Special Article
Medical Evaluation of Internationally Adopted Children
N Engl J Med 1991; 325:479-485August 15, 1991
- Abstract
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<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. (N Engl J Med 1991; 325:479–85.)
Media in This Article
Figure 1
Diagnoses of 254 Medical Problems Identified in 293 International Adoptees, According to Cause.Figure 2
Age Distribution of the Study Children and the Percentage Who Were Tuberculin-Positive.Article Activity
- Article
TRENDS in adoption have changed remarkably since the Journal last reviewed this issue more than 30 years ago.1 Because numerous social and demographic circumstances have limited the availability of U.S.-born babies for adoption, an increasing number of childless couples and single adults have sought to adopt children from abroad.2 More than 8000 adopted children now enter the United States each year from Asia, Central and South America, the Caribbean, and Eastern Europe.3 Among the 50 states Minnesota leads in international adoptions per capita, with an average of 700 such children entering yearly.3
Unlike refugee children, international adoptees typically undergo no standard medical evaluation in their countries of origin; moreover, many of these children have suffered prolonged periods of abandonment or deprivation for which no medical history can be obtained. Although this constraint limits the usefulness of retrospective surveys of medical illness in international adoptees, such surveys have emphasized that standardized screening of these children even after their arrival in the United States is sporadic at best.4 , 5 In one retrospective review of the medical charts of 128 children adopted from Asia or Latin America and evaluated in a single pediatric practice, 46 percent of those who underwent remedial surgical procedures were never screened for hepatitis B virus (HBV) infection.4
In contrast, the largest prospective studies of international adoptees have typically focused on children from a single country and have produced widely varying rates of prevalence. In several prospective studies of Korean adoptees, the rate of positivity for hepatitis B surface antigen (HBsAg) was approximately five times lower than estimated rates from the World Health Organization and other agencies.6 7 8 9 10 Prevalence rates for HBV infection in international adoptees from other areas, including Latin America and the Caribbean, are not available. Estimates of the prevalence of tuberculin reactivity in children adopted from abroad have varied nearly 20-fold (from 0.6 to 10 percent) in three studies.8 , 11 , 12 Infection with intestinal parasites, although recently examined in Latin American immigrants,13 has not been prospectively studied in international adoptees, who typically differ from immigrants or refugees in having undergone long periods of abandonment. Estimates of the risk of medical illnesses such as HBV infection, tuberculosis, and intestinal parasites in previous prospective studies of international adoptees have thus been confounded either by small numbers of patients or by substantial discrepancies in prevalence rates. Other reviews of medical illness in children adopted from abroad either offer general advice for physicians and parents or focus exclusively on a particular problem.2 , 14 , 15 There is therefore a need for large multinational prospective studies, to provide substantive medical data, identify predictors of medical illness, and assist in formulating standardized recommendations for the medical evaluation of this special population.
