PERINATAL STRESS REDUCTION, MUSIC AND MEDICAL COST SAVINGS

Fred J. Schwartz, M.D.

Some of the benefits of music in the labor and delivery suite that complement anesthesia are that it speeds up labor and decreases the amount of pain. It also decreases the stress response to labor which is beneficial to both mother and newborn. Couples coming to a delivery suite frequently perceive it as a foreign and unfamiliar environment. The act of choosing a musical program for childbirth allows a couple to exert some control over their environment. Music is very personal in that a particular piece may have a connection with certain past experiences and emotions. This acoustical painting of the hospital environment has been shown to make it less hostile and less anxiety provoking for patients. Since pain and enjoyment emerge as two distinct, though related dimensions of the birth process, music can express both the struggle and the joy of the occasion. The beauty here is that the benefits of the music can be utilized during natural childbirth, with childbirth under epidural anesthesia, and if need be during Cesarean section. Music can help the newborn know that a special event is happening and when the newborn comes into this world the music along with the familiar sound of voices is indeed special.

Music is particularly useful during Cesarean sections. Most anesthetics for C-sections are performed under epidural or spinal anesthesia. The pregnant mother is anesthetized from the chest down, while usually no intravenous sedatives or narcotics are given to the mother until the baby is born, because these can cause sedation or respiratory depression in the newborn. There is often some degree of discomfort for mother before the baby is born, when the uterus is manipulated. Music is an effective way to decrease the discomfort here. I try to get a feel for what the couple and their unborn child find soothing. If they don’t have an idea of what they want to hear, I usually suggest classical music or new age music. To me, this type of music fits beautifully with C-sections. To give you an idea of the contrast of requests I have had I will relate to you a Friday evening when there were 3 C-sections in a row to do. The first 2 were done to Beethoven Piano Sonatas. Our last couple was asked what they and their baby wanted to hear, and the mother replied, "My baby only likes rock & roll, but you have to play it real loud. She picked Bruce Springstein’s Born in the USA and this did seem fitting for the occasion.

An exaggerated stress response has negative effects during pregnancy and childbirth, just as it is detrimental in most disease processes. Most of the physiologic effects of stress are mediated through stress hormones called catecholamines. In the pregnant patient, elevated levels of these stress hormones cause decreased effectiveness of uterine contractions (Simkin, 1986). Some of these patients end up needing C-sections because of this. Intense anxiety has been associated with fetal death in the 3^rd trimester (Myers & Myers, 1979). More commonly, the extremely anxious patient in labor will have high catecholamine levels which decrease placental blood flow and can cause fetal distress. This is further compounded if the laboring patient hyperventilates, which can further decrease placental blood flow.

Music’s ability to slow respiratory rates and decrease the stress response is beneficial during labor. It has been shown to have the ability to shorten labor (Winokur, 1984). Even when the course of labor does not speed up when music is utilized, the perceived length of labor decreases (Clark, McCorkle & Williams, 1981). Other studies have shown that when music is played, pain is decreased (McKinney, 1990, Hanser, Larson & O’Connell, 1983.

FETAL AUDITORY ENVIRONMENT

The sounds and rhythm of the placental blood flow are a major part of what the fetus hears. Some earlier studies had been done by Dr. Lee Salk (1973), who noticed that most new mothers exhibited a natural preference for holding their infants on the left side of their chest near the heart. Dr. Salk analyzed a number of then popular books containing a large number of photographs and artistic representations of infants and adults. Almost 80% of these showed mothers holding their infants on the left side of their chests. This preference extended across all cultures. Balancing groups for left and right-sided dominance, Dr. Salk then replicated this left-sided preference in a large group of new mothers and babies (and used these heart sounds to calm newborns in the hospital nursery). He reasoned that there is an imprinting of the placental sound in utero so that similar sounds after birth have a functional connection with the original experience. This would explain some of the rhythmic similarities of modern music to intrauterine rhythms.

