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Introduction:
A NICU can be a stressful place. But Dr. Bob White, a neonatologist and professor at Notre Dame, believed there was a better way. He has convened doctors, nurses, researchers, architects, and regulators to study and gather the best practices for NICUs. Their recommendations have shaped NICUs around the world and improved outcomes for babies and their families. Fighting for NICU babies and their families. We are the Fighting Irish.
Welcome to Notre Dame Stories, the official podcast of the University of Notre Dame. Here we take you along the journey where curiosity becomes a breakthrough for people using knowledge as a means for good in the world.
Jenna Liberto:
Notre Dame research is leading to better outcomes for babies in neonatal intensive care units around the world, but fighting for NICU babies and their families is just one part of the University’s unique contribution to the medical field.
Kathleen Kolberg, associate dean, College of Science, and assistant director of the Center for Health Sciences Advising:
What we knew is kids who survived the NICUs commonly had a lot of neurological problems because, what we found out as we were doing the research is that busy, bright, noisy places tended to cause brain bleeds in babies.
Jenna Liberto:
For this episode of Notre Dame Stories, we sat down with Kathleen Kolberg. She helped develop the first set of standards for what is now the modern approach to NICU. She also prepares hundreds of students each year for careers in medicine. Kathleen, thank you for sitting down to talk with me. So I want to jump right into these NICU standards.
So Notre Dame research was integral in developing the first set of standards for what we now know as the “gold standard” for NICUs. Can you talk about, first of all, that’s a bit surprising for an institution that doesn’t have a medical school—maybe not everyone realizes that this research is being convened here—so tell us how that came to be, and then, more about how you were involved.
Kathleen Kolberg:
Yeah, and part of the power of Notre Dame is the power of collaboration. So we didn’t want to feel limited by not having our own medical school. At Harvard, Dr. Berry Brazelton and Dr. Heidelise Als developed methods by which you could observe and quantify infants’ behavior and their well-being, and then, premature infants. And so, that all happened in the 1980s. At the same time, Klaus and Kennell were doing research about the importance of infant closeness—how babies are more stable in contact with a parent or when being held.
Then, some research had come from Colombia, the country of Colombia, about how, in a low-resourced place, holding babies increased the survival rate dramatically. And so we looked at this and said, “We need to look at the closeness of parents. We need to look at the holistic health of the baby.”
And, at that time, NICUs were crowded. They were noisy—90 decibels was a “quiet” NICU—and that is, to give you an idea, that is a factory floor or a busy intersection in, say, New York City. So, if you stand on a street corner in New York City and all the traffic going by you, that’s 90 decibels. So it was loud, it was noisy, it was brightly lit 24 hours a day. And parents came in for an hour a day, and we’re like, “The physical environment here is not assisting care.” They had gotten a handle on good ventilation, good ways to assess how warm babies were, so keeping babies, we like to call it, “pink, sweet, and warm,” those things were starting to get really solidified. So then, when the baby can breathe, and when the baby’s not, you know, going hypoxic, etc., then you have a chance to look at neural development.
So, doing gentler care—coming out of Harvard—doing gentler care and assessing the baby as you go, and providing comfort measures to keep the baby from getting too stressed, drastically improved the outcomes. Well, that is really hard to do when it’s crowded and noisy and the parents can’t hold the baby.
Jenna Liberto:
And you’re not just talking about comfort of baby, you’re talking about actual brain development that can be influenced by sight, sound, parent contact.
Kathleen Kolberg:
Absolutely. So, when we learned about normal brain development, it was far more complex than people had considered. Babies aren’t born a blank slate. So babies are born, they learn in utero. Lots of in utero learning happens during the last half of a pregnancy, so mom’s voice, understanding the emotional tone, encoding mom’s diet as “this is something I should want to eat,” there’s really great research out of France about how you encode a diet by what mom eats during the pregnancy.
So, as we figured out, these things were really important, and the pre-term babies were missing them. Pre-term babies were not good at picking up tone of voice. There was research back in the 1990s about how a teacher could pick out students who had been premature, not knowing they’d been premature. But because they didn’t get the tone of her voice when she started to get irritated [. . .] they didn’t pick up on those little clues.
