Maternal singing during kangaroo care led to autonomic stability in preterm infants and reduced maternal anxiety

Impact of a music intervention on heart rate variability in very preterm infants

AIM

Infants born very preterm spend their early postnatal life in a neonatal intensive care unit, where irregular and unpredictable sounds replace the structured and familiar intrauterine auditory environment. Music interventions may contribute to alleviate these deleterious effects by reducing stress and providing a form of environmental enrichment.

MATERIAL AND METHODS

This was an ancillary study as part of a blinded randomised controlled clinical trial entitled the effect of music on preterm infant's brain development. It measured the impact of music listening on the autonomic nervous system (ANS), we assessed heart rate variability (HRV) through high-resolution recordings of heart rate monitoring, at three specific postmenstrual ages in premature infants.

RESULTS

From 29 included subjects, 18 were assessed for complete HRV dataset, including nine assigned to the music intervention and nine to the control group. Postmenstrual age appeared to be the main factor influencing HRV from 33 weeks to term equivalent age. Further analyses did not reveal any detectable effect of music intervention on ANS response.

CONCLUSION

This study found that ANS responses were not modified by recorded music intervention in very preterm infants during wakefulness or sleep onset. Further research is warranted to explore other factors influencing ANS development in this population.

Tiny shifts, major ripples: Unravelling micro-mechanisms in the building of mother-infant attachment and psychophysiological regulation

Parental nurturing touch plays a crucial role in early infant development by activating C-Tactile afferents, which trigger neurobiological pathways essential for parent-infant bonding and the building of attachment. This process is said to regulate the infant's parasympathetic nervous system, fostering emotional and physiological connection with the caregiver. Research has consistently shown that CT-mediated touch enhances infant parasympathetic tone, yet no clear patterns of mutual co-regulation between parent and infant have been reported. Here, we replicated our previous study design to test the impact of three minutes of maternal stroking touch on mother-infant cardiorespiratory regulation, using no-touch pre- and post-stroking baselines. To control for potential confounds, we standardised the infant's holding position, used active baselines (i.e., active group) instead of resting baselines (i.e., resting group) to account for maternal metabolic activity, and compared stroking with and without massaging oil in the active group. Electrocardiogram (ECG) and respiration were measured in 30 mother-infant dyads (active group) and 24 mother-infant dyads (resting group) (infants aged 5-14 weeks) to calculate RRI-intervals (RRI), respiration frequency (fR), and Respiratory Sinus Arrhythmia (RSA). Surprisingly, no significant changes in mother and infant cardiorespiratory measures were observed in the active contrary to the resting group and the use of massaging oil had no notable impact in the active group. We suggest that these lack of changes show that subtle experimental manipulations have an influence on maternal-infant co-regulation, emphasising the importance of using research designs that respect the individualised ecological environment of parent-infant interactions and the role of micro-processes and multisensory integration in shaping regulatory attachment dynamics.

Parental singing during kangaroo care: parents' experiences of singing to their preterm infant in the NICU

Introduction

Singing fosters emotional connections, attachment, bonding, and language development in infants. Prematurely born infants, however, are at risk of missing this vital communication, impacting neurodevelopment and family wellbeing, especially during prolonged hospital stays. Kangaroo care provides physiological and emotional support, while Creative Music Therapy (CMT) has demonstrated positive effects on neurodevelopment, parental wellbeing, and attachment. The Singing Kangaroo project, a Swedish-Finnish multi-center randomized controlled trial (RCT), investigated the impact of parental singing during kangaroo care. This qualitative follow-up study explores these findings through the lens of Antonovsky's Sense of Coherence (SOC) model.

Method

Semi-structured interviews were conducted with 28 families (20 intervention group, eight control group) at their infant's 5-month corrected age. The intervention group received CMT twice weekly during kangaroo care for 4 weeks in the NICU, while the control group received standard care. Data were analyzed inductively, followed by deductive categorization within the SOC framework, focusing on its three core components: Manageability, Comprehensibility, and Meaningfulness.

Results

Parents in the intervention group reported enhanced understanding of how singing fosters attachment and boosts their self-esteem, aligning with increased manageability and comprehensibility. Control group parents also experienced joy in singing, which positively influenced family wellbeing, albeit less extensively. Across both groups, singing was described as a meaningful activity that strengthened parent-infant bonding and promoted emotional connection within the family.

Conclusion

Parental singing during kangaroo care, particularly when supported by a trained music therapist, enhances parents' sense of coherence by fostering comprehensibility, manageability, and meaningfulness. This study highlights the long-term benefits of integrating CMT into family-centered NICU care to support both infants' neurodevelopment and family wellbeing.

Effect of music therapy on behavioral and physiological neonatal outcomes: A systematic review and dose-response meta-analysis

BACKGROUND

Previous studies have documented the effectiveness of music therapy in improving adverse neonatal outcomes in premature infants. However, this review aims to address the question of how long listening to music can enhance these neonatal outcomes.

METHODS

To conduct this dose-response meta-analysis, we searched the PubMed, Scopus, Web of Science, and Cochrane Library databases. The inclusion criteria comprised randomized clinical trials that investigated the effects of music therapy on improving adverse neonatal outcomes. Preterm infants were defined as those born between 27 and 37 weeks of gestation, as fetuses are known to respond to auditory stimuli starting at the 27th week of pregnancy. The initial search was performed on January 28, 2024, and there were no restrictions on the time frame for the search. Ultimately, we employed a two-stage random effects model using the "drmeta" package in Stata software to perform this dose-response meta-analysis.

RESULTS

In total, 30 articles (1855 participants) were identified for inclusion in our meta-analysis. According to pooled analysis with each minute increase in music therapy, the means of respiratory rate, pain score, SBP, DBP, behavioral score, and body temperature decrease by 35.3 beats per minutes, 15.3 VAS, 30.7 mmHg, 8.9 mmHg, 2.7, and 0.27°C. On the other hand, with each minute increase in listening to the music, the mean of O2 saturation, heart rate and sleep duration increase 1.7%, 89.2 beats per minutes and 5.081 minutes per day, respectively.

CONCLUSION

Music therapy improves the neonatal outcomes of O2 saturation, heart rate, respiratory rate, sleep duration, body temperature and systolic and diastolic blood pressures. Therefore, the existence of a dose-response relationship can indicate a causal relationship between music therapy and the improvement of neonatal outcomes.

Creative music therapy in preterm infants effects cerebrovascular oxygenation and perfusion

Creative music therapy (CMT) has been shown to promote the development of brain function and structure in preterm infants. We aimed to investigate the effect of CMT on cerebral oxygenation and perfusion to examine how the brain reacts to CMT. Absolute levels of cerebrovascular oxygen saturation (StO2) were measured in clinically stable preterm-born neonates (n = 20, gestational age: ≥30 weeks and < 37 weeks) using two near-infrared spectroscopy (NIRS)-based tissue oximeters over the right prefrontal cortex and left auditory cortex. We applied the systemic physiology augmented functional NIRS approach. Each CMT session lasted 55 min and involved 9 intervals, including two 10-minute intervals during which the music therapist hummed and held the neonate. We found that CMT-induced changes in cerebrovascular StO2, perfusion and systemic physiology (i) could be classified into two groups (group 1: increase in StO2 during the first singing interval, group 2: decrease in StO2), (ii) differed in female neonates compared to male neonates, and (iii) correlated with individual blood haematocrit levels. Our exploratory study (i) demonstrates the impact of CMT on the neonate's physiology and (ii) highlights the need to analyze functional NIRS measurements in neonates separately according to their response pattern to avoid erroneous conclusions, e.g. when only the group average of the signal change is determined.

Early parental vocal contact in neonatal units: rationale and clinical guidelines for implementation

This paper aims to present clear and evidence-based proposals for the integration of Early Parental Vocal Contact into the clinical practices of neonatal units. In the first part, we present a comprehensive rationale exploring the ontogenesis of voice perception in both term and preterm newborns that establishes a foundational understanding. This knowledge serves as a crucial starting point for developing evidence-based auditory and multisensory interventions aimed at fostering the developmental trajectory of preterm infants. Drawing insights from neuroscience and brain development, our proposals underscore the significance of tailoring auditory environments within neonatal settings. Special attention is given to the unique needs of preterm infants, factoring in their gestational age and maturation levels. In the second part clinical guidelines for implementation are provided and healthcare professionals are supported to assist parents in modulating their vocal interactions, aligning them with the infant's responses. Furthermore, we provide practical suggestions for engaging in discussions with parents about the content, duration, and frequency of vocal interventions. Finally, we delve into the potential roles of caregivers, parents, and health professionals within this enriched parental vocal interactional environment. Our perspective is firmly grounded in an infant and family-centered developmental care philosophy, aiming to enhance the overall well-being and the neurodevelopment of preterm infants in neonatal units.

