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Assessing the health of internationally adopted children

Most internationally adopted children (IAC) come from countries with high rates of infections and are at increased risk of infections acquired in their country of origin. They are usually healthier than refugees and often have a legally-required medical examinations before they leave their countries (1). However access to medical care, treatment facilities and the availability of tests vary between countries, and, although these children are declared healthy in their country of birth, disorders are often diagnosed after their arrival. Since the 1980s, the need for medically assessing IAC has been recognised (2). It is important that paediatricians are familiar with the recommended screening procedures and examine newly arrived adoptees within the first few weeks. Medically evaluating IAC is often challenging because their medical history before adoption and previous living circumstances may be unknown. A comprehensive evaluation is crucial, to identify latent infections or lack of protection towards vaccine-preventable diseases. This means that clinicians can treat medical problems and prevent infectious diseases in IAC and adoptive family members (3,4). Studies suggest that 35–42% of international adoptees have at least one infectious disease (5), with even an higher prevalence in those originating from Africa (6). The characteristics of international adoption are evolving. The number of IAC peaked around 2001 and has decreased since then. The age of international adoptees has increased and less children under one year of age are available for adoption (4). The countries of origin have also changed. In some publications, IAC originated from Africa are not included (2). However, the number of IAC from Africa has increased over the last decade and the leading country has been Ethiopia (4). Several publications have reported characteristics of IAC from Ethiopia (6,7) such as longer time spent with their birth families prior to institutionalisation, older age and a high prevalence of intestinal parasites infestation. Italy has the second highest rate of international adoption after the USA, with more than 300 adoptees every year, and has produced many publications regarding the medical care of IAC (5,8). An Italian study that assessed 1612 IAC between 2009 and 2015 found that 18% of IAC originated from Africa and half of those were from Ethiopia (5). The paper from Chiappini et al. (8) in this issue of Acta Paediatrica represents the largest cohort of African IAC, with 762 children, including 401 from Ethiopia, assessed in 11 paediatric centres from 2009 to 2015. Intestinal parasitic infections have been described in 8–43% of IAC in the literature and have been associated with reversible effects, such as growth delay, anaemia and gastrointestinal disorders (1). The most frequently reported intestinal infection is Giardia lamblia. Other parasites like Hymenolepis nana, Entamoeba histolitica, Strongyloides stercoralis, Blastocystis hominis and Toxocara canis have often been reported. However, the diagnosis of Toxocara canis has sometimes been based on serology, which does not allow clinicians to discriminate between current and past infections. Multiparasitosis, defined as more than one pathogenic or non-pathogenic intestinal parasite, is common. The prevalence of parasitic infections has been associated with increased age and multiple stools samples significantly increase the identification of parasites, even in the absence of gastrointestinal symptoms (7,9). Measuring hypereosinophilia is a non sensitive, but highly specific, test, as not all parasites induce eosinophilia (7). Stool cultures for bacteria are warranted for children with diarrhoea at the time of arrival (3). Chiappini et al. (8) reported that the prevalence of parasitic infection was 45% in IAC originated from Africa, which was lower than the rate reported in Ethiopian IAC by Miller et al. (6). It is well recognised that IAC face high risks of infection with Mycobacterium tuberculosis. The active disease is not common in IAC, but a high level of suspicion is necessary when considering a diagnosis of tuberculosis, particularly in young children or those with some degree of malnutrition. Screening is recommended for all children when they arrive in their new country and the traditional way to diagnose latent tuberculosis infection is the tuberculin skin test (TST), which can be performed at all ages. Induration of at least 10 mm is considered positive, regardless of whether the child has had the bacille Calmette-Gu erin (BCG) vaccination (1), and should require additional investigations. TST results in the 5–9 mm range also require careful evaluation, especially in young children (3). However, TST may yield false positive results due to the BCG vaccinations that most IAC have received in early life. Interferon-gamma release assays (IGRA) are a good alternative for children over the age of five, as there is no cross-reaction with BCG vaccines. However, before the age of five, there are limited data about the usefulness of this