I have always had a soft spot for musicals in theater or movies.
When my wife and son were traveling with me to a recent conference, the two of them decided to see the movie musical “La La Land” without me. I forgave them, because I knew that my daughter and I could soon see it ourselves (she was coming home for Spring Break).
Needless to say, I was not amused when my daughter told me after arriving home that La La Land was the only free film playing on the plane that she had not seen already. She could not resist watching, despite our earlier promise. It did not help that my son defended her, saying he probably would have done the same given the long flight across the country. L
I am not sure what it is about musicals, or music for that matter, that so deeply connects us to our basic physiology, and triggers our brains to activate or settle into states of positivity or calmness. The experience is real, and perhaps needs better defining in our overly medicalized environments.
Sound in the NICU
These days, as I walk around our new NICU, I notice it has become both welcomingly and disarmingly quiet. The move to a brand new single patient room formatted unit has been an amazing transformation for our unit, but not without massive changes in our culture and environment.
Given that the growing fetus can hear from the time that cochlear development matures at twenty-four weeks, our NICU babies are listening all the time. The question remains: exactly what ideally should they be listening to?
Every day, many unborn fetuses experience a daily dose rich with varying musical experiences in utero, orchestrated by their mothers or fathers to calm them and stimulate a nurturing environment. Often this may be accompanied by the soothing voices of parents who may also sing along with the music being played. Our NICU infants often miss out on the full depth of these experiences.
The impact of sound on infants
The impact of sounds in the NICU has been debated for some time. There is no dispute, though, that there are effects.
Sounds act like a neurodevelopmental drug. The challenge with existing data on sounds is the lack of exploration into the mechanisms of what sounds do in particular forms and specific doses.
The clearest evidence suggests that too much noise may be harmful for the growing newborn. Decibel levels in the NICU have been recommended to be below 45 decibels at all times. This is to protect infants from hearing loss and inadvertent stress responses to jolting loud noises, the sum of which may impact behavioral effects. Preterm infants already suffer a higher risk of hearing impairment compared to their term counterparts, so it behooves us to pay attention to the noises in our NICUs. What constitutes noise from formative sounds is our current challenge.
Reducing sounds in the NICU
It is hard not to miss the chatter of activity that was so much a part of our social fabric in our old open style NICU. These activities bonded staff and parents alike, and we have not resolved how to recreate this fabric in a much larger space with physical separation.
Many of our NICUs have adopted alarm fatigue exercises to evaluate and control the increasing number of alarms that aid our continual assessment of the neonate. Many of these alarms reach the critical levels in decibel range and pitch to potentially disturb our infants’ development.
Surprisingly, we have only recently recognized that eliminating all sounds and leaving infants in silence is no longer the end game.
Music and potential benefits
It is a delicate and formidable balancing act to control noxious volume and types of noise in the environment and replace the resulting silence with an appropriate musical replacement. Music is defined as intentional sound described in terms of pleasing harmonies, dynamics, rhythm, tempo and volume.
The potential benefits of music therapy have been described in the past. Can music therapy lead us closer to the ideal care model? What does the evidence show? Studies conclude that music interventions have a beneficial significant effect on heart rate, behavioral state, oxygen saturation, sucking/feeding ability, and length of stay.1,2 They suggest that infants may have better sleep, feeding patterns, and neurodevelopmental outcomes.
Going forward: Harmony in care
It seems to me that we need more information to determine how much noxious sound reduction we need, how many positive sounds and tones we need to add, and, in particular, how these may complement other developmental strategies that we have been gradually encouraging – particularly with greater parental involvement.
We should consider:
- Is there added value to parent-chosen music, or music chosen by music therapists, and are there differences with live music versus recorded music?
- Are the effects amplified during skin-to-skin, or with the use of a pacifier or with massage?
- Is there collateral benefit to mothers with improved relaxation in improving their ability to respond to their child and produce more milk?
Unfortunately, there has been less progress in this area as it has often been considered a softer science due to the lack of conformity on the treatment, the rigor of the study design, and the small sample sizes. We may be losing out on a huge opportunity to integrate sensory inputs and their role in developmental care of the newborn.
The truth is, it probably really does matter what our NICU babies hear all day and all night. We do not have a definite answer to its value in promoting the best neurodevelopment of the preterm neonate. Even if we cannot completely decipher the most optimal sounds and tones that they should be hearing, this should not stop us from trying.
Overall I see us gradually moving towards a more holistic model of neonatal care. One that brings together the science of neurophysiology, neuropsychology, neurodevelopment, sensory stimuli, and the powerful interplay that the human element has in all these spheres to generate the most synergistic approach to bedside care.
So, what would be reasonable recommendations now as we face the music of sound in the NICU? Probably not that dissimilar to what we say to parents of all newborns at discharge. Talk to your child, sing to your child, play music for your child, soothe your child with positive vocal and music experiences of any form especially when you anticipate them to be distressed. Let the music play on.
And now I am off to finally view La La Land, all by myself.
- OʼToole A, Francis K, Pugsley L. Does Music Positively Impact Preterm Infant Outcomes? Adv Neonatal Care. 2017 Apr 8.
- Standley J. Music therapy research in the NICU: an updated meta-analysis.
Neonatal Netw. 2012 Sep-Oct;31(5):311-6.