Short-term effectiveness of music therapy songwriting for mental health outcomes of at-risk parents in the NICU: a study protocol of an international multicenter mixed-methods trial

BACKGROUND

Preterm birth contributes to adverse mental health outcomes of parents dealing with a premature neonate. The main objective of this study is to determine whether music therapy (MT) songwriting during the infants' stay in the neonatal intensive care unit (NICU) is superior to standard care in reducing the risk of postpartum depression in high-risk parents of preterm children throughout the hospital treatment. The secondary objectives include assessment of effectiveness of MT in other aspects of mental health (anxiety level, perceived stress, mental wellbeing, coping, resilience). Furthermore, this trial will evaluate the medical and social factors that may be associated with the effects of MT songwriting.

PARTICIPANTS AND PROCEDURE

The study design is a sequential mixed method study with a dominant status QUAN to qual. The quantitative trial was designed as a parallel, multicenter, pragmatic, randomized controlled trial. The qualitative study is a descriptive phenomenological study that seeks to understand the lived experiences of participants exposed to songwriting. Participants are parents of premature infants hospitalized in NICU (106 families) in 5 hospitals, in Colombia and Poland. Intervention: 3 MT songwriting sessions per week across 3 weeks. Primary outcome: the risk of postnatal depression; secondary outcomes: anxiety level, mental wellbeing, resilience, stress, coping.

RESULTS

The results will be analyzed quantitatively and qualitatively.

CONCLUSIONS

This study will provide a report on the effectiveness of MT songwriting on mental health in at-risk parents of preterm infants.

"Preparation Is Key": Parents' and Nurses' Perceptions of Combined Parent-Delivered Pain Management in Neonatal Care

BACKGROUND

There is a knowledge-to-practice gap regarding parent-delivered pain management, and few studies have investigated parents' and nurses' participation in and acceptance of combined parent-delivered pain-alleviating interventions such as skin-to-skin contact (SSC), breastfeeding, and parental musical presence. This study investigated parents' and nurses' perceptions of and reflections on experiencing combined parent-delivered pain management.

METHODS

This qualitative study applies a collaborative participatory action research design using ethnographic data collection methods such as focus groups, video observations, and video-stimulated recall interviews with parents and nurses.

RESULTS

The results concern three main categories, i.e., preparation, participation, and closeness, as well as various sub-categories. Preparations were central to enabling combined parent-delivered pain management. Participation was facilitated by parental musical presence, in which parents shifted their attention toward their infant. Closeness and presence during neonatal care helped parents become active during their infant's painful procedures. Parental lullaby singing created a calm and trusting atmosphere and after the procedure, both parents and nurses felt that they had successfully supported the infant through a potentially painful procedure.

CONCLUSIONS

Mental and practical preparation is central to implementing combined parent-delivered pain management. When parents and nurses explored the interventions, they found the methods feasible, promoting self-efficacy and confidence in both parents and nurses.

Maternal singing sustains preterm hospitalized newborns' autonomic nervous system maturation: an RCT

BACKGROUND

Premature birth is known to affect the newborn's autonomic nervous system (ANS) maturation, with potential short and long-term impact on their neurobehavioral development. The purpose of the study was to investigate the effects of maternal directed singing and speaking on the preterm infants' autonomic nervous system (ANS) maturation as measured by the heart rate variability (HRV) parameters.

METHODS

In this multi-center randomized clinical trial, 30 stable preterm infants (m = 29,6 weeks of gestational age), without any abnormalities were randomized into an intervention (16) or a control group (14). HRV was measured weekly, for a total of 80 recordings during hospitalization, as well as before and after each session of singing or speaking.

RESULTS

The intervention group showed a significant increase of the percentage value of HRV power in the high frequency range when compared to the control group (p = 0.044). More specifically, the maternal singing significantly increased the high frequency power and decreased the low/high frequency power ratio (p = 0.037).

CONCLUSIONS

The preterm infant's vagal activity significantly increased in the intervention group, potentially enhancing their ANS maturation. The effect is specifically evidenced in the singing condition.

IMPACT

Maternal singing affects the autonomic nervous system maturation of preterm hospitalized newborns in the NICU. No previous studies investigated how early vocal parental intervention can affect preterm infants developement, throught their autonomic nervous system maturation. Early Vocal Contact as an early intervention involving parents has a positive impact on preterm infant's development and it can be easily implemented in the care of preterm infants.

TRIAL REGISTRATION

NCT04759573, retrospectively registered, 17 February 2021.

A Randomized Controlled Trial of a Neonatal Intensive Care Unit Language Intervention for Parents of Preterm Infants and 2-Year Language Outcomes

OBJECTIVE

To test whether a neonatal intensive care unit-based language curriculum for families with preterm infants enhances the language environment and postdischarge Bayley Scales of Infant and Toddler Development (BSID)-III language and cognitive scores.

METHODS

A randomized controlled trial was conducted with infants born at ≤32 weeks assigned to a parent-driven language intervention or health-safety lessons (controls). Recordings of adult word counts (AWC), conversational turns, and child vocalizations were captured at 32, 34, and 36 weeks. Primary outcomes included 2-year BSID-III language and cognitive scores.

RESULTS

We randomized 95 infants; 45 of the 48 intervention patients (94%) and 43 of the 47 controls (91%) with ≥2 recordings were analyzed. The intervention group had higher AWCs (rate ratio, 1.52; 95% CI, 1.05-2.19; P = .03) at 36 weeks, increased their AWCs between all recordings, and had lower rates of 2-year receptive language scores <7 (10% vs 38%; P < .02). The intervention was associated with 80% decreased odds of a language composite score of <85 (aOR, 0.20; 95% CI, 0.05-0.78; P = .02), and 90% decreased odds of a receptive score of <7 (0.10; 95% CI, 0.02-0.46; P = .003); there was no association found with cognitive scores. Increases in AWC and conversational turns between 32 and 36 weeks were independently associated with improved 2-year BSID-III language scores for both study groups.

CONCLUSIONS

Short-term parent-driven language enrichment in the neonatal intensive care unit contributes to increased AWCs at 36 weeks and improved 2-year language scores. In adjusted analyses, increases in conversational turns and AWCs at 36 weeks were independently associated with improved language scores. This low-cost, easily implemented intervention can potentially help to mitigate speech delays among preterm infants.

TRIAL REGISTRATION

Registered with www.

CLINICALTRIALS

gov, NCT02528227.

The effect of a live music therapy intervention on critically ill paediatric patients in the intensive care unit: A quasi-experimental pretest-posttest study

BACKGROUND

Music therapy as a nonpharmacological means of managing patient pain, anxiety, and discomfort is a recognised technique, although it is not widely used in the paediatric intensive care unit (PICU).

AIM

The aim of this study was to assess the clinical effect of a live music therapy intervention on vital signs and levels of discomfort and pain for paediatric patients in the PICU.

METHODS

This was a quasi-experimental pretest-posttest study. The music therapy intervention was carried out by two music therapists who were specifically trained, each possessing a master's degree in the field of hospital music therapy. Ten minutes before the start of the music therapy session, the investigators recorded the vital signs of the patients and assessed their levels of discomfort and pain. The procedure was repeated at the start of the intervention; at 2, 5, and 10 min during the intervention; and at 10 min following the conclusion of the intervention.

RESULTS

Two hundred fifty-nine patients were included; 55.2% were male, with a median age of 1 year (0-21). A total of 96 (37.1%) patients suffered a chronic illness. The main reason for PICU admission was respiratory illness, at 50.2% (n = 130). Significantly lower values were observed for heart rate (p = 0.002), breathing rate (p < 0.001), and degree of discomfort (p < 0.001) during the music therapy session.

CONCLUSIONS

Live music therapy results in reduced heart rates, breathing rates, and paediatric patient discomfort levels. Although music therapy is not widely used in the PICU, our results suggest that using interventions such as that used in this study could help reduce patient discomfort.

Musical and vocal interventions to improve neurodevelopmental outcomes for preterm infants

BACKGROUND

Preterm birth interferes with brain maturation, and subsequent clinical events and interventions may have additional deleterious effects. Music as therapy is offered increasingly in neonatal intensive care units aiming to improve health outcomes and quality of life for both preterm infants and the well-being of their parents. Systematic reviews of mixed methodological quality have demonstrated ambiguous results for the efficacy of various types of auditory stimulation of preterm infants. A more comprehensive and rigorous systematic review is needed to address controversies arising from apparently conflicting studies and reviews.

OBJECTIVES

We assessed the overall efficacy of music and vocal interventions for physiological and neurodevelopmental outcomes in preterm infants (< 37 weeks' gestation) compared to standard care. In addition, we aimed to determine specific effects of various interventions for physiological, anthropometric, social-emotional, neurodevelopmental short- and long-term outcomes in the infants, parental well-being, and bonding.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, RILM Abstracts, and ERIC in November 2021; and Proquest Dissertations in February 2019. We searched the reference lists of related systematic reviews, and of studies selected for inclusion and clinical trial registries.

