The effect of music therapy applied to neonatales on their pain: Systematic review

Received: 23-Nov-2022, Manuscript No. OAR-22-80740; Accepted: 30-Nov-2022, Pre QC No. OAR-22-80740 (PQ); Editor assigned: 25-Nov-2022, Pre QC No. OAR-22-80740 (PQ); Reviewed: 29-Nov-2022, QC No. OAR-22-80740 (Q); Revised: 30-Nov-2022, Manuscript No. OAR-22-80740 (R); Published: 01-Dec-2022

Introduction

Pain is an emotional and psychological mood, which occurs due to harmful stimuli. We can understand that infants feel pain through physiological symptoms such as change in their heart rate, increase in the number of breaths and change in the oxygen value or behavioral symptoms such as crying, facial expressions and motor movements. However, it is not easy to measure pain in neonates [1].

There are more than 40 scales used to measure the state of pain in infants, yet four of them are widely used. These are Premature Infant Pain Profile (PIPP), Neonatal Infant Pain Scale (NIPS), CRIES and FLACC pain scales [1,2].

Treatment of pain evaluated through these measurement tools is done with pharmacological and nonpharmacological treatment methods. Pharmacological methods are opioid, non-opioid and cholangitis; while nonpharmacological methods are breast milk, kangaroo care, sucrose application, massage and music therapy. Recent research has been conducted indicating that nonpharmacological methods outweigh [3].

Music therapy, one of nonpharmacological methods is diversion of the infant’s attention by making it listen to the mother’s voice, white noise, lullaby or musical instruments [4,5]. In such an application, infants showed recovery as decrease in pain, and increase in comfort and vital findings [6]. The mother’s heartbeat sound and her own voice were used for the relief of pain in neonates and found to be effective [4]. In an RCT study conducted with 60 premature infants, the oxygen saturation value of 30 infants who listened to music during peripheral central venous catheter insertion increased, and heart rates and pain scores decreased compared to the control group. Another RCT study, using white noise, the PIPP score, heart rate and respiratory rate decreased, while oxygen saturation value increased [7 ]. In an RCT study that listened to heart rate, there was an increase in SpO₂ value and a decrease in PIPP pain score of the experimental group [8].

The literature review showed that Standley (2002) conducted a meta-analysis study by scanning studies from 1964 to 1999 to examine the effect of music therapy on pain in premature infants. After the year 2002, there was neither systematic review nor meta- analysis study. In recent years, the use of voice applications in intensive care units has become prevalent. To see how effective this prevalence has been, the present study is designed to evaluate the effect of voice applications on pain in premature infants over the last 20 years (2002-2022). The study included case-control studies conducted in the last 20 years. This systematic review aimed both to determine the effectiveness of voice applications in premature infants and to be a guide to new research topics.

Premature Infant Pain Profile (PIPP)

It was developed by Steven et al. (1996) for premature infants aged 28 weeks-36 weeks. Its Turkish validity and reliability study was conducted by Akcan and Yigit (2015). It is applicable to preterm and term infants and is scored between 0 and 21. A score of 0 points-6 points indicate that there is no pain or it is minimal, 7 points-12 points indicate that there is moderate severe pain and 13 points - 21 points indicate severe pain. It is used as an assessment 15 seconds before and 30 seconds after the painful procedure (Table 1) [9].

Tab. 1. Premature Infant Pain Profile-(PIPP)

Neonatal Infant Pain Scale(NIPS)

It was developed by Lawrence et al. (1993) and its Turkish validity and reliability study was conducted by Akdovan (1999) [10,11]. It is appropriate for the assessment of pain in premature and neonates. The obtainable score from the scale consisting of six deaths in total varies between 0 and 7. A higher score indicates more severe pain (Table 2).

Tab. 2. Neonatal Infant Pain Scale (NIPS)

Cries pain scale

This scale, developed by Krechel and Bildner (1995), evaluates postoperative physiological pain [12]. It works through a system similar to Apgar score. It is used for over 32 weeks of gestational age and postoperative period infants. The lowest obtainable score is 0, while the highest is 10 points. A score of at least 4 points and over indicates pain (Table 3).

