Effect of Music by Mozart on Energy Expenditure in Growing Preterm Infants
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Effect of Music by Mozart on Energy Expenditure in
Growing Preterm Infants
WHAT’S KNOWN ON THIS SUBJECT: Music has been shown to AUTHORS: Ronit Lubetzky, MD,a,b,c Francis B. Mimouni,
reduce stress, decrease heart rate and salivary cortisol, and MD,c,d Shaul Dollberg, MD,a,c Ram Reifen, MD,e Gina
increase oxygen saturation, nonnutritive sucking rate, and even Ashbel, RN,a and Dror Mandel, MDa,c
weight gain in preterm infants. Departments of aNeonatology and bPediatrics, Tel Aviv Sourasky
Medical Center, Tel Aviv, Israel; cSackler School of Medicine, Tel
Aviv University, Tel Aviv, Israel; dPediatrics, Shaare Zedek
WHAT THIS STUDY ADDS: Exposure to Mozart music significantly
Medical Center, Jerusalem, Israel; and eFaculty of Agriculture,
lowers REE in healthy preterm infants. Food and Environment, Hebrew University, Jerusalem, Israel
KEY WORDS
metabolic rate, music, preterm infants, energy expenditure
ABBREVIATION
abstract REE—resting energy expenditure
This trial has been registered at www.clinicaltrials.gov (identi-
OBJECTIVE: The rate of weight gain in preterm infants who are ex- fier NCT00838474).
posed to music seems to improve. A potential mechanism could be www.pediatrics.org/cgi/doi/10.1542/peds.2009-0990
increased metabolic efficiency; therefore, we conducted this study to doi:10.1542/peds.2009-0990
test the hypothesis that music by Mozart reduces resting energy ex- Accepted for publication Jun 18, 2009
penditure (REE) in growing healthy preterm infants. Address correspondence to Dror Mandel, MD, Lis Maternity
Hospital, Tel Aviv Sourasky Medical Center, Department of
DESIGN. A prospective, randomized clinical trial with crossover was
Neonatology, 6 Weizman St, Tel Aviv 64239, Israel. E-mail:
conducted in 20 healthy, appropriate-weight-for-gestational-age, dmandel@post.tau.ac.il
gavage-fed preterm infants. Infants were randomly assigned to be PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
exposed to a 30-minute period of Mozart music or no music on 2 con- Copyright © 2009 by the American Academy of Pediatrics
secutive days. Metabolic measurements were performed by indirect
FINANCIAL DISCLOSURE: The authors have indicated they have
calorimetry. no financial relationships relevant to this article to disclose.
RESULTS: REE was similar during the first 10-minute period of both
randomization groups. During the next 10-minute period, infants who
were exposed to music had a significantly lower REE than when not
exposed to music (P ⫽ .028). This was also true during the third 10-
minute period (P ⫽ .03). Thus, on average, the effect size of music on
REE is a reduction of ⬃10% to 13% from baseline, an effect obtained
within 10 to 30 minutes.
CONCLUSIONS: Exposure to Mozart music significantly lowers REE in
healthy preterm infants. We speculate that this effect of music on REE
might explain, in part, the improved weight gain that results from this
“Mozart effect.” Pediatrics 2010;125:e24–e28
e24 LUBETZKY et al
Downloaded from by guest on November 4, 2015ARTICLES
Rauscher et al1 found that a group of growing steadily, and had no electro- surements, the environment was con-
36 college undergraduates improved lyte imbalance. None had any signifi- trolled to minimize possible unwanted
their spatial-temporal intelligence af- cant complication of prematurity, such noises and maintain noise constancy.
ter listening to 10 minutes of a Mozart as intracranial hemorrhage (of any The monitor alarms were kept silent
sonata. The findings, which were later grade), periventricular leukomalacia, (visual alarm only), and the ward’s
labeled “the Mozart effect,” refer to an necrotizing enterocolitis, supplemen- doors were closed to minimize outside
enhancement of performance or a tal oxygen requirements by 28 days of noise. Music was initiated 10 minutes
change in neurophysiologic activity as- age or by 36 weeks of postmenstrual before the beginning of the metabolic
sociated with listening to music.2,3 This age and at least 1 week before mea- measurements and was continued for
effect is not exclusive to adults, and surement, active infection, patent duc- the 30 minutes of REE recording. The
music has been shown to reduce tus arteriosus, or episodes of apnea of same procedure was applied during
stress even in preterm infants.3–6 In prematurity. They all were free of con- the no-music exposure period. Impor-
this group of patients, music de- genital anomalies or dysmorphism. Ac- tantly, no music was heard by the in-
creased heart rate, salivary cortisol, cording to our feeding protocol, in- fants during the whole study period ex-
and distress behavior and increased fants were uniformly fed (by gravity cept for the 30 minutes of exposure
oxygen saturation, nonnutritive suck- drainage) every 3 hours bolus feeds of related to the study.
