Medical Tourism & Health Policy

The Effects of Music Listening on Inconsolable Crying in Premature Infants G.Nityanandan

Background Premature infants in the Neonatal Intensive care units (NICU) across England and much of the developed world receive high end, highly technical care to ensure survival and healthy transition from the neonatal phase into infancy. The complexity of many of these procedures use to aid the neonates in the NICU may cause harm by acting as a stressor to the immature physiology of the neonates. For example, it is a well-documented phenomenon that frequent touch assessments and invasive interventions are a potential source of stress for the neonates.1 These stress inducing factors can lead to the decline in the stability of the neonate, thereby causing a notable depression in vital signs. This will then lead to more interventions being performed to stabilise the infant and this continues the vicious cycle of interventions that are potential stressors and the resultant stress that neonates are exposed to. If vital signs continue to drop, (e.g. if the baby has poorer oxygen saturation), insults to the delicate neurological makeup of the infants may occur – this leading to a variety of problems for the infant – both long term and short term2. Measures to improve and perhaps eradicate the negative effects of stress factors on the stability of neonates need to be explored.3 This would mean that interventions can be provided in a structured and safe manner in a way that it doesn’t have any negative impacts on the neonate. The idea of Music therapy as a means to help stabilize the negative physiologic changes upon exposure to stressors is not something that’s new to medicine. In adult medicine, Music Therapy has long been touted as an effective way to enhance the healing process (example analgesia in a cancer patient). The purpose of my paper is to uncover and assess the evidence that exists to back up the use of music therapy in the NICU when performing procedures that may be a potential stressor for the neonates. (E.g. Endotracheal Suctioning) A key point to note is that this paper is only looking at music therapy as an adjunct during stress inducing procedures and phenomena. It’s not an attempt to examine the validity of Music Therapy as a treatment in itself. A premature infant undergoes a stark change in environment when transitioning from the mother into the hospital environment. These neonates are subject to Premature infants transition too early from the safety of the womb into the unprotected world of the NICU environment. These neonates, with an immature neurological and vascular systems, are exposed to a myriad of stimuli that can be found in any normal ward environment. Touching a baby to assess its physical state is known to be a major cause of unfamiliar stress to the neonate. The average neonate in the Intensive Care Unit is touched, examined and repositioned around 10 times in a given 3 hour period4.

1

Zahr LK, Balian S. Responses of premature infants to routine nursing interventions and noise in the NICU. Nurs Res. 1995;44:179–185. [PubMed] 2 Rees S, Harding R, Walker D. The biological basis of injury and neuroprotection in the fetal and neonatal brain. Int J Dev Neurosci. 2011;29:551–563. [PMC free article] [PubMed] 3

Kuhn P, Zores C, Pebayle T, et al. Infants born very preterm react to variations of the acoustic environment in their incubator from a minimum signal-to-noise ratio threshold of 5 to 10 dBA. Pediatr Res.2012;71:386–392. [PubMed] 4

Zahr LK, Balian S. Responses of premature infants to routine nursing interventions and noise in the NICU. Nurs Res. 1995;44:179–185. [PubMed]

Each of these instances is a potential stressor for the neonate5. Each of these instances can adversely affect oxygenation, blood flow, heart rate, and behavioural responses.6 In a quixotic world, it might be possible to eliminate all the sources of stress in an NICU. However, if we were to temper that ideal with a bit of realism, we soon realise there are some non-essential stressors that can be eradicated from our clinical environments. One of the chief stressors as far as neonates are concerned is loud sounds or noise. This is indeed a modifiable factor that can not only be eradicated but also modified to possibly deliver a therapeutic effect. Enter Music Therapy. Music or sound therapy is the transmission of waveforms through the air, subsequent reception and interpretation of these sounds or vibrations by our auditory system. The structures in this system are formed in early foetal life.7 An extremely vital part of the auditory system, the cochlea, is where the inner and outer hair cells develop. These then attach to spiral ganglion cells that connect to the brainstem and the auditory cortex.8 An insult to the cochlea – be it ototoxic drugs or loud noises is a concern in our NICUs.9 The American Association of Paediatrics recommends that sound levels in NICUs should be kept under 45 dB10 the decibel level for common sound in the NICU are listed in Table 1 below. Table 111: Noise levels in the NICU Quiet Room Radio Switched On Cardiorespiratory Alarm Endotracheal Suctioning Telephone Ringing Cardiorespiratory Alarm (Inside Incubator) High Frequency Ventilation (Inside Incubator)

