#397 - On With VON - Neuroprotection vs. Neuropromotion in the NICU

Hello friends 👋

In this premiere episode of On with Von, The Incubator launches an exciting new collaboration with the Vermont Oxford Network (VON). Hosts Dr. Ben Courchia and Dr. Daphna Yasova Barbeau sit down with Dr. Roger Soll, President of VON, and Dr. Bob White, a pioneer in NICU design, to explore the critical "Evidence to Practice" gap in the NICU environment. Moving beyond simple neuroprotection, the conversation dives into neuropromotion, examining the impact of light, sound, and sensory inputs on the developing brain. From debunking misconceptions about retinopathy to optimizing design for family integration, this discussion offers actionable insights for every bedside clinician.

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About VON

Vermont Oxford Network (VON) is a worldwide community dedicated to improving the quality, safety, and value of care for newborn infants and their families through a coordinated program of data-driven quality improvement, education, and research. VON members use the world’s largest, most comprehensive databases of infant data to benchmark practices and outcomes and identify areas for improvement, including using reports that show outcomes at monthly, quarterly, semi-annually, and annual intervals.

VON Grand Rounds is a quarterly webinar and discussion presented by the VON Institute for Evidence- Based Practice. All VON Grand Rounds sessions are available on the VON website: https://public.vtoxford.org/qi-grand-rounds/

In November 2026, VON is hosting the Quality Congress, a conference for multidisciplinary teams to learn, share, and improve together in Chicago, IL.

https://public.vtoxford.org/annual-quality-congress/

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Short Bios

Dr. Robert White: Dr. Robert White graduated from Notre Dame (1971) and Johns Hopkins University School of Medicine (1974), completing his pediatrics residency, neonatology fellowship at Johns Hopkins Hospital, and a research fellowship at the Wellcome Research Laboratory in London. He then joined Memorial Hospital of South Bend, where he helped establish the NICU program at what is now Beacon Children’s Hospital. In 1990, Dr. White convened a multidisciplinary group of experts to examine the role of the physical environment in newborn care, leading to the Recommended Standards for Newborn ICU Design, now in its 10th edition and adopted by national and international hospital building codes. His work has been instrumental in the transition from open-ward NICUs to single-family and couplet care rooms. Dr. White co-leads the annual Gravens Conference on the Physical and Developmental Environment of the High-Risk Infant, now in its 38th year.

Dr. Roger Soll: Dr. Roger Soll is the H. Wallace Professor of Neonatology at the Larner College of Medicine and is President of the Vermont Oxford Network and Director of Network Clinical Trials and Follow-up. Dr. Soll is an authority in evidence-based medicine and randomized clinical trials. He is the coordinating editor of Cochrane Neonatal, part of the Cochrane Collaboration, and author or co-author of the Cochrane Reviews of surfactant therapy. He is the author of numerous peer reviewed articles and book chapters on the subject of surfactant replacement therapy and evidence-based medicine. A native of New York City, Dr. Soll graduated from Cornell University with a degree in Genetics and History of Science in 1975. He received his M.D. degree from the University of Health Sciences/Chicago Medical School in 1978. He returned to New York City to complete his residency training in Pediatrics at Bellevue Hospital/New York University Medical Center in 1981. After 2 years with the Public Health Service, Dr. Soll returned to academic training. He completed the post graduate fellowship in Neonatal-Perinatal Medicine at the University of Vermont in 1983 and has remained in Vermont ever since.

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The transcript of today's episode can be found below 👇

Ben Courchia MD (00:00.879)

Hello everybody, welcome back to the Incubator podcast. We are back today for the first episode of a brand new series that we are collaborating with Vermont Oxford Network on. Daphne, good morning. How are you?

