Music Therapy in the NICU – PediaCast CME 119
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Show Notes
Description
Kalin Moran, Lelia Emery, and Chloe Heintz are music therapists in the NICU at Nationwide Children’s Hospital. What exactly is music therapy? How does it help premature babies? And what evidence supports its use? Tune in to find out!
Instructions to obtain CME/CE Credit:
- Read this information page.
- Listen to the podcast.
- Complete the post-test at Nationwide Children’s CloudCME.
- CME credit expires 3 years from this episode’s release date.
- You can view your transcript and print a certificate of completion at Cloud CME.
- Need help creating a Cloud CME account? Click Here.
Still have questions? Contact CMEOffice@nationwidechildrens.org
Topic
Music Therapy in the Neonatal Intensive Care Unit
Presenters
Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital
Kalin Moran
NICU Music Therapist
Nationwide Children’s Hospital
Lelia Emery
NICU Music Therapist
Nationwide Children’s Hospital
Chloe Heintz
NICU Music Therapist
Nationwide Children’s Hospital
Learning Objectives
At the end of this activity, participants should be able to:
- Define music therapy and describe the training and credentialing required for board-certified music therapists.
- Explain the stages of auditory development in premature infants and their implications for NICU care.
- Recognize behavioral and physiologic signs of sensory overstimulation in NICU patients.
- Apply principles of developmentally appropriate auditory stimulation to support neurodevelopment and parent–infant bonding.
Links
Music Therapy at Nationwide Children’s Hospital
Giggle & Groove Music Therapy
Healing with Harmony: Music Therapy in the NICU – PediaCast 590
National Institute for Infant & Child Medical Music Therapy
Music Medicine and Music Therapy in Neonatal Care: a Scoping Review of Passive Music Listening Research Applications and Findings on Infant Development and Medical Practice
Disclosure Statement
No one in a position to control content has any relationships with ACCME-defined ineligible companies.
Commercial Support
Nationwide Children’s has not received any commercial support for this activity.
CME/CE Accreditation Statement
In support of improving patient care, Nationwide Children's Hospital is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses Credentialing Center (ANCC), and the Accreditation Council for Pharmacy Education (ACPE), to provide continuing medical education for the healthcare team.
AMA Statement
The Nationwide Children's Hospital designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AAPA Statement
Nationwide Children's Hospital has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.
APA Statement
Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. Nationwide Children's Hospital designates this activity for 1.0 continuing education credits.
ASWB Statement
As a Jointly Accredited Organization, Nationwide Children's Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.0 general continuing education credits.
ADA CERP Statement
Nationwide Children’s Hospital is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at CCEPR.ADA.org. Nationwide Children’s Hospital designates this activity for 1.0 continuing education credit.
Contact Us
CMEOffice@nationwidechildrens.org
Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by the Music Therapy Program at Nationwide Children's Hospital.
[MUSIC]
[Dr Mike Patrick]
Hello, everyone. And welcome to PediaCast CME.
We are so glad that you are here. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It's episode 119. And we are calling this one Music Therapy in the NICU. I want to welcome all of you to the program.
We are so happy to have you with us. You know, music can be powerful medicine, especially for our smallest and most vulnerable patients. In the neonatal intensive care unit, carefully designed music therapy interventions can support physiologic stability, promote neurodevelopment, and strengthen parent-infant bonding.
But what does music therapy in the NICU actually look like? How do clinicians balance meaningful sound with the risks of overstimulation? And what role can parents play through their own voice and musical connections with their baby?
Well, to help us explore these questions, we are joined by three NICU music therapists from Nationwide Children's Hospital, Kalin Moran, Lelia Emery, and Chloe Heintz. Together, they're going to share how music therapy supports infant development, helps regulate the sensory environment, and empowers caregivers during their NICU journey. Before we get started, I do want to remind you that after listening to this episode, be sure to claim your free Category 1 credit for continuing medical education, both CME and CE.
It is easy to do. Just head over to the show notes for this episode. That's going to be at pdacastcme.org.
You'll find a link to the post-test in the show notes. Follow that link to Cloud CME. You're going to want to click on the Materials tab and then take and pass the post-test, and the Category 1 credit is yours.
And we do offer credit, of course, to doctors, but also all sorts of pediatric professionals, including nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And it's because Nationwide Children's is jointly accredited by all of those professional organizations that we can offer the credits you need to fulfill your state's continuing medical education requirements. Of course, you'll want to be sure the content of this episode matches your scope of practice.
Complete details are available at pdacastcme.org. Also, I want to remind you the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
Your use of this audio program is subject to the PDACAST CME Terms of Use Agreement, which you can find at pdacastcme.org. So, let's take a quick break. We'll get our experts settled into the studio, and then we will be back to talk about music therapy in the neonatal intensive care unit.
It's coming up right after this.
[MUSIC]
[Dr Mike Patrick]
Kalin Moran, Lelia Emery, and Chloe Heintz are music therapists in the neonatal intensive care unit at Nationwide Children's Hospital. They have a passion for supporting premature babies and term infants with conditions that require an acute stay.