47dB 53dB 78dB 63dB 78dB 52db 64db

At this point, it does seem rather counterintuitive to add additional sounds in the NICU Environment given that we are already well above the recommended levels of 45 dB However, it’s still imperative that we forge ahead and explore the viability and value of using such therapy by critically appraising studies that have been conducted around this topic.

5

Aita M, Johnston C, Goulet C, Oberlander TF, Snider L. Intervention Minimizing Preterm Infants' Exposure to NICU Light and Noise. Clin Nurs Res. 2012 [PubMed] 6 Wachman EM, Lahav A. The effects of noise on preterm infants in the NICU. Arch Dis Child Fetal Neonatal Ed. 2011;96:F305–F309. [PubMed] 7 Graven S, Browne JV. Auditory Development in the Fetus and Infant. Newborn Infant Nurs Rev.2008;8:187– 193. 8 McMahon E, Wintermark P, Lahav A. Auditory brain development in premature infants: the importance of early experience. Ann N Y Acad Sci. 2012;1252:17–24. [PubMed] 9 Hall JW., 3rd Development of the ear and hearing. J Perinatol. 2000;20:S12–S20. [PubMed] 10 Noise: a hazard for the fetus and newborn. American Academy of Pediatrics. Committee on Environmental Health. Pediatrics. 1997;100:724–727. [PubMed] 11 Thomas KA, Uran A. How the NICU environment sounds to a preterm infant: update. MCN Am J Matern Child Nurs. 2007;32:250–253. [PubMed]

Music Therapy Music Therapy as the name suggest is the culmination of a method and objective. It refers to the utilisation of Music – sounds that are placed into soothing/pleasing scales, rhythm, tempo and volume to deliver treatment goals.12 This could range from combatting depression to stress reduction for the patient. Before we begin our search into the specific evidence, I would like to mention a noteworthy article that I found on the Neonatal Network Journal (Appendix 1). Standley13 found that music therapy increased feeding which may have benefits on length of stay and growth of neonates. Also a survey of Finnish Neonatal Nurses showed music could increase the feeling of security, improve sleep, decrease stress, and reduce pain in premature infants.14 In another study, parents thought that music would decrease stress, improve sleep, and decrease crying in their infant hospitalized in the NICU.15 Surveys of both parents and nurses found that Music has a certain anti-stress factor that can be very useful when it comes to treating neonates. However, to better appreciate the validity of these studies, I had to do a literature review to find evidence of improved clinical outcomes for neonates when they’re exposed to a stress inducing scenario (e.g. Endotracheal Intubation/ Heel Lance) due to the inclusion of Music Therapy.

12

Stouffer JW, Shirk BJ, Polomano RC. Practice guidelines for music interventions with hospitalized pediatric patients. J Pediatr Nurs. 2007;22:448–456. [PubMed] 13 .Standley J. Music therapy research in the NICU: an updated meta-analysis. Neonatal Netw.2012;31:311– 316. [PubMed] 14 Polkki T, Korhonen A, Laukkala H. Nurses' expectations of using music for premature infants in neonatal intensive care unit. J Pediatr Nurs. 2012;27:e29–e37. [PubMed] 15 Polkki T, Korhonen A, Laukkala H. Expectations associated with the use of music in neonatal intensive care: a survey from the viewpoint of parents. J Spec Pediatr Nurs. 2012;17:321–328. [PubMed]

Method In order to give my search a more focussed direction and hone in on the most relevant resources, I utilised the PICO (Population, Intervention, Control/Comparison, and Outcome) structure to create terms for my database search. The terms that I used can be found in Table 2 below.

Table 2: Search terms for PICO Population

Definition Search Terms Used Preterm Babies (