ing rate, and even weight gain, thereby their mother’s breast milk or a pre-
Metabolic studies were conducted while
decreasing the length of their hospital term infant formula. We verified after
the infants were prone and asleep and
stay.3–6 discharge that all infants who were re-
at the same time of the day (noon time)
The mechanism of this effect of music cruited in this study had normal brain-
for all infants, starting 1 hour after the
on the rate of weight gain is unknown. stem auditory responses (a routine
completion of the last feed. The same
One potential mechanism is that of in- procedure in all infants who are dis-
type (breast milk versus formula) and
creased metabolic efficiency; there- charged from our NICU). The study was
amount of food was given to the infants
fore, we conducted this randomized, approved by the local institutional re-
on both study days. Measurements
prospective clinical trial with cross- view board, and written informed con-
were stopped during body movements
over to test the hypothesis that music sent was obtained from both parents
(⬍5% of the time of measurement).
by Mozart reduces resting energy ex- of each infant.
During the metabolic study, infants
penditure (REE) in growing healthy were cared for in their own, convective
Design
preterm infants. incubator. Air temperature inside the
This study was a prospective, random-
incubator was skin servocontrolled to
METHODS ized trial with crossover of the effect of
keep temperature over the back at
music (compared with no music) on
Patients 37°C. Thus, the 2 energy expenditure
REE. The sequence in which exposure
The study was conducted in the NICU at measurements were made in nearly
was given (music first followed by no
the Lis Maternity Hospital, Tel Aviv Med- music or the opposite) was selected by identical thermal environments.
ical Center (Tel Aviv, Israel). We aimed randomization, by using random num-
Measurements
to study healthy, growing, appropriate- bers. Each infant was studied on 2 con-
weight-for-gestational-age, gavage-fed secutive days. We tested only the music Metabolic measurements were per-
infants at the postmenstrual age of of Mozart present on the Baby Mozart formed by indirect calorimetry, by us-
30 to 37 weeks. Postmenstrual age CD (Baby Smart, Rehovot, Israel), which ing the Deltatrac II Metabolic monitor
was calculated in completed weeks on was played on a mini-CD device at a (Datex-Ohmeda, Helsinki, Finland). This
the basis of last menstrual period, con- volume of 65 to 70 dB. Before the study, instrument uses the principle of the
sistent ⫾1 week with early, first- the CD system was calibrated accord- open-circuit system that allows contin-
trimester ultrasound examination. All ing to the American Academy of Pediat- uous measurements of oxygen con-
infants were clinically and thermally rics recommendations7 not to exceed sumption and carbon dioxide produc-
stable while cared for in a skin servo- volume of 75 dB and to maintain back- tion using a constant flow generator.
controlled incubator. At the time of the ground noise near the infant’s ear The measurement ranges for both ox-
study, they all were tolerating full en- ⬍45 dB. According to this acoustic ygen consumption and carbon dioxide
teral feeding (150 –160 mL/kg weight measurement, speakers were placed production of 5 to 2000 mL/min allow
per day) without significant gastric re- inside the incubator at a distance of 30 measurements in preterm infants with
siduals (⬍5% of total feed), were cm from the infants’ ears. In both mea- small tidal volumes. Before the mea-
PEDIATRICS Volume 125, Number 1, January 2010 e25
Downloaded from by guest on November 4, 2015surement, the device performs a self- Assessed for eligibility (n = 20)
calibration that is based on indepen-
dently measured barometric pressure.