But what exactly is music therapy? How does it help these young babies? What evidence do we have to support music therapy in the neonatal intensive care unit?
What evidence do we have that confirms the benefit? And how can pediatric providers promote and support music therapy in their practices? We'll answer these questions and more but first let's offer a warm PDACAST CME welcome to our guests.
Kalin Moran, Lelia Emery, and Chloe Heintz, thank you all for stopping by the studio today.
[Kalin Moran]
Thanks for having us, Dr. Mike.
[Lelia Emery]
Happy to be here.
[Chloe Heintz]
Yeah, so glad we could join.
[Dr Mike Patrick]
Yeah, we are really glad that you're here talking about music therapy. We have done this before for our parent podcast back last September. That was episode 590 on PDACAST. We called it Healing with Harmony Music Therapy in the NICU, and we'll put a link to that episode in the show notes. But we wanted to get back together on the CME podcast just to sort of go a little bit deeper into the science of music therapy and to really raise awareness amongst pediatric providers that this is something that can be beneficial to young infants. So, let's start with you, Kalin, just sort of the basics. What exactly is music therapy and how does someone become a music therapist?
[Kalin Moran]
I love answering this question, and I'm going to start with the clinical definition and then kind of simplify it from there. So, the American Music Therapy Association defines music therapy as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. I know that's a long-winded definition, so I like to simplify it as we're using music to accomplish individualized goals.
And these goals could vary from promoting wellness, managing stress, alleviating pain, enhancing memory for our older adult populations, improving communication. But here on the NICU, we're really working on some specific goals, which we'll kind of dive into in a bit, such as, you know, promoting comfort and promoting their developmental growth as they stay here on the NICU. As to become a BORTH certified music therapist, it requires a minimum of a bachelor's degree in a music therapy program, and that includes 1,600 hours of hands-on clinical training.
And the coursework in undergrad includes everything from child and human development, anatomy, psychology, music theory, and, of course, music therapy principles. The final step to get credentials is a six-month full-time internship, and we have a wonderful internship program here. Shout out to Morgan and Jackson, who are about to finish their internships this month.
And then finally, music therapy is a licensed profession in the state of Ohio.
[Dr Mike Patrick]
So, you report to a board just like other health care professionals do.
[Kalin Moran]
Correct. Yeah.
[Dr Mike Patrick]
Now, for clinicians who may be unfamiliar with this specialty and, you know, music therapy, it's not just playing music for babies. There's a lot more intentionality and thought and planning that goes into this. Lelia, can you give us a little bit more information on how you figure out, you know, in what ways are you going to present music to these infants?
[Lelia Emery]
Absolutely. So, a lot of people do think that music therapy is simply playing music therapy for infants. Obviously, the first step is that it's implemented by a board-certified NICU-trained music therapist.
So, Chloe, Kalin, and I actually all have additional training specifically with premature infants. So, what that means is we're able to take into account the infant's developmental stage and capacity for stimulation. Our preterm population is so fragile and sensitive, and we're really trained to look at those cues to help make sure that we are giving them the right amount of stimulation, not too little and not too much.
And the interventions that we use, especially with our preterm infants, are highly protocolized. They're very stepwise, very cautious interventions. It looks like us using least alerting music styles, evidence-based practice.
So that's primarily live singing, either voice only, primarily voice only, or with gentle guitar picking accompaniment. So that looks like playing one note at a time on the guitar while you're also singing along. We do that at 60 beats per minute.
The songs that we use with our preterm infants are very simple, two, maybe three-chord songs, depending on how much their little brains can process. And obviously, we're always assessing their tolerance for that stimuli. And then we can also support and empower caregivers to use their voices appropriately.
We know from several music therapy studies that infants not only prefer their mom's voice, but they prefer it to all others. So, they know when I'm singing versus when mom is singing, and they'd rather hear mom, which is really cool to get to pass on to parents, especially when they're nervous about singing for their baby because they don't think they sound good. Your baby thinks you're Beyonce.
You have to take advantage of that time.
[Dr Mike Patrick]
And a lot of folks sing to their babies when they're in utero, right? And so that's a voice that could be familiar and soothing to the baby because they're, of course, not in public necessarily when moms are doing that. So, I can understand why moms would be a little self-conscious with other folks around singing.
But it is something you probably did with your baby, and then you can imagine why that would be soothing, right?
[Lelia Emery]
Yeah, absolutely. That's kind of what we tell parents all the time. For our really hesitant parents, we have a parent recording program.
So, they can record their voice privately, and then it can also play back to their baby. So, they don't have to feel the pressure of doing it live and in person when there's lots of other medical staff around. Yeah, yeah.
[Dr Mike Patrick]
I would imagine as you are judging the baby's response, of course, you're looking at behavior. But I'll bet you guys are actually looking at the monitor as much as the nurses are, right? Like checking their heart rate and their respirations, their O2 sat and all those things to see what the response in their vital signs is, which can be very telling.
