The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) as a Model for Clinical Music Therapy Interventions with Premature Infants

DEANNA HANSON ABROMEIT    The University of Iowa Hospitals and Clinics

                 The University of Iowa School of Music

ABSTRACT: The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) (Als, 1982, 1986, 1995, 1996; Als & Cilkerson, 1997) is a theoretical research-based model of nursing care that addresses the specific needs of the individual infant and is modified to meet the infant's developmental changes (Tribotti & Stein, 1992). Based on the NIDCAP model, clinical applications for music therapy practice with premature infants are addressed in three ways: Individualizing interventions, providing balanced sensory stimulation, and parental involvement. The use of recorded music and multimodal sensory stimulation are discussed. Included are guidelines for recorded music listening with premature infants.

Premature infants face enormous developmental challenges as they enter the world. During normal fetal development, the fetus is in a continuous state of reciprocal relationships. The early development of an infant's neurobehavioral subsystems (autonomic, motor, state, attentional/interactive systems and self-regulation) are interrelated and in turn support the development and differentiation of other systems (e.g., the sensory systems) (Als, 1982; Als, 1986; Tribotti & Stein, 1992). The ideal environment for these systems to develop is within the maternal womb. Unlike full-term infants, much of the preterm infants earliest development occurs in an environment vastly different from the maternal womb, which is ideally suited for these important neurophysical changes. Premature birth places infants in an unnatural environment and forces them to adapt to a much different array of stimuli and circumstances than that of the womb.

The environment of the premature infant differs in important ways from that of the womb. Sound in the nursery environment is often continuous, leaving little differentiation between day and night (Gardner & Lubchenco, 1998). In addition, sounds may be magnified, rather than attenuated. Causes of excessive noise may include the conversations of staff and family members, equipment alarms, monitors and motors. Further, the premature infant will experience multiple caregivers and will receive unnatural stimulation that may be painful, random, and lacking in interrelated interaction. These experiences may cause the infant's premature neurobehavioral subsystems to become defensive, leading to maladaptive and life threatening responses such as cardiorespiratory problems like apnea (cease in breathing) and bradycardia (heart rate that is too low) as well as stress behaviors (e.g., state lability, sleep deprivation and avoidance behaviors) (Gardner & Lubchenco, 1998). Long-term effects could include psychological concerns, attentional and school difficulties and lower IQ (Wolke, 1998).

In recent years, a growing body of literature has addressed thetherapeutic use of music to reduce the negative effects of the nursery environment and to promote healthy development. In a review of literature, Cassidy and Ditty (1998) noted that there is no standard protocol for presenting music to premature infants, thus encouraging music therapists to be proactive in developing standards of practice for this population. However, safe and appropriate interventions must be based on a broad understanding of premature development as well as the effects of the specific musical stimulus on the premature infant. The focus of this article is to describe a nursing model of premature infant development, the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) and how the theories and nursing practices of NIDCAP can provide a theoretical basis to begin forming appropriate clinical application of music therapy interventions with premature infants.

Therapeutic Uses of Music with Infants A number of studies have documented benefits of music in the nursery environment. The majority of this research has studied the effects of recorded music. Over the past decade, various types of acoustic stimuli have been studied: intrauterine maternal pulses with synthesized female vocals (Burke, Walsh, Oehler & Gingras, 1995; Collins & Kuck, 1991; Leonard, 1993; Marchette, Main, Redick & Shapiro, 1992), intrauterine sounds (Moore, Gladstone & Standley, 1994), lullabies (Caine, 1991; Cassidy & Standley, 1995; Moore, Gladstone & Standley, 1994; Standley & Moore, 1995; Standley, 1997), children's music (Caine, 1991), and classical music (Kaminski & Hall, 1996; Lorch, Lorch, Diefendorf & Earl, 1994; Marchette, Main, Redick & Shapiro, 1992). The effects of these stimuli have been examined with infants ranging in age from 24 weeks gestational age premature to healthy full-term newborns. All of these studies were conducted in a hospital setting using observation skills and/or medical monitors for data collection. The cumulative outcomes demonstrate positive benefits to the infant's overall health (physiological, behavioral, developmental).

Table 1 provides a summary of the primary outcomes from studies using recorded acoustic stimuli. As illustrated in Table 1 the presentation of recorded lullabies was the most often selected stylistic category, demonstrating a wider variety of outcomes.