SELECTION CRITERIA

We included parallel, and cluster-randomised controlled trials with preterm infants < 37 weeks` gestation during hospitalisation, and parents when they were involved in the intervention. Interventions were any music or vocal stimulation provided live or via a recording by a music therapist, a parent, or a healthcare professional compared to standard care. The intervention duration was greater than five minutes and needed to occur more than three times.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. We analysed the treatment effects of the individual trials using RevMan Web using a fixed-effects model to combine the data. Where possible, we presented results in meta-analyses using mean differences with 95% CI. We performed heterogeneity tests. When the I2 statistic was higher than 50%, we assessed the source of the heterogeneity by sensitivity and subgroup analyses. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 trials recruiting 1532 infants and 691 parents (21 parallel-group RCTs, four cross-over RCTs). The infants gestational age at birth varied from 23 to 36 weeks, taking place in NICUs (level 1 to 3) around the world. Within the trials, the intervention varied widely in type, delivery, frequency, and duration. Music and voice were mainly characterised by calm, soft, musical parameters in lullaby style, often integrating the sung mother's voice live or recorded, defined as music therapy or music medicine. The general risk of bias in the included studies varied from low to high risk of bias. Music and vocal interventions compared to standard care Music/vocal interventions do not increase oxygen saturation in the infants during the intervention (mean difference (MD) 0.13, 95% CI -0.33 to 0.59; P = 0.59; 958 infants, 10 studies; high-certainty evidence). Music and voice probably do not increase oxygen saturation post-intervention either (MD 0.63, 95% CI -0.01 to 1.26; P = 0.05; 800 infants, 7 studies; moderate-certainty evidence). The intervention may not increase infant development (Bayley Scales of Infant and Toddler Development (BSID)) with the cognitive composition score (MD 0.35, 95% CI -4.85 to 5.55; P = 0.90; 69 infants, 2 studies; low-certainty evidence); the motor composition score (MD -0.17, 95% CI -5.45 to 5.11; P = 0.95; 69 infants, 2 studies; low-certainty evidence); and the language composition score (MD 0.38, 95% CI -5.45 to 6.21; P = 0.90; 69 infants, 2 studies; low-certainty evidence). Music therapy may not reduce parental state-trait anxiety (MD -1.12, 95% CI -3.20 to 0.96; P = 0.29; 97 parents, 4 studies; low-certainty evidence). The intervention probably does not reduce respiratory rate during the intervention (MD 0.42, 95% CI -1.05 to 1.90; P = 0.57; 750 infants; 7 studies; moderate-certainty evidence) and post-intervention (MD 0.51, 95% CI -1.57 to 2.58; P = 0.63; 636 infants, 5 studies; moderate-certainty evidence). However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention (MD -1.38, 95% CI -2.63 to -0.12; P = 0.03; 1014 infants; 11 studies; moderate-certainty evidence). This beneficial effect was even stronger after the intervention. Music/vocal interventions reduce heart rate post-intervention (MD -3.80, 95% CI -5.05 to -2.55; P < 0.00001; 903 infants, 9 studies; high-certainty evidence) with wide CIs ranging from medium to large beneficial effects. Music therapy may not reduce postnatal depression (MD 0.50, 95% CI -1.80 to 2.81; P = 0.67; 67 participants; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of music therapy on parental state anxiety (MD -0.15, 95% CI -2.72 to 2.41; P = 0.91; 87 parents, 3 studies; very low-certainty evidence). We are uncertain about any further effects regarding all other secondary short- and long-term outcomes on the infants, parental well-being, and bonding/attachment. Two studies evaluated adverse effects as an explicit outcome of interest and reported no adverse effects from music and voice.

AUTHORS' CONCLUSIONS

Music/vocal interventions do not increase oxygen saturation during and probably not after the intervention compared to standard care. The evidence suggests that music and voice do not increase infant development (BSID) or reduce parental state-trait anxiety. The intervention probably does not reduce respiratory rate in preterm infants. However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention, and this beneficial effect is even stronger after the intervention, demonstrating that music/vocal interventions reduce heart rates in preterm infants post-intervention. We found no reports of adverse effects from music and voice. Due to low-certainty evidence for all other outcomes, we could not draw any further conclusions regarding overall efficacy nor the possible impact of different intervention types, frequencies, or durations. Further research with more power, fewer risks of bias, and more sensitive and clinically relevant outcomes are needed.

The effects of live parental infant-directed singing on infants, parents, and the parent-infant dyad: A systematic review of the literature

Singing to infants is widely accepted as an enjoyable, positive, and beneficial interaction between the parent and infant across cultures. Whilst the literature suggests that live infant-directed singing impacts the infant, the parent doing the singing and the dyad in powerful ways, no systematic review of the evidence has yet been conducted. To this end, this systematic review identified 21 studies that investigated the effect of live parental infant-directed singing. These impacts were categorized as either being directly related to the infant, the parent, or the parent-infant dyad. Three main themes - one for each of the impact categories considered - were identified using thematic analysis techniques; infant-directed singing impacts on: infants' emotional regulation, provides validation of the parent's role, and promotes affect attunement within the dyad. The findings reinforce the benefits of live parental infant-directed singing for all parties involved, particularly when parents sing to typically developing infants born at full term. In contrast, the findings were inconsistent for pre-term infants. The implications of these findings are discussed.

NICU sensory experiences associated with positive outcomes: an integrative review of evidence from 2015-2020

To inform changes to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, studies investigating sensory-based interventions in the NICU with preterm infants born ≤32 weeks were identified. Studies published between October 2015 to December 2020, and with outcomes related to infant development or parent well-being, were included in this integrative review. The systematic search used databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar. Fifty-seven articles (15 tactile, 9 auditory, 5 visual, 1 gustatory/olfactory, 5 kinesthetic, and 22 multimodal) were identified. The majority of the sensory interventions that were identified within the articles were reported in a previous integrative review (1995-2015) and already included in the SENSE program. New evidence has led to refinements of the SENSE program, notably the addition of position changes across postmenstrual age (PMA) and visual tracking starting at 34 weeks PMA.

Family-Integrated Neonatal Music Therapy: A Descriptive Pilot Study of Parental Perceptions on Music Therapy Participation and Long-Term Influences

Purpose: Following a family-integrated music therapy (MT) approach, describe parental perceptions on the use of music with maternal voice to soothe and connect with the infant and the long-term influence of this approach on parents' integration of music postdischarge. Design: In this descriptive, observational within-subjects pilot cohort study, board-certified music therapists instructed and recorded mothers in singing selected songs of kin. Infants received the recorded sessions weekly from enrollment to discharge. Parents were surveyed at 1- and 6-year postdischarge. Sample: Medically stable preterm infants (n = 12) and their English-speaking parents (n = 17). Main Outcome Variable: Parent perceptions on participation and long-term influence on family integration of music during hospitalization and postdischarge. Results: Parents reported knowledge of soothing and interacting with their children as the highest benefit of MT. They also perceived the effects of an easier transition home, enhanced learning and child development, and personal benefits of positive mood and enhanced relaxation.

Premature Triadic Music Therapy (PT-MT) for babies and their parents: a pilot study

OBJECTIVE

We aim to test the feasibility and effectiveness of Premature Triadic Music Therapy (PT-MT) in the premature baby unit.

METHODS

The design was a clinical pre-test-post-test trial with a convenience sample. Inclusion criteria were a gestational age higher than 28 weeks for preterm infants and the absence of shock or extreme distress for parents. Six preterm children (with a gestational age of 33 to 36 weeks) and their parents participated in the study. For the children, we measured heart rate, blood perfusion, and blood saturation at three different times (pre-PT-MT, during PT-MT, after PT-MT) as quantitative indicators of distress. Their parents completed the Edinburgh Postnatal Depression Scale (EPDS) before and after the PT-MT intervention.

RESULTS

We found a statistically significant lower heart rate and a marginally statistically significant higher blood perfusion during PT-MT, as compared to the baseline. However, these changes were not present at the end of PT-MT. The parents' EPDS scores were not statistically significantly lower at the post-test, although, the Medians of the scores did decrease.

CONCLUSIONS

PT-MT is a promising intervention for the reduction of distress in both parents and children. Further studies should include a higher number of sessions and participants.