Others have connected the similarities between womb sounds and the "nonsense sounds" that mothers use in talking to their babies. Some of these calming sounds are "hush", "shush", "shah"(Yiddish), "ushuru"(Ethiopian), and "enshallah"(Egyptian). Perhaps the similarities to womb sounds also explain the spiritual use of similar sounds in different religions, i.e. Om(Buddhism), Shalom(Hebrew), Tibetan overtone chanting, Gregorian chants.

Ultrasound studies have shown that at 16 weeks gestation the fetus can respond to outside sound (Hepper, 1994, Shahidullah & Hepper, 1992). The sounds of the blood flow through the placenta can be heard at a loud level in the womb. These sound levels are highest for the lower sound frequencies below 500 Hz, (Gerhardt & Abrams, 1996). This is about as loud as it gets on a crowded dance floor on a Saturday night. A good deal of attention has been given to the so called "Mozart Effect" where exposure to this music increased spatial IQ in college students (Rauscher, Shaw & Ky, 1995), as well as work with preschool children which showed that music training can enhance language development, spatial and mathematical abilities (Rauscher, et al, 1997). Evidence points to the fact that similar learning benefits extend far back into the prenatal period, and that the sounds and rhythms in the womb may contain information important to the development of the fetal brain (Devlin, Daniels & Roeder, 1997, Shetler, 1989). The newborn can differentiate a recording of his own mother’s prenatal womb sounds from a recording of another mother (Righetti, 1996). The newborn can also differentiate emotional content in the recording of his prenatal womb sounds and respond with changes in movement and heart rate (Righetti, 1996). us supplier mugen power longer life batteries for T-mobile MyTouch 3G Slide

There is a vast amount of potential information available to the fetus that can be given in the playing of just one musical note or in singing or talking a single syllable. The content of this sound is full of informational and emotional content that can accessed and used by the fetus in many deep, profound ways. The synaptic network in the fetal brain as well as the infant brain undergoes learning dependant reorganization. This process involves synaptic pruning, the regression of neural circuits as well as the synaptic sprouting of the developing brain. This is consistent with the observation of psychologists that infants and children may have enhanced behavioral abilities that diminish later in life (Johnston, 1995). Since fetal hearing is probably the major component of this learning dependent synaptic pruning and sprouting, the fetus is participating in a 2^nd and 3^rd trimester auditory amphitheater that is perhaps more important that any other classroom. It is apparent that we have only begun to explore the connection between sound and neurobiological development in the fetus and newborn.

A subsequent study showed that stimulation with the TransitionsTM, womb sound music was helpful in the care of mechanically ventilated, agitated premature babies with low oxygen levels. Significant increases in oxygen saturation as well as decreased levels of agitation were found with the use of music (Collins & Kuck, 1991).

Another study showed that when lullaby music was played in the neonatal intensive care unit (NICU) that there were less episodes of oxygen desaturation (Caine, 1991). There is no doubt that some of the high decibel sounds from alarms and equipment in the NICU are harmful to the neonate. In one study a group of premature babies were insulated from their audio environment with earmuffs (Zahr & Traversay, 1995). They had higher oxygen saturations and more time in the sleep state compared to a control group. Several other studies have shown a doubled daily weight gain when premature babies in the NICU were exposed to music therapy (Caine, 1991, Coleman, Pratt & Abel, 1996). Additional studies using music with premature babies have shown a 3 to 5 day earlier discharge from the NICU (Caine, 1991, Coleman, Pratt & Abel, 1996, Standley, 1996).

Some of the critical elements for growth and earlier discharge from the NICU are decreased blood oxygen availability and increased oxygen consumption from stress. The increased stress response also consumes precious calories. It is clear that the use of music therapy not only has a beneficial effect on the growth and development of these premature babies, but may lead to cost savings in their medical care, which is a significant problem for modern society. In the United States alone, the extra cost of intensive care for these low birth weight infants is over 1,000 dollars a day per baby or over 3.5 billion dollars a year. The added costs of special education and continued cost of medical care for these children are larger than the initial costs for their NICU care (Lewit, et al, 1995). Many of these babies suffer hearing and visual disabilities, mental retardation, cerebral palsy or learning disabilities. Ultimately the costs are those experienced by human beings who are not able to realize their full potential.