In addition to studies regarding acoustical stimuli, researchers have also examined the effects of multisensory stimulation (Burns, Cunningham, White-Traut, Silvestri & Nelson, 1994;

Shoemark, 1999; Standley, 1998; Whipple, 2000; White-Traut & Tubeszeski, 1986). Auditory, tactile, visual and vestibular, or ATVV, multimodal sensory intervention is one prominent form of multisensory stimulation. ATVV is a systematic application of sensory stimuli that includes gentle massage and vestibular rocking paired with auditory stimuli of talking or singing and visual stimuli in the form of the face position of the caregiver (White-Traut & Tubeszeski, 1986). A decision tree has been developed to modify ATVV stimulation to the individual responses of each premature infant (Burns et al., 1994). The decision tree provides parameters to adapt the stimulation based on the infants physiological and behavioral cues (Burns et al., 1994; Shoemark, 1999b).

Originally the ATVV multimodal sensory stimulation intervention used primarily speech as the auditory stimulus. Subsequently, Standley (1998) modified the ATVV intervention to include humming as the auditory stimulation. In Standley's study, 40 premature infants (greater than 32 weeks gestational age) who were exposed to ATVV demonstrated greater weight gain per day than a control group who received more conventional care.

Table 1

Outcomes from the Presentation of Recorded Music to Infants

Decreased heart rate                     Collins & Kuck (1991);

Improved behavior state                 Burke et al. (1995); Leonard (1993)

Lullabies      Increased oxygen levels on Day 1        Cassidy & Standley (1995); Moore et al.

                                                                              (1994); Standley & Moore (1995)

Decreased heart rate                Collins                      Decreased heart reate                        Collins& Kuck (1991); Marchette et al.(1992)

Decreased heart rate on Day 1 only  Cassidy & Standley (1995)

Improved behavior state                   Caine (1991)

Decreased hospital stay                    Gained 991)

Decreased initial weight loss              Caine (1991)

Reinforced non-nutritive sucking         Standley (1997)

Decreased formula intake, number      Caine (1991)

 of days of oral feeding

Decreased oxygen levels following      Standley & Moore (1995)

Termination of music on Day 2 & 3    

Increased heart rate on Day 2 & 3       Cassidy & Standley (1995)

Classical          Improved behavior state                        Kaminski & Hall (1996)

Variation in physiological response        Lorch et al. (1994)

dependent on type of music presented

(stimulative vs. sedative)

      In 1999, Shoemark introduced another adaptation of the ATVV protocol (Shoemark, 1999a, 19996). She used short,melodic phrases as the auditory stimuli to an infant 24 weeks after he was born (at 27 weeks gestational age) to encourage positive vocalizations (e.g., cooing). Shoemark also adapted the decision tree for clinical care to reflect the change in the auditory stimulation. This adaptation increases the music therapist's control over the stimuli and helps to prevent overstimulation of the infant. From a review of available literature, it is difficult to characterize

the most appropriate auditory stimulation, especially given the individualistic nature of infant responses. Suggestions include simulating the maternal environment as closely as possible (Glass, 1994), perhaps through the use of simulated womb sounds. However, at present little is known about the actual realistic replication of the womb sound recordings presented to the premature infant. Furthermore, it may be argued that the nursery is already a noisy, overstimulating environment so that it may be contra-indicated to add more acoustic stimuli such as music.

Nursery environments strive for an overall quiet and calm auditory environment. Compared to other environmental sounds, musical sound waves have organized structural characteristics of pitch, dynamics, timbre and harmony. The structural characteristics of music can be introduced at a level of complexity that each infant can handle. Music can be adapted to fit infants in their patterns of behavior organization and ability to handle specific stimuli and can change as they do.

Table 2

Music Therapy Outcomes Related to NIDCAP Outcomes

Improved behavior state                                 Improved neurobehavioral organization

Increased oxygen saturation levels                  Decreased days on ventilatorand supplemental  oxygen; extubated sooner

Promotes intimacy between parent/ infant         Increased parent infant bonding

Increased mean weight gain                              Increased daily weight gain

Improved non-nutritive sucking                         Earlier nipple feeding

Other benefits--Music therapy                          Other benefits--IDCAP

Decreased heart rate                                         Fewer long-term developmental delays

Decreased respiratory rates                               Fewer medical complications

Decreased hospital costs

Music can be adapted to fit infants in their patterns of behavior organization and ability to handle specific stimuli and can change as they do. The extent through the use of sensitive and appropriate clinical indicators within the control of the neonatal nursery.

