MANUSCRIPT CITATION

Dane E Anderson & Aniruddh D Patel. Infants born preterm, stress, and neurodevelopmental in the neonatal intensive care unit: might music have an impact? Developmental Medicine & Child Neurology. 2018 Jan 24;ePub ahead of print  doi: 10.1111/dmcn.13663. PMID 29363098

REVIEWED BY

Katherine Sanchez BSpPath(Hons)
Speech Pathologist
Murdoch Children’s Research Institute & University of Melbourne
katherine.sanchez@mcri.edu.au

Angela Morgan PhD
Senior Research Fellow
Murdoch Children’s Research Institute, Royal Children’s Hospital & University of Melbourne
angela.morgan@mcri.edu.au

Alicia Spittle PhD
Senior Research Fellow
Murdoch Children’s Research Institute, Royal Women’s Hospital & University of Melbourne
aspittle@unimelb.edu.au

TYPE OF INVESTIGATION

Review

QUESTION

Does musical exposure decrease stress and improve neurodevelopmental outcomes in hospitalized preterm infants?

METHODS

• Design: Literature review (non-systematic)
• Search terms: focused on topics “neonates” and “music.”
• Search engines: Google Scholar, PubMed, PsychNet/Info
• Exclusion criteria: animal model studies, basic auditory work, literature reviews, theses, meta-analyses, studies not available in English.

MAIN RESULTS:

Of 140 research papers considered eligible for this study, the authors selected the ten that they considered to be the most methodologically rigorous for inclusion. The methodological quality was not assessed with a standardised measure, but the authors report that they considered blinding, control/comparison groups and statistical methods. These ten papers were listed in tables summarizing their methodologies, outcomes, and methodological strengths and weaknesses. The authors reported that the selected papers described a number of significant relationships, including between music exposure and:

• behavioural measures (5 studies)
• improved feeding (2 studies)
• heart rate or blood pressure (5 studies)
• improved respiratory rate (3 studies)
• arterial or pulse oximetry (4 studies)
• decreased resting energy expenditure (1 study)
• reduced initial weight loss (1 study)
• increased serum β-endorphins (1 study)

CONCLUSION:

The authors conclude that the literature supports a measurable effect of music on neonatal stress, and highlight that as a non-invasive intervention, it may have significant value in moderating the effects of preterm birth on neural development.

They recommend that future research should be “rigorous and consistent” to facilitate meta-analysis, and recommend consideration of a range of dependent variables, including measures of hypothalamic–pituitary–adrenal axis regulation, and pain. Further, they recommend long term follow up of neurodevelopmental outcomes such as language development and emotional regulation, preferably using other efficacious auditory interventions as a control, and ideally using qualified music therapists to deliver a safe, individualized, culturally appropriate, and responsive intervention. Finally, the authors suggest research into the interactions between music and other developmental care interventions to evaluate whether a cumulative effect may be present.

COMMENTARY:

The use of music to soothe babies predates written history (1). As more medically vulnerable infants survive, and spend long periods hospitalized, Developmental Care has evolved to optimize neurodevelopment. As part of the emergence of Developmental Care, medical research has reflected a growing interest in the role of music with hospitalized neonates, its effectiveness and the mechanisms by which it may change infant outcomes.

Here (2), Anderson and Patel examined studies of musical interventions for hospitalized neonates, excluding reviews and meta-analyses. They chose ten papers that they perceived as methodologically rigorous, and summarized them to “highlight the most well-supported data.”(2) Based on these papers, they suggested that music had effects on behavioral and physiological infant metrics, ranging from reduced inconsolable crying to reduced resting energy expenditure. Further, the authors emphasized studies that explored the mechanisms by which music affects behavioral and physiological markers. It should be noted that the strength of the selected evidence varied (e.g. methodologies ranging from within-subject comparison designs to randomized controlled trials (RCTs), and was not subject to a standardized measure of methodological rigor. A further consideration, as the authors note, is that the examined studies used a range of stimuli, from commercially-available recordings to live parent performance. This methodological heterogeneity may have a considerable effect on outcomes.

While previous meta-analyses and systematic reviews on this topic exist (3–6), this review took a neurodevelopmental perspective, and highlighted only those studies that seemed most rigorous, based on author perception. However in the absence of a replicable, standardized evaluation of methodological quality, and a systematic approach to study selection, the conclusions must be interpreted cautiously.

The authors (2) highlighted pertinent directions for research – uncovering mechanisms by which music affects preterm infants; and investigating long-term neurodevelopmental effects of musical interventions. They further emphasized the need for trained music therapists to deliver direct interventions, to avoid overstimulation of the infant. We would add that indirect interventions delivered by music therapists such as training parents to deliver infant-led musical stimulation may provide a safe and culturally-responsive intervention, and merits further research (7).

With recent evidence suggesting that preterm neonates may be suffering from sensory deprivation (8,9), this review complements previous evidence (3–6) in suggesting that music therapy may moderate the effects of preterm birth on neurodevelopment. However further investigation through well-designed and adequately powered RCTs, which give appropriate consideration to the nature of the musical stimuli provided, will be essential in establishing the short- and long-term effectiveness and safety of this intervention.

REFERENCES

1. Adams G. The first children’s literature? The case for Sumer. Child Lit 1986;14:1–30.
2. Anderson DE, Patel AD. Infants born preterm, stress, and neurodevelopment in the neonatal intensive care unit: might music have an impact? Dev Med Child Neurol 2018; early online.
3. Hartling L, Shaik MS, Tjosvold L, Leicht R, Liang Y, Kumar M. Music for medical indications in the neonatal period: a systematic review of randomised controlled trials. Arch Dis Child – Fetal Neonatal Ed 2009;94:F349–54.
4. Pölkki T, Korhonen A. The effectiveness of music on pain among preterm infants in the NICU: a systematic review: JBI Database Syst Rev Implement Rep 2014;12:354–73.
5. Standley J. Music therapy research in the NICU: an updated meta-analysis. Neonatal Netw J Neonatal Nurs 2012;31:311–6.
6. van der Heijden MJE, Oliai Araghi S, Jeekel J, Reiss IKM, Hunink MGM, van Dijk M. Do hospitalized premature infants benefit from music interventions? A systematic review of randomized controlled trials. PLOS ONE 2016;11:e0161848.
7. Haslbeck F, Stegemann T. The effect of music therapy on infants born preterm. Dev Med Child Neurol 2018;early online.
8. Lagercrantz H. Are extremely preterm born children with autism the victims of too much isolation in the incubator? Acta Paediatr 2017;early online.
9. Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M, Kidokoro H, et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr 2014;164:52-60.e2.