Is that something you guys do?
[Lelia Emery]
Absolutely. Once you know what to look for, NICU infants are very clear at telling you what they want and what they don't want. And some of those ways are with their heart rate, their respiration rate, and even their oxygen saturation.
So, we look at those very closely while we are singing to the babies. And a lot of times we'll actually write down those vitals afterwards to take stock kind of across the board of all of our sessions with them.
[Dr Mike Patrick]
Yeah, that must be really rewarding, too, when you see a kid who's, you know, fussy and, you know, seems anxious and their heart rate's up. And then you start your therapy and you really see them from a behavior standpoint relax and you see the heart rate come down. For you guys, I mean, that is just, you know, an immediate cause and effect that must be pretty rewarding for your work.
Yeah?
[Lelia Emery]
Yes, it really is.
[Dr Mike Patrick]
So, Lelia, the NICU can be sort of at baseline, a noisy place. So how do you, you know, distinguish, especially from the baby's point of view, like, these are harmful noises, but these are good noises. And as you're doing music therapy, does that impact, like, the next baby over in terms of ambient noise?
Or, you know, is there enough private area that you really can block out sort of the ambient noise of the NICU and let the baby just focus on the therapy?
[Lelia Emery]
That is a really good question. Yes, anyone who's ever walked through a NICU knows it can be very noisy. There's lots of things going on.
There's monitors beeping. There's CPAP is really loud. And so, part of our job is to make sure that they get exposed to meaningful sound.
I know we've mentioned before that a lot of times parents will play music when the baby is still in utero, which is amazing. It's wonderful. The great thing about the womb is that it actually can filter out the noxious stimuli, the stuff that's too much for our infants.
But when they're born early and they're in our NICU, we have to become that barrier. So, we're the ones who have to make sure that the only or most of what noise is getting around them is appropriate for their development. So meaningful sound can look like speech sounds talking to the baby or live singing, or like I mentioned before, maybe one instrument.
And the reason of that is when you are presenting meaningful sound to someone, if you look at it from like a visual standpoint, noise is just like a wall of sound. Whereas singing or rhythmic speech, like reading a baby book, those actually creates a really nice sound wave that can cut through the background noise. So that's pretty cool.
We love to do that. Noise can negatively impact their development. So that can be characterized by background talking monitors, sound that's not developmentally appropriate.
The incubators are great at blocking out some of that. But we also have to be careful that we're not putting things on the incubators because that can actually amplify the sound or make it worse. So, if you ever see parents wanting to talk to their baby or maybe a family member wants to call on the phone, I encourage them to not place it directly on the incubator.
So, while we know that noise is really bad, meaningful sound in the NICU is actually required for development. So much of what our babies need to grow and thrive is developed when they're in utero. So, we get to be the ones to give them that when they're in the NICU.
[Dr Mike Patrick]
Yeah, and as we, since this particular episode is really focused on providers, I wanted to dive just a little bit deeper into the science compared to the last time that we all chatted together. Can you walk us through how auditory development unfolds in premature infants and how the therapies that you provide take that development into account?
[Lelia Emery]
Yes, that's another great question. Auditory development is really complex, and a lot goes on before babies are born that we don't even think about. So right around 26 weeks postmenstrual age, auditory brainstem response is present.
And around 28 weeks postmenstrual age, consistent auditory response is seen. So, NICU music therapists, our interventions that we provide start at 28 weeks postmenstrual age. And that's because of this reason that we can see a consistent auditory response.
We can know when we're being overstimulating or when the baby is reacting positively to that stimuli. Prior to that, there isn't much research out there. So, we are not going to mess with that younger population.
The final 10 to 12 weeks in utero, fetus needs to experience auditory stimulation for everything to develop. You can kind of think of it like running a marathon. You can't just go out one day.
Well, most people can't just go out one day and run a marathon. You have to at least run a mile before you can go run 26. And development in general is a lot like that, with auditory development being the same way.
They have to have exposure to those speech sounds for the neural pathways to form and to connect. So, some other really cool things that happen in auditory development around 28 weeks, the tonotopic tuning of hair cells in the cochlea happens. So those hair cells and connections in the cochlea are mature enough to tune for specific sound frequencies.
While our babies do hear low frequency sounds first, too much noise actually hinders the upper range of the frequencies that they need to develop. And auditory discrimination, this really plays a big part in that for later in life.
[Dr Mike Patrick]
Yeah, I would imagine those frequencies of the human voice are ones that they really pick up on because they're hearing that as their family's talking. And if they have siblings that are around, you know, when they're in utero. And so, I can imagine how like just the background noise of the NICU and those low frequency noises kind of just wash over the human speaking frequencies and can be quite a problem.
[Lelia Emery]
Yeah, definitely. So, by 35 weeks, actually, auditory processing facilitates learning and memory formation. So, prior to this, our interventions are really geared toward just supporting their overall development.
But once they get to 35 weeks, they have memories. They might recognize familiar songs. This actually plays into one of the other interventions that we do in the NICU.
