Recorded music risks overstimulation in NICUs. The live elements of music such as rhythm, breath, and parent-preferred lullabies may affect physiologic function (eg, heart and respiratory rates, O2 saturation levels, and activity levels) and developmental function (eg, sleep, feeding behavior, and weight gain) in premature infants.
A randomized clinical multisite trial of 272 premature infants aged ≥32 weeks with respiratory distress syndrome, clinical sepsis, and/or SGA (small for gestational age) served as their own controls in 11 NICUs. Infants received 3 interventions per week within a 2-week period, when data of physiologic and developmental domains were collected before, during, and after the interventions or no interventions and daily during a 2-week period.
Three live music interventions showed changes in heart rate interactive with time. Lower heart rates occurred during the lullaby (P < .001) and rhythm intervention (P = .04). Sucking behavior showed differences with rhythm sound interventions (P = .03). Entrained breath sounds rendered lower heart rates after the intervention (P = .04) and differences in sleep patterns (P < .001). Caloric intake (P = .01) and sucking behavior (P = .02) were higher with parent-preferred lullabies. Music decreased parental stress perception (P < .001).
The informed, intentional therapeutic use of live sound and parent-preferred lullabies applied by a certified music therapist can influence cardiac and respiratory function. Entrained with a premature infant’s observed vital signs, sound and lullaby may improve feeding behaviors and sucking patterns and may increase prolonged periods of quiet–alert states. Parent-preferred lullabies, sung live, can enhance bonding, thus decreasing the stress parents associate with premature infant care.
Comments
The Effects of Music Therapy by Mozart on Vital signs and Weight gain in Preterm Infants
We read with interest the article "The Effects of Music Therapy on Vital Signs, Feeding, and Sleep in Premature,"1 in which Loewy et al collected 272 premature infants aged >or= 32 weeks with respiratory distress syndrome, clinical sepsis, and/or SGA (small for gestational age) who received three live music interventions per week within a two-week period. The effect of music therapy has been shown to reduce stress and can accelerate premature infant's transition to oral feeding.2, 3 This effect of music on resting energy expenditure might explain, in part, the improved weight gain that results from this "Mozart effect". It seems that Mozart repeats the melodic line much more frequently than other widely known composers. 4
We conducted a prospective randomized analysis on premature infants admitted to the Hospital Universitario Nuestra Senora de Candelaria (Tenerife, Spain) with postmenstrual age of 24 to 36 weeks, from August 2010 to June 2012. Postmenstrual age was calculated in completed weeks on the basis of last menstrual period, consistent 1 week with early, first- trimester ultrasound examination.
This study was a prospective, randomized trial with crossover of the effect of music compared with no music. We tested the music of Mozart present on the Baby Mozart CD. Before the study, the CD system not to exceed volume of 70 dB and speakers were placed inside the incubator at a distance of 30 cm from the infants' ear, all days for two hours. We measured vital signs such as heart rate and pulse oximetry, score Premature Infants Pain Profile (PIPP) before and after therapy and weight gain at the end. Were considered according to the following inclusion criteria: (1) All infants were clinically and thermally stable; (2) they all were tolerating full enteral feeding; and (3) None had any significant complication of prematurity. Results are expressed as mean -/+ SD (P< .05 was considered significant).
Eighty-four preterm infants were included (43 exposed and 41 non- exposed music). No statistically significant differences in clinical and demographic variables were found between groups. The mean of days at begin the therapy was 20.23 days (SD-/+3.33). The mean music therapy duration was 16.00 days (SD-/+2.21). After two hours of music therapy had a significantly lower heart rate (P=0.021, 95% CI) and PIPP (P=0.002, 95% CI) than controls. The weight gain at the end was significantly higher than no exposed to music (P=0.004, 95% CI).
As stated by Loewy et al, 1 neonates have been shown to benefit from the initiation of stimulation programs during hospitalization. In our opinion, music will take its place in the NICU environment and be part of evidence-based strategies to improve outcome of preterm infants.
