[Position paper]

Premature Infants: Perspectives on NICU-MT Practice

By Jayne M.Standley

Abstract

Music research began in the Neonatal Intensive Care Unit (NICU) over 25 years ago. Initially, medical staff resisted the idea that music therapy could impact premature infant medical outcomes. Today Neonatal Intensive Care Unit-Music Therapy (NICU-MT) is well known in the U.S. with over 300 specially trained Board Certified Music Therapists (MT-BCs), and it is evolving in international settings. Over 50 research studies in refereed journals provide evidence-based methodology for NICU-MT and document important and unique infant benefits from music.

Quality of medical services is evaluated by benchmarks of benefit that are also economical and efficient. NICU-MT is underutilized and improves both medical and developmental outcomes for infants while reducing medical costs. For these reasons, it is an important new benchmark of quality NICU care. It behooves the profession to describe and promulgate specialized NICU-MT treatment techniques. Because of the extreme fragility and unique needs of premature infants still undergoing fetal development, it is also timely that the music therapy profession begins to develop specialized training for clinical treatment in this area.

This article offers a perspective on NICU-MT by integrating music research with developmental theory, medical treatment, and MT clinical practice. It also provides suggestions for development of the specialization of NICU-MT.

Keywords: perspectives, NICU, premature, music, standards, evidence-based

Overview

When music research began in the NICU (Neonatal Intensive Care Unit) over 25 years ago, the concept of a music therapist serving on the treatment team for premature infants receiving intensive care was novel. In this critical care area professionals were protective of their very fragile patients. Initially, there was resistance to music being added to the medically controlled environment since all sound was perceived as noise, music was considered nonessential during intensive care treatment and possibly dangerous to the developing infant, and research from a field not traditionally included in medical treatment was viewed with suspicion. Today NICU-MT is well known nationally and evolving in international settings (Haslbeck & Costes, 2011;Standley, 2001a). In 2004, a survey of NICU nurses in the U.S. demonstrated that 68% wanted music included in NICU treatment (Martin, Woods, Shoaf, Block, & Kemper, 2004). Of the top 25 U.S. children’s hospitals, over 50% now provide NICU MT. Such NICU-MT is congruent with individualized developmental and family-centered care (Hillmer, Swedberg, andStandley, 2011). Music therapists outside the U.S. sometimes use NICU-MT evidence-based methodologies and interventions such as infant-directed singing (Shoemark, 2008a).

Over 50 research studies in refereed medical and music therapy journals provide multiple types of evidence-based NICU-MT methodology and document multiple benefits for premature infants (Gooding, 2010; Loewy, Stewart, Dassler, Telsey, & Homel, 2013; Standley, 2012). NICU medical staff and professionals are advocating the importance of auditory input, including music, for premature infant development (Graven & Browne, 2008; McMahon, Wintermark, & Lahav, 2012). Animal studies demonstrate neurologic growth from fetal music listening that has relevance for maturation of premature infants (Kim, Lee, Shin, Chung, Lee, & Shin, 2013) as do the research results with newborns showing unique development related to music listening (Perani, Saccuman, Scifo, Spada, Andreolli, Rovelli, et al., 2010). NICU early intervention research shows improved outcomes (Nordhov, Ronning, Ulvund, Dahl, & Kaaresen, 2011) as do NICU-MT clinical applications of evidence-based methods (Standley & Swedberg, 2011). Many allied health professionals and NICU parent groups are embracing the benefits (Discenza, 2013; Pölkki, T., Korhonen, A., & Laukkala, H., 2012).

For the purposes of this paper, NICU-MT is specific to the treatment of premature infants while in the NICU and does not include music therapy for term newborns born with medical problems or premature infants after initial discharge to home or to a secondary hospital for continued care or upon readmission of premature infants following initial discharge. Though NICU-MT has strong evidence and research base showing benefits for premature infants, it is not yet a standard of medical care in the U.S. A recent addition to NICU care, Child Life Services, is a newer area of clinical service already included in pediatric standards of care. It is considered essential for medical treatment of children and the standard is for services seven days a week with or without reimbursement (payment for the service by the parents’ medical insurance company). The recommended professional staffing ratio is 1 per 15 -20 patients. Of the 396 general and children’s hospitals with pediatric residency programs in 2012, 82% had Child Life specialists (Committee on Hospital Care, 2000). If the field of music therapy were able to achieve a similar status with a staffing ratio of 1 to 20, we would need 856 MT-BC, NICU-MTs to serve 17,109 NICU beds in the U.S. alone. Striving for this level of service provision is a wonderful goal, but a monumental task.

