The Full-Term and
Premature Newborn
& & & & & & & & & &
The Influence of Auditory Experience on the Behavior of Preterm
Newborns
M. Kathleen Philbin, RN, PhD
This review of the research literature is addressed to clinicians who care for,
interact with, and advise parents of preterm newborns. In summary,
research on the effects of sound on preterm infant behavior and
development provide only a little reliable clinical guidance as many of the
studies are flawed, some badly. Some studies use a high sound level (i.e.,
loud) stimulus yet fail to report effects of the stimulus on vital signs,
movement, and behavioral state. Only a handful of studies report long term
effects regardless of the length of exposure to the experimental stimulus. A
consistent problem is that the ambient sound in the nursery research setting
is neither described nor considered as a facet of the auditory stimulus yet all
reports of ambient nursery sound show high levels without respite periods
quiet. Therefore, unless other documentation is provided, ambient nursery
noise is likely an unreported confounding variable in these studies. The
clinician is cautioned, therefore, to carefully evaluate any finding before
implementing an intervention program of sound stimulation with preterm
infants. There are many reports of efforts to reduce nursery noise by
changing staff behavior but none describes more than marginal success.
Given this general failure of noise reduction through behavior change an
alternative is proposed of achieving quiet by changing the crowded,
reverberant nature of the physical space. Recommendations for care that
can be drawn from this literature include measuring and reducing nursery
noise, facilitating parents' efforts to talk and sing to their own babies, and
limiting purposefully added sound stimulation to quite specific clinical
situations.
Journal of Perinatology 2000; 20:S76 ± S86.
NURSERY NOISE: CHARACTERISTICS AND ABATEMENT
STRATEGIES
Reports of Nursery Noise
To understand the influence of auditory experience on preterm
newborns it is necessary to account for the acoustic environment to
University of Texas - Houston Medical School, Houston, TX.
This literature review was supported by grant # 1 RO3 NR03396 - 01 from the National Institute
of Nursing Research and by the University of Texas Ð Houston Departments of Pediatrics and
Otolaryngology.
Address correspondence and reprint requests to M. Kathleen Philbin, RN, PhD, Department of
Pediatrics, Otolaryngology Laboratory, Rm. 6.133, 6431 Fannin Street, Houston, TX 77030.
S76
& & & &
which the infant is exposed. Unless stated otherwise, nursery noise
must be assumed to be a feature of that environment in all studies
conducted in nurseries. The assumption is reasonable because high
levels of nursery noise have been documented extensively over the
past thirty years and there are no known reports of quiet hospital
nurseries.1 ± 19 This review of the literature on the effects of auditory
experience of preterm infants begins, therefore, with a summary of
reports of the ambient acoustic environment of hospital nurseries and
a summary of attempts at noise abatement.
Documentation of nursery noise comes from North America,
Europe, Scandinavia, India, Asia, and Australia. The authors'
perspectives represent the disciplines of audiology, child life,
education, engineering (biomedical, electrical, mechanical),
medicine (neonatology, neurology, otolaryngology, and psychiatry),
nursing, psychology (perception, child development, clinical,
comparative, behavioral), and physiology. In a nutshell, nursery
room and incubator noises are shown to be generally loud and
chaotic, lacking in pattern or rhythm.
The motivations for investigating nursery noise have varied. Long
and his colleagues noticed changes in measurements of cerebral
blood flow accompanying noise bursts.10 A number of investigators
worried about the contribution of nursery noise to hearing loss.6,19
GaÈdeke et al.14 observed disturbances in infant sleep. Philbin et al.20
wondered if the noise was associated with preterm infants' difficulties
with habituation.
Figures 1 and 2 display published sound levels for nurseries and
incubators. Some published levels are not included here because
those data appear to be averages of individual measurements. (For
the error involved in taking arithmetic averages of nonlinear
numbers, see Gray.21 ) Recalling that each raise of 6 dBA represents a
perceived doubling of loudness, the nurseries are seen to be
remarkably dissimilar; the most noisy is about 64 times louder than
the most quiet. The most quiet nursery is in Lund, Sweden with a
mean level of about 38 dBA in regular working conditions with
several incubators running.1 By comparison, a typical home bedroom
is about 30 to 40 dBA at night, depending on the type of heating or air
conditioning system. The other A-weighted levels in the figure can be
compared with this lowest level, therefore, and can be understood as a
multiple of the loudness of the home bedroom at night.
The well-documented contribution of low frequencies to nursery
sound is illustrated by the higher C-scale/linear measurement by
Blennow et al.1 for the same room. The 15- to 20-dB differences in
levels between the A- and C-weighting scales show large
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# 2000 Nature America Inc. All rights reserved. 0743-8346/00 $15
www.nature.com/jp
Influence of Auditory Experience on Preterm Newborns Philbin

Figure 1. Nursery sound levels reported in the literature. Nurseries are shown to be remarkably dissimilar in sound or noise levels. The nursery with the highest
A- weighted sound level ( 75 dBA ) would be perceived as about 64 times more noisy than nursery with the lowest A- weighted level (38 dBA ) . However, as levels
may be even greater inside the incubator (Figure 2 ) measurements of local conditions are needed to inform clinical decisions about housing for the individual
infant.

