On breastfeeding, ear infections, SIDS and jaw development
by Tara Haelle
Even three years after my oldest son had last used a pacifier, I continued to find Soothies stashed in random places – office drawers, car glovebox, an old camera bag. Conservatively, I estimate I bought more than a dozen in my son’s first six months, trying to account for the ones that got lost, dropped, and left behind while also ensuring one was always in easy reach, regardless of where I was. Because Soothies worked. For my first son. The second? Not so much. In fact, he’s not very interested in any type of pacifier except his hands, which serve the same self-soothing purpose. And if the research is any guide, he will not necessarily have any particular advantage or disadvantage than my older son. The studies show pacifiers to confer both benefits and risks, in differing amounts depending on the child’s personality, age, and frequency of use.
The Goods on Sucking
The most established benefit is relief from anxiety or pain. Sucking, with or without eating, helps infants comfort themselves and gain control when feeling stressed. The calming effect of pacifiers is solidly established, as is their effectiveness as pain relievers for all sorts of medical interventions: heel sticks, circumcision, immunizations, catheterization, punctures for IVs, and other such procedures. Using a pacifier dipped in sugar appears even better at pain relief, but no better than breastfeeding, which also works. For preemies in particular, non-nutritive sucking has been linked to shorter hospital stays and better bottle feeding, and no studies that looked at preemie use of pacifiers found any harms. Babies not given a pacifier will often become thumbsuckers for the same soothing effects, which can be good – thumbs are always readily accessible – or problematic – taking away a pacifier is easier than taking away a thumb when it’s time to break the habit.
Another clearly established benefit of pacifiers is a reduced risk of sudden infant death syndrome (SIDS) up through a year old, though it’s not clear why. Routine pacifier use reduces SIDS risk by 15% to 30%, and using a pacifier “at last sleep” cuts SIDS risk in half. However, SIDS itself is still rare, and it’s estimated that about 2,700 babies would need to go to sleep with a pacifier to prevent one SIDS death. Some of the theories for why pacifiers help is that they help prevent obstruction to the breathing passages by encouraging a forward position of the tongue, they improve mouth breathing when nasal passages are blocked, they encourage back sleeping, and they increase arousal – but none of these have evidence to support them, and pacifiers could be a “marker” for another factor that reduces SIDS risk. We don’t really know why the suckers work.
What are the Trade-offs?
Pain relief, comfort, and a very slightly lower likelihood of dying in sleep are certainly benefits, but what are you trading them for if your child uses a pacifier? The two clearly established possible risks for pacifiers are ear infections and dental problems. Evidence does consistently show that using a pacifier slightly increases the risk of ear infections, primarily after 6 months old. The increased risk was relatively small, such as one study in which recurrent ear infections occurred to 16% of pacifier users but only 11% of non-users. And it’s possible to strike a balance between SIDS risk reduction and ear infection risk: one study showed 21-29% fewer ear infections among parents counseled to give their children pacifiers only at bedtime, compared to parents receiving no recommendations. As with SIDS risk reduction, however, it’s not clear why pacifiers increase the risk of ear infections. The sucking might influence pressure in the middle ear, making it more susceptible to infections from reflux, or the middle ear may be affected by dental changes.
Which brings us to how pacifiers affect teeth. Bacteria, particularly Candida and Staphylococcus, can live on paci surfaces and tend to prefer latex over silicone, but there isn’t strong evidence that pacifiers increase the risk of infection or tooth decay – unless you’re dipping it in sugar or using your spit to clean it, which can transfer bacteria from your mouth to your child’s. Pacifiers can, however, contribute to misalignment of the teeth, including open bite, crossbite and overjet, though only after 18 months to 2 years old and with a good 4 to 6 hours of daily sucking. Many jaw changes will likely reverse naturally if the child stops using the pacifier while teeth are still coming in, and it’s primarily 3-, 4- and 5-years-olds who are at highest risk for jaw misalignment.
What About Breastfeeding?
The biggest worry many have about pacifiers is their influence on breastfeeding, and the evidence here is tricky. Generally, there isn’t much to support breastfeeding worries, but we could do with more research in this area. Early studies found that women stop breastfeeding sooner when their infants use pacifiers, but these were all observational studies. Later, better randomized controlled studies found no effect from pacifiers – including one where babies started using them as early as 2 weeks old – so there’s no current evidence pacifiers cause women or babies to stop breastfeeding sooner.
