Babies who are in the NICU need pacifiers.
I know. Today, pacifiers are frequently portrayed as this awful thing that no good parent should subject their baby to.
They can cause nipple confusion, negatively impact breastfeeding success and duration, and can cause dental problems and even ear infections.
Now, I’m not saying there’s no truth to these statements. But I am saying it’s not a black and white issue. There are quite a few positives to pacifier use in general and there are some major positives for NICU babies in particular.
(I’m only going to be talking NICU benefits specifically in this post – I’ll write another post about pacifiers in “typical” newborns eventually!).
Pacifiers in Hospitals
In the early 90’s, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) began a global initiative to encourage breastfeeding. They called it the Baby-Friendly Hospital Initiative (BFHI).
“Baby-Friendly Hospital” is a designation that hospitals can obtain by having certain practices in place called the Ten Steps to Successful Breastfeeding (source).
One of the required steps is that pacifiers not be given to breastfed babies. So most hospitals with this designation do not provide pacifiers at all – even at the request of the parent (it’s no wonder so many people think pacifiers are terrible when the hospital won’t even give you one).
Because of this, some parents already have it in their minds that pacifiers should not be used under any circumstance. This becomes an issue when their child ends up in the NICU for one reason or another.
Pacifiers in the NICU
The NICU is a different world – the typical “newborn rules” don’t really apply here because these are not typical newborns. They are sick or premature or need some help adjusting to life outside the womb.
Babies in the NICU begin their lives outside of mom in a much more traumatic way than the average newborn.
These babies get feeding tubes pushed down their noses, breathing tubes placed in their airways, needles stuck into their arms, hands, scalps, legs, and feet to start IVs, more needles stuck in their heels to draw blood, and on and on…
These painful things are all necessary for baby’s health and well-being and, frequently, they’re needed to keep baby alive.
The worst thing a typical newborn has to endure the first few days of life is one or two lab draws for newborn screenings or to check bilirubin (jaundice) levels.
Some NICU babies will have DOZENS of lab draws. That’s dozens of needle sticks. And that’s not even considering those other things I mentioned.
So what does this all have to do with pacifiers?
Why Babies like Pacifiers
Babies are capable of two different suck patterns which are used for two different purposes. These are referred to as nutritive sucking and non-nutritive sucking. They are both primal reflexes that full-term babies are born with.
- Nutritive sucking occurs when baby is actually receiving milk.
- You’ll notice a “suck-swallow-breathe” pattern when baby is at the breast or bottle which allows baby to feed.
- This pattern takes longer to develop in preemies but we’ll talk about that later.
- Non-nutritive sucking is a comfort reflex.
- When baby is using this type of suck, it isn’t for the purpose of feeding, but for relaxation.
- Babies start doing this in the womb as early as 13 weeks!
Sucking (whether nutritive or non-nutritive) is a pleasurable activity for babies. Firstly, because it releases the “love” hormone (oxytocin).
Secondly, babies are preoccupied with their mouths. When they’re sucking on something, they’re more focused on that and less focused on what’s going on around them.
Which brings me to reason number one why NICU babies need pacifiers…
Reason #1: Pacifiers Provide Pain Relief
Babies feel pain (a seemingly obvious fact that was disputed just a few decades ago). This includes both full-term and preterm babies.
I’ve seen a preemie weighing less than one pound cry when I had to draw blood for labs.
Babies this tiny sound like kittens when they cry, which is both adorable and heart-breaking. (And yes – I gave this baby a pacifier. And yes – they do make teeny tiny pacifiers for these teeny tiny babies!)
In the NICU, a lot of the necessary things we have to do to keep baby alive and healthy can be painful (as I talked about earlier).
We can, and sometimes do, use the same pain and sedation medications used in adults (like morphine, fentanyl, precedex, versed, etc.).
We typically reserve these powerful medications for major interventions, like intubation (placing a breathing tube) or chest tube insertion (for a collapsed lung – aka: a pnemothorax).
However, using narcotics and sedatives for pain that can be relieved by simply allowing baby to suck on a pacifier is unnecessary and risky.
For example, we wouldn’t use these medicines for things like heel sticks (lab draws) or placing an NG tube.
But the long-term negative effects for baby that we have begun seeing related to untreated pain in the NICU is astounding.