Figure 2. Incubator sound levels reported in the literature. As perceived loudness doubles every 6 to 10 dB, sound or noise levels inside incubators are shown to
vary considerably. The higher C-weighted /linear levels indicate significant low - frequency components to the noise. Motor design, age, condition, and
cleanliness all determine levels generated by the incubator itself whereas the integrity of seals and contact with the shell determine levels introduced from
outside. An infant's cry can markedly raise interior levels and yet not be heard on the outside.
Journal of Perinatology 2000; 20:S76 ± S86 S77
 Philbin
contribution of low-frequency sounds to both nursery and incubator
environments.
Comparing the levels in incubators with those in the nursery, it is
clear that incubators do not necessarily provide a more benign
auditory environment. Sound inside the incubator may involve
considerable masking and abrupt loud sounds caused by objects
striking the plastic walls and port doors snapping shut.4,22
Additionally, the baby compartment of an incubator may be very
loud when the infant cries because the closed, reverberant container
can function like an amplifier.6 The advantage of Blennow's quiet
Swedish nursery, therefore, is lost to the infants inside the incubators
because, at 60 to 63 dBA, they are more noisy than the room itself. In
this nursery, therefore, there is good reason for moving infants out of
the incubator earlier rather than later and managing temperature
stability with clothing and blankets (Blennow G, personal
communication, 1996). However, in the noisy Vermont nursery
measured by Long et al.10 the incubator, although noisy itself, is
relatively less noisy than the nursery room.
These data suggest that clinicians need to know the parameters of
their own nurseries' acoustic environments and improve conditions
in both incubators and rooms accordingly. The acoustic environment
of the individual infant depends on the ambient sound levels of the
nursery, on the type and condition of the incubator's motor and seals,
on the presence in the near environment of respiratory equipment,
and on the baby's own behavior.
Abatement of Nursery Noise
A dozen or more authors have published their efforts to lessen noise
produced by equipment and people in nurseries.23 ± 26 Vidyasagar et
al.27 exemplify the succinct statement, with data, in a classic letter to
the editor. Gottfried et al. 7,28,29 conducted a lengthy teach-in on the
consequences to social development through a variety of letters,
articles, and book chapters. Lawson et al.,13 writing separately and in
teams, and also Linn et al.,30 likewise described the potential of noisy
nurseries for bad effects on infants' social development. GaÈdeke et
al.14 made painstakingly precise measurements of the thresholds for
noise that disturbed infants' sleep and followed this up with equally
painstaking measurements of the nursery to show that these wake-
up conditions existed in their own facility. Peltzman et al.,12 among
the most novel, rigged a bed so that an adult could lay with his head
in an incubator for several hours and then tested hearing to show
temporary threshold shifts (i.e., temporary hearing loss). Using the
precise methods and calculations of an engineer, Ciesielski et al.17
dissected incubator noise down to small frequency bands to show
exactly where the noise was loudest on the spectrum and then related
the sounds to specific metabolic and cardiovascular disturbances.
Programs that combine staff education about noise with
exhortation to be quiet have had limited or temporary success.10,26,31
Long et al.10 used a self-correcting approach that involved the staff in
identifying noise sources. Noisy equipment was subsequently repaired,
moved, or adapted to be more quiet. The nursery was then re-
measured, found to be noisy yet, and the staff again identified noise
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Influence of Auditory Experience on Preterm Newborns
sources. Ultimately, there were no noise sources remaining other
than the behaviors of staff themselves. (The contribution of building
acoustics was not considered.) At Boston City Hospital the program to
reduce noise was incorporated into a larger, ongoing infant
development program that emphasized staff education in tailoring
care to each infant's tolerance for stimulation.25 In Madison, WI
sound pressures were measured over the course of a clinical
intervention project to improve infant developmental outcomes.31
Staff education consisted of a lecture and reading materials and
consultation from a nurse clinician and occupational therapist.
Although some aspects of the infant's hospital course were improved
the sound pressures were not reduced.
Several groups have attempted to reduce sound pressures by
instituting day±night cycling of lights or by limited quiet periods.
Mann et al.32 for example, report a program to reduce light and noise
for twelve hours each night in their hospital in Nottingham,
England. The noise-reduction method was to turn off the radio and
``urge'' staff and visitors ``to make as little noise as possible.'' They
report a 10-dB reduction in sound pressures at night but do not
report the actual pressures. Strauch et al.26 introduced a quiet hour
once in each 8-hour work shift after a period of planning, staff
education, and implementation. In their protocol physician rounds,
the movement of large equipment and phone ringing were excluded
during quiet hour. Staff were urged to whisper at the bedside, to
refrain from slamming, banging, and dragging equipment, and to
rearrange nonurgent caregiving to another time. Lighting was also
reduced. Mean sound pressures for the same times of day were
reduced from 50 to 78 dBA before the program to 40 to 65 dBA after it
was in effect for 2 weeks. This translates to a reduction in perceived
loudness of a half to a quarter below pre-program levels. Infant sleep
states were also significantly different between the control period and
the quiet hour. Light sleep and deep sleep increased from 33.9% to
84.5% and crying decreased from 14.3% to 2.4%. Parents and staff
believed there were other advantages to the quiet hour in terms of
reduced stress and increased opportunities for uninterrupted activities.
The program did not, however, address the noise levels occurring
during the remaining times of day.