Tab. 3. Cries pain scale

Flacc Pain Scale

Pain measurement is carried out through evaluation of five behavioural categories developed by Merkel et al. in 1997 [13]. It is used for term, preterm and non-expressive children in the age range of 3 years-7 years (Table 4) [14].

Tab 4. Flacc pain scale

Nursing practices and voice applications in pain management of neonates

Music has been accepted as a way of therapy for centuries [15 ]. It is believed that music is used in therapy because it affects people in many aspects and it is easy to use [16].

Music therapy is defined as “the use of music and/or musical elements (rhythm, sound melody) designed and used by a trained music therapist to optimize and improve the quality of life of a person, family or group” by the World Federation of Music Therapy [17].

Pythagoras (585 BC-500 BC) was one of the first founders of music therapy. Research has been conducted on treatment of psychiatric patients by playing rhythmic sounds. Plato (400 BC) pointed that music ensures tolerance and comfort in people [18]. In his work Kitabu-s Sifa (The Book of Healing), Avicenna referred to music in medical field as “one of the most effective ways of treatment is to increase the mental and spiritual powers of the patient, to give him/her the courage to fight the disease better, to make him listen to the best music and to bring him together with the people he loves” [19].

Nightingale described music therapy in the 1800s as a nursing initiative that increased patient comfort by reducing pain and anxiety [16]. Today, it is frequently used in the treatment of pain and anxiety particularly among the symptoms that occur in other interventional diagnosis-treatment phases applied to patients in intensive care, psychiatry, surgery, pediatrics, obstetrics, and oncology chemotherapy stage [20].

In a study that evaluated 29 research results, music was used to reduce pain and anxiety in patients, to eliminate the side effects of treatment and to increase patient satisfaction [21]. Loewy et al. (2013) examined the effect of music on 272 premature infants and found that their heart rate decreased, while their sleep patterns and milk absorption increased through music therapy [22]. Clacatera et al. (2014) played musical sounds to 42 infants hospitalized in the pediatric surgery unit and found a positive change in their cardiac parameters with reduced perception of pain. The mother’s heartbeat sound and voice were used for the pain relief in neonates and found to be effective [4]. In an RCT study conducted with 60 premature infants, the oxygen saturation value of 30 infants who listened to music during peripheral central venous catheter insertion increased, and heart rates and pain scores decreased compared to the control group. Another RCT study, using white noise, the PIPP score, heart rate and respiratory rate decreased, while oxygen saturation value increased [7]. In an RCT study that listened to heart rate, there was an increase in SpO₂ value and a decrease in PIPP pain score of the experimental group [8]. Nine RCT studies on heel lance and circumcised infants found that pain responses reduced in infants who listened to music [23]. In another RCT study, the study group listened to white noise while the control group did not. The study results showed that the level of pain in the infants in the control group was significantly higher than in the study group [5]. In another study conducted on 60 preterm infants in the neonatal intensive care unit, the study group had listened to music for 30 minutes twice a day for seven days. There was a significant difference in physiological parameters of the study group and the control group with an increase in SpO₂ level and decrease in respiratory rate and in heart rhythm [24].

This study aimed to determine the current nursing practices for the elimination of infants’ pain and to update the future practices so that nurses can develop a professional care in the pain care of neonates.

Method

The research is a systematic review.

Population and sample of the research

The population of our study consisted of randomized controlled studies published between 2002 and 2022 that examined the effect of voice application on pain in premature infants.

Data collection

We reviewed the electronic databases of Google Akademik,ULAKBİM, Clinical Key, DynaMed, Elsevier, Ebsco, Asos Index, HiperKitap, ProQuest, Sage Premier Journals, Science Direct, Scopus, Springer Nature, Turcademy, Web of Science for the present study

Data collection process

The MeSH (Medical Subjects Headings) system was used to determine the keywords. These keywords, prepared in Turkish and English were as follows: “premature”, “pain”, “music”, “white noise”, ‘‘lullaby’’, “agrı”, “muzik”, “beyaz gurultu”, “ninni’’, ‘‘anne sesi’. The keywords were searched in combinations in the keywords, title and abstract parts. The articles accessed by such screening were included in the study. This process was ended on January 1, 2022 accessing 9301 articles and including 17 of them in the study. The elimination phases of the studies are indicated in the PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) 2020 flow diagram (Figure 1).

