Medical Testing Recommended for
International Adoptees

By Deborah A. Borchers, M.D., F.A.A.P.

Last Revised: 5/17/00

It is suggested that families make an appointment with their child's health care provider within one to two weeks after your arrival home. This will allow you to have their child examined for any contagious illnesses, evaluated for any conditions that need additional medical referrals (chronic problems), and allow the child's physician to review the child's immunization status.

Some physicians may see a child, in his/her clean, middle-class attire, and tell parents that testing is not necessary. This is not true. Children adopted from other countries may have any and all of these illnesses with absolutely no symptoms, namely no cough for TB, no diarrhea for parasites, no jaundice for hepatitis B, no developmental concerns specific to lead poisoning alone, and no growth failure for thyroid dysfunction. Physicians need to look at these children as if they were with birth parents in native attire in the country of birth. Most physicians would not balk at doing tests for such a child.

A good reference for physicians is a book that should be on the desk of all pediatricians, the Red Book, a publication of the American Academy of Pediatrics. This book, updated every three years, has a chapter which details the testing for all children who have been adopted from other countries, particularly with reference to infectious diseases. Most of the tests listed here are in this book and are recommended by numerous US experts in international adoption medicine.

Recommended blood, urine and screening tests

Your child should have several blood tests after she arrives home

A Hepatitis B profile is needed to evaluate children for acute or chronic hepatitis B. This should include the Hepatitis B surface antigen , Hepatitis B core antibody and Hepatitis B surface antibody (HBsAg, anti-HBc or HBcAb, and anti-HBs or HBsAb). These basic tests will show if a child has hepatitis B, has been exposed or has had the vaccine, or is a carrier of the disease. If any of the tests are positive, the doctor may recommend further testing to delineate the extent of the illness. Unfortunately, the test results are commonly misinterpreted. If a parent has a question about the interpretation of the testing, contact a specialist in gastroenterology or infectious diseases, or the Hepatitis B Coalition (612-647-9009) or Hepatitis B Foundation (215-884-8786) for more information. Since the incubation period of this illness is 3 to 6 months, it is recommended that children be retested six months after their arrival home to be sure that theydo not have this illness, particularly if they received any blood tests or vaccinations while in the country of birth. It is necessary to do all of the tests listed above (and not just the Hepatitis B surface antigen commonly done by most doctors as a screen), as up to 60 percent of children with Hepatitis B may be missed with only doing the usual blood screen. All children with Hepatitis B infection should also be examined for Hepatitis D and have liver function tests. In addition, all children with either acute or chronic Hepatitis B infections should be referred to a pediatric liver or infectious diseases specialist for long term care.
Hepatitis C has also been seen in some adoptees, and it is recommended by that all international adoptees be screened for the antibody to this virus. As with Hepatitis B testing, children should be retested for Hepatitis C antibody 6 months after arrival home. Antibody acquired from a child's birth mother may persist until a child is 15 to 18 months old. If the initial antibody for Hepatitis C is positive, repeat testing should be done at that age along with a PCR test for the virus itself.
HIV testing by ELISA for HIV-1 and HIV-2 is recommended for all children. This illness, although rare in many countries from which children are adopted at present, is recommended for parental piece of mind and for early identification of HIV. Some countries at higher risk of HIV exposure include Cambodia, Thailand, Haiti and Romania. If a child is less than 18 months of age, it is recommended that s/he also have a HIV PCR test. This is because the HIV test is not as reliable for children less than 18 months of age. Because it is estimated that the incidence of HIV will be increasing in the near future, it is also recommended that this testing be repeated 6 months after arrival home. Live virus vaccines (MMR, Varivax for chicken pox, and the Oral Polio Vaccine) should not be given to a child until the HIV test results have been reviewed by a physician.
A stool examination for ova and parasites, giardia antigen and bacterial infections is recommended for all international adoptees, not just (but especially) for those with diarrhea. Families need to contact the laboratory that process the stool specimen to see if special handling instructions are necessary with collecting this specimen. Children living in impoverished orphanages are at a higher risk, as are children who are significantly malnourished. It is not necessary for children to have diarrhea for them to have illnesses diagnosed by these tests. Most doctors will obtain three specimens, collected 48 hours apart, to make completely sure that the children have no infection, particularly if they are symptomatic. Children living in an orphanage setting may pass several parasites at one time. If a parasite is found, it is recommended that the stool examination be repeated after treatment. Some assymptomatic parasite infections found in international adoptees will resolve without any treatment. There are also numerous cases of children adopted internationally who have tested negative for parasite infections just after being adopted, but have passed large worms months to years later.
