Fetal development of sucking
The value of NNS
Motor system benefits
Techniques to support NNS
The BHFI context
Expansion of the Ten steps
Original Ten Steps to Successful Breastfeeding 
Every facility providing maternity services and care for newborns should implement the following Ten Steps
Expanded BFHI for Neonatal Units 
Promoting and Protecting Breastfeeding for Vulnerable Infants in the Spatz Ten Steps Model 
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
Educate and train all staff in the specific knowledge and skills necessary to implement this policy.
Correct breast milk management (storage and handling)
3. Inform all pregnant women about the benefits and management of breastfeeding.
Inform all hospitalized pregnant women at risk for preterm delivery or birth of a sick infant about the management of lactation and breastfeeding and benefits of breastfeeding.
Providing parents with information to make an informed decision to breastfeed
4. Help mothers initiate breastfeeding within a half-hour of birth.
Encourage early, continuous, and prolonged mother–infant skin-to-skin contact (kangaroo mother care) without unjustified restrictions. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.
Assisting mother with the establishment and maintenance of milk supply.
Create opportunities for NNS at the breast
5. Show mothers how to maintain lactation even if they are separated from their infants.
Show mothers how to initiate and maintain lactation and establish early breastfeeding with infant stability as the only criterion.
Managing the transition to breast
6. Give newborns no food or drink other than breastmilk unless medically indicated.
Develop procedures to feed the infant the breast milk
7. Practise rooming-in – that is, allow mothers and infants to remain together 24 h a day.
Enable mothers and infants to remain together 24 h a day.
8. Encourage breastfeeding on demand.
Encourage demand feeding or, when needed, semi-demand feeding as a transitional strategy for preterm and sick infants.
Measuring milk transfer
9. Give no artificial teats (also called dummies or soothers) to breastfeeding infants.
Use alternatives to bottle-feeding at least until breastfeeding is well established and use pacifiers and nipple shields only for justifiable reasons.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Prepare parents for continued breastfeeding and ensure access to support services/groups after hospital discharge.
Preparation of infant and family for discharge; and appropriate follow-up care
Presumed risks associated with pacifier use
Implications for clinical practice
Medical conditions justifying pacifier use
Infants weighing less than 1,500 g and/or is younger than 32 weeks gestational age ;
Infants at risk for hypoglycaemia ;
Infants in need of early oral stimulation to maintain and develop the sucking reflex ;
Severe illness of the mother preventing her from breastfeeding (temporarily or permanently), such as Herpes simplex virus type 1 ;
Maternal medication preventing mother from breastfeeding, such as sedating psychotherapeutic drugs and cytotoxic chemotherapy ;
Infants in NICU environments in need of calming, pain relief and decrease of stress ;
Infants receiving tube feeds .
General recommendations for safe pacifier use
Cessation of pacifier use
Recommendations for future research
Benefits of NNS
Risks associated with pacifier use
Implications for clinical practice – ‘justifiable use’
Recommendations for safe pacifier use
• Increased levels of oxygenation
• Decreased heart rate
• Improved glucose-utilization resulting in increased improved digestion.
• 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
• Increased risk of caries
• Intestinal parasitic disease
• Nipple confusion (not proven)
• Shortened breastfeeding duration
• < 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
• 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
• Self-consolation and soothing
• Self-regulatory state modulation
• Comforts sick/preterm infant
• Increased time sleeping
• Increased alertness with better feeding
• Lower energy consumption
• Combine pacifier use with maternal voice
• Do not coat pacifier in sweet solution, except when used simultaneously for pain relief
• 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
• 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.
• Improved muscle tone and coordination
• 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.
• 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
• 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
• Used at bedtime reduce risk for SIDS