And something as simple as allowing baby to suck on a pacifier can help prevent these negative effects.
We can also use something sweet (like mom’s breast milk or sucrose) with the pacifier to promote even more comfort. Because more comforting hormones are released by the presence of something sweet.
AND if we can use mom’s milk, that’s a huge plus because baby can get some of those wonderful nutrients and antibodies while also getting some pain relief!
Couldn’t Baby Just Latch onto Mom Instead?
Now you’re probably wondering, “well if sucking works so well for pain relief, why not just let baby latch on to mom and suck at the breast?” This is ABSOLUTELY something we could do!
This would serve the same purpose, but better because baby gets skin to skin contact and mom gets to be directly involved in providing her baby with pain relief. It’s a win-win.
Mom would need to pump first to empty her breasts (since the goal at this time wouldn’t be feeding) and in some scenarios, this would be perfect. However, it isn’t possible 100% of the time for a few reasons.
The most obvious reason being – mom can’t be at the bedside 24/7 (I mean she technically probably could if she really wanted to, but we definitely encourage mom to get some good rest and food and take care of herself throughout this stressful period of time).
So if mom isn’t there and an IV goes bad, or baby pulls out the NG tube, or we need to draw labs, etc. – we still need something to use in her place and a pacifier is the best substitute we have.
Another reason it isn’t always possible to do things while baby is latched at the breast is because of positioning and sterility issues.
If we need to draw labs from an artery (like for blood cultures) – this may be difficult to keep sterile and do properly with baby on mom. Or if we needed to start an IV – this may be difficult if we need to start it in an area that can’t be easily accessed when baby is at the breast.
The last reason this may not be possible is that baby may not be stable enough to be picked up or it may not be best to remove them from their bed (especially if they’re in an isolette).
Taking a small/premature baby out of their warm, quiet isolette can be very stressful for them.
We want to soothe their pain and prevent a stress-response from occurring – not stress them out further.
And some babies may simply not be stable enough to tolerate being moved in addition to whatever painful procedure we may have to do.
Another question you might have is – aren’t there other ways to comfort the baby/relieve pain besides just pain medication and pacifiers? Yes! And we use those methods too. But that is a whole other post (which I will write).
The short explanation to the above question is: yes there are other things we can do, but those other things are typically much more effective if baby can suck at the same time. Our goal is for your baby to be in the least amount of pain possible.
Reason #2: Pacifiers Help Develop/Maintain the Sucking Reflex
When babies are separated from their mommies for a length of time, they can actually start to lose the reflex that allows them to coordinate “suck, swallow, breathe”. In addition, if mom can’t put infant to breast for any reason, the same problem can happen.
Examples of situations where baby may be separated from mom, or where mom may not be able to put infant to breast, include:
- Mom being very sick and needing intensive care
- Mom having an infection that could be transmitted to baby (like Herpes Simplex Virus with open lesions to the nipples)
- Mom ingesting things that may be bad for baby to receive through breast milk (like certain drugs – both prescription and recreational)
- And of course, if baby is in the NICU and is therefore not able to be with mom 24/7
In addition to these issues that may necessitate pacifier usage, premature babies (preemies) absolutely benefit from pacifier use.
Preemies of any age can non-nutritive suck to some extent at birth (unless baby has other problems – like neurological issues). But these very small, under-developed babies can’t regularly go to the breast to practice this reflex of sucking.
Non-nutritive sucking is the oral motor skill that must be developed before nutritive sucking can occur. This means that if baby can’t practice non-nutritive sucking, it is going to take even longer for baby to learn nutritive sucking.
Inability to coordinate suck, swallow, and breathe is one of the biggest factors that keeps babies in the NICU longer.
Which makes sense because if baby can’t coordinate these – baby can’t eat!
Providing pacifiers to preemies early helps them develop and maintain this reflex as well as develop the muscles used to suck and swallow (which they would usually develop in the womb by sucking their fingers and swallowing amniotic fluid). This will then help them start feeding quicker and therefore, get home faster!
Reason #3: Pacifiers Help Babies Prepare for Feeding
There are two reasons for this.
- Sucking on a pacifier during tube feedings can help baby begin to associate sucking with feelings of a full belly.
- This means that when baby feels hungry, he/she will want to suck because they know sucking = full tummy.
