Music Therapy for Premature Infants in the NICU
Every year, approximately 9.6% of infants in the United States, and 15 million worldwide are born prematurely (Scott et al., 2018). For those born prematurely, many are diagnosed with illnesses or disabilities that hinder physiological and mental development. Several studies have been conducted to gather data in an attempt to improve the well-being of parents who have an infant in a neonatal intensive care unit, as well as increase the premature infant’s health (Ettenberger et al., 2017). By using several approaches, music therapy is proven to have positive effects not only on the health and development of these infants but on the parents and the parent-child relationships as well (Haslbeck, 2012).
The neonatal intensive care unit, also commonly referred to as the NICU, is home to many infants born prematurely, or before 37 weeks (O’Toole et al., 2017). Premature infants have a lower survival rate since they are not able to fully mature during the remainder of the third trimester, a vital time for organ maturity (Haslbeck, 2012; O’Toole et al., 2017). Unfortunately, there are several stressors in the NICU that can harm infant growth. Besides having difficulties feeding and motor abilities, infants are often overstimulated by sound. This is putting infants in situations of sensory overstimulation that can overstress their bodies. Infant overstimulation can have detrimental effects on their health and should be further considered during interactions with family and doctors, as well as therapies and techniques for premature infants. Besides potentially harmful NICU environments, premature infants often develop neurological disabilities, developmental disabilities, and behavioral problems (Scott et al., 2018). Since they are more susceptible to neonatal illnesses such as intraventricular hemorrhage or sepsis, they are at a higher risk for these long-term effects. Along with these risks, individuals born prematurely were found to have behavioral problems involving internalizing, externalizing, and attention which increased social withdrawal and depression, lower academic performance, increased attention deficit hyperactivity disorder, and aggression compared to those born non-prematurely (Scott et al., 2018). According to Aylward (2005), over 50% of low birth weight infants will need special education, up to 20% will repeat grades, and 16% to 47% will experience symptoms of attention deficit hyperactivity disorder. Even though the odds of these problems increase for these infants, the cause-effect relationship between birth weight and cognitive disorders can be confounded by other factors related to those conditions.
Music has potential to drastically affect the body in psychological and physiological ways, especially for infants. Through methods of reporting and physiological measurements, music has been proven to lower the perception of pain, positively affect heart rate, increase learning and behavior, lower stress levels, and produce more desirable states (Haslbeck, 2012; O’Toole et al., 2017). These positive aspects of music stimuli affect the development of infants by reducing physical stressors on their bodies and increasing brain maturity. One important effect is an increase in oxygen saturation level. Cevasco and Grant (2005) conducted a two year study of 188 infants that investigated several factors regarding music, specifically lullabies, and premature weight gain. Although weight gain prior to post intervention in the hospital was not statistically significant, their results found that music provided positive sucking patterns for infants, increasing oxygen saturation level. Increased levels of oxygen saturation lead to better eyesight, calmer states, faster times to fall asleep, increased initiation of nutritive sucking, and faster weight gain. Furthermore, the researchers found infants who listened to lullabies had lower weight loss, lower behaviors of stress, and a short length of stays in isolettes, NICU, and hospital overall due to the positive impacts on oxygen saturation rate, as well as heart and respiratory rates.
With music being a universal healing method, techniques in the field of music therapy became popularly used for premature infants in the NICU as well as in various other settings. Due to the challenges that can arise while being in a NICU setting, such as overstimulation, music therapists’ have to be NICU-MT certified to practice in the NICU. In the neonate setting, music therapy is used “as an intervention based on music and auditory stimulation that incorporates musical elements such as rhythm and melody or sounds based on the acoustic intrauterine environment...used by either music therapists or other healthcare professionals in neonatal care” (Haslbeck, 2012, p. 205)
(Miami Herald, 2019)
One big challenge that families can face while their baby is in the NICU is feeding. In order to go home from the NICU, babies need to be able to receive their nutrients by not fully relying on gavage feedings (forced feedings). Jayne Standley, a music therapy professor at Florida State University, knew that feeding in the NICU could be a long and difficult process, and she decided that she was going to find a way that music could help the baby progress. The Pacifier-Activated-Lullaby (PAL) is a music therapy method developed by Jayne Standley to promote non-nutritive sucking (sucking when there is no fluid being produced) for infants, therefore leading to better nutritive feeding abilities and self-regulation (Haslbeck, 2012; Standley et al., 2010). The PAL uses electrical signals to an attached cassette and provides music only when an infant sucks, growing the suck-swallow-breathe reflex that is essential to weight gain and growth (Haslbeck, 2012). The original researcher conducted a randomized study that included three trials with 68 premature infants, and the results showed a shorter length of gavage feedings as well as female infants learning how to nipple feed faster than male infants (Standley et al., 2010). Additionally, Cevasco and Grant (2005) studied the PAL music therapy method in their two year study. By placing speakers in the corners of infants’ isolettes or cribs, infants were assigned to four groups corresponding to the number of trials, and each used the PAL for fifteen minutes per trial. The researchers studied their suckling in an attempt to see if it went along with the music, specifically how many times they stopped, and for how long. Despite not reaching statistical significance and having music played at 65 dB, which is above the recommended level, infants increased their sucking time, showed improvement in learning, coordination, and endurance. Furthermore, Cevasco and Grant (2005) found infants using the PAL stayed awake and alert, but still calm, after feedings instead of agitated or sleepy like those not using PAL.
