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The Family Physician and International Adoption

DANA E. JOHNSON, M.D., PH.D.
University of Minnesota Medical School­Minneapolis

Few experiences in medicine can be more professionally and personally rewarding than a child's first visit to your office. For some parents, however, the route to your practice may not be a traditional or typical one. Last year, over 13,000 children¹ arrived in their physician's examination room through a process that included a home study conducted by a social worker, fingerprints checked by the Federal Bureau of Investigation, mountains of paperwork, the intimidation of a foreign bureaucracy and difficult, indeterminate periods of waiting.

See article in this issue.

Quarles and Brodie point out in their article in this issue of American Family Physician² that international adoptions are booming. The number of children from abroad who are adopted into American families has more than doubled since 1992.¹ Therefore, it is likely that most family physicians will care for one or more international adoptees. Moreover, international adoptees require different medical care than that needed by children born in the United States. Most international adoptees do not fit the stereotype of a starving orphan. The smiling, chubby appearance of the child you examine offers few visible reminders of the spectrum of problems that may exist. Therefore, before you act, consider how medical care should be modified for these children. Asking the questions "how," "where," "why," "when" and "to what extent" will help you remember how care for a child adopted from abroad should differ from care given to his or her family.

How?

The answer to how a particular child came to be adopted is both simple and complex. Obviously, the child arrived in the family through adoption, but the process of adoption differs significantly from the experience of having a birth child--not necessarily better or worse, just different. Each family has a story; take time to hear it. Was this their way to resolve a problem with infertility? What is their view of the child's country of origin? How do their extended families feel about the adoption, etc.? Acknowledging these differences and valuing their experiences will enhance your standing with the family. More importantly, these details will help you appropriately advise them throughout their adoption experience.

Where?

A child arrives from both a country and a care environment. As a general rule, countries with a high per capita income have good health care for children. Adoptees from these countries typically bring with them accurate medical records, up-to-date vaccinations, and a history of good growth and normal development. However, medical information, immunization records and the general health status of a child are suspect when the child is arriving from a country that has difficulty providing the minimum requirements of health for their people. While the child now resides in a community where tuberculosis, hepatitis B, syphilis and intestinal parasites are uncommon, the child might have been exposed to these problems before his or her arrival. Because disorders that are commonly encountered in international adoptees rarely present with visible manifestations, all of these children--no matter how healthy they appear--require appropriate laboratory evaluation after they have been placed in their adoptive homes.

Before arriving in the United States, a child will usually have been cared for either in a foster home or in an institution (orphanage or hospital). Foster care generally provides a superior environment where growth and development are often on par with that of children in birth homes. Institutions are the worst of all environments for infants and young children and, unfortunately, are the sites where care is provided in countries that place two out of three international adoptees.¹ A low caregiver-to-child ratio and the lack of a consistent caregiver's individualized care lead to delays in speech acquisition, attachment, and the development of social skills and growth.

Why?

Most international adoptees were abandoned at an early age because of the economic strain or social consequences of keeping the child. However, a substantial number of children become eligible for adoption when parental rights are terminated because of neglect or abuse. Emotional and nutritional neglect as well as physical and sexual abuse are the constant companions of poverty, mental illness, alcoholism and drug dependence. Help your families recognize the inevitable emotional consequences of these experiences and obtain appropriate treatment.

When?

While most families prefer to adopt newborns, regulations imposed by placing countries often delay referral of children until after the first or second year of age. Normal brain development requires both an intact genome and appropriate environmental input during early life. We would not expect normal development in a child who has a deletion in their genome, and we would not expect normal development in a child with "environmental deletions." The greater the deficit in genome or in appropriate environmental stimuli, the more problems we observe.

Consequently, no child who has spent his or her first years in an orphanage or a hospital will be completely normal. While optimism is appropriate because of the tremendous resilience shown by most children, helping parents develop realistic expectations of a child who has been in an institution, ensuring appropriate evaluation of suspected problems, and identifying and coordinating effective therapeutic interventions are of immeasurable aid to families who have adopted these at-risk children.

To What Extent?