Daphna Yasova Barbeau MD (00:17.436)

Good morning. I'm doing really well. I'm going to disclose as we get started that this is a full circle moment for me. One of my very first conferences as a fellow was the Gravens Conference. I heard Dr. White talk about NICU design, and we heard a bunch of lectures about trauma-informed care and working with families. And I was like, "This is it. I get it. This is what I want to do with my whole entire life." So it's quite an honor for us to be discussing this here on the Incubator and sharing it with our community. I can't wait to get started. But before we do, maybe you can tell us a little bit more about what this ongoing collaboration with VON will look like.

Ben Courchia MD (01:04.121)

Well, I think for the people who are joining us, we alluded to this during our end of year recap. We're very excited about this collaboration with the Vermont Oxford Network, where we will come to you quarterly to extend the Grand Rounds that are such well-attended and popular events for VON. We will discuss with the speakers of these Grand Rounds the various questions that time did not allow us to get around to. It will be a nice little review of what was discussed and an extension of the discussion that already took place during the Grand Rounds and the webinar. Without further ado, we are joined by none other than Dr. Roger Soll and as you mentioned earlier, Dr. Robert White. Roger, Bob, thank you so much for joining us today on the podcast.

Roger Soll (02:01.77)

That's a great pleasure.

Ben Courchia MD (02:04.197)

The Grand Rounds that we are going to be discussing today is a VON Grand Rounds that first aired on November 12th, 2025. The title of the Grand Rounds was, "Evidence to Practice: The NICU Environment." The handout to the slides and the recording of the Grand Rounds are available on the VON website. For people who have not visited the site, it is public.vtoxford.com. In there, you can navigate to the Grand Rounds section and log in to access both the video recording and the slides. This was a very interesting discussion. Without wasting too much more time, I wanted to direct our first question to Dr. Soll. In the form of a review, you have approached the NICU environment from a variety of categories, including sound level and light exposure. Then we'll talk a little bit about design with Dr. White. But can you tell us a little bit about what do we know and what don't we know about appropriate sound and light exposure for babies in the NICU?

Roger Soll (03:26.056)

Thanks, Ben and Daphna. This is part of a series of Grand Rounds. We were funded by the Gerber Foundation to take a look at the infant and family experience in the NICU. In the past couple of years, we've focused specifically on infant experience around pain—acute pain and chronic pain. But this year, we wanted to take a look at the reviews that address the general environment that the infant and family find themselves in. We all know it's a pretty noxious environment. It's bright. It's loud. 40 years into this, you walk in these rooms, there are alarms going on, and we're talking in my loud voice. It's clearly a concerning issue. When we try to quantitate it, we find that there's somewhat limited evidence to understand what directions we should take. We know, for example, that the sound levels, even in our best efforts, rival being in heavy traffic and are just short of the sound of standing in the subway system as a train pulls in. It's hard to fathom that that's what the babies are exposed to, but we're so inured to it that I don't think we recognize that.

The bright lights, similarly. But let's start with sound. So what have people done? Well, there's one very small study. It involves only 32 infants and they put little earplugs on babies and they show very little. With 32 babies, you can't say much of anything. That doesn't mean that we can't get in there and make differences. We'll get into the idea of what is the right level. Is it silent? Is it not? I'm going to defer to Bob when we discuss that more. But let's talk a little bit then about light. We know, again, very bright lights. It's for our convenience. We can see everything that we're doing. We can see the babies. There is that work from Penny Glass in the New England Journal from well over 20 years ago that suggested that exposure to bright light was related to retinopathy. That study, though well-intended, is very flawed. It was an observational trial. It was not really looking at retinopathy; it was looking at behavior and this was an incidental finding.

When we do trials, either looking at dimming the lights or cycling the lights, we find that there's more evidence. There are over 20 trials, almost 10 or 11 in each of those categories. Again, we don't really find the gold. It doesn't tell us, "Oh, we now know what to do about retinopathy." How does this work? Yet you walk into any number of units and there are quilts over all the babies. The babies are left in this dark environment, or we've turned towards the idea that private rooms are the way to go. But the fact is—and Alan Jobe has a beautiful review of this that is referenced in the Grand Rounds—we may be causing harms. There's a right level; it's not a yes or no. It's not an on-off switch for the lights. And so that's the nuance, and that's where work like Bob's really comes in as we think about the right environment to put the kids in.