So it appears that by a relatively small expenditure for music in our neonatal ICU’s we can decrease the time in the NICU by over 3 days and save over 3,000 US dollars for every premature baby.

Premature birth is the predominant cause of low birth weight and neonatal mortality in the United States (Wegman, 1996). The fact remains that in the US almost 1 out of every hundred babies dies shortly after birth. (Paneth, 1995). This is the highest rate of all the industrialized countries. Despite all our best efforts, the consequences of premature labor will continue to be a huge problem for society. A large amount of attention has been given to the prevention of preterm labor. Despite a large amount of research and funds dedicated to programs to prevent preterm labor, the incidence of prematurity in the US has not decreased (Paneth, 1995).

A number of factors have been associated with the risk of prematurity and low birth weight (Table 1). Many of these factors are interrelated. In the United States, a large amount of these premature births occur in the adolescents, who as a group have higher rates of poverty, lack of prenatal care, poor nutrition, stress, tobacco use, alcohol intake, and drug abuse (Shiono & Berman, 1995, Hedegaard, Henriksen & Niels, 1996).

TABLE 1: FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT

1. Age below 18 years
2. Lack of prenatal care
3. Maternal stress
4. Poverty
5. Tobacco use
6. Drug and alcohol use
7. Previous preterm delivery
8. Infection

To gain more insight into premature birth it is interesting to look at some of what we know about how labor is inititiated. Thousands of years ago, Hippocrates believed that the baby decides when the birth process begins. There is now good evidence to show that the fetus does initiate labor (Nathanielsz, 1995). Evidence points to fetal initiation of labor about 2 to 3 weeks before birth. In the fetal brain, the hypothalamus increases secretion of CRH (corticotrophin releasing hormone) and this stimulates the pituitary to release ACTH (adrenocorticotrophin). This stimulates the fetal adrenal cortex to secrete cortisol. The placenta then produces more estrogen and less progesterone and this eventually sets off the contractions of labor.

Since we know that the fetus is involved in initiating labor it is interesting to speculate on why the fetus would initiate premature birth. We do know that pregnancies that contain a lot of stress are more inclined to be concluded prematurely. And that tobacco and cocaine use increase the stress response in the parturient, and this likely is true also in the fetus. There is a biologic explanation for the fetus being able to react to a maternal stress response by initiating labor. In the human species, our fight or flight stress response was often effective during primitive times for our survival, although in modern times it has become more of a catalyst for disease. It stands to reason that for biologic survival of the species there would be a mechanism to allow initiation of labor under stressful conditions. Especially in the past, it was much more common for the pregnant woman and fetus to be exposed to the risk of cataclysmic death from the environment or infectious diseases and epidemics. In these situations, some of these premature babies might survive. For the mother, delivery of the baby would allow her to direct her energies toward survival and future childbearing.

As far as other possible mechanisms for initiation of labor, there could be some hormonal transfer from the mother to the fetus through the placenta. Or perhaps a lack of certain nutrients either from poor maternal diet or decreased supply of these nutrients via decreased placental blood flow. Perhaps there is a kind of dialogue that goes on during pregnancy between the mother and her unborn baby that is interrupted in some way by maternal stress. What about the transfer of emotions(or lack of) from the mother to the fetus? It is obvious that the expression of love, nurturing and acceptance is expressed by the mother to the fetus by her voice; through the wide gamut of tonality, rhythm and inflection produced by her talking and singing. It is very possible that this vocal information(or lack of) has an effect on the fetal initiation of labor. It is intuitive that there is a profound interplay of information and emotion involved here and this dialogue is sacred and precious.