Furthermore, wholesale use of music is problematic. Music that may be appropriate for other populations (e.g., music used therapeutically with full-term infants, school aged children or adults) may not be appropriate for premature infants, and responses may vary considerably with the individual. Due to the complicated medical and developmental issues faced by premature infants it is important to introduce any stimulation in an individualized manner.

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) has been designed to help structure and individualize neonatal care and provides a model for the neurobehavioral development of the premature infant. The outcomes of NIDCAP studies have demonstrated very similar benefits as those identified in research regarding the therapeutic use of music for young infants. Table 2 illustrates the compatibility of NIDCAP and music therapy through their documented benefits (Brown & Heermann, 1997; Burke etal., 1995; Caine, 1991; Cassidy & Standley, 1995; Collins & Kuck, 1991; Kaminski & Hall, 1996; Lawhon, 1996; Leonrd, 1993; Marchette et al., 1992; Moore et al., 1994; Standley, 1997, 1998). NIDCAP offers the music therapist guidelines for selecting stimuli and interventions, and assessing outcomes.The following sections provide an overview of the principles and application of NIDCAP, and its relevance to music therapy programming for premature infants.

A Description of The Newborn Individualized Developmental Care and Assessment Program (NIDCAP)

In an effort to minimize the adverse reactions that premature infants have to their environment, neonatal specialists are adopting changes in the approach to neonatal care. One notable change is the reduction of standardized protocols and procedures for all infants, and greater emphasis on care based on relationships between the individual infant and his or her caregiver (Als & Gilkerson, 1997). The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is a theoretical research-based model of nursing care that addresses the specific needs of the individual infant and is modified to meet the infant's developmental changes (Tribotti & Stein, 1992). NIDCAP provides a foundation upon which caregivers in the special care nursery environment can provide "neurodevelopmentally supportive, individualized and family-centered" care (Als, 1996, p. 4).

The NIDCAP model describes the infant as being in a continuous interaction with its subsystems (the autonomic, motor, state, attentional/interactive systems) of development and selfregulation, which are influenced by the environment. These interrelated subsystems are supportive to the development and differentiation of the other systems and modeled as concentric

circles that provide continuous feedback to the other systems and environment (Als, 1982, 1986; Tribotti & Stein, 1992).

During normal fetal development these subsystems are developmentally supported in the maternal environment (Tribotti & Stein, 1992). NIDCAP provides a model to support this development within the nursery environment. The goal of NIDCAP is to reduce an infant's stress behaviors and increase his or her ability to self-regulate through assessment of behavioral cues and individualized interventions, thus improving their medical and developmental outcomes (Als, 1986).

Within the NIDCAP model, diagnosis and prognosis can be made through the Assessment of Preterm Infants' Behavior (APIB) (Als, 1996). The APIB is a systematic and comprehensive

assessment tool designed specifically for use with premature infants and at-risk newborns (Als, 1982, 1986, 1996). The assessment focuses on specific tasks to determine the regulation and balance of the infant's subsystems and identifies the infant's response in three ways: tasks which are already well integrated; tasks which stress the infant but can be handled with support; and tasks which are clearly not appropriate for the infant at this stage. Assessment tasks are "graded sequences of increasingly vigorous environmental inputs or packages, moving from distal stimulation presented during sleep to mild tactile stimulation, to medium stimulation paired with vestibular stimulation" (Als, 1986, p. 18). Assessment of the interactive/attentional subsystem is a priority in order to encourage the infant's behavioral organization. These tasks are presented when the infant's behavioral organization indicates their receptiveness (Als, 1982, 1986).

The APIB details individual responses to the tasks using a classification of stress and defense behaviors, as well as selfregulatory and approach behaviors. An understanding of theMusic Therapy with Premature Infants infant's behaviors allows for the implementation of appropriate developmental goals. Behaviors are categorized by the autonomic, motor, and state subsystems. Autonomic stress and defense behaviors can include seizures, respiratory pauses, irregular breathing and holding of breath, color changes, spitting up, hiccoughing, gasping, coughing, yawning, sighing, startling and sneezing. Motor stress signals can include flaccidity, hyperextensions of legs, arms or trunk, fingersplays, facial grimacing or hyperflexions, as well as frantic activity and squirming. Stress signals for state related behaviors can include sleeplessness, crying, irritability, hyper-alertness, staring, and roving eye movements (Als, 1982, 1986).

