Primary Care of International Adoptees



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Am Fam Physician. 1998 Dec 1;58(9):2025-2032.

  See related patient information handout on international adoption, written by the authors of this article.

  Related Editorial

International adoptees are presenting to family physicians with increasing frequency. U.S. citizens have adopted over 100,000 international children since 1979. Prospective parents may seek advice from their physician during the adoptive process. If available at all, medical information on the child is often scanty. History and physical examination alone are often insufficient for diagnosis of common problems in this population. Adoptive parents may have concerns about growth and development, and appropriate immunizations. In addition, bacterial, viral and parasitic infections endemic in countries of origin create unusual challenges for the U.S. primary care physician. A basic understanding of the process of international adoption, a skillful evaluation of the child and selected laboratory studies enable the family physician to support the prospective parents and assist in a smooth transition of the child into a new family.

International adoption has been a growing phenomenon since the 1950s. After the Korean War, international adoptions started to take place as a relief effort for war orphans. In 1955, Congress passed the Refugee Relief Act to facilitate adoption of these orphans.1  Currently, about 13,000 children are adopted from abroad each year. The largest numbers of children have come from South Korea, with numbers from other countries waxing and waning in relation to the geopolitical climate. The 1988 Seoul Olympics and the Romanian Revolution in 1989 both affected patterns of adoption from those countries. Table 1 reveals international adoption trends over the past decade. Children from Russia and China have accounted for over 50 percent of international adoptions in the past two years.2 Not surprisingly, infants and toddlers (younger than four years of age) comprise the majority of adopted children.3 Female adoptees outnumber male adoptees.35

TABLE 1

International Adoptions by U.S. Citizens

Country of origin Number of adoptions

1989

South Korea

3,544

Colombia

736

India

648

Philippines

465

Chile

253

All others

2,091


Total

7,737

1991

Romania

2,594

South Korea

1,818

Peru

705

Colombia

521

India

445

All others

2,398


Total

8,481

1994

South Korea

1,795

Russia

1,530

China

787

Paraguay

483

Guatemala

436

All others

2,500


Total

7,531

1997

Russia

3,816

China

3,597

South Korea

1,654

Guatemala

788

Romania

621

All others

2,267


Total

12,743


Information retrieved September 14, 1998, from the Internet: http://travel.state.gov/orphan_numbers.html

TABLE 1   International Adoptions by U.S. Citizens

View Table

TABLE 1

International Adoptions by U.S. Citizens

Country of origin Number of adoptions

1989

South Korea

3,544

Colombia

736

India

648

Philippines

465

Chile

253

All others

2,091


Total

7,737

1991

Romania

2,594

South Korea

1,818

Peru

705

Colombia

521

India

445

All others

2,398


Total

8,481

1994

South Korea

1,795

Russia

1,530

China

787

Paraguay

483

Guatemala

436

All others

2,500


Total

7,531

1997

Russia

3,816

China

3,597

South Korea

1,654

Guatemala

788

Romania

621

All others

2,267


Total

12,743


Information retrieved September 14, 1998, from the Internet: http://travel.state.gov/orphan_numbers.html

The prospective parents are generally college-educated, white suburban couples earning approximately $36,000 per year. Parents usually are in their mid-30s, have been married for seven years and have no other children.3 Single-parent adoptions are also becoming more common.

International Adoption Process

The adoption process occurs in three stages: identifying the child, obtaining custody from the host nation and arranging for immigration to the United States.

Identification of a child can be accomplished through adoption agencies, attorneys and adoption facilitators. Parents can also adopt independently by traveling to the host country.

In the second phase, the adoption is completed in the host country and steps are taken to ensure that the child is ready for immigration to the United States.

In the third phase, the parents and child must fulfill specific legal and medical requirements before the child's arrival in the United States. Included in these requirements is a permanent residency visa medical examination, outlined in Table 2.6 The child will not be granted a visa until all requirements have been fulfilled.