One possibility is that fetal intrauterine hearing of the maternal placental blood flow sounds are in some way connected to the fetus initiating premature labor. Is there some way in which the fetal brain processes changes in womb sound rhythm or the sound matrix of the womb sound itself? It is known that biologic rhythmicity is a fundamental aspect of healthy human beings. For instance, the rhythm of our heart beat is not like a metronome, but there is a normal beat to beat variability. As we age the variability of our biologic rhythms decrease. And once we reach death there is no rhythm or variability. The fetus in distress usually has a decreased variability of the fetal heart rate. These changes in fetal heart rate variability are sometimes used diagnostically to make clinical decisions during pregnancy and childbirth. Since the predominant rhythmic component of fetal intrauterine hearing is the sound of the mother’s blood flow pulsing through the placenta is it not likely that that the fetal brain uses this sound and rhythmic information in deciding to initiate labor? We know that maternal stress often manifests itself as a hyperactive sympathetic nervous system and a decrease in maternal heart rate variability (Ekholm, et al, 1996). So perhaps the fetus perceives decreases in maternal heart rate variability and uses this information as part of the initiation of preterm labor. lcd replacement

Another interesting possible cause for preterm labor is an exaggerated maternal apprehension for the safety of of the baby as well as the worry that Braxton Hicks contractions are foreboding a premature labor (Cheek, 1995). This will usually provoke a call to the midwife or obstetrician and bedrest and other active treatment to prevent preterm labor. This will often increase the patient’s anxiety even more and lead to continuing painful Braxton Hicks contractions. The telepathic communication from the mother to the fetus will be interrupted at this point and the mother’s sense of anxiety picked up by the fetus. This maladaption of the fetal maternal bonding process then sets off the initiation of the labor cascade by the fetus. Successful use of hypnosis during this time has been used to prolong the pregnancy in this situation (Cheek, 1995, Omer, Friedlander & Palti, 1986).

What appears to be a common attribute here is that an exaggerated maternal stress response can lead to the initiation of preterm labor. Besides the documented clinical use of hypnosis in the treatment of preterm labor, both the use of hypnosis and meditation have been documented to decrease stress hormone levels in various clinical situations (Sudsuang, Chentanez & Veluvan, 1991). Music alone has been shown to diminish stress-induced increases in stress hormones (Spintge & Droh, 1987). It has also been shown that music combined with guided imagery decreases stress hormone levels (McKinney, Tims, Kumar & Kumar, 1997), as well as the Bonny method of Guided Imagery and Music (GIM) (McKinney, et al, 1997). The psychological aspects of maternal stress during pregnancy in adolescents have been shown to decrease with music therapy (Liebman & MacLaren, 1991).

My interests led me to develop a script of guided imagery with music to affect the maternal-fetal dialog, The Transitions Maternal and Fetal Wellness Program (Schwartz & McDonald, 1996). This would hopefully influence some of the risk factors related to preterm labor and low birth weight. The tape combines guided imagery and music with the intention to decrease overall stress, strengthen communication between mother and fetus and get mother to center on the here and now. Messages are given to gently reinforce that mother should not drink alcohol, take drugs or smoke, as well as the importance of nutrition and exercise (for full text of guided imagery script see Transitions Music web site: http:/www.mindspring.com/~wombsnd).

Initial anecdotal reports from a group of low socioeconomic mothers have indicated higher birth weights in the mothers exposed to this guided imagery and music (personal communication, Hetty Watters, RNC, MA). A large multicenter study is being initiated to explore these benefits in various populations. Some of the maternal and neonatal variables that will be studied are gestational age, birth weight, APGAR scores, duration of labor, birth complications and cost of medical care, as well as maternal and paternal-fetal attachment. It may be intuitively clear that this type of therapy will be helpful. However, it is only with data that shows the medical benefits of music that we will see wide scale use of these therapies.

In conclusion, the use of perinatal sound and music is very important to the potential for acquiring information that can impart learning, healing and psychological change. Appropriate audio therapy in the perinatal period can positively influence state of consciousness and protect from an inappropriate stress response. This gives us an opportunity to impart our love as well as our wisdom. The implications are that these modalities will lead to physical and emotional benefits to mother and newborn as well as medical cost savings.

The hospital care of premature, low birth weight infants requires large resources in technology and personnel. The economic cost of care in the United States for Neonatal Intensive Care Unit (NICU) and Intermediate ICU averages between $1,000 and $2,000 per day or over 3.5 billion dollars a year. The added costs of special education and continued cost of medical care for these children are larger than the initial costs for their NICU care (Lewit, et.al., 1995). Many of these babies suffer hearing and visual disabilities, mental retardation, cerebral palsy or learning disabilities.