Several investigators have taken an alternate approach of blocking
sound at the infant's ear. Clinicians should use caution with ear-
covering devices, however, as they attenuate only some of the
frequencies that affect infants, require a tight seal to the skin all
around the ear, and can cause skin breakdown. Baer et al.33 studied
the effect of ear covers on vital signs of 10 low-birth-weight
newborns before, during, and after a glass bottle was placed on the
top of the incubator. There were no effects on heart or respiratory rate
changes but there were significantly fewer episodes of oxygen
desaturation. To maintain the ear-cover seal and protect skin
integrity, however, data collection was limited to 1 hour and infants
were positioned supine. Zahr 34 reports a similarly designed study in
which infants were observed for four 2-hour periods on each of two
consecutive days. The sound stimulus was unmeasured, ambient
nursery activity. Infants maintained higher and less variable blood
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Influence of Auditory Experience on Preterm Newborns
oxygen saturations when wearing the ear covers, but the use of
supplemental oxygen is not reported. They also had less frequent
behavioral state changes, longer periods of sleep, and more total
sleep. However, there were no controls for the effects of nursing-care
differences as a consequence of the unmasked study conditions.
Although hearing protection may have promise for brief periods or
for specific events, the effects of continuous or prolonged use on
behavioral organization skin integrity, posture, and head shape
remain unstudied. The effect of long-term masking on speech
discrimination also warrants investigation.
In summary, the evidence from both the literature and common
experience is that behavior change alone is inadequate for abatement
and control of nursery noise. In fact nurseries unlike some other
healthcare, business, and residential environments have not been
designed for quiet. Rather the traditional design priorities of
conserving space and infection control have inadvertently determined
that nurseries would be noisy due to crowding and highly reverberant
surfaces. These conditions provide ongoing disincentives to the
human effort to maintain quiet.
Traditional design priorities, however, may not satisfy con-
temporary program requirements. New economic and social forces
favor priorities for increased space for family privacy and comfort at
the bedside.35 Further, new information about infant development
and stable physiology argues for environments that attract parents to
stay at the bedside provide quiet. Fortunately, new sound-absorbent
materials for floors, walls, and ceilings satisfy the traditional
requirements for infection control. Space requirements for new
priorities, however, appear to be at odds with space restrictions
favored by traditional priorities. Regardless of the outcome of
individual institution's space allotments, considerable improvement
in noise levels can be achieved by careful attention to the acoustical
design of the building.36
Gray and Philbin37 studied the relative effects of changing staff
behavior and the physical space of the nursery using a series of sound
measurements made over 8 years in the same level III nursery. Their
emphasis was on increasing the periods of quiet, rather than simply
eliminating loud noise events. In 1986 the L min or most quiet
perceptible sound level in a 5-day period was variable, usually at
about 65 dBA and rarely about 55 dBA. Nights were no more quiet
than days, and weekends no different than weekdays. In 1991, after a
10-month period of staff education, internal publicity, and
individual demonstrations of the effect of sound on the behavior and
vital signs of very low birth weight infants, the L min had dropped to a
steady level of 56 dBA. Brief but perceptible loud events, described by
L max, were fewer in number but remained high at 80 to 98 dBA.
There were still no differences between day±night and weekend±
weekday sound levels. In 1993 the nursery was renovated and
bacteriostatic carpet and acoustic ceiling materials were installed.
Smaller stainless steel sinks replaced the deep steel scrub sinks and
some improvements were made in the air-handling ducts. Bed
locations were not changed. In the empty nursery the mean sound
pressure was 55 dBA at 1000 Hz before renovation and 40 dBA
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Philbin
afterwards. Once in operation the post renovation L min for the NICU
was 38 to 45 dBA. With the unit fully occupied, the pressure at 1000
Hz at the bedside during a medical emergency was 52 dBA. The
overall effect of changes in the building, therefore, was to
dramatically reduce the amount of loud sound and to greatly
increase the amount and degree of quiet.
In summary, nurseries are reported to be very noisy and attempts
at making them more quiet by changing staff behavior appear to be
only marginally successful. Ear coverings to protect individual
infants from the noise are little studied and pose potential problems
for the infants. Until recently, however, the literature has paid little
attention to the contribution of the physical space to creating
conditions predisposed to high noise levels. Increased space at the
bedside, sound absorbent surface materials, and engineered
acoustical control may provide successfully in reducing nursery noise
for the future.
EFFECTS OF NURSERY NOISE ON INFANT SLEEP
Studies of the effects of noise on infant sleep use term infants as
subjects. These studies are reviewed briefly here, however, because
preterm infants can be expected to show the same or greater
sensitivity to sound as term infants even at term gestational age.
GaÈdeke et al.14 studied the effect of noise similar to that recorded
in childrens' hospital sick rooms on healthy infants 3 to 36 weeks
old. The noise stimulus included frequencies between 100 and 7000
Hz at sound levels between 50 and 75 dB. The healthy infants who
served as subjects of the research were able to attain all stages of
sleep. However, the results show that most healthy newborns are
disturbed or wakened in sleep by hospital sounds at these levels. At
lower levels (e.g., 65 dB) about 20% of infants were disturbed after
12 minutes of exposure. At higher levels (e.g., 70 dB) 1 of 2 to 2 of 3
of the babies were disturbed or wakened after only 3 minutes of
exposure. Similar disturbances of sleep by similar sounds are reported
by Miller and Byrne,41 Wedenberg,42 and by Steinschneider et al.43 Noise
levels used in these studies are typical of hospital nurseries reported in
the literature. The recommended permissible noise criteria for new
nurseries are based on these demonstrated effects on sleep.44
STUDIES COMPARING FULL TERM AND PRETERM
INFANT RESPONSES TO SOUND
Although it would be helpful to clinicians to understand how preterm
infant responses to sound differ prior to term gestational age from
those of term infants, few studies have made the comparison directly.
