Problem-Solving: Pacifiers in the NICU and Aversions


I’m wondering if you have any insight into this. Despite developmental care and a good general awareness of feeding issues that may come down the road, we’ve had a group of chronic babies (<28 weeks at birth, long respiratory course- still on HFNC at 38+ weeks) that go from loving their pacifiers to gagging on them. Of course, it’s not surprising that these chronic, sick babies with arduous courses don’t want their pacifiers (or anything for that matter) in/near their mouths. Is there anything to do earlier in the course to prevent this? Besides developmental care/kangaroo care/making oral experiences as positive as possible/stopping with gagging. Some nurses are asking if we should avoid pacifiers earlier on in the course? Start therapy earlier? I don’t typically intervene in these kids earlier besides education for staff on developmental/kangaroo care (but do see them once stable respiratory wise and we’re thinking about nipple feeding to help guide readiness/nipple selection). Any thoughts? My gut is that we just to be extra vigilant about making sure the baby is ready/looking for/accepting the pacifier and tolerating it all along, encouraging skin to skin vs. actual interventions, but would love your input. Thanks as always for your expertise with these little ones!



You are such a critical thinker. They are so lucky to have you! It’s not the pacifier but rather most likely how the nurses may be inadvertently “giving it” to the infant.

I encourage infant-guided offering of the pacifier when the infant is able from a respiratory and GI perspective to accept it.

That means we need to use the infant’s communication to thoughtfully guide us.

Infant-guided neuroprotective offering of a pacifier means using the infant’s rooting response (by gently moving the pacifier across the infant’s lips) and then honoring the infant’s response. If WOB and/or RR is increased, the infant may not open his mouth and is saying “Not right now. I need to breathe; please wait and ask me again in a little while.”   Too often, caregivers mistake the infant’s not opening his mouth as an indication to just “place the pacifier” or “put the pacifier in”. But it is typically not lack of skill why he doesn’t take the pacifier, but rather he is purposefully not rooting to say, “not right now”. It is an adaptive/compensatory behavior whose meaning may be misinterpreted or misunderstood by some caregivers, especially those who are task -oriented versus infant-guided. GI discomfort may lead to the same response from the infant. Imagine being “asked/expected/”forced” to suck on a pacifier when don’t feel good in your GI system. The infant will remember how he felt. Good intentions to give a pacifier can inadvertently create negative experience.

When caregivers bypass this communication, motor mapping in the brain for the root-to-latch sequence will be altered and maladaptive behaviors can result.

Gagging, grimacing, pushing the pacifier out are all overt refusal behaviors. They look very different then “engagement” behaviors of rooting and focused attention. It really isn’t rocket science.

Perhaps even more worrisome is the stress created by being asked/expected/”forced” to do something that does not feel good right then.

The stress that results, like all NICU stress, has the potential to increase cortisol, change via the amygdala along the HP-axis, and change the architecture of the brain.

This is the pathway to learned refusal behaviors and learning to “hate” the pacifier.

The infant’s communication matters, as does every early experience using his mouth. Neuroprotection can be supported via an infant-guided approach to feeding readiness as well as feeding.



Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part I: Theoretical underpinnings for neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 096-105). Thieme Medical Publishers.

Shaker, C. S. (2017, April). Infant-guided, co-regulated feeding in the neonatal intensive care unit. Part II: Interventions to promote neuroprotection and safety. In Seminars in speech and language (Vol. 38, No. 02, pp. 106-115). Thieme Medical Publishers.

Shaker, C. (2013). Reading the Feeding: The amount of milk a preemie drinks largely determines readiness for discharge from the neonatal intensive care unit. But just because an infant feeds well today doesn’t mean it will last. In the long term, fostering a child’s consistent, positive response to feeding may be more important. The ASHA Leader, 18(2), 42-47.

I hope this is helpful.


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