Instead, women may be actually using pacifiers to help wean, or women already having breastfeeding problems may be more likely to use a pacifier. Pacifiers may also be related to other factors that also just happen to be linked to shorter breastfeeding. So why do professional organization recommendations suggest avoiding pacifiers for the first four to six weeks? Most studies have investigated breastfeeding duration several months down the line, not the earliest days. Establishing successful breastfeeding is already challenging enough that professional organizations are cautious about a potential interference: there isn’t strong evidence to show pacifiers are a problem (one study’s results are barely significant and others contradict them), but there isn’t great evidence to show it isn’t a problem in the first several weeks either.
Further, pacifiers used specifically to postpone feedings can reduce milk production by reducing breast stimulation (since the child is sucking the paci rather than the breast) – but that’s only if a mom is giving her child a pacifier instead of feeding a hungry child. There’s not much to show that using a paci between feedings will cause any issues for mothers who are confident about breastfeeding, as long as moms recognize that the child truly is not hungry and her breasts are getting regular stimulation to induce milk production.
In fact, interestingly, one recent study offers the possibility that pacifiers might actually support breastfeeding. A hospital put pacifiers, but not formula, under lock and key (though parents could bring them from home) and compared breastfeeding rates before and after the restriction. To the researchers’ surprise, exclusive breastfeeding dropped from 79% (out of 812 babies) to 68% (out of 1,278 babies) while the supplemental formula feeding increased from 18% to 28% and exclusive formula-feeding increased from 1.8% to 3.4%. It’s just one study, but it’s possible that exhausted moms who could only keep crying babies at the breast for so long were opting for formula when a pacifier wasn’t available.
What about nipple confusion? The way a baby physiologically sucks a pacifier or a bottle – the way she uses her tongue – is different than the way she sucks a breast. Nipple confusion, or nipple preference, refers to the concern that she will become too used to one way of sucking and then be unable or unwilling to suck on the breast effectively to get the milk. Yet the only evidence that exists for nipple confusion with pacifiers comes from anecdotes. (Bottles are a different story since the concerns relate to how hard the baby has to work to get the milk out of a bottle versus a breast.)
Sucking is one of a handful of reflexes newborns have at birth, along with the grasping and startle reflexes. Long before birth, a fetus sucks on her hands, feet, arms, and whatever she can get into her mouth, and none of this interferes with her later ability to suck on a breast. While a baby can be uncoordinated, or “disorganized,” in learning to properly latch and feed from the breast, there is no research evidence that using a pacifier or a bottle interferes with this ability. It’s possible that a baby’s struggles to latch or suck properly might accompany use of a paci, or that underlying problems with breastfeeding may be interpreted as nipple confusion, but no evidence shows that a paci or bottle causes the baby to be unable to unwilling to latch onto a breast properly.
There’s not much evidence that pacifiers affect speech development, but one possible area of concern is allergies for children with a family history of latex allergy. The risk of allergy plus the lower risk of bacterial and fungal growth on silicone make silicone a better choice. (Boiling new pacifiers for 5 minutes and washing them regularly helps too.) There’s no evidence that any one pacifier shape or type is better than another, so it’s pretty much baby preference.
There are also safety concerns regarding choking and strangulation. Although deaths have occurred related to pacifiers, most occurred before 1999, usually from pacifier cords or ribbons. Since 2008, the Consumer Product Safety Commission requires testing for durability, safe design and lead and phthalate limits. The few injuries that continue to occur result from nipple breakage or small parts breaking off pacifiers. To dodge those problems, avoid clip-on ribbons or strings and pacifiers with small parts or decorations that could become choking hazards. Pull on nipples to make sure they’re strongly attached (unless they are one complete piece as Soothies are) and check them regularly for cracks, tears or swelling so you can toss pacis past their prime.
Bottom line: the benefits – pain relief, soothing, SIDS risk reduction – appear to be greatest leading up to 6 months old and then start gradually declining as risks slowly increase, first with ear infections and then, after 2 years old, with dental problems. Pacifiers and breastfeeding seem to mix fine with moms who are confident about their breastfeeding plans and aren’t using them to put off feedings.