15041611Voices: A World Forum for Music Therapy1504-1611Grieg Academy Music Therapy Research Centre, Uni Research
Healthhttps://dx.doi.org/10.15845/voices.v17i2.916ResearchMusic Therapy Intervention for the Mother-Preterm Infant Dyad: Evidence
From a Case Study in a Brazilian NICUPalazziAmbrapalazziambra@gmail.comMeschiniRitaPiccininiCesar A.Institute of Psychology, Federal University of Rio Grande do
Sul, BrazilS. Stefano Rehabilitation Institute, ItalyOosthuizenHelenBatesDebbieGhettiClaire17201717222220173152017Copyright: 2017 The Author(s)2017
This study investigated the contributions of music therapy to the mother-preterm
infant dyad in a NICU. A single case study was carried out involving a mother and her
preterm daughter (27 GW). They participated in nine sessions of the Music Therapy
Intervention for the Mother and her Preterm Infant -MUSIP, with the aim of
sensitizing the mother to the importance of singing. After the MUSIP and in the pre-
and post-discharge periods, the mother was interviewed in order to provide an
assessment of the intervention; furthermore, the dyad was videotaped during singing
and non-singing interactions. The interviews with the mother and the written
descriptions of the video footage were examined through thematic analysis. The
results showed music therapy contributed: a) to the empowerment of the infant,
through relaxation, stabilization of oxygen saturation, the presentation of new
competences and engagement in singing; and b) to the empowerment of the mother,
through relaxation, the overcoming of embarrassment and the fear of interacting with
the infant, and through the strengthening of her maternal competences and her
autonomy in singing. Together, the results highlighted the importance of music
therapy to the mother-infant interaction, because singing contributed to more
prolonged face-to-face contact and more diversified expressions of affection.
Almost 11% of newborns worldwide are born before the 37th week of gestational age (WHO, 2010). Premature birth can affect the
infant's long term development, and the hospitalization of the infant in the Neonatal
Intensive Care Unit (NICU) is a traumatic experience for the whole family, as both
mothers and fathers may experience higher levels of stress, anxiety, and depression
(Flacking, Ewald, Nyqvist, & Starrin,
2006; Fleck & Piccinini, 2013;
March of Dimes, PMNCH, Save the
Children, & WHO, 2012; Shaw et
al., 2014).
The impact of prematurity on the mother-infant relationship is still a controversial
issue. The recent meta-analysis conducted by Bilgin and Wolke (2015), who examined 34 studies published between 1980 and 2013,
showed no significant differences in the sensitivity and the responsiveness of mothers
of term and preterm infants during their interaction in the first years of life.
Nevertheless, some studies showed that prematurity might affect bonding and
mother-infant interaction (Forcada-Guex,
Pierrehumbert, Borghini, Moessinger, & Muller-Nix, 2006; Korja, Latva, & Lehtonen, 2012). Beyond the
biological vulnerability involved in prematurity, adverse psychosocial factors represent
a multiple-risk situation and require the implementation of early interventions (Linhares, Carvalho, Machado, & Martinez,
2003; Moreira et al., 2011;
White-Traut & Norr, 2009).
Music therapy is an emergent discipline in this context, both in research and clinical
work, and it showed positive effects on the infants, on their parents and on the
parent-infant relationship (Haslbeck, 2012;
Standley, 2012). Several studies highlighted
the fetus's and newborn's early auditory abilities of recognizing and reacting to
maternal voice and music (Al-Qahtani, 2005;
Kisilevsky et al., 2003; McMahon, Wintermark, & Lahav, 2012; Moon & Fifer, 2000). Besides this, the
mother-infant dialogue, defined by Malloch and Trevarthen (2009) as communicative musicality, is made of
specific musical elements that contribute to the regulation of the infant's attention,
the development of linguistic structure, the communication of emotions, and the
regulation of social behavior (Butler et al.,
2014). In particular, by emphasizing the musical elements naturally presented
in infant-directed speech, maternal singing is especially powerful in enhancing
mother-infant bonding (Peretz, 2010; Trehub, Becker, & Morley, 2015).
According to the recent review of literature conducted by Palazzi, Nunes, and Piccinini
(2017), music therapy interventions
carried out by music therapists can be found among the music-based interventions in the
NICU (Ettenberger et al., 2014; Haslbeck, 2014; Loewy, Stewart, Dassler, Telsey, & Homel, 2013; Standley et al., 2010; Ullsten, Eriksson, Klässbo, & Volgsten,
2016), as well as musical stimulation interventions conducted by other
healthcare professionals (Alipour, Eskandari,
Ahmari Tehran, Eshagh Hossaini, & Sangi, 2013; Keidar, Mandel, Mimouni, & Lubetzky, 2014) or by parents
(Arnon et al., 2014; Filippa, Devouche, Arioni, Imberty, & Gratier,
2013; Nöcker-Ribaupierre, Linderkamp,
& Riegel, 2015). These interventions can employ a receptive approach with
recorded sounds and music (Alipour et al.,
2013; Standley et al.,
2010), or an active approach through live music and singing (Ettenberger et al., 2014; Haslbeck, 2014; Loewy et al., 2013; Malloch et al., 2012; Ullsten et al.,
2016).
Music therapy and musical stimulation have shown positive effects on the preterm infant,
on oxygen saturation, on the regulation of the heart rate, on respiratory rate, on sleep
patterns, on non-nutritional sucking, on weight gain and on the reduction of the
duration of hospitalization (Bieleninik, Ghetti,
& Gold, 2016; Haslbeck, 2012;
Standley, 2012). Among the music therapy
interventions, we highlight those that employ live contingent or infant-directed singing
with lullabies, parents' preferred songs and improvised singing (Malloch et al., 2012; Shoemark, 2011; Haslbeck, 2014;
Loewy, 2015; Ullsten et al., 2016). For example, Haslbeck (2014) investigated the interactive potential of
Creative Music Therapy (CMT, Nordoff & Robbins,
1977) on 18 preterm infants. The author used an inductive approach based on
the principles of grounded theory (Glaser &
Strauss, 1967; Strauss & Corbin,
1998) and therapeutic narrative analysis (Aldridge & Aldridge, 2002). By analyzing the video footage of the
intervention and parental interviews, the author identified several categories, such as
communicative musicality from episodes of interactional synchrony
between the music therapist and the infant, the music therapist's responsiveness to the
infant's behaviors, and the infant's and parents' empowerment. According to Haslbeck
(2013, 2014), through communicative musicality in the CMT, both
parents and infants might be empowered to self-regulate, orientate, participate, and
engage in the interaction between them. Results suggested that CMT enhances
self-regulation, orientation, and a greater engagement on the part of the infant, as
well as promoting parental sensitivity.