In contrast, smooth respiration and a pink, stable color can indicate stability of the autonomic system. Motor stability indicators include regulated muscle tone, smooth movements,

hand clasping, sucking and hand-to-mouth actions. The infant has stable state and attention regulation when they demonstrate clear, robust sleep states, rhythmical crying, ability to self quiet, alertness, animated facial expression, cooing and smiling (Als, 1982, 1986).

The basis of the APIB is that the infant will demonstrate behaviors that protect it from inappropriate stimuli in timing, complexity and intensity. In addition, the infant will be able to maintain a balanced integration of its subsystems, as well as an ability to attend to stimuli that is appropriately timed, complex and intense. The goal of this assessment is to evaluate the infant's observed behaviors in response to sensory stimulation (Als, 1986).

Because caregivers can learn valuable information from observation of the infant in their environment, a guide for implementing systematic and natural observation, the Naturalistic Observation of Newborn Behavior (NONB) has been developed as an assessment tool of the APIB. The NONB Sheet allows the caregiver to collect infant stress and self-regulatory responses to their autonomic, motor and state organizational sub-systems as they relate to their environment and to caregiving interactions. These observations allow the caregiver to modify the interactions and the environment in a manner that best supports the infant's development (Als, 1995). Thus, therapists

have tools to assess the infant's ability to handle sensory stimulation.

NIDCAP training and certification for the use of the APIB is extensive and costly1 (Als, 1986, 1996). However, music therapists can use the NIDCAP framework for assessment and intervention guidelines in order to design and adapt interventions appropriate to the individual needs of the premature infant. Therefore, collaboration with NIDCAP certified nurses and extensive training with the nursery staff can be an important professional prerequisite for music therapists who plan to work in a neonatal unit utilizing developmental care mod els. The following section describes in greater detail how principles of NIDCAP can be integrated into music therapy practice with high-risk infants.

NIDCAP as a Model for Music Therapy Practice

Three principles may make interventions most effective for the premature infant. First, interventions should be individualized to the infant's needs and responses. Second, balanced stimulation should be provided to encourage developmental growth yet avoid overstimulation. Third, interventions should involve the parents (Gardner & Lubchenco, 1998).

Individualizing Interventions

Music therapy interventions can be individualized by responding to the infant's behaviors, development, and medical stability through reciprocal and adaptable interactions matched to the infant's level of organization and development as is recommended in the NIDCAP model (Burns et al., 1994). Understanding the premature infant's ability to maintain a balanced integration of his or her subsystems as well as understanding how the sensory systems develop are vital for the therapist providing early intervention.

Goals for premature infants can be global in nature, whereas the application of the interventions are guided by the goals and individualized to each infant's stability and behavior organization. Following the NIDCAP guidelines, music therapists should address the following general goals: First, support the infant's neurobehavioral and sensory system development; second, increase developmentally appropriate interactions that address social, emotional, cognitive, motor and communication development; and third, increase opportunities for developmentally appropriate normal caregiver (staff and parent) interaction. Once an assessment has been completed and goals set, the music therapist must determine how to present balanced stimulation.

Providing Balanced Stimulation

Balanced stimulation can be passive or interactive, and can range from simple to more complex stimuli, depending on the infant's age and developmental maturity. Similar to the reciprocal relationship of the neurobehavioral subsystems, the development of the sensory systems is also reciprocal in that the maturity of early sensory systems is believed to influence the development of the later ones (Lickliter, 1993). Based on years of empirical data, Gottleib (1983) determined that the onset of sensory systems in a wide variety of species including humans-develop in the order of tactile, vestibular, gustatoryolfactory, auditory and visual. Subsequent studies support these findings (Lickliter, 1993).

Based on the hierarchical and integrative development of these sensory systems, Glass (1994) has identified two principles to guide the implementation of sensory intervention for the vulnerable newborn. First, sensory stimulation should begin with the most mature system (i.e., tactile, vestibular, auditory, visual) (Gottlieb, 1983), and second, the best sensory stimulation is that which is similar to what the mother pro-vides, as it is the most natural to both the fetus and the newborn (Glass, 1994). These two principles regarding appropriate stimulation will guide the selection and implementation of individualized interventions. That is, the music therapist should

consider, in conjunction with music therapy goals, whether the infant is able to process the stimuli and the conditions for the presentation of music or aural stimuli (Cassidy & Ditty, 1998).

