Evaluating physiologic outcomes of music interventions in the neonatal intensive care unit: a systematic review

Neuroimaging-Guided Music Interventions for Infants in NICU

This Viewpoint discusses the use of neuroimaging to tailor music-based protocols among infants in the neonatal intensive care unit (NICU).

Assessing HeartSong as a Neonatal Music Therapy Intervention: A Qualitative Study on Personal and Professional Caregivers' Perspectives

BACKGROUND

The music therapy HeartSong intervention pairs newborn infant heartbeats with parents' Song of Kin. Formal evidence on professional and personal caregiver perspectives of this intervention is lacking.

PURPOSE

This survey study evaluates the HeartSong music therapy intervention from parent and staff perspectives.

METHODS

A qualitative study assessing inclusion of HeartSong for family neonatal intensive care unit (NICU) care surveyed 10 professional caregivers comprising medical and psychosocial NICU teams anonymously reflecting their impressions of the intervention. Digital survey of parents/guardians contacted through semistructured phone interviews relayed impressions of recordings: subsequent setup, Song of Kin selection, and use of HeartSong, including thoughts/feelings about it as an intervention.

RESULTS

Professional and personal caregivers valued the HeartSong intervention for bereavement support, family support, including parental, extended family/infant support, and to enhance bonding. Emergent themes: memory-making, connectedness/closeness, support of parent role, processing mental health needs of stressful NICU days, and subsequent plans for lifelong HeartSong use. Therapeutic experience was named as a crucial intervention aspect and participants recommended the HeartSong as a viable, accessible NICU intervention.

IMPLICATIONS FOR PRACTICE AND RESEARCH

HeartSong's use showed efficacy as a clinical NICU music therapy intervention for families of critically ill and extremely preterm infants, when provided by trained, specialized, board-certified music therapists. Future research focusing on HeartSong in other NICU populations might benefit infants with cardiac disease, parental stress, and anxiety attending to parent-infant bonding. Costs and time benefits related to investment are needed before implementation is considered.

Music Therapy and Family-Integrated Care in the NICU: Using Heartbeat-Music Interventions to Promote Mother-Infant Bonding

BACKGROUND

Family-integrated care in the neonatal intensive care unit (NICU) is the criterion standard. Parent-infant bonding may be an indicator of successful family involvement. Music therapy (MT) is a growing service in the NICU, with interventions to support meaningful family involvement and improve bonding.

PURPOSE

To study the effects of heartbeat-music interventions to support mother-infant bonding in the NICU and explore experiences of mothers participating in MT.

METHODS

Parallel-group randomized trial (MT vs standard care) to compare Mother-to-Infant Bonding Scale (MIBS) scores from baseline to 1 week postenrollment. MT included 2 heartbeat-music interventions (recorded maternal lullaby and heartbeat for infants, and recorded infant heartbeat and preferred music for mothers). Five mothers were randomly asked to complete a survey regarding their experiences with MT services.

RESULTS

One hundred mothers enrolled. In total, 44.3% completed the MIBS follow-up. Covarying out baseline MIBS, one-way analysis of covariance found no statistical difference between groups for MIBS 1-week follow-up (MT: mean = 0.64, SD = 1.6; standard care: mean = 0.57, SD = 1.5; P = .60) but underpowered in post hoc. Comforting, family cohesion, and personal growth and development themes emerged in qualitative analysis of survey responses.

IMPLICATIONS FOR PRACTICE

MT remains a viable service for purposefully including parents in the care of their NICU infants. Nurses and music therapists must work closely to successfully implement meaningful interventions such as heartbeat-music.

IMPLICATIONS FOR RESEARCH

Heartbeat-music interventions should be further studied for diverse applications, including family integration, family coping, and bereavement.

Music Therapy Intervention in an Open Bay Neonatal Intensive Care Unit Room Is Associated with Less Noise and Higher Signal to Noise Ratios: A Case-Control Study

BACKGROUND

Noise reduction in the Neonatal Intensive Care Unit (NICU) is important for neurodevelopment, but the impact of music therapy on noise is not yet known.

OBJECTIVE

To investigate the effect of music therapy (MT) on noise levels, and whether individual MT (IMT) or environmental MT (EMT) increases meaningful signal-to-noise ratios (SNR).

STUDY DESIGN

This case-control study was conducted in a level III NICU. Noise levels were recorded simultaneously from two open bay rooms, with a maximum of 10 infants in each room: one with MT and the other without. MT sessions were carried out for approximately 45 min with either IMT or EMT, implemented according to the Rhythm Breath and Lullaby principles. Noise production data were recorded for 4 h on 26 occasions of EMT and IMT, and analyzed using R version 4.0.2 software.

RESULTS

Overall average equivalent continuous noise levels (Leq) were lower in the room with MT as compared to the room without MT (53.1 (3.6) vs. 61.4 (4.7) dBA, p = 0.02, d = 2.1 (CI, 0.82, 3.42). IMT was associated with lower overall Leq levels as compared to EMT (51.2 vs. 56.5 dBA, p = 0.04, d = 1.6 (CI, 0.53, 1.97). The lowest sound levels with MT occurred approximately 60 min after the MT started (46 ± 3.9 dBA), with a gradual increase during the remaining recording time, but still significantly lower compared to the room without MT. The SNR was higher (18.1 vs. 10.3 dBA, p = 0.01, d = 2.8 (CI, 1.3, 3.86)) in the room with MT than in the room without MT.

