Music Therapy Research in the NICU: An Updated Meta-Analysis

Jayne Standley, PhD

medical personnel showed that 72 percent supported music is the use of music to enhance devellistening with 86 percent supporting NICU-MT to reduce opmental care and promote stress of preterm infants.3,4 maturation of preterm infants. The research base in this Abstract Music has been used to pacify, area encompasses physiologic Purpose: To provide an overview of developmental and to increase tolerance for stimulaand developmental benefits and medical benefits of music therapy for preterm infants. tion, to enhance nipple feeding includes studies by professional Design: Meta-analysis. ability, to promote sleep followboard-certified music therapists Sample: Empirical music studies with preterm infants in ing painful nursing procedures, (MT-BC) and those by medical the neonatal intensive care unit (NICU). to provide multimodal stimupersonnel. It also includes various Main Outcome: Evidence-based NICU music therapy lation that is developmentally music techniques using either live (NICU-MT) was highly beneficial with an overall large appropriate according to postor recorded music. Goodings significant effect size (Cohens d 5 0.82). Effects because menstrual age, and to promote comprehensive literature review of music were consistently in a positive direction. attachment with the infants of the research in NICU-MT Results: Results of the current analysis replicated findings mothers. The purpose of this identified four basic uses of music: of a prior meta-analysis and included extended use of meta-analysis on MT research developmentally appropriate music.1 Benefits were greatest for live music therapy (MT) and for use early in the infants NICU stay (birth with preterm infants treated in music listening for pacification; weight ,1,000 g, birth postmenstrual age ,28 weeks). the NICU over the last 20 years music as a base for pacification Results justify strong consideration for the inclusion of was to compare standard NICU during layered, progressive multhe following evidence-based NICU-MT protocols in best care with music versus stantimodal stimulation; music as practice standards for NICU treatment of preterm infants: dard NICU care without music. reinforcement for nonnutritive music listening for pacification, music reinforcement of Analyses included calculation sucking with transfer to improved sucking, and music pacification as the basis for multilayered, of effects by research demo feeding skill; and mothers singing multimodal stimulation. graphics: study design, published during kangaroo care to promote versus nonpublished status, early attachment.5 versus later time of the research, The MT procedures conand dependent variable (heart rate, behavior state, respiraducted by carefully trained parents have also shown benefit. tory rate, oxygen saturation, length of stay, sucking/feeding Whipple ascertained that parents trained in music-based mulability, weight gain, and blood pressure). Additionally, analytimodal stimulation visited more often and spent less time ses of effects by population demographics included postoverstimulating their infants.6 menstrual age at study, weight at birth, and infant gender. Currently, music is used in many NICUs, and evidenceFinally, analyses on effects by music characteristics included based NICU-MT protocols are receiving reimbursement live versus recorded music and reported decibel levels. from third-party payers for health services.7 A meta-analysis of this body of research was conducted to determine overall
eonata l i n t ensi v e c a r e u n i t music t h er a py

(NICU-MT) 

BACKGROUND

The MT research with preterm infants has been ongoing for more than 20 years. Early in its development, medical experts were cautious and cited a lack of research to justify the use of music in NICU care.2 However, recent surveys of NICU
Accepted for publication February 2012.

Disclosure The author has no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity.

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effects of music for preterm infants and to develop best practice guidelines for NICU-MT. Severity of prematurity at birth is highly correlated with lowered cognition at school age and future need for special education.8 Preterm birth increases risks for infant development, and MT has been proposed as an effective early intervention. Music is an intentional, preferred auditory stimulus with potential for soothing, learning, and neurologic development that is perceived early in fetal development.9 It can mask ambient, environmental sound that occurs without control of volume, duration, or location and can alleviate the unfortunate consequences of noise such as fatigue, stress, hyperalerting, or startle responses.10 Fetal learning research shows that higher order auditory perception begins before birth with early development of discrimination of music versus environmental noise and awareness of music variations such as familiarity, tempo, and volume.11 Because many cognitive elements of music are processed simultaneously or in sequence by both cerebral hemispheres, repeated listening and music training stimulate neurologic development, particularly in the corpus callosum.1214 Music listening is a highly pleasurable activity of which the preterm infant is capable and research has shown benefits from exposure to it. Early in the development of NICU-MT, Standley conducted a meta-analysis to ascertain benefits of music for preterm infants.1 At that time, ten studies were found that had been completed by both MT-BC and by medical professionals. Results of that initial meta-analysis showed an overall large significant effect size (Cohens d 5 0.83) across various dependent variables. The MT effects in these few early studies were not differentiated; neither by infants postmenstrual age at the time of study, birth weight, or type of music delivery, nor by physiologic, behavioral, or developmental measures of benefit. The small sample sizes, small number of studies, and inconsistent reporting of patient demographics contributed to this lack of finding. This initial meta-analysis showed multiple benefits from short periods of continuously playing music in the incubator with infants remaining calmer and demonstrating weight gains, more stable physiologic measures, and higher oxygen saturation levels.1519 Infants listening to music also reached discharge criteria significantly sooner.21 In a six-month postdischarge follow-up, infants receiving music listening were rated by their mothers as calmer and less irritable than those not receiving music.22 Other music procedures tested included live singing with progressive, layered, multimodal stimulation for increasing tolerance to stimulation, contingent music to increase nonnutritive sucking, and contingent music for sucking to improve subsequent feeding ability.2325 In the second decade of the development of NICU-MT research, almost all of the initial dependent measures of the effects of music have been replicated. Most of these newer studies have used the audiology precautions first identified by Cassidy and Ditty. 26 The MT assessment and practices have been described for integration with Newborn