Ben Courchia MD (06:59.513)

Yeah, and in that editorial by Dr. Jobe, one of the quotes that stands out is the idea that "judicious light exposure is appropriate until more is known about the effect of light on preterm infants." I think it highlights the fact that maybe we shouldn't have an all-or-none approach and that more data is probably going to be best to inform what we should be doing. We were talking about sound levels. You mentioned in your presentation that 45 decibels is really the maximum that we should not exceed in the NICU, which should be around the level of sound around your home. The NICU is definitely louder than most of our homes. It gives us a lot of things to think about.

Dr. White, I wanted to turn to you. Dr. Soll has prompted you so nicely. One of the things that you mentioned is that best outcomes require both optimal care and optimal design. I thought this was a very interesting quote. In the beginning of your presentation, you make a very important distinction between neuroprotection, which is something that we probably all are using in our vernacular, but you differentiate that from neuropromotion. Can you tell us a little bit what you mean by these two different terms and how does that inform how we approach the sensory environment in the NICU?

Bob White (08:24.942)

Yeah, thanks, Ben. I think the example about earplugs is a perfect way to illustrate this. Most of our NICUs used to be too noisy. I want to emphasize Roger's reference to 45 decibels as background sound. Our background for most NICUs is significantly greater than that. We're not saying kids should never be exposed to more than 45 decibels. In fact, if their mom is singing to them at 60 or 70 decibels, that's wonderful. So earplugs only go halfway. It takes away the noxious stimuli, but it also prevents any of the nurturing stimuli. That's the sweet spot that we have to get to. There was a time in NICUs where the design was such that there was no way to get away from it. You had 10 or 12 babies in the same room and alarms were all audio, lights were all on because we didn't have oximeters to see if the baby was pink or not. We've done a really good job, I think, in most NICUs of getting rid of most of those noxious stimuli. But what we are still missing is reintroducing the nurturing stimuli.

I think there's a couple of NICUs I visited that could be models for how we think of this. One of them is in Stockholm, where families are there 20 to 22 hours a day, holding their babies most of the time in private rooms. In that setting, a private room is a great setup because it's a family and they're there; the baby is not in isolation, he's in the midst of a very desirable environment. I visited another NICU in Barcelona that was quite different. It must have been built 30 or 40 years ago. It was a big open room, like many of our NICUs were built at that time. But in that room were six or seven mothers in rocking chairs, holding their babies, talking to each other, rocking their babies in the midst of this wonderful community. That too is a terrific environment. You don't have to have private rooms, you don't have to have open design. What you have to have is something that brings that human contact to the babies in whatever form that society and that NICU can support.

Ben Courchia MD (11:11.203)

I think that's such an interesting point because it seems that from the early steps of our conversation, there's truly a threshold where we should try to remove noxious stimuli that could be present in a NICU. But in a desire to maybe do too much, we could reach the point of sensory deprivation. This is something that you guys both address in your presentation. Can you tell us a little bit about what we know about sensory deprivation and what could be ultimately the effects on the newborns in the NICU?

Roger Soll (11:45.434)

I'll start on that. We know that there are measurable differences in language acquisition and language understanding based on the environment. For babies in single rooms with limited exposure, there are measurable differences. I'm not sure that those differences in themselves are clinically meaningful, but it raises the red flag. It says it may not be an all-good thing. It really makes us entertain the idea that there is a sweet spot about these exposures and that you can go too far. I love Bob's examples that there's no one right issue, not for any one NICU and certainly not for any one family. There is an equity issue that creeps into this that is important for us to address. Even if we design what we think might be the perfect NICU for these exposures, the whole interaction with the family needs support. I love the image in Barcelona, Bob, of the moms all together, because when I first heard of single rooms, I had a tinge of sadness. Despite the chaos of our one big barn of a room, families bonded and supported each other, conversed with each other. There's so much more to this than just measuring light and sound. Bob, I'll defer to you. You have thought more about this.

