CONTEXT: Given the recent expansion of research in the area of music therapy (MT) for preterm infants, there is a need for an up-to-date meta-analysis of rigorously designed studies that focus exclusively on MT.
OBJECTIVE: To systematically review and meta-analyze the effect of MT on preterm infants and their parents during NICU hospitalization and after discharge from the hospital.
DATA SOURCES: PubMed/Medline, PsycINFO, Embase, Cochrane Database of Systematic Reviews, CINAHL, ERIC, Web of Science, RILM.
STUDY SELECTION: Only parallel or crossover randomized controlled trials of MT versus standard care, comparison therapy, or placebo were included.
DATA EXTRACTION: Independent extraction by 2 reviewers, including risk of bias indicators.
RESULTS: From 1803 relevant records, 16 met inclusion criteria, of which 14 contained appropriate data for meta-analysis involving 964 infant participants and 266 parent participants. Overall, random-effects meta-analyses suggested significant large effects favoring MT for infant respiratory rate (mean difference, –3.91/min, 95% confidence interval, −7.8 to −0.03) and maternal anxiety (standardized mean difference, –1.82, 95% confidence interval, −2.42 to −1.22). There was not enough evidence to confirm or refute any effects of MT on other physiologic and behavioral outcomes or on short-term infant and service-level outcomes. There was considerable heterogeneity between studies for the majority of outcomes.
LIMITATIONS: This review is limited by a lack of studies assessing long-term outcomes.
CONCLUSIONS: There is sufficient evidence to confirm a large, favorable effect of MT on infant respiratory rate and maternal anxiety. More rigorous research on short-term and long-term infant and parent outcomes is required.
- GA —
- gestational age
- HR —
- heart rate
- KC —
- kangaroo care
- MT —
- music therapy
- O2 SAT —
- oxygen saturation
- RCT —
- randomized controlled trial
- RR —
- respiratory rate
- SMD —
- standardized mean difference
- STAI —
- State-Trait Anxiety Inventory
Preterm birth and prematurity is a major medical, psychological, and socioeconomic problem worldwide. More than 1 in 10 of the world’s newborns are born prematurely, corresponding to 14.9 million premature infants each year.1 Children born prematurely are vulnerable to mortality, morbidity, and various forms of disability, neurodevelopmental disorders, developmental delays, and long-lasting sequelae.2 Perinatal interventions may significantly impact long-term growth and development in high-risk preterm infants.3 Cautious, infant-specific, nonpharmacological early intervention methods, such as kangaroo care (KC) and music therapy (MT), have been initiated in NICUs to minimize adverse short- and long-term consequences of prematurity. The evidence base supporting the use of MT in the NICU is gradually accumulating, with positive immediate and short-term outcomes demonstrated for a variety of MT approaches.4 More than 400 professional music therapists worldwide have obtained specialized training in MT in the NICU,5,6 and ∼50% of the top 25 US children’s hospitals offer MT in their NICUs.6
MT within the setting of prematurity relates to the informed use of music and aspects of a therapeutic relationship to promote optimal infant development and facilitate secure attachment with primary caregivers. When used within a NICU environment, MT may facilitate infant sensory regulation7 and promote ongoing neurologic development. Music therapists tailor MT to the developmental readiness of the neonate and may include live or prerecorded music with a focus on the infant or on the caregiver/infant dyad. Music therapists can help caregivers recognize engagement/disengagement cues and support caregivers in using infant-led musical interactions to facilitate developmental progress while promoting bonding.
Six systematic reviews of MT and music-based interventions for premature infants have been published.4,8–12 Three of these reviews4,9,10 followed reporting guidelines outlined in the PRISMA statement.13 None of the aforementioned 6 reviews required music therapist involvement (in either development of or implementation of the MT protocol) as a condition of inclusion, and a majority of these reviews included studies with designs that are less rigorous than randomized controlled trials (RCTs).4,8,9,11,12 The single systematic review that restricted inclusion to RCTs included music-based interventions without music therapist involvement.10 The results of Hartling et al10 demonstrate preliminary evidence that music may have beneficial effects on physiologic parameters, behavioral states, oral feeding rates, and pain among preterm infants, although the authors did not complete meta-analysis because of heterogeneity in outcomes, interventions, and populations.10 The motivation to conduct the current systematic review was to provide an updated analysis of RCTs specific to MT as implemented by or in consultation with a trained music therapist. The requirement for music therapist involvement helps assure that at least an entry-level understanding of the theory, practice training, and research related to the professional use of MT for premature infants has been achieved.
