Music is often used as a nonpharmacological pain management strategy, but little evidence is available about its role in pediatric critical care patients.
To determine the effect of a live music intervention versus a recorded music intervention on heart rate, blood pressure, and respiratory rate in pediatric critical care patients receiving mechanical ventilation and sedation.
An exploratory randomized controlled trial was performed in a pediatric intensive care unit. Participants were randomly allocated to receive a live music intervention with standard care or a recorded music intervention with standard care. Each intervention was delivered by a board-certified music therapist for 15 minutes. Heart rate, respiratory rate, and blood pressure were measured at baseline and at 15-minute intervals for 60 minutes after the intervention.
A total of 33 patients aged 0 to 2 years completed the study: 17 were assigned to the live music group and 16 to the recorded music group. In the live music group, a significant reduction in heart rate was observed immediately after the intervention and was sustained at 60 minutes after the intervention. Although the live music group also exhibited a downward trend in blood pressure, those differences were not significant.
The results of this study indicate that live music interventions may be more effective than recorded music interventions in reducing pain and anxiety in pediatric critical care patients. The advantage of live music may be due to the adaptability of the music delivery by a trained music therapist.
Respiratory failure resulting from severe viral infection is a leading cause of mechanical ventilation among patients in pediatric intensive care units (ICUs).1,2 Although it can be lifesaving, mechanical ventilation in the ICU can cause stress, anxiety, and pain. Music has been used in medical settings as a nonpharmacologic approach to reducing stress, pain, and anxiety.3–5
In adult patients receiving mechanical ventilation and sedation, listening to recorded music can reduce physiological parameters associated with anxiety,6 including heart rate, respiratory rate,7,8 and systolic and diastolic blood pressure.8,9 These benefits have been demonstrated during the music intervention7,8 and for up to 90 minutes after the intervention,10 suggesting the potential for a relaxation effect of listening to recorded music in adult patients. Listening to recorded music also can reduce the amount of sedative medication needed,11 decrease cortisol levels,12 and improve delirium states among patients receiving mechanical ventilation.13 Therefore, listening to music may be useful as a nonpharmacologic pain management strategy, reducing the amount of sedative medication needed and associated side effects.
The use of live music allows for individualized intervention in accordance with the patient’s physiological parameters.
Although the benefits of music have been documented in adult populations, few studies have focused on music interventions for critically ill pediatric patients.14,15 Research on children receiving mechanical ventilation has indicated a potential positive impact of listening to recorded music, with 30 minutes of classical music resulting in decreased heart rate and respiratory rate in 84 children aged 1 to 16 years compared with a control group that received no intervention.16 These findings were contradicted by Stouffer and Shirk,17 who found no significant impact of recorded patient-preferred music on heart rate or respiratory rate in 34 children (aged 3 months to 8 years); however, children in the music group had significantly lower systolic blood pressure. These mixed results indicate that although music may be beneficial for children receiving mechanical ventilation, additional research on the topic is needed.
The use of live music as an intervention for patients receiving mechanical ventilation has not been as well studied as the use of recorded music but may hold promise for pediatric patients. The use of live music allows for individualized intervention, in which the music therapist can modify and adapt the music in accordance with the patient’s physiological parameters, such as heart and respiratory rates.18,19 This process may entrain the child’s vital signs (ie, synchronize a physiological rhythm with an external stimulus), helping to reduce signs of anxiety or stress. In pediatric research, live music has been found to reduce postoperative pain and facilitate self-regulation.20,21 Although some research has indicated that live music may be beneficial for children and infants,22 the use of live music for children receiving mechanical ventilation requires further investigation.
