The Effect of Maternal Presence on Premature Infant Response to Recorded Music

Musical and vocal interventions to improve neurodevelopmental outcomes for preterm infants

BACKGROUND

Preterm birth interferes with brain maturation, and subsequent clinical events and interventions may have additional deleterious effects. Music as therapy is offered increasingly in neonatal intensive care units aiming to improve health outcomes and quality of life for both preterm infants and the well-being of their parents. Systematic reviews of mixed methodological quality have demonstrated ambiguous results for the efficacy of various types of auditory stimulation of preterm infants. A more comprehensive and rigorous systematic review is needed to address controversies arising from apparently conflicting studies and reviews.

OBJECTIVES

We assessed the overall efficacy of music and vocal interventions for physiological and neurodevelopmental outcomes in preterm infants (< 37 weeks' gestation) compared to standard care. In addition, we aimed to determine specific effects of various interventions for physiological, anthropometric, social-emotional, neurodevelopmental short- and long-term outcomes in the infants, parental well-being, and bonding.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, RILM Abstracts, and ERIC in November 2021; and Proquest Dissertations in February 2019. We searched the reference lists of related systematic reviews, and of studies selected for inclusion and clinical trial registries.

SELECTION CRITERIA

We included parallel, and cluster-randomised controlled trials with preterm infants < 37 weeks` gestation during hospitalisation, and parents when they were involved in the intervention. Interventions were any music or vocal stimulation provided live or via a recording by a music therapist, a parent, or a healthcare professional compared to standard care. The intervention duration was greater than five minutes and needed to occur more than three times.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. We analysed the treatment effects of the individual trials using RevMan Web using a fixed-effects model to combine the data. Where possible, we presented results in meta-analyses using mean differences with 95% CI. We performed heterogeneity tests. When the I2 statistic was higher than 50%, we assessed the source of the heterogeneity by sensitivity and subgroup analyses. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 trials recruiting 1532 infants and 691 parents (21 parallel-group RCTs, four cross-over RCTs). The infants gestational age at birth varied from 23 to 36 weeks, taking place in NICUs (level 1 to 3) around the world. Within the trials, the intervention varied widely in type, delivery, frequency, and duration. Music and voice were mainly characterised by calm, soft, musical parameters in lullaby style, often integrating the sung mother's voice live or recorded, defined as music therapy or music medicine. The general risk of bias in the included studies varied from low to high risk of bias. Music and vocal interventions compared to standard care Music/vocal interventions do not increase oxygen saturation in the infants during the intervention (mean difference (MD) 0.13, 95% CI -0.33 to 0.59; P = 0.59; 958 infants, 10 studies; high-certainty evidence). Music and voice probably do not increase oxygen saturation post-intervention either (MD 0.63, 95% CI -0.01 to 1.26; P = 0.05; 800 infants, 7 studies; moderate-certainty evidence). The intervention may not increase infant development (Bayley Scales of Infant and Toddler Development (BSID)) with the cognitive composition score (MD 0.35, 95% CI -4.85 to 5.55; P = 0.90; 69 infants, 2 studies; low-certainty evidence); the motor composition score (MD -0.17, 95% CI -5.45 to 5.11; P = 0.95; 69 infants, 2 studies; low-certainty evidence); and the language composition score (MD 0.38, 95% CI -5.45 to 6.21; P = 0.90; 69 infants, 2 studies; low-certainty evidence). Music therapy may not reduce parental state-trait anxiety (MD -1.12, 95% CI -3.20 to 0.96; P = 0.29; 97 parents, 4 studies; low-certainty evidence). The intervention probably does not reduce respiratory rate during the intervention (MD 0.42, 95% CI -1.05 to 1.90; P = 0.57; 750 infants; 7 studies; moderate-certainty evidence) and post-intervention (MD 0.51, 95% CI -1.57 to 2.58; P = 0.63; 636 infants, 5 studies; moderate-certainty evidence). However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention (MD -1.38, 95% CI -2.63 to -0.12; P = 0.03; 1014 infants; 11 studies; moderate-certainty evidence). This beneficial effect was even stronger after the intervention. Music/vocal interventions reduce heart rate post-intervention (MD -3.80, 95% CI -5.05 to -2.55; P < 0.00001; 903 infants, 9 studies; high-certainty evidence) with wide CIs ranging from medium to large beneficial effects. Music therapy may not reduce postnatal depression (MD 0.50, 95% CI -1.80 to 2.81; P = 0.67; 67 participants; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of music therapy on parental state anxiety (MD -0.15, 95% CI -2.72 to 2.41; P = 0.91; 87 parents, 3 studies; very low-certainty evidence). We are uncertain about any further effects regarding all other secondary short- and long-term outcomes on the infants, parental well-being, and bonding/attachment. Two studies evaluated adverse effects as an explicit outcome of interest and reported no adverse effects from music and voice.

