By: Alyson Ware, MS, CCC-SLP, CLC, Medical Committee Member

A stay in the neonatal intensive care unit (NICU) is not listed on the birth plan for most families. Various diagnoses and clinical observations may contribute to admitting an infant to the NICU such as prematurity, hypoglycemia (low blood sugar), cardiac or craniofacial abnormalities, genetic differences, and/or respiratory distress. When a baby enters the NICU, the medical team’s focus is to achieve medical stability so the infant can transition home with as minimal support as possible. Although medical stability is critical, how the care is rendered is crucial in reducing the trauma the infant and family experience during their time in the NICU.

Toxic stress is defined as “strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship” (Shonkoff et al., 2012). The NICU is filled with stressors, such as (but not limited to) the physical environment, psychosocial factors, and clinical procedures. Bright lights, alarms, and noxious smells can impact development and induce pain (Szymczak & Shellhaas, 2014). Not only is the infant at risk of experiencing toxic stress but the caregivers are as well. Employing strategies to empower caregivers and improve bedside connection can decrease the amount of stress and prevent triggering previous trauma. Here are five ways the NICU speech-language pathologist (SLP) can mitigate traumatic experiences and empower families while their baby is inpatient. 

1. Protect their eyes. Use light dimmers, and only use light when necessary. Providing an eye shield for the infant when muted lighting isn’t available can assist in vision development and help with state regulation, which is important for participation in therapeutic activities. 
2. Decrease the volume. Noise fills the NICU constantly, from blaring alarms to loud voices. Although alarms are unavoidable, they can be managed by responding to them quickly and silencing them when indicated. Additionally, having unrelated conversations away from the bedside and using a quieter voice when interacting with the infant can decrease the level of noise the infant is exposed to each day.
3. Guard their nose. Noxious scents are prevalent across the NICU due to infection protocols and can induce pain to the infant (Frie et al., 2017). Ways to reduce noxious smell exposure include sanitizing hands away from the bedside and waiting until they are fully dry prior to coming to the infant's bedside, using unscented skincare, and avoiding perfume.
4. Support the caregiver-infant bond. Caregivers may struggle with finding their role in the infant’s care while they are in the NICU. Encouraging caregivers to take an active approach in their infant’s care can improve caregiver confidence and infant safety (Coughlin, 2015; Tessier, 2010). Teaching the family how to support their infant during bedside procedures (e.g., heel stick, nasogastric tube placement) can be beneficial in mitigating pain for the infant and empower the caretaker in being the agent of comfort for their child. 
5. Learn the family’s history. It is very common to hear someone in the NICU ask, “Is this your first baby?” Although well-intentioned, this question may be triggering for some since roughly “26% of all pregnancies end in miscarriage and up to 10% of clinically recognized pregnancies” (Dugas & Slane, 2022). Additionally, some may have had other life events, such as losing a family member recently, mental health challenges, addiction, or prior poor experiences with medical professionals or settings that may influence their ability to cope in the NICU environment. Reading the medical chart prior to interacting with the family can prevent the clinician unintentionally triggering the family and improve their ability to counsel them in the care of their infant. It is critical that clinicians working in the NICU can identify signs of depression, anxiety, and other social needs the family may have and refer to the appropriate provider. 

The NICU is a challenging setting for the infant, family, and medical providers. By utilizing trauma-informed practices, the NICU SLP can lessen the infant’s and family’s exposure to stress and improve outcomes. Additionally, clinicians also need to be aware of their own needs and prioritize self-care, as frequent exposure to traumatic situations can take a toll on the witness. Clinicians can manage this by taking breaks, debriefing with the appropriate colleagues, and attending counseling (Coughlin, 2016).

References

Coughlin, M. (2015). The Sobreviver (Survive) Project. Newborn & Infant Nursing Reviews, 15(4), 169-173. https://doi.org/10.1053/j.nainr.2015.09.010

Coughlin, M. (2016). Trauma-Informed Care in the NICU: Evidence- based Practice Guidelines for Neonatal Clinicians. New York, NY: Springer Publishing Company.

Dugas, C., Slane, V.H. (2022) Miscarriage. StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532992/

Frie, J., Bartocci, M., Lagercrantz, H., & Kuhn, P. (2018). Cortical responses to alien odors in newborns: an fNIRS study. Cerebral Cortex, 28(9), 3229-3240. https://doi.org/10.1093/cercor/bhx194

Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics, Siegel, B. S., Dobbins, M. I., Earls, M. F., ... & Wood, D. L. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246. https://doi.org/10.1542/peds.2011-2663

Szymczak, S. E., & Shellhaas, R. A. (2014). Impact of NICU design on environmental noise. Journal of Neonatal Nursing, 20(2), 77-81. https://doi.org/10.1016/j.jnn.2013.07.003