Effectiveness of Music Therapy on Pediatric Postoperative Distress

 

As a student of health sciences specializing in child health, as well as an avid disciple of classical music performance, I found myself gravitating toward the field of music therapy during my undergraduate years. It was a perfect intersection between healthcare and music, and led me to do my senior year thesis project on it. The topic of the project, What is the effectiveness of music therapy on pediatric postoperative distress?, encompassed all of my passions; music, healthcare, and child health. Part of my project was conducting a systematic literature review on this topic.

The systematic literature review posed as a challenge from the start, because of how often academic literature used music medicine and music therapy interchangeably. It seemed that regardless of the geographic region, the study design, or the purpose of music therapy interventions, the term “music therapy” was frequently used to describe passive music listening, which is music medicine. Many of the studies took place in North America, which was unexpected since the USA and Canada both clearly regulate the profession and field of music therapy. 

My inclusion criteria for the systematic review were studies of any design, that measured the effects of postoperative music therapy, with participants of age 0-18 years, and sample size of >1. While I recognize that “postoperative music therapy for pediatric surgical patients” is a very specific context and thus I was not expecting a wealth of studies, I was still surprised at how only 3 studies met my inclusion criteria. I found mainly two reasons for this: 1) Most studies that seemed to meet my criteria used music medicine rather than music therapy, and 2) There is a lack of music therapy research with the pediatric population compared to the adult population. The latter reason intrigued me.

As the Nordoff-Robbins approach shows, tapping into the inner musical child is often encouraged and the value of childlike traits are emphasized in music therapy. My undergraduate studies in child health taught me that early childhood development is crucial in shaping the child’s future adult self. Early childhood adversity is extremely influential. Thus finding healthy coping mechanisms is important, as it is a strong indicator of the child’s future responses to adversity. Children’s early pain experiences are linked to their reports of pain, anxiety, and sensitivity to medical events, and negative perception of the healthcare system, even when they are adults years later1. Management of postoperative distress is also correlated with positive surgical outcomes2,3,4. Therefore, it is important to continue to refine postoperative pain-inducing symptom management for children. Unfortunately, there is more research for adults than children regarding music therapy. My education in child health made me curious to see the effects of music therapy on children under postoperative vulnerable conditions. I chose invasive surgeries because not only are invasive surgeries physically taxing and painful on the body, the long term hospitalization and follow-up treatments after often result in isolation, loneliness, lack of control, and symptoms of depression and anxiety. 

There is much effort spent in trying to minimize acute pain management for pediatric patients. However, currently there is limited evidence regarding the efficacy of analgesics used in postoperative pain treatment in pediatric patients. Opioid medications are very often an important component of pediatric postoperative pain treatment, but have been associated with perioperative complications11. There are only a few evidence-based reports available to guide the use of opioid medications in children. Because there is wide range of interpatient variability in postoperative pain, it is often managed by roughly outlined protocol or by trial and error, which often leads to patients being either undertreated or overtreated11. There is also danger with unregulated opioid use, as there are risks of toxicity and dose-related side effects. It is recommended that combinations of multimodal regimens and anaesthetic techniques should be used to treat acute pain management. From an economic perspective, opioids and analgesics are extremely costly and lowering its usage could allocate the financial resources to be used for other areas of need. Tapping into music therapy’s potential for pain management without dangerous side effects could be a valuable contribution pediatric postoperative care, both in terms of efficacy and cost-effectiveness.

The three studies that are included in my systematic literature review included neonates with cardiac conditions, teenagers undergoing spinal fusion surgery, and teenagers undergoing bone marrow transplants. 

