The Importance of Rhythmic Stimulation for Preterm Infants in the NICU
Abstract
:1. Introduction
1.1. Rhythm Perception In Utero
1.1.1. Maternal Heartbeat
1.1.2. Maternal Breathing
1.1.3. The Mother’s Voice
1.1.4. Maternal Walk
1.1.5. Intersensory Redundancy
1.1.6. Links between Multimodal Fetal Rhythms and Music
1.2. Rhythm Production In Utero
1.3. Rhythmic Stimulation in NICU
1.3.1. Rhythmic Vestibular Stimulation
1.3.2. Rhythmic Breathing Stimulation
1.3.3. Rhythmic Sucking Stimulation
1.3.4. Rhythmic Multimodal Stimulation
- Vestibular and heartbeat sound: Vestibular rhythmic stimulation shows different effects, depending on the stimuli, the rhythms chosen, the frequency of the stimuli, the quantity of stimuli proposed, and the duration of intervention. Always seeking to be as close as possible to the stimulations provided in utero, many authors have proposed multi-modal rhythmic stimulations by combining, for example, rocking with intrauterine cardiac noise and female voice [74] or a rocker bed with a heartbeat sound, whether or not it is triggered by the preterm infant [75]. The rhythmical stimulation could take place for 15 min/h (fixed-interval stimulation group); the infant provoked 15 min of rhythmic stimulation each time it was motorically inactive for 90 s (self-activating stimulation group), or the infant provoked 15 min of rhythmic stimulation by being inactive for 90 s, but the stimulation took place only once per hour for the fixed-interval stimulation group (quasi self-activating stimulation group). As in the original study [76], compared with the control group (without any rhythmical stimulation), the immediate effect of the rhythmical stimulation was an increase in quietness in the three experimental groups, with fewer abnormal reflexes and better orienting responses. The authors highlighted the importance of contingency (that the infant can produce an action, such as triggering the rhythmic movement of the bed) and the temporal pattern of stimulation (that it occurs once every hour).
- Multisensory stimulations, including rhythmical stimulation: Interventions of two programs incorporate rhythmical stimulations in a multisensory stimulation program.
- Mother’s voice and heartbeat sound: Studies have stimulated preterm infants with the mother’s voice and heartbeat at 30 min intervals, four times per 24 h [89]. Rhythmical maternal sound stimulation (MSS) starts within 7 days after birth and is continued until discharge from the NICU. Maternal sound and heartbeat were recorded for each infant during maternal speaking, reading, and singing. The authors found an overall decreasing trend in cardiorespiratory events (CREs) with age. With nearly the same stimulation (audio-recording of the mother’s voice and heartbeat sounds, four times per day for a duration of 45 min each over a period of 1 month), Webb et al. [90] used cranial ultrasonography measurements at 30 days of life. Extremely preterm infants exposed to their mothers’ voices and heartbeats during their first month of life in an incubator had significantly larger auditory cortexes bilaterally compared with control preterm infants, although the mother’s actual voice and live heartbeat would be even more effective [91].
- Music: Music interventions are especially difficult to fully describe due to the complexity of music stimuli (rhythm, pitch, tempo, harmonic, structure, timbre, jitter, shimmer, etc.), variety of music experiences, and factors due to music interventions. It is therefore difficult to know the effects of the rhythm itself. We only know that there is no music without rhythm, whereas there can be music without melody [42]. Music has often been effectively used in neonatal intensive care units, especially with high-risk infants [14]. Moreover, music is thought to improve neurodevelopment in preterm infants by promoting synaptic plasticity and the differentiation, activation, readjustment, and growth of neurons [92]. A review of music therapy in the NICU between 1970 and 2010 revealed previously unsuspected perceptual, adaptative, and active engagement capacities of preterm infants during music therapy [93]. The authors focused on music or auditory stimulation interventions that incorporated musical elements, such as rhythm and sounds, based on the acoustic rhythmic intrauterine environment, such as recorded womb sounds, the mother’s voice, breathing sounds, and heartbeats. The review showed that music has positive effects on the preterm infant, calming and relaxing the infant and decreasing its stress level. Another systematic review of music-based intervention research published from 2010 to 2015 showed poor quality of music intervention studies [94]. The authors recommended improving the reporting quality, scientific rigor, and clinical relevance of music intervention research and suggested a seven-component checklist to advance the scientific rigor and clinical relevance of music intervention research. A recent study showed that preterm infants can learn and memorize from their auditory environment and that they can discriminate music played in the neonatal unit from the same music with a faster tempo [18]. Preterm infants are therefore able to recognize the temporal structure of a known piece of music at a specific tempo and to differentiate it from the same piece played at a faster tempo. Rhythm processing has further been shown to be especially important for language processing and recognition. Early postnatal music intervention increases neural responses related to music tempo processing and recognition [95].
