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05 n309 16755

  1. 1. DESCRIPTIVE STUDY TO ASSESS THE EFFECTIVENESS OF CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL AND BEHAVIOUR PARAMETERS AMONG PRETERM NEONATES ADMITTED IN NICUWITH RESPIRATORY DISTRESS M.Sc. Nur sing Disser tation Protocol submitted to Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore. By Miss. DEEPTHIMOL K P M.Sc. NURSING 1ST YEAR 2009-2011 Under the Guidance of HOD, Department of Paediatric Nursing Josco College of Nursing Nelamngala, Bangalore -562 123 Karnataka 1
  2. 2. 2 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE,KARNATAKA PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, 1 2 3 4 5 NAME OF THE CANDIDATE NAME OF THE INSTITUTE JOSCO COLLEGE OF NURSING, NELAMNGALA,BANGALORE COURSE OF STUDY AND SUBJECT MSc NURSING 1st YEAR PAEDITRIC NURSING DATE OF ADMISSION OF COURSE TITLE OF THE TOPIC BRIEF RESUME OF THE STUDY 6 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 8 7.1 7.2 DESCRIPTIVE STUDY TO ASSESS THE EFFECTIVENESS OF CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL AND BEHAVIOUR PARAMETERS AMONG PRETERM NEONATES ADMITTED IN NICUWITH RESPIRATORY DISTRESS ENCLOSED INTRODUCTION NEED FOR STUDY REVIEW OF LITERATURE STATEMENT OF THE PROBLEM OBJECTIVES OF THE STUDY OPERATIONAL DEFENITIONS HYPOTHESIS ASSUMPTION LIMITATION PROJECTED OUT COME MATERIALS AND METHODS 7 Miss. DEEPTHIMOL K P ENCLOSED SOURCE OF DATA METHODS OF DATA COLLECTION BIBILOGRAPHY ENCLOSED KARNATAKA, BANGALORE PERFOMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
  3. 3. 3 1. Name of the Candidate and Miss. DEEPTHIMOL K P Address (in block letters) 2. Name of the Institution JOSCO COLLEGE OF NURSING NELAMANGALA,BANGALORE M. Sc. NURSING 3. 4. Course of Study And Subject PAEDIATRIC NURSING Date Of Admission of Course DESCRIPTIVE STUDY TO ASSESS THE 5. Title of the Topic EFFECTIVENESS OF CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL BEHAVIOUR PARAMETERS PRETERM NEONATES ADMITTED IN NICU WTTH RESPIRATORY DISTRESS. 6.0 BRIEF RESUME OF THE STUDY INTRODUCTION
  4. 4. 4 “Angels live in the heart of kids; Music is well said to be the speech of angels." Thomas Carlyle In the present era of science and technology, where quality is the supreme priority, Quality Of Life can only be accredited by decreased morbidity and mortality rate of newborn. The UNICEF’s Flagship Publication, The State of World’s Children (15th Jan 2009) reported that a million neonatal death occurs in India every year. The popularity and credibility of alternative treatment modalities such as music therapy also have increased over the past decade. Support for the use of music with infants is not limited to music therapy literature; in fact, authors in several other fields of study have written about the benefits of using music to create a nurturing environment for infants. Such articles have been published in journals intended for nurses (Hicks, 1995; Olson, 1998; Standley, 2002) physicians (Jones and Kassity, 2001; Marwick, 2000) paediatric nurse practitioners (Klein and Winkelstein, 1996) and music educators (Fox, 2000). In this growing field of interest, current research has provided health care professional with many reasons to use music in their repertoire of treatment options for newborns. 6.1 NEED FOR THE STUDY Music benefits documented for full term newborns may also apply to the premature infants, that is, lullabies promote language development, familiar
  5. 5. 5 music is recognized, reinforcing and comforting and infants orient to and avidly attend to music more than other auditory stimuli. This burgeoning area of researches provides exciting possibilities for the practice of music therapy in the Neonatal Intensive Care Unit (NICU) and for music education in early childhood (Standley, 2008). Preterm babies are also having some sort of anxiety and stress even though we are not taking care of. Several studies have shown how music therapy enhances the efficacy of nursing interventions that is the majority of NICU staff preferred live recorded music and music appears to be an acceptable intervention in Neonatal Intensive Care Unit (http//:web.mac.com). Music therapy is an important intervention that is soothing for the infants. Music therapy can also encourage parental involvement, support infant development and optimize preterm infants’ neuro developmental outcomes (Nordoff and Robbins, 1997; Haselbeck, 2004). Elena and Nick (2008) reported that music has an effect on the state of paediatric patients, potentially improving the physiological well being of long term hospitalized children when exposed to live music. The highest mortality among infants is due to prematurity. Prematurely born infant emerges into a hectic, cold, noisy and bright environment filled with