A complete blood count to check for anemia is recommended. A hemoglobin electrophoresis is also recommended for children of Asian, African and Mediterranean descent who are anemic to identify thalassemia (a blood condition similar to sickle cell anemia) and sickle cell anemia, both genetic blood disorders. All children should also have a lead level, as several international adoptees have had elevated lead levels leading to anemia. Behaviors associated with lead poisoning include pica (eating dirt and other non-food items) and irritability. Left untreated, lead poisoning may result in developmental delays. If a child is found to be anemic or have lead poisoning, repeat testing should be done to monitor for improvement in these conditions.
A blood test for syphilis (usually a RPR or VDRL) is recommended to evaluate the child for syphilis, which could have been acquired from his/her birth mother. If this test is positive, further blood tests are necessary. A spinal tap to check for Neuro-syphilis which could cause developmental problems may also be recommended.. If a child has a medical history that states "syphilis treated in child", make sure that the child has a full evaluation anyway and do not assume that the treatment was adequate.
A screen for hypothyroidism (a TSH) is recommended now for all children adopted internationally Low thyroid disorders have been diagnosed in a significant number of international adoptees, and the reason is not yet known. Symptoms may include a low resting heart rate, fatigue, and being overweight (gaining weight easily). Most birth children born in the US are screened for this disorder before discharge from the hospital of birth. In children adopted by six to twelve months of age, physicians should consider doing the metabolic screen which is done on all newborns in the state in which the child now lives. This test, done free of charge, screens for some very rare conditions which need immediate treatment.
A PPD test should be placed on a child's arm to screen him/her for tuberculosis. Many children born in other countries have received a vaccine shortly after birth called the BCG. This vaccine is supposed to protect against tuberculosis, and the children may have some reaction to the PPD after receiving this vaccine. However, it is still strongly recommended that all international immigrants be screened for exposure to tuberculosis, regardless of whether they have received the vaccine. This test can safely be done on children as young as five or six months, and can be done just after a child arrives home as long as the BCG scar is not freshly healing. It should be read (looked at to see if it is positive or negative) in 48 to 72 hours by a health care professional, not just a parent. Because these children are children at high risk for disseminated tuberculosis (spreading beyond the lungs, potentially to the kidneys and brain), a positive result is one where the injected area is raised above the skin 10 millimeters or more. The interpretation of this test does not change even if the child had the BCG vaccine. Some physicians will do an additional skin test at the time of the PPD to evaluate if the child's immune system will allow him/her to react to the test. Regardless of whether this control test was done, children need to have a repeat PPD test six months after arrival. If positive, a chest x ray is recommended. If the x ray is negative, the child should be started on Isoniazid, an anti-tuberculosis antibiotic, which should be taken without fail for the next nine months. Even if a child was reportedly treated for a positive TB test in the orphanage, the treatment should be repeated.
A dipstick urinalysis should be done on a urine specimen to evaluate for any blood, protein or infection in a child's urinary system that may need further evaluation.
For children that received DTP immunizations in the country of birth, a physician may choose to do blood testing for Diphtheria and Tetanus antibody levels to see if the vaccines were effective. This test is unreliable if the immunizations were given within six months prior to the blood test. Due to problems with inadequate storage, inadequate reaction to the vaccines, or potentially falsified records, many adoptees show no immunity to these two portions of the DTP shot, despite having reportedly received three or more of these shots. A physician should not assume that the immunizations were effective, and doing this test is one way to verify immunity. Most physicians now believe that the immunizations should be repeated, as this presents low risk to the child.

Summary of blood testing recommended by medical adoption experts

Hepatitis B screen, including Hepatitis B surface antigen, Hepatitis B surface antibody, Hepatitis B core antibody.
Hepatitis C screen.
HIV ELISA and PCR screen.
Stool examination for ova and parasites, giardia antigen, and bacterial culture. Three specimens, obtained 48 hours apart, are strongly recommended, particularly for children formerly in an orphanage.
Complete blood count; hemoglobin electrophoresis is recommended for children who are anemic and at risk for abnormal hemoglobins, such as children of African, Asian or Mediterranean descent.
Lead level.
Blood screen for syphilis.
TSH to rule out low thyroid levels; consider the state metabolic screen.
A PPD to evaluate for tuberculosis. A test of 10 mm is considered positive and should necessitate further evaluation and treatment.
A urinalysis dipstick.
Diphtheria and Tetanus antibodies may be done if vaccines were given to verify immunity.
Calcium, phosphatase, alkaline phosphatase and rickets survey if there is a suspicion of rickets.
· Six months after arrival home children should have repeat testing for Hepatitis B, Hepatitis C, HIV and tuberculosis (with a repeat PPD test).