Most investigators compare the two groups of infants at term
gestational age and are interested in whether preterm infants show
more reactivity to a stimulus than term infants do. The results are
mixed and depend on the way in which the question is tested and on
differences in responsiveness within the subject groups.
In 1971 Bench and Parker reported differing responses of 10
preterm infants (28 to 36 weeks' post conceptional age at birth) and
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 Philbin
10 full-term infants in deep sleep and light sleep using a controlled
experimental design.45 Both groups were tested at term gestational
age. The stimuli were a series of loud (85 dB), broad-band sound
pulses each lasting 500 msec and separated by 5 seconds of ambient
room sound (53 dB). The large 30-dB difference between the
background and signal would cause the signal to be perceived as very
loud. Full-term babies were found to respond more reliably than
preterm babies but only in a light sleep state. The groups responded
similarly in a deep sleep state. The small sample size and difficulty in
judging responses limit the generalizability of the findings.
Gerber et al.46 and Gerber and Mencher 47 compared the eye and
limb movements of term and preterm infants in response to wide-
band and narrow-band white-noise stimuli in a controlled
experimental design. Their sample of 11 preterm infants was born
between 26 and 35 weeks post conception and tested at 1 to 18 weeks
after birth. Subjects' ages at testing are reported as, simply ``still
preterm''.46 The authors found that preterm infants responded to 24%
of trials whereas term infants responded to only 17%. Both groups
respond more to wide-band stimuli (judged to be more complex)
than to narrow-band. The authors do not report the infants'
behavioral state or whether the differences in responses are
statistically significant.
In 1979 Field et al.48 studied the heart rate, movement, and
behavioral state responses of 18 preterm and 18 full-term infants
across two sound and one tactile stimulus conditions. The term
newborns were between 38 and 41 weeks post conception and tested
at 3 days after birth. The preterm infants were born at 31 to 36 weeks
post conception and tested between 36 and 39 weeks. These
differences place the preterm infant group at a younger post
conceptional age than the term group at time of testing and weaken
the comparability of the subject groups. The term infants showed
habituation of heart rate to the stimulus during the 10 habituation
trials whereas the preterm infants did not. The number of limb
movements decreased for both groups over the habituation trials and
both groups showed a return to greater movement after a strong
dishabituating stimulus. The term infants tended to show more deep
sleep over the habituation trials whereas the preterm infants showed
less.
Als et al.49,50 have compared large numbers of term and preterm
infants at term gestational age on a neurobehavioral assessment of
responses to simple and complex stimuli in auditory and other
sensory domains. Their studies show the preterm to be more likely
than the term infant to have more motor, autonomic, and state
changes in response to auditory, visual, handling, and social
stimuli.38,39 The preterm is also likely to require more examiner
facilitation to complete the test and to have more difficulties in
attending to stimuli in an alert state. Not all preterms show these
differences, however, whereas some healthy term infants do show
them.
The studies of Als et al. have larger samples than the other studies
reviewed here and their subjects are grouped into three gestational
age cohorts at 26 to 32, 33 to 37, and 38 to 41 weeks. Their finding
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Influence of Auditory Experience on Preterm Newborns
that a small group of preterms function like term infants whereas a
small group of term infants function like preterms may explain the
conflicting results of other studies with relatively small sample sizes
and more inclusive gestational age cohorts.
CLINICAL INTERVENTIONS USING SOUND STIMULATION
FOR PRETERM INFANTS
In general, the studies of clinical interventions using sound
stimulation for preterm infants lack a substantive theoretical base
and a history of testing theory with basic science or comparative
animal behavior studies. Many of the studies reviewed in this section
are isolated phenomenological reports based on an assumption that
nurseries lack a particular kind of auditory stimulation that would
benefit preterm infants. Linn et al.30 provide an excellent discussion of
questions relevant to adding planned stimulation to the NICU
environment. Gardner et al.,51 Ulrich,52 and Harrison53 also provide
reviews of the literature regarding infant stimulation programs.
Philbin and Klaas54 provide a checklist for evaluating research on the
effects of sound on infants.
Static, Patterned Stimuli: Heartbeat, Breathing Sounds,
and Vestibular Stimulation
A number of investigators have combined static, mechanized
vestibular stimulation with recordings of artificial heartbeats or other
sounds. The rationale for this auditory stimulation was generally
based on studies of term infants from the 1970s and evidence of
heartbeat sounds in the uterine environment that has been
supplanted by more accurate methodologies and relevant animal
models. Philbin and Klaas55 provide a review of these studies. The
studies reviewed here are grouped along an axis of more protocol
driven or mechanistic stimulation to more individualized stimulation
provided by a human caregiver.
Most of the studies of protocol-based, mechanistic auditory and
vestibular stimulation lack information about ambient nursery and
incubator sound and about the acoustical properties of the stimulus.
