What are the possible dangers to a premature infant in an environment filled with excessive stimulation?

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Volume 18, Issue 6, December 2012, Pages 210-216

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Many variables affect length of stay (LOS) in the NICU including but not limited to the gestational age at birth, birth weight, time on the ventilator, the provision of oxygen at 36 gestational weeks or later, and retinopathy of prematurity (Beeby, 2003). LOS research has shown that treatment is highly differentiated across NICUs and differences can be attributed primarily to problems with monitoring/treating apnea and poor feeding ability (Eichenwald et al., 2001). For infants born at 28 weeks gestation or earlier, higher numbers of painful procedures experienced and earlier gestational age resulted in decreased blood cortisol levels and behavioral stress response reactivity over time (Grunau et al., 2005). This points to possible changes in underlying stress response systems for premature infants during their time in the NICU. At eight months corrected chronological age, infants born at 28 weeks gestation or earlier had significantly higher levels of salivary cortisol when exposed to a positive novel stimulus than infants born between 29 and 32 weeks gestation and term infants. The cortisol response to novelty was predicted by neonatal pain and gestational age at birth, while higher basal cortical levels at 8 months old was associated with higher numbers of skin-breaking painful procedures (Grunau et al., 2004). One explanation is a possible “resetting” of the basal arousal systems for premature infants born extremely early. If infants are experiencing shifts in their set point for arousal, the arousal system could be influenced by the processing of environmental experiences. Infants who engage in an intervention that elicits pleasurable responses at the same stage of development that painful NICU treatment occurs may be able to alter their set point of arousal and, therefore, allow better self-regulation.

The abilities to self-soothe, modulate emotions, and tolerate changes in stimulations experienced within an environment are all related to the development of regulation (DeGangi, 2000, Kopp, 1982). The biological factors contributing to behavioral regulation abilities have been discussed not only in relation to gestational age at birth but also the disruption of brain maturation in regionally specific areas. Neuroanatomical studies using magnetic resonance imaging have identified neurological abnormalities seen in early cerebral white matter volume loss, cystic abnormalities, and immature patterns of myelination (Clark et al., 2008, Nadeau et al., 2003, Peterson et al., 2000, Stewart et al., 1999, Taylor et al., 2004, Woodward et al., 2006). The region of the brain primarily affected for premature infants is the periventricular zone which affects neuronal integration and cortical projection. Disorganization of fiber tracts connecting subcortical and cortical regions as well as disruption of myelination formation is attributed to damage in this region (Clark et al., 2008, Counsell et al., 2003, Huppi et al., 2001). This type of white matter damage may inhibit infants’ abilities to learn how to regulate emotional responses and respond appropriately to stimulation as the brain is forming the intricate coordination of neural processes.

The existing literature addressing the effects of developmental music protocols for premature infants provides support for the acquisition of coordinating advanced behavioral regulation skills (Standley, 1998, Standley, 2002, Standley and Swedberg, 2008, Whipple, 2000, Whipple, 2008). To date, the studies utilizing behavioral measures indicate that premature infants improve oxygen saturation rates, are discharged home sooner, return to homeostasis sooner after painful procedures, and show trends of consistent patterns of increases in weight gain in response to developmental music interventions.

Many nurses and neonatologists are reluctant to add another type of stimulation to the NICU environment. Some researchers have suggested there is not enough conclusive evidence supporting the use of music with premature infants since most studies have small sample sizes (Hartling et al., 2009). However, a review of twenty years of music therapy in the NICU discovered significant effects across multiple measures including behavioral, length of stay, and physiological measures (Standley, 2011). There are multiple NICUs incorporating developmental multimodal interventions across the nation provided by trained NICU Board Certified music therapists. This controlled study was designed to investigate how a specific music therapy protocol impacts premature infant development.

