Child Maltreatment in the NICU: Recognizing the Unseen Harms
“In the smallest moments of care, we hold the greatest power: to heal or to harm. It is not just the machines and medicine that save these fragile lives - it is the presence of gentle hands, the quiet protection of sleep, the soothing voice of a parent. Every act of compassion writes a story of resilience, a story that says: ‘You are safe, you are loved, and you are meant to thrive.’” - Mary Coughlin
A colleague of mine recently reached out about a super heart wrenching situation that involved a painful invasive procedure on a very young, chronically ill child where the procedural outputs took precedence over the young child's (and her parent's ) experience of the situation.
How many times has this occurred on your watch?
Here are my two (maybe more) cents on the topic...
The Neonatal Intensive Care Unit (NICU) is a place of immense fragility, where the smallest and most vulnerable among us fight for survival. Clinicians work tirelessly to provide life-saving care, often under intense pressure. However, even in this highly specialized environment, there are moments when well-meaning actions—or inactions—can unintentionally result in harm. This is where the concept of child maltreatment within a healthcare context becomes critically important.
When we think of child maltreatment, we often picture clear instances of neglect, abuse, or exploitation. But within the walls of the NICU (or any healthcare setting to be honest), maltreatment can take on more subtle forms—ones that may go unrecognized but can have lasting impacts on the infants and young children in our care. These acts are often unintended, but they are real, and they can have long-term developmental, emotional, psychological and physical consequences.
Understanding Child Maltreatment in Healthcare Settings
Child maltreatment in healthcare settings, including the NICU, can involve actions or omissions that cause undue pain, fear, or emotional distress. In a NICU environment, where preterm and critically infants are already at high risk for developmental and emotional challenges, these actions - no matter how subtle - can exacerbate their vulnerability.
Some forms of maltreatment in this context might include:
Inadequate Pain Management
Preterm and critically ill infants often undergo painful medical procedures, from blood draws to catheter placements. Failing to provide adequate pain relief, whether pharmacological or non-pharmacological, can lead to prolonged suffering. Research shows that untreated pain in neonates can have long-term consequences, affecting brain development and leading to heightened sensitivity to pain later in life. Despite this, pain management in neonatal and pediatric care is often insufficient, and some procedures are performed without adequate analgesia. Trauma-informed developmental care recognizes that pain, whether physical or emotional, must be minimized to promote optimal development.Prolonged Separation from Parents
One of the most underappreciated forms of maltreatment in the NICU and beyond is unnecessary or prolonged separation from parents. Babies are biologically wired to seek comfort and regulation from their primary caregivers. The presence of a parent not only soothes the infant but also plays a vital role in brain development, bonding, and emotional resilience. When babies are separated from their parents for extended periods, they may experience heightened stress, which can have long-lasting developmental implications. The emotional impact on parents, who may feel helpless and disconnected from their baby, is significant as well. Family-centered care practices that promote parent involvement should be prioritized ALWAYS!!!The Emotional Toll of Restraint
Procedures that require physical restraint, such as catheter insertions or certain imaging tests, can be traumatic for a baby. When these procedures are performed without considering the baby’s distress - when parents are asked to hold down their child or when babies are left to cry without comfort - we risk doing emotional and psychological harm. Trauma-informed developmental care encourages clinicians to minimize restraint and to use comfort measures such as swaddling (not as an alternative restraint), skin-to-skin contact, and parental presence to reduce the emotional impact on the child.Medical Neglect Through Inaction
While NICU clinicians are highly trained and deeply committed, oversights can still occur. Medical neglect in this setting might manifest as a lack of timely response to signs of distress. The consequences of such neglect can range from immediate physical harm to long-term developmental delays or emotional trauma.Lack of Sleep Protection
Sleep is a crucial aspect of a baby’s growth and development, especially for preemies in the NICU. Without adequate sleep, infants may experience delays in brain maturation, immune function, and overall development. Unfortunately, frequent interruptions for medical assessments, bright lighting, and loud noises can prevent restorative sleep. Failing to protect sleep could be seen as a form of unintentional maltreatment, as it robs the baby of essential rest that supports healing and growth.Frightening Feeding Experiences
