DESCRIPTIVE STUDY TO ASSESS THE EFFECTIVENESS OF

CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL AND

BEHAVIOUR PARAMETERS AMONG PRETERM NEONATES

ADMITTED IN NICUWITH RESPIRATORY DISTRESS

M.Sc. Nursing Dissertation Protocol submitted to

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

By

Miss. DEEPTHIMOL K P

M.Sc. NURSING 1ST YEAR

2009-2011

Under the Guidance of

HOD, Department of Paediatric Nursing

Josco College of Nursing

Nelamngala,

Bangalore -562 123

Karnataka

0

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE,KARNATAKA PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE CANDIDATE Miss. DEEPTHIMOL K P

2 NAME OF THE INSTITUTEJOSCO COLLEGE OF NURSING,NELAMNGALA,BANGALORE

3 COURSE OF STUDY AND SUBJECTMSc NURSING 1st YEARPAEDITRIC NURSING

4 DATE OF ADMISSION OF COURSE

5 TITLE OF THE TOPIC

DESCRIPTIVE STUDY TO ASSESS THE EFFECTIVENESS OF CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL AND BEHAVIOUR PARAMETERS AMONG PRETERM NEONATES ADMITTED IN NICUWITH RESPIRATORY DISTRESS

6BRIEF RESUME OF THE STUDY

6.0 INTRODUCTION6.1 NEED FOR STUDY6.2 REVIEW OF LITERATURE6.3 STATEMENT OF THE PROBLEM6.4 OBJECTIVES OF THE STUDY6.5 OPERATIONAL DEFENITIONS6.6 HYPOTHESIS6.7 ASSUMPTION6.8 LIMITATION6.9 PROJECTED OUT COME

ENCLOSED

7MATERIALS AND METHODS

7.1 SOURCE OF DATA7.2 METHODS OF DATA COLLECTION

ENCLOSED

8 BIBILOGRAPHY ENCLOSED

2RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

PERFOMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. Name of the Candidate and

Address (in block letters)Miss. DEEPTHIMOL K P

2. Name of the Institution

JOSCO COLLEGE OF NURSING

NELAMANGALA,BANGALORE

3. Course of Study And Subject

M. Sc. NURSING

PAEDIATRIC NURSING

4. Date Of Admission of Course

5. Title of the Topic

DESCRIPTIVE STUDY TO ASSESS THE

EFFECTIVENESS OF CLASSICAL MUSICAL

THERAPHY ON PSYCOLOGICAL

BEHAVIOUR PARAMETERS PRETERM

NEONATES ADMITTED IN NICU WTTH

RESPIRATORY DISTRESS.

36.0 BRIEF RESUME OF THE STUDY

INTRODUCTION

“Angels live in the heart of kids;

Music is well said to be the speech of angels."

Thomas Carlyle

In the present era of science and technology, where quality is the supreme

priority, Quality Of Life can only be accredited by decreased morbidity and

mortality rate of newborn. The UNICEF’s Flagship Publication, The State of

World’s Children (15th Jan 2009) reported that a million neonatal death occurs in

India every year.

The popularity and credibility of alternative treatment modalities such as

music therapy also have increased over the past decade. Support for the use of

music with infants is not limited to music therapy literature; in fact, authors in

several other fields of study have written about the benefits of using music to

create a nurturing environment for infants. Such articles have been published in

journals intended for nurses (Hicks, 1995; Olson, 1998; Standley, 2002)

physicians (Jones and Kassity, 2001; Marwick, 2000) paediatric nurse

practitioners (Klein and Winkelstein, 1996) and music educators (Fox, 2000). In

this growing field of interest, current research has provided health care

professional with many reasons to use music in their repertoire of treatment

options for newborns.

46.1 NEED FOR THE STUDY

Music benefits documented for full term newborns may also apply to the

premature infants, that is, lullabies promote language development, familiar music

is recognized, reinforcing and comforting and infants orient to and avidly attend

to music more than other auditory stimuli. This burgeoning area of researches

provides exciting possibilities for the practice of music therapy in the Neonatal

Intensive Care Unit (NICU) and for music education in early childhood (Standley,

2008).

