Breastfed babies and pacifiers

To pacify or not to pacify?

This is a really difficult question to answer, because this goes all the way back to Evidence-based information and informed choice. Only you, the parent can make that decision. But it’s best to make that an educated one.

What is a pacifier?

A pacifier is a rubber, plastic, or silicone nipple substitute given to an infant to suckle upon.

Pacifier recommendations

Both UNICEF’S baby friendly hospital initiative and the AAP recommend only introducing pacifiers after the 6-8 week mark, after breastfeeding has been established.

The WHO doesn’t recommend the use of pacifiers for breastfed babies at all.

The pros of using a pacifier

Reduced risk of SIDS

There are some studies that found pacifier use at sleep time decreases the risk of sudden infant death syndrome (SIDS). But it is still unclear as to why. Pacifier use decreased SIDS risk more when mothers were ≥20 years of age, married, nonsmokers, had adequate prenatal care, and if the infant was ever breastfed. So, it’s quite clear that there is an entire criterion that has to be met for it to be truly effective.

Studies are yet to show the difference between the sucking of a pacifier and the sucking of the breast. As sucking on a pacifier to fall asleep takes the same amount of time as breastfeeding an infant to sleep does. Future studies will probably show that the sucking at the breast is just as, if not more effective at reducing the risk of SIDS.

Benefits to NICU babies

One study has found that giving pacifiers to premature infants and making them listen to lullabies has a positive effect on their transition period to oral feeding, their sucking success and vital signs (peak heart rate and oxygen saturation).

The suck-swallow-breathe coordination is an important skill that every newborn must acquire for feeding success. In most cases the development and maintenance of the sucking reflex is not a problem, but sometimes the skill may be compromised due to factors such as long-term mother–infant separation or medical conditions. In such situations the use of pacifiers can be considered therapeutic and even provide medical benefits to infants.

Sucking on hands and digits is an innate behavior seen in babies. Non-nutritive sucking provides comfort, state regulation and an opportunity to organize oromotor development. More rapid weight gain, lower incidence of necrotizing enterocolitis and earlier hospital discharge have also been attributed to non-nutritive sucking during nasogastric tube feedings.

It’s important to note that the above research has found non-nutritive sucking beneficial, and not the use of a pacifier itself. Non-nutritive sucking is best done at the breast, when possible.

A substitute when the breast is unavailable

The sucking reflex is a very innate behavior in babies, and they use sucking for many reasons including comfort, sleep and pain relief. When a baby has high sucking needs and is separated from the mother for extended periods of time, a pacifier may be able to meet their sucking needs.

The cons

Weight gain and milk supply issues

When sucking on a pacifier, some babies may not cue for hunger, and this can cause them to stretch feedings for longer than it should have. When a baby suckles, the hormone cholecystokinin is released into the intestine. Cholecystokinin is responsible for satiety and sleepiness, helping to soothe an infant. This hormone is released when a baby suckles on a pacifier or the breast. So, it’s easy to see how this may trick a baby into thinking they just had a feed from the breast. This may stretch feedings out even longer and may result in weight gain issues and even supply issues for the mother.

Nipple confusion

Nipple confusion is an infant’s difficulty with or preference for one feeding mechanism over another after exposure to artificial nipples. It is literal confusion between the different teats. When nipple confusion occurs, a baby may start to latch shallow on the breast like they do on a pacifier which can cause damage to the mother’s nipples and also insufficient weight gain in the baby. Severe nipple confusion may result in complete breast refusal which may sometimes be irreversible.

Increased risk of Thrush

One study cultured and followed 95 healthy children aged 12 to 24 months, for yeast. None developed oral candidiasis, but those who used a pacifier were almost twice as likely to be colonized with any candida species. The pacifiers also cultured positive for Candida albicans in 22% of silicone pacifiers and 75% of latex pacifiers.

Increased risk of otitis media (ear infections)

One survey of parents of children aged 12 months or younger also found the risk of developing otitis media to be twice as high in pacifier users.

Another study has found pacifier use appears to be a risk factor for recurrent acute otitis media.

Overweight

Pacifier use beyond early infancy is associated with accelerated infant growth and toddler overweight, although the reasons for this relationship are still unclear.

Increased risk of malocclusions

Dental caries, malocclusion and gingival recession are commonly cited problems associated with pacifiers. Most studies have found that these problems exist with prolonged or inappropriate use.

One study showed significant differences in dental arch and occlusion characteristics in users at 24 months and 36 months of age compared with those that had stopped sucking by 12 months of age. Another study looked at children aged two to five years and also found significant increases in overjet (greater than 4 mm), open bite and posterior crossbite in pacifier users. The longer the use was, in months, the stronger the association with open bite and crossbite.

Premature weaning from the breast

Several studies’ results imply that pacifier use may be a marker of breastfeeding difficulties or decreased maternal motivation to breastfeed, as opposed to being the causal agent in early weaning.

In one study, a cohort of 441 mothers were enrolled and 79% participated. Ninety-four per cent were followed up to 1 year. Daily pacifier use was associated with early cessation of breastfeeding and a reduced duration of full breastfeeding. Finger sucking was not associated with a reduced duration of breastfeeding.

The verdict on pacifiers

No one can make the decision for you, but it’s important that you make an informed choice about pacifiers. Knowing both the pros and the cons to using a pacifier while breastfeeding is incredibly important. Pacifiers do hold great value such as being used in the NICU when babies can’t breastfeed, but overall, breastfed babies don’t need pacifiers as they can suckle at the breast whenever they need to.