LITERATURE REVIEW

Individualized Developmental Care Assessment Program (NIDCAP)ahighly regarded set of guidelines for developmental medical treatment of preterm infants.27 In 2009, Hartling and colleagues conducted a systematic review of music benefits for infants in the neonatal period, which included some studies with preterm infants. 28 Only studies with randomized controlled trials were included and they identified a total of nine. Only five of these studies were with preterm infants: three that evaluated pain responses during heel sticks and two that dealt with behavioral or physiologic changes. The studies with term infants included the use of music as an analgesic during circumcision and the use of MT protocols to attempt to soothe withdrawal symptoms of addicted infants. This partial review of very diverse uses of music with term and preterm infants concluded that there was preliminary evidence to support MT with medical treatment but criticized the small sample sizes of the included studies.

METHOD

Criteria for inclusion in this meta-analysis were (a) experimental studies using group or individual subject designs; (b) subjects who were preterm and low birth weight infants receiving treatment in a NICU; (c) music included as a separate independent variable contrasted with standard NICU care without music; (d)reports in the English language; and (e) reported design, procedures, and results amenable to replicated data analysis. Metaanalysis guidelines stipulate that all research should be included, whether published or not, to eliminate referee bias. Therefore, all studies meeting the aforementioned criteria were included. The procedures followed the four basic steps of a metaanalysis: (a) a complete literature search was conducted to find all possible members of the defined population of studies; (b) the characteristics and findings of the collected studies were identified, described, and coded; (c) these codes were reviewed for reliability and agreement; then (d) each studys results were statistically analyzed and converted to computed effect sizes using meta-analysis software. 29 The identification process was conducted by trained researchers and included exhaustive searches of the Journal of Music Therapy (19642010), Dissertation Abstracts (19501999), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE (19832010), and Google Scholar. Keywords for searches of electronic indexes included neonates, preterm infants, low birth weight, NICU, music, MT, and auditory stimulation. The reference lists of all relevant articles located in the electronic search were also reviewed. All unpublished studies were obtained by interlibrary loan or commercial sources. Thirty studies met criteria for inclusion in the meta-analysis. These studies are marked with an asterisk in the reference list.

Study Inclusion

RESULTS

The value of each dependent variable reported in the selected studies was converted to the estimated effect sizeCohens d.30 Table 1 shows design, independent variable, dependent

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TABLE 1 Authors Arnon et

n Design

and Results by Study Design (N ) Independent Variable ML: live voice, frame drum, & harp Dependent Variable Heart rate Respiration rate Oxygen saturation Behavior state Cohens d 4.48 1.07 0.43 3.89 4.57 1.81 0.27 0.77 0.99 0.50 0.84 0.73 0.00 1.19 0.09 0.23 0.16 0.16 0.69 0.92 0.86 1.95 0.49 0.70 1.26 0.46 1.05 0.88 1.36 1.70 0.13 0.55 0.72 1.29 0.55 0.81 0.58 0.73 0.87 4.40 1.03 0.32 0.31 1.50 p .00 .00 .10 .00 .00 .00 .40 .05 .12 .07 .00 .01 1.00 .01 .84 .63 .39 .44 .01 .00 .00 .00 .05 .05 .00 .19 .03 .06 .00 .00 .78 .11 .10 .01 .09 .01 .10 .07 .02 .00 .03 .46 .11 .00

al.31

W (31)

Bailey32 Blumenfeld & Eisenfeld33 Britt & Kisilevsky34 Burke et al.35 Caine21

B (86) W (11) B (28) W (4) B (52)

ML: recorded ML: live mother singing ML: recorded ML: recorded ML: recorded

Length of stay Oxygen saturation Feeding behavior Behavior state Behavior state Length of stay Weight gain Behavior state

Cassidy36 Cassidy & Standley18 Cevasco37 Cevasco & Grant38

B (63) B (20) B (20) W (62) B (100) W (30) B (66) al.40

ML: recorded ML: recorded ML: recorded mother singing PAL: recorded ML: recorded ML: recorded ML: recorded

