Music in perinatal care and education

Her arms rested over the edge of the birthing tub, her laboring body buoyant in the water. Breathing through a contraction, her eyebrows furrowed slightly. Warm, dim light hummed throughout the room. A midwife, an assistant, her partner, and I floated through the suite offering her encouragement and support as she worked to bring her baby earthside. 

Photo by Rebekah Vos on Unsplash

Another wave of intensity swelled throughout her body. The “rhythmic sound of blood coursing through the uterine artery” was her baby’s surround sound. Simultaneously, the escalation of energetic strings on her playlist interrupted her concentration. She laughed. Something about the sound of this music struck her as funny, and she asked her husband to please advance the playlist. I sometimes think back to this little moment as evidence of how powerful music can be.

Then as her labor progressed, she produced her own music, a sound deep within that reverberated through the room, the vibrations of an ancient song.  

Elena Mannes, author of The Power of Music, has shown that “music stimulates more parts of the brain than any other human function.” 

Music can be used as a relatively low-cost, low-intervention tool in perinatal care. Though its use may seem innocuous, as with any tool, it should be used intentionally.  

 

Early on 

Photo by Greta Hoffman

Mannes points out that the “human relationship to sound starts early… The fetus begins to develop an auditory system between seventeen and nineteen weeks. Already, we are in a world of sound, of breath and heartbeat, of rhythm and vibration.”

She also highlights Dr. Sheila Woodward’s work which looked at the transmission of music into the human uterus and the human fetus and newborn response to music and found that a “fetus responds to a music stimulus from at least the 32nd week of gestation; and that the neonate alters the normal sucking pattern to activate longer periods of a music stimulus which has been repeatedly presented during the intrauterine stage and shorter periods of a novel music stimulus.”

Healthy Children Project’s Karin Cadwell shares a fond memory:  “I learned to play the guitar when pregnant with one kid. I wouldn’t exactly call what I was doing ‘music’ but it was probably rhythmic against my belly. She was only a few days old and I was mixing bread with a dough hook in my mixer and she was pushing her legs up and down exactly to the beat!” 

What’s more, the authors of Prenatal Music Exposure Induces Long-Term Neural Effects conclude that “prenatal exposure to music can have long-term plastic effects on the developing brain and enhance neural responsiveness to the sounds used in the prenatal training…Furthermore, we found that these plastic changes are long lasting, as the effect of prenatal exposure persists for at least four months without any additional stimulation.”

The authors declare some practical implications:  “… since the prenatal auditory environment modulates the neural responsiveness of fetuses, it seems plausible that the adverse prenatal sound environment may also have long-lasting detrimental effects. 

Such environments may be, for example, noisy workplaces and, in case of preterm infants, neonatal intensive care units. 

Furthermore, as prenatal exposure still affected the [event-related potentials (ERPs)] responses months after birth, additional fetal exposure to structured sound environments might be beneficial for supporting the auditory processing of, for example, infants at risk for dyslexia in whom basic auditory processing was shown to be impaired.”

 

Language learning 

Photo by Mălina Sîrbu

A more recent study looked at the language learning implications of prenatal music exposure. Sonia Arenillas-Alcón, et al conclude that their “findings support the idea that daily musical exposure during the last trimester of pregnancy is associated with enhanced encoding of low-frequency sound components, such as those typical of the fundamental frequency of human speech, that relate to pitch perception.” 

Matthew J. Traxler writes about prosodic (the rhythm and intonation of language)  features of language learning in Introduction to Psycholinguistics: Understanding Language Science. “Infants … appear to be endowed with perceptual and representational skills that enable them to tell the difference between different speech sounds from the moment they are born (or at most, within the first 24-48 hours),” Traxler writes. 

 

Music in therapy 

There’s compelling evidence that shows the importance of music as a therapeutic tool, like during labor and in other environments like the NICU.

Photo by Raul Angel on Unsplash

Marissa Rivera Bolaños recounts her experience with the didgeridoo during labor on the Womb Revolution blog: “…It resonates through your body as a non-touch massage…. During the birth, I just remember the sound was very grounding…. My husband played it directly into my belly while I circled my hips and sang my birth song. I felt like the vibrations were helping soften every cell of my body.” 

Andrea M. Cevasco , PhD, MT-BC, NICU-MT quotes a mother in The Effects of Mothers’ Singing on Full-term and Preterm Infants and Maternal Emotional Responses who said that knowing her infant listened to her singing helped her to cope with the baby’s stay in the NICU.

