NICU music therapy

1. Introduction

Version followed: the bedside procedure follows the published Clinical Practice Protocol of Creative Music Therapy (CMT) for preterm infants and parents (Haslbeck & Bassler 2020). Two other named models are described where they add or differ: First Sounds: Rhythm, Breath and Lullaby (RBL; Joanne Loewy, Louis Armstrong Center for Music and Medicine, Mount Sinai, New York) and the NICU-MT model of Jayne Standley (Florida State University), which includes Multimodal Neurologic Enhancement (MNE) and the Pacifier-Activated Lullaby (PAL). Where these schools disagree, the guide says so.

NICU music therapy is a specialist adjunct within neonatal intensive care. It is not a stand-alone psychotherapy and does not replace medical or nursing care. A credentialed music therapist uses live, infant-directed sound (humming, singing, soft rhythm and breath-matched instruments), and in some models carefully controlled recorded music, to support the preterm infant's physiological self-regulation, feeding and sleep–wake organisation. The work also supports parents' coping and their bond with the infant [source: Haslbeck & Bassler 2020; Loewy et al. 2013 abstract; Standley 2014].

The core idea of change differs by school:

CMT sees change as coming from moment-to-moment responsiveness. The therapist matches the infant's breathing, facial expression and state with improvised humming and singing, and this "communicative musicality" gives the infant regulation and the parents a sense of empowerment [source: Haslbeck & Bassler 2020].
RBL holds that live sound entrained to the infant's observed vital signs (heartbeat rhythm, breath sounds) can draw heart rate and breathing toward calmer patterns. Parent-chosen "songs of kin" also carry family culture and bonding into the NICU [source: Loewy et al. 2013 abstract; Loewy 2015 abstract].
Standley's NICU-MT works on developmental steps matched to gestational age. Music is first used for pacification. It is then paired with touch and movement, and later with sucking, so that tolerance of stimulation and feeding skills grow [source: Standley 2014; Dräger NICU music document].

Evidence status, as the main review gives it: a Cochrane review (Haslbeck et al. 2023; 25 studies, 1,532 infants, 691 parents) found that music and vocal interventions may lower infant heart rate. It found no difference in oxygen saturation or respiratory rate, and found the effects on neurodevelopment at two years and on parental anxiety or depression uncertain. No study reported harms, but many studies did not look for them [source: Cochrane plain-language summary, Haslbeck et al. 2023].

Professional frame. In the United States this is practised by board-certified music therapists (MT-BC, Certification Board for Music Therapists; professional body AMTA). Many also hold NICU-specific training: the FSU NICU-MT certificate (an 8-hour class, two days of clinical fieldwork, readings and an exam, with a registry listing; Standley states it requires MT-BC status), First Sounds RBL tiered training, or CMT training [source: FSU NICU-MT certificate page; Standley 2014; ArtEZ RBL training page; Haslbeck & Bassler 2020]. In the UK, the title music therapist is regulated by the HCPC, and BAMT is the professional association [uncertain: UK NICU-specific training routes]. Haslbeck & Bassler state that CMT should be delivered only by music therapists specially trained in it. Standley recommends specialised NICU training before practice. A psychotherapist without music-therapy registration and NICU training should not deliver these interventions to infants. Their roles are parent psychotherapy, referral and collaboration with the NICU music therapist [synthesis].

2. Framework

NICU music therapy is better described as a set of developmentally staged procedures within the unit's care plan than as a fixed sequence of therapy phases [synthesis].

Developmental stages (Standley NICU-MT) [source: Standley 2014]

About 23–30 weeks postmenstrual age (survival and pacification): quiet, consistent music only, with no touch or interaction. The therapist keeps their face more than about 10 inches from the infant.
About 30–34 weeks (cautious stimulation): music during passive touch such as kangaroo care. Methods that call for interaction are contraindicated until the infant tolerates minimal stimulation. Standley places touch and guided interaction as appropriate from about 32 weeks.
About 34–40 weeks (interactive and discharge): work on sleep–wake cycles, suck–swallow–breathe coordination and visual tracking. This is when PAL is typically introduced (around 34 weeks) [source: Dräger NICU music document].
One clinical guidance document gives a minimum of 28 weeks postmenstrual age for music, with daily nursing approval [source: Dräger NICU music document]. [uncertain] This differs from Standley's position that quiet music can be used from 23 weeks; follow your unit's protocol.