The purpose of this exploratory study was to evaluate the effect of a live music intervention with standard care on physiological signs of anxiety in pediatric patients receiving life support, compared with a recorded music intervention with standard care. Heart rate, respiratory rate, and mean arterial pressure (MAP) were selected for evaluation as physiological signs of anxiety to parallel previous research in adult populations7–9 and provide objective measures of physiological changes. In this study, recorded music consisted of music played on a CD player or another portable music device; live music consisted of a live music intervention provided by a board-certified music therapist trained to adapt the music to the patient’s needs within a therapeutic relationship. The study aim was to gather initial data on the effect of a live music intervention versus a recorded music intervention on heart rate, blood pressure, and respiratory rate in children receiving mechanical ventilation and sedation.
This study used a quantitative research design with participants randomly assigned to an experimental or a control condition. The study protocol and informed consent form were reviewed and approved by the institutional review boards at Children’s Healthcare of Atlanta and Colorado State University. The study was registered in the ClinicalTrials.gov database (NCT03629145). All participants had written informed consent provided by a caregiver.
A total of 34 patients were enrolled in the study, 33 of whom completed the study. One participant did not receive the allocated intervention because the person no longer met inclusion criteria. This number of participants was deemed appropriate by the hospital review board and is above the minimum suggested in the literature for exploratory research.23 Patients were included in the study if they were 0 to 2 years of age, were currently receiving invasive conventional mechanical ventilation as a result of a respiratory illness, were receiving continuous infusions of sedative medications, and had a caregiver present to provide consent. Some participants had an additional comorbid diagnosis such as asthma, prematurity, and/or a genetic abnormality. Patients were excluded from the study if they were receiving high-frequency oscillatory ventilation or neuromuscular blockade, had a prior diagnosis of profound hearing impairment, had undergone a tracheostomy, were suspected of having experienced child abuse or neglect, were in custody of the state with no identified caregivers, had caregivers who were not authorized to provide consent for medical procedures, or were admitted to the hospital because of a traumatic brain injury.
As part of the recruitment process, 2 board-certified music therapists attended interdisciplinary rounds on the pediatric ICU at a free-standing children’s hospital in the southeastern United States to help identify potential participants. The primary investigator (H.I.B.) then reviewed the potential participant’s electronic medical record to further assess eligibility for inclusion in the study. The primary investigator then requested approval from the patient’s attending intensivist and primary nurse before seeking consent from the patient’s caregiver. Once consent was obtained from all patients’ caregivers, the research team determined the timeline for the study, and each patient’s primary nurse arranged for the patient’s vital sign measurements needed for the study to be automatically recorded in the patient’s electronic medical record. Participants were then randomly assigned to the live or recorded music group using a block randomization procedure created by the study’s statistician. Each participant had a single session of the allocated intervention lasting 15 minutes.
Heart rate, respiratory rate, and MAP were measured at 7 time points and recorded in the patient’s electronic medical record. Mean arterial pressure was obtained through readings from an arterial catheter or a blood pressure cuff, depending on the patient’s standard monitoring method. To ensure that a patient’s vital signs were stable before beginning the intervention, they were measured 15 minutes before and again immediately before beginning the intervention. Patients’ physiological data were measured at 7 time points: 15 minutes before the intervention, immediately before the intervention, immediately after the intervention, and 15, 30, 45, and 60 minutes after the intervention.
Patients were 0-2 years of age, receiving invasive conventional mechanical ventilation and continuous infusions of sedative medications.
Music Therapy Intervention
Live Music With Standard Care
The live music intervention with standard care was performed by 1 of 2 board-certified music therapists using guitar and voice. The music therapist began with a guitar medley, softly picking guitar strings through a simple chord progression in a major key. This soft and stylized introduction to the guitar allowed the music therapist to introduce 1 auditory stimulus at a time to the patient, as recommended in previous research with critical care populations.24 The music therapist then added voice and sang popular Western lullabies while continuing to play the guitar as accompaniment with simple rhythmic patterns, as suggested in previous research.24 These lullabies were chosen because they incorporate major keys, simple harmonic progressions, and repetitive melodies, as recommended in previous literature with critical care populations.21,24–26 During the process of obtaining informed consent, the lullabies included in the study were discussed with caregivers to ensure that they would be preferred by the patient. The music therapists adapted the music to the current needs of the patient and family throughout the intervention. For example, the music therapist would reduce or increase the tempo of the music to match the vital signs of the patient, reduce their own singing volume if the caregiver joined in singing, and/or alter the timbre of the music in response to any facial or bodily responses of the patient. Standard care was not interrupted, but no additional interventions were delivered during the time frame of data collection.