Preterm babies are also having some sort of anxiety and stress even though

we are not taking care of. Several studies have shown how music therapy

enhances the efficacy of nursing interventions that is the majority of NICU staff

preferred live recorded music and music appears to be an acceptable intervention

in Neonatal Intensive Care Unit (http//:web.mac.com).

Music therapy is an important intervention that is soothing for the infants.

Music therapy can also encourage parental involvement, support infant

development and optimize preterm infants’ neuro developmental outcomes

(Nordoff and Robbins, 1997; Haselbeck, 2004).

Elena and Nick (2008) reported that music has an effect on the state of

paediatric patients, potentially improving the physiological well being of long

term hospitalized children when exposed to live music.

The highest mortality among infants is due to prematurity. Prematurely

born infant emerges into a hectic, cold, noisy and bright environment filled with

5

Mysterious equipments and peopled by masked strangers who try to help. Thus

the experience in Neonatal Intensive Care Unit contains frequent aversive

procedures, excess handling and disturbance of rest, noxious oral medications,

noise and bright light. These conditions are sources of stress and anomalous

sensory stimulation (Zentner, 1996).

The holistic movement has become a challenge to health care

professionals and music is one of the few interventions that can be considered

truly holistic. Research and clinical findings support the uses of music in a variety

of physical and psychological conditions (www.musictherapy.com).

Music alleviates both acute and chronic pain and found a 30% decrease in

the use of pain medications with the use of therapeutic music (Herth, 1998).

Whipple and Glynn (1992) stated that soothing music resulted in a

significant increase in the pain threshold of 10 healthy female volunteers.

The length of hospitalization was shorter and average daily weight gain

was greater for infants, whose parents received training in music, although these

differences were not significant. A one month post discharge follow up showed

little difference between experimental and control group parent infant interaction

in the home (Whipple, 2000).

66.2 REVIEW OF LITERATURE

Searching the literature is the first and vital stage of a research. The

purpose of literature review is to discover what has previously been done about

the problem to be studied, what methods have been employed in other researches,

suggestions for further studies etc. The most important types of information for a

research review are finding from empirical investigations. Literature review is

defined as a critical summary of research on a topic of interest, often prepared to

put a research problem in context ( Polit and Beck, 2008).

A brief account of various studies conducted by different investigators and

a few citations from books, which are found to be relevant to the study are

included in this chapter.

6.2.1 PRETERM NEONATES AND RESPIRATORY DISTRESS

Preterm babies are babies born of less than 37 completed weeks (Singh,

2004; Kenner and Lott, 2003).

Preterm infants can be categorized by weight as well as gestational age. A

child weighing less than1500 grams is considered as very low birth weight infant

and 1501 to 2500 grams constitute a moderately low birth weight infant (Wong et

al., 2006).

About 10 to 12 % of Indian babies are born preterm as compared to 5 to

7% incidence in the west (Singh, 2004). More than a half million babies in the

7

United States-that is 1 in every 8- are born premature every year (Centre

for Disease control and Prevention, 2008).

The factors contribute to the preterm delivery are late initiation of prenatal

care, lower socio economic status and substance abuse (Kenner and Lott, 2003).

Multiple pregnancies (twins, triplets) are another significant factor for

preterm birth (March of Dimes, 2006).

Pregnant women exposed to passive smoking or those who smoked are at

an increased risk of preterm delivery (Richard, 27 March 2009; Mc Cowan,

2009).

Parenting behaviours, particularly parent child synchrony were associated

with neuro behavioural development of preterm infants ( Treyvaud et al., 2009).

6.2.2 AUDITORY SENSITIVITY OF NEONATES

While newborn human infants are immature beings in many ways, their

sense of hearing is actually quite well developed at birth; they are able to detect

changes in loudness of only 3 dB and to perceive timbre and pitch much like

adults do (Fassbender, 1996).