CMT session structure [source: Haslbeck & Bassler 2020]

Preparation: needs assessment with the team and parents, setting goals, a musical history from the parents, and scheduling around care routines and rest.
Infant-only bedside segment: observation, then containing touch, then humming entrained to the infant's breathing, for about 15–20 minutes.
Kangaroo care segment with a parent: monochord sounds, with humming added after about 90 seconds, for about 15–20 minutes.
Closure, reflection with the parents, documentation, and discharge planning (a written report with home music recommendations, and an optional phone call about two weeks after discharge).
Dose: 2–3 sessions a week, about 20 minutes each, only when the infant is clinically stable.

RBL structure [source: ArtEZ RBL training page; Aalborg 2018 First Sounds Tier II announcement; Loewy et al. 2013 abstract]

Three prongs:
- environmental music therapy, which addresses the unit's sound environment;
- music psychotherapy and trauma-informed work with parents and caregivers;
- live music interventions for infants: rhythm on the gato box, breath sounds on the ocean disc, and sung lullabies or songs of kin.
The multisite trial gave three sessions a week over two weeks to infants of 32 weeks or more [source: Loewy et al. 2013 abstract].
Training is tiered: Tier I and Tier II are named, and Tier II ends with a competency post-test [source: ArtEZ page; Aalborg 2018 announcement].

MNE dose: reported as 15–20 minutes twice a week in one trial [source: Dräger NICU music document, citing Walworth et al. 2012].

Recorded music: at most 4 hours a day, alternating 30 minutes of music with 30 minutes of silence, and never left playing unattended with a high-risk infant [source: Dräger NICU music document].

Criteria for moving on or stepping back

Advance when:
- the infant is clinically stable (team decision);
- the infant tolerates the current level of stimulation without stress cues;
- developmental readiness is reached, e.g. the infant is preparing for oral feeds before PAL [source: Standley 2014; Haslbeck & Bassler 2020; Dräger document].
Step back when:
- subtle stress cues appear: pause for about 15 seconds, then retry;
- stronger cues appear: stop all stimulation and let the infant rest;
- the infant is too unstable for kangaroo care: change from the kangaroo care segment to bedside-only work [source: Standley 2014; Haslbeck & Bassler 2020].
Stop entirely during painful or stressful procedures. Music can be used immediately after them to help recovery [source: Dräger document; Standley 2014].

3. Guiding principles

Medical priority and team integration. Sessions happen only with the neonatal team's agreement and when the infant is stable, and the infant's needs override everything, including parents' wishes. Practically: check with the bedside nurse before every session, and accept a cancellation without argument [source: Haslbeck & Bassler 2020; Dräger document].
Read the infant first, then sound. Watch breathing, facial expression, gestures, muscle tone and behavioural state before making any sound. Practically: spend the first minutes observing silently [source: Haslbeck & Bassler 2020].
Entrainment and responsiveness. Sound is matched to the infant's breathing (CMT, RBL) or heartbeat rhythm (RBL), then gently guided toward a slower, steadier pattern. Practically: begin at the infant's tempo and only then slow down [source: Haslbeck & Bassler 2020; Drexel Q&A 2013].
Less is more; simple and predictable. Use a calm, slow, simple voice with few notes, repetition and narrow pitch ranges. Recorded music should be voice alone or voice with one instrument, slow, at constant volume and with few chords. Practically: no complex or dynamic music near a fragile infant [source: Haslbeck & Bassler 2020; Dräger document].
Live over recorded. Live, infant-directed singing that responds to cues is preferred over recordings, because recordings cannot adapt to the infant [source: Dräger document; HealthManagement summary of Loewy et al. 2013].
Protect hearing and the sound environment. Keep within unit decibel limits measured at the infant's ear. Avoid free-field speakers in open bays, headphones on infants, mobiles, musical toys, radio, white noise and nature sounds. Practically: measure, and do not guess [source: Dräger document; Standley 2014]. See Section 4, "Sound environment and hearing safety".
Developmental staging. Match the type and amount of stimulation to postmenstrual age and observed tolerance. Practically: no interactive stimulation for very immature infants [source: Standley 2014].
Family-centred, parent as primary musician. The therapist acts as facilitator and collaborator, not educator, and supports parents' intuitive caregiving. Familiarity matters more than voice quality. Practically: praise what parents already do with their infant [source: Haslbeck & Bassler 2020; Dräger document].
Culture and song of kin. Use the family's own songs, language and rituals: parent-chosen, culturally based songs [source: Loewy 2015 abstract; Aalborg 2018 announcement; Haslbeck & Bassler 2020].
Parents' trauma and grief are part of the work. RBL offers parents music psychotherapy, as a non-confrontational space for fear, anxiety and grief, before they work musically with their infant [source: Loewy 2015 abstract].
Integrate rather than fight the unit's noise. In CMT the monochord can be tuned to the most common monitor tone, and the therapist may sing in the key of an alarm [source: Haslbeck & Bassler 2020].
Infection control. Disinfect hands, arms and instruments on entering and leaving the patient zone [source: Haslbeck & Bassler 2020].
Continuity to home. A family lullaby can serve as a familiar thread from the NICU through discharge to home, and a written home music plan supports this [source: Loewy 2015 abstract; Haslbeck & Bassler 2020].

