Sandra Iverson

Medical Evaluation of Internationally Adopted Children

BACKGROUND Despite many reports of medical illness in children adopted from abroad, there are currently no accepted guidelines for medical evaluation of this population. METHODS Two hundred ninety-three children adopted from 15 countries (mean age, 14.0 months; 55 percent girls) were evaluated by history taking, physical examination, and screening tests for hepatitis B virus (HBV), human immunodeficiency virus type 1, tuberculin reactivity, intestinal parasites, syphilis, excretion of cytomegalovirus, renal disease, and anemia. All but four were seen within one month of their arrival in the United States. RESULTS Fifty-seven percent of the children (168 of 293) were found to have at least one important medical condition. Eighty-one percent of the diagnoses were established by screening test, rather than by history taking or physical examination. Infectious diseases made up the majority of the medical conditions (73 percent). Serologic testing for hepatitis B surface antigen was positive in 5 percent of the children. Characteristics associated with the acquisition of HBV infection included arrival within the first three years of the study (P = 0.017), Asian origin (P = 0.011), and receipt of a blood transfusion abroad (P = 0.008). Ten children (3 percent) had positive Mantoux skin tests, and four of these had active pulmonary tuberculosis. Tuberculin reactivity was significantly associated with older age (P less than 0.001) and lower weight (P = 0.037). Intestinal parasites were isolated from 14 percent of the international adoptees. Non-Korean adoptees were 16 times more likely to be harboring at least one intestinal parasite than were Korean adoptees (P = 0.005). CONCLUSIONS Directed screening tests should be a routine component of the medical evaluation of all children adopted from abroad, regardless of age, sex, or country of origin.

Iron Deficiency in International Adoptees from Eastern Europe

OBJECTIVE To assess iron deficiency (ID) in international adoptees after adoption. STUDY DESIGN Participants (n = 37) were adopted into the United States from Eastern Europe before they were 24 months of age. Baseline (within 1 month post-adoption) and follow-up (6 months post-adoption) assessments included routine post-adoption clinical evaluations, anthropometrics, dietary intakes, and iron measures (hemogram and serum analysis). RESULTS At adoption and follow-up, mean percent transferrin saturation and mean corpucuscular volume were low compared with the US population. Mean serum ferritin concentration became lower than the US population at follow-up, although the mean daily iron intake was more than the Recommended Dietary Allowance. Participants with Giardia lamblia at baseline had more compromised iron status at baseline and follow-up. Growth rate (change in z-score/months between assessments) was negatively correlated with change in serum ferritin concentrations between baseline and follow-up (r = -0.34; P < .05). CONCLUSIONS International adoptees had compromised iron status, with ID more prevalent in participants with G lamblia, a parasite that may interfere with iron absorption. The persistent ID at follow-up was likely caused by the erythropoietic demands of catch-up growth.

Adoption as an intervention for institutionally reared children: HPA functioning and developmental status.

Institutional care, particularly when experienced early in life, is associated with delays in social and emotional development that often persist years after adoption. It has been hypothesized that compromise of the hypothalamic-pituitary-adrenocortical (HPA) axis due to adverse condition in institutions is a mediator of later emotional and behavioral problems. The first goal of our project was to investigate whether improvements in the social and emotional environment are associated with changes in HPA axis function. The second goal was to explore whether HPA alterations related to early social adversity were associated with more compromised general development and social and emotional functioning post adoption. Children adopted from Eastern European orphanages (N = 76, mean age was 17 months, SD = 5) were followed as part of an ongoing longitudinal study. Data, including diurnal cortisol patterns, were collected at two time points: baseline (within one month of adoption) and follow-up (six months later). Cortisol values were averaged over two days of saliva sampling after wake-up and before bedtime. We found that morning cortisol values increased between the baseline assessment (M = 0.27 μg/dl, SD = 0.13) and follow-up (M = 0.33 μg/dl, SD = 0.20), t(76) = -2.1, p<0.05. HPA functioning was not associated with general developmental level at either the initial or six months post-adoption assessments. However, dysregulation of the HPA axis (i.e., flatter diurnal pattern) at follow-up was associated with more behavioral and emotional problems. Overall, these results suggest that investigating specific physiological mechanisms is important in identifying children at risk for persistent social and emotional problems and in understanding the long-term consequences of early adversity. Future work should investigate whether disturbance in the HPA system is a heightened risk for long-term negative developmental outcomes.