TABLE 2

Requirements of Permanent Residency Visa Medical Examination

For all applicants:

Medical history and physical examination to rule out signs of excludable conditions (as follows):

Syphilis, lymphogranuloma venereum, active tuberculosis, HIV infection, chancroid, gonorrhea, granuloma inguinale, infectious leprosy

Insanity, sexual deviation, some cases of mental retardation

Narcotic or alcohol addiction

Any disease, deformity or condition that prevents immigrant from earning a living

Any additional testing or examination requested by the medical officer, based on local conditions or personal history

note: Each patient will fit in a classification system—class A includes psychiatric disorders, mental retardation and dangerous contagious diseases, as outlined above; class B is defined as “physical defect, disease, or disability serious in degree or permanent . . . ”; class C is defined as minor conditions. Persons in classes B or C may be granted a visa to the United States. The decision to grant or deny a visa is made by cognizant consular and immigration authorities.


HIV = human immunodeficiency virus.

Adapted with permission from Mitchell MA, Jenista JA. Health care of the internationally adopted child. Part 1: Before and at arrival into the adoptive home. J Pediatr Health Care 1997;11:51–60.

TABLE 2   Requirements of Permanent Residency Visa Medical Examination

View Table

TABLE 2

Requirements of Permanent Residency Visa Medical Examination

For all applicants:

Medical history and physical examination to rule out signs of excludable conditions (as follows):

Syphilis, lymphogranuloma venereum, active tuberculosis, HIV infection, chancroid, gonorrhea, granuloma inguinale, infectious leprosy

Insanity, sexual deviation, some cases of mental retardation

Narcotic or alcohol addiction

Any disease, deformity or condition that prevents immigrant from earning a living

Any additional testing or examination requested by the medical officer, based on local conditions or personal history

note: Each patient will fit in a classification system—class A includes psychiatric disorders, mental retardation and dangerous contagious diseases, as outlined above; class B is defined as “physical defect, disease, or disability serious in degree or permanent . . . ”; class C is defined as minor conditions. Persons in classes B or C may be granted a visa to the United States. The decision to grant or deny a visa is made by cognizant consular and immigration authorities.


HIV = human immunodeficiency virus.

Adapted with permission from Mitchell MA, Jenista JA. Health care of the internationally adopted child. Part 1: Before and at arrival into the adoptive home. J Pediatr Health Care 1997;11:51–60.

Each stage has many potential roadblocks; the time from initial notification of availability to “delivery” of the child may be emotionally tumultuous for the prospective parents.

The initial notification includes a package containing a description of the child, a picture and an often incomplete or vague personal and medical history.7 South Korea is an exception, providing detailed, legible records and appropriate radiographs.6 Parents may ask their family physician to review this history before making a decision to adopt a particular child. Once the child's picture arrives, prospective parents bond quickly and tend to start viewing the child as their own. A pre-adoption visit to the family physician is recommended so parents can learn about well-child care and discuss any specific medical problems noted in the history (i.e., the needs of a child with a cleft palate). It is important to help parents realize that the provided history may be inaccurate and that the child may be a little different than what they imagine. Encouraging parents to maintain an open perspective is important. Phrases such as “oxygen deprivation,”“encephalopathy” or “perinatal asphyxia” may appear in the history and may represent either no appreciable diagnosis or something more ominous.8

To help focus expectations, parents with concerns should be encouraged to ask if the workers in the orphanage or foster care system see this child as being any different from others of the same age in the same situation.6

Medical Evaluation

The “delivery” of international adoptees often involves long airplane flights across multiple time zones in the company of strangers, possibly including new parents, only to arrive in a foreign environment and meet more strangers. So that the parents and the child may adapt to each other, it is recommended that the initial medical visit be delayed two to four weeks, unless an acute or unstable medical condition is present. In fact, one half of adoptees require treatment for common pediatric illnesses (e.g., otitis media) within the first month.4 Delaying the initial medical visit will allow the parents to spend some time observing the child so they will be able to describe behaviors and define complaints. The physician's goals at this initial visit should include ensuring that the child is free from conditions that would impair the health of the child or the family, evaluating and treating known medical problems and helping parents understand underlying cultural differences.3

In about four out of five cases, the physical examination will not reveal the presence of common medical conditions.9 Hepatitis, tuberculosis, parasites, human immunodeficiency virus (HIV) infection and syphilis are examples of problems that may be present although not clinically apparent. Recommended laboratory tests include hepatitis B virus, purified protein derivative (PPD), rapid plasma reagin, HIV, stool for ova and parasites, complete blood count and urinalysis3,6,10 (Figure 1).9

FIGURE 1.