4. Intervention inventory

The procedures below are delivered by a trained NICU music therapist within the unit's care plan. Where the guide addresses a psychotherapist directly, the role is parent support and collaboration [synthesis].

4.1 Preparation: needs assessment, musical history and scheduling (CMT)

Purpose: set goals with the team and family, collect the family's musical material, and pick a time that protects the infant's rest [source: Haslbeck & Bassler 2020].
Steps:
1. Agree on referral and goals with the neonatal team and the parents. Obtain and document the parents' informed consent as unit policy requires, and follow the unit's safeguarding procedures if concerns arise about the infant's or family's safety [synthesis].
2. Ask the parents about:
  - their musical heritage;
  - songs they like;
  - their comfortable singing range;
  - any music sung or heard during pregnancy (song of kin).
3. Offer lullaby material or a flyer that encourages vocal contact.
4. Agree a session time that avoids care rounds, procedures and rest periods.
5. CMT only: tune the monochord to the unit's most common monitor tone.
Example language (illustrative): "What songs do you sing at home, or did you sing while you were pregnant? Any language, any style. Your voice is the one your baby already knows."
Watch for:
- songs tied to loss, a previous pregnancy or traumatic events. Ask before using a song, and offer to keep it private [synthesis];
- parents who feel ashamed of their singing. Familiarity matters more than voice quality [source: Dräger NICU music document].

4.2 Silent observation and containing touch (CMT)

Purpose: read the infant's state before making sound, and offer a holding boundary [source: Haslbeck & Bassler 2020].
Steps:
1. Disinfect hands, arms and the instrument.
2. Sit at the bedside.
3. Observe breathing, facial expression, gestures, muscle tone, mimicry and behavioural state.
4. If the infant tolerates touch, place gentle hands on the head and feet. Then rest a light hand on the chest or back, adjusting the pressure to the breathing.
- Standley's staging: no touch or interaction for very immature infants (about 23–30 weeks), and guided touch from about 32 weeks [source: Standley 2014]. Follow the unit's developmental-care policy on touch [synthesis].
Example language (illustrative, to the parent): "I'm just watching how she's breathing for a minute before I make any sound."
Watch for:
- stress cues, such as finger splay, grimace, averted gaze, arching or colour change. If they appear, remove touch and pause;
- calmer breathing and a relaxed tone, which suggest the touch is containing [source: Standley 2014; Dräger document].

4.3 Entrained humming: infant-directed improvisation (CMT)

Purpose: soothe and regulate through a voice that follows the infant's breathing [source: Haslbeck & Bassler 2020].
Steps:
1. Start with a few long, calm notes, repeated, timed to the infant's breathing.
2. Keep the voice calm, slow, simple and predictable, in a children's-song range with flowing breath.
3. Follow the cues:
  - eyebrows lift or attention brightens: let pitch and tempo rise slightly;
  - signs of overarousal: narrow the pitch range, move lower, slow down and repeat closing notes.
4. Continue for about 15–20 minutes, adjusted to the infant.
Example language: not applicable; the intervention is wordless humming.
Watch for:
- working: slower and more regular breathing, relaxed face and hands, quiet-alert or sleep states;
- not working: rising heart rate, irregular breathing, hiccoughs, grimace. Stop or simplify [source: Haslbeck & Bassler 2020; Standley 2014].

