Department of Neonatology, University Hospital Zurich, Zurich, Switzerland.
Zentrum für Kinder und Jugendmedizin, University Freiburg, Freiburg, Germany.
Cochrane Database Syst Rev. 2023 Sep 7;9(9):CD013472. doi: 10.1002/14651858.CD013472.pub2.
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.
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.
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.
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.
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 I 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.
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.
早产会干扰大脑成熟，随后的临床事件和干预措施可能会产生额外的有害影响。音乐治疗在新生儿重症监护病房越来越多地被应用，旨在改善早产儿及其父母的健康结果和生活质量。对各种类型的早产儿听觉刺激的疗效进行了系统评价，结果存在矛盾。需要进行更全面和严格的系统评价，以解决似乎相互矛盾的研究和综述所带来的争议。
我们评估了音乐和声乐干预对早产儿（<37 周妊娠）生理和神经发育结果的总体疗效，与标准护理相比。此外，我们旨在确定各种干预措施对婴儿生理、人体测量、社会情感、神经发育短期和长期结果、父母幸福感和依恋的具体影响。
我们于 2021 年 11 月在 Cochrane 对照试验中心注册库（CENTRAL）、MEDLINE、Embase、CINAHL、PsycINFO、Web of Science、RILM 摘要和 ERIC 进行了检索；2019 年 2 月在 Proquest 论文库进行了检索。我们还检索了相关系统评价的参考文献列表，以及入选和临床试验注册库的研究。
我们纳入了在住院期间有<37 周妊娠的早产儿的平行和群组随机对照试验，以及涉及干预措施的父母。干预措施是指由音乐治疗师、父母或医疗保健专业人员提供的任何现场或通过录音进行的音乐或声乐刺激，与标准护理相比。干预持续时间超过五分钟，且需要进行三次以上。
三位综述作者独立提取数据。我们使用 RevMan Web 对个体试验的治疗效果进行了分析，使用固定效应模型对数据进行了合并。在可能的情况下，我们使用均数差和 95%置信区间（CI）进行了荟萃分析。我们进行了异质性检验。当 I 统计量高于 50%时，我们通过敏感性和亚组分析评估了异质性的来源。我们使用 GRADE 评估证据的确定性。
我们纳入了 25 项试验，共纳入 1532 名婴儿和 691 名父母（21 项平行组 RCTs，4 项交叉 RCTs）。婴儿的胎龄从 23 周到 36 周不等，发生在世界各地的 NICU（1 级到 3 级）。在这些试验中，干预措施在类型、提供方式、频率和持续时间上差异很大。音乐和声乐主要以摇篮曲风格的平静、柔和、音乐参数为特征，通常结合了母亲的歌声，无论是现场还是录音，都被定义为音乐治疗或音乐医学。纳入研究的一般偏倚风险从低到高不等。音乐和声乐干预与标准护理相比，音乐/声乐干预并不能增加婴儿在干预期间的血氧饱和度（MD 0.13，95%置信区间（CI）-0.33 至 0.59；P = 0.59；958 名婴儿，10 项研究；高确定性证据）。音乐和声音可能也不会增加干预后的婴儿血氧饱和度（MD 0.63，95%CI -0.01 至 1.26；P = 0.05；800 名婴儿，7 项研究；中等确定性证据）。干预可能不会增加婴儿的发育（贝利婴幼儿发展量表（BSID）），包括认知成分评分（MD 0.35，95%CI -4.85 至 5.55；P = 0.90；69 名婴儿，2 项研究；低确定性证据）；运动成分评分（MD -0.17，95%CI -5.45 至 5.11；P = 0.95；69 名婴儿，2 项研究；低确定性证据）；和语言成分评分（MD 0.38，95%CI -5.45 至 6.21；P = 0.90；69 名婴儿，2 项研究；低确定性证据）。音乐治疗可能不会降低父母的状态-特质焦虑（MD -1.12，95%CI -3.20 至 0.96；P = 0.29；97 名父母，4 项研究；低确定性证据）。干预可能不会降低婴儿在干预期间的呼吸频率（MD 0.42，95%CI -1.05 至 1.90；P = 0.57；750 名婴儿；7 项研究；中等确定性证据）和干预后（MD 0.51，95%CI -1.57 至 2.58；P = 0.63；636 名婴儿，5 项研究；中等确定性证据）。然而，音乐/声乐干预可能会降低早产儿在干预期间的心率（MD -1.38，95%CI -2.63 至 -0.12；P = 0.03；1014 名婴儿；11 项研究；中等确定性证据）。这种有益的效果甚至在干预后更加强烈。音乐/声乐干预降低了婴儿的心率（MD -3.80，95%CI -5.05 至 -2.55；P < 0.00001；903 名婴儿，9 项研究；高确定性证据），CI 范围从中等到较大的有益效果。音乐治疗可能不会降低产后抑郁（MD 0.50，95%CI -1.80 至 2.81；P = 0.67；67 名参与者；2 项研究；低确定性证据）。音乐治疗对父母状态焦虑的影响证据非常不确定（MD -0.15，95%CI -2.72 至 2.41；P = 0.91；87 名父母，3 项研究；极低确定性证据）。我们不确定音乐治疗对婴儿的所有其他短期和长期结局、父母的幸福感和依恋/联系的任何进一步影响。两项研究将不良影响作为一个明确的研究结果进行了评估，未报告音乐和声音的不良影响。
音乐/声乐干预与标准护理相比，在干预期间和可能在干预后都不会增加婴儿的血氧饱和度。证据表明，音乐和声音不会增加婴儿的发育（BSID）或降低父母的状态-特质焦虑。干预可能不会降低早产儿的呼吸频率。然而，音乐/声乐干预可能会降低早产儿的心率，这种有益的效果在干预后更加强烈，表明音乐/声乐干预在干预后会降低早产儿的心率。我们没有发现音乐和声音有任何不良影响的报告。由于所有其他结局的证据确定性都较低，我们无法得出关于总体疗效或不同干预类型、频率或持续时间可能产生的影响的任何进一步结论。需要更多的、更少偏倚的、更敏感和更具临床相关性的研究来进一步研究。
