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BFHI and Justifiable Use of the Pacifier

July 2017

More and more, research continues to back the use of expressed breast milk or breastfeeding as an essential practice which should be promoted, protected, and supported to ensure the survival of newborn infants. With the implementation of the Baby-Friendly Hospital Initiative in 1991, rates for breastfeeding initiation and continuation have continued to rise in all areas of the world. However, the BFHI was developed for full-term, healthy newborns.

baby pacifier

Several movements are currently underway to adapt the Ten Steps to Successful Breastfeeding to the NICU population of preterm and ill infants. One, from the Nordic and Quebec working group, formed in 2009 to study the use of pacifiers for non-nutritive sucking in the NICU population. Their proposal, published in 2013, is entitled, “Neo-BFHI: The Baby Friendly Hospital Initiative for Neonatal Wards. Three Guiding Principles and Ten Steps to protect, promote and support breastfeeding. Core document with recommended standards and criteria” (http://www.forskningsdatabasen.dk/en/catalog/2304008166).

Step 9 of the Ten Steps currently reads, “Give no pacifiers or artificial nipples to breastfeeding infants.” The Ten Steps was aimed, originally, at full-term, healthy infants who were breastfeeding well, and research indicated that use of pacifiers early on in this type of breastfeeding relationship had the potential to create multiple breastfeeding difficulties. These infants are normally able to transfer milk well, and to have both nutritive sucking and non-nutritive sucking at the breast.

In the NICU population of preterm and ill infants, non-nutritive sucking (NNS) is important for comfort, development of mature, well-regulated suck/swallow/breathe patterns, supporting physiological stability, reduce stress, increasing levels of oxygenation, and assisting in self-regulating state modulation with neurobehavioral organization and maturation.

Lubbe and Ham-Baloy (2017) discuss the presumed risks associated with the use of a pacifier, stating that premature weaning, risks for chronic otitis media, misalignment of the teeth, and nipple confusion could be related to early introduction and prolonged use of a pacifier. The 2013 work of Nyqvist et al. suggests that “justifiable use of a pacifier” within the hospital setting may be beneficial to infants under the following circumstances:

  • Infants weighing less than 1500 g and/or younger than 32 weeks gestation
  • Infants at risk for hypoglycemia
  • Infants in need or early oral stimulation to maintain/develop the sucking reflex
  • Severe maternal illness preventing her from breastfeeding (temporarily or permanently)
  • Maternal medication preventing mother from breastfeeding
  • Infants in NICU environments in need of calming, pain relief, and decrease of stress
  • Infants receiving tube feeds

Recommendations are made in the Nyqvist document for “safe and appropriate pacifier use”, including delayed and limited use, use in non-breastfeeding infants at sleep, infection control suggestions, design safety, and weaning from the pacifier.

As the global guidelines for Neo-BFHI continue to be developed for release in the coming year(s), appropriate pacifier use needs to be considered for NICU infants. These two papers are excellent reads for nurses in both NICU and Mother-Infant units.


Kathy Parkes, MSN-Ed, BSPsy, RN, IBCLC, RLC, FILCA

Professional Development Educator



Lubbe, W. and ten Ham-Baloy, W. (2017). When is the use of pacifiers justifiable in the baby-friendly hospital initiative context? A clinician’s guide. BMC Pregnancy and Childbirth; 17: 130. doi: 10.1186s12884-017-1306-8
Nyqvist, K.H., Haggkvist, A.P., Hansen, M., Kylberg, E., Frandsen, A.L., Maastrup, R., and Haiek, L.N. (2013). Expansion of the baby friendly hospital initiative. Ten steps to successful breastfeeding into neonatal intensive care: Expert group recommendations. J Hum Lact; 29: 300.


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