- Premature babies often have trouble waking up enough to eat properly and also have trouble organizing their suck pattern.
- Full-term babies typically don’t really have this problem – at least not to the extent that preemies usually do.
Allowing a baby to non-nutritive suck for a few minutes before a feeding is associated with greater alertness and organization during the feed and, therefore, better feeding.
As I said in the last section – anything that gets baby eating well faster will also help baby go home faster.
A final note here: if you have a premature baby in a NICU, you will likely have a Speech-Language Pathologist (SLP) who will work with your baby when they’re old enough and stable enough to begin trying to feed. They will assess your baby’s sucking patterns and determine the most appropriate way to feed the baby.
For example, if your baby is having trouble getting organized to feed, the SLP will likely tell you (and the nurses) to allow baby to suck on a pacifier for a few minutes before trying to feed. This is because of that reason in the pink box above!
Reason #4: Pacifiers Help with Digestion
Without diving into a super confusing anatomy and physiology lesson, the gist of how pacifiers help with digestion is this:
Non-nutritive sucking is associated with better glucose-utilization – which basically means milk can be better-absorbed, which improves digestion.
In addition to this, pacifiers do not seem to stimulate gastro-esophageal reflux the way that feeding does. This mean preemies (who frequently have reflux issues) can freely suck on a pacifier without experiencing worsening reflux symptoms!
Reason #5: Pacifiers can Help Prevent Oral Aversion
NICU babies have a lot of opportunities for negative experiences involving their mouths. We place breathing tubes down their airways, feeding tubes down their throats, and suction their mouths and throats as needed. None of these things are pleasant. They are uncomfortable at best and painful at worst.
When babies have repeated bad experiences like this with few positive experiences, they learn to dislike anything placed in their mouths.
Why does this matter? Feeding again – of course!
Non-nutritive sucking (like with a pacifier) early on is one pleasant experience we can provide to help offset the negative experiences.
Babies can develop bad enough oral aversions that they have to go home with a feeding tube because they gag and drop their vital signs when you try to give them a bottle or breastfeed.
This is an extreme case, but even best case scenario – a baby with an oral aversion will take longer to establish feeding which means a longer hospital stay.
Pacifiers don’t Affect Breastfeeding in Preterm Infants
Not only are there so many positives to giving NICU babies pacifiers, but the idea that pacifiers have a negative impact on breastfeeding in preterm infants (<34 weeks) is just wrong.
There have been studies that show that not only do pacifiers not affect breastfeeding in a negative way (source), but pacifiers may also improve sucking skills and accelerate time to full breastfeeding (source).
Home Faster and Fewer Issues Later in Life
Yes, pacifiers have the potential to affect breastfeeding in full-term babies. And yes, we do want you to breastfeed – fed is great, but breast is still best (if possible).
And yes pacifiers can cause dental issues and ear infections, but these problems are associated with pacifier use in older babies/children (six months at the youngest).
So I hope you can see that the benefits for babies in the NICU greatly outweigh the potential risks.
A positive you can see quickly is the affect on feeding and length of stay in the hospital.
Longer-term benefits are associated with proper pain control while in the NICU (and we know from reason #1 that pacifiers can help with pain control!). I will have a post on pain control in the NICU eventually, but basically –
NICU babies have much higher rates of anxiety, depression, bipolar disorder, attention disorders, and sensory problems later in life than the general population.
Newer research has begun to link the cause of these statistics to stress hormones released when these babies are in pain repeatedly. Appropriate pacifier use in NICUs is such a simple way to help prevent these mental health problems.
So if you have a baby in the NICU and you come in and see your baby with a pacifier that you didn’t request or expressly give permission for, please understand that there are important reasons for these babies to have them.
We don’t just use them to stop babies from crying, we use them because they are mentally and physically beneficial for your baby.
I hope you found this post helpful in outlining why NICU babies are not “typical” newborns, why their needs differ, and why pacifiers promote proper growth and development in these little ones.
If you have or had a baby in the NICU, leave a comment below and let me know your experience with pacifiers in the unit!
“Babies used to make me nervous, but these squirmy things are awesome once you’ve read the manual”,
(-David Z. Hirsch)
Carol-Ann, the NICU Nurse
*If you’d like more information on this topic, this journal article from BMC Pregnancy & Childbirth was used as a reference for much of this post.*