Head circumference Oxygen saturation Weight gain Length of stay Weight gain Limb motor activity Oxygen saturation Heart rate Oxygen saturation Behavior state Length of stay

Chapman15 Chou, Wang, Chen & Pai39 Coleman et

Collins &

Kuck19

B (17)

ML: recorded music & heart beat

Oxygen saturation Behavior state Heart rate

Flowers, McCain & Hilker41 Keith, Russell & Lai et al.43 Lorch et al.17 Lubetsky et al.44 MacDowell45 Moore, Gladstone, & Standley46 Standley23 Standley25 Standley24 Standley47 Standley et al.48 Standley & Moore20 Standley & Whipple51 Swedberg49 Walworth et al.50 Weaver42

W (9) W (22) B (30) W (10) W (18) W (12) W (22) B (40) B (36) W (12) B (32) B (14) B (20) B (208) B (108) B (60)

ML: recorded music & heart beat ML: recorded Recorded music with kangaroo care ML: recorded ML: recorded ML: recorded-Mother singing ML: recorded MMS: live voice ML: recorded or MMS live PAL: recorded PAL: recorded PAL: recorded ML: recorded MMS: live or PAL recorded MMS: live voice and/or guitar PAL: recorded

Oxygen saturation Behavior state Inconsolable crying Sleep behavior Systolic blood pressure Resting energy expenditure Heart rate Oxygen saturation Length of stay Weight gain Head circumference Nonnutritive sucking rate Feeding rate Days of gavage feeding Oxygen saturation Length of stay Length of stay Behavior state

Note: B 5 between groups design; W 5 within groups design; ML 5 music listening; PAL 5 pacifier activated lullaby device; MMS 5 multimodal stimulation with music.

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variables, and results by study. The overall meta-analysis resulted in a very large effect size (Cohens d 5 0.82) for MT with standard NICU care versus standard NICU care alone. Because the 95 percent confidence interval (CI) did not include zero, this effect size is considered statistically significant and indicates that music consistently has a positive and significant impact in the NICU. The total number of subjects in this analysis was 1,725an average of 38.3/study which was comparable to that of the previousstudy.1 Homogeneity analysis of the effect sizes showed that results were not differentiated by between/within design (29 variables using group comparisons vs. 16 using subjects as their own control), by published (35 variables) versus nonpublished (10 variables) status, or by early (pre-2000, 23 variables) versus later (post-2000, 22 variables) time of completion. Many diverse dependent variables encompassing physiologic, behavioral, and length of stay parameters were included in the sample, so data were analyzed with all variables and also with only the primary variable of each study. Some meta-analyses limit inclusion to one variable/study to avoid weighting results with multiple dependent variables from the same study. There was no difference between these two analyses in the overall effect size for music, so it was determined that all 45 dependent measures should be included in this analysis to increase the amount of information about effects of music across diverse dependent variables. Table 2 shows effect sizes for each dependent variable in hierarchical order. Positive benefits of MT were found across physiologic, length of stay, and behavioral measures. Significant effects for music were found for heart rate, behavior state, oxygen saturation, sucking or feeding ability, and length of stay in the NICU. Results for weight gain, measures of head circumference, and systolic blood pressure were not significant. This table also demonstrates replication accumulating within the literature base with multiple studies measuring each dependent variable, except respiration rate and blood pressure.
TABLE 2
n  Neonatal

TABLE 3

n  Neonatal

Intensive Care Unit Music Therapy Effects by Population Demographics N of Studies Cohens d p

Demographics Postmenstrual age at study ,28 weeks 2831 weeks 3235 weeks .35 weeks Birth weight ,1,000 g 1,0001,500 g .1,500 g Gender ,50% female .50% female Note: *Not significant.

3 12 17 4 4 16 8 10 30

1.04 0.87 0.82 0.68 2.15 0.97 0.73 0.59 0.93

.97* .01 .00 .84* .00 .00 .36* .10* .00

Intensive Care Unit Music Therapy Effects by Dependent Variable N of studies 4 11 1 9 4 7 6 2 1 Cohens d 1.19 1.09 1.07 0.97 0.85 0.71 0.43 0.24 0.13 p .00 .00 1.00* .04 .00 .00 .38* .43* 1.00*

