Running head: MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

Berklee College of Music
Office of Graduate Studies
Music Therapy Department

We hereby approve the culminating project of
The Effects of Music Therapy on Neonates Undergoing Retinopathy of Prematurity
Screening
Susan Bakouros, MT-BC
Candidate for the degree of Master of Arts in Music Therapy

Heather Wagner, PhD, MT-BC Primary
Advisor

Brian Jantz, MA, MT-BC

Kristin Rarey, MD

Cynthia Callahan, BSN, RN

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

The Effects of Music Therapy on Pain Scores in Neonates Undergoing Retinopathy of
Prematurity Screening

Susan Bakouros, MT-BC
Berklee College of Music
and
PeaceHealth Southwest Medical Center

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MUSIC THERAPY AND RETINOPATHY OF PREMATURITY
Abstract
Premature infants who are less than 30 weeks gestational age or 1500 grams at birth require
screening for a dangerous retinal disease, retinopathy of prematurity (ROP). During and after
ROP screening exams, newborns typically experience adverse effects such as pain, increase in
apnea/bradycardia/desaturation spells, feeding intolerance, and risk of infection. This study
examined the effects of music therapy on pain scores during retinopathy of prematurity
screenings using the Neonatal Pain, Agitation, and Sedation Scale (NPASS). The music therapy
protocol was provided during the screening exam, in one eye. The infants acted as their own
control by not receiving the music therapy protocol during the exam for the other eye. These
data are meant to inform the medical community and promote the use of music therapy to
mitigate pain and stress responses during ROP exams.

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Acknowledgements
I wish to acknowledge and thank those who have supported me throughout this journey. Special
thanks to my committee members Heather Wagner, Brian Jantz, Cynthia Callahan and Kristin
Rarey, as well as contributor Alicia Bower. Additionally, I wish to recognize my loved ones and
family members who have given me the encouragement and strength to succeed.

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Table of Contents
Abstract ........................................................................................................................................... 3
Acknowledgements ......................................................................................................................... 4
The Effects of Music Therapy on Neonates Undergoing Retinopathy of Prematurity Screening.. 6
Literature Review............................................................................................................................ 7
Infants in the Neonatal Intensive Care Unit (NICU) ................................................................................ 7
Music Therapy in the NICU ..................................................................................................................... 8
Retinopathy of Prematurity (ROP) ......................................................................................................... 12

Method .......................................................................................................................................... 13
Participants/Setting ....................................................................................................................... 13
Design ..................................................................................................................................................... 14
Procedures ............................................................................................................................................... 15
Assessments ............................................................................................................................................ 16
Data Analysis .......................................................................................................................................... 16

Results ........................................................................................................................................... 17
Discussion ..................................................................................................................................... 21
Conclusion .................................................................................................................................... 23
References ..................................................................................................................................... 25
Appendix A ................................................................................................................................... 28
Appendix B ................................................................................................................................... 31
Appendix C ................................................................................................................................... 32

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The Effects of Music Therapy on Neonates Undergoing Retinopathy of Prematurity Screening
In the United States alone, several hundred thousand screening exams are performed each
year to assess high risk infants for a retinal disease called retinopathy of prematurity (ROP)
(Dunbar et al., 2009). While these exams have been adopted as the primary way to assess infants
for the risk of this disease, research shows that there is still a need to minimize pain and adverse
effects associated with these screenings. With infants becoming viable at younger ages, such as
23 weeks, the need for ROP exams has and will continue to increase.
After providing music therapy for two years with infants in the Neonatal Intensive Care
Unit (NICU), I have directly seen the benefit of music therapy in this setting. Infants in the
NICU are extremely sensitive and additional training for this population must be completed by
any music therapist providing these services. Personally, I have received additional training for
board certified music therapists from First Sounds: Rhythm, Breathe, Lullaby at Mount Sinai,
Beth Israel in New York and from Florida State University’s National Institute for Infant and
Child Medical Music Therapy. This additional training is essential to understand how to use live
music in the moment to benefit these infants.
Due to the immense fragility of this population, music therapy interventions can cause
harm if not provided correctly. It is vital for music therapists to not only learn the specific
interventions used in this setting, but also to learn regulate these interventions to match infants
and promote the desired response. My additional training has helped me to understand what an
infant needs in each moment and how to provide services safely to this fragile population. I have
personally seen the benefit music therapy interventions can have in helping infants to tolerate
painful procedures. After reading the literature concerning retinopathy of prematurity and
witnessing these exams first hand, I realized that these NICU infants are in great need of a non-

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invasive intervention to help them cope with the adverse effects associated with these exams. I
hypothesized that music therapy could be used to decrease infant’s pain during ROP screenings.
Literature Review
An increasing amount of research has shown that music therapy in the Neonatal Intensive
Care Unit (NICU) can be beneficial in addressing many issues for preterm infants. Music therapy
is defined by the American Music Therapy Association (AMTA) as “the clinical and evidencebased use of music interventions to accomplish individual goals within a therapeutic relationship
by a credentialed professional who has completed an approved music therapy program” (AMTA,
2018, para. 1). Published research has supported the use of music therapy in the NICU for
feeding support, pain management, procedural support, stabilization of vitals, neurodevelopment
enhancement, decreasing parental stress and anxiety, and enhancing bonding/attachment.
Infants in the Neonatal Intensive Care Unit (NICU)
The incidence of prematurity is consistently rising in the United States and advances in
technology and medicine have led to an increase in survival rate in premature infants (March of
Dimes, 2019, para. 2). The World Health Organization (WHO; 2018) estimates that 15 million
babies are born prematurely around the world every year, with prematurity being the leading
cause of death across the world in children under the age of five. Prematurity is defined as
infants who are born less than 37 weeks completed gestation. Preterm infants are often
considered viable outside of the womb at 23-24 weeks gestation (WHO, 2018).
An increasing number of infants born prematurely survive, yet there are risks,
complications, and stressors that may affect the child throughout his/her lifetime. Complications
of prematurity may include feeding difficulties, respiratory distress, difficulty with regulating
vital signs and nervous system function, as well as prolonged length of stay in the NICU (Kenner
& McGrath, 2010). Children who are born extremely premature show an increase in cognitive