Infants admitted to four different NICUs in Florida and Texas were invited to participate in this study from October, 2008, to March, 2010. Infants were referred by NICU physicians or nurses for music therapy intervention and then randomly assigned to experimental or control condition groups with randomization order generated by a computerized random number generator. Parents were informed of the study by the staff music therapists working at each participating hospital and written informed

A total of 168 infants born prior to 37 weeks gestation and meeting all enrollment criteria were enrolled in the current study. One parent chose to remove their infant from study participation after providing parental signed consent. This parent stated she did not want to take the chance that her infant would not receive music therapy intervention if he/she was assigned to the control group. No infants admitted in the study died nor were any transferred to another hospital. Prior research has

This study demonstrates that premature infants who received Developmental Multimodal Stimulation with music had positive neurodevelopmental gains as measured by significantly shortened LOS. There were differences by gender in type of music stimulation received. These findings are similar to the smaller study previously conducted (Standley, 1998) finding gender differences in length of stay for DMS using only singing. The differences found by gender and types of music stimulation are interesting

This study is the largest examination of the neurodevelopmental effects of developmental multimodal stimulation for premature infants to date. Adding DMS to standard patient care in the NICU is a safe and low cost intervention to improve neurodevelopmental outcomes of premature infants. Future research recommendations include investigating gender differences by birth weight and type of music stimuli to refine clinical protocol recommendations. Longitudinal analysis investigating effects of

No external funds were used for the completion of this study.

No authors have any conflict of interest with the completion of this study.

The authors would like to thank the NICU medical staff at Florida Hospital Orlando, Lawnwood Regional Medical Center, Tallahassee Memorial HealthCare, and The Woman’s Hospital of Texas for their support and participation in this study.

A.L. Stewart et al.
J.M. Standley
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C.A.C. Clark et al.

S.J. Counsell et al.

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E. Eichenwald et al.

R.E. Grunau et al.

Premature infants are highly sensitive to pain because of their immature and vulnerable nervous systems, which lead to peripherally inserted central venous catheter (PICC) difficulty. The objective of this study was to investigate the application of a music intervention (MI) during PICC placement procedures in premature infants.
A randomized controlled trial was conducted on sixty premature infants (gestational age of 28 weeks to 36 weeks). Infants hospitalized to receive PICC puncture and meeting the study entry criteria were randomly assigned to an MI group (n = 30) or a control group (n = 30). The effects of MI were assessed by determination of heart rate, blood oxygen saturation, pain rating, cortisol concentration and operating time during PICC placement procedures in both groups. Furthermore, pain level was identified using premature infant pain profile.
There was no statistically significant difference between the two groups in terms of heart rate, blood oxygen saturation and pain score before intervention (P > 0.05). During PICC placement procedures, a significant increase in term of blood oxygen saturation (P < 0.05) and reductions in terms of heart rate (P < 0.05) and cortisol accumulation were observed in the group receiving music intervention compared with the control group. Furthermore, MI led to a significant reduction in pain score (mean difference: 3.4, 95% confidence interval: [2.0, 4.8]), and remarkably decreased the time needed for PICC placement in the MI group compared to control group.
During PICC placement procedures for premature infants, MI significantly reduced stress hormone levels, physiological parameters and behavioral response of pain.

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The effect of kangaroo care (KC) has not been adequately studied in mothers. This present study was undertaken to determine if music during KC has a greater effect than KC alone, on maternal state anxiety (MSA) in the early postpartum period.
In a randomized controlled trial, 90 Iranian women who were scheduled for a repeat Cesarean-section, were randomized into three groups: KC, music during KC, and a control group. Mothers’ pain scores were evaluated using a visual analog scale (VAS). If the VAS score was ≤3, then MSA was measured by using the State-Trait Anxiety Inventory (STAI) Scale (Spielberg). Interventions were 30 min KC for mother–infant dyads, or playing music for the mothers during KC. Six hours later, in cases where the VAS was ≤3, the MSA was re-measured using Spielberg's scale for all mothers.