CONCLUSION

Integrating MT modalities such as IMT and EMT in an open bay NICU room helps reduce noise. Both MT modalities resulted in higher SNR compared to the control room, which may indicate that they are meaningful for the neurodevelopment of preterm infants.

Parents’ Views with Music Therapy in the Pediatric Intensive Care Unit: A Retrospective Cohort Study

Purpose: Music therapy intervention (MT) could be used as an adjunctive therapy in PICU for anxiety and pain management. The aim of the study was to examine the perception of MT by children’s parents in a PICU of a tertiary care teaching hospital. Methods: This is a retrospective cohort study summarizing the results of an institutional quality improvement initiative. Questionnaires were distributed to parents whose children were exposed to MT. Results: From April 2019 to July 2021, 263 patients received a total of 603 h of MT. Twenty-five questionnaires were distributed to parents over a 4-month period (February–June 2021). A total of 19 (76%) parents completed the questionnaire. The majority of parents thought that MT helped their child to communicate (89%), feel less isolated (100%) and cope with stress during hospitalization (100%). The majority of parents also thought that MT contributed to physical recovery (90%) and alleviated feelings of anxiety (90%). Parents also believed that MT should be offered as an out-patient service. Conclusions: Our study agrees with other studies on the positive potentials of MT in PICU. Music therapy intervention could be used to promote children’s and parents’ psychological well-being. Further studies are warranted to evaluate the impact of MT on long-term post-ICU outcomes.

Use of Musical Intervention in the Pediatric Intensive Care Unit of a Developing Country: A Pilot Pre–Post Study

Music is frequently used in different clinical settings, and it is implemented as a complementary, low-cost and useful intervention to reduce pain, anxiety and to improve relaxation. This pilot pre–post study aimed to examine the feasibility and preliminary effectiveness of a specific musical intervention in patients ≤16 years admitted to the Pediatric Intensive Care Unit (PICU) of an Iraqi hospital. The COMFORT Behavior Scale (CBS) was used by nurses to assess the level of sedation. Fifty-nine children were enrolled during the study period (March 2020–August 2021). CBS was lowered by 2.2 (95% CI: 1.9 to 2.6) points after 30 min, and by 3.3 (95% CI: 2.9 to 3.6) points after 60 min from music initiation. Thirty minutes after music initiation, heart rate decreased by 6.3 (95% CI: 4.5 to 8.1) beats per minute, whereas at 60 min, heart rate decreased by 9.1 (95% CI: 7.2 to 10.9) beats per minute. No clinically significant variations were detected in the other vital signs (blood pressure, respiratory rate and oxygen saturation). These findings support the feasibility of musical intervention in a developing country. CBS and heart rate variation may be worth following up in larger and conclusive studies.

Music therapy for preterm neonates in the neonatal intensive care unit: An overview of systematic reviews

AIM

To summarise the quantity and quality of evidence for using music therapy for preterm infants in the neonatal intensive care unit (NICU).

METHODS

We performed an overview of evidence for the effectiveness and safety of MT for preterm infants in the NICU. We performed a random-effects meta-analysis of data from studies that fit the definition of MT.

RESULTS

We identified 12 eligible systematic reviews and the methodological quality by AMSTAR-2 ranged from moderate to critically low. We identified 14 eligible randomised trials and 7 observational studies where the intervention fits the definition of MT. Meta-analysis of the RCTs showed that MT significantly decreases heart rate, mean difference (MD) (95% CI), -3.21 [-5.22, -1.19], respiratory rate, MD -2.93 [-5.65, -0.22], and maternal anxiety, MD -17.50 [-20.10, -14.90], and increases feeding volume, MD 29.59 [12.79, 46.38]. Long-term neurodevelopmental or safety outcomes were not reported. GRADE assessment of outcomes ranged from low to very low, downgraded for high risk of bias in the included studies, inconsistency and imprecision.

CONCLUSION

Low to very low certainty evidence suggests that MT in preterm infants improves short-term physiological parameters, feeding and maternal anxiety but safety and long-term outcomes were not reported.