The objective was to review RCTs to examine the effects of MT versus standard care or standard care combined with other therapies for preterm infants and their parents/caregivers during NICU hospitalization and after discharge from the hospital.
We searched electronic databases for eligible studies and hand-searched reference lists from existing review papers. We screened the following databases: PubMed/Medline, PsycINFO, Embase, Cochrane Database of Systematic Reviews, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Education Resources Information Center), Web of Science, and RILM. Databases were searched using the following terms: (prematur* OR preterm OR neonat* OR low birth weight OR LBW OR parent OR caregiver OR NICU) AND (music* OR music therap* OR auditory stimulation) AND (randomized controlled OR randomised controlled OR RCT). Searching was not restricted to any language, reference type, or year of publication. Unpublished studies were included, but no additional steps were taken to locate unpublished material.
One reviewer screened database search results to identify relevant titles and abstracts. All potentially relevant records were extracted to EndNote reference management software. Duplicates were detected and deleted, and 2 reviewers independently inspected titles and abstracts of potentially relevant records to exclude irrelevant reports. Studies were included if they met the following criteria:
Participants: children born prematurely, defined by the World Health Organization as birth before 37 completed weeks of gestation, or fewer than 259 days since the first day of the woman’s last menstrual period,14 and their parents/caregivers. We aimed to include children up to 3 years of age who were born preterm, to assess longer-term neurodevelopmental outcomes of this high-risk group.3 There were no restrictions as to gender, ethnicity, or type of setting.
Intervention: all forms of MT carried out by, or in consultation with, a trained music therapist, conducted in hospital, community, or home settings.
Comparison: trials in which MT combined with standard treatment is compared with: standard care alone; standard care combined with other therapies; or standard care with placebo. Placebo treatment could involve the use of headphones to deliver silence or nonmusic auditory stimuli (eg, white noise).
Outcomes: reported at least 1 outcome of the following domains: psychodevelopmental, behavioral, physiologic, anthropometric, socioemotional development, parental functioning, adverse effects, and length of hospitalization.
Study design: RCT studies (parallel and crossover).
Two reviewers reviewed and independently assessed full texts to determine eligible studies. Any disagreements were resolved through discussion with a third reviewer. When information about music therapist involvement was not reported or unclear in the paper, we contacted authors for clarification.
Data Collection and Extraction Process
Two reviewers independently extracted data and confirmed accuracy using a shared, pilot-tested data extraction sheet for information on participants, interventions, control conditions, outcomes, and results. We contacted study authors via e-mail to request missing data or for clarification and provided each with an individualized data table for reporting the requested data. Risk of bias was assessed by 2 reviewers independently, using the Cochrane risk of bias tool.15 Any discrepancies were resolved through consultation with the third reviewer.
Relevant outcomes for which data were available from >1 study were aggregated using meta-analysis; outcomes where data were available for only 1 study were described narratively. In the meta-analyses, we analyzed means and SDs of end-point data for intervention and control conditions. When >1 treatment condition included music, the intervention that used live music was selected for analysis instead of the recorded music group. The preference for live music interventions and use of sung voice is consistent with active MT approaches that are individually tailored to infant and infant/parent dyadic responses. When >1 treatment condition used live music, we selected the intervention that most strongly reflected the authors’ theoretical rationale for the study (frequently the first-listed MT intervention). When there were multiple MT conditions with equivalent intervention that varied by frequency of intervention, we selected the MT condition with maximal frequency for analysis. When MT was compared with a nonmusic comparison condition and a standard care condition, we selected the standard care condition as a basis for comparison. We selected end-point data immediately postintervention for treatment and control groups. When studies included >1 postintervention end point, the data point directly after completion of intervention was selected for analysis. When data were reported for clinical subgroups (eg, based on gender or gestational age [GA]) but were not available for the whole sample, we calculated weighted means and pooled SDs to obtain a single result for each study outcome to avoid artificially inflated heterogeneity estimates between studies.
