February 2018

Wendy Jeenes

Midwife and music therapist

A family-centred psycho-social support intervention –

live music therapy on the neonatal unit at Royal

Cornwall Hospital

Singing to babies – not

new…

Music therapy is an established psychological

clinical intervention, which is delivered by

HCPC registered music therapists to help

people whose lives have been affected by

injury, illness or disability through supporting

their psychological, emotional, cognitive,

physical, communicative and social needs.

Atypical parenting environment:

“I still have difficulties feeling like a mother” (Spinelli et al 2015)

Multiple barriers exist on NNU that may

impede initiation of sensitive parenting and

secure attachment (Balbernie 2013)

Physical separation known to increase

maternal stress, anxiety and depression (Flacking

et al 2012)

Mothers of preterm infants at higher risk of

depression than mothers of term infants in

immediate postpartum period (Vigod et al 2010)

Babies of perinatally depressed mothers are at

risk for a large array of negative outcomes

(Guedeney et al 2014)

• Attachment and perinatal mental health being addressed

nationally (Better Births / PMH teams / more mum and

baby units / PIP-UK / MABIM / video interactive

guidance/etc.)

• Standards: Toolkit For High Quality Neonatal Services

(DOH 2009)

• POPPY report (NCT 2009): early psychosocial needs of

NICU/NNU families still needs attention

• Bliss Family Centred Charter (https://www.bliss.org.uk/starting-the-audit)

Music therapy?

MUSIC THERAPY ON NNU – research

• positive effects for heart rate, O2 sats (Arnon et al 2006)

• sucking (Loewy et al 2013)

• shorter hospital stay (Cevasco 2008)

• soothe/calm – painful interventions (Whipple 2008)

• attunement/engagement (qualitative) (Haslbeck 2013)

Systematic review of RCTS’s - live music vs standard

care (Bieleninik et al 2016): regulates respiration,

positive effect on maternal anxiety.

Sound and premature babies

• Hearing earliest sense to develop in utero – 20 weeks,

mature by 35 weeks

• Maternal voice most predominant sound (Parncutt 2009)

• Premature babies miss out on last trimester – less likely to

recognise mums voice than term babies (Kreuger 2010)

• Developmental care: 50 dB – peaks at 70 dB (Hanson

Abromeit 2003)

• Maternal voice, prosody, ‘motherese’ has role in emotional

attunement and attachment (Stern 1985) (Trevarthen and

Malloch 2000)

The music

• Preferred lullabies, ‘song of kin’ (Loewy 2013)

• Repeated pitches, phrases and rhythms (O’Gorman

2006) – predictable

• Limited lyrics. Vowel sounds, hum or baby’s name

(O’Gorman 2006) (Gilad and Arnon 2010)

• Smooth vocalisations, no stressed consonants

(O’Gorman 2006)(Arnon et al 2006)

• Melody not exceeding an octave, smooth contour, no

attack (Shoemark and Abromeit 2015)

• Comfortable vocal range – lower to mid vocal register,

warm tone (O’Gorman 2006)

The music (cont.)

• Infant directed singing

• Guitar accompaniment – minimal harmony especially for

earlier babies (eg. plucked triad accompaniment)

(Ettenberger 2014)

• Soft volume

• Slow tempo - simple triple or quadruple time – lullaby style

(Shoemark et al 2015)(O’Gorman 2006)(Loewy 2013)

• Occasions of silence

• Watch cues - stop if overstimulated

• Gato box – soft ‘heartbeat’ percussion instrument, can

entrain to babies breathing or heartbeat (Loewy 2013).

https://drive.google.com/open?id=1qiNBbSX5QGVHKVjcbForw1lRk4dVQf-O

https://drive.google.com/open?id=1C_dM88uUFD6-6tG2U5NVh_oY8c-Ub9jv

Evaluation

• 12 week pilot project from October 2017

• Aim: family-centred psycho-social intervention that supporting

bonding

• Funded by Cornwall Music Therapy Trust

• 4 hours a week, split to include weekends

• Referrals: self, nurses or invited by music therapist

• Fitting in with Family-Centred and Developmental Care

principles of the unit – collaboratively developed with

developmental care lead nurse

Response from families – main themes

• Calming and soothing for baby and relaxing for

parents – main theme from parents/families

• Voice/language introduction and social/cultural

functions were identified as benefits

• Bonding cited as a benefit

“(it made me feel) relaxed – takes your mind away for a while!”

“…in the future it will give us something to do together to help

us bond.”

“It helps them relax so easier to soothe.”

“…helps baby to bond, feel loved and wanted and later

encourages them to react and respond”

“it introduces your voice”

1

2

3

4

5 8

Family member

singing (37% of

sessions)

Therapist singing

Mum or foster mum singing

Dad

Grandfather

Sister

Participation data

Number of sessions per baby as percentage

Singing participation (as percentage)

Response from Staff – main themes:

• Supports bonding, calming and relaxing to both

staff and families

• Normalising, positive (out of negative)

• Settles distressed babies

• When describing benefits staff consistently

described parent and baby as a unit rather than

as separate

“…supportive intervention for both mothers and fathers, for

them to see their baby relaxed during therapy”

“Positive developmental experience, enhancing bonding”

“Gives space for parents to interact positively with their infant

and to relax both parent and infant”

“It is relaxing for both parents and relatives and babies – both

need to feel calm”

Finally - HOW IS THIS THERAPEUTIC?

1. Space to talk - birth experience, feelings. Positive regard.

2. Relaxation, stress relieving, distracting

3. Introduction of family voices

4. Bonding - neurobiological and developmental psychological

attachment theories:

• right brain (emotional) development (Schore 2005)

• parent looks to understand infants internal response to music

‘affect attunement’ (Stern 1985) – watching for subtle cues

• ‘reflective function’ awareness of the infant and child’s

emotional as well as physical development (Slade 2005)

Therapeutic holding – mothering the mother

End notes

• Find a music therapist: BAMT website, check HCPC registration

https://www.bamt.org

http://www.hcpc-uk.co.uk

• Local music therapy charities/organisations

Thank you.

