The reality that we find in pediatric hospitals has a network of many variables, on the one hand the situation of families, who feel overwhelmed by their child's hospital admission, and children who live many experiences that can lead to pain and suffering. Pediatric patients, especially the youngest ones, do not have the emotional maturity necessary to understand, assimilate and handle everything that is happening to them. Music can help them a lot.

The work objectives are mainly two:

1. Reduce anxiety and stress in children and family members by facilitating emotional expression and promoting positive changes in mood states.

2. Reduce the perception of pain.

We work with live music based on research that supports this methodology. The intervention techniques we use are live musical listening, working with song repertoire and musical improvisation.

Music therapy is the clinical intervention using music to achieve therapeutic objectives by a qualified professional. It is a stable health profession that uses music and the therapeutic relationship to treat the physical, psychological, cognitive, emotional and social functions of the patient. There are studies carried out with very favorable results when interventions are aimed at reducing pain, anxiety and depression. Music Therapy is particularly adaptive to all human conditions. Music has the ability to energize or relax, facilitate thinking or distract our attention. It helps us contact reality or facilitate spaces to develop creativity and fantasy. Music therapy sessions promote emotional expression, giving meaning to the individual's personal circumstances. In Spain the discipline is at the beginning of its proliferation, initially demonstrating its possibilities to healthcare personnel and carrying out research for its consolidation. Different teams of music therapists currently work in hospitals in Barcelona and Madrid with adults and children in different services.

Hospital context

The situation of families in the hospital is complex, and each family experiences it differently. But it is a reality and a common aspect that when a child is admitted to hospital, parents feel overwhelmed. Parents take turns being with their child, and receive support from family, friends and associations. At the time of hospitalization, they focus all their energy on their sick child. The entire family enters a crisis and changes develop throughout its structure: in the siblings, parents, grandparents and in the hospitalized child. The crisis is based on the fear, anxiety and helplessness that everyone carries in the face of a situation that they do not manage, in which they intervene little actively and that, ultimately, overwhelms them. They are in a space where they believe that they cannot do anything, because they are not doctors or nurses, and they do not have knowledge of what is happening to their son, nor do they know what can happen to him. How can they get out of this situation that causes feelings of guilt, anxiety and fear... without knowing very well how to approach your children?

Likewise, children also experience all of this in addition to the feeling of loneliness due to normalized social isolation. Furthermore, they are living in an environment that is not familiar, that is not comfortable, where they live many experiences that can lead to pain and suffering. Surgery, stay in the ICU, isolation room, rehabilitation, taking medication, cures, comings and goings of health personnel... Continuous bombardment of sensory stimuli and fully mechanized areas where children are passive subjects of their healing process. Children, especially the youngest ones, do not have the emotional maturity necessary to understand, assimilate and handle everything that is happening to them and around them. There is much documentation showing that hospitalization is one of the most stressful aspects a child can experience. (Langford, 1961; Belmont, 1970; Menke, 1981; Froehlich, 1984, in Dun 1995). For hospitalized children, music therapy can be an alternative for communication, as it gives them the opportunity to express their emotions without the need, in principle, to put words to them. Sometimes it is difficult for a child to explain what their experience is like, especially for younger children since their language skills are not yet developed. (Mc Donnell, 1984 in Dun 1995). There are studies that indicate that babies under three months old show symptoms of distress when they are separated from their mother. Separation in 6-month-old children can produce states of suffering or continued crying (Petrillo and Sanger, 1980 in Marley, 1984). Young children between 1 and 3 years old show a great deal of stress during separation. At this age, dependence on the mother is very strong. Their biggest fear is being abandoned. (Petrillo and Sanger, 1980 in Marley 1984).

Music therapy sessions provide an experience for children and families that helps normalize and familiarize themselves with the strange and, at times, hostile hospital environment. The experience with music gives them the opportunity to have contact with situations that are not related to the hospital world, giving positive stimulation and a feeling of security because they are an active part of something: they sing, play instruments, or move to the rhythm of the music. music.

Once we are aware of all the cognitive, physical and emotional variables that surround children and family members in the hospital environment, we can plan objectives in order to carry out the intervention with Music Therapy.