Other recommended evaluations

In addition to blood and urine testing, it is strongly recommended that children have other medical screens for problems for which he/she is at high risk. Some of these problems may have no apparent symptoms at the time of his/her adoption, but statistics show that these children are at increased risk for concerns in these areas.
A hearing screen by audiometry or BSER (terms familiar to physicians) is recommended for all children adopted from other countries. In many countries, the health care for these children is marginal. Many previously institutionalized children have had ear infections diagnosed after arrival in the United States, and it is assumed that these children may have previously had (undiagnosed) infections while still in their orphanage. Early intervention with children with hearing impairment is necessary to ensure proper language development and hearing augmentation, so it is helpful to have this screen done soon after arrival home, preferably once all ear infections have been treated.
Likewise, a vision screen and evaluation by an ophthalmologist (an M.D.) is recommended. Crossed eyes is a common problem in institutionalized children. In many countries there is no knowledge of birth history, so it is not known if the birth mother had any infections that could compromise the child's vision long term. These infections could include Toxoplasmosis (a parasite infection often passed through cat feces) and Rubella (German measles). Similarly, a family history of eye problems is not known, so the ophthalmologist should screen for any hereditary eye problems.
A developmental screen is recommended to evaluate a child's developmental level at the time of her arrival home. In some states this information may be useful in helping a family to qualify for a special needs adoption subsidy. This can be done by a physician or nurse through a test known as the Denver Developmental Screening Test (DDST), easily administered in the doctor's office, or through agencies in your county. These agencies, often associated with the local county Board of Mental Retardation and Developmental Disabilities, include a program known as Early Intervention. This program is available (free of charge) to all children less than three years old who have developmental concerns. Specialists in the program help to facilitate the development of children identified at an early age as having developmental delays. Despite the name, a referral to this program does not mean that a child is retarded. In many counties, the parent can initiate the referral. Most children born in other countries may qualify for at least some services by being at risk, namely by being previously institutionalized in an orphanage. The therapists in the program assist parents by working with their child in their home or in a school setting. Referrals may be made at any time a parent has a concern about their child's development, not just necessarily at the time of his/her arrival home.

Immunizations

Some children born in other countries will have received immunizations prior to their adoption. Others may receive immunizations at the time of their medical evaluation for their US visa. Generally, the timing falls into one of three categories:

Immunizations given to children while in orphanages should be repeated. According to multiple adoption medicine specialists, blood testing performed on children in similar institutional care in Eastern Europe, China and other countries demonstrated that the children did not have full antibody protection against the diseases for which they had been immunized, despite records that reflected a full set of immunizations. There are strong questions about the proper storage and administration of the vaccines, as well as whether the records are even accurate reflecting that the shots were even given. All live virus vaccines, such as the MMR (Measles, Mumps, Rubella or German Measles) and Chicken Pox vaccine should be repeated (once the HIV test is shown to be negative). Blood testing should also include testing for the Hepatitis B Antibody (as mentioned earlier), as this will show if a child has antibody to Hepatitis B. Most of the vaccines used these days have such low side effects that it is safe to repeat them, even if a child actually received the vaccines overseas.

Immunizations given to children in foster homes in Korea are thought to be more reliable, and probably do not need to be repeated. When in doubt, it is suggested that these children also have testing done to see if these shots were effective. Again, it is completely safe to repeat most vaccines, with no risk to a child.

Immunizations given to children at the time of the medical evaluation for the visa are considered to be the safest and most reliable of the vaccines. The record needs to be presented to your doctor so that s/he can then time the administration of future vaccines using that information.

Written by Deborah Borchers, M.D.

Written August 25, 1998, revised May 8, 2000.

Dr. Borchers is a general pediatrician and adoption medicine specialist at the Eastgate Pediatric Center in Cincinnati, Ohio (513/753-2820). These tests are in agreement with recommendations by the American Academy of Pediatrics Committee on Infectious Diseases as well as a consensus of physicians in the US with expertise in international adoption. This article may be reprinted and shared with parents, social workers and physicians.

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Medical Testing Recommended for International Adoptees