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Investigating the Benefits of Music Therapy for Mothers of Babies in the Neonatal Intensive Care Unit

Haleigh Somberg, UNC-SON Senior Honors Thesis Advisor: Claudia Christy

Monday, April 30, 2020

Approved by:

Claudia G. Christy, MSN, RN, CCRC, ACRP-CP

Claudia G. Christy

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Honor pledge: I certify that no unauthorized assistance has been received or given in the completion of this work -Haleigh Somberg

Abstract

The importance of breastfeeding is widely known and supported by literary evidence, as are various interventional methods to promote breastfeeding efficacy for mothers. After a review of the current literature, a dearth of information was found surrounding the method of music therapy and its benefits for improving lactation efficacy. The literature indicates that mothers in the Neonatal Intensive Care Unit (NICU) setting are predisposed to higher levels of stress and anxiety, which negatively impacts their productivity during times of attempted lactation. The aim of this study is to investigate the experiences and perceived effectiveness of music therapy as an interventional method to increase lactation success for mothers of babies in the NICU. A

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Investigating the Benefits of Music Therapy for Mothers of Babies in the Neonatal Intensive Care Unit

The importance of breastfeeding to a child's survival, growth rate, and proper

developmental progression is widely known and respected. For infants in Neonatal Intensive Care Units (NICUs), breast milk is extremely beneficial as they are at greater risk for health problems early in life among a myriad of other challenges that they face (Texas Health and Human Services Commission, n.d.). Mothers of babies in the NICU face a plethora of barriers when it comes to breast feeding that mothers in a "normal" birth setting would not. Among these barriers are issues with underdeveloped breasts, physiological and emotional hardships, and increased levels of stress and anxiety to name a few- all of which can affect a mother's ability to produce an adequate milk supply for her baby and interfere with the quality of the milk produced (Medela, 2015).

There are many studies that have been conducted to evaluate methods to increase

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results from these surveys were cross-analyzed, compared, and synthesized to make suggestions for future clinical practice.

Background and Literature Review Breastfeeding

Breastfeeding is defined as the process of feeding a child human breast milk (William, 2018). It is one of the simplest and most effective ways to ensure proper growth and

developmental progression for an infant (Texas Health and Human Services Commission, n.d.). A mother's milk contains antibodies that aid in the protection of her infant from many common childhood illnesses, and provides various nutrients and energy necessary for the first few months of life (Newman, 2018). The current World Health Organization (WHO) recommendations uphold that breastfeeding should be initiated within the first hour of birth, continued exclusively for the first six months of the infant's life, and maintained for up to two years of age (Texas Health and Human Services Commission, n.d.). Additionally, WHO estimates that nearly 1.5 million lives could be saved yearly if all infants were breastfed according to these guidelines (World Health Organization, 2017). While effective breastfeeding requires proper technique, teaching, and adequate practice on the mother's end, there are other variables that can impact its success- environmental, internal, and external.

NICU Acuity

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majority of these babies have a LBW (Stanford Children’s Health, n.d.). Breast milk is especially important for vulnerable and (for the majority) underweight infants in the NICU setting. A mother's milk helps provide protection against infections, necrotizing colitis, and has been linked to enhanced neurodevelopmental outcomes for NICU babies (Texas Health and Human Services Commission, n.d.). Long-term benefits of breast milk have proven to positively influence

cardiovascular, bone, and cognitive function, as well as decrease risks for obesity and diabetes in adulthood (Cricco-Lizza, 2016).

Breastfeeding barriers (stress)

Barriers to breastfeeding for mothers of term babies include a lack of knowledge, poor family or social support, lactation issues, busy lifestyle, younger women, low-income mothers, embarrassment of feeding in public, body image issues, and the list goes on (Mgongo et al., 2019). Mothers of babies in the NICU are faced with certain unique challenges to breastfeeding that other mother-baby couplets may not be. Due to the acuity of the NICU, many mothers aren't even able to breastfeed directly through latching at first, and must implement other methods of milk delivery such as pumping and bottle feeding which can negatively impact the mother-baby bonding experience (La Leche League, 2018). In a study conducted by Ionio et al. in 2016, researchers evaluated the complications reported by mothers attempting to breastfeed in the NICU setting, and found that they are at a significantly increased risk for developing elevated levels of anger, anxiety, depression, and stress. This study also provided evidence that preterm mothers consistently reported higher levels of weakness and fatigue throughout the day, than mothers of term babies (Ionoi, et al, 2016).