The neonates often experience some auditory asymmetry in their

perception of sound. Specifically, several studies have shown that the right ear is

slightly more sensitive to auditory signals than the left ear (Bertoncini et al., 1989;

Eldredge and Salamy, 1996; Kei, McPherson et al., 1997).

8

Typical newborns have immature but functional hearing ability and they

are able to discriminate subtle differences between sounds soon after birth

(Atkinson and Braddick, 1982).

Four day olds can distinguish between changes in consonant-vowel

syllables presented dichotically (Bertoncini et al., 1989).

Even term newborns could be affected by noise in that it hinders their

independent attempts to sleep, self-soothe and pay attention (Philbin and Klaas,

2000).

6.2.3 NOISE LEVELS IN NEONATAL INTENSIVE CARE UNIT

Noise levels were found to be above the American Academy of Paediatrics

recommended 45 dB levels and the recommended impulse maximum of 65dB was

also exceeded in Neonatal Intensive Care Unit (Darcy and Hancock, 2008).

Zahr and De Traversay (1996) pointed out in their study to develop

aggressive anti noise policies to substantially and consistently reduce the noise in

the Neonatal Intensive Care Unit.

Excess noise in the NICU correlates with a decreased oxygen saturation

and an increased heart rate and sleep disturbances (Kellman, 2002).

Exposure to aberrant noise levels in the NICU may cause sensorineural

damage, induce stress and contribute to language or auditory processing disorders

in the preterm neonates (Schulte, 1997).

9One study found that loud noises in the Neonatal Intensive Care Unit

significantly changed the behavioural and physiological responses of infants (Zahr

and Balian, 1995).

Exposure to noise in the NICU may result in cochlear damage and the

noise may disrupt the normal growth and development of premature infants

(American Academy of Paediatrics, 1997; White, 2005).

A study reported that existing NICU environment has very high sound

pressure levels (SPL) and this can cause hearing impairment, sleep disturbances,

somatic effect, impaired auditory perception and affect emotional development in

babies (Gupta, 2005).

Music is credited to ensure autonomic stability, reduce stress and quieten

the baby, increases oxygen saturation and reduces heart rate (Singh, 2004).

6.2.4 PRETERM NEONATES’ STRESS IN NEONATAL

INTENSIVE CARE UNIT

Environmental factors in the Neonatal Intensive Care Unit have major

implications for the care of the sick newborn infant. Broad evidence implicates

the environment in the Neonatal Intensive Care Unit as a factor in neonatal

morbidity.

Abnormal sensory input can be a source of potentially overwhelming stress

and at a sensitive period during development can modify the developing brain.

The NICU environment therefore assumes a crucial role in the care of the sick

neonates (Mhairi et al., 2005).

10

Music has been found to reduce stress hormones and enhance the immune

system, which allows healing to occur more rapidly in sick patients (Knight,

2001).

Classical music strengthens our natural regulatory and recovery processes

and is particularly noticeable in the relief of the physical, mental and spiritual

effects of stress (WHO stress conference, 1995).

6.2.5 THERAPEUTIC USES OF CLASSICAL MUSIC THERAPY

The term classical music originates from the Latin term classicus, meaning

taxpayer of the highest class. The origins of Indian classical music can be found

from the oldest of scriptures, part of the Hindu tradition, the Vedas.

Haydn has been referred to as the “Father of classical music”. Indian

classical music is monophonic in nature and based around a single melody line

which is played over a fixed drone. The performance is based melodically on

particular ragas and rhythmically on talas (www.wikipedia.com).

Many styles of music exist within classical music; the most recognizable

being the symphony, opera, choral works, chamber music, Gregorian chant, the

madrigal, and the Mass.

Music can enhance the immediate environment provide a diversion and

lessen the impact of potentially disturbing sounds for paediatric patients (Barrera,

Rykov et al., 2002; Klein and Winkelstein, 1996).