Work objectives

1. Reduce anxiety and stress in children and family members by facilitating emotional expression and promoting positive changes in mood states.

Many parents express the feeling of not being able to help, or of not being able to do anything for their children. The health personnel are treating their children while they, the ones who know them best, cannot help at all. Therefore, it is important to involve parents in Music Therapy sessions. To serve children who cannot talk to the music therapist, parents are asked what their favorite songs are, what music they listen to at home, and they are invited to join the session. When faced with the invitation, they usually respond affirmatively. On the one hand, it helps them feel useful by actively doing something positive for their child. Additionally, they are given the opportunity to interact with their child in a different way than is typical in an inpatient setting. Creativity, play, and music activate mechanisms that help alleviate the stress and anxiety situation in which they are immersed.

“Music therapy has been used with hospitalized children to offer relief and security and offer a sense of normality to patients and their families. It can also be of great help in reducing stress for families and patients” (Bailey, 1986, in Dun 1995).

“Listening to your musical preferences has been shown to be effective in reducing stress and increasing relaxation in a study carried out where the main stimulus was listening to music” (Davis and Thaut, 1989, in Dun 1995)

In addition, reducing anxiety helps the feeling of having more control over the situation.

2. Reduce the perception of pain

The factors that affect pain perception according to Wepman are the following:

Cognitive factors: positive or negative expectations of pain and feelings of control or helplessness.

Emotional factors: anxiety and “vigilance”, which is a survival mechanism closely linked to anxiety and that causes an increase in the perception of stimuli.

Symbolic factors: They play an important role in the perception of pain, when pain has special symbolic connotations.

It could be stated that the pain threshold depends largely on the patient's mood and emotional state. These factors are what research and treatments in music therapy are based on. Music can be used to reduce the perception of pain as an active focus of attention or distraction using positive environmental musical stimuli.

“By using a musical stimulus during a medical intervention, the perception of pain is significantly reduced by distracting the patient towards the musical stimulus.” (Malone, 1996)

Stimulation through sound as a way to control pain is used in different hospital settings. The use of music as an effective pain reliever is known as “audioanalgesia.” Its effectiveness has been proven in dental operations and its effectiveness is currently being proven in other areas. (Gadner et al. 1960).

“The beneficial effect of music was observed with children during the postoperative period of heart surgery, on heart rate, lung capacity and on pain reduction (using the facial pain scale). However, more in-depth studies are necessary” (Hatem et al. 2006)

The surrounding musical stimulus similar to the child's tastes causes the pain threshold to vary, generating a calm and more relaxed environment during the intervention, also facilitating the work of health personnel. In this way, and whenever the health personnel request it, we have accompanied musically during the removal of catheters and intravenous lines, dressings, as well as the performance of different nursing procedures. Through music, a different climate is created from the usual one where music is the means of expression and channeling of pain.

Work in the plant

Preliminary phase

Information on cases in nursing control: The work of music therapists is being supported by hospital staff and those responsible for the pediatric cardiology service. This makes the job easier and more effective.

When they arrive at the plant they meet with the nurses who can care for us at that moment and they tell us what the situation is like that day. We inform about the children admitted and their status, new registrations and/or cancellations and they tell us which are the ideal candidates to treat with Music Therapy that day. Priority is normally given to the following cases:

Children under two years of age.

Long-stay hospitalized children who have undergone the Fontan procedure.

Children who have just come up from the ICU or are going down to the operating room.

Children suffering from withdrawal syndrome.

Children who are going to have a specific intervention that afternoon: performing a cure, changing their route, removing the catheter...

Children with symptoms of weakness, nervousness, anxiety or depression.

We record the information in files, keeping the patient's personal data anonymous:

Age and sex.

Reason for intervention: Nervousness, lack of sleep, AS, weakness...

Current situation in which the patient is: before or after an intervention, if they are accompanied, long or short stay, etc.…

Information to families and informed consent: Each of the families that will be assisted is explained what our work consists of, what are the specific objectives that we want to achieve with the intervention and how we are going to do it. Any possible doubts are resolved and the family members decide if they want us to enter or not. If the answer is affirmative, they must sign an informed consent that will be filed along with the documentation of the intervention such as monitoring and vital signs records.