Jayamala AK, et al notes that their study results “suggest that music therapy has a positive effect in reducing stress in mothers of hospitalized premature neonates thereby increasing the amount of expressed breast milk. A relative increase in the amount of breast milk expressed is a boon to the premature baby for its growth and development as it requires additional nutrition. Music therapy being a non invasive method; can easily be used clinically as a method to increase breast milk secretion.” 

And the results of Caine’s work suggest that “music stimulation may have significantly reduced initial weight loss, increased daily average weight, increased formula and caloric intake, significantly reduced length of the NBICU and total hospital stays, and significantly reduced the daily group mean of stress behaviors for the experimental group.”

MUSIC AND HEALTH CARE: A Paper Commissioned by the Musical Connections Program of Carnegie Hall’s Weill Music Institute by Lea Wolf, MSW and Dr. Thomas Wolf details how music enjoyed by patients can reduce staff stress too.  (p .13)  

Annie Jameson plays alchemy crystal singing bowls which produce resonance and help people de-stress, release anxiety and relax deeply, she says. Her music can be used alongside most therapies to induce tranquility, she adds. 

“Because the brain of each individual patient has absorbed musical building blocks of his or her local sonic environment in infancy and developed expectations and preferences based on this experience, choosing appropriate musical selections is an important challenge,” Wolf and Wolf write. 

This is particularly evident in the anecdote I share up top as I sat alongside my laboring friend. The same sounds conjured comedy in her brain, whereas I was unaffected. 

The authors go on to offer a strategy for music choice in health care. 

Music in perinatal education and normalization 

Song can serve as a way to share stories and lessons and influence popular culture. 

If you’ve completed the Lactation Counselor Training Course (LCTC), you’ll be familiar with the jaunty  When you counsel tune which serves as a reminder to honor the mother as the expert of her baby(ies) and the agent of her decision-making. It  goes to the tune of Frère Jacques:

When you counsel
When you counsel 
Never judge 
Never judge 
Praise mother and baby 
Praise mother and baby 
Don’t command 
Do suggest 

If you’ve never heard T’Amentanefer Lumukanda Camara (TaNefer)’s viral “Teach Me How to Breastfeed” video, you’ll want to drop everything else to acquaint yourself. 

Equally entertaining is Sparrow Folk’s Ruin Your Day song, commentary on breastfeeding in public. 

On our Weird Findings installation, we shared a beautiful video from the Pokot community in Kenya which uses song to deliver a PSA about infant feeding. 

Finally, we prefer this version of Dua Lipa’s original: I’m Lac-a-tating.

Lindsey Brown McCormick’s, PhD, LPCC-S, PMH-C, CLC light bulb moment

[Photo by Andrea Piacquadio]
We consider ourselves life-long learners here at Healthy Children Project. Sometimes learning occurs gradually, and sometimes there are the ‘light bulb’ moments.

We put a call out to our followers to share “Aha!” moments with us. Maybe it was a myth busted during the Lactation Counselor Training Course (LCTC) or maybe it happened during a visit with a dyad.

We also called for stories about your babies’ and children’s ‘light bulb’ moments. When have you seen your little ones’ faces light up in discovery and understanding?

The call for stories is still open! Please send your reflections to info@ourmilkyway.org with “Light Bulb” in the subject line.

Lindsey Brown McCormick, PhD, LPCC-S, PMH-C, CLC is the owner of Women Thrive Counseling & Consulting LLC. This is her light bulb moment. 

——

Dr. McCormick
Used with permission

I did not go into the field of mental health counseling with the goal or intention of working with mothers/birthing people and babies. It was never on my radar as something that clinicians even specialized in. The birth of my daughter changed everything for me. 

I’ve been working in the field of trauma and traumatic stress since 2010. My spouse and I welcomed our daughter, currently our only child, into the world November 2021. I was induced and labored for 22 hours before I was whisked away into the operating room for an emergency cesarean. Though everything was seemingly normal on the surface, between the complications faced in labor and the OR, internally I was far from okay. The spiral of postpartum anxiety had entered the chat. 

It was after we came home, in the stillness of the village that lived so far away, crying on my couch with a cluster feeding newborn, I realized two things: 1) I didn’t know anything about perinatal mental health, and 2) I didn’t know where I could even go to learn. 