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Music therapy is defined by Webster's as "therapy based on engagement in musical activities: the therapeutic use of music (as to reduce anxiety, improve cognitive functioning, promote physical rehabilitation, or enhance interpersonal communication) that typically involved listening to music, singing, playing musical instruments, or composing music (Meriam-Webster n.d.).” Specific forms of music therapy were not individually evaluated in this study (i.e. a mother listening to music, vs. a mother singing to herself; classical vs. rock audio music), but rather the intervention of music therapy as a whole, regardless of the method of its

administration.

Dr. Steven Feher spearheaded a study in 1989 that is regarded by many to be the first research formally conducted to evaluate the relationship between the intervention of music therapy and its effect on a mother's success with breastfeeding in the NICU setting (Hughes, n.d.). In this study, Dr. Feher and his fellow researchers compared the intervention of a 20-minute audio/visual tape for mothers while breastfeeding/pumping to a group of mothers who did not receive this intervention during their lactation sessions. The study showed a 63% increase in milk production among the intervention group, and an increased duration of milk expression. In addition, these mothers reported decreased levels of stress compared to the control group (Feher, Berger, Johnson & Wilde, 1989).

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the control group, as well as a 2.36-fold increase in milk production (p<.001, 95% CI 1.54-3.63) (Kittithanesuan, Ciarakul, Kaewjungwal, Poovorawan, & Yong, 2017). In 2019, a study among first-time mothers of breastfeeding infants was conducted to evaluate the effectiveness of music therapy relaxation techniques on maternal stress levels using the Perceived Stress Scale (PSS) to evaluate self-reported feelings of stress, anthropometric analysis, and maternal cortisol levels both pre and post intervention. This study provided statistically significant (p<.05) evidence that music therapy lowered PSS scores, and concluded that simple relaxation methods can be

effective to decrease maternal stress (Mohd Shukri, Wells, Eaton, Mukhtar, Petelin, Jenko-Praznikar, & Fewtrell, 2019). These studies do not directly pertain to NICU mothers, but given the dearth of research surrounding music therapy, they are still helpful in determining the general benefits of music therapy on lactation and providing statistically significant evidence that is important for this study.

In 2015, a study was conducted that included 30 mothers of premature infants in the NICU. These mothers were randomly assigned music therapy as an intervention while pumping their breast milk, and a statistical analysis was run using a salivary cortisol assay comparison pre/ post intervention, as well as a PSS evaluation. This study concluded that music therapy was associated with a reduction in maternal stress levels as evidenced by PSS scoring, and decreased secretion of salivary cortisol. A significant increase (p-value=.0333) in milk expression was also noted during the intervention of music therapy during a pumping session (Ak, 2015). A meta-analysis was conducted in 2016 that reviewed 14 RCTs concluded that the intervention of music therapy while breastfeeding or pumping in the NICU produced significantly large effects

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improved maternal mental state particularly relating to decreased stress/anxiety in the NICU setting as reported by mothers and proven through the individual measures utilized in each study.

When comparing the above studies that were conducted regarding the benefits of music therapy on lactation, the common theme among the findings appears to be increased maternal milk production and decreased maternal stress and/or anxiety. Stress has been noted to be the primary killer of a mother’s supply of breastmilk, especially in the first few weeks after delivery-so it is crucial to focus on decreasing this modifiable risk factor for ineffective or non-productive lactation (Patel, n.d).

Methods Design and Setting

The design of this study is a semi-structured survey with a qualitative analysis preformed using the results. The survey was designed for administration to lactation nurses in order to obtain their opinions regarding the benefits of music therapy for mothers of babies in the NICU environment.

Procedure

Thorough research was conducted via literature review in order to gain a general

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International Review Board (IRB) approval was obtained. Once approved and declared non-human subject research by the IRB, the survey process began.

Participants

Participants in this study included six lactation nurses, all of which provided specialized services to mothers of babies in the NICU. Each nurse interviewed had their Registered Nurse- Bachelor’s of Science in Nursing (RN-BSN), and their Certified Lactation Counselor (CLC). The six participants worked in hospitals across the United States, and were selected primarily based on the services provided by each hospital as detailed on the hospital's website. One of the nurses was selected based upon information found during the literature review directly from the

lactation department at her respective hospital. Two of the six surveys were conducted in person, and the other four were conducted over the phone.