Parenting a child from another country is a lifelong commitment. Encourage families to be involved with local and national adoptive parent support groups. Adoptive families benefit from hearing how other parents deal with prejudice in transracial adoption, answer questions from their child regarding their adoption and their birth parents, and handle transitional issues during adolescence. Inform your families about culture camps where adoptees can gain appreciation of their culture and develop pride in their country of origin. Adoptive Families of America (800-372-3300) maintains an extensive listing of local parent support groups and parenting resources. Finally, remember that all members of the family share the benefits and burdens of adoption. Nothing is more troubling than to see relationships disrupt because of unrecognized and untreated psychologic needs brought about by the stresses inherent in adoption or the challenges involved in parenting a child who was institutionalized.

Appropriate medical care for international adoptees involves more than a single visit to a physician's office. It is a partnership between you and the family that extends beyond an initial assurance that a child is free from organic illness. Family physicians are well suited to provide comprehensive family-centered care that is critical for many families who have adopted children from abroad. Counseling adoptive families and caring for their children has been one of the highlights of my career and can be for you as well.

Dr. Johnson is professor of pediatrics and director, Division of Neonatology, at the University of Minnesota Medical School­Minneapolis, where he is also co-director of the International Adoption Clinic.

REFERENCES

1. Immigrant orphans admitted to the United States by country of origin or region of birth 1988-1997. Washington, DC: U.S. Department of Justice, Immigration and Naturalization Service.
2. Quarles CS, Brodie JH. Primary care of international adoptees. Am Fam Physician 1998;58:2025-40.

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IUDs: Time for a Renaissance

DAVID A. GRIMES, M.D.
DAVID HUBACHER, PH.D.
Family Health International
Research Triangle Park, North Carolina

As noted by Canavan in this issue of American Family Physician,¹ the intrauterine device (IUD) remains a seldom-used method of contraception. Surveys of U.S. women have shown that IUDs have a poor reputation. However, the same surveys showed that women using IUDs have the highest satisfaction with this method of contraception. Among physicians, fear of litigation is the most common reason for not offering IUDs to their patients.² However, in reality, neither manufacturers nor physicians are being sued over contemporary devices.³ These paradoxes--among both women and clinicians--have hurt women's health in recent decades.

See article in this issue.

Upper genital tract infection and subsequent infertility are the principal concerns about IUD safety. These fears are largely unfounded. Pelvic inflammatory disease occurs much less frequently with IUD use than most physicians and patients think; moreover, the occurrence of pelvic inflammatory disease is associated with the insertion of the IUD and not with the device itself. Both epidemiologic and bacteriologic evidence points to contamination of the endometrial cavity at the time of insertion as the mechanism for IUD-related infection. Despite this transient contamination, infection rarely occurs. Because prophylactic antibiotics significantly reduce the risk of infection after induced abortion, several trials have examined the potential usefulness of antibiotics for IUD insertion. In a recent trial in Los Angeles County,⁴ azithromycin (Zithromax), given in a dose of 500 mg orally one hour before insertion, had no significant benefit when compared with placebo. The most important finding of this trial was the near absence of upper genital tract infection in women during the first three months after IUD insertion.

Canavan raises but does not settle the question of the IUD string and its relation to pelvic inflammatory disease. First, the risk of IUD-related pelvic inflammatory disease is inversely associated with the duration of use. If the string drew bacteria into the uterus, then the risk of infection would increase with time. It does not. Second, cohort studies from China comparing the use of IUDs with and without tail strings have found no important differences in the low rates of pelvic inflammatory disease. Third, a randomized controlled trial⁵ comparing the same device with and without a tail string reached the same conclusion. Thus, the hypothesis that the string poses a risk is untenable, and the issue of "biofilm" becomes clinically irrelevant.

The risk of tubal infertility related to IUD use is low. Although findings of some case-control studies have raised this concern, findings of cohort studies, which are less subject to bias than are case-control studies, have provided reassurance. Women in New Zealand and Norway who discontinued using their IUDs because of problems did not have a significant increase in infertility compared with women who stopped using an IUD to become pregnant.^6,7

Women infected with human immunodeficiency virus (HIV) need highly effective contraception. Based on theoretic concerns about increased susceptibility to upper genital tract infection, the World Health Organization and International Planned Parenthood have recommended that women with HIV infection not use an IUD.^8,9 However, a recent cohort study¹⁰ in Nairobi, Kenya, showed that HIV-infected women, compared with uninfected women, do not have a significant increase in the risk of pelvic inflammatory disease in the early months after insertion of an IUD. Long-term follow-up of these women is continuing.