Besides supporting the preterm infant's development, music-based interventions promote
maternal well-being, by reducing stress and anxiety (Ak, Lakshmanagowda, G C M, & Goturu, 2015; Arnon et al., 2014; Bieleninik et al., 2016; Cevasco, 2008) and by enhancing breastfeeding (Ak et al., 2015; Keith,
Weaver, & Vogel, 2012; Vianna et al.,
2011). In particular, interventions that involve maternal singing and speech
have positive effects on both the infant and the mother (Arnon et al., 2014; Filippa et al., 2013). Finally, some studies showed that music therapy
contributes to the mother-infant interaction by enhancing attachment, parental
responsiveness, interactional synchrony and communicative musicality
between mother and infant (Cevasco, 2008; Ettenberger et al., 2014; Haslbeck, 2014; Walworth, 2007).
Research showed greater benefits of music therapy with live music (Arnon et al., 2006; Garunkstiene, Buinauskiene, Uloziene, & Markuniene, 2014) and emphasized
the importance of the parent’s inclusion and accompaniment (Ettenberger et al. 2014; Edwards, 2011; Haslbeck, 2014).
Nevertheless, most research focuses on the effects of recorded music on the preterm
infant, without investigating maternal perspectives and mother-infant interaction (Haslbeck, 2012). Therefore, the aim of this study
was to investigate the contributions of music therapy to the mother-preterm infant dyad
in a Brazilian NICU, based on the structure of themes and on the theoretical background
of Haslbeck’s studies (2013, 2014). Our initial expectation was that music
therapy would contribute to help both the mother and the infant to relax, to sensitize
the mother to the importance of singing in the NICU as a resource for interacting with
the infant, and to enhance the quality of mother-infant interaction.
MethodsParticipants
Participants were a mother (Natalia)1 and her preterm daughter (Ana), who had no syndromes or congenital
anomalies and was admitted to the NICU of a public hospital in Porto Alegre (State of
Rio Grande do Sul, Brazil).
Natalia was 24 years old; she lived in Porto Alegre, had concluded primary education,
and was unemployed. She had three children: two of them, 1 and 3 years old, were from
previous relationships, whilst Ana was the daughter of her third partner who had been
incarcerated almost a year earlier. The family had a low socioeconomic income. Ana
was born at 27 weeks2 of gestational
age with a weight of 685 g. The Apgar Score3 at birth was 2 (1st minute), 4 (5th minute), and 6 (10th
minute). After birth, due to symptoms of sepsis and respiratory distress, Ana was put
in an incubator and submitted to orotracheal intubation. Besides the preterm birth,
the infant presented no other severe clinical condition. After 118 days of
hospitalization in the NICU, Ana had a weight of 2620 g at discharge; she could
breathe autonomously and breastfeed.
Design, procedures and instruments
A single case study design (Stake, 2006) was
used, with five phases of data collection. In Phase 1 (Pre-intervention), 20 days
after the infant's birth, the mother was invited to participate in the study, she
signed the Informed Consent Form and took part in the following interviews: the
Interview about motherhood in the context of prematurity (NUDIF/PREPAR, 2009a), which was used
to investigate the experience of motherhood in the post-partum period; and the
Interview about the mother's musical history (Palazzi, Meschini, & Piccinini, 2014a),
which investigated the acoustic environment and the mother's experiences and musical
preferences throughout life and during pregnancy. Both interviews were structured but
conducted in a semi-directed manner. Moreover, a Demographic data sheet
(NUDIF/PREPAR, 2009b)
was filled out in this phase together with a Clinical data sheet for the
mother and her preterm infant/post-partum (NUDIF/PREPAR, 2009c), which was updated at each
phase of data collection.
In Phase 2 (Intervention), a week after Phase 1, the mother participated in the
Music Therapy Intervention for the Mother-Preterm Infant Dyad
–MUSIP (Palazzi, Meschini,
& Piccinini, 2014b). The MUSIP is a music therapy intervention that
aims at sensitizing the mother to the importance of singing to her infant and
supporting the mother-infant dyad during maternal singing. It was created for this
study based on music therapy research on prematurity. The MUSIP is organized in eight
sessions, divided between meetings with the mother and sessions with the
mother-infant dyad in the NICU. However, the structure of the MUSIP had to be adapted
in this study in order to meet the mother's needs and the space availability in the
NICU as described below. Besides this, due to Ana's clinical instability, the
sessions with her started at 31 weeks of post-menstrual age4.
Session one only involved the mother, was conducted in a room of the Neonatology Unit
and lasted approximately 45 minutes; sessions two, three, four, and five were carried
out in the NICU with the mother and the infant in the incubator; furthermore,
sessions six, seven, eight, and nine were held with Natalia during skin-to-skin
contact with Ana (kangaroo care). The sessions with the dyad in the NICU lasted 15 to
20 minutes. In session one, the mother and the music therapist sang some songs
selected by the mother (“Fico assim sem você” [“I stay like this without you”] by
Claudinho and Buchecha and the Brazilian lullaby “Nana nenê” [“Rockabye baby”]), with
and without guitar accompaniment. Sessions two, three and four aimed at accompanying
and supporting the mother during the experience of singing for the daughter, by
stimulating the observation of the infant's responses and by emphasizing the
interactive potential of singing. Sessions five and six focused on the improvised
humming with the dyad in the NICU and lastly, sessions seven, eight, and nine aimed
at encouraging the mother to write a song for the infant.5 A music therapist, the first author of this study,
conducted the nine sessions of the MUSIP (approximately once a week for 2 months)
with the clinical supervision of another music therapist, the second author of this
study.
In Phase 3 (Post-intervention), a week after the end of the MUSIP, the mother took
part in the Assessment interview of the music therapy intervention for the
mother and her preterm infant (NUDIF/PREPAR, 2014b), which investigated the impact
of the intervention on maternal feelings about the music therapy, the therapist and
her satisfaction with the intervention, as well as her perceptions about the changes
in the infant and in their bonding. It was a structured interview conducted in a
semi-directed manner.
Furthermore, the dyad participated in a session of the Observation of the
mother-preterm infant interaction (Palazzi & Piccinini, 2014), during maternal singing in the NICU. This
session aimed at observing infant's and mother's behaviors and their interactions,
during singing and non-singing episodes. The mother was oriented to interact with the
infant approximately 2 to 8 minutes during each episode. The music therapist, with
the help of a psychology student, videotaped the observation sessions by using a
GoPro Hero 3+ camera within the NICU, and a Sony DCR-sr85 camera out of the NICU. The
video footage focused on mother-infant interaction.
In Phase 4 (Pre-discharge), carried out before the infant's discharge, the mother
took part in another assessment interview adapted for the pre-discharge phase, and a
new observation session was conducted during breastfeeding in the NICU. To conclude,
in Phase 5 (Post-discharge), a week after discharge, a new observation session was
held in a hospital room in two different moments: during maternal singing and during
non-singing while changing the diaper. The first author carried out all the MUSIP
sessions, the observation sessions in Phase 3 and 5, and all maternal interviews in
Phase 1. A psychology student conducted the observation session in Phase 4, as well
as all the clinical data sheets of the infant throughout the phases, and conducted
the assessment interviews with the mother in Phase 3 and 4. All the observation
sessions and the MUSIP sessions (with the exception of session two) were audio or
videotaped. Two psychology students were responsible for transcribing maternal
interviews. This study was approved by the Ethics Committees of the Psychology
Institute of the Federal University of Rio Grande do Sul (UFRGS) (n. 985.941) and of
the hospital (n. 1.069.283).