Currently, a formalized NICU-MT training program exists in the U.S. that awards a special certificate upon completion and requires the applicant to be a Board Certified Music Therapist. The National Institute for Infant and Child Medical Music Therapy, approved by the Certification Board for Music Therapy as a continuing education provider, conducts the program through an affiliation of four universities and five medical centers. Training is in three phases and consists of a minimum of eight hours of lecture, 16 hours of hands-on training in an affiliated NICU, and completion of online tests for two text books. Hundreds of U.S. and international music therapists have been trained, including persons from England, Spain, Germany, Denmark, Norway, Belgium, Malaysia, Japan, China, Korea, Australia, Canada, Argentina, Venezuela, and Singapore. It is timely that music therapy professionals come together to promulgate NICU-MT specialization information for training, clinical practice, and research and seek inclusion in NICU medical standards of care. Doing so would emphasize primary professional commitment to the wellbeing of fragile, premature infants.

Need for Conceptual Continuity

Music therapy is very diverse in approach and use across many agencies and types of client services. Music therapists understand and accept this. Other professionals may perceive such diversity as lack of focus in the clinical area in which they specialize. Even within the NICU, music therapists address a plethora of problem areas: infant medical, developmental, and learning issues, parent/infant attachment, parent stress, and sometimes bereavement/counseling issues. The more specific music therapists are in articulating benefits and outcomes, the greater the medical acceptance of music therapy as integral to NICU care where treatment is intense with life and death implications and care is immediately oriented to survival of the infant.

The premature infant’s neurologic system is incomplete and very different from that of a term infant. Environmental stimuli and interactions such as music therapy can do damage if not carefully coordinated with fetal developmental milestones by gestational week. For very premature infants the medical model of care is the gold standard with developmental, learning, or psychosocial issues following the most intensive care stage. Medical emphases change as the infant achieves viability, is removed from life support, and has completed medical treatment for major problems caused by organ immaturity such as patent ductus arteriosus, necrotizing enterocolitis, gastroesophageal reflux, intraventricular hemorrhage, apnea, and/or bradycardia. This usually occurs at approximately 32-34 gestational weeks. Signs and symptoms of continuing critical medical needs such as need for oxygen after 34 gestational weeks or intraventricular hemorrhages are monitored prior to approving developmental interventions such as music therapy. Such intense and unique needs raise many concerns: concerns for the welfare of the infants and their parents, concerns for liability for malfeasance, and concerns for the credibility of the profession in medical treatment.

The perspective suggested here proposes that NICU-MTs match theories of music therapy use to developmental maturation of the infants measured in gestational weeks. Because the setting is controlled by intensive care medical treatment, music therapy benefits can be articulated within the medical model using accepted outcome measures. Infant behavior can be interpreted in accordance with medically generated guidelines and care is taken not to conflict with them. In Australia and Europe, some healthcare settings are striving to become more inclusive of a bio psychosocial model and NICU music therapy is developing in theory and practice along those lines (Shoemark, 2008b). These two emphases are compatible and NICU music therapists do not have to reject one to focus on the other. Focus of treatment is a matter of choice of the music therapist and the medical site.

Problems occur when music is used in the NICU setting without music therapy expertise. Volunteer musicians seek opportunities to perform in the NICU without knowing the consequences of overstimulation or how to use music to the greatest benefit. Severely premature infants are too volatile for music provision by those not attuned to appropriate repertoire, style, or signs of infant distress. Additionally, parents or other professionals sometimes bring toys or mobiles into the NICU environment with auditory components such as lullabies or heartbeats without understanding the consequences for their own or nearby infants. A need for careful monitoring of music stimuli in the NICU according to known issues of benefit versus damage is indicated and can be met by designation of the NICU-MT as the expert on music provision.

Music therapy research and clinical descriptions must include medical or developmental measures of benefit, specifically the primary critical variables measured in intensive care treatment such as physiologic measures (heart rate, respiration rate, weight gain, oxygen saturation, days in hospital, apnea, bradycardia, etc.) or developmental/behavioral milestones (behavior state, ability to transition from state to state or to self-soothe, feeding skill, and caregiver/infant attachment). In order to clarify benefits of specific procedures, the music used should be fully described with careful attention to content, complexity, duration, and decibel (dB) level (Standley & Walworth, 2010).

Research shows that music is effective in multiple ways whether live or recorded. Though live music is the preference of the profession, there are too many premature infants for their needs to be fully met by the limited number of music therapists available to provide services. Parents and caregivers of premature infants are greatly stressed by NICU treatment and sometimes have difficulty with parent/infant attachment. Their understanding and involvement in the care of their child is critical and adds an additional need for music therapy service. Therefore, the music therapy profession must embrace all possible benefits and methodologies to meet the needs of this unique population and their families.