4.4 Activating song (CMT)

Purpose: invite interaction with older or alert infants [source: Haslbeck & Bassler 2020].
Steps:
1. Change from humming to singing words when the infant is alert, mouthing or moving the fingers. This is mainly for older infants.
2. Use a family song or a simple lullaby, sung slowly.
3. Return to humming at any sign of stress.
- Standley also advises changing from words to humming when the infant shows stress, and singing a little faster with more facial expression when the infant is engaged [source: Dräger document].
Example language (illustrative, to the parent): "He's looking toward your voice. Try one more verse, nice and slow."
Watch for:
- engagement cues: turning toward the voice, eye contact, sucking movements of the lips [source: Drexel Q&A 2013];
- disengagement cues: averted gaze, finger splay. Then simplify.

4.5 Monochord during kangaroo care (CMT)

Purpose: relax the parent and infant during skin-to-skin holding, and support parent singing [source: Haslbeck & Bassler 2020].
Steps:
1. Observe the dyad first.
2. Rest the monochord against the parent's elbow or arm so the parent feels its vibration.
3. Fade in long, sustained strums entrained to the parent's or infant's breathing (e.g. one strum over several breath cycles).
4. After about 90 seconds, add humming within the parent's vocal range, weaving in the family's favourite music.
5. Ask whether the parent wants to relax, listen or sing along. Invite deep breathing, closed eyes and attention on the infant.
6. Continue for about 15–20 minutes.
- If the infant is too unstable for kangaroo care, work at the bedside instead.
Example language (illustrative): "You can just listen, hum along, or sing whatever comes. Let your breathing slow with the sound."
Watch for:
- parental tension or tearfulness. Allow silence and offer to stop [synthesis];
- infant stress cues: stop the instrument first.

4.6 Integrating monitor alarms and unit sounds (CMT)

Purpose: reduce the startle and disruption of alarms by bringing them into the music [source: Haslbeck & Bassler 2020].
Steps:
1. Tune the monochord to the dominant monitor tone before the session.
2. If an alarm sounds during singing, continue calmly in the alarm's key.
3. Defer at once to staff responding to the alarm.
Example language: not applicable.
Watch for:
- the infant staying calm through an alarm (one of the published case examples);
- never masking or delaying a clinical response [synthesis].

4.7 Closure and fade-out (CMT)

Purpose: end without abrupt change [source: Haslbeck & Bassler 2020].
Steps:
1. Reduce the notes, tempo and rhythm, and repeat the last note.
2. During kangaroo care, play the monochord for 1–2 minutes more, fade it out, hold the silence, then slowly remove the instrument.
3. Hold the infant briefly, then withdraw your hands slowly.
4. Disinfect on leaving.
Example language (illustrative): "Let's just stay in the quiet for a moment."
Watch for: startle or state change when your hands lift. If it happens, hold a little longer [synthesis].

4.8 Parent reflection, empowerment and family involvement (CMT)

Purpose: build parents' self-efficacy and attachment, and include siblings and grandparents [source: Haslbeck & Bassler 2020].
Steps:
1. After the session, ask how the parents experienced it and what they noticed in their infant.
2. Name the positive interactions you observed.
3. Encourage daily infant-directed speech, humming or singing, as the parents prefer.
4. Optionally, invite songwriting or a music diary.
5. For siblings or grandparents:
  - let them choose a song;
  - model it in lullaby style;
  - then coach them, or accompany while they sing.
Example language (illustrative): "When you hummed, her hands opened and her breathing settled. That was your voice doing that."
Watch for:
- working: parents beginning to sing on their own, or describing feeling closer or calmer. The pilot data reported fewer depressive symptoms and more physical closeness [source: Haslbeck & Bassler 2020];
- guilt or grief surfacing. Refer to parent psychological support [synthesis].