In the following weeks, my spouse would arrive home from work and I would dump everything that I had discovered that day onto him. I was so energized, so eager to learn, and I was jumping into the deep end of this new clinical niche. I enrolled in a perinatal mental health training program. Upon completing that, I enrolled in the Certified Lactation Counselor training course. Bridging these disciplines, as a practitioner, just made sense to me. There can be a significant amount of mental health problems that arise from attempting to body feed: anxiety, trauma, and grief, to name a few. And, as an attachment theory and parenting nerd, I absorbed research on skin-to-skin care like a sponge. 

As I’ve continued to specialize in this field, I greatly appreciate the value of blending perinatal mental healthcare and lactation care, the healing benefits of skin-to-skin care after a traumatic birthing experience, and the neuroscience of matrescence and infant (0-3) development. It’s provided me opportunities to learn more about the relationship between my daughter and me. It’s positively influenced my parenting style. It’s positively influenced my approach as a counselor and an educator. There are FEW psychotherapists who have lactation credentials out there, and I feel honored to be one of them. 

 

School Age Parenting Program nurses complete Lactation Counselor Training Course enhancing support for students

Spring can be an especially busy time for pregnant and parenting teens. There’s prom, Easter egg hunts, Eid al-Fitr, Holi, Passover and other festivities,  the summer school enrollment process, all alongside their typical school responsibilities. Then there’s the excitement of pending graduation for some. 

Nurse Michelle and Nurse Ashlee

Michelle Alkinburgh, BSN, RN and Ashlee Anzalone, RN, health care coordinators at the Racine Unified School District’s School Age Parenting Program (SAPAR), recently completed the Lactation Counselor Training Course (LCTC) in an effort to further support their students who are managing the multiplicity of being pregnant or parenting in high school. 

The duo is proud to report that many of their young parents choose to breastfeed even while juggling all of their other demands.

“We have many moms who breastfeed the first few weeks and have had three moms who breastfed for a year!” they exclaim.  

In the U.S., one estimation suggests that of the  “approximately 425,000 infants born to adolescents… only 43 percent will initiate breastfeeding, in contrast to 75 percent of mothers of adult age…” [Kanhadilok, et al, 2015]

Over 30 years ago, the state of Wisconsin required school districts to provide programming and services to school-age parents. As such, SAPAR  programming has been in place since the requirement was established.  

SAPAR is intended to retain pregnant and parenting students in school, promote academic progress, increase knowledge of child development and parenting skills, improve, decision-making regarding healthy choices, prevent subsequent teen pregnancies and child abuse and neglect, including that of the teen mother, and assist in post-secondary education and/or employment.  The program is open to all students under the age of 21 years who are not high school graduates and are parents, expectant parents or have been pregnant during the last 120 days. [Retrieved from https://rusd.org/academics/alternative-programs/pregnant-parenting-teens

Alkinburgh and Anzalone report that they average around 100 enrolled students each year.  During the 2022/23 school year, they served 104 students.

Healthy Children Project’s Carin Richter notes that programs like SAPAR aren’t often sustained for as long as Racine’s programming; instead,  they’re often met with a lot of opposition and are frequently cut from school budgets, she observes.

“I am impressed with the school district that promotes her program and the school board, PTA, and school staff that encourage this type of program,” Richter offers. 

The team comments on their strength and sustainability: 

“[Our program] has two nurse case managers with extensive knowledge and experience in maternal and child health, allowing us to help when medical issues arise, not just for our parents but also their children.  We provide health education, childbirth and parenting classes, and assist with community resources and academic needs.  We work together as a team with our students, families, school staff, medical providers and community partners.  

The national average graduation rate for teen parents is about 50 percent,  but our program changes that!  Last year 94 percent  of our eligible Seniors graduated providing more job opportunities, financial stability and college or apprenticeship options. Teens 15 to 19 years old also have higher rates of infant mortality and maternal complications. We had zero percent.”

Students Anika Moreno and Gregory Sanders Jr. pictured with their child.

Each work day is different for the duo. There are no defined hours and they often work with students for several years.  

“Our work requires a lot of flexibility and patience, but it is so rewarding to see our students succeed,” they begin. “We provide school visits throughout the district, and also phone, virtual, home and community visits to meet the individual needs. You may find us busy helping students get health insurance, find a medical provider, manage pregnancy symptoms to stay in school, check a blood pressure, obtain a medical excuse, meet with support staff, talk to a parent, help enroll in community programs, get a crib or car seat, find diapers, etc.  We may be assisting with childcare, nutrition, housing, employment or transportation needs.  We also do a lot of health teaching and use evidenced-based curriculum specifically designed for young parents to help them learn and have an opportunity to earn additional credit toward graduation. Our goal is that our students stay in school, graduate high school and have healthy babies.”