  6. 6. 6 Mysterious equipments and peopled by masked strangers who try to help. Thus the experience in Neonatal Intensive Care Unit contains frequent aversive procedures, excess handling and disturbance of rest, noxious oral medications, noise and bright light. These conditions are sources of stress and anomalous sensory stimulation (Zentner, 1996). The holistic movement has become a challenge to health care professionals and music is one of the few interventions that can be considered truly holistic. Research and clinical findings support the uses of music in a variety of physical and psychological conditions (www.musictherapy.com). Music alleviates both acute and chronic pain and found a 30% decrease in the use of pain medications with the use of therapeutic music (Herth, 1998). Whipple and Glynn (1992) stated that soothing music resulted in a significant increase in the pain threshold of 10 healthy female volunteers. The length of hospitalization was shorter and average daily weight gain was greater for infants, whose parents received training in music, although these differences were not significant. A one month post discharge follow up showed little difference between experimental and control group parent infant interaction in the home (Whipple, 2000). 6.2 REVIEW OF LITERATURE
  7. 7. 7 Searching the literature is the first and vital stage of a research. The purpose of literature review is to discover what has previously been done about the problem to be studied, what methods have been employed in other researches, suggestions for further studies etc. The most important types of information for a research review are finding from empirical investigations. Literature review is defined as a critical summary of research on a topic of interest, often prepared to put a research problem in context ( Polit and Beck, 2008). A brief account of various studies conducted by different investigators and a few citations from books, which are found to be relevant to the study are included in this chapter. 6.2.1 PRETERM NEONATES AND RESPIRATORY DISTRESS Preterm babies are babies born of less than 37 completed weeks (Singh, 2004; Kenner and Lott, 2003). Preterm infants can be categorized by weight as well as gestational age. A child weighing less than1500 grams is considered as very low birth weight infant and 1501 to 2500 grams constitute a moderately low birth weight infant (Wong et al., 2006). About 10 to 12 % of Indian babies are born preterm as compared to 5 to 7% incidence in the west (Singh, 2004). More than a half million babies in the
  8. 8. 8 United States-that is 1 in every 8- are born premature every year (Centre for Disease control and Prevention, 2008). The factors contribute to the preterm delivery are late initiation of prenatal care, lower socio economic status and substance abuse (Kenner and Lott, 2003). Multiple pregnancies (twins, triplets) are another significant factor for preterm birth (March of Dimes, 2006). Pregnant women exposed to passive smoking or those who smoked are at an increased risk of preterm delivery (Richard, 27 March 2009; Mc Cowan, 2009). Parenting behaviours, particularly parent child synchrony were associated with neuro behavioural development of preterm infants ( Treyvaud et al., 2009). 6.2.2 AUDITORY SENSITIVITY OF NEONATES While newborn human infants are immature beings in many ways, their sense of hearing is actually quite well developed at birth; they are able to detect changes in loudness of only 3 dB and to perceive timbre and pitch much like adults do (Fassbender, 1996). The neonates often experience some auditory asymmetry in their perception of sound. Specifically, several studies have shown that the right ear is slightly more sensitive to auditory signals than the left ear (Bertoncini et al., 1989; Eldredge and Salamy, 1996; Kei, McPherson et al., 1997).