Data analysis
To analyze data, we examined the mother’s interviews in the pre-MUSIP (Phase 1),
post-MUSIP (Phase 3) and in the pre-discharge (Phase 4) period, as well as the video
footage of the mother-infant dyad during MUSIP (Phase 2) and during the observation
sessions (Phase 3, 4, and 5). Initial interviews were used to describe the case. The
assessment interviews in the post-MUSIP and in the pre-discharge period were examined
through thematic analysis (Braun & Clarke,
2006), with the aim of investigating maternal perceptions about the music
therapy contributions to the mother-preterm infant dyad in the NICU, in particular to
the infant, the mother and the mother-infant interaction.
Video footage of MUSIP sessions were analyzed as follows: 1. First, we watched the
video footage and wrote a general report on all sessions; 2. Secondly, we selected
three of the six videotaped sessions (sessions four, six, and nine)6, and we identified and selected the
first non-singing episode (3-4 minutes) and the last maternal singing episode (3-8
minutes) of each session, with a total of approximately 14 minutes of singing and 11
minutes of non-singing7; 3. Lastly,
the first author wrote detailed descriptions regarding infant's and mother's
behaviors and mother-infant interactions during singing and non-singing episodes. The
initial and final time of each behavior under observation were noted, so as to also
have recorded information about the duration of infant's and mother's behaviors and
their interactions.
We used a similar procedure for the video footage concerning the sessions of the
Observation of the mother-preterm infant interaction (Phase 3, 4,
and 5). 1. First, we identified and selected the last 3 minutes of each video
excerpt, with a total of approximately 6 minutes of singing and 4 minutes of
non-singing8; 2. Secondly, the
first author wrote detailed descriptions regarding infant's and mother's behaviors
and mother-infant interactions during singing and non-singing episodes, highlighting
the initial and final time of each behavior under observation, so as to have
information about the duration of infant's and mother's behaviors and their
interactions. A psychology student subsequently reviewed all video excerpt
descriptions in an attempt to ensure consensus. Interviews and video excerpts
contributed to data triangulation (Stake,
2006) allowing for an in-depth analysis of the case, based on maternal
perceptions, on infant's and mother's behaviors, and on their interactions.
Data were integrated and analyzed through thematic analysis (Braun & Clarke, 2006), using a deductive approach based on
the structure of themes and on the theoretical background of Haslbeck (2013, 2014). The analysis was based on two themes:a)
empowerment of the infant and b) empowerment of the
mother. In particular, the interviews and the descriptions were read
several times, so as to identify vignettes and excerpts of the descriptions that
portrayed the themes used for analysis.
Haslbeck’s (2013, 2014) structure of themes was originally created from studies
that involved the therapeutic process between the music therapist and the infant.
Therefore, this structure was adapted for the purposes of this study in order to
consider the interactional process between mother and preterm infant. The original
themes that referred to the music therapist's behaviors were adapted and employed to
analyze maternal behaviors. The original structure also involved other themes, such
as the responsiveness between the music therapist and the infant, which was not used
in this study, since this category and all the dimensions about mother-infant
interactions were included in the themes of empowerment of the infant and empowerment
of the mother. Furthermore, the original structure involved the theme of
communicative musicality, which was also investigated in this study, but it will be
presented in a future publication. In conclusion, we added other characteristics to
the themes based on the literature being specifically derived from data from this
study.
Results
Results will be presented in two sections; the first one is related to the interviews
and the observations about the empowerment of the infant, while the
second one refers to the empowerment of the mother. During the
presentation of the results, each theme will be analyzed more in detail and described
through vignettes from the interviews and excerpts from the descriptions of the infant's
and mother's behaviors and the mother-infant interactions, during singing and
non-singing episodes.
Empowerment of the infant
According to Haslbeck's definition (2013,
2014), empowerment of the infant
refers to the infant's ability to relax, calm down, and enhance
self-regulation, orientation, and interaction. This theme involves the infant's
relaxation, the presentation of new competences, the participation and the engagement
in singing, and for the purposes of this study, we also included the stabilization of
oxygen saturation.
In the first MUSIP sessions, the infant was still unstable, showing frequent
agitation and saturation drops. Therefore, in session four the empowerment of
the infant could not be identified during singing and non-singing.
However, in session six, Ana was more relaxed and in quiet sleep state during both
singing and non-singing. Moreover, in session nine, singing contributed to a greater
relaxation of the infant when compared to the non-singing episode. In this session
the infant showed new competences, as well as participation and engagement during
singing. In fact, while her mother was singing, the infant was in an alert quiet
state, moving herself and vocalizing:
(05:06)9 The mother adopts
kangaroo care with the infant and she moves her closer to her face, while
singing.
(05:12) Ana vocalizes a glissando (La#4 Re#4 Mi4). The mother looks at the
daughter and keeps singing.
(05:28) Ana moves her head and vocalizes again (glissando from La4 to Mi4
approximately) and keeps moving her body. (S9/singing)10
In the post-MUSIP and pre-discharge period, the empowerment of the
infant appeared more evident. For example, during the assessment
interview of the intervention, Natalia reported that the MUSIP sessions and her
spontaneous experiences of singing helped her daughter calm down when she was
agitated,
But then, I realized that she liked me singing to her, with her in my arms or with
her in the incubator, and touching her, I felt that it made her much calmer when
she was agitated, she really liked it, even now she likes it. (Int3).
Besides enhancing the infant's relaxation, the MUSIP contributed to stabilizing Ana's
oxygen saturation since the mother reported that when she sang, the saturation
increased and kept stable. Natalia emphasized the joint positive effect of singing
and kangaroo care on re-stabilizing oxygen saturation: “When her saturation
starts dropping, I ask to pick her up, I sing and I rock her, and then she
stabilizes” (Int3). Moreover, the mother reported that when she talked to
Ana, her saturation kept decreasing, while when she sang the saturation remained more
stable:
When I don't sing, she stays calm in her corner, then her saturation drops. But
when I sing, when I hug her, and I sing to her, she stabilizes. Then she stays
stable, it doesn’t drop as much when I sing to her. I can see this. (Int4)
Relaxation during maternal singing was also reported in the descriptions of the
observation sessions in the post-MUSIP. In fact, the infant slept throughout the
session, without displaying any signs of agitation, while the mother hummed
improvised tunes, rocked, and caressed her. The mother also reported that after the
music therapy sessions, the infant seemed to recognize the maternal voice and react
to singing, by opening her eyes and smiling:
I feel that [the sessions] helped her, because she pays more attention to the
voices, she already recognizes the voices, she already recognizes mine from the
others … from the nurses' voices, I think that she recognizes it; she already
recognizes my voice. Sometimes, she opens her eyes, sometimes not […], just gives
a little smile at the corner of her mouth. (Int3).
In the pre- and post-discharge period, both the interview and the descriptions of the
observation sessions highlighted the empowerment of the infant
through the presentation of new competences and the engagement in singing,
more than through relaxation as it was shown in the post-MUSIP. In fact, during
singing and non-singing the infant interacted actively through her gaze, prolonged
face-to-face contact with her mother, and vocalizations:
(02:43) The infant looks at her mother.
