SWADDLING

Pros
- Arouse less/sleep longer
o Increase daytime sleep periods, total daytime sleep, fewer startles, lower HR variability, better sleep
efficiency, fewer spontaneous awakenings
- In preterm: improved neuromuscular development, less physiologic distress, better motor organization, more self-
regulatory ability, soothes pain
o Return to baseline HR and SpO2 more quickly after heel lance
o Less effective than pacifier but less subject to rebound
- Decreased crying, increase in parental satisfaction/dec stress
o Excessive crying in infants with cerebral damage
- Supportive in NAS, neonatal cerebral lesions
- Thermoregulatory
- No effect on rickets/motor development
Cons
- Hip dysplasia, especially in extension & adduction, especially if immediately after birth
- Hip dislocation, especially with prolonged swaddling
o Comments by orthopedists remark that many studies examining swaddling focused on “traditional”
methods of swaddling with legs abducted and extended, or with the infant strapped to a backboard.3,4
o “Modern” methods of swaddling encourage loose wrapping of the legs for lower extremity freedom of
movement.2,3,4
- Increased risk of SIDS, especially in prone position
o 4 studies for inclusion criteria: Swaddling risk varied according to position placed for sleep; the risk was
highest for prone sleeping (OR, 12.99 [95% CI, 4.14–40.77]), followed by side sleeping (OR, 3.16 [95% CI,
2.08–4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27–2.93]). Limited evidence suggested swaddling risk
increased with infant age and was associated with a twofold risk for infants aged >6 months. Current advice
to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration
should be given to an age after which swaddling should be discouraged.5
- Increased risk of respiratory infections, especially in tight swaddling
- Delayed postnatal weight gain with swaddling immediately after birth

1. Van Sleuwen et al. “Swaddling: A Systematic Review.” Pediatrics. 2006.

http://pediatrics.aappublications.org.pitt.idm.oclc.org/content/pediatrics/120/4/e1097.full.pdf
2. “How to Hip-Healthy Swaddle Your Baby.” International Hip Dysplasia Institute. 2011.
https://www.youtube.com/watch?v=LLqfRQdUP7k
3. Karp, HN. “Safe Swaddling and Healthy Hips: Don’t Toss the Baby out With the Bathwater.” Pediatrics. 2008.
http://pediatrics.aappublications.org.pitt.idm.oclc.org/content/121/5/1075.2
4. Clarke, NM. “ Swaddling and Hip Dysplasia: An Orthopaedic Perspective.” Archives of Disease in Childhood. 2013.
http://adc.bmj.com.pitt.idm.oclc.org/content/99/1/5
5. Pease et al. “Swaddling and the Risk of SIDS: A Meta-Analysis.” Pediatrics. 2016.
http://pediatrics.aappublications.org.pitt.idm.oclc.org/content/pediatrics/137/6/e20153275.full.pdf
PACIFIER
Pros
- Pain relief, especially w/ sucrose, self comfort, calm, reorganize, gain control
- Reduction in risk of SIDS (2005, 2006)
o Increased arousal responsiveness, forward positioning of tongue decreases risk of oropharyngeal
obstruction, enhances ability to breathe through mouth if nasal passage obstruction occurs, pacifier use
encourages prone sleeping
o AAP recommends 1mo (in breast feeding) – 1y
- Preterm infants have shorter hospital stays, earlier transition to bottle feeds, improved bottle feeds.
o The time to transition to full breastfeeding (123·06 ± 66·56 hours) and the time to discharge (434·50 ±
133·29 hours) in the pacifier group were significantly shorter compared to the control group (167·78 ± 91·77
and 593·63 ± 385·32 hours, respectively) (p < 0·05). The weight at transition to full breastfeeding (1944·12 ±
275·67 g) and the weight of discharge (1956·45 ± 268·04 g) in the pacifier group were significantly lower
compared to the control group (2155·58 ± 345·57 and 2159·75 ± 341·22 g, respectively) (p < 0·05). Sucking
skills of the infants in the pacifier group at 48 hours after transition to oral feeding and before the discharge
was better than in the control group (p < 0·05). Pacifier use improved the sucking skills and shortened the
time to transition to full breastfeeding and to discharge in preterm infants receiving complementary
feeding. Pacifier use may be recommended to accelerate transition to full breastfeeding and to improve the
sucking skills in preterm infants who were fed by both oral route and complementary feeding in the
neonatal intensive care units.2
Cons
- Oral health and dentition
o 3+ and especially in 5+  higher incidence of anterior open bite, posterior crossbite, narrow intercuspid
width
- Questionable impact on breastfeeding?
o Pacifier use may be associated with early breast weaning or may be a marker of breastfeeding difficulties;
therefore, it should be avoided until breastfeeding is well established.1
o Observational studies23–25 and a randomized controlled trial (RCT)21 showing that pacifier use is
associated with early breast weaning have led to concerns. However, an RCT that studied the effect of
pacifier use on breast-feeding in 281 mother-infant pairs for three months postpartum had a different
conclusion.26 Although an observational association was noted between pacifier use and early weaning,
when the data were analyzed further, the intervention (advice to avoid pacifier use) did not significantly
reduce weaning at three months. The authors concluded that pacifier use may be a marker of breast-
feeding difficulties, but does not appear to be the cause of early weaning. The intervention group used
pacifiers less often, but had no significant difference in crying or fussing, suggesting that other soothing
methods are as effective as pacifier use. A more recent RCT on preterm infants did not demonstrate a
significant effect of pacifier use on early weaning.
- Otitis Media
o There are two proposed mechanisms for how pacifier use could cause otitis media: reflux of nasopharyngeal
secretions into the middle ear from sucking, and eustachian tube dysfunction from altered dental structure
o One widely cited, open, controlled cohort study of more than 400 patients evaluated the incidence of otitis
media in infants whose parents were counseled to restrict pacifier use to when the infant was falling asleep.
This counseling reduced continuous pacifier use by 21 percent and led to 29 percent fewer episodes of otitis
media in the intervention group.3 A more recent prospective cohort study from the Netherlands found that
35 percent of 216 children using pacifiers and 32 percent of 260 children in the control group developed at
least one episode of otitis media.42 However, rates of recurrent otitis media were higher in the pacifier
group (16 versus 11 percent), leading the authors to conclude that pacifier use may increase the risk of
recurrent otitis media.
o Wean children in 2nd 6mo of life according to AAP1

1. Sexton, S. “Risks and Benefits of Pacifiers.” American Family Physician. 2009.

http://www.aafp.org.pitt.idm.oclc.org/afp/2009/0415/p681.html
2. Nelson, AM. “A comprehensive review of evidence and current recommendations related to pacifier usage.” Journal of
Pediatric Nursing. 2012. http://ac.els-cdn.com.pitt.idm.oclc.org/S0882596312000085/1-s2.0-S0882596312000085-
main.pdf?_tid=ab8cdfd8-8d16-11e7-a2c8-00000aacb362&acdnat=1504051596_e9dac22973eed96a48880d04f570d117
3. Kaya, et al. “Effects of pacifier use on transition to full breastfeeding and sucking skills in preterm infants: a randomised
controlled trial.” Journal of Clinical Nursing. 2017. https://www.ncbi.nlm.nih.gov/pubmed/27754572