  9. 9. 9 Typical newborns have immature but functional hearing ability and they are able to discriminate subtle differences between sounds soon after birth (Atkinson and Braddick, 1982). Four day olds can distinguish between changes in consonant-vowel syllables presented dichotically (Bertoncini et al., 1989). Even term newborns could be affected by noise in that it hinders their independent attempts to sleep, self-soothe and pay attention (Philbin and Klaas, 2000). 6.2.3 NOISE LEVELS IN NEONATAL INTENSIVE CARE UNIT Noise levels were found to be above the American Academy of Paediatrics recommended 45 dB levels and the recommended impulse maximum of 65dB was also exceeded in Neonatal Intensive Care Unit (Darcy and Hancock, 2008). Zahr and De Traversay (1996) pointed out in their study to develop aggressive anti noise policies to substantially and consistently reduce the noise in the Neonatal Intensive Care Unit. Excess noise in the NICU correlates with a decreased oxygen saturation and an increased heart rate and sleep disturbances (Kellman, 2002). Exposure to aberrant noise levels in the NICU may cause sensorineural damage, induce stress and contribute to language or auditory processing disorders in the preterm neonates (Schulte, 1997).
  10. 10. 10 One study found that loud noises in the Neonatal Intensive Care Unit significantly changed the behavioural and physiological responses of infants (Zahr and Balian, 1995). Exposure to noise in the NICU may result in cochlear damage and the noise may disrupt the normal growth and development of premature infants (American Academy of Paediatrics, 1997; White, 2005). A study reported that existing NICU environment has very high sound pressure levels (SPL) and this can cause hearing impairment, sleep disturbances, somatic effect, impaired auditory perception and affect emotional development in babies (Gupta, 2005). Music is credited to ensure autonomic stability, reduce stress and quieten the baby, increases oxygen saturation and reduces heart rate (Singh, 2004). 6.2.4 PRETERM NEONATES’ STRESS IN NEONATAL INTENSIVE CARE UNIT Environmental factors in the Neonatal Intensive Care Unit have major implications for the care of the sick newborn infant. Broad evidence implicates the environment in the Neonatal Intensive Care Unit as a factor in neonatal morbidity. Abnormal sensory input can be a source of potentially overwhelming stress and at a sensitive period during development can modify the developing
  11. 11. 11 brain. The NICU environment therefore assumes a crucial role in the care of the sick neonates (Mhairi et al., 2005). Music has been found to reduce stress hormones and enhance the immune system, which allows healing to occur more rapidly in sick patients (Knight, 2001). Classical music strengthens our natural regulatory and recovery processes and is particularly noticeable in the relief of the physical, mental and spiritual effects of stress (WHO stress conference, 1995). 6.2.5 THERAPEUTIC USES OF CLASSICAL MUSIC THERAPY The term classical music originates from the Latin term classicus, meaning taxpayer of the highest class. The origins of Indian classical music can be found from the oldest of scriptures, part of the Hindu tradition, the Vedas. Haydn has been referred to as the “Father of classical music”. Indian classical music is monophonic in nature and based around a single melody line which is played over a fixed drone. The performance is based melodically on particular ragas and rhythmically on talas (www.wikipedia.com). Many styles of music exist within classical music; the most recognizable being the symphony, opera, choral works, chamber music, Gregorian chant, the madrigal, and the Mass.
