Growth Impairment in International Adoption
In this referred cohort, growth impairment clustered with several measured factors, especially fetal alcohol spectrum disorder, but the observational design cannot determine causation or extend prevalence estimates beyond the study setting.
> Research explainer: This briefing examines verified primary research published 54 days before the briefing date. It is not a same-day research update and does not provide medical advice.
Evidence
This research explainer examines a retrospective cohort of 1,955 internationally adopted children referred to a tertiary pediatric center in Italy between 2015 and 2025. The study assessed growth using World Health Organization standards. Stunting was defined as a height-for-age Z-score below −2 standard deviations, thinness as a BMI-for-age Z-score below −2 standard deviations, and underweight as a weight-for-age Z-score below −2 standard deviations in children younger than 10 years. [pmid:42350820]
In the cohort, stunting was observed in 12.2% of children, underweight in 12.7% of children under 10 years, and thinness in 5.6%. These are measures at first presentation to this referral center, rather than estimates for all internationally adopted children. [pmid:42350820]
The investigators used a population-averaged generalized estimating equations model to examine overall growth impairment across stunting, underweight, and thinness. Anemia, age 1–4 years, Asian origin, and fetal alcohol spectrum disorder (FASD) were reported as independent risk factors in that model. FASD had the strongest reported association with overall growth impairment, with an odds ratio of 4.77 (95% confidence interval 3.32–6.86; p<0.001). [pmid:42350820]
Outcome-specific analyses focused on stunting. Reported independent associations included age 1–4 years (OR 3.09), Asian origin (OR 1.48), anemia (OR 2.30), FASD (OR 4.26), and abnormal thyroid-stimulating hormone (TSH) levels (OR 1.83). [pmid:42350820]
The source also reports that anemia was significantly associated with parasitic infections (p=0.05). Among children with available ferritin and thyroid data, hypoferritinemia was associated with abnormal TSH levels (p=0.024); however, that relationship was not confirmed in univariate logistic regression. [pmid:42350820]
Analysis — Interpreting clustered associations
The central contribution of this cohort is its description of a cluster of measured characteristics associated with growth impairment at referral. FASD’s odds ratio was the largest reported for the overall growth-impairment model, while anemia, younger age, Asian origin, and abnormal TSH levels also appeared in the reported analyses. That pattern is compatible with multiple prenatal, clinical, infectious, and endocrine-related factors being relevant to assessment in this population, but it does not show how those factors interact or which, if any, directly produce impaired growth. [pmid:42350820]
The outcome definitions matter when reading the prevalence figures. Stunting, underweight, and thinness are distinct anthropometric measures, and the study applied underweight only to children younger than 10 years. Consequently, the three percentages describe related but non-interchangeable outcomes evaluated across differing eligible age ranges. [pmid:42350820]
The anemia findings add useful context without resolving mechanism. The observed association between anemia and parasitic infections supports the authors’ discussion of infectious burden as a possible contributor to nutritional impairment. Yet a statistical association cannot distinguish whether infection, nutritional status, another measured or unmeasured factor, or several processes together account for the pattern. [pmid:42350820]
Similarly, the ferritin–TSH result deserves a deliberately narrow reading. It was reported only among participants with available ferritin and thyroid data, reached statistical significance in the stated comparison, and was not confirmed in univariate logistic regression. The source therefore does not establish a stable association between hypoferritinemia and abnormal TSH, much less a causal pathway. [pmid:42350820]
The cohort’s referral setting is especially important. A tertiary pediatric center may receive children whose circumstances or health profiles differ from those of internationally adopted children who were not referred there. The findings are most informative as a description of this center’s consecutively referred population over 2015–2025, not as a population-wide prevalence statement. [pmid:42350820]
Limitations
This was a retrospective cohort from one Italian tertiary referral center, so its associations do not establish causation and may not generalize to all internationally adopted children. [pmid:42350820]
The source reports data collected from 2015 through 2025 and provides no evidence about prevalence outside that study period. [pmid:42350820]
Some analyses had narrower data availability: the hypoferritinemia–TSH comparison was limited to children with available ferritin and thyroid data, and its significance was not confirmed in univariate logistic regression. [pmid:42350820]
Finally, although the authors recommend early comprehensive nutritional, infectious, and endocrine screening, this cohort did not test whether screening improves outcomes. The recommendation should therefore be distinguished from evidence of effectiveness. [pmid:42350820]