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and neuromotor impairments as well as impairments in intellectual functioning and behavioral
disturbances (Kenner & McGrath, 2010).
Music Therapy in the NICU
The benefits of music therapy in the NICU are diverse and are not simply for the infants,
but for the caregivers and providers as well. Music therapy has been shown to be valuable in
helping infants through feeding support, enhancing bonding and attachment with caregivers and
can stabilize physiologic parameters as well as mitigate pain responses.
Feeding support. Preterm infants often have feeding intolerance and are in need of
feeding facilitation and support. The development of suck, swallow, breathe is vital for infants
to learn how to feed, but does not typically develop until 34-37 weeks corrected gestational age
(Kenner & McGrath, 2010). In order for infants to feed successfully, they must have
neuromaturation, maintainability of energy, and rhythm for suck-swallow-breathe coordination
(Kenner & McGrath, 2010). Until infants have developed neurologically they are fed through a
nasogastric tube. Music therapy can be beneficial in helping the infant to pace and organize their
suck, as well as engage the rhythmic patterns needed for suck, swallow, breathe
coordination. This can increase their overall oral intake (Loewy, 2016).
Contingent music has also shown to have benefits in feeding support with the use of
Pacifier Activated Lullaby, or PAL. Infants who were given the PAL had an increase in nonnutritive sucking, endurance, and had decreased need for feeds given through nasogastric tube.
This led to a shorter length of stay in the NICU (Standley, 2000). The PAL has also been used
with a recording of the mother’s voice. This use of the PAL with mother’s voice was shown to
have statistical significance with an increase in feeding rate and oral intake (Chorna, Slaughter,
Wang, Stark, & Maitre, 2014).

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Parents in the NICU. Music therapy has been found to be advantageous to parents in the
NICU. Engaging in music therapy can decrease parental anxiety and stress while enhancing
bonding/attachment with their infant. In some cases when the infant is very premature, parents
may not be able to touch or hold their infant for several days after birth. There are many music
therapy techniques that may help the parents bond with their infant. One specific example is
called “Song of Kin,” developed by Loewy (2016). This technique involves a special song that
parents can create for their child with the help of a music therapist. Facilitation of Song of Kin
has shown to be beneficial in giving parents a sense of control in the NICU, as well as a unique
way to bond with their baby (Loewy, 2016). Coaching parents to sing to their infants can
enhance bonding and attachment, especially when singing their own special songs.
Parents of babies in the NICU have also shown benefit from receiving music therapy in a
self-care group. With the implementation of family centered care in most NICUs, parent’s needs
are emphasized and are often treated in addition to their infant’s critical care. In Bogota,
Columbia, a music therapy self-care group was employed with the use of interventions such as
guided relaxations, breathing techniques and music therapy used for self-expression. This study
showed that these music therapy support groups were beneficial in reducing parental stress and
anxiety levels and improved parent’s mood (Roa & Ettenberger, 2018).
Physiological responses and pain. Many premature infants have difficulty regulating
their nervous systems which can present as incidences of bradycardia, apnea, or oxygen
desaturations. Music can have a positive impact on physiological processes such as heart rate,
respiratory rate, and oxygen saturation. Researchers found that live and recorded music can have
a positive effect on physiologic parameters, behavioral states, and pain in preterm infants
(Hartling et al., 2009).

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Loewy, Stewart, Dassler, Telsey, and Homel (2013) examined the use of three different
receptive music therapy interventions, including the therapist playing an ocean disc, singing
lullabies (often parent preferred) and a gato box, a small, two-toned drum that imitates the
heartbeat. Results showed that ocean disc, a sealed drum that creates wave-like sounds, had a
favorable outcome in decreasing heart rate and increasing sleep patterns (Loewy et al., 2013).
This outcome is most likely due to the therapist’s entrainment to the infant’s breath and
respiratory rate and the therapist’s use of the instrument itself. Ocean disc was found to be
beneficial in recreating the sounds of the womb in utero. This creates a familiar sound for the
infant and can emphasize homeostasis.
In utero, the infant’s environment is dark, quiet, and calm. Comparatively, many NICUs
are known to be loud, bright, and have many noxious stimuli which can adversely affect the
premature infant’s brain development. The premature infant is underdeveloped and therefore less
equipped to deal with the stressors of the NICU (Donia & Tolba, 2016). Some researchers
contend that the repeated stress on these infants can also have adverse effects on their immune
systems (Grunau, Holsti, & Peters, 2006). If music therapy can be beneficial in decreasing stress
in these infants, then it could have a positive impact on their immune systems as well.
While in the NICU, premature infants are subjected to many painful procedures which are
necessary and often life-saving measures. Infants receiving frequent painful procedures may also
develop a low pain threshold, making them hypersensitive to negative stimuli and pain (Grunau,
Holsti, & Peters, 2006). Many infants have to undergo procedures such as heel stick, IV starts,
lumbar punctures, peripherally inserted central catheter (PICC) line insertion, umbilical line
starts, arterial sticks, and intubation. These are among the more painful procedures that infants
can experience in the NICU, but other procedures such as insertion of a nasogastric tube or blood
pressure checks can be perceived as painful for the infant. Due to the central nervous system’s

