Musical and vocal interventions to improve neurodevelopmental outcomes for preterm infants

Background Preterm birth interferes with brain maturation, and subsequent clinical events and interventions may have additional deleterious effects. Music as therapy is offered increasingly in neonatal intensive care units aiming to improve health outcomes and quality of life for both preterm infants and the well‐being of their parents. Systematic reviews of mixed methodological quality have demonstrated ambiguous results for the efficacy of various types of auditory stimulation of preterm infants. A more comprehensive and rigorous systematic review is needed to address controversies arising from apparently conflicting studies and reviews. Objectives We assessed the overall efficacy of music and vocal interventions for physiological and neurodevelopmental outcomes in preterm infants (< 37 weeks' gestation) compared to standard care. In addition, we aimed to determine specific effects of various interventions for physiological, anthropometric, social‐emotional, neurodevelopmental short‐ and long‐term outcomes in the infants, parental well‐being, and bonding. Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, RILM Abstracts, and ERIC in November 2021; and Proquest Dissertations in February 2019. We searched the reference lists of related systematic reviews, and of studies selected for inclusion and clinical trial registries. Selection criteria We included parallel, and cluster‐randomised controlled trials with preterm infants < 37 weeks` gestation during hospitalisation, and parents when they were involved in the intervention. Interventions were any music or vocal stimulation provided live or via a recording by a music therapist, a parent, or a healthcare professional compared to standard care. The intervention duration was greater than five minutes and needed to occur more than three times. Data collection and analysis Three review authors independently extracted data. We analysed the treatment effects of the individual trials using RevMan Web using a fixed‐effects model to combine the data. Where possible, we presented results in meta‐analyses using mean differences with 95% CI. We performed heterogeneity tests. When the I2 statistic was higher than 50%, we assessed the source of the heterogeneity by sensitivity and subgroup analyses. We used GRADE to assess the certainty of the evidence. Main results We included 25 trials recruiting 1532 infants and 691 parents (21 parallel‐group RCTs, four cross‐over RCTs). The infants gestational age at birth varied from 23 to 36 weeks, taking place in NICUs (level 1 to 3) around the world. Within the trials, the intervention varied widely in type, delivery, frequency, and duration. Music and voice were mainly characterised by calm, soft, musical parameters in lullaby style, often integrating the sung mother's voice live or recorded, defined as music therapy or music medicine. The general risk of bias in the included studies varied from low to high risk of bias. Music and vocal interventions compared to standard care Music/vocal interventions do not increase oxygen saturation in the infants during the intervention (mean difference (MD) 0.13, 95% CI ‐0.33 to 0.59; P = 0.59; 958 infants, 10 studies; high‐certainty evidence). Music and voice probably do not increase oxygen saturation post‐intervention either (MD 0.63, 95% CI ‐0.01 to 1.26; P = 0.05; 800 infants, 7 studies; moderate‐certainty evidence). The intervention may not increase infant development (Bayley Scales of Infant and Toddler Development (BSID)) with the cognitive composition score (MD 0.35, 95% CI ‐4.85 to 5.55; P = 0.90; 69 infants, 2 studies; low‐certainty evidence); the motor composition score (MD ‐0.17, 95% CI ‐5.45 to 5.11; P = 0.95; 69 infants, 2 studies; low‐certainty evidence); and the language composition score (MD 0.38, 95% CI ‐5.45 to 6.21; P = 0.90; 69 infants, 2 studies; low‐certainty evidence). Music therapy may not reduce parental state‐trait anxiety (MD ‐1.12, 95% CI ‐3.20 to 0.96; P = 0.29; 97 parents, 4 studies; low‐certainty evidence). The intervention probably does not reduce respiratory rate during the intervention (MD 0.42, 95% CI ‐1.05 to 1.90; P = 0.57; 750 infants; 7 studies; moderate‐certainty evidence) and post‐intervention (MD 0.51, 95% CI ‐1.57 to 2.58; P = 0.63; 636 infants, 5 studies; moderate‐certainty evidence). However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention (MD ‐1.38, 95% CI ‐2.63 to ‐0.12; P = 0.03; 1014 infants; 11 studies; moderate‐certainty evidence). This beneficial effect was even stronger after the intervention. Music/vocal interventions reduce heart rate post‐intervention (MD ‐3.80, 95% CI ‐5.05 to ‐2.55; P < 0.00001; 903 infants, 9 studies; high‐certainty evidence) with wide CIs ranging from medium to large beneficial effects. Music therapy may not reduce postnatal depression (MD 0.50, 95% CI ‐1.80 to 2.81; P = 0.67; 67 participants; 2 studies; low‐certainty evidence). The evidence is very uncertain about the effect of music therapy on parental state anxiety (MD ‐0.15, 95% CI ‐2.72 to 2.41; P = 0.91; 87 parents, 3 studies; very low‐certainty evidence). We are uncertain about any further effects regarding all other secondary short‐ and long‐term outcomes on the infants, parental well‐being, and bonding/attachment. Two studies evaluated adverse effects as an explicit outcome of interest and reported no adverse effects from music and voice. Authors' conclusions Music/vocal interventions do not increase oxygen saturation during and probably not after the intervention compared to standard care. The evidence suggests that music and voice do not increase infant development (BSID) or reduce parental state‐trait anxiety. The intervention probably does not reduce respiratory rate in preterm infants. However, music/vocal interventions probably reduce heart rates in preterm infants during the intervention, and this beneficial effect is even stronger after the intervention, demonstrating that music/vocal interventions reduce heart rates in preterm infants post‐intervention. We found no reports of adverse effects from music and voice. Due to low‐certainty evidence for all other outcomes, we could not draw any further conclusions regarding overall efficacy nor the possible impact of different intervention types, frequencies, or durations. Further research with more power, fewer risks of bias, and more sensitive and clinically relevant outcomes are needed.