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The EffectofMusicReinforcementforNon-NutritiveSuckingonNippleFeedingOfPrematureInfants PDF
The EffectofMusicReinforcementforNon-NutritiveSuckingonNippleFeedingOfPrematureInfants PDF
T
he premature infants suck-
ing ability is a critical behav- In this randomized, controlled multi-site study, the pacifier-activated-lullaby sys-
ior for both survival and neu- tem (PAL) was used with 68 premature infants. Dependent variables were a) total
rological development, and number of days prior to nipple feeding, b) days of nipple feeding, c) discharge
must be sophisticated enough to sus- weight, and d) overall weight gain. Independent variables included contingent
tain independent nipple feeding. Oral music reinforcement for non-nutritive sucking for PAL intervention at 32 vs. 34 vs
feeding is a complex task for the pre- 36 weeks adjusted gestational age (AGA), with each age group subdivided into
mature infant affected by many vari- three trial conditions: control consisting of no PAL used vs. one 15-minute PAL
ables, especially the immaturity of the trial vs. three 15-minute PAL trials. At 34 weeks, PAL trials significantly shortened
neurological system and its readiness gavage feeding length, and three trials were significantly better than one trial. At
to coordinate the suck-swallow- 32 weeks, PAL trials lengthened gavage feeding. Female infants learned to nip-
breathe response. Research suggests ple feed significantly faster than male infants. It was noted that PAL babies went
that promoting non-nutritive sucking home sooner after beginning to nipple feed, a trend that was not statistically sig-
(NNS) will facilitate nipple feeding, nificant.
but more detailed investigation is
needed for development of effective
care protocols (McGrath & Braescu, essarily prolong hospitalization. This nally regulated rhythms (Goff, 1985).
2004). Feeding opportunities offered study was designed to test specific In fact, the appearance of sucking
too early may lead to negative physi- parameters of a music reinforcement behavior coincides with the first
ologic outcomes, such as apnea and protocol to promote NNS and subse- appearance of fetal brain waves. NNS
bradycardia. Delaying the initiation quent effects on duration of gavage is a reflex requiring physiologic matu-
of feeding opportunities may unnec- feeding. ration but is capable of being altered
by learning experiences (Anderson &
Vidyasagar, 1979; Bernbaum, Pereira,
Jayne M. Standley, PhD, MT-BC, is a Robert
O. Lawton Distinguished Professor of Music, Development of Watkins, & Peckham, 1983). NNS sig-
Florida State University and Tallahassee Non-Nutritive Sucking nificantly reduces distress and physio-
Memorial HealthCare, Tallahassee, FL. logical responses of premature infants
NNS is the first rhythmic behavior subjected to painful procedures (Boyle
Jane Cassidy, PhD, is Professor and Chair of in which the infant engages and is
Music Education, Louisiana State University et al., 2006; Cignacco et al., 2007;
theorized to contribute to neurologi- Mathai, Natrajan, & Rajalakshmi,
and Womans Hospital of Baton Rouge, Baton
Rouge, LA. cal development by facilitating inter- 2006; South, Strauss, South, Boggess,
Roy Grant, PhD, MT-BC, is a Retired
Professor of Music, the University of Georgia, Jennifer Jarred, MM, MT-BC, is a Music Therapist, Florida State University, Tallahassee, FL, and
Athens, GA. Lawnwood Regional Medical Center, Fort Pierce, FL.
Andrea Cevasco, PhD, MT-BC, is an Kristen Adams, MM, MT-BC, was a Music Therapy Intern, Florida State University and
Assistant Professor of Music Therapy, the Tallahassee Memorial HealthCare, Tallahassee, FL, at the time this article was written.
University of Alabama, Tuscaloosa, AL. Acknowledgments: Healing HealthCare Systems and Ohmeda Medical provided equipment
Catherine Szuch, MM, MT-BC, is a Research and technical support to the study. We are indebted to them for this support. The study would not
Assistant, the University of North Carolina have been possible without extensive assistance from a great many medical personnel. Sincere
Medical Center, Chapel Hill, NC. appreciation is expressed to the nursing staff and the physicians of the four nurseries involved:
Tallahassee Memorial HealthCare Neonatal Intensive Care Unit (Dr. Todd Patterson,
Judy Nguyen, MM, MT-BC, is a Music Neonatologist), Womans Hospital Baton Rouge Neonatal Intensive Care Unit (Dr. Steven
Therapist, Yale Childrens Hospital, New Spedale, Neonatologist), Athens Regional Medical Center Special Care Nursery (Dr. Lia Fasse,
Haven, CT. Neonatologist), and UNC Medical Center NC Childrens Hospital Newborn Critical Care Center
Darcy Walworth, PhD, MT-BC, is an (Dr. Dianne Marshall and Dr. Carl Bose, Neonatologists). Special appreciation is given to the fol-
Assistant Professor of Music Therapy, Florida lowing individuals who assisted with referrals or liaison within the hospitals: Luci Butler, MT, stu-
State University and Tallahassee Memorial dent at University of Georgia; Cori Pelletier, MT, student at University of Georgia; Jennifer
HealthCare, Tallahassee, FL. Whipple, MT-BC; and Cindy Quackenbush, RN, Kim Bloyd, RN, and Stephanie Bickis, RN, at
Danielle Procelli, MM, MT-BC, was a Music
Tallahassee Memorial HealthCare. We are most appreciative to the parents who allowed their
Therapy Intern, Florida State University and infants to participate in this study.