  12. 12. 12 Music can enhance the immediate environment provide a diversion and lessen the impact of potentially disturbing sounds for paediatric patients (Barrera, Rykov et al., 2002; Klein and Winkelstein, 1996). Classical music decreased the tension but had little effect on other feelings (Mc Craty, Barrios et al., 1998). Music has been found to be an effective anxiolytic for patients undergoing anxiety-producing procedures and allows for less pain medications, less sedatives and an increased recovery time (Miluk, 1994). Classical music can decrease patient’s perceptions of, and responses to pain, even in very young premature infants (Butt, Kisilevsky, 2000; Joyce, Keck et al., 2001). Nursing pioneering leader Florence Nightingale (1860) recognized the healing power of music. Today nurses can use music in a variety of settings to benefit patients and neonates. 6.2.6 EFFECT OF CLASSICAL MUSIC THERAPY ON PHYSIOLOGICAL PARAMETERS Classical music has an effect on the state of paediatric patients, potentially improving their physiological and psychological wellbeing (Elena and Nick, 2008).
  13. 13. 13 When compared with recorded music or no music therapy; live music therapy is associated with a reduced heart rate at 30 minutes after music therapy in stable preterm neonates (Shmuel et al., 2006). Taped intrauterine sounds combined with female vocal singing resulted in significant reduction in agitated behaviours and improved oxygenation in newborns (Collins, 2001). Music listening increases oxygen saturation levels in neonates (Cassidy and Standley, 1995; Collins and Kuck, 1991; Standley and Moore, 1995). Live music therapy is associated with a reduced heart rate at 30 minutes after music therapy (Staneslow et al., 2006). 6.2.6 EFFECT OF CLASSICAL MUSIC THERAPY ON BEHAVIOURAL RESPONSES When examining infant’s overt responses to stimuli, researchers must be wary of interpreting their movements as purposeful; newborns have undeveloped motor skills and thus, a limited capacity for deliberate movements. One way to consistently observe behaviours for an entire population of infants is to use a standard scale and that scores based on a general state of alertness. In studies using behaviour state as a dependent variable, music generally has a stabilizing effect on alertness. The incidence of stress and anxiety behaviours may be
  14. 14. 14 reduced when exposing the newborns to music therapy (Burke et al., 1995; Caine, 1991; Larson and Ayllon, 1990; Leonard, 1993; Whipple, 2000). Listening to music can cause behaviour state to decrease overall (Burke, Walsh et al., 1995) return to normal following a stressful intervention (Butt and Kisilevsky, 2000) or reduce lability (Collins and Kuck, 1991; Kaminski and Hall, 1996). Live music significantly reduced the behavioural distress and it was especially effective for children of one year old and younger who were receiving needle sticks (Malone, 1996). Live music therapy is associated with a deeper sleep at the 30minutes after therapy (Staneslow et al., 2006). Live music therapy is associated with a reduced heart rate and a deeper sleep at 30 minutes after therapy in stable preterm neonates (Shmuel et al., 2006). Auditory stimulation in the form of heart beat lengthened the duration of quiet sleep period. Some NICUs have urged using sound as a protective window for the infant-when music is played, the infant will not be disturbed (Schulte, 1997). 6.2.7 CLASSICAL MUSIC THERAPY AND ITS EFFECTS ON RESPIRATORY DISTRESS
  15. 15. 15 The hospital care of premature and low birth weight infants requires expensive technology and experienced care. Many studies have looked at the institution of developmental care in the Neonatal Intensive Care Unit. Significant increase in oxygen saturation was found with the use of classical music therapy in neonates (Malinova et al., 2004). When lullaby music was played in the Neonatal Intensive Care Unit, there were less episodes of oxygen desideration in preterm neonates (Caine, 1991). A study involving premature infants’ exposure to harp music resulted in overall a significantly lower salivary cortisol level and lowers the respiratory rate (Block and Jennings, 2003). If a baby suffered from lack of oxygen during his prenatal development, no matter whether he is premature or not, his activity of cell ferments is lowered. After listening to classical music, activity of babies’ cell ferments rose. They took babies’ blood pressure, pulse, rhythm of breathing and they observed a classical reaction of adaptation and improved the oxygenation status (Mikheeva, 2006). 6.3 STATEMENT OF THE PROBLEM Study to assess the Effect of Classical Music Therapy on Physiological and Behavioural Parameters among Preterm neonates admitted in Newborn Nursery of selected Paediatric Hospitals in Bangalore city.