Bob White (13:15.138)

I can't say it any better than that, Roger. You summarized it very well.

Daphna Yasova Barbeau MD (13:21.127)

I really loved the underpinning. There are things we can definitely do in the NICU, and I want to get to some of those low-hanging fruit recommendations. I think finally the community is beginning to embrace that parents as equal or potentially highlighted members of the team are absolutely critical to long-term neurodevelopment. We've reached that point because we've updated our technology, we've updated our protocols, and our developmental outcomes still aren't improving. It sounds like this step is absolutely critical to not just get to the survival of infants, but really the thriving of infants. Dr. White, you've lectured so nicely about this, that NICU design definitely impacts the babies. But what are some critical things we have to do to make NICU design more inviting for families such that they want to spend more time, such that they feel they're supposed to spend more time? I recognize that's not just NICU design, it's also a culture shift in the unit. But what is the bare minimum that we have to do to say to families, "We welcome you here, you're supposed to be here, you're absolutely critical to the long-term development of your baby"?

Bob White (14:51.342)

Well, Daphna, as you said, the culture of the staff is so basic to making this happen that the design has to be something that facilitates that, not that drives it. If you have a staff that really is welcoming to families, then design has to provide the optimal setting for various types of family situations. If the family can't get there or won't come, a single-family room is not the ideal setting for the baby. You have to have alternatives for that. Some places, Harvard for example, have an area for their feeder and grower babies—the 30-somethings—that intentionally puts several babies in the same room together. They benefit from, if not the conversation of their own parent, the conversation of two or three nurses who are caring for babies together and carrying on that conversation. Babies are now exposed to that language that they get in utero from their mother normally. If we put them in a private isolation room, they won't get it.

So then we have these more open rooms and a philosophy that supports babies getting this stimuli from whichever source is available to them. In our unit, we have rockers and volunteers who come in and support the care of babies. They'll sing to them, read books to them, and talk to them for hours at a time. That may be a good alternative for some NICUs. One thing I don't want to overlook is that I think we have to make sure our staff understand what their responsibility is. I think there is too often a task-oriented mission for staff where they take the vital signs, do the feedings, change the diaper, and once the feeding is in, they're off to do some charting, maybe a couple minutes of free time, and then they're on to the next assignment. We have to make sure that staff understand that part of their responsibility is the nurturing of that baby. They need to spend that time not just making sure a feeding goes in, but that the baby is talked to, is touched and rocked and given the kind of stimulus that you would do if you were that baby's mother or father. I'm not sure that's inherent in all of our practices. So this falls on all of us to get the design right, but also to get all of the opportunities for stimuli that babies need to make that part of our practice.

Roger Soll (17:59.114)

I love that point, Bob, but that lies to me with the hospital administrator. I'm having trouble thinking of any bedside caregiver who doesn't want to spend more time—at least the vast majority—who would love to be able to talk and coo and examine. We leave so little time. We commit ourselves just to what we think is the life-saving care and not, as you're saying, Bob, the quality-enhancing care. So I think that's a great point, but I argue that it's a staffing issue, not necessarily a cultural issue with the individuals, but an issue of expectations and staffing and what we commit to.