This is worrisome in that the overall stimulation to the experimental
group appears to be very strong in some studies and may continue for
a long period of time.56 ± 58 Many of the studies use very small samples
and none using both auditory and vestibular stimuli separate the
effects of one from the other. Additionally, the acoustic stimulation
provided by the source of vestibular stimulation (usually a moving
waterbed) appears to be unrecognized. Neither is there a control for
the halo effect of a special bed even though the outcomes could be
influenced by unmasked caregivers. Very few studies follow the
infants' development after discharge, the studies of Thoman et al.,56
Barnard and Bee,59 and Scarr-Salapatek and Williams60 being notable
exceptions.
Some studies indicate that exposure to patterned, static stimuli
offers advantages to weight gain and head growth whereas others do
not. Perhaps the most consistent finding is better state control and
longer periods of sleep for the experimental babies, at least during the
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Influence of Auditory Experience on Preterm Newborns
experimental period. However, these studies are weakened by the
absence of important safeguards against bias such as masked
caregivers and data collectors and the lack of a measurement of
nursing intervention.
In 1991 Thoman et al.56 studied infants' responses to an auditory
stimulus patterned to resemble breathing. Infants were exposed
continuously, for an average of 22 days, to a stuffed toy that emitted
breath sounds and to a quiet stuffed toy. The acoustic properties of
the stimulus and the ambient room sounds were not reported. The 58
subjects were cared for in seven different hospitals and group
assignment was not random. The groups were, however, similar in
gestational age at birth (28 to 29 weeks), age at enrollment in the
study (33 weeks), and number of days exposed to the stimulus (22
to 24 days).
Outcome measures were the gestational age at discharge, the
amount of contact with the stuffed toy, and the amount of time in
various sleep states (both measured on time lapsed videotape).
Differences in nursing-care practices between the hospitals make the
results difficult to interpret but these were well documented through
the videotape recordings. In general the infants exposed to the breath
sounds increased their contact with the stuffed toy over the course of 2
weeks whereas infants exposed to the quiet toy did not. There were no
significant effects on behavioral state during hospitalization or age at
discharge.
Sleep and awake states after discharge were studied by videotape
in five weekly 24-hour sleep recordings. The group with auditory
stimulation showed significantly more quiet sleep periods at home
over all 5 weeks and a greater increase in quiet sleep than the control
infants. The groups did not differ in length of quiet or active sleep
periods or duration of the longest sleep period. The finding is
interesting but very difficult to interpret given the sampling problems,
large number of hospital settings, and lack of information about
room, incubator, and stimulus acoustical properties. Alternative
explanations for the effect could be increased sleep due to masking of
the nursery noise, and qualitatively different nursing and/or parental
care between the study groups.
In an earlier study Korner and her associates 61 studied the effects
of an oscillating waterbed on preterm infants' respiration. The
stimulus was chosen to be strong enough to prohibit habituation and
infants were stimulated for seven days continuously. Infants included
in the study were between 28 and 34 weeks' gestation at birth, not
critically ill, and were breathing room air by the fifth postnatal day.
There were 20 infants in the experimental groups and 11 in the
control group. Infants were placed on the waterbeds from the third to
fifth postnatal day and remained there for the duration of the study.
Vital signs, weight loss, and amount of emesis were the same among
all of the groups. The experimental group had significantly less
apnea than the control group. Additionally, the experimental group
apnea decreased over time whereas control group apnea increased
over time.
The finding is not surprising given that physical stimulation is the
usual means of reinstating breathing during apnea. However, there
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Philbin
are important problems with the study that should be considered
before applying the findings to clinical practice. First, the outcome
measure was apnea as recorded in nurses' notes and data were
collected retrospectively. Nurses were aware of the infants' group
assignment and the study relies on nurses recording every monitor
alarm warning that the heart rate was less than 100 beats per minute
or respirations less than 20 per minute. No distinctions were made
between spontaneously resolving apneas and those requiring
intervention or between apneic events of varying lengths. The authors
do not report the effect of the waterbed on the delivery of nursing
care, infant positioning and other practices that could affect apneic
phenomena. They also do not control for a possible halo effect of the
bed itself, for example with an alternate ``special'' bed. Neither do
they report possible untoward effects of this amount of strong
stimulation, for example on sleep, crying, alert periods, motor
activity, or post-study habituation.
In 1976 Kramer and Pierpont58 combined an hour of oscillating
waterbed before each feeding with a tape recording of heartbeat and a
woman's voice for virtually the entire period of housing in an
incubator. The small sample of 11 experimental and 9 control
infants were between 30 and 34 weeks' gestation at birth, had
uneventful courses, and tolerated enteral feedings by the seventh
postnatal day. The strong stimulation package included auditory
stimulation at 74 to 84 dB and 25 to 30 oscillations of the waterbed
each minute. The experimental group gained significantly more
weight and had a greater biparietal diameter but was similar to the
control group on the Dubowitz et al.62 or Brazelton63 assessment scales
and in head circumference. The study design does not permit
discriminating between the effects of the waterbed per se, the
oscillations, or either of the two auditory stimulations. There may be
a reverse halo effect in that the waterbeds had been used for 4 years
and the caregiving staff regarded the standard bed as less desirable.
Data collectors were not masked regarding the infants' group
assignments. Finally, there were no follow-up studies of the infant's
development or growth or studies of possible adverse effects of the
long exposure to the strong experimental stimuli.
