In 2022, for the first time in 20 years, infant mortality increased by 3%.1 Infant mortality continues to vary by race, with non-Hispanic Black neonates affected disproportionately.2,3 Non-Hispanic Black infants have the highest mortality rate at 10.62/1000 live births. The infant mortality rates for Hispanic (5.03/1000 live births), non-Hispanic White (4.49/1000 live births), and non-Hispanic Asian (3.38/1000 live births) infants are less than half.3 Sixty-six percent of infant deaths occur in infants less than 37 weeks’ gestation.3 Additionally, disorders related to short gestation and low birth weight are the leading causes of death for non-Hispanic Black (237/1000 live births) and non-Hispanic Asian (75/1000 live births) infants.3

Racism and implicit bias persist in health care. Racism is a social system that consciously regards certain racial groups as inferior.4 On the other hand, implicit bias refers to an unconscious judgment against an individual or group of individuals based on personal experiences or perceptions of a particular group or culture.5 Implicit bias may be unintentional and typically goes unnoticed by healthcare workers; however, it may be painfully obvious to patients and their families. Implicit bias can threaten the care that is provided to our patients, and have a negative effect on the patient-provider relationship. This practice can lead inconsistent care, placing the patient’s life at risk.

Microaggressions are everyday verbal or nonverbal comments, questions, looks, or body language that communicate derogatory, hostile, or negative messages toward a specific individual or group based strictly on their marginalized group membership. Microaggressions are a form of implicit bias and include statements often heard in the NICU such as “Wimpy White Boy” and “Strong Black Female.” Unfortunately, these inappropriate labels have become part of the NICU culture. While these comments are not meant to cause harm or be taken negatively, they may cause great distress to the parents and families of these infants. A provider may even consider the phrase “Strong Black Female” to have a positive connotation. As health care providers to neonatal patients, it is important to always include families in concert with the care and wellbeing of the infant. As such, families are our patients too. Phrases such as these do not instill confidence in parents that Black infants will be monitored as closely as infants who are White.

With the mindset of “She is a strong Black female; she will do fine”, a provider may overlook the very subtle signs that neonates exhibit when their systems are trying to compensate during the early period of clinical instability. Instead of verbalizing how well Black female neonates do, race needs to be taken out of the discussion and consideration needs to be given to the infant’s gestation and disease processes that are common during that time. On the other end of the spectrum, a provider may overlook clinical manifestations pointing to other diagnoses because they are blinded by the “Wimpy White Boy” mindset. Again, the infant’s gestation needs to be kept in mind and alternative differential diagnoses need to be considered without taking race into account. Clinical vigilance should be equal in all our neonatal patients.

Inappropriate labeling in the NICU is rampant, unnecessary, and harmful. By bringing this awareness to everyone, we can help in the delivery of all-inclusive care without bias and racism. The terms “Wimpy White Boy” and “Strong Black Female” may seem harmless but can have devastating effects on our neonatal patients and their families. Eradicating these inappropriate labels brings us one step closer to equality in healthcare quality and access.

—Desi M Newberry, DNP, NNP-BC; Anjavi Sharma, BSN, RN, and Amanda Williams, BSN, RN

Duke University School of Nursing, Durham, NC

—Tracey Bell, DNP, NNP-BC

University of Pittsburgh School of Nursing, Pittsburgh, PA

1. Hagan C. Infant mortality rate sees first rise in 20 years. NCHS: A Blog of the National Center for Health Statistics. Published November 1, 2023. Accessed November 16, 2023.https://blogs.cdc.gov/nchs/2023/11/01/7479/ 2. Adams S, Davis T, Lechner B. Perspectives on race and medicine in the NICU. Pediatrics. 2021;147(3):e2020029025. 3. Ely D, Driscoll A Infant Mortality in the United States, 2019: Data From the Period Linked Birth/Infant Death File. Centers for Disease Control and Prevention; 2021. Accessed November 16, 2023. https://www.cdc.gov/nchs/data/nvsr/nvsr70/NVSR70-14.pdf 4. Centers for Disease Control and Prevention. Racism Centers for Disease Control and Prevention. 2023. https://www.cdc.gov/dhdsp/health_equity/racism.htm 5. Kalevor S, Uveges M, Meyer E. Using everyday ethics to address bias and racism in clinical care. AACN Adv Crit Care. 2022;33(1):111-118.