Ideal Mode of Auditory Stimulation in Preterm Neonates in Neonatal Intensive Care Unit: A Systematic Review

The objective of this review was to find out the best mode of auditory stimulation for preterm neonates admitted to the neonatal intensive care unit. We also aimed to find out the different effects of different types of auditory stimulation in these neonates. Advanced neonatal care and technological advances in neonatal intensive care units have led to increased survival of preterm-born neonates, but this in turn leads to increased incidences of disabilities like cerebral palsy, visual impairment, delayed social development, etc. Early intervention is provided to facilitate further development and prevent delays in all domains. Auditory stimulation is proven to benefit these neonates to stabilize their vitals and improve their auditory performance in later life. Different modes of auditory stimulation have been studied worldwide, but none of the studies has presented the ideal mode of auditory stimulation for these preterm neonates. In this review, we have discussed the effects produced by different types of auditory stimulation and compared their pros and cons. For conducting a systematic review, a search strategy adopted by MEDLINE is used. A total of 78 articles published between 2012 and 2017, on the effects of auditory stimulation on preterm infants' performance were reviewed. Out of that, eight studies that met the inclusion criteria and focused on short-term and long-term effects were included in this systematic review. Search terms included preterm neonates, auditory stimulation, and early intervention. Randomized controlled trials and cohort studies were included. Auditory stimulation by maternal sound provides physiological and autonomic stability, but the behavioral states of preterm neonates improved with auditory stimulation by music therapy with lullabies. Maternal singing during kangaroo care may be recommended for providing physiological stability.

NeoConnect: The Design, Implementation, and Impact of a Virtual Family-Centered NICU Program

BACKGROUND

Familial involvement in the neonatal intensive care unit (NICU) reduces parental stress and strengthens parental-infant bonding. However, parents often face barriers to in-person visitation. The coronavirus disease-2019 COVID-19 pandemic has exacerbated limitations to parental bedside presence.

OBJECTIVE

To design, implement, and evaluate a technology-based program to connect NICU babies with their families during the COVID-19 pandemic.

METHODS

We created NeoConnect at our level IV NICU, which included parental audio recordings and video chats between parents and their babies. Parental and NICU staff input on NeoConnect was gathered via preimplementation surveys. Inaugural families and staff members completed a postparticipation survey.

RESULTS

Prior to implementation, all parents who were surveyed (n = 24) wished they could be more involved in their baby's care. In the first 3 months of NeoConnect, 48 families participated in the audio recording project and 14 families participated in the video chat initiative. Following implementation, 85% of surveyed staff (28/33) reported that the patients became calmer when listening to their parents' recorded voice and 100% of surveyed parents (6/6) reported that video chats reduced their stress level.

CONCLUSION

Harnessing technology as a tool to increase parental involvement in the NICU is feasible and beneficial for NICU patients and their families.

Effect of the Kangaroo Mother Method after Preterm Delivery on Maternal Stress and Anxiety in the Context of the COVID-19 Pandemic-A Cohort Study

BACKGROUND

The kangaroo mother method (KMM) may benefit infants and mothers in many ways. However, few studies focused on its efficacy on maternal anxiety and stress, especially in the context of the COVID-19 pandemic.

OBJECTIVE

To examine the effect of the kangaroo mother method (KMM) on postnatal stress and anxiety in mothers of preterm infants in neonatal intensive care, in the context of the COVID-19 pandemic.

METHODS

A cohort study of two groups of 56 mother-infant dyads recruited from a neonatal intensive care unit was conducted. Two groups were compared in terms of the mean duration of KMM during the twelve days of the study: the intervention group (mean duration of more than ninety minutes per day) and the control group (less than ninety minutes). Maternal stress was measured using the Parental Stressor: Neonatal Intensive Care Unit (PSS: NICU) scale and STAI E/R questionnaire before and after intervention (KMM). Demographic and other maternal covariates were extracted from medical records. Daily NICU records were used to track the frequency and duration of KMM sessions.

RESULTS

Mothers of the intervention group scored lower on the PSS: NICU and STAI E/R, although no statistically significant differences were found (p > 0.05).

CONCLUSIONS

Contrary to research based on biological and physiological parameters in newborns or performed before the COVID-19 pandemic, the differences found in applying subjective scales in mothers in the context of the COVID-19 pandemic were not significant. Therefore, mothers' perception of physical contact with their preterm infants may not have been as positive due to their fear of transmitting COVID.

Clinical practice guideline for kangaroo mother care in preterm and low birth weight infants

Kangaroo mother care has reduced mortality and morbidity in preterm and low birth weight infants and has many benefits, such as promoting breastfeeding. Based on the current evidence in China and international, we developed a clinical practice guideline for kangaroo mother care in preterm and low birth weight infants using the Grading of Recommendations, Assessment, Development and Evaluation and proposed 34 recommendations for 20 key questions. Our goal is to promote the appropriate implementation of kangaroo mother care in clinical practice.

Neonatal Musicality: Do Newborns Detect Emotions in Music?

This study aimed to explore healthy, term neonates’ behavioural and physiological responses to music using frame-by-frame analysis of their movements (Experiment 1; N = 32, 0–3 days old) and heart rate measurements (Experiment 2; N = 66, 0–6 days old). A ‘happy’ and ‘sad’ music was first validated by independent raters for their emotional content from a large pool of children’s songs and lullabies, and the effect of the emotions in these two music pieces and a control, no-music condition was compared. The results of the frame-by-frame behavioural analysis showed that babies had emotion-specific responses across the three conditions. Happy music decreased their arousal levels, shifting from drowsiness to sleep, and resulted in longer latencies in other forms of self-regulatory behaviour, such as sucking. The decrease in arousal was accompanied by heart rate deceleration. In the sad music condition, relative ‘stillness’ was observed, and longer leg stretching latencies were measured. In both music conditions, longer latencies of fine motor finger and toe movements were found. Our findings suggest that the emotional response to music possibly emerges very early ontogenetically as part of a generic, possibly inborn, human musicality.

Correlation between diminished vagal tone and somatic dysfunction severity in very and extremely low birth weight preterm infants assessed with frequency spectrum heart rate variability and salivary cortisol

Osteopathic manipulative treatment (OMT) is evolving in the neonatal intensive care unit (NICU) setting. Studies showed its efficacy in length of stay and hospitalization costs reduction. Moreover, it was suggested that OMT has a modulatory effect on the preterm infants' autonomic nervous system (ANS), influencing saturation and heart rate. Even if OMT is based on the palpatory examination of the somatic dysfunctions (SD), there are controversies about its identification and clinical relevance. The objective of this study was to evaluate the inter-rater reliability, clinical characteristics, and functional correlation of the SD Grade score with the heart rate variability (HRV) and the salivary cortisol (sCor) using a multivariate linear model approach. To evaluate those features, we implemented an ad hoc SD examination for preterm infants that was performed by 2 trained osteopaths. It was based on the new variability model of SD that includes an SD Grade assessment procedure. The ANS features were assessed by frequency parameters of HRV studying high frequency (HF), low frequency (LF), and HF/LF, whereas sCor was tested with a radioimmunoassay. The ANS assessment was standardized and performed before SD testing. Sixty-nine premature infants were eligible. SD Grade showed excellent concordance between the blinded raters. Using SD Grade as a grouping variable, the infants presented differences in GA, Apgar, pathological findings, length of stay, and ventilatory assistance. In our multivariate model, HF, LF, and LF/HF resulted linearly correlated with SD Grade. Instead, sCor presented a linear correlation with 5' Apgar and respiratory distress syndrome but not with SD Grade. SD Grade was in line with the natural history of the underdevelopment due to prematurity. Our models indicate that the cardiac vagal tone is linearly related with SD Grade. This finding may improve the multidisciplinary decision making inside NICU and the management of modifiable factors, like SD, for cardiac vagal tone regulation.

Sensory stimulation program improves developments of preterm infants in Southwest China: A randomized controlled trial

Preterm infants are prone to growth and developmental delay, especially social-emotional development. Sensory stimulation may benefit developmental outcomes for these vulnerable infants. This study aims to determine whether 5-integrated sensory stimulation (5-ISS) improves preterm infant social-emotional development. A randomized, parallel trial was conducted from November 2018 to January 2020 at three tertiary hospitals in Kunming, China. Preterm infants were eligible if gestational ages were from 28 to 36 weeks based on ultrasound results when discharged from neonatal wards. Two hundred preterm infants (male n = 110, female n = 90) were randomly allocated to the 5-ISS intervention group (n = 98) and the standard care group (n = 102). Social-emotional development was assessed with the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE). Temperament was assessed with the Infant Behavior Questionnaire-Revised. Anthropometry, which included weight, length, and head circumference, was measured at corrected ages of 1, 3, and 6 months. Demographic and clinical characteristics were similar between the intervention and the standard care groups. At 1- and 3-month corrected age, no significant differences between the two groups were observed in terms of infant development and temperament. At 6 months, significant disparities were found in the social-emotional development scale (mean difference −0.29, 95% CI: −0.58, < -0.001, p = 0.01), infant length (mean difference 0.70, 95% CI: < 0.001, 1.4, p = 0.03), distress to limitation (p = 0.04), and sadness (p = 0.03). A mixed model revealed that the 5-ISS intervention positively affected social-emotional development, length, distress to limitation, and sadness for preterm infants. Integrated sensory stimulation has benefits on social-emotional development, temperament, and length for preterm infants. This program provides a feasible method to promote social-emotional development for preterm infants.