4.9 Gato box heartbeat entrainment (RBL)

Purpose: use rhythm to entrain the infant's heart rate toward a slower, even rate [source: Drexel Q&A 2013; Remo RBL kit page].
Steps:
1. Observe the heart rate on the monitor.
2. Play the gato box (a small slit or tone box) softly with soft mallets, matching the infant's heartbeat tempo.
3. Once matched, slow the tempo gradually.
- [uncertain] The exact tempo-reduction steps, volume and duration are taught in RBL training and are not given in the sources.
Example language: not applicable.
Watch for:
- working: heart rate lowers and stays steadier; RBL trial data reported lower heart rate during rhythm and lullaby interventions [source: Loewy et al. 2013 abstract];
- not working: rising heart rate or arousal. Stop.

4.10 Ocean disc breath and womb-like sound (RBL)

Purpose: provide a soft "whoosh" sound, entrained to the infant's breathing, that RBL describes as orienting, soothing and womb-like, to support sleep and quiet-alert states [source: Drexel Q&A 2013; HealthManagement summary; Remo RBL kit page].
Steps:
1. Tilt the ocean disc (a frame drum filled with small beads) slowly to make a wave-like sound.
2. Time each wave to the infant's breathing rate.
3. Keep it very soft, and stop at stress cues.
- [uncertain] Detailed RBL timing and volume parameters are not given in the sources.
Example language: not applicable.
Watch for:
- working: in the RBL trial, entrained breath sounds were followed by lower heart rate and changes in sleep patterns [source: Loewy et al. 2013 abstract].
- Schools disagree: a guidance document from the Standley/FSU tradition advises against womb-sound imitations such as whooshing drums and ocean discs. It argues that infants born before about 32 weeks do not retain womb sounds, and that these sounds give no rhythm or language input [source: Dräger NICU music document]. [uncertain] Follow the model your unit has adopted and your own training.

4.11 Song of kin and parent-preferred lullaby (RBL)

Purpose: use the family's own culturally meaningful songs, sung live, to support bonding, reduce parental stress and give the infant a familiar thread through to home [source: Loewy 2015 abstract; Loewy et al. 2013 abstract].
Steps:
1. Elicit the parents' chosen song(s) (see 4.1).
2. Sing them live in lullaby style, slow and soft, adapted to the infant's breathing and state.
3. Invite the parent to sing, with the therapist supporting.
4. Carry the song into discharge planning.
- [uncertain] The specific musical steps RBL uses to adapt a song (tempo, key, simplification) are not described in the sources.
Example language (illustrative): "Let's slow your song right down, like a lullaby. I'll start, and you join when you're ready."
Watch for:
- reported benefits: higher sucking and caloric intake were reported with parent-preferred lullabies, along with reduced parental stress [source: Loewy et al. 2013 abstract];
- songs with painful associations for the parents [synthesis].

4.12 Music psychotherapy for parents (RBL)

Purpose: give parents a non-confrontational space to express fear, anxiety and grief about the premature birth, and to build hope, security and containment, before or alongside their musical work with the infant [source: Loewy 2015 abstract; ArtEZ RBL training page].
Steps: [uncertain] The session procedures are taught in RBL training and are not detailed in the sources. As a [synthesis]:
1. Meet the parent away from the incubator if possible.
2. Invite them to choose or play music that fits how they feel.
3. Reflect on what comes up.
4. Agree how they want to bring their voice to the infant.
Example language (illustrative): "Before we go to the bedside, is there a song that fits how this week has felt?"
Watch for: acute distress, trauma symptoms or postnatal depression. Liaise with perinatal mental health services [synthesis].

4.13 Environmental music therapy (RBL)

Purpose: address the NICU sound environment for infants, families and staff [source: ArtEZ RBL training page; Aalborg 2018 First Sounds Tier II announcement].
Steps: [uncertain] The procedures are not described in the sources. Consistent with the sources on noise, a [synthesis]:
1. Observe and measure sound levels in the bay.
2. Agree quiet times with staff.
3. Replace unpredictable noise with soft, predictable live sound only where the levels allow, for example quiet guitar to replace unit noise [source: Drexel Q&A 2013].
Watch for: adding to noise rather than reducing it.