NICU Clinical Treatment Integrated With Developmental Care

Because of the extreme fragility of the severely premature infant, life sustaining medical treatment is the top priority despite implications of side effects for long-term developmental damage. During initial entry into the NICU, medications may be necessary that damage hearing, oxygen may be needed in amounts that destroy eyesight, and muscle-relaxing medications may lead to flaccid cerebral palsy. If the infant survives the crisis of premature birth, then medical and care procedures are individualized and given in accordance with guidelines for each week of gestational development and infant responses. Developmental care of premature infants is organized into three stages: survival/pacification, cautious stimulation, and transition to interactive stimulation (Westrup, 2007; Standley & Walworth, 2010). Developmental NICU-MT clinical services are integrated into, and compliant with, these developmental stages.

Survival/Pacification Stage (23-30 gestational weeks)

The medical community advocates the following during the survival pacification stage: no touching, no interacting, no disturbance of sleep. Therefore uninterrupted music listening, either live or recorded, with the fewest alerting stimuli possible, is the most appropriate method for music therapy. The therapist’s face should be more than 10 inches from the infant to not overstimulate the infant. Attempts at interaction or reciprocal socialization should be avoided, as should touch. Research in this area has shown that quiet, consistent music (less than 65 dB Scale C) soothes, masks aversive auditory stimuli, and enhances medical indicators of infant wellbeing such as oxygen saturation (Cassidy & Standley, 1995;Standley & Moore, 1995; Strutzel, 2012). Use of lullabies in the child’s native language simultaneously promotes language development while pacifying and are specifically designed to soothe and quiet infants.

Cautious Stimulation Phase (30-34 gestational weeks)

At this stage, parents and caregivers are allowed to visit with the infant and provide touch, usually the weight of their unmoving hand resting on the infant’s chest. At this gestational age, the infant should remain in the most relaxed state for effective growth and neurologic development, i.e., with arms and legs folded in the fetal position. Reaching out is contraindicated and should not be misinterpreted. When removal from the incubator is permitted, then kangaroo care (skin-to-skin contact with the disrobed infant lying quietly on the caregiver’s bare chest) is highly beneficial and can only be provided by the primary caregivers (Feldman, Eidelman, Sirota, & Weller, 2002). During this phase music listening during passive touch such as kangaroo care is beneficial. Methods to elicit infant interaction with the parent or therapist are contraindicated until the infant can tolerate minimal stimulation. Then, multimodal music therapy can lead to socialization ability. Gender differences in response to this technique show that males respond better to a cappella voice if touch is applied while females respond better to greater complexity such as guitar accompaniment for voice combined with touch (Walworth,Standley, Robertson, Smith, Swedberg, & Peyton, 2012).

Interactive/discharge phase (34-40 gestational weeks)

The following infant milestones evolve in this phase and are a criterion for discharge from the NICU.

Infant must establish sleep/wake cycles. Brain cells grow during sleep and cease dividing when the infant is overstimulated; facilitating the infant’s return to a sleep state after painful procedures is critical for his/her future prognosis. After discharge at around 4.5 pounds, premature infants are often characterized as irritable with difficulty in achieving adequate sleep states. Music listening is excellent after distressing medical procedures to return the infant to a sleep state (Whipple, 2008). Music also lengthens the sleep state of healthy term newborns (Olischar, Shoemark, Holton, Weninger, & Hunt, 2011) and may have potential to do so for premature infants.
Infant must coordinate suck/swallow/breathe ability and build endurance for feeding indicated by satisfactory weight gain. Music reinforces sucking and facilitates oral feeding ability (Standley, Cassidy, Grant, Cevasco, Szuch, et al., 2010).
Infant must learn to tolerate, then respond to stimuli, then begin to reciprocate social interaction (Standley & Walworth, 2010). Touch and guided interaction are excellent from 32 weeks forward. Social interaction should not be forced; the therapist waits for it to appear according to each individual infant’s maturation. Overstimulation cues must not be confused with social interaction. Stimulation must be stopped when these appear. Systematic multi-modal stimulation is highly effective in promoting neurologic maturation that is evidenced by tolerance to the combined stimuli of touch, singing, and movement.
Infant must orient to and track visual and auditory stimuli. Music is an excellent cue for initiating tracking ability.

