The Other MMS: Multimodal Stimulation with Premature Infants

Music Makes Sense meets Multimodal Stimulation

Multimodal stimulation (MMS) is one of the coolest music therapy applications to come out of the research in the last decade! Dr. Jayne Standley at Florida State University has spearheaded the multimodal stimulation research in the NICU (Neonatal Intensive Care Unit) at TMH (Tallahassee Memorial Hospital). Before I tell you about my experience with MMS, however, it is important to understand some basic ideas supported by the research literature regarding premature babies.

The first concept is that premature babies need sleep in order for their brains to develop. When they are sleeping, they form up to 250,000 neurons per minute. As you can imagine, any interruption to sleep can cause the baby to lose a lot of brain development! In fact, any startle response sends cortisol (a stress hormone) to the brain and stops the brain development until the baby can return to a relaxed state. The environment of a NICU is naturally startling no matter what we do to decrease the noise and intrusions. The medical staff is there to save the baby by whatever means necessary and survival takes precedence over development. The beeping of equipment, people talking, alarms, machinery and routine hands-on medical care are all startling to these babies.

The second concept to understand is that as the baby's brain is developing, it sends out new brain cells from the center outward to other parts of the brain. It is necessary for these brain cells to quickly find a job to do in that area of the brain or else they simply die off, never to be "re-born." A premature baby under all the necessary sedation and medication does not have the opportunity for normal environmental sensory input in order for all of these brain cells to find a "job" and establish themselves permanently in the brain.

These competing ideas of needing to provide appropriate stimulation without startling the baby led Dr. Standley to develop MMS for premature babies primarily 34 adjusted gestational weeks and older. The technique involves gradually layering different types of stimulation in a way that the baby tolerates the input without startling. The protocol works best with two people so that one can hold the baby while the other therapist plays guitar and sings. The music is gradually introduced so that only soft arpeggiated finger picking at a slow tempo and major key are used at first. If the baby does not startle, then the therapist can start humming and eventually begin singing. Most common children's songs are okay and there are even ways to adapt adult folk and easy listening songs to be appropriate for use as accompaniment. A trained music therapist is important for this aspect of the protocol.

The therapist holding the baby proceeds by gently stroking the baby on the face, back, arms, legs, etc., in a set pattern. The therapist is constantly observing positive and negative responses from the baby. Smiles, coos and snuggling are good signs, but any jerking movements, grimaces or cries indicate that the touching protocol immediately must stop until the baby is again relaxed. If the baby is able to tolerate the entire sequence of touch, then the therapist goes through the sequence again while adding gentle rocking. At this point the baby will be listening to music, feeling motion and touch. MMS continues for 15 minutes and is great before feeding time since it prepares the baby to appropriately accept physical handling and environmental input.

The music is a key factor for MMS because it helps to mask the sounds of medical equipment and other startling aural sensations. Sedative music has also proven to be very powerful in stabilizing the respiration rates of premature babies. In addition, the rhythmic music is essential in providing structure and timing for the touch/stroking and rocking.

It is very important to emphasize that MMS should only be done by a board certified music therapist with the NICU-MT certification. Parents of premature infants may also participate in the protocol under the supervision of the music therapist in order to increase parent child bonding.

I was able to participate in MMS during my training to become NICU-MT certified. I am used to holding a baby, since we just had a baby two years ago, but premature babies are so fragile! They are truly precious little miracles and I am always impressed by the parents of these little ones and how well they handle the stress and emotional duress of being separated from their babies so much while they are in NICU. One of the babies I was able to do some MMS with was not very cooperative, but he certainly wanted to communicate! If you remember the saying and gesture, "Talk to the hand!", this little guy had obviously been practicing! I was only able to do a few different touch strokes during the entire 15 minutes because he kept giving me the halt sign. Still, babies have good and bad days just like us and it is really the cumulative effect over multiple interventions that will hopefully show his progress in appropriately tolerating stimuli.

Another baby I worked with allowed me to do almost the entire protocol, including the rocking. This was great! I do have to admit, however, that my arm was rather tired after the 15 minutes. I guess it has been long enough since our own little one was small enough to be cradled that my baby holding muscles have already atrophied!

My description is only meant to be an introduction to one of the evidence-based music therapy interventions currently in use with premature infants. The definitive guide to music therapy in neonatal care can be found in Dr. Standley's book, "Music Therapy with Premature Infants."