Before starting the session, we talk to the child briefly if he or she has language, to make a prior evaluation of his or her physical and mental abilities. Also with family members and we ask them if they want to do something special musically: a specific song, a style, etc. We have been given different situations in this sense, such as children who study a musical instrument, another young person who is passionate about flamenco and who studied guitar, parents who are fond of classical music and, of course, the hits of the moment.

Session development

With all the information collected previously at a medical and psychological level and, taking into account the specific moment that the child and the family are experiencing, we decide what we believe the patient is needing and what is the best intervention to carry out:

Instrumentation of songs.

Instrumental improvisations: melodic or percussion.

Vocal improvisations: with or without text.

Specific songs.

Activities that involve movement or body expression.

Music to induce sleep.

Song creation.

Musical relaxation, etc.

During the session, the monitor is monitored in case there are significant changes in the patient's constants that should later be recorded or evaluated.

Information collection and supervision

After each intervention, the session is evaluated by completing two sheets. One medical and another specific to music therapy and the patient's way of acting. In the medical record we take into account above all the heart and respiratory rate, and oxygen saturation. The values before and after the intervention are noted. In the music therapy sheet we write down the activities we have carried out and describe how the session and the patient's response were musically: Tonality, scales, tempo, rhythm, dynamics, etc. and how it has affected the patient's change in mood, emotion, relaxation or activation. Everything is recorded and archived.

Music therapy techniques

Importance of live music: Live music can adapt to the present moment and adapt immediately to what is happening at that moment, to the rhythm of each child or the group participating in the session. This allows the sound impact to be richer and for all participants to access the music regardless of its internal rhythm, its tonality and the physical and/or cognitive reality that accompanies it. In Music Therapy, the priority is to be able to guide the patient's needs and problems through music. In this way, music is selected or created for its clinical relevance, usefulness and attraction for the subject (Patxi del Campo, 2000). Furthermore, musical quality favors participation, creating creative and rewarding experiences.

In the hospital setting, we work with live music instead of recorded music based on research that supports this methodology. They compare values such as anxiety, vigor, tension, fatigue, etc. before and after a Music Therapy session with recorded music or live music. The changes in these values are much more significant when the session is with live music.

With live Music, the Music Therapist can interact with the patient, being instantly aware of each change that occurs in them. This constant feedback helps us to incorporate the necessary changes that are useful to achieve the proposed objective.

Techniques used

Musical improvisation: Speaking in musical terms, improvising is defined as the art of spontaneously creating music while playing, rather than performing an already written composition. Improvisation as a technique is used in different clinical settings, including hospitals. Improvisation is an active technique, where the patient and the therapist play together. Although musical listening has clinical benefits, making music in an active and improvised way involves the child's attention, leads him to engage actively and personally, and allows emotional expression in an artistic-creative way (Kenneth Bruscia, 1999). . The flexibility of improvisation does not require musical aptitude to participate, so it is not limited to any age group or level of development. (Kenneth Bruscia, 1999).

Live Musical Listening: In this technique, the patient plays a passive role, since it does not involve a specific performance. He does not play instruments or sing, but rather plays a more receptive role. Music therapists play or sing, picking up the mood of the present moment and leading the musical activity. Listening to music can be very effective as a guide to relaxation or inducing sleep. The patient's preferences and usual sound environment (family musical preferences or habits), age, etc. are evaluated. And music is chosen that promotes relaxation. For example, a steady, slow beat, chords or notes that are long and predictable in structure and form, can promote slow, deep breathing.

Very different musical styles and structures are used. Trying to have a range of possibilities that is as wide and varied as possible to be able to access any type of person regardless of their origin, age, social condition, abilities or pathology, etc. It will depend on each specific session whether we use stimulating or sedative, sad or happy music, based on high or low tones, minor or major tones, varied styles from jazz, flamenco, pop, classical, etc. from old songs to the most current hits. The choice within this crucible will depend on what the patient needs at that moment and what the objective is to achieve.

Bibliography

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Text reviewed and adapted by Cristina Oroz Bajo Original documentation in MUSA