(04:34) The infant looks at her mother again and stops breastfeeding.
(04:36) The mother stares at her daughter's face, looking at her, the infant
follows her mother's gaze and they look at each other in a mutual gaze until
04:41 when the mother asks “What’s the matter?”.
(05:02) The infant stops breastfeeding, follows her mother's gaze and moves her
hand on her breast until 05:12.
(05:36) The infant stretches her arm. (Ob4/non-singing);
(00:45) The infant vocalizes in a more prolonged manner
(00:59) The infant quietly moans and vocalizes again (Sol#4 Fa#4 Sol#4), while
the mother is dressing her. (Ob5/non-singing)
During singing there were more prolonged mother-infant gazes and also wider movements
of the arms, diversified vocalizations, and several facial expressions. The infant
looked at the mother more frequently when she was singing compared to the non-singing
episodes:
(06:41) During the break in maternal singing, the infant vocalizes in a clear
and prolonged manner.
(06:50) After moaning, the infant looks at the mother and moves her arms, while
the mother keeps rocking her and singing.
(07:30) Face-to-face contact and mother-infant gaze. Ana shows her tongue,
Natalia smiles and sings.
(07:33) Face-to-face contact, the mother smiles, the infant looks at another
direction.
(07: 38) The infant looks at the mother again, face-to-face contact, the mother
smiles.
(07:42) The mother keeps singing, rocking and looking at the daughter, the
infant looks at her mother, face-to-face contact.
(07:45) The infant shows her tongue and at the same time the mother rubs the
infant's nose with her own nose (face-to-face contact ends). (Ob5/singing)
Empowerment of the mother
According to Haslbeck's definition (2013,
2014), the empowerment of the
mother refers to her ability to relax, calm down, interact with the
infant, and increase maternal competences. This theme involves mother's relaxation,
the strengthening of maternal competences, and in this study, it also includes the
overcoming of the embarrassment and the fear of interacting with the infant and the
autonomy in singing.
During the first MUSIP sessions, the mother was anxious and agitated when she sang to
her daughter. However, in session four she prepared herself for the singing
experience by closing her eyes and leaning on the incubator, which was identified as
an attempt to relax. The descriptions of session four showed the mother's autonomy in
singing, since she hummed for her daughter without waiting for the music
therapist:
(11:52) The mother starts singing spontaneously in Sib major, the music
therapist accompanies her.
(12:16) Natalia starts the verse autonomously, by singing with open eyes and
checking the infant's responses. (S4/singing)
The mother's relaxation was more evident in the descriptions of singing episodes
related to sessions six and nine. While she was singing during kangaroo care with the
infant, Natalia closed her eyes and leaned her head or mouth on Ana’s head for a
longer period. This behavior was not present in the non-singing episodes of the
MUSIP, suggesting that Natalia probably associated this position with the experience
of singing to her daughter. Furthermore, in these sessions, she overcame the
embarrassment and the fear of interacting with her daughter, which have been reported
as the mother's initial difficulties in the first interviews. She also showed
maternal competences, by touching her daughter, caressing her, and being responsive
to the infant's behaviors:
(15:43) Natalia puts her mouth on Ana’s head, caresses her body and hums very
softly. The mother sings with closed eyes and caresses rhythmically her
daughter's body. Natalia stays in the same position until 17:46.
(S6/singing);
(05:04) Ana moans and the mother looks at her, with a worried expression.
(05:12) Ana vocalizes a glissando (La#4 Re#4 Mi4) and Natalia answers by
kissing her and speaking to her gently. (S9/singing)
In the non-singing episodes of the same sessions (six and nine), the strengthening of
maternal competences was also perceived. The mother touched her infant and used
expressions of affection, but she altered her gaze focus more frequently. Sometimes,
she looked at her daughter, while other times she looked at the NICU:
(02:16) Natalia looks to the side.
(02:19) The mother looks at her daughter.
(02:32) The mother looks to the side and then she looks at her daughter
again.
(02:33) The mother says 'sh' to her daughter and kisses her head.
(02:40) Natalia looks quickly in front of her and then again at her
daughter.
(02:44) The mother caresses her daughter's body and looks at her body.
(S9/non-singing)
Lastly, we observed greater autonomy of the mother in singing, compared to the prior
sessions, since Natalia hummed improvised tunes to her daughter:
(18:01) The mother stops caressing her daughter and sings without the
accompaniment of the music therapist.
(18:10) The mother improvised a melody, by humming autonomously.
(S6/singing)
In the post-MUSIP, the empowerment of the mother through relaxation
appeared both in the interview and in the observation session. In fact, the mother
reported that she “felt good” and more “relieved”
during music therapy and when she sang to Ana. She highlighted that music therapy
helped her to “loosen up,” “feel less embarrassed”
of talking to her daughter, and overcome the fear of touching her, since singing was
always associated to touching or kangaroo care. This contributed to “build a
bonding” between the mother and the infant, to stimulate Natalia's
interest for her daughter and to help her “taking care” of Ana:
[The sessions] helped me a lot. In all, all senses. They helped me a lot with Ana,
they helped me from A to Z. Because at the beginning I didn't care a lot, I didn't
feel very close. But not now, now I want to know, I want to know why, I want to
touch her, I want to pick her up, I want to move her, I want to interact with Ana.
Before not so much, I was more… Not now, now I want to, I want to. And this helped
me a lot, the sessions helped a lot (Int3).
Furthermore, music therapy contributed to the empowerment of maternal competences and
the mother's autonomy in singing, since Natalia integrated the improvised humming in
her daily routine at the NICU, by using singing as a resource to calm her daughter
down when she was agitated or when the oxygen saturation dropped:
Once a day I always do it here [sing]. Even if for just a little while, but … ;
She is calm in the incubator, but her saturation commonly drops. So I try to sing,
I hug her and I sing to her, rocking her (Int3).
Similarly, the descriptions of the observation sessions showed that Natalia sang
autonomously to her daughter, with improvised humming, and adding many prolonged and
diversified expressions of affection:
(02:21) Natalia opens her eyes, looks at her daughter and kisses her.
(02:33) The mother looks at the daughter, takes her hand and gently pats her
bum.
(02:46) The mother touches her daughter's ear and cheek and, at the same time,
she caresses Ana's head with her own cheek.
(03:06) Natalia sings again, while she caresses her daughter and looks at her.
(Ob3/singing)
In the pre-discharge interview (Phase 4), the empowerment of the
mother was more visible through the strengthening of her competences and
her autonomy in singing, than through relaxation. In fact, in this phase the
interactive potential of singing was more evident. Whilst answering a question made
by the interviewer about the contributions of the music therapy, Natalia
reported:
Moreover, [the sessions helped me] to talk to her, I don't know, with everything.
To feel closer to her, to loosen up, to caress her a little more, not to have so
much fear, concern about … staying close to her and talking to her, thinking that
she didn't understand, but she understands everything, (Int4).
