Music Therapy and Premature Infants

Okay, okay, I know what you're thinking: If these infants benefit so much from listening to music, why the heck would you need a music therapist in the NICU? What would they do that is so different?

This is a question that music therapists are always fighting to answer with every population with which we work.

Whenever I personally am working with a client, the question I ask myself is, "What does this client need?"

Music Therapists working in Level II nurseries ask themselves the same questions. In the NICU, this is what the premature infants need:

  • Weight Gain
  • Ability to properly feed
  • Acclimation to the environment outside of the womb

I know from my internship that premature infants cannot be sent home until they can show that they physiologically and neurologically able to be as "independent" as possible. This means no episodes of bradycardia (dangerously slow heart rate), tachycardia (dangerously quick heart rate), apnea (infant forgets to breathe), they can breastfeed or take a bottle the way he/she should, and isn't easily overstimulated.

Knowing these needs, specific music therapy techniques were created to facilitate infant development as they are continuing to develop outside of the womb. The two most common interventions used are:

  • Multimodal Neurological Enhancement
  • Pacifier-Activated Lullaby

Multimodal Neurological Enhancement

Many premature infants are incredibly sensitive to any form of sensory input or stimulation because their minds and bodies have not yet learned how to acclimate to that input and maintain homeostasis. In fact, when a premature infant is overstimulated, it negatively impacts neurological development.

In order to facilitate neurological development and the child's ability to self-regulate, multimodal neurological enhancement, formerly known as multimodal stimulation was developed. MNE is a progression for premature infants at least 32 weeks GA which involves the layering on of 3 different forms of non-threatening, non-invasive stimulation: first, auditory (singing), then tactile (skin-to-skin pressure touch), then vestibular (rocking). The therapist begins with guitar or humming, followed by singing with lyrics, tactile massage progression that hits very specific points of the body, followed by rocking. The progression lasts a maximum 0f 20 minutes, and during that time, the music therapist is watching for negative signs of overstimulation on both the monitor and on the infant. These signs include grimace, red face, splayed fingers, arched back, "halt" hand (their hand literally goes up like they are wanting a high-five), and crying. When a negative sign is shown, a layer (perhaps lyrics or massage) is withdrawn so that the child can self-regulate and return to homeostasis. Based on the theory that we neurologically develop from the head down, the massage progression hits several points of the nervous system on the body: head, back, arms, chest, legs, forehead, and cheek. The idea is that the infant learns to take in and organize this input while still remaining in homeostasis.

In researching and testing this music therapy intervention, here is what the results showed. Brace yourself, this is pretty incredible:

For female premature infants who received MNE using guitar and singing as auditory stimulation (along with vestibular and tactile stimulation), length of stay was decreased by an average of 21.3 days compared to those who received no intervention.

For male premature infants who received MNE using guitar and singing, length of stay was decreased by an average of 1.1 days. When presented with singing as the only form auditory stimulation, length of stay was decreased by an average of 16.8 days compared to those who received no intervention.

Let me put this in perspective for you. In presenting these infants with non-threatening, soothing forms of stimulation to which they learn to tolerate and process, they are somehow able to be released from the hospital 2-3 weeks earlier than if they received no intervention. If you're a parent, it means you can take your baby home sooner. If you're a hospital administrator, it means saving money BIG time.

MNE isn't just for the infant either. It's for the parent, too. Often times, music therapists will teach one or both of the parents how to perform the progression. Research shows that this parent training decreases anxiety in mothers; not to mention it is a wonderful way to allow a parent to feel as if they are helping their child while also teaching them how to bond in a helpful and appropriate manner.

While the word "stimulation" is scary and disconcerting to nurses and neonatologists, music therapists are well-trained to know what to look for while performing this progression. We are looking for and be careful to respond quickly and appropriately to negative signs of overstimulation. With premature infants getting out of the hospital so much sooner because of MNE, why wouldn't anyone want music therapy as part of the infants' treatment?

Pacifier-Activated Lullaby

Non-nutrituve sucking (NNS) is a reflex that develops in the womb around 34 weeks GA. When babies are born prematurely, that ability may or may not naturally develop. In addition, during hospital stay, when the babies are fed through tubes, they may experience oral aversion and have a negative association with items going in their mouths.

The pacifier-activated lullaby is a device used to increase non-nutritive sucking for premature infants who are not feeding properly. The idea behind the PAL is that music is used as a contingency for sucking; the baby sucks the pacifier, the sensor picks up on it, and automatically plays music. The baby then makes a connection: Oh, when I suck, I get music! A positive association is made! Moreover, when the association is made, the music therapist can change the settings on the device so that a stronger sucking threshold or a greater number of sucks is needed to elicit the musical response from the device, thus further developing and strengthening the NNS.

Anyone else blown away by this?

Similar to last week, I am absolutely overwhelmed and exhausted by writing this, not because writing is difficult, but because there is so much research in this area! It was hard to find a way to get so much information into one blog post.

From a personal standpoint, I've seen firsthand how music therapy is beneficial. Yes, yes, it decreases hospital stay, but it does more than that. Some parents don't get the chance to be with their child all day, every day in the NICU; the infant lays in his/her open crib or isolette for most of the day. Moreover, some new mothers are scared out of their wits as they see their tiny infants laying there. They may be asking themselves, Am I allowed to touch him? What if I hurt him? Is there anything I can do to help him? Music therapists have the time and training to be able to sit and listen to mom/dad, talk with them, console them, and provide them with a safe and helpful intervention that not only helps the baby, but facilitates bonding between parent and child. And if the parent is not there, the infant can still receive that warm contact through MNE.

I've seen a mom's anxiety and nervousness decrease as I walked her through the progression. I've seen an infant go from being able to tolerate only humming to being able to take in and process all three forms of stimulation. It works, guys. The research is all there. So now the question is,

Why wouldn't a NICU want music therapy?



Standley, J., Cassidy, J., Grant, R., Cevasco, A. Szuch, C., Nguyen, J., Walworth, D., Procelli, D., Jarred, J., Adams, K. (2010). The effect of music reinforcement for non-nutritive sucking via the PAL on achievement of oral feeding by premature infants in the NICU. Pediatric Nursing36 (3), 138-145.

Standley, J. (2012). Music therapy research in the NICU: an updated meta-analysis. Neonatal Network: Journal of Neonatal Nursing, 31(5), 311-16.

Standley, J.M. (2000). The effect of music to increase non-nutritive sucking of premature infants. Pediatric Nursing, 26(5), 493-95, 498-99.

Standley, J.M. (2003). The effect of music-reinforced non-nutritive sucking on feeding rate of premature infants.

Standley, J.M. (1998). The effect of music and multimodal stimulation on physiologic and developmental responses of premature infants in neonatal intensive care. Pediatric Nursing, 21 (6), 532-39.

Standley, J.M. (2002). Music therapy in the NICU: Promoting the growth and development of premature infants. Journal of Pediatric Nursing, 17(2), 107-113.

Standley, J.M., & Walworth, D. (2010). Music therapy with premature infants: research and developmental interventions, 2nd Ed. SilverSpring, MD: American Music Therapy Association,

Walworth, D. Standley, J., Robertson, A,. Smith, A. Swedberg, O., Peyton, J.J. (2012). Effects of neurodevelopment stimulation on premature infants in neonatal intensive care: Randomized controlled trial. Neonatal Netowrk: The Journal of Neonatal Nursing.