In addition, periodic testing for accu- Excluded (n = 2)
racy was performed by alcohol burn- Enrollment
Tachycardia (n = 1)
ing according to the manufacturer’s Excessive movements (n = 1)
Is it randomized?
instructions. This method is safe and
allows prolonged measurements while
allowing reasonable access to the in-
fant for routine care. Validation stud-
ies have shown the technique to give Music first: n = 5 No music first: n = 13
results equivalent to direct measure-
ments.8,9 In our hands, the instrument Allocation
has an intra-assay coefficient of varia-
tion of 3%. For controlling for interob-
server variation, all measurements
were performed by a single investiga-
tor (Dr Lubetzky). Lost to follow-up (n = 0) Lost to follow-up (n = 0)
Follow-Up
Statistical Analysis
This study is a pilot study that was de-
signed to estimate the effect size of
music on REE. Thus, an empirical num-
ber of 20 infants (ie, 40 measure-
ments) was chosen. Comparison of Analyzed (n = 5) Analyzed (n = 13)
Analysis
energy expenditure values between
groups was performed by using paired
t test. For this purpose, REE results (re- FIGURE 1
corded every minute by the instru- Cohort flowchart.
ment) were averaged over the first,
second, and third 10-minute periods of gender, birth weight, gestational age, during the third 10-minute period (P ⫽
the consecutive 30-minute total study Apgar scores, weight, and chronologi- .03). Thus, on average, the effect size
time, whether it was a music or no- cal age at the time of the study, as well of music on REE is a reduction of
music exposure period. Results are ex- as major medications given or proce- ⬃10% to 13% from baseline, an ef-
pressed as means ⫾ SD; P ⱕ .05 was dures undertaken. Of note, 8 of 18 in- fect obtained within 10 to 30 minutes.
considered significant. fants received caffeine for a history of When multiple regression analysis
previous apneas of prematurity but was used, the effect of music on REE
RESULTS did not have any active apneas, and remained significant, even after we
Twenty preterm infants were recruited there were no changes in drug dosage introduced the caffeine intake as a
to the study (Fig 1). One of them was ex- during both periods of the study. By potential confounder.
cluded because of tachycardia before randomization, 5 of 18 infants were
the beginning of the measurement. An- first studied during the music period. DISCUSSION
other 1 was excluded because of exces- Table 2 depicts the results of REE mea- As hypothesized, we found in this pilot
sive body movements during the second surements. REE was similar during the randomized clinical trial with cross-
measurement. The excessive move- first 10-minute period of both random- over of music versus no music expo-
ments of the infant were observed dur- ization groups. During the next 10- sure that within 10 minutes of listening
ing the no-music session and thus could minute period, infants who were ex- to Mozart music, healthy infants stud-
not have been an adverse effect of music. posed to music had a significantly ied at a postmenstrual age of 30 to 37
Characteristics of the study infants lower REE than when not exposed to weeks had a 10% to 13% reduction of
are listed in Table 1 and describe their music (P ⫽ .028). This was also true their REE. In our study, this effect
e26 LUBETZKY et al
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TABLE 1 Demographic and Clinical The clinical implications of our find- term periodicity, namely the repetition
Characteristics
ings belong to the field of speculation. of the melody. It seems that Mozart re-
Characteristic Value
Indeed, whether reduced EE induced peats the melodic line much more fre-
Maternal age, y
Mean ⫾ SD 32.5 ⫾ 3.96
by exposure to music leads to better quently than other widely known com-
Range 26–39 metabolic efficiency and is the basis posers. This has led Hughes to state that
Gravidity, median (range) 2 (1–9) for enhanced growth rates is unclear. “the super organization of the cerebral
Parity, median (range) 2 (1–2)
Previous studies found that preterm cortex resonates with great organization
Prenatal steroids 16 (88.9)
(Celestone), n (%) infants who were exposed to music found in Mozart’s music.”10 If this state-
Gender of infants (male/ 6:12 had enhanced growth that may even ment is accurate, then it would be fasci-
female) have led to a decrease in their length of nating to assess whether such organiza-
Gestational age, wk
Mean ⫾ SD 29.3 ⫾ 2.2 hospital stay.3–6 There are many mech- tion also exists in the immature brains of
Range 26–35 anisms that may lead to increased rate preterm infants.