Daphna Yasova Barbeau MD (18:44.359)

I do love the idea though that there are ways that we can rethink our routine care. The way we open the isolette, the way we wake the baby up, the way we settle the baby back to sleep. Certainly, there are some good resources for that such that they don't take that much more time to tell the baby what we're doing as we're doing it, that we place hands before we flip the baby over, that we place hands before we close the baby up saying, "This is the start of our time together, this the end of our time together." Just exactly like you said, Dr. White, as if it was a baby in your own home. When we take that perspective, it just changes the way we interact with the babies every single time. I love that concept. We're going in there at least eight times a day, maybe 10 times a day. Every single time is an opportunity for a positive interaction, even though we have those tasks to perform. That's a concept I've been working on with my nurses. It's not just our responsibility to make sure that babies bond with parents, but babies can bond with anybody. So bonding with the staff doesn't replace parents, but I think it is another opportunity to teach them about healthy human relationships.

I want to make sure that we move forward to some of these concrete, lowest hanging fruit recommendations. I can imagine some people are listening and saying—and you guys address this—"I don't have any control over the design in my unit." But if we look at things specifically, there are small things that we can do every single day. There were actually a number of questions that came along in the chat from your discussion during the webinar that we didn't get to address because there wasn't enough time. So that's why we're here today. Some of these specific questions are, for example, for noise, what is the right type of noise? Are there certain sounds? Is it music? Is it mother's voice? If we're going to provide positive stimulation, neural stimulation, what does that auditory stimulation look like or sound like?

Roger Soll (21:07.734)

Let me just start us off. Bob is going to know the details more than I. But I love your question because when I first read Bob's work, it was like, "Well, I'd love to know this, but I'm not building my new unit." We're working in our old units. So all of these suggestions that Bob has propounded, we could find in various quality improvement initiatives. "What can I do given my resources and my limitations that can move things forward?" There, as you're alluding to, Daphna, are a lot. We know "wrong" noise. We had the alarms set so we could hear them down the hallway while we're eating lunch. There was never any good reason for that. So there are any number of ways of looking at alarms and the technology around that. But one of the most obvious issues is just to begin to lower the sounds of the technology, and everyone can do that and everyone can commit to that and rethink that. Bob, I'll punt it over to you. I took the lowest lying fruit.

Bob White (22:13.696)

Well, I think technology has helped a lot in that. As you know, many of us now have devices that bring the alarms to our phones that we carry with us and aren't sounding at the bedside or down the hallway. I do want to talk about how multisensory stimuli are really crucial. I think sometimes we think of light or sound as isolated stimuli and play some recorded music, maybe the mom's voice, maybe some lullabies to a baby without really considering the rest of the stimuli that might be occurring. By itself, I think those can be beneficial, and Roger's done a really good job of helping us understand how they can be. But we still have to recognize that the normal way those stimuli are received, both in the fetus and in healthy infants after birth, is as part of a multisensory experience. They're being rocked and hear that lullaby and feel the warmth of the person holding them. That's a different sensation than just getting music played into your incubator, especially if occasionally along with that music is a heel stick or an IV poke. So we have to be really intentional about making these stimuli that we're trying our best to help babies' brains develop presented in a way that's as natural as possible.

Daphna Yasova Barbeau MD (24:12.934)

I love that. I really want to highlight what you've said there because I think this is an important piece. What I heard you say is we shouldn't just snuggle the baby, turn on the music, and walk away on a loop hoping that that will just give the baby all the developmental stimulation they need for the day. I wonder if this is a good time to talk about infant cues in receiving some of the stimulation. That might help bedside professionals decide when a baby is ready for positive stimulation and when could positive things done on top of negative things actually negatively reinforce what's supposed to be a pleasurable experience.

Bob White (25:00.888)

Yeah, that's a great point. We have a whole group of experts, speech therapy for example, who know this literature and understand that piece of it. So hopefully everybody's got those folks in their NICU and take full advantage of them.

Roger Soll (25:20.342)

Daphna, your point about the individualization is key. We've all been to medical appointments where the caregiver just does their shtick in front of us and has no idea of who we are or what we need to hear. You just have to think about the baby. Frequently, we just have a checklist of what we're going to do without any sense of, "Is this the right time for the baby? Is this baby ready for it? What part of this can we do now?" Some of the cultural changes involve making us as a staff responsible to the baby and to each other. The nurses have to be empowered to come up to me and go, "Shh, Roger. Now is not the time to hold rounds with 12 people." I promise you, I've been shushed many times.