Despite this, in the pre-discharge period Natalia reported that she did not sing
anymore for her daughter, because Ana was no longer agitated, she could pick her up
more often, thus preferring to just talk to her.
In fact, in the pre- and post-discharge period, in the non-singing episodes, the
mother talked to her daughter through infant-directed speech11 that is contingent with the infant's behaviors,
such as gaze and sucking:
(04:41) Mother-infant face-to-face contact, the infant does not suckle anymore
and the mother repeats “What’s the matter?”.
(04:48) The mother requests an answer from her daughter by saying “Mmm?” (Fa#4)
and rocks her gently, the infant looks at her mother.
(04:51) Mother-infant face-to-face contact, the infant does not suckle, the
mother asks “Don't you want to breastfeed anymore?”.
(04:54) The infant suckles again and the mother says “Ah! Yes, of course you
want to!” while she takes her daughter's hand and caresses her face.
(Ob4/non-singing).
Even though in the pre-discharge period the mother stopped singing for her daughter,
she reported that she wanted to sing at home after discharge with the whole family
when the infant would be agitated to calm her down and help her to sleep. According
to Natalia, music therapy seemed to represent a transitional stage that helped her to
awaken her maternal competences, to connect with the infant, and talk more to her. In
the post-discharge (Phase 5) period, we observed that when Natalia sang she dedicated
more exclusive attention to her daughter, showing more diversified expressions of
affection and allowing Ana to more face-to-face contact and interactions:
(08:05) Mother-infant face-to-face contact, the mother keeps patting her bum
and singing, the infant looks at the mother.
(08:07) The mother caresses her daughter's nose with her own nose and at the
same time the infant moans.
(08:13) The infant shows her tongue, the mother smiles, takes her daughter’s
arms and moves them. (Ob5/singing)
In the pre- and post-discharge period we observed that the mother was responsive to
her daughter's behaviors, for example imitating her facial expressions, answering to
the infant’s visual contact and stopping singing to wait for her daughter's
answers:
(00:07) The infant makes visual contact with the mother and the mother says “Shush”
to her. The infant looks at her.
(02:45) The mother smiles, opens her eyes wider and turns her head to the
right, then she caresses her daughter's face, head and body, mother-infant
face-to-face contact. (Ob4/non-singing).
Nevertheless, during non-singing episodes the mother alternated her gaze focus,
sometimes looking at her daughter and other times at the NICU environment, as
previously pointed out:
(03:28) The infant moves her eyes and stops breastfeeding. The mother looks at
her infant, moving.
(03:36) The infant starts breastfeeding again; the mother looks at her without
moving.
(03:55) The mother looks in front of her, the infant keeps breastfeeding.
(04:04) The mother looks at her daughter again, the infant breastfeeds and
looks at her mother.
(04:06) The mother looks again in front of her, the infant breastfeeds.
(Ob4/non-singing)
On the contrary, when the mother sang, the expressions of affection and face-to-face
contact were more prolonged. In fact, after discharge, the mother looked at the
infant during the whole observation session:
(06:58) The infant looks to the side and then again at the mother and
burps.
(07:03) The mother smiles and caresses her nose with her own nose.
(07:19) The infant stares at the mother with her eyes wide open.
(07:22) Natalia imitates her expression.
(09:22) The mother stops rocking her, stops singing and during the break she
caresses her daughter's nose. Then she waits for the infant's answers, she
caresses her and sings again. Face-to-face contact. (Ob5/singing).
Discussion
This study investigated the contributions of music therapy to the mother-preterm infant
dyad in a Brazilian NICU. Based on the literature, our initial expectation was that
music therapy would contribute to help both the mother and the infant to relax, to
sensitize the mother to the importance of singing in the NICU as a resource for
interacting with the infant, and to enhance the quality of mother-infant
interaction.
Regarding the first theme that was analyzed, the empowerment of the
infant increased as she grew and her health stabilized. In fact, she could
gradually relax more, stabilize, and maintain the oxygen saturation, also presenting
small competences. We observed these aspects over the last MUSIP sessions, as well as in
the post-MUSIP and in the pre- and post-discharge periods, when Ana displayed new
competences, by engaging herself during singing. Obviously, this evolution was
associated both to the infant’s improvement and to her stabilization. Nevertheless,
evidence suggested that music therapy also contributed to it, since the infant was more
engaged in the interaction during maternal singing, with prolonged and diversified
gestures, vocalizations, gazes, and facial expressions.
These results support the findings of previous studies that showed the benefits of live
music on the physiological and behavioral responses of the preterm infant (Arnon et al., 2006; Ettenberger et al., 2014; Garunkstiene et al., 2014; Loewy et al., 2013). In particular, live music interventions
with infant-contingent singing promoted the infant's self-regulation and development
(Haslbeck, 2014; Malloch et al., 2012; Shoemark, 2011). Besides music therapy intervention being with live singing,
the MUSIP involved the mother's singing. Interventions that use maternal voice showed
positive effects both on the infant and the mother, since the maternal voice is a
privileged source of stimulation for the fetus and the newborn, and can promote
mother-infant bonding and affective communication (Arnon et al., 2014; Butler et al., 2014; Cevasco, 2008;
Filippa et al., 2013).
We believe that music therapy's benefits added to other positive factors, such as the
mother-infant skin-to-skin contact during kangaroo care, which was always associated to
singing since session six. Arnon et al.
(2014) compared maternal singing during kangaroo care to kangaroo care alone
in a randomized study with 86 infants and their mothers. The results showed that mothers
felt less anxious and infants showed better stability of the autonomic nervous system
when the mothers were singing. In our study, we observed a combined effect of maternal
singing and kangaroo care on relaxation, stabilization of oxygen saturation, and on the
development of the infant's competences.
As far as the empowerment of the mother is concerned,
she could relax more throughout the MUSIP and in the follow-up sessions, overcome the
embarrassment and the fear of interacting with the infant and improve her maternal
competences, both in singing and non-singing episodes. Nevertheless, when the mother
sang, she could better engage with her infant with expressions of affection, touching
her and showing more prolonged face-to-face contact. Research showed that music therapy
can reduce maternal anxiety and stress (Ak et al.,
2015; Arnon et al., 2014; Cevasco, 2008), promote her relaxation and help
her develop maternal competences (Ettenberger et
al., 2014). In fact, singing can help the mother feel less powerless about
prematurity and participate in her infant's well-being, contributing to the
mother-infant relationship (Cevasco, 2008). In
particular, in this study, the intervention was important to awaken maternal competences
that might have been affected by the infant’s premature birth, by the mother’s personal
difficulties and by the traumatic experience of the hospitalization in the NICU.
Therefore, music therapy interventions should be implemented in the beginning of the
hospital stay, in order to meet the mother’s and infant’s early needs, as well as the
demands of the mother-infant relationship, especially in the context of prematurity. It
is also important to develop family-centered interventions, including both parents in
music therapy, guiding and supporting them in the vocal interaction with the preterm
infant (Edwards, 2011; Haslbeck, 2014; Shoemark,
2011).