Predictors of Mycobacterium tuberculosis Infection in International Adoptees

OBJECTIVE. The objective of this study was to measure the factors that are associated with Mycobacterium tuberculosis infection in international adoptees. METHODS. A retrospective chart review was conducted on 880 international adoptees who presented to the International Adoption Clinic at the University of Minnesota between 1986 and 2001. Five tuberculin units of purified protein derivative were placed intradermally on the left forearm. The largest diameter of induration was measured in millimeters between 48 and 72 hours. Nutritional status was assessed using anthropometric measures at initial screening. Data on age, birth country, and year of adoption were assessed. RESULTS. Adoptees (mean age: 26 months; range: 1–200 months; 62% female) came from 33 birth countries. Twenty-eight percent and 5% had evidence of chronic and acute malnutrition, respectively. Twelve percent had evidence of M tuberculosis infection. The odds of M tuberculosis infection increased 7% for each subsequent year during the period studied, increased 142% with each additional year of age for children ≤24 months of age at baseline screening, and increased 15% with each additional year of age for children >24 months of age at the time of evaluation. Tuberculin skin test induration response was not associated with nutritional status or birth region. CONCLUSIONS. Our study demonstrated a high prevalence of M tuberculosis infection and malnutrition in internationally adopted children, placing them at considerable risk for progression to tuberculosis disease. These findings also support current guidelines recommending completion of tuberculin screening immediately after adoption.

Auxological Evaluation and Determinants of Growth Failure at the Time of Adoption in Eastern European Adoptees

AIM To identify factors contributing to growth failure in international adoptees (IAs) from Eastern Europe. STUDY DESIGN 138 IAs from Eastern Europe, 6-59 months old, were evaluated within 3 weeks of US arrival. Complete history, anthropometry, and serum for growth factors were obtained. Facial features were examined for risk of prenatal alcohol exposure. RESULTS Upon arrival, mean height (-1.23 +/- 1.07), weight (-1.43 +/- 1.29), and occipitofrontal circumference (OFC) (-0.63 +/- 1.10) SDS in IAs were significantly less than population means for US children. In a multiple regression model, age, low birth weight (LBW), insulin-like growth factor binding protein-3, and high risk for fetal alcohol syndrome were independent predictors of height SDS. LBW also independently predicted lower weight SDS and smaller OFC SDS. CONCLUSIONS We recommend that IAs undergo screening upon US arrival to identify risk factors for poor growth, particularly evidence of LBW and fetal alcohol exposure. Catch-up growth should be monitored in all children following adoption.

Determinants of Catch-Up Growth in International Adoptees from Eastern Europe

Children raised in orphanages frequently experience growth suppression due to multiple risk factors. Placing such children in more nurturing environments through adoption leads to significant catch-up growth (CUG), the determinants of which are not entirely understood. The goal of this study was to perform an auxological evaluation and examine the degree and correlates of CUG in international adoptees. Children adopted from Eastern Europe, (, 71 males), 7 to 59 months of age, were recruited within 3 weeks of their arrival to the US. At baseline, mean height SDS was and 22% were <−2 SDS for height. IGF-1 and/or IGFBP-3 levels <−2 SDS were present in 32%. CUG, defined as a gain of >+0.5 in height SDS, was seen in 62% of adoptees at 6 months after adoption; 7% of children remained <−2 SDS for height (two had growth hormone deficiency). Growth factors improved in the majority of children. Younger age, greater degree of initial growth failure, and higher caloric intake were significantly associated with improved linear growth in multiple regression models. In summary, most adoptees demonstrate excellent CUG within six months after adoption. If growth failure persists after 6 months of appropriate caloric intake, nutrition-independent causes should be considered.

HEALTH STATUS OF EASTERN EUROPEAN (EE) ORPHANS REFERRED FOR ADOPTION.|[dagger]| 791

The orphanages of EE recently surpassed Korea (FY94 n=2,196 v 1,757) as the principal international source of children adopted in the US. Counseling prospective adoptive parents about medical needs of these children is challenging since little is known about their health status. Over a 24-month period, referral documents were evaluated for 252 orphans from EE(f/m-60/40-76%-Russia, 17%-other former USSR, 4%-Romania, 2%-Bulgaria, 1%-Poland. Low birth weight <2500g was common (48%) and could be accounted for by prematurity (27%) and nutritional insufficiency (mean birth weight-by-length z-score = -1.04±1.0, n=68). The child represented the fourth pregnancy or greater in 46% of cases (range 1-14). There was a significant relationship between increasing maternal parity and lower birth weight-by-length z-scores (p<0.01 by ANOVA). Reasons for children being available for adoption included death of both parents (4%), termination of parental rights (16%), foundling (5%) and voluntary relinquishment of parental rights (75%). Maternal alcoholism was noted in 17% and fetal alcohol syndrome in 2.4% of referrals. Children were referred at a mean age of 28.9±25.7m (range=0.75-125m) and had been living in orphanages for an average of 21.9±20.6m (range=0.75-100m). Stature was profoundly affected, with children falling behind one month of linear growth for each 3.4 months in the orphanage (r=0.68, p <.001). Head growth was also impaired in this population (mean OFC z-score = -1.1±1.9; 20% ≤-2.5). Because of the prevalence of low birth weight, alcohol exposure, high-risk social circumstances, long-term institutionalization, and linear and head growth failure, classifying children from EE orphanages as an “at-risk” group, with possible special needs (e.g., delays in motor, speech and social skills, behavioral and attachment issues) may assist prospective adoptive parents in their decision-making process.