Methods
Between April 1986 and June 1990, 293 children adopted from abroad were evaluated by medical history, physical examination, and seven screening tests (Table 1Table 1
Screening Tests Performed in the Medical Evaluation of International Adoptees at the University of Minnesota.). Partial results for 52 of these children, examined prospectively and consecutively between April 1986 and November 1987, have been reported12 but were not subjected to statistical analysis because of the small sample; data on these children and a subsequent cohort of 241 adoptees have been combined in the present report. Fifty-five percent of the children were girls, their mean age was 14.0 months (range, 1 month to 13 years), and all but four were seen within 1 month of their arrival in the United States. Forty-one percent of the children were adopted from Korea, 31 percent from Central or South America, 18 percent from India, 7 percent from Haiti, and 3 percent from other places, including the Philippines, Morocco, Samoa, and Taiwan. All the children were referred to us by their adoptive parents, who consented to the screening evaluation; 58 percent of the children had been examined on one or more occasions by a physician in the United States. In our clinic, all the children were evaluated by a pediatric nurse practitioner, who recorded a medical history from the adoptive parents and accompanying medical records, if available, before performing the initial physical examination. A pediatric occupational therapist performed a developmental examination. A pediatrician subsequently examined each child, coordinated the screening evaluation, and worked with the nurse practitioner and occupational therapist to organize any follow-up or referral.Serum specimens for HBV testing were processed in the blood bank of the University of Minnesota Hospital, where testing for HBsAg and antibodies to the hepatitis B surface and core antigens (anti-HBs and anti-HBc, respectively) was performed by enzyme-linked immunosorbent assay (ELISA). Specimens that tested posi tive for anti-HBc were subsequently referred to the St. Paul, Minnesota, Red Cross to distinguish IgG from IgM antibody response. Urine specimens for the isolation of cytomegalovirus were collected in a sterile urine bag after washing of the perineum and were inoculated onto skin-fibroblast cultures that were observed for cytopathic effect in the diagnostic virology laboratory of the University of Minnesota. Serum samples were analyzed for the presence of antibodies to human immunodeficiency virus type 1 (HIV-1) by ELISA. In children under the age of 15 months, peripheral-blood mononuclear cells from a blood sample treated with heparin were cocultured with phytohemagglutinin-stimulated normal mononuclear cells in 15 ml of RPMI (GIBCO, Grand Island, N.Y.) supplemented with recombinant interleukin-2; supernatants were sampled weekly for six weeks and assayed for the production of p24 antigen by ELISA, according to previously described methods.16 Fresh fecal material was examined for ova and parasites in the diagnostic microbiology laboratory of the University of Minnesota with the saline-mount technique; 1 percent iodine stain was employed for fecal samples treated with formalin. A complete blood count and rapid plasma reagin card test for syphilis were performed in the clinical laboratory of the University of Minnesota. Purified-protein-derivative (Mantoux) and candidal skin-test antigens were applied intradermally by the pediatric nurse practitioner, who also recorded each child's height, weight, and head circumference. In order to compare the weights of children of different ages and ethnic backgrounds, we converted these measurements to standard normal z scores by subtracting the mean weight for each child's age from the child's weight and dividing the result by the standard deviation for the child's age, using means for age and standard deviations published by the World Health Organization.17 , 18
Six independent characteristics that could be corroborated by history or physical examination at the initial clinic visit were examined for their prognostic value in the identification of children with HBV infection, tuberculosis, or intestinal parasites: sex, age at the first clinic visit (corrected for length of gestation, if available from the medical history), weight at the first visit (standardized for age as a z score), date of arrival in the United States, infant mortality rate in the country of origin, and immunization status (complete or incomplete). Rates of infant mortality19 were used as a measure of children's health in the country of origin. For HBV infection, evidence of a blood transfusion abroad or HBV vaccination was also assessed for predictive value. Fisher's exact test was used to compare qualitative characteristics. These historical characteristics were included in logistic-regression models to assess which of the measures were significantly associated with the presence of HBV infection, tuberculosis, intestinal parasites, or multiple medical diagnoses. Two-sided tests were used for all statistical analyses, and a P value of less than 0.05 was considered to indicate significance.