Altogether, our findings support previous research, showing that the MUSIP had positive
effects on the infant, the mother, and their interaction. The mother's participation
through singing provided her with the opportunity of actively engaging herself in her
infant's care, reducing her feelings of incompetence in the NICU (Cevasco, 2008; Ettenberger
et al., 2014). In particular, besides including the mother, the MUSIP provided
a constant accompaniment of the dyad and valued the mother's musical preferences. Both
factors were shown to be important for the efficacy of the intervention and the
continued participation of mothers in these studies (Blumenfeld & Eisenfeld, 2006; Ettenberger et al., 2014; Loewy,
2015). Both the mothers and the fathers of hospitalized infants in NICUs
struggle with very challenging and intensive feelings. Therefore, it is important to
provide them with longer interventions in order to establish a therapeutic relationship
between the music therapist and the parents (Ettenberger et al., 2014). In our study, the role of the music therapist with
her sensitive listening, was fundamental in encouraging maternal singing and in
supporting the mother to feel more confident about her own competences and to engage
more in the interaction with her daughter. The therapist’s singing and guitar
accompaniment were used as a resource of interaction with the mother-infant dyad, which
contributed to establish the therapeutic relationship. However, studies with these
characteristics are not so common, since most research involves short and specific
interventions, rarely addressed to the dyad and generally to the infant (Palazzi, Nunes, & Piccinini, 2017).
The singing episodes highlighted the contingency between the mother's and infant's
behaviors, showing that their empowerment contributed to their
relationship. Some studies suggested that music-based interventions promote attachment
(Cevasco, 2008), parental responsiveness
(Walworth, 2007), mother-infant relationship
(Ettenberger et al., 2014), and
interactional synchrony (Haslbeck, 2014). For
example, in the research conducted by Ettenberger et al. (2014), the mothers reported that music therapy helped
them to be more motivated to stay with their infants, to know them better and to
communicate more love to them. Similarly, in our study the mother reported that
initially she was not very interested in her daughter, but music therapy helped her to
be more motivated and to be willing to know, touch, stay and interact with her. During
maternal singing, both the mother and the infant engaged more, shared more prolonged
face-to-face contact and mutual gazes, and interacted with facial expressions, maternal
voice, and infant's vocalizations. In fact, maternal singing has shown to provide a
greater engagement of the infant and to increase attention, contributing to enhance the
emotional coordination of the dyad (Nakata &
Trehub, 2004; Peretz, 2010).
Our results support the initial expectation that music therapy contributes to relax both
the mother and the infant, to sensitize the mother to the importance of singing in the
NICU, and to enhance the quality of mother-infant interaction. However, we also found
unexpected results. For example, we highlight the mother’s difficulties to sing to her
daughter during the first four sessions, as well as her agitation and anxiety. This
shows the importance of the presence of a music therapist in the NICU threatening
environment to support and accompany maternal singing. The music therapist in this
context can play the role of a mediator in the transition to motherhood, by helping the
mother to awaken her maternal competences and facilitating mother-infant
interaction.
Limitations
Before concluding, it is worth mentioning some limitations of this study. First, it
was impossible to fully meet all the initial eligibility criteria, due to the
complexity of the clinical conditions associated with prematurity. For example, the
mother was not primipara and was already used to singing to her children. This might
have contributed to strengthen the benefits of the intervention. On the other hand,
she did not live with the father of the infant, had a limited availability of time,
was worried about her children at home, and had little family support. All these
factors might have made her engagement in the intervention more difficult. In
addition, we have evidence from just one dyad, so it is important to adopt the MUSIP
with a bigger sample.
Secondly, we could not investigate maternal anxiety and depression in the pre- and
post- intervention, and we suggest to examine it in future studies. The presence of
maternal depression might have complicated the intervention, by limiting the mother’s
engagement in singing to her daughter and in the interaction with her.
Thirdly, we adapted the application of the MUSIP, due to several conditions involving
the infant, the mother, and the NICU, and we carried out just one individual session
with the mother and all the other sessions with the mother-infant dyad. Despite being
a limitation, the adaptation of the MUSIP also represented an advantage that made a
more individualized intervention possible, suited to the needs of the mother-infant
dyad. This might have contributed to strengthen the role of the mother in the
interaction with her daughter. In fact, it is important to carry out interventions
that are close to the clinical reality (Ettenberger et al., 2014) and, therefore, the application of the MUSIP
requires the music therapist's sensitivity to the needs of the infant, the mother,
and the NICU. Furthermore, it is important to highlight that this study was carried
out in a public hospital in Porto Alegre, where the majority of the families of the
hospitalized infants have a low income. Families in this socioeconomic situation may
have more difficulties in getting involved in interventions. For instance, they may
have problems in coming everyday to the hospital, because of the distance and costs
of the travel. Mothers may have other children at home and may not have adequate
social support for them while at the hospital. All this factors, together with
personal difficulties to deal with the infant’s premature birth, might have affected
the implementation of the original protocol of the MUSIP.
Fourthly, the structure of the themes used in the analysis (Haslbeck, 2013, 2014)
was originally based on the music therapist-infant interaction and was adapted for
this study to analyze the mother-infant interaction. The fact that the analysis was
based on a deductive approach from two of Haslbeck’s themes might have contributed to
disregard some aspects of our findings. Nevertheless, we tried to limit this risk, by
adding to the themes some specific aspects emerging from the data of our study.
A qualitative approach was adopted to assess these themes, which allowed us to
conduct an in-depth analysis, but it did not provide statistical data about the
frequency of the observed behaviors. Lastly, the single case study does not provide
an exhaustive comprehension of the phenomenon and the evolution of the mother-infant
dyad was also due to factors such as the infant's development.
Conclusions
Despite these limitations, we might also highlight some methodological contributions of
our study. The use of a qualitative approach and the emphasis on maternal perspective
and the mother-infant interaction; all mentioned as rare aspects in research (Haslbeck, 2012).as well as data triangulation,
through the interviews, to understand maternal perceptions and the direct observation of
the mother-infant interaction. The intervention we proposed also has relevant
contributions. It included the participation of the dyad, it provided emotional support
for the mother, and the opportunity to develop new abilities through singing to her
preterm daughter; it contributed to the empowerment of the dyad and to
humanize and “harmonize” the threatening environment of the NICU (Cleveland, 2008). In conclusion, the intervention also may have
had a multiplier effect on other mothers who did not directly participate in the MUSIP,
but whose awareness about the importance of singing to their hospitalized infants was
raised.
This study supports the literature, by showing the contributions of music therapy to the
preterm infant, the mother and the mother-infant interaction. Music and maternal
singing, being universal and early elements in mother-infant bonding, allowed the mother
to approach her daughter, even in the adverse environment of the NICU.
Music therapy also contributed to the psychological well-being of this mother and to her
relationship with her preterm daughter. Therefore, we stress the importance of including
music therapy in NICU care, since it is a cost-effective intervention that promotes the
infant's development, the maternal well-being, and the mother-infant bonding. Investing
in the mother-infant relationship is fundamental both to infant's development and to the
public health, since it contributes to health promotion and prevention and it decreases
the expensive costs commonly involved in prematurity.
