Every year, approximately 120,000 children are adopted in the United States.1 In total, Americans who were adopted in childhood account for 2% of the country's population. The journeys of adopted children are multiple, with 38% joining families via the foster care system and 25% adopted internationally. This article focuses on a subset of the nearly 40% of adopted children in the US placed by private domestic adoption—those children who are adopted during early infancy.1
Infants adopted in the US come from a multitude of races and ethnicities, with approximately one-half described as white according to demographic data.1 Infants adopted via private domestic adoption in the US come into highly variable social settings that include two-parent homes (comprised of both different-sex parent couples and same-sex parent couples), single parent homes, and blended families.
In the Nursery
In many instances, the birth parents will have made a plan to place the infant for adoption prior to delivery. In the best of situations, prenatal care will be typical, and an adoption agency social worker will have gathered significant psychosocial, emotional, and cultural history. The birth mother will have been guided through decisions about what involvement she wants with the infant after delivery. Some birth parents do not want to have any further knowledge or contact, even requesting not to know the sex of the infant. Others will have the infant “room-in,” provide care and feeds, name the baby, and have family or friends meet the infant.
The type of adoption being pursued may also affect the newborn nursery course. Domestic or private adoptions may be “open” or “closed.” Closed adoption implies that the adoptive parents and infant will have no further contact with the birth parents after the adoption is finalized. Currently, most domestic adoptions in the United States are open. An open adoption simply means the birth parents and adoptive parents agree to remain known to one another after the adoption, but the relationship varies widely from loosely in touch if information is needed to photograph and letter updates to regular visits with a defined role in the child's life. Typically, in open adoptions, the birth parents play a role in selecting the adoptive parents. Adoptive parents may even be involved in prenatal visits or the delivery. Some hospitals have workflows for accommodating adoptive parents to board at the hospital or have a dedicated space for bonding with the infant peripartum.
Seeking cues for added situational awareness will be helpful for how to meet the birth parents' needs while providing the infant with thorough care.
After careful review of maternal laboratory results, prenatal imaging, prenatal testing and visits, and social work consultation, a factual summary of pertinent positives and negatives should be summarized in the infant's chart. Extra care should be taken to formally ask and document as much family medical history, pregnancy history, and social history as possible. While remaining respectful and nonjudgmental, asking the birth parents explicit questions is imperative (Table 1).
Topics That Should Be Discussed with Birth Parents
Similarly, the physical assessment and newborn nursery screening should be scrupulous, as the nursery records may be the only medical history the child and adoptive family will have to inform future medical and therapeutic decision-making.2 The remainder of the newborn care should follow usual standards;2,3 however, any issues identified need either definitive management or a complete and documented recommended plan for addressing prior to discharge. For example, a persistent murmur that would ordinarily be deemed innocent enough to monitor on an outpatient basis deserves an echocardiogram for formal characterization. Even plans dictated by readily available clinical practice guidelines or a common authoritative source (such as the Red Book4) should be highlighted and explicitly stated on the discharge summary and papers.
The Role of the Pediatrician in the Pre-Adoption Process
Families considering adoption often have many questions that relate to the health of the infant. For newborns and young infants, these issues can include antepartum and perinatal health considerations such as pregnancy complications, frequency of routine prenatal care, and preterm birth. Other considerations include antenatal substance use or exposure to sexually transmitted infections. The authors' approach to parents' questions of this nature is to provide truthful and evidence-based information regarding the condition at hand to adequately inform prospective parents of its health implications. Parents considering adoption may overestimate and in other cases underestimate the pediatric health considerations of a health history detail, so assisting families in making the decisions that position them to best parent their adopted children is always advisable.
Special consideration should be paid to families who intend to adopt a child with known special health care needs. This is a broad category of children but includes infants with a prenatally diagnosed condition such as a chromosomal abnormality or syndrome, infants with anatomic abnormalities requiring surgical correction at a later stage of life, and neurologic conditions without clearly defined trajectories such as hypoxic-ischemic encephalopathy. These infants all require more frequent medical visits and, consequently, a parent or parents who feel comfortable taking on this additional responsibility. In certain cases, infants with special health care needs may have a less well-defined developmental or neurocognitive outcome, and acknowledging this uncertainty, although difficult for families to hear, remains extremely important.
