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Music therapy with premature infants in the NICU.

Background on Premature Infants

When speaking about infants, prematurity includes: "preterm infants" (born before 37 gestational weeks); and "low birth weight infants" (premature by birth weight of less than 2500g) (Kelly, 2006). Many premature infants are fragile at birth and require medical care typically provided in neonatal intensive care units (NICU) for days or even weeks (Torpy, 2009). As medical treatment continues to advance the survival rates for premature infants continues to rise, especially when associated with increases in gestational age (GA) (Gooding, 2010).

Developmentally, premature infants often suffer from impairment with respect to several abilities including: the inability to suck or swallow; difficulty with nutrient processing/absorption (which may lead to cognitive impairment); smaller brain volume; and challenges to regulate body temperature (Gooding, 2010; Torpy, 2009). Further, there are several health conditions that premature infants are at risk for such as: jaundice, increased risk of infections, interventricular hemorrhage, patent ductus arteriosus (failure of a fetal heart value to close post birth), respiratory illnesses, apnea, and anemia (Kelly, 2006).

While the NICU environment can be heralded as the reason that many premature babies survive given the high quality of care provided, this environment poses a challenge to premature infants as they navigate their development in a setting quite different than that of the mother's womb (Hanson Abromeit, 2003). Premature infants receive care from multiple caregivers and as a result may be subjected to overstimulation from the sounds, sights and interactions (Whipple, 2005). The problem with overstimulation is that it can lead to maladaptive or even life threatening responses (Hanson Abromeit, 2003). There are many therapeutic interventions provided in the NICU to help address the issues discussed above and music therapy is also one intervention making an impact.

Implications for Music Therapy in the NICU

Music therapy offers a variety of benefits in the NICU to both the premature infants and their parents, but must be implemented with caution as music experiences can also be over-stimulating for premature infants (Standley, 2002). Music therapist, Dr. Jayne Standley has done considerable work with premature infants in the NICU environment and offers guidelines and recommendations on its use. For example, music should have: constant rhythm and volume, and stable and soothing melodies: ideally coming from a single female voice in a higher register or single instrument (Standley, 2002). Since music therapy interventions are tailored to the individual needs of the premature infant they can vary depending on the infant's stage of development. Of importance to consider when designing interventions are the three stages of premature infant development: survival/pacification; cautious stimulation; and the interactive/discharge stage (Standley, 2014). Below considerations, goals and interventions for music therapy at the three stages are highlighted.

Survival/Pacification Stage: 23-30 Gestational Weeks

During this stage it is important to limit touching and interacting with the infant, and not to disturb sleep. The prominent intervention here is passive music listening being continuously provided from inside the incubator. Standley, 2014 explains that quiet consistent music (<65dB) masks ambient noise and has been demonstrated to sooth infants. Research has also shown that listening to continuous music for up to four hours a day for premature infants has a number of physiological benefits such as: reduced infant stress, increased weight gain, stabilized heart and respiratory rates, increased oxygen saturation and reductions in apnea and bradycardia (Caine, 1991; Standley, 2002; Standley, 2014; Standley & Moore, 1995). Overall, music listening enriches the NICU environment by reducing stress for everyone in the unit including parents and medical personnel (Crouch, 2010).

Cautious Stimulation Phase: 30-34 Gestational Weeks

During this developmental stage the primary therapeutic approach is multimodal stimulation (MMS): an intervention pairing live music with sequences of tactile and vestibular stimulation. MMS increases sensory tolerance while facilitating infant development (Crouch, 2010), but once again the therapist must be cautious to monitor for overstimulation. Gentle touch or massage working from the top centre of the body to the lower parts and limbs may provide considerable soothing while encouraging breathing. This type of massage also facilitates parent-infant attachment. MMS has been shown to: increase weight gain and decrease hospital stay (Standley, 1998); promote environmental tolerance (Whipple, 2005); and encourage infant socialization abilities (Standley, 2014). There are additional benefits for both infants and parents when parents are included in MMS music therapy sessions and also trained to use MMS independent of the therapist. One of the most important interventions is parent-infant directed singing, which has been linked to improved parent-infant attachment (Standley, 2014). By providing parents with an effective technique such as this, it often leads to reduced parental stress while also providing encouragement.

Musical entrainment to the infant's biological rhythms is the other principal intervention used at this stage. An example of this work is provided by Loewy et. al (2013) who used a gato drum to rhythmically match an infant's heartbeat and also included a specialized ocean drum that mimicked womb sounds to match an infant's breathing. They found that these types of interventions lowered infant heart rate and improved sleep patterns.

Interactive/Discharge Phase: 34-40 Gestational Weeks

The crucial goals for infants at this stage surround developing the coordination of the suck/swallow/breathe rhythm (Standley, 2014). This rhythm is vital for oral feeding, but also as it is the first rhythm learned, it is critical to the development of other internal rhythms. At this stage, music is used as a reinforcer when an infant sucks on a pacifier to help promote the development of non-nutritive sucking (sucking without intention of feeding). Here pacifiers are modified to play music when the infant sucks on the pacifier and to stop playing music when the infant stops sucking. A music therapist developed device known as the Pacifier Activated Lullaby (PAL) is a specifically wired pacifier and speaker that plays music when an infant sucks correctly. The music is calm and pleasing to the baby, and this reinforcement inspires infants to continue the sucking motions to hear more of the music. The PAL device promotes the development of sucking and feeding skills to assist infants in becoming healthier and stronger. (Florida State Office of Research). Additionally, music used in this stage has been linked to outcomes such as earlier discharge, increased feeding (Standley, 2002), and the promotion of eye contact, language development and vocalization (Gooding, 2010).

