketchy and unreliable, at best. Certainly one would not want to immunize a child unnecessarily. However, without proper documentation one cannot take a chance. This leaves the doctor with two options. One is to re-immunize the child, assuming that he did not receive ANY vaccines. Two is to do a blood test measuring the level of protections against a specific disease to evaluate if he is protected. This test measures the level of antibodies (lgG titers) against specific disease such as measles, polio, tetanus, chicken pox, mumps and hepatitis B. The doctor can then immunize the child against specific illnesses from which they have no protection.
The Browns were quite relieved to find that Justin’s growth and development was right on track for a normal 11-month-old male. His examination was also completely normal. Although I couldn’t fully decipher his immunization status, given my inability to read Russian, it did appear that he had received a number of immunizations. I did measure his serum titers and found that he only needed the chicken pox and hepatitis B vaccines, which we started that first day. So far he has thrived and grown into a healthy and bright little boy.
For parents who are considering adopting a child from abroad, a wealth of information is available to help make informed and proper choices. A plethora of Internet sites dealing with international adoptions gives information on how one gets started to links with families who have gone through the process and are willing to share their experiences. In the case with the Internet, however, one must be cautious and careful. Prospective parents need to do their homework, and be informed. A new phenomenon is occurring in the legal profession. That is in the area of “wrongful adoptions”, whereby parents are suing agencies because the child they have adopted from a foreign country has severe medical or behavioral problems. This is heart wrenching and devastating for all parties concerned. The best way to avoid this is to go into it having researched ALL aspects.