11

Classical music decreased the tension but had little effect on other feelings (Mc

Craty, Barrios et al., 1998).

Music has been found to be an effective anxiolytic for patients undergoing

anxiety-producing procedures and allows for less pain medications, less sedatives

and an increased recovery time (Miluk, 1994).

Classical music can decrease patient’s perceptions of, and responses to

pain, even in very young premature infants (Butt, Kisilevsky, 2000; Joyce, Keck

et al., 2001).

Nursing pioneering leader Florence Nightingale (1860) recognized the

healing power of music. Today nurses can use music in a variety of settings to

benefit patients and neonates.

6.2.6 EFFECT OF CLASSICAL MUSIC THERAPY ON

PHYSIOLOGICAL PARAMETERS

Classical music has an effect on the state of paediatric patients, potentially

improving their physiological and psychological wellbeing (Elena and Nick,

2008).

When compared with recorded music or no music therapy; live music

therapy is associated with a reduced heart rate at 30 minutes after music therapy in

stable preterm neonates (Shmuel et al., 2006).

12

Taped intrauterine sounds combined with female vocal singing resulted in

significant reduction in agitated behaviours and improved oxygenation in

newborns (Collins, 2001).

Music listening increases oxygen saturation levels in neonates (Cassidy

and Standley, 1995; Collins and Kuck, 1991; Standley and Moore, 1995).

Live music therapy is associated with a reduced heart rate at 30 minutes

after music therapy (Staneslow et al., 2006).

6.2.6 EFFECT OF CLASSICAL MUSIC THERAPY ON

BEHAVIOURAL RESPONSES

When examining infant’s overt responses to stimuli, researchers must be

wary of interpreting their movements as purposeful; newborns have undeveloped

motor skills and thus, a limited capacity for deliberate movements. One way to

consistently observe behaviours for an entire population of infants is to use a

standard scale and that scores based on a general state of alertness. In studies

using behaviour state as a dependent variable, music generally has a stabilizing

effect on alertness. The incidence of stress and anxiety behaviours may be

reduced when exposing the newborns to music therapy (Burke et al., 1995; Caine,

1991; Larson and Ayllon, 1990; Leonard, 1993; Whipple, 2000).

Listening to music can cause behaviour state to decrease overall (Burke,

Walsh et al., 1995) return to normal following a stressful intervention (Butt and

13

Kisilevsky, 2000) or reduce lability (Collins and Kuck, 1991; Kaminski and Hall,

1996).

Live music significantly reduced the behavioural distress and it was

especially effective for children of one year old and younger who were receiving

needle sticks (Malone, 1996).

Live music therapy is associated with a deeper sleep at the 30minutes after

therapy (Staneslow et al., 2006).

Live music therapy is associated with a reduced heart rate and a deeper

sleep at 30 minutes after therapy in stable preterm neonates (Shmuel et al., 2006).

Auditory stimulation in the form of heart beat lengthened the duration of

quiet sleep period. Some NICUs have urged using sound as a protective window

for the infant-when music is played, the infant will not be disturbed (Schulte,

1997).

6.2.7 CLASSICAL MUSIC THERAPY AND ITS EFFECTS ON

RESPIRATORY DISTRESS

The hospital care of premature and low birth weight infants requires

expensive technology and experienced care. Many studies have looked at the

institution of developmental care in the Neonatal Intensive Care Unit.

Significant increase in oxygen saturation was found with the use of

classical music therapy in neonates (Malinova et al., 2004).

14

When lullaby music was played in the Neonatal Intensive Care Unit, there

were less episodes of oxygen desideration in preterm neonates (Caine, 1991).

A study involving premature infants’ exposure to harp music resulted in

overall a significantly lower salivary cortisol level and lowers the respiratory rate

(Block and Jennings, 2003).

If a baby suffered from lack of oxygen during his prenatal development, no

matter whether he is premature or not, his activity of cell ferments is lowered.