Primary care of the international adoptee. (HIV = human immunodeficiency virus; PPD = purified protein derivative)

View Large


FIGURE 1.

Primary care of the international adoptee. (HIV = human immunodeficiency virus; PPD = purified protein derivative)


FIGURE 1.

Primary care of the international adoptee. (HIV = human immunodeficiency virus; PPD = purified protein derivative)

The most common infectious conditions in this population are related to parasites, and these conditions are probably the most alarming to adoptive parents. Case series studying international adoptees have revealed that nearly one third of these children have intestinal parasites on arrival in the United States.10 Giardia and Ascaris are the most common pathogens discovered. The prevalence of these conditions is highly dependent on the geographic location and setting from which the child originated. Several reports cite the presence of two or more parasites, and in one study,5 up to 45 percent of Romanian children were multiply infected. Older ambulatory children and low-birth-weight infants are at higher risk.8 Symptoms, which are usually minimal or vague, include bloating, diarrhea, weight loss, lactose intolerance and, in extreme cases, failure to thrive. Such symptoms, however, are not necessarily reliable indicators of ongoing infection.

Laboratory evaluation should consist of three separate stool examinations for children who are symptomatic or who are coming from a suspect foster care environment. Asymptomatic, healthy children require only one screening sample.6 Immunosuppressed children (including those who are malnourished or who have other serious infections) are at increased risk for parasitic hyperinfection and death; empiric therapy may be a consideration.11 Stool samples should be obtained again after treatment to ensure eradication. Nonintestinal parasites, such as scabies and lice, are common in these children (up to 10 percent) and are treated with topical agents.4 Malaria, although uncommon, can be missed because it is not often considered at the time of initial evaluation.

The World Health Organization estimates that the carrier rate for hepatitis B virus (HBV) is 10 to 15 percent in Asia, 1 percent in Central and South America and 0.5 percent in North America.5,9 Five percent of Chinese and Korean children, up to 10 percent of Asian Indian children and 20 percent of Romanian adoptees are found to have chronic HBV infection.12 In one study,5 53 percent of adoptees showed serologic evidence of infection with HBV. When acquired in the first year of life, HBV becomes chronic in more than 90 percent of cases.11,12 Anicteric or asymptomatic infection is most common in young children.11

Complications of chronic HBV infections include cirrhosis and hepatocellular carcinoma. Diagnosis is made by demonstrating a positive HBsAg that persists for six months (Table 3).11 The risk of horizontal transmission is 5 percent. Therefore, all intimate household contacts should be immunized. The Centers for Disease Control and Prevention (CDC) does not recommend routine notification of schools or day care facilities if a child has HBV infection. However, adolescent patients should receive appropriate counseling regarding the risk of sexual transmission. If the child has HBV infection, screening for hepatitis D virus infection is also recommended, especially if the child is from the Mediterranean region or South America.8 Many hepatologists recommend annual screening for hepatocellular carcinoma with alphafetoprotein measurements, abdominal ultrasound examinations or both.12,13

TABLE 3

Interpretation of Hepatitis B Virus Serology

HBsAg Anti-HBc Anti-HBs Interpretation

Negative

Negative

Negative

Not immune, not exposed or very recent exposure

Positive

Positive/negative

Negative

Acute or chronic infection

Positive

Negative

Negative

Newly acquired infection

Negative

Positive

Negative

Acute infection in the “window” phase

Negative

Positive/negative

Positive

Recovering infection or immune or passively acquired maternal antibody*

Negative

Negative

Positive

Immune from vaccine or passive maternal antibody*

Positive

Positive/negative

Positive/negative

Chronic infection if results persist unchanged for 6 months


HBsAg = hepatitis B surface antigen; anti-HBc = antibody to hepatitis B core antigen; anti-HBs = antibody to hepatitis B surface antigen.

*—Infants less than nine months of age.

Adapted from the American Academy of Pediatrics 1997 Red Book and other sources. [corrected]

TABLE 3   Interpretation of Hepatitis B Virus Serology

View Table

TABLE 3

Interpretation of Hepatitis B Virus Serology

HBsAg Anti-HBc Anti-HBs Interpretation

Negative

Negative

Negative

Not immune, not exposed or very recent exposure

Positive

Positive/negative

Negative

Acute or chronic infection

Positive

Negative

Negative

Newly acquired infection

Negative

Positive

Negative

Acute infection in the “window” phase

Negative

Positive/negative

Positive

Recovering infection or immune or passively acquired maternal antibody*

Negative

Negative

Positive

Immune from vaccine or passive maternal antibody*

Positive

Positive/negative

Positive/negative

Chronic infection if results persist unchanged for 6 months


HBsAg = hepatitis B surface antigen; anti-HBc = antibody to hepatitis B core antigen; anti-HBs = antibody to hepatitis B surface antigen.