The studies are: 

  1. Yurkovich, J., Burns, D. S., & Harrison, T. (2018, March). The Effect of Music Therapy Entrainment on Physiologic Measures of Infants in the Cardiac Intensive Care Unit: Single Case Withdrawal Pilot Study. J Music Ther, 9(55), 62-82. doi:10.1093/jmt/thx017
  2. Nelson, K., Adamek, M., & Kleiber, C. (2017, February). Relaxation Training and Postoperative Music Therapy for Adolescents Undergoing Spinal Fusion Surgery. Pain Manag Nurs, 18(1), 16-23. doi:10.1016/j.pmn.2016.10.005.
  3. Robb, S. L., & Ebberts, A. G. (2003, January). Songwriting and Digital Video Production Interventions for Pediatric Patients Undergoing Bone Marrow Transplantation, Part I: An Analysis of Depression and Anxiety Levels According to Phase of Treatme. J Pediatr Oncol Nurs, 20(1), 2-15. doi:10.1053/jpon.2003.3

The Yurkovich study found that music entrainment had positive effects on physiological markers for the neonates who underwent cardiac surgery, including heart rate, respiratory rate, blood pressure, and oxygen saturation. The Nelson study found that adding preoperative music assisted relaxation training to prepare for postoperative music therapy had a positive but insignificant effect on pain, anxiety, and observations of pain behaviour, compared to only postoperative music therapy. The Robb study found that songwriting and digital video production had significant effects on reducing anxiety and depression. The following table outlines the outcomes of each study. 

The studies have small sample sizes, and intervention and methodological heterogeneity among all three studies. Despite these challenges, there were some valuable key components from this analysis.

Regarding the results, the study by Robb et al showed that songwriting had a more significant effect on reducing anxiety compared to depression, which might suggest that there are components of composition that help decrease anxiety for children. Additionally, the only music therapy outcome that had a negative effect was decrease in oxygen saturation in the study by Yurkovich et al. Although it showed an overall average decrease in oxygen saturation with music therapy, there were significant increases for two of the five neonates. This shows that music entrainment used can have positive effects for cardiac markers and the average does not necessarily reflect the true benefits of music therapy for increasing oxygen saturation. 

Furthermore, the study by Nelson et al showed that having preoperative music-assisted relaxation training had an insignificant but positive effect on pain, anxiety, and observed pain behaviour. Although it was not music therapy, giving an opportunity for the pediatric patients to practice music relaxation techniques prior to the surgery seems to have additive positive effects with postoperative music therapy. Since the patients were only given one chance to receive the music relaxation techniques, it made me question if the outcomes would have been more positive if they had more chances to receive it, or if it was preoperative music therapy instead of music relaxation. Are the outcomes more positive when there is preoperative music interventions as well as postoperative music therapy solely because the patient is receiving more number of sessions? Or do preoperative music interventions help create more familiarity when the patient receives postoperative music therapy and thus result in more positive outcomes? The dynamics and effects of preoperative music therapy and postoperative music therapy together may be worth exploring further into. 

There are generally more complexities associated with children than adults. An important factor to consider are the effects of family members. Children are greatly influenced by their family and loved ones, especially in younger ages. This was briefly mentioned in the study by Nelson et al, where the family members’ anxiety was correlated with the child’s anxiety.  The study recommended looking further into allowing the family members to receive music therapy as well. The process of the child undergoing invasive procedures and recovering often causes anxiety not only on the child, but also on their family. It’s been shown that adult distress behaviours in turn affect the child’s distress behaviours5. When children observe parental anxiety, this propagates their own anxiety and results in more negative outcomes. Parental and staff coping-promoting and distress-promoting behaviours can predict as much as 55% of the variance in child distress6