Family Issues

Infant must form attachment and establish cause and effect relationships with caretakers (Melnyk, Tu, Small, Stone, Sinkin, Crean, et al., 2006). Attachment is difficult if caregivers are not present in the NICU due to the mother having a Caesarian or other medical treatment, or to all caregivers having a job, other children in the home, distance from home, or lack of transportation. Teaching each of these persons infant directed singing and interaction techniques with music may contribute to attachment. Mother/infant attachment is the single greatest predictor of future development of the child. Premature birth interruption of the pregnancy timeline and the considerable stress and fear that emanate from distress about the infant’s wellbeing also interrupt the usual birth hormonal responses that contribute toward immediate attachment. Family-based NICU care is intended to promote greater attachment during medical treatment. Music therapy is advocated as being an important component of this intent.
Caregivers are often stressed by NICU care of their child that can affect mood, attachment with the infant, and feelings of self-worth. Parent counseling and encouragement throughout the stay are often necessary. Training in other parent/infant interactions as the child is developmentally ready is also helpful.
Family must learn to interpret and respond to infant signals while avoiding overstimulation. Teaching caregivers to use multimodal stimulation techniques is an excellent method for reducing overstimulation. Research shows that family empowerment is important to parent stress reduction as discharge approaches (Gooding, Cooper, Blaine, Franck, Howse, & Berns, 2010).
Family must learn to care for infant’s special needs (i.e., monitors, oxygen, tracheotomy tubes, etc.). Music and counseling reduce parent stress.
Family must learn importance and techniques of early intervention and developmental training for the child. Early intervention music therapy activities for family training and participation are provided in the book by Standley and Walworth (2010) and with the Bright Start music curriculum (Walworth, 2013).

Medical, Developmental, and Social Benefits of NICU-MT

Evidence-based NICU-MT clinical treatment with diverse, reimbursed procedures have been described in the research literature and utilized in hospitals for several years (Hillmer, Swedberg, & Standley, 2011;Standley & Walworth, 2010). Reimbursement is key to NICU-MT job development in U.S. hospitals that do not have socialized medicine. Each patient has to fund his/her own treatment and many people who can afford to can pay medical insurance premiums for help with these costs. Non-profit hospitals have huge budget deficits since they must provide critical services to indigent people and those without insurance. Insurance companies have reimbursed evidence-based music therapy protocols in the NICU to the extent that the hospital actually generates more funds than the salary of the music therapist costs. Many hospitals are hiring NICU-MTs because of these medical and economic benefits.

A one-year analysis of the impact of this program on infants and their families at a major hospital found that clinical results were identical to researched outcomes for infants born 28 to 35 gestational weeks (Standley & Swedberg, 2011). Such replication from clinical application provides strong evidence for benefits of NICU-MT in standard care of premature infants. The following examples describe NICU-MT clinical procedures, connect music therapy treatment to problems of premature birth, and cite expected beneficial outcomes as per medical standards.

Neurologic Problem: Over-responsiveness/Hypersensitivity to Stimulation

Due to neurologic immaturity premature infants are hypersensitive to stimuli and all forms of stimulation are cumulative. The younger the infant’s gestational age, the more easily he/she is overwhelmed by any stimulation, including touch, lights in the NICU, environmental sound in the NICU, and distress and pain from daily care or medical procedures. Initial indices of overstimulation include several subtle disengagement cues: hiccoughs, grimace, clinched eyes, eyes averted, tongue protrusion, finger splay, and struggling movement. When these occur, it is recommended that all stimulation stop immediately. After a 15 second pause if the disengagement cue has disappeared, the prior stimulation may be tried again. If it is tolerated without a disengagement cue, then additional stimuli might be slowly added, one-at-a-time as long as disengagement cues do not reoccur. More potent disengagement cues consist of: crying, whining, fussing, cry face, spitting/vomiting, hand outstretched or in halt position. When these cues occur, medical protocol dictates that one cease all stimulation, return the infant to the incubator, and leave it uninterrupted to rest. At this stage, continued interaction and music are contraindicated. With regard to neurologic maturation, it should be recognized that developmental maturation rates and responses vary by gender. Male infants develop more slowly and show more overreaction to all stimuli, including music (Cassidy & Ditty, 2001; Standley & Walworth, 2010).

Music Use: Unchanging music promotes homeostasis even during other forms of stimulation (Walworth, et al., 2012).

Outcomes: Infants will tolerate repeated stimulation. This habituation or lack of response indicates improved neurologic maturation. Training parents in using this technique sensitizes their responsiveness to their infants’ cues and reduces overstimulation. Parent empowerment improves long-term outcomes.

Survival and Stabilization Problem: Failure to Thrive Results in Death or Greater Evidence of Developmental Disabilities after Discharge

Physiological survival variables include stable and adequate heart rate, respiration rate, oxygen saturation, and weight gain.

Music Use: Recorded or live singing of lullabies played at a dB level below 65 dB on Scale C for up to 4 hours a day improves measures of physiological well-being.