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immaturity and fragility, procedures that would not often be designated as painful, can indeed be
experienced this way (Donia & Tolba, 2016).
Among the benefits of music therapy is procedural support. This is defined by Beer and
Lee (2017) as the interactive use of music by a board-certified music therapist during an invasive
or painful medical procedure; the music is designed to specifically address a patient’s needs
including reducing anxiety and pain perception, and to encourage healthy coping behaviors. In
the NICU, the music therapist is bedside and uses interventions such as vocal holding, contingent
singing, ocean disc, entrainment, and Iso principle to bring the infant to desired behavioral states
or stabilize physiologic functions. The use of entrainment during these painful procedures is
utilized to meet the patient in the moment of their pain, and work to decrease their perceived pain
to bring them to the desired behavior state (Beer & Lee, 2017). Another technique used during
painful procedures with premature infants is lullaby singing. The use of live singing of these
predictable songs has been shown to be effective in improving homeostatic processes (Ullsten,
Eriksson, Klassbo, & Volgsten, 2017).
As more music therapists have been providing procedural support, the model for this
intervention during invasive and non-invasive medical procedures has continued to develop.
Ghetti (2012) explains the use of music therapy in the moment while the music therapist
continually provides flash assessments to gauge the patient’s response and positively affect the
outcome of less perceived pain.
Studies have shown music therapy to benefit infants’ physiological parameters and
behavioral states during these painful procedures. Tramo et al. (2011) examined the incidence of
inconsolable crying and found that the infants who were exposed to recorded music decreased
this behavior. Using recorded lullabies as a positive stimulus during heel stick, these researchers
also found that the infants heart rate decreased when compared to those in the control group

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Other studies of live and recorded music show that music can increase transcutaneous oxygen
saturations in preterm infants (Chou, Wang, Chen, & Pei, 2003). Infants listening to recorded
music during endotracheal suctioning were found to have higher oxygen saturations and elevated
saturation levels above baseline for as long as 45 minutes after the lullaby was played (Chou et
al., 2003; Jabraeili, Sabet, Gharebaghi, & Hamidi, 2016). The improvement that was noted, well
after the time of the music intervention, is a unique benefit to support the use of music. Music
therapy can have a positive effect and ongoing benefits even after the session has been
completed.
Retinopathy of Prematurity (ROP)
A complication that premature infants may experience is retinopathy of prematurity (ROP),
an ocular disorder that primarily affects preterm infants who are born before 30 weeks of
gestation or at an extremely low birth weight, less than 1500 grams (Fierson, 2013). An
estimated 14,000-16,000 low birth weight and premature infants are diagnosed with ROP, and of
these approximately 1,500 require treatment for the disease (Lyon & Warren, 2006). If untreated,
ROP can cause irreversible vision loss in affected babies. A thorough retinal exam by a pediatric
ophthalmologist is required to assess ROP.
It is well documented that there are negative side effects and stressors on the infant
resulting from these retinal exams (Mitchell, Green, Jeffs, & Roberson, 2011). Infants are at risk
for pain, stress, apnea, bradycardia, tachycardia, and gastrointestinal disorders. These side effects
can occur up to 72 hours after the exam has been performed (Jiang et al., 2016). The American
Academy of Pediatrics suggests using combinations of different behavioral and pharmacologic
interventions during painful procedures (Samra & McGrath, 2009). Some methods, such as
swaddling and administration of sucrose, are commonly used to ease infant stress. While these
methods are used to decrease immediate pain in these infants, recent research has questioned

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whether sucrose used during pain procedures can be detrimental to infant brain development and
behavioral outcomes. A recent study determined that repeated use of sucrose can have
detrimental outcomes on memory function and can negatively impact brain volumes (Ranger et
al., 2019).
Retinopathy of prematurity and music therapy. Music therapy can be used to affect
physiological responses during painful procedures for infants in the NICU (Shabani, Nayeri,
Karimi, Zarei, & Chehrazi, 2016). The gate control theory suggests that music can serve as
incoming sensory information and can inhibit the amount of pain that is transmitted to the brain
(Melzack & Wall, 1965). This theory suggests that music therapy provided as procedural support
for these infants during their ROP exams would serve as an inhibitor to the pain receptors. Thus,
infants are likely to perceive less pain.
Interventions such as vocal holding, humming, and ocean disc have been used to create a
soothing and familiar environment for these infants (Loewy et al., 2013). These interventions
will be utilized to decrease pain response and stabilize vital signs during these important, and yet
painful, retinal exams.
Method
Participants/Setting
This study took place in a Level III Neonatal Intensive Care Unit in Vancouver,
Washington. The participants of this study were infants who qualified for retinal screening for
retinopathy of prematurity. Guidelines by pediatric ophthalmologists and neonatologists are set
to ensure that all babies who qualify receive screening for this disease. These guidelines require
that infants who were born at less than 30 weeks gestation, and/or under 1500 grams, undergo
screenings for ROP (Fierson, 2013). Depending on the severity of the disease, the exams are
repeated every one to three weeks until the risk from this disease has passed. Once the eye has