Recorded Music With Standard Care
The recorded music intervention with standard care involved a recording of a board-certified music therapist playing the same simple guitar medley used in the live music intervention group, followed by the music therapist playing guitar and singing the same 10 Western lullabies used for the live music intervention. The recording was created in a professional music studio to achieve consistency and similarity between the live and recorded music interventions, which would help determine whether the ability to adapt the music in the moment to patient reactions could account for any differences in the results. The recording was played at the bedside on a portable speaker. Although in previous studies headphones were used to deliver a recorded music intervention, we chose playing music from a speaker to allow caregiver participation. In addition, because the patients in this study were sedated as well as nonverbal owing to their age, they would have been unable to communicate their comfort level with respect to music volume through headphones. The portable speaker allowed the music therapist and caregiver to control music volume to avoid hearing damage.
Data Analysis Procedures
The data were analyzed using a 2-way repeated-measures analysis of variance in which the music condition was the independent variable and the patient’s vital signs were the dependent variable. The data collection 15 minutes before the intervention was intended to ensure that the patient’s vital signs were stable before the intervention began, so that any changes after the intervention could be interpreted as most likely due to the intervention. A t test showed that there were no significant differences between groups at 15 minutes before and immediately before the intervention. The model was fit using an unstructured covariance matrix, and the degrees of freedom were estimated using the Kenward-Roger degrees of freedom approximation. Values were considered significant at P less than .05. Effect sizes were calculated using Cohen’s d.
Thirty-three patients completed the study between January 2018 and February 2019 (Figure 1). Seventeen participants received the live music intervention with standard care, and 16 received the recorded music intervention with standard care. Patient characteristics are summarized in Table 1. The patients were between the ages of 15 days and 2 years, with a mean age of 5.47 months (median age 3.7 months for intervention group and and 1.6 months for control group). Eighteen patients had comorbidities, including prematurity (n = 11), genetic abnormalities (n = 3), neurologic conditions (n = 3), and asthma (n = 1). The participants had a variety of racial/ethnic backgrounds, including White (58%), African American (24%), Asian (9%), and multiracial (9%). For all patients, English was the primary language spoken at home.
Patients had been intubated for an average of 3.27 days when the intervention was provided, with 27% of patients receiving the intervention within the first 24 to 47 hours of initiation of invasive mechanical ventilation and 21% receiving the intervention within 48 to 71 hours. Although respiratory syncytial virus was the most common upper respiratory infection requiring mechanical ventilation (57.5%), 39% of participants had multiple upper respiratory infections, including combinations of coronavirus, adenovirus, influenza, parainfluenza, human metapneumovirus, rhinovirus, enterovirus, and pneumonia. Forty-eight percent of the patients were sedated with a combination of fentanyl and dexmedetomidine, per the unit’s standard sedation protocol. The remaining participants were sedated with different combinations of morphine, ketamine, lorazepam, and midazolam.
A 2-way repeated-measures analysis of variance was conducted to compare the main and interaction effects of live and recorded music on heart rate, respiratory rate, and MAP. No main effects of intervention group were found for heart rate, MAP, or respiratory rate. A main effect of time was found for heart rate (F5,29 = 9.38, P < .001), with a significant decrease from mean (SD) values before (144.1 [20.6] beats per minute) to after (129.1 [22.0] beats per minute) the intervention (Table 2).