Outcomes: Infants demonstrate stable heart rate, stable respiration rate, reduced apnea/bradycardia, increased oxygen saturation, and increased weight gain.

Neurologic Problem: Autonomic System Immaturity Results in Apnea

Gentle stroking promotes breathing in the neonate. Stroking should progress cephalocaudally and proximodistally, the directions in which the brain develops and, therefore, the infant is most capable of tolerating touch. It should never be given or continued when signs of overstimulation are present.

Music Use: Gentle touch and kangaroo care are excellent therapies that can also be paired with live or recorded music when the infant is neurologically ready. Multi-modal stimulation benefits are well documented and replicated in the refereed literature (Walworth, et. al, 2012).

Outcome: Faster neurologic maturation leads to stable oxygen saturation, earlier cessation of oxygen use, and to earlier discharge from the NICU.

Neurologic Development: Opportunity for Nonnutritive Sucking

Sucking is the first rhythmic behavior in which the infant engages and it is theorized to contribute to neurological development by facilitating internally regulated rhythms. Research shows that non-nutritive sucking is the most beneficial developmental care intervention (Byers, 2003). Research has shown that non-nutritive sucking increases oxygenation in the premature infant. Subsequent reduction in the provision of life sustaining oxygen reduces damage to the retina. The coordinated suck/swallow/breathe ability does not develop until 34 weeks of gestation and is necessary for independent oral feeding, a criterion for discharge. Prior to that premature infants are fed by tube. It is generally recommended that pacifiers be paired with tube feedings since research has shown this non-nutritive sucking opportunity increases daily weight gain.

Music Use: Pacifiers can be paired with music to enhance non-nutritive sucking and pacification (Field, Hernandez-Reif, Feijo, & Freedman, 2006;Standley, et al., 2010). The music to stimulate sucking should be developmentally, culturally, and age appropriate and should transition from moderate to slower tempo to lull the infant asleep.

Outcome: Faster return to sleep state following painful stimuli, faster acquisition of independent oral feeding, and earlier discharge results.

Development: Opportunity for Parent/Infant Early Attachment

The mother/infant attachment that usually happens at birth (Haft & Slade, 2006) is disrupted by the infant’s removal from the mother’s presence for life saving medical procedures and then by isolation in the life support environment of the radiant warmer or incubator. Initially, infants identify their mother by smell. Therefore, placing a cloth with the mother’s breast milk in the isolette comforts the premature infant and promotes attachment with the mother especially if she cannot be physically present in the NICU.

Music Use: Though more specific long-term research is needed in this area, some applications can be suggested from general research in attachment. An object with the mother’s smell may be paired with music listening to enhance pacification. A lullaby sung by the mother and played repeatedly during quiet rest becomes familiar and comforting, promotes attachment, and provides a familiar reference for the infant when the transition to the home environment is made. Infant-directed singing strengthens parent/infant attachment (Shoemark & Dearn, 2008).

Outcome: Attachment, the strongest variable predicting long-term outcomes, is promoted. There is developmental danger of over-stimulation if an infant response is expected or promoted too soon.

Neurologic Development: Opportunity for Cause/Effect Learning

Premature infants are capable of learning and do so through exposure to cause/effect relationships while in the womb (James, 2010) or during premature development (Standley, 2001b). Premature delivery from the womb with subsequent isolation in a stationary isolette severely restricts environmental changes and stimuli, and restricts learning leading to developmental delay. Term infants learn multiple language concepts via auditory eavesdropping on their mother’s environmental sound field during the final weeks of gestation. This opportunity is lost to the severely premature infant resulting in language delay. Language development is faster if the language is individually directed to the infant (in live interaction rather than recorded) and if it is provided in parentese (speech with song like qualities). Parentese, or the way adults tend to speak to babies, is very similar to lullaby music and this seems to be true across all cultures. Characteristics of parentese include extended vowels, mellifluous sounds, narrow pitch range rising for stimulation and falling for pacification, and repeated pitch contours (Trehub, Unyk, & Trainor, 1993).

Music Use: Lullabies sung by a female voice (mother or other female) in the child’s native language have shown to be effective reinforcement for learning. Also, term newborns attend more fixedly to music than to other auditory stimuli that may also be true for premature infants (Standley & Walworth, 2010). Music is a highly satisfactory input mode for the relay of information to the preterm infant whether provided by the music therapist or the parent.

Outcome: Sung lullabies pacify and simultaneously promote long-term language development. Contingent music increases developmental skills such as sucking, or breathing.

Developmental Milestone: Nutritive Sucking Ability and Independent Oral Feeding.