Studies were coded by reported decibel levels of the music: those greater than 75 dB and those equal to or less than 75dB. Only the studies reported at 75 dB or less had significant effects for music (d 5 0.77, r 5 0.36, CI 5 10.66/10.88, p , .00). Results of this meta-analysis showed differentiated effects by population demographics (Table 3). Music benefits for infants aged 2835 postmenstrual weeks at the time of the NICU-MT intervention were significant but were not significant for infants 28 weeks or 35 weeks. The NICU-MT effect sizes consistently decreased as birth weight rose. Females were more responsive than males to MT, a gender difference reported in various studies. Finally, this meta-analysis showed that effects were differentiated by live versus recorded music and by whether infants remained in the incubator untouched or were touched during the NICU-MT intervention (infant held during music with kangaroo care, infant held during music with massage as part of multimodal stimulation, infant not held but touched when given pacifier activated lullaby [PAL] device for music reinforcement of sucking; Table 4). Live music was more beneficial when
Table 4
n  Neonatal

Dependent Variable Heart rate Behavior state Respiration rate Oxygen saturation Sucking/feeding ability Length of stay Weight/REE Head circumference Blood pressure

Intensive Care Unit Music Therapy Effects Sizes by Music Condition Cohens d 0.89 p .00

Music Type & Condition Recorded music listening, no physical contact except placement of speakers in the incubator Live music, either MT or mother singing, no physical contact Recorded music listening with touch Live music with touch Note: *Not significant.

1.4 0.49 0.44

.00 .00 .73*

Note: *Not significant. REE 5 resting energy expenditure.

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no touch was used, but recorded music was more effective when paired with some type of touch to the infant. The studies using live music interactions were all conducted by qualified music therapists. The recorded music studies were a combination of those by MTs and those conducted by medical personnel. The effect size of this study is virtually the same as that found in the prior analysis of the first ten studies in this area.1 Although the number of studies has tripled in the last ten years and new dependent variables have been measured, effects remained consistently positive for the benefits of music, that is, powerful documentation and replication of the positive benefits of MT in the NICU. In this study, we analyzed results by the decibel level of the music and found better benefits for music below 75 dB Scale C. These data are suspect, however, because many studies did not report which audiometer scale was used. We have found through testing of sound within the incubator that there is an approximate difference of 10 dB between Scale A used to measure the range of the speaking voice and Scale C used to measure the more widespread frequencies of music. Care should be taken in future reports of music use in the NICU to clarify scale of the decibel measurement. The homogeneity analysis of effects for recorded versus live music with or without touch present showed live music with greater benefit when touch was not included. However, it should be noted that this analysis is confounded by use of music, delivery of music, and medical procedures in combination with music. It should be noted that there is also probably confounding between type of MT intervention and the measured dependent variable. The studies using the multimodal stimulation protocol and the PAL protocol that have both shown consistent and highly significant positive results measured length of staya very important and beneficial dependent variable that ranked only sixth in strength of effect size. These highly positive benefits were averaged with that of the measure of head circumference that was the only dependent variable showing no difference because of music. Therefore, the clinical importance of this particular finding is highly suspect. Further research to isolate and refine the most effective NICU-MT protocols combining music and touch of infants is warranted. The NICU-MT can alleviate some of the problems of NICU treatment by reducing lengths of stay, raising oxygen saturation levels, and improving sleep and feeding skills. Since positive MT effect sizes decreased as birth weight increased, it is evident that NICU-MT is more effective early in the infants stay. Results also showed greater music benefits for female infants. Music volume is an important consideration, and care should be taken to maintain music volume below 6575 dB Scale C. Music stimulation can be processed early in development and has unique auditory input and neurologic consequences for preterm infants. Results of this meta-analysis show evidence of increased maturation and development that may be

DISCUSSION

contributing more to long-term outcomes that has currently been measured. Perhaps one of the most important outcomes of NICU-MT is not yet fully documented in the research literature: lullaby selections for preterm infants convey the human voice and may provide much needed language stimulation with important long-term consequences for future learning. Music alone or combined with the human voice would seem to be a valuable resource for enhancing developmental goals in the NICU while functioning to reduce stress; to provide developmental stimulation during a critical period of growth; to promote attachment with parents; and/or to facilitate neurologic, communication, and social development. Research investigating long-term developmental outcomes for infants receiving NICU-MT is warranted.

This comprehensive, updated meta-analysis on music research with infants treated in the NICU replicated findings of a prior meta-analysis of the first ten studies in this field.1 Significant benefits of MT were found on measures of heart rate, behavior state, oxygen saturation, sucking/ feeding ability, and length of stay. Benefits were greatest for live MT and for use early in the infants NICU stay (birth weight , 1,000 g, birth postmenstrual age ,28 weeks). Results justify strong consideration for the inclusion of these evidence-based NICU-MT protocols in best practice standards for NICU treatment of preterm infants: music listening for pacification, music reinforcement of sucking/feeding ability, and music as a basis for pacification during multilayered, multimodal stimulation.

CONCLUSION

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For further information, please contact: Jayne Standley, PhD Music Therapy College of Music Kuersteiner Music Building 042 The Florida State University Tallahassee, FL 32306-1180 E-mail: jstandley@fsu.edu

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