Over the last two decades there has been a marked increase in the population of low and very low birth weight infants. These infants are deprived of their normal intrauterine environment and they are susceptible to the effects of stress in the NICU. The adverse effects of stress in the NICU are reflected by heart rate variations, increasing oxygen consumption and decreased blood oxygen levels as well as marked blood pressure fluctuations, failure to thrive, and increased levels of agitation. The NICU infant cannot always communicate the feeling of pain, yet when pain is sensed this sets off a stress reaction, which includes an increase in stress hormone levels (Arnand and Hickey, 1987).

While it is felt that sensory stimulation is necessary for optimal neurological development, the sights and sounds of the modern NICU provide an inappropriate sensory environment for the premature infant (Collins, 1996). An infant in the NICU is exposed to average ambient noise levels ranging from 50 TO 88 dB, with peak levels of over 100 dB from sources such as ventilators, monitor alarms, incubator fans and motors, conversations, radios, telephones, water faucets, and cabinet doors (Lynam, 1995). The act of closing an incubator porthole can reach over 110 dB, or the equivalent of a riveting machine. Loud noise and abrupt peaks in sound levels can be highly arousing for the medically fragile premature baby. Subsequently, conditions such as hypoxemia, blood pressure instability, increased apnea and bradycardia, altered cerebral blood flow, and a predisposition for intraventricular hemorrhage can occur (Lynam, 1995). Besides causing distress, these sounds can inhibit sleep-wake cycles and prevent descent into REM sleep states necessary for maturation and weight gain.

Since the 1980’s, a number of studies have looked at the institution of developmental care, in the NICU (Als,et.al., 1994, Petryshen,et.al, 1997). This approach recognizes the importance of the environment and the appropriate level of stimulation necessary to foster brain growth and to integrate physiological and behavioral processes. Developmental care incorporates light and noise management, positioning/bundling, use of pacifiers, kangaroo care consisting of skin contact with mother or caregiver, and "clustering" of stimulative procedures, allowing for delineation of awake and restful state cycles. Some of the very significant benefits of developmental care are improved clinical outcomes as well as faster weight gain, earlier discharge from the hospital, and significant decreases in the cost of hospitalization. The inclusion of playing music and other sounds is a natural extension to the practice of developmental care.

In order to understand what is an appropriate environment to strive for in the premature baby one can look back at the environment that the premature baby abruptly loses. The intrauterine environment plays an essential role in the growth and development of the fetus. The whole "nature vs. nurture" controversy has ignored the influence of the womb on intelligence and personality. Most previous studies have looked at identical twins in examining genetic and environmental effects on intelligence. The assumption in these studies were that identical twins that are separated in infancy share only genetic effects on their intelligence. This approach ignored the shared environment these twins shared in the womb. A meta-analysis of 212 studies spanning the last 70 years showed that the womb accounts for 20% of the shared IQ component of these identical twins separated at birth. (Devlin, Daniels and Roeder, 1997). This explains the striking correlation between the IQ’s of twins, especially those of adult twins raised apart. The explanation for this is that a significant amount of learning takes place in the uterus. There is no doubt that intrauterine auditory stimuli contribute a large part of this environment.

EVIDENCE FOR INTRAUTERINE HEARING AS MAJOR SOURCE OF LEARNING

Ultrasound studies have shown that at 16 weeks gestation the fetus can respond to outside sound (Hepper, 1994, Shahidullah and Hepper, 1992). Hearing is the first sense to develop and the last to deteriorate in the life cycle. Babies learn to adapt to their mother’s breathing, her movements, and her voice as she speaks or sings. The sounds of the blood flow through the placenta can be heard at a very loud level in the womb. For the lower sound frequencies below 500 Hz, mean sound levels are 80 decibels with peaks to 95 decibels (Gerhardt and Abrams, 1996). This is about as loud as it gets on a crowded dance floor on a Saturday night. The fetus hears the mother’s heartbeat about 26 million times. This rhythm protects us, and throughout our lives it will attract us as one of the most important components of music, because it symbolizes primary security and dependable return (Decker-Voigt, 1997).