Esther Pozo Garcia, MD Paloma Gonzalez Carretero, MD, PhD Evelio Antonio Dominguez Suarez, PNP Santiago Lopez Mendoza, MD, PhD
Department of Pediatrics Hospital Universitario Nuestra Senora de Candelaria 38010 Santa Cruz de Tenerife, Spain
REFERENCES
1. Loewy J, Stewart K, Dassler AM, Telsey A and Homel P. The Effects of Music Therapy on Vital Signs, Feeding, and Sleep in Premature. Pediatrics, 2013; 131; 902-918
2. Yildiz A, Arikan D. The effects of giving pacifiers to premature infants and making them listen to lullabies on their transition period for total oral feeding and sucking success. J Clin Nur. 2012 Mar; 21(5-6): 644 -56
3. Standley J. Music therapy research in the NICU: an updated meta- analysis. Neonatal Netw 2012 Sep-Oct; 31(5):311-6
4. Lubetzky R, Mimouni FB, Dollberg S, Reifen R, Ashbel G, Mandel D. Effect of music by Mozart on energy expenditure in growing preterm infants. Pediatrics. 2010; 125:e24-e28
Conflict of Interest:
None declared
Flawed Research Invalidates: "Effects of Music Therapy..."
"The Effects of Music Therapy..." is ambitious in taking on important features of music research, but the flaws compromise the results.
The theoretical foundation is weakened by irrelevant citations. e.g., Abram's study of the intrauterine acoustics of fetal sheep are used to validate "cultural (musical) preferences which begin in the womb". 1
The study appears to violate the principle of "intention to treat" as two sites drop out after 12 months and those data seem to disappear.
Unfortunately, the data from a stellar primary intervention, mother's song, is irreparably confounded by no data of mothers' private singing, trained as study singing. The intervention dose (mother song) is, therefore, unknown.
Although the data are all observational and scored by 25 therapists and graduate students at 11 sites over 30 months, there was no effort to achieve inter-rater reliability.
Measuring background sound levels in the 11 sites is declared "not within the scope of the investigation", even though the authors correctly describe its importance. Rather, levels ? 55 dBA, a very low ceiling, are assumed because the NICUs have "concern for noise and ambient sound". Without known background levels, it is a guess whether an infant heard the experimental signal.
Meaningless data are found significant. e.g., a heart rate change from 0.2 to 0.6 beats per minute over 30 minutes is termed significant and "enhanced". However, the significance is a function of sample size (84,592 heart beats) and is functionally meaningless. The feeding variable is scored as more mature ("intermittent sucking", "enhanced and differentiated") or less mature ("suck without pausing"). These patterns are not operationally defined or given criteria for scoring, but the authors write: "The impact of live rhythm and preferred melody to enhance sucking is clear." Actually, not.
The assessment questionnaires about parents' NICU experiences and emotional states have no testing for validity or reliability making the meaning of the data uncertain. However, similar validated and reliable assessments for NICU parents are available.
"The Effects of Music Therapy on Vital Signs, Feeding, and Sleep" is commendable for taking on important but rarely attempted features of music research: multiple study sites, three live (not recorded) variables studied together, and the three components of music (rhythm, timbre and melody) incorporated into those variables. Most importantly, each mother is carefully assisted to sing her own "music of kin" to her infant, quite unlike the typical study using recorded, standardized, or imposed song.
Nurses, parents, and therapists want to support infant development. And, although the journal is not responsible for the uses made of its contents, its prestige confers credibility. Whoosh and heart beat tapes abound and, while this study does not recommend it, naive clinicians will apply the stimuli and try to achieve the outcomes claimed in this study, giving professional music therapists, and developmentally trained nurses and therapists yet another bucket of misinformation to manage.
1. Abrams A, Gerhardt K. The acoustic environment and physiological responses of the fetus, J Perinatol. 2000;20 (2):S31 - S36
Conflict of Interest:
None declared