The Role of Music Therapy with Infants with Perinatal Brain Injury

Perinatal brain injury occurs in 5.14/1000 live births in England. A significant proportion of these injuries result from hypoxic ischaemic encephalopathy (HIE) in term infants and intracranial haemorrhage (IVH) or periventricular leukomalacia (PVL) in preterm infants. Standardised care necessitates minimal handling from parents and professionals to reduce the progression of injury. This can potentially increase parental stress through the physical inability to bond with their baby. Recent research highlights the ability of music therapy (MT) to empower parental bonding without handling, through sharing culturally informed personal music with their infant. This review therefore aimed to systematically evaluate the use of MT with infants diagnosed with perinatal brain injury in a neonatal intensive care unit (NICU). Search terms were combined into three categories (audio stimulation (MT), population (neonates) and condition (brain injury), and eight electronic databases were used to identify relevant studies following PRISMA guidelines. Eleven studies using music or vocal stimulation with infants diagnosed with perinatal brain injury were identified and quality assessed using Cochrane ROB2, the ROBINSI Tool and the Newcastle Ottawa Scale. Studies used either voice as live (n = 6) or pre-recorded (n = 3) interventions or pre-recorded instrumental music (n = 2). Studies had two primary areas of focus: developmental outcomes and physiological effects. Results suggested the use of music interventions led to a reduction of infants' pain scores during procedures and cardiorespiratory events, improved feeding ability (increase oral feeding rate, volume intake and feeds per day) and resulted in larger amygdala volumes than control groups. Additionally, MT intervention on the unit supported long-term hospitalised infants in the acquisition of developmental milestones. Vocal soothing was perceived to be an accessible intervention for parents. However, infants with PVL showed signs of stress in complex interventions, which also potentially resulted in an increase in maternal anxiety in one study. MT with infants diagnosed with perinatal brain injury can have positive effects on infants' behavioural and neurological parameters and support parental involvement in their infants' developmental care. Further feasibility studies are required using MT to determine appropriate outcome measures for infants and the support required for parents to allow future comparison in large-scale randomised control trials.

Auditory Processing of the Brain Is Enhanced by Parental Singing for Preterm Infants

As the human auditory system is highly malleable in infancy, perinatal risk factors, such as preterm birth, may affect auditory development. In comparison to healthy full-term infants, preterm infants show abnormal auditory brain responses at term age, which may have long-term detrimental outcomes. To achieve an optimal neonatal care environment for preterm-born infants, many early interventions have been developed. Musical interventions developed for neonatal intensive care units (NICUs) have shown beneficial effects on vital functions and weight gain of preterm infants and might also influence basic auditory processing and thereby enhance outcomes. In the present study, we tested the effect of parental singing during kangaroo care on auditory processing of standardized audio stimuli. Preterm infants (born between 24 and 32 weeks of gestation) were randomized to singing intervention (n = 13) or control (n = 8) groups. The auditory processing was tested using two audio paradigms assessed with magnetoencephalography (MEG) at term corresponding age. To verify that the paradigms elicit responses in MEG, we studied 12 healthy full-term infants. In the singing intervention group, parents were instructed by a music therapist twice a week for 4 weeks to sing or hum during kangaroo care in an infant-directed way. The control group received standard kangaroo care. The results show that the infants in the singing intervention group show larger neural responses than those in the control group when controlling for the total amount of singing during kangaroo care. Our findings suggest that incorporating singing into kangaroo care may be beneficial for preterm infants, but the effect may not be due to exposure to singing but instead positive parenting, improved parental self-esteem and improved caregiver sensitivity.

Clinical benefits of music-based interventions on preterm infants' health: A systematic review of randomised trials

AIM

This systematic review aimed to differentiate and isolate the results of different music-based interventions used with preterm infants in the neonatal intensive care unit and explore their clinical benefits.

METHODS

The last search was performed on 5 July 2021 on Web of Science, Scopus, EMBASE, PsycINFO, CINAHL, LILACS and CENTRAL. Only randomised clinical trials that explored the health benefits of music-based interventions were considered.

RESULTS

A total of 39 studies were included. All music-based interventions were divided into music medicine and music therapy. The overall results suggested that music medicine interventions were associated with a significant improvement in pain relief; in turn, improvements in cardiac and respiratory function, weight gain, eating behaviour, and quiet alert and sleep states were more consistent in studies that followed a music therapy approach with the presence of a music therapist.

CONCLUSION

This review supports the beneficial effects of music-based interventions on the health of preterm infants in a neonatal intensive care unit; however, it also offers suggestions for future studies in order to increase the number of interventions with music therapists, since the results of music therapy approaches were more consistent for physiological and behavioural outcomes.

Maternal Singing but Not Speech Enhances Vagal Activity in Preterm Infants during Hospitalization: Preliminary Results

BACKGROUND

Early parental interventions in the Neonatal Intensive Care Units (NICUs) have beneficial effects on preterm infants' short and long-term outcomes. The aim of this study was to investigate the effects of Early Vocal Contact (EVC)-singing and speaking-on preterm infants' vagal activity and autonomic nervous system (ANS) maturation.

METHODS

In this multi-center randomized clinical trial, twenty-four stable preterm infants, born at 25-32 weeks gestational age, were randomized to either the EVC group or control group, where mothers did not interact with the babies but observed their behavior. Heart Rate Variability (HRV) was acquired before intervention (pre-condition), during vocal contact, and after it (post condition).

RESULTS

No significant effect of the vocal contact, singing and speaking, was found in HRV when the intervention group was compared to the control group. However, a significant difference between the singing and the pre and post conditions, respectively, preceding and following the singing intervention, was found in the Low and High Frequency power nu, and in the low/high frequency features (p = 0.037). By contrast, no significant effect of the speaking was found.

CONCLUSIONS

Maternal singing, but not speaking, enhances preterm infants' vagal activity in the short-term, thus improving the ANS stability. Future analyses will investigate the effect of enhanced vagal activity on short and long-term developmental outcomes of preterm infants in the NICU.

Autonomic development in preterm infants is associated with morbidity of prematurity

BACKGROUND

Previous studies have described an association between preterm birth and maturation of the autonomic nervous system (ANS); however, this may be impacted by multiple factors, including prematurity-related complications. Our aim was to evaluate for the effect of prematurity-related morbidity on ANS development in preterm infants in the NICU.

METHODS

We compared time and frequency domains of heart rate variability (HRV) as a measure of ANS tone in 56 preterm infants from 2 NICUs (28 from each). One cohort was from a high-morbidity regional referral NICU, the other from a community-based inborn NICU with low prematurity-related morbidity. Propensity score matching was used to balance the groups by a 1:1 nearest neighbor design. ANS tone was analyzed.

RESULTS

The two cohorts showed parallel maturational trajectory of the alpha 1 time-domain metric, with the cohort from the high-morbidity NICU having lower autonomic tone. The maturational trajectories between the two cohorts differed in all other time-domain metrics (alpha 2, RMS1, RMS2). There was no difference between groups by frequency-domain metrics.

CONCLUSIONS

Prematurity-associated morbidities correlate with autonomic development in premature infants and may have a greater impact on the extrauterine maturation of this system than birth gestational age.

IMPACT

Autonomic nervous system development measured by time-domain metrics of heart rate variability correlate with morbidities associated with premature birth. This study builds upon our previously published work that showed that development of autonomic tone was not impacted by gestational age at birth. This study adds to our understanding of autonomic nervous system development in a preterm extrauterine environment. Our study suggests that gestational age at birth may have less impact on autonomic nervous system development than previously thought.

Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications

BACKGROUND

Neonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies.

OBJECTIVES

To describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed.

ELIGIBILITY CRITERIA

Human neonates ≤1 month of corrected age.

SOURCES OF EVIDENCE

A protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center's librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020.

CHARTING METHODS

A single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction).

RESULTS

Of the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band.

CONCLUSIONS

Neonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.