After listening to classical music, activity of babies’ cell ferments rose. They took

babies’ blood pressure, pulse, rhythm of breathing and they observed a classical

reaction of adaptation and improved the oxygenation status (Mikheeva, 2006).

6.3 STATEMENT OF THE PROBLEM

Study to assess the Effect of Classical Music Therapy on Physiological and

Behavioural Parameters among Preterm neonates admitted in Newborn Nursery of

selected Paediatric Hospitals in Bangalore city.

Preterm deliveries, 8 to 10% of live births in the United States account for

roughly 75 to 80% of neonatal morbidity and death (Kennel and Lott, 2003;

March of Dimes, 2003).

Prematurity and low birth weight (LBW) contributes to more than 85% of

neonatal mortality. Neonatal survival is a very sensitive indicator of population

growth and socio economic development. The issue of neonatal death is a serious

15national health concern especially in developing countries where 96% of the

World’s approximate 5 million annual neonatal deaths occur (WHO 2006).

The global burden of neonatal deaths is estimated to be 5 million, of which

3.2 million deaths occur during the first week of life. Almost a quarter of these

deaths are shared by India with three babies dying every minute and every fourth

baby born being a low birth weight (Nair, 2006).

The major problems that the newborn encountered are those of adaptation

to the extra uterine environment. Premature infants will generally need maximal

physiological support and should be cared for in a well equipped intensive care

unit (Singh, 2004).

6.4 OBJECTIVES OF THE STUDY

1. Assess the effect of classical music therapy on physiological parameters

in preterm neonates.

2. Assess the effect of classical Music therapy on behavioural parameters

in preterm neonates.

3. Assess the effect of classical music therapy on the respiratory distress

in preterm neonates.

6.5 OPERATIONAL DEFINITIONS

Effect

According to Oxford Dictionary “effect” means results of outcome or

change produced by action.

16In this study, effect is the difference in physiological and behavioural

parameters in the preterm neonates during and after classical music therapy.

Classical Music Therapy

It is the use of classical music with a client or groups or in a process

designed to facilitate and promote communication, relationship, mobilization,

expression, organization and other relevant therapeutic objectives in order to meet

physical, emotional, mental, social and cognitive needs.

Preterm neonates

Preterm neonate means babies born of less than 37 completed weeks. In

this study, preterm neonates mean babies born of 30 to 36 weeks.

Physiological parameters

Physiological parameters are Heart rate (HR), Respiratory rate (RR) and

Oxygen saturation (SpO2).

In this study physiological parameters include Heart rate (HR),

Respiratory rate (RR) and Oxygen saturation (SpO2).

Behavioural parameters

According to Oxford dictionary, behaviour is the way one conducts oneself

and the treatment of others.

In this study the behavioural parameters include the observable physical

response of preterm neonates in response to classical music therapy and the

behavioural parameters include deep sleep, restless sleep, quiet alert, active alert

and crying.

17Nursery

Newborn nursery is a facility in the hospital for the intensive approach to

neonatal care, for close observation and expert management.

6.6 HYPOTHESIS

H1 HA: Classical music therapy will significantly improve the physiological

and behavioural parameters of preterm neonates.

H0: Classical music therapy will not significantly improve the

physiological and behavioural parameters of preterm neonates.

H2 HA: Classical music therapy will significantly influence the respiratory

distress in preterm neonates.

H0: Classical music therapy will not significantly influence the respiratory

distress in preterm neonates.

6.7 ASSUMPTION

1. Preterm Neonates suffering with respiratory distress need a peaceful and

calm environment.

2. This classical musical therapy will enhance the better improvement in

progress of respiratory distress in preterm neonates.

6.8 LIMITATIONS

1 The study was limited to a population of preterm neonates with a

gestational age of 30 to 36 weeks.

182 The study was limited to a sample size of 50 preterm neonates

admitted in the Inborn Nursery (IBN).

3 The study was limited to preterm neonates with mild to moderate

respiratory distress.

4 The duration of study was only 6 months.

6.9 PROJECTED OUTCOME

The study will also help to improve the respiratory patterns in the preterm

neonates suffering with respiratory distress.