4.14 Lullaby singing and recorded music for pacification (Standley NICU-MT)

Purpose: pacify the infant, support sleep, and give early language input, using the family's native language [source: Standley 2014; Dräger document].
Steps:
1. Prefer live, infant-directed singing.
2. If recordings are used, choose music with:
  - voice alone or voice with one instrument;
  - a light rhythm, slow tempo and constant volume;
  - a higher vocal range (mother's voice preferred) in the family's language;
  - three chords or fewer and a repetitive lullaby structure;
  - selections that are varied over time.
3. Place speakers so the sound reaches both ears. Avoid headphones and free-field speakers in open bays.
4. Alternate 30 minutes of music with 30 minutes of silence, up to 4 hours a day.
5. Never leave a recording unattended with a high-risk infant.
6. Use music when the infant is awake, at sleep onset, during kangaroo care, or just after a painful procedure, never during one.
Example language: not applicable.
Watch for: the overstimulation cues in 4.21. Stop the music at once if they appear [source: Dräger document; Standley 2014].

4.15 Multimodal Neurologic Enhancement (MNE) (Standley NICU-MT)

Purpose: gradually build the infant's tolerance of layered sound, touch and movement, to reduce stress affecting sleep and neurodevelopment [source: Dräger document].
Steps:
1. Follow the staged progression taught in NICU-MT fieldwork. It begins with live lullaby singing and then adds touch, then rocking.
2. Stroke from the top of the body downward and from the midline outward.
3. Advance only while the infant tolerates each layer.
4. Step back at stress cues: pause about 15 seconds for subtle cues, and stop altogether for stronger ones.
- The full published sequence is taught in training and is not reproduced here.
Example language: not applicable.
Watch for:
- reported outcome: MNE given 15–20 minutes twice a week was associated with earlier discharge in one trial [source: Dräger document, citing Walworth et al. 2012];
- timing: the intervention is for infants ready for interaction, not the very immature (see Section 2).

4.16 Pacifier-Activated Lullaby (PAL)

Purpose: reinforce non-nutritive sucking with music, to build sucking strength, oral-motor control and suck–swallow–breathe coordination before oral feeding. It is also reported for infants with neonatal abstinence syndrome [source: Dräger document; Standley 2014].
Steps:
1. Typically start around 34 weeks, when the infant is preparing for breast or bottle feeds.
2. Coordinate with speech and language therapy and occupational therapy.
3. Fit the device: a pressure sensor in the pacifier, and a regulatory-approved device.
4. Set the criteria:
  - each suck burst meeting the set criteria plays lullaby music (often the mother's voice) for about 10 seconds, and the music stops unless sucking resumes;
  - the therapist adjusts the suck strength, sucks per burst and music length as the infant progresses.
5. Standley describes the music moving from a moderate to a slower tempo to lull the infant.
Example language (illustrative, to the parent): "Every time he sucks strongly, he hears your voice. That's helping him practise for feeding."
Watch for:
- working: stronger and more sustained sucking, and progress in oral feeds. Reported outcomes include faster feeding progress and shorter hospital stays [source: Dräger document, citing Chorna et al. 2014];
- fatigue or stress cues: end the session.

4.17 Music during kangaroo care (Standley NICU-MT)

Purpose: add soothing music during skin-to-skin holding once the infant is neurologically ready, from about 30–34 weeks [source: Standley 2014].
Steps:
1. Begin kangaroo care as per unit policy.
2. Add soft live or recorded lullaby, sung by the parent where possible.
3. Keep the music passive and avoid eliciting interaction at this stage.
Example language (illustrative): "Just hum, no need for words. She can feel your chest moving."
Watch for: stress cues, and parent fatigue.

4.18 Post-procedure recovery music

Purpose: help the infant return to sleep and stability after painful or stressful procedures [source: Standley 2014; Dräger document].
Steps:
1. Wait until the procedure has ended; music is contraindicated during it.
2. Offer soft lullaby or humming.
3. Stop if the infant does not settle.
Watch for: return to a calm state, and regular breathing and heart rate.