I have a daughter who was born five weeks early, and she doesn’t get those little clues either. She had to grow and use her cognition, you know, use the thinking about tones of voice, and learning to get that. And if we’re going to do that, if we’re going to say mom’s smell, parents’ tone of voice, learning so much about language . . . Language processing was a big problem for preemies because so much language processing is learned during those last months in utero. So if we have to replace that, if we have to support that afterwards, I would say that’s an evolutionary expectation. If we’ve got an evolutionary-expectant environment, we need to replace that with an appropriate environment.
If you’ve got 90 decibels, a normal speech sound isn’t the predominant thing. That’s not what the baby’s picking up. But if we can make 45 decibels the norm—which is what the standards hold us to now, and, you know, mom or dad or grandma’s holding the baby, and you teach families how to look for signs that the baby’s ready for interaction or not, or whether to back off the interaction, then the 50–52 decibel voice is the predominant sound.
We even have student volunteers in the NICU because, in the United States, unlike Europe, people have to go back to work and leave their babies in the NICU. That doesn’t happen in other countries. That’s the thing about having international meetings, our European colleagues are like, “Well, why can’t your parents just move into the hospital?” Like, “They got to go back to work.” And they’re like, “Why?” So we have student volunteers who will read. Who will read so that we’ve got this predominant language sound.
Jenna Liberto:
Talk more about your students that are involved in this sort of hands-on research, or even if they’re not doing research while they’re reading, they’re certainly learning and absorbing. And then, what are they taking that to go and do?
Kathleen Kolberg:
Yeah. There’s a number of developmental psychology, developmental neurobiology, and then embryology courses where students learn these principles, and then they can go out and volunteer. Two of the big places they volunteer is they volunteer with us in the newborn intensive care unit [and] they also volunteer at A Rosie Place for Children.
I don’t know if you’re familiar with A Rosie Place, but it is a hospital for medically fragile children. Again, the whole thing that drove this NICU revolution was looking at the babies and families—figuring out what they need and building an environment to have it. Rosie Place for Children is the continuation of that after they’re discharged, after they graduate from the NICU. Some of these children end up—we believe in the sanctity of life, we believe children who have very severe medical conditions that make them fragile deserve the best care. And families need help. And you can’t just hire a babysitter if your kid’s on a ventilator, if your kid has to be tube-fed, if your kid has special needs. And so there are students who volunteer in the unit and students who volunteer with the Rosie Place after the graduation.
Jenna Liberto:
How is that uniquely preparing them for medical school? Again, to mention that’s not something that happens on our campus, but how are you preparing students in a really unique way for that next step?
Kathleen Kolberg:
Yeah, I love how we prepare our students. I think we’re sending out people who are going to be change agents in medicine and be great docs. So it’s not just our office, it is all across campus. People are making sure that, yes, they learn the science deeply so that they can use it for the benefit of patients.
They’re also doing really good work in ethics training, and in our department, we have the Center for Compassionate Care in Medicine, where we’re offering an entire suite of classes that teach about the science of compassion. How does compassion prevent burnout? How does compassion improve patient care, improve the wellness of the caregiver, and improve the culture of the clinical site where it is practiced?
And it’s not just some mushy touchy-feely thing. There’s real data behind it. And we want to send our students off protected. We want them to go off prepared, but we want them to have the suite of tools to prepare, to protect them emotionally from what they’re about to experience. Because unless you’re in the military or the police or fire . . . Most people will not see in a lifetime what a medical professional will see in a year for tragedy unless you happen to be military or fire or police.
Jenna Liberto:
Can you give me a specific example about the kind of training that prepares them?
Kathleen Kolberg:
Yes. So in my Psychology and Medicine class, for example, we do two sessions on delivering bad news and medical errors. If you make a medical error, how do you respond to that? Because errors will happen. You hope that they’re caught before they harm a patient. And then, how do you, at the end of it, process that? Because everybody goes into medicine to help people, and then sometimes you will either come close to hurting somebody or hurt somebody. Well, that’s a session we want to prepare them for ahead of time, how to give bad news.