Upon achieving 34 weeks gestational age, critically premature infants often need special therapy to develop sustained feeding attention, capability, and sucking response strong enough to allow them to gain adequate daily nutrition by mouth. Failure to develop this ability can prolong hospitalization for several weeks.

Music Use: Contingent music has been shown to increase non-nutritive sucking which transfers immediately to learned oral feeding ability (Chorna, Slaughter, Wang, Stark, & Maitre, 2014; Standley, et al., 2010). In this procedure, a pacifier is adapted so that a suck activates an electrical circuit that immediately enables music to play. The immediacy of the music reinforcement following the suck instantly teaches the infant to suck more and longer which leads to improved feeding ability.

Outcome: Earlier independent oral feeding and earlier discharge result in improved long-term outcomes and reduced medical costs.

Need for NICU-Music Therapy Specialization

In the field of medicine, an important treatment ethic is “first, do no harm.” Premature infants are a unique population, perhaps the most medically and developmentally fragile population served by music therapy. Premature infants have vulnerability and needs different from all other babies. Extreme care must be taken to not overwhelm the infant’s immature neurologic system that interrupts brain cell development. Specialized professional guidelines for NICU music therapists would serve to protect infants and to improve quality of care. The following issues are cited to highlight the need for specialization standards in this area.

Much knowledge critical for NICU-MT practice is not typically taught in current music therapy preparation programs, including fetal development milestones from 23-38 weeks, especially neurologic milestones; medical standards and guidelines for NICU care of premature infants; and premature infant responses to environmental stimuli by gestational age. Infants born as early as 23 gestational weeks have only a 50% chance of surviving and remain extremely fragile for weeks with a poor prognosis for long-term outcomes (Vohr, Papile, Verter, Mele, Dusick, Wright, et al., 2000). The neurologic system develops primarily in the final trimester (weeks 26-38) and is vulnerable to damage from medical care or environmental conditions. Though caution is paramount with infants at very early gestational ages, by 37-38 weeks, stimulation equivalent to that given to a term newborn is appropriate.
Music therapists have a responsibility to assure that procedures conducted with severely premature NICU infants enhance medical treatment and do no harm to the infant. Details such as music selection, verification of dB level, and length of exposure are critical (Cassidy and Ditty, 1998). Neurologic immaturity results in interruption of neurologic development caused by NICU care and environmental stimuli such as sound. Severely premature infants can have up to one-third less brain volume as demonstrated by fMRI assessment at age 8-9 years. Thus, premature infants are extremely vulnerable to long-term damage through overstimulation.
Persons providing music in the NICU should be trained. Volunteers, medical staff, or parents sometimes bring music into the NICU without understanding the implications. It is a possibility that music therapists without NICU training can do harm to the infant and reduce music therapy acceptance by the medical profession, allied therapies, and developmental specialties.

Suggested Guidelines for NICU Music Therapy Specialization

Specialized uses of music therapy in the NICU are in development but acceptance within the medical community is still being generated one NICU at a time by each music therapist attempting to start a new program. Promulgating clinical practice and specialization guidelines would hasten development and acceptance of this music therapy specialization. Hopefully, the profession will begin discussion of policies and develop actions to facilitate this goal. Following are suggested guidelines to stimulate such discussion.

NICU music therapists will complete specialized training prior to practicing in the NICU. A recent survey found that training resulted in perceived benefits of higher quality of care provision and higher salaries (Peczeniuk-Hoffman, 2012).
NICU music therapists will adhere to medical guidelines for development of clinical protocols.
NICU music therapy protocols will comply with developmental guidelines by gestational week.
NICU music therapy clinical services seeking insurance reimbursement will comply with specific delineation of the clinical intervention: assessment techniques, details of evidence-based therapeutic intervention, timeline for provision, and documentation.
NICU music therapy research will meet medical standards for appropriate research design, methodology, and publication, including:
1. Human subject committee approval
2. Citation of prior research in related areas
3. Emphasis on use of dependent variables that measure aspects of developmental infant status and medical change that the literature shows likely to be affected by the intervention. Studies might include at least one common medical/developmental indicator of benefit since the medical professionals referring infants for MT are seeking evidence in these areas: physiologic indicators of medical well-being (heart rate, blood pressure, oxygen saturation, weight gain), developmental milestones, behavior states (quiet sleep, active sleep, drowsiness, quiet alert, active alert, and crying), and/or length of NICU stay. Qualitative research does not typically include such variables but may choose to add some when deemed appropriate to facilitate dialogue with the medical community.
4. Publication of completed studies that include enough detail for replication and full delineation of results. NICU music therapists will avoid publishing incomplete, partial, or misleading results
Standards of NICU music therapy care will specify services 7 days/week.
Staffing ratios for adequate service provision will be established. A ratio of 1 to 20 is recommended.
In NICU standards of care, music therapists will be identified as the experts who determine uses of music in the NICU and will be consulted prior to music being initiated by others, including parents, volunteers, medical staff, or other professionals.