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completed full vascularization, or the disease is resolved with surgery, the exams are
discontinued (Lyon & Warren, 2006). A convenience sample of sixteen infants who qualified for
ROP screening were referred to the music therapist by the pediatric ophthalmologist. All parents
of infants taking part in this study gave written and verbal consent prior to the infant’s
participation (see Appendix A).
Inclusion criteria:
•

Infants born before 30 weeks gestation

•

Infants born weighing less than 1500 grams

•

Infants with clear risk factors for ROP, including long-term use of oxygen for life
sustaining treatment, or unstable course of oxygen treatment
Exclusion criteria:

•

Infants who are not qualified to undergo retinal screening based on the guidelines set by
AAP guidelines

•

Infants with congenital deformity of outer or inner ear that would interfere with hearing
capabilities

•

Infants who are too medically unstable to undergo retinopathy screenings

Design
A single-subject design using repeated measures was employed with sixteen participants.
Each infant received retinal screenings every one to three weeks, depending on severity of the
disease. Infants served as their own controls to discover the feasibility and effectiveness of this
music therapy protocol during procedural support for ROP exams. The music therapy protocol
was provided during the screening exam in one eye. The administration of the music therapy
protocol during either the first or second eye being examined was randomly selected according to
a computer program. The infant did not receive the music therapy protocol during the exam for

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the other eye, making it the control. Each infant had a ten-minute period of rest after the first eye
had received the ROP exam to allow for regulation and stabilization of vitals before the exam
began on the second eye. Other standard practices such as swaddling, use of pacifier and sucrose
were used to mitigate pain and provide comfort to the infant during the exam.
Procedures
Literature has shown the effectiveness in using ocean disc and humming to stabilize
physiologic parameters and support infants through painful procedures. These interventions were
used to create a music therapy protocol to be provided as procedural support during ROP
exams(Ullsten, Eriksson, Klassbo, & Volgsten, 2017; Loewy et al., 2013). This music therapy
protocol consisted of vocal holding/humming and playing of an ocean disc, a sealed drum with
metal balls to create an ebb and flow sound. The music therapist used the ocean disc to entrain to
the infant’s respiratory rate which provided auditory containment for the infant. The ocean disc
was played for two minutes prior to the start of the procedure and continued throughout the
exam. At the start of the exam, the music therapist hummed an unspecified melodic tune and
matched the pitch of the infant’s cry with her own voice using vocal holding. This holding of a
specified note then resolved to the dominant of the unspecified tune once the infant had entrained
to the music therapist. Using the Iso principle, the therapist matched the music to the
mood/behaviors of the infant and gradually altered the music to bring the infant to the desired
behavioral state of decreased pain. After the exam had been completed, the music therapist
ceased humming and played ocean disc for an additional two minutes.
The music therapy intervention started two minutes before the exam and continued until
two minutes post-exam period. In the unlikely situation that the infant showed signs of over
stimulation from the procedure or music therapy protocol, music therapy was discontinued
immediately and the data for this session was not used. Signs of overstimulation include, but are

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not limited to, instances of sustained bradycardia/apnea/desaturations, frequent
sneezing/yawning, halt hand, splayed fingers, tongue protrusion, or arched back. The researcher,
a board-certified music therapist pursuing her master’s degree in music therapy, was the
principal investigator. An independent/unbiased observer assessed this specific music therapy
protocol and the potential decrease of infant pain.
All infants had mydriatic, dilation drops placed in each eye twenty minutes prior to the
exam. Immediately before examination, tetracaine was used as an ophthalmic anesthetic. All of
the infants were offered sucrose two minutes prior to the exam and a pacifier if the infant showed
interest in sucking; additionally each infant was swaddled tightly. These measures are part of the
standard of care.
Assessments
An independent observer who was specifically trained using this pain assessment evaluated
infant pain using the NPASS: Neonatal Pain, Agitation, Sedation Scale (Hummel, 2017). This
researcher had been given permission by the creator to use this tool for this research study (see
Appendix B). The infant’s vitals and behavioral state were assessed for two minutes before the
music therapist entered the room to create a baseline prior to the exam. The observer continued
to evaluate the infant’s state and vitals throughout the exam and music therapy protocol to
inform their NPASS score. Pain assessments were performed immediately prior to exam, upon
insertion of eye retractor, at 30 seconds, and one minute after the start of the exam. A post-exam,
pain assessment was performed at five minutes after the exam has ceased (see Appendix C).
Data Analysis
The NPASS scores were collected by an unbiased independent observer who was
specifically trained in using this assessment to measure procedural pain. The infant was assessed
based upon five categories: crying and irritability, behavioral state, facial expression, tone and

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17

extremities, and physiologic data. The higher the infant was scored based upon these criteria, the
more pain the infant exhibited. These scores were compared to the pain scores collected during
exams in which the infant did not receive procedural support through the music therapy protocol.
All data was kept and stored in a secure, locked location and all infants received a subject
number to ensure anonymity. These data are intended to inform the medical community on
alternative therapies and the potential benefits for pain management in procedural support for
premature infants.
Results
These data collected during this study was analyzed by a statistician. Sixteen participants
and thirty-two separate eye exams were analyzed. For the primary objective to discover if music
therapy can decrease pain scores during ROP screening exams, an independent samples t-test
showed that infant pain scores during the eye exam were significantly lower when infants
received the music therapy protocol (with protocol: M = 14.44, SD = 6.66; without protocol: M =
21.75, SD = 7.34; t30 = 2.95, p < .01). Table 1 and Figure 1 depict this data.
Table 1
T test for Total NPASS scores
Levene's Test for
Equality of
Variances
F
TOTAL
NPASS