And then, of course, by the time infants are termed, they tend to prefer higher registers. So, women's voices singing. And they can also recognize sounds in their native language as well as grammar and syntax errors.
So, I'm not saying, you know, the baby might be a little judgy, but they will know if that doesn't make sense.
[Dr Mike Patrick]
That is great. Chloe, I wanted to bring you into the conversation. How is it that you recognize when a NICU baby is being overstimulated?
Like, how do you know when you need to back off a little bit?
[Chloe Heintz]
Yeah, there are many ways that babies communicate to us that they might be overstimulated. Some are more obvious than others, but I'll kind of break it down by category. So, they might give an autonomic response.
So, the obvious ones there being a drop in heart rate or oxygen saturation. They can also have visceral responses, maybe retching or emesis, sneezing or yawning. Those are more subtle signs.
They could also have a motor response with showing us some disorganized movement. The classic NICU hand halts that they're literally telling us stop. They might exhibit some hypotonia or hyperextension as well.
And then we can look at their state and kind of see if they're able to maintain a behavioral state. So, if they're asleep, are they in a deep sleep or are they kind of restless? If they're awake, are they able to be quiet alert or are they kind of in this in-between state where they're not really quite all there?
They might be averting their gaze. They might be staring. They might have a glazed look, or they could just be awake and irritable and not able to console.
And then another way that we can recognize when babies are becoming overstimulated, again, this might not be seen as an overstimulation response, but we can actually look at the self-regulatory behaviors of infants. So, when you see infants bringing their hands to mouth, they're maybe trying to change their position, grasping onto things or sucking. These can be a sign that maybe baby is becoming overstimulated, but they're working really hard to not let it affect their quality of life in that moment.
So, but we can still look at that as a sign.
[Dr Mike Patrick]
Yeah. So, they're using coping mechanisms.
[Chloe Heintz]
Yes, exactly.
[Dr Mike Patrick]
When you do suspect that overstimulation is occurring, do you just stop or are there, you know, is there a particular way that you address that overstimulation?
[Chloe Heintz]
Yeah, that's a great question. I think the first thing to do is to think about what we're doing as clinicians and what might be triggering that response in infants. And if we can pause, yes, we should pause, allow the baby to kind of reorganize.
However, we if we can't stop for whatever reason, we need to provide them with the support that they need. So, we can actually look at the synaptic theory to help guide our responses. This is a model of care that shows us that infants are constantly interacting with their environment.
So, as we've all mentioned already, infants are constantly communicating their wants, their needs, what they like, what they don't like. And so, we need to be able to understand the language, so to speak, and read their cues so that we can enhance their strengths. So those self-regulatory behaviors that I mentioned before and also support their limitations.
So, if they are having like an autonomic stress response, they drop their SATs, we're not going to let them hang out in the 60s. We're probably going to have the RN boost them. Or if they're having a motor response, we're going to provide that containment and help them get back to that regulated spot.
[Dr Mike Patrick]
And you call that Synactive Theory, correct?
[Chloe Heintz]
Yeah, the Synactive Theory of infant development.
[Dr Mike Patrick]
And again, that is just really observing their behavior and their vital signs and understanding how changes in those things relate to stress or stability. Is that right?
[Chloe Heintz]
Yeah, exactly. So just essentially being able to read infant cues for how much they're able to tolerate and getting them back to that good enough environment so that they can regulate and then move on to more meaningful interactions with their environment.
[Dr Mike Patrick]
And that is Synactive Theory?
[Chloe Heintz]
Yes.
[Dr Mike Patrick]
See, this is completely new to me. This is fantastic. I love learning new stuff.
[Chloe Heintz]
Wow, that's great. I'm glad we could introduce a new idea to you.
[Dr Mike Patrick]
Yeah, absolutely. So, Lelia, what types of music therapy then are used with premature babies? We talked about, you know, simple melodies and, you know, just plucking one string on the guitar.
Are there other specific things that you guys do with premature babies as relates to music therapy?
[Lelia Emery]
Yes. So those things you just mentioned kind of play into the interventions we do. The first one, the one that we can start at 28 weeks postmenstrual age, is live music listening.
And that is a NICU music therapist singing to the baby for 20 minutes max. And when we're singing, we're doing those least alerting music styles. So nice, slow, steady lullabies.
The great thing about lullabies is they're so predictable and they tend to be pretty short, so you can repeat them several times. Baby brains love that. One, it's how babies, kids, even adults learn through repetition.
We can kind of start that really early. The kind of unique thing that music therapists have learned over the years through research studies is that while female infants like to get live singing with gentle guitar accompaniment, male infants actually do better with voice alone rather than adding into the guitar. So, we take that into account as well.
From there, once they reach that 28 weeks and they show us that they can tolerate 20 minutes of auditory stimulation, if our parents are interested in doing a recording, we can provide that to them as well. We have special little speakers here that can go inside of an incubator. Talk to your music therapist if you want to implement that at your hospital.