Concluding Thoughts

NICU music therapists work as part of an interdisciplinary team who attend to the physical, psychosocial, emotional and medical needs of the infant and their caregivers. As with all client populations, music therapists working with premature infants and their families need to be culturally sensitive. While infants may not be aware or overtly affected by cultural norms, their parents and caregivers are, and providing culturally relevant music may assist parents in feeling involved, connected, and comfortable with the care their infants are receiving. The benefits of including music therapy in the NICU for premature infants and their families are significant, resulting in healthier babies, reduced hospital stays while making the NICU environment more pleasant, and soothing with reduced stress.

A conference on "NICU Music Therapy: First Sounds: Rhythm, Breath, and Lullaby & EMT as a Noise Modulator: A Continuum of Care" will take place for the first time in Toronto, Ontario in May 2015 delivered by Dr. Joanne Loewy and music therapist Andrew Rossetti. It will feature research, case-based illustrations and music medicine origins on how music therapy fits into the goals inclusive of continuity of care from pregnancy to birth, and though NICU and special care within the hospital stay and beyond. This conference will take place at the Music and Health Research Collaboratory at the University of Toronto To view recent relevant articles please visit: /2013/04/15/health/live-music-soothes-premature-babies-a-new-study -finds.html?pagewanted=all&_r=0 and content/early/2013/04/10/peds.2012-1367.abstract


Caine, J. (1991). The effects of music on the selected stress behaviours, weight, caloric and formula intake, and length of hospital stay of premature and low birth weight neonates in a newborn intensive care unit. Journal of Music Therapy, 32(4), 208-227.

Crouch, K. (2010). Music Therapy in the Neonatal Intensive Care Unit. Rhythms For Living. Retrieved from: http://www.rhythmsforliving. com/rhythmsforliving/NICU.html

Florida State University. (n.d.). Pacifier Activated Lullaby. Office of Research. Retrieved from:

Gooding, L. F. (2010). Using music therapy protocols in the treatment of premature infants: An introduction to current practices. The Arts in Psychotherapy, 37(3), 211-214.doi:10.1016/j.aip.2010.04.003

Hanson Abromeit, D. (2003). The newborn individualized developmental care and assessment program (NIDCAP) as a model for clinical music therapy interventions with premature infants. Music Therapy Perspectives, 21(2), 60-68. doi:10.1093/mtp/21.2.60

Kelly, M. M. (2006). The basics of prematurity. Journal of Pediatric Health Care, 20(4), 238-244. doi:10.1016/j.pedhc.2006.01.001

Loewy, J., Stewart, K., Dassler, A., Telsey, A., & Homel, P. (2013). The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics, 131(5),902-918.doi:10.1542/peds.2012-1367

Standley, J. (2014). Premature infants: Perspectives on NICU-MT practice. Voices, 14(2). Retrieved from /view/767/645

Standley, J. (2002). A meta-analysis of the efficacy of music therapy for premature infants. Journal of Pediatric Nursing, 17(2), 107-113. doi:10.1053/jpdn.2002.124128

Standley, J. (1998). The effect of music and multimodal stimulation on physiologic and developmental responses of premature infants in neonatal intensive care. Pediatric Nursing, 24(6), 532-538.

Standley, J., & Moore, R. (1995). Therapeutic effects of music and mother's voice on premature infants. Pediatric Nursing, 21(6), 509-512, 574.

Torpy, J. (2009). Premature infants. Journal of the American Medical Association, 301(21),2290. doi:10.1001/jama.301.21.2290

Whipple, J. (2005). Music and multimodal stimulation as developmental intervention in neonatal intensive care. Music Therapy Perspectives, 23(2), 100-105. doi:10.1093/mtp/23.2.100

Dr. Amy Clements-Cortes is Assistant Professor, Music and Health Research Collaboratory (MaHRC), University of Toronto and Senior Music Therapist/Practice Advisor, Baycrest, Instructor and Supervisor, Wilfrid Laurier University. Amy has extensive clinical experience working with clients across the lifespan. She has given over 80 conference and/or invited academic presentations, is published in peer reviewed journals and books, and has supervised over 30 music therapy internships, 30 undergraduate research studies, and 3 Masters students MRPs, She is the Clinical Commissioner for the WFMT, Vice-Chair and BOD Member Room 217, and Past President, (CAMT). Amy is co-editor of the Canadian Association for Music Therapy 40th Anniversary Journal, Chair of the 40th Anniversary Conference and Co-Chair of the 3rd IAMM Conference 2014. Amy is on the editorial review board of the WFMT Journal and Music Therapy Perspectives; Co-investigator in the AIRS SSHRC Project; and coordinator of the MaHRC Alzheimer Study.
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Title Annotation:music and health; neonatal intensive care units
Author:Clements-Cortes, Amy
Publication:Canadian Music Educator
Date:Mar 22, 2015
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