Parents' Perception of Family-Centered Music Therapy with Stable Preterm Infants

Premature birth places considerable demands on preterm infants and their families. Most of these infants are treated on a neonatal intensive care unit immediately after birth, leading to psychosocial stress for parents and making it more difficult to build a stable parent-child bond. We hypothesized that accompaniment with live music therapy by a music therapist supports the parents to get in contact with their child and to promote the parents’ wellbeing. Preterm infants born at less than 32 gestational weeks received creative music therapy twice a week until discharge. At the time of discharge, the parents were asked to complete a Likert-style questionnaire to evaluate the music therapy. Six items related to socio-demographic characteristics, 4 items to observations on the infant and 10 items to personal perception. Of 40 preterm infants receiving music therapy, 32 (80%) parents completed the questionnaires. Thirty (94%) of these parents were able to relax during the music therapy session. Relaxation in their infants was observed by 29 (91%) during and by 28 (88%) after music therapy. Parents perceived music therapy as a positive change and enrichment during their infant’s hospital stay. All parents were thankful for the music therapy they received. Music therapy supports the parents of preterm infants in the first time after birth until discharge from the hospital.

Music therapy for preterm neonates in the neonatal intensive care unit: An overview of systematic reviews

AIM

To summarise the quantity and quality of evidence for using music therapy for preterm infants in the neonatal intensive care unit (NICU).

METHODS

We performed an overview of evidence for the effectiveness and safety of MT for preterm infants in the NICU. We performed a random-effects meta-analysis of data from studies that fit the definition of MT.

RESULTS

We identified 12 eligible systematic reviews and the methodological quality by AMSTAR-2 ranged from moderate to critically low. We identified 14 eligible randomised trials and 7 observational studies where the intervention fits the definition of MT. Meta-analysis of the RCTs showed that MT significantly decreases heart rate, mean difference (MD) (95% CI), -3.21 [-5.22, -1.19], respiratory rate, MD -2.93 [-5.65, -0.22], and maternal anxiety, MD -17.50 [-20.10, -14.90], and increases feeding volume, MD 29.59 [12.79, 46.38]. Long-term neurodevelopmental or safety outcomes were not reported. GRADE assessment of outcomes ranged from low to very low, downgraded for high risk of bias in the included studies, inconsistency and imprecision.

CONCLUSION

Low to very low certainty evidence suggests that MT in preterm infants improves short-term physiological parameters, feeding and maternal anxiety but safety and long-term outcomes were not reported.

Effects of Live Music Therapy on Autonomic Stability in Preterm Infants: A Cluster-Randomized Controlled Trial

Unbuffered stress levels may negatively influence preterm-infants’ autonomic nervous system (ANS) maturation, thus affecting neurobehavior and psycho-emotional development. Music therapy (MT) is an evidence-based treatment modality in neonatal care. When coupled with skin-to-skin care (SSC), it may reduce stress responses in both preterm infants and their parents and enhance family-centered care. Accordingly, we aimed to compare the effects of combined MT and SSC and SSC alone on ANS stabilization in preterm infants. In a single-center, cluster-randomized trial design, ten two-month time-clusters were randomized to either combined MT and SSC or SSC alone. Families of preterm infants were offered two sessions of the allocated condition in the NICU, and a three-month follow up session at home. The primary outcome variable was stabilization of the ANS, defined by change in the high frequency (HF) power of heart rate variability (HRV) during the second session. Secondary outcomes included other HRV measures, parent–infant attachment, and parental anxiety at each session. Sixty-eight families were included. MT combined with SSC improved infants’ ANS stability, as indicated by a greater increase in HF power during MT compared to SSC alone (mean difference 5.19 m²/Hz, SE = 1.27, p < 0.001) (95% confidence interval 0.87 to 2.05). Most secondary outcomes were not significantly different between the study groups. MT contributes to preterm-infants’ autonomic stability, thus laying an important foundation for neuro-behavioral and psycho-emotional development. Studies evaluating longer-term effects of MT on preterm infants’ development are warranted.

Parental Book-Reading to Preterm Born Infants in NICU: The Effects on Language Development in the First Two Years

Background: After preterm birth, infants are at high risk for delays in language development. A promising intervention to reduce this risk is represented by the exposure to parental voices through book-reading in Neonatal Intensive Care Units (NICU). This study investigated the possible advantages of book-reading to preterm neonates during their NICU stay on their subsequent language development. Methods: 100 families of preterm infants were recruited. The parents of 55 preterm infants (Reading Group) received a colored picture-book on NICU admission and were supported to read to their neonate as often as possible and to continue after hospital discharge. Forty-five infants (Control Group) were recruited before the beginning of the intervention. Infant language development was assessed with the Hearing and Language quotients of the Griffith Mental Development Scale at the corrected ages of 3, 6, 9, 12, 18 and 24 months. Results: Regardless of group membership, Hearing and Language mean quotients decreased between 9 and 18 months; nevertheless, this decrease was considerably reduced in the Reading group, compared to the Control Group. Conclusions: Reading in NICUs represents a suitable intervention that could positively influence language development and parent-infant relationships in preterm children. The study findings support its implementation as a preventive measure.

Psychosocial and Neurobiological Vulnerabilities of the Hospitalized Preterm Infant and Relevant Non-pharmacological Pain Mitigation Strategies

Background: Preterm pain is common in the Neonatal Intensive Care Unit (NICU), with multiple invasive procedures occurring daily. Objective: To review the psychosocial and neurobiological vulnerabilities of preterm infants and to provide an updated overview of non-pharmacological strategies for acute procedural pain in hospitalized preterm infants. Methods: We utilized a narrative review methodology, which also included a synthesis of key pieces of published systematic reviews that are relevant to the current work. Results and Conclusions: Preterm infants are uniquely susceptible to the impact of painful procedures and prolonged separation from caregivers that are often inherent in a NICU stay. Non-pharmacological interventions can be efficacious for mitigating procedural pain for preterm infants. Interventions should continue to be evaluated with high quality randomized controlled trials, and should endeavor to take into account the neurobiological and psychosocial aspects of preterm vulnerability for pain prevention and management strategies.

Available Instruments to Assess Pain in Infants

Pain assessment in newborns and infants is challenging for clinicians. Although behavioral and behavioral-physiological scales are validated pain assessment instruments, their use in this age group has significant limitations. In this review, we summarize the methods currently available for assessing pain in neonates and infants. It is possible that these pain detection methods are also useful for assessing the quality of anesthesia and analgosedation in these populations. Further research should be aimed at confirming the usefulness of these tools in infants and identifying additional pain assessment options for clinical practice.

Cerebral oxygenation in preterm infants during maternal singing combined with skin-to-skin care

BACKGROUND

Our aim was to investigate the effect of music therapy in combination with skin-to-skin care (SSC) on regional cerebral oxygenation (rSO₂) measured with near-infrared spectroscopy (NIRS) in premature infants and to study physiological stability during the interventions.

METHODS

This was a prospective single-center observational cohort study conducted in a tertiary neonatal intensive care unit. The study consisted of four phases: (1) baseline measurements in an incubator for 30 min; (2) quiet SSC for 30 min (SSC-Pre); (3) SSC with live maternal singing accompanied by live guitar music for 20 min (SSC-Music); (4) final quiet SSC for another 30 min (SSC-Post).

RESULTS

The primary outcome measure of mean rSO₂ for the 31 preterm infants analyzed showed a significant increase from baseline during SSC-Music (76.87% vs 77.74%, p = 0.04) and SSC-Post (76.87% vs 78.0%, p = 0.03) phases. There were no significant changes observed in heart rate (HR), peripheral oxygen saturation (SpO₂), and cerebral fractional tissue oxygen extraction (cFTOE). The coefficient of variation (CV) of rSO₂ and SpO₂ decreased during each intervention phase.

CONCLUSION

Combining music therapy with SSC appears to be safe in preterm neonates. The impact of the small increase in rSO₂ and reduced variability of SpO₂ and rSO₂ warrants further investigation.

IMPACT

Music therapy combined with skin-to-skin care (SSC) is safe in clinically stable premature infants and could be encouraged as part of developmental care. This is the first report where near-infrared spectroscopy (NIRS) was used to detect the simultaneous effect of music therapy and SSC on cerebral rSO₂ in preterm infants. Music therapy with SSC caused a modest increase in rSO₂ and decreased the coefficient of variation of rSO₂ and peripheral oxygen saturation (SpO₂), which suggest short-term benefits for preterm infants.

Maternal Stress, Depression, and Attachment in the Neonatal Intensive Care Unit Before and During the COVID Pandemic: An Exploratory Study

The main aim of the present study was to investigate the effects of the COVID-19 pandemic on the mothers' postnatal depression, stress, and attachment during their stay in the Neonatal Intensive Care Unit (NICU). Twenty mothers of very premature infants born before 32weeks of gestational age were recruited at the Geneva University Hospital between January 2018 and February 2020 before the COVID-19 pandemic started. Mothers were screened for postnatal depression after their preterm infant's birth (Edinburgh Postnatal Depression Scale, EPDS), then for stress (Parental Stressor Scale: Neonatal Intensive Care Unit, PSS:NICU), and attachment (Maternal Postnatal Attachment Scale, MPAS) at infant's term-equivalent age. Data were compared with 14 mothers recruited between November 2020 and June 2021 during the COVID-19 pandemic. No significant differences were found in the scores for depression, stress, and attachment between the two groups. However, a non-statistically significant trend showed a general increase of depression symptoms in mothers during the COVID-19 pandemic, which significantly correlated to the attachment and stress scores. Moreover, the PSS:NICU Sights and Sounds score was significantly positively correlated with EPDS scores and negatively with the MPAS score only in the During-COVID group. To conclude, we discussed a possible dampened effect of the several protective family-based actions that have been adopted in the Geneva University Hospital during the health crisis, and we discussed the most appropriate interventions to support parents in this traumatic period during the COVID-19 pandemic.