Bob White (26:05.742)

I want to add here that if your NICU doesn't have NIDCAP or SENSE or one of the developmental programs that are really well researched and developed, you need to get on that train. This is not something that our instincts are enough to tell us with what a baby at 26 weeks or 34 weeks is most appropriate to receive. These programs will be really helpful. There's therapists again who are familiar with them who should be on board with your NICU and can implement them.

Roger Soll (26:50.016)

We're not here to plug any one program, but I agree with you, Bob. SENSE makes a lot of sense to me, mostly because it doesn't just say, "Here's light or here's sound." It's an integrated approach. I'm sure there are others that could be taken, but I'm very impressed with the fact that they've tried to look at it about the whole infant and about the multiple dimensions that you mentioned, Bob.

Ben Courchia MD (27:13.221)

I want to make sure that we get to some of the questions that were asked during the Grand Rounds. One of them that keeps coming back is the one related to the exposure to light in relation to gestational age. There are a few people who are asking for clarification on the gestational age at which lights should remain on in the unit versus when they can be turned off. Maybe this is not the framework that you guys used to think about that, but can you give any information on that topic specifically?

Roger Soll (27:46.838)

I'm not sure I can, except to question whether the lights should be left on for everyone or off for everyone. Obviously now with various nursing situations in individual rooms, you have choices. From a physiologic point of view, cycling light makes sense to me. Infants are aware and have circadian rhythms and patterns, even at a very immature age. All of the work that has been done suggesting that light exposure and retinopathy is related is deeply flawed, and I don't know whether it belongs in any discussion based on gestational age or otherwise. Everything from the animal models during phototherapy about the possible harms of light there to the work from Glass and colleagues. So I don't have a good answer for that. Bob, do you have any further insight?

Bob White (28:38.446)

Well, I think at best, Roger, your research has shown that cycle lighting is not harmful. And we know in the second trimester that the pathways are not developed such that babies could even respond to lighting stimuli to the pineal gland. So I think continuous dim lighting is optimal until you get to the third trimester. Once you're there, though, we know that babies have a circadian rhythm in utero. Mothers will tell you this. We know that the primary stimulus is light. There are other stimuli. We've done a lot of work on melatonin and breast milk, for example, that's shown that melatonin levels vary depending on whether the breast milk is expressed during the day or at night. We give babies breast milk from their mothers according to that routine. Mothers separate it according to when they pump it and we give it to babies at the same time of day as their mothers pumped it. None of this is evidence-based in terms of proving that it makes a difference for babies. But on the other hand, it is trying our best to replicate the biology that these babies would optimally be in in utero.

Ben Courchia MD (30:04.333)

An interesting follow-up question to that—and quite specific—is regarding caffeine and whether there are any data available to suggest that caffeine has a positive or negative effect on circadian rhythms of the babies.

Roger Soll (30:18.976)

Good question, I don't know. The dosing is usually around the whole day, not like my morning coffee that I'm enjoying now. So I don't quite know how we would tease that out per se.

Bob White (30:36.78)

I agree. In the absence of that data, I give my babies caffeine early in the morning so that their peak levels are during the day and their lowest levels are at night. I don't see any downside to that. I do think that makes more sense than it being given at random times whenever the order happens to get written.

Daphna Yasova Barbeau MD (31:01.83)

I love that concept about "it makes sense." And I guess that brings me to a philosophical question. I know we said we have some data, we're lacking some data, there's still some holes in exactly what's right for which baby at what gestational age. But are there things that are transferable from child development studies that have been done for decades, bonding studies that have been done for decades? Stimulus deprivation studies. This is not new science. We just have younger and smaller babies. So how much do we have to prove before we can make certain decisions that may have been proven in other populations or in other situations?