  16. 16. 16 Preterm deliveries, 8 to 10% of live births in the United States account for roughly 75 to 80% of neonatal morbidity and death (Kennel and Lott, 2003; March of Dimes, 2003). Prematurity and low birth weight (LBW) contributes to more than 85% of neonatal mortality. Neonatal survival is a very sensitive indicator of population growth and socio economic development. The issue of neonatal death is a serious national health concern especially in developing countries where 96% of the World’s approximate 5 million annual neonatal deaths occur (WHO 2006). The global burden of neonatal deaths is estimated to be 5 million, of which 3.2 million deaths occur during the first week of life. Almost a quarter of these deaths are shared by India with three babies dying every minute and every fourth baby born being a low birth weight (Nair, 2006). The major problems that the newborn encountered are those of adaptation to the extra uterine environment. Premature infants will generally need maximal physiological support and should be cared for in a well equipped intensive care unit (Singh, 2004). 6.4 OBJECTIVES OF THE STUDY 1. Assess the effect of classical music therapy on physiological parameters in preterm neonates. 2. Assess the effect of classical Music therapy on behavioural in preterm neonates. parameters
  17. 17. 17 3. Assess the effect of classical music therapy on the respiratory distress in preterm neonates. 6.5 OPERATIONAL DEFINITIONS Effect According to Oxford Dictionary “effect” means results of outcome or change produced by action. In this study, effect is the difference in physiological and behavioural parameters in the preterm neonates during and after classical music therapy. Classical Music Therapy It is the use of classical music with a client or groups or in a process designed to facilitate and promote communication, relationship, mobilization, expression, organization and other relevant therapeutic objectives in order to meet physical, emotional, mental, social and cognitive needs. Preterm neonates Preterm neonate means babies born of less than 37 completed weeks. In this study, preterm neonates mean babies born of 30 to 36 weeks. Physiological parameters Physiological parameters are Heart rate (HR), Respiratory rate (RR) and Oxygen saturation (SpO2). In this study physiological parameters include Heart rate (HR), Respiratory rate (RR) and Oxygen saturation (SpO2).
  18. 18. 18 Behavioural parameters According to Oxford dictionary, behaviour is the way one conducts oneself and the treatment of others. In this study the behavioural parameters include the observable physical response of preterm neonates in response to classical music therapy and the behavioural parameters include deep sleep, restless sleep, quiet alert, active alert and crying. Nursery Newborn nursery is a facility in the hospital for the intensive approach to neonatal care, for close observation and expert management. 6.6 HYPOTHESIS H1 HA: Classical music therapy will significantly improve the physiological and behavioural parameters of preterm neonates. H0: Classical music therapy will not significantly improve the physiological and behavioural parameters of preterm neonates. H2 HA: Classical music therapy will significantly influence the respiratory distress in preterm neonates. H0: Classical music therapy will not significantly influence the respiratory distress in preterm neonates. 6.7 ASSUMPTION