*—Infants less than nine months of age.

Adapted from the American Academy of Pediatrics 1997 Red Book and other sources. [corrected]

Tuberculosis is a world-wide problem. Children are at higher risk because of poverty, institutional living and poor medical care.12 In international children younger than 15 years, tuberculosis is at least 10 times more prevalent than it is in a comparable U.S.–born population.14 In addition, extrapulmonary tuberculosis occurs in 25 percent of untreated children in this age group.11 In Asia, and South and Central America, vaccination with bacille Calmette-Guérin is common and can often complicate evaluation, because the vaccination does not always convey immunity. Underlying malnutrition or inadequate quality controls for the vaccine may prevent some children from developing a sufficient immune response after receiving it. Therefore, all internationally adopted children should have a PPD test. Screening should be performed with the Mantoux test only.6,11  Definition of a positive PPD test and appropriate treatment are reviewed in Table 4.6 Because of the risk of multi–drug-resistant tuberculosis, especially in southeast Asia, it is recommended that cultures be aggressively obtained in patients with active disease; an infectious disease consultation may aid in selection of appropriate drug therapy.8

TABLE 4

Interpretation of a Purified Protein Derivative (PPD) Test

Induration (mm) Interpretation* Recommended action

< 5 mm

Negative

Observation

≥ 5mm

Positive if:

  • Known/suspected contact

  • Clinical or radiographic evidence of TB

  • Immunosuppressed† or HIV-positive

Chest radiograph—look for clinical evidence of disseminated disease

Infectious disease consultation‡

Prophylaxis or treatment based on findings

≥ 10mm

Positive if:

  • Younger than 4 years of age

  • Chronic malnutrition, renal failure or diabetes

  • Born in high-prevalence area

As above

≥ 15mm

Positive in all persons

As above


TB = tuberculosis; HIV = human immunodeficiency virus.

*—Interpretation does not change because of suspected or known vaccination with bacille Calmette-Guérin.

†—Such as severe malnutrition or measles.

‡—If chest radiograph is positive or there is evidence of extrapulmonary disease, cultures and an infectious disease consultation are recommended before treatment with a multidrug regimen.

Adapted with permission from Mitchell MA, Jenista JA. Health care of the internationally adopted child. Part 1: Before and at arrival into the adoptive home. J Pediatr Health Care 1997;11:51–60.

TABLE 4   Interpretation of a Purified Protein Derivative (PPD) Test

View Table

TABLE 4

Interpretation of a Purified Protein Derivative (PPD) Test

Induration (mm) Interpretation* Recommended action

< 5 mm

Negative

Observation

≥ 5mm

Positive if:

  • Known/suspected contact

  • Clinical or radiographic evidence of TB

  • Immunosuppressed† or HIV-positive

Chest radiograph—look for clinical evidence of disseminated disease

Infectious disease consultation‡

Prophylaxis or treatment based on findings

≥ 10mm

Positive if:

  • Younger than 4 years of age

  • Chronic malnutrition, renal failure or diabetes

  • Born in high-prevalence area

As above

≥ 15mm

Positive in all persons

As above


TB = tuberculosis; HIV = human immunodeficiency virus.

*—Interpretation does not change because of suspected or known vaccination with bacille Calmette-Guérin.

†—Such as severe malnutrition or measles.

‡—If chest radiograph is positive or there is evidence of extrapulmonary disease, cultures and an infectious disease consultation are recommended before treatment with a multidrug regimen.

Adapted with permission from Mitchell MA, Jenista JA. Health care of the internationally adopted child. Part 1: Before and at arrival into the adoptive home. J Pediatr Health Care 1997;11:51–60.