Meta-analyses for each outcome were performed using weighted mean differences on the original metric when possible (ie, when the outcome was measured on the same scale, or could be transferred to the same scale, in all included studies assessing that outcome). When different scales were used for the same outcome, we used effect sizes (standardized mean differences [SMD]; Hedges’ g). We interpreted effect sizes in line with common guidelines (ie, 0.2, small; 0.5, medium; 0.8, large16;). For crossover studies, SEs depend on the correlation between measurements, which is often not reported. We assumed a correlation of 0; that is, we analyzed data from crossover trials as if they were from parallel trials. This approach is conservative because crossover trials are underweighted.15 We calculated fixed-effects and random-effects meta-analyses and inspected I2 as a measure of heterogeneity. Because heterogeneity was high for most outcomes, we only present random-effects meta-analyses. We inspected study design (parallel versus crossover) and clinical characteristics (treatment frequency, postmenstrual age at study start, birth weight) as potential sources of heterogeneity. Although we had planned to address these sources of heterogeneity quantitatively by subgroup analyses or meta-regression, we refrained from such advanced analyses because of the limited number of studies per outcome, and relied instead on visual examination of the figures (except for study design). Meta-analyses were performed using R (Version 3.2.3, GNU project, Boston, MA) and R package meta. We analyzed all subjects who were assigned to the treatment intervention regardless of whether they received the full treatment or not (intention-to-treat).
We identified a total of 1803 records from electronic searching and 20 studies from hand-searching. The last date of searching was April 29, 2015. After excluding duplicates and clearly irrelevant references, we obtained 74 studies to assess for eligibility. Of these, 16 met inclusion criteria and were included in the systematic review (Table 1); most of these (14) also had usable data for meta-analyses (Fig 1). The final sample included 6 crossover RCTs,7,17–21 6 RCTs with 2 parallel arms,22–27 and 4 RCTs with 3 parallel arms.28–31 Sample size ranged from 22 to 272 participants with a median of 52. Table 1 displays study characteristics.
Selected trials included a total of 1071 infant participants (496 female, 46%) and 286 parent participants. Six trials included parents/caregivers,7,17,21,23,26,29 with 1 trial specially targeting mothers.26 Fathers participated in at least 2 studies,7,29 but were not specifically targeted in any study. Recruitment settings included NICU level I, level II (intermediate care to grow and gain feeding skills), and level III (high-risk care for infants requiring advanced treatment to sustain life), and no included studies provided MT after discharge from the NICU. GA, defined as the time elapsed between the first day of the last menstrual period and the day of delivery,32 varied from 24 to 37 weeks with a median of 32 weeks. Birth weight varied from 620 g to 2715 g. Infants’ postmenstrual age at study start (the sum of GA, as defined above, and chronological age [the time elapsed since birth32]) varied from 27 to 47 weeks. All trials included medically and clinically stable preterm neonates. Some studies included infants with all grades of periventricular leukomalacia or/and intraventricular hemorrhage24,31; respiratory distress syndrome, clinical sepsis and small size for GA7; and chronic lung disorders or oxygen dependency.20,22
There was marked variation across studies for type of MT approach used, with lullabies being the most common, often with parents providing live, infant-directed lullabies.7,17,18,23 Use of recorded lullaby music20,22 or exposure to recorded maternal voice19 were less common. Other variations included use of the Pacifier Activated Lullaby system to promote nonnutritive sucking,25,27,30 Pacifier Activated Lullaby combined with mother’s recorded voice,24 parent-focused interactive MT,26 and developmental multimodal stimulation either with accompanied or unaccompanied live lullaby singing.31 The majority of studies (n = 13) compared MT combined with NICU standard care to standard care alone,7,18–20,22–28,30,31 and 3 studies compared KC combined with MT to KC alone.17,21,29 In all studies, trained music therapists were involved in at least 1 aspect of study design or implementation.
Of 45 different outcomes in the included studies, 39 were deemed directly related to our outcome inclusion criteria. We consulted with a panel of neonatal researchers to determine which of these outcomes were most clinically relevant and included those outcomes in meta-analyses if they were available from >1 study. Other relevant outcomes were summarized narratively (see Table 1).
We present outcomes of the meta-analyses first, followed by outcomes described narratively. Within those 2 sections, we organize presentation of the results by time span: immediate (during or directly after a single intervention session), short-term (after the completion of the intervention period), and long-term outcomes (posthospitalization); and by level (infant, parent, service-level), as data permits.
Effects of MT Versus Standard Care: Results of Meta-analyses
An overview of the meta-analysis results is given in Table 2.