Results
One hundred sixty-eight of 293 children (57 percent) had clinical or laboratory findings indicative of serious medical illness. In 81 percent of the children with at least one medical illness, the diagnosis was suggested by a screening test and was not evident from the history or physical examination. Infectious diseases made up the majority (73 percent) of the medical conditions, even after common infections, such as acute upper or lower respiratory tract infections or dermal parasites, had been excluded (Fig. 1Figure 1
Diagnoses of 254 Medical Problems Identified in 293 International Adoptees, According to Cause.).HBV Infection
HBV testing was positive for one or more indicators in 61 of 287 children. As shown in Table 2Table 2
HBV Serologic Testing in Children Adopted from Abroad., 2 percent of the study group (five children) had evidence of acute HBV infection (HBsAg positivity and elevated hepatic aminotransferase levels), and another 2 percent had evidence of past infection with HBV, as documented by the presence of anti-HBc and anti-HBs. Three percent (nine children), all from Asian countries, had evidence of chronic HBV infection, as indicated by the presence of HBsAg and IgG anti-HBc.20 In 13 other children less than six months old, the passive transfer of maternal antibodies could not be excluded as a possible cause of the anti-HBc, anti-HBs, or both, and an additional 4 children older than six months of age were positive for anti-HBs in the absence of documented vaccination. In 69 percent of 31 children who received three vaccinations for HBV, anti-HBs developed, whereas 1 child first vaccinated at four months of age had acute HBV infection. Data on these children are not included in Table 2. We found no children who were asymptomatic carriers of HBV (positive for HBsAg alone). The prevalence of HBsAg positivity in these children adopted from abroad was 5 percent (95 percent confidence interval, 2.5 to 7.5 percent), a rate 10 times higher than that in the United States (0.5 percent).15 , 21 Age, sex, weight, and country of origin did not differ between the children positive for HBsAg and their seronegative counterparts, but significantly more Asian than non-Asian children were HBsAg-positive (P = 0.011). In addition, historical variables, including date of arrival and previous transfusion, were also associated with subsequent HBV infection. On average (±SD), 274 children who were negative for HBsAg had arrived 41.9±12.2 months after April 1986, whereas 14 seropositive children had arrived 33.7±16.4 months after April 1986 (P = 0.017). Among 10 children with evidence of a blood transfusion abroad, 4 had viral hepatitis: 2 from India, 1 from Taiwan, and 1 from Colombia. The remaining six children had no evidence of hepatitis. By comparison, only 10 of 268 children who did not have transfusions were positive for HBsAg. This difference was significant (P = 0.008). By logistic-regression analysis, viral hepatitis was approximately 15 times more likely to occur in the children who received a transfusion abroad than in those who did not.
Tuberculosis
Ten of 293 children (3 percent) had a Mantoux skin test with induration of 10 by 10 mm or larger 72 hours after intradermal inoculation. In nine of these children, there was neither historical nor physical evidence of vaccination with bacille Calmette–Guérin; the mean (±SD) of the smallest diameter of induration was 13.7±3.7 mm. One 5 1/2-year-old child from Korea had a scar consistent with bacille Calmette–Guérin vaccination on the left deltoid that had been noted at admission to his orphanage four years earlier. His Mantoux skin test showed induration of 12 by 12 mm. Thirty-three of the children (11 percent) had anergy, as judged by the failure to respond with induration after intradermal inoculation with the Mantoux skin test and candidal antigens.
Seven of the 10 children were newly identified reactors, and 4 were subsequently shown to have active disease, confined to the chest in all of them: a 3-month-old Korean girl, a 4-year-old Korean boy, and 2 Indian girls, 8 1/2 00BD and 10 years old. In addition, all four children with active pulmonary tuberculosis were found to have other infectious diseases as well, including the excretion of cytomegalovirus, HBV infection, hemiparesis due to earlier poliomyelitis, and dermal or intestinal parasites. Mycobacterium tuberculosis, sensitive to isoniazid, was isolated from two of these children, but not from the other two, who had received partial therapy with isoniazid abroad. All the children with active disease had full clinical and radiographic recovery after 9 to 12 months of therapy with two agents. The six children without evidence of active disease each received isoniazid for nine months. Mantoux skin tests were negative in 22 adoptive-family contacts of the children with active disease.
Figure 2Figure 2
Age Distribution of the Study Children and the Percentage Who Were Tuberculin-Positive. shows the age distribution of the sample and gives rates of tuberculin reactivity. Analysis of historical variables by logistic regression confirmed that older age and lower weight were significant characteristics of the children with a positive Mantoux skin test, whereas variables such as sex, date of arrival, country of origin, and immunization status were not significantly associated with tuberculin reactivity (Table 3Table 3
Characteristics Associated with Tuberculin Reactivity in Children Adopted from Abroad.).Intestinal Parasites
Stool samples from 279 children were submitted to the diagnostic microbiology laboratory for examination for parasites. Forty-seven pathogens were identified in 38 patients, for an overall rate of prevalence approaching 14 percent (95 percent confidence interval, 10 to 18 percent); this prevalence is markedly higher than that in children in the United States.22 Giardia lamblia was the most frequent pathogen (in 26 children), followed by Trichuris trichiura (6), Blastocystis hominis (4), Necator americanus (4), Ascaris lumbricoides (3), Strongyloides stercoralis (2), and Hymenolepsis nana (2). Although frequently identified, nonpathogenic amoebae such as Endolimax nana and Entamoeba coli were omitted from this tabulation. Stool samples from five children contained two or more parasites. For example, a seven-year-old Haitian boy presented with grand mal seizures and was found to have cerebral cysticercosis; his stool samples, although repeatedly negative for Cysticercus cellulosae, contained A. lumbricoides, G. lamblia, N. americanus, T. trichiura, and B. hominis.