No significant interaction effects were found for MAP or respiratory rate. The interaction effect for heart rate was significant (F5,29 = 9.39, P < .001). Post hoc analysis for the live music intervention group indicated significant changes from baseline (Table 3), with means and SDs shown in Figure 2. A decrease in heart rate was significant at P < .001 for the measurements immediately after the intervention (d = 0.597) and at 15 (d = 0.510), 45 (d = 0.732), and 60 (d = 0.470) minutes after the intervention (Figure 3). The measurement at 30 minutes after the intervention was also below the baseline measurement, but the difference was not statistically significant. Of the 17 patients who received the live music intervention, the heart rate in 14 patients did not return to the baseline measurement during the 60 minutes during which the patients’ vital signs were tracked. No significant changes in heart rate were observed in the recorded music intervention group.
This exploratory study was conducted to determine the effects of a live music intervention with standard care on heart rate, blood pressure, and respiratory rate in pediatric patients receiving mechanical ventilation and sedation. The results indicate that the live music intervention was associated with a significant decrease in heart rate in children receiving mechanical ventilation and sedation because of an upper respiratory infection. Although the results were significant only for heart rate, decreases were found for all measured vital signs after the live music intervention, possibly indicating reduced anxiety and/or pain.6 Moreover, in most patients in the live music intervention group, heart rate remained below the baseline value for 60 minutes after the intervention, possibly indicating a relaxation effect extending longer than the actual intervention. These results are promising and suggest that further research on the effects of live music on critically ill children receiving mechanical ventilation and sedation is warranted.
In contrast to the findings for the live music intervention, the recorded music intervention group showed no significant changes in vital signs after the intervention. These results are inconsistent with those of previous studies that indicated benefits of the use of recorded music with adult7–11 and pediatric16,17 patients receiving mechanical ventilation and sedation. Our study showed increases in both heart rate and MAP in the recorded music intervention group, but additional studies with larger sample sizes are needed to explore further the effect of recorded music on vital signs in the critical care pediatric population.
In our study, live music was more effective than recorded music in altering vital signs in pediatric patients receiving mechanical ventilation and sedation. The significant decrease in heart rate and non-significant decreases in both respiratory rate and MAP indicate that patients may benefit from live music interventions provided by a music therapist. However, these results must be interpreted with caution given the limited number of indicators of stress or anxiety used in this study. Mean respiratory rate decreased in both the live and recorded music groups immediately after the intervention, but in both groups it had nearly returned to the baseline measure 15 minutes after completion of the intervention. A decrease in MAP was also found for the live music group immediately after the intervention; however, it had returned to the baseline level by 15 minutes after the intervention. Again, research involving larger sample sizes is needed to better understand the impact of both recorded and live music on MAP and respiratory rate in pediatric patients receiving mechanical ventilation and sedation.
This study has some limitations. Although the patients were randomly assigned to the intervention groups, the study was conducted in a single critical care unit, and the results may not be generalizable to other critical care environments. Standard nursing care was not altered during the delivery of the intervention, nor was it tracked after the cessation of the intervention. During the 60 minutes in which vital signs were being measured after the intervention, routine nursing procedures necessary in critical care environments were not accounted for. These procedures, such as suctioning, can increase heart rate, respiratory rate, and blood pressure. Correlating changes in vital signs to specific interventions or procedures would have been helpful in determining the duration of the intervention. Furthermore, although music was patient-preferred according to the caregivers, the songs were previously chosen, which did not allow for any specific requests such as a patient’s favorite song. Future studies might allow for customization of music to best meet the preferences of patients.
In summary, the results of this study suggest that live music interventions may be helpful in combating pain and anxiety among pediatric patients receiving mechanical ventilation and sedation in an ICU. Our data showed a significant decrease in heart rate in the live music intervention group compared with the baseline measurement, which was sustained for 60 minutes after completion of the intervention. Nevertheless, additional research is needed on the potential benefits of live music in this population. A better understanding of the possible effects of this music therapy intervention may lead to valuable insights regarding optimal timing and frequency of the intervention.
The authors thank the patients and their families for their participation in the study, as well as the treatment team members who provide exceptional care for these patients every day.
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