Once they get a little bit older, once they get to be about 32 weeks postmenstrual age and they're stable enough and big enough to get out of bed, to be held by someone other than a parent, that's when we can introduce multimodal neurologic enhancement. And that is essentially live singing. Plus, we add in very slow touch progression.
So, getting some positive tactile stimulation and then also adding in vestibular stimulation. So gentle rocking, if the infant is showing that they can tolerate all of that. The great thing about multimodal is it helps them to integrate multisensory stimuli, which we all know as regular people living in the world is kind of required to be a human.
You know, you walk outside and you're hit by the sunshine and the wind blowing and a car horn and maybe a dog is barking down the street. That is a lot of stimulation for a preemie to take. And when they've been in the hospital for three, four months, we want to be able to provide some sort of bridge.
So that way, the first time they go outside, they're not just completely overwhelmed with life. One other intervention that we use with preterm infants, this starts right around 34 weeks. And this is when I mentioned the auditory developmental stage where they start forming memory is really important, is something called the Pacifier Activated Lullaby.
This is actually a speaker box that connects to a baby's pacifier, and it can actually tell when the baby gives a good quality non-nutritive suck on the paci. And when they do that, the speaker will play 10 seconds of the lullaby recording that we have. So obviously, we like to use mom's voice if possible.
The great thing about the PAL is it kind of shows the baby, gives them some nice positive reinforcement for that non-nutritive suck, the suck-swallow-breathe reflex that is needed to bottle feed later. It can also be a really great way to introduce something really positive to their mouth. A lot of our long-term babies in the NICU have been intubated for a while, so their oral skills are, their oral system is a little nervous.
They're not really sure about that. A lot of that input hasn't been very positive. So, this can be a great way to show them like, hey, it's OK, you can just suck on your paci and listen to music.
[Dr Mike Patrick]
There's something just incredibly fascinating about that. It's almost like a baby's own PCA pump, you know, but instead of pushing a button and getting some pain medicine, you suck on your binky and get to hear your mom's voice. I just I love that.
[Lelia Emery]
Right. Yeah, it's really, really cool. And the therapist can actually change the settings to as the baby gets stronger and more coordinated, they can kind of encourage that along.
[Dr Mike Patrick]
So, Caitlin, I would imagine that there are a lot of families who think music therapy is pretty cool because it is and they see the benefits that it has for their babies. Do you get asked a lot about how do we continue to do this when we go home from the NICU?
[Kalin Moran]
Yeah, absolutely. We do. And so, we love to give suggestions on the type of music that can be used.
And it's based on a baby's postmenstrual age as well as their developmental capacity. So, I want to start with kind of these level one songs, these beginner songs that we would start with because they are the most simple. They're going to use two chords.
These are songs like The Itsy-Bitsy Spider, Mary Had a Little Lamb, Hush Little Baby, all very super simple level one songs to start with. And if a baby can tolerate those, we might move up to level two. These are songs like The Muffin Man, Twinkle Twinkle, I'm a Little Teapot.
And then level three songs would be a little bit more complicated using slightly more chords. But these are songs like You Are My Sunshine, Baby Beluga, Skidamarink. And so, we love to give some examples because these are typically songs that a lot of us already know or heard as children.
But once babies are able to tolerate more complex music, we want to incorporate parent preferred music so that we can not only support the infant, but the whole family as a whole. So, I've been, you know, I've played anything from Adele to Billie Eilish, Warren Wallen, Jimmy Buffett, James Taylor, Taylor Swift, you name it. We want to incorporate music that is important to the family to make our sessions therapeutic for everyone.
[Dr Mike Patrick]
Yeah, that does seem really important. And when the baby goes home, they're likely to be exposed to those same songs and artists that the that the family is listening to. So that definitely makes sense.
I'm wondering, as we're talking about this, if there's a role for this sort of music therapy for colicky babies, because one theory of babies who now we're talking outside of the NICU age, but they, you know, colic often is fussiness that happens toward the late afternoon and into the evening hours. And one theory is it's caused from stimulation overload. So, like during the morning, the early and midafternoon, there's just so much stimulation.
And then by crying, babies are able to block out all of that, all of that stimulation. And so, I just, you know, I wondered if for colicky babies, and I know you can't answer this, but, you know, in terms of future research, you know, could music therapy help to prevent colic episodes, you know, if it's used at the right time? Or could that also be used to soothe the babies who are colicky?
Because I think, you know, you know, folks think, oh, it's because their belly hurts or, you know, it's their formula or whatever. But I don't buy that. When you look at the pattern of the crying and the age at which this happens, I really think it's probably more brain development involved.
And I just wonder if there's music therapy, like if you guys could solve colic, you would be the heroes of so many moms and dads, right? What do you think about that, Kalin?
[Kalin Moran]
Yeah, I'm going to pass this off to Lelia, actually.
[Lelia Emery]
Yeah, so that's actually a great idea. And we totally should look into that.