Analysis of our data points to several risk factors for the acquisition of intestinal parasites, as shown in Table 4.Table 4
Characteristics Associated with the Isolation of Intestinal Parasites in Children Adopted from Abroad. Mean age was higher and mean weight was lower in the children with parasites than in those without (P<0.001 for both comparisons). Intestinal parasites were isolated significantly less often in children from Korea, the country with the lowest infant mortality rate (P<0.001), and in children who had received consistent pediatric care, as indicated by a full course of immunizations appropriate for their age (P = 0.032).Examination of these prognostic variables with logistic-regression analysis determined that children from countries other than Korea were 16 times more likely to have at least one intestinal parasite than were Korean children of identical age, weight, and sex. Only 2 of 117 stool samples from Korean children contained parasites, for an extremely low prevalence of 2 percent. Both children with parasites had undergone prolonged periods of abandonment before entering an orphanage. In children from India, Central or South America, and Haiti, the prevalence rate of 28 percent (45 of 162 children) was significantly higher (P = 0.023). The statistical model validated the clinical prediction that children at risk of intestinal parasitosis are older, come from countries other than Korea, and fall below their expected weight for age.
Cytomegalovirus, HIV-1, and Other Infections
Cytomegalovirus was isolated from the urine of 111 of 247 children (45 percent). Haitian children had the highest prevalence (81 percent), and those from India (77 percent), the Philippines (75 percent), Central and South America (46 percent), and Korea (29 percent) followed. Only three children who were positive on culture had presumptive evidence of congenital cytomegaloviral disease: a two-year-old Korean girl with seizures, deafness, and intracranial calcifications, and two infant boys (one Filipino and one Indian) with perinatal hepatitis who were seronegative for hepatitis A virus and HBV.
Testing for HIV-1 was performed with a standard ELISA in all adoptees 15 months of age or older. We also cultured for the virus in younger children, according to the recommendations of the Task Force on Pediatric AIDS of the American Academy of Pediatrics.23 Adoptees at high risk (e.g., with a history of drug abuse in either biologic parent, prostitution in the biologic mother, transfusion abroad, or a high incidence of HIV-1 disease in the country of origin) have been tested since the clinic's inception. HIV-1 screening was broadened to include all international adoptees in October 1989. None of the 64 children subsequently tested were found to have HIV-1 infection; a three-year-old Colombian girl with a normal physical examination and no risk factors according to her history had a positive ELISA and indeterminate Western blotting for antibodies to HIV-1 but was negative on culture and on polymerase chain reaction. Both ELISA and Western blotting for antibodies to HIV-2 were negative in this child.
Other infectious diseases included salmonellosis in four patients, Campylobacter jejuni gastroenteritis in three, serologic confirmation of earlier paralytic poliomyelitis in two, infection with hepatitis A virus in two, secondary syphilis in one, and a variety of dermal infections including scabies, lice, molluscum contagiosum, and ringworm.