- Voice: Similar to the fetus and the full-term newborn, the preterm infant reacts more to its mother’s voice by displaying accelerated cardiac rhythm compared to when the voice is absent [96]. Just as the contingent voice is important to the infant’s responses [91], better self-regulation of the preterm infant has been observed during the interaction when the song is contingent to the infant’s reactions [97]. Similarly, the beneficial effects of singing are greater when the parents sing directly to the child versus when the mother sings as if her child were present [98]. Linguistic research shows that lullabies of all cultures combine language information and use calming, rhythmic stimuli. Lullabies, with no tempo change, were used to reinforce non-nutritive sucking rates of preterm infants. Contingent lullabies, such as pacifier-activated lullabies (PALs), increase pacifier-sucking rates of preterm infants [99], increase subsequent feeding rates [100], and shorten gavage feeding lengths when used at the specific gestation age of 34 weeks [101]. Rhythmic lullabies reinforce the sucking rates produced by preterm infants. Consequently, sucking rhythms are modified by lullabies: the more the preterm infant sucks, the more the lullabies provided. The preterm infant can learn to suck–swallow–breathe with music contingency.
- Kangaroo care: The importance of the multiplicity of rhythms in synchrony with each other and their possible link with musical rhythms has been shown in utero [10]. In the neonatal unit, the different rhythms are clearly less numerous and are only rarely presented together. The rare moment when the infant is again simultaneously in the presence of several rhythms in synchrony is when it is exposed to kangaroo care on the mother’s chest (skin-to-skin contact). The full-body contact and the sound of the mother’s heartbeat are thought to simulate sensations that the infant experienced prenatally [102]. In this position, the infant can again hear its mother’s heartbeat, perceive her breathing rhythm, and hear the rhythm of her speech if she is speaking or the rhythm of the song if she is singing. Intersensory redundancy is again present in a skin-to-skin-contact situation. When a mother speaks to her child (infant-directed speech), she uses the motherese, which accentuates the melodic contours and uses a slower rhythm, better perceived by the child [103]. Similarly, the infant-directed singing, used by the mother when she sings to her child, has more accentuated melodic contours and a slower rhythm that is better perceived by the child [104]. Parent–infant skin-to-skin contact, commonly known as kangaroo care, underscores the importance of maternal body contact for the infant’s physiological, emotional, and cognitive regulatory capacities [105]. Compared with kangaroo care alone, combining kangaroo care and maternal singing can be especially beneficial for mothers as it reduces their anxiety levels [106]. Here, the mother was instructed to sing with a repetitive, soothing tone, softly, simply, and with a slow tempo, i.e., the characteristics of infant-directed singing. In the preterm infants in the group exposed to kangaroo care and maternal singing, the authors observed better autonomic stability and a calming effect. During kangaroo care, the skin-to-skin contact between mother and preterm infant provides multisensory rhythmic stimulation in a unique, interactive way that can significantly decrease or mask the harmful effects of environmental stimuli. Roa and Ettenberger [107] studied kangaroo care using the rhythm, breath, and lullaby (RBL) model developed by Loewy [108] in order to replicate the auditory environment in the womb, such as slow tempo and repetition. With RBL, parents experience less anxiety, decreased stress levels, increased maternal relaxation, and more motivation [109,110] The music, the humming, and the vibration of a monochord placed on the kangaroo parent’s elbow so that the rhythmical vibrations can be felt by the preterm infant create a sense of closeness and intimacy, a new way of meeting and being together [111]. Kostilainen et al. [112] investigated the effects of daily singing combined with kangaroo carrying during the first weeks after preterm birth. Parents were encouraged to sing or hum at a slow tempo with repetitive and simple melodies during the kangaroo care for the time they liked. Parents who sang felt a positive impact on their well-being: singing improved interaction and made it easier for them to connect naturally with their child. They felt more relaxed when they sang, and they also felt that their child was more relaxed. Thus, singing during kangaroo care was mostly experienced as a shared, intimate moment between parent and infant. Can the multiplicity of rhythms created by skin-to-skin contact and the addition of a lullaby promote trans-natal continuity, potentially affording additional synchronization cues?
2. Empirical Pilot Study
2.1. Method
2.1.1. Participants
2.1.2. Procedure
2.1.3. Data Analysis
2.2. Results
2.3. Discussion
3. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Conflicts of Interest
References
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Provasi, J.; Blanc, L.; Carchon, I. The Importance of Rhythmic Stimulation for Preterm Infants in the NICU. Children 2021, 8, 660. https://doi.org/10.3390/children8080660
Provasi J, Blanc L, Carchon I. The Importance of Rhythmic Stimulation for Preterm Infants in the NICU. Children. 2021; 8(8):660. https://doi.org/10.3390/children8080660
Chicago/Turabian StyleProvasi, Joëlle, Loreline Blanc, and Isabelle Carchon. 2021. "The Importance of Rhythmic Stimulation for Preterm Infants in the NICU" Children 8, no. 8: 660. https://doi.org/10.3390/children8080660
APA StyleProvasi, J., Blanc, L., & Carchon, I. (2021). The Importance of Rhythmic Stimulation for Preterm Infants in the NICU. Children, 8(8), 660. https://doi.org/10.3390/children8080660