4.19 Parent and caregiver training in infant-directed singing and cue reading (Standley NICU-MT)

Purpose: extend the benefits beyond sessions by teaching parents, nurses and other caregivers infant-directed singing, multimodal stimulation and reading infant cues [source: Standley 2014; Dräger document].
Steps:
1. Demonstrate the engagement and stress cues on the parent's own infant.
2. Model singing and the changes to make: humming when the infant is stressed, more animation when engaged.
3. Watch the parent try, and give specific feedback.
Example language (illustrative): "See her fingers spreading? That's her saying 'a bit much'. Drop to a hum and see what happens."
Watch for: parents growing confident and adjusting to cues on their own.

4.20 Pairing the mother's lullaby with her scent (Standley NICU-MT)

Purpose: support attachment. Standley describes placing a cloth carrying the mother's milk in the isolette and pairing her lullaby with quiet rest [source: Standley 2014].
Steps:
1. Agree the cloth with nursing and infection-control policy.
2. Play or sing the mother's lullaby during quiet rest periods.
Watch for: unit infection-control rules [synthesis].

4.21 Sound environment, hearing safety and stop cues (all models)

Purpose: protect immature auditory systems and avoid overstimulation [source: Dräger document; Standley 2014].
Steps:
1. Measure music at the infant's ear on the C scale.
  - One guidance document gives 65–75 dBC for music, with background noise no higher than 50 dB.
  - Standley (2014) gives music below 65 dBC.
  - [uncertain] The sources differ; use the stricter limit and your unit's policy.
2. No headphones on infants (or on a pregnant abdomen), no earmuffs, mobiles, musical toys, radio, white noise or nature sounds, and no free-field speakers in open bays.
3. Test any equipment for interference with monitors and ventilators, and for tolerance of incubator heat and humidity.
4. Stop at the cues below.
Stop cues:
- Subtle (pause about 15 seconds, then retry): hiccoughs, grimace, clenched or averted eyes, tongue protrusion, finger splay, struggling movement.
- Stronger (stop all stimulation and let the infant rest): crying, fussing, cry face, spitting up or vomiting, a hand held out in a "halt" position, rising heart rate, irregular breathing, colour change, arching.
- Sources: Standley 2014; Dräger document.
For parents and staff: live singing at the bedside should be soft. Clinicians playing drums or amplified music in other settings should not carry those volumes into the NICU [synthesis].

4.22 Palliative and end-of-life sessions (CMT)

Purpose: offer music when the team recommends it or the parents request it in palliative care [source: Haslbeck & Bassler 2020].
Steps: [synthesis]
1. Follow the family's lead on songs, silence and who is present.
2. Keep the music soft and simple.
3. Offer to record, or write down, a family song if the family wishes and the unit allows.
Watch for: later grief triggers. A song used at the end of life may become painful or precious; ask the family before using it again, and refer for bereavement support [synthesis].

4.23 Documentation, team feedback and discharge music plan (CMT)

Purpose: integrate the work with the team and support continuity at home [source: Haslbeck & Bassler 2020].
Steps:
1. Document each session.
2. Feed back to staff and parents, and attend integrative rounds.
3. Write a final report before discharge with written home music recommendations.
4. Optionally, phone the parents about two weeks after discharge.
- Fully describe any music used: content, complexity, duration and dB level [source: Standley 2014].
Watch for: home recommendations that keep music soft, live and responsive, rather than continuous background audio [synthesis].

5. Handling problems

Much of the guidance below is the guide's own [synthesis]. Points drawn from the sources are tagged.