The pandemic of HIV infection, although of great concern, has not proved to be a significant problem in internationally adopted children. Romanian children in orphanages were reported to have a 10 percent seropositive rate, although subsequent U.S. case studies have not confirmed this rate.4,5,10 Screening for HIV is required before immigration to the United States for children older than 15 years, but testing in some countries of origin may be suspect and may inadvertently increase the risk of transmission (i.e., through the use of reused needles).3,13 Enzyme-linked immunosorbent assay (ELISA) tests may be inadequate in children who are younger than 18 months of age, because of maternal antibodies. Thus, a Western blot or immunofluorescent antibody test should be used to confirm a positive ELISA.11 The CDC has not reported any cases of seroconversion after adoption.6 Considering recent advances in life-prolonging treatment for HIV, routine screening for all adoptees is recommended.

Syphilis is encountered in international adoptions in fewer than 1 percent of cases.7,10 A screening rapid plasma reagin test is recommended because of the availability of efficacious treatment and the severe complications of untreated disease. False-positive tests may occur as a result of other spirochete infections (e.g., pinta, yaws), usually in children from endemic tropical regions. A positive rapid plasma reagin test should be confirmed with a fluorescent treponemal antibody or microhemagglutinin test for Treponema pallidum. A positive maternal history of syphilis should strongly suggest the possibility of congenital syphilis and prompt closer evaluation of the child, including lumbar puncture for a cerebrospinal fluid VDRL test.11 Children presenting with acquired syphilis should indicate to physicians the possibility of past sexual abuse.11 Evaluation and treatment regimens that were initiated in other countries are often inadequate (for example, single-dose, short-acting penicillin) and suspect.8 Follow-up treatment should be continued until serology is negative.

In addition to the issue of infection, routine health maintenance and well-child care are easily addressed at the initial visit. Missing immunizations, and abnormal hearing and vision screening test results are noted in more than 33 percent of adoptees.4 HBV, Haemophilus influenzae, measles-mumps-rubella and varicella vaccinations are the ones that are most commonly missing.6 Ineffective vaccination may occur when severe malnutrition causes a blunted or absent immune response.6,10 A high index of suspicion and a low threshold for revaccination are important in reviewing immunization records in these patients. If the record is “too perfect,” it should be considered suspect, and revaccination should be considered.10

Dental problems are also prevalent (20 percent) but are usually amenable to repair. If the child is younger than three months of age, a phenylketonuria screening test should be performed.6 Growth curves are also important, with the caveat that many of these children will not follow a standard American growth chart. “Catch-up” growth is not uncommon during the first year of adoption as a result of better nutrition. As mentioned, failure to thrive may indicate occult parasitic infection.

Developmental delay is a common problem. The International Adoption Clinic in Boston has reported that 33 percent of adoptees demonstrated gross motor delays, 40 percent had fine motor delays and 16 percent had cognitive and language delays.15 These numbers were significantly higher when adoptees from the former Soviet Union and Eastern Europe were studied.7 Cultural and language differences may also hamper initial efforts to evaluate the child, possibly delaying the detection of developmental problems; this is a frequent complaint of adoptive parents.13 Establishing a baseline assessment of development at the initial visit and following the child's progress over the next three months is warranted. Isolated gross motor delay is often associated with caloric deprivation.8 Accelerated or “catch-up” development is common, but early intervention and special needs programs may help the child reach his or her development potential. Older children may take longer to exhibit development and growth “catch up.” Language proficiency should be assessed at an early stage, and English as a second language services should be sought.13

During the initial examination, it is important to document all scars, bruises and evidence of past sexual or physical abuse. The psychologic trauma associated with such events may not be fully evident until months or years later.6 Maladaptive behaviors, including episodes of anger and unprovoked acting out (often diagnosed as attachment disorder) may be severe and can be detrimental to a child's integration into a new family. These behaviors, often rooted in institutional experiences, may require more than understanding and patience; intensive mental health support may be necessary.2 Fetal alcohol syndrome is a particular concern to parents who adopt children from Eastern Europe and the former Soviet Union. In one study,7 investigators reported that only one of 56 children had overt fetal alcohol syndrome; however, problems attributable to fetal alcohol syndrome may not be apparent at the initial visit and may manifest as the child gets older. Also reported were unpublished data from records reviewed for children from these regions, indicating a 19 percent maternal alcohol use, so these parental fears may be justified.7