Equal variances
assumed
Equal variances
not assumed

.034

Sig.

t-test for Equality of Means
t

.854 2.950

df

Sig. (2-tailed)

30

.006

2.950 29.72
0

.006

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TOTAL NPASS SCORES
21.75

14.4375

NO MUSIC THERAPY

MUSIC THERAPY

Figure 1. Mean Total NPASS scores without the music therapy protcol and with the music
therapy protocol.
Following this, a one-way ANOVA was conducted to investigate differences in pain
scores observed with and without the music therapy protocol at successive time-points across the
eye exam. There were no significant differences in pain scores before or after the eye exam
which depict the infant’s baseline prior to the exam, and a return to this baseline after the exam
(see Table 2). However, pain scores were consistently and significantly lower when infants
received the music therapy protocol at onset of the procedure (with protocol: M = 3.00, SD =
2.72; without protocol: M = 5.31, SD = 3.34; F1,30 = 4.63, p < .05), thirty seconds into the
procedure (with protocol: M = 4.56, SD = 2.71; without protocol: M = 6.88, SD = 2.50; F1,30 =
6.30, p < .05), and one minute into the procedure (with protocol: M = 5.13, SD = 1.50; without
protocol: M = 8.06, SD = 2.18; F1,30 = 19.78, p < .01). These data are shown in Table 2 and
Figure 2.

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Table 2
ANOVA Pain Scores Across Time
Sum of
Squares
PreNPASS

Between
Groups

30secNPASS

1minNPASS

PostNPASS

Df

.125

1

.125

9.875

30

.329

Total

10.000

31

Between
Groups

42.781

1

42.781

Within Groups

277.438

30

9.248

Total

320.219

31

42.781

1

42.781

Within Groups

203.688

30

6.790

Total

246.469

31

69.031

1

69.031

Within Groups

104.688

30

3.490

Total

173.719

31

.031

1

.031

s

58.437

30

1.948

Total

58.469

31

Within Groups

OnsetNPASS

Mean
Square

Between
Groups

Between
Groups

Between
Groups

F

Sig.

.380

.542

4.626

.040

6.301

.018

19.782

.000

.016

.900

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NPASS SCORES ACROSS TIME
9
8
7
6
5
4
3
2
1
0
E1 Pre NPASS

E1 Onset NPASS E1 30sec NPASS
Avg NO MT

E1 1min NPASS

E1 Post NPASS

Avg YES MT

Figure 2. Average NPASS scores at each interval throughout the exam without the music
therapy protocol and with the music therapy protocol
A secondary outcome was analyzed to assess if music therapy had lasting effects when
music therapy was received during the exam on the first eye, but not the second. The principle
investigator hypothesized that the effects of the music therapy protocol would continue even
after the music therapy had been discontinued. ANOVA analysis of these NPASS scores
between groups showed a trend such that infants who received the protocol on their first eye
were observed to have lower pain scores during the second eye exam without receiving the
music therapy protocol (M = 18.38, SD = 6.35) as compared to the observed pain scores of the
first, non-music therapy trial for the infants who did not receive the protocol until their second
eye exam (M = 25.13, SD = 7.02; t30 = 2.95, p < .01). The following results were yielded in Table
3.

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Table 3
ANOVA NPASS scores spillover effect of music therapy
Sum of
Squares
PreNPASS

OnsetNPASS

Between
Groups

1minNPASS

PostNPASS

Mean Square

.563

1

.563

Within Groups

3.875

14

.277

Total

4.438

15

Between
Groups

16.000

1

16.000

Within Groups

94.000

14

6.714

110.000

15

3.063

1

3.063

Within Groups

106.875

14

7.634

Total

109.938

15

Between
Groups

12.250

1

12.250

Within Groups

21.500

14

1.536

Total

33.750

15

.000

1

.000

Within Groups

45.000

14

3.214

Total

45.000

15

Total
30secNPASS

df

Between
Groups

Between
Groups

F

Sig.

2.032

.176

2.383

.145

.401

.537

7.977

.014

.000

1.000

Discussion
This is the first prospective study to explore whether music therapy used as procedural
support can have an effect on pain scores in neonates undergoing retinopathy of prematurity
screening. Results showed that music therapy used as procedural support was statistically
significant in decreasing overall pain scores, and pain scores throughout the exam. This study
also found a trend toward the decrease in pain scores in which infants received the music therapy

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22

protocol during the examination of the first eye but not the second eye. This suggests that the
effects of the music therapy protocol can continue to last even after music therapy has been
discontinued. This could hold implications for further research to discover how long the effects
of music therapy can last after being discontinued when used as procedural support.
The strengths of this study included the involvement of a single music therapist providing
the music therapy protocol and a single pediatric ophthalmologist performing exams. All exams
were performed using binocular indirect ophthalmoscopy (BIO). The same independent observer
was employed for 12 of the exams while a single but different observer was used for the other
four exams. Both of these observers were specifically trained in using NPASS and were unbiased
in their assessments.
The limitations of this study were most notably the reduced sample size of 16 eye exams
and 32 separate eyes total; music therapy and non-music therapy. While the sample size for this
study was small, the data analysis showed statistical significance, which point toward evidentiary
support for this music therapy protocol. The observers collecting pain scores were unbiased but
the music therapist and pediatric ophthalmologist were not blind during this study as they
administered the eye exam and music therapy protocol.
Many variables were accounted for at the beginning of this study, and many variables
surfaced that were unforeseen. For three of the screening exams, the time of the exam fell
directly before a feeding which could contribute to an increased pain score due to the infants
being more irritable and showing hunger cues. The data for one exam was discarded from the
study as the nurse fed the baby a bottle in the transition period between the examination of each
eye. The infant was showing vigorous hunger cues and the nurse was unaware of the effects that
feeding the infant could have on study data. Other variables of note included whether the infant
was on continuous positive airway pressure (CPAP) at the time of the examination. CPAP