Six hours post intervention, there was no significant difference in the overall mean scores of MSA between the groups, but the severity of MSA in the two experimental groups was less than in the control group (P = 0.02), although not between the two experimental groups.
The findings of this study provide evidence that KC has an effect on the severity of MSA in mothers who were delivered by C-section, however, music during KC had no more effect than KC alone. More research is needed to document the effectiveness of selected or familiar music during KC on state anxiety in early postpartum.
Two-week-old full-term newborns (26 born to depressed mothers and 26 born to non-depressed mothers) were videotaped for three 2-min intervals during: (1) a baseline silent period, (2) the playing of a musical lullaby and, (3) the lullaby with vocals added. More maternal depression symptoms were associated with more obstetric complications and newborns spending less time awake during the two music intervals. When the lullaby was played, infants born to mothers with more obstetric complications cried more and made more facial expressions. Infants who made more facial expressions at baseline spent more time awake during the musical lullaby with vocals but showed more distress, whereas fewer facial expressions indicated greater attention. Greater birthweight was related to sleeping longer during baseline, but spending more time awake and making fewer facial expressions during the musical lullaby without voice. The findings are discussed in terms of potential factors that may relate to infant music preferences in the very early weeks of human development.
Hypotension in the first few days of a pre-term baby's life is not an uncommon event. This paper will define hypotension and give the reader a clear understanding of how blood pressure is maintained in the first few days of life. It will provide information on the physiology of cardiac output (CO), and blood pressure (BP) regulation in the newborn infant. An appreciation of this physiology is essential to effectively administer and manage the commonly used pharmacological agents ‘inotropes’ in the Neonatal Intensive Care Unit (NICU).
Although studies have examined the effects of interventions focused on preterm infants, few studies have examined the effects on maternal distress (anxiety, depressive symptoms, post-traumatic stress symptoms, parenting stress) or parenting. This study examined the effects of the auditory–tactile–visual–vestibular (ATVV) intervention and kangaroo care (KC) on maternal distress and the mother–infant relationship compared to an attention control group.

240 mothers from four hospitals were randomly assigned to the three groups. Maternal characteristics in the three groups were similar: 64.1% of ATVV mothers, 64.2% of KC mothers, and 76.5% of control mothers were African American; maternal age averaged 26.3 years for ATVV mothers, 28.1 for KC mothers, and 26.6 for control mothers; and years of education averaged 13.6 for ATVV and KC mothers, and 13.1 for control mothers. Mothers only differed on parity: 68.4% of ATVV and 54.7% of KC mothers were first-time mothers as compared to 43.6% of control mothers. Their infants had a similar mean gestational ages (27.0 weeks for ATVV, 27.2 for KC, and 27.4 for control) and mean birthweights (993 g for ATVV, 1022 for KC, and 1023 for control).
Mothers completed questionnaires during hospitalization, and at 2, 6 and 12 months corrected age on demographic characteristics, depressive symptoms, state anxiety, post-traumatic stress symptoms, parenting stress, worry about child health, and child vulnerability (only at 12 months). At 2 and 6 months, 45-min videotapes of mother–infant interactions were made, and the HOME Inventory was scored. Behaviors coded from the videotapes and a HOME subscale were combined into five interactive dimensions: maternal positive involvement and developmental stimulation and child social behaviors, developmental maturity, and irritability.
Intervention effects were examined using general linear mixed models controlling for parity and recruitment site. The groups did not differ on any maternal distress variable. Kangaroo care mothers showed a more rapid decline in worry than the other mothers. The only interactive dimensions that differed between the groups were child social behaviors and developmental maturity, which were both higher for kangaroo care infants. Change over time in several individual infant behaviors was affected by the interventions. When mothers reported on the interventions they performed, regardless of group assignment, massage (any form including ATVV) was associated with a more rapid decline in depressive symptoms and higher HOME scores. Performing either intervention was associated with lower parenting stress. These findings suggest that as short-term interventions, KC and ATVV have important effects on mothers and their preterm infants, especially in the first half of the first year.