Putting child development aside, there are also great economical benefits to music therapy in tertiary care. A study by Walworth (2005) shows that music therapy-assisted echocardiogram for pediatric patients took less time, staff, and equipment resources, due to the child becoming more comfortable7. In comparison to non-music therapy assisted echocardiograms, music therapy-assisted echocardiograms did not require medication to calm the child down, and also did not need the help of a Registered Nurse to comfort the child. The overall savings was $74.20 per patient, resulting in a total savings of $6,830 for the 92 patients in the study. Furthermore, the costs of the Intensive Care Unit (ICU) in Canada are quite costly. The average length of stay for surgical patients in the ICU is 2.8 days, and average stay in the in-patient units is 3.9 days8. The average daily cost of an ICU stay can range around $3,592, and pediatric ICUs are even more costly due to complexities of children9. Although there is not yet sufficient research proving that postoperative music therapy reduces the number of hospitalizations for pediatric surgical patients, there is evidence of a reduction as high as 37% for adult surgical patients10. If a similar outcome could be applied to pediatric patients, this would mean a reduction of 1.04 days in intensive care, and since the average daily cost in the ICU is $3,592, this would result in a savings of $3735.68 per patient. This suggests that postoperative music therapy has high potential for economic savings through decrease of hospitalization days. Surgery is costly, with costs starting from preoperative preparation, the number of healthcare professionals required, anaesthetics, number of nights spent postoperatively, and recovery. As a further step, it is recommended looking into the economic benefits of music therapy for surgical patients by looking at their recovery, discharge rates, onset of side effects, costs of other commonly used interventions, and for any other costs involved.

This systematic review reveals that there is a very limited number of studies done on postoperative music therapy for children, but the positive results show that it is valuable to continue studying it due to its effectiveness. Future studies should incorporate additional contextual factors related to children, such as the role of family and preoperative preparation, for a more thorough understanding of the potential of postoperative music therapy.

 

References

  1. Hamers, J. P., Abu-Saad, H. H., van den Hout M. A., & Halfens, R. J. (1998, January). Are children given insufficient pain-relieving medication postoperatively? J Adv Nurs. 27(1), 37-44.
  2. Kehlet, H. (1999). Acute pain control and accelerated postoperative surgical recovery. Surg Clin North Am, 79(2), 431-443. https://doi.org/10.1016/S0039-6109(05)70390-X
  3. Bonnet, F., & Marret, E. (2007). Postoperative pain management and outcome after surgery. Best Pract Res Clin Anaesthesiol, 21(1), 99-107. https://doi.org/10.1016/j.bpa.2006.12.007
  4. Allvin, R., Ehnfors, M., Rawal, N., & Idvall, E. (2008). Experiences of the postoperative recovery process: an interview study. Open Nurs J, 2, 1-7.
  5. Nelson, K., Adamek, M., & Kleiber, C. (2017, February). Relaxation Training and Postoperative Music Therapy for Adolescents Undergoing Spinal Fusion Surgery. Pain Manag Nurs, 18(1), 16-23. doi:10.1016/j.pmn.2016.10.005.
  6.  Frank, N. C., Blount, R. L., Smith, A. J., Manimala, M. R., & Martin, J. K. (1995). Parent and staff behavior, previous child medical experience, and maternal anxiety as they relate to child procedural distress and coping. Journal of Pediatric Psychology, 20, 277 – 290.
  7. Walworth, D. D. (2005). Procedural-support music therapy in healthcare settings: A cost-effectiveness analysis. Journal of Pediatric Nursing, 20, 276−284.
  8. Fixler, T., Menaker, R. J., Blair, G. K., & Wright, J. G. (2011). Pediatric surgical capacity and demand: analysis reveals a modest gap in capacity and additional efficiency opportunities. Healthcare Quarterly, 14(3), 28-34. doi:10.12927/hcq.2011.22574
  9. Canadian MIS Database, 2013–2014, Canadian Institute for Health Information.
  10. Zhou, K. N., Li, X. M., Yan, H., Dang, S. N., & Wang, D. L. (2011). Effects of music therapy on depression and duration of hospital stay of breast cancer patients after radical mastectomy. Chinese Medical Journal, 124(15), 2321-2327. https://doi.org/10.3760/cma.j.issn.0366-6999.2011.15.014
  11. Ferland, C. E., Vega, E., & Ingelmo, P. M. (2018). Acute pain management in children: challenges and recent improvements. Curr Opin Anaesthesiol, 31(3), 327-332. doi: 10.1097/ACO.0000000000000579.
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