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

23

prongs are inserted into the nose can be more irritating to an infant than the CPAP mask which
covers the nose. Infants on CPAP prongs could have showed higher pain scores due to the fact
that they were more irritable from the beginning of the exam.
During the music therapy protocol and examination, infants showed signs of discomfort
but not overstimulation. None of the exams needed to be discontinued due to signs of shut down
or overstimulation which point toward the infants being able to tolerate the procedure due to the
music therapy protocol. As this is the first prospective study to examine the effects of music
therapy on pain scores in neonates undergoing retinopathy of prematurity screening exams, more
research should be implemented to validate and replicate the findings of this study. Future
studies should include a larger sample size and a possible randomized controlled trial could be
implemented to further discover the effects of music therapy as procedural support with this
population.
Conclusion
Research has indicated that preterm infants need more non-pharmacologic methods to
decrease pain associated with ROP exams. Currently, music therapy is an underused modality in
the NICU and could has shown promising results with little, to no side effects. Music therapy
interventions, provided by a board-certified music therapist, specially trained in the use of music
therapy in the NICU, could have significant implications for this fragile population. With
advances in medicine and viability of infants at younger gestational ages, the number of ROP
exams is increasing to ensure that infants do not develop this retinal disease. It is vital that these
high risk infants receive non-invasive, non-pharmacologic interventions, like music therapy, to
decrease adverse effects that are associated with these exams.
The findings of this study advocate that music therapy during retinopathy of prematurity
exams is safe and may be associated with a decrease in pain scores in infants undergoing this

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

24

procedure. This is consistent with other findings in the literature showing that music therapy can
have positive outcomes on pain and can improve physiologic stability in preterm infants. Due to
the fact that this was a feasibility study, there were limitations to this study including the small
sample size. The findings from this study need to be replicated in a larger prospective study or
randomized controlled trial in order to verify these results. This study suggests that music
therapy could be the non-pharmacologic, non-invasive treatment that these infants need to
decrease the adverse effects associated with these exams. The results of this study show the
promising nature of using music therapy as procedural support to decrease pain for these fragile
infants.

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

25

References
American Music Therapy Association (AMTA). (2018). Retrieved from www.musictherapy.org
Beer, L, E., & Lee, K, V. (2017). Music therapy procedural support: Opportunities for practice.
Music and Medicine: An International Journal, 9(4), 262-268.
Chorna, O, D., Slaughter, J, C., Wang, L., Stark, A, R., & Maitre, N, L. (2014). A pacifieractivated music player with mother’s voice improves oral feeding in preterm infants.
Pediatrics, 133(3), 462-467.
Chou, L., Wang, R., Chen, S., & Pai, L. (2003). Effects of music therapy on oxygen saturation in
premature infants receiving endotracheal suctioning. Journal of Nursing, 11(3), 209-216.
Donia, E, A., & Tolba, O, A. (2016). Effect of early procedural pain experience on subsequent
pain responses among premature infants. Egyptian Pediatric Association Gazette, 64(2),
74-80.
Dunbar, J, A., Hsu, V., Christensen, M., Black, B., Williams, P., & Beauchamp, G. (2009).
Cost-utility analysis of screening and laser treatment of retinopathy of prematurity.
Journal of American Academy of Pediatric Ophthalmology and Strabismus, 13(2), 18690.
Fierson, M, W. (2013). Screening examination of premature infants for retinopathy of
prematurity. Pediatrics, 131(1), 189-195.
Ghetti, C, M. (2018). Music therapy as procedural support for invasive medical procedures:
Toward the development of music therapy theory. Nordic Journal for Music Therapy,
21(1), 3-35.
Grunau, R., Holsti, L., & Peters, J. (2006). Long-term consequences of pain in human neonates.
Seminar Fetal Neonatal Medicine, 11(4), 268-275.

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

26

Hartling, L., Shaik, M, S., Tjosvold, L., Leicht, R., Liang, Y., & Kumar, M. (2009). Music for
medical indications in the neonatal period: A systematic review of randomized controlled
trials. Archives of Disease in Childhood Fetal Neonatal Edition, 94(5), 349-354.
Hummel, P. (2017). Psychometric evaluation of neonatal pain, agitation, and sedation (NPASS)
scale in infants and children up to age 36 months. Pediatric Nursing, 43(4), 175-184.
Jabraeili, M., Sabet, T., Gharebaghi, M., & Hamidi, M. (2016). The effect of recorded
mum’s lullaby and Brahms Lullaby on oxygen saturation in preterm infants: A
randomized double-blind clinical trial. Journal of Caring Science, 5(1), 85-93.
Jiang, J., Zhang, Z., Zhang, J., Wang, Y., Nie, C., & Luo, X. (2016). Systemic changes and
adverse effects induced by retinopathy of prematurity screening. International Journal of
Ophthalmology, 9(8), 1148-1155.
Kenner, C., & McGrath, M., J. (2010). Developmental care of newborns and infants: A guide for
health professionals. Glenview, IL:. National Association of Neonatal Nurses.
Loewy, J., Stewart, K., Dassler, A., Telsey, A., & Homel, P. (2013). The effects of music therapy
on vital signs, feeding, and sleep in premature infants. Pediatrics, 131(5), 902-919.
Loewy, J. (2016). First sounds: Rhythm, breath, lullaby trainer compendium. New York:
NY: Satchnote Armstrong Press.
Lyon, D., & Warren, F. (2006). A clinical guide to retinopathy of prematurity. Review of
Optometry, 143(12), 53-66.
March of Dimes. (2019). Fighting premature birth: the prematurity campaign. Retrieved from
www.marchofdimes.org/mission/prematurity-campaign.aspx
Melzack, R., & Wall, P, D. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.
Mitchell, A., Green, A., Jeffs, D., & Roberson, P. (2011). Physiologic effects of retinopathy of
prematurity eye screening examinations. Advances in Neonatal Care, 11(4), 291-297.