7.0 MATERIALS AND METHODS

7.1 SOURCE OF DATA

Preterm neonates suffering with respiratory distress.

7.1.1 RESEARCH DESIGN

The present study was intended to assess the effect of Classical music

therapy on physiological and behavioural parameters among preterm neonates

admitted in Newborn nursery of selected paediatric hospitals in Bangalore. The

methodology adopted for the study is quasi experimental–Time series design.

Research approach : Quasi experimental

Research design : Time series design

In this study the data were collected from each sample for 4 consecutive

days and the same subjects act as their control group on alternate days. Six

19observations regarding physiological and behavioural parameters were collected

before, during and after classical music therapy at specific time intervals from

each sample. Respiratory distress was also assessed by Downey’s score at specific

time intervals.

The design is diagrammatically represented as:

Before (BMT) During (DMT) After (AMT)

G1 E O1 O2 O3 O4 O5 O6 X O13 O14 O15 O16 O17 O18

O7 O8 O9 O10 O11O12

G1 C O1 O2 O3 O4 O5 O6 ------- O13 O14 O15 O16 O17 O18

O7 O8 O9 O10 O11 O12

G1 E - Experimental group on Day 1 and Day 3

G1 C - Control group on Day 2 and Day 4

BMT - Before Classical Music Therapy

DMT - During Classical Music Therapy

AMT - After Classical Music Therapy

7.1.2 SETTING OF THE STUDY

Settings are the specific place where data collection occurs (Polit and Beck,

2008).

In this study the setting was In Born Nursery (IBN) of Selected Paediatric

Hospitals in Bangalore.

207.1.3 POPULATION

The population refers to the aggregate or totality of those confirming to

asset of specifications (Polit and Beck, 2008). In the study the population

includes Preterm neonates admitted in the In Born Nursery of Selected Paediatric

Hospitals in Bangalore.

7.2 METHODS OF DATA COLLECTION

7.2.1 SAMPLE AND SAMPLING TECHNIQUE

Sample is the small proportion of a population selected for observation and

analysis (Polit and Beck, 2008). Preterm neonates admitted in the inborn nursery

of Selected Paediatric Hospitals in Bangalore with a gestational age between 30 to

36 weeks who fulfil the inclusion criteria were selected as samples for the study.

7.2.2 SAMPLE SIZE

The sample size was 50 and the sampling technique used in the present

study was non probability sampling.

7.2.3 CRITERIA

Inclusion criteria

Preterm neonates between the gestational age of 30 to 36 weeks.

Preterm neonates with a birth weight of 1.5 kg and above.

Preterm neonates with mild to moderate respiratory distress.

21

Exclusion criteria

Preterm neonates with severe respiratory distress and critically ill.

Preterm neonates with congenital anomalies.

Preterm neonates with extremely low birth weight (<1.5 kg).

Parents or care givers not willing to provide the consent.

7.2.4 DATA COLLECTION PROCESS

The data collection was done in Preterm neonates with mild to moderate

respiratory distress admitted in In Born Nursery were the study subjects.

After getting Human Ethical Committee clearance and permission from

institution and respective units and parents of subjects, the data collection was

done with the help of prepared tool.

The investigator first established a rapport with the parents or care givers.

The purpose of the study was explained. It was assured to them that all the data

will be kept strictly confidential and used only for this study purpose and obtained

the informed consent.

After conducting a structured interview to parents or caregivers, socio

demographic data were collected.

227.2.5 DATA ANALYSIS PLAN

The data obtained were analyzed by appropriate statistical test. The

analysis pertaining to socio demographic data was given in frequency distribution

table and whenever necessary statistical means and standard deviation were used.

The effect of classical music therapy on physiological parameters was

analyzed by Analysis of Variance (ANOVA) and Analysis of Covariance

(ANCOVA). The analysis of behavioural parameters and respiratory distress was

done by Wilcoxon Signed Ranks Test.