Immediate Effects of MT on Infant Well-Being: Physiologic
Immediate physiologic outcomes that were meta-analyzed included heart rate (HR), respiratory rate (RR), and oxygen saturation (O2 SAT; Fig 2, Table 2). Overall, we found significant effects favoring MT for RR (P = .048), a nonsignificant trend favoring MT for HR (P = .058), and no effect on O2 SAT (P = .431; Table 2). Heterogeneity was high for HR and RR but not for O2 SAT; this heterogeneity was not explained by study design (Table 2). Visual inspection of results for HR (Fig 2A) suggested Johnston et al19 as a potential outlier. The authors of this study noted that the volume of the recorded mother’s voice used as a sound stimulus might have been too high. For RR, although there was no obvious outlier (Fig 2B), the study showing the least beneficial effect27 provided MT offered during a painful procedure. Overall, the results suggested that MT reduced infants’ RR by 3.91 breaths per minute (Fig 2B).
Immediate Effects of MT on Infant Well-Being: Behavioral
Immediate behavioral outcomes included measures of behavior state and behavioral distress. Behavior state was assessed with slight variations. Three studies17,18,21 used a 7-point behavior state numeric rating scale (adapted from refs 33,34), 127 used continuous recording of 6 behavior states (adapted from ref 33), and 17 evaluated the percentage of time in an active sleep state. All except 17 measured this outcome on a scale where low scores represent more time spent in sleep states; therefore, we reversed the data for this study. Behavioral distress was also examined in different ways. One study20 evaluated the duration of inconsolable (crying) episodes in minutes, whereas another27 assessed stress behaviors and signs of overstimulation using continuous recording of 9 categories of minimal to maximal stress behaviors (adapted from refs 35,36). Meta-analyses of these outcomes suggested high heterogeneity and overall nonsignificant results (Fig 3, Table 2). For behavior state, heterogeneity was not explained by study design (Table 2). The study showing the most beneficial effects of MT18 was clinically similar to the other studies (Fig 3A, Table 1). For behavioral distress, study design may have explained the heterogeneity (Table 2). The crossover study20 showed a large, significant effect in favor of MT, whereas the parallel study27 showed no significant effect (Fig 3B). However, other factors may also be responsible for this difference. More positive results were found with 2 MT sessions20 than with 1.27 Less favorable effects were found for MT during a painful heel stick procedure27 than during periods of inconsolable crying.20 Overall, there was no conclusive evidence that MT improves immediate behavioral outcomes, in spite of a large overall effect size for behavioral distress (SMD –1.47; Fig 3B).
Short-term Effects of MT on Infant and Parent
Effects on infant and parent in the short term included infant weight gain, time to full oral feeds, and maternal anxiety. Weight gain was analyzed as average daily weight gain29,31 or as total weight gain across the intervention period30 (which we transformed to average daily weight gain). Heterogeneity was high (Table 2) and could not be due to study design because all 3 studies were parallel. One small study,29 suggested as a potential outlier, reported stronger effects in favor of MT than the remaining studies (Fig 4A), and may have been affected by KC, which was a part of the intervention. Time to full oral feeds was defined as days before nipple feeding, computed as days from birth to date of last nasogastric/orogastric tube feed. Heterogeneity was low (Table 2). The average effect of 4 days fewer until full oral feeds for those receiving MT was not significant (Fig 4B). Maternal anxiety was analyzed using the State-Trait Anxiety Inventory (STAI)17,21 or its Colombian adaptation.29 We selected state anxiety (STAI Factors 1 and 2 in ref 29) because it may be a more sensitive indicator of caregivers’ current distress than trait anxiety. Heterogeneity was high (Table 2), with the parallel study29 showing smaller effects than the 2 crossover studies (Fig 4C). The overall effect was significant, with a large effect size in favor of MT (SMD, –1.82; Fig 4C). In summary, we found evidence of a beneficial effect of MT on maternal anxiety, whereas there was not enough evidence to confirm or refute any effects on other short-term outcomes.
Short-term Effects of MT on Service-Level Outcomes
Postmenstrual age at discharge and length of hospitalization were assessed in a number of parallel RCTs. We found moderate heterogeneity (Table 2). Confidence intervals were wide (Fig 5), so there was too little evidence to confirm or refute any effects on these outcomes.
Effects of MT: Narrative Summary of Additional Outcomes
An overview of the outcomes included in the narrative summary is given in Table 1.
Immediate Effects of MT on Infant Well-Being: Physiologic/Behavioral
Blood pressure was assessed in 1 study and showed no statistically significant difference for inconsolable/crying infants receiving recorded lullaby music.20 End-point data were not available from Calabro et al,22 which precluded inclusion of the study in meta-analyses, but no significant effects were found for HR, RR, or O2 SAT.