Feeding should be a social, nurturing, enjoyable experience, but for many babies in the NICU, feeding is fraught with overwhelm. When feeding becomes frightening or overwhelming for a baby, it can lead to oral aversion, anxiety, delayed feeding development, and lifelong consequences associated with relational health and trust. Ensuring that feeding experiences are safe, nurturing, relational and gentle helps prevent distress and supports healthy development.Skin Protection
Preemies and critically ill newborns have extremely delicate skin, and the frequent application and removal of adhesives, such as those used for medical devices and monitors, can cause skin damage. Without careful attention to protecting the skin, these fragile babies can suffer from painful tears, unnecessary pain and long-term skin conditions. Trauma-informed care advocates for the gentle removal of adhesives and the use of skin protection strategies to minimize damage.Failure to Promote Compassionate Collaborative Care
Parents in the NICU often experience overwhelming stress, fear, and uncertainty about their child’s condition and care. When healthcare providers fail to communicate effectively or do not provide the emotional support parents need, it can lead to feelings of helplessness and disempowerment. Compassionate collaborative care involves recognizing parents as integral members of the care team, supporting their emotional well-being, and empowering them to advocate for their child. Without this partnership, parents may struggle with feelings of inadequacy or guilt, and their emotional health may be negatively impacted. These negative consequences have implications for their own child's developmental trajectory.
Moving Toward Trauma-Informed Developmental Care
The traditional focus of NICU care has been on survival, but as our understanding of the lifelong impacts of early adversity grows, we must expand our lens. Trauma-Informed Developmental Care (TIDC) challenges us to consider not only the physical outcomes but also the emotional and psychological well-being of the infants in our care. At its core, TIDC is about creating a healing environment that reduces stress and trauma for both babies and their families.
This shift calls for:
Pain Management as a Priority: Clinicians must ensure that pain management is proactive, not reactive. This involves using evidence-based strategies to minimize discomfort during procedures, including local anesthesia, sedation, and non-pharmacological interventions like skin-to-skin contact and swaddling.
Promoting Family-Centered Care: Parents should be viewed as essential partners in the care team. Whenever possible, they should be present during procedures, encouraged to hold and soothe their baby, and involved in decision-making. Babies are soothed by their parents' voices and touch, and parents find empowerment in their ability to support their child through challenging experiences.
Protecting Sleep, Skin, and Feeding Experiences: A comprehensive TIDC approach ensures that babies’ sleep is safeguarded, their feeding experiences are nurturing and safe, and their skin is handled with the utmost care. Every interaction with the baby, from feeding to applying medical devices, should be grounded in the principles of minimizing harm and promoting healing.
Compassionate Collaborative Care for Families: NICU care isn’t just about the babies; it’s about the whole family. Providers must engage in compassionate communication, respect parents’ expertise in knowing their child, and offer emotional support that fosters resilience. This family-centered approach ensures that parents leave the NICU not feeling traumatized but empowered and capable of caring for their child.
A Call to Action
Child maltreatment in the NICU isn’t about blame—it’s about awareness. By adopting trauma-informed developmental care principles, we can ensure that our tiniest patients not only survive but also thrive. We have a responsibility to protect these fragile lives from harm, not only through medical interventions but through compassionate, empathetic care that recognizes their emotional and developmental needs.
As we move forward in neonatal care, let us commit to practices that prioritize the dignity, comfort, and resilience of both babies and their families. The NICU should be a place of healing in every sense of the word - where science and compassion work hand in hand to provide the best possible outcomes for our most vulnerable children.
With heartfelt love and fierce compassion,
Mary Coughlin
I’d love to hear your thoughts and experiences about advocating for compassionate care in the NICU. It takes courage to challenge the status quo and speak up for the tiniest voices among us. Together, we can continue to push boundaries, ensuring every baby and family receives the compassionate, trauma-informed care they deserve.