We have an adult intensive care doc who comes and gives a session on how to give bad news. And he runs cases with them and he says, “Lots of people will not want to give the patient bad news, so when you’re in training, be the person who volunteers to do it. Because one of the greatest gifts you can give to your patients is being good at this. So get as much practice as you can so that, when people are having the worst day of their life, you can at least do this communication part well. And you can be that compassionate witness. And you can be their compassionate support person.”
Jenna Liberto:
You must hear back from your students who are putting this into practice. What is that like?
Kathleen Kolberg:
We hear back from the students. I’ll get emails from time to time. I’ll lead off, for instance, in the embryology class, every chapter is: Here’s normal development, here’s when development goes wrong, and then here’s the clinical sequela of that. And so students were telling me they found that emotionally difficult. And so we start out with a compassionate witness, talk about how to care for people when you can’t fix whatever’s wrong. And I get feedback all the time from students about how helpful that was when they started going through their rotations.
Jenna Liberto:
I want to go back a little bit, Kathleen, to, again, you talked about what our NICU used to look like. Now that we know what we know, and Notre Dame has acted as this convenor of experts to move us forward, what do they look like now? And here in South Bend is one example, right?
Kathleen Kolberg:
Yeah, here in South Bend is one example. So there are several times that we had started to design our new unit with what we knew at the time, and it got postponed. And then, it got postponed. And then, now, we’re really grateful it got postponed half a dozen times because we were ready to put the couplet care practice into work, into reality.
So what it looks like now is not even a regular hospital room. It’s normal in full-term postpartum to keep moms and babies together. That wasn’t normal 30 years ago—it’s normal now—well, maybe 40 years ago, but it’s normal now. And why were we separating moms and babies? And the initial resistance was, “Well, nurses who are specialists on preemies don’t want to take care of moms.” And so, we said, “Well, we could double staff.” One of our partners, our research partners in Europe, they did it at their hospital, at the Karolinska Institute, and it worked. And nurses decided they wanted to be double-trained. We didn’t really anticipate that.
What we found when we opened the one at Beacon Memorial Children’s Hospital is that the nurses wanted to be double-trained. Initially, we thought we would just double staff each room, but that’s not what we had to do. So keeping moms and babies together is great because we know—there’s an old saying, Winnicott from 1960 said, “There’s no such thing as a baby, there’s always a baby and somebody.” And there’s lots of research showing that young animals that are separated and solo in a box don’t do nearly as well physiologically as those who are in contact with somebody else. Jeff Alberts at IU Bloomington has done great work with mice on that.
So we knew we wanted to keep moms and babies together, but then we started looking at dads. And dad or grandma or whoever the support person is would be torn. Baby goes to the NICU, and mom, who may be very ill, and that’s why she delivered early, is going to another unit, maybe, on another floor. And then, where does the support person go? And people had tried all kinds of things. Stanford tried doing glasses so that they could talk to each other, so there were all kinds of things. And then, it was like, “Well, just keep them together. Don’t try to use technology so that mom could see the baby through a camera and dad could see mom through a camera while he’s with the baby; just keep them together.” And it’s worked really well.
Jenna Liberto:
And now what you’re modeling is this shift from, “we’re taking care of the baby,” and even that had to evolve to, really, just thinking about it in a different way. The philosophy of caring for a family at those most important moments.
Kathleen Kolberg:
Right. And that is the philosophy of how you have a healthy pregnancy and first part of life, right? That all takes place inside a family. So if parents are prepared when they take their baby home, you get better outcomes in the long run. Some of our graduate students who were in on the initial studies looking at cycled light versus continuous light in the NICU, and looking at noise in the NICU, they went on to careers where they looked at these long-term outcomes, and parent sensitivity, “highly protective.”
So babies who were born with a very high level of acuity, babies who were born, who we would say, “Oh, we’re kind of worried about the long-term outcome for that baby,” did much better if the parents were really prepared, knew what to do, knew how to read cues. So it all goes back to looking at the baby and doing what the baby needs. That was always the secret and, if you think about it, that is the basis of everything, right? It is the loving relationship that is the basis of quality of life. So our philosophers will tell us that, but medicine tells us that if we just go look.