Other common medical problems include iron deficiency anemia and thalassemia. If a suspected iron deficiency anemia does not respond to iron therapy, lead poisoning should be considered.13 Congenital anomalies have been noted to range from 2 to 10 percent, including such conditions as cleft lip, hypospadias, single limb defect and ventricular septal defect.4,9 Accurate age determination can be a problem with older children. Radiographs and level of sexual maturity can be helpful, but no specific test can pinpoint a child's age. “Catch-up” growth confuses the situation even more. Every effort should be made to help parents determine a “birthday,” but frequently a “best guess” approach may be required.16 Circumcision is frequently requested and is the most common elective surgery in the first two years after adoption.3,4

The Authors

CHRISTOPHER S. QUARLES, LCDR, MC, USNR, is staff physician at Branch Medical Clinic in La Maddalena, Italy. He received a medical degree from the University of Missouri at Kansas City School of Medicine and completed a residency in family practice at Puget Sound Family Medicine Residency, Naval Hospital, Bremerton, Wash.

JEFFREY H. BRODIE, CAPT, MC, USN, is program director of the Puget Sound Family Medicine Residency, Naval Hospital, Bremerton, and associate clinical professor in the department of family practice at the University of Washington School of Medicine, Seattle. Dr. Brodie received a medical degree from the University of Oregon Health Sciences University School of Medicine, Portland, and completed a residency in family practice at Naval Hospital, Camp Pendleton, Calif.

Address correspondence to Jeffrey H. Brodie, CAPT, MC, USN, Department of Family Practice, Naval Hospital, Bremerton, WA 98312-1898. Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense.


Information in Figure 1 from Hostetter MK, Iverson S, Thomas W, McKenzie D, Dole K, Johnson DE. Medical evaluation of internationally adopted children. N Engl J Med 1991;325:479–85.

REFERENCES

1. Kim WJ. International adoption: a case review of Korean children. Child Psychiatry Hum Dev. 1995;25:141–54.

2. King P, Hamilton K. Bringing kids all the way home. Newsweek. 1997;129:60–6.

3. Hostetter M, Johnson DE. International adoption. An introduction for physicians. Am J Dis Child. 1989;143:325–32.

4. Jenista JA, Chapman D. Medical problems of foreign-born adopted children. Am J Dis Child. 1987;141:298–302.

5. Johnson DE, Miller LC, Iverson S, Thomas W, Franchino B, Dole K, et al. The health of children adopted from Romania. JAMA. 1992;268:3446–51.

6. Mitchell MA, Jenista JA. Health care of the internationally adopted child. Part 1: Before and at arrival into the adoptive home. J Pediatr Health Care. 1997;11:51–60.

7. Albers LH, Johnson DE, Hostetter MK, Iverson S, Miller LC. Health of children adopted from the former Soviet Union and Eastern Europe. Comparison with preadoptive medical records. JAMA. 1997;278:922–4.

8. Hostetter MK, Johnson D. Medical examination of the internationally adopted child: screening for infectious diseases and developmental delay. Post-grad Med. 1996;99(4):70–82.

9. Hostetter MK, Iverson S, Thomas W, McKenzie D, Dole K, Johnson DE. Medical evaluation of internationally adopted children. N Engl J Med. 1991;325:479–85.

10. Jenista JA. Infectious disease and the internationally adopted child. Curr Opin Infect Dis. 1993;6:576–84.

11. American Academy of Pediatrics. Committee on Infectious Diseases. 1997 Red Book: Report of the Committee on Infectious Diseases. Elk Village, Ill.: American Academy of Pediatrics, 1997.

12. Adoption/medical news. Chronic hepatitis B: diagnosis.Palm Bay, Fla.: Adoption Advocates Press,1995;1:1–2.

13. Mitchell MA, Jenista JA. Health care of the internationally adopted child. Part 2: Chronic care long-term medical issues. J Pediatr Health Care. 1997;11:117–26.

14. Adoption/medical news. Tuberculosis: headache or horror? Palm Bay, Fla.: Adoption Advocates Press, 1996;2:1–3.

15. Miller LC, Kiernan MT, Mathers MI, Klein-Gitelman M. Developmental and nutritional status of internationally adopted children. Arch Pediatr Adolesc Med. 1995;149:40–4.

16. Adoption/medical news. Estimating an unknown age of a child. Palm Bay, Fla.: Adoption Advocates Press, 1996;2:1–2.


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