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Acta Pdiatrica ISSN 0803-5253



Maternal singing for preterm infants during kangaroo care comforts both
the mother and baby
Preterm birth is a major health problem worldwide. Major
advances have been made in neonatal intensive care over
the last few decades, resulting in increased survival rates of
preterm infants and a reduction in major neuromotor
impairments. However, there is now a greater awareness
of the high risk of adverse brain development among
children who are born very immature, together with the
subsequent cognitive and behavioural problems. In particular, children who are born extremely preterm have
language delay and abnormal auditory event related potentials (1). One of the factors that may contribute to the risk of
adverse brain development in preterm infants is maternal
separation while they are in the neonatal intensive care
The contact between the mother and her offspring is
essential for all mammals. Research in rodents has shown
that early maternal contact, which takes the form of sensory
stimulation through licking behaviour, has an impact on the
infants brain systems, enabling them to manage stress and
enhance their social adaptation mechanisms include fine
tuning of the hypothalamuspituitaryadrenal axis and
epigenetic modifications (2). On the other hand, prolonged
physical separation between mothers and infants exerts
lifelong negative effects on the offspring and is also known
to cause maternal stress, anxiety and depression (3).
Kangaroo care was developed in Bogota, Columbia, to
enable preterm infants to maintain body temperature
through skin-to-skin contact with the parents body (4)
and in the last few decades, it has been introduced to many
neonatal units worldwide. The technique has been associated with better autonomic functioning, sleep, reduced pain
response, improved motherinfant interaction and maternal
mood in early infancy, as reviewed by Flacking et al. (5).
Studies on the long-lasting effects on children0 s brain
development are scarce, but a recent report indicated that
10-year-old children who were born preterm and received
kangaroo care during the neonatal period showed attenuated stress responses and better sleep and executive function (6).
The mothers voice provides another important source of
sensory stimulation for the foetus and child. For example,
quail chicks that were not allowed to hear their mothers
call during late prenatal development, because of other
noise, did not recognise their mothers voice when they
hatched. Similarly, the preterm infant who is cared for in a
neonatal intensive care unit, and is often exposed to
elevated sound levels, loses significant contact with his or
her mothers voice. It has been suggested that disrupting

exposure to the maternal voice in preterm infants adversely

affects a babys brain development. For example, neonates
born preterm were less able to discriminate between a
strangers voice and their own mothers voice (7), and it was
suggested that subsequent language development may be
negatively affected.
Music therapy interventions in neonatal intensive care
have previously focused on the effects of recorded music.
These showed significant benefits when it came to measures
of heart rate, behaviour state, oxygen saturation, sucking/
feeding ability and length of hospital stay, as reported in a
recent meta-analysis by Standley. This stated that live music
therapy provided the greatest benefits, but pointed out that
the live music studies focused mainly on music therapists
singing, not mothers. Studies on the effects of maternal
singing during neonatal intensive care are scarce, but a
novel Italian report showed that when mothers sang to their
preterm infants and talked to them it had positive effects on
their autonomic stability (8).
Recent music therapy research has focussed its interest
on infant directed singing (9), which is a natural way to sing
interactively to an infant and ideally performed by a parent.
The underlying assumption is that interactive singing has an
emotional component that enhances bonding, autonomic
stability and brain development.
During kangaroo care, skin-to-skin contact with the
preterm infant provides multisensory stimulation, including
emotional, tactile, visual and auditory stimuli. It is actually
possible that maternal singing is transmitted better during
skin-to skin care, because the vibrations in the mothers
thorax contribute to the sensory experience. However, there
has been a lack of studies on this combination.
In the current issue of Acta Paedicatrica, Arnon et al.
(10) present a unique and well-designed study on the effect
of maternal singing during kangaroo care in a neonatal
intensive care unit. They hypothesised that this combination would ameliorate autonomic stability and maternal
anxiety and compared the results with the effects of
kangaroo care on its own.
This study included 86 stable preterm infants, with a
postmenstrual age of 3236 weeks, and their mothers. The
prospective, randomised intervention featured a cross-over,
repeated measures design, so that each motherinfant dyad
acted as their own control. Two sessions were performed
over 2 days, starting with kangaroo care on its own for
10 min, followed by either maternal singing and kangaroo
care or just kangaroo care for 20 min. The sessions ended
with another 10 min of just kangaroo care.

2014 Foundation Acta Pdiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 995996




Mothers were instructed to sing using a repetitive,

soothing tone, softly, simply and with slow tempo. The
researchers provided a sound analyser and asked the
mothers to keep the sound between 60 and 70 decibels
and to include lullabies, preferably the ones that they sang
during pregnancy. The heart rates, oxygen saturation and
respiratory rates were recorded for the mother and child
and the childs behavioural state and the mothers anxiety
were assessed.
The authors reported that when they compared maternal
singing and kangaroo care with just kangaroo care, they
were unable to demonstrate additive effects on mean heart
rate, respiratory rate, oxygen saturation or behavioural
state. This is not unexpected as kangaroo care on its own
has clear effects (5). On the other hand, heart rate
variability changed, with a decreased low frequency/high
frequency ratio, and this indicated increased autonomic
stability and a calming effect during kangaroo care with
maternal singing, compared with kangaroo care alone. The
study design controlled for some possible confounders,
including body temperature and the infants head position.
Finally, direct evaluation of the mothers showed that they
felt less anxiety after maternal singing, as demonstrated by
lower scores on the State Trait Anxiety Inventory scale, a
well-validated score of anxiety.
This study adds an important new perspective on the use
of kangaroo care, which is now a standard initiative in
many units caring for preterm infants. Singing during skinto-skin care seems to be a natural way to deliver music to
the infant for many mothers. If the mother also benefits
from her own singing, it is not far-fetched to believe that her
relief transmits to the child.
On the other hand, some mothers will not feel at all
comfortable singing to their child in the neonatal unit and,
in this study, 15 of the 116 motherinfant dyads refused to
take part. Although mothers should be encouraged to sing
lullabies to their children, this study underscores that it
must be done with great respect for the mothers own
attitude towards singing.
Maternal singing for preterm infants during kangaroo
care may comfort most mothers and babies. But what about
fathers? They commonly perform kangaroo care with
positive effects on active fatherhood. A recent brain imaging
report underscored the common neural basis of maternal
and paternal care, showing that childcare experiences also
led to morphological changes in the father0 s brain (11).
Future studies are needed to elucidate whether paternal
singing is also beneficial for the infant and the father.
This study by Arnon et al. was performed well and shows
meaningful immediate advantages for the preterm infant


and the singing parent. The major question is whether

encouraging parents to sing lullabies during skin-to-skin
care during infancy improves long-term neurodevelopment,
with a particular emphasis on the effects on language
development. This needs to be evaluated in future studies.

Aden (ulrika.aden@ki.se)
Department of Woman and Child Health, Neonatology
Unit, Karolinska Institutet, Stockholm, Sweden

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2014 Foundation Acta Pdiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 995996