Teenage dads can get a bad rap, but Alkinburgh and Anzalone note that “they really want to be great dads.” The nurses offer individual, joint and group meetings for young fathers and cover topics like infant care, co-parenting, child support, etc.  

“We try to make learning fun and engaging,” the duo says. “For example, we may have a diaper changing race or have them practice giving a baby a bath with our infant model and newborn care kit.” 

To add to their skill-base, the team needed to do some unlearning about breastfeeding myths through the LCTC.  

“Now that we know the newest research-based facts, we can best educate our students,” they say. “We already started using the awesome counseling skills they taught us in the training and it has really helped us ask more open- ended questions to address students’ concerns and goals.” 

Overall, the nurses have experienced a positive attitude for breastfeeding in their community at large. For instance, the district offers private lactation rooms in each of their schools for staff and students to use when needed. 

For those interested in supporting the program’s mission, the team offers: “Be kind, supportive and share with others how truly valuable a program like ours really is!” They also suggest donating, volunteering or partnering with community organizations that help support their students  like the Racine Diaper Ministry, Salvation Army, Cribs for Kids, Parent Life, Halo, and United Way. 

Find the program on Facebook here.

Centers for Disease Control and Prevention (CDC) changes their breastfeeding policy for HIV-infected mothers

Without major announcement, in February 2023,  the Centers for Disease Control and Prevention (CDC) changed their breastfeeding policy for HIV-infected mothers and no longer recommend advising against breastfeeding.

Photo by Paul Hanaoka

The new recommendation gets closer to the updated 2010 World Health Organization (WHO) guideline on HIV and infant feeding. Before 2010, “WHO guidance on HIV and infant feeding (UNICEF et al., 2003; WHO et al., 2006) recommended an individualized approach in which women living with HIV would be counselled on feeding options according to their household circumstances.”

The new CDC guideline acknowledges that, “For mothers on antiretroviral therapy (ART) with a sustained undetectable HIV viral load during pregnancy, the risk of transmission through breastfeeding is less than 1%, but not zero,” as determined in the PROMISE Study.

The guideline goes on to recommend “patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.” Read the full document here.

Organizations like the National Institute of Health Office of AIDS Research, the Infectious Disease Society of America and National Association of County and City Health Officials announced the new guidance, but it has gone largely unacknowledged in the field of lactation.

“This change in HIV policy serves as a reminder to always check sources. New research findings and policy reconsiderations make it imperative that the most up-to-date information is available to the families we serve,” Healthy Children Project’s Karin Cadwell PhD, RN, FAAN, IBCLC, ANLC comments.

Photo by Wren Meinberg

In the U.S., HIV diagnoses among women have declined in recent years; still, nearly 7,000 women received an HIV diagnosis in 2019. (The CDC has commented on the effect of the COVID-19 pandemic: “Data for 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state and local jurisdictions. While 2020 data on HIV diagnoses and prevention and care outcomes are available, we are not updating this web content with data from these reports.”)

How does the U.S. compare in their recommendations to other high-income countries?

The British HIV Assocation’s 2018 guidelines for the management of HIV in pregnancy and postpartum states that “Women who are virologically suppressed on cART with good adherence and who choose to breastfeed should be supported to do so, but should be informed about the low risk of transmission of HIV through breastfeeding in this situation and the requirement for extra maternal and infant clinical monitoring” among other recommendations for helping manage lactation in HIV-positive mothers.

Photo by Laura Garcia

A National Health Service (NHS) Greater Glasgow and Clyde document Management of infants born to HIV positive mothers reads: “There is now evidence from developing countries that breast feeding while mum’s viral load is fully suppressed is safe, and BHIVA/CHIVA no longer regard a decision to breast feed as grounds for referral to child protection services. For HIV positive women who choose to breast feed, maternal HAART should be carefully monitored and continued until one week after all breastfeeding has ceased. The mother’s viral load should be tested monthly to ensure that HIV virus remains undetectable; this testing will be undertaken by the obstetric/ID team. It is recommended that breastfeeding be exclusive, and completed by the end of 6 months.”

You can learn more about Canada’s approach here and Switzerland’s here.

For more, check out  Lacted’s Clinical Question and the CDC’s Preventing Perinatal HIV Transmission.