Birth weight, g of weight gain; 1 of them could be an
Mean ⫾ SD 1115.2 ⫾ 254.0 Another important question is whether
Range 726–1601 increase in appetite. Previous studies music may be considered a legitimate
Apgar score at 1 min, 8 (1–9) were performed of children who were therapy for preterm infants. Beyond
median (range) fed by mouth; therefore, the effect on
Apgar score at 5 min, 9 (4–10)
the issues of survival of extremely low
median (range)
weight gain through an increase in ap- birth weight infants, neonatologists
HFOV duration, median 0.7 (0.0–4.0) petite or efficiency of the suck-swallow and pediatric neurologists are now
(range), d mechanism may have been possible.3,5
CPAP duration, median 2.2 (0.0–11.0)
more concerned by the potential for
(range), d
No studies have been performed to long-term disabilities. Indeed, preterm
Erythropoietin treatment, 9 (50) verify whether music may improve birth disrupts the developmental pro-
n (%) nutrient absorption through a hor- gression of brain structures and af-
Caffeine treatment, n (%) 8 (44.4)
monally driven mechanism. From our fects the development of the sensory
Chronological gestational
age, wk study, it is tempting to speculate that systems. There is a concern that the
Mean ⫾ SD 33.00 ⫾ 1.72 decreased REE leads to increased met- unfavorable environment of the NICU
Range 30–37 abolic efficiency and thus to improved
Chronological age, d may compound this morbidity. Modifi-
Mean ⫾ SD 30.4 ⫾ 14.1 weight gain; however, our study is a cation of the environment could mini-
Range 5–51 pilot study in nature, limited to a very mize the iatrogenic effects.11 Sug-
HFOV indicates high-frequency oscillatory ventilation; short period of 30 minutes, and re- gested interventions include elements
CPAP, continuous positive airway pressure.
flects only REE, a component of but not such as control of external stimuli
all of total energy expenditure. (vestibular, auditory, visual, tactile),
lasted as long as the music was heard Other legitimate questions can be clustering of nursery care activities,
(ie, up to 30 minutes of the study). asked. The first is that whether the ef- and positioning or swaddling of the
Based upon the fact that infants who fect that we observed is a music effect preterm infant.12 Individual strategies
had been first randomly assigned to or a “Mozart effect.” In a study of adults have also been combined to form pro-
the music period and were studied the that analyzed the effect of music by grams such as the Newborn Individual-
following day for 30 minutes of no mu- Mozart, Hayden, Liszt, Bach, Chopin, ized Developmental Care and Assess-
sic had at baseline an REE very similar Beethoven, and Wagner, Hughes2,10 ment Program (NIDCAP).11–13 Future
to that of the first 10 minutes of the found that Mozart’s music continued studies are essential to determine
music period probably means that the to score significantly higher on reduc- whether music will take its place in the
effect of music that we observed is not tion of seizure activity than the selec- NICU environment and be part of
long lasting and is no longer present tions from the other 6 composers. This evidence-based strategies to improve
24 hours after music is stopped. Mozart effect may be related to long- outcome of preterm infants.
It is interesting that by using the same
apparatus, Carlsson et al14 found no ef-
TABLE 2 REE Measurements
fect of music on REE in obese adults.
Parameter REE With Music, Mean ⫾ SD, REE Without Music, Mean ⫾ SD, P
kcal/kg per d kcal/kg per d We have no explanation for their differ-
Beginning (0–10 min) 53.15 ⫾ 11.66 56.58 ⫾ 17.48 .310 ing results, but Carlsson et al used mu-
Middle (10–20 min) 57.08 ⫾ 7.38 61.59 ⫾ 9.38 .028 sic by Satie, Bach, Bartok, Stravinsky,
End (20–30 min) 53.89 ⫾ 8.12 61.44 ⫾ 13.07 .030 and Henze; their patients all were ex-
PEDIATRICS Volume 125, Number 1, January 2010 e27
Downloaded from by guest on November 4, 2015posed to silence first (no crossover), CONCLUSIONS speculate that this effect of music on REE
and their dietary intake was not ExposuretoMozartmusicsignificantlylow- might explain, in part, the improved weight
controlled. ers REE in healthy preterm infants. We gain that results from this Mozart effect.
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e28 LUBETZKY et al
Downloaded from by guest on November 4, 2015Effect of Music by Mozart on Energy Expenditure in Growing Preterm Infants
Ronit Lubetzky, Francis B. Mimouni, Shaul Dollberg, Ram Reifen, Gina Ashbel and
Dror Mandel
Pediatrics 2010;125;e24; originally published online December 7, 2009;
DOI: 10.1542/peds.2009-0990
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on November 4, 2015Effect of Music by Mozart on Energy Expenditure in Growing Preterm Infants
Ronit Lubetzky, Francis B. Mimouni, Shaul Dollberg, Ram Reifen, Gina Ashbel and
Dror Mandel
Pediatrics 2010;125;e24; originally published online December 7, 2009;
DOI: 10.1542/peds.2009-0990
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/125/1/e24.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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