Figure 1: PRISMA 2009 Flow Diagram

Coding the study

The coding form was created by the researcher and consisted of seven sections, including author/year, country/city, research aim, research method/randomization, sample, intervention and study results. The coding was done using Microsoft Office Word.

Ethics

The literature was reviewed and studies were found as the research was a systematic review. Therefore, no ethics committee approval was obtained because it was not necessary.

Limitations of the study

The studies were selected through participants (P: Population), interventions (I: Interventions), comparison groups (C: Comparators), results (O: Outcomes) and research methods (S: Study Designs)

• Population: Infants born before the week 37.6.

• Interventions: Voice application to the infant.

• Comparator: Infants in the control group.

• Physical vital signs (pulse, saturation, respiratory rate, etc.) and pain assessment scales (PIPP, NIPP).

• Studies with randomized control groups.

Inclusion Criteria:

• Written in Turkish or English

• Being published between 2002 and 2022

• Inability to access full text of the studies

• Using the RCT methodology

Exclusion criteria:

Congress declarations, non-experimental studies and qualitative studies.

Reporting

The systematic review and meta-analysis control list of PRISMA published in 2020 was used in the study

Findings

With the keywords determined, a total of 9301 studies were accessed between 2002 and 2022 through the screening in 16 databases. Of these studies, 128 were eliminated due to duplication,148 were not in full text, 8456 were qualitative studies, 26 did not have language compatibility, 500 were not suitable for the method and 52 were out of the specified year range, thus the study group was created with the remaining 17 studies.

The sample group of 17 studies included in the systematic review consisted of preterm infants. The sample size ranged from a minimum of 25 to a maximum of 206. All studies selected were RCT studies. Table 4.1 shows detailed features of the studies and the detailed coding table that shows the study results (Table 5).

Tab. 5. Coding tables of the studies included in the study

Of the studies obtained, 46.9% were conducted in Turkey, 17.7% in China, 11.8% in Iran, 5.9% in Taiwan, 5.9% in Lebanon, 5.9% in Japan and 5.9% in Australia. While 58.8% of the studies used a single voice and a single experimental group, 41.2% used more than one voice and experimental group.

In total, there were 19 voice applications in 28 experimental groups. Of the sound interventions used, 26% were white noise, 16% were mother’s voice, 21% were lullabies, 10.7% were heartbeats, 21% were music and 5.3% were intrauterine sounds. While the positive effect rate in voice interventions was found to be 88.2%, the studies that were negative or had no effect were determined as 11.8%.

Discussion

This study was conducted to reach scientific generalizations about the use of voice interventions in pain in premature infants in order to examine their effect on pain in premature infants by synthesizing the findings of RCT between 2002 and 2022. The results of 17 studies were included in the discussion of the study

Considering publication years of the studies included in this research, most studies have been conducted in 2022, followed by the year 2021 and others (Table 5). The reason that there have been more studies recently can be the desire to support pain management in premature infants using non-pharmacological methods.

Three studies in voice interventions applied to the experimental groups among the included research showed no benefit in pain reduction [25-27 ]. Sharara-Chami et al. (2022) played music besides analgesic administration given to infants to be circumcised. In this research with 206 samples, there were 103 experimental groups [25]. The infants were subject to pain assessment of two blind and independent observers. An increase was found in heart rate and crying time of the experimental group. However, the played music did not affect pain. In another study by Ren et al. (2022), white noise was given during radial artery blood sampling [26]. From the sample group of 60 people, the experimental group of 29 people listened to white noise at 50 dB and the control group at 0 dB. There was no difference in pain levels between the two groups during and after the intervention. Therefore, white noise did not have any effect on pain. Sener Taplak and Bayat (2021) conducted a study examining the effect of the breast milk odor, white noise and facilitated tucking on pain and physiological parameters during EA in infants under mechanical ventilation [27]. The sample group was divided into 22, 21 and 21, respectively and control group. Infants who underwent white noise and facilitated tucking were found to be more effective at relaxation before the EA intervention than the other groups. However, no difference was found between the groups in pain reduction.