Other Medical Diagnoses
Neurologic disease was the second largest category of medical conditions, with 32 diagnoses (13 percent). Five children were globally retarded in gross motor, fine motor, and cognitive development. Other neurologic conditions, affecting nine children, included craniosynostosis, cerebral atrophy, brachial plexus injury, facial palsy, neurofibromatosis, seizures due to cysticercosis, and hearing loss in nine children. Twelve children had ophthalmologic corroboration of visual problems, including four with myopia, five with esotropia, and one each with nystagmus, optic atrophy and papilledema, and amaurosis. Hematologic conditions (7 percent) included hemoglobin levels of less than 10 mmol per liter in 17 children more than six months old, glucose-6-phosphate dehydrogenase deficiency in 1 child, and IgA deficiency and recurrent otitis media in 1 child. Renal and metabolic disorders (5 percent) included hematuria in six children, hematuria and proteinuria in a child with deformed pinnae, one child with hypospadias, one child with an undescended testicle, and one case each of rickets, hypercalcemia, and lactose intolerance. Among the congenital abnormalities (2 percent), there were single cases of limb deformity, spondyloepiphyseal dysplasia, albinism, and Morquio's syndrome, as well as two cases of ventricular septal defect.
Children with Two or More Serious Medical Diagnoses
In 27 children, two or more serious medical diagnoses were made. Acute upper and lower respiratory tract infections, excretion of cytomegalovirus, and dermal parasites were excluded from this tabulation. Table 5Table 5
International Adoptees with Three or More Serious Medical Diagnoses. lists relevant medical data on nine children who were found to have three or more medical diagnoses. All these children required referral to pediatric specialists for medical or surgical therapy. Notably, all but one of these children were from Asia, their mean age was 42.1 months, and eight were girls. According to logistic-regression analysis, older age (P<0.001) and lower weight (P = 0.009) were significantly related to multiple medical diagnoses; female sex was not itself a significant variable, but appeared to reflect the predominance of girls among the adoptees older than five years. Statistical analysis therefore indicated that multiple medical diagnoses are approximately three times more frequent in older children whose weight is more than 1 SD below the norm for age.Discussion
Using seven simple and noninvasive screening tests, we found that 57 percent of the 293 children adopted from abroad who were prospectively evaluated in our clinic had a serious medical condition. A remarkable proportion of these conditions (81 percent) were "silent diseases," predominantly of an infectious nature, that were not otherwise evident from the medical history or physical examination. Although our evaluation was performed in a specialized clinic, the ready availability of virtually all the screening tests makes them accessible to primary care givers and specialists alike. The statistical analysis of the results of medical screening now permits us to propose guidelines for standardized medical screening in children adopted from abroad.
In our study, the HBV profile was preferable to a single determination of HBsAg-positivity, in that the condition of nine children with chronic HBV infection would have been misdiagnosed had they been screened only for HBsAg. We found no asymptomatic carriers among our patients, corroborating the suggestion of others that exposure to HBV in infancy is more likely to result in acute or chronic disease than in the carrier state.15 In children who are positive for HBsAg, differentiating the carrier state from acute or chronic disease is of the utmost importance in providing appropriate prognostic information, given the risk of complications such as cirrhosis and hepatocellular carcinoma. The household contacts of HBsAg-positive children should be speedily vaccinated to prevent horizontal transmission.24 25 26
Our data also underscore the need to determine the HBV profile of all international adoptees, regardless of age, country of origin, previous testing abroad, or date of arrival. The children in our study group adopted before January 1988 were largely of Korean origin, but were not included in Korean vaccination programs, and many of the later cases of HBV infection in our study were ascribable to countries where routine HBV immunization is not practiced.
In all the children subsequently found to have active tuberculosis, screening by the Mantoux skin test rather than by symptoms at presentation provided the first clue to diagnosis. In our study, the rates of prevalence of tuberculin reactivity (3 percent; 95 percent confidence interval, 1 to 5 percent) and active disease (1 percent; 95 percent confidence interval, 0 to 2 percent) were more than 150 times greater than in the general U.S. population.27 Because of the likelihood of resistance to common antituberculous agents,28 aggressive attempts should be made to isolate the causative organism for sensitivity testing in international adoptees who have a positive Mantoux test and clinical or radiologic evidence of active tuberculosis.