Potential Psychological and Biological Mechanisms Underlying the Effectiveness of Neonatal Music Therapy during Kangaroo Mother Care for Preterm Infants and Their Parents

Neonatal music therapy (MT) has become more accessible worldwide. Previous research suggests multiple benefits of MT for preterm infants and their caregivers; however, far too little attention has been paid to understanding the mechanisms of change in previous Neonatal Intensive Care Unit (NICU)-MT research so far. This perspective article describes potential mechanisms of MT interventions exposed during kangaroo mother care on the preterm infant's response (behavioral and physiological outcomes) and the mother-infant relationship. The paper focuses on the hypothalamic-pituitary-adrenal axis' role in stabilization of behavioral state, the autonomic nervous system's role in stabilization of physiologic state, as well as co-regulation as a potential mechanism for the developing of the parent-infant relationship. Mechanisms play a pivotal role in understanding variables related to the therapy course and well as in generating new knowledge regarding treatment susceptibility and optimizing resources. Understanding of the mechanisms of how interventions may lead to specific outcomes plays an important role in addressing the issue of improvement of currently available approaches of MT used in the NICU.

NICU music therapy effects on maternal mental health and preterm infant's emotional arousal

In recent decades, music therapy in the Neonatal Intensive Care Unit (NICU) has been shown to regulate preterm infant's physiological responses and improve maternal mental health. This study investigated the effects of the music therapy intervention for the mother-preterm infant dyad (MUSIP) for maternal anxiety, postnatal depression, and stress, and preterm infants' weight gain, length of hospitalization, heart rate (HR), and oxygen saturation (So₂ ). A pre-experimental design was used with 33 mother-preterm infant dyads in a Brazilian NICU: 16 dyads in the Music Therapy Group (MTG) and 17 dyads in the Control Group (CG). The MTG took part in the MUSIP, aimed at supporting maternal singing with the preterm baby. Infants' HR and So₂ were recorded at each minute from 10 min before to 10 min after sessions 1, 3, and 6. Before infants' discharge, maternal anxiety and depression scores were lower in the MTG compared to the CG. Anxiety, depression, and stress levels decreased significantly after the intervention in the MTG. With regard to infants, HR and So₂ ranges were higher during music therapy, compared to before and after sessions. MUSIP improved maternal mental health and affected preterm infants' emotional arousal, with positive trends in decreasing HR, stabilizing So₂ , and reducing length of hospitalization.

The Importance of Rhythmic Stimulation for Preterm Infants in the NICU

The fetal environment provides the fetus with multiple potential sources of rhythmic stimulation that are not present in the NICU. Maternal breathing, heartbeats, walking, dancing, running, speaking, singing, etc., all bathe the fetus in an environment of varied rhythmic stimuli: vestibular, somatosensory, tactile, and auditory. In contrast, the NICU environment does not offer the same proportion of rhythmic stimulation. After analyzing the lack of rhythmic stimulation in the NICU, this review highlights the different proposals for vestibular and/or auditory rhythmic stimulation offered to preterm infants alone and with their parents. The focus is on the beneficial effects of auditory and vestibular stimulation involving both partners of the mother-infant dyad. A preliminary study on the influence of a skin-to-skin lullaby on the stability of maternal behavior and on the tonic emotional manifestations of the preterm infant is presented as an example. The review concludes with the importance of introducing rhythmic stimulations in the NICU.

Parental Attitudes toward Consent for Music Intervention Studies in Preterm Infants: A Cross-Sectional Study

(1) Background: This study investigated parents' motives for enrolling preterm infants into music therapy intervention studies during Neonatal Intensive Care hospitalization. (2) Methods: We surveyed Israeli parents of preterm infants after they consented or refused to participate in such studies. The pre-piloted questionnaires evaluated attitudes toward research and music therapy intervention studies. The study included 116 (57%) parents who agreed to participate in music therapy studies and 87 (43%) who declined. (3) Results: Infants of those who agreed to participate were younger (17 ± 2.3 vs. 28 ± 4.7 days old, p = 0.03) and sicker (Clinical Risk Index for Babies score 6.1 ± 2.7 vs. 3.68 ± 4.1, p = 0.04). More single-parent families declined to participate (p = 0.05). Parents agreed to participate because they thought the study might help their child, would improve future care of preterm infants and increase medical knowledge (all p < 0.05). In addition, they perceived music as beneficial for brain development, thought it might improve bonding, and routinely listened to music daily. (4) Conclusions: When recruiting parents and preterm infants for music therapy intervention studies, one should highlight potential contributions to the child's health, future children's health and medical knowledge. Stressing music as a potential tool for brain development and augmenting bonding is important. The best time to recruit is when improvements are still anticipated.

Combining Kangaroo Care and Live-Performed Music Therapy: Effects on Physiological Stability and Neurological Functioning in Extremely and Very Preterm Infants

Interventions such as kangaroo care (KC) and live-performed music therapy (LPMT), are increasingly used to facilitate stress reduction in neonates. This study aims to investigate the effect of combining the two on physiological responses and neurological functioning in very preterm infants. Infants received six sessions of LPMT. KC was added to one LPMT session. Physiological responses included heart rate, respiratory rate and oxygen saturation. We videotaped infants for 30 min before and after two sessions to assess general movements (GMs). We included 17 infants, gestational age median 26.0 weeks (IQR 25.6–30.6 weeks), of whom six were males. Combined interventions showed a decrease in heart rate from mean 164 bpm before to 157 bpm during therapy, p = 0.001. Oxygen saturation levels increased during combination therapy from median 91.4% to 94.5%, p = 0.044. We found no effects of LPMT or combined interventions on GMs. Infants with a postnatal age (PNA) <7 days generally seem to display less optimal GMs after therapy compared with infants with a PNA >7 days. In conclusion, combining interventions is equally beneficial for physiological stability and neurological functioning as LPMT alone. Future studies should focus on the effects of this combination on parent-infant bonding.

Parental Perception of Vocal Contact with Preterm Infants: Communicative Musicality in the Neonatal Intensive Care Unit

In this study, we evaluate mothers’ subjective experience of speaking and singing to their infants while they are in their incubators. We also discuss the relevance of the theoretical framework of Communicative Musicality for identifying the underlying mechanisms that may help explain its beneficial effects, both for parents and infants. Nineteen mothers talked and sung to their stable preterm infants in the incubators, for 5 min each, in three sessions over a period of 6 days. After each session, mothers were asked to assess in a self-report questionnaire the ease and the effectiveness of addressing their infants by speaking and singing and their prior musical experience. Perceived ease and effectiveness in communication were found to increase progressively from one session to the next. Mothers rated the speech to be increasingly more effective. This intuitive mean of interaction between parents and infants could be encouraged and supported by the nurses and the medical staff. Furthermore, individual musical experience affects perceived ease of communicating vocally with infants after a premature birth and should thus be encouraged during pregnancy.

Family-centered music therapy-Empowering premature infants and their primary caregivers through music: Results of a pilot study

BACKGROUND

In Neonatal Intensive Care Units (NICUs) premature infants are exposed to various acoustic, environmental and emotional stressors which have a negative impact on their development and the mental health of their parents. Family-centred music therapy bears the potential to positively influence these stressors. The few existing studies indicate that interactive live-improvised music therapy interventions both reduce parental stress factors and support preterm infants' development.

METHODS

The present randomized controlled longitudinal study (RCT) with very low and extremely low birth weight infants (born <30+0 weeks of gestation) and their parents analyzed the influence of music therapy on both the physiological development of premature infants and parental stress factors. In addition, possible interrelations between infant development and parental stress were explored. 65 parent-infant-pairs were enrolled in the study. The treatment group received music therapy twice a week from the 21st day of life till discharge from hospital. The control group received treatment as usual.

RESULTS

Compared to the control group, infants in the treatment group showed a 11.1 days shortening of caffeine therapy, 12.1 days shortening of nasogastric/ orogastric tube feed and 15.5 days shortening of hospitalization, on average. While these differences were not statistically significant, a factor-analytical compound measure of all three therapy durations was. From pre-to-post-intervention, parents showed a significant reduction in stress factors. However, there were no differences between control and treatment group. A regression analysis showed links between parental stress factors and physiological development of the infants.