In the light of the evidence reported in this study, new studies will be necessary to
examine MUSIP potential and its effectiveness. New studies with a longitudinal design
are needed in order to investigate the long-term effects of music therapy on the mother
and her infant. Lastly, it is fundamental to involve in the interventions not just the
mother, but also the father, focusing on the dyad and on the triad interaction, and
investigating the parental perspectives about music therapy in the context of
prematurity.
All names were altered to preserve the privacy of the participants.
The calculated obstetric gestational age was of 23 weeks, while Ballard score
indicated 27 weeks. In neonatology, the Ballard assessment is a commonly used
technique to calculate a newborn's gestational age. It assigns a score to both
neurologic and physical characteristics. The sum of all criteria allows an estimate
of gestational ages between 26 and 44 weeks. The New Ballard Score adds other
criteria, which determine gestational ages prior to 20 weeks (Ballard et al., 1991).
The Apgar score assesses the clinical status of the newborn infant, according to five
components (heart rate, respiration, muscle tone, reflex irritability and skin color)
at the 1st, 5th, and 10th minute after birth, and assigns a range from 0 to 10 to
each component. The Apgar score, which is the result of the sum of the five
components, allows the classification of the newborn without asphyxia (Apgar score of
8 to 10), with mild asphyxia (Apgar score of 5 to 7), with moderate asphyxia (Apgar
score of 3 to 4), and with severe asphyxia (Apgar score of 0 to 2) ( Apgar, 1953).
Post-menstrual age is considered as the sum of the gestational age at birth (time
elapsed between the first day of the last normal menstrual period and the day of
delivery) and the chronological age (time elapsed after the infant's birth) (AAP, 2004).
A more detailed description of the MUSIP original protocol can be found in the first
author’s Master’s dissertation (Palazzi,
2016).
Session four was selected for being the first videotaped session with the
mother-infant dyad; session six was chosen for being the first session with the
mother and the infant during kangaroo care, and session nine was selected for being
the last session of the intervention.
In session six, the first non-singing episode was much shorter than the last singing
episode. Therefore, we selected the first two non-singing episodes after the selected
singing episode in the same session.
In the observation session during diaper change, carried out in Phase 5, the video
excerpt lasted less than 3 minutes; therefore the whole video was selected for the
analysis.
These time indications refer to the time identified in the analysis of MUSIP video
footage and of the observation sessions.
The letter ‘S’, followed by a number, refers to the MUSIP session (session four, six,
or nine); the abbreviations 'Int' and 'Ob' refer respectively to the maternal speech
from the interviews or the descriptions derived from the sessions of observation;
lastly, the number that follows the abbreviations 'Int' and 'Ob' refers to the phase
in which the interviews or sessions took place (Phase 3, 4, or 5).
The expressions “infant directed-speech”, “motherese,” or "baby-talk" refer to the
prototypical speech that parents and caregivers use when they talk to infants or
children. Infant-directed speech has a higher pitch and is warmer, more rhythmic,
repetitive, and contingent with the infant's state (Saint-Georges et al., 2013).
AkJLakshmanagowdaP BG C MPGoturuJ2015Impact of music therapy on breast milk secretion in mothers of
premature newborns94CC04CC06https://doi.org/http://dx.doi.org/10.7860/JCDR/2015/11642.5776AldridgeDAldridgeG2002Therapeutic narrative analysis: A methodological proposal for the interpretation of
music therapy traces.0212Retrieved fromhttp://musictherapyworld.net/modules/mmmagazine/issues/20021205144406/20021205150303/TherapeutNarrativeAnalysis.pdfAlipourZEskandariNAhmari TehranHEshagh HossainiS KSangiS2013Effects of music on physiological and behavioral responses of
premature infants: A randomized controlled trial193128132https://doi.org/10.1016/j.ctcp.2013.02.007Al-QahtaniN H2005Foetal response to music and voice455414417https://doi.org/10.1111/j.1479-828X.2005.00458.xApgarV1953A Proposal for a New Method of Evaluation of the Newborn
Infant321260267https://doi.org/10.1213/00000539-195301000-00041ArnonSShapsaAFormanLRegevRBauerSLitmanovitzIDolfinT2006Live Music Is Beneficial to Preterm Infants in the Neonatal Intensive
Care Unit Environment332131136https://doi.org/10.1111/j.0730-7659.2006.00090.xArnonSDiamantCBauerSRegevRSirotaGLitmanovitzI2014Maternal singing during kangaroo care led to autonomic stability in
preterm infants and reduced maternal anxiety10310391044http://dx.doi.org/10.1111/apa.12744American Academy of
Pediatrics. (2004). Age Terminology During the Perinatal Period. Pediatrics,
114, 1362. Retrived from:
http://pediatrics.aappublications.org/content/114/5/1362.full.htmlBallardJ LKhouryJ CWedigKWangLEilers-WalsmanB LLippR1991New Ballard Score, expanded to include extremely premature
infants1193417423https://doi.org/10.1016/S0022-3476(05)82056-6BieleninikŁGhettiCGoldC2016Music therapy for preterm infants and their parents: A
meta-analysis1383e20160971http://dx.doi.org/10.1542/peds.2016-971BilginAWolkeD2015Maternal sensitivity in parenting preterm children: A
meta-analysis1361e177e193http://dx.doi.org/10.1542/peds.2014-3570BlumenfeldHEisenfeldL2006Does a mother singing to her premature baby affect feeding in the
neonatal intensive care unit?4516570http://dx.doi.org/10.1177/000992280604500110BraunVClarkeV2006Using thematic analysis in psychology3277101http://dx.doi.org/10.1191/1478088706qp063oaButlerS CO’SullivanL PShahB LBerthierN E2014Preference for infant-directed speech in preterm
infants37505511http://dx.doi.org/10.1016/j.infbeh.2014.06.007CevascoA M2008The effects of mothers’ singing on full-term and preterm infants and
maternal emotional responses453273306http://dx.doi.org/10.1093/jmt/45.3.273ClevelandL M2008Parenting in the neonatal intensive care unit37666691http://dx.doi.org/10.1111/j.1552-6909.2008.00288.xEdwardsJ2011The use of music therapy to promote attachment between parents and
infants38190195http://dx.doi.org/10.1016/j.aip.2011.05.002EttenbergerMOdell-MillerHCárdenasC RSerranoS TParkerMLlanosS M C2014Music therapy with premature infants and their caregivers in Colombia
– A mixed methods pilot study including a randomized trial142https://voices.no/index.php/voices/article/view/756>FilippaMDevoucheEArioniCImbertyMGratierM2013Live maternal speech and singing have beneficial effects on
hospitalized preterm infants1021010171020http://dx.doi.org/10.1111/apa.12356FlackingREwaldUNyqvistK HStarrinB2006Trustful bonds: a key to "becoming a mother" and to reciprocal