In 1983 Barnard and Bee59 reported the effects of temporally
patterned vestibular and auditory stimulation during hospitalization
on the development of preterm infants near term and at 2 years. The
design of the study compares stimuli in a range of contingent
responsiveness to the infant's behavior. The infants were between 30
and 33 weeks' gestational age at birth and generally started using the
experimental bed 7 days after birth. No measure of illness is reported
but the authors suggest that subjects were not critically ill. The
infants' economic circumstances were similar, an important
consideration in terms of the follow-up findings.
The 28 control infants received standard nursery care whereas the
three groups of experimental infants received heart beat sounds and
side-to-side movement of their beds for at least 15 minutes an hour,
24 hours a day for at least 7 days. The bed moved 3 in. horizontally
30 times a minute and the auditory stimulation of heartbeat sounds
was played at 85 dB about 2 ft from the infant's head with most of
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 Philbin
the acoustic energy below 500 Hz. Together and separately, these are
strong stimuli relative to the threshold of responding in preterm
infants at this age. One group of 26 infants received this treatment
regardless of their behavior. A second group of 23 infants received the
stimulation each time they maintained motor inactivity for 90
seconds and could reactivated it by nonmovement any number of
times within an hour. A third group of 10 infants could activate the
stimulation only once in each hour. There was no attempt to
coordinate the stimulation with sleep cycles.
The immediate effect of the rocking bed was to reduce overall
activity and shorten the periods of activity in the experimental
groups. These shorter cycles of activity were still present in the self-
activating group at the end of the treatment period. When compared
on the Brazelton scales one or more of the experimental groups
showed a wider range of behavioral states at 34 weeks and better
orientation to auditory and visual stimuli at discharge.63 All three
treatment groups exceeded the control group on the Mental
Development Index of the Bayley Scales of Infant Development at 24
months but the findings are confounded by more organized
environments as measured on the HOME scale.64,65 The study shows
that preterm infants at 30 to 33 weeks' gestational age can be shaped
to respond contingently but does not address the appropriateness of
directing this capacity toward extended vestibular and auditory
stimulation.
By contrast with these studies of static, mechanical stimulation,
Korner and Thoman66 studied some of the short-term effects of
common methods of comforting used by parents in the Western
World. They standardized various holding positions, seating positions,
and the vestibular stimulation involved in pushing a stroller to and
fro. These standard stimuli were presented in random order following
spontaneous crying. Subjects were all newborn term infants.
Comparisons of the time to stop crying following each type of
stimulation showed that vestibular-proprioceptive stimulation was
the most effective intervention followed by interventions that provided
contact. The least effective were those that provided no contact. There
were no other differences between the groups of infants that could
account for these effects.
In another study that combined human responsiveness to the
individual infant with a stimulation protocol White-Traut and her
colleagues report a multimodal intervention for preterms provided by
a skilled caregiver. The protocol consisted of 10 minutes a day of
gentle massage, 5 minutes of rocking, and concurrent talking and
singing stimulation.67 The 17 experimental infants received this
treatment daily for a minimum of ten days. The control infants
received standard nursing care. There was no control for possible
halo influences of the ``special treatment'' status of the experimental
infants on nursing care. The results of this carefully done study
showed no significant differences between the groups in weight gain
or length of hospital stay.
In a controlled follow-up study, the auditory stimulation (gentle
talking by the caregiver) was separated from the other stimuli such
that the caregiver spoke to the infant before touching.68 With this
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Influence of Auditory Experience on Preterm Newborns
advance notice, infants had a higher proportion of heart rate in the
normal range ( <140 beats per minute [bpm] ) during
stimulation, and greater alertness after stimulation. Touch without
advance auditory stimulation produced higher than normal heart
rates ( >140 bpm). The authors conclude that ``tactile stimulation
alone may be too arousing for these infants. . .''.68 This finding
supports consistent behavioral observations regarding better state,
motor, and autonomic control when caregivers speak softly to a
preterm infant before touching or handling.
Further contrast with the studies of mechanized stimulation is
provided by a highly individualized program with follow-up after
discharge described by Scarr-Salapatek and Williams.60 This
controlled study of 60 infants found significantly greater weight gain
during hospitalization and significantly better developmental
outcomes during hospitalization and at 12 months for the
experimental infants. The individualized intervention in the hospital
was holding, rocking, talking to, and playing with the infants at
feedings and at designated play times. The stimulation was provided
by practical nurses skilled in baby care. The control infants received
only the handling associated with nursery routines. There was no
attempt to influence parent participation, which limited for both
groups. After discharge the experimental mothers, all very poor and
mostly young and single, were visited weekly by an experienced infant
development specialist/social worker who provided simple, age-
appropriate toys and coached the mother in a wide range of skills
related to child development. The effects of the experimental care
during hospitalization argues well for nursing assignments that
allow time for holding and playing and for hospital programs that
facilitate parental care.
In conclusion, then, many of the studies of mechanistic
stimulation lack expected safeguards for validity and reliability and
use combinations of strong stimuli. Their findings are mixed and do
not include possible, untoward short- and long-term effects of the
stimulation. The studies of protocols or mechanical devices that
provide some opportunity for the infant to influence the stimulation
also tend to include more rigorous methodology. These studies find
limited physiological or developmental advantages of the stimula-
tion.59,68 By contrast, a well-done study of individualized (non±
protocol-driven) stimulation provided by sensitive, skilled caregivers
shows both developmental and physiologic advantage during the
hospital period. In addition, follow-up guidance for parents during
the first year of life shows significant developmental advantages at 12
months.60
Music
Despite many commentary articles attributing positive effects of
music on hospitalized preterm and full-term infants there are few
studies of the phenomena and most of these lack common
safeguards for validity and reliability.69 ± 72 A review of this literature in
the Journal of Music Therapy raises concerns about the methodology
for presenting the sound stimulus and stresses the need to determine
appropriate levels and frequencies of the music stimulus as well as
Journal of Perinatology 2000; 20:S76 ± S86
Influence of Auditory Experience on Preterm Newborns
appropriate gestational ages for exposure.73 The article also
comments on the potential for improving music therapy research by
including scientific content from medicine, nursing, audiology, and
psychology.