AUTHORS' CONCLUSIONS

Music/vocal interventions do not increase oxygen saturation during and probably not after the intervention compared to standard care. The evidence suggests that music and voice do not increase infant development (BSID) or reduce parental state-trait anxiety. The intervention probably does not reduce respiratory rate in preterm infants. However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention, and this beneficial effect is even stronger after the intervention, demonstrating that music/vocal interventions reduce heart rates in preterm infants post-intervention. We found no reports of adverse effects from music and voice. Due to low-certainty evidence for all other outcomes, we could not draw any further conclusions regarding overall efficacy nor the possible impact of different intervention types, frequencies, or durations. Further research with more power, fewer risks of bias, and more sensitive and clinically relevant outcomes are needed.

Premature Triadic Music Therapy (PT-MT) for babies and their parents: a pilot study

OBJECTIVE

We aim to test the feasibility and effectiveness of Premature Triadic Music Therapy (PT-MT) in the premature baby unit.

METHODS

The design was a clinical pre-test-post-test trial with a convenience sample. Inclusion criteria were a gestational age higher than 28 weeks for preterm infants and the absence of shock or extreme distress for parents. Six preterm children (with a gestational age of 33 to 36 weeks) and their parents participated in the study. For the children, we measured heart rate, blood perfusion, and blood saturation at three different times (pre-PT-MT, during PT-MT, after PT-MT) as quantitative indicators of distress. Their parents completed the Edinburgh Postnatal Depression Scale (EPDS) before and after the PT-MT intervention.

RESULTS

We found a statistically significant lower heart rate and a marginally statistically significant higher blood perfusion during PT-MT, as compared to the baseline. However, these changes were not present at the end of PT-MT. The parents' EPDS scores were not statistically significantly lower at the post-test, although, the Medians of the scores did decrease.

CONCLUSIONS

PT-MT is a promising intervention for the reduction of distress in both parents and children. Further studies should include a higher number of sessions and participants.

The effect of maternal multisensory stimulations on bath stress in premature infants: A randomized controlled clinical trial

Bathing in Neonatal Intensive Care Unit (NICU) is a stressful experience to preterm infants. Reducing this stress is an important challenge in bathing preterm infants. The aim of present study was to evaluate the effects of maternal supportive interventions on the stress caused by swaddled bathing in preterm infants. In this randomized clinical trial, 48 preterm infants randomly allocated into control and intervention groups. In intervention group the mothers were asked to initiate multisensory supportive interventions 5 min before and through swaddled bathing. In controls the mothers were only present during bathing. To determine the level of stress, infant responses were recorded by camera 5 min before bathing and 5 min after bathing. Then infants' stress measured by using Newborn Stress Scale (NSS). Finding was shown that the level of stress in control group was especially increased after bathing that was statistically significant (p < 0.001). Although there was an increase in stress among interventions but it was not statistically significant (p > 0.05). Considering the positive effects of multisensory interventions in decreasing the stress of preterm infants, it can be recommended as cost-free and non-pharmacological care during infants bathing.

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.

A scoping review of mother-child separation in clinical paediatric settings

There is increasing evidence to suggest that autonomic regulation of hospitalised infants is affected by separation from their mother. This review explored the extent of the evidence relating to the impact of separation on infants and children and aimed to identify suitable measures of the impact of mother-child separation. We conducted a scoping review of seven databases using the main search terms 'physiological', 'psychological', 'infant/child', 'maternal separation' and 'hospital'. Thirty-four articles containing data relevant to the effects of mother-child separation on either member of the pair were included. Findings highlight the central importance of the mother's presence in mediating the stressful effects of hospitalisation on her child. The majority of articles reported on psychological effects of separation on mothers of infants or on younger children. We identified no articles reporting on physiological effects on the older child or mothers of older children or psychological effects on mothers of older children. Only nine articles used validated tools to measure the effects of separation. There is a need for more evidence, based on validated measurement, about the psychological effects of separation on the child, particularly the older child, and on the physiological effects of separation on the mother-child pair during hospitalisation.