Observational assessment of the infant's ability to process stimuli can be accomplished using the NONB Sheet (Als, 1995). Careful observation of the infant in its environment provides the music therapist with information regarding a given infant's behaviors that indicate stress and self-regulation, what sorts of stimuli are stressful to the infant, and how that infant interacts with the therapist. The NONB Sheet offers an organizational structure for the assessment through a frequency count of commonly observed stress and self-regulatory behaviors in addition to heart rate, oxygen saturation, respiration rates and positioning. Through observational assessment of the

infant's behaviors in the nursery environment the music therapist will be aware of the infant's signals of stress and selfregulation in order to appropriately adapt the intervention. In addition to an observational assessment, the music therapist should review the infant's chart and medical history, as well as communicate with nursing and other medical staff.

Selecting Stimulation

The collective literature on music therapy with premature infants illustrates two emerging trends in the manner of aural stimulation to this population: (a) use of recorded music and (b) live humming or singing paired with other sensory system stimulation. The majority of studies to date have used recorded music as the mode of auditory stimulation with beneficial outcomes (Burke et al., 1995; Caine, 1991; Cassidy & Standley, 1995; Collins & Kuck, 1991; Kaminski & Hall, 1996; torch et al., 1994; Marchette et al., 1992; Moore et al., 1994; Shoemark, 1999; Standley & Moore, 1995; Standley, 1997).

Recorded music is available at anytime, convenient for nurses and other caregivers to use and an affordable form of developmentally appropriate stimulation. It can be useful in helping an infant transition from an agitated state (e.g., distressed facial expression, vocal fussing, motor arousal) to a more quiet, drowsy or sleep state (Shoemark, 1999a). Unfortunately, recorded music cannot be as easily adapted as live music to the infant's changing behaviors.

For example, one of the key features of many musical selections is a wide dynamic range, that is, large changes in sound volume (e.g., solo to large ensemble, or pianissimo to forte interpretation of dynamics). Thus, one musical recording may provide a suitable and safe level of stimulation at one point, and seconds later be too loud and thus overly stimulating. In short, recorded music must be carefully monitored by caregivers to ensure it is a safe and developmental ly appropriate sensory stimulation.

There are many musical sounds that have been recommended for healthy babies. Some may be inappropriate for the premature infant's sensitivity to sensory stimulation. The Guidelines for Music Listening in the Appendix present a framework for music therapists to use as a guiding principle in the design of recorded sound stimulation for medical staff and families in neonatal units. The Guidelines do not offer a prescriptive use of recorded music for music therapy interventions, but do provide a basis for incorporating music listening in the nurseries in a safe, appropriate and normalizing manner. Recommendations include type and location of playback equipment, music selections, volume levels, and appropriate duration and use of recorded music stimulation. Live singing is briefly addressed to offer suggestions for its use by caregivers (staff and families) within the context of their daily caregiving activities.

The Guidelines for Music Listening were a collaborative effort between the music therapist and nursing staff at a Level III (indicates a statewide regionalization guide for the highest level of neonatal care) neonatal care unit in a large Midwestern teaching hospital. They have been used in this facility and written into the standards of practice for the Special Care Nurseries. The Guidelines for Music Listening incorporate NIDCAP principles, as well as recommendations from the music therapy and nursing literature and clinicians in other centers (H. Shoemark, personal communications 1998, 1999, 2001; J. Standley, personal communications 1998, 1999).

More recently, multimodal stimulation has emerged as a viable music therapy intervention for premature infants (Shoemark, 1999a, 19996; Standley, 1998; Whipple, 2000) in which live singing or humming is paired with additional sensory stimulation such as touch and rocking. In keeping with the NIDCAP philosophy, multimodal stimulation introduces sensory stimulation in a systematic manner adapting to the infant's ability to handle the sensory stimulation in a balanced

and integrated way (Burns et al., 1994; Shoemark, 1999a, 1999b; Standley, 1998; Whipple, 2000; White-Traut & Tubeszewski, 1986).

The lullaby, a musical form traditionally viewed as an appropriate type of stimulation for infants, is often used in multimodal stimulation. The lullaby is the most common form of auditory stimulation studied in the literature, in part because of its common use for comfort in cultures around the world. Lullabies may provide a tool to regulate an infant's behavior state (i.e., calming down, attention focused more on self) allowing the infant to communicate emotional information

(Rock, Trainor & Addison, 1999). The lullaby can easily become multimodal if the singer provides tactile (touch between the caregiver and infant), vestibular (a natural rocking or swaying

motion), auditory (presentation of song) or visual (caregiver) sensory stimulation.