Tallahassee Memorial HealthCare, Tallahassee, Statement of Disclosure: The authors reported no actual or potential conflict of interest in rela-
FL, at the time this article was written. tion to this continuing nursing education article.
df = 3, 60, p = 0.004). Overall, data significant (F = 2.758, df = 4, p = number of PAL trials affected benefits.
showed little difference among vari- 0.036). No other comparisons were PAL trials significantly shortened
ables by site, and gender was equal- significant. length of gavage feeding for 34-week
ized in the random assignment Analysis of total weight gain from babies, and three trials were signifi-
among groups; therefore, it was birth to discharge was significant for cantly better than one trial. PAL trials
assumed these groupings did not age at study (F = 4.629, df = 2, p = significantly increased length of gav-
affect overall results of PAL trials, and 0.014). Tukey HSD post hoc analysis age feeding for 32-week babies. These
data were pooled for further analyses. showed that the 36-week AGA infants results would indicate that the PAL is
Results for each of the four gained significantly more weight than most effective when introduced at 34
dependent variables were subjected to the other two age groups, but this was gestational weeks, the point in time
Two-Way Analyses of Variance for expected because they were born when most infants are deemed neuro-
comparison by age at study and num- smaller and stayed in the hospital logically ready to nipple feed (McGrath
ber of PAL trials. Table 5 shows means, longer. & Braescu, 2004).
standard deviations, and significance Analysis of weight gain for age at The sample was very small in the
comparisons among means using study by PAL trials was significant (F = 36-week age group receiving three PAL
Tukey post hoc analysis. 2.739, df = 4, p = 0.037). Tukey HSD post trials due to the rarity of infants meet-
Analysis of gavage feeding days hoc analysis showed no significance for ing criteria for continued inclusion in
showed significance for age at study specific age by trial comparisons. the study. Specifically, most infants
(F = 14.137, df = 2, p = 0.0001). Tukey enrolled at 36 weeks who were not nip-
HSD post hoc analysis showed that all ple feeding began to do so after one
36-week AGA infants took significant- Discussion PAL trial. Therefore, it was impossible
ly longer to oral feed than the 32 or to fulfill the planned cohort for the 36-
34-week infants, and three PAL trials The purpose of this study was to week, three-trial group. This age group
shortened the interval, but not signif- ascertain whether the PAL benefitted deserves further study with a design
icantly so. Analysis of gavage feeding infant transition from gavage to nipple that does not require multiple PAL tri-
days for age at study by trials was also feeding, and if age of presentation or als at this gestational age.
Overall, the results of this PAL pro- presentation and multiple trials had non-crying, preterm neonates. Research in
Nursing and Health, 1(2), 69-75.
tocol by age at study and trials do not never been attempted. This protocol Caine, J. (1992). The effects of music on the selected
demonstrate significant weight gain proved effective in significantly short- stress behaviors, weight, caloric and formula
benefits except those related to longer ening gavage days for 34-week AGA intake, and length of hospital stay of premature
stay in the hospital. Similar to findings infants. Future research must be exact and low birth weight neonates in a newborn
intensive care unit. Journal of Music Therapy,
by Cevasco and Grant (2005), there are in assessing and comparing specific 28(4), 180-192.
trends that may warrant future protocol parameters to improve care Cassidy, J., & Ditty, K. (2001). Gender differences
research with revised protocols and procedures. Much more research in among newborns on a transient otoacoustic
design. Cevasco and Grant (2005) this area is warranted. emissions test for hearing. Journal of Music
Therapy, 38(1), 28-35.
showed increasing weight gain with Cassidy, J., & Standley, J. (1995). The effect of music
increasing age and increasing PAL listening on physiological responses of prema-
usage; however, this study demonstrat- Clinical Implications ture infants in the NICU. Journal of Music
ed such results in the 36-age group Therapy, 37(4), 208-227.
A PAL intervention can significant- Cevasco, A., & Grant, R. (2005). Effect of the pacifier
only. This studys results for weight ly shorten gavage feeding days and activated lullaby on weight gain of premature
gain by age may be primarily due to length of hospitalization for premature infants. Journal of Music Therapy, 42(2), 123-
36-week infants longer stay in the infants when used at the specific gesta- 139.
NICU associated with necessity for tion age of 34 weeks. The intervention
Chapman, J.S. (1979). Influence of varied stimuli on
development of motor patterns in the prema-
completion of three trials prior to dis- protocol should begin with a PAL treat- ture infant. In G. Anderson & B. Raff (Eds.),
charge. ment of 15 minutes approximately 30 Newborn behavioral organization: Nursing
It should be noted that there were minutes prior to a feeding trial and research and implications (pp. 61-80). New
several confounding factors in this should continue daily until the infant
York: Alan Liss.