CONCLUSION

This pilot study suggests that a live-improvised interactive music therapy intervention for extremely and very preterm infants and their parents may have a beneficial effect on the therapy duration needed for premature infants before discharge from hospital is possible. The study identified components of the original physiological variables of the infants as appropriate endpoints and suggested a slight change in study design to capture possible effects of music therapy on infants' development as well. Further studies should assess both short-term and long-term effects on premature infants as well as on maternal and paternal health outcomes, to determine whether a family-centered music therapy, actually experienced as an added value to developmental care, should be part of routine care at the NICU.

Preterm infants with severe brain injury demonstrate unstable physiological responses during maternal singing with music therapy: a randomized controlled study

Preterm infants with severe brain injury are at high risk for poor outcomes and, therefore, may benefit from developmental care modalities such as music therapy (MT). In this prospective, randomized intervention, preterm infants with severe brain injury (grade 3 or 4 intraventricular hemorrhage or periventricular leukomalacia) who underwent skin-to-skin contact (SSC) with or without maternal singing during MT were evaluated for physiological responses, including autonomic nervous system stability (low frequency (LF)/high frequency (HF) power), heart rate, respiratory rate, oxygen saturation, and behavioral state. Maternal anxiety state and physiological data were also evaluated. A total of 35 preterm infants with severe brain injuries were included in the study analysis. Higher mean ± standard deviation (SD) LF/HF ratio (1.8 ± 0.7 vs. 1.1 ± 0.25, p = 0.01), higher mean ± SD heart rate (145 ± 15 vs. 132 ± 12 beats per minute, p = 0.04), higher median (interquartile range) infant behavioral state (NIDCAP manual for naturalistic observation and the Brazelton Neonatal Behavioral Assessment) score (3 (2-5) vs. 1 (1-3), p = 0.03), and higher mean ± SD maternal anxiety (state-trait anxiety inventory) score (39.1 ± 10.4 vs. 31.5 ± 7.3, p = 0.04) were documented in SSC combined with maternal singing during MT, as compared to SSC alone.Conclusion: Maternal singing during MT for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. A unique MT intervention should be designed for preterm infants with severe brain injury and their mothers. What is Known: • Preterm infants with severe brain injury are at high risk for poor outcomes. • Music therapy benefits brain development of preterm infants without severe brain injury, however it is unknown whether maternal singing during music therapy for preterm infants with severe brain injury is beneficial. What is New: • Maternal singing during music therapy for preterm infants with severe brain injury induces physiological and behavioral instability and increases maternal anxiety during NICU hospitalization. • A unique music therapy intervention should be designed for preterm infants with severe brain injury and their mothers.

Parent-Infant Skin-to-Skin Contact and Stress Regulation: A Systematic Review of the Literature

Several studies have focused on neonatal maternal separation (MS) to investigate behavioural and neuroendocrine reactions to lack of contact, but only a few have focused on early separation in the first days or weeks after birth. This literature review investigates the vital importance of contact and touch by exploring how skin-to-skin contact (SSC) regulates stress in the mother-infant relationship. Various databases such as PubMed, Scopus, and ScienceDirect were searched for literature published between 2015 and 2020. From 1141 articles, 22 were declared eligible. The reviewed articles showed how SSC regulates child stress by biological indicators such as the autonomic nervous system (ANS), heart rate variability (HRV), cortisol, and oxytocin. This research concludes the importance of SSC for stress regulation, especially during the COVID-19 pandemic. With no research to date indicating a possible risk of neonatal COVID-19 transmission following SSC, SSC should continue to be practiced for all women, as recommended by the WHO.

An acute dose of intranasal oxytocin rapidly increases maternal communication and maintains maternal care in primiparous postpartum California mice

Maternal-offspring communication and care are essential for offspring survival. Oxytocin (OXT) is known for its role in initiation of maternal care, but whether OXT can rapidly influence maternal behavior or ultrasonic vocalizations (USVs; above 50 kHz) has not been examined. To test for rapid effects of OXT, California mouse mothers were administered an acute intranasal (IN) dose of OXT (0.8 IU/kg) or saline followed by a separation test with three phases: habituation with pups in a new testing chamber, separation via a wire mesh, and finally reunion with pups. We measured maternal care, maternal USVs, and pup USVs. In mothers, we primarily observed simple sweep USVs, a short downward sweeping call around 50 kHz, and in pups we only observed pup whines, a long call with multiple harmonics ranging from 20 kHz to 50 kHz. We found that IN OXT rapidly and selectively enhanced the normal increase in maternal simple sweep USVs when mothers had physical access to pups (habituation and reunion), but not when mothers were physically separated from pups. Frequency of mothers' and pups' USVs were correlated upon reunion, but IN OXT did not influence this correlation. Finally, mothers given IN OXT showed more efficient pup retrieval/carrying and greater total maternal care upon reunion. Behavioral changes were specific to maternal behaviors (e.g. retrievals) as mothers given IN OXT did not differ from controls in stress-related behaviors (e.g. freezing). Overall, these findings highlight the rapid effects and context-dependent effect a single treatment with IN OXT has on both maternal USV production and offspring care.

Effects of Early Vocal Contact in the Neonatal Intensive Care Unit: Study Protocol for a Multi-Centre, Randomised Clinical Trial

Preterm infants are at risk for developing altered trajectories of cognitive, social, and linguistic competences compared to a term population. This is mainly due to medical and environmental factors, as they are exposed to an atypical auditory environment and simultaneously, long periods of early separation from their parents. The short-term effects of early vocal contact (EVC) on an infant’s early stability have been investigated. However, there is limited evidence of its impact on the infant’s autonomic nervous system maturation, as indexed by heart rate variability, and its long-term impact on infant neurodevelopment. Our multi-centric study aims to investigate the effects of EVC on a preterm infant’s physiology, neurobehaviour, and development. Eighty stable preterm infants, born at 25–32 weeks and 6 days gestational age, without specific abnormalities, will be enrolled and randomised to either an intervention or control group. The intervention group will receive EVC, where mothers will talk and sing to their infants for 10 min three times per week for 2 weeks. Mothers in the control group will be encouraged to spend the same amount of time next to the incubator and observe the infant’s behaviour through a standard cluster of indicators. Infants will be assessed at baseline; the end of the intervention; term equivalent age; and 3, 6, 12, and 24 months corrected age, with a battery of physiological, neurobehavioral, and developmental measures. Early interventions in the neonatal intensive care unit have demonstrated effects on the neurodevelopment of preterm infants, thereby lowering the negative long-term effects of an atypical auditory and interactional environment. Our proposed study will provide new insight into mother–infant early contact as a protective intervention against the sequelae of prematurity during this sensitive period of development. Early intervention, such as EVC, is intuitive and easy to implement in the daily care of preterm infants. However, its long-term effects on infant neurodevelopment and maternal sensitivity and stress are still unclear. Trial Registration: NCT04759573, retrospectively registered, 17 February 2021.

Nurturing and quiet intervention (NeuroN-QI) on preterm infants' neurodevelopment and maternal stress and anxiety: A pilot randomized clinical trial protocol

OBJECTIVES

Primary objective of this pilot study is to evaluate the feasibility and acceptability of the NeuroN-QI and the study procedures. Secondary objectives are to assess the feasibility and acceptability of the NeuroN-QI by the nurses, assess the nurses' training needs about the components of the NeuroN-QI, and estimate the preliminary effects of the NeuroN-QI on infants' neurodevelopment as well as maternal stress and anxiety at infants' 36 weeks of gestational age.

DESIGN

A two-group pilot parallel randomized clinical trial stratified by center.

METHODS

The pilot study will be conducted in two neonatal intensive care units (NICUs). A sample of 24 mother-infant dyads born between 26 and 31^6/7 gestational age will be randomized into an experimental or control group. Fifty nurses will be recruited. The NeuroN-QI consists of four 2-hour skin-to-skin contact sessions/week with a 15-minute auditory stimulation by mothers with controlled ambient levels of light and noise. A 1-hour quiet period will follow where infants will rest in their incubator/crib with their mother's milk for olfactory stimulation and where the light and noise control will be continued. In the control group, mother-infant dyads will do four skin-to-skin contacts per week and receive standard care. Acceptability and feasibility of the NeuroN-QI in addition to maternal stress and anxiety will be measured through questionnaires, while infants' neurodevelopment will be assessed with Assessment of Preterm Infant Behaviour and General Movement Assessment.

CONCLUSIONS

This pilot trial will address knowledge gaps and generate evidence in neonatal care by evaluating the feasibility and acceptability of a multi-component developmental care intervention.

IMPACT

This project is an innovative step towards optimizing the neurodevelopmental trajectory of infants in NICUs and consequently promoting their long-term health outcomes.

TRIAL REGISTRATION

NCT04593095.