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

27

Ranger, M., Tremblay, S., Chau, C, M, Y., Holsti, L., Grunau, R, E., & Goldowitz, D. (2019).
Adverse behavioral changes in adult mice following neonatal repeated exposure to pain
and sucrose. Frontiers in Psychology, 9, 1-14.
Roa, E., & Ettenberger, M. (2018). Music therapy self-care group for parents of preterm infants
in the neonatal intensive care unit: A clinical pilot intervention. Medicines, 5(4), 134-144.
Samra, H., & McGrath, J. (2009). Pain management during retinopathy of prematurity eye
examinations: A systematic review. Advances in Neonatal Care, 9(3), 99-110.
Shabani, F., Nayeri, N., Karimi, R., Zarei, K., & Chehrazi, M. (2016). Effects of music therapy
on pain responses induced by blood sampling in premature infants: A randomized crossover trial. Iranian Journal of Nursing and Midwifery Research, 21(4), 391-396.
Standley, J. (2000). The effect of contingent music to increase non-nutritive sucking of
premature infants. Pediatric Nursing, 26(5), 493-499.
Standley, J., Lawton, R, O., Cassidy, J., Grant, R., Cevasco, A., Szuch, C., Nguyen, J.,
Walworth, D., Procelli, D., Jarret, J., & Adams, K. (2010). The effect of music
reinforcement for non-nutritive sucking on nipple feeding of premature infants. Pediatric
Nursing, 36(3), 138-145.
Tramo, M, J., Lense, M., Ness, V, C., Kagan, J., Settle, D, M., & Cronin, H, J. (2011). Effects of
music on physiological and behavioral indices of acute pain and stress in premature
infants: Clinical trial and literature review. Music and Medicine, 3(2), 72-83.
Ullsten, A., Eriksson, M., Klassbo, M., & Volgsten, U. (2017). Live music therapy with lullaby
singing as affective support during painful procedures: A case study with microanalysis.
Nordic Journal of Music Therapy, 26(2), 142-166.
World Health Organization (WHO). (2018). Preterm birth. Retrieved from
http://www.who.int/news-room/fact-sheets/detail/preterm-birth

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Appendix A

CONSENT TO PARTICIPATE IN RESEARCH
The Effect of Music Therapy on Pain Scores in Neonates undergoing Retinopathy
of Prematurity Screening
Susan Bakouros, MT-BC from the Neonatal Intensive Care Unit at PeaceHealth
Southwest Washington, will be conducting a research study.
You were selected as a possible participant in this study because your infant will be
receiving eye exam screenings for retinopathy of prematurity. Your participation in this
research study is voluntary.
Why is this study being done?
This study is being done to determine if music therapy can benefit babies who receive
retinal screening exams for retinopathy of prematurity.
What will happen if I allow my child to take part in this research study?
If you allow your child to participate in this study, the researcher will:
•
•

Ask you to allow the researchers specific access to your baby’s medical information,
including gestational age, medical diagnosis and medications.
Provide a music therapy protocol during your child’s eye exam to mitigate pain
responses during the exam. The music therapist will use a combination of ocean
disc and vocal holding techniques to match your baby’s behaviors and vital signs to
help bring the infant to the desired state of decreased pain.

How long will I be in the research study?
Participation will include any and all eye exams that your child is required to receive.
Are there any potential risks or discomforts that I can expect from this study?
•

The music therapist will be using well-defined music therapy interventions, provided
by a board-certified NICU music therapist; these interventions have been wellstudied in earlier research and have shown no significant risks to infants. In the
unlikely event that your infant shows signs of overstimulation, the music therapy
protocol will be discontinued immediately.

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

29

Are there any potential benefits if I participate?
•

•

Your baby may benefit from the music therapy interventions by experiencing
reduced symptoms of pain during and after their screening exam for retinopathy of
prematurity.
The results of the research may impact other infants undergoing screenings for
retinopathy of prematurity in the future.

What other choices do I have if I choose not to participate?
•

•

You do not have to allow your infant to participate in the study. Your infant may still
be eligible to receive standard music therapy services outside the study parameters,
if you choose to accept those services.
If you choose not to allow your infant to participate in the study, he or she will still
receive all appropriate NICU care, and no needed services or therapies will be
withheld.

