Starting about 10 years ago, in response to the markedly increased numbers of children being adopted from abroad, a minor sub-specialty emerged in the field of pediatrics, pediatricians interested in adoptions, or “adoption pediatricians.” In 2000, The American Academy of Pediatrics recognized this new group, The Section on Adoption and Foster Care. This section of the Academy is “…dedicated to improving the health and well-being of children in foster care and those who have been adopted.” Pediatricians, especially, but not limited to this group, can be very helpful in guiding families through the medical aspects of the adoption process.
The process is quite different for domestic and international adoptions. In domestic adoptions, most families are involved with the prospective birthmother when she is pregnant. For international adoptions the baby is already born and in some cases the child is already much older.
The main role of the adoption pediatrician is to help the family to assess the risks inherent in the international adoption process. Only the family can decide to accept or reject the referral for a child, but the pediatrician can help them understand what information they have been given. They can interpret the accuracy of the information and explain the limitations of the information provided.
The families are usually given a medical history on the child from the adoption agency abroad. The details of this history vary widely from country to country. Sometimes, the history is quite detailed with monthly reports from doctor visits; other times it is just one or two paragraphs. Certain countries, such as Russia, use medial terminology that is different from what is used in this country. The pediatrician can review the medical history, interpret the medical jargon, and help you decide how the child is growing and developing compared to United States children. Here, it might be important to use a pediatrician who is familiar with the reports from different countries. The terminology used can be very scary even for pediatricians, so understanding the real implications of the different diagnoses is important. Parents sometimes are asked by the agency to accept or reject a referral in a brief time period (sometimes within 24 to 48 hours.) Obviously, it is helpful to identify a pediatrician who can do this in a timely manner.
Very important in this process is plotting the length (or height), weight and head circumference on standard growth curves. While the percentiles might be different in children from different countries, all children grow at the same rate. If the child was small at birth, continued to grow poorly and had a head circumference which was disproportionately small for that length, that child might have fetal alcohol syndrome. This information is important to prospective parents.
Also, many international referrals come with photos. The pediatrician can sometimes identify physical findings suggestive of a genetic or congenital syndrome. Sometimes, an eye turning inward may be a sign of cerebral palsy (even more commonly, it is an isolated finding suggestive of a refractive error). Many families think that the child in the photo has an eye turning in, but in reality, it is pseudo-strabismus, a normal finding due to a flat nasal bridge seen in all infants especially Asian infants. In addition, the pediatrician should try to assess the development of the child that is demonstrated on the photo. Can the child sit unsupported? Can the child walk? It is reassuring to see the developmental stages indicated on the written report in the photos. This is the only way to verify the accuracy of the report. If a video is provided by the agency, this is an excellent opportunity to review the development norms achieved by the prospective adoptive child.
Pediatricians (but also internists and travel clinics) can prepare the family for travel to foreign countries to pick up their child. The Centers for Disease Control has a web site, http://www.cdc.gov/travel which can also help in identifying what vaccines are recommended and disease outbreaks that might have been reported from that part of the world. Hepatitis A and/or B shots could be necessary. It would probably also be helpful to review which prescription and over-the-counter medications should be taken on the trip.
While on the trip abroad to pick up the child, many issues may come up. The child might be sick or there might be developmental concerns such as lack of eye contact. Most pediatricians provide 24-hour phone coverage for their practices and most “adoption pediatricians” encourage e-mails. The e-mails eliminate the time zone differences and provide the ability to send photos or even short video clips of the child.
Upon arrival back in the United States, the child should be examined as soon as possible. The emphasis of the examination should be on plotting the length, weight and head circumference, identifying any abnormal physical findings and assessing development. Many parents are unaware of normal findings in children, such as Mongolian spots. Mongolian spots are slate-grey or bluish pigmentation of the skin which is most commonly seen in the lower back area. They can be misinterpreted as bruises. Reviewing these normal things with the families is very helpful in reassuring them about their new child.
Most children who have been adopted from outside the United States should get blood and stool tests upon arrival. The pediatrician should understand the risk of different diseases in children from different countries. Also, most international adoptees need some vaccinations to conform to US standards. The pediatrician can review the immunizations provided to the child and construct an immunization schedule to fully protect the child (and to ensure acceptance into daycare, pre-school, and other schools). Immunizations indicated on vaccine records should not always be accepted; depending upon the country, antibody titers may need to be drawn.
Pediatricians also tend to focus on child development. Understanding, the developmental age of the child is important in approaching parenting techniques. Pediatricians can identify developmental delays and help facilitate referrals to Early Intervention Programs. These are programs by which federal funding is channeled through the local counties to provide therapies for children who have developmental delays.
For domestic adoption, the role of the pediatrician is quite different. Most adopting parents are involved during the pregnancy of the prospective birth- mother. Obstetrical records should be obtained and reviewed by someone who can read the usually hand-written notes. This does not have to be an adoption specialist. Many women feel comfortable asking their own OB-GYN (obstetrician-gynecologist) with whom they already have a relationship. The physician would then review the records to ensure that there are no red flags during the pregnancy. The family history listed on the obstetrical chart should match the information given to the lawyer or agency. The prospective birthmother should be keeping all appointments. The maternal labs should be reviewed. The ultrasound, if obtained, should reveal a healthy baby whose size reflects its gestational age.
After the baby is born, a pediatrician in the hospital will examine the newborn daily. By having a pediatrician already identified at home, the two pediatricians can discuss the baby’s physical exam and facilitate the flow of information from the hospital to office.
Obviously, all infants need continuity of pediatric care. Adopted children should be treated in the same manner as all children. However, if developmental concerns arise, a pediatrician who cares for many adopted children, in general, may be more aggressive in referring to Early Intervention Programs.
Michael Traister, MD, is a board-certified pediatrician with a practice in New York City, and has been affiliated with The AFA for many years. For the last two years he’s served as a member of the Adoption Advisory Council.