In recent studies of music therapy in the NICU, researchers have begun to focus on the effects of using the mother’s voice and its comparison to recorded singing. Cevasco and Grant (2005) conducted a study with the PAL and found that infants, even as young as one day old, increased their sucking rate when hearing their mother’s voice compared to another female's voice. Similarly, Haslbeck (2012) found live music of female voices to be more beneficial than recorded, engaging the infant to enjoy an activity with the mother and initiate a bond between them.
Parents with premature infants in the NICU can have several concerns that impact their mentality as well as their relationship with their infant. After observing hospitalized children separated from their parents in the 1930s, John Bowlby and Mary Ainsworth developed attachment theory which showed infant-parent bonding as essential to healthy development (Bretherton, 1992). Despite often being focused on the child’s relationship with the mothers, there have been other studies suggesting alternate figures such as fathers, siblings, and daycare providers can provide the satisfaction of an intimate relationship that an infant needs in its first year of life (Bretherton, 1992). Infant-parent bonding is difficult for premature infants in the NICU since parents are often physically separated from their infants through isolettes or rooms. This physical separation along with parent’s trauma and emotional struggles due to the end of pregnancy, survival uncertainty, and feelings of fear and guilt can cause negative parental stress, affecting their attachment process (Haslbeck, 2012).
Two common methods - kangaroo care and kinesthetic stimulation - are often used in the NICU to help with the attachment process. Kangaroo care provides premature infants with skin-to-skin contact with parents, often lying on their chests. Haslbeck (2012) also stated if an infant is too fragile to be touched, kinesthetic stimulation allows for rocker-beds to sway infants’ mattresses back and forth, often timed with music that is played through the crib. This added element of music can provide additional development and growth that would not be achieved with the methods alone. In addition to standard care such as kangaroo care and kinesthetic stimulation, music therapy benefitted infants’ feeding habits overall (O’Toole et al., 2017). Having positive feeding habits helps babies in the NICU go home sooner, and being well enough to go home is what you want to help with bonding. In Ettenberger et al. (2017), a treatment group using music therapy along with kangaroo care was compared to a control group of standard care alone. Although the study with thirty-six infants was not statistically significant, the infants in the music therapy group went home approximately 60 days sooner and reported 50% re-hospitalizations four months after discharge than the group without music therapy.
Different music therapy techniques can not only benefit the infant, but also benefit parents and the relationship with their infant. Whipple (2000) used observation of interaction through stress behaviors and parent self-reports of twenty sets of parents and premature, low birth weight infants, to see if training parents with an hour of music instruction and techniques would affect interaction. The study found parents with the instruction reported spending more time with their infants as well as shorter hospitalization stay and greater weight gain. However, the results were not statistically significant due to the small sample size and a follow-up one month after discharge showed little difference between the control and experimental groups. Without knowing what the home environment was after discharge, further research with longitudinal studies could show how increased parent training could provide long term benefits. Promoting parental presence through music therapy can encourage bonding and lower anxiety and fear that comes with being in a hospital environment (Ettenberger et al., 2017; O’Toole et al., 2017). Translating those skills to the home setting is essential for continuing the benefits of music therapy after being discharged from the hospital.
Many babies in the NICU are diagnosed with illnesses or disabilities that hinder physiological and mental development. The NICU environment can be very stressful for the babies and their families. There are many positive aspects of music stimuli, such as increased learning and behavior and lower stress levels, that affect the development of infants by reducing physical stressors on their bodies and increasing brain maturity. Music therapy can be an essential part of the growth and development for a baby in the NICU.
-Amanda Brennen, MT Intern
References
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