Evidence points to the fact that learning extends back into the prenatal period, and that the sounds and rhythms in the womb may contain information important to the development of the fetal brain (Devlin, Daniels and Roeder, 1997, Shetler, 1989). The newborn can differentiate a recording of his own mother’s prenatal womb sounds from a recording of another mother (Righetti, 1996). The newborn can also differentiate emotional content in the recording of his prenatal womb sounds and respond with changes in movement and heart rate (Righetti, 1996).

There is a vast amount of potential information available to the fetus that can be given in the playing of just one musical note or in singing or talking a single syllable. The content of this sound is full of informational and emotional content (Schwartz, 1997). The fetus and newborn have an innate capacity to perceive this information at a very deep, profound level. To label an interaction with a newborn as infantile is to ignore the genuine receptivity of the newborn, who is already prewired for the reception of love, nurturing and emotional wisdom. These communicative processes which take place before and after birth contribute to the promotion of the child’s physical development, behavioral characteristics and level of intelligence (Lipton, 1998).

The synaptic network in the fetal brain as well as the infant brain undergoes learning dependant reorganization. This process involves synaptic pruning, the regression of neural circuits as well as the synaptic sprouting of the developing brain. There is a substantial reduction in neurons and synaptic connections that occurs during the last trimester as well as a more modest reduction during childhood. This is consistent with the observation of psychologists that infants and children may have enhanced behavioral abilities that diminish later in life (Johnston, 1995). Since fetal hearing is probably the major component of this learning dependent synaptic pruning and sprouting, the fetus is participating in a 2^nd and 3^rd trimester auditory amphitheater that is perhaps more important than any other classroom. It is apparent that we have only begun to explore the connection between sound and neurobiological development in the fetus and newborn.

STUDIES ON NICU MUSIC

Some of the hindrances to growth and earlier discharge from the NICU are decreased blood oxygen availability and increased oxygen consumption from stress. The increased stress response also consumes precious calories. The use of music in the NICU has been shown to decrease the stress response and increase oxygen levels. Womb sound music has been shown to be helpful in the care of mechanically ventilated, agitated premature babies with low oxygen levels. Significant increases in oxygen saturation as well as decreased levels of agitation were found with the use of music (Collins and Kuck, 1991). Another study showed that when lullaby music was played in the neonatal intensive care unit (NICU) that there were less episodes of oxygen desaturation (Caine, 1991).

There is no doubt that some of the high decibel sounds from alarms and equipment in the NICU are harmful to the neonate. In one study a group of premature babies were insulated from their audio environment with earmuffs (Zahr and Traversay, 1995). They had higher oxygen saturations and more time in the sleep state compared to a control group. Several studies using music with premature babies in the NICU have shown a 3 to 5 day earlier discharge from the NICU (figures 1, 2 and 3, Caine, 1991, Coleman, Prat and Abel, 1998, Standley, 1996). Other studies have shown a doubled daily weight gain when premature babies in the NICU were exposed to music therapy (figure 1, Coleman, Pratt, et.al., 1998, Standley, 1998, Caine, 1991).

Previous studies have been inconsistent in regard to weight gain changes with music (Standley, 1996). A gender difference as far as music benefits have been observed in most studies, with the benefits of music predominantly benefiting the female babies (Standley, 1998). This can probably be explained by the fact that newborn girls have more sensitive hearing than boys at birth (Cassidy, J.W. and Ditty, K.M., 1998).

After music was introduced in our NICU at Piedmont Hospital in early 1998, we noticed a trend for faster growth of head circumference (HC) in our premature babies exposed to music (Schwartz, 1998). In a post hoc analysis this effect of music on HC growth was found to be significant in Dr. Jayne Standley’s study on effect of music and multimodal stimulation in the NICU (Standley, 1998).