Some distinctions between IUDs are important. Table 6 in Canavan's article notes heavier bleeding in association with IUDs. While this is true for the copper-bearing device (Paragard T 380A), the opposite is true with the T-shaped progesterone system (Progestasert): it reduces average blood loss. Indeed, progestin-releasing devices can treat heavy menses or dysmenorrhea. Table 6 in Canavan's article also indicates a 26-fold increase in the risk of septic abortion in women who use IUDs. This figure for septic second-trimester fetal loss comes from one case-control study conducted 20 years ago and relates to IUDs that are no longer marketed in the United States. However, in that study, if the IUD were removed in the first trimester, the relative risk of septic second-trimester fetal loss was 1.2 (95 percent CI, 0.2 to 6.9). Other investigators have not found an increased risk of febrile spontaneous abortion among IUD users.¹¹

Women and their clinicians need to take a fresh look at IUDs. Contemporary IUDs are very safe and are also highly effective. The cumulative 10-year probability of an accidental pregnancy with the copper-bearing T 380A is similar to that with tubal sterilization. When compared with tubal sterilization, an IUD is less expensive, safer, more convenient and immediately reversible. Indeed, the copper T 380A can be considered a "reversible method of sterilization."

As noted a decade ago by a World Health Organization scientific group,¹² "the currently available copper and hormone-releasing IUDs, when properly used, are probably the most effective and reliable reversible method of fertility regulation." This upbeat assessment still holds true today. Nevertheless, use of the IUD has languished in the United States. As implied in Canavan's review, family physicians have a key role in the renaissance of the IUD.

Dr. Grimes is vice president of biomedical affairs at Family Health International and clinical professor in the Department of Obstetrics and Gynecology at the University of North Carolina, Chapel Hill. He has served as chair of the steering committee of the Task Force on Post-ovulatory Fertility Regulation of the World Health Organization. He is board certified in both obstetrics and gynecology and in preventive medicine. Dr. Hubacher is an epidemiologist at Family Health International and specializes in examining clinical issues in contraceptive use; his current research includes IUDs and injectables.

REFERENCES

1. Canavan TP. Appropriate use of the intrauterine device. Am Fam Physician 1998;58:2075-88.
2. Kooiker CH, Scutchfield FD. Barriers to prescribing the Copper T 380A intrauterine device by physicians. West J Med 1990;153:279-82.
3. Westhoff C, Marks F, Rosenfield A, Roig A, Nicholas A. Clinical and legal factors influencing IUD use in the United States. In: Bardin CW, Mishell DR, eds. Proceedings from the Fourth International Conference on IUDs. Boston: Butterworth-Heinemann, 1994:100-8.
4. Walsh T, Grimes D, Frezieres R, Nelson A, Bernstein L, Coulson A, et al. Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices. Lancet 1998;351:1005-8.
5. Potts DM, Champion CB, Kozuh-Novak M, Alvarez-Sanchez F, Santiso-Galvez R, Tacla X, et al. IUDs and PID: a comparative trial of strings versus stringless devices. Adv Contracept 1991;7:231-40.
6. Wilson JC. A prospective New Zealand study of fertility after removal of copper intrauterine contraceptive devices for conception and because of complications: A four-year study. Am J Obstet Gynecol 1989;160:391-6.
7. Skjeldestad F, Bratt H. Fertility after complicated and non-complicated use of IUDs. A controlled prospective study. Adv Contracept 1988;4:179-84.
8. WHO Scientific Working Group on Improving Access to Quality Care in Family Planning: medical eligibility criteria for initiating and continuing use of contraceptive methods. Geneva: Family and Reproductive Health, WHO, 1996.
9. International Planned Parenthood Federation International Medical Advisory Panel. Statement on contraception for clients who are HIV positive. IPPF Med Bull 1991;25:1-2.
10. Sinei SK, Morrison CS, Sekadde-Kigondu C, Allen M, Kokonya D. Complications of use of intrauterine devices among HIV-1-infected women. Lancet 1998;351:1238-41.
11. Kim-Farley RJ, Cates W Jr, Ory HW, Hatcher RA. Febrile spontaneous abortion and the IUD. Contraception 1978;18:561-70.
12. Mechanism of action, safety and efficacy of intrauterine devices. Report of the World Health Organ Tech Rep Ser 1987;753:1-91.

Copyright © 1998 by the American Academy of Family Physicians.
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