It is my hope that this perspective on clinical practice integrating research, developmental theory, and medical guidelines will stimulate discussion and facilitate international communication of NICU-MT research and practice. Ongoing international symposia and conferences featuring this topic will promote collaboration and rapid dissemination of known practices for future development to build upon. Premature infants throughout the world will benefit greatly if music therapy is included as an essential and necessary service in global NICU care.

References

Byers, J. (2003). Components of developmental care and the evidence for their use in the NICU. MCN, The American Journal of Maternal/Child Nursing, 28, 174-180.

Cassidy, J. W., & Ditty, K. M. (1998). Presentation of aural stimuli to newborns and premature infants: An audiological perspective. Journal of Music Therapy, 35, 70-87.

Cassidy, J.W., & Ditty, K.M. (2001). Gender differences among newborns on a transient otoacoustic emissions test for hearing. Journal of Music Therapy, 38, 28-35.

Cassidy, J. W., &Standley, J. M. (1995). The effect of music listening on physiological responses of premature infants in the NICU. Journal of Music Therapy, 32, 208-227.

Chorna, O., Slaughter, J., Wang, L., Stark, A., & Maitre, N. (2014). A pacifier-activated music player with mother’s voice improves oral feeding in preterm infants. Pediatrics, 3, 462-468.

Committee on Hospital Care (2000). Child life services. Pediatrics, 106, 1156-1159.

Discenza, D. (2013). Prematures and feeding therapy: New lullaby-powered research. The Journal of Neonatal Nursing, 32(6), 429-430.

Feldman, R., Eidelman, A., Sirota, L., & Weller, A. (2002). Comparison of skin-to-skin (kangaroo) and traditional care: Parenting outcomes and preterm infant development. Pediatrics, 110(1), 16-26.

Field, T., Hernandez-Reif, M. Feijo, L. & Freedman, J. (2006). Prenatal, perinatal and neonatal stimulation: A survey of neonatal nurseries. Infant Behavior & Development, (29)24-31.

Gooding, J., Cooper, L., Blaine, A,, Franck, L., Howse, J., & Berns, S. (2011). Family support and family-centered care in the neonatal intensive care unit: Origins, advances, impact. Seminars in Perinatology, 35(1), 20-28.

Gooding, L. F. (2010). Using music therapy protocols in the treatment of premature infants: An introduction to current practices. The Arts in Psychotherapy, 37, 211-214.

Graven, S., & Browne, J. (2008). Auditory development in the fetus and infant. Newborn and Infant Nursing Reviews, 8(4), 187-193.

Haft, W. & Slade, A. (2006). Affect attunement and maternal attachment: A pilot study. Infant Mental Health Journal, 10(3), 157-172.

Haslbeck, F., & Costes, T. (2011). Advanced training in music therapy with premature infants: Impressions from the United States and a starting point for Europe. British Journal of Music Therapy, 25, 19-31.

Hillmer, M., Swedberg, O., & Standley, J. (2011). Medical music therapy with premature infants: Family-centered services. In A. Meadows (Ed.), Developments in music therapy practice: case study perspectives (pp. 49-69). Gilsum NH: Barcelona Press.

James, D. K. (2010). Fetal learning: A critical review. Infant and Child Development, 19(1), 45-54.

Kim, C., Lee, S., Shin, J. W., Chung, K., Lee, S., Shin, M., et al. (2013). Exposure to music and noise during pregnancy influence neurogenesis and thickness in motor and somatosensory cortex of rat pups. International Neurourology Journal, 17, 107-113.

Loewy, J., Stewart, K., Dassler, A., Telsey, A., & Homel, P. (2013). The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics, 131(5), 902-918.

Martin, K., Woods, C., Shoaf, R., Block, S., & Kemper, K. (2004). Attitudes and expectations about music therapy for premature infants among staff in a neonatal intensive care unit. Alternative Therapies in Health & Medicine, 10, 50-54.

McMahon, E., Wintermark, P., & Lahav, A. (2012). Auditory brain development in premature infants: The importance of early experience. Annals of the New York Academy of Science, 1252, 17-24.

Melnyk, B. M., Tu, X., Small, L., Stone, P. W., Sinkin, R. A., Crean, H. F., et al. (2006). Reducing premature infants' length of stay and improving parents' mental health outcomes with the creating opportunities for parent empowerment (COPE) neonatal intensive care unit program: A randomized, controlled trial. Pediatrics, 118(5), e1414-e1427.

