AAP Guidance: Adopted Kids Need Thorough Health Exam

Troy Brown, RN

April 29, 2019

A clinical report from the American Academy of Pediatrics (AAP) stresses that every adopted child needs a thorough health evaluation to identify current and potential health needs.

The exam should take place as soon as possible after placement in an adoptive home and include a medical history, comprehensive physical examination, diagnostic testing, and age-appropriate behavioral and developmental screening.

"Children who are adopted from foster care or institutions have often experienced physical and/or psychological trauma or high levels of stress that may affect them in the long term," report coauthor Elaine E. Schulte, MD, MPH, FAAP, said in an AAP news release. "It's important to recognize these children may need special medical services, mental health support, or educational plans."

The new clinical report, which provides practical guidance for general pediatricians, was published online today in Pediatrics by Veronnie Faye Jones, MD, PhD, MSPH, FAAP, Department of Pediatrics, School of Medicine, University of Louisville, Kentucky, and the Children's Hospital at Montefiore, Bronx, New York City, and colleagues.

Pediatricians Have Unique Role With Adoptive Families

There are multiple paths for adopting children, the authors note, including domestic versus international adoptions, and private adoptions versus those completed through public foster care systems. In addition, adoptions can be "open", with continued contact possible between birth and adoptive families, or "closed", in which the birth and adoptive families have no identifying information or planned contact.

Pediatricians are uniquely positioned to help adoptive families provide for their child's health needs. This can begin before the child is adopted in some cases.

Prior to adoption, pediatricians can work with parents to collect pertinent health information and develop questions to pursue regarding their child's health needs. Pediatricians may also have an opportunity at this time to help parents explore issues related to the structure of the adoption arrangement, such as their comfort level communicating with the birth mother in cases of open adoption.

Many adopted children have experienced emotional trauma and other adverse childhood events, "which have been shown to impact the genetic predisposition of the emerging brain architecture and can alter lifelong health outcomes," the authors say.

Pediatricians can help adoptive parents develop strategies for anticipating and easing some of these issues for their adopted child.

Comprehensive Health Evaluation Needed

"Children who have been adopted through the foster care system or who have been in institutions are at increased risk for physical, mental, and behavioral health issues, so we need to make sure that we're bringing them in early — basically as soon as they're adopted — to start that process of doing a history and physical. Even with limited information that we might have, we need to be as thorough as possible," Jones told Medscape Medical News.

Children should undergo age-appropriate screenings, which may include newborn screening panels and hearing, vision, dental, and formal behavioral and developmental screenings. Children may also need to be brought up to date with immunizations, and those who have been adopted internationally should undergo testing for tuberculosis, HIV, hepatitis B virus, and sexually transmitted infections.

The health evaluation should "confirm and clarify existing medical diagnoses; assess for any previously unrecognized medical issues, including oral health problems; discuss developmental and behavioral concerns; and make appropriate referrals. This evaluation typically includes a thorough review of the medical history, incorporating an assessment of health risks, a developmental assessment, and a complete, unclothed physical examination," the authors explain.

Clinicians also need to assess the child's nutritional status, particularly when the child has been in an institutional setting or adopted internationally. Some adoptive parents wish to breastfeed their child and pediatricians may need to provide guidance or referrals for assistance with inducing lactation.

Regardless of whether the child has been adopted domestically or internationally, adopted children may be at risk for deficiencies in iron, calcium, and vitamin D resulting from past dietary inadequacies.

Evaluation May Take More Than One Visit

The comprehensive evaluation may require more than one visit, the authors write. It may not be possible to complete the entire evaluation at once, either because of time constraints or because the child is unable to tolerate parts of the assessment.

Needing to bring a child back for more than one visit "happens more than you think," Jones said. "[These children] may have issues with trust. [There may be] parts of your physical exam that you may not want to do right away or that the child may not want to happen right away. It just may take some time. You want to build trust in order to get as much information as possible."

He notes that a lot of these children have multiple issues and can be complex cases. Bringing the family in several times to address those issues can help build trust, which is critical for the child's wellbeing and for ensuring the most complete evaluation possible.

"There's nothing worse than when you have a child that's already gone through some traumatic things in their life and you're forcing them to do things that make them develop more stress. If you can avoid it, avoid it. Take as much time as the family needs," Jones said.

"You're there to support the families and identify the issues the children may have that may be present when you first see them or that may arise later on," she added.

"Be Patient" and "Don't Give Up"

Patience and tenacity are key for clinicians, Jones continued. Clinicians need to accept that complete medical records and health information may be unavailable and to do the best they can.

Having incomplete information "can be exceptionally frustrating for the families, frustrating for the physicians, and any caregiver that's taking care of this child. But just try to partner [and] collaborate with as many people that have been involved with this child as possible, to get as much information as possible," Jones explained. That may include schools, the legal system, and the child welfare system, she added.

Don't give up, Jones said. "Just be patient and do what needs to be done for the best interests of the child."

Adoption Specialists Can Help

Specialty assistance is available for clinicians who have questions or who may be overwhelmed with the child's needs.

"If the general pediatrician is not familiar with what things adopted children may need as far as special issues and comprehensive testing, then it may be time to consult an adoption specialist," Jones explained. If a clinician is overwhelmed by the case, has questions, or needs additional information, that's also a good time to call on a specialist.

Jones said the AAP's Council on Foster Care, Adoption, and Kinship Care has made a number of resources available to physicians, including a link to adoption specialists.

The report authors have disclosed no relevant financial relationships.

Pediatrics. Published online April 29, 2019. Full text

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