Roger Soll (31:50.934)

So I'll start that because I'm branded as the evidence person. And there are some questions. We talk about trials where we're only concerned that there is no harm. That's a whole new thinking about certain trial designs. And there are obvious benefits that don't need measuring. So for example, if I was studying singing to your baby... I don't think I would have to look for the obvious benefits. I know that the mother and child are happy in these moments. I know the psychology of it from, as you said, Daphna, hundreds of other studies of parenting. I would have to know if there's a measurable harm, which I don't think I could even imagine. And so I'd say, sing away. Read away, with all the reading book literature. With the obvious benefits to the family and their support, you'd have to prove that there was a harm involved for me to say that these issues aren't worth addressing. These cultural issues, including the staff... I think some of the things Bob mentioned, the staff has to feel that its role is part of this nurturing. But it's hard to think of the downside and it's hard to think about what you would even be looking for as the outcomes to put the kibosh on some of these issues.

I'll go on just one point longer though. Others are profound. How you set the lights? That could have both real harms and benefits that I don't know how to measure. I can't assume anything about it. So some of the issues we're discussing in optimizing care seem self-evident and we should do it to support families, even from the satisfaction and bonding point of view. Others do require more thoughtful investigation.

Bob White (33:50.838)

I don't have anything to add because if I were answering this question, I'd be going to the literature and looking up Roger Soll to see what he had to say about it.

Roger Soll (34:01.75)

Well, if I could sing, I would sing to the babies.

Ben Courchia MD (34:01.797)

I wanted to ask one more question about noise in the NICU because I feel like we have the intention of moderating the sound that babies are exposed to, but sometimes we may be doing some harmful things. We've all been to the bedside of a baby that has an iPad and something is playing, hopefully maybe some classical music, but there are sound machines that are placed at the baby's bedside that are turned on and we think, "This is good for the baby." And they're on for hours and hours on end. Do you guys have any thoughts or any directives that you could share with the audience about those specifics? Dr. White, I'm going to turn to you.

Bob White (34:51.5)

I don't think that's natural. I don't think that's how babies in utero receive their stimuli. I'm not in favor of that practice and I don't know of any data that supports it. I will bring up again the issue that when adverse things happen to a baby, I don't think they're too young to learn to associate bad stimuli with whatever this presumably beneficial stimuli is being offered to them at the same time.

Daphna Yasova Barbeau MD (35:26.214)

And I'll say, there's some great data about full-term healthy infants and using white noise long-term in the nursery at home. And they show worse outcomes and sometimes implications for long-term hearing. So I think that we can potentially bring that into the NICU and say we probably see that just magnified in our units. Again, we've talked about some real easy take-home points for sound. What's the lowest hanging fruit in any unit then for light given the data that we had?

Bob White (36:06.978)

I think providing some form of cycled lighting during the third trimester is safe and possibly effective. That light should not be direct lighting. It should be indirect. It needs to be at least 30 or 40 foot-candles brighter than the background lighting, the nighttime lighting, to have a biological impact. With those provisos, I don't think specific timing is important. I don't think a number of hours is likely to be important as well. So I don't think you can put too fine a point on it, but I do think it's beneficial to babies. I think it's the environment they will go to at home. And a model that we should set for families that they don't have to keep the baby in a quiet nursery all the time once they take the baby home. We can model that behavior before the kids go.

Daphna Yasova Barbeau MD (37:21.261)

I know we're getting close to time. I have one more question that I know is a debate in lots of units. I think it has to do with sound and light and sleep and family engagement. I think our nurses are understanding how important sleep is. But the question always comes up when a parent presents for kangaroo care at a non-touch time. I wonder what you can tell us the data says about this. Should we offer kangaroo care whenever it's available? Or should we be optimizing sleep between touch times? And maybe that has a gestational age component to it as well.

Bob White (38:03.616)

I've got opinion, Roger has data, so I'll let him go first.