Jenna Liberto:
How widespread has the implementation of what you’re talking about been? You’ve mentioned partners in Europe. We know this is being put into practice here in our community in South Bend. Is it having a large-enough reach that we can really see the impact here, or we will in future generations?
Kathleen Kolberg:
Yes, we’re looking at many new units. When we design these standards, they’re not about going back and changing an old unit because the footprint might not be the same. Yale was the next unit after ours to go up, and they’re doing all kinds of wonderful research, but when new units are being built, our standards are recommended. We then submit them to the architect body, and the architecture bodies for hospitals will weigh in as to whether they’re required or not. A lot of our things get required within a couple of years after publication, and that process is ongoing right now because we’ve only just been published a little over a year, and people kind of pushed back a little bit, and they said, “Well, do you have enough data?”
Guess what? Nobody had any data. It was just convenience. Why did we have lights on 24 hours a day? [It] was convenient, we could look. Then, once we had good ways to measure oximetry in babies, we didn’t need those lights on 24 hours a day, but we had them on because it’s the way it [had] always been done.
Jenna Liberto:
So what’s your hope for this work, Kathleen, or for your students that will take this out into the world?
Kathleen Kolberg:
Yeah. One of the things I always tell my students is, “You should find the thing you want to advocate for. Look around. See what’s working well, what’s not working well, and then research it. How can you make it better?” There’s plenty of data saying advocacy is very protective for you in the practice of medicine. That you’re thinking about how to make things better instead of just having things come at you. And I have three students, former students, who come back sharing their own advocacy projects in various areas of medicine, and they’re taking it to heart, and they’re making positive changes.
Jenna Liberto:
And finally, Kathleen, for a place like Notre Dame to fight for our most vulnerable population, premature babies, for families, talk a little bit about the “why” behind this specific effort—the specific commitment—to fighting for families with for great NICU care.
Kathleen Kolberg:
Right. So, I went into developmental biology because of family tragedies around pregnancy and losing an infant sister. And so that started the passion, and lots of other people have that passion, and we all came together. And there is nothing better than sending home a family to start a new life together full of promise. So when you’ve got full-term babies, that’s taking care of mom. There are people on campus working to improve outcomes for full-term babies and for moms after pregnancy, and that’s hugely important because way too many babies and moms are at risk in the United States.
Jenna Liberto:
Well, we thank you for your work. Thank you for telling me about your research, and just all the best to you and your students.
Kathleen Kolberg:
We have great students.
Jenna Liberto:
Thank you so much, Kathleen. Appreciate the conversation.
One of Kathleen’s remarkable students, Ainee Martin, a chemical and biomolecular engineering major, is headed to medical school after graduation. She says experiences like working in a NICU were part of the holistic education she received at Notre Dame.
Ainee Martin, it’s such a pleasure to meet you. Thanks for joining me today.
Ainee Martin ’25:
Of course. Thank you for having me.
Jenna Liberto:
I’m so curious to know how you came to be at Notre Dame. So I’ll start by asking you what we ask all our guests, and that’s, “What’s your Notre Dame story?”
Ainee Martin ’25:
OK. So I was originally born in Haiti, actually, and I lived there until I was 7. And when I was there, I went through the 2010 earthquake, which was like one of the key experiences I remember there, and it was also the very first time I got to see what impacts doctors have in tragedy, so that was very memorable for me. So I kept this with me, and then I moved to West Palm Beach, Florida.
So, at Florida, I was just like, “I’ll just go to a school in Florida. I’m here, I’ll just go to an in-state school, and . . .” But there was this program at my school that they started called Path to College, where they just try to get low-income kids to college in general. And one of the things that we learned about was this national program called QuestBridge, where they try to get low-income kids to top-tier universities because, usually, we don’t apply to those universities because they’re like, “Oh, you probably don’t think that you can get in.” But they’re like, “Let’s, like, stop that mindset and then have you actually apply to these universities.”
And then, randomly, after sophomore year, I moved to Indiana. But when you’re in Indiana, the school that everyone talks about is Notre Dame, so I was like, “OK, I have to do some research.” And Notre Dame did participate in the college match, so I was like, “OK, they’re on here. Let me do some research. What do they do?” And their motto that I found out was “to be a force for good,” and I felt like this really was what I wanted to do with my life, so I felt like the school was right for me.
