Music intervention in the NICU implications and future

Music intervention in the NICU: implications and future directions Shmuel Arnon M. D. Neonatal Department Meir Medical Center Kfar-Saba Israel

Rembrandt, c. 1650: Saul and David

Music therapy and stress reduction Ancient cultures 1950 -music therapy as a profession 5000 music therapists in USA’s hospitals Oncology Childbirth Pediatrics

Music and the preterm infant Creative Arts Therapies include: Music therapy, Art therapy, Movement therapy and Drama Therapy Only music therapy has the ability to form communication and interaction between the infant and his parent. Can be part of the developmental care milieu A systematic process of intervention

Developmental Care Modalities Nesting Family centered care Massage Oral stimulation NIDCAP Sleepwake cycle Clustering Light control Kangaroo Care Swaddling music

Physiology

Physiology - facts Fetuses By 27 weeks - respond to load tone. By 34 weeks - respond selectively to maternal voice and heart beat Neonates Intrauterine experience of sounds elicit emotional attachment to the mother Preterm infants Exposed to higher frequencies at greater intensities Experience sensory deprivation of maternal voice

Safe sound levels - recommendations Hourly Leq 50 d. B(A) Hourly L 10 55 d. B(A) A 1 -second Lmax 70 d. B(A) J. Perinatol 2000 Dec; 20(8 Pt 2): S 88 -93.

Sound Analyser

Actual sound levels Knutson, Allysa Jennie J ped (rio) (2012).

Questions to be answered What kind of music How to deliver effectively music therapy in the NICU that complies with DC Evidence based data

Music Therapy for preterm infants M usic thera py ha s sig nifica for pr nt be eterm nefits infan ts J Standley J Ped Nurs 2002, 17(2)

Guidelines for use of Music in the NICU – 2002 Can begin at 28 weeks’ gestational age Sounds should be constant, stable, relatively unchanging, least alerting Female or children voices+1 instrument Constant volume Quite environment (<50 d. B) Music <70 -75 d. B Maximum time per day: 1. 5 h (alternating) Music or sounds generating by toys should be avoided Lullabies should be provided by the mother J Standley J Ped Nurs 2002, 17(2)

Definitions Music Intervention using music as a tool for achieving a positive effect NICU-MT - Using music therapist to enhance parental music intervention in a systematic method that complies with DC principles.

Music Intervention Advantages Fairly easy to implement (video A ) Mothers and medical personnel like it. Research supports intervention Creates quite background PAL: Pacifier Activated Lullaby Disadvantage The preterm infant has no ability to discriminate music from noise, background noise <50 d. B No control of music intensity, no personal attention Habituation No parental active participation Does not comply with DC principles (STS)

Arnon et al Using live music Birth, 33, 2, June 2006 , 131– 136

MT NICU-MT Advantages Comprehensive treatment that re-structures the parents and their child and environment Active parental role Quantitative systematic approach to music as therapy Complies with DC principles Disadventage Requires qualified personnel Needs span of attention Limited research (video C)

Music during KC (STS) All senses are involved Hearing Touching Tasting Smelling Sighting Soothing

Music therapy guidance maternal singing Arnon et al, Acta Paediat. 103 (10), Oct. 2014, 1039– 1044

Arnon et al - conclusions Maternal singing during KC reduces maternal anxiety and leads to autonomic stability in stable preterm infants This effect is not detected in behavioral state or physiological parameters commonly used to monitor preterm infants

Music Therapy for Preterm Infants and Their Parents: A Meta-analysis Bieleninik et al. Pediatrics 2016; 38(3)

Conclusions There is sufficient evidence to confirm a large, favorable effect of MT on infant respiratory rate and maternal anxiety More rigorous research on short-term and long-term infant and parent outcomes is required.

The Effects of Music Therapy on Vital Signs, Feeding, and Sleep in Premature Infants J. Lowey et al, Pediatrics Vol. 131 No. 5 May 01, 2013

Results , cont. Pediatrics Vol. 131 No. 5 May 01, 2013

MT in hospitals Israel NICU-MT: None MT-MA degree (Bar Ilan, Haifa, Levinski, David Yelin) Hospitals in Israel – Few MT, no formal jobs USA More than 400 professional music therapists worldwide have obtained specialized training in MT in the NICU 50% of the top 25 US children’s hospitals offer MT in the NICU

Centers for NICU-MT Norway Switzerland Grieg Academy Music Therapy Research Centre The Louis Armstrong Center for Music & Medicine, Mount Sinai Beth Israel University of Kansas University of Gdansk, Psychology Department Klinische Musiktherapeutin, Bazel Germany Israel Music Academy and Therapeutics, Berlin University of Haifa, School for Arts USA Poland

Future Implication Expanding NICU-MT to variable daily activities Support medical procedure Part of routine care

Acknowledgments NICU infants, parents and team Music therapists, Haifa University Music