Field of lactation gains child psychologist

The field of lactation just gained another amazing care provider. Kenya Malcolm, PhD, CLC is a child psychologist, consultant, and trainer in Rochester, New York. Dr. Malcolm’s work focuses on programs and interventions in early childhood in mental health settings, preschools and pediatric offices. Among her many responsibilities, Dr. Malcolm is the HealthySteps program coordinator at a large pediatric practice.

Dr. Malcolm says, “The research is pretty clear that working with caregivers early to support children is the best way to promote optimal family and child health. So, that’s what I do!”

In fun, Dr. Malcolm is not only passionate about mental health, but she’s a self-described stationery nerd.

“I think that color coding is a great way to take notes and stay organized but I’ve been mocked for my pen collection!” she begins. When her LCTC instructor Dr. Anna Blair recommended using multiple ink colors on the Lactation Assessment & Comprehensive Intervention Tool (LAT), Dr. Malcolm says she felt validated.

She was again validated during the first few sessions of the course while learning about the benefits of breast/chest feeding not only for the baby but for lactating people.

“That’s when I knew I’d made the right decision to sign up for the course,” she reflects.

Because Dr. Malcolm is new to lactation counseling, she says that “every successful chest feeding story is my favorite right now.”

Photo by Luiza Braun

“All the moms have been so happy that they’re successful!” she explains. “I was not supported in breastfeeding my own kids when they were born and honestly, being a CLC is like an opportunity to be the superhero I wish I had 20 years ago.”

In becoming that superhero, Dr. Malcolm subscribes to reflective practice as a guiding principle in her work, and more specifically, in her leadership roles.

Dr. Malcolm remembers the words of one of the founding members of ZERO to THREE Jeree H. Pawl: “How you are is as important as what you do.”

Here’s more of what Dr. Malcolm had to say:

“Reflective supervision is a special kind of supervision that focuses on the practitioner’s own thoughts, feelings, and behaviors to support their ability to provide good care to the folks they are working with. Working with caregivers and children is tough work and usually includes navigating systems that are very siloed with rigid expectations. As humans, we often respond in ways that are just as much about ourselves as about the family in front of us. Reflective supervision is a necessary space for slowing down and looking at our actions to improve care, reduce bias and disparities, and improve the well-being of everyone involved. Reflective capacity is a skill and reflective supervision is considered a necessary component of support for people who are working with young children and families by most major organizations working toward the health of families.”

In Dr. Malcolm’s side gig with The Society for The Protection and Care of Children, participants introduce themselves with their baby pictures “as a way to hold in mine our own younger selves who continue to show up in our work.” The work focuses on training staff in Infant Mental Health (IMH) principles, Reflective Supervision, and infant/early childhood mental health conceptualization and diagnosis using the DC0-3 across New York state.

“One IMH principle is that we always hold the baby in mind,” Dr. Malcolm begins. “But it’s not just the baby in front of us. We also have to be aware of the baby whose needs are still present in our own selves. That’s why reflective spaces are so important. Our own biases and histories are present in all of our current interactions–another IMH tenant is that our early experiences matter– and we want to be mindful of how those are showing up in our work in both helpful and not so helpful ways.”

Dr. Malcolm tackles another big idea. Responding to an article on moral injury she wrote on social media, “I… think there’s a savior fantasy that many health professionals have that is sometimes traumatic to lose while in the field.” This phenomenon often rings true for lactation care providers. Dr. Malcolm advises doing the self- work it takes for true humility and reflection.

She shares this anecdote:

Source: United States Breastfeeding Committee (USBC)

“I was observing a lactation counseling visit last week and a mom came in with questions about a possible tongue tie and some nipple pain with feeding. Since the latch was poor, the LC provided some strategies for improving latch that helped to address some of the pain. Like, mom agreed that there was less pain with position changes. But mom was not actually interested in working on latch; she was focused on the possibility of the tongue tie. The LC did a great job of talking through her observations and assessment and providing next-step ideas to Mom. But the LC and I really wanted mom to want to improve her latch. It would be easy to feel like that was an unsuccessful visit because we didn’t save the day in the way we wanted. But mom left feeling heard and supported. Many of us go into human services work to be a hero (I actually used the words “being a superhero” two answers ago!! I’m tempted to change that answer now, but I’m not going to.) of our own design. Families don’t need that. They need support to be at their own best.”

You can connect with Dr. Malcolm here.