8.0 BIBILOGRAPHY

1. Aikman E, Nolte AG. The effect of constant baroque music on premature

infants. Curationis 1997 Jul; 20 (2): 17-20.

2. Aitken JC, Wilson S, Coury D, Moursi AM. The effect of music distraction

on pain, anxiety and behaviour in paediatric dental patients. Paediatric

Dent. 2002 Mar-Apr; 24(2):114-8.

3. Allen TA. Music therapy. Ann Rev Res 2004; 38 (3): 170-92.

4. Als H, Lawhon G, Brown E. Individualized behavioural and environ-

mental care for the very low birth weight preterm infant at high risk for

bronchopulmonary dysplasia: neonatal intensive care unit and develop-

mental outcome. Paediatrics 1986; 78:1123-1132.

5. American Academy of Paediatrics, Committee on Environmental Health.

Noise: A Hazard for the Foetus and Newborn Paediatrics. Paediatrics

1997; 100 (4): 724-727.

236. Anagnostakis D, Petmezakis J, Papazissis G, Messaritakis J, Matsaniotis N.

Hearing loss in low-birth-weight infants. Am J Dis Child 1982; 136: 602-

604.

7. Andrea Marie Cevasco. The Effects of Mothers’ Singing on Full-Term and

Preterm Infants and Maternal Emotional Responses. Music Therapy

Doctoral Dissertation, The Florida State University 2006.

8. Anne Harding. No drop in US preterm births. 2006 stats show. Reuters

Health. Jan16, 2009.

9. Annette M Whitehead and Pleaur. Exploring the effects of music therapy

on paediatric pain. Journal of music therapy 2007; 44(3): 217.

10. Arnon S, Shapsa A, Forman L, Regev R, Bauer S, Litmanovitz I, Dolfin T.

Live music is beneficial to preterm infants in the neonatal intensive care

unit environment. Birth 2006 Jun; 33(2): 131-6.

11. Astolfi P, Zouta LA. Risks of preterm delivery association with maternal

age, birth order, and foetal gender. Human Reproduction 1999; 14: 2891-

2894.

12. Atkinson J, Braddick O. Sensory and perceptual capacities of the neonate.

In P. Stratton (Ed.), Psychobiology of the human newborn. New York:

Wiley.1982; 191-220.

13. Aucott S, Donohue PK, Atkins E. Neuro developmental care in the NICU.

Ment Retard Dev Disabil Res Rev 2002; 8(4):298

2414. Balaka B, Baeta S, Agbere. Risk factors and with preterm delivery in the

teaching hospital of lone, Togo. Bellettin de I a Societee de Pathologie

Exotique 2006 April.

15. Barrera ME, Rykov MH, Doyle SL. The effects of interactive music

therapy on hospitalized children with cancer: A pilot study. Psycho-

oncology 2002; 11(5):379.

16. Bayo MV, Garcia AM, Garcia A. Noise levels in an urban hospital and

worker’s subjective responses. Arch Environ Health 1995; 50: 247.

17. Zupan J. Perinatal mortality in developing countries. New England Journal

of Medicine 2005; 352: 2047-2048.

18. http://ezinearticles.com/?Music-Therapy-for-Baby&id=166218

19. http://www.bellmusicschool.com/

20. http://www.early-child-development.com/

21. http://www.music-research.org/

22. http://www.todaysparent.com/

23. http://www.rrh.org.au

24. http://www.musictherapyworld.net.

25. http://www.babygotosleep.com

26. http://www.nichd.nih.gov.

27. http://www.mayoclinic.com

28. http://www.marchofdimes.com.

29. http://www.medscape.com

2530. http://www.3.interscience.wiley.com

31. http://www.betterhealth.vic.gov.au.

32. http://www.abcnews.go.com.

33. http://www.jama.com.

26

9SIGNATURE OF THE CANDIDATE

10REMARKS OF THE GUIDE

11NAME AND DESIGNATION OF

11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12 12.1 REMARKS OF THE PRINCIPAL