Cheour-Luhtanen, M., Alho, K., Sainio, K., Rinne, T.,
study. Every infant from whom con- is independently nipple feeding. The Reinikainen, K., Pohjavuouri, M., ... Naatanen,
sent was received and who was ran- lullaby selected for reinforcement of R. (1996). The ontogenetically earliest discrimi-
domly assigned to the 32 to 33-week sucking should be in the native lan- native response of the human brain.
age group completed participation in Psychophysiology, 33, 478-481.
guage of the infants family if possible. Cignacco, E., Hamers, J., Stoffel, L., van Lingen, R.,
the project. However, some assigned to In this way, the infant will be receiving Gessler, P., McDougall, J., & Nelle, M. (2007).
the 34 to 35-week age group and many critical language input while being The efficacy of non-pharmacological interven-
more assigned to the 36 to 37- week reinforced for sucking. The protocol tions in the management of procedural pain in
age group graduated and failed to used in this study is recommended.
preterm and term neonates. A systematic liter-
ature review. European Journal of Pain, 11(2),
complete the study because they began 139-152.
nipple feeding or were discharged Criteria for Referral DiPietro, J., Cusson, R., Caughy, M., & Fox, N. (1994).
before conclusion of trials. Infant is determined to be able to Behavioral and physiologic effects of nonnutri-
Independent feeding is one main crite- tolerate two simultaneous modes
tive sucking during gavage feeding in pre-term
infants. Pediatric Research, 36(2), 207-214.
rion for discharge, and infants who of stimulation (pacifier and audi- Field, T., Hernandez-Reif, M., Feijo, L., & Freedman,J.
began to feed well were immediately tory stimulation). (2006). Prenatal, perinatal and neonatal stimu-
sent home. Since the research design Infant has no severe abnormali- lation: A survey of neonatal nurseries. Infant
required that some infants at 34 or 36 Behavior and Development, 29(1), 24-31.
ties that affect ability to suck/feed Field, T., Ignatoff, E., Stringer, S., Brennan, J.,
weeks AGA still need gavage feeding or to learn, including abnormali- Greenberg, R., Widmayer, S., & Anderson, G.
throughout three PAL trials across 3 to ties of the oral cavity, hydro- (1982). Nonnutritive sucking during tube feed-
5 days, a bias for length of stay was cre- cephalus, Down syndrome, signif- ings: Effects on preterm neonates in an inten-
ated for the two older groups. Some sive care unit. Pediatrics, 70(3), 381-384.
icant neurological disorders (PVL, Gardner, S.L., Garland, K.R., Merenstein,S. L., &
participants excelled at acquiring nip- IVH, HIE). Lubchenco, L.O. (1997). The neonate and the
ple feeding skills and left before com- Infant has no indication of infec- environment Impact on development. In G.B.
pleting the research trials. tion requiring quarantine. Merenstein & S.L. Gardner (Eds.). Handbook of
The PAL shows some potential for neonatal intensive care (4th ed.) (pp. 564-608).
Infant is not on ventilator or St. Louis, MO: Mosby.
facilitating nipple feeding, and contin- CPAP. Gill, N., Behnke, M., Conlon, M., NcNeely, J., &
ued research is warranted to further Infant is ready to begin some OG Anderson, G. (1988). Effect of nonnutritive
refine the PAL intervention protocols. feeds. sucking on behavioral state in preterm infants
Nipple feeding is necessary for dis- before feeding. Nursing Research, 37(6), 347-
350.
charge. Infants begin training at 34 Goff, D.M. (1985). The effects of nonnutritive sucking
weeks AGA, and a few succeed imme- References on state regulation in pre-term infants.
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oral feed. At a U.S. average NICU cost feeding enhances growth and maturation in Developmental and Behavioral Pediatrics,
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of approximately $2000/day, this can Harrison, L. (1985). Effects of early supplemental
Boyle, E., Freer, Y., Khan-Orakzai, A., Watkinson, M.,
be an expensive and depressing period Wright, E., Ainsworth, J., & McIntosh, N. (2006). stimulation programs for premature infants:
for the family awaiting discharge Sucrose and non-nutritive sucking for the relief Review of the literature. Maternal-Child Nursing
(Standley, 2003a). Interventions that of pain in screening for retinopathy: A ran- Journal, 14(2), 69-90.
can speed up this process without domised controlled trial. Archives in Disease in Hill, A. (1992). Preliminary findings: A maximum oral
Childhood: Fetal and Neonatal Edition, 91(3), feeding time for premature infants, the relation-
physiologic harm to the infant are 166-168. ship to physiological indicators. Maternal-Child
highly desired. In prior research, one Britt, G., & Myers, B. (1994). The effects of Brazelton Nursing Journal, 20(2), 81-92.
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Burroughs, A., Asonye, U., Anderson-Shanklin, G., & trin, motilin, insulin and insulin-like growth factor
subsequent feeding rate. However, a Vidyasagar, D. (1978). The effect of nonnutritive 1 in premature infants receiving enteral feed-
specific PAL protocol testing age of sucking on transcutaneous oxygen tension in ings. Acta Paediatrica Scandinavica, 81, 974-
977.