Singing directly to the infant may encourage a reciprocal relationship in that infants have demonstrated a preference to infant-directed singing (that which is sung in the presence of an infant) (Trainor, 1996). Perhaps infant-directed singing contains prosodic qualities of a communicative intent by the adult (Fernald, 1989). Multimodal stimulation, using the lullaby, provides a structure for the music therapist to follow in im-plementing an intervention that is completely adaptable to the infant's immediate responses. It is also a type of music-based intervention that can be taught to parents (Whipple, 2000).

Involving the Parents in Care

Historically, parents around the world have comforted and nurtured their infants with music, especially the lullaby. Because music is found across cultures in various forms and is often a natural part of nurturing (e.g., lullaby music may provide a normalizing factor), music may help families in the nurseries to connect to their babies on a personal and intimate level. Instruction in music-based activities that supports parents' successful and positive interaction with their infant sustains a family-centered approach (Koch, 1999). Family-centered music therapy interventions allow families to reflect their values and preferences, and may foster in them a greater sense of confidence. For example, encouraging parents to sing to their infants' favorite songs in a lullaby manner (e.g., singing the chorus of a popular song at a slow tempo) may instill a greater comfort level in the parent as compared to an unfamiliar song such as a traditional children's lullaby or song. It also allows the parents an opportunity to express their preferences, either culturally or personally to their infant. Parents who are uncomfortable singing directly to their infant can be encouraged to use appropriate recorded music or taped versions of their voice. Taped recordings of an infant's mother's voice have demonstrated positive benefits to premature infants (Nocker-Ribaupierre, 1999).

Written instruction in a family-friendly manner (i.e., nontechnical terms, clear and familier wording) reinforces therapist modeling and consultation in the use of music. For example, when choosing recorded music that is both appropriate and specific to the individual infant, provide a family-focused guide that highlights relevant information. Presenting families with information on the types of appropriate music, when to play or stop the music, and the importance of safe volume levels (see Appendix) can provide a reference to families to support therapist consultation. As parents become more comfortable identifying their infant's stress responses (Koch, 1999), they can initiate the use of music interventions themselves (Shoemark, 1999) thus providing a calmer environment with fewer disruptions and variability (Whipple, 2000).

Conclusion

Within the collective literature on the therapeutic application of music, a trend has emerged in which infants are exposed to two types of aural stimulation: recorded music or live singing, or humming paired with other sensory system stimulation. This literature indicates positive trends in infant outcomes that complement the developmental care literature. Basing music therapy interventions on a theoretical researchbased model of nursing care, such as NIDCAP, gives the music therapist a foundation in which to provide individualized interventions that match the musical stimulation to the behavioral responses of the infant.

Behavioral responses of individual infants to musical stimulation can be measured using the Naturalistic Observation of Newborn Behavior (NONB) Sheet (Als, 1995). The Guidelines for Music Listening in the Appendix provide a framework for appropriate music selections and presentation. Infant-directed singing encourages reciprocal relationships and communication between the caregiver and infant (Trainor, 1996; Fernald, 1989). Infant-directed songs sung in a lullaby fashion may be most effective as infants become more self-focused and calm (Rock, Trainor & Addison, 1999).

Unfortunately, not all aspects of clinical practice with this population can be addressed within the scope of this article. However, it is hoped that music therapists and medical staff will take into consideration the broad scope of practice and clinical expertise required for the application of music therapy interventions in the nursery environment. The music therapist is the expert on matching the appropriate music to the needs of the infant while the medical and nursing staff provide the medical guidance. At this time, music therapy with premature infants is a limited area of practice, but with continued clinical practice by music therapists knowledgeable in the issues of premature infant development, clinical research (both quantitative and qualitative) and collaboration between disciplines, standards of practice can be further developed. Nevertheless, a music therapy program that is built on current researchbased knowledge, adapts to the individual needs of the infant, and is multi-disciplinary and family-centered will compliment the medical care of premature infants and ultimately benefit their development and families.

The music therapist is the expert on matching the appropriate music to the needs of the infant while the medical and nursing staff provide the medical guidance.

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Additional References

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Panneton, R. K. (1985). Prenatal auditory experience with melodies: Effects on pontnatal auditory p