Analysis

Qualitative survey data was analyzed through a thorough systematic method of comparison. Surveys were considered void if all questions were not answered, but of the six administered, 100% were complete and therefore used as valid data sources. Due to the

subjective nature of the data obtained, no statistical parameters could be selected to measure or quantify it. Correlations between answers were identified and noted through cross-analysis and synthesis of the responses provided.

Results

In order to compare feedback from the various survey questions, the cross-analysis of answers was used to determine common themes from which conclusions could be drawn.

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inability to breastfeed within the hour immediately following birth due to the severity of the baby's condition in the NICU setting. Another nurse added that if the mother and care team are aware that a birth is going to place a baby in the NICU ahead of time, that she would hope the discussion about the potential complications with breastfeeding this baby would occur prior to her giving birth to help relieve some of the burden surrounding the high intensity situation that would soon take place after birthing her baby (See Appendix A, Q2).

Of the six lactation nurses interviewed, each noted music therapy in some form as a common intervention that they use for mothers to improve the success of lactation sessions (appendix A, Q1). The variations of music therapy noted ranged from encouraging the mother to sing or hum, listening to audio recordings of the mother's choice, or playing opera. All of the nurses surveyed confirmed that music therapy has proven to be successful for their patients (appendix A, Q1&Q3). When commenting on the perceived successes they have noticed, all 6 mentioned one of the benefits as effectively decreasing stress/anxiety levels for the mother. Two nurses commented on their perception that music therapy increases secretion and milk yield, and one nurse noted that it provides the mothers with an "escape" of sorts from the busy and stressful NICU environment (appendix A, Q3).

Of the answers provided regarding barriers to effective lactation in the NICU setting, increased maternal stress/anxiety was the common denominator among the six surveys (See appendix A, Q4). Other barriers noted were a distracting environment, lack of knowledge, detachment issues, the “unknowns,” and emotional trauma.

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about the impact of lactation initiation and continuation of breastfeeding among mothers in the NICU (See Appendix A, Q5). Of the six responses, each noted the crucial importance of early lactation on the likelihood that it is continued outside of the NICU setting. One nurse described the importance of finding a relaxation method that was effective for the mother as a necessity before her discharge, but that this it is difficult to achieve at times as some mothers have a very short stay and others have a difficult time finding what actually helps in that short time. Another nurse noted that a critical step in the continuation of breastfeeding outside of the NICU relied on those health professionals in the next step of care, and a hope that they would continue the practices that had been first initiated in the NICU with the mother and baby on their next unit. A comment was also made about the difficulties that RN-CLCs face in following a mother/baby pair throughout her hospitalization. She described the process of transferring units after the NICU, and the difficulty of being able to follow-up with those patients in a timely manner to evaluate their progress and to address any concerns with lactation.

While none of the answers addressed the effects of music therapy on the continuation of breastfeeding outside of the NICU, with the answers provided, the conclusion was drawn that if music therapy was the intervention of choice that proved beneficial for the mother, that she was more likely to continue breastfeeding in the future outside of the NICU using this method.

Discussion

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All of the nurses referenced music therapy as a common intervention that they use in lactation therapy, and each noted its effectiveness in reducing maternal stress and anxiety, which was statistically proven in several of the studies included in the research that was conducted prior to the administration of this survey. Through reviewing that literature, the common themes of the effectiveness of this intervention were identified to be decreased maternal stress and increased milk yield. Likewise, these were the two common denominators reported through these survey answers.

When considering the findings of this survey, and those of the literature review, it is helpful to understand why they are important. In the context of this study, music therapy serves primarily as a relaxation technique used during lactation by RN-CLCs to help the mothers breastfeed more efficiently. Stress can affect breastfeeding by altering the contents of the breast milk, and impacting the maternal milk supply both directly and indirectly (Medela, 2015). When a mother experiences stress, her cortisol levels increase as well as her adrenaline and

norepinephrine hormones, which directly affect the baby as maternal cortisol is passed to the baby through the milk ingested (Ionoi, et al, 2016). Stress affects the mother in a myriad of external ways that can impact the success of a mother’s lactation efforts (Domas, 2018). Limitations

The primary limitation of this study was a small sample size (n=6). The sample size of six was not by choice, but resulted from the difficulty of finding lactation nurses with experience in the NICU environment. Of those identified and contacted, there was a relative lack of

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research should be conducted to analyze individual methods such as comparing singing efficacy to audio recordings.