Utilising recorded music to reduce stress and enhance infant neurodevelopment in neonatal intensive care units

AIM

This paper summarises published evidence on the use of recorded music in high-risk infants to reduce stress and improve neurodevelopment, forming recommendations for proposed clinical applications in neonatal intensive care units.

METHODS

We searched two comprehensive library catalogues and two databases for articles evaluating the impact of recorded music interventions on hospitalised preterm infants. Original and review papers published in English in the 10 years prior to this search were selected if the study included a component of recorded music interventions.

RESULTS

Most original studies (80.95%) and all literature reviews (100%) reported positive effects of recorded music interventions for preterm infants, primarily in the short term. No negative effects were reported. Evidence is emerging regarding the neurobiological mechanisms of recorded music on longer-term effects on preterm infant neurodevelopment. Clinical applications were suggested drawing upon available evidence. Due to generally small sample sizes and variability in study design, unanswered questions remain.

CONCLUSION

Carefully designed recorded music interventions appear to be safe, feasible and effective in reducing stress and improving neurodevelopment of hospitalised infants. Additional rigorous, well-powered trials with relevant outcomes are needed to further refine specific elements for recorded music interventions to better inform practice.

The Soundscape of Neonatal Intensive Care: A Mixed-Methods Study of the Parents' Experience

Parents who have infants hospitalised in neonatal intensive care units (NICUs) experience high levels of stress, including post-traumatic stress disorder (PTSD) symptoms. However, whether sounds contribute to parents’ stress remains largely unknown. Critically, researchers lack a comprehensive instrument to investigate the relationship between sounds in NICUs and parental stress. To address this gap, this report presents the “Soundscape of NICU Questionnaire” (SON-Q), which was developed specifically to capture parents’ perceptions and beliefs about the impact that sound had on them and their infants, from pre-birth throughout the NICU stay and in the first postdischarge period. Parents of children born preterm (n = 386) completed the SON-Q and the Perinatal PTSD Questionnaire (PPQ). Principal Component Analysis identifying underlying dimensions comprising the parental experience of the NICU soundscape was followed by an exploration of the relationships between subscales of the SON-Q and the PPQ. Moderation analysis was carried out to further elucidate relationships between variables. Finally, thematic analysis was employed to analyse one memory of sounds in NICU open question. The results highlight systematic associations between aspects of the NICU soundscape and parental stress/trauma. The findings underscore the importance of developing specific studies in this area and devising interventions to best support parents’ mental health, which could in turn support infants’ developmental outcomes.

Sleep Promotion for Preterm Infants in the NICU

Sleep is a crucial human physiologic need. Preterm infants in the NICU are exposed to noxious stimuli that often disrupt and shorten their sleep periods. Sleep disruption may have a negative effect on clinical outcomes, growth, and development and may also delay hospital discharge. Increasing evidence suggests that sleep quality is critical for brain development and synaptic plasticity and is associated with long-term neurodevelopmental outcomes. The purpose of this article is to discuss the importance of sleep in preterm infants, describe tools commonly used to assess infant sleep and identify different sleep-wake states, and identify interventions that promote sleep in preterm infants in the NICU. Nurses play a vital role in implementing appropriate interventions that promote preterm infants' sleep.

Benefits of a bedtime routine in young children: Sleep, development, and beyond

This paper presents a conceptual model and reviews the empirical evidence to support a nightly bedtime routine as a key factor in the promotion of not only healthy sleep, but also of broad development and wellbeing in early childhood. A bedtime routine embodies the characteristics of nurturing care and early child stimulation, which are deemed to be essential for positive outcomes, especially for at-risk children. Furthermore, common, adaptive components of a bedtime routine can contribute to an array of positive developmental outcomes beyond improved sleep, inclusive of language development, literacy, child emotional and behavioral regulation, parent-child attachment, and family functioning, among other outcomes. These bedtime routine components include activities in the broad domains of nutrition (e.g., feeding, healthy snack), hygiene (e.g., bathing, oral care), communication (e.g., reading, singing/lullabies) and physical contact (e.g., massage, cuddling/rocking). A bedtime routine can provide multiple benefits to child and family functioning at a time of day that many parents are present with their children. Although additional research on hypothesized routine-related child outcomes and mechanisms of action are needed, promoting a bedtime routine may be a feasible and cost-effective method to promote positive early childhood development worldwide, particularly for socioeconomically disadvantaged and other at-risk young children.