In 14 studies included in our research, voice applications applied to the experimental groups were found to be have positive effects on pain [4 -8, 28-35]. Sound interventions applied to experimental groups in the studies that our research included simulation of the heartbeat, maternal heartbeat, maternal voice, white noise, lullaby, music and intrauterine sounds.

In the study conducted by Karadag et al. (2022), heartbeat simulation was applied to the experimental group. The PIPP score showed a significant result in the control group (p=0.001) [8]. In a study conducted by Sarhangi et al. (2021), the experimental group listened to their mother’s heartbeat during blood collection. In pain assessment measured immediately after the intervention and 10 minutes later, there was a significant result compared to the control group (p<0.05). In their study, Kuçuk Alemdar and Kardas Ozdemir (2017) played intrauterine sounds to the experimental groups [31,34]. There was a significant difference after the NIPS pain assessment (p<0.05).

Yu et al. (2022), Kahraman et al. (2020) and Kuçuk Alemdar (2018) played mother’s voice to the experimental groups [28, 31, 34]. In these studies, there was a significant difference in the results of pain assessment in the experimental groups versus control groups (p<0.001, p<0.001 and p<0.05, respectively) [6].

Dora and Tural (2021), Kahraman et al. (2020) and Kuçukoglu et al. (2016) used white noise as sound intervention in their studies. They found that pain decreased after the intervention applied in the experimental groups (p<0.001, p<0.001 and p<0.05, respectively) [5-7].

Barandouzi et al. (2020), Tang et al. (2018), Uematsu and Sabue (2018), Qiu et al. (2017), and Shah et al. (2017) played music to the experimental groups [29,32,33,35-37]. The results from their studies showed a significant difference in pain scores of the experimental groups compared to the control groups (p=0.009, p<0.05, p<0.0001, p<0.05 and p<0.05, respectively).

Dora and Tural (2021), and Tekgunduz et al. (2019) played lullaby to the experimental groups as sound intervention. There was a significant difference in pain scores of the groups listening to lullaby compared to the groups that did not listen (p<0.001 and p<0.05, respectively) [ 7,30].

Conclusion

We found 9301 studies related to our topic and published between 2002 and 2022 examining the effect of voice interventions on pain in premature infants. Upon elimination, a total of 17 studies using RCT method were included in our research. In three of these studies, voice intervention did not give positive results on pain, while in 14 of them gave positive results. In premature infants, voice applications had a positive effect on pain with a rate of 82.3%. Besides pain assessment, positive results were obtained with the increase in SpO₂ value, stabilization in heart rate, decrease in respiratory rate and shortening of crying times. However, meta-analysis studies should be conducted to clearly deem sound applications positive or negative.

Pain management is pointed as one of the independent tasks of a nurse. Therefore, the nurse should evaluate the severity of the infant’s pain, and plan and implement pharmacological and non-pharmacological pain management strategy developed with the health team. Among non-pharmacological pain procedures, there are a limited number of evidence-based studies for voice interventions (music, lullaby, white noise, mother voice, etc.). The results of the current study can be considered an evidence-based study in pediatric nursing and can contribute to its use in nonpharmacological pain management.

Suggestions

• The frequency of studies with much evidence can be increased. Further double blind studies can be conducted.

• Sample size can be increased.

• Multi-centred studies can be carried out.

Acknowledgements

The research received no external or grant funding. All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by G.M., O.T. and G.M., O.T., and P.U. participated in conceiving the design of the study, collecting the data and the data analysis The first draft of the manuscript was written by O.T., and supervision was made by G.M., and P.U. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. The authors have declared that they have no competing or potential conflicts of interest.

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