Jenna Liberto:
And gosh, we’re glad you’re here. What is that like? Going from Notre Dame not really being on your radar to, then, that first day you set foot on campus as a student?
Ainee Martin ’25:
I knew nothing. All I knew was the pictures online. When you Google it, you just see the Dome, so I’m like, “OK, cool. There’s a pretty bright dome.” That's kind of all I knew. But then, when I came here, it was so cool. And I think it, actually, was, like, kind of special that I got to experience it for the very first time, and like, “Oh, I’m going to be a student here.” So I really enjoyed that.
Jenna Liberto:
And now tell me what you’re studying.
Ainee Martin ’25:
So I’m actually majoring in chemical engineering, which is, it’s just a hard one. People kind of give you stares when you say that you’re majoring in chemical engineering. And then, you get even more stares when you tell them that you’re pre-med.
Jenna Liberto:
Why is that?
Ainee Martin ’25:
Because it's like, "You're chemical engineering and that’s like one of the hardest majors, then, you’re also adding medicine to it?" Sorry. But I chose that major, specifically, because when I was younger, like I said, I was doing these choice programs, so I was constantly learning about medicine, and always medicine. I’m like, “OK, I’m in college now. I know I want to learn about medicine in medical school. I know I’m going to have to learn all of these things again. Do I really want to learn about medicine in undergrad? This is like my last chance to learn something new.” I was actually, unintentionally, choosing a major that fit perfectly with medicine, because they even have a pre-med track for chemical engineers, so I was like, “OK, cool.” So I chose that one because I thought it was like my last chance to learn something new.
Jenna Liberto:
And you are very close to graduating now; it seems like that was the right choice. I’d love to hear more about your experiences as an undergraduate student and, in particular, we’re exploring this relationship Notre Dame has with NICU standards. So neonatal intensive care units across the country look to Notre Dame for best practices. And you, one of your experiences, really speaks to that. Just first, tell me about the experience you had working in a NICU.
Ainee Martin ’25:
OK. So the way I went about choosing to work at the NICU was that, I knew that we needed clinical experience for the medical school applications, and when I was doing some research online, one of the key things was, you should do something that actually interests you. And the areas I had chosen were either NICU or pediatrics. Because I could see myself being a pediatrician working with children or working with like NICU patients. So I chose those two, and then I got placed into the NICU. And my main roles were helping out the staff, like nurses and the front desk staff.
But then, I also had the opportunity to go back and hang out with the kids—not the kids, the babies—and like read to them and hold them. And, at first, I kind of just wanted to spend time with the kids, but then I realized that, when you’re a doctor, you’re going to have to learn how to work with the nurses as well. You really only gain respect for people after you experience all the hard work that they do.
So seeing all the hard work these nurses are putting in, I’m like, “Wow! This is so like, this is . . . you guys are awesome!” One of the biggest things that we learned about our NICU at Memorial is that they really emphasize contact with the baby. Instead of having a bunch of babies together, they have one baby per room, for example, or two babies per room if they’re siblings. And they have people in there talking to them, and they have the mom [have] physical contact with them and everything, so I really got to see that firsthand.
Like reading to the baby—the baby’s by itself. The baby’s not like crowded with a bunch of other babies. Reading to them, helping their parents out when their parents need anything. Like if they want anything to be more comfortable, I would be the volunteer they send to help them out. So that was really super nice. Like I got to see, firsthand, about how our NICU was very revolutionary.
Jenna Liberto:
Would you say, so you clearly went in with this knowledge that here’s Notre Dame’s influence on how we practice medicine, or this setup of this NICU, but you felt that too? Would you say that’s true?
Ainee Martin ’25:
No, yeah.
Jenna Liberto:
What did that feel like?
Ainee Martin ’25:
I think it felt like, being a Notre Dame student, and like learning about it—Notre Dame has an impact. That’s what it felt like. Look at the impact that Notre Dame can have on something like this. Look at the change—look at the positive change—that it does. And it kind of really rings true to their motto of “be a force for good,” because you can, actually, see how they’re being a force for good in these babies’ lives and these parents’ lives and these families.