Roger Soll (38:06.816)

Well, I'm not sure I have data on that point except to say that we find too many barriers to getting the baby in mom's arms. Many of them we just make up. The baby's on CPAP, the baby's on this, the baby's unstable. I really would not allow those theoreticals to stand in the way of getting babies in their mother's or caregiver's arms, skin to skin. The studies seem to show some dose effect. Kangaroo mother care may be overestimated in its impact on things like mortality, but cannot be underestimated in terms of the relationship of the mother and baby and the potential benefits downstream. So I wouldn't start thinking of excuses to become a barrier to that.

Bob White (38:56.27)

I'm not aware of any evidence that "No Touch Times" has any support for it. I'll refer people again to Karolinska in Stockholm, where babies are held 22 hours a day between the mother and the father, and they do really well.

Daphna Yasova Barbeau MD (39:13.637)

I love that. We were just highlighting how important parent bonding and kangaroo care is overarching of some of our other light and sound opportunities. We know we have a lot of trainees who are listening, a lot of young career NEOs. Where are some opportunities for people who are interested in making this part of their life's work? Where do we still really need research and data in this area of expertise?

Bob White (39:49.932)

I'm going to bring Bobby Pineda's name into this and go back to the SENSE program. A program like that is still not fully refined, and we can use additional information. Bobby and I debate about some of the recommendations in SENSE on multiple occasions, because some of it's not yet evidence-based. It's our best guess. Those guesses are based on data that Roger and Vermont Oxford have generated for the most part, but we need more. Looking at programs that help people understand what's the best stimuli for babies at a given gestational age—the more we can learn about that, the better.

Roger Soll (40:43.178)

And there's also just the issue of what we already think we know, or at least what we know we're doing that's wrong, that can be stopped. So quality improvement as a personal commitment for these younger folks, I think, is extremely important. There's absolutely no question we can lower the noise and the level of noise in our units with a commitment towards something as simple as quality improvement and sticking to that commitment. Towards Bob's point, there are lots of researchable areas as well, and I think that after we choose the low-lying fruit, we can start to think, "Okay, what is the exact way to do this?"

Daphna Yasova Barbeau MD (41:26.661)

Well, I hope that this brings up a lot of interest in people. Can you give us some resources, places where people can go if they are all in now that they've heard you talk about it and they want to learn more about what they can bring to the bedside in their own unit?

Bob White (41:47.182)

Come to the Gravens Conference.

Daphna Yasova Barbeau MD (41:48.294)

That's right. It's a great conference, my favorite conference. And I did want to also highlight, Dr. White, I think that you were a huge part of these NICU recommended standards that are housed on the University of Notre Dame site, nicuedesign.nd.edu. I think they give people a lot of concrete ways to make changes both on NICU design and developmental care standards in their units.

Bob White (42:17.045)

And we are putting together a supplement to the Journal of Perinatology that talks a lot about all of these other elements. Whatever design you're in, there are elements that can help families and staff provide the optimal developmental care for babies. So that should be out in Journal of Perinatology in the last half of this year.

Roger Soll (42:42.24)

And please do take a look at our original recordings on the Vermont Oxford Network website and join us the next time. Our upcoming conference will be looking at transfusion thresholds with Ravi Patel. And I love the fact that since we never get to answer all the questions, we'll get to join Ben and Daphna to discuss that further.

Ben Courchia MD (43:03.269)

I was going to say the same thing, Roger. We invite people to go back to listen again to the full presentation on NICU design. It's available on public.vtoxford.org. And while you're there, please register for the upcoming Grand Rounds. The next one will be given on Wednesday, February 4th at 3 PM Eastern time, "Evidence to Practice: Transfusion Thresholds." And now you know that if you leave a question in the chat, it will be asked either during the webinar or after. So even more reason for you to engage with the Vermont Oxford Network and to be active members of the conversation. Dr. Soll, Dr. White, this was phenomenal. Thank you again for your time and for your body of work.