As far as preventing those instances, I'm not really sure what we could do. Like I said, we'd have to explore some ideas. But calming those colicky babies, yes, I do think there is a way for music therapy to play a role because, like you mentioned, you think it has something to do with neurological development.
It's actually kind of similar to how we calm our infants with neonatal abstinence syndrome. We use something called the ISO principle. So, we're talking with our preterm infants about how we start really low, and we gradually add more as they can tolerate it.
The ISO principle for our colicky, agitated babies is going to be the opposite. We're going to start with maybe that more complex song, a baby beluga, while we're holding them. Maybe we're rocking, maybe we're patting.
And then gradually we can fade out the stimuli as they start to calm. It's one of those things that I feel like you kind of have to try it and see it to believe it. But we do this, like I said, all the time with our kind of neurologically overwhelmed infants.
And it can be really, really helpful. The hardest part, of course, is when you're dealing with that in the moment to remember the steps and to calm yourself down. But I definitely think it's worth a try.
[Dr Mike Patrick]
Yeah. Oh, yeah. It is definitely worth a try.
And I mean, because colic really does, it's, you know, you can understand why, especially new parents who maybe weren't expecting colic to just be so frustrated and to actually have a plan of how to deal with it in a way that actually could work, I think would definitely be something that would be helpful. If you do that study, I would be happy to be a part of the project because that sounds so fascinating to me. Let's move on to a parent's voice, Kalin.
We've mentioned this several times that babies prefer the parent's voice, and especially with boys, they want the parent's voice alone. They can't do the multimodal thing quite, you know, as quickly as girls can do, which, by the way, is also true in adults, at least in my family. My wife can multitask without a problem.
And I'm like, if I take my mind off this one thing I'm doing, you know, everything just becomes a mess. So, it makes sense that you do see that gender difference, even in premature babies. Anyway, parent's voice is important.
How do you really work intentionally to incorporate a parent's voice into music therapy?
[Kalin Moran]
Yeah, we really want to encourage parents that their voices are most comforting to their baby. So, whether that's talking to them, reading stories, singing to them, it really helps support their language and brain development. If you think about babies born premature, they're exposed to the harsh sounds that we've talked about in the NICU, whereas a full-term baby, they'd still be in their mother's belly hearing her voice.
So, we want to encourage them to continue using their voice. And there is an interesting research article from 2018 that kind of highlights the effects of maternal voice exposure on preterm infant development. And this article states, maternal voice can foster maternal closeness and support postnatal bonding with when physical closeness is not possible, right?
So, for our moms who maybe aren't able to hold their baby yet or aren't able to hold them as often as they'd like, using their voice can promote that physical closeness and that bonding. Extended stays in the NICU can cause prolonged separation, which can create a strain for both parents and the infant and decrease attachment and parental caregiving. So, the use of parent voice can increase that participation and ultimately create a sense of empowerment for them.
Similarly, there was another systematic search that was done by Williamson and McGrath in 2019. And so, I'm just going to quote their work. Maternal voice has physiological as well as behavioral and emotional effects on preterm infants.
Several studies found that maternal voice increased automatic stability, improving heart rate and respirations, as well as weight gain. No negative effects were identified. And I just think that quote speaks really powerfully to the impact that voice and music can have on our infants.
So, incorporating maternal voice into routine cares by the bedside and just empowering parents to feel more involved in their infant care without, you know, being distracted or obstacles. We just want them to feel as empowered as possible to be involved in their baby's care and development.
[Dr Mike Patrick]
Yeah, yeah, absolutely. Chloe, we've talked about, you know, live versus recorded. You know, if you can do it, if a parent can, you know, sing live, that's great.
But recorded singing and talking is also a possibility. Do you see a difference between those two? Like, is there advantage of the live performance, so to speak?
Or are the recorded music and the recorded voice just as soothing to these premature babies?
[Chloe Heintz]
Yeah, that's a great question. Generally speaking, we as music therapists recommend live singing over-recorded just because you can respond in the moment to those communications that the infant is presenting us with. So, the signs of overstimulation or engagement, depending on how they're feeling that day.
And so, we can manipulate in real time what we're doing with our voice. So, in that sense, live music is really a powerful tool. However, when that's not an option, recorded music or recorded voice can be a developmentally appropriate option for sound at the bedside.
Babies are awake. It can be something for them to attend to, can be a positive stimulus. And it can also provide the empowerment for family and caregivers to help them be involved and feel like they're providing something meaningful, even when they maybe can't be at the bedside as much as they would like to be.
[Dr Mike Patrick]
Yeah, and so if you can have that, the parent's voice or the music that seems to be most soothing and has the most relaxing effect and change for the better and vital signs, if you can figure out what those things are and then record them and play them when a baby needs it, I can definitely see the advantage. So, it's encouraging to know that the recorded voice and the recorded music do play an important role and can be helpful for babies, for sure. Now, there are other types of noise that we think about, but there's not necessarily science behind it.