Listening to Relaxing Music Improves Physiological Responses in Premature Infants: A Randomized Controlled Trial

BACKGROUND

Premature infants are exposed to high levels of noise in the neonatal intensive care unit (NICU).

PURPOSE

This study evaluated the effect of a relaxing music therapy intervention composed by artificial intelligence on respiratory rate, systolic and diastolic blood pressure, and heart rate.

METHODS

A double-blind, randomized, controlled trial was conducted in the NICUs of 2 general public hospitals in Andalusia, Spain. Participants were 17 healthy premature infants, randomly allocated to the intervention group or the control group (silence) at a 1:1 ratio. To be included in the study, the subjects were to be 32 to 36 weeks of gestation at birth (M= 32.33; SD = 1.79) and passed a hearing screening test satisfactorily. The intervention lasted 20 minutes, 3 times a day for 3 consecutive days, while infants were in the incubator. Infants' heart rate, respiratory rate, and blood pressure were assessed before and after each intervention session.

RESULTS

After each session, the respiratory rate decreased in the experimental group (main between-groups effect (F1,13 = 6.73, P = .022, ηpartial = 0.34). Across the sessions, the heart rate increased in the control group (main between-groups effect, F1,11 = 5.09, P = .045, ηpartial = 0.32).

IMPLICATIONS FOR RESEARCH

Future studies can use this music intervention to assess its potential effects in premature infants.

IMPLICATIONS FOR PRACTICE

Nurses can apply the relaxing music intervention presented in this study to ameliorate the impact of the stressful environment on premature infants.

Does Music Positively Impact Preterm Infant Outcomes?

BACKGROUND

The hospital environment leaves preterm infants (PTIs) exposed to various stressors that can disrupt their growth and development. Developmental interventions such as music may be an important strategy to mitigate PTI's stress. This brief evaluates current evidence regarding the impact of music therapy on outcomes for PTIs.

PURPOSE

The question guiding this brief is "Do various types of music therapy positively affect physiologic indicators, feeding behaviors/length of stay (LOS) and pain management outcomes for PTIs?"

SEARCH STRATEGY

CINAHL/MEDLINE Complete and PubMed databases were searched using keywords preterm infants, premature infants, preterm baby, premature baby, NICU baby, music, and music therapy. The search was limited to 5 years for English studies evaluating the effects of music therapy on physiological indicators, feeding, pain outcomes, and length of stay. The search yielded 12 studies addressing these concerns.

FINDINGS

Music therapy was shown to positively affect physiologic indicators, feeding, length of stay, and pain outcomes for PTIs. In addition, music decreased parental stress.

IMPLICATIONS FOR PRACTICE

Thoughtful consideration should be given regarding the value of diverse types of music and parental involvement when incorporating music into an individualized plan of care. Furthermore, the development of guidelines with a focus on ambient sound reduction is an important strategy when adding music as an intervention.

IMPLICATIONS FOR RESEARCH

Further research is needed to investigate ambient sound levels in conjunction with musical interventions. In addition, the impact of various types of music, differences in gender, reduction of stress, pain for infants, and parental role in music requires further evaluation.

Constructing optimal experience for the hospitalized newborn through neuro-based music therapy

Music-based intervention for hospitalized newborn infants has traditionally been based in a biomedical model, with physiological stability as the prime objective. More recent applications are grounded in other theories, including attachment, trauma and neurological models in which infant, parent and the dyadic interaction may be viewed as a dynamic system bound by the common context of the neonatal intensive care unit (NICU). The immature state of the preterm infant’s auditory processing system requires a careful and individualized approach for the introduction of purposeful auditory experience intended to support development. The infant’s experience of an unpredictable auditory environment is further compromised by a potential lack of meaningful auditory stimulation. Parents often feel disconnected from their own capacities to nurture their infant with potentially life-long implications for the infant’s neurobehavioral and psychological well-being. This perspectives paper will outline some neurological considerations for auditory processing in the premature infant to frame a premise for music-based interventions. A hypothetical clinical case will illustrate the application of music by a music therapist with an infant and family in NICU.