Infant unstable or a session is cancelled.
- Sessions happen only when the infant is clinically stable; they are often rescheduled, and the infant's needs override the parents' disappointment [source: Haslbeck & Bassler 2020].
- Response: explain this openly to the parents beforehand, offer the parent-only part (reflection, song choice, music psychotherapy) instead, and reschedule [synthesis].
Overstimulation during a session.
- For subtle cues, pause about 15 seconds, then retry more simply. For stronger cues, stop all stimulation and let the infant rest [source: Standley 2014].
- In CMT, narrow the range, go lower, slow down and repeat closing notes [source: Haslbeck & Bassler 2020].
- If overstimulation recurs, step back a developmental level: no interaction, quiet music only [synthesis].
No visible response, or a "stuck" plateau.
- Check the timing (feeds, procedures, sleep state), the sound level and the bay noise.
- Shorten the session, or change from the infant-only segment to kangaroo care if possible.
- Review the goals with the team. Physiological changes may be small and short-lived [synthesis; heart-rate effects as reported in the Cochrane plain-language summary 2023].
Parents reluctant to sing: embarrassment, "I can't sing".
- Familiarity matters more than voice quality [source: Dräger document].
- Response: start with listening only, then humming, then one line. Let the therapist sing first and the parent join, and never insist [synthesis].
- Illustrative: "Your baby isn't judging pitch. She's listening for you."
Parental trauma, grief and musical trauma triggers.
- A premature birth often brings fear, anxiety and grief [source: Loewy 2015 abstract].
- Some songs may be tied to an earlier loss, a traumatic birth, a deceased relative, or a song sung during an emergency.
- Monitor alarms and unit sounds can themselves become triggers for parents after discharge.
- Response:
  1. Ask about song associations before using them.
  2. Let parents veto any song.
  3. Offer a new song rather than a loaded one.
  4. Slow down or stop if the parent dissociates or becomes overwhelmed. Ground them with breathing and naming the present, and return to silence.
  5. Screen for postnatal depression, acute stress and PTSD symptoms through the unit's perinatal mental health pathway, and refer.
- [synthesis] This guidance is not detailed in the sources.
Non-adherence: parents not present or not practising between sessions.
- CMT allows sessions with other caregivers or the infant alone if parents are unavailable [source: Haslbeck & Bassler 2020].
- Response: explore the barriers (work, other children, travel, distress). Offer a short daily task, such as one song at kangaroo care, and involve the nurses [synthesis].
Rupture with parents. Examples: a parent feels pushed aside, criticised for their singing, or angry at a cancellation.
- Response: name it, apologise for your part, and return control (song choice, whether to sing, when to stop). Keep the therapist in a facilitator, not teacher, role [source for stance: Haslbeck & Bassler 2020; repair steps: synthesis].
Parents' wishes conflict with the infant's needs. Examples: wanting louder or longer music, recordings left running, mobiles or headphones.
- Response: explain the sound limits and the cues. Offer a compromise, such as more live singing during kangaroo care within limits [source on limits: Dräger document; Standley 2014; approach: synthesis].
Staff friction, noise, open bays and multiple infants.
- Avoid free-field music in open bays [source: Dräger document].
- Response: agree times with nurses, work at the individual bedside, integrate alarms rather than compete with them [source: Haslbeck & Bassler 2020], and share outcomes at rounds [synthesis].
Cultural and language fit.
- Use songs in the family's language and from their traditions, the song of kin [source: Loewy 2015 abstract; Dräger document].
- Use interpreters for the conversations, and never impose a "standard" lullaby [synthesis].
Conflicting models within one team (e.g. ocean disc use; decibel limits).
- Response: agree one written unit protocol, apply the stricter sound limit, and document the model followed [synthesis; conflicts as given in Section 4].
Infection control lapses. Disinfect hands, arms and instruments on entry and exit [source: Haslbeck & Bassler 2020]. Do not share instruments between infants without cleaning them [synthesis].
Infant deterioration or death. Offer palliative music if the team recommends it or the parents ask [source: Haslbeck & Bassler 2020]. Afterwards, offer bereavement support and care about reusing that song [synthesis].
Therapist distress. Arrange regular supervision, and debrief after deaths or critical events [synthesis].
Scope. A psychotherapist who is not a trained NICU music therapist should not deliver infant-directed interventions such as MNE, PAL, entrainment or the RBL instruments. Support parents psychologically and refer to the credentialed NICU music therapist [synthesis; training requirements per Haslbeck & Bassler 2020 and Standley 2014].

Sources

Sources:

Works cited through the sources above (further reading, not drawn on directly):

Haslbeck FB, Mueller K, Karen T, Loewy J, Meerpohl JJ, Bassler D (2023). Musical and vocal interventions to improve neurodevelopmental outcomes for preterm infants. Cochrane Database of Systematic Reviews, CD013472.pub2.
Standley JM, Walworth D (2010). Music Therapy with Premature Infants (2nd ed.). AMTA. [uncertain]
Walworth D et al. (2012), Neonatal Network (MNE trial), and Chorna O et al. (2014), Pediatrics (PAL with mother's voice). Both cited as given in the Dräger document. [uncertain: that document's page ranges may contain an error]

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