So, you know, a lot of folks think about white noise machines or having a television on in the background to go to sleep. Are those things beneficial for these babies, or is it really the simple melodies and the parent voice is really what's important and the things that we think might be soothing? Because maybe we use a white noise machine or maybe we leave a TV on when we sleep.
Those aren't necessarily going to be the best things for babies, though, right, Kalin?
[Kalin Moran]
I'm really glad you asked this question because there's a lot of misconceptions about the use of music and sound on the NICU. And so, one common one that we get is, oh, we think classical music would be best for our baby, when actually classical music can be really overstimulating. There's often a lot of instrumentation, very complex.
It's not predictable. So, we want to encourage them to use lullabies, simple songs that are repetitive, predictable. And then another misconception we get is kind of relating to when and how long to play music.
So, if a baby's sleeping and the tendency might be to keep the music on, when actually we want to give them periods of silence, periods to let their brain kind of process all that they just took in instead of keeping the music on. We really try to keep the stimuli to 20 to 30 minutes for our fragile babies because we know how important periods of silence are for them. And you mentioned TV.
So, this is another really important topic to discuss. I know we often feel bad if we have to leave an infant at the bedside and there's no noise or no one to be with them. So sometimes the TV will get turned on.
But there is actually no evidence to show that this is helpful for our infants. And so, we do not recommend TVs for our fragile infants. Similarly, we don't recommend sound machines either.
I know these are very common for our term healthy babies that are not on the NICU. However, for babies on the NICU, we do not recommend using sound machines, white noise. We want to give them the positive auditory stimuli that we've talked about as well as periods of silence.
[Dr Mike Patrick]
Yeah, so important. In terms of parents voice, you know, there's, you know, we do baby talk, right? You know, you can kind of picture it in your mind, you know, how you talk to a baby.
Does it matter how a parent talks? So, you know, we say the parent's voice is important, whether it's live, whether it's recorded. Is it just conversation or do you have to talk in a certain way in order for it to have the most benefit?
[Lelia Emery]
Yeah, that's a good question. I think that as music therapists and as developmental therapists, we can educate parents on how to use their voice appropriately. We often tell parents to pretend like they're trying to get their baby to go to sleep.
So, talking slow, smooth, no sudden jumps or stops or starts. And both they're talking to their baby, the same when they're reading stories and the same when they're singing to their babies. So, it does matter a little bit how you talk.
But the most important thing is that the parents are engaging and using their voice to help see their baby.
[Dr Mike Patrick]
Yeah. In terms of the NICU staff, you know, we do have a lot of nurses who listen to this podcast. What can the NICU nursing staff do to sort of encourage this process to educate and empower parents to use music in an appropriate way? Chloe?
[Chloe Heintz]
Yeah. So, NICU teams can offer programs like Sounds of Love. You can rope your music therapist in.
We always love to help support our babies and families in the NICU to help encourage that parent voice, both live at the bedside, but also recorded with the help of music therapists to manage those sound levels and play those recordings safely. We also can have NICU teams encourage live music at the bedside. So, encouraging parents to sing to their baby while they're there at the bedside or if they're instrumentalists, reach out to music therapy to help them play for their baby appropriately.
Obviously, there are some instruments that are not NICU appropriate, but parents are usually able to adapt and provide something for their baby that's also meaningful to them as an instrumentalist.
[Dr Mike Patrick]
You may not be able to bring a harp up to the bedside, right?
[Chloe Heintz]
Right. Yeah.
[Dr Mike Patrick]
But, you know, you can for multiple reasons. Yeah. They can record it, though.
[Chloe Heintz]
Well, it depends on the baby's age and what they can handle.
[Dr Mike Patrick]
If they just pluck one string.
[Chloe Heintz]
Oh, yeah. If they, it's possible to do it in a simple way that could be non-alerting.
[Dr Mike Patrick]
Yeah. Yeah. Because otherwise, then you're more into classical music and it's more complex.
And ultimately, you're going to kind of know because when you're watching the baby's reaction and their behavior and their vital signs and all of those things kind of give you an idea. Oh, no, this is too complex. Right.
[Chloe Heintz]
Yeah. Yeah. I'll come back to watching the baby again.
[Dr Mike Patrick]
Yep. Yep. What about pediatric providers then, especially in primary care?
So, we have premature babies who have graduated from the NICU. They're seeing their primary care doc now. This is a baby that has benefited from music therapy.
How can pediatric providers encourage parents to continue this? And I think, you know, one way is by raising awareness and sort of teaching the principles of music therapy, which hopefully we're doing in this podcast. But are there other things that pediatric providers can do to encourage parents to continue with music therapy or for older babies, you know, who are more fussy to encourage music therapy even outside of the NICU?
[Chloe Heintz]
Yeah, that's a great question. So obviously in the NICU, we can educate and provide the most supportive environment possible. We can't really control what parents and families then do at home, but we can provide that education, and your clinicians and maybe primary care can provide resources for families.
So generally speaking, when those babies hit term, they might be ready for more things like other sorts of recorded music, mobiles, things like that. We still wouldn't recommend sound machines or TV. I think the AAP doesn't recommend those under two years old.
