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Table 2 Summary of benefits, risks, implications and recommendations for safe pacifier use

From: When is the use of pacifiers justifiable in the baby-friendly hospital initiative context? A clinician’s guide

Benefits of NNS Risks associated with pacifier use Implications for clinical practice – ‘justifiable use’ Recommendations for safe pacifier use
Physiological benefits
• Increased levels of oxygenation
• Decreased heart rate
• Improved glucose-utilization resulting in increased improved digestion.
Gastro-intestinal:
• Does not affect acid and non-acid gastro-oesophageal reflux
Full term up to six months:
May result in:
• Early breast weaning
• Otitis media
• Dental malocclusion
• Suffocation
• Poisoning
• Allergies
• Increased risk of caries
• Infections
• Intestinal parasitic disease
• Nipple confusion (not proven)
• Shortened breastfeeding duration
Medical conditions
• < 1,500 g and/or < 32 weeks gestation
• At risk for hypoglycaemia
• Needing oral stimulation to maintain and develop sucking reflex
• Severe maternal illness preventing breastfeeding (e.g. Herpes Simplex)
• Maternal medication contra-indicated for breastfeeding (e.g. psychotherapeutic drugs)
• NICU infant needing calming, pain relief and stress management
• During tube feedings
General:
• Determine individual feeding programme by qualified health professional
• Counsel parents and caregivers about safe and appropriate pacifier use
• Information provided should include ‘justifiable’ reasons for pacifier use in hospital
• Information should include alternative ways of infant soothing
• Recommendations to minimize pacifier use should be provided.
Delay introduction and limited use:
• Delay introduction of use until one month of age to establish breastfeeding
• Limit use to soothing of a breast-fed infant
• Parents to differentiate between a hungry baby or in need of comforting by means of sucking
• Not used to delay or replace meals
Behavioural:
• Self-consolation and soothing
• Self-regulatory state modulation
• Comforts sick/preterm infant
• Increased time sleeping
• Increased alertness with better feeding
• Lower energy consumption
   Combination use:
• Combine pacifier use with maternal voice
• Do not coat pacifier in sweet solution, except when used simultaneously for pain relief
Sleep:
• Use when putting down to sleep and do not re-insert when infant falls asleep.
• Avoid ad lib use throughout the day
• Do not use to replace or delay meals in full term infants
• Pacifier use is a parental choice
Infection:
• Avoid infection by cleaning and replacing pacifier regularly – do not lick
• Never share between siblings
• Bigger children should not play or walk around with a pacifier.
Motor system:
• Improved muscle tone and coordination
   Cessation:
• Weaning from six months of age to prevent otitis media and dental problems
• Start cessation at age six months and if situation requires no later than four years of age.
Neurological:
• Precedes nutritive feeding by supporting accelerated maturation of sucking
• Aids neurobehavioral organization and coordination in poor suck, swallow and breathe coordination
• Protects against aspiration
• Faster transition to oral feeds
• Pain management
• Better weight gain
• Earlier discharge
   Design safety:
• Use a single-piece unit only
• Made of durable material to prevent choking hazard
• Replace when worn out
• Never tie a string to the pacifier to prevent strangling the child
• Symmetrical nipple shape to support correct tongue position when sucking
• Flanges minimum dimensions of 43 mm to prevent lodging in the soft palate
• Ring behind the flange for removal in case of aspiration
• Mouth shield larger than the infants mouth (over 3 cm)
• Ventilation holes in shields to permit air passage
• Texture inner surface to prevent irritation and rashes from trapped saliva
SIDS:
• Used at bedtime reduce risk for SIDS