Each year approximately 10,000 children enter the United States from abroad.  These children are often from foster homes or orphanages where there is poor hygienic conditions, workers are not routinely screened for contagious illnesses, and there is inadequate nutrition available.  Although children must have a physical examination by a physician selected by the US embassy in order to get a visa, this usually results in an inadequate health screening.  Many children enter the United States with conditions that were not evident by history and physical examination. Parents who are adopting a child from a foreign country should notify their pediatrician and make arrangements to have the child evaluated upon arrival in the United States. 

Many of the laboratory tests done prior to coming to the US are unreliable and the child may be in the incubation period of an illness or become infected after the screening was performed.  Immunizations records are often falsified and children with records of having shots, have not demonstrated serological evidence of immunity.  In addition, emotional conditions have not been diagnosed and this is a common problem with international adoptees. 

Common Problems of Adoptees- 28% of adoptees have serious medical problems that were not recognized prior to adoption. 
1. Poor growth secondary to nutritional and emotional deprivation 
2. Developmental delays in all areas with some children demonstrating marked global delays 
3. Infectious diseases 
4. Emotional problems 
5. Anemia 
6. Scabies and lice 
7. Congenital malformations including craniofacial defects, congenital heart disease, and neurologic diseases 
8. Psychiatric and school problems are not uncommon in these children. 

Screening in the United States
1. Tuberculosis- The child should have a PPD and if negative and the child is not symptomatic, no chest xray is necessary.  The child should have a repeat PPD in 4-6 months.  The BCG status must be verified and the interpretation of the PPD in BCG recipients must be interpreted. 
2. Hepatitis B.  The child should be screened with a HBsAg, anti-HBsAg, and anti-HBcAg.  If there is no evidence of active or previous infection, HBV immunization should be started.  The test should be repeated in 4-6 months. 
3. Hepatitis C 
4. HIV and if negative, repeated in 4-6 months 
5. Stool for Ova and Parasites.  One sample is sufficient if the child is not symptomatic. 
6. Stool culture for Salmonella, Shigella, Yersinia, and Campylobacter if child having diarrhea. 
7. VDRL 
8. Anemia.  The child may be from an area with a high incidence of sickle cell anemia and thallessemia syndromes 
9. Lead levels 
10. Hearing and vision 
11. Documentation of immunizations.  Most immunizations given internationally are of good and reliable quality and if they are well documented and the dates and intervals are consistent with recommendations in the US, do not have to be repeated 

Careful evaluation and follow up is important in international adoptees and studies seem to indicate that some of the growth, developmental, and emotional delays may be reversible when they enter the United States and their new homes. 

References
1. Redbook 
2. Miller Laurie. Editorial. Caring for Internationally Adopted Children.  NEJM vol 341 No 20. Nov. 11, 1999 
3. Miller, Laurie. Developmental and Nutritional Status of Internationally Adopted Children.  Arch Pediatric and Adolesc. Med. Vol.; 149, Jan 1995 
4. Hostetter Margaret.  Medical Evaluation of Internationally Adopted Children  NEJM Vol 325 No 7 Aug. 15, 1991 
5. Jenista Jerry. The Immigrant, Refugee, or Internationally Adopted Child Pediatrics in Review November 2001