Effects of Live Music Therapy on Autonomic Stability in Preterm Infants: A Cluster-Randomized Controlled Trial

Unbuffered stress levels may negatively influence preterm-infants’ autonomic nervous system (ANS) maturation, thus affecting neurobehavior and psycho-emotional development. Music therapy (MT) is an evidence-based treatment modality in neonatal care. When coupled with skin-to-skin care (SSC), it may reduce stress responses in both preterm infants and their parents and enhance family-centered care. Accordingly, we aimed to compare the effects of combined MT and SSC and SSC alone on ANS stabilization in preterm infants. In a single-center, cluster-randomized trial design, ten two-month time-clusters were randomized to either combined MT and SSC or SSC alone. Families of preterm infants were offered two sessions of the allocated condition in the NICU, and a three-month follow up session at home. The primary outcome variable was stabilization of the ANS, defined by change in the high frequency (HF) power of heart rate variability (HRV) during the second session. Secondary outcomes included other HRV measures, parent–infant attachment, and parental anxiety at each session. Sixty-eight families were included. MT combined with SSC improved infants’ ANS stability, as indicated by a greater increase in HF power during MT compared to SSC alone (mean difference 5.19 m²/Hz, SE = 1.27, p < 0.001) (95% confidence interval 0.87 to 2.05). Most secondary outcomes were not significantly different between the study groups. MT contributes to preterm-infants’ autonomic stability, thus laying an important foundation for neuro-behavioral and psycho-emotional development. Studies evaluating longer-term effects of MT on preterm infants’ development are warranted.

Parental Attitudes toward Consent for Music Intervention Studies in Preterm Infants: A Cross-Sectional Study

(1) Background: This study investigated parents' motives for enrolling preterm infants into music therapy intervention studies during Neonatal Intensive Care hospitalization. (2) Methods: We surveyed Israeli parents of preterm infants after they consented or refused to participate in such studies. The pre-piloted questionnaires evaluated attitudes toward research and music therapy intervention studies. The study included 116 (57%) parents who agreed to participate in music therapy studies and 87 (43%) who declined. (3) Results: Infants of those who agreed to participate were younger (17 ± 2.3 vs. 28 ± 4.7 days old, p = 0.03) and sicker (Clinical Risk Index for Babies score 6.1 ± 2.7 vs. 3.68 ± 4.1, p = 0.04). More single-parent families declined to participate (p = 0.05). Parents agreed to participate because they thought the study might help their child, would improve future care of preterm infants and increase medical knowledge (all p < 0.05). In addition, they perceived music as beneficial for brain development, thought it might improve bonding, and routinely listened to music daily. (4) Conclusions: When recruiting parents and preterm infants for music therapy intervention studies, one should highlight potential contributions to the child's health, future children's health and medical knowledge. Stressing music as a potential tool for brain development and augmenting bonding is important. The best time to recruit is when improvements are still anticipated.

Preterm infants with severe brain injury demonstrate unstable physiological responses during maternal singing with music therapy: a randomized controlled study

Preterm infants with severe brain injury are at high risk for poor outcomes and, therefore, may benefit from developmental care modalities such as music therapy (MT). In this prospective, randomized intervention, preterm infants with severe brain injury (grade 3 or 4 intraventricular hemorrhage or periventricular leukomalacia) who underwent skin-to-skin contact (SSC) with or without maternal singing during MT were evaluated for physiological responses, including autonomic nervous system stability (low frequency (LF)/high frequency (HF) power), heart rate, respiratory rate, oxygen saturation, and behavioral state. Maternal anxiety state and physiological data were also evaluated. A total of 35 preterm infants with severe brain injuries were included in the study analysis. Higher mean ± standard deviation (SD) LF/HF ratio (1.8 ± 0.7 vs. 1.1 ± 0.25, p = 0.01), higher mean ± SD heart rate (145 ± 15 vs. 132 ± 12 beats per minute, p = 0.04), higher median (interquartile range) infant behavioral state (NIDCAP manual for naturalistic observation and the Brazelton Neonatal Behavioral Assessment) score (3 (2-5) vs. 1 (1-3), p = 0.03), and higher mean ± SD maternal anxiety (state-trait anxiety inventory) score (39.1 ± 10.4 vs. 31.5 ± 7.3, p = 0.04) were documented in SSC combined with maternal singing during MT, as compared to SSC alone.Conclusion: Maternal singing during MT for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. A unique MT intervention should be designed for preterm infants with severe brain injury and their mothers. What is Known: • Preterm infants with severe brain injury are at high risk for poor outcomes. • Music therapy benefits brain development of preterm infants without severe brain injury, however it is unknown whether maternal singing during music therapy for preterm infants with severe brain injury is beneficial. What is New: • Maternal singing during music therapy for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. • A unique music therapy intervention should be designed for preterm infants with severe brain injury and their mothers.

Sensory Stimulation in the NICU Environment: Devices, Systems, and Procedures to Protect and Stimulate Premature Babies

Prematurity deprives infants of the prenatal sensory stimulation essential to their correct development; in addition, the stressful environment of the NICU impacts negatively on their growth. The purpose of this review was to investigate the effects of NICU noise pollution on preterm infants and parents. We focused on the systems and projects used to control and modulate sounds, as well as on those special devices and innovative systems used to deliver maternal sounds and vibrations to this population. The results showed beneficial effects on the preterm infants in different areas such as physiological, autonomic, and neurobehavioral development. Although most of these studies highlight positive reactions, there is also a general acknowledgement of the current limits: small and heterogeneous groups, lack of structured variable measurements, systematic control groups, longitudinal studies, and normative values. The mother's presence is always preferred, but the use of music therapy and the devices analyzed, although not able to replace her presence, aim to soften her absence through familiar and protective stimuli, which is a very powerful aid during the COVID-19 pandemic.