The following studies represent the range of research available.
Details of the studies are presented to provide a basis for the critique
of this literature, with the more solidly designed studies presented
first.
Two studies exemplify attention to the science and details of
behavioral research. A small sample observational study by Burke et
al. in 1995 contrasted the effects of music on the recovery from
endotrachial suctioning of four preterm infants with bronchopul-
monary dysplasia.74 The experimental conditions included an aural
music stimulus, a combined aural-vibro-tactile music stimulus, and
ambient room sound. Observations were done in a closed isolation
room to limit the intrusion of nursery noise. Each of the 18 trials
lasted 15 minutes following suctioning, were counterbalanced, and
spread over 8 to 21 days. Subjects ranged in age from 34 weeks'
gestational age to 3 months corrected age at entry into the study.
Results showed an effect of aural music on lowering heart rate and of
both types of music on improving oxygen saturation. The aural-
vibro-tactile music resulted in more alert behavioral states and both
types of music resulted in increased sleep and high arousal. This
multidisciplinary team of investigators uses caution in making
recommendations and reminds the reader of the need to
individualize care for each infant and to put a specific intervention in
the larger context of a treatment program.
Another carefully done, interdisciplinary study by Lieb et al.75
used a small sample and phase-lag design to test the effect of a
multimodal intervention. The study presented preterm infants with
simultaneous visual, auditory, vestibular, and tactile stimuli while
they were feeding. The auditory portion of the stimulation package
consisted of the nurse talking or singing to the infant and
modulating the stimulation in interaction with the infant's
behavior. The investigators, parents, and staff were all aware of the
group assignment. No effects of the intervention were shown in
Brazelton Scales at discharge or in weight gain at discharge,
although the intervention infants are reported to have received fewer
calories per kilogram of body weight.63 The intervention infants,
however, had higher 6-month mental and motor scores on the
Bayley Scales of Infant Development.64 Possible sources of the
developmental advantage include the experimental condition itself
as well as the long-term influence of the clinicians' behavioral
example on parents' social interactions with their infants after
discharge.
Another group of studies of the effects of music has problems in
subject selection, group assignment, data collection and analysis, and
interpretation of results. For example, a frequently cited study by
Chapman76 was designed to test the effect of multiple, short periods of
tape-recorded music or speech on the pattern and amount of limb
movement. However, the only significant effect reported is an
unplanned outcome, namely the attainment of an arbitrary weight at
Journal of Perinatology 2000; 20:S76 ± S86
Philbin
an earlier date by the experimental group. This finding is frequently
cited in other music studies as a positive effect of music on growth
although no statistical analysis of the data was presented and only
group means (without variability, range, or measures of
significance) were given to show comparability of groups at birth.
This study had a large sample of 50 subjects in each of three groups
drawn from three different hospitals. No information is given
regarding the assignment of infants from each hospital to study
groups, leaving the possibility that each group was drawn exclusively
from a different hospital. If this was the case, the findings could be
due to nutritional management between hospitals rather than to the
experimental condition.
Although the range of gestational ages at birth was very large (26
to 33 weeks), no information is given regarding the acute or chronic
conditions of the subjects and all are reported to have had ``. . .no
physiological problems at birth''.77 The method of random
assignment to groups is not given and it appears that investigators,
staff, and parents knew the group assignments. A follow-up study
using the same subjects tested infant growth and development at
discharge (with the Rosenblith scales) and 9 months (with the
Bayley scales) post discharge.64,78,79 No significant group differences
were found on any measure.
Another frequently cited study by Collins and Kuck reports
improved oxygen saturation and less active behavioral states in
preterm infants as a consequence of exposure to music.80 This study is
based on an explicit assumption ``that infants in a NICU are subject
to the same stressors that negatively affect the physiologic parameters
of anxious adult ICU patients''.81 The assumption is that auditory
perception, and physiologic and behavioral responses are also similar
between adults and preterms, an assumption not substantiated by
known physiology or brain/behavior development of the preterm
newborn. The study used a small sample of 17 infants with a wide
range of gestational ages at birth and time of testing. The gestational
age at testing was 25 to 39 weeks' gestational age, yet all subjects
were intubated. However, despite the very different kinds of
physiologic problems and behavioral repertoires known among
intubated infants at 25 weeks' gestational age and those at 39 weeks'
gestational age, no information is given regarding the medical
histories of the subjects.
All infants were initially observed in an agitated, fussy state that
served as the baseline control. After 10 minutes the music was played
loudly at 80 dB for the next 10 minutes. Without alternate
presentation of experimental and control conditions or a separate
control group receiving no music, it is predictable that most of these
intubated infants would be less active due to fatigue after 20 minutes
of fussing. The positive results are based on paired t-tests of
unmasked behavioral ratings by the investigator and on a difference
in mean oxygen saturations of 89% and 92%. This difference in
oxygen saturations is arguably not physiologically relevant in any
case and particularly lacks meaning given the disparate physiologic
conditions of the subjects and the lack of information about
respiratory management during the study period.