Conclusion

With the impacts of stress on lactating mothers in the NICU widely known and discussed, it is important that more research be conducted on specific interventional methods to help

facilitate relaxation and reduction of this stress among those who are breastfeeding. From these findings, it can be concluded that the lactation nurses interviewed believe that music therapy is an effective means to accomplish decreased maternal stress and anxiety levels, and facilitate more effective lactation sessions with better yield. Further quantitative studies should be conducted in order to determine a statistical basis for these findings by which clinical recommendations using numerical evidence can be made.

Although there is a lack of numeric and statistical evidence provided by this study, the general consensus among the six nurses regarding the benefits of music therapy provides

evidence for more productive lactation sessions resulting from this intervention. As noted by one of the nurses surveyed- given the acuity of the NICU, finding a method that facilitates effective lactation is crucial for the initiation and continuation of breastfeeding.

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References

Ak, J. (2015). Impact of Music Therapy on Breast Milk Secretion in Mothers of Premature Newborns. Journal Of Clinical And Diagnostic Research. doi:

10.7860/jcdr/2015/11642.5776

Bieleninik, U., Ghetti, C., & Gold, C. (2016). Music Therapy for Preterm Infants and Their Parents: A Meta-analysis. Pediatrics, 138(3). doi: 10.1542/peds.2016-0971

Cricco-Lizza R. (2016). Infant Feeding Beliefs and Day-to-Day Feeding Practices of NICU Nurses. Journal of pediatric nursing, 31(2), e91–e98.

https://doi.org/10.1016/j.pedn.2015.10.012

Domas, K. (2018, February 20). How Does Stress Impact Breastfeeding? Retrieved from https:// insured.amedadirect.com/stress-impact-breastfeeding/

Feher S, Berger L, Johnson J, Wilde J. (1989). Increasing breast milk production for premature

infants with a relaxation/imagery audiotape. Pediatrics;83(1):57‐60.

Hughes, V. (n.d.). Music Milk Miracles. Retrieved from

https://www.lactationtraining.com/easyblog/entry/music-milk-miracles

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Kittithanesuan, Y., Chiarakul, S., Kaewkungwal, J., & Poovorawan, Y. (2017). Effect of music on immediately postpartum lactation by term mothers after giving birth: A randomized controlled trial. Journal of the Medical Association of Thailand. 100. 834-842.

La Leche League. Successfully breastfeeding your premature baby. (2018, October 28). Retrieved from https://www.laleche.org.uk/successfully-breastfeeding-premature-baby/ Medela. (2015, April 28). Challenges with breastfeeding in the NICU. Retrieved from

https://www.medela.com/breastfeeding-professionals/nicu/feeding/challenges

Merriam-Webster. Music Therapy. (n.d.). Retrieved from https://www.merriam-webster.com/dictionary/music

Mgongo, M., Hussein, T. H., Stray-Pedersen, B., Vangen, S., Msuya, S. E., & Wandel, M. (2019). Facilitators and Barriers to Breastfeeding and Exclusive Breastfeeding in Kilimanjaro Region, Tanzania: A Qualitative Study. International Journal of Pediatrics, 2019, 1–7. doi: 10.1155/2019/8651010

Newman, J. (2018, January 2). How Breast Milk Protects Newborns • KellyMom.com. Retrieved from https://kellymom.com/pregnancy/bf-prep/how_breastmilk_protects_newborns/ Patel, S. (n.d.). 4 factors that can decrease breast milk supply – and how to replenish it: Your

Pregnancy Matters: UT Southwestern Medical Center. Retrieved from https://utswmed.org/medblog/decrease-breast-milk-supply/

Stanford Children's Health. (n.d.). The Neonatal Intensive Care Unit (NICU). Retrieved from

https://www.stanfordchildrens.org/en/topic/default?id=the-neonatal-intensive-care-unit-nicu-90-P02389

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William, C. S. (2018, December 21). Definition of Breastfeeding. Retrieved from https://www.medicinenet.com/script/main/art.asp?articlekey=38708

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Appendix

Appendix A: Semi-structured Survey Questions that were administered to the Lactation Nurses

Q1: What methods do you use to assist mothers of premature babies in the NICU in the initiation and maintenance of successful lactation?

Q2: At what point do you initiate breast pumping and feeding education to a new mother of a premature infant in the NICU?

Q3: Have you ever used music therapy to promote lactation in mothers with premature children in the NICU setting, and how effective was it?

Q4: In your experience, what are the primary barriers to successful lactation for mothers of premature babies in the NICU?

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