Nordhov, S. M., Ronning, J. A., Ulvund, S. E., Dahl, L. B., & Kaaresen, P. I. (2011). Early intervention improves behavioral outcomes for preterm infants: randomized controlled trial. Pediatrics, 129(1), e9-e16. Retrieved from pediatrics.aapublication.org.proxy.lib.fsu.edu

Olischar, M., Shoemark, H., Holton, T., Weninger, M., & Hunt, R. W. (2011). The influence of music on aEEG activity in neurologically healthy newborns ≥32 weeks' gestational age. Acta Pǽdiatrica, 100, 670-675.

Peczeniuk-Hoffman, S. A. (2012). Music Therapy in the NICU: Interventions and Techniques in current practice and a survey of experience and designation implications. Master's Theses, Paper 93. Retrieved from http://scholarworks.wmich.edu/masters_theses/93

Perani, D., Saccuman, M. C., Scifo, P., Spada, D., Andreolli, G., Rovelli, R., et al. (2010). Functional specializations for music processing in the human newborn brain. Proceedings of the National Academy of Sciences, 107(10), 4758-4763.

Pölkki, T., Korhonen, A., & Laukkala, H. (2012). Expectations associated with the use of music in neonatal intensive care: A survey from the viewpoint of parents. Journal for Specialists in Pediatric Nursing, 17, 321-328.

Shoemark, H. (2008a). Infant-directed singing as a vehicle for regulation rehearsal in the medically fragile full-term infant. Voices: A World Forum for Music Therapy, 8(2). Retrieved from https://voices.no/index.php/voices/article/view/437/361

Shoemark, H. (2008b). Keeping parents at the centre of family centred music therapy with hospitalized infants. Australian Journal of Music Therapy, 19, 3-24.

Standley, J.M. (2001a). Musicoterapia para recien nacidos prematuros en cuidados intensivos neonatales (Music therapy for premature infants in neonatal intensive care.) (Spanish translation by Clancy, C.). Acta Pediatrica Espanola, 59(11), 623-629.

Standley, J.M. (2001b). The power of contingent music for infant learning. Bulletin of the Council for Research in Music Education, 149(Spring), 65-71.

Standley, J.M. (2012). Music therapy research in the NICU: An updated meta-analysis. Neonatal Network: The Journal of Neonatal Nursing, 31, 311-316.

Standley, J. M., & Moore, R. (1995). Therapeutic effects of music and mother's voice on premature infants. Pediatric Nursing, 21, 509-512, 574.

Standley, J., Cassidy, J., Grant, R., Cevasco, A., Szuch, C., Nguyen, J. et al. (2010). The effect of music reinforcement for non-nutritive sucking via the PAL (Pacifier-Activated Lullabies Apparatus) on achievement of oral feeding by premature infants in the NICU. Pediatric Nursing, 36, 138-145.

Standley, J.M., & Swedberg, O. (2011). NICU music therapy: Post hoc analysis of an early intervention clinical program, Arts in Psychotherapy, 38, 36-40.

Standley, J.M., & Walworth, D. (2010). Music therapy with premature infants: Research and developmental interventions. 3rd ed. Silver Spring: American Music Therapy Association.

Strutzel, M. R. (2012). The effects of recorded lullabies on infants receiving phototherapy. Electronic Theses, treatises and dissertations, Paper 5209. Retrieved from http://diginole.lib.fsu.edu/etd/5209

Trehub, S. E., Unyk, A., & Trainor, L. (1993). Adults identify infant-directed music across cultures. Infant Behavior and Development, 16(2), 193-211.

Vohr, B. R., Papile, L., Verter, J., Mele, L., Dusick, A. M., Wright, L. L., et al. (2000). Neurodevelopmental and functional outcomes of extremely low birth weight infants in the national institute of child health and human development neonatal research network, 1993-1994. Pediatrics, 105(6), 1216-1226.

Walworth, D. (2013). Bright start music: a developmental program for music therapists, parents, and teachers of young children. Silver Spring: American Music Therapy Association.

Walworth, D.,Standley, J., Robertson, A., Smith, A., Swedberg, O., & Peyton, J. J. (2012). Effects of neurodevelopmental stimulation on premature infants in neonatal intensive care: Randomized controlled trial. Neonatal Network: The Journal of Neonatal Nursing, 31(5), 311-316.

Westrup, B. (2007). Newborn Individualized Developmental Care and Assessment Program (NIDCAP) – Family-centered developmentally supportive care. Early Human Development, 83, 443-449.

Whipple, J. (2008). The effect of music-reinforced nonnutritive sucking on state of preterm, low birthweight infants experiencing heelstick. Journal of Music Therapy, 45, 227-272.