In nearly 14 percent of the international adoptees, intestinal parasites were isolated from a single stool sample. In children presenting with diarrhea, screening for parasites was accompanied by culture for salmonella, shigella, campylobacter species, and Yersinia enterocolitica, and seven additional cases were discovered. Data from a prospective study of intestinal parasitosis in Latin American immigrants indicate that more than one stool sample is not necessary unless the child remains symptomatic after treatment.13 Although our results support this conclusion, especially in Korean children, we would add that a follow-up stool sample should be obtained after treatment, since new parasites emerged in five treated children in our study group. Other characteristics associated with the acquisition of intestinal parasites included older age, lower weight, and an incomplete series of the immunizations that are a paradigm for pediatric health care. The singular absence of intestinal parasitosis in Korean adoptees raised in government-subsidized foster homes is probably ascribable to their higher standard of living and excellent pediatric care.
Forty-five percent of the children in our study had asymptomatic excretion of cytomegalovirus, a proportion that appears to parallel that of North American children of similar ages.29 30 31 The implications of the excretion of cytomegalovirus for international adoptees and their potentially nonimmune adoptive mothers of childbearing age have been discussed at length elsewhere.32 33 34 We currently recommend that serologic testing for antibodies to cytomegalovirus in the adoptive mother, rather than culture for cytomegalovirus in the adoptee, be used to assess the risk of primary infection.
In conclusion, our prospective study has documented a high prevalence of medical illness in children adopted from abroad. In 81 percent of the cases, the diagnosis was determined by screening test and was not evident from medical history or physical examination. Although more than one third of the medical problems could be corrected, a failure to detect them might have entailed long-term consequences for the child or other family members. The high rate of medical diagnoses in children adopted from abroad, the prevalence of serious diseases such as HBV infection, tuberculosis, and intestinal parasites, and the fact that many of the medical problems can be remedied argue strongly that directed screening tests should accompany the medical history and physical examination in all such children, regardless of age, sex, or country of origin.
Supported by a grant from the Emma B. Howe Foundation and a CLINFO grant (CLN347) from the University of Minnesota Clinical Research Center.
Source Information
From the International Adoption Clinic, Department of Pediatrics (M.K.H., S.I., K.D., D.E.J.), and the Division of Biostatistics, School of Public Health (W.T., D.M.), University of Minnesota, Minneapolis. Address reprint requests to Dr. Hostetter at UMHC Box 296, University of Minnesota, 420 Delaware St. SE., Minneapolis, MN 55455.
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- Citing Articles (30)
Citing Articles
1
S. Boisrame-Gastrin, D. Tande, M.-R. Munck, S. Gouriou, P. Nordmann, T. Naas. (2011) Salmonella carriage in adopted children from Mali: 2001-08. Journal of Antimicrobial Chemotherapy 66:10, 2271-2276
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R. Vanhoof, P. Gillis, O. Stévart, C. Boland, O. Vandenberg, F. Fux, J.-M. Collard, S. Bertrand. (2011) Transmission of multiple resistant Salmonella Concord from internationally adopted children to their adoptive families and social environment: proposition of guidelines. European Journal of Clinical Microbiology & Infectious Diseases
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Sobenna A. George, Catherine A. Ko, H. Lester Kirchner, Jeffrey R. Starke, Therese A. Dragga, Anna M. Mandalakas. (2011) The Role of Chest Radiographs and Tuberculin Skin Tests in Tuberculosis Screening of Internationally Adopted Children. The Pediatric Infectious Disease Journal 30:5, 387-391
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Kevin B. Spicer, Dwight A. Powell. (2010) Immunizations for Internationally Adopted Children. Pediatric Annals 39:8, 517-524
