Filling the Gaps: Bringing Music Into Critical Care Rooms

ACLP Bulletin | Spring 2017 | VOL. 35 NO. 2

Suzanne Lee

Each member of the health care team plays an important role in providing quality care to patients and families. Whether it be the doctor who has identified the cause of the patient’s illness, the housekeeper who has cleaned the patient room, the nurse who has attended to the patient’s daily needs, or the child life specialist who has provided normalization for the patient during a hospital stay, each role is vital to the delivery of high quality care. In some hospitals, the child life assistant is the person who checks in with families to fulfill patients’ developmental play needs and carries out activity sessions with patients. As a child life assistant in the Pediatric Intensive Care Unit (PICU) at Dell Children’s Medical Center, this role also enabled me to see opportunities for comfort to be enhanced. One such measure that I identified as a needed resource was the use of sound machines to offer timed music and white noise options to calm patients’ fears, allay anxiety, or to just provide stimulation in a room where no one else was present, if appropriate. Since the rooms did not have a music or sound machine, I carried out a quality improvement project that would provide parents with regular music or sound options.

I began by investigating what pediatric research had to say about the benefits of sound or music machines, for PICU patients in particular. According to Hugh et al. (2014) “too much noise can lead to disturbances in sleep and arousal in infants, and acoustic disturbance can have direct physiologic effects on infants that can negatively influence the quality and quantity of their sleep” (p. 2), as well as affect healthy speech intelligibility (Saint Louis, 2014). Because hearing loss has been known to be induced at high levels, conservative noise limits are advised for infants (Hugh et al., 2014). The resonance properties of the infant’s smaller ear canal amplify higher-frequency sounds in the ear canal, and with continued exposure, these higher-frequency sounds can damage the developing ear canal (Hugh et al., 2014). In fact, when Hugh and colleagues tested 14 commercially available sleep machines at maximum volume and close distance, three exceeded workplace safety limit for adults, one significantly (Hugh et al., 2014).

Given the physiological and auditory effects that too much noise can have on the hospitalized infant, the study by Hugh and colleagues attempted to better understand the risks associated with infant sound machines and develop recommendations for caregivers on the maximum output levels of these machines for the ear canals of a 6-month-old infant. 
In acknowledging that infant sound machines can oftentimes be overused—playing continuously and at maximum sound levels, which can be dangerous to an infant’s ear canal development and provide disruptions in sleep—the study concludes with the following recommendations: 

1. Place the infant sound machine as far away from infants as possible (at least 200 cm away from the infant).

2. Set the volume as low as possible. Specifically, a 50-dBA equivalent noise level averaged over 1 hour is recommended as maximum safe exposure for infants in hospital nurseries and NICUs.

3. Limit the duration of use with timed shut-off.

Because hearing loss has been known to be induced at high levels, conservative noise limits are advised for infants (Hugh et al., 2014). 

Discussing the Hugh et al., study, Dr. Blake Papsin, chief otolarynologist at the Hospital for Sick Children in Toronto and one of the authors, summarizes, “Farther away is less dangerous, a lower volume is better and shorter durations of time, all things that deliver less sound pressure to the baby” (Saint Louis, 2014, para 8).

With this information as guidance, a pilot test was undertaken with a single patient: a critical care, cardiac 6-month-old infant in the PICU at Dell Children’s Hospital. The Munchkin Nursery Projector and Sound System, identified as being the most economical and usable machine with the highest consumer ratings, was installed on a countertop 200 cm from the patient’s head. In addition to providing music/ sounds (heartbeat, ocean, rain, lullabies, Mozart, and white noise), the machine also had the option to project images (fish in the sea, a tropical bird in the rainforest, and a sheep in the sky at night) onto the ceiling above the patient’s bed.

For nine days, each assigned day shift nurse used the sound machine when they identified that the infant required calming, playing a selected choice of one of the 10 sound options for no longer than 60 minutes at one time (based on the machine’s timer). At the end of their shift the patient’s assigned nurse completed a short questionnaire that asked for feedback on the ease of use of the machine and its perceived usefulness as a sound tool. When nurses worked more than one day during the nine days, they completed a questionnaire at the end of each shift. A total of seven different nurses completed the questionnaire over the nine days.

Ease of use: 43% of the nurses found the sound machine “very easy” to use, with more than half of the nurses noting it was “easy” to use. Supporting comments included:
  • “Seems like a therapeutic exercise that is easy to use and it is readily available.”
  • “I like it.”
  • “Soothing, helps block out the noise from the unit.”
  • “Calming.”

Of the three nurses who used the projector, two thought it might not be located close enough for this patient to see it on the ceiling.

Usefulness: 6 of the 7 nurses found the different sound options to be “more useful” for this patient than a crib mobile or white noise machine. The 7th nurse found the different options to be “equally useful.” Supporting comments from these nurses included:

  • “Patient seemed to calm easy and stay calm.”
  • “Volume control good! More options for sounds and more variety of stimulation for long-term patients—applies to a larger age range!”
  • “More options.”
All 7 nurses were unanimous in indicating that they would like this projector/sound machine in each room of the PICU. Conclusions of this pilot were provided to the child life department and formed the basis of a funding request for music/sound machines for each PICU room. These conclusions were as follows:

  • “The ease of use and usability of the Munchkin Nursery Projector and Sound System were found to be “easy” to “very easy” to use by nurses who used the sound machine during their day shift.”
  • “The location of the installation of the sound machine in the room needs to take into consideration the auditory development of the infant’s ear canal and the recommendations of Hugh et al. (2014) on the use of sound machines.”
  • “The majority of nurses found the different sound options to be “more useful” for this patient than a mobile or white noise machine.”
Taking the time to learn what research says about music at bedside for infants changed the primary way the needs of infants in the PICU are met at Dell Children’s. As a result of this pilot, the child life department purchased and installed a Munchkin Sound Machine in each room in the PICU and the child life assistant presented the pilot results and recommendations of Hugh and colleagues (2014) to all PICU nurses at a weekly meeting. The child life specialist helped ensure that any education follow-up questions by nurses during use were addressed. 

Further, because so many patients move from the PICU to the intermediate care unit (IMC), the IMC nurses found that they were being asked by parents whose children had transferred from PICU rooms if they could use the music/ sound machine that they had in their previous rooms. As a result, the IMC nurse manager purchased and installed the same sound machines in each IMC room according to the guidelines. Prior to the use of the sound machines, the IMC nurse manager shared findings from the PICU pilot study as well as the recommendations from Hugh et al. (2014) with IMC nurses. Note by note, these music/sound machines are enhancing the child life care of the critical care infants at Dell Children’s Medical Center. In acting on a need that was identified during activity visits to patient rooms and play sessions with infants, music and calming sounds have been brought into a silent space with a simple quality improvement project.BulletinArticleBlueIcon


Hugh, S., Wolter, N., Propst, E., Gordon, K., Cushing, S., & Papan, B. (2014). Infant sleep machines and hazardous sound pressure levels. Pediatrics, 133(4), 1-5.

Saint Louis, C. (2014, March 3). Infant sleep machines at maximum volume reported as hearing risk. New York Times, A16.