One study assessed the percentage of time in a quiet alert behavior state,7 demonstrating a statistically significant increase during presentation of live lullaby music followed by a decrease after intervention. Another study22 assessing behavioral distress using 11 categories of negative disorganized states (adapted from ref 34), but without usable end-point data for meta-analysis reported, found no significant effects.
Short-term Effects of MT on Infant: Physiologic/Behavioral
Use of the Pacifier Activated Lullaby significantly improved oral feeding rates,24,25 oral feeding volume,24 and oral feeding frequency.24 Live, parent-preferred, culturally-specific lullabies were associated with higher levels of caloric intake and sucking behavior than a well-known lullaby.7 Infants receiving developmental multimodal stimulation took less time to integrate feeding behaviors than control infants as demonstrated by a positive trend for decreased number of days receiving intravenous nutrition and decreased number of days to full oral feeds.31
Short-term Effects of MT on Parent
Mother–infant bond was assessed in 2 studies (Table 1), but data from 1 study23 were reported incompletely and could not be included in a meta-analysis. Results from both trials were nonsignificant.23,29 Effects of mothers’ singing on their adjustment to their preterm infants was evaluated in 1 study, again with nonsignificant results.23 Another study7 found a statistically significant decrease in parental perception of stress, which could, however, not be compared between conditions because of the design.
Long-term Effects of MT on Infant and Parent
One study evaluated long-term outcomes in mothers26 and another study in infants.29 Mother-focused interactive MT with or without KC led to statistically significant increases in breastfeeding rates at first follow-up visit (7–15 days postdischarge), and nonsignificant trends toward increased breastfeeding rates at point of discharge and 30 and 60 days after discharge.26 One study29 aimed to assess infant development, but did not analyze these data because of high attrition.
Risk of Bias of Included Studies
The use of cross-over designs and wash-out periods were generally judged to be adequate. Lack of clarity was relatively common for details of randomization procedures (sequence generation, allocation concealment) and whether outcome assessors were blinded (Table 3). None of the included studies tested the success of blinding.
This systematic review and meta-analysis examined the effect of MT on preterm infants and their parents/caregivers during NICU hospitalization and after discharge to home. Although the impact of MT on preterm infants and caregivers has long been of interest, to our knowledge this study is the first comprehensive meta-analytic review restricted to RCTs with music therapist involvement. Our meta-analysis showed significant positive effects of MT on the clinically important outcomes of RR and maternal anxiety. Narrative synthesis of less common outcomes also suggested some benefits of MT during and immediately after NICU hospitalization.
MT reduced infants’ RR by 3.91 breaths per minute, an effect that probably carries clinical significance as an indicator of a relaxation response. Although the effect on reduced HR with MT intervention did not achieve statistical significance, an observed trend toward lowered HR is also consistent with a relaxation response. Taken together, these findings suggest that MT lowers stress and contributes to clinical stability.
The significant positive, short-term effect of MT on maternal anxiety was large according to Cohen’s guidelines for interpreting effect sizes.16 The observed reduction in mean anxiety scores also corresponded to a shift from clinical to subclinical levels of anxiety37 in 2 of the 3 included studies.17,21 Elevated maternal anxiety is associated with postpartum depression38 and impaired parenting39 in mothers of preterm infants, whereas reduction in maternal anxiety is associated with improvements in child development during the first 2 years of life.40 The 3 studies included in the meta-analysis of maternal anxiety all used live music in conjunction with KC, demonstrating greater improvements than with KC alone. These results support the beneficial impact of interventions that instate the parent in a nurturing and caregiving role (provider of KC) that includes engagement in live music.
Prematurity is associated with significant public health costs. The high prevalence and costs demand attention in many high-income countries. Preterm infants are hospitalized longer than full-term infants (13 vs 1.5 days41), and daily costs of NICU care per infant exceed $3500 in the United States.42 The 3-day reduction in length of hospitalization in our meta-analysis failed to reach statistical significance, but if confirmed in a larger study, would have important implications for service costs.
One of the major limitations of this review is the lack of long-term observations. We intentionally included preterm infants through the first 3 years of life to assess the long-term impact of MT on preterm infants and their parents/caregivers. Despite an exhaustive search, we were only able to identify 2 studies that assessed long-term outcomes for infants or parents.26,29 Our restriction to RCTs with music therapist involvement undoubtedly reduced the number of eligible studies that assess long-term outcomes for preterm infants. Six of the 16 studies included in the systematic review were crossover studies, precluding the ability to assess long-term effects, and 11 studies had intervention protocols lasting ≤5 days.