  19. 19. 19 1. Preterm Neonates suffering with respiratory distress need a peaceful and calm environment. 2. This classical musical therapy will enhance the better improvement in progress of respiratory distress in preterm neonates. 6.8 LIMITATIONS 1 The study was limited to a population of preterm neonates with a gestational age of 30 to 36 weeks. 2 The study was limited to a sample size of 50 preterm neonates admitted in the Inborn Nursery (IBN). 3 The study was limited to preterm neonates with mild to moderate respiratory distress. 4 6.9 The duration of study was only 6 months. PROJECTED OUTCOME The study will also help to improve the respiratory patterns in the preterm neonates suffering with respiratory distress. 7.0 MATERIALS AND METHODS 7.1 SOURCE OF DATA Preterm neonates suffering with respiratory distress. 7.1.1 RESEARCH DESIGN
  20. 20. 20 The present study was intended to assess the effect of Classical music therapy on physiological and behavioural parameters among preterm neonates admitted in Newborn nursery of selected paediatric hospitals in Bangalore. The methodology adopted for the study is quasi experimental–Time series design. Research approach : Quasi experimental Research design : Time series design In this study the data were collected from each sample for 4 consecutive days and the same subjects act as their control group on alternate days. Six observations regarding physiological and behavioural parameters were collected before, during and after classical music therapy at specific time intervals from each sample. Respiratory distress was also assessed by Downey’s score at specific time intervals. The design is diagrammatically represented as: Before (BMT) During (DMT) G1 E O1 O 2 O 3 O 4 O 5 O6 X After (AMT) O13 O14 O15 O16 O17 O18 O7 O8 O9 O10 O11O12 G1 C O1 O 2 O 3 O 4 O 5 O 6 ------- O13 O14 O15 O16 O17 O18 O7 O8 O9 O10 O11 O12 G1 E - Experimental group on Day 1 and Day 3 G1 C - Control group on Day 2 and Day 4
  21. 21. 21 BMT - Before Classical Music Therapy DMT - During Classical Music Therapy AMT - After Classical Music Therapy 7.1.2 SETTING OF THE STUDY Settings are the specific place where data collection occurs (Polit and Beck, 2008). In this study the setting was In Born Nursery (IBN) of Selected Paediatric Hospitals in Bangalore. 7.1.3 POPULATION The population refers to the aggregate or totality of those confirming to asset of specifications (Polit and Beck, 2008). In the study the population includes Preterm neonates admitted in the In Born Nursery of Selected Paediatric Hospitals in Bangalore. 7.2 METHODS OF DATA COLLECTION 7.2.1 SAMPLE AND SAMPLING TECHNIQUE Sample is the small proportion of a population selected for observation and analysis (Polit and Beck, 2008). Preterm neonates admitted in the inborn nursery of Selected Paediatric Hospitals in Bangalore with a gestational age between 30 to 36 weeks who fulfil the inclusion criteria were selected as samples for the study.
  22. 22. 22 7.2.2 SAMPLE SIZE The sample size was 50 and the sampling technique used in the present study was non probability sampling. 7.2.3 CRITERIA Inclusion criteria • Preterm neonates between the gestational age of 30 to 36 weeks. • Preterm neonates with a birth weight of 1.5 kg and above. • Preterm neonates with mild to moderate respiratory distress. Exclusion criteria • Preterm neonates with severe respiratory distress and critically ill. • Preterm neonates with congenital anomalies. • Preterm neonates with extremely low birth weight (<1.5 kg). • Parents or care givers not willing to provide the consent. 7.2.4 DATA COLLECTION PROCESS The data collection was done in Preterm neonates with mild to moderate respiratory distress admitted in In Born Nursery were the study subjects.