Will information about me and my participation be kept confidential?
•

Yes. While we will use information about your child collected during the study, all of
that information will be treated in a way that protects your child’s anonymity. In other
words, the data used in the study will not include your child’s name or any identifying
information. Careful safeguards will be in place to make sure that your child’s (and
your family’s) identity remains confidential. Those safeguards include:
• Limits on the number of researchers with access to your child’s and family’s
identifying information
• Computer software and physical safeguards, including passcodes and other
security measures

What are my rights if I take part in this study?
You can choose whether you want to be in this study, and you may withdraw your
consent and discontinue participation at any time.
• Whatever decision you make, there will be no penalty to you, and no loss of benefits
to which you were otherwise entitled.
• You may refuse to answer any questions that you do not want to answer and remain
in the study.
Who can I contact if I have questions about this study?
•

• The research team:
If you have any questions, comments or concerns about the research, you can talk to the
one of the researchers. Please contact:

1. Susan Bakouros, MT-BC at (503) 956-7754; susan.bakouros@gmail.com
2. Heather Wagner, PhD, MT-BC at (860) 550-4884; hwagner@berklee.edu

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

30

PeaceHealth System Institutional Review Board:
If you have questions about your rights while taking part in this study, or you have concerns
or suggestions and you want to talk to someone other than the researchers about the
study, please call the IRB at (541) 686-6949 or email to: IRB@peacehealth.org.
•

You will be given a copy of this information to keep for your records.
SIGNATURE OF STUDY PARTICIPANT

Name of Participant
Signature of Participant

Date

SIGNATURE OF PERSON OBTAINING CONSENT

Name of Person Obtaining Consent
Signature of Person Obtaining Consent

Contact Number
Date

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY

31

Appendix B
9/28/2018

Berklee College of Music Mail - NPASS Permission

Susan Bakouros

NPASS Permission
2 messages
Susan Bakouros
To: phummel@lumc.edu
Cc: Heather Wagner

Wed, Aug 22, 2018 at 10:50 AM

Dear Pat,
I am a graduate student at Berklee College of Music pursuing my master's degree in music therapy. I am a NICU music
therapist at PeaceHealth Southwest Medical Center and would like to ask your permission to use your NPASS scoring
system for my thesis project. I will be collecting data on pain scoring during retinal exams for retinopathy of prematurity to
ascertain if there is a difference between pain scores when using music therapy. I will be sure to properly cite and
reference the scoring system. Please let me know if you have any questions.
I appreciate your help.
Thank you,
Susan Bakouros, MT­BC
PATRICIA A. HUMMEL
To: Susan Bakouros
Cc: Heather Wagner

Fri, Aug 24, 2018 at 8:00 AM

That sounds like an amazing project/study!
You do have permission to use the N­PASS tool
I'm attaching the tool for you to use as you want.
Let me know if you need more than this email.
Regards,

Pat Hummel, Ph.D., NNP­BC, PPCNP­BC
Loyola University Medical Center
2160 S 1st Ave
Maywood, IL 60153
708­327­9055
fax 708­216­9434

From: Susan Bakouros
Sent: Wednesday, August 22, 2018 12:50:09 PM
To: PATRICIA A. HUMMEL
Cc: Heather Wagner
Subject: [External] NPASS Permission
Warning: This email originated from the Internet!
DO NOT CLICK links if the sender is unknown, and NEVER provide your password.
[Quoted text hidden]

Confidentiality Notice:
This e­mail, including any attachments is the property of Trinity Health and is intended for the sole use of the intended
recipient(s). It may contain information that is privileged and confidential. Any unauthorized review, use, disclosure, or
https://mail.google.com/mail/u/1?ik=f510e86aed&view=pt&search=all&permthid=thread-a%3Ammiai-r-3738575842126214932&simpl=msg-a%3As%3A-8864336…

1/2

MUSIC THERAPY AND RETINOPATHY OF PREMATURITY
Appendix C
ROP NPASS Scoring Criteria Data Sheet
Date of Exam:________

Eye: FIRST/SECOND

Participant:___________________

GA:______

Pre NPASS Scoring: (5 minutes before exam)
Crying/Irritability:
Extremities/Tone
-2 -1 0 +1 +2
-2 -1 0 +1 +2
Facial Expression:
Vital Signs:
-2 -1 0 +1 +2
-2 -1 0 +1 +2

Music Therapy: YES/NO
CGA______
Behavior State:
-2 -1 0 +1 +2

Onset NPASS Scoring:
Crying/Irritability:
-2 -1 0 +1 +2
Facial Expression:
-2 -1 0 +1 +2

Extremities/Tone
-2 -1 0 +1 +2
Vital Signs:
-2 -1 0 +1 +2

Behavior State:
-2 -1 0 +1 +2

30 Sec. NPASS Scoring:
Crying/Irritability:
-2 -1 0 +1 +2
Facial Expression:
-2 -1 0 +1 +2

Extremities/Tone
-2 -1 0 +1 +2
Vital Signs:
-2 -1 0 +1 +2

Behavior State:
-2 -1 0 +1 +2

1 min. NPASS Scoring:
Crying/Irritability:
-2 -1 0 +1 +2
Facial Expression:
-2 -1 0 +1 +2

Extremities/Tone
-2 -1 0 +1 +2
Vital Signs:
-2 -1 0 +1 +2

Behavior State:
-2 -1 0 +1 +2

2 min. NPASS Scoring:
Crying/Irritability:
-2 -1 0 +1 +2
Facial Expression:
-2 -1 0 +1 +2

Extremities/Tone
-2 -1 0 +1 +2
Vital Signs:
-2 -1 0 +1 +2

Behavior State:
-2 -1 0 +1 +2

Post NPASS Scoring: (5 minutes post exam)
Crying/Irritability:
Extremities/Tone
-2 -1 0 +1 +2
-2 -1 0 +1 +2
Facial Expression:
Vital Signs:
-2 -1 0 +1 +2
-2 -1 0 +1 +2

Behavior State:
-2 -1 0 +1 +2

32