breastfeeding. Stories of mothers of very preterm infants at a neonatal
unit6217080http://dx.doi.org/10.1016/j.socscimed.2005.05.026FleckAPiccininiC A2013O bebê imaginário e o bebê real no contexto da
prematuridade: do nascimento ao 3º mês após a alta.The imaginary baby and the real baby in the context of
prematurity: from birth to 3 months after discharge401430Forcada-GuexMPierrehumbertBBorghiniAMoessingerAMuller-NixC2006Early dyadic patterns of mother-infant interactions and outcomes of
prematurity at 18 months1181e107114http://dx.doi.org/10.1542/peds.2005-1145GarunkstieneRBuinauskieneJUlozieneIMarkunieneE2014Controlled trial of live versus recorded lullabies in preterm
infants237188http://dx.doi.org/10.1080/08098131.2013.809783GlaserBStraussA1967New York, NYAldineHaslbeckF B2012Music therapy for premature infants and their parents: An integrative
review21203226http://dx.doi.org/10.1080/08098131.2011.648653HaslbeckF B2013Creative music therapy with premature infants: An analysis of video
footage231535https://doi.org/10.1080/08098131.2013.780091HaslbeckF B2014The interactive potential of creative music therapy with premature
infants and their parents: A qualitative analysis2313670http://dx.doi.org/10.1080/08098131.2013.790918KeidarR HMandelDMimouniF BLubetzkyR2014Bach music in preterm infants: No “Mozart effect” on resting energy
expenditure342153155http://dx.doi.org/10.1038/jp.2013.138KeithD RWeaverB SVogelR L2012The effect of music-based listening interventions on the volume, fat
content, and caloric content of breast milk-produced by mothers of premature and
critically ill infants122112119http://dx.doi.org/10.1097/ANC.0b013e31824d9842KisilevskyB SHainsS M JLeeKXieXHuangHYeH HZhangKWangZ2003Effects of experience on fetal voice recognition143220224http://dx.doi.org/10.1111/1467-9280.02435KorjaRLatvaRLehtonenL2012The effects of preterm birth on mother–infant interaction and
attachment during the infant’s first two years91164173http://dx.doi.org/10.1111/j.1600-0412.2011.01304.xLinharesM B MCarvalhoA E VMachadoCMartinezF E2003Desenvolvimento de bebês nascidos pré-termo no primeiro
ano de vidaDevelopment of premature infants in the first year of
life15772LoewyJStewartKDasslerA MTelseyAHomelP2013The effects of music therapy on vital signs, feeding, and sleep in
premature infants1315902918http://dx.doi.org/10.1542/peds.2012-1367LoewyJ2015NICU music therapy: Song of kin as critical lullaby in research and
practice1337178185http://dx.doi.org/10.1111/nyas.12648MallochSTrevarthenC2009EnglandOxford University PressMallochSShoemarkHČrnčecR N CPaulCPriorMCowardS2012Music therapy with hospitalized infants – The art and science of
communicative musicality334386399http://dx.doi.org/10.1002/imhj.21346March of
Dimes, PMNCH, Save the Children, & WHO. (2012). In C. P. Howson, M. V. Kinney,
& J. E. Lawn (Eds.), Born Too Soon: The Global Action Report on Preterm
Birth. World Health Organization: Geneva.McMahonEWintermarkPLahavA2012Auditory brain development in premature infants: the importance of
early experience12521724http://dx.doi.org/10.1111/j.1749-6632.2012.06445.xMoonC MFiferW P2000Evidence of transnatal auditory learning208 Pt 23744MoreiraC IGerhardtCSteibelDSilveiraFCaronN ALopesR C S2011A impossível tarefa de segurar o sol com a
mãoThe impossible task of holding the sun with your
hand182237253NakataTTrehubS E2004Infants’ responsiveness to maternal speech and singing27455456http://dx.doi.org/10.1016/j.infbeh.2004.03.002Nöcker-RibaupierreMLinderkampORiegelK P2015The Effects of mothers’ voice on the long term development of
premature infants: A prospective randomized study732025NordoffPRobbinsC1977New York, NYJohn DayNúcleo de Infância
e Família - Federal University of Rio Grande do Sul - PREPAR Project. (2009a).
Interview about motherhood in the context of prematurity.
Unpublished instrument.Núcleo de Infância
e Família - Federal University of Rio Grande do Sul - PREPAR Project.
(2009b). Demographic data sheet. Unpublished
instrument.Núcleo de Infância
e Família - Federal University of Rio Grande do Sul - PREPAR Project. (2009c).
Clinical data sheet for the mother and her preterm infant/post-partum.
Unpublished instrument.Núcleo de Infância
e Família - Federal University of Rio Grande do Sul - PREPAR Project. (2014b).
Assessment interview of the music therapy intervention for the mother and
her preterm infant. Unpublished instrument.PalazziA2016Master´s DissertationFederal University of Rio Grande do Sul, Psychology Institute. Porto Alegre, BrazilPalazziAPiccininiC A2014Unpublished instrumentPalazziAMeschiniRPiccininiC A2014aUnpublished instrumentPalazziAMeschiniRPiccininiC A2014bUnpublished instrumentPalazziANunesC CPiccininiC A2017Music therapy and musical stimulation in the context of prematurity: a
review of literature from 2010 to 2015http://dx.doi.org/10.1111/jocn.13893PeretzI2010Towards a neurobiology of musical emotionsSlobodaP99126OxfordOxford University PressSaint-GeorgesCChetouaniMCasselRApicellaFMahdhaouiAMuratoriFLaznikM CCohenD2013Motherese in interaction: at the cross-road of emotion and cognition? (A systematic review)8e7810310.1371/journal.pone.0078103ShawR JLiloE AStorfer-IsserABallM BProudM SVierhausN SHuntsberryAMitchellKAdamsM MHorwitzS M2014Screening for Symptoms of Postpartum Traumatic Stress in a Sample of
Mothers with Preterm Infants353198207ShoemarkH2011Translating 'infant-directed singing' into a strategy for the
hospitalizaed familyEdwardsJ161178New YorkOxford University PressStakeR E2006New York, NYGuilford PressStandleyJ M2012Music therapy research in the NICU: An updated
meta-analysis315311316StandleyJCassidyJGrantRCevascoASzuchCNguyenJWalworthDProcelliDJarredJAdamsK2010The 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 NICU363138145StraussA LCorbinJ1998Grounded theory methodology. An overviewDenzinNLincolnY S158183London, EnglandSageTrehubS EBeckerJMorleyI2015Cross-cultural perspectives on music and musicality370166420140096https://doi.org/10.1098/rstb.2014.0096UllstenAErikssonMKlässboMVolgstenU2016Live music therapy with lullaby singing as affective support during
painful procedures: A case study with microanalysis262142166https://doi.org/10.1080/08098131.2015.1131187ViannaM N SBarbosaA PCarvalhaesA SCunhaA J L A2011Music therapy may increase breastfeeding rates among mothers of
premature newborns: a randomized controlled trial873WalworthD D2007The effect of developmental music groups for parents and premature or
typical infants under two years on parental responsiveness and infant social
development. The Florida State UniversityPaper 1271World Health
Organization. (2010). Bulletin of the World Health Organization, 88,
31-38. http://dx.doi.org/10.2471/BLT.08.062554White-TrautRNorrK2009Ecological Model for Premature Infant Feeding384478490http://dx.doi.org/10.1111/j.15526909.2009.01046.x