  23. 23. 23 After getting Human Ethical Committee clearance and permission from institution and respective units and parents of subjects, the data collection was done with the help of prepared tool. The investigator first established a rapport with the parents or care givers. The purpose of the study was explained. It was assured to them that all the data will be kept strictly confidential and used only for this study purpose and obtained the informed consent. After conducting a structured interview to parents or caregivers, socio demographic data were collected. 7.2.5 DATA ANALYSIS PLAN The data obtained were analyzed by appropriate statistical test. The analysis pertaining to socio demographic data was given in frequency distribution table and whenever necessary statistical means and standard deviation were used. The effect of classical music therapy on physiological parameters was analyzed by Analysis of Variance (ANOVA) and Analysis of Covariance (ANCOVA). The analysis of behavioural parameters and respiratory distress was done by Wilcoxon Signed Ranks Test. 8.0 BIBILOGRAPHY
  24. 24. 24 1. Aikman E, Nolte AG. The effect of constant baroque music on premature infants. Curationis 1997 Jul; 20 (2): 17-20. 2. Aitken JC, Wilson S, Coury D, Moursi AM. The effect of music distraction on pain, anxiety and behaviour in paediatric dental patients. Paediatric Dent. 2002 Mar-Apr; 24(2):114-8. 3. Allen TA. Music therapy. Ann Rev Res 2004; 38 (3): 170-92. 4. Als H, Lawhon G, Brown E. Individualized behavioural and environmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and developmental outcome. Paediatrics 1986; 78:1123-1132. 5. American Academy of Paediatrics, Committee on Environmental Health. Noise: A Hazard for the Foetus and Newborn Paediatrics. Paediatrics 1997; 100 (4): 724-727. 6. Anagnostakis D, Petmezakis J, Papazissis G, Messaritakis J, Matsaniotis N. Hearing loss in low-birth-weight infants. Am J Dis Child 1982; 136: 602-604. 7. Andrea Marie Cevasco. The Effects of Mothers’ Singing on Full-Term and Preterm Infants and Maternal Emotional Responses. Music Therapy Doctoral Dissertation, The Florida State University 2006. 8. Anne Harding. No drop in US preterm births. 2006 stats show. Reuters Health. Jan16, 2009.
  25. 25. 25 9. Annette M Whitehead and Pleaur. Exploring the effects of music therapy on paediatric pain. Journal of music therapy 2007; 44(3): 217. 10. Arnon S, Shapsa A, Forman L, Regev R, Bauer S, Litmanovitz I, Dolfin T. Live music is beneficial to preterm infants in the neonatal intensive care unit environment. Birth 2006 Jun; 33(2): 131-6. 11. Astolfi P, Zouta LA. Risks of preterm delivery association with maternal age, birth order, and foetal gender. Human Reproduction 1999; 14: 28912894. 12. Atkinson J, Braddick O. Sensory and perceptual capacities of the neonate. In P. Stratton (Ed.), Psychobiology of the human newborn. New York: Wiley.1982; 191-220. 13. Aucott S, Donohue PK, Atkins E. Neuro developmental care in the NICU. Ment Retard Dev Disabil Res Rev 2002; 8(4):298 14. Balaka B, Baeta S, Agbere. Risk factors and with preterm delivery in the teaching hospital of lone, Togo. Bellettin de I a Societee de Pathologie Exotique 2006 April. 15. Barrera ME, Rykov MH, Doyle SL. The effects of interactive music therapy on hospitalized children with cancer: A pilot study. Psychooncology 2002; 11(5):379. 16. Bayo MV, Garcia AM, Garcia A. Noise levels in an urban hospital and worker’s subjective responses. Arch Environ Health 1995; 50: 247.
  26. 26. 26 17. Zupan J. Perinatal mortality in developing countries. New England Journal of Medicine 2005; 352: 2047-2048. 18. http://ezinearticles.com/?Music-Therapy-for-Baby&id=166218 19. http://www.bellmusicschool.com/ 20. http://www.early-child-development.com/ 21. http://www.music-research.org/ 22. http://www.todaysparent.com/ 23. http://www.rrh.org.au 24. http://www.musictherapyworld.net. 25. http://www.babygotosleep.com 26. http://www.nichd.nih.gov. 27. http://www.mayoclinic.com 28. http://www.marchofdimes.com. 29. http://www.medscape.com 30. http://www.3.interscience.wiley.com 31. http://www.betterhealth.vic.gov.au. 32. http://www.abcnews.go.com. 33. http://www.jama.com.
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  28. 28. 28 9 SIGNATURE OF THE CANDIDATE REMARKS OF THE GUIDE 10 NAME AND DESIGNATION OF 11 11.1 GUIDE 11.2 SIGNATURE 11.3 CO-GUIDE 11.4 SIGNATURE 11.5 HEAD OF THE DEPARTMENT 11.6 SIGNATURE 12 12.1 REMARKS OF THE PRINCIPAL

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