It seems logical that the early loss of the intrauterine sound environment would affect brain maturation in the premature baby. Previous work on prenatal intrauterine sound stimulation has shown increases in newborn head circumference and developmental abilities (Logan, 1991). Head circumference is a reliable indicator of brain size in the first 2 years of life (Sheth, 1995, Bray, 1969). We know that malnutrition during infancy leads to reduced head circumferences and IQ,s later in life (Winick, 1969). There is a definite negative effect on cognitive abilities in the very low birth weight baby (<1.5 kg.) with subnormal head growth in whom catch-up growth does not occur. Decreased head circumference at age 8 months is a strong predictor of decreased intellectual capacity at eight years of age (Hack, 1991). Low birth weight babies who do not catch up in their HC growth have decreased cognitive abilities later on.

Since it appears that we can foster increased brain growth along with increased synaptic connections in premature babies with music stimulation, the implications are that we can use music to decrease the developmental delays that are common in premature babies. It has been shown that by exposing premature babies to a recording of the baby’s own mother’s voice in the hospital, the results at age 5 months showed a significant enhancement in verbal and motor development (Nocker-Ribaupierre, 1999, 1995). At age 20 months there remained a trend for these infants to maintain these leads in verbal and motor development despite a small sample size (24 patients control, 24 patients audio stimulation). At age 6 there was still a trend for better verbal skills in the stimulated group.

It becomes clear that there is indeed an effect of music and sound on brain development which extends as far back as the fetal period. This is a natural extension of the "Mozart Effect" in preschool children, showing that music training can enhance language development, spatial and mathematical abilities (Rauscher, et al,1997), as well as work that showed exposure to Mozart increased spatial IQ in college students (Rauscher, Shaw and Ky, 1995).

The newborn baby, and especially the premature baby have a distinct framework of experience with sounds and music. We know that newborns prefer female voices to male voices, and prefer their own mother’s voice to other women’s voices. Some of the most commonly used audio stimulation in the NICU have been lullabies, classical and womb sound music, as well as mother’s spoken voice and singing. Previous studies on the use of music with premature and term babies have mostly looked at the benefits of lullabies, classical and womb sound music (Cassidy and Ditty, 1998). Musical selections for fragile premature babies must be carefully considered. The emphasis must be given to simplicity, as well as gentle rhythms, flowing and lyrical melodies, simple harmonies, and a soft tone color. Transient changes in amplitude must be avoided, as well as abrupt tempo changes. Complexity of sound timbre and color should be avoided as well as complex combinations of different instruments. However, the premature baby responds to quality and precision of musical expression, and has the capability of responding to a beautiful recording which expresses love and wisdom.

What tradition is as old, or as universal, as that of singing lullabies to our babies? All families within all cultures from the beginning of time have "lulled" their young ones to sleep with song (Boyd, 1994). The word "lullabye" itself comes from two roots buried deep in the history of the english language. "Lulla" means to soothe and is still used today in the verb "to lull". It may have had it’s origin in onomatopoeia because it is easy to imagine a parent improvising a melody for a distressed child, or a sleepy one, uttering no more words than "la-la-la." "Bye" is an old word meaning "sleep" and the word may actually have originated as a contraction of the saying "god be with ye" (Daiken, 1959).

Lullabies may be particularly effective because in general they combine the benefits of the female voice in a simply orchestrated format. All lullabies have the same characteristics: they are slow (about 60-82 beats per minute—about like a normal resting adult heartbeat). They are regular and monotonous, and repetitive; there are no exciting disruptions in rhythm and/or melody; and they are most effective when sung in a low voice. Research has shown that high pitches tend to create tension, or excitement, while lower pitches tend to promote relaxation. All these characteristics contribute to a baby’s sense of security, safety and strength.

SETTING UP AN NICU MUSIC SYSTEM

It is important to recognize that a music system should be designed so that it can be used efficiently, with minimum use of personnel time, and minimal need for upkeep of the components of the system. It would be optimal to include a music therapist in both the design and the use of the music system. However, it is recognized that playing music 24 hours a day to this patient population necessitates educating the NICU personnel in the intricacies of music therapy in this population. Neonatal nurses are extremely busy and if they will be responsible for deciding on music times it is best incorporated into their daily flowsheets, along with the charting for therapies and medications. Since the nurses are naturally somewhat preoccupied responding to critical situations, incorporating a simple box to check if music was played during the shift with room for specific comments will remind the neonatal nurse to think about music time. Initially, some of the neonatal nurses may not be sensitive to the benefits of NICU music, but with time most become very aware of the many benefits that the preemies receive from the music. Another option is to include the NICU physical therapist or occupational therapist in on the music treatments and have them become advocates. It is helpful to put up a small poster at each bedside (perhaps attached to the CD player) with a succinct summary of the benefits of NICU music therapy. This helps to remind the nurses to play the music as well as developing interest from the parents of these babies.