Their motto isn’t just a model, they’re actually doing exactly what they say they’re going to do. And I . . . And it’s like, “OK, and they’re teaching me how to be a force for good, as well.” And I can’t wait to take what I get from them into my own career, if that makes sense.
Jenna Liberto:
Yes, it does. And this is an experience, a meaningful experience, it sounds like you had, but it’s also research. So what is it like being an undergraduate researcher at a leading Catholic research university like Notre Dame?
Ainee Martin ’25:
OK, so my research normally doesn’t really involve the NICU. My research is very lab-based for my [. . .] teacher. And he does small-scale drug synthesis for a rare disease, the rare disease lab called Niemann-Pick Type C. So that was what my research was on, developing small-scale synthesis.
And, overall, I think being an undergrad researcher here is very educational and sometimes very humbling. And also, it felt good to play a role in something that could actually impact people in real life. Like, they weren’t projects that are not going to be used ever. They’re projects that could actually make an actual impact. So that felt really good.
Jenna Liberto:
How has Notre Dame, would you say, and, in particular, experiences like the one you had in the NICU, like your undergraduate research with Niemann-Pick Type C, how has that prepared you now for this next chapter for you? And I know, as we’re speaking, you are actively in the application process for med school.
Ainee Martin ’25:
I think it really completely shaped my perspective, honestly. So those, both of those experiences, I combined them into this huge project that I had throughout my entire undergraduate year. And, overall, throughout the four years, what I learned was, in order to engineer better medicines, it really requires a very interdisciplinary thought—which includes, like, the sciences, the research, but also the human context that I saw at the NICU, the human context that I saw in my classes that I took here. Because they have some really cool classes.
Like, I took a really cool class called Race in Medicine and Technology that was super interesting, and that led me to take a bunch of different case competitions that Notre Dame offers. And like their health, like the Eck [Institute for Global Health] has a super-great case competition about how you can help people in lower-income countries.
Like, one of the cases I focused on was TB in Nigeria, for example, and I just think that all of these opportunities that Notre Dame provides really show you a holistic view of what you’re trying to do. If it’s medicine, you can see the human side, you can see the research side, and you can see, literally, any side.
Medicine isn’t just, “Oh, here’s the research and here’s the cure.” It’s, “Can you speak to this patient? Can you understand what they’re going through? Can you understand the human side of it?” To me, I thought being a doctor—like, yes, we’re interacting with the patient, but I thought, at first, the most important thing was curing the patient.
But to me now, the most important thing is connecting with the patient, not just curing the patient, because yeah, sure, you can cure the patient, but if you don’t actually connect with them, and actually know what’s going on and form that connection with them, you’re probably not advancing medicine. You’re probably not helping them out in the long run, like holistically, if that makes sense.
Jenna Liberto:
What a beautiful way to say that. Yeah, it’s about the people. It’s about the people here, and it certainly is in medicine. Before we finish our conversation, Ainee, I’m thinking about the experience you shared with us at the beginning of this interview, being a, you were a young person in Haiti when the earthquake happened, and you talked about seeing the doctors work with people in your area.
Now that you’ve had those four years of experience going into pursuing that for yourself, what do you hope you can do when you take all this knowledge out into the world?
Ainee Martin ’25:
I honestly hope I could have the same exact impact those doctors had on me onto other people. To me, they were kind of like a saving grace. Like, “Oh, we’re in this really terrible situation.” I, honestly, kind of felt very helpless, and then they come in and they just put their all into it.
They didn’t have to come in. They probably didn’t think that their presence had as much impact as it did, but it really did have a huge impact. And that’s kind of what I want to do. I just want to have an impact on people. I just want to help people.
Jenna Liberto:
We wish you just all the best, and good luck with your med school applications.
Ainee Martin ’25:
Thank you so much.
Jenna Liberto:
Thanks for talking to me.
Thanks for joining us for Notre Dame Stories, the official podcast of the University of Notre Dame. This is our last episode of the academic year. We’ll return in the fall, but in the meantime, you can find us on stories.nd.edu. You can also watch all the What Would You Fight For podcast episodes there, plus listen to some old favorites like “The Great Crown Caper.”
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