Birth Certificate Problematic With International Adoption

By Shalmali Pal,
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.
December 26, 2011/

Although international adoptees often have scant birth and medical records, pediatricians should delay changing an adopted child's for at least 12 months, even after an age determination assessment, according to a new guideline on adoptee evaluation and treatment from the American Academy of Pediatrics (AAP).

International adoptees often arrive in the U.S. with an incomplete birth certificate and medical history, thus questions arise as to the child's accurate date of birth. As a result, pediatricians are often called upon to render an age determination based on standard measures, such as dental eruption and radiographic bone age.

When making an age determination, a difference of a few weeks or months will not matter as much in children under the age of 1. But for an older adoptee, age determination could influence placement in school, wrote Veronnie Jones, MD, PhD, and colleagues on the AAP Committee on Early Childhood, Adoption, and Dependent Care.
  • Every year, more than 100,000 children are adopted in the United States, and these children may have multiple health care needs. They require a comprehensive health evaluation, including a review of all available medical records and a complete physical examination.
  • The American Academy of Pediatrics recommends that age-appropriate screens be performed on these children, including newborn screening panels; hearing, vision, and dental screens; and formal behavioral/developmental screens.

Delaying any changes on the birth certificate more than a year after adoption allows for "catch-up growth" and extended observation of the child's physical and emotional development, they wrote in a clinical report in Pediatrics.

The recommendation regarding age determination is one of several that the AAP has developed to help pediatricians properly evaluate and treat adoptees.

It's estimated that more than 100,000 children are adopted in the U.S. and an average of 22,000 international adoptees have entered the U.S. annually for the past four years. The latter may contend with infectious disease, developmental delays, and risk factors such as poverty, malnutrition, and little prenatal care.

The guideline takes pediatricians through the process from the pre-adoption stage to assessing the child at different developmental stages.

In the pre-adoption stage, parents may request that the pediatrician review the medical records of the child or the biological parents. Specific issues to address are growth trends, developmental progress, and family history. The guidelines stressed that video and photos can be included in the records, but they cannot be used to make a conclusive diagnosis.

Because an international adoptee's medical history may be incomplete, pediatricians should review potential health risks secondary to the child's country of origin, according to the guidelines.

During a physical exam, healthcare providers must be aware that many adoptees have never been seen by a doctor, so the process may cause distress. Having a translator present can help with foreign adoptees. Also, ethnically oriented growth charts should be used and attention should be paid to the child's general appearance.

A "thorough but sensitive" exam of the genital area should be performed to identify any possible sexual abuse. The authors cautioned that the timing of this exam may have to be adjusted based on the child's history and anxiety levels.

For diagnostic testing and immunizations, the guidelines stated that both can be repeated, particularly for children born outside the U.S. An accelerated immunization schedule can be used.

For a child with chronic healthcare concerns, the pediatrician should manage referrals to specialists, but must plan such referrals carefully so as not to overwhelm the adoptee.

Other recommendations in the clinical report are:

  • Hearing and vision screening for all adopted children
  • Mental health reviews for children adopted from foster care or institutions
  • Developmental screening for all children, using validated screening tools


The authors warned that language barriers may bias development screening results in foreign adoptees; early scores on screening tools may not be predictive of later functioning. On the other hand, pediatricians should keep in mind that developmental delays in expressive and receptive language may not be solely related to learning a new language.

The authors concluded that establishment of a medical home for adopted children would be the best way to fully address their needs.

AAP clinical reports expire five years after publication unless reaffirmed, amended, or retired at five years or before.

Any author conflicts have been resolved by the AAP board of directors.

Primary source: Pediatrics
Source reference:
Jones VF, et al "Comprehensive health evaluation of the newly adopted child" Pediatrics 2012; 129: 453-462.

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