And then when you are using those devices, those recorded music, we want to make sure that they're limited to a low volume, that they're only being played for up to 20 minutes at a time. Kalin mentioned this earlier, but silence is really important for receptive listening and processing of those sounds. And continuous noise can actually increase sound levels in the environment and damage hearing, which is not good.
Just like you would in the NICU, you always want to look to the baby for their cues of what they're tolerating, what they're engaging with, things like that. And then also I want to plug, we have an outpatient music therapy group that clinicians could recommend. We do a group called Giggle and Groove that is for community members and also NICU graduates who are between the ages of six months and two years corrected age.
And it's just a music therapy developmental fun group that we do on Wednesdays.
[Dr Mike Patrick]
Giggle and Groove, right? Yep. And is there information about that on the website?
I know you guys have a music therapy program website at Nationwide Children's Hospital's main website. Can folks find more out about the Giggle and Groove there?
[Chloe Heintz]
Yes, you can.
[Dr Mike Patrick]
Perfect. And we will put a link again to music therapy at Nationwide Children's Hospital. Also, as I mentioned at the beginning of our podcast, we'll put a link to the interview that we did with these same music therapists called Healing with Harmony Music Therapy in the NICU, which is really directed toward parents.
And so, I think as providers out there want to, you know, provide support and awareness and resources for their families, that particular episode, again, it's PediaCast 590 may be helpful. We also have a link to the National Institute for Infant and Child Medical Music Therapy out of Florida State University. Kalin, what sort of resources are available at that site?
[Kalin Moran]
Yeah, great question. That resource will give a lot of information on the NICU music therapy training that we mentioned we all specifically have. It's kind of an extension.
So, you need your at least minimum of a bachelor's to become a certified music therapist. It's a continued training with hands-on, as well as more like reading and an exam to complete that certification.
[Dr Mike Patrick]
Great. And again, we'll have a link to that in the show notes too, over at pediacastcme.org for this particular episode. And then we also have a really interesting article from BMC Pediatrics entitled Music Medicine and Music Therapy in Neonatal Care, a Scoping Review of Passive Music Listening Research Applications and Findings on Infant Development and Medical Practice.
So really interesting article that dives a lot deeper into the science of this from BMC Pediatrics. And we'll put a link to that article in the show notes as well. So once again, Kalin Moran, Lelia Emery, and Chloe Heintz, all NICU music therapists at Nationwide Children's Hospital.
Thanks so much for stopping by and teaching all of us a little bit more about what you do. Really appreciate it.
[Kalin Moran]
Thank you. It's been a pleasure.
[Lelia Emery]
Thanks for having us.
[Chloe Heintz]
It's been fun, Dr. Mike. Thank you.
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[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. We really do appreciate your support. Thanks again to our guests this week.
They did a great job. Kalin Moran, Lelia Emery, and Chloe Heintz, all music therapists in the NICU at Nationwide Children's Hospital. Don't forget, you can find our podcast wherever podcasts are found.
There may be an easier way for you to listen. We're in the Apple podcast app, Spotify, iTunes, and Google Play. iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android.
Our landing site is pediacastcme.org. You'll find our entire archive of past programs there, along with show notes for each of the episodes, our CME information, terms of use agreement, and our handy contact page if you would like to reach out and say hi or suggest a future topic for the program. Reviews are also helpful wherever you get your podcasts.
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Simply search for PediaCast. You've listened to the podcast, so now be sure to claim your free category one continuing medical education credit. That's CMEs and CEs.
It's easy to do. Just head over to the show notes for this episode at pediacastcme.org. You'll find a link to the post test in the show notes.
Follow that link to Cloud CME. Click on the materials tab taken past the posttest and the category one credit is yours. Super easy, right?
And again, we do offer that credit to doctors, but also nurses, nurse practitioners, physician assistants, pharmacists, psychologists, social workers, and dentists. Of course, you want to be sure the content of the episode matches your scope of practice. Again, complete details on all that is available at pediacastcme.org.
A couple of other podcasts I want to tell you about. We do have a podcast for parents, which I have already mentioned in this episode, one of the available episodes from last September on music therapy. But we have lots more, over 600 episodes for parents.
They're all evidence-based and we do cover pediatric news and interview plenty of pediatric and parenting experts. Shows are available at the landing site for that program, just pediacastcme.org. Also available wherever podcasts are found, simply search for PediaCast.
And then we also have a faculty development podcast that is from the Center for Faculty Advancement, Mentoring, and Engagement at the Ohio State University College of Medicine. So, if you are a teacher in academic medicine at Ohio State or beyond, really a faculty member in any of the health sciences anywhere in the country, then this is a podcast for you and you can find FAMEcast at famecast.org and wherever podcasts are found, just search for FAMEcast. Thanks again for stopping by.
And until next time, this is Dr. Mike saying, stay informed, keep it evidence-based and take care of those kids. So long, everybody.
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