Growing evidence supports the positive impact of music on child health.
The study by Uggla et al. 1 in this issue of Acta Paediatrica adds valuable knowledge to the growing literature on the use of music in clinical child care. The authors performed a randomised control trial (RCT) on the effects that specifically designed music therapy had on the heart rates of children, from two to 16 years of age, receiving haematopoietic stem cell transplants. As with all good initial studies, this research has prompted a number of questions for future research. The authors argue that the kind of music therapy they introduced may have prevented the development of post-traumatic stress disorder (PTSD) after stem cell transplantation, which is itself a traumatic experience. On the basis of previous studies, they stated that the high heart rates observed during such surgery were an indicator of an increased risk of future PTSD after the operation. The results of their study provided the first confirmation of their hypothesis that individualised and interactive music therapy would lower the heart rate in these children and possibly also lower the risk of subsequent PTSD. However, the latter hypothesis was not tested in this study as there was no follow-up. First of all, there are a couple of technical notes that need to be highlighted. The sample sizes were small, with 12 in the music group and nine in the control group. In a straight forward randomisation process with such small numbers, researchers run the risk that, from some points of view, the groups may not be comparable from the start. One way of avoiding this would have been to match subjects in pairs with regard to the most important variables, which in this case were clinical condition, age and heart rate. The randomisation would then have taken place within each matched pair. In this way, important baseline group differences could have been avoided. The results would have been easier to interpret had the groups had equal heart rates at baseline. But having said that, I do accept their conclusion that the music therapy was successful in lowering heart rates in the music therapy group. A puzzling aspect of this study is that such a large group of subjects and parents – 16 of 40 families – initially refused to participate, and a smaller problem was that one patient in the music group and two children in the control group were lost during the intervention and follow-up periods. It would be interesting to know more details about why so many children and, or, parents did not want to participate in the music therapy. How was this raised with them? Did the staff display a negative attitude? Were the parents afraid that the music therapy would distract the staff′s attention from the medical treatment? Many questions remain. It is obvious that if the staff had displayed a detached or critical attitude about the study it may have dramatically reduced the participation rate. There is a growing body of literature on how heart rate variability provides a very sensitive indicator of autonomic balance and imbalance. In the Uggla et al. study, the authors, quite sensibly, used heart rate assessments that were part of the daily hospital routine. Because they were able to show significant results, despite the fact that they carried out such a simple assessment, it is likely that they would have been able to show more diverse and clearer effects if they had analysed heart rate variability by carrying out more extensive continuous recordings of the children's heart rates. Numerous RCTs have shown that listening to partly self-selected music has stimulated parasympathetic activity and reduced sympathetic activity in adult patients facing stressful situations, such as before or waking up from surgery 2, having a caesarian section 3 and undergoing heart examinations such as myocardial scintigraphy 4. Listening to music could also affect endocrine function as well as heart rates in relation to medical interventions. A well-known example is the RCT by Nilsson 5, which showed that subjects waking up from heart surgery displayed rising plasma oxytocin levels if they were allowed to listen to individually preselected music, whereas the opposite trend was observed in the comparison group, who woke up in silence. This is of particular importance because oxytocin relieves pain and anxiety. It is also relevant to this study, as oxytocin seems to play an important role in establishing social relationships. It has been shown that oxytocin receptor polymorphism, together with childhood social experiences, may contribute to the shaping of an adult's personality and brain structure and the neural correlates of mentalisation 6. This may serve as a further illustration of the potential importance of beneficial music experiences in helping to prevent PTSD after child trauma. It has been known for some time that slow rhythmic cues activated by eye movement desensitisation and reprocessing (EMDR) may stimulate parasympathetic activity in adult patients with PTSD 7, and this may make it possible for these patients to reprocess their traumatic experiences and handle them more effectively. There are obvious parallels between the rhythmic activation induced by means of rhythmic visual movements in EMDR and slow music rhythms. In simpler terms, the calming rhythmic music may have facilitated the child′s processing of the traumatic components during the bone marrow transplant. Of course, it is important that the choice of music is adapted to the experiences and needs of the individual patient and this is particularly important if the patient is a child. The Uggla et al. 1 paper in this issue describes a very sensitive and interesting system for approaching the child, using a musical dialogue between the therapist, child and, in some cases, parents. This combined a mixture of passive listening and actively doing things. However, that kind of interaction has to be introduced by a well-educated music therapist. In a more general sense, I hope that the potential of, and knowledge regarding, musical experiences in both the treatment and education of children will be used more extensively in the future. It is not just heart rate, heart rate variability and oxytocin that are involved in our responses to music, the immunological and endocrinological systems are influenced as well 8. Reactions to music seem to be programmed in us and music can be effectively used for both beneficial and negative purposes 8. In some situations, musical experiences are not just a short distraction, and they might also have long-lasting effects, as in this study by Uggla et al.
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