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D. Tande, S. Boisrame-Gastrin, M. R. Munck, G. Hery-Arnaud, S. Gouriou, N. Jallot, P. Nordmann, T. Naas. (2010) Intrafamilial transmission of extended-spectrum- -lactamase-producing Escherichia coli and Salmonella enterica Babelsberg among the families of internationally adopted children. Journal of Antimicrobial Chemotherapy 65:5, 859-865
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Marita Andersson Grönlund, Magnus Landgren, Kerstin Strömland, Eva Aring, Leif Svensson, Torsten Tuvemo, Ann Hellström. (2010) Relationships between ophthalmological and neuropaediatric findings in children adopted from Eastern Europe. Acta Ophthalmologica 88:2, 227-234
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Rene S. Hendriksen, Matthew Mikoleit, Christian Kornschober, Regan L. Rickert, Susan Van Duyne, Charlotte Kjelsø, Henrik Hasman, Martin Cormican, Dik Mevius, John Threlfall, Frederic J. Angulo, Frank M. Aarestrup. (2009) Emergence of Multidrug-Resistant Salmonella Concord Infections in Europe and the United States in Children Adopted From Ethiopia, 2003–2007. The Pediatric Infectious Disease Journal 28:9, 814-818
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Alexander W. Kay, Carol A. McCarthy. (2009) RENAL AND MILIARY TUBERCULOSIS IN AN INTERNATIONALLY ADOPTED INFANT. The Pediatric Infectious Disease Journal 28:8, 751-753
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Jacqueline Bruce, Amanda R. Tarullo, Megan R. Gunnar. (2009) Disinhibited social behavior among internationally adopted children. Development and Psychopathology 21:01, 157
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Kristine Fortin, Ana Carceller, Monique Robert, Isabelle Chevalier, Valérie Lamarre, Marc H Lebel. (2007) Prevalence of positive tuberculin skin tests in foreign-born children. Journal of Paediatrics and Child Health 43:11, 768-772
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S. T. H. Bontemps, J. C. G. Coolen, W. E. Tjon A Ten, M. A. Runne, J. C. Mulder, R. A. A. Pelleboer. (2007) Recente gegevens bij medische screening van buitenlandse adoptiekinderen. Tijdschrift voor kindergeneeskunde 75:4, 133-138
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Marinus H. Van IJzendoorn, Marian J. Bakermans-Kranenburg, Femmie Juffer. (2007) Plasticity of Growth in Height, Weight, and Head Circumference: Meta-analytic Evidence of Massive Catch-up After International Adoption. Journal of Developmental & Behavioral Pediatrics 28:4, 334-343
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Amanda R. Tarullo, Jacqueline Bruce, Megan R. Gunnar. (2007) False Belief and Emotion Understanding in Post-institutionalized Children. Social Development 16:1, 57-78
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Johnnie A. Yates, Prativa Pandey. (2006) Medical Problems of Internationally Adopted Children Presenting to a Travel Medicine Clinic in Nepal. Journal of Travel Medicine 13:6, 381-383
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Linda Grey Tirella, Wilma Chan, Laurie C. Miller. (2006) Educational Outcomes of Children Adopted From Eastern Europe, Now Ages 8–12. Journal of Research in Childhood Education 20:4, 245-254
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Magnus Landgren, Marita Andersson Grönlund, Per-Olof Elfstrand, Jan-Erik Simonsson, Leif Svensson, Kerstin Strömland. (2006) Health before and after adoption from Eastern Europe. Acta Paediatrica 95:6, 720-725
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Laurent Peyrin-Biroulet, Anthony Donnais, Hélène Barraud, Fabien Darfeuil, Jérôme Watelet, Hervé Hudziak, Jean-Pierre Bronowicki, Marc-André Bigard, Laurence Chone. (2006) Hépatite A transmise par un enfant adopté asymptomatique. Gastroentérologie Clinique et Biologique 30:4, 609-610
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Laurie C. Miller, Wilma Chan, Aina Litvinova, Arkady Rubin, Kathleen Comfort, Linda Tirella, Sharon Cermak, Barbara Morse, Igor Kovalev, . (2006) Fetal Alcohol Spectrum Disorders in Children Residing in Russian Orphanages: A Phenotypic Survey. Alcoholism: Clinical and Experimental Research 30:3, 531-538
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Jeannette BAKKER, Karin HORSTHUIS, Frederik G. J. COBELENS, Frank J. A. BEEK, Tom W. J. SCHULPEN. (2005) Value of routine chest radiography in the medical screening of internationally adopted children. Acta Paediatrica 94:3, 366-368
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