S83
 Philbin
Several studies use a nearly identical method of nonrandom
subject assignment termed matching.82 ± 84 Although subjects were
non-randomly selected to achieve similar group averages for days
of life at testing, birth weight, and sex, there is no statistical
analysis of initial group differences on these parameters despite a
range of 1 to 67 days of life at testing in one study and a range of
2 to 34 days in another.83 In one study, for example, the group
exposed to music had 3 of the 10 subjects on assisted ventilation at
the time of testing whereas the control group had 7 of the 10 on
assisted ventilation. Not surprisingly, the less ill experimental group
(exposed to music) are reported to have better oxygen saturation
levels than the more ill control group that heard a tape recording
of the mother's voice.
Another small sample study of preterm infants investigates
whether they will suck on a pacifier longer if the sucking is
accompanied by music.85 The theoretical basis for the study assumes
a causal relationship between longer durations of non-nutritive,
pacifier sucking and less fatigue during nutritive sucking. Such a
relationship, however, is not documented in the literature. The aim of
the study is to demonstrate that music accompanying pacifier
sucking increases the duration of non-nutritive sucking and,
therefore, decreases fatigue and improves nutritive bottle-feeding in a
group of undefined ``poor'' feeders. The pacifier-music apparatus is
in development as a commercial product. The 12 experimental
infants were born between 24 and 33 weeks' gestational age at birth
and tested between 32 and 41 weeks. The infants' time in hospital
ranges from 1.3 to 9 weeks at time of testing. Despite the wide age
range, however, the subjects are not stratified. No information is
given about the infants' acuity of illness, appropriateness of
gestational age for weight at birth, hospital course, or chronic illness.
No information is presented regarding the investigators' reliability in
identifying behavioral state or behavioral signs of stress, observations
crucial to the design.
To test non-nutritive sucking a pressure sensitive pacifier is held
into the infant's mouth by an investigator who is aware of the
auditory condition being tested. The most minimal sucking pressure
will activate the music. There is no control for the obligatory nature
of the preterm infant's suck response and the infant is unable to
expel the pacifier. Despite this, however, the study is described as an
investigation of contingent learning. The experimental and control
conditions are alternated but the experimental music condition is 2.5
times longer than the control condition. All investigators and
assistants are aware of the condition while data is recorded. No data
regarding behavioral state or physiologic indicators of stress are
offered yet all infants are reported as showing no signs of stress. There
is no statistical analysis of the data and results are shown only as a
graph of means without error bars. The infants are judged to be
selectively sucking to hear the music. The study reports improved
feeding in the experimental infants.
In summary, many but not all, of the studies of the effects of
music have problems in subject selection and group assignment,
sample size, potential for investigator bias in data collection, and
S84
Influence of Auditory Experience on Preterm Newborns
meager data analysis. Many attribute benefits that are not
supported by the data and some promote commercial products.
Possible adverse effects of the experimental stimulation are not
investigated.
RECOMMENDATIONS FOR CLINICAL PRACTICE
Measure Noise Levels in Nurseries and Incubators
Given the known, adverse effects of nursery noise on the behavior and
physiology of newborns, and the abundant documentation of high
levels of nursery noise around the globe, hospitals are arguably
obliged to measure the sound levels of nurseries and incubators.
Several publications describe methods of measurement so that
hospital personnel can accomplish the task independently.86,87 In
addition, professional acoustical engineers can perform these
measurements.
Reduce Nursery Noise
The acoustic conditions of hospital nurseries are unlike any normal
infant environment and provide the background against which all
other sound is discriminated Ð or not. Nursery noise also causes
physiologic stress for infants interferes with sleep and can contribute
to adults' work-related errors.88,89 The priority for improving early
auditory experience for preterm infants therefore, is to make nurseries
more quiet.36,44
Provide Individualized, Parental Care for Hospitalized
Infants
Various aspects of parental care are shown to be associated with
developmental advantages for preterm infants if they are
individualized to the particular infant by a sensitive caregiver. These
aspects of parental care include holding and rocking to comfort,
talking and singing during feeding, speaking before handling, and
time together in social interaction and physical closeness.60,66,68,75
Therefore, clinicians can be reasonably assured that it is beneficial
for family members to hold a preterm infant in a relaxed atmosphere
and to speak or sing to the infant as they are naturally inclined to do,
rather than as they are directed to do.
Limit Added, Auditory and Vestibular Stimulation to
Specific Situations
There appears to be little or no basis for exposing hospitalized sick
and preterm infants to tape recordings regardless of their content. Not
only are the purported benefits not established, the possible negative
short-term and long-term consequences are largely unexplored.
Additionally persuading parents and staff to expose hospitalized
infants to tape recordings tends to place a nonresponsive machine
between the caring person and the infant as illustrated by
Bouteloup.71 The single, demonstrated exception may by a temporary
benefit of assisting agitated, term-age infants hospitalized with
chronic respiratory disease and poor state regulation to calm
themselves following a stressful procedure.74
Journal of Perinatology 2000; 20:S76 ± S86
Influence of Auditory Experience on Preterm Newborns
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