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What parents should do before an international adoption

The data from adoptees in the Yale International Adoption Clinic was similar to the CDC results. Of the 93 children screened here, 22 were from China and 38 were from Russia. We saw elevated lead levels in three of the children from China and one from Russia. The CDC study once again underscores the need for careful evaluation of these children by physicians familiar with these issues.

The International Adoption Clinic
In the Yale International Adoption Clinic, we now see an average of three children every Monday morning. This correlates with the overall increase we see nationally. A typical evaluation usually takes a couple of hours. Our nurse practitioner first addresses the parents’ general questions, which may include issues surrounding diet, sleeping patterns or tantrums. Then one of the pediatric infectious disease specialists performs a complete medical examination, after which our behavioral/ developmental pediatrician provides an age-appropriate assessment of the child’s development in gross motor, fine motor and language skills. Blood tests recommended by the American Academy of Pediatrics are performed at the end of the visit. In a few days, we have the results from the lab work back and we call the parent and send a letter to the child’s regular pediatrician. The parents also get a copy of our letter.

No X-ray vision
One of the things I emphasize to parents is that we pediatricians can’t tell the health of a child just by looking at him or her. Physicians don’t have X-ray eyes. That’s the lesson we learned in 1989 when the work we did in Minnesota showed that half of the internationally adopted children we tested had a major medical issue at the time of their arrival. You have to do the blood work to know exactly what’s going on, a point Dr. Miller makes loud and clear in her editorial.

Shift in trends
Before 1991, 70 percent of international adoptions came from Korea, where the children are raised in foster homes, not orphanages. These children tend to have better nutrition and better development. Adoptions from Romania began in 1991 and were quickly followed by the opening of programs in Russia and China. In 1991, Korea limited the number of adoptable children and now 70 percent of the children come from China and Russia, 20 percent from Korea and 10 percent from Southeast Asia and South America.

Steps to take before adoption
Parents interested in international adoptions should know what to expect. A lot depends on the agency working for them.

First, the agency should supply baseline data on the child–the height, weight and head circumference at birth, as well as at regular intervals. It’s important to see the growth patterns over time.

There should also be detailed information in the child’s record about physical examinations performed. Be wary of reports that say, "Everything looks okay." Instead, look for written findings that include explicit information about the head, eyes, nose, throat, chest, heart, abdomen, etc.

Tests for certain diseases, such as hepatitis B, HIV or syphilis are not standardized and are performed inconsistently. Parents need to know that the accuracy of those tests done in other countries cannot be guaranteed. In China, Russia and Eastern Europe, adoption specialists have found that laboratory testing for hepatitis B is wrong 6 - 10 percent of the time. Parents should be sure they understand who pays for these tests. Sometimes it’s included in the agency fee, but repeat tests may be extra.

Look in the record for discussion of the child’s development, such as the age at which the child rolled from back to stomach, followed a toy with the eyes, sat alone, crawled or stood alone.

Expect a video of the child if coming from Russia or Eastern European countries, such as Lithuania or Romania, where this is a standard practice. If there is not a video available, that should raise a red flag. As a rule, agencies working in South Korea, China, Southeast Asia and South America do not provide videos.

Talk with other agencies and parents to see if the information you are getting is detailed and complete, or very scanty.

Beware of agencies that guarantee a perfectly healthy child or seem reluctant if you seek medical advice. A realistic approach to the issues of adoption is preferable to a Cinderella story. Remember, these are children who, in many cases, have spent a lot of time in orphanages. The child may even be an older child who remembers his separation from his biological parents and now has to attach again.

Unique problems
In addition to the overall guidelines, each country has its own unique issues. Children from Russia and Eastern Europe, for example, have a higher percentage of fetal alcohol syndrome. There’s a higher prevalence of hepatitis B in China, where 8 to 10 percent of women of childbearing age are infected. In Korea, watch for TB.

In Russia and in South American countries, syphilis is more common. Adoptions from South America should include DNA testing to make sure the woman who has surrendered the child is actually the child’s mother.

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Dr. Hostetter is professor and chief of pediatric immunology at Yale University School of Medicine and director of the Yale Child Health Research Center.