REFERENCES

• Arnon S, Shapsa A, Forman L, Regev R, Bauer S, Litmanovitz L. (2006) Live music is beneficial to preterm infants

in the neonatal intensive care unit environment. Birth.;33:131–136.

• Balbernie, R. (2013) The importance of secure attachment and infant mental health in Journal of Health Visiting 1

(4) pp 210 – 217

• Bieleninik, Ł., Ghetti, C. and Gold, C., (2016). Music therapy for preterm infants and their parents: A meta-

analysis. Pediatrics, p.e20160971.

• Cervasco A, Grant R. (2005) Effects of the pacifier activated lullaby on weight gain of premature infants. Journal of

Music Therapy;42(2): 123–139

• Centre for Mental Health and London School of Economics, (2014). The costs of perinatal mental health problems.

London: Centre for Mental Health and London School of Economics

• Edwards J. (2011) The use of music therapy to promote attachment between parents and infants. The Arts in

Psychotherapy;38:190-195.

• Ettenberger, M., Odell-Miller, H., Rojas Cárdenas, C., Torres Serrano, S., Parker, M. and Camargo Llanos, S.

(2014) Music Therapy With Premature Infants and Their Caregivers in Colombia – A Mixed Methods Pilot Study

Including a Randomized Trial in Voices: A World Forum for Music Therapy 14 (2)

• Fancourt D and Perkins R. (2018) Effect of singing interventions on symptoms of postnatal depression: three-arm

randomised controlled trial. The British Journal of Psychiatry 1-3 [online] doi: 10.1192/bjp.2017.29

• Flacking, R., Lehtonen, L., Thomson, G., Axelin, A., Ahlqvist, S., Moran, V.H., Ewald, U. and Dykes, F., (2012).

Closeness and separation in neonatal intensive care. Acta Paediatrica, 101(10), pp.1032-1037.

• Gilad E, Arnon S. (2010) The role of live music and singing as a stress- reducing modality in the neonatal intensive

care unit environment. Music and Medicine.;2(18):18-22.

• Guedeney, A., Guedeney, N., Wendland, J. and Burtchen, N., (2014) Treatment–Mother–infant relationship

psychotherapy. Best Practice & Research Clinical Obstetrics & Gynaecology, 28(1), pp.135-145.

REFERENCES CONT.

• Hanson Abromeit, H. (2003) The Newborn Individualized Developmental Care and Assessment Program

(NIDCAP) as a model for clinical music therapy interventions with premature infants. Music Therapy Perspectives

21(2): 60–68.

• Haslebeck, F. (2013) The interactive potential of creative music therapy with premature infants and their parents: A

qualitative analysis in Nordic Journal of Music Therapy 23 (1) pp 36–70

• Krueger C. (2012) Exposure to maternal voice in preterm infants. Adv Neonatal Care.; 10(1):13–18.

• Loewy, J., Stewart, K., Dassler, A-M., Telsey, A. and Homel, P. (2013) The Effects of Music Therapy on Vital Signs,

Feeding, and Sleep in Premature Infants in Pediatrics 131, pp 902 - 918

• National Childbirth Trust (2009) POPPY Steering Group. Family-centred care in neonatal units. A summary of

research results and recommendations from the POPPY project. London: NCT.

• NHS & Department of Health October (2009) Toolkit for High Quality Neonatal Services. London: Department of

Health.

• O’Gorman, S. (2006). The infant’s mother: Facilitating an experience of infant-directed singing with the mother in

mind. British Journal of Music Therapy, 20, 22-30.

• Parncutt, R., (2009). Prenatal and infant conditioning, the mother schema, and the origins of music and

religion. Musicae Scientiae, 13(2_suppl), pp.119-150.

• Royal College of Paediatrics and Child Health (2016) National Neonatal Audit Programme Annual Report on 2015

data. London: RCPCH

• Schore, A.N., (2005). Attachment, affect regulation, and the developing right brain: Linking developmental

neuroscience to pediatrics. Pediatrics in Review, 26(6), pp.204-217.

• Shoemark, H, Hanson-Abromeit, D, Stewart, L. (2015) Constructing optimal experience for the hospitalized

newborn through neuro-based music therapy (2015) Frontiers in Human Neuroscience September 2015 | Volume

9 | Article 487 [online]

REFERENCES CONT.

• Slade A. (2005) Parental reflective functioning: An introduction. Attachment & Human Development, September 2005;

7(3): 269 – 281

• Spinelli, M., Frigerio, A., Montali, L., Fasolo, M., Spada, M.S. and Mangili, G., (2016). ‘I still have difficulties feeling

like a mother’: The transition to motherhood of preterm infants mothers. Psychology & health, 31(2), pp.184-204.

• Stern, D.N., (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology.

Karnac Books.

• Trevarthen, C., & Malloch, S.N. (2000). The dance of wellbeing: Defining the musical therapeutic effect. Nordic

Journal of Music Therapy, 9(2), 3–17.

• Vigod, S.N., Villegas, L., Dennis, C.L. and Ross, L.E., (2010). Prevalence and risk factors for postpartum depression

among women with preterm and low‐birth‐weight infants: a systematic review. BJOG: An International Journal of

Obstetrics & Gynaecology, 117(5), pp.540-550.

• Whipple J. (2008) The effect of music- reinforced nonnutritive sucking on state of preterm, low birthweight infants

experiencing heelstick. J Music Ther.;45(3):227–272