The comprehensiveness of our review is also impacted by the limited sample size in areas of long-term and service-level outcomes. Because it is likely that various other influences impact service-level and long-term outcomes due to the distal nature of these outcomes, larger sample sizes could better enable the detection of treatment effects over time. To address the limitations of previous systematic papers, we undertook comprehensive searching following the strict guidelines of the PRISMA statement.13 We believe this systematic review contains all relevant studies that have been conducted in this field, but it is possible that there are unpublished studies of which we were not aware.
Studies included in the review demonstrated a fairly high level of clinical heterogeneity, especially variations in the type, duration, and frequency of MT. This clinical heterogeneity may have contributed to heterogeneity in observed effects, and more research is needed to systematically explore such variations and learn from such comparisons.
Our meta-analysis was limited by data reporting issues in the included studies. We attempted to contact the authors of 11 of the 16 included studies to request missing data, and successfully obtained requested data in 6 cases. Our systematic review was also limited by the lack of transparent intervention reporting among included studies in relation to total number of sessions and detailed protocols for intervention and control groups. However, a majority of the included studies specified type of music used and duration of intervention.
Implications for Clinical Practice
The findings of this review have important implications for future practice. There was a strong tendency toward facilitating parental involvement in MT within the included studies, either targeting mothers as participants,17,26 using mother’s recorded voice for infants,19,23,24 or including both parents/caregivers when applicable.7,21,29 A key policy priority should be taken to involve both parents in MT sessions to facilitate mutually beneficial interactions that support infant development, help parents assume a primary caregiving role, and foster healthy bonding during the critical period of NICU hospitalization. Greater efforts are needed to ensure follow-up of preterm infants after discharge.
Implications for Future Research
This review highlighted the need for improved transparency in research reporting and several areas that require additional investigation. Rigorously designed studies using larger sample sizes, standardized outcome measures, and interventions implemented by music therapists with specialized NICU training are required. Transparent and complete reporting of study interventions and results is crucial, because transparency enables replication and transfer of research to clinical practice settings.43 Researchers are strongly encouraged to follow pertinent reporting guidelines, such as those by Robb et al,43 for music-based interventions, which are evidence-based and consistent with CONSORT and TREND statements. Conducting parallel group RCTs to evaluate long-term effects of MT and extending intervention periods past discharge from the NICU will help assess the long-term impact of MT, a substantial gap in knowledge at present.
Several of the included studies had small sample sizes, which may put them at higher risk for underpowered analyses. Reliable and valid outcome measures are required, especially in the area of assessing parental psychological outcomes. Ideally, parental psychological outcomes would be measured over longer periods of time to assess durability of change. Because preterm parents perceive premature birth as a stressful and traumatic situation, research should address parental stress, anxiety, postpartum depression and quality of life. Separation between infant and parents because of intense or prolonged hospitalization can complicate development of healthy parent–infant relationships. Research assessing the long-term effects of MT on the development of healthy infant/parent bonding and secure attachment is indicated.
The current systematic review reflected a high level of clinical heterogeneity, which may be expected given the broad range of outcomes that may be addressed with MT. More research is needed to explore the differential impact of various MT approaches, frequencies, durations, and interventional time points. By systematically analyzing the impact of clinical heterogeneity, we may be able to determine when and how MT is best used to promote certain outcomes.
We would like to thank Elise Marie Angeltveit, MT graduate student, who assisted with database searching and record screening, and Trond Jacob Markestad, Bente Vederhus, and Hallvard Martin Reigstad for consultation regarding the clinical relevance of outcome measures and meta-analysis results.
- Accepted June 14, 2016.
- Address correspondence to Christian Gold, The Grieg Academy Music Therapy Research Centre, Uni Research Health, Uni Research, Lars Hilles gate 3, 5015 Bergen, Norway. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: The study was funded through the University of Bergen, POLYFON Kunnskapsklynge for musikkterapi, and the Research Council of Norway (grant 213844, the Clinical Research and the Mental Health Programmes).
POTENTIAL CONFLICT OF INTEREST: Dr Bieleninik has indicated she has no potential conflicts of interest to disclose. Claire Ghetti and Christian Gold are trained music therapists.
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- Copyright © 2016 by the American Academy of Pediatrics