Our neonatal music system at Piedmont Hospital in Atlanta, Georgia, has a dedicated CD music system at all 16 patient locations. The CD players, which sit on small wall mounted brackets, have CD carousels which accept our 5 common CD’s which have the same order of CD’s in each unit so the nurses know which CD they are playing each time. In addition, there is an individual slot for an extra CD if the parents wish to expose their child to music they have perhaps been exposed to prenatally. The CD players have a headphone output with a separate volume control. We use a small headphone plug to minijack adapter so we can plug in a self amplified computer speaker. The adapter also converts the stereo signal to a mono signal because we use only one of the 2 computer speakers. We have found that an inexpensive Labtec computer speaker system for under $20 (model LCS-150) delivers clear sound and can be cleaned easily. The speaker sits between 3 and 10 inches from the baby’s ear in the incubator or isollete. Sound levels are intermittently measured at the baby’s ear with a battery operated Radio Shack digital sound level meter (cat. no. 33-2055, around $50), so that approximate mean sound levels are 75 dB with peak levels of 80 dB. If sound levels are adjusted according to a baby’s response to the music they are only decreased from these levels. In our unit we typically expose the smallest, most premature babies to womb sound music, and then advance to lullabies and simply orchestrated classical music. Some of the most unstable premature babies do not respond well to any kind of stimulation, including music. We are careful to monitor the behavioral and physiologic response these babies have with the music and occasionally music is not initially played, or played at low volume, depending on the response.

In our unit, the neonatal nurses choose the timing, frequency and duration of music interventions, as well as which music selection is played. The following are some guidelines that the nurses use for the music interventions:

NICU MUSIC GUIDELINES for behavioral changes

Consider the behavioral state when music is played.

Try not to disrupt the sleep state.

Use music to help change the behavioral state from agitation or fussiness and move towards one of quiet alertness or sleep state.

Play the music for the transition into minimal stimulation time.

NICU MUSIC GUIDELINES for desirable physiologic changes

Increase in oxygen saturation

Decrease in heart rate

Mild decrease in blood pressure

The following are some of the titles that have been used in NICU music studies. Please note that studies have not been done to compare the relative effectiveness of any of these titles.

Lullabies

A Child’s Celebration of Lullaby (Music for Little People)

A Child’s Gift of Lullabies (Someday Baby)

Dream a Little Dream (Transitions Music)

Lullaby Berceuse (Music for Little People)

Lullaby Magic (BMG/Discovery Music)

Lullaby Magic 2 (BMG/Discovery Music)

MusicBabies (MMB Music)

The Rock-A-Bye Collection (Someday Baby )

Classical Music

Adagio-Karajan (PolyGram Records)

Mozart for Babies (Perleberg Music)

Perchance to Dream, Carol Rosenberger (Delos International)

Womb Sound and Heart Beat Music

Baby Go To Sleep 1 (Audio- Therapy Innovations)

Baby Go To Sleep 2 (Audio- Therapy Innovations)

Transitions 1 (Transitions Music)

Transitions 2 Music to Help Baby Sleep (Transitions Music)

Womb Sound Classics for the New Arrival (Perleberg Music)

Baby’s Mother’s Voice

Spoken word and singing

SUMMARY

With a relatively small expenditure for music in our neonatal ICU’s we can decrease the time in the NICU by over 3 days and save between 2,000 and 6,000 US dollars for every premature baby. The initial cost of music system hardware for each NICU patient area is recouped by a corresponding decrease in medical cost of care within several weeks. Not only are there medical and economic advantages from this type of intervention. There is no doubt that music transfers love and other emotions as well as wisdom and this conveys long term developmental benefits which will allow our little patients to approach their full potential as human beings.

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