Anticipatory Guidance

International Adoptions


This page will focus on the medical considerations of International Adoption.  For more information regarding the process of international adoption, see U.S. Citizenship and Immigration Services (1) and Bureau of Consular Affairs at the U.S. Department of State (2), particularly their booklet: Intercountry Adoption From A to Z.


For further information, or for specialty consultation, click on the link BELOW to visit the Univeristy of Chicago Adoption Clinic.  


The Adoption Clinic specialists are able to assist with pre-adoption assessments, travel clinic visis, developmental and behavioral evaluations and referrals to specialized care as needed.



The role of the physician is important in pre-adoption counseling, medical evaluation of adoptees, and ongoing medical care and guidance.  Adopted children are often institutionalized in their home countries prior to adoption, and may receive poor health care, nutrition, and stimulation; they are also at risk for infectious disease, abuse, and neglect (3). 

As more than 22,000 international adoptees enter the U.S. yearly, it is important for all pediatricians to be familiar with the issues particular to this population (4).  

Pre-Adoption Counseling

The adoption process can be difficult and lengthy, and it is important that physicians guide potential parents to choose a reputable adoption agency.  These agencies will typically refer the parents to a specific child abroad, organize travel arrangements, and facilitate presentation of the child to the parents, at which point the parents may accept or reject the child for adoption. 

This process can be emotionally charged and parents must often make the decision with incomplete or inaccurate information regarding the child’s health and development3. 

Physicians should encourage parents to proactively obtain the available medical records for a potential adoptee, but should advise parents of common medical issues encountered in adoptees which may not be disclosed

Parents should be counseled on any identified conditions, keeping mind that these children are more likely to suffer from associated morbidities, due to poor medical care in their home countries.

When reviewing provided medical records, the physician should be particularly cognizant of issues of growth and development.  Height and weight should be plotted on growth curves, keeping in mind that children may lose an average of one month of growth per three months of institutionalized care3. 

Head circumference is particularly important, as microcephaly is the last anthropomorphic measure to be affected by malnutrition and may be a marker of other severe medical problems. 

While developmental milestones are often delayed according to chronological age, they should be considered particularly alarming if they do not at least mirror height-age. Video footage of the potential adoptee can be very helpful in this evaluation.  Adopted children often experience considerable catch-up in growth and development, with best outcomes seen in children adopted at younger ages.

As the parents will often travel to the country from which the child is to be adopted, the pediatrician should guide the parents to appropriate travel medicine services - Click on the link BELOW to visit the University of Chicago Travel Clinic and explore the services offered.  


The physician can review country-specific risks the child may be exposed to and may also provide anticipatory guidance for parents on initial care of the child, including food, supplies, and medications to bring with them (3,4).  Click on the link BELOW to see CDC country-specific recommendations for travel.


Initial Medical Evaluation

All international adoptees are required to undergo screening examination to identify infectious disease prior to entry into the U.S.  It remains crucial, however, that adoptees are evaluated by a pediatrician soon after entering the country. 

The physician will often need to repeat any necessary screening tests done in the country of origin, and should review and potentially repeat immunizations if immunity cannot be demonstrated.  An assessment of growth and development are also particularly important.  

In older children, particular care should be given to screening for emotional and psychological problems (5).

A listing of some suggested evaluation components is provided in the article Preparing Families for International Adoption, Pediatr Rev. 2004.  For more in-depth explanations of the broad and complex issues of immunizations (6) and infectious disease (7) in international adoption, please see the excellent UpToDate reviews of these topics. 

Ongoing Care of Adoptees

Adopted children often experience difficulty adjusting to their new environment and bonding with their new caretakers.  Sleep is often troublesome, as they may not be used to sleeping alone or in a western-style bed.  The adjustment and attachment processes often occurs gradually over time and parents should be advised not to rush. 

The physician is well-positioned to counsel parents as to variants of normal behavior which may concern parents.

Parents should be encouraged to disclose with their child the story of adoption, especially after age 3, to foster adjustment and to avoid negative implications regarding adoption by hiding the truth.  This process may take place over many years as the child develops and begins asking questions; these questions should be answered truthfully as appropriate to the child’s level of understanding. 

As adoptees reach their teenage years, they will often become curious about their birth parents and may seek them out; this behavior is normal and should not be viewed as rejection of the adoptive parents (4).



  1. Immigration through Adoption. US Citizsh Immigr Serv. 2014. Available at: Accessed July 2, 2014.
  2. Intercountry Adoption. Bur Consul Aff - US Dept State. 2014. Available at: Accessed July 2, 2014.
  3. Bledsoe JM, Johnston BD. Preparing Families for International Adoption. Pediatr Rev. 2004;25(7):242–250.
  4. Barratt MS. International adoption. Pediatr Rev. 2013;34(3):145–6.
  5. Schwarzwald H. Adoption. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2014.
  6. Staat MA. International adoption: Immunization considerations. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2014.
  7. Staat MA. International adoption: Infectious disease aspects. In: Basow D, ed. UpToDate. Waltham, MA: UpToDate; 2014.