Parents considering adoption include those without prior children and those who have living children. Those with children may already have children old enough to remember and have a perspective about the adoption process and welcoming the new baby to the family. Research suggests that older children who are made to welcome an adopted sibling are often underprepared during the pre-adoption process but that overall the adjustment to having an adopted sibling falls within the range of parental expectations for expanding the family.5
Parents of adopted children must also navigate the eventual impact that the adopted child's race or ethnicity may play during their upbringing. Adoption as an institution enables a unique scenario where a child's race or ethnicity may be entirely different than anyone else in the family. It is generally accepted that as early as young childhood (age 3–5 years), children become aware of physical differences between themselves and members of other racial groups.1 For parents of infants, this gain of awareness of difference is remote yet its eventuality is still important; moreover, the impact of racism or other forms of discrimination may still be felt in other areas of the family's life during infancy. The pediatrician should be sure to guarantee that the medical home is a safe space.
Families may seek input from their pediatrician for resources they may read or consult prior to or after adoption. Brief, easy-to-read references are available online for families at the Child Welfare Information Gateway ( https://www.childwelfare.gov/topics/adoption/adoptive/before-adoption/) and the American Academy of Pediatrics (AAP) Healthy Children website ( https://www.healthychildren.org/English/family-life/family-dynamics/adoption-and-foster-care/Pages/default.aspx).
In the Office
The First Office Visit
Regardless of the nursery course, a comprehensive medical evaluation is advised for infants after they join families through adoption. This should be timed shortly after the adoption process has been completed to ensure that there is not a lapse in well-child care and that pertinent details from the patient's birth history and, when available, family history, may be populated in the medical record. Additionally, parents who adopt an infant may not have had the benefit of a “prenatal consultation,” or visit reserved for welcoming a prospective family to a medical office or clinic and help parents better understand the medical home's policies and procedures. Adequate time should be allocated in a provider's schedule to make new families feel welcome.
Adoptive mothers who wish to provide breast milk to their infant may be directed to work with an international board certified lactation consultant on induced lactation, but such a referral should be made while simultaneously setting appropriate expectations and metrics of success with breast milk production via this method. Donated breast milk from a human milk repository or from a birth mother might be options for infant feeding in certain circumstances, but numerous logistical issues preclude these feeding strategies from being accepted as the baseline expectation for adopted infants.
With this in mind, infants joining adoptive families are much more likely to be fed formula. Parents should be counseled about proper formula preparation as well as mixing and handling techniques, and infants should receive vitamin supplements as indicated by their intake according to AAP Bright Futures Guidelines.6 Careful attention should be paid to ensuring that parents feel they are offering their baby the best nutrition source, as breast milk for most adopted infants will not be an option. Research suggests that mothers are vulnerable to feeling guilt about not breast-feeding,7 so offloading this burden from adoptive parents' minds can be warranted.
Caring for an infant who is being adopted is a special privilege. Careful attention to detail with history taking, record-keeping, and examination is essential for helping newly formed families feel equipped to build their future.
- Jones VF, Schulte EECommittee on Early ChildhoodCouncil on Foster Care, Adoption, and Kinship Care. The pediatrician's role in supporting adoptive families. Pediatrics. 2012;130(4):e1040–e1049. doi:10.1542/peds.2012-2261 [CrossRef] PMID:23008457
- Kilpatrick SJ, Papile L-AAmerican Academy of Pediatrics, American College of Obstetricians and Gynecologists. Care of the newborn. In: Guidelines for Perinatal Care. 8th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017:347–390.
- Chung EK, Gable EK, Golden WC, et al. Current scope of practice for newborn care in non-intensive hospital settings. Hosp Pediatr. 2017;7(8):471–482. doi:10.1542/hpeds.2016-0206 [CrossRef] PMID:28694290
- Kimberlin DW, Long SS, Brady MT, Jackson MA, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Evanston, IL: American Academy of Pediatrics; 2018.
- Meakings SM, Coffey A, Shelton KH. The influence of adoption on sibling relationships: experiences and support needs of newly formed adoptive families. Br J Soc Work. 2017;47(6):1781–1799. doi:10.1093/bjsw/bcx097 [CrossRef]
- American Academy of Pediatrics. Bright futures guidelines. https://brightfutures.aap.org/Pages/default.aspx. Accessed January 14, 2020.
- Lakshman R, Ogilvie D, Ong KK. Mothers' experiences of bottle-feeding: a systematic review of qualitative and quantitative studies. Arch Dis Child. 2009;94(8):596–601. doi:10.1136/adc.2008.151910 [CrossRef] PMID:19602520
Topics That Should Be Discussed with Birth Parents
Gestational age when prenatal care was established
Prenatal use of alcohol, tobacco, marijuana, cocaine, opioid, prescription, or any other substance
Maternal health conditions
Maternal or paternal mental health conditions
Maternal family history: not just what is of newborn consequence, but a thorough history including first- and second-degree maternal relatives
Paternal family history: same as maternal family history
Parental social history, including housing, occupation, and any circumstances relevant to the pregnancy (such as abuse, assault, siblings)